What’s New in the DSM-5 for Substance Use Disorders

The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), was published in May 2013. It has brought about significant changes in the diagnosis of substance use disorders.

Major Changes

One of the major changes affecting all of the diagnoses is the elimination of the Multiaxial Assessment System, or “five axis system,” for organizing diagnoses. I recommend that counselors keep the five axis system in their heads as a way of organizing their assessments. I also recommend keeping Axes three, four, and five, not for purposes of diagnoses, but for purposes of informing assessments. For example, chronic pain disorders serve as a trigger for relapse to opioids in persons with such disorders. Chronic pain disorders would previously be coded on Axis III (General Medical Conditions), the stressors listed in Axis IV (Psychosocial and Environmental Problems) can be used as a basis for developing a relapse prevention plan, and information from Axis V (Global Assessment of Functioning) can furnish counselors with a basis for understanding a client’s level of functioning, particularly if the assessment is done on the level of current functioning compared to the highest level in the last year, providing us with additional information about whether the client’s functioning has been improving, deteriorating or remaining stable.

Another major change is the elimination of the “substance dependence” and “substance abuse” diagnoses. Instead, there is a determination of severity. The seven criteria for dependence and the four criteria for abuse have been collapsed into a total of eleven criteria. The criterion for the previous abuse diagnosis of recurrent substance-related legal problems has been eliminated and new criterion of craving the substance has been added, still with a total of eleven criteria. The following show how the determination of severity is made:

Meeting none or one of the criteria results in no diagnosis.
Meeting two or three results in a determination of “Mild” severity, most comparable to the old abuse diagnosis.
Meeting four or five of the criteria results in a determination of “Moderate” severity, which could be comparable to either the old abuse or dependence criteria.
Meeting six or more of the criteria results in a determination of “Severe,” which is comparable to the old dependence criteria.

The elimination of “substance dependence” may have some unintended consequences. One of the indicators for admission into residential or inpatient treatment in the previous and current editions of the ASAM Criteria is a diagnosis of substance dependence. In terms of admission criteria for methadone maintenance programs, a requirement is that the person be assessed as “addicted” to an opioid for at least one year. Physiological dependence was a specifier in the DSM-IV, not in the DSM-5. Since there is a difference between addiction—meaning compulsion, loss of control, continued use in spite of adverse consequences, and craving—and a diagnosis of severe opioid use disorder, which is the equivalent of the DSM-IV diagnosis of opioid dependence, how will methadone programs determine what one year of addiction is?

I believe that the change from the DSM-IV in which the categorical diagnoses were replaced with continuums of severity in the DSM-5 is a significant improvement. Before, there were enough signs and symptoms to meet the diagnosis or there weren’t—a client either had the disorder or did not have it. There are individuals who, under the DSM-IV, would not have met a diagnosis because they were “sub-threshold,” but who would have a diagnosis under the DSM-5. As an example, say that a counselor has a client who met the dependence criteria of the substance taken in larger amounts or over a longer period of time than intended and a persistent desire or unsuccessful efforts to cut down or control substance use, both indicators of loss of control. Under the DSM-IV, that client would meet neither a diagnosis of dependence nor of abuse; however, the client would meet a diagnosis of mild substance use disorder under the DSM-5.

An examination of the DSM-5’s elimination of the legal problems criterion from the old abuse diagnosis presents a mixed analysis. The reasons supporting the elimination include the fact that people of color, those who are poorly educated, and those of lower socioeconomic status are overrepresented on the criminal justice system. There are geographic inequalities too; for example, recreational use of marijuana is legal in Colorado, but crossing the state line into Utah with one ounce or less opens the person to a misdemeanor charge with the potential of six months incarceration and/or a $1,000 fine. In the past, individuals with a single DUI and no other indicators of abuse have been incorrectly diagnosed with abuse. In addition, the criterion of legal problems carries with it little diagnostic weight.

On the other hand, there are concerns about the removal of the legal problems criterion. For some individuals, legal problems may serve a Screening, Brief Intervention, and Referral to Treatment (SBIRT) function of intervening earlier in the progression of a substance use problem. Legal problems often serve as the impetus for treatment. As legal problems are removed, if the individual does not meet at least two other criteria, thereby not generating a substance use diagnosis, what will happen to drug court clients for whom treatment would normally be reimbursed by insurance?

Other substance use disorder changes in the DSM-5 are the change from nicotine disorder to tobacco disorder, inclusion of caffeine withdrawal for the first time—the DSM-IV had a diagnosis of “caffeine intoxication” but no withdrawal—and cannabis withdrawal. Cannabis withdrawal is particularly important because some of the symptoms can be long-lasting and misinterpreted as willful noncompliance with treatment, which may result in an inappropriate decision by staff to terminate treatment administratively.

An interesting factoid is that cocaine use disorder appears nowhere in the index under cocaine and it doesn’t appear in the index in the list of different substance use disorders. However, it does appear in the body of the DSM in a section titled “Stimulant-Related Disorders.”

Terms and Specifiers

The term “addiction” is used for the first time in the history of the DSM in the section titled “Substance-Related and Addictive Disorders” and refers to gambling. The diagnosis of “pathological gambling” in the DSM-IV—commonly referred to as “compulsive gambling”—and listed as an impulse control disorder, is now moved to the Substance-Related and Addictive Disorders section and is named “gambling disorder.” It might be useful for counselors to view the diagnostic criteria for gambling disorder and see how closely they mirror the criteria for substance use disorders.

The specifier for “with physiological dependence” has been eliminated, as well as the one for “polysubstance dependence.” The specifier of “sustained partial remission”—meaning the full criteria for dependence has not been met for twelve months or longer, but one or more of the criteria for dependence or abuse has been met—has been replaced with “in early remission,” meaning that no criteria met for at least three months but less than twelve months with the exception of craving. “Sustained partial remission” and “early sustained remission” have been eliminated completely.

Under the DSM-IV, a client could be in early partial remission, which refers to not meeting full criteria for at least one month but less than twelve months, but the individual could meet one or more of the abuse or dependence criteria. Many counselors had great difficulty with the suggestion that a client could still be using and yet be in remission. Sustained full remission—no criteria met at any time during a period of twelve months or longer—has been replaced with sustained remission, which means that no criteria was met at any time during a period of twelve months or longer with the exception of craving. The specifier “on agonist therapy” has been eliminated but “in a controlled environment” remains.

Weight

I previously mentioned the concept of weight in determining diagnostic criteria. Think of criterion weight as the influence or impact of that specific criterion in determining the diagnosis. The assumption in both the DSM-IV and DSM-5 is that all of the criteria carry equal weight, resulting in diagnoses being made by simply adding up the number of criteria met.I of fact

In point of fact this is not so. Criteria most likely to be associated with the severe categories of a substance use disorder include: wanting to cut down or control use but being unable to do so; withdrawal; failure to fulfill major role obligations; important social, occupational, or recreational activities are given up or reduced because of the substance use; and compulsion, when the substance is taken in larger amounts or over a longer period of time than was intended. These are referred to as the “Big Five” and this is the pattern that most addiction counselors associate with addiction.

On the other hand, tolerance and dangerous use are actually in common among those with no diagnosis. This makes sense when you realize that tolerance is a function of practice, for example, if “social drinkers” stop drinking for a period of time and then resume drinking at the same level, they will find that they get a greater effect from the same amount of alcohol as they used before they stopped. An individual may drive impaired, whether or not he or she is arrested, because of foolishness (e.g., a father drinking too much to celebrate his daughters wedding). This is the pattern that counselors are more likely to associate with abuse because there is no loss of control.

Implications

It appears that those in the mild designation and who meet none of the “Big Five” may be able to benefit from harm reduction or moderation management strategies. Think of the DUI offender who does not meet any of the criteria for a substance use disorder; in the DSM-IV, he or she might have met only the legal criteria. Alternatively, those in the severe designation who meet at least of three of the “Big Five” might need more intensive and/or extended treatment services and have a greater potential for relapse.

For me, this model helps to resolve a conundrum. The terms “alcoholism” and “alcoholic” are very important and have significant implications as when an AA member stands up at a meeting and says, “My name is John and I am an alcoholic.” However, the terms are neither diagnostic nor precise. We have all occasionally observed people who were labeled “alcoholic” who appeared to return to nonproblem drinking which creates cognitive dissonance because of the belief that alcoholism is an insidious, progressive, incurable, and fatal disease. Is it possible that awareness of criteria weight could resolve the dissonance? An added benefit may be the resolution of the ongoing conflict that exists between those clinicians who subscribe to the harm reduction or moderation management models, and those who believe in the disease/abstinence model.

The main conclusion is that the changes in the DSM-5 relative to substance use disorders more likely reflect the reality of clients who present with substance use disorders and the issue of criterion weight may resolve some lingering dilemmas.

Dedication: I would like to dedicate this article to the memory of David Powell, PhD, who was a major force in the field with his most significant contributions being in the area of clinical supervision, and who was my colleague and dear friend for thirty-five years. I hope I can do you proud, David.

References

Kopak, A. M., Proctor, S. L., & Hoffmann, N. G. (2012). An assessment of the compatibility of current DSM-IV and proposed DSM-5 diagnosis of cannabis use disorders. Substance Use and Misuse, 47(12), 1328–38. doi:10.3109/10826084.2012.714039.

Mee-Lee, D., Shulman, G. D., Fishman, M. J., Gastfriend, D. R., & Griffith, J. H. (Eds.). (2001). Patient placement criteria for the treatment of substance-related disorders. Chevy Chase, MD: American Society of Addiction Medicine.

Mee-Lee, D., Shulman, G. D., Fishman, M. J., Gastfriend, D. R., & Griffith, J. H. (Eds.). (2013). The ASAM Criteria: Treatment criteria for addictive, substance-related and co-occurring conditions. Carson City, NV: The Change Companies.

Proctor, S. L., Kopak, A. M., & Hoffmann, N. G. (2012). Compatibility of current DSM-IV and proposed DSM-5 diagnostic criteria for cocaine use disorders. Addictive Behaviors, 37(6), 722–8.