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The Importance of DSM and ICD Definitions of Dependence

The Importance of DSM and ICD Definitions of Dependence. Carlton Erickson, Ph.D. Director, Addiction Science Research and Education Center University of Texas at Austin, USA APIA-Singapore, 2004.

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The Importance of DSM and ICD Definitions of Dependence

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  1. The Importance of DSM and ICD Definitions of Dependence Carlton Erickson, Ph.D. Director, Addiction Science Research and Education Center University of Texas at Austin, USA APIA-Singapore, 2004

  2. “An alcoholic is someone who drinks more than his doctor!”Anonymous

  3. We must clarify the words “addiction” and “alcoholism”, both of which have lost their scientific and clinical value

  4. According to DSM-IV: • • substance (drug, chemical) abuse - overuse of drugs in cases where people are making poor judgments about drug use: (“a problem to solve”) • • not a minor problem, since drug abusers produce a majoreconomic impact on society

  5. But this is the disease* • • substance (drug, chemical) dependence - impaired control over drug use, probably caused by a dysfunction in the brain’s “pleasure pathway” (“a disease to conquer”) • • this requires twelve-step or other programs (treatments) • • dependence = addiction; alcohol abuse • is not “alcoholism” • * Based on the Diagnostic and Statistical Manual-IV-TR • (DSM-IV-TR)

  6. Sources • • Diagnostic and Statistical Manual of Mental Disorders, Fourth Ed. - Text Revision (DSM-IV-TR), 2000 • • Morrison, J., DSM-IV Made Easy, Guilford Press, NY, 1995 • • ICD-10 Classification of Mental and Behavioral Disorders, W.H.O., 1992

  7. Dependence Criteria • • DSM-III-R: at least 3 of 9 persisting for at least 1 month • • DSM-IV: 3 or more of 7 occurring at any time in a 12-month period • • ICD-10: 3 or more of 7 occurring together for at least one month or repeatedly in a 12-month period

  8. Clustering Criteria • 1. tolerance 2. withdrawal • 3-4. impaired control (only 1 for ICD-10) • 5. neglect of activities • 6. time spent in alcohol-related activity • • inability to fulfill roles (DSM-IIIR only) • • hazardous use (DSM-IIIR only) • 7. continued use despite problems • • compulsion (ICD-10 only)

  9. Abuse Criteria • • 2 (DSM-IIIR) to 4 (DSM-IV, ICD-10) • DSM-IV: • • at least one in a 12-month period • • never met criteria for dependence • • evidence is weaker than for dependence

  10. Measurement Tools • • Structured Clinical Interview for DSM-IIIR (SCID) • • Semi-structured Assessment for the Genetics of Alcoholism (SSAGA) - DSM-IIIR • • Psychiaric Research Interview for Substance and Mental Disorders (PRISM) - DSM-IV • • Alcohol Use Disorders and Associated Disabilities Interview Schedule (AUDADIS) - DSM-IV

  11. Measurement Tools (2) • • Comprehensive International Diagnostic Interview (CIDI) • • Structured Clinical Assessment for Neuropsychiatry (SCAN) • • Substance Use Disorders Diagnostic Schedule (SUDDS)

  12. Weaknesses • • not accurate for youth and adolescent dx of dependence • • not for “process addictions” (sex, gambling, etc.) - chemicals only • • accuracy depends on administrator - some surveys are unstructured • • are not used all the time

  13. RESEARCH VALIDITY ESTIMATE (RVE) (A Thoughtful Appraisal of High-Quality Scientific Research) High RVE • many large, well-controlled studies • replicable results • much peer-reviewed, published literature Low RVE • few replicable studies • highly speculative results • little peer-reviewed, published literature 100 - 0

  14. Drugs Associated wth Neurotransmitters • Why do people have “drugs of choice”? • • Dopamine - amphets, cocaine, ETOH • • Serotonin - LSD, ETOH • • Endorphins - opioids, ETOH • • Gamma-aminobutyric acid - benzos, ETOH • • Glutamate -ETOH • • Acetylcholine - nicotine, ETOH • (Marijuana?) 70

  15. What Goes Wrong With The Neurotransmitter System(s)? • genetic “malfunctions”? • drug-induced changes? • other aspects of the environment, besides drugs? 60

  16. Genetics of Alcohol Dependence • • family, twin, & adoption studies • • “the tendency to become alcohol dependent is inherited” • • major question: what is passed from parent to child? • • alcohol dependence (perhaps other dependencies?) is polygenetic! 80

  17. Rationale Based on Genetics abnormal genes abnormal proteins abnormal transmitter synthesizing enzymes abnormal transmitter breakdown enzymes abnormal receptors neurotransmitter dysfunction in the pleasure pathway impaired control 90

  18. The Future • • Blood markers? (GGT, CDT…) • • Brain imaging? • • Genetic markers? • • Combination of above? • • What can we learn from other diseases?

  19. Remember the Best Academic Website in the World! www.utexas.edu/research/asrec

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