DSM-5 and Substance Use Disorders

Editor:

Although Drs. Michael Norko and Lawrence Fitch provide an interesting review of the changes in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)¹ for substance use disorders (SUDs),² I disagree with some of their assessments and conclusions about the diagnosis of addiction.

The DSM-5 Substance-Related Disorders Work Group published an article for clinical guidance³ in which it discussed the various assessments and judgments that went into the criteria for substance use disorders in DSM-5. The decision was made to combine the previously separate categories of abuse and dependence. However, a continuum of severity was to be used based on counting the number of criteria. The more extreme or severe substance use disorder was considered an addiction, although the term was omitted because of the stigma attached to the word (Ref 2, p 485). The idea was that what was formerly considered abuse would now be considered a moderate substance use disorder, and what was formerly considered substance dependence (or addiction) would now be considered a severe substance use disorder. DSM-5 criteria thresholds are used that would yield the best agreement with the prevalence of DSM substance abuse and dependence disorders combined for a diagnosis of substance use disorder.

There were concerns that a threshold of two criteria was too low and that such low severity levels were not true cases (i.e., would not separate case from noncase).^3,4 The two-symptom threshold was too low to separate from no diagnosis.⁴ Hence, DSM-5 subsequently used the two- to three-symptom threshold for public health purposes and to help with treatment of unhealthy behavior rather than for a specific abuse or addiction diagnosis.

The Work Group also clarified that craving was not particularly helpful in diagnosing addiction. Some studies have suggested that craving is redundant of the other criteria. The psychometric benefit of adding a craving criterion was equivocal, but the DSM-5 Work Group decided to use a suggested craving query while awaiting the development of biological craving indicators. Three of the SUD criteria (tolerance, withdrawal, and craving) do not specifically identify addicted behavior.

It does not make clinical or scientific sense, in that it lacks specificity, that the diagnosis changes from no diagnosis (2 of 11 criteria in field trials)⁴ to the most severe form of the disorder (addiction) with the addition of 2 of 9 criteria/symptoms, if a threshold of 4 of 11 criteria is used. This is not a scientifically sound or clinically helpful method of diagnosing addiction or what was formerly called substance dependence. I would submit that the DSM-5 suggestion of considering addiction as the most severe or extreme form of SUD (Ref 2, p 485) makes the most sense in requiring 6 of 11 SUD criteria.