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Thursday, May 31, 2012

Rationale for Changes in DSM-5

Dear Editor:
Thank you for the opportunity to respond to Professor Edwards’s (2012—p. 699 this issue) interesting commentary on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). As usual, he has written a letter that is at once erudite, thoughtful, and informative. I would like to explain that his position on “dependence” is a rare example of two long-time friends in disagreement. I spend a good deal of time teaching medical students and general physicians about addictive disorders. It is not easy to explain why compulsive drug-taking behavior is called “dependence” in DSM-IV (American Psychiatric Association, 1994) and is known in the vernacular as “addiction,” whereas “dependence” in a patient strictly following doctor’s orders is considered “normal” even while the patient is becoming tolerant to beta-blockers for hypertension, antidepressants for a mood disorder, benzodiazepines for anxiety, or opioids for pain. In the course of medical treatment for pain, when
tolerance and withdrawal are observed, the average physician concludes, “dependence equals addiction” and begins
to restrict the analgesic, resulting in needless suffering on the part of the patient.
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