While severe consequences could accompany substance-induced mental disorders , remission was expected within days to weeks of abstinence . Despite these clarifications, DSM-IV substance-induced mental disorders remained diagnostically challenging because of the absence of minimum duration and symptom requirements and guidelines on when symptoms exceeded expected severity for intoxication or withdrawal. In addition, the term “primary” was confusing, implying a time sequence or diagnostic hierarchy. Research showed that DSM-IV substance-induced mental disorders could be diagnosed reliably and validly by standardizing the procedures to determine when symptoms were greater than expected and, importantly, by requiring the same duration and symptom criteria as the corresponding primary mental disorder. This evidence led to the DSM-5 Substance-Related Disorders Work Group recommendation to increase standardization of the substance-induced mental disorder criteria by requiring that diagnoses have the same duration and symptom criteria as the corresponding primary diagnosis. However, concerns from the other DSM-5 work groups led the Board of Trustees to a flexible approach that reversed the DSM-IV standardization. This flexible approach lacked specific symptom and duration requirements and included the addition of disorder-specific approaches crafted by other DSM-5 work groups. DECISIONS: 1) For a diagnosis of substance-induced mental disorder, add a criterion that the disorder “resembles” the full criteria for the relevant disorder. 2) Remove the requirement that symptoms exceed expected intoxication or withdrawal symptoms. 3) Specify that the substance must be pharmacologically capable of producing the psychiatric symptoms. 4) Change the name “primary” to “independent.” 5) Adjust “substance-induced” to “substance/medication-induced” disorders, since the latter were included in both DSM-IV and DSM-5 criteria but not noted in the DSM-IV title.Because of the DSM-5 Task Force interest in biomarkers, the Substance-Related Disorders Work Group, consulting with outside experts, considered pharmacokinetic measures of the psychoactive substances or their metabolites, genetic markers, and brain imaging indicators of brain structure and function.
Many measures of drugs and associated metabolites in blood, urine, sweat, saliva, hair, and breath have well established sensitivity and specificity characteristics. However, these only indicate whether a substance was taken within a limited recent time window and thus cannot be used to diagnose substance use disorders. Genetic variants within alcohol metabolizing genes ,hydroponic vertical farming genes related to neurotransmission such as GABRA2 , and nicotinic and opioid receptor genes including CHRNA5 and OPRM1 show replicated associations to substance use disorders. However, these associations have small effects or are rare in many populations and thus cannot be used in diagnosis. Perhaps in future editions, DSM may include markers as predictors of treatment outcome Positron emission tomography imaging of brain functioning indicates that dopamine is associated with substance use . However, measuring brain dopamine markers involves radioligands, limiting their use. Functional MRI produces structural and functional data, but few fMRI or PET studies have differentiated brain functioning predating and consequent to onset of substance use disorders . Furthermore, brain imaging findings based on group differences are not specific enough to use as diagnostic markers in individual cases. Finally, abnormalities in brain regions and functioning that are associated with substance use disorders overlap with other psychiatric disorders. In sum, biomarkers are not yet appropriate as diagnostic tests for substance use disorders. Continued research in this area is important.Since then, the reliability and validity of cannabis withdrawal has been demonstrated in preclinical, clinical, and epidemiological studies . The syndrome has a transient course after cessation of cannabis use and pharmacological specificity . Cannabis withdrawal is reported by up to one-third of regular users in the general population and by 50%–95% of heavy users in treatment or research studies . The clinical significance of cannabis withdrawal is demonstrated by use of cannabis or other substances to relieve it, its association with difficulty quitting , and worse treatment outcomes associated with greater withdrawal severity . In addition, in latent variable modeling , adding withdrawal to other substance use disorders criteria for cannabis improves model fit.In DSM-IV, caffeine withdrawal was included as a research diagnosis to encourage research . The accumulated evidence from preclinical and clinical studies since the publication of DSM-IV supports the reliability, validity, pharmacological specificity, and clinical significance of caffeine withdrawal .
Based on factor analysis studies, the work group proposed modifying the DSM-IV research criteria so that a diagnosis in DSM-5 would require three or more of the following symptoms: 1) headache; 2) fatigue or drowsiness; 3) dysphoric mood or irritability; 4) difficulty concentrating; and 5) nausea, vomiting, or muscle pain/stiffness . DSM-IV did not include caffeine dependence despite preclinical research literature because clinical data were lacking . Relatively small-sample clinical surveys published since then and the accumulating data on the clinical significance of caffeine withdrawal and dependence support further consideration for a caffeine use disorder , particularly given concerns about youth energy drink misuse and new alcohol-caffeine combination beverages . However, clinical and epidemiological studies with larger samples and more diverse populations are needed to determine prevalence, establish a consistent set of diagnostic criteria, and better evaluate the clinical significance of a caffeine use disorder. These studies should address test-retest reliability and antecedent, concurrent, and predictive validity .DSM-IV included nicotine dependence, but experts felt that abuse criteria were inapplicable to nicotine , so these were not included. Nicotine dependence has good test-retest reliability and its criteria indicate a unidimensional latent trait . Concerns about DSM-IV-defined nicotine dependence include the utility of some criteria, the ability to predict treatment outcome, and low prevalence in smokers . Many studies therefore indicate nicotine dependence with an alternative measure, the Fagerström Nicotine Dependence Scale . DSM-IV and the Fagerström scale measure somewhat different aspects of a common underlying trait . Because DSM-5 combines dependence and abuse, studies addressed whether criteria for nicotine use disorder could be aligned with other substance use disorders , potentially also addressing the concerns about DSM-IV-defined nicotine dependence. Smoking researchers widely regard craving as an indicator of dependence and relapse . Increasing disapproval of smoking and wider smoking restrictions suggest improved face validity of continued smoking despite interpersonal problems and smoking-related failure to fulfill responsibilities as tobacco use disorder criteria. Smoking is highly associated with fire-related and other mortality , suggesting the applicability of hazardous use as a criterion for tobacco use disorders, parallel with hazardous use of other substances. To examine the alignment of criteria for tobacco use disorder with those for other substance use disorders, an item response theory analysis of the seven dependence criteria, three abuse criteria, and craving was performed in a large adult sample of smokers . The 11 criteria formed a unidimensional latent trait intermixed across the severity spectrum, significantly increasing information over a model using DSM-IV nicotine dependence criteria only. Differential item functioning was found for craving and hazardous use, but differential total score functioning was not found. The proposed tobacco use disorder criteria were strongly associated with a panel of validators, including smoking quantity and smoking shortly after awakening . The tobacco use disorder criteria were more discriminating than the DSM-IV nicotine dependence criteria and produced a higher prevalence than DSM-IV criteria, addressing a DSM-IV concern . An item response theory secondary analysis of 10 of the 11 criteria from adolescent and young adult substance abuse patients also revealed unidimensionality and a higher prevalence of DSM-5 tobacco use disorder than DSM-IV nicotine dependence .In utero alcohol exposure acts as a neurobehavioral teratogen, with lifelong effects on CNS function and behavior . These effects are now known as neurobehavioral disorder associated with prenatal alcohol exposure. Key features include neurocognitive and behavioral impairments diagnosed through standardized psychological or educational testing, caregiver/teacher questionnaires, medical records, reports from the patient or a knowledgeable informant, or clinician observation. Prenatal alcohol exposure can be determined by maternal self-report, others’ reported observations of maternal drinking during the pregnancy, and documentation in medical or other records. Neurobehavioral disorder associated with prenatal alcohol exposure was not included in DSM-IV. The proposed diagnostic guidelines allow this diagnosis regardless of the facial dysmorphology required to diagnose fetal alcohol syndrome . Many clinical experts support the diagnosis , and clinical need is suggested by substantial misdiagnosis, leading to unmet treatment need . However, more information is needed on this disorder before it can be included in the main diagnosis section of the manual.In DSM-IV, pathological gambling is in the section entitled “Impulse-Control Disorders Not Elsewhere Classified.” Pathological gambling is comorbid with substance use disorders and is similar to substance use disorders in some symptom presentations ,vertical agriculture biological dysfunction , genetic liability , and treatment approaches .
The work group therefore concurred with a DSM-5 Task Force request to move pathological gambling to the substance use disorders chapter. The work group also recommended other modifications . The name will be changed to “Gambling Disorder” because the term pathological is pejorative and redundant. The criterion “illegal acts to finance gambling” was removed for the same reasons that legal problems were removed from substance use disorders . The diagnostic threshold was reduced to four or more criteria to improve classification accuracy . A further reduction in the threshold was considered, but this greatly increased prevalence without evidence for diagnostic improvement. Future research should explore whether gambling disorder can be assessed using criteria that are parallel to those for substance use disorders .Since 2007, the Substance-Related Disorders Work Group addressed many issues. The members conducted and published analyses, and they formulated new criteria and presented them widely for input. The DSM-5 Task Force requested a reduction in the number of disorders wherever possible, and the work group accomplished this. The DSM process requires balancing many competing needs, which is always the case when formulating new nomenclatures. The process also entails extensive, unpaid collaboration among a group of experts with different backgrounds and perspectives. Scientific controversies arose and received responses . Conflict of interest could undermine confidence in the work group’s recommendations , but in fact, as monitored by APA, eight of the 12 members received no pharmaceutical industry income over the 5 years since the work group was convened, two received less than $1,200 and two received less than $10,000 in any single year. Some individuals assume that financial interests advocated directly to the work group . Actually, this never happened. While such advocacy could have occurred surreptitiously through unsigned DSM-5 web site comments, few comments stood out as particularly influential since they covered such a wide range of opinions. An exception to this was the web site advocacy of nonprofit groups to include neurobehavioral disorder associated with prenatal alcohol exposure . Ultimately, the work group recommendations attracted considerable interest, and the DSM-5 process stimulated much substance use disorder research that otherwise would not have occurred. Implementing the 11 DSM-5 substance use disorders criteria in research and clinical assessment should be easier than implementing the 11 DSM-IV criteria for substance abuse and dependence, since now only one disorder is involved instead of two hierarchical disorders. A checklist can aid in covering all criteria. Eventually, reducing the number of criteria to diagnose substance use disorders will further aid implementation, which future studies should address. The statistical methodology used to examine the structure of abuse and dependence criteria was state of the art, and the data sets analyzed were large and based on standardized diagnostic procedures with good to excellent reliability and validity. However, these data sets, collected several years ago, were not designed to examine the reliability and validity of the DSM-5 substance use disorder diagnosis. Many studies showed that DSM-IV dependence was reliable and valid , suggesting that major components of the DSM-5 substance use disorders criteria are reliable as well. However, field trials using standard methodology to minimize information variance are needed to provide information on the reliability of DSM-5 substance use disorder diagnosis that can be directly compared with DSM-IV , in addition to studies on the antecedent, concurrent, and predictive validity of DSM-5 substance use disorders relative to DSM-IV dependence. The amount of data available to address the topics discussed above varied, and new studies will be needed for some of the more specific issues. However, major concerns regarding the combination of abuse and dependence criteria were conclusively addressed because an astonishing amount of data was available and the results were very consistent.