Dependency and Addiction: DSM-5 Criteria, Withdrawal, and Models
The Dependency and Addiction domain tests whether you can apply DSM-5 substance use disorder (SUD) criteria, separate dependence from tolerance and from physical withdrawal, and predict the course of withdrawal by class. Items often ask for severity, the safest detox setting, or the distinction between addiction and physical dependence.
DSM-5 SUD: 11 criteria in four groupings
- Impaired control: using more or longer than intended; unsuccessful cutting down; time spent obtaining, using, or recovering; craving.
- Social impairment: role failure; continued use despite interpersonal problems; giving up activities.
- Risky use: hazardous situations; continued use despite physical or psychological harm.
- Pharmacological: tolerance; withdrawal. Two or three criteria = mild, four or five = moderate, six or more = severe. Tolerance and withdrawal alone do not establish addiction: a patient on long-term prescribed opioids can be physically dependent without SUD.
Withdrawal timelines that get tested
- Alcohol: tremor and anxiety, seizures at 12-48 hours, delirium tremens at 48-96 hours with fever, tachycardia, and hallucinations. Untreated DT carries meaningful mortality; benzodiazepines are the treatment.
- Benzodiazepines: similar picture but later and longer; short-acting agents such as alprazolam produce earlier, sharper withdrawal.
- Opioids: rhinorrhea, yawning, cramps, diarrhea, piloerection at 8-24 hours; intensely unpleasant but rarely fatal.
- Stimulants: a crash with dysphoria, hypersomnia, and anhedonia; no life-threatening syndrome.
Theories worth naming
The disease model frames addiction as chronic and relapsing. Opponent-process theory explains withdrawal as the rebound of a counter-adaptive response. Incentive sensitization holds that repeated use sensitizes "wanting" while "liking" plateaus. Cross-tolerance explains why alcohol, benzodiazepines, and barbiturates share withdrawal risk.
Worked example
A 45-year-old drinks a fifth of vodka daily, has tried to stop twice, misses work, keeps drinking despite a duodenal ulcer, and reports morning tremor relieved by a drink. Reasoning: criteria met are attempts to cut down, role failure, use despite physical harm, tolerance, and withdrawal - five, so moderate SUD. The morning tremor plus daily heavy use means supervised benzodiazepine detox, not abrupt cessation.
Traps
- Counting tolerance and withdrawal as proof of addiction.
- Sending a heavy daily drinker home to "taper" without assessing seizure risk.
- Confusing opioid withdrawal (miserable, nonfatal) with alcohol withdrawal (potentially fatal).