What are the diagnostic criteria for Alcohol Use Disorder (AUD)?

Diagnostic Criteria for Alcohol Use Disorder (AUD)

According to the DSM-5, Alcohol Use Disorder is diagnosed when a person exhibits at least two of eleven specific criteria within a 12-month period, indicating a problematic pattern of alcohol use leading to clinically significant impairment or distress. 1

DSM-5 Diagnostic Criteria

The diagnosis requires meeting at least 2 of these 11 criteria within a 12-month period:

1. Alcohol often consumed in larger amounts or over longer periods than intended
2. Persistent desire or unsuccessful efforts to cut down or control alcohol use
3. Great deal of time spent obtaining, using, or recovering from alcohol
4. Craving or strong desire to use alcohol
5. Recurrent alcohol use resulting in failure to fulfill major role obligations
6. Continued alcohol use despite persistent social or interpersonal problems caused/exacerbated by alcohol
7. Important activities given up or reduced because of alcohol use
8. Recurrent alcohol use in physically hazardous situations
9. Continued use despite knowledge of physical or psychological problems caused/exacerbated by alcohol
10. Tolerance, defined as either:
    • Need for markedly increased amounts to achieve intoxication/desired effect
    • Markedly diminished effect with continued use of same amount
11. Withdrawal, manifested by either:
    • Characteristic alcohol withdrawal syndrome
    • Alcohol (or related substance) taken to relieve/avoid withdrawal symptoms

Severity Classification

The severity of AUD is classified based on the number of criteria met 1:

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

Screening Tools

AUDIT (Alcohol Use Disorders Identification Test)

• Considered the gold standard screening tool 1, 2
• 10-question assessment evaluating:
  • Alcohol consumption patterns
  • Dependence symptoms
  • Alcohol-related problems
• Scores range from 0-40 points
• Scoring interpretation:
  • 8+ indicates hazardous or harmful alcohol consumption
  • Higher scores correlate with greater likelihood of AUD

CAGE Questionnaire

• Simpler 4-question screening tool 1
• Questions assess:
  • Feeling need to Cut down on drinking
  • Annoyed by criticism about drinking
  • Guilty feelings about drinking
  • Eye-opener drinks (morning drinking to steady nerves)
• Two or more "yes" responses indicate probable AUD
• Less sensitive than AUDIT for detecting hazardous drinking 2

Clinical Considerations

• AUD manifests differently at various severity levels, with distinct symptom clusters 3:

  • Mild cases often primarily show excessive consumption/tolerance symptoms
  • Moderate cases typically add loss of control/social dysfunction symptoms
  • Severe cases frequently include withdrawal/craving symptoms in addition to the above

• Proper documentation using ICD-10 codes is important for treatment planning 2:

  • F10.1: Harmful use of alcohol
  • F10.2: Alcohol dependence syndrome
  • F10.21: Alcohol dependence in remission

• Screening for AUD is recommended in clinical practice but remains underutilized, with only about 1 in 6 US adults reporting being asked about their drinking behavior 4

• Despite AUD affecting up to 14% of US adults annually, less than 9% of patients receive appropriate medication treatment, with most only receiving counseling 4

Pitfalls in Diagnosis

• Double-barreled nature of some criteria can lead to over or under-endorsement 5
• Inconsistent definitions of key terms by patients can affect accurate reporting 5
• Variability in thresholds for endorsing certain criteria (e.g., "larger/longer" and "quit/cut down") 5
• Failure to distinguish between different manifestations of AUD at different severity levels 3

The comprehensive assessment of AUD should include both standardized screening tools and a thorough evaluation of the specific criteria to accurately determine diagnosis and severity, which directly impacts treatment decisions and outcomes.