Addictology
Basic Olicognograph: Addict Approach
Modern day management of diagnostic have much to do with statistical exploration, scale, combination of criteria, in symptoms explorations, characteristics, criteria, check ups of follow up. Addictology is especially prone to these sort of series to clear the complexity of symptoms, when still more or less critical prognosis or risks factors instead of backward "clinics", making often quite difficult and very ambitious those intenting to follow tightly patients moods and "opportunities to prevent distress".
DSM-IV Criteria for Substance Dependence: A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring at any time in the same 12- month period: 1) tolerance, as defined by either of the following: - need for markedly increased amounts of the substance to achieve intoxication or desired effect - markedly diminished effect with continued use of the same amount of the substance; 2) withdrawal, as manifested by either of the following: - the characteristic withdrawal syndrome for the substance - the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms; 3) the substance is often taken in larger amounts or over a longer period than was intended; 4) there is a persistent desire or unsuccessful efforts to cut down or control substance use; 5) a great deal of time is spent in activities necessary to obtain the substance (eg, visiting multiple doctors or driving long distances), use the substance (eg, chain-smoking), or recover from its effects; 6) important social, occupational, or recreational activities are given up or reduced because of substance use; 7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (eg, current cocaine use despite recognition of cocaine induced depression or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).
Addiction: Frame of Management indications |
||||
psychic disorder |
social instability |
need for structured treatment |
dependence degree |
|
low |
low, medium |
low |
low |
controlled consumption |
low |
low, medium |
low |
high |
abstain |
medium |
low, medium |
low |
high |
ambulatory, poorly structured |
medium |
low, medium |
high |
high |
ambulatory, highly structure |
medium |
high |
low |
high |
interned poorly structured |
medium |
high |
high |
high |
interned very structured |
high |
high |
high |
high |
protected accomodation, low entry |
By side of theories on addiction, over the decades, up to the neurofunctional imaging: 3 basic ‘ground rules’ had "Skinner's" (historic) derived behavioral approach of addiction: 1) Denial of the existence of inner (‘psychological’) states. 2) Stimulus–Response as the basis for the subject’s action. 3) The individual as the core unit of analysis. Previous Conditionned Pavlov reflex included. Then Cognitivism left principles 2 and 3 of behaviorals untouched. Instead of Stimulus–Response, certainly, we had Stimulus–Cognition–Response, but the fundamental problem of ‘motivation’ remained. Moreover, cognitivism was an explicitly dualistic theory. Cognitivist argued that: 1) Cognitions are distributed, throughout systems and throughout social groups. It is therefore intrinsically a social process. 2) Cognition is situated. Human beings exist in a ‘systems’ relationship with the world, in which feedback and feedforward causal ‘loops’ condition movement towards or away from homeostasis. Stimulus-Response (or Stimulus–Cognition–Response) is an absurdly simple model of the complexity of the realities of organisms moving in and out of homeostasis (or ‘control’). 3) Cognition is embodied. In other words, consciousness is an ‘emergent property’ of embodied, sociated organisms, in the same way that ‘meaning’ is an emergent property of language (that is, the ‘conduit metaphor’ is false: meanings are not ‘put into’ language. The metaphor of mind as ‘software’ and brain as ‘hardware’ is highly misleading. 4) Language is primarily functional: that is, it is an attempt to ‘get things done’ not, primarily, to be ‘veridical’. It is also situated: the response of subjects to questions (or, for that matter, questionnaires) is system (or context) specific. One cannot assume that a statement made in one context will necessarily be given in another. Statements are not ‘representations’ of ‘inner states’.
Interventions that have been found to be effective include strategies aimed at the enhancement of motivation for recovery, CognitiveBehavioralTreatment, including broad spectrum treatment with a CBT focus and other related forms, 12-steps treatment, various forms of family, social network, and marital therapy, and social competence training. The data for psychodynamically oriented treatments and others are less convincing: 1) Cue-induced cravings are key contributors to substance abuse and relapse; 2) Exposure therapy can weaken craving responses to cues; 3) Situational contexts may limit the effects of exposure therapy; and 4) Internal states constitute powerful cues and contexts for drug abuse.
Modern theories about addictions involved pain and suffering, reward neural system and hedonic sensation. More lately addiction is now also seen as a disorder of learning and memory with vulnerability risks varying according patients. It can be viewed as a form of drug-induced neural plasticity. 5 brain's areas are of special importance: ventral tegmental region, prefrontal cortex, nucleus accumbens and also amygdala and hippocampus. At level of neurotransmitters: dopamine (important in nucleus accumbens) has had a core paper in the reward system, reviewed with learning and internal hedonic representations. Other neurotransmitters are primary like GABA (with universal neuron inhibitory function than: of control), enkephalin (from pain system), catecholamines and serotonine plays all important part. At an even more basic neurobiochemical and genetic which consider smaller molecular effects (cellular universal?) impulsed by neurotransmitters, on synapse membrane you find best-established molecular mechanisms of addiction in upregulation of the cAMP (second messenger pathway), occuring in many neuronal cell types in response to chronic administration of opiates or other drugs of abuse. We omit some detail on membranes molecular structure). This upregulation and activation involve the transcription factor CREB semeegly mediating in tolerance and dependence. While by contrast, induction of another transcription factor, termed 1FosB, exerts the opposite effect and may contribute to sensitized responses to drug exposure.
Looking up, for relating functional neuro-histologic evidence, toward the mood and psycho-cognitive sensations theories proposed to explain the compulsive element of addiction including hedonic and/or opponing-process with incentive-sensitization and learning-based theories. So the need to alleviate negative affective or mood states by continued drug use would underly the compulsive element of addiction. The theory of incentive sensitization draws a distinction between drug “liking” (an affective response) and drug “wanting.” It would explain the excessive wanting of drug and the excessive incentive salience attached to drug-associated stimuli drives compulsive drug seeking, drug taking and relapse. At last learning-based theories of addiction propose that repeated drug exposure is associated with particularly strong memories, mediated by drug-induced changes in brain reward regions. Accordingly, drug taking would be a learned response to conditioned stimuli, such as drug-associated cues.
