CLASSIFICATION AND DIAGNOSTIC SYSTEMS. THE ROLE OF WPA SECTIONS IV

How to Improve the Classification of Addictive Disorders: Conceptual & Strategic Issues Nady el-Guebaly, MD • • Tarek A. Gawad, MD • Chair, WPA Addiction Psychiatry Section Medical Director, Addiction Centre & Network, CHR Secretary, WPA Addiction Psychiatry Section. • • • Professor & Head, Addiction Psychiatry Division, U of Calgary • Acting Director of the New Psychiatric & Addiction Hospital, Faculty of Medicine, Cairo University. Deputy Manager of Addiction Unit, Department of Psychiatry, Faculty of Medicine, Cairo University. ISAM President Elect. ISAM President • Centre Network • • • • • • • • • • I. DEFINITIONS & CURRENT NOSOLOGIES II. VALIDITY OF CATEGORIES III. CATEGORIES VS DIMENSIONS V. ROLE OF FUNCTIONAL IMPAIRMENT VI. PHENOTYPES & NEUROSCIENCES VII. Psychological Phenotypes/Dimensions VIII. CULTURAL DIVERSITY IX. THE RELIABILITY IMPERATIVE FOR PATIENTS, USERS & STAKEHOLDERS VIII. CULTURAL DIVERSITY GOALS OF CLASSIFICATIONS I. DEFINITIONS & CURRENT NOSOLOGIES (a) Criticize is to advance & not undercut Addiction? Huss “Alcoholism” 1849  Jellinek “Disease” ’60  Edwards “Dependence” ’76 (Inst Med p 27) - Disease - Medical Disorder – WHO’04 - Behavioral Disorder - Social problem - Public Health Problem - Crime or sin! Webster: Disease – “any departure from health or a particular disorder with a specific cause & characteristic symptoms” Illness – “condition of being ill or in poor health” • Medicine has never agreed on definitions of “disease or illness”, i.e., • biomedical “biological disadvantage/dysfunction” • sociopolitical “undesirability/handicaps”, or • relation to treatability, i.e., AMA & Disulfiram (Res. DSM V p 4) ICD-10 , DSM IV & OTHERS (b) • ICD – 10: “The term disorder is used … to avoid even greater problems inherent in the use of terms such as disease & illness. Disorder is not an exact term but is used here to imply the existence of a clinically recognizable set of symptoms or behaviors associated in most cases with distress & with interference with personal functions” (WHO ’92). Nosology vs Diagnosis: Identification of diagnostic constructs vs identification of person. • • ICD 10 has conceptual parity with rest of medicine i.e. Cardiology does not distinguish between Pathology & Behavior DSM IV stands alone • II. VALIDITY OF CATEGORIES • • Have we sacrificed validity on the altar of reliability! No natural boundaries, undefined symptomatic thresholds, lack of temporal stability & no treatment specificity Validity? Reliability • • • ICD & DSM Alcohol dependence … high reliability! (>68%, G. Andrews) Relevance of tolerance & withdrawal? Chr. pain & addiction, BZ Alcohol ABUSE vs. HARMFUL alcohol use (lowest concordance 33%)  physical psychological social (role obligations)  physical psychological III. CATEGORIES VS DIMENSIONS • Categories are arbitrary What about Axis II? Personality Disorders H. Skinner’s alcohol spectrum Abst Moderate Abuse Dep. • Dimensions offer clinical advantages & merging both categories & dimensions models highlight continuum IV. COMORBIDY RATES • Trend started with DSM-III-TR, now high clinically & epidemiologically • Artifact of nosological rules: splitting vs. lumping • Often spurious & reflect different facets of same problem: anxiety & depression in withdrawal vs. clinical entity • Promoted integrated treatment V. ROLE OF FUNCTIONAL IMPAIRMENT  ICD 10 assigns function as separate  DSM-IV considers it integral to criteria plus Axis V: Global Assessment Functioning (GAF); Soc & OC Function Assmt. Sc (SOFAS)  DSM V: separate classification & beyond GAF (Nagi’ 76 & Jette’ 97) • Factors: Intraindiv. - natural course trajectories / resiliencies - cognitive impairment as predictor - comorbidity spec. substance abuse (impact on services & adaptation to rehabilitation) Extraindiv. - such as environment Pathways to reduction (Medication, Retraining) VI. PHENOTYPES & NEUROSCIENCES Proposals vary from cautious to extreme but is the field ready? • Mental disorders as complex genetic traits • Genes were not designed to create disorders, but temperaments & behaviors useful for survival Need for Transnosological markers but are we there? Male Caucasian twins, 54 MZ, 65 DZ (van den Bree) COGA 1000 Families (Begleiter)      Low  Feigner probable vs definite alc. level response (Schuckit) chrm. 1  DSM III alcohol dependence  Cloninger type 2 alcoholism Alcoholism or Depression chrm 1 Max Nbr of drinks/24 hrs chrm 4 Electrophysiology ex. P300 chrm 4 “Unaffected”/resilience chrm 4 VII. Psychological Phenotypes/Dimensions (Bobe) • • Psychological functioning & organization: etiological dimension Experience of illness & meaning of symptoms for patient & professional phenomenological dimension, predictor of outcome & compatible interpretation with standardized psychological schools, ex: psychodynamic defense mechanisms, cognitive behavioral Transactional: Drunk & Proud … Lush … Wino! • Conflict between: • • Ideals of objectivity & subjectivity: each is half a science! Group classification & singularity of individual • Perhaps a set of appendix classifications? Instead of Axes? Biological – Psychological – Social - Spiritual VIII. CULTURAL DIVERSITY We have a double challenge: • International acceptance • Abuse of psychiatry / addiction Jellinek’s alcoholic types, cultural? • Gamma alcoholic (US): loss of control, “once started unable to stop” • Delta (Fr) – may control but unable to abstain IX. THE RELIABILITY IMPERATIVE FOR PATIENTS, USERS & STAKEHOLDERS • Nosologies function as public policy • While based on science & ethical principles, we must also address: • Patients, families & community concerns • Interest of users (remuneration) • Concerns of other stakeholders (government, industry) X. CHALLENGES OF BEHAVIORAL ADDICTIONS • Gambling Sex Eating Internet • Impulse control disorders? • Reward Circuit disorders (Stress & Fear Circuit) • Does response to treatment or 12 Step approach = Cause? Ex. Co-dependence / addiction GOALS OF CLASSIFICATIONS Plato  Aristotle  Hippocrates  Ideal, abstract Thorough, logic Personalized, empathy • Standardization of communication & facilitation of research OR Goals of clinical services & improved outcomes through better managed plan • A healthy tension that is not discipline-specific! • Special groups: Women, Age,… GOALS (b) A. FUTURE MULTIAXIAL SYSTEM Axis I - Genotype: genes for symptoms, resiliency & medication response II - Neurobiological: intermediate phenotypes (imaging, cognitive/ emotional function); targeted pharmacotherapy III - Behavioral: expressed behaviors; targeted therapies IV - Environmental modifiers/precipitants V - Therapeutic targets & response (Charney, DSM V) B. DIAGNOSIS; Standardized, Multi-axial I. Illness  ICD II. Disability & Functioning  Intern Classification of Function III. Context (psychosocial environment)  WHO QL IV. Quality of Life & FORMULATION; Personalized I. Contextual clinical problems II. Patients’ positive assets III. Expectations of health restoration & promotion C. REPORT CARD ON POTENTIAL VALIDATORS (Kendell ’90) Alcohol Dependence ANTECEDENT • Family studies • Pre-morbid personality • Demographic factors • Precipitating factors CONCURRENT • Psychological trts • Biological trts Alcohol Abuse A C C C A C (Def Mech) B B B B (GGT) C D PREDICTIVE • Diagnostic consistency • Overall functioning over time • Response to treatment A C C C D C HOW TO REACH A DIAGNOSIS BY CRITERIA? • Cumbersome & frustrating • Focus on checklists: • Discourages true understanding of patient • Undermines clinician-patient relationship • Relies on cross-sectional information (sacrifices historical & developmental data) Thank You