teori penagihan, kesan fisiologi dan dsm iv

7/29/2019 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

teori penagihan, kesan fisiologi dan dsm iv

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