PSY5135: Issues and Trends in Addiction-Related Treatments

Substance use disorders and behavioral addictions affect tens of millions of people in the United States, creating enormous individual, family, and societal burden. PSY5135 prepares mental health practitioners to understand addiction comprehensively — its neurobiological underpinnings, its psychological and social dimensions, and the full range of evidence-based treatments — while navigating the ongoing debates in the field about disease models, harm reduction, and abstinence-only approaches.

Understanding addiction: brain disease model and beyond

The dominant scientific framework in addiction medicine is the brain disease model of addiction (BDMA), most prominently articulated by Alan Leshner (1997) and Nora Volkow (NIDA director). The BDMA holds that repeated substance use causes lasting neurobiological changes in the brain's reward circuitry — particularly the mesolimbic dopamine system — that impair impulse control, alter motivational priorities, and produce compulsive drug-seeking behavior that persists even when the person wants to stop. Key neurobiological concepts include: dopaminergic reward prediction error (Schultz, 1997); sensitization of drug-craving circuits (Robinson & Berridge incentive salience); and prefrontal cortical hypoactivation reducing executive control over behavior (Goldstein & Volkow, 2002).

The BDMA has been critiqued for overstating inevitability (most people with SUDs recover, many without treatment), for potentially reducing autonomy and moral agency, and for potentially increasing stigma (paradoxically) if a "brain disease" label implies permanent damage. PSY5135 examines these critiques — including the social learning perspective (SUDs as learned behaviors amenable to re-learning) and the biopsychosocial model — while acknowledging the significant neuroscientific evidence supporting the BDMA for understanding severe, chronic SUDs.

DSM-5 substance use disorder classification

The DSM-5 (2013) replaced the DSM-IV's separate "abuse" and "dependence" categories with a single Substance Use Disorder (SUD) diagnosis with a severity specifier: mild (2–3 criteria), moderate (4–5), or severe (6+) of 11 criteria organized in four domains: (1) Impaired control — taking more or longer than intended, unsuccessful efforts to cut down, spending great time obtaining/using/recovering, craving; (2) Social impairment — failure to fulfill major role obligations, continued use despite interpersonal problems, giving up activities; (3) Risky use — use in physically hazardous situations, continued use despite knowledge of a physical/psychological problem caused by use; (4) Pharmacological criteria — tolerance (diminished effect with same dose or need for larger dose to achieve effect) and withdrawal (syndrome upon cessation or reduction). Notably, legal problems was removed as a criterion (too culturally variable), and craving was added. Gambling Disorder was moved into the Substance-Related and Addictive Disorders chapter as the first recognized behavioral addiction.

Evidence-based treatment approaches

Co-occurring disorders (CODs)

At least 50% of individuals with substance use disorders have a co-occurring mental health disorder (SAMHSA, 2021 National Survey on Drug Use and Health). Common co-occurrences include: depression (both sharing neurobiological pathways), anxiety disorders (particularly PTSD — the self-medication hypothesis), ADHD, bipolar disorder, and antisocial/borderline personality disorders. Integrated dual diagnosis treatment (simultaneous rather than sequential treatment of both disorders in the same setting) is the evidence-based best practice (Drake et al., 2004), replacing the older sequential model ("treat the addiction first, then the mental health issue").

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