As I mentioned in my previous post, the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will significantly change diagnoses related to alcohol and drugs. No longer will the diagnosis of abuse exist, but instead we will have one category or diagnosis of problematic substance use behavior with varying degrees of severity. At issue is what to call this disorder.

Presently, the term addiction does not appear anywhere in the DSM, but instead the term dependence is used to describe behavior that traditionally invovles compulsive use, loss of control, and continued use despite consequences. Unfortunately, the term also describes a normal process that has nothing to do with problematic behavior or addiction, such as a person who becomes “dependent” on insulin for diabetes, or pain medicines for chronic pain. In these instances, the term dependence describes something entirely different than what is in the DSM. So what to do?

It sounds likely that the upcoming new version of the DSM will use the term addiction and drop dependence because of its dual meaning. Other terms  including appetitive disorders have been thrown around, but this label would require significant public education. Those who are against using the term addiction say: (1) it carries too much stigma, (2) has no clear scientific definition, and (3) is overly identified with drug abuse instead of capturing the full range of excessive behavioral problems (e.g., sex, food, gambling).

In truth, there is no perfect term, but at least addiction is a commonly used term that most understand, even if it presently is not associated with a universally agreed upon definition. I support using the term, but also believe the field needs to evolve its thinking and define addiction more broadly to include the full range of problematic behaviors that go beyond just drugs and alcohol. At CPDD speakers suggested gambling will be included in the new diagnosis, and potentially internet addiction in the near future, but sex and food – perhaps the two most powerful addictions due to their link with our survival – will likely not make the cut.

What does this mean? It means that politics win over science and many folks who need help will not receive it because insurance companies will have a reason not to pay for something if it is not officially in the DSM and/or does not have the right diagnostic codes.

This past week I attended the 71st Annual Scientific Meeting of the College on Problems of Drug Dependence in Reno, Nevada. As usual, many of the world’s leading addiction scientists attended the conference to bat around the latest ideas in the field. One of the most memorable sessions for me was focused on the work group responsible for alcohol and drug diagnostic categories in the upcoming new edition of the Diagnostic Statistics Manual (DSM5) of Mental Disorders.

Presently, problems with alcohol and drugs fall into two general diagnositic categories – abuse and dependence. It turns out that these categories are largely the product of researchers sitting around a table and theorizing, and not so much on sound science. Substantial data now suggests that these categories do not represent distinct diagnoses, but instead should be combined to reflect a unidimensional continuuam of substance-problem severity. In technical terms, factor analysis revealed they load on the same factor and using Item Response Theory suggests the curves all stack on top of each other. What does all this mean?

It means that in the new DSM5 there will be no “abuse diagnosis” and only one diagnositic category with varying degrees of severity. This brings up the loaded topic of what we call this category – an issue I will write about in my next post. But for now, I want to conclude on three points:

• Labels have power, and for years while doing clinical work I labeled folks as having abuse/dependence diagnoses. For many clients these labels took on great meaning – both positive and negative – and may continue to influence their life today. Now I learn that my labeling was likely incorrect at times, and it teaches me that perhaps we need to not forget that labels are socially constructed, even when influenced by science. What we label as a disorder may be entirely normal in another culture or time.
• We diagnose and label people largely because of politics and money. Diagnoses determine what insurance will pay for, who gets treatment, what gets researched, and how as a society we want to understand and talk about specific problems.
• Diagnoses, labels, and categories of behavior are beneficial when they link to specific interventions that have been shown to be scientifically valid.

For more details on this issue, see: Martin CS, Chung T, Langenbucher JW (2008). How should we revise diagnositic criteria for substance use disorders in the DSM-V? J Abnorm Psychol, Aug; 117(3):561-75.

Once a year I am fortunate to have the opportunity to teach a graduate level class at the university on the foundations of addiction treatment. And every year I struggle with how best to organize the class time, materials, and lectures in a way that optimizes students retention and liklihood that they will “act” on what they learn. This of course is an age-old topic, but recently two guys, Chip and Dan Heath, wrote a best seller called “Made to stick: Why some ideas survive and others die” that sheds some light on what is important.

They propose that getting ideas to stick , and more importantly increasing the chances that people will act on those ideas, is enhanced when they are: simple, unexpected, concrete, credible, emotional, and expressed in stories (SUCCESs). The book is well-written and provides numerous examples of how these principles play out in the real world.

After devouring the book, I decided to use the principles in my teaching efforts. The results were very positive, as my students reported that story writing (instead of tests) and a final paper based on using class experiences to illustrate the SUCCESs principles resulted in an exciting, fun, and very different class. Whether I can say for sure that the material they learned will be retained and acted upon in the future would require an outcome study that I may consider in the future. 

These ideas can be translated into many settings: teaching, counseling, coaching, translational research, and implementation science. Here is my summary of the ideas applied to addiction: Making Addiction Education Stick.

When working with those who wish to change addictive behavior I am often struck by how many issues require attention after conducting an evaluation. Not only do most struggle with multiple addictions, but there are often mental health, legal, financial, social, housing, and employment issues to grapple with as well. Combined, these problems can easily seem overwhelming, particularly if you are of a mindset that every issue needs some specific intervention.

Here is where systems thinking plays a key role in successful treatment and long term management. In short, systems thinking helps us to understand that addictive behavior is an outcome of a complex system of interacting issues, for example:

In this diagram, mutliple mental health, addiction, physical and environmental problems combine to create many problems for this individual. In treatment, we identified the different issues, and then spent time drawing arrows between them and talking about how they all relate. We then uncovered a key leverage point for change that in all prior treatment episodes had been missed – an undiagnosed sleep apnea. Turns out it is hard to make progress on much in life if you are constantly in a daze. After a night at the sleep disorders lab and a confirmed diagnosis, we started  treating the sleep problem and within days were making progress on the other issues.

Of all the problems listed for this patient, would you have thought the key to making significant progress was a sleep issue? The most powerful leverage points are most often not obvious.