DSM5 Substance Use Disorders Part 2

Yesterday, I posted about the changes in diagnosis of substance use disorders (SUDs) in DSM5 by addressing a key point about whether addiction is a disease, and what that actually means. This is second post that derives from a conversation that Maia Szalavitz and I have been having on this topic. You can read her post on this topic here.

2. What about DSM5 and the changes from DMS4? This is mostly a technical question relating to cut points. How many substance-related symptoms or criteria does one have to have before calling it a disease, meaning a focus of treatment interventions? As it turns out, there is no clear cut-point. Essentially, the more symptoms one has, the more likely they are to be associated with distress and dysfunction. Earlier in the course of the disorder (and most cases don't progress beyond mild to moderate disorder), most symptoms are "internal" meaning that the individual struggles with control of ingestion, especially once ingestion starts. (Going over self-limposed limits, persistent desire to quit/cut down, continued use despite internal problems such as heartburn, hangover, nausea.) The only "external" one is driving while intoxicated (no DUI). About 3/4 of people meeting DSM4 criteria for alcohol dependence only have these symptoms, and the problem is resolved after about 3-4 years on average and does not recur. 20 years after onset 40% report low risk non problem drinking. Proportions differ by drug of course, especially in the proportion of ever-users who become dependent (highest for smoking, lowest for cannabis/hallucinogens, intermediate for alcohol.) 

We have been studying people in rehab, hospitals and AA for the past 60 years, and then generalizing to people with the disorder in the community who are not in those places. It turns out that people in rehab are those with the most severe, treatment-refractory disease, the most co-morbidity, and the least social support. In terms of the spectrum of severity, the folks in rehab are the equivalent to people with depression or asthma who are hospitalized: a small proportion with the most severe, treatment-refractory illness. The problem is, we've made the mistake of generalizing from that sample to community dwellers, thinking everyone has exactly the same disease. Of course, this is absurd. This mistake has cost us dearly. For example, there are no treatment options for people with milder forms of the disorder, since no one goes to rehab who doesn't have to, usually with significant overt coercion such as a DUI. In SUDs, we are now where depression was 60 years ago. Then the only options you had were the state hospital, where you'd get committed for 6-12 months and get thorazine and ECT, or psychoanalysis which didn't work and was available only to a few. Prozac, in 1988, changed all that. Now, most people with depression go to their family physician and get a prescription for an antidepressant. Obviously this is much less stigmatizing and traumatic that the state hospital. Rehab is essential the state hospital at this point. This is all going to change soon, especially for alcohol. 

Another consequence of the peculiar development of ideas about addiction in the US (because of AA, as you (Maia) have pointed out) is that it is all or none, and inevitably severe and progressive. The new (really old and backward looking) definition of addiction by ASAM is an example of that kind of thinking. In your (Maia's) post, you use the word "alcoholic." This term needs to be retired for several reasons. First, it suggests black/white thinking, although the reality is infinite shades of grey when discussing SUDs. Second, it is strongly associated with images of severe, end-stage drunks (another stigmatizing term.) Third, it has no scientific or clinical meaning and is imprecise, being defined by the writer and readers in whatever way this wish.

But rather than only two or three discreet versions of "problem drinking" (another imprecise term), there are instead infinite shades of grey. Furthermore, severity or even presence of a problem usually waxes and wanes over the years. Again, contrary to popular belief, SUDs are not always progressive. For alcohol use disorder most are not. 

3. What else could the committee have done? There was and is no scientific basis for creating two distinct categories. Well, they could have made the cut point higher, such as 5 criteria rather than 2 for a diagnosis. But then that would simply be enshrining the AA ideology into medical diagnosis: you either have it or you don't, it's always severe or it isn't addiction, it's something else. And there would be no impetus to provide treatment for the much larger group of people who have milder forms of the illness and who desire help. They don't go to rehab because who would? It's an obnoxious often toxic treatment with enormous stigma that is terribly inconvenient and expensive. Other alternatives are needed. I believe that over time, people with come to understand that mild SUD is very common, and often self limited, or at least not chronic. In my opinion this will reduce stigma.

4. Finally, the new criteria at least technically will not increase diagnosis of an SUD, especially when it comes to drinking, since almost all cases of alcohol abuse w/o dependence are due to one criterion: admitting to drinking and driving (no DUI.) All other abuse criteria only occur among people with severe chronic addiction. How this is used in practice will become clear over time. My guess is that there will not be a significant increase in clinicians making diagnoses, although there should be. There should be because mild alcohol dependence is unrecognized and not diagnosed or addressed. So I think the same severely addicted people who are are now clinical diagnosed will continue to be.*

*A new study was published online 1/24/13 that shows very little change in overall prevalence of alcohol use disorder between DSM-IV and DSM5 diagnoses. I'll have more on that article later.

MW

DSM5 Substance Use Disorders 1: Advance or Retreat?

I recently had a (friendly) exchange with Maia Szalavitz on the changes to the diagnosis of substance use disorders in DSM5. She and I disagree as to what is likely to happen, and whether DSM5 is a step forward or backward, although we agree on the eventual goal of reducing stigma and making treatment more accessible in more places and with more choice concerning the type and format of treatment offered. 

Here are some of my thoughts about the changes in diagnosis in DSM5. This is Part 1 from an email reply to Maia. 

1. First, is addiction a disease? Well, of course it is. it's hereditary, has a predictable onset, course, complications and characteristics. It causes people great harm and even death. It is a disorder of brain regulation of ingestive behavior, similar to eating disorders. Two ideas can make this assertion seem less clear. 

The first is that disordered behavior is caused by something other than a disordered brain. Western analytical philosophy and religions have asserted that there is a "mind" or "soul" that is not produced by a brain, but there certainly is no evidence to that effect. Try behaving or thinking or feeling without a brain. What is the function of a brain? Besides regulating basic physiological functions such as heart rate or blood sugar, it also regulates mood, thinking, perception, memory and behavior. Example: there is an optimal range for mood just as there is an optimal range for blood pressure, temperature or blood sugar. Basically the optimal mood is neither too high nor too low. When the brain/body loses the capacity to regulate blood pressure, we have hypertension. With blood sugar we get hyperglycemia (diabetes) or hypoglycemia. And with mood, we get mania or depression. Depression is almost never a natural response to anything that happens, you've got to be genetically vulnerable. Same goes for ingesting intoxicants. With drinking, for example, there is an optimal range ("moderate" or "social" drinking.) When the brain loses the capacity to regulate intake you get addiction. 

The second idea that gets in the way is that we have to pin down the exact pathophysiology before calling something a disease, but there are many/most diseases where we really do not understand them that well. Alzheimer's disease, multiple sclerosis, arthritis, and macular degeneration are all examples. The hang-up is the false distinction between "physical" (e.g. below the neck) and "behavioral or psychological" meaning roughly above the neck. But this is really just a distinction of scale. It seems "physical" if we can somehow see the pathology (including with a microscope, scanner or blood test), but "psychological" (again, meaning non-material) if we cannot. That's why people make the mistake of thinking that being able to detect blood flow changes in the brain means it is "real," but we don't need an fMRI scan to know that something like addiction is real, we already know that from other data.

An additional concern that is often expressed is that calling addition a disease may absolve a person of moral blameworthiness for what they do, such as commit a crime while high. The mistake is thinking that calling something a disease makes it inevitable and out of any control of an individual, and it quickly gets into the question of free will vs determinism. I thought this one through a long time ago and concluded that in practical terms it makes no difference. That is, if in fact everything is predetermined we cannot know that and it simply means that as we deliberate using our "free will" the resultant decision is predetermined. But so what? We still have to go through the process because that's how things work. Even if you try to "opt out" by saying, "Well, I have no control, so I'm not going to do anything" is a decision that itself would have been predetermined, but it is still a "freely made" decision, meaning that the individual can "change her mind" later and "decide" to take a different course. So in my view, a more practical question is: what would be the effect of absolving everyone of responsibility for their actions if they could show their behavior was due to a genetic abnormality or disease? It turns out, for example, that a tendency towards criminality is inherited, and is triggered by serious abuse or neglect in the first few years of life. This event causes changes in gene expression and is irreversible. Should we hold serial murderers responsible because they lack empathy for others, which is not something they had a choice about? Studies of twins reared apart demonstrate that almost all of our personality traits, career paths, preferences, even the way we part our hair is genetically influenced, often to a remarkable degree. Pedophiles don't choose their urges and preferences for small children. Should they be held accountable? I use these examples to point out that on a practical basis, we have to protect ourselves collectively against these destructive behaviors and the people who carrry them out, whether they "have a choice" or "can't help themselves" or not. So, should drunk drivers be prosecuted for their behavior? Should someone who kills a convenience store clerk during a meth binge be held responsible? Should opioid addicts who steal and rob to obtain opioids be held responsible? Obviously, the answer is yes, because otherwise we will end up with a world that looks like Mad Max, or The Congo.