The Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered to be the ”bible” of classification and diagnostic criteria for mental disorders. After a wait of approximately 13 years since the revised Fourth Edition, the DSM-5 was released on May 18th. I will briefly detail some of the changes to the category of Substance Use Disorders.
In the previous edition, Substance Use Disorders (SUDs) were divided into two separate diagnostic entities: Substance Abuse and Substance Dependence. Substance Abuse was considered less severe than Substance Dependence. For a further explanation of these two diagnostic entities, please read my January 2013 blog, “What is a Substance Use Disorder?” In the new edition of the DSM, these two diagnostic entities have been eliminated and replaced with the term Substance Use Disorders on a severity continuum with three levels: mild, moderate, and severe.
There are now 11 symptom criteria to assess for each individual presenting with the possibility of an SUD. In the new edition, a person needs at least two criteria for a SUD diagnosis. In the previous edition, a person needed only one symptom criterion to meet the diagnosis of Substance Abuse. These symptom criteria must be present within the past 12 months and lead to “clinically significant impairment or distress.” They are:
- ______ is often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful efforts to cut down or control _____ use.
- A great deal of time is spent in activities necessary to obtain ______, use _____, or recover from its effects.
- Craving, or a strong desire or urge to use ____.
- Recurrent _____ use resulting in a failure to fulfill major role obligations at work, school, or home.
- Continued _____ use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of _____.
- Important social, occupational, or recreational activities are given up or reduced because of _____use.
- Recurrent _____ use in situations in which it is physically hazardous.
- ____ use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by _____.
- Tolerance, as defined by either of the following:
- A need for markedly increased amounts of _____ to achieve intoxication or desired effect.
- A markedly diminished effect with continued use of the same amount of ____.
- Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for ____
- ____ is taken to relieve or avoid withdrawal symptoms.
Severity of an SUD is now determined by the number of symptom criteria present over the past 12 months. In order to have a diagnosis of a “Mild Substance Use Disorder,” the patient must have met the above criteria for 2 to 3 symptoms. For a diagnosis of “Moderate Substance Use Disorder,” the patient must meet 4 to 5 symptom criteria. For a diagnosis of “Severe Substance Use Disorder,” the patient must meet 6 or more symptom criteria.
While the newly merged diagnosis of Substance Use Disorder seems to be perceived as an improvement, primarily due to greater simplicity of diagnosing, I am not such a fan. As you may have read in my previous blog on “What is a Substance Use Disorder?” I see Substance Abuse and Substance Dependence as two distinct entities with clear differences. I have previously written that Substance Abuse is essentially a pattern of inconsistent loss of control over a substance or substances, whereas Substance Dependence exhibits a more consistent pattern of loss of control. I believe the difference goes beyond severity factors, toward a more distinct pattern of use. I have often found that individuals who have met the criteria for Substance Abuse have difficulty relating to the individual who is considered Substance Dependent. Time will tell whether this newly merged diagnostic entity improves our work or hinders it.
Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction. He can be reached at nlessa@chat2recovery.com.