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Changes in the DSM Stir Up Controversy

Diagnosing an individual with a substance use problem involves following criteria provided by the Diagnostic and Statistical Manual (DSM) of Mental Disorders. The current manual is the 4th edition, but work is being completed now to publish the new manual, due out in 2013. With each new edition, physicians and other mental health experts have reevaluated and examined disorders from new perspectives.

When a new edition of the manual is published, it comes at the end of long discussions about the changes proposed for the diagnosis of mental disorders. Some changes result in controversy about the decision to add or omit criteria for diagnosis, and the inclusion or rejection of certain problems as a recognized disorder.

Marc A. Schuckit, M.C. is the editor of the Journal of Studies on Alcohol and Drugs (JSAD) and is working as a member of the Substance Use Disorder Work Group reviewing information for the DSM-V. In the July edition of the JSAD, Schuckit wrote an editorial detailing his views of the proposed changes, as well as including letters from three experts in the field.

Historically, the 11 criteria established for alcohol and drug use problems were divided into two diagnoses: abuse and dependence. If a person exhibited three of a possible seven criteria, they were diagnosed with dependence. However, if a person only met one to four of the criteria, they were diagnosed with abuse.

The committee determined that the current process is cumbersome for clinicians. A system that required clinicians to work through two separate syndromes created complications, and the experts sought to eliminate the possibility of a person receiving a diagnosis after meeting only one criterion. Schuckit explains that one item cannot possibly indicate a syndrome.

The new system will combine the separate dependence and abuse diagnoses and require a patient to meet two or more criteria in order to receive a diagnosis. With the new criteria, a patient will be diagnosed with "alcohol use disorder," for instance, but will not be diagnosed with specific alcohol dependence or alcohol abuse.

Schuckit says that the changes are meant to make the process easier for clinicians to use.

However, some experts in the field are not pleased with the changes. Griffith Edwards, D.M., expressed disagreement in a letter to the editor. Edwards explained that he did not believe that the proposed changes were beneficial or necessary, and that the changes gave the impression of a field that was "in disarray."

Edwards believes that experience in the field shows that many patients may meet criteria for abuse, but may not warrant a more serious diagnosis of dependence. Edwards also believes that the new guidelines are not in step with criteria established by the World Health Organization’s manual, the International Classification of Diseases (ICD).

Edwards is concerned that deviating from the ICD may encourage the belief that the American viewpoint is being valued over the ICD and might serve to polarize the DSM.

There is still hope.

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