PowerPoint  Lecture Notes Presentation
Chapter 10
Substance Related Disorders
Abnormal Psychology, Eleventh Edition
by
Ann M. Kring, Gerald C. Davison, John M. Neale,
& Sheri L. Johnson
Table 10.1 Percentage of US Population
Reporting Drug Use in Past Month (2006)
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Substance Dependence and Abuse

Substance dependence (addiction)
» Occupational or social problems, much time trying to obtain substance,
continued use despite problems, etc.

Involves either tolerance or withdrawal
» Tolerance
– Greater amounts required to produce desired effect
» Withdrawal
– Physiological and psychological consequences when individual
discontinues or reduces substance use


Restlessness, anxiety, cramps, death
Substance abuse
» Maladaptive use of substance
» No physiological dependence

In 2006, 22 million met criteria for dependence or abuse.
» Of those 15 million involved alcohol.
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Alcohol Dependence and Abuse

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
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Alcohol Abuse and Dependence

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
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Alcohol Abuse and Dependence

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
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Prevalence of Alcohol Abuse

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
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Prevalence of Alcohol Abuse




White adolescents and adults more likely to
abuse alcohol than African Americans
Binge & 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, mood, or anxiety disorders, or
schizophrenia
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Short-term Effects of Alcohol

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
– Increase in negative emotions
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Short-term Effects of Alcohol

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
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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

» 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
12th in US 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
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Fetal Alcohol Syndrome

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
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Nicotine and Cigarette Smoking

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
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Prevalence and Health
Consequences


About 440,000 Americans die prematurely
each year (USD-HHS, 2004)
Cigarettes kill 1,100 people every day
» 1 of 6 deaths related to tobacco use


Lung cancer is most common cancer
Cigarettes also cause or exacerbate:
» Emphysema, cancers of larynx, esophagus,
pancreas, bladder, cervix, stomach
» Sudden infant death syndrome and pregnancy
complications
» Cardiovascular disease
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Prevalence and Health
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
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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
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Prevalence

Most frequently used
illicit drug in US
» 15,000,000 reported
using it in 2006


Heavier use in US
than in Europe,
African, or Canada
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
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Figure 10.2 Trends in Young Adults’ Use
in Previous Month from 2002 to 2006
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Effects of Marijuana

Major active ingredient

» THC (delta-9tetrahydrocannabinol)

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
» Impairment of skills needed
for driving
Physiological
»
»
»
»
Bloodshot & itchy eyes
Dry mouth and throat
Increased appetite
Reduced pressure within the
eye
» Increased BP
» Abnormal heart rate
– May exacerbate preexisting
cardiovascular problems
» Damage to lung structure
and function in long term
users
– Impairment present for
several hours after ‘high’
has worn off
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Marijuana and the Brain

CB1 and CB2
» Two cannabinoid brain receptors
» High concentration in hippocampus
– Contributes to STM deficits

Increased blood flow to emotion regions
» Amygdala and anterior cingulate gyrus

Decreased blood flow to temporal lobe
» Associated with auditory attention
– Poor performance on listening tasks

Habitual use leads to tolerance
» Withdrawal symptoms also observed
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Therapeutic Effects of Marijuana




Reduces nausea 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:
» Federal law prohibits dispensing marijuana for
medicinal purposes
» Medical use can be prohibited by federal
government even if states approve
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Opiates

Group of addictive sedatives that in moderate doses
relieve pain and induce sleep
»
»
»
»

Opium
Morphine
Heroin
Codeine
Synthetic sedatives
» Seconal and valium

Opiates legally prescribed as pain medications
include:
» Hydrocodone combined with other substances yields Vicodin,
Zydone, and Lortab
» Oxycodone the basis for OxyContin, Percodan, & Tylox.
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Prevalence of Opiate Use

Herion
» 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
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Psychological and Physical Effects of
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
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Psychological and Physical Effects of
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
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Figure 10.3 ER Visits for Hydrocodone
and Oxycodone ODs
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Synthetic Sedatives

Barbituates

» 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
Heavy dosages
» 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
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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 (Comer et al.,
2001)
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Stimulants: Methamphetamine

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)
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Stimulants: 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 & 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).
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Stimulants: Cocaine

Crack
» Form of cocaine that quickly become
popular in the 80s
» Rock crystal that is heated, melted, &
smoked
» Cheaper than cocaine
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Hallucinogens, Ecstasy, and PCP

Hallucinogen effects include:
» Colorful visual hallucinations
» Synestesias
– Overflow from one sensory
modality to another

» Alterations in time
perception
» Lability of mood
» Anxiety & paranoia
LSD

» Extracted from mushroom
psilocybe mexicana

In 2006, there were about
100,000 users, down from 1
million in 2002
»
African Americans less likely to use
than others
Mescaline
» Active ingredient of peyote

Ecstasy
» Increase feelings of intimacy
and enhances mood
» Chemically similar to mescaline
and amphetamines
» Acts on serotonin
» Its use peaked in 2001, with 1.8
million users.
» d-lysergic acid diethylamide

Other hallucinogens
Psilocybin

PCP (phencyclidine)
» Angel dust
» Animal tranquilizer
» Causes severe paranoia and
violence
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Figure 10.5 Process of Becoming a
Drug Abuser
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Etiology of Substance-Related Disorders:
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
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Etiology of Substance-Related Disorders:
Genetic Factors


Relatives and children of problem drinkers have higher-thanexpected 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
– Evidence for physiological intolerance in this group

CYP2A6
» Gene associated with metabolism of nicotine
» Smokers with defect in this gene less likely to become dependent (Rao
et al., 2000)
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Etiology of Substance-Related Disorders:
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

People take 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

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.
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Figure 10.6 Reward Pathways in Brain affected
by Different Drugs
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Etiology of Substance-Related
Disorders: 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.
» Crying in one’s beer

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
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Etiology of Substance-Related Disorders:
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.
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Etiology of Substance-Related
Disorders: Sociocultural factors

Alcohol is the most common abused substance worldwide
(Smart & Ogborne, 2000)
» Highest consumption in France, Spain, & Italy where
consumption is widely accepted (deLint et al., 1978)

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
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Etiology of Substance-Related
Disorders: 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)
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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 (Saffer, 1991)
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Treatment of Substance Related Disorders:
Alcohol Abuse and Dependence

In 2006, 4 million people over the age of 12 received treatment
for alcohol abuse or dependence
» Over 21 million people over the age of 12 were in need of treatment
for alcohol or drug problems

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.
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Table 10.2 The12 Steps of AA
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Treatment of Substance Related Disorders:
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
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Treatment of Substance Related Disorders:
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
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Treatment of Substance Related Disorders:
Alcohol Abuse and Dependence

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, &
acamprosate
– Most effective when combined with CBT
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Treatment of Substance Related Disorders:
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
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Treatment of Substance Related Disorders:
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
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Treatment of Substance Related Disorders:
Illegal 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)
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Prevention of Substance-Related
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
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