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4.1 Addiction week 5 summary

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Summary for the course 4.1 addiction at eur clinical psy master's program, detailed in-depth notes

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  • October 25, 2022
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  • 2022/2023
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ADDICTION WEEK 5

DIAGNOSTIC ASSESSMENT

Hasin 2013 – DSM5 criteria for SUDs: recommendations and rationale

Should abuse and dependence be kept as two separate diagnoses?
- reliability of abuse is lower than dependence
- syndrome requires more than one symptom, but abuse only required one criterion
- abuse is often assumed milder than dependence but not always the case
- all cases of dependence meet criteria for abuse
- hierarchy lead to poor reliability
- unidimensionality found for abuse and dependence criteria (except for legal
problems)
- abuse and dependence criteria are always intermixed in a spectrum
- decision: combine abuse and dependence into one disorder  SUD

Should any diagnostic criteria be dropped?
- legal problems got removed: low prevalence, poor fit with other criteria, no added
info
- tolerance: concerns but didn’t get dropped

Should any criteria be added?
- craving: included in ICD10 so increase consistency, added total info, biological
treatment target  added
- consumption: quantity of frequency, worsening of modeling fit  not added

What should the diagnostic threshold be?
- agreement maximized with 2 or more criteria
- concerns that this is too low (indicators of severity, need to identify all cases that
merit intervention
- supervised medical use of certain substances can lead to invalid SUD diagnoses!

How should severity be represented?
- no universal set of weight for certain criteria
- decision: using criteria count from 2 to 11 as a severity indicator
- 2-3 (mild), 4-5 (mod), 6 or more (severe)
- specifier got removed  predictive value was inconsistent
- course:
o specifiers for time frame and completeness of remission were too complex
o decided on 2 categories:
o early remission for more than 3 months but less than 12 without meeting
criteria other than craving
o sustained remission more than 12 months without meeting criteria other than
craving
o they updated maintenance therapy with examples e.g. methadone

,Could the definitions of substance-induced mental disorders be improved?
- decisions:
- for diagnosing substance-induced mental disorder, add criterion that the disorder
resembles the full criteria of the relevant disorder
- remove the req. that symptoms exceed expected intoxication or withdrawal
symptoms
- specify that substance must be capable of producing psychiatric symptoms
- change the name primary (mental disorder, prior to substance use or persist more
than 4 weeks after cessation, implies hierarchy) to independent
- change “substance induced” to “substance/medication induced”

Could biomarkers be utilized in making SUD diagnoses?
- decision was not to add any markers
- genetic variants don’t have enough evidence
- measuring dopamine markers is difficult and overlaps with other disorders

Should polysubstance dependence be retained?
- decision was to eliminate polysubstance dependence
- this allowed diagnosis for multiple substance users who failed to meet dependence
criteria for one, but had 3 or more dependence criteria collectively across substances
- became irrelevant with new additions

Substance-specific issues
Should cannabis, caffeine, inhalant and ecstasy withdrawal disorders be added?
- validity and reliability of cannabis withdrawal proven cannabis use
disorder/withdrawal/intoxication added
- insufficient evidence for inhalants and hallucinogens? (but they are disorders now in
the dsm5 I have, I’m confused?)
- evidence support reliability and clinical significance of “caffeine withdrawal” 
added, more research needed for addition of “caffeine use disorder”, not there yet

Should nicotine criteria be aligned with diagnostic criteria for the other SUDs?
- tobacco use disorder is more discriminating and produces higher prevalence than
nicotine dependence, unidimensionality with substance use patients
- decision: align dsm5 criteria for tobacco use disorder with criteria for other SUDs

Should neurobehavioral disorder associated with prenatal alcohol exposure be added?
- they included it in section 3 for suggestions but more info needed before it can get a
main diagnosis

Issues not related to substances
Should gambling disorders and other putative behavioral addictions be added to SUDs?
- pathological gambling was in impulse control disorders, they changed the name to
gambling disorder and removed “illegal acts to finance gambling” criterion, reduced
diagnostic threshold

, - no standard diagnostic criteria and limited data on other Bas (mostly for internet
addiction and shopping), internet gaming was added to section 3 of suggestions for
the future

Should the name of the chapter be changed?
- addition of gambling required a change in name for the chapter
- tension over the terms “addiction” and “dependence”, advocating addiction as a
general term and dependence specific to tolerance/withdrawal
- no consensus
- now it’s called “substance related and addictive disorders”, it includes gambling


Fong 2021 – Chapter 5 Assessment, Psychiatry Online
- initial psychiatric evaluation includes: patient’s use of tobacco, alcohol, psychoactive
substances, prescribed medication and other supplements
- 1) describing current and past patterns of substance use emphasis on excessive,
harmful or hazardous ones
- 2) diagnosing any substance related disorder that may be present not
- 3) documenting the effect of substance use on the person’s mental and physical state
- readiness to change, co-occurring psy disorders, medical history, physical exam.,
family history, social factors also important

Before assessment:
- review of medical record beforehand
- check prescription drug monitoring program database
- administer and review substance use screening forms in advance

conducting the substance use assessment with open-ended questions

structure of assessment
- substance use history (all 10 classes of drugs should be considered)
- ask about non-substance related disorders (behavioral addictions)
- distinguish substance use from substance use disorder (and substance induced
disorders)
- SUD treatment history
- psychiatric history (current and before the onset of substance use)
- medical history
- family history
- social history (home, health, purpose, community)
- collateral information (objective additional info from other people)
- physical and mental status examination (including cognitive and memory testing)
- lab tests

potential adverse effects related to substance use assessment
- missing diagnoses, wrong diagnoses, spending too much time, being scared to trigger
urges with questions (false notion)

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