The American Psychiatric Association has come out with the proposed fifth revision of its Diagnostic and Statistical Manual (DSM-V). The biggest news is the elimination of the two-category diagnoses of abuse and dependence. They are proposed to be folded into one diagnosis, substance use disorder, with accompanying dimensional criteria estimating severity, lethality and so forth. Is this an advance? In my view, yes. Unequivocally yes. Here's why: the abuse and dependence category have never worked the way they were intended and the have added to a lot of confusion about diagnosis. Newer research has demonstrated that substance use and its consequences exist along a single continuum. What were criteria for abuse in DSM-IV are mostly found in late-stage severe addicts. Things like role failure (inability to perform as a parent, student, employee, professional) and legal problems. DSM-IV Dependence criteria, on the other hand are among the first symptoms experience, and the most common symptoms among those with milder forms of the disorder. Things like going over self-imposed limits, a persistent desire to quit or cut down, and continuing to use in spite of physical or psychological symptoms caused by substance use, like insomnia, dyspepsia or hangover. The most common form of alcohol dependence is characterized by mostly the "internal" symptoms experienced as impaired control, in the absence of serious life disruption. Unfortunately, we keep focusing on the most severe chronic or recurrent forms of the disorder, rather than the much large group of people with milder disorders that usually remit without recurrence.
So I think the overall direction is positive, that is, a single substance use disorder diagnosis that can range from mild to moderate to severe. What do you think?