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Keywords:

  • Addiction;
  • dependence;
  • DSM V

At a personal and professional level, it is not easy to disagree publicly with a respected colleague and good friend. However, in choosing to focus on cosmetic changes that he and his colleagues have proposed for DSM-V (changing the term ‘dependence’ to ‘addiction’), Dr O'Brien's essay avoids mentioning the significant problems that are all too visible within the proposed criteria. Sadly, the Committee has repeated the errors of the recent past by applying a common set of criteria to all substance use disorders (and adding non-drug ‘addictions’), while ignoring some very important differences that are especially relevant to diagnosis, treatment considerations and medications development, as well as genetic and translational research. In the alcohol field, we have an accepted standard of heavy drinking (five drinks or more per day for men and four drinks or more per day for women) that can be used to evaluate whether medications have been effective in producing a stable moderate drinking outcome [1]. The issue of heavy drinking, heavy drinking days/drinking days and the number of years of heavy drinking and bouts of alcohol withdrawal are all important in approaching the question of alcohol addiction severity [2]. These are ignored in the defining criteria for alcohol use disorder (alcohol addiction). Since the introduction of DSM-III-R and DSM-IV, with their categorical approach to a common substance use disorder diagnosis based heavily on psychosocial criteria, data from clinical populations and community-wide samples given the same diagnosis of alcohol dependence have produced paradoxical conclusions that cannot be explained [3]. While the literature indicates that patients in treatment for alcohol addiction are unlikely to be able to resume drinking and to sustain a stable moderate drinking outcome [2], population-based studies of people with alcohol dependence indicate that individuals meeting DSM criteria go in and out of periods of moderate and heavy drinking [4]. Given that many (if not most) clinical trials of medications to treat alcoholism routinely recruit from the community via radio and newspaper advertising, there is a high likelihood of a placebo response in clinical trials of medications to treat an alcohol use disorder, as a stable moderate drinking outcome appears not to be uncommon in individuals who simply meet current and projected DSM-V criteria (more on the latter below). A similar problem has bedeviled the depression field over this same period: as the criteria were broadened to include a more heterogeneous population (where two individuals meeting a different set of criteria can both be diagnosed with major depressive disorder), the placebo response rate (and the rate of failed trials) has soared, approaching 50% [5].

The broader criteria, and the failure to focus on issues known to be associated with more severe alcohol-specific consequences, also impacts on genetics and translational research, where animal models are relevant to traditional physiological and behavioral criteria, but the DSM has reified uniquely human psychosocial consequences in the diagnosis [6]. Indeed, because the psychosocial consequences of alcoholism tend to be a more common presentation in cultures with an abstinence tradition, while health consequences tend to be more important in countries where heavy drinking is more normative, the DSM suffers from cultural relativism [3]. More particularly, for primary care physicians who carry the bulk of the responsibility for the diagnosis and treatment of alcoholism, the specific health consequences and the amount of alcohol consumed (and ‘loss of control’) are far more important in making the diagnosis than psychosocial consequences.

Paradoxically, the DSM-V makes the problem worse than its predecessors. The DSM-V Committee has collapsed the diagnoses of alcohol abuse and alcohol dependence into a single categorical disorder, thus adding three additional psychosocial criteria to the former diagnosis of alcohol dependence. There is considerable overlap among the four explicitly psychosocial criteria (items 1, 3, 9 and 10), as well as overlap between items 6 and tolerance in item 4. Because the diagnosis of alcohol use disorder can be made with as few as two criteria, the reader will readily understand the problem. A man who fails to provide child support or alimony payments, and who is performing poorly at work, may be drinking heavily on occasion—but may also be involved in an angry divorce, be mild to moderately depressed and/or be temperamentally irresponsible. Based on two psychosocial criteria and the subjective judgement of the rater, he may qualify for the diagnosis of alcohol use disorder. On the issue of severity, the DSM-V Committee considers any four criteria as grounds for a more severe disorder rather than alcohol-specific elements, including impaired capacity to maintain moderate drinking, health consequences and/or specific consequences with prognostic significance such as persistent sleep abnormalities or cognitive impairment.

Finally, Dr O'Brien refers to the influence of the alcohol dependence syndrome [7] on DSM-III-R. Sadly, the committee that created the document lost a great deal in the translation to American English. Edwards & Gross differentiated between dependence severity (related to drinking behavior) and the severity of the consequences of drinking [8]. The latter could be influenced by culture and/or comorbid psychopathology; but the former was more explicitly related to alcohol addiction. Edwards and colleagues, as well as others, demonstrated the utility of dependence severity in predicting the possibility of a moderate drinking outcome [9] in studies of heritability [10] and in clinical laboratory research [11,12]. The DSM-III-R Committee, following the paradigmatic directive of the American Psychiatric Association, collapsed the two-dimensional syndrome into a single category; and in the absence of any comparable data supporting the construct across all addictions, applied the category to all abused substances. DSM-V now plans to expand the category to gambling and potentially other non-drug addictions—seemingly without considering important differences among different addictions and/or the relevance of specific psychosocial consequences to each addictive disorder.

However, back to Dr O'Brien's essay and its enthusiastic refocus on the term ‘addiction’. Would a rose by another name smell just as sweet [13]? Sadly, since DSM-III-R, we have lost sight of the meaning of the term in a thicket of psychosocial criteria. With DSM-V, it is hard to smell the rose!

References

  1. Top of page
  2. Declaration of interests
  3. References
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  • 13
    Shakespeare W. Romeo and Juliet Act II Scene II.