Are you or have you ever been a college binge drinker? Welcome to alcoholism, a diagnosis your college self could qualify for under the changes proposed to the next edition of psychiatry’s diagnostic manual, the DSM-5.
As the New York Times noted on Saturday in an article that rapidly became one of the most emailed, the DSM-5, short for the Diagnostic and Statistical Manual of Mental Disorders 5, will have just one diagnosis for addiction problems, though they will be characterized as either mild, moderate or severe. Currently, alcohol and other drug problems come in two flavors. The first, “substance abuse” is a short-term, self-limiting problem: it encompasses most heavy drinking in college. The second “substance dependence,” is what everyone else calls addiction or alcoholism and is typically chronic and marked by relapses.
Fortunately, the new diagnosis will get rid of the confusing term “dependence” (physically needing a drug to function isn’t actually addiction) and the stigmatizing term “abuse.” Unfortunately, however, it will also tremendously elevate the number of people considered alcoholics. One Australian study suggested that using DSM-5 definitions will increase the number of people diagnosed with alcoholism by a stunning 60%.
The Times’ Ian Urbina writes:
“The chances of getting a diagnosis are going to be much greater, and this will artificially inflate the statistics considerably,” said Thomas F. Babor, a psychiatric epidemiologist at the University of Connecticut who is an editor of the international journal Addiction. Many of those who get addiction diagnoses under the new guidelines would have only a mild problem, he said, and scarce resources for drug treatment in schools, prisons and health care settings would be misdirected.
“These sorts of diagnoses could be a real embarrassment,” Dr. Babor added.
Proponents of the new system argue that it will allow substance problems that might develop into serious addictions to be nipped in the bud:
“We can treat them earlier,” said Dr. Charles P. O’Brien, a professor of psychiatry at the University of Pennsylvania and the head of the group of researchers devising the manual’s new addiction standards. “And we can stop them from getting to the point where they’re going to need really expensive stuff like liver transplants.”
Yet because it’s impossible to determine which college bingers will moderate after graduation and who will go on to have lifetime problems, the distinction between abuse and dependence is difficult to pinpoint. The reality is that most college binge drinkers and drug users don’t develop lifelong problems. But most addiction treatment programs encourage them to see themselves as having a chronic, relapsing disease that requires a lifetime of attendance at 12-step meetings to keep in check. Currently, about 31% of college students meet criteria for “alcohol abuse,” while only 6% have the alcoholism-equivalent diagnosis of dependence.
Earlier editions of the DSM explicitly said there are alcohol and other drug problems that legitimately exist but do not reach the level of addiction; Alcoholics Anonymous itself differentiates between “problem drinkers” who can learn to moderate and alcoholics who can’t. DSM-5 obliterates the distinction. If the change is finalized, anyone whose drinking or drug use creates any problems will essentially be an addict or alcoholic with a “mild” case of the disease and presumably, therefore, not someone who can learn control over his habits.
While researchers have been encouraging the widespread adoption of “brief interventions” and other techniques that don’t require abstinence or a label — with great success — this change could swing the field in the opposite direction.
And that poses a huge problem, particularly for adolescents and young adults with mild problems who may be pushed to adopt an addict identity and to see themselves as having no way to control their drinking or drug use if they ever “relapse.” Rather than empowering those who do have control to use it, these programs essentially tell kids that if they ever have just one drink or puff on a joint, they’re lost.
While that strategy may help some people with addiction avoid relapse, research shows that it makes relapses worse if they do occur. And given that the overwhelming majority of teens who are treated will not remain abstinent for life, this strategy is counterproductive for most who will be exposed to it.
In my years of covering addiction, I’ve heard the story dozens of times: someone with a mild problem enters treatment, is convinced they have a more severe case and meets others who help him or her get worse. One teenage girl told me about meeting someone who turned her on to cocaine while in treatment for marijuana; another young man told me how treatment was the source of his perception that “who I was, was an alcoholic and drug addict.”
Clearly, treatment for young people already labels too many of them as addicts and alcoholics; the last thing we need is the DSM legitimizing this harmful practice. It should rename substance abuse “substance misuse,” and label addiction, “addiction.” From any perspective, it’s absurd to potentially label the 40% of college students who get drunk at least once a month as having “mild” alcoholism.