Substance Use Disorders Diagnosis

DSM IV-TR (2000)

-clear descriptions -almost no change in criteria

and then..

-1917: statistical manual for the use of institutions for the insane (22 diagnoses) -1933: "the standard" (standard classified nomenclature of disease) -1943: medical 203 (war department technical bulletin) -1949: WHO 6th revision of ICD **too many different versions->american psychiatric association takes over**

DSM III

-Robert Spitzer began the work in 1974 and relied on research criteria -goals: make DSM more consistent; standardize diagnostic practices, improve uniformity; > 1,000 APA members gave feedback -many new categories -NIMH supported field trials to test reliability -Published in 1980 -494 pages and 265 mental disorders

what is craving?

-an intense desire or urge for a drug -most likely when person is in place where they typically got or used the substance -studies shown it can be a sign of impending relapse

DSM V what happened?

-analyses of published research found abuse and dependence criteria loaded on single factor (interrelated) -term "addiction" replaced by "substance use disorder" -severity defined by # of criteria met -New diagnoses: cannabis and cafeine withdrawal

Rosenhan Experiment

-asked if sane people would be recognized as sane by hospital staff in a psychiatric ward? -what happened: all were forced to say they had mental illness and had to agree to take antipsychotic meds and all received the diagnosis of schizophrenia in remission -hospitals were angered and administrative leadership challenged him to send pseudopatients to their facilities to prove that their staff could detect them -the results: they guessed that 41 out of 193 were fake patients BUT they were completely wrong b/c Rosenhan never sent anyone -this forced APA to go back to revising the DSM to be more consistent with diagnoses

why a BRAIN disease?

-brain imaging found that drugs change the brain structure and function: decision-making, learning, memory, and behavior control -changes can be long lasting: may lead to harmful, self-destructive behaviors

conditions in need for further study

-caffeine use disorder -internet gaming disorder

DSM III-R

-chaired by Spitzer -categories renamed/reorganized -significant changes to diagnostic criteria -6 categories deleted -had section of "disorders to be studied" -567 pages and 292 mental disorders

Labels for problem Alcohol Use

-drunk -inebriate -drunkard -problem drinker -alcoholic -deviant drinker -excessive drinker -addiction -DSM IV: dependence as a syndrome (compulsive use, tolerance, withdrawal)

Guiding principles for revision

-focus on being clinically useful -use science/data; not clinical consensus -go big (global, multidisciplinary)

other addictive disorders

-gambling addiction -used to be pathological gambling under impulse control disorder not elsewhere classified -now is considered an addictive disorder

Progress in Science

-huge advances in genetics and brain imaging -chance to better understand the neurobiology of psychiatric disorders -"etiology-based" system for classification

Addiction characteristics

-inability to consistently abstain -impairment in behavioral control -craving -failure to recognize significant problems with one's behavior and interpersonal relationships -dysfunctional emotional response -often see cycles of relapse and remission -without treatment or recovery activities, addiction is typically progressive (can result in disability or premature death)

Who should use DSM V

-people with clinical training and experience -criteria focus on symptoms, behaviors, cognitive functions, personality traits, physical symptoms, and their duration GOAL: tell the difference b/t diagnosis and normal variations in life and/or temporary responses to stress

Dependence vs. addiction

-physical dependence does NOT equal addiction -physical dependence can happen when someone uses a drug daily -happens because body naturally adapts to regular exposure to a substance -take that substance away: start to see symptoms -physical dependence can lead to craving the drug to relieve the withdrawal symptoms -addiction may include physical dependence, BUT needs other criteria as well

ASAM definition of Addiction

-primary, chronic disease of brain reward, motivation, memory and related circuitry (leads to characteristic biological, psychological, social and spiritual manifestations) -end result: person pathologically pursues reward and/or relief through substance use/other behaviors

why do we need diagnoses for mental disorders?

-provides a common language to clinicians and researchers

DSM II

-published in 1968 -APA took atheoretical position about nature and cause of disorders -symptoms not specified in detail -134 pages and 182 mental disorders

insufficient data to identify as mental disorders

-sex addiction -exercise addiction -shopping addiction

The facts

-since no evidence of a distinction b/t substance abuse and substance dependence Solution: -combine abuse and dependence into a single diagnosis with graded clinical severity

New disorders in DSM V

-social communication disorder -disruptive mood dysregulation disorder -persistent depressive disorder -premenstrual dysphoric disorder -hoarding disorder -excoriation (skin picking) disorder -binge eating

DSM IV (1994)

-task force chair: Allen Frances -more international and MH org involved -3 step workgroup process: lit. review; analysis of research data to ID criteria in need of change; multi-level field trials related to diagnosis in clinical practice -886 pages and 297 mental disorders

DSM V why change?

-term "dependence" was problematic: confusion b/t dependence and addiction; tolerance and withdrawal in patients who are prescribed medications that affect the CNS = very normal; contrast, addiction is compulsive drug-seeking behavior -studies didnt support diagnosis of abuse (single criterion) -no category for people who met 2 DSM IV drug dependence criteria

managing craving

-try to view craving for what it is -identify/learn about your craving triggers, and how to manage them -use behavioral (anti-craving) techniques -get help/guidance from trained treatment professionals -consider an anti-craving medication

Criterion A: impaired control

1. substance is often taken in larger amounts or over a long period than was intended 2. a persistent desire or unsuccessful efforts to cut down or control substance use 3. a great deal of time spent in activities necessary to obtain, use or recover from its effects 4. craving, or a strong desire or urge to use the substance

Substance-Related Disorders

10 classes of drugs: 1.alcohol 2.caffeine 3. cannabis 4. hallucinogens 5.inhalants 6. opioids 7.sedatives, hypnotics and anxiolytics 8. stimulants 9. tobacco 10. other (unknown) substances

Criterion D: Pharmacological

10. tolerance, as defined by either of the following: -a need for markedly increased amounts of the drug to achieve intoxication or desired effect -markedly diminished effect with continued use of the same amount of the drug 11. withdrawal, as manifested by either of the following: -the characteristic withdrawal syndrome for the drug -use of the drug, or one closely related to it, to relieve or avoid withdrawal symptoms

Before the DSM (diagnostic and statistical manual)...

1880: goal was to improve communication about patients institutionalized in mental hospitals (census) -only 7 categories of mental illness: 1.mania 2.melancholia 3.monomania 4.paresis 5.dementia 6.dipsomania 7.epilepsy

Diagnosis

Oxford def: identification of the nature of an illness or other problem by examination of the symptoms

Criterion B: social impairment

5. recurrent substance use resulting in a failure to fulfill major role obligations at work/school/home 6. continued substance use despite having persistent or recurrent social/interpersonal problems caused or exacerbated by the effects of the drug 7. important social, occupational, or recreational activities are given up or reduced because of substance use

Criterion C: Risky Use

8. recurrent substance use in situations in which it is physically hazardous 9. substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the drug

Substance use disorders

A problematic pattern of substance use leading to clinically significant impairment or distress manifested by at least 2 of the following (occurring within 12 month period): -criteria 1-4: impaired control -criteria 5-7: social impairment -criteria 8-9: risky use -criteria 10-11: pharmacological criteria

DSM IV Substance Dependence

At least 3 of the following: -tolerance -withdrawal -loss of control -inability to stop -neglecting activities -time spent using substance -substance use despite resulting problems

Section II in DSM V

Emerging measures and models: -assessment measures -cultural formulation -alternative DSM V model for personality disorders -conditions for further study

What is addiction?

a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences

what changed?

added CRAVING as a criterion for diagnosis: -highly validity through clinical trials and brain imaging -potentially future biomarker for SUD diagnosis dropped LEGAL CONSEQUENCES: -subject to local laws and enforcement of them -poor clinical utility

Members included in the revision process

docs, psychologists, social workers, nurses, counselors, epidemiologists, statisticians, neuroscientists, and neuropsychologists, patients, families, lawyers, consumer orgs, and advocacy groups

DSM IV Abuse Diagnosis

maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one or more of the following: -failure to fulfill major role obligations -recurrent use in physically hazardous situation -recurrent substance-related legal problems -continued use despite recurrent substance-related social or interpersonal problems

gambling disorder

persistent and recurrent problem gambling behavior, leading to clinically significant impairment or distress (shown by 4 of following in 12 month period): -need to gamble w/increasing amounts of $ to get desired excitement -restless/irritable when trying to cut down/stop -repeated unsuccessful efforts to control/cutback/stop gambling -preoccupation w/gambling (persistent thought of past gambling experiences) -gambles when feeling distressed -after loss of $, returns for more gambling -lies to conceal extent of involvement in gambling -jeopardized or lost spouse/job/school opportunity due to gambling -relies on others for $ to relieve financial problems due to gambling

DSM I

was published in 1952 by APA (american psychiatric association) and it contained 130 pages and 106 mental disorders -got feedback on criteria from 500 psychiatrists (10% APA membership)