DSM-5 Alcohol Use Disorder Diagnosis Draws Controversy

Diagnosis manual combines alcohol abuse and alcohol dependence

Woman With Doctor
Diagnosing Alcohol Abuse Disorders. &Getty Images

After more than a decade of revisions, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in 2013 by the American Psychiatric Association (APA)—but not without controversy. The DSM-5 is widely used by health professionals to diagnose behavioral health problems and is used for insurance billing purposes.

Several sections of the new DSM-5 have come under criticism, including the section dealing with alcoholism.

Alcohol Abuse Disorders

In the previous version of the manual, DSM-IV, published in 1994, alcohol use disorders were divided into two categories, alcohol abuse and alcohol dependence.

According to the APA, "The distinction between abuse and dependence was based on the concept of abuse as a mild or early phase, and dependence as the more severe manifestation."

Instead of two separate diagnoses, the revised manual has a single diagnosis of alcohol use disorder (AUD) which, according to the APA, will "better match the symptoms that patients experience."

In the fifth edition of the manual, AUD can be categorized as mild, moderate or severe. The diagnosis is based on 11 criteria. The severity of the disorder is graded by the number of criteria the individual meets. From 0 to 1, the person does not have an AUD. From 2 to 3, the diagnosis is mild; from 4 to 5, moderate; and 6 or more, severe.

Confusion Over the Term Dependence

According to the APA, a reason for combining the two separate diagnoses into one was primarily because the diagnosis of alcohol dependence caused confusion.

Most people thought dependence meant addiction. Dependence, however, can be your normal body response to using a substance, such as when you become physiologically dependent on a medication while following your doctor's prescribed regimen.

11 Criteria for an Alcohol Abuse Disorder Diagnosis

The following abbreviated descriptions are what health professionals use for diagnosis as the 11 criteria of alcohol use disorder:

Criteria for Diagnosis Alcohol Use Disorder (AUD)
Missing work or school
Drinking in hazardous situations
Drinking despite social or personal problems
Craving for alcohol
Build up of tolerance
Withdrawals when trying to quit
Drinking more than intended
Trying to quit without success
Increased alcohol-seeking behavior
Interference with important activities
Continued use despite health problems

The craving criteria replaced a previous symptom of reoccurring legal problems due to drinking, which the APA eliminated because of varying cultural considerations that made the criteria difficult to apply internationally.

Critics Claim Alcoholism Mislabeled With New Criteria

According to the new criteria, a college student who binge drinks on weekends and occasionally misses a class would be diagnosed with a mild alcohol abuse disorder. This is part of where the controversy lies. Critics say the revised criteria could lead to college or underage binge drinkers to be mislabeled as mild alcoholics, a diagnosis the could follow them into their later years.

Task Force Believes Newer Manual Provides for More Accurate Diagnosis

The task force that helped revise the manual claims the new criteria is a step in the right direction toward a more accurate diagnosis of the disorder.

"The field of substance abuse and addiction has witnessed an explosion in important research in the past two decades," said Dr. David Kupfer, chairman of the DSM-5 task force. "The changes reflect the best science in the field and provide new clarity in how to diagnose these disorders."

One of the authors of the previous DSM-IV disagrees that research should be the only factor in diagnosis. "The DSM-5 decision to lump beginning drinkers with end-stage alcoholics was driven by researchers who are not sensitive to how the label would play out in young people's lives," said Dr. Allen Frances, chairman the DSM-IV task force.

One Study Shows New Criteria Does Not Do Much for Diagnosis

One scientific study in 2013 by researchers at Virginia Commonwealth University that studied 7,000 twins shows that the new criteria do not result in improved alcohol-related diagnosis. The new criteria do not result in less accurate diagnoses either.

Needless Increase in Diagnoses

Critics of the revisions claim the DSM-5 expands the list of what is considered mental illness and leads to a needless increase in diagnoses. The most damaging criticism of the DSM-5 came from the National Institute of Mental Health (NIHM), which withdrew its support of the manual two weeks before its publication. The NIMH, the largest funding agency for mental health research, announced that it would be reorienting its research away from DSM categories.

Meeting Criteria Is Not Enough for Diagnosis

According to Dr. Thomas Insel, director of the NIMH when the manual was released, claimed that the main problem with the DSM-5 was validity. Meeting criteria does not go far enough to warrant a diagnosis. He said, "This would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever," implying that symptoms alone rarely indicate the best choice of treatment or an accurate diagnosis.

The NIMH is in the process of developing its own Research Domain Criteria (RDoC) as an alternative to the DSM.  It would find new ways of classifying mental disorders based on dimensions of observable behavior and objective neurobiological measures.

Sources:

American Psychiatric Association. "Substance-Related and Addictive Disorders." May 2013.

Edwards, AC, et al. "Assessment of a Modified DSM-5 Diagnosis of Alcohol Use Disorder in a Genetically Informative Population." Alcoholism: Clinical & Experimental Research. 24 January 2013.

Insel, T. "Transforming Diagnosis." National Institute of Mental Health. 29 April 2013.

The Partnership and DrugFree.org. "Critics of Mental Health Disorder Manual Say Mental Illness Being Overdiagnosed." Join Together. 29 March 2013.

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