One issue being raised in the proposed revisions
to the DSM is that of patients who are at
heightened risk of developing addiction in the
near future but do not now meet the diagnostic
criteria.^185 One suggestion* is to add a severity
category of “mild” to the proposed “moderate”
and “severe” diagnosis categories. This
modification would help to identify risky
substance users and increase the chances that
they receive needed services to prevent their
risky use from progressing to addiction, while
reducing the risk of their receiving unnecessary
treatment which might accompany a more
severe diagnosis.^186
International Statistical Classification of
Diseases (ICD). Like the DSM, the ICD does
not present a disease category of addiction;
rather, it presents mental health disorders that
are linked to psychoactive substance use
including nicotine, alcohol and other drugs.^187
Like the DSM, the ICD offers two categories
related to addiction: in this case, harmful use
and dependence syndrome. Harmful use is
defined as “a pattern of psychoactive substance
use that is causing damage to health. The
damage may be physical (e.g., hepatitis
following injection of drugs) or mental (e.g.,
depressive episodes secondary to heavy alcohol
intake).” The ICD defines dependence
syndrome as “a cluster of behavioral, cognitive
and physiological phenomena that may develop
after repeated substance use. Typically, these
phenomena include a strong desire to take the
drug, impaired control over its use, persistent
use despite harmful consequences, a higher
priority given to drug use than to other activities
and obligations, increased tolerance and a
physical withdrawal reaction when drug use is
discontinued.”^188
The DSM vs. the ICD. While there is
considerable overlap between the diagnostic
definitions provided in the DSM and the ICD,
the ICD definitions connote more of a disease
state while the DSM definitions imply more of a
behavioral disorder. In addition, the ICD is used
- Made by NAADAC, the Association for Addiction
Professionals.
more frequently internationally while the DSM
is used more frequently in the United States and
Canada.^189 Access to the ICD codes is free to
the public via the Internet, whereas providers
must pay the American Psychiatric Association
for access to the DSM manual and codes, either
by purchasing the text version of the manual or
by paying to access the information online.^190
The DSM is used more commonly than the ICD
in research studies, whereas the ICD has become
the primary tool used by health care facilities to
index health care data.^191 The DSM criteria for
addiction involving nicotine are used less
frequently by researchers and clinicians than
criteria for addiction involving alcohol and other
drugs.† 192Like the DSM, the ICD currently is undergoing
revisions and there is hope that the parties
involved in the revisions to these classification
systems will take the opportunity to standardize
the language used to describe the full spectrum
of clinical addiction,^193 with an increased focus
on the disease itself rather than different
disorders linked to specific substances.It also is important to clarify that addiction is a
medical condition with significant behavioral
components.^194 Recognizing that current
diagnostic classification systems like the DSM
and ICD do not sufficiently take into account the
shared underlying genetic and neurobiological
dimensions of addiction and various health
conditions--instead relying primarily on
subjective reports of symptoms of seemingly
unique and unitary conditions--the National
Institute of Mental Health (NIMH) has begun to
classify these conditions in a new way. The
Research Domain Criteria project (RDoC) aims
to develop a classification system based on
observable behavior and neurobiological
measures that underlie different manifestations
of addiction and related conditions which
currently are classified and addressed as distinct
conditions.^195 Should this new system take hold,† Measures of addiction involving nicotine that are
considered to have greater predictive validity in terms
of outcomes include the Fagerstrom Test for Nicotine
Dependence (FTND) and Nicotine Dependence
Symptom Scale (NDSS).