Psych disorders CH 11- Substance-Related Addictive, and Impulse Control Disorders

Substance use disorders are the misuse of

psychoactive substances

Substance use

Taking moderate amounts of a substance in a way that doesn’t interfere with functioning

Substance intoxication

Physical reaction to a substance

Substance dependence - Tolerance

Needing more of a substance to get the same effect or a reduced effects from the same amount

Substance dependence - Withdrawal

Physical response when substance is discontinued after regular use 

Substance use disorder in DSM-5

• Need two or more symptoms within a year

  • Taking more of the substance than intended

  • Desire to cut down use, but not being able to

  • Excessive time spent using/acquiring/recovering 

  • Craving for the substance

  • Role distribution 

  • Interpersonal problems 

Depressants

behavioral sedation

Stimulants

increase alertness and elevate mood

Opiates

produce analgesia (pain relief) and euphoria

Hallucinogens

alter sensory perception

Other drugs of abuse

include inhalants, anabolic steroids

Psychological and physiological effects of alcohol

• CNS depressant

• Influences several neurotransmitter systems

• Specific target is GABA (inhibitory neurotransmitter) 

Effects of chronic alcohol use

Liver disease, pancreatitis, cardiovasular disease, and brain damage

Chronic alcohol withdrawal including

Delirium tremens: hallucinations and body tremors

Fetal alcohol syndrome

Problems in fetus from alcohol use during pregnancy, results in cognitive, behavioral, learning problems in the child

Long term heavy alcohol use may lead to

Dementia

Wernicke-Koraskoff syndrome 

confusion, loss of muscle coordination, and unintelligible speech 

Progression of alcohol related disorders

• 20% can stop drinking on their own

• dependence develops over time but course may be variable

• those who start drinking at age 11 or earlier are at higher risk for chronic or severe alcohol use disorders

• Drinking doesn’t cause violence but increases the likelihood of impulsive behavior 

Sedatives

calming (ex: barbiturates)

Hypnotic

sleep inducing

Anxiolytic

anxiety reducing (ex: benzodiazepines)

Sedative, hypnotic, and anxiolytic related disorders have generally

tranquilizing effects, combining depressants can have dangerous synergistic effects

• act on GABA receptors in the brain

• Those who seek help for use more likely to be female, white, 35+ 

Stimulants

• Most widely consumed drugs in the US due to both caffeine (coffee, energy drinks, and soft drinks) and nicotine (tobacco)

• Increase alertness and energy

• Examples include amphetamines, cocaine, nicotine, and caffeine 

Effects of amphetamines

• produce elation, vigor, reduce fatigue followed by extreme fatigue and depression

• Stimulate CNS by enhancing and blocking reupatek of norepinephrine and dopamine 

• Ex: Ritalin or Adderall for ADHD and methamphetamine (crystal meth) 

Effects of cocaine

• Short lived sensations of elation, vigor, reduced fatigure

• Effects result from blocking the reuptake of dopamine 

Effects of nicotine

Stimulates nicotinic acetylcholine receptors in CNS resulting in sensations of relaxation, wellness, pleasure

• Smoking has complex relationship to negative effect 

  • Appears to help improve mood in short-term

  • Depression occurs more in those with nicotine dependence 

Effects of caffeine 

• Used by 85% of Americans

• Found in tea, coffee, cola drinks, and cocoa products

• Small does evelate mood and reduce fatigure

• Regular use can result in tolerance and dependence

• Caffeine blocks the reuptake of the neurotransmitter adenosine

Opiate

natural chemical in the opium poppy with narcotic effects

Opioids

natural and synthetic substances with narocotic effects

The nature of opiates and opioids are often referred to as

analgesics

Effects of opioids 

• Low does induce euphoria, drowsiness, and slowed breathing

• Withdrawal symptoms an be lasting and severe

Brain makes similarly acting substances called

enkephalins, beta-endorphins, and dynorphins (endogenous opiods)

Cannabis Related Disorders

• Active ingredients are tetrahydrocannabinols (THC)

  • Brain makes its own version of THC called anandamide 

• Reaction include altered perceptions and mood swings

• Evidence regarding tolerance is contradictory

  • Evidence of both tolerance and reverse tolerance

• Frequent, long term users may experience impairments of memory, concentration, relationships with others, and employment 

• Can increase risk for panic attacks and psychosis in vulnerable people 

How is cannabis used in the treatment of some diseases?

• Reduced nausea and vomiting from chemotherapy

• Increase appetite for people with cancer or HIV/AIDS

Hallucinations

• altered sensory perceptions (ex: hearing or seeing things that aren’t present) 

• also produce delusions and paranoia

Examples of hallucinogens

• LSD, psilocybin (from specific mushrooms), mescaline (from peyote) PCP 

• Tolerance builds quickly, but resets after brief periods of abstinence 

Inhalants

• Highest drug use during early adolescence

• Found in volatile solvents

• Breathed into lungs directly → rapid absorption

• Ex: spray paint, hair spray, paint thinner, gasoline, nitrous oxide

• Effects similar to alcohol intoxication

• Produce tolerance and prolonged withdrawal symptoms

• Multiple negative physiological effects

  • Damage to bone marrow, kidneys, liver brain

Steroids

• Derived or synthesized from testosterone

• Used medically (ex: for asthma) or to increase body mass

• No associated high

• Dependance based on wanting to maintain effects of substance (ex: increased muscle mass)

• Can increase risk for heart attack, stroke, liver tumors, kidney failure, and psychiatric problems (ex: depression)

  • Stopping chronic use can also increase depression, leading to relapse 

Agonist substitution

Safer drug with a similar chemical composition as the abused drug (ex: Methadone for heroin and other opiates; Nicotine patch for smoking)

Antagonist drugs

Drugs that block or counteract the positive effects of substances (ex: naltrexone for opiates) 

Aversive treatment

Drugs that make use of substances extremely unpleasant (Ex: antabuse for alcohol)

Efficacy of biological treatment

Ineffective when used alone

Inpatient vs outpatient psychosocial treatment

Little difference in effectiveness

Psychosocial treatment - Community Support Programs

Alcoholics Anonymous (AA) and related groups (ex: NA) may be helpful; research is mixed through social support may e key ingredient 

Psychosocial treatment - Balancing treatment goals 

Controlled drinking vs complete abstinence 

Psychosocial treatment - Component treatment

Incorporate several elements such as psychotherapy and contingency management

Psychosocial treatment - Comprehensive treatment and prevention programs

• Individual and group therapy 

• Aversion therapy and convert sensitization 

  • Substance paired with something neg (ex: nausea) 

• Contingency management 

  • Get rewards for making progress towards a goal

• Community reinforcement 

  • Get help from helpful people; avoid unhelpful people 

• Relapse prevention 

  • Looks at the learned aspects of dependence and sees relapse as a failure of cognitive and behavioral coping skills

Motivational Interviewing (MI) is typically delivered as part of a

single “feedback” session

Basic Principles of Motivational Interviewing (MI)

• Express empathy

• Develop discrepancy 

• Avoid argumentation

• Role with resistance 

• Support self-efficacy

  • Elicit “change talk” from the client, not you 

Preventative Substance Misuse efforts

• Shift away from education and to comprehensive approaches

• Programs like DARE reduce illicit substance use but don’t affect use of alcohol or tobacco 

Harm Reduction

Framework reduce existing negative affects through public health initiatives (knows abuse exists and aims to reduce harms related to the substance) 

• Free breakfast programs, vaccines, and safe sex education programs can all be considered harm reduction 

Harm Reduction Example - Heroin and Other Opioids

• Needle exchange programs and safe injection sites to reduce risk of blood borne infections like HIV

• Medications like Methadone, Buprenorphine, and Naltrexone 

• Availability of and training to use Naloxone/Narcan 

Harm Reduction Example - Alcohol

• Managed alcohol programs 

• Designated driver programs

• Medicates like Naltrexone 

Other Harm Reduction Examples 

• Test strips for fentanyl and other substances

• Referrals to treatment for substance use disorder (in patient rehab, CBT, etc) 

• Housing first programs 

Does Harm Reduction work?

• Safe injection sites linked to decreases in overdose death and blood borne pathogen infections

• Medications for opioid addiction are related to better treatment retention, fewer risky behaviors, and increased likelihood of eventual abstinence 

Harm reduction encourages people to use drugs

Drugs will be used whether harm reduction strategies exist or not, better to make drugs safer to use for both them and the people around them 

Harm Reduction discourages people from seeking treatment

Often a first step for individuals who wouldn’t otherwise seek it out. Engaging with harm reduction programs can connect individuals with resources for more long term treatment 

(T/F) Most people in the US use a psychoactive substance

True: ~85% use caffeine, a stimulant

(T/F) Although it may be unpleasant, withdrawal from a psychoactive substance is not dangerous 

False: can be dangerous especially alcohol withdrawal

(T/F) Depressants inhibit central nervous system activitiy

True: Depressants act on GABA and inhibit CNS activity

(T/F) Cannabis has documented medical uses

True: Cannabis has an increasing number of documented medical uses

(T/F) Substance use disorders are fundamentally psychological and are not influenced by biological factors. 

False: Substance-use disorders have genetic and other biological components 

Intermittent explosive disorder

Rare condition characterized by frequent aggressive outbursts leading to injury and or destruction of property 

Kleptomania 

• Failure to resist urge to steal unecessary items 

• Disorder may be more common in women than in men and typically starts in adolescence 

• Comorbid with mood disorders and substance use disorders 

Pyromania

• Involves having an irresistible urge to set fires

• Rare even among convicted arsonists

• Treatment usually focuses on identifying urges and practicing incompatible behaviors 

Gambling disorder 

• Leading to significant distress or impairment

• Associated with:

  • Difficulty stopping/reducing gambling

  • Restlessness/irritability when trying to cut back

  • Need to gamble with increasing amounts of money

  • Frequent preoccupation

• Similarities in biological origins of gambling and substance use disorders

Gambling Problems College Students

• Availability: phone apps

• Acceptability: it’s everywhere you look

• Access": may have more disposable income 

• Age: just like other addictions, there is a window of risk based on differential development of limbic versus prefrontal regions of the brain

Gambling disorder treatment

• Psychosocial treatment similar to substance abuse

• Cognitive-behavioral interventions help reduce the symptoms of gambling disorder

• Brief and full course treatments have both been found to help and both are recommended 

• Motivation to get better is critical; dropout is high

• Research is limited, but multipart CBT interventions are under investigation

  • Scheduling alternative activities, setting financial limits, relapse prevention

(T/F) Gambling use disorder seems to have a genetic component

True: Gambling use disorder seems to have a genetic component similar to that seen in substance use disorder 

(T/F) Intermittent explosive disorder is common, especially among adolescents 

False: Intermittent explosive disorder is not often diagnosed 

(T/F) Many people with kleptomania also have mood disorders

True: Mood disorders are often co-morbid with kleptomania, as are, to a lesser extent, substance use disorders 

(T/F) Most arsonists are pyromaniacs

False: Only about 3% of arsonists are diagnosed with pyromania