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Commentary: DSM-5: New Addiction Terminology, Same Disease

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Some over the years have wanted to envision addiction as being represented on a pyramid where mere use falls at the base of the pyramid, abuse falls partway up, and dependence lives at the peak. This type of approach suggests a continuum in which an individual might go up and down on the pyramid depending upon the conditions at any given time. Yet no such continuum exists. Those with addictive disease generally recognize that they are using in a manner that differs from their peers from the time of their very first use. And it is only a very rare individual who does not have addictive disease, then develops the illness as a result of the impact of addictive substances on his or her brain.

DSM-5 has now arrived. It is critical to recognize that addictive disease itself has not changed with this new publication. The disease is what it was. We may use different terminology, as “abuse” is now gone, and “dependence” has returned to its pharmacologic roots where it will again refer to the development of tolerance and withdrawal. We applaud DSM-5 for using the term “addictive disorders” within its overall framework. DSM-5 does not, however, speak to addiction but rather to some of the markers seen with addictive illnesses.

Let’s use alcohol as an example. DSM-5 has “Alcohol Use Disorder,” which comes in mild, moderate and severe flavors, suggesting the inadequate pyramid approach. There are 11 possible symptoms of the “use disorder,” of which two are necessary to achieve a mild specifier, four for moderate and six for severe. “Alcohol use disorder is defined by a cluster of behavioral and physical symptoms,” the authors of DSM-5 state. I have no problem with that except that some may confuse “alcohol use disorder” with addictive disease or with alcoholism or with what the field in general has defined as being a specific abnormality of the brain’s reward system producing repetitive use despite negative consequences.

In DSM-5, mild alcohol use disorder is present if the patient has tolerance and withdrawal. Nothing else is necessary. Yet tolerance and withdrawal are measurable metabolic factors that are present for alcohol within just a few hours of use. How much tolerance and withdrawal are necessary to achieve this particular part of the diagnosis? In fact, anyone drinking a couple of glasses of wine with dinner each evening will have measurable and noticeable tolerance and withdrawal. It won’t be present to the extent of causing significant dysfunction, but it will be quite evident on exam. That person now has a mild alcohol use disorder. But that shouldn’t be confused with mild addiction or mild alcoholism, or even mild DSM-IV abuse. It isn’t any of those things.

As for moderate alcohol use disorder, let’s say that we have a patient who drinks in larger amounts or over longer periods than intended, persistently tries and fails to stop drinking, fails to fulfill major role obligations and recurrently uses alcohol in situations where such use is physically hazardous. If these are the only difficulties present, the patient has a moderate degree of severity of the illness. We’ll hypothesize that the patient drinks only in a binge-like manner so tolerance/withdrawal do not develop to the point that either is counted. If they were present, we’d have someone with a severe alcohol use disorder, yet the individual drinking in a binge-like manner may well have greater risk of morbidity/mortality than the individual utilizing a consistent amount on a daily basis. So the moderate and severe specifiers in this case may actually be the reverse of the actual case where we utilize such specifiers to indicate or suggest risk, danger and need for treatment.

DSM-5 failed again to put alcohol use disorders together with sedative use disorders, continuing the scientifically inaccurate suggestion that the two somehow differ from one another, and undoubtedly leading yet another generation of clinicians to the inevitable conclusion that there is no problem prescribing a benzodiazepine to an individual with an “alcohol use disorder.” Alcohol is simply a central nervous system depressant, like barbiturates and benzodiazepines, and the authors of DSM-5 seem to have overlooked the importance of grouping like substances together.

Ultimately, the definitions in DSM-5 are definitions for a new set of illnesses. They have different terminology and are accompanied by new defining structures. A patient who ends up in the ER only once each year due to a suicide attempt, car accident, slip/fall, barroom brawl, each time after imbibing considerable alcohol, does not meet criteria for even a mild alcohol use disorder. And a college student who is not an alcoholic does meet criteria for a mild alcohol use disorder if he has tolerance and hangovers.

Now it’s up to us to remember that addictive illness is still addictive illness; it remains unchanged despite the arrival of DSM-5.

Stuart Gitlow MD MPH MBA

Dr. Gitlow is President, American Society of Addiction Medicine (ASAM). His commentary reflects personal opinion and is not necessarily reflective of the official position of ASAM.

7 Responses to this article

  1. Avatar of art sampson
    art sampson / January 19, 2014 at 7:06 pm

    Alcoholism is caused by alcohol

  2. Carlos / June 12, 2013 at 2:48 pm

    My problems with the DSM system is that all 300 plus diagnoses are based on consensus that are based on “clinical experience” and not scientific research that would in fact verify or not whether there is a brain disorder. It is way too hypothetical, and somehow not enough emphasis is place by the Am. Psychiatric Association to demand scientific research so that this diagnosis is more uniform and lacking in personal biases of the practitioners. For example: In the prior DSM IV and its versions, I kept seeing clinicians traditionally giving patients a diagnosis of “Opiate Dependence” or other Substance Dependence Disorder way after (a week or so) the patient has already gone through detoxification, and the patients no longer meets the criteria for that Diagnosis 304.0. I think this diagnosis should be reserved for patients that are going in the hospital or other facilities for medical detoxification. When the persons has gone pass the detox, if done correctly he/she do no longer meet that criteria and some other diagnosis should be used like Obsessive Disorder. Alcohol Use Disorder or Opiate Use Disorder may even be a lot more fitting than depencence the patients are no longer experiencing, Which is what is actually happening with the patient. He/she is no longer physically tolerant (which has supposely lower), and obviously they are no longer going through withdrawls. He/she is cognitively obsessing over using or drinking again. And they are no longer physically dependent like the Diagnosis for dependency strongly implies. In all other field of medicine, the diagnosis drives the treatment the patients receive. The use of disease, seem to be use also by institutionalized. The evidence suggest the possibility of a disease, but the data does not seem be conclusive. There is way too many different possibilities. And we do not have any unbiase measuring instruments (like a termometer, X-Ray, or blood test) to measure the existance, intensitive or differences from one patient to another.

    These are not to be clear so in Substance Use treatment. I am hoping with the new system, that we are going toward more systematic and uniformity. There is too much flexibility and there are too many differences and interpretation from one practitioner to another, seems sloppy to me.

  3. Stuart Gitlow / June 10, 2013 at 1:36 pm

    Mr. Abbott, thank you for your comment. I wasn’t stating anything other than standards in the field that have been known for well over 40 years with the statements that you quoted from the article. There are extensive studies in the literature demonstrating both points. The second statement, by the way, refers to rare cases because there are indeed some psychoactive drugs that cause damage to specific areas of the brain such that addictive disease arises when it was not present previously. Alcohol isn’t one of those. I can’t turn someone who isn’t alcoholic into an alcoholic by giving them alcohol. What I can do, of course, is make their illness evident, but generally there will have been other markers present beforehand.

  4. Stuart Gitlow / June 10, 2013 at 1:31 pm

    Mr. Kilcullen, thank you for your comment. Withdrawal is a simply defined syndrome – see the standard text in the pharmacologic field for this (Goodman & Gilman’s Pharmacologic Basis of Therapeutics). It merely requires removal of the drug and central nervous system hyper-arousal owing to readaptation. Being “sick” in the am from having consumed excessive tolerance-inducing substance the night before is, by definition, withdrawal, because such symptoms can be avoided through a gradual taper of the drug that was utilized the night before.

  5. Avatar of Joe Kilcullen
    Joe Kilcullen / June 9, 2013 at 4:39 pm

    There is a world of difference between withdrawal and being sick in the AM from having consumed an excessive amount of a toxic substance the night before. I also challenge your statement that no one has gone from not having the disease to getting it after repeated abuse of ethanol.

  6. Michael Abbott / June 7, 2013 at 7:41 pm

    “Those with addictive disease generally recognize that they are using in a manner that differs from their peers from the time of their very first use. And it is only a very rare individual who does not have addictive disease, then develops the illness as a result of the impact of addictive substances on his or her brain.” What in the world is this man talking about? As for disease severity, I think that severity may refer to the intensity of treatment needed, not associated morbidity/ mortality. What does the rest of the ASAM membership think of the concepts expressed by their president?

  7. Avatar of Susan Hart
    Susan Hart / August 17, 2013 at 3:02 pm

    Thanks for all the info and comments on the new DSMV. All would be “well” if there are a set of rules that would work universally. This disease kills many who really didn’t have to die, I believe my life was saved so I can help save others.
    Carlos what new system are you referring to?

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