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Alcohol-Use Disorder

Alcohol-Use Disorder 

A.  A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:

  1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) 
  3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  4. tolerance, as defined by either of the following:

a.   a need for markedly increased amounts of the substance to achieve intoxication or desired effect

b.   markedly diminished effect with continued use of the same amount of the substance
(Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)

  1. withdrawal, as manifested by either of the following:

a.   the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)

b.   the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)

  1. the substance 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 substance use
  3. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  4. important social, occupational, or recreational activities are given up or reduced because of substance use
  5. 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.
  6. Craving or a strong desire or urge to use a specific substance.

Severity specifiers:

Moderate: 2-3 criteria positive

Severe: 4 or more criteria positive

Specify if:

With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)

Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present) 

Course specifiers (see text for definitions):

Early Full Remission

Early Partial Remission

Sustained Full Remission

Sustained Partial Remission

On Agonist Therapy

In a Controlled Environment


Rationale for Changes to Substance-Related Disorders

Tentative new title of new combined section:  Addiction and related disorders

 Combining Substance Abuse and Dependence Into One Disorder

Background. The basis of the criteria for DSM-III-R and DSM-IV substance dependence (Rounsaville et al., 1986) was the Alcohol Dependence Syndrome (Edwards and Gross, 1976), a dimensional construct representing impaired control over drinking that was generalized to drugs by the World Health Organization (Edwards et al., 1981). The dependence syndrome was described as a psychobiological process leading to impaired control over persistent, heavy drinking or drug use. The causes of dependence were considered different from the causes of substance-related consequences or disabilities, giving rise to a “bi-axial” concept of alcohol and drug disorders (Edwards & Gross, 1976), with dependence on one axis and consequences on the other. The bi-axial concept led to the DSM-III-R and DSM-IV disorders, dependence and abuse. Although Edwards assumed association between the two axes (Edwards & Gross, 1986), DSM-III-R and DSM-IV made dependence take precedence hierarchically over abuse. DSM-IV required that three of seven criteria be met for dependence, and one of four for abuse. 

Problems with the abuse/dependence distinction. Early signals of problems in the DSM-IV differentiation between abuse and dependence came from studies showing that while the test-retest reliability of DSM-IV dependence was uniformly very good to excellent, the reliability of DSM-IV abuse was lower and more variable (Hasin et al., 2006; Table 3). Many assumed that abuse was often a prodromal phase of dependence, but several prospective studies showed that this was not the case (Hasin et al., 1990, 1997; Grant et al., 2001; Schuckit et al., 2001; 2008). Further, general population studies showed that the most common way for DSM-IV alcohol abuse to be diagnosed was with a single criterion, hazardous use (generally driving after drinking) (Hasin et al., 1999; Hasin & Paykin, 1999). While certainly unwise and risky behavior, whether a psychiatric diagnosis is warranted based on this symptom alone is questionable. An additional problem with the DSM-IV division between abuse and dependence explicitly mentioned by several authors was that of “diagnostic orphans” (Hasin & Paykin, 1998; 1999; Pollack and Martin, 1999; Ray et al., 2008; Degenhardt et al., 2002; Lynskey & Agrawal, 2007; Martin et al., 2008), i.e., individuals who meet two criteria for dependence but none for abuse. Such individuals could have substance problems at the same severity level as others with a diagnosis, but were left undiagnosed by DSM-IV.  

Understanding the relationship of abuse and dependence criteria. Many analyses were conducted to better understand the relationship of abuse to dependence criteria. These included factor analytic studies, latent class analyses, and item response theory analyses.  

      Factor analyses. Several studies of alcohol abuse and dependence criteria in U.S. samples found significantly better fit for a two-factor model generally corresponding to abuse and dependence criteria (Harford and Muthen, 2001; Muthen et al., 1993; Muthen, 1995; Grant et al., 2007), but with the factors very highly correlated. Other studies using data from male Virginia twins (Gillespie et al., 2007), the National Epidemiologic Survey on Alcohol and Related Conditions) (Agrawal & Lynskey, 2007), and the Australian general population (Teesson et al., 2002) showed that both 1- and 2-factor models corresponding to cannabis dependence and abuse fit the data well, but preferred the 1-factor model due to highly correlated factors in the 2-factor model, with two studies (Teesson et al., 2002; Agrawal & Lynskey, 2007; Lynskey & Agrawal, 2007) dropping some abuse items to achieve unidimensionality. Using NLAES data (Blanco et al., 2007), two factors were also found for cannabis abuse and dependence criteria, also with a high correlation (.77) between the two factors. Among adolescents, a one-factor model fit the data well for alcohol (Gelhorn et al., 2008) and cannabis (Hartman et al., 2008). The high correlations between dependence and abuse raised questions about the utility of the two-factor solutions. 

      Latent class analyses. Latent class analysis (LCA) is used to identify homogeneous classes of individuals, and assign individuals to classes. LCA of DSM-IV abuse and dependence criteria using data from a large genetics study identified four classes (Bucholz et al., 1996) largely differentiated by successively greater endorsement probabilities for all criteria across classes. In heavy-drinking twins, four classes were found for women and five for men using DSM-IV dependence and abuse criteria (Lynskey et al., 2005). LCA results generally supported the idea of a gradient of severity for alcohol use disorders defined by the number of criteria, with inconsistent results on the presence (Lynskey et al., 2005) or absence (Bucholz, 1996) of a separate abuse class. For drug disorders, in both population-based (Grant et al., 2006; Agrawal et al., 2007) and treated adolescents (Chung & Martin, 2005), LCA identified classes based largely on severity.   

      Item Response Theory analyses: U.S. alcohol studies. When factor analysis identifies a unidimensional set of criteria, then Rasch and IRT models provide information on the severity level of individual criteria. IRT analyses show that alcohol abuse and dependence criteria were intermixed on an underlying spectrum of severity (Langenbucher et al., 2004; Kahler and Strong, 2006; Martin et al., 2006; Saha et al., 2006; Saha et al., 2007; Gelhorn et al., 2008) although some analyses required removal of criteria to achieve unidimensionality (Langenbucher et al., 2004; Saha et al., 2006). IRT analyses of alcohol problem scales (as distinct from diagnostic criteria) in various samples suggested similar structure (Krueger et al., 2004; Kahler et al., 2003a; Kahler et al., 2003b). An additional analysis using the “discontinuity” approach (Hasin & Beseler, 2009) produced findings consistent with the IRT results.  

      Item Response Theory analyses: international alcohol studies.  To understand how alcohol abuse and dependence criteria perform in international settings, Borges et al. (in press) conducted IRT analyses of data from patients attending 7 emergency rooms in 4 countries: Argentina, Mexico, Poland and the U.S. DSM-IV abuse and dependence formed a unidimensional continuum in the patients regardless of the country of survey. In IRT analyses of drinkers from an Australian general population sample (Proudfoot et al., 2008) for current criteria and in an Israeli general population data (Shmulewitz et al., under review) similar results were obtained within the same sample for current and lifetime criteria. 

      Item Response Theory analyses: drug abuse and dependence. Fewer IRT analyses have been conducted for drug use disorders, but these are generally consistent with the studies on alcohol, showing that drug abuse and dependence criteria were intermixed on an underlying spectrum of severity. These include studies of the cannabis abuse and dependence criteria in the NESARC (Compton et al., 2009), other substances in NESARC (Lynskey & Agrawal, 2007), cannabis use disorder symptoms in an American Indian community sample (Gilder et al., 2009), a twin study of several different substances (Gillespie et al., 2007), two adolescent cannabis studies (Martin et al., 2006; Hartman et al., 2008), and a study of alcohol, cannabis, cocaine and heroin abuse and dependence criteria in 663 adult patients in treatment for substance and psychiatric problems (Hasin et al., in preparation).

This large body of literature on the structure of abuse and dependence criteria in clinical and general population samples suggests that the DSM-IV abuse and dependence criteria can be considered to form a unidimensional structure, with abuse and dependence criteria interspersed across the severity spectrum. 

Summary and conclusion. Problems identified with the DSM-IV division between abuse and dependence led to many studies of the structure of the abuse and dependence in a variety of general population and clinical settings. Given the empirical evidence, the DSM-V Substance Use Disorders Workgroup recommends combining abuse and dependence into a single disorder of graded clinical severity, with two criteria required to make a diagnosis. 1280


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Chung T, Martin CS 2005. Classification and short-term course of DSM-IV cannabis, hallucinogen, cocaine, and opioid disorders in treated adolescents. J. Consult. Clin. Psychol. 73, 995-1004.

Compton WM, Saha TD, Conway KP, Grant BF 2009. The role of cannabis use within a dimensional approach to cannabis use disorders. Drug Alcohol Depend. 100, 221-227.

Dawson DA, Saha TD, Grant BF. 2009. A multidimensional assessment of the validity and utility of alcohol use disorder severity as determined by item response theory models. In press, Drug Alcohol Depend.

Degenhardt L, Lynskey M, Coffey C, Patton G. 2002. Diagnostic orphans' among young adult cannabis users: persons who report dependence symptoms but do not meet diagnostic criteria. Drug Alcohol Depend. 67:205-12.

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Gelhorn H, Hartman C, Sakai J, Stallings M, Young S, Rhee SH, Corley R, Hewitt J, Hopfer C, Crowley T. 2008. Toward DSM-V: an Item Response Theory analysis of the diagnostic process for alcohol abuse and dependence in DSM-IV. J. Amer. Acad. Child Adol. Psychiatry 47, 1329-1339.

Gilder DA, Lau P, Ehlers CL. 2009. Item response theory analysis of lifetime cannabis use disorder symptom severity in an American Indian community sample. J. Stud. Alc Drugs 70, 839-849.

Gillespie NA, Neale MC, Prescott CA, Aggen SH, Kendler KS, 2007.  Factor and item-response analysis DSM-IV criteria for abuse of and dependence on cannabis, cocaine, hallucinogens, sedatives, stimulants and opioids.  Addiction 102, 920-930.

Grant BF, Stinson FS, Harford TC, 2001. Age at onset of alcohol use and DSM-IV alcohol abuse and dependence: a 12-year follow-up. J. Subst. Abuse 13, 493-504.

Grant BF, Harford TC, Muthen BO, Yi H-Y., Hasin DS, Stinson FS, 2007. DSM-IV alcohol dependence and abuse: further evidence of validity in the general population. Drug Alcohol Depend. 86,154-166.

Grant JD, Scherrer JF, Neuman RJ., Todorov AA, Price RK, Bucholz KK. 2006. A comparison of the latent class structure of cannabis problems among adult men and women who have used cannabis repeatedly. Addiction 101, 1133-1142.

Harford TC, Muthen BO, 2001. The dimensionality of alcohol abuse and dependence: a multivariate analysis of DSM-IV symptom items in the National Longitudinal Survey of Youth. J. Stud. Alcohol 62, 150-157.

Hartmen CA, Gelhorn H, Crowley TJ, Sakai JT, Stallings M, Young SE, Rhee SH, Corley R, Hewitt JK, Hopfer CJ. 2008. Item Response Theory analysis of DSM-IV cannabis abuse and dependence criteria in adolescents. J. Amer. Acad. Child Adol. Psychiatry 47, 165-173.

Hasin DS, Beseler CL 2009. Dimensionality of lifetime alcohol abuse, dependence and binge drinking. Drug Alcohol Depend 101:53-61.

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Hasin D, Paykin A: 1999. Dependence symptoms but no diagnosis: diagnostic “orphans” in a 1992 national sample. Drug Alch Dependence, 53:215-222

Hasin D, Paykin A: 1998. Dependence symptoms but no diagnosis: diagnostic “orphans” in a community sample. Drug Alch Dependence, 50:19-26

Hasin D, Paykin A: 1999. Dependence symptoms but no diagnosis: diagnostic “orphans” in a 1992 national sample. Drug Alch Dependence, 53:215-222

Kahler CW, Strong DR, Hayaki J, Ramsey SE, Brown RA. 2003a. An item response analysis of the alcohol dependence scale in treatment-seeking alcoholics.  Journal of Studies on Alcohol 64, 127–136.

Kahler CW, Strong DR, Stuart GL, Moorek TM, Ramsey SE. 2003b. Item functioning of the alcohol dependence scale in a high risk sample. Drug Alcohol Dependence 72, 183–192.

Kahler CW, Strong DR, 2006.  A Rasch model analysis of DSM-IV alcohol abuse and dependence items in the National Epidemiologic Survey on Alcohol and Related Conditions.  Alcohol. Clin. Exp. Res. 30, 1165-1175.

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Krueger RF, Nicol PE, Hicks BM, Markon KE, Patrick CJ, Iacono WG, Mague M, 2004.  Using latent trait modeling to conceptualize an alcohol problems continuum.  Psychol. Assess. 16, 107-119.

Langenbucher JW, Labouvie E, Martin CS, Sanjuan PM, Bavly L, Kirisci L, 2004.  An application of item response theory analysis to alcohol, cannabis, and cocaine criteria in DSM-IV.  J. Abnorm. Psychol. 113, 72-80.

Lynskey MT, Agrawal A, 2007.  Psychometric properties of DSM assessment of illicit drug abuse and dependence:  results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).  Psychol. Med. 37, 1345-1355.

Lynskey M, Nelson EC, Neuman RJ, Bucholz KK, Madden PA, Knopik VS, Slutske W, Whitfield JB, Martin NG, Heath AC, 2005. Limitations of DSM-IV operationalizations of alcohol abuse and dependence in a sample of Australian twins. Twin Res. Hum. Genet. 8, 574-584.

Martin CS, Chung T, Kirisci L, Langenbucher JW, 2006.  Item response theory analysis of diagnostic criteria for alcohol and cannabis use disorders in adolescents:  implications for DSM-V.  J. Abnorm. Psychol. 115, 807-814.

Martin CS, Chung T, Langenbucher JW, 2008. How should we revise diagnostic criteria for substance use disorders in DSM-V? J Abnormal Psychology, Vol. 117, No. 3, 561–575.

Muthen BO, Grant B, Hasin D. 1993. The dimensionality of alcohol abuse and dependence: factor analysis of DSM-III-R and proposed DSM-IV criteria in the 1988 National Health Interview Survey.  Addiction 88, 1079-1090.

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Proudfoot H., Baillie, A.J., Teesson, M., 2006.  The structure of alcohol dependence in the community.  Drug Alcohol Depend. 81, 21-26.

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Saha TD, Chou SP, Grant BF, 2006.  Toward an alcohol use disorder continuum using item response theory:  results from the National Epidemiologic Survey on Alcohol and Related Conditions.  Psychol. Med. 36, 931-941.

Saha TD, Stinson FS, Grant BF, 2007.  The role of alcohol consumption in future classifications of alcohol use disorders.  Drug Alcohol Depend. 89, 82-92.

Schuckit M, Smith TL, Danko GP, Bucholz KK, Reich T, Bierut L, 2001. Five-year clinical course associated with DSM-IV alcohol abuse or dependence in a large group of men and women. Am. J. Psychiatry 158, 1084-1090.

Schuckit MA, Danko GP, Smith TL, Bierut LJ, Bucholz KK, Edenberg HJ, Hesselbrock V, Kramer J, Nurnberger JI Jr, Trim R, Allen R, Kreikebaum S, Hinga B. 2008. The prognostic implications of DSM-IV abuse criteria in drinking adolescents. Drug Alcohol Depend 97, 94-104.

Shmulewitz D, Keyes K, Beseler C, Aharonovich E, Aivadyan C, Spivak B, Hasin D. The alcohol use disorder continuum in Israel: Item Response Theory results. Under review.  

 Elimination of Legal Problems Criterion for Substance Use Disorder Diagnosis

Statistical analysis of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), National Longitudinal Alcohol epidemiologic Survey (NLAES), adults and youth from the high risk family study Collaborative Study on the Genetics of Alcoholism (COGA) international data from patients treated in the Emergency Departments, and a clinical sample of 663 patients treated for substance and psychiatric disorders all indicate that the legal problems criterion has an extremely low prevalence relative to other criteria, and its removal from the diagnosis has very little effect on the prevalence of substance use disorders while adding little information to the diagnoses in the aggregate. 

 Addition of New Diagnostic Criterion Representing Craving

Craving is defined as a strong desire for a substance, usually a specific substance. It is a common clinical symptom, tending to be present on the severe end of the severity spectrum. It has been variously defined as a trait with a time component (present or recent past) or as a lifetime component (ever experienced in your life). As a time limited state, craving has been frequently used in published clinical trials as an outcome measure. Brain imaging studies have demonstrated subjective craving precipitated by drug-related cues and correlated with increased activity (blood flow) and dopamine release (PET study) in specific parts of the brain reward system. In large population studies (e.g., NESARC, COGA) craving has been defined by a question about strong urges for the drug in the past.

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Hasin DS, Fenton M, Keyes KM: Craving and the dimensionality of alcohol dependence in an adult clinical sample. In preparation.

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Addition of an Empirically Determined Severity Qualifier for Substance Use Disorders

Three measures of alcohol use disorder severity were assessed in relation to several external valuators (various measures of consumption, family history, major depression and antisocial personality disorder): (1) simple counts of substance use disorder criteria; (2) count of diagnostic criteria with each criterion weighted by its relative severity derived from item response theory analysis; and (3) count of diagnostic criteria each weighted by its frequency of occurrence (Dawson et al. in press). The results show that un-weighted symptom counts of the diagnostic criteria appeared equally effective, less time consuming, and similarly associated with external correlates of the disorder, as the later two scalar measure of alcohol use disorders. Using a different analytic strategy, early onset of drinking and family history of alcohol problems in parents or siblings produced a similar result (Hasin and Beseler, 2009). 

Among adolescents, 2 or 3 criteria identify a group with severity of alcohol use disorder very close to that of adolescents with DSM-IV alcohol abuse, while 4 or more criteria identify a group with severity very close to that of DSM-IV dependence. Using criterion counts results in much more homogeneous groups than DSM-IV’s abuse and dependence groups (Gelhorn et al., 2008). 

The cutoffs of 2 or more criteria for a substance use diagnosis, with 2 or 3 criteria reflecting moderate severity and 4 or more criteria reflecting severe severity of a substance use disorder were empirically determined using several databases including the NESARC, COGA, large emergency room studies conducted in several countries, and a clinical study. Kappa statistics and Receiver Operating Characteristic analyses were calculated to identify the proposed cut-points associated with the greatest sensitivity and specificity across drug classes. The proposed cutoff points have been shown to yield similar prevalence and high concordance in relation to the combined DSM-IV substance abuse and dependence diagnoses.  

Although counts of criteria-met provide a useful measure of differences in severity-of-disorder among different individuals, there is not strong evidence showing that criterion counts usefully measure change in severity in one person over relatively brief periods of a few days, weeks, or months. Measures of such shorter-term changes are needed, e.g., to assess whether a treatment is improving the severity of a patient’s disorder. For that purpose an extensive clinical-trials literature (for example, Anton et al., 2006; Crits-Christoph et al., 1999; O’Malley et al., 2007) has relied on three measures obtained at intake and follow-up: (a) self-report of frequency of use (number of days patient used the substance, e.g., in the last week, or the last month), (b) when possible, similar reports from another closely-involved observer (e.g., a spouse), and (c)  tests for the substance or substance-related biological products in appropriately-timed samples of urine, blood, saliva, breath, or hair (such tests may disconfirm false-negative reports and encourage valid reporting). The Substance-Related Disorders Workgroup recommends those three procedures as measures of within-subject, across-time, changes in severity of substance use disorder over periods of a few days, weeks, or months

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Crits-Christoph P, Siqueland L, Blaine J, Frank A, Luborskky L, onken LS, Muenz LR, et al. 1999. Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Arch. Gen. Psychiatry 56, 493-502.

Dawson, D.A., Grant B.F. Submitted. Should symptom frequency be factored into scalar measures of alcohol use disorder severity? Addiction.

Dawson, D.A., Saha, T.D., Grant, B.F. In press. A multidimensional assessment of the validity and utility of alcohol use disorder severity as determined by item response theory models. Drug Alcohol Dependence.

Gelhorn H, Hartman C, Sakai J, Stallings M, Young S, Rhee SH, Corley R, Hewitt J, Hopfer C, Crowley T. 2008. Toward DSM-V: an Item Response Theory analysis of the diagnostic process for alcohol abuse and dependence in DSM-IV. J. Amer. Acad. Child Adol. Psychiatry 47, 1329-1339.

Hasin DS, Beseler CL. 2009. Dimensionality of lifetime alcohol abuse, dependence and binge drinking. Drug Alcohol Depend. 101, 53-61.

O’Malley SS, Garbutt JC, Gastfriend DR, Dong Q, Kranzler HR. 2007. Efficacy of extended release naltrexone in alcohol-dependent patients who are abstinent before treatment J. Clin Psychopharmacoloogy 27, 507-512.

The DSM-IV Disorders covered under this heading include  
    Alcohol Abuse and Alcohol Dependence.  

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