Diagnosis of SUD—DSM-5

Diagnosis of SUD is performed using the Diagnostic Statistical Manual - DSM-5.²⁴ The DSM is the standard psychiatric system of classification for mental disorders used for clinical, research, policy, and reimbursement purposes in the United States. It has widespread importance and influence on how disorders are diagnosed, treated, and investigated. Since its first publication in 1952, DSM has been reviewed and revised five times; the new version, DSM-5, was published in 2013. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook used by healthcare professionals in the United States and much of the w'orld as the authoritative guide toward the diagnosis of mental disorders.

The DSM-5 recognizes substance-related disorders resulting from the use of ten separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens (phencyclidine or similarly acting arylcyclo- hexylamines, and other hallucinogens, such as LSD); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants (including amphetamine-type substances, cocaine, and other stimulants); tobacco; and other or unknown substances. While some major groupings of psychoactive substances are specifically identified, the use of other or unknown substances can also form the basis of a substance-related or addictive disorder.

The DSM-5 recognizes that people are not all automatically or equally vulnerable to developing substance-related disorders and that some people have lower levels of self-control that predispose them to develop problems if they’re exposed to drugs.

There are two groups of substance-related disorders: substance use disorders and substance- induced disorders.

• • Substance use disorders are patterns of symptoms resulting from the use of a substance that you continue to take, despite experiencing problems as a result.
• • Substance-induced disorders, including intoxication, withdrawal, and other substance/ medication-induced mental disorders, are detailed alongside substance use disorders.

Criteria for Substance Use Disorders

Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria:

• 1. Taking the substance in larger amounts or for longer than you’re meant to.
• 2. Wanting to cut down or stop using the substance but not managing to.
• 3. Spending a lot of time getting, using, or recovering from use of the substance.
• 4. Cravings and urges to use the substance.
• 5. Not managing to do what you should at work, home, or school because of substance use.
• 6. Continuing to use, even when it causes problems in relationships.

• 7. Giving up important social, occupational, or recreational activities because of substance use.
• 8. Using substances again and again, even when it puts you in danger.
• 9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
• 10. Needing more of the substance to get the effect you want (tolerance).
• 11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.

Severity of Substance Use Disorders

The DSM-5 allows clinicians to specify how severe or how much of a problem the substance use disorder is, depending on how many symptoms are identified.

• • Two or three symptoms indicate a mild substance use disorder.
• • Four or five symptoms indicate a moderate substance use disorder.
• • Six or more symptoms indicate a severe substance use disorder.

Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.”

Placement Criteria for SUD (ASAM)

ASAM’s criteria, formerly known as the ASAM patient placement criteria, is the result of a collaboration that began in the 1980s to define one national set of criteria for providing outcome- oriented and results-based care in the treatment of addiction.²⁵ Today the criteria have become the most widely used and comprehensive set of guidelines for placement, continued stay, and transfer/ discharge of patients with addiction and co-occurring conditions. ASAM’s criteria are required in over 30 states.

ASAM (2015) definition of addiction:

Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.

Addiction is characterized by the inability to consistently abstain, impairment in behavioral control, and craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

Other factors that can contribute to the appearance of addiction, leading to its characteristic biopsycho-socio-spiritual manifestations, include: ^[1]

• • Cognitive and affective distortions, which impair perceptions and compromise the ability to deal with feelings, resulting in significant self-deception.
• • Disruption of healthy social supports and problems in interpersonal relationships which impact the development or impact of resiliencies.
• • Exposure to trauma or stressors that overwhelm an individual’s coping abilities.
• • Distortion in meaning, purpose, and values that guide attitudes, thinking, and behavior.
• • Distortions in a patient’s connection with self, with others, and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others).
• • The presence of co-occurring psychiatric disorders in patients who engage in substance use or other addictive behaviors.

• [1] The presence of an underlying biological deficit in the function of reward circuits, suchthat drugs and behaviors which enhance reward function are preferred and sought asreinforcers. • The repeated engagement in drug use or other addictive behaviors, causing neuroadaptation in motivational circuitry, leading to impaired control over further drug use or engagement in addictive behaviors.