Background: Previous research has identified a link between the loss of a significant person, grief complications, and substance abuse. People with substance use disorder (SUD) are more vulnerable to complicated grieving symptoms following loss. From sociocognitive theories, the model of coping with stress assumes that substance use is one of the responses used to cope with traumatic life events. The main objective of this study is to identify the coping strategies of people with SUD and to analyze (...) their relationship to complicated grief (CG).Methods: A sample of 196 bereaved drug-dependent patients was assessed, after providing written consent, in sociodemographic variables, drug and bereavement related characteristics, CG symptomatology (Inventory of Complicated Grief) and coping strategies (Coping Strategies Inventory).Results: There are differences in relation to the coping strategies used among patients with CG, using more those focused on emotional expression, social withdrawal, wishful thinking, and self-criticism.Conclusion: We can conclude that, in general, CG in patients with SUD is more associated with the use of less adaptive coping strategies. This data can contribute to a better understanding of the different variables involved in the grieving process among people with SUD. It is important to point out the clinical implications of addressing what the coping strategies associated with improved grief outcomes among people with addiction problems are. (shrink)

Substance use disorders (SUDs) constitute a growing global health crisis, yet many limitations and challenges exist in SUD treatment research, including the lack of objective brain-based markers for tracking treatment outcomes. Electroencephalography (EEG) is a neurophysiological technique for measuring brain activity, and although much is known about EEG activity in acute and chronic substance use, knowledge regarding EEG in relation to abstinence and treatment outcomes is sparse. We performed a scoping review of longitudinal and pre-post treatment EEG (...) studies that explored putative changes in brain function associated with abstinence and/or treatment in individuals with SUD. Following PRISMA guidelines, we identified studies published between January 2000 and March 2022 from online databases. Search keywords included EEG, addictive substances (e.g., alcohol, cocaine, methamphetamine), and treatment related terms (e.g., abstinence, relapse). Selected studies used EEG at least at one time point as a predictor of abstinence or other treatment-related outcomes; or examined pre- vs. post-SUD intervention (brain stimulation, pharmacological, behavioral) EEG effects. Studies were also rated on the risk of bias and quality using validated instruments. Forty-four studies met the inclusion criteria. More consistent findings included lower oddball P3 and higher resting beta at baseline predicting negative outcomes, and abstinence-mediated longitudinal decrease in cue-elicited P3 amplitude and resting beta power. Other findings included abstinence or treatment-related changes in late positive potential (LPP) and N2 amplitudes, as well as in delta and theta power. Existing studies were heterogeneous and limited in terms of specific substances of interest, brief times for follow-ups, and inconsistent or sparse results. Encouragingly, in this limited but maturing literature, many studies demonstrated partial associations of EEG markers with abstinence, treatment outcomes, or pre-post treatment-effects. Studies were generally of good quality in terms of risk of bias. More EEG studies are warranted to better understand abstinence- or treatment-mediated neural changes or to predict SUD treatment outcomes. Future research can benefit from prospective large-sample cohorts and the use of standardized methods such as task batteries. EEG markers elucidating the temporal dynamics of changes in brain function related to abstinence and/or treatment may enable evidence-based planning for more effective and targeted treatments, potentially pre-empting relapse or minimizing negative lifespan effects of SUD. (shrink)

There is a long-standing failure to create an ethical culture around substance use disorders (SUDs) or dependence that actively supports people’s recovery efforts. Issues which impede the development of prorecovery environments are complex, but include the far-reaching effects of the social stigma that surrounds SUDs; and the failure to harness relational and social support that allows debates to transcend blaming individual substance users. As part of efforts to create prorecovery environments, it is important to acknowledge that bioethics (...) debate on SUDs is narrow in scope, prioritising topics related to its traditional interests in individual autonomy and novel technologies. As a result, it has not played a significant role in helping to transform the ethical cultures in which substance use recovery takes place. For example, it largely neglects the ethical challenges of developing an empathic, person-centred approach to substance use problems that listens and responds to the voices of clients. It has also participated little in efforts to develop a positive response to reducing the toxic effects of stigma. Indeed, some contributions from the field fan stigma, rather than alleviate it. The aim of this paper is to seed broader ethical debate, in academic literature and lay/professional communities, on how societies should respond to SUDs: steering a course between the critical, but narrow approach of bioethics and the empowerment discourse of evidence-based treatments. (shrink)

Virtual Reality Therapy has been shown to be effective in treating anxiety disorders and phobias, but has not yet been widely tested for Substance Use Disorders and it is not known whether health care practitioners working with SUDs would use VRT if it were available. We report the results of an interview study exploring practitioners’ and researchers’ views on the utility of VRT for SUD treatment. Practitioners and researchers with at least two years’ experience delivering or researching (...) and designing SUD treatments were recruited. Interviews were thematically analyzed, resulting in themes relating to the safety and realism of VRT, and the opportunity for the additional insight it could offer to during SUD treatment. Participants were positive about employing VRT as an additional treatment for SUD. VRT was thought suitable for treating adults and people with mental health issues or trauma, provided that risks were appropriately managed. Subsequent relapse, trauma and over-confidence in the success of treatment were identified as risks. The opportunity VRT offered to include other actors in therapy, and observe reactions, were benefits that could not currently be achieved with other forms of therapy. Overall, VRT was thought to offer the potential for safe, realistic, personalized and insightful exposure to diverse triggering scenarios, and to be acceptable for integration into a wide range of SUD treatments. (shrink)

In the Peruvian Amazon, tobacco (Nicotiana rustica) is considered a master plant and is the main curing tool of local healers. Among its several medicinal uses, we find drinking tobacco juice with the purpose of purging in order to heal on a physical, mental, and spiritual level. This specific practice is part of the addiction treatment protocol developed at Takiwasi Center. The goal of this investigation was to focus on the effects of the tobacco purge as reported by therapists at (...) Takiwasi and to elaborate its relevance within the context of addiction treatment. In order to obtain information on this topic, we performed research fieldwork based on a participant-observation approach, and retrospective data analysis on information from interviews conducted by psychotherapists with patients. As alleged effects of the tobacco purge, therapists reported that patients experienced feelings of mental clarity with the greatest frequency (n = 80), followed by noteworthy physical effects including discomfort and intoxication (n = 63). An effect on sleep and dreams was also common (n = 36) and many found the experience directly related to addiction treatment and the desire to consume substances (n = 20). (shrink)

Ethics in Mental Health-Substance Use aims to explore the comprehensive concerns and dilemmas occurring from mental health and substance use problems, and to inform, develop, and educate by sharing and pooling knowledge, and enhancing expertise, in this fast developing region of ethics and ethical care and practice. This volume concentrates on ethical concerns, dilemmas, and concepts specifically interrelated, as a collation of problem(s) that directly or indirectly affect the life of the individual and family. Whilst presenting a balanced (...) view of what is ethically best practice today, this title challenges concepts and stimulates debate, exploring all aspects of the development in treatment, intervention and care responses, and the adoption of research-led best practice. (shrink)

Mothers with prenatal substance use disorder often show broad deficits in their reflective functioning, implying severe risk for the relationship with their baby. Two different types of prenatal maternal RF may be important for parenting: adult attachment-focused-RF, regarding parent's own childhood experiences, and parenting-focused RF regarding their own current process of becoming a parent. However, their inter-relations and potentially different roles for parenting intervention outcomes are not clear. This study examined the associations between mothers' prenatal AAI-RF and pre- and (...) post-natal PRF, and their role in mother-infant interaction and substance use as treatment outcomes. The participants were 57 treatment-enrolled pregnant mothers with SUD and 50 low-risk comparison mothers. AAI-RF was measured with the Adult Attachment Interview. For a subsample of 30 mothers with SUD, PRF was measured with Pregnancy Interview, and with Parent Development Interview at 4 months. Mother-infant interaction was measured with Emotional Availability Scales at 4 and 12 months, and maternal substance use by post-natal substance relapses. Prenatal AAI-RF and pre- and post-natal PRF were highly associated with each other. Only higher prenatal PRF predicted better mother-infant interaction quality at 4 months and less substance use during the child's first year. Interestingly, prenatal PRF and AAI-RF predicted opposite changes in mother-infant interaction: lower prenatal PRF, but higher AAI-RF predicting more positive change. AAI-RF was especially associated with a change in maternal intrusiveness and hostility, indicating that it represents a more general regulatory tendency. Further studies are needed in larger and lower-risk samples. Our results suggest, however, that AAI-RF and PRF are partially distinct and should be uniquely targeted in perinatal interventions. (shrink)

Previous studies suggest that psychopathic traits commonly present as comorbid with substance use disorders. Moreover, neuroimaging and psychometric findings suggest that psychopathic traits may predispose individuals to a sensitized reward response to drugs. Given that substance use disorders are characterized by a neurocognitive bias toward drug-reward relative to non-drug reward, it is possible that heightened psychopathic characteristics may further predispose to this processing bias. To evaluate this possibility, we assessed psychopathic traits (measured using the PCL-R; Hare, (...) 2003 ) in 105 probationers/parolees and evaluated the relationship between PCL-R scores, lifetime duration of drug use, and biases in neural response to drug- compared to food-related videos. Psychopathic traits (potentially driven by interpersonal/affective traits) were positively correlated with drug > food reactivity within the right insula and left amygdala. In addition, psychopathic traits modulated the relationship between drug use and drug > food reactivity within the left dorsomedial prefrontal cortex, right insula, and left caudate nucleus. Specifically, lifetime duration of drug use correlated positively with drug > food reactivity in participants with lower levels of psychopathic traits and correlated negatively with drug > food reactivity in individuals with higher levels of psychopathic traits. These results help reconcile prior studies on psychopathy and drug-stimulus processing and provide neurocognitive support for the notion that psychopathic traits serve as an underlying risk factor for substance use disorders. These results suggest that different treatment regimens for substance abuse for individuals with higher or lower levels of psychopathy may be beneficial and suggest that reduction of neurocognitive biases to drug-related stimuli may offer useful targets for future treatment protocols. (shrink)

BackgroundInformed consent is a key element of ethical clinical research. Addicted population may be at risk for impaired consent capacity. However, very little research has focused on their comprehension of consent forms. The aim of this study is to assess the capacity of addicted individuals to provide consent to research.Methods53 subjects with DSM-5 diagnoses of a Substance Use Disorder and 50 non psychiatric comparison subjects participated in the survey from December 2014 to March 2015. This cross-sectional study was carried (...) out at a community-based Outpatient Treatment Center and at an urban-located Health Centre in Spain. A binary judgment of capacity/incapacity was made guided by the MacArthur Competence Assessment Tool for Clinical Research and a clinical interview. Demographics and clinical characteristics were assessed by cases notes and the Mini-Mental State Examination, the Global Assessment Functional Scale and the Clinical Global Impression Scale.ResultsNPCs performed the best on the MacCAT–CR, and patients with SUD had the worst performance, particularly on the Understanding and Appreciation subscales. 32.7 % SUD people lacked research-related decisional capacity. There were no statistically significant differences between the groups in terms of capacity to consent to research.ConclusionsThe findings of our study provide evidence that a large proportion of individuals with SUD had decisional capacity for consent to research. It is therefore inappropriate to draw conclusions about capacity to make research decisions on the basis of a SUD diagnosis. In the absence of advanced cognitive impairment, acute withdrawal or intoxication, we should assume that addicted persons possess decision-making capacity. Thus, the view that people with SUD would ipso facto lose decision-making power for research consent is flawed and stigmatizing. (shrink)

Substance use disorder (SUD) care among women in the sex trade poses multiple ethical challenges. We propose a framework with three lenses—autonomy, power, and place—that can inform and help improve more ethical clinical care for people who trade sex seeking SUD treatment. A relational perspective on autonomy, an analysis of power relations in the clinic, and a geographical analysis can inform how we create space for people with experience in the sex trade in substance use treatment facilities and (...) beyond. We conclude with some practical applications of this framework, all while integrating a composite clinical vignette throughout our analysis. This analysis addresses a clinical and ethical gap in ways to provide better care for women in the sex trade, an understudied and chronically marginalized population deserving of care that meets them where they are. (shrink)

In this article, I develop a novel relational egalitarian theory of social exclusion that explains how society fails to treat socially excluded individuals – such as people experiencing homelessness, individuals with substance use disorders and mental illness and sex workers – as equals. I argue that society places and keeps excluded individuals at the very bottom of the social status hierarchy by treating them as socially invisible, or by rendering them physically invisible, or both. The upshot, then, is (...) that part of what is wrong with social exclusion is that it creates the invisible social class. (shrink)

Opioid use disorder rarely presents as a unitary psychiatric condition, and the comorbid symptoms likely depend upon the diverse risk factors and mechanisms by which OUD can arise. These factors are heterogeneous and include genetic predisposition, exposure to prescription opioids, and environmental risks. Crucially, one key environmental risk factor for OUD is early life adversity. OUD and other substance use disorders are widely considered to derive in part from abnormal reward circuit function, which is likely also implicated in (...) comorbid mental illnesses such as depression, bipolar disorder, and schizophrenia. ELA may disrupt reward circuit development and function in a manner predisposing to these disorders. Here, we describe new findings addressing the effects of ELA on reward circuitry that lead to OUD and comorbid disorders, potentially via shared neural mechanisms. We discuss some of these OUD-related problems in both humans and animals. We also highlight the increasingly apparent, crucial contribution of biological sex in mediating the range of ELA-induced disruptions of reward circuitry which may confer risk for the development of OUD and comorbid neuropsychiatric disorders. (shrink)

In the 2000s, several psychiatrists cited the lack of relational disorders in the DSM-IV as one of the two most glaring gaps in psychiatric nosology, and campaigned for their inclusion in the DSM-5. This campaign failed, however, presumably in part due to serious “ontological concerns” haunting such disorders. Here, I offer a path to quell such ontological concerns, adding to previous conceptual work by Jerome Wakefield and Christian Perring. Specifically, I adduce reasons to think that collective disorders (...) are compatible with key metaphysical commitments of contemporary scientific psychiatry, and argue that if one accepts the existence of mental disorders in individuals as medical, then one has good reasons to accept the existence of collective disorders as medical. First, I outline how collective disorders are reconcilable with both the harmful dysfunction model of disorder and a denial of mind-body dualism. I then identify some potential weaknesses in the main pre-existing example of a collective disorder, offering my own examples as supplements. These examples’ medical plausibility is bolstered by: work in philosophy of biology on the generalized selected effects theory of function, and work in analytic philosophy of mind on collective mentality. Finally, after offering preliminary responses to the objection that the recognition of collective disorders may lead to an overpathologization of everyday life, I spell out ways in which this recognition may have empowering effects for some would-be patients; for example, by providing substance to the notion of a “sane response to an insane world.”. (shrink)

This research qualitatively investigated four treatments for addiction in Brazil that use ibogaine as the main tool in the process. Ibogaine is a substance derived from an African plant, Tabernanthe iboga, traditionally used in its region of origin and which leads to intense sensations during its acute effects and also different experiences of oneself and the surrounding world in the period after its use. It’s considered a non‐typical psychedelic. We visited the clinics and interviewed professionals and patients of these (...) places. In this article, we focus on how ibogaine is used for addiction and depression treatment and how its effect is understood. There is variation in patient screening and preparation, how the ibogaine is determined, and the care practices proposed after the treatment. These variations seem to be influenced by the context where ibogaine is inserted and their practices. We identified three different contexts that influence ibogaine use in Brazil: the market of addiction treatment clinics, the Brazilian urban religious use of ayahuasca, and the medical context of ibogaine use developed by Howard Lotsof. (shrink)

Prior research has demonstrated that antisocial behavior, substance-use disorders, and personality dimensions of aggression and impulsivity are indicators of a highly heritable underlying dimension of risk, labeled externalizing. Other work has shown that individual trait constructs within this psychopathology spectrum are associated with reduced self-monitoring, as reflected by amplitude of the error-related negativity (ERN) brain response. In this study of undergraduate subjects, reduced ERN amplitude was associated with higher scores on a self-report measure of the broad externalizing (...) construct that links these various indicators. In addition, the ERN was associated with a response-locked increase in anterior theta (4–7 Hz) oscillation; like the ERN, this theta response to errors was reduced among high-externalizing individuals. These findings suggest that neurobiologically based deficits in endogenous action monitoring may underlie generalized risk for an array of impulse-control problems. (shrink)

Background: Psychopathy and substance use disorders are highly co-morbid and their co-occurrence is associated with higher severity of addictive behavior and increased risk of violent offending. Both substance use disorders and psychopathy are related to prominent impairments in emotion processing, which are also central features of alexithymia. The nature of the relationship between psychopathy and alexithymia is not well understood and has been particularly understudied among substance dependent individuals. Aims: Our goal was to evaluate (...) the levels of psychopathy and alexithymia in a relatively homogeneous sample of heroin dependent individuals and healthy controls and to examine group differences in the pattern of associations between these constructs. Methods: We examined 62 participants (31 heroin dependent individuals and 31 healthy controls) with the Psychopathy Checklist: Screening version (PCL:SV, Hart et al., 1995) and the Toronto Alexithymia Scale-20 (TAS-20, Bagby et al., 1994). Results: Heroin dependent individuals were characterized by higher levels of both psychopathy and alexithymia as compared to the control group. In addition, heroin dependent individuals with higher levels of psychopathy reported more difficulties in identifying and verbalizing emotional states. In the heroin group, alexithymia was more strongly associated with the impulsive/antisocial characteristics (impulsivity, irresponsibility, antisocial behavior) than with the interpersonal/affective features of psychopathy (grandiosity, manipulativeness, lack of empathy and remorse). Conclusions: Our findings suggest that alexithymia may be one potential mechanism linking psychopathy with opioid use disorders. The development of interventions targeting alexithymia could have significant applications in relapse prevention programs and psychotherapy of substance use disorders with concurrent psychopathy. (shrink)

Aims: Attentional bias, alcohol craving, and anxiety have important implications in the development and maintenance of alcohol use disorder. The current study aims to test the effectiveness of a Virtual Reality Cue-Exposure Therapy to reduce levels of alcohol craving and anxiety and prompt changes in AB toward alcohol content.Method: A 49-year-old male participated in this study, diagnosed with severe AUD, who also used tobacco and illicit substances on an occasional basis and who made several failed attempts to cease substance (...) misuse. The protocol consisted of six VR-CET booster sessions and two assessment sessions over the course of 5 weeks. The VR-CET program consisted of booster therapy sessions based on virtual reality exposure to preferred alcohol-related cues and contexts. The initial and final assessment sessions were focused on exploring AB, alcohol craving, and anxiety using paper-and-pencil instruments and the eye-tracking and VR technologies at different time points.Results: Pre and post assessment sessions indicated falls on the scores of all instruments assessing alcohol craving, anxiety, and AB.Conclusions: This case report, part of a larger project, demonstrates the effectiveness of the VR-CET booster sessions in AUD. In the post-treatment measurements, a variety of instruments showed a change in the AB pattern and an improvement in craving and anxiety responses. As a result of the systematic desensitization, virtual exposure gradually reduced the responses to significant alcohol-related cues and contexts. The implications for AB, anxiety and craving are discussed. (shrink)

Background Our objective was to evaluate whether the description of a machine learning (ML) app or brain imaging technology to predict the onset of schizophrenia or alcohol use disorder (AUD) influences healthcare professionals’ judgments of stigma, empathy, and compassion. Methods We randomized healthcare professionals (N = 310) to one vignette about a person whose clinician seeks to predict schizophrenia or an AUD, using a ML app, brain imaging, or a psychosocial assessment. Participants used scales to measure their judgments of stigma, (...) empathy, and compassion. Results Participants randomized to the ML vignette endorsed less anger and more fear relative to the psychosocial vignette, and the brain imaging vignette elicited higher pity ratings. The brain imaging and ML vignettes evoked lower personal responsibility judgments compared to the psychosocial vignette. Physicians and nurses reported less empathy than clinical psychologists. Conclusions The use of predictive technologies may reinforce essentialist views about mental health and substance use that may increase specific aspects of stigma and reduce others. (shrink)

This is a review of the biographic drama Love and Mercy. More than a story of the evolution of The Beach Boys, it is the story of the lead Beach Boy, Brian Wilson, and his struggle with substance abuse, mental illness, family stress, emerging love, and a controlling psychologist. Interwoven are many bioethics themes, including the doctor–patient relationship, conflict of interest, autonomy, and patient welfare. For those unaware of the sadness and torment running directly alongside the sunny, bubbly life (...) of The Beach Boys, this film is an eye-opener. It is also a great reminder of the importance of boundaries between clinicians and their patients. (shrink)

This case describes an adolescent in a crisis of a chronic medical condition whose situation is complicated by substance abuse and mental illness. D. Micah Hester provides an analytic approach, teasing apart the multiple layers of medical, developmental, and moral issues at hand and describing possible responses and outcomes. Amy T. Campbell examines existing legal guidelines for adolescent decision making, arguing that greater space exists for clinical discretion in these matters than commonly thought. Cheryl D. Lew discusses the development (...) of agency in adolescent patients, the ideal of autonomous decision making in the context of impairment and chronic illness, and the obligation of healthcare teams to examine an adolescent patient’s decisions in relation to her identity. (shrink)

Alcohol use disorder is one of the most common substance use disorders contributing to both behavioral and cognitive impairments in patients with AUD. Recent neuroimaging studies point out that AUD is a typical disorder featured by altered functional connectivity. However, the details about how voxel-wise functional coordination remain unknown. Here, we adopted a newly proposed method named functional connectivity density to depict altered voxel-wise functional coordination in AUD. The novel functional imaging technique, FCD, provides a comprehensive analytical method (...) for brain's “scale-free” networks. We applied resting-state functional MRI toward subjects to obtain their FCD, including global FCD, local FCD, and long-range FCD. Sixty-one patients with AUD and 29 healthy controls were recruited, and patients with AUD were further divided into alcohol-related cognitive impairment group and non-cognitive impairment group. All subjects were asked to stay stationary during the scan in order to calculate the resting-state gFCD, lFCD, and lrFCD values, and further investigate the abnormal connectivity alterations among AUD-NCI, ARCI, and HC. Compared to HC, both AUD groups exhibited significantly altered gFCD in the left inferior occipital lobe, left calcarine, altered lFCD in right lingual, and altered lrFCD in ventromedial frontal gyrus. It is notable that gFCD of the ARCI group was found to be significantly deviated from AUD-NCI and HC in left medial frontal gyrus, which changes probably contributed by the impairment in cognition. In addition, no significant differences in gFCD were found between ARCI and HC in left parahippocampal, while ARCI and HC were profoundly deviated from AUD-NCI, possibly reflecting a compensation of cognition impairment. Further analysis showed that within patients with AUD, gFCD values in left medial frontal gyrus are negatively correlated with MMSE scores, while lFCD values in left inferior occipital lobe are positively related to ADS scores. In conclusion, patients with AUD exhibited significantly altered functional connectivity patterns mainly in several left hemisphere brain regions, while patients with AUD with or without cognitive impairment also demonstrated intergroup FCD differences which correlated with symptom severity, and patients with AUD cognitive impairment would suffer less severe alcohol dependence. This difference in symptom severity probably served as a compensation for cognitive impairment, suggesting a difference in pathological pathways. These findings assisted future AUD studies by providing insight into possible pathological mechanisms. (shrink)

In this two-part analysis, I analyze Marc Lewis’s arguments against the brain-disease view of substance addiction and for a developmental-learning approach that demedicalizes addiction. I focus especially on the question of whether addiction is a medical disorder. Addiction is currently classified as a medical disorder in DSM-5 and ICD-10. It is further labeled a brain disease by NIDA, based on observed brain changes in addicts that are interpreted as brain damage. Lewis argues that the changes result instead from normal (...) neuroplasticity and learning in response to the intense rewards provided by addictive substances, thus that addiction is not a brain disease and by implication not a medical disorder at all. I argue that even if one accepts Lewis’s reinterpretation of the brain evidence, his conclusions do not follow. Relying on my harmful-dysfunction analysis of medical disorder, I defend the view that substance addiction is in fact a medical disorder and a brain disorder. In Part 1, I identify five arguments Lewis puts forward against the brain-disease view and evaluate them as arguments that addiction is not a disorder: Addiction is not a chronic, relapsing condition; There is no clear boundary between addiction and other strong desires; Negative consequences are not unique to disorders; The brain disease model does not account for behavioral addictions; and, Addiction is like love. I argue that Lewis’s arguments are invalid because they fail to take account of the context of addiction and its relation to biological design. (shrink)

Nurses die by suicide at a higher rate than the general population. Previous studies have observed mental health problems, including substance use, as a prominent antecedent before death. The purpose of this study was to explore the characteristics of nurses who died by suicide documented in the death investigation narratives from the National Violent Death Reporting System from 2003 to 2017 using thematic analysis and natural language processing. One thousand three hundred and fifty‐eight subjects met these inclusion criteria. Narratives (...) from 601 subjects were thematically analyzed and 2544 individual narratives were analyzed using natural language processing. The analyses revealed five themes: “mental health treatment,” “poor general health and chronic pain,” “substance use,” “worsening mental health after bereavement,” and “repeating a family member's suicide.” Mental health/substance use, chronic illness, and chronic pain were seen to coexist in a complex, interdependent manner that appeared to be entangled in the nurses' narratives before death. These findings echo the need for reducing the stigmatization of mental health problems in nursing and removing barriers to help‐seeking behaviors as early preventative interventions. Future research is needed to determine if a comprehensive healthcare integration approach to address these entangled problems would reduce suicide vulnerability in nurses and improve their quality of life. (shrink)

The Handbook of Implicit Cognition and Addiction features the work of an internationally renowned group of contributing North American and European authors who ...

This study explored drug users’ attitudes toward and understanding of randomized controlled trials testing addiction therapies. A video portraying a fictional consent conference for a randomized controlled trial with placebo arm was shown to poor male and female drug users of diverse ethnic status and sexual orientation. The video stimulated focus group discussion in which participants’ comments often reflected “experimental realism”—a realistic view of the trial—and adequate understanding of the uncertain efficacy of the treatment being tested, as well as the (...) concepts of randomization and placebo control. However, participants’ comprehension of the nature of placebos was compromised by the widespread view that placebos are a way of testing a subject’s willpower and personal control over his or her addiction. Comments also showed a mistrust of the video investigator’s integrity and competence and signs of therapeutic misconception and misestimation. The study’s findings underscore the importance of tailoring informed consent encounters to the personal and sociohistorical context of participants’ lived experiences. (shrink)

Mental and substance use disorders have been identified as the leading cause of global disability, and the global burden of mental illness is concentrated among those experiencing disability due to serious mental illness. Music has been studied as a support for SMIs for decades, with promising results; however, a lack of synthesized evidence has precluded increased uptake of and access to music-based approaches. The purpose of this scoping review was to identify the types and quantity of research at (...) intersections of music and SMIs, document evidentiary gaps and opportunities, and generate recommendations for improving research and practice. Studies were included if they reported on music's utilization in treating or mitigating symptoms related to five SMIs: schizophrenia, bipolar disorder, generalized anxiety disorder, major depressive disorder, or post-traumatic stress disorder. Eight databases were searched; screening resulted in 349 included studies for data extraction. Schizophrenia was the most studied SMI, with bipolar disorder studied the least. Demographics, settings, and activity details were found to be inconsistently and insufficiently reported; however, listening to recorded music emerged as the most common musical activity, and activity details appeared to have been affected by the conditions under study. RCTs were the predominant study design, and 271 unique measures were utilized across 289 primary studies. Over two-thirds of primary studies reported positive results, with 2.8% reporting worse results than the comparator, and 12% producing indeterminate results. A key finding is that evidence synthesis is precluded by insufficient reporting, widely varied outcomes and measures, and intervention complexity; as a result, widespread changes are necessary to reduce heterogeneity, increase replicability and transferability, and improve understandings of mechanisms and causal pathways. To that end, five detailed recommendations are offered to support the sharing and development of information across disciplines. (shrink)

Novelty seeking is regarded as a core feature in substance use disorders. However, few studies thus far have investigated this feature in problematic Internet pornography use. The main aim of the present study was to examine group differences in electrophysiological activity associated with novelty processing in participants with high tendencies toward PIPU vs. low tendencies using event-related potentials. Twenty-seven participants with high tendencies toward PIPU and 25 with low tendencies toward PIPU completed a modified three-stimulus oddball task (...) while electroencephalogram was recorded. Participants were instructed to detect neutral target stimuli from distracting stimuli. The distracting stimuli contained a familiar sexual stimulus and a set of novel sexual stimuli. The novel-familiar difference waves were calculated to identify specific group difference in novelty effect. While both groups demonstrated a sustained novelty effect in the late positive potential within the 500–800 ms time windows, the novelty effect was greater in the high tendencies toward PIPU group than in the low tendencies toward PIPU group. This result suggests that individuals with high tendencies toward PIPU allocate more attentional resources for novelty processing. Enhanced brain responding to novel sexual stimuli may facilitate pornographic consumption and play an essential role in the development and maintenance of PIPU. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Appreciating Anorexia:Decisional Capacity and the Role of ValuesThomas Grisso (bio) and Paul S. Appelbaum (bio)Keywordscompetence, consent, anorexia, appreciation, decision makingTan and her colleagues (2006) reported that persons with anorexia nervosa typically manifest no difficulty satisfying the criteria for abilities associated with competence to consent to or refuse treatment. Their results led them to conclude that these patients generally had no problem grasping the nature of anorexia and its possible (...) consequences (understanding), typically did not have difficulty processing information when making treatment decisions (reasoning), and usually neither denied that they had a disorder nor manifested distorted beliefs about the potential consequences of treatment for the disorder.Nevertheless, these authors found, some anorexia patients said that they knew they might die and that they would rather die than suffer the alternative consequences (e.g., loss of identity, feeling of being disgusting). They point out that these beliefs, suggesting questionable competence, were not identified by the usual criteria for competence to consent to treatment. Therefore, they propose that we should consider a modification of the criteria for competence to consent to treatment. They argue for inclusion of "pathological values" as the basis for a finding of incompetence. Their notion of a pathological value (as we summarize it based on their Discussion) includes (a) a personal value (b) on which treatment refusal is based, that (c) is not authentic, and (d) is due to a mental disorder.Second, Tan and colleagues were concerned that the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), currently used widely to assess competence to consent to treatment, did not seem to take values into account when examining deficits related to lack of appreciation or reasoning. They point out that most patients with anorexia nervosa in their study had "pathological values" that influenced their thinking about treatment, yet they did not obtain poor scores on the instrument's appreciation scale, which assesses whether patients deny that they have the illness or offer reasons for accepting or refusing treatment that are based on delusional premises or a serious distortion of reality. Moreover, almost all of the anorexia patients in the study obtained adequate scores on reasoning, which examines the ability to process options and consequences when weighing a treatment decision. [End Page 293]Reasons for Caution in Altering Criteria for CompetenceA fundamental step in considering Tan and her co-worker's proposal is to examine whether it is necessary to add a concept of "pathological values" to the legal construct of competence to consent to treatment. Modifying the legal doctrine of consent is important if that is needed to improve its validity or reliability. But modifications of the doctrine would have considerable costs, including a long process of producing logical and empirical evidence for its necessity, developing methods to assess the new concept, and then a process of debate, persuasion, and education to change laws, ethical guidelines, and medical training. Moreover, principles of theory building urge parsimony. A theory should employ no more concepts or assumptions than are required to account for the phenomena that the theory seeks to organize or explain. So one must be sure that modifications are truly necessary before adding complexity to the theory of decisional competence.In addition, there is an inherent danger in altering a concept like competence to consent to treatment on the basis of the study of any one mental disorder. It is not at all clear how the modification might influence findings of competence when applied to other disorders. Using a study of patients with anorexia nervosa as the impetus for changing the competence concept runs this risk. For example, anorexia is one of a class of mental disorders that is characterized by a failure to abstain from behavior (here, limiting food intake and other behaviors designed to reduce weight) that has negative consequences for the person. Other conditions in this category might include substance abuse disorders and impulse control disorders (e.g., pathological gambling). Even if one concludes that revised criteria for competence would reduce false-positive findings of competence in this group of disorders, one would have to consider carefully its impact on the full range of disabling mental conditions.Moreover, the sensitivity... (shrink)

This commentary on “Her Own Decision: Impairment and Authenticity in Adolescence” by Campbell, Derrington, Hester, and Lew adds further consideration of obligations for guardians and physicians of minors who struggle in making serious decisions regarding medical treatment.

BackgroundAdverse Childhood Experiences have been associated with long-term physical and mental health conditions, toxic stress levels, developing unstable interpersonal relationships, and substance use disorders due to unresolved childhood adversities.AimsThis study assessed the perspectives of mental health providers regarding their adult patients’ coping with ACEs during COVID-19 in Houston, Texas. Specifically, we explored how individuals with ACEs are coping with the increased stresses of the pandemic, how MHPs may provide therapeutic support for individuals with ACEs during this pandemic, pandemic- (...) class='Hi'>related challenges of accessing and utilizing mental health services for individuals with ACEs, and the awareness and treatment of ACEs among MHPs.MethodsTen in-depth semi-structured virtual interviews were conducted with licensed MHPs from November 2021 to April 2022 in Houston, Texas. Interviews were coded and analyzed for emerging themes through an inductive open coding approach to discover insights regarding coping with ACEs during COVID-19.ResultsFour key themes experienced by individuals with ACEs emerged from the MHP interviews: Maladaptive emotional dissonance and coping outlets during the pandemic, Difficulties with social connectedness and significance of social support, Heightened daily life stressors and coping with the ongoing disruption of the pandemic, and Changing interactions with the mental health system. Themes from this study highlighted that resilience, seeking treatment, and strong social support can help develop healthy coping strategies among individuals with ACEs.ConclusionThis study may help inform best clinical practices to develop interventions and policies regarding ACEs such as a resilience-promotion approach that targets all the socio-ecological levels. In addition, findings highlight the synergy of psychotherapeutic and pharmacological management via tele-health modalities, in helping individuals with ACEs continue receiving the care they deserve and need during a persistent pandemic and an uncertain future. (shrink)

The definitive book on ethics for chemical dependency treatment professionals.

Recent experiments have shown that when individuals with a substance use disorder are confronted with drug-related cues, they exhibit an automatically activated tendency to approach these cues. The strength of the drug approach bias has been associated with clinically relevant measures, such as increased drug craving and relapse, and activations in brain reward areas. Retraining the approach bias by means of cognitive bias modification has been demonstrated to decrease relapse rates in patients with an alcohol use disorder and (...) to reduce alcohol cue-evoked limbic activity. Here, we review empirical and theoretical literature on the drug approach bias and explore two distinct models of how the drug approach bias may be embodied. First, we consider the “biological meaning” hypothesis, which grounds the automatic approach bias in the natural meaning of the body. Second, we consider the “sensorimotor hypothesis,” which appeals to the specific sensorimotor loops involved in the instantiation of addictive behaviors as the basis of the automatic approach bias. In order to differentiate between the adequacies of these competing explanations, we present specific, predictions that each model should make. (shrink)

Ethical clinical practice requires cultural competency. In the United States, Hispanics report stronger attitudinal barriers to drug abuse treatment than any other racial/ethnic group. Hispanics report feeling that drug abuse treatment providers do not understand their unique cultural needs and are unfamiliar with their experiences of discrimination and immigration. Using this case study to explore broader ethical and policy issues, this study investigates the extent to which US universities train counselors to address the culturally specific needs of Hispanic patients and (...) how this is reflected in practice in Los Angeles County. Based on a content analysis of the required courses, syllabi, and course descriptions at 30 universities related to culture/race/racism/ethnicity/diversity at the undergraduate and graduate levels on the addiction therapist track, and thematic analysis of eight in-depth interviews with counselors working in outpatient rehabilitation centers in Los Angeles, I argue that cultural competency education for drug abuse counselors is too surface level and infrequent to adequately prepare students for a career in addiction counseling for Hispanic clients. Significant changes must be made to how cultural diversity is valued and prioritized in the field of psychology to provide better care for Hispanic people with a substance use disorder and fulfill the moral obligation to eliminate this health disparity. Although this study focuses on counselors in Los Angeles, these findings are relevant for professionals and healthcare systems across the United States and beyond who seek to provide equitable and effective care for Hispanic patients. (shrink)

BackgroundLow-stakes crimes related to alcohol and/or drugs are common around the world, but research is lacking on police–suspect interactions of such crimes. A large proportion of these suspects are intoxicated during interrogations, and many may have substance use disorder, making them potentially vulnerable to interrogative pressure.MethodsTo address this lack of knowledge, the taxonomy of interrogation methods framework and a common classification of question types were applied in the coding of written police interrogations. Two archival studies, one pilot and (...) one main study analyzed police interrogations with suspects of alcohol- and drug-related crimes in Sweden.ResultsFor both Study 1 and 2, suspects showed signs of alcohol and/or drug intoxication, hangover or withdrawal in more than 50% of all interrogations. In Study 2, additional coding indicated that suspects displayed signs of substance use disorder in 57% of the interrogations. The main results from both studies revealed a large number of direct questions asked by the police across all interrogations, and relatively little use of the strategic interrogation techniques from the taxonomy of interrogation methods framework. In fact, when it came to interrogation techniques, law enforcement used more confrontational techniques in their interactions with intoxicated suspects compared to sober suspects. Furthermore, suspects displaying signs of substance use disorder were significantly more cooperative and prone to confess than suspects without indicators of substance use disorder.ConclusionAs the first novel study on low-stakes crime interrogations related to alcohol and/or drugs, the present study provides useful information about current Swedish interrogation practices and areas for improvement. The study results indicate that suspects displaying signs of intoxication or substance use disorder may be more vulnerable during police interrogations. This may in turn have the potential to inform the development of new interrogation policies. Due to the novelty of this research, more studies are needed, both on a national and international level, to examine interrogations in low-stakes crimes further. (shrink)

_Substance use disorders belong to the class of externalizing behaviours that are generally more common among men than women. Those women who do have substance disorders therefore deviate more from the norms of society compared with men, tend to live in an environment characterized by high risk of violence and other forms of abuse, and tend to be survivors of childhood trauma. In terms of seeking treatment, women often have difficulty acknowledging their problems with substance use (...) disorders, and professionals are reluctant to ask women about drug or alcohol use. Even when they do seek treatment, women in many countries face practical and financial barriers to access treatment. For women who do enter treatment, outcomes are generally comparable to outcomes for men, suggesting that facilitating entry into treatment can yield substantial benefits for women with addictions._. (shrink)

Eugen Bleuler introduced the concept of double bookkeeping in schizophrenia to describe the tendency for people who experience delusions to simultaneously be convinced of the delusional content and yet to act as if the delusion(s) was untrue/irrelevant or be unbothered by discrepancies. We open the question of whether there exists a double reality in individuals with addiction and whether double bookkeeping can be applied to addiction. While double bookkeeping has primarily been explored in schizophrenia, this concept may hold promise in (...) elucidating insight deficits in individuals with substance use disorders. We propose two forms of addiction double bookkeeping: 1) Partial compartmentalization: individuals demonstrate some awareness of the deleterious consequences of drug use, but continue to engage in addictive behaviors; and 2) Total compartmentalization: individuals who act as if the negative consequences of addiction do not exist, reflecting a more generalized and deeper lack of awareness into their own actions. We propose that a basic alteration in the individual’s sense of self occurs in addiction double bookkeeping as it does in schizophrenic double bookkeeping. We describe the proposed double reality in addiction from first-person and third-person perspectives, accounting for their differences. Three clinical exemplar cases are presented, and conceptual implications are explored. (shrink)

As physicians, we have seen patients with substance use disorders leave the hospital against medical advice, slipping through the cracks of our health care system. In fact, despite a high burden of life‐threatening illnesses, patients with SUDs are at a nearly threefold increased risk of leaving the hospital against medical advice. Leaving against medical advice is associated with an increased thirty‐day mortality rate as well as an increased rate of hospital readmission. When a patient leaves in this way, (...) the health care system loses the opportunity to engage with someone who is struggling with an SUD and whose health is at imminent risk. Fortunately, there are ways to address some of these challenges within existing organizational frameworks. Addiction consult teams and supervised injection facilities are two interventions that have proven successful. (shrink)

Eugen Bleuler introduced the concept of double bookkeeping in schizophrenia to describe the tendency for people who experience delusions to simultaneously be convinced of the delusional content and yet to act as if the delusion(s) was untrue/irrelevant or be unbothered by discrepancies. We open the question of whether there exists a double reality in individuals with addiction and whether double bookkeeping can be applied to addiction. While double bookkeeping has primarily been explored in schizophrenia, this concept may hold promise in (...) elucidating insight deficits in individuals with substance use disorders. We propose two forms of addiction double bookkeeping: 1) Partial compartmentalization: individuals demonstrate some awareness of the deleterious consequences of drug use, but continue to engage in addictive behaviors; and 2) Total compartmentalization: individuals who act as if the negative consequences of addiction do not exist, reflecting a more generalized and deeper lack of awareness into their own actions. We propose that a basic alteration in the individual’s sense of self occurs in addiction double bookkeeping as it does in schizophrenic double bookkeeping. We describe the proposed double reality in addiction from first-person and third-person perspectives, accounting for their differences. Three clinical exemplar cases are presented, and conceptual implications are explored. (shrink)

Ayahuasca is a psychedelic beverage from the Amazon rainforest, used in spiritual and religious settings for medical purposes. Since the 1990s onwards, several religious and neo‐shamanic groups have been using it in Uruguay within the psychospiritual networks. Some participants go to rituals of ayahuasca looking for therapeutic alternatives to certain ailments, such as substance use disorders (SUDs). In this chapter, three cases of former patients who recovered in a neo‐shamanic center that uses ayahuasca for the treatment of SUDs (...) are described and analyzed. The center is conducted by a psychologist trained in the Peruvian vegetalismo tradition. An ethnographic description of the ritual setting as well as the process of psychotherapeutic intervention of the center are described. In‐depth interviews were used to collect the narratives of the three patients. A medical anthropology perspective is used, focusing on different subjective trajectories: the general biographic trajectory, SUDs trajectory, spiritual trajectory, and the trajectory under the entheogenic field, ayahuasca included. As we discuss, the impact of ayahuasca rituals ceremonies should be explained not only by ayahuasca as a psychedelic compound, but as a psychotherapeutic tool immersed in a social, cultural, and spiritual setting aimed at the treatment of SUDs. (shrink)

Mental capacity and autonomy are often understood to be normatively neutral? the only values or other norms they may presuppose are those the assessed person does or would accept. We show how mental disorder threatens normatively neutral accounts of autonomy. These accounts produce false positives, particularly in the case of disorders (such as depression, anorexia nervosa and schizophrenia) that affect evaluative abilities. Two normatively neutral strategies for handling autonomy-undermining disorder are explored and rejected: a blanket exclusion of mental disorder, (...) and functional tests requiring consistency, expression of identity, reflective non-alienation or lack of compulsion. Finally, we suggest ways in which substantivist alternatives to neutrality can be made more promising through increased transparency, democratic contestability of conditions for capacity and autonomy, and a historically sensitive caution concerning restrictions of liberty. (shrink)

This article examines the unique disadvantages experienced by Black people and other people of color with substance use disorder in health care, and argues that an intersectional approach to enforcing disability rights laws offer an opportunity to ameliorate some of the harms of oppression to this population.

The insight a patient shares into their own psychosis is fundamental to their condition - it goes to the heart of what we understand 'madness' to be. Can a person be expected to accept treatment for a condition that they deny they have? Can a person be held responsible for their actions if those actions are inspired by their own unique perceptions and beliefs - beliefs that no-one else shares? The topic of insight in schizophrenia and related disorders (...) has become a major focus of research in psychiatry and psychology. It has important clinical implications in terms of outcome, treatment adherence, competence, and forensic issues. In order to study 'insight' a broad perspective is required. This involves applying knowledge from the cognitive and brain sciences, as well as from philosophy and the social sciences. Insight and Psychosis comprises a series of in-depth, well-referenced, scholarly overviews from each of these perspectives with a strong empirical foundation - including in some cases the presentation of new data and meta-analysis of the published literature. These are integrated and synthesised by the editors, both acknowledged experts in the field. The scope is truly international and spans theoretical perspectives, clinical practice, and consumer views. The book will act as a source for students and researchers interested in pursuing any number of questions and controversies around lack of insight and awareness, and will guide clinical psychologists and psychiatrists who seek a broader view of the many facets of insight that might arise during their day-to-day work. (shrink)

One of the great insights of postmodern thought is that our understanding is perspectival, and that we have the perspectives we do because we have privileged one element of certain important binaries over others. Western civilization, or our understanding of it, is based upon our privileging of the male perspective over the female, the rich over the poor, and the white over the black. If that order were reversed and we privileged the perspective of those who had been marginalized, we (...) would see things very differently. Traditional attempts to understand both our own identity and the identity of God all hinge on Aristotle’s privileging of substance over relation. The distinction between substance and relation is another important binary that has shaped Western Civilization. This paper looks at both human and divine identity by privileging relation over substance and considering identity from that marginalized perspective. (shrink)

Substance addiction affects millions of individuals worldwide and yet there is no consensus regarding its conceptualisation. Recent neuroscientific developments fuel the view that addiction can be classified as a brain disease, whereas a different body of scholars disagrees by claiming that addictive behaviour is a choice. These two models, the Brain Disease Model and the Choice Model, seem to oppose each other directly. This article contends the belief that the two models in the addiction debate are polar opposites. It (...) shows that it is not the large amount of addiction research in itself what sets the models apart, but rather their extrapolated conclusions. Moreover, some of the most fiercely debated aspects - for instance, whether or not addiction should be classified as a disease or disorder - are irrelevant for the conceptualisation of addiction. Instead, the real disagreement is shown to revolve around capacities. Discussing addiction-related capacities, especially regarding impaired control, rather than the assumed juxtaposition of the two models can be considered the true addiction debate. More insight into the extent to which the capacities of the addicted individual were affected would be highly useful in various other areas, especially legal responsibility. (shrink)