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.


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.