Module 6: Addiction and obsessive-compulsive related disorders

Question 1

How many symptoms do you need for over 1 year for substance use disorder?

What is the disorder called after diagnosis?

Answer 1

2 or more out of 11 criteria

Diagnosis is substance specific (need to specify what drug is being used), after allocating the diagnosis, it may be called an “alcohol use disorder, a cannabis use disorder” etc

Question 2

What are the 11 criteria of SUD?

Answer 2

1. Using more than planning to
2. Worrying about stopping and failed attempts to control use of drug
3. Spending a lot of time using or obtaining drug
4. Failure to fulfil life obligations, home/work/school
5. Craving the drug
6. Continuing despite mental/physical health problems
7. Continue despite having negative impacts on social relationships
8. Repeated use in a dangerous situation knowing its dangerous
9. Giving up or reducing normal activities
10. Need for increased amounts to achieve same effect/high, diminished impact from same amount of drug
11. Withdrawal symptoms - like nausea, tremors, anxiety

Question 3

What is the severity specificer for SUD?

Answer 3

Based on how many criteria you fulfill:

2+ = meets criteria for substance use disorder
2-3 = Mild
4-5 = Moderate
6+ = severe and described as an addiction

Question 4

What’s the difference between physical vs psychological dependence?

Answer 4

1. Physical dependence = pain, nausea flu-like symptoms, shaking when not using the drug, anxiety can stem from the physical symptoms experienced
2. Psychological dependence = irritability, anxiety, depression when not using the drug, anxiety can stem from the withdrawal symptoms and where to continue to access the drug

Question 5

How does the risk of dependency vary across drugs?

Answer 5

depends on the physiological effects on the body:

heroin has a high risk of becoming dependent, while many people drink a lot of alcohol without becoming dependent

Question 6

How does tolerance for drugs change after taking drugs?

Answer 6

Increases in tolerance spread to other substances, eg. higher tolerance for alcohol also allows a higher tolerance for benzodiazepines which are neurologically similar to alcohol

Question 7

How long does dependence last?

Answer 7

Use of dependence only goes away after a few months of not taking the substance

Question 8

How does the process model of addiction vary between individuals?

Answer 8

1. people can spend more/less time in different addiction stages depending on the substance,

eg. heroin users are more likely to quickly jump from experimentation to regular use to heavy use due to the addictiveness of the drug, to increase the high and alleviate the withdrawal symptoms).

Transitions from experimentation to regular to dependency is lower for alcohol.

Question 9

What are the 5 stages of developing a substance addiction?

Answer 9

1. Commencing substance use with positive attitudes, openness and social settings
2. Experimentation with substance
3. Regular use
4. Heavy use
5. Dependence of abuse

Question 10

What are behavioural addictions and how are they formed and maintained through conditioning?

Answer 10

1. behaviours paired with an increase in pleasure and reward, which leads us to want to increase the intensity and the maintenance of those behaviours

Salience - activity becomes the most important activity in life
Feelings of cravings - thinking about the activity
Loss of control - lack of ability to moderate time spent doing activity
Tolerance - increasing activity to achieve the same former effects
Withdrawal - effects when activity is discontinued/reduced
Negative effects - despite negative consequences, individuals continue

Question 11

What is the only non-substance related disorder in the DSM and why?

Answer 11

Gambling disorder

There is insufficient evidence to form criteria for other behavioural addictions. Common addictions (not in DSM) = phone, shopping, sex, internet, video game, food addiction
Debated whether these behaviours should be called ‘addictions’ since they cause distress and impairment, and many people try to stop but fail from lack of control

Question 12

What does the transdiagnostic framework say about addictions?

Answer 12

• there are core underlying mechanisms that underlie both behavioural addictions and substance use disorders
• Some substance use disorders may overlap or transition into behavioural addictions

Question 13

What are the gambling disorder criteria?

Answer 13

1. Is preoccupied with gambling
2. restless /irritable
3. Repeated and unsuccessful efforts to control/stop gambling
4. Preoccupied with thoughts of gambling
5. Gambles when feeling distressed
6. After losing money, returns to ‘get even’
7. lies to conceal the extent of gambling
8. Jeopardise relationships, jobs, or educational or career opportunities because of gambling

Question 14

What must be ruled out for a diagnosis of gambling disorder?

Answer 14

not explained better by a manic or hypomanic episode

Question 15

What are the severity specifiers for gambling disorder?

Answer 15

mild (4 or 5 symptoms),
moderate (6 or 7 symptoms)
severe (8 or 9 symptoms)

Episodic: Meeting diagnostic criteria at more than one time point, with symptoms subsiding between periods of gambling disorder for at least several months

Persistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple years

Question 16

What is the Suggested Diagnostic Criteria for Internet Addiction Disorder (from 2005)?

Answer 16

Is preoccupied with the internet (e.g., thinks about previous online activity or anticipates next online session)
Needs to use the internet with increasing amounts of time to achieve the desired satisfaction.
Has made unsuccessful efforts to control, cut back, or stop use
Is restless, moody, depressed, or irritable when attempting to cut down or stop use
Has stayed online longer than originally intended.
Has jeopardised or risked the loss of a significant relationship, job, or educational or career opportunity because of the internet
Has lied to family members, therapists, or others to conceal the extent of involvement with the internet.
Uses the internet as a way of escaping problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression).

Question 17

What are the rates of comorbidity for SUDs?

Answer 17

37% with alcohol use disorder have another mental illness
53% with drug use disorder have another mental illness

Question 18

What risk factors are SUDs linked with?

Answer 18

Physical health
Social and occupational functioning
Increased self-harm and suicide
Increased risk of violence
Homelessness
Issues with interpersonal relationships

Question 19

What percentage of total years lived with a disability comes from SUDs globally?

Answer 19

23% of total years lived with a disability globally are from substance use + psychological disorder

Annual cost of premature death ($45 billion) for drug + psych disorders

Question 20

Whats the peak onset for SUDs?

Answer 20

75% with a substance use disorder develop the disorder before 25 years (YOUNG disorder)

Peak age to develop SUD is 15-25 years

Question 21

Why does SUD have such a high comorbidity rate with other psych disorders?

Answer 21

1. USE AS A COPING MECHANISM Some people use substances as a coping mechanism for their mental health illness, to decrease symptoms or as a form of escapism
2. SUD HAS CAUSED A DISORDER Maybe continue using substance use because substance use has caused a mental health condition, increased impairment from drug and mental health may cause
3. HAVE SIMILAR UNDERLYING ETIOLOGIES - Substance use and mental health problems have similar aetiologies including trauma and childhood adverse experiences (ACEs)

Question 22

Is having a psych disorder increase chance of taking drugs?

Answer 22

People with mental health issues are 1.7x more likely to use illicit drugs (not nicotine or alcohol)
People with mental health issues are 1.8x more likely to have used cannabis, 2.2x more likely to have used meth, 1.4x more likely to have used ecstasy, 2.1x more likely to have used non-medical pharmaceutical drugs

Question 23

What is most common SUD and which gender is more affected?

Answer 23

1. alcohol SUD
2. males

Question 24

What are the most common physiological/health impacts of SUDs?

Answer 24

lung disease, cardiovascular, violence, dementia, suicide, driving accidents, cancer or other deaths from 15000 = smoking, 1100 = alcohol, 1700 = drugs

Question 25

What is half-life and does it make it stronger or weaker?

Answer 25

Half-life = how long drugs stay in the system) - A shorter half-life of a drug often has stronger addictive properties, eg.

Morphine = 2.-3.5 hours STRONGER
Fentanyl = 3-4 hours STRONG
Methadone = 24 hours WEAKER

Question 26

What are examples of opioids / depressants?

Answer 26

1. heroin
2. morphine
3. methadone

Feeling - feelings of reward/euphoria, calm
Cessation length - 5-7 days, nausea, insomnia, muscle aches, yawning, vomiting, flat/negative affect, common catalyst to reuse

Question 27

What are examples of stimulants?

Answer 27

1. cocaine
2. ecstasy
3. MDMA / amphetamines

Feelings - feelings of euphoria, appetite suppression, alertness
Strong withdrawal from quicker cessation from short half-life and have a crash
Crash = vivid/negative dreams, fatigue, increased appetite, fatigue, psychomotor agitation

Question 28

What are examples of hallucinogens?

Answer 28

CHANGES TO PERCEPTION
Cannabis, LSD, psilocybin/mushrooms, mescaline

Quick tolerance rate: a few days, leading to higher levels of consumption
Increased risk of having ‘bad trips’ / links to experiencing psychotic symptoms, changing reality percept, auditory, visual and tactile information
Risk: may become more aggressive/violent or more catatonic

Question 29

What do the drugs share in common in chemical processes?

Answer 29

1. All drugs lead to DOPAMINE in the reward pathway through unique modes of action and all DISRUPT neurotransmitter functioning
2. Some increase / decrease the release, synthesis or receptors of NTs

Question 30

Examples of different mechanisms of different ‘common’ drugs of abuse:

Answer 30

1. Amphetamines
   BLOCK receptor to inhibit/ slow down dopamine release
   Outcome: increases the release of dopamine, decreases overall brain activity, excess dopamine can resemble symptoms of schizophrenia
2. Antidepressant mechanism: block degeneration of amine NTs, increases amine activity
3. Cocaine: blocks the reuptake of dopamine, serotonin and norepinephrine, and the NTs stay in high concentration in the synapse

Question 31

How does low vs. high doses of MDMA/ecstasy change brain chemicals?

Answer 31

Low doses = increases dopamine release
High doses = increases serotonin release, leading to hallucinogenic effects

After a few hours the body tries to reduce its naturally occurring serotonin to balance the excess in the synapse, leading to strong withdrawal effects.
Outcome: these drugs stimulate axons to release serotonin but can also damage/destroy axons, causes sleep, memory and attention problems, anxiety and depression.

Question 32

What drug stimulates neurons directly?

Answer 32

PCP mechanism: NMDA antagonist, stimulates serotonin and dopamine receptors directly, leading to visual/auditory/perceptual hallucinations by directly stimulating sensory neurons.

Used in animal studies to study and treat schizophrenia.
Outcome: long term effects speech and decision making, suicidal thoughts, paranoia, isolation, anxiety, depression

Question 33

How does THC cannabis affect the brain?

Answer 33

THC is an endogenous cannabinoid receptor agonist, leads to heightened sensory experience, affects learning, memory, attention, effects can last hours, longer half-life can show traces of THC in blood/urine for weeks.

THC blocks cannabinoid receptor that controls how much GABA is released, so LESS GABA means there IS LESS CONTROL OF DOPAMINE RELEASE, leads to EXCESS DOPAMINE

Outcome: it disrupts cannabinoid function responsible for perception, memory, appetite, pleasure, pain, mood, anxiety, long term = anxiety, depression

Question 34

What are two older models of addiction?

Answer 34

Disease model of addiction = changes within the brain that impair control, and brain impairment occurs

Outcome: Categorical, does not take into consideration severity and impairment levels, suggests its irreversible and not treatable

Choice/moral theory = continual substance use is from rational choices, suggests people are in control of their decisions, suggests SELF-BLAME

Question 35

In the Biopsychosocial model of addiction, what are the social factors that increase risk?

Answer 35

1.glorification and social acceptance of drugs
2. peer pressure on university campus
3. traumatic or family experiences,
4. adjustment difficulties

Question 36

In the Biopsychosocial model of addiction, what are the biological factors that increase risk?

Answer 36

1. family history
2. individual differences to reacting to different substances from individual chemical makeup
3. genetic vulnerability

Question 37

What is reward deficiency syndrome? How is it a genetic factor linked to addiction?

Answer 37

some people are born with underactive reward circuits called hypodopaminergic functioning, so there is a lower dopamine functioning baseline level, so these individuals might be more primed to be more susceptive to the rewarding/euphoric effects of a drug

Higher concordance rates in twins, first degree relatives, adoptive studies of biological parents, for many different drugs

Question 38

Are genetic factors substance specific?

Answer 38

Genetic vulnerabilities doesn’t seem to be substance specific, but rather vulnerable to the rewarding effects of drugs

Question 39

In the Biopsychosocial model of addiction, what are the psychological factors that increase risk?

Answer 39

1. Social reinforcement that people receive from using the substance,
2. Pre-existing or new mental health problems
3. Problems with impulsivity, and using drugs as a way to regulate emotions

Question 40

How is the reward pathway implicated in addiction?

Answer 40

Reward system in the brain activates several brain structures when experiencing a reward, either a drug or behaviour or stimulus
The reward system is intertwined with dopamine pathways

Neurotransmitters involved in reward pathways: glutamate, serotonin, dopamine, opioids, cannabinoids.

Brain releases dopamine when seeing or experiencing a drug

Ongoing substance use keeps reward activation and prevents withdrawal effects

Question 41

What are the 2 dopamine pathways involved in addiction?

Answer 41

Mesolimbic pathway = from the ventral tegmental area to the ventral striatum, involved in stimulus reward processing
limbic = reward processing

Mesocortical pathway = from the ventral tegmental area forward to the frontal lobes, involved in emotion and motivation processing, cognitive executive control
mesocortical = cognitive/executive control

Question 42

What happens to reward pathways in the binge/intoxication stage?

Answer 42

In binge/intoxication stage, there is a DOWNREGULATION of positive reward pathways,

so individuals INCREASE their levels of drug use to get the same high, increasing the tolerance of the drug

Question 43

How does the reasons of motivation for using the drug change from the intoxication stage to the withdrawal stage?

Answer 43

In binge/intoxication stage, motivation is driven by positive rewarding experiences

In the withdrawal/negative affect stage, the motivation for drug use is from avoiding withdrawal symptoms and negative experiences

In the preoccupation/anticipation/ craving stage, has exaggerated motivation for the drug

Question 44

How is classical conditioning involved in addiction?

Answer 44

where cues for drug administration (joint/bong/cigarette) ready the body and help anticipate outcomes, leading to cravings even when a person is not intoxicated, involved in relapse

Question 45

How is operant conditioning involved in addiction?

Answer 45

1. Positive reinforcement where drug is seen as being rewarding, eg. having a better time socialising, reinforces behaviours
2. Negative reinforcement = the drug/alcohol remove a negative experience, eg. avoiding withdrawal symptoms, delayed negative reinforcement = drugs can remove or delay withdrawal syndromes/hangover

Question 46

What are the 3 cognitive theories on addiction?

Answer 46

Outcome expectancy theory = the expected positive effects of using the drug increases the likelihood of taking it again

Beck’s cognitive theory = dysfunctional beliefs about the need for substances predicts its use and relapse, eg. coping mechanisms, “I can’t cope unless i drink”

Relapse prevention theory = drug reuse is predicted by a situation that is high risk, the absence of coping strategies, positive expectations of drugs, or low self-efficacy/sense of control/powerlessness leads to continued drug use

Question 47

What are the 6 steps in the Behaviour Change Model of Addiction (Pre, P, C, P, A, M, R)

Answer 47

1. Pre-contemplation= no intention to start change/unaware of impact of drug use or need to stop
2. Contemplation = intending to start changing, considering pros/cons around their substance use
3. Preparation = ready to start change, thinking about strategies to stop use, concerns about failure
4. Action = committing to changing use by reducing drug amount or frequency
5. Motivation = active monitoring their drug use/abstinence, are self-aware of their issues and factors that may be triggering
6. Relapse = reusing drug, need for support and treatment

Criticisms = people don’t necessarily move through the stages in the same order, may jump backwards and forwards in the ‘cycle of addiction’

Question 48

What are some sociocultural factors that can lead to addictions?

Answer 48

1. Socioeconomic status (what drugs are affordable?)
2. Peer influence
3. Family modelling
4. Within culture: availability, cost and social acceptability of the drug
5. Policies and laws as deterrents, eg. smoking and drug laws

Question 49

Why might complete abstinence not be a very good treatment?

Answer 49

1. complete abstinence might result in strong withdrawal effects – thus controlled use could make it more likely to succeed

2.removing the drug also remove other important support systems for that person, ie. social support involved in drug use, so abstinence might more quickly result in relapse back to those support systems?

Question 50

What does treatment goals depend on?

Answer 50

1. Patients perspective and individual differences
2. severity/duration of symptoms
3. The more consistent an agreement is between the clinician and patient, the higher chance of effective treatment for addiction - as it provides support and mutual understanding

Question 51

What are the main two biological treatments for drug addiction?

Answer 51

1. Detoxification (initial step) - clearing the build up of drugs in the body
2. antagonist drugs

Question 52

What does detoxification do?

Answer 52

Replacement therapy is sometimes used to counter the effect of severe withdrawal like nicotine patches
Replacements reduce withdrawal symptoms by slowly reduces the amount of nicotine entering the body,
By controlling for severe withdrawal effects, it hopes to increase individuals motivation for quitting because they encounter less coping and physiological problems

Question 53

What does an antagonist drug do?

Answer 53

block the rewarding effects of the drug and reduce motivation to use drug for reward

methadone which has a slower half life and helps reduce rewarding effects of drugs
Eg. antabuse helps create nausea when paired with alcohol, creating negative associations between nausea/alcohol

Question 54

Why are psychological treatments hard?

Answer 54

Many individuals would be in the precontemplation/or contemplation phase when engaging in psychological treatments

High drop out is also from people still using drugs when seeking help, eg. going to AA meetings intoxicated

Question 55

What are aversion therapies?

Answer 55

therapy where one is presented with an unpleasant stimulus while taking the drug, like taking antabuse or getting an electric shock to associate pain/nausea with drug and thus reduce the motivation to continue using

Limitation = Often need to be self-induced therapies which may/may not be successful

Question 56

What are 12-Step Programs?

Answer 56

Such as Alcohol/Narcotics Anonymous used for social learning principles which teach people alternative behaviours, eg. including relaxation and meditation techniques = goal of abstinence
Regular meetings sharing stories and getting mentoring and tips
Support groups can reduce stigma around drug use

Question 57

What are criticisms of 12-Step Programs?

Answer 57

Criticism = constantly talk about substance abuse / forefront of mind
Criticisms that it is more biassed towards people with religious principles

Mixed results about efficacy and best used in combination with other treatments

Often biological and psychological treatments are effective IN COMBINATION, and not so much in ISOLATION

Question 58

How does CBT treat drug addictions?

Answer 58

CBT = stimulus control and contingency management plans

Focus on identifying triggers, eg. bars, social groups, settings, beer glass, negative emotions

Alternative behaviours to challenge triggers = washing glass, calling someone

Pairing it with patients values = methods to challenge triggers + identifying motivations eg. they are doing this to stop the addiction impacting relationships or work functioning

Replacing the behaviour with something more valuable - not just about taking away the drug

Question 59

What is motivational interviewing?

Answer 59

pre/contemplative individuals may be conflicted/ambivalent about whether they want to stop their addiction and need to think about if they are ready to change

Forcing people to move to a different stage of the behaviour change cycle - could it cause further RELAPSE or DISENGAGEMENT

Motivational Interviewing identifies what stage people are at and motivates them to progress!!

Question 60

How does Decision Balance help additions?

Answer 60

by considering the pros/cons of KEEPING THE SAME or CHANGING,

1. SAME = relationship impacts, social support, preventing withdrawal effects, drug highs
2. CHANGING = saving money, withdrawal effects, stabler life

Question 61

What do sociocultural models of addiction consider?

Answer 61

1. the environmental factors that explain individual suffering, eg. war of drugs culture and drug culture within users

Question 62

How might discrimination actually help drug addictions?

Answer 62

After drug decriminalisation in Portugal

• treatment numbers increased significantly
• hiv/aids infections and drug deaths and offences have significantly decreased

SUGGESTED THAT cultural stigma around drugs decreases after decriminalisation - increasing help seeking and reduces drug stigma

Question 63

What is drug culture?

Answer 63

shared values/customs and beliefs and rituals and behaviours over time that forms bonds between people in a drug culture - will impact recovery/help seeking

Question 64

What are some examples of values in drug culture?

Answer 64

1. Antisocial viewpoint of mainstream society
2. Rejection of middle-class values: honesty, hard work, security
3. Hedonism: excitement/pleasure over stability/security
4. Outward appearance: owning things of prosperity
5. Valuing continued participation from others
6. Emotional detachment: valuing emotional aloofness and see emotions as a sign of weakness

Question 65

Whats the prevalence rate of addition of minority groups vs majority in the US?

Answer 65

Statistics of alcohol use in minorities is not in proportion to ethnic minority demographics, minorities seem to have same or higher rates of alcohol use in US despite only representing a tiny portion of the population

Suggest minorities are more vulnerable to drug use from various sociocultural factors, eg. poverty, lower SES, education opportunities

Question 66

What did the study by Laving et al find on shame and OCD?

Answer 66

1. Shame is common emotion in OCD due to unacceptable thoughts, rituals and unwanted perceptions

Method: A systematic review and meta-analysis on association of shame with OCD and unacceptable thoughts.

Results: a significant, moderate and positive correlation between total OCD and shame and significant, weak and positive relationships were found between shame and three OCD symptom dimensions:
- unacceptable thoughts, symmetry concerns, harm obsessions
shame in OCD can be a barrier to seeking treatment and impair quality of life

Question 67

How does Brene Brown’s talk on shame link with the findings of Laving et al?

Answer 67

Brown discusses how self-beliefs about one’s own worthiness and belonging play a huge impact in their sense of worthlessness and belonging, more specifically that a major barrier to feeling connected to others comes from the self belief that we are unworthy of connection.

This is supported by previous cognitive models of OCD, that find that shame has also previously been found to perpetuate negative self-beliefs in OCD.

Question 68

How can shame impact identity and symtpoms of OCD and treatment?

Answer 68

Brown observes that shame, more specifically the feeling of disconnection, may act as a barrier towards vulnerability and a way to feel positive emotions. From these behaviours, Laving et al. found that feelings of shame were associated with a number of different OCD symptoms, and appear to impact help-seeking for the condition.

Overall, feelings of shame and negative self-beliefs are moderately linked to OCD behaviours, and appear to perpetuate symptoms and hinder the ability to seek out support. Brown stresses that these emotions and beliefs play a huge impact on our behaviour and contribute to our sense of self, and only through open communication and positive self-talk can we practise more joy, gratitude and self-compassion. Brown’s advocacy seems to be directly applicable to people with OCD, as those with OCD as a population seem to be more likely to experience these negative beliefs and emotions.