Addiction and dependence in DSM-V

Abstract

As preparations for the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) are under way, this paper focuses upon changes proposed for the substance use disorders section. It briefly outlines the history behind the current nomenclature, and the selection of the term ‘dependence’ over ‘addiction’ in earlier versions of the DSM. The term ‘dependence’, while used in past decades to refer to uncontrolled drug-seeking behavior, has an alternative meaning—the physiological adaptation that occurs when medications acting on the central nervous system are ingested with rebound when the medication is abruptly discontinued. These dual meanings have led to confusion and may have propagated current clinical practices related to under-treatment of pain, as physicians fear creating an ‘addiction’ by prescribing opioids. In part to address this problem, a change proposed for DSM-V is to alter the chapter name to ‘Addiction and Related Disorders’, which will include disordered gambling. The specific substance use disorders may be referred to as ‘alcohol use’ or ‘opioid use’ disorders. The criteria for the disorders are likely to remain similar, with the exception of removal of the ‘committing illegal acts’ criterion and addition of a ‘craving’ criterion. The other major change relates to the elimination of the abuse/dependence dichotomy, given the lack of data supporting an intermediate stage. These changes are anticipated to improve clarification and diagnosis and treatment of substance use and related disorders.

During the mid-1980s a group of addiction experts organized by the American Psychiatric Association, with representation from the World Health Organization, met to revise the Diagnostic and Statistical Manual version III (DSM-III) of the substance-related disorders section. This international committee met over several years in cities such as Washington, Copenhagen and New York, and their work was published in 1987 as DSM-III-R (revised). This was an important achievement because the committee agreed that the disorder in question was compulsive, uncontrolled, drug-seeking behaviour, and defined it by a set of criteria that produced excellent inter-rater reliability. The committee made most decisions unanimously because there was general agreement from the experts as to how the syndrome should be defined (the names of the members are contained in the preface to DSM-III-R). There was a significant disagreement, however, among members of the committee with respect to the label that should be used. The clinicians on the committee were in favor of calling the disorder ‘addiction’ or ‘addictive disorder’, but the non-clinicians argued that the word ‘addiction’ was pejorative and would lead to alienation of the patients whom we want to help. They argued in favor of the more neutral term ‘dependence’, as the discussions were influenced heavily by work on the alcohol dependence syndrome by Professor Griffith Edwards and colleagues [1].

Clinicians, however, pointed out that the word ‘dependence’ was already in use to mean something completely different and normal. They pointed out that ‘tolerance’, consisting of reduced effect of a drug with repeated use, and ‘withdrawal symptoms’ that occurred with medications given to treat pain, depression or anxiety were already labeled ‘dependence’ and were in no way similar to the disorder of uncontrolled drug-seeking as defined in the proposed DSM-III-R. After much discussion and debate, the word ‘dependence’ was chosen by the margin of a single vote.

In 1994 DSM-IV accepted the terminology of DSM-III-R with only minimal changes. Thus, since 1987 the research community has become very comfortable with the use of the term ‘dependence’ for the syndrome of uncontrolled drug-seeking defined originally in DSM-III-R. Unfortunately, the consequences of this terminology for general physicians and their patients have become complicated and often confusing [2]. The word ‘dependence’ was already in use for many years prior to DSM-III-R to describe the adaptations that occur when medications that act on the central nervous system are ingested with rebound if the medication is discontinued abruptly. If the word also stands for compulsive, uncontrolled, drug-seeking behavior, there is inevitable confusion and patients exhibiting normal tolerance and withdrawal without any evidence of abuse or aberrant behavior are associated with those who meet DSM-III-R ‘dependence’ criteria.

Educators with responsibility for teaching about addiction to medical students and general physicians have to explain that there is a normal physiological response called ‘physical dependence’, and there is ‘addiction’, which is drug-seeking behavior called ‘dependence’ in the DSM. The erroneous implication is that ‘dependence’ in the DSM was not physical or physiological. Most importantly, the major reason given for the under-treatment of pain with opioids has been the fear that the physician will create an addiction when, in reality, addiction in the course of pain treatment is relatively uncommon. Thus patients have been made to suffer by receiving inadequate pain medication doses when there is evidence of tolerance or withdrawal symptoms [3].

In order to address these problems, the proposed changes for DSM-V include some changes in terminology. The overall section is labeled ‘Addiction and Related Disorders’. Gambling disorder has been included in this section as anon-substance or behavioral addiction. Other non-pharmacological addictions were also reviewed, but only gambling met criteria for inclusion at this time; internet addiction will be recommended for the Appendix in order to encourage further research.

The ‘abuse category’ has been eliminated from the proposed structure because of the lack of data to support an intermediate state between drug use and drug addiction. The symptoms created for DSM-III-R remain the same, except for the elimination of the ‘legal difficulties’ symptom and the addition of ‘drug craving’. Tolerance and withdrawal symptoms are not counted towards the diagnosis when the patient is involved in an appropriate medical treatment program for a problem such as pain, depression or anxiety. Patients enrolled in such programs can qualify for a substance use disorder only if they have other symptoms of aberrant behavior demonstrating compulsive drug-seeking.

Some working-group members voted in favor of a return to the use of the word ‘addiction’ because the word has become so commonplace in recent years and does not seem pejorative to them. The media has stories about ‘addiction to oil’ and women wear tee-shirts emblazoned with ‘addiction to pink’ or to shopping, etc. Of course, connotations of words change with time and culture; we acknowledge that there are no current studies that can be cited on whether the choice of labels might be pejorative. Because some scientists remain opposed to the use of the word ‘addiction’, we proposed a compromise. The proposed label in DSM-V is now called ‘substance use disorder’, with severity rated according to the number of symptoms.

The proposed changes to DSM-IV have been listed on the American Psychiatric Association website with an invitation for public comment, and we received in all about 8000 with about 500 specifically on substance-related disorders. The comments were reviewed by the Substance Related Disorders Working Group and the final version will be tested in a field trial later this year. The same process will be used for other categories of DSM-V. The final version will be published in 2013.

These changes have already been presented publicly at meetings of the American Psychiatric Association, the Research Society on Alcoholism (RSA) and the College on Problems of Drug Dependence (CPDD). At the 2009 CPDD meeting the audience was asked if there were any problems with the use of the word ‘addiction’ as a diagnosis, and there were no objections. At the 2010 RSA symposium on DSM-V, the audience present was almost unanimous in its support of the word ‘addiction’. Nevertheless, the working group, in an effort to minimize controversy, is recommending the more neutral label of ‘substance use disorder’ with subcategories of ‘alcohol use disorder’, ‘heroin use disorder’, etc. Our hope is that these changes will produce clarification while avoiding the confusion produced by the word ‘dependence’ in previous versions of the DSM.