Substance-Related and Addictive Disorders

Timothy W. Fong MD UCLA Addiction Medicine Clinic UCLA Addiction Psychiatry Fellowship DSM-5 What You Need to Know June 8, 2013

Financial Disclosures
Speaker Bureau Reckitt Benckiser Pfizer one80 Research Support NIDA OPG (California) Annenberg Foundation AACI Psyadon

Overview
DSM-IV Toward DSM-5 DSM-5 Clinical Implications

Growth of the DSM

DSM-I (1952) 106 disorders, 130 pp. DSM-II (1968) 182 disorders, 134 pp. DSM-III (1980) 265 disorders, 494 pp. DSM-III-R (1987) 292 disorders, 567 pp. DSM-IV (1994) 365 disorders, 886 pp. DSM-IV-TR (2000) 371 disorders, 943 pp.

DSM-IV (1994)
27 member Task Force 13 Work Groups
50-100 advisors, over 1000 participants

Published in five volume Sourcebook Comprehensive literature reviews Field trials Inclusion of Clinical Significance Criterion

DSM-IV TR (2000)
Changes made in the descriptive text Changes made to a handful of criteria sets Some diagnostic codes were changed to reflect updates to the ICD-9 coding system Available in 22 languages

Substance Use Disorders (Abuse and Dependence)

Substance Abuse (DSM-IV)

If not dependent, 1+ in the same year of repetitive: Failure to fulfill major obligations Physically hazardous Legal problems Social / interpersonal problems
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Substance Dependence (DSM-IV)

3+ in the same year:
Tolerance Withdrawal Larger amounts / longer period than intended Attempts to cut down Excessive time spent with alcohol Activities given up due to alcohol Continued use despite problems
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Specifiers to Substance Dependence

With physiological dependence Without physiological dependence Course
Early Full Remission Early Partial Remission Sustained Full Remission Sustained Partial Remission

On Agonist Therapy In a Controlled Environment

Substance Related Disorders

Substance Intoxication Substance Withdrawal Substance Induced Disorders

Substance-Induced Disorders
Persisting Dementia Persisting Amnestic Disorder Psychotic Disorder with Delusions/ Hallucinations Mood Disorder Anxiety Disorder Sleep Disorder

Pathways Toward DSM-V

Limitations and Problems with DSM-IV

Categorical, not dimensional Did not incorporate advances in research High frequency of co-occurring disorders Diagnostic Orphans (2+ dependence) Nearly 20 years have passed

DSM-V Workgroup
DSM V Workgroup on Substance-Related Disorders was convened in 2007 in order to better describe the current category of Substance Use Disorders Explored whether the diagnoses encompassing Substance-Related Disorders in DSM-IV reflect current and clinically useful understanding of this disease.

DSM-V Workgroup
Marc Auriacombe, M.D. Alan J. Budney, Ph.D. Wilson M. Compton, M.D. Thomas J. Crowley, M.D. Bridget F. Grant, Ph.D., Ph.D. Deborah S. Hasin, Ph.D. Walter Ling, M.D. Charles P. OBrien, M.D. Nancy Petry, Ph.D.
18

Preliminary Workgroup Recommendations: Chapter Heading Addictions and Related Disorders Substance, Gambling and Related Disorders Appetitive Behavior and Related Disorders
19

Substance-Related and Addictive Disorders

Substance Use Disorder Substance-Induced Disorders
Substance Intoxication Substance Withdrawal Substance-Induced Mental Disorders

Substance-Related and Addictive Disorders

Substance Use Disorder (single category)
Craving / strong desire to use a substance has been added Legal problems removed 11 symptoms

What about the word Addiction?

the word [ addiction] is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.

Substance Use Disorder

1. 2. 3. 4. 5. 6. ______ is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control _____ use. A great deal of time is spent in activities necessary to obtain __________ , or recover from its effects. Craving, or a strong desire or urge to use _____________ Recurrent ______ use resulting in a failure to fulfill major role obligations at work, school, or home. Continued ______ use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of ______ use. 8. Recurrent ______ use in situations in which it is physically hazardous. 9. ______ 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 alcohol. 10.Tolerance, as defined by either of the following: 1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. 2. A markedly diminished effect with continued use of the same amount of ______ 11.Withdrawal, as manifested by either of the following: 1. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal). 2. ______ is taken to relieve or avoid withdrawal symptoms. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.

Substance Use Disorder

Impaired Control (1-4)
larger amounts, cant cut down, spends time, craves
has there has ever been a time when you had such strong urges to take the drug that they could not think of anything else.

Substance Use Disorder

Social Impairment (5-7)
Failure to fulfill obligations Social/interpersonal problems Reduced activities / given up

Substance Use Disorder

Risky Use
Using in hazardous situations Using despite physical or psychological harm Failure to abstain despite difficulty it is causing

Substance Use Disorder

Pharmacological Criteria
Tolerance
Increased dose to achieve effect Reduced effect with usual dose Differentiate from individual sensitivity

Withdrawal
Occurs with decline in blood/tissue levels

Dimensional Ratings
Provide richer characterization of patients condition
Document all symptoms

Track improvement over time

Self-rated and clinician rated measures

Severity
No disorder (0) mild (1-3) moderate (4-5), severe (6+)

Specifiers
Early remission
3-12 months

Sustained remission
>12 months

New specifiers
in a controlled environment on maintenance therapy

Cannabis Withdrawal
Irritability/Anger/Aggression Anxiety/nervousness Insomnia Decreased Appetite / Weight Loss Restlessness Depressed mood Physical C/O (non-specific)

Caffeine Withdrawal
Formerly, in DSM-IV Appendix
Headache. Marked fatigue or drowsiness. Dysphoric mood, depressed mood, or irritability. Difficulty concentrating. Flu-like symptoms (nausea, vomiting, or muscle pain/stiffness

Tobacco Use Disorder

No tobacco abuse in DSM-IV Therefore this is a new set of diagnostic criteria

Behavioral Addictions in DSM-5

Gambling Disorder (Pathological Gambling)
Eliminates legal criteria Nine total criteria

Solidifies relatedness to SUD through biological and clinical perspective

Gambling Disorder Criteria

A. Persistent and recurrent maladaptive gambling behavior as indicated by the following: Preoccupation Lying Tolerance Withdrawal Chases Bailed Out Cant stop Lost opportunities Gambles to escape

Conditions NOT in DSM-V

Internet Addictions (appendix) Video game addiction Compulsive shopping Food addiction
Binge-eating not the same

Hypersexual Disorder Miscellaneous Discontinuation Syndrome

DSM-V Improvements
Helps to differentiate compulsive behavior (addiction) vs. normal responses to drug-taking behavior (dependence) No more diagnostic orphans Substance-Induced Mental D/O moved to respective primary d/o sections

Addiction and Related Disorders Chapter Comment Examples 2010

This is a desirable change. Great change! I like the entire concept of "Addiction and Related Disorders," as many beyond the traditionally ingested addictions bring clients to treatment this change is befitting with the extent of research that demonstrates the properties of addiction are similar when comparing 38 substances and activities.

Clinical Implications

Clinical Implications
Handling milder symptoms
Reimbursement issues

Dealing with change in severity over time Missing out on false negatives ?
(+ abuse but for SUD)

Recording Procedures
Use specific name of substance Severity modifier first
Moderate alcohol use disorder

Other category does exist

Consequences
Epidemiology: Epidemic or Rare Disease Research Core of what we study Treatment What are we treating? Policy Disease, excessive behavior Societal View Stigma

Future areas of study

Prodromal symptoms Substance-induced Conditions Dopamine Agonists Primary vs. secondary Biomarkers
Anatomical Chemical

Contact Information Timothy Fong MD UCLA Addiction Medicine Clinic 310-825-9989 (appts) 310-825-1479 (office) tfong@mednet.ucla.edu uclagamblingprogram.org