Defining alcohol abuse sparks debate

Removing alcohol abuse from psychiatry's diagnostic bible is drawing fire.

Proposed changes for the DSM-5 include merging alcohol dependence and abuse categories into a single diagnosis: substance abuse disorder.

Doctors, insurers, scientists, and those in the legal system turn to the manual when drawing the line between what psychiatrists consider normal and not normal.

June's issue of the Journal of Studies of Alcohol and Drugs includes a critique of the changes and a defence.

"Our goal was to try to make the criteria easier for the usual clinician to use, and so we're no longer asking them to remember one criteria set for abuse and a separate set for dependence," said Dr. Marc Schuckit, the journal's editor.

While Schuckit served on the DSM-5's substance use committee, he said the views in the editorial reflect his own opinions and experience with the group's consensus approach.  

Abolishing the abuse category was done because there wasn't enough data to support an inbetween state, Dr. Griffith Edwards of the National Addiction Centre in London, UK said in a critical letter appearing in the same issue.

"This decision goes against clinical experience, which suggests that people can develop destructive and disruptive drinking behaviour without clinical symptoms of dependence," Edwards wrote.

Binge drinking

Schuckit countered that the committee members turned to the term substance use disorder as a compromise because they were reluctant to use the term dependence since that diagnostic approach is changing. Addiction was also avoided since it has a broader meaning to the public.

Edwards concluded that science has come a long way since the founding text on the "evil genius" of alcohol problems was published in 1804.

"The quest continues for terminology that can capture 'the evil genius of the habit' as an identifiable disorder while acknowledging that not all problems with psychoactive substances relate to that syndrome," Edwards said.

He noted that the DSM could end up enshrining an American point of view compared with the World Health Organization's  International Statistical Classification of Diseases, or ICD.

Schuckit said his committee evaluated more than 100,000 cases using the current abuse-and-dependence approach and the proposed substance use disorder approach and found no difference.

Schuckit aimed to set the record straight after a New York Times article suggested the DSM-5 could categorize 40 per cent of college students with substance abuse based on heavy drinking.

In his editorial, Schuckit said most illnesses diagnosed from the DSM present a blurry image depending on one's perspective. It's like viewing an elephant's trunk and eyelashes from the front versus from behind, which could seem more dangerous.

Previous editions of the Diagnostic and Statistical Manual of Mental Disorders have also stirred up questions and controversy.