As someone who mostly appreciated the DSM-IV (though recognized its shortcomings), this is my biggest concern with the DSM-V, and why I consider it to be a step backwards in many ways.
CAVEAT: My understanding of the DSM-V is based on earlier drafts/non-final editions, so some of these details may be stale, but it appears the general principles that I object to haven't changed.
The DSM-IV-TR was very specific with its definitions of "substance abuse" and "substance dependence". My main complaint with the former was the way two of the criteria were poorly worded. It referred to the amount of legal trouble and/or risk that the person took to obtain the drug and could, if very broadly (mis-)interpreted, be used to identify any user of any illegal drug as suffering from "substance abuse" just by definition[0]. This is mostly a quibble about the wording of one detail, though; I think that these were good definitions overall and were more helpful than not.
Criticially, the DSM-IV-TR was able to distinguish between casual users of a drug (be it caffeine, alcohol, marijuana, heroin, etc.) and those who actually suffered from "addition" (a term I put in scare quotes because it does not have a medical definition, unlike the words "abuse" and "dependence").
This is a crucial distinction. If you send someone who drinks infrequently but is not an alcoholic to rehab, you are providing treatment for a disorder that they do not have. Thus, you wouldn't be surprised (or concerned) to find their behavior unchanged six months later. You would not consider it a "relapse" if they continued to drink infrequently.
Unfortunately, the DSM-V turns this on its head, by allowing "fill-in-the-blank" intoxication disorders. Think of generic classes in Java - they work the same way. Given the name of any drug, you can provide the corresponding disorder - in this case, "caffeine intoxication disorder", or "marijuana abuse syndrome"[1]
The problem with the new wording is that it encourages over-diagnosis of mental disorders. Instead of requiring a professional to distinguish between disorders and non-disorders (easy), it lumps all together as disorders, and requires professionals to distinguish between those which require treatment and those which don't (hard).
This is not only more difficult medically, but more problematic legally. No doctor or hospital wants to accept the liability of saying that they saw a patient previously diagnosed with a disorder and then determined that they didn't need treatment. This is far worse than simply failing to diagnose a disorder.
This may seem like a minor point, but it's not. We've been struggling with issues of overdiagnosis and overtreatment of non-disorders (not just drug-related) for years; in a very subtle way, the DSM-V further entrenches this problem.
[0] Incidentally, DSM-V did drop the "legal trouble" criterion.
[1] I forget the exact wording of the latter; this was a while ago and I believe they changed it.
The problem with the new wording is that it encourages over-diagnosis of mental disorders. Instead of requiring a professional to distinguish between disorders and non-disorders (easy), it lumps all together as disorders, and requires professionals to distinguish between those which require treatment and those which don't (hard).
Don't most of them include wording similar to "... and causes problems in the patient's day to day life" after a list of diagnostic criteria?
Thus, Bob drinks 15 cups of coffee per day, and it doesn't bother him doesn't suffer from CID, but Ann who drinks 12 cups of coffee per day, and suffers significantly if she cannot get coffee (or is perhaps routinely overdosing on caffeine) does suffer from CID?
Comments
As someone who mostly appreciated the DSM-IV (though recognized its shortcomings), this is my biggest concern with the DSM-V, and why I consider it to be a step backwards in many ways.
CAVEAT: My understanding of the DSM-V is based on earlier drafts/non-final editions, so some of these details may be stale, but it appears the general principles that I object to haven't changed.
The DSM-IV-TR was very specific with its definitions of "substance abuse" and "substance dependence". My main complaint with the former was the way two of the criteria were poorly worded. It referred to the amount of legal trouble and/or risk that the person took to obtain the drug and could, if very broadly (mis-)interpreted, be used to identify any user of any illegal drug as suffering from "substance abuse" just by definition[0]. This is mostly a quibble about the wording of one detail, though; I think that these were good definitions overall and were more helpful than not.
Criticially, the DSM-IV-TR was able to distinguish between casual users of a drug (be it caffeine, alcohol, marijuana, heroin, etc.) and those who actually suffered from "addition" (a term I put in scare quotes because it does not have a medical definition, unlike the words "abuse" and "dependence").
This is a crucial distinction. If you send someone who drinks infrequently but is not an alcoholic to rehab, you are providing treatment for a disorder that they do not have. Thus, you wouldn't be surprised (or concerned) to find their behavior unchanged six months later. You would not consider it a "relapse" if they continued to drink infrequently.
Unfortunately, the DSM-V turns this on its head, by allowing "fill-in-the-blank" intoxication disorders. Think of generic classes in Java - they work the same way. Given the name of any drug, you can provide the corresponding disorder - in this case, "caffeine intoxication disorder", or "marijuana abuse syndrome"[1]
The problem with the new wording is that it encourages over-diagnosis of mental disorders. Instead of requiring a professional to distinguish between disorders and non-disorders (easy), it lumps all together as disorders, and requires professionals to distinguish between those which require treatment and those which don't (hard).
This is not only more difficult medically, but more problematic legally. No doctor or hospital wants to accept the liability of saying that they saw a patient previously diagnosed with a disorder and then determined that they didn't need treatment. This is far worse than simply failing to diagnose a disorder.
This may seem like a minor point, but it's not. We've been struggling with issues of overdiagnosis and overtreatment of non-disorders (not just drug-related) for years; in a very subtle way, the DSM-V further entrenches this problem.
[0] Incidentally, DSM-V did drop the "legal trouble" criterion.
[1] I forget the exact wording of the latter; this was a while ago and I believe they changed it.
Don't most of them include wording similar to "... and causes problems in the patient's day to day life" after a list of diagnostic criteria?
Thus, Bob drinks 15 cups of coffee per day, and it doesn't bother him doesn't suffer from CID, but Ann who drinks 12 cups of coffee per day, and suffers significantly if she cannot get coffee (or is perhaps routinely overdosing on caffeine) does suffer from CID?