1/8/15 Comparing Alcohol Use in the DSM-IV-TR,
DSM-5, and ICD-10
Presented by Norman G. Hoffmann, PhD
Misti Storie, MS, NCC
Director of Training & Professional Development
NAADAC, the Association for Addiction Professionals
www.naadac.org
misti@naadac.org
January 8, 2015
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§  Asking Questions
§  Polling Questions
§  Follow-up Emails
Webinar Presenter
Webinar Learning Objectives
1
2
3
4
Describe the similarities
and differences
between the DSM-IV
and DSM-5 diagnostic
criteria for alcohol use
Identify the five DSM-5
criteria found primarily
among those with a
severe diagnosis of
alcohol dependence
Describe the similarities
and differences
between the DSM-5
and ICD-10 diagnostic
criteria for alcohol
dependence
Explain when and why
one might use the
ICD-10 diagnosis of
unspecified substance
disorder
Norman Hoffmann, PhD
Phone: 828-454-9960
Email: evinceassessment@aol.com
Overview
Overview
•  We will be focusing on the comparisons among diagnostic formulations from
the DSM-IV and DSM-5 to the ICD-10 criteria
•  The change from the DSM-IV to the DSM-5 marks a shift from a categorical to
a dimensional diagnostic perspective
•  However, we will also be covering issues related to how individual groups of
criteria may be more important than the formal diagnosis
•  The mandate to use ICD-10 diagnostic codes in 2015 requires matching the
dimensional DSM-5 diagnoses back to a categorical formulation
•  This out of the box perspective can be integrated with the concept of an
outcomes-based approach to individualized treatment that, in theory, is
superior to the common requirement for using evidence-based treatment
models
•  Empirical evidence suggests that irrespective of the diagnostic formulation
used, some criteria indicate a more severe and chronic condition
2 1/8/15 Historical Background
Historical Background
•  DSM-II (1968-1980)
•  DSM-III-R (1987-1994)
•  Diagnoses: Episodic excessive drinking; habitual excessive
drinking; and alcohol addiction
•  Addiction defined as the inability to go one day without drinking
and experiencing withdrawal
•  DSM-III (1980-1987)
•  Diagnoses: Abuse and dependence
•  Dependence defined as having tolerance and/or withdrawal plus
pathological use and/or impairment in social or occupational
functioning
Empirical Perspective
•  To my knowledge, there is no rigorous evidence to support any of the previous
diagnostic formulations
•  To a large extent, this is also true for the DSM-5
•  Diagnoses: Abuse and Dependence
•  Dependence defined as having three or more positive criteria out
of nine criteria
•  DSM-IV (1994-2000)
•  Diagnoses: Abuse and dependence
•  Dependence defined as having three or more positive criteria out
of seven criteria
•  DSM-IV-TR (2000-2013)
•  Essentially identical to the DSM-IV
DSM-5 Substance Use Disorder Criteria
1.  Use in larger amounts or longer than intended
2.  Desire or unsuccessful effort to cut down
3.  Great deal of time using or recovering
4.  Craving or strong urge to use
•  Since the DSM-III-R tolerance and withdrawal have moved from required
criteria for dependence to being two among 11 with the advent of the DSM-5
5.  Role obligation failure
6.  Continued use despite social/interpersonal problems
•  The DSM-5 removes the artificial categorizing of some criteria as being for
abuse and others for dependence by eliminating both terms and replacing
them with a dimensional concept of severity based on the number of positive
criteria
7.  Sacrificing activities to use or because of use
8.  Use in situations where it is hazardous
DSM-5 SUD Criteria continued
DSM-5 Initial VS. DSM-5 Final
9.  Continued use despite knowledge of having a physical or psychological
problem caused or exacerbated by use
•  Initially the proposed DSM-5 had two diagnostic categories: moderate and
severe defined by 2-3 and 4+ positive criteria – conforms best to abuse vs.
dependence classification
10.  Tolerance
11.  Withdrawal
•  Final formulation has three diagnostic categories: mild (2-3), moderate (4-5),
and severe 6+ positive criteria)
Criteria 1-4 relate to use
•  Original “moderate” becomes “mild” – no empirical foundation for either
distinction
Criteria 5-8 relate to behavioral issues associated with use
Criteria 9-11 relate to physical/emotional issues
3 1/8/15 Unresolved Issues
•  Are the divisions among the DSM-5 mild, moderate, and severe diagnoses
optimal?
•  What are the clinical implications for the matches and mismatches with the
DSM-5 and ICD-10 diagnoses?
•  What are the financial implications if the DSM-5 proposed matches or the
actual ICD-10 criteria are used for reimbursement?
•  The ICD-10 has two forms; will that make a difference for reimbursement?
Audience Polling Question #1
Do you feel that the dimensional diagnoses of the DSM-5 are more
appropriate than the categories of the DSM-IV-TR?
Sustained Remission
Remission vs. Recovery
•  No positive diagnostic findings (other than craving) for 12 consecutive months
•  Remission is clearly defined by the DSM-5: no problems irrespective of
continued use
•  Substance use is NOT part of the remission definition
•  Recovery has many definitions
•  This remission definition is appropriate for both misuse and chronic addiction
•  The concept of recovery tends to involve much more than remission
•  Possible levels of outcome: 1) abstinence without problems; 2) some use
without problems; 3) use with sub-diagnostic problems; 4) meets current
diagnosis
•  Treatment is typically not reimbursed for some aspects of recovery – e.g.,
serenity, interpersonal relationships, employable, etc.
•  Payment for treatment has the primarily expectation for remission not recovery
DSM-5 Criteria Differentials
•  All criteria are not equal in implications
•  Some criteria are found predominately among those with the severe alcohol or
other substance use disorder diagnoses
Distribution of Positive Alcohol Criteria for 6,871 Males
DSM-IV Criteria Based
on SUDDS-IV Results
1. Unplanned use
DSM-5 Designations
No Dx
Mild
Mod.
Sev.
Pop.
Prev.
2%
8%
11%
79%
27%
<1%
4%
7%
88%
21%
3. Time spent using
2%
6%
11%
81%
28%
4. Craving/compulsion
1%
3%
7%
89%
21%
<1%
3%
9%
88%
25%
3%
13%
14%
70%
34%
•  Other criteria are more common among the mild to moderate alcohol use
disorder group
2. Unable to cut down
•  Tolerance and dangerous use are actually common among those with no
diagnosis
5. Role failure
6. Social Conflicts
4 1/8/15 Distribution of Positive Alcohol Criteria for 6,871 Males
DSM-IV Criteria Based
on SUDDS-IV Results
7. Sacrifice activities
8. Dangerous use
9. Contraindications
10. Tolerance
11. Withdrawal
Self-medication
DSM-5 Designations
Pop.
Prev.
No Dx
Mild
Mod.
Sev.
<1%
2%
9%
89%
8%
15%
3%
15%
10%
12%
11%
11%
<1%
76%
11%
3%
5%
62%
66%
7%
9%
90%
11%
75%
7. Sacrifice activities
DSM-5 Designations
No Dx
Mild
Mod.
DSM-IV Criteria Based on
SUDDS-IV Results
DSM-5 Designations
No Dx
Mild
8%
9%
80%
31%
36%
0%
2%
6%
92%
24%
30%
3. Time spent using
0%
1%
7%
92%
26%
33%
4. Craving/compulsion
<1%
<1%
3%
96%
23%
19%
5. Role failure
<1%
5%
5%
90%
26%
27%
6. Social Conflicts
3%
10%
10%
77%
33%
Sev.
Pop.
Prev.
DSM-5 SUD Criteria Primarily In Severe
Designation
The “Big Five”
4%
93%
25%
•  Criteria 2: Wanting to cut down/setting rules
8. Dangerous use
6%
8%
9%
77%
29%
•  Criteria 4: Craving and/or compulsion to use
9. Contraindications
3%
9%
10%
78%
32%
•  Criteria 5: Failure at role fulfillment due to use
10%
5%
10%
75%
32%
•  Criteria 7: Sacrifice activities to use
11. Withdrawal
0%
2%
3%
95%
20%
Self-medication
%
%
%
%
%
Sample of Alcohol Diagnostic Documentation
2
3
4
X
X
X
Case 1
Severe
X
Case 2
Mild
X
X
Moderate
Moderate
X
X
Case 3
Case 4
X
X
5
6
7
8
X
X
3. Great deal of time using
10. Tolerance
9
10 11
X
X
X
X
X
X
•  Criteria 11: Withdrawal symptoms
CASE 3: Positive DSM-5 Criteria
Diagnostic Criteria
1
Pop.
Prev.
3%
3%
Alcohol Diagnosis
Sev.
2. Unable to cut down
<1%
10. Tolerance
Mod.
1. Unplanned use
23%
Distribution of Positive Alcohol Criteria for Females
DSM-IV Criteria Based
on SUDDS-IV Results
Distribution of Positive Alcohol Criteria for 801 Females
X
X
*Cases 3 & 4 with the same diagnosis may have different prognoses if the
Big Five are related to outcomes
X
1. Unplanned use: more or longer use
8. Use in hazardous situation (impaired driving)
6. Recurrent interpersonal conflicts
Conclusions
•
No loss of control indicated
•
Misuse and possible irresponsible behavior
•
Moderation may be a reasonable initial goal
5 1/8/15 CASE 4: Positive DSM-5 Criteria
1. Unplanned use: more or longer use
2. Desire/efforts to cut down
Implications for Disposition
•  Education and brief counseling may be appropriate for majority of mild use
disorders
4. Craving/compulsion to use
5. Role obligation failures
7. Sacrificing activities to use
Conclusions
•  Abstinence will virtually always be required to achieve remission for those with
a severe diagnosis
•  For those with a moderate diagnosis, the pattern may be as important as the
number of positive criteria
•  Loss of control clearly indicated
•  Positive on 4 of the “Big Five”
•  Abstinence indicated goal for recovery
•  Those positive on any of the Big Five criteria should be carefully evaluated
regarding the current and projected trajectory of their condition
Final Criticism of the DSM-IV
CLINICAL (Medical) NECESSITY
•  Loss of control not required for a dependence diagnosis –
e.g., tolerance, spending time using, and occasionally
drinking more/longer than intended – got the chronic
diagnosis
•  Some abuse criteria are stronger indications of a serious
condition than some dependence criteria
•
Role obligation failure is a Big Five criterion
•
Tolerance is often seen in mild cases or even among those with
no diagnosis
•  Persons in the severe designation with positive “Big Five” findings will require
a more intensive and longer continuum of care to achieved treatment
effectiveness
•  Persons in the mild designation typically will benefit from shorter & less
intensive interventions to achieve efficiency
•  Each treatment plan can be informed by prior empirical outcome data on
comparable cases and modified based on the individual’s treatment response
Sample Hypotheses for Clinical Practice
•  Hypothesis #1: Clients positive on three or more of the “big five” will require
initial residential placement and/or more intensive and longer continuum of
care to achieve good results
•  Hypothesis #2: Clients in mild or moderate designations without any positive
findings on the “big five” may be able to moderate or stop use with less
intensive and briefer services
Audience Polling Question #2
Do you plan to use the Big Five in your clinical practice?
6 1/8/15 DSM-IV vs DSM-5 Alcohol Diagnoses
Males N = 6,871
ICD-10 Clinical Diagnostic Criteria
Females N = 801
•  Harmful use: actual physical, mental, cognitive harm (does not count C6 or C8)
100%
100%
80%
80%
60%
60%
(f) Continued despite actual harms – C9
e
(e) Neglect of interests/time spent using – C3, C5, C7
No Dx
en
de
nc
x
e
(d) Tolerance – C10
Mild
ep
D
e
(c) Withdrawal – C11
Mod.
D
ep
en
de
x
D
us
o
Ab
N
nc
e
No Dx
us
0%
0%
Severe
D
Mild
20%
o
20%
(b) Difficulty controlling use – C1 & C2
40%
N
Mod.
(a) Desire/compulsion to use – C4
Ab
Severe
40%
•  Dependence: any three of the following:
ICD-10 Research Diagnostic Criteria
ICD-10 and the Big Five
•  Harmful use:
•  actual physical, mental, cognitive harm
•  impaired judgment – C8
•  dysfunctional behaviors – C6
•  The criteria for dependence in the ICD-10 encompass the concepts of the Big
Five
•  Dependence: same as with the clinical version
•  The expectation would be that the ICD-10 diagnosis of dependence would
likely be equivalent to the severe designation of the DSM-5 or moderate with
Big Five positives
•  The research version is newer
•  All DSM-5 criteria are accounted for with the research criteria – but the
combinations might not correspond to the DSM-5 matches – e,g. 2
dependence criteria no ICD-10 Dx
•  Tolerance & harm from use are the exceptions
•  The problem arises with the fact that there are two versions of the ICD-10
where harmful use is defined differently
More Thoughts on ICD-10
Compatibility from Two Views
•  The ICD-10 has a code F1x.9 Unspecified Mental and Behavioral Disorder in
the substance use disorder section (p. 76 of the WHO bluebook for ICD-10
criteria) for “misuse”
Option 1:
•  This diagnosis could be used for problems related to substances that are not
included in clinical version of the ICD-10 – interpersonal conflicts, use in
dangerous circumstances, arrests, etc.
•  2 or more such problems for “misuse” coded F1x.9 (x = substance code) could
be compatible with mild DSM-5 diagnosis
Use any positive finding on the DSM-5 criteria to match on the basis of where
each criterion loads on the ICD-10
•  Likely to over diagnosis as some components of the DSM-5 category are not
part of ICD-10
•  Example: Job problems (DSM Criterion 5) or interpersonal conflicts (DSM
Criterion 6) due to use do not neglect of interests for the dependence criteria
nor necessarily a “dysfunctional behavior” for harmful use
•  Global match based on DSM-5 criteria most likely to produce a good fit.
7 1/8/15 DSM-5 VS. ICD-10 Clinical Alcohol Diagnoses for
6,871 Males
Compatibility from Two Views
Option 2:
Use items that definitely load on the respective ICD-10 criteria as
an independent determination of the ICD-10 diagnosis
100%
80%
•  Likely to be more conservative and compatible with the intent and
spirit of the ICD-10
60%
•  Allows for more detailed comparison of where the DSM-5 and
ICD-10 are compatible and where not
40%
•  Less likely to produce a good fit.
20%
ICD-10
Dependence
Harmful use
Misuse
No Dx
0%
No Dx
Mild
Moderate
Severe
DSM-IV-5 Diagnoses
DSM-5 VS. ICD-10 Research Alcohol Diagnoses for
6,871 Males
100%
DSM-5 VS. ICD-10 Research Dx Based on DSM-5
Criteria for 6,871 Males
100%
80%
60%
ICD-10
Diagnosis
80%
ICD-10
Diagnosis
Dependence
60%
Dependence
Harmful use
40%
No Dx
20%
Harmful use
40%
No Dx
20%
0%
0%
No Dx
Mild
Moderate
Severe
No Dx
DSM-IV-5 Diagnoses
Mild
Moderate
Severe
DSM-IV-5 Diagnoses
DSM-5 VS. ICD-10 Clinical Alcohol Diagnoses 801
Females
DSM-5 VS. ICD-10 Research Alcohol Diagnoses 801
Females
100%
100%
80%
ICD-10
Dependence
60%
Harmful use
40%
Misuse
No Dx
20%
80%
ICD-10
Diagnosis
60%
Dependence
40%
Harmful use
No Dx
20%
0%
0%
No Dx
Mild
Moderate
DSM-IV-5 Diagnoses
Severe
No Dx
Mild
Moderate
Severe
DSM-IV-5 Diagnoses
8 1/8/15 DSM-5 VS. ICD-10 Research Dx Based on DSM-5
Criteria for 801 Females
DSM-5 vs ICD-10 Diagnostic Prevalence
100%
•  Those who do not get a DSM-5 diagnosis will not get an ICD-10 diagnosis
80%
ICD-10
Diagnosis
60%
Dependence
Harmful use
40%
No Dx
20%
•  Regardless of ICD-10 clinical or research version, fewer will get an ICD-10
diagnosis
•  Virtually all with a severe DSM-5 diagnosis meet dependence for ICD-10
•  60% to 100% of those with a moderate DSM-5 diagnosis meet dependence
criteria depending on the method of comparison
0%
No Dx
Mild
Moderate
Severe
DSM-IV-5 Diagnoses
DSM-IV VS. ICD-10 Clinical Alcohol Diagnoses for
6,871 Males
DSM-IV VS. ICD-10 Research Alcohol Diagnoses
6,871 Males
100%
100%
80%
ICD-10
Dependence
60%
Harmful use
40%
Misuse
No Dx
20%
80%
ICD-10
Diagnosis
60%
Dependence
Harmful use
40%
No Dx
20%
0%
0%
No Dx
Abuse
Dependence
DSM-IV-5 Diagnoses
No Dx
Abuse
Dependence
DSM-IV-5 Diagnoses
DSM-IV and the ICD-10
•  Almost all with no DSM-IV diagnosis will not get an ICD-10 diagnosis
•  Almost all with a DSM-IV diagnosis of dependence will get and ICD-10
diagnosis of dependence
•  Those with a DSM-IV diagnosis of abuse will divide up similarly to those with a
mild DSM-5 diagnosis
Audience Polling Question #3
•  As with the DSM-5 fewer people will get a diagnosis with the ICD-10
Are you or your program prepared to use the ICD-10 coding for billing?
9 1/8/15 Diagnostic Formulation Comparison
Advantages of the DSM-5
•  Almost all who do not get a diagnosis with the DSM-IV will not get one with
either the DSM-5 or ICD-10 criteria
•  Provides a more detailed documentation of diagnostic constructs/criteria
•  Almost all who get a dependence diagnosis with the DSM-IV will get a severe
diagnosis with the DSM-5 or dependence with ICD-10
•  Allows for consistent documentation for distinguishing between potentially
chronic vs. transient conditions
•  Avoids artificial division of criteria as is the case with the DSM-IV and ICD-10
•  The abuse diagnosis of the DSM-IV tend to be scattered among the mild to
moderate diagnoses of the DSM-5 and harmful use or unspecified diagnoses
of the ICD-10 or will not get a diagnosis with either
•  The issue of whether the distinctions among mild, moderate, and severe are
appropriate can be determined by systematic documentation
Clinical Implications
Assessment Implications
•  The “Big Five” seem to be important for identifying empirical severity and
prognosis
•  Days of use is NOT a severity indication – the number of positive diagnostic
criteria is the basic DSM-5 severity measure
•  These five criteria may be critical in differentiating those with a chronic
condition from those where it is more transient
•  Individualized treatment planning requires more than just a diagnosis – need
to know which diagnostic criteria are positive
•  Consistent documentation of assessment findings and treatment response and
outcomes can refine routine clinical practice
•  Days of use is irrelevant to documenting remission
•  Such documentation does not require a research protocol
•  Matching assessment with treatment response and initial outcomes can refine
the effectiveness and efficiency of treatment
Thinking Outside the Box
The Demographic Risk Scale
•  Diagnoses are only part of the formula for treatment planning for individualized
treatment
•  Four demographic characteristics have been found to predict risk for relapse
•  The pattern of positive findings for individual diagnostic criteria may be as
important in some cases as the diagnosis itself
•  Many other clinical, demographic, and societal issues may often be
overlooked in treatment planning
•  Linking intake and ongoing assessment with treatment response and
outcomes during a treatment continuum of 90 days can inform treatment
innovation and outcome improvement
•  Among those referred to treatment as a diversion by courts, the demographics
also predict risk for criminal recidivism
•  The Demographic Risk Scale is formed by adding one point for each of the
following?
•  Being under the age of 25
•  Never married
•  Not a high school graduate or having a GED
•  Unemployed
10 1/8/15 Outcomes-based Treatment
Summary
•  Implementing so-called evidence-based treatment modes does not guarantee
good treatment outcomes
•  None of the diagnostic formulations match perfectly with another
•  Initial outcomes during treatment and during the period of maintenance/
aftercare can inform programs about level of effectiveness
•  The best agreement is with those who have no diagnosis or a severe/chronic
diagnosis
•  The greatest discrepancies are with the milder condition(s)
•  Linking such outcomes with assessment information and other data typically
collected at intake and/or reviewed prior to transfer/discharge forms a strategy
for continuous quality improvement
•  A few criteria appear related to greater chronicity and more guarded prognosis
– documenting the need for greater detail in diagnostic documentation
•  Findings can focus attention on where improvements might be made or where
the program has strengths
•  Monitoring of treatment response and initial outcomes can refine prognosis
and inform treatment plans
THANK YOU
www.naadac.org/DSMandICD10
Norman Hoffmann, PhD
Phone: 828-454-9960
Email: evinceassessment@aol.com
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