Friday, April 02, 2010

New criteria for addiction

The DSM -- Diagnostic and Statistical Manual -- defines the disorders that the psychiatric profession officially recognizes.  Where a patient has insurance coverage, the treatment professional needs to fit the client's issues into one of the recognized categories in order to obtain payment.  Thus the DSM is much like a statement of the law, which is why the making of each new edition of the DSM has been compared to the making of laws and sausages -- the less you see, the more you'll have respect. A participant in the making of the current edition, years ago, told me that it was like a smoke-filled room in old Chicago, with the loudest egos battering each other into submission. This year, the creators of the DSM-V have broken with that sordid tradition by opening a public window into the current state of the draft.  Dr. Nora Volkow, the director of the National Institute of Drug Abuse (NIDA) recently sent an email blast to just about everyone concerned with addiction to publicize the current draft and solicit comment.
I have been tied up with other work and have not had a chance to review the material.  Fortunately, LifeRing convenor Lloyd E. has stepped into the breach, and has composed the following comment, for which I am grateful to him:

Diagnostic criteria for the medical conditions commonly known as alcoholism and addiction will be significantly changed in the new DSM-5.  The Diagnostic and Statistical Manual of Mental Disorders  is produced by the American Psychiatric Association and is the standard diagnostic tool used by doctors and insurance companies.
The DSM-5 Substance-Use Disorders Workgroup is recommending that the currently separate categories of substance abuse and dependence be dropped in favor of a single disorder of graded clinical severity.
The DSM-4 used the terms “abuse” and “dependence” in an attempt to blunt the stigma of addiction, but they have proved untenable and misleading.  The term “dependence” is problematic because it encourages people to associate addiction to withdrawal symptoms rather than the obsessive nature of drug cravings.   And it is difficult to see why the word should be used for the ongoing condition of someone who is having success in recovery.  The term “abuse” has been criticized because it is a moral, not a medical, term.  And really, it is the addicted person who is abused, not the drug.  The new criteria will suggest a single continuum, instead of two discrete conditions.
The distinct diagnoses of substance dependence and abuse will be replaced by a single Substance-Use Disorder  with varying severity.   The disorder will have a subcategory for each of the popular drugs such as Alcohol-Use Disorder or Amphetamine-Use Disorder.
It is important to remember that the DSM is only a diagnostic tool.  It is not concerned with the biology or etiology of addiction. It does not preclude that specific biological changes may occur in the brain, but it bases diagnosis on behavioral criteria because the biology of the brain is not well enough understood and is not accessible to clinicians.
DSM-5 will identify Substance-Use Disorder as “a maladaptive pattern of substance use leading to clinically significant impairment or distress.”  The lists of manifestations previously given for abuse and dependence will be combined into one list.  If a person manifests two or three items, a diagnosis of “moderate” Substance-Use Disorder is given.  For four or more, the disorder qualifies as “severe.”  The presence of cravings, or strong desires use a specific substance, is proposed as an additional manifestation not present in DSM-4.  For those in recovery the disorder is characterized as being in various stages of remission from Early-partial to Sustained-Full remission.
The APA is soliciting comments until April 20, 2010.  The DSM-5 will be published in May 2013.
Substance-Use Disorder:
A.  A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period: 
1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) 
2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) 
3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
4. tolerance, as defined by either of the following: 
a.   a need for markedly increased amounts of the substance to achieve intoxication or desired effect 
b.   markedly diminished effect with continued use of the same amount of the substance
(Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)
5. withdrawal, as manifested by either of the following: 
a.   the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) 
b.   the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)
6. the substance is often taken in larger amounts or over a longer period than was intended 
7. there is a persistent desire or unsuccessful efforts to cut down or control substance use 
8. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects 
9. important social, occupational, or recreational activities are given up or reduced because of substance use 
10. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance 
11. Craving or a strong desire or urge to use a specific substance.
Severity specifiers:
Moderate:  2-3 criteria positive
Severe:  4 or more criteria positive
Specify if:
With Physiological Dependence:  evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)
Without Physiological Dependence:  no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present) 
Course specifiers (see text for definitions):
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy 
In a Controlled Environment

 For more details, click to the APA Call for Comments site.

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