DSM-5: Psychiatry's Contested Bible

By Michael Dhar 04/05/13

The new 1,000-page psychiatrists' Big Book will redefine addiction. Critics are already demanding a boycott. The Fix guides you through the highlights.

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Next month a hotly anticipated book will hit the shelves, and its publishers already know it will sell big. Likely to clock in at 1,000 pages, it's not one of the thrillers, sizzlers or self-helpers that typically populate bestseller lists. The fifth edition of the DSM, or Diagnostic and Statistical Manual of Mental Disorders, will find a waiting nook in the library of any individual or organization paid to provide mental health and addiction care, including doctors and therapists, treatment programs, drug companies and the insurance industry. Its ubiquitous influence has earned it the name "the Bible of psychiatry."

And that’s why you need to know about what’s inside it—and behind it. The big book plays a big role in the life of anyone seeking help for addiction, from the diagnosis you may get from your doctor to the bill your insurance company may send you. (It looms especially large for the 40% of addicts who have a dual diagnosis.)

The volume—published by the American Psychiatric Association (APA)—consists entirely of a labyrinthine system that classifies and categorizes diagnoses and symptoms of mental illness and addiction. And all for only $199.

The APA began work on this 2013 version of the DSM in the late '90s. The organization's stated goal was to improve all mental health care by rooting it deep in new science, recognizing the big strides in neuroscience made over the last two decades. Those advances have, for one thing, almost entirely redefined addiction as a brain disease.

But the manual has already sparked a raging controversy—one psychiatrist likened the kerfuffle to a “bar-room brawl" and "Armageddon"—and garnered much media attention (plus over 1,600,000 Google listings for “DSM-5”). Now, with the book still at the printer, one international psychology group has called for the book's boycott. What many overlook, however, is that the current battle represents a long-simmering conflict in psychiatry that goes public only at DSM revision time—but can be traced back to the late ‘70s.

Like the DSM’s two previous major revisions, published in 1975 and 1994, this one expands the number of psychiatric diagnoses and will almost certainly result in many more people receiving such a diagnosis. Advocates for DSM-5 say that the science justifies these changes; many critics see ulterior motives. The consequences of more people with more diagnoses are also at issue. Both sides agree that more diagnoses could mean earlier interventions. But will this lead to more effective—and more cost-effective—treatment strategies, saving precious resources as healthcare costs spiral out of control? Or to a cash cow for drug companies and doctors who prescribe psychoactive drugs, diverting already-scarce funds from the addicts who most need them?

Here's The Fix's guide to what matters most:

  • How is "addiction" changing?
  • How will diagnoses be made differently?
  • Who objects to the changes and why?
  • What will be the consequences of more diagnoses?
  • How are Big Pharma dollars mixed up in this?
  • How much does the DSM-5 matter, anyway?


How is "addiction" changing?

The DSM-5 is the first to include the word “addiction.” But this change is largely cosmetic, appearing only in the title of the section “Addiction and Related Disorders.” Previous versions shied away from this charged word, Charles O'Brien, MD, PhD, the head of the University of Pennsylvania’s Center for Studies in Addiction and the chair of the DSM-5's Substance-Related Disorders Work Group, tells The Fix.

The new DSM also puts one “behavioral” disorder—compulsive gambling—on a par with addiction to substances.

The red meat of the new changes lies in the definitions of the conditions. The previous DSM identified two separate substance disorders: “substance abuse” and “substance dependence.” But the line dividing one from the other remained blurry. The DSM-5 collapses the two into one continuum, defining “substance use disorders” on a range from mild to moderate to severe; the severity of the diagnosis depends on how many of the six criteria apply. So rather than dividing the universe into “alcoholics” and “non-alcoholics,” for example, the new “alcohol disorder” spectrum could include everyone at levels from "mild" (your "normal" college binge drinker) to "severe" (someone whose drinking is out of control and who meets all six criteria). You can even be “almost” alcoholic, with four criteria.

The DSM's research showed that changes to criteria number were necessary to maintain accuracy after collapsing the two previous disorders. Now two criteria can earn you an “alcohol use disorder” diagnosis (previously “alcohol dependence” required three symptoms, while the milder “substance use” diagnosis required one). The latest manual also nixes the “legal problems” criteria (a lifestyle problem) and adds “craving” (a brain dysfunction). Studies have shown the importance of treating craving symptoms, whereas legal problems varied too greatly by location, O'Brien says.

The new DSM also puts one—and only one—“behavioral” disorder on a par with addiction to substances: "disordered gambling," which was previously dubbed "pathological gambling" and listed under "Impulse-Control Disorder." At one stage of drafting the new version, "internet addiction disorder" was set to be included, but it has now been relegated to an obscure appendix of conditions “deserving of further study." The difference? Disordered gambling, a time-honored problem, had many more studies backing it up, O’Brien tells us. Other "disordered" behaviors—sex, eating, shopping, video gaming, etc.—aren't included at all, but will likely have their day in due course.

 How will diagnoses be made differently?

Traditionally, psychiatric diagnoses have depended, to a large degree, on subjective measures: a patient’s experience and a therapist’s evaluation. But science is all about “objective” facts. The introduction of the “substance use disorder” as a severity scale is meant to help addiction treatment fall in line with physical medicine, with its numerically precise diagnostics like blood pressure and cholesterol levels.

“What we're trying to do is make the DSM-5 diagnoses more like a neuroscience diagnosis,” O'Brien says. “It allows for much more precise treatment.”

The DSM-5 also does away with the term “dependence,” which was widely misused and misunderstood, O'Brien says. The term led patients and doctors alike to confuse physical dependence with addiction. Though it plays a role in addiction, dependence refers only to the body's symptoms of tolerance and withdrawal in response to chemicals. It doesn't include the psychological compulsions that also contribute to people's inability to stop using.

The APA's ambitions toward better science also explain the inclusion of the first behavioral disorder as an official diagnosis under "Addiction." A burgeoning body of evidence shows that engaging in, say, compulsive cybersex has the same effect on the brain as overdoing cocaine. “There is substantive research that supports the position that pathological gambling and substance-use disorders are very similar in the way they affect the neurological reward system,” O’Brien told Recovery Today. PET scans and MRIs have demonstrated these physical changes in the brains of people with behavioral disorders and substance disorders alike.

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