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Addictions

The Diagnostic Criteria for Substance Use Disorders (Addiction)

A. Tom Horvath, Ph.D., ABPP, Kaushik Misra, Ph.D., Amy K. Epner, Ph.D., and Galen Morgan Cooper, Ph.D.

list with boxes checkedThe DSM-5 establishes nine types of Substance-Related Disorders:

1. Alcohol
2. Caffeine*
3. Cannabis (e.g., marijuana)
4. Hallucinogens
5. Inhalants
6. Opioid (e.g., heroin)
7. Sedatives, Hypnotics, or Anxiolytics (e.g., valium, "qualudes")
8. Stimulants (cocaine, methamphetamine)
9. Tobacco

*Substance use disorder does not apply to caffeine.

Regardless of the particular substance, the diagnosis of a substance use disorder is based upon a pathological set of behaviors related to the use of that substance. These behaviors fall into four main categories:

1. Impaired control
2. Social impairment
3. Risky use
4. Pharmacological indicators (tolerance and withdrawal)

Let's review each of these key diagnostic criteria in greater detail.

1.A. Impaired control:

Impaired control may be evidenced in several different ways:

1) Using for longer periods of time than intended, or using larger amounts than intended; 2) Wanting to reduce use, yet being unsuccessful doing so; 3) Spending excessive time getting/using/recovering from the drug use; 4) Cravings that are so intense it is difficult to think about anything else.

2.B. Social impairment

You may recall our definition of addiction: Addiction is repeated involvement with a substance or activity, despite the substantial harm it now causes, because that involvement was (and may continue to be) pleasurable and/or valuable. Social impairment is one type of substantial harm (or consequence) caused by the repeated use of a substance or an activity.

5) People may continue to use despite problems with work, school or family/social obligations. This might include repeated work absences, poor school performance, neglect of children, or failure to meet household responsibilities.

6) Addiction may also be indicated when someone continues substance use despite having interpersonal problems because of the substance use. This could include arguments with family members about the substance use; or, losing important friendships because of continued use.

7) Important and meaningful social and recreational activities may be given up or reduced because of substance use. A person may spend less time with their family, or they may stop playing golf with their friends.

3.C. Risky Use

The key issue of this criterion is the failure to refrain from using the substance despite the harm it causes.

8) Addiction may be indicated when someone repeatedly uses substances in physically dangerous situations. For instance, using alcohol or other drugs while operating machinery or driving a car.

9) Some people continue to use addictive substances even though they are aware it is causing or worsening physical and psychological problems. An example is the person who continues to smoke cigarettes despite having a respiratory disorder such as asthma or COPD.

4.D. Pharmacological indicators: Tolerance and Withdrawal

For many people, tolerance and withdrawal are the classic indicators of advanced addiction. As such, these are particularly important concepts. This criterion refers to the adjustment the body makes as it attempts to adapt to the continued and frequent use of a substance. This adjustment is called maintaining homeostatic balance.

10) Tolerance occurs when people need to increase the amount of a substance to achieve the same desired effect. Stated differently, it is when someone experiences less of an effect using the same amount. The "desired effect" might be the desire to avoid withdrawal symptoms. On the other hand, it may be the desire to get high. People experience tolerance differently; i.e., people vary in their sensitivities to different substances. Specific drugs will vary in terms of how quickly tolerance develops and the dose needed for tolerance to develop.

11) Withdrawal is the body's response to the abrupt cessation of a drug, once the body has developed a tolerance to it. The resulting cluster of (very unpleasant and sometimes fatal) symptoms is specific to each drug. We discuss these specific symptoms in each substance category. Although withdrawal is very unpleasant, it does not usually require medical assistance. However, withdrawal from some drugs can be fatal. Therefore, consult with a medical professional before attempting to stop drug use after a period of heavy and continuous use. This will ensure that quitting is as safe and comfortable as possible.

If a person is experiencing withdrawal symptoms at the time they are being evaluated for treatment, they will be diagnosed with both substance use and substance withdrawal.

A person needs to meet at least 2 of these criteria to be diagnosed with a substance-use disorder. The severity of addiction is determined by the number of criteria met

 

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