The latest DSM-5 tweaks are game changers

June 8, 2012
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Gambling gets highlighted in one of the latest changes
The latest DSM-5 tweaks are game changers
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 It only took 55 years. A small group of compulsive gamblers (probably members of AA), recognizing that they suffered from an addiction much as do alcoholics, founded Gamblers Anonymous  in 1957, using AA principles as a template. Since then, the addictions field has debated about the nature of gambling and other so-called “process addictions.” But in the grim, gray Diagnostic and Statistical Manual of Mental Disorders, gambling remained in the shadows as an “impulse-control disorder not elsewhere classified.”

The process of developing the latest edition of the diagnostic manual, the DSM-5 (no more Roman numerals), has gone public like no previous revisions, with various constituencies challenging the proposals one after another as they come up on the dsm5.org website. Thus far, arguments over the proposed DSM-5 addictions category have focused on the elimination of the duality of “substance abuse” and “substance dependence,” with the substitute of Substance Abuse and Addictive Disorders, which can present as a mild, moderate or severe variety in use of alcohol, cocaine and so forth. Many addiction professionals have lamented the elimination of a category that they see as a straightforward acknowledgement of dependency on drugs.

It therefore came as a surprise on May 1 when the DSM-5 task force on Addiction and Related Disorders (formerly Substance-Related Disorders) proposed to add gambling under their umbrella, right next to opiates, alcohol and cocaine. The nine proposed diagnostic criteria for a gambling disorder are similar to those for the other addictive disorders, with the three levels of severity that are also found in all of the DSM-5 substance use disorders. In general, there is a lower threshold for diagnosing gambling disorders than there had been under the DSM-IV-TR, and thankfully there is a rule-out of diagnosing a gambling disorder if the patient is bipolar.

Located in the Recommended for Further Study section, which warns of possible new diagnoses in subsequent editions, is another behavioral or process addiction: that of Internet use disorder. Oddly, it focuses exclusively on Internet gaming behavior. This is admittedly an area of concern, but other Internet problems such as compulsive downloading of pornography are not in the mix.

Change regarding symptoms

With the furor over the deletion of abuse vs. dependence, another DSM-5 change in the addictions realm has gone under the radar. This involves expansion of the list of symptoms for substance abuse disorders to 11 (it had been 4 for abuse and 7 for dependence), and increased ease in getting diagnosed. For example, one of the 2 out of 11 symptoms that can garner a diagnosis is tolerance. Now, if you are a drinker of almost any sort, or an individual who is prescribed a sleep medication, you will develop some tolerance. One could even say it is a normal phenomenon, and not necessarily a criterion for diagnosing a disorder if tolerance remains on a mild level.

Another symptom is “hazardous use.” Again, hundreds of thousands of college students have fallen at a frat party and countless people might have driven under the influence one time. Certainly, these behaviors can result in tragedy and should not be minimized, but the jury is out on whether this should be the sole basis for generating an abuse diagnosis.

To some, such as Thomas Babor, PhD, a famous psychiatric epidemiologist and editor of the journal Addiction, the changes in DSM criteria will have the effect of artificially inflating the number of diagnoses, thus burdening the public health system by adding millions to the patient roster. To many others, however, these changes increase opportunities for early intervention and for reducing both harm to individuals and costs to society stemming from health, criminal justice and social services accessed by those who misuse psychoactive chemicals.

A pragmatic middle course would be for vigilance on the part of single state agencies responsible for monitoring the function of addiction treatment centers, as well as from grant providers, other regulatory bodies, and third-party payers, over any attempts to troll for a “checkbook diagnosis” (similar to the concept of “diagnostic creep”) to increase client population and revenue.

Peter L. Myers, PhD, is co-author of Becoming an Addictions Counselor: A Comprehensive Text. He is Past President of the International Coalition for Addiction Studies Education (INCASE; www.incase.org) and is Editor of the Journal of Ethnicity in Substance Abuse. His e-mail address is nyprof@gmail.com.

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Comments

Change for the Good? I think not! by Harold Smith, LPC, CADC

I come from the school that teaches "if something works, then don't fix it". The distinction between Abuse and Dependence under the DSM-IV or the DSM-IV-TR works because it differentiates between behavioral problems and physiological problems. The criteria for Abuse under the current diagnostic manual characterizes behavioral problems. If the therapist is able to help the patient make the connection between their substance use and the problems it is causing, then change without any further intervention can occur. The criteria for Dependence under the current diagnostic manual characterizes a combination of physiological problems (loss of control, increased tolerance, withdrawal symptoms, physiological of psychological problems caused or exacerbated by) with behavioral problems which is often chronic and requires long term maintenance. With the proposed changes in the DSM-5, there is no longer that distinction. Everyone who is assessed for an alcohol or other substance use problem and meets 2 or more of the proposed criteria, will more or less be labeled as "alcoholics or addicts".
Not to change the subject, but the inclusion of gambling disorder under the umbrella of Addiction Disorders is absurd. Yes the disease of compulsion comes in many forms (gambling, sex, over-eating, workaholic, etc.)and yes, alcohol and drug addiction, which is perhaps is the worst form but do we really need to label every behavior that is unhealthy as an addiction. If so, why stop at gambling disorder? Thanks for letting me share.

DSM 5 and gambling

Great article which points out the "generalist creep" as much as it does the diagnostic creep that seeks to include most any compulsive behavior under the title "addiction." I can only hope that state agencies will pay attention to this in their oversight of programs that provide care to those with substance use disorders.
Joan Standora

DSM 5 and gambling

Great article which points out the "generalist creep" as much as it does the diagnostic creep that seeks to include most any compulsive behavior under the title "addiction." I can only hope that state agencies will pay attention to this in their oversight of programs that provide care to those with substance use disorders.
Joan Standora

Continuity of Symptoms

Many of us prefer the world and diagnoses to be clear and straight forward. Even when we have numerical objective data to base our opinions on, such as it is with blood pressure levels, it can become problematic to define "hypertension" as a disease. It is for the most part a "risk" except largely in severe cases where immediate and irreversible harm is imminent.

I think the continuum of addiction is quite similar to the continuum of blood pressure. With blood pressure concerns we make the diagnosis primarily based on the ability to demonstrate improved prognoses with therapy or in unusual circumstances when the physiological symptoms are disabling. The fact is the higher the blood pressure the higher the risk. The question is when to make the diagnosis? A second question is when to initiate therapy, and thirdly under what circumstances can we predict improved outcomes with therapy/interventions.

Many therapist in the addiction field have limited education or training to appreciate complex, multi-faceted conditions. That there are those who want it black and white, or at least objective enough to further research makes sense to me.

Let's say it the way it is ...these criteria are at the very best our best guesses and until objective and verifiable data is present I suspect little progress in the debates and feelings over addiction deffinitions. And even then? How long did it take to have the average individual accept that the world was round rather than flat when the scientific evidence clearly demonstrated such?

I think to increase the symptomatology variables associated with addiction makes sense given the variety of ways individuals with the disease manifest the disease and as with most any disease process variable severity is the rule rather than exception. The question is how many of the variables need to be present in the context of substance or processes to assure that prognoses are predictable or treatment has salutory effects? There is no good reason to make a diagnosis if it does not promote better outcomes, or at the very least a more accurate prognosis. As long as the criteria allow us to assure better outcomes or make a prognosis I am in favor. I have to assume that the panel of DSM 5 experts took all of this into account. If not? What did they use to base their opinions on important criteria and the number needed to make the diagnosis? Hopefully the literature and their clinical experience was the basis for determining which symptoms are most important in predicting prognosis or the benefits of treatment.

basis for new criteria

It would seem that the DSM5 panels do use research and clinical experience, with a big dose of political jousting and plain resistance to change. For example, they almost did away with catatonic schizophrenia subtype in DSMIV-TR but left it after all out of stodginess , until DSM5, where it is finally eliminated. The personality disorders are a hotch-potch of categorical and dimensional approaches, stuck between paradigms.

Peter L. Myers, Ph.D.