The Importance of DSM
and ICD Definitions of
Dependence
Carlton Erickson, Ph.D.
Director, Addiction Science Research and
Education Center
University of Texas at Austin, USA
APIA-Singapore, 2004
“An alcoholic is someone
who drinks more than his
doctor!”
Anonymous
We must clarify the
words “addiction” and
“alcoholism”, both of
which have lost their
scientific and clinical
value
According to DSM-IV:
• substance (drug, chemical) abuse overuse of drugs in cases where people
are making poor judgments about drug
use: (“a problem to solve”)
• not a minor problem, since drug abusers
produce a major economic impact on
society
But this is the disease*
• substance (drug, chemical) dependence impaired control over drug use, probably
caused by a dysfunction in the brain’s
“pleasure pathway” (“a disease to conquer”)
• this requires twelve-step or other programs
(treatments)
• dependence = addiction; alcohol abuse
is not “alcoholism”
* Based on the Diagnostic and Statistical Manual-IV-TR
(DSM-IV-TR)
Sources
• Diagnostic and Statistical Manual of
Mental Disorders, Fourth Ed. - Text
Revision (DSM-IV-TR), 2000
• Morrison, J., DSM-IV Made Easy,
Guilford Press, NY, 1995
• ICD-10 Classification of Mental and
Behavioral Disorders, W.H.O., 1992
Dependence Criteria
• DSM-III-R: at least 3 of 9 persisting
for at least 1 month
• DSM-IV: 3 or more of 7 occurring at
any time in a 12-month period
• ICD-10: 3 or more of 7 occurring
together for at least one month or
repeatedly in a 12-month period
Clustering Criteria
1. tolerance
2. withdrawal
3-4. impaired control (only 1 for ICD-10)
5. neglect of activities
6. time spent in alcohol-related activity
• inability to fulfill roles (DSM-IIIR only)
• hazardous use (DSM-IIIR only)
7. continued use despite problems
• compulsion (ICD-10 only)
Abuse Criteria
• 2 (DSM-IIIR) to 4 (DSM-IV, ICD-10)
DSM-IV:
• at least one in a 12-month period
• never met criteria for dependence
• evidence is weaker than for
dependence
Measurement Tools
• Structured Clinical Interview for DSM-IIIR
(SCID)
• Semi-structured Assessment for the Genetics
of Alcoholism (SSAGA) - DSM-IIIR
• Psychiaric Research Interview for Substance
and Mental Disorders (PRISM) - DSM-IV
• Alcohol Use Disorders and Associated
Disabilities Interview Schedule (AUDADIS) DSM-IV
Measurement Tools (2)
• Comprehensive International
Diagnostic Interview (CIDI)
• Structured Clinical Assessment
for Neuropsychiatry (SCAN)
• Substance Use Disorders
Diagnostic Schedule (SUDDS)
Weaknesses
• not accurate for youth and
adolescent dx of dependence
• not for “process addictions” (sex,
gambling, etc.) - chemicals only
• accuracy depends on administrator some surveys are unstructured
• are not used all the time
RESEARCH VALIDITY
ESTIMATE (RVE)
(A Thoughtful Appraisal of
High-Quality Scientific Research)
100
-0
High RVE
• many large, well-controlled studies
• replicable results
• much peer-reviewed, published literature
Low RVE
• few replicable studies
• highly speculative results
• little peer-reviewed, published literature
Drugs Associated wth
Neurotransmitters
Why do people have “drugs of choice”?
70
• Dopamine - amphets, cocaine, ETOH
• Serotonin - LSD, ETOH
• Endorphins - opioids, ETOH
• Gamma-aminobutyric acid - benzos, ETOH
• Glutamate -ETOH
• Acetylcholine - nicotine, ETOH
(Marijuana?)
What Goes Wrong With
The Neurotransmitter
System(s)?
60
• genetic “malfunctions”?
• drug-induced changes?
• other aspects of the
environment, besides drugs?
Genetics of
Alcohol Dependence
80
• family, twin, & adoption studies
• “the tendency to become alcohol
dependent is inherited”
• major question: what is passed from
parent to child?
• alcohol dependence (perhaps other
dependencies?) is polygenetic!
Rationale Based on Genetics
abnormal genes
abnormal proteins
abnormal transmitter synthesizing enzymes
abnormal transmitter breakdown enzymes
abnormal receptors
90
neurotransmitter dysfunction in the pleasure
pathway
impaired control
The Future
• Blood markers? (GGT, CDT…)
• Brain imaging?
• Genetic markers?
• Combination of above?
• What can we learn from other
diseases?
Remember the Best
Academic Website in the
World!
www.utexas.edu/research/asrec