DSM-5 Alcohol Use Disorder Diagnostic Criteria
Alcohol use disorder (AUD) is diagnosed when a patient meets at least 2 of 11 specific criteria within a 12-month period, with severity graded as mild (2-3 criteria), moderate (4-5 criteria), or severe (6 or more criteria). 1
Diagnostic Criteria
The diagnosis requires a problematic pattern of alcohol use leading to clinically significant impairment or distress, with at least 2 of the following 11 criteria occurring within a 12-month period: 1
Impaired Control (Criteria 1-4)
- Drinking larger amounts or for longer periods than intended 1
- Persistent desire or unsuccessful efforts to cut down or control use 1
- Spending a great deal of time obtaining, using, or recovering from alcohol 1
- Craving or strong desire/urge to use alcohol (new criterion added in DSM-5) 1, 2
Social Impairment (Criteria 5-7)
- Recurrent use resulting in failure to fulfill major role obligations at work, school, or home 1
- Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by alcohol 1
- Important social, occupational, or recreational activities given up or reduced because of alcohol use 1
Risky Use (Criteria 8-9)
- Recurrent use in physically hazardous situations 1
- Continued use despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or exacerbated by alcohol 1
Pharmacological Criteria (Criteria 10-11)
- Tolerance: Need for markedly increased amounts to achieve intoxication/desired effect, or markedly diminished effect with continued use of the same amount 1
- Withdrawal: Characteristic withdrawal syndrome, or alcohol (or related substance like benzodiazepine) taken to relieve or avoid withdrawal symptoms 1
Severity Classification
The severity grading is straightforward and based solely on criterion count: 1
- Mild AUD: 2-3 criteria met
- Moderate AUD: 4-5 criteria met
- Severe AUD: 6 or more criteria met
Key Changes from DSM-IV
DSM-5 eliminated the previous distinction between "alcohol abuse" and "alcohol dependence," combining them into a single dimensional disorder with severity specifiers. 1 The legal problems criterion from DSM-IV was removed, and craving was added as a new criterion. 1, 2 This change was based on extensive factor analyses showing that all criteria formed a single unidimensional continuum rather than two separate disorders. 1, 2
Clinical Application Considerations
Early warning signs: When assessing patients, pay particular attention to social problems from drinking, major role problems, and drinking larger amounts/for longer than intended, as these first-onset criteria are associated with faster transition to full AUD (hazard ratios of 3.24,2.53, and 2.04 respectively). 3
Prevalence and comorbidity: AUD affects 13.9% of U.S. adults in any 12-month period and 29.1% lifetime, with highest rates among men (17.6% 12-month), Native Americans (19.2% 12-month), and younger adults. 4 AUD shows significant comorbidity with other substance use disorders, major depressive disorder, bipolar I disorder, and personality disorders, with odds ratios ranging from 1.2 to 6.4. 4
Treatment gap: Only 19.8% of individuals with lifetime AUD ever receive treatment, representing a critical public health concern. 4
Medical use exception: For patients using cannabis or other substances under medical supervision, tolerance and withdrawal alone should not count toward diagnosis if no other criteria are met. 2 This same principle applies when considering pharmacological criteria in the context of medically supervised alcohol use for specific conditions.
Screening tools: The AUDIT (Alcohol Use Disorders Inventory Test) remains the gold standard screening instrument, developed by WHO with proven sensitivity and specificity across clinical settings and countries. 1