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Nosology of the Substance Use Disorders: How Deep Is the ICD – DSM Dichotomy?

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Nosology of the Substance Use Disorders: How Deep Is the ICD – DSM Dichotomy? REVIEW ARTICLE Nosology of the substance use disorders: How deep is the ICD – DSM dichotomy? Munish Aggarwal, Anindya Banerjee, Debasish Basu Abstract The two main nosological systems followed for classification of substance related disorders are International Classification of Diseases (ICD), which is supported by the World Health Organization (WHO) and The Diagnostic and Statistical Manual of Mental Disorders (DSM), a publication of the American Psychiatric Association. The categories in both systems of classification are similar and the substances covered are almost identical. The concept of dependence is similar in both, with fair reliability and validity but diagnostic criteria for dependence are more stringent in ICD-10 compared to DSM-IV. The concepts of harmful use (ICD-10) and abuse (DSM-IV) are markedly different with poor concordance. The ICD-DSM dichotomy regarding classification of substance related disorders is expected to reduce in subsequent editions of these nosological systems. INTRODUCTION of the problem across the scientific community, Mental disorders are manifested by the and helps in control of the disorder. This also quantitative deviation in behavior, ideation and paves the way for transcultural comparisons, and emotion from a normative concept. The diagnosis generates data for planning, policy – making and of mental disorders is inherently difficult due to service allocation. the problems in defining “the norm” and quantifying At present, two systems of classifications the degree of deviance that would invite the label of mental disorders are widely followed- The of a diagnosis. The problems that arise during International Classification of Diseases (ICD), the diagnosis of other psychiatric illness also which is supported by the World Health apply to substance use. This has been addressed Organization (WHO) and The Diagnostic and by the systematic classification of mental Statistical Manual of Mental Disorders (DSM), disorders, which also includes the substance use proposed by American Psychiatric Association disorders. (APA). The aim of the present paper is to review Nosology or systematic classification is the the evolution of nosology of substance use process by which the complexity of phenomena disorders and to compare and contrast the is reduced by arranging them into categories nosology of substance abuse disorders as according to some established criteria for one or defined by ICD-10 and DSM-IV. 1 more purpose. Classification of mental disorders WHO NOMENCLATURE AND DEFINITIONS OF are useful in developing a system of comparable REPETITIVE SUBSTANCE USE2 diagnosis enabling the communication of scientific and research work done in this clinical Unsanctioned use discipline. This leads to better comprehension This is defined as the use of a substance that is Journal of Mental Health & Human Behavior, 2008 18 Aggarwal et al : ICD-DSM Dichotomy Substance use not approved by a society or by a group within For the diagnosis of both harmful use and that society. The term implies that this disapproval substance abuse, substance dependence must is accepted as a fact in its own right, without the be ruled out. need to determine or justify the basis of the disapproval Substance Dependence A widely accepted definition given by WHO is: “A Dysfunctional use syndrome manifested by a behavioral pattern in Substance use that is leading to impaired which the use of a given psychoactive drug or psychological or social functioning, for example class of drugs, is given a much higher priority loss of employment or marital problems. than other behavior that once had higher value. The term syndrome is taken to mean no more Hazardous use than clustering of phenomenon so that not all the It is a pattern of substance use that increases components need always be present or not the risk of harmful consequences to the user. always present with the same intensity. The Some would limit the consequences to physical dependence syndrome is not absolute, but is a and mental health (as in harmful use); some would quantitative phenomenon that exists in different also include social consequences. In contrast to degrees. The intensity of the syndromes is harmful use, hazardous use refers to patterns of measured by the behaviors that are elicited in use that are of public health significance despite relation to using the drug and by the other behavior the absence of any current disorder in the that are secondary to drug use. No sharp cut-off individual user. The term is used currently by WHO point can be identified for distinguishing drug but is not a diagnostic term in ICD-10 dependence from non-dependent but recurrent drug use. At the extreme the dependence Harmful use syndrome is associated with compulsive drug It is a pattern of psychoactive substance use that using.”4 is causing damage to health. The damage may The central notion of this definition is be physical (e.g. hepatitis following injection of continued in both DSM-IV and ICD-10. drugs) or mental (e.g. depressive episodes secondary to heavy alcohol intake). Harmful Evolution of ICD & DSM & Substance Use use commonly, but not invariably, has adverse Nosology social consequences; which in themselves, however, are not sufficient to justify a diagnosis International classification of disease (ICD) of harmful use. The first edition of international classification of disease was modification of the Bertillon Substance Abuse Classification of Causes of Death and was A maladaptive pattern of substance use adopted in 1900. It has been named as manifested by recurrent and significant and international List of Causes of Death.5 The sixth adverse consequences related to the repeated revision contained a critical expansion of the use of substances in one or more areas like scope of the international classification by fulfillment of role obligations, physically hazardous covering morbidity in addition to mortality and was use, legal problems and interpersonal problems. renamed the “Manual of International These problems must occur repeatedly during the Classification of Diseases, injuries and Causes same 12 month period.3 of Death” (ICD-6).5 It for the first time contained, Journal of Mental Health & Human Behavior, 2008 19 Aggarwal et al : ICD-DSM Dichotomy Substance use a classification of mental disorders, entitled had only one criterion, namely evidence of “mental, psychoneurotic, and personality tolerance or withdrawal. However, the criteria for disorders.”1. The first ICD classification of alcohol and cannabis dependence also included substance-related problems was published in impairment in social or occupational functioning 1967 in ICD-8.5 It was classified as alcoholism and a pattern of pathological use. with personality disorders and neuroses. In ICD- In a seminal article, Edwards and Gross11 9, alcoholism and substance abuse has been gave a set of essential elements, for the provisional classified under “neurotic disorders, personality description of a clinical syndrome of alcohol disorders, and other non-psychotic mental dependence. They mentioned that all must not disorders (300-316)”. 303- Alcohol dependence always be present and not always be present in syndrome; 304- drug dependence; 304-non the same intensity. The essential elements 6-7 dependent abuse of drugs. included Diagnostic and Statistical Manual of Mental 1. A narrowing in the repertoire of drinking Disorders (DSM) behavior. The first edition of DSM (DSM-I) was published 2. Salience of drink seeking behavior. in 1952. Substance use disorders were grouped 3. Increase tolerance to alcohol. under personality disorders, and alcoholism was defined as ‘well established addiction to alcohol 4. Repeated withdrawal symptoms. without recognized underlying disorder’. Drug 5. Repeated relief or avoidance of withdrawal addiction was not defined separately but there symptoms by further drinking. was a statement that ‘Addiction is usually 6. Subjective awareness of a compulsion to symptomatic of a personality disorder.8 The proper drink. personality classification is to be made as an 7. Reinstatement of the syndrome after drinking. additional diagnosis.’ Alcohol intoxication was called a ‘non-diagnostic term’, similar to being a This article made major change in the boarder in an institution or a malingerer. In DSM- classification of substance dependence in the II (1968)9, drug dependence and alcohol use subsequent editions of DSM (DSM-III) and ICD disorders were still part of broad rubric of (ICD-9). The major deviation in their “Personality Disorders and certain other non- conceptualization from the previous classification psychotic disorders”; separate diagnosis of was that it was based on the behavioral alcohol use was encouraged. Categories of drug manifestations rather than etiological dependence were added for drugs like opioids, classification. barbiturates, hypnotics, cocaine, cannabis, DSM-IV & ICD-10: CURRENT NOSOLOGY hallucinogens and stimulants. DSM – III was published in 1980, and DSM-IV substance use disorders were, for the first time, It categorizes Psychoactive Substance Use classified separately.10 Distinction was made under Substance related disorder:- between substance abuse and dependence. This broad category has been into Substance abuse had three criteria: a pattern of pathological use, impairment in social or 1. Substance use disorder: Substance occupational functioning, and duration of one dependence and substance abuse are covered month or more. Dependence for most substances under this heading.
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