Week 1 – Part 1: Course:
Reading 1: Martin – Historical and cultural perspectives on substance use and substance use
disorders:
• INTRO
o SUD = substance use disorders
o Diagnostic criteria for these have been refined since mid-20th century until now
§ Controversial
§ Culture plays a role in this – affects how we define/perceive it
o Modern theory of nature of substance dependence = chronic substance use can
produce neuroadaptations in brain (reward, motivation…) à lead to compulsion
• PSYCHOACTIVE SUBSTANCE USE: HISTORY, PATTERNS, CULTURAL VARIATION
• History of substance use:
o These have been used for millennia (alcohol, opium, cannabis…) – seen in bible, Greek
myths… - spread with war, trade, migration
• Patterns of substance use:
o Use ≠ SUD
o No drug is identical but they all lead to similar outcome
§ Many ways to classify them -> clinical, chemical…
o Mainly affect the CNS – different ways of taking them affects addiction risk, speed of
absorption
§ Lungs = fastest absorption – then blood & intestine
§ Culture affects what we see as a problematic level of use (daily alcohol in West
in fine)
o Quantity = amount used in one episode (e.g., 3 shots, 1g)
§ Hard to tell for some cause of uncertainty on purity of the drug
§ V important to differentiate quantity & frequency (1 drink/day vs 7/week)
o SPU = simultaneous polydrug use à mixing drugs – often on purpose
§ To get a desired effect (cannabis & alcohol)
§ Reduce the effect of another drug (nicotine & alcohol)
§ Increased social problems linked to this + overdose L
• Cultural variation in substance use patterns:
o Cultural norms = affect view/behavior around drugs
§ Can also vary in subcultures
o Norms = abstinence – pattern – contexts – purpose
§ Can help regulate use
§ Wasn’t seen as bad until it was linked to lower classes & criminality in past
o Level of use in country ≠ drug control policy (US vs NL) – could be geographical
location – biological differences in effect of drug across race/ethnicity (e.g., alcohol in
Asians)
§ General predictors across cultures (male, higher class)
History - Been used for ages + spread with trade/war/migration
Pattern - Different ways of taking them (affects absorption speed) – CNS
- Quantity = amount used in 1 episode – frequency = how often (both important)
- SPU = mixing drugs -> increased problems – overdose L
Culture - Norms (pattern, context, purpose, abstinence) affects view & behavior around drugs
- Level of use not closely linked to control policy -> norms; geography; biology
• HISTORICAL PERSPECTIVES ON SUBSTANCE USE DISORDERS:
• Historical developments in understanding & classifying mental disorders:
o Understanding of SUD has changed over time
1
, o Questions around how to define a mental disorder
o Mental illness = happens within an individual – some functioning has gone wrong
§ Causes harm/distress (not caused by society)
• Historical description of substance problems:
o Substance use’s social/health problems described by many activists in past
§ Not well understood until the concept of addiction came up (discovered with
alcohol – a patient couldn’t stop despite the complaints from it)
o Controversies over these “self-induced” disorders vs ones without control
• Jellinek’s description of alcoholism syndromes:
o Described it negatively – emphasis on illness progression
o 4 phases:
§ Pre-alcoholic -> drinking is socially motivated – relief drinking & tolerance
§ Prodromal phase -> drinking to escape problems – drink a lot, large amounts,
shame from drinking, chronic hangovers…
§ Crucial phase -> loss of control, morning drinking, loss of relationships…
§ Chronic phase -> no self-control – just deterioration until death
o Alpha (drink with prblm) – beta (no prblm) – gamma – delta – epsilon alcoholism
§ This classification was wrong but v influential (description of clinical signs)
• DSM-I & DSM-II SUD criteria:
o DSM-I = 1952 – mainly cause of mental health problems cause by WW2
o Alcoholism = severe enough to cause social, psychological, or physical impairment
§ Daily drinking was often necessary for functioning
o DSM-II = episodic excessive drinking (4 or more episodes/year); habitual excessive
drinking (over 12 episodes a year); alcohol addiction (constant, withdrawal symptoms,
no control)
• The alcohol dependence syndrome:
o Attempt to define the core of the illness (no cultural influence)
§ Tolerance – withdrawal – use to avoid withdrawal – compulsion use – salience
of use – stereotypes use patterns – rapidly going back to addiction after stop
• DSM-III SUD criteria:
o Moved to SUD (≠ personality disorder)
§ Focus on core > social aspect of it
• DSM-III-R SUD criteria:
o Continued use despite social consequences – no criterion is necessary/sufficient
o Abuse < dependence (unsure if part of the same)
• Research on alcohol dependence subtypes:
o Hard to agree on – but 2 types of persons with alcohol dependence
§ Type I/A/essential/affiliative/apollonian à moderate heritability – gradual
onset – moderately abusive drinking – same F/M ratio
§ Type II/B/reactive/schizoid/Dionysian à high heritability – early onset –
antisocial traits – under controlled drinking – more M > F (2:1)
o Higher prevalence of type A > B – can be seen as severity levels
§ Most people show a mix of these
- Substance use problems not well understood until addiction came up
Jellinek - Focus on progression of illness (phases + “species”/types)
DSM - I) Causes social/psych/physical impairment
- II) Added severity categories
- III) Abuse < dependence – bring focus to core (> social aspect)
Subtypes - A = meh heritability + later onset – B = high heritability + early onset
- More about severity levels – really a mix of both
2
, • CULTURAL PERPSECTIVES ON SUBSTANCE USE DISORDERS:
o Role of culture in defining the illness – determines need for intervention
§ Universalistic approach = focus on common elements across cultures
• Allows cross-cultural comparison
§ Relativistic approach = influence of culture – can lead to CBS (culture-bound
syndromes)
• Seen in Jellinek’s species (some more common in certain cultures)
§ L Unsure if prevalence dif between countries is true or just cultural difference
o Differences in concepts/diagnoses/individual criteria
§ Some symptoms are culture bound (e.g., driving after drinking)
§ Cultures with similar norms have similar description of addiction
• Drinking = lower amount seen as addiction in India (≠Greece)
• Social acceptability – familiarity – social class linked to drug
o (e.g., opium in China – eating in upper class vs smoking in low)
o !!! V important to take culture into account when diagnosing/treating someone
Culture - Role in defining addiction + treatment + diagnosis
- Similar cultural norms lead to similar description of addiction
Approaches - Universalistic = focus on common elements across cultures
- Relativistic = influence of culture – can lead to CBS (culture bound syndrome)
• CURRENT DIAGNOSTIC SYSTEMS FOR SUBSTANCE USE DISORDERS:
• Diagnostic criteria for SUD in the International Classification of Diseases:
o First mentioned in ICD-8 (1967)
o ICD-10 = 2 types of SUD
§ Substance dependence (3 or more/6 – over 12 months – tolerance; craving;
withdrawal; low self-control; harmful use; much time spent)
§ Harmful use (pattern of use causing physical or psych damage)
• Harmful use is ≠ DSM def
• DSM-IV SUD criteria:
o Use of addiction constructs (tolerance, withdrawal, neg consequences…)
§ Abuse (at least 1/4 criteria) -> role impairment; hazardous use; legal problems;
social problems
§ Dependence (at least 3/7 criteria) over 12 months -> tolerance; withdrawal;
larger/longer; quit/cut down; much time spent using; reduced activity;
psych/physical problems; craving
o This was based on little data (little time since DSM-IIIR)
• Limitations of DSM-IV SUD diagnostic algorithms:
o No accepted understanding of substance abuse
§ Low agreement on who qualifies for substance abuse diagnosis
o Criterion for abuse & dependence have overlapping content
§ Debate over social for abuse vs physiologic for dependence (mix of both)
o Not bad enough to be a mental disorder (no mention of genetics – don’t mention age
of onset)
o Factor analyses suggest more of a general substance problem (≠ abuse + dependence)
o Some don’t fit into any of the two but still should be diagnosed
o à This all led to removal of substance abuse
ICD - 2 types = substance dependence + harmful use
DSM - Abuse vs dependence (no mention of harmful use)
Limitations - No clear def of abuse – abuse vs dependence is hard to differentiate – general
substance problem – few things not mentioned
3
, • SUBSTANCE USE DISORDERS IN DSM-5
o SUD in different substance classes
o Symptoms = all dependence symptoms + 3 of the abuse symptoms + craving
§ Diagnosed if 2+/11
• DSM-5 uses a single SUD for each drug class:
o No more abuse vs dependence -> just one SUD per drug class
• SUD is defined by a diagnostic threshold of 2+/11 symptoms:
o Should avoid false-positive + judge importance of treating substance problems at
certain level of severity (& personal/societal costs for this)
§ May be too lenient?
• Issues of SUD terminology:
o Discussion over using term “dependence” (more biological) vs “addiction” (can be
seen as more negative)
§ Ended up with … use disorder
• Revising, adding, and deleting individual criteria in DSM-5:
o Added craving in DSM-5 + cannabis withdrawal + removed legal problems
§ No revision of DSM-IV dependence when Qs around it
§ Talk about consumption criterion (frequency) – but too influenced by culture
• DSM-5 made steps toward integrating categorical & dimensional approaches to SUD diagnoses:
o Dimensional approach = severity threshold
§ Good to make decisions on treatment + see those not diagnosed with symptom
§ Mild – moderate – severe levels
• Noncriterion features of substance problems not in DSM-5 but interest to researchers:
o Some other signs/symptoms/correlates/risk factors à can be linked to dependence;
linked to other disorders
§ Some are v important to look into with patient (legal, interpersonal…)
DSM-5 - Combined dependence & abuse (use symptoms of all - legal + craving)
- 2+/11 symptoms for diagnosis – no consumption criterion
- 3 severity levels
• MODERN UNDERSTANDING OF SUBSTANCE DEPENDENCE:
o Modern theories = focus on how substance use leads to neuroadaptations in brain
systems linked to reward, motivation…
§ This is a culturally universal way of understanding addiction
o -> Reward circuit (mesolimbic dopamine tract) -> repeated substance use can ‘hijack’
the reward system – leading to cravings
§ Also adaptations with tolerance -> leads to seeking more of the substance
§ Withdrawal symptoms
Modern theory - Focus on biology
- Neuroadaptations caused by substance use = affect reward, motivation,
affective regulation, inhibition, tolerance/withdrawal
à Leads to increased substance use
- Future biological marker of SUDs? -> would need pre-addiction neuroimaging (as a supplement J)
- New psychoactive drugs? -> yes v likely – need to keep track of this
- Globalization & economic expansion? -> can lead to higher drug use – higher SUD risk
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