208 Chapter 26
Empirical studies suggest that there is a single dimension of harmful use
that encompasses both sorts of symptoms. More broadly, the current fo-
cus on present-or-absent categories such as harmful use or dependence
may need to give way to a more dimensional approach to classifying
patterns of use and abuse.
2 There are some lively controversies as to how best to operationalise
concepts such as tolerance or withdrawal symptoms. For example, text-
book cases of severe alcohol withdrawal syndrome with full-blown
hallucinations and seizures are largely confined to adults. On the other
hand, acute withdrawal symptoms after alcoholic binges may be com-
mon among children and adolescents, particularly if the symptoms of a
hangover are also due to alcohol withdrawal, as some have suggested.
Thus ‘narrow’ and ‘broad’ interpretations of the same diagnostic criteria
can lead to very different estimates of how common substance use
disorders are at different ages.
3 Most regular smokers can be classified as having a psychiatric disorder,
namely nicotine dependence disorder. Indeed, according to surveys in
some countries, this is one of the commonest psychiatric disorders in
the general population. There is no doubt that smoking causes enor-
mous damage to the population’s physical health and that nicotine is
addictive – but does being a regular smoker correspond to what most
people would think of as a psychiatric disorder? If so, should mental
health professionals be spending much more time tackling cigarette
smoking? Or is this a step in the wrong direction, shifting the primary
responsibility from more appropriate agencies such as family doctors
and schools?
4 If you are concerned about creeping medicalisation (or ‘psychiatrisa-
tion’), you may be alarmed by a proposed DSM-5 category of ‘addiction
and related disorders’ which will encompass not only substance use
disorders but also behavioural addictions such as pathological gambling
(and potentially other conditions such as compulsive shopping, internet
addiction and videogame addiction). It sounds like a metaphor that has
got out of hand, and yet pathological gambling can involve tolerance
and withdrawal symptoms, is helped by opiate antagonists; and has
been linked in both neuoroimaging and genetic studies to dopaminergic
systems. It’s certainly an interesting debate.
Treatment
The vast majority of adolescents with substance misuse problems do not
come to Child and Adolescent Mental Health Services. For those who
do, there is no evidence that general counselling is effective. Some forms
of manualised family therapy have shown good effects when delivered
by the original programme developers, but have been less successful
when delivered in everyday practice. Brief Strategic Family Therapy seems