Decoding DSM-5 Substance Use Disorders Classification

Learn more about the DSM-5 substance use disorders classification and how it informs treatment in this comprehensive article.

What is the DSM-5?

The DSM-5 stands for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. It provides descriptions, symptoms, and other criteria for diagnosing mental health disorders. The DSM-5 is the standard reference that healthcare providers use to diagnose mental conditions.1

The American Psychiatric Association (APA) publishes the DSM. It provides a common language and criteria for classifying mental disorders. The DSM is regularly updated with new research and clinical experience.

DSM-5 Substance Use Disorders

The Difference Between DSM-5 Substance Use Disorders and Behavioral Disorders

The DSM-5 describes substance use disorders (SUD) and separates them from non-substance addictions in the following ways:

DSM-5 Substance Use Disorders

Substance use disorders are characterized by cluster symptoms indicating that a person continues using the substance despite significant substance-related problems.

The set of diagnostic criteria includes:

  1. Impaired control over substance use
  2. Social impairment due to substance use
  3. Risky use of the substance
  4. Tolerance
  5. Withdrawal

Substances Included in the DSM-5 Substance Use Disorders Classification

Some of the substances included for DSM-5 substance use disorders classifications are:

  • Alcohol
  • Cannabis
  • Hallucinogens
  • Inhalants
  • Opioids
  • Sedatives
  • Stimulants
  • Tobacco
  • Other or unknown substances

Behavioral Addictions

Behavioral addictions are a newer area of recognition in the field of mental health. In the DSM-5, the only officially recognized condition in this category is gambling disorder. It’s characterized by a persistent and recurrent problematic gambling behavior leading to significant impairment or distress.

It’s classified similarly to substance use disorders with criteria that reflect:2
  • A need to gamble with increasing amounts of money
  • Repeated unsuccessful efforts to control or stop gambling
  • Gambling that leads to distress or impairment

Internet Gaming Disorder

This condition is included in Section III of the DSM-5. This is the section for conditions that need further research before being officially recognized as disorders.

Internet gaming disorder is listed as a condition for further study, suggesting that it’s on the radar of the APA as a potential addition in future versions of the DSM.

Internet gaming disorder is when someone uses Internet games so much that it affects their functioning.3

The Importance of Distinguishing Between DSM-5 Substance Use Disorders and Behavioral Disorders

It’s important to understand the differences between DSM-5 substance use disorders and behavioral addictions for a several reasons, including:

  • Clinical recognition: Recognizing that behavioral patterns are similar to substance abuse helps legitimize them as mental health conditions.
  • Diagnostic criteria: By distinguishing substance use disorders and behavioral addictions, clinicians can create unique diagnostic criteria for each disorder. These criteria will focus on the specific behaviors and symptoms of each disorder.
  • Treatment approaches: Understanding the differences and similarities between substance-related and non-substance-related disorders allows clinicians to develop appropriate treatment plans.
  • Research: Differentiating disorders in the DSM-5 encourages specific paths of research. This helps to further understand and treat each condition based on its unique characteristics.

The distinction between DSM-5 substance use disorders and non-substance-related addictions helps with the appropriate diagnosis, research, and treatment of these disorders.

How Does the DSM-5 Substance Use Disorders Classification Help Clinicians Understand Addiction?

The DSM-5 introduced several changes from previous versions. One of these changes is a more dimensional approach to diagnosis that reflects a continuum of severity rather than a categorical presence or absence of a disorder. This is particularly evident in the diagnosis of SUD.

Dimensional Assessments

The DSM-5 uses dimensional assessments to measure the severity and complexity of substance use disorders. These assessments consider the number and intensity of symptoms.4

This is different from the DSM-IV. The DSM-IV used two categories for substance-related disorders: substance abuse and substance dependence.

Each category had specific criteria. The DSM-5 combines these into a single disorder measured on a continuum from mild to severe.

Severity Specifiers

The severity specifiers are a key element of the DSM-5 assessment. The criteria of DSM-5 substance use disorders use the number of diagnostic criteria met to determine the severity of the disorder:

  1. Mild substance use disorder: The presence of 2-3 symptoms.
  2. Moderate substance use disorder: The presence of 4-5 symptoms.
  3. Severe substance use disorder: The presence of 6 or more symptoms.

Here’s how these assessments and severity specifiers help clinicians with diagnosis:

Individualized Diagnosis

They allow for a more nuanced understanding of a person’s disorder based on the number and severity of symptoms, rather than a simple yes/no diagnosis.

Tailored Treatment

By providing a clearer picture of severity, clinicians can better tailor treatment plans to a person’s needs.

Monitoring Progress

Severity specifiers can also help in monitoring a person’s progress over time. As the number of symptoms decreases, so does the severity classification. This can be encouraging for patients and useful for clinicians in assessing treatment effectiveness.

Research and Outcome Prediction

These specifiers make it easier to study the results of different levels of DSM-5 substance use disorders severity. They can predict how the disorder will progress and if there will be complications like withdrawal or other mental health disorders.

Communication Between Professionals

They provide a common language that clinicians can use to communicate about the severity and implications of a person’s substance use. This aids in coordinated care.

Dimensional assessments and severity specifiers in the DSM-5 substance use disorders classification allow for a more detailed understanding of addiction. They reflect the complex nature of addictive behaviors and their impact.

The Validity and Reliability of DSM-5 Substance Use Disorders Classification

The DSM-5’s approach to diagnosing substance use disorders has spurred considerable debate among researchers, clinicians, and policy makers regarding its validity and reliability. These debates have potential implications for those seeking treatment and support.

Here’s an exploration of some of the central points of these debates and their impacts:

Validity Concerns

The DSM-5 uses a hybrid categorical and dimensional approach to diagnosis. While this recognizes the spectrum of severity, some argue that it may not fully capture the complexity of addiction.

The cut-offs for mild, moderate, and severe SUDs are also somewhat arbitrary. There’s a debate about whether the presence of two symptoms is sufficient for a mild diagnosis. Critics suggest that this threshold may pathologize what could be lower-risk substance use.

The criteria for SUDs are applied uniformly across different substances, despite clear differences in the use and effects of various substances. Some argue that this uniformity may not accurately reflect the unique challenges associated with specific substances.

Reliability Issues

Some diagnostic criteria can be subjective. They may rely heavily on the person’s self-reporting or the clinician’s interpretation of behaviors.

The high comorbidity of SUDs with other mental health conditions can also complicate diagnosis. This is because symptoms may overlap with or be influenced by other disorders. This could potentially lead to misdiagnosis or underdiagnosis.

Impact on People Seeking Treatment

There are many potential impacts of these arguments on those seeking treatment, including:

  • Potential for stigma: A diagnosis of SUD, even at a mild level, carries the potential for stigma. This could deter some people from seeking help due to fear of being labeled as having an addiction.5
  • Limiting treatment resources: The expanded criteria may also mean more people qualify for a diagnosis. This can stretch already limited treatment resources thinner and affects the quality of care for those with severe disorders.
  • Lack of treatment information: The severity specifiers of the DSM-5 substance use disorders aim to guide treatment intensity. But, there’s concern that they may not fully inform clinicians about the best course of treatment. This is because the number of symptoms does not always correlate with the best intervention strategies.

In response to these debates, many in the field call for ongoing research and refinement of the DSM criteria. Some researchers and clinicians are looking towards other systems and models, like the International Classification of Diseases (ICD) for SUD diagnosis and treatment.

How Does the DSM-5 Substance Use Disorders Address the Use of Multiple Substances?

Polysubstance use refers to the use of multiple substances at the same time. This is common among people with substance use disorders. In 2019, 50% of drug overdoses involved more than one substance.6

Here’s how the DSM-5 approaches this issue:

  • Criteria overlap: The diagnostic criteria for DSM-5 substance use disorders are similar across different substances. This allows for the possibility that the same behavior could be due to the use of multiple substances.
  • Specifying substances: When diagnosing an SUD, clinicians are instructed to specify the particular substance that’s the focus of the diagnosis. In cases of polysubstance use, a separate diagnosis can be made for each substance if the criteria are met for each one independently.
  • Other (or unknown) substance use disorder: For situations where someone uses multiple substances but the specific substances are not known, the DSM-5 substance use disorders includes a category called “other (or unknown) substance use disorder.” This is a catch-all category that can be used when the substance doesn’t fit into one of the specific substance categories listed in the DSM-5.
  • Associated features supporting diagnosis: The DSM-5 substance use disorders classification also allow clinicians to consider the broader context of a person’s substance use. This includes how multiple substances may interact with one another and the cumulative effect on the person’s health and functioning.

Impact on Diagnosis and Treatment

Polysubstance use can complicate the diagnostic process. This is because effects of different substances can overlap, mask, or worsen each other. This makes it harder to attribute symptoms to a single substance.

Clinicians must also be careful not to overlook other SUDs when someone presents with a clear problem with one substance. All substances used by the person should be evaluated.

Despite these provisions, the DSM-5’s approach to polysubstance use has received criticism. Some experts argue that it doesn’t fully capture the complexity of interactions between different substances.

Because each substance is treated separately, the approach may not adequately reflect the integrated experience of people who use multiple substances and their specific treatment needs.

DSM-5 Substance Use Disorders Classification: Understanding Addiction and Recovery

DSM-5 substance use disorders classifications outline specific criteria for categorizing the current status of SUDs in the context of remission and relapse. These designations help clinicians and patients understand the progression and regression that can occur over time.

Early Remission

Early remission is applied when someone, after meeting criteria for SUD, doesn’t meet those criteria (except for craving) for at least 3 months but for less than 12 months.

This is a critical period that indicates a person is in the process of recovery but is still at a higher risk for relapse due to the shorter duration of abstinence.

Sustained Remission

Sustained remission is used when someone hasn’t met the SUD criteria (except for craving) for a period of 12 months or longer. Sustained remission suggests a more stable state of recovery.The likelihood of relapse might be lower but not impossible.7

The significance of these stages includes:

  • Recognizing where a person is in the course of SUD recovery can help tailor treatment interventions.
  • Providing information about the prognosis of the disorder. Often, the longer someone’s in remission, the better their prognosis.
  • Both the risk and the triggers for relapse can change over time. An individual in early remission may be at risk due to more acute withdrawal symptoms. Someone in sustained remission may encounter relapse triggers in stress or life transitions.

Relapse

Relapse is defined as the return to substance use after a period of abstinence or significant reduction in use. About 40-60% of people with SUD will relapse.8

Relapse is not considered a standalone diagnostic category but rather an event that can occur during the course of DSM-5 substance use disorders treatment.

The significance of relapse includes:

  • A relapse can indicate that the current treatment approach needs to be re-evaluated and adjusted to better meet the person’s needs.
  • Recognizing relapse as a possible part of the SUD trajectory can help frame addiction as a chronic disease.
  • By acknowledging relapse as a component of the disorder, it may help reduce the stigma and self-blame that people often experience.
  • Identifying patterns in relapse can lead to the development of better prevention strategies and can help people early warning signs.

Maintenance Therapy and Controlled Use

The DSM-5 substance use disorders classification recognizes that some people may not achieve complete abstinence.

But, they may engage in maintenance therapy or controlled use that doesn’t meet SUD criteria. These cases must be assessed individually to determine if criteria for SUD are met.

These aspects of SUDs help people understand the dynamic and long-term nature of the disorders. They emphasize the need for flexible treatment approaches and the development of robust support systems for the recovery journey.

How Do DSM-5 Substance Use Disorders Address Stigma and Self-Disclosure?

The DSM-5 does not provide specific guidelines or strategies for addressing issues related to stigma and self-disclosure in clinical practice. But, the DSM-5 does contribute to reducing stigma by framing SUD as a medical condition.

This can help change public perception and encourage a more compassionate view of addiction. By using standardized criteria for diagnosis, it also aims to move away from character judgments about people with SUD.

To further address stigma and facilitate self-disclosure during the treatment process, healthcare providers often adopt the following strategies:

Person-Centered Language

Health professionals are encouraged to use person-first language. For example, they can say “person with a substance use disorder” rather than “addict” or “alcoholic.”

Confidentiality

Adherence to strict confidentiality laws reassures patients that their information is protected.

Trauma-Informed Care

Recognizing the high incidence of trauma in those with SUD, practitioners strive to create an environment where patients feel safe to disclose sensitive information.

Motivational Interviewing

Techniques like motivational interviewing involve an empathetic communication style that helps people explore their own desire to change.

Cultural Competence

It’s important for providers to understand and respect the diverse cultural backgrounds. Cultural backgrounds can affect perceptions of substance use and willingness to seek help.

While these strategies aren’t explicitly outlined in the DSM-5, they’re often included into clinical practice. These approaches can encourage people to seek and continue treatment. They can also improve the outcomes for those struggling with addiction.

Considerations for Gender and Sexual Diversity in the Assessment of DSM-5 Substance Use Disorders

The DSM-5 doesn’t explicitly integrate gender and sexual diversity considerations into the criteria for SUD. The diagnostic criteria are written to be applicable to all people, regardless of gender identity or sexual orientation.

In clinical practice, healthcare providers are more aware that gender identity and sexual orientation can influence the risk, prevalence, and presentation of SUD.

Here are some ways considerations for gender and sexual diversity are integrated into SUD assessment and diagnosis:

Tailored Screening and Assessment

Clinicians are encouraged to use screening and assessment tools that are sensitive to the specific needs and experiences of LGBTQ+ patients. Some assessment tools have been adapted or developed to be more inclusive and relevant for these populations.

Training and Competency

Healthcare professionals are trained to be culturally competent in addressing the needs of people from various gender and sexual minorities.

This includes understanding social stressors such as discrimination, stigma, and violence that contribute to substance use and impact mental health.

Recognition of Disparities

It is recognized that LGBTQ+ patients may face higher rates of substance use due to discrimination. Research has shown that LGBTQ+ individuals were almost twice as likely to have an SUD than their heterosexual counterparts.9

Clinicians are trained to ask about and consider this during the assessment process.

Treatment Environment

A nonjudgmental treatment environment is critical. This can include displaying symbols that indicate an LGBTQ+-friendly space or having staff members who are part of the LGBTQ+ community.

Providers are encouraged to ensure that treatment settings are welcoming and affirming of all gender identities and sexual orientations.

Inclusive Health History

Taking an inclusive health history is essential. Clinicians should ask about sexual orientation and gender identity in a respectful and confidential manner to inform treatment planning.

History taking should also account for factors like:

  • Partnership status
  • Family of choice
  • Other social support systems

It’s important for clinicians to create an environment where all patients feel safe disclosing their gender identity and sexual orientation. 

By being mindful of these considerations, healthcare providers can ensure that diagnosis and treatment are as effective as possible.

The Implications of Changing DSM-5 Substance Use Disorders Diagnostic Criteria

Changes in the diagnostic criteria within the DSM-5 can have profound implications for understanding and treating SUD.

Here’s how these changes could impact various aspects of the field:

Clinical Practice

If the criteria become stricter, fewer people may meet the threshold for diagnosis. This could potentially leave some without access to necessary treatment.

On the other hand, if the criteria are broadened, it could mean more people qualify for a diagnosis. This could impact treatment resources.

Diagnoses based on DSM-5 substance use disorders criteria often dictate insurance coverage. Changes in the DSM could affect coverage for treatment, with certain diagnoses or severities receiving more or less coverage.

Research and Epidemiology

Alterations in diagnostic categories may lead to changes in the reported prevalence of SUDs. This can affect public health planning and policy-making.

New or revised criteria can also shift the focus of research studies to explore different aspects of SUD, such as emerging substances of abuse or intervention strategies.

Public Perception and Stigma

How DSM-5 substance use disorders are categorized and described can influence public stigma. A move toward more medical terms can help reduce stigma.

Changes in the DSM can also lead to increased awareness and understanding of SUDs if these changes are explained to the public. But, pathologizing language can worsen stigma.

Changes to the DSM-5 substance use disorders criteria and categories can influence a wide array of areas. It’s crucial that any revisions to the DSM are made with careful consideration of these implications.

DSM-5 Substance Use Disorders

Get Help at Continuum Outpatient Center

If you or someone you know has questions about DSM-5 substance use disorders criteria, Continuum Outpatient Center is here to help. Continuum Outpatient Center is a substance use and mental health facility located in San Antonio, Texas.

About Continuum

At Continuum Outpatient Center, the DSM-5 is a key tool for diagnosing these disorders. These tools help our clinicians understand the disorders and their impacts on a person’s life. The DSM-5 substance use disorders can help guide the level of care and types of services provided.

But our program does not only focus on diagnostic tools. We work with each person using a holistic wellness approach to treat the whole person. This combined approach provides the most effective treatment suited for long-term recovery.

Our focus is on helping people develop healthy coping skills, rebuild strong relationships, and address trauma histories.

Contact Continuum Outpatient Center Today

Contact Continuum Outpatient Center today to start your journey to recovery. Call us at 210.405.5935 or visit contact for more information about DSM-5 substance use disorders and available treatment options.

Questions About Treatment?

Reach out to our knowledgeable and compassionate Continuum Outpatient Center team for the guidance and support you need for sustainable recovery. We’re here to help you build a foundation for long-term happiness, wellness, and healing.