a spectrum of apples, oranges, lemons, plums?

DSM_5_2Howard Wetsman picks apart the spectrum approach of the DSM5

Making a spectrum out of the illnesses that have been put in the substance use category of DSM IV is like making a spectrum out of an apple, an orange, a lemon, a lime, a blue fruit (if there was one) and a plum. You’d have the colors but your mixing different things. Sometimes a metaphor can be taken too far.

First there is the assumption that the substance use disorders actually hold together and are separate from other disorders in the DSM. It is an assumption and not one that is supported by the evidence of recent studies. DSM is concerned with behavior, not with biology. Illness is biology from which behavior can manifest, but it’s the biology that comes first. So before we look at the substance use disorders and say they can be made into a spectrum we have to see if they are separate from other things that look like addiction (overeating, compulsive sex, compulsive gambling, etc.) and are the same as each other (that substance abuse is the same as addiction, only less of a problem).

The evidence I’ve seen suggests that it can’t be done. Biologically, addiction to opioids and addiction to sugar binging have more in common than addiction to opioids and abuse of opioids. There are a lot of reasons that people with normal brains choose to do stupid things with drugs, but there’s a real commonality about why people with addiction use. That commonality extends beyond drugs to anything that makes the reward system go “Bam.” When we try to put people with normal brains who abuse substances in addiction treatment they don’t understand what we’re talking about. When we try to put addicts in treatment with people with normal brains they get confused and try to “use like a normal person.”

Read the rest of the post here.

 

DSM 5 Substance Use Disorders: A Concise Summary

DSM_5_2Terry Gorski has a nice summary of substance use disorders in the DSM-5.

Here’s his analysis at the end of the post:

The DSM 5 is criticized for combining the the DSM IV categories of substance dependence (addiction marked by a pattern of compulsive use or loss of control) and substance abuse disorders (using in a manner that causes problems but does not have a pattern of compulsive use). The 2011 definition of addiction by the American Society of Addiction Medicine (ASAM) is consistent with DSM IV but not DSM 5.

The DSM IV, like the ASAM definition is based upon the idea that there is a DIFFERENCE IN KIND between substance abuse and dependence/addiction.

The DSM 5 is inconsistent with the ASAM definition because it is based upon the idea that there is only A DIFFERENCE IN DEGREE between abuse and addiction based upon the number of symptoms.

This is a critical difference in the underlying theory of addiction between the DSM IV and DSM 5 and a break in the progressive development of the fundamental concept if addiction which began with the DSM III.

 

2012’s most popular posts #10 – Almost Alcoholic

This article demonstrates a big problem in understanding addiction and the a big problem in the current diagnostic categories.

…when we think about alcohol abuse or alcoholism, our thoughts often go to situations like this where someone is at a stage where they are doing immediate damage to themselves or others, but what about the stage many people go through before getting to full-blown alcoholism? What about the pain and suffering, not to mention health damage, that occurs in this almost alcoholic stage? If we had more awareness of this area on the drinking spectrum, could we prevent situations like this from occurring?

It is estimated that 22 million Americans suffer from an addiction to alcohol or drugs. Helping professionals have long viewed the problem of alcoholism and addiction in absolute terms: either you are addicted, or you are not. The official psychiatric diagnostic category — alcohol dependence — is what is commonly called alcoholism. The alcoholic must drink more or less continuously to maintain a level of alcohol in his or her body. If all the alcohol is metabolized the alcoholic goes into withdrawal and experiences severe, even life-threatening physical symptoms.

What’s the issue?

Let’s start by stating that addiction/alcoholism is the chronic and relapsing form of the problem characterized by loss of control over their use of the substance.

Problems with the current DSM categories include:

  • DSM dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
    • The current DSM dependence criteria capture people who are not do not have the chronic relapsing form of the problem—many of them will experience spontaneous remission.
    • The current DSM dependence criteria capture people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Same kind?

My problem with the spectrum approach is that it frames all AOD problems as one kind of problem that occurs in varying degrees. The problem here is that addiction and non-chronic dependence are different kinds of problems with vast differences in appropriate treatment approaches.

Your cousin Bob who drank way too much in college and got into some trouble but then cut back when he started a family has a problem that is a different kind or type from Aunt Suzie who has multiple treatments, has had the problem for decades and it’s severely impaired her work, family relationships, friends, housing, etc.

The article illustrates my concern with this sentence [emphasis mine]:

Alcohol abuse is the diagnosis used when an individual is not yet physically dependent on alcohol but has nevertheless experienced one or more severe consequences directly attributable to drinking.

What’s the solution?

One option would be to add addiction as a third category to separate the those with the chronic and relapsing form and those with loss of control from the others.

Another option might be to create two spectrums, one for forms of misuse (abuse to non-chronic dependence) and another for addiction (the chronic relapsing form with loss of control).

Keep only 2 categories, but eliminate abuse and add addiction.

I’m sure there are a lot more options. I’m concerned about the spectrum approach, but I fear the train may have already left the station. We’ll see.

Related articles

The DSM-5 is coming

Change is coming, but is it good?

DSM_5_2At its December meeting today, APA’s Board of Trustees approved the final diagnostic categories and criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The trustees’ action marks the end of the manual’s comprehensive revision process, which has spanned over a decade and included contributions from more than 1,500 experts. These final diagnoses and descriptive criteria will be available when DSM-5 is completed and published in May 2013.

Related posts

 

 

 

Addiction diagnoses to rise

I’ve posted before about problems with the proposed approach to addiction in the DSM-5.

These changes were intended to clear up language problems, specifically the conflation of dependence and addiction leading to “false positives” for addiction. Looks like the DSM-5 is causing its own language problems before it’s even adopted. [emphasis mine]

Many scholars believe that the new manual will increase addiction rates. A study by Australian researchers found, for example, that about 60 percent more people would be considered addicted to alcohol under the new manual’s standards. Association officials expressed doubt, however, that the expanded addiction definitions would sharply increase the number of new patients, and they said that identifying abusers sooner could prevent serious complications and expensive hospitalizations.

Further, I’m pretty skeptical of the suggestion that the current abuse diagnostic category constitutes a medical illness requiring any kind of medical treatment, and they are looking forward to the new criteria being more inclusive and being classified as having form of addiction?

The article demonstrates that the inevitable slide into viewing low-severity AOD problems as the first stage of addiction:

“We can treat them earlier,” said Dr. Charles P. O’Brien, a professor of psychiatry at the University of Pennsylvania and the head of the group of researchers devising the manual’s new addiction standards. “And we can stop them from getting to the point where they’re going to need really expensive stuff like liver transplants.”

On top of this, conflicts of interest are being exposed. It’s pretty clear that this would be a major boon for drug companies, particularly with the Affordable Care Act simultaneously increasing access to healthcare for people with AOD problems and increasing physician responsibility to treat AOD problems that they are poorly equipped to address.

Some critics of the new manual have said that it has been tainted by researchers’ ties to pharmaceutical companies.

“The ties between the D.S.M. panel members and the pharmaceutical industry are so extensive that there is the real risk of corrupting the public health mission of the manual,” said Dr. Lisa Cosgrove, a fellow at the Edmond J. Safra Center for Ethics at Harvard, who published a study in March that said two-thirds of the manual’s advisory task force members reported ties to the pharmaceutical industry or other financial conflicts of interest.

Dr. Scully, the association’s chief, said the group had required researchers involved with writing the manual to disclose more about financial conflicts of interest than was previously required.

Dr. O’Brien, who led the addiction working group, has been a consultant for several pharmaceutical companies, including Pfizer, GlaxoSmithKline and Sanofi-Aventis, all of which make drugs marketed to combat addiction.

He has also worked extensively as a paid consultant for Alkermes, a pharmaceutical company, studying a drug, Vivitrol, that combats alcohol and heroin addiction by preventing craving. He was the driving force behind adding “craving” to the new manual’s list of recognized symptoms of addiction.

“I’m quite proud to have played a role, because I know that craving plays such an important role in addiction,” Dr. O’Brien said, adding that he had never made any money from the sale of drugs that treat craving.

Dr. Howard B. Moss, associate director for clinical and translational research at the National Institute on Alcohol Abuse and Alcoholism, in Bethesda, Md., described opposition from many researchers to adding “craving” as a symptom of addiction. He added that he quit the group working on the addiction chapter partly out of frustration with what he described as a lack of scientific basis in the decision making.

“The more people diagnosed with cravings,” Dr. Moss said, “the more sales of anticraving drugs like Vivitrol or naltrexone.”

Almost alcoholic?

This article demonstrates a big problem in understanding addiction and the a big problem in the current diagnostic categories.

…when we think about alcohol abuse or alcoholism, our thoughts often go to situations like this where someone is at a stage where they are doing immediate damage to themselves or others, but what about the stage many people go through before getting to full-blown alcoholism? What about the pain and suffering, not to mention health damage, that occurs in this almost alcoholic stage? If we had more awareness of this area on the drinking spectrum, could we prevent situations like this from occurring?

It is estimated that 22 million Americans suffer from an addiction to alcohol or drugs. Helping professionals have long viewed the problem of alcoholism and addiction in absolute terms: either you are addicted, or you are not. The official psychiatric diagnostic category — alcohol dependence — is what is commonly called alcoholism. The alcoholic must drink more or less continuously to maintain a level of alcohol in his or her body. If all the alcohol is metabolized the alcoholic goes into withdrawal and experiences severe, even life-threatening physical symptoms.

What’s the issue?

Let’s start by stating that addiction/alcoholism is the chronic and relapsing form of the problem characterized by loss of control over their use of the substance.

Problems with the current DSM categories include:

  • DSM dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
    • The current DSM dependence criteria capture people who are not do not have the chronic relapsing form of the problem—many of them will experience spontaneous remission.
    • The current DSM dependence criteria capture people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Same kind?

My problem with the spectrum approach is that it frames all AOD problems as one kind of problem that occurs in varying degrees. The problem here is that addiction and non-chronic dependence are different kinds of problems with vast differences in appropriate treatment approaches.

Your cousin Bob who drank way too much in college and got into some trouble but then cut back when he started a family has a problem that is a different kind or type from Aunt Suzie who has multiple treatments, has had the problem for decades and it’s severely impaired her work, family relationships, friends, housing, etc.

The article illustrates my concern with this sentence [emphasis mine]:

Alcohol abuse is the diagnosis used when an individual is not yet physically dependent on alcohol but has nevertheless experienced one or more severe consequences directly attributable to drinking.

What’s the solution?

One option would be to add addiction as a third category to separate the those with the chronic and relapsing form and those with loss of control from the others.

Another option might be to create two spectrums, one for forms of misuse (abuse to non-chronic dependence) and another for addiction (the chronic relapsing form with loss of control).

Keep only 2 categories, but eliminate abuse and add addiction.

I’m sure there are a lot more options. I’m concerned about the spectrum approach, but I fear the train may have already left the station. We’ll see.

Even more on the DSM-V

The Fix follows up on the previous piece about the coming changes in the DSM-V.

The writer captures my concerns:

I don’t foresee any negative results from dropping those two misguided terms. (abuse and dependence) But what does concern me is the fact that rather than still having two separate and distinct conditions—one, a short-term, self-limiting disorder and the other a condition likely to be chronic and relapsing—there will now be only one way to have a drug problem. The gradations of the condition will likely be delineated as “mild,” “moderate” or “severe” substance use disorder. While the word “addictive” will appear in the heading that labels the overall category, it will not figure in the diagnoses themselves. For example, you could have mild, moderate or severe opioid dependence disorder or gambling disorder. (So far, gambling is the only behavioral addiction to make the DSM cut.)

But this elision of the problems formerly known as abuse and dependence will, I fear, cause major problems for many people, especially teenagers and young adults. What it means, in a worst-case scenario, is that every college binge drinker will be at risk for being labeled an alcoholic and every high school stoner, an addict.

It’s unfortunate that the author trots out gross stereotypes and caricatures in paragraphs 9 through 12. She falls into the cognitive errors that Kathryn Shultz describes so well at 9:59 through 11:17 of this great talk:

Good thing we don’t use Jayson Blair, Stephen Glass, Jack Kelley and partisan medial outlets to slander writers in general 😉

More on the DSM-V

The Fix has a good opinion piece on the DSM-V, praising its movement away from dependence and abuse.

The focus on dependence also implied that cocaine—which does not produce physical dependence—isn’t “really” addictive. That lulled many people in the ’80s—including yours truly—to think that cocaine wasn’t likely to be hard to kick. We all know better now.

Moreover, with the term “dependence” in the medical definition of addiction itself, it became very difficult to teach people that needing a drug to function isn’t the essence of addiction. The misdefinition encapsulated the idea that suffering withdrawal—rather than compulsive use despite negative consequences—was fundamental to the problem. That meant that the drive to take drugs—now demoted to being called merely “psychological dependence”—was less important than getting sick if you couldn’t get the drug.

In reality, this desire—and related repetitive drug-taking—matters far more than how sick you get when you try to stop.

I’m in complete agreement. All of our public education on addiction has to go through explaining that only 2 dependence diagnostic criteria out of 7 focus on physical dependence (3 criteria are required for a diagnosis.) and that dependence and addiction are not the same thing.

That said, I’m pretty concerned about the spectrum approach planned for the DSM-V. While problem AOD use and addiction may behaviorally appear to be part of the same continuum, they are categorically distinct rather than being different degrees of the same problem.

Top Posts of 2011 #5 – Substance Use and Dependence Following Initiation of Alcohol or Illicit Drug Use

There is a new NSDUH report on the development of dependence upon a substance in the 2 years following substance use initiation as explained below.

For the purposes of this report, persons who initiated use of a substance 13 to 24 months prior to the interview are referred to as “year-before-last initiates.” Year-before-last initiates were assigned to three mutually exclusive categories reflecting their substance use trajectories following initiation: those who had not used the substance in the past 12 months (“past year”), those who had used the substance during the past year but were not dependent on the substance during the past year, and those who had used the substance and were dependent on the substance during the past year.

The report provides a peek into two interesting statistics. The first is the 2 year capture rates for each drug. That is the percentage of people who develop DSM dependence upon a drug. Please note that dependence is only one harm associated with drug use.

Percentages of Year-Before-Last Initiates Who Were Dependent on the Initiated Substance in the Past Year, by Substance: 2004-2006

The second statistic is the percentage of people who used it for the first time 2 years ago, but have not used it at all in the last year.

Percentages of Year-Before-Last Initiates Not Using the Initiated Substance in the Past Year, by Substance: 2004-2006 Does this suggest that this is the rough percentage of people who experiment with a drug briefly and then do not use it again? Does the difference between these two statistics tell us the capture rate for casual use?
I’m not sure. It will be interesting to see more about this in coming years.