Wednesday, December 5, 2012

The New DSM-5 meets the DWI: Dangers of New Diagnostic Criteria

The DSMs go on and on, courtesy of

The New DSM-5 meets the “Old” New York DWI

The manual, known as the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., aka the “Bible” of diagnosing mental disorders/diseases is about to have a major revision. This book will be the DSM-5, the last one being the DSM-4 which began life in 1994. The manual is slated for release in June 2013. Throughout this blog post I will alternate between Roman numerals and numbers for the DSM editions, my demonstration of contempt for this continued antiquation by condescending psychiatrists.

My familiarity with the book began back in my early days as a Chiropractic College student. The early 1980s had me taking a number of Abnormal Psychology classes. This background in Ab-normal psych was necessary for my National Board Certification as well as my introduction to being able to differentially diagnose the physical problems of my patients from their overlaying and underlying mental/emotional ones.

Practicing law since 1998 I have seen my fair share of changes both in law and medicine. Each change in a statute, a regulation, a definition, a term, an interpretation, and a law brings with it a number of issues (problems) both direct and collateral. People’s lives stand in the cross hairs of this “progress” and confusion.

Numbers for Legal Measurement of Criminal Behavior

As a New York DWI lawyer the BAC (Blood Alcohol Concentration) for DWI has gone lower and lower over the past four decades in all fifty states. Now the level stands at a .08 BAC nationally to declare that someone is “legally” intoxicated, or under the influence of alcohol.

Alcohol is the “only” drug (legal, socially acceptable, readily available) so far that has a number (a quantity) associated with it’s functional impact upon a person equals a criminal activity. There is no measure (amount in blood) for the effect of marijuana, or ambiene, or oxycodone. Nor are there any statutes that state a specific quantity of this or that amount of a drug/substance in the blood stream while driving would equate to a crime.

So what does all this have to do with the New DSM-V and New York DWIs?

I’m glad you asked, because the New DSM is as subjective as they come to now pathologizing normal activity. That scares me as an attorney because we are now as a society going to punish you for your criminal activity (DWI), and then label (categorize/diagnose) you as person in need of treatment. College binge drinkers beware, because you can now be diagnosed as mild alcohol abuser in need of treatment.

see this recent magazine article on college kids and the dangers of this new wider criteria for making a substance addiction (alcoholic) diagnosis:

Who is Going to Use (and rely) Upon the New DSM-V Guidelines with NY DWIs?

Sweeping changes to the manual will affect broad criteria for addiction. The community of healthcare providers who use the manual (including OASAS certified drug/alcohol evaluators) will rely upon this wider range of behavior to give a diagnosis and a treatment plan.

Mandated NY DWI Drug /Alcohol Assessments will include these new diagnoses and their commensurate recommendations which will then be relied upon by the Courts/Judges, the District Attorneys, and the County Probation Departments. Allen J. Frances, a professor of psychiatry and behavioral sciences at Duke University who has contributed to the D.S.M., has stated that the “new” definitions amount to “the medicalization of everyday behavior” and will create “false epidemics.” In short, addiction diagnoses will multiply like rabbits, which could result in millions of people being diagnosed (IMHO inappropriately) as addicts.

The Perfect Psychiatric Storm (increased business for providers)

The problem is twofold:
(1) there is an expanded list of recognized symptoms for drug and alcohol addiction, and
(2) they have reduced the number of symptoms required for an addiction diagnosis.

ADD 1 plus 2 = millions of people now diagnosed with alcohol addiction

This information is based on changes posted on the Web site of the American Psychiatric Association, which produces the manual.

Psychiatry has No Gold Standard

In medicine, certain tests are utilized to form and/or confirm a diagnosis. These tests or procedures are known as the “Gold” standard. An MRI will be used to diagnosis a disc herniation of the spine. So the MRI is the Gold standard for the diagnosis and then called for treatment of that condition. Certain blood tests are the Gold standard to diagnose certain bacterial and viral disorders. The Gold standard is not perfect medicine, merely the best scientific evidence to be obtained under reasonable circumstances. Unfortunately, the field of psychology is very subjective. There is a wide range of opinions among the community of practitioners as to how to make a mental diagnosis.

Under the new criteria (DSM-V), those DWI offenders who often drink more than intended and/or crave alcohol may be considered mild addicts. Under the old criteria (DSM- IV), more serious symptom behavior, such as repeatedly missing time from work or school, AND being arrested for DWI/DUI, were required before a person could receive a diagnosis as an alcohol abuser.

Are YOU merely an "Unhealthy" User OR a "Severe" Abuser?

Great to have new defintions but what exactly is a craving? Many days I have cravings (desires) for specific foods, like pizza, Chinese, or thai. But do I also have a craving or a feeling for other things? And are cravings in and of themselves bad?

“Craving” is a new symptom of addiction. Is craving a scientifically measurable thing? Or is the definition of craving really a feeling and subjective?

Out with the Simple (Clear Cut) Past (DSM-IV) and in with the New Confusing (DSM-V)

1. DSM-IV created separate diagnoses for "abuse" and "dependence" in people having problems with drugs and alcohol. The new DSM-5 will instead will use the broader term "substance use disorders" as the diagnosis for people with such problems.

2. No longer will evaluators use increasing physical tolerance (for drugs and alcohol) and withdrawal symptoms as criteria for a disorder diagnosis. These are considered a normal physiologic response to the use of these drugs. Allowing doctors to prescribe and monitor their patients with prescription drugs that lead to these "normal" body responses.

In the words of one of the revisers: “The term dependence is misleading, because people confuse it with addiction, when in fact the tolerance and withdrawal patients experience are very normal responses to prescribed medications that affect the central nervous system,” said Charles O’Brien, M.D., Ph.D., chair of the APA’s DSM Substance-Related Disorders Work Group. “On the other hand, addiction is compulsive drug- seeking behavior which is quite different. We hope that this new classification will help end this wide-spread misunderstanding.”

3. The word "addiction" is GONE. It is history, a term of the past, everyone will now have or not have a Use Disorder.

Ah, the myriad of Use Disorders: There are Alcohol-Use Disorder, Marijuana-Use Disorder, Opioid-Use Disorder, and the list goes on. USE DISORDERS are now de riguer because the new revisiers thought the word addiction or to be an addict was politically incorrect (to be fair they used the terms pejorative and stigmatizing).   

4. The DSM-V also has new interesting diagnostic criteria for something they call “cannabis withdrawal.” I guess this is where someone stops smoking pot after being a pothead (do they still call them that?).

The APA says that this is caused by “cessation of cannabis use that has been heavy and prolonged,” which results in “clinically significant distress or impairment in social, occupational, or other important areas of functioning,” and is characterized by at least three of these symptoms: irritability, anger or aggression; nervousness or anxiety; sleep difficulties (insomnia); decreased appetite or weight loss; restlessness; depressed mood; and or physical symptoms such as stomach pain, shakiness or tremors, sweating, fever, chills, and headache.

Goodbye Addiction and Dependence Welcome Substance Use-Disorder

Welcome to this Brave New World where millions of college students and first time DWI offenders may now face labels, embarrassment, and inappropriate treatment programs.

Always consult with an attorney about any criminal or non-criminal charges you have pending to discuss your options and/or defenses.

I am certified in Field Sobriety and Breath Alcohol Testing, and an active member of the National College of DUI Defense (NCDD). My online materials include over 500 blog posts, dozens of articles, and over 500 informative videos on my youtube channel.

I have co-authored Strategies for Defending DWI Cases in New York, in both 2011 and 2013. These are West Thomson legal manuals on New York State DWI defense, and focus on the best practices for other lawyers handling a New York DWI case. I was selected by Super Lawyers as a Upstate New York 2013 Rising Star in DWI/DUI Defense based on my experience, contributions, and professional standing.