The American Psychiatric Association’s proposed diagnostic criteria for the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) will eliminate the current categories of substance abuse and dependence, replacing them with the new category “addiction and related disorders.” This will include “substance use disorders,” with each drug identified as a category such as “alcohol use disorder.” The DSM Substance-Related Disorders Work Group members also have recommended a new category of behavioral addictions, in which gambling will be the sole disorder.
“The field of substance abuse and addiction has witnessed an explosion in important research in the past two decades,” said David Kupfer, M.D., chair of the DSM-5 Task Force. “These work group recommendations reflect the best science in the field and provide new clarity in how to diagnose these disorders.”
DSM is the standard classification of mental disorders used by mental health and other health professionals for diagnostic and research purposes. The APA today released the proposed diagnostic criteria, which will be available for public comment until April 20.
The proposed criteria will be reviewed and refined over the next two years. During this time, the APA will conduct three phases of field trials to test some of the proposed diagnostic criteria in real-world clinical settings. The proposed criteria for substance use disorder are very similar to those now used to describe substance abuse and dependence in DSM-IV, the previous edition of the manual, although categories of moderate and severe will be added to describe severity. A drug craving symptom will also be added, and the symptom of problems with law enforcement will be eliminated because of cultural considerations that make the criteria difficult to apply internationally.
“The term dependence is misleading, because people confuse it with addiction, when in fact the tolerance and withdrawal patients experience are very normal responses to prescribed medications that affect the central nervous system,” said Charles O’Brien, M.D., Ph.D., chair of the Substance-Related Disorders Work Group. “On the other hand, addiction is compulsive drug seeking behavior which is quite different. We hope that this new classification will help end this wide-spread misunderstanding.”
O’Brien also explained the work group’s reasoning behind the new category of behavioral addiction. “There is substantive research that supports the position that pathological gambling and substance use disorders are very similar in the way they affect the brain and neurological reward system,” he said. “Both are related to poor impulse control and the brain’s system of reward and aggression.” Pathological gambling is listed in the current version of DSM, but in a different category. While “internet addiction” was considered for inclusion in this category, the work group decided there was insufficient research data to do so. They are recommending it be included in the manual’s appendix instead, with a goal of encouraging additional study.
The proposed revisions also will include a separate category that is not part of substance use disorder: miscellaneous discontinuation syndromes. This will include two categories of antidepressant medications – tricyclic and selective serotonin reuptake inhibitors (SSRIs). Withdrawal syndromes occur when a person has been taking a substance that has affected the central nervous system, and those cells have adapted over time to reduce their response to the substance. “If the substance is abruptly discontinued, in some cases the body responds with a rebound effect that creates unpleasant, and sometimes serious, symptoms of withdrawal,” said O’Brien.