What are the DSM‑5 criteria for diagnosing an active alcohol use disorder and how is severity determined?

DSM-5 Criteria for Active Alcohol Use Disorder

Active 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+ criteria). 1

The 11 Diagnostic Criteria

AUD is defined as a problematic pattern of alcohol use leading to clinically significant impairment or distress, manifested by at least two of the following occurring within a 12-month period: 1

Impaired Control (Criteria 1-4)

• Larger amounts/longer periods: Alcohol is often taken in larger amounts or over a longer period than intended 1
• Persistent desire to cut down: There is a persistent desire or unsuccessful efforts to cut down or control alcohol use 1
• Time spent: A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects 1
• Craving: Strong desire or urge to use alcohol 1

Social Impairment (Criteria 5-7)

• Role obligations: Recurrent alcohol use resulting in failure to fulfill major role obligations at work, school, or home 1
• Social/interpersonal problems: Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol 1
• Activities given up: Important social, occupational, or recreational activities are given up or reduced because of alcohol use 1

Risky Use (Criteria 8-9)

• Physically hazardous use: Recurrent alcohol use in situations in which it is physically hazardous 1
• Physical/psychological problems: Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol 1

Pharmacological Criteria (Criteria 10-11)

• Tolerance: A need for markedly increased amounts of alcohol to achieve intoxication or desired effect, OR a markedly diminished effect with continued use of the same amount 1
• Withdrawal: The characteristic withdrawal syndrome for alcohol, OR alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms 1

Severity Determination

The severity classification is determined by a simple count of criteria met: 1

• Mild AUD: 2-3 criteria met 1
• Moderate AUD: 4-5 criteria met 1
• Severe AUD: 6 or more criteria met 1

This criterion count approach was validated because as the count increases, so does the likelihood of substance use disorder risk factors and consequences. 1 Research confirms that all alcohol use validators (craving, binge drinking frequency, problematic use, harmful drinking) are associated with greater likelihood of all three AUD severity levels, while psychiatric disorders and functional impairment are specifically associated with severe AUD. 2

Critical Exception: Medically Supervised Use

Tolerance and withdrawal alone do not constitute AUD when these occur as normal physiological adaptations during appropriate supervised medical use of psychoactive substances (including opioids, stimulants, sedative-hypnotics, or cannabis in some jurisdictions). 1 Under these conditions, tolerance and withdrawal in the absence of other criteria should not be diagnosed as AUD. 1

Screening Tools for Clinical Practice

The AUDIT (Alcohol Use Disorders Identification Test) is the gold standard screening tool, developed by WHO in 1982, with proven sensitivity and specificity across different countries and clinical settings. 1, 3

Alternative brief screening includes: 3

• CAGE Questionnaire: 4 questions with 85% sensitivity and 89% specificity; two or more "yes" responses indicate AUD
• AUDIT-C: Shortened 3-question version focusing on consumption patterns with maintained sensitivity

Important Clinical Considerations

Avoid using the term "alcoholic" as it is stigmatizing and not clinically useful—the DSM-5 concept of AUD represents an important advancement by recognizing varying levels of severity rather than arbitrary categorical distinctions. 1, 3

All criteria are not equally severe in practice: Research demonstrates substantial variability in implied severity across different criteria combinations at each level of endorsement, with nontrivial overlap in implied severity across criterion counts. 4 However, the simple criterion count remains the validated approach for clinical diagnosis. 1

AUD frequently co-occurs with other psychiatric conditions that may complicate diagnosis and treatment, particularly major depression, PTSD, borderline personality disorder, and antisocial personality disorder, which are specifically associated with severe AUD. 3, 2