DSM 5 Substance Use Disorders: A Concise Summary

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, commonly referred to as the DSM-V or DSM 5, is the latest version of the American Psychiatric Association’s gold standard text on the names, symptoms, and diagnostic features of every recognized mental illness, including addictions. This edition was published in May 2013, nearly 20 years after the original publication of the previous edition, the DSM-IV, in 1994.

The DSM-V recognizes substance related disorders resulting from the use of ten separate classes of drugs:

1. alcohol,
2. caffeine,
3. cannabis,
4. hallucinogens (phencyclidine or similarly acting arylcyclohexylamines), other hallucinogens such as LSD,
5. inhalants,
6. opioids,
7. sedatives,
8. hypnotics,
9. anxiolytics,
10. stimulants (including amphetamine-type substances, cocaine, and other stimulants), tobacco, and
11. other or unknown substances.

Therefore, while some major grouping of psychoactive substances are specifically identified, use of other or unknown substances can also form the basis of a substance related or addictive disorder.

The DSM 5 explains that activation of the brain’s reward system is central to problems arising from drug use –- the rewarding feeling that people experience as a result of taking drugs may be so profound that they neglect other normal activities in favor of taking the drug. While the pharmacological mechanisms for each class of drug is different, the activation of the reward system is similar across substances in producing feelings of pleasure or euphoria, which is often referred to as a “high.”

The DSM 5 also recognizes that people are not all automatically or equally vulnerable to developing substance related disorders, and that some individuals have lower levels of self-control, which may be brain-based, which predispose them to developing problems if exposed to drugs.

There are two groups of substance-related disorders:
1. Substance use disorders and
2. Substance-induced disorders.

Substance use disorders are patterns of symptoms resulting from use of a substance which the individual continues to take, despite experiencing problems as a result.

Substance-induced disorders are symptoms that can be caused directly by the drug during or immediately after individual episodes of use.

The substance-induced disorders include:

1. Intoxication,
2. Withdrawal,
3. Substance induced mental disorders (including substance induced psychosis, substance induced bipolar and related disorders, substance induced depressive disorders, substance induced anxiety disorders, substance induced obsessive-compulsive and related disorders, substance induced sleep disorders, substance induced sexual dysfunctions, substance induced delirium and substance induced neurocognitive disorders.)

Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria:

1. Taking the substance in larger amounts or for longer than the you meant to
2. Wanting to cut down or stop using the substance but not managing to
3. Spending a lot of time getting, using, or recovering from use of the substance
4. Cravings and urges to use the substance
5. Not managing to do what you should at work, home or school, because of substance use
6. Continuing to use, even when it causes problems in relationships
7. Giving up important social, occupational or recreational activities because of substance use
8. Using substances again and again, even when it puts the you in danger
9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance
10. Needing more of the substance to get the effect you want (tolerance)
11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.

The DSM 5 allows clinicians to specify how severe the substance use disorder is, depending on how many symptoms are identified.

MILD: Two or three symptoms indicate a mild substance use disorder,

MODERATE: four or five symptoms indicate a moderate substance use disorder, and

SEVERE: six or more symptoms indicate a severe substance use disorder. Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.”

The DSM 5 is criticized for combining the the DSM IV categories of substance dependence (addiction marked by a pattern of compulsive use or loss of control) and substance abuse disorders (using in a manner that causes problems but does not have a pattern of compulsive use). The 2011 definition of addiction by the American Society of Addiction Medicine (ASAM) is consistent with DSM IV but not DSM 5.

The DSM IV, like the ASAM definition is based upon the idea that there is a DIFFERENCE IN KIND between substance abuse and dependence/addiction.

The DSM 5 is inconsistent with the ASAM definition because it is based upon the idea that there is only A DIFFERENCE IN DEGREE between abuse and addiction based upon the number of symptoms.

This is a critical difference in the underlying theory of addiction between the DSM IV and DSM 5 and a break in the progressive development of the fundamental concept if addiction which began with the DSM III.

GORSKI BOOKS:

Straight Talk About Addiction

12 Responses to DSM 5 Substance Use Disorders: A Concise Summary

  1. THANK YOU! Especially for the distinction made with the ASAM.

    • Terry Gorski says:

      I encourage you to carefully compare the two source documents while paying attention to the underlying principles suggested by how addiction is diagnosed. Some of the changes are obvious and some subtle. Many of the reviews miss the impact that eliminating abuse disorders will have. They also minimize the confusion that will result because DSM 5 did define the same words used in ASAM in very different ways.

  2. […] Terry Gorski has a nice summary of substance use disorders in the DSM-5. […]

  3. Amanda Booth Bice says:

    Thank you for the clarification. Does DSM V recognize PolySubstance Abuse or Dependence/Addiction?

    • Terry Gorski says:

      Yes. You specify by drug. I believe DSM 5 is a major step backwards in addiction science. It has taken the most vital distinction replicated over-and-over again and removed it from the calculus of diagnosing addiction. This vital distinction is this: the brain of alcohol and drug addicts respond differently to the ingestion if alcohol and other drugs that do abusers who are not addicted.
      The distinction between abuse and addiction had been eliminated in DSM 5. This can only be done if huge volumes if research is ignored or twisted to fit preconceived notions. This will have catastrophic impacts upon the future of treatment and research locking addiction science into a new dark ages.
      The future is in understanding the complex integration between the addicted brain, personality and conditions habits, and the impact upon lifestyle and relationships. This is called the BIOPSYCHOSOCIAL MODEL. People are talking about it, but the full implications have not yet entered broad stream treatment. DSM 5 will slow that down. The old evidence on differences between abuse and addiction will have to be raised again.

      • enigmastop says:

        Thank you, Terry, for helping us better understand addiction in a very confusing time right now (changes in the DSM 5). I know that this will require more substantial training and education among treatment providers, which I haven’t received yet. We continue to practice under the DSM IV TR. I think the new edition excludes any legal consequences re: symptomology of addiction. I would think a person on parole/probation, who continually risks their freedom in favor of the substance is demonstrating a symptom of addiction.

      • Terry Gorski says:

        The DSM 5 does exclude repeated legal problems due to drugs. This is because little or no effort was made to coordinate the DSM 5 with the Criminal justice Drug Policy (i.e. War on Drugs Policy) that now dominates the efforts at drug control world wide. This policy contradicts in many ways the Public Health Addiction Policy which treats addiction as a health care problem. The Affordable Care Act (ACA) also failed to address this major contradiction in public policy.

        Here are some of my previous blogs that may be of interest to you:
        1. Relapse Prevention In The Criminal Justice System: Applications of the CENAPS Model
        2. Drug War Policy: Get Tough and Be Dumb Approaches To Addiction That Don’t Work: http://wp.me/p11fHz-83

  4. christi says:

    So if I drink coffee, a morning pleasure, add cream, chocolate, and sugar…more pleasure…I like the stimulant effect, have a couple of the symptoms…it takes my time, and money, cuts into my productivity, I tend to say “ok but first lets have some coffee,” the significant other, boss, clients and co-workers think I drink too much, I know it’s probably unhealthy, haven’t told the doctor the truth, he thinks I drink a couple a day, and I really drink 8 cups a day…which is probably excessive…but…
    So my diagnosis is what?
    Oh, and can I go residential? Lol

    • Terry Gorski says:

      A pretty normal person in first year of recovery who is addicted to coffee. Caffeine addiction was eliminated from DSM 5. The issue is not what you diagnosis is, that is only relevant to bill for payment for treatment. The important issue is do you find this pattern of coffee use a problem. It would be important to explore a number of areas: Are the other people upset because you drink coffee or because of how you act when you drink coffee? Are there other relationship problems hiding behind the coffee drinking issue. Addiction is biopsychosocial and effects the whole person. Addiction does not live in he drug. It lives in the total response to the drug.
      “The problem with common sense is that it ain’t very common.” ~ Will Roger

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