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