Wednesday, July 15, 2009

Bipolar Disorder

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Bipolar disorder, also known as manic depression, manic depressive disorder or bipolar affective disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated mood clinically referred to as mania or, if milder, hypomania. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms, or mixed episodes in which features of both mania and depression are present at the same time. These episodes are usually separated by periods of "normal" mood, but in some individuals, depression and mania may rapidly alternate, known as rapid cycling. Extreme manic episodes can sometimes lead to psychotic symptoms such as delusions and hallucinations. The disorder has been subdivided into bipolar I, bipolar II, cyclothymia, and other types, based on the nature and severity of mood episodes experienced; the range is often described as the bipolar spectrum.

Data from the United States on lifetime prevalence varies, but indicates a rate of around 1 percent for Bipolar I, 0.5 to 1 percent for Bipolar II or cyclothymia, and between 2 and 5 percent for subthreshold cases meeting some, but not all, criteria. The onset of full symptoms generally occurs in late adolescence or young adulthood. Diagnosis is based on the person's self-reported experiences, as well as observed behavior. Episodes of abnormality are associated with distress and disruption, and an elevated risk of suicide, especially during depressive episodes. In some cases it can be a devastating long-lasting disorder; in others it has also been associated with creativity, goal striving and positive achievements.

Genetic factors contribute substantially to the likelihood of developing bipolar disorder, and environmental factors are also implicated. Bipolar disorder is often treated with mood stabilizer medications, and sometimes other psychiatric drugs. Psychotherapy also has a role, often when there has been some recovery of stability. In serious cases in which there is a risk of harm to oneself or others involuntary commitment may be used; these cases generally involve severe manic episodes with dangerous behavior or depressive episodes with suicidal ideation. There are widespread problems with social stigma, stereotypes and prejudice against individuals with a diagnosis of bipolar disorder. People with bipolar disorder exhibiting psychotic symptoms can sometimes be misdiagnosed as suffering from schizophrenia, another serious mental illness.

The current term "bipolar disorder" is of fairly recent origin and refers to the cycling between high and low episodes (poles). A relationship between mania and melancholia had long been observed, although the basis of the current conceptualisation can be traced back to French psychiatrists in the 1850s. The term "manic-depressive illness" or psychosis was coined by German psychiatrist Emil Kraepelin in the late nineteenth century, originally referring to all kinds of mood disorder. German psychiatrist Karl Leonhard split the classification again in 1957, employing the terms unipolar disorder (major depressive disorder) and bipolar disorder.

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Attention-Heficit/Hyperactivity Disorder (ADHD or AD/HD)

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Attention-deficit/hyperactivity disorder (ADHD or AD/HD) is a neurobehavioral developmental disorder. ADHD is defined as a “persistent pattern of inattention or hyperactivity—impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development.” It is the most commonly diagnosed psychiatric disorder in children. It affects about 3 to 5% of children globally with symptoms starting before seven years of age.ADHD is generally a chronic disorder with 30 to 50% of those individuals diagnosed in childhood continuing to have symptoms into adulthood. As they mature, adolescents and adults with ADHD are likely to develop coping mechanisms to compensate for their impairment.

Though previously regarded as a childhood diagnosis, ADHD can continue throughout adulthood. Four percent of American adults are estimated to live with ADHD. ADHD is diagnosed twice as frequently in boys as in girls, though studies suggest this discrepancy may be due to subjective bias. ADHD management usually involves some combination of medications, behavior modifications, lifestyle changes, or counseling.

ADHD and its diagnosis and treatment have been considered controversial since the 1970s. The controversies have involved clinicians, teachers, policymakers, parents and the media, with opinions regarding ADHD that range from not believing it exists at all to believing there are genetic and physiological bases for the condition and also include disagreement about the use of stimulant medications in treatment. Most healthcare providers accept that ADHD is a genuine disorder; debate in the scientific community centers mainly around how it is diagnosed and treated.

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Computer Addiction

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Computer addiction, or more broadly computer overuse, is excessive or compulsive use of computers that interferes with daily life. The Diagnostic and Statistical Manual of Mental Disorders (the DSM) criteria for substance dependency have been used to argue that some individuals suffer from computer addiction. However, the existence of "computer addiction" is currently debated.

History

There are examples of computer overuse dating back to the earliest computer games. Many NetNews users were considered obsessive in the 1980s.[citation needed] With the widespread use of computers in the 21st century, it may be difficult to distinguish users who are "highly engaged" in their computer use from those who might be considered "addicted".

Press reports have noted that some Finnish Defence Forces conscripts were not mature enough to meet the demands of military life, and were required to interrupt or postpone military service for a year. One reported source of the lack of needed social skills is overuse of computer games or the Internet. Forbes termed this overuse "Web fixations", and stated that they were responsible for 12 such interruptions or deferrals over the 5 years from 2000-2005.

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Alcoholism

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Alcoholism is a term with multiple and sometimes conflicting definitions. In common and historic usage, alcoholism refers to any condition that results in the continued consumption of alcoholic beverages, despite health problems and negative social consequences. Modern medical definitions[1] describe alcoholism as a disease and addiction which results in a persistent use of alcohol despite negative consequences. In the 19th and early 20th centuries, alcoholism, also referred to as dipsomania described a preoccupation with, or compulsion toward the consumption of, alcohol and/or an impaired ability to recognize the negative effects of excessive alcohol consumption.

Although not all of these definitions specify current and on-going use of alcohol as a qualifier for alcoholism, some do, as well as remarking on the long-term effects of consistent, heavy alcohol use, including dependence and symptoms of withdrawal.

While the ingestion of alcohol is, by definition, necessary to develop alcoholism, the use of alcohol does not predict the development of alcoholism. It is estimated that 9% of the general population is predisposed to alcoholism based on genetic factors.[citation needed] The quantity, frequency and regularity of alcohol consumption required to develop alcoholism varies greatly from person to person. In addition, although the biological mechanisms underpinning alcoholism are uncertain, some risk factors, including social environment, stress,[3] emotional health, genetic predisposition, age, and gender have been identified. For example, those who consume alcohol at an early age, by age 16 or younger, are at a higher risk of alcohol dependence or abuse. Also, studies indicate that the proportion of men with alcohol dependence are higher than that of the proportion of women, 7% and 2.5% respectively, although women are more vulnerable to long-term consequences of alcoholism. Around 90% of adults in United States consume alcohol and more than 700,000 of them are treated daily for alcoholism. Professor David Zaridze, who led the international research team, calculated that alcohol had killed three million Russians since 1987.

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Addiction

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The term "addiction" is used in many contexts to describe an obsession, compulsion, or excessive psychological dependence, such as: drug addiction (e.g. alcoholism), video game addiction, crime, money, work addiction, compulsive overeating, problem gambling, computer addiction, nicotine addiction, pornography addiction, etc.

In medical terminology, an addiction is a state in which the body depends on a substance for normal functioning and may occur along with physical dependence, as in drug addiction. When the drug or substance on which someone is dependent is suddenly removed, it will cause withdrawal, a characteristic set of signs and symptoms. Addiction is generally associated with increased drug tolerance. In physiological terms, addiction is not necessarily associated with substance abuse since this form of addiction can result from using medication as prescribed by a doctor. Physical dependence is different from psychological dependence (addiction). The latter is often characterized by a compulsive need for a drug for psychological reasons, while the former is characterized by need for the drug due to tolerance and the need to prevent withdrawal symptoms on discontinuing the use of a drug. Physical dependence however, commonly occurs with both addiction and therapeutic use of drugs.

However, common usage of the term addiction has spread to include psychological dependence. In this context, the term is used in drug addiction and substance abuse problems, but also refers to behaviors that are not generally recognized by the medical community as problems of addiction, such as compulsive overeating.

The term addiction is also sometimes applied to compulsions that are not substance-related, such as problem gambling and computer addiction. In these kinds of common usages, the term addiction is used to describe a recurring compulsion by an individual to engage in some specific activity, despite harmful consequences, as deemed by the user himself to his or her individual health, mental state or social life.



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Drug Rehabilitation

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Drug rehabilitation (often drug rehab or just rehab) is an umbrella term for the processes of medical and/or psychotherapeutic treatment, for dependency on psychoactive substances such as alcohol, prescription drugs, and so-called street drugs such as cocaine, heroin or amphetamines. The general intent is to enable the patient to cease substance abuse, in order to avoid the psychological, legal, financial, social, and physical consequences that can be caused, especially by extreme abuse.

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Substance abuse

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Although the term substance can refer to any physical matter, substance abuse has come to refer to the overindulgence in and dependence of a food or other chemical leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others.

The disorder is characterized by a pattern of continued pathological use of a fatty foods, that results in repeated adverse social consequences related to eating, such as failure to meet work, family, or school obligations, interpersonal conflicts, or dating problems. There are on-going debates as to the exact distinctions between substance abuse and substance dependence, but current practice standard distinguishes between the two by defining substance dependence in terms of physiological and behavioral symptoms of substance use, and substance abuse in terms of the social consequences of substance use.

Substance abuse may lead to addiction or substance dependence. Medically, physiologic dependence requires the development of tolerance leading to withdrawal symptoms. Both abuse and dependence are distinct from addiction which involves a compulsion to continue using the substance despite the negative consequences, and may or may not involve chemical dependency. Dependence almost always implies abuse, but abuse frequently occurs without dependence, particularly when an individual first begins to abuse a substance. Dependence involves physiological processes while substance abuse reflects a complex interaction between the individual, the abused substance and society.



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Drug abuse

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Drug abuse has a huge range of definitions related to taking a psychoactive drug or performance enhancing drug for a non-therapeutic or non-medical effect. All of these definitions imply a negative judgement of the drug use in question (compare with the term responsible drug use for alternative views). Some of the drugs most often associated with this term include alcohol, amphetamines, barbiturates, benzodiazepines, cocaine, methaqualone, and opium alkaloids. Use of these drugs may lead to criminal penalty in addition to possible physical, social, and psychological harm, both strongly depending on local jurisdiction. Other definitions of drug abuse fall into four main categories: public health definitions, mass communication and vernacular usage, medical definitions, and political and criminal justice definitions. Read More ..

Monday, July 13, 2009

SOBERLYMPICS IV

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SELF celebrated its 16th anniversary by hosting a month long sportsfest. Elimination games began on August 22 and culminated on September 20 with championship games dubbed Soberlympics IV played at the Taal View House sports quadrangle. With the theme Kapatiran sa Palaro: Pakikiisa ng SELF sa Barangay, SELF opened its doors to its host community and invited neighbors to play in the sportsfest with the SELF Family. A Sports Committee composed of Barangay Miranda Counselor Eliseo “Ute” Caraan, SELF’s President and Founder Martin Infante and Technical Supervisor Jimmy Nalilin supervised the competition. At 7:30 AM on the day of the championships, the contestants and spectators assembled in front of the SELF administration building for the flag raising ceremonies. Then, the four competing teams — dressed in their respective colors of red, green, yellow and blue — paraded to the sports quadrangle followed by guests and supporters. Colorful opening rites were held before the start of the games. They began with an invocation by Yellow Panthers captain Michael, followed by the singing of the TC philosophy. Then, Program Operations Manager Lea Tumbado gave the welcome address and SELF Residents Coordinating Council President David led the athletes in reciting the Oath of Sportsmanship. Counselor Ute next gave a brief speech in which he expressed his excitement about the coming together of SELF with his Barangay. Finally, Jimmy Nalilin as the Chair of the Rules Committee read the Rules of the Game. Being an Olympic year, the sportsfest organizers found it fitting to adapt the traditional lighting of the Olympic torch.

Team captains ran a relay around the quadrangle bearing the Soberlympics torch. The final lap was run by Sports Coordinator Karlo Aliling who raced up the stairs to the balcony. There he lit a ball of flame that came sliding down a wire, setting fire to an improvised Olympic cup ... upon which Kuya Martin declared, “Let the games begin!” The first event was the much awaited Cheering Showdown, which showcased exciting choreography performed by resident and staff participants. It was a dance-off the likes of which have never been seen. But, alas, there could only be one winner and the judges awarded the trophy to the Red Dragons. Volleyball championships came next, followed by the various badminton divisions. When it came time for the culminating event — the basketball finals — spectators filled the bleachers, balcony and roof tops to cheer their teams on. After the competitions, Holy Mass was celebrated at the Multi-Purpose Hall, followed by an al fresco fellowship dinner, with many SELF Family Association members and guests from Barangay Miranda in attendance. The awarding ceremonies followed immediately and the champions received their respective trophies. Finally, The Long Road to the Summit, a video presentation that looked back on SELF’s early years and the many challenges it surmounted, closed the month long celebration of its 16th anniversary. As in every competition, this one saw its share of winners and losers. But in the eyes of the participants and all those who came to support them that day, winning was only secondary to the friendships that were built and the fun and excitement that swept throughout the entire SELF community.
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Showtime 2007

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SELF celebrated its 15th anniversary in style with SHOWTIME, a musical variety show featuring selections from Broadway and Hollywood, thanks to the generous support of the SELF Family Association. With the incomparable director Fritz Ynfante at the helm, the show featuring numbers from Cabaret, Cats, Chicago, Footloose, Grease, Sing Sing, Sister Act, Sound of Music and South Pacific went off without a hitch. All in attendance acclaimed the caliber of the presentation—complete with stage lights, costumes and special effects—as very professional. Of course, not to be forgotten is the therapeutic value of the presentation. Residents in recovery put in long hours of dedication and discipline over some two months of rigorous training and preparation that ensured the success of SHOWTIME.
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INDUCING A KEY BREAKTHROUGH

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Ruel was admitted to SELF on September 15, 2007 at the age of 24 due to substance abuse, paranoia and hallucinations. He had been abusing methamphetamines on and off for the last eight years. Two weeks prior to his admission, Ruel had asked for his father’s help as he could no longer cope with his paranoid delusions, that a camera was filming him around the clock. In response, his father immediately brought him to The Medical City hospital.

There Ruel was diagnosed with psychosis secondary to methamphetamine dependence. He was prescribed Zyprexa, which shortly before his transfer to SELF was discontinued.

Background:

Ruel was around six years old when he was adopted by an Italian doctor. While growing up Ruel craved love and affection from his father and his siblings but this was largely unsatisfied as his father was constantly abroad and his only companions at home were helpers and his stepmother. To assuage his loneliness he turned to friends for comfort and in the process grew distant from his brothers and sisters and hardly had any contact with his father.

In 3rd year High School around the age of 16, Ruel joined his siblings who were doing drugs. In doing so he experienced a connection with them that he had never felt before. These, according to Ruel, were the only times he truly bonded with and got to know them.

For 4th year High School, Ruel transferred to a boarding school in Thailand. There, aside from doing drugs, Ruel also became a heavy gambler. He finally wound up becoming exploited by a teacher and learned to “sell” his own body just to earn money. He was eventually kicked out of the boarding school for keeping drugs in the dormitory.

As an intervention his father moved the family from Thailand to New Zealand and enrolled his kids in another boarding school. It was there, Ruel said, that he developed a closer relationship with his siblings. They would often go out together during weekends and he was able to feel that he had a loving and supportive family.

Despite this, the trauma of the sexual abuse he suffered in Thailand kept haunting him. He started having dreams that put into question his gender identity. To address this, he underwent professional counseling with a psychiatrist. Ruel, however, bounced around from one relationship to another. It was not until he turned 22 that he was able to enter into a more permanent relationship. He met a woman who became his live-in partner and he eventually decided to settle down in Manila with her.

It went well for a couple of months but soon the issue of the woman earning more than Ruel began to strain the relationship. He was unable to meet his partner’s demand that he get a better paying job because he had lost interest in studying and failed to earn a college degree. This is when he once more turned to drugs to alleviate his feelings of insecurity. His situation worsened as his father, disappointed with his behavior, stopped giving financial support. So, at the age of 23 Ruel found himself suffering from a broken intimate relationship and a serious drug problem that was causing him severe episodes of paranoid delusions.
Initial Intervention

After allowing Ruel to settle down in the Pre-admission Department for several days, he underwent the standard medical and clinical assessments by the facility doctor and psychiatrist. Among other things, it was established that Ruel suffered from dyslexia but had never been treated for it. He was not prescribed any medications.

Ruel found the first couple of months in the program difficult due to his continuing paranoia that led to his lack of trust in the people around him. He was so suspicious that he even refused to take vitamin pills, claiming that these were designed for the program to read his mind. His old issue of sexual abuse also manifested as he showed an extreme sensitivity to touch, reacting aggressively whenever there was contact between him and another resident.

On his fourth month, Ruel was made to undergo another psychiatric assessment. This time he was prescribed anti-psychotic medication (Seroquel) and an anti-depressant (Lexapro) to address his condition. However, he refused to take the medications and his erratic behavior continued.

The Breakthrough:

On the sixth month, with no improvement to speak of, the staff decided to go ahead and subject him to a case conference to get him to identify and face his real issues. Predictably he failed. However, this failure and the disappointment it caused pushed him to start opening up in subsequent counseling sessions.

As a result, just two weeks later, he underwent a second case conference. This time, he was able to open up and share all his issues and concerns and agreed to start taking medications. As a follow-up the program allowed him to have a dialogue with his father during which he was able to share all the guilt he had about their relationship.

Upon taking the medications, Ruel displayed a marked improvement in his behavior. His behavior remained consistent in the succeeding months despite the pressures that went with his promotion to TC Coordinator.

On his 14th month he earned another dialogue with his father and they were able to resolve the issues discussed in their first dialogue. He also convinced his father to let him finish his rehabilitation program.
Over the months, Ruel was progressively weaned off his medications as his behavior improved. In November 2008 he was deemed ready and sent off to Reentry where his leadership and people skills were honed working in the COD office.

In March 2009 he asserted his desire to work in the kitchen in the administrative building. With the granting of this request Ruel was also promoted to Aftercare. He is now preparing for graduation.

Conclusion:

Ruel’s case once again demonstrates the efficacy of combined therapy in the treatment of substance induced psychosis and addictive behavior. In his case the TC approach created the necessary dissonance that pushed him to open up and identify, share and face the issues at the root of his condition, including his need to take medication. Taking the prescribed medication, on the other hand, facilitated his full participation in and to reap the healing benefits of the TC processes.
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Drug Addiction

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Drug addiction is a pathological condition. The disorder of addiction involves the progression of acute drug use to the development of drug-seeking behavior, the vulnerability to relapse, and the decreased, slowed ability to respond to naturally rewarding stimuli. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) has categorized three stages of addiction: preoccupation/anticipation, binge/intoxication, and withdrawal/negative affect. These stages are characterized, respectively, everywhere by constant cravings and preoccupation with obtaining the substance; using more of the substance than necessary to experience the intoxicating effects; and experiencing tolerance, withdrawal symptoms, and decreased motivation for normal life activities. By the American Society of Addiction Medicine definition, drug addiction differs from drug dependence and drug tolerance.

It is, both among scientists and other writers, quite usual to allow the concept of drug addiction to include persons who are not drug abusers according to the definition of the American Society of Addiction Medicine. The term drug addiction is then used as a category which may include the same persons who under the DSM-IV can be given the diagnosis of substance dependence or substance abuse.

Drugs causing addiction

Drugs known to cause addiction include illegal drugs as well as prescription or over-the-counter drugs, according to the definition of the American Society of Addiction Medicine.

* Stimulants:
o Amphetamine and Methamphetamine
o Caffeine
o Cocaine
o Nicotine

* Sedatives and Hypnotics:
o Alcohol
o Barbiturates
o Benzodiazepines, particularly flunitrazepam, triazolam, temazepam, and nimetazepam
o Methaqualone and the related quinazolinone sedative-hypnotics

* Opiate and Opioid analgesics
o Morphine and Codeine, the two naturally-occurring opiate analgesics
o Semi-synthetic opiates, such as Heroin (Diacetylmorphine), Oxycodone, Hydrocodone, and Hydromorphone
o Fully synthetic opioids, such as Fentanyl and its analogs, Meperidine/Pethidine, and Methadone

Addictive drugs also include a large number of substrates that are currently considered to have no medical value and are not available over the counter or by prescription.

An article in The Lancet compared the harm and addiction of 20 drugs, using a scale from 0 to 3 for physical addiction, psychological addiction, and pleasure to create a mean score for addiction. Caffeine was not included in the study. The results can be seen in the chart above.

Addictive potency

The addictive potency of drugs varies from substance to substance, and from individual to individual

Drugs such as codeine or alcohol, for instance, typically require many more exposures to addict their users than drugs such as heroin or cocaine. Likewise, a person who is psychologically or genetically predisposed to addiction is much more likely to suffer from it.

Although dependency on hallucinogens like LSD ("acid") and psilocybin (key hallucinogen in "magic mushrooms") is listed as Substance-Related Disorder in the DSM-IV, most psychologists do not classify them as addictive drugs.[citation needed]

Prevalence

The most common drug addictions are to legal substances such as:

* Caffeine
* Nicotine in the form of tobacco, particularly cigarettes
* Alcohol

The physiological basis of drug addiction

Researchers have conducted numerous investigations using animal models and functional brain imaging on humans in order to define the mechanisms underlying drug addiction in the brain. This intriguing topic incorporates several areas of the brain and synaptic changes, or neuroplasticity, which occurs in these areas.

Acute effects

Acute (or recreational) drug use causes the release and prolonged action of dopamine and serotonin within the reward circuit. Different types of drugs produce these effects by different methods. Dopamine (DA) appears to harbor the largest effect and its action is characterized. DA binds to the D1 receptor, triggering a signaling cascade within the cell. cAMP-dependent protein kinase (PKA) phosphorylates cAMP response element binding protein (CREB), a transcription factor, which induces the synthesis of certain genes including C-Fos.

Reward circuit

When examining the biological basis of drug addiction, one must first understand the pathways in which drugs act and how drugs can alter those pathways. The reward circuit, also referred to as the mesolimbic system, is characterized by the interaction of several areas of the brain.

* The ventral tegmental area (VTA) consists of dopaminergic neurons which respond to glutamate. These cells respond when stimuli indicative of a reward are present. The VTA supports learning and sensitization development and releases dopamine (DA) into the forebrain. These neurons also project and release DA into the nucleus accubems, through the mesolimbic pathway. Virtually all drugs causing drug addiction increase the dopamine release in the mesolimbic pathway, in addition to their specific effects.
* The nucleus accumbens (NAcc) consists mainly of medium-spiny projection neurons (MSNs), which are GABA neurons. The NAcc is associated with acquiring and eliciting conditioned behaviors and involved in the increased sensitivity to drugs as addiction progresses.
* The prefrontal cortex, more specifically the anterior cingulate and orbitofrontal cortices, is important for the integration of information which contributes to whether a behavior will be elicited. It appears to be the area in which motivation originates and the salience of stimuli are determined.
* The basolateral amygdala projects into the NAcc and is thought to be important for motivation as well.
* More evidence is pointing towards the role of the hippocampus in drug addiction because of its importance in learning and memory. Much of this evidence stems from investigations manipulating cells in the hippocampus alters dopamine levels in NAcc and firing rates of VTA dopaminergic cells.

Stress response
See also: Stress response

In addition to the reward circuit, it is hypothesized that stress mechanisms also play a role in addiction. Koob and Kreek have hypothesized that during drug use corticotropin-releasing factor (CRF) activates the hypothalamic-pituitary-adrenal axis (HPA) and other stress systems in the extended amygdala. This activation influences the dysregulated emotional state associated with drug addiction. They have found that as drug use escalates, so does the presence of CRF in human cerebrospinal fluid (CSF). In rat models, the separate use of CRF antagonists and CRF receptor antagonists both decreased self-administration of the drug of study. Other studies in this review showed a dysregulation in other hormones associated with the HPA axis, including enkephalin which is an endogenous opioid peptides that regulates pain. It also appears that the µ-opioid receptor system, which enkephalin acts on, is influential in the reward system and can regulate the expression of stress hormones.

Behavior

Understanding how learning and behavior work in the reward circuit can help understand the action of addictive drugs. Drug addiction is characterized by strong, drug seeking behaviors in which the addict persistently craves and seeks out drugs, despite the knowledge of harmful consequences. Addictive drugs produce a reward, which is the euphoric feeling resulting from sustained DA concentrations in the synaptic cleft of neurons in the brain. Operant conditioning is exhibited in drug addicts as well as laboratory mice, rats, and primates; they are able to associate an action or behavior, in this case seeking out the drug, with a reward, which is the effect of the drug. Evidence shows that this behavior is most likely a result of the synaptic changes which have occurred due to repeated drug exposure. The drug seeking behavior is induced by glutamatergic projections from the prefrontal cortex to the NAc. This idea is supported with data from experiments showing the drug seeking behavior can be prevented following the inhibition of AMPA glutamate receptors and glutamate release in the NAc.

Allostasis

Allostasis is the process of achieving stability through changes in behavior as well as physiological features. As a person progresses into drug addiction, he or she appears to enter a new allostatic state, defined as divergence from normal levels of change which persist in a chronic state. Addiction to drugs can cause damage to your brain and body as you enter the pathological state; the cost stemming from damage is known as allostatic load. The dysregulation of allostasis gradually occurs as the reward from the drug decreases and the ability to overcome the depressed state following drug use begins to decrease as well. The resulting allostatic load creates a constant state of depression relative to normal allostatic changes. What pushes this decrease is the propensity of drug users to take the drug before the brain and body have returned to original allostatic levels, producing a constant state of stress. Therefore, the presence of environmental stressors may induce stronger drug seeking behaviors.

Neuroplasticity

Neuroplasticity is the putative mechanism behind learning and memory. It involves physical changes in the synapses between two communicating neurons, characterized by increased gene expression, altered cell signaling, and the formation of new synapses between the communicating neurons. When addictive drugs are present in the system, they appear to hijack this mechanism in the reward system so that motivation is geared towards procuring the drug rather than natural rewards. Depending on the history of drug use, excitatory synapses in the nucleus accumbens(NAc) experience two types of neuroplasticity: long-term potentiation (LTP) and long-term depression (LTD). Using mice as a model, Kourrich et al. showed that chronic exposure to cocaine increases the strength of synapses in NAc after a 10-14 day withdrawal period, while strengthened synapses did not appear within a 24 hour withdrawal period after repeated cocaine exposure. A single dose of cocaine did not elicit any attributes of a strengthened synapse. When drug-experienced mice were challenged with one dose of cocaine, synaptic depression occurred. Therefore, it seems the history of cocaine exposure along with withdrawal times with affects the direction of glutamatergic plasticity in the NAc.

Once a person has transitioned from drug use to addiction, behavior becomes completely geared towards seeking the drug, even though addicts report the euphoria is not as intense as it once was. Despite the differing actions of drugs during acute use, the final pathway of addiction is the same. Another aspect of drug addiction is a decreased response to normal biological stimuli, such as food, sex, and social interaction. Through functional brain imaging of patients addicted to cocaine, scientists have been able to visualize increased metabolic activity in the anterior cingulate and orbitofrontal cortex (areas of the prefrontal cortex) in the brain of these subjects. The hyperactivity of these areas of the brain in addicted subjects is involved in the more intense motivation to find the drug rather than seeking natural rewards, as well as an addict’s decreased ability to overcome this urge. Brain imaging has also shown cocaine-addicted subjects to have decreased activity, as compared to non-addicts, in their prefrontal cortex when presented with stimuli associated with natural rewards. The transition from recreational drug use to addiction occurs in gradual stages and is produced by the effect of the drug of choice on the neuroplasticity of the neurons found in the reward circuit. During events preceding addiction, cravings are produced by the release of DA in the prefrontal cortex. As a person transitions from drug use to addiction, the release of dopamine (DA) in the NAc becomes unnecessary to produce cravings; rather, DA transmission decreases while increased metabolic activity in the orbitofrontal cortex contributes to cravings. At this time a person may experience the signs of depression if cocaine is not used. Before a person becomes addicted and exhibits drug-seeking behavior, there is a time period in which the neuroplasticity is reversible. Addiction occurs when drug-seeking behavior is exhibited and the vulnerability to relapse persists, despite prolonged withdrawal; these behavioral attributes are the result of neuroplastic changes which are brought about by repeated exposure to drugs and are relatively permanent.

The exact mechanism behind a drug molecule’s effect on synaptic plasticity is still unclear. However, neuroplasticity in glutamatergic projections seems to be a major result of repeated drug exposure. There are several ways in which glutamate transmission is altered. One way is by increasing presynaptic release of glutamate and the other is increased response to glutamate. The two main glutamate receptors involved are NMDAR and AMPAR. The expression of these receptors on the cell surface increases with repeated drug use. This type of synaptic plasticity results in LTP, which strengthens connections between two neurons; onset of this occurs quickly and the result is constant. In addition to glutamatergic neurons, dopaminergic neurons present in the VTA respond to glutamate and may be recruited earliest during neural adaptations caused by repeated drug exposure. As shown by Kourrich, et al., history of drug exposure and the time of withdrawal from last exposure appear to play an important role in the direction of plasticity in the neurons of the reward system.

An aspect of neuron development that may also play a part in drug-induced neuroplasticity is the presence of axon guidance molecules such as semaphorins and ephrins. After repeated cocaine treatment, altered expression (increase or decrease dependent on the type of molecule) of mRNA coding for axon guidance molecules occurred in rats. This may contribute to the alterations in the reward circuit characteristic of drug addiction.

Neurogenesis

Drug addiction also raises the issue of potential harmful effects on the development of new neurons in adults. Eisch and Harburg raise three new concepts they have extrapolated from the numerous recent studies on drug addiction. First, neurogenesis decreases as a result of repeated exposure to addictive drugs. A list of studies show that chronic use of opiates, psychostimulants, nicotine, and alcohol decrease neurogenesis in mice and rats. Second, this apparent decrease in neurogenesis seems to be independent of HPA axis activation. Other environmental factors other than drug exposure such as age, stress and exercise, can also have an effect of neurogenesis by regulating the hypothalamic-pituitary-adrenal (HPA) axis. Mounting evidence suggests this for 3 reasons: small doses of opiates and psychostimulants increase coricosterone concentration in serum but with no effect of neurogenesis; although decreased neurogenesis is similar between self-administered and forced drug intake, activation of HPA axis is greater in self-administration subjects; and even after the inhibition of opiate induced increase of corticosterone, a decrease in neurogenesis occurred. These, of course, need to be investigated further. Last, addictive drugs appear to only affect proliferation in the subgranular zone (SGZ), rather than other areas associated with neurogenesis. The studies of drug use and neurogenesis may have implications on stem cell biology.

Psychological drug tolerance

The reward system is partly responsible for the psychological part of drug tolerance;

The CREB protein, a transcription factor activated by cyclic adenosine monophosphate (cAMP) immediately after a high, triggers genes that produce proteins such as dynorphin, which cuts off dopamine release and temporarily inhibits the reward circuit. In chronic drug users, a sustained activation of CREB thus forces a larger dose to be taken to reach the same effect. In addition it leaves the user feeling generally depressed and dissatisfied, and unable to find pleasure in previously enjoyable activities, often leading to a return to the drug for an additional "fix".

Sensitization

Sensitization is the increase in sensitivity to a drug after prolonged use. The proteins delta FosB and regulator of G-protein Signaling 9-2 (RGS 9-2) are thought to be involved:

A transcription factor, known as delta FosB, is thought to activate genes that, counter to the effects of CREB, actually increase the user's sensitivity to the effects of the substance. Delta FosB slowly builds up with each exposure to the drug and remains activated for weeks after the last exposure—long after the effects of CREB have faded. The hypersensitivity that it causes is thought to be responsible for the intense cravings associated with drug addiction, and is often extended to even the peripheral cues of drug use, such as related behaviors or the sight of drug paraphernalia. There is some evidence that delta FosB even causes structural changes within the nucleus accumbens, which presumably helps to perpetuate the cravings, and may be responsible for the high incidence of relapse that occur in treated drug addicts.

Regulator of G-protein Signaling 9-2 (RGS 9-2) has recently been the subject of several animal knockout studies. Animals lacking RGS 9-2 appear to have increased sensitivity to dopamine receptor agonists such as cocaine and amphetamines; over-expression of RGS 9-2 causes a lack of responsiveness to these same agonists. RGS 9-2 is believed to catalyze inactivation of the G-protein coupled D2 receptor by enhancing the rate of GTP hydrolysis of the G alpha subunit which transmits signals into the interior of the cell.

Individual mechanisms of effect

The basic mechanisms by which different substances activate the reward system are as described above, but vary slightly among drug classes.

Depressants

Depressants such as alcohol, barbiturates, and benzodiazepines work by increasing the affinity of the GABA receptor for its ligand; GABA. Narcotics such as morphine and heroin, work by mimicking endorphins—chemicals produced naturally by the body which have effects similar to dopamine—or by disabling the neurons that normally inhibit the release of dopamine in the reward system. These substances (sometimes called "downers") typically facilitate relaxation and pain-relief.

Stimulants

Stimulants such as amphetamines, nicotine, and cocaine, increase dopamine signaling in the reward system either by directly stimulating its release, or by blocking its absorption (see "reuptake"). These substances (sometimes called "uppers") typically cause heightened alertness and energy. They cause a pleasant feeling in the body, and euphoria, known as a high. This high wears off leaving the user feeling depressed. This sometimes makes them want more of the drug, and can worsen the addiction.

Theories about causes for epidemic outbreak of addiction

Nils Bejerot

Nils Bejerot (1921 –1988) was a Swedish psychiatrist and criminologist. He attacked the symptom theory of addiction - that addictions are a symptom of other more fundamental personal or socioeconomic problems - and separated five essential factors from all of the other factors that are involved in addiction. Bejerot's point was that all of these other factors should be understood as susceptibility or risk factors. Therefore mental illness may make someone susceptible to drug experimentation and use, but it is not a causal factor. Similarly, poverty may increase susceptibility, but there is no automatic causal relationship with addiction. Many poverty-stricken communities are free of addiction epidemics, as are many people with mental illness.

Bejerot's analysis was that the presence of five factors on their own constitutes a risk that an individual will become an addict, or that a community will be affected by an epidemic of addiction:

* Availability of the addictive substance
* Money to acquire the substance
* Time to use the substance
* Example of use of the substance in the immediate environment
* A permissive ideology in relation to the use of the substance.

Bejerot's opinion was that drug addicts must be prosecuted. This does not mean that Bejerot proposed what he called the harsh American sentences. - The society must (in his view), however, make it very uncomfortable to abuse illicit drugs. Drug addicts should be offered treatment, mandatory if necessary, but not treatment that helped them to continue the abuse of the drug.

Medical definitions

The terms abuse and addiction have been defined and re-defined over the years. The 1957 World Health Organization (WHO) Expert Committee on Addiction-Producing Drugs defined addiction and habituation as components of drug abuse:

Drug addiction is a state of periodic or chronic intoxication produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include: (i) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (ii) a tendency to increase the dose; (iii) a psychic (psychological) and generally a physical dependence on the effects of the drug; and (iv) detrimental effects on the individual and on society.

Drug habituation (habit) is a condition resulting from the repeated consumption of a drug. Its characteristics include (i) a desire (but not a compulsion) to continue taking the drug for the sense of improved well-being which it engenders; (ii) little or no tendency to increase the dose; (iii) some degree of psychic dependence on the effect of the drug, but absence of physical dependence and hence of an abstinence syndrome [withdrawal], and (iv) detrimental effects, if any, primarily on the individual.

In 1964, a new WHO committee found these definitions to be inadequate, and suggested using the blanket term "drug dependence":

The definition of addiction gained some acceptance, but confusion in the use of the terms addiction and habituation and misuse of the former continued. Further, the list of drugs abused increased in number and diversity. These difficulties have become increasingly apparent and various attempts have been made to find a term that could be applied to drug abuse generally. The component in common appears to be dependence, whether psychic or physical or both. Hence, use of the term 'drug dependence', with a modifying phase linking it to a particular drug type in order to differentiate one class of drugs from another, had been given most careful consideration. The Expert Committee recommends substitution of the term 'drug dependence' for the terms 'drug addiction' and 'drug habituation'.

The committee did not clearly define dependence, but did go on to clarify that there was a distinction between physical and psychological ("psychic") dependence. It said that drug abuse was "a state of psychic dependence or physical dependence, or both, on a drug, arising in a person following administration of that drug on a periodic or continued basis." Psychic dependence was defined as a state in which "there is a feeling of satisfaction and psychic drive that requires periodic or continuous administration of the drug to produce pleasure or to avoid discomfort" and all drugs were said to be capable of producing this state:

There is scarcely any agent which can be taken into the body to which some individuals will not get a reaction satisfactory or pleasurable to them, persuading them to continue its use even to the point of abuse — that is, to excessive or persistent use beyond medical need.

The 1957 and 1964 definitions of addiction, dependence and abuse persist to the present day in medical literature. It should be noted that at this time (2006) the Diagnostic Statistical Manual (DSM IVR) now spells out specific criteria for defining abuse and dependence. (DSM IVR) uses the term substance dependence instead of addiction; a maladaptive pattern of substance abuse, leading to clinically significant impairment or distress, as manifested by three (or more) specified criteria, occurring at any time in the same 12-month period. This definition is also applicable on drugs with smaller or nonexistent physical signs of withdrawal, for ex. cannabis.

In 2001, the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine jointly issued "Definitions Related to the Use of Opioids for the Treatment of Pain," which defined the following terms:

Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

Tolerance is the body's physical adaptation to a drug: greater amounts of the drug are required over time to achieve the initial effect as the body "gets used to" and adapts to the intake.

Pseudo addiction is a term which has been used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may “clock watch,” and may otherwise seem inappropriately “drug seeking.” Even such behaviors as illicit drug use and deception can occur in the patient's efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.

The Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR doesn’t use the word addiction at all. Instead it has a section about Substance dependence

"When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. This, along with Substance Abuse are considered Substance Use Disorders...."

A definition of addiction proposed by professor Nils Bejerot:

"An emotional fixation (sentiment) acquired through learning, which intermittently or continually expresses itself in purposeful, stereotyped behavior with the character and force of a natural drive, aiming at a specific pleasure or the avoidance of a specific discomfort."

Addiction and drug control legislation

Depending on the jurisdiction, addictive drugs may be legal only as part of a government sponsored study, illegal to use for any purpose, illegal to sell, or even illegal to merely possess.

Most countries have legislation which brings various drugs and drug-like substances under the control of licensing systems. Typically this legislation covers any or all of the opiates, amphetamines, cannabinoids, cocaine, barbiturates, hallucinogenics and a variety of more modern synthetic drugs. Unlicensed production, supply or possession is a criminal offence.

Usually, however, drug classification under such legislation is not related simply to addictiveness. The substances covered often have very different addictive properties. Some are highly prone to cause physical dependency, whilst others rarely cause any form of compulsive need whatsoever. Also, under legislation specifically about drugs, alcohol is not usually included.

Although the legislation may be justifiable on moral or public health grounds, it can make addiction or dependency a much more serious issue for the individual: reliable supplies of a drug become difficult to secure, and the individual becomes vulnerable to both criminal abuse and legal punishment.

It is unclear whether laws against drugs do anything to stem usage and dependency. In jurisdictions where addictive drugs are illegal, they are generally supplied by drug dealers, who are often involved with organized crime. Even though the cost of producing most illegal addictive substances is very low, their illegality combined with the addict's need permits the seller to command a premium price, often hundreds of times the production cost. As a result, the addict sometimes turns to crime to support their habit.
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Sunday, July 12, 2009

15 Years of Healing

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IN all of its 15 years, this is the first time that SELF will combine two major affairs in one celebration. To celebrate our 15th year as a healing community, we saw it but fitting to hold our 13th Graduation Rites as a way of highlighting this important achievement. Gathered here today, we are all filled with excitement and hope. Excitement because we have worked so hard to conceive a program that would appropriately honor this milestone. Every member of the SELF Family is eagerly waiting to entertain you with a fabulous musical show they took so much time to prepare. And hope because we are once again going to send off to our society another batch of 18 trustworthy and God-fearing individuals imbued with a sense of mission towards humanity.

The Miracles of God

But, as we say in TC, “No free Lunch!” SELF, too, had its fair share of ups and downs during its growing period. I am reminded of other major milestones in SELF’s history and, if only to give glory to the miracles of God, please allow me to tell two short stories. The first happened in 1996. SELF was being evicted from its first facility in Las Piñas. Year after year, pressures from the surrounding residential associations and the city mounted. At the same time, SELF was already in need of a bigger house. Finding a new venue, however, was easier said than done. Well, in a bizarre twist of fate, what no entity or official could do to make us move, ironically God did in his own majestic way. That June a fire gutted the entire facility. From that fire rose a steadfast determination to find a new home for SELF. The journey took us to a temporary shelter in Tagaytay where, sadly, abusive landlords drove us to the edge of desperation. However, this harassment again became the very fuel that once again set us off in search of a better place. In 1999 we began to build Taal View House and in June 2000 SELF’s first permanent home was inaugurated.

A New Culture

The second story is about an event that significantly changed the way SELF runs its Therapeutic Community program. In 2002 SELF suffered a major crisis in its organization: management was in disharmony and negative practices found their way into the program. The situation demanded a strong will to make things right no matter what the cost. We undertook a drastic change in personnel and began to nurture a new culture. Today, we have evolved into a community that is Strict, Yet Caring. Strict but not abusive; Caring yet not enabling. All practices in the TC now conform to three rules. They all have to be Respectful, Logical and Practical. With this, my passion has grown to levels I never before imagined they could reach. I’ve never been so happy to work with the residents and staff as I have in these last four years. Life at SELF has never been better! And it is a distinct pleasure to graduate a total of 18 residents under our revamped program. As you might have observed, we have gone all out with this celebration. After all, we reason, this only happens once every 15 years. A lot of effort has gone into organizing this affair and, right now, I have only two wishes: that you keep remembering us in your prayers and that you sit back and enjoy our fabulous show. I thank our Family Association for their steadfast support and generous contributions and sponsoring this entire affair. I would also like to thank Fritz Ynfante for tirelessly training and coaching our residents and staff through long and grueling hours, so that they could present this entertaining number, from their hearts, for all of you to enjoy. So standby for Showtime! Finally, to all of you who came from far distances to be with us tonight, thank you so much for making us a part of your lives.

Special Award
And now it gives me great pleasure to introduce our Keynote Speaker for today. Our speaker and I go way back, since 1972 when we graduated from High School at the Ateneo. Though we were classmates and good friends then, the relationship was short-lived as this was also the time I started my crazy affair with drugs. My good friend Jess took the straight and narrow path and soon found himself a career in the insurance business. Sadly, I never saw him again until around 1997 when our 25th homecoming called for the reunion of our class. By this time Jess was a top executive of Philamlife and I was proud of his achievement. There and then, I invited him to be a member of our Board and have since always counted on him for advice. In he year 2000 SELF was in the process of building this facility and we were saddled with debts for its construction. The inauguration was just around the corner and our coffers were dry. SELF needed a miracle. Just then, after one of our Board meetings, Jess casually asked me to ride with him on the way home. When I boarded his car, he pulled out an envelope full of cash and handed it over to me and said: “Know what, Mart, I am privileged to have enjoyed a vacation paid by my company. But for some reason I chose not to spend this money as I felt I could put it to good use. Now, I know what it was intended for.” Jess, that act was the miracle that set off more miracles to come. A few days later, a FAM member also came to our rescue and, on the very week of our inauguration, busy as we all were, the Lord sent SELF 10 admissions in the span of five days. That June recorded our highest revenues ever and we were able to begin paying off much of our debts. Jess, in a meeting held in your absence early this year, the Board unanimously agreed to award you, at this fitting occasion of our 15th Anniversary, with a Certificate of Appreciation for everything you have done for SELF. Ladies and gentlemen, it gives me great pleasure to call on stage the President of Philam Plans and SELF Board Consultant Mr. Jess Hofileña to receive this award and to deliver his Keynote message.
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