How Anthropology Can Contribute to Psychiatric diagnoses for ClubDrug Related Disorders

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How Anthropology Can Contribute to Psychiatric
diagnoses for Club-Drug Related Disorders
Lee Hoffer, Ph.D. Linda Cottler, Ph.D., MPH
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Acknowledgements
Principal Investigator Linda Cottler, Ph.D.,
MPH Project Manager Stacey Light Interviewers
John Randell , Marsha Campbell Funding
National Institute on Drug Abuse, 1 RO1
DA14854-01
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Abstract
New, emerging, or infrequently used drugs of
abuse such as club-drugs present a unique
challenge to psychiatric epidemiology. To
understand the clinical significance of new drugs
of abuse such as Ecstasy, Rohypnol, GHB and
Ketamine, questions to assess characteristics of
drug use are borrowed from other assessments.
However, in this transfer there is the potential
that questions about a recognized drug of abuse
may miss important nuances, patterns of use, or
consequences for new drugs of abuse. This
potential weakness makes anthropologic research a
valuable tool to psychiatry. Medical anthropology
uses what other disciplines call naturalistic
research methods. These methods rely upon
participant-observation, observing subjects in
their natural settings, and in-depth interviewing
techniques. Interviews are open-ended, or
semi-structured, meaning that while an
anthropologist has research questions which
initially structure his/her inquiry the research
is primarily directed by interaction with the
subjects. The researcher is guided to important
features of, or attitudes about drug use. In an
effort to enhance an ongoing NIDA-funded study to
understand more about Ecstasy use, abuse, and
dependence in Sydney, Miami, and St. Louis this
poster highlights methods from a qualitative
sub-study of 50 active Ecstasy users. The sample
was stratified into two groups of users one who
reported experiencing withdrawal symptoms from
Ecstasy and one who did not. All participants
were randomly selected. This poster will detail
how methods such as negative-case analysis,
ethnographic interviewing, and grounded theory
techniques can be used to clarify tolerance,
withdrawal, comorbidity, and diagnostic
specificity relevant to club-drug use.
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Types of qualitative research

• Focus groups

2. Linguistic research 3. Case studies 4. Life
History 5. Social Network studies 6. Free
listing, card sorting 7. Video / photographic
8. Ethnography / Naturalistic research
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Medical anthropology

• Research paradigm

• Focused on social action not individual
  behavior
• Characterizes subjects lives outside of, yet in
  relation to, conventional medical institutions,
  settings, and relationships
• Delineates social influences on behaviors
  relevant to interactions with medical systems
• Non-clinical
• Informal
• Subjects are experts and participants (not
  patients)
• Adaptable, informant led research, no
  pre-determined boundaries, inductive and holistic
  (what is meaningful to subject)
• Goal understanding informants beliefs,
  behaviors, and attitudes, high internal
  validity (historic / context dependent)

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Medical anthropology (cont.)

• Ethnographic methods

• In-depth, open-ended interviews
• Adaptable question guide (focusing on whats
  important to the subject), similar in some ways
  to clinical interview

• Participant-observation
• Becoming an ad-hoc member of the group one is
  researching to better understand customs, norms,
  behaviors, relationships, and social interactions
  
• But also to gain subjective insight into
  experiences
• Requires developing, fostering, and maintaining
  on-going relationships with subjects (rapport
  maintenance)
• Often complex (multi-dimensional) researcher /
  subject relationship
• Raises complicated practical research concerns
  (e.g., subject payments, informed consent, legal
  issues)

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History of Ecstasy (MDMA)

• History since 1980s, designer drug
• Increased popularity in 1990s but also increased
  media coverage, club-drug
• NIDA Community Epidemiological Workgroup reports
  have noted increases in indicators of use over
  last seven years
• Difficult to determine true prevalence due to
  lack of systematic epidemiologic studies
• (CD-SLAM) first specific study
• New drug for Risk Behavior Assessment (RBA)
  survey
• Evolving picture of clinical symptoms and
  presentation of abuse and dependence (unknown
  addiction liability)

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What we know about Ecstasy (MDMA)

• Limited descriptive studies (Medical
  Anthropology)
• Rave and Ecstasy use
• Drug use patterns different from heroin, cocaine,
  and other hard drugs (less habitual use, less
  frequent use)
• Drug users less urban, more affluent and educated
• Internet an important source of information for
  users
• Minimal data on neuro-biological mechanisms of
  action in humans
• Minimal data on clinically presentation,
  associated harms, and addiction liability
• No research on withdrawal symptoms (on-going
  studies)

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The DSM-IV and Ecstasy (MDMA)

• Classified as a hallucinogen
• Specifier without psychological addiction
• No associated withdrawal syndrome
• Criterion 1 (tolerance) questionable
• Criterion 2 (withdrawal) not applicable
• Criteria 3-7 applicable
• Several specific Hallucinogen related disorders
  
• Withdrawal (Criterion 2a) is a maladaptive
  behavioral change, with physiological and
  cognitive concomitants, that occurs when blood or
  tissue concentrations of a substance decline in
  an individual who had maintained prolonged heavy
  use of the substance. (DSM-IV, p.194)

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Sub-study Research Aims

• Comparative study subjects who report
  withdrawal symptoms associated with Ecstasy use
  from CD-SLAM study compared to those who do not
  report withdrawal symptoms

• Identify, characterize, and describe withdrawal
  symptoms reported by Ecstasy users
• Bring attention to social (environmental) factors
  that influence, confound or mask withdrawal
  reports
• Investigate validity of general DSM-IV criteria
  for dependence for Ecstasy use
• Compare and contrast qualitative sub-study
  findings to SAM and SCAN findings
• Evaluate concept looking toward DSM-V

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Sub-study design

• Part of reliability and validity study of
  Ecstasy use (using a community sample).
• SAM and RBA interviews conducted at Time 1 and
  Time 2 by different non-clinical interviewers.
• At Time 2, 50 Sample randomized to receive
  (WHO-SCAN) diagnostic interview to measure
  concordance and validity

• The remaining 50 of the sample not randomized
  to the SCAN become eligible for the sub-study.

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Sub-study design (cont.)

• The subjects who are eligible are then stratified
  based on SAM questions that correspond to DSM-IV
  withdrawal criteria (Q.14 Q.15)
• Withdrawal Group
• Subjects who report 3 withdrawal symptoms or
• Report using Ecstasy to avoid withdrawal symptoms
• Non-withdrawal Group
• Subjects who report
• No use of Ecstasy to avoid withdrawal symptoms
• Once the stratification occurs, subjects are then
  randomized by group for selection into sub-study
  (13)
• This protocol will produce N25 for each
  sub-study group.

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Sub-study design
Time I (N 300)
Subjects receive RBA SAM
Time II
Random assignment (12)
(N150)
(N150)
Subjects receive RBA SAM
Subjects receive RBA SAM
Random assignment (13)
Random assignment (13)
(SCAN) Clinical Interview (N150)
(N25)
(N25)
Ethnographic Sub-study (N50)
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Question guide format
? Is withdrawal symptom X the result of other
substances used before, during, or after Ecstasy
use
Yes
No
? Is withdrawal symptom X the result of the
social context of use
Yes
No
? Is withdrawal symptom X masked by
pre-existing morbidity
Yes
No
? Is withdrawal symptom X (findings?)
Yes
No
? Is withdrawal symptom X Biologically
plausible
? answers that prompt additional questioning
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Research process

• Step One
• Research Question
• Specific
• General / descriptive

• Step Two
• Decide Research Focus
• Formative or Exploratory
• Comparative
• Theory testing
• Theory building

• Step Three
• Select Research Method
• Focus groups
• Life Histories
• Case studies
• Social Network study
• Free listing, card sorting
• Video / photographic study
• Ethnography (participant observation)

• Findings
• Descriptive
• Hypothesis
• Theory

• Themes compared / contrasted
• Frequency and variation in themes considered
• What is missing
• Negative case analysis

Data Collection
Data Analysis
Coding reliability checks
Data cleaning
Verbatim Transcription
Coded Data Set
Coding
Raw data set

• Themes identified and defined
• Prior to research
• As data is collected

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The methodological features study
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Relative contribution of each method
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How can Ethnographic research contribute to
biological psychiatry?

• Practically assist in development of structured
  instruments (survey questions and answer
  categories)
• Identify, characterize, and describe the
  phenotypic expression of mental illness in
  everyday life (i.e., outside clinical settings)
• Evaluate clues about protective and risk
  factors associated with social behaviors
• Provide findings biological psychiatry can
  investigate mechanistically
• Outline social relationships that potentially
  impact gene / environment interactions
• Provide cross-disciplinary validity checks of
  diagnostic criteria
• Generate hypothesis
• Signal new associations not obtainable from
  structured instruments

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Implications

• By integrating qualitative research methods,
  psychiatry can benefit through a greater
  understanding of how clinically relevant
  diagnostic criteria might be understood in the
  everyday lives of substance users. In the long
  run, this combined perspective will make
  recognizing, identifying, measuring and
  quantifying these behaviors easier.
• Instead of applying generic DSM-IV criteria for
  substance dependence to new and less frequently
  used drugs, anthropology can assist psychiatry in
  tailoring these criteria, and/or think of them in
  new ways.
• Just as psychiatry can provide unique information
  about clinical presentations of substance
  dependence, medical anthropology can provide
  unique information about the social
  presentation of dependence. Combining these
  perspectives will naturally draw attention to
  gene / environment interactions.
• In science, utilizing combined methodologies
  across conventional disciplinary boundaries will
  always yield more valid results than using any
  single method or paradigm in discovery.