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!


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