By Terence T. Gorski, Author
In this brief article I will define critical terms needed to understand the nature and severity of withdrawal from mind altering drugs and then I will present the initial recommendations for defining the symptoms of cannabis withdrawal in the DSM-V as of December 20, 2010.
The Diagnostic and Statistical Manual Fifth Edition (DSM-5) is proposing that recent research shows that people who regularly use Cannabis (Marijuana) can develop both dependence and withdrawal. This withdrawal syndrome has been clinical observed for decades in regular, heavy, and long term users of cannabis. Although I disagree with the symptom formulation, it is a major step forward to acknowledge that a marijuana addict can and often experience withdrawal symptoms.
My major critique of the symptoms describes are the absence of the following symptoms frequently reported by marijuana addicts: (1) Difficulty in paying attention or staying task focused for more the a few moments; (2) the tendency to dissociate or entered a non focused state of consciousness unpredictably during the withdrawal period. In the past I have referred to this as “the vacant stare phenomena; and (3) a profound sense of lethargy and lack of interest or motivation which is often described as an amotivational syndrome.
It is important to remember that in the DSM-V dependence and withdrawal are not definitive indicators of addiction to any drug. The definitive indicator of addiction is what DSM-IV calls a pattern of compulsive use, in other words the need to continue to use the drug in spite of adverse consequences and or the desire to stop. This pattern of compulsive use can occur with or without dependence and withdrawal. It is also possible to develop dependence and withdrawal on prescription drugs, including antidepressants and pain killers, without becoming addicted to them.
To exhibit cannabis withdrawal, people usually need to be using cannabis regularly (which refers to the frequency, which refers to a regular and predictability of pattern of use; heavily, which refers to the quantity or amount used during an typical episode of use, and duration, which refers to the length of time a person has been using in the same pattern.
The term dependence is defined as the need to use a substance in order to function normally physically, psychologically, and socially.
The term tolerance is defined as the need to use a drug more frequently and in greater quantities in order to be able to function normally. Withdrawal is a set of symptoms ranging from mild to disabling according to The Gorski Symptom Severity Scale.
The Gorski Symptom Severity Scale was developed by Terence T. Gorski as part of the GORSKI-CENAPS Model of Recovery and Relapse Prevention. It uses a 10 point severity rating scale to measure severity of symptoms based upon the amount of disruption a group of symptoms causes to the ability to perform basic acts of daily living. The scale uses four general categories of severity: mild, moderate; severe; and disabling. These general categories of severity are integrated with a ten point numerical rating of the severity level. They are as follows:
1. Mild – (Level 1, 2 & 3 on the severity scale) means that the symptoms are present and experienced as an energy draining nuisance, but normal functioning can be maintained in all areas of life with extra effort;
The terminology used in DSM IV and IV that compares with mild severity is clinically significant distress.
2. Moderate – (Level 4, 5 & 6 on the severity scale) means that the symptoms are present and require so much energy to manage them that normal functioning cannot be maintained in all areas. As a result people with mildly impairing symptoms begin selecting the most important life areas to maintain and beginning letting other less important areas go;
3. Severe – (level 7, 8, & 9) means that the symptoms are so severe and disruptive that the quality of life is affected in all areas in spite of using extra effort to function normally. The person can still maintain the appearance of a normal life, but it is apparent they are struggling and not doing well; disabling – (level 10) means the person is unable to function effectively in any area of life. They cannot maintain a job, intimate relationship, parenting responsibility. regular self-care activities, or friendships.
The DSM IV and V combine the Gorski Severity Scale levels 4 – 10 under the description of “impairment in social, occupational, or other important areas of functioning.”
The DSM-IVR and the DSM-V list a description of each symptom. This is a quantitative description answering the question “is the symptom present” but DSM does not clearly designate frequency or severity of symptoms. As a result, only the number of discrete symptoms is used to arrive at an overall diagnostic judgment.
The criteria for determining if people are experiencing withdrawal symptoms, according to the DSM-V working group are:
A. Cessation of cannabis use that has been heavy and prolonged
B. Three (3) or more of the following develop within several days after Criterion A
1. Irritability, anger or aggression
2. Nervousness or anxiety
3. Sleep difficulty (insomnia)
4. Decreased appetite or weight loss
6. Depressed mood
7. Physical symptoms causing significant discomfort: must report at least one of the following:
– stomach pain,
Additional Criteria B Symptoms Recommended by Terence T. Gorski (Not included in DSM-V):
(1) Difficulty in paying attention or staying task focused for more the a few moments;
(2) the tendency to dissociate or entered a non focused state of consciousness unpredictably during the withdrawal period. In the past I have referred to this as the vacant stare phenomena; and
(3) a profound sense of lethargy and lack of interest or motivation which is often described as an amotivational syndrome.
C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
D. The symptoms are not due to a general medical condition and are not better accounted for by another disorder