Wednesday, February 10, 2010

DSM-V: How Does It Stack Up?

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?


  1. Now that I've read the proposed changes, I agree that "abuse" and "dependence" should be abandoned in favor of "substance use disorders" along with the proposed ranking system for severity. (Unfortunately, it was mistakenly reported in the media today that the new terminology would be "addiction and related disorders", which made me fear that those would less-severe problems would not seek help because of the "addiction" label.) I recall thinking, while writing Sober for Good, that the current criteria for "abuse" are generally "worse" than those for "dependence". So the new system makes sense. Now, if we can develop the kind of treatment system for those with substance use disorders at the less-severe end of the spectrum that Dr. Willenbring has been talking about...

  2. Addendum:
    A new study by John Kelly and fellow MA General Hospital researchers suggests that the new terminology will also lower punitive attitudes that some health care professionals may have toward people with substance use problems, thus having the potential to lower barriers that keep people from seeking help. However, in doing my research for a new book on addiction treatment for Viking Penguin, I find that a lot of labeling still goes on in addiction treatment (e.g.,in group treatment, clients repeatedly introducing themselves as "addicts" or "alcoholics" each time they speak, within a single session.) I am gathering information about how this impacts treatment-seeking and outcome of treatment and welcome feedback.