Monday, February 15, 2010

DSM-5 Diagnostic Changes Substance Abuse

The American Psychiatric Association has released the draft version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This is a work that has been ten years in the making and will replace DSM-IV-TR as the official diagnostic manual for mental health. The DSM-5 is still a work in progress. The draft report has been released to allow for public review and comment before 3 phases of field trials will take place in real world settings before the final version is published in 2013. Anyone can review the document at and comment before April 20th. There are a number of proposed revisions which I will discuss here over the next few days but today just want to focus on the proposed changes in substance abuse disorders.

The DSM-5 proposes the elimination of the categories of substance abuse and substance dependence replaced by the category of addictions and related disorders. There will be no differentiation between abuse and dependence. Instead all will be referred to as substance use disorders with varying levels of severity. This has been proposed to try to eliminate the confusion between physiologic dependence upon alcohol or a drug and addiction per se as well as to address the problem with our current categories in which the psychosocial consequences of abuse are given more weight than in the dependence diagnosis itself.

A Substance-Use Disorder will be defined as a clinically significant impairment or distress as manifested by 2 (or more) of the following, occurring within a 12-month period:

Failure to fulfill major role obligations at work, school, or home

Recurrent use of substances in situations in which it is physically hazardous

Continued use despite persistent social and interpersonal problems caused by the

Tolerance - diminished effect with the continued use of the same amount of the substance

Withdrawal syndrome

Taken in larger amounts or over a longer period than was intended

Persistent desire or unsuccessful attempts to cut down on the substance use

A great deal of time spent in activities necessary to obtain the substance

Giving up important occupational or recreational activities

Continued use despite knowledge of having a persistent physical or psychological problem caused or exacerbated by the substance

Craving or a strong desire or urge to use a specific substance

Two to three criteria positive will be referred to as moderate severity with four or more referred to as severe. There will be a separate specifier for with or without physiological dependence.

The proposed changes are also designed to take into account that abuse and dependence are not necessarily two separate categories but represent different severity points on a continuous spectrum of problems. I think these proposed changes represents more the real world than our old categories but will lead to some disagreement about how to define the term alcoholic or addict which are not diagnostic terms per se but are commonly used in the treatment and recovery field. I invite any comments on what you think about these proposed changes.

Thought for the day

Are my actions likely to enhance or detract from an other's well being today?


  1. Greetings to all. In today's society and profession, we as those who have taken on the career to provide help with people struggling with substance abuse problems or addictions, the proposed changes seem to be more specific in terms of finally including, realizing, and representing the different severity points and spectrum of problems that do in fact contribute to substance-use on a continuum, especially on a cutltural spectrum. What I feel is significant is that Substance-Use Disorder takes away the stigma of abuse and dependence for a person who life is greatly impacted and dominated by drugs and alcohol use. In my opinion and from experience as well as working with both adults and adolescents, there are a number of significant indirect and direct different severity points that contribute to one's struggle with addiction or use that ultimately influence such drug and alcohol use by both adults and adolescents. Many times, a person and his/her overall environment greatly impacts substance use in such a powerful way as a result of being exposed to many harmful and dangerous influences, situations, and distressing conditions. I believe these changes can and will help those struggling with substance-use as a teaching tool to help them learn about what and how their significant problem(s) is deemed to be diagnosed, viewed, and understood in terms of use, abuse, and dependence. I look forward to these new proposed changes as the saying goes with tx and recovery..."it is a lifetime process." Thank you for allowing em to comment. Peace and many blessings to you - a'ho. John M

  2. Substance Abuse and Substance Dependence are qualitatively different, not quantitatively different along a continuum. Substance Abuse is not a chronic progressive illness. Why not combine moles and melanomas under the category "skin conditions and related disorders" and rate it on a level of severity? This is a huge step backwards.


Thank You For Your Comment!

CARF - Commission on Accreditation of Rehabilitation FacilitiesNATSAP | National Association of Therapeutic Schools and ProgramsNBCCNAADAC