What are the differences in diagnosing substance use disorder between the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and the International Classification of Diseases, Eleventh Revision (ICD-11)?

Diagnostic Differences Between DSM-5-TR and ICD-11 for Substance Use Disorders

Core Structural Difference

The fundamental distinction is that DSM-5-TR uses a single dimensional "substance use disorder" diagnosis with severity grading (mild, moderate, severe), while ICD-11 retains the traditional separation between "harmful substance use" and "substance dependence" as distinct diagnostic categories. 1, 2

DSM-5-TR Approach

Single Dimensional Diagnosis

• DSM-5-TR eliminated the DSM-IV distinction between "abuse" and "dependence," combining them into one disorder called "substance use disorder" with 11 criteria. 1, 3
• The diagnosis requires at least 2 of 11 criteria met within a 12-month period. 3
• Severity is determined purely by criterion count: mild (2-3 criteria), moderate (4-5 criteria), or severe (6+ criteria). 3, 4

Key Criteria Changes

• DSM-5 removed the "legal problems" criterion from DSM-IV. 3
• DSM-5 added "craving" as a new criterion based on factor analyses showing all criteria form a single unidimensional continuum. 3
• The 11 criteria remain as individual items that are counted separately. 1

ICD-11 Approach

Dual Categorical System

• ICD-11 preserves the well-established distinction between "harmful substance use" and "substance dependence" as separate diagnostic entities. 5, 2
• Substance dependence remains the "master diagnosis" in ICD-11, maintaining diagnostic coherence. 2

Condensed Criteria Structure

• ICD-11 condenses the former six ICD-10 dependence criteria into three pairs. 5
• Only two of these three pairs must be fulfilled to diagnose substance dependence. 5
• Within each pair, fulfilling just one symptom or aspect is sufficient for that criterion to be met. 5

Specificity Concerns

• This pairing structure may reduce diagnostic specificity compared to ICD-10, potentially increasing false-positive diagnoses. 5
• The ICD-11 criterion "substance use often continues despite the occurrence of problems" is more broadly worded than ICD-10's "persisting substance use despite clear evidence of overtly harmful consequences." 5
• In multinational studies, alcohol dependence was diagnosed approximately 10% more often using ICD-11 compared to ICD-10. 5

Concordance Between Systems

Agreement Patterns

• DSM-5 and ICD-10/ICD-11 show high convergence for the most severe cases and for those without any diagnosis. 6, 7
• For severe disorders, classification agreement is almost perfect between ICD-11 and DSM-5. 7

Divergence in Mild-to-Moderate Cases

• Most DSM-5 moderate alcohol use disorder cases are classified as dependence under ICD-10/ICD-11 criteria. 6
• DSM-5 mild cases show much more variation, being divided between harmful use or misuse categories depending on whether clinical or research ICD criteria are applied. 6
• DSM-5 substance use disorder appears to capture a different aspect of problematic use and selects a different group of individuals compared to ICD-10/ICD-11 systems. 7

Clinical Implications

Billing and Documentation

• U.S. Centers for Medicare and Medicaid Services require providers to bill using ICD-10 designations, despite DSM-5 being widely used clinically. 6
• This creates practical challenges when translating between systems, particularly for mild and moderate severity cases. 6

Diagnostic Threshold Differences

• The DSM-5 two-criterion threshold for any substance use disorder diagnosis is lower than traditional dependence thresholds, potentially capturing a broader population. 1, 7
• ICD-11's requirement of two pairs (with only one symptom per pair needed) may also lower the diagnostic threshold compared to ICD-10. 5

Common Pitfalls

Avoid Assuming Equivalence

• Do not assume that DSM-5 "moderate" severity automatically equals ICD-11 "dependence"—the overlap is imperfect. 6
• Be cautious when comparing prevalence rates across studies using different classification systems, as they may identify different populations. 7

Risk of Over-Diagnosis

• The broader ICD-11 criterion wording may lead to diagnosing dependence simply because a substance is illegal in a particular country, rather than based on true clinical impairment. 5
• DSM-5's lower threshold (2 criteria) may capture individuals with less severe problems than traditional dependence diagnoses. 1

Documentation Considerations

• When using DSM-5 clinically but billing with ICD codes, carefully map the specific criteria met to determine the most appropriate ICD-11 category (harmful use vs. dependence). 6
• For tolerance and withdrawal occurring under medical supervision, these should not count toward DSM-5 diagnosis if no other criteria are met. 3