DSM criteria for substance use disorders
Substance use disorder (SUD) is characterized by the harmful use of substances leading to significant impairment in various aspects of life, including control, social relationships, and risky behaviors. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides specific criteria for diagnosing SUD, which integrates previously separate categories of substance dependence and substance abuse into a single diagnosis. This diagnosis is assessed on a spectrum of severity, ranging from mild to severe, based on the number of criteria met.
To qualify for a diagnosis, individuals must exhibit at least two of eleven criteria across four categories: impaired control, social impairment, risky use, and pharmacological dependence. Examples of these criteria include increased use beyond intended amounts, neglect of responsibilities, and development of tolerance or withdrawal symptoms.
Notably, cultural considerations have influenced the evolution of these criteria, with some elements, such as legal issues, being removed to accommodate diverse contexts. The prevalence of SUD is significant, with millions of individuals in the U.S. estimated to meet the criteria, highlighting the importance of awareness and treatment options. As research continues, the DSM-5 also opens the door to understanding behavioral addictions, reflecting the complexity and multifaceted nature of addiction in contemporary society.
DSM criteria for substance use disorders
DEFINITION: Substance use disorder describes the use or abuse of a substance that leads to impaired control, social impairment, risky behaviors, and/or pharmacological dependence.
Substance Use Disorders
The fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013, outlines the criteria for substance use disorders in the chapter "Substance-Related and Addictive Disorders." The US Substance Abuse and Mental Health Services Administration used DSM-5’s criteria for its 2022 National Survey on Drug Use and Health. The diagnosis of substance use disorders in the DSM-5 encompasses two previously distinct categories, substance dependence and substance abuse. As an update from previous editions of the DSM, the DSM-5 considers substance use disorder as a single diagnosis that is measured on a scale from mild to severe. Changes to the DSM criteria may affect rates of diagnoses and severity assessments. A revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) was published in 2022, however, it did not change the criteria for substance use disorders.
The previous distinction between substance abuse and substance dependence was based on the idea that individuals with substance-related disorders typically progressed from misusing or overusing a particular substance to developing a physical addiction to that substance. However, it is possible for someone to become dependent on a substance without having abused that substance. For example, a person can become physiologically dependent on a prescribed pain medication without ever having used that substance in a manner other than prescribed. Once physiological dependence is established, the person also may become psychologically dependent and may then begin to engage in the adverse behaviors indicative of abuse. In this scenario, the dependence actually preceded what would typically be considered abusive behavior. Furthermore, the concept of abuse as an earlier or milder stage of substance use disorder did not reflect patients' experiences, as the abuse criteria often encompassed severe risk-taking and other harmful behaviors.
Different substances are categorized under separate use disorders (such as stimulant use disorder and alcohol use disorder), but the overarching criteria for substance use disorders apply to nearly all of the separate use disorders, with some exceptions. For example, cannabis use disorder is rarely associated with clinically significant withdrawal symptoms, and amphetamine use disorder is sometimes associated with reverse tolerance, or sensitization. Substances use disorders include alcohol use disorder, tobacco use disorder, cannabis use disorder, stimulant use disorder, hallucinogen use disorder, and opioid use disorder, among others. Many prescription drugs and over-the-counter medications also can be the source of a substance use disorder.
Diagnostic Criteria
According to the DSM-5-TR, in order to be diagnosed with substance use disorder an individual must meet at least two of eleven separate diagnostic criteria. The number of diagnostic criteria determines the level of severity: meeting two to three criteria indicates a mild substance use disorder, meeting four to five criteria indicates a moderate substance use disorder, and meeting six or more criteria indicates a severe substance use disorder.
The eleven criteria fall into four categories: impaired control, social impairment, risky use, and pharmacological dependence. The criteria within the category of impaired control include taking more of the substance and for a longer period of time than intended; unsuccessful attempts to reduce or stop use; spending a lot of time obtaining, using, or recovering from use; and craving the substance. The criteria within the category of social impairment include failure to fulfill obligations due to use; continued use despite problems that are caused or worsened by use; and important activities that are reduced or given up because of the use. Criteria based on evidence of risky use include repeated use in hazardous situations and continued use despite physical or psychological problems that are caused or exacerbated by substance use. Pharmacological dependence is indicated by tolerance to the effects of the substance and symptoms of withdrawal when using less.
Previous editions of the DSM included a diagnostic criterion for problems with law enforcement, which has been eliminated in the DSM-5 due to cultural and geographical considerations that made the criterion difficult to apply internationally. The criterion regarding cravings has been added to the diagnostic criteria in the DSM-5.
Prevalence Estimates
True prevalence statistics for substance use disorders are difficult to obtain. Many persons who meet diagnostic criteria for a substance use disorder remain unknown because they do not seek treatment or underreport their substance use and substance-related problems out of shame and social stigma. Many also suffer from comorbid psychiatric illnesses; for example, people who have a substance use disorder are about twice as likely to suffer from mood disorders than the general population.
The Substance Abuse and Mental Health Services Administration (SAMHSA) reported on data collected for the 2022 National Survey on Drug Use and Health (NSDUH). The NSDUH is an annual survey of civilians in the United States aged twelve years and older; it includes national estimates of substance use and substance use disorder.
Based on its findings, SAMHSA reported an estimated 70.8 million people in the United States used illicit drugs in the past year. An estimated 48.7 million met the DSM criteria for substance use disorder, including 8 million people who were classified with a substance use disorder for both alcohol and illicit drugs, 27.2 million who had a substance use disorder for illicit drugs only, and 29.5 million who had alcohol use disorder only.
The most common illicit substance used was marijuana (61.9 million people). About 8.9 million people misused opioids such as heroin (1 million) and prescription pain relievers (8.5 million). About 587,000 people used both.
Future Considerations
The DSM chapter "Substance-Related and Addictive Disorders" contains one condition, gambling disorder, in a newly introduced category of behavioral addictions. The decision to rename pathological gambling and reclassify it as a behavioral addiction is based on research that supports its similarities to substance use disorders in clinical expression, brain origin, and treatment options. A second potential behavioral addiction, Internet gaming disorder, has been classified in Section III of the DSM-5, which is reserved for disorders that require further research before they can be considered as formal diagnoses. The DSM-5 also does not consider caffeine use disorder to be a psychiatric disorder, although caffeine use can cause addition and withdrawal symptoms that characterize substance use disorders.
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