What are the diagnostic changes for stimulant‑related disorders across the Diagnostic and Statistical Manual of Mental Disorders (DSM) versions III, III‑TR, IV, V, and V‑TR, and the International Classification of Diseases (ICD) versions X and XI?

Evolution of Stimulant-Related Disorder Diagnosis Across DSM and ICD Versions

Overview of Major Structural Changes

The diagnostic approach to stimulant-related disorders has evolved from separate "abuse" and "dependence" categories in DSM-III/IV and ICD-10 to a unified dimensional model in DSM-5/5-TR, while ICD-11 maintains the traditional dependence-focused structure with enhanced dimensional options. 1

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DSM Evolution (DSM-III → DSM-III-R → DSM-IV → DSM-5 → DSM-5-TR)

DSM-III (1980)

• Introduced the first symptom-based categorical approach with separate "stimulant abuse" and "stimulant dependence" diagnoses, prioritizing diagnostic reliability over validity through polythetic criteria 1
• Established the foundational two-category system that would persist through DSM-IV 2

DSM-III-R (1987)

• Refined dependence syndrome elements across psychoactive substances, with factor analysis demonstrating that dependence criteria formed a single unidimensional factor for cocaine and stimulants 2
• Validated the dependence syndrome concept showing excellent internal consistency and approximating Guttman scales where higher scores indicated greater severity 2

DSM-IV (1994-2000)

• Maintained the abuse/dependence dichotomy with 7 dependence criteria and 4 abuse criteria (hazardous use, social/interpersonal problems, neglect of roles, legal problems) 3, 4
• Demonstrated consistently strong reliability and validity for dependence, but poor reliability and validity for the abuse diagnosis 1, 4
• Required 3+ of 7 dependence criteria or 1+ of 4 abuse criteria within 12 months 4

DSM-5 (2013) - Major Paradigm Shift

• Eliminated the abuse/dependence distinction entirely, combining them into a single "Stimulant Use Disorder" diagnosis with 11 criteria based on data from over 200,000 participants 1, 4
• Dropped the "legal problems" criterion due to poor psychometric performance and lack of contribution to the unidimensional continuum 3, 4
• Added "craving" as a new criterion based on factor analyses showing all criteria form a single unidimensional continuum 1, 3
• Introduced dimensional severity grading: mild (2-3 criteria), moderate (4-5 criteria), severe (6+ criteria) within a 12-month period 1
• The 11 criteria include: 7 former dependence criteria + 3 abuse criteria (hazardous use, social/interpersonal problems, neglect of roles) + craving 3

DSM-5-TR (2022)

• Retained the DSM-5 unified structure with 11 criteria and dimensional severity grading 1
• Maintained the two-criterion threshold, which is lower than traditional dependence thresholds and captures a broader population 1
• Demonstrated excellent concordance with ICD-10 and DSM-IV (all κ ≥ 0.9) supporting clinical utility 1

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ICD Evolution (ICD-10 → ICD-11)

ICD-10 (1992-2021)

• Maintained separate categories for "harmful stimulant use" and "stimulant dependence" within the traditional 11 disorder groupings 5, 1
• Preserved the well-validated dependence syndrome as the master diagnosis with consistently high reliability and validity 1
• Used purely categorical classification without dimensional extensions 5

ICD-11 (Adopted 2019, Implemented 2022) - Evolutionary Refinement

• Retained the traditional separation between "harmful stimulant use" and "stimulant dependence" as distinct diagnostic categories, contrasting with DSM-5-TR's unified model 1
• Expanded from 11 to 21 disorder groupings, reorganizing by shared etiology, pathophysiology, and phenomenology 5
• Substance dependence remains the "master diagnosis" with a narrower, more specific diagnostic approach that maintains better specificity and reduces false-positive diagnoses 1
• Introduced optional dimensional assessments for select disorders, allowing severity ratings while maintaining categorical structure 5, 1
• Eliminated the separate grouping for childhood/adolescence-onset disorders, redistributing cases to emphasize developmental continuity across the lifespan 5
• Field studies with 928 clinicians showed 82.5%-83.9% rated ICD-11 as "quite" or "extremely" easy to use, with higher diagnostic accuracy and faster time to diagnosis compared to ICD-10 5

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Key Diagnostic Differences Between Current Systems (DSM-5-TR vs. ICD-11)

Structural Approach

• DSM-5-TR uses a single dimensional "Stimulant Use Disorder" with severity determined purely by criterion count (2-11 criteria) 1
• ICD-11 maintains distinct "harmful use" and "dependence" categories with category-specific thresholds, preserving the clinically meaningful distinction with empirical support 1

Diagnostic Threshold

• DSM-5-TR's two-criterion threshold casts a wider diagnostic net, potentially capturing milder presentations that may not meet ICD-11 dependence criteria 1
• ICD-11's dependence-focused approach maintains a narrower, more specific threshold that reduces false positives 1

Dimensional Assessment

• DSM-5-TR integrates severity grading systematically into every diagnosis with validated criterion validity 1
• ICD-11 offers optional dimensional qualifiers that can be applied selectively based on clinical context 5, 1

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Clinical Implications and Pitfalls

Concordance Issues

• Despite structural differences, DSM-5-TR shows excellent concordance with ICD-10 (κ ≥ 0.9), but concordance with ICD-11's narrower dependence threshold may be lower for mild severity cases 1
• The DSM-5-TR mild category (2-3 criteria) may not align with ICD-11 harmful use, creating potential diagnostic discordance in borderline cases 1

Common Pitfalls to Avoid

• Do not assume DSM-5-TR and ICD-11 diagnoses are interchangeable—the two-criterion DSM-5-TR threshold captures a broader population than ICD-11 dependence 1
• Avoid over-relying on criterion count alone—consider functional impairment, treatment response, and longitudinal outcomes (mortality, morbidity, quality of life) to validate clinical significance 1
• Recognize that craving adds diagnostic breadth in DSM-5-TR but showed mixed incremental value beyond dependence criteria in psychometric studies 3

Cross-Cultural Considerations

• Measurement equivalence problems across cultural groups may generate apparent epidemiological variation that does not reflect true prevalence differences, limiting cross-cultural diagnostic comparability 1
• Both systems require validation in diverse populations to ensure diagnostic criteria capture culturally variant presentations 1

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Future Directions and Harmonization Needs

• Establishing formal harmonization working groups to align diagnostic thresholds between DSM-5-TR and ICD-11, particularly for mild/harmful use categories, can enhance clinical utility 1
• Developing shared biomarker standards and neurobiological assessment tools can improve diagnostic objectivity beyond self-report criteria 1
• Prioritizing longitudinal outcome studies examining mortality, morbidity, treatment response, and quality of life across the mild severity range can validate the clinical significance of lower-threshold diagnoses 1