Substance-Related Disorders PDF

Substance-Related Disorders What is a Substance? Any natural or synthetic product that has psychoactive effects – it changes perceptions, thoughts, emotions, and behaviors e.g., alcohol, marijuana, cocaine, heroin Substance Substance abuse dependence E...

Substance-Related Disorders What is a Substance? Any natural or synthetic product that has psychoactive effects – it changes perceptions, thoughts, emotions, and behaviors e.g., alcohol, marijuana, cocaine, heroin Substance Substance abuse dependence Excessive use Physiological need for increasing amounts Tolerance Withdrawal Biochemical Physical changes in the symptoms from body abstinence  Dependence Big Tolerance effect Need for Drug Response to progressively larger effect first exposure doses to achieve same effect After repeated exposure, more Withdrawal drug is needed to produce Discomfort and same effect distress with Little effect discontinued use Small Large Drug dose Changes in DSM-5 Addition of Gambling Disorder Substance use disorder replaced substance abuse and substance dependence Removal of recurrent legal problems criterion; replaced with craving / strong desire to use Greater differentiation among disorders involving different substances (e.g., alcohol use disorder, cannabis use disorder) Alcohol Use disorder Problematic use involving 2 of 11 features over a 12-month period: Larger amounts, longer time than intended Persistent desire / unsuccessful attempts to stop Time on alcohol related activities Craving, strong urge Use despite failure to fulfill major obligations Use despite social / interpersonal problems Other activities given up (social, occupational, recreational) Use in situations in which it is physically hazardous Use despite knowledge of a condition worsened by use Tolerance Withdrawal Alcohol-Related Disorders Lifetime prevalence in U.S. is 13% (5% meet for “dependence”) More common in men More than 37% of alcohol abusers suffer from at least one coexisting mental disorder Surgeon General’s Report Annual cost of substance misuse estimated at $249 billion dollars for alcohol and $193 billion for illicit drugs Includes health care costs, lost productivity, & costs to the criminal justice system  Associated Problems Alcohol implicated in high percentage of homicide, assault, & rape reports Alcohol implicated in 40% of deaths from car accidents  Effects of Alcohol on the Brain Lower levels, impact on “pleasure areas” Higher levels, depresses brain functioning mesocorticolimbic pathway Multiple brain regions, including: Cerebral cortex (decreased inhibition) Limbic system (emotions, memory) Cerebellum (coordination) Hypothalamus (increased sexual desire) Long Term Effects of Alcohol Fetal alcohol syndrome – intellectual impairment, facial deformities Alcohol amnestic disorder (Korsakoff’s syndrome) – confusion, memory loss Alcohol withdrawal delirium (delirium tremens) – hallucinations (lasts 3-6 days) Key Factors Genetic vulnerability Combined with learning Parental guidance Psychological factors (personality disorders, depression, schizophrenia) (Impulsivity, antisociality, distress tolerance) Use in response to stress (e.g., veterans) Expectations Relationship distress Sociocultural Cognitive Behavioral Perspective Operant conditioning: drug  tension reduction  reinforced Positive expectancies for alcohol’s effects associated with greater risk for abuse Cues are very important!  classical conditioning Opponent-process model Substance Disorders Abstinence-Based model (e.g., AA) Harm Reduction model Cognitive Behavioral Therapies Behavioral: Aversive classical conditioning Cue exposure and response prevention Cognitive: Identify expectations for drug use Challenge expectations Anticipate problem situation and develop coping skills Motivation Interviewing Treatment Modalities Self-help groups (AA) Individual Psychotherapy Enhancing Motivation Stimulus Control Coping with Urges Correcting cognitive distortions Alternative behaviors Identifying other ways of obtaining reinforcement Coping with Negative Affect Maintaining Gains Identify, plan for high-risk situations Plan for how to deal with a lapse Project MATCH Two trials: 952 outpatients 774 patients receiving aftercare following inpatient treatment Conditions: CBT, motivational enhancement therapy, & 12 step facilitation Project MATCH Most hypotheses not supported “matching clients on the basis of any single attribute hypothesized and tested in project MATCH is unlikely to markedly enhance the effectiveness of any of these three treatments.” Cue Exposure Some evidence of utility in mild-to- moderate drinkers Motivational Interviewing Evidence suggesting Motivational Interviewing may be helpful (e.g., Brown & Miller, 1993) Evidence is somewhat mixed Five Principles Express empathy Develop discrepancy Avoid argument Roll with resistance Support self-efficacy Stages of Change Relapse Prevention Abstinence violation effect (lapse vs. relapse) Coping skills Psychopharmacology Antidepressants and benzodiazepines: Reduce withdrawal symptoms and mood swings Antagonist drugs: Block or change effects of addictive drug Naltrexone– opioid antagonist Methadone: Synthetic opioid, given for life  methadone clinics Other substances Opium & derivatives (heroin, morphine) Stimulants (cocaine, amphetamines, meth) Hallucinogens (LSD, ectasy, marijuana*) Legalization of Marijuana Adults 19 to 30 years old, ~ 42% reported cannabis use in the past year, 29% in the past month, and 10% use on 20+ occasions in the past 30 days (2023). Legalized: Medical use - 36 states Recreational use - 18 states Observational Outcomes: Demand for higher potency Tax revenue short of expectations Higher rates of marijuana- related driving fatalities Increased ER visits & hospitalizations Conclusions Substance use disorders represent a tremendous societal problem Different treatments offer benefits Intensity of treatment program selected to suit problem SEXUAL VARIANTS, ABUSE & DYSFUNCTIONS WHAT IS “NORMAL” SEX? Kinsey reports (1950s) Findings shocked America Many “unusual” sexual behaviors are quite common Kinsey scale SOCIOCULTURAL INFLUENCES  Degeneracy theory (Simon Tissot, 1750s): Semen is necessary for sexual vigor, so avoid masturbation and patronizing prostitutes  Abstinence theory (Sylvester Graham, 1830s; successor John Harvey Kellogg): discouraged masturbation; suggestion it could cause insanity  Case of the Sambia of Papau New Guinea  Ritualized homosexual acts (semen conservation) normative prior to heterosexual relationships; “female pollution”  Homosexuality and American Psychiatry  Prior to 1974, considered a disorder  Higher rates of psychopathology (anxiety, depression) among gay men and lesbians – now often conceptualized as product of stigmatization / discrimination PARAPHILIC DISORDERS Fantasies, sexual urges or behaviors, consistently involving Non-human objects Suffering or humiliation of self or partner Children or non-consenting adults Must either: (1) cause distress or impairment; or (2) place the person or others at risk of harm Depends highly on cultural norms Prevalence unclear; Overwhelmingly men PARAPHILIAS  Fetishistic disorder: Use of inanimate objects Must impair functioning  Transvestic disorder: Almost always heterosexual men: recurrent intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing Autogynephilia – sexual arousal to the thought of being a woman Must impair functioning  Voyeuristic Disorder  Observation of unsuspecting others (undressing or engaging in sexual activity)  Exhibitionistic Disorder (indecent exposure)  Exposing genitals to others  May be accompanied by suggestive gestures or masturbation Louis C.K.  Frotteuristic Disorder  Rubbing one’s genitals on a nonconsenting person  Sexual Sadism Disorder  Inflicting physical or psychological pain on another  Involving nonconsenting person or impair functioning  Notorious serial killers: Ted Bundy, BTK Killer  Sexual Masochism Disorder  Made to experience pain, degradation  Often have preset limits  Must impair functioning CAUSES? Risk factors Male Strong sex drive Presumed sensitivity to conditioning / dependence on visual sexual imagery GENDER DYSPHORIA Previously gender identity disorder (new term emphasizes discomfort rather than identity) Incongruence between experienced/ expressed Elliot Page, gender and assigned gender (usually natal gender), Actor of at least 6 months duration Separate criteria for children and for adolescents/adults  Few studies, small sample sizes  Gender dysphoria in children Caitlyn Jenner  Many boys identify as gay without gender dysphoria later in life  A minority identify as trans later in life  Unclear how this may change  Research has examined sex-dimorphic neural structures  Controversies & Treatment  Gender affirming care  Puberty blockers, cross-sex hormones, surgery SEXUAL ABUSE  Childhood sexual abuse  Hard to estimate prevalence or typical consequences (4-6% of U.S. reports being a victim of abuse)  Controversies  Children’s testimony of abuse  Recovered memories  Rape and sexual assault  Motivation for rape: sexual motives, power PEDOPHILIC DISORDER  Recurrent, intense sexual urges or fantasies about sexual activity with prepubescent children  Nearly all male; victims 2/3 female DSM SEXUAL DYSFUNCTION DISORDERS Sexual desire disorders Male hypoactive sexual desire disorder Female sexual interest/arousal disorder Disorders of excitement Male erectile disorder Orgasmic disorders Men: early / delayed ejaculation Female orgasmic disorder Sexual pain disorders Genito-pelvic pain/ penetration disorder BIOLOGICAL FACTORS Diabetes Cardiovascular disease Multiple sclerosis Renal failure Vascular disease Spinal cord injury Prescription drugs (antihypertensives, antidepressants, tranquilizers) Recreational drugs (alcohol, marijuana) Hormonal imbalances PSYCHOSOCIAL CAUSES Depression, anxiety, schizophrenia, bipolar, etc. Shame, negative attitudes towards sex Performance anxiety; spectator role Sexual abuse Stressful life events Relationship difficulties (both a cause and consequence) Miscommunication Differences in desires and expectations Conflicts other than about sexual issues BIOLOGICAL TREATMENTS Treat underlying medical disorder Oral medications Viagra, Cialis, Levitra Women: Addyi and Vyleesi INDIVIDUAL & COUPLES THERAPY Psychoeducation CBT to address attitudes, beliefs, inhibiting individuals Address conflicts in relationship Re-establish seduction rituals Sensate focus – sexual contact without expectation of a completed sexual act CONCLUSIONS