Interview with Howard Shaffer of the Division on Addiction at Cambridge Health Alliance

Defining addiction, making research more transparent, and dealing with the DSM-V

(The “Five-Question Interview” series.)

Like many incredibly busy people, Dr. Howard J. Shaffer, associate professor of psychology at Harvard Medical School, is generous with his time. This paradox works to the advantage of Addiction Inbox readers, as Dr. Shaffer, the director of the Division on Addiction at the Cambridge Health Alliance, a Harvard Medical School teaching affiliate, has graciously consented to be the next participant in our “Five-Question Interview” series. In addition to maintaining a private practice, Dr. Shaffer has been a principal or co-principal investigator on a wide variety of research projects related to addiction, including the Harvard Project on Gambling and Health, and a federal research project focusing on psychiatric co-morbidity among multiple DUI offenders. He is the past editor of the Journal of Gambling Studies and the Psychology of Addictive Behaviors.


1. Addiction is not like most medical/mental disorders. If you have cancer or schizophrenia, for example, you can’t recover by abstaining from certain things. What’s your response to those who say that the disease model of addiction is misleading?

We should remember that the concept of disease is difficult to define. This makes deciding whether addiction is a disease most difficult. However, I think most people accept the idea that addiction reflects a kind of dis-ease. Whenever people get into this disease model debate, it’s useful to remember that most models of addiction are misleading, and the disease model is no exception. The map is not the territory, the menu is not the meal, and the diagnosis is not the disorder.

Scientific models are simplified representations of complex phenomena. Models of addiction focus our attention to certain features of addiction and blind us to other potentially important aspects of the disorder.1 For example, the moral model of addiction suggested that bad judgment was the cause and piety was the solution. Some neurobiological models of addiction suggest that molecular activity is the cause and medication is the solution. Both of these views are simplifications.

Rather than trying to fit addiction into a particular box, I prefer to think of addiction as a complex multidimensional syndrome – with interactive biological, psychological, and social causes. In this way addiction is similar to other medical, mental and behavioral disorders than we previously have considered. My colleagues and I have been developing a syndrome model of addiction 2-4 that suggests people are vulnerable because of biological, psychological and social influences. When vulnerable people are exposed to a social context that reliably and robustly shifts their subjective state in a desirable direction, they are at the highest risk for developing addiction. What I like about this kind of model is that it holds the potential to help us determine who is at most risk so that we can predict the development of addiction – just like we can predict who is at risk for cardiovascular and other diseases. This kind of etiological model will help us establish primary and secondary prevention programs that can reduce the onset of addiction.

2. You have a book coming out soon about problem gambling and how it can be managed. Is gambling a legitimate addiction?

Gambling, as well as most other behavior patterns, can become excessive, lead to adverse consequences, and squeeze out many previously important and healthy behavior patterns. 5,6 Some behavior patterns like eating broccoli rarely lead to addiction, but other improbable behaviors like listening to music, or playing video games might.

I don’t think about the idea of a “legitimate” addiction anymore, though I used to. Now I think about addiction as a unitary disorder that has a variety of expressions. For example, AIDS is a syndrome with many different expressions. Syndromes like AIDS and addiction are complex because not all of the signs and symptoms associated with the disorder are present all of the time. Gambling addiction is more rare than alcohol dependence. However, the characteristics of different expressions of addiction and the sequelae across sufferers are more similar than different. Further, the treatments – including the medications – that are effective with one expression of addiction often work with another expression. Scientific evidence suggests that behaviors, such as excessive gambling, and substance use, such as cocaine, have similar effects on the neurocircuitry of reward – how the brain processes information to produce the experience of pleasure.

For a pattern of behavior, whether substance involved or not, to be considered as an addiction, it must reliably and robustly shift subjective experience in a desirable direction, lead to adverse consequences, and be associated with identifiable underlying biological and psychological features, for example, genetic influences and trauma.

3. You host the Transparency Project. What is it and why did you create it?

The Transparency Project is the world’s first data repository for addiction-related industry-funded research. Most people don’t realize that private industry funds the majority of scientific research. This particular funding stream is important. However, tobacco industry funded research properly encouraged people to worry that private funding can adversely influence research. In fact, I think observers should worry about the potential bias that might accompany any research, including research supported by public funding sources. There is no warranty that can assure unbiased research, except sound methods and careful data analysis reflecting sound scientific principles. Furthermore, critics shouldn’t presume that research is biased just because it has a particular kind of funding source. We are encouraging scientists who have received industry funding to send their data to the Transparency Project so that others can download and use their data. This should magnify the value of the data by having others analyze it similarly or differently from the original research. This strategy also should help observers both confirm and question findings, thereby leading to important dialogues about the central issues that are so very important to the advance of scientific knowledge.

4. What’s going on right now at the Division on Addiction that you are particularly excited about?

During 2012, we are celebrating our 20th anniversary at the Division on Addiction. The syndrome model is emerging as an important conceptual guide to our work going forward; we are very excited to see that others are similarly interested in this perspective. Very soon, for example, the American Psychological Association will be releasing another of our new books, the APA Addiction Syndrome Handbook. I am also very excited about our DUI research 7-11 as well as our efforts to develop new technology that will help lay interviewers—those often staffing DUI treatment programs—to assess complex psychiatric disorders and triage patients into the care they so desperately need. This is our Computer Assessment and Referral System or CARS project. Lots of people around the world are expressing interest in coming to the Division to study and conduct research focusing on addiction. For me, it is very satisfying to see young people come to the field of addiction with a sense of curiosity, wonder and scientific rigor that have not always been present in this area of interest.


5. How do you feel about the proposed DSM-V changes regarding addiction?

By now, most people interested in addiction are aware that the American Psychiatric Association has expressed some interest in moving Pathological Gambling from the impulse control disorder category to a new Addiction and Related Disorders category. This would represent the first time that the term “addiction” appears in the DSM. If this happens, it is a big deal and, in my opinion, represents a step forward. In many ways it reflects a syndrome model perspective toward addiction. Although pathological gambling has clinical, epidemiological, etiological, physiological, and treatment commonalities with substance use disorders, my colleague Ryan Martin and I have noted that these similarities also exist among the substance use disorders and a variety of other behavioral expressions of addiction (e.g., excessive shopping). A relatively large literature evidences these commonalities. Consequently, we think that the DSM-V work group should avoid creating a long list of addictions and related disorders/diagnoses organized by the objects of addiction. Instead, the syndrome model of addiction encourages an addiction diagnosis that is independent of the objects of addiction, other than as a clinical feature. Diagnostic systems need to identify the core features of addiction and then illustrate these with substance-related and behavioral expressions of this diagnostic class. Conceptualizing addiction this way avoids the incorrect view that the object causes the addiction and shifts the diagnostic focus more sharply toward patient needs.

References

1. Kuhn TS. The structure of scientific revolutions. Second ed. Chicago: University of Chicago Press; 1970.
2. Shaffer HJ, LaPlante DA, LaBrie RA, Kidman RC, Donato AN, Stanton MV. Toward a syndrome model of addiction: multiple expressions, common etiology. Harvard Review of Psychiatry 2004;12:367-74.
3. Shaffer HJ, LaPlante DA, Nelson SE, eds. The APA Addiction Syndrome Handbook. Washington, D.C.: American Psychological Association Press; in press.
4. Shaffer HJ, LaPlante DA, Nelson SE, eds. The APA Addiction Syndrome Handbook. Washington, D.C.: American Psychological Association Press; in press.
5. Shaffer HJ, Martin R. Disordered Gambling: Etiology, Trajectory, and Clinical Considerations. Annual Review of Clinical Psychology 2011;7:483-510.
6. Shaffer HJ, Korn DA. Gambling and related mental disorders: a public health analysis. In: Fielding JE, Brownson RC, Starfield B, eds. Annual Review of Public Health. Palo Alto: Annual Reviews, Inc.; 2002:171-212.
7. Albanese MJ, Nelson SE, Peller AJ, Shaffer HJ. Bipolar disorder as a risk factor for repeat DUI behavior. Journal of Affective Disorders in press.
8. LaPlante DA, Nelson SE, Odegaard SS, LaBrie RA, Shaffer HJ. Substance and psychiatric disorders among men and women repeat driving under the influence: offenders who accept a treatment-sentencing option. Journal of Studies on Alcohol and Drugs 2008;69:209-17.
9. Nelson SE, Laplante DA, Peller A, Labrie RA, Caro G, Shaffer HJ. Implementation of a Computerized Psychiatric Assessment Tool at a DUI Treatment Facility: A Case Example. Administration and Policy in Mental Health and Mental Health Services Research 2007;34:489-93.
10. Peller AJ, Najavits LM, Nelson SE, LaBrie RA, Shaffer HJ. PTSD Among a Treatment Sample of Repeat DUI Offenders. Journal of Traumatic Stress in press.
11. Shaffer HJ, Nelson SE, Laplante DA, Labrie RA, Albanese M, Caro G. The epidemiology of psychiatric disorders among repeat DUI offenders accepting a treatment-sentencing option. Journal of Clinical and Consulting Psychology 2007;75:795-804.

Is Shoplifting the Opiate of the Masses?

Another look at "behavioral addictions" and the DSM-V.

The DSM-V, when it debuts it 2012, is set to replace the category of “Substance-Related Disorders” with a new category entitled "Addiction and Related Disorders."  Gambling is the only behavioral addiction currently recommended for inclusion, but some experts have set their sights on shoplifting—an activity that is even more difficult to picture as a legitimate addiction than gambling. Or is it?

Long before gambling was widely looked upon as an addictive disorder, compulsive shoplifting already had a name: kleptomania. The National Association for Shoplifting Prevention claims that about 9-10% of the population show a “lifetime prevalence” for shoplifting. This is remarkably similar to the percentages commonly bandied about for alcoholics, drug addicts, unipolar depressives,  compulsive gamblers, and compulsive overeaters.

A recent University of Florida survey pegged shoplifting losses, or “shrink,” in 2009 at more $11 billion annually. Plato, in The Republic, wanted to know whether thieves are made or born. It’s a good question. Curiously, the stealing doesn’t seem to be about money: The most recent study measuring income and shoplifting shows that Americans with incomes over $70,000 shoplift 30% more more than their fellow citizens earning less than $20,000 a year. And the actual items stolen by compulsive shoplifters often seem nonsensical, or even surreal. As director John Waters said of Pink Flamingos’ star and compulsive shoplifter Divine: “I saw him walk out of a store once with a chain saw and a TV.”

There is a definite “rush” to the act of stealing, writes Rachel Shteir in The Steal, her informative book about shoplifting. One shoplifter said it was equal to drugs but only lasted a few minutes—“And you’re back to yourself again. In your mind, you think, It was all for a stupid blouse, or stupid soap. For this, I risked everything.” Another source quoted in the book says, “I shoplifted every day, like someone with a drug addiction.”  Seconds before another women is arrested, she quizzes herself: “All she needs in the world is one crummy formal dress so why is there a blue silk jacket, one that she doesn’t particularly like, in her camera bag?” And a shoplifting Lee Grant says in the movie Detective Story: “I didn’t need it. I didn’t even like it.” The objects seem to lose their intrinsic value once they have been stolen, and the shoplifter must get high again with another theft.

If, as some neurobiological researchers insist, addictive disorders are not independent disorders, but outward manifestations of an underlying disease pathology called addiction syndrome, then the definition might be stretched to include gambling, shoplifting, and certain other “activity-based expressions of addiction.” Sometimes the alcoholic, the drug addict, the depressive, the compulsive gambler, and the obsessive overeater are all one and the same person. And drug addicts show a remarkably ability to substitute one drug for another. Perhaps a recovering cocaine addict might hope to assuage that sense of craving, of inchoate need, through excessive gambling. Or a shoplifter might use alcohol as a means of dampening the impulse to steal compulsively. While we don’t use the term kleptomania anymore, “shoplifting crops up as a symptom of many types of mental illnesses—bipolar disorders and anxiety disorders as well as substance abuse, eating disorders, and depression,” writes Shteir. Compulsive shoplifting, Shteir concludes, is “as difficult to stamp out as oil spills or alcoholism.”

For some, shoplifting brings a rush “similar to a cocaine or heroin high,” according to psychiatist Jon Grant at the University of Minnesota School of Medicine. To find out just how similar, psychiatrists there tried treating shoplifters with naltrexone, a drug that blocks opioid receptors and is used to treat alcoholism and heroin addiction. In 2009, in an article for the April issue of Biological Psychiatry, Grant and colleagues at the University of Minnesota School of Medicine recorded the results of their work with 25 kleptomaniacs, most of them women. All of the participants had been arrested for shoplifting at least once, and spent at least one hour per week stealing. The 8-week study is believed to be the first placebo-controlled trial of a drug for the treatment of shoplifting. In the April 10 issue of Science, Grant said that “Two-thirds of those on naltrexone had complete remission of their symptoms.”

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