DSM V Heals All Substance Abuse and Dependence

Disorders

Tiffany Hairston, MA

John Laux, PhD

The University of Toledo

DSM V Combines Abuse & Dependence

Soon, instead of having substance abuse or dependence, you’ll have a substance use

disorder.

Background? DSM III-R & IV’s substance dependence was based on

the Alcohol Dependence Syndrome (Edwards & Gross, 1976)

Dimensional construct representing impaired control over drinking

Syndrome = psychobiological process leading to impaired control over persistent & heavy drinking.

Background? The causes of dependence were different from causes of

substance-related consequences/disabilities.

Gave rise to dependence and abuse.

Edwards saw the two axes as continuum, but DSM made dependence take precedence hierarchically over abuse.

W.H.O generalized this model to drugs.

Problems with the DSM III-TR & IV Model

General population studies showed the most common way for alcohol abuse to be diagnosed was with a single criterion: hazardous use (questionable)

“diagnostic orphans”: Ss who meet 2 criteria for dependence but none for abuse.

Problems with the DSM III-TR & IV Model Test-retest Reliability

test-retest reliability of DSM-IV dependence is good to excellent

the reliability of DSM-IV abuse is lower and more variable.

Research fails to support that abuse is a prodromal phase of dependence.

Problems with the DSM III-TR & IV Model

Clinical & general population samples suggest

DSM-IV abuse & dependence criteria are a unidimensional structure

Severity Spectrum

Abuse Dependence

The “Why” Summary and Conclusion No evidence of a distinction between Abuse &

Dependence.

What should we do?

Combine abuse & dependence into a single disorder of graded clinical severity

2 criteria required to make a diagnosis.

New DSM Category: “Substance Use and Addictive Disorders” includes both substance use disorders and non-

substance addictions.

Gambling Disorder (previously an Impulse-Control Disorders Not Elsewhere Classified) has been moved into this category.

Substance Use and Addictive Disorders

Substance-Induced Psychotic Disorder Substance-Induced Sleep-Wake

Disorder

Substance-Induced Bipolar Disorder Substance-Induced Sexual

Dysfunction

Substance-Induced Depressive

Disorder

Substance-Induced Delirium

Substance-Induced Anxiety Disorder Mild Neurocognitive Disorder

Associated with Substance Use

Substance-Induced Obsessive-

Compulsive or Related Disorders

Major Neurocognitive Disorder

Associated with Substance Use

Substance-Induced Dissociative

Disorder

Substance Use and Addictive Disorders

Alcohol Use Disorder Opioid Use Disorder

Amphetamine Use Disorder Phencyclidine Use Disorder

Cannabis Use Disorder Sedative, Hypnotic, or Anxiolytic Use

Disorder

Cocaine Use Disorder Tobacco Use Disorder

Hallucinogen Use Disorder Other (or Unknown) Substance Use

Disorder

Inhalant Use Disorder

Substance Use and Addictive Disorders

Alcohol Intoxication Inhalant Intoxication

Amphetamine Intoxication Opioid Intoxication

Caffeine Intoxication Phencyclidine Intoxication

Cannabis Intoxication Sedative, Hypnotic, or Anxiolytic

Intoxication

Cocaine Intoxication Other (or Unknown) Substance

Intoxication

Hallucinogen Intoxication

Substance Use and Addictive Disorders

Alcohol Withdrawal Opioid Withdrawal

Amphetamine Withdrawal Sedative, Hypnotic, or Anxiolytic

Withdrawal

Caffeine Withdrawal Tobacco Withdrawal

Cannabis Withdrawal Other (or Unknown) Substance

Withdrawal

Cocaine Withdrawal

Gambling Disorder

Substance Use Disorder Defined A. A maladaptive pattern of substance use leading to

clinically significant impairment or distress, as manifested

by 2 (or more) of the following, occurring within a 12-

month period:

Substance Use Disorder Defined 1. recurrent substance use resulting in a

failure to fulfill major role obligations at

work, school, or home (e.g., repeated

absences or poor work performance related

to substance use; substance-related

absences, suspensions, or expulsions from

school; neglect of children or household)

Substance Use Disorder Defined 2. recurrent substance use in situations in

which it is physically hazardous (e.g.,

driving an automobile or operating a

machine when impaired by substance use)

Substance Use Disorder Defined 3. continued substance use despite having

persistent or recurrent social or

interpersonal problems caused or

exacerbated by the effects of the substance

(e.g., arguments with spouse about

consequences of intoxication, physical

fights)

Substance Use Disorder Defined

4. tolerance, as defined by either of the

following:

a need for markedly increased amounts of

the substance to achieve intoxication or

desired effect

markedly diminished effect with continued

use of the same amount of the substance (Note: Tolerance is not counted for those taking medications under

medical supervision such as analgesics, antidepressants, ant-anxiety

medications or beta-blockers.)

Substance Use Disorder Defined 5. Withdrawal, as manifested by either of the

following:

a. the characteristic withdrawal syndrome for the substance

b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)

Substance Use Disorder Defined 6. The substance is often taken in larger

amounts or over a longer period than was

intended

Substance Use Disorder Defined 7. There is a persistent desire or unsuccessful

efforts to cut down or control substance use

Substance Use Disorder Defined 8. A great deal of time is spent in activities

necessary to obtain the substance, use the

substance, or recover from its effects

Substance Use Disorder Defined 9. Important social, occupational, or

recreational activities are given up or

reduced because of substance use

Substance Use Disorder Defined 10. The substance use is continued despite

knowledge of having a persistent or

recurrent physical or psychological

problem that is likely to have been caused

or exacerbated by the substance

Substance Use Disorder Defined 11. Craving or a strong desire or urge to use a

specific substance.

Determining Severity Need 2 criteria for SUD

2-3 criteria = moderate

4 or more = severe

Gambling Disorder A. Persistent and recurrent maladaptive gambling

behavior as indicated by five (or more) of the following: 1. is preoccupied with gambling (e.g., preoccupied with

reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble

2. needs to gamble with increasing amounts of money in order to achieve the desired excitement

3. has repeated unsuccessful efforts to control, cut back, or stop gambling

4. is restless or irritable when attempting to cut down or stop gambling

Gambling Disorder 5. gambles as a way of escaping from problems or of

relieving a dysphoric mood 6. after losing money gambling, often returns another

day to get even 7. lies to family members, therapist, or others to conceal

the extent of involvement with gambling 8. has jeopardized or lost a significant relationship, job,

or educational or career opportunity because of gambling

9. relies on others to provide money to relieve a desperate financial situation caused by gambling

B. The gambling behavior is not better accounted for by a Manic Episode.

Case Study #1 Sara reports that she first tried crack cocaine at age 35, which was

2 years ago. She states that she only used on weekends, at least $20 worth but $40 worth on average. Sara indicates that this pattern continued for most weekends until 1 month ago, when she was sober for approximately 30 days from all substances. Client used crack cocaine again 3 days ago, which was her most recent use. She does not believe she is addicted to crack cocaine and insists that it has not caused her any problems because "nobody knows" she is using again. However, Sara does admit that when she began using crack cocaine, both her father and her then-boyfriend were very upset and told her not to use, but she has continued to use anyway despite her family's ongoing objections and arguments.

Case Study #1 DSM-IV-TR:

305.60 Cocaine Abuse

Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

DSM-V:

No Substance Use Disorder diagnosis

Must have at least 2 criteria

Case Study #2 Sara reports that she first tried marijuana at age 8. She states that her

father kept marijuana in the home and used it regularly at the time. Sara indicates that she did not use marijuana again until age 17, when she began smoking a "couple of joints" daily, which she reports took up a considerable amount of her time. This pattern of daily use continued for 15+ years until 2008, when she was put on probation and "had to drop weekly" for her probation officer. Client reports that she was "tired of" using marijuana, and went the whole year without it (2008-2009). However, Sara relapsed in 2009 and has been using at least 1 "blunt" every day since. She denies having any problems as a result of her marijuana use; however, she was arrested and charged with both drug paraphernalia and drug possession in 2008. Sara denies ever experiencing any symptoms of withdrawal for cannabis. She did admit that her marijuana use negatively impacted her employment because "I would end up quitting my jobs, I wasn’t thinking right”. Sara last used marijuana yesterday, 2 "blunts".

Case Study #2 DSM-IV-TR:

304.30 Cannabis Dependence

Unsuccessful efforts to cut down or control substance use

Spending a great deal of time using

Occupational activities are given up because of substance use

DSM-V:

Cannabis Use Disorder, Moderate

2-3 criteria = moderate

Case Study #3 Sara reports that she first used opiates at age 14 after breaking her

collarbone. She states she took the medication as prescribed. Client tried opiates again at age 19, when she began buying Percocet 10’s off the street, and was using 2-3 pills daily. Sara reports that this pattern continued "off and on" until age 35. She denies that her use ever increased from ages 19-35, "because I couldn't afford it". At the age of 35, Sara indicates that she began using heroin because "it was around", and started snorting "10 cc's" daily to achieve her desired effects. Within 1 month, client was using "40 cc's" per day to achieve her desired effects, and approximately 1 year ago, Sara began injecting the drug for a more intense/faster high, which she admits took up a great deal of her time. This pattern of daily use continued until 3 months ago, when Sara was put on Suboxone at the X Clinic. Client reports that she stayed sober for 1 month, but could not afford the cost of the Suboxone treatment and eventually relapsed. When she tried to stop using opiates, Sara reports that she experienced the following symptoms: muscle aches, "sick to my stomach", and not being able to sleep. Her last use of heroin was "20 cc's" injected 3 days ago.

Case Study #3 DSM-IV-TR:

304.00 Opioid Dependence

Tolerance

Withdrawal

Unsuccessful efforts to cut down or control substance use

Spending a great deal of time using

DSM-V:

Opioid Use Disorder, Severe

4 criteria = severe