DSM 5 Substance Use Disorders, Lecture notes of Psychiatry

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DSM 5

SUBSTANCE USE

DISORDERS

Ronald W. Kanwischer LCPC, CADC Professor Emeritus Department of Psychiatry SIU School of Medicine

I have no financial relationships to disclose with regard to this presentation. This talk is free of commercial bias.

What’s In a Name?

 “An Odious Disease” Dr. Benjamin Rush, 1784

 The word “alcohol” didn’t come into use until the eighteenth century and was used to designate the intoxicating ingredient in liquor.

 “alcoholism” was first used in 1849 by Dr. Magnus Huss to describe chronic intoxication with physical and social pathology

 A century later the word “alcoholic” was common in the United States

Slang and Professional Language used to describe a problem with alcohol and the problem drinker

 Drunkard  Inebriety/Inebriates  Tipplers  Intemperance  Dipsomania (thirst frenzy)  Drunkard  Barrel fever  Alcoholism

 Jellinek’s Disease  Problem Drinker  Alcoholic  Problematic alcohol use  Deviant drinker  Excessive drinking  Addiction (from the Latin, “to adore”, to surrender oneself)

The Evolution of the Concepts of Addiction

 In the first edition of the DSM in the 1950’s, alcoholism and drug addiction were grouped with “sociopathic personality disturbances”

 Signs and symptoms were not described, but instead the idea that addiction came from an “underlying brain or personality disorder”.

The Evolution of the Concepts of Addiction

 In DSM II (1968) added “subtypes” of alcoholism.

 Episodic excessive drinking, habitual excessive drinking, and alcohol addiction.

 In DSM II, drug dependence was expanded to include subcategories.  Specific drug classes and physiological signs of dependence (withdrawal and tolerance)

The Evolution of the Concepts of Addiction

 DSM III, cont.

 The idea of a public health model was introduced to explain addiction.  The dependence category required either tolerance or withdrawal (or both) to be present.  Abuse was the presence of drug related problems in the absence of physiological symptoms.

The Evolution of the Concepts of Addiction

 DSM III-R (1987)

 Reflected a growing concept that addiction really involved a broader behavioral syndrome and was not only defined by physical symptomology.  “Abuse” remained as a category for people who never met the “dependence” diagnosis.

The Evolution of the Concepts of Addiction

 DSM IV-R cont.  Dependence has to meet three or more of seven physiological or behavioral criteria. (this left some diagnostic orphans, none of the criteria for abuse and only one or two in the dependence category)  DSM V  Factor analyses found that the abuse and dependence criteria actually loaded on a single factor and are interrelated with each other.  The term “addiction” is not applied as a diagnostic term, the more neutral term, “substance use disorder” is used to describe the wide range of the disorder.

American Society of Addiction

Medicine, April 2011

 Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Substance – Related and Addictive

Disorders Changes

 The DSM IV “recurrent substance related legal problems” is switched out with “craving, or a strong desire or urge to use a substance”.

 A new criteria threshold is in place to establish a substance use disorder…it is now “two or more” criteria. Past abuse was one or more or three or more for dependence.

Substance – Related and Addictive

Disorders Changes

 Cannabis withdrawal and caffeine withdrawal are new disorders.

 The DSM IV specifier for “physiological subtype” is eliminated.

 The DSM IV diagnosis of “polysubstance dependence” is eliminated.

Substance – Related and Addictive Disorders

Changes

 Additional Specifiers:

 “in a controlled environment”, “on maintenance therapy”

DSM V Criteria for an Substance Use

Disorder

 A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

Impaired Control

1. Alcohol is often taken in larger amounts or over a longer period than was intended.