The diagnostic process in most developed countries follows a predictable sequence. First, the clinician performs an evaluation. The evaluation identifies symptoms. Then, the clinician uses this information to make a diagnosis (or several diagnoses). We might say a diagnosis is a label that summarizes a set of symptoms. In some cases, a diagnosis may also point to the cause of that set symptoms. Once the clinician makes a diagnosis, a treatment plan is then developed. The purpose of the treatment plan is to eliminate or diminish troubling symptoms. Some clinical models rest on the assumption that the reduction of symptoms leads to improved health and well-being. However, other models do not assume that symptom reduction leads to improvement. Instead, the focus is on improving the quality of life. From this perspective, improving the quality of life results in symptom reduction. This type of model is called psychiatric rehabilitation.
Diagnostic labels also serve another useful purpose. Healthcare providers use these labels to bill insurance companies or other funding sources. In the United States, there are two primary funding streams for addiction treatment: 1) public healthcare services (funded by the United States government) and 2) private health insurance (usually funded by employers). Many people seeking addiction treatment do not have private health insurance. This is because private health insurance is usually provided through employers. In advanced stages of addiction, it is usually difficult to maintain full-time employment. Furthermore, health insurance companies share information with each other. As such, many people with addictions are reluctant to use private insurance. It creates a lasting record of the addiction.
The person seeking treatment must meet the diagnostic criteria to be eligible for reimbursement. This intuitively makes sense. No one should receive "treatment" if there is nothing wrong that requires treatment. The most common diagnostic method for addiction follows the American Psychiatric Association (APA) guidelines. The APA publishes these guidelines in the Diagnostic and Statistical Manual of Mental Disorders, commonly called DSM-5 (APA, 2013).
When a credentialed and/or licensed treatment provider determines a person meets the diagnostic criteria they assign a diagnosis. Then, treatment services can begin. In the United States, private healthcare insurance pays for treatment services for people with insurance. For people without insurance, each state delivers treatment services. Usually these services are provided by the public mental health service delivery system in each state. Although each state's services vary, the federal government pays for these services to some degree. You can find and locate federally-funded treatment services here.
The DSM-5 provides a description of symptoms. Together, these symptoms form the basis for a diagnosis. The specific causes of addiction and treatment methods are not included. However, DSM-5 briefly mentions the biological causes of addiction such as the brain's reward system, and mentions the relationship between cravings and classical conditioning.
Diagnostic categories describe symptoms; not people with those symptoms. For this reason, we strive to avoid the use of the term "addict." This term labels and defines someone according to a diagnosis. A person is not an addict. A person is someone with an addiction. In fact, the DSM-5 avoided the use of the term "addiction" altogether. The authors of DSM-5 thought the word "addiction" could have a potentially negative connotation. Therefore, they chose to use the term Substance Use Disorder instead. The authors believed this to be a more neutral term. We have chosen to use the word addiction because it is a widely recognized term. We have previously provided our definition of this term.
Although the DSM-5 (APA, 2013) is the most frequently used method for diagnosing addictive disorders, there is no law that requires its use. There are other (but less well-known) approaches to diagnosis and treatment. Despite this fact, the DSM remains the unofficial standard for diagnosing addictions. Consequently, DSM- 5categories form the organizational structure for addiction research. Thus, although there are many valid disagreements about the DSM, its role within the health care system is without competition (Bentall, 2006).
A diagnostic assessment begins by collecting information from many different sources. This may include clinical interviews, questionnaires, laboratory findings, and medical records. Ideally, it also includes input from friends, family members, and romantic partners. Factors considered in the assessment include: the number and type of substances being used; the routes of administration (e.g. inhalation, injection); the frequency of use; the psychological and physical symptoms; family history; any co-occurring mental or physical disorders; prior treatment attempts; and life circumstances (including child care responsibilities, pregnancy, work schedules, social environment, traumas, etc.). Clinicians gather this information to make a proper diagnosis. This information also helps to develop a treatment plan.
Ideally, clinicians conduct a complete bio-psycho-social-spiritual assessment. A thorough assessment of this type is more helpful than a simple diagnostic code. Furthermore, a bio-psycho-social-spiritual assessment is the foundation for an individualized treatment plan.
Most addictions fall into the DSM-5 category called Substance-Related and Addictive Disorders (APA, 2013). Other addictions that do not have specific DSM-5 diagnostic criteria are discussed in the section on activity addictions.
Within the Substance-Related and Addictive Disorders category are two sub-types: 1) substance use disorders, and 2) substance-induced disorders. With respect to addiction, the most common category is the substance use disorders. We discuss the basic diagnostic criteria for substance use disorders and substance-induced disorders in the following sections.
If you find yourself wondering if you might have addiction, the following list might be a good starting point for you. The list will help you to evaluate the harmful costs of the activity or substance use that concerns you. In addition to your own evaluation, try to imagine how others might rate your behavior on this list. You do not need to develop a precisely correct list of the costs of your addiction. However, it is important to recognize whether these costs are beginning to cause substantial harm. If so, then perhaps it is time to do something about the behavior that concerns you. In another chapter we will talk about various approaches to self-help and treatment for addiction.
Emotional costs of addiction: living with daily feelings of fear, anger, sadness, shame, guilt, paranoia, loss of pleasure, boredom, emotional instability, self-loathing (disgust with oneself), loneliness, isolation, and feelings worthlessness. The frequency and magnitude of these negative feelings could contribute to the development of an additional mental health disorder. Addictions regularly co-occur with other psychiatric disorders).
Social costs of addiction: disruption or damage to important relationships; decreased ability or interest in forming meaningful connections with others; and limiting one's social sphere to other unhealthy, addicted persons.
Physical and health costs of addiction: poor general health; poor personal hygiene; lowered energy and endurance; diminished enjoyment of sex or sexual dysfunction; poor sleep; and damaging the health of an unborn child (with certain types of substance use).
Intellectual costs of addiction: loss of creative pursuits; decreased ability to solve problems; and poor memory.
Work and productivity costs of addiction: decreased productivity in all aspects of life; missing important deadlines and failing to meet obligations; impaired ability to safely operate tools and equipment (including driving); and lost time due to accidents arising from being impaired (e.g., falling and breaking a leg).
Financial costs of addiction: money spent on the addiction itself; money spent dealing with the consequences of addiction (healthcare costs, legal costs, etc.).
Legal costs of addiction: direct legal costs due to involvement with an illegal drug or activity (e.g. selling drugs, child pornography); indirect legal costs because of what someone did while engaging in their addiction (DUI, bar fights, domestic violence, divorce); or did not do (failing to care for children properly).
Lost time due to addiction: sacrificing time spent in meaningful, life enriching activities in order to engage in addictive behaviors. Meaningful, life-enriching activities are of two basic types: 1) Love: time spent in relationships with others, and 2) Work: time spent being productive including employment, learning, working on personal projects, volunteering, and helping others. Time is a limited resource. When time is increasingly spent pursuing an addiction, it limits the amount of time available to devote to these two basic human activities.
Diminished personal integrity due to addiction: Most people have a strong sense of morality. This includes a sense of what is right and wrong; what one ought to do (and not do); how others should be treated; and a sense of responsibility toward one's family, community, employer, and to society as a whole. However a tiny percentage of people (roughly 1%) seem to be missing this sense of morality. Such people are often termed sociopathic, psychopathic, or antisocially disordered. Although the terms are not identical, they are similar enough for our purposes. This sociopathic 1% of the population will commonly develop addictions. Unfortunately, if someone in the other 99% of the population develops an addiction they will begin to behave in a manner similar to sociopaths as their addiction progresses. In other words, they begin to lose their morality and integrity.
As addicted people gradually lose their moral compass, they begin to disrespect the rights and needs other people. They even mistreat the people that matter to them most. This begins by failing to meet certain responsibilities, commitments, or obligations. Examples of these failures might be: failing to show up for things; becoming dishonest by failing to disclose information; or making excuses rather than making a sincere apology. This type of disregard will evolve into more obvious forms of disrespect and mistreatment as addiction progresses. This progression might include flat-out lying and deception; stealing from loved ones; and threatening these same people if their demands are not met. Unlike their sociopathic counterparts who lack a moral compass to begin with, people who once had a moral compass experience tremendous feelings of guilt and self-loathing as they break their own moral code. Addiction can only relieve these feelings temporarily.
A life that is absent of meaning and purpose due to addiction: This cost is perhaps the ultimate one. For some, this loss takes the form of experiencing a separation and estrangement from God. It might be a feeling that one has disappointed God by not fulfilling God's higher purpose. For others, it means losing the meaning and purpose of life. This meaning and purpose is ordinarily derived from our loving involvement with other people and a sense of purpose that occurs from our productive activities (work, learning, achievement, contribution to others, etc.) In either case, addicted persons have traded away these essential ingredients to life satisfaction for the sake of pursuing momentary pleasures. This is followed by the frantic effort for even more momentary pleasures.
The harmful costs of addiction to society
So far we've reviewed the substantial, harmful costs of addiction to individuals. Another way to consider these costs is to consider the cost of addiction to an entire society. The financial cost of addiction to the citizens of the United States is staggering. We can do no better than to quote the National Institute on Drug Abuse (NIDA), from their website: http://www.drugabuse.gov/infofacts/understand.html
"Drug abuse and addiction have negative consequences for individuals and for society. Estimates of the total overall costs of substance abuse in the United States, including productivity and health- and crime-related costs, exceed $600 billion annually (emphasis added). This includes approximately $181 billion for illicit drugs, $193 billion for tobacco, and $235 billion for alcohol. As staggering as these numbers are, they do not fully describe the breadth of destructive public health and safety implications of drug abuse and addiction, such as family disintegration, loss of employment, failure in school, domestic violence, and child abuse."
