Diagnostic and Statistical Manual of Mental Disorders Version V
Diagnostic and Statistical Manual of Mental Disorders Version V
Diagnosis is the basis not only for the management of clinical disorders but also for defining their occurrence in the community and identifying targets for prevention. More broadly, diagnostic terms are part of the language with which we communicate our data, our ideas and our conclusions to colleagues worldwide. In the mental health and substance use disorders fields, diagnoses are made predominantly on the basis of the definitions of these disorders in two major international diagnostic and classification systems. These are the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). These two international systems are undergoing revision at present, with projected publication dates of 2012 and 2014, respectively. This fact is of significance to those working in the area of substance use disorders, whether they be clinicians, epidemiologists, researchers or policy advisers. The present review focuses on papers published during 2005 and 2006 on the issues of diagnosis, with a particular focus on a series of papers published as part of the DSM-V research agenda-setting process.
The first edition of DSM was published in 1952 and comprised a standardized nomenclature, definitions of disorders and a statistical classification. Substance use disorders did not have a separate category. Instead they were grouped under the personality disorders. The statement that 'addiction is usually symptomatic of a personality disorder' reflected the view that there was a primary disorder of personality and that alcohol and drug misuse were simply manifestations of this. This conceptualization continued until the third edition was published in 1980. In DSM-III substance use disorders were classified separately from other mental health conditions. A distinction was made between substance abuse and dependence. Substance abuse was defined as pathological use and impairment in social or occupational functioning. Dependence required either pathological use or impairment plus either tolerance or withdrawal. Subsequent revisions to DSM (III-R and IV) emphasized a broader-based concept of substance dependence, which was derived from the pivotal clinical description of the dependence syndrome by Edwards and Gross.
The ICD is the principal international diagnostic and coding system of diseases and is auspiced by the WHO. Since 1946 the WHO has produced revisions every decade or two. The present revision, ICD-10, which was published in 1992, conceptualizes substance dependence in a way that is very similar to DSM-IV. The major additional diagnostic term that defines repetitive substance use in ICD-10 is 'harmful use'. This embraces repeated alcohol or drug use that has caused physical or mental harm. In ICD-10 there is no counterpart to DSM-IV substance abuse. The absence of a substance use disorders diagnosis that is based on social consequences reflects the tradition of the ICD in not admitting social problems as part of the criteria for a diagnosis. In turn, this reflects its need to be relevant to different cultures and their social mores, and to avoid being dominated by a particular culture.
In addition to the three central disorders (substance dependence, substance abuse and harmful use), which seek to characterize various forms of repeated substance use, there are many diagnostic entities in the two systems that reflect the complications of these core disorders. They include substance-induced amnestic syndrome, substance-induced psychosis, substance-induced mood disorders, substance-induced anxiety disorders, substance-induced non-amnestic cognitive disorders (residual disorders), as well as the withdrawal syndrome, which is more specifically integral to substance dependence. These complications are treated fairly similarly in DSM-IV and ICD-10.
Diagnosis is the basis not only for the management of clinical disorders but also for defining their occurrence in the community and identifying targets for prevention. More broadly, diagnostic terms are part of the language with which we communicate our data, our ideas and our conclusions to colleagues worldwide. In the mental health and substance use disorders fields, diagnoses are made predominantly on the basis of the definitions of these disorders in two major international diagnostic and classification systems. These are the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). These two international systems are undergoing revision at present, with projected publication dates of 2012 and 2014, respectively. This fact is of significance to those working in the area of substance use disorders, whether they be clinicians, epidemiologists, researchers or policy advisers. The present review focuses on papers published during 2005 and 2006 on the issues of diagnosis, with a particular focus on a series of papers published as part of the DSM-V research agenda-setting process.
The first edition of DSM was published in 1952 and comprised a standardized nomenclature, definitions of disorders and a statistical classification. Substance use disorders did not have a separate category. Instead they were grouped under the personality disorders. The statement that 'addiction is usually symptomatic of a personality disorder' reflected the view that there was a primary disorder of personality and that alcohol and drug misuse were simply manifestations of this. This conceptualization continued until the third edition was published in 1980. In DSM-III substance use disorders were classified separately from other mental health conditions. A distinction was made between substance abuse and dependence. Substance abuse was defined as pathological use and impairment in social or occupational functioning. Dependence required either pathological use or impairment plus either tolerance or withdrawal. Subsequent revisions to DSM (III-R and IV) emphasized a broader-based concept of substance dependence, which was derived from the pivotal clinical description of the dependence syndrome by Edwards and Gross.
The ICD is the principal international diagnostic and coding system of diseases and is auspiced by the WHO. Since 1946 the WHO has produced revisions every decade or two. The present revision, ICD-10, which was published in 1992, conceptualizes substance dependence in a way that is very similar to DSM-IV. The major additional diagnostic term that defines repetitive substance use in ICD-10 is 'harmful use'. This embraces repeated alcohol or drug use that has caused physical or mental harm. In ICD-10 there is no counterpart to DSM-IV substance abuse. The absence of a substance use disorders diagnosis that is based on social consequences reflects the tradition of the ICD in not admitting social problems as part of the criteria for a diagnosis. In turn, this reflects its need to be relevant to different cultures and their social mores, and to avoid being dominated by a particular culture.
In addition to the three central disorders (substance dependence, substance abuse and harmful use), which seek to characterize various forms of repeated substance use, there are many diagnostic entities in the two systems that reflect the complications of these core disorders. They include substance-induced amnestic syndrome, substance-induced psychosis, substance-induced mood disorders, substance-induced anxiety disorders, substance-induced non-amnestic cognitive disorders (residual disorders), as well as the withdrawal syndrome, which is more specifically integral to substance dependence. These complications are treated fairly similarly in DSM-IV and ICD-10.
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