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COMMENTARIES
Commentaries on Martin et al. (2014) WHO SHOULD STAY, WHO SHOULD LEAVE? Martin and colleagues [1] have delivered to us, as the authors have proven to do, a thoughtful, provoking and intriguing piece of work. Their key point, if I interpret it correctly, is that the two main current classification systems for substance use disorder, the International Classification of Diseases and Related Health Problems, 10th edition (ICD-10) [2] and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) [3] both mix the main features of the disorder (‘core features’ as per the authors) with their medical and social consequences (‘ancillary’ characteristics). The authors claim that these consequences (identified as five of the current 11 criteria for the definition of substance use disorder in the DSM-5 and the whole harmful use diagnostic in ICD10) ‘should have a fundamentally reduced significance in the definition and diagnosis of substance use disorders’. I believe that the authors here are simply being polite, or politically correct, as what they should mean by ‘reduced significance’ is really ‘none’. The list of their ‘core features’ would be ‘heavy use, compulsive use, the incentive salience of substance use, and physiological features’ (or, as described previously, ‘tolerance; withdrawal; using more or longer than intended; unsuccessful attempts or a persistent desire to quit or cut down; much time spent using; and craving’). As per the authors’ proposals, the behaviors to be dropped from the current classifications would be ‘physically hazardous use; frequent intoxication leading to a failure to fulfill role obligations; reduced social activities in favor of substance use; continued use despite knowledge of social/interpersonal problems; and continued use despite knowledge of physical/ psychological problems’. Altogether, therefore, this new proposed version of substance use disorder would have six symptoms currently in the DSM-5 plus an extra one, ‘heavy use’ (not defined by the authors, but two references are given). I am intrigued as to why the authors are suggesting these changes now, as the roots of this state of affairs are at least 30 years old. Also, the authors have access to main data sets and have indeed used unpublished data for their own analysis to help make some points in the manuscript. Why did they not actually test what I believe are empirical questions, such as: should we delete any criterion or set of criteria from the current systems and should we add any new criterion (i.e. heavy use)? What would we gain and lose if we add and delete symptoms (sensitivity, specificity, etc.)? How many current cases (people under treatment) for substance use disorder would we lose if we © 2014 Society for the Study of Addiction
plainly delete these five criteria from our definition, or just do not treat people with ICD-10 harmful use? Instead, the authors decided to present these suggestions only in narrative format, and I am intrigued by what the reasons are for that. Another matter for debate is the application of a uniform set of criteria for substance use disorder and the specificities of a particular substance. Most, if not all, points and examples made by the authors are discussed in the context of alcohol use disorder. Instead of presenting the discussion on alcohol use disorder exclusively, the authors choose to immediately make it general criteria for substance use disorder. One wonders if we would need to actually test the empirical questions formulated above across a set of substances, and not simply assume it would fit them all. My guess is that, as has been found before, problems with definitions, international issues and plain lack of consensus with what is heavy use—for alcohol and across substances in general—will abound. I agree that the current 11 criteria used in the DSM-5 for the diagnostic of substance use disorder are probably too many, and somehow redundant. However, which one(s) should stay and which one(s) should be removed are empirical questions for research. We ought to praise the authors for helping us in setting the stage to ask these questions going forward.
Declaration of interests No financial conflicts of interest associated with the work. I have served on the American Psychiatric Association Workgroup for Substance Use and Related Disorders for the DSM-5. Keywords Alcohol use disorder, DSM-5, ICD-10, nosology, psychiatry, substance use disorder. GUILHERME BORGES
Epidemiology, Instituto Nacional de Psiquiatria and Universidad Autonoma Metropolitana, Calzada Mexico Xochimilco 101, Mexico City 14370, Mexico. E-mail: [email protected]; [email protected]
References 1. Martin C. S., Langenbucher J. W., Chung T., Sher K. J. Truth or consequences in the diagnosis of substance use disorders. Addiction 2014; 109: 1773–8. 2. World Health Organization. International Classification of Diseases and Related Health Problems, 10th edn. Geneva, Switzerland: Author; 1992. Addiction, 109, 1779–1785
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1780
Commentaries
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn (DSM-5). Washington, DC: Author; 2013.
A LITTLE BIT OF BOTH I would like to begin by commending Martin et al. [1] for the questions they raise about the role of problematic consequences in the diagnosis of alcohol use disorders (AUD). The issue of what should be the core criteria in the diagnosis of dependence to alcohol has been debated for some time. Martin et al. review this debate and propose that consequences do not have a place as core criteria for such a diagnosis. I am not unsympathetic to this proposal. For example, as Martin et al. discuss, I and others have written about the potential misinterpretation of questions about DSM criteria by respondents in household surveys with resulting false positive diagnosis of alcohol dependence [2–5]. The potential socio-economic biases created by some criteria such as hazardous drinking (read drinking and driving) in the DSM-IV diagnosis of alcohol dependence and in the DSM-V diagnosis of AUD has also been recognized [6–8]. The trouble with Martin et al.’s proposal is that while it appropriately identifies weaknesses in the present diagnostic system, it proposes a new one with similar inherent limitations. To explain: Martin et al. propose that ‘substance use disorders should be defined to reflect the core illness dimensions’ of heavy use, compulsive use, incentive salience of substance use, physiological features, preoccupation, narrowing of the drinking repertoire, rapid reinstatement and development of allostasis. Martin et al. do not specifically identify the indicators for each of these core domains, but I strongly suspect that they, too, will be affected by subjective judgment and context. For instance, the alcohol field does not have a standard definition of heavy use. The standard American definition of binge drinking as the consumption of four drinks for women and five for men in about 2 hours [9] is usually thought to be too little drinking in European contexts. Similarly, there are no agreed-upon definitions of compulsive use. Some years ago [10], I argued that the alcoholic’s drinking did not satisfy phenomenological requirements for a diagnosis of compulsion, as suggested by Edwards & Gross [11] in their seminal description of the alcohol dependence syndrome. I still believe this is so. Similar difficulties may affect assessments of preoccupation and narrowing of the drinking repertoire. These, too, will depend upon ‘the eyes of the beholder’, and as such will also be subject to some of the same biases identified by Martin et al. in the present diagnostic system. Martin et al. are trying to wrangle a complex problem. Diagnostic criteria should be free of socio-economic, cul© 2014 Society for the Study of Addiction
tural and contextual bias, which cannot be avoided if consequences are indicators of substance use disorders. Unfortunately, in spite of advancements in the neuroscience and pathology of addiction, diagnostic schemes for substance use disorders still rely upon epiphenomena to identify these disorders, a situation that is likely to remain so in the immediate future. One way to limit the potential biasing impact of these indicators is to limit their number in the criteria. I do not think that we need all the 11 indicators now present in the DSM-V to achieve a diagnosis of substance use disorder. If we were able to eliminate ‘legal problems’ from the criteria, we should also be able to eliminate ‘hazardous drinking’ and other problematic indicators. However, this should be conducted in a systematic fashion, and should be based on research evidence. Perhaps the next step in diagnostic criteria development is to conduct a systematic assessment of the types of biases associated with each criterion and of their impact on disorders identification. Based on this evidence, and on consensus development among researchers and clinicians, diagnostic criteria can be refined until more specific knowledge about core symptoms of dependences become available. Declaration of interests None. Keywords Alcohol, AUD, diagnosis, DSM, review, substance use disorders. RAUL CAETANO
University of Texas School of Public Health, Dallas Regional Campus, 6011 Harry Hines Boulevard, Rooom V8.112, Dallas, TX 75390, USA. E-mail: [email protected] References 1. Martin C. S., Langenbucher J. W., Chung T., Sher K. J. Truth or consequences in the diagnosis of substance use disorders. Addiction 2014; 109: 1773–8. 2. Caetano R. The identification of alcohol dependence criteria in the general population. Addiction 1999; 94: 255–67. 3. Caetano R., Babor T. F. Diagnosis of alcohol dependence in epidemiological surveys: an epidemic of youthful alcohol dependence or a case of measurement error? Addiction 2006; 101: 111–4. 4. Slade T., Teesson M., Mewton L., Memedovic S., Krueger R. F. Do young adults interpret the DSM diagnostic criteria for alcohol use disorders as intended? A cognitive interviewing study. Alcohol Clin Exp Res 2013; 37: 1001–7. 5. Chung T., Martin C. S. Concurrent and discriminant validity of DSM-IV symptoms of impaired control over alcohol consumption in adolescents. Alcohol Clin Exp Res 2002; 26: 485–92. 6. Babor T. F., Caetano R. The trouble with alcohol abuse: what are we trying to measure, diagnose, count and prevent? Addiction 2008; 103: 1057–9. Addiction, 109, 1779–1785
COMMENTARIES
Commentaries on Martin et al. (2014) WHO SHOULD STAY, WHO SHOULD LEAVE? Martin and colleagues [1] have delivered to us, as the authors have proven to do, a thoughtful, provoking and intriguing piece of work. Their key point, if I interpret it correctly, is that the two main current classification systems for substance use disorder, the International Classification of Diseases and Related Health Problems, 10th edition (ICD-10) [2] and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) [3] both mix the main features of the disorder (‘core features’ as per the authors) with their medical and social consequences (‘ancillary’ characteristics). The authors claim that these consequences (identified as five of the current 11 criteria for the definition of substance use disorder in the DSM-5 and the whole harmful use diagnostic in ICD10) ‘should have a fundamentally reduced significance in the definition and diagnosis of substance use disorders’. I believe that the authors here are simply being polite, or politically correct, as what they should mean by ‘reduced significance’ is really ‘none’. The list of their ‘core features’ would be ‘heavy use, compulsive use, the incentive salience of substance use, and physiological features’ (or, as described previously, ‘tolerance; withdrawal; using more or longer than intended; unsuccessful attempts or a persistent desire to quit or cut down; much time spent using; and craving’). As per the authors’ proposals, the behaviors to be dropped from the current classifications would be ‘physically hazardous use; frequent intoxication leading to a failure to fulfill role obligations; reduced social activities in favor of substance use; continued use despite knowledge of social/interpersonal problems; and continued use despite knowledge of physical/ psychological problems’. Altogether, therefore, this new proposed version of substance use disorder would have six symptoms currently in the DSM-5 plus an extra one, ‘heavy use’ (not defined by the authors, but two references are given). I am intrigued as to why the authors are suggesting these changes now, as the roots of this state of affairs are at least 30 years old. Also, the authors have access to main data sets and have indeed used unpublished data for their own analysis to help make some points in the manuscript. Why did they not actually test what I believe are empirical questions, such as: should we delete any criterion or set of criteria from the current systems and should we add any new criterion (i.e. heavy use)? What would we gain and lose if we add and delete symptoms (sensitivity, specificity, etc.)? How many current cases (people under treatment) for substance use disorder would we lose if we © 2014 Society for the Study of Addiction
plainly delete these five criteria from our definition, or just do not treat people with ICD-10 harmful use? Instead, the authors decided to present these suggestions only in narrative format, and I am intrigued by what the reasons are for that. Another matter for debate is the application of a uniform set of criteria for substance use disorder and the specificities of a particular substance. Most, if not all, points and examples made by the authors are discussed in the context of alcohol use disorder. Instead of presenting the discussion on alcohol use disorder exclusively, the authors choose to immediately make it general criteria for substance use disorder. One wonders if we would need to actually test the empirical questions formulated above across a set of substances, and not simply assume it would fit them all. My guess is that, as has been found before, problems with definitions, international issues and plain lack of consensus with what is heavy use—for alcohol and across substances in general—will abound. I agree that the current 11 criteria used in the DSM-5 for the diagnostic of substance use disorder are probably too many, and somehow redundant. However, which one(s) should stay and which one(s) should be removed are empirical questions for research. We ought to praise the authors for helping us in setting the stage to ask these questions going forward.
Declaration of interests No financial conflicts of interest associated with the work. I have served on the American Psychiatric Association Workgroup for Substance Use and Related Disorders for the DSM-5. Keywords Alcohol use disorder, DSM-5, ICD-10, nosology, psychiatry, substance use disorder. GUILHERME BORGES
Epidemiology, Instituto Nacional de Psiquiatria and Universidad Autonoma Metropolitana, Calzada Mexico Xochimilco 101, Mexico City 14370, Mexico. E-mail: [email protected]; [email protected]
References 1. Martin C. S., Langenbucher J. W., Chung T., Sher K. J. Truth or consequences in the diagnosis of substance use disorders. Addiction 2014; 109: 1773–8. 2. World Health Organization. International Classification of Diseases and Related Health Problems, 10th edn. Geneva, Switzerland: Author; 1992. Addiction, 109, 1779–1785
bs_bs_banner
1780
Commentaries
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn (DSM-5). Washington, DC: Author; 2013.
A LITTLE BIT OF BOTH I would like to begin by commending Martin et al. [1] for the questions they raise about the role of problematic consequences in the diagnosis of alcohol use disorders (AUD). The issue of what should be the core criteria in the diagnosis of dependence to alcohol has been debated for some time. Martin et al. review this debate and propose that consequences do not have a place as core criteria for such a diagnosis. I am not unsympathetic to this proposal. For example, as Martin et al. discuss, I and others have written about the potential misinterpretation of questions about DSM criteria by respondents in household surveys with resulting false positive diagnosis of alcohol dependence [2–5]. The potential socio-economic biases created by some criteria such as hazardous drinking (read drinking and driving) in the DSM-IV diagnosis of alcohol dependence and in the DSM-V diagnosis of AUD has also been recognized [6–8]. The trouble with Martin et al.’s proposal is that while it appropriately identifies weaknesses in the present diagnostic system, it proposes a new one with similar inherent limitations. To explain: Martin et al. propose that ‘substance use disorders should be defined to reflect the core illness dimensions’ of heavy use, compulsive use, incentive salience of substance use, physiological features, preoccupation, narrowing of the drinking repertoire, rapid reinstatement and development of allostasis. Martin et al. do not specifically identify the indicators for each of these core domains, but I strongly suspect that they, too, will be affected by subjective judgment and context. For instance, the alcohol field does not have a standard definition of heavy use. The standard American definition of binge drinking as the consumption of four drinks for women and five for men in about 2 hours [9] is usually thought to be too little drinking in European contexts. Similarly, there are no agreed-upon definitions of compulsive use. Some years ago [10], I argued that the alcoholic’s drinking did not satisfy phenomenological requirements for a diagnosis of compulsion, as suggested by Edwards & Gross [11] in their seminal description of the alcohol dependence syndrome. I still believe this is so. Similar difficulties may affect assessments of preoccupation and narrowing of the drinking repertoire. These, too, will depend upon ‘the eyes of the beholder’, and as such will also be subject to some of the same biases identified by Martin et al. in the present diagnostic system. Martin et al. are trying to wrangle a complex problem. Diagnostic criteria should be free of socio-economic, cul© 2014 Society for the Study of Addiction
tural and contextual bias, which cannot be avoided if consequences are indicators of substance use disorders. Unfortunately, in spite of advancements in the neuroscience and pathology of addiction, diagnostic schemes for substance use disorders still rely upon epiphenomena to identify these disorders, a situation that is likely to remain so in the immediate future. One way to limit the potential biasing impact of these indicators is to limit their number in the criteria. I do not think that we need all the 11 indicators now present in the DSM-V to achieve a diagnosis of substance use disorder. If we were able to eliminate ‘legal problems’ from the criteria, we should also be able to eliminate ‘hazardous drinking’ and other problematic indicators. However, this should be conducted in a systematic fashion, and should be based on research evidence. Perhaps the next step in diagnostic criteria development is to conduct a systematic assessment of the types of biases associated with each criterion and of their impact on disorders identification. Based on this evidence, and on consensus development among researchers and clinicians, diagnostic criteria can be refined until more specific knowledge about core symptoms of dependences become available. Declaration of interests None. Keywords Alcohol, AUD, diagnosis, DSM, review, substance use disorders. RAUL CAETANO
University of Texas School of Public Health, Dallas Regional Campus, 6011 Harry Hines Boulevard, Rooom V8.112, Dallas, TX 75390, USA. E-mail: [email protected] References 1. Martin C. S., Langenbucher J. W., Chung T., Sher K. J. Truth or consequences in the diagnosis of substance use disorders. Addiction 2014; 109: 1773–8. 2. Caetano R. The identification of alcohol dependence criteria in the general population. Addiction 1999; 94: 255–67. 3. Caetano R., Babor T. F. Diagnosis of alcohol dependence in epidemiological surveys: an epidemic of youthful alcohol dependence or a case of measurement error? Addiction 2006; 101: 111–4. 4. Slade T., Teesson M., Mewton L., Memedovic S., Krueger R. F. Do young adults interpret the DSM diagnostic criteria for alcohol use disorders as intended? A cognitive interviewing study. Alcohol Clin Exp Res 2013; 37: 1001–7. 5. Chung T., Martin C. S. Concurrent and discriminant validity of DSM-IV symptoms of impaired control over alcohol consumption in adolescents. Alcohol Clin Exp Res 2002; 26: 485–92. 6. Babor T. F., Caetano R. The trouble with alcohol abuse: what are we trying to measure, diagnose, count and prevent? Addiction 2008; 103: 1057–9. Addiction, 109, 1779–1785
