In the Name of God

Quarterly Journal Research on Addiction

Vol. 10, No. 40, Winter 2017

Licence Holder: Drug Control Headquarters of the Presidency

Managing Director: Mahmoud Minooei, M.A.

Chief Editor: Hassan Ahadi, Ph.D.

Executive Director: Majid Ghorbani, M.A.

Editors: MohammadAli Mohammadifar, Ph.D.

Publisher: Drug Control Headquarters, Research & Education Office

Address: No. 20, Building of Presidential Drug Control Headquarters, after Hoveyzeh Cultural-Entertainment Complex, after Poonak Sq., Ashrafi Esfahani Blv., Tehran Postal Box: 1469915834

Tel/Fax: +98-21-47361730 Fax: +98-21-44411761

Email: [email protected]

The Journal is available at DOAJ, dchq.ir, ISC, magiran.com, SID, Iranmedex, ensani.ir & Noormags.com

Editorial Board

Zarindast, M. R., Ph.D. Professor of Pharmacology, Tehran Medical Sciences University Joghataei, M.T., Ph.D. Professor of Anatomy, Tehran Medical Sciences University Mohseni, T. A. R., Ph.D. Professor of Sociology, Tehran University Navabakhsh, M., Ph.D. Professor of Sociology, Open University-Science and Research Branch Mohammadkhani, P., Ph.D. Professor of Psychology, Welfare and Rehabilitation Sciences University Rezai, R. M., Ph.D. Associate Professor of Management of Treatment Services, Police University Rahimi, M. A., Ph.D. Associate Professor of Psychiatry, Tehran Medical Sciences University

Motavalian, S. A., Ph.D. Associate Professor of Epiodmiology, Tehran Medical Sciences University

Reviewers of This Issue

Mohammadkhani, P., Ph.D. Professor of Clinical Psychology, Welfare and Rehabilitation Sciences University Narimani, M., Ph.D. Professor of General Psychology, Mohaghegh Ardabili University Sohrabi, F., Ph.D. Associate Professor of Clinical Psychology, Allameh Tabatabai University PorHosein, R., Ph.D. Associate Professor of General Psychology, Tehran University Ghodrati, M., Ph.D. Assistant Professor of Psycology, Payame Noor University Najafi, M., Ph.D. Assistant Professor of General Psychology, Semnan University Aghayousefi, A., Ph.D. Assistant Professor of Psycology, Qom Payame Noor University Basharpoor, S., Ph.D. Professor of Psychology, Mohaghegh Ardabili University Abolmaali Alhoseini, Kh., Ph.D. Associate Professor of Psychology, Roudehen Islamic Azad University Shirazi, M., Ph.D. Assistant Professor of Psycology, Sistan and Baloochestan University Mirhashemi, M., Ph.D. Assistant Professor of Psycology, Roudehen Islamic Azad University Yaghoobi, A., Ph.D. Associate Professor of Psychology, Bu-Ali Sina University Abolghasemi, A., Ph.D. Professor of General Associate Psychology, Mohaghegh Ardabili University Sahebdel, H., Ph.D. Assistant Professor of Counseling, Qaenat Islamic Azad University

Instructions for Publishing Papers in Journal of Substance Abuse Addiction Research

- After mentioning the title and author(s), write the abstract as objective, method, results, conclusion, and keywords. - Persian and English abstract of papers should include maximum 150 word and from three to five words should be included for keywords. The English abstract is required to be written exactly in agreement with the Persian version. The exact spelling of the author and co-authors’ names should be written in footnote of the English abstract. - Bibliographical information should be inserted at the end of the paper in alphabetical order as follows: In accordance with APA style, put the English version of an author’s name in the footnote when mentioning it for the first time in the text. If the author has any colleagues (up to five persons), write their last names in the footnote. If the number of authors is higher than five, write the author’s name and then add the term et al. ; the mention of all the authors’ names is obligatory in the reference section. If you are to mention an author and colleagues’ names for the first time, there will be no need to mention the colleagues’ names in the following times; in such cases, use the term et al. - When necessary, write the author’s name and year of publication in parentheses in the text and insert the English equivalent of English terms at the end of that page. Add the name of all the instruments and expressions that are used in the text for the first time to the footnote. As much as possible, avoid using foreign words in the text. - Final acceptance and publication of paper in the journal hinges upon the approval of the editorial board and expert reviewers. - All the articles, to be eligible for publication, should enjoy the observation of the principles and framework for Scientific-Research criteria (introduction, main body of the paper including a theoretical or conceptual framework to explain or describe the variables and their relationships, method (population, sample, sampling method, and instrument), research results and findings, discussion and conclusion, acknowledgement, and reference). - Mention your suggestions in the last paragraph of the paper without inserting the heading of suggestions. - Briefly present the conclusion as the summary of the discussion. - Each paper can contain up to 13 A4 pages, each containing 240 words. - Papers should be necessarily typed in Microsoft Office Word Software with the font of Times New Roman and size of 11 and the related file should be forwarded accompanied by the paper. - The author(s)’ name should be written in full. The author(s)’ affiliation, academic degree, and email address should be mentioned below the author(s)’ names. As well, the corresponding author’s name along with the full address should be written below each article. Meta-analyses and Reviews: - Only an article will be accepted whose author has expertise in the relevant area and refers to his/her own name in the reference section (at least four times). - The general principles of writing such papers are similar to the above- mentioned ones. Notes: 1. The contents published in the journal are not necessarily reflective of Drug Control Headquarters’ ideas. The responsibility of the contents lies with the authors are 2. Quoting the contents of this journal (Research on Addiction) with citing the source is allowed. 3. This journal, hereby, invites all the researchers, professors, and experts to submit their research papers on addiction and narcotic drugs. 4. The journal is allowed to edit, modify, and coordinate scientific terms of papers up to the point that concepts do not get distorted. Babak Vojudi et al

Contents

Title Page

First words 7-10 11-22 Behavioral Activation and Inhibition Systems and Coping Styles in Opium Consumers, Methadone Maintenance Treatment Clients, and Normal Peers Abdollahi, M.H.; Baheshmat Juybari, Sh. Management and Implementation of Sampling from Injecting Drug Users 23-36 Exposed to High Risk Diseases Bagheri, A.; Saadati, M. Causal Relationship of Addiction Potential, Early Maladaptive Schemas, 37-52 Psychological Capital, and Basic Psychological Needs under Mediation of Family Communication Patterns Rashidi, A.R.; Hojat Khah, M.; Rasouli, A.; Jami, M. Comparison of Thought Control, Mindfulness, and Attachment Styles 53-68 between Students with High and Low Tendency to Addiction Mikaeel, N. On the Effectiveness of Transcranial Direct-Current Simulation (tDCS) in 69-80 Craving, Depression, and Anxiety among Students with Tramadol Abuse: Preliminary Study Narimani, M.; Pouresmali, A.; Alizadeh Goradel, J.; Mowlaie, M. On the Comparison of Risk-Taking and Cognitive Distortion in Students 81-88 With and Without Addiction Tendency Mashmool Haji Agha, S.; Abolghasemi, A. Addiction Prevention Components in the Content of Thinking and Lifestyle 89-100 Book of Seventh Grade from Teachers' Perspective Karimiyan, H.; Zavar, T.; Piri, M. The Rate of Addiction Prevalence in Industrial Environments 101-114 Mohammadi, K.; Asgari, A. The Mediating Role of Psychological Hardiness in the Relationship of 115-126 Religious Orientation, Self-Efficacy and Self-Concept with Addiction Tendency Jalilean Kaseb, F.; Rashidi, A.R.; Hojat Khah, M . Causal Model of Impact of Emotional Instability Personality on Tendency to 127-142 Risky Behaviors in Adolescents with the Mediating Role of Attitudes to Substance Use Mokhtarnia, I.; Zadeh Mohammadi, A.; Habibi, M.; Mirzaifar, F.

Title Page

On the Comparison of Effectiveness of Schema Therapy and Mindfulness in 142-156 Psychosomatic Symptoms in People with Stimulants Abuse Sydasyaban, S.; Monshi, Gh.R., Asgari, P. The Diagnostic Role of Delayed Reward Discounting and Sensation Seeking 157-168 in People with Stimulant and Opiate Use Disorders Ahmadi, F.; Hasani, J.; Moradi, A.R.; Sajdeipoor, S. Structural Model of Psychosocial Factors in the Addiction Potential of 169-182 Adolescents with Mediating Role of the Co-dependency Pazani, F.; Borjali, A.; Ahadi, H.; Kraskian Mojembari, A. Binaural Beats Effect on Addicted People Based on EEG 183-196 Malek Zadeh, D.; Rahati Ghouchani, S.; Kabrovi, H.R.; Azad Dadgar, M. Proposal of Integral-Differential Equation Model for Prevalence of 197-206 Substance Use Hosseini, H.; Tari Marzabad, A.; Hassanpour Ezatti, M.

Babak Vojudi et al

First words

Addiction, narcotics, and psychotropic drugs are considered among the global crises in the present age in such a way that they have affected all sectors of society and their harmful effects have involved all personal and social aspects; for this reason, addiction is considered as the mother of social harms and threats. This ominous phenomenon has been exploited by two components, including the increasing trend of the supply of narcotic and psychotropic drugs, as well as the increasing demand; in this way, it has sought to attract new customers through the use of economic instruments in international transactions with a turnover of $ 1,400 to 1,600 billion from drug trafficking in the world. In addition, it entails a political tool for the penetration of colonialism and the destruction of the adolescent and young generations of communities. The following are representative of the bitter realities in the field of addiction: a 19-percent increase in demand for substances and the increase in the number of substance consumers from 208 million people with a prevalence rate of 4.9 percent in 2006 to 247 million people with a prevalence of 2.5 percent in 2015; the spread of hashish and cannabis, amphetamines, stimulants, and cocaine and a change in the pattern of drug use; a 322-percent increase in new types of psychotropic substances in 2017 compared to 2009; an increase in mortality due to the excessive consumption of drug use to 187,100 people in 2013; The reduced age of consumption from an average age of 22.7 years in 2001 and to 18.5 years in 2011; the triple increase of substance use in men compared to women; the decline in motivation for treatment in drug addicts worldwide in such a way that only 10% of addicts are motivated to seek treatment; the general relapse to the drug cycle before the first three months of treatment; 247-percent growth of poppy cultivating area in Afghanistan from 58,000 hectares in 1997 to 201,000 hectares in 2016 and consequent 71-percent increase in opium production in Afghanistan from 2804 tons in 1997 to 4,800 tons in 2016. In the course of globalization age, Iran has not been safe from the mentioned threats in such a way that the prevalence of consumption and demand for substances have existed in all classes, such as the senior high school population (from 0.5 percent in 2002 to 1 percent in 2010 and 1.2 percent in 2015), in the student population of public universities (from 1 percent in 2002 to 2.6 percent in 2011 and to 5.6 percent in 2015), in the working population to 22.3 percent, and in the general population also to 9.9% in 2011. In this regard, the pattern of drug use has also changed from opium to crystal, Afghan crack to opium, marijuana to crystal, and it has been associated with the growth of women's entry into the addiction cycle. Meanwhile, in the 15-to-64 population of the country, positive attitude to substance use has increased from 11.5 percent in 2004 to 27.4 percent of in 2014. A glance at the causes and reasons for the onset of drug use in the general population (15-64 years) in 2011 leads us to such factors as the acquisition of pleasure, curiosity, recreation, the elimination of mental problems, the availability of substances, peer pressure, relief of pain, heavy work, reducing symptoms of physical diseases other than pain, and fixing of sexual problems. However, these reasons in 2015 have changed into entertainment, the attraction of

attention, coping with life problems, experiencing, higher pleasure in sex, family or others' insistence, withdrawal of another substance, overcoming the sleep problem or a physical problem, better learning and studying, and doing work or artwork better. By the statement of the above introduction, it is meant to have a look at the howness of prediction of the future status of addiction, narcotics and psychotropic substances, the resultant consequences and problems in the world and Iran. Based on the future status of drug addiction and psychotropic drugs, evidence suggests the following: A) The probability of increased drug consumption and trafficking: Migration and urbanization, marginalization and feelings of discrimination, population growth patterns and the lack of proper economic conditions, the emergence of new patterns of social relations, the lack of recreational enrichment skills, the pursuit of extreme pleasure, the transformation of traditional values, the development of subcultures, the weakening of moral and religious beliefs, the intensification of mental disorders arising from the postmodern age, the weakening of parental functioning in protecting children due to the lack of parental effective presence at home, and the weakness of individual and social skills in the new generation all indicate the increased consumption and smuggling of drugs in the countries of the world in such a way that it has been predicted that societies will face a 25 percent increase of substance use among the problematic addicts in 2050. B) Change in the pattern and type of the substances as well as their breadth and range of variation: The emergence of new psychosocial substances (NPS) with the legal nature of easy production, the spread of different types of marijuana, stimulant drugs and cocaine, and the presence of inhalants have all provide the grounds for changing the patterns of drug use and the simultaneous use of several types of substances. C) Changes in consumers' status: Decreased consumer age due to their following of Western lifestyles and the use of new substances, the failure of young people to achieve economic goals and, consequently, the tendency to use drugs or illegally earn money through retail and smuggling of drugs, an increase in women's entry into addiction due to their presence in the labor market and their vulnerability, pregnant addicted women, the entry of educated people and workers and divorced children into addiction to escape from psychological problems, increased mortality, especially due to the use of opioid drugs with impurities and excessive consumption, the reduced motivation for treatment in addicts and addiction relapse, the increase in AIDS rates arising from uncontrolled sexual relationships due to psychotropic substances consumption, increased concerns and worries, and a decline in public confidence in society are among other consequences of the future drug use situation. D) Exploiting new methods and genetic manipulations for the production of various chemicals, as well as using digital methods to increase the supply of substances and make the higher complexity of money laundering resulting from drug trafficking: The following constitute the other serious concerns in the future of addiction: taking advantage of the dark network of cybersets, the virtual market and safe haven for buyers and sellers of drugs, the difficulty in identifying the substance owners and consumers' identity, as well as the use of satellite networks to promote false beliefs and cultural deceptions, consequent increase of new customers in the field of drug use. E) Development of illegal trade: The entry of chemical precursors into the production cycle of industrial substances and unauthorized drugs will, on the one hand, increase Babak Vojudi et al substance production and, on the other hand, will increase money laundering and the introduction of dirty money into the country's economic cycle. F) Continuity, expansion, and production of substances in Afghanistan: The process of population growth in Afghanistan, the consumption of strong substances by more than three million Afghan people, the consolidation of Afghanistan's position in the production of poppy derivatives, the growth of the market for substance consumption in some Neighboring countries, and increased drug trafficking from Iran are among the other concerns about the state of drugs and psychotropic substances in the future. G) Fighting entities' exposure to numerous difficulties: Drug trafficker's attempt to achieve new markets, as a result of the stabilization of consumption patterns in developed countries and their attempt to shift the direction to land-to-sea provide the grounds for easy access to more substances in Iran. H) Increased underground cultivation of cannabis: At present, in some countries, such as the UK, the strong promotion of household cultivation and production of cannabis with different THC percentages are observed. Undoubtedly, this issue will continue to accelerate in other countries in the future, which will increase the consumption of this substance. I) Legal vacuums: The dynamism of narcotic and psychotropic drugs system and the weakness of the updated and efficient law, and a lack of a special procedure for drug offenses have led drug traffickers to escape from the confiscation of property and assets and, thereby, it has led to the reduced confiscation of their property and can provide the grounds for the criminals' trade. K) Reduced stagnation in treatment: The increased rate of addiction relapse due to the weakness of the effectiveness of treatment and harm reduction protocols as well as one-dimensional and sometimes ineffective actions and backwardness of the anti-drug addiction system behind the addiction system will lead to the passivity of fighting entities. Undoubtedly, in order to be able to more intelligently and actively fight against the addiction system, narcotic drugs, and psychotropic drugs, we need to have proper orientations and take special measures, and we must abandon the daily routines and administrative measures. For the achievement of this objective, we require to assign serious attention to research affairs in order to strengthen the boundaries of addiction knowledge and to base actions on scientific evidence, deepen the relationship of academic centers, seminaries and scientific institutions with the Drug Control Headquarters, to strengthen the knowledge of coherent planning by examining techniques and tactics and prioritizing effective programs to eliminate traffickers' initiative, to create sensitivity and concern, to produce mobility and effective role in the various layers of the society, including policymakers and executive officials, and to perform continuous evaluation of the performance and activities of the entities for examining the effectiveness of the effective programs, to take advantage of the use of popular networks in fighting and changing the approach from government prescriptive policies to participatory policies. Undoubtedly, the more effective role of scholars, elites, educators, and masters for joining the sacred fight against the spread of addiction is essential. We hereby make the most of the opportunity and announce the Presidential Drug Control Headquarters' readiness to support academic theses, dissertations, and special projects. It is hoped that we will witness the creation of mutations in all universities

through strengthening the research foundations for controlling and harnessing addiction in our Islamic country (God Willing).

Hamid Sarami Director General of the Department of Research and Education Presidential Drug Control Headquarters Winter 2016

Abstract Behavioral Objective: This study aimed to compare behavioral activation and inhibition Activation and systems and coping styles between opium consumers, methadone Inhibition Systems maintenance treatment clients, and normal peers. Method: A causal- and Coping Styles in comparative study was used in this Opium Consumers, retrospective and basic research. The statistical population of this research Methadone included all male opium abusers who had referred to treatment centers in Sari city Maintenance in 2016. The research sample consisted of 43 opium consumers (self- Treatment Clients, introduced), 45 methadone maintenance treatment clients, and 40 normal peers and Normal Peers who were selected by convenience sampling method. Behavioral activation- inhibition system scale (BIS-BAS) and Coping Strategies Inventory (CISS) were administered to the three groups for data Mohammad Hossein Abdollahi, collection. Results: The results showed Shahab Baheshmat Juybari that there was a significant difference between the three groups in behavioral activation and inhibition systems and coping styles. In addition, opium Mohammad Hossein Abdollahi consumers and methadone maintenance Associate Professor of Psychology treatment clients showed higher levels of Department, Kharazmi University, behavioral activation system and Tehran, Iran emotion-focused and avoidance-oriented E-mail: [email protected] coping than normal peers. Conclusion: These findings can help experts gain a Shahab Baheshmat Juybari better and more accurate understanding M.A. Student of General Psychology, of the cause of substance abuse, and the Kharazmi University, Tehran, Iran use of proper methods for the prevention of addiction and expansion of helpful treatments of addiction.

Keywords: behavioral activation and inhibition systems, coping styles, Research on Addiction substance abuse Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir/ 12 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Substance use dependence imposes a great deal of harm on the affected people, health care system (Peiper et al., 2016), and communities (Klein, 2016) inasmuch as increasing the likelihood of developing physical conditions (Tremain et al., 2016) and mental disorders (Agrawal, Budney & Lynskey, 2012). Given the fact that drug abuse programs impose heavy costs on societies (Harrop & Richard, 2016; Hansen et al., 2011), the etiology and prevention of the factors affecting drug abuse are necessary (Denney & Connor, 2016). For this reason, a large volume of research has focused on the identification of preventive factors and potential risks associated with drug use in the hope that the identification of the vulnerable groups will lead to the development of effective strategies for the prevention of drug abuse (McConnell, Memetovic & Richardson, 2014). As a result, researchers have recently focused on the psychological variables associated with drug abuse (e.g., Hopwood et al., 2008; Fernandez-Montalvo & L´opez-Go˜ni, 2010; Ljuez et al., 2008; cited in Hopwood et al. 2015). In the same direction with above-mentioned necessity, the present study aims at identifying the factors affecting the onset and continuation of substance abuse (in particular, opium). The theoretical foundation of this study is based on Gray's Reinforcement Sensitivity Theory (RST) (1970) and Endler & Parker's Stress Coping Model (1990). In recent years, Gray's Bio Psychological Model (1970) has been used as a useful theoretical framework for understanding the factors affecting the onset and continuation of maladaptive behaviors, such as antisocial personality (Morgan et al., 2014), depression (Li, Xu & Chen, 2015), and drug abuse (Urosevic et al., 2015). RST (1970) focuses on the role of two motivational systems of behavioral inhibition and behavioral activation (Li et al., 2015). Behavioral inhibition system is described as sensitivity to the signs of punishment and failure, increased avoidance behaviors, and anxiety, whereas behavioral activation system is described as sensitivity to signs of reward and avoidance of punishment (Derefinko et al., 2016). In explaining the role of these two motivational systems in drug abuse, one can argue that alcohol and drugs have a rewarding role; thus, since individuals with a strong behavioral activation system have a high sensitivity to rewards, the increased activity of this system is correlated with substance abuse and alcohol abuse (Morgan et al., 2014). Therefore, the increased sensitivity of the behavioral activation system is a stimulus for willingness to rewards (Luciana et al., 2012) such as substance abuse. Behavioral activation system, known as the infrastructure of sensitivity to rewards, is facilitated by the release of dopamine (Wahlstrom et al., 2010). As a result, the oversensitivity of behavioral activation system predicts substance abuse and increased craving for substance use. In some studies, the behavioral- inhibitory-activation scale scores were correlated with electroencephalographic indicators of addiction abstinence (Sutton & Davidson, 1997), response to punishment and reward (Carver & White, 1997), and clinical anthropology Mohammad Hossein Abdollahi & Shahab Baheshmat Juybaril 13

(Alloy et al., 2006) (cited in Urosevic et al., 2015). In fact, compulsory substance abuse is correlated with the malfunction of the brain mechanisms that disturb the correct discoing-making ability. Substance abuse may be caused by poor decision-making ability that causes the affected people to overcome their long- term negative consequences due to the tendency to immediately satisfy their needs or to escape from the adverse conditions (Balconi, Finocchiaro & Canavesio, 2014), because increased sensitivity to rewards seems to stimulate people to seek more risks in order to experience psychological stimulation (Hinnant et al., 2016). In people in the process of substance use withdrawal, the behavioral activation system also influences the decision-making process and, thereby, is effective in the therapeutic outcomes. In the theoretical description of this effect, Boog et al. (2014) assume that high levels of sensitivity to reward lead to an increase in the rate of drug relapse and failure in the treatment of drug abuse. As described in the section of the theoretical basis, the role of these motivational systems in substance abuse is ambiguous due to contradictory results in the literature related to this area. For example, in Hasking's research (2006), behavioral activation systems did not predict substance abuse, especially alcohol abuse. However, the results of some other studies were inconsistent with that of this study. In the research conducted by Knyazev (2004), the behavioral activation system was found to be the best personality predictor of substance abuse. The effect of behavioral inhibition system on substance abuse was weak and affected by the type of substances. In the same way, the inhibition system had a protective role in women, while it increased the risk of substance abuse in men. In a longitudinal study, Urosevic et al. (2015) showed that the increased sensitivity of the behavioral activation system was associated with the onset of drug use and the increased alcohol consumption. These results supported the existence of a relationship between increased reward sensitivity and the onset of drug use. Derefinko et al. (2016) emphasized that the constructs of Reinforcement Sensitivity Theory are involved in prolonged substance abuse, as studied in physiology. On the other hand, coping styles have a decisive influence on the behavioral and emotional responsiveness of individuals when facing the stresses of everyday life and on the explanatory model of substance abuse (Robertson, Xu & Stripling, 2010). According to the addiction stress coping model, individuals tend to use psychoactive substances to extricate themselves from the experiences and thoughts about stressful events (Aldridge & Roesch, 2008; Kalichman et al., 2006; cited in Floyd et al. 2010). Lazarus & Folkman (1984) refer to coping as cognitive and behavioral potentials to tackle stress (cited in Kronenberg et al., 2015). Three types of coping styles have been discussed in the research literature, which include problem-focused strategies (e.g., problem-solving behaviors, seeking social support), emotion-focused strategies (e.g., anxiety and self-criticism), and avoidance strategies (e.g., wishful thinking and deny of problems). In Endler & Parker's Coping Style Model (1990), emotion-focused and avoidance styles are considered as 14 Research on Addiction Quarterly Journal of Drug Abuse maladaptive and problem-solving style is considered as the adaptive style to cope with the stresses of everyday life (Marquez-Arrico, Benaiges & Adan, 2015). Previous studies have investigated the relationship between coping styles and a range of substance abuse behaviors (e.g., Hasking & Oei, 2004; Sanchez et al., 2010) and findings from different studies show that emotion-focused and problem-focused coping styles are predictors of alcohol consumption and substance use (Cooper et al., 1988; Hasking & Oei, 2004; Johnson & Pandina, 2000; cited in Eitle & Eitle, 2013). The role of coping styles in people in the process of substance use abstinence has also been examined. In this regard, Murphy & Khantzian's longitudinal study (2012) showed that the coping style in people in the process of substance use abstinence will be improved after treatment. With regard to search for finding empirical support from the coping styles model in the field of addiction, an examination of the experimental literature reveals conflicting results. Feil & Hasking (2008) reported that the avoidance coping style is correlated with alcohol consumption. Robertson, Xu & Stripling (2010) showed that active coping style was not associated with the consumption of alcohol and other drugs among adolescent girls, but the avoidance style was related to higher alcohol consumption. Contrary to previous studies, Iwamoto et al. (2011) reported that coping styles could not predict substance use but had a significant relationship with depression. Martindale et al. (2013) indicated that coping styles and lifestyle strategies improved the people under the treatment of substance use disorder. McConnell, Memetovic & Richardson (2014) found that adaptive coping styles were associated with a lower rate of tobacco and alcohol consumption, while a different result was revealed for maladaptive styles. Adaptive style had a protective role against the tendency to use tobacco. Marquez-Arrico, Benaiges & Adan (2015) conducted a study on substance abuse patients with and without schizophrenia and the results showed that substance abuse patients with and with schizophrenia differ from each other only in the level of adaptive styles. In addition, substance abusers with schizophrenia used adaptive coping styles to a lesser extent than the normal group. Gundy et al. (2015) showed that the problem-focused coping style is less likely to predict drug disorder such as marijuana among American- African and white youths. In white youths, the avoidance style was associated with an increased risk of alcohol consumption, marijuana use, and other drug use disorders, while the avoidance style was associated with a lower probability of marijuana use in American-African youths. Individuals' skills in the face of life styles are effective in people's tendency to substance abuse. In the meantime, the behavioral inhibition-activation system and coping styles play a central role in this regard. The contradictory results and the non-evaluation of the aforementioned variables in a comprehensive model are the main motives behind the conduct of this study.

Mohammad Hossein Abdollahi & Shahab Baheshmat Juybaril 15

Method Population, sample, and sampling method A causal-comparative research method was used in this retrospective and basic research. In this design, the three groups of opium users, methadone maintenance treatment clients, and normal peers were compared in terms of two dependent variables, namely coping styles and behavioral activation and inhibition system. The statistical population of this research included all male opium abusers who had referred to treatment centers in Sari city in 2016. The research sample consisted of 43 opium consumers (those who referred to addiction treatment centers for the first time and had not received any treatment in addiction treatment clinics previously), 45 methadone maintenance treatment clients, and 40 normal peers who were selected by convenience sampling method after announcing their consent. The criteria for the inclusion of participants in this study were being male, aged from 20 to 40 years, and non-dependence on non- opioid substances (such as crystal or other drugs) in opium users; being under methadone treatment and no drug use (for the minimum period of one month) in the methadone treatment group; and not having physical and psychological problems and having at least primary school education in the normal group. In addition, severe psychiatric disorders in all three groups and history of drug use in the normal group were considered as the exclusion criteria. The normal group consisted of 40 participants from among the patients' companions who were selected via convenience sampling method. It is noteworthy that the three groups were matched in terms of gender (all were male), age (F = 1.86, P = 0.05), and education (P> 0.05, X2 = 1.166). The administration procedure was in such a way that one of the researchers provided explanations to the clients and companions about the research. As a result, the participants entered the study with informed consent and awareness of the research objectives. Instruments 1. Behavioral Activation-Inhibition System Scale (BIS-BAS): This questionnaire was developed by Carver & White (1994) and includes 20 items and two subscales, namely behavioral inhibition and behavioral activation. The behavioral inhibition subscale consists of 7 items that measure the sensitivity of behavioral inhibition or response to the threat and the feeling of anxiety when confronted with threatening symptoms. The behavioral activation subscale contains 13 items that measure the sensitivity of the behavioral activation system and comprises three other minor subscales, including drive (D), fun seeking (F), and reward responsiveness (R). Carver & White (1994) have reported the internal consistency of the behavioral inhibition system equal to 0.74 and that of the behavioral activation system equal to 0.71. Mohammadi (2008) conducted a research in order to study the psychometric properties of Behavioral Activation- Inhibition System Scale in Iranian society, and reported the internal consistency 16 Research on Addiction Quarterly Journal of Drug Abuse of behavioral inhibition system and behavioral activation system to be equal to 0.69 and 0.78, respectively (cited in Amiri, Ghasemi Navab & Abdollahi, 2014). 2. Coping Strategies Inventory (CISS): This questionnaire was developed by Endler & Parker (1990) and evaluates problem-focused, emotion-focused, and avoidance-focused coping styles. The dominant style of each individual is determined by his/her score in each of the three dimensions of coping styles. The scale items are scored based on a 5-point Likert scale from never (1) to always (5). The reliability of this test was calculated by Endler and Parker (1990) through Cronbach's alpha as follows: the problem-focused style for girls (90%) and boys (92%), emotion-focused style for girls (85%) and boys (82%), and avoidance-focused style for girls (0.82) and boys (0.85). Jafarnejad (2003) reported the reliability coefficients of 0.80, 0.83 and 0.72 for emotion-focused, problem-focused, and avoidance-focused styles, respectively. Piri & Shahrara (2005) obtained the Cronbach's alpha coefficients for problem-focused, emotion-focused, and avoidance-focused styles to be equal to 0.81, 0.85, and 0.80, respectively (cited in Shahgholian, Jannesar Shargh & Abdollahi, 2007). Results The age range of the members of the three groups was 21-to-38 years. The mean (standard deviation) of the opium users' age was equal to 29.21 (3.78), methadone treatment group's age equaled 29.58 (4.64), and normal peers' age was 30.58 (3.55) years. In terms of education, most of the participants in this research held diploma degrees. The descriptive statistics of the research variables are presented in Table 1. Table 1: Descriptive statistics of the research variables for each group Methadone Opium users Normal peers Variables Treatment M SD M SD M SD Behavioral Inhibition 15.12 1.8 15.68 2.76 18.83 2.55 System Behavioral Activation 32.65 3.40 31.32 3.10 28.80 3.70 System Drive 10.14 1.78 9.66 1.62 8.66 1.55 Reward responsiveness 12.86 1.93 12.23 2.10 10.32 2 Fun seeking 9.65 1.67 9.61 1.71 8.71 1.77 Problem-focused coping 45.26 5.93 46.41 7.08 51.37 7.73 style Emotion-focused coping 55.91 5.75 53 5.56 48.66 7 style Avoiding coping style 54.79 5.60 52.75 6.52 45.54 6.98

Multivariate analysis of variance analysis should be used to compare the mean scores. One of the assumptions of this analysis is the normal distribution of the scores where Shapiro-Wilk test was used to evaluate this assumption. The results of this test are presented in Table 2.

Mohammad Hossein Abdollahi & Shahab Baheshmat Juybaril 17

Table 2: Shapiro-Wilk test results assessing the normal distribution of the data Variable Df Shapiro-Wilk ratio Sig. Inhibition-activation system 128 0.989 0.379 Coping styles 128 0.989 0.436

As it is shown in Table 2, the normal distribution of scores has been observed in both variables. In addition, Levene's test was used to assess the assumption of error variances equality, and its results are presented in Table 3. Table 3: Levene's test results examining the error variances equality Variable F Error degrees of freedom Sig. Inhibition-activation system 0.176 125 0.945 Coping styles 0.057 125 0.945

Moreover, the results of Box's test indicate that the assumption of equality of covariance matrices has been met (P > 0.05). Therefore, multivariate analysis of variance in the inhibition-activation system was run and the results were indicative of the existence of a significant difference (P < 0.001; F = 11.63; Wilks's lambda = 0.456). Univariate analysis of variance was used to examine the patterns of difference as follows. Table 4: Results of univariate analysis of variance for patterns of difference Variable Df Mean Square F Sig. Behavioral Inhibition System 2 167.11 28.540 0.0005 Behavioral Activation System 2 159.52 13.750 0.0005 Drive 2 23.86 8.660 0.0005 Reward responsiveness 2 73.22 18.020 0.0005 Fun seeking 2 11.91 4.020 0.02

As it is observed in the above table, there is a significant difference in all components. Tukey's post hoc test was used to examine the difference between the groups. The results showed that the normal group had obtained higher scores than both groups of methadone treatment clients and opium users in the component of the inhibition system. However, there was no significant difference between the methadone treatment clients and opium users. On the other hand, the normal group had obtained lower scores than the other two groups in the components of the behavioral activation system, drive, reward responsiveness, and fun seeking; however, no significant difference was observed between methadone treatment clients and opium users. In addition, multivariate analysis of variance was also performed on coping styles and the results indicated a significant difference (P <0.001, F = 16.60, Wilks's lambda = 0.507). Univariate analysis of variance was used to examine the patterns of difference as follows.

18 Research on Addiction Quarterly Journal of Drug Abuse

Table 5: Results of univariate analysis of variance for patterns of difference Variable Df Mean Square F Sig. Problem-focused 2 44.06 9.110 0.0005 coping style Emotion-focused 2 55.10 13.370 0.0005 coping style Avoidance-focused 2 98.21 24.180 0.0005 coping style

As it has been shown in Table 5, there is a significant difference in all components. Tukey's post hoc test was used to examine the differences between the groups. The results showed that the normal group has obtained higher scores in problem-focused component than the other two groups, i.e. methadone-treated group and opium users. However, there was no significant difference between the methadone treatment group and opium users in this raged. In addition, the normal group obtained lower scores in the components of emotion-focused coping style and avoidance coping style than methadone treatment group and opium users. However, there was no significant difference between the methadone treatment group and opium users in these two components. Discussion and Conclusion The present study was an attempt to compare behavioral inhibition and activation systems and coping strategies between opium users, methadone maintenance treatment patients, and normal peers. The findings of the study showed that there is a difference between the three groups in terms of the activity of behavioral inhibition-activation systems. In other words, there was a higher level of behavioral activation system and a lower inhibition system in opium users and methadone maintenance treatment clients than the normal group. In the normal group, the other of this result held true. This finding is in part consistent with those of the studies carried out by Urošević et al. (2015), Boog et al. (2014), Taylor, Reeves, James & Bobadilla (2006), Franken & Muris (2006), and Knyazev (2004). However, this result is not consistent with that of the study conducted by Hasking (2006). To explain this contradiction, Hasking (2006) argued that the absence of any correlation between the sensitivity of the behavioral activation system and drug abuse is attributable to the low level of consumption among alcohol abusers. The result of this study on the sensitivity of the behavioral activation system in opium users and people in the process of substance use withdrawal is another confirmation of Gray's Reinforcement Sensitivity Theory (RST) (1970). Considering that the behavioral activation system is highly sensitive to rewards and opium has also a rewarding property, the abuse of this substance in people with a strong behavioral activation system is justifiable. Balconi, Finocchiaro & Canavesio (2014) examined the effect of behavioral activation system along with Iowa gambling task on substance abusers' decision-making, and their findings indicated the faulty decision- making behavior of people with a behavioral activation system with regard to Mohammad Hossein Abdollahi & Shahab Baheshmat Juybaril 19 the etiology of substance abuse in such a way that these individuals cannot refrain from instant pleasures and will ignore their long-term consequences. In addition, Boog et al. (2014) regard the behavioral index of reward sensitivity to be a predictor of failure in drug abuse treatment. Considering that the individuals under methadone maintenance treatment in the present study showed high a high sensitivity in behavioral activation system, clinical considerations in this area assume significant importance because this factor can be effective in the continuation of treatment. Moreover, two groups of opium users and methadone maintenance treatment clients obtained higher scores in the subscale of the behavioral activation system. In this regard, it can be argued that chronic substance abuse is explained by significant deficiencies in the decision-making process based on the response to rewards (Balconi, 2014). The fact that the two groups of opium users and methadone maintenance treatment clients have a high sensitivity to responding to immediate rewards compared to their normal peers is indicative of the substance dependent individuals' motivational defects in the decision-making process. The reward responsiveness is effective in inducing the individuals' extreme estimates for immediate rewards. In Franken & Muris's research (2006), the components of fun seeking and drive were correlated with alcohol and drug abuse. In line with these findings, the present study showed that opium users and methadone maintenance group gained higher scores in this subscale than the normal group. In addition, the findings of this study showed that there is a difference between the three groups in terms of coping strategies. The analysis of the data obtained from the research samples showed that opium abusers and methadone maintenance treatment group use more emotion-focused and avoidance strategies in dealing with stresses than the normal group, whereas the normal group used problem-focused strategies to deal with tensions stresses to a greater extent. This finding is partly consistent with the results of research done by Gundy et al. (2015), McConnell, Memetovic & Richardson (2014), Robertson, Xu & Stripling (2010), and Feil & Hasking (2008). According to Endler & Parker's Coping Style Model (1990), emotion-focused and avoidance styles are considered as maladaptive and problem-solving style is considered as the adaptive style to cope with the stresses of everyday life and some scholars (e.g., Floyd et al., 2010; McConnell, Memetovic & Richardson, 2014) emphasize that many people with maladaptive coping styles tend to substance abuse in dealing with stresses and negative events. Robertson, Xu & Stripling (2010) also acknowledge that the higher degree of exposure to negative events is associated with a higher level of substance use. To explain the relationship of emotion-focused coping style and avoidance coping style with substance abuse, one can claim that these individuals have a weak relationship with others while facing tensions and incidents; therefore, they do little effort in search for social support. The individuals under methadone maintenance treatment, like the opium user group, used emotion-focused and avoidance strategies to cope with stress. Murphy & Khantzian (2012) emphasize that coping strategies are 20 Research on Addiction Quarterly Journal of Drug Abuse improved during treatment; however, no difference was found between the two groups of opium users and methadone treatment group in the present study. In explaining this inconsistency, it seems that this improvement can be seen in coping styles in longitudinal studies. Since one of the criteria for inclusion in the present study was to be under methadone treatment for at least one month, it can be said that longitudinal studies are needed to assess this improvement. The results of this research can be taken into consideration at both theoretical and practical levels. At the theoretical level, the findings of the present study confirmed the assumptions of Gray's Reinforcement Sensitivity Theory (1990) and Endler & Parker's Coping Style Model (1990) about substance abuse. At the practical level, the results of this study can be an appropriate empirical basis for the development of training, interventional, and therapeutic programs. One of the limitations of this research was the use of convenience sampling method and the small sample size; thus, it is that other sampling methods be used in future studies. Reference Agrawal, A., Budney, A. J., & Lynskey, M. T. (2012). The co‐occurring use and misuse of cannabis and tobacco: a review. 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Abstract Management and Implementation of Objective: The study of hidden populations, such as Injecting Drug Sampling from Users (IDU) is very crucial due to their Injecting Drug Users exposure to high risk diseases and their role in public health. Conventional Exposed to High statistical methods for sampling from these populations are not efficient Risk Diseases because of the restrictions in attendance among these populations. Despite the introduction of respondent-driven sampling as a successful method for Arezo Bagheri, Mahsa Saadati sampling from hidden populations, a limited number of studies have used this method due to the lack of researchers’ knowledge. Method: The main purpose of the current research was to study the influential factors in managing and Arezo Bagheri implementing respondent-driven Assistant Professor of National sampling method. Results: Researchers Population Studies & Comprehensive should consider key points in designing Management Institute, Tehran, Iran coupons, defining the degree and payment method of incentives, and Mahsa Saadati preventing the irregular growth of the Assistant Professor of National sample size for monitoring this sampling Population Studies & Comprehensive method. Conclusion: Without taking Management Institute, Tehran, Iran into consideration the requirements of E-mail: [email protected] sampling implementation and management, one cannot expect to achieve representative samples from these populations via this sampling method. Keywords: hidden populations, injection drug users (IDU), high risk diseases, respondent driven sampling method Research on Addiction Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir 24 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Hidden populations or hard-to-reach populations refer to the sub-populations that usually constitute 1 to 10% of the total population of the society. Some of these populations, such as injecting drug users have received the attention of health researchers since this group of population is exposed to high-risk diseases, such as AIDS and threatens the health of the community. Sampling from these populations has particular problems since standard statistical sampling methods require a list of members of the population to be sampled. The use of family planning framework is inefficient when the desired population is small relative to the target population, is geographically dispersed, contains illegal behaviors (such as addiction) or consists of the networks that can be penetrated with difficulty (Watters & Biernacki, 1989). For example, researchers cannot sample injecting drug addicts through family plans because these societies often hide their habits from those who live with them. In some studies on hidden populations, probabilistic sampling methods have been used, but these methods suffer from the issue of no absolute coverage of the target population (Ramirez-Valles et al., 2005). On the other hand, these methods do not include the addicts who come to these institutions. Institutional sampling is one of these sampling methods; for example, the addicts who are in jail or who refer to addiction treatment centers for drug abuse counseling have not been randomly selected. Other studies in which non-probability sampling methods have been used for sampling from these populations provide a more comprehensive coverage of the target population compared to probability methods; however, the results of these methods are not statistically valid. Chain referral methods are among these methods. For example, in Snowball sampling method (Goodman, 1961), which is one of these sampling methods, a more complete coverage of the target community is provided through access to people via their social networks; however, it still faces inaccurate statistical estimates. In order to eliminate the interpretation problems of the results in chain referral methods, researchers attempted to modify and change the snowball sampling method and to convert it into probability sampling (Frank & Snijders, 1994). These methods are, in fact, a subset of the probability sampling methods that are referred to as adaptive designs or link tracing designs (Thompson & Frank, 2000). The respondent- driven sampling method is one of the variety of adaptive designs that was used by Heckathorn in 1997 for the first time in sampling from American drug addicts and is an efficient method to sample the hidden populations. This sampling method has been used in studies assessing the hidden populations, such as injecting drug users (Mumtaz et al., 2014; Yaung, Di Clemente, Halgin, Sterk & Havens, 2014; Stromer et al., 2006), sex workers (Liu, Liu, Cai, Rhodes & Hong, 2009), and Men who have Sex with Men (MSM) (Chopra et al., 2009). In Iran, a pilot study was conducted to administer respondent-driven sampling method in Tehran in 2005, which demonstrated the effectiveness of Arezo Bagheri & Mahsa Saadati 25 this method for studying the population of injecting drug users (Arzani et al., 2007). Injecting drug users aged 18 years and older in Tehran were also studied in a research on access to harm reduction programs (syringe replacement and methadone treatment programs) (Rahnema et al., 2014). In addition, a study was also conducted to estimate the prevalence of HIV infection among injecting drug users in Tehran in 2015 (Malekinejad et al., 2015). Bagheri & Saadati also introduced respondent-driven sampling method, compared it with other common sampling methods, and examined the methods of its estimation in 2014 and 2015. Despite the introduction of this sampling method by Heckathorn nearly two decades ago, the complexities of the implementation and management of this sampling method have challenged its employment for researchers (Bagheri & Saadati, 2015; Saadati and Bagheri, a and b, 2016; Bagheri & Saadati a and b, 2016; Bagheri & Saadati, 2017). Therefore, the current study aims at investigating the implementation procedure of the respondent-driven sampling method and the considerations that lead to the efficiency in the management and implementation of this method, especially for studies in the field of drug addiction. Method Population, sample, and sampling method One of the most important steps in designing the respondent-driven sampling method is the formative assessment that studies the diversity of social networks in the target population about demographic characteristics, the assessment of the target population's willingness to participate in the sample design, finding seeds for the start of recruitment chains, training of respondents (interviewers) in order to interview their own peers (subscribed) and decide on applicable issues, such as the use of incentives, the location where the questionnaire and interviews are to be conducted. The next step is to select the seeds, which are, in fact, individuals with a degree (network size). Sampling from seeds begins and researchers randomly select them from the statistical population. The distinctive features of the seeds in injecting drug users are the number of years of drug injection, the preference of the type of consumed drugs, the use or non-use of the used syringes, and attempt or non-attempt for sex working. Another important element in the implementation and management of this sampling method is the coupon. Coupon is, in fact, the quota of each person through which s/he can make his/her peers join the sample design. It has been mentioned that three coupons are usually assigned to each member in this method (Abdul-Quader, Heckathorn, Sabin & Saidel, 2006). Coupons provide information on the design, working time and location of the census bureau, the involvement of the recruiter and the recruited individuals through the allocation 26 Research on Addiction Quarterly Journal of Drug Abuse of unique coupon identification numbers, assistance in the recruitment process, and the allocation management of incentives. Another component that influences the way in which this sampling method is implemented and managed is the incentives that are assigned to the recruiters respondent-driven sampling design as a reward for the assignment of respect and value to the time and the effort that participants make towards recruitment and participation in the sampling (Verma, 2013). There are two types of these incentives. Primary incentives are the ones that are awarded to the recruiter for his/her participation in the sampling. On the other hand, secondary incentives are the ones the recruiter receives after the recruitment of his/her peers in the sampling. In the primary stages of the respondent-driven sampling method, formative assessments are carried out and, then, this sampling method commences. Researchers non-randomly choose the seeds from the statistical population for membership in the sample. The seeds that have completed the sampling process as recruiters receive some coupons to recruit their peers or recruited members. The first wave of sampling is produced by the recruitment of seeds. In the following waves, each of the recruited members becomes the recruiter of the new wave. The first wave recruitment produces the second wave, and the sampling continues to reach the appropriate sample size. Primary incentives as well as secondary incentives, if necessary, are awarded to all sample members. Figure (1) shows how different networks have been produced from different seeds. The seeds and their corresponding waves are called chains.

Zero First wave wave

Second Third wave wave Fig. 1: Formation of different chains from different seeds Arezo Bagheri & Mahsa Saadati 27

The estimation of the proportion of hidden populations, especially the populations exposed to high-risk diseases is highly regarded by the policy- makers who are in contact with these populations. To calculate this estimate, the hypothetical population consists of two groups; for example, IDUs are divided into two groups, i.e. HIV positive (group A) and HIV negative (group B). When the whole information about the social network exists in variable X, xij = 1 if there is a direct relationship between individuals i and j; otherwise, xij = 0. In this sampling method, relationships are reciprocal in such a way that if xij = 1, i then xji = 1. The degree of the ith individual is defined as D = ∑j xij, and Ta represents the total number of relations that arise from individuals in group A. If Na is the number and Dais the sum of the degrees of members of group A, then, Ta is defined as: 푖 푇푎 = ∑푖∈퐴 퐷 = 푁푎.퐷푎 (1)

If the social network X is assumed, the probability of a random relationship that connects a member of group A to a member of group B is defined as follows: 푇푎푏 푆푎푏 = (2) 푇푎 where 푇푎푏 is the number of nodes that are members of group A and B. The number of connections from group A to group B is equal to the number of connections from group B to group A. this number of connections can be calculated from the number of connections that have been derived from group A (푇푎 in the probability that one of these connections with an individual from group B is 푆푎푏 (푇푎.푆푎푏 = 푇푎푏)) and from group B (푇푏 in the probability that one of these connections with an individual from group A is 푆푏푎 (푇푏.푆푏푎 = 푇푎푏 )). Assuming the number of connections to be equal with each other and using 푇푎 and 푇푏 definitions in Equation (1), the following equation is obtained:

푁푎퐷푎푆푎푏 = 푁푏퐷푏푆푏푎 (3)

If both sides of equation (3) are divided by N, i.e. the total population, then 푃푎 and 푃푏 in 푃푎퐷푎 푆푎푏 = 푃푏 퐷푏 푆푏푎 can be computed. In this way, by considering 푃푎 + 푃푏 = 1 and using the system resolution with two equations and two unknowns, the values of population ratios can be calculated from the following equations using information about the structure of the networks that connect the groups in the population to each other:

푆푏푎퐷푏 푃푎 = (4) 푆푏푎퐷푏+푆푎푏퐷푎

The estimate of 푃푏 can also be calculated similarly. Results This section examines the key points in the management and implementation of respondent-driven sampling method, which include the design, coupon 28 Research on Addiction Quarterly Journal of Drug Abuse identification and management techniques, incentive management, sample growth control, and recruitment termination. A) Design and methods for the identification and management of coupons: Coupons play an important role in the implementation process of the respondent- driven sampling method whose design method will be discussed below. * Essential and basic characteristics: Each coupon must contain information, including a unique identification number in the design, location, working hours and days of the Census Directorate, phone number, and expiration date. The factors effective in the design of coupons include the spoken language, the level of education, and age of the participants in the design, the number of Census Directorate, the various populations that are being sampled at the same time, the number and type of various logos belonging to the supporting organizations of the design that is printed on the coupon, and the variety of the available papers for printing the coupons. In order not to have a coupon shortage at the Directorates, it is better to print a number of coupons three times as large as the sample size. If more than one respondent-driven sampling design is being performed simultaneously, it would be better to consider different colors for the coupons of these designs. The size of coupons should not be too small to be lost nor be too large to be maintained with difficulty. * Expiration Date: It refers to the time framework during which a participant is expected to deliver a coupon to his/her peer for recruitment and the peer is to deliver it to the Census Directorate. There are many reasons to put an expiration date on coupons; for example, the increase in the recruiter and new member's enthusiasm for the delivery of coupons, the management of coupons, and the determination of the probabilistic number of participants involved in the design, and the possibility of termination of the design in case of the absence of valid coupons in the statistical population (World Health Organization, 2013). * Activating time period: It is inserted on the coupon and it begins from the moment the participant leaves the Directorate until the moment the coupons are delivered to his/her peers (1 to 3 days). The main objective of this period is to reduce the recruiting speed and provide an incentive for the random recruitment of peers. Coupon Identification Methods: All coupons have identification numbers for the recognition of both the recruiter and recruited person. Coupon identification method depends on the implementation method of the coupon in two ways as follows. Systematic identification method: This method is useful when there is no computer in the Census Directorate to manage the recruitment of participants in the design (Verma, 2013). Depending on the number of seeds in the design, this method begins by assigning a unique number to each of the seeds. For example, in a 10-seed design, the first two digits of each coupon are the seed number, which are from 1 to 10. In most of respondent-driven sampling designs, up to three peers are eligible for recruitment. In this state, the number that appears following the seed number is actually the three coupons that are assigned Arezo Bagheri & Mahsa Saadati 29 to the seed for recruitment. For example, if the seed number is 5 and three coupons are assigned to it, then, as shown in Fig. 2, it will receive the coupons numbered 51, 52, and 53 (World Health Organization, 2013). If the recruited member numbered 53 is interviewed, s/he will be assigned coupons numbered 531, 532, and 533. This process proceeds based on the number of waves per design. As a result, the coupon numbered 533 represents the second wave of the seed numbered 5. Among the advantages of this approach, one can refer to the ease of the management process of coupons, addition of seeds, and the ease of determining which seed member and wave belong to the recruited person. The disadvantages of this method are the need for accurate numbering and the possibility of assigning very long numbers, which raises the possibility of an error. 511 51 512

513 521 5 52 522 523

531 53 532 533 Figure 2: Coupon Numbering for Seed No. 5

* Sequential Identification Method: This method uses 4-digit numbers for the numbering of coupons in the design, where these numbers range from 1000 to the last number required for all coupons. In this method, coupon identification numbers are inserted and printed on them beforehand. The advantages of this approach include easy numbering and follow-up of the recruitment process when using a computer, printing coupon identification numbers on coupons before the design implementation, and short coupon numbers (only four digits). Among the disadvantages of this method, one can refer to the lack of direct supervision over the recruitment process in the design, the possibility of error occurrence in the numbering of the coupons due to the irrelevance of coupon numbers with each other, and the inapplicability of this method in the absence of a computer system for numbering. Coupon Management System: Coupon management is performed to follow up the recruiter and the recruited person, to ensure that the incentives are given to the participant correctly, to follow up the number of completed waves in the design, to follow up the seeds' chains that are in the growing process and the seeds to be added to the design, to assess and decide on when the number of coupons should be reduced, when the design should be terminated, and when the 30 Research on Addiction Quarterly Journal of Drug Abuse coupon should be stopped, and when the recruitment patterns should be analyzed. B) Management of Incentives: Incentives are awarded to members without judgment about how they are used (Semaan, Santibanez, Garfein, Heckathorn & Des Jarlais, 2009). The incentives should not be so small in value that illegitimate populations are reluctant to participate in the design, nor be so large in value that the likelihood of the sale or the theft of coupons increases. In addition, the high values of incentives make people who are not eligible for inclusion into the design to pretend to be qualified for participation. Verma (2013) referred to an East African sampling design on injecting drug addicts wherein the value of high incentives in the design had led many non-injecting drug users to pretend injecting drugs in order to receive incentives, and those who had participated in the design sold their coupons for the purpose of profitability. * Types of incentives: Material and non-material incentives include such examples as food coupons and gifts, including clothes and telephone cards to be awarded to participants in the design. * The motives for people's participation: Although it seems that the receipt of incentives is a clear and obvious factor for the participation of people in the design, this is not the main reason for their participation. In most of the respondent-driven sampling questionnaires, there are some question samples to examine the causes of coupon acceptance, such as the receipt of incentives and results of high-risk disease tests, acceptance of the recruiter's suggestion, finding the design interesting and helpful, and the availability of enough time (WHO, 2013). According to the results obtained from the addicts' sampling design, more than 60% of the female sex workers and Men who have Sex with Men in the Dominican Republic in 2008 announced the receipt of HIV test results as their main reason for participation (Johnston, Malekinejad, Kendall, Luppa & Rutherford, 2008). Amount of incentives: A formative assessment is required to determine the appropriate incentives to the statistical population. The amount of incentives depends upon the project budget, living standards in the host country, government policies, and the population under study. Requests for incentives: In order request for the primary incentives of participants in the design, they should enjoy conditions such as having a recruiting coupon (other than the seeds), eligibility for participation in the design, completion of the interview stages. In order to receive secondary incentives, the person usually needs to refer to the Census Directorate once more. It is suggested that the recruiter's secondary incentives not be awarded at the same time as receiving the primary incentives; in addition, the recruiter's incentives and the recruited person's incentives are suggested to be awarded on independent days (Verma, 2013). Arezo Bagheri & Mahsa Saadati 31

C) Sample growth control and recruitment termination: The estimation of the length of the time required to achieve the optimal sample size in the respondent- driven sampling design is not an easy task, and it depends upon the statistical population under study, the optimal sample size, the number of seeds with which the design begins, the amount of incentives, and the size of social networks. * Sample growth control: On the one hand, the high growth of sample size has caused some problems in the Census Directorate due to an increase in the number of visits; on the other hand, the sudden cessation of recruitment on the verge of achieving the desired sample size results in the accumulation of a large number of undelivered coupons in the statistical population. The effect of the exponential increase in the sample size can be reduced through the control of the linear growth rate of the sample and by limiting the number of coupons (Johnston et al., 2008). * The end of the respondent-driven sampling design: In the respondent-driven sampling design, the Census Directorate should stay open until the payment of secondary incentives and provision of consultation to the people coming to the Directorate for participation in the design after completing the design. Information on the "completion of the design after reaching the desired sample size" should be inserted on the coupon. It should be ensured that the coupons have an expiration date that indicates the duration of their validity. The expiration date of the coupon must be some time after the date of delivery. When the desirable sample size is obtained, the expiration date of the coupons should be shortened so that the recruiter does not go to the Directorate after the end of the design. The delivery of coupons should be stopped when the design achieves the desired sample size. The Census Directorate would better stay open and active several weeks after the achievement of the desired sample size in the design in order to explain the reasons for the termination of the recruitment to the clients, provide health counseling for the recruited people with valid coupons, and award the secondary incentives. Discussion and Conclusion The study of hidden populations, such as injecting drug users, is of interest to policy-makers since these populations are at exposed to high-risk diseases, such as HIV and Hepatitis C (HVC) because of the shared use of the injection tools and also due to unprotected sex (Friedman et al., 2017; Grinsztejn et al., 2017; Visavakumet al., 2016; Nielsen et al., 2016; Wenz et al., 2016). Knowledge of demographic characteristics and the suffering level of these populations from high-risk diseases is essential because it is possible to adopt health care programs and counseling services for the individuals suffering these diseases that need as well as for the healthy people who are exposed to these infections. Some studies on hidden populations of injecting drug addicts have been carried out through the commonly used sampling methods where the generalization of the results of these methods to these populations is not 32 Research on Addiction Quarterly Journal of Drug Abuse statistically valid (Fotiou et al., 2016; Lewis et al., 2016). The respondent-driven sampling method, which is one of the chain-referral sampling methods, is an efficient sampling method that produces asymptotically unbiased estimates of the rate of hidden populations, such as injecting drug users due to the possession of strong social networks (Bagheri & Saadati, 2014 & 2015). Therefore, the main objective of this study is to familiarize researchers interested in studying injection drug users with this sampling method, and also to point out the practical aspects in order to increase the efficiency of using this sampling method in such studies. In the following, some results of this study in the management and implementation of this sampling method are referred to. The most important stages of the management and implementation of the respondent-driven sampling method include the design, coupon identification and management techniques (each recruiter's quota for recruiting from among his/her peers), incentive management (the amount paid to each recruiter to compensate for the time and cost of participating in the design), and sample growth control and recruitment termination (the time and completion procedure of the sampling). The key points that should be considered when designing coupons are the legibility and intelligibility of the coupons even for uneducated students. In addition, when the recruiting process goes ahead in a slow and an unexpected fashion, the number of coupons delivered to the recruiters should not be reduced. The slowness of the recruitment process in the first months of the census may have been arisen from the non-recruiting activity of some of the seeds. Coupon numbering can also manage efficient seeds, infertile seeds (seeds with no recruitment), and the number of waves completed by each seed (World Health Organization, 2013). In addition to the payment of incentives, Verma (2013) referred to some successful financial incentives, such as financial payment equivalent to a common meal, the budget for one week's grocery shopping, fund for one week's urban transit and transportation. In a study carried out in 2008, a list of incentives in terms of their quantity and type has been presented. This list is the result of the experiences from 107 respondent-driven sampling methods conducted outside of the United States (Malkinezhad et al., 2008). The payment of secondary incentives has been controversial in some previous studies. The payment of these incentives leads to the participation of people with low socioeconomic status, the presence of repetitive and non-eligible participants, and also the identification of the individuals in the population who compete with others for recruitment. In the review of previous respondent-driven sampling designs, secondary incentives were of less value than the primary ones (Malekinejad et al., 2008). It is also not an easy task to predict the completion time of the design except in the designs with a previous executive record. It should be noted that even if the sample size has reached the desired level and the expiration date of the design has not expired, each valid coupon coming to the Directorate should be included Arezo Bagheri & Mahsa Saadati 33 in the sample. In case of the non-sampling and receipt of incentives for the volunteers for participation in the design, other designs that will be carried out in the future will be affected (Verma, 2013). Considering the applied considerations addressed in this study towards the management and implementation of successful respondent-driven sampling method, researchers are advised to use this sampling method in their studies on addiction to achieve generalizable results to the population of injecting drug users. Reference Abdul-Quader, A. S., Heckathorn, D. D., Sabin, K., & Saidel, T. (2006). Implementation and analysis of respondent driven sampling: lessons learned from the field. Journal of Urban Health, 83(1), 1-5. Bagheri, A. & Saadati, M. (2014). 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Razani, N., Mohraz, M., Kheirandish, P., Malekinejad, M., Malekafzali, H., Mokri, A., … , & Rutherford, G. (2007). HIV risk behavior among injection drug users in Tehran, Iran. Addiction, 102(9), 1472-1482. Saadati, M., Bagheri, A. (2015a). Adaptive versus Conventional Sampling in Demographic Studies. The Third Conference, Asian Population Association on July 27-30 in Kuala Lumpur, Malaysia. Saadati, M., Bagheri, A. (2015b). Sampling Migrants by Respondent Driven Sampling Method, The international conference on migration patterns, 27-28 October, consequences and policies, statistical research center, Tarbiat Modares University, Tehran, Iran. Saadati, M. & Bagheri, A. (2016a). Irregular Estimation of the Population Ratio of Hidden Populations Exposed to High-Risk Diseases, Journal of Health System Research, 12 (4), 520-534. Semaan, S., Santibanez, S., Garfein, R. S., Heckathorn, D. D., & Des Jarlais, D. C. (2009). Ethical and regulatory considerations in HIV prevention studies employing respondent-driven sampling. International Journal of Drug Policy, 20(1), 14-27. Stormer, A., Tun, W., Guli, L., Harxh,i A., Bodanovskaia, Z., Yakovleva, A., & Bino, S. (2006). An analysis of respondent driven sampling with injection drug users (IDU) in Albania and the Russian Federation. Journal of Urban Health, 83(1), 73-82. Thompson, S, & Frank O. (2000). Model-Based Estimation with Link-Tracing Sampling Designs. Survey Methodology, 26, 87-98. Verma, V. (2013). Sampling elusive populations: Applications to studies of child labour. Geneve: ILO. Visavakum, P., Punsuwan, N., Manopaiboon, C., Pattanasin, S., Thiengtham, P., Tanpradech, S., … , & Prybylski, D. (2016). HIV prevalence and risk behaviors among people who inject drugs in Songkhla, Thailand: A respondent-driven sampling survey. The International journal on drug policy, 31, 163-169. Watters, J. K., & Biernacki, P. (1989). Targeted sampling: options for the study of hidden populations. Social problems, 36(4), 416-430. Wenz, B., Nielsen, S., Gassowski, M., Santos-Hövener, C., Cai, W., Ross, R. S., ... , & Zimmermann, R. (2016). High variability of HIV and HCV seroprevalence and risk behaviors among people who inject drugs: results from a cross -sectional study using respondent-driven sampling in eight German cities (2011–14). BMC Public Health, 16(1), 927. DOI: 10.1186/s12889-016-3545-4. World Health Organization (2013). Introduction to HIV/AIDS and sexually transmitted infection surveillance: Module 4: Introduction to Respondent Driven Sampling . Geneva: Switzerland. Young, A. M., DiClemente, R. J., Halgin, D. S., Sterk, C. E., & Havens, J. R. (2014). Drug users’ willingness to encourage social, sexual, and drug network members to receive an HIV vaccine: A social network analysis. AIDS and Behavior, 18(9), 1753- 1763.

Abstract Causal Relationship of Objective: This study was aimed to Addiction Potential, investigate mediating role of family communication patterns in the relationship Early Maladaptive between basic psychological needs, psychological capital, and early maladaptive Schemas, schemas in prediction of addiction potential. Psychological Capital, Method: The research method used in this study was descriptive and correlational. The and Basic statistical population of the research Psychological Needs consisted of all male and female high school students of Kermanshah in the academic under Mediation of year 2014-2015. Through Morgan table, 400 students (200 girls and 200 boys) were Family Communication selected by multistage cluster sampling and Patterns responded to five questionnaires, namely Revised Family Communication Patterns, Addiction Potential Scale, Young’s Schema Questionnaire, Lathan's Psychological Ali Reza Rashidi, Mohsen Capital Questionnaire, and Psychological Hojat-Khah, Aras Rasouli, Basic Needs Scale. Results: The results Mehrdad Jami showed that the research model with the mediating role of family communication Ali Reza Rashidi patterns (in conversation subscale) has a Department of Guidance and Counseling, good fitness. The results also showed that Razi University, Kermanshah, Iran maladaptive schemas of failure, E-mail: [email protected] dependency, emotional deprivation, and Mohsen Hojat Khah mistrust have a significant positive Department of Guidance and Counseling, relationship with addiction potential, and the Razi University, Kermanshah, Iran subscales of self-efficacy, resiliency, and connection have a negative relationship with Aras Rasouli addiction potential, which was shown to Department of Guidance and Counseling, Islamic Azad University, Kermanshah predict addiction potential. Conclusion: The Branch, Kermanshah, Iran tested model enjoys a desirable fitness and can be an important step in the identification Mehrdad Jami of individual and familial areas of addiction M.A. in Guidance and Counseling. potential. In addition, this model can act as a good model for the design and development Research on Addiction of programs for the prevention of risky Quarterly Journal of behaviors. Drug Abuse Keywords: addiction potential, family communication patterns, early maladaptive Presidency of the I. R. of Iran schemas, psychological capital, Drug Control Headquarters psychological basic needs Department for Research and Education

Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir/ 38 Research on Addiction Quarterly Journal of Drug Abuse

Introduction The emotional and mental health of people depends on the family health (Ismailpour, Khajeh & Mohammadi, 2013). On the other hand, adolescence can be considered as one of the most important periods of a person's life. This period is a critical time of development that creates profound physical and psychological transformative changes in the person and causes the mental and physical order of the adolescent to collapse. Adolescents in this emotionally immature period are extremely fragile and highly sensitive in terms of experience and social status (Khalili, Sohrabi, Radmanesh & Afkhami Ardakani, 2011). Drug use is increasing among adolescents around the world in such a way that it constitutes one of the most common psychiatric disorders in adolescence and young adult age group (Kaplan, Shaddock & Grebe, 2002). Research findings indicate that the use of most drugs begins in adolescence (D'Amico & McCarthy, 2006). The results of numerous studies on this age group show that 14.2 to 33 percent of the high school students had used psychoactive substances (Pavlovic & Jakovljevic, 2008; Thomas & Schwentke, 2008), 5 to 36 percent of them had used marijuana (Henry, Smith & Caldwell, 2007) ), 37.2 to 80.5 percent of them had drunk alcohol (Johnson, 2001), 6.7 to 42.7 percent of them had smoked tobacco or cigarettes (Premark, Land & Fine, 2008), 4.4 to 4.9 percent of them had used inhaling substances (Pavlovic & Jakovljevic, 2008; Thomas & Schwentke, 2008), 4.1 percent of them had used amphetamines (Pavlovic & Jakovljevic, 2008), 19 percent of them had used cannabis, 2.4 to 3.7 percent of them had used cocaine (Premark, Land & Fine, 2008), and 0.7 to 2.3 percent of them had used heroin (Pavlovic & Jakovljevic, 2008). It also seems that there is a special potential and room for the acceptance and consumption of narcotics in one's orientation to addiction, and the pre-addictive backgrounds of addicts, such as their beliefs and ideas about themselves, and their personality traits are significantly different from those of the healthy ones. In fact, the addiction potential theory suggests that some people are susceptible to addiction and if they are exposed to addiction, they will become addicted; however, if one is not susceptible to addition, s/he will not get addicted. In other words, the condition and background for the use of drugs are prepared (which is referred to as addiction potential) before one turns to drug use (Zeinali, Vahdat & Hamednia, 2007). Today, it has been revealed that no single factor is a necessary and sufficient condition for addiction, but addiction is the result of a combination of various factors. Some of these factors increase the risk and others reduce the risk. From among the determinants of drug use tendency, psychological variables are very important because psychologists believe that the impact of biological and social factors must be viewed from the lens of the person's psychological tendencies to drug use (Ahmadi Tahoor Soltani & Najafi, 2011). One of the most important cognitive factors in dealing with tasks and, in general, the outside world is the mental frameworks or templates through which one sees the outside world; Young refers to them as "early maladaptive schemas." Early Ali Reza Rashidi et al 39 maladaptive schemas are self-defeating emotional and cognitive patterns that are established in the early stages of growth and evolve in the course of life (Young, 2015). The maladaptive schema is the product of the conversation between the parents and the child that has been gradually established in the child's mind and has now systematically but ineffectively dominated his/her life. Maladaptive schemas are the cognitive infrastructures that lead to the formation of irrational beliefs and have been composed of cognitive, emotional, and behavioral components. When these schemas are activated, levels of emotions are released which directly or indirectly lead to the incidence of psychological disturbances, such as depression, anxiety, occupational inability, substance abuse, interpersonal conflicts, and the like (Young, 2015). One of the other variables that appears to provide the grounds for the individual's tendency to addiction is psychological capital. Although psychological capital is a multidimensional construct, one should not simply ignore the individual and organizational factors that affect it. Research has shown that psychological capital, as an individual variable, can predict performance and satisfaction better than any other individual characteristics that are effective. Psychological capital is a positive, growth-enhancing psychological state that includes some components, such as self-efficacy, optimism, hope, and resiliency (Luthans, Bugling & Lester, 2006). Research has shown that positive emotions act as a suppressor, help individuals overcome negative emotions faster, and, ultimately, play an important role in the well-being of a person (Tugade, Fredrickson & Barrett, 2004). If basic psychological needs are met, a sense of self-confidence and self- worth is shaped in people. On the other hand, if these needs are not met, the person will have a fragile, negative, alienated, and critical perception of the self (Chen & Jang, 2010). The satisfaction degree of basic psychological needs of individuals is among the other effective factors that can somehow contribute to individuals' tendency to addiction (Deci & Ryan, 2000). Moreover, research findings show that the individuals who feel competent have warm relationships with others and, at the same time, feel that they are independent and autonomous; thus, they enjoy a higher level of psychological well-being. According to Maslow, the individuals whose needs are satisfied to a greater extent are more physically and emotionally healthy (Shultz & Schultz, 2010). Generally, according to the above-mentioned points, it seems that the mentioned factors affect addiction potential under the influence of other important variables, such as family communication patterns. Numerous studies have shown that behavioral problems and deviations are more rooted in families, and that poor family practices caused by divorce or parental death may lead juveniles to participate in high-risk behaviors. On the other hand, the level of parental support and warmth has been found effective in the acquisition of adolescent health. On the whole, substance use is one of the major concerns and issues of today's world, which has a deterrent effect on the society's growth and prosperity. 40 Research on Addiction Quarterly Journal of Drug Abuse

In addition, substance use is a serious and worrisome threat that occasions a number of biological, psychological, and social consequences. Substance dependent individuals face a large number of problems and many of these problems go back to the period before the onset of drug use. Since the prevention approaches of addiction have not been complete in the past decades, the role of some cognitive factors, such as basic psychological needs and psychological capital has remained vague. These cognitive factors contain the elements and factors associated with positive psychology, such as self-efficacy, optimism, hope, resilience, autonomy, competence, and empathy. The current research was carried out due to the need for the identification of the risky and potential factors in drug abuse so that it may provide a basis for the development of preventive programs. Therefore, the following has been proposed with the aim of determining the causal relationship of addiction potential with psychological capital and basic psychological needs through initial maladaptive schemas under the mediating role of family communication patterns.

Vulnerability

Deprivation

Shame

Unrelenting Standards Self-Control Communication patterns Enmeshment

Devotion

Subjugation

Emotional Inhibition

Addiction Social Isolation potential

Failure

Dependence

Abandonment

Entitlement

Basic Psychological Needs

Capital

Ali Reza Rashidi et al 41

Method Population, sample, and sampling method The statistical population of this study consisted of the male and female high school students of Kermanshah that amounted to the number of 18322 students. From among different districts of Kermanshah, districts 1 and 3 were randomly selected and, then, the number of 14 schools (7 girls' schools, 7 boys' schools) was randomly selected. Afterwards, some classes were selected from each high school and necessary coadunations were performed with the relevant high school principal and teachers of each class for the administration of the questionnaires. Prior to the administration of questionnaires, the researchers provided explanations on the completion instructions and the confidentiality of the students' information. Since there was the risk of participant drop, the number of 450 questionnaires was distributed and collected over a period of three weeks. Finally, the data pertaining to 400 participants were analyzed. The criteria for the inclusion of participants in the research were studying at public schools, and aged from 20 to 15 years. On the other hand, the students who were guests or had been transferred to the school from other schools as well as those who suffered from specific physical and mental illnesses were not included in the research. Bootstrapping method was used to study the indirect relationships of the paths. Data analysis was performed using AMOS-18 and SPSS-21. Instruments 1. Addiction Potential Scale (APS): This questionnaire has been developed by Wade & Butcher (1992) and has also been standardized in Iran (Minooea & Salehi, 2003). It includes 41 questions. The reliability coefficients of this scale in normal samples (with a one-week interval) have been obtained equal to 0.69 and 0.77 in men and women, respectively. Minooea (2003) reported the Cronbach's alpha coefficient of 0.53 for this scale. In the present study, the Cronbach's alpha coefficient was obtained equal to 0.80. 2. Young’s Schema Questionnaire (YSQ): This 75-item questionnaire was developed by Jeffrey Young (1988) to evaluate early maladaptive schemas. The number of 18 schemas measure emotional deprivation, abandonment, mistrust/abuse, social isolation, defectiveness/shame, failure, dependence/incompetence, vulnerability to harm or illness, enmeshment, subjugation, devotion, approval-seeking/recognition-seeking, entitlement/ grandiosity, insufficient self-control/self-discipline, emotional inhibition, unrelenting standards, negativity/pessimism, and punitiveness. These 18 schemes are categorized into five domains in accordance with the initial development domains (Young, Klosko & Weishaar, 2011). The results of factor analysis also support the internal structure of the questionnaire. The Cronbach's alpha reliability of this questionnaire has been reported equal to 0.49. In terms 42 Research on Addiction Quarterly Journal of Drug Abuse of the questionnaire validity, the correlation of its scores with Jones' Irrational Beliefs has been calculated and the coefficient value of 0.43 has been obtained (Barazandeh, 2005). In this research, the Cronbach's alpha coefficient of 0.65 was obtained. 3. Lathan's Psychological Capital Questionnaire: This questionnaire was designed by Lutman's, Aeolia & Norman (2007) to measure psychological capital and consists of 4 subscales, namely self-efficacy, optimism, hope, and resilience, each of which consist of six items. Therefore, there are a total of 24 items in this questionnaire. Avery, Lutman's, Smith & Palmer (2010) reported the Cronbach's Alpha coefficients of hope, self-efficacy, resilience, and optimism equal to 0.87, 0.87, 0.72, and 0.78, respectively and reported the Cronbach's Alpha coefficient of 0. 93 for the total scale. In terms of validity, Lutman's (2012) obtained an appropriate and very high validity for this questionnaire. Bahadori Khosroshahi, Hashemi Nosrat-Abad & Babapour Kheiroddin (2014) obtained the Cronbach's alpha reliability of 0.85 for this questionnaire. In the present study, the Cronbach's alpha coefficients of the above subscales were obtained equal to 0.68, 0.54, 0.55, and 0.78, respectively. 4. Psychological Basic Needs Scale: This scale has been derived from Sorbet, Halva, Flats Gully & Kristiansen's Basic Needs Scale (2009). This scale consists of 21 items where 7 items belong to autonomy subscale, 6 items pertain to competence, and 8 items belong to relatedness. These questions are answered based on a 7-point Likert scale from strongly disagree (1) to strongly agree (7). Lavasani, Khezri Azar, Amani & Alizadeh (2011) obtained the Cronbach's alpha coefficients of 0.58, 0.66, and 0.63 for autonomy, competence, and relatedness, respectively. In the present study, Cronbach's alpha coefficients of the above subscales were calculated to be 0.64, 0.55, and 0.62, respectively. 5. Revised Family Communication Patterns (PFCP): This tool is a self- assessment scale that was designed by Fitzpatrick & Richie (1994) and measures the extent to which the respondent agrees or disagrees on the items in a five- point range from strongly disagree to strongly agree. This tool measures the dimensions of conversation and conformity where the first 11 items are related to the conformity dimension and the next 15 item are related to the conversation dimension. In Iran, Kouroshonia (2006) obtained the Cronbach's alpha reliability of the conversation and conformity dimensions equal to 0.87 and 0.81, respectively. In his research, the correlation coefficient of the dimensions with the total score was reported equal to 0.75. In Keshtkaran's research (2009), the Cronbach's alpha coefficient of 0.74 as obtained for the totals scale and the coefficients of conformity and conversation dimensions were 0.83 and 0.87, respectively. In the present study, Cronbach's alpha coefficient of 0.50 was obtained for conformity and 0.75 was obtained for conversation.

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Results A hypothetical model was designed to assess the direct and indirect relationships between the research variables based on the research background and the hypotheses. Table 1: Measurement parameters of modified direct relationships (with addiction potential) Non- Standard Critical Standar Path Standard Sig. Estimate Ratio d Error Estimate Emotional deprivation with 0.14 0.48 3.8 0.17 0.007 addiction potential Mistrust with addiction 0.12 0.44 0.42 0.23 0.003 potential Dependence/incompetence with 0.11 0.20 0.09 0.19 0.02 addiction potential Failure with addiction potential 0.12 0.55 2.64 0.13 0.009 Entitlement with addiction 0.08 0.19 3.02 0.38 0.07 potential Autonomy with addiction -0.09 -0.22 -4.71 0.15 0.08 potential Relatedness with addiction -0.22 -0.40 -5.21 0.09 0.001 potential Self-efficacy with addiction -0.15 -0.56 4.22 0.12 0.001 potential Resilience with addiction -0.20 -0.44 -5.45 0.10 0.001 potential Conformity with addiction 0.11 0.22 1.3 0.08 0.01 potential Conversation with addiction -0.31 -0.68 -6.3 0.10 0.001 potential

As it has been shown in Table 1, from among the early maladaptive schemas, emotional deprivation with the beta coefficient of 0.14, mistrust with the beta coefficient of 0.12, dependence with the beta coefficient of 0.11, and failure with the beta coefficient of 0.12 had a positive relationship with addiction potential. In addition, from among the subscales of the basic psychological needs, relatedness with the beta coefficient of -0.22 had a negative relationship with addiction potential. From among the subscales of the psychological capital, self- efficacy with the beta coefficient of -0.15 and resilience with the beta coefficient of -0.20 had a negative relationship with addiction potential. Finally, from among the subscales of family communication patterns, the conformity subscale with the beta coefficient of 0.11 had a positive relationship with addiction potential and conversation with the beta coefficient of -0.31 had a negative relationship with addiction potential.

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Table 2: Measurement parameters of modified direct relationships (with conformity subscale) Standard Non- Critical Standard Path Standard Sig. Estimate Ratio Error Estimate Failure with conformity 0.08 0.25 2.6 0.15 0.11 Dependence with conformity 0.12 0.39 3.12 0.11 0.002 Undeveloped self with 0.09 0.18 1.8 0.21 0.14 conformity Self-control with conformity -0.08 -0.15 -2.1 0.16 0.22 Autonomy with conformity -0.09 0.25 3.3 0.23 0.11 Resilience with conformity -0.13 0.42 2.9 0.10 0.001

As it has been shown in Table 2, from among the early maladaptive schemas, the dependence subscale with the beta coefficient of 0.12 had a positive relationship with conformity. In addition, from among the subscales of psychological capital, resilience with the beta coefficient of -0.13 had a negative relationship with addiction potential. Table 3: Measurement parameters of modified direct relationships (with conversation subscale) Non- Standard Critical Standard Path Estimate Standard Ratio Error Sig. Estimate Emotional deprivation with -0.20 -0.49 -5.9 0.13 0.001 conversation Mistrust with conversation -0.09 -0.21 -2.6 0.11 0.07 Undeveloped self with conversation -0.08 -0.19 -1.9 0.15 0.08 Relatedness with conversation 0.15 0.58 4.34 0.10 0.001 Self-efficacy with 0.07 0.26 5.3 0.09 0.09 conversation Resilience with conversation 0.17 0.45 3.42 0.12 0.001

As it has been shown in Table 2, from among the early maladaptive schemas, the emotional deprivation subscale with the beta coefficient of -0.20 had a negative relationship with conversation. In addition, from among the subscales of basic psychological needs, the relatedness subscale with the beta coefficient of 0.15 had a positive relationship with conversation. From among the subscales of psychological capital, resilience with the beta coefficient of 0.17 had a positive relationship with conversation. Table 4: Bootstrap results for modified indirect relationships in the mediation model (conformity) Standard Upper Lower Path Sig. Estimate bound bound Failure with addiction potential 0.08 0.15 0.03 0.11 through conformity Dependence with addiction potential 0.10 0.20 0.10 0.03 through conformity Resilience with addiction potential 0.00 -0.12 -0.10 -0.25 through conformity 5 Ali Reza Rashidi et al 45

As it has been shown in Table 4, the relationship of dependence with addiction potential with the beta coefficient of 0.10 and that of resilience with addiction potential with the beta coefficient of -0.12 were indirectly proved through conformity. Table 5: Bootstrap results for modified indirect relationships in the mediation model (conversation) Standard Upper Lower Path Sig. Estimate bound bound Emotional deprivation with addiction 0.18 0.25 0.12 0.004 potential through conversation Mistrust with addiction potential through 0.06 0.17 0.05 0.08 conversation Relatedness with addiction potential -0.21 -0.14 -0.31 0.001 through conversation Self-efficacy with addiction potential -0.09 -0.05 -0.15 0.12 through conversation Resilience with addiction potential through conversation -0.17 -0.10 -0.25 0.001

As it has been shown in Table 5, the relationship of emotional deprivation with addiction potential with the beta coefficient of 0.18, that of relatedness with addiction potential with the beta coefficient of -0.21, that of resilience with addiction potential with the beta coefficient of -0.17 were proved to be significantly indirect under the mediating role of conversation. In order to evaluate the modified model, its structural part was studied using fitness indicators. Table 6 shows the fitness indices of the modified model.

Table 6: Goodness of fit indices of the modified model under the mediating role of conformity subscale Fitness Indices Value Chi square of goodness of fit test 22.25 Sig. 0.09 Df 5 Chi-square ratio to df 4.45 Goodness of fit index (GFI) 0.78 Adjusted goodness of fit index (AGFI) 0.75 Normalized fitness index (NFI) 0.74 Comparative fit index (CFI) 0.77 Incremental fit index (IFI) 0.78 Tucker-Lewis Index (TLI) -0.74 Root Mean Square Error of Approximation (RMSEA) 0.09

The goodness of fit index indicates that the research model enjoys a relatively moderate fitness because as this index is closer to one, the model benefits from a more suitable and better fitness. According to the goodness of fit index in Table 6, the model has a moderate fitness with the mediation of conformity.

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Table 7: Goodness of fit indices of the modified model under the mediating role of conversation subscale Fitness Indices Value Chi square of goodness of fit test 6.24 Sig. 0.19 Df 1 Chi-square ratio to df 6.24 Goodness of fit index (GFI) 0.99 Adjusted goodness of fit index (AGFI) 0.98 Normalized fitness index (NFI) 0.97 Comparative fit index (CFI) 0.95 Incremental fit index (IFI) 0.98 Tucker-Lewis Index (TLI) 0.99 Root Mean Square Error of Approximation (RMSEA) 0.03

The goodness of fit index of the present model is equal to 0.99; therefore, it can be concluded that the model has a very desirable fitness under the mediation of conversation.

Failure 0.08 0.11

Dependence R2 = 0.22

0/12 Conformity Addiction potential Disbelief 0.13 R2 = 0.18

Fig. 1: The modified model (with the mediating role of conformity subscale)

Due to the absence of any causal relationship between some of the research variables and addiction potential, these variable were eliminated from the model. The modified model was applied based on the indices and this model is presented in the diagram. Moreover, considering the goodness of fit index that is equal to 0.75, the research model has a relatively moderate fitness with the mediation of conformity subscale.

Ali Reza Rashidi et al 47

2 Emotional -0.20 R = 0.22 deprivation

0.11 0.12 Addiction potential Mistrust 0.09 0.16 Relatedness -0.20 R2 = 0.18 -0.15 -0.31 Self-efficacy 0.077 Conversation

Disbelief -0.20

Fig. 2: The modified model (with the mediating role of conversation subscale)

Due to the absence of any causal relationship between some of the research variables and addiction potential, these variable were eliminated from the model. The modified model was applied based on the indices and this model is presented in figure 2. Moreover, considering the goodness of fit index that is equal to 0.99, the research model has a relatively desirable fitness with the mediation of conversation subscale. Discussion and Conclusion According to the results of this study, there was a negative relationship between the relatedness subscale and addiction potential from among the subscales of basic psychological needs. In explaining this finding, it can be argued that relatedness is considered as the internal and psychological food that is essential for the psychological development and sustainability, well-being, and coherence. It seems that the individuals in whom the need for relatedness has not been properly satisfied experience a mental emptiness within themselves. For this reason, it is hypothesized that these individuals tend to addiction to a greater extent in order to fill this gap when dealing with challenges and problems. In terms of this hypothesis, the results of the study showed that there is a positive relationship between the conformity subscale and addiction potential, and a negative relationship between the conversation subscale and addiction potential from among the subscales of family communication patterns. It can be said that all family members in such families are encouraged to participate freely and easily in interaction, discussion, and conversation about a wide range of issues. Individuals in these families share their activities, thoughts, and feelings with each other, and the parents in these families help with the development of mental health factors by utilizing a constructive relationship through the warm-hearted conversation with their children. Therefore, this communication pattern will help the adolescent become resistant against addiction in such a way that the more 48 Research on Addiction Quarterly Journal of Drug Abuse interactions and conversation are in the family, the less the probability of addiction tendency will be in these families. It can be said that children in families with a lack of communication with their parents tend to use drugs to overcome their psychological distress, such as depression and anxiety. In fact, in such families, members are prohibited to have open and sincere communication through the observance of the hierarchy in the family. It seems that adolescents in families with conformist communication patterns are more likely to be affected by their criminal friends and to have a higher rate of addiction tendency since they learn conformity and accept the beliefs of their companions without thinking. In other words, these children come to a kind of blind imitation and low level of self-esteem. In addition, the results of this research indicated that only the resilience subscale from among the subscales of psychological capital has a negative relationship with the conformity subscale and a positive relationship with the conversation subscale. In these families with high conversation orientations, there is a high rate of communication, and the members are allowed to develop communication and express their ideas and opinions. It seems that the reinforcement of protective factors in the developmental environment of the children in such families along with the promotion of life skills and personal self-esteem leads to the development of resilience in children. On the other hand, in families with a strong conformity dimension, the children are reared with a lower level of resilience since parents do not provide the grounds for their children's personal growth due to the excessive parental domination. According to the results of this research, there is a positive relationship only between the relatedness subscale and the conversation subscale from among the subscales of basic psychological needs. The children in families with a strong conversation dimension assign value to the family conversations and parental beliefs and opinions. In these families, open communication is dominant. The children raised in such families are independent in decision-making and in determining their relationships. For this reason, individuals in these families have a stronger sense of intimacy as well as stronger interpersonal and social ties. The results showed that, from among the subscales of early maladaptive schemas, the emotional deprivation subscale has a negative relationship with the conversation dimension and the dependence subscale has a positive relationship with the conformity dimension. It seems that children who grow up in families with a stronger conversation dimension among family members will have a more intimate relationship with parents. Individuals in these families easily express their opinions and assign value and respect to each other's opinions and ideas. Seemingly, the children raised in these families are less likely to develop the maladaptive schema of emotional deprivation. Since these families expect their children to behave in accordance with the wishes of the parents and parents assign less value to the children's opinions in decision-making, the independence of family members and children is somehow ignored and children go towards Ali Reza Rashidi et al 49 obedience. Therefore, the grounds for the personal growth of these children are provided to a lesser extent. In families with a high degree of conformity, it seems that there will be more scope for the incidence of dependence/incompetence schema for children. The results of this study showed that the indirect relationship between emotional deprivation schema and addiction potential is negative through the mediation of the conversation dimension; in other words, the individuals suffering emotional deprivation schema tend to avoid intimate relationships. The members of families with a strong conversation orientation interact freely, spontaneously, and repeatedly. Grown-up children in these families enjoy higher morale and social interactions, and feel less vulnerable in terms of attention and affection since they have received enough attention. Since parents provide the family members with enough time to give their comment freely, it seems less likely that the emotional deprivation schema is developed in the children. Hence, children in these families get involved in addiction to a lesser extent in the face of problems and challenges of life because of the sense of emotional support and the higher spirit they hold. Moreover, the results of this study showed that the indirect relationship of dependence/ incompetence with addiction potential is significantly positive through the mediation of the conformity dimension. This finding can be explained by the fact that the children with this schema feel that they do not have the ability and competence to make decisions due to the dogmatic relationships within the family and the unilateral decision-making on part of parents. As a result, children gradually find a dependent personality and they will find that they do not have sufficient independence in the conduct of responsibilities and tasks. Indeed, such families are less concerned with the development and growth of their children's personality. Eventually, children in these families with a stronger sense of conformity will find a negative self-concept about their own abilities; accordingly, they will experience more failure and disappointment. Thus, they seem to be more potential for entanglement in addiction. The results of this study showed that the indirect relationship between the resilience subscale and addiction potential is negative through the mediating role of the communication pattern of conformity and is positive through the mediating role of the conversation dimension. To interpret this finding, one can argue that since resilience is, in fact, the degree of individuals' adaptability and flexibility against stressful events, the factors effective in it can introduced as the type of patterns and interactions within families. In families with high rates of conversation, people have stronger social relationships because of open interactions and broader communications. As a result, family members are less likely to suffer mental and psychological damage when problems arise. This will ultimately make people in these families have less potential for addiction. To interpret the indirect relationship of resilience with addiction potential through the mediation of the conformity dimension, one can argue that these individuals do not accept their ability in coping with unpleasant events and lack self-confidence; therefore, 50 Research on Addiction Quarterly Journal of Drug Abuse their parents try to make the necessary decisions directly for their children. However, with this function, such children gradually become weaker in interpersonal and social relations. Thus, they will be more vulnerable, and, ultimately, experience more frustration, disappointment, and failures. Overall, they will be less able to cope with addiction due to their lower spirits. The results of this study also showed that the indirect relationship of the relatedness subscale with addiction potential is positive through the mediating role of conversation; in other words, those who have a stronger relatedness subscale prefer to interact and express freely their beliefs and ideas in their families. According to the personality traits of these individuals who like to establish more intimate relations and have a higher social morale, they will unconsciously move towards the conversational relations between family members. Due to the empathy and free exchange of ideas among family members, it seems that members suffer less stress in the face of problems since they can divide the imposed pressure in the self. For this reason, children in families with a strong conversation dimension will experience a higher level of psychological well-being and mental relaxation when problems and stressful events arise. Finally, they will have a lower degree of potential and readiness for addiction form the personality point of view. Since the statistical population of this study included high school students in public schools, the generalization of these findings to other statistical populations should be practiced with caution. In this study, the participants were indigenous people of Kermanshah; therefore, care and discretion should be taken into account in the generalization of the results to other populations, cultures, and ethnicities. Considering the significant role of family in the reinforcement and formation of early maladaptive schemas, basic psychological needs, and psychological capital as the factors effective in addiction potential, it is suggested that family communication patterns be strengthened through the conduct of educational programs in schools. Considering the mediating role of family communication patterns in the early maladaptive schemas, basic psychological needs, and psychological capital, it is recommended that some strategies and solutions be devised in the process of addiction treatment or addiction prevention programs. References Abolghasemi, A., Pourkord, M. & Narimani, M. (2009). The Relationship of Social Skills and Self-Efficacy with Tendency to Substance Use in Adolescents . Journal of Sabzevar University of Medical Science, 16 (4), 181-188. Ahmadi Tahoor Soltani, M. & Najafi, M. (2011). Comparison of Metacognitive Beliefs and Ambiguity Tolerance between Addicts, Smokers, and Normal People. Journal of Clinical Psychology, 3 (12), 59-68. Avery, J. B., Lutman's, F., Smith, R. M., & Palmer, N. F. (2010). Impact of positive psychological capital on employee well-being. Journal of Occupational Health Psychology, 15(1), 17-28. Ali Reza Rashidi et al 51

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Abstract Comparison of Objective: Thought Control, Objective: The aim of this study was to compare the thought control, Mindfulness, and mindfulness, and attachment styles between students with high and low Attachment Styles tendency to addiction. Method: The present study was a causal-comparative between Students research and its statistical population with High and Low consisted of University of Mohaghegh Ardabili's students in the academic year Tendency to of 2015-2016 where 283 participants were chosen by systematic random Addiction sampling method and completed the questionnaires. Luciano et al.'s Thought Control Questionnaire, Braun and Ryan's Mindful Attention Awareness Scale, Mirhesami's Tendency to Addiction, and Collins and Read's Adult Attachment Style Questionnaire Nilofar Mikaeeli constituted the measurement instruments used in this study. Results: The results showed that the students with higher tendency to addiction enjoyed a lower level of thought control; and the degree of mindfulness in the Nilofar Mikaeeli students with a lower tendency to Associate Professor of Psychology addiction is more than that in the other Department, University of Mohaghegh group. Moreover, the mean scores of Ardabili, Ardabil, Iran avoidant attachment, and ambivalent E-mail: [email protected] attachment in students with a high tendency to addiction were higher than those in students with a low tendency to addiction. Conclusion: The difference between the two groups in these variables shows the importance of thought control, mindfulness, and attachment style in students' tendency to Research on Addiction addiction and implicitly indicates the Quarterly Journal of Drug positive effects of mindfulness and self- Abuse control training on the prevention of addiction among students. Presidency of the I. R. of Iran Keywords: thought control, Drug Control Headquarters Department for Research and Education mindfulness, attachment styles, tendency to addiction Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir/ 54 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Addiction refers to the pathogenic dependence on the use of one or more types of narcotic drugs that causes the incidence of drug-seeking behaviors. In this situation, if the person does not take the intended narcotic drugs, s/he will be inflicted with deprivation symptoms (Bahari & Garousi, 2013). Addiction, as a physical illness, is a major personal and social problem that threatens the society's health from socio-economic, political, and cultural perspectives inasmuch as the physical and psychological complications it brings to addicts (Dinmohamadi, Amini, & Yazdan-khah, 2007). Substance abuse in Iran is one of the most important cultural, social, and health issues in such a way that more than 90% of the people worry about this issue. Statistics indicate that 2.65% of the adults in Iran suffer from substance abuse, and a 20-year meta-analysis conducted on students suggests that the substance abuse trend is steadily rising (Sarami, Ghorbani & Taghavi, 2013). Different evidence suggests that addiction is currently one of the costliest and biggest problems in our society, and young adults, as the stimulating engine of the country, are among the most vulnerable group in this regard (Rafeei & Alipour, 2015). The importance of this stratum of the community and its tendency to drug use and vulnerability to addiction have converted university students' addiction prevention programs into one of the major axes (Dick, & Hancock, 2015). There are a large number of facilitators that increase university students' tendency to addiction, such as the experience of living with low family monitoring, peer impacts, easy access, stress, and future career concerns. The tendency or potential to use drugs is one of the most serious predictors of addiction; in fact, it can be claimed that the first step of addiction pertains to a tendency that results from the individual's subjective evaluations of the issue (Gha'emi, Samsmam Shari'at, Asef Vaziri & Baluchi, 2008). According to addiction potential theory, some people are potentially more likely to get addicted, and if they are exposed to addiction, they will become addicted sooner. However, if an individual does not have addictive potential, s/he will not get addicted. Accordingly, addicted people experience a relatively different lifestyle from the healthy people and grow in psychosocial areas in such a way that they become prone to addiction (Zainali, Vahdat & Garadingeh, 2010). The majority of addicts have had many psychological and personality failures and disorder before addiction while these disorders appear to be more destructive after drug addiction (Oraki, Bayat & Khodadoost, 2012). From among personality traits, thought control is one of the most important factors that is based on the relatively new approach of self-regulation. Based on self- regulation models, one's problems in thought control and the use of wrong thinking strategies lead to his/her involvement in addiction (Sa'ed, Yaghoubi, Roshan, & Soltani, 2011). The low level of thought control whose causative role has been recognized in most of the addiction theories is a part of the set of Nilofar Mikaeeli 55 deficiencies pertaining to the malfunctioning of prefrontal cortex for intelligent control, which is observed in people at high risk of drug use (Tarter, et al., 2003). Intelligent control (or mental control) is referred to as the ability to suppress a dominant response to provide a non-dominant response. This ability is the amount of control that a person has over his/her impulses and emotions and includes the ability to focus and change attention. Self-control is one of the skills related to executive performance and is a method for the desired management of individuals' feelings and behaviors. Thought control is, in fact, an attempt not to contemplate a particular thought (such as drug use) (Vohs & Baumeister, 2004). In Sa'ed et al.'s study (2011), "uncontrollability" and the need for "thought control" in addicted people were reported to be significantly more inefficient than those of the other group. Addicted individuals like those with a deficiency in the prefrontal cortex are not sensitive to the future consequences of their behavior and have some problems in thought control, self-regulation, and decision-making in life (Bisma Becharar et al., 2001). One of the important attributes experienced in substance abuse disorder is the temptation or desire to consume drugs. The World Health Organization has introduced temptation as the foundation for the onset of drug dependence, loss of control, and relapse (Drummond, 2000). According to most of the existing theories, temptation can be considered as the central phenomenon and the main factor in the persistence of substance abuse and also relapse to substance abuse after therapeutic courses (Ekhtiari, Behzadi, Oghabian, Edalati & Mokri, 2006). Accordingly, the most important component of personality and behavior that can resist against this temptation is the control of thoughts and emotions because self-control is an intrapersonal conflict between reason and desire (Rachlin, 1995). Research has shown that people who are not able to control their emotions are more likely to be persistent consumers of substances (Wells, 1995). In their study, Basarhpour, Atadokht, Khosrovian, & Narimani (2013) reported a negative relationship between self-control and substance abuse, and stated that individual differences in cognitive self-control can affect the therapeutic effects of substance abuse disorders. Cognitive control can also be a predictor of drug use craving among addicts (Basharpour et al., 2014). In addition, Kokkonen, Kinnunen, & Pulkkinen (2002) reported that low self-control in adolescence would predict tobacco dependence in adulthood. Research on individual differences supports the potential importance of mindfulness in substance abuse because of its relationship with self-control (Karyadi, & Cyders, 2015). Mindfulness helps one understand that negative emotions are not a permanent constituent of his/her personality. It also allows the individual to respond with reflection rather than show incidental reaction to events (Emanuel, Updegraff, Kalmbach, & Ciesla, 2010). Different dimensions of mindfulness can be related to addiction. One of the most widely used scales of mindfulness introduces the following five facets as the constituent factors of mindfulness: acting with awareness (being in the present moment and 56 Research on Addiction Quarterly Journal of Drug Abuse consciousness of the action we are doing), describing (the ability to express the inner and outer experiences), observing (presence in internal and external experiences), nonjudging of inner experience (acceptance of feelings and experiences without positive or negative evaluation), and nonreactivity to inner experience (allowing the emotions to come and go) (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). According to Bishop, et al. (2004), two key concepts are emphasized in mindfulness: 1) Paying attention to what is happening right now (recent experience); and 2) Adopting an open, curious, and receptive attitude relative to those experiences. Mindful consciousness (acting with awareness) can be predictive of alcohol abuse more than the other facets of mindfulness (Karyadi, & Cyders, 2015). This variable has been reported to be the best predictor of uncontrolled substance abuse in Levin, Dalrymple, & Zimmerman's study (2014). Various studies have shown that the increase in the rate of mindfulness can support a person in exposure to risky situations, significantly reduce the level of anxiety in him/her by knowledge about what is happening around him/her, and increase the ability to cope with the temptations created in relation to drug consumption (Oraki et al., 2012). Bowen et al. (2006) conducted a study on addicts and showed that doing mind-boggling exercises led addicts to experience a significant reduction in drug use, anxiety, and depression three months later. Other studies have also supported the effectiveness of mindfulness in drug use craving (Brewer, Bowen, Smith, Marlatt, & Potenza, 2010). All of these studies, in fact, indicate the importance of increasing the mindfulness state in reducing the desire and tendency to substance abuse. One of the reasons for the effectiveness of mindfulness therapy for addicts has been the reinforcement of patients' motivations for treatment and the increase in their consciousness and awareness of their performance (Oraki et al., 2012). One of the mechanisms that is likely to contribute to the relationship of mindfulness with addictive behaviors is the representation of behaviors in individuals' minds. According to action identification theory, one's interpretation of his/her behavior with high or low expressions is the basis of his/her perception of the self and the continuation of that behavior (Vallacher, & Wegner, 1987). For example, working with a musical instrument can be identified as a low-level action (like the fingers' play on wires) or can be represented as a high-level action (like a musician's behavior). Addictive behaviors, such as alcohol abuse, can be identified as low- level actions (such as quaffing a liquid) or high-level actions (such as relieving stress). Based on this theory, when a behavior is unfamiliar, the low-level representation will become dominant, the behavior will persist automatically as a habit, and will allow the representation of a high-level action. This theory suggests that the ability to use both high- and low-action identities leads to self- regulation (Wegner, Vallacher, & Dizadji, 1987). According to this theory, various studies have shown that the abuse of a substance is the automatized result of a degree of behavioral representation in the person's mind. For example, the Nilofar Mikaeeli 57 degradation of the representation of alcohol consumption from a high-level action (relieving stress) to a low-level behavior (quaffing a fluid) can turn it into a habit and, actually, alcohol abuse. Mindfulness allows a person to monitor his/her behavior and prevent unwanted behavior by being vigilant and conscious about various components of the behavior that s/he performs (Schellhas, Ostafin, Palfai, & de Jong, 2016). This situation actually increases one's control of his/her behavior and reveals mindfulness identification with self-control. In fact, the consciousness caused by mindfulness can change the person's mental state from fantasy and/or rumination about the future, etc. to the objective understanding of the position for dominating high-risk behaviors. Although the factors pertaining to the onset of drug use may be a simple curiosity, the factors pertaining to the persistence of drug use can be related to attachment styles. According to self-deterministic theory, attachment is one of the three basic psychological needs of humans (Ryan & Deci, 2000). Initial attachment experiences with caregivers guide the feelings, thoughts, and behaviors in later relationships. According to attachment theory, early experiences with parents and secure or insecure attachment style affect the coming close relationships, and the children who are not emotionally attached to one parent will have more delinquent tendencies (Baldwin, Baldwin, & Cole, 1990). Attachment styles affect the person's methods to deal with stressful situations; in addition, separation from the source of the immune system can be related to the disruption of the relationship between the person and the human resources around him/her and his/her tendency to drug use to escape fear, anxiety, and taking refuge in dreams (Bahadori Khosroshahi, Hashemi Nosrat Abad & Beyrami, 2010). Besharat, Ranjbar Noshiri & Rostami (2008) showed that there is a difference between family functioning of the patients with opioid disorders and family functioning of normal people; in addition, ineffective familial characteristics can predict the intensity of opioid disorders among drug addicts. Bahr, Maughan, Marcos, & Li (1998) conducted a study on the relationship between attachment styles and drug use on 13250 adolescents and found that attachment to parents was associated with the risk of drug use during adolescence. In addition to the numerous pieces of research evidence regarding the relationship between substance abuse and attachment styles, some studies have investigated the relationship between "addictability" or addiction potential and attachment and have reported the existence of a significant relationship between the two variables. In this regard, Zeinali, Vahdat & Garadingeh (2010) argued that there is a negative relationship between the parental authoritative parenting style and children's willingness to addictiveness; and there is a positive relationship between the authoritarian parenting style and children's willingness to addictiveness. Moreover, there is a positive correlation between the parental neglectful parenting style and children's tendency to addiction. It has also been reported that the maternal neglectful parenting style is the predictor of children's 58 Research on Addiction Quarterly Journal of Drug Abuse addiction tendency; however, the paternal neglectful parenting style was not found to be the predictor of children's addiction tendency. According to Nurco, & Lerner (1996), the parents who cannot support their children emotionally are more likely to have children who use alcohol or drugs. Mothers' inattention to the children's needs leads to the development of insecure attachment styles in the children, and this brings about failure in self-regulation and the lack of mental structures associated with internal control of behavior in children. As a result, these individuals become dependent on external things and objects, and drug use becomes one of the methods to compensate for their internal deficiencies. Therefore, substance abuse is represented as an ineffective strategy for coping with emotional disturbances in people with anxious-avoidant attachment styles (Asghari, Alipour & Sayadi, 2015). Khosroshahi Bahadori et al. (2010) claimed that positive attitude toward substance use has a negative relationship with secure attachment style and has a positive relationship with insecure ambivalent and avoidant attachment styles. One of the primary functions of attachment is the regulation of emotional experiences in interpersonal relationships. Individuals with secure attachment style seek social support when faced with emotional stresses, while people with insecure attachment style take refuge in other remedies, such as alcohol or drug use for the purpose of emotional self-regulation. Substance abuse is, in fact, an artificial passive strategy and an attempt to cope with insecure attachment, reduce emotional distress, and modify interpersonal relationships. Individuals with secure attachment style have the ability to process their adaptive emotional information and to use efficient and effective communication methods and to manage their affective and emotional relationships. Secure attachment can predict the individuals' well-being through communication with adaptive and adapted strategies, and appropriate emotional relationships, whereas insecure attachment is linked to negative mood, anxiety, avoidance, and interpersonal problems via maladaptive strategies of emotional and affective regulation (Schindler, Thomasius, Sack, Gemeinhardt, & Küstner, 2007). Anderson (2012) believes that insecure attachment is recognized as an important vulnerability factor to addiction, and avoidant attachment has the highest positive correlation with substance abuse from among the insecure attachment patterns. It has been proven that people with secure attachment simply find help from others while accepting the situation, but avoidant people have difficulty accepting the available situation and finding support, and are oversensitive to negative emotions and attachment patterns (Kobak, & Sceery, 1988). Ambivalent and avoidant people always suffer from some sort of distress. These people are distracted and show negative emotions in the face of new situations, and may take refuge in ineffective emotional regulation methods, such as substance use to escape from their unpleasant situations (Kassel, Wardle, & Roberts, 2007). The individuals with avoidant attachment styles struggle to achieve personal power and compensatory self-confidence, and prevent stressful memories and Nilofar Mikaeeli 59 thoughts. Unlike the individuals with insecure-avoidant attachment style who encounter difficulty in emotional reconstruction, people with insecure- ambivalent style face difficulty both in differentiation and reconstruction, are more sensitive to negative information, and experience higher levels of emotional stress. People with anxious styles also experience higher levels of emotional stress. In addition, anxious attachment style (ambivalent) is characterized by a negative model of the self, while the avoidant style is represented by the negative model from others (Feeney, & Noller, 1996). According to the theory of addiction potential and considering the importance of prevention in health policies, it is essential that the individuals at risk and their psychological characteristics be identified and preventive measures be taken in this regard. Therefore, this research is an attempt to respond to the following question: Do the students who are prone to addiction more than others differ from other students in terms of thought control, mindfulness, and attachment styles? Method Population, sample, and sampling method The present study was carried out through a causal-comparative research method on a statistical population including University of Mohaghegh Ardabili's students in the academic year of 2015-2016 (approximately 13000 students). From among these students, the number of 370 participants was chosen in accordance with Cochran formula and by systematic random sampling method. After the exclusion of the incomplete questionnaires, 283 individuals remained as the final participants in the data analysis stage. The participants who had obtained the score above 3 (a total score of 48) from the range of 1 to 5 in terms of "addiction potential" were placed in the group with a high level of addiction potential and the remainder were placed in the group with a low level of addiction potential. Instruments 1. Addiction Potential Questionnaire: This scale consists of 16 questions and its general objective is to measure individuals' tendency to addiction from three dimensions, i.e. social, individual, and environmental domains. It has been designed by Mirhesami (2009) and has been inspired by the research projects conducted by Farhad et al. (2006). The items are scored based on a 5-point Likert scale and, thereby, the total score is in the range of 16 to 80. Higher scores in this scale represent one's higher tendency to addiction. Cronbach's Alpha reliability of the scale has been reported to be 0.79 in a sample of students (Mirhesami, 2009). Cronbach's alpha coefficient in this study was obtained equal to 0.65. 2. Mindful Attention Awareness Scale: This has been designed by Brown, & Ryan (2003) and contains 15 questions. It measures the level of awareness about 60 Research on Addiction Quarterly Journal of Drug Abuse daily experiences and being released from past and future mental attitudes (e.g., questions on eating, driving, and living without awarnes or with awareness). The items are answered based on a 6-point scale from 6 = almost always to 0 = almost never. The total score varies from 0 to 175, and higher scores are indicative of higher levels of mindfulness. The psychometric properties of this scale have been verified. It enjoys acceptable validity and has a high positive correlation with most of the indicators related to well-being and mental health. The Cronbach's alpha coefficients in seven sample groups that have used this tool have been reported to range from 0.82 to 0.87 (Brown, & Ryan, 2003). In Iran, this instrument has been used and the Cronbach's alpha coefficient of 0.82 has been reported for it, and it has also been shown that there is a relationship between mindfulness and self-knowledge and mental health (Ghorbani, Bing, Watson, Davison, & Mack, 2003). The Cronbach's alpha coefficient in the study was obtained equal to 0.80. 3. Thought Control Questionnaire: The Thought Control Ability Questionnaire, designed by Luciano, Algarabel, Tomás, & Martínez (2005), was used. This questionnaire has been designed to measure perceived ability of thought suppression. It consists of 25 questions that are scored based on a 5- point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Its Cronbach's alpha was reported to be equal to 0.92 in the initial measurement and was reported to be 0.88 through test-retest method within an 8-week time interval. The factor analysis carried out on this questionnaire among students of Isfahan University showed that the factor loadings of 23 questions were higher than 0.59 (Barati & Arizi, 2015). In this study, Cronbach's alpha coefficient of the scale was obtained equal to 0.87. 4. Collins & Read Adult Attachment Questionnaire: Collins and Read (1990, cited in Pakdaman, 2001) constructed this questionnaire and prepared its materials based on descriptions of Hazan-Shaver attachment self-report on the three main attachment styles. It consists of 18 questions that are scored on a 5- point Likert scale from not at all corresponds to my state (1) to extremely corresponds to my state (5). It measures three subscales of Anxiety (equivalent to ambivalent attachment style), Depend (equivalent to secure attachment style), and Close (equivalent to avoidant attachment style) where each of the subscales has 6 questions. Researchers have shown that the subscales of Close, Depend, And Anxiety have remained stable over a period of 2 months and even over a period of 8 months, and reported Cronbach's alpha for each subscale to be above 0.80 in 3 samples of students. The results of re-test reliability of this questionnaire within a one-month interval showed that it had a reliability coefficient of 0.95 (Pakdaman, 2001). In this study, Cronbach's alpha reliability of this questionnaire was obtained equal to 0.68.

Nilofar Mikaeeli 61

Results The descriptive statistics of demographic variables are presented in Table 1 according to the type of tendency. Table 1: Descriptive statistics of the sample group based on the type of drug addiction tendency High tendency to Low tendency to addiction Variable addiction N Percentage N Percentage Female 107 72 42 28 Gender Male 48 38 78 62 Associate's 3 43 4 57 Educational program Bachelor's 139 43 105 57 Graduate studies 15 68 7 32 Native 107 56 83 43 Residence Nonnative 51 62 31 38 Engineering 10 56 8 44 Basic Sciences 29 74 10 26 Agricultural 20 45 24 55 Literature and 22 55 18 45 Humanities Mathematical 16 73 6 27 Faculty Sciences Psychology and Educational 30 59 21 41 Sciences Electrical and 18 72 7 28 Mechanical Uncertain values 17 25 27 18

The descriptive statistics of the research variables are presented in Table 2 based on the type of drug tendency.

Table 2: Descriptive statistics of the research variables based on the type of drug tendency Students with low tendency to Students with high tendency Variable addiction to addiction Mean SD Mean SD Thought control 75.51 13.66 68.31 13.62 Mindfulness 61.47 8.85 52.72 10.21 Avoidant attachment 8.35 3.36 9.57 3.99 Secure attachment 12.09 3.21 11.59 3.49 Ambivalent attachment 6.90 3.57 9.76 3.58

Multivariate analysis of variance should be used to examine the differences between the groups in terms of the research variables. One of the assumptions of using this parametric test is the equality of covariance matrices. The results of the Box test indicated that this assumption has been met (P> 0.05, F = 2.88). In addition, the results of Leven's test were indicative of the satisfaction of the assumption of the equality of error variances. Therefore, multivariate analysis of variance was run and its results showed the presence of a significant difference 62 Research on Addiction Quarterly Journal of Drug Abuse

(P< 0.001, F = 14.974, Wilks's lambda = 0.754). Univariate analysis of covariance was used to examine the patterns of difference as follows. Table 3: Results of ANCOVA for examining the patterns of difference in the variables based on the type of addiction tendency Variable Mean Squares F Sig. Mindfulness 531.74 59.39 0.0005 Thought control 3582.85 19.24 0.0005 Avoidant attachment 103.87 7.82 0.006 Secure attachment 1.28 0.11 0.735 Ambivalent attachment 566.60 44.31 0.0005

As it has been shown in Table 3, there is a significant difference in mindfulness according to the type of addiction tendency (P <0.001, F = 59.39). Based on the descriptive statistics, the students with lower addiction potential were reported to have gained higher scores. Moreover, there was a significant difference in thought control regarding the type of addiction tendency (P <0.001, F = 19.24). Based on the descriptive statistics, the students with lower addiction potential were reported to have gained higher scores. In addition, there was a significant difference in terms of avoidant attachment according to the type of addiction tendency (P <0.01, F = 7.82). Regarding the descriptive statistics, the students with lower addiction potential obtained lower scores. Finally, there was a significant difference in ambivalent attachment according to the type of addiction tendency (P <0.001, F = 44.31). Considering the descriptive statistics, the students with lower addiction potential were reported to have obtained lower scores. However, no significant difference was observed in terms of secure attachment. Discussion and Conclusion The results showed that the students with a higher addiction tendency have lower thought control than the students with a lower degree of addiction tendency. This finding is consistent with that of the study conducted by Kokkonen et al. (2002) who had introduced low self-control in adolescence as a predictor of tobacco dependence in adulthood. In a study carried out by Basharpour et al. (2014), it was found that cognitive control could also be a predictor of drug craving among addicts. The prevalence of thought control inefficiencies and problems in addicted individuals has also been reported by Sa'ed et al. (2011). Probably, the poor functioning of the prefrontal cortex in these individuals leads to a lack of intelligent control because this problem is more likely to occur in people at higher risk of drug use (Basharpour et al., 2014). The other reason for the difference between the two groups of university students in terms of the degree of thought control pertains to their ability to act in acting non-impulsively and disagreeing with their desire and temptation that plays an effective role in addiction (Drummond, 2000) and thought control (Rachlin, 1995). The theory of self-regulation has shown that the loss or weakness of thought control and the use of wrong strategies in the thinking process can lead to Nilofar Mikaeeli 63 addiction. One of the most important differences between addicts and non- addicts is the ineffectiveness of thought control in the group of addicts (Sa'ed et al., 2011). The thought control ability reflects the individuals' level of control over the impulses and emotions. Self-control is a management method of people's feelings and behavior and is, in fact, an attempt to avoid contemplating a particular thought (such as drug use) (Vohs & Baumeister, 2004). It is natural that a group of students with a higher level of addiction potential than others will have less control over their thinking. This group is not sensitive to the consequences of their behavior and shows problems in thought control (Becharar et al., 2001). The high thought control in the group with a low level of addiction potential makes it more successful than the other group in the face of temptation (as the central phenomenon of drug abuse) because self-control is the key to the successful resolution of the inner conflict between reason and temptation (Rachlin, 1995), and people with less thought control are not able to control their emotions and are likely to be permanent drug users (Wells, 1995). In addition, the results showed that the level of mindfulness in the students with a lower degree of addiction potential is greater than that in the other group. Few studies have compared mindfulness between the groups at risk of addiction and normal groups; and most of the studies in this area have investigated the effectiveness of mindfulness exercises in addicts (e.g., Bowen, 2006). One of the reasons for the effectiveness of mindfulness therapies has been the reinforcement of patients' motivations for treatment and the increase in their consciousness and awareness of their performance (Oraki et al., 2012). Palinkas et al. (1996) attribute the preventive cause of mindfulness in addiction to the ability to significantly reduce the level of anxiety and increase the power of coping with the temptations associated with drug use (cited in Oraki et al., 2012). Mindfulness allows a person to monitor his/her behavior and prevent unwanted behavior by being vigilant and conscious about various components of the behavior that s/he performs. The level of anxiety in the person with a higher level of mindfulness decreases significantly with awareness of the events occurring around him/her. In fact, an increase in mindfulness reinforces the person in exposure to risk situations. Mindfulness increases the power of coping with the temptation of substance abuse. One of the reasons for the effectiveness of mindfulness treatments in addicts can be the enhancement of motivation and increased consciousness and awareness of their own performance. Moreover, based on action identification theory, mindfulness alerts the individual about the various components of his/her behaviors and makes him/her monitor his/her behaviors and prevent unwanted behaviors (Schellhas et al., 2016). Therefore, it is natural that the scores of the two groups of students differ in the level of mindfulness. In addition, the mean score of avoidant attachment and ambivalent attachment in students with high addiction tendency was higher than those in the other group. This finding is consistent with that of the studies carried out by 64 Research on Addiction Quarterly Journal of Drug Abuse

Kassel et al. (2007), Anderson (2012), Schindler et al. (2007), Bahadori Khosroshahi et al., (2010), McNally, Palfai, Levine, & Moor (2003), and Caspers, Cadoret, Langbehn, Yucuis, & Troutman (2005) who indicated that insecure attachment is an important factor of vulnerability to addiction and is related to substance abuse. According to Molnar, Sadava, DeCourville, & Perrier (2010), anxious attachment style is a risk factor for substance abuse. Casper et al. (2005) have also demonstrated the existence of a relationship between substance abuse and insecure attachment style. The findings of this study are also consistent with the results reported by Zeinali et al. (2010) who found a positive relationship between the parental authoritative parenting style and tendency to addictiveness. However, the current findings are not consistent with the finding reported in the majority of related studies in terms of the negative relationship between secure attachment and substance abuse. As Newcomb (1995) has stated, substance abuse is adopted by the individuals with an insecure attachment style as a self-treatment approach to emotional distress and lack of control and also as a way to cope with emotional distress. Possibly, ambivalent and avoidant individuals may use drugs as an ineffective emotion regulation method to escape from the negative emotions they experience (Kassel et al., 2007). It seems that anxiety is correlated with perceived attachment and distress and substance abuse is adopted as a self-medication method against emotional distress (Newcomb, 1995) and as an attempt to cope with emotional distress and the lack of control (Petraitis, Flay, Miller, Torpy, & Greiner, 1998). Insecure attachment in children can lead to the failure of self-regulation and the inability of the psychological structures associated with the internal control of behavior in children; thus, these individuals will become highly dependent on the external affairs and objects and use substances as one of the methods to compensate for their inadequacies. The insecure attachment style has an impact on individuals' approaches to encounter stressful situations and contributes to the reduction of healthy interpersonal links; accordingly, it leads to people's tendency to drug use to escape fear and anxiety, and to take refuge in dreams and fantasies. Another reason for the effectiveness of attachment styles in people's addiction potential is their effect on self-regulation. According to Nurco, & Lerner (1996), insecure attachment results in self-regulation failure and the lack of psychological structures associated with internal control of behavior in children. One of the reasons for the positive attitude to drug use among the individuals with insecure attachment is the fact that the regulation of emotional experiences in interpersonal relationships is rooted in attachment. For this reason, people with a secure attachment style seek social support when faced with emotional stress, while those with an insecure attachment style take refuge in other methods, such as drinking alcohol or drug use to regulate their emotions (Khosroshahi Bahadori et al., 2010). The use of self-report scales and the non-examination of other effective variables, such as family and social factors are among the limitations of this Nilofar Mikaeeli 65 research. On the whole, considering the significant difference between students with high and low addiction potential in terms of attachment style, thought control, and mindfulness, it seems that these variables are important in the prediction of student addiction and it is necessary to hold training workshops on self-control and mindfulness with emphasis on the prevention of addiction among students. Using scales such Addiction Potential Scale, it is possible to identify the groups exposed to risk and organize self-control, self-regulation, and mindfulness workshops to take an effective step in addiction prevention. Early interventions on parents and the training of secure attachment styles and appropriate communication with children can also be among the other suggestions of this study for future research. Reference Andersen, T. E. (2012). Does attachment insecurity affect the outcomes of a multidisciplinary pain management program? 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Abstract On the Effectiveness Objective: The aim of the present study was to examine the effectiveness of of Transcranial Transcranial Direct-Current Simulation (tDCS) in drug use craving, depression, Direct-Current and anxiety in students with tramadol abuse. Method: An experimental single- Simulation (tDCS) in subject research design was employed for the conduct of this study. All the Craving, Depression, students with tramadol abuse in Mohaghegh Ardabili University in the and Anxiety among academic year of 2015-2016 constituted the statistical population of this study. Students with For this purpose, three students were selected by convenience sampling Tramadol Abuse: method. For data collection purposes, Franken's Craving Questionnaire (2002) Preliminary Study and Lewinda's Depression, Anxiety and Stress Scale (DASS-21) (1995) were used. Treatment sessions of transcranial Mohammad Narimani, Asghar direct-current simulation (tDCS) were Pouresmali, Jaber Alizadeh- held in ten 20-minute sessions in such a Goradel, Mehri Mowlaie way that the anode electrode was placed on left dorsolateral prefrontal cortex (F3) and the cathode electrode was placed on Mohammad Narimani Professor of Psychology Department, the right dorsolateral prefrontal cortex Mohaghegh Ardabili University, Ardabil, (F4) and 2 milliamperes of direct electric Iran current were passed through the Asghar Pouresmali participants' skulls for 20 minutes. Ph.D. in Psychology, Young Researchers and Results: The results of this study Elite Club, Ardabil Branch, Islamic Azad indicated the effectiveness of this University, Ardabil, Iran method in the reduction of craving and E-mail: [email protected] depression among tramadol abusers, but Jaber Alizadeh-Goradel it could not have any significant effect on Ph.D Student of Clinical Psychology, Shahid individuals' anxiety. Conclusion: Beheshti University, Tehran, Iran According to the results, it appears that Mehri Mowlaie Transcranial Direct-Current Simulation Ph.D Student of Psychology, Mohaghegh (tDCS) can cause a reduction in Ardabili University, Ardabil, Iran depressive symptoms and craving in tramadol users. Hence, it is suggested that addiction therapists and Research on Addiction psychotherapist in the domain of Quarterly Journal of addiction use Transcranial Direct- Drug Abuse Current Simulation (tDCS) as an Presidency of the I. R. of Iran intervention method towards the Drug Control Headquarters treatment of these patients. Department for Research and Education Keywords: transcranial direct-current simulation (tDCS), dorsolateral Vol. 10, No. 40, Winter 2017 prefrontal cortex, craving, anxiety, http://www.etiadpajohi.ir/ depression, tramadol 70 Research on Addiction Quarterly Journal of Drug Abuse

Introduction From among the pseudo-opioid analgesics popular with young people and particularly students, one can refer to tramadol. University students are more likely to take this type of pill than other substances due to a number of reasons, including living in places without parental supervision such as dormitories, stresses arising from living in another city, academic anxiety, especially during exams, huge advertisements about the non-addictive effects of tramadol and its effect on the increase of attention and concentration, the low price and availability of this substance compared to other substances. This drug was first proposed in Germany in 1970 to relieve post-surgical pains and control chronic pains (Radbruch, Grond, & Lehmann, 1996). At present, substance abuse among young people in Iran has led to such a progressive development that tramadol abuse with 26.5% lies in the first rank among the other drugs according to the statistics released by Drug Control Headquarters (Fathi, Bashirian, Barati & Mehdi Hazaveh'ea, 2012). There are a number of reasons for this increase as follows: the ease of access and consumption, ignorance of the risks of abuse, parents and the government's obscurity regarding the negative consequences of taking tramadol, especially its addictive effect, and the lack of serious attention to design and implement preventive programs (Fathi et al., 2012). Craving, temptation, or eagerness for consumption are among the most complex issues that one faces when it comes to the treatment of addictive disorders. Tiffany, & Drobes (1991) defined drug use craving as a term that covers and entails a wide range of phenomena, including the expectation of amplifying effects and strong tendency to drugs. Hormes, & Rozin (2010) defined craving as follows: a very strong and urgent yearn for something so that it is impossible to focus on anything other than the subject matter. Various studies have shown that craving is known as the central phenomenon and the main cause for continued drug abuse, as well as cause of addiction relapse after therapeutic courses. On the other hand, drug addiction is a chronic disease that is often accompanied by another psychiatric disease. Mood disorders and depression are among the most common first-axis disorders caused by addiction based on the fifth revised version of the Diagnostic-Statistical Manual of Mental Disorders. The prevalence of major depressive disorder in individuals is about 50-60% and the degree of depression is close to 10% (Ilegn, Jain, & Trafton, 2008). In addition to the reports pertaining to the high comorbidity of substance abuse with mood disorders and the high rates of depression and anxiety among drug users, research findings confirm the same neurological position of craving, depression, and anxiety in such a way that the Dorsolateral Prefrontal Cortex plays an important role in mood disorders and craving according to brain imaging (Da Silva et al., 2013). On the other hand, the available therapies and treatment methods for substance abuse which address disorders and consider the Mohammad Narimani et al 71 individuals' mental status are limited and are weak in terms of the duration of long-term success (Vincent, Shoobridge, Ask, & Allsop, 1998). Considering the new interventional strategies in the field of addiction, the development of noninvasive brain stimulation techniques, such as transcranial direct current stimulation (tDCS) has come up with acceptable results in terms of the reduction of craving, depression, and anxiety. This technique acts based on the use of direct and low electric current on the skull in order to make changes pertaining to polarity in cortical irritability. Anodic and cathodic stimulation subsequently leads to the increase and decrease of cortical irritability (Nitsche & Paulus, 2000). Fregni, Liguori, & Fecteau (2008) examined the effect of cortical stimulation of the prefrontal cortex with transcranial direct current stimulation on the reduction of cue-provoked smoking craving among cigarette smokers and found that the stimulation of the right or left dorsolateral prefrontal cortex by direct stimulation with electric current reduced drug use craving. Other studies have shown that the stimulation of the right or left dorsolateral prefrontal cortex leads to a reduction in depression (Da Silva et al., 2013) and anxiety (Edson, Jaisa, Felipe, Michael, Nitsched, & Ester, 2015). Students' general health and mental health (as the elites in the community) are the main worries and concerns of planners and decision-makers; however, a small number of studies have been carried out in this area and there are a limited number of researchers who directly conduct therapeutic research among students. Moreover, it is known that the reduction of craving and the decline of mental symptoms that play a major role in the desire for substance use and addiction relapse are currently among the main challenges of other psychotherapy approaches since craving is the first important phenomenon in addiction relapse. Accordingly, the present study seeks to investigate the effectiveness of transcranial direct-current simulation (tDCS) (the placement of anode on left dorsolateral prefrontal cortex (F3) and the cathode on the right dorsolateral prefrontal cortex (F4)) in craving, depression, and anxiety among students with tramadol abuse. Method Population, sample, and sampling method An experimental single-subject research design was employed for the conduct of this study. Single-subject designs fall within the category of quasi- experimental research wherein changes in the dependent variable are measured in one subject. Since it is difficult to find a group of students using tramadol, the single-subject research design was selected for the conduct of this study. In these designs, the dependent variable is measured several times during the baseline stage and one or more stages of the treatment, that is, when the independent variable is presented. In this research, the ABA baseline was used. In the baseline stage, the levels of craving, depression, and anxiety were measured (step A). Then, the intervention stage included transcranial direct-current simulation (step 72 Research on Addiction Quarterly Journal of Drug Abuse

B) and the re-evaluation of craving, depression, and anxiety in the post-test phase was performed (step A). Eventually, a follow-up was conducted after two weeks. The independent variable in this study was transcranial direct-current simulation; and the dependent variables included therapeutic changes arising from the use of this therapeutic approach into the rate of craving, depression, and anxiety. At the intervention stage, the participants received 10 sessions of brain stimulation from the skull. In this state, the anode electrode was placed on left dorsolateral prefrontal cortex (F3) and the cathode electrode was placed on the right dorsolateral prefrontal cortex (F4) and 2 milliamperes of direct electric current were passed through the participants' skulls for 20 minutes. The effectiveness of the intervention was assessed by comparing the participants' responding process in the baseline stages with the treatment and continuation of responses in the follow-up phase. All the students with tramadol abuse in Mohaghegh Ardabili University in the academic year of 2015-2016 constituted the statistical population of this study. Considering the available population and the intervention nature of this research, and also due to the inclusion of certain conditions and time constraints, as well as the conditions for the satisfaction of the inclusion criteria and exclusion criteria, three participants were selected as the sample units. The inclusion criteria were being university student, the lack of comorbidity with major psychiatric disorders, no history of brain injury or stroke, and willingness in participation in the research. On the other hand, the exclusion criteria were the history of epilepsy, brain surgery, tumor, head impact resulting in anesthesia, head trauma or seizure in the individual or family, the presence of shunt and physical instruments in the body and snail planting, the history of bipolar disorder or psychotic symptoms of drug dependence (other than tramadol), presence of heart pacemakers, metal, and prosthesis, and implantation. Instruments 1. Demographic information: The demographic information, including age, level of education, occupation, duration of tramadol use, history of medication, and marital status was gathered through closed and open questions. 2. Desire for Drug Questionnaire: This questionnaire consists of 14 questions and has been developed by Franken, Hendriks, & Van den Brink (2002). It has been derived from the Desire for Alcohol Questionnaire, which is used for heroin dependents. However, it was later used to measure the desire for the use of other substances due to its feature of measuring the overall craving. This instrument examines the current craving and includes three subscales, namely desire and intention, negative reinforcement, and control. The questionnaire is scored based on a 7-point Likert scale (strongly opposite to strongly agree). In other words, the response to each item is rated from 1 to 7. Franken et al. (2002) calculated the reliability of this scale by Cronbach's alpha and obtained the value of 0.85 for the whole scale; in addition, they reported the coefficient values of 0.77, 0.80, Mohammad Narimani et al 73 and 0.75 for the subscales, i.e. desire and intention, negative reinforcement, and control, respectively. Mousayi, Mousavi, & Kafi (2012) reported the Cronbach's alpha coefficients of 0.96 for opium users, 0.95 for crack users, 0.90 for methamphetamine users, 0.94 for heroin inhaler, and 0.98 for heroin injectors. 3. Lewinda's Depression, Anxiety and Stress Scale (DASS-21): This questionnaire was developed by Lewinda (1995) and has 21 items, which are answered on a Likert scale from never (0) and low (1) to high (2) and very much (3). The items numbered 1, 6, 8, 11, 12, 14, and 18 assess stress; the items numbered 2, 4, 7, 9, 15, 19; and the items numbered 3, 5, 10, 13, 16, 17, and 21 asses depression. A large number of studies have been carried out to validate this questionnaire. Cronbach's alpha coefficients on a 717-particpant sample were obtained equal to 0.71, 0.73, and 0.81 for depression, anxiety, and stress. In terms of the convergent validity of the scale, the correlation coefficients of Beck Depression scores with the depression, stress, and anxiety scores of this questionnaire were obtained equal to 0.66, 0.49, and 0.67, respectively, which were significant (Sahebi, Sadaat Salari & Asghari, 2005). Procedure The initial design of transcranial direct-current simulation dates back to over 100 years ago. A number of primary experiments had been carried out using this technique on animal and human specimens before the 19th century. In 1804, Adeline embarked on a research project on transcranial direct-current simulation and the results indicated that this method would be effective in the improvement of depressed people's mood. In the 1960s, a person named Albert managed to demonstrate that this method could affect brain function by altering the stimulation of the cerebral cortex. He also discovered that positive and negative stimuli have different effects on cortical irritability. Although these findings were important for the use of transcranial direct-current simulation, pharmacotherapy showed itself as a more effective treatment method since limited research was carried out again on transcranial direct-current simulation. This argument continued until the present time, and this method regained its importance as much as the new techniques of brain stimulation and new brain imaging techniques after the increase in the interests in doing studies on brain functions and therapeutic applications (Janicak, Davis, Gibbons, Ericksen, Chang, & Gallagher, 1985). In this research, the participants first filled out the questionnaires to determine the pre-test score. In the next stage, transcranial direct-current simulation was performed for 10 consecutive days upon the skulls where the anode electrode had been placed on left dorsolateral prefrontal cortex (F3) and the cathode electrode was placed on the right dorsolateral prefrontal cortex (F4) and 2 milliamperes of direct electric current were passed through the participants' skulls for 20 minutes. After the end of the intervention, the research variables were re-evaluated. Moreover, one month after the completion of re- intervention, the variables were evaluated in the follow-up stage. 74 Research on Addiction Quarterly Journal of Drug Abuse

Results Considering the single-subject research design, the indexes of the change trend, recovery slope and percentage were used for data analysis in each patient and the trend of changes in scores during the sessions was shown separately on the graphs. The ups and downs of the dependent variable are the basis for the judgment on the rate of change. In addition to this criterion, the clinical significance was also used for data analysis. The following formula was used to objectify the degree of recovery.

퐏퐨퐬퐭퐭퐞퐬퐭 퐬퐜퐨퐫퐞−퐩퐫퐞퐭퐞퐬퐭 퐬퐜퐨퐫퐞 Recovery percentage = 퐏퐨퐬퐭퐭퐞퐬퐭 퐬퐜퐨퐫퐞

The first participant was 21 years old and was an engineering student with a history of three-year tramadol use (a daily dose of 600 milligrams). The second participant was 22 years old and a student of Humanities with a history of two- year tramadol use (a daily dose of 800 milligrams) and, finally, the third participant was 20 years old and a student of basic sciences with a history of two-and-a-half-year tramadol use (a daily dose of 1000 milligrams). The descriptive statistics of the research variables are presented in Table 1 for each participant and test stage. Table 1: Descriptive statistics of the research variables for each participant and test stage Mean SD Recovery Effect Variable Participants Follow- Follow- Pretest Posttest Pretest Posttest percentage size up up First 37.83 30 28.56 7.42 5.64 4.72 0.26 1.14 Craving Second 42.26 34 35.21 10.26 6.78 5.34 0.24 1.09 Third 45.67 37.46 40.92 13.56 7.59 6.68 0.22 1.02 First 39.67 31.25 30.45 10.23 7.46 6.78 0.26 1.16 Depression Second 44.89 36.26 38.23 12.47 9.64 7.68 0.24 1.07 Third 48.52 38.46 39.39 13.56 11.27 9.44 0.25 1.12 First 42.25 43.34 43.39 12.41 12.44 13.21 0 0 Anxiety Second 38.56 38.78 39.42 10.45 11.23 11.79 0 0 Third 37.24 35.77 33.26 9.45 8.35 7.79 0.24 1.06

The results of Table 2 show that craving and depression have been clinically reduced in all three participants as the percentage of recovery and the effect size indicate these changes. However, anxiety has been reduced only in the third participant and the method has not had any effect on anxiety in the first and second participants. The obtained effect sizes indicate the effect of transcranial direct-current simulation, and the obtained effect sizes are considered to be large according to Cohen's categorization. Mohammad Narimani et al 75

50 40 ولع Cravingمصرف 30 Depressionافسردگی 20 10 Anxietyاضطراب 0 up-پیگیریFollow پس آزمونPosttest پیش Pretest آزمون

Fig. 1: Scores changes in the first participant in terms of craving, depression, and anxiety

According to figure 1, there is a significant reduction in craving and depression, but there is no significant change in the anxiety variable.

50 40 Craving ولع مصرف 30 Depressافسردگی 20 ion Anxiety اضطراب 10 0 up-پیگیریFollow پس آزمون Posttest پیش آزمونPretest

Fig. 2: Scores changes in the second participant in terms of craving, depression, and anxiety

According to figure 2, there is a significant reduction in craving and depression, but there is no significant change in the anxiety variable.

50 40 30 Craving ولع مصرف 20 Depress افسردگی 10 ion Anxietyاضطراب 0 Pretest Posttest Follow-up

Fig. 3: Scores changes in the third participant in terms of craving, depression, and anxiety 76 Research on Addiction Quarterly Journal of Drug Abuse

According to figure 1, there is a significant reduction in craving, depression, and anxiety. Discussion and Conclusion The research finding reported by Fregni (2008) and Boggio (2008) are consistent with that of the confirmed hypothesis regarding the effect of the anodic stimulation on left dorsolateral prefrontal cortex and the cathodic stimulation on the right dorsolateral prefrontal cortex. The results of these studies showed that the simultaneous anodic and cathodic stimulation of F3 and F4 reduces craving for cigarette smoking and craving for alcohol consumption. Although the results of the anodic F3 and the cathodic F4 arrangement were more suitable, the placement of the electrodes exactly on the opposite mode was also effective. The significant effect of transcranial direct current stimulation on the reduction of craving in the prefrontal cortex confirms the important role of the dorsolateral prefrontal cortex in craving. In addition, the results of this part of the study are consistent with those of the research conducted by Hajloo, Pouresmaeali, Alizadeh Goradel & Molaei (2015) who confirmed the simultaneous stimulation of the anodic F3 and cathodic F3 in daily and social smoking craving. In a study conducted by Politi, Fauci, Santoro, & Smeraldi (2008) on 36 cocaine users, it was revealed that 10 sessions of the left dorsolateral prefrontal cortex stimulation brought about a decrease in cocaine craving. Boggio et al. (2008) administered one session of stimulation in the left and right prefrontal cortex on 13 alcohol users, and reported a temporary decline in craving on both sides. Amiaz, Levy, Vainiger, Grunhaus, & Zangen (2009) conducted the left dorsolateral prefrontal cortex stimulation on 48 nicotine users during 10 sessions and reported a decrease in craving. In another study, Fregni et al. (2008) reported the temporary reduction of craving in both sides of the hemisphere after one session of stimulation in the left and right prefrontal cortex on 24 nicotine users. Based on the previously-done studies and the present study, it can be argued that the increasing or decreasing stimulation of the left or right prefrontal cortex can interfere with the balance of activity in the two hemispheres. The left and right dorsolateral prefrontal cortex stimulation can normalize the states of drug use craving. A number of the cerebral cortex centers that are active in drug use craving in humans, as well as the limbic and prefrontal structures have become activated by stimulation. These areas of the brain were broadly related to the left hemisphere of the brain. Moreover, the activation of the anterior cingulate cortex has been seen during the experience of substance craving (Garavan, et al., 2000). To explain this finding, one can argue that transcranial direct current stimulation has been used frequently in the withdrawal of using tramadol, alcohol, and opiates (Kaluss, Sexton, Loo, & Ebmeier, 2014). Stimulants in the reward system directly increase the level of extracellular dopamine through the release of dopamine or prevention of its reabsorption at the pre-synaptic terminus, but some substances (such as nicotine, alcohol, and cannabis) affect the neurons Mohammad Narimani et al 77 containing Gamma-aminobutheric acid or glutamate and, thereby, boosts dopaminergic transmission in the reward system's circuit. These are the events that are observed during the use of transcranial direct current stimulation through the skulls. Additionally, the regulation of dopamine release in the nucleus of the acombensis is carried out by the prefrontal cortex and, thereby, the response to the stimulating stimuli will be controlled (Feltenstein, & See, 2008). Many studies have been carried out on animals and have shown that anodic stimulation increases the neuronal firing and cathodic stimulation leads to the opposite results (Bindman, Lippold, & Redfearn, 1964). Therefore, based on these pieces of evidence, it is assumed that the increase in both the activity of the right prefrontal region and in the left prefrontal region leads to a decrease in craving (Fregni, Liguoiri, Fecteau, Nische, Pascual-Leone, & Boggio, 2008). Dorsolateral pre-frontal cortex is one of the important regions of the prefrontal cortex, which is responsible for recognizing and designating actions, assessing the future outcomes of the current behavior and the predictive outcomes, and social control. Therefore, a possible mechanism that the stimulation of this area leads to a decrease in craving is that this stimulation increases social control; in other words, it increases the participants' ability to suppress their inclinations. Another explanation is that the prefrontal cortex group stimulation also stimulates the dopaminergic pathways. In particular, it is assumed that the diffusion of mesomellant dopamine into striatum leads to the regulation of the substance received through the mediation of motivational processes. The dopaminergic modulation through cortical stimulation by this method has been confirmed in the study conducted by Nitsche, Lampe, Antal, Lietanz, Lang, Tergau (2006). The results of this study also indicated that transcranial direct current stimulation has reduced depression in the three tramadol users. This finding is in line with other findings in this regard. Rigonatti et al. (2008) did a study on the effectiveness of transcranial direct current stimulation on depression and showed that the anodic stimulation of the prefrontal cortex in depressed subjects reduced the depressive symptoms where this reduction was equivalent to the effect of a 6-week fluoxetine. In seven studies conducted on the effectiveness of transcranial direct current stimulation in the reduction of depression, the significant effect of this method on the treatment of depression was proved (Vigod et al., 2014). Depression disorder is usually associated with activity changes and cortical stimulation, especially in prefrontal areas. Recent studies on the change of prefrontal cortex and establishment of a trade-off between the prefrontal cortex activities of the left and right hemispheres have proved the significant effects of transcranial direct current stimulation on the reduction of depressive disorder symptoms (Arul-Anandam & Loo, 2009). Transcranial direct current stimulation is a promising non-pharmacological intervention for the treatment of depression disorders. In a study conducted by Boggio et al. (2006), it has been shown that the dorsolateral prefrontal cortex stimulation 78 Research on Addiction Quarterly Journal of Drug Abuse through transcranial direct current is associated with a mood change towards positive emotional states. Depression disorder is usually associated with activity changes and cortical stimulation, especially in prefrontal areas. Recent studies on the change of prefrontal cortex in the left and right hemispheres have revealed the significant effects of transcranial direct current stimulation on the reduction of depressive disorder symptoms (Boggio et al., 2006). The result of this study is consistent with that of the research conducted by Brunoni et al. regarding the enhancement of the cognitive function and pain relief by transcranial direct current stimulation. The anodic stimulation of the left dorsolateral prefrontal cortex (the region responsible for the treatment of depression) has led to the promotion of performance across a number of cognitive-behavioral tasks, the utilization of higher levels of cognitive functions, such as working memory, verbal influence, and programming ability (Brunoni et al., 2012). However, the results on the effect of transcranial direct current stimulation on anxiety reduction in tramadol users showed that the anxiety scores in the post- test did not decrease significantly compared to the pre-test in all three participants. This finding is inconsistent with other research findings in this area. For example, in a review of previous studies, Pallanti & Bernardi (2009) concluded that the brain magnetic stimulation above the dorsolateral prefrontal cortex is useful in the treatment of anxiety disorders. Moreover, Edson et al. (2015) suggested the effectiveness of transcranial direct current stimulation in the reduction of anxiety in substance users. To explain this finding and the inconsistency, one can refer to the nature of the current research samples. Indeed, the tramadol users during the treatment process experience a higher incidence of insomnia, body pain, trembling, and other symptoms as a result of decreased craving. These symptoms naturally increase anxiety or at least do not decrease anxiety during the treatment. In the end, it can be concluded that the results of the present study indicate that the right and left dorsolateral prefrontal cortex stimulation reduce the degree of craving and depression in tramadol users. Since a limited number of studies have been done on the effect of transcranial direct current stimulation on the reduction of craving in tramadol users, the results of this study can be used by experts and practitioners in the field of addiction treatment as a non-invasive method in the completion of therapeutic and treatment processes. This research suffered from some limitations, such as the self-report scale for data collection on tramadol craving, depression, and anxiety as well as the single-subject research design and the limited sample size, which make the generalizability of results a difficult task. According to the results and evidence of this study, it is recommended that this method be used by psychologists and psychiatrists in psychiatric clinics and psychiatric services and addiction treatment clinics as an intervention and prevention method.

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Abstract On the Comparison Objective: This research was an attempt of Risk-Taking and to compare risk-taking and cognitive distortion between students with and Cognitive Distortion without addiction tendency. Method: This descriptive research was a causal- in Students With and comparative study whose statistical population consisted of all male high Without Addiction school students in Bostanabad city in the academic year of 2014-2015. The Tendency number of 200 students (100 students with addiction tendency and 100 students without addiction tendency) was selected from among the students as the research participants. Addiction Samad Mashmool-Haji-Agha, Tendency Scale, Risk-Taking Scale, and Abbas Abolghasemi Cognitive Distortion Scale were used for data collection purposes. The data were analyzed via MANOVA test. Results: The results of this research showed that risk-taking and cognitive distortion in Samad Mashmool-Haji-Agha students with addiction tendency were M.A. in General Psychology, Islamic higher than those in normal students. Azad University, Science and Research Conclusion: The findings of this study Branch, Ardabil, Iran revealed that risk-taking and cognitive E-mail: [email protected] distortion are among the important variables in addiction tendency. Abbas Abolghasemi Therefore, it is necessary to take risk- Professor of Psychology Department, University of Guilan, Rasht, Iran taking and cognitive distortion into consideration according to the current research findings in order to provide services pertaining to prevention, psychopathology, and counseling programs.

Keywords: risk-taking, cognitive distortion, addiction tendency

Research on Addiction Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir 82 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Addiction and drug abuse have been among the most serious problems in the human society in recent years and have also been among the most complex human phenomena. With regard to the young population of Iran, drug addiction is one of the issues that threatens the young generation, especially students, and this period is the peak of the manifestation and outbreak of addiction (Salimi, Gohari, Kermanshahi, & Javdan, 2015). Statistics show that about 16 percent of Iranian addicts are under the age of 19 years (Dadkhah, Shalchi & Yaghouti, 2015). Addiction is a physical, psychological, and social disease where numerous pre-addictive factors are involved in its incidence (Galanter, 2006). However, not all the individuals who are exposed to drugs get addicted, but a person gets addicted who has addiction tendency (Hiroi, & Agatsuma, 2005). Before the person begins to take addictive drugs during the period of growth along with the formation of his/her behaviors, thoughts, ideas, and personal characteristics, the grounds for the emergence of addiction are provided (Dadkhah, Shalchi & Yaghouti, 2015). The existence of addiction tendency will affect adolescents' risk-taking for drug use since adolescence is an important growth period that is associated with the process of identity formation. Some part of this growth process is risk-taking that appears in the form of unhealthy behaviors, such as cigarette smoking and the use of other substances (Ahmadi Tahour, Asgari & Toughiri, 2013). Risk- taking is a behavior that leads a person to be exposed to physical and psychological threats, and even death. Moore (2000) defines risk-taking as a phenomenon in which one exposes him/herself to a loss or injury in such a way that there is a high probability of getting harmed. In addition, Valentina, Luca, Mercedes, Francesca, & Sabrina (2016) reported that risk-taking in adolescents has a significant role in the experience of drug use. In this regard, Lee & Park (2015) also showed that there is a positive relationship between risk-taking and drug use and smoking. Lindgren, Mullins, Neighbors, & Blayney (2010) found that there was a significant relationship between risk-taking and drug use (alcohol, narcotics, and hallucinogenic drugs). Doherty, Appel, & Murphy (2004) concluded that risk-taking behaviors have a relationship with alcohol consumption, drug use, aggressive behavior, and illegal conduct. In addition, in regard to addiction tendency, cognitive factors are among the areas of interest to researchers. In this regard, consideration and attention to cognitive distortions have assumed great importance since one's concepts or beliefs are the subject of cognitive distortions. Due to the fact that the majority of these concepts and beliefs start from childhood, the thought processes that support such concepts may reflect childhood mistakes. Cognitive distortions appear when information processing is false or ineffective. In other words, information analysis is sometimes distorted in people's minds. These types of distortions, which are called cognitive errors or cognitive distortions, appear in various forms. These Samad Mashmool-Haji-Agha & Abbas Abolghasemi 83 distortions, when occurring alternately and frequently, can lead to discomforts or psychological disorders and abnormal behaviors, such as drug use (Goldin, Manber-ball, Werner, Heimberg, & Gross, 2009). Hedayatfard & Mahboobeh (2015) showed that people with substance abuse obtained high scores in cognitive distortions compared to normal people. In the same way, Ahmadi Tahour & Najafi (2011) indicated that impaired cognitive beliefs act as an important psychological factor in the prediction of people's tendency to drug use. Haji Alizadeh, Bahraini, Naziri & Modares Gharavi (2009) reported that there was a higher percentage of the individuals with cognitive distortions among substance abusers than healthy subjects. Miller, Adam, & Chrstianne (2013) found that the children who gained high scores in cognitive distortions were more susceptible to substance abuse. In addition, Zainah, Rohany, Asmawati, Rozainee, & Fatimah (2014) reached the conclusion that the addicts with high scores in cognitive distortions had a lower tendency to treatment. However, the results of some studies have shown that the availability of risk-taking has not been effective in tendency to cigarette smoking and drug use (Lee & Park, 2015), and these variables are also considered as the factors for the acquisition of achievements (Mazloumi, Latifi & Asaee, 2007). Therefore, doing research in this area is always important and, addiction prevention is mandatory due to the numerous and widespread problems caused by it. In this regard, it is noteworthy that addiction prevention requires the identification of the risk factors and the underlying factors in drug dependence. Accordingly, this study aimed at comparing risk-taking and cognitive distortion between students with or without addiction. Method Population, sample, and sampling method A causal-comparative research method was used for the conduct of this study. The statistical population of this study consisted of all male high school students in Bostanabad city in the academic year of 2014-2015 (N=902). After the conduct of necessary coordination with the Education Office of East Azerbaijan Province and obtaining the permission for the conduct of this research, the Addiction Tendency Scale was administered to 500 students and, thereby, the students with addiction potential were identified. Then, 100 students with high scores on addiction tendency (cut-off score of higher than 50) were chosen and 100 students without addiction tendency were randomly selected from the population. Instruments 1. Addiction Potential Scale: This scale was constructed by Weed, & Butcher (1992) and has been validated in Iran by Kordmirza, Azad & Eskandari (2003). This scale contains 41 items, which are answered based on a four-point Likert scale from strongly disagree (0) to strongly agree (3) and the total score ranges 84 Research on Addiction Quarterly Journal of Drug Abuse from 0 to 108. Higher scores represent a higher degree of the respondent's addiction potential and readiness. The Cronbach's alpha coefficient of this scale has been reported equal to 0.90. Moreover, the convergent validity of this scale has been assessed and its correlation with Hopkins Symptom Checklist-25 has been obtained equal to 0.45. To assess its reliability, the normal group's scores have been compared with drug users' scores, and the mean score of the drug using group was higher (Zargar, 2006). The cut-off point for screening equals 50. 2. Adolescents' Risk-Taking Scale: This scale has been developed by Zadeh- Mohammadi, Ahmad Abadi & Heidari (2011). This scale consists of 38 items wherein respondents announce their agreement or disagreement on the items on a 5-point Likert scale from strongly agree (5) to strongly disagree (1). The Cronbach's alpha coefficient for this scale has been reported to be in the range of 0.44 to 0.94. It contains the following subscales: sexual risk-taking, hazardous driving, violence, cigarettes, narcotic drugs and psychotropic substances, and alcohol. 3. Cognitive Distortion Scale: This scale has been developed by Beck, Baruch, Balter, Steer, & Warman (2004) to measure cognitive insight and contains 15 items. Respondents are requested to rate the degree of their approval of each statement on a 4-point scale (from strongly agree to strongly disagree). The Cronbach's alpha coefficient of this scale has been reported to lie in the range of 0.68 to 0.74. This scale measures the following components: all-or- nothing thinking, overgeneralization, mental filter, disqualifying or discounting the positive, catastrophizing, magnification/minimization, emotional reasoning, should and must statements, labeling, and personalization. Results It is notable that 80% of students of the participants with addiction potential and 50% of the participants without addiction potential were the first-child in family. From among the students with addiction potential, 62% were studying in Humanities while 57% of the students without addiction potential were studying in experimental sciences. In addition, 33% of the students with addiction potential reported to have experienced smoking and alcohol drinking, and the other group did not have any history of drug use. The mean and standard deviation of the age of students with and without addiction potential were equal to 17.90 (0.61) and 17.88 (0.84) years, respectively. The results of t-test indicated the equality of mean values of age for the groups (P>0.05). The descriptive statistics of the research variables are presented in the following table for each group.

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Table 1: Descriptive statistics of risk-taking and cognitive distortion for each group With addiction potential Without addiction potential Variable Mean SD Mean SD Risk-taking 59.41 8.88 42.50 5.21 Cognitive 99.90 14.49 1.35 9.86 distortion

Multivariate analysis of variance should be used to investigate the difference between the groups in the linear combination of the variables. One of the assumptions for using this test is the equality of error variances. The results of Leven's test showed that this assumption has been met in risk-taking variable (F = 1.35, P> 0.05) and cognitive distortion (F = 1.24, P> 0.05). The results of multivariate analysis of variance were indicative of a significant difference between the groups (P< 0.001, F = 8.04, Wilks's lambda = 0.18). Univariate analysis of variance was used to assess difference patterns as in Table 2. Table 2: Results of univariate analysis of variance for the examination of patterns of differences Variable Mean Square F Sig. Eta squared Power Risk-taking 69075.64 7.610 0.001 0.67 1 Cognitive distortion 15340.77 27.700 0.001 0.56 1

As it is observed in Table 2, there is a significant difference between the two groups in both variables. Regarding the descriptive statistics, the group with addiction potential had gained higher scores in both variables. Discussion and Conclusion The present study was an attempt to compare risk-taking and cognitive distortion between students with or without addiction potential. The results showed that there is a significant difference between the two groups of students in terms of risk-taking in such a way that the risk-taking mean score in students with addiction potential was higher. This finding is in line with the research findings reported by Wagner (2001), Doherty, Appel, & Murphy (2004), Lindgren, Mullins, Neighbors, & Blayney (2010), Lee & Park (2015), and Valentina, Luca, Mercedes, Francesca, & Sabrina (2016). In their survey, Valentina, Luca, Mercedes, Francesca, & Sabrina (2016) reported that risk-taking in adolescents has a significant role in the experience of drug use. Lee & Park (2015) found that there was a positive correlation between risk-taking and drug use. Lindgren, Mullins, Neighbors, & Blayney (2010) claimed that there was a relationship between risk-taking and drug use (alcohol, narcotics, and hallucinogenic drugs). Doherty, Appel, & Murphy (2004) concluded that risk-taking behaviors have a relationship with alcohol consumption, drug use, aggressive behavior, and illegal conduct. To explain this finding, one can argue that adolescence is associated with the process of identity formation. A section of this growth process is risk- taking that appears in the form of unhealthy behaviors, including cigarettes smoking and the consumption of other substances (Ahmadi Tahour, Asgari & 86 Research on Addiction Quarterly Journal of Drug Abuse

Toghiri, 2013). In the meantime, the adolescents with a high degree of risk- taking are more likely to be exposed to abnormal behaviors. Similarly, according to the optimal level of arousal theory, risk-taking and sensation-seeking individuals need new and fresh experiences in order to reach the level of arousal and some of them may opt for substance abuse as a new experience. The need for making new experiences and escape from monotony in people with high risk- taking and sensation-seeking can be an effective factor in drug abuse (Zuckerman, 1994). The other section of the results showed that there is a significant difference between the students with and without addiction potential, and the mean score of distortion scores in students with addiction potential was higher than that in the peers without addiction potential. This finding is consistent with those of the studies carried out by Ahmadi Tahour & Najafi (2011), Haji-Alizadeh, Bahrainian, Nasiri & Modares Gharavi (2009), Miller, Adam, & Chrstianne (2013), Zainah, Rohany, Asmawati, Rozainee, & Fatimah (2014), and Hedayatfard & Mahboobeh (2015). Ahmadi Tahour & Najafi (2011) claimed that impaired cognitive beliefs act as an important psychological factor in the prediction of people's tendency to drug use. In the same way, Haji Alizadeh, Bahraini, Naziri & Modares Gharavi (2009) reported that there was a higher percentage of the individuals with cognitive distortions among substance abusers than healthy subjects. Miller, Adam, & Chrstianne (2013) indicated that the children who gained high scores in cognitive distortions were more susceptible to substance abuse. In addition, Zainah, Rohany, Asmawati, Rozainee, & Fatimah (2014) reported that the addicts with high scores in cognitive distortions had a lower tendency to treatment. Similarly, Hedayatfard & Mahboobeh (2015) showed that people with substance abuse obtained higher scores in cognitive distortions compared to normal people. To interpret this finding, one can argue that cognition is an important mediator in substance abuse. The existence of cognitive distortion disrupts self-regulation behaviors and induces various psychological consequences, such as stress, anxiety, and so on. In such a situation, the person takes on the use of the substance to extricate him/herself from this pressure. In this regard, distorted cognitive beliefs weaken coping skills, form cognitive (irrational fighting beliefs) and behavioral interactions (ineffective behaviors), and provide the grounds for substance use. Therefore, specific cognitive interventions as well as behavioral interventions can be useful and effective in counteracting the distorted beliefs, and it is possible to prevent the occurrence of addiction by equipping individuals with appropriate and effective cognitive strategies and skills. Since the individuals with cognitive distortions and risk-taking are prone to addiction, it is necessary to emphasize these psychological characteristics in educational and training programs of addiction prevention and treatment.

Samad Mashmool-Haji-Agha & Abbas Abolghasemi 87

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Adolescent Suicidal Ideation? Psychology of Violence, 3(4), 340–353. DOI: 10.1037/a0031355. Moore, S. (2000). A research agenda for adolescent risk- taking: where do we go from here? Journal of Adolescence, 23(3), 371- 376. Salimi, H., Gohari, S., Kermanshahi, F. & Javdan, M. (2015). Prediction of Addiction Potential Based on Family Process and Content Model in High School Students. Quarterly Journal of Research on Addiction, 9 (34), 53-63. Valentina, C., Luca, B., Mercedes, G., Francesca, D., & Sabrina M. (2015). Links between Psychotropic Substance Use and Sensation Seeking in a Prevalence Study: The Role of Some Features of Parenting Style in a Large Sample of Adolescents. Journal of Addiction, 14(1), 962-678. Wagner, M. K. (2001).Behavioral characteristics related to substance abuse and risk- taking, sensation seeking, anxiety sensitivity, and self-reinforcement. Addictive Behaviors, 26(3), 115-120. Weed, N. C. & Butcher, J. N. (1992). New measures for assessing alcohol and drug abuse with the MMPI-2: The APS and AAS. Journal of Personality Assessment, 58(2), 389- 404. Zadeh-Mohammadi, A., Ahmad Abadi, Z. & Heidari, M. (2011). Construction and Assessment of Psychometric Features of Iranian Adolescents Risk-Taking Scale, Iranian Journal of Psychiatry and Clinical Psychology, 17 (3), 218-225. Zainah, Z. A., Rohany, B., Asmawati, D., Rozainee, D., & Fatimah, Y. (2014). Family Functioning, Cognitive Distortion and Resilience among Clients under Treatment in Drug Rehabilitation Centers in Malaysia. Procedia -Social and Behavioral Sciences, 140(4), 150–154. Zargar, Y. (2006). Construction of Iranian Addiction Potential Scale. Second Congress of the Iranian Psychological Association, Tehran. Zuckerman, M. (1994). Behavioral expressions and biosocial bases of sensation seeking. Cambridge University Press, New York.

Addiction Prevention Abstract Components in the Objective: This study focuses on teachers' perspective about addiction Content of Thinking prevention elements in the content of the Thinking and Lifestyle book of the and Lifestyle Book of seventh grade in the academic year of 2013-2014. Method: This study is a Seventh Grade from descriptive survey with a sample of 74 Teachers' seventh-grade teachers who were selected by stratified random sampling Perspective method. A researcher-constructed questionnaire was the measurement instrument in this study that reviewed teachers' perceptions and expectations in Hajar Karimiyan, Taghi Zavar, Mosa seven elements. Results: The results Piri showed that teachers believed the highest attention has been paid to the emotion and stress management component about substance in the content of Thinking and Hajar Karimiyan Lifestyle book of the seventh grade. M.A. in Educational Psychology, Moreover, Freedman test results showed Department of Psychology, Azarbaijan that emotions and stress management had Shahid Madani University, Azarbaijan, the highest mean score and education Iran. about substance abuse had the lowest Taghi Zavar mean score. However, the results of Associate Professor, Department of paired t-test showed the existence of a Psychology, Azarbaijan Shahid Madani significant difference between teachers' University, Azarbaijan, Iran perceptions and expectations in addiction E-mail: [email protected] prevention elements and, thereby, it is Mosa Piri necessary to pay more attention to the Associate Professor, Department of components of addiction prevention. Psychology, Azarbaijan Shahid Madani Conclusion: Teachers' perspective about University, Azarbaijan, Iran addiction prevention elements in Thinking and Lifestyle book of the seventh grade is positive and it is important to pay attention to addiction prevention issues and life skills, such as Research on Addiction thinking skills and the integration of Quarterly Journal of Drug teaching materials in textbooks in Abuse different aspects. Presidency of the I. R. of Iran Key words: addiction prevention, book Drug Control Headquarters content, Thinking and Lifestyle Department for Research and Education

Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir/ 90 Research on Addiction Quarterly Journal of Drug Abuse

Introduction In recent decades, the world has witnessed shocking statistics about the prevalence of substance abuse, generally at the community level, especially in the teenage and young adult population (Ammari, Pashashrifi, Hashemian & Mirzamani, 2011). Meanwhile, adolescents' addiction to narcotic drugs has more serious consequences because the survival and development of any society hinges on the vitality, happiness, and active participation of adolescents in the future of the society. On the other hand, adolescents are in a critical situation due to rapid physical and mental changes and their emerging identity and, thereby, they are more sensitive to environmental inclinations and more at risk to drug addiction (Sarrami, Ghorbani & Minooi, 2013). The adolescents' tendency to drug use is one of the biggest concerns among parents. The average age of the onset of smoking in Iran has been reported to be 16.6 years and the highest age proportion of the onset of addiction (45.7) has been between the ages of 17 and 22 years. This is so while the early onset of drug use increases the higher consumption, more frequent use, and the use of more hazardous substances (Fathi & Fadavi, 2012). Adolescence is a critical period in life wherein inappropriate behavioral patterns start. Childhood and adolescent injuries have a relationship with drug abuse (Draucker, Claire Burke, & Mazurczyk, 2013). Poor self-efficacy provides the basis for substance abuse in students (Bruckner et al., 2013). Ibabe, Stein, Nyamathi, Bentler, & Peter (2013) conducted a study on the homeless in Los Angeles and California and showed that the history of injury and drug use as well as the history of chronic homelessness and psychological stress are predictors of substance abuse. In addition, there is a relationship between ineffective coping strategies and unsuitable problem-solving methods in addicts. Addicts use more inappropriate problem-solving methods, such as helplessness, inhibition, and avoidance, and they use constructive problem-solving methods, such as creativity, trust, and willingness to a lesser extent. People lacking social skills and having poor decision-making show the worst precociousness and highest rates of drug use (Bahrami, Mo'azedian, & Hosseini al-Madani, 2013). Moreover, antisocial and aggressive behaviors are the most important risk factors for substance use (Ammari et al., 2011), and the school students who feel incompetent turn to drug use to escape stress and problems and, finally, their vulnerability is more than their peers (Pourkord, Abolghasemi, Narimani & Jamalui, 2013). Numerous studies have shown that substance abuse disorder has an unfavorable prognosis and imposes tremendous direct and indirect medical costs on the family and society (Bahrami et al., 2013). The difficulty and high cost of treatments has directed the main focus towards primary prevention programs on drug abuse, especially at school level and among students (Mehri, Esmaeili, Rostami, & Torkashvand, 2012). The adolescents and young adults who turn to Hajar Karimiyan et al 91 addiction not only cannot be a constructive element for society anymore, but they will be neutral creatures in the best state, and will be the origin of social irregularities and anomalies at the worst sate until they can be extricated from addiction. The complications of substance abuse are irreparable in many cases and even the most effective treatment is likely to encounter relapse. In such a situation, it assumes high importance to logically replace prevention with treatment, and it is assumed that preventing people from becoming infected is more effective than the treatment of this disorder (Jamali & Ghorbani, 2008). In recent years, different approaches and techniques for the treatment of substance abuse and relapse prevention have received attentions, one of the most important of which was life-skills training on drug prevention. Through life- skills training, individuals can express assertion in the community and meet their need for respect inasmuch as the establishment of healthy and friendly relationships with peers and others (Herbert et al., 2005, Kopelowice, Liberman, & Zarate, 2006). Over the fifty years since the first prevention program, various strategies and plans have been introduced for the prevention of drug abuse (Botvin, Griffin, & Williams, 2001). One of the reasons for tendency toward drug use is the lack of young people's familiarity with life skills (Botvin & Griffin, 2004). Schools have always had a special place in the comprehensive education prevention plan (Jamali & Ghorbani, 2008). Nies, & Ma Ewen (2001) have found that school education is a major step in the early prevention of adolescent addiction. Ariza et al. (2013) also indicated that school-based programs are effective in reducing cannabis use. Faggiano et al. (2010) also found that school- based and student-oriented programs are effective in the reduction of smoking and drug use. Bruckner et al. (2013) analyzed the content of preventive school curricula in the United States with regard to the application of educational standards in these programs, and reported that public social and emotional skills have been used in primary schools for addiction prevention, and information- and knowledge-based programs on the consequences of drug use have been used in secondary schools for addiction prevention. Tahiri, Gashi, Lsmajli, & Muja (2012), Cuijpers (2002); Farmani, Mo'azedian, Hosseini al-Madani & Bahrami (2011); Taremian & Amir Houshang (2007); Younesi & Mohammadi (2006); Ghaderi Dehkordi (2000) have all pointed out that information is provided about the consequences of drug use and education on drugs at schools. Similarly, Matsumoto et al. (2011) examined the possible impact of intervention through self-teaching books on drug addicts and showed that the use of workbook increases their awareness of drug dependence problems and motivates them to be treated. Some scholars (Speath, Weichold, Rainer, & Wienser, 2010; Bahrami et al., 2013; and Refahi, 2008) believe that the most effective and most accessible programs among all preventive programs in schools are life and social skills training programs. These skills include decision-making and problem-solving, creative and critical thinking, ability to communicate effectively, interpersonal 92 Research on Addiction Quarterly Journal of Drug Abuse relationships, self-awareness and empathy, and emotional and stress management. These programs usually expand protective factors and reduce risk factors. Botvin's Life Skills Training Program (1998) was designed to prevent drug abuse, smoking, and alcohol drinking. This program is aimed at educating about substances, drugs and attitudes toward them, teaching resistance skills to social effects, and promoting and developing self-management skills and interpersonal skills. In their research, Turner (2008); Watson, Jeanne, & Gordon (2006); Botvin, Griffin, & Williams (2001); Botvin & Griffin (2004, 2005); Zollinger (2003); and Bahrami et al. (2013) showed that the teaching of decision- making and problem-solving skills is effective in the reduction of addiction. Drug prevention training in school curricula is one of the basic goals of education for bringing up a healthy and creative generation of the community. In order to make prevention programs effective, the way the content and gist of the plans are presented to students is of importance. It is important to focus on two important points in presenting the content of school drug addiction education: 1- Curriculum should lay their emphasis on life skills and social skills and the principles governing the curriculum should be observed. 2. It should be presented as an extracurricular program in the form of educationally attractive and appropriate programs to the children, adolescents, and young people's interests. In addition, the presentation of the content of educational addiction prevention programs in the curriculum of different school grades with the observance of horizontal and vertical cohesion is one of the structures of each proposed model for addiction prevention in schools (Jamali & Ghorbani, 2008). Since the textbook is considered to be the most basic source of learning in the educational system of our society and considering the educational position in changing misbehaviors in the positive direction and promoting the standards of living, it is imperative to include proper content in terms of primary addiction and abuse prevention in textbooks. Therefore, textbooks at different levels, especially the high school level, should be reviewed and evaluated. In this regard, in addition to the consideration of content by materials developers, teachers need to learn about drugs, substance abuse, and national programs on fighting against these problems to be informed and knowledgeable about the consequences of this phenomenon and find awareness, sensitivity, and appropriate attitudes to fight this problem. In this way, teachers will be able to gain the skills required for winning students' confidence and talking to them about the sensitive issues related to drug abuse. In the case of the non-assignment of attention to these points, it is possible that the inclusion of a specific subject in the curriculum does not have any positive result except a waste of time for teachers and students; therefore, it may lead to the development of a pessimistic attitude toward the national plan of fighting against drugs among the addresses (Mehriar & Jazayeri, 1998). Hence, it seems important and necessary to examine teachers' viewpoint as the implementers of education programs about the content of Thinking and Lifestyle Book in terms of the addiction prevention program. Hajar Karimiyan et al 93

The main research question in this research is formulated as follows: To what extent addiction prevention components have been assigned credit in the content of Thinking and Lifestyle Book from teachers' perspective? Method Population, sample, and sampling method This study is a descriptive survey and its statistical population included the number of 91 seventh-grade teachers in Miandoab and Shahin Dezh cities who taught Thinking and Lifestyle book in the academic year of 2013-2014. From among this population, 74 seventh-grade teachers were selected via stratified random sampling method based on Krejcie & Morgan table where 34 teachers (46%) were male and 40 teachers (54%) were female. The number of 10 (13.5%) teachers was in the age range of 23-30 years, 23 teachers (31.1%) were in the age range of 31-40 years, and 41 teachers (55.4%) were in the age range of 41 years and above. In addition, 23 subjects (31.1%) were Empirical Sciences teachers, 11 subjects (14.9%) were Educational Affairs teachers, 15 subjects (20.2%) were Educational Sciences teachers, 12 subjects (16.2%) were Persian Literature teachers, and 13 subjects (17.6%) were teachers of other subjects. The number of 17 teachers (23%) had a 1-10-year teaching experience, 16 (21.6%) had an 11-20-year teaching experience, and 41 (55.4%) had a 21-30-year teaching experience. In terms of education degree, four teachers (5.4%) had high school diplomas or associate's degrees, 65 teachers (8.87%) had bachelor's degrees, and 5 teachers (6.8%) had master's degrees. Instruments A 40-item researcher-constructed questionnaire was used in this study to review teachers' perceptions and expectations. The items were scored on a five-point Likert scale (very high, high, moderate, low, and very low). For the construction of this questionnaire and selection of the components and indicators of addiction prevention, theoretical and empirical background and relevant and accessible resources relating to the objectives of the Comprehensive Document for the Prevention of Addiction were used. After the determination of the initial components and items, the reliability and validity of the questionnaire were examined. In this way, the components and relevant items were submitted to curriculum development experts and educational psychologists in order to evaluate the content validity of the questionnaire; and their corrective comments were applied. The reliability of the questionnaire was obtained equal to 0.95 through Cronbach's alpha in the final administration. The construct validity was determined through exploratory factor analysis by principal component analysis and Varimax rotation. For the evaluation of the assumption of correlation between variables, Bartlett's test of Sphericity was used and the results indicates the presence of the required correlation (P < 0.001; Bartlett's test of Sphericity = 2.271; KMO = 0.822). 94 Research on Addiction Quarterly Journal of Drug Abuse

Principal component analysis was used to perform factor analysis. The initial results of this analysis showed 13 factors (components) with an eigenvalue higher than one, which explained 0.69 of the variance. Due to the loadings below 0.45, 16 items were excluded from the analysis. Once more, 21 items were eliminated as a result of the conduct of Varimax rotation in the factor analysis. This led to the final extraction of 7 factors (components) with 40 items, namely training about drugs (7 items), thinking skills (9 items), skills of success and coping with failure (8 items), communication skills (4 items), emotional management and coping with stress (4 items), assertiveness (4 items), and self- awareness and empathy (4 items). The following Cronbach's alpha coefficients were obtained for the components as: 0.92 for thinking skills, 0.90 for training about drugs, 0.88 for skills of success and coping with failure, 0.88 for communication skills, 0.87 for emotional management and coping with stress, 0.82 for assertiveness, and 0.76 for self-awareness and empathy. Results The descriptive statistics of the components of addiction prevention in the content of Thinking and Lifestyle textbook (the 7th school grade) and its comparison with the mean score (3) are presented in Table 1. Table 1: Descriptive statistics of components of addiction prevention in the content of Thinking and Lifestyle textbook Component Mean SD t Sig. Thinking skills 2.74 0.70 33.310 0.0005 Training about drugs 2.44 0.84 23.880 0.0005 Skills of success and coping with failure 3.15 0.66 40.260 0.0005 Communication skills (interpersonal 2.82 0.78 30.980 0.0005 relationships) Emotional and stress management 3.26 0.76 36.620 0.0005 Assertiveness 2.84 0.80 30.580 0.0005 Self-awareness and empathy 3.05 0.66 20.430 0.0005 Total 2.92 0.602 39.830 0.0005

As shown in Table 1, according to teachers' opinions, the highest mean score was related to emotional and stress management component and the lowest mean score belonged to training on drugs. For the comparison of the mean difference between teachers' perceptions and expectations, dependent t test was run and its results are presented in Table 2.

Hajar Karimiyan et al 95

Table 2: Dependent t test for the examination of the mean difference between teachers' perceptions and expectations about the components of addiction prevention in the content of Thinking and Lifestyle textbook Component Status Mean SD t Sig. Perceptions 2.74 0.70 Thinking skills 13.01 0.0005 Expectations 4.21 0.75 Perceptions 2.44 0.87 Training about drugs 14.60 0.0005 Expectations 4.26 0.72 Skills of success and coping with Perceptions 3.15 0.66 14.02 0.0005 failure Expectations 4.45 0.66 Communication skills (interpersonal Perceptions 2.82 0.78 10.14 0.0005 relationships) Expectations 4.09 0.79 Perceptions 3.26 0.76 Emotional and stress management 10.18 0.0005 Expectations 4.33 0.69 Perceptions 2.84 0.80 Assertiveness 10.85 0.0005 Expectations 4.16 0.81 Perceptions 3.05 0.66 Self-awareness and empathy 9.56 0.0005 Expectations 4.15 0.78

As it can be observed in Table 2, the mean score of perceptions is lower than that of expectations (P <0.001). Friedman test was used to rank the components and the results are presented in Table 3. Table 3: Ranking of addiction prevention components based on Friedman test No. Component Mean of ranks Ranking 1 Thinking skills 3.54 6 2 Training about drugs 2.91 7 3 Skills of success and coping with failure 4.75 2 4 Communication skills (interpersonal relationships) 3.63 5 5 Emotional and stress management 4.93 1 6 Assertiveness 3.88 4 7 Self-awareness and empathy 4.36 3

Discussion and Conclusion The aim of this study was to investigate teachers' viewpoint regarding the importance of the content of Thinking and Lifestyle textbook (the seventh school grade) in components of drug addiction prevention. The findings showed that the mean scores of components of addiction prevention (thinking skills, training about drugs, skills of success and coping with failure, communication skills (interpersonal relationships), emotional and stress management, assertiveness, empathy and self-awareness) were significant with the mean score; and this reflects the attention of Thinking and Lifestyle textbook to the components of addiction potential from teachers' viewpoint. Since the mean score of emotional and stress management component is higher, this component has received teachers' attention more than the other components in Thinking and Lifestyle textbook. On the other hand, training about drugs component has taken up the lowest mean score from teachers' perspective. In addition, from teachers' 96 Research on Addiction Quarterly Journal of Drug Abuse viewpoint, the thinking skills component has also received little attention. To explain this finding, it can be argued that the consumption and abuse of drugs are among the most risky behaviors during childbirth, adolescence, and youth (Rutter, 2002; Weinberg et al., 2002; cited in Babapour Khairuddin, Dardashzadeh & Tusi, 2011). Therefore, considering the personal and social problems caused by students' low level of awareness and drug addiction disadvantages, educational programs and curricula as well as the contents of textbooks related to this issue should provide students with sufficient information. The use of other countries' experiences and programs, such as school-based programs with emphasis on students (Ariza et al., 2013) and the use of general and emotional skills for addiction prevention (Faggiano et al., 2010) can be effective in informing students about disadvantages of drug use and reduction of substance consumption. The findings indicated that there is a significant difference between the two states of perceptions and expectations in the component of drug addiction. The results of Friedman test showed that the component of emotional and stress management had the highest and the component of training about drugs had the lowest mean rankings. The findings of this study are consistent with those of the studies carried out by Ariza et al. (2013), Huang et al. (2012), Speath, Weichold, Rainer, & Wienser (2010), Faggiano et al. (2009), Turner (2008), Botvin, & Griffin (2004), Zollinger (2003), Boyd (1991), Bagheri & Bahrami (2003). These authors reported that life-skills education can be founded upon substance abuse preventive behaviors. On the other hand, the obtained results are to some extent consistent with those of the studies conducted by Bruckner et al. (2013), Tahiri (2012), Matsu Motto (2011), Cuijpers (2002), Farmani et al (2011), Younesi & Mohammadi (2006). These researchers have shown that what is happening nowadays in high schools about drug addiction prevention is to get information about the consequences of drugs and teach about drugs. In addition, it should be taught about the losses of drug use, smoking, and alcohol drinking tailored to the education level and other curriculum contexts at all levels of education. Considering research findings and the review of the research on addiction prevention, one can say that the training of decision-making and problem- solving skills to students helps them choose the best possible decision and solution in dealing with problems since these skills are among the thinking skills and effective factors in addiction prevention. However, in the content of the book, thinking skills are the second component after training about drugs that has not received enough attention. This is so while the teaching of thinking and decision-making skills has a positive effect on decreasing addicted people's attitude toward the risks of narcotic drugs and tendency to drug use (Bahrami et al., 2013). Turner (2008), Watson et al. (2006), Botvin & Griffin (2005), Marilyn (2005), Zollinger (2003), and Bahrami et al. (2013) showed that decision- making and problem-solving skills and, consequently, thinking skills are the Hajar Karimiyan et al 97 effective components in prevention. Hence, school curricula should prepare students to identify problems and pertaining solutions by creating appropriate educational opportunities. Therefore, the inclusion of the topics of addiction prevention and life skills, including thinking skills and training about drugs in textbooks can be important in many ways because the inclusion of these materials in the textbooks leads to students' familiarity with this social problem. In addition, life skills training is effective in changing attitudes and increasing learners' awareness about the complications of drug abuse. It is suggested that the components of addiction prevention, especially thinking skills and training about drugs be assigned more credit in Thinking and Lifestyle textbook (the seventh school grade). Teachers, as principal implementers of school curriculum, are also recommended to acquire the required training on the methods and foundations of drug prevention. Moreover, other methods, especially the content analysis technique, are suggested to be used in future research on addiction prevention in order to study and analyze the content of the mentioned book regarding the assignment of attention to the components of drug addiction prevention. References Ammari, H., Pashashrifi, H., Hashemian, K. & Mirzamani, M. (2011). Reviewing the Impact of Addiction Prevention Program (Cheer) on Hazardous Behavior (Behavior anomaly and comparative behavior anomaly) of Juvenile Prone to Drugs Abuse Hazard. Journal of Social Studies, 7 (26), 61-86. Ariza, C., Pereza, A., Sanchez, F., Diegueza, M., Espelta, A., Pasarin, L., …, Nebota, M. (2013). Evaluation of the effectiveness of a school-based cannabis prevention program. Journal of Drug and Alcohol Dependence, 132, 257-264. Babapour Khairuddin, J., Dardashzadeh, R. & Tusi, F. (2011). Comparison of brain - behavioral systems between smokers and non-smokers. 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Abstract The Rate of Addiction Objective: The present research aims Prevalence in at examining the prevalence of addiction in industrial environments in Industrial 2013 in Isfahan where demographic characteristics such as age, gender, Environments education, employment information, and history of addiction were examined in addition to the determination of the prevalence of addiction regarding the type of drug (industrial or conventional). Method: For this purpose, the number of 163 staffs in industrial environments in Isfahan was selected as the research participants Kourosh Mohammadi, Ali Asgari through multistage cluster sampling method. Results: The results of this study showed that 25.1% of staffs working in industrial environments were addicted to drugs where 9.6% were addicted to industrial drugs and the rest (15.5%) were addicted to the conventional ones. In addition, the Kourosh Mohammadi findings revealed that 13.8% of the Ph.D. Student in Educational Psychology, staffs were addicted to alcohol and University of Semnan, Semnan, Iran, E- mail: [email protected] 61% were addicted to smoking cigarette and hookah. Conclusion: The Ali Asgari findings of this research suggest that Assistant Professor, Department of staffs' addiction can be predicted by Psychology, University of Kharazmi, some environmental and socio- Karaj, Iran economic factors, such as low wages, inattention to staffs' welfare, and discrimination and negligence in industrial environments. The most frequently used drug was crystal compared to other substances where this finding can be an alarming call for industries due to the effects of this Research on Addiction substance. Quarterly Journal of Drug Keywords: prevalence, addiction, Abuse industrial drugs, conventional drugs Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir 102 Research on Addiction Quarterly Journal of Drug Abuse

Introduction The phenomenon of drug addiction has long been considered as a national problem in Iran and its adverse effects have been shown in all aspects of the social life in each community. In recent years, addiction has taken up widespread and overwhelming dimensions in the economic field and has left harmful and irreversible effects. The main target audience of the drug mafia has been the active youth of the country and Iranian families and their orientation toward conventional drugs however, today, one of the main target groups in the narcotics mafias in Iran is the production and labor force sector. Due to this stratum's vulnerability in terms of fatigue and labor pressure, new drugs with industrial and conventional varieties and with advertising labels commensurate with the conditions of this active population of the community have entered the industrial and manufacturing market in Iran. Some studies, including the one conducted by Walsh, Bowman, Tzelepis, & Lecathelinais (1993) account for the employees' conditions and their surrounding factors in work environments, especially in hard work and physical conditions that have been used in recent years by drug mafias in the world and have facilitated tendencies toward drug addiction. In recent years, the studies done by the World Labor Organization have shown that drug users' absenteeism in the workplace is two to three times higher than that of other employees. Drug dependent people seek medical treatment expenses 3 times more than other employees, and claim compensation 5 times more than other employees. In work environments, between 25% and 30% of work accidents are affected by drug use. Substance abuse accounts for 50% of the whole decline in the production rate of factories. Substance abusers experience incidents outside the workplace 12 times more than other employees. Addicts allocate less than 60% of their ability to work (Taheri Nakhost, 2012). The issue of addiction prevalence in industrial environments should be considered as a basic necessity at the forefront of planning and decision-making community before having to describe the conditions that indicate an increase in addiction in industrial environments, a severe decline in productivity and production, and the halt of the growth and fluctuation of the country's economy. Therefore, today, it is imperative that all the responsible authorities of the country, especially Drug Control Headquarters should immediately enter into action in the area of planning and preventive measures. Since the need for the conduct of an effective program in the field of addiction in industrial environments is the existence of basic information and statistics about the status quo, it is necessary to conduct extensive studies in order to provide the appropriate conditions for the explanation of precise statistics on the prevalence of addiction in industrial environments. In 1964, the World Health Organization concluded that the term "addiction" was no longer a scientific term and implied a humiliating sense and, thus, this Organization replaced the term "drug dependency" for it. Essentially, two Kourosh Mohammadi & Ali Asgari 103 concepts of "physical dependency" and "psychological dependency" are used to define different aspects of narcotic drug dependency and other substances (Mohammadi, 2008). The term "prevalence" refers to all diagnosed cases (old and new) in a particular time period or in a given period in a population. The wider definition of prevalence or abundance is the sum of all individuals who experience a condition or disease at a given time (or at a certain time), divided by the population at risk for catching the disease or condition at that time or in the middle of a period of time. Although prevalence is expressed as percentage, it is actually the prevalence of a ratio (John, 1999). Most drug users are the employed adults while the majority of them have not experienced drug use in adolescence. Although addiction rates are higher among special populations (such as offenders and unemployed people), prevalence data indicate that 70% of today's users (over the past 30 days) were from 18 to 49 years of age who were working full time. In addition, 7.7% of full-time employees are drug users. These statistics show that most consumers should be sought for in the workplace not in schools or streets. There is much evidence that drug use is associated with accidents, absenteeism, and reduced productivity. Although the nature of this relationship is not clear and it is not possible to precisely claim that there is a causal relationship between substance use and such issues, researchers have shown that drug use among staff is associated with increased absenteeism and losses (Kandel & Yamaguchi, 1985; Lehman & Dixon, 1995). Similarly, the use of illicit drugs is associated with an increased risk of accidents and injuries and, finally, drug use is associated with increasing costs of treatment and the higher use of social security facilities (Polak et al., 1998). The workers who use alcohol and drugs often hide their problems. Fear and denial are the biggest barriers to finding help from others. The employer's responsibility is performance control rather than the clinical diagnosis of alcohol or substance use. The employer must report any retrogression in workers' performance in specified time periods. When a persistent and repetitive pattern of work deficiency is observed, it can be indicative of substance use, and it is logical that this issue be taken into consideration (Soltani et al., 2010). Regarding the role of this problem in job performance, this study attempts to extract the latest available information about addiction prevalence in industrial environments in Isfahan province in terms of the type of substance and other demographic features. Method Population, sample, and sampling method A descriptive research method was used in this study to measure addiction prevalence in industrial environments of Isfahan province. All employees in the industrial environments of Isfahan province constituted the statistical population of this study. Through multistage cluster sampling method, 1163 individuals were randomly selected as the sample units. The measurement tool used in this

104 Research on Addiction Quarterly Journal of Drug Abuse study was a Drug Prevalence Questionnaire that has been developed by the Drug Control Headquarters and its initial form has been used by Yaghubi, Taremian, Peirovi, & Zafar (2012) in a research entitled "The prevalence of drug use among university students at the Ministry of Science". Results The descriptive statistics of drug use prevalence are presented in Table 1. For the ease of diagnosis and differentiation, different drugs have been classified in terms of the type of effect in total classes, including narcotics and alcoholic beverages. The narcotic class also includes three subcategories of "lethargic" substances, such as opium and its derivatives, heroin, sedative medicines (neophene and norgesic) and heroin crack; "hallucinative" substances such as cannabis and other derivatives of cannabis (marijuana, grass), and LSD; and "stimulants", such as crystal and ecstasy, as well as alcoholic beverages, including vodka, beer, handmade sweets, and wine. Table 1: Frequency of the classified substance use prevalence (based on their effectiveness type) among employees in industrial environments Percentage of Total class Class based on the effect type N. Percentage total class Lethargic substances 137 11.8 Opiates Hallucinogenic substances 51 4.4 25.1 Stimulants 104 8.9 Alcoholic drinks Psychotropic substances 161 13.8 13.8

The results also showed that the use of conventional drugs with 15.5% had a higher frequency than the use of industrial drugs with the frequency of 9.6%. The descriptive statistics of drug use prevalence in terms of drug use are presented in Table 2. Table 2: Prevalence of drug use among industrial workers in terms of persistence of use Substance Substance type Frequency Percentage Frequency Percentage type Opium 94 8.08 Opium sap 3 0.26 Heroin 14 1.2 Opium extract 18 1.5 Crystal 95 8.2 Marijuana 16 1.38 Crack 3 0.26 Hashish 20 1.72 Ecstasy 9 0.77 Hemp 13 1.1 Norgesic 2 0.17 Grass 2 0.17 Buprenorphine 3 0.26 Total 292 25.1

The descriptive statistics of prevalence of drug use based on gender are presented in Table 3.

Kourosh Mohammadi & Ali Asgari 105

Table 3: Prevalence of drug use among industrial workers in terms of substance type and gender

type

Gender Gender

Substance

Frequency Percentage Frequency Percentage

Substance type Female 6 6.4 Female 0 0 Opium Male 88 93.6 Crack Male 3 100 Total 94 8.08 Total 3 0.26 Female 1 7.2 Female 0 0 Heroin Male 13 92.8 Ecstasy Male 9 100 Total 14 1.2 Total 9 0.77 Female 2 2.1 Female 0 0 Crystal Male 93 97.9 Norgesic Male 2 100 Total 95 8.2 Total 2 0.17 Female 0 0 Female 0 0 Opium Male 3 100 Buprenorphine Male 3 100 sap Total 3 0.26 Total 3 0.26 Female 2 11.1 Female 0 0 Extract Male 16 88.9 Marijuana Male 16 100 Total 18 1.5 Total 16 1.38 Female 1 5 Female 0 0 Hashish Male 19 95 Hemp Male 13 100 Total 20 1.72 Total 13 1.1 Female 0 0 Female 5 3.1 Alcoholic Grass Male 2 100 Male 156 96.9 drinks Total 2 0.17 Total 161 13.84

The descriptive statistics of prevalence of drug use based on marital status and substance type are presented in Table 4. Table 4: Prevalence of drug use among industrial workers in terms of substance type and marital status Single Married Divorced Widow

Substance type Chi-square Sig.

N N N N

Percentage Percentage Percentage Percentage

Conventional 56 4.8 83 7.1 26 2.2 15 1.3 6.63 0.08 drugs Industrial drugs 48 4.1 37 3.2 20 1.7 7 0.60 5.71 0.12 Alcoholic drinks 78 6.7 61 5.24 19 1.6 3 0.26 2.8 0.41

The descriptive statistics of prevalence of drug use based on employment and substance type are presented in Table 5.

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Table 5: Prevalence of drug use among industrial workers in terms of substance type and employment status Official Temperate Contractual Hour- Daily work Seasonal based work Substance

type

N N N N N N

Percentage Percentage Percentage Percentage Percentage Percentage Opium 33 2.8 19 1.6 30 2.6 0 0 8 0.7 4 0.34 Heroin 8 0.7 2 0.18 4 0.34 0 0 0 0 0 0 Crystal 11 0.95 30 2.6 48 4.1 0 0 6 0.51 0 0 Crack 0 0 1 0.08 2 0.18 0 0 0 0 0 0 Ecstasy 2 0.18 3 0.26 4 0.34 0 0 0 0 0 0 Norgesic 0 0 1 0.08 1 0.08 0 0 0 0 0 0 Buprenorp 0 0 0 0 3 0.26 0 0 0 0 0 0 hine Opium sap 0 0 1 0.08 2 0.18 0 0 0 0 0 0 Extract 2 0.18 5 0.43 9 0.77 0 0 2 0.18 0 0 Marijuana 3 0.26 5 0.43 8 0.7 0 0 0 0 0 0 Hashish 3 0.26 2 0.18 15 1.3 0 0 0 0 0 0 Hemp 1 0.08 0 0 8 0.7 0 0 3 0.26 1 0.08 Grass 1 0.08 1 0.08 0 0 0 0 0 0 0 0 Alcoholic 64 5.5 63 5.4 23 2 0 0 9 0.77 2 0.18 drinks

The descriptive statistics of prevalence of drug use based on residential place and substance type are presented in Table 6. Table 6: Prevalence of drug use among industrial workers in terms of substance type and residential place City Suburb Village Substance type N Percentage N Percentage N Percentage Opium 21 1.8 51 4.4 22 1.9 Heroin 2 0.18 12 1.03 0 0 Crystal 55 4.73 34 2.9 6 0.51 Crack 2 0.18 1 0.08 0 0 Ecstasy 6 0.51 3 0.26 0 0 Norgesic 2 0.18 0 0 0 0 Buprenorphine 3 0.26 0 0 0 0 Opium sap 2 0.18 1 0.08 0 0 Extract 8 0.7 8 0.7 2 0.18 Marijuana 2 0.18 2 0.18 12 1.03 Hashish 12 1.03 5 0.43 3 0.26 Hemp 8 0.7 4 0.34 1 0.08 Grass 2 0.18 0 0 0 0 Alcoholic drinks 81 7 46 4 34 2.9

The descriptive statistics of prevalence of drug use based on age group and substance type are presented in Table 7.

Kourosh Mohammadi & Ali Asgari 107

Table 7: Prevalence of drug use among industrial workers in terms of substance type and age group Under 15 15-19 20-25 26-30 31-35 Above 35 years years years years years years

Substance type

N N N N N N

Percentage Percentage Percentage Percentage Percentage Percentage Opium 8 0.7 4 0.34 3 0.26 30 2.6 30 2.6 19 1.6 Heroin 0 0 2 0.18 5 0.43 2 0.18 4 0.34 1 0.08 Crystal 7 0.60 25 2.1 6 0.51 15 1.3 30 2.6 12 1.03 Crack 0 0 1 0.08 2 0.18 0 0 0 0 0 0 Ecstasy 0 0 4 0.34 1 0.08 1 0.08 2 0.18 1 0.08 Norgesic 0 0 1 0.08 0 0 0 0 1 0.08 0 0 Buprenorphine 0 0 0 0 1 0.08 1 0.08 1 0.08 0 0 Opium sap 0 0 2 0.18 0 0 1 0.08 0 0 0 0 Extract 1 0.08 4 0.34 4 0.34 5 0.43 3 0.26 1 0.08 Marijuana 3 0.26 2 0.18 1 0.08 2 0.18 2 0.18 5 0.43 Hashish 3 0.26 1 0.08 12 1.03 3 0.26 1 0.08 0 0 Hemp 1 0.08 0 0 8 0.7 0 0 3 0.26 1 0.08 Grass 0 0 0 0 1 0.08 0 0 1 0.08 0 0 Alcoholic 12 1.03 33 2.8 38 3.3 19 1.6 37 3.2 22 1.9 drinks

The descriptive statistics of prevalence of drug use based on education level and substance type are presented in Table 8.

Table 8: Prevalence of drug use among industrial workers in terms of substance type and education Primary Seconda High Associate's Bachelor Master's Illiterate Literate Ph.D. school ry school school degree 's degree degree

Substance type

N N N N N N N N N

Percentage Percentage Percentage Percentage Percentage Percentage Percentage Percentage Percentage O pium 4 0.34 5 0.43 25 2.1 26 2.2 19 1.6 4 0.34 8 0.7 2 0.18 1 0.08 Heroin 1 0.08 2 0.18 1 0.08 5 0.43 2 0.18 2 0.18 0 0 0 0 0 0 Crystal 2 0.18 3 0.26 14 1.2 24 2.06 38 3.3 7 0.60 4 0.34 3 0.26 0 0 Crack 0 0 0 0 2 0.18 1 0.08 0 0 0 0 0 0 0 0 0 0 Ecstasy 0 0 0 0 0 0 1 0.08 4 0.34 1 0.08 2 0.18 1 0.08 0 0 Norgesic 0 0 0 0 0 0 1 0.08 1 0.08 0 0 0 0 0 0 0 0 Buprenorp 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0.18 1 0.08 hine O pium sap 0 0 0 0 0 0 1 0.08 2 0.18 0 0 0 0 0 0 0 0 Extract 0 0 1 0.08 3 0.26 5 0.43 7 0.6 1 0.08 1 0.08 0 0 0 0 Marijuana 0 0 0 0 1 0.08 2 0.18 5 0.43 3 0.26 3 0.26 2 0.18 0 0 Hashish 1 0.08 3 0.26 6 0.51 4 0.34 3 0.26 0 0 2 0.18 1 0.08 0 0 Hemp 0 0 0 0 2 0.18 1 0.08 9 0.77 1 0.08 0 0 0 0 0 0 Grass 0 0 0 0 0 0 1 0.08 0 0 1 0.08 0 0 0 0 0 0 Alcoholic 7 0.6 13 1.1 24 2.06 17 1.5 34 2.9 27 2.3 6 0.51 25 2.1 8 0.7 drinks The descriptive statistics of industrial workers' attitudes to the factors effective in addiction prevalence are presented in Table 9.

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Table 9: Descriptive statistics of industrial workers' attitudes to the factors effective in addiction prevalence Very Low High Very low high

Factors

N N N N

Percentage Percentage Percentage Percentage Expansion of facilities for employees 69 5.9 99 8.5 342 29.4 636 54.7 Expansion of joyful sports facilities for 53 4.6 100 8.6 353 30.4 640 55 employees Education and information on the dangers of 45 3.9 71 6.1 296 25.5 731 62.9 addictive substances Increased control over the distribution and consumption of substances in industrial 4 14.9 138 11.9 355 30.5 478 41.1 environments Establishment and strengthening of 59 5.1 148 12.7 347 29.8 587 50.5 counseling units in industrial environments Increased employee wage and benefits 67 5.8 234 20.1 277 23.8 560 48.2 Creation of a suitable opportunity to raise 138 11.9 303 26.1 381 32.8 312 26.8 the staffs' level of education Elimination of discrimination and injustice 55 4.7 279 24 406 34.9 401 34.5 in dealing with employees Creation of job security for employees 68 5.8 241 20.7 429 36.9 403 34.7 Addressing staffs' physical and mental status 52 4.5 140 12 411 35.3 543 46.7 Establishment of life insurance, health care 258 22.2 279 24 252 21.7 351 30.2 and seniority for employees

For the prediction of the use of conventional substances by 20 risk and protective factors, logistic regression analysis was used, and the pertaining results are presented in Table 10. Table 10: Logistic regression analysis results on predicting the use of conventional substances among industrial workers EXP(B) Predictors β Standard Wald Sig. (Superiority error test ratio) Low wage -0.217 0.263 0.678 0.410 0.805 High wage -0.102 0.313 0.106 0.744 0.903 Easy access to drugs 0.402 0.478 0.710 0.399 1.495 Low price of drugs -0.469 0.415 1.276 0.259 0.626 Fellow addict* 0.513 0.275 3.462 0.05 1.670 An addicted member in the family* -0.026 0.248 2.121 0.0005 0.970 Low education 0.087 0.286 0.092 0.762 1.091 Lack of knowledge about drug 0.195 0.335 0.339 0.560 1.216 complications Fatigue caused by high workload* -0.189 0.414 2.543 0.03 0.828 Lack of welfare facilities* -0.265 0.413 3.127 0.0005 0.767 Discrimination -0.282 0.412 0.469 0.494 0.754 Euphoria -0.331 0.312 1.125 0.289 0.718 Technical work pressure* 0.166 0.427 2.234 0.0005 1.181 Depression, sadness, and worries* -0.310 0.344 1.787 0.02 0.734 Kourosh Mohammadi & Ali Asgari 109

Table 10: Logistic regression analysis results on predicting the use of conventional substances among industrial workers (B) Standard Wald EXP Predictors β Sig. (Superiority error test ratio) Physical illness* 0.235 0.311 2.756 0.0005 1.265 Family disputes* 0.284 0.286 3.895 0.03 1.328 The need for vigilance at work or -0.018 0.382 0.006 0.962 0.972 awakening at night Sexual impotence* 0.386 0.381 3.025 0.0005 1.471 Lack of job security -0.178 0.374 0.227 0.634 0.837 Lack of insurance 0.206 0.343 0.360 0.549 1.228

As it has been shown in Table 10, the Wald statistic shows that eight predictive variables are significant in predicting conventional substance use. These eight variables include "the presence of a fellow addict", "the presence of addicts in the family", "fatigue caused by high workload", "lack of welfare facilities", "technical work pressure", "depression, sadness, and worries", "physical illnesses", "family disputes", and "sexual impotence". To predict the use of industrial substances by means of 20 risk and protective factors, logistic regression was used and the results are presented in Table 11. Table 11: Logistic regression analysis results on predicting the use of industrial substances among industrial workers EXP(B) Standard Wald Predictors β Sig. (Superiority error test ratio) Low wage* -0.414 0.267 2.411 0.01 0.661 High wage* 0.119 0.255 0.218 0.641 1.126 Easy access to drugs* -0.157 0.488 3.104 0.00 0.854 Low price of drugs 1.141 0.481 5.635 0.01 3.129 Fellow addict -0.135 0.212 0.409 0.523 0.874 An addicted member in the family -0.236 0.220 1.154 0.283 0.798 Low education 0.116 0.242 0.230 0.632 1.123 Lack of knowledge about drug complications* 0.893 0.329 7.370 0.00 2.443 Fatigue caused by high workload -0.471 0.422 1.245 0.265 0.624 Lack of welfare facilities* 0.838 0.406 4.263 0.03 2.312 Discrimination* -0.186 0.359 16.268 0.04 0.830 Euphoria -0.059 0.323 0.033 0.855 0.943 Technical work pressure 0.301 0.488 0.381 0.537 1.351 Depression, sadness, and worries* 0.883 0.329 7.191 0.00 2.418 Physical illness* -0.875 0.337 6.738 0.00 0.417 Family disputes -0.703 0.244 0.089 0.766 0.930 The need for vigilance at work or -0.390 0.386 1.022 0.312 0.677 awakening at night Sexual impotence -0.136 0.281 0.233 0.629 0.873 Lack of job security* 0.467 0.369 1.604 0.02 1.595 Lack of insurance -0.308 0.310 0.015 0.902 0.963

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As it has been shown in Table 11, the Wald statistic shows that nine predictive variables are significant in predicting industrial substance use. These nine variables include "low wage", "easy access to substances", "low price of drugs", "lack of knowledge about drug complications", "lack of welfare facilities", "discrimination", "depression, sadness, and worries", "physical illnesses", and "lack of job security ". Discussion and Conclusion From among the total 1163 research samples, 15.5% were addicted to conventional drugs and 9.6% were addicted to industrial drugs. A total of 25.1% of industrial workers suffer drug addiction. Due to the sensitivity of industrial activities and occupations, the existence of these statistics can be a serious warning to the country's industrialists that a significant number of their active forces face abnormal levels of consciousness. Some industrial substances, such as ecstasy and semi-industrial substances, such as crack heroin have faced a dramatic drop in consumption compared with the previous research findings. On the other hand, the industrial substance of crystal has faced an increasing growth, and it seems to be due to some reasons, such as easy access, low price, and ease of use of crystal. This substance has the highest frequency of consumption, which is a serious danger. However, in comparison with conventional drugs, the results showed that the prevalence of industrial substances in industrial environments was far lower than the prevalence of use of conventional drugs. To explain this finding, one can argue that the prevalent industrial narcotics in Iran are very limited at present and, therefore, industrial narcotics show fewer statistics in comparison with the prevalence of conventional substances that are more diverse and more varied. These results can be attributed to the imbalance between the two groups of industrial and conventional substances in terms of the number and variety of prevalent substances. In addition, from the total of 1163 research samples, the highest frequency of drug use in industrial environments respectively pertained to crystal with8.2%, opium with 8.08%, hashish with 1.72%, opium extract with 1.5%, marijuana with 1.38%, and heroin with 1.2% regardless of the classification and type of effect. On the other hand, the lowest consumption frequency in industrial environments was revealed to respectively belong to cocaine, LSD, rice tablet with zero percent, although substances such as grass with 0.17% are categorized in substances low levels of consumption. These results were obtained while the use of such substances as ecstasy with 0.77% are still in the second rank of industrial materials used by industrial workers. According to these results, it can be claimed that crystal is at the top of the list of consumed substances, and the increasing trend of consumption of this hazardous substance can lead to a permanent change in patterns of consumption towards industrial and hazardous substances such as crystal. Similarly, regardless of the classification of substances, it should be noted that alcoholic Kourosh Mohammadi & Ali Asgari 111 addiction is at the apex of all hazardous substances with 13.44% of frequency of use. The results also showed that unmarried individuals tend to use industrial substances because the percentage of the use of industrial substances in this group is more than that of conventional substances. However, married people are more addicted to conventional substances. It seems that marital status is related to the pattern of drug use in industrial settings. According to these results, divorced people or those who have lost their spouses were reported to have the highest frequency of using conventional substances and alcoholic drinks. In addition, the results of this study showed that the highest frequency of taking opium, heroin, crystal, and hashish in industrial environments pertained to employees with secondary school and high school education, and the lowest frequency of consumption pertained to the employees with master's and doctoral education. In other words, an increase in the level of education has reduced the level of substance consumption. The highest consumption frequency of crystal and ecstasy is also observed among the employee with high school education (38% for crystal and 34% for ecstasy), but alcohol consumption is prevalent in almost all educational levels. This result means that knowledge and awareness can play an effective role in the prevalence or non-prevalence of addiction in industrial environments. The highest frequency of taking narcotics and alcoholic drinks belongs to the employees who live in cities and in the suburbs. In this regard, the highest frequency consumption of conventional and industrial drugs pertains to the individuals living in the suburbs. It seems that the increasing trend of immigration to the suburbs of big cities is a major contributor to the prevalence of addiction. However, the results of this study showed there is a significant difference between two genders in terms of drug use in industrial environments. In all types of substances, men were revealed to be more prevalent users than women with a high percentage difference (above 97%). But it is noteworthy that industrial environments are essentially male-oriented and the low percentage of women's drug consumption in this study cannot be regarded as a criterion for other researchers. Alcohol drinking, hashish, opium, crystal, opium extract, marijuana, and hemp have been experienced for the first time by a small percentage of industrial workers under the age of 15 years. However, the age over 20 years was the time when drug and alcohol consumption had been experienced. The results also showed that most industrial substances, such as crystal and ecstasy have been experienced in the age range of 15 to 19 years. From among the 20 factors that were included in the questionnaires presented to the participants, almost all factors, including the ones pertaining to the employees' level of income and wage, facilities and welfare services, easy access to substances, low cost of substances, difficult work conditions in industrial environments, etc. are among the predictors of the prevalence of drug addiction in industrial environments. Of course, it should not be forgotten that none of these factors alone can predict addiction; however, the combination and

112 Research on Addiction Quarterly Journal of Drug Abuse proximity of these factors together can be a serious warning to the field of industry management that makes them pay serious attention to the employees' key requirements and needs in planning the management of industrial units. The highest levels of opium and heroin consumption, as well as alcoholic drinks were reported to have been experienced by official personnel, whereas the most frequent use of crystal and ecstasy was reported to have been experienced by contractual staff. Moreover, the lowest levels of consumption in all substances belonged to seasonal staffs. According to the results of this research, employers and the authorities of the large industrial centers are suggested to avoid the employment of repression methods and expulsion and punitive mechanisms for addicted staffs in order to strengthen the employees' morale working in industrial environments and to motivate and create self-reliance in them. They are recommended to establish a continuous and persistent educational and counseling unit in all large and medium industrial units for training about the complications of industrial drugs and for teaching the preventive skills. It is also suggested that the "Committee on Prevention of Drug Addiction in Industrial Environments" with the centrality of Drug Control Headquarters be established in the permanent presence of entities and representatives of employers and workers at the national and provincial levels, and all issues related to workers' problems and addiction status in these centers be continuously monitored. In this way, the necessary decisions to be implemented in industrial environments will be made independently. Under the guidance and supervision of the Drug Control Headquarters, addiction prevention units in all organizations of the mining and commerce industry should be established in order to whet the sensitivity of the custodial entities. In addition, many industrial workers suffer from communication problems in families. In this regard, it is suggested that short-term and cross-sectional family counseling programs be implemented individually and collectively in these settings. Considering the high rates of addiction prevalence in industrial settings, it is suggested that the Drug Control Headquarters arrange an educational short- term curriculum based on direct and face-to-face teaching methods. Such a program can act as an urgent sedative and the Ministry of Industry, Mine and Trade can provide necessary coordination to cover industrial centers. Reference Bolhari, J. (2003). Evaluation of drug abuse in prisons in Iran. Quarterly Journal of Research on Addiction, 1 (3), 13-20. Felner, R. D., Brand, S., Mulhall, K. E., Counter, B., Millman, J. B., & Fried, J. (1994). The parenting partnership: The evaluation of a human service/corporate workplace collaboration for the prevention of substance abuse and mental health problems, and the promotion of family and work adjustment, Journal of Primary Prevention, 15(2), 123–146. DOI: 10.1007/BF02197143. Kourosh Mohammadi & Ali Asgari 113

Hawkins, D. J., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other substance problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112(1), 64–105. John, M. (1999). Epidemiology Culture. Translated by Babak Boob, Tehran: Samat Publications. Kandel, D. B. (1996). The parental and peer contexts of adolescent deviance: An algebra of interpersonal influences. Journal of Drug Issues, 26, 289- 315. Kandel, D. B., & Yamaguchi, K. (1985). Developmental patterns of the use of legal, illegal and medically prescribed psychotropic drugs from adolescence to young adulthood. NIDA research monograph, 56, 193-235. Lehman, A., & Dixon, L. (1995). Double Jeopardy, Chronic Mental Illness and Substance Use Disorders. Harwood Academic Publishers, Switzerland. Maboodian, B. (2004). Alcoholism: Etiology, Related Disorders, and Therapeutic Approaches. Tehran: Ghalame Ashena Publication. Mohammadi, K. (2008). Narcotic Drugs and Addiction. Isfahan: Fine Arts. Polak, L., Turk, J. L., Frey, F. R. (1998). Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) study. Journal of American Medical Association, 264, 2511–2518. SAMHSA, CSAT, (1999). Substance Abuse in Brief: Effective Treatment Saves Money, Rockville, MD: SAMHSA CSAT. Soltani, I. (2010). Prevalence of addiction in employees of Mobarakeh Steel Company in Isfahan: a Case study. Library of Mobarakeh Steel Co. of Isfahan. Taheri Nakhost, H. (2012). Primary prevention of addiction with an emphasis on the work environment. Tehran: Drug Control Headquarters. UNODC (2002). The science of drug abuse epidemiology. New York: United Nations Publication. Walsh, R. A., Bowman, J. A., Tzelepis, F., & Lecathelinais, C. (2005). Smoking cessation interventions in Australian drug treatment agencies: A national survey of attitudes and practices. Drug and Alcohol Review, 24(3), 235–244. DOI: 10.1080/09595230500170282. Yaghoubi, N., Nasr Esfahani, M. & Shahmohammadi, D. (1995). Epidemiological Study of Mental Disorders in Urban and Rural Areas of Sowme'eh Sara, Gilan. Journal of Thought and Behavior in Clinical Psychology, 1 (4), 55-66. Yaghoubi, H., Taremian, F., Peirovi, H. & Zafar, M. (2012). The prevalence of drug use among university students at the Ministry of Science. Quarterly Journal of Research on Addiction, 8 (32), 9-36.

The Mediating Role of Abstract Objective: This study aimed to Psychological investigate the mediating role of Hardiness in the psychological hardiness in the relationship of religious orientation, Relationship of self-efficacy, and self-concept with Religious Orientation, tendency to addiction. Method: This study was a descriptive-correlational Self-Efficacy and Self- research. The research population included male bachelor's students of Concept with Razi University among whom 358 Addiction Tendency students were selected by multistage cluster sampling method. Allport's Religious Orientation scale, Scherrer's Self-Efficacy Questionnaire, Beck Self-Esteem Scale, Ahvaz Hardiness Inventory and Addiction Potential (APS) were used Fatemeh Jalilean-Kaseb, Mohsen for data collection purposes. Results: Hojat Khah, Alireza Rashidi The results indicated that self- efficacy, self-concept, and intrinsic religious orientation have a significant negative relationship with Fatemeh Jalilean-Kaseb tendency to addiction with the M.A. student of Family Therapy, Razi University, Kermanshah, Iran, mediating role of through E-mail: [email protected] psychological hardiness. Conclusion: Due to the impact of the research Mohsen Hojat Khah variables on tendency to addiction, Assistant Professor of Guidance and Counseling Department, Razi University, Kermanshah, Iran the results of this study can be used in practical programs in the field of Alireza Rashidi addiction prevention and treatment. Assistant Professor of Guidance and Counseling Department, Razi University, Kermanshah, Iran Keywords: religious orientation, self- efficacy, self-concept, psychological hardiness, tendency to addiction

Research on Addiction Quarterly Journal of Drug Abuse

Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir

116 Research on Addiction Quarterly Journal of Drug Abuse

Introduction One of the major problems in the current world of is addiction. It is possible to find an acceptable solution to prevent and overcome this global problem in spite of many efforts and heavy costs on combating it (Rezaei & Senobari, 2013). Addiction is a person's bondage to a substance or narcotic drug in which s/he will become psychologically and physically dependent upon that drug, his/her individual and social behaviors are disrupted, and the human community is harshly damaged (Asghari, Kordmirza, & Ahmadi, 2013). Drug addiction has been one of the most important health and social crises in the last decade. The fight against addiction requires the recognition of all its dimensions (economic, social, etc.); therefore, the recognition of addicts' personality and behavioral characteristics is of particular importance in order to combat, prevent, and treat addiction. Different studies have referred to such factors as personality traits and the powerful role of personality traits in interaction with other environmental factors as the effective factors in the onset and continuation of the problematic consumption of drugs (Dermody, Cheon, & Munuck, 2013). One of the personality variables that is related to substance use tendency is the person's attitude towards him/herself. In fact, self-concept is a person's image in relation to his/her whole being, which is reflected in a set of actions and behaviors and makes it possible to self-adapt in interaction with others and confront different situations (Cooper, & Pervin, 1998). Self-concept is the general assessment of the self where this assessment results from the individual's mental evaluations of his/her characteristics that may be positive or negative. Positive self-concept shows that one accepts him/herself as a person with strengths and weaknesses, and this increases his/her self-confidence in social relationships. Negative self- reflection reflects a sense of inferiority and disorientation as well as self-denial. According to Barnet, & Gotlib (1988), it is likely that negative life events emerge in people who do not have a high level of self-value; in this regard, research has shown that self-concept is the key to individual behaviors. In fact, this is the self- concept that provides the necessary motivations for the required actions and behaviors. Ghanbari Zarandi, Mohammadkhani & Hasheminesab (2016) reported that the individuals with high self-esteem affect the consumption of alcohol, cigarettes, and other substances through their self-control ability and social skills. The results of the research conducted by Foroo'odin & Sadr al-Sadat (2002) showed that there is a significant difference between addicts and non- addicts in terms of self-concept, and negative self-concept can be an effective factor in tendency to addiction. Self-efficacy is one of the other personality variables that is related to substance abuse. Self-efficacy, as a personality construct, refers to an individual's judgment about his/her ability to develop certain behaviors that have led to certain goals and are helpful in coping with stressful situations. Self- efficacy is one of the most important components of success and adaptation Fatemeh Jalilean-Kaseb et al 117

(Snyder, Lopez, & Shane, 2002). People who have high self-efficacy challenge difficult tasks rather than avoid them, have a high rate of commitment to their goals, experience relaxation rather than anxiety and fear when faced with a problem, their weakened trust recovers quickly after failure, trust their own solutions, and are also flexible (Bandura, 1993). Low self-esteem, low self- efficacy, and the lack of adaptive power to cope with day-to-day life events in women can be the starting point for drug addiction (Dehghan, Ghassemi, Safari, Ebrahimi, & Etemadi, 2013). Persons with low self-efficacy seem to be more likely to get addicted than those with high self-efficacy because of their poor spirits in solving their life problems and the doubt about their abilities in the face of stressful situations. According to Jalali & Ahadi (2015), low levels of self- efficacy are effective in juvenile tendency to substance abuse. Moreover, Asghari, Kordimirza & Ahmadi (2013); Bahadori & Khanjani (2013); Abolghasemi, Pourkord & Narimani (2009); Oraki (2010); and Tate et al. (2007) found that self-efficacy has a negative relationship with substance consumption tendency and the individuals with low self-efficacy have a higher tendency toward the use of narcotic drugs. Religious beliefs is one of the other factors that can play an important role in the lack of addiction tendency in youth. Regarding the role of religious beliefs and their dominance over human life aspects, religious beliefs can have an effective role in preventing a person from tendency towards drugs. Turiano et al. (2012) stated that religious beliefs lead to improved health, increased quality of life, and increased self-esteem. The individuals with a high degree of religiosity have better compatibility with stressful situations, experience lower levels of negative emotions and depression, and avoid the consumption of psychiatric drugs and alcohol. Because of the adoption of healthy methods in life, religious people have a higher life expectancy than ordinary people (Koenig, & Cohen, 2002). Since Iran is an Islamic and religious country, religion is considered as a strong source of internal and external control, which can be an effective factor in the youth's lack of tendency to addiction. Yavari, Noori & Hasanabadi (2015); Pournikdsst, Taghizadeh, Aliakbari, Omidian & Mikaeli (2014); Sheikholeslami et al. (2013); Zargar, Najarian & Namani (2008); Toofani (2001); and Yong, Hamann, Borland, Fong, & Omar (2009) showed that there is a relationship between religious attitudes and addiction. In addition, Sanchez, & Nappo (2008) indicated that religion therapy has had a positive effect on the recovery of addicted high school students. Psychological hardiness is among the other influential variables in tendency to addiction, which makes people able to function properly against stressful events and situations. Psychological hardiness creates a particular internal attitude that affects people's confrontation method with different issues of life. Kobassa,. Maddi, & Kohen (1982) considered the hardiness construct as a source of resistance in the face of stressful events of life. In fact, individuals with a strong psychological hardiness are less likely to suffer from physical and

118 Research on Addiction Quarterly Journal of Drug Abuse psychological injuries, such as addiction due to their fighting and assertive epithets as well as their strengths and endurance against stressful environmental incidents. From Kobassa's (1979) point of view, a person with psychological hardness is the one who has the ability to deeply feel the integration with and/or commitment to the activities that s/he is doing. Such a person believes that s/he is capable of controlling or influencing the events, and views mental stresses as changeable characteristics. It seems that, according to theoretical and historical foundations, people with strong religious tendencies, high self-efficacy, and strong and positive self-concept enjoy a higher level of psychological hardiness against stressors and stressful situations. In other words, psychological hardiness increases the individual's ability to resist against temptations and addiction tendency. Johnson showed that religious beliefs play a major role in people's health and adaptation. According to Zargar et al. (2008), psychological hardiness and religious attitude have the highest importance in explaining the variances of addiction potential and its subscales. Mollazadeh Esfanjani, Kafi & Salehi (2011) reported a relationship between psychological hardiness and addiction. In the same way, Jokar, Moein & Honarparvaran (2014); Zahed & Rajabi (2011) also suggest that psychological hardiness has a positive relationship with self- efficacy and self-concept. Moreover, Yasminejad, Golmohammadian, & Feli (2011), Azemoodeh et al. (2007); and Medi (2002) also stated that there is a relationship between religious orientation and psychological hardiness, and the individuals with internal orientation enjoy higher levels of commitment, control, and strength in comparison with the individuals with an external orientation. Iran now has one of the youngest populations in the world, and since addiction mostly threatens the younger generation of any society, Iran is not an exception. Therefore, it is needed to make a serious decision to prevent addiction in Iran. In this regard, this research aims to investigate the role of religious orientation, self-concept, and self-efficacy in predicting addiction tendency in students through the mediating role of psychological hardiness. Method Population, sample, and sampling method This study falls within the category of descriptive correlational research type. The statistical population of this research includes the total number of male students of Razi University of Kermanshah in bachelor's program in the academic year of 2012-2013, which equaled 5299 students according to the statistics released by Razi University of Kermanshah. A 358-particpant sample was selected using Cochran formula through randomized cluster sampling method. Instruments 1. Addiction Potential Scale (APS): It was first constructed by Wade, & Butcher in 1992, and its Iranian scale was constructed by Zargar, Najarian & Na'ami Fatemeh Jalilean-Kaseb et al 119

(2006) (cited in Zarger et al., 2008). It consists of two factors and 36 items plus 5 lie detecting items. Each question is scored on a continuum from 0 (strongly disagree) to 3 (strongly agree). In the first factor (active potential), most of the items pertained to antisocial behaviors, desire to use drugs, positive attitude towards drugs, depression, and sensation seeking. In the second factor (passive potential), most of the items are related to lack of assertiveness and depression (Zarger et al., 2008). The Cronbach's alpha reliability of this tool was reported to be 0.99, while the values of 0.91 and 0.75 were reported for active and passive factors, respectively (Zargar & Ghafari, 2009). In terms of the construct validity, the scores of this scale were correlated with the SCL-25 scores and the coefficient of 0.45 was obtained (Zarger et al., 2008). In the present study, the reliability of this test was obtained equal to 0.93 and the reliability coefficients of active and passive potential factors were obtained equal to 0.92 and 0.85, respectively. 2. Ahvaz Hardiness Inventory Scale (AHIS(: This scale was developed by Kiamrasi, Najarian & Mehrabizadeh in 1998 and contains 27 items. The items are scored from 0 (never), 1 (rarely), 2 (sometimes), to 3 (most often). The items numbered 6, 7, 10, 13, 17, and 21 are scored in reverse. The score of this scale ranges from 0 to 81. Cronbach's alpha coefficient for the whole scale was obtained equal to 0.76 (Najarian et al., 1998). In terms of validity, the scores of this scale were correlated with the scores of Maslow's Self-Actualization Scale, Hardiness Scale, and Anxiety Questionnaire among students and the correlation values of 0.55, 0.70, and 0.44 were obtained, respectively. These correlations were significant and represented the acceptable validity of the scale. In the present study, Cronbach's Alpha for the whole scale was obtained equal to 0.75. 3. Sherer General Self-efficacy Scale: This scale was developed by Sherer & Madux (1982) and includes 17 items that have been translated into Persian by Berati in 1996. Scherer & Madux reported its reliability to be 0.82. In terms of validity, the correlation between the scores of this questionnaire and Rotter Internal-External Locus of Control Scale was obtained significant. Each item is scored from 1 (strongly disagree) to 5 (strongly agree). Items numbered 1, 13, 8, 9, 3, and 15 are scored in reverse. This scale has a maximum score of 87 and a minimum score of 17. Najafi & Fooladchang (2007) reported the reliability of this scale through Cronbach's alpha to be 0.80 and reported its validity by correlating it with Rosenberg's Self-Esteem Scale (0.96). In this study, Cronbach's alpha was obtained equal to 0.80. 4. Allport Religious Orientation Scale: Allport & Ross developed this scale for measuring the internal and external orientation of religion in 1950. This test contains 21 items where questions 1 from 12 measure external orientation and items 13 to 21 measure internal orientation. The items are scored from 1 (strongly disagree) to 5 (strongly agree). In the initial studies on this scale, it was observed that the correlation of the external orientation with the internal orientation was 0.21 (Allport & Ross, 1967). The internal consistency of this

120 Research on Addiction Quarterly Journal of Drug Abuse scale was obtained equal to 0.71 and its retest reliability was obtained equal to 0.74 (Mokhtari et al., 2001). In the present study, the Cronbach's alpha coefficient of 0.78 was obtained for the total scale and the coefficients of 0.52 and 0.70 were obtained for external and internal religious orientations, respectively. 5. Beck's Self-Concept Scale: This measure was first constructed by Beck in 1990 to examine individuals' self-concept. Later on, Beck, Steer, Epstin, & Brown evaluated the scale in that year. This 25-item scale measures individual's attitudes about the self. The items numbered 2, 3, 11, 13, 19, 21, and 23 are scored in reverse. The scale score ranges from 25 to 125. Beck et al. (1990) reported Cronbach's alpha coefficient of 0.82, retest reliability coefficient of 0.88 (with a one-week interval), and retest reliability coefficient of 0.0.65 (with a three-month interval). This scale was validated in Iran by Nabavi in 1994. In terms of the criterion validity of this scale, a significant difference was obtained between normal and depressed people. The alpha-Cronbach's coefficient was reported to be 0.85 while this value was obtained equal to 0.89 in the present study. Results The descriptive statistics of the research variables are presented in Table 1. Table 1: Descriptive statistics of the research variables in the sample group Variable Mean SD Min. Max. Tendency to addiction 40.59 22.49 2 103 Self-concept 90.09 2.97 56 113 Self-efficacy 50.51 6.49 35 64 External religious orientation 22.16 2.97 14 30 Internal religious orientation 28.53 4.04 20 37 Psychological hardiness 49.46 6.04 33 61

The measurement parameters of the direct relations of the proposed model are presented in Table 2. Table 2: Parameters for measuring the direct relationships of the proposed model Non- Critical Standard Paths β standard Sig. coefficient ratio error External religious orientation with 0.03 0.06 -0.63 0.10 0.52 psychological hardiness Internal religious orientation with 0.29 0.93 -6.07 0.15 0.001 psychological hardiness Self-efficacy with psychological hardiness 0.12 0.30 5.59 0.11 0.01 Self-concept with psychological hardiness 0.23 0.67 4.77 0.14 0.001 Psychological hardiness with addiction tendency -0.35 -0.58 -8.53 0.06 0.001 External religious orientation with -0.06 -0.82 5.8 0.14 0.10 addiction tendency Internal religious orientation with -0.30 -1.62 -7.77 0.20 0.001 addiction tendency Self-efficacy with addiction tendency -0.28 -1.14 -7.34 0.15 0.001 Self-concept with addiction tendency -0.16 -0.79 -4.18 0.18 0.001 Fatemeh Jalilean-Kaseb et al 121

The goodness of fit indexes are presented in Table 3.

Table 3: Goodness of fit indexes of the modified model X2 Df X2/df GFI AGFI GFI NFI RMSEA Sig. 1.11 1 1.11 0.97 0.95 0.98 0.99 0.04 0.21

According to the results in Table 3, the proposed model has an acceptable goodness of fit. However, as GFI, AGFI, CFI, and NFI indices are closer to one, they will represent a better fit of the model. Bootstrap results of the indirect relations of the modified model are presented in Table 4.

Table 4: Bootstrap results of the indirect relations of the modified model Standard Upper Lower Paths Sig. estimate bound bound The relationship between self-efficacy and tendency to addiction through psychological -0.15 -0.12 -0.23 0.001 hardiness The relationship between internal religious orientation and tendency to addiction through -0.27 -0.21 -0.34 0.001 psychological hardiness The relationship between self-concept and tendency to addiction through psychological -0.29 -0.25 -0.33 0.001 hardiness

The external religious orientation has no causal relationship with psychological hardiness and addiction tendency. The modified model is presented in Fig. 1.

Internal religious

orientation 2 2 0.46=R 0.28 0.22=R -0.29 Psychological -0.38 Addiction 0.12 hardness tendency Self-efficacy 0.26 0.21 -0.14 Self-concept

Fig. 1: The proposed model of causal relationship of religious orientation, self-concept, and self-efficacy with addiction tendency through the mediating role of psychological hardiness

Discussion and Conclusion The path analysis of the proposed model of the study showed that the indirect relation of internal religious orientation with addiction tendency is negatively influenced by psychological hardiness, which means that religious orientation reduces addiction tendency through psychological hardiness. This finding can

122 Research on Addiction Quarterly Journal of Drug Abuse be explained by the fact that religious people evaluate stressful events in a different way due to their specific inner beliefs and ideas. In different situations, they show more compassion and hardiness and this finding is consistent with the ones reported by Yavari, Noori & Hasanabadi (2015); Sheikholeslami et al. (2013); Asghari, Kordmirza & Ahmadi (2013); Abolghasemi, Pourkord & Narimani (2009) ; Toofani (2001); Zargar, Najarian & Namani (2008); Turiano et al. (2012); Sanchez & Nappo (2008); and Yong et al (2009). Indeed, religiosity can moderate the effects of severe life crises. The components of the sense- making system, influenced by religion, (including beliefs, co-ordinates, expectations, and goals) act as the centerpiece of one's emotions and actions (Sil Bremen, 2005). Therefore, the higher the individual's level of religiosity, the higher the value and meaning one assigns to the surrounding world. In fact, at the time of the emergence of stress and tension, religiosity acts like a shield, makes the person modify the psychological stress under the mediation of his/her cognitive beliefs, and affects the process of thinking and evaluation of everyday life events. In this way, even a lot of seemingly negative events are evaluated as positive and meaningful events and one will feel a positive sense. It also leads the individual to show a higher degree of psychological hardiness in the face of more difficult problems and to have more control over his/her actions and behaviors. In addition, when dealing with tensions, s/he is less stressed and less vulnerable and, in fact, s/he has a higher degree of mental health and psychological well-being and shows lower levels of addiction tendency. In addition, the present study showed that there is a significant relationship between self-concept and the tendency to addiction through the mediation of psychological hardiness. The presence of a positive relationship between self- concept and psychological hardiness is consistent with the results of the studies conducted by Dehghani et al (2013); Mollazadeh Esfanjani, Kafi & Salehi (2011); Foroo'odin & Sadr al-Sadat (2002); Stucky (2003); Bokstein (2000); and Miller (1995). This finding can be explained by the fact that people with negative self-concept do not have precise knowledge of their existent selves, their strengths, and weaknesses. Therefore, at the time of the occurrence of problems, they do not accept their ability and this increases their disappointment. Such individuals do not feel self-sufficient and valued when problems arise due to the lack of sufficient motivation. In such situations, they feel they have no control over the decisions and events and feel less committed; therefore, they will have a weakened resistive spirit and it reduces the degree of psychological hardiness in such individuals in dealing with problems. In other words, the individual's negative self-concept do not believe in their inner strengths. Hence, they do not have the ability to accept that they can solve the problems in stressed situations. In other words, it can be concluded that these individuals have less psychological hardiness in the face of stresses and challenges and, thereby, they suffer more failures and experience more stress and anxiety, which can ultimately lead to addiction. The individuals with positive self-concept evaluate a higher Fatemeh Jalilean-Kaseb et al 123 percentage of their life experiences as positive and tend to assess stressful life events in less stressful ways. This makes them more psychologically healthy and less oriented to addiction. There was also a significant indirect relationship between self-efficacy and addiction tendency with the mediating role of psychological hardiness. The significant positive relationship between self-efficacy and psychological hardiness is consistent with the research findings reported by Jalali & Ahadi (2015); Dehghani et al. (2013); Bahadori & Khanjani (2013); Asghari, Kordimirza, & Ahmadi (2013); Abolghasemi, Pourkord & Narimani (2009); Doolan et al. (2008); McClaar et al. (2008); Tate et al. (2007); and Sterling et al. (2007). The above finding can be explained by the fact that self-efficacy is a factor that acts as a cognitive mediator and affects people's thoughts and feelings. In fact, the sense of self-efficacy prevents frustration and despair in a stressful situation, which is one of the common reasons for young people's addiction. It can also be argued that people with low self-efficacy easily stop efforts and endeavors to deal with problems while people with high self-efficacy face problems with improved skills and have more control over their affairs. Hence, self-efficacy can protect individuals against addiction tendency through psychological hardiness. Regarding the mediation role of psychological hardiness in students' tendency to addiction, necessary measures and strategies should be devised to increase psychological hardiness, especially in academic environments. Considering the role of religious orientation and self-efficacy in decreasing addiction tendency and considering the considerable role of families in strengthening and shaping family members' religious tendencies, it is suggested that various effective programs be implemented to strengthen family members' religious basis. Similarly, some strategies should be devised to improve and enhance young people's self-efficacy through educational and practical programs in the family, community, and educational settings. Reference Abolghasemi, A., Pourkord, M., & Narimani, M. (2009). The relationship of social skills and self-efficacy with tendency to drug use in adolescents, Journal of Sabzevar University of Medical Sciences, 16 (4), 181-188. Allport, G. W., & Ross, I. M. (1967). Personal religions orientation and prejudice. Journal of Personality and Social Psychology, 5(4), 432-443. Asghari, F., Kordmirza, E., & Ahmadi, L. (2013). On the Relationship between Religious Attitude, Locus of Control, and Substance Abuse Tendency in Students. Quarterly Journal of Research on Addiction, 7 (25), 103-112. Azemoodeh, P., Shahidi, S., & Danesh, Esmat. (2007). The Relations hip of Religious Orientation with Hardiness and Happiness, Journal of Psychology, 11 (41), 60-74. Bahadori, J. & Khanjani, Z. (2013). The Relationship of Coping Strategies and Self- efficacy with Substance Abuse in Students. Quarterly Journal of Knowledge and Research in Applied Psychology, 14 (53), 80-90.

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Causal Model of Abstract Impact of Emotional Objective: The aim of this study was to propose the model of the impact of Instability Personality emotional instability personality on on Tendency to Risky tendency to risky behaviors with the mediating role of attitudes to substance Behaviors in use in adolescents. Method: This study is a descriptive one where Structural Adolescents with the Equation Modeling is used to propose Mediating Role of the model. The population of this study included all school students of Qods Attitudes to County in Tehran Province in 2015. The number of 644 students was Substance Use selected by multistage random sampling as the participants of this Iraj Mokhtarnia, Ali Zadeh study. The data were gathered through Mohammadi, Mojtaba Habibi, Big Five Personality Questionnaire, Frozan Mirzaifar Attitude towards Drug Abuse Questionnaire, and Adolescents Risk- Iraj Mokhtarnia taking Questionnaire. Results: The results of structural equation modeling Ph.D. Student of Clinical Psychology, analysis showed that the Conceptual Department of Psychology, School of Education Sciences and Psychology, Model of the research had an acceptable fitness with the data Shahid Beheshti University, Tehran, Iran, (df/S–Bχ2=2.56, CFI=0.98, GFI= 0.96, E-mail: [email protected] RMSEA= 0.049). In this model, all Ali Zadeh Mohammadi direct and indirect paths for the Associate professor, Shahid Beheshti prediction of risky behaviors in University, Tehran, Iran adolescents were obtained significant. Mojtaba Habibi The results also showed that attitude Assistant Professor, Iranian National towards substance use had a mediating Center for Addiction Studies, Tehran role in the relationship between University of Medical Sciences, Tehran, instability personality and risky Iran behaviors in adolescents. Conclusion: Frozan Mirzaifar Therefore, this study revealed how M.A in guidance & counseling, Alzahra interpersonal factors in a model affects University, Tehran, Iran risky behaviors in adolescents. Keywords: emotional instability Research on Addiction personality, attitude towards substance Quarterly Journal of Drug use, risky behaviors, adolescents Abuse Presidency of the I. R. of Iran

Drug Control Headquarters Department for Research and Education

Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir 128 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Risk behaviors are defined as the behaviors that endanger the individual's safety and, in some cases, endanger the safety of others. These behaviors are used to stimulate the excitement and passionate feelings that are common in adolescents (Bonino, Cattelino, Ciairano, Mc Donald, & Jessor, 2005). Proposing Problem Syndrome Behavior, Jessor (2014) enumerates the categories of high-risk behaviors as smoking, drug use, alcohol drinking, hazardous driving, and early sexual activity. DiClemente, Hansen, & Ponton (2013) also developed risky behaviors to violence and overeating, and addressed tendency toward these behaviors among adolescents. The irreparable harms and damages of each of the high-risk behaviors in adolescents as well as the high financial and schedule costs changing such behaviors at the individual and social levels have made it a social crisis (Soleimani, Jazayeri & Mohammadkhani, 2001). In addition to the fact that tendency to high-risk behaviors make adolescents susceptible to mental disorders, such behaviors are among the most important causes of adolescent mortality (Sana'eanasab, Irani & Rafati, 2009; Boesky, 2007). Such behaviors are also among the most important causes of mortality in adolescents (Sarrami, Ghorbani & Minooea, 2013; Eaton, Kann, Kinchen, Shanklin, Flint, & Hawkins, 2012). High-risk behaviors have adverse effects on adolescents' health, and also committing at least one of these types of behaviors during adolescence anticipates the possibility of the occurrence of other problems and adulthood inconsistencies (US preventive services task force, 2010). Moreover, according to the coincidence rule of high-risk behaviors, the tendency toward a high-risk behavior also provides the probability of the incidence of other high-risk behaviors in adolescents (Zadeh Mohammadi & Ahmadabadi, 2008). Most scholars believe that any failure in adolescent developmental stages increases the likelihood of being trapped in high-risk behaviors. This can be due to the fact that this period is considered as a period of the outbreak of high-risk behaviors, or this period is recognized with at least an increase in such behaviors (Diclemente et al., 2013). Ellis, Del Giudice, Dishion, Figueredo, Gray, & Griskevicius (2012) believe that the risky behaviors in adolescents are some sort of adaptation to the difficult conditions of life more than the consideration of these behaviors as pertinent to developmental stages. In this adaptation, the adolescents' personality and environmental factors are involved. In this regard, Diclemente et al. (2013) believe that the first factors effective in the attitude toward high-risk behaviors are psychological factors. One of the most important psychological factors is individuals' personality traits, and the purpose of personality examination is to go for behavioral prediction. Research also supports the susceptibility of personality in the incidence of maladaptive behaviors and psychopathology of children and adolescents (Ingram, & Price, 2001). Research has shown that there is a relationship between personality and Iraj Mokhtarnia et al 129 disorders, such as aggression, tendency to high-risk behaviors, behavioral and emotional disorders, lack of proper training of children, delinquency, and learning difficulties (Barlas, & Egan, 2006). Some personality traits predispose individuals to specific behaviors; in this regard, emotional instability is among the personality traits in adolescents that is closely related to tendency toward high-risk behaviors. Emotional instability refers to the feelings of anxiety, depression, anger, and dissatisfaction among adolescents (Barbaranelli, Fida, Paciello, Di Giunta, & Caprara, 2008). These people have irrational thoughts and are less able to control their impulses and, thereby, act in tune with poor stress conditions. Research suggests that those personality traits that act unpredictably in relation to anxiety or are accompanied by neurotic and hasty states are directly related to high-risk behaviors (Correa, Hinsley, & De Zuniga, 2010; Mehroof, & Griffiths, 2010). In addition to the direct relationships of personality instability with the appearance of maladaptive behaviors, there are also factors that act as mediators in the relationship between them; attitude is considered one of the mediating factors among the foundations of personality and behavior. Cattell described attitudes as the most basic concepts in traits. He believes that attitudes are the actions or the desire to act in response to a particular situation, and attitudes usually originate from the innate drives that are called erg. In this regard, middle sub-goals are at play between traits' ergs and attitudes; therefore, attitudes are the upper levels of traits that are represented (Cattel, 1983; 1990). Allport (1931) also believes that attitudes are, in fact, the consistency of behaviors and, on the other hand, are related to personality traits. In general, in terms of the relationship between high-risk behaviors and attitudes to them, it can be argued that tendency to risky behaviors is a gradual process that is initiated with a positive attitude toward them. Here, the existence of positive attitudes about high-risk behaviors increases the likelihood of the incidence of such behaviors (Alloy, Riskind, & Manos, 2005; Barlow, & Durand, 2011). Although theories and some studies have shown that attitudes are related to behaviors, social psychosocial research has indicated that not all attitudes do lead to behavior; in fact, there are some conditions for attitudes to be converted to behavior (Eisen &Fishbin, 1971). In this research, one of the research objectives is to examine whether a particular attitude, such as attitude toward drug use contributes to the prediction of high-risk behaviors and to see whether the conditions for converting attitudes to behavior in these variables have been observed. In the same way, theories of personality traits emphasize the presence of the relationship between attitudes and personality. However, to the best of the authors' knowledge, few studies, if any, have been done in this area. As a result, one of the questions that the research seeks to answer is whether personality instability has a direct impact on irrational attitudes toward drug use and how such a feature affects attitude to drug use. The third challenge that the present research seeks to respond to is to propose the

130 Research on Addiction Quarterly Journal of Drug Abuse model that explains tendency toward high-risk behaviors in adolescents based on the conceptual model of the research. In fact, here, the main objective is to see whether such a model enjoys suitable fitness indexes and these indexes support the data obtained from such a model in reality? Method Population, sample, and sampling method The current research method is descriptive where structural equation modeling was used for examining the model. The statistical population of this study included the first- and second-year male and female high school students of Qods County in Tehran province in the academic year of 2014-15. Multistage random cluster sampling method was used for the selection of participants. After obtaining research permission from the Education Office of Qods County and receiving the names of all schools, eight schools (4 boys and 4 girls' schools) were selected by random sampling method. At the next step, 10 individuals were randomly selected from each class. In order to select the sample size, the "more the better" rule was followed in structural equation modeling method (Boomsma, & Hoogland, 2001). Therefore, it was attempted to use a large sample size and, thereby, a 644-participant sample was selected. The inclusion criteria were the age of 13-17 years and studying in one of the first or second periods of high school. On the other hand, the exclusion criteria were parental divorce, mother's death, and father's death. The data were analyzed using SPSS21 and LISREL8.8. Of the whole sample, 46.4% were male and 53.6% were female. In addition, 21.1% of the participants were in the first period and 78.9% of them were in the second period. The mean (standard deviation) of participants' age was 15.42 years (1.17 years). Instruments 1. Iranian Adolescents Risk-Taking Scale: This questionnaire was designed by Zadeh Mohammadi & Ahmadabadi (2008) by considering the credible instruments in the field of risk-taking, such as Juvenile Risk Questionnaire (Gullone, Moore, Moss, & Boyd, 2000) and Youth risk behavior survey (Brener et al., 2004) and also by taking into account the cultural conditions and social constraints of the Iranian society. There are 38 items for assessing adolescents' vulnerability to 7 categories of high-risk behaviors, such as high-risk driving, violence, smoking, drug use, alcohol consumption, sexual relations and sexual behavior, and orientation to opposite gender. The respondents announce their agreement or disagreement with these items on a 5-point scale from strongly agree (5) to strongly disagree (1). The items numbered 1 to 6 pertain to risky driving, questions 7 to 11 belong to violence, questions 12 to 16 pertain to smoking, questions 17 to 24 are related to drug use, questions 25 to 30 measure alcohol consumption, questions 31 to 34 tap into orientation to opposite sex, and questions 35 to 38 measure sexual risk-taking. High score in each of the factors Iraj Mokhtarnia et al 131 indicates the high risk of adolescents in that factor. Its reliability has been assessed by internal consistency method and its validity was verified using exploratory factor analysis. Cronbach's alpha of the total scale has been reported to be equal tto 0.938, while smoking, drug use, alcohol consumption, sexual relationship and behavior, and orientation to opposite sex have taken up the Cronbach's alpha coefficients of 0.931, 906.0, 0.907, 0.856, and 0.809, respectively (Zadeg Mohammadi & Ahmadabadi, 2008). In the present study, all factors of the questionnaire were used other than alcohol consumption and sexual behavior. In addition, in the present study, the five-factor model was used and factor analysis method and the maximum probability estimation method by means of data fitness were employed to assess the model. According to the results of the indexes, the five-factor model represents a suitable fitness in the population. Moreover, Cronbach's alpha coefficients of 0.80, 0.77, 0.90, 0.90, and 0.83 were obtained for risky driving, violence, cigarette smoking, drug use tendency, and orientation to the opposite sex. 2. Drug Attitudes Questionnaire: The questionnaire was developed and validated by Delavar, Alizadeh & Rezaei (2004) to assess people's attitudes towards narcotics in five dimensions of mental attitude, physiological attitude, social attitude, attitude to drug use, attitude towards the use hazards of drug use. It consists of 49 five-choice questions based on Likert scale (1 = strongly agree, 5 = strongly disagree). The questions numbered 3, 9,12,17,19, 21, 22, 23, and 2 belong to attitude toward the physiological effects of drug use the questions numbered 1, 5, 6, 7, 8, 10, 11, 14, 16, 18, 20, and 24 measure attitude towards the psychological effects of drug use, the questions numbered 2, 4, 13, and 15 pertain to attitude to the social effects of drug use, questions numbered 37, 38, 39, 40, 41, 42 , 43, 44, 45, 46, 47, 48, and 49 belong to attitude towards the hazards of drug use. A higher score indicates a highly irrational attitude towards drug use. Delavar et al. (2004) reported the internal consistency Cronbach's alpha coefficients of the scale and its sub-scales to range from 0.86 to 0.92, and also reported the retest reliability coefficients of the sale and sub-scales to lie between 0.84 and 0.86. In terms of the validity of this questionnaire, factor analysis method (principal component analysis) and group differentiation method were used. Rezaei, Delavar, & Najafi (2012) confirmed the Five Attitudes to Drug Use Scale using confirmatory factor analysis. In addition, in the present study, Cronbach's alpha coefficients of 0.88 0.80, 0.55, 0.82, and 0.87 were obtained for psychological effects, physiological effects, social effects, attitude toward the hazards of drug use, and attitude toward substance use, respectively. 3. Children and Adolescents Emotional Instability Personality Scale: This scale has been derived from the 65-item Big Five Factor Scale (child and adolescent form) by Barbaranelli, Caprara, Rabasca, & Pastorelli (2003) with the aim of measuring the five big personality factors among 8-year-old children. It

132 Research on Addiction Quarterly Journal of Drug Abuse consists of five main factors, namely extraversion/energy, agreeableness, conscientiousness, emotional instability, and intelligence/openness. The items are scored on a 5-point Likert scale. The questions numbered 4, 6, 8, 15, 17, 29, 31, 39, 41, 49, 54, 58, and 61 point to emotional instability. Muris, Meesters, & Diederen (2005) used junior version of the Eysenck Personality Questionnaire and Strengths & Difficulties Questionnaire to assess the convergent validity of this scale, and reported a high correlation between the similar factors. The calculated Cronbach's alpha for extraversion/energy factor was 0.78, it was 0.80 for agreeableness, it was 0.74 for conscientiousness, it was 0.83 for emotional instability, and it was 0.71 for intelligence/openness. Talebi (2014) used exploratory factor analysis and confirmed the four factors of extraversion, emotional instability, intelligence, and conscientiousness, and reported the Cronbach's alpha coefficients of 0.73, 0.83, 0.67 and 0.63 for them, respectively. In addition, in terms of the convergent validity of the scale, Eysenck questionnaire, Aeschbach's Behavioral Problems and Academic Self- Efficacy were found to have a significant relationship with the Big Five Factor Questionnaire. In the present study, the Emotional Instability Scale has been selected with four randomly selected packages, where the first package includes the questions numbered 8, 17, and 58; the second package includes the questions numbered 31, 49, and 54; the third package includes the questions numbered 6, 29, 15; and the fourth package Includes the questions numbered 41.39, 4, and 61. The internal consistency of the packages was evaluated as desirable. Results The correlation matrix of the studied variables is presented in Table 1. Table 1: Correlation matrix of the research variables Variables 1 2 3 4 5 6 7 8 9 10 11 1. Emotional ------instability 2. Mental effects of 0.20 ------drug use 3. Physiological effects 0.13 0.77 ------of drug use 4. Social effects of 0.13 0.36 0.39 ------drug use 5. Effects of drug use 0.08 0.40 0.42 0.38 ------6. Dangers of drug use 0.15 0.38 0.34 0.30 0.70 ------7. High-risk driving 0.27 0.23 0.20 0.19 0.22 0.27 - - - - - 8. Violence 0.43 0.26 0.22 0.26 0.32 0.37 0.55 - - - - 9. Cigarette smoking 0.20 0.36 0.30 0.28 0.61 0.59 0.27 0.39 - - - 10. Tendency to 0.16 0.35 0.32 0.27 0.60 0.60 0.30 0.44 0.67 - - substance use 11. Orientation to the 0.18 0.20 0.17 0.13 0.23 0.22 0.40 0.39 0.25 0.26 - opposite sex Mean 34.79 19.04 16.38 4.43 14.99 15.08 17.92 11.19 6.85 10.69 11.04 SD 9.22 7.63 6.50 2.17 5.56 5.29 5.35 4.45 3.28 3.94 4.65 Correlation values above 0.12 are significant at p <0.001. Iraj Mokhtarnia et al 133

Structural equation modeling was used to evaluate the theoretical model of the research. All the modeling assumptions were investigated, and Robust Maximum Likelihood was used because of the violation of the normality assumption in a number of variables. Therefore, Robust Maximum Likelihood in the asymptotic covariance matrix was chosen before the calculation of the model fitness. In addition, the results of LISREL software and fitness of structural models showed that the assumptions of the "overly defined modeling" and "non-multicollinearity" have been also observed among the variables. In addition, the inflation variance index value of 5

According to Table 2, the chi-square value of 161.66 was found to be significant. In the present study, the ratio of Satorra-Bentler Scaled Chi-Square (S–B χ2) to degree of freedom was obtained less than 3 (df / S-Bχ2 = 2.56), which indicates an appropriate fit for the model. When the distribution assumptions are faulty, S–B χ2 is used as a correction index of Chi-square test.

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The root mean square error of approximation was obtained lower than 0.05, which indicates the optimal fit of the model. This index shows the average of the residual values between the observed covariance/correlation from the sample and the expected model. Moreover, as the value of the standardized root mean square residual is closer to zero, it fits the model more. The good of fit index was reported to be 0.96; this index is conceptually similar to R2 in regression analysis; and if this index is greater than or equal to 0.90, then the model is considered scientifically acceptable. The value of 0.94 was obtained for the adjusted goodness of fit index, which shows the acceptability of the model. As this index is higher than 0.90, it represents the better fit of the model. Also, the comparative fit index value is higher than 0.90, which indicates an acceptable fit between the model and the data (Meyers, Gamst & Guarino, 2012). Therefore, the fit indexes of the model in general showed that the collected data would be as acceptable as possible to support the research model. After the acceptance of the model, the model paths results were investigated and the results are presented in Table 3.

Orientation to Violence Risky driving opposite sex Drug use Smoking 0.80 0.33 0.83 0.54 0.37

Mental effects Tendency to high-risk 0.47 behaviors 0.84 Physical effects Package 1 0.18 0.62 0.43 Exciteme Attitude 0.80 0.17 0.38 Social effects Package 2 nt to drug 0.89 instabilit use 0.83 y Dangers of drug Package 3 0.84 use 0.73 Drug use Package 4

Fig. 1: Relations between the endogenous and exogenous variables of the model with standardized coefficients

Iraj Mokhtarnia et al 135

Table 3: Indexes of direct, indirect, and total effects of each of the paths based on the theoretical model Path Standard Independent Mediating Dependent Effect type β error of t variable variable variable estimate Tendency Emotional Direct - to high-risk 0.18 0.04 4.11 instability effect behaviors Tendency Emotional Attitude to to high-risk Indirect 0.14 0.03 2.84 instability drug use effect behaviors Tendency Emotional Attitude to to high-risk Total effect 0.31 0.07 4.41 instability drug use behaviors Tendency Emotional Direct - to high-risk 0.17 0.06 3.06 instability effect behaviors Tendency Attitude to drug Direct - to high-risk 0.84 0.12 7.16 use effect behaviors

According to the results of Table 3, emotional instability has a direct effect on the tendency to high-risk behaviors. Also, due to the significance of the direct, indirect, and total effects, the mediating role of attitude toward drug use is confirmed. In addition to the reports in Table 3, in the research model, attitude toward substance use has a direct effect on adolescents' tendency toward high- risk behaviors with the standard beta value of 0.84 and the standard error of 12.0 by considering the significance test value of 7.16. In addition, the personality trait of emotional instability with the standard beta of 0.17, the standard error of 0.06, and the significance test value of 3.06 has a direct effect on attitude toward drug use. Discussion and Conclusion The results of the obtained indexes showed that the conceptual model is a suitable and desirable model that has a high value of explained variance for predicting the criterion variable. In other words, the structure of the model and the research variables had a significant effect on the tendency toward high-risk behaviors. Most research in the field of social psychology has reported contradictory effects of attitudes on the incidence of such behaviors. In a large number of the early studies, no evidence was obtained to show that there is a close relationship between attitude to drug use and high-risk behaviors (Bohner, 2002). Hence, some researchers have suggested that research on the attitude construct should be discarded in full, but other researchers have attempted to determine the conditions affecting the relationship between attitude and behavior instead of excluding research on the concept of attitudes (Ajzen, 2001). In this regard, they identified methodological issues and factors involved in this area. According to Ajzen & Fishbein (1973), only if both attitude and behavior are

136 Research on Addiction Quarterly Journal of Drug Abuse proportionate and consistent in terms of the degree of specificity, one should expect the existence of a close relationship between attitude and behavior. In the present study, a close relationship was found between attitude toward drug use and tendency to substance use. However, the other challenge and question is raised in terms of the way the relationship between attitude toward addiction and other high-risk behaviors such as high-risk driving, violence, smoking, and orientation to the opposite sex (which were considered as latent variables in this study) may be established. Through two perspectives, one can answer this question. Attitudes are related to schemas; hence, it seems that people who have a positive attitude towards drug use generally have schemas with irrational recognition about risky behaviors. These people are likely to think that "high- risk behaviors are not very harmful", "because they are worth being experienced the value of experiencing," or "I am very strong and not vulnerable to these behaviors." it can be due to this reason that Strom (1990) believes that one attitude does not lead to just one answer, but is reflected in most of the different behaviors of an individual. The second explanation involves the principle of the coincidence of high-risk behaviors. When a person finds a positive attitude towards a risky behavior, s/he will probably experience another risky behavior. The significant value of beta showed that the relationship between adolescents' personality traits and tendency towards high-risk behaviors in the conceptual model was significant. Therefore, the data supported the path of adolescents' personality instability towards tendency towards high-risk behaviors in the developed model. This finding is consistent with those of the studies conducted by Mami, Ahadi, Naderi, Enayati & Mazaheri (2012), Soleimani, Hasani & Arianakia (2014), Gullone, Moore, Moss, & Boyd (2000), Cyders, Flory & Rainer (2009). The most important characteristic of personality traits is the prediction of individuals' attitudes and behaviors; therefore, personality traits are an appropriate predictor of tendency toward high-risk behaviors. As Allport (1938) states, attributes are a real construct that occurs with certain behaviors. In this view, attributes are not object-oriented and do not wait to be moved by forces of stimuli; rather, they stimulate the human being to look for environmental stimuli and reveal themselves; therefore, personality traits are an appropriate predictor of tendency to high-risk behaviors in adolescents. Theories of personality traits have introduced the factor of neuroticism, which was studied in this research under the title of Emotional Instability, as a predictor of tendency toward high-risk behaviors (Feist & Feist, 2008). According to Karney & Bradbury (1997), personality traits, such as emotional instability and neuroticism, tend to be followed by permanent vulnerabilities that may harm the self and even others. Anxiety (equal to the factor of neuroticism or emotional instability) is the common point of Freud's view and Traits Approach. Both of these perspectives emphasize the importance of anxiety in shaping behaviors. People who obtain a high score in this factor usually have an extreme emotional response and can restore to the normal state Iraj Mokhtarnia et al 137 after the emotional excitement. This irritability predicts the tendency toward a variety of high-risk behaviors. On the other hand, one of the characteristics of these people is the conduct of hasty actions; hence, they are very unable to control their desires and temptations (for example, smoking). In the eyes of these people, desires are so strong that one cannot resist them when they are at hand, although they may regret their behavior later on (Whiteside & Lynam, 2001; Eysenck & Eysenck, 1977). In addition to these explanations, it can be argued that emotional instability is a general tendency to experience negative emotions, such as anger, fear, and impulsivity in such a way that many addicts refer to the experience of distress, anger, fear as the reason for their addiction (Kameli, Jajarmi, Abedi & Kameli, 2014). People who get a high score on this factor experience more stressful events on the one hand, and they are susceptible to experiencing negative emotions and helplessness regardless of the level of stress, on the other hand. Therefore, readiness to experience stressful events and negative emotions make these people ineffective in coping with stressful events (Aliloo, Arji, Bakhshipour & Shahjouyi, 2011). In such a situation, they cannot embark on solving problems, and the absence of problem-solving skills increases the likelihood of occurrence of high-risk behaviors. As it was stated earlier, emotional instability is a natural tendency to act impulsively, and these people prefer immediate rewards to future rewards, so they tend to smoke and take opiate drugs or be with the opiate sex because they also find a good way to reduce their anxiety in this way in addition to experiencing an instant pleasure. Research also suggests that these individuals tend to be smokers or drug users since they can control their negative emotions in this way. Research has also shown that people who have obtained a high score on emotional instability have irrational cognitions and emotions. These people do not think logically in choosing their own behavior and they usually act in haste. In this case, there is evidence that adolescents consider fewer consequences in their behaviors and decisions; therefore, a teenager with the emotional instability trait considers most of the dangers lower than what they are in the real sense (Mishra & Lalumière, 2011). In addition, the results showed that attitude toward drug use has a mediating role in the relationship between the personality trait of emotional instability and tendency to high-risk behaviors. To explain this question, it was required to explain all the paths developed in the model. Therefore, the direct effect of personality instability on tendency to drug use was discussed. Moreover, the effect of attitude toward drug use on tendency toward high-risk behaviors was explained. Considering the lack of research findings in this regard, it is possible to use Cattell, Eysenck, and Allport's views to describe and explain this finding. Cattell (1990) believes that attitudes are the high levels of traits that can be represented. If this perspective is taken into account, this finding can be explained in such a way that the attitudes consistent with personality traits satisfy the drive-based needs of the students; therefore, it seems that those who are emotionally unstable meet their need for the reduction of anxiety and stress

138 Research on Addiction Quarterly Journal of Drug Abuse through positive attitudes toward drug use and tendency to drug use. This finding can also be explained from Eysenck & Eysenck's perspective (1981). In Eysenck's hierarchy of behavior organization, attitude to addiction can be the fourth level of this process that is also associated with personality traits which is the second level. With the explanation that the factor of the relationship in this process is the third level of behavioral organization that involves people's ordinary cognitions and thoughts, positive attitudes to addiction can be a feature of emotionally unstable individuals who, in most situations of life, experience negative cognitions and emotions. Thus, it is possible to predict people's rational or irrational attitudes through personality traits. People with emotional instability seem to have irrational attitudes toward the effects of drug use. These people hold negative thoughts and perceptions to different subjects, and they use fewer rational explanations in the face of difficulties and problems. These results are also supported by the research findings reported by Karimi, Abdollahpoor & Kord (2012). They believe that attitudes are similar to personality traits and attitudes are a construct that reflects individual differences and has a common variance with the Big Five-Factor Model of Personality that predicts a number of individual differences. In general, the results of this study showed that the effect of emotional instability, as the most important intrapersonal factor, along with the attitudes toward substance use could predict tendency toward high-risk behaviors in adolescents. Therefore, the research model was developed by considering the relationships between variables, which showed that the data obtained from the research support this model. Similarly, the present study showed how attitudes toward drug use, as a mediating variable, can influence the relationship between emotional instability and tendency to high-risk behaviors. Although the present model had the highest determination coefficient in the prediction of drug use tendency, the predictive variables had considered only individual and psychological factors in the prediction of drug use tendency; therefore, there is a research gap in this regard. As a result, other researchers are suggested to examine the environmental factors along with individual and psychological factors and to compare the fitness indices between the two models. It is also recommended that other researchers develop a therapeutic program for changing attitudes by taking into account this model and examine its effects on reducing the incidence of high-risk behaviors in experimental and quasi-experimental studies. The non-examination of the non-changeability in males and females and the uncontrollability of the gender role of children can affect the results of this research. Therefore, this can be one of the limitations of the present research. Also, considering that attitudes toward substance use and tendency towards high-risk behaviors are the tools that participants are likely to fill out with caution, this behavior may have affected the research validity.

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On the Comparison of Abstract Objective: This study aimed at Effectiveness of comparing the effectiveness of schema Schema Therapy and therapy and mindfulness in psychosomatic symptoms and its Mindfulness in dimensions (somatization, obsessive - compulsion, sensitivity in Psychosomatic interpersonal relationships, Symptoms in People depression, anxiety, hostility, phobic anxiety, paranoid and psychotic) in with Stimulants Abuse people with stimulants abuse. Method: For this purpose, a quasi- experimental along with pretest- posttest, control group, and a three- month follow-up was employed. The statistical population of the study Samira Sydasyaban, Gholam Reza consisted of the patients who presented Monshi, Parviz Asgari to the addiction center of dependent outpatients affiliated with the Welfare Organization of Ahvaz in 2014. From among this population, 45 patients Samira Sydasyaban were selected via purposive sampling Department of Psychology, Isfahan method and were assigned randomly (Khorasgan) Branch, Islamic Azad into two experimental groups and one University, Isfahan, Iran control group. The schema therapy experimental group participated in 10 Gholam Reza Monshi one-hour sessions and the mindfulness Associate Professor, Islamic Azad experimental group were treated in University, Isfahan (Khorasgan) Branch, eight 45-minute sessions. The Mental Isfahan, Iran, E-mail: Health Questionnaire was [email protected] administered before the beginning of the treatments, in the final session of Parviz Asgari the interventions, and three months Department of Psychology, Ahvaz Branch, after the treatment. The control group Islamic, Azad University, Ahvaz, Iran received no intervention. Results: The results indicated that schema therapy and mindfulness were effective in the relapse prevention of stimulant abuse. Schema therapy was more effective Research on Addiction than mindfulness. Conclusion: Schema therapy and mindfulness are Quarterly Journal of Drug effective in the reduction of Abuse psychosomatic symptoms due to the presence of common components in Presidency of the I. R. of Iran the two approaches Drug Control Headquarters Keywords: schema therapy, Department for Research and Education mindfulness, psychosomatic Vol. 10, No. 40, Winter 2017 symptoms, stimulants abusers http://www.etiadpajohi.ir

144 Research on Addiction Quarterly Journal of Drug Abuse

Introduction For many years, humans have been consuming drugs in different ways in the hope of reducing their pains and changing their consciousness states (Davison & Neale, 2001). Despite the complications of addiction, such as mental and physical disorders, it will be added to the number of victims of this deadly trap day by day (Yousefi & Khaledian, 2012). There is a kind of bias in the consumption or non-consumption of narcotics or psychotropic substances which, to some extent, misleads a person and leads him/her to the use of defensive mechanisms of denial (Mokri, Ekhtiari, Edalati, & Naderi, 2011). The consumption behavior loses its pleasure stage by stage and becomes compulsory. In addition to the emergence of dependence, substance use causes varying degrees of physical and/or physical damage to the consumers. Under these circumstances, the full body of the addiction illness is visible through a combination of dependence and destruction. This devastation and dependence is observed to a greater extent in the abuse of substances, such as amphetamines and other types of stimulants. Addiction to narcotics and stimulants is a chronic illness that is often associated with other psychiatric illnesses (Ilgen, Jain, Kim, & Trafton, 2008). Psychiatric disorders along with substance abuse disorders have harmful effects on physical and psychological health. Basic depression, anxiety, borderline personality disorder, and antisocial personality disorder are among the most common psychiatric diagnoses among addicts (Roberts & Xineg, 2007; Astals, Díaz, Domingo, Santos, Bulbena, & Torrens, 2009). ) In fact, psychosomatic symptoms are very common in addicted patients, and are so severe in many cases that can estimate, for example, the features of a major depression or anxiety disorder (Mc-Governetal, 2009). In recent years, special attention has been paid to the psychological treatment of psychosomatic symptoms caused by drug abuse disorder. Researchers believe that the psychotherapies provided for drug use have rarely considered the consequent disorders despite the high prevalence of these disorders and their interaction with each other. This issue has made the interventions designed in the area of substance abuse disorders ineffective and has led to the incidence of recurrent relapses in patients (Hasin, Liu, Nunes, Mac- Cloud, & Samet, 2002, cited in Janis, Leigh, Gisarah,& Marlatt, 2009). Due to the high costs and serious damages of substance abuse throughout the world, cost-effective therapies are needed to treat substance abuse and addiction (World Health Organization, 2006). In recent years, there have been many advances in the treatment of substance use disorders. Such examples as medical, psychological, and social interventions are representative of these advances (Mc-Kay, 2009). Kamarzarin, Zare & Brooki (2012) showed that 20% to 0.9% of the drug addicts undergoing treatment experience relapse. Due to the multidimensional nature of drug dependence and the chronic, progressive, and relapsing nature of this disease, Samira Sydasyaban et al 145 therapies that emphasize only one aspect, such as pharmacology, have not yielded a successful performance in relapse prevention. One of the most prominent psychological interventions in the treatment of addiction and relapse prevention in recent years has been cognitive therapeutic modeling, including schema therapy and mindfulness that helps patients acquire the required coping skills to manage risk situations and treat psychological disorders. This therapeutic approach has progressed in recent years and different types of therapies have originated from it that are widely used to treat depression, anxiety, fear, pain, and addiction. In fact, many substance abuse clients have certain patterns of thinking that keep the disorders active and may prevent the occurrence of any changing. These patterns of thinking are believed to be related to expectations, perceptions of allowing drug use, and individuals' beliefs about drug use. These beliefs include thoughts and ideas about pleasure seeking, problem-solving, prominence, and escape that may have been shaped in the childhood (Beck, Wright, Newman, & Liese, 1993, cited in Janis et al., 2009). Schema therapy is among the ones that affect psychological aspects; indeed, it is a modern and integrated therapy that emphasizes the roots of psychological problems, the use of stimulating techniques, and presentation of the concept of coping styles (Yang, Klosco, & Vishar, 2003; translated by Hamidpur & Andouz, 2009). Maladaptive schemas are powerful predictors of pessimism, depression, frustration, and anxiety among people, especially those who have experienced psychological and physical trauma during their lives. In addition, the existence of healthy patterns meets the need for the mental reconstruction of individuals in relation to the belief in each experience (Dalgleish, 2004). In this type of therapy, the diagnosis and identification of early maladaptive schemas will be addressed and this will increase the rate of recovery and reduce the relapse rate (Horlly, & Baker, 2010). The conduct of this research leads to an increase in the individuals' level of knowledge and awareness based on the therapies and this research also examines the effectiveness of the two therapies in physical and psychological symptoms. In addition, these therapeutic methods help patients overcome mental and physical problems in private and social life. Gilbert, & Leahy (2008) indicated that schema therapy has the highest level of experimental support for treating stimulant users. Recent research on drug users suggests that schema therapy is superior to medical therapies and supportive care. In general, a growing body of evidence has been gathered that shows that schema therapy is a durable treatment alternative for people with drug use (Dagbaghi, Asgharnejad, Atef, & Bolhari, 2007). In addition, one can point out the mindfulness therapy whose main mechanism is self-control (Crane, 2008). Mindfulness training requires metacognitive learning and new behavioral strategies to focus on attention, prevent mental ruminations and tendency to disturbing responses, expand new thoughts, and reduce unpleasant psychological symptoms (Aghajani, 2011). Mindfulness helps one to understand that negative emotions may occur, but are

146 Research on Addiction Quarterly Journal of Drug Abuse not a permanent and stable constituent of personality. It also allows the individual to respond to the surrounding events with thinking and reflection rather than to respond imperceptibly to the incidents (Emanuel, Updegraff, Kalmbach, &Ciesla, 2010). Mindfulness is a method for the provision of a better life, the relief of pains, and enrichment and meaningfulness of life (Siegel, 2010). Research has also shown that mindfulness exercises are useful for a significant range of people with various problems. For instance, mindfulness can reduce physical and psychological symptoms, such as sadness and depression (Talebizadeh, Shahmiri & Ja'farifard, 2011), insomnia and sexual problems (Miklowitz, Alatiq, Goodwin, Geddes, & Fennell, 2011), chronic pain (Rosenzweig et al., 2010), and addiction to anything (Siegel, 2010). In this regard, Morone, Lynch, Greco, Tindle, & Weine (2015), and Feldman, Hayes, Kumar, Greeson, & Laurenceau (2007) have also shown that mindfulness can influentially mitigate a large number of physical, mental, mental, chronic health problems, and stress. Various studies have shown that mindfulness is correlated with psychosomatic symptoms; however, it decreases neurotic symptoms (for example: Bear, Ruth, Gregory, Allen, & Kristin, 2004; Janis et al., 2005; Varplanken, Friborg, Oddgeir, Trafimoww, & Woolf, 2007; Kingston, Chadwick, Meron, & Skinner, 2007; Carmody, Reed, Kristeller, & Merriam, 2008). Moreover, related research findings (Feldman, Hayes, Kumar, Greeson, & Laurenceau, 2007; Avants, Beitel, & Margoline, 2009; and Witkiewitz, & Bowen, 2010; Witkiewitz, & Bowen, 2013) have shown that the training of mindfulness and schema therapy has been significantly positive in increasing the effectiveness of the treatment of stimulant dependence, and it is effective in relapse prevention of opioid use. Indeed, these methods are more effective than conventional cognitive behavior therapies. In the same way, these therapies have been effective in the decrease of addicts' psychosomatic symptoms, especially the symptoms of depression, anxiety, and hypochondriasis. In other studies, the training of mindfulness has been effective in reducing depression and anxiety (Mitmansgruber, Beck, Thomas, Stefan, & Schubler, 2011); reducing depression and anxiety and increasing self-esteem (Vollenweider, Liechti, Gamma Greer, & Geye, 2012), and in reducing depression, anxiety, and drug use tendencies (Platter, & Kelley, 2013). Indeed, addiction to stimulants is a biological, psychological, and social issue; and many factors are effective in the etiology of addiction and lead to the onset of drug use and, then, addiction in interaction with each other. The individual, environmental, and social factors, as the underlying background factors, may lead to the purposeful design of programs on the prevention, diagnosis, treatment, and follow-up of addiction (Vernon & Kelman, 2010).

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Method Population, sample, and sampling method A quasi-experimental research design along with pre-test, post-test, follow-up and the control group was used for the conduct of this study. The statistical population of the study included the patients who had presented to the outpatient addiction center in Ahvaz welfare organization in 2014. The number of 75 non- addicted patients was selected using non-probabilistic sampling method. All the population members were given SCL 90 questionnaire so that 45 married male patients with opiate dependency diagnosis who obtained higher scores in each subscale could be selected. Subsequently, these patients were randomly assigned to two 15-participant experimental groups (15 participants each group) and one control group (15). Then, the pretest was administered to all groups and, thereafter, the intervention was administered to the experimental groups, and the post-test was performed. Eventually, after the passage of 3 months, the follow- up was conducted, as well. The criteria for entering the study were the placement in the 19-to-40-year-old age group, the availability of criteria for the diagnosis of opiate dependence on the basis of the fifth edition of the Practical Guide and Diagnostic Manual for Psychiatric Disorders, the passage of more than one week from successful detoxification, and not taking regular antipsychotic medications at the time of admission to the treatment program. Instruments Symptom Check-List (SCL-90-R): This scale contains 90 questions. It was first introduced by Derogatis, Lippman & Covi (1973). Minnesota Multidimensional Questionnaire was used to assess the convergent validity of this scale. The correlation between the scores of the two scales represented the acceptable validity of SCL-90-R. Each of the questions is scored on a 5-point Likert scale from "no" (zero) to "severely" (four). It consist of 9 dimensions of disease symptoms and 3 general indexes. This questionnaire has been used as a diagnostic tool to measure the symptoms in alcohol addicts, individuals with sexual dysfunction, cancer patients, heart failure patients with severe physical illnesses, and students in need of guidance and counseling (Fathi Ashtiani, 2009). The reliability of this instrument has been reported to equal 0.1, 0.91, and 0.97 through split-half, Guttman, and Cronbach's alpha METHODS, respectively (Fooladvand, 2007). In this research, the reliability coefficients of the questionnaire were obtained equal to 0.75, 0.85, and 0.90 through Cronbach's alpha, Spearman-Brown, and Guttman methods, respectively. Procedure In the first experimental group, group schema therapy was presented for 10 sessions, including: First session: Establishing a relationship with the patient's perception and examining how problems are created and survive; Second session: Teaching the patient about the nature of addiction, determining the

148 Research on Addiction Quarterly Journal of Drug Abuse patients and therapist's expectations of the therapy, teaching cognitive- behavioral patterns and creating a therapeutic agreement; Third session: Reviewing thoughts, consequences, and antecedents; identifying compulsions, avoidance, and fundamental beliefs; Fourth session: identifying distorted thoughts, evaluating the clients' thinking cycle and behavior, and training cognitive distortions and identifying them; Fifth session: Correcting ineffective thoughts, changing and modifying cognitive distortions; Sixth session: teaching the schema-driven pattern; teaching schema therapy; and conceptualizing the patient's problem in the form of schemas; Seventh session: identifying the early ineffective schemas; identifying schema-based areas, processes, behaviors, and styles; Eighth session: Modifying the schema of using emotional techniques, discussing past experiences; making imaginative dialogue with parents; discussing the current events; focusing on mental imagery and emotional evacuation; Ninth session: Modifying schemas; using behavioral techniques to remove continuous behavior of schemas; eliminating convictions and increasing healthy coping behaviors; Tenth Session: Modifying schemas; using cognitive techniques; critical review of supporting evidence of schemas; reviewing and examining the contradictory evidence with schemas; working on position/anti- position technique; making illustrative training cards in conflict with schemas; and profit and loss analysis of schemas. In addition, mindfulness sessions included as follows: First session: Giving the pre-test, setting the overall routines by considering the aspect of confidentiality and personal life of individuals, inviting participants to introduce themselves, doing physical examination exercises, assigning homework, discussing and determining weekly sessions, distributing ribbons and pamphlets; Session 2: Performing body review on a daily basis, deeply breathing every day for 10 to 15 minutes, selecting a new activity and doing it mentally, writing a practice report in the registration sheet; Session 3: It started with the practice of seeing and hearing. In this exercise, participants were asked to look and listen in a non-judgmental manner for 2 minutes. This exercise was followed by meditation and was then followed by breathing with attention to physical senses. Talking about homework, doing the three-minute breathing exercise (this meditation consists of three stages: attention to the exercise at the moment of doing, attention to breathing, and attention to the body), doing one of the exercises of mindfulness; Fourth session: Doing sitting meditation with attention to breathing, body sounds, and thoughts (four-dimensional sitting meditation), talking about stress responses and one's reaction to difficult situations and alternative attitudes and behaviors, mindful walking; Fifth session: Doing sitting meditation, performing body mindfulness movements; Sixth session: Doing 3- minute spatial breathing, discussing homework in pair groups, doing exercises titled "Creation, thinking, separate views", performing four meditation exercises for 1 hour; Seventh session: Performing four-dimensional mediation and awareness of whatever that comes to the mind at the moment. In fact, it was Samira Sydasyaban et al 149 focused on the theme: What is the best way to take care of myself? The participants were asked to tell which of their life events were pleasant and unpleasant, and how can they design a program with the inclusion of enough pleasant experiences. Three-minute space breathing was also done at the end of this session; Eighth session: Performing body scan meditation, practicing a 3- minute space breathing, meditating on ways to overcome obstacles, asking questions about the whole session, such as whether the participants achieved their expectations? Do they feel that their personality has grown? Do they feel that their coping skills have been increasing and whether they want to continue their meditation exercises or not? Results The number of 14 participants (11.7%) of the sample was under the age of 20 years, the number of 38 participants (31.7%) were between 20 and 30 years old, and the number of 68 participants (56.6%) were over 30 years old. Sixteen participants (13.3%) were unemployed, 26 participants (21.7%) were workers, 44 participants (36.7%) worked freelance, and 34 participants (28.3%) were employees. The descriptive statistics of the research variables are presented in Table 1 for each test type and group. Table 1: Descriptive statistics of the research variables for each test type and group Pretest Posttest Follow-up Variables Group Mean SD Mean SD Mean SD Schema therapy 3.02 0.38 1.60 0.46 1.61 0.51 Somatic Mindfulness 2.85 0.37 2.09 0.35 2.03 0.32 complaints Control 2.97 0.26 2.99 0.25 3.02 0.21 Schema therapy 2.95 0.27 1.33 0.33 1.46 0.50 O bsession- Mindfulness 2.81 0.36 2.08 0.44 2.03 0.41 Compulsion Control 2.95 0.36 3 0.23 2.98 0.25 Schema therapy 2.87 0.19 1.29 0.30 1.48 0.46 Interpersonal Mindfulness 2.82 0.27 1.94 0.50 1.91 0.47 sensitivity Control 2.85 0.29 2.87 0.27 2.91 0.30 Schema therapy 3.02 0.36 1.60 0.27 1.49 0.60 Depression Mindfulness 2.73 0.33 1.96 0.42 1.68 0.56 Control 2.89 0.23 2.86 0.26 2.87 0.24 Schema therapy 3.05 0.30 1.19 0.44 1.45 0.53 Anxiety Mindfulness 2.84 0.30 1.87 0.51 1.77 0.51 Control 2.89 0.23 2.86 0.26 2.87 0.24 Schema therapy 2.92 0.39 1.48 0.52 1.49 0.50 Aggressiveness Mindfulness 2.91 0.37 2.04 0.52 2.01 0.49 Control 2.75 0.53 2.86 0.47 2.84 0.48 Schema therapy 2.74 0.48 1.58 0.46 1.74 0.50 Phobic anxiety Mindfulness 2.91 0.28 1.89 0.57 1.95 0.43 Control 2.91 0.30 2.94 0.26 2.95 0.26 Schema therapy 2.95 0.39 1.52 0.40 1.41 0.40 Paranoid Mindfulness 2.91 0.40 2.25 0.58 2.19 0.56 Control 2.92 0.43 2.95 0.42 2.90 0.36 Schema therapy 2.95 0.36 1.57 0.46 1.52 0.45 Psychosis Mindfulness 2.91 0.40 2.25 0.58 2.19 0.56 Control 2.93 0.43 2.96 0.42 2.90 0.36

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To analyze the research hypothesis, multivariate covariance analysis was used. One of the assumptions for using this analysis is the equality of error variances. The results of Leven's test are presented in Table 2. Table 2: The results of Leven's test for examining the equality of error variances for each test type Variable Test type F Df Sig. Pretest 0.58 57 0.56 Somatic complaints Posttest 0.50 57 0.61 Follow-up 0.53 57 0.56 Pretest 1.05 57 0.35 Obsession-Compulsion Posttest 1.01 57 0.37 Follow-up 1.20 57 0.18 Pretest 1.20 57 0.30 Interpersonal sensitivity Posttest 1.23 57 0.19 Follow-up 2.33 57 0.10 Pretest 0.99 57 0.37 Depression Posttest 0.55 57 0.57 Follow-up 1.01 57 0.16 Pretest 0.69 57 0.50 Anxiety Posttest 1.18 57 0.23 Follow-up 1.12 57 0.26 Pretest 2.18 57 0.12 Aggressiveness Posttest 0.11 57 0.89 Follow-up 0.15 57 0.85 Pretest 1.12 57 0.30 Phobic anxiety Posttest 1.20 57 0.10 Follow-up 0.81 57 0.66 Pretest 0.16 57 0.85 Paranoid Posttest 1.28 57 0.11 Follow-up 2.36 57 0.10 Pretest 0.22 57 0.79 Psychosis Posttest 2.15 57 0.14 Follow-up 1.09 57 0.34

As it has been shown in Table 2, the assumption of the equality of error variances has been met for all components (P> 0.05). Therefore, multivariate covariance analysis was performed with post-test scores. The results showed that there is a significant difference in the linear combination of the components (P <0.05, F = 21.540, Wilks's lambda = 0.03). To study the patterns of difference, univariate analysis of covariance was used as in Table 3.

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Table 3: Univariate covariance analysis results for examining patterns of difference in the effectiveness of mindfulness intervention and schema therapy Variable Sum of Df Mean F Sig. squares Square Somatic complaints 17.56 2 8.78 72.46 0.0005 Compulsion 23.79 2 11.89 113.44 0.0005 Sensitivity 22.08 2 11.04 131.89 0.0005 Depression 28.54 2 14.27 162.27 0.0005 Anxiety 29.25 2 14.62 92.71 0.0005 Aggressiveness 21.12 2 10.56 53.53 0.0005 Public anxiety 15 2 7.50 46.46 0.0005 Paranoid 20.11 2 10.05 106.46 0.0005 Psychosis 18.85 2 9.92 78.75 0.0005

As it is observed in the table above, there is a significant difference in all components (P <0.001). The Bonferroni post-hoc test was used to examine the difference between the groups (pairwise comparison of the means between the two groups). The results showed that there was a significant difference between the control group and the experimental group regarding the psychological symptoms and its dimensions (somatic complaints, obsession-compulsion, interpersonal sensitivity, depression, anxiety, aggression, public anxiety, paranoia, and psychosis). According to the descriptive statistics, the experimental groups had obtained lower mean values. Moreover, the mean of psychosomatic symptoms and its dimensions in the schema therapy group was lower than that of the mindfulness group. In other words, the effectiveness of schema therapy training in the improvement of psychosomatic symptoms was more than that of the mindfulness training. To examine the stability of the effectiveness, multivariate covariance analysis was run on follow-up scores. The results of this analysis indicated that the difference was significant and the intervention was stable (P <0.05, F = 2.110, Wilks's lambda = 0.46). To study the patterns of difference, univariate analysis of covariance was used as in Table 4. Table 3: Univariate covariance analysis results for examining patterns of difference in the stability of the effectiveness of mindfulness intervention and schema therapy Variable Sum of squares Df Mean Square F Sig. Somatic complaints 0.09 2 0.04 2.08 0.13 Compulsion 0.29 2 0.14 2.86 0.06 Sensitivity 0.17 2 0.08 2.33 0.10 Depression 1.71 2 0.85 11.10 0.0005 Anxiety 0.47 2 0.23 3.20 0.04 Aggressiveness 0.08 2 0.04 0.25 0.77 Public anxiety 0.38 2 0.19 1.72 0.04 Paranoid 0.17 2 0.08 2.06 0.13 Psychosis 0.05 2 0.02 0.72 0.49

As it has been shown in Table 4, there was a significant difference in the components of depression, anxiety, and public anxiety. The Bonferroni post-hoc

152 Research on Addiction Quarterly Journal of Drug Abuse test was used to examine the pairwise comparison of the groups. The results showed that there is a significant difference between the control group and the experimental groups in these three components. However, there was no significant difference between the two experimental groups. Discussion and Conclusion This study aimed at comparing the effectiveness of schema therapy and mindfulness in psychosomatic symptoms in stimulant drug users. Regarding the findings of this study, it can be concluded that the scores obtained in the psychosomatic symptoms in the experimental groups had experienced a reduction compared to the control group's scores. Moreover, schema therapy was found to be more effective than mindfulness. This finding is consistent with previous findings reported by Dabaghi et al. (2007), Bear et al. (2004), Janis et al. (2005), Feldman et al. (2007), Varplanken et al. (2007), Kingston et al. (2007), Gilbert & Leahy (2012), Morone et al. (2015), Avants et al. (2009), Horlly & Baker (2010), Rosenzweig et al. (2010), Siegel (2010), Witkiewitz, & Bowen (2013), Miklowitz et al. (2011), Mitmansgruber et al. (2011), and Platter, & Kelley (2012). To interpret this finding, one may argue that, in fact, individual emotions and mood are socially useful and can be used to convey feelings to others, to produce social interaction, and to create and eliminate relationships with others (Rio, 2011). Most substance abusers have a negative thinking system about themselves as well as their current and future experiences. The negative barriers are interpreted as impassable barriers, even when there are more positive attitudes about the individual's experiences. They tend to the worst possible interpretation of what has happened to them. It can be said that the lack of experience, loneliness, grief, hostility, inability to communicate probably, and the lack of facilities for gaining positive emotions lead the individual towards drug use. Stimulatory effects of stimulant drugs increase false mood and a type of transient euphoria in the individuals, and motivate the use of stimulants and produce positive brain responses to substance use and, ultimately, addiction. The adjustment and regulation of these factors through psychological training, such as schema therapy and mindfulness can play an effective role in controlling the destructive functions of individuals because emotions act as solutions to the challenges, stresses, and problems of life (Rio, 2011). In other words, since emotions play an important role in life, the training of such methods to the individuals who use narcotics, especially stimulants can regulate psychosomatic symptoms and emotions while it has a relationship with acceptance and positive social interactions (Saarni, 2012). This can lead to effective meditation with tempting and stressful situations (Gross, 2010) and increase activity in response to social situations (Tugade & Frederickson, 2008). In this regard, the teaching of mindfulness and schema therapy can make individuals aware of their positive and negative emotions and can bring their timely acceptance and expression of these emotions, can play an important role in reducing destructive behaviors and Samira Sydasyaban et al 153 increasing the desired behaviors to prevent drug use. It can be argued that both of these training methods lead to the modulation of negative psychosomatic symptoms, consequent modification of the judgment and positive perception about the self among stimulant consumers due to the use of similar techniques, such as awareness, acceptance, and reconstruction of maladaptive foundations. This, in turn, can be effective in reducing their consumption behaviors. In addition, stimulant users cannot use their emotions in useful ways in different situations of life both in happiness and sadness, and this causes other problems, including negative perceptions of the self, concerns about social status, anxiety, and inappropriate family and social behaviors in them. They all can pave the way for tendency to substance use in order to reduce these nervous pressures. Moreover, although schema therapy and mindfulness have individually been adjusted in the origin, the presence of group factors facilitates the activation of schema therapy techniques and has significant compensatory effects on central schemes, such as exclusion, social isolation, distrust, and emotional deprivation. In fact, due to the establishment of close links and relationships between the group members, the possibility of real exposure and the linking of the initial experiences with schematic processes of here and now in a supportive environment will also increase. On the other hand, the increase of the learning opportunities leads to the reinforcement of the sense of self-efficacy and risk- taking among the members for the conduct of new behaviors. In the same way, the group members also learn to empathize and meet their emotional needs in the group instead of abandoning their emotions via taking refuge in problematic addictive behavior (Farrell, Shaw & Webber, 2010). An important point in the application of group therapy is that it is cost-effective, and facilitates and expedites the treatment process. Many addicted patients suffer from some kind of depression and have a unique feeling for their problems and thoughts. This unique feeling exacerbates the social isolation of these patients and strengthens the social isolation of being unique. Group therapy easily makes it possible for some of these people to come together in one place and interact with each other and talk about similar problems. In this regard, the loss of these negative emotions not only makes people more relaxed and comfortable but also helps them develop relationships outside of the healthcare environment. In addition, the group members help each other during the course of the interaction, support each other during the course of the treatment, and assure each other, give each other suggestions and insights. Reference Aghajani, A. (2011). 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The Diagnostic Role Abstract of Delayed Reward Objective: The aim of this study was to evaluate the diagnostic role of delayed Discounting and reward discounting and sensation seeking Sensation Seeking in people with stimulant and opiate disorders. Method: This study employed in People with a causal-comparative research design. The target population of this study Stimulant and Opiate included all patients with stimulant Use Disorders and/or opiate disorders who referred to medical centers where 90 persons (45 stimulant users and 45 opiate users) were selected by convenience sampling method and completed Monetary-Choice Farshad Ahmadi, Jafar Hasani, Questionnaire, Sensation Seeking Scale Ali Reza Moradi, Saber Form-V. Results: The results of the Sajdeipoor diagnostic function showed that delayed reward discounting and sensation seeking variables have grouped 86.66% of stimulant users and 84.44% of opiate Farshad Ahmadi correctly. In other words, generally, M.A. in Clinical Psychology, University 85.60% of the sample units were of Kharazmi, Tehran, Iran classified correctly. Conclusion: Delayed reward discounting and Jafar Hasani sensation seeking played a significant Department of Clinical Psychology, role in the differentiation and diagnosis of University of Kharazmi, Tehran, Iran, stimulant and opiate disorders. Therefore, E-mail: [email protected] it is recommended that these two Ali Reza Moradi disorders be given special attention in the Professor of Clinical Psychology, pertinent prevention and treatment University of Kharazmi, Tehran, Iran programs. Saber Sajdeipoor Keywords: delayed reward discounting, Ph.D. in Health Psychology, University sensation seeking, opiate and stimulant of Kharazmi, Tehran, Iran disorders

Research on Addiction Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir 158 Research on Addiction Quarterly Journal of Drug Abuse

Introduction One of the biggest problems that has been affecting human societies over time is the phenomenon of addiction. According to the definition presented by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the main feature of each type of addiction and substance-related disorder, which consists of ten classes, is a set of cognitive, behavioral, and physiological symptoms that indicate that an individual continues to use drugs despite the important problems that may happen to him/her. From among the 10 classes available in substance abuse disorders, opioid addiction is one of the oldest and, at the same time, the most common type of addiction. The 12-month period of opioid prevalence is observed about 37% among adults aged 18 years and over. The comorbidity of other psychiatric disorders with opioid use, including mild depression, disordered depression, major depression, and antisocial personality disorder is common. Other types of drug abuse are related to stimulant drugs. The high prevalence of stimulant use has become one of the most important health problems in recent years worldwide. The 12-month period of the prevalence of amphetamine-type stimulants in the United States has been estimated to be 2% among the adolescents aged from 12 to 17 years and has been similarly estimated about 2% among the people aged over 18 years. Its comorbidity with psychological disorders, such as post-traumatic stress, antisocial personality disorder, attention-deficit/hyperactivity disorder, and gambling disorder is common (American Psychiatric Association, 2013). One of the factors that plays an important role in addiction and can affect the vulnerability, exacerbation, relapse, and craving of substance abuse and addiction is a phenomenon called "delayed reward discounting" (MacKillop et al., 2011). Delayed reward discounting was actually produced by the observation of people's decisions in different situations when they had different values. People are always faced with choices to make in everyday life between the current time alternative with a lower value and the future time alternative with a higher value. This phenomenon, influenced by various cognitive and emotional factors, has a great influence on individual performance in all aspects of life as well as in the field of psychiatric disorders. This component obviously exists in drug dependence, gambling disorders, obesity, attention-deficit/hyperactivity disorder, schizophrenia, and a wide range of health behaviors (Sheffer et al., 2012). Delayed reward discounting is a behavioral economic indicator for impulsive decision-making (Madden, & Bickel, 2009). In fact, people with addiction are defective in ignoring and neglecting immediate rewards and they sacrifice the larger and better rewards that are to receive in the future f smaller for the sake of and instant rewards. In this regard, no domestic research has been conducted, but international research findings in this area indicate that delayed reward discounting is one of the variables that is highly available in addicts. This Farshad Ahmadi et al 159 variable implies the concept that they take precedence over the receipt of smaller instant rewards than larger delayed rewards (MacKillop et al., 2011). Delayed discounting shows that the value of getting reward ceases with an increase in delay. This is in line with the findings of human and non-human research where people sacrifice larger, but delayed rewards for immediate and smaller rewards, and label such a choice as impulsiveness and label its opposite choice as self-control (Ainslie, 1974). Delayed reward discounting is also used in medical treatment (Bickel, Odum, & Madden, 1999). This variable is an indicator for determining the degree of willingness to impulsiveness, self- control, disinhibition, arousal, and experience level or delayed emotions. Delayed reward discounting can be considered as one of the consequences of emotion regulation or the level of sensation seeking in individuals because the proper management of emotions and the inappropriate control of sensation seeking can have a direct effect on individuals' delayed reward discounting (Kopstein, Crum, Celentano, & Martin, 2001). ) Considering the important role of delayed discounting in the development, prevention, and treatment of a wide range of substance use disorders (MacKillop et al., 2011), as well as its high correlation with sensation seeking in opiate and stimulant use disorder, which have a high comorbidity with each other, the investigation of the diagnostic role of delayed reward discounting in stimulant and opioid use disorders and the determination of the similarities and differences between these two disorders based on this variable assume significant importance. Another effective factor in the process of substance abuse is sensation seeking (Wagner, 2001). Zuckerman defines sensation seeking as a trait that is characterized by diverse, fresh, new, and complex emotions and experiences, and a willingness to address the physical, social, and financial risks of these experiences (Desilva, 1999). Sensation seeking is considered to have four dimensions (Zuckerman, 1971; Zuckerman, 1994), which include: 1. Thrill and adventure seeking: the desire for doing the physical activities that have speed, danger, and freshness; 2. Experience seeking: It refers to the search for new experiences by means of travel, music, art or heterogeneous lifestyle with the individuals who have similar tendencies; 3. Disinhibition: It refers to the tendency to impulsiveness, rebelliousness against social norms, and preference of unpredictable situations; and 4. Boredom susceptibility: It refers to the hatred of repetitive experiences, routine affairs, and predictable people. The high level of sensation seeking is not inefficient, but its ineffectiveness appears to be found in substance abusers (Mitchell, 1999). In addition, Zuckerman describes sensation seeking as the individuals' need to achieve an optimal level of arousal and its preservation. According to Zuckerman, the optimal level of arousal in sensation seekers is higher than those who do not have this feature (Aleston, 1994). Zuckerman believes that a biological model of sensation seeking is correlated with an optimal level of catecholamine activity. In addition, he highlighted the role of dopamine in the primary reward system and reported the

160 Research on Addiction Quarterly Journal of Drug Abuse presence of a link between sensation seeking and this system. In sensation seekers, the dopaminergic system is less active; therefore, some people use drugs to search for new stimulants that increase the activity of this system (Loas et al., 2001). The three characteristics of thrill seeking, experience seeking, and disinhibition (which are the important dimensions of sensation seeking) are in fact the dimensions that Madden, & Bickel (2009); Green, Fisher, Perlow, & Sherman (1989) described in the description of delayed reward discounting with such titles as non-self-control, impulsiveness, and experience of immediate emotions. Therefore, considering the important role of sensation seeking in people's tendency to a wide range of substance abuse disorders (Michel, 1999), the diagnostic and differential role of this component in the disorder of drug and opioid use, and the determination of similarities and the differences between these two disorders assumes significant necessity. As it was stated above, delayed reward discounting and sensation seeking have a considerable role in the process of substance use disorder, including development, treatment, and prevention. These factors have been investigated in numerous studies on various types of substance use disorders, and it has been shown that the malfunction of these factors plays a major role in drug use disorder. Previous studies confirm the existence of delayed reward discounting and sensation seeking in both groups considering the high comorbidity of opioid and stimulant use. It was also shown that these two disorders are characterized by delayed by a high level of delayed reward discounting (MacKillop et al., 2011) and inappropriate sensation seeking (Alipour, Sa'eedpour & Hassani, 2015). However, the discrete and joint role of these variables in opiate and stimulant use disorders has not been studied. Therefore, the purpose of this study was to investigate these factors in drug and opiate use disorders so that the better recognition of these two disorders can be reached and, ultimately, this research h questions can be responded to: Do sensation seeking and delayed reward discounting have a diagnostic role in these disorders? Method Population, sample, and sampling method The present study was a causal-comparative research. The population of this study consisted of the men with opiate and stimulant use disorders who had referred to one of the treatment centers and addiction treatment clinics in Tehran and Marivan during the period of 2014-15. According to the inclusion criteria, 45 opioid patients and 45 patients with stimulant use were selected as the sample units. The entry criteria included informed consent, minimum reading and writing literacy, no physical diseases, no use of psychiatric drugs, the age range of 18 to 45 years, and diagnosis of stimulant and opioid drug abuse based on expert opinion of the center and semi-structured interview of SCID-I.

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Instruments 1. Semi-structured clinical interview of ISCID: This interview is used to diagnose major axis I disorders based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (American Psychiatric Association, 1999). One of the objectives of constructing and expanding this structured interview was to provide an efficient and user-friendly instrument so that the clinical assembly could benefit from the advantages of structured interviewing. This interview has been designed to meet the research and therapeutic needs. After the release of DSM-IV-TR, some amendments were made on it each year (by 2010) based on research findings and clinical experience to adapt the instrument in the best way. These amendments have also been compiled, translated, and implemented in the Persian version. In recent pieces of research, the diagnoses used in this structured interview have been proved to enjoy a higher validity than the standard clinical interviews (Mohammadkhani, Jokar, Jahani Tabesh & Tamanayifar, 2010). 2. Monetary-Choice Questionnaire: This questionnaire was developed by Kirby, Petry, & Bickel (1999), and is a valid self-report tool for measuring delayed reward discounting. The respondents need to respond to 27 two-choice items with smaller immediate rewards and larger delayed rewards. This is a one- factor test and does not have any sub-scale. The responsive patterns of temporal discounting specify the performance in individuals. The known K value consists of three levels of measurements from 25 to 35 dollars (small), 50 to 60 dollars (average), and 75 to 85 dollars (large). Participants in this questionnaire select the hypothetical rewards that are planned to measure delayed reward discounting (Johnson & Bikel, 2002; Lagorio, & Madden, 2005; Robbins, Curran, & de Wit, 2012). The K values of delayed reward discounting have a largely positive correlate with each other in three levels of small, medium, and large measurements (P <0.001, R = 0.86-0.96). Therefore, the average value of K is considered as the indicator of delayed discounting in order to avoid the first type error. Kirby et al. (1999) reported Cronbach's alpha coefficient of this scale in the range of 0.83 to 0.95. The reliability and validity of this test are in progress in Iranian culture. 3. Sensation Seeking Scale (Form V): This scale has been developed by Zuckerman. Form V is a shortened form of the fourth version that was produced in 1978. Many studies have been conducted on this scale based on factor analysis where four sub-scales, namely "thrill and adventure seeking", "experience seeking", "disinhibition", and "boredom susceptibility" have been extracted. For each of the factors, ten items have been considered. There are a total number of 40 items in this scale. The items of this scale are two-part questions where the two parts of each item are separated from each other by two components, namely "A" and "B" so that the audience can respond to one component of each item. The raw score in each of the four factors is from zero to ten and the scoring is specified based on the key sheet. Then, the scores earn their true value score by

162 Research on Addiction Quarterly Journal of Drug Abuse referring to the conversion table. Cronbach's alpha of the scale has been reported in the range of 0.83 to 0.86. Results The descriptive statistics of the demographic variables are presented in Table 1 for each group.

Table 1: Descriptive statistics of demographic variables for each group Variable Group N. Mean SD Stimulant users 45 26.02 6.04 Age Opiate users 45 27.96 7.62 Stimulant users 45 13.01 2.78 Education Opiate users 45 12.64 2.95

Independent t-test results showed that the two groups were matched in terms of age (P>0.05; t = 0.74) and education (P>0.05; t = 0. 53). The descriptive statistics of the research variables are presented in the following table for each group.

Table 2: Descriptive statistics of the research variables for each group Stimulant users Opiate users Variable Mean SD Mean SD Delayed reward discounting 40.27 2.54 38.74 2.78 Sensation seeking (experience seeking) 8.18 1.23 5.84 1.73 Sensation seeking (adventure) 7.22 1.92 5.69 2.03 Sensation seeking (boredom susceptibility) 2.49 1.75 4.18 1.61 Sensation seeking (disinhibition) 7.18 1.71 6.71 2.06

In the beginning, it should be noted that the analysis of the diagnostic function is considered as the multivariate analysis of variance analysis in various sources. For this purpose, the results of investigating the difference between the groups in the predictor variables using multivariate analysis of variance are considered as one of the main assumptions of diagnostic function analysis. One of the assumptions of MANOVA is the equality of covariance matrices. The results of the M box test showed that this assumption has been met (P>0.05, F = 1.86). The results of multivariate analysis of variance were indicative of the presence of a significant difference between the two groups (P< 0.001, F = 32.18, Wilks's lambda = 0.22). Univariate analysis of covariance was used to examine the patterns of difference as follows.

Table 3: Results of ANCOVA for examining the patterns of difference Variable Df F Sig. Delayed reward discounting 88 7.43 0.001 Experience seeking 88 54.18 0.0005 Adventure 88 13.73 0.0005 Boredom susceptibility 88 22.57 0.0005 Disinhibition 88 1.82 0.102

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As it has been shown in Table 3, there is a significant difference between the two groups in all variables other than disinhibition. To determine the diagnostic role of predictive variables in the group membership of the research participants, stepwise diagnostic function analysis was used, and the pertaining results are presented in the following table.

Table 4: Results of the stepwise diagnostic function analysis Steps Entered variables Wilks's lambda F Sig. 1 Experience seeking 0.221 54.16 0.0005 2 Boredom susceptibility 0.196 44.27 0.0005 3 Adventure 0.173 35.62 0.0005 Delayed reward 4 discounting 0.158 28.44 0.0005

Table 4 shows the variables that have a significant contribution to the diagnostic function through the stepwise method in the order of importance. The results of the analysis of diagnostic function and the significance test are presented in the following table.

Table 5: Results of the diagnostic function analysis Function's Diagnostic Percentage Canonical Wilks's Chi Eigen Df Sig. function value of variance correlation lambda square 1 1.263 100 0.792 0.217 73.484 4 0.0004

Since there are two comparison groups, a diagnostic function has been obtained. According to the results of Table 5, the Eigenvalue of the function that makes a differentiation between opioid and stimulant user groups is equal to 1.263, which explains 100% of the variance. The canonical correlation of this function equals 0.79, and the chi-square value is equal to 73.4484, which indicates the significance of the created distinction in the groups has emanated from this function. Table 6 shows the correlation coefficients of the predictive variables entered into the model and the diagnostic function.

Table 6: Correlation coefficients of predictive variables and diagnostic function Predictive variables Diagnostic function Experience seeking 0.57 Boredom susceptibility 0.45 Adventure 0.37 Delayed reward discounting 0.28

Experience seeking has made the highest contribution to the created function and the other variables have been listed in the order of importance. The final results and summary of the diagnostic function analysis are presented in Table 7 for each group.

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Table 7: Final results of diagnostic analysis for each group Group Stimulants Opiates Total Stimulants 39 6 45 Frequency Opiates 7 38 45 Stimulants 86.66 13.34 100 Percentage Opiates 15.56 84.44 100

As it has been shown in Table 7, the diagnostic function could correctly group 86.66% of stimulant users and 84.44% of opiate users. In other words, 60/85% of the total participants have been classified correctly. Discussion and Conclusion The present study aimed to analyze the diagnostic role of delayed reward discounting and sensation seeking in stimulant and opioid users. The results indicated that delayed reward discounting and sensation seeking were more effective in stimulant users than in opioid users. The results of studies done by Robles et al. (2012), Johnson et al. (2007), Kirby et al. (1999), Baker et al. (2007), and Bickel et al (1999) showed the significant effect of delayed reward discounting in drug users was significantly higher than that in non-drug users. However, no study thus far has compared stimulant users and opioid users in this regard. To explain these findings, one can mention the preference for instant rewards, more pleasure, and craving for drug use in substance users. Addicts have the power to control and have the ability to delay rewards and pleasures to a lesser extent, which causes the persistence, relapse, and craving for drug use (MacKillop et al., 2011). One can also mention the phenomenon of tolerance among substance users. Substance users turn to the use of higher amounts of substances for the acquisition of initial immediate pleasure and fun. In addition, since the use of stimulants is associated with instant rewards and pleasures (Semple, Zians, Grant, & Patterson, 2005); therefore, the degree of delayed reward discounting in stimulants consumers is more than that in opioid users. On the other hand, researchers have reported a close relationship between impulsiveness and delayed reward discounting and have labeled delayed reward discounting as impulsiveness (Ensil, 1975; Logue, Rodriguez, Pena-Correal, & Mauro, 1984), and a significant correlation between these two components and addiction (Baldacchino, Balfour, Passetti, Humphris, & Matthews, 2012). Stimulants have a more powerful effect on impulsiveness, and the rate of relapse is directly related to impulsiveness; in addition, impulsiveness in stimulant users is higher than that in opioid users (Miller et al., 2001). Therefore, it can be claimed that delayed reward discounting is higher in stimulant users than that in opioid users. Researchers have defined delayed reward discounting as a behavioral economic indicator for impulsive decision-making (Madden & Bickell, 2009). In fact, addicts are defective in ignoring and neglecting immediate rewards and Farshad Ahmadi et al 165 sacrifice the larger and better rewards that are to receive in the future for the sake of smaller and instant rewards. In this regard, international research findings in this area indicate that delayed reward discounting is one of the variables that is highly found in addicts (MacKillop et al., 2011). Therefore, according to previous findings and studies, delayed reward discounting is more likely to occur in stimulant users than opioid users, and it is necessary that prevention and necessary therapies be conducted by modifying this variable in such individuals. This signifies the importance and the need for the assignment of special attention to this variable, which can create a variety of psychiatric and psychological disorders in individuals, and can also provide the grounds for positive outcomes throughout life from educational performance to addiction treatment (Hirsh, Morisano, & Peterson, 2008). In addition, the results of data analysis showed that sensation seeking is higher in the group of stimulant users than that in the opioid users. This finding is consistent with the research findings reported by Ravson, & Washton (2002); Siqueira, Bodian, & Rolnitzky (2000); and Alipour, Sa'eedpour & Hassani (2015). To interpret this finding, one can refer to the malfunctioning of in the dopaminergic system that is associated with the search for new and high-risk behaviors (Lesch et al., 1996), and it is also possible to mention factors such as the existence of a more active behavioral activation system, which is related to sensation seeking. This system is known as the one that explains the identified substance use disorders (Fowles, 1994). Since one of the most important personality traits in people's vulnerability to risky experiences, such as tendency to substance abuse is sensation seeking and may open the door to new experiences, it can disinhibit the high-risk behaviors and provide a means to escape from monotony and boredom (New Comb, & Mc Gee, 1991). In addition, considering that stimulants create risky behaviors and lead to the avoidance of monotony and boredom to a greater extent than opiates do, stimulant users are likely to have the highest inclination to making new and risky experiences. In this way, they can reach the level of arousal and predict the fewer risks of the addictive and stimulant substances. Hence, there is a higher level of sensation seeking in stimulant users than that in opiate users (Leeman, Hoff, Krishnan- Sarin, Patock-Peckham, & Potenza, 2014). Accordingly, it can be said that the inappropriate level of sensation seeking predicts the individual's tendency toward different types of drugs. Moreover, the more the level of sensation seeking in individuals is adjusted through positive methods, the lower their tendency towards drug use (Hansen, & Breivik, 2001). One of the limitations of the present research was that it was not possible to do research on women for various reasons and, thereby, the current research was done only on the affected men. It is suggested that the role of gender be examined in future research. In therapeutic and diagnostic interventions, the role of delayed reward discounting and sensation seeking should be assigned special attention in terms of etiology, continuity, and therapeutic treatment.

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Abstract Structural Model of Objective: The aim of this study is to explain the structural model based on Psychosocial Factors the mediating role of co-dependency in in the Addiction psychological and social factors with adolescents' addiction potential. Potential of Methods: This study was descriptive Adolescents with and structural equation modeling. The study population included all boy and Mediating Role of the girl students in District 16 of Education Co-dependency in Tehran who attended public schools in the second period in Academic Year 2015-2016. The sample comprised 400 students who were selected using multi- stage cluster sampling and responded to Fariba Pazani, Ahmad Borjali, Addiction Potential Scale, Stonebrink's Hassan Ahadi, Adis Kraskian- co-dependency scale, Keen's social health, and psychological factors (risk Mojembari factors and protective substance(. Results: The results showed that model fit indices after modification and Fariba Pazani deletion of non-significant relationship Ph.D. student of Health Psychology, Islamic between some subscales of variables Azad University, Karaj, Iran and covariance social factors; both co- dependency and addiction potential Ahmad Borjali Associate Professor of Psychology were desirable. Conclusion: It seems Department, Allameh Tabatabai University, co-dependency as a learned behavior, Tehran, Iran including self-neglect and loss of E-mail: [email protected] individual identity are formed under the influence of psychological factors and Hassan Ahadi Professor of Health Psychology, Islamic Azad mediate relationship of these social University, Karaj, Iran factors and psychosocial factors and readiness for addiction potential. Adis Kraskian-Mojembari Keywords: Psychosocial factors, Assistant Professor of Psychology Department, Islamic Azad University, Karaj, adolescent addiction potential, co- Iran dependency

Research on Addiction Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir 170 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Today, social harms are among the major concerns of human societies. Each society, in accordance with its conditions, culture, the transition and development process, its growth and degeneration, faces a variety of problems that have undeniable effects in the development of society. Smoking, alcohol drinks and other illicit drugs by adolescents are one of the most significant health, psychological and social challenges somehow engaging most countries in the world and incurring many problems on societies (Hawkins, Catalano, & Miller, 1992). The adolescence is a significant evolutionary period that is associated with identification. Part of this growth process is an excitement seeking that manifests itself in the form of unhealthy sexual behaviors, alcohol consumption, smoking, and other substances. Consumption of substances among adolescents has different causes. Some adolescents consider alcohol and drugs as a kind of outbreak and as a way of facilitating social ties and increasing dignity among peers. Some adolescents consume substances to seek pleasure, combat boredom, satisfy curiosity, and escape or cope with problems (New Hampshire, 1995). Botvin & Kantor (2000) showed that the average age of the first drink of alcohol, smoking cigarettes and other substances among students was about 12 years of age. While the average age of the first consumption of hashish was reported at about 14 years of age. Typically, the first cigarette experience occurs between the ages of 11 and 15 (Wilford, 1992) and leads to regular consumption in two to three years (Pierce & Gilpin, 1996). Addiction as a social harm, along with problems such as unemployment, poverty, divorce, etc. influenced by the individual psychological reasons which are formed in the context of the family, with his peers and in society. Due to its numerous consequences in the political, economic and cultural system, the country requires serious attention and determination to reduce its damage, especially in the main target population, i.e. adolescents. Effective factors in addiction such as low psychological capital, lack of communication skills, poor self-concept and so on along with biological, spiritual, cultural and social factors, indicate the complexity of this social harm. Adolescence is the transition from childhood to adulthood with features such as rapid physical, emotional and cognitive changes, the process of identification, peer influence and excitement seeking provide a good context for influencing social harms especially addiction. Co-dependence as a personality trait formed in the context of a person's social relationship is a connect loop to the lack of individual and social health and is the basis of many addictive behaviors, especially drug use. Mohammadkhani (2005) surveyed the prevalence of alcohol consumption, cigarettes and other drugs in high school students in 10 provinces of the country and showed that a total of 19% of students at least once smoked cigarettes, alcoholic beverages or other substances. Based on the findings of this study, 14.7% of students reported smoking cigarettes, 9.8% alcohol consumption Fariba Pazani et al 171 and 2.5% of students reported other substances. Given the fact that no factor alone is a necessary and sufficient condition for substance consumption and consumption of substances is the result of a combination of various factors, in order to cope with this phenomenon, it is necessary to consider the role of aggravating factors in the tendency to consume substances simultaneously. In preparation for the use of substances, two psychological and social areas were considered. In the psychological dimension, the risk of substance abuse and delinquent behaviors is often seen in people who have behaviors such as excitement seeking, low avoidance of harm, and poor control of impulse (Kodjo, & Klein, 2002; Mohammadkhani, 2007). Other factors beyond the substance consumption include the unfamiliarity of adolescents with life skills and unfamiliarity with happy ways of life and being sociable. In this regard, Botvin and Griffin (2004) consider decision-making skills, coping with anxiety, communication skills and courage. Kuperminc and Allen (2001) investigated the relationship between social orientation and social problem solving skills and behaviors. The findings showed that the positive social orientation plays a significant role in the amount of delinquency behaviors and drug consumption (Kuperminc & Allen, 2001; quoted by Mohammadkhani, 2007). In terms of psychological characteristics, we can point to factors such as self-concept and optimism that are expressed in the framework of resilience by the adolescents who, despite the existence of factors such as poverty, and the inefficient family, have been successful in their lives. Negative self-concept is one of the effective factors in substance consumption that adolescents consume to compensate for their shortcomings and to establish relationships with peers with anti-social behaviors. Disappointment and pessimism in the future discourage people from changing their way of life and solving their problems, and thus turn to substances to evade discomfort. Regarding the social factors, Durkheim believes that any kind of disconnection between the individual and the society in such a way that people are not absorbed in the social frameworks provides an anomaly and conducive to the growth of social deviations. According to Keyse (1998), social health means a person's personal report of the quality of its relationship with others. In his view, social health is a combination of several factors that in total show how well a person is performing in his social life, for example, as a neighbor, partner and citizen. He believes that social health includes five components, which include social integration, which means assessing the individual's quality of interrelationship in society and social groups. Social contribution represents an individual's assessment of his social value. The social acceptance is the individual's interpretation of society and the characteristics of others. Social coherence is about people who hope for the future of the community and believe that they themselves and others benefit from the potential for social development and that the world can be better for them and for others. In the context of the individual and social anomy, a kind of addiction is formed as co-dependence, in

172 Research on Addiction Quarterly Journal of Drug Abuse which the individual does not value himself much. These people enter into relationships that are unilateral and emotionally malicious or associated with abuse. This type of addiction was used initially to describe the relationship that exists among the family members of the alcohol addict, but it can include all those who live in abusive families and social anomies. Durkheim identifies two types of anomy: one at the individual level and the other at the social level. Anomy at the individual level is a kind of individual feeling of abnormalities that are accompanied by disorders within one person and is, in essence, a sense of abnormality, emptiness, and powerless. In social anomy, individual emotions are measured in relation to the social system. When there is no social balance, the person lacks the means to regulate his behavior and adapt it to the social criteria prescribed and also lacks the sense of collective support and social support. Here, we can say that social factors are effective on both types of disorder, that is, the sick society produces sick people and the increase in the sick people in the community itself leads to the sickness of the community (Yazdanpanah, 2003). Wanderman and Florin (2000) argue that participation in the community through participation contributes to the idea that individuals have an ideal in life and is indicative of the health of individuals. Gamson argues that participation in social movements encompasses the development of personal identity and represents an opportunity for self-understanding. According to Hughey, Speer, and Peterson (1999), community participation gives young people the opportunity to expand social relationships with people other than their families and peers in different social situations and help them develop a proper understanding of themselves and others, and thereby reinforce their social identity (Cicognani, Menezes, Nata, & Marcon, 2007). Socialization means the harmonization and alignment of the individual with values, and norms and social group attitudes is one of the main tasks of education for students. The transformation of a heterogeneous society into a unified and integrated society through the development and strengthening of culture and common identity is a significant function of the educational system. The study of social factors emphasizes the role of education in the transfer of culture, socialization, autonomy reduction, and the strengthening of social order along with innovation and change. Social health and social capital with significant components of trust, solidarity and social participation are one of the most significant indicators of development. With the decline in health and social capital, we will see discrimination, inequality, migration, lack of public trust, reduced social participation, the decline of charity, the increase in deviations and addiction, and the collapse of the family and the intergenerational gap (Akbari, 2004). Considering the above, the main problem of the researcher in this study was to develop a structural model considering the intermediary role of co- dependence in relation to psychological and social factors with adolescent's addiction potential and its fit according to the experimental data. The main Fariba Pazani et al 173 question of the research is whether the co-dependence mediates the effect of psychosocial factors on the addiction potential? Method Statistical Population, Sample and Sampling Method The research method is descriptive correlational. The statistical population of the present study comprised female and male students who were studying the second period of public high schools in the Academic Year 2015-16 in district 16, Tehran. The age range of these students was 16-18. Based on the random cluster sampling method, in the first stage, two high schools were randomly selected from 7 high schools for the two sexes. In the second stage, among the second class high schools, a class was randomly selected from among the second period high schools. According to many researchers, the minimum sample size for modeling is 200 people (Hu, 2008; quoted by Naseri Palangard, Sadeghi Boroujerdi, Yousefi & Sadeghi Kalani, 2016). Durbin and Klein (2006) also believe that minimum 10 and maximum 20 samples are needed in exploratory factor analysis for each variable. In this study, the sample population was 400 in total, 200 female students and 200 boys. Instruments 1. Addiction Potential Questionnaire: This questionnaire consists of three subscales of addiction potential, addiction admission, and alcoholism, derived from the Minnesota multidimensional questionnaire. The addiction potential scale has been developed as an indicator of correlated personality factors of addictive disorders by Weed, Butcher, Mckenna, and Ben-Porath (1992) and includes 39 questions. The scale of addiction admission, in principle, measures the scale of admission or acceptance, which was developed by Weed et al. (1992) to measure the likelihood of accepting alcohol or medication problems. This scale consists of 12 questions. The alcoholism scale was also developed by MacAndrew (1965) and originally designed to distinguish outpatient mental patients who do not have substance and alcohol abuse, and it was made up of people under treatment for alcohol abuse with 49 questions. On the scale of addiction potential, the female and male cut-off scores are 23 and 24, respectively. On the scale of addiction admission, the women's cut-off score is 2 and male 3. Finally, in the scale of alcoholism, the cut-off score is 20 for females and 22 for males. In Minooie and Salehi's research (2003), entitled the practicality of credibility, validity and standardization of addiction potential tests, addiction admission and alcoholism in order to identify those exposed and susceptible to substance abuse among the students the results showed that the two groups of addicts and students differed in scores, which shows a reasonable validity. The validity of the test was also reported by Minooei and Salehi (2003) by Cronbach's alpha 0.54 and 0.5 by making it into two halves.

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2. Stonebrink's co-dependence questionnaire: This questionnaire was developed by Stonebrink (1988), which consists of 29 items and 4 subscales of need for control (7 questions), interpersonal dependence (8 questions), self- alienation (7 questions) ) and interconnectedness (7 questions) that are used to measure the co-dependence in the family and friends of drug addicts. The score is in the form of a 4-degree Likert point that is considered for "never", "sometimes", "often" and "always", for points 0, 1, 2, 3, respectively. Questions 1, 5, 9, 13, 17, and 25 are the subscale of the need for control; Questions 2, 6, 10, 14, 18, 22, 26, and 29 sub-scale of interpersonal dependence; Questions 3, 7, 11, 15, 19, 23, and 27 sub-scales of self-alienation; questions 4, 8, 12, 16, 20, 24, and 28 are sub-scales of interconnectedness. The alpha coefficient for the total was 0.79, for the need to control 0.45, for interpersonal dependence is 0.75. To assess the convergent validity, a significant relationship was found between its scores and the poor performance family. 3. Keyse's Social Health Questionnaire: The questionnaire consists of 20 items and 5 subscales, which has been developed by Keyse at the McArthur Scientific Foundation in 2004. In several studies, its validity and credibility were tested. Questions 1 to 4 pertain to the subscale of social flourishing, questions 5- 7 are related to the subscale of social solidarity, questions 8 to 10 belong to social coherence, questions 11 to 15 belong to the subscale of social acceptance, and questions 16 to 20 belong to the subscale of social participation. The scoring for this questionnaire is based on the 5-point Likert scale as very high, = 5 to very low = 1. Its reliability for the whole scale was 0.78, social integration was 0.71, social acceptance 0.74, social participation 0.74, social flourishing 0.70, and social solidarity 0.77 (Baba Poor Kheiruddin, Tusi & Hekmati, 2009). 4. The Psychological Factors Questionnaire (Risk Factors and substance consumption): This questionnaire is based on the model of risk and protective factors and the composite model of the onset of drug use (Botvin, & Kantor, 2000), which are made of components including the theory of the substance consumption etiology within the field of cognitive-emotional theories (Ajzen &Fishbein, 1980; Fishbein & Ajzen, 1975), Social Learning Theories (Bandura, 1986), Social Development Theory (Hawkins and Weis, 1985), Social Control Theory (Elliot, 1989), Social Ecosystem Model (Kumper & Turner, 1991), the theory of self-humiliation (Kaplan, 1975), the multi-stage social learning model (Simons, Conger, & Whitbeck, 1988); Family interaction theory (Brook, Brook, Gordon, Whiteman, & Cohen (1990), and the theory of trouble-making behavior (Jessor, Donovan, & Costa, 1991), which are normalized on approximately 3000 students in Iran. Result The descriptive statistics of the study variables are presented in Table 1.

Fariba Pazani et al 175

Table 1. Descriptive Statistics of the Studied Variables The The Variables Number Mean standard Variables Number Mean standard deviation deviation Social 400 9.96 1.93 Excitement seeking 400 19.19 4.97 flourishing Social Interpersonal 400 10.11 2.16 400 13.22 4.46 Solidarity dependence social 400 11.02 2.68 Need for control 400 11.73 2.63 coherence Social 400 12.05 2.79 Self-alienation 400 9.06 3.69 acceptance social 400 16.60 3.02 Interconnectedness 400 10.93 3.73 participation Self-concept 400 10.63 3.67 Addiction potential 400 20.34 4.72 Addiction Courage 400 20.78 4.72 400 4.63 1.74 admission Optimism 400 11.04 4.24 Alcoholism 400 22.27 5.46

After doing the proposed software reform and creating covariance between some subscales, the goodness of fit indices of the model were in a favorable situation and the structural model of the relationship between psychosocial factors in the adolescents' potential well fitted with the mediating role of co- dependence. Table 2. Indices of Goodness of Fit Analysis in the Final Model Goodness of fit indices Index name Value Limit 흌ퟐ 2.55 Less than 3 풅풇 (Root mean estimation error) RMSEA 0.70 Less than 0.1 CFI (comparative fit index) 0.91 Higher than 0.9 NFI (Normed fit index) 0.92 Higher than 0.9 GFI (Goodness of fit index) 0.95 Higher than 0.9 AGFI (adjusted goodness of fit index) 0.91 Higher than 0.9 As it can be seen, the goodness of fit indices of the model after correction and elimination of irrational relationships and the creation of covariance among some subscales of variables of social factors, co-dependence and addiction potential are in a favorable situation. The correctional diagram in non- standardized mode is presented in the following table.

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Figure 1. Correction Model in Non-standardized Mode

The correction Figure in the standardized mode is presented in the following table.

Figure 2. Correction Model in Standardized Mode Fariba Pazani et al 177

Discussion and Conclusion Co-dependence is a good substrate for the emergence of addiction and obsessive- compulsive behaviors. Cermak (1986) refers to co-dependence as a personality disorder that is determined based on the need to manage and control affairs in order to cope with intense adverse outcomes, to neglect one's needs, to deviate the limits and boundaries of intimacy and separation, depression and illnesses related to stress and pressure. Regarding the multidimensional status (physical, mental, emotional, and spiritual) of co-dependence and its generalization to different development stages of life, the present study shows the relationship between the formation of co-dependence with both psychological and social factors with social health components. Co-dependence, as a valid diagnostic concept (Harkness & Cotrell, 1997), is an acquired behavior that is shaped under the effects of growth in a dysfunctional family and social disorders and plays a significant role in creating addictive and coercive behaviors such as Internet addiction, work, ... and medications. Co-dependence can be cured and in situations where most of its causative factors are not under the control of the education system and therapists, the identification of this situation in adolescents and intervention can have a significant preventive effect on social harm, especially substance consumption. This treatment involves separating a person from a disharmonious relationship that requires a clear and vivid idea of "self." The concept of who we are and what our goals and intentions are and what limitations we consider for our involvement in life. The finding of this study that is the favorable goodness of fit of the structural model of the relationship between psychosocial factors with the mediating role of co-dependence in the adolescent addiction preparation is in line with that of Parker, Faulk, & Lobello (2003), which considered co-dependence as a disorder separate and independent from behavioral harms. The results of this model regarding with the role of psychological factors with the co-dependence is consistent with the results of the research done by Knudson and Terrell (2012); Marks, Blore, Hine, and Dear (2012); Talwar, Verma, Singh, and Sharma (2011); Ho, Cheung, and Cheung (2010); Loughead (1991); and Carvajal, Clair, Nash, and Evans (1998). The relationship of co-dependence with social factors in the intended model is consistent with the results of Chang (2010) on the relationship between co- dependence and cultural orientation and research of Heydarnejad, Bagheri Benjar, and Esanlou (2012). The relation of co-dependence in the intended model with the substance consumption is in line with the results of the research of Cullen and Carr (1999), and Motawali Khan and Ahmadi (2015). Another finding of this model is the mediating role of co-dependence on the impact of psychological and social factors on the addiction potential. Van Eck, Markle, and Flory (2012) showed that excitement seeking is a moderating variable between the symptoms of attention deficit / hyperactivity disorder and drug abuse in adolescence. Hicks, Schlegel, Friedman, and McCarthy (2009) showed that the expectation of the socialization consequences following alcohol

178 Research on Addiction Quarterly Journal of Drug Abuse consumption is positively correlated with the self-concept improvement associated with alcohol consumption. Shayer, Botvin, and Diaz (1999) concluded that perceived adequacy and effective refusal skills were related with reduced alcohol consumption, and stated that both should be an integral part of school-based prevention strategies. Carvajal et al. (1998) examined three factors of optimism, happiness and self- esteem that are mainly related to psychological and physical well-being in a social penetration model for predicting drug abuse. The results showed that these variables play a decisive role in avoiding drugs. In explaining the mediating role of interconnectedness, we can mention the following consistent studies. Winstanley et al. (2008) in their research showed that the average and high level of social capital has a negative relationship with consumption and dependence on substances. The disorganization of the place of residence has a positive relationship with the substance consumption and dependence on it. In line with this finding, Greenfield, Rehm, and Rogers (2002) showed that there is a significant relationship between social integration and alcohol consumption. Also, Lochman and Wayland (1994) showed that adolescents with low social acceptance and high aggression have a positive correlation with marijuana, drugs, alcohol consumption and delinquent activities. These findings can be explained within the framework of the self-humiliation theory. Based on this theory, general self-esteem is the main factor in substance abuse and its prevention. Adolescents who feel they are rejected by others and do not have acceptable social performance, show some reactions: first, they feel they should symbolically fight against the standard criteria and values, second, they avoid traditional social models; third, they feel that they can enhance their self-esteem by doing unconventional behaviors and ultimately connect with deviating peers who strengthen value in them. This view introduces concepts of self-esteem, isolation and distraction from society and communication with deviant peers, and relies on interpersonal traits and concepts of commitment and attachment theories as well as social learning to explain substance abuse. Mental and personal weaknesses and inadequacies along with inappropriate social, and family conditions and lack of proper human relationships gradually face the person with mental and psychological problems. In the study of the lives of addicts, family disorder is most clearly seen in most cases, and many addicts seek addiction to escape these disturbances and psychological problems. Therefore, parents should eliminate the background of any mental and psychological harm in the family. Considering that in this research model, quantitative methods were used to understand the relationship between variables. Using longitudinal and long-term methods can aid in improving the results. This research was conducted in the adolescent group and its generalizability is limited to other age groups such as young people and middle-aged people. Another limitation of this research is the data collection information tools, which is a kind of self-report, and yet the Fariba Pazani et al 179 credibility of the responses of individuals is contemplative. It is suggested that research be conducted on the addiction preparation and its outcomes in societies other than the high school students. 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Binaural Beats Abstract Effect on Addicted Objective: This study was aimed to investigate binaural beats effect on People Based on addicts to evaluate use of this technology EEG as an aid in the stable treatment of addiction. Method: The population of this study included 15 addicted people who admitted to rehab clinic with an average age of 30.5 that were chosen Danial Malek-Zadeh, Saeed under medical supervision and by using Rahati Ghouchani, Hamid the Eysenck Personality Questionnaire and urine test. Then, 10 addicted people RezaKabrovi, Mahya Azad received the controlled binaural beats in Dadgar three sessions and 5 addicted people who were as control received just the normal treatment. Urine dopamine test, Electroencephalography (EEG) and Brunel Mood Scale (BRUMS) are Danial Malek-Zadeh administered to the participants. MSc of Biomedical Engineering, Islamic Results: Controlled binaural beats can Azad University, Mashhad Branch, Mashhad, Iran, E-mail: [email protected] reduce anger, tension, confusion and increased vigor and the desire to Saeed Rahati Ghouchani continue the treatment for get full Associate Professor, Department of Electrical recovery in addicted people. Engineering, Islamic Azad University, Mashhad Branch, Mashhad, Iran Conclusion: By using controlled binaural beats in conjunction with other Hamid RezaKabrovi activities in the treatment process can Assistant Professor, Department of Biomedical Engineering, Islamic Azad accelerate and consolidation the people University, Mashhad Branch, Mashhad, Iran treatments without side effects. Keywords: Binaural Beats, Addiction, Mahya Azad Dadgar Dopamine, Electroencephalography MSc of Biomedical Engineering, Islamic Azad University, Mashhad Branch, Mashhad,

Iran

Research on Addiction Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir 184 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Addiction is a psychological, social and economic illness that results from unnecessary and unlawful use of certain substances such as alcohol, opium, hashish, etc., and causes the psychological or physiological dependence of the addicted person to substance (Naseri, Palangerd, Mohammadi, Doleh, & Nasseri, 2013). This dependence has undesirable effects on the physical, psychological and social function of the addicted person and, in severe cases, even threatens his personal and social life (Noel, Brevers, & Bechara, 2013, quoted by Soleimani, Senobar, 2015). Addiction and complications from substance abuse are one of the major problems in the world. Difficulties with addiction impair all aspects of the life of the individual, the family, and even the community, and spoil the huge social resources in the material and spiritual realm (Lee, Herrenkohl, & Kosterman 2013, quoted by Soleimani, Senobar, 2015). In fact, drug addiction and drug abuse as a social issue is a phenomenon that ruins the society's ability to organize and maintain the existing order, disrupts the normal functioning of social life and causes structural transformations in the economic, social, political and cultural systems of a community (Miri Ashtiani, 2006). In a brief estimation, eight people die every day and, on the other hand, at least 100 new drug users are being added every year, and the country incurs more than 10 trillion Tomans annually (Mozaffar, Zakeriyayi & Sabeti, 2009). According to the American Society of Addiction Medicine, addiction is a chronic and primary disease of brain rewards, motivation, memory and related brain circuits. Disturbance in each of these circuits leads to biological, psychological, social and spiritual manifestations. Following rewards or opiate relief is a behavioral reflection to such disorders. Addiction is described as a disorder in behavioral control, desire to consume, declining recognition of the underlying issues, and personal relationships and ineffective emotional reactions, and like other chronic diseases, often include the relapse and recovery cycle. Addiction without treatment or employment in recovery activities is progressive and can lead to disability or early death (American Society of Addiction Medicine, 2011). For the fuller expression of "addiction", it can be said that the addiction of Neurotransmitters and interactions factors affect the structure of the brain reward, including the nucleus accumbens, the anterior cerebral cortex, the brain base and the amygdala. These effects change the incentive hierarchy, create addictive behaviors and ultimately replace them with healthy behaviors. Also, addiction affects neurotransmitters and interactions between the cerebral cortex and the hippocampal circuits of the brain reward structure (Hyman, Malenka, & Nestler, 2006). The nucleus accumbens is the most significant center of brain pleasure (brain reward system), and the neurotransmitter dopamine plays an essential role of the reward system of the brain (Mavridis, 2015). Dopamine increases in the brain when it comes to sexual pleasure, food, etc. Drugs that are Danial Malek-Zadeh et al 185 being misused also have this attribute that their consumption is associated with pleasure and euphoria, which actually act as a behavioral reinforcement (Hyman, Malenka, & Nestler, 2006). Substance in addicts can also enhance their previous behaviors by eliminating distressing or unpleasant conditions such as pain, anxiety, or depression (Jamssadok, quoted by Rezaei, 2008). In fact, side effects of drugs can be mentioned as the behavioral problems, restlessness, impatience, paranoid thoughts, depression and increased aggression, social behavior change, and social isolation of consumers (Gorman et al., 2004; quoted by Nejati, Shiri, & Noori , 2012). Therefore, addiction is not only a matter of drug, but there is a two-way relationship between the substance and the personality of the consumer (Oraki & Hosseini Nasab Bazkiani, 2012). There has been a lot of research about the behavioral problems of people involved with addiction. Soleimani, Najafi, Elahi, and Sharghi (2013) evaluated the frequency of anxiety and depression in addicts under drug treatment. Their results showed that 49.3% of 51 patients had anxiety symptoms and 51% had symptoms of depression. The results of a study conducted by Ketabi, Maher, and Barjali (2011) also showed that addicts receive high scores in Eysenck psychosis and psychosis, and in another study, Nasetizai (2007) showed that 95% of drug addicts also during the first 6 months of quit due to mood and anxiety problems return to recurrence. Finally, Terracciano, Crum, Bienvenu, and Costa (2008); Pourkord, Abolghasemi, Narimani, and Rezaei Jamalouyi (2013); Karimi, Hemmatisabet, Ahmadpanah and Mohammad beigi (2013); Rostami, Ahadi, and Cheraghali Gol (2012); Ghasemi Hamed, Rabiei, Haghayegh, and Palahang (2011) concluded that being in stressful situations and using inefficient and exciting solving methods leads to a defective cycle and increased stress and decreased compatibility in them. And ultimately it increases the incidence of relapse in these individuals. Drugs used to treat anxiety have many side effects, although they have a rapid effect, and should be taken for 8 to 12 months, and in most cases, anxiety relapses again. One of the major drawbacks of these drugs is the development of tolerance and dependence in the long term (Pour Afkari, 2010). Behavioral therapy methods, non- pharmacological anxiety-reducing therapies including therapeutic touch, use of heat and cold, various methods of relaxation (hypnosis, guided imagination, thinking deviance, biofeedback, meditation, yoga, progressive muscle relaxation and muscle relaxation of Benson) and music therapy that can reduce the amount of anxiety. These methods are non-invasive, in addition to being safe and inexpensive (Zolfaghari, 2003; quoted by Hashemi & Zakeri-Moqaddam, 2012). Sokhadze, Cannon, and Trudeau (2008) concluded that the eclectic method of neuropsychological methods, conventional psychological treatments and neurofeedback had a significant effect on cognitive (such as executive control) and emotional performance improvement (such as temptation, high sensitivity to drugs, symptomatic treatment and executive control). Zolfagharzadeh, Khalilzadeh, Ghashhoni, and Hashemian (2016) also showed that patients with

186 Research on Addiction Quarterly Journal of Drug Abuse methamphetamine-dependent substances can improve the severity of their craving under the influence of neuro-feedback. In the present study, the effect of binaural beats on the brain signals of addicted people is investigated. According to the research, the ability to follow brain activity is considered the application of binary beats technology (Carlo Calaberse, 2007). If two audio signals are broadcasted at different frequencies of the two ears, the internal sound frequency that the brain perceives will equal to the difference between the two signals, which is the binaural beats phenomenon. The binaural beats provide a suitable basis for simulating the auditory system at low frequencies below the auditory frequency (Lane et al., 1988). Previous research has suggested that binaural beats technology in the beta frequency band in the EEG signal can enhance memory and attention activities (Kennerly, 1994) or the use of binaural beats in the alpha frequency band range can enhances people's calmness (Foster, 1996). Electroencephalography, on the other hand, is one of the non-invasive methods for measuring the activity of brain waves from sensors placed on the scalp skin. The human brain has millions of neurons, due to the electrical activity of these neurons, a small voltage signal is created on the skull surface. This is called electroencephalography (Jailani, Norhazman, & Zaini, 2013). The brain has four alpha, beta, delta and theta frequencies. Beta waves are fast-moving brain waves that interact with thinking, focusing and analyzing information. Alpha waves are associated with calm and silence. Waves of theta are related to memory, deep relaxation and fantasy. Delta waves are the slowest brain waves associated with deep sleep (jailani, Norhazman, & Zaini, 2013). Given the significance of addiction and its treatment and the results of the past research, since the frequencies associated with different genes of human brain activity produce different, but certainly predictable, effects on the brain (Jailani et al., 2013), in this research attempts were made to investigate the effect of binaural beats at a given frequency on patients hospitalized in the addiction treatment center, so that this technology can be used as a treatment aid for them. But since this technology is new and its use as a stimulant of emotion is under investigation, the published articles in this area are very limited and its investigation on addicted people is not yet done with the aim of accelerating their treatment. Method Population, sample and sampling method This research is a quasi-experimental study using pre-test and post-test with the control group. Participants in this study conducted an Eysenck Personality Test, under the supervision of a psychiatrist and social worker close to the patients, among male addicts admitted to Khorasan Razavi Therapeutic Community Clinic, the Pioneer Health Institute of the Sun Land in Mashhad. After giving the necessary explanations to the psychologist, the social worker and the clinic Danial Malek-Zadeh et al 187 officials, 20 men in the age range of 30.5 were considered to participate in this research. Then, using the Eysenck Personality Test, the participants were selected and the subjects that were most similar in terms of personality and basic conditions were selected (Ketabi, Maher, & Barjali, 2011). Subsequently, the participants were informed about the test and they filled in the consent form for the test. Also, the Brums mood questionnaire was used to examine the status of individuals as a result of applying the stimulus. Using these results, the two groups were screened for the magnitude and type of affectedness. Regarding the care provided by the Center for Addiction Treatment and the medical records of the subjects, participants were prohibited from taking active drugs during the project, or they were among people who did not generally receive drug treatment. However, for more precision in the work, all subjects who participated at the beginning and the end of the study had dopamine test from their urine sample. According to this test and urine test, the data of 5 people were inappropriate for analysis and only the results of 15 people were reviewed. Among them, the effect of binaural beats was considered on 10 people in the first group and the remaining 5 subjects were studied as control group and during the usual treatment in the clinic. Instruments 1. Recording Brain Signal: The EEG signal was recorded by using a 10-channel FlexComp Infiniti encoder device. In this study, eight channels of Tables (1) and a standard placement of 10-20 was used. Also, electrodes are fixed on the head using a conductive adhesive of the electrodes. To record signals on a computer, the device software was used, and finally for output analysis, data is called in MATLAB software. Table 1. Channels used to Record EEG Signal 1 2 3 4 5 6 7 8

Cz T3 T4 Pz F7 Fz Fpz F8

The i-Dozer software was used to broadcast the binaural beats. This software is used to combine and play binaural beat frequencies with different frequencies. According to the purpose of this research, 7 Hz frequency was used to create relaxation for addicted people (Pejman, Rahati, & Fathi, 2013). Playback of songs and binaural beats is also done using the ASUS N53S laptop, and played with a Philips handset. 2. Brums Mood Questionnaire: Another tool for collecting data in this research is a questionnaire derived from the personal statements of the participants. For better information on the mental status of the people at the end of each session, the participants were asked to fill in the Brums mood questionnaire (Lane et al., 1988). Modulo et al. (2011) also used this questionnaire to assess and compare the quality of life and the mental states of male and female athletes. The questionnaire has 24 questions about expressing

188 Research on Addiction Quarterly Journal of Drug Abuse the person's emotions. By examining and analyzing using the test key and consulting with the psychologist, 6 states of anger and aggression, depression, tension, confusion, fatigue, and vigor are measured. At the end, each of these mental states was assigned with scores ranging from 0 to 16, where increase in the score indicates the intensity of the state. Procedure The protocol for recording this research is based on previous studies. The test was administered in 3 consecutive days at identical hours in a room controlled by light and temperature (about 24 °C), as well as calm and without any possible contamination in the clinic. For adapting people with the testing process, 10 minutes were considered. Also, people were asked to avoid taking relaxing and caffeinated drinks 12 hours before the start of the test. In each session, the participant (Fig. 1) was placed on a comfortable chair with closed eyes, without any sudden movement or speaking, and the electrode cap and headphones were placed on his head.

Figure 1. A View of the Testing Process

The experiment is designed so that each participant in each 11-minute session is influenced by the neutral music as the foreground and binaural beats at the same time. In order to observe the changes, the evaluation of the operation mode and the result of applying the waves, 2 minutes before and 2 minutes after applying binaural beats, the brain signaling test was also administered to the subjects in the same conditions (Pejman, Rahati, & Fathi, 2013). At the end of each session, the Brums mood questionnaire was provided to the participants. In the control group, the procedure was performed without music playback and binaural beats. Danial Malek-Zadeh et al 189

Figure 1. Signal Recording Protocol

Data were processed using MATLAB software. First, for eliminating the noise and the existing artifacts, using the downstream and the upstream filters tailored to the pre-processing of signals. Then, in order to understand and compare the variations of the Binaural distribution, 14 characteristics including time characteristics (moderate, diffraction, skewness and sharpness), frequency characteristics (Delta band relative power (0 to 4 Hz), theta band relative power (4 to 8 Hz), the slow alpha band relative power (8 to 10 Hz), the relative power of the fast alpha band (10 to 13 Hz), the relative power of the beta band (13 to 30 Hz), the signal energy, the relative power of the band 6.5 to 7.5 Hz and maximum band power 6.5 to 7.5 Hz), and nonlinear characteristics (Lyapanov exponent and fractal dimension) were extracted from the first 3 minutes and the final 3 minutes of each signal (Pejman, Rahati, & Fathi, 2013). Due to the broadness of the characteristics, the extracted characteristics of the elementary and end segments were measured in MATLAB software by t test. Frequency domain characteristics are among the characteristics that show relatively good performance in different brain signal processes. Various methods have been developed for estimating the power of spectrum from data, which usually provide a good estimate of the specific type of signals. Due to the significance of spectral changes in the EEG signal in frequency bands of delta, theta, slow alpha, fast alpha, beta, and gamma for various mental and mental states, several articles were reviewed and, given these, the frequency characteristics were considered. After calculating the power of each band, the relative power of each band is considered as a characteristic, which is obtained by dividing the power of that frequency band in the total power of the signal spectrum frequencies.

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Another approach used to derive the characteristic of the EEG signal is the use of nonlinear characteristics. Nonlinear techniques can describe processes produced in biological systems in more effective ways. Parameters expressing chaotic behavior fall into two categories. The first group is the ones that emphasize the dynamics of chaotic behaviors, such as Lyapanov exponent. These sets of parameters describe the behavior of the system over time. The second group emphasizes the geometric nature of the motion paths in the space state, such as the fractal dimension. The Lyapunov exponent value expresses how fast the predictability is lost in the system. This feature is intended to measure the rate of trajectory absorption or desorption of a system's state of equilibrium points. To calculate the largest Lyapunov exponent (MLE) from a time series, we need to examine the widening gap between successive samples. An MLE signal is calculated using the equation (1), where dn is the consecutive time interval at time n-th, and d0 is the consecutive interval in the initial time. Equation (1): 1 d λ = ln n n d0 The fractal dimension also indicates the geometric characteristics of the absorption substrate. The speed of computing is high. The Higuchi Algorithm method is used to calculate fractal dimension. In this method, using the series of input data x1, x2, …,xn a new series is made as equation (2). Equation (2):

N−m xk ={x(m),x(m + k),x(m + 2k), …,x(m + [ ]k)} m k

Where m denotes the initial point of each series and   represents the integer k of the number. For each xm, the length Lm(k) is equal to equation (3): Equation (3): ∑ |푥(푚 + 푖푘) − 푥(푚 + (푖 − 1)푘| (푁 − 1) ( ) 푖=1 퐿푚 푘 퐽 = 푁 − 푚 [ ] 푘 푘 N−1 Where N represents the number of samples and is the normalization [N−m]k k coefficient. For each value k, the length of k length is obtained, and then their mean is calculated as the mean length. This action is repeated up to k max. The Higuchi Algorithm is the best approximated line with the least squares of error 1 for the ln (L(k)) in terms of ln ( ). k Result Using the results of the t test, the characteristics with the highest change from the first and the last part of the recorded signal were investigated. The descriptive statistics of the various characteristics are presented in Table 2. Danial Malek-Zadeh et al 191

Table 2. Descriptive Statistics and Significance Values for Different Characteristics Standard The statistics Mean significance deviation Moderate -0.2050 1.68 0.54 Diffraction 0.00098 0.003 0.003 Skewness 0.165 0.01 0.47 broadness 3.125 0.01 0.37 Delta band relative power (0 to 4) 92.707 0.002 0.001 Theta band Relative power (4 to 8) 0.0014 0.00 0.24 Slow alpha band relative power (8 to 10) 20.0052 3.05 0.03 Fast alpha band relative power (10 to 13) 932.10 0.00 0.04 gamma-band relative power (13 to 30) 966.79 0.01 0.29 Signal energy 0.0001 0.00 0.02 The maximum relative power of band 6.5 to 7.5 0.1365 0.02 0.52 relative power of band 6.5 to 7.5 0.1183 0.015 0.53 Lyapunov exponent 7.5087 0.01 0.001 Fractal dimension 1.2779 0.01 0.005

As shown in Table 2, the characteristics of 1-power of the Delta band, 2- Lyapunov exponent, 3-signal energy, 4-variance, 5-power of the alpha band (8- 10 Hz) and 6-fractal dimension, have the values P <0.05 and in fact, the differences are significant. Also, the intuitive results indicated that frequency characteristics such as delta frequency band power and nonlinear characteristics had the most decreasing differences during the sessions. Therefore, according to the Delta brain wave characteristic, it can be stated that the consciousness of addicted people after reduction of binaural beat and relaxation level in these individuals has increased. Finally, it has been shown that the results of the EEG signal corresponded to the personal statements of the People in the Brums Questionnaire. Reduction in the amount of nonlinear and frequency characteristics extracted from signals such as the results of the completed questionnaires by the participants, indicate that inducing relaxation in people is done by binaural beat. Figure (2) shows the changes in the states of the end of the first session and the third session of the participants. In these horizontal axis diagrams, the horizontal axis represents the states and vertical axis the level of each of these states. Analysis of the Brums questionnaires of the first and final of the participants through the test key under the psychiatrist's supervision showed that most people after the binaural beats faced a reduction of anger, tension and confusion and increased vigor and the desire to continue the treatment and were fully recovered. To better illustrate the results of the questionnaires, the mean scores for each of the six states of anger, depression, tension, confusion, fatigue, and vigor that have scores between 0 and 16 are presented in Table 3. Also, changes in each of the states are expressed as percentages, indicating that the state of anger, depression, and tension were greatly reduced after applying binaural beats. The

192 Research on Addiction Quarterly Journal of Drug Abuse state of confusion acts depending on the person and their vigor and their fatigue was mutually increased, which ultimately reflects the improvement of the negative spiritual states and increase in calmness in them.

Figure 2. The Result of the Addiction Participant Registration Questionnaire A) End of the First Session B) End of the Second Session

The descriptive statistics of the changes and the mean scores of the 6 states expressed in the Brums questionnaire are presented below in Table 3.

Table 3. Descriptive Statistics of Changes and Mean Scores in 6 States Expressed in the Brums Questionnaire Index Test type Anger Depression Tension Confusion Fatigue Vigor Percentage of Post- Test -88% -66% 77% -45% 78% 77% changes First -3.40% -4.64% -5.10% -4.10% 3.22% 2.90% Mean scores session (0 to 16) Last -3% -4.22% -3.60% -3.40% 3.80% 10% session

Finally, in order to confirm the results of questionnaires and analyze brain signals, Figure (2) shows the brain mapping of one of the participants as a result of listening to the desired binaural beat. As shown in this figure, the most effect of people in the frequency bands are related to relaxation, such as delta and alpha.

Danial Malek-Zadeh et al 193

Figure 2. Brain Map

Discussion and Conclusion The purpose of this study was to investigate the effect of binaural beats on addicted individuals, with the assumption that they have a fast effect and more manifestation than non-addicted people. Since the new binaural beat technology and its use as a stimulant of emotion are newly emerging, the published articles in this area are very limited and this study is considered to be new due to the discussion of the effects of binaural beats on a specific group of individuals who sample the long-term effect of the stimulus. According to the results done in the experimental group treated with binaural beats and control group, it was found that these waves have a positive effect on the treatment of addicted people and in addition to the reduced anger, tension and confusion and increased vigor, it has helped them as a supplemental therapy. Different methods were presented to improve the mental states of addicted people. More conventional methods mentioned in this article, which are consistent with the present research topic, can be used, namely, the use of music or neurofeedback to improve addicts. In fact, art therapy is one of the oldest and most commonly used methods. Due to the incomplete efficacy of drug therapy and the increasing attention to non-pharmaceutical methods, art therapy, especially music therapy, has been considered as one of the most commonly used treatments (Guetin, 2009; Wakim, 2010; Mc Caffrey, 2011; Stanczyk, 2001). Khorramabadi et al. (2012) showed that musical therapy sessions in addicted people who are quitting and recovering can increase positive emotion and decrease anxiety. In addition, Punkanen (2007) in his study showed that using active and passive music therapy programs in the drug recovery phase can relieve mood and anxiety disorders of addicts, and Salmani, and Senobar (2015) also stated that music therapy alone or along with other psychological interventions can be an effective way to reduce the anxiety of addicts in the non- drug rehab. In a study by Khorramabadi and Asadi (2016), it was shown that music therapy as a complementary therapy helps people to improve their general attitude toward mental and social performance. In explaining the results, it can

194 Research on Addiction Quarterly Journal of Drug Abuse be said that listening to relaxing music by stimulating alpha waves in the brain can provide a relaxing condition through the release of endorphins, dopamine, and decreasing the secretion of catecholamine, thereby reducing depression, anxiety and anger. (Salmani & Senobar, 2015). In regard to the neurofeedback effect, Zolfagharzadeh et al. (2016) showed that patients with methamphetamine-dependent substances can improve their craving under the effect of neurofeedback. The Studies of Sokhadze et al. (2008) also suggested the effectivity of neurofeedback on the reduction of tempting idea of morphine consumption. On the other hand, past studies in the use of binaural beat rate have shown that binaural beats affects psychological and mental performance (Lane et al., 1988), or in the alpha band range, it can create relaxation (Foster, 1996). In addition, binaural beats have a positive effect on physiological parameters such as anxiety (Carlo Calaberse, 2007), and after applying them, they appear to be cooler (jailani, Norhazman, & Zaini, 2013). Finally, in a general conclusion, by comparing the results of this study with previous papers, in addition to verifying the general effects of these waves on individuals, it can be stated that these results are consistent with the effect of binaural beats on the addicted people and this technology with decreasing negative mental states and improvements in the individual can be helpful as a treatment aid. As a result, it is suggested that in addiction treatment centers, prisons, or any other organization engaged in addiction recovery, the use of binaural beats apart from complementary therapies be developed, and by increasing the number of sessions and using different binaural beats frequencies, the effect of this technology be studied along with other current treatments in the overall treatment process. In addition, in subsequent studies one can observe the similarity of the effects of these stimuli with the addictive substance used and plan for its prediction and control. It should be noted that due to the intensity of changes in frequency characteristics and nonlinear characteristics, regarding the focus on the control of mental states, later works focus more on this group of characteristics. Because of some limitations, the present research was conducted only on men. In future research, both groups of women and men can be evaluated for further understanding of changes. Reference American Society of Addiction Medicine (ASAM) (2011). Public policy statement: Definition of addiction. Coping strategies and the degree of stress susceptibility among addicts treated with methadone maintenance and healthy people. Journal of Addiction Research, 5 (18), 20-7. Factors Affecting Women's Addiction. Journal of Women and Culture, 4 (16), 94-83. Foster, D. S. (1996). EEG and subjective correlates of alpha-frequency binaural-beat stimulation combined with alpha biofeedback. Retrieved at http://www.MonroeInstitute.org/research/alpha-binaural-beat.html. genders? .Clinics, 66(2), 255-260. Ghasemi, Nizam al-Din; Rabiei, Mehdi; Haghayegh; Seyyed Abbas and Palahang, Hassan (2011). Comparison of excitement seeking level, coping strategies and stress susceptibility Danial Malek-Zadeh et al 195

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Proposal of Integral- Abstract Differential Equation Objective: Prevalence of substance use is among the problems that have Model for increasingly grown around the world and Prevalence of affect the addicted individuals' social interactions with others. The aim of this Substance Use paper was to introduce an integral- differential equation model for the prevalence of substance abuse among the people of a supposed population. Method: The connection structures of the discrete systems and networks that Hamid Hosseini, Abalfazl Tari exist among the members of a supposed collection can end in a discrete Marzabad, Majid Hassanpour networking model and, finally, in a Ezzati model of differential-integral equation in continuous mode. In this research, the level of drug users' purity and health has been investigated by considering peer Hamid Hosseini M.A. Student of Applied Mathematics, influence. Results: In this study, in Shahed University, Tehran, Iran addition to the proposal of simple E-mail: [email protected] discrete models for the prevalence of substance abuse, a new alternative model Abalfazl Tari Marzabad along with an integral-differential Assistance Professor of Applied Mathematics, Shahed University, Tehran, equation model is introduced that avoids Iran the inertia existing in the previous models related to the prevalence of substance Majid Hassanpour Ezzati abuse problem. Conclusion: Some Assistance Professor of Applied analyses were conducted on discrete Mathematics, Shahed University, Tehran, Iran network models for the prevalence of substance abuse in a supposed population and the mathematical equation was proposed for the diffusion of substance abuse by considering individuals' resilience and peer influence.

Keywords: mathematical model, drug dependence, prevalence Research on Addiction Quarterly Journal of Drug Abuse Presidency of the I. R. of Iran Drug Control Headquarters Department for Research and Education

Vol. 10, No. 40, Winter 2017 http://www.etiadpajohi.ir 198 Research on Addiction Quarterly Journal of Drug Abuse

Introduction Based on the nature of science, most of the natural events and accidents that we experience in reality can be expressed in the language of mathematics. This language conversion helps to use the unlimited tools available in mathematical science and, consequently, draw conclusions as a result of the conduct of the analysis and programming. Drug abuse is one of the most rapidly growing problems, and its prevalence among societies has affected other people, especially healthy people more than ever. Since the consumption of various types of drugs is associated with mental disorders, this can be the basis for the incidence of many accidents and crimes, such as traffic accidents, conflicts, and other social harms in the country. The level of drug use is not the same among the members of any given society and depends on factors, such as individuals' flexibility and addicts' impact on other people in the community. In this research, it was attempted to present an integral-differential equation model by means of discrete network systems for investigating the prevalence of drug addiction. The reason for the selection of the differential-integral equation model is that it has been proved in recent years that differential equations and integral-differential have been frequently used in the mathematical modeling of the prevalence of infectious and viral diseases that are epidemiologically and asymptomatically similar to addiction (Medlock, & Kot, 2003). Since addiction has a reversible effect and the affected person will not be safe even after recovery, this reversibility feature for the diseases similar to addiction can only be modeled by the differential-integral equation models (Van den driessche, & Zou, 2007). It should be noted that while the consumption of narcotics and the individuals' dependence on the disease are taken into consideration, the prevalence and epidemiology of this disease are clearly different from the prevalence of infectious and viral diseases, such as measles, influenza, etc. So far, no similar mathematic model has been proposed in relation to the prevalence of drug use. However, similar studies have been carried out in relation to the prevalence of alcohol consumption through a similar way in the modeling (Braun, Wilson, Pelesko, Buchanan, & Gleeson, 2006; Wilson, Buchanan, Gleeson, & Braun, 2004; French, Teymuroglu, Lewis, & Braun, 2010). In the mentioned sources, a discrete network model along with a stable rate function and calculations has been proposed for the behavior and prevalence of these conditions in a population. Here, in order to analytically test the stability, new simple models have been proposed under the inspiration of a discrete network model and, finally, a differential-integral equation model is introduced. There are a lot of circumstances wherein it has been shown that people from one community can influence the amount of other people's desire and willingness for drug use. In fact, the investigation of previous studies leads one to find that the influence and effect of some individuals from one population on other people represent the same outbreak and prevalence (Funk, Salathe, & Jansen, 2010). For further Hamid Hosseini et al 199 reading about the history of the available models in social discussions, readers are hereby referred to the references of this study. Essentially, this study aims to assess the index of drug use by individuals or groups of the community. In this way, the dynamics of a society will be assessed by factors, such as flexibility, the readiness of the people of that society, and their social relationships. The mechanism of these models contains the potential for the simulation of the impact of drug users on non-addicted people (cited in Braun et al., 2006). Method Basic differential equation model: The starting point of investigations is the following differential equation:

푑푣 푖 = 푣 (1 − 푣 )(푛 − 푟 ) (1) 푑푡 푖 푖 푖 푖

This equation has a stable rate function and is used in a discrete network system (Braun et al., 2006). In equation (1), the function 푣푖 = 푣푖(푡) models the probability of the incidence of drug-related problems for person i at the moment t (including arrest, car accident, conflict, and arguments). It is assumed that drug- related problems for one person can be considered to be quantitative rather than qualitative. Here, the term "purity" of people or their addiction (addiction to one or more types of drugs) for 푣i is considered. From now on, this function is introduced as the function of addiction. This function falls within the category of probabilistic functions and takes values between zero and one. So if person i is pure, 푣i ≅ 0; and if person i is addicted푣i ≅ 1. Then, 푛푖 = 푛푖(푡) is the impact function, which is used to measure the influence of other people by considering 푤ij weights.

푛푖(푡) = ∑ 푤푖푗푣푗(푡), 푗 In this case, 푤ij > 0 is the magnitude of the relationship between person i and j. It is also assumed that the 푤ijs are normalized (∑푗 wij = 1 for each i); besides, we can consider the weights 푤ij symmetric in addition to a particular state (푤ij = 푤ji for each j and i). 푟i is the flexibility of individual i (0 ≤ 푟i ≤ 1). Whatever the size of 푟iis close to number one, person I will be less likely to get addicted. Here, the individuals' flexibility level is shown with constant r. Also, the following initial condition is required for the problem determination and its answer.

(2) 푣푖(0) = 푔푖 Discrete network model: In the mentioned sources, the discrete network model has been considered, which, in some way, models the addiction of person i from the time period m to m + 1 in a large network as follows.

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푚+푙 푚 푚 푚 푚 푚 푚 (3) 푣푖 − 푣푖 = λ푣푖 (1 − 푣푖 )(푛푖 − 푟푖) 푛푖 = ∑푗 푤푖푗푣푗 .

푚 Here, 푣푖 is the level of purity and health for individual i at timet푚, which takes values between zero and one; and λ > 0 is a constant ratio. If we assume that the length of the steps is small and we also re-scale the time, then the differential equation (1) will appear as an approximation out of the complete and large network equation above. The spread of the disease to the networks has always been one of the most important issues of scientific research in the past, especially when the communication connections and paths are defined between community members (nodes) in the network either randomly or in a predetermined manner. These resources suggest the following relationships:

푚 1 , 푣0̅ > 푟̅ (4) lim 푣푖 = { 푚→∞ 0 , 푣0̅ < 푟̅

Here, 푣0̅ is the mean and initial index of addiction, and 푟̅is the flexibility of the mean. When푣0̅ > 푟̅, the population will include the primary consumers of narcotics; and when푣̅0 > 푟̅, the population is directed towards purity in an imposed fashion. In Braun et al.'s work (2006), a therapeutic model has been presented. They have assumed that a small percentage of people in a population with high addiction rates could be treated. These unhealthy people (with high addiction rates) are eliminated for a certain period of time from their populations for the sake of treatment and, then, are returned to a general population with the same attribute of their own addiction, which has now been reduced to half of their level of flexibility. In addition, the numerical calculations lead one to find that if the 7% of the population are strictly treated according to a regular basis, the entire population will get clean and pure. This can be used as a very useful tool in rehabilitating addicted patients. In the next section, a collection of very simple models derived from the discrete network model will be considered. This set of models contains very simple and important models, including single-variable models, two-patch differential equation model, and the differential-integral model. In the integral- differential equation model, the impact and influence of other people in the population are calculated by a simple mean. Moreover, in the following of introducing the models, a new model will also be introduced as an alternative model using the Heaviside function. In the last section, the obtained model of the differential-integral equation will be expanded. The main objective here is to bring discrete models into a continuous framework and format. It is fulfilled using the convolution of the two functions 푣 and푤. The review and testing of this continuous model are more realistic and more practical than the previous discrete model. By means of this Hamid Hosseini et al 201 continuous model, the possibility of the conduct of more numerical analysis is given to mathematicians in order to decide on the actual results. It should be noted that our assumption in this paper is that there is a unique solution for the given differential-integral equation, but there is no evidence of its availability here. The interested readers can refer to French et al.' reference (2010) for the proof of the answer. Instrument Models inspired by discrete networks: In this section, as it was mentioned, three very discrete models will be presented. Single variable bitable model: Assume that all people in the population are equal in terms of impact, flexibility, and the value of addiction function (homogeneous population), and these people are in contact with each other with equal communication weights. In this case, the differential equation (1) is converted to the initial value problem with respect to time.

푣́ = 푣(1 − 푣)(푣 − 푟) , 푣(0) = 푣0

It should be noted that zero, one, and r are fixed points and the rate function of 푣(1 − 푣)(푣 − 푟) denotes that if 푣0 < 푟, because of the smallness of the additive function 푣, its flexibility will approach zero (pure mode). In addition, whenever 푣0 > 푟, the additive function 푣 will move to a side (addiction mode). These results are exactly compatible with equation (4). Two-patch model: Another simple model being considered here involves two different populations. At the outset, the hypothesized population is divided into two different groups. The first group includes a large population of addicts with moderate drug addiction, and the second group includes a small population of addicts with high addiction rates who have a high interest in drug use. In this situation, the model will be in the form of an ordinary differential equation in the following state:

(5) 푣1́ = 푣1 (1 − 푣1 )(푘푣1 + (1 − 푘)푣2 − 푟1 ), 0 ≤ 푘 ≤ 1, (6) 푣́2 = 푣2(1 − 푣2)(푘푣1 + (1 − 푘)푣2 − 푟2) Where: 0 0 (7) 푣1(0) = 푣1 , 푣2(0) = 푣2 .

In this model, we will, in fact, deal with two homogeneous populations. Suppose that the addiction function 푣2 includes a small set of people who are highly eager to consume drugs, with the assumption that 푣1 introduces the rest of the population. In order for the drug users' influence to be negligible on a given population, 푘 ≅ 1.

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It should be noted that the following initial conditions are very determinative in the process of work. In reality, the mean value of the initial status of a population is also important at the start of work.

0 0 푣1(0) = 푣1 , 푣2(0) = 푣2

If the majority of the population have had a high rate of dependence on drug 0 use from the outset ( 푣1 → 1) due to the initial conditions, then the entire population will become more addicted with the passage of time. Otherwise, if the initial conditions of the majority of the population are small from the 0 beginning (푣1 → 0), then the entire population will be willing to purity and health over time and their readiness and willingness to drug use will be reduced. Average peer influence model: Here, it is assumed that there are J people that 1 are connected with each other with weights of 푤 = (푖 = 1,…, 퐽) and have an 푖 퐽 equal flexibility and constant r. in this case, the following model of the differential equation will come out:

푑푣 1 (8) 푖 = 푣 (1 − 푣 )(푛 − 푟), 푛 = ∑퐽 푣 , 푖 = 1, … ,퐽. 푑푡 푖 푖 푖 푖 퐽 푗=1 푗

푖 Under the assumption of 푣 = 푣(푥 ,푡) and with the definition of 푥 = in the 푖 푖 푖 퐽 limit state, the following integral-differential equation on the interval [0, 1] will be considered: 휕푣 (9) = 푣(1 − 푣)(푛 − 푟) 휕푡 Where 1 (10) 푛(푡) = ∫0 푣 (푥,푡)푑푥

The above equation can be considered as an approximation of equation (8). We can immediately conclude the following relationships, which are indeed the advantages of this simple approximation in the continuous space:

1 1 , ∫ 푣0푑푥 > 푟, (11) lim 푣(푥,푡) = { 0 푡→∞ 1 0 , ∫0 푣0푑푥 < 푟,

Again, with a little carefulness, it can be observed that the above relations are similar to relations (4). Now, with respect to the definition of the function 푛(t) (as a known function), and considering the additive function 푣at a given point of 푥̅, we can obtain the above differential equation in separation:

푣(푥̅,푡) 푑푢 (12) ∫ = 푁(푡) 푣0(푥̅) 푢(1−푢) Hamid Hosseini et al 203

Where 푡 (13) 푁(푡) = ∫0(푛(푠) − 푟)푑푠 And, immediately, with its solution, we obtain: 1 − 푣 (푥̅) −1 (14) 푣(푥̅,푡) = (1 + 0 e−N(t) ) 푣0(푥̅)

If 0 < 푣0(푥̅) < 1 for each 푥̅ ∈ [0 ,1] in relation (10), then, 0 ≤ 푣 ≤ 1. It should be noted that we obtain a typical differential equation for function n by integrating equation (9) with respect to x:

푑 1 1 (15) [∫ 푣 푑푥] = [∫ 푣(1 − 푣) 푑푥] (푛 − 푟) 푑푡 0 0 And with the following assumption 1 (16) 훽(푡) = ∫ 푣(1 − 푣) 푑푥. 0 we will have: 푑 (17) (푛 − 푟) = 훽(푛 − 푟) 푑푡 in such a way that 훽(푡) ≥ 0. Assume that β is nonnegative, then we can solve the linear differential equation (17) for n-r in terms of β, and we will have:

푡 ∫ 훽(푠)푑푠 (18) 푛(푡) − 푟 = (푛(0) − 푟)푒 0 Now, we can arrive at two conclusions: a) If we assume 푛(0) > r, then, 푛(푡) − 푟 ≥ 푛(0) − 푟, then, when 푡 → +∞, we will have:

푡 ( ) − ∫ (푛(푠)−푟)푑푠 푒−푁 푡 = 푒 0 ≤ 푒−(푛(0)−푟)푡 → 0

Therefore, we conclude from (10) that whenever 푣(푥̅, 푡) → 1 then, 푡 → +∞. b) If 푛(0) < 푟, we will conclude as above that: when 푣(푥̅, 푡) → 0 then 푡 → +∞. As a result, relation (11) is proved. New switch model: Such a model is now recommended that includes a substitution with Heaviside function dependent on the symbol of the function 푛푖 − 푟푖. This model has a long-term behavior and dynamics similar to the double stable machine (3). In this case, we have:

푑푣 (19) 푖 = −퐻(푟 − 푛 )푣 − 퐻(푛 − 푟 )(푣 − 1) 푑푡 푖 푖 푖 푖 푖 푖 where

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(20) 푛푖(푡) = ∑푗 푤푖푗푣푗(푡) And 퐻 = 퐻(푠) is the Heaviside function. 1 and s > 0 퐻(푠) = 0 and s ≤ 0

푑푣 It is notable that if 푛 < r , then i = −푣 , so 푣 → 0 (purity). And if 푛 > r , i i dt i i i i 푑푣 then 〖 i = −(푣 − 1) and 푣 → 1 (addiction). In any case, 푣 cannot be dt i i i greater than one or smaller than zero, which is the same as in the double stable the bitable model.

:퐻(푟푖 − 푛푖) + 퐻(푛푖 − 푟푖) = 1, we can understand that میدر Finally, since

푑푣 (21) 푖 = −푣 + 퐻(푛 − 푟 ) 푑푡 푖 푖 푖

Results Integral-differential equation model: In this section, a model of differential- integral equation is introduced using the contents of the previous section. In fact, the purpose of presenting this model is to generalize the discrete network model as a continuous model. For the start, we propose the following integral- differential model under the inspiration for the discrete network model.

휕푣 (22) = 푣(1 − 푣)(푛 − 푟) 휕푡

In this model, 푣 = 푣(푥, 푡) shows the individuals' level of purity in position x and time t. Similar to what has already been stated, if 푣 ≅ 0, the intended person is pure and non-addicted; in addition, the addicted people will have an addictive function with a value between zero and one depending on their level of addiction. Obviously, addicts with a high rate of addiction have an addictive function close to 1 (푣 ≅ 1). The function 푛 = 푛(푥,푡) shows the influence of other individuals in relation to individuals in the position x and time t, which is equivalent to the convolution of the two functions v and w.

∞ (23) 푛(푥, 푡) = (푤 ∗ 푣)(푥,푡) = ∫−∞푤(푥 − 푦)푣(푦,푡)푑푦.

Here, 푤 > 0 is the weight function or the footprint (∫푅 wds = 1). This function 푤 = 푤(푠) imposes a translation invariance to the model, which does not exist in discrete states. We also assume that the individuals' flexibility is also constant (0 ≤ 푟 ≤ 1). To complete the model, we need the initial condition of 푣(. ,0) = 푣0.. Hamid Hosseini et al 205

We now consider a community of people who are systematically arranged on the line of real numbers in such a way that the person is placed in the location of 푥푖 = 푖∆푥 (0 < ∆푥 ≪ 1) . As it was mentioned, it is assumed that the relationships are modeled between the population members with the footprint function of w. With the assumption of 푤푖푗 = ∆푥 푤(푥푖 − 푥푗) , we can approximate the function 푛푖(푡)in equation (1) by an integral.

(24) 푛푖 = ∑푗 푤푖푗푣푗 = ∑푗 ∆푥 푤 (푥푖 − 푥푗)푣(푥푗,.)

≅ ∫ 푤(푥푖 − 푦)푣(푦,.) 푑푦 = 푛(푥푖, .). It is noteworthy that this model, like models (1) and (3), has this feature that when individuals have their own orientation in both paths of purity and addiction, then they will have a lower degree of potential for being affected by other people in the population (affected by the parameter 푣(1 − 푣).

Discussion and Conclusion Based on the proposed model, the analysis, programming, control, and organization of the phenomenon of the prevalence of drug use are mathematically modelable. Based on the behavior of the assumed population, the designed mathematical model designed is used after validation to predict and modify the behavior of the population based on the changes in the parameters. Moreover, with a comprehensive and consistent therapeutic model, we can identify individuals with high addiction potential among a pure and healthy population. With the passage of time, we observe that the healthy people in the given population have been able to have positive effects on addicted people and to reduce their willingness and attachment to drug use. In addition, via the proposed model, the rate of prevalence among individuals in a community can be estimated. This issue can be numerically analyzed with advanced mathematical tools, such as approximation by partial derivatives. It should also be noted that the differential-integral model presented in this paper can be a good start for those interested in mathematical subjects for further analysis. The numerical analysis of the model (24) is proposed to be done with new and more precise methods as new research work so that more accurate analyses can be performed. Reference Braun, R. J., Wilson, R. A., Pelesko, J. A., Buchanan, J. R., Gleeson, J. P. (2006). Applications of small word network theory in alcohol epidemiology. Journal of Studies on Alcohol and Drugs, 67(4), 591-599. DOI: 10.15288/jsa.2006.67.591. Braun. M, (1992). Differential equation and their applications: An Introduction to Applied Mathematics (Texts in Applied Mathematics) (v. 11), Fourth Edition, Springer, 67-80.

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French, D. A., Teymuroglu, Z., Lewis, T. J., Braun, R. J. (2010). An integro-differential equation model for the spread of alcohol abuse. Journal of Integral Equations and Applications, 22(3), 443-464. Funk, S., Salathe, M., Jansen, V. A. A. (2010). Modeling the influence of human behavior on the spread of infectious diseases: A review. Journal of the Royal Society, Interface, 7(50), 1247-1256. DOI: 10.1098/rsif.2010.0142. Hethcote, H. W. (2002). The mathematics of infectious diseases. SIAM Review, 42(4), 599- 653. Medlock, J., & Kot, M. (2003). Spreading disease: Integro-differential equations old and new, Mathematical biosciences, 184(2), 201-222. Van den Driessche, P., Zou, X. (2007). Modeling relapse in infectious diseases. Mathematical Biosciences, 207(1), 89-103. Wang, J., Pang, J., Liu, X. (2014). Modeling diseases with relapse nonlinear incidence of infection: a multi-group epidemic model, Journal of Biological dynamics, 8(1), 99-116. DOI: 10.1080/17513758.2014.912682. Wilson, R. A., Buchanan, J. R., Gleeson, J. P., Braun, R. J. (2004). A network model of alcoholism and alcohol policy, Proc. Mathematics Problems in Industry Workshop. p