Clinical Assessment and Diagnosis
Clinical assessment and diagnosis
This domain tests whether you can move from screening to a defensible diagnosis and initial level-of-care recommendation. Expect items on DSM-5-TR substance use disorder criteria, ASAM Criteria dimensions, differential diagnosis, standardized instruments, and documentation.
Core rules
- Screening is brief and identifies risk; assessment is comprehensive and establishes diagnosis, severity, and needs.
- DSM-5-TR SUD requires at least 2 of 11 criteria in 12 months; 2–3 mild, 4–5 moderate, 6+ severe. Tolerance and withdrawal are not counted for prescribed medications taken as directed.
- Use ASAM's six dimensions: intoxication/withdrawal, biomedical, psychiatric/cognitive, readiness, relapse potential, recovery environment.
- Distinguish substance-induced from independent psychiatric disorders by timing, persistence, and history; do not diagnose on intoxication alone.
- Use validated tools (AUDIT, DAST-10, TLFB, ASI) and collateral information; urine drug screens detect presence, not impairment or use pattern.
Worked example
A 34-year-old reports drinking 5–6 drinks most nights, two blackouts, continued use despite liver enzyme elevation, craving, and unsuccessful attempts to cut down. No withdrawal seizures; mild anxiety. That is 5 criteria → moderate alcohol use disorder. ASAM dimension 1 is low risk, dimension 2 needs lab follow-up, dimension 3 has mild anxiety, dimension 4 ambivalent. Recommendation: outpatient level of care with medication evaluation and integrated anxiety treatment, not residential placement based on severity alone.
Traps
Calling any use "addiction"; counting a single criterion; assuming withdrawal equals severe disorder; missing substance-induced depression; and treating a positive screen as a diagnosis.