The proposed 2/11 symptom algorithm for DSM-5 substance-use disorders is too lenient.

Substance-use disorder (SUD) diagnoses are critically important for research and clinical practice. Unlike the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), the draft diagnostic criteria for SUDs in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) define a single SUD for various substance classes - such as ‘alcohol-use disorder’ (AUD)- based upon 11 symptoms. This criterion set is composed of all seven DSMIV substance dependence symptoms, three of the four DSM-IV substance-abuse symptoms (all but legal problems) and a craving symptom. AUD and other SUDs would be diagnosed if a person has at least 2/11 cooccurring symptoms. The 2/11 threshold was chosen, in large part, to emulate rates of any DSM-IV SUD (abuse plus dependence) (http://www.DSM5.org). We believe that the 2/11 algorithm is too lenient and creates serious multiple problems. The proposed algorithm would diagnose many whose substance involvement has questionable clinical significance, leading SUD diagnosis away from mainstream neuro-behavioral theory regarding what constitutes a mental ‘disorder’ and ‘addiction’. Further, the algorithm allows so much heterogeneity that the clinical and research utility of the diagnostic category would be greatly compromised. We illustrate these points with past-year AUD symptom data from 29993 lifetime drinkers aged 21 years and above, from wave 2 of the National Epidemiological Survey of Alcohol Use and Related Conditions (NESARC; Grant et al. 2003) (analytic details available upon request). Unlike wave 1, wave 2 had a craving item allowing us to study proposed DSM-5 diagnoses with respect to AUD prevalence, severity and heterogeneity.