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detailed ch 12 notes

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Konstantine Zakzanis

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Chapter 12: Substance-Related Disorders The pathological use of substances falls into 2 categories: Substance dependence: characterized by DSM-IV-TR as presence of at least three of the following:  Person develops tolerance, indicated by either larger doses of the substance being needed to produce the desired effect OR the effects of the drug becoming markedly less if the usual amount is taken  Withdrawal symptoms (negative physical and psychological effects- develop when the person stops taking the substance or reduces the amount). An example of substance withdrawal is alcohol withdrawal commonly known as the delirium tremens  Person uses more of the substance or uses it for a longer time than intended  Person recognizes use of the substance; he/she may have tried to reduce usage but has been unable to do so  Much of the person’s time is spent in efforts to obtain the substance or recover from its effects  Substance or use continues despite psychological or physical problems caused by the drug (smoking- knowing that it increases the risk for cancer  Person gives up or cuts back participation in many activities - DSM-5 has suggested that pathological gambling fall into substance dependence description, as well as other behavioural addictions - DSM-5 may drop distinction between substance abuse and dependence and instead replace with an inclusive category named addiction and related disorders  both disorders should be included on a single continuum Substance abuse (less serious): person must experience one of the following as a result of re- current use of the drug  Failure to fulfill major obligations (absence from work or neglecting children)  Exposure to physical dangers (operating machinery or driving while intoxicated)  Legal problems (arrests for disorderly conduct or traffic violations)  Persistent social or interpersonal problems (arguments with a spouse) - DSM-IV-TR section on substance-related disorders involves other diagnoses:  substance intoxication: diagnosed when the ingestion of a substance affects the CNS and produces maladaptive cognitive and behavioural effects ALCOHOL ABUSE AND DEPENDENCE - Those who begin drinking in early life develop their first withdrawal symptoms in their 30’s or 40’s - alcohol dependence may include tolerance and withdrawl reactions - patient is often anxious, depressed, weak, restless and unable to sleep – tremors of muscles, pulse increases, blood pressure and temperature elevations are also common - In rare cases, a person who has been drinking heavily may experience delirium tremens when the level of alcohol in the blood drops suddenly person will have hallucinations (snakes, cockroaches, spiders may appear to be crawling up the wall or over the person’s body, person may claw at his/her own skin to get rid of it - increase tolerance is evident following heavy, prolonged drinking – levels of alcohol in blood may also be low compared to what they drank, suggesting that the body adapts to the drug and becomes able to process it more efficiently - changes in liver enzymes that metabolize alcohol may account for tolerance, but research may indicate that tolerance results from changes in the number or sensitivity of GABA or glutamate receptors - withdrawl may result from a loss of the inhibitory effects in the brain of alcohol, leading to a state of excitation - a person who abuses alcohol rather than is physically dependent on it, experiences negative social and occupational effects from the drug, but does not show tolerance, withdrawal or the compulsive drinking patterns usually seen in alcohol dependance - Polydrug or polysubstance abuse: using/abusing more than 1 drug at a time (estimated that 80-85% of alcohol abusers are smokers too)  alcohol serves as a cue for smoking – smoking is twice as frequent in situations where person is always drinking  nicotine and alcohol have cross-tolerance: nicotine can induce tolerance for the rewarding effects of alcohol and vice versa can create serious health problems (mixing alcohol and barbiturates is a common means of suicide)  alcohol is believed to contribute to the deaths from heroin, for it can reduce the amount of the narcotic needed to make a dose lethal - lifetime prevalence of alcohol misuse was more than 3 in 10, and only 1 in 4 with alcohol dependence ever received treatment - prevalence rates are higher in males, younger cohorts and whites - The prototypical drinking driver in Canada is a male between the ages of 25 and 34 who drinks large amounts of alcohol on a regular basis or is a social drinker who occasionally drinks heavily - problem drinking is also comorbid with mood and anxiety disorders, and with other drug use and schizophrenia - drinking is on the rise in Canada – over past decade, there was a 9% increase in alcohol consumption, with the increase being almost twice as high in BC  alcohol related deaths increased to a similar degree - big problem with binge drinking in college and university students - study revealed that 50% of men and 40% of women have engaged in binge drinking (having five drinks in a row for men and four for women) - ¼ students frequently binge drank, at least once a week - seems that greater proportion of Canadian students drink, but heavy alcohol use is higher among American students - students who reported having their first experience of drunkness before age 16 are more likely to be heavy drinkers in college - great lack of parental awareness on child’s substance abuse (only 34% were aware of the use) – single parents, parents from blended families and higher-achieving student’s parents were more likely to know about their childs drug use - many believe that alcohol abusers have a common downhill progression – abuser passes through four stages, beginning with social drinking and progressing to stage at which he only lives to drink - however, do not always see a progression from alcohol abuse to alcohol dependence – do not have one single pattern of alcohol abuse - difficulties with alcohol usually begin later in women than men, and are often after a stressful experience  also the time between the onset of heavy drinking and alcohol abuse is briefer in women than in men - problem drinkers use health services four times more often than non-abusers, and their medical expenses are twice as high as non-drinkers -suicide rate is higher in drinkers than for general population - alcohol contributes to many accidents and other injuries, such as rape, assault, and family violence Short-term effects of alcohol:  Alcohol is metabolized by enzymes after being swallowed and reaching the stomach  Most of it goes into the small intestines where it is absorbed into the blood  Then it is broken down, mostly in the liver which can metabolize about 30 millilitres of 50% alcohol per hour (quantities in excess of this amount stay in the blood stream)  Absorption of alcohol can be rapid, but removal is always slow  Effects of alcohol vary with level of concentration in bloodstream, which in turn depends on the amount ingested, the presence or absence of food in stomach to retain the alcohol and reduce its absorption rate, the size of the persons body, and the efficiency of the liver  Has a biphasic effect - Initial effect of alcohol is stimulating- drinker experiences an expansive feeling of sociability and well-being as the blood-alcohol level rises, but after the blood-alcohol level peaks and begins to decline, alcohol acts as a depressant that may lead to negative emotions  Large amounts of alcohol interfere with complex thought processes, motor coordination, balance, speech, and vision  Alcohol produces its effects through its interactions with several neural systems in the brain – stimulates GABA receptors, increases levels of serotonin and dopamine (may be the source of pleasurable effects) and inhibits glutamate receptors, which may cause the cognitive effects of alcohol intoxication, like slurred speech and memory loss Long-term effects of prolonged alcohol abuse:  Chronic drinking creates severe biological damage and psychological deterioration  Almost every tissue and organ of the body is affected adversely by prolonged consumption of alcohol  A pint of 80-proof spirits supplies about half a day’s caloric requirements (these calories don’t supply the nutrients essential for health), heavy drinkers often reduce their intake of food  Alcohol also contributes directly to malnutrition by impairing the digestion of good and absorption of vitamins  Eg. Deficiency of B complex vitamins can cause amnestic syndrome, severe loss of memory for both recent and long past events  Prolonged alcohol use with reduction in the intake of proteins contributes to the development of cirrhosis of the liver, a potentially fatal disease in which some liver cells become engorged with fat and protein, obstructing their function – may also get formation of scar tissue in liver, which obstructs blood flow, causing further cell damage  Common physiological changes include damage to the endocrine glands and pancreas, heart failure, hypertension, stroke, and capillary hemorrhages, which are responsible for the swelling and redness in the face (especially the nose) of chronic alcohol users  Alcohol reduces the effectiveness of the immune system and increases susceptibility to infection and cancer  Women’s risk of breast cancer increases steadily with the amount they drink  Heavy alcohol consumption during pregnancy is the leading cause of mental retardation (Fetal alcohol syndrome: growth of fetus is slowed, & cranial, facial, & limb anomalies are produced)  FAS has great human and economic cost, occurring around 1 in every 100 pregnancies, thus costing health care billions annually  Positives: light drinking (fewer than 3 drinks a day) especially wine has been related to decreased risk for coronary heart diseases and stroke INHALENT USE DISORDERS - alarming amount of young people begin their substance abuse by inhaling substances - The peak age of inhalant use is 14-15 years, with initial onsets in children as young as 6 - inhalants are dangerous because they are inexpensive and readily available - inhalant use disorders can involve behaviours like sniffing, huffing (breathing fumes from a rag), and bagging(breathing fumes from a plastic bag held to the mouth) - gasoline sniffing is widespread among certain groups in northern Canada, and is especially prevalent amount aboriginal children and adolescents -most inhalents act like depressants, and thus can be seen as similar to alcohol and sedatives - inhaled substance can result in feelings of euphoria and psychic numbing, but can also cause damage to CNS -nausea and headaches are experienced eventually in almost all cases NICOTINE: - Nicotine: addicting agent of tobacco, it stimulates receptors, called nicotinic receptors, in the brain. - evidence suggests that the main receptor mediating nicotine dependence is the nicotinic acetylcholine receptors – exposure to nicotine influences brain nicotinic cholinergic receptors to facilitate nt release, thus producing stimulation, pleasure and mood modulation -nicotine may act differently on bran of males vs females – PET scans found greater brain activation in women when performing tasks than men when nicotine was not involved, but when nicotine was administered, these brain differences disappeared  females have substantially greater changes in cognitive activity after nicotine exposure - Study found that the addictive effects of nicotine start very shortly after one’s first puff - Estimated that smoking causes more than 47,000 deaths annually in Canada, and can account for 1/5 deaths in US - Approximately 17% of Canadians are smokers - some long term health problems associated with long term cigarette smoking are lung cancer, emphysema, cancer of the larynx and esophagus, and a number of cardiovascular diseases - most harmful components in smoke are nicotine, carbon monoxide, and tar - health risks from smoking decline greatly over a period of 5 to 10 years after quitting, to levels on slightly above those of non-smokers, but the destruction of lung tissue is irreversible - daily smokers smoke an average of 14.9 cigs per day – with males smoking three more cigs than females do per day - data suggests that cigarette smoking contributes to erectile problems in men Second-hand smoke (environmental tobacco smoke (ETS)): contains higher concentration of ammonia, carbon monoxide, nicotine, and tar than does the smoke actually inhaled by the smoker blamed for more than 500,000 deaths a year in the US two thirds of smoke from a cigarette is not inhaled by the smoker but enters the air around them has at least twice the nicotine and tar as the smoke inhaled by smoker regular exposure increases chances of contracting lung disease by 25% and heart disease by 10% can cause eye, nose, and throat irritations, headaches, dizziness, nausea, coughing and wheezing in otherwise healthy people  infants and children exposed to second hand smoke are more likely to suffer chronic respiratory illness, impaired lung function, middle ear infections and food allergies MARIJUANA: Marijuana: consists of the dried & crushed leaves & flowering tops of the hemp plant (Cannabis sativa) Hashish: much stronger than marijuana, made by removing and drying the resin exudate of the tops of high quality cannabis plants Effects of Marijuana: Psychological  Makes people feel relaxed and sociable  Large doses have been reported to bring rapid shifts in emotion, to dull attention, to fragment thoughts, and impair memory  Time seems to move more slowly  Very heavy doses sometimes elicit hallucinations and other effects similar to LSD, including extreme panic  Amount of THC is higher today than two decades ago, indicating the THC content is two or three times higher  Brain has cannabis receptors and have also found that the body produces its own cannabis-like substance, anandamide  Receptors in hippocampus may account for short term memory loss that sometimes follows marijuana use  Current marijuana use resulted in an average decrease of 4.1 IQ points, but only among heavy users who smoked at least 5 joints per week – lighter use did not diminish IQ scores  Impairs psychomotor skills required for driving  Heavy use of marijuana during teenage years may contribute to psychological problems in adulthood Somatic  Short term effects: blood-shot and itchy eyes, dry mouth and throat, increased appetite, reduced pressure within the eye, and somewhat raised blood pressure  No evidence yet that it has an effect on a normal heart  Growing evidence that it is associated with respiratory disorders and seriously impairs lung functioning (coughing, wheezing, bronchitis etc)  Concurrent marijuana and cig smoking is associated with increased risk for respiratory symptoms and chronic obstructive pulmonary disease  It may be addictive  May have reverse tolerance – experienced smokers only need few hits, while less experienced users will need more to experience similar state of intoxication Therapeutic  Marijuana and related drugs can reduce the nausea and loss of appetite that accompany chemotherapy for some cancer patients  treatment for the discomfort of AIDS, as well as glaucoma, epilepsy, & multiple sclerosis SEDATIVES AND STIMULANTS Sedatives: (often called downers), slow the activities of the body and reduce its responsiveness. This group of drugs include: Opiates- addictive sedative that relieve pain & induce sleep when taken in moderate doses Opium- originally the principal drug of illegal international trafficking and known to the people of the Sumerian civilization as long ago as 7000 B.C Morphine- (alkaloid) named after Morpheus (Greek god of dreams) Bitter tasting powder, powerful sedative and pain reliever, addictive Heroin- used initially as a cure for morphine addiction, heroin was substituted for morphine; it was then proved to be even more addictive and potent. User feels a warm ecstasy immediately after injection, but then experiences letdown, bordering on stupor - opium and its derivatives (morphine and heroin) produce euphoria, drowsiness, reverie and lack of coordination -opiates produce their effects by stimulating neural receptors of the bodys own opoid system (endorphins and enkephalins) - opiates are clearly addicting – users show both increased tolerance and withdrawal symptoms - reactions to not having dose of heroin can increase eight hours after last injection – individual will have muscle pain, sneezes, sweats, yawns a great deal (symptoms resemble influenza)  withdrawal symptoms become more severe within 36 hours – involve uncontrollable muscle twitching, cramps, chills and excessive sweating, raises in heart rate and blood pressure, inability to sleep, vomits, and has diarrhea  symptoms typically persist for about 72 hours and diminish over a 5 to 10 day period - heroin is typically confined to poor neighbourhoods; heroin and cocaine abuse is very prevalent from street youth - have had an increase in purity of the drugs (20 to 50% pure, rather than 5%), causing increases in mortality rates Barbiturates- began as aids for sleeping and relaxation (addictive). The brain can become damaged and personality deteriorates with prolonged excessive use - sedatives are thought to produce its psychological effects (reduce anxiety and relax muscles) by stimulating the GABA system - with excessive doses, speech becomes slurred, judgement, concentration and ability to work may be severely impaired - very large doses can be fatal because the diaphragm muscles relax to the extent that they suffocate - frequently sedatives are used as a means of suicide - drinking alcohol potentiates (magnifies) the depressant effects of sedatives - abrupt termination of sedatives causes severe withdrawal symptoms and can cause sudden death Stimulants: (or uppers) act on the brain and the sympathetic nervous system to increase alertness and motor activity: Amphetamines o Discovered after seeking a treatment for asthma o First amphetamine, Benzedrine was synthesized in 1927 o Were used to control mild depression and appetite o Produce effects by causing the release of dopamine and norepinephrine, and blocking their reuptake o Wakefulness is heightened, intestinal functioning is inhibited, appetite is reduced, heart rate quickens, and blood vessels in the skin and mucous membranes constrict o Individual seems to be possessed with boundless energy and self-confidence o Larger doses can make people nervous and confused, and produce states similar to those with schizophrenia, including its delusions o Tolerance to amphetamine develops rapidly – as tolerance increases, user may stop taking the pills and inject methedrine, the strongest amphetamine, directly into the vein Caffeine: o Can produce tolerance and habitual users may have withdrawal symptoms o Causes increases in metabolism, body temperature and blood pressure, increased urine production, tremors, sleepiness is warded off, and appetite diminishes o Extremely large doses can cause headaches, diarrhea, nervousness, convulsions and even death (very difficult to achieve death since drug is excreted by the kidneys without any accumulation) o Individuals that drink two cups of regular coffee a day can suffer from headaches, fatigue, and anxiety if caffeine is withdrawn from daily diet Cocaine o Was extracted from the leaves of the coca plant in the mid-1800’s and has been used since then as an anaesthetic o Freud used it to treat depression o Acts rapidly on the brain, blocking the reuptake of dopamine in mesolimbic areas that are thought to yield pleasurable states o Increases sexual desire and produces feelings of self-confidence, well-being, and indefatigability o Overdose may bring on chills, nausea, insomnia, paranoid breakdown, and hallucinations of insects
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