Case study: John
John is 28 years old and has an addiction to heroin. He lives with his brother who is trying to take care of him. He has worked in a variety of part-time jobs but has been fired from most of them, mainly because of his very poor appearance due to lack of personal care. He has spent much of his time finding ways to obtain heroin to satisfy his addiction and has left other aspects of his life unattended. On a couple of occasions, he has stolen money from colleagues at work and has been caught. He has occasionally used dirty syringes or shared them with others when the urge to consume heroin became overwhelming.
John and his brother have no contact with their father. Their parents divorced when they were young because his father had problems with alcohol and was very violent, especially with John. The situation at home was unsustainable. When John was aged 6 years, he and his brother, who is 5 years older, were placed into foster care, although they continued to have regular contact with their mother. She could not afford to take care of them both by herself. At that age, John was already very shy and anxious, worrying about everything; however, his brother was less anxious and “he took the role of big brother very seriously”, as John said during an interview with his psychologist. His brother managed to obtain some qualifications and started working as soon as he was 17; however, at the same age, John started selling and consuming cannabis with friends and was unsuccessful in his attempts to find work. John remembers the foster care years as very stressful. He is still a person who worries a lot and is very pessimistic. He feels that he was “unwanted” and he finds this difficult to deal with. His brother, however, is more understanding of their mother’s circumstances and has tried to adapt to the situation.
John started consuming drugs during adolescence, and this unfortunately developed into his current addiction to heroin. He started taking heroin at the age of 20 when he was living as a squatter with some friends. He says heroin is the only drug that makes him forget all his worries and feel happiness for a few moments, although more recently he does not feel these “positive” effects as frequently. He feels that he needs the heroin “to survive”, and he struggles to control the impulse to go and find more of the drug.
John had an overdose a couple of years ago and after being in the hospital for a month, followed by time in a treatment centre, he went to live with his brother. During his treatment he was given methadone, but after finishing the treatment he had a relapse episode. He then attended the clinic again with his brother to start another course of treatment. This is a transcript of three minutes of a recent interview between John and a psychologist at the treatment centre:
Psychologist John, I’ve seen in your medical history that you have visited several treatment centres in the past. Could you tell me why you have decided to come to a centre again?
John Well, I feel very sick right now because I took heroin again four days ago and my brother kept me locked in at home. This is what happens when I don’t have my drug. I’m shaking, my nose is running and my whole body is in pain. I know I should stop but I don´t know how. I have tried everything but in the end I do it again. I have messed everything up. I have lost the opportunity to have a normal life again.
Psychologist You say you have messed everything up; would you mind telling me what has happened exactly?
John I was given methadone for a while, and I was feeling much better. I was basically clean. My brother found a good job for me, and this time I wanted to do it well. The other day I saw a sheet of foil in the kitchen and I felt the urge again. I went for a run to distract myself. I managed my “desire” until I saw an empty used syringe in a park on my way home. Before I realised, I was in my old place asking for a dose. I thought it was OK just to have a bit, but again … I was wrong.
I’m also ashamed to admit that I stopped in a shop and I stole a wallet to buy the drug. I’ve done a lot of crazy and embarrassing things in my life to get it … .
Psychologist How did taking the drug make you feel?
John Not as good as when I first started taking heroin, but … after what happened before, I had half of the dose this time. I just wanted to stop my impulse or desire by having a little bit.
Psychologist What do you mean by “what happened before”?
John I was taking quite a lot of heroin in those days. I felt I needed more and more to feel the effect I wanted. The quantity I normally took did not make me feel as good as before, so one day I increased the dose … . It was too much, my body couldn’t handle it and I woke up in a hospital.
(a)With reference to Table 1.3 in Topic 5, Section 1.3, identify three pieces of evidence in John’s case study that would meet three different criteria for a substance use disorder as described in the DSM-5 (one piece of evidence for each criterion).
In your answer, describe the evidence from the case study and briefly justify why you think the evidence matches the chosen criterion.
Word limit: 200 words
(b)Identify one possible genetic, one social and one psychological (e.g. personality) risk factor that may have contributed to John’s addiction.
Use your knowledge from the module materials for the role of genetic, social and psychological risk factors in addiction to support your answers.
Word limit: 250 words
(c)How did the sheet of foil John saw in his kitchen and the syringe he saw in the park drive his behaviour?
Explain your answer based on what you have learnt about reward-related learning and cue-evoked relapse, using terminology related to conditioning in your answer.
Word limit: 150 words
