Historical perspectives on drug use and addiction; diagnosing addiction Flashcards
What led to the ‘moral model’ of addiction?
Attempts by religious groups to control excess
What was the principle of the ‘moral model’ of addiction?
Drunkenness = sin
- self-directed change demanded of the “sinner”
- failure resulted in intensified prayer or punishment
What characterised the ‘gin craze’ of the 1730s - 1740s in Great Britain?
Fast importation of gin which was becoming the drink of the poor
Which idea did physicians raise in early 19th century?
Habit of drunkenness as a disease of the mind
Who first used the term ‘alcoholism’?
What was its meaning?
Dr Magnus Huss (1851)
- alcoholism: disease relating to overconsumption of alcohol
What did the emerging educated middle class in victorian society against intoxication and drunkenness?
Moral causes to improve the health of the working poor
- intoxication / drunkenness not compatible with workers using machinery
What was the Temperance movement (19th century)?
Philanthropic lobby group that formed strong alliances with the Church to praise mass abstinence
What was the Society for the Study and Cure of inebriety (19th century)?
Provided a place for temperance performers, physicians and public health doctors to discuss the problem of excessive alcohol consumption
How was the ‘medical model’ of addiction born?
With the Society for the Study and Cure of inebriety (19th century):
- temperance performers, physicians and public health doctors discussed the problem of excessive alcohol consumption
What came with the emerging ‘medical model’ of addiction (19th century)?
> First attempts at treatment:
- secluded the inebriate in houses in the countryside
> Moral component still present
- worthy vs. unworthy drunk (case vs. non-case)
How was the term ‘alcoholism’ used with the new medical model of addiction?
To describe a worthy person suffering from a progressive disease, and who required help
How did the Temperance movement use the term ‘addiction’?
Narrow moralised and medicalised meaning
- limited to drinkers
- always morally reprehensible
- referred to progressive disease
What was the leading image of addiction the late 19th and early 20th century in Great Britain?
According to Temperance movement:
- limited to drinkers
- always morally reprehensible
- referred to progressive disease
- “overwhelming involvement”
How did the definition of addiction evolve in the mid-20th century?
Large scope, encompassing all socially unacceptable uses of alcohol and other drugs
-> less precise definition
What does the “loss of the soul” refer in addiction?
People don’t just change what they do, they change who they are
What are the four descriptions of the term “addiction” described by Bruce Alexander in ‘Globalisation of Addiction’ (2008)?
- Multitude of habits and pursuits related only to alcohol
- narrow definition used by Temperance movement - Any use of prohibited substance
- rising psychoactive drugs in 20s - Gambling and other behaviours
- emerging scientific evidence - Behaviours that are not considered part of treatable illness
How can we measure problems?
- Categorical measurement
- Ordinal measurement
- Dimensional measurement
What does the categorical classification system consist of?
> Assessment of presence or absence of an attribute
or
Selection of best category for an individual from a set of options
-> process of diagnosis (= basis of medicine)
What does the dimensional classification system consist of?
Quantitative assessment of specific attribute along a continuum of intensity, frequency, or severity
- e.g. blood pressure, symptom level, personality traits
What does the ordinal classification system consist of?
> Categories that are ordered
- e.g. low, medium, high
- > refines the diagnostic system
> “Cut points” can be used to convert scales into ordinals
- indicate thresholds for membership in a category
-> Practical compromise between categorical and dimensional
What are the three prominent reasons to make a diagnosis?
- Better communication between professionals and patients
- Helps guide treatment
- Informs prognosis
What is a syndrome?
A clustering of signs and symptoms
How does a syndrome permit clinical recognition?
Signs and symptoms must be sufficiently regular and coherent
What was the consequence of the lack of quantifiable data on diagnosis?
Vague and poorly defined relationship between symptoms and diagnosis
What was needed to counter the lack of quantifiable data for diagnosis?
Standardisation of diagnosis through ‘operational definitions’
What did the US-UK Diagnostic Project (Cooper et al., 1972) reveal?
- Psychiatrists in New York and London were given vignettes to diagnose
- New Yorkers were twice as likely to diagnose schizophrenia
- because they used a broad psychodynamic concept of diagnosis
-> need of standardisation of diagnosis
What are the two major diagnostic standards?
- Diagnostic and Statistical Manual of Mental Disorders (DSM)
- APA - International Classification of Disease (ICD)
- WHO
How was substance use characterised in the DSM (1952)?
Alcoholism, drug addiction grouped in deep seated personality disturbance
- no clear symptoms defined
- “underlying brain or personality disorder”
How was substance use characterised in the DSM-II (1968)?
> Still characterised as personality disorder
> Addition of:
- physiological signs of dependence (withdrawal/tolerance)
> Based on Jellinek’s ‘The disease concept of Alcoholism’ (1960)
How did Jellinek classify alcoholism (alcohol abuse) (1960)?
In term of severity:
- Alpha
- Beta
> Full syndrome of physiological and psychological dependence
- Gamma
- Delta
- Epsilon
Who was Griffith Edwards (1928-2012)?
Considered father of addiction psychiatry in the UK
How did Griffith Edwards define alcohol dependance in ‘The Description of the Alcohol Dependance Syndrome’ (1976)?
Medical definition: Alcohol Dependance Syndrom (ADS)
- Narrowing of drinking repertoire
- Salience of drink-seeking behaviour
- Relief from symptoms when drinking
- Increased physical tolerance to alcohol
- Repeated withdrawal symptoms when abstaining
- Reinstatement (relapse) after abstinence
- Awareness of compulsion to drink
What are the two separate diagnoses defined with the work of Griffith Edwards (1976)?
Alcohol abuse vs. Alcohol dependence
How were alcohol abuse and alcohol dependence differentiated?
With a spectrum:
> Proper use
> Hazardous use
- use of drug other than directed
> Misuse / abuse
- problematic behaviour
- use in risky situations
- use despite adverse consequences
> Dependence
- at least 3 features of alcohol dependence syndrome (ADS) as stated by Griffith Edwards (1976)
How was substance use characterised in the DSM-III (1980)?
> First category for substance use disorders
> Abuse and dependence considered two separate conditions
How was substance use characterised in the DSM-III-R (1987)?
Addition of behavioural and physiological aspects given equal weight
How was substance use characterised in the DSM-IV (1994)?
> 12 classes of drugs
> Problems
- e.g. intoxication, withdrawal, dementia, amnestic syndrome, psychotic/mood disorders
> Clear separation of abuse and dependence
How was substance use characterised in the DSM-IV-TR (2000)?
> Specific number of criteria required for criteria
> Problem of “diagnostic orphans”
> Abuse = pejorative term
> Dependence = physiological adaptation
What characterises the diagnostic criteria of alcohol abuse in the DSM-IV?
Abuse is inferior to dependence
- it has no criteria of dependence
What characterises the criteria of alcohol dependence in the DSM-IV?
Maladaptive pattern of alcohol abuse, leading to clinically significant impairment or distress, manifested by 3 or more occurring during the same 12-month period:
- Tolerance
- Withdrawal
- Impaired control
- Neglect of activities
- Time spent drinking
- Drinking despite problems
What was discussed by Hasin et al. (2013) in their review on substance abuse criteria in the DSM-5?
- Should abuse and dependence be kept as separate diagnoses?
- Item Response Theory analysis
- > no - What should the diagnostic threshold be?
- Categorical system needed because diagnosis is key in medicine
- > set a number of symptoms as criteria - How should severity be represented?
- As criteria count increases so does likelihood of SUD risk factors and consequences
- > use criteria count (2-11) as overall severity indicator
What characterises the definition of substance use disorder in the DSM-5 (2013)?
> 11 criteria
> term “addiction” is not used at all
> Severity of disorder:
- 2 to 3 symptoms present in last year = mild
- 4 to 5 = moderate
- 6 and more = severe
What is addiction?
Disorder involving loss of the normal flexibility of human behaviour, leaving a dehumanised state of compulsive behaviour
Why was the term “dependence” removed from the latest version of the DSM regarding addiction?
Confusion around the terminology:
- dependence used for severe end of spectrum
- BUT may refer to physiological aspects of addiction
