Substance use disorders

Here's a number examiners want burned into your brain: 11. The DSM-5/DSM-5-TR diagnoses a substance use disorder (SUD) from a single list of 11 criteria, and where you land on that list decides everything, including how sick the diagnosis says you are.

The 11 criteria cluster into four groups. Impaired control (using more/longer than intended; wanting to cut down but can't; spending lots of time obtaining/using/recovering; craving). Social impairment (failing role obligations; using despite social/interpersonal problems; giving up important activities). Risky use (using in physically hazardous situations; continuing despite a physical or psychological problem you know it causes). And pharmacological criteria — tolerance and withdrawal.

Know those last two cold. Tolerance = needing more substance to get the same effect (or a diminished effect from the same amount). Withdrawal = a substance-specific syndrome when you stop or cut down, typically relieved by taking the substance again. The classic trap: tolerance and withdrawal occurring during appropriate medical supervision (e.g., prescribed opioids for pain) do not count toward a diagnosis.

Severity is a simple count of how many of the 11 criteria are met over a 12-month period: mild = 2–3, moderate = 4–5, severe = 6 or more. Fewer than 2 means no diagnosis. This same 11-criteria template applies across substance classes — alcohol, opioids, stimulants, cannabis, and so on — which is exactly why it's high-yield.

Clinical Pearl: Memorize the severity thresholds as 2-3-6: 2–3 mild, 4–5 moderate, 6+ severe, counted from the same 11 criteria across a 12-month window — and remember tolerance/withdrawal under legitimate medical care don't count.