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Chapter Eleven - Substance-Related Disorders.docx

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David Moscovitch

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[ ELEVEN ] – SUBSTANCE-RELATED DISORDERS Substance-related disorders = abuse of drugs ppl take to alter the way they think, feel, and behave Polysubstance use = using multiple substances PERSPECTIVES ON SUBSTANCE-RELATED DISORDERS  Substance = chemical cmpds ingested in order to alter mood/beh’ Levels of Involvement  Substance use = ingestion of psychoactive substances in moderate amnts tht dN significantly interfere w/ soc/edu/occupational f’n’g i.e. drinking cup of coffee, smoking cigarette, marijuana, cocaine  Substance intoxication = physiological reac’n to ingested substances (i.e. drunkenness/getting high) - exp’d as impaired judgment, mood changes, lowered motor ability - criteria: person dvlps reversible substance-specific syndrome due to recent ingestion of (or exposure to) a substance  Substance abuse = maladaptive pattern of substance use leads to clinically significant impairment/distress as manifested by 1/more of these during same 12mth period: 1.) job/edu/rel’nshps disrupted; 2.) put in physically dangerous situations; 3.) have related legal problems; and/or 4.) cont’d substance use despite having persistent/recurrent soc/interpersonal problems caused/exacerbated by effects of substance (i.e. physical fights, arguments with spouse about consequences of intoxication)  Substance dependence = person is physiologically (d) on drug(s), req’s i↑’ly more of drug to exp’ same effect (tolerance), and will respond physically in –ve way when substance no longer ingested (withdrawal) - alcohol withdrawal delirium = aka delirium tremens (DTs); person can exp’ frightening hallucinations and body tremors - w/drawal from many substances can bring on chills, fever, diarrhea, nausea & vomiting - not all substances physiologically addicting i.e. dN go t/ severe physical w/drawal when you stop taking LSD/marijuana  Substance dependence = person is psychologically (d) on drug(s); measured by drug-seeking beh’s - repeated use of drug - desperate need to ingest more of substance (i.e. steal money to buy drugs) - likelihood tht use will resume after period of abstinence  According to standard psychiatric definition, any drug user who passes 3 of 9 tests is hooked: 1.) takes substance or does activity more than originally intended 2.) wants to cut back or has tried to cut back but failed 3.) spends lots of time trying to get/take substance, set up/do activity, or recovering 4.) often intoxicated or suffers w/drawal symptoms when expected to fulfill obligations at work/school/home 5.) curtails or give sup important soc/occupational/recreational activities b/c of substance/activity 6.) uses substance/does activity despite persistent soc/psych/phys problems caused by substance/activity 7.) needs more and more of substance/activity to achieve same effect (tolerance) 8.) suffers characteristic w/drawal symptoms when activity/substance is discont’d (cravings, anxiety, depression, jitters) 9.) takes substance/does activity to relieve/avoid w/drawal symptoms  Today’s commonly used drugs ranked by addictiveness: 1.) nicotine 2.) ice, glass (methamphetamine smoked) 3.) crack 4.) crystal meth (methamphetamine injected)  (d)ce can be present w/o abuse i.e. cancer patients who take morphine for pain Diagnostic Issues  Symptoms of other Ds can complicate substance abuse picture significantly i.e. do some ppl drink to excess b/c they are depressed, or do drinking and its consequences (loss of friends/job) create depression?  Researchers estimate more than ½ the ppl w/ alcohol Ds have additional psychiatric D, such as major depression, ASPD, bipolar D  Substance use might occur concurrently w/ other Ds b/c: i.) substance-related Ds and anxiety & mood Ds highly prevalent in society and may occur together so frequently just by chance ii.) drug intoxication and w/drawal can cause symptoms of anxiety, depression, and psychosis, and can i↑ risk taking iii.) mental health Ds cause substance use D  To define when symptom is result of substance abuse or not, basically, if symptoms seen before other psychological D, would diagnose w/ substance-related D, and if symptoms seen after other psychological D, would not diagnose w/ substance-related D  Indvdl substances: - depressants = result in beh’al sedation and can induce relaxation i.e. alcohol, sedatives, barbiturates, benzodiazepines - stimulants = cause us to be more active & alert and can elevate mood i.e. amphetamines, cocaine, nicotine, caffeine - opiates = major effect is to produce analgesia temporarily (reduce pain) and euphoria i.e. heroin, opium, codeine, morphine - hallucinogens = alter sensory perception and can produce delusions, paranoia, hallucinations i.e. marijuana, LSD - other drugs of abuse = other substances tht are abused but dN fit neatly into other categories i.e. inhalants (airplane glue), anabolic steroids, over-the-counter & prescription meds Pathological Gambling  Person displays persistent and recurrent maladaptive gambling beh’ as indicted by 5/more of following: 1.) preoccupied w/ gambling (i.e. reliving past gambling exp’s, handicapping/planning next venture, thinking of ways to get money w/ which to gamble) 2.) needs to gamble w/ i↑’g amnts of $ to achieve desired excitement 3.) has repeated unsuccessful efforts to ctrl/cut back/stop gambling 4.) restless/irritable when attempting to cut down/stop gambling 5.) gambles as way of escaping from problems/of relieving dysphoric mood (i.e. feelings of helplessness, guilt, anxiety, depression) 6.) after losing $ gambling, often returns another day to get even (chase loss) 7.) lies to family members/therapist/others to conceal extent of involvement w/ gambling 8.) has committed illegal acts such as forgery/fraud/theft/embezzlement to finance gambling 9.) has jeopardized/lost significant rel’nshp/job/edu or career opportunity b/c of gambling 10.) relies on others to provide $ to relieve desperate financial situation caused by gambling  Gambling beh’ not better acc’d for by manic episode DEPRESSANTS  1ly d↓ CNS activity—reduce levels of physiological arousal and help us relax  Most likely to produce symptoms of phys (d), tolerance, and w/drawal Alcohol Use Disorders  Criteria: a) recent ingestion of alcohol b) clinically significant maladaptive beh’/psych changes (i.e. inappropriate sexual/aggressive beh’, impaired judgment, impaired soc/occupational f’n’g) tht dvlp’d during/shortly after use c) 1/more of following sings, dvlp’g during/shortly after use: slurred speech, incoordination, unsteady gait, nystagmus (involuntary rapid and repetitive mvmt of eyes), impairment in attention/memory, stupor/coma  Initial effect: stimulant - inhibitions reduced, more outgoing  w/ cont’d drinking, alcohol depresses more areas of brain  impedes ability to f’n properly - motor coordination impaired, reac’n time slowed, become confused, judgment ability reduced  although alcohol makes us more outgoing, it makes it difficult for neurons to communicate w/ each other  alcohol influences a # of diff neuroreceptor sys’s: - blackouts—loss of memory for what happens during intoxication—may results from interaction w/ glutamate sys’ - serotonin sys’—affects mood, sleep, and eating beh’—sensitive and thought to be responsible for alcoholic cravings - effects on dopamine rewards sys: may be responsible for pleasurable feelings ppl exp’ when drinking - alcohol results in release of endogenous opioids—our bodies’ naturally occurring analgesics—which may explain why alcohol has pain-numbing effects  LT effects of heavy drinking often severe: - w/drawal from chronic alcohol use typically includes hand tremors, nausea/vomiting, anxiety, transient hallucinations, agitation, insomnia, DTs - liver disease - pancreatitis - cardiovascular Ds - brain damage (i.e. memory and ability to perform certain tasks may be impaired) - at worst: Wernicke’s disease—confusion, loss of musc coordination, and unintelligible speech—or dementia—general loss of intellectual abilities  Whether alcohol will cause organic damage depends on genetic vulnerability, frequency of use, length of drinking binges, blood-alcohol levels attained during drinking periods, and whether body given time to recover btwn binges  Fetal alcohol syndrome (FAS) = combo of problems tht can occur in child whose mother drank while pregnant, including fetal growth retardation, cognitive deficits, beh’ problems, learning difficulties, often have characteristics facial f/s Statistics on Use  M more likely than F to drink and also more likely to drink heavily - 16% of M classified as heavy drinkers - 4% of F classified as heavy drinkers  Drinking practices vary across societies i.e. higher proportion of CDN than USA students drink alcohol, but higher proportion of USA students are binge drinkers Statistics on Abuse and Dependence  Abt 9% of CDN drinkers exp’ some level of problem w/ alcohol, w/ abt 3% CDN adults thought to be alcohol (d) in any given year  Among general pop’n, young (18-29), single M most likely heavy drinkers and have alcohol use problems  Outside CAN, rates vary widely - lowest reported 1.2% in rural villages in Taiwan - highest reported 14.1% in USA  Low prevalence rates among Asian studies - cultural diff’s can be acc’d for by diff attitudes toward drinking, availability of alcohol, physiological reac’ns, family norms & patterns Progression  Many who abuse/are (d) on alcohol fluctuate btwn heavy & abstinent  20% w/ severe alcohol (d) have spontaneous remission and dN re-exp’ problems w/ drinking  Course of alcohol dependence may be progressive for most ppl, although course of alcohol abuse may be more variable i.e. early use may predict later abuse  Alcohol dN cause aggression BUT may reduce fear associated w/ being punished and may impair ability to consider consequences of acting impulsively  Ppl w/ poorer executive cognitive f’n (planning/organizing abilities) are more likely than others to behave aggressively when intoxicated  Alcohol intoxication can also i↑ risk of being victim of vio’ Sedative, Hypnotic, or Anxiolytic Substance Use Disorders  Sedative = calming  Hypnotic = sleep-inducing  Anxiolytic = anxiety-reducing  Barbiturates = family of sedative drugs prescribed to help ppl sleep i.e. Amytal, Seconal, Nembutal  Benzodiazepines = used 1ly to reduce anxiety i.e. Valium, Xanax, Rohypnol, Halcion  Rohypnol has same effect as alcohol w/o telltale odour - now nn’d ―date rate drug‖  At low doses, barbiturates relax musc and can produce mild feeling of well-being - large doses: ~ to heavy drinking—slurred speech and problems walking, concentrating & working - extremely high doses: diaphragm musc relax so much as to cause death by suffocation  hence, common means of suicide  At low doses, benzodiazepines used to calm indvdl and induce sleep, and prescribed as musc relaxants and anticonvulsants - nonmedical use: first feel pleasant high and reduction of inhibition, ~ to alcohol effects - cont’d use: tolerance and (d) can dvlp - try to stop: exp’ symptoms like those of alchol w/drawal  Criteria dN differ substantially from alcohol Ds  Like alcohol, affect brain by acting on GABA NT sys’ and aar, when ppl combine alcohol w/ any of these drugs, synergistic effects (total effects reach dangerous levels) Statistics  Barbiturate use d↓’d and benzodiazepine i↑’d since 1960  4% CDNS use benzodiazepines, w/ higher rates among women, elderly and smokers STIMULANTS  Most commonly used psychoactive drugs in CAN Amphetamine Use Disorders  At low doses, can induce feelings of elation & vigour, and can reduce fatigue - however after period of elevation, come back down and ―crash‖, feeling depressed/tired  Reduce appetite (TF) some ppl take to lose weight  Prescribed for ppl w/ narcolepsy (excessive sleeping), and sometimes children w/ ADD/ADHD (Ritalin)  DSM-IV-T criteria: - significant beh’al symptoms (i.e. euphoria/affective blunting) - changes in sociability, interpersonal sensitivity, anxiety, tension, anger, stereotyped beh’, impaired judgment, and impaired soc/occupational f’n’g - physiological symptoms occur during/shortly after ingestion, including HR/BP changes, perspiration/chills, nausea/vomiting, weight loss, musc weakness, respiratory depression, chest pain, seizures, or coma  Severe intoxication can cause hallucinations, panic, agitation, and paranoid delusions  Tolerance builds quickly, making it doubly dangerous  w/drawal often results in apathy—prolonged periods of sleep, irritability, and depression  MDMA/ecstasy = ―just like speed but w/o comedown, and you feel warm and trippy like acid, but w/o possibility of major freak-out‖; first used as appetite suppressant in Germany  Ice = purified crystallized form of amphetamine; ingested t/ smoking; causes marked aggressive tendencies and stays in sys longer than cocaine, making it particularly dangerous  Amphetamines stimulate CNS by enhancing activity of norepinephrine and dopamine - help release of these NT’s and block their reuptake, thereby making more of them available t/o sys  Too much amphetamines—and (TF) too much norepinephrine and dopamine—can lead to hallucinations and delusions Cocaine Use Disorders  Use and misuse of drugs wax & wane according to societal fashion, moods, and sanctions  Cocaine replaced amphetamines as stimulant of choice in 1970s  Derived from leaves of coca plant, a flowering bush indigenous to SA  DSM-IV-TR criteria: a) recent use of cocaine b) clinically significant maladaptive beh’al/psych’al changes (i.,e. euphoria/affective blunting, changes in sociability, hypervigilance, interpersonal sensitivity, anxiety, tension, or anger, stereotyped beh’s, impaired judgment or impaired soc/occupational f’n’g) tht dvlp’d during/shortly after use c) 2/more of following dvlp’g during/shortly after cocaine use: tachycardia/bradycardia; papillary dilation; elevated/lowered BP; perspiration/chills; nausea/vomiting; evidence of weight loss; psychomotor agitation/retardation; musc weakness / respiratory depression / chest pain / cardiac arrhythmias; confusion/seizures/dyskinesias/dystonias/coma  In small amnts i↑’s alertness, produces euphoria, i↑’s BP and pulse, and causes insomnia and loss of appetite; effects short lived - paranoid common  Subtle deficits in auditory info processing in cocaine-exposed infants may help explain growing evidence tht fetal cocaine exposure is associated w/ subsequent lang deficits among children exposed while still dvlp’g in mother’s uterus Statistics  Use across most ages d↓’d in CAN in past 15 yrs  Most often snorted t/ nose, but may also be injected  Crack cocaine used by < 1% adults and abt 2% students  ―up‖ comes 1’ly from effect of cocaine on dopamine sys’ - enters bloodstream and carried to brain where it blocks reuptake of dopamine - causes repeated stimulation of next neuron—―pleasure pathway‖  Few –ve effects noted at first  Cont’d use: disrupted sleep, i↑’d tolerance (need for higher doses), paranoia, user becomes gradually socially isolated  W/drawal symptoms: feelings of apathy and boredom - vicious cycle Nicotine Use Disorders  Nicotine is a colourless, oily (l) that gives smoking its pleasurable qualities  Today, about 25% CDNs smoke  DSM-IV-TR w/drawal symptoms: depressed mood, insomnia, irritability, anxiety, difficulty concentrating, restlessness, i↑’d appetite, weight gain  Small doses: stimulate CNS; relieve stress and improve mood; high BP; i↑ risk of heart disease & cancer  High doses: blur vision, cause confusion, lead to convulsions, and sometimes cause death  Inhaled t/ lungs where it enters bloodstream - 7-19 sec after inhalation, reaches brain  Stimulates specific receptors—nicotinic acetylcholine receptors—in midbrain reticular formation and limbic sys’ (site of ―pleasure pathway‖)  May affect fetal brain, possibly i↑’g likelihood tht children of mothers who smoke during pregnancy will smoke later in life  Smokers dose themselves t/o day in effort to keep nicotine at steady level in bloodstream (10-50 nanograms per mL)  Potential explanation for finding tht nicotine i↑’s alcohol responding is tht simultaneous smoking may make drinking more rewarding in terms of effects on dopamine reward sys’  Linked w/ signs of –ve affect: depression, anxiety, anger - many who quit smoking but later resume report depression/anxiety were responsible for relapse - severe depression found to occur significantly more often among ppl w/ nicotine (d) Caffeine Use Disorders  DSM-IV-TR criteria: a) recent consumption of caffeine usually in excess of 250mg (i.e. more than 2-3 cups of coffee) b) 5/more of following signs, dvlp’g during/shortly after use: restlessness; nervousness; excitement; insomnia; flushed face; dieresis; gastrointestinal disturbance; musc twitching; rambling flow of thought & speech; tachycardia or cardiac arrhythmia; periods of inexhaustibility; psychomotor agitation  Most commonly used psychoactive substance (90% of all NA)  Aka ―gentle stimulant‖ b/c thought to be least harmful of all the addictive drugs  Small doses: elevate mood, d↓ fatigue  Larger doses: feel jittery, cause insomnia  Takes relatively long time to leav
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