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W1657187716 abstract "DSM-5, following the recommendations of its substance-related disorders workgroup, radically reformulated the diagnostic criteria for substance use disorder (SUD). The changes have generated considerable controversy and concern, and are here reviewed and evaluated. DSM-IV included two substance use disorders, substance dependence and substance abuse. Dependence attempted directly to capture the concept of addiction as a psychiatric disorder, understood as impaired-control use. (The label addiction itself was narrowly rejected in earlier DSM revisions due to its purportedly pejorative nature.) Dependence diagnosis required any three or more of seven possible symptoms indicating impaired-control substance use, including two physiological dependence symptoms (tolerance, withdrawal) and five behavioural symptoms (giving up activities, continuing use despite harmful physical or psychological effects, trying to stop but cannot, taking larger amounts than intended, spending much time obtaining and taking the substance). Abuse diagnosis represented problematic use and required any one or more of four possible substance-related symptoms, including hazardous use (most commonly, driving while intoxicated), interpersonal problems (e.g., arguing with spouse), failure to fulfill role obligations at work, school, or home, and legal problems. ‘Abuse’ has long been a questionable disorder category. The ‘dependence syndrome’ model of addiction as impaired control over use 1, 2 is generally accepted as the most plausible conceptual justification for understanding addiction as a true psychiatric disorder rather than as moral weakness, social deviance, or rational choice. Since DSM-III-R, DSM diagnostic criteria for substance use disorders have been based on this model. Consistent with the model, the original intention was for ‘dependence’ to be the sole addiction disorder category 3. However, pragmatic concerns about having a diagnostic label for anyone needing help with substance use overrode validity concerns, and the abuse category was included in successive DSM editions until DSM-5. DSM's ‘abuse’ criteria clearly conflated social deviance with addictive pathology. ICD's parallel but narrower ‘harmful use’ category rejects face-invalid abuse criteria such as hazardous use and insists on substance-caused physical or mental health problems, thus at least ensuring medical need for intervention. Two rationales have been used to justify the DSM's ‘abuse’ category despite its face invalidity. First, the dependence syndrome model portrays addiction as a ‘biaxial’ concept with two components, an impaired-control motivational dysfunction and a harmful consequence component involving negative social, psychological, and physical consequences of excessive use 1. The model asserts that harmful consequences by themselves do not imply addiction (e.g., heavy recreational drinking without alcoholism can cause liver cirrhosis or automobile accidents). Nonetheless, the components are sometimes interpreted as distinct categories of psychiatric disorder: impaired-control use (dependence/addiction) and a residual category of harmful use without dependence (abuse). However, as both the DSM-5 definition of mental disorder and the ‘harmful dysfunction’ analysis of mental disorder 4, 5 make clear, harm without an underlying dysfunction is not a medical disorder. The biaxial conception, properly understood, requi-res both impaired control and consequent harm as components of every diagnosis of substance use disorder 6 and thus provides no support for an ‘abuse’ disorder category. Second, it is commonly claimed that abuse is mild or prodromal dependence, thus justifying its disorder status. This empirical claim has been amply disconfirmed. Substance abuse—however worthy of intervention—does not predict later dependence at substantial rates and does not correlate with validators in the same pattern as dependence 7. Abuse is also highly contextually anchored; for example, a large percentage of abuse diagnoses are due to driving under the influence of alcohol, which occurs at increased rates among those of higher socioeconomic status simply because they have automobiles 8, 9. To its credit, DSM-5 finally eliminated the substance abuse category. However, rather than acknowledging that the abuse category lacks conceptual validity as an addictive disorder and placing it in the Z Codes for non-disordered problems often treated by clinicians, DSM-5 took another route. Much of the abuse category was assimilated to dependence, in keeping with the empirically discredited ‘mild or prodromal dependence’ account of abuse. The workgroup relied heavily in its deliberations on factor analyses and item response theory analyses of abuse and dependence symptom items, most of which fail to discriminate abuse symptoms from dependence symptoms as distinct clusters or syndromes. However, researchers have long noted that the DSM dependence items are poorly worded to draw the dependence/abuse distinction among the highly correlated dependence and abuse items 10. Nonetheless, rather than taking the conceptual implausibility of the technical results as confirming the need for rewording and reevaluating the items and strengthening the validity of the dependence criteria, the workgroup interpreted the technical results as refuting the idea of there being abuse that is not a form of dependence: ‘The “abuse category” has been eliminated from the proposed structure because of the lack of data to support an intermediate state between drug use and drug addiction’ (11, p. 867). The implication was that abuse symptoms (including, e.g., hazardous use, despite all the contrary considerations) could be considered variants of dependence symptoms and could validly be retained as impaired-control measures. Conceptual grounding in the dependence syndrome model was thus abandoned in favor of obeisance to a literal reading of the technical results. The consequences for the decision process are vividly presented in the following description by a workgroup member of a scene that could be right out of one of Solomon Asch's social psychology experiments in which group pressure causes an individual to affirm things that are plainly false: ‘I was one of the last holdouts against combining the abuse and dependence criteria because, to me, the dependence process and its consequences do seem conceptually distinct. However, as I looked around the table at my colleagues in our in-person meeting on this issue and considered the overwhelming abundance of evidence in favor of combining the abuse and dependence criteria, I found I no longer had grounds to hold to my position’ (12, p. 703). In fact, the evidence for homogeneity of dependence and abuse was not ‘overwhelming’. The failure of a technical method to clearly discriminate two things, or the demonstration that two things are intercorrelated in ways that allow them to fit a unidimensional mathematical model, is not a demonstration that two things do not exist. It is only a demonstration that the specific method of analysis using the specific selected measures does not discriminate them if they do exist—and in this case, we have strong independent clinical and personal evidence that the two entities, addiction and harmful use, do exist. Unidimensionality of item response analysis results can mean many things other than that there exists only one entity varying in severity 13, and no far-reaching conclusion can be drawn before alternative hypotheses are systematically tested, a task not undertaken by the workgroup. Moreover, there are many other sources of potential evidence that were not given weight. Observing that DSM-5′s decisions were based on a highly selective citing of evidence, Edwards concluded that the workgroup's reconceptualization ‘goes against clinical experience, which suggests that people can develop destructive and disruptive drinking behavior without clinical symptoms of dependence’ (14, p. 701), as for example in college students’ harmful binge drinking independent of addiction. The workgroup's premature embrace of specific technical analyses to override compelling clinical and conceptual realities brings to mind Wittgenstein's famous admonition: ‘In psychology there are experimental methods and conceptual confusion… The existence of the experimental method makes us think we have the means of solving the problems that trouble us; though problem and method pass one another by’ (15, p. 232; emphasis in original). DSM-5 thus moved the abuse criteria, with all their validity problems, into an expanded category renamed ‘substance use disorder’ (SUD). Only the ‘legal problems’ criterion was abandoned because it was rarely used and plainly a matter of social deviance, not pathology. Additionally, a new ‘craving’ criterion was added both because craving is intuitively a phenomenological counterpart to impaired control and because it is an attractive target of pharmacological intervention. With 11 possible symptoms rather than 7, the idea was that SUD represents an enlarged and more valid impaired-control category with dimensional structure ranging from mild to severe cases; 2 or 3 symptoms is ‘mild’, 4 or 5 ‘moderate’, and 6+ ‘severe’ SUD. Mechanically combining existing abuse and dependence criteria in SUD without reformulation exacerbated a problem of symptom criterion redundancy, weakening validity. Criteria overlap in meaning so that it is possible to satisfy multiple criteria and spuriously reach diagnostic threshold due to just one actual feature. For example, one can imagine satisfying the three symptoms of failure to fulfill role obligations, use despite social/interpersonal problems, and activities given up or reduced, all based on the same problem, lessened marital engagement due to time spent drinking with one's friends. Yet this one feature has low face validity for indicating impaired-use disorder. With so many more symptom options in SUD than in the former dependence category, it becomes much easier for an individual to meet three criteria. Thus, one might think that to maintain validity, the threshold number of symptoms needed for diagnosis would be raised to a higher number. This would be especially true because the added abuse symptoms appear to have less validity than the former dependence symptoms in identifying impaired-control dysfunction. Thus, the number of symptoms needed to have confidence that there is a dysfunction should be increased. The workgroup did the opposite; they lowered the number of symptoms required for diagnosis to 2. This is probably the most controversial substance-related change made by the DSM-5. If one considers SUD an expanded impaired-control addiction category analogous to dependence, then this change dramatically increases—indeed, more than doubles—the estimated prevalence of addiction. DSM-5′s SUD revision with its 2-symptom diagnostic threshold allows continued diagnosis of those with two abuse symptoms (e.g., drives under the influence and argues with spouse about it) and those with one abuse and one dependence symptom (e.g., has developed some tolerance to alcohol and drives under the influence). Moreover, diagnosis newly applies to those with two dependence symptoms (e.g., increased tolerance and drinks larger amounts than intended), dubbed by the literature as ‘diagnostic orphans’ as if they had been incorrectly abandoned rather than purposely placed below a plausible diagnostic threshold. However, studies show that these groups resemble former abuse cases more than dependence cases in prognosis. In terms of addiction as impaired control, the evidence is that probably they are mostly false positives, as validity evaluation of DSM-5 SUD suggests. DSM-5 has been heavily criticized for the lowered SUD diagnostic threshold. Before looking at the rationales offered for this change, one might ask: ‘What did this effort yield in terms of increases in diagnostic validity and clinical utility?’ Clinical utility for now appears weakened, primarily because virtually all treatment studies have used dependence samples. Consequently, nothing is known about what works with the much larger and more heterogeneous SUD category. Predictive studies have generally shown quite different long-term outcomes for members of the DSM-IV dependence category and the added SUD cases. Nor do the ‘mild’ SUD cases correspond to the former abuse cases, so that no simple translation is possible. More importantly for long-term scientific purposes, recent analyses present a markedly disappointing picture regarding validity 6. Looking at alcohol use disorder (AUD), which is by far the largest SUD category, DSM-5 AUD provides no gain at all in predictive validity or correlation with crucial validators relative to DSM-IV combined alcohol dependence and abuse. For example, DSM-5 AUD is not significantly different from DSM-IV combined dependence and abuse in levels of standard lifetime validators including episode duration, number of episodes, frequent heavy drinking, number of symptoms, suicidal ideation, service use, and family history. One-year validator results are similarly without validity gains. Alternatively, if one construes SUD as an expanded impaired-control category and compares DSM-5 AUD to DSM-IV alcohol dependence, then DSM-5 AUD represents a major loss of validity 6. DSM-5 AUD is significantly lower than DSM-IV alcohol dependence on every one of the above-mentioned validators except episode duration. Depending on the baseline of comparison, DSM-5 AUD shows no validity gain or substantially decreased validity relative to DSM-IV. Concerns that the threshold of two or more criteria is too low…(e.g., that it produces an overly heterogeneous group or that those at low severity levels are not ‘true’ cases)…were weighed against the competing need to identify all cases meriting intervention, including milder cases, for example, those presenting in primary care. Construed one way, this argument is a textbook example of begging the question. Mild cases of a disorder are still true cases, and no one is objecting to identifying mild cases of addiction. The objection is that the added cases—which are indeed symptomatically mild—are not mild cases of addictive disorder but rather not true cases of addictive disorder at all. Just as sneezing due to dust in the air is not a mild case of a cold, developing some tolerance to alcohol over time from social and mealtime drinking and driving home from social occasions after drinking is not generally mild addictive disorder. The workgroup's reply that we need to identify all cases including the mild ones begs the question of validity. However, the explanation was probably intended as asserting a pragmatic point, that although the added cases may not be true cases of impaired control, for practical reasons we must be able to diagnose them as disorders to help them. The problem with this pragmatic argument is that it abandons validity as the criterion for category formulation, thereby undermining the integrity of research needed for developing more effective methods for helping those with true addictions. When there was a separate category of abuse, the pragmatic argument was more compelling because the invalidity was segregated in its own category and scientific study could focus on dependence. The present approach leaves the field with no reasonably valid target category for scientific study. The reality is that no one set of criteria is capable of both identifying the addicted and identifying all who could use help for substance use. Identifying the latter group while talking as if one is identifying the former group creates a state of confusion worse than before and presents an obstacle to scientific progress. [T]he substance use disorders criteria represent a dimensional condition with no natural threshold….To avoid a marked perturbation in prevalence without justification, the work group sought a threshold for DSM-5 substance use disorders that would yield the best agreement with the prevalence of DSM-IV substance abuse and dependence disorders combined. This argument offers an example of the classic ‘sorites’ or ‘balding man’ fallacy—the fallacy of inferring from the fact there is no sharp boundary between a concept and its opposite that therefore the distinction can be drawn anywhere one likes. The fact that the division between addiction and non-addiction is fuzzy does not imply that the threshold is entirely arbitrary and can be placed to accomplish such extraneous goals as preserving prevalence rates generated by other criteria that have been acknowledged to be invalid. A fuzzy concept can still have many reasonably clear cases, and the boundary should be drawn with an eye to avoiding the classification of conceptually relatively clear cases on the incorrect side of the distinction. Day shades into night, and childhood into adulthood, and the boundaries are fuzzy, but day/night and child/adult still have clear cases that make these vague distinctions extremely useful, and despite the vagueness, there are ways of drawing the distinctions that would be manifestly incorrect. If one can arbitrarily draw a concept's boundary anywhere one wishes, one has in effect discarded the distinction. That, I suggest, is in effect what DSM-5 did with the concept of ‘addiction’ when it arbitrarily placed the SUD threshold at 2 of 11 symptoms to achieve the goal of preserving earlier prevalence rates, without careful attention to the face conceptual validity of the cases that would fall on either side of the new threshold. Another argument in defense of the 2-symptom threshold concerns dimensionalization in service of prevention. The lower SUD threshold can be seen as part of DSM-5′s move toward dimensional criteria that allow for diagnosis of prodromal and mild conditions to promote prevention. The question is whether the lower end of the severity dimension represents disorders at all, or whether the risk of disorder is sufficiently high to warrant the massive numbers of additional diagnoses. Challenged to justify the fact that the new criteria will pathologize mild conditions, the workgroup Chair, Charles O'Brien, explained as follows: ‘We can treat them earlier. And we can stop them from getting to the point where they're going to need really expensive stuff like liver transplants’ (17, p. A11). However, this justification is based on an assumption that study after study has shown to be false, namely, that DSM-IV cases of abuse and dependence orphanhood that are newly classified as SUD are an early stage of dependence and have severe outcomes over time. To take O'Brien's example seriously, the established alcohol consumption risk factor for liver cirrhosis requires heavy drinking for decades, which is unlikely to occur at the milder end of the SUD spectrum. There are about 27 000 yearly U.S. cirrhosis deaths (from all causes, not just alcohol), <0.01% of the population, whereas DSM-5 extends the SUD ‘impaired control’ label to approximately an additional 7% of the entire population each year (about 21 000 000 people) over and above the 5% or so identified by DSM-IV dependence 6. There is no evidence that the cirrhosis cases come out of the added group in significant numbers, nor that such massive diagnostic overreach is a feasible let alone cost-effective way of addressing the prevention of cirrhosis or identifying those at risk. Putting substance-related symptoms together and calling the result a ‘severity dimension’ of SUD does not make SUD a construct-valid disorder. Non-disordered conditions can be severe (e.g., pain in childbirth, normal grief, binge drinking upon arrival at college). Moreover, the diagnostic threshold should be the point at which the diagnostician is justified in attributing a disorder (e.g., impaired control) rather than a non-disorder 18. In SUD's polythetic diagnostic criteria set, every symptom is given equal weight in meeting diagnostic threshold requirements, so adding weaker indicators of dysfunction from the former abuse criteria allows ample false positives to arise when the diagnostic threshold is reached by combinations of weak symptoms. The workgroup denied the accusation that the new criteria would add to disorder diagnoses: ‘a concern that “millions more” would be diagnosed with the DSM-5 threshold is unfounded’ (16, p. 841). This answer (which contradicts the ‘prevention’ argument that presupposes increased diagnosis) disingenuously construes the baseline as DSM-IV combined dependence and abuse, which, by design, DSM-5 SUD matches in prevalence. The critics of course have in mind a comparison to DSM-IV dependence, which was generally considered the ‘real’ impaired-control category. As noted, many millions more are indeed diagnosed by DSM-5 SUD. The name change from ‘dependence’ to ‘substance use disorder’ was justified by the claim that the label ‘dependence’ confused addiction with ‘physiological dependence’ consisting of tolerance and withdrawal symptoms. The workgroup argued, correctly, that physiological dependence is an expectable consequence of the body's adaptation to some medications, including opioid pain medication, and not sufficient by itself to imply addiction (i.e., impaired-control use) 19. This understanding was already reflected in DSM-IV's text and its three-symptom dependence threshold which required at least one additional behavioural symptom of impaired control even when tolerance and withdrawal were present. Nonetheless, the workgroup argued that the verbal confusion of ‘dependence’ with ‘physiological dependence’ was a problem in pain medicine, where doctors and patients may resist adequate opioid medication for fear of inducing physiological dependence that is misconstrued as addiction. The potential for confusion certainly exists. However, there is no solid evidence that physicians’ or patients’ reluctance about opioid medication for non-cancer pain was generally based on this verbal confusion. Nevertheless, the urgent, overriding importance of this terminological change to facilitate prescription of opioid medication was emphasized by the workgroup's Chair: ‘Of all the changes proposed by the DSM-5 work group, this one consistently is greeted by standing ovations when presented to audiences of physicians with the responsibility for the treatment of pain’ (20, p. 705). This emphasis in the DSM-5 revision process represented a major historic misstep. At the time the workgroup was making these arguments, a massive problem of abuse of opioid medication for non-cancer chronic pain was emerging in the United States, with resultant heroin addiction and a startling number of overdose deaths, as well as associated social dislocations reaching into communities where it had rarely been seen before. Earlier arguments that it was safe to extend opioid use to non-cancer pain were clearly overstated ovations by pain physicians notwithstanding. Perhaps some physician and patient caution about prescription opioid painkillers was not such a bad thing after all. The DSM-5 workgroup was blind to this growing problem that, as they deliberated, was reaching epidemic proportions. If the opioid misstep had stopped at a purely terminological change, it would have been minimally impactful on research and clinical diagnosis, but it did not. Recall that DSM-5 lowered the SUD diagnostic threshold from DSM-IV's 3 of 7 symptoms to any 2 of 11 symptoms, including tolerance and withdrawal. Thus, the DSM-5 workgroup actually created the very problem that supposedly they were trying to address; they made it possible to diagnose SUD (i.e., addiction) based on the two physiological dependence symptoms alone, thus potentially confusing physiological adaptation with impaired-control use. This self-created problem conflicted with the goal of facilitating prescription of opioids for pain. An important exception to making a diagnosis of DSM-5 substance use disorder with two criteria pertains to the supervised use of psychoactive substances for medical purposes, including stimulants, cocaine, opioids, nitrous oxide, sedative-hypnotic/anxiolytic drugs, and cannabis in some jurisdictions. These substances can produce tolerance and withdrawal as normal physiological adaptations when used appropriately for supervised medical purposes. Under these conditions, tolerance and withdrawal in the absence of other criteria do not indicate substance use disorders and should not be diagnosed as such. Note that the labeling of withdrawal symptoms during prescribed use of opioids and other medications as ‘normal’ in order to argue that withdrawal symptoms during prescribed use should not be used as an indicator of SUD involves a potentially misleading equivocation on the meaning of ‘normal’. Having withdrawal symptoms when cutting down on opioids is not a normal human condition in the sense of ‘non-disordered’ and is recognized as a separate category of DSM disorder. Moreover, withdrawal disorder often leads to impaired-control use and so has traditionally been a central indicator of addiction. Withdrawal is ‘normal’ only in the weak sense of being an expectable reaction as the body adjusts to the presence of the substance. However, many disorders are expectable under certain conditions, such as a broken bone when a certain level of pressure is applied to a limb. Prescribed use may expectably induce the complication of withdrawal disorder, and by itself, this does not imply addiction, but calling it ‘normal’ and eliminating it from SUD criteria suggest that physicians should not be concerned about it in the context of assessing addiction in patients, and this is far from the case. Equivocation aside, the ad hoc approach of excluding the tolerance and withdrawal symptom criteria only when evaluating SUD in medically supervised substance use has two fatal problems. First, it is conceptually incoherent. If, as the workgroup argued, tolerance and withdrawal are not a use disorder when the drug is prescribed, then they are not a use disorder when the same drug is not prescribed, for the very same reason provided by the workgroup—namely, they do not by themselves imply impaired-control use. Moreover, the workgroup's approach yields the absurdity that changes in laws can cause and ‘cure’ disorders. For example, the criteria allow the absurdity that if a medical marijuana user having only tolerance and withdrawal symptoms moves from a state where cannabis use is legal and medically supervised to a state where its use is illegal, and continues precisely the same pattern of medical use with the same symptoms, the individual has gone from being non-disordered to being disordered. Even the results of research will differ by locale due to differences in the legal status of various substances. Second, this approach violates the DSM-5′s (and harmful dysfunction analysis’) definition of mental disorder, which states that the existence of disorder cannot be merely a matter of deviance or conflict with society. Yet, the only difference between the disordered and the non-disordered under DSM-5′s SUD criteria may be that one is taking the substance in accordance with legal rules while the other is not. This approach makes DSM-5 diagnosis overtly an instrument of social control unrelated to disorder status, the very outcome that the definition of mental disorder was designed to avoid. The most troubling implication of these conceptually misguided features of DSM-5 SUD diagnosis is that, with an opioid abuse epidemic upon us, diagnosing an individual who may be developing an opioid SUD while taking prescribed pain medication is now more difficult than before. Such an individual who is experiencing marked tolerance and withdrawal symptoms (which are excluded from consideration) must display two additional behavioural symptoms to be diagnosed, rather than just the one required by DSM-IV. The timing for such ill-conceived changes could not be worse. An additional issue is that there is a degree of arbitrariness to the workgroup's focus on physiological dependence as a potential source of false-positive addiction diagnoses among individuals taking prescribed medication. It has long been observed that taking prescribed opioids can lead to false-positive versions of many of the behavioural SUD symptoms as well. For example, a rural individual attempting to escape chronic pain may well spend much time and give up other activities to maintain an opioid prescription if the only available pharmacy is in a distant town. It is also clear that craving when confronted with triggers can exist even without impaired-control use—and the workgroup recognized this by allowing craving to persist consistent with an individual being in remission. Again, the workgroup might have spent more effort systematically refining the symptom items to achieve greater conceptual validity. To conclude, I have argued that the concerns about DSM-5 SUD diagnostic criteria are quite justified, and the arguments put forward by the DSM-5 workgroup to address critics’ concerns generally spurious. Despite some welcome improvements including the elimination of the abuse category and the clarification of terminology, DSM-5′s substantial changes to SUD diagnosis fail to strengthen validity or clinical utility and diverge markedly from projected ICD-11 criteria. In adding highly face-invalid criteria such as hazardous use and social conflicts to a category that is supposed to represent a motivational dysfunction of impaired control, and then lowering the diagnostic threshold to a level that allows weaker-validity criteria by themselves to qualify for diagnosis, DSM-5 has cast into doubt the hard-fought and still controversial validity of SUD as a category of psychiatric disorder. The changes weaken and even abandon the conceptual foundations of the substance disorders field as part of psychiatry. My analysis presupposes that there is such a thing as impaired control of use that warrants psychiatric diagnosis. This assumption is currently under challenge from a variety of quarters. If this assumption is false, then by all means we should move on to a different conceptualization of the kinds of compulsive harmful substance use that we now conceptualize as addiction. The problem is that the DSM-5 workgroup verbally retained the impaired-control framework while reformulating diagnostic criteria in ways inconsistent with that framework. This undermines the ability to pursue good science addressing the validity of the concept of addiction and of the impaired-control model. If ICD-11 resists the temptation to move toward some of DSM-5′s innovations, it will provide a much-needed alternative approach to addictive disorder diagnosis that could become the field's preferred standard for advancing addiction science." @default.
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W1657187716 title "DSM-5 substance use disorder: how conceptual missteps weakened the foundations of the addictive disorders field" @default.
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