THE DSM IV
This is the book that contains all of the criteria for mental health or psychiatric disorders. It is published by the American Psychiatric Association who develops work groups of experts in each group of disorders to determine exactly what symptoms or criteria a patient must have to be diagnosed with a particular disorder. This fourth edition was published in 1994 and is actually the sixth edition published since there was a second and third revised edition. Recently DSM IVTR was published which is a text revision of the above book.
As in all of medicine there are some diagnoses that appeared in the DSM IIIR edition that did not make it to the DSM IV edition and some diagnoses that appear in DSM IV that were not in DSM IIIR. This does not reflect the discovery or disappearance of these diagnoses but merely how we categorize them in relation to other diagnoses and therefore how we name them. Each diagnosis in DSM has its own code. Substance use disorders are categorized by group of chemically similar substances and their is no diagnosis listed of addiction or chemical dependency though we generally refer to patients with any substance dependency as chemically dependent or addicted. The dividing line between abuse and dependency is very gray and fuzzy in DSM though we all acknowledge that it exists and is easier to determine when referring to or evaluating one particular patient.
We use the five axis comprehensive diagnosis format suggested by the American Psychiatric Association when a patient is admitted for chemical dependency treatment.
AXIS 1-PRIMARY PSYCHIATRIC DIAGNOSIS I.E. ALCOHOL DEPENDENCE OR A MOOD DISORDER SUCH AS MAJOR DEPRESSION
AXIS 2-PERSONALITY DISORDERS WILL BE COVERED IN ANOTHER CHAPTER
AXIS 3-ANY GENERAL MEDICAL PROBLEM I.E. DIABETES, HYPERTENSION, MIGRAINE HEADACHE, ETC.
AXIS 4-PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS I.E. FINANCIAL PROBLEMS, DIVORCE, SEPARATION FROM CHILDREN, PENDING LEGAL CHARGES, ETC.
AXIS 5-GLOBAL ASSESSMENT OF FUNCTIONING ON A SCALE FROM 10-100 I.E. A 90 IS GOOD FUNCTIONING IN ALL AREAS WITH MINIMAL PSYCHOLOGICAL, SOCIAL, OR OCCUPATIONAL PROBLEMS. 50 IS SERIOUS DYSFUNCTION IN ALL AREAS AND 40 WOULD INCLUDE SOME IMPAIRMENT OF REALITY TESTING.
The book is set up so that for each code or diagnosis there is a narrative telling the reader the incidence or frequency of the disorder in addition the statistics on age, sex, and ethnic prevalence. This is followed by a list of symptoms which are usually behaviors that an observer would see in a patient. There may be from three to 20 behaviors listed for a particular disorder. A qualifying statement is made about the behaviors which usually includes a time limitation. i.e. "1. you must have 3 out of 7 of these behaviors over a one year time period to have this disorder. 2. you must have 7 out of 13 of these behaviors over the previous 3 months to have this disorder. 3. you must have 2 behaviors from Group A, one from Group B, and 2 from Group C over 6 months to have this disorder." Though the substance dependencies are divided by group i.e. alcohol dependence, cocaine dependence, cannabanoid dependence, opiate dependence, hallucinogen dependence etc. the criteria for each one are the same set of behaviors only referring to that group of drugs. So a patient coming into chemical dependency treatment might get an AXIS 1 diagnosis of
AXIS 1 (1) ALCOHOL DEPENDENCE
If more than three substance together fulfill the criteria we would give a diagnosis of polysubstance dependence. The next chapter will discuss what these criteria or behaviors for substance dependency are and what they mean.