Goal: To recognize and differentiate different patterns of behavior that show evidence of addiction and inadequate impulse-control

Transcription

1 Goal: To recognize and differentiate different patterns of behavior that show evidence of addiction and inadequate impulse-control

2 Addiction and Impulse-Control Bad behavior versus sick behavior Is bad behavior itself sufficient basis for presumption of mental disorder? Key issues: Inappropriateness Excessiveness/absence of self-control or restraint 2

3 Addiction and Impulse-Control: Alcohol and Drug Use Drugs throughout history Use of psychoactive (i.e., mood-or perception-altering) chemicals in all cultures throughout recorded history Numerous examples, both natural (e.g., peyote, kava, opium) and human-made (e.g., fermented beverages, heroin) Varied forms of administration: swallowed, smoked, injected 3

4 Addiction and Impulse-Control: Alcohol and Drug Use Substance use disorders Impaired control Social impairment Risky use Tolerance and withdrawal (as both pharmacological and psychological phenomena) Before DSM-5 (and still widely used): substance abuse versus substance dependence but dropped due to inconsistent usage and poor diagnostic reliability Specify substance (e.g., alcohol use disorder, heroin use disorder, etc. 4

5 Addiction and Impulse-Control: Alcohol and Drug Use Substance use disorder: DSM-5 criteria 11 possible signs, minimum of 2 required over 12-month period Signs almost always the same, regardless of substance Amount of use per se is not a criterion Severity rating of mild/moderate/severe based on number of signs Seen by many as a chronic disease, hence also specifiers of in early/sustained remission No lab test 5

6 Addiction and Impulse-Control: Alcohol and Drug Use Demoting tolerance and withdrawal In DSM-IV, presence of T&W prompted specifier of with physiological dependence Many substance abuse professionals disagree and focus on alcoholism and drug addiction as chronic diseases DSM-5 focuses more on substance use disorder as behavioral disorder DSM-5 does not say disease but does include specifiers of in early/sustained remission 6

7 Addiction and Impulse-Control: Alcohol and Drug Use Demographics of substance use disorders 12-month prevalence for alcohol use disorder in U.S.: 5% adolescents, 8.5% adults, men 2:1 more than women, rates decrease with age Other 12-month prevalence rates in U.S.: Cannabis 3.4% adolescent, 1.5% adult Opioids 1.0% adolescent, 0.5% adult Stimulants 0.2% adolescent and adult Racial/ethnic factors: for most substances, highest in Native Americans, then Caucasian, Hispanic, African-American, Asian European countries report lower figures 7

8 Addiction and Impulse-Control: Alcohol and Drug Use Substance-induced disorders Substance intoxication Blood-alcohol levels (BAC) and links to automobile accidents (DUI, OUI), homicides, suicides Being high on other drugs entails similar, though lesser links Substance withdrawal Often viewed as the classic symptom of addiction Very variable across substances: strongest for nicotine, crack, and crystal meth; moderate for sedatives, alcohol, heroin, cocaine; mild or absent for marijuana, hallucinogens Potentially deadly: alcoholic delirium tremens (DT s), cardiac arrest for sedatives and anti-anxiety drugs 8

9 Addiction and Impulse-Control: Alcohol and Drug Use How addictive are alcohol and other drugs? Nicotine is generally regarded as most addictive, most difficult to quit Crack and crystal meth Alcohol, sedatives, heroin, cocaine somewhat less so Marijuana, hallucinogens, ecstasy viewed as much less addictive 9

10 Addiction and Impulse-Control: Non- Substance-Related The behavioral addictions New terminology and placement in DSM-5 Considered but rejected (at least for now): hypersexuality, shopping, exercise Gambling disorder is listed as an addiction 4 or more signs over 12-month period (why 4, when substance use disorder is only 2?) Also rated mild/moderate/severe, and also in early/sustained remission 10

11 Addiction and Impulse-Control: Aggressive, Disruptive and Antisocial Formerly referred to as impulse-control disorders in DSM-IV While they might have addictive or compulsive qualities, DSM-5 lists them in a different category, separate from behavioral addictions These disorders comprise behaviors that violate the rights of others and create conflict with authority and society In children and adolescents, might be linked with delinquency In adults, often linked with criminal behavior 11

12 Addiction and Impulse-Control: Aggressive, Disruptive and Antisocial Oppositional defiant disorder Angry and irritable mood, argumentative behavior and refusal to follow rules or requests from authority, spiteful Minimum 6-months duration Usually first appears between ages 3 and 8 Prevalence ~3%, predominantly male Conduct disorder Violation of rules, laws, rights of others, including aggression, destruction of property, theft, lying, truancy, etc. Minimum 12-month duration, both childhood- and adolescent-onset possible Often preceded by ODD Prevalence ~4%, predominantly male 12

13 Addiction and Impulse-Control: Aggressive, Disruptive and Antisocial Intermittent explosive disorder Recurring unprovoked aggressive outbursts Aggression occurs without premeditation, is not designed to achieve any specific goal Verbal and physical aggression, toward people, animals, and/or objects 12-months duration Prevalence ~3%, usual onset late childhood/early adolescence 13

14 Addiction and Impulse-Control: The Manias Mania refers to patterns of wildly excitable, poorly-controlled, intensely-motivated activity (think maniac ) Three in DSM-5: Trichotillomania (Unit 6) classified as an obsession-related disorder Pyromania (compulsive fire-setting) and kleptomania (compulsive stealing, shoplifting) are classified as impulse-control disorder Both show pattern of increased tension before and relief after Both rare (<1%), the former primarily male, the latter female 14

15 Addiction and Impulse-Control: The Manias/Paraphilic Disorders Paraphilic disorders (connected to popular image of sex maniac ) separate category in DSM Paraphilia = intense, persistent sexual interest in activity or target not focused on genital stimulation with consenting adult partner Paraphilic disorder paraphilia plus distress, impairment, or harm to others (similar, but not identical to popular concept of sexual perversion or sexual deviation) Might have compulsive/addictive qualities, but are not classified as addictions 15

16 Addiction and Impulse-Control: The Manias/Paraphilic Disorders Exhibitionistic disorder Fetishistic disorder Frotteuristic disorder Sexual masochism disorder Tranvestic disorder ( cross-dressers, transgendered) Voyeuristic disorder May be diagnosed based on fantasies and/or actions Generally no physical harm to another All require 6-month duration Much more common among males 16

17 Addiction and Impulse-Control: The Manias/Paraphilic Disorders Two more, which typically do involve physical harm to another Pedophilic disorder ( child molestation): exclusive or non-exclusive, attraction to male/female/both, victims at least 5 years younger Sexual sadism disorder ( rape) May be diagnosed based on fantasies and/or actions All require 6-month duration, tend to be very chronic, repetitive Also much more common in males 17

18 Addiction and Impulse-Control Differential and co-morbid considerations Other specified (especially paraphilic disorders) and unspecified Differential diagnosis and co-morbidity: Overlap with, yet distinct from, obsession-related disorders Substance use disorders frequently co-occur with all these others All these disorders frequently co-occur with personality disorders, especially antisocial Can be hard to distinguish from, or may co-occur with, manic episodes 18