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It's the thought that counts: Craving metacognitions and their role in abstinence from methamphetamine use
Abstract
Craving is frequently reported as a trigger for relapse by those trying to remain abstinent from psychoactive substances. Metacognitive beliefs about managing craving may play an important role in determining further cognition and behavior. They are, therefore, important to measure in treatment and may serve as target cognitions to be modified in support of behavioral change. As part of the assessment battery of a randomized controlled trial among 214 methamphetamine users, we included the Craving Beliefs Questionnaire (CBQ), a measure designed to assess an individual's perception of the potential negative impact of craving, at baseline. Changes in abstinence rates were significantly related to CBQ score, suggesting that craving beliefs are associated with changes in methamphetamine use. Further validation of the CBQ is warranted. Future clinical research among methamphetamine users could focus on directly manipulating craving beliefs through cognitive therapy to affect abstinence.
... Research suggests craving metacognition may contribute to an individual's likelihood of abstinence success (Lee, Pohlman, Baker, Ferris, & Kay-Lambkin, 2010;Nosen & Woody, 2009). For example, Lee and colleagues found lower baseline Craving Beliefs Questionnaire (CBQ; Beck, Wright, Newman, & Liese, 1993) scores in individuals who later reported abstinence compared to those who did not go on to achieve abstinence. ...
... metacognitions (Beck et al., 1993). The CBQ has been used to measure metacognitions for different substances including alcohol (Loeber, Croissant, Heinz, Mann, & Flor, 2006), methamphetamine (Lee et al., 2010), and heroin (Chang et al., 2011) and in different therapies including combined cognitive behavioural therapy and motivational interviewing (Lee et al., 2010). The CBQ has demonstrated sensitivity to change (e.g., Chang et al., 2011;Grant, Kunic, MacPherson, McKeown, & Hansen, 2003;Loeber et al., 2006) and predicted abstinence (Lee et al., 2010). ...
... metacognitions (Beck et al., 1993). The CBQ has been used to measure metacognitions for different substances including alcohol (Loeber, Croissant, Heinz, Mann, & Flor, 2006), methamphetamine (Lee et al., 2010), and heroin (Chang et al., 2011) and in different therapies including combined cognitive behavioural therapy and motivational interviewing (Lee et al., 2010). The CBQ has demonstrated sensitivity to change (e.g., Chang et al., 2011;Grant, Kunic, MacPherson, McKeown, & Hansen, 2003;Loeber et al., 2006) and predicted abstinence (Lee et al., 2010). ...
Recent craving research has focused on individuals' beliefs about cravings. Yet, measures about craving beliefs have rarely been compared with other craving belief measures or measures of craving itself. We aimed to develop a craving metacognition measure with a simple factor structure that could be used by people with a range of alcohol use patterns. This article introduces the Craving Metacognition Scale, a measure of individuals' craving metacognitions. Items were generated based on specific beliefs and attitudes related to craving and drinking, sourced from existing questionnaires and edited to emphasise metacognitive appraisal. Two samples tested the scale: one of individuals seeking treatment for alcohol use issues (n = 115) and the other of undergraduate students who drank regularly (n = 92). The items were refined based on contribution to the total score and divergence from existing measures. The final 13‐item scale showed strong internal consistency (α = .93) and good convergence with existing measures, such as the Jellinek Alcohol Craving Questionnaire‐now (Pearson's r = .698) and the Metacognition Questionnaire for Alcohol Abusers subscales (between r = .602 and r = .811). The Craving Metacognition Scale shows preliminary evidence of psychometric validity. It has a simple factor structure that measures craving metacognitions reported by individuals with a range of drinking habits.
... The current literature shows that MA abusers with high drug cravings are likely to develop cognitive functional impairments, including those affecting executive function, attention, social cognition, flexibility, and memory (Potvin et al., 2018;Bernheim et al., 2016;Buck & Siegel, 2015). Meanwhile, Lee et al. (2010) believed that metacognition also plays an important role in stopping addictive behavior and predicting relapse. ...
... Over the decades, there has also been a great deal of literature on metacognition and addictive behavior. Some studies have shown that metacognitive beliefs have a strong cross-diagnostic influence on addictive behaviors: smoking behaviors (Hamonniere & Varescon, 2018;Nosen & Woody, 2014;Spada et al., 2015a), gambling behaviors (Caselli et al., 2018a;Mansueto et al., 2016;Rogier et al., 2021;Spada et al., 2015b), alcohol behaviors (Caselli et al., 2018b;Ottonello et al., 2019;Hamonniere et al., 2020;Delonca et al., 2021) as well as drug behaviors (Hamonniere et al., 2021;Lee et al., 2010). Although a few studies on metacognitive monitoring and addictive behavior, such as alcohol behaviors (Spada & Wells, 2009) and smoking behaviors (Nikcevic & Spada, 2010), exist, there are few studies on the effect of metacognitive monitoring on MA cravings. ...
Background and objective
Metacognitive monitoring refers to the process in which an individual analyzes their own mental state, then monitors and adjusts cognitive activities to achieve a predetermined goal. Recent research has suggested a strong link between metacognition and drug cravings. Conversely, few studies on the impact of metacognitive monitoring on methamphetamine (MA) cravings exist. Thus, this study investigated whether drug cravings would impair MA abusers’ metacognitive monitoring and explored the prediction effects of drug cravings.
Method
Seventy MA abusers from the Zhejiang Compulsory Isolation Drug Rehabilitation Center and 65 non-users from the Wenzhou Medical University were recruited for this experimental study. The judgments of learning (JOL) paradigm was used to examine metacognitive monitoring, and cue-induced pictures were used to induce MA abusers’ drug cravings. Analysis of covariance (ANCOVA), partial correlation, and regression analysis were performed.
Results
Compared with non-users, MA abusers had significantly poorer metacognitive monitoring and tended to overestimate their performance. Furthermore, there was a significant correlation between the accuracy of JOLs and drug cravings, which indicated that metacognitive monitoring was weakened by drug cravings with higher cravings imposing more severe impacts. In addition, the regression analysis suggested that drug cravings can predict metacognitive monitoring.
... Studies revealed that substance addiction portray much elevated levels of dysfunctional thinking [3] with schemas associated with extreme difficulties in emotional expression manifesting to be the most powerful in polysubstance abusers [4] A Turkish study showed that there was a relationship between dysfunctional thoughts and relapse among alcohol dependent males [5] Another study also confirmed this relationship among methamphetamine consumers [6,7] proposed to assess the dysfunctional beliefs of patients, to give careful consideration to patients who have the most dysfunctional beliefs and to take care of them through cognitive and behavioral therapies. ...
... High scores in factor disadvantages mean low beliefs related to the disadvantages of alcohol consumption, high scores in the factor Advantages mean high beliefs related to the advantages, and high scores in the factor Moral rules mean low beliefs related to moral rules. Some items are scored in ascending order from zero to four (items 1,4,7,8,11,15,18,21,24,27,29,30,34,37,39,40,43) while some others are counted in descending order from four to zero (items 2, 3,5,6,9,10,12,13,14,16,17,19,20,22,23,25,26,28,31,32,33,35,36,38,41,42,44,45,46,47,48). Internal consistency was assessed using Cronbach's alphas, reliable if alphas are equal or higher than 0.7 [11]. ...
The French ASP questionnaire was made to estimate the patients’beliefs concerning alcohol. These beliefs presented in the ASP model stands for Anticipatory, Solace (relief-oriented) and Permissive (facilitative) beliefs. The aim of this study was to explore the beliefs associated with alcohol in Saudi Arabia and to validate the Arabic version of the ASP. This study includes 144 subjects between ages 18-62, mean age was 31.33 (SD = 7.75). There were 52.4% male and 47.6% female. The exploratory factor analysis displayed seven models with two and three-factor solutions; the best model found is a three-factor solution of 37 items. Confirmatory factor analysis considered this model as satisfactory. The internal consistency is considered as excellent. The Arabic version of the ASP questionnaire could evaluate the patients’ beliefs related to alcohol consumption in three aspects or factors (disadvantages, advantages and moral rules) each factor includes Anticipatory, Solace and Permissive beliefs. Testing the new version of the questionnaire in a larger study sample will provide us with a better understanding of the psychometric stability of this questionnaire.
... Consistent with metacognitive models, they found that appraisals of alcohol-related intrusions as unpleasant (e.g., "this thought disturbs me") and as uncontrollable and linked to action (e.g., "this thought is stronger than my will"; "this thought can really make me drink") correlated with increased craving, greater tendencies to suppress alcohol-related thoughts, more severe depressive symptoms, and decreased cessation self-efficacy. Beliefs like "once craving starts I have no control over my behaviour" and "cravings can drive you crazy" have also been shown to predict abstinence status among treatment-seeking methamphetamine users (Lee, Pohlman, Baker, Ferris, & Kay-Lambkin, 2010). ...
... For example, in recently abstinent alcohol abusers, appraisals of alcohol-related intrusions as unpleasant (e.g., "this thought disturbs me") and as uncontrollable and linked to action (e.g., "this thought is stronger than my will"; "this thought can really make me drink") correlated with increased craving, greater tendencies to suppress alcohol-related thoughts, more severe depressive symptoms, and decreased cessation selfefficacy (Hoyer et al., 2007). Beliefs like "once craving starts I have no control over my behaviour" and "cravings can drive you crazy" have also been shown to predict abstinence status among treatment-seeking methamphetamine users (Lee et al., 2010). ...
... It was demonstrated that craving metacognition rather than craving intensity can predict outcomes of treatment (Heinz et al., 2006). It has also been found that metacognition about craving can be influenced by psychological treatment (Loeber et al., 2006) and this itself is related to relapse and substance use (Spada et al., 2009; Lee et al., 2010). Whether cholesterol is associated with the cognition aspect of psychological craving is unknown. ...
... ), was employed in this study because recent studies have employed the Craving Belief Questionnaire as a measurement of metacognition about craving (Loeber et al., 2006; Lee et al., 2010). The higher CS score indicates a stronger craving tendency. ...
Objective:
Lipids may play some roles in the central nervous system functions that are associated with drug addiction. To date, cholesterol is known to influence relapse of cocaine use. However, the relationship between cholesterol and heroin craving is unclear. This study examined the concurrent association between cholesterol and craving.
Method:
The serum lipid levels of 70 heroin users who were undergoing or had undergone a methadone maintenance therapy were measured. Their craving and demographic data were assessed.
Results:
Total cholesterol and low-density lipoprotein cholesterol are negatively associated with craving before (r = -0.33, P < 0.01, and r = -0.36, P < 0.01, respectively) and after controlling for the effects of potential confounders (β = -0.38, P < 0.01, and β = -0.42, P < 0.01, respectively).
Conclusions:
Cholesterol could be associated with the cognitive aspect of craving and may be a potential marker to predict risk of drug relapse.
... Craving as a construct is still a matter of debate within clinical research. [56,57] examined the role of metacognition in suppressing cravings. They found that the internal strategies and cognitive processes that control cravings had a great deal to do with relapse prevention, which may also address the role amphetamines play in assisting executive functioning. ...
... Previous literature about craving beliefs suggests that craving beliefs modify the course of methamphetamine use [16]. But it is not known if craving beliefs affect the course only in less dependent individuals as seen in smokers [17] or if it is effective for people with severe SUD as well. ...
... Previous literature about craving beliefs suggests that craving beliefs modify the course of methamphetamine use [16]. But it is not known if craving beliefs affect the course only in less dependent individuals as seen in smokers [17] or if it is effective for people with severe SUD as well. ...
Background:
Cognitions associated with craving and substance use are important contributors for the psychological theories of Substance use disorders (SUD), as they may affect the course and treatment. In this study, we aimed to validate Turkish version of two major scales 'Beliefs About Substance Use'(BSU) and 'Craving Beliefs Questionnaire'(CBQ) in patients with heroin use disorder and define the interaction of these beliefs with patient profile, depression and anxiety symptoms, with an aim to use these thoughts as targets for treatment.
Methods:
One hundred seventy-six inpatients diagnosed with heroin use disorder and 120 participants in the healthy comparison group were evaluated with CBQ, BSU, Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI) and sociodemographic data questionnaire. Patient group was also evaluated with Addiction Profile Index. Reliability and validity analysis for scales were conducted. Linear regression analysis was conducted to evaluate the determinants of BSU and CBQ scores.
Results:
Cronbach alpha level was 0.93 for BSU and 0.94 for CBQ. Patient group showed significantly higher CBQ, BSU, BAI and BDI scores (p < 0.001). BSU score significantly correlated with API-substance use profile score, API-diagnosis, BAI, BDI and CBQ (p < 0.005), whereas CBQ scores significantly correlated with API-diagnosis, API-impact on life, API-craving, API-total score, BSU, BAI, BDI and amount of cigarette smoking (p < 0.002). Number of previous treatments and age of onset for substance use were not correlated with either BSU or CBQ. BAI and BDI scores significantly predicted BSU score, however only BDI score predicted CBQ score (p < 0.003).
Conclusions:
Craving beliefs were highly correlated with addiction profile. Anxiety and depression are significant modulators for patients' beliefs about substance use and depression is a modulator for craving and maladaptive beliefs, validating emotion-cognition interplay in addiction.
... On similar lines, in smoking cessation, Nosen and Woody (2009) showed that negative metacognitive beliefs about craving were positively correlated with craving severity and depressive symptoms, and predicted smoking status at one-month follow-up. In addition, Lee, Pohlman, Baker, Ferris, and Kay-Lambkin (2010) showed in methamphetamine users that metacognitive beliefs about craving were associated with relapse after psychological intervention. Furthermore, another study showed that successful smoking abstinence was associated with decreases in metacognitive beliefs about craving (Nosen & Woody, 2014). ...
A wide research base has shown the link between metacognitive beliefs and psychopathology and there is currently evidence that elevated levels of maladaptive metacognitive beliefs are present in the majority of psychological disorders. An increasing body of evidence also suggests that metacognitive beliefs may play a role in alcohol use, nicotine use, gambling, online gaming and problematic internet use. This article provides a systematic review of empirical studies that have examined metacognitive beliefs and addictive behaviours. Thirty-eight studies were included, with results showing a significant positive association between metacognitive beliefs and addictive behaviours. These results are consistent with the metacognitive model of addictive behaviour that supports the central role of metacognitive beliefs in the development and maintenance of addictive behaviours. However, our review highlights the paucity of longitudinal and experimental studies, preventing the determination of the causal status of metacognitive beliefs in addictive behaviours. Despite this limitation, the current evidence has important treatment implications because it suggests that interventions that target metacognitive beliefs could be beneficial for people presenting with addictive behaviours.
... On similar lines, in smoking cessation, Nosen and Woody (2009) showed that negative metacognitive beliefs about craving were positively correlated with craving severity and depressive symptoms, and predicted smoking status at one-month follow-up. In addition, Lee, Pohlman, Baker, Ferris, and Kay-Lambkin (2010) showed in methamphetamine users that metacognitive beliefs about craving were associated with relapse after psychological intervention. Furthermore, another study showed that successful smoking abstinence was associated with decreases in metacognitive beliefs about craving (Nosen & Woody, 2014). ...
Résumé
Les croyances métacognitives désignent les croyances qu’un individu détient à propos de ses pensées et des stratégies pour les réguler. D’après le modèle métacognitif de Wells (1994), certaines croyances métacognitives dysfonctionnelles contribueraient au développement et au maintien des troubles mentaux. Nous disposons en effet aujourd’hui de nombreuses données attestant d’un lien significatif entre ces croyances métacognitives et la majorité des psychopathologies. Parmi ces études, certaines ont étudié spécifiquement les liens entre métacognitions et conduites addictives. Il semble que des croyances spécifiques à propos des pensées et du comportement addictif jouent un rôle dans le développement et le maintien d’une conduite problématique. Ces études ont abouti récemment à la proposition d’un modèle métacognitif des addictions. Nous proposons à travers cet article une synthèse des études sur le sujet, une présentation dudit modèle et de ses implications cliniques.
... Situational increases in drug craving are often proximal to drug use in the laboratory and real-world settings and have been identified has one of the strongest predictors of lapse and relapse during quit attempts (Shiffman et al. 1996;Shiffman and Waters 2004;Leeman et al. 2009;Epstein et al. 2009;Preston and Epstein 2011;for review, Sinha 2013). For example, in cocaine-and MA-dependent individuals, the magnitude of craving and craving-related beliefs are predictive of relapse during treatment (Hartz et al. 2001;Rohsenow et al. 2007;Paliwal et al. 2008;Galloway and Singleton 2009;Lee et al. 2010). Further, tonic craving for MA has been observed at least 5 weeks into abstinence and appears to render users particularly vulnerable to relapse within this period (Hartz et al. 2001;Galloway and Singleton 2009;Zorick et al. 2010). ...
RationaleReductions in cue-induced craving and subjective response to drugs of abuse are commonly used as initial outcome measures when testing novel medications for the treatment of addiction. Yet neither the relationship between these two measures at the individual level nor the moderating effects of pharmacotherapies on this relationship has been examined. Objective
This secondary data analysis sought to examine (1) the predictive relationship between cue-induced craving and subsequent acute subjective response to methamphetamine (MA) and (2) whether the opioid-receptor antagonist naltrexone moderated this association in a sample of non-treatment-seeking individuals who met DSM-IV criteria for MA use disorder (abuse or dependence). Methods
Participants (n = 30) completed two 4-day medication regimens (oral naltrexone 50 mg or placebo, in a randomized, counterbalanced, and double-blind fashion). On day 4 of each medication regimen, participants completed a cue-reactivity paradigm followed by intravenous MA administration. Methamphetamine craving was assessed after the cue-reactivity paradigm, and subjective response to MA was assessed during MA infusion. ResultsCue-induced craving for MA was positively associated with post-infusion subjective MA effects, including positive (i.e., stimulation, good effects, feel drug, high), negative (i.e., anxious and depressed), and craving-related (i.e., want more, would like access to drug, crave) responses. Naltrexone, vs. placebo, significantly reduced the association between cue-induced craving and positive subjective response to MA. Conclusions
The findings indicate that naltrexone moderates the predictive relationship between cue-induced craving and positive subjective effects of MA, thereby suggesting a behavioral mechanism by which naltrexone may be efficacious in treating MA use disorder.
... For example, some clinical interventions focus on modifying clients' metacognitions about clinical symptoms (e.g., Wells, 2000), and our results suggest that it would be worthwhile to consider how the effectiveness of these interventions might be influenced by cravings. This is particularly important given that such interventions have been used to treat substance-based and addiction disorders (e.g., Caselli, Gemelli, Spada, & Wells, 2016;Lee, Pohlman, Baker, Ferris, & Kay-Lambkin, 2010). ...
Cravings for food and other substances can impair cognition. We extended previous research by testing the effects of caffeine cravings on cued-recall and recognition memory tasks, and on the accuracy of judgements of learning (JOLs; predicted future recall) and feeling-of-knowing (FOK; predicted future recognition for items that cannot be recalled). Participants (N = 55) studied word pairs (POND-BOOK) and completed a cued-recall test and a recognition test. Participants made JOLs prior to the cued-recall test and FOK judgements prior to the recognition test. Participants were randomly allocated to a craving or control condition; we manipulated caffeine cravings via a combination of abstinence, cue exposure, and imagery. Cravings impaired memory performance on the cued-recall and recognition tasks. Cravings also impaired resolution (the ability to distinguish items that would be remembered from those that would not) for FOK judgements but not JOLs, and reduced calibration (correspondence between predicted and actual accuracy) for JOLs but not FOK judgements. Additional analysis of the cued-recall data suggested that cravings also reduced participants’ ability to monitor the likely accuracy of answers during the cued-recall test. These findings add to prior research demonstrating that memory strength manipulations have systematically different effects on different types of metacognitive judgements.
... Moreover, the S-REF model has been applied to addictive disorders, such as alcohol, substance and tobacco abuse (Lee et al. 2010;Nikčević and Spada 2008;Spada et al. 2012;). Many authors have postulated that metacognition might be related to the presence of maladaptive coping responses to inner states and that it could lead to addictive behaviors as a way of coping with negative emotions (Toneatto 1999;Wells and Matthews 1994). ...
Gambling disorder is associated with elevated comorbidity with depressive and anxious disorders, and one variable that might help in the understanding of this association is metacognition. In the present study, the relationship between gambling and metacognition and the mediating role of metacognition in the relationship between gambling and depressive and anxious symptomatology were assessed. The sample comprised 124 pathological gamblers from centers that assist pathological gamblers and 204 participants from the general population. The results showed that pathological gamblers had higher levels of depressive and anxious symptomatology. Additionally, pathological gamblers had higher scores for positive beliefs about worry, negative beliefs of uncontrollability and danger, and beliefs about the need to control thoughts; these factors were also positively correlated with depressive and anxious symptomatology. Metacognition also fully mediated the association between gambling and depressive and anxious symptomatology. These results suggest that metacognition could contribute to explaining gambling disorder and the symptomatology associated with it.
... One study (Turkcapar, Kose, Ince, & Myrick, 2005) found that beliefs that craving is uncontrollable were higher in relapsed alcohol-dependent Turkish men than abstainers. Similarly, another study (Lee, Pohlman, Baker, Ferris, & Kay-Lambkin, 2010) found higher craving belief scores (i.e., more beliefs that craving is uncontrollable) were associated with lower likelihood of abstinence achievement in methamphetamine users. Because beliefs concerning craving have been studied in differing substance use domains, it follows that similar investigations and findings would extend to smoking outcomes. ...
Introduction: Decreased abstinence self-efficacy is linked to increased craving and negative affect, as well as poorer smoking outcomes,
such as lapse, relapse, and withdrawal symptom severity. Research suggests that beliefs and cognitions concerning ourselves
and the world orient us toward specific goals and thus impact our judgments and behavior. This study serves to investigate
whether motives for smoking mediate the relationship between beliefs about craving and abstinence self-efficacy judgments
and whether this may differ by nicotine dependence.
... Furthermore, methamphetamine craving has been observed to be present for at least 5 weeks into abstinence, rendering the user particularly vulnerable to relapse during 7 to 14 days of abstinence (Zorick et al., 2010), and is a significant predictor of subsequent use during outpatient treatment (Galloway and Singleton, 2009;Hartz et al., 2001). Craving beliefs, or interpretations and decisions about cravings, have also been shown to predict relapse in a sample of regular methamphetamine users (Lee et al., 2010). On this basis, methamphetamine craving has been advanced as a surrogate marker of methamphetamine dependence (Galloway and Singleton, 2009). ...
Background:
Despite initial reports of a decline in use in the early 2000s, methamphetamine remains a significant public health concern with known neurotoxic and neurocognitive effects to the user. The goal of this review is to update the literature on methamphetamine use and addiction since its assent to peak popularity in 1990s.
Methods:
We first review recent epidemiological reports with a focus on methamphetamine accessibility, changes in use and disorder prevalence rates over time, and accurate estimates of the associated burden of care to the individual and society. Second, we review methamphetamine pharmacology literature with emphasis on the structural and functional neurotoxic effects associated with repeated use of the drug. Third, we briefly outline the findings on methamphetamine-related neurocognitive deficits as assessed via behavioral and neuroimaging paradigms. Lastly, we review the clinical presentation of methamphetamine addiction and the evidence supporting the available psychosocial and pharmacological treatments within the context of an addiction biology framework.
Conclusion:
Taken together, this review provides a broad-based update of the available literature covering methamphetamine research over the past two decades and concludes with recommendations for future research.
... Le craving pouvant être un facteur de risque de rechute [4,7,8], les croyances dysfonctionnelles sont considérées elles aussi comme un facteur indirect de rechute (par le biais de l'activation du craving). En effet, des études ont montré que les patients qui rechutaient étaient ceux qui présentaient au préalable le plus de croyances dysfonctionnelles relatives au craving [9,10]. Cependant, le nombre trop limité des recherches sur ce thème, notamment dans l'espace francophone, ne permet pas de généraliser une relation directe de cause à effet entre croyances et rechute chez les patients alcoolo-dépendants. ...
Among patient with alcohol use disorders (AUD), cognitions (beliefs, thoughts, schemas) play an important role in alcohol abuse and in craving, defined as a strong and irresistible urge to consume a product. Various types of beliefs, said to be dysfunctional, were specifically identified among AUD patient as being able to favor a relapse. The aim of this research concerns the comorbidity (qualitative part of the research) and the dysfunctional beliefs relative to the craving (quantitative part of the research). The evolution of craving related beliefs are analyzed during a post-cure care. Ten French patients in post-cure care for AUD were received in clinical interview, and in structured interview (MINI). They also filled the French form of the Craving Beliefs Questionnaire at the two moments: At the beginning of post-cure care, then at the end. On the quantitative part, the results show that the irrational beliefs decrease among every patient. However, this evolution is not correlated with the number of post-cure care from which they benefit. A hypothesis is whether it is the global residential care in itself that influences the cognitions-beliefs.
... In cognitive aspects, craving lexicon will be helpful to prepare a model on the implicit and explicit cognitive processes that underlie drug craving. It is believed that better insight into the craving concept will contribute to the treatment of substance abuse and relapse prevention (4,(8)(9)(10)(11)(12) and craving measurement (13,14). To our best knowledge, there is no published report on the range of terms used as synonyms for � drug craving� among drug dependents in different groups or languages. ...
Drug craving is defined as an urge to continue substance abuse. Drug dependents use different terms to express their subjective feeling of craving. This study was an attempt to generate an understanding of craving terminology among different groups of Persian speaking Iranian opiate dependents.
Terms used for the meaning of drug craving were listed by 36 ex-opiate dependents in focus group discussion meetings in the first phase of the study. These terms were composed from Craving Terms Questionnaire. In the second phase, 120 subjects in 3 groups of opiate dependents and a group of Current Opiate Abusers rated usage frequency of each term in the questionnaire under a Twelve-Step Program, Methadone Maintenance, and Other Abstinence-based Programs.
Eighty nine terms were categorized in stimulation and triggering, attention bias and obsession, decision making difficulty, information processing impairment, withdrawal induction, drug euphoric experience, mental urge, motor control problem, negative valancing and stigmatizing. Terms for the three categories of mental urge, attention bias and obsession and motor control problem were used more than others. Patients in Methadone Maintenance Treatment (MMT) group used different categories of craving terms in comparison to other groups. Abstinent cases reported higher total score for craving terms in comparison to other groups in Twelve-Step Program and other abstinence-based programs.
Each craving-related term is associated with some aspects of the multidimensional concept of craving. A drug-craving thesaurus could provide a better understanding of craving nature from a drug dependent point of view. There are differences among abstinence vs. maintenance based treated opiate dependents in using craving terms. Addiction therapists will benefit from accessing drug dependents' lexicon to assess and create therapeutic alliance with their clients.
Re-Visioning Psychiatry explores new theories and models from cultural psychiatry and psychology, philosophy, neuroscience and anthropology that clarify how mental health problems emerge in specific contexts and points toward future integration of these perspectives. Taken together, the contributions point to the need for fundamental shifts in psychiatric theory and practice: • Restoring phenomenology to its rightful place in research and practice • Advancing the social and cultural neuroscience of brain-person-environment systems over time and across social contexts • Understanding how self-awareness, interpersonal interactions, and larger social processes give rise to vicious circles that constitute mental health problems • Locating efforts to help and heal within the local and global social, economic, and political contexts that influence how we frame problems and imagine solutions. In advancing ecosystemic models of mental disorders, contributors challenge reductionistic models and culture-bound perspectives and highlight possibilities for a more transdisciplinary, integrated approach to research, mental health policy, and clinical practice.
Background
Opioids have been prescribed to reduce suffering from pain and to enhance quality of life. Due to the addictive potential and the lack of other effective alternatives to treat severe acute and chronic pains, opioids remain a serious public health issue. While, opioids directly influence the drug-seeking behavior, tolerance and withdrawal processes, through neuroadaptation, the brain's endogenous opioid system also adapts in the presence of chronic pain and could contribute to the difficulty of treatment. Despite the seemingly obvious interaction between the presence of pain and opioid-abuse, little is known about the underlying mechanisms in the brain.
Purpose
To review the current understanding of the interaction mechanisms of neurotransmitter circuitries in pain modulation and reward in the brain and the effects of L-tetrahydropalmatine (L-THP) and its metabolites in pain management and opioid use disorder and gain a better insight on the pharmacological profile and in vivo effects of L-THP and its metabolites.
Method
A detailed literature search on available (preclinical and clinical) studies about the effects of L-THP and its metabolites against drug addiction and chronic pain has been performed. The data was collected using various search engines such as PubMed, ScienceDirect, Google scholar and articles in English up to December 2020 were included in this review.
Results
L-THP and its metabolites demonstrated analgesic and anti-addiction effects. Due to their dual pharmacological properties (D1 partial agonist and D2 antagonist) these compounds could be used as molecular tools to provide a better understanding of the interactions between pain and addiction.
Conclusion
The available data confirms the potential of L-THP and its metabolites to treat both chronic pain and drug addiction. However, further clinical trials are needed to establish safety and efficacy.
Objective:
Drug craving serves as the major motivator to propagate drug use and is thought to elicit relapse in abstinent individuals. Although craving for methamphetamine has been investigated using both laboratory and neuroimaging methodologies, the relationship between drug-induced craving and neural responses to methamphetamine cues has yet to be explored. Therefore, the present study investigated whether methamphetamine-induced craving responses in the laboratory were associated with neural response to methamphetamine cues.
Method:
Non-treatment-seeking individuals with methamphetamine use disorder (n = 15) completed two sessions, one in the laboratory where they underwent a methamphetamine infusion, and one in the magnetic resonance imaging scanner where they viewed methamphetamine cues. Participants reported their craving for methamphetamine over the course of the laboratory session. Analyses examined the association between peak ratings of methamphetamine-induced craving and neural activation to methamphetamine cues.
Results:
In individuals with a methamphetamine use disorder, methamphetamine-induced craving was positively associated with neural methamphetamine cue reactivity in the precuneus, putamen, and ventromedial prefrontal cortex (Z > 2.3, p < .05).
Conclusions:
There is a shared neurobiology underlying cue- and drug-induced craving in individuals with methamphetamine use disorder. Treatments that disrupt this circuitry may decrease craving and help prevent relapse.
Revisioning Psychiatry explores new theories and models from cultural psychiatry and psychology, philosophy, neuroscience, and anthropology that clarify how mental health problems emerge in specific contexts and points toward future integration of these perspectives. Taken together, the contributions point to the need for fundamental shifts in psychiatric theory and practice: • Restoring phenomenology to its rightful place in research and practice; • Advancing the social and cultural neuroscience of brain-person-environment systems over time and across social contexts; • Understanding how self-awareness, interpersonal interactions, and larger social processes give rise to vicious circles that constitute mental health problems; • Locating efforts to help and heal within the local and global social, economic, and political contexts that influence how we frame problems and imagine solutions. In advancing ecosystemic models of mental disorders, contributors challenge reductionistic models and culture-bound perspectives and highlight possibilities for a more transdisciplinary, integrated approach to research, mental health policy, and clinical practice.
The title of this chapter evokes the common ground between anthropology and psychiatry, and by extension suggests Edward Sapir’s (1932) enduringly astute essay on this topic, written already eighty years ago, as a starting point for defining a cultural phenomenology of psychiatric illness. Sapir was a close collaborator of Harry Stack Sullivan, based in part on the concordance of Sullivan’s interpersonal psychiatry and Sapir’s anthropological understanding that the locus of culture is in the interaction of specific individuals. Sapir begins by observing that cultural anthropology emphasizes the group and its traditions, and the testimony of discrete individuals is of interest only insofar as they can be assumed typical of their community. Despite the presence in ethnography of "a kaleidoscopic picture of varying degrees of generality" from the broadly shared to the idiosyncratic, the individual note creates "disquieting interruptions to the impersonality of his [the anthropologist’s] thinking" (1932, p. 230). Psychiatry’s concern for individual pathology tends to be dominated by a need to magnify the biological approach in order to maintain legitimacy in the medical profession, even though "attempts to explain a morbid suspiciousness of one’s companions or delusion as to one’s status in society by some organically definable weakness of the nervous system or of the functioning of endocrine glands may be no more to the point than to explain the habit of swearing by the absence of a few teeth or by a poorly shaped mouth" (1932, p. 232). Psychiatric morbidity is "not a morbidity of organic segments or even organic functions but of experience itself," and it is unrealistic to "assume that ll experience is but the mechanical sum of physiological processes lodged in isolated individuals" (1932, p. 232). Sapir’s argument, perhaps ironically, is that anthropology and psychiatry most fruitfully overlap precisely at their respective blind spots: he individual for anthropology, experience for psychiatry. Culture as "superorganic" or abstracted from individual experience is a deterrent to "the more dynamic study of… cultural patterns because these cannot be disconnected from those organizations of ideas and feelings which constitute the individual" (1932, p. 233).
What do psychiatrists encounter when they encounter psychopathological experience in their patients? How should we interpret such experiences? In this chapter, we contrast a checklist approach to diagnosis, which is standard today and which treats psychiatric symptoms and signs (i.e., "the psychiatric object", Marková & Berrios, 2009; see also Chapter 2, this volume) as readily operationalizable object-like entities, with a nonstandard phenomenological approach that emphasizes the importance of a specific kind of interpretive interview. The descriptive methods of today’s psychiatry perpetuate what has been called psychiatry’s "problem of description" (Spitzer, 1988) because these methods are not adequately tailored to the ontological nature of the "psychiatric object." The psychiatric object is typically portrayed as an objective, thinglike entity, unproblematically graspable as it exists "in itself" through a behaviorist third-person perspective and as being indicative of a specific and modular physiological dysfunction. We will propose a different epistemological approach, considering the nature of mental disorders to be primarily constituted by the patient’s anomalies of experience, expression, and existence that typically involve suffering and dysfunction (Parnas, Sass, & Zahavi, 2013). Introduction: Is There a Problem in Contemporary Psychiatry?. More than thirty years ago, psychiatry, attempting to match somatic medicine in its scientific-biological foundations, underwent an "operational revolution," introducing criteria-based diagnoses and "operational definitions" of such criteria (American Psychiatric Association [APA], 1980). The operational project radically abridged, simplified, and condensed the then existing corpus of clinical knowledge into diagnostic manuals accessible to the grand publique because they are written in lay language and stripped of theoretical and psychopathological reflection. These manuals have long been the main source of clinical knowledge for psychiatrists in training (Andreasen, 2007). Moreover, it is assumed that a structured interview, that is, an interview in which a psychiatrist asks the patient a series of preformulated questions in a fixed sequence, is an adequate methodology for obtaining psychodiagnostic information. We will argue that this is a mistaken assumption.
The descriptions of psychiatric disorders in DSM-5 (APA, 2013) represent only some of the diverse forms of clinical presentations worldwide and throughout history. Cultural variation may help explain why current DSM diagnoses only partially map onto their putative biological substrates at the genetic or neurocircuitry level. It is more likely that these biological domains constitute dimensional vulnerability factors that pattern disorder expression more generally (e.g., mood dysregulation), and that specific syndromes arise from the interaction of this general vulnerability with other contextual factors, including culturally patterned illness expressions. This hypothesis raises several questions: How can research on cultural variation help elucidate the full range of underlying mechanisms that culminate in a given illness prototype? What cultural-contextual information can help clarify the relationship between related but diverse presentations of psychopathology? How can cultural variation be included in a universalistic nosology, such as DSM-5? This chapter presents a model of interdisciplinary triangulation that suggests how combining findings from sociocultural contextual analysis, neurobiological substrates of mental illness, and psychological dimensions can identify the substrates of illness phenomenology. The model will first be illustrated through an example of research on language, and then applied to a cultural syndrome included in the DSM-5 Appendix: ataque de nervios (attack of nerves). The chapter concludes by discussing how this model helped the DSM-5 revision process and by suggesting areas for future research. Psychopathology is experienced, expressed, and interpreted around the world with considerable cultural variation. To date, no blueprint exists that can untangle the contributions to this variation from neurobiological, psychological, and cultural levels of analysis (Kendler, 2008). As a result, classification systems of psychopathology rely almost exclusively on phenomenological description - in its simplest sense of that which is apparent to an external observer (Andreasen, 2007; Hyman, 2010) and with only the barest attention to other aspects of illness phenomenology, such as the sufferer’s own subjective description of lived experience and an accounting of the sociocultural environment that helps pattern illness expression (Csordas, Chapter 5, this volume; Heidegger, 1962 /1927; Merleau-Ponty, 1996 /1945; Parnas & Gallagher, Chapter 3, this volume).
Introduction In this chapter, we propose a model to describe the various ways in which biological mechanisms of anxiety and their psychological correlates are embedded in, shape, and are shaped by particular cultural contexts. Our approach focuses on a set of processes, including attentional looping, catastrophic cognitions, and interpretive biases, and uses several versions of our "multiplex model" in order to illustrate the profound effects of culture on panic attacks, panic disorder, worry/generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), anxiety symptoms, and somatization more generally. In doing so, we illustrate how local conceptualizations of the body alter the experience of somatic and panic-related symptoms. Our illustrations come mainly from research and clinical work with traumatized Cambodian refugees. The multiplex models illustrate the importance of a dimensional approach to psychopathology - such as catastrophic cognitions, panic, somatic sensations, trauma associations, biology of trauma (e.g., amygdala reactivity) - in line with NIMH’s RDoC initiative (Morris & Cuthbert, 2012; Sanislow et al., 2010; see also Kirmayer & Crafa, 2014, for critique); the models also provide insights into how a biocultural phenomenology of mental disorders may be advanced. More specifically, the multiplex models demonstrate how certain somatic symptoms may be subject to "bioattentional" looping, a positive feedback effect whereby interpretation of the symptoms in terms of the local ethnophysiology, ethnopsychology, and ethnospirituality may "loop back" and amplify their physiological effects, creating a vicious circle (for a review, see Hinton & Good, 2009; Hinton & Hinton, 2002; Hinton, Hinton, Eng, & Choung, 2012; Hinton & Kirmayer, 2013; Kirmayer & Blake, 2009; Kirmayer & Sartorius, 2007). As conceptualized in the multiplex models, trauma associations and metaphor associations also may play a role in the generation and escalation of the somatic symptoms and general distress. Furthermore, the multiplex models are nested in that they involve core processes embedded within the matrices of other processes, including coping, treatment, and interpersonal contexts (e.g., Kleinman & Becker, 1998), what we refer here to as sociocultural pragmatics. Altogether, the models demonstrate how anxiety ontologies can vary greatly across cultures, with important implications for assessment and treatment.
After a two-centuries-long alliance with medicine, psychiatry (its structure, objects, language, and praxis) remains as opaque as ever. Explaining why this is the case should be the task of the epistemology of psychiatry (EP). Surprisingly enough, until recently psychiatry lacked an epistemology to explore the nature and legitimacy of psychiatric knowledge. Instead, its problems have been addressed in part by the general epistemology of medicine (Berrios, 2006; Wulff, Pedersen, & Rosenberg, 1986) and in part by work in the philosophy of psychiatry, which began to appear after World War II (see, e.g., Blanc, 1998; Griffiths, 1994; Kehrer, 1951;Lanteri-Laura, 1963; Lewis, 1967; Natanson, 1969; Palem, 2010; Palmer, 1952; Reznek, 1991; Siegler & Osmond, 1974; Spiegelberg, 1972; Spitzer & Maher, 1990; Strauss, 1958; and others). In the hands of Anglo-American writers (such as Fulford, Thornton, & Graham, 2006; Radden, 2004) the philosophy of psychiatry has now become a voluminous industry. Given its bias in the direction of analytical philosophy, a great deal of this work has been openly justificatory of the neurosciences in general and of biological psychiatry in particular (Bolton & Hill, 2003; Kendler & Parnas, 2008; Murphy, 2006; more on this later). This predictable state of affairs throws into relief the urgent need for a dedicated epistemology that may act as an independent auditor of all psychiatric narratives, past and present, and that conceives of psychiatry as a sui generis discipline, broader than the conventional sciences, language-bound, and closely dependent on its historical period. This chapter will present a sketch of a new EP along these lines. We are using the concept of "EP" to refer to the discipline of examining the various sources of knowledge underlying psychiatry and its objects in order to further develop understanding concerning their nature and stability. Because we feel that philosophy of psychiatry, while pursuing a similar aim, is too constraining in its methods and sources of knowledge, we have adopted the broader term of "epistemology" to widen the field. Within EP, there will naturally be many approaches and ways of tackling the questions, but as far as the discipline is concerned we are talking about a single general epistemology rather than many epistemologies of psychiatry.
Introduction Every year more than eight hundred thousand people die by suicide, and more than twenty times that number attempt suicide (World Health Organization [WHO], 2014). In addition to the confusion and pain generated by the loss of a beloved family member or friend, suicide has major consequences for society. The WHO estimates the actual burden of suicide to be twenty million life-years and predicts that, by 2020, suicide could be responsible for 2.4 percent of the total burden of disease (WHO, 2006). These statistics not only clearly show the importance suicide has on society but also highlight our inability to properly implement prevention strategies. Suicide represents the extreme of a behavioral continuum comprising different forms and severities of self-injurious behaviors (van Heeringen, 2001). It is generally assumed that suicide is a complex behavior resulting from the interaction of different distal and proximal risk factors. Distal risk factors such as familial history of suicide, genetic and epigenetic factors, early life adversity, and personality traits confer vulnerability to suicide, while proximal risk factors like psychopathology, recent life events, hopelessness, and acute substance intoxication are better understood as precipitants of the suicidal crisis. The presence of comorbid major depressive disorder (MDD) and substance abuse are among the strongest proximal risk factors. Indeed, studies suggest that 50 to 70 percent of suicide completers die during an episode of MDD (Arsenault-Lapierre, Kim, & Turecki, 2004; Cavanagh, Carson, Sharpe, & Lawrie, 2003), although most individuals who are affected by MDD and other mood disorders will not die by suicide (F. Angst, Stassen, Clayton, & Angst, 2002; J. Angst, Angst, & Stassen, 1999; J. Angst, Degonda, & Ernst, 1992; Blair-West, Cantor, Mellsop, & Eyeson-Annan, 1999). Age and other sociodemographic factors such as educational level, employment, and income moderate the impact of proximal factors on suicide risk (Brezo, Paris, Tremblay, et al., 2007; Brezo, Paris, & Turecki, 2006; van den Bos, Harteveld, & Stoop, 2009). Among risk factors influencing suicide more distally are personality traits and familial history of suicidal behavior, both considered strong predictors of suicide (Hawton & van Heeringen, 2009; Suominen et al., 2004).
Introduction A few short weeks before the long-awaited publication of DSM-5, Thomas Insel, director of the National Institute of Mental Health (NIMH), stated that the manual suffers from a "lack of validity" (Insel, 2013). To remedy this problem, he envisaged a new direction for psychiatry whereby clinicians and researchers classify disorders based on underlying neurobiological causes rather than on highly variable symptoms. The anticipation of DSM-5 and professional efforts surrounding it generated unprecedented questioning from both consumers and practitioners. The public, advocacy groups, and even senior members of the psychiatric community raised questions, not only regarding decisions to include or exclude specific types of problems from the revised manual but also concerning the scientific foundation of the whole enterprise. Many of these criticisms were based on recognizing the limited advances that have been made in the biological understanding and treatment of mental disorders. Psychiatry aims to link behavioral science to underlying mechanisms, using the techniques of neuroscience. Yet decades of work on cognitive, molecular, and systems neuroscience have taught most scientists a lesson in humility: despite an enormous investment in research with an emphasis on the neural correlates of typical and atypical behavioral "phenotypes," breakthroughs are sorely lacking. In spite of the global efforts and the accumulation of a large body of findings, the lack of clinical advances has undermined many working assumptions concerning the neurobiological basis of psychiatric distress. The genetic and neuroimaging revolutions - which seemed poised to elucidate and ultimately explain conditions categorized as psychopathologies and psychiatric disorders - have produced modest results that speak only obliquely to the vast, complex dynamics revealed by behavioral science. Many scholars are disillusioned with imaging studies of the living human brain, and further recognize that genetic polymorphisms putatively appearing to increase risk of schizophrenia in one person may actually predispose another to bipolar disorder (Bilder, 2011). Furthermore, some scientists argue that the therapeutic effects of drugs that comprise the backbone of modern psychiatry - antidepressants and atypical antipsychotics - are largely indistinguishable from placebos in common clinical situations (Raz & Harris, in press). These findings challenge the extent to which the study of pharmaceutical drugs contributes to our understanding of psychological conditions.
Introduction to the Problem WHO [World Health Organization] is making a simple statement: mental health - neglected for far too long - is crucial to the well-being of individuals, societies and countries and must be universally regarded in a new light. (WHO, 2001, p. ix) WHO has received an increasing number of requests from countries for assistance and country-specific action. The need for - and relevance of - an economic perspective in planning, provision, and assessment of services, and for scaling up care for MNS [Mental, Neurological and Substance use] disorders is another reason to revise the focus of the mental health strategy. Moreover, a comprehensive programme for action can inspire stakeholders and accelerate progress by bringing together partners with a common purpose. (WHO Mental Health Gap Action Programme, 2008, p. 9) How does a term such as "global mental health" become a normative object of medical and epidemiological evaluation and estimation to the degree that remedial strategies can be deployed toward its improvement? When WHO reports that, worldwide, "Depression is the leading cause of disability as measured by YLDs [years lost due to disability]" and that "by the year 2020, depression is projected to reach 2nd place of the ranking of DALYs [disability adjusted life years] calculated for all ages, both sexes," how does WHO wish us to understand the object so as to act on it? We move closer to the intended object with the WHO estimate that the treatment gap for mental, neurological, and substance abuse disorders is greater than 75 percent (Barbui et al., 2010), and through comorbidities is linked further, as cause and consequence, to primary health concerns in those locales (Prince et al., 2007, p. 1). The opening quote from WHO frames their engagement with global mental health as a response to pleas for help from low- and middle-income countries (LMICs). In a podcast interview of three of the founders of the new global mental health movement, including Shekhar Saxena, coordinator for mental health at WHO, Graham Thornicroft estimated that every year a quarter of all adults will have a mental illness, with a lifetime prevalence of 50 percent.
Introduction: At the center of psychiatry as a clinical discipline is the human encounter between patient and clinician. Although we can imagine forms of psychiatry in the future that might eliminate this relationship in favor of self-management or interactions with artificial intelligence, there are arguments for insisting that the interaction of two human beings allows unique forms of communication, understanding, and intervention. What is distinctive about this embodied encounter are the dynamics of interpersonal interaction, which include processes of empathy, identification, and emotional connection based on similarity, but also the recognition of difference, otherness, or alterity. In some ways, the construct of empathy stands in for larger questions about the nature of the relationship between patient and clinician. Of course, this relationship involves much more than empathy, but thinking about empathy provides a way to begin to explore the phenomenology and dynamics of the clinical encounter. Contemporary mental health practitioners rely on empathy to understand patients’ experiences and to maintain the interpersonal relatedness that facilitates helping and healing. Various forms of psychopathology, unusual or extreme experiences, and differences in cultural background or social position all present challenges to clinicians’ ability to empathize. Failures of empathy may undermine the working alliance, but they may also convey diagnostic information about psychopathological processes or the status of the clinician-patient relationship. When empathy reaches its limits, the other may be experienced as alien, uncanny, and unknown. Theories of psychopathology, which may include structural models and causal mechanisms, offer alternative ways to explain alien or inaccessible experience (Glover, 2014). Clinicians learn to use these models to guide their response to patients, and, in some circumstances, such technical models or explanations may enhance or restore empathy. But cultural difference also demands that we learn to use our imagination in disciplined ways to build bridges between different worlds of experience and to respect the limits of our understanding of the other. Forms of Knowledge in the Clinical Encounter Clinical understanding demands attention to multiple sources of knowledge, each with its own epistemology and methods of inquiry (McHugh & Slavney, 1998).
Introduction The ability to effectively process and regulate emotional information is a crucial social skill that undergoes important developmental changes from childhood through adolescence and adulthood. Clinical studies indicate that individuals diagnosed with psychiatric disorders, in particular anxiety and mood disorders, exhibit abnormalities in emotion processing and regulation (Phillips, Ladouceur, & Drevets, 2008). Evidence from epidemiological, genetic, and neuroimaging studies suggests that abnormalities in neural connectivity within and between regions of the brain implicated in emotion processing and regulation may play an important role in the neuropathophysiology of these disorders (Almeida & Phillips, 2012; Hajek, Carrey, & Alda, 2005; Leibenluft, Charney, & Pine, 2003; Merikangas et al., 2011; Phillips et al., 2008; Versace et al., 2015). Collectively, these neural connections, or networks, constitute the Brain’s "connectome" (Hagmann, 2005; Sporns, Tononi, & Kötter, 2005). It is possible that altered development of these neural networks might contribute to the developmental trajectories of these disorders in vulnerable youth or youth at familial risk for these disorders. In this chapter, we will focus particularly on bipolar disorder (BD), a serious and recurrent neuropsychiatric illness that affects 2-5 percent of the population (Merikangas et al., 2007) and ranks as one of the top ten leading causes of disability in the world (WHO, 2001). One of the chief clinical features of BD is the difficulty in regulating a range of emotions. In particular, BD is characterized by a pervasive mood disturbance that involves rapid fluctuations and changes in the valence and intensity of emotional states ranging from episodes of sadness, irritability, and anger to episodes of extreme happiness, elation, increased activity, and risky behavior. he emergence of BD in children and adolescents is of particular concern because early onset of BD has been associated with severe presentation and course, including high rates of hospitalization, psychosis, suicidal behavior, substance abuse, and other psychosocial problems (Birmaher et al., 2006; Geller et al., 2002; Perlis et al., 2004). Moreover, evidence from adoption, twin, high-risk, and family studies indicate that BD is highly heritable (Birmaher et al., 2009; DelBello & Geller, 2001; Goodwin & Jamison, 2007; Tsai, Lee, & CC, 1999; Tsuang & Faraone, 1990).
In 1918, Victor Tausk - a lawyer who, under the influence of Freud, had turned to psychoanalysis - read a paper to the Vienna Psychoanalytic Society entitled "On the Origin of the ‘Influencing Machine’ in Schizophrenia" (published as Tausk 1919 and, in English translation, as Tausk 1933). Tausk reports on a thirty-one-year-old patient Natalija A. who had formed the belief that she, her mother, and her friends were being manipulated by a machine located in Berlin. Although she is uncertain about the nature of the machine, she suspects that it functions by means of telepathy. In a strange coincidence, a version of the influencing machine delusion also appears in the very first extended description in English of what psychiatry would come to call "schizophrenia. " James Tilly Matthews, an inmate in Bethlem at the turn of the nineteenth century, was the subject of a detailed case history by his doctor John Haslam (Haslam, 1988; see also Jay, 2012, and Porter, 1985). In the years before being committed to Bethlem, Haslam had been living in Paris when Franz Mesmer was making the rounds of Parisian salons and demonstrating the new force he believed he had discovered and which he called "animal magnetism. " Once in Bedlam, Matthews came to believe that a gang of villains was operating outside the walls of the hospital and using a machine - the "Air Loom" - to torment him with magnetic waves. Tausk notes that as new technologies enter popular culture, they creep into patients’ delusions. In the twentieth century (Linn, 1958) the influencing machine is conceived of as a robot; in the twenty-first, it is replete with contemporary tropes: manipulation by Marilyn Manson; persecutors projecting pornography into a patient’s eyes by "laser radiation", Muslims and Russians monitoring a patient’s sexual activities; and airport security tracking someone by means of a computer chip inserted into his neck (Hirjak & Fuchs, 2010). The chapters in this section provide a variety of arguments for the claim that trying to understand psychiatric disorders or symptoms outside of the appropriate cultural context is deeply problematic. The influencing machine delusion provides a particularly clear illustration of one more way in which the study of culture can serve a revisioned psychiatry.
Re-Visioning Psychiatry explores new theories and models from cultural psychiatry and psychology, philosophy, neuroscience and anthropology that clarify how mental health problems emerge in specific contexts and points toward future integration of these perspectives. Taken together, the contributions point to the need for fundamental shifts in psychiatric theory and practice: • Restoring phenomenology to its rightful place in research and practice • Advancing the social and cultural neuroscience of brain-person-environment systems over time and across social contexts • Understanding how self-awareness, interpersonal interactions, and larger social processes give rise to vicious circles that constitute mental health problems • Locating efforts to help and heal within the local and global social, economic, and political contexts that influence how we frame problems and imagine solutions. In advancing ecosystemic models of mental disorders, contributors challenge reductionistic models and culture-bound perspectives and highlight possibilities for a more transdisciplinary, integrated approach to research, mental health policy, and clinical practice.
Introduction: Therapist can assess patients’ maladaptive beliefs about drug via Craving Beliefs Questionnaire (CBQ), which was originally developed by Wright to measure beliefs about the craving phenomenon. The aim of the study is to assess the psychometric properties of CBQ and its usefulness in the patients with alcohol dependency. Method: The study population was consisted of 70 alcohol addict male patients. Beliefs about substance use questionnaire (BSU), craving beliefs questionnaire (CBQ), Beck anxiety inventory (BAI), clinical institute withdrawal assessment (CIWA), automatic thoughts questionnaire (ATQ) and dysfunctional attitudes scale (DAS) were used as the assessment tools. Results: The internal consistency of the CBQ for the alcohol dependent was adequate (Cronbach’s alpha 0.94). Item-total score correlations were between 0.50 and 0.84 for alcohol-dependent patients. The principal component analysis revealed one main factor. Positive correlations found between CBQ, and BSU, BAI and ATQ. In discriminant validity analysis, mean CBQ scores were found significantly higher than occasional drinkers and none-alcohol drinkers. Conclusion: Our results supported that the Turkish version of the CBQ has an adequate instrument for evaluating alcohol-related craving beliefs in alcoholic patients. However, further studies should be performed for assessing its validity in large number of social drinkers and alcohol-dependent patient.
Objective: The craving is a strong desire to consume a psychotropic substance and is one of the symptoms of withdrawal syndrome in drug addiction. As a theoretical construct, craving is complex and described by different authors, which results in various theoretical models, but there is a consensus on the importance of its treatment. This paper conducted a literature review to identify and describe the most widely used techniques of Cognitive Behavior Therapy for the management of craving and to verify the impact of applying these techniques on outcome variables, specifically the craving.
Method: Searches were conducted in the databases of PubMed and PsycInfo using the following descriptors in association: “craving”, “cognitive therapy” “behavior therapy” and “cognitive behavior therapy”.
Results: 198 papers were found, out of which thirty four were selected for analysis. The cognitive behavior therapy treatment includes various techniques such as Relapse Prevention, Psychoeducational, Humor and Stress Management, Motivational Interviewing, Exposure to the Relapse Prevention and Relaxation techniques. The manual for Project MATCH is one of the most cited and used for the treatment of drug addicts. Cue Exposure Therapy (CET), Attentional Bias Modification (ABM) and newer “mindfulness” therapeutic methods are studied, and have shown promising results, but still need to be further investigated.
Conclusion: Various treatments have been proposed and have allowed the achievement of significant improvements in the reduction of craving.
Re-Visioning Psychiatry explores new theories and models from cultural psychiatry and psychology, philosophy, neuroscience and anthropology that clarify how mental health problems emerge in specific contexts and points toward future integration of these perspectives. Taken together, the contributions point to the need for fundamental shifts in psychiatric theory and practice: • Restoring phenomenology to its rightful place in research and practice • Advancing the social and cultural neuroscience of brain-person-environment systems over time and across social contexts • Understanding how self-awareness, interpersonal interactions, and larger social processes give rise to vicious circles that constitute mental health problems • Locating efforts to help and heal within the local and global social, economic, and political contexts that influence how we frame problems and imagine solutions. In advancing ecosystemic models of mental disorders, contributors challenge reductionistic models and culture-bound perspectives and highlight possibilities for a more transdisciplinary, integrated approach to research, mental health policy, and clinical practice.
Background
Metacognitive models theorize that more negative appraisals of craving-related thoughts and feelings, and greater efforts to avoid or control these experiences, exacerbate suffering and increase chances the person will use substances to obtain relief. Thus far, little research has examined how attempts to quit smoking influence the way people perceive and respond to cravings.
Method
As part of a larger study, 176 adult smokers interested in quitting participated in two lab sessions, four days apart. Half the sample began a quit attempt the day after the first session; craving-related beliefs, metacognitive strategies, and negative affect were assessed at the second session.
Results
Participants who failed to abstain from smoking more strongly endorsed appraisals of craving-related thoughts as negative and personally relevant. Negative appraisals correlated strongly with distress and withdrawal symptoms. Attempting to quit smoking increased use of distraction, thought suppression and re-appraisal techniques, with no difference between successful and unsuccessful quitters. Negative beliefs about cravings and rumination predicted less change in smoking one month later.
Conclusions
Smoking cessation outcomes and metacognitive beliefs likely have a bidirectional relationship that is strongly related to negative affect. Greater consideration of the impact of cessation experiences on mood and craving beliefs is warranted.
One of the major problems of opiate treatment evaluation research has been the lack of comparability of research findings. Studies vary both in the domains selected as outcome variables and in the criteria for "success" within these domains. For example, some major outcome studies concentrate exclusively on drug use and criminality as outcome variables (e.g. DeLeon, 1986; DeLeon et al, 1986), whereas others regard factors such as employment and psychiatric status as also constituting relevant outcome domains (Hubbard et al, 1983; McLellan et al, 1986; Simpson & Marsh, 1986).
The use of methamphetamine is widespread and poses significant challenges for treatment providers. Much of the treatment knowledge about this group has been extrapolated from studies of treatment for cocaine dependence. Medications have been shown to be of limited effectiveness for methamphetamine users, making psychological interventions the treatment of choice.
This paper describes a systematic review of cognitive-behavioural and behavioural interventions for methamphetamine users. A systematic search of published literature was undertaken focusing only on randomised trials.
There were a relatively small number of intervention studies that compared cognitive-behavioural or behavioural interventions using randomised trial methodology. Most commonly, studies examined cognitive-behaviour therapy (CBT) and/or contingency management (CM). Treatment with CBT appears to be associated with reductions in methamphetamine use and other positive changes, even over very short periods of treatment (two and four sessions). CM studies found a significant reduction of methamphetamine during application of the procedure, but it is not clear if these gains are sustained at post-treatment follow-up.
The review highlights that there are effective treatments for methamphetamine dependence. Alcohol and other drug (AOD) clinicians are familiar with these types of interventions and should use them and convey to clients that they are effective. Services and policy makers should ensure that best practice interventions are implemented within AOD services.
Psychological intervention is effective in addressing methamphetamine use and dependence. CBT and contingency management are two accessible interventions that are implemented easily within current AOD services. There is still more work to conduct in improving methamphetamine treatment, however, and further research into cognitive-behavioural and behavioural treatments for methamphetamine users is required, with a focus on improving longevity of the effect of intervention and improving effectiveness among more complex presentations.
This book discusses the most important techniques available for longitudinal data analysis, from simple techniques such as the paired t-test and summary statistics, to more sophisticated ones such as generalized estimating of equations and mixed model analysis. A distinction is made between longitudinal analysis with continuous, dichotomous and categorical outcome variables. The emphasis of the discussion lies in the interpretation and comparison of the results of the different techniques. The second edition includes new chapters on the role of the time variable and presents new features of longitudinal data analysis. Explanations have been clarified where necessary and several chapters have been completely rewritten. The analysis of data from experimental studies and the problem of missing data in longitudinal studies are discussed. Finally, an extensive overview and comparison of different software packages is provided. This practical guide is essential for non-statisticians and researchers working with longitudinal data from epidemiological and clinical studies.
The clinical experience of cognitive therapies is adding to the understanding of emotional disorders. Based on clinical experience and evidence, this groundbreaking book represents a development of cognitive therapy through the concept of metacognition. It provides guidelines for innovative treatments of emotional disorders and goes on to offer conceptual arguments for the future development of cognitive therapy. Offers a new concept in cognitive therapy and guidelines for innovative treatment. Clinically grounded, based on a thorough understanding of cognitive therapies in practice. Written by a recognized authority and established author.
[This book] is written for students of cognitive psychology, and also for clinicians and researchers in the areas of cognition, stress and emotional disorders. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
"Cognitive Therapy of Substance Abuse" was written in response to the ever-growing need to formulate and test cost-effective treatments for substance abuse disorders. Representing a major advance for meeting this pressing need, cognitive therapy offers a well-documented and demonstrably efficacious psychosocial treatment model. Emanating from the research and practical experience of Aaron T. Beck and his colleagues, this book demonstrates how cognitive therapy can be easily replicated by therapists and counselors alike.
This volume concentrates on clinical procedures in a way that is both teachable and testable. An ideal treatment manual that can be utilized independently, or in conjunction with psychopharmacological or 12-step programs, [this book] will be valued by all mental health practitioners who work with substance abusers, regardless of their orientation or the extent of their previous experience with either cognitive therapy or substance abuse. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The present study explored the relationships between metacognitions, emotion, alcohol use and problem drinking. A convenience sample of 97 participants completed the following questionnaires: Hospital Anxiety and Depression Scale (HADS), Meta-Cognitions Questionnaire 30 (MCQ-30), Quantity Frequency Scale (QFS) and Alcohol Use Disorders Identification Test (AUDIT). A cross-sectional design was adopted and data analysis consisted of correlational and multiple regression analyses. Metacognitions were found to be positively and significantly associated with alcohol use and with proneness to problem drinking. Positive and significant relationships were also observed between anxiety and depression on the one hand, and alcohol use and proneness to problem drinking on the other. Multiple regression analyses indicated that anxiety and beliefs about the need to control thoughts independently predicted alcohol use, and anxiety alone predicted proneness to problem drinking. These preliminary results would seem to suggest that metacognitive theory may be relevant to understanding alcohol use. Copyright © 2005 John Wiley & Sons, Ltd.
Longitudinal studies are increasingly popular in epidemiology. In this tutorial we provide a detailed review of methods used by us in the analysis of a longitudinal (multiwave or panel) study of adolescent health, focusing on smoking behaviour. This example is explored in detail with the principal aim of providing an introduction to the analysis of longitudinal binary data, at a level suited to statisticians familiar with logistic regression and survival analysis but not necessarily experienced in longitudinal analysis or estimating equation methods. We describe recent advances in statistical methodology that can play a practical role in applications and are available with standard software. Our approach emphasizes the importance of stating clear research questions, and for binary outcomes we suggest these are best organized around the key epidemiological concepts of prevalence and incidence. For prevalence questions, we show how unbiased estimating equations and information-sandwich variance estimates may be used to produce a valid and robust analysis, as long as sample size is reasonably large. We also show how the estimating equation approach readily extends to accommodate adjustments for missing data and complex survey design. A detailed discussion of gender-related differences over time in our smoking outcome is used to emphasize the need for great care in separating longitudinal from cross-sectional information. We show how incidence questions may be addressed using a discrete-time version of the proportional hazards regression model. This approach has the advantages of providing estimates of relative risks, being feasible with standard software, and also allowing robust information-sandwich variance estimates. Copyright © 1999 John Wiley & Sons, Ltd.
In this study 10 patients with problem drinking behaviour were assessed using a semi-structured interview to investigate (a) whether they held positive and/or negative metacognitive beliefs about alcohol use, (b) whether alcohol use was perceived to have an impact on negative emotions, (c) whether alcohol was used as a coping strategy, and if so what its main goal was, (d) how individuals knew whether they had achieved their goal and what signalled the cessation of using and (e) how alcohol use impacted on self-consciousness. All patients endorsed positive metacognitive beliefs and six endorsed negative metacognitive beliefs about alcohol use. Positive metacognitive beliefs concerned the usefulness of alcohol as an emotional, cognitive and image self-regulation tool. Negative metacognitive beliefs concerned uncontrollability and harm. Seven patients indicated that during a drinking episode negative emotions subsided. Nine out of ten patients stated that alcohol was used as a coping strategy and that its main goal was to reduce negative emotions and/or improve mood. However, nine out of ten patients also reported that they did not know how to determine whether they had achieved their goals. Instead the signal for stopping use came from being sick and/or blacking out. All patients reported that alcohol use helped to reduce self-consciousness. The results support a metacognitive conceptualization in which problem drinking is supported by disruptions of metacognitive monitoring and control. The conceptual implications for understanding problem drinking from a metacognitive perspective are discussed. Copyright © 2006 John Wiley & Sons, Ltd.
Advances in treating generalized anxiety disorder (GAD) are likely to result from a better understanding of the dysfunctional cognitive mechanisms underlying persistent worrying. In a cognitive model of GAD, Wells (1995) proposed that pathological worry is maintained by maladaptive metacognitions (negative beliefs about worry concerning uncontrollability and danger, and negative appraisal of worrying [meta-worry]) and linked behaviors. Twenty-four patients with GAD were compared with sex-matched groups — social phobia, panic disorder, and nonpatients — on measures of negative metacognitions and worry. It was hypothesized that patients with GAD would obtain higher negative metacognitive belief scores and higher meta-worry scores than the other groups; differences in negative metacognitions would be independent of the general frequency of worry. A group of individuals with major depression was also examined as a subsidiary exploration of relative metacognitive and worry characteristics of this disorder. All of the hypotheses were upheld in the univariate ANOVAs. There was a loss of one hypothesized significant difference between the GAD and panic disorder groups in meta-worry when general worry frequency was controlled. However, the GAD group still had higher meta-worry scores than the panic group. This effect appears to be the result of patients with panic having intermediate meta-worry scores falling between the GAD and other groups. Differences between the GAD group and all other groups in negative metacognitive beliefs concerning uncontrollability and danger remained when general worry was controlled. The results add further support to the cognitive model, and treatment implications are briefly discussed.
This text is a Stata-specific treatment of generalized linear mixed models, also known as multilevel or hierarchical models. These models are "mixed" in the sense that they allow fixed and random effects and are "generalized" in the sense that they are appropriate not only for continuous Gaussian responses but also for binary, count, and other types of limited dependent variables.
This article discusses extensions of generalized linear models for the analysis of longitudinal data. Two approaches are considered: subject-specific (SS) models in which heterogeneity in regression parameters is explicitly modelled; and population-averaged (PA) models in which the aggregate response for the population is the focus. We use a generalized estimating equation approach to fit both classes of models for discrete and continuous outcomes. When the subject-specific parameters are assumed to follow a Gaussian distribution, simple relationships between the PA and SS parameters are available. The methods are illustrated with an analysis of data on mother's smoking and children's respiratory disease.
Metacognition has been defined as cognition about cognition. Metacognition can include beliefs and attitudes about cognitive events such as thoughts, feelings, memories, images, sensations, and perceptions. Cognitive models of addictions have addressed the role of beliefs and attitudes in substance misuse, but the role of metacognition has been neglected. Metacognitive effects (beliefs about the effect of psychoactive substances on cognition) is differentiated from metacognitive consequences (beliefs about the effect of refraining from psychoactive substances on cognitive experience). In this study of 20 types of cognitive experience in 108 treatment-seeking substance abusers, the major metacognitive effects of drugs and alcohol were reduction, detachment from, and intensification of the cognitive event. The major metacognitive consequences of not consuming a substance included beliefs that the cognitive experience would be too uncomfortable, sleep would be disturbed, persistence of the cognitive event, and intensification of the cognitive event. An interaction between metacognitive effects and consequences and the type of cognitive event was found.
Longitudinal studies are increasingly popular in epidemiology. In this tutorial we provide a detailed review of methods used by us in the analysis of a longitudinal (multiwave or panel) study of adolescent health, focusing on smoking behaviour. This example is explored in detail with the principal aim of providing an introduction to the analysis of longitudinal binary data, at a level suited to statisticians familiar with logistic regression and survival analysis but not necessarily experienced in longitudinal analysis or estimating equation methods. We describe recent advances in statistical methodology that can play a practical role in applications and are available with standard software. Our approach emphasizes the importance of stating clear research questions, and for binary outcomes we suggest these are best organized around the key epidemiological concepts of prevalence and incidence. For prevalence questions, we show how unbiased estimating equations and information-sandwich variance estimates may be used to produce a valid and robust analysis, as long as sample size is reasonably large. We also show how the estimating equation approach readily extends to accommodate adjustments for missing data and complex survey design. A detailed discussion of gender-related differences over time in our smoking outcome is used to emphasize the need for great care in separating longitudinal from cross-sectional information. We show how incidence questions may be addressed using a discrete-time version of the proportional hazards regression model. This approach has the advantages of providing estimates of relative risks, being feasible with standard software, and also allowing robust information-sandwich variance estimates.
Aims: The present study extends the findings of a pilot study conducted among regular amphetamine users in Newcastle, NSW, in 1998. It compares key features between current participants in a state capital city (Brisbane) and a regional city (Newcastle) and between the 1998 and current Newcastle sample.
Cross-sectional survey. Setting Brisbane and Newcastle, Australia.
The survey was conducted among 214 regular amphetamine users within the context of a randomized controlled trial of brief interventions for amphetamine use.
Demographic characteristics, past and present alcohol and other drug use and mental health, treatment, amphetamine-related harms and severity of dependence.
The main findings were as follows: (i). the rate of mental health problems was high among regular amphetamine users and these problems commonly emerged after commencement of regular amphetamine use; (ii). there were regional differences in drug use with greater accessibility to a wider range of drugs in a state capital city and greater levels of injecting risk-taking behaviour outside the capital city environment; and (iii). there was a significant increase in level of amphetamine use and percentage of alcohol users, a trend for a higher level of amphetamine dependence and a significant reduction in the percentage of people using heroin and benzodiazepines among the 2002 Newcastle cohort compared to the 1998 cohort.
Further longitudinal research is needed to elucidate transitions from one drug type to another and from recreational to injecting and regular use and the relationship between drug use and mental health in prospective studies among users.
Intervention research should evaluate the effectiveness of interventions aimed at: preventing transition to injecting and regular use of amphetamines; toward reducing levels of depression among amphetamine users and interventions among people with severe psychopathology and personality disorders; and toward reducing the prevalence of tobacco dependence among amphetamine users.
The present study sought to replicate and extend a small pilot study conducted by Baker, Boggs & Lewin (2001) which demonstrated that brief interventions consisting of motivational interviewing and cognitive-behaviour therapy (CBT) were feasible and associated with better outcomes compared with a control condition.
Randomized controlled trial (RCT).
Greater Brisbane Region of Queensland and Newcastle, NSW, Australia.
The study was conducted among 214 regular amphetamine users.
Demographic characteristics, past and present alcohol and other drug use and mental health, treatment, amphetamine-related harms and severity of dependence.
The main finding of this study was that there was a significant increase in the likelihood of abstinence from amphetamines among those receiving two or more treatment sessions. In addition, the number of treatment sessions attended had a significant short-term beneficial effect on level of depression. There were no intervention effects on any other variables (HIV risk-taking, crime, social functioning and health). Overall, there was a marked reduction in amphetamine use among this sample over time and, apart from abstinence rates and short-term effects on depression level, this was not differential by treatment group. Reduction in amphetamine use was accompanied by significant improvements in stage of change, benzodiazepine use, tobacco smoking, polydrug use, injecting risk-taking behaviour, criminal activity level, and psychiatric distress and depression level.
A stepped-care approach is recommended. The first step in providing an effective intervention among many regular amphetamine users, particularly those attending non-treatment settings, may include provision of: a structured assessment of amphetamine use and related problems; self-help material; and regular monitoring of amphetamine use and related harms. Regular amphetamine users who present to treatment settings could be offered two sessions of CBT, while people with moderate to severe levels of depression may best be offered four sessions of CBT for amphetamine use from the outset, with further treatment for amphetamine use and/or depression depending on response. Pharmacotherapy and/or longer-term psychotherapy may be suitable for non-responders. An RCT of a stepped-care approach among regular amphetamine users is suggested.
The authors argue that human desire involves conscious cognition that has strong affective connotation and is potentially involved in the determination of appetitive behavior rather than being epiphenomenal to it. Intrusive thoughts about appetitive targets are triggered automatically by external or physiological cues and by cognitive associates. When intrusions elicit significant pleasure or relief, cognitive elaboration usually ensues. Elaboration competes with concurrent cognitive tasks through retrieval of target-related information and its retention in working memory. Sensory images are especially important products of intrusion and elaboration because they simulate the sensory and emotional qualities of target acquisition. Desire images are momentarily rewarding but amplify awareness of somatic and emotional deficits. Effects of desires on behavior are moderated by competing incentives, target availability, and skills. The theory provides a coherent account of existing data and suggests new directions for research and treatment.
This study investigated the role of metacognition as a mediator of the relationship between emotion and smoking dependence. A sample of 104 smokers completed the following questionnaires: Hospital Anxiety and Depression Scale (HADS), Metacognitions Questionnaire 30 (MCQ-30), and Fagerström Test of Nicotine Dependence (FTND). Three dimensions of metacognition (positive beliefs about worry, negative beliefs about worry concerning uncontrollability and danger, and beliefs about cognitive confidence) were found to be positively and significantly correlated with smoking dependence. A positive and significant correlation was also observed between anxiety and depression on the one hand, and smoking dependence on the other. Structural equation modeling was used to test a mediational model in which emotion predicted metacognition which in turn predicted smoking dependence. The results supported the hypothesis that the relationship between emotion and smoking dependence is partially mediated by metacognition, suggesting that metacognitive theory may be relevant to understanding smoking dependence. The implications of these findings are discussed.
In this article the authors explore the experience of craving of methamphetamine users and seek to illuminate how differences in craving contribute to use patterns. Using in-depth interviewing, data were collected from 82 active methamphetamine users in the metropolitan Atlanta area. The constant comparison method common in grounded theory guided the data analysis. Narrative responses corresponded with three types of craving described in the literature: cue-, drug- and withdrawal-induced. However, the narratives also problematize this typological view as well as the characterization of craving as invariably leading to drug use. Types of craving cues were sometimes inseparable, and users indicated that the different types of craving could occur in the same situation. Further, many users described being able to overcome craving through personalized methods of control. This study complements the largely quantitative work on craving and highlights the importance of improving drug abuse treatment and harm reduction programs.
- N K Lee
N.K. Lee et al. / Journal of Substance Abuse Treatment 38 (2010) 245–250
STATA Statistical Software (Version 10.1). College Station.
- Stata Corp
Stata Corp. (2005). STATA Statistical Software (Version 10.1). College
Station. Texas: STATA Press Publication.