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CULTURAL DIVERSITY IN GAMBLING AND SUBSTANCE ADDICTION: IMP CULTURAL DIVERSITY IN GAMBLING AND SUBSTANCE ADDICTION: IMP

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CULTURAL DIVERSITY IN GAMBLING AND SUBSTANCE ADDICTION: IMP - PPT Presentation

Developed by Sachin J Karnik PhD LCSW CADC NCGCII CPS Director of Prevention amp Clinical Services Delaware Council on Gambling Problems Inc EMail sachinkarnikdcgporg ID: 576558

addiction gambling drug brain gambling addiction brain drug drugs prevention kindle substance problem process reward moal science cocaine elsevier

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CULTURAL DIVERSITY IN GAMBLING AND SUBSTANCE ADDICTION: IMPLICATIONS FOR CLINICAL INTERVENTIONS AND PREVENTION PROGRAMMING

Developed by:Sachin J. Karnik, Ph.D., LCSW, CADC, NCGC-II, CPSDirector of Prevention &Clinical ServicesDelaware Council on Gambling Problems, Inc.E-Mail: sachin.karnik@dcgp.org

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CONTACT INFORMATIONSACHIN J. KARNIK, Ph.D.

LCSW, LCDP, CADC, NCGC-II, CPSDirector of Prevention & Clinical Services100 West 10th Street, Suite 303Wilmington, DE 19801Phone: 302-655-3261E-Mail: sachin.karnik@dcgp.org2Slide3

OBJECTIVES

This workshop examines the nature of problems gambling in a multi-cultural context, where perspectives about gambling as related to ethnic diversity will be examined. Specifically, clinical connections will be presented, in the context of diversity, with regards to accurate diagnosis, culturally bound syndromes, and various co-occurring disorders as well as cross-addiction issues. Effective treatment approaches will be presented and small group exercises will be conducted to build practical understanding of the application of culturally sensitive practice with regards to prevention programming and treatment approaches. Also, neuro-psychological basis of cultural conditioning will be presented in the context of identification, assessment, and effective treatment of addictive disorders with an emphasis on gambling disorder. From a clinical standpoint, DSM V differential diagnostic processes as related to cultural background and the unraveling accurate etiology will be presented. Finally, implications of cultural conditioning processes in the development of prevention programs will also be examined. This workshop attempts to bridge together fragmented areas in the addictions and promote greater understanding of how culture shapes reality.3Slide4

(PART 1)WHAT IS ADDICTION?

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ADDICTION – TO BIND A PERSON“Addiction; from the Latin verb ‘

addicere,’ to give or bind a person to one thing or another. Generally used in the drug field to refer to chronic, compulsive, or uncontrollable drug use, to the extent that a person (referred to as an ‘addict’) cannot or will not stop the use of some drugs. It usually implies a strong (Psychological) Dependence and (Physical) Dependence resulting in a Withdrawal Syndrome when use of the drug is stopped. Many definitions place primary stress on psychological factors, such as loss of self-control and overpowering desires; i.e., addiction is any state in which one craves the use of a drug and uses it frequently. Others use the term as a synonym for physiological dependence; still others see it as a combination (of the two).”GAMBLING ADDICTIONReference: Koob, George F.; Arends, Michael A.; Le Moal, Michel. Drugs, Addiction, and the Brain (Kindle Locations 370-375). Elsevier Science. Kindle Edition.

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MOLECULAR & CELLULAR BASIS OF ADDICTION

Addiction is a complex phenomenon with important psychological and social causes and consequences. However, at its core, it involves a biological process: the effects of repeated exposure to a biological agent (drug) on a biological substrate (brain) over time.Ultimately, adaptations that drug exposure elicits in individual neurons alter the functioning of those neurons, which in turn alters the functioning of the neural circuits in which those neurons operate. This leads eventually to the complex behaviors (for example, dependence, tolerance, sensitization, and craving) that characterize an addicted state.7Slide8

NEUROTRASMISSIONDrugs of abuse alter the way people think, feel, and behave by disrupting neurotransmission

, the process of communication between brain cells. Over the past few decades, studies have established that drug dependence and addiction are features of an organic brain disease caused by drugs' cumulative impacts on neurotransmission. 8Slide9

NEUROTRANSMITTERSA person reads. The words on the page enter the brain through the eyes and are transformed into information that is relayed, from cell to cell, to regions that process visual input and attach meaning and memory. When inside cells, the information takes the form of an electrical signal. To cross the tiny intercellular gap that separates one cell from the next, the information takes the form of a chemical signal.

The specialized chemicals that carry the signals across the intercellular gaps, or synapses, are called neurotransmitters.9Slide10

NEUROTRANSMISSIONThe ebb and flow of neurotransmitters—neurotransmission

—is thus an essential feature of the brain's response to experience and the environment. To grasp the basic idea of neurotransmission, compare the brain to a computer. A computer consists of basic units (semiconductors) that are organized into circuits; it processes information by relaying electric current from unit to unit; the amount of current and its route through the circuitry determine the final output. The brain's corresponding basic units are the neurons—100 billion of them; the brain relays information from neuron to neuron using electricity and neurotransmitters; the volume of these signals and their routes through the organ determine what we perceive, think, feel, and do.10Slide11

THE BRAIN: A LIVING ORGANOf course, the brain, a living organ, is much more complex and capable than any machine. Brain cells respond with greater versatility to more types of input than any semiconductor; they also can change, grow, and reconfigure their own circuits.

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WHAT IS CULTURE?Culture is the conceptual system developed by a community or society to structure the way people view the world. It involves a particular set of beliefs, norms, and values that influence ideas about relationships, how people live their lives, and the way

people organize their world. 12Slide13

SPOKEN AND UNSPOKEN RULESCulture is not a definable entity to which people belong or do not

belong. Within a nation, race, or community, people belong to multiple cultural groups and negotiate multiple cultural expectations on a daily basis. These expectations, or cultural norms, are the spoken or unspoken rules or standards for a given group that indicate whether a certain social event or behavior is appropriate or inappropriate. 13Slide14

CULTURE AND GROUPSThe word “culture

” is sometimes applied to groups formed on the basis of age, socioeconomic status, disability, sexual orientation, recovery status, common interest, or proximity. Counselors and administrators should understand that each client embraces his or her culture(s) in a unique way and that there is considerable diversity within and across races, ethnicities, and culture heritages. Other cultures and subcultures often exist within larger cultures.14Slide15

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CULTURAL BOUND SYNDROMESDSM-IV-TR

The fourth edition of Diagnostic and Statistical Manual of Mental Disorders classifies the below syndromes as culture-bound syndromes:Name Geographical localization/populationsRunning amok Malaysia, Indonesia, Philippines, Brunei, SingaporeAtaque de nervios Hispanic people as well as in the Philippines where it is known as "Nervous Breakdown"Bouffée délirante West Africa and HaitiBrain fag syndrome West African studentsDhat syndrome IndiaFalling-out, blacking out Southern United States and CaribbeanGhost sickness Native AmericanHwabyeong Korean

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CULTURAL BOUND SYNDROMESKoro Chinese

and Malaysian populations in southeast Asia; Assam; occasionally in WestLatah Malaysia and IndonesiaLocura Latinos in the United States and Latin AmericaMal de pelea Puerto RicoNervios Latin America, Latinos in the United StatesEvil eye Mediterranean; Hispanic populations and EthiopiaPiblokto Arctic and subarctic Eskimo populationsZou huo ru mo (Qigong psychotic reaction) ChineseRootwork Southern United States, Caribbean nationsSangue dormido Portuguese populations in Cape VerdeShenjing shuairuo Chinese

Shenkui, shen-kʼuei ChineseShinbyeong

KoreanSpell African American, White populations in the southern United States and EthiopiaSusto Latinos in the United States; Mexico, Central America and South America

Taijin kyofusho JapaneseZār

Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies19Slide20

ELEVEN CRITERIA IN DSM V FOR DIAGNOSIS OF ANY SUBSTANCE USE DISORDER&LINKAGE WITH GAMBLING DISORDER

CRITERIA20Slide21

SUBSTANCE INGESTION & IMAGINATION

1 - The individual may take the substance in larger amounts or over a longer period than was originally intended. (DSM – V)(Ingestion, Quantity, and Time - Chemical Addiction)1 - Needs to gamble with increasing amounts of money in order to achieve the desired excitement. (DSM-V)(Fascination/Imagination/Conception, Quantity, and Time – Gambling Addiction)21Slide22

CONTROL ILLICIT DRUG USE2 - The individual may express a persistent desire to cut down or regulate substance use and may report multiple unsuccessful efforts to decrease or discontinue

use. Is restless or irritable when attempting to cut down or stop gambling. (DSM V)Attempt to “regulate” gambling activity by addicted gamblers:Desire to gambling within limitsDecision to walk away after loss limit reached is changed22Slide23

USE-ABUSE-RECOVERY FROM EFFECTS3 - The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects.

Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble). (DSM V)Obtaining money (non-ingestion)Energy is being used in gambling without ingestion…23Slide24

CRAVING4- Craving is

manifested by an intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug previously was obtained or used. DSM V: After losing money gambling, often returns another day to get even (“chasing” one’s losses). (Craving in problem gambling with winning, losing, temporarily stopping, etc.)DSM V does NOT discuss craving in the s/s of gambling disorder explicitly. Intense desire/urge to place betsEuphoric Recall, selective recall, etc.24Slide25

SOCIAL IMPAIRMENT

Recurrent substance use may result in a failure to fulfill major role obligations at work, school, or home (Criterion 5). The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (Criterion 6). Important social, occupational, or recreational activities may be given up or reduced because of substance use (Criterion 7). The individual may withdraw from family activities and hobbies in order to use the substance. Problem Gambling:Lies to conceal the extent of involvement with gambling.Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.25Slide26

RISKY USEThis may take the form of recurrent substance use in situations in which it is physically hazardous (Criterion 8).

The individual may continue substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (Criterion 9). The key issue in evaluating this criterion is not the existence of the problem, but rather the individual’s failure to abstain from using the substance despite the difficulty it is causing.Risk in Problem Gambling26Slide27

TOLERANCETolerance (Criterion 10) is signaled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed.

Tolerance is NOT discussed in the DSM V criteria for gambling disorder.Tolerance effect in gambling….27Slide28

WITHDRAWAL Withdrawal (Criterion 11) is a syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance.

Withdrawal in problem gambling…28Slide29

DIVERSITY OF HUMAN DYNAMICS• An understanding of race, ethnicity, and culture (including one’s own) is necessary to appreciate the diversity of human

dynamics and to treat clients effectively. • Incorporating cultural competence into treatment improves therapeutic decision-making and offers alternative ways to define and plan a treatment program firmly directed toward progress and recovery. 29Slide30

PREVENTION SCIENCEPrevention Science

is the application of a scientific methodology that seeks to prevent or moderate major human dysfunctions before they occur. Reference for this slide: Coie, J. D., Watt, N. F., West, S. G., Hawkins, J. D., Asarnow, J. R., Markman, H. J., Ramey, S. L., ... Long, B. (January 01, 1993). Thescience of prevention. A conceptual framework and some directions for a national research program. The American Psychologist, 48, 10,1013-22.30Slide31

PRECURSORS OF DYSFUNCTIONRegardless of the type of issue on hand, the factors that lead to the problem must be identified and addressed. Prevention research is thus focused primarily on the systematic study of these potential precursors of dysfunction, also known as

risk factors; as well as components or circumstances that reduces the probability of problem development in the presence of risk, also known as protective factors. 31Slide32

PREVENTION INTERVENTIONSPreventive interventions aim to counteract risk factors and reinforce protective factors in order to disrupt processes or situations that give rise to human or social dysfunction.

Prevention is an active process that creates and rewards conditions that lead to healthy behaviors and lifestyles. Prevention efforts target different individuals and groups with different programs, depending on their needs. 32Slide33

ORIGIN OF THE WORD “PREVENT”Prevent comes from the Latin word praevenire

. Venire means to come. Prae means before. “To come before.”To prevent is to act in anticipation of; to act ahead of; to precede. So, prevention is the act of anticipating by action – the act of coming before.33Slide34

PREVENTION – AN ACTIVE PROCESSPrevention is an active process of creating conditions and personal attributes that promote the well-being of people.

Prevention Efforts: Identifying the factors which cause a condition and then reducing or eliminating them.”34Slide35

AGENT – HOST – ENVIRONMENT(Public Health Model)

Agent is the drug or disease Host is the body in which it resides (with its particular susceptibilities, knowledge, and attitudes)Environment is the context in which it occurs (for example, peer pressure).To successfully prevent problem gambling (gambling disorder), it is necessary to affect all three elements.35Slide36

PREVENTION ACCORDING TO SAMHSAAs defined by

SAMHSA, “A proactive process that empowers individuals and systems to meet the challenges of life events and transitions by creating and reinforcing conditions that promote healthy behaviors and lifestyles.” (CSAP promotes six strategies to implement comprehensive prevention.)36Slide37

CSAP’S 6 PREVENTION STRATEGIES

Information dissemination - pushing out information to create awareness about a community issue, problem or invitation to get involved is readily accomplished via social mediaEducation - depending on how this is done it could be a push or a pull strategy. Social learning puts the individual in the center, making our ability to get noticed and engage people even more important than ever beforeAlternatives - this strategy is often focused on alternative activities in for specific populations e.g., youth.  Social media provides an alternative enabling sharing our thoughts, ideas, experiences, products, artifacts and intentions so it becomes a kind of alternative.Problem ID & Referral - when we see problem we have a unique opportunity to provide support helping people find what they need.  A good many social media offer a way to get or give help.Community-based Process - coalitions and providers are often engaged in the process of helping community members engage to envision a better future and a path for getting there. Social media is a way to engage, learn, share, produce and create change.Environmental strategies - policy strategies and social media can play a role in influencing these strategies from documenting rallies in real time to sharing day-to-day conversations about these strategies as they develop. 

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COMMISSION ON CHRONIC ILLNESS - 1957

(The traditional definition, which has been used for a broad range of prevention efforts, draws upon a classification system first proposed by the Commission on Chronic Illness in 1957.) Primary prevention is directed at averting a potential health problem before it starts. Secondary prevention is directed at early detection and, as appropriate, early intervention. Tertiary prevention is directed at minimizing disability and avoiding relapse. Therefore, prevention can be thought of as taking place along a continuum.

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IOM – CLASSIFICATION SCHEME

An alternative classification scheme for prevention, offered by Gordon in 1983. This continuum of care concept is used by the Institute of Medicine (IOM) , part of the National Academy of Sciences, to illustrate interventions needed by those at different levels of risk for substance abuse and mental health disorders. These universal , selective , and indicated prevention categories are defined and illustrated in the next few slides. The chart shows that those who have an identified problem are in need of treatment. Treatment includes screening and care for existing problems. Once standard treatment has been provided, individuals require aftercare or maintenance as part of rehabilitation and to help them remain drug-free.39Slide40

Prevention-Treatment-Maintenance

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UNIVERSAL PREVENTION

Universal prevention measures address an entire population (national, local, community, school, or neighborhood) with messages and programs aimed at preventing or delaying the use of alcohol, tobacco, and other drugs (and…gambling). The mission of universal prevention is to deter the onset of substance abuse by providing all individuals with the information and skills necessary to prevent the problem. The entire population is considered at risk and able to benefit from prevention programs. 41Slide42

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SELECTIVE PREVENTION

Selective prevention measures target subsets of the total population that are considered at risk for substance abuse (and problem gambling) by virtue of their membership in a particular segment of the population. Examples include children of adult alcoholics, students who are failing academically, and those who live in high drug use neighborhoods. Selective prevention targets the entire subgroup, regardless of the degree of risk of any individual within the group. 43Slide44

INDICATED PREVENTION

Indicated prevention measures are designed to prevent the onset of substance abuse in individuals who do not meet the medical criteria for addiction, but who are showing early danger signs, such as falling grades and some use of alcohol and/or marijuana. The mission of indicated prevention is to identify individuals who are exhibiting early signs of substance abuse (problem gambling) and other problem behaviors and to involve them in special programs.44Slide45

RESTORING WELLNESS

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WHAT IS GAMBLING DISORDER IN THE DSM V?

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GAMBLING DISORDER

An important departure from past diagnostic manuals is that the substance-related disorders chapter of the DSM V has been expanded to include gambling disorder. This change reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance use disorders to a certain extent. 47Slide48

DSM V: GAMBLING DISORDERSigns/Symptoms – part 1

Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:Preoccupation: The person is preoccupied with gambling and has frequent thoughts about gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble, etc.Tolerance: Similar to drug tolerance, the person needs to gamble with increasing amounts of money in order to achieve the desired excitement or “rush”Loss of Control: The person has made repeated unsuccessful efforts to control, cut back, or stop gambling48Slide49

DSM V: GAMBLING DISORDER Signs/Symptoms – part 2

Withdrawal: The person is restless or irritable when attempting to cut down or stop gamblingEscape: The person gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)Chasing: After losing money gambling, the person often returns another day to get even (“chasing” one’s losses)Lying: Lies to family members, therapist, or others to conceal the extent of involvement with gambling49Slide50

DSM V: GAMBLING DISORDER Signs/Symptoms – part 2

Illegal Activity: The person has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling (DSM IV)Risked Relationships: The person has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gamblingBailout: Relies on others, such as friends or family, to provide money to relieve a desperate financial situation caused by gambling** The gambling behavior is not better accounted for by a Manic Episode

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PSYCHODYNAMIC VIEW OF ADDICTION

A psychodynamic view of addiction:integrates the neurobiology of addiction with a focus on the factors that produce vulnerability to addiction.This perspective is deeply rooted in the psychodynamic aspects of clinical practice developed from a contemporary perspective with regard to substance use disorders. The focus of this approach is on: developmental difficultiesemotional disturbances structural (ego) factorspersonality organization, and the building of the “self”Reference: Koob, George F.; Arends

, Michael A.; Le Moal, Michel. Drugs, Addiction, and the Brain (Kindle Locations 398-403). Elsevier Science. Kindle Edition.

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ACUTE REINFORCEMENT/SOCIAL DRUG-TAKING

Stages of addiction to drugs of abuse.   Drug taking invariably begins with social drug taking and acute reinforcement and often, but not exclusively, moves in a pattern of use from escalating compulsive use to dependence, withdrawal, and protracted abstinence. During withdrawal and protracted abstinence, relapse to compulsive use is likely to occur with a repeat of the cycle. Genetic factors, environmental factors, stress, and conditioning all contribute to the vulnerability to enter the cycle of abuse/ dependence and relapse within the cycle. Reference: Koob, George F.; Arends, Michael A.; Le Moal, Michel. Drugs, Addiction, and the Brain (Kindle Locations 282-287). Elsevier Science. Kindle Edition.

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PATTERNS OF ADDICTIONDifferent drugs produce different patterns of addiction, with an emphasis on different components of the addiction cycle.

Addiction cycle in problem gambling…Reference: Koob, George F.; Arends, Michael A.; Le Moal, Michel. Drugs, Addiction, and the Brain (Kindle Locations 307-313). Elsevier Science. Kindle Edition. 54Slide55

OPIOIDS ADDICTION & GAMBLING ADDICTION

OPIOIDSOpioids are a classic drug of addiction, in which an evolving pattern of use includes intravenous or smoked drug taking, intense initial intoxication, the development of profound tolerance, escalation in intake, and profound dysphoria, physical discomfort, and somatic withdrawal signs during abstinence. GAMBLING ADDICTIONNothing ingested in the body.Dream of winningTolerance to winning and losingEscalation of betsDysphoria of losingPhysical discomfortWithdrawal during abstinence55Slide56

HOMEOSTASIS

Homeostasis is the property of a system in which a variable (such as the concentration of a substance in solution, or its temperature etc.) is actively regulated (or controlled) inside a defined environment (mostly within a living organism’s body) to remain stable and relatively constant despite changes that would otherwise change, or disturb, the value of the variable. Homeostasis in drug addictionHomeostasis in gambling addiction56Slide57

HOMEOSTASIS IN SUBSTANCE AND GAMBLING ADDICTIONSHomeostatic changes in substance addiction.Pathological homeostasis.

Homeostatic changes in gambling addiction.57Slide58

PREDICTIVE HOMEOSTASISPredictive homeostasis is an anticipatory response to an expected challenge in the future, such as the stimulation of insulin secretion by gut hormones which enter the blood in response to a meal

. This insulin secretion occurs before the blood sugar level rises, lowering the blood sugar level in anticipation of a large influx into the blood of glucose resulting from the digestion of carbohydrates in the gut. Such anticipatory reactions are open loop systems which are based, essentially, on “guess work”, and are not self-correcting.  Anticipatory responses always require a closed loop negative feedback system to correct the over- and undershoots to which the anticipatory systems are prone.Predictive Homeostasis in problem gambling58Slide59

ANTICIPATORY RESPONSEAnticipatory response in substance use.Anticipatory response before gambling activity.

Closed-loop negative feedback system:Recreational gamblersProblem gamblers59Slide60

ALLOSTASIS

Allostasis is the process of achieving stability, or homeostasis, through physiological or behavioral change. This can be carried out by means of alteration in HPA axis hormones, the autonomic nervous system, cytokines, or a number of other systems, and is generally adaptive in the short term. Allostasis is essential in order to maintain internal viability amid changing conditions.60Slide61

OPPONENT PROCESS THEORYOpponent process

theory states that the initial emotional response to a stimulus does not simply fade, but diminishes as the result of a counteracting, or opponent, process. This secondary process overshoots the neutral point, making a rebound effect observable sometime after the stimulus is withdrawn, much like a perceptual afterimage. With repetition, the opponent process kicks-in more quickly and forcefully. 61Slide62

THREE MAJOR AFFECTIVE PHENOMENAThree major affective phenomena are observed, corresponding to different stages of the primary and secondary processes.

First, there is affective or hedonic contrast between the primary and secondary processes. Parachutists experience terror before their first free-fall, followed by elation shortly after landing. Second, frequent repetition of the unconditioned stimulus gives rise to affective or hedonic habituation (also called tolerance or adaptation). After many free-falls the parachutist no longer feels terrified before each jump. Third, as the primary process diminishes with repetition, the secondary process emerges as a long-lasting, high-amplitude affective after reaction. Experienced parachutists are claimed to have a deep sense of well-being that may last into the next day. 62Slide63

AFFECTIVE DYNAMICS

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NEGATIVE AFFECT & DEPENDENCE

“The notion of dependence on a drug, object, role, activity or any other stimulus-source requires the crucial feature of negative affect experienced in its absence. The degree of dependence can be equated with the amount of this negative affect, which may range from mild discomfort to extreme distress, or it may be equated with the amount of difficulty or effort required to do without the drug, object, etc.”Reference: Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 822-828). Elsevier Science. Kindle Edition. 66Slide67

RAPID ACUTE TOLERANCE AND OPPONENT-PROCESS-LIKE ACTIONS

A key common element of all drugs of abuse in animal models is dysregulation of brain reward function associated with the cessation of chronic drug administration. Rapid acute tolerance and opponent-process-like actions against the hedonic effects of cocaine have been reported in humans who smoke coca paste. After a single cocaine smoking bout, the onset and intensity of the “high” are very rapid via the smoked route of administration. Rapid tolerance is evident, in which the “high” decreases rapidly despite significant blood levels of cocaine. Human subjects also report subsequent dysphoria, again despite significant blood levels of cocaine. Intravenous cocaine produces similar patterns (a rapid “rush” followed by an increased “low”) Reference: Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 834-837). Elsevier Science. Kindle Edition. 67Slide68

CHRONIC PERTURBATION OF BRAIN REWARD HOMEOSTASIS

Compulsive use of cocaine is accompanied by the chronic perturbation of brain reward homeostasis.Elevations in baseline ICSS (intracranial self-stimulation) thresholds temporally precede and are highly correlated with escalated cocaine intake. Post-session elevations in ICSS reward thresholds then fail to return to baseline levels before the onset of subsequent self-administration sessions, thereby deviating more and more from control levels. Gambling Activity: Pre-gambling, while gambling, post-gambling thresholds.Reference: Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 837-847). Elsevier Science. Kindle Edition. 68Slide69

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PROGRESSIVE ELEVATION IN REWARD THRESHOLDSThe progressive elevation in reward thresholds is associated with a dramatic escalation in cocaine consumption. After escalation occurs, an acute cocaine challenge facilitates brain reward responsiveness to the same degree as before but results in higher absolute brain reward thresholds in

LgA (long access) rats than in ShA (short access)rats.Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 847-850). Elsevier Science. Kindle Edition. 71Slide72

HEDONIC ALLOSTASIS MODEL OF DRUG ADDICTION

With intravenous cocaine self-administration in animal models, such elevations in reward threshold begin rapidly and can be observed within a single self-administration session, bearing a striking resemblance to human subjective reports. These results demonstrate that the elevated brain reward thresholds following prolonged access to cocaine fail to return to baseline levels, thus creating a progressive elevation in “baseline” ICSS thresholds and defining a new set point. These data provide compelling evidence for brain reward dysfunction in escalated cocaine self-administration and strong support for a hedonic allostasis model of drug addiction.Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 871-876). Elsevier Science. Kindle Edition. 72Slide73

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SELF-ADMINISTERED INJECTIONSFIGURE 1.11   Rats (n = 11) were allowed to self-administer 10, 20, 40, and 80 injections of cocaine (0.25   mg per injection), and intracranial self-stimulation thresholds were measured 15   min, 2   h, 24   h, and 48   h after the end of each intravenous cocaine self-administration session.   The horizontal dotted line in each plot represents 100% of baseline levels. The data are expressed as the mean percentage of baseline intracranial self-stimulation thresholds. ∗ p   <   0.05, ∗ ∗ p   <   0.01, compared with baseline; #p   <   0.05, ## p   <   0.01, compared with baseline.  

Reference: Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 878-892). Elsevier Science. Kindle Edition. 74Slide75

ALLOSTASIS AND NEUROADAPTATION

More recently, opponent process theory has been expanded into the domains of the neurocircuitry and neurobiology of drug addiction from a physiological perspective. An allostatic model of the brain motivational systems has been proposed to explain the persistent changes in motivation that are associated with vulnerability to relapse in addiction, and this model may generalize to other psychopathologies associated with dysregulated motivational systems. Allostasis from the addiction perspective has been defined as the process of maintaining apparent reward function stability through changes in brain reward mechanisms (Koob and Le Moal, 2001). The allostatic state represents a chronic deviation of brain reward set point that is often not overtly observed while the individual is actively taking the drug. Thus, the allostatic view is thatKoob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 893-900). Elsevier Science. Kindle Edition. 75Slide76

INTERNAL VIABILITY MAINTENANCEAllostatic response in drug addiction.Attempt to achieve stability by continuing to gamble.

Physiological and Psychological Allostatic Responses:Drug AddictionProblem Gambling76Slide77

CROSS-TOLERANCETolerance to a drug makes a person tolerant to other drugs of the same pharmacological class.

An example of cross tolerance would be a person using one type of opioid leading to a higher threshold (i.e. the need for a higher dose) of a different opioid.Cross-tolerance in problem gambling….77Slide78

TWEAKTWEAK is a five-item screening tool. The acronym stands for

tolerance, worry about drinking, eye-opener, amnesia, and (k) cutting down.Tolerance in problem gamblingWorries about gamblingFirst thoughts about gambling when waking upAttempts to cut down gambling78Slide79

SUBJECTIVE WORLD OF THE CLIENTThe subjective world of the client is the client’s own inner world as connected to the outer world.

Entering into the subjective world through psychotherapy…..Drug addicts’ subjective world.Problem gamblers’ subjective worlds.79Slide80

DESIGNER DRUGS & GAMBLINGDesigner drugs are analogues of controlled drugs.

Designer drugs are created by chemically altering an illegal drug (so it is, at least initially, legal) while retaining the psychoactive properties. MDMA/Ecstasy is a designer drug, an analogue of amphetamine.Gambling Machines – Table Tames: Artificially constructed.80Slide81

NORMALIZE BRAIN ACTIVITYAcamprosate (Campral

) helps normalize brain activity and reduce cravings for alcohol.Craving reduction in problem gambling? Medications: NaltraxoneOther psych meds, as appropriateNormalization of brain activity in problem gambling.81Slide82

RETICULAR ACTIVATING SYSTEMThe RAS (Reticular Activating System) oversees the general arousal and activity level of the central nervous system.

Arousal in substance addictionArousal in gambling addiction??Sexual arousalGambling addiction and sex addictionSex, drug, rock and roll, & GAMBLING!!!82Slide83

RAS (BRAIN’S IGNITION SYSTEM)The Brain's Ignition SystemThe reticular activating system (RAS) acts like the ignition system of the brain, that awakens an individual from sleep to a state of heightened awareness

.Reference: http://www.buzzle.com/articles/reticular-activating-system.html83Slide84

MIND IS PROJECTED BY THE BRAINEvery conscious or unconscious function of the mind can be traced back or mapped to some part of the brain, which is one of the most complex organizations of matter in the universe. The mind is projected by the brain and its every process has an origin in some actual neuronal network.

Reference: http://www.buzzle.com/articles/reticular-activating-system.html84Slide85

15 – RAS (BRIDGE BETWEEN HIGHER & LOWER PARTS OF THE BRAIN)

Research in neuroscience has revealed, that the reticular activating system (RAS) is responsible for many cognitive functions related to awareness. This was revealed through study of mammalian brains. Evolutionarily, it is one of the oldest regions and it plays a big role in shaping the survival instinct in humans, besides acting as a bridge between the higher and lower parts of the brain. Reference: http://www.buzzle.com/articles/reticular-activating-system.html85Slide86

86Slide87

COCAETHYLENEWhen cocaine and alcohol are used together, they form a potent stimulant in the body called “

cocaethylene.” Cocaethylene is the product of a drug interaction between cocaine and alcohol. It was once thought to be more potent than cocaine, but research has not supported this claim. Cocaine hydrochloride is the most common form of pure cocaine.Substance + gambling activity = potent experience87Slide88

TECHNICAL ECLECTICISMTechnical Eclecticism refers to therapists using various techniques that are true to certain theoretical principles.

Theoretical eclecticism refers to using different theories when working with different clients, is NOT a recommended practice, because the therapist is not practicing out of a consistent set of beliefs about how people change.TREATMENT IMPLICATIONS IN SUBSTANCE AND GAMBLING DISORDER88Slide89

TRANSACTIONAL ANALYSIS(Psychotherapy Technique)

“Games that alcoholics play” are associated with Transactional Analysis (TA). TA includes the concept of games, which are a series of transactions between people, with an intense negative emotional payoff.Using TA in working with problem gamblers.89Slide90

OPIATE WITHDRAWALNausea, cramping, excessive sweating and heartbeat irregularities are all symptoms that are routinely alleviated with medication during treatment for withdrawal from opioids.

Similar withdrawal symptoms in problem gambling. GAMBLING WITHDRAWAL90Slide91

INHALANTSSome inhalants reduce blood pressure.

* (Gambling and blood pressure)Some inhalants are general anesthetics.(Gambling and feeling being pain free.)Some reduce oxygen to the brain.(Gambling and oxygen level.)Some intoxicating effects are achieved by inhaling hair sprays, nitrous oxide and gasoline.(Toxic “intoxication” in problem gambling.)91Slide92

ALCOHOL ABSORPTIONMost alcohol is absorbed into the bloodstream from the small intestine. Only about a fifth of the alcohol is absorbed from the stomach. Most of the alcohol remains to pass into the small intestine, and is absorbed into the bloodstream from there.

Alcohol + Gambling: What is actually absorbed in the system of the gambler?92Slide93

AA ASSUMPTIONSAA assumes that alcoholism is a disease that cannot be cured but can be controlled. The assumption that alcoholism is a disease has validity. However, misunderstandings can arise when the differences between alcohol abusing and alcohol dependent people are ignored.

Gambling addiction: a brain disease93Slide94

CATHARSIS & CATHEXIS(Psychotherapy Connection)

In psychodynamic theory, the process by which clients become able to express emotions that have been repressed is called catharsis. Catharsis occurs when clients experience relief by releasing, usually through talking about their problems, anxiety-causing material from unconscious. Cathexis is the focusing of the libido’s energy on an object or a idea.Catharsis and Cathexis in the treatment of gambling disorder.94Slide95

BLACKOUTSThe hippocampus is the part of the brain involved in blackouts. The hippocampus is important to memory, and is sensitive to the effects of central nervous system depressants. Blackouts are periods in which a person may seem to be functioning normally, but later has no recollection of what one did.

Blackouts in problem gambling95Slide96

REWARD DEFICIENCY SYNDROMEThe reward deficiency syndrome is used to account for drug seeking behavior. People may seek out drugs if the “reward cascade” in the mesolimbic region of the brain prevents enough dopamine from being produced.

Problem Gambling and Reward Deficiency Syndrome.96Slide97

NEGATIVE SYMPTOMAnhedonia is a negative symptom.

A negative symptom is one in which something that should be present is missing, or is not present to a sufficient degree. Anhedonia is the inability to experience pleasure. Delusions, visual hallucinations, disorganized speech, and auditory hallucinations are positive symptoms, where something is present that should not be present, or is present to too great a degree.Anhedonia in problem gambling97Slide98

BAC – Blood Alcohol ConcentrationAt a BAC of .05, most people begin to have lowered inhibitions, impaired judgement, and motor control.

Similar process in gambling activity???Thoughts, Emotions, Memories, and Desires: level in the mind of the problem gambler.Level of gambling activity thoughtsLevel of gambling activity emotionsLevel of gambling activity memoriesLevel of gambling activity desires98Slide99

ALCOHOL WITHDRAWALA person who is experiencing alcohol withdrawal is most likely to experience:Hand Tremors

InsomniaHallucinationsSeizuresWithdrawal in problem gambling99Slide100

PSYCHIATRIC PERSPECTIVE OF DRUG ADDICTION:(Impulse Control Disorders)

From a psychiatric perspective, drug addiction has aspects of both impulse control disorders and compulsive disorders. Impulse control disorders are characterized by an increasing sense of tension or arousal before committing an impulsive act, pleasure, gratification, or relief at the time of committing the act, and regret, self-reproach, or guilt following the act (see early versions of the DSM of the American Psychiatric Association). Koob, George F.; Arends, Michael A.; Le Moal, Michel. Drugs, Addiction, and the Brain (Kindle Location 395). Elsevier Science. Kindle Edition. 100Slide101

PSYCHIATRIC PERSPECTIVE OF DRUG ADDICTION:(Compulsive Disorders)

Compulsive disorders are characterized by anxiety and stress before committing a compulsive repetitive behavior and relief from the stress by performing the compulsive behavior. As an individual moves from an impulsive disorder to a compulsive disorder, a shift occurs from positive reinforcement to negative reinforcement that drives the motivated behavior. Drug addiction progresses from impulsivity to compulsivity in a collapsed cycle of addiction that consists of three stages: preoccupation/ anticipation, binge/ intoxication, and withdrawal/ negative affect. Different theoretical perspectives from experimental psychology, social psychology, psychology, and neurobiology can be superimposed on these three stages, which are conceptualized as feeding into each other, becoming more intense, and ultimately leading to the pathological state known as addiction (Figure 1.4; for further reading, see Koob and Le Moal, 1997).Koob, George F.; Arends, Michael A.; Le Moal, Michel. Drugs, Addiction, and the Brain (Kindle Locations 395-397). Elsevier Science. Kindle Edition.

101Slide102

Diagram showing stages of impulse control disorder and compulsive disorder cycles related to the sources of reinforcement.   In impulse control disorders, increasing tension and arousal occur before the impulsive act, with pleasure, gratification or relief during the act, and regret or guilt following the act. In compulsive disorders, recurrent and persistent thoughts (obsessions) cause marked anxiety and stress followed by repetitive behaviors (compulsions) that are aimed at preventing or reducing distress. Positive reinforcement (pleasure/ gratification) is more closely associated with impulse control disorders. Negative reinforcement (relief of anxiety or relief of stress) is more closely associated with compulsive disorders.

Koob, George F.; Arends, Michael A.; Le Moal, Michel. Drugs, Addiction, and the Brain (Kindle Locations 406-410). Elsevier Science. Kindle Edition. 102Slide103

OPERANT CONDITIONINGOperant conditioning (sometimes referred to as

instrumental conditioning) is a method of learning that occurs through rewards and punishments for behavior. Through operant conditioning, an association is made between a behavior and a consequence for that behavior.For example, when a lab rat presses a blue button, he receives a food pellet as a reward, but when he presses the red button he receives a mild electric shock.As a result, he learns to press the blue button but avoid the red button.103Slide104

DIFFERENT TYPES OF POSITIVE REINFORCERS

There are many different types of reinforcers that can be used to increase behaviors, but it is important to note that the type of reinforcer used depends upon the individual and the situation. While gold stars and tokens might be very effective reinforcement for a second-grader, they are not going to have the same effect on a high school or college student.Natural reinforcers are those that occur directly as a result of the behavior. For example, a girl studies hard, pays attention in class and does her homework. As a result, she gets excellent grades.Token reinforcers are points or tokens that are awarded for performing certain actions. These tokens can then be exchanged for something of value.Social reinforcers involve expressing approval of a behavior, such as a teacher, parent, or employer saying or writing "Good job" or "Excellent work."Tangible reinforcers involve the presentation of an actual, physical reward such as candy, treats, toys, money and other desired objects. While these types of rewards can be powerfully motivating, they should be used sparingly and with caution.

104Slide105

PHARMACOLOGY FOR ADDICTION WHAT IS A DRUG, AND WHAT IS PHARMACOLOGY?The following terms need to be defined for pharmacological discussions of addiction.

Pharmacology is the study of the interaction between chemical reagents or drugs and living organisms. Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 1094-1098). Elsevier Science. Kindle Edition. 105Slide106

DRUGA drug is any chemical agent that affects an organism. Obviously, this definition can be murky in the domain of drugs of abuse, when one crosses into the realm of natural preparations that

contain psychoactive or psychotropic drug entities.106Slide107

PSYCHOTROPICPsychotropic can be defined as an effect of a drug on the mind or behavior. For example, most drugs of abuse are derived from plant preparations. Many of them are alkaloids, such as nicotine in tobacco and caffeine in coffee and tea. An alkaloid is an organic compound that normally has basic chemical properties and contains mostly basic nitrogen atoms. So when does a compound transition from being a foodstuff to a drug?

Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 1098-1106). Elsevier Science. Kindle Edition. 107Slide108

IDENTIFIABLE PSYCHOTROPIC EFFECTOne metric is when it begins to have an identifiable psychotropic effect. Other terms that are often used in the drug abuse field and should be defined in the context of this book are

toxicology, pharmacotherapeutics, pharmacokinetics, and pharmacodynamics. 108Slide109

SIMPLE DEFINITIONSToxicology is the study of the harmful effects of drugs.

Pharmacotherapeutics is the study of the diagnostic or therapeutic effects of drugs. Pharmacokinetics is the study of the factors that determine the amount of a given drug at a given site of action. Pharmacodynamics is the study of how a drug produces its biological effect.109Slide110

Drug ClassificationDrugs can be classified three ways: behavioral classification,

pharmacodynamic classification, and legal classification. Behavioral classification includes five main categories: stimulants, opioids, sedative hypnotics, antipsychotics, antidepressants, and psychedelics. Each of these categories is more or less self-explanatory. Reference: Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 1113-1124). Elsevier Science. Kindle Edition. 110Slide111

BEHAVIORAL CLASSIFICATION•

Stimulants include drugs that stimulate or produce arousal and behavioral activation. Examples of stimulants are cocaine, amphetamines, nicotine, and caffeine. • Opioids are natural, semisynthetic, or synthetic drugs that bind to opioid receptors and produce analgesia. Analgesia can be defined as the reduction of pain or elevation of pain thresholds. • Sedative hypnotics are drugs that sedate or decrease arousal, producing an anti-anxiety effect, hypnosis, or sleep. Hypnosis is defined as the induction of sleep. Two examples of this class of drugs are alcohol and benzodiazepines. • Antipsychotics are drugs that are used to treat psychosis and include the classic antipsychotics such as haloperidol (trade name: Haldol), and modern second generation drugs, such as olanzapine (trade name: Zyprexa). • Antidepressants are drugs that are used to treat major depressive episodes and include selective serotonin reuptake inhibitors, such as fluoxetine (trade name: Prozac) and escitalopram (trade name: Lexapro), among others. 111Slide112

Cont..• Psychedelics

are drugs that produce psychedelic experiences. Psychedelic can be defined as mind-altering. Another term that is often used to describe this drug class is hallucinogen, but the true meaning of the term hallucination is to experience something that is not there; therefore, the term psychedelic is preferred. Psychedelics include lysergic acid diethylamide (LSD) and psilocybin (derived from psychedelic mushrooms).Reference: Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 1124-1128). Elsevier Science. Kindle Edition. 112Slide113

ANHEDONIADefinition:

The inability to experience pleasure.ATOD:Can be precipitated by the prolonged use of stimulants, which cause the depletion of dopamine.Gambling Addiction:Desentization due to wins and losses.Sense of deep escape and “numbing out.”113Slide114

ANERGIADefinition:Lack of energy; can be precipitated by the use of stimulants.

Gambling Addiction:Energy, money, and the betting activity.114Slide115

ATAXIAATAXIA: Unsteady gait; Present with intoxication from alcohol, inhalants, and other substances. Can also be due to brain damage.

Problem Gambling: The “high of winning” – a type of intoxicationUse of alcohol and gambling and ataxia.115Slide116

116Slide117

117Slide118

INTUITIVE HEDONICSIntuitive hedonics, the part of common- sense psychology regarding the dynamics of pleasure. Intuitive hedonics

includes beliefs about the formation of, and factors influencing, a broad range of subjective responses including enjoyment, liking, and affect.118Slide119

SIX AREAS ON LIKING AND ENJOYMENTsix areas of psychology that bear on liking or enjoyment: classical

conditioning, Weber's law, opponent processes, adaptation or habituation, mere expo- sure, and cognitive dissonance.119Slide120

WEBER'S LAWWeber's law states that the just noticeable difference between two levels of stimulation is a constant fraction of the baseline level of stimulation (Levine &

Shefner, 1991). Consequently, at high levels of stimulation, a large absolute change in stimulation must occur to be noticed, whereas at low levels of stimulation, even a small absolute change in stimulation can be noticed. For our translation into natural scenarios, detection thresholds are less important than the general notion that the psychological impact of a stimulus will be smaller when the baseline level of stimulation is larger.3120Slide121

CLASSICAL CONDITIONINGClassical conditioning refers to the "process of using an established relation- ship between a stimulus and response to bring about the learning of the same response to a different stimulus" (Hawkins, Best, & Coney, 1992, p. 246). This characterization is typical of contemporary consumer behavior text

books (although there remain a number of unresolved issues concerning the details of classical conditioning; see Klein & Mowrer, 1989). Experimental demon- strations of classical conditioning usually involve measurement of behavior, but there is also empirical evidence that attitudes can be conditioned (Stuart, Shimp, & Engle, 1987). Because we are primarily interested in beliefs about liking, we asked respondents directly about affective responses.121Slide122

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