Substance use disorders (SUD) are a prominent public health problem in the United States of America. Substance use disorders, by definition, beget significant health and social consequences. The purpose of this study was to investigate the association between negative educational outcomes (failure to complete high school and low-literacy) and behavioral, clinical, and social correlates in people with SUD. It was hypothesized that men with high school completion would report less negative clinical, social, and behavioral correlates. Independent analyses ran for each behavioral, clinical, and social correlate failed to reject the null hypothesis that differences between the high school completion and non-completion groups were not statistically significant. This study utilized intake data for a sample of socially disadvantaged adult males with SUD at an inpatient treatment facility in a large urban area. Of significance, only 33.9% of this sample reported completing high school. Census Data estimates that 81.2% of adults in the same county are high school graduates, suggesting a significant relationship with high school non-completion in this group of people with SUD. This research presents a starting point for a conversation related to accommodations for literacy challenges in treatment programs for SUD. The theoretical basis for this study relates to the underlying development of competence and identity that is achieved through educational success early in life, which can affect later life outcomes (Erikson, 1963). The relationship between high school completion and reported confidence for achieving sobriety in the study was not significant. A separate analysis also found non-significant results using reported school-aged reading and writing problems as the independent variable. Among many limitations, the time that the data was collected and the age range of the sample is thought to have impacted the results. Future directions include recommendation to investigate the influence of educational attainment on treatment outcomes. A secondary analysis explored SUD and spirituality. Ellis and Shoenfeld (1990) argued that the spirituality component of Alcoholics Anonymous, which is largely incorporated into inpatient SUD treatment for socially disadvantaged populations, was impeding people from potential recovery. In this study men who placed value on spirituality were statistically significantly more confident in their ability to find treatment success than those who did not place value on spirituality, indicating an association between spirituality and confidence for success in treatment. / School Psychology / Accompanied by one .pdf file: BioPsychoSocial.pdf

Although the extant literature suggests that associations with deviant peers (ADP) contribute to the persistence and exacerbation of adolescent conduct problems (CP) and substance use (SU), few studies have investigated processes through which these relations develop, the stability of ADP, risk factors for ADP, or prospective relations among patterns of ADP, CP, and SU across adolescence and substance use disorder (SUD) in early adulthood. Relations among ADP with CP and ADP with SU may be due to selection processes (i.e., youth select into ADP groups) and/or socialization processes (youth are influenced by deviant peers once they enter the ADP group). In addition, selection and socialization processes may be moderated by neuropsychological and temperamental (i.e., emotionality) factors, though there is a dearth of literature examining moderators of these processes. The present study addressed these gaps in the literature by examining five research aims: (1) identify subgroups of youth who vary in type and levels of ADP and CP/SU at three different ages using latent class analysis, (2) investigate the stability of ADP and CP/SU subgroup membership using latent transition analysis, (3) examine the prospective relations among ADP and CP/SU subgroup membership, (4) investigate potential neuropsychological and emotion regulation moderators of selection and socialization processes, and (5) evaluate prospective prediction to SUD in early adulthood from patterns of ADP and CP/SU subgroup membership across adolescence. Participants were youth who participated in a large-scale research project conducted through the Center for Education and Drug Abuse Research at the University of Pittsburgh. Youth and their families completed multiple assessments, beginning when youth were 10-12 years old, followed by assessments at 12-14, 16, and 22 years old. Results indicate (a) deviant peer groups vary based on type and severity of deviant behavior; (b) deviant peer group involvement increased across adolescence and continuity of deviant peer involvement was evident; (c) youth selected peers based on similar levels of deviant behavior across ages 10 to 16 years, but were influenced by these deviant peers to engage in CP and/or SU from ages 12-14 to 16 years; (d) relations between youth deviant behaviors and later selection of deviant friends differed according to levels of youth neuropsychological functioning and temperamental emotionality; and (e) earlier involvement with deviant peers, involvement with deviant peer groups defined by severe CP and SU, and youth engagement in both CP and SU were related to the greatest risk for SUD in early adulthood. / Psychology

Traumatic brain injury (TBI) is a prominent healthcare concern in the U.S. as millions of TBI-related emergency department visits occur annually. Recent reports estimate more than 5 million Americans currently suffer from life-long disabilities and psychiatric complications associated with TBI. While the risk of TBI has conventionally been considered to be male dominated, analyses of sex-comparable sports indicate that rates of concussions are higher and recovery time is longer following brain injury in females. Following anxiety and depression, substance use disorder (SUD) is the third most common de-novo neuropsychiatric condition diagnosed in both male and female TBI patients. Importantly, during adolescence the primary neuronal networks that regulate reward behaviors and perception of drug-induced euphoria are not fully developed, corroborating epidemiological studies identifying TBI sustained during adolescence as a risk factor for problematic drug use. Yet, to date, little is known about how TBI-induced molecular changes affect brain structures essential for the perception of reward and processing drug-induced euphoria. The following experiments were designed to test the hypothesis that adolescent TBI-induced neuroinflammation in areas such as prefrontal cortex (PFC) and nucleus accumbens (NAc) results in remodeling of neuronal reward networks and affect how the rewarding effects of cocaine shift as a consequence of TBI. Notably, the extent of sex differences in SUD susceptibility in TBI has not be investigated. Therefore, we also investigated whether the immune response stimulated by early-life TBI alters maturation of reward neurocircuits, leading to increased SUD vulnerability in a sex-dependent manner. Following the induction of TBI using the controlled cortical impact (CCI) model of brain injury, we utilized a biased, three-phased cocaine conditioned place preference (CPP) assay to assess the behavioral response to the rewarding effects of cocaine following adolescent injury in male and female C57BL6 mice. Furthermore, we characterized the effect of CCI-TBI on the stimulation of neuroinflammation within the PFC and NAc, comprising the reward pathway. Specifically, our studies revealed a sex-specific increase in 1) sensitivity to the rewarding efficacy of a subthreshold doses of cocaine interpreted from significantly higher cocaine CPP shifts, 2) the activation and phagocytosis of microglia observed by the positive expression of neuronal synaptic proteins in microglia sorted using flow cytometry, 3) increase in permeability of the blood-brain barrier indicated by discontinuous and depleted expression of tight junction proteins that line microvasculature isolated from reward nuclei, 4) decreased neuronal complexity, arborization, and spine density quantified from Golgi-cox stained NAc neurons, 5) changes in expression of genes related to the dopamine system analyzed by qRT-PCR in only male mice injured during adolescence. Additionally, our results imply that high levels of female hormones can promote neuroprotection against increased sensitivity to the rewarding properties of cocaine following injury, associated with decreased neuroinflammatory profiles after TBI in adolescent females. The studies herein aimed to elucidate underlying neuropathological outcomes following TBI in the reward circuitry that could be contributing to increased risk of addiction-like behavior observed clinically. Our findings suggest that TBI during adolescence may enhance the abuse liability of cocaine in adulthood and vulnerability to the rewarding effects of cocaine could be higher as a result of brain injury. Key pathological findings in the NAc such as activated microglial phagocytosis, BBB changes, reduced neuronal complexity, and changes in dopamine gene expression in areas of the reward pathways support the notion that neuroinflammation may contribute to how the rewarding efficacy of cocaine are affected post-TBI during adolescence. The ultimate goal of this research is to 1) advance TBI and SUD literature with the potential to increase awareness and help health care providers inform TBI patients about the increased risk for SUDs, and 2) to translate identified correlated mechanisms into novel targeted therapies that would provide a launching point for the treatment of patients with TBI-related SUD. / Biomedical Sciences

Posttraumatic stress disorder (PTSD) co-occurs with substance use disorders at high rates, but the neurobiological basis of this relationship remains largely unknown. Identifying mechanisms that underlie this association is necessary, and recognizing pathologies shared by these disorders may provide pertinent information in understanding their functional relationship. Separate lines of evidence suggest that PTSD and drug addiction may share a common feature, that is, dysregulation of the brain's reward circuitry. We hypothesize that PTSD results in reduced dopaminergic neurotransmission which may contribute to deficient reward function and vulnerability to drug-seeking behavior. To address this hypothesis, we combined single-prolonged stress (SPS), a rodent model of PTSD, with a series of behavioral and neuropharmacological assays to assess dopaminergic reward function and cocaine intake. The results of the studies presented herein extend our understanding of the effects of severe stress on drug reinforcement and consumption, and establish a potential mechanism by which PTSD produces deficient reward function through alterations in the dopamine system. A modified SPS procedure consisting of 2 hours of restraint, 20 minutes of group swimming, isoflurane exposure until loss consciousness, and 7 days of isolation was used to induce severe stress in our studies. Initial studies were conducted to examine the effect of SPS on cocaine-conditioned reward and anhedonia-like behavior in adult male Sprague-Dawley rats. Using a biased conditioned place preference paradigm, unstressed controls demonstrated a significant preference for the cocaine-paired context following four pairings with cocaine (5-20 mg/kg, i.p.). Preference for the cocaine-paired side was significantly lower in rats exposed to SPS, suggesting a deficit in the rewarding properties of cocaine following exposure to severe stress. Anhedonia-like behavior was assessed by a two-bottle choice sucrose preference test. Robust consumption of sucrose solution (0.25-1%) was observed in rats that underwent control handling, however, SPS significantly reduced sucrose intake compared to controls. These results suggest an increase in anhedonia-like behavior or a reduction in the rewarding effects of sucrose as a non-drug reinforcer. Finally, basal behavioral activity in SPS rats was compared to unstressed controls in a 24-hour test. Results indicate a significant reduction in spontaneous nocturnal activity following SPS versus control handling. In contrast, hyperlocomotion induced by an acute cocaine injection (5-20 mg/kg, i.p.) was unaltered between rats that underwent SPS or control handling. These data suggest that deficient behavioral activity may be specific to voluntary movements or behavior, and support an increase in anhedonia following exposure to SPS. Intravenous cocaine self-administration was conducted to examine the effect of SPS on the acquisition, motivation, and escalation of cocaine intake. Acquisition of cocaine self-administration was studied using an escalating dose regimen in which rats had sequential access to 0.1875, 0.375, and 0.75 mg/kg/infusion on a fixed-ratio 1 schedule of reinforcement. Rats exposed to SPS did not significantly differ from control handled animals in the latency to meet acquisition criteria (consumption of 6.75 mg/kg/day for 3 consecutive days) or the general pattern and level of cocaine intake at each dose. A subsequent study assessing the breakpoint for cocaine self-administration using a progressive-ratio schedule of reinforcement determined a dose-dependent increase in motivation to work for cocaine (0-1.5 mg/kg/infusion) across both experimental groups. However, motivation to obtain cocaine was similar between SPS and unstressed rats, as there was no significant difference in breakpoint for cocaine self-administration at any dose of cocaine tested. To evaluate potential differences in the transition to escalated cocaine intake, self-administration was measured using an extended-access procedure in which unlimited cocaine (0.375 mg/kg/infusion) was available for six hours daily. Upon extended-access to cocaine, SPS significantly attenuated cocaine intake compared to control handling over 14 sessions. Despite a significant reduction in cocaine intake, rats exposed to SPS still significantly escalated their cocaine intake over the course of 14 days. These results suggest that escalation of cocaine intake occurred in the presence of lower total doses of cocaine in the SPS exposed animals compared to controls. In addition, SPS rats demonstrated a greater percent increase in cocaine consumption compared to controls. This finding suggests that rats exposed to SPS compensated for a decrease in cocaine reinforcement by escalating their intake to a greater magnitude than controls. These studies indicate that SPS may not alter the acquisition of cocaine self-administration or motivation for cocaine. However, the finding of reduced cocaine intake upon extended-access in SPS rats is consistent with a deficit in cocaine-induced reward. The ability of SPS rats to escalate cocaine intake in the presence of less cocaine, or a greater magnitude of escalated cocaine intake than controls, may reflect mechanisms leading to enhanced vulnerability to cocaine abuse. To understand the mechanisms of reduced reward and behavior in the SPS model of PTSD, a series of neurochemical assays was used to assess the ability of SPS to induce dysfunction of dopaminergic neurotransmission. Using high performance liquid chromatography, tissue levels of dopamine and the dopamine metabolites DOPAC and HVA were measured immediately and one week following SPS or control handling. Tissue obtained from SPS rats demonstrated significant decreases in dopamine, DOPAC, and HVA content in both the nucleus accumbens and caudate putamen immediately following SPS and one week later, suggesting a potential deficit in dopaminergic tone. Quantitative autoradiography was used measure the density of dopamine transporters and dopamine D1 and D2 receptors. [3H]WIN35428 binding to dopamine transporters was higher in the nucleus accumbens of SPS rats compared to controls, suggesting an increase in dopamine transporter density following severe stress. The level of [3H]WIN35428 binding in the caudate putamen was not different between groups. [3H]Raclopride binding to D2 receptors was significantly reduced in both the nucleus accumbens and caudate putamen following SPS versus control handling. These results suggest a decrease in the density of striatal D2 receptors. D1 receptor expression was not significantly altered by SPS, as no significant difference in [3H]SCH23390 binding was detected in SPS rats compared to controls. A preliminary functional assessment of dopamine transporters revealed a significant increase in dopamine uptake in the nucleus accumbens of SPS rats compared to controls, whereas uptake in the caudate putamen was unaltered between groups. Enhanced dopamine uptake following SPS is consistent with the increase in dopamine transporter density observed in the nucleus accumbens of SPS rats. Activation of D1 receptors and G-protein mediated transduction was assessed using an adenylyl cyclase assay with the D1 agonist SKF82958. In the caudate putamen, a significant decrease in D1 receptor-stimulated cAMP production was revealed in SPS rats compared to controls, whereas SKF82958-induced cAMP was unchanged in the nucleus accumbens. Finally, the function of D2 dopamine receptors was assessed by D2 receptor-stimulated [35S]GTPγS binding using quinpirole. In the caudate putamen, [35S]GTPγS binding following stimulation of D2 receptors was enhanced by SPS compared to control handling, whereas no difference was observed between groups in the nucleus accumbens. These results indicate increased D2 receptor-mediated activation of G-proteins in the caudate putamen following SPS. In summary, the studies described herein tested the hypothesis that reduced dopaminergic function may be a mechanism for deficient reward and heightened susceptibility to drug use in PTSD. Results demonstrated a significant reduction in cocaine-conditioned reward, as well as attenuated sucrose preference and spontaneous activity in rats exposed to SPS. These findings are consistent with the presence of a dysfunctional reward system which may contribute to anhedonia-like behavior in PTSD. Furthermore, reward deficits may promote altered patterns of cocaine taking behavior and vulnerability to substance abuse. Results demonstrated significant escalation of drug intake following exposure to SPS, which occurred in the presence of less cocaine than controls. A greater increase in cocaine intake was observed in SPS rats over the course of escalation, which may reflect a mechanism for enhanced vulnerability to the development of a substance use disorder in PTSD. Dopaminergic dysfunction may contribute to deficient reward capacity and an altered pattern of cocaine intake in SPS. SPS-induced alterations in dopamine function included a reduction in striatal dopamine content alongside enhanced dopamine transporter levels and function. Mild alterations in D2 receptor density and the function of D1 and D2 receptors were also observed. These findings support the hypothesis that PTSD results in reduced dopaminergic neurotransmission, which may contribute to deficient reward function and altered drug-seeking behavior. Identifying the pathology of PTSD, such as altered dopamine neurotransmission, may lead to enhanced treatment strategies and interventions to prevent substance abuse in persons with PTSD. / Pharmacology

Clinicians and researchers have identified a pattern of "mixed" symptoms that are sometimes exhibited by individuals with bipolar spectrum disorders (BSDs). However, the criteria for these mixed states as outlined by the American Psychological Association have been criticized for being too stringent for most individuals that experience impairing episodes of mixed symptomatology (e.g., Akiskal, 1996). Mixed states are associated with a more impairing course of illness and suicidality. More research is needed on mixed states, and there is particularly little evidence for risk factors in recent-onset samples. The aims of this study were to 1) examine the prevalence of mixed states in a sample of individuals with recent-onset bipolar spectrum disorders, 2) examine the symptom structure of hypomanic and depressive episodes, and 3) examine some of the risk factors associated with mixed states. Participants in sample 1 were adolescents, initially aged 14-19, selected for exhibiting either moderate or high Behavioral Approach System (BAS) risk for first onset of BSDs. Participants in sample 2 were 18-24 year old undergraduates from Temple University recruited for having a bipolar spectrum diagnosis. Mixed states captured 37.10% of all episodes examined in sample 1, yet only 13 (10.48%) of these episodes met available research criteria for mixed mood episodes. Factor analysis yielded two adequate models that fit the data; one model had two factors that aligned with traditional depressive and hypomanic symptomatology, and another model had three factors that aligned with hypothesized overactivity, inhibited depression, and irritable risk taking components of bipolar disorder. Latent class analysis allowed for examining observed patterns of responses within individuals, and then grouping heterogeneous groups of individuals into classes based on similarities on dimensions of interest, performance within dimensions, or both (Nylund, Bellmore, Nishina, & Graham, 2007). The latent class analysis showed that three classes best defined bipolar spectrum individuals in sample 1: low impulsivity, aggressive, and substance problems classes were obtained. The `aggressive' class was significantly more likely than the `low impulsivity' class to experience any mixed symptomatology, although a continuous measure of mixed symptoms did not yield significant differences between classes. Overall, the results from the current study support findings suggesting that mixed mood states are more commonly experienced than originally believed. These results extend previous studies to include individuals with bipolar spectrum disorders, not solely bipolar I and II disorders. These findings also suggest that non-treatment-seeking samples may have different types of mixed mood states than those seeking treatment. These findings add support to the literature that individuals with BSDs and comorbid substance use diagnoses are at increased risk for chronic illness, and show that these individuals are also more likely to experience mixed mood states than those without comorbid substance use diagnosis. Treatment providers should be aware of the complications that are inherent in bipolar individuals with comorbid substance diagnoses, as they are more likely to experience more episodes as well as mixed symptoms. / Psychology

Background With the impending legalization of recreational cannabis in Canada, it is important to examine the strength of association between cannabis use and common mental health concerns including depression, anxiety, and suicide and the extent to which these associations have changed over time. It is also important to examine the moderating effects of developmental age and biological sex on these associations. Methods This study uses Statistics Canada data from the 2002 and 2012 Canadian Community Health Survey’s Mental Health Component (CCHS-MH) which represent repeated cross-sectional surveys from nationally representative samples of Canadians 15 years of age and older (2002 n=36,984; 2012 n=25,113). Stepwise multivariate analyses were performed using linear regression for psychological distress and binary logistic regression for Major Depressive Episode (MDE) and suicidal thoughts and attempts. Time was accounted for as a binary indicator (2002 vs. 2012) and an interaction term between cannabis use and time was added to all the models. Additional interaction terms were added to the models to test the moderating effects of cannabis frequency, developmental age, and biological sex. Sensitivity analyses were performed to adjust for other substance use and socioeconomic covariates. Weighting and bootstrapping was utilized to present results reflective of the Canadian population. Results Cannabis use was positively associated with emotional problems, and this association strengthened over time, particularly for depression and suicidal thoughts and attempts. These temporal associations were similar across age groups and for males and females, and remained after controlling for other substance use and socioeconomic status. Conclusions Findings provide a baseline assessment of the Canadian population prior to legalization and direction for health promotion and prevention campaigns. Results highlight the need for awareness and regular monitoring of the cooccurrence of cannabis use and emotional problems and offer guidance for future research. / Thesis / Master of Health Sciences (MSc) / Using Statistics Canada data from the 2002 and 2012 Canadian Community Health Survey’s Mental Health Component, this dissertation determines the strength of association between cannabis use and common mental health concerns including depression, anxiety, and suicide and the extent to which these associations have changed over time. Cannabis use was positively associated with emotional problems, and this association strengthened over time, particularly for depression and suicidal thoughts and attempts. These temporal associations were similar across age groups and for males and females, and remained after controlling for other substance use and socioeconomic status. These results add novel insights to the existing literature about the changing relationship between cannabis use and emotional problems over time and potential mechanisms of this change are discussed. Given the impending legalization of recreational cannabis in Canada, clinical and research implications of results are discussed at length.

Bakgrund: Användandet av substanser är ett ökande problem såväl globalt som i Sverige. Förekomsten av samsjuklighet anses vanligt förekommande då individer lider av både psykisk ohälsa och ett substansbrukssyndrom. Patienter med substansbrukssyndrom är i stort behov av att samverkan mellan olika instanser är välfungerande för att få adekvat hjälp i sin situation. Trots lagstiftning kring samverkan har brister uppmärksammats. Syfte: Syftet var att belysa specialistsjuksköterskans erfarenheter av samverkan mellan psykiatrisk vård och andra aktörer när patienter har substansbrukssyndrom. Metod: En intervjustudie med specialistsjuksköterskor som arbetade inom öppen- och sluten psykiatrisk vård. Studien hade en induktiv ansats och grundade sig i Graneheim och Lundmans kvalitativa innehållsanalys. Resultat: I resultatet framkom det erfarenheter av utmaningar i samverkan som delats in bristfällig kunskap, resursbrister, bristande uppföljning efter LVM kopplat till otillräcklig kommunikation samt utmaningar i samsynen kring patientgruppen. Erfarenheter av att främja god samverkan lyfts även i resultatet genom positiva erfarenheter av samverkan samt vikten av att samverka med närstående. Konklusion: Att belysa specialistsjuksköterskans erfarenheter av samverkan kan leda till att specialistsjuksköterskan når en fördjupning och medvetandegör sin kunskap. Detta kan bidra till en säkrare och mer personcentrerad vård för patientgruppen samt att specialistsjuksköterskan synliggör de främjande komponenterna och utmaningarna i samverkan. / Background: Substance abuse is an increasing problem both globally and in Sweden. The occurrence of co-morbidity is considered common when individuals suffer from both mental illness and substance abuse syndrome. Patients with substance abuse syndrome are in great need of well-functioning cooperation between different agencies in order to receive adequate help with their situation. Despite legislation regarding cooperation, shortcomings have been noticed. Purpose: The purpose was to illustrate the specialist nurse's experiences of collaboration between psychiatric care and other actors when patients have substance abuse syndrome. Method: An interview study with specialist nurses who worked in outpatient and inpatient psychiatric care. The study had an inductive approach and was based on Graneheim and Lundman's qualitative content analysis. Results: The results revealed experiences of challenges in cooperation divided into insufficient knowledge, resource shortages, lack of follow-up after LVM linked to insufficient communication and challenges in consensus around the patient group. Experiences in encouraging good collaboration is also highlighted in the results through positive experiences of collaboration and the importance of collaborating with close relatives. Conclusion: Highlighting the specialist nurse's experiences of collaboration can lead to the specialist nurse reaching greater depth in and raising awareness of their knowledge. This can contribute to a safer and more person-centered care for the patient group and that the specialist nurse makes visible the promoting components and the challenges in the collaboration.

Thesis advisor: Stephen J. Pope / This dissertation attends to the crisis of addiction in the United States. The increasing number in annual overdoses and the inadequacy of national responses to curtail these preventable deaths demands an immediate moral response. In the last year, deaths caused by overdose increased by nearly 29 percent, and 20.8 million people in the United States are currently living with substance use disorders. The number of families affected by addiction presents a striking testimony to the scope of the problem. Nevertheless, there is still enormous disagreement over the nature of addiction and therefore how to best treat it. This dissertation will therefore offer a theological approach to addiction in order to advocate for a social response to this crisis.This dissertation proceeds in five chapters. In the first chapter, I evaluate the medical and moral models of addiction. This first chapter engages research in neurobiology and psychology and argues that these models are premised upon a false dichotomy between determinism and freedom of the will. The second chapter explores disagreements in bioethics over the meanings of health, disease, and illness. These different definitions contribute to the chasm between the medical and moral models of addiction. This chapter proposes a holistic account of health for understanding addiction and healing. The third chapter grounds this holistic account of health in Karl Rahner’s transcendental anthropology in order to uphold the fundamental relationality of human persons and to move past the false dichotomy presented in chapter one between determinism and freedom of the will. This chapter then offers a theological examination of sin as a power or force that preconditions freedom. It concludes by proposing a theological and relational account of autonomy. The fourth chapter engages philosophy of the mind in order to argue for a nonreductive approach to mentality that appreciates the ways in which human persons are co-constituted by bottom up and top down causality. A nonreductive approach to mentality offers a way to understand addiction as an interacting set of processes and patterns. This fourth chapter concludes by considering the possibility for responsibility by examining narrativity, vulnerability, and imagination. It argues that there is a moral responsibility to imagine a better world for people living with addictions, and to bring that world about. Finally, the fifth chapter draws upon the theological virtue of solidarity and the principle of the preferential option for the poor in order to articulate a preferential option for people living with addictions. I argue here that Church institutions can stand in solidarity with people who suffer from addiction by acting as providers, educators, and lobbyers. / Thesis (PhD) — Boston College, 2022. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Theology.

Maltreatment is a pervasive global problem known to have cascading consequences that persist long after exposure subsides (Masten and Cicchetti, 2010). Maltreatment is often co-occurring, involving exposure to multiple types. Cumulative maltreatment, or exposure to multiple types of neglect and abuse, is proposed to be of critical importance for developmental psychopathology. However, a cumulative approach to studying maltreatment provides little insight into the developmental processes whereby it exerts its effects on health. Thus, we employed both a cumulative approach and a multidimensional approach to facilitate our comprehensive understanding of maltreatment experiences related to behavioral development. Given the high prevalence of maltreatment, it is important to cultivate a greater understanding of the processes linking maltreatment and health and to identify developmental periods of vulnerability to its deleterious effects. The present study uses a longitudinal design and a multidimensional approach to examine the effects of maltreatment on delay discounting and health-promoting and health-demoting behaviors during adolescence and across the transition from adolescence to young adulthood. The study sample includes 167 adolescents (aged 13–14 at Time 1; 53% male) who participated across 5 time points over 6 years. At Time 5, adolescents provided retrospective reports of their exposure to maltreatment during adolescence across ages 13–18. Delay discounting, substance use, and body mass index (BMI) were assessed at each time point. We used a developmental cascade model with autoregressive, cross-lagged, and cross-sectional associations to examine the longitudinal multivariate change processes and indirect effects from maltreatment exposure during adolescence to delay discounting and health-promoting and health-demoting behaviors during adolescence and across the transition to young adulthood. Our results indicate that cumulative maltreatment affects health-demoting behavior via its effects on delay discounting and that maltreatment of omission but not commission drives this effect. Furthermore, the findings identify adolescents exposed to maltreatment of omission as being especially vulnerable to marijuana use via elevated delay discounting. Identifying mediating processes linking maltreatment exposure to health-promoting and health-demoting behaviors may be instrumental for preventing deleterious developmental cascades and interrupting related health problems during adolescence and across the transition from adolescence to young adulthood. / Doctor of Philosophy / Maltreatment is a pervasive global problem that casts a long shadow, often involving exposure to multiple types of abuse or neglect. Cumulative maltreatment involves exposure to different types of neglect and abuse and is especially problematic for adjustment and health. However, a cumulative approach to studying maltreatment provides little insight into the developmental processes whereby it exerts its effects on health. We took a cumulative approach and a multidimensional approach to improve our understanding of how maltreatment experiences relate to health in adolescence and young adulthood. Given the high prevalence of maltreatment, it is important to understand how maltreatment and health are related and to identify developmental periods of vulnerability to maltreatment. The present study includes 167 adolescents (aged 13–14 at the study outset; 53% male) who participated across 6 years. At ages 17–18, adolescents provided reports of their exposure to maltreatment during adolescence (across ages 13–18). Delay discounting, substance use, and body mass index (BMI) were gathered at each assessment. We examined the cascading effects of cumulative maltreatment, abuse, and neglect on delay discounting and health behaviors over time. Our results indicate that cumulative maltreatment affects health-demoting behavior via delay discounting and that maltreatment of omission but not commission drives this effect. Furthermore, the findings identify adolescents exposed to maltreatment of omission as being especially vulnerable to marijuana use via elevated delay discounting. These findings may inform prevention and intervention efforts aimed at mitigating risks for adolescents exposed to neglect during adolescence and across the transition from adolescence to young adulthood.

Bakgrund: Psykisk ohälsa och substansbruk utgör båda separat globala hälsoproblem. Samsjuklighet i form av psykisk ohälsa och substansbruk är vanligt förekommande och komplexiteten av denna sjukdomsbild utgör utmaningar för hälso- och sjukvården.  Syfte: Studiens syfte var att beskriva upplevelser av möten med omvårdnadspersonal bland personer med samsjuklighet i form av psykisk ohälsa och substansbruk.  Metod: En allmän litteraturstudie genomfördes, i enlighet med Nio-Stegsmodellen av Polit och Beck. Denna översikt inkluderade och metodiskt analyserade nio originalartiklar, med användning av innehållsanalysmetodiken som beskrivits av Graneheim och Lundman.  Resultat: Tre huvudkategorier framträdde: Personen bakom substansbruket, Vårdrelations betydelse och Utmaningar kopplade till samsjuklighet, tillsammans med sex underliggande subkategorier.  Slutsats: Personer med samsjuklighet i form av psykisk ohälsa och substansbruk utgör en komplex patientgrupp. Studiens resultat tyder på att vårdsystemets utformning och upplevd bristande kunskap hos omvårdnadspersonalen utgör hinder för dessa patienter att erhålla adekvat vård. Det krävs en ökad kunskap och förståelse hos omvårdnadspersonal för de unika utmaningar som dessa personer står inför för att bättre kunna möta deras behov. Ytterligare forskning på detta område behövs därmed för att förbättra vården av denna patientgrupp. / Background: Mental health and substance use both separately constitute global health challenges. Comorbidity of mental health issues and substance use is common, and the complexity of this clinical picture poses challenges for healthcare.  Aim: The study's aim was to describe experiences of encounters with nursing staff among individuals with comorbidity of mental illness and substance use.  Method: A general literature review was conducted, adhering to the Nine-Step model by Polit and Beck. This review included and methodically analyzed nine original articles, employing the content analysis methodology outlined by Graneheim and Lundman.  Results: Three main categories were identified: The person behind the substance use, The significance of the care relationship, and Challenges related to comorbidity, along with six associated subcategories.  Conclusions: People with comorbidity in the form of mental disorder and substance use constitute a complex patient group. This study’s results imply that the design of the healthcare system and the perceived lack of knowledge among nursing staff pose barriers for these patients to receive adequate care. There is a need for increased knowledge and understanding among nursing staff regarding the unique challenges faced by these people to better meet their needs. Further research in this area is therefore needed to improve the care of this patient group.