7.2 DSM-5-TR Substance Use Disorder Criteria
Key Takeaways
- DSM-5-TR diagnoses a substance use disorder when 2 or more of 11 criteria occur within 12 months and cause clinically significant impairment or distress; each substance is diagnosed separately.
- The 11 criteria cluster as impaired control (larger/longer, cut-down, time spent, craving), social impairment (role failure, interpersonal problems, activities given up), risky use (hazardous use, use despite physical or psychological harm), and pharmacological (tolerance, withdrawal).
- Craving was added in DSM-5; recurrent legal problems were removed from the DSM-IV abuse list and are not required for the diagnosis.
- DSM-5 combined DSM-IV abuse and dependence into one use-disorder spectrum; polysubstance dependence was eliminated.
- Tolerance and withdrawal are not required; when they occur solely because a medication is taken as prescribed under medical supervision, those two criteria are not counted toward a use disorder.
7.2 DSM-5-TR Substance Use Disorder Criteria
Quick Answer: A DSM-5-TR substance use disorder (SUD) is a problematic pattern of use leading to clinically significant impairment or distress, shown by at least 2 of 11 criteria within 12 months. Craving is one of the 11. Recurrent legal problems from DSM-IV abuse are gone. Tolerance and withdrawal are not required. Diagnose each substance separately.
Domain II.D of the November 2022 ADC candidate guide asks counselors to use established diagnostic criteria for evaluating substance use and names the Diagnostic and Statistical Manual of Mental Disorders (DSM). IC&RC's current ADC Reference List, updated February 2025, still cites DSM-5 (2013). The DSM-5-TR (2022) text revision did not change the 11 SUD criteria or the severity bands you will use in 7.3. Independent ADC prep by OpenExamPrep teaches the current clinical criteria and says so — it does not claim a partnership with the American Psychiatric Association or with IC&RC.
Who may formally assign a diagnosis is a license, agency, and jurisdiction question (Domain IV scope). The exam still expects you to apply the criteria during evaluation: count them, name the substance, and avoid DSM-IV leftovers.
What changed from DSM-IV — and what did not
DSM-IV split abuse (1 of 4 consequences, including legal problems) from dependence (3 of 7, with a physiological subtype). That split produced odd cases: people with many "abuse" items and no "dependence," and people whose only "abuse" item was an arrest. DSM-5 combined those lists into one SUD per substance on a mild-to-severe spectrum.
Two criterion-level changes matter on the exam:
- Added: craving — a strong desire or urge to use. People in recovery can crave for years; that fact is why remission specifiers (7.3) except craving.
- Removed: recurrent legal problems. Arrests vary by neighborhood, policing, and race. Legal history still belongs in the biopsychosocial record (7.4) as context. It is not a required diagnostic checkbox.
Polysubstance dependence was eliminated. You do not write a single "polysubstance" dependence diagnosis because the person uses three drugs. You can diagnose alcohol use disorder and opioid use disorder in the same person if each substance meets 2+ criteria.
Tobacco use disorder uses the same 11-criterion logic. Gambling disorder lives in the same DSM chapter but is not a substance. Caffeine use disorder remains a condition for further study, not a full SUD you should invent on an intake.
The 12-month rule and the 2+ threshold
Criterion A is a pattern, not a single binge. The 11 items must occur within a 12-month period. Two items is the floor for a diagnosis (severity in 7.3). One item — for example, a single DUI with no other criteria — is not an SUD, though it is still a risk event that belongs in the history.
Clinically significant impairment or distress is part of the stem. Counting two trivia items with no functional meaning is not the spirit of the criteria. On the exam, though, if the vignette clearly meets two criteria, do not withhold the diagnosis because the client "doesn't look like an addict."
Four clusters, 11 criteria
The 11 items are easier to remember as four clusters. The clusters are a study device; the diagnosis still counts items, not clusters. You do not need one item from each cluster.
Impaired control (criteria 1–4)
- Larger amounts or longer period than intended. "I meant to have two beers; I finished the handle."
- Persistent desire or unsuccessful efforts to cut down or control use. Repeated failed rules ("only weekends," "only after 5 p.m.").
- A great deal of time obtaining, using, or recovering. Hours in procurement, intoxication, and hangover — not a two-minute pour.
- Craving — a strong desire or urge to use. This is the DSM-5 addition. It can persist in remission.
Social impairment (criteria 5–7)
- Failure to fulfill major role obligations at work, school, or home (missed shifts, neglected children, dropped classes) because of use.
- Continued use despite persistent or recurrent social or interpersonal problems caused or made worse by use (arguments, lost friendships, partner ultimatums).
- Important social, occupational, or recreational activities given up or reduced (quit the team, stopped seeing family, dropped hobbies that competed with use).
Risky use (criteria 8–9)
- Recurrent use in physically hazardous situations (driving, mixing sedatives, using at heights or with machinery, using alone with a lethal opioid supply).
- Continued use despite knowledge of a persistent physical or psychological problem likely caused or exacerbated by the substance (keep drinking after pancreatitis; keep using cocaine after panic attacks attributed to use).
Pharmacological (criteria 10–11)
- Tolerance — need for markedly increased amounts to get the desired effect, or markedly diminished effect with the same amount.
- Withdrawal — the characteristic withdrawal syndrome, or the substance (or a close relative, such as a benzodiazepine for alcohol) taken to relieve or avoid withdrawal.
Pharmacological criteria are not required. A person can have a severe SUD with no documented withdrawal. A person can have tolerance from prescribed opioids without an opioid use disorder if they take the medication as prescribed under medical supervision — DSM-5-TR instructs you not to count tolerance and withdrawal solely on that basis in that situation. Recreational extra doses, running out early, and doctor-shopping are a different story: then you count the behavioral criteria, and you may count pharmacological ones if they are not solely iatrogenic.
| Cluster | Criteria | Quick stem | Exam trap |
|---|---|---|---|
| Impaired control | 1–4 | Amount, cut-down, time, craving | Thinking craving is "not a real criterion" because it is subjective |
| Social impairment | 5–7 | Roles, relationships, activities given up | Using one messy Saturday as role failure |
| Risky use | 8–9 | Hazardous situations; use despite known harm | Treating a single DUI as the whole diagnosis |
| Pharmacological | 10–11 | Tolerance, withdrawal | Requiring both before you will diagnose |
How to count in a vignette
Work the vignette like a checklist. Mark only what the stem actually supports. Do not infer withdrawal because "they look dependent." Do not skip craving because it is hard to observe — if the person describes an urge that organizes the day, it counts.
Worked count
A 44-year-old drinks daily. They intend to stop at two drinks and regularly finish a fifth (criterion 1). They have tried dry January three years running and never last a week (criterion 2). They spend evenings drinking and mornings hung over (criterion 3). They describe a strong urge by 4 p.m. (criterion 4). They missed six workdays after blackouts (criterion 5). Their partner has threatened to leave; they still drink (criterion 6). They dropped the bowling league because it interfered with drinking (criterion 7). They drove after drinking twice this year (criterion 8). They keep drinking after a clinician explained alcohol's role in their gastritis (criterion 9). They need more alcohol to "feel normal" (criterion 10). Morning tremor stops after the first drink (criterion 11). That is 11 of 11 — a severe alcohol use disorder once you apply 7.3. The same person with only criteria 1, 4, and 5 has three items — still a diagnosis, mild if those three are the current total.
A 22-year-old with one cannabis possession charge and no other criteria does not have a cannabis use disorder because of the arrest. Ask the other 11. If they also fail classes, spend most waking hours high, and cannot cut down, the diagnosis rests on those items, not on the docket number.
What the 11 criteria do not do
- They do not replace a urine test (7.1). Toxicology can support recent use; it does not count as two criteria by itself.
- They do not replace intoxication and withdrawal diagnoses, which are separate DSM categories for the acute syndrome (7.3).
- They do not require the person to accept the label. You can meet criteria while saying "I don't have a problem." That disagreement is assessment data (and often sustain talk from 6.2), not a veto.
- They do not let you diagnose "addict" as a DSM term. Write the substance and the disorder: opioid use disorder, alcohol use disorder.
- They do not make legal eligibility for a program. Payers and courts have their own rules; DSM is the clinical language.
When two substances are in play, complete two checklists. Cross-tolerance (alcohol and benzodiazepines) matters for withdrawal risk (Chapter 3–4) and for criterion 11 (taking a related drug to avoid withdrawal), but it does not merge the two disorders into one count of 11.
Which statement correctly states the DSM-5-TR threshold for a substance use disorder?
Compared with DSM-IV, which change in DSM-5 / DSM-5-TR substance use disorder criteria is accurate?
A client uses more alcohol than planned, spends hours obtaining and recovering from it, reports strong urges to drink, and has missed work twice in 12 months because of drinking. There is no withdrawal. Which reading is BEST?