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PSYB32H3 (1,174)
Chapter 12

chapter 12

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University of Toronto Scarborough
Konstantine Zakzanis

Chapter 12: Substance-Related Disorders - pathological use of substances falls into two categories 1. substance dependence (more serious) require three of following characteristics according to DSM-IV-RT (lecture notes) DSM-5 work group recommended adding pathological gambling into this description reflects inclusion of behavioural addictions internet addiction not included at present, work group felt theres not enough evidence for inclusion diagnosed as being accompanied by physiological dependence (addiction) if tolerance or withdrawal is present; this is associated w/ more severe problems 2. substance abuse (less serious) must exp. one of the following as result of current use of drug (lecture notes) - other substance-related disorders: substance intoxication: diagnosed when ingestion of substance affects central nervous system and produces maladaptive cognitive and behavioural effects if person addicted is denied this diagnosis and exp. withdrawal = receives a diagnosis of both substance dependence and substance withdrawal e.g., DTs (delirium tremens) drugs can cause dementia and symptoms of other Axis I disorders - numerous diagnostic and classification problems have been identified: lack of clear distinction in reality between substance abuse vs. substance dependence several arguments for shift in DSM-5 theres quantitative severity distinction rather than qualitative distinction between abuse and dependence = both disorders should be included in a single continuum seek revision of substance use criteria: legal problems criterion is poor discriminator substance abuse disorder symptoms oversample moderate pathology and less useful in characterizing mild or severe pathology comorbidity is not well delineated (portrayed) Alcohol Abuse and Dependence - abuse is often used to refer to both aspects of excessive and harmful use of alcohol - alcohol dependence include tolerance or withdrawal reactions physically dependent = generally more severe symptoms of the disorder those who begin drinking early in life, develop first withdrawal symptoms in 30s or 40s in chronic users, abrupt withdrawal may be dramatic because body has become accustomed to the drug subjectively, patients often: anxious, depressed, weak, restless, and unable to sleep tremors of muscles, esp. small musculatures of fingers, face, eyelids, lips, and tongue, may be marked, and pulse, blood pressure, and temperature are elevated in rare cases, chronic user will exp. delirium tremens when lvl of alcohol in blood drops suddenly becomes delirious, tremulous hallucinations, primarily visual but may be tactile (perceptible to touch) unpleasant and very active creatures (snakes, cockroaches, spiders, and the like) may appear to be crawling up wall or over persons body or fill the room feverish, disoriented, and terrified may claw frantically at their skin to get rid of vermin may cower in corner to escape advancing army of fantastic animals delirium and physiological paroxysm (sudden outburst) caused by withdrawal = drug is addictive - increased tolerance evident following heavy prolonged drinking blood lvls in alcohol of such ppl are unexpectedly low after excessive drinking = body adapts to drug and becomes able to process it more efficiently - changes in liver enzymes that metabolize alcohol can account for small extent of tolerance... most researchers no believe central nervous system is implicated research indicated: changes in # or sensitivity of GABA or glutamate receptors withdrawal = may result from increased activation in some neural pathways to compensate for alcohols inhibitory effects in brain when drinking stops = inhibitory effects of alcohol lost = state of overexcitation - although tolerance mostly due to physiological factors, highlighted role of psychological factors response expectations and consequences of behaviour can have direct influence development of addictions often reflects interplay of biological and psychological factors - drinking pattern in those alcohol dependent = drinking is out of control need to drink daily unable to stop or cut down despite repeated efforts go on occasional binges; intoxicated for 2, 3 or more days may suffer black outs and have no recollection of events during intoxication craving may be so overpowering = forced to ingest alcohol in non- beverage form (such as hair tonic) causes: social and occupational difficulties quarrels w/ family or friends violent behaviour frequent absences from work loss of job arrests for intoxication or traffic accidents - in contrast, alcohol abuse exp.: negative social and occupation effects from drug doesnt show tolerance, withdrawal, or compulsive drinking patterns thats seen in alcohol dependent person - alcohol abuse or dependence often part of polydrug (or polysubstance) abuse: using or abusing more than on drug at a time 80-85% of alcohol abusers are smokers canadian addiction programs offer smoking cessation services for those w/ other addictions - most programs place little emphasis on smoking cessation alcohol serves as cue for smoking alcohol and nicotine are cross-tolerant: nicotine can induce tolerance for rewarding effects of alcohol and vice versa creats serious health problems, taken together are synergistic: effects of each combine to produce esp. strong reaction Prevalence of Alcohol Abuse and Comorbidity with Other Disorders - based on DSM-IV criteria estimated in 2007: alcohol abuse = lifetime: 17.8% & 12month: 4.7% alcohol dependence = lifetime: 12.5% & 12month: 3.8% 1/4 received treatment lifetime prevalence of alcohol misuse is 3/10 americans prevalence rates higher in men, younger cohorts, and whites course was often chronic w/ average of 4 yrs for alcohol dependence - table 12.1, pg 400: summarizes epidemiological data obtained in Canada - prototypical heavy drinker in Canada: young adult male, not married, and relatively well off financially - comorbid w/ several personality disorders and alcohol misuse; mood and anxiety disorders; other drug use and schizophrenia factor in 25% of suicides important to assess comorbidity because it could predict higher relapse rates and less initial treatment improvement - drinking is on the rise in Canada 9% increase over all in alcoholic consumption, twice as high (16%) in BC alcohol related deaths increased to similar degree Course of the Disorder - at one time, thought that alcohol abusers have a common downhill progression on basis of survey of 2 000 members of AA, Jellinek (1952): male alcohol abuser passes through 4 stages, beginning w/ social drinking and progressing to stage which e lives only to drink - however, data reveal considerable fluctuations in drinking patterns heavy drinking for some periods of time to abstinence or lighter drinking in others no single pattern of alcohol abuse - jellineks account doesnt apply to women usually begin later age often after inordinately stressful exp. time interval between onset of heavy drinking and alcohol abuse is briefer tend to be steady drinkers who drink alone and more unlikely to binge Costs of Alcohol Abuse and Dependence - according to WHO (world health organization): alcohol abuse is 4th leading cause of worldwide disability accounts for more years lost to death or disability than use of tobacco or illegal drugs exceptionally high in Russian men - although most w/ drinking problem dont seek professional help, a large proportion of new admissions to mental and general hospitals are them use health services 4x more often than non-abusers medical expenses 2x high as non drinkers - suicide rates are higher in alcohol abusers than general populn - alcohol-related fatalities have declined in Canada in 1997, 31% of drivers had alcohol lvls above legal limit drunk drivers kill 3 to 4 ppl per day and injure 187 ppl every day increases severity and likelihood of traffic accidents prototypical drinking driver in canada: male, ages 25-34 who drinks large amount of alcohol on regular basis or social drinker and drinks heavily
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