Transcript Dr. Sachin Karnik`s presentation on Cultural Diversity - 800

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, CPS
Director of Prevention &
Clinical Services
Delaware Council on Gambling Problems, Inc.
E-Mail: [email protected]
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CONTACT INFORMATION
SACHIN J. KARNIK, Ph.D.
LCSW, LCDP, CADC, NCGC-II, CPS
Director of Prevention & Clinical Services
100 West 10th Street, Suite 303
Wilmington, DE 19801
Phone: 302-655-3261
E-Mail: [email protected]
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OBJECTIVES
• This workshop examines the nature of problems gambling in a multicultural 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.
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(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 ADDICTION
•
Reference: 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.
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NEUROTRASMISSION
• Drugs 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.
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NEUROTRANSMITTERS
• A 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.
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NEUROTRANSMISSION
• The 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.
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THE BRAIN: A LIVING ORGAN
• Of 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.
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SPOKEN AND UNSPOKEN RULES
• Culture 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.
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CULTURE AND GROUPS
• The 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.
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15
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CULTURAL BOUND SYNDROMES
• DSM-IV-TR
• The fourth edition of Diagnostic and Statistical Manual of Mental
Disorders classifies the below syndromes as culture-bound syndromes:
• Name
Geographical localization/populations
• Running amok
Malaysia, Indonesia, Philippines, Brunei,
Singapore
• Ataque de nervios
Hispanic people as well as in the Philippines
where it is known as "Nervous Breakdown"
• Bouffée délirante
West Africa and Haiti
• Brain fag syndrome West African students
• Dhat syndrome
India
• Falling-out,
• blacking out
Southern United States and Caribbean
• Ghost sickness
Native American
• Hwabyeong
Korean
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CULTURAL BOUND SYNDROMES
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Koro Chinese and Malaysian populations in southeast Asia; Assam; occasionally in West
Latah Malaysia and Indonesia
Locura Latinos in the United States and Latin America
Mal de pelea
Puerto Rico
Nervios
Latin America, Latinos in the United States
Evil eye
Mediterranean; Hispanic populations and Ethiopia
Piblokto
Arctic and subarctic Eskimo populations
Zou huo ru mo
(Qigong psychotic reaction)
Chinese
Rootwork
Southern United States, Caribbean nations
Sangue dormido Portuguese populations in Cape Verde
Shenjing shuairuo
Chinese
Shenkui, shen-kʼuei
Chinese
Shinbyeong
Korean
Spell African American, White populations in the southern United States and Ethiopia
Susto Latinos in the United States; Mexico, Central America and South America
Taijin kyofusho
Japanese
Zār
Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern
societies
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ELEVEN CRITERIA IN DSM V FOR
DIAGNOSIS OF ANY SUBSTANCE USE
DISORDER
&
LINKAGE WITH GAMBLING DISORDER
CRITERIA
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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)
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CONTROL ILLICIT DRUG USE
• 2 - 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 limits
• Decision to walk away after loss limit reached is changed
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USE-ABUSE-RECOVERY FROM EFFECTS
• 3 - 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…
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CRAVING
• 4- 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 bets
• Euphoric Recall, selective recall, etc.
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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.
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RISKY USE
• This 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 Gambling
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TOLERANCE
• Tolerance (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….
27
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…
28
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 decisionmaking and offers alternative ways to define and
plan a treatment program firmly directed
toward progress and recovery.
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PREVENTION SCIENCE
• Prevention 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). The
science of prevention. A conceptual framework and some directions for a national research program. The American Psychologist, 48, 10,
1013-22.
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PRECURSORS OF DYSFUNCTION
• Regardless 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.
31
PREVENTION INTERVENTIONS
• Preventive 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.
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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.
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PREVENTION – AN ACTIVE PROCESS
• Prevention 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.”
34
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.
35
PREVENTION ACCORDING TO SAMHSA
• As 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.)
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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
media
Education - 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 before
Alternatives - 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.
37
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.
38
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.
39
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.
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42
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.
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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.
44
RESTORING WELLNESS
45
WHAT IS GAMBLING
DISORDER IN THE DSM V?
46
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.
47
DSM V: GAMBLING DISORDER
Signs/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 gambling
48
DSM V: GAMBLING DISORDER
Signs/Symptoms – part 2
• Withdrawal: The person is restless or irritable when
attempting to cut down or stop gambling
• Escape: 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 gambling
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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 gambling
• Bailout: 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 difficulties
emotional disturbances
structural (ego) factors
personality 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.
52
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 ADDICTION
• Different 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.
54
OPIOIDS ADDICTION & GAMBLING ADDICTION
OPIOIDS
• Opioids 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 ADDICTION
• Nothing ingested in the
body.
• Dream of winning
• Tolerance to winning and
losing
• Escalation of bets
• Dysphoria of losing
• Physical discomfort
• Withdrawal during
abstinence
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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 addiction
• Homeostasis in gambling addiction
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HOMEOSTASIS IN SUBSTANCE AND GAMBLING
ADDICTIONS
• Homeostatic changes in substance addiction.
• Pathological homeostasis.
• Homeostatic changes in gambling addiction.
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PREDICTIVE HOMEOSTASIS
• Predictive 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 selfcorrecting. 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 gambling
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ANTICIPATORY RESPONSE
• Anticipatory response in substance use.
• Anticipatory response before gambling
activity.
• Closed-loop negative feedback system:
– Recreational gamblers
– Problem gamblers
59
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.
60
OPPONENT PROCESS THEORY
• Opponent 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.
61
THREE MAJOR AFFECTIVE
PHENOMENA
• Three 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.
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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.
66
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.
67
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 selfadministration 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 837847). Elsevier Science. Kindle Edition.
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PROGRESSIVE ELEVATION IN REWARD
THRESHOLDS
• The 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.
71
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 selfadministration 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.
72
73
SELF-ADMINISTERED INJECTIONS
• FIGURE 1.11 Rats (n = 11) were allowed to selfadminister 10, 20, 40, and 80 injections of cocaine
(0.25 mg per injection), and intracranial selfstimulation 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.
74
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 that
Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs,
Addiction, and the Brain (Kindle Locations 893-900). Elsevier Science. Kindle
Edition.
75
INTERNAL VIABILITY MAINTENANCE
• Allostatic response in drug addiction.
• Attempt to achieve stability by continuing to
gamble.
• Physiological and Psychological Allostatic
Responses:
– Drug Addiction
– Problem Gambling
76
CROSS-TOLERANCE
• Tolerance 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….
77
TWEAK
• TWEAK is a five-item screening tool. The
acronym stands for tolerance, worry about
drinking, eye-opener, amnesia, and (k)
cutting down.
• Tolerance in problem gambling
• Worries about gambling
• First thoughts about gambling when waking
up
• Attempts to cut down gambling
78
SUBJECTIVE WORLD OF THE CLIENT
• The 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.
79
DESIGNER DRUGS & GAMBLING
• Designer 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.
80
NORMALIZE BRAIN ACTIVITY
• Acamprosate (Campral) helps normalize brain
activity and reduce cravings for alcohol.
• Craving reduction in problem gambling?
– Medications:
• Naltraxone
• Other psych meds, as appropriate
• Normalization of brain activity in problem
gambling.
81
RETICULAR ACTIVATING SYSTEM
• The RAS (Reticular Activating System) oversees
the general arousal and activity level of the
central nervous system.
• Arousal in substance addiction
• Arousal in gambling addiction??
• Sexual arousal
• Gambling addiction and sex addiction
• Sex, drug, rock and roll, & GAMBLING!!!
82
RAS (BRAIN’S IGNITION SYSTEM)
• The Brain's Ignition System
• The 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.html
83
MIND IS PROJECTED BY THE BRAIN
• Every 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.html
84
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.html
85
86
COCAETHYLENE
• When 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
experience
87
TECHNICAL ECLECTICISM
• Technical 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 DISORDER
88
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.
89
OPIATE WITHDRAWAL
• Nausea, 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 WITHDRAWAL
90
INHALANTS
• Some 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.)
91
ALCOHOL ABSORPTION
• Most 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?
92
AA ASSUMPTIONS
• AA 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 disease
93
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.
94
BLACKOUTS
• The 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 gambling
95
REWARD DEFICIENCY SYNDROME
• The 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.
96
NEGATIVE SYMPTOM
• Anhedonia 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 gambling
97
BAC – Blood Alcohol Concentration
• At 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 thoughts
Level of gambling activity emotions
Level of gambling activity memories
Level of gambling activity desires
98
ALCOHOL WITHDRAWAL
• A person who is experiencing alcohol
withdrawal is most likely to experience:
– Hand Tremors
– Insomnia
– Hallucinations
– Seizures
• Withdrawal in problem gambling
99
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.
100
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.
101
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.
102
OPERANT CONDITIONING
• Operant 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.
103
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.
104
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.
105
DRUG
• A 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.
106
PSYCHOTROPIC
• Psychotropic 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.
107
IDENTIFIABLE PSYCHOTROPIC EFFECT
• One 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.
108
SIMPLE DEFINITIONS
• Toxicology 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.
109
Drug Classification
• Drugs 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 selfexplanatory.
•
Reference: Koob, George F.; Arends, Michael A.; Le Moal, Michel (2014-07-12). Drugs, Addiction, and the Brain (Kindle Locations 11131124). Elsevier Science. Kindle Edition.
110
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.
111
Cont..
• Psychedelics are drugs that produce psychedelic
experiences. Psychedelic can be defined as mindaltering. 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.
112
ANHEDONIA
• Definition:
– 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.”
113
ANERGIA
• Definition:
– Lack of energy; can be precipitated by the use of
stimulants.
• Gambling Addiction:
– Energy, money, and the betting activity.
114
ATAXIA
• ATAXIA: 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 intoxication
• Use of alcohol and gambling and ataxia.
115
116
117
INTUITIVE HEDONICS
• Intuitive 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.
118
SIX AREAS ON LIKING AND
ENJOYMENT
• six 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.
119
WEBER'S LAW
• Weber'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.3
120
CLASSICAL CONDITIONING
• Classical 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.
121
REFERENCES
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•
•
•
•
•
•
•
•
•
•
•
Copstead, Lee-Ellen; Banasik, Jacquelyn (2013). Pathophysiology (5th ed.). St Louis, Missouri: Elsevier
Saunders. ISBN 978-1-4557-2650-9.
Jump up^ Selye, H. (1973) Homeostasis and Heterostasis. Perspectives in Biology and Medicine, 16, 441-445
Day, Trevor A. (2005). "Defining stress as a prelude to mapping its neurocircuitry: No help from allostasis". Prog.
Neuropsychopharmacol. Biol. Psychiatry 29 (8): 1195–1200. doi:10.1016/j.pnpbp.2005.08.005. ISSN 0278-5846.
Klein, Robyn (2004). "Chapter 3". Phylogenetic and phytochemical characteristics of plant species with adaptogenic
properties (PDF) (MS). Montana State University. Archived from the original (PDF) on October 17, 2006.
McEwen, Bruce S. (1998a). "Protective and Damaging Effects of Stress Mediators". Seminars in Medicine of the
Beth Israel Deaconess Medical Center. N. Engl. J. Med. 338: 171–
9. doi:10.1056/NEJM199801153380307. PMID 9428819.
McEwen, Bruce S. (1998b). "Stress, Adaptation, and Disease: Allostasis and Allostatic Load". Ann. N. Y. Acad.
Sci. 840: 33–44.doi:10.1111/j.1749-6632.1998.tb09546.x. PMID 9629234.
McEwen, Bruce S.; Wingfield, John C. (2003). "The concept of allostasis in biology and biomedicine". Horm.
Behav. 43 (1): 2–15.doi:10.1016/S0018-506X(02)00024-7. ISSN 0018-506X.
Schulkin, Jay (2003). Rethinking homeostasis : allostatic regulation in physiology and pathophysiology. Cambridge,
MA: MIT Press.ISBN 9780262194808. OCLC 49936130.
Sterling, P.; Eyer, J. (1988). "Allostasis: A new paradigm to explain arousal pathology". In Fisher, S.; Reason, J.
T. Handbook of life stress, cognition, and health. Chicester, NY: Wiley. ISBN 9780471912699. OCLC 17234042.
Sterling, Peter (2004). "Chapter 1. Principles of Allostasis". In Schulkin, Jay. Allostasis, homeostasis, and the costs of
physiological adaptation. New York, NY: Cambridge University Press. ISBN 9780521811415. OCLC 53331074.
Wingfield, John C. (2003). "Control of behavioural strategies for capricious environments". Anniversary
Essays. Anim. Behav. 66 (5): 807–16.doi:10.1006/anbe.2003.2298.
SAMSAH TIP 59
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