I am fascinated by the upcoming changes to the DSM (Diagnostic and Statistical Manual of Mental Disorders) aka the shrink's bible, and not in a good way. I wonder and question the confusion of making appropriate diagnoses of my DWI clients, many who are unfortunately (or fortunately) college aged.
Over my years of practice I have poured over numerous journal articles and peer reviewed papers that have been written concerning the mounting trend of binge drinking, and heavy episodic drinking amongst college students.
What is a BINGE?
Remember that 4 drinks at one time for a woman, and 5 drinks for a man is considered (classified) as a "binge." In the UK (United Kingdom) 11 drinks is considered a BINGE! Culturally we are still a puritanical, uptight, and neurotic country. Where else in the world can you vote, contract, marry, and enlist BUT NOT be allowed to consume alcoholic beverages before the age of 21? America.
When is a Binge NOT a Binge?
What is not taken into consideration (in classifying a binge) is a person's tolerance (over time the adaptation to alcohol) or a person's particular size (bodyweight) or unique genetics (we are all different) or their food consumption with the alcohol or the real time of the consumption (over the course of hours or minutes).
I caution people against being labeled as binge drinking because I have had a number of alcohol evaluators base their final diagnosis primarily upon this one criteria. They have "sentenced" (recommended) people to a once a week sobriety program, for a year! Yeah, a year! I had one client, weighed in at 240 lbs, 6' 4, and loved a six pack with his Saturday football game. He was labeled as a binge drinker.
I don't think he is a binge drinker. For me, at a buck forty dripping wet, 3 drinks is a binge! Seriously, my tolerance ain't what it was in College. I guess I'm staying on the proverbial porch, and not the one pictured below.
Diagnosing Drug/Alcohol Disorders: More Questions than Real Answers
I recently watched a NAADAC (National Association of Alcoholism and Drug Abuse Counselors) webinar about the DSM-V (coming in 2013) versus the old DSM-IV. I was left with more questions than answers.
Considering that this guide (DSM-V) will be used by the NYS OASAS counselors and evaluators in the future along with everyone that they report to (DAs, Judges, Probation) makes it a very important book in my library.
There are 11 criteria for diagnosing a Disorder (the new term) BUT a few are being taken out of the running:
1. Developing Tolerance (a normal physiologic response to continued drug use)
2. Having Withdrawl Symptoms after not drinking (using) (also seen as normal physiologic response to continued drug use)
3. Using Larger Amounts than Intended
4. Unsuccessful Attempts at Controlling (limiting) or Cutting Down consumption of drug/substance
5. Giving Up important activities (in favor of drug use)
6. Time Spent getting drug X or recovering from drug X (alcohol or other substance)
7. Continued Use despite physical and/or psychological problems
8. Major Role Problems: failing to fulfill major role obligations
9. Hazardous Use in dangerous situations (I like to think this is an overlay with #10) ie. DWI
10. Legal Problems: Experiencing legal problems from use ie. DWI, domestic violence, etc.
11. Continued Use despite Social Problems (failed relationships)
The GOOD Changes
I think some of these (11) overlap or can be combined. The new DSM-V drops the value of:
BUT gives greater weight and significance to:
Sacrificing Activities (Giving Up)
Unsuccessful Cutting Down (back)
Time Spent Using
IMO The common sense of these coming changes lies in that using Collateral Contacts (friends, family, co-workers) these second group of criteria can be assessed and investigated more accurately and honestly. Collateral Contacts are people who know you and your behavior. An evaluator must contact, consult, and confirm with them before rendering a final diagnosis.
NOW The BAD Changes
-They are eliminating the bad/good dicotomy of abuse vs. dependence entirely.
This made the old DSM-IV so easy, two main categories, very clear cut, one requiring treatment and one not (merely education)
-Now everyone is either NO diagnosis, or SUD (substance use disorder) or AUD (alcohol use disorder). They are either "Moderate" SUD or "Severe" SUD (the term, dependence would work well here).
MY Questions of the New DSM-V
1. How are they going to weight the criteria for moderate or severe Substance Use Disorder (SUD) or Alcohol Use Disorder (AUD)?
Differential Diagnosis (of a condition or a disease) is based upon criteria BUT the weighting of the criteria (quality and quantity) is left to the subjectivity of the evaluator. The new guidelines state that 2 or 3 criteria of the 11 = Moderate SUD and 3 or 4 criteria of the 11 = Severe SUD. ALL diagnostic criteria are not created equal. Studies done have shown two main criteria indicate a serious problem (my terms and words):
(a) use of larger and larger amounts than intended, over 37% of people with problem drinking and
(b) hazardous use (use in dangerous situations), almost 25% of people with problem drinking.
BTW "problem drinking" is my term not their's aka serious
2. Where are the real Cut Points between Moderate SUD, and Severe SUD?
2 or 3, or 3 or 4 doesn't sound very clear cut or scientific to make an appropriate diagnosis of a problem. With so few cut points (no diagnosis or moderate or severe) some people may be mis-categorized (up categorized or diagnosed). Where are the degrees of these issues?
3. What are the Clinical (treatment) Implications (recommendations) for these new guidelines?
This is also very nebulous and unspoken. It is purely up to the clinician, evaluator, or mental health professional to decide what is needed or appropriate. An overlay or underlay of mental issues are another matter entirely. How many people are using to deal with mental issues? Confusing one SUD diagnosis with a mental issue can be a real disaster.
More questions than answers. We will see how all of this pans out over time. I believe that DWI/DUI defense attorneys must scrutinize these reports (evaluations), discuss everything before and after with their clients, talk to the evaluators, and be ready to discuss all of this with a Judge and a district attorney.
My final question:
How many Unhealthy Users will be mis-labeled as a person with a DIS-ORDER?
Let nothing I have written have you ever believe that I am pro-drug addiction or pro-alcohol abuse, I believe in the value of substance use, medical or otherwise, IF used appropriately. I enjoy drinking, and see and know the value of drugs in our society. I do believe that some people are genetically predisposed to issues with just about everything. What I am against or concerned about are the curtailing of rights or freedoms without cause or justification. Prohibition was a bad "experiment" and should not be repeated. Scarier still are doctors and/or healthcare providers making inappropriate diagnoses or recommendations.
Lawrence Newman, D.C., Esq.
Doctor of Chiropractic
Attorney and Counselor at Law
Ithaca, NY 14850