Am J Psychiatry 1993; 150:695-704
Copyright © 1993 by American Psychiatric Association
Should protracted withdrawal from drugs be included in DSM-IV?
SL Satel, TR Kosten, MA Schuckit and MW Fischman
Department of Psychiatry, Yale University School of Medicine, New Haven, Conn.
OBJECTIVE: The authors reviewed both clinical data and selected laboratory
research related to withdrawal from alcohol, opiates, and stimulants in
order to draw a conclusion about whether the phenomenon of protracted
withdrawal exists and should be included in DSM-IV. METHOD: Studies were
located through computerized searches and reference sections of published
articles. RESULTS: Symptoms extending beyond the period of acute withdrawal
in alcohol and opiate dependence have been fairly consistently described;
this is not the case with cocaine. Nevertheless, protracted alcohol and
opiate withdrawal has not been conclusively demonstrated because of the
failure of studies to do multiple time point sampling, to use standardized
instruments and control groups, and to re-administer the substance in an
attempt to suppress withdrawal symptoms. Further, the concept of protracted
withdrawal itself is ambiguously defined. This confounds interpretation of
the literature and precludes derivation of a unified concept of the term,
which would be necessary for adding the diagnosis to DSM-IV. CONCLUSIONS:
There is insufficient documentation to justify inclusion of protracted
withdrawal in DSM-IV because of methodologic limitations of the studies and
lack of consensus definition of the term itself. An outline for
conceptualizing protracted withdrawal is offered in which the symptoms can
be seen as: 1) a global post-use syndrome, 2) attenuated physiologic
rebound, 3) toxic residuals, 4) expression of preexisting symptoms unmasked
by cessation of use. Future efforts to identify signs and symptoms of
protracted withdrawal should carefully define the parameters of the
syndrome.
