Editorial: Diagnosing Drug Problems and the DSM

Abstract

The articles in this special issue of Contemporary Drug Problems reflect the many problematizing frameworks that have been applied to the consumption of mood-altering drugs at different times and in different locations. In contemporary public debate, drug consumption is variously addressed as medical issue, public health issue, social issue, law and order issue, and moral issue. The resulting field of negative images and associations not only constitutes drug users as certain kinds of people, but is drawn upon to promote particular responses and to silence other possibilities. This editorial discusses key site for the representation and reproduction of habitual and harmful drug use as medical problem: the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association.A new edition of the manual, the DSM-V, is currently in preparation, and significant revisions have been proposed for the substance-use disorders, including change in terminology from dependence to addiction. The proposed revisions and the resulting commentary provide an opportunity to critically consider the effects of the DSM' s medicalizing and classificatory framework. This editorial emphasizes the continued reliance of the manual's categories on hybrid combination of ethical and medical judgment, which is at odds with its definition of disorder. It also highlights the distinctions between legitimate and illegitimate drug users that are embedded in the proposed category of substance-use disorder. As one of the rationales for the change in terminology in the DSM-V is the issue of opiate dependence in pain patients, the editorial also briefly discusses the model of addiction found in pain medicine.DSM disorders and diagnosisDiagnosis as classificatory practice is central to medicine. It identifies and constitutes the presenting problem or set of symptoms as disease and implies that the proper response is treatment. It also establishes the authority of the medical professional over the problem, and establishes the identity of the patient as person with certain condition (Jutel, 2011).But as Allan Horwitz has observed, diagnosis had only minor role in psychiatry as it was practiced in the first part of the 20th Century. In the psychodynamic framework that was then dominant, the focus was on neurosis, not disease, and the problems of most patients were seen as the result of psychic conflicts, personality dynamics, and reactions to stresses (2000, pp. 45-46). The publication of the DSM-III in 1980 marked paradigm shift because it established system based on specific and distinct categories of disorder. It ushered in the medicalized framework that Horwitz calls diagnostic psychiatry, an approach based on the premise that clusters of symptoms indicate underlying diseases. The number of distinct disorders recognized by psychiatry has grown with each subsequent edition of the manual, to the 400 diverse behavioral and psychological conditions found in the DSM-IV.But what is disorder, according to the DSM? The definition of mental provided in the introduction to the DSM-IV reflects the assumptions of psychiatry. It describes disorder as a clinically significant behavioral or psychological syndrome or pattern that is associated with distress, disability, or significantly increased risk of suffering death, pain, disability, or an important loss of freedom (American Psychiatric Association, 2000, p. xxxi). But, crucially, to be disorder, the syndrome must be considered a manifestation of behavioral, psychological, or biological dysfunction in the (American Psychiatric Association, 2000, p. xxxi). The manual explicitly states that disorder cannot be merely deviant behavior, nor conflict between the individual and society, nor an expectable response to an event such as the death of loved one. …