Revisions to Mental Health Manual May Turn Binge Drinkers into ‘Mild’ Alcoholics

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Man in bar with a beer

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.

MORE: Why College Binge Drinkers Are Happier, Have High Social Status

“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.”

MORE: DSM-5 Could Categorize 40% of College Students as Alcoholics

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.”

MORE: Happy Hour? ‘Wet Houses’ Allow Alcoholics to Drink, With Surprising Results

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.”

MORE: Study: Do Early Drinkers Become Heavy Drinkers?

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.

8 comments
RickdeLuna
RickdeLuna

I could possibly not be an alcoholic, it could just be for one given year and denial could buy me a lifetime or death, oh my.

markecc
markecc

scott.the.scribe1 "Alcohol is a toxin... a poison." All drugs are poisons depending on the amount ingested, what is your point?

People choose to consume alcohol. They tried prohibition of alcohol and it didn't work. People made illegal stills to manufacture it.

The (illegal) drug war is equally going badly because people want-need drugs.
“50,000 people have been killed in drug-related violence in December, there will probably have been over 60,000 drug war-related deaths in Mexico, more than the number of Americans who died in Vietnam."

The legal drugs prescribed by psychiatrists are no better than illegal drugs. If a doctor was giving a measured amount of alcohol to a patient , the toxin/poison of alcohol would magically become a medicine.

What is your disease?

scott.the.scribe1
scott.the.scribe1

Alcohol is a toxin... a poison.


Alcohol causes immense amounts of personal and societal harm.


Make excuses for the substance if you want but even a simplistic Web search will reveal immense amounts of harm related to alcohol consumption.

markecc
markecc

People use (the drug) alcohol to feel better. The psychiatrists want you to take their pharmaceutical drugs to feel better.

A person should have a choice of what drug to take.

If you can still go to work, work successfully and use alcohol in your free time what is the problem? Alcohol is cutting into the pharmaceutical drug Co. profits.

FloydmoistBleumonge
FloydmoistBleumonge

Come on jew lady. Let's not water it down. There are (eh-hem)drinkers who have problems, ten there are those of us who are problem drinkers. Big difference.

drwillenbring
drwillenbring

Maia, I love your writing and I think you do a great job of bringing recent developments in addictions to the people, but on this one, I think you are missing the mark.

First, what prompted the changes from DSM-IV to DSM5 was that "Alcohol Abuse" in DSM-IV did not perform as expected. Most importantly, as defined there, it is not less severe than "Dependence." Multiple studies have now shown that the early symptoms of an alcohol use disorder are mostly "Dependence" (under DSM-IV) symptoms, not "Abuse" symptoms. The only "Abuse" criterion that occurs early is "Hazardous Use," mostly when people admit to drinking and driving (not DUI.) The other "Abuse" criteria only occur very late in the game, among the most severely addicted people. They include "Role Failure" such s losing your job, being unable to parent or go to school, "Repeated Interpersonal Problems" such as divorce, and "Legal Problems" such as DUI. What occurs early are "Dependence" (again, under DSM-IV) criteria, such as Repeatedly Going Over Limits" and "A Persistent Desire to Quit or Cut Down," but finding that hard to do. Under DSM-IV, alcohol "dependence" prevalence peaked between the ages of 18-21, about one third of all people with alcohol dependence were in this group. Thus, DSM-IV criteria, properly applied, already labeled a lot of young people with "dependence," commonly equated with "alcoholism." 90% of people with "abuse" but not "dependence" were there because they admitted to drinking and driving (again, no DUI) but few if any other symptoms. 

DSM5 is an advance, because it acknowledges that addiction occurs in mild, self-limited forms as well as moderate and severe progressive forms. For example, using DSM-IV criteria, 72% of people who meet criteria for alcohol dependence have a single episode lasting 3-4 years on average, and it then resolves and does not recur. Why would we expect alcohol use disorder, a brain disease, to be different from most other medical disorders such as depression, arthritis or asthma? Some people have a mild form that goes away, others have moderate disease that waxes and wanes for a long time, and others have severe, treatment-resistant disorders that have a high mortality rate. 

So, the advantage to DSM5, is that it removes an artificial and false distinction between "Abuse" and "Dependence" and replaces it with a more nuanced and evidence-based approach that includes mild as well as severe disease. We think addiction is severe and progressive in most instances because we've focused on people in rehab, which is like examining people with asthma who are in the ICU on a ventilator. Most people with the disorder never end up in rehab or the ICU. 

The key to seeing the advance in the DSM5 approach is in understanding that substance use disorders, like most other human ailments, exist along a continuum from mild to severe. 

One more thing: most heavy drinkers don't have alcohol use disorders. They are instead "at-risk" drinkers, people who drink more than is medically advisable but who do not yet have a disorder. They are similar to people who smoke but who don't have cancer, people with elevated blood pressure or cholesterol who have not had a heart attack. They have an elevated risk of developing disease (in the case of alcohol, an alcohol use disorder, meaning addiction to alcohol) but they do not currently have that disorder. Fortunately they respond very well to feedback and advice, so if we can make this more available to people, we can prevent progression to alcohol use disorder. For those interested, check out rethinkingdrinking.niaaa.nih.gov. 

My website is www.alltyr.com, my blog is Substance Matters at www.mattsub.blogspot.com, and my Twitter handle is @AddictionDrW. 

johnnyb
johnnyb

@markeccspot on markecc, its also a depressant, so how much of that can the individual afford to consume, again individual, we are all different people, with different constitutions, different personalities, different upbringing and conditioning, different mentalities and psychologies, different strengths and weaknesses, etc, one bottle to one is like three to another, and so can the potential damage be, its the same with any mind altering substance, their all alterers, the drug pushers of mind altering substances reckon their mind bending shit is better than the other blokes,sounds like the bloke selling the kiff  hes calling good gunga down the street, to me, and to me, and are all just drug dealers, trying to make a smoke, a quid ,some sort of profit at the end of the day, that's why any drug that gives an effect is a drug that might suit, or not suit, any number of individuals, and if all drugs were treated that way in the equal way they actually are,as poisons, and either their ok for you, or not, and had nothing to do with "them" and "their story", wed all be ok, basically get rid of all the lies, and their so called , right or proper drugs, vested in their drug sories, we might just be better equipped mentally, emotionally, and physically to deal with the consumption, and management.ie;  drug consumption and management education centres, remember that song I want a new drug, well that's where you go to find out which drugs suit you, instead of having dealers selling poisons that they reckon are the ants pants, my drugs are better than yours crap, all drugs are equal, they either make you feel good or dont, and that depends on all the things I mentioned above,and more, that's the reality, in the real world, in the real picture., how much could you, should you, and can you take, that doesn't mess with your head and your life, and helps you relieve the same thing we all take drugs for, a comfortable, enjoyable, thinking and feeling effect, Never mind what and who,s drug it is, let the drug dealers fight that out between themselves, the chemist, the GP, the psyche, the drug company, the grower, the drug dealer on the street, same bloke, different haircut.

MatthewWolmutt,LICSW
MatthewWolmutt,LICSW

I agree with Dr. Willenbring regarding the changes in Substance Use Disorder changes in DSM-5; however, I believe even the mild, moderate, and severe categories are still not up to par with what we know about SUD at this time.  For instance, we know of type I and type II alcohol use disorders, and that type I responds much better to anti-craving medications, has accompanying conduct issues, there is more of a live time course, stronger genetic links, etc, etc...  If the diagnosis is meant to define the disorder and the proper course of treatment it is beyond me why we have limited diagnoses used for such a disorder.  I often wonder if it is accurate to say the research on substance use disorders is comparable to dismissing the fact of multiple mood disorders, throwing mood disorders all into one category, and running with the data accumulated.  I mean to say I speculate much of the research on SUD is skewed because of major lack of acknowledgment of the various sub-types of SUDs.  If I am anywhere near accurate in this assumption we have major problems in the research.

Matthew Wolmutt, MSW, LICSW, Co-occurring Disorder Specialist