Are you an alcoholic— or just a problem drinker? It may not matter, according to the latest version of the DSM, psychiatry’s diagnostic manual.
And now, in a new study of the different levels of alcohol misuse, scientists say the changes made to the DSM-5 may not even represent a significant improvement in the diagnosis of alcoholism. In fact, the revised definition collapses the medical distinction between problem drinking and alcoholism, potentially leading college binge drinkers to be mislabeled as possible lifelong alcoholics. The changes take effect in May, when the DSM-5 will be released.
For their research, published in Alcoholism: Clinical and Experimental Research, researchers led by Alexis Edwards of Virginia Commonwealth University studied more than 7,000 fraternal and identical twins. They wanted to see if the new diagnostic system would alter alcohol-related diagnoses, compared to the earlier definition. The twins responded to questions that assessed whether they met varying criteria such as loss of control over drinking, trying and failing to cut down or quit, and hazardous use (such as drunk driving) that doctors commonly use to define alcohol problems.
“What the analyses suggest is that it isn’t clear whether the new criteria represent an improvement. That isn’t to say that our results suggest that the DSM-5 criteria are worse than the DSM-4 either, though,” says Edwards.
In the DSM-5, “alcohol use disorder” is now a single condition, rather than two different conditions. Prior editions of the DSM included the less severe “alcohol abuse,” which was meant to apply to people with short-term and less entrenched problems such as college binge drinkers, and the more severe “dependence,” which became synonymous with hard core alcoholism. The new diagnosis combines abuse and dependence into a single condition with varying levels of severity.
That means that the new version tends to pick up slightly less severe cases than the previous criteria. “[I]t is not clear that the proposed diagnostic changes will result in a more accurate diagnosis,” the study’s authors write. “[A]t best, one group of low severity cases will be replaced by another; at worst a group of individuals who exhibit more severe problems will be excluded from the DSM-5 diagnosis, while less severely affected individuals will meet diagnostic criteria.”
The loss of the “abuse” diagnosis is especially worrying to those concerned with teen and college drinking. Under the new system, people who binge drink during adolescence and early adulthood will be seen, essentially, as “mild” alcoholics — even though studies show that they are much more likely to grow out of the problem than they are to wind up with longer term alcohol-related problems. Around 40% of college students engage in binge drinking frequently enough that they might qualify for the diagnosis — but only 5% of graduates over 26 are current alcoholics.
“Although the spectrum/continuum concept is the best way to study alcoholism, it is not the best way to label people who have problems with alcohol,” says Dr. Allen Frances, professor emeritus of psychiatry at Duke and former chair of the DSM-IV task force that wrote the earlier edition, “The DSM-5 decision to lump beginning drinkers with end stage alcoholics was driven by researchers who are not sensitive to how the label would play out in young people’s lives.”
He is particularly concerned about the potential legacy that such labels can have throughout a lifetime. “Diagnoses made casually and based on insufficient evidence can stick with someone for life, causing needless stigma and affecting job and insurance opportunities long after the substance problem has resolved,” he says. “Many young people who get into early trouble because of substance abuse never become dependent and shouldn’t be lumped together with long term addicts.” This may become especially problematic under the Affordable Care Act, which increases screening for alcohol problems that could pick up these mild cases and leave them on the patient’s electronic medical record.
An earlier study found that the new criteria would increase the number of people classified as having alcohol problems by nearly 62% over DSM IV, suggesting that it would include more people with mild problems not previously seen as significant enough to warrant a psychiatric label. Louise Mewton of the University of New South Wales in Australia, the lead author of that research, worries that the DSM-5 will pathologize normal behavior. She says, “Diagnosis should [have] clear implications for treatment and prognosis. The inclusion of the mild alcohol use disorder in DSM-5 is unlikely to be informative in such a way.”
Edwards’ study, however, found that the criteria would only increase diagnosis by 5%, which seems more reassuring. Ultimately, however, the effect that the change in diagnostic criteria will have on rates of alcohol abuse disorders can only be appreciated once doctors and counselors start to put the new definition into practice.