DSM-5 criteria for substance use disorder (SUD)

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the updated version of the fourth edition of DSM. It is a professional reference book on mental health disorders and brain-related conditions written, edited, reviewed, and published by the American Psychiatric Association. The DSM-5 was published in May 2013.

The DSM-5 defines substance use disorder (SUD) as a disorder related to the use of a drug of abuse, including alcohol. SUD is included in the broader class named “substance-related and addictive disorders.” It includes separate disorders associated with taking different substances of abuse, such as alcohol use disorder and opioid use disorder.

The DSM-5 criteria for diagnosing addiction include excessive consumption and an inability to reduce or stop consuming the substance. Other criteria include experiencing cravings; spending increasing amounts of time seeking, consuming, and recovering from the effects of the substance; using it in hazardous physical circumstances; and continuing usage despite being aware of its negative health outcomes or that it is causing relationship problems. The DSM-5 also lists failing to fulfill obligations and giving up important social, occupational, and recreational activities because of substance use and exhibiting tolerance and withdrawal syndrome as criteria for diagnosing addiction.

Diagnostic criteria help identify and treat addiction by setting and standardizing the requirements for assessing and diagnosing SUDs and planning individualized and effective treatment for the patient. Additionally, these criteria help identify SUDs when they are still mild or moderate so that treatment is provided to prevent problematic substance use from progressing to full-blown addiction.

What is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is an update of the fourth edition of the mental health reference book published by the American Psychiatric Association (APA), namely the DSM-4, in 1994. It is a medical reference book intended for healthcare practitioners to help them diagnose disorders accurately and plan the most effective treatment. The DSM-5 was originally released in May 2013. A revised version of the fifth edition, named DSM-5-TR, with TR signifying “text revision,” was released in March 2022. The DSM is written, edited, and reviewed by the APA.

What are the DSM-5 criteria for substance use disorder (SUD)?

The DSM-5 criteria for substance use disorder (SUD) are listed below.

• Consuming the substance excessively: This is a symptom of impaired control over substance use and manifests as consuming the substance in larger amounts or more frequently than intended.
• Being unable to reduce or quit consumption: Impaired control is acknowledged as a core symptom of substance use disorder, according to a 2022 article by Chandra Sripada published in the journal Behavioural Brain Research, titled “Impaired control in addiction involves cognitive distortions and unreliable self-control, not compulsive desires and overwhelmed self-control” and manifests as not being able to reduce or stop consumption despite wanting to.
• Spending increasing amounts of time on substance-related activities: An individual with substance use disorder tends to spend increasing amounts of time seeking and acquiring drugs, consuming them, and recovering from their effects.
• Experiencing cravings: Substance craving or “wanting” is a key feature of addiction and a powerful contributor to the maintenance of addictive behaviors. Cravings are triggered by environmental cues related to earlier instances of drug use, such as people, places, or drug paraphernalia; internal cues like stress or negative emotions; or withdrawal-related stress.
• Failing to fulfill obligations: There is a failure to fulfill major role responsibilities at home, school, and/or work that has the potential to lead to housing instability, homelessness, unemployment or dependence on welfare, relationship distress or dissatisfaction, and instability in the family.
• Continuing use despite it causing relationship problems: An individual with substance use disorder persists in using the substance despite being aware that its usage is causing or worsening their social and/or interpersonal relationships.
• Giving up important occupational, social, and recreational activities because of substance use: An individual with substance addiction tends to give up or reduce their participation in meaningful occupational, social, and recreational activities due to substance use.
• Using substances in physically hazardous situations: The individual with an addiction tends to use substances in dangerous situations, such as driving or operating heavy machinery under the influence of alcohol, and smoking in bed.
• Continuing usage of the substance despite being aware of its adverse health impact: Substance abuse is known to lead to multiple medical and psychiatric conditions. However, persistent drug use despite being aware of these negative health effects is common.
• Exhibiting tolerance to the substance: Repeated substance use leads to neural adaptations that decrease sensitivity to the effects of the drug, as explained by the National Institute on Drug Abuse in their June 2018 publication titled “Understanding Drug Use and Addiction DrugFacts.” As a result, the individual needs more of the substance to experience the earlier level of high (tolerance).
• Experiencing withdrawal symptoms upon stoppage of the substance: Chronic substance use causes physiological dependence that manifests as unpleasant physical symptoms (withdrawal) upon stopping or reducing usage.

How does DSM-5 define substance use disorder (SUD)?

DSM-5 defines substance use disorder (SUD) as a part of the overarching class of substance-related and addictive disorders associated with the consumption of a substance of abuse including alcohol, according to a 2016 release by the Substance Abuse and Mental Health Services Administration (SAMHSA) titled “Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet].”

A disorder “class” is a group of similar disorders. The disorder associated with a specific substance of abuse is classed as a separate use disorder, such as alcohol use disorder and opioid use disorder, according to a release by the American Psychiatric Association titled “Substance-Related and Addictive Disorders.”

What are the different substance use disorders (SUDs) defined by DSM-5?

The different substance use disorders (SUDs) defined by DSM-5 are listed below.

• Alcohol use disorder: Alcohol is one of the most commonly used drugs in the world and has a place in many societies and cultures. Alcohol use is not always problematic. Its use ranges from low-risk consumption to alcohol addiction, the latter condition marked by the development of increasing tolerance and manifestation of withdrawal symptoms, according to a StatPearls [Internet] release titled “Alcohol Use Disorder” by Nehring et al., last updated on 16 March 2024.
• Cannabis use disorder: Cannabis use disorder is more common in men compared to women, and younger individuals are more likely to have the disorder than adults aged 45 years and more, according to a 2016 release by the National Institutes of Health, titled “Marijuana use disorder is common and often untreated.” Authors Jason Patel and Raman Marwaha in a StatPearls [Internet] release titled “Cannabis Use Disorder” last updated on 20 March 2024 note that cannabis use has escalated in recent years due to state-directed legislature.
• Phencyclidine use disorder or other hallucinogen use disorder: The DSM-5 also uses the phrase “any hallucinogen-related substance use disorders” for this specific diagnosis, according to a 2016 SAMHSA release titled “Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet].” There are two types of hallucinogens: classic hallucinogens like LSD (lysergic acid diethylamide), psilocybin (mushrooms), peyote (mescaline), DMT, and ayahuasca; and dissociative drugs like phencyclidine, ketamine, dextromethorphan in high doses, and salvia divinorum. Individuals with hallucinogens addiction take these substances to experience their mind- and reality-altering effects.
• Inhalant use disorder: Individuals with this disorder intentionally breathe in vapors from specific chemical agents or commercial products to achieve a psychoactive or mind-altering effect, according to a 2011 article by Howard et al., published in the journal Addiction Science & Clinical Practice, titled “Inhalant Use and Inhalant Use Disorders in the United States.”Common substances that are abused by individuals with inhalant addiction include glues and adhesives; aerosols like fabric spray, hair spray, spray paint, deodorants, and room fresheners; anesthetics like the gas nitrous oxide; cleaning agents like lacquers, thinners, and degreasers; and solvents and gases like nail polish remover, gasoline, lighter fluid, fire extinguisher, and paint thinner.
• Opioid use disorder: Opioids include synthetic substances like fentanyl; prescription pain medications like codeine, morphine, oxycodone (OxyContin®), and hydrocodone (Vicodin®); and the illegal drug heroin. The National Institute on Drug Abuse in their publication titled “Opioids” observes that individuals with opioid addiction tend to mix opioids with other drugs, a phenomenon that has been linked to a majority of drug overdosing deaths in recent years.
• Sedative, hypnotic, or anxiolytic use disorder: Sedatives include hypnotics, which are sleep aids, and anxiolytics, which are anti-anxiety medicines (SAMHSA, 2016). Although these drugs are widely prescribed, individuals with sedative addiction, hypnotic addiction, and anxiolytic addiction tend to misuse these to self-medicate psychiatric symptoms and consume them in ways not authorized by the prescriber.
• Stimulant use disorder: The diagnosis refers to a maladaptive pattern of using amphetamine-type substances, cocaine, or any other stimulant, according to a December 2021 publication by the U.S. Department of Veterans Affairs, titled “Stimulant Use Disorder: A VA Clinician’s Guide.” Individuals with stimulant addiction misuse illicit substances like speed, ice, and cocaine and prescription drugs, such as those prescribed for attention-deficit/hyperactivity disorder (ADHD) and narcolepsy.
• Tobacco use disorder: The diagnosis is assigned to individuals who are dependent on nicotine. Nicotine is a psychoactive drug and a central nervous system stimulant. Individuals with nicotine addiction smoke cigarettes, cigars, and pipes and/or chew or snuff tobacco.
• Caffeine use disorder: The DSM-5 includes caffeine use disorder in Section 3, Conditions for Further Study because there is, as yet, no evidence to suggest that it is a clinically significant disorder that should feature in the book (SAMHSA, 2016). However, caffeine withdrawal syndrome has been listed as a substance-related and addictive disorder.

How does the DSM-5 severity spectrum for substance use disorder categorize different levels of addiction?

The DSM-5 severity spectrum for substance use disorder categorizes different levels of addiction as mild, moderate, and severe. A criteria count from 2 to 11 serves as the severity scale. As the count increases, there is an increased likelihood of addiction risk factors and repercussions, according to a 2013 article by Hasin et al., published in the American Journal of Psychiatry, titled “DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale.”

The presence of 2-3 criteria indicates a mild SUD. Those who meet 4-5 criteria are diagnosed as having moderate SUD. An endorsement of 6 or more criteria indicates severe SUD. Addiction tends to develop over time. If left untreated, the condition gradually worsens. The DSM-5 severity spectrum allows clinicians to formulate the most effective treatment plan for an individual. The greater the severity, the more intensive the treatment.

What changes did DSM-5 make in the classification of addiction compared to DSM-4?

The DSM-5 made the following changes in the classification of addiction compared to DSM-4: at the class level about the grouping of specific disorders; at the substance level regarding the identification of “drugs of abuse;” at the disorder level to specify diagnostic criteria; and at the individual criteria level, according to a 2016 SAMHSA publication titled “Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet].” These changes reflect changing medical knowledge about addiction and are informed by clinical and public health requirements, according to a 2013 article by Regier et al., published in the journal World Psychiatry, titled “The DSM-5: Classification and criteria changes.”

The alterations also strive to overcome the problems in the guidelines and direction proposed by DSM-4, according to a 2013 article by Hasin et al., published in the American Journal of Psychiatry, titled “DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale.”

What are the main differences between DSM-4 and DSM-5 in diagnosing addiction?

The main differences between DSM-4 and DSM-5 in diagnosing addiction are listed below.

• Combination of abuse and dependence disorders into one diagnosis: In DSM-4, substance use disorder comprised two separate diagnoses: substance abuse and substance dependence. In DSM-5, these two diagnoses have been combined and included under the single rubric of substance use disorder.
• Alteration in the threshold for an SUD diagnosis: The DSM-4 diagnosis for substance abuse required the fulfillment of one or more symptoms (out of four) and no history of substance dependence while the requirement for a substance dependence diagnosis was three or more symptoms (out of seven). In DSM-5, the requirement for an SUD diagnosis is the endorsement of 2 out of 11 criteria, according to a 2016 release by the Substance Abuse and Mental Health Services Administration (SAMHSA) titled “Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet].”
• Addition of severity index: The DSM-4 did not specify the severity of a substance abuse problem. Typically, dependence was considered to be more severe than abuse, and individuals who met the criteria for both abuse and dependence were given a dependence diagnosis. The DSM-5 added a severity indicator based on the number of symptoms manifested by the individual and then measured on a continuum from mild to severe (SAMHSA, 2016).
• Inclusion of the “cravings” criterion: The DSM-5 has added “cravings” as a criterion for an SUD diagnosis. Craving is defined as a powerful desire or urge to use a substance. This criterion was not included in DSM-4 (SAMHSA, 2016).
• Elimination of the “legal problems” criterion: The DSM-5 eliminated the “legal problems” criterion that was a component of the abuse diagnosis in the DSM-4. This criterion referred to repeated legal problems, such as arrests due to disorderly behavior stemming from substance use (SAMHSA, 2016).
• Reclassification of the types of substances of abuse: In DSM-4, amphetamine use disorder and cocaine use disorder, including crack use, were distinct diagnoses. DSM-5 includes changes in the classification of these substances. Cocaine (including crack) and amphetamines have been grouped with other stimulants (except caffeine) in DSM-5 under a single “stimulant” class. Additionally, the DSM-4 included phencyclidine use disorder and hallucinogen use disorder as distinct diagnoses. The DSM-5 clubs these two diagnoses under the single category of hallucinogen-related disorders (SAMHSA, 2016).
• Broadening of the SUD classification: In DSM-4, SUDs were clubbed under the class substance-related disorders, which included only disorders involving substances or drugs. In DSM-5, this classification has been expanded to include gambling disorder, and the category was renamed Substance-Related and Addictive Disorders (SAMHSA, 2016).
• Modified definition of remission: In DSM-4, the specifier for “early full remission” was fulfilling no criteria for dependence or abuse for at least one month but for less than 12 months. The manual specified “early partial remission” as meeting one or more criteria for dependence or abuse for at least one month but for less than 12 months, without meeting the full criteria for dependence. In DSM-5, the specifier for early remission is fulfilling no criteria for SUD (except craving) for at least three months but for less than 12 months. Sustained remission is defined as meeting no criteria for SUD (except craving) for at least 12 months, according to a release by the American Psychiatric Association titled “Highlights of Changes from DSM-IV-TR to DSM-5.”
• Elimination of physiological subtype and polysubstance dependence: The DSM-5 eliminates the DSM-4 diagnoses of polysubstance abuse and the physiological subtype specifier for dependence.

What are the main differences between the DSM-5 and ICD-10 criteria for addiction diagnosis?

The main differences between the DSM-5 and ICD-10 criteria for addiction diagnosis are listed below.

• Variation in the approach to classification: The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), follows a categorical approach to classify SUDs and comprises two diagnoses: harmful use and dependence, according to a 2016 article by Proctor et al., published in the journal Addictive Behaviors, titled “Diagnostic Concordance between DSM-5 and ICD-10 Cannabis Use Disorders.” The DSM-5 eliminates the categorical approach and instead, adopts a dimensional approach where SUD is a single category and a central diagnosis that unifies multiple conditions.
• Alterations in the threshold for an SUD diagnosis: The DSM-5 diagnosis for SUD requires the fulfillment of at least two criteria (out of 11) within the previous 12 months. The ICD-10 diagnosis for substance dependence requires the simultaneous endorsement of three or more criteria (out of six) for at least a month or repeated occurrence of these symptoms within a period of 12 months, according to a 2017 article by John B. Saunders published in the journal Current Opinion in Psychiatry, titled “Substance use and addictive disorders in DSM-5 and ICD 10 and the draft ICD 11.”
• Variations in substance groups: The ICD-10 sub-divided psychostimulants into two groups: cocaine being one class, and other stimulants like amphetamine-like compounds and caffeine being the other group (Saunders, 2017). The DSM-5 combines stimulants like amphetamines and cocaine into a single stimulant use disorder category, according to a 2016 SAMHSA release titled “Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet].” Caffeine is considered a separate substance group with caffeine use disorder listed as a condition that merits further investigation.
• Elimination of polysubstance dependence: The ICD-10 contains a diagnosis of polysubstance dependence that is not included in the DSM-5.

What are the updates in ICD-11 for diagnosing addiction?

The updates in ICD-11 for diagnosing addiction are listed below.

• Expansion of the classes of psychoactive substances: The number of psychoactive substance classes has increased from 9 in ICD-10 to 14 in ICD-11, according to a 2022 article by Matone et al., published in the journal Clinical Psychology in Europe, titled “Alcohol and Substance Use Disorders Diagnostic Criteria Changes and Innovations in ICD-11: An Overview.” The additional substance classes include cannabis, nicotine, caffeine, synthetic cathinones, and MDMA (Methylenedioxymethamphetamine) or related drugs including MDA (3,4-Methylenedioxyamphetamine). The ICD-11 has also introduced separate categories for “unknown or unspecified psychoactive substances.” Anxiolytics have been added to the sedatives or hypnotics class in the ICD-11. The ICD-10 substance class “other stimulants, including caffeine” has been segregated in the ICD-11 into two classes, namely “stimulants including amphetamines, methamphetamine or methcathinone,” and “caffeine.” In the ICD-10, the class “hallucinogens” also included dissociative drugs like phencyclidine. In the ICD-11, “dissociative drugs including ketamine and phencyclidine [PCP]” is a new category and one that is distinct from “hallucinogens.”
• Reclassification of primary diagnoses of SUDs: The primary diagnoses classes of SUDs in the ICD-11 are “substance dependence,” “harmful pattern of psychoactive substance use,” and “episode of harmful psychoactive substance use” (Matone, 2022). In contrast, there were only two such classes in the ICD-10, namely “substance dependence” and “harmful substance use.”
• Introduction of the “hazardous use of substances” condition: The condition refers to a pattern of drug-use behavior that significantly increases the risk of adverse physical or mental health consequences to the user or other people and thus, merits intervention from a healthcare professional, according to a 2017 publication by Poznyak et al., published in the journal Epidemiology and Psychiatric Sciences, titled “Aligning the ICD-11 classification of disorders due to substance use with global service needs.”
• Introduction of the “harmful pattern of psychoactive substance use” condition: The “harmful substance use” classification of the ICD-10 has been modified to “harmful pattern of substance use” in the ICD-11 (Matone, 2022). The modified condition refers to a pattern of drug-use behavior that causes clinically significant harm to the physical or mental health of the drug user or other people (Poznyak et al., 2017). Harmful use is further specified as episodic or continuous.
• Introduction of the “single episode of substance use” condition: The new diagnostic category of “single episode of harmful use” facilitates the recognition of substance-use episodes that have harmed the health of the drug user or other people in the absence of symptoms that fulfill a substance dependence diagnosis or a harmful pattern of drug use (Poznyak et al., 2017).
• Introduction of severity qualifiers for intoxication: The ICD-11 introduces a severity of intoxication scale where the classifications are mild, moderate, and severe (Matone, 2022).
• Simplification of the substance dependence diagnosis: The substance dependence diagnosis has been simplified in the ICD-11. A diagnosis is made if at least two of the three key symptoms–manifesting impaired control, prioritizing substance use over other activities, and exhibiting tolerance or withdrawal–are present.
• Elimination of the multiple drug use category: The category “multiple drug use and use of other psychoactive substances” present in the ICD-10 has been eliminated from the ICD-11.

What are the diagnostic overlaps between DSM-5, DSM-4, ICD-10, and ICD-11 in diagnosing addiction?

The diagnostic overlaps between DSM-5, DSM-4, ICD-10, and ICD-11 in diagnosing addiction are listed below.

• Diagnoses of SUD, substance dependence, and abuse: The DSM-4 diagnoses of substance abuse and substance dependence fulfill part of the criteria for a SUD diagnosis in DSM-5. This is due to the merging of the DSM-4 criteria of substance abuse and substance dependence into a single SUD category in DSM-5, according to a 2021 article by Livne et al., published in the journal Drug and Alcohol Dependence, titled “Agreement between DSM-5 and DSM-IV measures of substance use disorders in a sample of adult substance users.”
• Diagnosis of disorder severity: A majority of DSM-4 abuse diagnoses that also meet two dependence criteria are categorized as mild SUD according to the DSM-5, according to a 2014 article by Kopak et al., published in the journal Current Addiction Report, titled “The Elimination of Abuse and Dependence in DSM-5 Substance Use Disorders: What Does This Mean for Treatment?” Those conditions that meet two or three abuse criteria and 2-3 dependence criteria in the DSM-4 are categorized as moderate SUD in the DSM-5. The DSM-4 dependence diagnoses that endorse three dependence criteria and a maximum of two abuse criteria receive a moderate SUD diagnosis in the DSM-5. A majority of DSM-4 dependence diagnoses that fulfill four or more criteria are diagnosed as severe SUD by the DSM-5.
• Definition of alcohol and cannabis use disorder: The proposed classification of alcohol and cannabis use disorders in ICD-11 is almost similar to the classifications specified by ICD-10 and DSM-4, according to a 2016 publication by Lago et al., in the journal The Lancet Psychiatry, titled “Concordance of ICD-11 and DSM-5 definitions of alcohol and cannabis use disorders: a population survey.”
• Classification of use disorder and dependence: There is almost perfect agreement between the ICD-10 and ICD-11 definitions of use disorder and dependence for all substances except inhalants, according to a 2023 article by Afroz et al., published in the journal BJPsych Open, titled “Study on Concordance of ICD-11, ICD-10, and DSM-5 Diagnostic Guidelines for Alcohol and Opioid Use Disorders.” For instance, the six criteria for substance use dependence in ICD-10 are experiencing cravings; difficulty in controlling drug use; exhibiting withdrawal, developing tolerance; spending increasing amounts of time on drug-related activities and neglecting activities not involving the use of drugs; and continuing drug use despite adverse consequences. These criteria overlap with those specified for disorders due to substance use in ICD-11, such as harmful patterns of use and withdrawal.

Why are diagnostic criteria important in identifying and treating addiction?

Diagnostic criteria are important in identifying and treating addiction because these yardsticks influence all facets of SUD treatment–evaluation, diagnosis, choice of a therapeutic protocol, and billing or reimbursement. Most importantly, these criteria underlie the decisions about who is or is not eligible for treatment.

SUDs tend to develop over time. The progression from problematic substance use to full-blown addiction moves along a different trajectory for different substances. For instance, all substances of abuse do not produce withdrawal and tolerance, but they are still able to damage the user’s health and disrupt their lives. The introduction of criteria like impaired control and a single episode of harmful use makes it possible to identify SUDs when they are still mild or moderate and treat them to halt the addiction process. Gradation of SUDs along a severity spectrum reduces the all-or-none thinking approach–the perception that an individual is either addicted or not addicted–that was once prevalent in the clinical arena. Expanding the coverage of SUDs creates opportunities for identifying and providing treatment to those who need it.