DSM 5: Simple Procedure for Evaluating Addiction 

August 15, 2016

The DSM 5 allows clinicians to specify how severe the substance use disorder is, depending on how many symptoms are identified.
MILD: Two or three symptoms indicate a mild substance use disorder;
MODERATE: Four or five symptoms indicate a moderate substance use disorder, and
SEVERE: Six or more symptoms indicate a severe substance use disorder. 

DSM: Severe Addiction
SEVERE: six or more symptoms indicate a severe substance use disorder. Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.” 
Here are the eleven symptoms (DSM Criteria):

Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria:
1. Taking the substance in larger amounts or for longer than the you meant to

2. Wanting to cut down or stop using the substance but not managing to

3. Spending a lot of time getting, using, or recovering from use of the substance

4. Cravings and urges to use the substance

5. Not managing to do what you should at work, home or school, because of substance use

6. Continuing to use, even when it causes problems in relationships

7. Giving up important social, occupational or recreational activities because of substance use

8. Using substances again and again, even when it puts the you in danger

9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance

10. Needing more of the substance to get the effect you want (tolerance)

11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.

Take an alcohol and drug use history. Then ask the patient if he/she has ever experienced this (the symptom/criteria). Keep going between the patient’s discussion of each criteria and what they reported in the alcohol and drug use history. 
Then you can add a recovery specifier. They offer four options: 

Clinicians can also add one of four specifiers 

1. In early remission,

2. In sustained remission,

3. On maintenance therapy (such as methadone or Suboxone);

4. In a controlled environment (such as detox, residential living, sober living home, jail/prison, etc.)

Try it with patient or in a group and let me know how it goes by posting on my Facebook Page: www.facebook.com/GorskiRecovery 


Marijuana Addiction: Integrating DSM IV, DSM V, and the GORSKI-CENAPS MODEL

July 15, 2014

By Terence T. Gorski, Author
GORSKI BOOKS

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Warning: Continued use of this substance may lead to continued use of this substance.

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
5. Restlessness
6. Depressed mood
7. Physical symptoms causing significant discomfort: must report at least one of the following:
– stomach pain,
– shakiness/tremors,
– sweating,
– fever,
– chills,
– headache

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

Original Publication as a FaceBook Note:


DSM 5 Substance Use Disorders: A Concise Summary

October 15, 2013

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, commonly referred to as the DSM-V or DSM 5, is the latest version of the American Psychiatric Association’s gold standard text on the names, symptoms, and diagnostic features of every recognized mental illness, including addictions. This edition was published in May 2013, nearly 20 years after the original publication of the previous edition, the DSM-IV, in 1994.

The DSM-V recognizes substance related disorders resulting from the use of ten separate classes of drugs:

1. alcohol,
2. caffeine,
3. cannabis,
4. hallucinogens (phencyclidine or similarly acting arylcyclohexylamines), other hallucinogens such as LSD,
5. inhalants,
6. opioids,
7. sedatives,
8. hypnotics,
9. anxiolytics,
10. stimulants (including amphetamine-type substances, cocaine, and other stimulants), tobacco, and
11. other or unknown substances.

Therefore, while some major grouping of psychoactive substances are specifically identified, use of other or unknown substances can also form the basis of a substance related or addictive disorder.

The DSM 5 explains that activation of the brain’s reward system is central to problems arising from drug use –- the rewarding feeling that people experience as a result of taking drugs may be so profound that they neglect other normal activities in favor of taking the drug. While the pharmacological mechanisms for each class of drug is different, the activation of the reward system is similar across substances in producing feelings of pleasure or euphoria, which is often referred to as a “high.”

The DSM 5 also recognizes that people are not all automatically or equally vulnerable to developing substance related disorders, and that some individuals have lower levels of self-control, which may be brain-based, which predispose them to developing problems if exposed to drugs.

There are two groups of substance-related disorders:
1. Substance use disorders and
2. Substance-induced disorders.

Substance use disorders are patterns of symptoms resulting from use of a substance which the individual continues to take, despite experiencing problems as a result.

Substance-induced disorders are symptoms that can be caused directly by the drug during or immediately after individual episodes of use.

The substance-induced disorders include:

1. Intoxication,
2. Withdrawal,
3. Substance induced mental disorders (including substance induced psychosis, substance induced bipolar and related disorders, substance induced depressive disorders, substance induced anxiety disorders, substance induced obsessive-compulsive and related disorders, substance induced sleep disorders, substance induced sexual dysfunctions, substance induced delirium and substance induced neurocognitive disorders.)

Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria:

1. Taking the substance in larger amounts or for longer than the you meant to
2. Wanting to cut down or stop using the substance but not managing to
3. Spending a lot of time getting, using, or recovering from use of the substance
4. Cravings and urges to use the substance
5. Not managing to do what you should at work, home or school, because of substance use
6. Continuing to use, even when it causes problems in relationships
7. Giving up important social, occupational or recreational activities because of substance use
8. Using substances again and again, even when it puts the you in danger
9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance
10. Needing more of the substance to get the effect you want (tolerance)
11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.

The DSM 5 allows clinicians to specify how severe the substance use disorder is, depending on how many symptoms are identified.

MILD: Two or three symptoms indicate a mild substance use disorder,

MODERATE: four or five symptoms indicate a moderate substance use disorder, and

SEVERE: six or more symptoms indicate a severe substance use disorder. Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.”

The DSM 5 is criticized for combining the the DSM IV categories of substance dependence (addiction marked by a pattern of compulsive use or loss of control) and substance abuse disorders (using in a manner that causes problems but does not have a pattern of compulsive use). The 2011 definition of addiction by the American Society of Addiction Medicine (ASAM) is consistent with DSM IV but not DSM 5.

The DSM IV, like the ASAM definition is based upon the idea that there is a DIFFERENCE IN KIND between substance abuse and dependence/addiction.

The DSM 5 is inconsistent with the ASAM definition because it is based upon the idea that there is only A DIFFERENCE IN DEGREE between abuse and addiction based upon the number of symptoms.

This is a critical difference in the underlying theory of addiction between the DSM IV and DSM 5 and a break in the progressive development of the fundamental concept if addiction which began with the DSM III.

GORSKI BOOKS:

Straight Talk About Addiction


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