The Fault in Our Diagnostic Criteria: The Weakness of the DSM-V Criteria for Substance Use Disorder
The DSM-V is the fifth iteration of the Diagnostic and Statistical Manual of Mental Disorders. In a nutshell, it is a book that describes how physicians should diagnose psychiatric problems.
Without some form of standardization, it would be difficult to study new treatments for mental conditions or treat individual patients. In this way, the DSM-V helps us provide quality care to our patients.
However, there are some valid critiques of the text and I want to explore those in today's post.
Before we start, let's remind ourselves about how we diagnose substance use disorder according to the DSM-V. There are eleven criteria which describe ways in which substance use impacts a patient's life. These eleven criteria fall into four major groups: impaired control of substance use, social impairment due to substance use, risky substance use, and pharmacologic factors. A patient is diagnosed with substance use disorder if they meet two or more criteria and the severity of their substance use disorder can be classified as mild, moderate, or severe depending on the number of criteria they meet.
Substance Abuse Impacts on a Patient
The most common critique of these criteria is that they are subjective. It is possible that different examiners could disagree on the severity of an individual's substance use disorder, or might disagree on whether a patient has substance use disorder at all.
The first scenario that comes to mind is that of a bad actor. A duplicitous examiner could easily bend the definitions of these criteria in order to obtain a diagnosis of substance use disorder or inflate the severity of that diagnosis. A patient who reports decreasing their alcohol intake from nightly to every other night might be classified as meeting criteria #2 “persistent desire to reduce use of substance” as an example. This criteria really refers to trying and failing to reduce use, not being able to decrease use successfully.
What might motivate an examiner to do this? Well, consider a drug treatment center that wants to enroll a patient in expensive inpatient rehab. They might stretch the definitions to make that patient meet more criteria in an attempt to deceive the patient and their family into thinking that their expensive treatment plan is justified.
Most of the time, however, disagreements about diagnosis are due to honest differences in assessment rather than malicious application of the criteria.
To illustrate this point, let's consider a single diagnostic criteria, “criteria #5: unable to fulfill major obligations at home, work, or school.” Let say that a particular patient is drinking heavily and as a result he is chronically late to work. The patient loses his job, but finds it impossible to stop drinking on his own and therefore decides to seek treatment.
It seems pretty clear that this patient lost his job due to his drinking and physician evaluating him counts this as one diagnostic criteria fulfilled. Check.
However, after speaking with the patient, the physician calls his ex-employer to obtain collateral information. On speaking with the boss, the doctor learns that the patient was not fired for being late, but rather because the company was downsizing. It had nothing to do with the patient's behavior.
So does the patient meet criteria #5 or not? Do you take the patient's boss at their word or assume that the layoff was motivated by poor work performance, at least in part? Some would argue that regardless of the reason for the firing, the patient is none-the-less failing to meet his obligations at work due to his chronic tardiness. Others might feel that the patient actually meets criteria #6 “continued use despite social consequences” because the patient could not stop drinking even though he lost his job.
Keep in mind that this example is only a single detail from an entire patient evaluation, which consists of dozens of such facts which need to be evaluated and judged against the DSM-V criteria in order to arrive at a diagnosis of substance use disorder. In this light, it's easy to understand how two independent examiners can arrive at different diagnoses for the same patient.
The problems that we have described are that of inter-observer reliability. The good news is that doctors typically agree on whether a patient has a substance use disorder or not, at least for alcohol, opioids, and cocaine. The inter-observer reliability of these three disorders are 81%, 94%, and 92% respectively. However, doctors are more likely to disagree about cannabis use disorder, with an inter-observer reliability of only 65%.
Why is it that doctors are more likely to disagree about the diagnosis of cannabis use disorder?
At least in part, it is due to the second critique of the DSM-V diagnostic criteria, namely that the criteria are interpreted in the context of Western social norms.
We pretend that the diagnosis of mental health disorders should work exactly like the diagnosis of physical ailments, such as cancer or diabetes. However, unlike physical diseases, there are no lab tests or imaging studies that provide objective diagnostic evidence for psychiatric conditions. Rather the evidence we need for diagnosis is made up of behaviors and thoughts. These behaviors and thoughts cannot be divorced from the patient's and doctor's worldview and lived experiences.
I think I am getting a little too abstract, so let's consider a concrete example. Consider diagnostic criteria #6 “continued use despite social consequences.”
A patient who continues using methamphetamine despite being kicked out of their parent's home and losing their job seems to meet this criteria. What if that patient had been smoking an equal amount of cannabis, however?
In many states, recreational use of cannabis has been legalized. Even in those where it remains illegal, it is generally considered less taboo than the use of “hard drugs” such as methamphetamine. Therefore, it is less likely for the cannabis smoker to be ostracized by their parents or lose their jobs, even if that person is using cannabis daily.
If you don't buy that example, because you believe that cannabis is innately safer than methamphetamine, let's consider two different methamphetamine users. One is poor and the other is wealthy.
The poor user loses their job and as a consequence has to live in their car. Since they cannot afford a dentist, they lose all their teeth. While sleeping in their car one night, they are arrested in a police sweep and because methamphetamine is found on their person, they are charged with felony drug possession.
The wealthy user works in a position where they are never drug tested and therefore never has to worry about losing their job. If they're late sometimes, it's not a big deal because they are a salaried worker. They receive regular dental care and despite their meth use, they keep all their teeth. Their risk of arrest is low because they do not have to obtain their drugs on the street, but rather can afford a dealer who comes to them. Even if the police find drugs on their person, they can afford an expensive criminal defense attorney and their charges are dropped.
Both patients are using the same drug, but the poor user suffers more consequences. While the rich user may still be suffering from social and health consequences of their methamphetamine use, these consequences are less severe and harder to identify. How can we consider the DSM-V criteria objective if this is the case?
Speaking in a broader sense, let's consider what would happen in a society which decriminalized all drug use and provided free-to-use healthcare for all citizens. In such a society, the social and health impact of substance use would be greatly decreased. In this light, we see that the DSM-V criteria are almost entirely dependent on the society in which a patient lives.
The disagreement among doctors regarding the diagnosis of cannabis use disorder and alcohol use disorder reflect this sociological dynamic. Cannabis and alcohol are viewed by Western society as less dangerous than “hard drugs” such as heroin, cocaine, and methamphetamine. For this reason, patients are less likely to suffer social and legal consequences for cannabis or alcohol use and doctors are less likely to recognize these consequences.
The DSM-V actually acknowledged this dynamic, at least partially. In the DSM-IV, the diagnostic criteria for “substance abuse” (which is no longer used as a diagnosis) included “recurrent substance-related legal problems.” This item was not included in the diagnostic criteria for substance use disorder in the DSM-V as it was recognized as problematic because privileged users could avoid the legal ramifications of substance use.
With all that said, what's the take away? We will never create a perfect diagnostic tool that can distinguish between problematic substance use and non-problematic use. It is very clear that some people experience harm from their use of substances. We have called this disorder various name throughout the years—addiction, substance use disorder, alcoholism, soldier's disease, substance abuse, habit, dipsomania, dependence. Regardless of the name, they describe a similar pattern of problematic substance use which harms the lives of real people, their friends, and family.
The criteria laid out in the DSM-V are imperfect and our application of them can be flawed, but at the end of the day, they provide a framework for doctors to use in order to diagnosis and treat patients with problematic substance use. It's important that we keep in mind the subjective nature of the diagnostic criteria and continuously examine our application of these criteria, but discarding them entirely benefits no one.
I use the diagnostic criteria as a jumping off point in my treatment of patients with substance use disorder. The most important part of the diagnostic process is not which exact criteria the patient meets or their precise degree of severity but rather it is gaining a deep understanding of the patterns, behaviors, and thoughts which underlie their relationship to substance use.
If you or someone you love is suffering from problematic drug or alcohol addiction use and is seeking treatment, contact the clinic by calling or clicking the “Get Started” button in order to schedule a discovery call and initial evaluation, both of which are free.
We are here to help.
North Tampa Executive Health Clinic is directed by Dr. Jack McGeachy. He provides confidential and comfortable addiction treatments and therapy for opioid and alcohol use disorder. Rather than a rehab or detox, meaning that each patient is cared for one-on-one by a medical doctor, in contrast to other treatment programs. Heed Help? Book your in office appointment in the Tampa office or via video conferencing today.
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