Friday, December 27, 2013

Exploring New Terrain: DSM-5 and Substance Use Disorders

Explore DSM-5 at the 2014 FMHCA Annual Conference
by Aaron Norton, LMHC, CAP, CRC    

It's been six months since the release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and counselors are gradually shifting towards full implementation of the new criteria. For many, this task is overwhelming and perhaps unwelcome.

After all, human beings are in many ways creatures of habit, and counselors are no exception. It takes a great deal of time and effort to re-educate ourselves every time the "bible of psychiatry" written in dry, academic prose gets tampered with, and if you're like me, you're pretty busy and can think of much more interesting things to do with your limited spare time. Personally, the best way I could think of to force myself to learn about the DSM-5 was to register for a number of trainings and start scheduling my own presentations on the topic, paying homage to the old saying, "We teach what we need to learn" (or is it, "Those who can't, teach?").

Still, this nearly 1,000 page snoozer offers us far more utility than bibliotherapeutic treatment of insomnia via bedtime reading, filling an empty space on our office bookshelves, or serving effectively as an expensive paper weight. The DSM-5, as imperfect as it may be, is the "gold standard" of diagnosis and case formulation here in the U.S. It helps us organize our thoughts, identify effective treatments, and measure clinical progress. Knowledge of its contents is required of counseling students in CACREP-accredited programs, interns sitting for their licensure exams, and clinicians who work with third party payers who want to ensure that we're submitting claims for treatment of a disorder vs. preventative care. In this professional climate, updating ourselves on DSM revisions is a matter of necessity, not luxury.

FMHCA is doing its part in helping counselors accomplish this daunting task by providing a two-day conference this February dedicated to updating counselors on a variety of changes impacting our field. By my count, the conference includes nearly nine hours of DSM-5 update training, including my three hour workshop on using the DSM-5 and the newly released 2013 American Society of Addiction Medicine (ASAM) treatment criteria to conduct quality substance abuse assessment and evaluation. I'm hoping to make the DSM-5 update easier by focusing on the paradigm shift in the new edition and connecting each change to that shift.

What do I mean by "paradigm shift?" Let's start with a brief glimpse of the history of the DSM. The first edition, published in 1952, was dramatically brief in comparison to the heavy volume we're now so familiar with. It consisted of brief, psychodynamic-oriented descriptions of disorders. The next paradigm shift of the DSM came with the third edition published in 1980, which implemented a medical model with very specific criteria for disorders and a litany of statistical data supporting each. Not surprisingly, the DSM expanded dramatically in length with that edition.

The DSM-5 was intended to establish a new paradigm shift within the context of the existing medical model of diagnosis. As I see it, the six most salient examples of this shift include efforts to:

  1.  Reduce the dichotomous nature of diagnosis (i.e. "You either have the disorder, or you don't") by shifting towards a spectrum approach to classifying disorders with more specific information attached to the diagnosis (e.g. more specifiers available for each diagnosis, including extra scales of severity);
  2. Streamline and simplify diagnosis by combing similar disorders and then providing more options within the diagnosis in the form of new specifiers. (You'll be happy to know, by the way, that for the first time in DSM history, the volume actually decreased in size.);
  3. De-pathologize "different" by more clearly delineating between abnormal and disordered human experience;
  4.  Reduce the frequency of inaccurate or generic diagnosis;
  5. Enhance consideration of cultural and developmental factors in the diagnostic process; and
  6. Eliminate the phenomenon of "mind-body dualism" inherent in previous editions. It's official; the large group of psychiatric professionals tasked with developing the new edition have decided that our brains are, in fact, part of our bodies. Consequentially, it no longer makes sense to separate the physical aspects of human wellness from the mental aspects of wellness as though the two are entirely separate realms with no overlap.
Changes made to substance use and related disorders provide an excellent example of all of these paradigm shifts:
  1. Streamline and simplify diagnosis and reduce the dichotomous nature of diagnosis: Because the DSM-IV diagnoses of Substance Abuse and Substance Dependence differed primarily in severity, the two disorders have been collapsed into one substance use disorder with an added spectrum of severity in the form of mild, moderate, and severe specifiers based on the number of symptoms the client meets. This measure also solves the problem of "diagnostic orphans," a concept a little too complex to address in this article (although it will be covered at FMHCA's annual conference). It also eliminates the DSM-IV problem of the absence of a diagnosis for Nicotine Abuse. Previously, only Nicotine Dependence could be diagnosed, but in the DSM-5 a milder tobacco use disorder is available. The symptoms have also been reordered into groups that may make more sense to the clinican.
  2. De-pathologize: The more loaded terms "abuse and dependence" have been replaced with the more neutral phrase "substance use disorder." Also, the threshold for the number of symptoms needed for a diagnosis has increased from one to two to strengthen the legitimacy of the diagnosis.
  3.  Reduce the phenomenon of inaccurate or generic diagnosis: The diagnosis Polysubstance Dependence has been deleted, because it was so frequently inaccurately applied by clinicians. For the first time, craving (a strong desire or urge to use) has been added to the diagnostic criteria;
  4. Increase cultural and developmental sensitivity in the diagnostic process: The symptom for recurrent problems with law enforcement was eliminated "because of cultural considerations that make the criteria difficult to apply internationally" and many of the statistics on substance use disorders provide detail on differences among age groups;
  5. Eliminate mind-body dualism: The specifiers "with physiological dependence" and "without physiological dependence" have been removed. Frankly speaking, the delineation between physical and psychological addiction is silly. Cannabis Withdrawal has been added as a diagnosis based on decades of consistent research and case history of a clear withdrawal syndrome experienced by many chronic, daily marijuana users. This addition contradicts the popular societal myth that marijuana isn't physically addictive; it's just psychologically addictive. Caffeine Withdrawal has also been added, although Caffeine Use Disorder exists only in Section III of the DSM-5 to be considered for future revisions.

As helpful as I view some of these changes, the new criteria raise a few interesting dilemmas for counselors to ponder.

For example, the Americans with Disabilities Act and the Rehabilitation Act acknowledge that Alcoholism and drug addiction (or "chemical dependency" as some government programs label it) can be protected disabilities, provided that other requirements for a disorder to be considered a disability are met and the individual is no longer using the substance. Traditionally, a DSM-IV diagnosis of Substance Abuse was not sufficient to be considered a disability, whereas Substance Dependence may be. Moreover, Substance Abuse could be considered a temporary diagnosis, whereas Substance Dependence was considered a chronic disorder, regardless of whether or not it was in remission. How will rehabilitation counselors, diagnosticians employed by social programs, and others involved in social program eligibility now delineate between abuse and dependence?

And now that the criterion for "recurrent substance-related legal problems" has been removed, how will diagnosticians be able to determine if a defensive client with a significant history of substance-related arrests still meets criteria for a substance use disorder based on the remaining criteria?

And now that the DSM criteria for substance use disorders has changed, what will change with ASAM treatment criteria?

As much as I want to be helpful with this article, I'm not going to give away the farm, folks. I'll be happy to answer explore these issues in detail at FMHCA's annual conference in February. I hope to see you there!

Sunday, June 2, 2013

Reflections on DSM-5: Strengths and Controversies

The DSM-5 is a tool used by mental health professionals for case conseputalization
A couple weeks ago, the American Psychiatric Association (APA) unveiled the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), triggering headlines such as "DSM-5 is here: What the controversial new changes mean for mental health care" and "Controversial update to psychiatry manual, DSM-5, arrives."

Aaron Norton, LMHC, presents on DSM-5
The buzz word, of course, is "controversy."  And why not?  Few, if any, areas of modern medicine are more controversial than Psychiatry.  Mental illness remains, in many respects, stigmatized by society-at-large.  Many struggle to accept mental disorders as legitimate medical conditions.  Throw in the fact that although the DSM was created to aid trained mental health professionals with case conceptualization for treatment planning, others use it to build a case for or against someone in criminal and civil case proceedings, disability determination, and eligibility for a number of social programs. 

The stakes are high and the implications are vast, so any changes in the way mental health professionals categorize, label, or conceptualize mental disorders are bound to be met with some degree of skepticism or criticism both within and outside the field.  I think that's just par for the course.

But what are the hot button issues with this revision?  What are critics alleging?  I'll briefly explore two of the most commonly discussed controversies:

1) The creation of new disorders pathologizes normal human behaviors and experiences.  Disruptive Mood Dysregulation Disorder, Premenstrual Dysphoric Disorder, Mild Neurocognitive Disorder, and Binge Eating Disorder are among the most controversial additions, and the removal of the Bereavement exclusion from the criteria for a Major Depressive episode has triggered criticism that normal human grief has been unnecessarily labeled a disorder.  I think this is a valid concern in the sense that I am attuned to the risk of medicalizing unpleasant or abnormal human experience.  But when I read the criteria for these new disorders, it seemed obvious to me that the new edition isn't targeting common temper tantrums, the occasional fast food drive thru experience, mild absentmindedness, or the typical mood fluctuation that many women experience during "that time of the month."  I think the criteria paint a fairly clear picture of a severe symptom presentation causing a clinically significant degree of impairment or distress that often warrants treatment.  And because I recognize that the neurobiology of a clinically depressed person isn't different if that individual is grieving the loss of a loved one, removal of the Bereavement exclusion makes logical sense to me.  Moreover, there are several examples in the DSM-5 of the de-stigmatization of abnormal human experiences.  Changes in the category of Paraphilic Disorders and the re-classification of Gender Dysphoria are, I think, great examples.  Of course, the DSM is essentially the brainchild of the APA, an association that exclusively represents psychiatrists vs. mental health professionals who treat mental illness without prescribing medication (e.g. counselors, therapists, psychologists, clinical social workers), so some are concerned that the APA is in bed with "Big Pharma," and therefore benefits from classifying relatively benign human experiences as a form of mental illness.  Meanwhile, while some believe that the DSM-5 revisions will cause an increase in the number of Americans who are deemed "mentally ill," others are concerned that revisions will squeeze some Americans out of diagnostic labels.  For example, some critics of the merger of Aperger's Disorder into Autism Spectrum Disorder fear that some individuals currently diagnosed with Asperger's won't meet the new diagnostic criteria despite the APA's findings to the contrary.

2) The classification system is arbitrary and/or not organized based on the neurobiological characteristics of the disorder.  Just prior to the release of the DSM-5, Dr. Thomas Insel, the Director of the National Institutes of Mental Health, alleged that "the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure," opining that "patients with mental disorders deserve better."  I certainly agree
Thomas Insel, MD
that the DSM's classification system is not ideal, but I also believe that mental health is a complex subject area; it can't necessarily be reduced to a set of data points extrapolated from a routine lab test.  As we continue to develop new technologies for study of the human brain, I imagine the way we classify mental disorders will continue to evolve.  Indeed, there are several examples of changes in the DSM-5 that stem from advancements in the field of Neuroscience.  Gambling Disorder shifted into the new Substance Use and Addictive Disorders chapter due to commonalities in the underlying neurobiology of both addictive experiences.  Asperger's Disorder was merged in with Autism and two other developmental disorders based on evidence that the four disorders were, on a biological level, varying degrees of severity of the same disorder.  The DSM-IVTR chapter entitled "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" was eliminated, and disorders previously listed in that chapter were reorganized into chapters of disorders with similar underlying neurobiological processes.  Lastly, I'm not certain that any critics of the current classification system have any better ideas at the present.  Two weeks after posting his criticisms of the DSM-5, Insel co-wrote a press release conceding that "Today, the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), along with the International Classification of Diseases (ICD) represents the best information currently available for clinical diagnosis of mental disorders."

So what do I like about the DSM-5?  I like that several revisions reinforce the notion that the distinction between the body and brain are, essentially, more myth than fact.  People often think of mental health as a distinctively separate realm from physical health, as though the two were entirely disconnected spheres of the human experience.  But what are mental disorders if not biological?  They involve genetics, neurotransmitters and hormone levels, brain structures, electrical impulses that travel through the body, encoding of information into short-term and long-term memory, organization of various mental constructs imprinted through life experience, and the intriguing interface between environmental exposure and internal biology (e.g. epigenetics).  Even "non-medical" treatments such as psychotherapy are, in essence, biological interventions in the sense that they involve refined integration of the brain and trigger neurological processes such as neuroplasticity and neurogenesis.  The field of psychoneuroimmunology is bursting with findings substantiating the connection between Mind and Body.  Consequentially, I'm pleased with subtle verbiage changes such as scrapping the phrase "due to a general medical condition" for a more accurate word choice of "due to another medical condition."  And I'm thrilled that somatic disorders can now be diagnosed even if an individual has a known, legitimate, diagnosed medical condition.

I also like that the classification system is less dichotomous.  Several disorders have been merged together and conceptualized as varying points on a spectrum.  The truth is that two people with the same diagnosis can experience dramatically different levels of severity and functioning.  

Finally, the DSM-5 is overall a somewhat more simplified and streamlined product than the DSM-IVTR.  Its shorter in length with several examples of less convoluted wording.  Some old diagnostic labels that have become pejorative labels have been renamed (e.g. "Mental Retardation" became "Intellectual Disability").

All in all, I think the DSM-5 is an improved product in comparison to the DSM-IVTR. Its imperfect and flawed, like any organizational system, but it's probably the best that we have for now.  We'll see what changes with future revisions.

Highlights of Changes from DSM-IVTR to DSM-5
APA's DSM-5 website

Want to learn more about DSM-5 revisions?  If your agency or practice would benefit from an-service training, ask me about my presentation on DSM-5.  I'm available for workshops, conferences, and in-service training in the Tampa Bay area.

Aaron Norton, LMHC provides training on DSM-5