DSM-V Draft Includes Major Changes to Addictive Disease Classifications

The first draft of the American Psychiatric Association’s (APA) latest Diagnostic and Statistical Manual of Mental Disorders (DSM-V) eliminates the disease categories for substance abuse and dependence and replaces it with a new “addictions and related disorders” — just one of several major changes to the “Bible” used almost universally to diagnose (and get insurance reimbursement for) behavioral-health problems.

“Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system,” the APA explained in a Feb. 10 press release.

“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 APA’s DSM  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.”

The new category for addictive diseases would include a variety of “substance-use disorders” broken down by drug type, such as “cannabis-use disorder” and “alcohol-use disorder.” Diagnostic criteria for these disorders in DSM-V would remain “very similar” to those found in the current DSM-IV, according to APA. However, the symptom of “drug craving” would be added to the criteria, while a symptom that referred to “problems with law enforcement” would be eliminated “because of cultural considerations that make the criteria difficult to apply internationally,” APA said.

Also new to the DSM-V are diagnostic criteria for “cannabis withdrawal,” which the APA says is caused by “cessation of cannabis use that has been heavy and prolonged,” results in “clinically significant distress or impairment in social, occupational, or other important areas of functioning,” and is characterized by at least three of these symptoms: irritability, anger or aggression; nervousness or anxiety; sleep difficulties (insomnia); decreased appetite or weight loss; restlessness; depressed mood; and or physical symptoms such as stomach pain, shakiness or tremors, sweating, fever, chills, and headache.

Battle Over ’Addiction’ and ’Dependence’

The APA has gone back and forth between use of the terms “addiction” and “dependence” to describe alcohol and other drug problems, noted researcher Stanton Peele, Ph.D. “Every book I’ve written has the word “addiction” in the title, so I’m glad the term will now be recognized,” wrote Peele in the Huffington Post on Feb. 11. “But the change back may make us wonder whether we will have to reconsider every twenty years or so whether it is more beneficial or harmful to use a word loaded with cultural meanings (“addiction”), or a more neutral term (“dependence”).”

In fact, “dependence” made it into the DSM-IV by just a single vote, O’Brien noted in a May 2006 editorial in the American Journal of Psychiatry co-authored by Nora Volkow, M.D., director of the National Institute on Drug Abuse, and T-K Li, M.D., then-head of the National Institute on Alcohol Abuse and Alcoholism.

“Experience over the past two decades has demonstrated that this decision was a serious mistake,” the trio wrote. “The term ’dependence’ has traditionally been used to describe ’physical dependence,’ which refers to the adaptations that result in withdrawal symptoms when drugs, such as alcohol and heroin, are discontinued. Physical dependence is also observed with certain psychoactive medications, such as antidepressants and beta-blockers. However, the adaptations associated with drug withdrawal are distinct from the adaptations that result in addiction, which refers to the loss of control over the intense urges to take the drug even at the expense of adverse consequences.”

Gambling Addiction Makes the Cut

The proposed DSM-V also would add a new category of “behavioral addictions” which contains a single disorder: gambling addiction. “Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual’s appendix instead, with a goal of encouraging additional study,” according to an APA press release.

The net effect is that the term “addiction” would now be officially applied to more than alcohol and other drug related disorders. “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,” said O’Brien. “Both are related to poor impulse control and the brain’s system of reward and aggression.”

Peele argues that the APA’s addictions category could be expanded even further to include “life-harming, compulsive” involvement with things like sex and food, which are classified in the DSM-V draft as separate “hypersexuality” and “binge eating” disorders.

The APA also is looking to create a classification for patients who suffer withdrawal symptoms when they stop taking tricyclic and selective serotonin reuptake inhibitors, two types of antidepression medication. These “miscellaneous discontinuation syndromes” fall outside the definition of substance-use disorders, APA said, but share some common traits with use of addictive drugs. “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.

Comments Deadline: April 20

APA is accepting public comments on the DSM-V revisions until April 20. “This is the first complete revision of the DSM since 1994,” said NIDA Director Nora Volkow in a Feb. 11 letter to addiction professionals. “… In light of the advances in research on substance abuse and addiction since the last revision, many suggested changes have been proposed in this revision. Therefore, this is an important opportunity to offer your comments on the new criteria.”

All of the proposed changes and information about submitting comments can be found on the DSM-V website.

In addition to O’Brien, members of the DSM-V Substance-Related Work Group included Marc Auriacombe, M.D., Guilherme Borges, M.D., Kathleen Bucholz, Ph.D., Alan Budney, Ph.D., Thomas Crowley, M.D., Bridget Grant, Ph.D., Deborah Hasin, Ph.D., Walter Ling, M.D., Spero M. Manson, Ph.D., and Nancy Petry, Ph.D.