What's the DSM-5, Why Does It Matter and What’s Your New Diagnosis?

THE BOOK! Imagine a tome so powerful that you couldn't get treatment unless it said you should...It sounds like science fiction - it's actually real.

The DSM-5 is the 5th edition of the American Psychiatric Association’s (APA's) diagnostic guide book, called the Diagnostic and Statistical Manual, or DSM for short.

Often called psychology’s bible, the DSM provides lists of behavioral symptoms which clinicians use to diagnose different mental health conditions.

But why should you care?...

Well, for clinicians, the DSM is important because it provides a common language and diagnosis framework - and for everyone else, the DSM is important because you won’t get insurance coverage for a mental health condition unless you meet the DSM diagnostic guidelines.

What’s Different in the New Edition?

When considering substance use disorders, the new edition has a few substantial changes.

• In the fourth edition, substance use disorders were divided into 2 separate conditions: abuse and dependence. In the new edition, these disorders have been combined into one, called substance use disorder.
• A person can now get diagnosed with a mild, moderate or severe substance use disorder. In the last edition, you either had a disorder or you did not, and there were no shades of gray or considerations about severity. 
• The APA has strengthened the diagnosis. Under DSM-IV guidelines, a person only needed to show a single symptom for a diagnosis of substance abuse. Under the new guidelines, a person must show at least 2 symptoms to get diagnosed with a substance use disorder.

Diagnosing Substance Use Disorders

Here are the 11 criteria (paraphrased) used in the DSM-5 to diagnose a substance use disorder.

Count how many of the following symptoms match your experience over the past 12 months. Don’t count a symptom unless it caused or causes significant impairment or distress.

1. Recurring substance use has led to your failing to fulfill major responsibilities at school, work or home.
2. You repeatedly use drugs or alcohol in risky situations, such as when operating machinery or driving a car.
3. You experience alcohol or drug cravings.
4. You continue to use alcohol or drugs despite the fact that you realize that your use of alcohol or drugs causes or worsens reoccurring social or relationship problems (it keeps getting you into fights with your wife, for example).
5. You have developed a drug or alcohol tolerance. You need more than you used to to experience the same effects.
6. You experience withdrawal symptoms when you stop using or significantly cut down your use, or - you use other similar substances to stave off withdrawal symptoms (for example, using Valium when not drinking).
7. You often take/drink more drugs or alcohol than you had planned on - and/or you use/drink for longer than you had planned on (for example, you often stop for a drink after work with friends and intend to have just one or two - and then you don’t leave until closing time.)
8. You have a persistent desire to cut down or stop your use of drugs or alcohol, or - you have tried and failed to cut down or stop your use of drugs or alcohol.
9. You tend to spend a lot of your time using drugs or alcohol, recovering from your use of drugs or alcohol or doing what’s needed to get drugs or alcohol.
10. You have given up or reduced your participation in social, occupational or recreational activities that used to be important to you, and replaced these activities with drug or alcohol use.
11. You continue to use drugs or alcohol despite knowing that drugs or alcohol cause or worsen a persistent physical or mental health problem.¹

Scoring

• If you identify with 0 or only 1 of the criteria you do not meet the minimum threshold for a substance use disorder diagnosis
• If you identify with 2 or 3 criteria, you have a mild substance use disorder
• If you identify with 4 or 5 criteria you have a moderate substance use disorder
• If you identify with 6 or more criteria, you have a severe substance use disorder²

Why Did the APA Change the Diagnosis?

The APA explained the reasoning behind the changes as:

1. Eliminating the Artificial Distinction between Abuse and Dependence

It could be quite difficult to differentiate between mild dependence and severe substance abuse. In reality the line between abuse and dependence was mostly artificial, to allow for easier categorization.

Though the retest validity and reliability of the DSM-IV dependence diagnosis was quite good, the test retest validity and reliability of the abuse diagnosis was much worse.³

2. Ditching 'Dependence'

The dependence/addiction terminology was confusing.

While dependence is used medically to describe normal bodily adaption to a consumed substance (as you might become dependent on blood pressure medication) it was also used in the previous edition to describe addiction, and this led to a lot of unnecessary head scratching.

In the new edition, the word dependence is rightfully gone, replaced by addiction.

3. Strengthening the Diagnosis

In the previous edition, showing a single symptom, such as a distress-causing legal problem stemming from use, earned you a diagnosis of substance abuse. In practice, this meant that approximately 70% of people diagnosed with substance abuse met only a single criteria after being charged with a DUI.

While nobody would minimize the problems associated with impaired driving, many people arrested for a DUI do not really have substance use disorders requiring treatment (The DSM-V has also dropped the legal problems symptom from the diagnostic criteria).⁴

Criticisms

Considering its influence, it’s not surprising that the DSM attracts controversy and dissent.

NIMH - It Lacks Validity

Here’s a big one - The National Institute of Mental Health (NIMH), announced it will no longer use DSM categories as a basis for future research, citing a lack of validity.

While the NIMH still supports the DSM-V as the best current standards manual for the diagnosis and treatment of mental disorders, they say it’s not really good enough, given what we know now about the workings of the brain.

They’re calling for research that will support a move to diagnoses made more on changes to the structure and function of the brain, rather than based on clusters of symptoms - essentially a move away from diagnosing diseases like addiction from the way they make people act, and toward diagnosing these brain diseases based on how they change the workings of the brain.⁵

It May Rob Treatment Resources from Those with the Most Serious Problems

By classifying those who just meet the minimum criteria for a mild substance use disorder with the same condition as those with the most serious problems, some critics wonder if this could increase the number of people who qualify for treatment and overwhelm an already overwhelmed treatment system.

As the numbers who qualify go up - especially on the milder end of the spectrum - the percentage of those with more serious problems able to access treatment resources may go correspondingly down.⁶

It Muddies the Waters

And on at the consumer level, there are those that suggest that rather than clarify things, the new DSM simply leads to weakened diagnoses, especially when relying mainly on the truth-telling of people likely predisposed to denial.

According to addiction counselor Jim LaPierre LCSW, CCS, Executive Director of Higher Ground Services in Maine, “Addicts and alcoholics are already looking to minimize the significance of their use. If we say that someone is ‘mildly’ addicted we help them to rationalize. Accurate diagnoses of severity of substance abuse and addiction is highly contingent upon accurate self reporting. Given that alcoholics and addicts tend to downplay the frequency and amounts they use, this simply muddies the waters further.”

How Will The DSM-5 Change Things for Patients?

While only time will reveal the new edition’s actual impact, at the consumer level, it may not change things all that much.

Here’s why:

While it’s true that clinicians often have to use DSM-5 diagnostic criteria for insurance purposes when referring patients to treatment, these professionals are still left with some pretty considerable wiggle-room that lets them apply the diagnosis that’s going to bring the most beneficial outcome.

For each diagnostic criteria, the clinician has to decide if it has caused significant impairment - and that’s a pretty subjective decision to make - so If your doctor thinks you need treatment, and she knows you need to meet at least 4 criteria to qualify for treatment, then she is very likely going to use her subjective judgment to find the 4 criteria that get you the treatment you need.⁷