+

Chapter 10
Substance
Related Disorders

Abnormal Psychology, Eleventh Edition

by
Ann M. Kring, Gerald C. Davison, John M. Neale,
& Sheri L. Johnson
+ Percentage of Indonesian Population Reporting 2

Drug Use in 2003-2006 (Based on BNN survey)

Based on areas Based on substance

 Jakarta : 23%  Marijuana : 74.9 %
 Medan : 15%
 Anti-Depressant : 32.5 %
 Bandung : 14%
 Ecstasy : 25.7 %
 Surabaya : 6.3 %
 Amphetamine : 21.5 %
 Maluku utara : 4.3 %
 Padang : 5.5 %
 Kendari : 5%
 + Substance Dependence and Abuse 3

Dependence ( Adiction) Abuse

 Occupational or social problems,  Maladaptive use of substance
much time trying to obtain
substance, continued use despite  No physiological dependence
problems, etc.
 In 2006, 22 million met criteria
 Involves either tolerance or for dependence or abuse.
withdrawal
 Of those 15 million involved
 Tolerance
alcohol.
 Greater amounts required to
produce desired effect
 Withdrawal
 Physiological and psychological
consequences when individual
discontinues or reduces
substance use
 Restlessness, anxiety, cramps,
death
+ Alcohol Dependence and Abuse 4

 Alcohol abuse
 Negative social and occupational effects
 No tolerance, withdrawal, or compulsive usage

 Alcohol Dependence
 More severe symptoms such as tolerance and withdrawal
 Withdrawal results in:
 Anxiety
 Depression
 Weakness
 Restlessness
 Insomnia
 Muscle tremors
 Face, fingers, eyelids, other small musculature
 Elevated BP, pulse, temperature
+ Alcohol Abuse and Dependence 5

 Delirium tremens (DTs)

 Can occur when blood alcohol levels drop
suddenly
 Results in:
 Deliriousness
 Tremulousness
 Hallucinations
 Primarily visual; may be tactile

 2.5% of alcohol abusers develop dependence

+ Alcohol Abuse and Dependence 6

 Polydrug abuse
 Many users abuse multiple substances
 e.g., cigarettes, cocaine, marijuana
 85% of alcohol are smokers

 Synergistic
 Some combinations of drugs produce stronger
reaction
 Alcohol and barbiturates
 May cause death
 Alcohol and heroin
 Alcohol reduces amount of heroin needed to
produce lethal dose
+ Prevalence of Alcohol Abuse 7

 Lifetime prevalence (Kessler et al., 1994)

 20% for men
 8% for women
 Lifetime prevalence:
 Abuse - 17%
 Dependence – 12%
 Binge drinking
 5 drinks in short period
 43.5% prevalence among college students
 Heavy use drinking
 5 drinks, 5 or more times in a 30 day period
 17.6% prevalence among college students
+ Short-term Effects of Alcohol 8

 Enters
the bloodstream through small intestine
 metabolized by the liver

 Effects vary by concentration

 Concentration varies by gender, height, weight,
liver efficiency
Affects brain areas associated with error
monitoring and decision making.
 Biphasic effect
 Initially stimulates
 Later depresses
+ Short-term Effects of Alcohol 9

 Effect of ingesting large amounts

 Impaired speech and vision
 Interference in complex thought processes
 Poor coordination
 Loss of balance
 Depression and withdrawal

 Interacts with several neural systems

 Stimulates GABA receptors
 Increases dopamine and serotonin
 Inhibits glutamate receptors
+ Long-term Effects of Alcohol 10

 Malnutrition  Damage to endocrine

 Alcohol interfereswith glands and pancreas
digestion and absorption
of vitamins from food  Heart failure
 Deficiency of B-complex  Erectile dysfunction
vitamins
 Hypertension
 Amnestic syndrome
 Severe loss of memory  Stroke
for both long and short
term information  Capillary hemorrhages
 Facial swelling and
 Cirrhosis of the liver redness, especially in
 Liver cells engorged with nose
fat and protein impeding
functioning  Destruction of brain cells
 Cells die triggering scar  Especially areas
tissue which obstructs important to memory
blood flow
+ Fetal Alcohol Syndrome 11

 Heavy alcohol intake during pregnancy

 Fetal growth slowed
 Cranial, facial and limb anomalies occur

 Moderate alcohol intake

 1 drink per day
 Learning and memory impairments
 Growth deficits

 Total abstinence recommended by NIAAA

+ Nicotine and Cigarette Smoking 12

 Nicotine
 Addicting agent of tobacco
 Principal alkaloid
 Active chemicals that give drugs their
physiological and psychological altering
properties
 Stimulates dopamine neurons in mesolimbic
area
 Involved in reinforcing effect
+ Prevalence and Health 13

Consequences
Prevalence decreased since mid 1960s although use
increased through the 1990s, among white adolescents
 More prevalent among white & Hispanic youth than African
Americans
 African Americans less likely to quit and more likely to get
lung cancer
 Metabolize nicotine more slowly

 Chinese Americans have lower lung cancer rates

 Metabolize less nicotine

 More prevalent among men than women

 Exception: 12 to 17 year olds

 Secondhand smoke (ETS, environmental tobacco smoke)

 Higher levels of ammonia, carbon monoxide nicotine and
tar
 Causes 40,000 deaths per year in US
+ Marijuana 14

Drug derived from dried and ground

leaves and stems of the female hemp plant
(Cannibis sativa)
Hashish
 Stronger than marijuana
 Produced by drying the resin exudate of the
tops of plants
+ Prevalence 15

 Most frequently used illicit drug in US

 15,000,000 reported using it in 2006

 Peaked in 1979 then began to decline

 Rose again in 90s

 Greater
use by men than women although rates
among women increased faster in 1990s
+ Effects of Marijuana 16

 Major active ingredient  Physiological

 THC (delta-9-  Bloodshot & itchy eyes
tetrahydrocannabinol)  Dry mouth and throat
 Psychological  Increased appetite
 Feelings of relaxation and  Reduced pressure within
sociability the eye
 Rapid shifts of emotion  Increased BP
 Interferes with attention,  Abnormal heart rate
memory, and thinking
 Decline in IQ over time  May exacerbate
 Heavy doses can induce
preexisting
hallucinations and panic cardiovascular
problems
 Impairment of skills
needed for driving  Damage to lung
 Impairment present for structure and function in
several hours after ‘high’ long term users
has worn off
+ Therapeutic Effects of Marijuana 17

 Reducesnausea and loss of appetite caused by

chemotherapy (Salan et al., 1975)
 Relieves discomfort of AIDS (Sussman et al.,
1996)
 Analgesic effects due to ability of THC to block
pain signals from reaching the brain.
 Supreme Court rulings:
 Federallaw prohibits dispensing marijuana for
medicinal purposes
 Medical use can be prohibited by federal
government even if states approve
+ Opiates 18

 Group of addictive sedatives that in moderate doses relieve

pain and induce sleep
 Opium
 Morphine
 Heroin
 Codeine

 Syntheticsedatives
 Seconal and valium

 Opiateslegally prescribed as pain medications include:

 Hydrocodone combined with other substances yields
Vicodin, Zydone, and Lortab
 Oxycodone the basis for OxyContin, Percodan, & Tylox.
+ Prevalence of Opiate Use 19

 Heroin
 Estimated1,000,000 individuals addicted to
heroin in US
 300,000 in 2006 alone
 From 1995 to 2002, rates of use among adults 18
to 25 increased from 0.8% to 1.6%
 Accounted for 62 to 82% of drug-related hospital
admissions in Baltimore, Boston, & Newark.
 Heroin is more pure (25 to 50%) than in the past
 Increases likelihood of overdose

 OxyContin prescriptions jumped 1800% between

1996 and 2000 (DEA, 2001)
 2.8 million users (SAMSHA, 2004)
 Can be dissolved for injection or snorting
 Street price from $25 to $40 per pill
+ Psychological and Physical Effects of 20

Opiates
 Euphoria, drowsiness, reverie, and lack of coordination
 Loss of inhibition, increased self-confidence
 Severe letdown after about 4 to 6 hours

 Heroin and OxyContin

 Rush
 Intense feelings of warmth and ecstasy following
injection
 Stimulate receptors of the body’s opioid system
 Endorphins and enkephalins

 Tolerance develops and withdrawal occurs

 Muscle soreness and twitching, tearfulness, yawning
 Become more severe and also include cramps,
chills/sweating, increase in HR and BP, insomnia, &
vomiting
 Withdrawal lasts about 72 hours
+ Psychological and Physical Effects of 21

Opiates

 29 year follow up of 500 heroin addicts (Hser, et al.,

1993)
 28% dead by age 40
 Half by suicide, homicide, or accident
 One-third by overdose

 Many users resort to illegal activities to obtain

money for drugs
 Theft, prostitution, dealing drugs

 Exposure to infectious diseases via shared needles

 e.g. HIV
 Evidence suggests that free needles reduces
infectious diseases associated with IV drug use
 + Synthetic Sedatives 22

 Barbituates  Heavy dosages

 Induce muscle relaxation,
reduce anxiety, produce mild
euphoria
 In 1940s prescribed to aid
sleep
 Usage declined from 1975
thru 1990s but increased
recently
 Other synthetic sedatives
 Benzodiazepines
 e.g., Valium, Ketamine
 Stimulate GABA system
 Slurred speech
 Unsteady gait
 Impaired judgment &
concentration
 Irritability & combativeness
 Accidental suffocation due to
excessive relaxation of
diaphragm muscles
 Alcohol magnifies depressant
effects
 Tolerance & withdrawal
 Delirium, convulsions & other
symptoms
+ Stimulants: Amphetamines 23

 Increase alertness and motor activity

 Reduce fatigue
 Amphetamines
 Synthetic stimulants
 Benzedrine, Dexedrine, Methedrine
 Trigger release of and block reuptake of norepinephrine and
dopamine
 Produce high levels of energy, sleeplessness
 Reduce appetite, increase HR, constrict blood vessels in skin
and mucous membranes
 High doses can lead to:
 Nervousness, agitation, irritability confusion, paranoia,
hostility
 Tolerance can develop after only 6 days use (Comer et al., 2001)
+ Stimulants: Methamphetamine 24

Amphetamine derivative (aka crystal meth)

 Can be taken orally, intravenously, or intranasally
(snorting)
 In 2006, over 700,000 people used
methamphetamine (SAMHSA, 2007).
Chronic use damages brain
 Reduction in hippocampus volume (see figure
10.4; abusers represented by yellow bars)
+ Stimulants: Cocaine 25

 Alkaloid obtained from coca leaves

 Reduces pain
 Produces euphoria
 Heightens sexual desire
 Increases self-confidence and indefatigability

 Blocks reuptake of dopamine in mesolimbic areas of brain

 Overdose
 Chills, nausea, insomnia, paranoia, hallucinations; possibly heart
attack & death
 Not all users develop tolerance
 Some become more sensitive
 May increase risk of OD

 In
2006, 2.4 million people over the age of 12 reported using
cocaine, and 700,000 reported using crack (SAMHSA, 2007).
+ Stimulants: Cocaine 26

 Crack
 Form of cocaine that quickly become popular in
the 80s
 Rock crystal that is heated, melted, & smoked
 Cheaper than cocaine
 + Hallucinogens, Ecstasy, and PCP 27

 Hallucinogen effects include:  Mescaline

 Colorful visual hallucinations  Active ingredient of peyote
 Synestesias
 Ecstasy
 Overflow from one sensory
 Increase feelings of intimacy and
modality to another enhances mood
 Alterations in time perception  Chemically similar to mescaline
 Lability of mood and amphetamines
 Anxiety & paranoia  PCP (phencyclidine)
 Angel dust
 LSD
 Animal tranquilizer
 d-lysergic acid diethylamide
 Causes severe paranoia and
 Psilocybin
violence
 Extracted from mushroom
psylocube mexicana
+ Figure 10.5 Process of Becoming a Drug 28

Abuser
+ Etiology of Substance-Related Disorders: 29

Developmental approach

 Li et al. (2001) Two paths to alcohol abuse

1. First group began drinking in early
adolescence, increased drinking throughout
high school
2. Second group drank lesser amounts in early
adolescence, increased drinking in middle
school and again in high school.
 Boys more likely to be in the first group,
girls in the second group
 Developmental studies do not account for all
cases
 Not an inevitable progression through stages
 Etiology of Substance-Related Disorders:
+ Genetic Factors
30

 Relatives and children of problem drinkers have higher-

than-expected rates of alcohol abuse or dependence
 Greater concordance in MZ than DZ twins
 In men
 Alcohol, caffeine, smoking, marijuana, & drug abuse in
general
 In women
 Role of genetics less clear
 Fewer available studies
 Findings are mixed

 Genetic and shared environmental risk factors for illicit drug

abuse and dependence appear to be nonspecific
 Ability to tolerate large quantities of alcohol may be an
inherited diathesis
 Asians have low rates of alcohol abuse
 CYP2A6
 Gene associated with metabolism of nicotine
 Smokers with defect in this gene less likely to become
dependent (Rao et al., 2000)
+ Etiology of Substance-Related Disorders: 31

Neurobiological Factors
 Nearly all drugs, including alcohol, stimulate the dopamine system
in the brain
 Some evidence that people dependent on drugs or alcohol have a
deficiency in the dopamine receptor DRD2
 Peopletake drugs to avoid the bad feelings associated with
withdrawal
 Explains frequency of relapse

 Incentive-sensitization theory (Robinson & Berridge, 19983, 2003)

 Distinguish
 Wanting (craving for drug)
 Liking (pleasure obtained by taking the drug)
 Dopamine system becomes sensitive to the drug and the cues
associated with drug (e.g., needles, rolling papers, etc.)
 Sensitivity to cues induces & strengthens wanting

 Brainimaging studies show that cues for a drug (needle or a

cigarette) activate the reward and pleasure areas of the brain
+ Etiology of Substance-Related Disorders: 32

Psychological factors
 Mood alteration
 Tension reduction may be due to “alcohol myopia”
(Steele & Joseph, 1990)
 User focuses reduced cognitive capacity on
immediate distractions
 Less attention focused on tension-producing
thoughts
 Effect similar for smoking
 Cognitive distraction also reduces aggressive
behavior in intoxicated individuals
 However, alcohol and nicotine may increase tension
when no distractions are present.
 Expectancies about drugs effects influence behavior
 People who expect alcohol to reduce stress & anxiety
are most likely to drink
 The greater perceived risk, the less likely it is to be
used
+ Etiology of Substance-Related Disorders: 33

Psychopathology and Personality

 Personality factors that predict onset of substance

related disorders:
 Negative emotionality
 Desire for increased arousal and positive affect
 Constraint
 Harm avoidance, conservative moral values, &
cautious behavior
 Kindergarten children who were rated high in anxiety
and novelty seeking more likely to get drunk, smoke,
and use drugs in adolescence.
+ Etiology of Substance-Related Disorders: 34

Sociocultural factors

 Alcohol
is the most common abused substance
worldwide (Smart & Ogborne, 2000)
 Men consume more alcohol than women but
differences vary by country
 Israel
 Men drank 3x as much as women
 Netherlands
 Men drank 1½x as much as women

 Availability
 Usage is higher when alcohol and drugs are easily
available
+ Etiology of Substance-Related Disorders: 35

Sociocultural factors

 Family factors
 Parental alcohol use (Hawkins et al., 1997)
 Psychiatric, marital, or legal problems in the
family linked to drug abuse
 Lack of emotional support from parents
increases use of cigarettes, marijuana, and
alcohol (Cadoret et la., 1995a)
 Lack of parental monitoring linked to higher
drug usage (Chassin et al., 1996; Thomas et al.,
2000)
+ Etiology of Substance-Related Disorders: 36

Sociocultural factors

 Social network
 Social influence or social selection?
 Bullers et al.(2001) found evidence for both
 Having peers who drink influences drinking
behavior (social influence) but individuals also
choose friends with drinking patterns similar
to their own (social selection)
 Advertising and Media
 Countries that ban ads have 16% less
consumption than those that don’t (Saffer, 1991)
+ Treatment of Substance Related Disorders:
37

Alcohol Abuse and Dependence

 Inpatient hospital treatment

 Detoxification
 Withdrawal from alcohol under medical
supervision
 The therapeutic results of hospital treatment are
not superior to those of outpatient treatment
 Alcoholics Anonymous (AA)
 Largest self-help group for problem drinkers
 Regular meetings provide support, understanding,
and acceptance
 Promotes complete abstinence
 Although some studies have shown AA participation
predicts better outcome, recent studies suggest AA
no more effective than other forms of therapy.
+ Treatment of Substance Related Disorders: 38

Alcohol Abuse and Dependence

 Couples and Family Therapy

 Emphasizes support from problem drinker’s
partner
 Reduced problem drinking maintained1 year
after therapy ended
 Also reduced couples’ overall level of distress
+ Treatment of Substance Related Disorders: 39

Alcohol Abuse and Dependence

 Cognitive and Behavioral Treatments

 Contingency-Management Therapy
 Patient and family reinforce behaviors inconsistent with
drinking
 e.g., avoiding places associated with drinking
 Teach problem drinker how to deal with uncomfortable
situations
 e.g., refusing the offer of a drink
 AKA Community-reinforcement approach
 Relapse Prevention
 Strategies to prevent relapse
 Brief motivational interventions
Designed to curb heavy drinking in college
+ Treatment of Substance Related Disorders:
40

Alcohol Abuse and Dependence

Controlled drinking
 Beliefthat problem drinkers can consume
alcohol in moderation
 Avoid total abstinence and inebriation
 Guided self-change

Medications
 Antabuse (disulfiram)
 Produces nausea and vomiting if alcohol is
consumed
 Other medications include naltrexone,
naloxone, & acamprosate
 Most effective when combined with CBT
+ Treatment of Substance Related Disorders:
41

Nicotine Dependence

 Peer behavior important

 If others in social network stop smoking, increases likelihood
that individual will also stop
 Rapid smoking treatment
 Rapid puffing, focused smoking, & smoke holding
 Scheduled smoking
 Reduce nicotine intake gradually over a few weeks
 Physician’s advice
 By age 65, most smokers have quit (USDHHS, 1998b)
 Nicotine replacement treatments
 Gum, patches, or inhalers
 Reduce craving for nicotine
 Combining patch with antidepressants improved success rate
+ Treatment of Substance Related Disorders: 42

Illegal Drug Abuse and Dependence

 Detoxification central to treatment

 Psychological treatments
 Desipramine and CBT showed effectiveness for
cocaine use
 CBT especially helpful for users with high
dependence levels (Carroll et al., 1994, 1995)
 Operant conditioning
 Tokens that can be traded for desirable goods are
given to users who abstain (Dallery et al., 2001)
 Motivational interviewing or enhancement thereapy
 CBT plus Rogerian therapy effective for alcohol and
drug use (Burke et al., 2003)
 Self-help residential homes for heroin users
 Non-drug environment
 Group therapy
 Guidance and support from former users
+ Treatment of Substance Related Disorders: Illegal
43

Drug Abuse and Dependence

 Drug replacement treatments and medications

A meta-analysis of stimulant medication as a
treatment for cocaine abuse revealed little
evidence that this type of medication is effective
 Heroin replacements
 Synthetic narcotics
 Methadone, levomethadyl acetate,
bupreophine
 Used to wean heroin users from dependence
 More effective if combined with psychological
support & treatment (Lilley et al., 2000)
+ 44

Prevention of Substance-
Related Disorders
 Often aimed at adolescents
 Utilizesome or all of the following elements:
 Enhancing self-esteem
 Social skills training
 Peer pressure resistance training
 Parental involvement in school programs
 Warning labels on alcohol bottles
 Education regarding alcohol impairment
 Testing for drugs and alcohol at school or work