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Chapter 11summary - Summary Abnormal Psychology: an


Integrative Approach

Abnormal Psychology (Athabasca University)

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Chapter 11

CHAPTER 11: Substance-Related, Addictive, and Impulse-Control Disorders


 DSM 5 changes: they’ve lumped together what used to be the impulse-control disorders and substance-
related disorders
 Gambling looks a lot like an addictive behaviour. It has the same sorts of biochemical changes that
occur. It looks more and more like an addiction and has been treated in addiction centers for a long time
as an addiction
 So now this new category lumps all those 3 things together

Addictive and Impulse-Control Disorders


 problems related to the use and abuse of psychoactive substances
o wide-ranging physiological, psychological, and behavioural effects
 gambling also included in this category
 includes impulse-control disorders
o intermittent explosive disorder, kleptomania, pyromania

Important Terms and Distinctions


 substance use versus substance intoxication
o involves some kind of impairment
o usually has to do with how much you have taken of the drug
o but you can be an intoxicater and not be an abuser of the drug
o abuse needs to get in the way of functioning – get in the way of some of your roles in society or
something. There needs to be a regular pattern
 substance abuse versus substance dependence
o dependence = you need it to get through your day, drinking to feel normal
o that comes from tolerating the substance
 tolerance versus withdrawal
o aspect of physiological dependence
o textbook differentiates between physiological and psychological dependence
o you don’t have psychology without the hardware, the physiology.
o You don’t have psychological dependence without tolerance and withdrawal

Substance Use Disorders


Tolerance, defined as either:
 a need for increased amounts of the substance to achieve desired effect, or
 diminished effect with continued use of the same amount of the substance

Withdrawal, manifested as either:


 the characteristic withdrawal syndrome for the substance (typically opposite to the drug effects. If you’re
taking a sedative for example, when you stop it, you get anxious and wound up)
 OR
 Using the same (or a closely related) substance to relieve or avoid withdrawal symptoms
o you may not actually experience the withdrawal syndrome
o DSM 4 you used to have to specify whether somebody with this disorder met criteria

Five Main Categories of Substances


 depressants  behavioural sedation (anything that’s a downer)
o e.g., alcohol, sedatives, anxiolytic drugs
 stimulants  increase alertness and elevate mood (anything that’s an upper)
o e.g., cocaine, nicotine, caffeine (these all have different mechanisms of action)

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 opiates  analgesia and euphoria (they are used for pain killing and making you feel better)
o e.g., heroin, morphine, codeine, oxycotin
 hallucinogens  alterations in sensory perception (
o e.g., marijuana, LSD, mushrooms, (club drugs like MDMA fit in between opiates and
hallucinogens)
 other drugs of abuse include inhalants (e.g., “poppers”, “huffing”) and anabolic steroids (e.g., “juice”)
o solvants that people are inhaling, … anything that doesn’t really fit into one of the other
categories

Substance Use Disorders


 DSM-IV used to have two separate disorders:
o Substance dependence
o Substance abuse
o “the idea that once you’re a pickle you can’t go back to being a cucumber”
o now we’ve combined the symptoms and now you’ve got a symptom count to have a specifier
o so now it’s easier to get diagnosed with one than it was before
o they took out the “legal problems” one and added the “experience of craving a drug”
 DSM 5 combined the categories
o Number of symptoms indicates severity
o 2 to 3 = mild substance use disorder
o 4 to 5 = moderate substance use disorder
o 6+ = severe substance use disorder

Substance Use Disorders


 failure to fulfill a …. CHECK THIS SLIDE. I think there are 4 things here

Substance Use Disorders


 using MORE of the substance, or using for more time, than intended
 persistent desire, or unsuccessful efforts to, cut down or control use
 spending a lot of time obtaining, using or recovering from the effects of a substance

Canadian Costs of Substance Abuse


SEE THIS SLIDE
Figure 1: Costs attributable to substance abuse by cost category in Canada, 2002
 if we can get ride of these law enforcement costs by funneling them right into a health care program
 if you reduce recidivism rates, they stop returning to the justice system
 the biggest costs is indirect, it’s productivity losses (people screwing up their jobs – coming to work
hungover, etc)
 direct health care costs (health care problems that can occur from alcohol abuse for instance)
 it costs society a lot of money, these problems

Depressants (alcohol is a dirty drug. Affects a lot of different things)


 physiological effects
o NMDA receptor blocked, requiring up-regulation of glutamatergic system
 May be responsible for withdrawal symptoms (e.g., agitation)
o Facilitates 5-HT receptor function which may be involved in dopaminergic reward
o Increases inhibitory function of GABA (GABA is responsible for sedation. If you have too much
GABA, it gets in the way of creating memory. That’s why you get blackouts)
 May account for sedation and memory impairments

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Effects of Acute Alcohol Administration (see this slide for the picture)
- it has stimulant properties when it first hits your body (feelings of euphoria)
- as it comes down, you start to get irritated and dopey

Depressants: Alcohol
 psychological effects
o euphoria and stimulation increase as BAC rises
 shooters: quick spike in blood alcohol increases euphoric stimulation
o irritability and sedation increase as BAC falls
 this is why at the end of the night it’s all bar fights in the parking lot
o 10% decrease in reaction time at BAC .08%
 5 or more drinks… textbook specifies
o increases body sway
o memory storage and retrieval impairments
o reduces behavioural inhibition
 e.g., increase aggression, increase risk-taking

Harmful Effects of Acute Administration


 alcohol poisoning
o BAC .06 = moderately intoxicating
o BAC .08 = legally intoxicating
o BAC .15 = upper range of social acceptance
 Meeting new friend at the Jets game… gets to be a little obnoxious
o BAC .30 to .40 = loss of consciousness
o BAC .50 = death within 120 minutes due to respiratory failure
 IT IS DANGEROUS TO POUND DRINKS
 Your body can’t register it all and you don’t feel it for a while
 Hangover
o Low blood sugar, dehydration, GI irritation
o Low-grade alcohol withdrawal
ALCOHOL IS THE ONE YOU CAN DIE FROM IN WITHDRAWAL

Alcohol Withdrawal
 early minor syndrome
o begins 8 to 12 hours after the last drink
o agitation, tremors, cramps, nausea, vomiting, sweating, vivid dreaming and heart rate
irregularities
o usually over in 48 hours
o sometimes people move on from this and they are okay. But sometimes, it moves on into late
major syndrome
 late major syndrome (delirium tremens of DTs)
o after two days of minor symptoms, more agitation, confusion, disorientation, hallucinations,
seizures
o may last 7 to 10 days
o potentially fatal if untreated
o treated with diazepam, low-stimulus environment, food and water, comfort and reassurance

Harmful Effects of Chronic Consumption


 long term consumption of alcohol has deleterious effects on nearly every organ system of the body
 liver

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o fatty deposits  cirrhosis


o 8x more prevalent in alcohol dependence
o heavy drinking women more at risk than heavy drinking men

Harmful Effects of Chronic Consumption


 the nervous system
o e.g., Wernicke-Korsakoff syndrome
 due to thiamin deficiency
o cancer
 mouth, throat and liver at risk
 particularly when combined with smoking
o reproduction
 male chronic consumption  impotence, shrunken testes, loss of sexual interest
 there is a feminizing hormone that occurs as part of a metabolism of alcohol. It feminizes
the male body

Harmful Effects of Chronic Consumption


 fetal alcohol syndrome (FAS)
o mental retardation, poor coordination, and muscle tone, slow growth, organ malformation,
peculiar facial characteristics (more details about that in the textbook)

Sex Differences
 women are generally more vulnerable to the harmful physiological effects of alcohol than men
o smaller body size
o more body fat
 more fat means less water in body
 less water in body means higher BAC
o less sensitive to sedating effects of alcohol, depending on where she is in her menstrual cycle
 makes it harder to gauge her level of intoxication

Standard Drink
 a standard drink contains 13.6g of alcohol
 one standard drink is approximately: one 355 ml (12 ounce) can of 5% beer or
 one 146 ml (5 ounce) glass of 10% to 12% wine or
 one 44 ml (1.5 ounce) of 40% hard liquor or spirits

If he wants to keep his health risk low, what’s the maximum number of drinks per week an otherwise healthy,
average man should have?
Low risk:
 intake is unlikely to be associated with harm
 males LESS THAN 21 standard drinks per week
 females LESS THAN 14 standard drinks per week
 only 2 per day, and you should take one day off. So really it’s closer to 12.
 That’s unlikely to be associated with medically serious harm
 The number of drinks goes up with the number of levels

Hazardous drinking
 intake likely to increase risk of developing alcohol related to …. SEE THIS SLIDE
Harmful drinking (alcohol misuse)
 intake associated with the development of phsycical or psychological harm

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 males > 50 standard drinks per week


 females > 35 … SEE THIS SLIDE

binge drinking = five or more standard drinks during a drinking episode – during two hours, technically
more common in youth
adolescence to age 24

Alcohol Use in Canada


 most Canadian adults drink in moderation
o 23% exceed low risk guidelines
o 17% drink at high risk levels
 men more likely than women to drink, and are also more likely to drink heavily

Alcohol Use Problems:


 9% of Canadian drinkers have problems
o 3% of Canadians may be dependent drinkers
 most people with alcohol use problems can moderate or cease drinking on occasion
 as many as ¾ of people with alcohol problems recover without help
 a lot of people with problems with alcohol CAN stop drinking from time to time
 you can still have alcohol problems, even if you can stop occasionally
 there is such a thing as spontaneous recovery. People who get over their alcohol problems without any
professional help at all
o ¾ of people could recover without help at all
o there are some myths about alcohol use disorders that are still floating around. “once an
alcoholic, always an alcoholic” etc.

Sedatives, Hypnotics, or Anxiolytics


 sedative = calming
 hypnotic = sleep inducing
o e.g. barbiturates
 anxiolytic = anxiety reducing
o e.g., benzodiazepines
 Effects of these drugs are similar to large doses of alcohol
o Combining these drugs with alcohol is synergistic
o Synergistic = the effects are not simply additive; they interact to produce more effect than either
drug alone
 All exert their influence via their effects on GABA (inhibitory neurotransmitter, basically chills people
out. It also changes consciousness)

Sedatives, Hypnotics, or Anxiolytics


 since 1960, barbiturate use has decreased and benzodiazepine use has increased
o they produce the effects of alcohol without the smell of alcohol
o you can get the same alcohol-type effects without smelling like booze
o benzo use has increased… I’m not sure why that is. Could be that they are prescribed more
widely and are more available
 signs of intoxication:
o slurred speech
o incoordination
o unsteady gait
o nystagmus (eyes aren’t focusing on the right spot)

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o impairment in attention or memory


o stupor or coma

Sedatives, Hypnotics, or Anxiolytics


 signs of withdrawal:
o autonomic hyperactivity
o increased hand tremor
o insomnia
o nausea or vomiting
o transient halllucinations
o psychomotor agitation
o anxiety
o seizures

EACH CLASS OF SUBSTANCE has its own withdrawal symptoms. Withdrawal is a sign of physiological
dependence. (probably know these…)

Stimulants
 most widely consumed drug in Canada and the United States
 stimulants increase alertness and increase energy
 examples include amphetamines, cocaine, nicotine, and caffeine
o despite their different mechanisms of action, they have similar subjective effects
 amphetamine use produces elation, vigour, and reduction of fatigue
 amphetamine use increases the release of dopamine and norepinephrine, while blocking reuptake
 effects of use are followed by a “crash”
o e.g., feeling depressed and tired

Stimulants: Amphetamines
 signs of intoxication:
o tachycardia (increase in heartrate) or bradycardia (slowing of heartrate)
o pupillary dilation (our bodies do that when they are pumped about something)
o elevated or lowered blood pressure
o perspiration or chills
o nausea or vomiting
o weight loss
o psychomotor agitation or retardation
o muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias
o confusion, seizures, dyskinesia, dystonia or coma

Stimulants: Amphetamines
 Signs of withdrawal:
o Dysphoric mood
o Fatigue
o Vivid, unpleasant dreams
o Insomnia or hypersomnia
o Increased appetite
o Psychomotor retardation or agitation

Molly: Hallucinogen or Amphetamine?


 short answer is “yes”

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 molly = methylenedioxymethamphetamine
 (MDMA), which is classified as hallucinogen and amphetamine
o pills that are marketed as ecstasy… it used to be pure MDMA when it was first introduced as a
club drug. But drug dealers would find ways to make it cheaper
o you may have also experienced some of the effects of meth

Stimulants
 MDMA also increases dopamine, norepinephrine, and serotonin
o May result in memory impairments, over time
o Risk of death associated with low sodium levels and hyperthermia that result from use
o Drink water when you are using MDMA

The book: BUZZED: The Straight Facts About the Most Used and Abused Drugs from Alcohol to Ecstasy

Stimulants
 excessive use of amphetamine can lead to psychosis
 methamphetamine has effects similar to amphetamine
o increases dopamine, norepinephrine and serotonin
o less susceptible to breakdown by MAO, so it lasts longer

Stimulants: Amphetamines
 amphetamine increases norepinephrine and dopamine by both increasing their presynaptic release AND
by blocking their reuptake
 see this slide for the chart….

Stimulants: Cocaine
 cocaine use produces short-lived sensations of elation, vigour, and reduction of fatigue
 used by ~1% of adults, ~6% of students
 crack = cocaine that has been dissolved and then boiled in a mixture of water and ammonia or baking
soda until it forms lumps or rocks
 signs of intoxication and withdrawal are the same as for amphetamine intoxication

Stimulants: Cocaine
SEE THIS SLIDE for chart..
 cocaine increases dopamine by blocking its reuptake
 they used to really think that cocaine was a wonder-drug
 that it had no ill-effects, that it would just make you energetic
 “free of terrible side-effects!” there is no drug like that. Every drug comes with a bit of a cost

Stimulants: Nicotine
 stimulates the central nervous system, specifically nicotinic acetylcholine receptors
 results in sensations of relaxation, wellness, pleasure
 nicotine uses dose themselves to maintain a steady state of nicotine

Video: Hurd/ Herd Studios : Tobacco Dependence


https://www.youtube.com/watch?v=gCT9msDT9RM

Stimulants: Nicotine
 signs of withdrawal:
o dysphoric or depressed mood

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o insomnia
o irritability, frustration, or anger
o anxiety
o difficulty concentrating
o restlessness
o decreased heart rate
o increased weight gain

Stimulants: Caffeine
 found in tea, coffee, cola drinks and cocoa products
 caffeine is an adenosine antagonist
o adenosine inhibits neurotransmitter release
 small doses elevate mood and reduce fatigue
 used by over 80% of North Americans
 regular use can result in tolerance and dependence
 no DSM-IV criteria for caffeine dependence or abuse, only caffeine intoxication
o we don’t talk about dependence or abuse in DSM 5 (those are old categories)
o we talk about substance use disorder specific to that class of substance, and then specify mild,
moderate or severe

Stimulants: Caffeine
 Signs of intoxication:
o Restlessness
o Nervousness
o Excitement
o Insomnia
o Flushed face
o Diuresis
o GI disturbance
o Muscle twitching
o Rambling flow of thought and speech
o Tachycardia or cardiac arrhythmia
o Periods of inexhaustibility
o Psychomotor agitation

Hallucinogens
 substances that change the way the user perceives the world
 may produce delusions, paranoia, hallucinations, and altered sensory perception
 examples include LSD, PCP, psilocybin (mushrooms), mescaline (peyote), ketamine

Hallucinogens
 LSD is most common form of hallucinogenic drug
 Tolerance tends to be rapid, and withdrawal symptoms are uncommon
 Psychotic delusional and hallucinatory symptoms can be problematic
 Mechanisms of action for hallucinogens (e.g., ketamine, PCP) can be complicated

Cannabis
 active ingredient is tetrahydrocannabinol (THC)

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 subjective effects can vary


o elevated mood, sedation, distortions in sense of time, visuo-spatial distortions, paranoia,
irritability, anxiety
 impairment in motivation is possible
o amotivational syndrome (where you just don’t feel like doing anything…. Not enough evidence
to say that it is a definite thing. But certainly possible)

Cannabis
 cannabis intoxication
o conjunctival injection (red eye)
o increased appetite
o dry mouth
o tachycardia (increased heart rate)

Cannabis
 cannabis withdrawal
o irritability, anger, or aggression
o nervousness or anxiety
o sleep difficulty
o decreased appetite or weight loss
o restlessness
o depressed mood
o abdominal pain, shakiness/tremors, sweating, fever, chills, or headache

Mechanism of Action: Cannabis


IT IS COMPLICATED

Opioids
 refers to a class of natural and synthetic substances that have morphine-like effects
o prescribed as analgesics, anesthetics, antidiarrheal agents and cough suppressants
o examples include heroin, opium, codeine, and morphine
 brain has natural opioids
o enkephalins and endorphins

Opioids
 awareness of opioid use has been increasing, possibly due to increase in misuse of opioid prescriptions
o oxycodone abuse in the Maritimes
 speedball = combination of cocaine and heroin
o why would you take a drug that makes you sleepy and not sleepy at the same time?
o Their ultimate effects are on dopamine. So their combined effects can be quite pleasurable
 opioid dependence is associated with high rate of mortality
 people who inject their own opiates have their own lifestyle/subculture
o a lot of people with addictive problems will say “at least I never injected.” Like that is really
despicable compared to some of the other behaviours they engage in.

Opioids: Heroin
 once across the blood-brain barrier, heroin is converted to morphine
 morphine is a powerful agonist of the mu opioid receptor subtype
 binding of mu receptor inhibits the release of GABA

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o GABA inhibits dopaminergic neurons


 Increased activation of the dopaminergic reward parthway leads to the euphoria and “high” associated
with heroin use
Opidoids: Heroin
 picture of how it works
 WILL WE EVER HAVE TO LABEL SOMETHING LIKE THIS ON A TEST?

Opioidss
> signs of intoxication
Drowsiness
Slurred speech
Problems with attention and memory

Opioids
 signs fo withdrawal:
 dysphoric mood
 nausea or vomiting
 muscle aches
 lacrimation or rhinorrhea
 pupillary dilation, piloerection, or sweating
 diarrhea
 yawning
 fever
 insomnia
Associated with allergic reactions or the flu. You feel muscle achey, diarrhea, … people colloquially refer
to this as “getting sick” so they try to avoid it by taking more drug

Inhalants
 substances found in volatile solvents that are breathed into the lungs directly
o examples include spray paint, hair spray, paint thinner, gasoline, nitrous oxide
 rapidly absorbed with effects similar to alcohol intoxication
 tolerance and prolonged symptoms of withdrawal are common
 frequently first drug used by young people
 risk of severe, long-term damage to the brain, liver and kidneys
 SEE SLIDE for this last point

Anabolic Steroids
 steroids are derived or synthesized from testosterone
o used medicinally or to increase body mass
 users may engage in cycling or stacking
o cycling = using steroid in eight to 12 week cycles
o SEE THIS SLIDE…

Pathological Gambling
 Dopamine system implicated
o Includes a withdrawal syndrome
 Usually treated in addiction treatment settings
o Most people who present for treatment have trouble with machine gambling (e.g., VLTs)
o Prevalence rates are higher where gambling machines are available
 In US, people with PG tend to be not white, male, less educated, lower income, unmarried, unemployed

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 In Canada, Aboriginal people at elevated risk


o Up to 16 times more prevalent
Highly comorbid with nicotine dependence and other substance use disorders

Prevalence of Addictive Disorders


 pathological gambling
o ~2% in US
 alcohol use disorder
 ~14% of US men and ~4% of US women
 tobacco use disorder
o ~13% of US adults
 cannabis use disorder
o ~2% of US adults

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