This article featured in the September 2017 issue of Substance Dependence Treatment Review
In 2013, the most recent version of the diagnostic manual for mental disorders, the DSM-5, was released. Published by the American Psychiatric Association, the manual is a guidebook for psychiatric diagnosis in the U.S., Australia, and Canada, as well as for some psychiatrists and clinics in Europe. It had been 15 years since the last major revision of the DSM. Reception of the revision was largely positive, though with some warranted criticisms, most notably for changes in terminology. One of these changes included the criteria used to diagnose substance use disorder, aka substance dependence, alcohol disorder, alcohol dependence, also known as alcoholism and drug addiction.
The revisions included combining abuse and dependence criteria into a single category termed substance use disorder which was based upon findings from 200,000 participants in a national study.1 They also included the addition of cravings as a criterion and the removal of legal problems as a criterion. Cannabis and caffeine withdrawal symptoms were also added. The changes were seen as being a solution to overcoming several problems including the need for further studies on issues that lacked enough data to be relevant for clinicians.
Substance Use Disorder Defined
According to the DSM-5, a substance use disorder describes a problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress.2 The term substance use disorder is generalized and the actual substances have been enumerated. It should be noted that the term addiction or dependency is not found anywhere in the DSM-5. This has likely been done to decrease the potential repercussions of CMS coverage, disability, and reimbursement particularly with the Mental Health Parity and Addiction Equity Act.3
How are substance use disorders categorized?
When the categories of substance dependence and substance abuse were replaced with substance use disorder, the DSM-5 also listed the associated symptoms.These are broken down into four major groupings:
- Impaired control
- Social impairment
- Risky use
- Pharmacological criteria (i.e., tolerance)
The new DSM-5 describes a substance use disorder to follow a problematic pattern of use of an intoxicating substance which leads to significant impairment or distress. To be clinically diagnosed, the disorder should be manifested by at least two of the following with a 12 month period:
- The substance is regularly taken in larger amounts over a longer period of time than was ever intended
- There is a persistent desire to use or unsuccessful efforts to cut down, control, or quit the substance
- A large amount of time is spent seeking out or using the substance, or recovering from its effects
- The user experiences cravings or a strong urge to use
- Recurring use of the substance results in the inability to fulfill important obligations at home, work, or school
- Despite interpersonal or social problems, the individual continues to use
- Social, occupational, or recreational activities are discontinued or reduced because of the substance
- Use of the substance continues despite any knowledge of the physical or psychological effects caused or exacerbated by using
- A tolerance has developed (see definition)
- The need for increased amounts of the substance to achieve the desired effect
- A diminished effect of the substance results when the same amount is used
- A withdrawal manifests when the individual is not using (see definition)
- The characteristic withdrawal symptom as defined by the DSM-5 for the specific substance
- The substance, or another related one, is taken to alleviate withdrawal symptoms
According to the DSM-5 manual: two to three criteria are required to be diagnosed with a mild substance disorder; four to five criteria is moderate; and six to seven criteria, severe.1 The manual lists separately symptoms of an opioid disorder which are similar to the symptoms listed above.
Types of Substance Related Disorders in the DMS-5 Manual
The DSM-5 acknowledges nine different types of substances related to substance use, including:
- Sedatives, Hypnotics, or Anxiolytics
**Although caffeine is listed in the manual, the APA does not consider it to apply to a substance use disorder.
Pathological Behaviors of a Substance Disorder
Regardless of the substance, to be diagnosed with a substance use disorder, a pathological set of behaviors must be prevalent and related to the use. These behaviors are:
Impaired control can be identified in different ways. For it to be an evidentiary behavior of a substance use disorder, the individual may:
- Use for longer periods of time, or use more than what was intended
- Wish to reduce their intake, but be unable to do so
- Spend excessive amounts of time getting, using, and recovering from the substance
- Experience cravings that distract him or her from anything else
Social impairment is a consequence caused by repeated use of the substance. When being diagnosed with the disorder, a clinician might look for symptoms that include:
- An increase in problems with obligations related to family, work, or school
- Losing friendships or relationships, or arguing with family and friends about the continued use
- Losing interest in once meaningful social or recreational activities
This criterion is the failure to refrain from using even though it might be causing physical or psychological harm. The individual may:
- Repeatedly use the substance during situations that are physically dangerous (i.e driving while under the influence)
- Use even though it is causing or exacerbating psychological or physical problems
These are tolerance and withdrawal.Oftentimes these symptoms are indicators of an advanced disorder which usually requires clinical assistance either in an inpatient or outpatient setting.
This specific criterion refers to the bodies’ adjustment attempts to adapt to the regular use of a substance. Clinically known as maintaining a homeostatic balance, a tolerance happens when an individual needs to increase the amount of the substance in order the get the same effect which they are seeking. The desired effect is not necessarily the high, but could also be a precautionary measure to avoid the symptoms of a withdrawal. A tolerance varies from person to person as well as the actual substance and dosage.
A withdrawal is the body’s response to a discontinuation of the drug after a tolerance has developed. The resulting symptoms are specific to the substance, but are typically unpleasant, and sometimes life threatening. If an individual is experiencing the symptoms of a withdrawal during an evaluation for diagnosing a substance use disorder, they will be diagnosed with substance use and substance withdrawal in order to effectively address the medical situation.
According to the DSM-5 Manual, if any of the aforementioned symptoms and behaviors are present, there may be diagnostic criteria for a substance use disorder.
DSM-5 and Co-Occurring Disorders
The DSM-5 notes co-occurring and substance induced mental disorders. Unlike the DSM-IV where the mental disorders were categorized as being primary or substance induced, the DSM-5 has reversed this standardization criteria.4 Now the manual discusses a flexible approach that lacks the duration requirements for specific symptoms and includes an addition of treatment approaches to specific disorders. The DSM-5 criteria for a co-occurring mental health disorder is as follows:
- Criterion A: The disorder is representative of clinically significant symptoms of a known mental health disorder.
- Criterion B: Evidence gathered from a physical exam, lab testing, or a medical history show one or both of the following:
- The disorder developed during substance intoxication, or within one month of using. a withdrawal, or while taking a medication.
- The substance has the potential to produce a mental disorder.
- Criterion C: The disorder cannot be better explained by a mental health disorder that is not substance induced. Identifying an independent disorder might be shown through evidence that:
-Suggests the disorder preceded the onset of intoxication, withdrawal, or exposure to using
-A full mental disorder was prevalent for at least one month after the cessation of intoxication or acute withdrawal.
- The DSM-5's criterion C does not apply to any substance-induced neurocognitive disorders such as dementia or delusions, or hallucinogen persisting perception disorders, that exceed cessation, withdrawal, or intoxication.5
- Criterion D: The mental disorder does not occur only during delirium.
- Criterion E: The disorder causes significant impediment in important areas of functioning such as home, school, or work life.
DSM-5 in European Clinics
The DSM-5 is clinically binding for medical professionals in the U.S., Australia, and a handful of other countries. In Europe, the legally binding classification is the ICD-10, or the International Classification of Diseases 10.6 The later is the official document used by the WHO and classifies all pathologies, not only mental illnesses. Although the DSM-5 has no legal grounds in Europe, there is a major interest amongst health professionals, primarily because it continues to attract new generations of psychiatrists and psychologists around the world.
The DSM-5 is criticized for its monolithic diagnostic approach, anda seeming lack of interest in the social or psychological context of mental illnesses, in favor of scientific biological and behavioral factors. This is noticeable in the described symptoms of a substance use disorder. Unfortunately this can lead to discounting or overlooking psychotherapeutic and social reintegration practices which are effective in treatment. The DSM-5 promotes visual observation and standardized interviews using different behaviors grouped together and coined a 'disorder'. The treatment approach has most certainly had a role in the fragmentation of psychiatry, which now includes specialized centers rather than a therapeutic alliance that has the potential to treat the whole person as well as the long term illness.
Proponents of the ICD-10 encourage EU clinicians to boycott the DSM-5 and its unilateral thinking of psychology. Alternative systems of classifications, in order to preserve homogeneity and avoid a stigmatization of labels is also promoted by critics. Currently the ICD 11 is being drafted. Health professionals are hoping that the mistakes and methodology of the DSM-5 will provide cautionary guidance to its European counterpart.
This article featured in the September 2017 issue of Substance Dependence Treatment Review