DSM 5 Substance Use Disorders: A Concise Summary

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, commonly referred to as the DSM-V or DSM 5, is the latest version of the American Psychiatric Association’s gold standard text on the names, symptoms, and diagnostic features of every recognized mental illness, including addictions. This edition was published in May 2013, nearly 20 years after the original publication of the previous edition, the DSM-IV, in 1994.

The DSM-V recognizes substance related disorders resulting from the use of ten separate classes of drugs:

1. alcohol, 2. caffeine, 3. cannabis, 4. hallucinogens (phencyclidine or similarly acting arylcyclohexylamines), other hallucinogens such as LSD, 5. inhalants, 6. opioids, 7. sedatives, 8. hypnotics, 9. anxiolytics, 10. stimulants (including amphetamine-type substances, cocaine, and other stimulants), tobacco, and 11. other or unknown substances.

Therefore, while some major grouping of psychoactive substances are specifically identified, use of other or unknown substances can also form the basis of a substance related or addictive disorder.

The DSM 5 explains that activation of the brain’s reward system is central to problems arising from drug use –- the rewarding feeling that people experience as a result of taking drugs may be so profound that they neglect other normal activities in favor of taking the drug. While the pharmacological mechanisms for each class of drug is different, the activation of the reward system is similar across substances in producing feelings of pleasure or euphoria, which is often referred to as a “high.”

The DSM 5 also recognizes that people are not all automatically or equally vulnerable to developing substance related disorders, and that some individuals have lower levels of self-control, which may be brain-based, which predispose them to developing problems if exposed to drugs.

There are two groups of substance-related disorders: 1. Substance use disorders and 2. Substance-induced disorders.

Substance use disorders are patterns of symptoms resulting from use of a substance which the individual continues to take, despite experiencing problems as a result.

Substance-induced disorders are symptoms that can be caused directly by the drug during or immediately after individual episodes of use.

The substance-induced disorders include:

1. Intoxication, 2. Withdrawal, 3. Substance induced mental disorders (including substance induced psychosis, substance induced bipolar and related disorders, substance induced depressive disorders, substance induced anxiety disorders, substance induced obsessive-compulsive and related disorders, substance induced sleep disorders, substance induced sexual dysfunctions, substance induced delirium and substance induced neurocognitive disorders.)

Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria:

1. Taking the substance in larger amounts or for longer than the you meant to 2. Wanting to cut down or stop using the substance but not managing to 3. Spending a lot of time getting, using, or recovering from use of the substance 4. Cravings and urges to use the substance 5. Not managing to do what you should at work, home or school, because of substance use 6. Continuing to use, even when it causes problems in relationships 7. Giving up important social, occupational or recreational activities because of substance use 8. Using substances again and again, even when it puts the you in danger 9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance 10. Needing more of the substance to get the effect you want (tolerance) 11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.

The DSM 5 allows clinicians to specify how severe the substance use disorder is, depending on how many symptoms are identified.

MILD: Two or three symptoms indicate a mild substance use disorder,

MODERATE: four or five symptoms indicate a moderate substance use disorder, and

SEVERE: six or more symptoms indicate a severe substance use disorder. Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.”

The DSM 5 is criticized for combining the the DSM IV categories of substance dependence (addiction marked by a pattern of compulsive use or loss of control) and substance abuse disorders (using in a manner that causes problems but does not have a pattern of compulsive use). The 2011 definition of addiction by the American Society of Addiction Medicine (ASAM) is consistent with DSM IV but not DSM 5.

The DSM IV, like the ASAM definition is based upon the idea that there is a DIFFERENCE IN KIND between substance abuse and dependence/addiction.

The DSM 5 is inconsistent with the ASAM definition because it is based upon the idea that there is only A DIFFERENCE IN DEGREE between abuse and addiction based upon the number of symptoms.

This is a critical difference in the underlying theory of addiction between the DSM IV and DSM 5 and a break in the progressive development of the fundamental concept if addiction which began with the DSM III.