DSM-5 Draft Proposes Major Changes

The trusty Diagnostic and Statistical Manual of Mental Disorders (4th Edition, Text Revision)--better known as the DSM-IV-TR--is undergoing its first major revision in over a decade. The changes are primarily intended to ensure that the DSM reflects the most current scientific research, as well as correct problems that clinicians have experienced with the current diagnoses.

Most significantly for addiction professionals, the DSM-5 draft combines "substance abuse" and "substance dependence" into a single category, "substance-use disorder." The new substance-use disorder diagnosis can be met (with a "moderate" severity designation) with 2-3 positive criteria; if 4 or more criteria are positive, the disorder is said to be "severe." There are 11 criteria listed in total; all 7 of the old "dependence" criteria are carried over, plus 3 of the 4 old "abuse" criteria (more on that in a moment), plus a new criterion, "Craving or a strong desire or urge to use a specific substance."

This photo used with a Creative Commons license from Flickr user myguerrilla.

The former abuse criteria that was dropped is "Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)." The DSM-5 drafters justify its removal basically by arguing that it doesn't do anything--it is rarely used, according to their studies, and people who have recurrent legal problems as a result of their drug use nearly always meet other criteria (like drug use in physically hazardous situations such as driving, failure to fulfill major role obligations, or recurrent social or interpersonal problems).

On the merging of abuse and dependence, the DSM writers say that the most common way for "abuse" to be diagnosed was under the hazardous use criterion, specifically for drunk driving. The DSM writers question whether--though dangerous and unwise--that symptom alone justifies a psychiatric diagnosis. On the other hand, there were reports of "diagnostic orphans" who met 2 criteria for dependence (3 was required for a diagnosis) but none for abuse. So by creating a single category requiring 2 criteria to be met, they try to eliminate both premature diagnoses and those caught between dependence and abuse.

There's a sense in which the new "moderate" and "severe" severity specifiers take the place of abuse and dependence. The new criteria also allow for a specification of "with (or without) physiological dependence," depending on whether there is withdrawal or tolerance.

Many addiction professionals who deal with insurance plans and UR standards have expressed support for this change, arguing that they will make it easier to qualify for a diagnosis and then for the treatment program to provide appropriate care. Furthermore, it emphasizes that drug-related disorders occur on a single continuum rather than in two totally independent dimensions (abuse and dependence).

Others are more concerned, arguing that abuse should be thought of as a behavior and dependence as a disease, and by combining them it becomes easier for payers to deny clinically appropriate care. Even worse, it might signal a shift to the idea that any professional with "behavioral" health training would be eligible.

What do you think of collapsing "abuse" and "dependence" into a single diagnosis? Is it one step forward, or one step back?

Please leave comments, but you're also welcome to share your ideas with the DSM-5 writers themselves. You can leave comments on their website, but the deadline is Tuesday, April 20, so act quickly!