Current controversies in addiction
Lecture 1: introduction
Addiction – may imply character weakness or moral failure. Replaced by ‘dependence’
which implied emphasis on biological adaptations.
DSM-IV – distinction between substance abuse and substance dependence
DSM – 5 – abuse and dependence combined into single diagnosis ‘substance use disorder’
Diagnostic criteria for alcohol use disorder
1. Alcohol taken in larger amounts or over a longer period than intended
2. Persistent desire or unsuccessful attempts to cut down alcohol use
3. Great deal of time spent in activities to obtain or use alcohol or recover
4. Craving
5. Recurrent alcohol use resulting in failure to fulfil major role obligations
6. Continued alcohol use despite social problems caused by it
7. Important social, occupational or recreational activities sacrificed in favour of
drinking
8. Recurrent alcohol use in situations where it is hazardous
9. Continued alcohol use despite knowledge of damage to health
10. Tolerance
11. Withdrawl
DSM-5 criteria doesn’t really tell us what substance use disorder is
- To be diagnosed you have to meet any two from 11 diagnostic criteria
- Three severity categories (mild, moderate and severe)
- Across all severity categories there are 2036 possible combinations of symptoms
Comorbidity
- Substance use disorders are more common in people who have also been diagnosed
with; bipolar disorder, major depression, generalized anxiety disorder, social anxiety
disorder, PTSD and schizophrenia
Risk factors
- Heritability = between 30% and 70%
- Traumatic life events = particularly sexual abuse during childhood. Combined with
observed comorbidity this is consistent with the view that many cases of addiction
may primarily be a disorder of emotion regulation
,Different drugs for different reasons
- To get high; heroin, cocaine, MDMA, alcohol
- To increase alertness and reduce fatigue; nicotine, caffeine
- Social facilitation; alcohol, MDMA, cocaine
- To alleviate distress; alcohol, heroin, nicotine
Complete recovery IS possible
,Lecture 2: can anything be addictive
Gambling disorder
- Gambling encompasses a broad range of activities including national lottery, casino
slots machines and online betting
- 58% of UK adults gambles on at least one of these activities in the past year
- Approx. 0.7% of adults in the UK are problem gamblers and a further 1.1% are at
moderate risk of harms related to gambling
- Online gambling is the largest growth area accounting for over a third of the market.
There are over 33 million active online gambling accounts in the UK. Prevalence of
online gambling has increased from less than 1% in 1999 to 9% in 2016.
- Harmless effects of financial problems which lead to anxiety and depression,
substance use disorders, relationship breakdown, abuse or neglect of partners and
children or suicide.
- The financial costs of problem gambling ranges from 200 million to 1.2 billion.
- Gambling disorder was the first nonsubstance addiction to be recognized in the DSM
- Pathological gambling was recognized in earlier versions of the DSM although in the
category of impulse control disorders
How do we determine if something should be included as a new mental disorder?
1. Clear syndrome or patterns or symptoms
2. Leads to clinically significant distress of disability
3. May arise from psychobiological dysfunction
4. But it must not reflect an expected response to stressors or result primarily from
social conflicts of deviance
- New mental disorders must have diagnostic validity which can be defined by;
prognostic significance and psychobiological disruption and/ or treatment response
and clinical utility. The potential for benefits must outweigh potential harms
DSM 5 gambling disorder
- Must meet 4 or more of following criteria over the past year
- Preoccupation with gambling
- Betting larger amounts (tolerance?)
- Inability to cease or reduce gambling
- “Withdrawal symptoms” (e.g. irritability)
- Gambling to escape negative mood or problems
- Attempting to win back losses (”chasing”)
- Financially relying on others to cover losses
- Lying about or covering up gambling
- Losing important relationships or jobs because of gambling
, Does gambling disorder have diagnostic validity
- Prognostic significance
- YES. Gambling disorder symptom severity predicts clinical outcome (Merkouris et al.,
2016; doi: 10.1016/j.cpr.2016.06.004)
- Psychobiological disruption
- Yes, e.g. reduced grey matter in PFC.
- Treatment response
- YES. There are some effective psychological treatments, although does diagnostic
status predict treatment response?
- Clinical utility
- YES. Diagnosis predicts clinically significant impairment
- Diagnostic validators to differentiate disorders
- YES. Frequently comorbid with SUDs, bipolar disorder and depression, but diagnostic
criteria allow it to be distinguished
Other behavioural addictions
- The internet
- Social media
- Food
- Sugar
- Sexual activity
- Exercise
- Shopping
- Work
- Indoor tanning
- Joy-riding
- Psychic hotlines
- Harry Potter books
- Dancing
- Model railways
How to create new addictions using a theoretical and confirmatory approach
1. Observe the target behaviour and speculate that it might be addictive
2. Develop a screening tool by adapting DSM criteria for SUDs. Then demonstrate
that some people who perform the behaviour meet diagnostic criteria for
addiction to that behaviour.
3. Demonstrate that correlates of substance addiction are associated with scores
on the screening tool.
Lecture 1: introduction
Addiction – may imply character weakness or moral failure. Replaced by ‘dependence’
which implied emphasis on biological adaptations.
DSM-IV – distinction between substance abuse and substance dependence
DSM – 5 – abuse and dependence combined into single diagnosis ‘substance use disorder’
Diagnostic criteria for alcohol use disorder
1. Alcohol taken in larger amounts or over a longer period than intended
2. Persistent desire or unsuccessful attempts to cut down alcohol use
3. Great deal of time spent in activities to obtain or use alcohol or recover
4. Craving
5. Recurrent alcohol use resulting in failure to fulfil major role obligations
6. Continued alcohol use despite social problems caused by it
7. Important social, occupational or recreational activities sacrificed in favour of
drinking
8. Recurrent alcohol use in situations where it is hazardous
9. Continued alcohol use despite knowledge of damage to health
10. Tolerance
11. Withdrawl
DSM-5 criteria doesn’t really tell us what substance use disorder is
- To be diagnosed you have to meet any two from 11 diagnostic criteria
- Three severity categories (mild, moderate and severe)
- Across all severity categories there are 2036 possible combinations of symptoms
Comorbidity
- Substance use disorders are more common in people who have also been diagnosed
with; bipolar disorder, major depression, generalized anxiety disorder, social anxiety
disorder, PTSD and schizophrenia
Risk factors
- Heritability = between 30% and 70%
- Traumatic life events = particularly sexual abuse during childhood. Combined with
observed comorbidity this is consistent with the view that many cases of addiction
may primarily be a disorder of emotion regulation
,Different drugs for different reasons
- To get high; heroin, cocaine, MDMA, alcohol
- To increase alertness and reduce fatigue; nicotine, caffeine
- Social facilitation; alcohol, MDMA, cocaine
- To alleviate distress; alcohol, heroin, nicotine
Complete recovery IS possible
,Lecture 2: can anything be addictive
Gambling disorder
- Gambling encompasses a broad range of activities including national lottery, casino
slots machines and online betting
- 58% of UK adults gambles on at least one of these activities in the past year
- Approx. 0.7% of adults in the UK are problem gamblers and a further 1.1% are at
moderate risk of harms related to gambling
- Online gambling is the largest growth area accounting for over a third of the market.
There are over 33 million active online gambling accounts in the UK. Prevalence of
online gambling has increased from less than 1% in 1999 to 9% in 2016.
- Harmless effects of financial problems which lead to anxiety and depression,
substance use disorders, relationship breakdown, abuse or neglect of partners and
children or suicide.
- The financial costs of problem gambling ranges from 200 million to 1.2 billion.
- Gambling disorder was the first nonsubstance addiction to be recognized in the DSM
- Pathological gambling was recognized in earlier versions of the DSM although in the
category of impulse control disorders
How do we determine if something should be included as a new mental disorder?
1. Clear syndrome or patterns or symptoms
2. Leads to clinically significant distress of disability
3. May arise from psychobiological dysfunction
4. But it must not reflect an expected response to stressors or result primarily from
social conflicts of deviance
- New mental disorders must have diagnostic validity which can be defined by;
prognostic significance and psychobiological disruption and/ or treatment response
and clinical utility. The potential for benefits must outweigh potential harms
DSM 5 gambling disorder
- Must meet 4 or more of following criteria over the past year
- Preoccupation with gambling
- Betting larger amounts (tolerance?)
- Inability to cease or reduce gambling
- “Withdrawal symptoms” (e.g. irritability)
- Gambling to escape negative mood or problems
- Attempting to win back losses (”chasing”)
- Financially relying on others to cover losses
- Lying about or covering up gambling
- Losing important relationships or jobs because of gambling
, Does gambling disorder have diagnostic validity
- Prognostic significance
- YES. Gambling disorder symptom severity predicts clinical outcome (Merkouris et al.,
2016; doi: 10.1016/j.cpr.2016.06.004)
- Psychobiological disruption
- Yes, e.g. reduced grey matter in PFC.
- Treatment response
- YES. There are some effective psychological treatments, although does diagnostic
status predict treatment response?
- Clinical utility
- YES. Diagnosis predicts clinically significant impairment
- Diagnostic validators to differentiate disorders
- YES. Frequently comorbid with SUDs, bipolar disorder and depression, but diagnostic
criteria allow it to be distinguished
Other behavioural addictions
- The internet
- Social media
- Food
- Sugar
- Sexual activity
- Exercise
- Shopping
- Work
- Indoor tanning
- Joy-riding
- Psychic hotlines
- Harry Potter books
- Dancing
- Model railways
How to create new addictions using a theoretical and confirmatory approach
1. Observe the target behaviour and speculate that it might be addictive
2. Develop a screening tool by adapting DSM criteria for SUDs. Then demonstrate
that some people who perform the behaviour meet diagnostic criteria for
addiction to that behaviour.
3. Demonstrate that correlates of substance addiction are associated with scores
on the screening tool.
