Some important things to remember about these roles:

• They are not conscious choices. No parent decides, “I’m going to be a Chief Enabler” in my family. Kids don’t choose to become a Mascot or a Hero.
• The roles themselves aren’t “good” or “bad.” When growth and change is frowned upon, that is what’s bad for families. The stuckness and inability to grow beyond a role is what makes roles problematic in a family affected by addiction.
• These roles carry over into other areas of life, making intimate relationships problematic, or careers/professional relationships difficult to navigate.
• Treatment is helpful for becoming aware of these roles and how they are impacting your behavior. This is an area where therapy can be really useful and effective, and where insight can lead to making positive changes.

In prior articles, we’ve looked at the Chief Enabler and the Family Hero—two roles that are somewhat balanced in terms of having much that is positive about them and much that can be harmful or detrimental about them. These two roles are similar in that both Heroes and Enablers “over-function”—they tend to pick up the slack emotionally, financially, and in terms of physical chores. The drinker or substance abusers tend to not get to things (from dishes to bills to baseball games) because their focus is on using. The Hero and the Enabler both work hard—sometimes hard enough to make themselves physically ill—to maintain the appearance of a well-functioning family.

The Scapegoat

The Scapegoat is a very different type of role. This is the child who constantly gets in trouble, and constantly attracts negative attention. As a young child, this is the one who may be diagnosed with attention-deficit hyperactivity disorder (ADHD) or have “behavior problems” at school. Maybe a bully, or maybe just the class clown, this is the child who seems incapable of following rules or letting things be easy. For the Chief Enabler, this child is a thorn in his or her side.

Often as a teenager, the Scapegoat begins using drugs or alcohol. These children can have significant conflict with others in the family, and sibling issues between the Hero and the Scapegoat are common.

These children are sometimes described as the “lightning rods” for the family, since they seem to attract negative consequences. They are the typical acting-out child: they act out all the anger, frustration, rage and fear that all of the family members may feel. When a parent drinks or uses drugs, that parent’s behavior can be unpredictable and frightening for children. Rules may change based upon whether the parent is drunk, hung over, or seeking a drink. Conversations that take place while the parent is under the influence might not be remembered the next day. Permission granted can be taken back, and moods can flip on a dime. The inconsistencies of the using parent’s behavior, and the covering up or “making nice” that the enabler does can also be confusing at best, and infuriating at worst. The Hero just works harder at pretending everything is fine and that the family is fine, despite all these emotions. The Scapegoat is the family member who insists the family get attention—he is the one who screams “something is wrong” and does so by being “wrong.”

When looked at this way, the Scapegoat is easier to understand. On the surface, the Scapegoats just seem like such screw-ups; it can be hard to feel compassion for them. They appear to be committed to making a mess of their lives, and they often appear to be uncaring about the impact their behavior has on others. However, looking at the bigger picture of the whole family, it is easier to understand those who take on this role as not only a scapegoat but also a sacrificial lamb: they sacrifice their own life, health, and happiness to get the problems in the family noticed. The messes they make are the “cry for help” that may get the real problem in the family noticed.

The big risk with the Scapegoat is that by the time he or she reaches adulthood, he or she may well have developed an addiction or legal problems, or have continued “fallout” from the messes that were made during the teenage years to such a significant degree that they have severe trouble getting started in adult life. The Scapegoat needs help more urgently and at a younger age than the Hero; not only is the risk of substance abuse higher for children in this role—the risk of suicide is higher as well.

Read Part 2: Dysfunctional Family Roles: The Family Hero Tries to Hide the Obvious Here.

In families affected by addiction, or any family in which one or both of the parents are unable to fulfill their role as parent, there is a tendency for all family members to take on rigid and surprisingly predictable roles. In any group of children of addicts or alcoholics, ask about the roles in their families growing up and you will hear some very similar reports over and over again. In a dysfunctional family, the key difference regarding roles is that they are rigid: once you’re pegged as a Mascot or Hero, for example, you’re stuck. Behave in a way that is not in line with that role, and your entire family pressures you to get back in line. Placing a value on change, flexibility and authenticity (think of being authentic as embodying and expressing your individuality instead your role behaviors) are not typically part of dysfunctional family dynamics.

Several experts on addiction and family roles have named and described these typical roles. The names are a little different depending upon which author you’re reading: family systems therapist Virginia Satir used the terms placater, adjuster, distracter, blamer, and computer to label the different communication styles and roles family members take on. Claudia Black and Sharon Wegscheider Cruse built upon Satir’s work on communication styles and family roles, and used the names scapegoat, family mascot, hero/responsible one, and lost child to describe the different roles.

In an earlier article we discussed the role of the Chief Enabler, typically a role taken on by the addict or alcoholic’s partner. Here we’ll take a closer look at The Family Hero. This role could be taken on by any child in the family although birth order does seem to play a role with family heroes most commonly being the oldest child. The Family Hero is the child who lives the denial, devoting his or her life to proving that they are fine despite the “elephant in the living room.”

Characteristics of The Family Hero

The Family Hero is the perfect child. He or she takes on being perfect for the family as a way of proving that the addict or alcoholic’s drinking isn’t a problem. Look: I can get good grades, play a sport, and totally have my life together despite Mom or Dad’s drinking. The Family Hero crafts life to contradict the assumption by others outside the family that the drinking or drugging will affect the kids.

The children who take on the family hero role often do extremely well at whatever they take on, and are successful in the eyes of the world. They often become professionals; doctors or other healing professions are common. They often manage money well, and have very high standards for themselves and their own families.

They are often intolerant of their own emotions, and this is their Achilles heel. They need to be perfect, and they need their lives to be perfect to “undo” the imperfections they had to tolerate from early on. The problem is life is not perfect and uncontrollable things happen: accidents, being victimized, relationship problems, health issues…life tosses obstacles in our path constantly and the need to handle each one “perfectly” is a pressure family heroes place upon themselves.

Risks and Pitfalls

This places the Family Hero at high risk for developing substance abuse problems themselves. Finding a way to cope with the tremendous internal pressures isn’t easy and all those unmet needs from childhood can crash into the adult pressures to “have it all together.” Substance abuse isn’t the only risk: eating disorders are also common among women who have filled this role in a dysfunctional family. The efforts to control the uncontrollable can easily be channeled into controlling eating and weight, and focusing on something tangible: appearance and/or weight can make the overwhelming pressures of making “everything” perfect feel more manageable. Children who have taken on the Family Hero role also seem prone to depression and anxiety, as they try so hard to make everything better than it was during their own childhood but inevitably feel as if they have failed, either due to their own dissatisfactions and old wounds, or due to the challenges and “bumps in the road” that life hands them.

How to Help

Often as an adult, the Family Hero feels like he or she needs to do everything, take on every responsibility, and be in charge of all of it. While this is understandable, since so much didn’t get done in a responsible or timely way during childhood, this inability to delegate or share responsibility, and the need to be in control of everything all the time is draining and destructive. You can see how a Family Hero could grow up to become a Chief Enabler as the roles in adulthood are rather similar.

Psychotherapy aimed at helping shed the Family Hero role can be effective. Learning to tolerate imperfection and the notion of “good enough” (as opposed to perfect) can be life changing for these people.

Read Part 1: All in the Family: Are You the ‘Chief Enabler’ for an Addict? Here.

Before we continue, let me say something about family dysfunction. As a treatment provider for people with addictions and their families for many years, I saw how devastating addictions can be to lives young and old. What’s important to remember here is that despite having an addiction that often leads to very negative behaviors—including violence, abuse, neglect—and despite being labeled “dysfunctional” (we’ll get to that in a moment), these are families that also are bonded by love and loyalty. These are parents who love their children and want the best for them and children who love and defend their parents despite having suffered due to their behaviors.

Taking apart the word “dysfunctional,” the prefix ‘dys’ refers to pain. Dyspepsia is a stomachache; dysmenorrhea is the technical term for painful periods. Dysfunction in the family context means that a family is functioning in pain. Meals do get made, children attend school, play sports, parents work, but the context in which all this happens is emotionally painful. Sometimes my clients would get defensive about the term “dysfunctional,” telling me that it felt like blame to say their family “ didn’t function.” So I make a point of agreeing: there is functioning and often children from families impacted by addiction function very well in some ways; but it would also be unfair and inaccurate to fail to acknowledge the pain that occurs too.

Family Roles

In all families, affected by addiction or not, family members take on roles. Sometimes Mom takes on the role of the discipliner, sometimes Mom is the “banker” for the family. Dad might have been the “sports guy” or the social planner. Imagine a particular behavior—for example, climbing a tree or catching a frog—and most people would then be able to predict which family member would be most likely to engage in that behavior and which would be least likely. The kid who was “outdoorsy” or a girl who fit the “tomboy” role would be first in line. In healthy families, the roles arise from internal personality characteristics and are flexible—as a child grows, develops, and changes, so do the roles.

In families affected by addiction, certain specific roles seem to evolve. These roles are more rigid and predictable, and have been described by a few well-known writers in the field of addiction and family roles. The names change from writer to writer, but the basic roles are similar.

The Second in Command:

In families where addiction is impacting the dynamics, the alcoholics or addicts often have someone on “their side,” someone who takes on the task of keeping the family functioning by keeping the person who is using as functional as possible.  This person calls in sick for the drinker, or makes excuses at “Meet the Teachers Night.” They find themselves lying to the kids, the neighbors, their friends and ultimately themselves. Family systems therapists refer to this role as the Chief Enabler, or Codependent. Sometimes in the literature on addiction and alcoholism, people refer to the codependent person as “addicted to the addict.” These people seem to need the relationship more than they seem to need their own health. Let’s take a closer look at this role.

This role is a tough one: the job includes handling all the chores and responsibilities the drinker is not doing. The Chief Enabler just takes over, managing, organizing, acting as the Executive Director, administrative assistant, communications director, and database manager, over-functioning in all these roles (the school principal called? Your boss called? A run-in with police? “I’ll handle it” is the typical Chief Enabler response). He or she is the glue that holds the family together, usually working long hours; often at a job earning money and then at home taking care of all the details that can get left unmanaged when an addict uses.

The purpose of this role is to prevent the family (including the drinker) from experiencing the negative consequences of addiction. Of course this is impossible, which makes this person feel hopeless and frustrated, but also very important, since there are small successes and triumphs (such as a little league game attended by the addict or alcoholic, or open house at the school) along the way. The Chief Enabler feels “stuck” and often very angry about their stuckness because they know how important they are to the “success” of the family (in fact, it often feels like “if I don’t do it, it won’t get done”). People in this role often receive much praise and support from the community. People outside the family often admire the Chief Enabler, which is one of the few positives about being in this role—often others outside the family recognize how critical the Chief Enablers actions are to the health or even survival of the family—so you hear comments like, “Mary really holds that family together.” The other side of this coin is that they also feel alone and furious at being stuck with being the responsible one who has to take care of everything. The fact that these people often do an excellent job, partly because they’ve had so much practice, is their blessing and their curse and is the catch 22 they experience as “stuckness.”

Read more about Enabling Here.

However, a new study shows that this perception may not match the reality. Far from being a time gone by, the study provides evidence that psychedelic drug use is no relic from the ‘60s. It is, instead, a common practice that ranges from experimentation to religious ritual.

The study, authored by Teri S. Krebs and Pal-Orjan Jansen of the Department of Neuroscience at Norwegian University of Science and Technology, relied on data from over 57,000 respondents. The findings are published under the title “Over 30 million psychedelic users in the United States.”

The study authors utilized results from the 2010 National Survey on Drug Use and Health, a function of the Substance Abuse and Mental Health Services Administration. The study used telephone surveys, asking individuals 12 years and older about their drug use and other health-related topics.

The analysis showed that an estimated 32 million individuals in the United States have tried LSD, psilocybin (“magic mushrooms”), or mescaline (peyote and other types of cacti). Between the ages of 21 and 64, 17 percent of individuals have tried these drugs.

The age group where the largest concentration of psychedelic drug users was found was in the 30 to 34 age group. In this age range, 26 percent of males and 15 percent of females had tried some form of psychedelic drug.

The researchers explain that the rate of lifetime psychedelic drug use has not changed significantly in the decades since the ‘60s. The drugs continue to be widely used. However, there are several aspects of psychedelic drugs that make them different than other drugs.

The effects of the drugs, the way they work in the body, and the risks associated with them are clearly distinguishable from other drugs. They do not carry a risk of physical harm, they don’t lead to addiction and experts generally believe them to be less risky than alcohol or other types of drugs.

Psychedelic drugs, however, can cause anxiety and an experience of confusion.

The study authors note that older adults were more likely to have a lifetime history of LSD or mescaline use, while younger adults seemed to be more attracted to the use of “magic mushrooms.” The use of the mushrooms has been shown to have increased during the years since the 1970s.

The drugs are often sought for their reportedly mystical effects. The use of plants with psychedelic effects for such purposes has been traced as far back as 5,000 years.

To understand the effects of psychedelic drugs on humans further – read:

New Research Opens Door For Directly Understanding Effects of Psychedelics on Humans

Prescription Drug Abuse Statistics

According the National Institute on Drug Abuse, 7 million Americans used prescription drugs non-medically in 2010. The most common type of drugs abused is opioid analgesics like Vicodin, which are basically narcotic painkillers related to heroin. Other substances, such as amphetamine-like stimulants and tranquilizers, which treat anxiety, are also widely abused across the country. A report in the Los Angeles Times reveals that deaths from drug overdoses have increased for the eleventh consecutive year. The problem is believed to stem from the relative availability of prescription medicines and their reputation as “safe,” combined with the addictive nature of the substances.

Doctor Shopping

Doctor shopping is the practice of going to numerous doctors for prescriptions of narcotic medications to get more pills. It’s already outlawed according to general fraud, subterfuge, and deceit laws across virtually all states, but actually identifying it is extremely challenging without a centralized database. As a doctor, you have no way of knowing if a patient coming into your practice has already gotten another prescription from somebody else, unless each prescription is registered. The relative ease of doctor shopping means that some people are able to obtain vast quantities of narcotic medicines and then sell them for others to abuse.

PDMPs

This is why prescription monitoring programs were set up. They focus on potentially addictive drugs such as OxyContin, Adderall, Valium and Vicodin, and can be thought of as central databases for doctors to record their prescriptions. Before issuing a prescription, doctors check the database to determine whether the individual has been prescribed the drugs before or should already have a sufficient supply. The benefits of this are immediately obvious: not only will it prevent doctor shopping; it will also help to identify individuals who may be addicted to prescription drugs. Federal funding is available, which has driven the overwhelming majority of states to set up their own programs.

The programs have been widely adopted across the US, with states such as Wisconsin and Florida recently passing bills and implementing PDMPs. Now, only Missouri lacks a program, after the bill was defeated in 2012. Despite problems with the functionality of the databases and some funding issues, doctors in places such as San Diego have eagerly registered for the programs.

Problems With the Approach

Despite the positive outlook for prescription monitoring programs across the country, there are some potential issues with the strategy. The main one is the privacy, which was cited as a reason the idea isn’t being well received in Missouri. Essentially, confidential medical information is being placed onto a widely accessible database. Although the databases can only be accessed by medical professionals and pharmacists, there is an obvious concern about patient privacy.

Whether this fairly trivial intrusion into personal privacy is warranted by the scale of the prescription drug problem in the U.S. is open to debate, but ultimately doctors and pharmacists have the same information for their regular patients anyway.

Doctors have raised some more practical and defensible issues, though. One such criticism is that the databases are extremely time-consuming. Consulting a database before prescriptions are given and then recording any prescriptions takes time (particularly if there are server issues or problems with the functionality of the database), and this could impact the number of patients they could see.

Conclusion

Prescription monitoring programs will not prevent people from abusing prescription medicines. Patients will still often receive too many pills for their pain and later give in to the temptation of recreational use or give them to friends to do the same. However, the databases will do wonders to reduce the amount of prescription drugs available for people to abuse. Doctor shopping isn’t the whole problem, but it is a significant contributor, and the monitoring programs are exceptionally well-equipped to curb the practice. In this way, it’s a vital step toward reducing the shocking numbers of deaths each year from prescription drug overdoses, and something that should be welcomed with open arms.

Despite efforts by those who believe the drug is safe for medicinal and even recreational use, the DEA believes it still has a high potential for abuse and therefore the classification that it currently has no acceptable medical use stays in place. As a result, marijuana will continue to be treated by the federal government as a drug akin to LSD and heroin.

While those battling the drug war on the home front appear to be satisfied with the ruling, those who wish to conduct research believe their hands remain tied. According a recent ABC News report, the restrictions meant to protect the people are the very restrictions that make it difficult to perform the necessary studies to convince the DEA that the drug should be moved into a different category.

Essentially, the DEA wants FDA approval before removing marijuana from Schedule I classification. The research that the FDA needs completed to be able to provide approval cannot be conducted because of the current laws in place. The argument was made by the Drug Policy Alliance, suggesting that the federal government is responsible for blocking the research that needs to be completed.

While a number of studies have been completed or are underway, the biggest obstacle observed by opponents to the DEA classification is the fact that the studies must have FDA approval before they can begin. This is perceived by many to be a conflict of interest.

The answers to these questions come from A.A.’s early history. Several of the founders of A.A. would have labeled themselves Christians and as they developed the 12 Steps, they drew heavily on the teachings of the Oxford Group, a Christian organization that had developed practical steps for living. The founders saw that these principles were universal and that they could be applied to finding a solution for alcoholism. Before there was a Big Book, meetings and devotions were often based on Scripture from the New Testament. Does this mean A.A. is a Christian organization? Not exactly.

While A.A. has roots in the Christian tradition, it was decided by the group that A.A. would be of greatest benefit to the masses of suffering alcoholics if it did not establish a religious foundation or affiliation. Having seen the sectarianism that has the power to dismantle even the best intentioned of organizations and groups, the founders elected to develop a program that was based on universal principles without a specifically Christian bent. Though these principles are often detected within the pages of the Bible, they are also elements of many world religions.

While the development of faith in a Higher Power is a necessary element for the working of the 12 Steps, the A.A. literature does not define the identity of this God. Christians will naturally define their Higher Power as the Trinitarian God and they are free to do so. But adherents of other faiths are also welcome to define their Higher Power in accordance with their own doctrine. Those who come to the group as atheists or agnostics are encouraged, initially at least, to see the group as a power greater than themselves and to put their trust in that.

“Beyond a Higher Power, as each of us may envision Him, A.A. must never, as a society, enter the field of dogma or theology. We can never become a religion in that sense, lest we kill our usefulness by getting bogged down in theological contention.” (Bill W., Letter, 1954)

The purpose of this approach was not to diminish the Christian faith or to promote universalism or polytheism. The aim was to open the door wide to those who were dying in their alcoholism and desperately in need of a solution. Rightly, the founders understood that many of those sufferers were non-Christians and non-religious. They knew that placing a Christian label on the organization would shut the door on untold numbers of alcoholics who wanted help but didn’t want church.

The founders also realized the destructive power of sectarianism and denominationalism. Theological arguments and doctrinal differences would naturally arise and they believed that A.A. was not to be the forum for these debates. A.A. was a program with a spiritual foundation—there was no way around that. But how that spirituality was to be defined was up to the individual addict.

Today the 12-Step groups adhere to this principle of religious non-affiliation. The door is open to people of all faiths. Though many find God or become Christians through the program, they would likely never have gone so far as to enter a meeting if they thought this faith was a requirement for membership.

“While A.A. has restored thousands of poor Christians to their churches, and has made believers out of atheists and agnostics, it has also made good A.A.’s out of those belonging to the Buddhist, Islamic, and Jewish faiths. For example, we question very much whether our Buddhist members in Japan would have ever joined this Society had A.A. officially stamped itself a strictly Christian movement.

You can easily convince yourself of this by imagining that A.A. started among the Buddhists and that they then told you you couldn’t join them unless you became a Buddhist, too. If you were a Christian alcoholic under these circumstances, you might well turn your face to the wall and die.” (Bill W., Letter, 1954)

Or at least, this is how it should be. Unfortunately, peer groups are no different than any other type of self-organized entity in that they can be highly effective or completely dysfunctional depending on the quality of the input of the participants. Ultimately, those who attend peer support groups must put in a real effort to make sure these self-organized healing-centered associations deliver on their promise to assist, and without this type of care and concern a peer group may come nowhere close to living up to its potential as a force for good.

A lot of the responsibility for the quality of the peer group experience obviously falls on the shoulders of the group leader, who must use his education and experience to help steer discussions in a positive direction. But while a good leader has great influence, if the members of a peer group don’t hold up their end of the bargain, even the best leader will not be able to organize an assemblage that rises above the mediocre. The voluntary relationships that the members establish among themselves are the lifeblood of all peer support groups, and it is vital that recovering addicts and alcoholics who attend group meetings work hard to make these gatherings productive and enlightening for all.

To some extent this burden may seem a little unfair; after all, addicts in the early stages of recovery already have a lot on their plates, and asking them to take on the added responsibility of helping to ensure that peer support groups are run effectively may seem like a bit much. But passivity is not synonymous with recovery from chemical dependency, and anyone who is serious about overcoming a drug or alcohol problem should be ready to take an active role in his or her project of redemption at each step along the path. If a peer group is only as good as its members – and this truism is as rock-solid as they come – then each of those members must be prepared to expend effort and energy to facilitate the recovery process, for their own good as well as the good of their fellow addicts.

So what characteristics make a good peer support group member? There are many possible answers to this question, but the analysis of peer group dynamics that follows should provide some useful guidance for those seeking insight.

Recognizing and Respecting Boundaries and Communication Styles

Addicts and alcoholics in peer support groups share a common problem, but nevertheless each is a profoundly unique human being whose differences must be recognized and acknowledged. Human individuality is the main reason listening skills are just as important in communication as speaking skills, and peer group members should concentrate very closely on what their fellow group members are saying so that they can respond appropriately and constructively to what they are hearing—presume nothing but hear everything, this should be the credo of all peer support group members when dealing with their fellow recovering addicts.

But to gain real insight, it is also important to hear what people are not saying—while some people are comfortable speaking about their lives and their problems in public others are far more reserved and reticent, and everyone’s preferences and styles should be understood and respected. In ways that are sometimes subtle and sometimes obvious, each and every person in a peer support group will let the others know when they are ready to talk, how much information they are willing to disclose, and how much honest feedback they are comfortable receiving. Good peer group members realize this, they pay attention to the signs, and they adjust their interactions with their fellow recovering addicts and alcoholics accordingly.

The Power of the Practical

Recovering substance abusers attend group meetings hoping to find support and understanding, but they are also looking for practical advice to help them cope with the pitfalls and temptations they will inevitably face as they travel the path to sobriety. Whether their useful knowledge has been gained through wise analysis or trial-and-error, most recovering addicts have discovered strategies and techniques that have helped them make it through the rough times, and their “stories of the road” can be immensely helpful to others who will likely face, or are already facing, the same obstacles on their journey to good health. For the newly sober the possibility of relapse looms at every moment, and any ideas about how to handle cravings, overcome the depression that often accompanies withdrawal, or resist the triggers that can sabotage recovery in an instant can be extremely helpful.

In general, a positive attitude in the peer support group setting is highly recommended. But vague, pie-in-the-sky platitudes sound insincere and can actually interfere with the establishment of good relations between support group members. Hard-earned practical advice, on the other hand, will always be accepted with gratitude and appreciation.

The Grace of Acceptance

Giving good advice is wonderful, but accepting the suggestions and insights of others with good grace also helps to make the atmosphere in peer group sessions feel warm and inviting for all who come. When people feel free to share their thoughts about the situations others are experiencing, and when they know their efforts to help will be applauded, it enables them to connect more deeply with other recovering substance abusers and helps them open their hearts and minds to the guidance they will be offered by others in return. Regardless of whether the advice a particular person gives actually has the potential to help anyone else is irrelevant; just the fact that he or she feels comfortable speaking up and contributing is what matters the most.

Peer group members really do need each other, for validation as much as for anything else, and for this reason everyone who attends group meetings should give equal attention to all. Recovering addicts and alcoholics are searching desperately for a renewed sense of purpose, and having the chance to help others who are in a similar situation can help fill in the emotional and psychological gaps that will come to the forefront once drugs and alcohol are no longer around to provide their dubious compensations.

Following the Leader, and Letting the Leader Follow

As previously mentioned, group leaders play a vital role in managing and developing peer groups that actually work the way they are supposed to. But even though they are officially the ones in charge, group leaders still need all the help and support they can get. For example, peer group members who listen closely to what their leader says and ask questions or offer critiques can boost his or her efforts substantially, offering positive reinforcement to a message that may be of vital importance to everyone.

In peer groups, leaders are only as good as their followers. When recovering addicts and alcoholics are willing to support their leaders’ hard work by participating eagerly and attentively in the discussions they initiate, it sets a good precedent and encourages others to get more deeply involved as well.

Somatic symptom disorder (SSD) is the name of a newly defined mental health condition that appears in the May 2013 fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, a standard guidebook used by mental health professionals throughout the United States. The new disorder fully or partially replaces several other conditions, known collectively as somatoform disorders, included in the previous version of the DSM. People with SSD have distressing or disruptive symptoms of somatic illness, a term that doctors generally use to describe physical ailments that have no explainable physical cause. However, controversially, the SSD definition lets doctors diagnose the disorder even when a plausible physical explanation for their patients’ symptoms exists.

Background Information

The Diagnostic and Statistical Manual of Mental Disorders is the creation of an organization called the American Psychiatric Association. Committees of mental health professionals within this organization meet periodically to discuss new developments in mental health research, compare those developments with the current accepted norms of the psychiatric community, and decide whether they need to update the accepted norms in order to incorporate relevant information from the new findings. The decisions made by these committees are included in fully or partially revised updates of the DSM and publicly released. In addition to doctors, public health officials and insurance companies typically closely follow the criteria established by the latest DSM version.

Somatoform Disorder Basics

According to the newly outdated version of the DSM, known as DSM IV or DSM 4, somatoform disorders exist as a group of related conditions, all of which revolve around the presence of physical symptoms with mental or psychiatric origins. The full list of these conditions includes somatization disorder, which centers on chronic physical symptoms appearing in multiple parts of the body; conversion disorder, which centers on symptoms affecting the nervous system; pain disorder, which centers on the presence of severe pain; hypochondriasis (known commonly as hypochondria), which centers on a fear of having or contracting a serious physical ailment; and body dysmorphic disorder, which centers on a fixation with the “disfiguring” effects of minor or entirely self-perceived physical flaws.

The new version of the DSM, called DSM 5, eliminates somatization disorder, pain disorder and hypochondriasis as diagnosable mental disorders. It also eliminates another related condition called undifferentiated somatoform disorder. The American Psychiatric Association committee that made these changes gave several reasons for their decision. First, they wanted to do away with the considerable overlap in symptoms between different somatoform disorders. They also wanted to make it easier for non-specialist doctors to make appropriate diagnoses in their patients. In addition, they wanted to curb a tendency among doctors to treat the mind and body aspects of somatic symptoms as separate medical issues.

Somatic Symptom Disorder Basics

The newly established definition for somatic symptom disorder resembles the definition for somatization disorder in certain respects. Like somatization disorder, SSD centers on the presence of somatic symptoms that disrupt a person’s normal lifestyle. However, a person with SSD also experiences extreme or excessive degrees of emotional distress and has a preoccupation with his or her physical symptoms that manifests as a significant change in his or her behaviors, feelings, or thought processes. These combined symptoms must recur consistently for about six months.

To receive a diagnosis for one of the eliminated somatoform disorders, an individual needed to have a certain number of symptoms that came from four different categories or groups. The definition for SSD does away this requirement. Critically, the definition for SSD also gives doctors the freedom to diagnose the presence of the disorder even if a patient has a medical condition that substantially accounts for his or her symptoms.

Concerns in the Medical Community

Some mental health experts disagree with the validity of the terms used to define somatic symptom disorder. This disagreement typically focuses on the freedom that doctors have to diagnose the condition in people who have reasonable medical explanations for their somatic symptoms. Many experts believe that this freedom will lead to over-diagnosis of SSD, and also unnecessarily stigmatize certain physical ailments as the products of mental health problems. A recent field trial of the new SSD definition highlights some of these issues. During this trial, 7 percent of physically healthy individuals were misdiagnosed with SSD; in addition, 15 percent of all trial participants with heart disease or cancer—and 26 percent of all participants with fibromyalgia or irritable bowel syndrome—qualified for an SSD diagnosis.

Prescription Opioid Basics

All prescription opioids are based on substances that occur naturally in Papaver somniferum, a plant species popularly known as the opium poppy. Two of these medications, morphine and codeine, come more or less directly from ingredients contained in the sap of P. somniferum. Two other common prescription opioids, hydrocodone (Vicodin, Lortab), and oxycodone (OxyContin), are created in pharmaceutical laboratories through chemical manipulation of naturally occurring opioid substances. Three additional common opioid medications—fentanyl (Fentora, Actiq), synthetic codeine, and meperidine (Demerol)—are manmade substances designed to chemically resemble the natural opioids.

Each prescription opioid medication has its specific typical role in medical treatment. For instance, doctors typically use codeine to relieve relatively moderate pain or ease the effects of medically serious coughing or diarrhea. Morphine is commonly used to relieve severe pain in surgical settings, while doctors use hydrocodone and oxycodone for a range of conditions involving moderate to severe pain. Regardless of their particular common use, all prescription opioids (and illegal opioid drugs) achieve their pain-relieving effects in a similar way by entering the body and attaching themselves to sites in the nervous system called opioid receptors. When activated by the presence of opioids, these receptors help override pain signals traveling through the nervous system to the brain.

When opioids attach themselves to opioid receptors located in the brain, they produce an additional effect by triggering a dramatic increase in the levels of a brain chemical called dopamine; in turn, this dopamine increase produces intense pleasure. In prescription users, opioid abuse and addiction typically become issues when a given individual seeks out this pleasure as a recreational activity and increases his or her level of intake above the level sanctioned by a doctor. This situation differs fundamentally from the situation of prescription users who follow their doctors’ orders and come to depend upon opioids’ legitimate pain-relieving effects.

Suicide-Related Risks

Unfortunately, suicidal thinking and active suicide attempts are found among prescription opioid abusers and addicts with some regularity. In 2012, researchers from the American Psychiatric Institute for Research and Education examined suicide-related factors in almost 38,000 participants in a study called the 2009 National Survey on Drug Use and Health, which was conducted by the U.S. government’s Substance Abuse and Mental Health Services Administration.

These researchers found that about 15 percent of the survey respondents had misused a prescription opioid medication at least once. They also found that roughly 11 percent of all people who had misused prescription opioids for at least two years had considered suicide in the year before the survey. In addition, roughly 9 percent of all people who had misused these medications for less than a year had considered suicide during the same period of time. By comparison, only 3 percent of people who didn’t use prescription opioids considered suicide in the year before the survey.

The authors of the American Psychiatric Institute for Research and Education’s study noted several factors that help determine the risks for suicidal thinking in people who misuse prescription opioids. The most prominent factor is a level of misuse that qualifies for standard definitions of drug abuse or drug addiction; fully 23 percent of survey participants with suicidal thoughts self-reported this degree of medication misuse. Another important factor is the presence of symptoms consistent with a diagnosis of the psychiatric disorder known as major depression. In addition, the authors of the study concluded that the risks for suicidal thinking don’t end with the discontinuation of opioid use, and former long-term users continued to exhibit suicidal thought patterns significantly more frequently than people who have never used prescription opioids.

About 18 percent of all current prescription opioid users/abusers who considered suicide actually went on to make active suicide attempts, while 7 percent of former users/abusers with suicidal thoughts attempted suicide. By comparison, 11 percent of survey participants with suicidal thoughts who never used a prescription opioid attempted to kill themselves.