How are Substance Use Disorders Categorized in the DSM-5?
The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has combined the prior categories of ‘substance abuse’ and ‘substance dependence’ under ‘Substance Use Disorders’- which encompasses various types of addiction + dependence.
Let’s take a look at the criteria that is now used to diagnose substance use disorders, according to the American Psychiatric Association:
- The individual may take the substance in larger amounts or over a longer period than was originally intended.
- The individual may express a persistent desire to cut down or regulate substance use and may report multiple unsuccessful efforts to decrease or discontinue use.
- The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects.
- Craving is manifested by an intense desire or urge for the drug that may occur at any time but is more likely in an environment where the drug was previously obtained and/or used.
- Recurrent substance use may result in a failure to fulfill major role obligations at work, school or home.
- The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused – or exacerbated – by the effects of the substance.
- Important social, occupational or recreational activities may be abandoned or reduced because of substance use. The individual may withdraw from family activities and hobbies in order to use the substance.
- This may take the form of recurrent substance use in situations in which it is physically hazardous. (For example, driving while intoxicated.)
- The individual may continue substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been the cause of (or exacerbated by) the substance use. (For example, such as a challenge managing anger or liver damage.)
The key issue in evaluating this criterion is not the existence of the problem, but rather the individual’s failure to abstain from using the substance, despite the difficulty it is causing.
Tolerance and Withdrawal
- Tolerance is signaled by requiring a markedly increased dose of the substance to achieve the desired effect – or a markedly reduced effect when the usual dose is consumed. The degree to which tolerance develops varies greatly across different individuals as well as across substances and may involve a variety of central nervous system effects (such as negative impacts on coordination or passing out).
Tolerance may be difficult to determine by history alone, and laboratory tests may be helpful (e.g., high blood levels of the substance coupled with little evidence of intoxication suggest that tolerance is likely).
- Withdrawal is a syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing withdrawal symptoms, the individual is likely to consume the substance to relieve the symptoms.
Similar to tolerance, withdrawal symptoms vary greatly across the classes of substances, and separate criteria sets for withdrawal are provided for each drug class. Marked and generally easily measured physiological signs of withdrawal are common with alcohol, opioids, sedatives, hypnotics, and anxiolytics.
Withdrawal signs and symptoms with stimulants (such as amphetamines and cocaine), as well as tobacco and cannabis, are often present but may be less apparent. However, for most classes of substances, a past history of withdrawal is associated with a more severe clinical course (i.e., an earlier onset of a substance use disorder, higher levels of substance intake, and a greater number of substance-related problems).
*Note that neither tolerance nor withdrawal is necessary for a diagnosis of a substance use disorder.
If you want to learn more about the DSM-5 criteria and changes for Substance Use Disorders check out DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale.