Doctors ponder broader definition of addiction effect on mental illness diagnosis

Revision to DSM, the 'Bible of mental illness,' called drastic

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Can someone be just mildly alcoholic?

That -- in its simplest terms -- is at the heart of a change in a psychiatric manual that could have a major effect on diagnosis and treatment of alcoholism and other addictions.

The changes come as part of revisions to the definition of addiction in the Diagnostic and Statistical Manual of Mental Disorders, produced by the American Psychiatric Association and commonly referred to as the "Bible of mental illness."

Alcoholism isn't a medical term. Rather, the proposed guidelines would classify mild, moderate and severe forms of "alcohol use disorder" instead of the "alcohol abuse" and "alcohol dependency" used in the current edition.

"It's a drastic change," said Antoine Douaihy, associate professor of psychiatry and medical director of addiction medicine services at Western Psychiatric Institute and Clinic of UPMC. "I'm wondering what kind of impact this is going to have on how we approach, how we categorize and how we treat these patients."

Broadening the definition to include mild and moderate forms of the disorder -- along with other major changes involving addiction disorders -- could result in millions of people falling into the diagnostic categories who didn't previously qualify. Such an increase could have major financial ramifications in terms of insurance eligibility.

People now need two or more of 11 problematic behaviors over a 12-month period to be diagnosed with some degree of alcohol use disorder. These include "alcohol taken in larger amounts or over a longer period than was intended," "a persistent desire or unsuccessful effort to cut down or control alcohol use," and "craving or strong desire or urge to use alcohol." Other behaviors include classic physiological symptoms such as increased tolerance or withdrawal.

Many who treat patients who struggle with addiction believe that an expansion of those categories is much needed. "As a whole across the country, alcohol and drug problems are grossly under-diagnosed and under-recognized," said Neil Capretto, medical director at Gateway Rehabilitation Center. "A lot of practitioners think that you have to be living under a bridge on the North Side, but those are just a small percentage of the people."

As a practitioner "in the trenches," Dr. Capretto doesn't think that the new designation will have much impact on day-to-day treatment. By the time his patients get to rehab, they are generally addicted under any measure.

But to the extent that expanding the guidelines could get people into treatment sooner, he is in full support.

"Where in the past somebody might have been reluctant to make a diagnosis, they could now say, 'Well, it's mild,' " he said. "If you intervene earlier on, there's more potential to make an impact."

Brent Robbins, an associate professor of psychology at Point Park University, sees the issue differently. While it's true that more people could probably benefit from treatment, he's critical of the broadening of the definition of psychiatric ailments.

"With every DSM that's come along, there's a tendency toward a sort of bracket creep," he said, likening the changes on addiction to broadening of diagnostic criteria for autism, depression and attention deficit hyperactivity disorder. "There's a trend to define disorders in a way that would include more people than the previous edition."

To him, "mild addiction" is a confusing concept because addiction is a discrete concept that involves changes in the brain's biochemistry. There are real differences in how someone who abuses alcohol on occasion should be treated versus someone who is truly dependent on it, he said.

"Everyone who goes to frat parties at age 19 and drinks too much doesn't have an addiction," he said. "They are abusing the substance, clearly, but that's very different from someone who has an addiction. The difference between substance dependent and substance abuse is being lost, and that's not a good thing."

Mr. Robbins believes that collapsing abuse and dependence into one category can muddle how patients with different problems should be treated. He also worries that broadening the definition can trivialize the true problem of addiction.

Dr. Douaihy also worries how it will play out in practice. He supports many of the changes in principle, but questions some of the finer points -- the panel's decision to include cravings as a criterion, for example, while excluding one on consumption.

He also notes the possibility for gray areas. It can be difficult to distinguish symptoms of clinical withdrawal from an ordinary hangover, for example.

"There are all these debatable questions," he said. "How is it going to be played out?"

health

Anya Sostek: asostek@post-gazette.com or 412-263-1308. First Published May 18, 2012 12:00 AM


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