DSM 5 Criteria for Substance Use Disorders

The "Diagnostic and Statistical Manual of Mental Disorders", Fifth Edition, text revision, often called the DSM-V-TR or DSM-5-TR, is the latest version of the American Psychiatric Association’s gold-standard text on the names, symptoms, and diagnostic features of every recognized mental illness—including addictions.

The DSM-5-TR criteria for substance use disorders are based on decades of research and clinical knowledge. The DSM-5-TR was published in 2013, and in 2022, a text revision was published that included updated criteria for more than 70 disorders, including the requirements for stimulant-induced mild neurocognitive disorder.

Keep reading to learn more about the DSM-5-TR criteria for substance use disorders and how these conditions are diagnosed.

What Are Substance Use Disorders?

The DSM-5-TR recognizes substance-related disorders resulting from the use of 10 separate classes of drugs:

• Alcohol
• Caffeine
• Cannabis
• Hallucinogens
• Inhalants
• Opioids
• Sedatives
• Hypnotics, or anxiolytics
• Stimulants (including amphetamine-type substances, cocaine, and other stimulants)
• Tobacco
  

The activation of the brain’s reward system is central to problems arising from drug use. The rewarding feeling people experience due to taking drugs may be so profound that they neglect other normal activities in favor of taking the drug.

The pharmacological mechanisms for each class of drug are different. However, the activation of the reward system is similar across substances in producing feelings of pleasure or euphoria, often referred to as a "high."

The DSM-5-TR recognizes that people are not all automatically or equally vulnerable to developing substance-related disorders. Some people have lower levels of self-control that predispose them to develop problems if exposed to drugs.

Substance-Use vs. Substance-Induced Disorders

There are two groups of substance-related disorders: substance-use disorders and substance-induced disorders.

• Substance-use disorders are patterns of symptoms resulting from the use of a substance that you continue to take, despite experiencing problems as a result.
• Substance-induced disorders, including intoxication, withdrawal, and other substance/medication-induced mental disorders, are caused by the effects of substances.

DSM-5-TR Substance Use Disorder Criteria

Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria:

1. Taking the substance in larger amounts or for longer than you're meant to
2. Wanting to cut down or stop using the substance but not managing to
3. Spending a lot of time getting, using, or recovering from use of the substance
4. Cravings and urges to use the substance
5. Not managing to do what you should at work, home, or school because of substance use
6. Continuing to use, even when it causes problems in relationships
7. Giving up important social, occupational, or recreational activities because of substance use
8. Using substances again and again, even when it puts you in danger
9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance
10. Needing more of the substance to get the effect you want (tolerance)
11. Development of withdrawal symptoms, which can be relieved by taking more of the substance

It is important to note that people can experience tolerance and withdrawal in the context of taking prescription drugs to treat a medical or mental health condition. This does not necessarily mean that they have a substance use disorder, however.

Severity of Substance Use Disorders

The DSM-5-TR allows clinicians to specify how severe or how much of a problem the substance use disorder is, depending on how many symptoms are identified.

• Mild: Two or three symptoms indicate a mild substance use disorder.
• Moderate: Four or five symptoms indicate a moderate substance use disorder.
• Severe: Six or more symptoms indicate a severe substance use disorder.

Clinicians can also add "in early remission," "in sustained remission," "on maintenance therapy" for certain substances, and "in a controlled environment." These further describe the current state of the substance use disorder.

Understanding the severity of a substance use disorder can help doctors and therapists better determine which treatments to recommend. Choosing the appropriate level of care may improve a person's chances of recovery.

Substance-Induced Disorders

Substance-induced disorders involve problems that are caused by the effects of substances. Types of substance-induced disorders recognized in the DSM-5-TR include substance-induced mental disorders, intoxication, and withdrawal.

Substance/Medication-Induced Mental Disorders

Substance/medication-induced mental disorders are mental problems that develop in people who did not have mental health problems before using substances. They include:

• Substance-induced psychotic disorder: This condition involves experiencing delusions, hallucinations, or both within one month of using or withdrawing from alcohol, illicit substances, or prescription drugs.
• Substance-induced bipolar and related disorders: This condition involves experiencing manic/hypomanic symptoms, depressive symptoms, or both while using or during withdrawal from a substance.
• Substance-induced depressive disorders: This is a form of depression that can occur after using drugs, alcohol, or medications. To be diagnosed with this condition, depressive symptoms must not be related to intoxication or withdrawal.
• Substance-induced anxiety disorders: This condition involves experiencing anxiety or panic attacks due to using drugs, medications, or alcohol. Anxiety may occur during intoxication or withdrawal, but to be diagnosed, anxiety symptoms must not be symptoms of intoxication or withdrawal.
• Substance-induced obsessive-compulsive and related disorders: This condition is marked by the onset of obsessive and compulsive symptoms caused by substance use. To be diagnosed, symptoms must cause distress and impairment in a person's daily life.
• Substance-induced sleep disorders: This condition involves insomnia and other sleep problems caused by using drugs, alcohol, or certain medications.
• Substance-induced sexual dysfunctions: This condition involves experiencing difficulties with sexual arousal, desire, or performance due to substances and medications.
• Substance-induced delirium: This condition is marked by symptoms of delirium due to intoxication from a psychoactive substance, including illicit drugs, medications, and alcohol.
• Substance-induced neurocognitive disorders: This condition involves experiencing mild or major neurocognitive impairments caused by substance use that persist beyond the intoxication and acute withdrawal period.

In the text revision of the DSM-5, the information on substance-induced mild neurocognitive disorders was updated to include symptoms caused by stimulants such as methamphetamine and cocaine. Such additions were made in response to research demonstrating that prolonged stimulant use can produce lingering neurocognitive effects on learning, memory, and executive function.

Intoxication

Substance intoxication, a group of substance-induced disorders, details the symptoms that people experience when they are under the influence of drugs. Disorders of substance intoxication include:

• Marijuana intoxication
• Cocaine intoxication
• Methamphetamine intoxication (stimulants)
• Heroin intoxication (opioids)
• Acid intoxication
• Substance intoxication delirium

Withdrawal

Substance withdrawal involves experiencing physical, cognitive, and behavioral symptoms due to reducing or halting substance use. To be diagnosed with withdrawal, these symptoms must not be due to another mental disorder or medical condition.

Withdrawal from some substances (such as alcohol or barbiturates) can be severe and sometimes life-threatening. Other substances may not produce withdrawal effects when their use is halted. Some substances, such as opioids, may lead to withdrawal even when taken for a short period and for legitimate medical purposes.

Diagnosing Substance Abuse Disorders

Substance use disorders should be evaluated by a psychiatrist, psychologist, or licensed counselor specializing in drug and alcohol addictions. A health professional may utilize blood or urine tests to assess current drug use. However, it is important to note that there is not a lab test that can establish dependence or addiction. 

To diagnose a substance use disorder, a healthcare practitioner will evaluate the individual by completing a physical exam and taking a medical history. They will also ask questions about current and past substance use, including its frequency, amount, and duration.

Getting Help for a Substance Use Disorder

If you think that you or a loved one might have a substance use disorder, effective treatments are available that can help. The first step is to talk to your doctor or mental health professional about your options. Your treatment and recovery needs will vary depending on the nature and severity of your substance use. 

Residential treatment, outpatient treatment, day treatment/partial hospitalization, and sober living communities are some of the treatment options you might consider. Your treatment may involve psychotherapy, such as motivational-enhancement therapy (MET) or cognitive-behavioral therapy (CBT). Support groups can also aid your recovery, including in-person or online options.

Research also suggests that having adequate social support is important during addiction recovery. Reach out to trusted friends and family who can help you through this process. Mutual support groups and 12-step recovery groups can also be a great place to find encouragement, resources, and support.

There is no one-size-fits-all approach for treating substance use disorders. Work with your doctor to find the right approach to address your needs, provide appropriate support, and foster long-term recovery.