Is the DSM V Diagnosing Addiction Right?

What has long been considered the go-to resource for diagnosing mental and addictive disorders, has been recently critiqued by Dr. Thomas R. Insel, the Director of the National Institute of Mental Health.

Dr. Insel is considered an expert in the field of mental health disorders and says that the Diagnostic Statistical Manual of Mental Disorders (DSM) doesn’t account for important diagnostic tools such as the role of biology, neuroscience and genetics. Currently, the DSM looks at symptoms as the driving criteria to diagnose patients for mental and addictive disorders. For example, the critera for substance dependence is:

1.Tolerance, as defined by either of the following: (a) A need for markedly increased amounts of the substance to achieve intoxication or the desired effect or (b) Markedly diminished effect with continued use of the same amount of the substance.

2.Withdrawal, as manifested by either of the following: (a) The characteristic withdrawal syndrome for the substance or (b) The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.

3.The substance is often taken in larger amounts or over a longer period than intended.

4.There is a persistent desire or unsuccessful efforts to cut down or control substance use.

5.A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.

6.Important social, occupational, or recreational activities are given up or reduced because of substance use.

7.The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance (for example, current cocaine use despite recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

If someone has experienced 3 of these critera within the same 12 month period, they are diagnosed with substance dependence. According to Dr. Steven E Hyman, former Director of the National Institute of Mental Health, the DSM “chose a model in which all psychiatric illnesses were represented as categories discontinuous with ‘normal.’” Hyman explains that this caused a scientific dilemma because those who qualify for one diagnosis qualify for five by default but don’t actually have five diseases. Both Dr. Insel and Hyman explain that patients have an underlying condition that causes the symptoms. Therefore, the lens through which we look at patients and research should be through the overall condition rather than just the symptoms.

Dr. Insel asserts that the DSM created in the 1960s and 10970s is outdated and “As long as the research community takes the D.S.M. to be a bible, we’ll never make progress,” because people think everything has to match the criteria. He explains that biology doesn’t follow the rigid criteria of the DSM and we should look at the causes and condition. For example, over the past 40 years neuroscience has shown that genetic abnormalities can put people at risk for addiction, schizophrenia or bipolar disorder. The drugs created for disorders like bipolar disorder show nothing about the causes of the disorder and therefore drug makers have no goal for drug development that targets the problem before it manifests. Dr. Hyman, Insel and other experts would like the current direction of cancer research, such as characterizing it by genetic and molecular signatures, to serve as a model for the direction of mental health research.

With the newest DSM since 1994 set to come out in a few weeks, practitioners say it shouldn’t be disregarded entirely. It is still the primary tool available to diagnose disorders, but those like Dr. Insel and Hyman say that while using it, keep in mind that it doesn’t reflect the entire picture of the disorder – namely the causes of the condition – and it should not guide research.