The proposed changes in the diagnostic criteria for addiction in the long-awaited DSM-5, the Diagnostic and Statistical Manual of Mental Disorders, scheduled to be published next May, have proved unsettling to many in the treatment community. These largely professional disagreements assumed the status of a public controversy when a May 11 New York Times article reported that Dr. Howard Moss of the National Institute on Alcohol Abuse and Alcoholism had resigned from the DSM-5 Task Force.
The controversy is hardly surprising. In many ways, writing a new DSMis a sisyphean task. Since psychiatric disorders don’t announce themselves with biological diagnostic data, the coherent organization of a huge number of complex disorders into a “manual” to be used by researchers, healthcare professionals and third-party payers is daunting. How do you capture, in a few pages, illnesses and patterns of suffering that manifest uniquely in every new patient? Consider also that many patients have more than one psychiatric illness and that diagnosis depends, to a certain extent, upon the patient’s own ability to articulate their inner experience. No revision to the DSM would be greeted with universal praise from a field increasingly polarized between viewing nature or nurture as the essential cause.
Critics fear an expanded definition will lead to “false epidemics,” inflated statistics and millions of dollars of unnecessary treatment.
Addiction professionals need to know that there are likely to be three main changes to the definition of addiction:
1. Adding “craving or a strong desire to use” as a criterion.
2. Replacing the separate categories of substance “abuse” and “dependence” with a unified “Substance Use Disorder” rated for severity (Alcohol Use Disorder, say, or Severe Cocaine Use Disorder).
3. Adding Gambling Disorder to the Addictive Disorders, where previously Pathological Gambling was listed as an Impulse Control Disorder. (This change likely paves the way for other Addictive Disorders in future editions, such as sex addiction and internet addiction.)
What has sparked this heated debate is the expectation that the new definition will result in a great expansion in the number of addiction diagnoses. This alarms some in the treatment community who fear that it will lead to “false epidemics” of substance abuse and “the medicalization of everyday behavior,” inflated statistics about disease prevalence and millions of dollars wasted on unnecessary treatment. To take only one example, with the addition of “craving or strong desire or urge to use [a substance],” a college student who often drinks more than he or she intended to could receive a diagnosis of Mild Alcohol Use Disorder, despite the absence of any serious negative impact—as is currently reflected in the manual.
Along with the fear of unnecessary diagnoses comes the fear of unnecessary pharmacologic treatments. Critics argue that the changes in the diagnostic criteria and the availability of psychotropic medications for cravings may lead to an increase in the use of prescription drugs for the disorders. They also complain about the financial ties to the pharmaceutical industry among some of the clinicians responsible for drafting the revision.
Unfortunately there is no simple solution to this dilemma. The research universities and pharmaceutical companies working in psychiatry and addiction medicine all want the top researchers and clinicians, and so does the American Psychiatric Association (APA), which publishes the DSM. There is an imperative in our field to continually assess treatment outcomes to develop better data about whichinterventions are most effective for which patients under which circumstances—and this responsibility is shared by all of us in the treatment community, including the companies that make the drugs.
Critics with a more theoretical approach have a closely related concern: that the new DSM will reflect psychiatry’s focus on the biological (at the expense of the psychosocial) basis of mental disorders. That the APA leans toward biology is to be expected. Trends in the profession favor an increasingly medical viewpoint, with a growing appetite for the view that, as Director of the National Institute on Drug Abuse Dr. Nora Volkow says, “addiction is a brain disease.”
In fact, the default response to most psychiatric illness in the US is increasingly pharmaceutical. Whether or not it makes sense to have the APA produce the document that ultimately drives treatment dollars is another, larger question.
Yet the success rate of addiction treatment is so low partly because the “disorder” that comes into the consultation office is all tangled up with the patient’s entire entourage of circumstance and injury. Decisions about appropriate treatment should be based on a combination of factors, including addiction severity, other mental illness, pre-illness personality and collateral damage to the patient’s world.
Chronic drug use changes the chemistry of your brain, no doubt, and maybe for a long time. But trying to reduce the complexities of an individual’s addictive behavior to a “brain disease” doesn’t fully capture it, not even close.
Most clinicians who believe that addiction and many other mental disorders are primarily rooted in psychosocial influences argue not that medications are not useful but that they should be temporary aids as opposed to solutions. I count myself in this nurture school, which emphasizes that the insights, skills and growth that can occur in psychotherapy can be used by the patient long after the treatment episode ends.
As in other areas of psychiatry, there are pharmacological interventions in addiction medicine that are highly effective and useful in treating substance use disorders, an arsenal that now includes newer medications such as buprenorphine and naltrexone. These medications can be an indispensable part of the treatment plan for some patients, and we should continue to look for innovation from all directions: planning overall episodes of care, refining psychotherapy techniques and creating new drugs. Addiction is one of the most devastating and costly afflictions on the planet. We can’t afford to prejudice ourselves against any useful or promising treatments.
On balance, I disagree with those who are alarmed by the proposed changes in DSM-5. To my mind, changes that more accurately recognize the complexities of addiction and encourage robust treatment are more than welcome. The fact that binge drinking is so pervasive among college students and other young people indicates not that it is the norm, and therefore OK (not a problem), but that it is a very big problem indeed. Arguing otherwise is like saying that since so many Americans are obese, it needn’t be addressed because it is a cultural norm.