1. PSY 301 INTRODUCTION to PSYCHOPATHOLOGY Dr. İlkiz Altınoğlu Dikmeer Fall 2014 © 2012 John Wiley & Sons, Inc. All rights reserved.

2. PowerPoint  Lecture Notes Presentation Chapter 10 Substance Use Disorders Copyright © 2012 John Wiley & Sons, Inc. All rights reserved. Abnormal Psychology, Twelfth Edition by Ann M. Kring, Sheri L. Johnson, Gerald C. Davison, & John M. Neale & John M. Neale

3. Chapter Outline Chapter 10: Substance Use Disorders I. Clinical Descriptions, Prevalence, and Effects of Substance Use Disorders II. Etiology of Substance Use Disorders III. Treatment of Substance Use Disorders © 2012 John Wiley & Sons, Inc. All rights reserved.

4. Table 10.1: Percentage of U.S. Population Reporting Drug Use in Past Month (2010) © 2012 John Wiley & Sons, Inc. All rights reserved.

5. Substance Use Disorders DSM-IV-TR pathological use of substances divided into two categories: – Substance dependence (addiction) Occupational or social problems, much time trying to obtain substance, continued use despite problems, etc. Involves either tolerance or withdrawal – Substance abuse ( Maladaptive use of substance ) No physiological dependence DSM-5 has one category: – Substance use disorder – Categorize by specific substance: Alcohol Amphetamine Cannabis Cocaine Hallucinogen Inhalant Opioid Phencyclidine Sedative/hypnotic/anxiolytic Tobacco © 2012 John Wiley & Sons, Inc. All rights reserved.

6. Addiction Severe substance use disorder – Having four more severe symptoms, such as: Tolerance : Greater amounts required to produce desired effect Withdrawal: Negative physical and psychological effects from stopping or reducing usage Using more than intended amounts Trying unsuccessfully to stop Having physical or psychological problems made worse by drug Experience problematic relationships – With physiological dependence: Presence of either tolerance or withdrawal – Without physiological dependence: Absence of either tolerance or withdrawal

7. Tolerance – Greater amounts required to produce desired effect – Results from changes in the number or sensitivity of GABA / glutomate receptors Withdrawal – Negative physical and psychological effects from stopping or reducing usage e.g./ Restlessness, anxiety, cramps, twitching or pain in muscles – Results from increase of activation of neuroal pathways to compensate for drug’s inhibitoru effects in the brain. © 2012 John Wiley & Sons, Inc. All rights reserved.

8. Proposed DSM-5 Criteria for Substance Use Disorder © 2012 John Wiley & Sons, Inc. All rights reserved. Problematic pattern of use that impairs functioning. Two or more symptoms within a 1 year period: Failure to meet obligations Repeated use in situations where it is physically dangerous Repeated relationship problems Continued use despite problems caused by the substance Tolerance Withdrawal Substance taken for a longer time or in greater amounts than intended Efforts to reduce or control use do not work Much time spent trying to obtain the substance Social, hobbies, or work activities given up or reduced Continued use despite knowing problems caused by substance Craving to use the substance is strong

9. Alcohol Use Disorder Alcoholic – Physiologically dependent or heavy user Delirium tremens (DTs) – Can occur when blood alcohol levels drop suddenly – Results in: Deliriousness Tremulousness Hallucinations – Primarily visual; may be tactile Polydrug abuse – Many alcohol users abuse multiple substances e.g., cigarettes, cocaine, marijuana 85% of alcohol abusers are smokers © 2012 John Wiley & Sons, Inc. All rights reserved.

10. Prevalence of Alcohol Abuse Lifetime prevalence: – Abuse – 17% – Dependence – 12% Binge drinking – 5 drinks in short period (e.g., within an hour) – 43.5% prevalence among college students Heavy use drinking – 5 drinks, 5 or more times in a 30-day period 16% prevalence among college students © 2012 John Wiley & Sons, Inc. All rights reserved.

11. Prevalence of Alcohol Abuse White and Hispanic adolescents and adults more likely to binge drink than African Americans Binge and heavy use drinking lowest among Asian Americans Alcohol dependence highest among Native Americans and Hispanics 21.3% of those with alcohol abuse or dependence also have at least 1 mental disorder – e.g. personality disorders, mood or anxiety disorders, or schizophrenia © 2012 John Wiley & Sons, Inc. All rights reserved.

12. Short-term Effects of Alcohol Enters the bloodstream quickly through small intestine – Metabolized by the liver slowly at 1 ounce (3 mg) of 100 proof per hour (%50) Effects vary by concentration – Concentration varies by gender, height, weight, liver efficiency, food in stomach Size of drink defined by alcohol content – 12 oz. glass of beer, 5 oz. glass of wine, and 1.5 oz. of hard liquor are equal in alcohol content © 2012 John Wiley & Sons, Inc. All rights reserved.

13. Short-term Effects of Alcohol Interacts with several neural systems – Stimulates GABA receptors Reduces tension – Increases dopamine and serotonin Produces pleasurable effects – Inhibits glutamate receptors Produces cognitive difficulties (e.g., slowed thinking, memory loss) Effect of ingesting large amounts – Significant motor impairment – Poor decision making – Poor awareness of errors made © 2012 John Wiley & Sons, Inc. All rights reserved.

14. Long-term Effects of Alcohol Malnutrition – Calories from alcohol lack nutrients – Alcohol interferes with digestion and absorption of vitamins from food – Deficiency of B-complex vitamins causes Amnestic syndrome Severe loss of memory for both long- and-short-term information Cirrhosis of the liver – Liver cells engorged with fat and protein, impeding functioning – Cells die, triggering scar tissue which obstructs blood flow – Liver disease and cirrhosis rank 12 th in U.S. causes of death. Damage to endocrine glands and pancreas Heart failure Erectile dysfunction Hypertension Stroke Capillary hemorrhages – Facial swelling and redness, especially in nose Destruction of brain cells – Especially areas important to memory © 2012 John Wiley & Sons, Inc. All rights reserved.

15. Fetal Alcohol Syndrome Heavy alcohol intake during pregnancy – Leading cause of mental retardation – Fetal growth slowed – Cranial, facial and limb anomalies occur Total abstinence by pregnant women recommended © 2012 John Wiley & Sons, Inc. All rights reserved.

16. Tobacco Use Disorder Nicotine – Addicting agent of tobacco – Stimulates dopamine neurons in mesolimbic area Involved in reinforcing effect © 2012 John Wiley & Sons, Inc. All rights reserved.

17. Prevalence and Health Consequences About 440,000 Americans die prematurely each year Cigarettes kill 1,100 people every day – 1 of 6 deaths related to tobacco use Lung cancer is most common cancer – 87% caused by smoking Cigarettes also cause or exacerbate: – Emphysema, cancers of larynx, esophagus, pancreas, bladder, cervix, stomach, cardiovascular disease – Sudden infant death syndrome and pregnancy complications © 2012 John Wiley & Sons, Inc. All rights reserved.

18. Prevalence and Health Consequences More prevalent among White and Hispanic youth than African Americans – African Americans less likely to quit and more likely to get lung cancer Metabolize nicotine more slowly Smoke more menthol cigarettes, which is inhaled more deeply and longer 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 U.S. © 2012 John Wiley & Sons, Inc. All rights reserved.

19. Marijuana 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 In DSM-5, called Cannabis use disorder © 2012 John Wiley & Sons, Inc. All rights reserved.

20. Marijuana: Prevalence Most frequently used illicit drug in U.S. – 17,000,000 reported using it in 2010 Greater use by men than women Use more common in European- and Hispanic Americans than in African- and Asian-Americans, and Hispanics Heavier use in US than in Europe, Africa, or Canada © 2012 John Wiley & Sons, Inc. All rights reserved.

21. Figure 10.3: Trends in Drug use Among Young People Ages 18-25 © 2012 John Wiley & Sons, Inc. All rights reserved.

22. Effects of Marijuana Major active ingredient – THC (delta-9-tetrahydrocannabinol) Psychological – Feelings of relaxation and sociability – Rapid shifts of emotion – Interferes with attention, memory, and thinking Decline in IQ over time – Heavy doses can induce hallucinations and panic – Difficult to regulate dosage Effects take 30 minutes to appear Smoke more than intended waiting for effects – Interfere with cognitive functioning Impairs memory, complex motor skills Physiological – Bloodshot and itchy eyes – Dry mouth and throat – Increased appetite – Reduced pressure within the eye – Increased BP – Damage to lung structure and function in long-term users © 2012 John Wiley & Sons, Inc. All rights reserved.

23. Marijuana and the Brain  Two cannabinoid brain receptors – CB1 and CB2 – High concentration in hippocampus Increased blood flow to emotion regions – Amygdala and anterior cingulate Habitual use leads to tolerance – Withdrawal symptoms also observed © 2012 John Wiley & Sons, Inc. All rights reserved.

24. Therapeutic Effects of Marijuana Reduces nausea and loss of appetite caused by chemotherapy Relieves discomfort of AIDS, chronic pain Supreme Court rulings: – Federal law prohibits dispensing marijuana for medicinal purposes – Medical use can be prohibited by federal government even if states approve © 2012 John Wiley & Sons, Inc. All rights reserved.

25. Opiates Group of addictive sedatives that in moderate doses relieve pain and induce sleep – Opium – Morphine – Heroin – Codeine Synthetic sedatives – Separate category from DSM-5 sedative/hypnotic/anxiolytic use disorder Opiates legally prescribed as pain medications include: – Hydrocodone combined with other substances yields Vicodin, Zydone, and Lortab – Oxycodone the basis for OxyContin, Percodan, and Tylox © 2012 John Wiley & Sons, Inc. All rights reserved.

26. Prevalence of Opiate Use Heroin – Estimated 1,000,000 individuals addicted to heroin in U.S. – Accounted for 62 to 82% of drug-related hospital admissions in 2003  5 million pain meds users – OxyContin prescriptions jumped 1800% between 1996 and 2000 – Hydrocodone use increased from 4.5 to 5.7 million users – Oxycodone abuse increased 43% in just 1 year (1997 to 1998) – Rates of abuse of pain meds has remained stable since 2002 © 2012 John Wiley & Sons, Inc. All rights reserved.

27. Psychological and Physical Effects of Opiates Produce euphoria, drowsiness, 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 – Stimulate nucleus accumbens 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, and vomiting Heroin withdrawal begins w/in 8 hrs of the last injection and lasts about 72 hours, diminish gradually over a 5 to10-day period © 2012 John Wiley & Sons, Inc. All rights reserved.

28. Psychological and Physical Effects of Opiates 29 year follow-up of 500 heroin addicts – 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 reduce infectious diseases associated with IV drug use © 2012 John Wiley & Sons, Inc. All rights reserved.

29. Figure 10.4: ER Visits for Hydrocodone and Oxycodone ODs © 2012 John Wiley & Sons, Inc. All rights reserved.

30. Stimulants: Amphetamines 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 © 2012 John Wiley & Sons, Inc. All rights reserved.

31. Stimulants: Methamphetamine Methamphetamine (aka crystal meth) – Amphetamine derivative – Can be taken orally, intravenously, or intranasally (snorting) Chronic use damages brain – Impacts dopamine and serotonin systems – Reduction in hippocampus volume (yellow bars vs. non-users (blue bars) in figure 10.5, at right) © 2012 John Wiley & Sons, Inc. All rights reserved.

32. Stimulants: Cocaine Crack – Form of cocaine that quickly become popular in the ’80s – Rock crystal that is heated, melted, and smoked – Cheaper than cocaine 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 and death Not all users develop tolerance – Some become more sensitive May increase risk of OD Cocaine use declined between 2002 and 2009, dropping to 1.4% from 2% – Crack use is also declining © 2012 John Wiley & Sons, Inc. All rights reserved.

33. Hallucinogens, Ecstasy, and PCP LSD – d-lysergic acid diethylamide Hallucinogen effects include: – Colorful visual hallucinations – Psychedelic trip: expansion of consciousness Only 1-2% regular users – African Americans less likely to use than others Flashbacks – Hallucinogen persisting perception disorder (HPPD) Most common during stress Other hallucinogens: Mescaline – Active ingredient of peyote Psilocybin – Extracted from mushroom psilocybe mexicana Ecstasy (MDMA) – Methylenedioxymethamphetamine – Increase feelings of intimacy and enhances mood – Chemically similar to mescaline and amphetamines – Acts on serotonin – Improves interpersonal relations – Its use peaked in 2001, with 1.8 million users; may be rising again PCP (phencyclidine) – Angel dust – Animal tranquilizer – Causes severe paranoia and violence © 2012 John Wiley & Sons, Inc. All rights reserved.

34. Figure 10.6: Process of Becoming a Drug Abuser © 2012 John Wiley & Sons, Inc. All rights reserved.

35. Etiology of Substance-Use Disorders: Developmental Approach  Two paths to alcohol abuse ( Boys more likely to be in the first group, girls in the second group) 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 Developmental studies do not account for all cases – Not an inevitable progression through stages © 2012 John Wiley & Sons, Inc. All rights reserved.

36. Etiology of Substance-Related Disorders: Genetic Factors Relatives and children of problem drinkers have higher-than-expected rates of alcohol abuse or dependence Greater concordance in MZ than DZ twins 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 Deficient enzymes (ADH or alcohol dehydrogenases) Genes and smoking – People with SLC6AS less likely to smoke and more likely to quit – Smokers with defect in CYP2A6 gene less likely to become dependent © 2012 John Wiley & Sons, Inc. All rights reserved.

37. Etiology of Substance-Related Disorders: Neurobiological Factors Nearly all drugs, including alcohol, stimulate the dopamine system in the brain, particularly the mesolimbic pathway – Produce rewarding or pleasurable feelings – Some evidence that people dependent on drugs or alcohol have a deficiency in the dopamine receptor DRD2 – Vulnerability model vs. Toxic effect model Vulnerability in the dopamine system leads to substance use or substance use leads to dopamine system problems People take drugs to avoid the bad feelings associated with withdrawal – Explains frequency of relapse Incentive-sensitization theory – Distinguish Wanting (craving for drug) from 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 and strengthens wanting Brain imaging studies show that cues for a drug (needle or a cigarette) activate the reward and pleasure areas of the brain involved in drug use © 2012 John Wiley & Sons, Inc. All rights reserved.

38. Figure 10.7: Reward Pathways in Brain Affected by Different Drugs © 2012 John Wiley & Sons, Inc. All rights reserved.

39. Etiology of Substance-Use Disorders: Psychological factors Mood alteration – Tension reduction may be due to “alcohol myopia” User focuses reduced cognitive capacity on immediate distractions Less attention focused on tension-producing thoughts – Effect similar for smoking – However, alcohol and nicotine may increase tension when no distractions are present Crying in one’s beer Expectancies about drug effects – People who expect alcohol to reduce stress and anxiety are most likely to drink – Drinking and positive expectancies influence each other positively © 2012 John Wiley & Sons, Inc. All rights reserved.

40. Etiology of Substance-Use Disorders: Personality Personality factors that predict onset of substance-related disorders: – Negative emotionality or negative affect – Desire for increased arousal and positive affect – Low constraint Harm avoidance, conservative moral values, and cautious behavior Kindergarten children who were rated high in anxiety and novelty seeking more likely to get drunk, smoke, and use drugs in adolescence © 2012 John Wiley & Sons, Inc. All rights reserved.

41. Etiology of Substance-Use Disorders: Sociocultural Factors Alcohol is the most common abused substance worldwide – Highest consumption in France, Spain, and Italy where consumption is widely accepted 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 In 2003, drug use among youths who had been approached by drug dealers was 35 percent, compared to just under 7 percent among youths who had not been approached © 2012 John Wiley & Sons, Inc. All rights reserved.

42. Etiology of Substance-Use Disorders: Sociocultural Factors Family factors – Parental alcohol use – Marital discord, psychiatric or legal problems in the family linked to substance use – Lack of emotional support from parents increases use of cigarettes, marijuana, and alcohol – Lack of parental monitoring linked to higher drug usage © 2012 John Wiley & Sons, Inc. All rights reserved.

43. Etiology of Substance-Related Disorders: 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 © 2012 John Wiley & Sons, Inc. All rights reserved.

44. Treatment of Substance Use Disorders: Alcohol Use Disorders In 2009, 1.5 million people over the age of 12 received treatment for alcohol abuse or dependence – Over 17 million people over the age of 12 were in need of treatment for alcohol or drug problems, but did not get it – Only 1 in 4 who are physiologically dependent ever get treatment Inpatient hospital treatment – Detoxification Withdrawal from alcohol under medical supervision The therapeutic results of hospital treatment are not superior to those of outpatient treatment May be necessary for those without social support or with other serious psychological problems 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 © 2012 John Wiley & Sons, Inc. All rights reserved.

45. Table 10.2: The 12 Steps of AA © 2012 John Wiley & Sons, Inc. All rights reserved.

46. Treatment of Substance Use Disorders: Alcohol Use Disorders 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 – Relapse prevention Strategies to prevent relapse Motivational interventions – Designed to curb heavy drinking in college © 2012 John Wiley & Sons, Inc. All rights reserved.

47. Treatment of Substance Use Disorders: Alcohol Use Disorders Controlled drinking – Belief that 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, and acamprosate Most effective when combined with CBT © 2012 John Wiley & Sons, Inc. All rights reserved.

48. Treatment of Substance Use Disorders: Nicotine Dependence Peer behavior important – If others in social network stop smoking, increases likelihood that individual will also stop Physician’s advice – By age 65, most smokers have quit Scheduled smoking – Reduce nicotine intake gradually over a few weeks Nicotine replacement treatments – Gum, patches, or inhalers – Reduce craving for nicotine – Combining patch with antidepressants (Wellbutrin) improved success rate © 2012 John Wiley & Sons, Inc. All rights reserved.

49. Treatment of Drug Use Disorders Detoxification central to treatment Psychological treatments – Desipramine and CBT showed effectiveness for cocaine use CBT especially helpful for users with high dependence levels – Contingency management Vouchers that can be traded for desirable goods are given to users who abstain – Motivational interviewing or enhancement therapy CBT plus solution focus therapy effective for alcohol and drug use – Self-help residential homes Non-drug environment Group therapy Guidance and support from former users © 2012 John Wiley & Sons, Inc. All rights reserved.

50. Treatment of Drug Use Disorders: Drug Replacement Treatments and Medications Heroin substitutes – Synthetic narcotics Methadone, levomethadyl acetate, bupreophine Used to wean heroin users from dependence Opiate antagonists – Naltrexone Prevents feeling high © 2012 John Wiley & Sons, Inc. All rights reserved.

51. Prevention of Substance-Use Disorders Often aimed at adolescents Utilize some 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 – Correction of beliefs and expectations – Inoculation against mass media messages – Peer leadership © 2012 John Wiley & Sons, Inc. All rights reserved.

52. COPYRIGHT Copyright 2012 by John Wiley & Sons, Inc. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission of the copyright owner. © 2012 John Wiley & Sons, Inc. All rights reserved.