As clinical professionals everywhere welcome the fifth installment of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5), it is those of us who have our roots anchored in addiction medicine and behavioral health that find ourselves debating the new direction. While this isn’t the time or place to identify and discuss all the new developments the DSM-5 has to offer, or their relevance, there are some addiction-related changes and implications that certainly need to be acknowledged. All changes impact addiction and behavioral professionals to some degree so while the following is an overview, all experts would benefit from a thorough independent review sooner than later.
One of the more profound changes to the DSM-5 is the elimination of the disease categories for substance abuse and dependence. These categories have been replaced in the DSM-5 with a new addictions and related disorders category; one of several new changes that will impact the diagnosis of behavioral-health issues and depending on your job title, will change the way they are interpreted by insurance companies.
The APA officially stated, “Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system.”
Charles O’Brien, M.D., Ph.D., chair of the APA’s DSM Substance-Related Disorders Work Group went on to say, “The term dependence is misleading, because people confuse it with addiction, when in fact the tolerance and withdrawal patients experience are very normal responses to prescribed medications that affect the central nervous system.” He continued, “On the other hand, addiction is compulsive drug-seeking behavior, which is quite different. We hope that this new classification will help end this wide-spread misunderstanding.”
While previous versions of the DSM placed use, abuse, and dependence on a neatly ascending continuum that an individual can bounce around depending upon his or her current conditions, those of us deeply familiar with addictive disease knew that not only was there not a smooth continuum, but individuals are not able to bounce around the continuum. With the DSM-5, addictive disease has not changed, but abuse is now gone and dependence has returned to a place where it will refer to the development of tolerance and withdrawal as mentioned by Dr. O’Brien. While the DSM-5 has taken a much more dramatic position on the topic of abuse vs. dependence, there is always room for improvement. It seems as though the DSM-5 does not speak to addiction as much as it digs deeper into the markers associated with addictive illnesses. It will always be a question of severity and the DSM-5 makes an earnest attempt to address the best way to mark critical levels of severity, but the onus is on the clinician to use all the tools provided by training and experience. As we’ve learned, when you say substance abuser, in essence, the patient is being blamed for their illness, which is an evolutionary step for proper communication and treatment. Eliminating abuse is a reflection of evolving communication, understanding, and science.
The new category for addictive diseases would include a variety of substance-use disorders broken down by drug type, such as cannabis-use disorder and alcohol-use disorder. Diagnostic criteria for these disorders in DSM-V would remain very similar to those found in the current DSM-IV, according to the APA. However, the symptom of drug craving would be added to the criteria, while a symptom that referred to problems with law enforcement would be eliminated. Legal issues were essentially dropped from the criteria of substance-use disorders based on poor clinical correlation; yet another great example of how the DSM maintains a balanced connection to science and observational conclusion. Another important factor to note is that according to the APA, “gambling disorder is the only addictive disorder included in DSM-5 as a diagnosable condition.” With a behavioral addiction like Gambling disorder, it can be included based on the scientific data to support its inclusion.
Also new to the DSM-V are diagnostic criteria for cannabis withdrawal, which the APA says is caused by “cessation of cannabis use that has been heavy and prolonged”; results in “clinically significant distress or impairment in social, occupational, or other important areas of functioning”; and is characterized by at least three of these symptoms: irritability, anger or aggression; nervousness or anxiety; sleep difficulties (insomnia); decreased appetite or weight loss; restlessness; depressed mood; and/or physical symptoms such as stomach pain, shakiness or tremors, sweating, fever, chills, and headache.
Another new development is the fact that the DSM-5 now uses Alcohol Use Disorder and like addictions with severity on a spectrum with mild, moderate and severe qualifiers. There are 11 possible symptoms of the “use disorder,” of which two are necessary to achieve a mild specifier, four for moderate, and six for severe. “Alcohol use disorder is defined by a cluster of behavioral and physical symptoms,” the authors of DSM-5 state. This system is certainly a step in the right direction; however, once again, it is ultimately up to the clinical professional to assess variables such as quantity and frequency of consumption when identifying a patient’s location on the spectrum. This is where experience is key and the ability to read the entire scope of a patient’s experience will spell the difference between proper and improper treatment protocol.
The DSM-5 also introduces a behavioral addiction category that makes the process addiction waters a bit less murky, but not much. O’Brien explained the work group’s reasoning behind the new category of behavioral addiction. “There is substantive research that supports the position that pathological gambling and substance use disorders are very similar in the way they affect the brain and neurological reward system,” he said. “Both are related to poor impulse control and the brain’s system of reward and aggression.” Again, a step in the right direction; however, there is more clarification needed in future editions.
Overall, the DSM-5 has taken some huge steps in the right direction by incorporating the most current research and eliminated some of the clutter along the way. The APA is listening to the community and gradually making adjustments, which are reflected in the fifth edition; however, the text itself will never serve the clinical community the way pure experience and collaborative research do. The DSM is a lighthouse that steadfastly influences our general direction but can never stand as a constant for all patients. Every case is indeed unique and a true expert will consider all variables when determining the best course of action. That being said, the new guidelines will affect certain billing protocols and diagnosis. Like each knew edition before this one, we must respect the ever-evolving DSM and learn how to work with it so the best interest of every patient is served. It is important for us all to remember that even though many of the DSM’s ever-evolving categories are rooted in peer-reviewed research, many aren’t, which means that the APA is doing an excellent job balancing research and changing attitudes regarding addiction. While countless medical experts would agree that science and scientific research rest at the core of the evolving DSM approach to defining and treating addiction, it is my scientific opinion that the most significant categorical shifts related to addiction is the result of neuroscience, not political science. We have so much to learn from one another; however, there is no substitute for science and evidence-based protocol.