This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare three 1,000ish word posts on a particular class of mental disorders, with one of those focusing on changes made from the DSM-IV to the DSM-5.
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A Comprehensive Model of Addiction: Substance Use Disorders in the DSM-5 by Alisa Huskey
Much debate has centered on defining the psychopathology of addiction, resulting in continuous relabeling of the terms associated. The Diagnostic Statistical Manual of Mental Disorders, fourth edition (DSM-IV), for example, provides diagnostic criteria for two addiction-related disorders – Substance Abuse and Substance Dependence – while the DSM-5 folded the two together into Substance Use Disorder.
Over the past century, three primary models of addiction have emerged – medical, psychological, and traditional. Influence from the medical model has sparked interest in the biological origins and genetic predispositions of substance use; thus, addiction is now known as a disease as well as a psychosocial problem. Psychological and behavioral research in the field emphasizes the consequences of excessive substance use, both for the individuals and for others surrounding them. The development of substance dependence (or addiction) is conceptualized within the framework of learning (e.g., social, classical, and operant). The fundamental aspect of this model suggests that the negative psychosocial impairments of a substance should constitute a diagnosis of substance use. Ostensibly, regardless of whether an addiction is regarded as a disease or otherwise, the outcome is still the same. From the traditional point of view, typically espoused by the 12-step programs, addiction is a “loss of control.” It is believed that once the addiction develops, the weakness or chemical dependence forever remains. Because addiction is often viewed as a character flaw in such groups, abstinence is the only approach to “treatment.”
Addiction is commonly described as the “continued repetition of a behavior despite adverse consequence or a neurological impairment leading to such behavior” Addiction has physiological, psychological, and sociological components. Contrary to popular belief, addiction is not solely a physiological dependence upon a substance. In fact, the diagnostic criteria for Substance Abuse (SA) and Substance Dependence (SD) Disorders also include primarily social and psychological criteria. In the latest edition of the DSM (5), the diagnoses of SA and SD were rolled into one category labeled Substance Use Disorders (SUD).
Within the previous diagnostic criteria, the primary difference between substance abuse and dependence are levels of severity, with abuse being less severe than dependence. SA criteria are characterized by the negative consequences resulting from a maladaptive pattern of use (e.g. missing work or school, dangerous behaviors, interpersonal problems). Physiological as well as psychosocial components are encompassed within SD criteria, such as physical tolerance, withdrawal symptoms, and failed attempts to stop using. Consequences, such as those listed in the criteria for SA, are not part of SD criteria, but the psychological and functional impairments are still present. This symptom expression overlap causes SA and SD to be frequently diagnosed simultaneously. (I wanted to link to the “Rationale for Changes to Substance-Related Disorders Tentative new title of new combined section: Addiction and Related Disorders,” but apparently one needs a log-in to access the link. I got the pdf from one of your reading lists).
The dual nature of substance related disorders as defined by the previous DSM diagnostic systems (III-R and IV) originated from research on Alcohol Dependence Syndrome with differentiations between psychobiological dependence the consequences thereof. Epidemiological studies of large populations within the US indicate more occurrences of substance abuse than dependence. This is partially due to the level of symptomology required for diagnoses. For example, a diagnosis for substance abuse in the DSM-VI requires only one symptom criteria out of four, whereas substance dependence requires three out of seven. Research has consistently verified a strong relationship between the underlying characteristics substance abuse and dependence; thus, the differentiation was declared no longer necessary for diagnosis in the new DSM-5. The newly defined SUDs provide for a comprehensive, singular diagnosis, requiring individuals meet two or more out of 11 criteria. The criteria for SUD are essentially a combination of abuse and dependence symptomology.
SUDs are within the Substance-Related and Addictive Disorders chapter (previously called Substance-Related Disorders). The substance related disorders section includes substance induced disorders – substance intoxication and withdrawal. Substance intoxication is diagnosable for each substance, except for tobacco. This syndrome often occurs without the presence of a substance use disorder. According to the DSM-V, the “most common changes in intoxication involve disturbances of perception, wakefulness, attention, thinking, judgment, psychomotor behavior, and interpersonal behavior.” Withdrawal is diagnosable for each substance except of hallucinogens and inhalants. Symptoms of withdrawal involve physiological, cognitive, and behavioral components, resulting from a decrease in or cessation of substance use. Both intoxication and withdrawal must produce clinical significant changes or impairments.
Classes of SUDs in the DSM-5 include alcohol, cannabis, hallucinogens (categorized as phencyclidine or “other hallucinogens”), inhalants, stimulants, tobacco, and, opioids, sedatives, hypnotics, or anxiolytics. Previously, hallucinogens and phencyclidine were separate categories. The category of poly-substances is absent in the new DSM. There is also a new category for other or unknown. While caffeine is diagnosable as an intoxicant and withdrawal, it is not diagnosable as an SUD. In the DSM-IV caffeine is only classified as an intoxicant. Cannabis withdrawal is new as well. Nicotine dependence and withdrawal are redefined as a Tobacco SUD and Tobacco withdrawal. Each class of SUDs is a separately diagnosable disorder (e.g., Tobacco Use Disorder or Opioid Use Disorder).
Course specificers, a client’s state of remission, include “in early remission,” “in sustained remission,” “on maintenance therapy” and “in a controlled environment.” Each course specifier is detailed under specific disorders. For example, early remission for alcohol use disorder is specified if diagnostic criteria are not met for 3 to 12 months, and sustained remission is specified if criteria are not met for 12 months or longer. The “craving, or a strong desire or urge to use alcohol” criteria is an exception for these remission specifiers. “In a controlled environment” is specified if alcohol is restricted. These specifications for guiding treatment toward the level of addiction or substance use a person is experiencing. They are also useful in preventing job loss due to substance use, or in helping an individual return to work after having been diagnosed and treated.
Other major differences in the new SUD classification are the severity level specifiers, and a few criteria changes. Specifiers increase the precision of a diagnosis by denoting additional characteristics. The three categories of severity are dependent upon number of symptoms met – mild (2 to 3), moderate (4 to 5), and severe (6 or more). The criterion for recurrent legal problems, previously under substance abuse, was removed. Physiological dependence as evidence of tolerance and/or withdrawal symptoms is no longer a specifier for SD. The tolerance and withdrawal criteria remain in the main list of symptoms. “Craving or a strong desire or urge to use the substance” is a new symptom as an additional physiological criterion.
The changes in SUDs and related disorders reflect movement towards a more comprehensive model, which includes all three perspectives previously introduced – medical, psychological and traditional. The tolerance, withdrawal, and craving/urge criteria are all physiologically based symptoms, representing the disease (medical) model of addiction. At least six of the eleven criteria correspond with the psychological model, conceptualizing addiction as the consequences incited by substance use. For example, psychologically-based criteria specify that excessive time is spent acquiring the substance regardless of associated adversity, functionality impairments at work or school resulting from use, use is continued despite interpersonal, physical, or psychological impairments and dysfunctions, and physically hazardous situations continue to occur as a result of use. The lack of control (traditional) perspective is captured within two criteria, specifying that efforts to regulate use have been ineffective and substance use has increased in quantity and frequency. The criterion specifying that use is continued despite interpersonal impairments may also be considered reflective of the traditional model.
