The new, multi-tiered criteria for diagnosing substance problems are valid in comparison to the old methods of diagnosing such problems, according to new findings from a team of federal researchers.
In 2013, the American Psychiatric Association fundamentally altered the terms used to define and diagnose substance abuse and substance addiction. One of the stated rationales for this alteration was a desire to identify and help people who might not have received a diagnosis for substance problems under previously used guidelines. In a study published in May 2015 in the Journal of Studies on Alcohol and Drugs, researchers from the National Institute on Alcohol Abuse and Alcoholism assessed the degree to which the new diagnostic guidelines achieve this goal.
Old Definition of Diagnosable Substance Problems
Before 2013, the American Psychiatric Association (the nation’s source of the widely accepted definitions for all diagnosable substance problems) maintained a strict division between the criteria used to identify substance abuse and the criteria used to identify substance addiction. The diagnosis of alcohol abuse and other forms of substance abuse required the presence of just one out of four possible symptoms. Included on the symptom list were repeated run-ins with the legal system caused by substance use, a pattern of substance use that diminishes the ability to fulfill important responsibilities, a failure to modify substance use after exposure to seriously negative substance-related outcomes and repeated substance intake in situations that pose a clear hazard to self or others.
The diagnosis of alcoholism and other forms of substance addiction required the presence of a minimum of three out of seven potential symptoms. Addiction symptoms included an inability to limit substance use, repeated use of more of a given substance than intended, increasing tolerance to a substance’s mind-altering effects, the appearance of a withdrawal syndrome when substance intake stops or falls below a certain level, prioritization of substance-related issues over other daily concerns, ongoing participation in substance use after exposure to serious harm and an abandonment of previously preferred activities triggered by substance use.
New Definition of Diagnosable Substance Problems
The American Psychiatric Association (APA) abolished separate diagnoses for substance abuse and substance addiction in May 2013 and replaced them with a single diagnosis called substance use disorder (which has subtypes dedicated to each widely used addictive substance). The rationale for this major change is acknowledgment of the strong degree of overlap between abuse symptoms and addiction symptoms. However, the APA also wanted to increase the chances that people with relatively mild substance problems would receive appropriate help for their addiction. To this end, the substance use disorder diagnosis requires the presence of just two out of 11 possible symptoms (i.e., more symptoms than required for the old diagnosis of substance abuse, but fewer symptoms than required for the old diagnosis of substance addiction). In addition, substance use disorder is a tiered diagnosis. Mildly affected individuals have two or three symptoms, and moderately affected individuals have four or five symptoms. People with six or more symptoms have a severe case of the disorder.
Comparison of Criteria
In the study published in the Journal of Studies on Alcohol and Drugs, the National Institute on Alcohol Abuse and Alcoholism researchers used data from 36,309 participants in a nationwide project called the National Epidemiologic Survey on Alcohol and Related Conditions to compare the number of substance problems identified under the new diagnosis of substance use disorder to the number of cases identified under the old, separate diagnoses of substance abuse and substance addiction.
The researchers concluded that the new diagnosis of mild substance use disorder identifies more people with recent opioid-, alcohol- or sedative/tranquilizer-related problems than the old diagnosis of substance abuse, but fewer people with recent stimulant- or cannabis-related problems. The new substance use disorder diagnosis identifies fewer lifetime cases of substance problems than the older substance abuse diagnosis. The researchers found that the accuracy of the substance use disorder diagnosis improves for moderately affected and severely affected individuals. This conclusion applies to substance problems encountered in the recent past, as well as substance problems encountered over the course of a lifetime.
Overall, the study’s authors concluded that the change to the new substance use disorder diagnosis is justified. However, they point to a need to explore the usefulness of the diagnosis for recent substance problems versus its usefulness for identification of substance problems that occurred in the more distant past.