Drug Addiction In The DSM V...Considerations For The Future

Prior to the publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM) first edition in 1952, there was no formal system of classification and diagnosis of substance use disorders in the United States.  Substance use disorders have received increasing attention throughout the DSM’s next four major revisions, as is evident by the increasing proportion of the manual that is dedicated to this group of conditions.  It is necessary to look at the diagnostic evolution of these disorders to understand the rationale behind the proposed changes for the fifth edition of the DSM.

            Only one axis was used for the diagnosis of Substance Use Disorders in the first and second editions of the DSM.  In the manual’s first edition, information regarding substance abuse was limited to only one page, and was listed under the heading of sociopathic personality disturbance.  This suggests that at its inception, the DSM conceptualized substance use disorders as arising from specific personality features.  

            The DSM-III was the first edition to distinguish between substance abuse and dependence.  In order to qualify for a diagnosis of dependence, the patient had to show evidence of physiological dependence as indicated by tolerance and withdrawal.  Abuse was categorized by social and medical consequences of drug use.  These major changes in diagnostic criteria were modeled from a theory of Alcohol Dependence Syndrome created by Edwards and Gross in 1976 (Martin et al, 2008).  This model was generalized to all classes of drugs in the third and fourth editions of the DSM.  The DSM-III was also the first edition to include multi-axial diagnoses, which led to the “bi-axial” concept of substance use disorders.  

            The DSM-IV would retain the distinction between abuse and dependence, but would add a hierarchical approach to diagnosis.  This specified that substance abuse was to be considered a less severe diagnosis that would serve as a marker for the onset of substance dependence.  Another major change in diagnostic criteria was that physiological withdrawal and tolerance were no longer required for a diagnosis of dependence.  Abuse criteria was also expanded from two to four factors that were now categorized by negative legal and social consequences.

            Several major changes to the diagnostic criteria of substance use disorders have been proposed for the DSM-V.  The entire category of Substance-Related Disorders is to be renamed Addiction and Related Disorders.  This is being proposed to signify the distinction between substance addictions and newly proposed disorders related to compulsive behaviors such as gambling.  It has also been proposed that Dependence and Abuse diagnoses be subsumed under the heading of 'Substance Use Disorders'.  

            Another change that has been proposed for the next edition of the DSM is that the word dependence be limited to physiological dependence rather than being used as a label for addiction.  While the terms dependence and addiction have been used interchangeably in the past, it is argued by many members of the American Psychological Association that the words have two very distinct definitions.  In terms of formal medical lexicon, dependence is a normal and expected physiological response to the repeated use of drugs that act on the central nervous system which is distinctly different from compulsive drug seeking behavior common to addiction (Heit, 2009).  This ambiguity often leads to problems of misdiagnosis and stigmatization of patients who require opioid medications for pain management.  It has thus also been proposed that the DSM-V definitions of tolerance and withdrawal will include the specification that these criteria shall only be considered if substance use is not related to a prescribed medication that is taken as directed by a physician. 

            Empirical evidence from several studies has led to the recommendation that the diagnoses of Opioid Abuse and Opioid Dependence be subsumed under the heading of Opioid Use Disorder.  The DSM-III and DSM-IV both assumed that abuse was a prodromal phase of dependence, but recent studies using latent-factor statistical techniques have shown that many people first meet dependence criteria before they qualify for a diagnosis of abuse.  In fact, these studies examined the ‘problems with the law’ criterion of abuse, and found that the endorsement of this criterion was associated with the most extreme cases of substance-related problems (Wu et al, 2011).  In general, the reliability of abuse criteria in many of these studies has been found to be much lower and variable than dependence criteria.

            The current diagnostic distinctions between abuse and dependence have led to both ‘diagnostic orphans’ and ‘diagnostic imposters.’  The former refers to people who may meet two criteria for dependence but none for abuse.  Since a person must meet three criteria for dependence or one criterion for abuse, these people are often left undiagnosed despite their severe substance-related problems.  Since a diagnosis of abuse only requires one positive symptom the opposite situation may also occur.  Diagnostic imposters are people who meet diagnostic criteria for abuse despite low levels of substance use problems.  This is often seen with adolescents who meet the criteria of ‘significant problems with parents.’

            Empirical evidence indicates that if a categorical structure does exist, the categories are most likely distinguished by severity rather than by groups of symptoms.  This largest body of evidence comes from a 2010 study that analyzed the 11 total opiate use disorder criteria against a 2007 national survey on drug use and health that provided the largest sample of adult non-prescribed opioid users in the United States (WU et al, 2010).  The results of this study indicated that the four abuse and seven dependence criteria were highly correlation, r=.98.  More importantly, the factor analysis employed in this study identified two distinct groups of non-prescribed opioid users.  The affected group (7%) had a statistically significant higher probability of endorsing the eleven Opioid Use Disorder criteria than the less affected group (93%)  These findings suggest that users are likely to exist on a single continuum of severity.  The inclusion of severity scales in the DSM-V would allow clinicians to make more specific treatment recommendations by identifying different risk groups for customized treatment options.  For example, someone in the less severe range might benefit from motivational interviews, whereas someone on the opposite end of the spectrum would most likely require intensive inpatient treatment.

           These issues must be resolved in the DSM V in order to ensure better clinical diagnosis, treatment outcomes, and related research emerge in the future.  This is not only important for the United States as it is obvious that the DSM is used as a field manual throughout the world.  

          

The Neuropsychology of Borderline Personality Disorder

Review of Study Published in The Journal of Personality Disorders

          Borderline Personality Disorder is typically associated with deficits related to affect regulation, impulse control, interpersonal relationships, and self-identity.  Previous research also indicates that patients with Borderline Personality Disorder typically show several neuropsychological impairments that are related to right-hemisphere dysfunction.  This impairment is most often observed in the case of impulse control, attention, and decision-making.  According to past etiological models, these neuropsychological impairments can act as a moderator in the development of Borderline Personality Disorder.  Previous studies speculate that the dysfunctional cognitive processes may play an important role in the development of mental distortions that are commonly associated with the disorder.   However, previous research has yet to determine the exact pattern of these neuropsychological deficits, and examine their severity in comparison with other personality disorders.  The purpose of this study was to compare the severity of neuropsychological dysfunction in patients with Borderline Personality Disorder to patients diagnosed with other personality disorders, and a healthy control group. 

          The authors of this study tested two main hypotheses based on the empirical findings of previous research on personality disorders.  The first hypothesis was that patients with Borderline Personality Disorder will show more prominent neuropsychological deficiency than patients with other personality disorders.  The second hypothesis predicted that the observed neuropsychological deficits would be most related to impulsivity.

          Neuropsychological performance was measured using the Repeatable Brief Assessment of Neuropsychological Status (RBANS) test battery.  The RBANS was originally created to provide comprehensive evaluations in studies designed to evaluate the efficacy of therapeutic practices.  It consists of ten subtests that form five distinct index scores of immediate memory, delayed memory, language, visuo-spatial cognition, and attention.  The data collected from neuropsychological assessment were correlated with specific symptoms of Borderline Personality Disorder using the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). The ZAN-BPD defines four clinical dimensions of Borderline Personality Disorder and yields four separate scores for affective, cognitive, impulsivity, and interpersonal sectors.

          The results of this study showed a clear neuropsychological impairment in the Borderline Personality Disorder group compared with the healthy control group.  Post hoc tests indicated that these patients differed from the control group in domains of attention, immediate memory, and delayed memory.  The neuropsychological deficit was less noticeable in subjects with other personality disorders relative to the control group.  Several correlations were also found between RBANS scores and ZAN-BPD impulsivity scores.  

          This research suggests that attention, immediate memory, and delayed memory are the most severely impaired neuropsychological realms associated with personality disorders.  The results further suggest that the neuropsychological impairments observed in Borderline Personality Disorder may be related specifically to frontal and temporal lobe dysfunctions.  The frontal and temporal lobe profiles of the observed impairments also indicate that they are associated with impulsivity.

          One limitation of this study was the fact that the patient groups were treated with psychotropic medications prior to testing.  These medications could potentially affect cognitive performance as compared to the non-medicated control group.  Another limitation of this study is that its correlational design indicates an inability to draw causal conclusions.  The relationship between symptomology, etiology, and neuropsychology must be further studied in order to better understand the direct contribution of each variable on Borderline Personality Disorder features. 

          This study has several implications for future research.  While current models such as Dialectic Behavior Therapy have moderate records of success in the treatment of Borderline Personality Disorder, there is still much that remains a mystery about the etiology and symptomology of personality disorders in general.  This is a great example of the kind of research that will be necessary in order to better understand the origins and complex clinical presentations of these disorders.    

Link to Study 

Extra resources for the formal study of personality disorders:
Psychology Degree Resources
Psychcentral

Do Deficits in Mindfulness Underlie Borderline Personality Features and Core Difficulties?

 

Review of Study Published in the Journal of Personality Disorders

          Previous research includes several different models to identify the core mechanisms responsible for the diverse features associated with Borderline Personality Disorder.  This disorder presents with a variety of features that include ineffective interpersonal skills and emotion-regulation dysfunction.  Individuals diagnosed with Borderline Personality Disorder typically have issues related to awareness, attention, and self-acceptance.   Most previous research regularly associates mindfulness with the presentation of many of these issues; but there is limited research exploring the correlation between mindfulness and Borderline Personality Disorder symptoms.   The purpose of this study was to observe whether, in fact, mindfulness deficits underlie the broad areas of dysfunction commonly associated with the clinical features of this disorder.  To do this, the authors examined the relationship between mindfulness deficits and a diverse non-clinical sample that was representative of a wide range of Borderline Personality features.

            The authors tested three main hypothesis based on the empirical evidence of previous research.  The first hypothesis was that there would be a negative association between mindfulness, and the core areas of dysfunction of Borderline Personality Disorder.  The second hypothesis predicted that the association between mindfulness and these clinical features would be statistically significant when controlling for neuroticism.  The final hypothesis was that mindfulness would be able to predict Borderline Personality Disorder features beyond its associations with the regular functioning of the features associated with this disorder.

          The sample used for this study consisted of 342 undergraduate students who were currently enrolled in an introductory psychology course at the University of North Texas.  Mindfulness was measured using a fifteen item, Likert-type scale known as the Mindfulness Attention Awareness Scale.  This scale assesses several different traits that are characteristic of mindfulness including aspects of both attention and awareness.  Borderline Personality Disorder features were assessed using both self-report scales and written response items.  Neuroticism was also assessed due to its high correlation with Borderline Personality Disorder.  This was accomplished using a six item, likert-type scale that assessed the tendency towards negative emotions.  

            The results of this study indicate that mindfulness is positively correlated with interpersonal and emotional functioning, and negatively related to the dysfunctional emotional and interpersonal features associated with Borderline Personality Disorder.  Although weaker; the negative correlation with Borderline Personality Disorder remained statistically significant when controlling for neuroticism.  Analysis of data suggests that mindfulness significantly predicts Borderline Personality Disorder beyond the effects of features common to the disorder. This research suggests that the dysfunctional features of Borderline Personality Disorder may be explained by problems related to mindfulness combined with features of neuroticism.  Mindfulness was indicated as a main construct for explaining the primary areas of dysfunction common to Borderline Personality Disorder.

             One limitation of this study was the use of undergraduate psychology students to comprise the sample.  This may indicate a limited ability to generalize results to clinical populations.  Another limitation is the inability to draw causal conclusions due to the correlational design of the study.  The relationship between mindfulness and neuroticism must be studied further in order to understand the direct effects of each variable on Borderline Personality Disorder features.

          This study was meticulously designed and analyzed using strict data analysis procedures.  The major problem with this study is the inability to isolate all independent variables.  This is not a reflection of faulty methodology, but an indication of the complex clinical presentation of features related to this disorder.  This problem is most likely characteristic of all clinical studies that attempt to broadly examine Borderline Personality Disorder. 

          This study has broad implications for future research and clinical work.  I am interested in understanding how mindfulness meditation can be positively utilized in clinical application.  The relationship between mindfulness and Borderline Personality Disorder suggests that future research involving mindfulness meditation may be warranted.  It would be interesting to see if the introduction of mindfulness meditation would increase the efficacy of current therapeutic models.

 Link to Study 

Meditation Appears to Cause Changes in Brain's Gray Matter

MRI scans show increased volume in parts of brain linked to empathy, awareness

"A mindfulness meditation training program can trigger measurable changes in brain areas associated with awareness, empathy and sense of self within eight weeks, a new study has found."

"The meditation group participants spent an average of 27 minutes a day doing mindfulness meditation exercises. The MRI scans taken after the eight-week program revealed increased gray matter density in the hippocampus (important for learning and memory) and in structures associated with compassion and self-awareness."

"The investigators also found that participant-reported reductions in stress were associated with decreased gray matter density in the amygdala, which plays a role in anxiety and stress."

Link to Full Article

The positive effects of meditation have been known in the East for thousands of years, but the practice only started gaining popularity in Western society in the mid-20th century.  It wasn't until the 1960's that researchers began studying the effects of mediation and learning of its many benefits.  In the last 50 years scientific research has consistently indicated that the daily practice of meditation provides both mental and physical health benefits.  Until recently, researchers have had a very limited understanding of how meditation causes these positive changes.

This article, posted on January 25, 2011 in the health section of U.S. News and World Report, discusses the most recent research findings regarding this age-old practice.  The results of this study(as well as several others) indicate that the regular practice of meditation causes structural changes in the brain.  Increased density in the gray matter of the hippocampus and amygdala were observed after only two months of daily practice.  Neuroscience continues to provide proof of the brain's amazing plasticity.  Practicing meditation capitalizes on the brain's capacity for change, and translates to signifcant imporvements in daily life.  It is never too late to start!

Link To The National Center for Complementary and Alternative Medicine

A Perfect Example of Dangerously Innacurate Reporting

1 in 2 seniors on antidepressants face drug interactions 
Resulting side effects caused many to stop their prescription, new study finds 

WASHINGTON — More than half of older Americans taking an antidepressant for the first time were already taking another drug that could interact with it and cause side-effects, researchers reported on Friday.

"The research team used a Thomson Reuters database of claims for Medicare, the federal health insurance plan for people over 65."

"They found more than 39,000 patients who started antidepressants between 2001 and 2006. "Twelve commonly reported antidepressant side effects were identified in the month after drug initiation," Mark's team wrote."

"The side-effects meant patients often dropped the drug they were taking. Only 45 percent of those with documented side-effects refilled the prescription for the same antidepressant and a quarter quit taking antidepressants altogether."

"Many adults are at risk of this problem, the researchers noted — other studies show that 25 percent of older adults with chronic illnesses such as arthritis or heart disease also have depression, and they have also been shown to be helped by antidepressants."

Link to Full Article: Do not read if not capable of critical thinking


Wow, I don't even know where to start.  This is a perfect example of the kind of terrible reporting that leads people to annoyingly quote inaccurate statistics/facts.  I think it's important to point out that this article was published with no author by Reuters, and found on msnbc.com.  While I could rant about the inaccuracy of this article all day; I will restrain myself  to discussing a few of it's major problems.

First, I think it is interesting to notice that the research that this article refers to was performed by Thomson Reuters, parent company of Reuters.  Why do I find this interesting?  Maybe it's because the research was conducted by the same company that wrote and published this article.  I wonder if they stand to gain anything by writing about their own research?   Also, I find it suspicious when an article doesn't provide any information about where to find the original research that it references.

Second, the article isn't clear about the implications of the research that its reporting on.  The author haphazardly uses random quotes/statistics throughout the article to make oversimplified and overgeneralized statements about the use of antidepressants to treat depression in the "senior" population.

My biggest problem with this article is that it has the potential to unnecessarily alarm older readers who may be benefiting from the correct use of antidepressant medication.  It presents vague statements regarding antidepressant side effects, and potential drug interactions without providing any information about specific drugs/interactions that seniors should be aware of.  

My favorite quote from this article, "The side-effects meant patients often dropped the drug they were taking.  Only 45 percent of those with documented side-effects refilled the prescription for the same antidepressant and a quarter quit taking antidepressants altogether."  What a revelation!  Most people will either stop taking a medication that causes undesirable side effects or switches to a different medication with the help of their doctor.  The fact that 25 percent of seniors stop taking the antidepressants altogether isn't very alarming when compared to the almost identical proportion of the general public that reportedly does the same thing.  

This article is a great example of how important skepticism and critical thinking are when you get your "news" from the internet/mainstream media.