For certain classes some symptoms are less salient, and in a few instances not all symptoms apply (e.g., withdrawal symptoms are not specified for phencyclidine use disorder, other hallucinogen use disorder, or inhalant use disorder).
An important characteristic of substance use disorders is an underlying change in brain cir- cuits that may persist beyond detoxification, particularly in individuals with severe disorders.
The behavioral effects of these brain changes may be exhibited in the repeated relapses and in- tense drug craving when the individuals are exposed to drug-related stimuli. These persistent drug effects may benefit from long-term approaches to treatment.
Overall, the diagnosis of a substance use disorder is based on a pathological pattern of behaviors related to use of the substance. To assist with organization, Criterion A criteria can be considered to fit within overall groupings of impaired control, social impairment, risky use, and pharmacological criteria. Impaired control over substance use is the first criteria grouping (Criteria 1—4). The individual may take the substance in larger amounts or over a longer pe- riod than was originally intended (Criterion 1). The individual may express a persistent de- sire to cut down or regulate substance use and may report multiple unsuccessful efforts to decrease or discontinue use (Criterion 2). The individual may spend a great deal of time ob- taining the substance, using the substance, or recovering from its effects (Criterion 3). In some instances of more severe substance use disorders, virtually all of the individual’s daily activities revolve around the substance. Craving (Criterion 4) is manifested by an intense de- sire or urge for the drug that may occur at any time but is more likely when in an environ- ment where the drug previously was obtained or used. Craving has also been shown to involve classical conditioning and is associated with activation of specific reward structures in the brain. Craving is queried by asking if there has ever been a time when they had such strong urges to take the drug that they could not think of anything else. Current craving is of- ten used as a treatment outcome measure because it may be a signal of impending relapse.
Social impairment is the second grouping of criteria (Criteria 5—7). Recurrent substance use may result in a failure to fulfill major role obligations at work, school, or home (Crite- rion 5). The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (Cri- terion 6). Important social, occupational, or recreational activities may be given up or re- duced because of substance use (Criterion 7). The individual may withdraw from family activities and hobbies in order to use the substance.
Risky use of the substance is the third grouping of criteria (Criteria 8—9). This may take the form of recurrent substance use in situations in which it is physically hazardous (Cri- terion 8). The individual may continue substance use despite knowledge of having a per- sistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (Criterion 9). The key issue in evaluating this criterion is not the existence of the problem, but rather the individual’s failure to abstain from using the substance despite the difficulty it is causing.