Extra Stuf

SOCW 601 Fall 2015

Diagnosis
In DSM-4-TR the diagnostic category was called
Substance Related Disorders
Historically there were two main diferent diagnoses in
this category :
Substance Abuse
Substance dependence
Each had its own related yet distinctly diferent
diagnostic criteria

Diagnosis
The criteria for Substance Abuse existed generally, separate from a particular drug
Individual drugs have their own code:
305.00 Alcohol Abuse (use of alcohol that exhibits the diagnostic criteria for
substance abuse)
305.60 Cocaine Abuse (use of cocaine that exhibits the diagnostic criteria for
substance abuse)
Criteria for Abuse is met for the particular drug(s)
Same for dependence:
303.90 Alcohol Dependence
304.20 Cocaine Dependence
Although this has recently changed, you will continue to hear and see reference to
the terms/diagnoses for decades to come

DSM-4-TR criteria for Substance

Abuse
A. A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as manifested by
one (or more) of the following, occurring within a 12-month period:
1. Recurrent substance use resulting in a failure to fulfill major role
obligations at work, school or home (e.g., repeated absences or
poor work performance related to substance use; substancerelated absences, suspensions, or expulsions from school;
neglect of children or household
2. Recurrent substance use in situations in which it is physically
hazardous (e.g., driving an automobile or operating a machine
when impaired by substance use)

DSM-4-TR criteria for Substance Abuse

3. Recurrent substance-related legal problems (e.g.,
arrests for substance related disorderly conduct)
4. Continued substance use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the efects of the substance (e.g.,
arguments with spouse about consequences of
intoxication, physical fights)
B. The symptoms have never met the criteria for
Substance Dependence for this class of substance

DSM-4-TR criteria for Substance Dependence

A maladaptive pattern of substance use leading to clinically significant
impairment or distress, as manifested by three (or more) of the following,
occurring within a 12-month period:
1. Tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve

intoxication or desired efect
(b) Markedly diminished efect with continued use of the same amount of the
substance
2. Withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A
and B of the criteria sets for Withdrawal from the specific substances)
(b) the same (or closely related) substance is taken to relieve or avoid withdrawal
symptoms

DSM IV TR criteria for Substance Dependence

3. The substance is often taken in larger amounts and over a
longer period of time than was intended
4. There is a persistent desire or unsuccessful eforts to cut
down or control substance use
5. A great deal of time is spent in activities necessary to obtain
the substance (e.g., visiting multiple doctors or driving long
distances), use the substance (e.g., chain smoking), or recover
from its efects
(DSM-5 now also has symptom of craving, or a strong
desire or urge to use)

DSM-4-TR criteria for Substance Dependence

6. Important social, occupational, or recreational activities
are given up or reduced because of substance use
7. The substance use is continued despite knowledge of
having a persistent or recurrent physical or psychological
problem that is likely to have been caused or exacerbated
by the substance (e.g. current cocaine use despite
recognition of cocaine-induced depression, or continued
drinking despite recognition that an ulcer was made worse
by alcohol consumption)

Diagnosis
Historically substance abuse has been seen as a consistent pattern of use
leading to problems and some impairment in ones life and functioning, but
without the presence of dependence characteristics (tolerance, withdrawal, etc.)
Dependence has been seen as use with signs of tolerance and/or withdrawal,
problems not using and impairment in ones life and functioning due to use, just
more significant, more pervasive and varied, and longer term problems than
with abuse
Seen as progression from abuse to dependence, and once dependence is
present you dont go back to abuse
When the term addiction is used it is often used synonymously with substance
dependence
Addiction=substance dependence
So someone can have substance abuse problems but still not have
dependence/addiction

DSM-5
In DSM-5 the diagnostic category is called Substance-Related
and Addictive Disorders
Addictive disorders was added to reflect changes in the field
towards use of addiction as opposed to Chemical
Dependency or Substance abuse and to be more inclusive of
addictions that are not substance-based
DSM-5 now just has the diagnosis Substance-Related
Disorders:
Alcohol Use Disorder, Cocaine Use Disorder
The criteria for abuse and dependence are combined
also diagnoses of intoxication, withdrawal (p. 490)

DSM-5
There is now a rating system based on the number of
criteria they express:
Mild (presence of 2-3 symptoms)
Moderate (Presence of 4-5 symptoms)
Severe (Presence of 6 or more symptoms)
Mild still uses the old codes for Abuse, Moderate
and Severe use the old codes for dependence

Addiction
Addiction is not used as a distinct, specific medical
diagnosis
Still used to refer to/define use characterized by:
Preoccupation
Loss of control
Negative consequences

Preoccupation
Compulsive use , craving to use and drug seeking
behavior
Significant time is spent thinking about and planning
for obtaining and using substances
Problem solving, planning and decision
making/priorities are impacted by thoughts/images
of use
A great deal of time is spent in activities necessary to obtain the substance
(e.g., visiting multiple doctors or driving long distances), use the substance
(e.g., chain smoking), or recover from its effects
Craving, a strong desire or urge to use

Loss of control
Progression (use increases in frequency, amount, duration)
Decreased ability to not use, decreased ability to stop using once
started, using more than intended
Inability to successfully predict use and its consequences
Escalation-need to make the behavior more intense, more frequent, more
risky
The substance is often taken in larger amounts and over a longer period of time than was
intended
There is a persistent desire or unsuccessful efforts to cut down or control substance use
Tolerance
Withdrawal

Negative consequences
Use leads to recurrent negative consequences, impairment in life and functioning in multiple
areas:
Physical-health, activity, recreation
Financial
Occupational
Interpersonal
legal
Important social, occupational, or recreational activities are given up or reduced because of substance use
Continued use despite having persistent or recurrent social or interpersonal problems caused or
exacerbated by the effects of use
The substance use is continued despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by the substance
Recurrent use resulting in failure to fulfill major role obligations at work, school or home
Recurrent use in situations in which is physically hazardous

Process Addictions
Often these addictions are referred to in the professional
literature as:
Process addictions
Behavioral addictions
Non AOD-based addictions

Common characteristics of
addiction/dependence
Dynamic of achieving euphoria/pleasure, positive reinforcement
and/or escaping unwanted thoughts, feelings, sensations,
situations (negative reinforcement), release, distraction
Tolerance-seem to need more to achieve the same efect, loss
of reactivity/pleasure with same level of involvement and
exposure, spend more time (frequency, intensity, duration)
engaged in activity
Withdrawal-when separated from, not able to engage in
person experiences sense of mood disturbance (increased
irritability, depression, anxiety), disturbed sleep, concentration,
energy level and appetite, increased difficulty functioning

Common characteristics of
addiction/dependence
Sense of preoccupation-often thought about, urges/craving,
planning based around activity, a great deal of time is sent seeking
out, engaging in, or recovering from, other activities are forfeited
or reduced due to, compulsive seeking out/involvement in the
activity, feeling compelled to and increased difficulty not engaging
in, increasing more time and energy goes towards, becomes
the focus of ones life and identity, spend more time with people and
at places associated with, begin to expect others to share in/be
involved in
Loss of control- use of larger amounts and over longer period of
time than was intended, continued and unsuccessful eforts to quit
or curb, diminished ability to predict, control consequences of;
need to make the behavior more intense, more frequent, more risky

Common characteristics of
addiction/dependence
Negative consequences, such as:
Employment-causes problems at work with productivity
(failing to complete necessary work to specifications
and/or on-time due to), attendance (missing work or
being late due to), relationships (conflicts with coworkers, employer, customers) up to and including loss
of job

Common characteristics of
addiction/dependence
Relationships-increased conflicts, disagreements with
family and/or friends regardingwhich leads to strained
or lost relationships, increased isolation from old friends
and family to be with others also involved in,
Financial-spend money oneven to the detriment of
bills and necessities
Legal-conflict with law, loss of freedom related to

Common characteristics of
addiction/dependence
Sense of progression, worsening over time
Presence of familial history, which could suggest
influence of either genetics or social learning/modeling
Often people either do not recognize or deny there is a
problem, do not see the need for intervention

Gambling Disorder
p. 585
Currently the only process addiction with an official
diagnosis
In DSM-4-TR it was called Pathological Gambling and
was classified as an Impulse Control Disorder
Now in DSM-5 it is called Gambling Disorder and is
classified in the Substance-Related and Addictive
Disorders section (with the drugs)

DSM-5 Criteria Gambling Disorder

Persistent and recurrent problematic gambling behavior
leading to clinically significant impairment or distress,
as indicated by the individual exhibiting four (or more)
of the following in a 12-month period:
Needs to gamble with increasing amounts of money in
order to achieved the desired excitement
Is restless or irritable when attempting to cut down or
stop gambling

DSM-5 Criteria Gambling Disorder

Has made repeated, unsuccessful eforts to control, cut
back or stop gambling
Is often preoccupied with gambling (e.g. having
persistent thoughts of reliving past gambling
experiences, handicapping or planning the next
venture, thinking of ways to get money with which to
gamble)
Often gambles when feeling distressed (e.g. helpless,
guilty, anxious, depressed)

DSM-5 Criteria Gambling Disorder

After losing money gambling often returns another day
to get even (chasing ones losses)
Lies to conceal the extent of involvement with gambling
Has jeopardized or lost a significant relationship, job, or
educational or career opportunity because of gambling
Relies on others to provide money to relieve desperate
financial situations caused by gambling

DSM-5 Criteria Gambling Disorder

Have to decide that the gambling behavior is not better
explained by a manic episode
3 diferent ways to specify:
Episodic-vs.-persistent
Episodic-diagnostic criteria are met at diferent times,
with symptoms subsiding between periods of gambling
disorder for at least several months
Persistent-experiencing continuous symptoms

DSM-5 Criteria Gambling Disorder

Early-vs.-sustained remission
Early-after previously meeting criteria no criteria met for at
least 3 months but less than 12 months
Sustained-after previously meeting criteria no criteria met
for 12 months or longer
Severity
Mild: 4-5 criteria met
Moderate: 6-7 criteria met
Severe: 8-9 criteria met

Gambling Disorder
Many diferent types of gambling, more accessible than
ever before (internet, casinos, OTB, lottery, etc.)
Often present, co-morbid with other addictive disorders
nearly 20 % of pathological gamblers have
attempted suicidethis is higher than the suicide rate
for any other addictive disorder (ex. Many windows at
hotels in Las Vegas dont open)

Food Addiction
Although we know it exists and there are treatment
services, currently there is no official diagnosis of food
addiction
In DSM-5 there is now a diagnosis of Binge Eating
Disorder
It is not classified in the Substance-Related and
Addictive Disorders section
It is classified in the Feeding and Eating Disorders
section

Binge-Eating Disorder

p. 350

Recurrent episodes of binge eating. An episode of binge

eating is characterized by both of the following:
Eating, in a discrete period of time (e.g. within any 2hour period), an amount of food that is definitely larger
than what most people would eat in a similar period of
time under similar circumstances
A sense of lack of control over eating during the
episode, e.g. a feeling that one cannot stop eating or
control what or how much one is eating

Binge-Eating Disorder
The Binge-eating episodes are associated with three (or
more) of the following:
Eating much more rapidly than normal
Eating until feeling uncomfortably full
Eating large amounts of food when not feeling physically
hungry
Eating alone because of feeling embarrassed by how much
one is eating
Feeling disgusted with oneself, depressed, or guilty afterward

Binge-Eating Disorder
Marked distress regarding binge eating is present
The binge eating occurs, on average, at least once a
week for 3 months
The binge eating is not associated with the recurrent
use of inappropriate compensatory behavior as in
bulimia nervosa and does not occur exclusively during
the course of bulimia nervosa or anorexia nervosa

Binge-Eating Disorder
Can specify:
In partial remission-after full criteria for binge-eating
disorder were previously met, binge eating occurs at an
average frequency of less than one episode per week
for a sustained period of time
In full remission-after full criteria for binge-eating
disorder were previously met, none of the criteria have
been met for a sustained period of time

Binge-Eating Disorder
Can specify:
Mild: 1-3 binge-eating episodes per week
Moderate: 4-7 binge-eating episodes per week
Severe: 8-13 binge-eating episodes per week
Extreme: 14 or more binge-eating episodes per week

Eating Disorders
p. 338
Anorexia Nervosa and Bulimia Nervosa are also classified
in the Feeding and Eating Disorders section
Anorexia and Bulimia are sometimes classified as
addictions and a focus of treatment in addiction
programs (inpatient and outpatient)
Family dynamics/dysfunction often play a major role in
Anorexia and Bulimia, just like with the addictions, and
family intervention is often included
Family members also often take on similar unhealthy
roles like in alcoholic family

Eating Disorders
Lot of debate about whether these fit addiction
My bias-Its hard for me to connect Anorexia and
Bulimia to the addictions, but Binge-Eating disorder as
an addiction seems to fit with me
Approach-vs.-avoidance spectrum: Anorexia and Bulimia
(in that order) are more closely aligned to avoidance
(distress) conditions, especially anxiety disorders (and
research supports this) as opposed to approach
(eustress) conditions (i.e. impulse, addiction)

Sexual Addiction
Focuses on sexual arousal/acts and relationships
Dr. Patrick Carnes and his daughter Dr. Stefanie Carnes
are pioneers/leaders in the research and treatment of
this condition
The internet has sent this in a whole new direction given
the almost unlimited access to sex related resources
(internet porn, live cams and chats, sites like Adult
Friend Finder/Ashley Madison)

Sexual Addiction
No actual diagnosis of sexual addiction in DSM-5
In DSM-4-TR There was the Sexual Disorder section which included
both conditions of sexual dysfunction (pain, lack of arousal) and
the paraphilia conditions
Now the Paraphilic Disorders have their own category (but these
are not seen as addictions and sexual addiction is seen as
diferent from a paraphilia)
So is it an addictive disorder? Impulse control disorder?
Sexual/Paraphilic disorder? Can it be part of and better accounted
for by sexual activity with other disorders (ex. Sexual activity
related to Substance Use Disorders, manic episode, personality
disorders)?

Proposed Criteria
Proposed criteria (S. Carnes)
A pathological relationship to a mood altering experience (sex) that
the individual continues to engage in despite adverse consequences,
characterized by:
Loss of control-do more than you intend or want
Compulsive behavior-pattern of out of control behavior over time
Eforts to stop-repeated specific attempts to stop the behavior which
fail
Loss of time-significant amounts of time lost doing and/or recovering
from the behavior
Preoccupation-obsessing about or because of the behavior

Proposed Criteria
Inability to fulfill obligations-the behavior interferes with work, school,
family and friends
Continuation despite consequences-failure to stop the behavior even
though you have problems because of it (social, legal, financial,
physical, work)
Escalation-need to make the behavior more intense, more frequent,
more risky
Losses-losing, limiting or sacrificing parts of life such as hobbies,
family, relationships and work
Withdrawal-stopping behavior causes considerable distress, anxiety,
restlessness, irritability or physical discomfort

Personality Disorders
Used to be categorized on Axis 2 because they were
seen as more chronic, persistent
Presence complicates treatment for other comorbid
conditions, poorer prognosis and treatment response
General criteria for personality Disorder p. 646
Seen as existing in three general clusters
Cluster A: Odd-eccentric
Cluster B: Dramatic-emotional
Cluster C: Anxious-fearful

When all else fails

Unspecified _____ Disorder; Z Codes p. 715
Remember:
In practice conditions look more alike than diferent, are more complicated than
as they appear in DSM
Have to be life-long professional learners: If you are working in a particular
specialty area, then you need to know those conditions, how they look, how
they are diagnosed, and how to treat
We treat people not diagnoses
People are more than any label they may have
Regardless of the label people have strengths
More important than the diagnosis is how the diagnosis is afecting them, their
life and functioning