The mere use of substances - even to excess - is not enough to diagnose addiction, so we look for behavioral clues. The Diagnostic and Statistical Manual, 4th edition (DSM-IV) is the current standard for diagnosis that is used by most mental health professionals, and it contains a working definition of addiction (fig.1.1). Interestingly, the manual does not use the term “addiction”; instead, the terms “abuse” and “dependence” are defined.

Either abuse or dependence is present when the use of the substance continues despite negative consequences, interferes with important obligations, and causes noticeable distress or significant impairment in functioning.

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Fig.  1.1.  Diagnostic and Statistical Manual, 4th edition

Criteria for Substance Abuse
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (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) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

4) 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)

B. The symptoms have never met the criteria for substance dependence for this class of substance.

Criteria for Substance Dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12- month period:

1) 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

2) withdrawal, as manifested by either of the following: (a) the characteristic withdrawal syndrome for the substance, (b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

3) the substance is often taken in larger amounts or over a longer period than was intended

4) there is persistent desire or unsuccessful efforts to cut down or control substance use

5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain smoking), or recover from its effects

6) important social, occupational, or recreational activities are given up or reduced because of substance use

7) 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 (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association, Washington, D.C.