The Diagnostic and Statistical Manual of Mental Disorders DSM–5 is a manual used to diagnose mental illnesses in people, including those with addiction issues. The most recent edition, the DSM-5, was released in 2013 and included significant updates to how clinicians think about addiction.
Introducing "Substance Use Disorder": Understanding Addiction Along a Continuum
The American Psychiatric Association (APA) released the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013.
In decades past clinicians working in addiction had been forced to distinguish between substance abuse and substance dependence. The difference may seem slight but the two definitions each held their own definition.
In the past, substance abuse was understood as when a person continues to use a substance in spite of experiencing negative consequences such as legal, social, occupational, or health problems, whereas substance dependence was understood to include 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.
The new diagnostic criteria published in 2013 dropped 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 using. For instance, people who struggle with alcohol use will now be labeled with an "Alcohol Use Disorder" while people who struggle with cocaine use 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.
Substance Use Disorder Symptoms
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 are:
- Taking the substance in larger amounts or for longer than you're meant to.
- Wanting to cut down or stop using the substance but not managing to.
- Spending a lot of time getting, using, or recovering from use of the substance.
- Cravings and urges to use the substance.
- Not managing to do what you should at work, home, or school because of substance use.
- Continuing to use, even when it causes problems in relationships.
- Giving up important social, occupational, or recreational activities because of substance use.
- Using substances again and again, even when it puts you in danger.
- Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
- Needing more of the substance to get the effect you want (tolerance).
- Development of withdrawal symptoms, which can be relieved by taking more of the substance.
Substance Use Disorder: Levels of Severity
Substance use disorder is divided into three levels of severity: mild, moderate or severe.
Mild: If a person is judged to have two or three of the 11 symptoms, they are diagnosed with a mild substance use disorder.
Moderate: Four or five symptoms qualify for a moderate disorder
Severe: 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.
Othe Changes in DSM-5
There were two other changes in the 2013 edition of DSM. One of the biggest changes in the new criteria is removing recurring legal problems due to drug use as 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.
Why Change The Way Clinicians Disgnose Addiction?
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.