• Use/Consumption

• Substance-related problems

• Substance use disorders

• Addiction

It’s not that Billy [Martin] drinks a lot, it’s just that he fights a lot when he drinks a little. ~ Dick Young

• Neglect of interests; increased time to obtain, use or recover

ê ê ê ê ê ê ê ê ê ê ê

1 2 3 4 5 6 7 8 9 10 11

CriterionWhat if….?

= Abuse Criterion =Dependence Criterion

It’s the algorithm!

SUD Criterion DSM-IV DSM-5

Use in hazardous situationsABUSE

ü ü

Failure to fulfill major role responsibilities ü ü

Social or interpersonal problems ü ü

Legal Difficulties ü

ToleranceDEPENDENCE

ü ü

Withdrawal ü ü

Impaired Control ü ü

Attempts or desire to “cut down” ü ü

Time spent (obtaining, using, recovering) ü ü

Important activities given up ü ü

Use despite physical or psychological problems ü ü

Craving ü

DSM-5 Scorecard

Legal Problems Dropped ü

Abuse/Dependence Distinction Dropped ü

Craving Criterion Added ü

2/11 Algorithm ü

Retention of “Hazardous Use” Criterion ü

Lack of a Conceptual Core ü

Severity Grading ?

12.4

11.1

7.3

54.5

2.9

0

2

4

6

8

10

12

14

DSM-5 2/11 Any DSM-IV AUD DSM-5 3/11 DSM-IV Dependence DSM-5 4/11 DSM-5 5/11

What percentage makes the most sense??

Prevalence of Different AUD Definitions (Past Year)

Martin, Steinley, Verges and Sher (2011). The proposed DSM-5 2/11 symptom algorithm for SUDs is too lenient. Psychological Medicine, 41, 2008-2010.

Perc

ent o

f US

adul

ts 2

1+ w

ith a

n A

UD

Larger/Longer and Hazardous Use 18%

Larger/Longer and Quit/Cut Down 14%

Larger/Longer and Withdrawal 10%

Tolerance and Quit/Cut Down 10%

Larger/Longer and Tolerance 6%

Heterogeneity: Symptom Configurations Among Those with Exactly 2 Symptoms (n = 1,486)

Martin, Steinley, Verges and Sher (2011). The proposed DSM-5 2/11 symptom algorithm for SUDs is too lenient. Psychological Medicine, 41, 2008-2010.

28.3

38.1

47.2

54.1

0

10

20

30

40

50

60

2 3 4 5

Severity:5+ Drinks at Least Weekly for Different AUD Thresholds

Exact Number of DSM-5 Symptoms

Perc

ent o

f US

adul

ts a

ge 2

1+

Martin, Steinley, Verges and Sher (2011). The proposed DSM-5 2/11 symptom algorithm for SUDs is too lenient. Psychological Medicine, 41, 2008-2010.

•Polythetic approach to diagnosis means• Not all individuals who diagnose share overlapping symptoms• Many different combinations possible (2036!!)• Do these make a difference?

SUD SeverityMild Mod. Severe

# Criteria Met 2 3 4 5 6 7 8 9 10 11# of Possible Configurations 55 165 330 462 462 330 165 55 11 1

Psychiatric Disorder

Mild AUD Mod AUD Severe AUD

Any DUD 3.0 5.3 11.8Nicotine dep 2.2 3.5 6.0Major Dep 1.3 1.8 2.9Dysthymia 1.1 1.4 2.7Bipolar I 1.9 3.3 4.9Bipolar II 1.8 1.6 3.3Panic 1.5 1.9 3.4

Grant et al. JAMA Psychiatry. 2015 Aug;72(8):757-66 supplement

ORadj 12-Month DSM-5 AUD & Psychiatric Disorders

Adjusted for Sociodemographic Characteristics

Psychiatric Disorder

Mild AUD Mod AUD Severe AUD

Panic 1.5 1.9 3.4Agoraphobia 1.7 1.7 3.0Social phobia 1.0 1.7 2.3GAD 1.6 1.4 3.1PTSD 1.4 1.8 3.7Antisocial PD 1.9 2.8 4.6Borderline PD 2.1 2.9 5.9Schizotypal PD 1.6 2.2 4.1

Grant et al. JAMA Psychiatry. 2015 Aug;72(8):757-66 supplement

ORadj 12-Month DSM-5 AUD & Psychiatric Disorders

Adjusted for Sociodemographic Characteristics

Factor Structure of Mental Disorders (Krueger, 1999)

Best-fitting model for the entire National Comorbidity Survey, a 3-factor variant of the 2-factor internalizing/externalizing model. All parameter estimates are standardized and significant atP<.05

Internalizing and Externalizing

Hicks BM, Foster KT, Iacono WG, McGue M. (2013) Genetic and Environmental Influences on the Familial Transmission of Externalizing Disorders in Adoptive and Twin Offspring. JAMA Psychiatry. 2013;70(10):1076-1083.

Shared Etiology Among Externalizing Conditions

0

5

10

15

20

25

30

18-29 30-44 45-64 65+

Prev

alen

ce (i

n %

)

Age

severe

moderate

mild

Grant et al. JAMA Psychiatry. 2015 Aug;72(8):757-66

0

1

2

3

4

5

6

7

8

9

18-29 30-44 45-64 65+

Perc

enta

ge d

iagn

osed

with

Dru

g U

se D

isor

der

Age

mod/severe

mild

Grant, et al. JAMA Psychiatry. 2016;73(1):39-47

0

5

10

15

20

25

30

18-20 21-24 25-29 30-39 40-49 50-59 60+

Perc

enta

ge d

iagn

osed

with

Alc

ohol

U

se D

isor

der a

t 3-y

ear F

/U

Age at Baseline

Persistence

Recurrence

New Onset

Verges et al. (2012)

0123456789

10

18-20 21-24 25-29 30-39 40-49 50-59

Perc

enta

ge d

iagn

osed

with

Alc

ohol

U

se D

isor

der a

t 3-y

ear F

/U

Age at Baseline

PersistenceRecurrenceNew Onset

Verges et al. (2013) Am J Pub Health

0

10

20

30

40

50

60

29/30 35

Men

S-S M-M D-D E-MS-M D-M M-D

0

10

20

30

40

50

60

29/30 35

Women

S-S M-M D-D E-MS-M D-M M-D

Bachman et al., 2008

05

101520253035

29/30 35

Men

S-S M-M D-D E-MS-M D-M M-D

05

101520253035

29/30 35

Women

S-S M-M D-D E-MS-M D-M M-D

Bachman et al., 2008

0

10

20

30

40

29/30 35

Men

S-S M-M D-D E-MS-M D-M M-D

0

10

20

30

40

29/30 35

Women

S-S M-M D-D E-MS-M D-M M-D

Bachman et al., 2008

The Transformation of Zia

to

Screenshot of Zia McCabe video

0

0.2

0.4

0.6

0.8

1

10 20 30 40 50 60 70 80

Stan

dard

dev

iatio

ns

Age

Conscientiousness Emotional Stability

•

•

2

2.5

3

3.5

4

4.5

5

18 25 29 35

Impulsivity

6

6.5

7

7.5

8

8.5

9

9.5

10

18 25 29 35

Neuroticism

Littlefield, A., Sher, K. J., & Wood, P. K., 2009

0

0.5

1

1.5

2

2.5

3

3.5

4

18 19 20 21 25 26 35

Littlefield, A., Sher, K. J., & Wood, P. K., 2009

Littlefield, A., Sher, K. J., & Wood, P. K., 2009

Littlefield, A., Sher, K. J., & Wood, P. K., 2009

Model of SUD Vulnerabilit (adapted from Sher, 1991)

Family History of Alcoholism

Temperament/ Personality

Cognitive Dysfunction

DrugSensitivity

Parenting Behavior

Active Parental Drinking

LifeStress

EmotionalDistress

SchoolFailure

Coping Ability

Substance UseExpectancies

Peer Influence

Pathological SubstanceInvolvement

Centrality of Personality in Etiology of SUDs

Internal External

PositiveReinforcement Enhancement Social

NegativeReinforcement Coping Conformity

Cooper, 1995

0

1

2

3

4 Drinking Motivations

Cooper et al. (2016) The Oxford handbook of substance use and substance use disorders. Vol 1, pp. 375-421.

0

1

2

3

4

Marijuana Motivation

Cooper et al. (2016) The Oxford handbook of substance use and substance use disorders. Vol 1, pp. 375-421.

0

1

2

3

4Tobacco Motivation

Cooper et al. (2016) The Oxford handbook of substance use and substance use disorders. Vol 1, pp. 375-421

Screenshot of clip video 10 to 1:04

Screenshot of clip video 9 to 1:37

• Key concepts• Addictive substances have initial positively valenced effects• Over time, the nature of drug responses change

• Tolerance• Withdrawal• Incentive motivation

• These changes are durable• Multiple processes may be involved

• Incentive sensitization• Allostasis• Habit formation

Neurobiology of Addiction.George F. Koob, Ph.D.FOCUS 2011;9:55-65.

-Addictive drugs share the ability to produce long-lasting changes brain organization.

-The brain systems that are changed include those normally involved in the process of incentive motivation and reward.

- The critical neuroadaptations for addiction render these brain reward systems hypersensitive (“sensitized”) to drugs and drug-associated stimuli.

-The brain systems that are sensitized do not mediate the pleasurable or euphoric effects of drugs (drug “liking”), but instead they mediate a subcomponent of reward termed incentive salience or “wanting”

Incentive-Sensitization Theory

Berridge and Robinson (2016). Liking, wanting, and the incentive-sensitization theory of addiction. American Psychologist, 71, 670-679.

Drug-related attentional biasMeasuring

Incentive Salience?

RUM SOFA BED DOG POT SODA BOARRAIN ROACH BEER SHOT HIT HIKE BUILD

SMOKE STEAK PILLOW CAT BIRD COKE PILLCHILD HOTEL LAKE TOKE PHONE GIRL WINE

SELECTED EXAMPLES OF HEDONIC-AFFECTIVE PHENOMENA

ExampleFirst Few Stimulations After Many Stimulations

State A(input present)

State B(input gone)

State A’(input present)

State B’(input gone)

Dogs receiving electric shocks in harness

large cardiacacceleration

slow deceleration,small overshoot

small accelerationor none

quick deceleration,large overshoot

IV opiate useeuphoria, rush,

pleasure

craving, aversivewithdrawalsigns, short

duration

loss of euphoria,normal feeling,

relief

intense craving,abstinenceagony, long

duration

Early Mid Late Early Mid Late

Observed A State B State

First Several Times After Many Times

Opponent-Process Theory (Solomon & Corbit 1974)

Koob, G. F., & Le Moal, M. (2001). Drug addiction, dysregulation of reward, and allostasis. Neuropsychopharmacology, 24, 97-129.

Affective Response to the presentation of a drug

Initial experience of a drug with no prior drug history

Individual with repeated frequent drug use

Koob, G. F. (2003). Alcoholism: allostasis and beyond. Alcoholism: Clinical and Experimental Research, 27(2), 232-243.

Neuroplasticity in Brain Circuits associated with the Development of Addiction

Koob, G. F., & Volkow, N. D. (2010). Neurocircuitry of addiction. Neuropsychopharmacology, 35(1), 217-238.

Yin, H. H., & Knowlton, B. J. (2006). The role of the basal ganglia in habit formation. Nature Reviews Neuroscience, 7(6), 464-476.

Habit LearningHabitual control of instrumental behavior emerges gradually with repeated performance and is relatively unaffected by changes either in outcome value (e.g., devaluation) or in instrumental contingency

Representation of limbic circuitry, with tentative localization of functions involved in drug addiction

Everitt, B. J., & Robbins, T. W. (2005). Neural systems of reinforcement for drug addiction: from actions to habits to compulsion. Nature neuroscience, 8(11), 1481-1489.

Reflective

Impulsive

Behavioral Measures of Impulsivity

Dick, D. M., Smith, G., Olausson, P., Mitchell, S., Leeman, R., O’Malley, S. S., & Sher, K. J. (2010). Understanding the construct of impulsivity and its relationship to alcohol use disorders. Addiction Biology, 15, 217-226.

• Key Concepts• Shared pathology with other externalizing spectrum

disorders• Deficits in executive control/problems in impulsivity

• Multidimensional constructs• Excessive reward seeking/approach motivation• Associated with early onset problems• Associated with poor parenting and association with

deviant peers

1: Schutz, 2012; 2: Litten et al., 2015; 3: Sher, 2015

Erickson, 2011

Impulsive/Automatic/Fast Reflective/Controlled/Slow

Attentional Retraining

Approach Retraining

Cue exposure

Drug Rx’s targeting relevant neurocircuitry associated with behavioral targets (or modulation of learning) reward or habit

Self-control training

Motivational Interviewing

Various forms of CBT

Drug Rx’s targeting relevant neurocircuitry with behavioral targets (or modulation of learning) on executive function