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Diagnostic uncertainty

September 1, 2010
by Alison Knopf
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Changes in the proposed DSM-5 worry addiction counselors, research professionals

When the American Psychiatric Association (APA) announced proposed revisions in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) last spring, one change to the behavioral health field's guide to diagnosis-the elimination of substance abuse and dependence categories-galvanized the addiction field.

Some professionals expressed an immediate concern that people engaging in risky behavior no longer would be eligible for a low-level “abuse” diagnosis, and that there would be widespread confusion about how to use the new measures. Many were happy to see that the abuse and dependence categories would be disappearing, but remained concerned about how the new category of “substance use disorders” would be applied in everyday practice.

The new category of “substance use disorders” would replace the two abuse and dependence categories. This category comprises two subsets: moderate (2 to 3 criteria) and severe (4 or more criteria); there are 11 criteria in all. While the elimination of the abuse and dependence categories is acceptable to many, the way diagnoses would be arrived at is not.

NAADAC, The Association for Addiction Professionals, in its official comments on the DSM-5 proposals, states that the new substance use disorders category “is so broad that the diagnosis would be of little assistance in determining the type or level of care that would be most appropriate.”

As an example of risky behavior that it says would not fall under any official diagnosis under the DSM-5, NAADAC cites the “adolescent client who fails to fulfill role obligations at school and has arguments with his family about his alcohol use.” This client might need education and a brief intervention, but not the extended treatment and recovery support needed by “someone who experiences cravings, tolerance and is unable to reduce their substance use.” Yet, under the DSM-5, both of these individuals could receive the same diagnosis, and subsequently the same treatment, according to NAADAC.

A diagnosis is beneficial in determining whether someone needs treatment, agrees Marvin D. Seppala, MD, chief medical officer at the Hazelden treatment organization in Minnesota. But it doesn't dictate the level of treatment someone needs. Hazelden uses American Society of Addiction Medicine (ASAM) patient placement criteria to determine the level of treatment, and the DSM revisions won't change that, Seppala says.

Still, Seppala agrees that the proposed DSM changes could leave professionals who treat adolescents in a quandary.

“If I see an adolescent just starting down this path, but I don't really see the need for treatment, I might try some interventions and see what happens,” he says. “Sometimes there is a child, let's say a 16-year-old from a conservative religious family, and the child tried marijuana. That family is going to be extremely upset, and you need to have some sort of resource for them.” That child does not have a substance use disorder, Seppala says. “But the family needs an option, like Hazelden's Teen Intervene, for cases in which there is no evidence of a substance use disorder.”

The first phase of field trials for the long-awaited DSM-5 began in May and will continue until March 2011. Revisions will be made concurrently, and revised criteria will be posted online late next spring. The final draft of the manual is expected to be prepared during the first half of 2012, with publication scheduled for May 2013.

Old categories confusing

Ray Daugherty, president of the Lexington, Ky.-based Prevention Research Institute and co-developer of the Lifestyle Risk Reduction Model to address substance impairment and other health problems, does not object to eliminating the dependence and abuse categories in the DSM. He says these designations have been confusing to counselors.

“Many counselors think dependence is the diagnosis for alcoholism, because that's what they've been taught,” Daugherty explains. However, he notes that data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) show that one-third of people with dependence are in full sustained remission (no symptoms for at least 12 months), although they are still drinking. “And since the majority of our counselors work from a disease model, the assumption became that a DSM dependence diagnosis was intended to diagnose an irreversible disease state,” Daugherty says.

Daugherty also is pleased that the “abuse” category looks to be gone from the manual. “Abuse is not a category that comes before dependence,” says Daugherty, although the DSM-IV, by allowing only one or the other diagnosis, presumes that. “In fact, if you look at NESARC, you can build a case that the most severely affected people are the people who qualify for an abuse and dependence diagnosis, although that's not allowed in DSM-IV.”

Carlo C. DiClemente, PhD, professor of psychology at the University of Maryland, Baltimore County, agrees that abuse/dependence should be changed to “substance use disorders.” He says, “It's a good idea to rearrange the nomenclature, because the abuse and dependence categories have been confusing. The distinction has been difficult to establish-some people thought there was a continuum from abuse to dependence, and there isn't.”

DiClemente and Daugherty, who work together on a project for the Prevention Research Institute, also filed official comments on DSM-5.

But how to measure whether someone has a “substance use disorder” is of greater concern, according to DiClemente-especially for researchers. Typically, it is the DSM diagnosis that drives the selection of study subjects. If researchers are going to be testing treatment strategies on someone who meets a certain diagnosis, they need to know what that diagnosis means, DiClemente says.