DSM-5 Substance Abuse Disorders Draws Controversy

Eliminates Alcohol Abuse and Alcohol Dependence

Woman With Doctor
Diagnosing Alcohol Abuse Disorders. &Getty Images

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

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

Alcohol Abuse Disorders

In the previous version of the manual, DSM-IV, published in 1994, alcohol use disorders were broken down 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 new manual will have a single diagnosis of alcohol abuse disorder which, according to the APA, will "better match the symptoms that patients experience."

Confusion Over Use of 'Dependence' Term

According to the APA, the previous diagnosis of alcohol dependence caused confusion, because most people thought "dependence" meant "addiction." Dependence, however, can be a normal body response to using a substance, the APA says, such as when someone becomes physiologically dependent on a medication while adhering to a prescribed regimen.

Under the new manual, there will be one diagnosis of alcohol use disorder, but with the designation of mild, moderate or severe. The diagnosis will be based on whether or not the person exhibits any of 11 different symptoms.

The severity of the disorder will be graded by the number of criteria the person meets.

If it's 0 to 1, no diagnosis is made. From 2 to 3 criteria, the diagnosis is mild; 4 to 5, moderate; and 6 or more, severe.

11 Criteria for Diagnosis

Briefly, these are abbreviated descriptions of the 11 symptoms of alcohol use used to determine a diagnosis:

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

Mislabled As Alcoholic?

According to the new criteria, a college student who binge drinks on weekends and occasionally misses a class would be diagnosed with mild alcohol abuse disorder. And this is where the controversy lies, according to critics of the manual revisions.

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.

Promotes More Accurate Dianosis?

The task force that worked to revise the manual claims the new criteria will result in more accurate diagnosis.

"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.

Severe Problems Excluded?

Additionally, there is already one scientific study that indicates the new criteria would not result in improved alcohol-related diagnosis.

Scientists at Virginia Commonwealth University who studied more than 7,000 twins found that, while the new criteria may not result in less accurate diagnoses, it also wouldn't produce a clear improvement over the previous DSM-IV criteria.

"It is not clear that the proposed diagnostic changes will result in a more accurate diagnosis," the researchers reported. "At best, one group of low severity cases will be replaced by another; at worst, a group of individuals who exhibit more severe problems will be excluded from the DSM-5 diagnosis, while less severely affected individuals will meet diagnostic criteria."

Needless Increase in Diagnoses?

Other critics of the revisions claim the DSM-5 will expand the list of what is considered mental illness and lead to needless increases 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 "re-orienting its research away from DSM categories."

Symptoms Alone Not Enough

Dr. Thomas Insel, director of the NIMH, said the main problem with the DSM-5 is validity.

"...DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure," Dr. Insel wrote. "In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment."

The NIMH is currently trying to develop its own Research Domain Criteria (RDoC) as an alternative to the DSM.


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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