Diagnostic Uncertainty: Changes in the Proposed DSM-5 Worry Addiction Counselors, Research Professionals

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When the American Psychiatric Association (APA) announced proposed revisions in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) last spring, one change to the behavioral health field's guide to diagnosis-the elimination of substance abuse and dependence categories-galvanized the addiction field.

Some professionals expressed an immediate concern that people engaging in risky behavior no longer would be eligible for a low-level "abuse" diagnosis, and that there would be widespread confusion about how to use the new measures. Many were happy to see that the abuse and dependence categories would be disappearing, but remained concerned about how the new category of "substance use disorders" would be applied in everyday practice.

The new category of "substance use disorders" would replace the two abuse and dependence categories. This category comprises two subsets: moderate (2 to 3 criteria) and severe (4 or more criteria); there are 11 criteria in all. While the elimination of the abuse and dependence categories is acceptable to many, the way diagnoses would be arrived at is not.

NAADAC, The Association for Addiction Professionals, in its official comments on the DSM-5 proposals, states that the new substance use disorders category "is so broad that the diagnosis would be of little assistance in determining the type or level of care that would be most appropriate."

As an example of risky behavior that it says would not fall under any official diagnosis under the DSM-5, NAADAC cites the "adolescent client who fails to fulfill role obligations at school and has arguments with his family about his alcohol use." This client might need education and a brief intervention, but not the extended treatment and recovery support needed by "someone who experiences cravings, tolerance and is unable to reduce their substance use." Yet, under the DSM-5, both of these individuals could receive the same diagnosis, and subsequently the same treatment, according to NAADAC.

A diagnosis is beneficial in determining whether someone needs treatment, agrees Marvin D. Seppala, MD, chief medical officer at the Hazelden treatment organization in Minnesota. But it doesn't dictate the level of treatment someone needs. Hazelden uses American Society of Addiction Medicine …