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DSM-5 Draft Proposes Major Changes

April 16, 2010
by Daniel Guarnera
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The trusty Diagnostic and Statistical Manual of Mental Disorders (4th Edition, Text Revision)--better known as the DSM-IV-TR--is undergoing its first major revision in over a decade. The changes are primarily intended to ensure that the DSM reflects the most current scientific research, as well as correct problems that clinicians have experienced with the current diagnoses.

Most significantly for addiction professionals, the DSM-5 draft combines "substance abuse" and "substance dependence" into a single category, "substance-use disorder." The new substance-use disorder diagnosis can be met (with a "moderate" severity designation) with 2-3 positive criteria; if 4 or more criteria are positive, the disorder is said to be "severe." There are 11 criteria listed in total; all 7 of the old "dependence" criteria are carried over, plus 3 of the 4 old "abuse" criteria (more on that in a moment), plus a new criterion, "Craving or a strong desire or urge to use a specific substance."




This photo used with a Creative Commons license from Flickr user myguerrilla.




The former abuse criteria that was dropped is "Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)." The DSM-5 drafters justify its removal basically by arguing that it doesn't do anything--it is rarely used, according to their studies, and people who have recurrent legal problems as a result of their drug use nearly always meet other criteria (like drug use in physically hazardous situations such as driving, failure to fulfill major role obligations, or recurrent social or interpersonal problems).




On the merging of abuse and dependence, the DSM writers say that the most common way for "abuse" to be diagnosed was under the hazardous use criterion, specifically for drunk driving. The DSM writers question whether--though dangerous and unwise--that symptom alone justifies a psychiatric diagnosis. On the other hand, there were reports of "diagnostic orphans" who met 2 criteria for dependence (3 was required for a diagnosis) but none for abuse. So by creating a single category requiring 2 criteria to be met, they try to eliminate both premature diagnoses and those caught between dependence and abuse.




There's a sense in which the new "moderate" and "severe" severity specifiers take the place of abuse and dependence. The new criteria also allow for a specification of "with (or without) physiological dependence," depending on whether there is withdrawal or tolerance.




Many addiction professionals who deal with insurance plans and UR standards have expressed support for this change, arguing that they will make it easier to qualify for a diagnosis and then for the treatment program to provide appropriate care. Furthermore, it emphasizes that drug-related disorders occur on a single continuum rather than in two totally independent dimensions (abuse and dependence).

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The condensation of abuse & dependence into substance use disorder speaks to a continuum. Expermental use may lead to abuse and continuation on to dependence. As there is no demarcation line to differentiate but a neurobioligical change, this all-encompassing terminology with severity indicators denotes the actual continuum succinctly.
Carey Wainwright, NYC

Some abuse is just learned behavior. I would like to see the "abuse" level diagnoses expanded to assess for the existence of the mental and emotional impairment that is seen with the disease, even in its earlier stages, such as the existence of obsession or a denial system. Has the client made consistent life choices to support their use over other qualities of life? Does the client demonstrate a mental ability to face their behavior and its consequences, or is there persistent impaired judgment including minimization, blame, and rationalization?

Mavis Humes Baird, NYC

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Daniel Guarnera

Daniel Guarnera is the Director of Government Relations for NAADAC, The Association for...