Diagnostic Criteria for Assigned Substance-related and Addictive Disorder Essay

Explain the diagnostic criteria for your assigned substance-related and addictive disorder

Discussion: Treatment of Substance-Related and Addictive Disorders: Cannabis-Related Disorder “2018 data shows that every day, 128 people in the United States die after overdosing on opioids. The misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids such as fentanyl—is a serious national crisis that affects public health as well as social and economic welfare” (National Institute of Drug Abuse, 2020). Treatment can be challenging as they do not see their symptoms as painful to themselves or others. In this Discussion, you will explore personality disorders in greater detail and discuss treatment options using evidence-based research. Reference: National Institute of Drug Abuse. (2020). Opioid overdose crisis. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis Learning Objectives Students will: • Analyze diagnostic criteria for substance-related and addictive disorders • Analyze evidence-based psychotherapy and psychopharmacologic treatments for substance-related and addictive disorders • Analyze clinical features of clients with substance-related and addictive disorders • Align clinical features with DSM-5 criteria • Compare differential diagnostic features of substance-related and addictive disorders Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click submit, you cannot delete or edit your own posts, and cannot post anonymously. Please check your post carefully before clicking Submit! ASSIGNED SUBSTANCE-RELATED DISORDER: CANNABIS-RELATED DISORDER Post: • Explain the diagnostic criteria for your assigned substance-related and addictive disorder. • Explain the evidenced-based psychotherapy and psychopharmacologic treatment for your assigned substance-related and addictive disorder. • Describe clinical features that you would expect to observe in a client that may have the substance-related and addictive disorder you were assigned. Align the clinical features with the DSM-5 criteria. • Support your rationale with references to the Learning Resources or other academic resources. Diagnostic Criteria for Assigned Substance-related and Addictive Disorder Essay. Rubric Detail Select Grid View or List View to change the rubric’s layout. Name: NRNP_6670_Week4_Discussion_Rubric • Grid View • List View Show Descriptions Main Posting: Response to the discusion question is reflecive with critical analysis and synthesis representive of knowledg gained from the course readings for the module and current credible sources.– Outstanding Performance 44 (44%) – 44 (44%) * Thoroughly responds to the discussion question(s) *is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources. * supported by at least 3 current, credible sources Excellent Performance 40 (40%) – 43 (43%) * Responds to the discussion question(s) *is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module. * 75% of post has exceptional depth and breadth * supported by at least 3 credible references Competent Performance 35 (35%) – 39 (39%) * Responds to most of the discussion question(s) *is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module. * 50% of post has exceptional depth and breadth * supported by at least 3 credible references Proficient Performance 31 (31%) – 34 (34%) * Responds to some of the discussion question(s) * one to two criteria are not addressed or are superficially addressed *is somewhat lacking reflection and critical analysis and synthesis *somewhat represents knowledge gained from the course readings for the module. * post is cited with fewer than 2 credible references Room for Improvement 0 (0%) – 30 (30%) * Does not respond to the discussion question(s) * lacks depth or superficially addresses criteria *lacks reflection and critical analysis and synthesis *does not represent knowledge gained from the course readings for the module. * contains only 1 or no credible references Main Posting: Writing– Outstanding Performance 6 (6%) – 6 (6%) * Written clearly and concisely * Contains no grammatical or spelling errors * Fully adheres to current APA manual writing rules and style Excellent Performance 5.5 (5.5%) – 5.5 (5.5%) * Written clearly and concisely * May contain one or no grammatical or spelling error * Adheres to current APA manual writing rules and style Competent Performance 5 (5%) – 5 (5%) * Written concisely * May contain one to two grammatical or spelling error * Adheres to current APA manual writing rules and style Proficient Performance 4.5 (4.5%) – 4.5 (4.5%) *Written somewhat concisely * May contain more than two2 spelling or grammatical errors * Contains some APA formatting errors Room for Improvement 0 (0%) – 4 (4%) * Not written clearly or concisely * Contains more than two spelling or grammatical errors * Does not adhere to current APA manual writing rules and style Main Posting: Timely and full participation– Outstanding Performance 10 (10%) – 10 (10%) * meets requirements for timely and full participation * posts main discussion by due date Excellent Performance 0 (0%) – 0 (0%) NA Competent Performance 0 (0%) – 0 (0%) NA Proficient Performance 0 (0%) – 0 (0%) NA Room for Improvement 0 (0%) – 0 (0%) * does not meet requirement for full participation First Reponse Post to colleague’s main post that is reflective and justified with credible sources.– Outstanding Performance 9 (9%) – 9 (9%) * response exhibits critical thinking and application to practice settings * responds to questions posed by faculty * the use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives Excellent Performance 8.5 (8.5%) – 8.5 (8.5%) * response exhibits critical thinking and application to practice settings Competent Performance 7.5 (7.5%) – 8 (8%) * response has some depth and may exhibit critical thinking or application to practice setting Proficient Performance 6.5 (6.5%) – 7 (7%) * response is on topic, may have some depth Room for Improvement 0 (0%) – 6 (6%) * response may not be on topic, lacks depth First Reponse: Writing– Outstanding Performance 6 (6%) – 6 (6%) * Communication is professional and respectful to colleagues * Response to faculty questions are fully answered if posed * Provides clear, concise opinions and ideas that are supported by two or more credible sources * Response is effectively written in Standard Edited English Excellent Performance 5.5 (5.5%) – 5.5 (5.5%) * Communication is professional and respectful to colleagues * Response to faculty questions are answered if posed * Provides clear, concise opinions and ideas that are supported by two or more credible sources * Response is effectively written in Standard Edited English Competent Performance 5 (5%) – 5 (5%) * Communication is mostly professional and respectful to colleagues * Response to faculty questions are mostly answered if posed * Provides opinions and ideas that are supported by few credible sources * Response is written in Standard Edited English Proficient Performance 4.5 (4.5%) – 4.5 (4.5%) * Responses posted in the discussion may lack effective professional communication * Response to faculty questions are somewhat answered if posed * Few or no credible sources are cited Room for Improvement 0 (0%) – 4 (4%) * Responses posted in the discussion lack effective * Response to faculty questions are missing * No credible sources are cited First Reponse: Timely and full participation– Outstanding Performance 5 (5%) – 5 (5%) * meets requirements for timely and full participation * posts by due date Excellent Performance 0 (0%) – 0 (0%) NA Competent Performance 0 (0%) – 0 (0%) NA Proficient Performance 0 (0%) – 0 (0%) NA Room for Improvement 0 (0%) – 0 (0%) * does not meet requirement for full participation Second Reponse: Post to colleague’s main post that is reflective and justified with credible sources.– Outstanding Performance 9 (9%) – 9 (9%) * response exhibits critical thinking and application to practice settings * responds to questions posed by faculty * the use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives Excellent Performance 8.5 (8.5%) – 8.5 (8.5%) * response exhibits critical thinking and application to practice settings Competent Performance 7.5 (7.5%) – 8 (8%) * response has some depth and may exhibit critical thinking or application to practice setting Proficient Performance 6.5 (6.5%) – 7 (7%) * response is on topic, may have some depth Room for Improvement 0 (0%) – 6 (6%) * response may not be on topic, lacks depth Second Reponse: Writing– Outstanding Performance 6 (6%) – 6 (6%) * Communication is professional and respectful to colleagues * Response to faculty questions are fully answered if posed * Provides clear, concise opinions and ideas that are supported by two or more credible sources * Response is effectively written in Standard Edited English Excellent Performance 5.5 (5.5%) – 5.5 (5.5%) * Communication is professional and respectful to colleagues * Response to faculty questions are answered if posed * Provides clear, concise opinions and ideas that are supported by two or more credible sources * Response is effectively written in Standard Edited English Competent Performance 5 (5%) – 5 (5%) * Communication is mostly professional and respectful to colleagues * Response to faculty questions are mostly answered if posed * Provides opinions and ideas that are supported by few credible sources * Response is written in Standard Edited English Proficient Performance 4.5 (4.5%) – 4.5 (4.5%) * Responses posted in the discussion may lack effective professional communication * Response to faculty questions are somewhat answered if posed * Few or no credible sources are cited Room for Improvement 0 (0%) – 4 (4%) * Responses posted in the discussion lack effective * Response to faculty questions are missing * No credible sources are cited Second Reponse: Timely and full participation– Outstanding Performance 5 (5%) – 5 (5%) * meets requirements for timely and full participation * posts by due date Excellent Performance 0 (0%) – 0 (0%) NA Competent Performance 0 (0%) – 0 (0%) NA Proficient Performance 0 (0%) – 0 (0%) NA Room for Improvement 0 (0%) – 0 (0%) * does not meet requirement for full participation Total Points: 100 Name: NRNP_6670_Week4_Discussion_Rubric

ORDER A PLAGIARISM-FREE PAPER NOW

Since DSM-IV was published in 1994, its approach to substance use disorders has come under scrutiny. Strengths were identified (notably, reliability and validity of dependence), but concerns have also arisen. The DSM-5 Substance-Related Disorders Work Group considered these issues and recommended revisions for DSM-5. General concerns included whether to retain the division into two main disorders (dependence and abuse), whether substance use disorder criteria should be added or removed, and whether an appropriate substance use disorder severity indicator could be identified. Diagnostic Criteria for Assigned Substance-related and Addictive Disorder Essay. Specific issues included possible addition of withdrawal syndromes for several substances, alignment of nicotine criteria with those for other substances, addition of biomarkers, and inclusion of nonsubstance, behavioral addictions.

This article presents the major issues and evidence considered by the work group, which included literature reviews and extensive new data analyses. The work group recommendations for DSM-5 revisions included combining abuse and dependence criteria into a single substance use disorder based on consistent findings from over 200,000 study participants, dropping legal problems and adding craving as criteria, adding cannabis and caffeine withdrawal syndromes, aligning tobacco use disorder criteria with other substance use disorders, and moving gambling disorders to the chapter formerly reserved for substance-related disorders. The proposed changes overcome many problems, while further studies will be needed to address issues for which less data were available.

DSM is the standard classification of mental disorders used for clinical, research, policy, and reimbursement purposes in the United States and elsewhere. It therefore has widespread importance and influence on how disorders are diagnosed, treated, and investigated. Since its first publication in 1952, DSM has been reviewed and revised four times; the criteria in the last version, DSM-IV-TR, were first published in 1994. Since then, knowledge about psychiatric disorders, including substance use disorders, has advanced greatly. To take the advances into account, a new version, DSM-5, was published in 2013. In 2007, APA convened a multidisciplinary team of experts, the DSM-5 Substance-Related Disorders Work Group (Table 1), to identify strengths and problems in the DSM-IV approach to substance use disorders and to recommend improvements for DSM-5.

TABLE 1. DSM-5 Substance-Related Disorders Work Groupa
Enlarge table
Using a set of 2006 reviews (1) as a starting point, the work group noted weaknesses, highlighted gaps in knowledge, identified data sets to investigate possible solutions, encouraged or conducted analyses to fill knowledge gaps, monitored relevant new publications, and formulated interim recommendations for proposed changes. The work group elicited input on proposed changes through commentary (2), expert advisers, the DSM-5 web site (receiving 520 comments on substance use disorders), and presentations at over 30 professional meetings (see Table S1 in the data supplement that accompanies the online edition of this article). This input led to many further analyses and adjustments.

The revisions proposed for DSM-5 aimed to overcome the problems identified with DSM-IV, thereby providing an improved approach to substance use disorders. To this end, the largest question was whether to keep abuse and dependence as two separate disorders. This issue, which applies across substances (alcohol, cannabis, etc.), had the most data available. Other cross-substance issues included the addition or removal of criteria, the diagnostic threshold, severity indicator(s), course specifiers, substance-induced disorders, and biomarkers. Substance-specific issues included new withdrawal syndromes, the criteria for nicotine disorders, and neurobehavioral disorder associated with prenatal alcohol exposure. Additional topics for consideration involved gambling and other putative non-substance-related behavioral addictions. This article presents the evidence that the work group considered on these issues and the resulting recommendations. Diagnostic Criteria for Assigned Substance-related and Addictive Disorder Essay.

Overarching Issues
Should Abuse and Dependence Be Kept as Two Separate Diagnoses?
The DSM-IV criteria for substance abuse and dependence are shown in Figure 1. Dependence was diagnosed when three or more dependence criteria were met. Among those with no dependence diagnosis, abuse was diagnosed when at least one abuse criterion was met. The division into two disorders was guided by the concept that the “dependence syndrome” formed one dimension of substance problems, while social and interpersonal consequences of heavy use formed another (3, 4). Although the dimensions were assumed to be related (3, 4), DSM-IV placed dependence above abuse in a hierarchy by stipulating that abuse should not be diagnosed when dependence was present. The dependence diagnosis represented a strength of the DSM-IV approach to substance use disorders: it was consistently shown to be highly reliable (5) and was validated with antecedent and concurrent indicators such as treatment utilization, impaired functioning, consumption, and comorbidity (6–9).

FIGURE 1. DSM-IV and DSM-5 Criteria for Substance Use Disorders
a One or more abuse criteria within a 12-month period and no dependence diagnosis; applicable to all substances except nicotine, for which DSM-IV abuse criteria were not given.

b Three or more dependence criteria within a 12-month period.

c Two or more substance use disorder criteria within a 12-month period.

d Withdrawal not included for cannabis, inhalant, and hallucinogen disorders in DSM-IV. Cannabis withdrawal added in DSM-5.

However, other aspects of the DSM-IV approach were problematic. Some issues pertained to the abuse diagnosis and others pertained to the DSM-IV-stipulated relationship of abuse to dependence. First, when diagnosed hierarchically according to DSM-IV, the reliability and validity of abuse were much lower than those for dependence (5, 10). Second, by definition, a syndrome requires more than one symptom, but nearly half of all abuse cases were diagnosed with only one criterion, most often hazardous use (11, 12). Third, although abuse is often assumed to be milder than dependence, some abuse criteria indicate clinically severe problems (e.g., substance-related failure to fulfill major responsibilities). Fourth, common assumptions about the relationship of abuse and dependence were shown to be incorrect in several studies (e.g., that abuse is simply a prodromal condition to dependence [13–17] and that all cases of dependence also met criteria for abuse, a concern particularly relevant to women and minorities [18–20]).

The problems pertaining to the DSM-IV hierarchy of dependence over abuse also included “diagnostic orphans” (21–24), the case of two dependence criteria and no abuse criteria, potentially a more serious condition than abuse but ineligible for a diagnosis. Also, when the abuse criteria were analyzed without regard to dependence, their test-retest reliability improved considerably (5), suggesting that the hierarchy, not the criteria, led to their poor reliability. Finally, factor analyses of dependence and abuse criteria (ignoring the DSM-IV hierarchy) showed that the criteria formed one factor (25, 26) or two highly correlated factors (27–34), suggesting that the criteria should be combined to represent a single disorder.

To further investigate the relationship of abuse and dependence criteria, the work group and other researchers used item response theory analysis, which builds on factor analysis, to better understand how items (in this case, the criteria) relate to each other. Item response theory models indicate criterion severity (inversely related to frequency: rarely endorsed criteria are considered more severe) and discrimination (how well the criterion differentiates between respondents with high and low severity of the condition). Diagnostic Criteria for Assigned Substance-related and Addictive Disorder Essay.The results from these analyses are often presented graphically (Figure 2), where each curve represents a criterion. Curves toward the right indicate criteria of greater severity; steeper slopes indicate better discrimination (see Table S2 in the online data supplement for more detail about Figure 2).

FIGURE 2. Information Characteristic Curves from Item Response Theory Analysis of DSM-IV Alcohol Abuse and Dependence Criteria, Required to Persist Across 3 Years of Follow-Upa,b
a Red curves: DSM-IV abuse criteria. Black curves: DSM-IV dependence criteria. Blue curve: Craving.

b Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), Wave 2 (2004–2005), conducted by the National Institute on Alcohol Abuse and Alcoholism. Participants were noninstitutionalized civilians age 20 years and older (N=34,653). The NESARC had a multistage design and oversampled blacks, Hispanics, and young adults. Analyses were conducted with Mplus (version 6.12, Los Angeles, Muthén & Muthén, 2011) and incorporated sample weights to adjust standard errors appropriately. See supplementary Table S2 for more detail on this analysis.

Table 2 lists the 39 articles on the item response theory studies that were examined or conducted by the work group, which include over 200,000 study participants. Two main findings arose, with similar results across substances, countries, adults, adolescents, patients and nonpatients. First, unidimensionality was found for all DSM-IV criteria for abuse and dependence except legal problems, indicating that dependence and the remaining abuse criteria all indicate the same underlying condition. Second, while severity rankings of criteria varied somewhat across studies, abuse (red curves in Figure 2) and dependence (black curves in Figure 2) criteria were always intermixed across the severity spectrum, similar to the curves shown in Figure 2. Collectively, this large body of evidence supported removing the distinction between abuse and dependence.

TABLE 2. Item Response Theory Studies on DSM-5 Substance Use Disorder Criteria
Enlarge table
Substance use prevalence, attitudes, and norms vary across groups, settings, and cultures (72–74). Therefore, the work group examined the studies listed in Table 2 in detail for evidence of age, gender, or other cultural bias in the DSM-5 substance use disorder criteria. Such differences are identified in an item response theory framework by testing for differential item functioning (i.e., whether the likelihood of endorsing a criterion differs by group after accounting for mean group differences in the underlying substance use disorders trait). With the exception of legal problems, the criteria did not consistently indicate differential item functioning across studies. Even where differential item functioning was found (e.g., see references 35 and 36), no evidence of differential functioning of the total score (i.e., the underlying substance use disorders trait) was found. Diagnostic Criteria for Assigned Substance-related and Addictive Disorder Essay.  Thus, consistent gender or cultural bias was not found, although the extent of the changes proposed for DSM-5 criteria for substance use disorders suggested that there would be value in additional research using different analytic strategies to examine whether gender, age, or ethnic bias exists in the criteria.

DECISION: For DSM-5, combine abuse and dependence criteria into one disorder (Figure 1), with two additional changes indicated below.

Should Any Diagnostic Criteria Be Dropped?
If any criteria can be removed while retaining diagnostic accuracy, the set will be easier to use in clinical practice. The work group considered whether two criteria could be dropped: legal problems and tolerance.

Legal problems.
Reasons to remove legal problems from the criteria set included very low prevalence in adult samples (31, 35, 37, 38, 41, 57) and in many (58, 61, 69) although not all (58, 60, 68) adolescent samples, low discrimination (28, 36, 57, 64, 66, 69, 75), poor fit with other substance use disorder criteria (28, 32, 35, 47, 51, 76), and little added information in item response theory analyses (28, 37, 41, 44). Some clinicians were concerned that dropping legal problems would leave certain patients undiagnosed, an issue specifically addressed among heavy alcohol, cannabis, cocaine, and heroin users in methadone and dual-diagnosis psychiatric settings (57). None of these patients reported substance-related legal problems as their only criterion or “lost” a DSM-5 substance use disorder diagnosis without this criterion. Thus, legal problems are not a useful substance use disorder criterion, although such problems may be an important treatment focus in some settings.

Tolerance.
Concerns about the tolerance criterion included its operationalization, occasional poor fit with other criteria (51), occasional differential item functioning (68), and relevance to the underlying disorder (77). However, most item response theory articles on substance use disorder criteria (Table 2) did not find anything unique about tolerance relative to the other criteria.

DECISION: Drop legal problems as a DSM-5 diagnostic criterion.

Should Any Criteria Be Added?
If new criteria increase diagnostic accuracy, the set will be improved by their addition. The work group considered two criteria for possible addition: craving and consumption.

Craving.
Support for craving as a substance use disorder criterion comes indirectly from behavioral (78–82), imaging, pharmacology (83), and genetics studies (84). Some believe that craving and its reduction is central to diagnosis and treatment (83, 85), although not all agree (86, 87). Craving is included in the dependence criteria in ICD-10, so adding craving to DSM-5 would increase consistency between the nosologies.

Item response theory analyses of data from general population and clinical samples in the United States and elsewhere (42, 45, 47, 49, 57, 88) were used to determine the relationship of craving to the other substance use disorder criteria and whether its addition improved the diagnosis. Craving was measured using questions about a strong desire or urge to use the substance, or such a strong desire to use that one couldn’t think of anything else. Across studies, craving fit well with the other criteria and did not perturb their factor loadings, severity, or discrimination. Differential item functioning was generally no more pronounced for craving than for other criteria.Diagnostic Criteria for Assigned Substance-related and Addictive Disorder Essay.  In general population samples (e.g., the blue curve in Figure 2), craving fell within the midrange of severity (42). In clinical samples, craving was in the mid-to-lower range of severity, likely because of high prevalence (57). Some studies suggested that craving was redundant with other criteria (47, 49). Using visual inspection to compare item response theory total information curves for the DSM-5 substance use disorder criteria with and without craving produced inconsistent results (42, 47, 88). Using statistical tests to compare total information curves, the addition of craving to the dependence criteria did not significantly add information (45, 57). However, when craving and the three abuse criteria were added, total information was increased significantly for nicotine, alcohol, cannabis, and heroin, although not for cocaine use disorders (45, 57). Clinicians expressed enthusiasm about adding craving at work group presentations and on the DSM-5 web site. In the end, while the psychometric benefit in adding a craving criterion was equivocal, the view that craving may become a biological treatment target (a nonpsychometric perspective) prevailed. While awaiting the development of biological craving indicators, clinicians and researchers can assess craving with questions like those used in the item response theory studies (42, 45, 47, 49, 57, 88).

Consumption.
The work group considered adding quantity or frequency of consumption as a criterion. A putative criterion of five or more drinks per occasion for men and four or more drinks for women fit well with other criteria in the U.S. general population (36), as did at least weekly cannabis use and daily cigarette use (38, 40). However, issues included worsening of model fit (41), unclear utility among cannabis users (66), and lack of a uniform cross-national alcohol indicator (54). Quantifying other illicit drug consumption patterns is even more difficult.

DECISION: Do not add consumption. Add “craving or a strong desire or urge to use the substance” to the DSM-5 substance use disorder criteria (Figure 1). Encourage further research on the role of craving among substance use disorder criteria.

What Should the Diagnostic Threshold Be?
The studies in Table 2 and others (89–91) demonstrate that the substance use disorders criteria represent a dimensional condition with no natural threshold. However, a binary (yes/no) diagnostic decision is often needed. To avoid a marked perturbation in prevalence without justification, the work group sought a threshold for DSM-5 substance use disorders that would yield the best agreement with the prevalence of DSM-IV substance abuse and dependence disorders combined. To determine this threshold, data from general population and clinical samples were used to compute prevalences and agreement (kappa) between DSM-5 substance use disorders and DSM-IV dependence or abuse, examining thresholds of two or more to four or more DSM-5 criteria (Table 3). As shown, prevalence was very similar, and agreement (ranging from very good to excellent) appeared maximized with the threshold of two or more criteria, so it was selected. Another recent large independently conducted study further supported this threshold (92). Diagnostic Criteria for Assigned Substance-related and Addictive Disorder Essay.

TABLE 3. Agreement Between DSM-IV Abuse/Dependence and DSM-5 Substance Use Disorders at Different Diagnostic Thresholds
Enlarge table
Concerns that the threshold of two or more criteria is too low have been expressed in the professional (93, 94) and lay press (95), at presentations, and on the DSM-5 web site (e.g., that it produces an overly heterogeneous group or that those at low severity levels are not “true” cases). These understandable concerns were weighed against the competing need to identify all cases meriting intervention, including milder cases, for example, those presenting in primary care. Table 3 shows that a concern that “millions more” would be diagnosed with the DSM-5 threshold (95) is unfounded if DSM-5 substance use disorder criteria are assessed and decision rules are followed (rather than assigning a substance use disorder diagnosis to any substance user). Additional concerns about the threshold should be addressed by indicators of severity, which clearly indicate that cases vary in severity.

An important exception to making a diagnosis of DSM-5 substance use disorder with two criteria pertains to the supervised use of psychoactive substances for medical purposes, including stimulants, cocaine, opioids, nitrous oxide, sedative-hypnotic/anxiolytic drugs, and cannabis in some jurisdictions (96, 97). These substances can produce tolerance and withdrawal as normal physiological adaptations when used appropriately for supervised medical purposes. With a threshold of two or more criteria, these criteria could lead to invalid substance use disorder diagnoses even with no other criteria met. Under these conditions, tolerance and withdrawal in the absence of other criteria do not indicate substance use disorders and should not be diagnosed as such.

ORDER A PLAGIARISM-FREE PAPER NOW

DECISION: Set the diagnostic threshold for DSM-5 substance use disorders at two or more criteria.

How Should Severity Be Represented?
The DSM-5 Task Force asked work groups for severity indicators of diagnoses (mild, moderate, or severe). Many severity indicators are possible (e.g., levels of use, impairment, or comorbidity), and the Substance-Related Disorders Work Group sought a simple, parsimonious approach. A count of the criteria themselves serves this purpose well, since as the count increases so does the likelihood of substance use disorder risk factors and consequences (89–91, 98). The work group considered weighting the count by item response theory severity parameters, but comparing the association of weighted and unweighted criterion counts to consumption, functioning, and family history showed no advantage for weighting (98). Furthermore, since severity parameters differ somewhat across samples (31), no universal set of weights exists.

DECISION: Use a criteria count (from two to 11) as an overall severity indicator. Use number of criteria met to indicate mild (two to three criteria), moderate (four to five), and severe (six or more) disorders.

Specifiers
Physiological cases.
DSM-IV included a specifier for physiological cases (i.e., those manifesting tolerance or withdrawal, a DSM-III carryover), but the predictive value of this specifier was inconsistent (99–106). A PubMed search indicated that this specifier was unused outside of studies investigating its validity, indicating negligible utility.

DECISION: Eliminate the physiological specifier in DSM-5.

Course.
In DSM-IV, six course specifiers for dependence were provided. Four of these pertained to the time frame and completeness of remission, and two pertained to extenuating circumstances.

In DSM-IV, the specifiers for time frame and completeness of remission were complex and little used. To simplify, the work group eliminated partial remission and divided the time frame into two categories, early and sustained. Early remission indicates a period ≥3 months but <12 months without meeting DSM-5 substance use disorders criteria other than craving. Three months was selected because data indicated better outcomes for those retained in treatment at least this long (107, 108). Sustained remission indicates a period lasting ≥12 months without meeting DSM-5 substance use disorders criteria other than craving. Craving is an exception because it can persist long into remission (109, 110).

The work group noted that many clinical studies define remission and relapse in terms of substance use per se, not in terms of DSM criteria. The work group did not do this in order to remain consistent with DSM-IV criteria, and because the criteria focus on substance-related difficulties, not the extent of use, for the reasons discussed in the section on adding criteria. In addition, a lack of consensus on the level of use associated with a good outcome (111, 112) complicates substance use as a course specifier for the disorder.

The extenuating circumstance “in a controlled environment” was unchanged from DSM-IV. DSM-IV also included “on agonist therapy” (e.g., methadone or unspecified partial agonists or agonist/antagonists). To update this category, DSM-5 replaced it with “on maintenance therapy” and provided specific examples. Diagnostic Criteria for Assigned Substance-related and Addictive Disorder Essay.

DECISION: Define early remission as ≥3 to <12 months without meeting substance use disorders criteria (except craving) and sustained remission as ≥12 months without meeting substance use disorders criteria (except craving). Update the maintenance therapy category with examples of agonists (e.g., methadone and buprenorphine), antagonists (e.g., naltrexone), and tobacco cessation medication (bupropion and varenicline).

Could the Definitions of Substance-Induced Mental Disorders Be Improved?
Substance use and other mental disorders frequently co-occur, complicating diagnosis because many symptoms (e.g., insomnia) are criteria for intoxication, withdrawal syndrome, or other mental disorders. Before DSM-IV, the nonstandardized substance-induced mental disorder criteria had poor reliability and validity. DSM-IV improved this (113) via standardized guidelines to differentiate between “primary” and “substance-induced” mental disorders. In DSM-IV, primary mental disorders were diagnosed if they began prior to substance use or if they persisted for more than 4 weeks after cessation of acute withdrawal or severe intoxication. DSM-IV substance-induced mental disorders were defined as occurring during periods of substance intoxication or withdrawal or remitting within 4 weeks thereafter. The symptoms listed for both the relevant disorder and for substance intoxication or withdrawal were counted toward the substance-induced mental disorder only if they exceeded the expected severity of intoxication or withdrawal. While severe consequences could accompany substance-induced mental disorders (114), remission was expected within days to weeks of abstinence (115–118).

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 (113) and validly (119) by standardizing the procedures to determine when symptoms were greater than expected (although these were complex) 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. Diagnostic Criteria for Assigned Substance-related and Addictive Disorder Essay.