The Diagnostic Criteria For Substance Use Disorders
7. Sedatives, Hypnotics, or Anxiolytics 8. Stimulants 9. Tobacco
*Substance use disorder does not apply to caffeine.
Regardless of the particular substance, the diagnosis of a substance use disorder is based upon a pathological set of behaviors related to the use of that substance. These behaviors fall into four main categories:
1. Impaired control4. Pharmacological indicators
Let’s review each of these key diagnostic criteria in greater detail.
1.A. Impaired control:
Impaired control may be evidenced in several different ways:
1) Using for longer periods of time than intended, or using larger amounts than intended 2) Wanting to reduce use, yet being unsuccessful doing so 3) Spending excessive time getting/using/recovering from the drug use 4) Cravings that are so intense it is difficult to think about anything else.
2.B. Social impairment
You may recall our definition of addiction: Addiction is repeated involvement with a substance or activity, despite the substantial harm it now causes, because that involvement was pleasurable and/or valuable. Social impairment is one type of substantial harm caused by the repeated use of a substance or an activity.
5) People may continue to use despite problems with work, school or family/social obligations. This might include repeated work absences, poor school performance, neglect of children, or failure to meet household responsibilities.
3.C. Risky Use
4.D. Pharmacological indicators: Tolerance and Withdrawal
Criteria For Substance Use Disorders
NSDUH assesses substance abuse and substance dependence. DSM-IV and DSM-5 also assess substance intoxication, intoxication delirium, withdrawal syndrome, and withdrawal delirium for relevant substances. Because NSDUH does not assess those additional disorders, this report focuses only on changes to substance abuse and dependence criteria.
How Are Substance Use Disorders Categorized In The Dsm
The current edition of the Diagnostic and Statistical Manual of Mental Disorders has combined the prior categories of substance abuse and substance dependence under Substance Use Disorders– which encompasses various types of addiction and dependence.
Lets take a look at the criteria that is now used to diagnose substance use disorders, according to the American Psychiatric Association:
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Some Suggestions To Get Started:
- Learn all you can about alcohol and drug misuse and addiction.
- Speak up and offer your support: talk to the person about your concerns, and offer your help and support, including your willingness to go with them and get help. Like other chronic diseases, the earlier addiction is treated, the better.
- Express love and concern: don’t wait for your loved one to “hit bottom.” You may be met with excuses, denial or anger. Be prepared to respond with specific examples of behavior that has you worried.
- Don’t expect the person to stop without help: you have heard it before – promises to cut down, stop – but, it doesn’t work. Treatment, support, and new coping skills are needed to overcome addiction to alcohol and drugs.
- Support recovery as an ongoing process: once your friend or family member is receiving treatment, or going to meetings, remain involved. Continue to show that you are concerned about his/her successful long-term recovery.
What Is Harmful Use
Health officials consider substance use as crossing the line into substance abuse if that repeated use causes significant impairment, such as:
In other words, if someone drinks enough to get frequent hangovers uses enough drugs that they miss work or school smokes enough marijuana that they have lost friends or often drinks or uses more than they intended to use, their substance use is probably considered misuse or harmful use. However, there is a broad range of substance abuse in today’s society.
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Factors Affecting What Being High Feels Like
When people are stoned on marijuana, the experience is strongly affected by factors that have little to do with the drug, and more to do with the sensitivity of the person taking the drug to their surroundings and their feelings about the people they are with.
The frame of mind of the person using marijuana is known as “set” and the environment where they use marijuana as “setting.”
Should The Name Of The Chapter Be Changed
With the addition of gambling disorder to the chapter, a change in the title was necessary. The Board of Trustees assigned the title Substance-Related and Addictive Disorders, despite the DSM-5 Substance-Related Disorders Work Group having previously approved a title that did not include the term addiction. This lack of agreement over the title reflects an overall tension in the field over the terms addiction and dependence, as seen in editorials advocating addiction as a general term, reserving dependence specifically for tolerance and/or withdrawal, and the more than 80 comments on these editorials that debated the pros and cons of these terms.
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What Is The Dsm
The DSM-5 is the reference guide psychiatrists and other mental health professionals use to diagnose a variety of mental illnesses.1
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders provides the most up-to-date published information on mental disorders and diagnostic criteria. It also includes information on how racism and discrimination impact mental disorders.
The DSM-5 now categorizes substance use disorder into a single continuum. There are no longer two separate definitions for substance abuse and substance dependence.
Categories Of Substance Use Disorder Symptoms
The American Psychiatric Association , the health professionals behind the DSM-5, recognizes four categories of substance use disorder criteria.
The four categories are:
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What Does Being High On Marijuana Feel Like
Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital.
Many people who are curious about smoking pot, or who have family members or friends who use marijuana, wonder, “What does being high feel like?” Although the experience is different for everyone, there are certain effects that most users of feel when they smoke or eat pot.
Common responses to inhaling or ingesting marijuana include feeling:
Symptoms Of Dsm 5 Substance Use Disorder
A substance use disorder can lead to depression.
Symptoms of DSM 5 substance use disorder develop out of the brain and bodys growing dependence on drug/alcohol effects. In order to be diagnosed with this disorder, a person must exhibit at least two of the following 11 symptoms within a 12-month period:
- Loss of control over drug/alcohol use
- Investing large amounts of time obtaining substances
- Continued use in spite of relationship conflicts
- Risk-taking, such as using while driving
- Continued use in the face of developing health problems
- Increasing tolerance levels
- Loss of interest in activities once enjoyed
- Withdrawal episodes
Coping with a mental illness is no easy task, making drug abuse and addiction a common occurrence among those affected.
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Recent Literature Devoted To The Dsm
Given the recency of the finalized revision and its release, there is a relative paucity of research focused on the implications of the new diagnostic criteria. The vast majority of existing studies have concentrated on how the abuse and dependence designations of the DSM-IV compare to the index of the DSM-5. One focal issue which has arisen as a result of the collapse of the two distinct DSM-IV diagnoses is the increase in the prevalence of SUDs. Evidence has shown this increase in diagnosable cases can range anywhere from < 111 %, due primarily to the occurrence of diagnostic orphans now receiving a SUD diagnosis under the DSM-5 .
Evidence also shows certain patterns in the convergence of the two approaches . For instance, the majority of cases which met DSM-IV abuse criteria will not receive a DSM-5 diagnosis because they fail to meet the minimum two-criterion threshold for a mild SUD. Most DSM-IV abuse cases, which also endorsed two dependence criteria, will now receive a mild SUD designation, but some who endorsed multiple abuse criteria and two to three dependence criteria will now be classified with a moderate SUD. DSM-IV dependence cases who met three dependence criteria and no more than two abuse criteria will be classified as DSM-5 moderate SUDs, while almost all of those who met four or more dependence criteria will be classified as severe SUDs.
Needless Increase In Diagnoses
Critics of the revisions claim the DSM-5 expands the list of what is considered mental illness and leads to a needless increase in diagnoses. The most damaging criticism of the DSM-5 came from the National Institute of Mental Health , which withdrew its support of the manual two weeks before its publication. The NIMH, the largest funding agency for mental health research, announced that it would be reorienting its research away from DSM categories.
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Preventing Substance Use Disorder
Even though you have numerous danger factors for addiction, you can fight or prevent it. Risk factors can increase your odds of becoming hooked, but they do not ensure it.
If you have a suspicion that you have an addiction, get assistance from your doctor. Counseling, medicines, and other treatment options may be recommended by your doctor or treatment center. A healthy life may be lived after recovering from addiction.
The Dsm 5 Has Eleven Criteria For Substance Use Disorders Based On Decades Of Research
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or DSM-5, is the American Psychiatric Associations goldstandard text on mental health that was crafted by hundreds of mental health experts.
The DSM-5 has eleven criteria, or symptoms, for substance use disorders based on decades of research. The DSM-5 has helped change how we think about addictions by not overly focusing on withdrawal.
Three Levels of Severity
The DSM-5 includes guidelines for clinicians to determine how severe a substance use disorder is depending on the number of symptoms. Two or three symptoms indicate a mild substance use disorder four or five symptoms indicate a moderate substance use disorder, and six or more symptoms indicate a severe substance use disorder. A severe SUD is also known as having an addiction.
Doctors determine the severity level of the substance use disorder to help develop the best treatment plan. The higher the severity, the more intensive the level of treatment needed.
Most patients are likely to need ongoing treatment and recovery support using a chronic care model for several years. A doctor should monitor progress and adjust the plan as needed.
Like other illnesses, addiction gets worse over time. Similar to stages of cancer, there are levels of severity to describe a substance use disorder.
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The Prescription Exclusion: Diagnosis As Social Control
If the opioid misstep had stopped at a purely terminological change, it would have been minimally impactful on research and clinical diagnosis, but it did not. Recall that DSM-5 lowered the SUD diagnostic threshold from DSM-IV’s 3 of 7 symptoms to any 2 of 11 symptoms, including tolerance and withdrawal. Thus, the DSM-5 workgroup actually created the very problem that supposedly they were trying to address they made it possible to diagnose SUD based on the two physiological dependence symptoms alone, thus potentially confusing physiological adaptation with impaired-control use. This self-created problem conflicted with the goal of facilitating prescription of opioids for pain.
An important exception to making a diagnosis of DSM-5 substance use disorder with two criteria pertains to the supervised use of psychoactive substances for medical purposes, including stimulants, cocaine, opioids, nitrous oxide, sedative-hypnotic/anxiolytic drugs, and cannabis in some jurisdictions. These substances can produce tolerance and withdrawal as normal physiological adaptations when used appropriately for supervised medical purposes. Under these conditions, tolerance and withdrawal in the absence of other criteria do not indicate substance use disorders and should not be diagnosed as such.
Critics Claim Alcoholism Mislabeled With New Criteria
According to the new criteria, a college student who binge drinks on weekends and occasionally misses a class would be diagnosed with a mild alcohol abuse disorder. This is part of where the controversy lies.
Critics say the revised criteria could lead to college or underage binge drinkers to be mislabeled as mild alcoholics, a diagnosis the could follow them into their later years.
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The Pragmatic Argument For The 2
Concerns that the threshold of two or more criteria is too lowwere weighed against the competing need to identify all cases meriting intervention, including milder cases, for example, those presenting in primary care.
Construed one way, this argument is a textbook example of begging the question. Mild cases of a disorder are still true cases, and no one is objecting to identifying mild cases of addiction. The objection is that the added caseswhich are indeed symptomatically mildare not mild cases of addictive disorder but rather not true cases of addictive disorder at all. Just as sneezing due to dust in the air is not a mild case of a cold, developing some tolerance to alcohol over time from social and mealtime drinking and driving home from social occasions after drinking is not generally mild addictive disorder. The workgroup’s reply that we need to identify all cases including the mild ones begs the question of validity.
Toxicity And Side Effect Management
Patients who are physically dependent on sedative effects often require medication during the detoxification process to minimize the risks associated with complicated withdrawal. Acute intoxication can present with slurred speech, cognitive impairment, poor coordination, and unsteady gait. For alcohol and benzodiazepine withdrawal, the Clinical Institute Withdrawal Assessment scale helps determine the frequency of medication dosing to prevent withdrawal complications. In an emergency setting, treatment for alcohol and benzodiazepine intoxication is primarily supportive, with close monitoring of vitals. Benzodiazepines are considered a first-line treatment to prevent worsening withdrawal symptoms. In cases of severe benzodiazepine intoxication, particularly if the patient is becoming hypoxic, flumazenil may be indicated. Flumazenil reduces the expression of GABA subunit receptors, reversing the effect of benzodiazepines.
For opioid intoxication, naloxone is used to reverse respiratory depression caused by opioid overdose. Naloxone is a competitive mu-opioid receptor antagonist, which reverses the effects of opioids. It can be administered intramuscularly, intravenously, or nasally the fastest route of administration is intravenous.
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Severity Levels Of Substance Use Disorders
Similar to other mental health disorders, the DSM-5-TR lists three levels of substance use disorders.
The number of criteria the patient relates to, along with the family history of drug abuse and current health, determines a patients SUD severity.
What level a patient falls into can help doctors decide which addiction treatment programs are recommended for recovery.
The sooner a patient receives treatment, the less likely a SUD can develop into deeper issues.
The three levels of SUD severity are:
Diagnosing Substance Abuse Disorders With Dsm
Using the above criteria, identifying the severity of the substance abuse, and categorizing the persons symptoms is how mental health professionals use the DSM-5 to diagnose SUD.
Understanding how far along someone is in their substance use disorder helps doctors and therapists recommend the right treatments.
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Should Any Diagnostic Criteria Be Dropped
If any criteria can be removed while retaining diagnostic accuracy, the set will be easier to use in clinical practice. The work group considered whether two criteria could be dropped: legal problems and tolerance.
Reasons to remove legal problems from the criteria set included very low prevalence in adult samples and in many although not all adolescent samples, low discrimination , poor fit with other substance use disorder criteria , and little added information in item response theory analyses . Some clinicians were concerned that dropping legal problems would leave certain patients undiagnosed, an issue specifically addressed among heavy alcohol, cannabis, cocaine, and heroin users in methadone and dual-diagnosis psychiatric settings . None of these patients reported substance-related legal problems as their only criterion or lost a DSM-5 substance use disorder diagnosis without this criterion. Thus, legal problems are not a useful substance use disorder criterion, although such problems may be an important treatment focus in some settings.
Concerns about the tolerance criterion included its operationalization, occasional poor fit with other criteria , occasional differential item functioning , and relevance to the underlying disorder . However, most item response theory articles on substance use disorder criteria did not find anything unique about tolerance relative to the other criteria.
Alternative Psychometric Models For Latent Constructs
What would it mean for a list of such criteria to constitute a unidimensional latent construct? There are several alternative psychometric measurement models that can operationalize a latent construct. They quite literally imply different metaphysical assumptions ontologically, what construct exists, and epistemologically, how to do we identify it? but also different mathematical definitions. The discussion that follows gets slightly technical, and requires a few simple equations, but to keep things simple I assume there is only one latent construct and that the terms in the model have unit weights .
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Could Biomarkers Be Utilized In Making Substance Use Disorder Diagnoses
Because of the DSM-5 Task Force interest in biomarkers, the Substance-Related Disorders Work Group, consulting with outside experts, considered pharmacokinetic measures of the psychoactive substances or their metabolites, genetic markers, and brain imaging indicators of brain structure and function.
Many measures of drugs and associated metabolites in blood, urine, sweat, saliva, hair, and breath have well-established sensitivity and specificity characteristics. However, these only indicate whether a substance was taken within a limited recent time window and thus cannot be used to diagnose substance use disorders.
Genetic variants within alcohol metabolizing genes , genes related to neurotransmission such as GABRA2 , and nicotinic and opioid receptor genes including CHRNA5 and OPRM1 show replicated associations to substance use disorders. However, these associations have small effects or are rare in many populations and thus cannot be used in diagnosis. Perhaps in future editions, DSM may include markers as predictors of treatment outcome