PSCY Essay

Substance-Related and Addictive Disorders SSY 230: Lecture 10

Key Features of Substance Disorders

A substance is a chemical that alters a person’s mood or behavior when the person smokes, injects, drinks, inhales, snorts, or swallows it. Substance-related disorders reflect patterns of abuse of these substances, the resulting intoxication, and the consequences of discontinuing use of the substance. A person in a state of substance withdrawal shows physiological and psychological changes that vary according to the actual substance involved. Tolerance occurs when an individual requires increasingly greater amounts of the substance in order to achieve its desired effects, or when the person feels less of an effect after using the same amount of the substance.

A substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using a substance even though it causes significant problems in his or her life. Clinicians diagnose substance use disorders by assessing the individual on four categories of symptoms: loss of control, social impairment, risky use, and pharmacological changes. Based on the number of symptoms the individual demonstrates, clinicians assign a severity rating from mild to severe.

Substance Use Disorders

People with substance use disorders suffer a range of significant effects on their daily life. They neglect obligations at work, and their commitments to home and family erode. They may begin to take risks that are personally dangerous and put others in jeopardy, such as driving or operating machinery while intoxicated.

It stands to reason that legal problems can arise for people who abuse substances. In addition to being arrested for driving while under the influence of a substance, they may face charges of disorderly conduct or assaultive behavior. The substance use disorders also frequently instigate interpersonal problems as well, due to the fact that excessive use of drugs or alcohol creates strains on relationships with family, friends, and co-workers. In extreme cases, these disorders can also lead to health problems and even premature death.

Substance-Induced Disorders

Substance-related disorders also include substance-induced disorders, which are disorders arising from the effects of the substance itself.

People receive a diagnosis of substance intoxication when they experience a drug’s effects on their physiological functioning and show signs of significant impairment. The extent of substance intoxication depends on the specific drug, the speed with which it acts, and the duration of its effects. Efficient absorption of intravenous or smokable drugs into the bloodstream can lead to a more intense kind of intoxication than occurs with drugs taken in pill form.

The second category of substance-induced disorders includes those that reflect the effects of withdrawal, in which individuals develop behavioral changes specific to the particular substance. These changes include physiological and cognitive alterations associated with the discontinuation of the substance in question. Other disorders can also occur as a function of substance use, including psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder. People may also show comorbidity of the

substance-related disorder with another condition, such as an anxiety disorder or a mood disorder.

Drug Withdrawal

Disorders Associated with Specific Substances

According to the U.S. government’s Substance Abuse and Mental Health

Service (SAMHSA) National Survey on Drug Use and Health (NSDUH), in

2016 an estimated 11 percent of the population used illicit drugs at

least once in the preceding 30 days (that is, they were current users).

Marijuana is the most commonly used substance, with 28.6 million

people 12 and older reporting use of any illicit drug in the United States

within the past month.

Rates of current illicit drug use by individuals 12 years of age and older

vary considerably by demographic group. According to the NSDUH, the

three most significant grouping characteristics are race/ethnicity, age,

and gender.

The rate of past-month illicit drug use is 15.7 percent for American Indians or Alaska Natives, followed by 12.5 percent among people who identify as Black or African American, 10.8 percent for Whites, 9.2 percent for Hispanic or Latino, and 4.1 percent for Asian. The rates generally decline with age from the peak of 22.3 percent at ages 18 to 25 to 1.9 percent at ages 65 and older. Males have a higher rate of drug use (12.8 percent) than females (8.5 percent). Illicit drug use tends to be lower among college graduates, the employed, and Midwesterners and highest among people living in cities.

Disorders Associated with Specific Substances

Most drugs of abuse directly or indirectly target the reward center of the brain by flooding its circuits with dopamine. Overstimulation of the reward system produces the euphoric effects abusers seek and leads them to engage in the behavior that will allow them to repeat the experience. Drugs are more addictive than the natural “highs” produced by such activities as eating and sex because they release far more dopamine (2 to 10 times as much) than do natural rewards, and the effects last much longer.

Over time, the neurons in these dopamine pathways “down-regulate” in response to these surges in dopamine, meaning they produce less dopamine themselves or reduce the number of dopamine receptors. Users then need to take the drugs to raise their dopamine levels back to normal. In order to experience the effects they experienced initially from the drugs, they also need to take higher and higher levels; in other words, they develop tolerance.

In addition to dopamine, some drugs of abuse also influence glutamate, a neurotransmitter active in memory and learning. Long-term drug abuse can lower the individual’s level of glutamate and lead to memory impairments.

Because users learn to associate the pleasurable feelings of using the drug with the cues in the environment that were there when they took the drug, they develop classically conditioned responses that maintain their addiction.

Comorbidity

Individuals with mood and anxiety disorders are more likely to abuse substances. The most common comorbid conditions are mood disorders, anxiety disorders, borderline personality disorder, and antisocial personality disorder. People with schizophrenia are more likely to use alcohol and tobacco and to have drug use disorders.

There are three possible routes to the development of comorbid substance use and

other psychological disorders.

● The first is the similarity of risk factors in substance use and other

psychological disorders.

● Second, individuals with psychological disorders or symptoms may use drugs

as a form of self-medication.

● Third, people who use substances may subsequently develop a psychological

disorder, due either to changes in brain activity produced by the substances or

to changes in lifestyle that precipitate stress, which, in turn, leads to

symptoms of depression and anxiety.

Risk Factors of Early Drug Use

Drug use typically begins in adolescence, which is also the time of heightened vulnerability to other psychological disorders. Early drug use is also a risk factor for later substance use disorder and possibly for the subsequent development of other disorders as well.

The risks are particularly likely to occur in individuals who have a high genetic vulnerability. In one study following adolescents into early adulthood, only those heavy marijuana users with a particular gene variant had significantly higher risk of developing schizophreniform disorder.

Substance Use and PTSD

Higher rates of substance use disorders also occur in physically or emotionally traumatized individuals. This is a matter of particular concern for the veterans returning from the Iraq and Afghanistan wars. As many as half of veterans who have a diagnosis of PTSD also have a comorbid substance use disorder.

In addition, researchers estimate that 45 percent of offenders in state and local prisons have a comorbid mental health and substance use disorder. People with a comorbid substance disorder and either PTSD or a criminal history may have difficulty receiving treatment.

Veterans with PTSD and substance disorders may not receive treatment for the PTSD until the substance use disorder has been treated; however, traditional substance disorder clinics may defer treating the PTSD. Incarcerated criminals may also have difficulty receiving appropriate treatment in the prison system.

Clearly, individuals with comorbid disorders face particular challenges in treating their substance use disorders.

Alcohol

Alcohol use is associated with several categories of disorders including use disorders, intoxication, and withdrawal. According to the World Health Organization (WHO), worldwide there are 3.3 million deaths every year due to alcohol, representing nearly 6 percent of all deaths.

Patterns of alcohol use are associated with age. Young adults 21 to 25 have the highest rates of binge drinking and the highest rates of heavy drinking. The rates of binge and heavy drinking decline sharply through adulthood.

Although the rates of alcohol use by age are lower in those 65 years of age and older, longitudinal studies provide a different picture. People are less likely to start drinking after the young adult years, but many persist in their previously established patterns of alcohol use disorder throughout adulthood. Adults going through certain life transitions may alter their alcohol use patterns, however.

For men, parenthood is associated with lower rates of alcohol use after the age of 38; women show the opposite pattern. Men who lose their jobs have the highest rates of alcohol use after age 38; for women, there is no relationship between job status and alcohol-use persistence. These findings suggest that the relationships among alcohol use, life transitions, and gender are complex and that aging alone is not sufficient for understanding age-related changes in alcohol use disorders.

Alcohol

To understand how alcohol affects behavior, consider that from a physiological standpoint alcohol is a nervous system depressant, and the way it affects the individual depends on how much the drinker ingests.

In small amounts, alcohol has sedating effects, and the drinker therefore feels more relaxed. With larger amounts, drinkers may begin to feel more outgoing, self-confident, and uninhibited. Beyond that point, the depressant effects become apparent, leading users to experience sleepiness, lack of physical coordination, dysphoria, and irritability. In even larger amounts, alcohol can be fatal, leading the individual’s vital functions to shut down.

More severe effects also occur when the individual mixes alcohol with other drugs; potentiation makes the effects of two drugs taken together greater than the effect of either substance alone. Combining alcohol with another depressant can have a fatal outcome, for example.

Alcohol

The rate at which alcohol absorption occurs in the bloodstream depends on a number of factors, including how much a person consumes and over what time period, and whether food is present in the digestive system. Another factor is the drinker’s metabolic rate (the rate at which the body converts food substances to energy). The average person metabolizes alcohol at a rate of one third of an ounce of 100 percent alcohol per hour, which is equivalent to an ounce of whiskey per hour.

Following a bout of extensive intake of alcohol, a person is likely to experience an abstinence syndrome, or the phenomenon commonly called a “hangover.” The symptoms of abstinence syndrome include a range of phenomena including nausea and vomiting, tremors, extreme thirst, headache, tiredness, irritability, depression, and dizziness. As with alcohol absorption, the extent of abstinence syndrome the person experiences reflects the amount and rate of alcohol consumption and the individual’s metabolic rate.

Directly or indirectly, alcohol affects almost every organ system in the body. Long-term use can lead to permanent brain damage, with symptoms of dementia, blackouts, seizures, hallucinations, and damage to the peripheral parts of the nervous system. Two forms of dementia are associated with long-term heavy alcohol use.

Wernicke’s Disease Wernicke’s disease is an acute and potentially reversible condition characterized by delirium,

eye-movement disturbances, difficulties in

movement and balance, and deterioration of the

peripheral nerves to the hands and feet.

It is not alcohol itself but the associated deficiency

of thiamine (vitamin B1) that causes Wernicke’s

disease. Long-term heavy use of alcohol damages

the body’s ability to metabolize nutrients, and

alcohol users often have an overall pattern of poor

nutrition. Adequate thiamine intake can reverse

Wernicke’s disease.

Korsakoff’s SyndromeKorsakoff’s syndrome is a permanent form of dementia in which the individual develops

retrograde amnesia, the inability to remember

past events, and anterograde amnesia, the

inability to remember new information.

The chances of recovering from Korsakoff’s

syndrome are fewer than one in four, and about

another one in four people who have this

disorder require permanent institutionalization.

Effects of Alcohol Abuse

Chronic heavy alcohol consumption also causes a number of harmful changes in the rest of the body outside the nervous system,

including to the liver,

gastrointestinal system, bones,

muscles, and immune system.

Alcohol Withdrawal

When people abruptly stop ingesting alcohol after periods of chronic usage, they can experience sleep disturbances, profound anxiety, tremors, hyperactivity of the sympathetic nervous system, psychosis, seizures, or death.

Delirium tremens is a severe form of alcohol withdrawal that involves sudden changes in the person's mental state and/or nervous system. Most people refer to it as DTs.

DTs begin when alcoholics stop drinking after they have been consuming excessive amounts of alcohol for a period of time. It usually occurs in those who have a history of withdrawal. That means your risk for it is higher if you have been through alcohol withdrawals in the past. You are also more at risk for the condition if you have been drinking a lot over the course of several months, or have been an alcoholic for more than ten years.

Alcohol Use Disorders from a Biological Perspective

Twin, family, and adoption studies consistently point to the importance of genetic factors as contributors to alcohol-related disorders, with an estimated heritability of 50 to 60 percent. Pinpointing the genes responsible for alcohol-related disorders is a great challenge to researchers, however, because it is likely that multiple genes are active in their transmission. The greatest success has come from studies examining associations between genes that govern alcohol metabolism and neural transmission. Researchers are attempting to connect variations in some of these genes not only with patterns of alcohol use but also with comorbid disorders such as social anxiety disorder, personality traits, and early childhood predictors.

Sociocultural influences also appear to interact with genetic vulnerability. In a large nationwide study of midlife adults, researchers found differences between twins in the level of alcohol use, based on socioeconomic status. In families from lower socioeconomic levels, genetic factors seemed to play a larger role than the environment. In higher social status families, the amount of alcohol individuals use is affected by such factors as familial habits and traditions. These findings support the diathesis-stress model that relates genetic predisposition to environmental stressors.

Treatment Approaches from a Biological Perspective

In the biological perspective, treatment of individuals with alcohol use disorders relies on prescription medications, alone or in conjunction with psychologically based therapies. A large number of well-controlled studies support the use of naltrexone as an aid in preventing relapse. As an opioid receptor antagonist, it blocks the effects of the body’s production of alcohol-induced opioids, perhaps through involving dopamine. The individual who takes naltrexone is less likely to experience pleasurable effects of alcohol and even less likely to feel pleasure thinking about it. As a result, he or she will feel less of an urge to drink and therefore will be less likely to suffer a relapse of heavy drinking. A large number of studies provide supportive evidence about naltrexone’s effect on drinking, including its ability to lower the individual’s cravings and, hence, consumption.

Disulfiram is a medication that operates by the principles of aversion therapy. An individual taking disulfiram who consumes alcohol within a 2-week period will experience a variety of unpleasant physical reactions, including flushing, palpitations, increased heart rate, lowered blood pressure, nausea and vomiting, sweating, and dizziness. Although not as effective as naltrexone, it does work for highly motivated individuals, particularly those treated in supervised settings who are also older, have a longer drinking history, and participate in Alcoholics Anonymous meetings.

The third medication shown to be effective in treating alcohol use disorders is acamprosate, an amino acid derivative that appears to moderate glutamate receptors. Acamprosate reduces the risk of relapse by reducing the individual’s urge to drink and thereby reducing the drive to use alcohol as a way of reducing anxiety and other negative psychological states. The evidence on acamprosate is generally positive, though individuals who seem to benefit from it the most are those who are older when they become dependent on alcohol, have physiological signs of higher dependence, and have higher levels of anxiety. People who are more highly motivated to become fully abstinent at the start of treatment are more likely to remain on the medication and therefore more likely to improve. Individuals who have only recently stopped drinking and are of normal or close to normal body weight appear to derive greater benefit.

Dual-Process Theory

Psychological Perspective

Current psychological approaches to alcohol use disorders focus on the cognitive systems that guide people’s drinking behavior.

According to dual-process theory, one cognitive system generates fast, automatic processes that trigger an impulse to drink alcohol. These automatic processes are based on the conditioned positive associations with alcohol that people have formed.

The second, and slower, system consists of the controlled, laborious processing that would allow individuals to regulate and inhibit acting on those positive associations.

The dual-process theory posits that the more the individual can inhibit the automatic impulse, the less likely he or she is to consume excessive amounts of alcohol.

Personality may play a role in this process, because individuals who are lower in emotional control seem to find it more difficult to engage in the deliberate process of inhibiting their urges to drink.

Alcohol Use Disorders from a Psychological Perspective

Alcohol consumption is also guided by individuals’ expectations about what will happen to them after they consume alcohol. Individuals develop alcohol expectancies early in life, even before they first taste alcohol. These can include the potential for alcohol to reduce tension or help them cope with social challenges, feel better or sexier, or become more mentally alert. Expectancies about alcohol can also include people’s beliefs in their self-efficacy, or their ability to resist or control their drinking.

Cognitive factors also can influence what happens when a person consumes alcohol. According to alcohol myopia theory, individuals narrow their attentional focus the more alcohol they consume. This theory also predicts that when people drink alcohol, they also become more likely to engage in impulsive and potentially harmful behaviors, such as high-risk sexual activities. The high prevalence of binge drinking on college campuses presents a particular concern for this reason. As individuals consume greater amounts of alcohol, they are more likely to make risky choices because

the immediate temptation of the moment (such as engaging in risky sex) overcomes the long-term consequences of the behavior (such as developing a sexually transmitted disease).

Even individuals who engage in healthy lifestyle behaviors can be at risk for alcohol use disorders. In one large study examining alcohol use (beer) and engagement in physical activity, people who engaged in more activity were also more likely to drink beer the same day. College students who believe they are engaging in healthy activity may feel they have “earned” the right to drink, placing themselves at potential risk for developing regular habits in which they overuse alcohol.

Alcohol Use Identification Test

Clinicians who design interventions targeting individuals with alcohol use disorders begin by conducting an assessment of the alcohol use patterns of their clients. The AUDIT, or Alcohol Use Disorders Identification Test, is one such instrument.

The Alcohol Use Disorders Identification Test (AUDIT) provides a self-guided test that individuals can take to assess their alcohol consumption, drinking behaviors, and alcohol-related problems. Below is a summary of the questions found on the AUDIT, each of which is rated with a frequency scale:

1. How often do you drink alcohol?

2. How many alcoholic drinks do you typically have on a day you are drinking?

3. How often do you have 6 or more alcoholic drinks at one time?

4. How often have you found that you were not able to stop drinking daily once you had started?

5. How often during the past year has drinking alcohol kept you from doing something you were normally expected to do? 6. How often in the past year have you needed a first drink in the morning to get yourself going after a night of heavy drinking?

7. How often during the last year have you felt guilty or remorseful after drinking?

8. How often during the last year have you been unable to remember what happened the day before because of drinking too much alcohol?

9. Have you or someone else been hurt or harmed because of your drinking?

10. Has someone close to you or a health care professional spoken to you about your drinking or suggested that you cut down?

Treatment Approaches from a Psychological Perspective

There are several well-tested psychological approaches to treating alcohol use disorders. The most successful rely on cognitive-behavioral interventions, motivational approaches, and expectancy manipulation.

Part of effective treatment is relapse prevention, in which the clinician essentially builds “failure” into treatment. If the client recognizes that occasional slips from abstinence are bound to occur, then he or she will be less likely to give up on therapy altogether after suffering a temporary setback.

Mindfulness training may also be added to relapse prevention to help individuals gain greater insight into the factors that trigger their relapses as well as to recognize that substance use may be a way of avoiding the present moment.

Combined Behavioral Intervention

The COMBINE project (Combining Medications and Behavioral Interventions) developed the most comprehensive protocol for psychological treatment. In this treatment, known as Combined Behavioral Intervention (CBI), participants receive up to 20 sessions, according to their needs, beginning semiweekly and then eventually biweekly or less, for up to 16 weeks. The primary emphasis of CBI is on enhancing reinforcement and social support for abstinence. Clinicians assign motivational enhancement therapy at the outset, meaning they attempt to draw out the client’s own motivation to change. The clinical style used in CBI follows from the motivational interviewing perspective, in which the clinician uses a client-centered but directive style.

Clinicians expect and encourage families and significant others to participate throughout treatment, and they also encourage mutual help and involvement among clients, including participation in Alcoholics Anonymous (AA). CBI includes content modules focusing on coping skills (for coping with cravings and urges), ways to refuse drinks and avoid social pressure to drink, communication skills, assertiveness skills, management of moods, social and recreational counseling, social support for sobriety, and job-seeking skills. As

needed, clinicians may also monitor sobriety, provide telephone consultation, and provide crisis intervention. They also put procedures in place to work with clients who resume drinking during treatment. Toward the end of the treatment period, clients enter a maintenance phase and then complete treatment in a termination session.

Sociocultural Perspective

Researchers and theorists working within the sociocultural perspective regard stressors in the family, community, and culture as factors that, when combined with genetic vulnerability, lead the individual to develop alcohol use disorder. As indicated earlier, socioeconomic status seems to interact with genetic vulnerability as an influence on how much alcohol individuals consume.

Support of the sociocultural perspective first became apparent in a landmark longitudinal study in the early 1980s. Researchers followed individuals from childhood or adolescence to adulthood, the time when most individuals who become alcohol-dependent make the transition from social or occasional alcohol use to an alcohol use disorder.

Those most likely to develop alcohol use disorder in adulthood had a history of childhood antisocial behavior, including aggressive and sadistic behavior, trouble with the law, rebelliousness, lower achievement in school, completion of fewer years of school, and a higher truancy rate. These individuals also showed a variety of behaviors possibly indicative of early neural dysfunction, including nervousness and fretfulness as infants, hyperactivity as children, and poor physical coordination while growing up through the normal motor development milestones. Researchers concluded that these characteristics reflected a genetically based vulnerability, which, when combined with environmental stresses, led to the development of alcohol use disorder.

Sociocultural Perspective

Families can also provide social support in other ways that affect alcohol use by teenagers. In a 2-year study of more than 800 suburban adolescents, those who received high levels of social support from their families were less likely to consume alcohol. The effect seemed to be due primarily to the fact that these families were also more likely to strongly emphasize religion in the home.

Further, teens earning good grades in school were more likely to be receiving higher levels of social support from their families, which in turn was associated with lower rates of alcohol use. The teens who used alcohol were more likely to show poorer school performance over the course of the study.

Another approach within the sociocultural perspective takes into account the impact of socialization on patterns of alcohol use disorders. Researchers have demonstrated the benefits of cognitive-behavioral therapy designed specifically for women. Female-specific cognitive-behavioral therapy emphasizes the themes of self-care and self-confidence as well as addressing friendships, social support, and levels of assertiveness, using female models in relevant training vignettes and worksheets.

Stimulants The category of drugs called stimulants includes substances that have an activating

effect on the nervous system.

These differ in their chemical structure, their

specific physical and psychological effects, and

their potential danger to the user.

Stimulants are associated with disorders

related to use, intoxication, and withdrawal.

Amphetamines

Amphetamine is a stimulant that affects both the central nervous and the autonomic nervous systems. In addition to waking or speeding up the central nervous system, it also causes elevated blood pressure and heart rate, and decreased appetite and physical activity.

It may be used for medical purposes, such as to treat ADHD or as a diet pill. Even when used for medical purposes, however, amphetamine can cause dependence and have unpleasant or dangerous side effects.

Increasingly large doses can make users

hostile, violent, and paranoid. Users may also

experience a range of physiological effects

including fever, sweating, headache, blurred

vision, dizziness, chest pain, nausea, vomiting,

and diarrhea.

Methamphetamine is an addictive stimulant drug that is related to amphetamine but one that provokes more intense central nervous system effects. Whether taken orally, through the nose, intravenously, or by smoking, methamphetamine causes a rush or feeling of euphoria and becomes addictive very quickly.

Methamphetamine overdose can cause overheating of the body and convulsions, and if not treated immediately, it can result in death.

Long-term use of methamphetamine can lead users to develop mood disturbances, violent behavior, anxiety, confusion, insomnia, severe dental problems (“meth mouth”), and a heightened risk of infectious diseases including hepatitis and HIV/AIDS. The long-term effects of methamphetamines also include severe brain damage

Cocaine Cocaine is a highly addictive central nervous system

stimulant that an individual snorts, injects, or smokes. Users

can snort the powdered hydrochloride salt of cocaine or

dissolve it in water and then inject it.

Crack is the street name given to the form of cocaine that is

processed to form a rock crystal which, when heated,

produces vapors that the individual smokes.

The effects of cocaine include feelings of euphoria,

heightened mental alertness, reduced fatigue, and

heightened energy. The faster the bloodstream absorbs the

cocaine and delivers it to the brain, the more intense the

user’s high. Because this intense high is relatively short (5

to 10 minutes), the user may administer the drug again in a

binge-like pattern.

Cocaine

Like amphetamines, cocaine increases body temperature, blood pressure, and heart rate. Cocaine’s risks include heart attack, respiratory failure, stroke, seizures, abdominal pain, and nausea. In rare cases, the user can experience sudden death on the first use of cocaine or unexpectedly afterwards.

Other adverse effects on the body develop over time and include changes within the nose (loss of sense of smell, chronically runny nose, and nosebleeds), as well as problems with swallowing and hoarseness. Users may experience severe bowel gangrene due to a reduction of blood flow to the digestive system. Cocaine users may also have severe allergic reactions and increased risk of developing HIV/AIDS and other blood-borne diseases.

When people use cocaine in binges, they may develop chronic restlessness, irritability, and anxiety. Chronic users may experience severe paranoia in which they have auditory hallucinations and lose touch with reality.

Activity prompt:

Look at the graphics on the previous slide comparing the cost of powder cocaine and crack cocaine and showing a breakdown of

crack cocaine users by race/ethnicity. How do you think these realities interact and contribute to the overrepresentation of African Americans in the criminal justice system?

Cannabis

Cannabis is associated with disorders related to use, intoxication, and withdrawal. Marijuana is a mix of flowers, stems, and leaves from the hemp plant Cannabis sativa, a tall, leafy, green plant that thrives in warm climates. Although the plant contains more than 400 chemical constituents, the primary active ingredient in marijuana is delta-9-tetrahydrocannabinol (THC).

Hashish, containing a more concentrated form of THC, comes from the resins of the plant’s flowers. The marijuana and hashish that reach the street are never pure THC; other substances, such as tobacco, are always mixed in, too. Synthetic forms of THC serve some medicinal purposes, such as treating asthma and glaucoma and reducing nausea in cancer patients undergoing chemotherapy.

Most people who use marijuana smoke it as a cigarette or in a pipe. Users can also mix the drug in food or serve it as a tea. When smoked, marijuana reaches its peak blood level in about 10 minutes, but the subjective effect of intoxication does not become apparent for another 20 to 30 minutes. This effect may last 2 to 3 hours, but the metabolites of THC can remain in the body for 8 or more days.

Marijuana

Marijuana is the most commonly used illicit drug in the United States.

However, current prevalence statistics do not take into account the fact that both recreational and medical use of marijuana are now legal in a number of states, and federal regulation has eased in these states as well.

With these changes in legislation, the definition of an “illicit” drug will need to change in estimates of prevalence statistics. Furthermore, as marijuana use becomes decriminalized, it will be possible to examine the effects of its use on an individual’s daily life.

Marijuana

People take marijuana in order to alter their bodily sensations and perceptions of their environment. The effects they seek include euphoria, a heightened sense of sensuality and sexuality, and an increased awareness of internal and external stimuli.

However, marijuana use also carries a number of unpleasant effects including impaired short-term memory, slowed reaction time, impaired physical coordination, altered judgment, and poor decision making. Instead of feeling euphoric and relaxed, users may experience paranoia and anxiety, particularly when they ingest high doses.

Marijuana

THC produces its effects by acting upon specific sites in the brain, called cannabinoid receptors. The brain regions with the highest density of cannabinoid receptors are the areas that influence pleasure but also are active in memory, thinking and concentration, perception of time, sensory responses, and ability to carry out coordinated movement. Many of marijuana’s acute effects on cognitive functioning are reversible as long as the individual does not engage in chronic use.

Heavy and continued use of marijuana can produce a number

of deleterious effects on bodily functioning, including higher

risk of heart attack and impaired respiratory functioning. In

addition to developing psychological dependence on

marijuana, long-term users may experience lower educational

and occupational achievement, psychosis, and persistent

cognitive impairment. Particularly at risk are individuals who

begin using marijuana at an early age and continue to use it

throughout their lives.

Hallucinogens

Included in hallucinogen-related disorders are use and intoxication, but not withdrawal. Hallucinogens are drugs that cause people to experience profound distortions in their perception of reality. Under the influence of hallucinogens, people see images, hear sounds, and feel sensations that they believe to be real but are not. In some cases, users experience rapid, intense mood swings. Some develop a condition called hallucinogen persisting perception disorder, in which they experience flashbacks or spontaneous hallucinations, delusions, or disturbances in mood similar to the changes that took place while they were intoxicated with the drug. The specific effects and risks of each hallucinogen vary according to the particular substance.

LSD

People take lysergic acid diethylamide (LSD) in tablets, capsules, and

occasionally liquid form. Users show dramatic changes in their

sensations and emotions. They may feel several emotions at once or

swing rapidly from one emotion to another. With larger doses, users can

experience delusions and visual hallucinations. In addition, they may feel

an altered sense of time and self. They may also experience synesthesia,

in which they “hear” colors and “see” sounds. These perceptual and mood

alterations may be accompanied by severe, terrifying thoughts and

feelings of despair, panic, and fear of losing control, going insane, or

dying. Even after they stop taking LSD, users may experience flashbacks,

leading them to be significantly distressed and impaired in their social

and occupational functioning.

Unlike other substances, LSD does not seem to produce compulsive drug-seeking behavior, and most users choose to decrease or stop using it without withdrawal. However, it does produce tolerance, so users may need to take larger doses to achieve the effects they desire. Given the unpredictable nature of the drug’s effects, such increases in doses can be dangerous. LSD can also affect other bodily functions, with effects including sweating, loss of appetite, dry mouth, sleeplessness, tremors, and increased body temperature, blood pressure, and heart rate.

Peyote Peyote is a small, spineless cactus whose principal

active ingredient, mescaline, can also be produced

artificially. Users chew the mescaline-containing

crown of the cactus or soak it in water to produce a

liquid; some prepare a tea by boiling the cactus in

water to rid the drug of its bitter taste.

Used as part of religious ceremonies by native

peoples in northern Mexico and the southwestern

United States, mescaline has long-term effects on

these and recreational users that are not known.

However, its effects on the body are similar to those

of LSD, including increases in body temperature

and heart rate, uncoordinated movements, extreme

sweating, and flushing. In addition, mescaline may

cause flashbacks, much like those associated with

LSD.

Psilocybin AKA Magic Mushrooms

Psilocybin and its biologically active form, psilocin, are substances found in certain mushrooms. Users brew the mushrooms or add them to other foods to disguise their bitter taste.

The active compounds in psilocybin-containing mushrooms, like LSD, alter the individual’s autonomic functions, motor reflexes, behavior, and perception. Individuals may experience hallucinations, an altered sense of time, and an inability to differentiate between fantasy and reality. Large doses may cause flashbacks, memory impairments, and greater vulnerability to psychological disorders.

In addition to the risk of poisoning if the individual incorrectly identifies the mushroom, the bodily effects can include muscle weakness, loss of motor control, nausea, vomiting, and drowsiness.

PCP

Researchers developed phencyclidine (PCP) in the 1950s as an intravenous anesthetic, but it is no longer used medically because patients became agitated, delusional, and irrational while recovering from its effects. Users can easily mix the white crystalline powder with alcohol, water, or colored dye. PCP may also be available on the illegal drug market in pill, capsule, or colored powder forms that users can smoke, snort, or take orally. When individuals smoke PCP, they may apply the drug to mint, parsley, oregano, or marijuana.

PCP causes users to experience a sense of dissociation from their surroundings and their own sense of self. It has many adverse effects including symptoms that mimic schizophrenia, mood disturbance, memory loss, difficulties with speech and thinking, weight loss, and depression. Although these negative effects led to its diminished popularity as a street drug, PCP appeals to those who still use it because they feel that it makes them stronger, more powerful, and invulnerable. Despite its adverse effects, users can develop strong cravings and compulsive PCP-seeking behavior.

PCP

The physiological effects of PCP are extensive. Low to moderate doses produce increases in breathing rate, a rise in blood pressure and pulse, general numbness of the extremities, and loss of muscular coordination, as well as flushing and profuse sweating. At high doses, users experience a drop in blood pressure, pulse rate, and respiration, which may be accompanied by nausea, vomiting, blurred vision, abnormal eye movements, drooling, loss of balance, and dizziness. They may

become violent or suicidal. In addition, at high doses users may experience seizures, coma, and death. Those who combine PCP with other central nervous system depressants (such as alcohol) may become comatose.

MDMA

The chemical named MDMA and known on the street as ecstasy is a synthetic substance chemically similar to methamphetamine and mescaline. Users experience feelings of increased energy, euphoria, emotional warmth, distorted perceptions and sense of time, and unusual tactile experiences. Taken as a capsule or tablet, MDMA was once most popular among white teens and young adults at weekend-long dances known as raves.

Users of MDMA may experience a range of unpleasant psychological effects, including confusion, depression, sleep problems, cravings for the drug, and severe anxiety. The drug may be neurotoxic, which means that over time users may experience greater difficulty carrying out cognitive tasks. Like stimulants, MDMA can affect the sympathetic nervous system, leading to increased heart rate and blood pressure, muscle tension, nausea, blurred vision, fainting, chills or sweating, and involuntary teeth clenching. Individuals also risk severe spikes in body temperature, which in turn can lead to liver, kidney, or cardiovascular system failure. Repeated dosages over short periods of time may also interfere with MDMA metabolism, leading to significant and harmful buildup within the body.

MDMA

The main neurotransmitter involved with MDMA is serotonin. MDMA (labeled “ecstasy”) binds to the serotonin transporter responsible for removing serotonin from the synapse. As a result, MDMA extends the effects of serotonin. In addition, MDMA enters the neuron, where it stimulates excessive release of serotonin. MDMA has similar effects on norepinephrine, which leads to increases in autonomic nervous system activity. The drug also releases dopamine, but to a lesser extent.

Researchers find it difficult to investigate the long-term effects of MDMA use on cognitive functioning because users typically take it with other substances. However, significant negative effects on verbal memory do occur with MDMA use alone. MDMA’s effects on cognition appear to relate at least in part to the impact of the drug on the availability of an individual’s cognitive resources. Moreover, when combined with alcohol, MDMA produces a number of long-term adverse psychological effects including paranoia, poor physical health, irritability, confusion, and moodiness.

Opioids

Opioid-related disorders are connected to opioid use, intoxication, and withdrawal. An opioid is a substance that relieves pain.

Many legally prescribed medications fall within this category, including hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza), codeine, and related drugs. Clinicians prescribe hydrocodone products most commonly for a variety of painful conditions, including dental procedures and injuries. Physicians often administer morphine before and after surgical procedures to alleviate severe pain. Codeine, on the other hand, is prescribed for mild pain. Some opioid drugs—codeine and diphenoxylate (Lomotil), for example—are used to relieve coughs and severe diarrhea, respectively.

When people take them as prescribed, these medications are effective for managing pain safely. However, because of their potential to produce euphoria as well as physical dependence, they are among the most frequently abused prescription drugs. People who abuse OxyContin may snort or inject it and suffer a serious overdose reaction as a result.

The opioids of abuse include prescription pain relievers, heroin, and synthetic opioids such as fentanyl. The so-called opioid crisis, the rise in the number of individuals addicted to prescription painkillers and resulting deaths, is now seen as a major public health crisis in the United States.

Heroin

Heroin is a form of opioid. It is a painkilling drug synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Users inject, snort, sniff, or smoke heroin. The body then converts it to morphine, which binds to the opioid receptors throughout the brain and body, particularly those active in reward and pain perception. Opioid receptors are also located in the brain stem, which contains structures that control breathing, blood pressure, and arousal.

Users experience a surge of euphoric feelings, along with dry mouth, warm flushing of the skin, heaviness in the arms and legs, and compromised mental functioning. Shortly afterward, they alternate between feeling wakeful and drowsy. If users do not inject the drug, they may not feel euphoria at all. With continued use of heroin, users develop tolerance, meaning they need larger amounts of the drug to feel the same effect. Heroin has a high potential for addiction; it is estimated that as many as 23 percent of all users develop dependence.

Heroin

There are many serious health consequences of heroin use, including fatal overdoses, infectious diseases (related to needle sharing), damage to the cardiovascular system, abscesses, and liver and kidney disease.

Users are often in poor general health and therefore are more susceptible to pneumonia and other pulmonary complications, as well as damage to the brain, liver, and kidneys resulting from the toxic contaminants often added to the drug.

Chronic heroin users experience severe withdrawal should they discontinue its use. Severe cravings can begin within 2 to 3 days and last for as long as a week, and they can recur years later if the individual experiences certain triggers or stress.

There are also dangers to sudden withdrawal, particularly in long-term users who are in poor health. Withdrawal symptoms can include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes, and kicking movements.

Effects of Opioid Use

Abuse of opiates, whether prescription painkillers or heroin, can have a serious impact on your health. In addition to the hazards of overusing opioid painkillers, sharing needles for the injection of heroin or injecting crushed pills poses its own dangers.

These substances and practices can affect almost every part of your body, potentially leading to permanent damage to your health. While a multitude of health consequences can accompany long-term opiate abuse, many of the dangers are seen more acutely. Even a first time user can experience respiratory arrest, for example.

Sedatives, Hypnotics, and Anxiolytics

The category of sedatives, hypnotics, and anxiolytics (antianxiety medications) includes prescription medications that act as central nervous system depressants. A sedative has a soothing or calming effect, a hypnotic induces sleep, and an anxiolytic is used to treat anxiety symptoms. The sedating effects of these central nervous system depressants are due to the fact that they increase the levels of the neurotransmitter GABA, which inhibits brain activity and therefore produces a calming effect. Disorders within this category include use disorder, intoxication, and withdrawal.

These medications are among the most commonly abused drugs in the United States. They include benzodiazepines, barbiturates, nonbenzodiazepine sleep medications such as zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon. Although safe when taken as prescribed, these medications have high potential for abuse and dependence. The longer a person uses them, the greater the amount needed to produce the sedating effects. In addition to the risk of dependence, these medications can also have harmful effects on individuals taking other prescription and over-the-counter drugs.

For older adults, the risk of abuse is also high, particularly given the potential for drug interactions with alcohol and other medications. Moreover, older adults with cognitive decline may take their medication incorrectly, which in turn can lead to further cognitive decline.

Caffeine

Caffeine is a stimulant found in coffee, tea, chocolate, energy drinks, diet pills, and headache remedies. By activating the sympathetic nervous system through increasing the production of adrenaline, caffeine increases an individual’s perceived level of energy and alertness. It also increases blood pressure and may lead to increases in the body’s production of cortisol, the stress hormone.

Because caffeine is such a common feature of everyday life, people tend not to be aware of its dangers. When consumed in large quantities, caffeine can lead to many adverse reactions, including the development of other forms of substance dependence.

Caffeine

Disorders included in the caffeine-related category are intoxication and withdrawal, but not caffeine use disorder. Support is growing for adding caffeine use disorder as a diagnosis similar to other substance use disorders.

The DSM-5 was the first psychiatric manual in the United States to include caffeine withdrawal as a diagnosis (it was already a diagnosis in ICD-10). The symptoms of caffeine withdrawal include headache, tiredness and fatigue, sleepiness and drowsiness, dysphoric mood, difficulty concentrating, depression, irritability, nausea, vomiting, muscle aches, and

stiffness.

Particularly dangerous is the combination of caffeine and alcohol, a problem that is most severe on college campuses where as many as 75 percent report lifetime prevalence of using a caffeinated beverage. When users combine alcohol and caffeine, they may not realize how intoxicated they are and as a result may have a higher prevalence of alcohol-related consequences. In one daily-diary study of undergraduates asked to record their daily consumption of caffeine and alcohol, those who consumed caffeine in energy drinks had more alcohol-related problems.

Tobacco Individuals can be diagnosed with tobacco use disorder or tobacco withdrawal, but not tobacco intoxication. Nicotine is the psychoactive

Effect of Nicotine on the Body

substance found in cigarettes. The health risks of tobacco are well known; these risks are primarily associated with smoking cigarettes which, in addition to nicotine, contain tar, carbon monoxide, and other additives. Readily absorbed into the bloodstream, nicotine is also present in chewing tobacco, pipe tobacco, and cigars.

When nicotine enters the bloodstream, it stimulates the release of adrenaline (norepinephrine), which activates the autonomic nervous system and increases blood pressure, heart rate, and respiration. Like other psychoactive substances, nicotine increases the level of dopamine, affecting the brain’s reward and pleasure centers. Substances found in tobacco smoke, such as acetaldehyde, may further enhance nicotine’s effects on the central nervous system. The withdrawal symptoms associated with quitting tobacco use include irritability, difficulties with concentration, and strong cravings for nicotine.

Inhalants

Inhalants are a diverse group of substances that cause psychoactive effects by producing chemical vapors. These products are not in and of themselves harmful; in fact, they are all products commonly found in the home and workplace.

There are four categories of inhalants:

● Volatile solvents (paint thinners or removers, dry-cleaning fluids, gasoline, glue, and lighter fluid) ● Aerosols (sprays that contain propellants and solvents)

● Gases (butane lighters and propane tanks, ether, and nitrous oxide)

● Nitrites (a special category of products that individuals use as sexual enhancers)

Young teens (ages 12 to 15) tend to inhale glue, shoe polish, spray paint, gasoline, and lighter fluid. Older teens (ages 16 to 17) inhale nitrous oxide, and adults (ages 18 and older) are most likely to inhale nitrites. Within the category of inhalant disorders, individuals can be diagnosed as having inhalant use disorder or intoxication, but not inhalant withdrawal.

Inhalants

The effects of an inhalant tend to be short-lived; consequently, users try to extend their high by inhaling repeatedly over a period of several hours.

Inhalants have effects similar to those of alcohol, including slurring of speech, loss of coordination, euphoria, dizziness, and, over time, loss of inhibition and control. Users may experience drowsiness and headaches, but depending on the substance, they may also feel confused and nauseated.

The vapors displace the air in the lungs, causing hypoxia (oxygen deprivation), which is particularly lethal to neurons in the central nervous system. Long-term use may also cause the myelin sheath around the axon to deteriorate, leading to tremors, muscle spasms, and perhaps permanent muscle damage. The chemicals in inhalants can also cause heart failure and sudden death.

Theories and Treatment of Substance Use Disorders

Since all psychoactive substances operate on the reward

and pleasure systems in the brain, similarities exist in the

mechanisms through which individuals develop dependence

on them.

However, important differences exist between alcohol and

other substances in the receptor pathways for the

substance, the psychosocial factors associated with the

users’ dependence, and, ultimately, the best treatment

methods.

Biological Perspectives

Except in the case of alcohol dependence, weak evidence exists for the efficacy of pharmacotherapies. There are no FDA-approved treatments for dependence on cocaine, methamphetamines, marijuana, hallucinogens, ecstasy, or prescription opioids. There are, however, several treatments for heroin dependence that are particularly effective when combined with behavioral interventions.

Medically assisted detoxification is the first step in treatment of heroin dependence. During detoxification, individuals may receive medications to minimize withdrawal symptoms. To prevent relapse, clinicians may use one or more of three different medications. Developed more than 30 years ago, methadone is a synthetic opioid that blocks the effects of heroin by binding to the same receptor sites in the central nervous system. Proper use requires specialized treatment including group and/or individual counseling along with referrals for other medical, psychological, or social services. Methadone is not considered an ideal treatment because of its potential for dependence, even when combined with psychosocial interventions.

Buprenorphine, approved by the FDA in 2002, produces less physical dependence, a lower risk of overdose, and fewer withdrawal effects. Originally developed as a pain medication, it is also approved for treatment of opiate dependence. The FDA has also approved naltrexone for heroin dependence, but it is not widely used because patients are less likely to comply with treatment due to such side effects as nausea and headaches.

For nicotine dependence, clinicians may use biologically based treatments. Nicotine replacement therapies (NRTs), including nicotine gum and the nicotine patch, were the first FDA-approved pharmacological treatments. These deliver controlled doses of nicotine to the individual to relieve symptoms of withdrawal. Other FDA-approved products include nasal sprays, inhalers, and lozenges. Other biological approaches to nicotine dependence are medications that do not deliver nicotine, including bupropion (Wellbutrin), an antidepressant, and varenicline tartrate (Chantix), which targets nicotine receptors in the brain.

Psychological Perspectives

Whether or not individuals with dependence on substances other than alcohol receive biologically based treatment, cognitive-behavioral therapy (CBT) is now widely understood to be a crucial component of successful treatment and an important counterpart to biological theories and treatments.

The principles applied in treating substance use disorders other than alcohol through CBT are similar to those in treating alcohol dependence. Well-controlled studies support the efficacy of CBT for populations dependent on a wide range of substances. Clinicians may combine CBT with motivational therapies, as well as with behavioral interventions that focus on contingency management. In addition, clinicians can readily adapt CBT to a range of clinical modalities, settings, and age

groups.

Given the limitations of medication-only treatment, CBT also provides an effective adjunct in both inpatient and outpatient clinics. The ability to help clients develop coping skills is useful in fostering compliance with pharmacotherapies such as methadone and naltrexone as well. Because these interventions are relatively brief and highly focused, they are adaptable to clients treated within managed care who may not have access to longer-term treatment.

Non-Substance Related Disorders

Gambling Disorder

People who have gambling disorder are unable to resist recurrent urges to gamble despite knowing that it will bring negative consequences to themselves or others.

The diagnosis in DSM-IV-TR included gambling disorder as an impulse-control disorder. In DSM-5, it is included with substance use disorders because it is now conceptualized as showing many of the same behaviors, such as cravings, increasing needs to engage in the behavior, and negative social consequences.

The unique features of gambling disorder include behaviors such as chasing a bad bet, lying about how much has been lost, searching for financial bailouts, and committing crimes to support gambling.

Gambling Disorder

Gambling disorder often co-occurs with other psychological disorders. The highest risk of developing gambling disorder occurs among people who engage in gambling on games involving mental skill (such as cards), followed by sports betting, use of gambling machines, and betting on horse races or cock and dog fights. People with gambling disorder who bet on sports tend to be young men who have substance use disorders. Those who bet on slot machines are more likely to be older women who have higher rates of other psychological disorders and begin gambling at a later age. In general, women are less likely than men to engage in the type of gambling that depends on strategy, such as poker.

People with gambling disorder also have high rates of other disorders, particularly nicotine dependence (60 percent), dependence on other substances (58 percent), mood disorder (38 percent), and anxiety disorder (37 percent). Mood and anxiety disorders are more likely to precede, rather than follow, the onset of gambling disorder . Older adults are less likely than younger adults to have gambling disorder, but they are nevertheless at risk because of limited incomes and lack of access to more physically engaging activities.

The repetitive behaviors characteristic of gambling disorder may be viewed as resulting from an imbalance between two competing and relatively separate neurobiological mechanisms—those responsible for urges and those responsible for cognitive control. There may also be genetic contributions, perhaps including abnormalities in dopamine receptor genes.

Theories of Gambling Disorder

From a behavioral perspective, gambling disorder may develop in part because gambling follows a variable-ratio reinforcement schedule in which rewards occur, on average, every X number of times. This pattern of reinforcement produces behaviors that are highly resistant to extinction. Slot machines, in particular, produce payoffs on this type of schedule, maintaining high rates of response by gamblers. Classical conditioning also operates to maintain this behavior, because gamblers learn to associate certain cues with gambling, including their internal states or moods and external stimuli such as advertisements for gambling.

Cognitive factors too play an important role in gambling

disorder. People with this disorder seem to engage in a

phenomenon known as discounting of probabilistic rewards,

in which they discount or devalue rewards they could obtain

in the future compared to rewards they can obtain right

away. They also engage in other cognitive distortions, many

of which spring from poor judgment of the probabilities that

their gambling will lead to successful outcomes, as shown in

the next slide.

Type of Distortion

Representativeness

Examples of Cognitive Distortions Example

Gambler’s fallacy When events generated by a random process have deviated from the population average in a short run, such as a roulette ball falling on red four times in a row, individuals may erroneously believe that the opposite deviation (e.g.,

ball falls on black) becomes more likely.

Overconfidence Individuals express a degree of confidence in their knowledge or ability that is not warranted by objective reality.

Trends in number picking Lottery players commonly try to apply long-run random patterns to short strings in their picks such as avoiding duplicate numbers and adjacent digits in number string

Availability Illusory correlations Individuals believe events that they expect to be correlated, due to previous experience or perceptions, have been correlated in previous experience even when they have not been, such as wearing a “lucky hat” they wore when they

won previously.

Availability of others’ wins When individuals see and hear other gamblers winning, they start to believe that winning is a regular occurrence, which reinforces their belief that they will win if they continue to play.

Inherent memory bias Individuals are biased to recollect wins with greater ease than losses. They then reframe their memories regarding gambling experiences in a way that focuses on positive experiences (wins) and disregards negative experiences

(losses). This causes them to rationalize their decision to continue gambling.

Additional cognitive distortions

Illusion of control Individuals have a higher expectancy for success than objective probability would warrant.

Switching and double switching Individuals recognize errors and process gambling-related situations in a rational way when they are not actively participating but abandon rational thought when they personally take part in gambling.

Gambling Disorder

The pathways model approaches gambling disorder from a developmental perspective, proposing that three main paths lead to three distinct subtypes of people with gambling disorder. The person with the behaviorally conditioned subtype had few symptoms prior to developing the disorder but, through frequent exposure to gambling, develops positive associations, distorted cognitions, and poor decision making about gambling. The individual in the emotionally vulnerable subtype had pre-existing depression, anxiety, and perhaps a history of trauma; gambling helps this individual feel better. The third type of person with pathological gambling has preexisting impulsivity, attentional difficulties, and antisocial characteristics. For this individual, the risk of gambling provides thrills and excitement.

The pathways model suggests that differing therapeutic approaches may work for each of the three subtypes of gambling disorder, but cognitive-behavioral therapy has the greatest empirical support. The clinician begins teaching clients to understand the triggers for their gambling by having them describe their pattern of gambling behaviors. For example, common triggers include unstructured or free time, negative emotional states, reminders such as sports broadcasts or advertisements, and available money. Using this information to help clients analyze when they gamble and when they do not, the clinician then helps them

increase pleasant activities, think of ways to handle cravings or urges, become more assertive, and correct their irrational cognitions. At the end of treatment, the clinician helps prepare clients for setbacks using relapse-prevention methods in which the goal is not complete abstinence but a reduction to a point below pretreatment levels. The individual who shows positive effects may also show personality changes that will serve to protect against relapse.

Brief motivational interviewing may also be a beneficial treatment for individuals with problem gambling. The individual may choose to pursue complete abstinence or moderation as a goal of this treatment; both can be equally effective in reducing the amount of money gambled, the number of days the individual gambles, as well as the individual’s perception of having achieved treatment-related goals.

Other

Non-Substance Related Disorders

In addition to classifying gambling disorder as a

non-substance-related disorder, the DSM-5 authors considered adding Internet gaming disorder to the category. For now, however, they have included it in Section 3 as a disorder requiring further study.

Although there is ample evidence to indicate that Internet gaming is becoming a problematic behavior in its own right, the available research was not considered sufficiently well developed yet to justify inclusion in the diagnostic system. Therefore, the DSM-5 work group believed further investigations are required to produce reliable prevalence estimates.

Other disorders the work group considered adding were “sex addiction,” “exercise addiction,” and “shopping addiction,” to name a few. However, the group believed there were even fewer empirical studies in peer-reviewed articles to justify their inclusion even in Section 3.

Substance

Disorders: The Biopsychosocial Perspective

The biopsychosocial model provides an extremely useful approach for understanding substance use disorders and approaches to treatment.

Genetics clearly plays a role in the development of these disorders, and the action of substances on the central nervous system also operates to maintain dependence.

Developmental issues in particular are critical for understanding the nature of these disorders, which often have their origins during late childhood and early adolescence.

Moreover, because alcohol, drugs, and medications with high abuse potential continue to be widely available, sociocultural factors play a strong role in maintaining dependence among users.

Addictions have characterized human behavior throughout the millennia; however, with more widespread public education and advances in both genetics and psychotherapeutic interventions, it is possible that we will see advances in prevention as well.

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