Substance Use Disorders

DSM-IV-TR and DSM-5 Diagnostic Criteria

DSM-IV-TR Criteria for Substance Abuse:
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

• Recurrent substance use resulting in a failure to fulfill major role obligation at work, school, or home;
• Recurrent substance use in situations in which it is physically hazardous;
• Recurrent substance-related legal problems;
• Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

The symptoms have never met the criteria for substance dependence for this class of substance.

DSM-IV-TR Criteria for Substance Dependence:
A maladaptive pattern of substance use, leading to significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

1) Tolerance, as defined by either the following:

1. Need for markedly increased amounts of the substance to achieve intoxication or desired effect.
2. Markedly diminished effect with continued use of the same amount of the substance.

2) Withdrawal, as manifested by either of the following:

1. The characteristic withdrawal syndrome for the substance.
2. The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.

3) The substance is often taken in larger amounts or over a longer period than was intended.
4) There is persistent desire or unsuccessful efforts to cut down or control substance use.
5) A great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects.
6) Important social, occupational, or recreational activities are given up or reduced because of substance use.
7) The substance 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 the substance.

DSM-IV-TR Substance Dependence or Abuse Specifiers:
The following remission specifiers can be applied only after no criteria for dependence or abuse have been met for at least 1 month:

• Early Full Remission: This specifier is used if, for at least 1 month, but for less than 12 months, no criteria for dependence or abuse have been met.
• Early Partial Remission: This specifier is used if, for at least 1 month, but for less than 12 months, one or more criteria for dependence or abuse have been met (but the full criteria for dependence has not been met).

DSM-5 Diagnostic Criteria: Substance (e.g., Alcohol) Use Disorder*:
A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by 2 of the following, occurring within a 12-month period:

1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. 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.
10. Tolerance, as defined by either of the following:
    a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
    b. A markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following:
    a. The characteristic withdrawal syndrome for alcohol.
    b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Specify if:
In early remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met for at least 3 months but for less than 12 months (with the exception of criterion A4, “Craving, or a strong desire or urge to use alcohol,”1 may be met.

In sustained remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met at any time during a period of 12 months or longer (with the exception of criterion A4, “Craving, or a strong desire or urge to use alcohol,”1 may be met.

Specify if:
In a controlled environment.

Code based on current severity:

• Mild (2-3)
• Moderate (4-5)
• Severe (6+)

Note: Specifier for opioid use disorder adds the following:

• On maintenance therapy
• In a controlled environment

NOTE: When an individual meets the DSM-5 criteria identifiers for early remission the risk of imminent relapse has likely declined. When an individual has reached sustained remission, the individual is considered likely stable and the long-term prognosis significantly improves.

The American Society of Addiction Medicine defines addiction as follows:

“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”9

In addiction, there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. In terms of work relatedness, it can be of assistance to consider that addiction impairment can be explained as occurring in three major domains; craving, compulsion and the consequences ignored (the three Cs):

• The perpetual rumination and obsession related to craving a substance will result in distraction from job demands.
• Compulsions are the behaviors of either using or seeking out the desired substance, usually surreptitiously, while in the workplace. This results in disruption of performing job demands.
• Consequences ignored. The potential workplace consequences of substance dependence such as tardiness, absenteeism or performance concerns are often rationalized, minimized or denied by the individual with substance abuse or dependence when they occur.

The three clinical features of impairment as noted above will commonly eventually lead to a loss of control in terms of substance use, usually resulting in significant disability in meeting work role requirements.10