Which of the following most accurately represents the “rational path to madness?”

Eating Disorders 283

4,1 *)W1)711. 01271, WW2? OW/1W

\\\nUir31( nU12 ,/, ' 1. What are the symptoms and main

features of anorexia nervosa? pp. 258-260

2. What are the symptoms and main features of bulimia nervosa? pp. 260-264

3. How are people with anorexia ner- vosa similar to those with bulimia nervosa? How are they different? pp. 264-265

4. Theorists usually apply a multi- dimensional risk perspective to explain the eating disorders. What does this mean? p. 265

5. According to Hilde Bruch, how might parents' failure to attend

appropriately to their baby's internal needs and emotions contribute to the later development of an eating disorder? pp. 265-266

6. How might a person's hypothala- mus and weight set point contribute to the development of an eating disorder? pp. 267-270

7. What evidence suggests that socio- cultural pressures and factors may set the stage for eating disorders? pp. 270-275

8. When clinicians treat people with anorexia nervosa, what are their short-term and long-term goals?

What approaches do they use to accomplish them? pp. 275-278

9. How well do people with anorexia nervosa recover from their disor- der? What factors affect a person's recovery? What risks and prob- lems may linger after recovery? pp. 278-279

10. What are the key goals and approaches used in the treatment of bulimia nervosa? How success- ful are they? What factors affect a person's recovery? What risks and problems may linger after recovery? pp. 279-281

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SUBSTANCE-RELATED DISORDERS CHAPTER

66 am Duncan. l am an alcoholic." The audience settled deeper into their chairs at these familiar words. Another chronicle of death and rebirth would shortly begin [at] Alcoholics Anonymous. .

. . . "I must have been just past my 15th birthday when 1 had that first drink that everybody to ks about. And like so many of them . . . it was like a miracle. With a little beer in my gut, the world was transformed. l wasn't a weakling anymore, 1 could lick almost anybody on the block. And girls? Well, you can imagine how a couple of beers made me feel like l could have any girl I wanted.

"Though it's obvious to me now that my drinking even then, in high school, and after I got to college, was a problem, l didn't think so at the time. After oil, everybody was drinking and get- ting drunk and acting stupid, and I didn't really think l was different. . . . 1 guess the fact that hadn't really had any blackouts and that I could go for days without having to drink reassured me that things hadn't gotten out of control. And that's the way it went, until 1 found myself drinking even more—and mare often—and suffering more from my drinking, along about my third year of college.

... "My roommate, a friend from high school, started bugging me about my drinking. It wasn't even that I'd have to sleep it off the whale next day and miss class, it was that he had begun to hear other friends talking about me, about the fool I'd made of myself at parties. He sow how shaky 1 was the morning after, and he saw how different I was when I'd been drinking a lot—almost out of my head was the way he put it. And he could count the bottles that I'd leave around the room, and he knew what the drinking and carousing was doing to my grades. . . . [P]ortly because l really cared about my roommate and didn't want to lose him as a friend, i did cut down on my drinking by half or more. I only drank on weekends—and then only at night. . . And that got me through the rest of college and, actually, through law school as well. .

"Shortly after getting my law degree, l married my first wife, and ... for the first time since I started, my drinking was no problem at all. I would go for weeks at a time without touching a drop. . . .

"My marriage started to go bad after our second son, our third child, was born. I was very much career-and-success oriented, and I had little time to spend at home with my family. . . . My traveling had increased a lot, there were stimulating people on those trips, and, let's face it, there were some pretty exciting women available, too. So home got to be little else but a nagging, boring wife and children I wasn't very interested in. My drinking had gotten bad again, too, with being on the road so much, having to do a lot of entertaining at lunch when I wasn't away, and trying to soften the hassles at home. I guess I was putting down close to a gallon of very good scotch a week, with one thing or another.

'And as that went on, the drinking began to affect both my marriage and my career. With enough booze in me and under the pressures of guilt over my failure to carry out my responsibili- ties to my wife and children, I sometimes got kind of rough physically with them. I would break furniture, throw things around, then rush out and drive off in the car. 1 had a couple of wrecks, lost my license for two years because of one of them. Worst of all was when 1 tried to stop. By then I was totally hooked, so every time / tried to stop drinking, I'd experience withdrawal in all its horrors ... with the vomiting and the 'shakes' and being unable to sit still or to fie down. And that would go on for days at a time. . . .

TOPIC OVERVIEW Depressants Alcohol Sedative-Hypnotic Drugs Opioids

Stimulants Cocaine Amphetamines

Hallucinogens

Cannabis

Combinations of Substances

What Causes Substance-Related Disorders? Sociocultural Views Psychodynamic Views Cognitive-Behavioral Views Biological Views

How Are Substance-Related Disorders Treated? Psychodynamic Therapies Behavioral Therapies Cognitive-Behavioral Therapies

Biological Treatments Sociocultural Therapies

Putting It Together: New Wrinkles to a Familiar Story

292 ://CHAPTER 10

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2008). The rate may increase to as many as 29 of every 1,000 babies of women who are problem drinkers. In addition, heavy drinking early in pregnancy often leads to a miscarriage. According to surveys, around 11 percent of pregnant American women have drunk alcohol during the past month and 4.5 percent of pregnant women have had binge-drinking episodes (NSDUH, 2008).

Sedative-Hypnotic Drugs Sedative-hypnotic drugs, also called anxiolytic drugs, produce feelings of relaxation and drowsiness. At low dosages, the drugs have a calming or sedative effect. At higher dosages, they are sleep inducers, or hypnotics. The sedative-hypnotic drugs include bar- biturates and benzadiazepines.

Barbiturates First discovered in Germany more than 100 years ago, barbiturates were widely prescribed in the first half of the twentieth century to fight anxiety and to help people sleep. Although still prescribed by some physicians, these drugs have been largely replaced by benzodiazepines, which are generally safer drugs. Barbiturates can cause many problems, not the least of which are abuse and dependence. Several thousand deaths a year are caused by accidental or suicidal overdoses.

Barbiturates are usually taken in pill or capsule form. In low doses they reduce a per- son's level of excitement in the same way that alcohol does, by attaching to receptors on the neurons that receive the inhibitory neurotransmitter GABA and by helping GABA operate at those neurons (Ksir et al., 2008; Grilly, 2006). People can get intoxicated from large doses of barbiturates, just as they do from excessive alcohol.At too high a dose, the drugs can halt breathing, lower blood pressure, and lead to coma and death.

Repeated use of barbiturates can quickly result in a pattern of abuse (Dupont & Dupont, 2005). Users may spend much of the day intoxicated, irritable, and unable to do their work. Dependence can also result. The users organize their lives around the drug and need increasing amounts of it to calm down or fall asleep. A great danger of barbiturate dependence is that the lethal dose of the drug remains the same even while the body is building up a tolerance for its sedating effects. Once the prescribed dose stops reducing anxiety or inducing sleep, the user is all too likely to increase it without medical supervision and eventually may ingest a dose that proves fatal. Those caught in a pattern of barbiturate dependence may also experience withdrawal symptoms such as nausea, anxiety, and sleep problems. Barbiturate withdrawal is particularly dangerous because it can cause convulsions.

Risks and Consequences of Drug Misuse

Opioids ---------

Sedative-hypnotics Barbiturates Benzodiazepines

. -----------

Risk of Risk of Risk of Severe Organ Severe Social or Long-Lasting

Intoxication Dependency Damage or Economic Mental and Potential Potential or Death Consequences Behavioral Change High High Low High Low to moderate

Moderate

Moderate to high Moderate to high Moderate to high Low Moderate

Moderate Low Low Low

Stimulants (cocaine, amphetamines) High High Moderate Low to moderate Moderate to high

i Alcohol High Moderate High High High

Cannabis High Low to moderate Low Low to moderate Low

r Mixed drugs High High High High High

Source: Ksir et al., 2008; APA, 2000; Gold, 1986, p. 28.

Substance-Related Disorders :1/ 293

Benzodiazepines Chapter 4 described benzodiazepines, the antianxiety drugs developed in the 1950s, as the most popular sedative-hypnotic drugs available. Xanax, Ativan, and Valium are just three of the dozens of these drugs in clinical use. Altogether, about 100 million prescriptions are written each year for this group of drugs (Bisaga, 2008). Like alcohol and barbiturates, they calm people by binding to receptors on the neurons that receive GABA and by increasing GABA's activity at those neurons (Ksir et al., 2008). These drugs, however, relieve anxiety without making people as drowsy as other kinds of sedative-hypnotics.They are also less likely to slow a person's breathing, so they are less likely to cause death in the event of an overdose (Nishino et al., 1995).

When benzodiazepines were first discovered, they seemed so safe and effective that physicians prescribed them generously, and their use spread. Eventually it became clear that in high enough doses the drugs can cause intoxication and lead to abuse or dependence (Bisaga, 2008).As many as 1 percent of the adults in North America abuse or become physically dependent on these antianxiety drugs at some point in their lives (Sareen et al., 2004; Goodwin et al, 2002) and thus become subject to some of the same dangers that researchers have identified in barbiturate misuse.

Opioids Opioids include opium—taken from the sap of the opium poppy—and the drugs de- rived from it such as heroin, morphine, and codeine. Opium itself has been in use for thousands of years. In the past it was used widely in the treatment of medical disorders because of its ability to reduce both physical and emotional pain. Eventually, however, physicians discovered that the drug was physically addictive.

In 1804 a new substance, morphine, was derived from opium. Named after Mor- pheus, the Greek god of sleep, this drug relieved pain even better than opium did and initially was considered safe. However, wide use of the drug eventually revealed that it, too, could lead to addiction. So many wounded soldiers in the United States received morphine injections during the Civil War that morphine dependence became known as "soldiers' disease."

In 1898 morphine was converted into yet another new pain reliever, heroin. For several years heroin was viewed as a wonder drug and was used as a cough medicine and for other medical purposes. Eventually, however, physicians learned that heroin is even more addictive than the other opioids. By 1917 the U.S. Congress had concluded that all drugs derived from opium were addictive (see Table 10-3), and it passed a law making opioids illegal except for medical purposes.

Still other drugs have been derived from opium, and synthetic (laboratory-blended) opioids such as methadone have also been developed.All these opioid drugs—natural and synthetic—are known collectively as narcotics. Each drug has a different strength, speed of action, and tolerance level. Morphine and codeine are medical nar- cotics usually prescribed to relieve pain. Heroin is illegal in the United States in all circumstances.

Narcotics are smoked, inhaled, snorted, injected by needle just beneath the skin ("skin popped"), or injected directly into the blood- stream ("mainlined"). Injection seems to be the most common method of narcotic use, although the other techniques have been used increas- ingly in recent years (NSDUH, 2008). An injection quickly brings on a rush—a spasm of warmth and ecstasy that is sometimes compared with orgasm. The brief spasm is followed by several hours of a pleasant feeling called a high or nod. During a high, the drug user feels relaxed, happy, and unconcerned about food, sex, or other bodily needs.

Opioids create these effects by depressing the central nervous system, particularly the centers that help control emotion. The drugs attach to brain receptor sites that ordinarily receive endorphins— neurotransmitters that help relieve pain and reduce emotional tension (Kreek, 2008; Ksir et al., 2008). When neurons at these receptor sites

*sedative -hypnotic drugeA drug used in low doses to reduce anxiety and in higher doses fo help people sleep. Also called anxiolytic drug.

obarbiturateseAddictive sedative- hypnotic drugs that reduce anxiety and help produce sleep.

obenzadiazepineseThe most com- mon group of antianxiety drugs, which includes Valium and Xanax.

QopioidoOpium or any of the drugs derived from opium, including morphine, heroin, and codeine.

eopiumoA highly addictive substance made from the sap of the opium poppy.

0morphine0A highly addictive sub- stance derived from opium that is particularly effective in relieving pain.

oheroinoOne of the most addictive substances derived from opium.

oendorphinseNeurotransmitters that help relieve pain and reduce emotional tension. They are sometimes referred fo as the body s own opioids.

•• •• • • . •• • • • • •

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Substance Misuse and Depressants

The misuse of substances (or drugs) may lead to temporary changes such as intoxi- cation. Long-term and high use can lead to substance abuse or substance depen- dence. People who become dependent on a drug may develop a tolerance for it, experience unpleasant withdrawal symptoms when they abstain from it, or both.

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receive opioids, they produce pleasurable and calming feelings just as they would do if they were receiving endorphins. In addition to reducing pain and tension, opioids cause nausea, narrowing of the pupils ("pinpoint pu- pils"), and constipation.

Heroin Abuse and Dependence Heroin use exemplifies the kinds of problems posed by opioids. After taking heroin repeatedly for just a few weeks, users may become caught in a pattern of abuse:The drug interferes significantly with their social and occupational functioning. In most cases, heroin abuse leads to a pattern of dependence as well, and users soon cen- ter their lives on the substance, build a tolerance for it, and experience a withdrawal reaction when they stop taking it (Kreek, 2008). At first the withdrawal symptoms are anxiety, restlessness, sweating, and rapid breath- ing; later they include severe twitching, aches, fever, vomiting, diarrhea, loss of appetite, high blood pressure, and weight loss of up to 15 pounds (due to

loss of bodily fluids).These symptoms usually peak by the third day, gradually subside, and disappear by the eighth day. A person in withdrawal can either wait out the symptoms or end withdrawal by taking heroin again.

People who are dependent on heroin soon need the drug just to avoid going into withdrawal, and they must continually increase their doses in order to achieve even that relief.The temporary high becomes less intense and less important.The individuals may spend much of their time planning their next dose, in many cases turning to criminal activities, such as theft and prostitution, to support the expensive "habit" (Allen, 2005).

Surveys suggest that close to 1 percent of adults in the United States become addicted to heroin or other opioids at some time in their lives (APA, 2000). The rate of such de- pendence dropped considerably during the 1980s, rose in the early 1990s, fell in the late 1990s, and now seems to be relatively high once again (NSDUH, 2008). The number of persons currently addicted to these drugs is estimated to be as much as 323,000. The actual number may be even higher, however, given the reluctance of many people to admit an illegal activity.

What Are the Dangers of Heroin Abuse? The most immediate danger of heroin use is an overdose, which closes down the respiratory center in the brain, almost paralyzing breathing and in many cases causing death. Death is particularly likely dur- ing sleep, when a person is unable to fight this effect by consciously working to breathe. People who resume heroin use after having avoided it for some time often make the fatal mistake of taking the same dose they had built up to before. Because their bodies have been without heroin for some time, however, they can no longer tolerate this high level. Each year approximately 2 percent of persons dependent on heroin and other opioids die under the drug's influence, usually from an overdose (Theodorou & Haber, 2005; APA, 2000).

Users run other risks as well. Often the heroin they purchase has been mixed with a cheaper drug or even a deadly substance such as cyanide or battery acid. In addition, dirty needles and other unsterilized equipment spread infections such as AIDS, hepatitis C, and skin abscesses (Batki & Nathan, 2008). In some areas of the United States the HIV infection rate among persons dependent on heroin is reported to be as high as 60 percent (APA, 2000).

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Substance-Related Disorders :11 295

ecocaineoAn addictive stimulant obtained from the coca plant. It is the most powerful natural stimulant known.

Depressants are substances that slow the activity of the central nervous system. Long-term and excessive use of these substances can lead to a pattern of abuse or dependence.

Alcoholic beverages contain ethyl alcohol, which is carried by the blood to the central nervous system, depressing its function. Intoxication occurs when the concentration of alcohol in the bloodstream reaches 0.09 percent. Among other actions, alcohol increases the activity of the neurotransmitter GABA at key sites in the brain. The sedative-hypnotic drugs, which produce feelings of relaxation and drowsiness, include barbiturates and benzodiazepines. These drugs also increase the activity of GABA.

Opioids include opium and drugs derived from it, such as morphine and heroin, as well as laboratory-made opioids. They all reduce tension and pain and cause other reactions. Opioids operate by binding to neurons that ordinarily receive endorphins.

*Stimulants Stimulants are substances that increase the activity of the central nervous system, result- ing in increased blood pressure and heart rate, greater alertness, and sped-up behavior and thinking. Among the most troublesome stimulants are cocaine and amphetamines, whose effects on people are very similar. When users report different effects, it is often because they have ingested different amounts of the drugs. Two other widely used and legal stimulants are caffeine and nicotine.

Cocaine Cocaine—the central active ingredient of the coca plant, found in South America—is the most powerful natural stimulant now known. The drug was first separated from the plant in 1865. Native people of South America, however, have chewed the leaves of the plant since prehistoric times for the energy and alertness the drug offers. Processed cocaine is an odorless, white, fluffy powder. For recreational use, it is most often snorted so that it is absorbed through the mucous membrane of the nose. Some users prefer the more powerful effects of injecting cocaine intravenously or smoking it in a pipe or cigarette.

For years people believed that cocaine posed few problems aside from intoxication and, on occasion, temporary psychosis. Only later did researchers come to appreciate its many dangers.Their insights came after society witnessed a dramatic increase in the drug's popularity and in problems related to its use. In the early 1960s an estimated 10,000 persons in the United States had tried cocaine. Today 28 million people have tried it, and 2.4 million—most of them teenagers or young adults—are using it currently (NSDUH, 2008). In fact, 2 percent of all high school seniors have used cocaine within the past month ( Johnston et al., 2007).

Cocaine brings on a euphoric rush of well-being and confidence. Given a high enough dose, this rush can be almost orgasmic, like the one produced by heroin. At first cocaine stimulates the higher centers of the central nervous system, making users feel excited, energetic, talkative, and even euphoric. As more is taken, it stimulates other centers of the central nervous system, producing a faster pulse, higher blood pressure, faster and deeper breathing, and further arousal and wakefulness.

Cocaine apparently produces these effects largely by increasing sup- plies of the neurotransmitter dopamine at key neurons throughout the brain (Haney, 2008; Kosten et al., 2008) (see Figure 10-2). Excessive amounts of dopamine travel to receiving neurons throughout the central

efree-baseoA technique for ingesting cocaine in which the pure cocaine basic alkaloid is chemically separated from processed cocaine, vaporized by heat from a flame, and inhaled with a pipe.

ocrackGA powerful form of ready-to- smoke free-base cocaine.

nervous system and overstimulate them. In addition, cocaine appears to increase the activity of the neurotransmitters norepinephrine and serotonin in some areas of the brain (Haney, 2008; Ksir et al., 2008).

High doses of the drug produce cocaine intoxication, whose symptoms are poor muscle coordination, grandiosity, bad judgment, anger, aggression, compulsive behavior, anxiety, and confusion. Some people experience hallucinations, delusions, or both, a condition known as cocaine-induced psychotic disorder (APA, 2000).

A young man described how, after free-basing, he went to his closet to get his clothes, but his suit asked him, "What do you want?" Afraid, he walked toward the door, which told him, "Get back!" Retreating, he then heard the sofa say, "If you sit on me, kick your ass." With a sense of impending doom, intense anxiety, and momentary panic, the young man ran to the hospital where he received help.

(Allen, 1985, pp. 19-20)

As the stimulant effects of cocaine subside, the user experiences a depression-like let- down, popularly called crashing, a pattern that may also include headaches, dizziness, and fainting (Doweiko, 2006). For occasional users, the aftereffects usually disappear within 24 hours, but they may last longer for people who have taken a particularly high dose. These individuals may sink into a stupor, deep sleep, or, in some cases, coma.

Cocaine Abuse and Dependence Regular use of cocaine may lead to a pat- tern of abuse in which the person remains under its effects much of each day and func- tions poorly in social relationships and at work. Regular use may also cause problems in short-term memory or attention (Kubler et al., 2005). Dependence may also develop, so that cocaine dominates the person's life, higher doses are needed to gain the desired ef- fects, and stopping it results in depression, fatigue, sleep problems, irritability, and anxiety (Barry et al., 2009).These withdrawal symptoms may last for weeks or even months after drug use has ended.

In the past, cocaine use and impact were limited by the drug's high cost. Moreover, cocaine was usually snorted, a form of ingestion that has less powerful effects than either smoking or injection. Since 1984, however, the availability of newer, more powerful, and sometimes cheaper forms of cocaine has produced an enormous increase in abuse and dependence. Currently, close to 1 percent of all people over the age of 11 in the United States display cocaine abuse or dependence in a given year (NSDUH, 2008). Many people now ingest cocaine by free-basing, a technique in which the pure co-

caine basic alkaloid is chemically separated, or "freed," from processed cocaine, vaporized by heat from a flame, and inhaled through a pipe. Millions more use crack, a powerful form of free-base cocaine that has been boiled down into crystalline balls. It is smoked with a special pipe and makes a crackling sound as it is inhaled (hence the name). Crack is sold in small quantities at a fairly low cost, a practice that has resulted in crack epidemics among people who previously could not have afforded cocaine, primarily those in poor urban areas (Acosta et al., 2005).Almost 2 percent of high school seniors report having used crack within the past year ( Johnston et al., 2007).

What Are the Dangers of Cocaine? Aside from cocaine's harmful effects on behavior, the drug poses serious physical dangers (Kosten et al., 2008). Its growing use in powerful forms has caused the annual number of cocaine-related emergency room incidents in the United States to multiply by more than 100 times since 1982, from around 4,000 cases to 450,000 (SAMHSA, 2007). In addition, cocaine

296 ://CHAPTER 10

A CI °SEP iflOK •

Tobacco, Nicotine, and Addiction

'most 30 percent of all Americans over the age of 11 regularly smoke

tobacco (NSDUH, 2008). Surveys also suggest that 22 percent of all high school seniors have smoked in the past month (Johnston et al., 2007). At the same time, 440,000 persons in the United States die each year as a result of smoking. Smok- ing is directly tied to high blood pressure, coronary heart disease, lung disease, cancer, strokes, and other deadly medical problems (George & Weinberger, 2008; Hymowitz, 2005). Nonsmokers who inhale cigarette smoke from their environment have a higher risk of lung cancer and other diseases. And the 16.4 percent of all pregnant women who smoke are more likely than nonsmokers to deliver premature and underweight babies (Ksir et al., 2008; NSDUH, 2008).

So why do people continue to smoke? Because nicotine, the active substance in tobacco and a stimulant of the central nervous system, is as addictive as heroin,

perhaps even more so (Ksir et al., 2008; Report of the Surgeon General, 1988). Indeed, the World Health Organization estimates that 1.1 billion people worldwide are addicted to nicotine (Hasman & Holm, 2004). Regular smokers develop a toler- ance for nicotine and must smoke more and more in order to achieve the same results. When they try to stop smoking, they experi- ence withdrawal symptoms—irritability, in- creased appetite, sleep disturbances, slower metabolism, cognitive difficulties, and crav- ings to smoke (Brandon et al., 2009; APA, 2000). As a stimulant, nicotine acts on the same neurotransmitters and reword center in the brain as amphetamines and cocaine (George & Weinberger, 2008).

The declining acceptability of smoking in our society has created a market for products and techniques to help people kick the habit. A fairly helpful behavioral treatment for nicotine addiction is aversion therapy. In one version of this approach, known as rapid smoking, the smoker sits in

a closed room and puffs quickly on a ciga- rette, as often as once every six seconds, until he or she begins to feel ill and cannot take another puff. The feelings of illness become associated with smoking, and the smoker develops an aversion to cigarettes (George & Weinberger, 2008).

Several biological treatments have also been developed. A common one is the use of nicotine gum, an over-the-counter product that contains a high level of nico- tine that is released as the smoker chews. Theoretically, people who obtain nicotine by chewing will no longer feel a need to smoke. A similar approach is the nico- tine patch, which is attached to the skin like a Band-Aid. Its nicotine is absorbed through the skin throughout the day, sup- posedly easing withdrawal and reducing the smoker's need for nicotine. Studies find that both nicotine gum and the nicotine patch help people to abstain from smok- ing (George & Weinberger, 2008; Grilly, 2006). Still other popular biological prod.

ucts are nicotine lozenges, nicotine nasal spray, and the antidepressant drug bupropion (brand names Zyban and Wellbutrin).

The more one smokes, the harder it is to quit. On the positive side, however, former smokers' risk of disease and death decreases steadily the longer they continue to avoid smoking. This assurance may be a powerful motivator for many smokers, and, in fact, around 46 percent of

regular smokers want to stop and are even- tually able to stop permanently (NSDUH, 2008). In the meantime, more than 1,000 people die of smoking-related diseases each day.

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Substance-Related Disorders :fi 297

use has been linked to as many as 20 percent of all suicides by men under 61 years of age (Garlow, 2002).

The greatest danger of cocaine use is an overdose. Excessive doses have a strong ef- fect on the respiratory center of the brain, at first stimulating it and then depressing it, to the point where breathing may stop. Cocaine can also create major, even fatal, heart irregularities or brain seizures that bring breathing or heart functioning to a sudden stop (Ksir et al., 2008). In addition, pregnant women who use cocaine run the risk of

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having a miscarriage and of having children with abnormalities in immune functioning, attention and learning, thyroid size, and dopamine and serotonin activity in the brain (Kosten et al., 2008).

Amphetamines The amphetamines are stimulant drugs that are manufactured in the laboratory. Sonic common examples are amphetamine (Benzedrine), dextroamphetamine (Dexedrine), and methamphetamine (Methedrine). First produced in the 1930s to help treat asthma, amphetamines soon became popular among people trying to lose weight; athletes seek- ing an extra burst of energy; soldiers, truck drivers, and pilots trying to stay awake; and students studying for exams through the night. Physicians now know the drugs are far too dangerous to be used so casually, and they prescribe them much less freely.

Amphetamines are most often taken in pill or capsule form, although some people inject the drugs intravenously or smoke them for a quicker, more powerful effect. Like cocaine, amphetamines increase energy and alertness and reduce appetite when taken in small doses; produce a rush, intoxication, and psychosis in high doses; and cause an emotional letdown as they leave the body. Also like cocaine, amphetamines stimulate the central nervous system by increasing the release of the neurotransmitters dopamine, nor- epinephrine, and serotonin throughout the brain, although the actions of amphetamines differ somewhat from those of cocaine (Haney, 2008; Rawson & Ling, 2008).

Tolerance to amphetamines builds very quickly, so users are at great risk of becom- ing dependent (Acosta et al., 2005). People who start using the drug to reduce their appetite and weight, for example, may soon find they are as hungry as ever and increase their dose in response. Athletes who use amphetamines to increase their energy may also find before long that larger and larger amounts of the drug are needed. So-called speed freaks, who pop pills all day for days at a time, have built a tolerance so high that they now take as much as 200 times their initial amphetamine dose.When people who depend on the drug stop taking it, they may plunge into a deep depression and extended sleep identical to the withdrawal from cocaine. Around 0.4 percent of adults

display amphetamine abuse or dependence each year (NSDUH,2008).As many as 2 percent become dependent on amphetamines at some point in their lives (APA, 2000; Anthony et al., 1995).

One kind of amphetamine, methamphetamine (nicknamed crank), has had a major surge in popularity in recent years and so warrants special discus- sion. Almost 6 percent of all persons over the age of 11 in the United States have used this stimulant at least once.Around 0.3 percent use it currently (NSDUH, 2008). It is available in the form of crystals, also known by the street names ice and crystal meth, which are smoked by users.

Most of the nonmedical methamphetamine in the United States is made in small "stovetop laboratories," which typically operate for a few days in a remote area and then move on to a safer location (Ksir et al., 2008). Such laboratories have increased eightfold over the past decade. A major health concern is that they expel dangerous fumes and residue (Burgess, 2001).

Since 1989, when the media first began reporting about the dangers of smoking methamphetamine crystals, the rise in usage has been dramatic.At this point, 15 million Americans have tried this stimulant at least once (NSDUH, 2008). Until recently, use of the drug was much more prevalent in western parts of the United States, but its use has now spread east as well (NSDUH, 2007). Similarly, methamphetamine-linked emergency room visits are rising in hospitals throughout all parts of the country (DAWN, 2008).

Methamphetamine is about as likely to be used by women as men. Around 40 percent of current users are women. The drug is particularly popular today among biker gangs, rural Americans, and urban gay communities and has gained wide use as a "club drug," the term for those drugs that regularly find their way to all-night dance parties, or "raves" (Fchevarry & Nettles, 2009).

DON'T LET DRUG DEALERS CHANGE THE FACE OF YOUR NEIGHBOURHOOD. Call CrIrnestoppers anonymously on 0800 555111.

Stimulan

Stimulants are substances that increase the activity of the central nervous system. They may lead to intoxication, abuse, and dependence, including a withdrawal pattern marked by depression, fatigue, and irritability. Cocaine and amphetamines produce their effects by increasing the activity of dopamine, norepinephrine, and serotonin in the brain.

Substance-Related Disorders :11 299

Like other kinds of amphetamines, methamphetamine increases activity of the neu- rotransmitters dopamine, serotonin, and norepinephrine, producing increased arousal, attention, and related effects (Rawson & Ling, 2008). It can have serious negative effects on a user's physical, mental, and social life (NSDUH, 2007). Of particular concern is that it damages nerve endings (Rawson & Ling, 2008). But users focus more on meth- amphetamine's immediate positive impact, including perceptions by many that it makes them feel hypersexual and uninhibited ( Jefferson, 2005). Such perceived effects have contributed to several societal problems. For example, one-third of all men who tested positive for HIV in Los Angeles in 2004 reported having used this drug. In the area of law enforcement, one survey of police agencies had 58 percent of them reporting that methamphetamine is the leading drug they battle today.

oarnphetaminegA stimulant drug that is manufactured in the laboratory.

omethomplietamine.A powerful amphetamine drug whose surge in popu- larity in recent years has posed major health and law enforcement problems.

ehallucinogenGA substance that causes powerful changes primarily in sensor), perception, including stronger percep- tions, illusions, and hallucinations. Also called psychedelic drug.

eLSD (lysergic add diethylarnide)GA hallucinogenic drug derived from ergot alkaloids.

*Hallucinogens, Cannabis, and Combinations of Substances Other kinds of substances may also cause problems for their users and for society. Hallu- cinogens produce delusions, hallucinations, and other sensory changes. Cannabis substances produce sensory changes, but they also have depressant and stimulant effects, and so they are considered apart from hallucinogens in DSM-IV-TR. And many individuals take combinations of substances.

Hallucinogens Hallucinogens are substances that cause powerful changes in sensory perception, from strengthening a person's normal perceptions to inducing illusions and hallucinations. They produce sensations so out of the ordinary that they are sometimes called "trips." The trips may be exciting or frightening, depending on how a person's mind interacts with the drugs. Also called psychedelic drugs, the hallucinogens include LSD, mescaline, and MDMA (Ecstasy). Many of these substances come from plants or animals; others are laboratory-produced.

LSD (lysergic acid diethylamide), one of the most famous and most powerful hallucinogens, was derived by Swiss chemist Albert Hoffman in 1938 from a group of naturally occurring drugs called ergot alkaloids. During the 1960s, a decade of social rebellion and experimentation, millions of persons turned to the drug as a way of expanding their experience. Within two hours of being swallowed, LSD brings on a state of hallucinogen intoxication, sometimes called hallucinosis, marked by a general strengthening of perceptions, particularly visual perceptions, along with psychological changes and physical symptoms. People may focus on small details—the pores of the skin, for example, or individual blades of grass. Colors may seem enhanced or take on a shade of purple. Illu- sions may be experienced in which objects seem distorted and may appear to move, breathe, or change shape. A person under the influence of LSD may also hallucinate—seeing people, objects, or forms that are not actually present.

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300 ://CHAPTER 10

What Are the Dangers of Using Ecstasy? As MDMA has gained wider and wider use, the drug has received increasing research scrutiny. As it turns out, the mood and energy lift produced by MDMA comes at a high price (Ksir et al., 2008; Weaver & Schnoll, 2008; Wiegand et al., 2008). The problems that the drug may cause in- clude the following:

Immediate psychological problems such as confusion, depression, sleep difficulties, severe anxiety, and para- noid thinking. These symptoms may also continue for weeks after ingestion of MDMA.

Significant impairment of memory and other cognitive skills.

Physical symptoms such as muscle ten- sion, nausea, blurred vision, faintness, and chills or sweating. MDMA also causes many people to clench and grind their teeth for hours at a time.

Increases in heart rate and blood pres- sure, which place people with heart disease at special risk.

Reduced sweat production. At a hot, crowded dance party, taking Ecstasy can even cause heat stroke, or hyper- thermia. Users generally try to fix this problem by drinking lots of water, but since the body cannot sweat under the drug's influence, the excess fluid intake can result in an equally danger- ous condition known as hyponafremia, or "water intoxication."

Potential liver damage. This may happen when users take MDMA in combination with other drugs that are broken down by the same liver en- zyme, such as the cheaper compound DXM, which is commonly mixed in with Ecstasy by dealers.

How Does MDMA Operate in the Brain? MDMA works by causing the neurotransmit- ters serotonin and (to a lesser extent) dopa- mine to be released all at once throughout the brain, at first increasing and then de- pleting a person's overall supply of the neu- rotransmitters (Ksir et al., 2008; Malberg &

Bonson, 2001). MDMA also interferes with the body's ability to produce new supplies of serotonin. With repeated use, the brain eventually produces less and less serotonin (Baggot & Mendelson, 2001).

Ecstasy's impact on these neurotransmit- ters accounts for its various psychological effects—and associated problems. High levels of serotonin, such as those produced after one first ingests MDMA, produce feel- ings of well-being, sociability, and even euphoria. Conversely, abnormally low sero- tonin levels are associated with depression and anxiety. This is why "coming down" off a dose of Ecstasy often produces those psychological symptoms (Malberg & Bon- son, 2001). Moreover, because repeated use of Ecstasy leads to long-term serotonin deficits, the depression and anxiety may be long-lasting. Finally, serotonin is linked to our ability to concentrate; thus the re- peated use of Ecstasy may produce prob- lems in memory and learning (Zakzanis et al., 2007).

End of the Honeymoon? The dangers of MDMA do not yet seem to outweigh its pleasures in the minds of many individuals. In fact, use of the drug is still expanding to many social settings beyond raves, dance clubs, and college scenes (Weaver & Schnoll, 2008). Clearly, despite the research indications listed here, the honeymoon for this drug is not yet over.

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DU probably know of the drug MDMA

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by its common street name, Ecstasy. It is also known as X, Adam, hug, beans, and love drug. This laboratory-produced drug is technically a stimulant, similar to amphet- amines, but it also produces hallucinogenic effects and so is often considered a hal-

lucinogenic drug. MDMA was developed as far back as 1910, but only in the past two decades has it gained life as a "club drug"—one of the drugs that are extremely popular at all-night techno-dance parties known as "raves." Today, in the United States alone, consumers collectively take hundreds of thousands of doses of MDMA weekly despite the drug's illegal status (Weaver & Schnoll, 2008; McDowell, 2005). Altogether, 12 million Americans over the age of 11 have tried MDMA at least once in their lifetimes, 2 million in the past year (NSDUH, 2008). Around 6.5 percent of all high school seniors have used it within the past year (Johnston et al., 2007).