9.4 Substance Use, Addictive, and Co-Occurring Disorder Indicators (DSM-5-TR)
Key Takeaways
- DSM-5-TR substance use disorders use 11 criteria; severity is mild (2–3 criteria), moderate (4–5 criteria), and severe (6+ criteria), with craving added in DSM-5 and retained in the text revision.
- Substance-specific intoxication and withdrawal syndromes exist for alcohol, opioids, stimulants, cannabis, nicotine, sedatives/hypnotics/anxiolytics, hallucinogens, and inhalants; cannabis withdrawal is recognized in DSM-5-TR.
- Gambling disorder is the only behavioral addiction formally included in the DSM-5-TR Substance-Related and Addictive Disorders chapter, requiring 4+ criteria in a 12-month period.
- Co-occurring disorders (SUD + mental illness) are the rule, not the exception; integrated treatment is the evidence-based standard, and the clinician must distinguish primary mental disorders from substance-induced mental symptoms by onset, persistence during abstinence, and course.
- Ruling out substance-induced mood or psychotic symptoms requires evaluating whether symptoms began during intoxication/withdrawal and persist beyond the physiological window; symptoms lasting beyond a month of abstinence suggest a primary mental disorder.
9.4 Substance Use, Addictive, and Co-Occurring Disorder Indicators (DSM-5-TR)
Quick Answer: DSM-5-TR unified abuse and dependence into a single substance use disorder (SUD) with 11 criteria and three severity levels. The exam tests the 2-3 / 4-5 / 6+ severity cut-offs, common intoxication/withdrawal syndromes, gambling disorder as the lone behavioral addiction, and the integrated treatment principle for co-occurring disorders.
Why This Matters for the ASWB Clinical Exam
Substance use is present in a large share of clinical social work caseloads, and co-occurring mental illness is the norm. The exam repeatedly asks the clinician to (1) identify SUD severity from a vignette, (2) choose a validated screening tool, and (3) decide whether a mood or psychotic symptom is primary or substance-induced. Misjudging substance-induced symptoms leads to inappropriate diagnoses and treatment.
Substance Use Disorders: 11 Criteria and Severity
DSM-5-TR retains the single SUD diagnosis per substance, scored on 11 criteria organized in four groups:
| Group | Criteria |
|---|---|
| Impaired control | Hazardous use; use in larger amounts or longer than intended; craving; failed attempts to cut down |
| Social impairment | Failure to fulfill major role obligations; continued use despite social/interpersonal problems; activities given up |
| Risky use | Continued use despite physical/psychological problems; tolerance* |
| Pharmacologic | Withdrawal*; use to relieve or avoid withdrawal |
*Tolerance and withdrawal do not count toward the diagnosis if the substance is taken solely under medical supervision.
Severity:
- Mild: 2–3 criteria
- Moderate: 4–5 criteria
- Severe: 6 or more criteria
The early remission specifier applies when no criteria (except craving) have been met for at least 3 months but less than 12 months; sustained remission is 12 months or longer. A in a controlled environment specifier applies when the individual is in a locked setting or supervised setting with restricted access.
Intoxication and Withdrawal by Substance
The exam frequently tests substance-specific intoxication/withdrawal profiles:
| Substance | Intoxication Signs | Withdrawal Signs |
|---|---|---|
| Alcohol | Disinhibition, slurred speech, ataxia, impaired judgment | Tremor, sweating, tachycardia, anxiety, seizures, delirium tremens (hallucinations, autonomic instability) |
| Opioids | Pupillary constriction, sedation, slowed respiration | Pupillary dilation, piloerection, rhinorrhea, lacrimation, diarrhea, muscle aches, yawning |
| Stimulants (cocaine, amphetamines) | Pupillary dilation, tachycardia, hypertension, agitation, euphoria or dysphoria | Fatigue, vivid unpleasant dreams, hypersomnia, increased appetite, depression |
| Cannabis | Euphoria, conjunctival injection, increased appetite, dry mouth | Irritability, anxiety, sleep difficulty, decreased appetite (recognized in DSM-5-TR) |
| Nicotine | — | Irritability, anxiety, craving, increased appetite, dysphoric mood |
| Sedatives/hypnotics/anxiolytics | Sedation, ataxia, slurred speech | Autonomic hyperactivity, tremor, insomnia, anxiety, seizures |
| Hallucinogens | Perceptual changes, derealization, depersonalization | Generally not recognized |
| Inhalants | Belligerence, ataxia, nystagmus, euphoria | Usually mild; not formally recognized |
Screening Tools and SBIRT
- AUDIT-C: a 3-item alcohol screen (frequency, typical quantity, heavy-episode frequency); a score of 4+ for men or 3+ for women indicates risky drinking warranting further assessment.
- AUDIT: the full 10-item Alcohol Use Disorders Identification Test; a score of 8+ indicates hazardous use, 16+ likely dependence.
- DAST-10: Drug Abuse Screening Test for non-alcohol substances.
- SBIRT (Screening, Brief Intervention, Referral to Treatment): the integrated public-health framework that the exam treats as the preferred model for universal screening and brief intervention in medical and behavioral health settings.
Gambling Disorder (Behavioral Addiction)
Gambling disorder is the only non-substance behavioral addiction formally included in the DSM-5-TR Substance-Related and Addictive Disorders chapter. It requires 4 or more of nine criteria in a 12-month period: preoccupation, tolerance (need to increase stakes), withdrawal (restlessness/irritability when cutting down), repeated unsuccessful attempts to stop, gambling to escape negative mood, chasing losses, lying to conceal, endangering relationships or opportunities, and relying on others for money. Severity is mild (4–5 criteria), moderate (6–7), severe (8–9). Internet gaming disorder remains in Section III as a condition for further study, not a formal diagnosis.
Co-Occurring Disorders and Integrated Treatment
Co-occurring disorders (also called dual diagnosis) refer to the simultaneous presence of a substance use disorder and another mental disorder; prevalence is high (roughly half of those with severe mental illness also have a lifetime SUD). The exam expects the clinician to know that integrated treatment—simultaneous, coordinated care for both conditions by the same team or coordinated providers—is the evidence-based standard, not sequential or parallel treatment.
Primary vs. Substance-Induced Mental Symptoms
The key assessment task is distinguishing a primary mental disorder from a substance-induced mental disorder. DSM-5-TR indicators favoring a substance-induced disorder include:
- Onset during or within a month of intoxication or withdrawal
- Symptoms resolve with abstinence (typically within a month for alcohol- or stimulant-induced mood/psychotic symptoms)
- Severity proportional to substance use
Indicators favoring a primary mental disorder (independent of substance use) include:
- Onset before the SUD or during sustained abstinence
- Symptoms persist beyond 1 month of abstinence
- Family history of the primary mental disorder
- Course that does not follow the substance use pattern
When unclear, DSM-5-TR allows a provisional diagnosis that is revised once a sufficient abstinence period clarifies the picture. The clinician should not withhold SUD treatment pending a definitive primary diagnosis; both are addressed concurrently under the integrated model.
Opioid Use Disorder Indicators
Opioid use disorder (OUD) has specific indicators the exam tests: craving, continued use despite overdose risk, recurrent overdose or near-overdose events, and pharmacologic indicators (tolerance requiring dose escalation, withdrawal when the opioid is unavailable). The 4 Ps for prenatal substance exposure (Parent, Partner, Past, Pregnancy) is a screening mnemonic for use during pregnancy; neonatal abstinence syndrome (neonatal opioid withdrawal syndrome) is a recognized consequence of prenatal opioid exposure.
A 44-year-old man presents with depressed mood and insomnia that began during a 2-week heavy alcohol binge and persist for 3 weeks after his last drink. He has no prior depression history. The most accurate DSM-5-TR assessment is alcohol-induced depressive disorder if symptoms resolve with continued abstinence; if they persist beyond 1 month of abstinence and meet MDD criteria, the diagnosis becomes co-occurring MDD and AUD.
A 30-year-old reports 7 of the 11 DSM-5-TR SUD criteria for alcohol use in the past year, including failed attempts to cut down, craving, continued use after a DUI, and withdrawal tremors. Which severity level and specifier are most accurate?
A 48-year-old woman with established alcohol use disorder presents with 3 days of tremor, sweating, tachycardia, anxiety, and visual hallucinations. She has not consumed alcohol for 2 days. Which DSM-5-TR indicator most specifically indicates delirium tremens rather than uncomplicated alcohol withdrawal?
A 50-year-old man with depression and daily cannabis use reports his low mood, anhedonia, and insomnia began during a period of heavy use and have persisted for 5 weeks after he reduced to near-abstinence with a negative urine screen. What is the most appropriate DSM-5-TR assessment reasoning?