What are the sequential diagnosis criteria for substance use disorders via Diagnostic and Statistical Manual of Mental Disorders (DSM)?

DSM-5 Diagnostic Criteria for Substance Use Disorders

The DSM-5 has consolidated substance abuse and dependence into a single diagnosis called "substance use disorder" with severity levels based on the number of criteria met over a 12-month period. 1

Diagnostic Framework

The DSM-5 made significant changes to how substance use disorders are diagnosed compared to previous versions:

Key Changes from DSM-IV to DSM-5:

1. Combined diagnosis: Eliminated the separate categories of "substance abuse" and "substance dependence" in favor of a single "substance use disorder" diagnosis 1, 2

2. Severity spectrum: Implemented a severity scale based on symptom count:

   • Mild: 2-3 symptoms
   • Moderate: 4-5 symptoms
   • Severe: 6 or more symptoms 2

3. Criteria modifications:

   • Removed "legal problems" criterion
   • Added "craving" as a new criterion 1

4. Timeframe: All criteria must be present within a 12-month period 2

The 11 DSM-5 Criteria for Substance Use Disorders

To diagnose a substance use disorder, patients must meet at least 2 of the following 11 criteria within a 12-month period:

1. Impaired control criteria:

   • Taking the substance in larger amounts or for longer than intended
   • Unsuccessful efforts to cut down or control use
   • Spending significant time obtaining, using, or recovering from substance use
   • Experiencing craving or strong desire to use the substance

2. Social impairment criteria:

   • Recurrent use resulting in failure to fulfill major role obligations
   • Continued use despite persistent social or interpersonal problems caused by substance
   • Giving up important social, occupational, or recreational activities due to substance use

3. Risky use criteria:

   • Recurrent use in physically hazardous situations
   • Continued use despite knowledge of physical or psychological problems caused by the substance

4. Pharmacological criteria:

   • Tolerance (needing increased amounts for same effect)
   • Withdrawal symptoms when not using 1

Substance-Specific Considerations

While the core 11 criteria apply across substances, there are substance-specific considerations:

• Withdrawal syndromes: DSM-5 added withdrawal syndromes for cannabis and caffeine that were not in DSM-IV 1

• Tobacco use disorder: Criteria aligned with other substance use disorders 1

• Gambling disorder: Added as a non-substance addictive disorder in the same chapter 2

Diagnostic Process

1. Identify substance(s) of concern

   • Assess all potentially problematic substances

2. Evaluate each criterion systematically

   • Use structured interview approach to assess all 11 criteria
   • Document presence/absence of each criterion within past 12 months

3. Count criteria met

   • Tally the number of criteria present

4. Determine severity level:

   • Mild: 2-3 criteria
   • Moderate: 4-5 criteria
   • Severe: 6+ criteria

5. Assess for remission status (if applicable):

   • Early remission: No criteria met for 3-12 months
   • Sustained remission: No criteria met for 12+ months
   • In controlled environment: In setting where access is restricted

Clinical Considerations

• Diagnostic reliability: Research shows the combined criteria set has good reliability across substances 1

• Dimensional approach: The severity spectrum acknowledges the continuum nature of substance problems 3

• Diagnostic threshold: Setting the threshold at 2+ criteria was supported by extensive research showing good agreement with DSM-IV diagnoses 1

• Potential pitfalls:

  • Double-barreled questions can lead to over/under-endorsement of criteria 4
  • Inconsistent definitions of key terms may affect diagnosis 4
  • Tolerance and hazardous use criteria may function differently across population subgroups 5

Public Health Impact

Alcohol, tobacco, and cannabis consistently show:

• Earliest onset of use
• Highest prevalence of lifetime use
• Highest prevalence of lifetime disorder 5

These substances therefore have the greatest public health impact and should be prioritized in screening efforts.