Commentary: DSM Rewrite — Don’t Forget About the Adolescents

So much has been said about the making of the new DSM-5 that I agree with. I think it’s an excellent start by a group of thoughtful experts in our field. And there is much to like about the new proposal when applied to adolescents. For example, it appears to include the Substance Use Disorder domain with another related group of disorders labeled “Addictive Disorders.” I also appreciate that the Substance Use Disorders (SUD) domain will have three sub-types: mild, moderate and severe, and that so far there is no direct use of the nomenclature of “addiction” within this scheme.

But, for adolescents, I still see two problems with the proposed revisions.

One issue pertains to the proposed title of this section, “Substance Use Disorders and Addictive Disorders.” The title implies that a SUD (even the mild version) is a mild form of addiction. The term addiction was derived from Latin meaning “bound to” or “enslaved by.” With respect to substances, addiction is associated with continued and compulsive drug use in the presence of negative consequences. Whereas a teenager who reports the presence of the majority of the 11 symptoms is likely showing signs of continued and compulsive use, it is not clear that a mild or moderate case (e.g., presence of two or three criteria) represents a behavioral disorder that is at the low-end of addiction.

In prior DSM systems, this severe-end of drug use was accompanied by a less advanced but clinically relevant concept of abuse. This historical point leads us to my second major concern. The removal of the abuse concept is problematic. The diagnostic abuse category, despite its faults (e.g., DSM-IV’s liberal rule that the presence of one criteria was sufficient for an abuse diagnosis), is particularly appropriate for adolescents.

There is a large body of scientific literature that addresses the differences between patterns, trajectories and implications for intervention for adolescents and adult drug involvement (Chung & Martin, 2011). This body of work, often referred to as a bio-behavioral developmental perspective, indicates that adolescents with a substance use disorder, whether with or without a co-existing mental or behavioral disorder, are not simply “miniature adults.” Empirical data indicate that the progression from drug use, which usually begins in adolescence, to a severe-end state of addiction, represents a heterogeneous clinical continuum. This perspective supports the notion that drug involvement by youth at the early stages routinely involves the emergence of significant social and psychological consequences that merit early detection and referral to non-intensive treatments. The current construction of DSM-5 with its absence of an abuse category may prevent youth with a mild problem from getting appropriate services, such as a brief intervention.

To make a good start even better, particularly for adolescents, the term “Addiction” should not appear in the same category title as “Substance Use Disorders,” and developmental changes referred to above should be incorporated accordingly.

Ken C. Winters, PhD is Associate Director of the Parents Translational Research Center at the Treatment Research Institute. He is also Director of the Center for Adolescent Substance Abuse Research at the University of Minnesota.

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