Stirring the Pot: New Controversies in Addiction Diagnosis in the DSM-5

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June 5, 2013 by Dr. Bob Weathers

The new, fifth edition of the American Psychiatric Association’s “Diagnostic & Statistical Manual of Mental Disorders” (DSM-5) has recently been published (American Psychiatric Association, 2013).  To start with, the DSM-5 wields major influence over how physicians diagnose and treat their patients.  It also shapes how insurance companies decide which medical and psychiatric conditions to cover financially.  Furthermore, the DSM-5 affects how pharmaceutical companies design clinical trials.  Finally, various funding agencies use the DSM-5 to make decisions about which research they deem worthy of supporting with grants (University of Texas Addiction Science Research and Education Center, 2013).

You can begin to get a picture of how powerful an impact a thoroughly revised DSM will undoubtedly have, with reverberations for years to come…

In its new section entitled “Substance-Related and Addictive Disorders,” the DSM-5 discards previous terminology, including “dependence” and “abuse.” In addition, even the term “addiction” is no longer used diagnostically in this new classification system.

Dr. Charles O’Brien, chair of the DSM Substance-Related Disorders Work Group for the DSM-5, summarizes: “The revision combines the dual classifications of abuse and dependence into a single category of ‘Substance Use Disorder.’  It defines this overarching disorder as a spectrum of symptoms that go from ‘mild’ to ‘moderate’ to ‘severe’” (O’Brien, 2013).

Dr. Anna Lembke, Stanford professor of psychiatry, provides the following account related to the old terms of “dependence” and “abuse”:

The following dialogue is one I overheard my residents and medical students having earlier this year when attempting to apply the [old] DSM-IV criteria of “abuse” versus “dependence” to an in-patient with addiction on our service.

“Isn’t ‘abuse’ like when you get a DUI?” said the medical student.

“Yeah,” said the psychiatry resident, “and ‘dependence’ is when you get withdrawal, right?”

“I think ‘abuse’ leads to ‘dependence’,” said the neurology resident.

“Or maybe ‘abuse’ is not as bad as ‘dependence’?”

“So what about our patient? He’s pretty hard-core.”

“I see him all the time in the emergency room. Totally intoxicated.”

“I’ve seen him drunk on the train.”

That sealed the deal.

“Dependence it is!” they all agreed.

(Lembke, 2013)

In either case, both O’Brien and Lembke agree that there is little scientific support for such ill-defined, and subjectively vulnerable, criteria for assessing substance use. Hence, the DSM-5 has dispensed with using either term.

In one quite clear article, written to preview changes in the DSM, Andrews observed:

The new guidelines would do away with the diagnostic categories of “substance abuse,” which generally is defined by such short-term problems as driving drunk, and “substance dependence,” which is chronic and marked by tolerance or withdrawal. They would be replaced by a combined “substance use and addictive disorders” category (Andrews, 2012).

Somewhat confusingly, in light of the last previous sentence: the formal use of “addiction” is also eliminated in the DSM-5. (The chapter introducing the new diagnostic language is in fact, and perhaps unfortunately, titled “Substance-Related and Addictive Disorders,” as Andrews observed above.)  Yet to quote the DSM directly:

Some clinicians will choose to use the word addiction to describe more extreme presentations, but the word is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation (American Psychiatric Association, 2013, p. 485).

Criticisms of this new and radical replacement of old language with new have predictably stirred considerable controversy.  One quite articulate expression comes by way of the University of Texas Addiction Science Research and Education Center:

Our Center feels strongly about the loss of a category that identifies non-    pathological drinking and drugging, as the old category of “drug abuse” did (although we too do not like the word abuse). We are also dubious about a “substance use disorder” properly representing the overwhelming neurobiological and genetic evidence for “addiction (formerly dependence) as a brain disease.” Finally, the inclusion of the subjective phrase “addiction and related disorders” is not supported by the available research literature, and will almost certainly increase stigma against alcoholics and addicts, in addition to confusing the public about the differences between (for example) “cocaine addiction” and (for example) “cell-phone addiction” (University of Texas Addiction Science Research and Education Center, 2013).

All criticisms aside, for now: how then do professionals now propose to diagnose the new “substance use disorders”?   As but one example, “Alcohol Use Disorder” now lists eleven criteria.  These eleven criteria can be organized into four overall groupings: “impaired control, social impairment, risky use, and pharmacological criteria” (American Psychiatric Association, 2013, p. 483).

Now with the DSM-5 in publication, we infer that what used to be called “alcohol abuse” is to be called “alcohol use” and is assessed across a spectrum of severity (from mild to severe, based simply on the number of diagnostic criteria marked as present).

What used to be called “alcohol dependence” (see Dr. Lembke’s story above) included more severe symptoms, generally; “the [so-called] higher end of the substance use disorder spectrum” (Andrews, 2012).  The more severe “dependence” diagnosis necessitated assessing for such physiological features as withdrawal and tolerance.  Physical effects of withdrawal include sweating, tremors, insomnia, agitation, and anxiety symptoms.  Tolerance is defined by needs for increasing amounts of alcohol to experience intoxication and/or lessening of alcohol’s effect when drinking the same amount.

The physical effects of the former “dependence” now require assessing for one of the above four, earlier mentioned overall groupings (specifically, “pharmacological criteria”).  Finally, what was formerly “dependence” is now subsumed under “substance use disorders,” and diagnosed along the aforementioned spectrum of severity.

Confusing?  Undoubtedly so!  But at least some part of this confusion may be primarily semantic.  While the final verdict remains out on the usefulness of the DSM-5’s changes, there will also be understandable resistance to changing more familiar nomenclature (even if, as claimed by O’Brien and Lembke, it was unsupported scientifically).  Years ago I heard someone say that the history of ideas progresses one funeral at a time!  Maybe it is the “funeral” of the preceding DSM that ultimately points toward progress in the field of addiction recovery.  (Oops…did I just say “addiction”?)

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Andrews, M. (2012, May). APA clarifies Washington Post/Kaiser Health news article on DSM-5′s proposed criteria for substance use disorder.  DSM-5 Facts. Retrieved from http://dsmfacts.org/issue-accuracy/apa-clarifies-washington-postkaiser-health-news-article-on-dsm-5s-proposed-criteria-for-substance-use-disorder/

Lembke, A. (2013, April). DSM-5 gets it right, but… The fix: Addiction and recovery.  Retrieved from http://www.thefix.com/content/dsm-5-spectrum-disorder-risky-drinking8269

O’Brien, C. (2013, April).  Why we rewrote the book on addiction. The fix: Addiction and recovery.  Retrieved from http://www.thefix.com/content/dsm-5-substance-use-disorder-addiction-early-intervention8615

University of Texas Addiction Science Research and Education Center (2013). Changes coming to DSM soon. Retrieved from http://www.utexas.edu/research/asrec/changesdsm.html