Week 8 Substance-Related and Impulse Control Disorders PDF

Week 8: Substance-related and impulse control disorders Perspectives on substance-related disorders 💡 A drug is any substance that affects our bodies or minds. Doesn’t need to be a medicine or illicit substance...

Week 8: Substance-related and impulse control disorders Perspectives on substance-related disorders 💡 A drug is any substance that affects our bodies or minds. Doesn’t need to be a medicine or illicit substance Needs to be psychoactive (alters mood, behaviour or both) Example Alcohol Illicit drugs Sweets Cigarettes Caffeine Phone Substance use in Australia Smoking Proportion of smokers: 11% (down from 12.2% in 2016 and 24% in 1991) Use of e-cigarettes increased to 11.3% (up from 8.8% in 2016) Alcohol Proportion of excessive drinkers (4 standard drinks of more in one occasion): 25% (down from 29% in 2009) Week 8: Substance-related and impulse control disorders 1  Proportion of drinkers that exceed lifetime risk (2 standard drinks or more on any day): 16.87% (down from 21%) Illicit drugs Proportion of used illicit drugs (inc. pharma meds used for non-medical purposes) during lifetime: 43% (up from 38% in 2007) Proportion of used illicit drugs in the last 12 months: 16.4% (up from 13.4% in 2007) Key terms Psychoactive substances: chemical compounds that are ingested to alter mood and/or behaviour → alcohol, amphetamine, hallucinogens, caffeine Substance use: ingestion of substances in a way that doesn’t interfere with functioning Substance intoxication: the physical reaction to a substance → being drunk/high Substance dependence: Physiological dependence: development of tolerance → need for increasingly greater amounts to achieve same effects Psychological dependence: unsuccessful efforts to control use, and substantial effort expended to seek substance or recover from its effects Withdrawal: aversive physiological response when substance no longer ingested Substance-related and addictive disorders Disorders associated with the misuse of substances that alter emotion, behaviour and cognition. It comprises the ingestion of psychoactive substances in a way that significantly interferes with the user’s education, job, or relationships with others, or put them in physically dangerous situations. Diagnostic issues Week 8: Substance-related and impulse control disorders 2  High prevalence of comorbidities with other disorders Around 75% of people in addiction treatment centres have additional (co- occurring) psychiatric disorder → anxiety and alcoholism, stress and nicotine 40% = mood disorders / 25% = PTSD DSM-5 aims to distinguish whether or not a symptom results from substance abuse DSM-5-TR severity indicated based on number of symptoms present from: Mild: presence of 2 to 3 symptoms Moderate: presence of 4 to 5 symptoms Severe: presence of 6 or more symptoms Diagnostic criteria Criteria A A problematic pattern of use to clinically significant impairment or distress, as manifested by at least two of the following occurring in a 12 month period: Week 8: Substance-related and impulse control disorders 3  Types of substance use and substance use disorders Substance and neurotransmitters Most substances function as neurotransmitter agonists → they activate receptors sites in the brain to mimic the function of neurotransmitters. Key neurotransmitters Gamma-aminobutyric acid (GABA): inhibitory → involved with mood regulation and sleep Glutamate: excitatory → provides cellular energy, modulates communication between neurons, involved in pain, sleep, learning Serotonin: inhibitory → involved in mood, sleep, and memory Norepinephrine (noradrenaline): involved in automatic processes (heart rate/blood pressure), alertness, arousal, attention, focus Dopamine: operates on reward pathways, also involved in arousal, focus, concentration, memory, sleep, mood, motivation, and movement Depressants Substances that decrease Central Nervous System (CNS) arousal, behavioural activity, and induce relaxation → alcohol, sedatives, hypnotic / anxiolytic drugs Week 8: Substance-related and impulse control disorders 4  Alcohol related disorders Alcohol is produced when yeasts react with sugar and water, letting fermentation take place. Pathway through the body: ingestion → stomach → small intestine → major organs (heart, liver, lungs). It acts on a number of receptor systems (GABA, glutamate, serotonin) Immediate effects Initial effect: apparent stimulation, feelings of wellbeing, reduced inhibitions, more outgoing (inhibitory centres of our brain are slowed). Continued drinking: depresses more areas of the brain, impedes our functioning (impaired coordination, reaction time, perceptual effects) Long-term effects of chronic use Physical damage: liver disease, cardiovascular, disorders and brain damage Fetal Alcohol Syndrome (FAS): a combination of problems that may occur as a result of drinking alcohol during pregnancy Withdrawal: hand tremors, nausea/vomiting, anxiety, hallucinations, agitation, insomnia → can lead to withdrawal delirium (condition which produces hallucinations and body tremors) Sedatives, hypnotics, and anxiolytic related disorders Sedatives: calming, hypnotics (induce drowsiness), anxiolytics (reduce anxiety) Work by influencing GABA neurotransmitter system Synergistic effects: combination of alcohol + sedative hypnotic = dangerous levels Accounts for less than 1% of people seeking treatment for substance related disorders. Treatment for misuse of these drugs is more common in people who are white, female, and over 35 years old Week 8: Substance-related and impulse control disorders 5  Stimulants Substances that increase the CNS arousal, alertness, and energy. Most commonly consumed as a psychoactive substance. Amphetamines are stimulant drugs that are manufactured (ectasy, MDMA, Ritalin, dexamphetamine) → stimulates CNS by increasing release of and blocking uptake of norepinephrine and dopamine. Immediate effects: feelings of elation (followed by feeling depressed and tired), reduced fatigue, reduced appetite, anxiety, tension, impaired judgement, physical symptoms (heart rate or blood pressure changes) → very high doses can cause hallucinations and delusions. Long term effects: emotional blunting, changes in interpersonal sensitivity, stereotyped behaviour, anxiety, tension Tolerance: can build quickly Withdrawal: apathy, irritability, depression Stimulant-related disorders Cocaine: derived from coca plant leaves, found in South America Increases dopamine by blocking reuptake → dopamine accumulating in the synaptic space keeps stimulating the cell Estimated 5% of adults worldwide have used cocaine Week 8: Substance-related and impulse control disorders 6  Withdrawal: produces pronounced feelings of apathy and boredom Immediate effects: increases alertness, euphoria, increases blood pressure and heart rate, insomnia, loss of appetite Chronic use: disrupted sleep, tolerance, paranoia, social isolation, may result in premature aging of the brain, damage, to soft issue of the nose Tobacco-related disorder Derived from tobacco plant, generally ingested via smoking (reaches brain in 7 to 19 seconds). Nicotine stimulates the CNS and dopaminergic reward pathway by stimulating nicotinic acetylcholine receptors. Immediate effects: Small doses: may relieve stress and improve mood → does not cause intoxication High doses: blurred vision, confusion, convulsions Long term effects (via smoking): increased blood pressure, risk of CVD, cancer, depression, anxiety Withdrawal: depressed mood, restlessness, insomnia, irritability, difficulty concentrating, anxiety, increased appetite Caffeine intoxication Most widely used stimulant (coffee, tea, soft drinks, energy drinks, cocoa products). Caffeine seems to affect the neuromodulator adenosine and dopamine. Immediate effects: Small dose: elevates mood, decreases fatigue Larger dose: jittery, insomnia Withdrawal: headaches, drowsiness, unpleasant mood DSM-5-TR Criteria for Caffeine Intoxication Criteria A: Recent consumption of caffeine (typically a high dose, >250mg) Criteria B: At least 5 of the following signs or symptoms developing during, or shortly after caffeine use: Week 8: Substance-related and impulse control disorders 7  1. Restlessness 2. Nervousness 3. Excitement 4. Insomnia 5. Flushed face 6. Diuresis (increased urine output) 7. Gastrointestinal disturbance 8. Muscle twitching 9. Rambling flow of thought and speech 10. Tachycardia or cardiac arrhythmia 11. Periods of inexhaustibility 12. Psychomotor agitation Opioids Natural opiates (from opium poppies) and synthetic opiates (heroine/fentanyl) → activation opioid system in the brain. Opioid-use disorder Include natural illicit (heroin, opium) and prescription drugs (codeine, morphine, methadone, oxycodone). Immediate effects: analgesia, euphoria, drowsiness, slow breathing, and induced sleep (high doses can lead to death if respiratory system is depressed) Withdrawal: within 6 to 12 hours, excessive yawning, nausea and vomiting, chills, muscle aches, and insomnia → can persist for 1 to 3 days Use in Australia (AIHW, 2018) 3.1mil people had an opioid prescription in 2016 (oxycodone most common) 11% have used opioids from illicit use in their lifetime Week 8: Substance-related and impulse control disorders 8  Misuse of prescription opioids responsible for 49% of opioid deaths (twice as high as heroin deaths) Hallucinogens Substances that primarily alter sensory perceptions Cannabis use disorder Produced from varieties of the hemp plant, as a group, called cannabis → synthetic Marijuana: K2, Spice. Immediate effects Low doses: feelings of well-being, relaxation, heightened sensations, altered time perception, anxiety or irritability. High doses: paranoia, hallucinations and dizziness. Long-Term Effects: may include impairment of memory, concentration, negative effects on relationship and employment. Long-term, chronic smoke inhalation can damage lungs Tolerance & Reverse Tolerance (regular users experience mor effects from same dose after repeated use) Withdrawal: irritability, restlessness, appetite lose, nausea, sleep disruption 💡 Can be used for medicinal purposes – treat nausea, pain. NEVER TAKE SYNTHETIC WEED Hallucinogen-related disorder Other hallucinogenic substances (psychedelics) → e.g., d-lysergic acid diethylamide (LSD), psilocybin, phencyclidine (PCP), mescalin, dimethyltryptamine (DMT) Operate on different neurotransmitters (serotonin, ACTH) Week 8: Substance-related and impulse control disorders 9  Immediate Effects: Delusions, hallucinations and intensification of perceptual changes, physical symptoms (e.g., pupil dilation, rapid heartbeat, blurred vision), mystical experiences Bad trips a possibility (importance of Set and Setting; Noorani, 2021) Long term effects: no evidence of toxicity Tolerance develops quickly, but sensitivity returns after periods of abstinence Withdrawal: symptoms are not established (and so not part of DSM criteria) Therapeutic Use: Psilocybin and MDMA can be used in conjunction with psychotherapy for PTSD and treatment resistant depression → access to treatment limited in Australia Week 8: Substance-related and impulse control disorders 10  Causes and treatments of substance- related disorders Biological influences Genetics Evidence for genetic vulnerability to substances related disorders from twin and family studies Genetics may also impact how people experience and metabolise drugs The influence (and function) of specific genes in substance-related disorders is still being explored Neurobiology Most substances either directly or indirectly activate dopaminergic pathways and/or opioid-releasing neurons Activation of these systems makes substance effects feel pleasurable → use is positively reinforced Psychological influences Week 8: Substance-related and impulse control disorders 11  Positive reinforcement People repeat drug use to re-experience pleasure The circumstances around using the drug may be positively reinforcing Negative reinforcement People repeat the use of drugs to: Escape negative feelings → anxiety, pain, stress End unpleasant withdrawal effects 💡 People with higher levels of physical or psychological pain may be more vulnerable to substance abuse. Cognitive influences Expectancy effects What people expect to experience when they use drugs will in turn influence how they react → expectancies in relation to using drugs may be due to parents, peers, media, etc… Positive expectancies may increase the likelihood of use Cravings are triggered by cues related to substance use → availability of drug, places, (bars, vape shops), mood (depression, anxiety) Week 8: Substance-related and impulse control disorders 12  Social influences Exposure to substances Media depictions are highly influential (media depictions of smoking have a greater influence than peer pressure) Supervision and monitoring by parents influence exposure to substance-using peers Social perceptions of substance related disorders Moral weakness model of chemical dependence (a failure of self-control) Disease model of physiological dependence (an illness) Week 8: Substance-related and impulse control disorders 13  Cultural factors Norms around acceptable use of substances (alcohol consumption, use of hallucinogens for cultural reasons) Integrative model Substance related disorders cannot be predicted from a single factor: Treatments for substance related disorders Biological treatments Biological treatments aim to change the effects of substances by: Agonist substitution: providing an alternative way to achieve reinforcing effects (methadone substitution, nicotine replacement therapy) Antagonist substitution: reduces reinforcing effects (Naltrexone blocks effects of opioids) Aversive treatments: medications that cause unpleasant effects if the substance is ingested (Antabuse and alcohol) Week 8: Substance-related and impulse control disorders 14  Reducing withdrawal effects (Acamprosate reduces alcohol cravings) Psychosocial treatments Alcoholics anonymous (and similar) Frames substance-related disorders as a disease Belief in Christian God and total abstinence are central to their philosophy 12 step program: Week 8: Substance-related and impulse control disorders 15  💡 There is limited evidence over its efficacy, but there are suggested positive outcomes. Non-religious and minority groups report less positive experiences. Controlled use Aims to teach people to consume alcohol in safe amounts Initial evidence suggested this was more effective than abstinence across a 2- year period Later evidence suggested it may not be effective long term Impatient treatment Supports people through withdrawal Provides support therapy to return to community Social support may be the key factor for effectiveness No more effective than outpatient treatment Component treatment Includes multiple strategies such as: Aversion therapy: associates substance with negative physiological response and/or imagery Contingency management: manipulates antecedents and consequences Community reinforcement approach: builds relationships, teaches contingency management, supports employment, education, etc Motivational enhancement therapy: focuses on empathetic and optimistic counselling + focus on the individual’s core values Cognitive behaviour therapy: challenges positive beliefs about substance use, situations/people associated with the use of substance, and negative beliefs about ability to abstain Week 8: Substance-related and impulse control disorders 16  Prevention Education interventions: aimed at adolescents, can be effective fear based education is less effective Skills based training is more effective Changes to policy and law Advertising policy for cigarettes (plain packaging, warnings, aversive messages/images) Vaping laws (banned unless prescription Penalties for substance possession Gambling disorders and impulse control disorders Gambling disorder Criteria A - Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period: 1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement. 2. Is restless or irritable when attempting to cut down or stop gambling. 3. Has made repeated unsuccessful efforts to control, cut back, or stop. 4. Often preoccupied with gambling (e.g., persistent thoughts) 5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious). 6. After losing money gambling, often returns another day to get even 7. Lies to conceal the extent of involvement with gambling. 8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling. Week 8: Substance-related and impulse control disorders 17  9. Relies on others to provide money to relieve financial situations caused by gambling. Criteria B. The gambling behavior is not better explained by a manic episode. Impulse control disorders Disorders characterised by an irresistible urge to engage in an action. Intermittent explosive disorder Aggressive impulses resulting in serious assault or destruction of property. Lifetime prevalence: approx. 7.3% Limited research on treatment → suggests CBT may be effective Pyromania Setting fires. Limited knowledge of causes or treatment CBT can be effective (identify triggers and coping strategies) Kleptomania Stealing Act on impulse to steal Lifetime prevalence: less than 1% Often co-morbid with mood disorders and substance abuse Treatment relies on antidepressant medication and behavioural interventions Week 8: Substance-Related and Impulse Control Disorders Key Concepts and Definitions Drug: Any psychoactive substance that affects bodies or minds Week 8: Substance-related and impulse control disorders 18  Substance use: Ingestion of substances without interfering with functioning Substance intoxication: Physical reaction to a substance (being drunk/high) Substance dependence: Physiological: Development of tolerance Psychological: Unsuccessful efforts to control use Withdrawal: Aversive physiological response when substance use stops Substance Use in Australia Smoking: 11% (down from 24% in 1991) E-cigarette use: 11.3% (up from 8.8% in 2016) Alcohol: 25% excessive drinkers, 16.87% exceed lifetime risk Illicit drugs: 43% lifetime use, 16.4% in last 12 months Substance-Related and Addictive Disorders Defined as misuse of substances that alter emotion, behavior, and cognition High prevalence of comorbidities with other disorders DSM-5-TR severity: Mild (2-3 symptoms), Moderate (4-5 symptoms), Severe (6+ symptoms) Types of Substance Use Disorders 1. Depressants Alcohol Sedatives, hypnotics, and anxiolytics 2. Stimulants Amphetamines Cocaine Tobacco Week 8: Substance-related and impulse control disorders 19  Caffeine 3. Opioids 4. Hallucinogens Cannabis Other hallucinogens (LSD, psilocybin, etc.) Causes of Substance-Related Disorders 1. Biological Influences Genetics Neurobiology (dopaminergic pathways and opioid-releasing neurons) 2. Psychological Influences Positive reinforcement Negative reinforcement 3. Cognitive Influences Expectancy effects Cravings triggered by cues 4. Social Influences Exposure to substances Social perceptions Cultural factors Treatments for Substance-Related Disorders 1. Biological Treatments Agonist substitution Antagonist substitution Aversive treatments Week 8: Substance-related and impulse control disorders 20  Reducing withdrawal effects 2. Psychosocial Treatments Alcoholics Anonymous (12-step program) Controlled use Inpatient treatment 3. Component Treatments Aversion therapy Contingency management Community reinforcement approach Motivational enhancement therapy Cognitive behavior therapy 4. Prevention Education interventions Changes to policy and law Gambling Disorder and Impulse Control Disorders 1. Gambling Disorder Persistent and recurrent problematic gambling behavior Nine diagnostic criteria, four or more required for diagnosis 2. Impulse Control Disorders Intermittent explosive disorder Pyromania Kleptomania These disorders are characterized by an irresistible urge to engage in specific actions, often resulting in negative consequences. Treatment typically involves a combination of medication and behavioral interventions, with CBT showing effectiveness for some of these disorders. Week 8: Substance-related and impulse control disorders 21