DSM‐5 substance use disorder: how conceptual missteps weakened the foundations of the addictive disorders field
Published Nov 1, 2015 · J. Wakefield
Acta Psychiatrica Scandinavica
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Abstract
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 impairedcontrol 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 faceinvalid 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, requires 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