Another major change is the elimination of the “substance dependence” and “substance abuse” diagnoses. Instead, there is a determination of severity. The seven criteria for dependence and the four criteria for abuse have been collapsed into a total of eleven criteria. The criterion for the previous abuse diagnosis of recurrent substance-related legal problems has been eliminated and new criterion of craving the substance has been added, still with a total of eleven criteria. The following show how the determination of severity is made:
An examination of the DSM-5’s elimination of the legal problems criterion from the old abuse diagnosis presents a mixed analysis. The reasons supporting the elimination include the fact that people of color, those who are poorly educated, and those of lower socioeconomic status are overrepresented on the criminal justice system. There are geographic inequalities too; for example, recreational use of marijuana is legal in Colorado, but crossing the state line into Utah with one ounce or less opens the person to a misdemeanor charge with the potential of six months incarceration and/or a $1,000 fine. In the past, individuals with a single DUI and no other indicators of abuse have been incorrectly diagnosed with abuse. In addition, the criterion of legal problems carries with it little diagnostic weight.
On the other hand, there are concerns about the removal of the legal problems criterion. For some individuals, legal problems may serve a Screening, Brief Intervention, and Referral to Treatment (SBIRT) function of intervening earlier in the progression of a substance use problem. Legal problems often serve as the impetus for treatment. As legal problems are removed, if the individual does not meet at least two other criteria, thereby not generating a substance use diagnosis, what will happen to drug court clients for whom treatment would normally be reimbursed by insurance?
Other substance use disorder changes in the DSM-5 are the change from nicotine disorder to tobacco disorder, inclusion of caffeine withdrawal for the first time—the DSM-IV had a diagnosis of “caffeine intoxication” but no withdrawal—and cannabis withdrawal. Cannabis withdrawal is particularly important because some of the symptoms can be long-lasting and misinterpreted as willful noncompliance with treatment, which may result in an inappropriate decision by staff to terminate treatment administratively.
An interesting factoid is that cocaine use disorder appears nowhere in the index under cocaine and it doesn’t appear in the index in the list of different substance use disorders. However, it does appear in the body of the DSM in a section titled “Stimulant-Related Disorders.”
The term “addiction” is used for the first time in the history of the DSM in the section titled “Substance-Related and Addictive Disorders” and refers to gambling. The diagnosis of “pathological gambling” in the DSM-IV—commonly referred to as “compulsive gambling”—and listed as an impulse control disorder, is now moved to the Substance-Related and Addictive Disorders section and is named “gambling disorder.” It might be useful for counselors to view the diagnostic criteria for gambling disorder and see how closely they mirror the criteria for substance use disorders.
The specifier for “with physiological dependence” has been eliminated, as well as the one for “polysubstance dependence.” The specifier of “sustained partial remission”—meaning the full criteria for dependence has not been met for twelve months or longer, but one or more of the criteria for dependence or abuse has been met—has been replaced with “in early remission,” meaning that no criteria met for at least three months but less than twelve months with the exception of craving. “Sustained partial remission” and “early sustained remission” have been eliminated completely.
Under the DSM-IV, a client could be in early partial remission, which refers to not meeting full criteria for at least one month but less than twelve months, but the individual could meet one or more of the abuse or dependence criteria. Many counselors had great difficulty with the suggestion that a client could still be using and yet be in remission. Sustained full remission—no criteria met at any time during a period of twelve months or longer—has been replaced with sustained remission, which means that no criteria was met at any time during a period of twelve months or longer with the exception of craving. The specifier “on agonist therapy” has been eliminated but “in a controlled environment” remains.
I previously mentioned the concept of weight in determining diagnostic criteria. Think of criterion weight as the influence or impact of that specific criterion in determining the diagnosis. The assumption in both the DSM-IV and DSM-5 is that all of the criteria carry equal weight, resulting in diagnoses being made by simply adding up the number of criteria met.I of fact
In point of fact this is not so. Criteria most likely to be associated with the severe categories of a substance use disorder include: wanting to cut down or control use but being unable to do so; withdrawal; failure to fulfill major role obligations; important social, occupational, or recreational activities are given up or reduced because of the substance use; and compulsion, when the substance is taken in larger amounts or over a longer period of time than was intended. These are referred to as the “Big Five” and this is the pattern that most addiction counselors associate with addiction.
It appears that those in the mild designation and who meet none of the “Big Five” may be able to benefit from harm reduction or moderation management strategies. Think of the DUI offender who does not meet any of the criteria for a substance use disorder; in the DSM-IV, he or she might have met only the legal criteria. Alternatively, those in the severe designation who meet at least of three of the “Big Five” might need more intensive and/or extended treatment services and have a greater potential for relapse.
For me, this model helps to resolve a conundrum. The terms “alcoholism” and “alcoholic” are very important and have significant implications as when an AA member stands up at a meeting and says, “My name is John and I am an alcoholic.” However, the terms are neither diagnostic nor precise. We have all occasionally observed people who were labeled “alcoholic” who appeared to return to nonproblem drinking which creates cognitive dissonance because of the belief that alcoholism is an insidious, progressive, incurable, and fatal disease. Is it possible that awareness of criteria weight could resolve the dissonance? An added benefit may be the resolution of the ongoing conflict that exists between those clinicians who subscribe to the harm reduction or moderation management models, and those who believe in the disease/abstinence model.
The main conclusion is that the changes in the DSM-5 relative to substance use disorders more likely reflect the reality of clients who present with substance use disorders and the issue of criterion weight may resolve some lingering dilemmas.
Mee-Lee, D., Shulman, G. D., Fishman, M. J., Gastfriend, D. R., & Griffith, J. H. (Eds.). (2001). Patient placement criteria for the treatment of substance-related disorders. Chevy Chase, MD: American Society of Addiction Medicine.