Last Four Digits of IDNum: 2839
Question 3
Consider the DSM-IV criteria for substance dependence. To what degree do you think
that individuals identified by these criteria will overlap with your concept of what
“addiction” is? If our goal was to identify individuals who are etiologically homogenous
(i.e., subtypes who share the same causal mechanism underlying their disordered
substance use), how would you diagnose addiction?
Given the current criteria in the DSM-IV, there will certainly be individuals who
receive a substance dependence diagnosis who rightly fall under the categorization of
being addicted. The obvious problem, however, is that the DSM-IV criteria are so broad
that individuals who are categorized as substance dependent form an incredibly
heterogeneous group that will include individuals who do not possess any of the cardinal
features of addiction. For example, the urges and cravings that are intrinsically tied to
any empirical conception of addiction are not even required in the DSM-IV to garner a
diagnosis of substance dependence. In particular, individuals are only required to have
three or more of seven criteria over a 12 month span in order to be diagnosed as
substance dependent. Yet, the majority of the criteria emphasize the behavioral
manifestations of addiction (e.g., spending time obtaining the substance, taking large
amounts of the substance, giving up recreational activities to use the substance,
unsuccessful attempts to cut down on the substance) and little attention is paid to features
of addiction that are highlighted in the literature (negative affect is topically addressed by
one symptom and incentive saliency is eschewed in favor of a tolerance symptom).
Granted, I understand the desire to focus on behavioral correlates of addiction as
such criteria are easier to diagnose. Nevertheless, by ignoring cardinal substrates of
addiction in favor of behavioral correlates, the DSM-IV criteria do a poor job of actually
diagnosing individuals who are truly addicted. For instance, with the current criteria that
do not require any urges or cravings in order to be considered substance dependent, I
have no doubt that an unrepresentatively large portion of the US population, particularly
the college population, would be incorrectly diagnosed as substance dependent. Indeed,
the current criteria seem to attend to substance dependence as a problem of choice, rather
than an as a matter of disease, and thus it should be expected that the criteria does not
overlap with an empirical characterization of addiction.
In highlighting the problems with the current diagnostic criteria of substance
dependence, the implication is that there is a better way to identify a more homogenous
group of individuals who are addicted to some substance. In theory, the question is a
reasonable one, but the empirical literature does not support the notion of diagnosing
addiction in general at a level that would be clinically useful for treatment. In the
assigned Krueger et al. (2002) article, we see that there is significant heritability of some
externalizing factor that underlies substance dependence (and other disorders). Of
course, it is unreasonable to attempt to diagnose at such a broad level for two reasons:
identifying precise genetic markers of substance abuse would be difficult and, assuming a
definitive characterization were ever found, the diagnosis could only be that an individual
has a vulnerability for substance dependence, not that they have the actual disorder.
Indeed, the Krueger et al. (2002) article illustrates that non-shared environmental effects
differentiate the various externalizing disorders. Thus, in order to move from identifying
genetic vulnerabilities to diagnosing actual disorders, environmental effects that are no
longer common to all addictive disorders must be accounted for. As Robinson and
Berridge (2003) highlight, behavioral sensitization to drugs does not occur when context
is shifted because the ability for drugs to induce neural sensitization is context dependent.
Thus, while some broad etiologic commonalities underlying addiction may be found, in
order for them to be useful for disorder diagnoses and not vulnerability identification, a
finer degree of specificity is required that stands in opposition to the idea of diagnostic
criteria that identify a homogenous group of addicted individuals. Even if one were to
focus on what Baker avers as a preeminent motive for addictive drug use – negative
affect – one still requires more specificity in order to be able to diagnose individuals as
addicted users. All addicted users may experience negative affect that causes them to use
and relapse, but not all people with negative affect are addicted users.
Is it impossible then to diagnose substance dependence? No, the problem merely
requires a reformulation of the goals. Diagnostic criteria should be changed to reflect the
empirical literature’s emphasis on urges and cravings at least to the same degree that
behavioral manifestations of addiction are outlined. Yet, in order for diagnostic criteria
to be useful, the focus should be on identifying and treating the heterogeneous forms of
addiction as opposed to assuming the problem can be solved at a common etiological
level.