+
Chapter 10
Substance
Related Disorders
Abnormal Psychology, Eleventh Edition
by
Ann M. Kring, Gerald C. Davison, John M. Neale,
& Sheri L. Johnson
+
2
Percentage of Indonesian Population Reporting
Drug Use in 2003-2006 (Based on BNN survey)
Based on areas

Jakarta
: 23%

Medan
: 15%

Bandung : 14%

Surabaya : 6.3 %

Maluku utara : 4.3 %

Padang
: 5.5 %

Kendari
: 5%
Based on substance
 Marijuana
: 74.9 %
 Anti-Depressant
 Ecstasy
: 32.5 %
: 25.7 %
 Amphetamine
: 21.5 %
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3
Substance Dependence and Abuse
Dependence ( Adiction)


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
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


Negative social and occupational effects
No tolerance, withdrawal, or compulsive usage
 Alcohol


abuse
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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5
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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6
Alcohol Abuse and Dependence
 Polydrug
 Many


abuse
users abuse multiple substances
e.g., cigarettes, cocaine, marijuana
85% of alcohol are smokers
 Synergistic
 Some

Alcohol and barbiturates


combinations of drugs produce stronger reaction
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)
 Lifetime
prevalence:




20% for men
8% for women
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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8
Short-term Effects of Alcohol
 Enters
the bloodstream through small
intestine
 metabolized
 Effects
by the liver
vary by concentration
 Concentration
varies by gender, height, weight,
liver efficiency
Affects brain areas associated with error monitoring and decision
making.
 Biphasic
 Initially
effect
stimulates
 Later depresses
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Short-term Effects of Alcohol
 Effect
of ingesting large amounts
 Impaired speech and vision
 Interference in complex thought
 Poor coordination
 Loss of balance
 Depression and withdrawal
 Interacts
processes
with several neural systems
 Stimulates GABA receptors
 Increases dopamine and serotonin
 Inhibits glutamate receptors
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Long-term Effects of Alcohol

Malnutrition


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

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
 Fetal

alcohol intake during pregnancy
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

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


Chinese Americans have lower lung cancer rates


Metabolize less nicotine
More prevalent among men than women


Metabolize nicotine more slowly
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
 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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Effects of Marijuana

Major active ingredient


THC (delta-9tetrahydrocannabinol)

Physiological


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


Impairment present for several
hours after ‘high’ has worn off
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
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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
 Federal
Court rulings:
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





Synthetic sedatives


Opium
Morphine
Heroin
Codeine
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
 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
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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


Stimulate receptors of the body’s opioid system


Intense feelings of warmth and ecstasy following injection
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
 Exposure
needles
 e.g. HIV
 Evidence
drugs
to infectious diseases via shared
suggests that free needles reduces
infectious diseases associated with IV drug use
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Synthetic Sedatives

Barbituates




Benzodiazepines





Slurred speech
Unsteady gait
Impaired judgment &
concentration
Irritability & combativeness
Accidental suffocation due to
excessive relaxation of diaphragm
muscles

Alcohol magnifies depressant
effects

Tolerance & withdrawal
e.g., Valium, Ketamine
Stimulate GABA system
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




Delirium, convulsions & other
symptoms
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Stimulants: Amphetamines

Increase alertness and motor activity

Reduce fatigue

Amphetamines

Synthetic stimulants





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:


Benzedrine, Dexedrine, Methedrine
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
 d-lysergic acid diethylamide
Psilocybin
 Extracted from mushroom
psylocube mexicana
Mescaline
Ecstasy



Active ingredient of peyote
Increase feelings of intimacy and
enhances mood
Chemically similar to mescaline
and amphetamines
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.
2.
First group began drinking in early adolescence,
increased drinking throughout high school
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

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



Role of genetics less clear
Fewer available studies
Findings are mixed
In women

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)
30
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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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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.


 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:
Psychopathology and Personality
 Personality
disorders:



factors that predict onset of substance related
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.
33
+
34
Etiology of Substance-Related Disorders:
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
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35
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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36
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
 Countries
and Media
that ban ads have 16% less consumption than
those that don’t (Saffer, 1991)
+ Treatment of Substance Related Disorders:
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.
37
+ 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
38
+ Treatment of Substance Related Disorders:
Alcohol Abuse and Dependence
 Cognitive
and Behavioral Treatments
 Contingency-Management Therapy

Patient and family reinforce behaviors inconsistent with drinking


Teach problem drinker how to deal with uncomfortable situations


e.g., avoiding places associated with drinking
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
39
+ Treatment of Substance Related Disorders:
Alcohol Abuse and Dependence
 Controlled
 Belief
drinking
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

Most effective when combined with CBT
 Other
medications include naltrexone, naloxone, &
acamprosate
40
+ Treatment of Substance Related Disorders:
Nicotine Dependence

Peer behavior important


Rapid smoking treatment


Reduce nicotine intake gradually over a few weeks
Physician’s advice


Rapid puffing, focused smoking, & smoke holding
Scheduled smoking


If others in social network stop smoking, increases likelihood that individual will also
stop
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
41
Treatment of Substance Related Disorders:
Illegal Drug Abuse and Dependence
+
 Detoxification
central to treatment
 Psychological
treatments

Desipramine and CBT showed effectiveness for cocaine use


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 especially helpful for users with high dependence levels (Carroll et
al., 1994, 1995)
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
42
+ Treatment of Substance Related Disorders:
43
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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44
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