I've read with some interest and amusement the following first-hand account (2006) on the confusion surrounding the DSM-IV meaning of "dependence" :

One of us (C.O.) was a member of the committee who attended every one of the [DSM] committee meetings throughout the 1980s. There was good agreement among committee members as to the definition of addiction, but there was disagreement as to the label that should be used. The proponents of the term “addiction” believed that this word would convey the appropriate meaning of the compulsive drug-taking condition and would distinguish it from “physical” dependence, which is normal and can occur in anyone who takes medications that affect the CNS. Those who favored the term “dependence” felt that this was a more neutral term that could easily apply to all drugs, including alcohol and nicotine. The committee members argued that the word “addiction” was a pejorative term that would add to the stigmatization of people with substance use disorders. A vote was taken at one of the last meetings of the committee, and the word “dependence” won over “addiction” by a single vote.

Experience over the past two decades has demonstrated that this decision was a serious mistake. The term “dependence” has traditionally been used to describe “physical dependence,” which refers to the adaptations that result in withdrawal symptoms when drugs, such as alcohol and heroin, are discontinued. Physical dependence is also observed with certain psychoactive medications, such as antidepressants and beta-blockers. However, the adaptations associated with drug withdrawal are distinct from the adaptations that result in addiction, which refers to the loss of control over the intense urges to take the drug even at the expense of adverse consequences. For example, research has shown that when opiates are administered to a naive animal, adaptation begins to occur after the first dose so that the second dose has a discernibly decreased effect from the first. After several days of taking the medication, abrupt cessation produces a withdrawal syndrome varying with the duration of treatment and the dose level. This is an expected pharmacological response, and although it may occur among addicts, it is quite distinct from compulsive drug-seeking behavior. This has resulted in confusion among clinicians regarding the difference between “dependence” in a DSM sense, which is really “addiction,” and “dependence” as a normal physiological adaptation to repeated dosing of a medication. The result is that clinicians who see evidence of tolerance and withdrawal symptoms assume that this means addiction, and patients requiring additional pain medication are made to suffer. Similarly, pain patients in need of opiate medications may forgo proper treatment because of the fear of dependence, which is self-limiting by equating it with addiction.

The authors are now in the planning stages for DSM-V. There will be careful reviews of the criteria, but in the case of substance use disorders, the medical world drastically needs a change in labeling. Addiction is a perfectly acceptable word. It is used by the American Society of Addiction Medicine, the American Association of Addiction Psychiatrists, the American Journal on Addictions, and the oldest journal in the field, simply known as Addiction. It is clear that any harm that might occur because of the pejorative connotation of the word “addiction” would be completely outweighed by the tremendous harm that is now being done to the patients who have had needed medication withheld because their doctors believe that they are addicted simply because they are dependent.

So what (if anything) has DMS-5 done with respect to the dependence/addiction terminology?


1 Answer 1


To me, the copy of DSM-5 follows the idea put forward by proponents of the term “addiction” in the meetings mentioned in your quote whereby

proponents of the term “addiction” believed that this word would convey the appropriate meaning of the compulsive drug-taking condition and would distinguish it from “physical” dependence, which is normal and can occur in anyone who takes medications that affect the CNS.

In the second page of the preface to DSM-5 (page xlii), the following is stated.

Restructuring of substance use disorders for consistency and clarity. The categories of substance abuse and substance dependence have been eliminated and replaced with an overarching new category of substance use disorders—with the specific substance used defining the specific disorders. "Dependence" has been easily confused with the term "addiction" when, in fact, the tolerance and withdrawal that previously defined dependence are actually very normal responses to prescribed medications that affect the central nervous system and do not necessarily indicate the presence of an addiction. By revising and clarifying these criteria in DSM-5, we hope to alleviate some of the widespread misunderstanding about these issues.

The section on Substance Use Disorders is within the section titled Substance-Related and Addictive Disorders which starts on page 481.

The substance-related disorders encompass 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens (with separate categories for phencyclidine [or similarly acting arylcyclohexylamines] and other hallucinogens); inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants (amphetamine-type substances, cocaine, and other stimulants); tobacco; and other (or unknown) substances. These 10 classes are not fully distinct. All drugs that are taken in excess have in common direct activation of the brain reward system, which is involved in the reinforcement of behaviors and the production of memories. They produce such an intense activation of the reward system that normal activities may be neglected. Instead of achieving reward system activation through adaptive behaviors, drugs of abuse directly activate the reward pathways. The pharmacological mechanisms by which each class of drugs produces reward are different, but the drugs typically activate the system and produce feelings of pleasure, often referred to as a "high." Furthermore, individuals with lower levels of self-control, which may reflect impairments of brain inhibitory mechanisms, may be particularly predisposed to develop substance use disorders, suggesting that the roots of substance use disorders for some persons can be seen in behaviors long before the onset of actual substance use itself.


The substance-related disorders are divided into two groups: substance use disorders and substance-induced disorders. The following conditions may be classified as substance-induced: intoxication, withdrawal, and other substance/medication-induced mental disorders (psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders).


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