Teori Penagihan, Kesan Fisiologi Dan DSM IV
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Transcript of Teori Penagihan, Kesan Fisiologi Dan DSM IV
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Teori Penagihan
& Kesan Fisiologi& DSM-IV
Bengkel Rawatan dan Detoksifikasi Menggunakan
Ubat-Ubatan
Dr. Mohd Fadzli Mohamad Isa
Pakar Psikiatri
Hospital Sultan Abdul Halim
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Teori Penagihan
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Apa itu dadah?
- Jenis-jenisnya
- Kesan dadah: Biologi/Fisiologi, Psikologi, Sosial
Bagaimana dadah berfungsi?
Corak-corak ketagihan
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Dadah = ubat = drug = medicine
Masalah dengan dadah ialah ianya selalu di
salah guna atau misuse dan abuse
Di dalam Al-Quran, istilah Khamar digunakan bagi
semua bahan yang memabukkan atau boleh
menghilangkan fikiran
Dadah boleh dikategorikan sebagai satu daripada jenis
Khamar kerana ia boleh memabukkan,
mengkhayalkan, dan menyebabkan penagihan, dan
pergantungan, perubahan tingkah laku, emosi, ragam
dan pemikiran.
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Sabda Rasulullah S.A.W. yang maksudnya:
Setiap yang memabukkan adalah khamar dan setiapkhamar adalah haram
Riwayat Muslim
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Apa sebenarnya penagihan dadah?
Penyakit otak (mental) yang berlakudengan tingkahlaku kompulsif (tidakterkawal)
Meneruskan ketagihan walaupun
mengalami kesan negatif
Boleh menjadi kronik dan boleh berulang
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Why doesaddictionbegin?
Agent
Availability
Cost
Rapidity of Onset Tranquilizing Effects
Environment
Occupation
Peer Group
Culture
Social Instability
Host
GeneticPredisposition
DysfunctionalFamilies
Psychiatric Disorder
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Ketagihan dadah: Suatu PENYAKIT yang
kompleks
Ketagihan dadah adalah suatu penyakit yang rumit
Bermula dengan perlakuan pengambilan dadah
Keupayaan seseorang untuk memilih supaya tidak mengambil
dadah berkurangan selepas beberapa ketika
Ini disebabkan oleh kesan pengambilan dadah secara berpanjangan
yang memberi kesan ke atas fungsi otak dan mempengaruhi
kelakuan
Oleh itu, ketagihan adalah bersifat pengambilan, pencarian dan
penggunaan dadah secara tidak terkawal yang diteruskan walaupun
berdepan dengan kesan-kesan negatif
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Kawasan Otak & Fungs-
fungsinya
www.drugabuse.gov
Kawasan tertentu otak
mengawal fungsi yang
tertentu.
Sel saraf bergerak dari satu
kawasan ke kawasan lainmelalui satu laluan untuk
menyampaikan dan
menyatukan maklumat
Laluan ini dinamakan
REWARD PATHWAY
Bermula dari ventral
tegmental area (VTA),
kemudiannya ke nucleus
accumbens (NA), dan ke
prefrontal cortex (PFC).
Laluan ini diaktifkan
apabila seseorang
menerima gandaan positif
untuk sesetengah kelakuan
(ganjaran)
hippocampus
VTANucleus
accumbens
Pre-frontal
cortex
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Dopamine (D) and serotonin
(5HT) biasanya terbabit
dalam komunikasi antara sel
saraf dalam otak
Penggunaan dadah boleh
mempengaruhi fungsi
mereka
Dopamine terdapat dalam
banyak kawasan otak(biru)
yang berkaitan dengan
keseronokkan, motivasi,
fungsi motor dan
pengendalian rangsangan
5HT, (merah)berfungsi
dalam pembelajaran,
memori, tidur dan
perasaan
Neurotransmitter (Dopamin dan 5HT): Fungsinya dalam ketagihan
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REWARD PATHWAY
Diaktifkan apabila
seseorang menerima
tindakbalas positif
untuk beberapa
kelakuan (kelakuan
semulajadi atau pun
artificial seperti
dadah)
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Tikus itu terus menekan butanguntuk mendapakan lebih banyak
kokain/heroin kerana dadah itumembuatkan ia berasa bagus.Inilah penguat positif atauganjaran
Ganjaran semulajadi
termasuklah makanan, air danseks semuanya diperlukanuntuk meneruskankelangsungan spesis. Binatangdan manusia akan terusmenunjukkan kelakuan yang
memberi ganjaran dan akanmemberhentikan kelakuan ituapabila tiada lagi ganjaran
Inilah yang digelar rewardsystem
KAJIAN SAINTIS:DADAH, PENGUAT POSITIF DAN REWARD PATHWAY
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MODEL PERUBATAN PENAGIHAN DADAH
Penyakit kronik berulang (Chronic Relapsing Condition) eg. Asthma
Matlamat jangka pendek berhenti penagihan sepenuhnya(Abstinence) tidak realistik bagi kebanyakkan penagih
Usaha yang intensifdan berterusan untuk beberapa tahunmenggunakan pelbagai pendekatan untuk berhenti sepenuhnyaumumnya mengecewakan
Kepercayaan untuk mencapai berhenti sepenuhnya menghadkanhasil/faedah dan berisiko.
Penagih mencapai umur matang akan berhenti tabiat penagihan
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PATOFISIOLOGI PENAGIHAN OPIATE
Endorfin
opiate semula jadi
Morphin/Heroin
opiate sintatik, cepat jangka hayat
menekan/ mengurangkan pengeluaran endorfin
Adaptasi reseptor dan pengambilan kronik; supersensitiviti terhadapdopamin, acetylcholin, adrenalin, serotonin
Ketiadaan morfin/heroin menyebabkan simptom gian penerusanpenagihan
Untuk kesan lebih dan menghilangkan
gian menyebabkan tingkahlakuberisiko; jenayah, dadah menjadiprioriti kehidupan, pengambilandadah suntikan (masalah kesihatan)
Penagih tersiksa kerana perlukan kuantiti yang lebih atau mengubah cara pengambilan
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Drugs
BrainMechanisms
Behavior
Environment
Historical
Environmental
- Prior experience- Expectation- Learning
- Social interactions
- Stress- Conditioned stimuli
- Genetics- Circadian rhythms- Disease states- Gender
Physiological
Drug Addiction: A Complex Behavioral and
Neurobiological Disorder
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But, drug addiction is a chronicillness with relapse rates
similar to those ofhypertension, diabetes, and
asthma
McLellan et al., JAMA, 2000.
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DrugAddiction
Type IDiabetes
0102030405060708090
100
Hypertension Asthma
40to60%
30to50%
50to70%
50to70%
PercentofPatientsWhoRelapse
McLellan et al., JAMA, 2000.Thus, drug addiction should be treated and evaluated like any other chronic illness.
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Recovery from it--protracted abstinence andrestored functioning--is often a long-term processrequiring repeated treatments
Relapses to drug abuse can occur during or aftersuccessful treatment episodes
Participation in self-help support programs duringand following treatment can be helpful in sustaining
long-term recovery
Therefore
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relapse to drug abuse is similar to what happens with other chronicdiseases
Relapse: Part of Addiction as a Chronic
Disease
Just as an asthma attack can be tr iggered by smoke, or a
person with diabetes can have a react ion if they eat too
much sugar, a drug addict c an be tr iggered to return todrug abuse.
With oth er chron ic dis eases, relapse serves as a signal for
returning to treatment. The same response is jus t as
necessary wi th d rug addict ion.
As a ch ronic , recurr ing i l lness, addict ion m ay requirerepeated treatments unt i l abst in ence is ach ieved. Like
other diseases, drug addict ion can b e effect ively treated
and managed.
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Moral failure model
Failure of parents or parental surrogates (eg religious training,
schools, movies, television, music)
Unable to filter undesirable elements (drug culture, smoking)
Lack of ongoing morality that would prevent use of substance
Useful in the public health view point
Generally not useful in dependence
Might be useful in 12 steps
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Psychosocial model
See addiction as an inadvertent effect of repeated self medication
By vulnerable individual to relieve overwhelming anxiety or
psychic pain
Hopelessness
Depression
Boredom
Facing losses
Situational anxiety
Physical pain
Demoralisation
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This model can define population at risk
Young
Uneducated
Socio economically disadvantaged
This model also relies on the use of support system and self
help as a requirement for remission
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DRUG USE(Self-Medication)
STRESS
CRF
Anxiety
CRF
Anxiety
PERANAN STRESS DALAM PENGGUNAAN DADAH
Corticotropin-releasing
factor is a critical
coordinator of the
hypothalamic-pituitary-adrenal
(HPA) axis and is an
essential component in
mediation of endocrine
and behavioral
responses to stress
(Vale etal., 1981;
Vaughan et al., 1995).
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ProlongedDRUG
USE
Abstinence
RELAPSE
CRF
AnxietyWhat Happens When A Person Stops Taking A Drug?
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Teori Penagihan
Suatu penyakit kronik (dan berulang-ulang)
Bukan semata-mata perangai atau personaliti
Otak dan fungsi bahagian-bahagian tertentu otak.
Reward pathway menerangkan kesan dadah pada
otak dan tabiat penagihan
Stress, penyakit mental dan penagihan dadah.
in a nut shell .:
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Kesan Dadah ke atasFisiologi Badan
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Kesan dadah
Biologikal
(Fisiologi)
Psikologikal
Sosial
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Kesan dadah: Biologikal
Memberi kesan ke atas sistem saraf pusat (central
nervous system)
Kesan fisiologi fisiologi bergantung kepada jenisdadah
Setiap dadah mempunyai mekanisma tersendiri
yang membabitkanprecise brain receptors
Kesan ke atas fisiologi tubuh badan
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Penggunaan dadah
Paru-paru
Jantung
Hati
Usus
Buah pinggang dan
pundi kencing
Pembuluh darah
LANGSUNG
TIDAK LANGSUNG
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KEMASUKKAN DADAH KE
ARAH OTAK
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Kesan Fisiologi: Ganja
Komponen aktif: Tetra-hydro-cannabinol (THC)
0.25% - 8% THC
Menghisap sebatang ganja menyebabkan pengumpulan THC
dalam sel badan selama 7 hari dan dikeluarkan semua secara
fisiologi normal dari tubuh antara 4-6 minggu
Menghisap ganja secara berterusan selama 1 minggu hingga
sebulan akan menyebabkan THC sentiasa terkumpul dalam selbadan .
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Kesan Fisiologi: Opioid
Candu Mentah
Morfin
Heroin
Kodein
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Amphetamine-type stimulants (ATS)
Synthetically-manufactured central stimulants
Similar in pharmacological effects and chemical
structures
Amphetamine-group
substances:
- Amphetamine-
Methamphetamine
- Methcathinone
Ecstasy-group
substances:
- 3,4-methylenedioxy
methamphetamine
(MDMA)
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Kesan Fisiologi: ATS
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S
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DSM-IV
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Sejenis klasifikasi untuk membuat diagnosis penyakitpsikiatri dan mental (diagnostic classification)
American Psychiatric Association (APA):
DSM-I: 1952 (= ICD-6)
DSM-II:
DSM-III:1980 (= ICD-9)
DSM-III-R: 1987
DSM-IV: 1994 (= ICD-10)
DSM-IV-TR: 2000
DSM-V: 2013
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Kegunaan:
1. Klinikal (membuat diagnosis penyakit mental)2. Penyelidikan
3. Statistik (pengumpulan data)
Keperluan:
a) Pengurusan klinikal
b) Komunikasi
c) Penyelidikan dan pembelajaran akademik
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Disorders Usually First Diagnosed inDelirium, Dementia, Amnestic
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DSM-IV
Disorders Usually First Diagnosed in
Infancy, Childhood or Adolescence
, ,
and Other Cognitive
Disorders
Mental Disorders
due to General
Medical Condition
Substance-RelatedDisorders
Schizophrenia and
Other psychotic
Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious
Disorders
Dissociative Disorders
Sexual and Gender
Identity Disorders
Eating Disorders
Impulse Control
Disorders
Adjustment Disorders
DSM IV TR ICD 10
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DSM-IV-TR
Substance-related
disorders
ICD-10
Disorders related to
psychoactive drug use
Substance Use Disorders Abuse
Dependence
Substance-Induced
Disorders
IntoxicationWithdrawal
DeliriumPersisting dementia
Persistent amnestic disorderPsychotic disorder
Mood disorderSexual dysfunction
Sleep disorder
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Substance Use Disorder
Penggunaan jumlah yang lebih banyak atau lebihlama daripada yang dimahukan
Niat untuk berhenti yang berterusan ataupercubaan yang gagal untuk
mengurangkan/mengawal penggunaan
Banyak masa digunakan untuk mendapatkan,menggunakan atau pulih selepas penggunaan
Gian(Craving)
Gagal untuk memenuhi tanggungjawab (tempatkerja, sekolah, rumah)
Masalah sosial atau perhubungan yang disebabkanoleh penggunaan bahan
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Substance Use Disorder
Aktiviti sosial, pekerjaan dan rekreasi berkurangan/dihentikan
kerana penggunaan bahan
Penggunaan dalam keadaan yang berbahaya
Penggunaan walaupun mendapat masalah fizikal ataupsikologikal disebabkan penggunaan
Penggunaan yang semakin banyak (Tolerance)
Withdrawal
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Specifiers
Specifiers
In early remission: no criteria for > 3 months but 12 months
(except craving)
In a controlled environment: access to substance
restricted (ex. Jail)
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Terminology
Abuse
Dependence
Intoxication
ToleranceWithdrawal
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Terminology
Dependence: A state of psychic or physical dependence, orboth, on a drug, arising in a person following administration ofthat drug on a periodic or continuous basis. Thecharacteristics of such a state will vary with the agent involved
(WHO 1964).
The hallmarks of this pattern are:
tolerance
withdrawal
compulsive use
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Physical dependence
Tolerence
A need for markedly increased amounts of substance to
achieve intoxication or desired effect
Marked diminished effect with continuous use of sameamount
Withdrawal
Characteristic withdrawalSame or closely related substance is taken to relieve or
avoid withdrawal
DSM IV TR CRITERIA
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SUSBTANCE ABUSE
A maladaptive pattern of use in12 months
Not fulfill dependence
Impairment or distress
manifested by 1 or more from 4criteria :
- Failure to fulfill obligations at home,work or school
- Recurrent use in dangerous situations(drunk driving)
- Recurrent legal problems
- Continued use despite causingpersonal/social problems
SUBSTANCE DEPENDENCE
A maladaptive pattern of usein 12 months
Impairment or distressmanifested by 3 or more from7 criteria: Tolerance
Withdrawal
Substance is used more or longerthan intended
Desire to or unsuccessful efforts
to cut down Great time used in obtaining,
using, or recovering.
Important activities lost
Continuous use despiteconsequences.
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Abuse vs Dependence
Abuse
Misuse or overuse
Not accepted
culturally
Gives rise to
certain adverse
consequences
Dependence
Compulsiveuncontrollable use ofdrugs
Overwhelmingpreoccupation ofgetting the substance
There may besignificantconsequences
Tendency to relapseafter discontinuation
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Psychological dependence
Drug is central to a persons thoughts, emotions,
and activities that he need to continue its use
because it has a craving or compulsion.
Motivational component: great subjective need,
compulsion, drive to get the drug.
Habituation : Just "like" the drug; Drug effects
serve as
positive reinforcers
.
Ed d d G (1976)
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Edwards and Gross(1976)Narrowing of behavioural repertoire (primacy)
Salience of drinking or drug use (stereotyping)
Tolerance (tolerance)
Subjective awareness of compulsion (awareness of compulsion)
Repeated withdrawal (repeated withdrawal)
Avoidance of withdrawal (relieved drinking)
Post abstinence reinstatement (reinstatement after abstinence)
StereotypingPrimacy
Tolerance
Repeated withdrawals
Relieved drinkingAwareness of compulsion
Reinstatement after
abstinence
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Typical Presentation and Course:
Presented in:
acute intoxication
acute/chronic withdrawal
substance-induced conditions
cognitive disorder
medical complications
Remission and relapses are the rule (just like any otherchronic medical illness)
70 % eventually able to abstain or decrease use to notmeet criteria
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TERIMA KASIH