chapter 14 substance-related and impulse-control disorders

Chapter 14

Substance-Related and Impulse-Control Disorders

Copyright © 2011 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 142

DSM-5 Proposal

Combine the substance-related and impulse-control disorders into one new category, addiction and related disorders.


Substance Abuse

A substance is any natural or synthesized product that has psychoactive effects—it changes perceptions, thoughts, emotions, and behaviors.


In the United States, ethnic and age groups have different rates of drug use


The rate of illegal drug use by young adults has fluctuated over time


Substance-Related Conditions Recognized by the DSM-IV-TR Substance intoxication: Experience of significant

maladaptive behavioral and psychological symptoms due to the effect of a substance on the central nervous system.

Substance withdrawal: Experience of clinical significant distress in social, occupational, or other areas of functioning due to the cessation or reduction of substance use.


Substance-Related Conditions Recognized by the DSM-IV-TR, continued Substance abuse: Diagnosis given when recurrent substance use leads to significant harmful consequences.

Substance dependence: Diagnosis given when substance use leads to physiological dependence or significant impairment or distress.


Five categories of abused substances (1) central nervous system depressants, including

alcohol, barbiturates, benzodiazepines, and inhalants

(2) central nervous system stimulants, including cocaine, amphetamines, nicotine, and caffeine

(3) opioids, including heroin and morphine (4) hallucinogens and phencyclidine (PCP) (5) cannabis


DSM-IV-TR Criteria for Substance Abuse

One or more of the following occurs during a 12-month period, leading to significant impairment or distress:

1. Failure to fulfill important obligations at work, home, or school as a result of substance abuse.

2. Repeated use of the substance in situations in which it is physically hazardous to do so.

3. Repeated legal problems as a result of substance use.

4. Confirmed use of the substance despite repeated social or legal problems as a result of use.


DSM-IV-TR Criteria for Substance DependenceMaladaptive pattern of substance use, leading to

three or more of the following: Tolerance, as defined by either the need for markedly

increased amounts of the substance to achieve intoxication or desired effect; markedly diminished effect with continued use of the same amount.

Withdrawal, as manifested by either: the characteristic withdrawal syndrome for the substance; the same or closely related substance is taken to relieve or avoid withdrawal symptoms.

The substance is often taken in larger amounts or over a longer period than was intended.


DSM-IV-TR Criteria for Substance Dependence, continued

Persistent desire or unsuccessful efforts to cut back or control use.

A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.

Important social, occupational, or recreational activities are given up or reduced because of substance use.

The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem caused or exacerbated by the substance.


DSM-5 Proposal

Substance abuse and dependence may be combined in one diagnosis to be called substance-use disorder.

Diagnostic criteria for substance-use disorder will include: continued use of substances despite negative social,

occupational, and health consequences evidence of tolerance or withdrawal.

“Craving the substance” will be added because it is a common symptom of abuse/dependence

“Legal problems” will be removed from the criteria


Depressants

Depressants slow the central nervous system.

In moderate doses, they make people relaxed and somewhat sleepy, reduce concentration, and impair thinking and motor skills.

Includes alcohol, benzodiazepines, barbiturates, and inhalants.


Alcohol

Alcohol abuse Alcohol dependence Binge drinking Withdrawal


Long-term Effects of Alcohol Abuse Low-grade hypertension Alcohol-induced persisting amnesic disorder Wernicke’s encephalopathy Korsakoff’s pyschosis Alcohol-induced dementia


Cultural Differences in Alcohol Disorders


Ethnic Differences in Alcohol Use in the United States


Gender Differences


Benzodiazepines and Barbiturates Benzodiazepines (such as Xanax, Valium,

Halcion, and Librium) and barbiturates (such as Quaalude) are legally manufactured and sold by prescription, usually for the treatment of anxiety and insomnia.

Two common patterns of abuse can develop with these substances: 1. adolescents using them for recreational purposes 2. people (particularly women) using initially under

physician’s care but then increasing doses as tolerance develops


Inhalants

Inhalants: solvents such as gasoline, glue, paint thinners, and spray paints.

Greatest users of inhalants are young boys between 10 and 15 years of age.

Chronic users may have a variety of respiratory irritations and rashes.

Can also cause permanent damage to the central nervous system, and can lead to organ failure and death.


Stimulants

Activate the central nervous system, causing feelings of energy, happiness, and power, a decreased desire for sleep, and a diminished appetite

Include cocaine and the amphetamines (including the related drugs methamphetamines) Impart a psychological lift or rush Cause dangerous increases in blood pressure and heart rate,

alter the rhythm and electrical activity of the heart, and constrict the blood vessels, which can lead to heart attacks, respiratory arrest, and seizures

Caffeine and nicotine Prescription stimulants, including Dexedrine and Ritalin


Stimulants: Cocaine

Symptoms include:– behavioral changes (e.g., euphoria or affective

blunting; impaired judgment)– rapid heartbeat, dilation of pupils, elevated or

lowered blood pressure– weight loss, nausea or vomiting– muscular weakness– slowed breathing, chest pain, confusion – seizures, coma


Stimulants: Amphetamines

Used to combat depression or fatigue or boost energy and self-confidence; also in diet drugs

Cause the release of dopamine and norepinephrine and clock reuptake

Symptoms of intoxication are similar to cocaine intoxication


Stimulants: Nicotine

• No DSM-IV-TR diagnosis for the symptoms, but nicotine operates on both the central and peripheral nervous system

• Results in the release of several biochemicals that may have direct reinforcing effects on the brain, including dopamine, norepinephrine, serotonin, and the endogenous opioids


Stimulants: Nicotine, continued

• Withdrawal Symptoms • dysphoria or depressed mood• insomnia• irritability• frustration or anger• anxiety • difficulty concentrating• restlessness • decreased heart rate • increased appetite or weight gain


Stimulants: Caffeine

• The most heavily used stimulant drug

• 75% of caffeine ingested through coffee

• The average American drinks about two cups of coffee per day; a cup of brewed coffee has about 100 milligrams of caffeine

• Caffeine stimulates the central nervous system increasing levels of dopamine, norepinephrine, and serotonin


Stimulants: Caffeine, continued• Symptoms: Restlessness, nervousness,

excitement, insomnia, flushed face, frequent urination, stomach upset, muscle twitching, rambling flow of thought or speech, rapid heartbeat, periods of inexhaustibility, psychomotor agitation

• Withdrawal Symptoms: Marked fatigue or drowsiness, increased appetite or weight gain, marked anxiety or depression, nausea or vomiting


Opioids- derived from the opium poppy• Morphine

• Heroin

• Codeine

• Methadone


Hallucinogens and PCP

Hallucinogens are a mixed group of substances including LSD, MDMA (also called ecstasy), and peyote.

PCP, also known as angel dust, is a manufactured as a powder to be snorted or smoked. Although not classified as a hallucinogen, it has many of the same effects.


Cannabis

The leaves of the cannabis (or hemp) plant can be cut, dried, and rolled into cigarettes or inserted into food and beverages. In North America, the result is known as marijuana, weed, pot, grass, reefer, and Mary Jane

Cannabis is the most commonly used illegal drug in the United States, with about 40% of the population reporting use of it at some time in their lives, and 6% in the last month

About 7% of the population would qualify for a diagnosis of cannabis abuse, and 2 to 3% for a diagnosis of cannabis dependence

Occasional use is widespread: 30% of college students say they have used cannabis in the last year


Theories of Substance Use, Abuse, and Dependence These substances affect several

biochemicals that can have direct reinforcing effects on the brain.

The brain appears to have its own “pleasure pathway” that affects our experience of reward


BRAIN MAP SHOWINGSEPTAL/HIPPOCAMPAL


Biological Theories

Genetic Factors Family history, adoption, and twin studies all suggest that

genetics may play a substantial role in at least some forms of addiction.

Reward Sensitivity Substantial individual differences in sensitivity to the rewarding

properties of substances.


Psychological Theories

Social-learning theories: Children and adolescents learn alcohol-related behaviors from the modeling of their parents and important others in their culture.

Cognitive theories: focus on people’s expectations of its effects and their beliefs about the appropriateness of using it to cope with stress.

Personality characteristic of behavioral under control: the tendency to be impulsive, sensation-seeking, and prone to antisocial behaviors such as violating laws.


Sociocultural Approaches

Chronic stress combined with an environment that supports and even promotes the use of substances as an escape is a recipe for widespread substance abuse and dependence.

Substance use, particularly alcohol use, is much more acceptable for men than for women in many societies.

When women do become substance abusers, their patterns of use and reasons for use tend to differ from men’s.


Treatments for Substance-Related Disorders Biological Treatments

Medications, including antianxiety drugs, antidepressants, and antagonists

Methadone Maintenance Programs Behavioral and Cognitive Treatments

Aversive classical conditioning Covert sensitization therapy Contingency management programs Cognitive treatments Motivational interviewing Relapse prevention Alcoholics Anonymous


Impulse-Control Disorders

Include kleptomania, pyromania, pathological gambling, intermittent explosive disorder, and trichotillomania

People with these disorders often feel a mounting sense of tension relieved only by engaging in their impulsive act

Some researchers consider these disorders to be similar to substance-related disorders, and due to abnormalities in reward systems in the brain

Others consider them to be part of the obsessive-compulsive disorder continuum

DSM-5 authors have proposed moving these disorders to various categories depending on the available research for each disorder

chapter 14 substance-related and impulse-control disorders

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