The new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has a number of changes to addictions, substance-related disorders and alcoholism. This article outlines some of the major changes to these conditions.

According to the American Psychiatric Association (APA), the publisher of the DSM-5, the major change with substance abuse and alcohol abuse and dependence disorders has been the removal of the distinction between “abuse” and “dependence.” The chapter also moves “gambling disorder” into it as a behavioral addiction. According to the APA, this change “reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance use disorders to a certain extent.”

Criteria and Terminology

I always thought it was completely arbitrary that the DSM-IV made a distinction between someone struggling with substance “abuse” and “dependence.” To me — and to many other clinicians — they instead appeared to be the same disorder but on a continuum of abuse. Finally, the DSM-5 comes around to the convention wisdom of therapists in the field.

“Criteria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders, where relevant,” according to the APA.

There are two major changes to the new DSM-5 criteria for substance use disorder:

  • “Recurrent legal problems” criterion for substance abuse has been deleted from DSM-5
  • A new criterion has been added: craving or a strong desire or urge to use a substance

The threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria. This is a change from DSM-IV, where abuse required a threshold of one or more criteria be met, and three or more for DSM-IV substance dependence.

Cannabis withdrawal is new for DSM-5, according to the APA, as is caffeine withdrawal (which was in DSM-IV Appendix B, Criteria Sets and Axes Provided for Further Study).

“Of note, the criteria for DSM-5 tobacco use disorder are the same as those for other substance use disorders. By contrast, DSM-IV did not have a category for tobacco abuse, so the criteria in DSM-5 that are from DSM-IV abuse are new for tobacco in DSM-5.”

Severity of the DSM-5 substance use disorders is based on the number of criteria endorsed:

  • 23 criteria indicate a mild disorder
  • 45 criteria, a moderate disorder
  • 6 or more, a severe disorder

The DSM-5 removes the physiological subtype (not sure when this was ever used in the DSM-IV), as well as the diagnosis for “polysubstance dependence.”

Last, the APA notes that, “early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without substance use disorder criteria (except craving), and sustained re-mission is defined as at least 12 months without criteria (except craving). Additional new DSM-5 specifiers include in a controlled environment and on maintenance therapy as the situation warrants.”