DSM-5 Diagnostic Changes Substance Abuse

The American Psychiatric Association has released the draft version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This is a work that has been ten years in the making and will replace DSM-IV-TR as the official diagnostic manual for mental health. The DSM-5 is still a work in progress. The draft report has been released to allow for public review and comment before 3 phases of field trials will take place in real world settings before the final version is published in 2013. Anyone can review the document at www.dsm5.org and comment before April 20th. There are a number of proposed revisions which I will discuss here over the next few days but today just want to focus on the proposed changes in substance abuse disorders.

The DSM-5 proposes the elimination of the categories of substance abuse and substance dependence replaced by the category of addictions and related disorders. There will be no differentiation between abuse and dependence. Instead all will be referred to as substance use disorders with varying levels of severity. This has been proposed to try to eliminate the confusion between physiologic dependence upon alcohol or a drug and addiction per se as well as to address the problem with our current categories in which the psychosocial consequences of abuse are given more weight than in the dependence diagnosis itself.

A Substance-Use Disorder will be defined as a clinically significant impairment or distress as manifested by 2 (or more) of the following, occurring within a 12-month period:

Failure to fulfill major role obligations at work, school, or home

Recurrent use of substances in situations in which it is physically hazardous

Continued use despite persistent social and interpersonal problems caused by the
substance

Tolerance - diminished effect with the continued use of the same amount of the substance

Withdrawal syndrome

Taken in larger amounts or over a longer period than was intended

Persistent desire or unsuccessful attempts to cut down on the substance use

A great deal of time spent in activities necessary to obtain the substance

Giving up important occupational or recreational activities

Continued use despite knowledge of having a persistent physical or psychological problem caused or exacerbated by the substance

Craving or a strong desire or urge to use a specific substance

Two to three criteria positive will be referred to as moderate severity with four or more referred to as severe. There will be a separate specifier for with or without physiological dependence.

The proposed changes are also designed to take into account that abuse and dependence are not necessarily two separate categories but represent different severity points on a continuous spectrum of problems. I think these proposed changes represents more the real world than our old categories but will lead to some disagreement about how to define the term alcoholic or addict which are not diagnostic terms per se but are commonly used in the treatment and recovery field. I invite any comments on what you think about these proposed changes.

Thought for the day

Are my actions likely to enhance or detract from an other's well being today?