New Psychiatric Guidelines Tackle Substance Abuse

When psychiatrists, psychologists, researchers and insurers want to identify and classify a psychiatric disorder, they turn to the Diagnostic and Statistical Manual of Mental Disorders. Compiled by the American Psychiatric Association, and widely known as the DSM, the reference guide spells out criteria for making a given diagnosis. As the body of science grows and the understanding of mental disorders evolves, cultural priorities change. The DSM does too. It’s a dynamic resource.

Originally published in the 1950s, the DSM was intended as a public health service to document the incidence and prevalence of mental illness and to classify mental illnesses with objective criteria. By its third edition in 1980 (DSM-III), it had become the primary reference for clinicians. (A few years ago, we wrote about how some writers of the DSM-IV had financial links to the pharmaceutical industry.)

Another revision, DSM-V, is scheduled to be released next spring.

According to Kaiser Health News, the new changes affect more than a dozen categories of disorders including substance use and addiction.

Gone from the new guidelines would be the diagnostic categories of “substance abuse” (which embraces short-term problems including driving drunk) and “substance dependence” ( a chronic problem marked by tolerance or withdrawal). Instead, “substance use and addictive disorders” would cover both.

The merged criteria would be applied to the use of alcohol, cigarettes, illicit or prescription drugs and other substances into a single, 11-item list of problems typically associated with these disorders–being unable to reduce or control the use of the substance, and failing to meet one’s obligations.

Diagnoses would be based on how many criteria the patient meets: 0 to 1 = no disorder; 2 to 3 = mild disorder; 4 to 5 = moderate disorder; 6 or more = severe disorder.

Advocates contend that by creating a category for mild disorders, it might be easier to identify and address drug or alcohol problems before they become serious. It might be easier, they say, for primary care doctors to be reimbursed by insurers for screening for alcohol and drug problems, and conducting short counseling sessions that have been shown to be effective.

Under the federal health care reform law adopted in 2010, screening and behavioral counseling to reduce alcohol misuse is covered as a free preventive benefit for people in many health plans.

According to the National Institute on Alcohol Abuse and Alcoholism, a man is at risk for developing a substance use disorder if he drinks more than four drinks in a single day and more than 14 drinks per week; a woman’s risk is three drinks in a single day and more than seven drinks per week.

Some experts interviewed by KHN are troubled by the 11-point list of criteria that moves substance use disorders along a continuum from mild to severe. They say that clinical research does not support a natural escalation from nonuse to occasional use to risky use to addiction.

Some people, they point out, suffer sadness or transient depression when bad things happen to them, but that doesn’t mean they’ll progress to psychotic depression. The same could be true for substance abuse.

What if a college student had an episode of frat-party binge drinking and missed classes because of it (earning a score of 2)? What if he’s labeled as having a mild addictive disorder that might not be accurate? What if he resists treatment because he resents the label of “addict”?

Still, if your pattern is to drink heavily only in a social or recreational setting, you might be at risk for a substance use disorder. Consider that you might be putting yourself and others in danger.

Substance abuse might not have affected your work or personal life, but if certain events regularly prompt you to drink too much or take illicit drugs, you have a much higher risk of having a car accident or liver problems. If that describes you, consult your primary care doctor about the possibility of short-term treatment.

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