The draft version of the new DSM - Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was released for public comment recently. The DSM is viewed as the bible of the mental health community - used in defining what is a mental disorder by establishing criteria and terminology. Though the changes might appear cultural or semantic, their impact is far reaching - affecting legal matters, industry and government programs and medical and mental health treatment - with a potential of billions of dollars at stake for pharmaceutical companies, insurance and government health plans, doctors, researchers and patiences advocacy groups. It was last revised in 2000, and won't be finalized until 2013. And controversy is swirling around it. Dr Inaba explains.
CNS: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions.
CNS: The draft of the new DSM, (Diagnostic and Statistical Manual Disorders #5) was released for public comment – it is produced by the American Psychiatric Association. It’s viewed as the bible of the mental health community, in defining what a mental disorder is, by establishing criteria and terminology. And on first look, it seems like an exercise in semantics. But the impact of changing is far reaching - effecting legal matters, industry, government programs and of course the medical and mental health treatment communities. And, of course the billions of dollars at stake for pharmaceutical companies, insurance companies, government health plans, doctors, researchers, etc. This is the first update since 1994, so it will be almost 20 years by the time it’s finalized and released in 2013. Darryl, do you remember when the last version came out.
DARRYL: That was…when DSM #4 was accepted and it created a stir. It is vitally important for reimbursement, for acceptance of certain conditions that are billable to insurance and anytime there is something that involves that much money there will be lot of politics. They’re giving themselves 3 years to circulate the draft so people can either attack it or give input, before it is finalized in 2013, so that in itself tells me this will create a lot of controversy.
CNS: So far the only behavioral addiction included is gambling, none of the other ones like internet and sex.
DARRYL: That is a disappointment because the DSM #4 did recognize a lot of impulse control disorders that were well documented, and well accepted as a compulsive behavior that causes people tremendous harm and suffering, but it looks like they could not find enough scientific evidence for sex or internet addiction, so they are leaving those out now.
CNS: What becomes of those?
DARRYL: I imagine they’re going to be retained in some broader category. When they can’t fit something neatly into a specific mode it is classified as “N.O.S.” which stands for “not otherwise specified” and I suspect there will be some of that because people like Tiger Woods are in the news – people who are actively in treatment for sexual addictions, for internet addictions, for obsessive text messaging…things like that.
CNS: We’ve talked about the mechanisms and the obsessions of these behavioral problems before and I find it really interesting that they would exclude these things There are obvious changes in terminology like “mental retardation” is now “intellectually challenged”, but what is the thinking behind removing compulsive behaviors? Is it a lack of credible science at this point?
DARRYL: Well, that’s what the claim is. The architects and writers of the DMS are extremely politically correct. They tend to be careful about naming things or identify things in ways not to offend any specific race or any specific group of people to prevent creating a stigma or making the prejudice against certain of these conditions worse. Maybe people believe that we should not pay for somebody to get treated for sexual addiction or for shopping addiction or for hording.
CNS: Or maybe it’s viewed, at least by the framers of this document, as something so ubiquitous that it isn’t a mental disorder, but as a common part of society now.
DARRYL: They are trying to eliminate things that are just a common part of human behavior that sometimes cause some people problems. Whenever we talk about any of these disorders – sexual disorder or even internet disorder – we’re careful to note that all of these things are a common part of most people’s lives, it is the abnormal participation, the extreme obsession that classifies the activity as a disorder. Sexual addiction causes a person to have tremendous relationship problems, maybe even health problems. They are unable to participate in sex like most people do, they must do it obsessively and abnormally and that’s why I can’t understand the exclusion. I believe there is a lot of evidence that shows that some people are totally obsessed with the internet, totally obsessed with shopping, obsessed to the point that they’re not accomplishing anything. The shopaholics I’ve known will buy 5 Waterpick shower heads because they’re on sale even though they have only one shower in their house and it has a perfectly good shower head. They just can’t prevent themselves from picking it up, putting it in the cart and getting some relief from the act of buying it. They have maxed out credit cards, are deep in debt, experience tremendous suffering, relationship problems, family problems, yet they continue. So, I believe that is a disorder that merits inclusion as a diagnosis and treatment. You can treat it and help people get over it. Shopping is a normal behavior, but not the pathology we see in a shopping addiction. Gambling is included, and certainly a lot of people gamble. They’re thousands of normal gamblers, these people are not pathologic or problem gamblers, but evidence shows that certain people are so beyond normal in their gambling activity that they sacrifice so much and have so many catastrophic consequences that it becomes pathological and thereby merits inclusion as the first behavior compulsion to be added to the DSM 5. Maybe by 2013 we may see more inclusions.
I want to zero in on the changes in terms of addiction substance use disorder. Back in 1994, DSM 4 changed the term to describe a compulsion to drugs and created a whole new nomenclature that I’ve been using for 20 years in order to gain wider acceptance of the term substance use disorder. That term lifts the stigma attached to the word “addiction” and “addicts” and hopefully turns it into a more medically appreciated condition referred to as substance use disorder. That term indicates dependence and abuse. Some people are applauding the prominent use of the word addiction, some people are not. This highlights the politics that goes into the creation of this standard diagnostic manual. Although everybody recognized that the word addiction has negative connotations and therefore may not be good to use as a descriptive term…what occurred or what the authors are dealing with is the fact that when they use substance use disorder and substance dependence or substance abuse, they believed that substance dependence was so connected to the term addiction that it created problems for psychiatrists for whom this is the standard bible for the diagnosis and treatment of neuropsychiatric disorders. When psychiatrists prescribe antipsychotic medications, antidepressant medications, or mood stabilizing medications to treat those conditions - the medications produced dependence. This created a tolerance – the body became used to medication and caused withdrawal symptoms. The thinking that connected or confused the issue has to do with people thinking they were addicted because they took a major antipsychotic medication. It’s important to separate that type of dependence. A dependence on medication is okay because it is part of treatment versus addiction. The term addiction describes the compulsivity and the drug seeking behavior that occurs in addicts…in anyone who is dependent on a drug that can cause addiction.
Cannabis use disorder is going to be included in the new DSM 5 and they’re proposing a new terminology for withdrawal. It is called “discontinuation syndrome” instead of withdrawal and addresses what the treatment community has professed for years that cannabis dependence does occur – creating tolerance dependence and withdrawal symptoms. So that’s a new one. Caffeine is also included. I’ve always believed in the need to consider caffeine as a major addictive substance. And that rounds out the new spectrum of addiction and related disorders. I thought the spectrum would be much broader in terms of different behaviors and different ways people use this drug, but no…they’re just going to be defined by drug. They are going add the severity terms – looking at moderate use versus severe cannabis use disorder and further describing what that means. It is not just “you’re dependant” or “not dependant”, but rather within a spectrum of severity. I think one of the most interesting things happening in the substance abuse field is the addition of drug craving as a criteria for defining a problem or defining somebody with say an alcoholic disorder. That is big because up to now, even in DSM 4, it has been excluded. Craving wasn’t considered a biological condition but rather just a manipulation by addicts to return to using their drug. Because the actual science of addiction is growing the addition of drug craving as a criteria for defining conditions and describing what those cravings are is huge. I hope that will result in changes in how we treat addiction and increase the resources available. The one thing that I am happy to see is the elimination of law enforcement problems as criteria for diagnosing certain addiction problems. In the old system, one of the elements that indicated a substance use disorder was a problem with law enforcement - if a person had been arrested or jailed…now they’re saying no…that’s out of the picture. I think that’s good, maybe it is a move toward looking at the decriminalization of addiction.
CNS: Sounds like an aspect of that.
DARRYL: If we are going to decriminalize addiction, we have to augment the resources and interventions for treatment because it will be recognized as a medical condition so we need to address it as a medical problem. I am always fearful of changes that don’t result in adding the necessary resources for treatment. I certainly hope that doesn’t happen here.
CNS: It sounds like some potent changes are included in this document along with some semantic and politically correct statements, but it’s going to be 2 ½ years or so before it becomes finalized so we will have the chance to talk about it more. To those of you listening, please send us your comments or questions, we would love to hear them. Stop by our website, cnsproductions.com and drop us a note and we will respond if we can.