Considering a Numerical/ Dimensional Diagnostic Classification System and a Prototype Scale for Substance Dependence Disorders

Introduction

What do you think of when you hear the words: Imbecile, idiot, and moron! These are words that we (maybe I m the only one) frequently use (or think to myself) when I m driving on the freeway and I see someone driving much faster or way slower then I am. We also hear these derogatory terms in the heat of an angry discussion when individuals have run out of rational and logical arguments. But, did you know that these words were once used as scientific terms in England as part of an official diagnostic classification system to describe

individuals that were mentally retarded. One definition of Imbecile, reads:

A person with a degree of mental retardation between that of an idiot

and a moron; in a former classification of mentally retarded person, it

applied to a person with an adult mental age of from four to eight years,

and an I.Q. of from 26 to 50.

In the United States, the initial impetus for developing a classification of mental disorders was the need to collect statistical information. What might be considered the first official attempt to gather information about mental illness was the recording of the frequency of one category idiocy/ insanity, in the 1840

census (DSM-IV-TR).

Although present day negative terms like: Imbecile, idiot, and moron are no longer used scientifically because of their pejorative connotations, we are still unfortunately using a categorical diagnostic classification system (DSM-IV-TR) in 2007, to label people with terms like: Schizophrenic, Bi-polar, and Borderline. To this day, we continue to diagnose people with mental disorders in a categorical way, coded as either present or absent even though the DSM-IV-TR explicitly states that there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from having no mental disorder.

Given the upcoming revision of the Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition (DSM-V), this article provides a timely overview of some of the growing frustrations and limitations engendered by the DSM IV-TR categorical model. It also considers a 7 dimensional holistic alternative approach to the categorical model. Finally, it proposes a dimensional prototype scale for substance dependence disorders for the DSM-V, possibly as an interim adjunct to the traditional categorical classification scheme to stimulate more research in this area.

Categorical Models and Limitations

DSM-IV-TR is a categorical diagnostic classification system that divides mental disorders into types based on criteria sets with defining features. This type of system classifies clinical presentations based on the assignment to categories and works best in describing phenomena that have

clear boundaries. It is evident, however that the DSM-IV is abounding with problematic boundary disputes, many of which seem to be the result of arbitrary categorical distinctions. It is also evident that the DSM-IV inherently has problems with: stigma; stereotyping; and labeling. Categorical models indirectly promote the stigma of receiving a psychiatric diagnosis and the fear that the diagnosis will result in unwanted social and/ or occupational consequences.

These models can contribute to stereotyping when others automatically and incorrectly infer that anyone who has a mental disorder is unpredictable and/ or violent. For example, we might assume that because Bob has been diagnosed with Schizophrenia, he must be potentially violent and unpredictable.

This is the same argument that assumes that because someone lives in Iowa, he must be a farmer. They increase the labeling, problem (giving a name to a group of symptoms) that can be hard to shake, even if the person has made a full recovery. Although the text of the DSM-IV indicates that it classifies mental disorders - not people, and that it avoids the use of such expressions as a schizophrenic or an alcoholic, the reality is that real people get categorized as mental disorders and people are not diseases, disorders, and/ or disabilities, but people are people like you and I, who may suffer from having these problems.

Our present healthcare system is set up to focus on acute care rather than chronic
illnesses. It focuses on a Unitary Syndrome or a one dimensional model in which the
sole marker of treatment response or success is specific symptom-reduction. Likewise,
although, the multi-axial system of the third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III, 1980), was intended to be atheoretical in its
approach to diagnosis and classification and to promote a bio-psychosocial model, the
DSM-IV-TR is heavily dependent on the medical model with its biologically based view
of mental disorders and opposition to the psychoanalytical approach of Sigmund Freud.
The medical model can be traced back to the work

of Emil Kraepelin, a German
psychiatrist who thought that all mental disorders could be traced back to organic
diseases of the brain, rather than disordered emotions, behaviors, or psychological/
environmental stressors.

Kupfer, First, & Regier, however, report that, In the more than 30 years since the introduction of the DSM-III, the goal of validating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSM-defined syndromes. Epidemiologic and clinical studies have shown extremely high rates of co-morbidities among disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term

diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception, (2002, p. xviii).

Dimensional Models

It was suggested that the DSM-IV Classification be organized following a dimensional model rather than the categorical model used in DSM-III-R. A dimensional system classifies clinical presentations based on quantification of attributes rather than the assignment to categories and works best in describing phenomena that are distributed continuously and that do not have clear boundaries. Dimensional systems increase reliability and communicate more clinical information (because they report clinical attributes that might be sub-threshold in a categorical system), they also have serious limitations and thus far have been less useful than categorical

systems in clinical practice and in stimulating research. Numerical dimensional descriptions are much less familiar and vivid than are the categorical names for mental disorders. Moreover, there is yet no agreement on the choice of optional dimensions to be used for classification purposes. Nonetheless, it is possible that the increasing research on, and familiarity with, dimensional systems may eventually result in their greater acceptance both as a method of conveying clinical information and as a research tool (DSM-IV-TR, xxxi).

Dimensional models provide more reliable scores, help to explain symptom heterogeneity and the lack of clear boundaries between categorical diagnoses. They also retain important information about sub-threshold traits and symptoms that may be of clinical interest, and

allow for the integration of scientific findings concerning the distribution of traits and associated maladaptivity into a classification system. Dimensional models recognize that mental disorders lie on a continuum with mildly disturbed and normal behavior, rather than being qualitatively distinct. For example, the Axis II personality disorders are increasingly regarded as extreme variants of common personality characteristics. Dimensional models would identity patients on a specific level or dimension of cognitive or affective capacity rather than place them in a categorical box.

A joint committee of the American Psychiatric Association and the National Institute of Mental Health charged with identifying pressing issues for the DSM Fifth Edition (DSM-V) concluded that: there is a

clear need for dimensional models to be developed and for their utility to be compared with the existing typologies.

7 Dimensions Therapeutic Model

Healthcare consumers are increasingly advocating for a multidimensional model that takes into account an array of life-functioning domains that influence patient treatment progress. Evidenced-based meta-analysis studies also purport the prognostic power of life-functioning variables to predict outcome as well as their importance for treatment planning over a unitary model that has had little empirical support. Accurate diagnosis is also dependent on a thorough multidimensional assessment process along with the possible help of a multidisciplinary treatment team approach. Behavioral Medicine practitioners have come to realize that although a disorder may be primarily physical

or primarily psychological in nature, it is always a disorder of the whole person not just of the body or the mind.

They purport that there must be a holistic approach to mental disorders that places equal emphasis on assessing all life-functioning dimensions of individuals. There is a healing potential in assessing and treating patients as whole persons rather than as isolated collections of nervous tissue with chemical imbalances. The major task in assessing and treating mental illness is to regain social roles and identities that entail focusing on the individual and building a sense of responsibility and self-determination.

In 2004, the Addictions Recovery Measurement System (ARMS), was published describing the following seven life-functioning

therapeutic activity dimensions for progress outcome measurements.

1. Social/ Cultural Dimension

2. Medical/ Physical Dimension

3. Mental/ Emotional Dimension

4. Educational/ Occupational Dimension

5. Spiritual/ Religious Dimension

6. Legal/ Financial Dimension

7. Abstinence/ Relapse Dimension

The 7 Dimension recovery model was initially designed to measure patient progress by assessing therapeutic life-functioning activities. Researched may prove it to be effective as a generalized model for assessing and treating all pathological diseases, disorders, and disabilities. It s multidimensional assessment/ treatment process includes the internal interconnection of multiple dimensions from biomedical to spiritual - taking into account the effects of feedback and the existence of each

dimension mutually influencing each other simultaneously. Because of the complexity of human nature, treatment progress needs to be initially tailored and guided by an individualized treatment plan based on a comprehensive bio-psychosocial assessment that identifies specific problems, goals, objectives, methods, and timetables for achieving the goals and objectives of treatment.

Life-style addictions may affect many domains of an individual’s functioning and frequently require multi-modal treatment.

Note: These seven dimensions have been delineated in the book entitled, Poly-behavioral Addiction and the Addictions Recovery Measurement System (Slobodzien, 2005). Following are the 7 (life-functioning) dimensional scales with their individualized assessment criteria:

Social/Cultural Functioning Scale (1)

9 - No or minimal environment stressors. Interested & involved in a wide

range of activities.

8 - Transient environmental stress (difficulty concentrating after family argument)

7 - Mild acute/stressors- some difficulty in social functioning. Has meaningful relationships.

6 - Moderate difficulty in social functioning. Has conflicts with peers and few friends.

5 - Serious impairment in social functioning. Has no friends

4 - Major impairment in several dimensions (family relations)Avoids friends/ neglects family

3 - Severe environmental stressors are harmful to patient, family & others (Stays in bed all day).

2 - Gross environmental stressors are dangerous to patient, family & others. Gross impairment in communication (incoherent).

1 - Dangerous environmental stressors are life-threatening, to patient, family & others

Medical/ Physical Functioning Scale (2)

9 - No

disorder/disease symptoms stable medical condition

8 - Transient Common Disorder/ disease symptoms

7 - Acute- Common Disorder/ disease symptoms

6 - Moderate Clinically Marked medical condition

5 - Clinically Significant Medical condition

4 - Major Significant Chronic Medical conditions

3 - Severely Significant Chronic Medical conditions

2 - Grossly Severe Medical Conditions

1 - Terminal Medical Conditions

Mental/ Emotional Functioning Scale (3)

9 - Absent or minimal symptoms Good functioning in all areas

8 - Transient/ expectable symptoms reactions to psychosocial stressors

7 - Mild symptoms depressed mood/ mild insomnia

6 - Moderate - Clinically Marked symptoms flat affect, some panic attacks

5 -

Serious symptoms suicidal ideation, obsessional rituals

4 - Major symptoms some reality testing impairment & illogical speech

3 - Severe impairment in communication/ judgment Delusions/ hallucinations

2 - Grossly Severe some danger of hurting self/ others/ suicide attempts

1 - Persistent danger of severely hurting self/others

Educational/ Occupational Functioning Scale (4)

9 - No Impairment Good Functioning in all areas Educational/ Occupational

8 - Slight Impairment Temporarily falling behind in school/ work projects.

7 - Mild Impairment - Some difficulty with school/ Work functioning

6 - Moderate Impairment Clinically Marked conflicts with peers / co-workers.

5 - Serious Impairment Failing at school/ work

4 -

Major Impairment Unable to keep job/ school More than one dimension

3 - Severe Impairment Inability to function Almost all Dimensions

2 - Gross Impairment Unable to function Independently All Dimensions

1 - Dangerous Impairment Unable to function without Harming self or others

Spiritual/ Religious Functioning Scale (5)

9 - Absent or minimal symptoms Good functioning. Involved a wide range of healthy spiritual/ religious activities.

8 - Transient/ expectable symptoms reactions to slight violations of own moral values/ standards.

7 - Mild symptoms depressed mood/ mild insomnia. Neglects some spiritual relationships.

6 - Moderate - Clinically Marked symptoms guilt/ shame feelings due to

moderate violations of moral standards

5 - Serious symptoms suicidal ideation, obsessional rituals due to serious violations of morals.

4 - Major symptoms some reality impairment & illogical speech. Avoids healthy spiritualilty.

3 - Severe judgment impairments. Spiritual/ religious delusions & hallucinations.

2 - Grossly Severe some danger of hurting self/ others/ suicide attempts. Violent behaviors

1 - Persistent danger of severely hurting self/others

Legal/ Financial Functioning Scale (6)

9 - None or minimal legal/ financial problems. Involved in community/ charity programs.

8 - Transient financial/legal stressors (Credit card debt/ parking tickets)

7 - Minor law violations some legal/ financial difficulties -speeding, etc.

6 - Moderate

Clinically Marked. Misdemeanor arrests/ fines/ penalties for late payments

5 - Clinically Significant legal/ financial problems Felony arrests (gambling)

4 - Major Significant legal/ financial problems - jail time/ major debts owned.

3 - Severe legal/ financial problems. Criminal activities chosen.

2 - Grossly Severe legal/ financial problems- prison time/ bankruptcy

1 - Dangerous legal/ financial problems Suicidal/ homicidal

Abstinence/ Relapse Functioning Scale (7)

9 - No Impairment of Self- Control - Good Functioning No Relapse Potential

8 - Slight Impairment of Self-control. Very low relapse potential.

7 - Mild Impairment of Self-control Low -Relapse Potential

6 -

Moderate Impairment of Self-control Clinically Marked Moderately High relapse potential

5 - Serious Impairment of Self Control -Clinically Significant High - Relapse Potential

4 - Major Impairment of Self-control. Very High relapse potential More than One Dimension

3 - Severe Impairment Inability to Control Self. Severely High R/P Almost all Dimensions

2 - Gross Impairment - Unable to Control Self Independently Grossly High R/P. All Dimensions

1 - Dangerous Impairment - Unable to Control Self without harming self/ others. Dangerously High

Functioning/ Impairment Severity Levels of Self-control

9 - No Impairment of Self-Control Good Functioning

8 - Slight

Impairment of Self-control

7 - Mild Impairment of Self-control

6 - Moderate Impairment of Self-control Clinically Marked

5 Serious Impairment of Self Control - Clinically Significant

4 Major Impairment of Self- control. More than One Dimension.

3 Severe Impairment Inability to Control Self (Almost all Dimensions)

2 Gross Impairment Unable to Control Self Independently (All Dimensions)

1 Dangerous Impairment Unable to Control Self Without harming self /others

Note: The 7 - Dimensional scales can be individually rated and the scores can be averaged out to determine a functioning/ impairment score

or level of functioning.

The 7 - Dimensions model is a numerical, nonlinear, dynamical, non-hierarchical model that focuses on interactions between multiple risk factors and situational determinants similar to catastrophe and chaos theories in predicting and explaining addictive behaviors and relapse. Multiple influences trigger and operate within high-risk situations and influence the global multidimensional functioning of an individual. To put it simply, small changes in an individual s behavior can result in large qualitative changes at the global level and patterns at the global level of a system emerge solely from numerous little interactions. The clinical utility of the 7 Dimensions recovery model is in its ability to assist health care providers to quickly assess detailed information

about an individual s personality, background, substance use history, affective state, self-efficacy, and coping skills for prognosis, diagnosis, treatment planning, and outcome measures.

Substance Dependence (Prototype) Dimensional Scale

The 7 Dimensions model acknowledges that family genetics, and bio-psychosocial, historical, and developmental conditioning factors are difficult and sometimes impossible to be changed within individuals. Many healthcare consumers of addiction recovery services have a genetic pre-dispositional history for addiction. They have suffered and continue to suffer from past traumatic life experiences (e.g. physical, sexual, and emotional abuse, etc.) and often present with psychosocial stressors (e.g. occupational stress, family/ marital problems, etc.) leaving them with intense and confusing feelings (e.g. anger, anxiety, bitterness, fear, guilt, grief, loneliness, depression, and

inferiority, etc.) that reinforce their already low self-esteem. The complex interaction of these factors can leave the individual with much deeper mental health problems involving self-hatred, self-punishment, self-denial, low self-control, low self-respect, and a severe low self-esteem condition, with an overall (sometimes hidden) negative self-identity.

Additionally, when we consider that addictions involve unbalanced life-styles operating within semi-stable equilibrium force fields, the 7 - Dimensions philosophy promotes that there is a supernatural-like spiritually synergistic effect that occurs when an individuals multiple life functioning dimensions are elevated in a homeostatic human system. This bilateral spiritual connectedness reduces chaos and increases resilience to bring an individual harmony, wellness, and productivity.

Although, a dimensional system may ameliorate many of the problems associated with

the present DSM categorical system, there are still many issues that need to be addressed when attempting to integrate dimensions into the current classification system. The following Substance Dependence Scales were developed to introduce a prototype and to stimulate research for the future integration of categorical and dimensional diagnostic classification systems.

Tolerance Symtom Levels (1)

9 - No Tolerance Symptoms

8 - Minimal Tolerance Symptoms

7 - Mild Tolerance Symptoms

6 - Moderate Clinically Marked Tolerance Symptoms

5 - Clinically significant tolerance -markedly increased amounts of substance use to achieve desired effect

4 - Major clinically significant Tolerance symptoms

3 - Severe clinically significant Tolerance symptoms

2 - Gross clinically

significant Tolerance symptoms

1 - Clinically dangerous Significant tolerance Symptoms

Withdrawal Symptom Levels (2)

9 - No Withdrawal Symptoms

8 - Minimal Withdrawal Symptoms

7 - Mild Withdrawal Symptoms

6 - Moderate Clinically Marked Withdrawal Symptoms

5 - Clinically significant Substance is taken to relieve or avoid withdrawal symptoms

4 - Major Significant Withdrawal symptoms Needs Assistance

3 - Clinically severe Withdrawal symptoms Needs Partial Hosp.

2 - Clinically Gross Withdrawal symptoms - - Needs Medical Monitoring

1 - Clinically dangerous Withdrawal symptoms Needs Medical Management

Quantity/ Duration Levels (3)

9 - No Progressive Use

8 - Minimal amounts taken irregularly over a short period of time

7 - Minimal

Amounts taken regularly over a short period of time

6 - Clinically Marked Amounts taken regularly over long period of time

5 - Clinically Significant Larger Amounts often taken over a longer period then intended

4 - Major amounts often taken over a very longer period

3 - Severely harmful Amounts often taken over a very longer period

2 - Gross amounts often taken over a very longer period

1 - Lethal amounts often taken over a very longer period

Efforts to Control Use Levels (4)

9 - No efforts attempting to cut down/ control use (because no identified problem)

8 - Minimal efforts attempting to cut down/ control use

7 - Some successful efforts attempting to cut

down/ control use

6 - Some Unsuccessful efforts attempting to cut down/ control use

5 - Persistent unsuccessful efforts attempting to cut down/ control use

4 - Unable to cut down/ control use independently without assistance

3 - Unable to control use with assistance Residential Treatment/ Medications, etc.

2 - Unable to control use without 1:1 Medical Monitoring

1 - Unable to control use without 24-hr. Medical Management

Time Spent with Substance Use Activities (5)

9 - No time spent in obtaining/ substance(s)

8 - Time spent irregularly in obtaining/ using/ recovering from substance(s)

7 - Minimal time spent in obtaining/ using - substance(s)

6 - Moderate amounts of time spent in obtaining/ using/ recovering from

substance(s)

5 - A great deal of time spent in obtaining/ using/ recovering from substance(s)

4 - A major amount of time spent in obtaining/ using/ recovering from substance(s)

3 - A severely significant amount of time spent in obtaining/ using recovering from substance(s)

2 - Most free time spent in obtaining/ using/ recovering from substance(s)

1 - All free time spent in obtaining/ using/ recovering from substance(s)

Life-functioning Activities Given Up or Reduced (6)

9 - No reduction in social, occupational, recreational activities due to substance use

8 - Minimal periodic reduction in social, occupational recreate. activities due to substance use

7 - Minimal reduction in social, occupational,

recreational activities due to substance use

6 - Clinically Marked reduction in social, occupational, recreational activities due to substance use

5 - Important social, occupation, or recreational activities are given up or reduced due to substance use

4 - Clinically major reduction in life-functioning activities due to substance use

3 - Severe amount of life-functioning activities given up due to substance use

2 - Most life-functioning activities given up due to substance use

1 - All life-functioning activities given up due to substance use

Continued Use Despite Knowledge of Consequences (7)

9 - No Substance Use

8 - Minimal irregularly use despite knowledge of consequences

7 - Minimal use despite knowledge of consequences

6 - Clinically Marked use despite knowledge of consequences

5 - Continued use despite knowledge of consequences

4 - Major use despite knowledge of consequences

3 - Severe use despite knowledge of consequences

2 - Gross use despite knowledge of consequences

1 - Lethal use despite knowledge of consequences

Patterns/ Impairments/ Distress Levels

9 - Good Functioning No Pattern/ Impairment/ Distress from Substance Use

8 Slight maladaptive pattern/ impairment/ distress

7 Mild irregular pattern Impairment/ distress

6 - Moderate regular pattern Clinically Marked Impairment/ Distress

5 Serious clinically Significant pattern/ Impairment/ distress One Dimension

4 Major clinically significant

Pattern Impairment/distress More than One Dimension

3 Severe clinically harmful Pattern impairment/distress Almost all Dimensions

2 - Clinically gross Pattern/ Impairment/ Distress -All Dimensions

1 - Clinically dangerous Pattern/ Impairment/ Distress -All Dimensions

Note: By utilizing a dimensional approach, each specific criteria can be rated and scored to determine clinical significance and the subthreshold symptoms can be addressed as well. The total scores can then be averaged and appropriate cut-off scores can be established for effective treatment planning.

The 7 Dimensions model combines a multidimensional force field analysis of an individual s unique problems to identify positive strength prognostic factors, with behavioral contracting, and

a token- like - economy point system to accomplish this task. Force field analysis is a process whereby an individual s behavior is assessed to determine which are the key forces driving the addictive behaviors and which are the key forces restraining the addictive behaviors. A plan is implemented to identify the positive strength restraining factors to somehow manipulate those forces in order to increase the likelihood of moving an individual s behavior in a pro-social recovery direction.

Kurt Lewin (1947) who originally developed the Force Field Theory argued that an issue is held in balance by the interaction of two opposing sets of forces those seeking to promote change (driving forces) and those attempting to maintain the

status quo (restraining forces). Any given social event occurs at a given frequency in a given social context, and the frequency of the event is dependent upon forces acting to increase the event as well as forces acting to decrease the event. At any given point in time, there is a semi-stable equilibrium whereby the frequency of the social event will remain the same so long as there is neither change in the number or strength of the forces acting to increase the social event nor any change in the forces acting to decrease the event. Equilibrium is altered in either direction by increasing the frequency or intensity of the driving or the restraining forces and thereby creating a corresponding increase or decrease in the rate of an individual s addictive behaviors.

Conclusion

Dimensional approaches may not be the panacea for the ills of DSM-IV, but they are a step in the right direction. It is our hope that changes in the DSM-V will reflect the gradual integration of a numerical/ dimensional classification system. The challenge will be getting clinicians to change the way they practice, by changing treatment facility systems to incorporate evidence-based research findings on effective diagnostic dimensional assessment strategies and interventions leading to a new and improved DSM-V.

For more info see:

References
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.asam.org/ Arthur Aron, Ph.D., professor, psychology, State University of New York, Stony Brook; Helen Fisher, research professor, department of anthropology, Rutgers University, New Brunswick, N.J.; Paul Sanberg, Ph.D.,professor, neuroscience, and director, Center of Excellence for Aging and Brain Repair,University of South Florida College of Medicine, Tampa; June 2005, the Journal of Neurophysiology Gorski, T. (2001), Relapse Prevention In The Managed Care Environment. GORSKI-CENAPS Web Publications. Retrieved June 20, 2005, from: tgorski.com Lienard, J. & Vamecq, J. (2004), Presse Med, Oct 23;33(18 Suppl):33-40. Morgan, G.D.; and Fox, B.J. Promoting Cessation

of Tobacco Use. The Physician and Sports medicine. Vol 28- No. 12, December 2000. Kupfer, D. J., First, M. B. & Reigier, D. E. (2002) Introduction. In D. J. Kupfer, M. B. First, & D. E. Reigier (Eds.), A research agenda for DSM-V (pp.xv-xxiii). Washington, D.C.; American Psychiatric Association.

Slobodzien, J. (2005). Poly-behavioral Addiction and the Addictions Recovery Measurement System (ARMS), Booklocker.com, Inc., p. 5. U.S. Department of Health and Human Services. Healthy People 2010 (Conference Edition). Washington, DC: U.S. Government Printing Office; 2000.

James Slobodzien, Psy.D., CSAC, is a Hawaii licensed psychologist and certified substance abuse counselor who earned his doctorate in Clinical Psychology. He is credentialed by the National Registry of Health Service Providers in Psychology. He has

over 20-years of mental health experience primarily working in the fields of alcohol/ substance abuse and behavioral addictions in hospital, prison, and court settings. He is an adjunct professor of Psychology and also maintains a private practice as a mental health consultant.