Why do we need to give a diagnosis?

A diagnosis is a label that is given to a client by one who is trained and licensed, which indicates the illness and chronic conditions that the clients have or which they struggle (Rose, 2016)

Access to Treatment: withholding or changing access to treatment services for certain people based on a specific characteristic or membership in a group is an example of professional discrimination.
Judging: blatant or subtle, judging someone or an aspect of someone is discrimination.
Forwarding Stereotypes occurs when you buy into an existing stereotype and treat a client as if it is true.
Assumptions: automatically at risk of making blunders and of discriminating against them even if our intentions are positive.
Language: the language (verbal and non-verbal) we use with clients can also revel judgments.

The DSM-5 and Substance-Related and Addictive Disorders

The Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association is the manual used by clinicians and researchers to diagnose and classify mental disorders. It was first published in 1952 and has been revised multiple times.

DSM-I: Diagnostic and Statistical Manual: Mental Disorders (1952)
DSM-I Special Supplement: on plans for revision to better align with the International Classification of Diseases (1965)
DSM-II: Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition (1968)
DSM-II 6th printing change: Elimination of Homosexuality as a mental disorder and substitution of the new category Sexual Orientation Disturbance (1973)
DSM-III: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (1980)
DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition—Revised (1987)
DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (1994)
DSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013)

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the revised chapter of “Substance-Related and Addictive Disorders” includes substantive changes to the disorders grouped there plus changes to the criteria of certain conditions.

Scope of Practice and Diagnosing Clients

As a Certified Substance Abuse Counselor alone, without the benefit of the clinical training and license to practice as a Marriage & Family Therapist, a Clinical Social Worker, a Clinical Psychologist or as a Psychiatrist, you are limited to the extent to which you can diagnosis a client within your care. You will have the training to determine a diagnosis for a substance use disorder but not be qualified to diagnose the client with another mental health disorder. To do so would be to practice beyond the scope of your training and expertise. If in the process of assessing your client, the client reports having been diagnosed with a mental health disorder in the past by another qualified professional, you may report such client reported history as indicated below by an example diagnosis that would include PTSD and Major Depressive Disorder.

Example: Post Traumatic Stress Disorder (by client report, previously diagnosed by Dr. Sam Jones, MD, unverified) or

Major Depressive Disorder (by client report, previously diagnosed by County Mental Health Psychiatrist, identity unknown).

Substance Use Disorder

Substance use disorder in DSM-5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe. Each specific substance (other than caffeine, which cannot be diagnosed with a substance use disorder) is addressed as a separate use disorder (e.g., alcohol use disorder, stimulant use disorder, etc.), but nearly all substances are diagnosed based on the same overarching criteria. In this overarching disorder, the criteria have not only been combined but strengthened. Whereas a diagnosis of substance abuse previously required only one symptom, mild substance use disorder in DSM-5 requires two to three symptoms from a list of 11.

In DSM-IV, the distinction between abuse and dependence was based on the concept of abuse as a mild or early phase and dependence as the more severe manifestation. In practice, the abuse criteria were sometimes quite severe. The revised substance use disorder, a single diagnosis, will better match the symptoms that patients experience. Additionally, the diagnosis of dependence caused much confusion. Most people link dependence with “addiction” when in fact dependence can be a normal body response to a substance.

Substance use disorders are diagnosed by the type of substance used (e.g., “Stimulant Use Disorder”). Alcohol use disorders are subsumed under the category of substance use disorders. Criteria for achieving a “substance use disorder” now exist along a continuum of “mild,” “moderate,” and “severe,” combining the previously distinctive DSM-IV abuse and dependence symptoms to make up this continuum. One symptom, “legal difficulties from drug use,” which was formerly listed as a criterion for “substance abuse” is no longer present. One reason for this change is the growing inconsistency between state criminal laws that made for diagnostic differences. As laws related to marijuana emerge, including the legalization of “medical marijuana” in some states and the decriminalization of marijuana possession in others, this is an important change in diagnostic classification. An important new criterion for substance use disorders is “cravings,” reflecting factors surrounding the intensity of desire for ongoing substance use. Criteria for diagnosing substance use disorders along the continuum of current severity are as follows: “mild” severity requires 2–3 symptoms, “moderate” severity requires 4–5 symptoms, and “severe” requires 6 or more from a total of 11 symptoms (APA, 2013).

Addictive Disorders

The chapter also includes gambling disorder as the sole condition in a new category on behavioral addictions. DSM-IV listed pathological gambling but in a different chapter. This new term and its location in the new manual reflect research findings that gambling disorder is similar to substance-related disorders in clinical expression, brain origin, comorbidity, physiology, and treatment. Recognition of these commonalities will help people with gambling disorder get the treatment and services they need, and others may better understand the challenges that individuals face in overcoming this disorder.

While gambling disorder is the only addictive disorder included in DSM-5 as a diagnosable condition, Internet gaming disorder will be included in Section III of the manual. Disorders listed there require further research before their consideration as formal disorders. This condition is included to reflect the scientific literature on the persistent and recurrent use of Internet games, and a preoccupation with them can result in clinically significant impairment or distress. Much of this literature comes from studies in Asian countries. The condition criteria do not include general use of the Internet, gambling, or social media at this time.

Other Disorders of Interest

DSM-5 does not include caffeine use disorder, although research shows that as little as two to three cups of coffee can trigger a withdrawal effect marked by tiredness or sleepiness. There is sufficient evidence to support this as a condition, however, it is not yet clear to what extent it is a clinically significant disorder. To encourage further research on the impact of this condition, caffeine use disorder is included in Section III of DSM-5.

Source: © 2013 American Psychiatric Association Retrieved from https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/dsm-5-fact-sheets/

The DSM-5 and ICD-10 System of Diagnosis

Another change between the DSM-IV and the DSM-5 is that the DSM-5 no longer includes a coding system for diagnosis that is specific to the DSM-5. It now utilizes the International Classification of Diseases, Tenth Revision (ICD-10) numeric coding system.

The DSM-5 establishes nine types of Substance-Related Disorders (Horvath, et al., 2016):

1. Alcohol
2. Caffeine*
3. Cannabis (e.g., marijuana)
4. Hallucinogens
5. Inhalants
6. Opioid (e.g., heroin)
7. Sedatives, Hypnotics, or Anxiolytics (e.g., valium, "quaaludes")
8. Stimulants (cocaine, methamphetamine)
9. Tobacco

*Substance use disorder does not apply to caffeine.

Regardless of the particular substance, the diagnosis of a substance use disorder is based upon a pathological set of behaviors related to the use of that substance. These behaviors fall into four main categories:

1. Impaired control
2. Social impairment
3. Risky use
4. Pharmacological indicators (tolerance and withdrawal)

DSM-5 Substance Use Disorder 11 Criteria (American Psychiatric Association, 2013)

Impaired Control Impaired

Control over substance use is the first criteria grouping (Criteria 1-4).

1. The individual may take the substance in larger amounts or over a longer period than was originally intended.

2. The individual may express a persistent desire to cut down or regulate substance use and may report multiple unsuccessful efforts to decrease or discontinue use.

3. The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects. In some instances of more severe substance use disorders, virtually all of the individual’s daily activities revolve around the substance. In other instances, use is confined to limited time periods – a few hours per day, or a day or two per week or a weekend every few weeks.

4. Craving is manifested by an intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug previously was obtained or used. Craving has also been shown to involve classical conditioning and is associated with activation of specific reward structures in the brain. (Think Palov’s dog.) (Current craving is often used as a treatment outcome measure because it may be a signal of impending relapse.)

Social Impairment

Social Impairment is the second grouping of criteria (Criteria 5-7).

5. Recurrent substance use may result in a failure to fulfill major role obligations at work, school, or home.

6. The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

7. Important social, occupational, or recreational activities may be given up or reduced because of substance use. The individual may withdraw from family activities and hobbies in order to use the substance.

Risky Use

Risky Use of the substance is the third grouping of criteria (Criteria 8-9).

8. This may take the form of recurrent substance use in situations in which it is physically hazardous. (Driving while intoxicated.)

9. The individual may continue substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. (Anger issue or liver damage.) The key issue in evaluating this criterion is not the existence of the problem, but rather the individual’s failure to abstain from using the substance despite the difficulty it is causing.

Pharmacological Indicators: Tolerance and Withdrawal

Tolerance and Withdrawal are the final groupings (Criteria 10-11).

10. Tolerance is signaled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed. • The degree to which tolerance develops varies greatly across different individuals as well as across substances and may involve a variety of central nervous system effects (such as coordination and passing out). Tolerance may be difficult to determine by history alone, and laboratory tests may be helpful (e.g., high blood levels of the substance coupled with little evidence of intoxication suggest that tolerance is likely).

11. Withdrawal is a syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing withdrawal symptoms, the individual is likely to consume the substance to relieve the symptoms. • Withdrawal symptoms vary greatly across the classes of substances, and separate criteria sets for withdrawal are provided for the drug classes. Marked and generally easily measured physiological signs of withdrawal are common with alcohol, opioids, sedatives, hypnotics, and anxiolytics. Withdrawal signs and symptoms with stimulants (amphetamines and cocaine), as well as tobacco and cannabis, are often present but may be less apparent. Note that neither tolerance nor withdrawal is necessary for a diagnosis of a substance use disorder. However, for most classes of substances, a past history of withdrawal is associated with a more severe clinical course (i.e., an earlier onset of a substance use disorder, higher levels of substance intake, and a greater number of substance-related problems). Alcohol Use Disorder - Diagnostic Criteria As mentioned, there are 11 criteria for determining an Alcohol Use Disorder. (Formerly alcohol abuse or dependence.)

So in brief, substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria:

The substance is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control substance use.
A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
Craving, or a strong desire or urge to use the substance.
Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home.
Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
Recurrent use of the substance in situations in which it is physically hazardous.
The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Tolerance, as defined by either of the following: a) A need for markedly increased amounts of the substance to achieve intoxication or desired effect b) A markedly diminished effect with continued use of the same amount of the substance.
Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for the substance/alcohol (refer to criteria A and B of the criteria set for substance withdrawal) b) Substance / Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

The DSM-5 (American Psychiatric Association, 2013) allows counselors to specify how severe the substance use disorder is, depending on how many of the 11 symptoms/criteria are identified.

Two or three symptoms indicate a mild substance use disorder,
Four or five symptoms indicate a moderate substance use disorder, and
Six or more symptoms indicate a severe substance use disorder.

Counselors can also add specifiers:”

“in early remission,”
“in sustained remission,”
“on maintenance therapy,”
“in a controlled environment.”

Definitions of Remission and Controlled Environment

Once a substance use has been determined, what about recovery? The DSM uses the term “remission”. Remission means the person with the disorder meets none of the 11 criteria three months after last meeting any of the criteria. • Therefore recovery or remission does not even begin until three months after last use of the substance. Because relapse is so common, the DSM considers the first three months as a period when an attempt is made at abstaining.

Additional qualifications are:

In early remission: 3 to 12 Months

After full criteria for alcohol use disorder were previously met, none of the criteria for the alcohol use disorder have been met for at least three months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met). This early stage reflects the unstable nature of recovery – relapse is common during the first year.

In sustained remission: After 12 Months

After full criteria for alcohol use disorder were previously met, none of the criteria for the alcohol use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met).

In a controlled environment:

This additional qualification is used if the individual is an environment where access to alcohol is restricted. In other words, in a treatment center, halfway house, sober home, wilderness or similar supervised residential setting. This is why in our model language we state that the time period for recovery begins when the beneficiary leaves a controlled environment. In concluding this section, we now hope the reader has a thorough understanding of how professionals determine that someone with alcohol or drug problems meets the definition of a substance use disorder and how easy it is to misperceive the perniciousness of the disease – both by the user and family/friends.

Substance Use Disorders and ICD-10-CM Coding (APA Practice Organization, 2015)

Follow these steps to help you select the appropriate ICD-10-CM diagnostic code related to substance use disorders.

By Practice Research and Policy staff

While ICD-10-CM overall does not contain considerably more codes related to mental and behavioral disorders than found in ICD-9-CM, the section on substance use disorders is substantially larger and more detailed in ICD-10-CM. Effective Oct. 1, 2015, when ICD-10-CM diagnostic coding becomes mandatory, psychologists who assess or treat individuals with substance use disorders will be expected to indicate their choice of diagnostic codes the substance involved and the degree of the problem.

Substance use codes in ICD-10-CM follow the format F1x.xxx. The letter F indicates that the code is from Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders, of ICD-10-CM and the numeral 1 indicates a mental or behavioral disorder due to psychoactive substance use. The next digit, indicated by the first x, signifies the problematic substance (as shown in the table in Step 1 below). All digits after the decimal point add further specificity by indicating the nature and severity of the problem (see table in Step 2 below). For instance, F10.121 is the code for "Alcohol abuse with intoxication delirium." Importantly, not all specifiers are used with every substance (particularly perceptual disturbance), so users will want to refer to the complete ICD-10-CM code set.

To download the ICD-10-CM, visit the Centers for Disease Control and Prevention website and go to "FY 2016 release of ICD-10-CM" section. Select ICD-10-CM PDF format to access a PDF version of the document. It directs you to an index of compressed zip files. Within that index, select ICD10CM_FY2016_Full_PDF.ZIP. This zip folder contains five files. Open the final file labeled 'Tabular.'

Steps for identifying the correct ICD-10-CM code related to substance use disorders

1. Identify the substance involved.

Mental and Behavioral Disorders due to...	Code
...use of alcohol	F10
...use of opioids	F11
...use of cannabis	F12
...use of sedatives, hypnotics, anxiolytics	F13
...use of cocaine	F14
...use of other stimulants, including caffeine	F15
...use of hallucinogens	F16
...use of nicotine	F17
...use of inhalants	F18
…use of other psychoactive substances and multiple drug use	F19

Identify the correct specifiers and add the appropriate code extension.

Specifiers for Substance Coding	Code
Abuse	.1
Uncomplicated	.10
With intoxication	.12
...uncomplicated		.120
...delirium		.121
...with perceptual disturbance		.122
...unspecified		.129
Dependence	.2 ²
Uncomplicated	.20
In remission	.21
With intoxication	.22
…uncomplicated		.220
…delirium		.221
…with perceptual disturbance		.222
…unspecified		.229
With withdrawal	.23
…uncomplicated		.230
…delirium		.231
…with perceptual disturbance		.232
…unspecified		.239
Use, unspecified	.9
With intoxication	.92
…uncomplicated		.920
…delirium		.921
…with perceptual disturbance		.922
…unspecified		.929
With withdrawal	.93
…uncomplicated		.930
…delirium		.931
…with perceptual disturbance		.932
…unspecified		.939

References

APA Practice Organization (2015). Substance use disorders and ICD-10-CM coding. Retrieved from http://www.apapracticecentral.org/update/2015/09-10/substance-disorders.aspx

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Horvath, A.T., Misra, K., Epner, A.K, & Cooper, G.M. (2016). The diagnostic criteria for substance use disorders (addiction). Retrieved from https://www.mentalhelp.net/articles/the-diagnostic-criteria-for-substance-use-disorders-addiction/