Why was the DSM Updated in 2013?
For decades, psychologists and psychiatrists have depended on the Diagnostic and Statistical Manual of Mental Disorders to ensure that they are following best practices and evidence-based criteria for the diagnosis of mental illness, including substance use disorders. It has long been considered the gold standard of defining what constitutes mental health diagnosis.
While each edition of the manual has reflected the best knowledge of the time, once outdated, it can come across as naive at best, and inhumane at worst. Take the example of homosexuality, for example. In DSM-III, it was considered a mental illness. Nowadays, the inclusion of homosexuality as a defined mental disorder is considered a major landmark in the history of the oppression of sexual minorities.
As well as reflecting the thinking of the day, the DSM is updated to reflect up to date research in the fields of psychology, psychiatry, neuroscience, and other related areas of expertise. This research is reviewed, critiqued, analyzed and considered by the greatest minds in the field, who eventually come to a consensus about what should and should not be included in the DSM, and the criteria for each diagnosis.
DSM-5 represents a landmark in the history of mental illness, in that it is the first time that the opinions of the public have been considered in developing the DSM-5 criteria. This was only possible through the internet, and the amazing ability to reach people who would never otherwise be consulted.
Changes from DSM-IV to DSM-5 Diagnostic Criteria for Substance Use Disorders
While many areas of mental illness have not changed significantly from DSM-IV to DSM-5, the changes to the diagnostic criteria for substance use disorders are significant.
One of the most important ways that the criteria has changed is the language used to label the substance use disorders, which has changed from using the terms "abuse" and "dependence" to using the term "use." Why does this matter?
Let's start with the work abuse. The term is associated with cruelty, maltreatment, and harm, and is commonly associated with physical abuse or violence, emotional abuse, and most commonly, with sexual abuse. In fact, the shorthand "child abuse" is often used and understood to mean childhood sexual abuse. So how can this be related to substance use? A substance can't be abused, because as an inanimate object, it can't be hurt. So the "abuse" in the term "substance abuse," which was a diagnostic label in the DSM-IV, referred to the use of substances as a form of self abuse, with the substance as the means of that abuse. But is the intention of users of substances to cause themselves harm? Perhaps not.
In fact, for many people, the opposite is true. When asked why they use substances, they give reasons such as helping them to socialize or connect with others, providing themselves with positive, pleasurable experience, and helping them to relax.
Then there's the term, dependence. This is based on a now stereotypical view of addiction that "addicts" are helplessly enslaved by their addictions, and are unable to function without their drug or addictive behavior. This extreme view is now known to be inaccurate, and has caused a lot of stigma and distress for people with substance use problems.
The language of substance use is more accurate, and less stigmatizing to people who have substance use disorders, and represents an important shift in the thinking about addiction.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Fourth Edition, American Psychiatric Association. 2000.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. 2013.