Drug Addiction PDF

SUBSTANCE- RELATED, ADDICTIVE AND IMPULSE- CONTROL DISORDER -GROUP 7  CONTENTS OF THIS REPORT 0 Perspectives on Substance-Related 0 Other Drugs of Abuse 1 and Addictive Disorders 7 Levels of Involvement 0 Cause...

SUBSTANCE- RELATED, ADDICTIVE AND IMPULSE- CONTROL DISORDER -GROUP 7  CONTENTS OF THIS REPORT 0 Perspectives on Substance-Related 0 Other Drugs of Abuse 1 and Addictive Disorders 7 Levels of Involvement 0 Causes of Substance-Related Diagnostic Issues Disorders 8 0 Biological Dimensions Depressants Psychological Dimensions 2 Alcohol-Related Disorders Cognitive Dimensions Sedative-, Hypnotic-, or Anxiolytic-Related Social Dimensions Disorders Cultural Dimensions An Integrative Model 0 Stimulants 3 Stimulant-Related Disorders 0 Treatment of Substance-Related Tobacco-Related Disorders Disorders Caffeine-Related Disorders 9 Biological Treatments 0 Psychosocial Treatments Opioids Prevention 4 0 Cannabis-Related Disorders 1 Gambling Disorder 5 0 0 Hallucinogen-Related Disorders 6  CONTENTS OF THIS REPORT 1 Impulse-Control Disorders Intermittent Explosive Disorder 1 Kleptomania Pyromania  PERSPECTIVES ON SUBTANCE-RELATED AND ADDICTIVE DISORDERS Substance Abuse and Mental Health Services Administration (2012) “Currently, almost 9% of the general population are believed to use illegal drugs.” War on drugs- U.S Pres. administration Universal Catechism (1992)- Roman Catholic Church Danny, a 43-year-old man, found himself in jail for causing a fatal accident while driving under the influence. His life tells the story of many people struggling with substance-related disorders. Growing up as the youngest of three children, Danny was well-liked in school and started drinking and smoking at a young age. However, he often drank excessively and experimented with various drugs like cocaine and heroin. After high school, Danny briefly attended community college but dropped out after failing most of his classes, largely due to his partying habits. His family suspected he drank too much, but they were unaware of his drug use. Over the years, money and belongings sometimes went missing, raising concerns about Danny, but they never confronted him directly. Danny struggled to keep jobs, often quitting or getting fired due to poor attendance and performance. In his late 20s, he expressed a desire to get help for his drinking but still denied using other drugs. His family was hopeful when he checked into rehab, but he soon vanished and was later found living in an abandoned building, having spent their money on drugs. Danny had moments of improvement, even holding a job for two years, but he ultimately relapsed and committed robbery against his employer. Despite receiving probation and vowing to get help, he continued his destructive behavior. Eventually, while under the influence of multiple substances, he caused an accident that killed another driver. Danny’s story raises questions about why some people become dependent on drugs while others do not, and what leads them to harm their loved ones and themselves. We will explore these issues further when discussing the causes and treatment of substance-related disorders.  SUBSTANCE refers to chemical compounds that are ingested to alter mood or behavior. PSYCHOACTIVE- SUBSTANCES specific substances that affects brain and CNS, alter mood, behavior, or both. POLYSUBSTANCE USE using multiple substances  LEVELS OF INVOLVEMENT SUBSTANCE USE is the ingestion of psychoactive substances in moderate amounts that does not significantly interfere with social, educational, or occupational functioning. INTOXICATION Our physiological reaction to ingested substances—drunkenness or getting high —  impaired judgment, mood changes  LEVELS OF INVOLVEMENT SUBSTANCE ABUSE how much of a substance is ingested is problematic. how significantly it interferes with the user’s life (DSM-5) Drug abuser- A person who abuses drugs Addiction- drug dependence, drug-seeking behavior TOLERANCE SUBSTANCE DEPENDENCE someone may need to drink more coffee to feel the same level of alertness they once did with a smaller amount. WITHDRAWAL requires increasingly greater amounts of the drug to experience the same effect respond physically in a negative way when the substance is no longer ingested Headaches, nausea, or body aches. hallucinations and tremors. (severe)  DIAGNOSTIC ISSUES Historical Context Early DSM Classification: In earlier editions of the DSM, alcoholism and drug abuse were not recognized as distinct disorders. Instead, they were classified under "sociopathic personality disturbances," which reflected the view that substance use was merely a symptom of deeper personality issues. This perspective largely ignored potential genetic and biological factors and framed substance use as a matter of moral failing. Creation of Substance Abuse Disorder Categories: In the DSM-III, released in 1980, a separate category for substance abuse disorders was established. This marked a significant shift towards recognizing the biological and psychological complexities of substance use disorders.  DIAGNOSTIC ISSUES DSM-5 Updates Substance-Related Disorders: The DSM-5 includes a broad category termed "substance- related disorders," encompassing 11 symptoms that range from minor issues, such as failing to meet major role obligations due to substance use, to severe consequences like giving up significant activities.  CATEGORIES OTHER GAMBLING DEPRESSANTS STIMULANTS OPIATES HALLUCINOGENS DRUGS OF DISORDERS ABUSE The major These Other unable to These These effect of resist the substances substance substances substances these urge to alter sensory s that are result in cause us to substances gamble perception abused behavioral be more is to pro- and can but do not sedation active duce produce fit neatly and and alert analgesia delusions, into one of relaxation. and can temporarily paranoia, and the elevate (reduce hallucination categories. mood. pain) and s. euphoria. 1. DEPRESSANTS Primarily decrease central nervous system activity. 1. ALCOHOL 2. SEDATIVE,HYPNOTIC, ANXIOLYTIC DRUGS  ALCOHOL- RELATED  DISORDER CLINICAL DESCRIPTION EFFECTS OF ALCOHOL inhibitory centers in the brain are initially depressed or slowed. *encourage social interaction, less self conscious however, alcohol depresses more areas of the brain, which impedes the ability to function properly.  ALCOHOL- RELATED  DISORDER CLINICAL DESCRIPTION EFFECTS OF ALCOHOL Impaired motor coordination (e.g., staggering, slurred speech). Slowed reaction times and confusion. Impaired judgment and sensory deficits, making activities like driving dangerous. Episodic drinking- consumption of 6 or more alcoholic drinks on at least one occasion at least once per month (WHO, 2014) AFFECTED NEURORECEPTORS GABA System: An inhibitory neurotransmitter system; alcohol enhances GABA's effects, leading to reductions in anxiety and inhibiting neuron firing. Glutamate System: An excitatory system that plays a role in learning and memory, potentially contributing to alcohol-related blackouts. Serotonin System: Affects mood and craving, contributing to alcohol dependence. Alcohol- Related Disorders Where do alcohol travels in our body?  ALCOHOL-RELATED DISORDERS  EFFECTS  SHORT- TERM EFFECTS  Makes us more sociable  Blackouts, the loss of memory for what happens  Affects mood, sleep, and eating behavior and is thought to be responsible for alcohol cravings  LONG-TERM EFFECTS  includes hand tremors  nausea or vomiting  anxiety  transient hallucinations  ALCOHOL-RELATED DISORDERS  agitation  insomnia  (extreme) withdrawal delirium or delirium tremens (DTs)  liver disease, pancreatitis, cardiovascular disorders, and brain damage.  Dementia- neurological disorder, general loss of intellectual abilities (memory loss, cognitive decline etc.)  Wernicke-Korsakoff syndrome- results in confusion, loss of muscle coordination, and unintelligible speech.  Fetal alcohol syndrome (FAS)- cause by alcohol consumption during pregnancy.  Diagnostic Criteria for Alcohol Use Disorder Symptoms (At least 2 within a 12-month period): 1. Taking larger amounts than intended. 2. Persistent desire to cut down or control use. 3. Significant time spent obtaining or using. 4. Craving for the alcohol. 5. Failure to fulfill major role obligations. 6. Continued use despite social/interpersonal issues. 7. Reduced participation in important activities. 8. Use in physically hazardous situations. 9. Continued use despite known physical/psychological problems. 10. Tolerance symptoms 11. Withdrawal symptoms  Pr Pr Pr es es es en en en ce ce ce of of of 6 2- 4- or 3 5 mo sy sy re mp mp sy to to mp ms ms to ms Specify current Moderate severity Severe Mild  SEDATIVE-, HYPNOTIC-, OR ANXIOLYTIC- RELATED DISORDER  INCLUDES sedative (calming), hypnotic (sleep- inducing), and anxiolytic (anxiety- reducing) drugs Barbiturates (1882) Benzodiazepines (1960)  LOW Barbiturates HIGH DOSE DOSE 1 2 Mild sense of Impaired speech and motor relaxation and well- skills. being Increased risk of fatal overdose due to respiratory failure. Benzodiazepines and Their Use: These drugs serve similar therapeutic purposes but are also prescribed for muscle relaxation and seizure control. They provide initial euphoria and reduced inhibition but can lead to tolerance and withdrawal symptoms such as anxiety and tremors when discontinued.  Diagnostic Criteria for Sedative-, Hypnotic-, or Anxiolytic Disorder Symptoms (At least 2 within a 12-month period): 1. Taking larger amounts than intended. 2. Persistent desire to cut down or control use. 3. Significant time spent obtaining or using. 4. Craving for the substance. 5. Failure to fulfill major role obligations. 6. Continued use despite social/interpersonal issues. 7. Reduced participation in important activities. 8. Use in physically hazardous situations. 9. Continued use despite known physical/psychological problems. 10. Tolerance symptoms 11. Withdrawal symptoms  Pr Pr Pr es es es en en en ce ce ce of of of 6 2- 4- or 3 5 mo sy sy re mp mp sy to to mp ms ms to ms Specify current Moderate severity Severe Mild 2. STIMULANTS make you more alert and energetic  INCLUDES caffeine, nicotine amphetamines, and cocaine. Stimulant-Related Disorders Amphetamines (1887) amphetamines can induce feelings of elation and vigor and can reduce fatigue. Later on creates “crash”.  asthma and appetite suppressants  prescribed for people with narcolepsy  STIMULANTS INTOXICATION (AMPHETAMINE) euphoria or affective blunting (a lack of emotional expression), changes in sociability (paranoid about their relationships) interpersonal sensitivity anxiety tension anger stereotyped behaviors (aggressive behavior, reckless behavior) impaired judgment impaired social or occupational functioning. (job loss, termination, missed opportunities, loss productivity) Physiological symptoms occur during or shortly after amphetamine or related substances are ingested and can include heart rate or blood pressure changes, perspiration or chills, nausea or vomiting, weight loss, muscular weakness, respiratory depression, chest pain, seizures, or coma.  STIMULANTS INTOXICATION Severe intoxication or overdose hallucinations, panic agitation (feeling anxious, unrest, disturbances) Paranoid delusions (Carvalho et al., 2012). Withdrawal apathy (lack of interest or motivation) prolonged periods of sleep irritability depression Methylene-dioxymethamphetamine (MDMA) (Germany, 1912) Designer- drugs Appetite suppressant Ecstasy (MDMA) MDMA, commonly known as Ecstasy, gained popularity in the late 1980s. Recognized as a significant club drug. Methamphetamine, often referred to as “crystal meth” or “ice.” Purified form of amphetamine ingested primarily through smoking. Users describe effects including: “Feel happy” and “love everyone” Enhanced music appreciation and dancing enjoyment Increased social openness without fear of judgment (Levy et al., 2005).  COCAINE Historical Context:  Cocaine replaced amphetamines as the stimulant of choice in the 1970s (Jaffe, Rawson, & Ling, 2005).  Cocaine is derived from the coca plant, historically chewed by Latin Americans for relief from hunger and fatigue (Daamen et al., 2012).  Effects: Increases alertness, euphoria, blood pressure, and pulse. 01 Causes insomnia and loss of appetite. Short-lived effects often lead to repeated use for sustained Clinical impact. Descripti on Risks: 02 Paranoia and anxiety from cocaine use (cocaine-induced paranoia). Can lead to fatal cardiovascular issues.  STATISTICS Variation in admissions to emergency rooms by Nearly 5% of adults black demographics white white black female female males males globally have used s s cocaine; over 1.9 million in the U.S. 12% 12 % 23 % report annual use 29% (SAMHSA, 2009). 18% 18 % 29 % 23% Long-term Implications Dependence can escalate without immediate negative effects, leading to: Social isolation and increased tolerance. Potential risk of premature aging of the brain (Ersche et al., 2012). COCAINE-INDUCED PARANOIA- paranoia and exaggerated fear.  Diagnostic Criteria for Stimulant Use Disorder (APA, 2013) Symptoms (At least 2 within a 12-month period): 1. Taking larger amounts than intended. 2. Persistent desire to cut down or control use. 3. Significant time spent obtaining or using. 4. Craving for the stimulant. 5. Failure to fulfill major role obligations. 6. Continued use despite social/interpersonal issues. 7. Reduced participation in important activities. 8. Use in physically hazardous situations. 9. Continued use despite known physical/psychological problems. 10. Tolerance or withdrawal symptoms. TOBACCO- RELATED DISORDERS NICOTINE- A psychoactive substance causing dependence, tolerance, and withdrawal. Similar patterns observed compared to other drugs (Litvin et al., 2012). Health risks: including heart disease and cancer. Withdrawal symptoms can include anxiety, irritability, and increased appetite. Historical Context of Tobacco Use Nicotine extracted from tobacco— discovered by Jean Nicot in the 16th century. Tobacco cultivation dates back centuries among Native Americans. Current smoking rates: 20% in the U.S., down from 42.4% in 1965 (Litvin et al., 2012).  Clinical Description of Tobacco- Related Disorders Withdrawal symptoms include:Depressed mood, insomnia, irritability. Increased appetite, weight gain, anxiety, and difficulty concentrating.  MECHANISM OF NICOTINE ADDICTION Nicotine enters the bloodstream through inhalation, reaching the brain within seconds. 1 2 Stimulates nicotinic acetylcholine receptors in the brain's pleasure pathway. being depressed increases your risk of becoming dependent on nicotine, and at the same time, being dependent on nicotine will increase your risk of becoming depressed. CAFFEIN- RELATED DISORDERS Caffeine is the most common of the psychoactive substances, used regularly by almost 90% of all Americans “gentle stimulant”  WHERE IS CAFFEIN FOUND? tea, coffee, many cola drinks sold today, and cocoa products. “energy drinks”- highly consumed in US but banned in some European countries LOW LARGER Elevate your Jittery mood and (nervous or decrease anxious) fatigue Insomnia DOSES Duration: Caffeine takes about 6 hours to leave the body. Individual Responses Variation: Sensitivity to caffeine varies— some face withdrawal symptoms (e.g., headaches, drowsiness) Pregnancy Note: Moderate intake appears safe for pregnant women. Dependence & Withdrawal Regular use can lead to tolerance and dependence. Withdrawal Symptoms: Include headache, mood disturbances, etc. Brain Mechanism Neurotransmission: Caffeine blocks adenosine reuptake. Dopamine Role: Caffeine also influences dopamine, but its exact contributions need further study. OPIOID - RELATED DISORDER Opiate - refers to the natural chemicals in the opium poppy that have a narcotic effect (they relieve pain and induce sleep). Opioids - refers to the family of substances that includes natural opiates found the opium plant. Opiates induce euphoria, drowsiness, slowed breathing. High doses can Opium poppies lead to death if respiration is completely depressed. Opiates are also analgesics, substances that help relieve pain. People are sometimes given morphine before and after surgery to calm them and help block pain. Withdrawal from opioids can be so unpleasant that people may continue to use these drugs despite a sincere desire to stop. Symptoms within 6 to 12 hours; include excessive yawning, nausea and vomiting,chills, muscle aches, diarrhea, and insomnia temporarily disrupting work, school, and social relationships. The symptoms can persist for 1 to 3 days, and the withdrawal process is completed in about a week. Persistence opiod use may be related to comorbid mental disorders and sexual or physical abuse.  CANNABIS (MARIJUANA) - RELATED DISORDER  People who smoke marijuana often experience altered perceptions of the world.  Cannabis grows wild throughout the tropical and temperate regions of the world, which accounts for one of its nicknames, “weed".  Reactions to cannabis usually include mood swings. Otherwise  Users often report heightened normal experiences seem sensory experiences, seeing extremely funny, or the person vivid colors, or appreciating the might enter a dreamlike state in subtleties of music. which time seems to stand still.  Research on frequent cannabis  The feelings of well-being users suggests that impairments produced by small doses can of memory, concentration, change to paranoia, relationships with others, and hallucinations, and dizziness employment may be negative when larger doses are taken outcomes of long-term use (possibly leading to cannabis use disorders)  In Canada, for example, cannabis products are available for medical use, including an herbal cannabis extract (Sativex—delivered in a nasal spray), dronabinol (Marinol), nabilone (Cesamet), and the herbal form of cannabis that is typically smoked (Wang, Collet, Shapiro, & Ware, 2008). These cannabis derived products are prescribed for chemotherapy-induced nausea and vomiting, HIV-associated anorexia, neuropathic pain in multiple sclerosis, and cancer pain. HALLUCINOGEN - RELATED DISORDERS  There are a number of other hallucinogens, some occurring naturally in a variety of plants  Psilocybin (found in certain species of mushrooms), Lysergic acid amide (found in the seeds of the morning glory plant), Dimethyltryptamine (DMT) (found in the bark of the Virola tree, which grows in South and Central America) and Mescaline (found in the peyote cactus plant). Phencyclidine (or PCP) is snorted, smoked, or injected intrave nously, and it causes impulsivity and aggressiveness.  LSD (d-lysergic acid diethylamide), sometimes referred to as “acid,” is the most common hallucinogenic drug.  Ergotism— constricted the flow of blood to the arms or legs and eventually resulted in gangrene and the loss of limbs. Another type of illness resulted in convulsions, delirium, and hallucinations.  Hallucinugens seems to affect the brain in diverse and non-specific ways, meaning by affecting multiple  Physical symptoms include pupillary dilation, rapid heartbeat, sweating, and blurred vision. (American Psychiatric Association, 2013).  Tolerance develops quickly to a number of hallucinogens, including LSD, psilocybin, and mescaline (hallucinogen use disorders) (Jones, 2009)  The DSM-5 diagnostic criteria for hallucinogen intoxication are similar to those for cannabis: perceptual changes such as the subjective intensification of perceptions, depersonalization, and hallucinations. INHALANT USE DISORDER  INHALANTS The high associated with Inhalants include a the use of inhalants variety of resembles that of alcohol substances found in intoxication and usually volatile solvents includes dizziness, making them slurred speech, available to incoordination, breathe into the euphoria, and lethargy lungs directly. (American Psychiatric Association, 2013).  Some common inhalants that are used abusively include spray paint, hair spray, paint thinner, gasoline, amyl nitrate, nitrous oxide (“laughing gas”), nail polish remover, felt- tipped markers, airplane glue, contact cement, dry- cleaning fluid, and spot remover (Ridenour & Howard, 2012).  These drugs are rapidly absorbed into the bloodstream through the lungs when inhaled from containers or on a cloth held up to the mouth and nose.  Anabolic–androgenic steroids (more commonly referred to as steroids or “roids” or “juice”) are derived from or are a synthesized form of the hormone testosterone (Pope & Kanayama, 2012).  can be taken orally or through injection.  Research on the long-term effects of steroid use seems to suggest that mood disturbances are common (for example, depression, anxiety, and panic attacks) (Pope & Kanayama, 2012), and there is a concern that more serious physical consequences may result from regular use. Another class of drugs that causes drowsiness, pain relief, and the feeling of being out of one’s body.  Their ability to heighten a person’s auditory and visual perception, as well as the senses of taste and touch, has been incorporated into the activities of those who attend nightclubs, all-night dance parties (raves), or large social gatherings of primarily gay men (called “circuit parties”).  Higher doses or with alcohol or other drugs it can result in seizures, severe respiratory depression, and coma.  CAUSES OF SUBSTANCE- RELATED DISORDERS People continue to use psychoactive drugs for their effects on mood,perception, and behavior despite the obvious negative consequences of abuse and dependence.  Biological Dimension Familial and Genetic influences Research shows that many psychological Disorders, including substance- related disorders, are influenced by genetics. Nuerobiological Influences The use of psychoactive substances is partly driven by the pleasurable experiences they provide, which can be explained thorugh the brain’s “pleasure pathway”  Psychological Dimensions Positive Negative Reinforcement Reinforcement The feeling that result It refers to people using from using substances to escape psychoactive unpleasant feelings like substances are pain, stress, or anxiety. pleasurable in some way, and people will continue to take the drugs to recapture the pleasure.  COGNITIVE DIMENSIONS Expectancy effects play a key role, where individuals’ beliefs about drug outcomes shape their behavior. Once people stop taking drugs after prolonged or repeated use, powerful urges called “cravings” can interfere with efforts to remain off these drugs (Hollander & Kenny, 2012). DSM-5 includes cravings as one of the criteria for diagnosing a substance- related disorder. SOCIAL DIMENSIONS Exposure to psychoactive substances is a necessary prerequisite to their use and possible abuse, as previously discussed. You could probably list a number of ways people are exposed to these substances—through friends, through the media, and so on. Research on the consequences of cigarette advertising, for example, suggests the effects of media exposure may be more influential than peer pressure in determining whether teens smoke (Jackson, Brown, & L’Engle, 2007). CULTURAL DIMENSIONS Acculturation can either be a source of strength or stress, affecting drugg use. Cultural norms determine the acceptability and availability of substances, influencing abuse rates.  AN INTEGRATIVE MODEL It is clear that abuse and dependence cannot be predicted from one factor, be it genetic, neurobiological, psychological, or cultural. For example, some people with the genes common to many with substance abuse problems do not become abusers. Many people who experience the most crushing stressors, such as abject poverty or bigotry and violence, cope without resorting to drug. Treatment of Substance- Related Disorders Biological Treatments Psychosocial Treatments Prevention  TREATMENT OF SUBSTANCE -RELATED DISORDER Treating people who have substance-related disorders is a difficult task. Perhaps because of the combination of influences that often work together to keep people hooked, the outlook for those who are dependent on drugs is often not positive. Treatment for substance-related disorders focuses on multiple areas (Higgins et al., in press). The National Institute on Drug Abuse recommends 13 principles of effective treatment for illicit drug abuse based on more than 35 years of research (National Institute on Drug Abuse (NIDA), 2009) Sometimes the first step is to help someone through the withdrawal process; typically, the ultimate goal is abstinence. In other situations, the goal is to get a person to maintain a certain level of drug use without escalating its intake, and sometimes it is geared toward preventing exposure to drugs. Because substance abuse arises from so many influences, it should not be surprising that treating people with substance-related disorders is not a simple matter of finding just the right drug or the best way to change thoughts or behavior  BIOLOGICAL TREATMENTS  there have been a variety of biologically based approaches designed primarily to change the way substances are experienced.  In other words, scientists are trying to find ways to prevent people from experiencing the pleasant highs associated with drug use or to find alternative substances that have some of the positive effects (for example, reducing anxiety) without their addictive properties. BIOLOGICAL TREATMENTS AGONIST SUBSTITUTION ANTAGONIST TREATMENTS AVERSIVE TREATMENT  BIOLOGICAL TREATMENTS Agonist Substitution - involves providing the person with a safe drug that has a chemical makeup similar to the addictive drug (therefore the name agonist).  Methadone is an opiate agonist that is often given as a heroin substitute (Schwartz, Brooner, Montoya, Currens, & Hayes, 2010) - is a synthetic narcotic developed in Germany during World War II when morphine was not available for pain control; it was originally called adolphine after Adolph Hitler (Martínez- Fernández, 2002). Although it does not give the quick high of  When users develop a tolerance for methadone, however, it loses its analgesic and sedative qualities. Because heroin and methadone have cross-tolerance, meaning they act on the same neurotransmitter receptors, a heroin addict who takes methadone may become addicted to the methadone instead, but this is not always the case (Maremmani et al., 2009).  Research suggests that when addicts combine methadone with counseling, many reduce their use of heroin and engage in less criminal activity (Schwartz et al., 2009).  TREATMENT APPROACH NICOTINE: NRT & BUPROPION ALCOHOL: NALTREXONE, ACOMPROSATE (ZYBAN) (CAMPRAL) & DISULFIRAM (ANTABUSE) OPIOIDS: METHADONE & BUPRENORPHINE (SUBUTEX)  TREATMENT APPROACH NICOTINE: NICOTINE REPLACEMENT THERAPHY (NRT) & BUPROPION (ZYBAN)  In general, these replacement strategies successfully help people stop smoking, although they work best with supportive psychological therapy (Hughes, 2009).  All of these medical treatments have roughly the same effectiveness in helping people quit smoking, with a 6 month abstinence rate of approximately 20-25% (litvin et al., 2012).  BIOLOGICAL TREATMENTS Antagonist Treatments - antagonist drugs block or counteract the effects of psychoactive drugs, and a variety of drugs that seem to cancel out the effects of opiates have been used with people dependent on a variety of substances.  The most often prescribed opiate-antagonist drug, naltrexone, has had only limited success with individuals who are not simultaneously participating in a structured treatment program (Krupitsky & Blokhina, 2010)  When it is given to a person who is dependent on opiates, it produces immediate withdrawal symptoms, an extremely unpleasant effect. A person must be free from these withdrawal symptoms completely before starting naltrexone, and because it removes the euphoric  TREATMENT APPROACH NALTREXONE & ACOMPROSATE (CAMPRAL)  Acamprosate also seems to decrease cravings in people dependent on alcohol, and it works best with highly motivated people who are also participating in psychosocial interventions (Kennedy et al., 2010)  BIOLOGICAL TREATMENTS Aversive Treatment - In addition to looking for ways to block the euphoric effects of psychoactive drugs, clinicians in this area may prescribe drugs that make ingesting the abused substances extremely unpleasant. The expectation is that a person who associates the drug with feelings of illness will avoid using the drug.  The most commonly known aversive treatment uses disulfiram (Antabuse) with people who are alcohol dependent (Ivanov, 2009).  Antabuse prevents the breakdown of acetaldehyde, a by-product of alcohol, and the resulting buildup of acetaldehyde causes feelings of illness. People who drink alcohol after taking Antabuse experience nausea, vomiting, and elevated heart rate and respiration. Ideally, Antabuse is taken each morning, before the desire to drink arises.  Efforts to make smoking aversive have included the use of silver nitrate in lozenges or gum. This chemical combines with the saliva of a smoker to produce a bad taste in the mouth. Research has not shown it to be particularly effective (Jensen, Schmidt, Pedersen, & Dahl, 1991).  Both Antabuse for alcohol abuse and silver nitrate for cigarette smoking have generally been less than successful as treatment strategies on their own, primarily because they require that people be extremely motivated to continue taking them outside the supervision of a mental health professional. Other Biological Approaches Medication is often prescribed to help people deal with the often disturbing symptoms of withdrawal. Clonidine, developed to treat hypertension, has been given to people withdrawing from opiates. Because withdrawal from certain prescribed medications such as sedative drugs can cause cardiac arrest or seizures, these drugs are gradually tapered off to minimize dangerous reactions. In addition, sedative drugs (benzodiazepines) are often prescribed to help minimize discomfort for people withdrawing from other drugs, such as alcohol (Sher, Martinez, & Littlefield, 2010).  PSYCHOSOCIAL TREATMENTS  Most biological treatments for substance abuse show some promise with people who are trying to eliminate their drug habit. Not one of these treatments alone is successful for most people, however (Schuckit, 2009b).  Most research indicates a need for social support or therapeutic intervention. Because so many people need help to overcome their substance disorder, a number of models and programs have been developed. PSYCHOSOCIAL TREATMENTS INPATIENT FACILITIES ALCOHOLICS ANONYMOUS AND ITS VARIATIONS CONTROLLED USE COMPONENT TREATMENT  PSYCHOSOCIAL TREATMENTS Inpatient Facilities  The first specialized facility for people with substance abuse problems was established in 1935, when the first federal narcotic “farm” was built in Lexington, Kentucky most privately run, such facilities are designed to help people get through the initial withdrawal period and to provide supportive therapy so that they can go back to their communities (Morgan, 1981). Inpatient care can be extremely expensive (Bender, 2004).  Research suggests there may be no difference between intensive residential setting programs and quality outpatient care in the outcomes for alcoholic patients (Miller & Hester, 1986) or for drug treatment in general (National Institute on Drug Abuse (NIDA), 2009). Although some people do improve as inpatients, they may do equally well in outpatient care that is significantly less  PSYCHOSOCIAL TREATMENTS Alcoholics Anonymous and Its Variations  the most popular model for the treatment of substance abuse is a variation of the Twelve Steps program first developed by Alcoholics Anonymous (AA). Established in 1935 by two alcoholic professionals, William “Bill W.” Wilson and Robert “Dr. Bob” Holbrook Smith, the foundation of AA is the notion that alcoholism is a disease and alcoholics must acknowledge their addiction to alcohol and its destructive power over them. Since 1935, AA has steadily expanded to include almost 106,000 groups in more than 100 countries (White & Kurtz, 2008). In one survey, 9% of the adult population in the United States reported they had at one time attended an AA meeting (Room & Greenfield, 2006). The Twelve Steps of AA are the basis of its  philosophy. In them, you can see the reliance on prayer and a belief in God.  Although there are not enough data to show what percentage of people abstain from using alcohol as a result of participating in AA, research finds that those people who regularly participate in AA activities—or other similar supportive approaches—and follow its guidelines carefully are more likely to have a positive outcome (Kelly, 2013; Zemore, Subbaraman, & Tonigan, 2013).  PSYCHOSOCIAL TREATMENTS Controlled Use In the alcoholism treatment field, the notion of teaching people controlled drinking is extremely controversial, partly because of a classic study showing partial success in teaching severe abusers to drink in a limited way (Sobell & Sobell, 1978). The participants were 40 male alcoholics in an alcoholism treatment program at a state hospital who were thought to have a good prognosis. The men were assigned either to a program that taught them how to drink in moderation (experimental group) or to a group that was abstinence oriented (control group). The researchers, Mark and Linda Sobell, followed the men for more than 2 years, maintaining contact with 98% of them. During the second year after treatment, those who participated in the controlled drinking group were functioning well 85% of the time, whereas the men in the abstinence group were reported to be doing well only 42% of the time.  Although results in the two groups differed significantly, some men in both groups suffered serious relapses and required rehospitalization and some were incarcerated. The results of this study suggest that controlled drinking may be a viable alternative to abstinence for some alcohol abusers, although it clearly isn’t a cure.  The controversy over this study began with a paper published in the prestigious journal Science (Pendery, Maltzman, & West, 1982). The authors reported they had contacted the men in the Sobell study after 10 years and found that only 1 of the 20 men in the experimental group maintained a pattern of controlled drinking. The controversy over this study began with a paper published in  the prestigious journal Science (Pendery, Maltzman, & West, 1982).The authors reported they had contacted the men in the Sobell study after 10 years and found that only 1 of the 20 men in the experimental group maintained a pattern of controlled drinking.  controlled drinking is widely accepted as a treatment for alcoholism in the United Kingdom. Despite opposition, research on this approach has been conducted in the ensuing years (e.g., Orford & Keddie, 2006), and the results seem to show that controlled drinking is at least as effective as abstinence but that neither treatment is successful for 70% to 80% of patients over the long term—a rather bleak outlook for people with alcohol dependence problems.  PSYCHOSOCIAL TREATMENTS Component Treatment  Most comprehensive treatment programs aimed at helping people with substance abuse and dependence problems have a number ofcomponents thought to boost the effectiveness of the “treatment package” (National Institute on Drug Abuse (NIDA), 2009). For example, a person might be offered a drink of alcohol and receive a painful shock when the glass reaches his lips. The goal is to counteract the positive associations with substance use with negative associations. The negative associations can also be made by imagining unpleasant scenes in a technique called covert sensitization (Cautela, 1966); the person might picture herself beginning to snort cocaine and be interrupted with visions of herself becoming violently ill (Kearney, 2006). Contingency management the clinician and the client together select the behaviors that the client needs to change and decide on the reinforcers that will reward reaching certain goals, perhaps money or small retail items like CDs.   Community reinforcement approach In keeping with the multiple influences that affect substance use, several facets of the drug problem are addressed to help identify and correct aspects of the person’s life that might contribute to substance use or interfere with efforts to abstain. First, a spouse, friend, or relative who is not a substance user is recruited to participate in relationship therapy to help the abuser improve relationships with other important people. Second, clients are taught how to identify the antecedents and consequences that influence their drug taking. Third, clients are given assistance with employment, education, finances, or other social service areas that may help reduce their stress. Fourth, new recreational options help the person replace substance use with new activities. There is now strong empirical support for the effectiveness of this approach with alcohol and cocaine abusers (Higgins et al., in press).  Motivational Enhancement Therapy (MET) based on the work of Miller and Rollnick (2002), who proposed that behavior change in adults is more likely with empathetic and optimistic counseling (the therapist understands the client’s perspective and believes that he or she can change) and a focus on a personal connection with the client’s core values (for example, drinking and its consequences interferes with spending more time with family). By reminding the client about what he or she cherishes most, MET intends to improve the individual’s belief that any changes made (e.g., drinking less) will have positive outcomes (e.g., more family time) and the individual is therefore more likely to make the recommended changes.  Cognitive-behavioral therapy (CBT) is an effective treatment approach for many psychological disorders and it is also one of the most well designed and studied approaches for treating substance dependence (Granillo, Perron, Jarman, & Gutowski, 2013). This treatment addresses multiple aspects of the disorder, including a person’s reactions to cues that lead to substance use (for example, being among certain friends) and thoughts and behaviors to resist use. relapse prevention treatment model looks at the learned aspects of dependence and sees relapse as a failure of cognitive and behavioral coping skills (Witkiewitz & Marlatt, 2004). Therapy involves helping people remove any ambivalence about stopping their drug use by examining their beliefs about the positive aspects of the drug (“There’s nothing like a cocaine high”) and confronting  the negative consequences of its use (“I fight with my wife when I’m high”). High-risk situations are identified (“having extra money in my pocket”), and strategies are developed to deal with potentially problematic situations, as well as with the craving that arises from abstinence.  PREVENTION Over the past few years, the strategies for preventing substance abuse and dependence have shifted from education-based approaches (for example, teaching schoolchildren that drugs can be harmful) and one of this is the widely used Drug Abuse Resistance Education (DARE) program encourages a “no drug use” message through fear of consequences, rewards for commitments not to use drugs, and strategies for refusing offers of drugs.  Unfortunately, several extensive evaluations suggest that this type of program may not have its intended effects (Pentz, 1999). Fortunately, more comprehensive programs that involve skills training to avoid or resist social pressures (such as peers) and environmental pressures (such as media portrayals of drug use) can be effective in preventing drug abuse among some. These types of comprehensive programs may need to be replicated across communities and extended to more pervasive influences (for example, how drug use is portrayed in the media) to effect significant prevention results (Newton, Conrod, Teesson, & Faggiano, 2012).  The sociocultural disapproval of cigarette smoking can be understood through the personal experience of a former smoker: I began smoking (in Boy Scouts!) at age 11. By the time I was a college freshman, freed from the restrictions of school and home, my smoking had increased to a pack a day. The seminal Surgeon General’s Report Smoking and Health was issued that year (1964), but I didn’t notice. The warnings that began appearing on cigarette packs a couple of years later were also easy to ignore, since I had grown up knowing that smoking was unhealthy. As a graduate student and young professor I often smoked while leading class discussions, as had some of my favorite teachers. That ended in 1980, when an undergraduate student, no doubt empowered by the antismoking movement, asked me to stop because smoke bothered him.  A few years later there were hardly any social situations left in which it was acceptable to smoke. Even my home was no longer a refuge, since my children were pestering me to quit. And so I did. Now my status as former smoker puts me in company with fully half of all those who have ever smoked regularly and are alive today. For many of us, the deteriorating social environment for smoking made it easier to quit (Cook, 1993, p. 1750).  Implementing this sort of intervention is beyond the scope of one research investigator or even a consortium of researchersvcollaborating across many sites. It requires the cooperation of governmental, educational, and even religious institutions. We may need to rethink our approach to preventing drug use and abuse Newton et al., 2012). GAMBLING DISORDER  GAMBLING DISORDER Gambling has a long history—for example, dice have been found in Egyptian tombs (Greenberg, 2005). It is growing in popularity in this country, and in many places it is a legal and acceptable form of entertainment. Perhaps as a result, gambling disorder affects an increasing number of people, with a lifetime estimate of approximately 1.9% of adult Americans (Ashley & Boehlke, 2012). Research suggests that among pathological gamblers, 14% have lost at least one job, 19% have declared bankruptcy, 32% have been arrested, and 21% have been incarcerated (Gerstein et al., 1999). The DSM-5 criteria for gambling disorder set forth the associated behaviors that characterize people who have this addictive disorder. These include the same pattern of urges we observe in the other substance-related disorders. Note too the parallels with substance dependence, with the need to gamble increasing amounts of money over time and the “withdrawal symptoms” such as restlessness and irritability when attempting to stop. These parallels to substance-related disorders led to the recategorization of gambling disorder as an “Addictive Disorder” in DSM-5 (Denis, Fatséas, & Auriacombe, 2012). There is a growing body of research on the nature and treatment of gambling disorder. For example, work is under way to explore the biological origins of the urge to gamble among pathological gamblers. In one study, brain-imaging technology (echoplanar functional magnetic resonance imaging) was used to observe brain function while gamblers observed videotapes of other people gambling (Potenza et al., 2003). A decreased level of activity was observed in those regions of the brain that are involved in impulse regulation when compared with controls, suggesting an interaction between the environmental cues to gamble and the brain’s response (which may be to decrease the ability to resist these cues). Abnormalities in the dopamine system (which may account for the pleasurable consequences of gambling) and the serotonin system (involved in impulsive behavior) have been found in some studies of pathological gamblers (Moeller, 2009). Treatment of gambling problems is difficult. Those with gambling disorder exhibit a combination of characteristics—including denial of the problem, impulsivity, and continuing optimism (“One big win will cover my losses!”)—that interfere with effective treatment. Pathological gamblers often experience cravings similar to people who are substance dependent (Wulfert, Franco, Williams,Roland, & Maxson, 2008; Wulfert, Maxson, & Jardin, 2009). Treatment is often similar to substance dependence treatment, and there is a parallel Gambler’s Anonymous that incorporates the same 12-step program we discussed previously. However, the evidence of effectiveness for Gambler’s Anonymous suggests that 70% to 90% drop out of these programs and that the desire to quit must be present before intervention (Ashley & Boehlke, 2012). Cognitive behavioral interventions are also being studied, with one study including a variety of components—setting financial limits, planning alternative activities, preventing relapse, and imaginal desensitization. This preliminary research provides a more optimistic view of potential outcomes (Dowling, Smith, & Thomas, 2007). In addition to gambling disorder being included under the heading of “Addictive Disorders,” DSM-5 includes another potentially addictive behavior “Internet Gaming Disorder” as a condition for further study (American Psychiatric Association, 2013). There are indications that some individuals are so preoccupied with online games (sometimes in a social context with other players) that a similar pattern of tolerance and withdrawal develops (Petry & O’Brien, 2013). The goal of including this potentially new category of addictive behavior is to encourage additional research on its nature and treatment.  IMPULSE CONTROL DISORDER A number of the disorders we describe in this book start with an irresistible impulse —usually one that will ultimately be harmful to the person affected. Typically, the person experiences increasing tension leading up to the act and, sometimes, pleasurable anticipation of acting on the impulse. For example, paraphilias such as pedophilia (sexual attraction to children), eating disorders, and the substance-related disorders in this chapter often commence with temptations or desires that are destructive but difficult to resist. DSM-5 includes three additional impulse control disorders: intermittent explosive disorder, kleptomania,and pyromania (Muresanu, Stan, & Buzoianu, 2012). In DMS-IV-TR, gambling disorder was included as an impulse-control disorder but as we have seen it is listed as an addictive disorder in DSM-5. Finally, trichotillomania (hair pulling disorder) was also moved out of this category and is now included under the obsessive-compulsive-related disorders.  INTERMITTENT EXPLOSIVE DIORDER People with intermittent explosive disorder have episodes in which they act on aggressive impulses that result in serious assaults or destruction of property (Coccaro & McCloskey, 2010). It is unfortunately common among the general population to observe aggressive outbursts, when you rule out the influence of other disorders (for example, antisocial personality disorder, borderline personality disorder, a psychotic disorder,and Alzheimer’s disease) or substance use, this disorder is not often diagnosed. In a rare but important large study of more than 9,000 people, researchers found that the lifetime prevalence of this disorder was 5%27% (Kessler et al., 2006). This diagnosis is controversial and has been debated throughout the development of the DSM. One concern, among others,is that by validating a general category that covers aggressive behavior it may be used as a legal defense—insanity—for all violent crimes (Coccaro & McCloskey, 2010). Research is at the beginning stages for intermittent explosive disorder and focuses on the influence of neurotransmitters such as serotonin and norepinephrine and testosterone levels, along with their interaction with psychosocial influences (stress, disrupted family life, and parenting styles). These and other influences are being examined to explain the origins of this disorder(Coccaro, 2012). Cognitive-behavioral interventions (for example, helping the person identify and avoid “triggers” for aggressive outbursts) and approaches modeled after drug treatments appear the most effective for these individuals, although few controlled studies yet exist (McCloskey, Noblett, Deffenbacher, Gollan, &Coccaro, 2008). KLEPTOMANIA  KLEPTOMANIA The story of wealthy actress Winona Ryder stealing $5,500 worth of merchandise from Saks Fifth Avenue in Beverly Hills, California, in December 2001, was as puzzling as it was titillating. Why risk a multimillion-dollar career over some clothes that she could easily afford? Was hers a case of kleptomania a recurrent failure to resist urges to steal things that are not needed for personal use or their monetary value? This disorder appears to be rare, but it is not well studied, partly because of the stigma associated with identifying oneself as acting out this illegal behavior. The patterns described by those with this disorder are strikingly similar—the person begins to feel a sense of tension just before stealing, which is followed by feelings of pleasure or relief while the theft is committed (Grant, Odlaug, & Kim, 2010). People with kleptomania score high on assessments of impulsivity, reflecting their inability to judge the immediate gratification of stealing compared with the long-term negative consequences (for example, arrest, embarrassment) (Grant & Kim, 2002). Patients with kleptomania often report having no memory (amnesia) about the act of shoplifting (Hollander, Berlin, & Stein, 2009). Brain-imaging research supports these observations, with one study finding damage in areas of the brain associated with poor decision making (inferior frontal regions) (Grant, Correia, & Brennan Krohn, 2006). There appears to be high comorbidity between kleptomania and mood disorders, and to a lesser extent with substance abuse and dependence (Grant et al., 2010). Some refer to kleptomania as an “antidepressant” behavior, or a reaction on the part of some to relieve unpleasant feelings through stealing (Fishbain, 1987). Few reports of treatment exist, and these involve either behavioral interventions or use of antidepressant medication. In one exception, naltrexone—the opioid antagonist used in the treatment of alcoholism—was somewhat effective in reducing the urge to steal in persons diagnosed with kleptomania (Grant, Kim,& Odlaug, 2009). PYROMANIA  PYROMANIA Just as we know that someone who steals does not necessarily have kleptomania, it is also true that not everyone who sets fires is considered to have pyromania—an impulse-control disorder that involves having an irresistible urge to set fires. Again, the pattern parallels that of kleptomania, where the person feels a tension or arousal before setting a fire and a sense of gratification or relief while the fire burns. These individuals will also be preoccupied with fires and the associated equipment involved in setting and putting out these fires (Dickens & Sugarman, 2012). Also rare, pyromania is diagnosed in only about 3% of arsonists (Lindberg, Holi, Tani, & Virkkunen, 2005), because arsonists can include people who set fires for monetary gain or revenge rather than to satisfy a physical or psychological urge. Because so few people are diagnosed with this disorder, research on etiology and treatment is limited (Dickens & Sugarman, 2012). Research that has been conducted follows the general group of arsonists (of which only a small percentage have pyromania) and examines the role of a family history of fire setting along with comorbid impulse disorders (antisocial personality disorder and alcoholism). Treatment is generally cognitive-behavioral and involves helping the person identify the signals that initiate the urges and teaching coping strategies to resist the temptation to start fires (Bumpass, Fagelman, & Brix, 1983; McGrath, Marshall, & Prior, 1979). THANKS! Do you have any questions? [email protected] +91 620 421 838 yourcompany.com CREDITS: This presentation template was created by Slidesgo, including icons by Flaticon, and infographics & images by Freepik Please keep this slide for attribution  Instructions for use (free users) In order to use this template, you must credit Slidesgo by keeping the Thanks slide. You are allowed to: Modify this template. Use it for both personal and commercial purposes. You are not allowed to: Sublicense, sell or rent any of Slidesgo Content (or a modified version of Slidesgo Content). 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