Psychopathology Substance-Related And Addictive Disorders Flashcards
Substance-Use Disorders:
The DSM-5 describes substance use disorders as involving “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems” (p. 483). Symptoms represent four categories – impaired control, social impairment, risky use, and pharmacological criteria (tolerance and withdrawal) – and, for the diagnosis, the person must have two or more symptoms within a 12-month period. Substance use disorder can be diagnosed for all classes of substances except caffeine and are further described with specifiers to indicate the severity of the disorder (which is determined by the number of symptoms) and if the person is in early or sustained remission or in a controlled environment.
The treatment of substance use disorders varies, depending on:
The type of substance(s), the severity of the disorder, the presence of comorbidities, and the person’s preferences. However, treatment ordinarily includes individual, family, and/or group interventions and medication. Evidence-based interventions include cognitive behavioral therapy, motivational enhancement therapy, contingency management, family behavior therapy, the community reinforcement approach, and 12-step facilitation.
The community reinforcement approach (CRA) is based on:
The principles of operant conditioning and “helps people arrange their lifestyles so that healthy, drugfree living becomes rewarding and thereby competes with alcohol and drug use”. Community reinforcement and family training (CRAFT) was derived from CRA but was designed for individuals who refuse to seek treatment for their substance abuse problems. Consequently, rather than focusing on the person with the substance use disorder (the identified patient), a CRAFT therapist works with a concerned significant other (CSO) who is a family member or close friend. The primary goals of CRAFT are to (a) help the CSO influence the identified patient to enter substance-use treatment, (b) teach the CSO procedures to help reduce the identified patient’s substance use, and (c) help the CSO make positive life changes that improve the CSO’s quality of life whether or not the identified patient enters treatment.
In substance use disorders, medications used
Disulfiram, naltrexone, acamprosate, and topiramate are used to treat alcohol use disorder; methadone and naltrexone are used for opioid use disorder; and nicotine replacement therapy, bupropion, and varenicline are used for tobacco use disorder. While no medication has been approved by the FDA for cocaine use disorder, there is some evidence that bupropion, modafinil, long-acting amphetamine, and topiramate can improve abstinence (Chan et al., 2019; Kampman, 2019). (Additional information about drugs used to treat substance use disorders is provided in the physiological psychology and pharmacology content summary.)
Research has generally found that combined interventions are most effective for substance use disorders. As an example:
As an example, studies evaluating treatments for tobacco use disorder suggest that therapy (especially therapy that includes critical thinking skills training and social support) and medication (especially nicotine nasal spray and varenicline) are each effective when used alone but that the combination of therapy and medication is most effective (Fiore et al., 2008). There is also evidence that voucher-based reinforcement therapy (VBRT) and CBT is an effective combination for cocaine use disorder. VBRT is a type of contingency management and involves giving patients vouchers that can be exchanged for goods and services in the community when they achieve treatment goals. The studies have shown that VBRT is useful for promoting initial abstinence but that its effects fade when vouchers are discontinued. In contrast, CBT is less useful for promoting initial abstinence but helps patients maintain abstinence following treatment because it provides them with coping skills they can continue to use post-treatment (Kampman, 2019).
One of the best-known approaches to relapse prevention is Marlatt and Gordon’s
(1985; Larimer, Palmer, & Marlatt, 1999) relapse prevention therapy (RPT), which is a cognitive-behavioral approach. It describes substance addiction as a “learned habit pattern” and views lapses following a period of abstinence as being precipitated by a high-risk situation (e.g., a negative emotional state, interpersonal conflict, social pressure).
Relapse Prevention Therapy (RPT) also proposes that a laspse
It also proposes that a lapse is most likely to turn into a full-blown relapse when the person has poor coping skills, low self-efficacy, and high expectations about the positive effects of alcohol and responds to the lapse with an “abstinence violation effect” – i.e., with negative emotions, guilt, and a sense of personal failure. RPT utilizes cognitive and behavioral strategies that enable clients to recognize and deal more effectively with high-risk situations. Strategies include training in coping skills, enhancing self-efficacy, challenging myths about the positive outcomes of substance use, cognitive restructuring to view lapses as mistakes rather than the result of personal failure, and altering lifestyle factors that increase exposure or reduce resistance to high-risk situations.
Project MATCH, a multisite clinical trial, compared the effectiveness of
Cognitive behavioral coping skills therapy, motivational enhancement therapy, and twelve-step facilitation for clients who had received a DSM-III-R diagnosis of alcohol dependence or abuse. It also evaluated the client-treatment matching hypothesis, which predicts that client outcomes can be improved by matching clients with certain characteristics to treatments most appropriate for those characteristics. Clients were randomly assigned to one of the three treatments, and clients in each group were categorized in terms of several characteristics (e.g., alcohol involvement, psychiatric severity, anger, and social support for drinking versus abstinence).
Results of MATCH, a multisite clinical trial results indicated that
Results indicated that, at one-year and three-year follow-ups, all three treatments had produced significant reductions in drinking, with twelve-step facilitation having a slight advantage over the other two treatments. The results also provided some support for the matching hypothesis. For example, at the three-year follow-up, clients whose social networks were supportive of drinking benefited most from twelve-step facilitation, while clients who were high in anger benefited most from motivational enhancement therapy (Project MATCH Research Group, 1997, 1998).
Substance-Induced Disorders:
These disorders include substance intoxication, substance withdrawal, substance withdrawal delirium, and substance/medication-induced mental disorders.
Alcohol Intoxication:
This disorder involves problematic behavioral and psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment) with at least one of six symptoms: slurred speech, incoordination, unsteady gait, nystagmus, impaired attention or memory, stupor or coma.
Alcohol Withdrawal:
The diagnosis of this disorder requires at least two of eight symptoms that develop within several hours to a few days following cessation or reduction of heavy and prolonged alcohol use: autonomic hyperactivity, hand tremor, insomnia, nausea or vomiting, transient hallucinations or illusions, anxiety, psychomotor agitation, generalized tonic-clonic seizures.
Alcohol-Induced Major Neurocognitive Disorder:
This diagnosis requires evidence of a significant decline in one or more cognitive domains that interferes with independence in everyday activities. A specifier is used to indicate if the disorder is the nonamnestic-confabulatory type or amnestic-confabulatory type. The latter type is also referred to as Korsakoff syndrome, which has been linked to a thiamine deficiency and involves anterograde and retrograde amnesia and confabulation.
Opioid Intoxication:
This disorder involves significant problematic behavioral or psychological changes (e.g., initial euphoria followed by apathy or dysphoria and impaired judgment) plus pupillary constriction and the development of at least one of three symptoms during or shortly after opioid use: drowsiness or coma, slurred speech, impaired attention or memory. Opioids include opium, heroin, morphine, and codeine, which are derived from the opium poppy, and synthetic and partly-synthetic drugs, which include methadone, oxycodone, hydrocodone, and fentanyl.
Opioid Withdrawal:
This diagnosis requires the development of at least three of nine symptoms following cessation of heavy and prolonged opioid use or administration of an opioid antagonist after opioid use: e.g., dysphoric mood, nausea or vomiting, muscle aches, diarrhea, yawning, fever, insomnia.
