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PSYB32 - Final Exam Notes.doc

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Konstantine Zakzanis

PSYB32: Exam Notes Chapter 11: Schizophrenia Intro: • Diagnosis of ~ has existed for over a century • More research than any other psych problem • Lifetime prevalence of all psychotic disorders = 3% • Prevalence for schizophrenia is 1% • Real variation across geographic areas; Asian pop’ns have lowest prevalence • Significantly more likely in males • Sometimes begins in childhood, but usually appears in late teens/early adulthood • About 1/3 of those with a schizophrenia-spectrum disorder (schizophrenia, related disorders, related PDs, etc.) are early onset • Begins a bit earlier for men than for women • 10% of those with ~ commit suicide • 50% with ~ have a comorbid disorder (including many having depression, anxiety) • Many also have substance abuse (mainly in male schizophrenics) • Comorbidity with OCD is related to a previous history of suicide ideation + attempts • PTSD is also highly prevalent and underdiagnosed among military veteran schizophrenics Clinical Symptoms of Schizophrenia: • There are no “essential” symptoms out of the huge list so schizophrenics are heterogeneous Positive Symptoms: • Excesses/distortions such as disorganized speech, hallucinations, delusions • These define acute episodes • Disorganized speech (formally known as thought disorder): o Incoherence: person may make repeated refs to a central theme, fragments are too disconnected to understand o Loose associations/derailment: difficulty sticking to one topic, drifting off on a “train of associations”. This is similar to loose associations of manic people. o Disturbances in speech were once regarded as principal symptom of ~ • Delusions: o Beliefs held contrary to reality o persecutory delusions are common o over half of those with ~ have delusions o delusions are also found in mania, delusional depression, and other disorders o however, delusions in schizophrenics are often more bizarre and impossible • Hallucinations and other disorders of perception: o World feels different or unreal, depersonalization o Difficulty paying attention to goings on around you o Common auditory hallucinations that happen more often in ~ than other diagnoses:  Hearing voices arguing  Hearing own thoughts spoken by another voice  Hearing a voice commenting on own behv Negative Symptoms: • Behavioural deficits that tend to endure beyond acute deficits • Strong predictor of poor quality of life • Associated with earlier onset brain damage (enlarged ventricles) and progressive loss of cog skills (IQ decline) • Important to distinguish negative symptoms that are really of ~ from those due to other factors like side effect of meds or from depression • Avolition: lack of energy or interest or inability to persist in what are usually routine activities • Alogia: a negative thought disorder that can take several forms: o Poverty of speech: little info, vague, repetitive (poverty of content! Not # of words) • Anhedonia: inability to experience pleasure • Flat Affect: virtually no stimulus can elicit an emotional response o Found in majority of people with ~ o Vacant stare, muscles of face flaccid, eyes lifeless o Only the outward expression, inwardly they may not be impoverished at all!  Report same amount of emotion; just less facially expressive • Asociality: severly, impaired social relationships o Few friends, poor social skills, little interest in being with people, shy o More childhood social troubles are an early indicator o Deficits in recognizing emotional cues displayed by others Other Symptoms that are neither Positive or Negative • Catatonia: motor abnormalities like gesturing repeatedly, flailing limbs, or catatonic immobility: maintaining an unusual posture for extended amounts of time. These people may also have waxy flexibility where they can be moved into different positions • Inappropriate affect: emotional responses that are out of context, shifting rapidly in emotions for no discernible reason. • Both of these symptoms are very rare but also fairly unique to ~ History and Concept of Schizophrenia: • First discovered by Emil Kraplin and Eugen Bleuler. • Kraeplin called it dementia praecox at first (he had came up with 2 major groups of psychoses: manic-depressive and dementia praecox) Praecox = a common core (an early onset) • and he meant dementia as in mental enfeeblement and not the same dementia that old have • within this he included 3 concepts: dementia paranoids (paranoid schizophrenia), catatonia, hebephrenia (disorganized schizophrenia) • Bleuler disagree that: o it did not ahve to be an early onset o does not inevitably progress to dementia • thus, “dementia praecox” was no longer appropriate. Became Bleuler’s term “schizophrenia”. • Bleuler believed that the common aspect of schizophrenics was the “breaking of associative threads” in words and thoughts. Blocking = total loss of train of thought (total destruction of associative threads) • Prevalence has fallen sharply since 1960s • Part of the reason is that Bleuler first caused the diagnosis to expand such that many people were said to be schizophrenics and then the diagnosis later narrowed • Schizophrenic psychosis was a diagnosis in DSM 1 of schizophrenic + affective symptoms • Before, schizophrenia was diagnosed whenever delusions/hallucinations were present • Several personality disorders were also the same as schizophrenia back then • Those with acute onset and rapid recovery were also diagnosed incorrectly • Beginning in DSM 4, the diagnosis became significantly narrower in 5 ways: o Explicit, detailed criteria o People with symptoms of mood disorder were specifically excluded. Schizoaffective type is now listed as schizoaffective disorder in a separate section of psychotic disorders. This is a mixture of schizophrenia + mood disorders. o Requires min 6 months of disturbance for diagnosis with min 1 month of active phase  Active phase = at least two of: delusions, hallucinations, disorganized speech, disorganized or catatonic behv, negative symptoms  * if the delusions are bizarre or hallucinations consist of voices commenting or arguing, only that 1 symptom is needed  Remaining time of 6 months can be either prodromal (before active phase) or residual (after)  This criteria is to eliminate people who have a brief psychotic episode which is now diagnosed as either schizophreniform disorder (1-6 months) or brief psychosis (1 day to ` month; due to extreme stress)  Some of what DSM 2 called mild ~ are now PDs  Differentiating between paranoid schizophrenia and delusional disorder (= delusions such as erotomania = believing that one is loved by some other person, typically a stranger of high status. Unlike paranoid schizophrenia: no disorganized speech, hallucinations, and less bizarre delusions. It is quite rare and typically begins later in life. Related to ~ by genetics) o The criteria generally holds well cross-culturally but, people in developing countries have more acute onset and a more favourable course than in industrialized societies (unknown why this is) • Psychotic risk syndrome = new DSM 5 proposal so that young people can be identified as at risk before diagnosis of schizophrenia or something else • 9 dimensions for psychotic illnesses proposed: o hallucinations, delusions, disorganization, abnormal psychomotor behv, restricted emotion expression, avolition, impaired cognition, depression, mania Categories of Schizophrenia • 3 types in DSM, originally by Kraeplin = disorganized (hebephrenic), catatonic, paranoid • Disorganized Schizophrenia: o Disorganized speech, flat affect, shifts in emotion, disorganized not goal-directed behaviour, self-hygiene neglect • Catatonic Schizophrenia: o Alternate between immobility and wild excitement o Resist instructions/suggestions and just echo back the speech of others o Sudden onset compared to other forms, though likely to have previously shown apathy and withdrawal from reality o Seldom seen today because drug therapy works effectively on these motor processes th o In the early 20 century, it was often overdiagnosed where lethargic (sleeping sickness i.e. in Awakenings) should have been diagnosed • Paranoid Schizophrenia: o Presence of prominent delusions o Delusions of persecution most common but also grandeur, jealousy, ideas of reference = making unimportant events significant o Agitated, argumentative, angry, sometimes violent o Emotionally responsive though they may be stilted, formal o More alert and verbal than are people with other types o Delusions in their language but their lang is not disorganized • Diagnostic reliability is poor because it is difficult to differentiate between forms • The various types also have little predictive validity • Some additional types include undifferentiated schizophrenia: o People who meet criteria for schizophrenia but not for a particular subtype • Residual schizophrenia: o Client no longer meets full criteria for ~ but shows some signs of disorder • There is major argument to discontinue current subtypes that are rarely used • There has been research to find new subtypes based on which neurocog features or brain abnormalities. An executive subtype found, distinguished by impairment on Wisconsin Card Sorting Test. o Also, an executive motor subtype = deficits in card sorting + motor fxns o Motor subtype: only deficits in motor fxns o Dementia subtype: pervasive, general cog impairment • A primacy of cognition exists: cog effects appear before structural effects • When it comes to positive and negative, most people have mixed symptoms • Some suggest that positive symptoms should be split into: o Positive Symptoms: Hallucinations and delusions o Disorganized Symptoms: bizarre behaviour, disorganized speech • There is also such a thing as shared psychotic disorder = development of a delusional system within a close relationship with a delusional person Etiology of Schizophrenia: • Relatives of people with ~ at increased risk as relationship becomes closer • Negative symptoms have a stronger genetic component • Relatives also at risk for other disorders like schizotypal PD (i.e. weaker forms of ~) • Children of a non-schizophrenic co-twin of someone with schizophrenia are 10 times more likely to have schizophrenia. • There is a 44% chance that monozygotic twins will be concordant for ~ Molecular Genetics • Research has focussed on the endophenotypic strategy which is about endophenotypes (characteristics that reflect actions of genes predisposing an individual to a disorder even in absence of diagnosable pathology). By focussing on these instead of the genes of the entire phenotype of schizophrenia, the complexity of genetic analysis = reduced • Several studies have replicated a link with a gene called DTNBP1 • Evidence that G-protein signalling 4 (RGS4) gene located on chromosome lq23 has a role • None of the research is for sure though • Increasing evidence that genetic susceptibility overlap for schizophrenia and bipolar • Genain Quadruplets: 4 female quadruplets who all developed schizophrenia by 24 y.o o They experienced very difficult life outcomes despite identical genetics o Hester = severe impairment, Iris + Nora = moderate impairment but no careers or marriage, Myra was able to work and marry and function well generally o Differential treatment by their father (very cruel to Hester + Iris but kinder to others) Biochemical Factors • No biochem factor has unequivocal support but dopamine is most researched • Dopamine theory = schizophrenia caused by excess dopamine activity (based on the fact that antipsychotics operate by reducing dopamine activity. As well, the side-effects of antipsych’s are Parkinsonian and that is caused by low dopamine) • Also, amphetamine psychosis = amphetamines can produce a state that closely resembles paranoid schizophrenia + they can exacerbate existing schizophrenia. o release catecholamines (norepinephrine and dopamine) and prevent their inactivation o amphetamines worsen positive symptoms but lessen negative ones o antispychotics are antidotes to amphetamine psychosis • homovanillic acid(HVA, major dopamine metabolite)found in smaller amounts in schizophrenics o led researchers to oversensitive dopamine receptors rather than a high lvl of dopamine • dopamine appears to mainly be related to positive symptoms • excess dopamine activity thought to be most relevant is in mesolimbic pathway (the dopamine neurons here appear to be related to positive symptoms) o these neurons ARE affected by antipsychotics • mesocortical dopamine pathway begins in same region but goes to prefrontal (dopamine neurons in prefrontal cortex appear to be related to negative symptoms which typically precede appearance of positive ones) o these neurons are NOT affected by antipsych`s • Puzzling aspects of dopamine theory: o antipsychotics block dopamine receptors rapidly but: no effect for weeks o dopamine levels must be reduced below normal (producing Parkinsonian side effects) for the treatment to be effective. Normal levels are insufficient. • ^ probably bc there is more to it than just dopamine • Other neurotransmitters: o Dopamine neurons modulate activity of other neural systems (i.e. they regulate GABA) o Also, serotonin neurons regulate dopamine neurons in mesolimbic pathway o Low glutamate lvls in cerebrospinal fluid of schizophrenics  PCP = a street drug that can induce a psychotic state (both +ve and –ve symptoms) by interfering with glutamate receptors  Also, low glutamate can result in excess dopamine Schizophrenia and the Brain: Structure and Function: Enlarged Ventricles: • Most consistent finding of brain pathology = ~ (especially in male schizophrenics!) o This implies a loss of subcortical brain cells o ~ corresponds with poor performance on neuropsych tests, poor adjustment prior to disorder onset, and poor response to drug treatment o ~ can be detected in first episode and chronic schizophrenia o Likely that ~ have a neurodevelopmental origin and are not progressive o But, ~ are not unique to schizophrenia. Also happens in other psychoses like bipolar. • Moderately consistent findings also show structural problems in subcortical temporal- limbic and the bilateral medial temporal lobe regions (i.e.hippocampus, basal ganglia, prefrontal, temporal) • Also, reduction in cortical grey matter of temporal + frontal • Reduced volume in basal ganglia (caudate nucleus and limbic structures (suggesting atrophy) • Data suggests the origin of these brain abnormalities may not be genetic Prefrontal Cortex • ~ known to play a role in behv like speech, decisions, motives • Lack of illness awareness corresponds to poorer neuro psych performance, more so in schizophrenia than other psychoses which supports the hypothesis that lack of awareness is related to defective frontal lobe fxns • Schizophrenics have reductions in grey matter in ~ • Also, low glucose metabolic rates in ~ • Also, glucose rates fail to rise in response to doing neuropsych tests (less frontal activation). • As well as less prefrontal activation (prominent dysfunction) during episodic encoding and retrieval tests indicating episodic memory impairment in schizophrenics • Failure to shows frontal activation is related to severity of negative symptoms and is related to the theories of dopamine underactivity • Basal or orbital parts of ~ affected in schizophrenics who are violent, antisocial, substance abuse • Widespread thinning of cortex in prefrontal and temporal areas, apparently resulting from loss of dendrites and axons • As well, neurons are smaller in frontal cortex Congenital and Developmental Considerations • A possible interpretation of brain abnormalities is: caused by damage during gestation/birth • Presence at birth/infancy of craniofacial/midline anomalies and/or early fxnl impairments from CNS (especially frontal cortical) anomalies double risk of schizophrenia-spectrum disorders • Also possible that delivery complications that lead to a reduced supply of O2 in brain increase risk for those who already have the genetic predisposition • Another possibility is that a virus that invades brain +damages fetal development is responsible o Dnding an influenza epidemic, it was found that those exposed to the virus durist 2 trimester had much higher rates of schizophrenia than those exposed in 1 or 3rd o During 2 trimester: cortical dev is in a critical stage (neuron production occurs in neural tube and there is then cell migration to new location, so perhaps the process of cell migration is disrupted in schizophrenics) o There may also be some unidentified human endogenous retrovirus that attacks the nervous system and incorporates itself into the cellular genome code • Rare, but some show onset of positive symptoms before 12 y.o o In these people, there is clear evidence of general brain deterioration consistent with effects of a CNS virus (10% less brain tissue by 12, and deterioration proceeds to 25%+) • Parental exposure to infections including influenza, rubella, and toxoplasmosis (parasite) and maternal cytokines (which mediate host response to infection) associated with increased risk • 50% increased risk of schizophrenia among adults exposed to a viral CNS infection before 12 o but no increased risk from bacterial CNS infections • it is proposed that disorder then only typically begins in adolescence because that is when the prefrontal cortex matures and actually starts to play a larger role in behv. o Also, dopamine activity peaks in adolescence • Reduced cerebral blood volume accompanies the brain size decrease. Proposed that chronic cerebral blood volume results in neuronal loss and cog impairment • Reduced left auditory cortical activation (i.e. auditory hallucinations + memory retrieval) Psych Stress + Schizophrenia Social Class • Highest rates found in central city areas by people in lowest socio-economic class • Continuous progression of higher rates as social class decreases nd • Twice as high in lowest class compared to 2 lowest class, cross-culturally • Interestingly, a relatively small proportion of homeless in US are mentally ill but in Canada, mentally ill are a large proportion of homeless (i.e. 86% of homeless in Toronto) • This finding led to two hypotheses: o Sociogenic hypothesis : stressors associated with being in a low social class may cause or contribute to the development of schizophrenia o Social-selection theory: (reverse causality): during the course of their psychosis, schizophrenics may drift into poverty-ridden areas of a city or they may choose to move to areas where little social pressure exists o Data seems to be more supportive of social selection theory. But, we should not conclude that social enviro plays no role in schizophrenia • There is extremely high risk for schizophrenia in second-gen immigrants • Also, social defeat or exclusion might lead to alterations in CNS dopamine sensitivity and regulation of dopaminergenic systems Family • Early theorists considered fam relationships, especially mom-son, to be crucial in development of schizophrenia. Even the term schizophrenogenic mother = a cold, dominant, conflict-inducing, rejecting, overprotective, rigid/moralistic about sex, fearful of intimacy parent who was said to produce schizophrenia in her offspring • Poor family communication + hostility predict schizophrenia and also mania • *but, a poor family enviro could be a response to a disturbed child, rather than the cause Family and Relapse • Families have a huge effect on schizophrenics that could relapse • Families are either classified as high or low Expressed emotion (EE) • Significantly more clients who returned to high EE homes relaspsed • The negative symptoms of schizophrenia are most likely to elicit critical comments and relatives who are most critical tend to believe that the client can control their symptoms • *it is unclear to judge EE as causal or as the effect though • Research indicates that both interperations are correct (more EE causes a higher expression of unusual thoughts by client and more unusual thoughts meant more EE and critical comments) rd • “bidirectional relationship”, though there is also the 3 variable issue (some have proposed a genetic factor that causes disturbed communication since the family members themselves may have some but not all of the gene code for schizophrenia) Stress • Stress activates the hypothalamic-pituitary-adrenal (HPA) axis , causing cortisol secretion • Cortisol increases dopamine activity which may lead to schizophrenia symptoms • Heightened dopamine activity itself can also increase HPA activation making a person overly-sensitive to stress (this is another bidirectional relationship Developmental/High Risk Studies of Schizophrenia • Children who later developed schizophrenia had lower IQs • Pre~ boys were described as disagreeable by teachers an pre~ girls as passive • Both pre~ boys and girls were described as delinquent and withdrawn • They also had poorer motor skills and more expressions of negative affect • High-risk method (method was pioneered by Samoff Mednick who also contributed to maternal-virus theory): in Denmark that selected several high-risk subjects (children of mothers with chronic schizophrenia) and matched them on various variables to low-risk subjects • negative-symptom schizophrenia more often has a history of birth complications and failure to show electrodermal responses to simple stimuli • positive-symptom schizophrenia more often has a history of family instability • it has also been shown that reduced grey matter volumes actually happens before psychosis Therapies for Schizophrenia • traditional hospital care has little effect to create lasting change in the majority of mentally disordered people in general • many clients lack insight and refuse treatment, especially paranoid schizophrenics • family members sometimes have to turn to involuntary hospitalization via civil commitment or community treatment orders (CTOs) • trend though has been to have schizophrenics spends as little time as possible in psych hospital • There was a study that compared 3 different therapies for institutionalized schizophrenics: o Social learning ward: token economy + behv training + kept busy most of waking hours o Milieu-therapy ward: operated according to principles of Jone’s (who’s approach is similar to Pinel’s moral treatment). Treated as normal individuals rather than incompetent, mental. Also kept busy most of waking hours. o Routine hospital management: not kept busy most of waking hours. Custodial care + heavy antipsychotics. o About 90% of clients in all 3 groups were receiving meds initially. But over the course of the study, the amount in RHM went to 100% and the amount in SLW and MTW dropped to near 15%. Remarkable finding bc most had assumed lack of meds = unmanageable. o SLW > MTW > RHM • APA’s strategy outline = meds + treat comorbid + psychosiocial treatment to improve symptoms and ability to function socially and vocationally • Psychosocial treatments supported by APA = family interventions/psychoeducation, CBT, social skills training, assertive community treatment, and supported employment. Unfortunately, few of these are commonly used despite research showing their successes Biological Treatments • In the early 1930s, comas were induced with large doses of insulin • ECT was used after, minimally • A leukotomy is a procedure that is similar to a frontal lobe lobotomy that is just more specific • Main reason for abandonment of lobotomies was the introduction of drugs • Antipsychotic drugs are also referred to as neuroleptics meaning they produce side effects similar to symptoms of a neurological disease • Phenothiazine was one of the more frequently prescribed before o Antihistamines actually have a phenotiazine nucleus and the intro of antihistamines in 1940s was when phenothiazines were first noticed o Antihistamines are used to reduce surgical shock (as well as for allergies) o A new phenotiazine derivative called chlorapromazine (trade name Thorazine) created  Calming effect on schizophrenics  Blocks dopamine receptors in brain , reducing dopamine influence  Introduced to North America by Heinz Lehman • Other antipsychotics include the butyrophenones (i.e. haloperidol, Haldol) and the thioxanthenes (i.e. thiothixene, Navane). o Both are generally as effective as phenothiazines and work in similar ways (block dopamine D2 receptors consistent with a target-and-trigger hypothesis = antipsych’s target specific neurons and use their antagonistic properties to trigger the neurons) • All 3 groups of antipsychotics reduce positive symptoms but little effect on negative • Also, about 30-50% of schizophrenics do not respond favorably to conventional meds • Due to the side effects of antipsychotics, 50% quit meds after 1 yr • Because of the high non-compliance rate, clients are frequently treated with long-lasting antipsychotics like fluphenaxine, decanoate, prolixin (injected every 2-6 weeks) • Clients who don’t adhere to their meds are 5 times more likely to relapse • Clients who do respond favorably to antipsychotics are often kept on maintenance dose (just enough to continue therapeutic effect, so fewer side effects) o African-Americans are much more likely to be prescribed a MD that was too high • Antipsych’s have reduced long-term institutionalization but have created a revolving door effect of discharge and readmission • Side effects of antipsych’s: o Common ones: dizziness, blurred vision, restlessness, sexual dysfunction o some experience extrapyramidal (i.e. adverse) side effects (that stem from dysfunctions of nerve tracts that go from brain  spinal motor neurons).  resemble symptoms of Parkinson’s (tremors, shuffling gait, drooling).  Also, dystonia = state of muscle rigidity.  And, dyskinesia = abnormal motion of voluntary and involuntary muscles such as chewing movements, etc.).  Dystonia + dyskinesia = arching of back and twisted posture  Akasthisia = inability to remain still  These symptoms can be treated by drugs that treat Parkinson’s o Also, 10-20% of schizophrenics on antipsych’s also experience tardive dyskinesia = involuntary lipsmacking, chinwagging, and in more severe cases whole-body-involuntary-motion. TD has no known treatment. o 1% suffer from neuroleptic malignant syndrome = can be fatal. Severe muscular rigidity + fever + heart and bp increase + client may lapse into a coma • Antidepressants are also sometimes used concurrently to sort of treat negative symptoms • There are also now second-gen (Atypical) antipsych’s such as clozapine (Clozaril) which appear to generally work better and also for those who 1 gen meds didn’t help at all. These impact D3, D4 dopamine receptors as well as D2. And even, some serotonin receptors (S2, S3). o Among those, clozapine works better than olanzapine (based on fewer suicides, fewer motor side effects, reduced relapse) o Biochem mech of clozpine not fully known but we know it affects serotonin receptors o Does have serious side effects though:  Impairs immune system (in 1% of clients)  Sometimes seizures, dizziness, fatigue, drooling, weight gain nd • 2 other 2 gestantipsych’s = olanzapine (Zyprexa) and Risperidone (Risperdal) are also better than 1 gen and produce fewer motor side effects o Risperidone = lower hospitalization time + improves verbal working memory more than other antipsych’s by reducing serotonin receptor activity in frontal cortex • Also ziprasidone which had fewer adverse side effects and more effect on depressive symptoms • MATRICS = Measuement and Treatment Research to Improve Cognition in Schizophrenia has been established by the U.S. NIMH to focus more on treating negative + cog symptoms of schizophrenia rather than the pre-existing focus on positive • People younger than 18 are usually excluded from treatment trials since earlier onset st nd predicts greater severity. Antipsych’s (1 or 2 gen) are generally uneffective in under 18. • There is also a lot of tranquilizer use in institutions which is said to turn schizophrenia (natural psychosis) into iatrogenic psychosis (tranquilizer psychosis) which mean less of certain symptoms but much more apathy, which can only be treated by discontinuing drugs Drug Category Generic Name Trade Name phenothiazine chloropromazine Thorazine fluphenazine, decanoate Prolixin butyrophenone haloperidol Haldol thiozanthene thiothixene Navane tricyclic dibenzodiazepine clozapine Clozaril thienobenzodiazapine olanzapine Zyprexa benzisoxazole risperidone Risperdal dibenzothiazepine quetiapine Seroquel Psychological Treatments: • Cog impairments in schizophrenics limit degree that psych interventions help • Freud believed schizophrenics were incapable of establishing close relationships • Used to generally be assumed that there was no way to change cog distortions • CBT actually seems to be particularly effective at reducing negative symptoms as well as positive, depression, anxiety, social functioning. But, not relapse rate. • Has been suggested that perceptual delusions are result of cog style, not percep distortions • Family therapy works very well to reduce relapse rates • Personal therapy = a long-term, broad-spectrum CBT approach. Aims to teach client internal coping skills. Teaches clients to recognise inappropriate affect, deal with criticism and conflict with others, learn signs of relapse (i.e. social withdrawal/inappropriate behv). + some rational-emotive behv therapy to help lower stress levels and learn not to blow a smaller problem out of proportion. + muscle relaxation techniques + social skills training. • Cognitive Enhancement Therapy (CET) developed by Hogarty o = computer-based training in cog + social skills. o It has been shown that schizophrenics are unable to recognize facial affect in others o This therapy targets that + attention + working memory o Scaffolding instruction = tailoring task complexity to person’s current skill + potential aiming to ultimately get the client to be able to generalize to new situations o Those who exp’d scaffoldin relative to direct instruction had more cog improvements that lasted, higher lvls of positive affect, more self-esteem • Generally, CBT reduces positive symptoms while fam therapy + education reduce relapse • Deinstitutionalization occurred in 1960s forcing many schizophrenics to fend for themselves • New services were created and a new mental health specialty, case manager, was created o Initially, were brokers of services o major innovation = to provide direct services by a team with the Assertive Community Treatment and Case Management models (multidisciplinary teams) o Greater Vancouver Mental Health Services Agency = considered best in N. America • Community response teams also now exist for crisis interventions i.e. PACT = Program for Assertive Community Treatment. o Ontario = only province to implement ACT on wide scale o MCIT = Mobile Crisis Intervention Team = a 911/local hospital partnership in Toronto  Majority of the calls they receive are chronic schizophrenics + suicidal people • Only a generation ago, many professionals believed family was biggest culprit in schizophrenia. • Also increasingly recognized that early intervention is important o Early signs of risk = confusion, exaggerated self-opinion, suspiciousness, altered perceptions, odd thinking + speaking processes, lack of close friends, flat emotions, difficulty in social/school/work settings • Duration of untreated psychosis (DUP) = period between onset of first psychotic symptom and the time of treatment. o Predicts remission and positive symptom outcome after 1 yr o Recovery, better adjustment + med adhering, no substance abuse at baseline, fewer baseline negative symptoms predicted by shorter DUP • Critical period hypothesis: symptomatic and psychosocial deterioration occur aggressively during early years of psychosis + while it’s untreated. Then slows or stops and level attained endures over long term • Duration of untreated illness (DUI)= sum of duration of prodrome (time between onset of prodromal and onset of first psychotic symptom)+ DUP Community Services • an alternative to usual institutions are aftercare such as halfway houses or group homes (typically staffed by paraprofessionals = majors or grad students in clinical psych/social work) • the social learning ward treatment mentioned earlier as well as aftercare has been found to be successful, as well as less expensive than institutional care • club-house program = designed for people with psych problems, offers services, meals, activities, housing, etc. • there is a chronic shortage of subsidized housing in general in Canada o 1/3 of people in Toronto with a psych disorder face discrimination when trying to rent • laws do forbid employers from asking applicants if they have a serious history of mental illness, but, former psych hospital clients still have a lot of difficulty obtaining work • Edmund Yu Safe House Project was intended for transition housing but still not fully launched. Named after a former U of T med student who deteriorated into paranoid schizophrenic + homelessness. Shot to death by police when he had a small hammer aboard a Toronto bus • Substance abuse is another huge problem bc programs for substance abuse often exclude seriously mentally ill & vice versa (bc: comorbid condition is considered disruptive to treatment) o Schizophrenics with substance abuse often don’t take their antipsychotic meds • Survey found: 20% of people would be unwilling to be friends with a schizophrenic and 75% unwilling to marry. Those over 60 were least knowledgeable about ~ and most negative. • Psychiatrists actually may have more negative stereotypes than general pop’n • CAMH is now undergoing a $380 mill redevelopment to create first large-scale urban village mental health facility in world. Goal = make client’s exp closer to normal life o to be completed in 2012 (Began in 2006) o patients will be called “clients” instead o half of the land will be for hospital use, rest will be stores, art studios, library, fitness centre, etc. Ideal is that clients, staff, neighbour will mingle naturally Chapter 12: Substance Abuse Intro: • pathological gambling has been recommended for inclusion in DSM 5 • internet addiction not included at present because “not enough evidence” (riiiiight..... :p) • substance intoxication = a diagnosis made when ingestion of a substance affects CNS and produces maladaptive cog and behv effects • substance withdrawal = diagnosed when withdrawal is present such as the DTs (delirium tremers) that occur with alcohol withdrawal • drugs can cause dementia and symptoms of Axis 1 disorders • growing evidence of a lack of distinction in reality between the diagnoses abuse vs. dependence • as well, the current diagnostic criteria are not as good for characterizing mild/severe pathology • majorcategories are: alcohol, inhalants, sedatives, stimulants, amphetamines, hallucinogens Substance Dependence: • requires at least 3 of the following: o tolerance developed (defined as either larger doses needed for effect and/or effects of drug become less if usual amount taken) o withdrawal o person uses more or uses for longer time than intended o recognizes excessive use and has tried unsuccessfully to reduce usage o much of person’s time is spent trying to obtain or recover from the drug o use continues despite psych or physical problems caused/exacerbated by drug o gives up/cuts back participation in other activities bc of substance • substance dependence is diagnosed as being accompanied by physiological dependence if either tolerance and/or withdrawal are present • dependence = more serious than “abuse” Substance Abuse: • abuse = less serious than dependence • requires one of the following: o failure to fulfill major obligations o exposure to physical dangers (driving will intoxicated, etc.) o legal problems some argue this is a poor criterion o persistent social/interpersonal problems Alcohol: • those who begin drinking early in life develop first withdrawal symptoms in 30s/40s o anxious, depressed, weak, restless, unable to sleep, muscle tremors, higher bp + temp o in relatively rare cases, the DTs = delirium + tremors + visual hallucinations of things crawling over body, when alohol lvl suddenly drops • Changes in liver enzymes account, to a smaller extent, for tolerance. But, it mainly comes from a change in number/sensitivity of GABA/glutamate receptors (overexcitation occurs to counter the inhibitory effects of alcohol) • 80-85% of alcohol abusers are smokers • smoking is twice as frequent in situations when there is also drinking • alcohol and nicotine are cross-tolerant = they induce tolerance for the rewarding effects in each other and consumption of both drugs may be increased to maintain effects • the effects of some drugs together are synergistic = effects produce an especially strong rxn (i.e. alcohol and barbiturates which can be fatal. Also alcohol + heroin) Prevalence:/Stats • 17.8% prevalence of alcohol abuse • 12.5% prevalence of dependence • Only ¼ with dependence had ever received treatment • Rates highest in men, younger, white • Low-risk drinking = 14 drinks/week or less for men and 9 drinks/week or less for women • Especially strong gender differences for heavy drinking = 5+ drinks in one night, min once/week • Prototypical heavy drinker = unmarried, young adult male, relatively financially well of • The heaviest drinking 10% account for 50% of overall consumption • Problem drinking is comorbid with several PDs, mood, anxiety disorders, other drugs, schizophrenia. Also a factor in ¼ of suicides. • Drinking is on the rise in Canada, most significantly in BC • Binge drinking = 5 drinks in a row for men and 4 drinks in a row for women • ¼ students were frequent binge drinkers (once a week) • 1/6 Cdn students met criteria for heavy frequent drinking =usual daily consumption of 5+ drinks • Hangovers > memory loss > regrets> missing class bc hangover were most listed problem students listed of excessive drinking th • 4 most serious problem on campus, in terms of student views • Cdn > USA for proportion of drinkers o But, USA > Cdn for heavy alcohol use • Students living at home less likely to be heavy drinkers but, protective effect stronger in USA • Being drunk before 16 = more likely to be heavy drinker in college • ¼ Grades 7-12 students in Ontario acknowledge binge drinking in past month • Gender gap between males and females for binge drinking is decreasing • Only 34% of parents were aware of child’s alcohol use o More likely to know if single, mixed family, higher achieving student • Jellinek proposed that there is a 4 stage progression of alcohol abuse  dependence, but there is not much evidence for this, especially since progression is not inevitable • Difficulties with alcohol usually begin in a later age in women, usually after a crisis/stressor • Women tend to be steady drinkers who drink alone, less likely to binge • 4 leading cause of worldwide disability, more serious than tobacco or illicit drugs • Rates of hazardous drinking especially high in Russia where almost half of all deaths of working-age men due to hazardous drinking • A large proportion of new admissions to mental/general hospitals = problem drinkers o Use health services 4 times more often than non abusers o Medical expenses = twice as high • Suicide rate = much higher • Traffic fatalities have declined a lot but: 1/3 of fatally injured drivers had BAC’s over legal limit • Drunk drivers kill 3 to 4 people per day and injure nearly 200 per day • Prototypical drunk driver = male between 25-34, drinks a lot regular or is a social drinker who occasionally binges • Proposed that a nationwide req for 0 BAC for drivers under 21 • Substantial proportion of impaired drivers engage in antisocial acts (robbery, assault, etc) • over half of all murders committed under influence of alcohol • alcohol is the drug with the greatest direct link between intoxication and violence Short-Term Effects: • most goes into small intestines where it is absorbed into blood • it is then broken down by liver enzymes, which can metabolize 30ml of 100proof (i.e. 50% whisky) per hour • quantities in excess of this stay in bloodstream • biphasic effect: o an initial stimulating effect but after blood alcohol peaks, it acts as a depressant • stimulates GABA (major inhibitory neurotransmitter) = may be responsible for reducing tension o benzodiazepine tranquilizers also stimulate GABA in similar ways • increases serotonin + dopamine lvls (pleasurable effect) • inhibits glutamate = cog effects Long-Term Effects: • almost every tissue/organ is adversely affected by alcohol • severe malnutrition because alcohol provides lots of calories but they’re just empty calories and they also directly impair digestion + vitamin absorption o especially B complex vitamins which contribute directly to amnestic syndrome (severe recent and long-past event memory loss) • cirrhosis of liver = potentially fatal, liver cells engorged with fat + protein, impeding fxn o some cells die, triggering inflammatory process and scar tissue obstructs blood flow • endocrine gland + pancreas damage • heart failure, hypertension, stroke • capillary hemorrhages = leads to swelling/redness in face, especially nose • brain cells destroyed (loss of temporal gray matter) • immune system impairment o breast cancer risk in women increases linearly at 7% per drink/day regularly • fetal alcohol syndrome (FAS), partial FAS, alcohol-related neurodev disorder (ARND) o FAS in 1/100 pregnancies, leading cause of developmental + cog disability o 10% of Canadian women don’t realize there’s a risk o Half of women drink socially, half of all pregnancies are unplanned o ¼ of Canadian women drink prior to realizing they`ve conceived • Positive health benefits: light drinking (esp wine) = less than 3/day on avg = MAY reduce risk of coronary heart disease + stroke o French Paradox = despite their diet being rich in satur. fats, French have relatively low cholesterol. Hypothesis that this is due to wine. Though, other factors like eating more fresh foods, more exercise Inhalant Use: • Inhalant use is commonly a stepping stone to other drugs • Though not only kids + teens, an alarming # of young people begin their substance abuse with glue, whiteout, gasoline, spray point, aerosols, etc. o 17.3% admit to it and 2/5 8 graders believe solvent use is not dangerous o Peak age of onset is 14-15 • Huffing = breathing fumes from a rag ; bagging = breathing from a plastic bag • solvent use is considerably higher among Aboriginals (generally tendency of aboriginals to use more illicit drugs and Francophones to use more alcohol) • inhalants are depressants, similar to alcohol and sedatives • euphoria + psychic numbing but also, CNS damage, nausea headaches • linked with adjustment problems, more suicide, criminal behv, family problems Nicotine: • when Columbus began trade with natives, began to imitate their use of tobacco • stimulate nicotine acetylcholine receptors • the cholinergenic system leads to release of other neurotrans like dopamine • tobacco was once exchanged ounce for ounce for silver • there were public tortures + executions in Turkey by order of Sultan Murad IV who tried to dissuade alcohol use. He wasn’t very successful. • High reinforcing efficacy: monkeys will perform 600 lever presses to self-administer • Addictive effects begin from first puff (mental addiction occurs well before physical) • Huge gender difference in metabolic activity normally (female = more brain activity, particularly cortical + subcortical prefrontal) but alcohol makes gender gap disappear o Female smokers may have greater changes in cog activity from nicotine • Smoking causes about 50K deaths in Canada and 500K in USA • Is responsible in some way for 1/5 deaths in USA • Is the single most preventable cause of premature death • Fewer risks for cigar/pipe because they seldom inhale into lungs but more risk of mouth cancer • Nicotine, CO, tar = harmful components. (Tar has carcinogens) • Health risks decline greatly over 5-10 yrs after quitting but lung damage is irreversible • 17% of Canadians are smokers, prevalence has decreased steadily for years • Fewer young smokers in Canada overall but Quebec = 1/5 teens • Daily smokers avg nearly 15 cigs/day • Males smoke 3 more per day than females • Erectile problems can occur in males, since nicotine constricts blood vessels Second-Hand Smoke = ETS = Environmental Tobacco Smoke: • Higher concns of ammonia, CO, and 2 times amount of nicotine and tar • Blamed for 50,000 deaths in US • Said to be as dangerous as asbestos, radon nd • Blue Ribbon Campaign = campaign to clean air of 2 hand smoke • 2/3 of cigarette smoke is not inhaled but smoker and enters hte air • Regular exposure increases risk of lung disease by 25% and heart disease by 10% • Aggravates symptoms in people with allergies/asthma and general irritation in normal ppl • Linked with chronic bronchitis + asthma among ex and non smokers • Linked with hypertension among exsmokers • Infants more likely to suffer sudden infant death syndrome, resp illness, lung problems, middle ear infection, food allergies • Yukon was lest territory to institute ban on smoking in public places • Ontario has extended law to places like not smoking in cars with passenger under 16 Marijuana: • Dried and crushed leaves and flowering tops of hemp plant, cannabis sativa • Hashish = much stronger than mj and is produced by removing and drying the resin exudates of the top of high-quality cannabis plants • Can be smoked, chewed, prepared as tea, or eaten in baked goods • There is a UN treaty prohibiting sale of mj • In 2003, Canada moved towards decriminalizing small amounts (up to 15g) but Stephen Harper put an end to that. Decriminalization is very unlikely in future due to negative health risks. • Effects: sociable, relaxed, bloodshot itchy eyes, dry mouth + throat, increased eppetite, reduced pressure in eye, raised bp (no evidence of effects on heart), impairs lung fxn, coughing, wheezing, bronchitis, injury to airway tissue, impairs immune system • Large dose effects: rapid mood shifts, dull attention, fragment thoughts, impair memory, time moves slower, hallucinations similar to LSD that induce panic. o Concurrent mj and tobacco smoking significantly increases risk of resp symptoms and chronic obstructive pulmonary disease COPD (among those who’ve smoked at least 50 joints in a lifetime) o Same carcinogens as tobacco but more experienced since inhale deeper o 1 mj cig = 4 tobacco cigs in terms of tar, 5 in terms of CO, 10 for damage to airway cells • Dosage can be difficult to regulate since 30mins until effects appear • People with psych problems at greater risk of negative rxns (find lack of control frightening) • Major active chemical = THC = delta-9-tetrahydrocannabinol • Mj is generally becoming more potent (THC content 2-3 times higher than few decades ago) • Cannabis receptors: body makes own cannabis-like substance anandamide (Sanskrit for “bliss”) • Avg decline of 4.1 IQ points but only among heavy smokers (5 joints/day) • Impairments in encoding, storage, manipulation, retrieval in long-term/heavy smokers o Chronic use contributes to mild impairments, not severe • In 2004, largest pot bust in N. Am in Barrie, Ontario • Stepping stone theory  gateway theory that alcohol is a gateway drug for cannabis  amphetamines  cocaine • Mj use among adolescents has increased dramatically since early 1990s (doubled) • Canada is a high-use country • 50% of students admit to using mj at least once • Siginificantly higher use among males, peaking at 18-19 y.o • 40% of mj users do not go onto other drugs but they are more likely to experiment • Best predictor of cocaine use in adulthood is heavy use of mj during teens • Some think a network theory is more appropriate since not all move onto other drugs and not always in that order but there is still some link • Daily users more likely to use other drugs and suffer from anxiety disorder • 4/5s of those seeking treatment were single males • Being high on mj also impairs skills needed for driving. Effects persist for 8 hours after person believes no longer high. • Cannabinoid receptors in the hippocampus account for the short term mem loss • Tolerance threshold = 100-199 uses for mj in males and only 50-99 for females o Timing also matters: using after 17 = less likely to have marijuana disorder and using before 14 = more likely • Tolerance is strange for mj: experienced smokers need less puffs o Reverse tolerance = opposite of regular tolerance. THC is rapidly metabolized and stored in body’s fat and released slowly over a month • First legal grow-op in Canada = in Flin Flon, Manitoba called Rock Garden • Mj’s therapeutic effects = reduces nausea + loss of appetite that accompany chemotherapy o Reduces nausea where other anti-nausea agents fail o Mj also treats the discomfort of AIDS as well as glaucoma, epilepsy, and MS o People can apply for govn’t exemption from mj ban if they’ve used other means that haven’t worked. (2% are currently using mj for med reasons in Canada) Sedatives: • Harrison Narcotics Act in 1914 was when drugs were officially criminalized • ~ called downers, slow body’s activities, responsiveness • Sedatives include opium and its derivitives as well as synthetic barbiturates + tranquilizers Opiates: • Relieve pain, induce sleep • Opium = Principal drug of illegal international trafficking • Been around since Sumerian civilization 7000 BC, “plant of joy” • The alkaloid morphine, named after Morpheus = greek god of dreams = o Bitter powder separated from raw opium that is a powerful sedative + pain reliever o Used in a hypodermic needle to inject into veins to reduce pain o Before addictive properties noticed, it was used in common patent medicine • It was later realized that morhine can be converted to heroin o Originally used as cure for morphine addiction before it was realized to be addictive too o Called GOM God’s Own Medicine o Also used in patent medicine including a children’s soothing syrup o The brain converts heroin into morphine and binds to opioid receptors • Effects of opiates in general = euphoria, drowsiness, lack of coordination, no worries or fears, self-confidence + an initial rush (warm, suffusing ecstasy) o Opiod receptors produce opiods called endorphins and enkephalins o After 4-6 hours, there is a letdown period of stupor • Withdrawal = muscle pain, sneezing, sweating, tearful eyes, yawning (similar to influenza) o Symptoms become more severe within 36 hrs, persist for 72 hrs and diminish over week o = uncontrollable muscle twitching, cramps, alternating chills and flushing, rise in heart rate and bp, insomnia, vomiting, diarrhea. • More than a million heroin addicts in USA • Dependence highest among physicians,nurses than any other group with comparable education o Availability of opiates in med settings + high job stress o Used to be confined to poor neighborhoods and inner city but now more common among middle, upper middle class college students + young professionals o Now vies with cocaine for most popular drug among these groups • Canada = 1% lifetime prevalence of heroin use • Heroin + cocaine quite prevalent among street use • Vancouver = first in terms of per capita heroin + cocaine hospital visits/deaths • 8.7% of university students have used illicit drugs in general o Use of hallucinogens is declining though • In America, rate of new heroin users is increasing steadily • More drug casualties due to increased purity (from 5% pure  25-50%) • Some spend upwards of $200/day on opiates Synthetic Sedatives: • Barbiturates = major type of sedative that were synthesized for sleeping aids/relaxation • 1903 = when they were first produced • Since then many derivaties of barbituric acid • As the addictive properties where noticed, physicians prescribed it less • Today benzodiazepenes like Valium are more common • Methaqualone (Quaalude and Sopor) = popular street drug (similar effects to barbituarates • Effects: relax muscles, reduce anxiety, euphoric state • Excessive doss: slurred speech, unsteady gait, impaired judgement, concentration, loses emotional control, irritable, may fall into a deep sleep o Very large doses = brain damage, personality damage, and fatal bc diaphragm muscles relax so much that you suffocate o Sedatives frequently chosen as a means of suicide, esp with alcohol  Alcohol magnifies the depressant effects of sedatives • Withdrawal = delirium + convulsions similar to DTs from alcohol Stimulants: • ~ = uppers , such as cocaine • Act on brain and Sympathetic NS to increase alertness + motor activity Amphetamines (i.e. speed): • Originally found when pharmacologist Chen was studying ancient Chinese drug descriptions for an asthma treatment. • Desert shrub = mahuang, genus Ephedra. From this, isolated an alkaloid, ephedrine which was successful in treating asthma o Synthetic substitute of this = amphetamines • First amphetamine = Benzedrine , was available commercially as an inhalant to relieve stuffy noses. Was sometimes prescribed for mild depression/for diet drugs • Soldiers were supplied with them to ward off fatigue • Sometimes used to treat hyperactive children • Others = Dexedrine, Methedrine (methedrine = strongest) • Produce their effect by releasing norepinephrine and dopamine • Effects = more wakeful, inhibits intestinal functions, decreases appetite, higher heart rate, blood vessels in skin + mucous membranes constrict, euphoria, more outgoing, energetic, confidence • Larger doses: nervous, confused, palpitations, headaches, dizziness, sleepiness, suspicious, hostile, can even induce paranoid schizophrenia (delusions) • Tolerance develops rapidly • Speed freaks = give themselves rapid injections to maintain the intense euphoric activity for a few days and then crash for a few days and repeat • its use in workplace has been increasing o expression of “do more with less” in 1990s for workers, so they turned to speed Caffeine: • A less risky stimulant • World’s most popular drug • Two cups of coffee = between 150-300mg of caffeine. • effects occur within 30mins = higher metabolism, body temp, blood pressure, urine production, hand tremors, appetite diminishes, more alert o can exacerbate panic disorder o heightened arousal of sympathetic NS • extremely large does = headaches, diarrhea, nervousness, severe agitation, convulsions, death (but death is virtually impossible unless you grossly overuse caffeine tablets since the drug is excreted by kidneys without much accumulation) • people who drink just 2 reg cups of coffe/day can suffer from significant headaches, fatigue, anxiety if caffeine is withdrawn Cocaine: • Natural stimulant extracted from coca leaf, first used by natives of the Andean uplands • Introduced it to Spanish conquistadors • Alkaloid cocaine extracted from leaves of coca plant in mid-1800s. used as a local anaesthetic • Freud used it to combat depression and even prescribed it to a friend but later lost enthusiasm for the drug when he nursed a friend through a psychotic state brought upon by it • Sherlock holmes, Lady Gaga also used cocaine • Effects = reduces pain, acts rapidly on brain to block dopamine reuptake in mesolimbic areas (pleasurable state), increases sexual desire, self-confidence, is a vasoconstrictor (constricts blood vessels) • Overdose = chills, nausea, disturbances in eating and sleeping, paranoid breakdown (hallucinations of insects crawling beneath skin), personality changes, heightened irritability, impaired social skills, paranoid thinking • increasing risk for stroke, cog impairments like memory and attention difficulty • Has severe withdrawal • Developing fetuses exposed to it will be born addicted and can compromise blood supply for it • In mid 1980s, a new form of freebase, called crack appeared (increased amount of drug usage because was relatively inexpensive) • Cocaine use soared significantly during 1970s and 1980s by 260% • Crack = most dangerous illicit drug in society today Hallucinogens: • 1943, Albert Hoffman manufactured d-lysergic acid diethylamide = LSD • Referred to as a psychotomimetic bc produces effects similar to psychosis • “psychedelic” = Greek words for “soul” and “to make manifest” = term was used to emphasize the subjectivity of experienced expansions of consciousness • The experience is often called a trip • 4 other imp hallucinogens = o Mescaline = alkaloid = active ingredient of peyote cactus from isolating small disc-like growths  Used in religious rites of Natives o Psilocybin = crystalline powder that Hoffman isolated from the mushroom Psilocybe Mexicana (Aztec + Mexicans called the sacred shroom God’s Flesh) (i.e. the “magic” ingredient in magic mushroom)  was also once used to treat OCD and was actually successful o Each of these substances stimulates serotonin receptors o The other 2 are the synthetic compounds, jointly referred to as ecstasy:  MDA: methylenedioxyamphetamine • First synthesized in 1910 but properties not noticed till 1960s  MDMA:methylenedioxymethamphetamine  these are similar to mescaline and is also the psychoactive agent in nutmeg  ecstasy is called a designer drug bc synthesized  4.1% of Canadians have used ecstasy in lifetime • Timothy Leary + Richard Alpert of Harvard gave prisoners psilocybin as an experiment. Found they were less likely to be rearrested. Started taking some themselves, they were later fired. • manufacture of LSD and extraction of mescaline + psilocybin were relatively easy, inexpensive • no evidence of withdrawal but tolerance develops quickly • substantial decreases in deression found when given ketamine (another psychedelic drug) • effects of ecstasy: enhances intimacy, insight, improves interpersonal relationships, elevates mood, promotes aesthetic awareness, muscle tension, rapid eye movement, higher heart rate and bp, nausea, faintness, chills/sweating, anxiety, depression, confusion • lasting side effects: paranoia, confusion, memory complaints, permanent nerve damage • accidental OD with hypothermia being leading cause of death • person’s set = attitudes, expectations, motivations with regard to taking drugs o important determinant of rxn to hallucinogens o setting is also important • there is a danger of experiencing a bad trip (full blown panic attack (specific fear = of going crazy), usually short lived and subsides as drug metabolizes but: o a minority of people go into a psychotic state and require hospitalization • flashbacks = recurrence of psychedelic experiences which can still have physio effects long after (even weeks or months!) drug has worn off. o can occur in times of stress, illness, fatigue o not believed to be caused by drug-produced physical changes in nervous system bc only 15-30% of users ever have flashbacks Etiology of Substance Abuse: • generally a developmental process • the person must first have a positive attitude towards the substance -> begin to experiment with using it -> begin using it regularly -> heavy usage -> abuse or become heavily dependent on the drug • general idea = the person becomes ensnared by the biological processes of tolerance and withdrawal after engaging in prolonged, heavy use • the physical signs of withdrawal do not motivate substance misuse, but two elements do seem to play a role o the intense negative effects caused by withdrawal o urges • researchers are just beginning to consider the stages of the process separately o variables that cause substance dependence appear to depend on the stage being considered • recent data suggests that compared with adolescents with low exposure, those with high exposure to smoking in movies are three times more likely to try smoking or become smokers o the effect is strong among those who would otherwise be at low risk due to not having parents who smoke or who are low in sensation seeking o effect is strong enough the researchers have advocated that the movies involving smoking = automatically rated R • developmental model does not account for all cases of substance abuse or dependence o example: documented cases in which heavy use of tobacco or heroin did not end in addiction o progression through the stages is not inevitable o some people have periods of heavy use of a substance and then return to moderate use Social Variables: • socio-cultural variables can play a widely varying role in drug abuse o can affect people’s interest in and access to drugs • the highest alcohol consumption rates have typically been found in wine-drinking countries (France, Spain, Italy) where drinking alcohol regularly is widely accepted • cultural attitudes and patterns of drinking thus influence the likelihood of drinking heavily and therefore abusing alcohol • ready availability of the substance is also a factor • rates of alcohol abuse are also high among bartenders and liquor store owners, people for whom alcohol is readily available • as for smoking, rates of smoking increase if cigarettes are perceived as being easy to get and affordable • family variables are also important socio-cultural influences o if both parents smoke, a child is 4 times more likely to do so than if no other family member smokes o similarly, exposure to alcohol use by parents increases children’s likelihood of drinking as well • Canadian youth show that a host of chronic disease behavioural risk factors are more prevalent among those who have caregivers who smoke and peers who smoke and drink; protective factors were having self-esteem and coming from a home with a member with post-secondary education • A lack of emotional support from parents is also linked with increased use of cigarettes, cannabis and alcohol • a lack of parental monitoring leads to increased association with drug-abusing peers and subsequent use of drugs • the social milieu in which a person operates can also affect substance abuse o having friends who smoke predicts smoking o tobacco use among high school students is highest in certain subgroups: those with poor grades, behaviour problems, and a taste for heavy metal music • peer influences are also important in promoting alcohol and marijuana use o although peer influences is important, those who have a high self-efficacy are influenced less by their peers • the role of the media must also be considered – we are bombarded with TV commercials in which beer is associated with athletic-looking males, bikini-clad women and good times o supporting the role of advertising in promoting alcohol use is an analysis of consumption in 17 countries between 1970 and 1983  those countries that banned ads for spirits had 16% less consumption than those that did not • additional evidence also indicates that advertising does influence smoking o in a longitudinal study of non-smoking adolescents, those who had a favorite cigarette ad were twice as likely subsequently to begin smoking or to be willing to do so Psychological Variables: • mood alteration, situations, and the role of cognition o one team of Canadian investigators proposed that it is possible to approach this issue from a cost vs. benefit perspective  example: drinking occurs if the perceived benefits outweigh the costs  suggested that drinking motives vary along two dimensions: the valence of reinforcement (positive vs. negative) and locus (external reasons vs. internal, personal reasons) • (1) people can drink to obtain pleasurable outcomes or avoid negative outcomes • (2) they can drink in response to external, social stimulation or in response to external, social stimulation, or in response to internal, personal cues • (3) drinking for positive, internal reasons reflects drinking to enhance positive mood o measured by the enhancement scale o assessed via the social scale • (4) drinking for negative, internal reasons reflects drinking to reduce or avoid experiencing negative emotions o reflected by the coping scale o assessed via the conformity scale • extensive research on these 4 motives o concluded that young people drink primarily for social motives o less likely to drink for enhancement and there are even less likely to drink due to coping motives o social motives are associated with moderate alcohol use, while enhancement motives are more likely to be associated with heavy drinking o Dalhousie University study found that coping-anxiety motives moderated the link between daily anxious mood and alcohol consumption -> coping depression motives moderated the link between daily depressed mood and alcohol consumption  Problem drinking attaches great importance to drinking in order to cope  Some people will drink for multiple motives and there is surprisingly little research on these people • Cognitive Factors in Drinking o Many ways that cognitive factors may operate in drinking – reducing tension, for example o Alcohol may produce its tension-reducing effect by altering cognition and perception o Alcohol impairs cognitive processing and narrows attention to the most immediately available cues, resulting in what Steele and Josephs term ‘alcohol myopia” - the intoxicated person has less negative capacity to distribute activity o Extensive research has been conducted on the role of positive vs. negative cognitive expectations in drinking behaviour  Positive alcohol expectations predict higher levels of consumption and alcohol expectations predict higher levels of consumption tend to inhibit consumption  The belief that alcohol helps one cope with stress is one of several positive beliefs  Positive expectations are stronger predictors of drinking behaviour than negative ones o Several factors may be involved in the development of alcohol expectations, including direct personal experiences and more indirect, vicarious influences that involve the imitation and internalization of parental beliefs and beliefs displayed in the media o The expectation that drinking will reduce anxiety increases drinking, which in turn makes the positive expectations even stronger o Explicit cognition reflects controlled thought process that can be deliberated upon, while implicit cognition involves autonomic appraisal of cues that is more uncontrolled and perhaps not subject to conscious awareness o As an addiction develops, the automatic processing component gains strength and fosters an impulsive orientation that is reflected in cognitive tendencies o Much of the empirical basis of the implicit component of the dual-process model came from research using the Drug Stroop Task  A stroop task typically requires an individual to say whether a word matches a particular colour and ignore the actual content of the word  The Drug Stroop Effect is the tendency of addiction prone people to respond slower when colour-identifying a word that reflects addition o Cognitive processes and negative affect may be linked inextricably in some drinkers  Studies indicate that negative affective cues in the environment seem to activate alcohol-related concepts in problem drinkers with high levels of psychological distress  It seems that an orientation toward negative affect moods has cognitive implications for certain alcohol abusers • Beliefs About Prevalence and Risks o Marijuana use peaked in 1978, when almost 11% of high school seniors reported daily use • Personality and Drug Use o Personality variables attempt to explain why certain people are drawn to substance o Personality variables are stable individual differences that can be detected early in childhood and are believed to be relatively stable across the lifespan  Theoretical and empirical attempts to link personality factors with various form of substance abuse have focused on a class of personality variables involved in behavioural disinhibiton  High sensations seekers are thrill-seekers who enjoy heightened levels of arousal -> one way to increase arousal is to ingest certain drugs o Hans Eysenk – 3 factor model of personality  Believed that the 3 key dimensions of personality were extroversion- introversion, neuroticism vs. emotional stability, and psychoticism • According to this model, substance use and abuse are likely among individuals characterized by high levels of neuroticism and psychoticism o Drug abuse may be part thrill-seeking behaviour of the psychopath  Alcohol use is comorbid with several personality disorder for men and borderline personality disorder for women o When personality factors are identified as contributors to substance abuse, they tend to be regarded as distal factors that are less important that more proximal predic
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