Traditionally, clinicians working in addiction have been forced to distinguish between substance abuse and substance dependence. The difference may seem slight but the two conditions each hold their own definition. Substance abuse results when a person continues to use a substance in spite of experiencing negative consequences such as legal, social, occupational or health problems, whereas a person with substance dependence exhibits these issues and more serious symptoms like physical tolerance, withdrawal symptoms, issues with self-control, etc. Substance abuse, while a serious issue, was not considered as serious as having a full-blown addiction.
For years this designation helped to separate people with addictions from those with less serious issues, especially in cases where people may have been in trouble with the law or at work. However, new changes in the clinical diagnostic criteria have dropped this distinction.
A New Categorization
Last year the American Psychiatric Association (APA) released a new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the manual used to diagnose mental illnesses in people, including those with addiction issues. The new diagnostic criteria drop the substance abuse/dependence dichotomy in favor of a viewpoint that addiction occurs on a continuum of severity. The upgraded category is now termed "Substance Use Disorders."
Clinicians are to substitute the particular substance in question with whatever their patient is abusing. For instance, people who abuse alcohol will now be labeled with an "Alcohol Use Disorder" while people who abuse cocaine will receive a "Cocaine Use Disorder" label, etc. Whether or not a person qualifies for some type of substance use disorder depends on how many different types of behavioral symptoms they display.
Addiction Symptoms and Levels
The DSM–5 lists 11 separate specific symptoms, most of which are the same as the symptoms listed in previous DSMs, to be used to determine a substance use disorder. These diagnostic symptoms consist of certain types of behaviors that the person exhibits in conjunction with their particular substance use. They consist of symptoms such as the development of tolerance, withdrawal symptoms, having social or occupational problems as a result of usage, having cravings or strong urges to use, etc.
Substance use disorder is divided into three levels of severity: mild, moderate or severe. If a person is judged to have two or three of the 11 symptoms, they are diagnosed with a mild substance use disorder. Four or five symptoms qualify for a moderate disorder and six or more symptoms land a severe substance use disorder diagnosis. People with only one symptom are not diagnosed with a disorder.
As seen in this system, there is no longer a designation between abuse and addiction. Instead, addiction is considered to occur at three different levels of severity.
Two Additional Changes
One of the biggest changes in the new criteria is removing recurring legal problems due to drug use as a substance abuse or substance dependence diagnosis. However, a person with recurrent legal issues can still fit into a criterion such as "continued use despite social/interpersonal problems."
The other change is including cravings or strong urges to use a particular substance as a symptom. This has traditionally not been part of the DSM diagnostic criteria for substance abuse or substance dependence and may be a bit more challenging to diagnose since these cravings may be very subjective in nature.
Is There Really a Difference?
So you might be wondering, why change the way clinicians diagnose addiction? First, it is important to understand that the notion of addiction has not significantly changed in spite of the changes to the DSM but the way clinicians diagnose addiction has changed in order to conform to the experiences of clinicians who work in the field. Many found the old abuse and dependence designation to be unrealistic.
Interestingly enough, preliminary research on these changes has indicated that the vast majority of individuals previously diagnosed with substance abuse fall into the mild substance use disorder category and individuals previously diagnosed with dependence most often fall into the moderate and severe substance abuse disorder categories. People with no diagnosis by previous criteria still for the most part get no diagnosis.
However, the APA considers presenting addiction on a continuum (mild, moderate, severe) as a better way to help clinicians identify specific issues in people and design treatments for them. Though there are problems with the system—no reliable physical or biological markers, no clear definition of clinical implications for a mild, moderate or severe diagnosis—most clinicians in America will be using this system to diagnose addictions until the next version of the DSM is released.