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Abnormal_Chapter 12.docx

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Konstantine Zakzanis

Chapter 12: Substance-related Disorders Substance Dependence Characterized in the DSM-IV-TR as the presence of at least 3 of the following:  Development of tolerance by either 1. Larger doses of the substance being needed to produce the desired effect 2. Effects of the drug becoming markedly less if the usual amount is taken  Withdrawal → negative physical and psychological effects  Develop when the person stops taking substance or reduces the amount  May also use the substance to relieve or avoid withdrawal symptoms  Person uses more of the substance or uses it for a longer time than intended  Person recognizes excessive use of the substance → may have tried to reduce usage but has been unable to do so  Much of the person’s time is spent in efforts to obtain the substance or recover from its effects  Substance use continues despite psychological or physical problems caused or exacerbated by the drug  Ex: smoking despite knowing that it increases the risk for cancer)  Person gives up or cuts back participation in many daily activities because of the use of the substance  Diagnosed as being accompanied by physiological dependence (addiction) if either tolerance or withdrawal is present  Physical dependence on a drug is associated with more severe problems Substance Abuse Must experience 1 of the following as a result of recurrent use of the drug:  Failure to fulfill major obligations  Ex: Absences from work, neglect of children  Exposure to physical dangers  Ex: operating machinery, driving under the influence  Legal problems  Ex: Arrests for disorderly conduct, traffic violations  Persistent social or interpersonal problems  Ex: Arguments with a spouse  Substance intoxication → diagnosed when the ingestion of a substance affects the CNS and produces maladaptive cognitive and behavioural effects  Person addicted to a drug is denied it and experiences withdrawal → person receives diagnosis of both substance dependence and substance withdrawal  Ex: Alcohol withdrawal delirium (delirium tremens) is a form of substance withdrawal  Drugs can cause dementia and the symptoms of other Axis I disorders Chapter 12: Substance-related Disorders Alcohol Abuse and Dependence  Alcohol dependence may include tolerance or withdrawal reactions  People who are physically dependent on alcohol generally have more severe symptoms of the disorder  Those who begin drinking early in life develop their first withdrawal symptoms in 30s-40s  Effects of the abrupt withdrawal of alcohol in a chronic, heavy user may be dramatic due to their body’s acclimatization to the drug  Often anxious, depressed, weak, restless, and unable to sleep  Tremors of the muscles (fingers, face, eyelids, lips, and tongue), elevation in pulse, blood pressure, and temperature  Rare cases → person drinking heavily for a number of years may also experience delirium tremens when level of alcohol in blood drops suddenly  Person becomes delirious tremulous, visual and tactile hallucinations  Feel that unpleasant and very active creatures are crawling up the wall or over the person’s body  Person may claw as skin to get rid of the vermin or cower in the corner to escape an advancing army of these imaginary creatures  Delirium and psychological outburst caused by withdrawal is indication that the drug is addictive  Increased tolerance is evident following heavy, prolonged drinking  Levels of alcohol in the blood of such people are unexpectedly low after what is viewed as excessive drinking → body adapts to the drug and able to process it more efficiently  Changes in the liver enzymes metabolizing alcohol can account to a small extent for tolerance, but most researchers believe that the CNS is implicated  May result from changes in the # or sensitivity of GABA or glutamate receptors  May be the result of increased activation in some neural pathways to compensate for alcohol’s inhibitory effects  Drinking pattern of alcohol dependent people are out of control  May be unable to stop or cut down despite repeated efforts to abstain  Have a need to drink daily  Go on occasional binges and remain intoxicated for days  Suffer blackouts and have no memory of events that took place during intoxication  Craving may be so overpowering that they are forced to ingest alcohol in hair tonic  Causes social and occupational difficulties  Alcohol abusers experiences negative social and occupational effects from drugs but does not show tolerance, withdrawal, or compulsive drinking patters  Polydrug (polysubstance) abuse → using or abusing more than one drug at a time  Ex: 80-85% of alcohol abusers are smokers Chapter 12: Substance-related Disorders  Alcohol serves as a cue for smoking → smoking is 2x as frequent in situations where person is also drinking  Cross-tolerance between alcohol and nicotine  Nicotine can induce tolerance for the rewarding effects of alcohol (vice versa)  Consumption of both drugs may be increased to maintain rewarding effects  Some drugs taken together are synergistic → effects of combining produce an especially strong reaction (Ex: alcohol + barbiturates or heroin = death)  Prevalence of Alcohol Abuse and Co-morbidity with Other Disorders  Lifetime prevalence 17.8%, 12-month prevalence 4.7% for alcohol abuse  Lifetime prevalence 12.5%, 12-month prevalence 3.8% for alcohol dependence  Only 1 in 4 alcohol dependence had ever received treatment  Higher in men, younger cohorts, and whites  Chronic with an average of 4 years for alcohol dependence  Strong gender difference (25.1% for me, 8.9% for women), heritability = 50-60%  Drinking co-morbid with several personality disorders, mood and anxiety disorders, other drug use, and schizophrenia  Factor in 25% of suicides  Important to assess because co-morbid psychiatric disorders predict higher relapse rates and less initial treatment improvement among those also with substance abuse  Drinking and alcohol-related deaths increased over past decade in Canada  No single pattern of alcohol abuse → can vary from periods of heavy drinking to abstinence or lighter drinking at others  Difficulties with alcohol usually begin at a later age in women than in men and often after an inordinately stressful experience o The onset of heavy drinking and alcohol abuse is briefer than it is in men o Women with drinking problems tend to be steady drinkers who drink alone and less likely to binge  Costs of Alcohol Abuse and Dependence  Alcohol abuse is 4 leading cause of worldwide disability o Accounts for more years lost to death or disability than the use of either tobacco or illegal drugs  Most people with drinking problems do not seek profession help, but alcohol abuse constitute a large proportion of new admissions to mental and general hospitals o Use health services 4x more than non-abusers, medical expenses twice as high  Suicide rate for alcohol abusers much higher than that for general population  Increases both the likelihood and severity of traffic accidents o Drunk drivers kill average of 3-4 people per day and injure 187 people in Canada per day Chapter 12: Substance-related Disorders o Prototypical drinking driver is male 25-34 and drink large amounts of alcohol on a regular basis or occasionally drinks heavily (Canada) o Substantial proportion of impaired drivers have general tendency to engage in anti-social acts  Alcohol can lead to other injuries → rape, assault, family violence, homicide o Believed that over half of all murders are committed under the influence of alcohol o Alcohol is the drug with the most evidence of there being a direct link between intoxication and violence  Short-term Effects of Alcohol  Alcohol is metabolized by enzymes after being swallowed and reaching the stomach  Most of it goes into the small intestines where it is absorbed into the blood, broken down (in liver)  Quantities in excess of 30 ml of 100 proof (50% alcohol) per hour stay in the bloodstream  Absorption of alcohol can be rapid, but removal is always slow  Effects of alcohol varies with o Level of concentration of the drug in the bloodstream o Amount ingested in a particular periods of time o Presence or absence of food in the stomach to retain alcohol and reduce absorption rate o Size of a person’s body o Efficiency of the liver  Biphasic effect of alcohol as a drug o Initial effect of alcohol is stimulating → experience expansive feeling of sociability and well-being o When blood-alcohol level peaks and declines → alcohol acts as depressant that may lead to negative emotions o Large amounts of alcohol interfere with complex thought processes o Motor coordination, balance, speech, and vision impairments o Can become depressed and withdrawn  Produce effects through interactions with several neural systems in the brain o Stimulates GABA receptors → responsible for reducing tension o Also increase levels of serotonin and DA → source of ability to produce pleasure o Inhibits glutamate receptors → cause cognitive effects of alcohol intoxication  Ex: slurred speech, memory loss  Long-term Effects of Alcohol  Chronic drinking crates severe biological damage in addition to psychological deterioration Chapter 12: Substance-related Disorders  Can cause severe malnutrition o Alcohol provides calories → heavy drinkers often reduce their intake of food o “empty calories” → do not supply nutrients essential for health o Also contributes directly to malnutrition by impairing the digestion of food and absorption of vitamins o Deficiency of B-complex vitamins in older chronic abusers causes amnestic syndrome → severe loss of memory for both recent and past events o Memory gaps filled in with reports of imaginary, improbably events  Prolonged alcohol use with reduction in intake of proteins contributes to cirrhosis of the liver o Fatal disease in which liver cells become engorged with fat and protein and impede function o Cells die will die and trigger inflammatory process o Scar tissues develop and blood flow is obstructed  Other common physiological changes o Damage to the endocrine glands and pancreas, heart failure, hypertension, stroke o Capillary hemorrhages → responsible for the swelling and redness in the face (especially the nose) o Destruction of brain cells, significant loss of grey matter from the temporal lobes o Shorter-term abuse may produce some cognitive impairment on neuropsychological tests o Reduces effectiveness of immune system and increase susceptibility to infection and cancer  Heavy alcohol consumption during pregnancy is leading cause of mental retardation o Fetal alcohol syndrome → growth of fetus is slowed, cranial, facial, and limb anomalies produced o Partial fetal alcohol syndrome o Alcohol related neurodevelopmental disorder o Even moderate drinking should be avoided o FAS occurs in 1 out of every 100 pregnancies o Health care, social services, education, lost productivity = $5.3 billion in Canada o Leading cause of developmental and cognitive disabilities in Canadian children  Possible health benefits o Light drinking (<3 per day) related to decreased risk of coronary heart disease and stroke o French paradox → high in saturated fats, but low cholesterol levels that may be linked with consumption of low to moderate amounts of red wine Chapter 12: Substance-related Disorders Inhalant Use Disorders  Young people begin substance abuse by inhaling such substances as glue, correction fluid, spray paint, cosmetics, gasoline, household aerosol sprays, and the nitrous oxide found in spray cans of whipped cream  Peak age of inhalant use is 14-15 years with initial onsets in children as young as 6  Inexpensive and readily availability leads to its danger  Involve behaviours like  Sniffing (nasal inhalation)  Huff (breathing fumes from a small rag stuffed in mouth  Bagging (breathing fumes from a plastic bag held to the mouth)  Gasoline sniffing is a widespread problem among certain groups in northern Canada and especially prevalent among Aboriginal children/adolescents  Greater tendency for Aboriginal students to make greater use of illicit drugs, francophone students consume more alcoholic beverages  Inhalants act as a depressant (similar to alcohol and sedatives)  Can result in feelings of euphoria and psychic numbing  Can cause damage to central nervous system  Nausea and subsequent headaches experienced eventually in almost all cases  Inhalant use had higher levels of suicide, criminal behaviour, and family problems in juvenile delinquents Nicotine and Cigarette Smoking  Nicotine is the addicting agent of tobacco  Stimulates nicotinic receptors (nicotinic cholinergic receptors)  Facilitate NT release (Ex: DA) → produces stimulation, pleasure, and mood modulation  High reinforcing efficacy → reinforces drug-taking behaviour  Addictive effects of nicotine start very slowly after one’s first puff  Indications of mental addiction can be found well before actual physical addiction takes place  can occur after one puff/cigarette  Fundamental gender differences  Females having much greater brain activity especially in the cortical and subcortical prefrontal systems  These differences disappear when nicotine administered to men and women  Female smokers have substantially greater changes in cognitive activity after nicotine exposure Prevalence and Health Consequences of Smoking  47000+ die each year due to smoking causes in Canada Chapter 12: Substance-related Disorders  Single most preventable cause of premature death  Health risks of smoking significantly less for cigar and pipe smokers because they seldom inhale smoke into lungs (cancers of the mouth increases however)  Long-term cigarette usage → lung cancer, emphysema, cancer of the larynx and esophagus, number of cardiovascular diseases  Most harmful component in burning tobacco smoke → nicotine, CO, tar  Tar contains carcinogens  Health risks from smoking decline greatly after 5-10 years of quitting to levels only slight above those of non-smokers  May cause erectile problems in men → nicotine constricts blood vessels  ~17% of Canadians are smokers → prevalence decreased for many years  Males smoke 3 more cigarettes than do females per day Consequences of Second-Hand Smoke  Health hazards of smoking are not restricted to those who smoke  Environmental tobacco smoke (second-hand smoke) o Contain higher concentrations of ammonia, CO, nicotine, and tar than actually inhaling (at least twice the amount) o Classified to be a hazard as dangerous as asbestos and radon o 2/3 of smoke from cigarette enters air around smoker o Regular exposure increases chance of contracting lung disease by 25% and heart disease by 10% o Aggravates symptoms in people with allergies and asthma o Cause eye, nose, and throat irritations, headaches, dizziness, nausea, coughing, and wheezing in otherwise healthy people o Infants and children exposed more likely to suffer chronic respiratory illness, impaired lung function, middle ear infections, food allergies, and succumb to sudden infant death syndrome Marijuana  Consists of dried and crushed leaves and flowering tops of the hemp plant Cannabis sativa  Most often smoked, but can be chewed, prepared as a tea, or eaten in baked goods  Hashish → produced by removing and drying resin exudates of the tops of high-quality cannabis plants (much stronger than marijuana)  Considered illegal in most countries (bound by a UN treaty prohibiting its sale) Effects of Marijuana  Psychological Effects  Intoxicating effects depend on its potency and size of dose Chapter 12: Substance-related Disorders  Smokers find it makes them feel relaxed and sociable  Larger doses have been reported to bring rapid shifts in emotion, to dull attention, to fragment thoughts, and to impair memory  Time seems to move more slowly  Extremely heavy doses sometimes induce hallucinations and extreme panic  Major active chemical is delta-9 tetrahydrocannabinol (THC)  Amount of THC varies → believed to be 2-3x higher now that it was two decades ago  Body produces its own cannabis-like substance (anandamide) with its own cannabis receptors in the brain  Current marijuana use results in average decrease of 4.1 IQ points (only for heavy users that smoke 5 joints per week)  Lighter use did not result in diminished IQ scores  Impairment in encoding, storage, manipulation, and retrieval mechanisms in long-term r heavy cannabis use  Neurocognitive deficits greater among adults who began cannabis use in early adolescence and adolescents seem more susceptible to neurocognitive deficits  Chronic use contributes to mild impairments → seen in complex tasks, not simple ones  But also increased in psychological problems, health problems, financial problems, and vocational problems  Daily users found to be more likely to use multiple substances and suffer from anxiety disorder  Users are usually single males  Stepping-stone/gateway theory → premise that marijuana is dangerous not only in itself, but also because it is often the gateway that can lead young people to become addicted to more harmful drugs like heroin  Being high on marijuana impairs the complex psychomotor skills necessary for driving  Heavy use of marijuana during teenage years may well contribute to psychological problems in adulthood Somatic Effects  CB receptors in hippocampus account for the short-term memory loss that sometimes follows smoking marijuana  Short-term side effects  Blood-shot and itchy eyes, dry mouth and throat, increased appetite, reduced pressure within the eye, and somewhat raised blood pressure  Evidence of marijuana smoking being associated with host of respiratory disorders and related ailments  Seriously impairs lung functioning Chapter 12: Substance-related Disorders  Causes coughing, wheezing, bronchitis, injury to airway tissue, impaired functioning of immune system components  Concurrent smoking with regular tobacco associated with increased risk for respiratory symptoms and Chronic Obstructive Pulmonary Disease  Most users inhale marijuana smoke more deeply and retain it in their lungs for longer periods of time compared to regular tobacco  1 marijuana cigarette =  4 tobacco cigarettes in tar intake  5 in CO  10 in terms of damaged cells lining the airways  Habitual use of marijuana does produce tolerance  Lower threshold for females → using between 50-99 times associated with development of marijuana disorders  Late users less likely to have subsequent marijuana disorder  Causes reverse tolerance → experienced smokers need only a few puffs to become high, whereas less experienced users puff many times to reach similar state of intoxication Therapeutic Effects  Can reduce the nausea and loss of appetite that accompany chemotherapy for some cancer patients  Also a treatment for the discomfort of AIDS, glaucoma, epilepsy, and multiple sclerosis Sedatives and Stimulants  Harrison Narcotics Act (1914) made the unauthorized use of various drugs illegal and those addicted to them criminals Sedatives  Downers  Slow the activities of the body and reduce its responsiveness  Includes opiates (opium and derivatives), morphine, heroin, codeine  Synthetic barbiturates and tranquilizers  Opiates  group of addictive dedatives that relieve pain and induce sleep when taken in moderate doses  Opium  Morphine separated from raw opium  Bitter-tasting powder proved to be a powerful sedative and pain reliever Chapter 12: Substance-related Disorders  Found that it could be converted into another powerful pain-relieving drug → heroin  Heroin  Used initially as a cure for morphine addiction, it substituted for morphine in cough syrups and other patent medicines  Proved to be even more addictive and more potent than morphine → acting more quickly and with greater intensity Psychological and Physical Effects  Produce euphoria, drowsiness, reverie, and a lack of coordination  Heroin → rush, feeling of warm, suffusing ecstasy immediately following intravenous injection  User sheds worries and fears and has great self-confidence for 4-6 hours → then experiences letdown, bordering on stupor  Produce their effects by stimulating neural receptors of the body’s own opioid system  Heroin converted into morphine in the brain and then binds to opioid receptors  Body produces opioids (endorphins and enkephalins) → opium and its derivatives fit into receptors and stimulate them  Clearly addicting for users show both increased tolerance of the drug and withdrawal symptoms when they are unable to obtain another dose  Reaction to not having heroin may beginning within 8 hours of the last injection after high tolerance has built up  Typically has muscle pain, sneezes, sweats, becomes tearful, and yawns a great deal over the next few hours (resemble symptoms of influenza)  Withdrawal symptoms become more severe within 36 hours  May be uncontrollable muscle twitching, cramps, chills alternating with excessive flushing and sweating, and a rise in heart rate and blood pressure  Addicted person is unable to sleep, vomits, and has diarrhea  Symptoms typically persist for about 72 hours and then diminish gradually over a 5-10 day period  Dependence is many times higher among physicians and nurses than in any other group with a comparable educational background  Joint reflection of opiate availability in medical setting and high job stress  Heroin quite prevalent among street youth  Becoming popular with middle-and upper-middle class college students and young professionals  Increases in drug casualties due to the nature of the heroin now available  Increased purity of the drugs  Twenty years ago = 5% purity, Today = 25-50% purity  Opiates present a serious set of problems for the abuser  Deaths due to homicide, suicide, accidents, or overdose Chapter 12: Substance-related Disorders  Social consequences of using an illegal drug o Obtaining drug becomes centre of the abuser’s existence → governs all their activities and social relationships o High cost of these drugs means they have to acquire money through illegal means  Synthetic Sedatives  Barbiturates → originally synthesized as aids for sleeping and relaxation but became known for its addictive properties  Benzodiazepines (Valium) are more commonly used and abused  Methaqualone (Quaalude and Sopor) is similar in effect to barbiturates and has become a popular street drug  Sedatives relax muscles, reduce anxiety, and produce mildly euphoric state in small doses  Thought to produce these psychological effects by stimulating the GABA system  Excessive doses → speech becomes slurred, gait unsteady  Judgement, concentration, and ability to work may be severly impaired  User loses emotional control and becomes irritable and combative before falling
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