TASK 9 - SUBSTANCE-USE DISORDER Flashcards
drug addiction
= use of psychoactive drug/substance, causing intoxication (high); having the compulsion/urge to take drug (craving) although experiencing negative consequences
- physical dependence + abuse + psychological dependence
- withdrawal + craving
substance abuse
= when recurrent use results in harmful consequences
- can’t fulfil obligations, use in dangerous situations, legal problems, continued use despite problems
- repeated problems in at least one of the categories within 12-month period
substance dependence
= body requires the drug to feel “normal” due to tolerance
- only withdrawal
DSM-5 (general substance use disorder)
1. impaired centre control
must show 2 (OR MORE) of the following 10
- substance taken in increasingly larger amounts/ over longer periods of time than originally intended
- craving
- ongoing desire to cut down/ control substance abuse
- much time spent on obtaining, using or recovering from the substance
- compulsion
DSM-5 (SUD)
2. social impairment
- inability to meet responsibilities at home/work/school
- important activities are abandoned because of substance use
- ongoing substance use despite recurring social difficulties caused/made worse by the effects of the sentence
- interpersonal harm
DSM-5 (SUD)
3. risky use
- ongoing use in physically dangerous situations e.g. driving a car
- use continues despite awareness of physical/ psychological problems that come from the substance
- individual harm
DSM-5 (SUD)
4. pharmacological criteria
- changes in tolerance indicated by increased amounts to achieve desired effects/ diminished intoxication to same amount
- withdrawal demonstrated by characteristic withdrawal syndrome of the substance and/or taking the same/similar substances to relieve withdrawal symptoms
- tolerance + withdrawal
prevalence
- 6-5.1% (overall)
- onset: 15-64 = 51% have used illegal drugs/ non-medical prescribed drugs/ inhalants at some point in their lives
- comorbidity: mostly anxiety + mood disorders (53-76%)
substances
- give rewarding effect in beginning (dopamine)
- make you feel good, pleasure
- believed to have beneficial effects in past
- but all addictive + harmful long-term
substances
1) psycholeptics = depressants
= slow, suppress CNS
- decrease heart rate, calming effects
- alcohol, barbiturates, benzodiazepines, inhalants, (nicotine, caffeine)
substances
2) psychoanaleptics = stimulants
= activate, stimulate CNS
- more energy, arousal, alertness
- cocaine, amphetamines, nicotine, caffeine
substances
3) opioids
= works on body’s own opioid system
- pain relief
- heroin, morphine
substances
4) psychodysleptics = hallucinogens
- cause hallucinations
- LSD, mushrooms, phencyclidine (PCP)
substances
- cannabis
= depressant + stimulant + hallucinogen (1+2+4)
historical theories
1. moral model (BAD)
= BLAME addict; moral failure, weak; give in to drug/addiction
- 1850
historical theories
2. temperance model (BAD)
= BLAME substance; substance = evil
- introduction of prohibition
historical theories
3. symptomatic model (MAD)
= addiction = secondary disorder/symptoms; indirect consequence of primary disorder
- need treatment
historical theories
4. disease model (MAD)
= addiction = primary disorder
- need treatment
historical theories
5. learning theory/psychological model (SAD)
= addiction = learned behaviour due to experience (coping mechanism, operant conditioning)
historical theories
6. social model (SAD)
= addiction = learned behaviour with social pressure being an underlying cause
historical theories
7. bio-psycho-social model
= includes several factors of 1-6
- 1976
theories
- biological/genetic
- drugs alter the pleasure (dopamine) pathway to produce strong sense of reward
- -> VTA –> NAC (nucleus accumbens) –> PFC
- chronic use makes reward centres less sensitive –> tolerance + craving
- cue sensitivity + conditioned response to cues induces powerful craving
- heritable (general rather than specific)
- genetic variation in dopamine receptor/transporter gene
theories
- psychological
- social learning: modelling of parents
- expectation that alcohol reduces stress
- personality: behavioural under-control, impulsiveness, sensation-seeking, prone to antisocial behaviours
theories
- sociocultural
- chronic stress
- environmental reinforcements/ punishments –> abuse less common in societies with more restrictions
theories
- gender roles
- men + alcoholism: more likely because “masculine”; tend to start in socialising context
- societal acceptance of drinking in women went up, so did drinking in women
- women: less likely to carry risk (personality traits); suffer from alcohol earlier + may notice that sooner + may find effects scarier thus –> limit consumption; start in family/partner/lover context
theories
- place conditioning (alcohol)
= whether non-dependent drinkers show place preference for a location paired with alcohol + whether time spent in those places is related to subjective alcohol effects
- -> non-dependant consumers develop a preference for locations paired with alcohol consumption
- conditioning happened without explicit knowledge of the drug –> cue contingencies: behaviour influenced by drug before we’re even aware of it
addiction as a disease
= chronic disease, with underlying mechanisms seen in the brain
- reward system (= mesolimbic dopamine system) as centre
- depressed reward system = dopamine receptors decrease in availability –> decreased activation of PFC –> impaired control/ inhibition
- three recurring stages of addiction
addiction as a disease
1. binge + intoxication
- pavlovian learning: repeated experience of reward becomes associated with environmental stimuli that precede them
- dopamine cells start firing anticipatory to conditioned stimuli (drug intoxication) –> cue triggers craving + motivates drug-seeking behaviour
- drugs, unlike natural rewards (e.g. food), avoid satiation + continue to increase dopamine levels –> after abuse drug is the only reward strong enough to trigger response
addiction as a disease
2. withdrawal + negative affect
- addicted = drug triggers much smaller increases in dopamine levels –> less sensitive to drug + other rewards (= less motivated by everyday stimuli)
- -> conditioned pull toward reward
- amygdala over-activated
- anti-reward system becomes overactive = repeated exposure leads to adaptation in circuit of extended amygdala + the basal forebrain –> increased reactivity to stress –> emergence of negative emotions/withdrawal
- -> emotional push to escape withdrawal
- addiction changes: wanting euphoria to preventing dysphoria
- -> don’t see drug as pleasurable anymore; only take drug to escape distress/withdrawal
addiction as a disease
3. preoccupation + anticipation
- changes in function of involved PFCs (executive functioning especially)
- prefrontal region changes: impaired signalling of dopamine + glutamate in prefrontal regions
- down-regulation of signalling = impairment of executive processes –> weakened ability to resist strong urges + follow through on decision to stop taking the drug
addiction as a disease
- biological + social factors
- differ in vulnerability to various genetic, environmental, developmental factors = unique susceptibility (for initial drug use, sustaining drug use, progressive changes in brain)
- increasing vulnerability:
1. family history: heritability + modelling
2. early exposure to drug use: adolescence greatest vulnerability
3. exposure to high-risk environments: socially stressful environments
4. certain mental illnesses: mood disorders, psychoses, anxiety…
addiction as a disease
- implications for prevention + treatment
- adolescent brain is still developing, period of enhance neuroplasticity –> sensitive to effects of drugs
- -> eave drinking and raise legal smoking age to 21
- medical treatment can help to restore healthy function in affected brain circuitry + assist in preventing relapse
- behavioural interventions to help restore balance in brain circuitry
1. mitigate person’s stress reactivity and emotional states –> help manage strong urges
2. improve executive function and self-regulation –> help recovering patients plan ahead to avoid vulnerable situations
3. help patients to avoid environmental cues (circle of friends) –> reduce likelihood of conditioned craving
addiction as a disease
- criticism
A. chronic diagnosis cause demoralisation for treatment
- think they will relapse anyway, there is no recovery
B. many actually do recover naturally
- brain change ≠ malfunction –> might be normal plasticity + change back some time
addiction as a choice
= addictions work like other choices in which immediate rewards take precedence over long-term gains
- drug addicts can + do recover –> decision to take drugs or to quit are executed voluntarily
- addicts choose “locally” rather than “globally”
- trick is to acquire strategies for seeing overall summation of rewards over time & ignoring the attraction of immediate goal
- -> neither disease nor full on choice but something in-between: momentary states of dopamine enhancement triggered by cues shut down intertemporal flexibility (disease model) –> can’t consider moments other than “now”
- with recurrence of this cycle: this gets worse + it gets much harder to make the choice
addiction as a choice
- operant addiction
= can explain why people start but not maintenance/persistence of addiction
- positive reinforcement: drug high, pleasurable effect
- negative reinforcement: reduce withdrawal effects
addiction as a choice
- behavioural economics
- addicts always choose more attractive local option (= take drug –> more reward than not taking it)
- no pleasure without drug
- treatment implications: adapt global view (contingency management)
dual-process model
- hyperactive impulsive system (1) + dysfunctional reflective system (2)
- continuum hypothesis = assumes similar deficits across different alcohol related disorders: binge drinkers would show qualitatively similar but quantitatively less impairments than alcohol-dependent
dual-process model
1. hyperactive impulsive system
= emotional evaluation (limbic)
- impulsive prepotent behaviours
- strong impulse to take drug
- -> shown in craving, attention bias, approach bias
dual-process model
2. dysfunctional reflective system
= cognitive evaluation (prefrontal)
- inability to voluntarily inhibit the consumption
- have more difficulties controlling urges
- -> shoes in worse WM, decision making + response inhibition
integration of models
- disease + dual-process + choice
- have increase in reward seeking + compulsion in common
- -> dopamine system, impulsivity, local decisions
- have loss in control in common
- -> PFC deficits, loss of control, lack of global view
treatment
- biological
- detoxification = drugs used to dampen withdrawal symptoms but dosages are decreased slowly –> patient doesn’t become dependent (= help prevent relapse while brain is healing)
- drug replacement/maintenance therapy = substituting drug that has fewer damaging effects
a. antagonist drugs = block/ change effect of addictive drug, reducing the desire for it BUT cause severe withdrawal - alcohol: antabuse/disulfiram = makes alcohol punishing but only as long as they continue to take it
- nicotine: patches/gums or antidepressant bupropion
- heroin: opioid methadone, which has less severe effects
treatment
- behavioural
- alcohol: aversive classical conditioning with Antabuse then through operant conditioning they learn to avoid alcohol in order to avoid the aversive response
- covert sensitisation therapy: imagine unpleasant associations between drug + consequences to create conditional aversive response
- contingency management programmes: reinforcing abstinence
treatment
- cognitive
- identify situation in which they’re most likely to take drug
- identify expectations about drug taking + challenge those by reviewing negative effects
- motivational interviewing: elicit + solidify motivation + commitment to changing substance use
- mindfulness + meditation
treatment
- relapse prevention
- abstinence violation effect: when they violate their abstinence, they tend to attribute it to lack of will power and self-control rather than situation-factors –> violate it even more to suppress conflict + guilt (dietary-slip)
- relapse prevention programmes: teach people to see slip as situational and identify high risk situations to come up with coping/avoiding strategies
treatment
- community programmes (AA)
- by/ for people with alcohol related problems
- 12 steps
- -> 1. admit dependence
- group members provide moral + social support
- believe that people are never completely cured and will always be “recovering alcoholics”
treatment
- prevention programmes
- target younger people as onset predominantly during adolescent risk period
- focus education on immediate risk of excess + payoffs of moderation
- harm reduction model: drink safe like you drive safe
- learn to be aware of drinking habits + thought to calculate alcohol blood level
