Year: 2014
Type: editorial
Abstract: Hu et al. present data suggesting that tobacco use and the symptoms of nicotine addiction feed back on each other in a manner that results in an escalation in the frequency of use and an escalation in addiction 1. This vicious cycle explains why the earliest symptoms of addiction are strong predictors of the clinical course far into the future 2. To measure nicotine addiction, the authors turned to the Diagnostic and Statistical Manual (DSM) 3. However, they altered it by using it as a continuous rather than a dichotomous measure and by ignoring the three-criteria diagnostic threshold, by ignoring the stipulation that withdrawal can be present only in daily smokers, by ignoring its requirement for social or occupational impairment, and by ignoring the requirement that three criteria be clustered within a 12-month period. That is a good start, but why not just ignore the DSM entirely and use a validated measure of addiction? My comments are not intended to challenge this important work, but rather to challenge all researchers to hold the DSM to the same standards of evidence as they would any other measure of nicotine addiction. The DSM defines medical terms to provide researchers and physicians with a common vocabulary and metrics. The DSM more closely resembles a dictionary than a source of scientific information, because each factual statement in a scientific publication must be referenced, and not a single sentence in the 947 pages of DSM-V is supported by a reference 4. A psychiatrist, testifying on behalf of a tobacco company, asserted that the American Psychiatric Association is the authority on mental diseases, and nicotine addiction is precisely whatever the American Psychiatric Association defines it to be. In my opinion, the characteristics of disorders are defined by nature, not by the American Psychiatric Association, no offence intended. The DSM definition of nicotine dependence does not represent a consensus of opinion among professionals in the field, and to my knowledge has never been endorsed by any other professional organization. One way in which the scientific community can endorse a measure is by using it. A literature review conducted 16 years after the publication of DSM-IV failed to identify a single study conducted by an independent researcher in which the DSM criteria were used in their published form 5. If one were to examine 20 studies that used the DSM criteria, one might find 20 different versions of ‘the DSM criteria’. Even the developers of DSM-5 failed to incorporate the requirement that three criteria be clustered within a 12-month period in their evaluation of tobacco use disorder 6. As a gold standard to provide a common metric, the DSM has failed, as it has had just the opposite effect: everyone ‘does their own thing’. Scientists have long sought the ‘neurological underpinnings’ of addiction. Huang et al. have demonstrated a high correlation between scores on the Hooked on Nicotine Checklist and measures of neural organization in specific brain circuits in smokers 7. Activity in these circuits correlates strongly with the intensity of craving 8. A valid measure of a biological disorder should correlate with biological measures. The DSM criteria correlate poorly with all validated indicators of nicotine addiction 5. By emphasizing social and occupational impairment, the DSM more closely resembles a regulatory determination of disability than a biological measure. Researchers in need of a measure of nicotine addiction have a wide choice of measures that had to be validated prior to their publication 9-14. To be fair, the DSM is embraced as a gold standard by one group of professionals: the forensic psychiatrists who make a living testifying on behalf of the tobacco companies. The DSM criteria are so ambiguous that those who are so inclined can interpret them in ways that would preclude almost any smoker from being diagnosed with nicotine dependence. One such devotee of the DSM testified that the DSM requires evidence of social or occupational impairment, and therefore the deceased chain smoker, who had been married and employed, could not possibly have been addicted to nicotine. The tobacco industry relies on the DSM to assert that while nicotine is addictive in theory, no individual smoker was ever addicted to nicotine by DSM standards. For decades, the validity of the DSM diagnostic criteria was taken as a ‘given’, based on the authority of the American Psychiatric Association but, to my knowledge, the American Psychiatric Association has not been granted an exemption from the rules of science. The DSM criteria represent the American Psychiatric Association's hypothesis regarding how nicotine addiction must be diagnosed. There are other approaches 15. The DSM criteria must be treated as a working hypothesis until their validity has been established by the same scientific standards of proof that would be applied to any other measure. In the 34 years since the publication of DSM-III, this hypothesis has yet to be proven 5, 16. None.
Source: Addiction
DOI: 10.1111/add.12670
Author: Joseph R. DiFranza
Institution: University of Massachusetts Chan Medical School
Language: English
Subfield: Physiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W1551824478