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Chapter 123390

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PSYC 3390
Mary Manson

PSYC*3390 Chapter 12: Addiction Disorders Key Terms:  Addictive behaviour: behaviour based on the pathological need for substance or activity; it may involve the abuse of substances, such as nicotine, alcohol, or cocaine, or gambling (etc)  Psychoactive drugs: drugs that affect mental functioning  Toxicity: poisonous nature of a substance  Substance abuse: maladaptive patterns of substance use manifested by recurrent and significant adverse consequences related to the use of the substance  Substance dependence: severe form of substance-use disorder involving physiological dependence on the substance, tolerance, withdrawal, and compulsive drug taking  Tolerance: need for increased amounts of a substance to achieve the desired effects  Withdrawal symptoms: physical symptoms such as sweating, tremors, and tension that accompany abstinence from some drugs  Alcoholism: dependence on alcohol that seriously interferes with life adjustment  Mesocorticolimbic dopamine pathway (MCLP): centre of psychoactive drug activation in the brain. This area is involved in the release of dopamine and in mediating the rewarding properties of drugs  Addictive behaviour is one of the most pervasive and intransigent mental health problems in today’s society  The most commonly abused substances are those that affect mental functioning or psychoactive drugs: alcohol, nicotine, barbiturates, tranquilizers, amphetamines, heroin, ecstasy, and marijuana  For diagnostic purposes, addiction/substance-use disorders are divided into two major categories: organic impairment and substance-induced organic mental disorders and syndromes  Organic impairments results from the prolonged and excessive ingestion of psychoactive substance – ex. an alcohol-abuse dementia disorder involving amnesia, formerly called Korsakoff’s syndrome  Substance-induced organic mental disorders and syndromes stem from toxicity, the poisonous nature of the substance (example: amphetamine delusional disorder, alcoholic intoxication, or cannabis delirium) or from physiological changes in the brain due to vitamin deficiency  The majority fall into the second category, which focuses on the maladaptive behaviours resulting from regulate and consistence use of a substance  The system of classification for substance-abuse disorders (followed both by the DSM-IV and the ICD-10) provides two major categories: substance-dependence disorders and substance-abuse disorders  Substance abuse generally involves a pathological use of substance resulting in (1) potentially hazardous behaviour, such as driving while intoxicated, or (2) continued use despite a persistent social, psychological, occupational, or health problem  Substance dependence includes more severe forms and usually involved a marked physiological need for increasing amounts of a substance to achieve desired effects  Dependence in these disorders means that an individual will show a tolerance for a drug and/or experience withdrawal symptoms when this drug is unavailable  Tolerance, the need for increased amounts of a substance to produce a desired effect, results from biochemical changes in the body that affect the rate of metabolism and elimination of the substance from the body  Withdrawal symptoms are physical symptoms such as sweating, tremors, and tension that accompany abstinence from the drug DSM-IV-TR: Criteria for substance-dependence and substance-abuse disorders Substance-Dependence Disorder  a maladaptive pattern of substance use leading to clinically significant distress or impairment, as manifested by at least three of the following occurring at any time in the same 12-month period: o A) tolerance as defined by either a need for increased amounts of the substance to achieve intoxication or desired effect, or diminished effect with continued use of the same substance o B) withdrawal as manifested by either the characteristic withdrawal syndrome for the substance, or same or closely related substance is taken to relieve or avoid withdrawal symptoms o C) Substance is often taken in larger amounts or over a longer period of time then was intended o D) persistent desire or unsuccessful effort to cut down or control substance use o E) the person spends a great deal of time engaging in the activities necessary to obtain the substance, use the substance, or recover from its effects o F) the person has given up or reduced the amount of important social, occupational, or recreational activities because of substance abuse o G) continued substance use despite persistent or recurrent physical or psychological problem caused or exacerbated by the substance Substance-Abuse Disorder  A) a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by at least one of the following occurring within a 12 month period: o 1. Recurrent substance use that results in a failure to fulfill some major role obligations at work, school, or home o 2. Recurrent substance use in situations in which it is physically hazardous (e.g. driving) o 3. Recurrent substance-related legal problems (e.g. arrested for disorderly conduct) o 4. Continued substance use despite persistent or recurrent social or interpersonal problems cause or exacerbated by the effects of the substance  B. Person has never had symptoms or problems that have met the criteria for Substance Dependence for this class of the substance Alcohol abuse and dependence  The World Health Organization no longer recommends the term alcoholism but rather the term alcohol dependence syndrome – “a state, psychic and usually also physical, resulting from taking alcohol, characterized by behavioural and other responses that always include a compulsion to take alcohol on a continuous or periodic basis in order to experience its psychic effects and sometimes to avoid the discomfort of its absence”  Beer was first made in Egypt in 3000 B.C.E  In 800 C.E. Arabian alchemist developed the process of distillation, making the range and potency of alcoholic beverages greater  Excessive use of alcohol has been documented since its first discovery The prevalence, comorbidity, and demographics of alcohol abuse and dependence  Alcohol abuse and dependence are a major problem in the Western world and one of the most destructive of the psychiatric disorder  Lifetime prevalence of alcohol dependence about 12 percent in Canada (according to Canadian community survey)  Alcohol is the leading cause of young people  In 1995 over 6500 Canadians lost their lives as a result of alcohol consumption, with motor vehicle accidents, liver cirrhosis, and suicide being the leading causes of death  Approximately 40% of teens that die in car accidents have alcohol in their system  Plays a role in about 27% of male suicides and 17% of female suicides in Canada  Increases risk of intimate partner violence  Alcohol significantly impairs performance on cognitive tasks, especially as they become more difficult  Organic brain shrinkage also occurs frequently in those with alcohol dependence, esp. Among binge drinkers – people who abuse alcohol followed by periods of sobriety  37% of alcohol abusers suffer from at least one coexisting mental disorder – with depression ranking high among them  28.6% of those with an alcohol-use disorder have at least one personality disorder  Alcohol is associated with about 40-50% of murders, 40% of all assaults, and over 50% of all rapes  Alcohol is involved in more violent and nonviolent crimes than any other drug  Alcohol abuse and dependence cuts across all age, educational, occupational, and socioeconomic boundaries  Binge drinking remains widespread on university campuses – counts as five or more drinks one night for men and four or more drinks for women on one occasion during the preceding two weeks – reported by 30% of Canadian university students  Most problem drinkers – those who experience life problems as a result of alcohol – are men at a frequency of five times greater than women  Marriage, higher education, and being older are associated with lower incidence of alcoholism  There are varying rates of the disorder across different cultures  The course of alcohol abuse and dependence can vary and often people go through long periods of abstinence only to start drinking again The clinical picture of alcohol dependence  Causes decreases sexual inhibition but also decreased sexual performance  Blackouts – can be caused by high blood alcohol level but also a heavy drinker can blackout even after moderate drinking  Causes hangover including nausea, headache and fatigue  Effects on the brain o Has complex and seemingly contradictory effects on the brain o At lower levels, stimulates certain brain cells and activates the brain’s pleasure areas which release endogenous opioids that are stored in the body o At high levels, it depresses brain functioning, inhibiting the excitatory neurotransmitter glutamate, which slows down activity in different parts of the brain o Impairs the ability to learn, as well as higher brain centers important for judgment, rational processes, and self-control o Restraint declines, may indulge in impulses in impulses that are normally in check o Some motor impairment, and drinker’s discrimination and perception of cold, pain and discomforts are dulled o Typically feel warmth, expansiveness, and well-being o Unpleasant realities are screened out and drinker’s feeling of self-esteem and adequacy rise o In most states, a person is considered intoxicated at .08% blood alcohol and cannot drive (different in Canada) – muscular coordination, speech, vision, and thought processes are impaired o When the blood alcohol reaches .5%, the entire neural balance is upset and the individual passes out (differs among individuals)  Becoming unconscious acts as a safety device because levels of .55% is usually lethal o Blood alcohol differs based on physical condition, amount of food in the stomach, and the duration of their drinking o Tolerance can be gradually built up so that more and more alcohol is need to produce the desired effects o Women metabolize alcohol less effectively and thus become intoxicated on lesser amounts of alcohol  Development of alcohol dependence o Usually progresses from early, to middle, to late-stage alcohol-abuse disorder o some researchers believe that moderate amounts are not harmful o however, any alcohol for pregnant women is considered to be dangerous o fetal alcohol syndrome  heavy drinking of expectant mothers can affect the health of unborn babies, particularly binge drinking and heavy drinking in the early days of pregnancy  newborn infants of mothers who drank heavily have physical and behavioural abnormalities, including aggressiveness and destructiveness, and many experience alcohol withdrawal  they also show growth deficiencies, facial and limb irregularities, damage to the central nervous system, and impairment in cognitive functioning  alcohol abuse is the third leading cause of birth defects (the first two being Down syndrome and spina bifida)  research gathered worldwide suggests fetal alcohol syndrome affects 1 in 100 babies  although the amount to be considered dangerous is not known, strongest symptoms are associated with binge and heavy drinking compared to light and moderate drinking  it is still highly recommended that pregnant women abstain from drinking alcohol until safe amount is determined  the physical effects of chronic use o alcohol must be assimilated by the body, except for about 5-10% that is eliminated through breath, urine, and perspiration o the assimilation work is done by the liver and when large amounts are ingested, the liver can get overworked and suffer irreversible damage o 15 to 30% of heavy drinkers develop cirrhosis of the liver, a disorder that involves extensive stiffening of blood vessles o About 40 to 90% of the 26,000 annual cirrhosis deaths every year are alcohol related o A high calorie drug: a pint of whiskey is the equivalent of about 8 to 10 ordinary cocktail, about 1200 calories, the ordinary calorie intake for a day o Because it does not contain any nutritional value, the excessive drinker can suffer malnutrition o Also decreases the body’s ability to utilize nutrients, therefore popping vitamins won’t help o Also has gastrointestinal effects that can cause stomach pains  Psychosocial effects of alcohol abuse and dependence o Chronic users suffer fatigue, oversensitivity, and depression o Eventually results in impaired reasoning, poor judgment, and gradual personality deterioration o Behaviour becomes coarse and inappropriate, and drinker becomes less responsible, loses pride in personal appearance, neglects spouse and family, and becomes to touch, irritable and unwilling to discuss the problem o May result in job loss and marital breakup o By the time general health is deteriorated, brain and liver damage may have occurred  Psychoses associated with severe alcohol abuse o Acute reactions including confusion, excitement, and delirium o Some evidence that delirium may be associated with low levels of thiamine in alcoholics o Called “alcoholic psychosis” because they are marked with a temporary loss of contact with reality o For those that have drank heavily for a long time, there is “alcohol withdrawal delirium” – occurs after a prolonged drinking spree, slight noises and movements can cause excitement or agitation  Full blown symptoms include 1) disorientation for time and place in which, ex., a person may mistake the hospital for a church or jail, no longer recognize friends, think nurses are old friends  2) vivid hallucinations, usually of small fast moving animals  3)acute fear, in which animals may change form, size or colour in terrifying ways  4) extreme suggestibility, can see an animal if it is merely suggested  5) marked tremors of the hands, tongue and lips  6) other symptoms including perspiration, fever, a rapid and weak heartbeat, a coated tongue and foul breath  Usually lasts 3-5 days followed by a deep sleep  Individual may not drink again for weeks or months but usually drinking resumes  Death rate during this used to be 10% but drugs like chlordiazepoxide have markedly reduced this o “alcohol amnestic disorder” (formally known as Korsakoff’s syndrome)  Memory defect, usually in regards to recent events, sometimes accompanied by falsification of events (confabulation)  May not recognize picture, faces, or rooms they have just seen and fill gaps with their own information  Individuals appear delirious, delusional, and disoriented for time and place but usually about their attempt to fill in memory gaps  Unable to form new associations to make new memories retrievable  Occurs in older excessive drinkers  Also includes impairments in judgment, planning, intellectual decline, and emotional deficits  Have cortical lesions  Caused by vitamine B (thiamine) and other vitamin deficiencies  See case study on p. 425 Biological factors in the abuse and dependence of alcohol and other substances  So why do people become addicted? First main reason is the ability of addictive drugs to activate areas of the brain that produce intrinsic pleasures and sometimes immediate, powerful reward. Second is a person’s biological make-up, including genetic and environmental factors that increase the need to seek mind-altering substances to an increasing degree as use continues  The neurobiology of addiction o Alcohol is usually ingested orally, the slowest route, whereas cocaine is done intravenously or nasally o The mesocorticolimbic dopamine pathway (MCLP) is the centre of psychoactive drug activation in the brain. Made of axons in the middle portion of the brain known as ventral tegmental area and connects to the nucleus accumbens and the prefrontal cortex  this area is involved in the control of emotions, memory, and gratification  alcohol produces euphoria by stimulating this part of the brain o McGill researchers the first to demonstrate that alcohol promotes dopamine release in the brain, specifically in the nucleus accumbens – may directly do this or indirectly by decreasing GABA neurons which inhibit dopamine neurons  Genetic vulnerability o Many experts believe that genetics probably plays a role in developing sensitivity to the addictive power of drugs like alcohol o Long term analysis have found that one-third of alcoholics had at least one parent with an alcohol problem (39 studies following over 6000 alcoholics and 4000 nonalcoholics for over 40 years) o Males: having one alcoholic parent increased rate of alcoholism by 12.4% to 29.5%, and having two increased to 41.2% o For females, no parents with it was 5%, but one increased to 9.5% and two it increases to 25% o Sons of alcoholics at high risk because of inherent motivation to drink or sensitivity to the drug o Adoptive studies have found that children of biological alcoholics but non-alcoholic foster parents were twice as likely to develop alcoholism in their 20s than the control group o Another study found that adopted (biological parents with alcoholism) 17% developed it, and those raised by their alcoholic parents, 25% developed it o Asian and Inuit people show hypersensitive reaction including flushing of the skin, a drop in blood pressure, heart palpitations, and nausea following ingestion  Found in about half of Asians because they have a mutant enzyme that fails to break down alcohol molecules in the liver during the metabolic process o Genetics is not the full picture as much of the evidence is ambiguous and there is caution about its use as a causal factor o Studies of high risk subjects (i.e. males of alcoholics in the 20s) have not found their psychopathology to be much different than controls from the general population o Much evidence points to the importance of gene-environment interactions in the development of substance abuse disorders  Genetic influences and learning o Almost everyone on Western countries is exposed to alcohol to some extent, mostly through peer pressure, parental example or advertising o There are numerous positive reinforcements for using alcohol in our social environments and everyday lives Psychosocial causal factors in alcohol abuse and dependence  Alcoholics become physiologically dependent on alcohol to enjoy social situations  Failures in parental guidance o Stability is often lacking in families of substances abusers o Parent substance abuse is associated with early adolescent substance use o Negative parental models can have long-range effects once child leaves the household o Alcohol-abusing parents are less likely to keep track of their children, and lack of monitoring leads to affiliation with drug using peers o The stress and negative affect prevalent in families with an alcoholic parent also contributes to this – increases amount of negative uncontrollable life events o Women who have a history of child sexual abuse are at risk for developing a wide range of psychological problems including substance abuse  Psychological vulnerability o Many potential alcohol abusers tend to be emotionally immature, expect a great deal of the world, require an inordinate amount of praise and appreciation, react to failure with marked feelings of hurt and inferiority, have low frustration tolerance, and feel inadequate and unsure of their abilities to fulfill expected male or female roles o Also are significantly more impulsive and aggressive o About half of persons with schizophrenia have alcohol or drug abuse or dependence o Studies have found a 75 to 80% association of substance abuse with antisocial personality disorder o In a survey of 8 alcohol treatment programs, 57.9% had a personality disorder and 22.7% met criteria for antisocial personality disorder o Degree of association between depression and alcohol-abuse problems are stronger among women o Treatment options need to be weighed differently for comorbid disorders  Stress, tension reduction, and reinforcement o High association between alcohol consumption and negative affectivity such as anxiety and somatic complaints – drink to relax o Tension-reduction hypothesis is the idea that anyone who finds alcohol to be tension- reducing is in danger of becoming an alcoholic o 24-80% of alcohol abusing women have a history of sexual abuse – linking trauma with alcohol o Similar findings between trauma and alcoholism in veterans o Difficult to accept this as sole explanatory hypothesis – would be way more common because alcohol does tend to reduce tension in most people who use it o Also doesn’t explain why some are able to control their excessive drinking and function in society  Expectations of social success o Many young people expect that alcohol will lower tension and anxiety, and increase sexual desire and pleasure in life o Adolescents begin drinking because of the expectations that alcohol will increase their popularity and acceptance of peers o Researchers suggest that prevention efforts should be targeted at children before they start to drink so that the positive feedback cycle between expectancy and drinking is never established o Time and experience are moderating variables for alcohol expectancies (moderating variable influences the association between two variables)  Marital and other intimate relationships o Adults with less intimate and supportive relationships tend to show greater drinking following sadness and hostility compared to those in supportive relationships o Usually begin after crises that lead to hurt and self-devaluation o A spouse’s behaviour can influence this.. i.e. a man with a drinking wife will start making decisions based on assuming his wife will be drinking, making it easier to drink o Excessive use of alcohol is a common cause of divorce and is often a hidden factor in the tw
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