Set to release May 2013, the DSM-V, Diagnostic and Statistics Manual, has made new revisions to defining Addiction as well as raising a riot among other categories. Could the DSM-V changes harm more than help those it effects?
In relation to addiction, the DSM-V will no longer be using term or labels such as “substance dependence” and “substance abuse” but will instead classify addiction problems under the heading “Substance Use and Addictive Disorders.”Substance abuse—which was used to characterize drug problems that fall short of outright addiction, like college binge drinking—is a highly stigmatizing and misleading term. If “child abuse” means harming a child, does “drug abuse” mean harming a drug? It never made any sense linguistically and only served to associate drug users with abusive people in the public mind. Indeed, one randomized controlled trial showed that healthcare professionals who read vignettes about patients described as “substance abusers” supported more punishment and less therapy than those who read about the same patients identified as having “substance use disorders.”
Even worse is “substance dependence.” The term was placed into a revision of the third edition of the DSM, DSM III-R, in the ’80s as a euphemism for addiction with the intention of using a “medical sounding,” or nonstigmatizing, phrase.Dr. Charles O’Brien, a professor of psychiatry at the University of Pennsylvania whose addiction expertise is so renowned that Penn even named it treatment center after him, described the events in a 2006 article co-written with NIDA director Nora Volkow:
There was good agreement among committee members as to the definition of addiction, but there was disagreement as to the label that should be used. The proponents of the term “addiction” believed that this word would convey the appropriate meaning of the compulsive drug-taking condition and would distinguish it from “physical” dependence, which is normal and can occur in anyone who takes medications that affect the [brain]. Those who favored the term “dependence” felt that this was a more neutral term that could easily apply to all drugs, including alcohol and nicotine. The committee members argued that the word “addiction” was a pejorative term that would add to the stigmatization of people with substance use disorders.A vote was taken at one of the last meetings of the committee, and the word “dependence” won over “addiction” by a single vote. Experience over the past two decades has demonstrated that this decision was a serious mistake.
Moreover, with the term “dependence” in the medical definition of addiction itself, it became very difficult to teach people that needing a drug to function isn’t the essence of addiction. The misdefinition encapsulated the idea that suffering withdrawal—rather than compulsive use despite negative consequences—was fundamental to the problem. That meant that the drive to take drugs—now demoted to being called merely “psychological dependence”—was less important than getting sick if you couldn’t get the drug.
In reality, this desire—and related repetitive drug-taking—matters far more than how sick you get when you try to stop. In fact, with heroin withdrawal, the severity of symptoms like vomiting and diarrhea isn’t particularly linked to relapse risk, which is far more associated with how much the person wants the drug. With cocaine, which doesn’t make you sick at all if you quit abruptly, the entire addiction is “in your head” or “psychological”—but that obviously doesn’t make crack not addictive!
Other changes to made include a possible removal of Asperger’s Syndrome from the manual that could result in denial of needed services and widespread underdiagnosis of autism, addition of certain mood disorders, and addition of substance induced disorders.