Abstract
The problem of addiction to psychoactive substances, such as alcohol and other drugs, has been addressed in psychiatry traditionally from the perspective of a mechanistic-reductionist epistemological model, whose main focus in clinical care is to avoid or suppress the use of these substances, rather than understanding the meaning of a treatment and the meaning of the alterations of consciousness produced by these addictive substances. This paper attempts to contribute towards overcoming this epistemological perspective from the perspective of phenomenological psychopathology. In the first part of the article, the main characteristics of phenomenology and its incorporation into the field of mental health will be presented. Then the issue of addiction will be analysed from two ways of understanding it: the mechanistic-reductionist model and the phenomenological dialectical model. Finally, the pragmatic consequences of the dialectical perspective of phenomenology, called Dialectical Phenomenology (DPh), which seeks to enrich the diagnostic process in the mental health clinic, allowing scientific diagnoses to approach the complexities of clinical reality, will be presented.
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Notes
ICD-11, under the heading “Disorders due to Substance Use and Addictive Behaviors” maintains the classic division between substance dependence (whose essential features are: impaired control over substance use; increasing precedence of substance use over other aspects of life and persistence of use despite harm or negative consequences; and physiological features indicative of neuroadaptation to the substance, including tolerance and withdrawal symptoms following cessation or reduction in use) and two other behavioural disorders: Episode of Harmful Substance Use (an episode of use that has caused clinically significant damage to a person’s physical or mental health or resulted in behaviour leading to harm to others); and Harmful Pattern of Substance Use (a pattern of repeated or continuous use that has caused damage to a person’s physical or mental health or resulted in behaviour leading to harm to others).
While this distinction may be relevant for “… capturing the public heath impact of substance use in morbidity and mortality statistics” (First et al., 2021, p. 46), it is not based on any accurate observation of the subjective experience of people who are addicted to substances. As we argue throughout this paper, the understanding of these experiences could improve clinical care. There is no specification, for example, of what “ impaired control over substance use”, or "clinically significant damage to a person's physical or mental health" means for a particular person.
DSM-5 abandons the distinction between dependence and other harmful uses, adopting a single Substance Use Disorder category. This classification allows three levels of severity to be established for this category. (APA, 2022): mild (two or three out of eleven symptom criteria), moderate (four or five out of eleven symptom criteria) or severe (six or more out of eleven symptom criteria). The eleven symptom criteria are:
Using more of a substance than intended or using it for longer than you’re meant to; trying to cut down or stop using the substance but being unable to; experiencing intense cravings or urges to use the substance; needing more of the substance to get the desired effect — also called tolerance; developing withdrawal symptoms when not using the substance; spending more time getting and using drugs and recovering from substance use; neglecting responsibilities at home, work or school because of substance use; continuing to use even when it causes relationship problems; giving up important or desirable social and recreational activities due to substance use; using substances in risky settings that put you in danger, and continuing to use despite the substance causing problems to your physical and mental health.
Again, though the two first symptoms do refer to a subjective experience of distress, the way the category is constructed allows, for example, a severe form to be diagnosed abstractly, without considering any of the value, existential and cultural aspects of the suffering person.
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Messas, G., Dörr-Álamos, S. Dialectics of addiction: a psychopathologically-enriched comprehension of the clinical care of the addicted person. Phenom Cogn Sci (2024). https://doi.org/10.1007/s11097-024-09969-8
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DOI: https://doi.org/10.1007/s11097-024-09969-8