disorder. Future research on core neurobiological addic-tion models should provide greatly sharpened tools fordiagnosis and treatment, while further empirical researchon DSM-5 SUD may identify a shorter, more user-friendlyclinical criterion set if such a set is shown to be as valid asthe 11-criteria DSM-5 SUD [3]. In the meantime, theDSM-5 SUD criteria can continue to serve as a clinicalreference point for neurobiological studies, and providethe field with a standard set of reliable, valid, evidence-based criteria for clinical and research use.

Declaration of interests

None.

Keywords Addiction, alcohol, alcoholism, diagnosis,drug, DSM-IV, DSM-5, substance abuse, substancedependence, substance use disorder.

DEBORAH HASIN

New York State Psychiatric Institute, Columbia University,New York, NY, USA. E-mail: dsh2@columbia.edu

References

1. Martin C. S., Langenbucher J. W., Chung T., Sher K. J. Truthor consequences in the diagnosis of substance use disorders.Addiction 2014; 109: 1773–8.

2. Edwards G., Gross M. M. Alcohol dependence: provisionaldescription of a clinical syndrome. BMJ 1976; 1: 1058–61.

3. Hasin D. S., O’Brien C. P., Auriacombe M., Borges G.,Bucholz K., Budney A. et al. DSM-5 criteria for substanceuse disorders: recommendations and rationale. Am J Psy-chiatry 2013; 170: 834–51.

4. Koob G. F., Buck C. L., Cohen A., Edwards S., Park P. E.,Schlosburg J. E. et al. Addiction as a stress surfeit disorder.Neuropharmacology 2014; 76: 370–82.

5. Wise R. A., Koob G. F. The development and maintenance ofdrug addiction. Neuropsychopharmacology 2014; 39: 254–62.

6. Koob G. F., Volkow N. D. Neurocircuitry of addiction.Neuropsychopharmacology 2010; 35: 217–38.

7. Volkow N. D., Baler R. D. Addiction science: uncoveringneurobiological complexity. Neuropharmacology 2014; 76:235–49.

8. Bossert J. M., Marchant N. J., Calu D. J., Shaham Y. Thereinstatement model of drug relapse: recent neurobiologicalfindings, emerging research topics, and translationalresearch. Psychopharmacology (Berl) 2013; 229: 453–76.

9. Jasinska A. J., Stein E. A., Kaiser J., Naumer M. J., YalachkovY. Factors modulating neural reactivity to drug cues inaddiction: a survey of human neuroimaging studies.Neurosci Biobehav Rev 2014; 38: 1–16.

10. Carroll K. M., Rounsaville B. J., Nich C., Gordon L. T., WirtzP. W., Gawin F. One-year follow-up of psychotherapy andpharmacotherapy for cocaine dependence. Delayed emer-gence of psychotherapy effects. Arch Gen Psychiatry 1994;51: 989–97.

11. Verweij K. J., Agrawal A., Nat N. O., Creemers H. E., HuizinkA. C., Martin N. G. et al. A genetic perspective on the pro-posed inclusion of cannabis withdrawal in DSM-5. PsycholMed 2013; 43: 1713–22.

12. Pergadia M. L., Agrawal A., Heath A. C., Martin N. G.,Bucholz K. K., Madden P. A. Nicotine withdrawal symptomsin adolescent and adult twins. Twin Res Hum Genet 2010;13: 359–69.

13. Prescott C. A., Sullivan P. F., Kuo P. H., Webb B. T., Vittum J.,Patterson D. G. et al. Genomewide linkage study in the Irishaffected sib pair study of alcohol dependence: evidence for asusceptibility region for symptoms of alcohol dependenceon chromosome 4. Mol Psychiatry 2006; 11: 603–11.

14. Keyes K. M., Eaton N. R., Krueger R. F., Skodol A. E., Wall M.M., Grant B. et al. Thought disorder in the meta-structure ofpsychopathology. Psychol Med 2013; 43: 1673–83.

‘TRUTH OR CONSEQUENCES’—WHATABOUT TRUTH OR DARE

Martin et al. [1] present a provocative argument for thereduced significance of negative psychosocial and healthconsequences of substance use in the diagnosis of sub-stance use disorder (SUD). We agree that there is nodoubt that we can do better at diagnosis of SUD.However, Martin et al. argue that ‘data’ indicate thatsubstance-related consequences introduce systematicbias and degrade the validity of diagnostic systems.‘Truth’: we cannot find the ‘data’ supporting this con-clusion and so, while interesting, it remains unclear if itis truth.

There are no agreed rules for how we decide on a set ofcriteria for a disorder. Martin et al. and others have movedthe field forward through the use of a common factormodel [2,3], the basic premise being that a disorder is alatent construct indicated by a set of imperfect indicatorsor criteria. There are multiple papers showing that if weapply a common factor model the SUD criteria form aninternally consistent dimension and perform well acrossage and gender [2–8]. Martin and colleagues argue thatwe will have a more valid and less biased diagnostic systemif we remove the negative psychosocial and health conse-quences in the current diagnostic criteria. A good indica-tor we have of this is how they perform in assessing thelatent construct. Is there any evidence (data) that remov-ing them improves the current nosology? Not yet thereisn’t.

Of course we should improve the nosology when thedata warrant it. The removal of the legal criteria in thelatest round of DSM is a clear example of improvementthrough removal. Australian enforcement of drivingunder the influence (DUI) is extensive and penalizationis robust. Australians have embraced this public health

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measure with a passion, so that those who flaunt therestrictions have more severe problems with alcohol.The item response theory (IRT) analyses also showedthat it performed poorly as a criterion [3,5]. It contrib-uted little to the assessment of the underlying construct.The data drove the removal of that criterion fromDSM5.

What of the other criteria focused on negative psycho-social and health consequences? What about the hazardcriterion? Unlike the legal criteria, the hazard criterionloads well on the underlying construct. The elimination ofthe hazard criterion would lead to a considerable decreasein the prevalence of alcohol use disorders in Australia,with those no longer receiving a diagnosis more likely to beyoung males with drug use disorders and suicidal behav-iours. We would risk excluding a potentially clinically sig-nificant group of individuals with alcohol use disorderfrom future intervention [9]. While it is argued that thehazard criterion should be removed, the data are less clearcut.

How well do the ‘new’ proposed criteria perform? Theutility of a quantity and frequency of use criterion inimproving diagnosis is questionable [6] and its ability toadd any information to the assessment of the underlyingconstruct has not been demonstrated. The argument byMartin et al. that this is because the negative psychosocialand health consequences are included could be testedbut, so far, the case to include quantity and frequency isnot supported by the data.

What of the other proposed criteria? Martin et al. indi-cate that the proposed criteria of heavy use, compulsiveuse, incentive salience and physiological features are notso set and clear in adolescents and young adults. Thechallenge is that when young adults are asked there aresubstantial inconsistencies in young adults’ interpreta-tions of questions reflecting impaired control overalcohol. Interpretations of questions designed to measuretolerance to the effects of alcohol and use of alcohol inhazardous situations are largely understood, but ques-tions designed to tap compulsive use are not well under-stood [10]. We do not have robust measures of theseconstructs. Martin et al. hint at this, and it is not an insig-nificant problem. It is the reason we have a broader set ofcriteria so that we can assess the underlying construct. Itis premature to narrow that construct on the existingevidence.

Leaving aside the issues of data and measurement, theconceptual issues raised in the paper also warrant discus-sion. Negative health and psychosocial consequences donot merely indicate consequences, but also the failure toregulate in the face of these consequences. The authorsmake this point in parenthesis on page 8. The failure of aregulatory system cannot be judged unless the contextwithin which such failure occurs is considered. We agree

that the consequences alone are not sufficient for disor-der; but we would also argue that tolerance and with-drawal without behavioural indicators of the failure ofthe inhibitory systems is not necessarily a disorder.

The classification of mental disorders is movingtowards a better understanding of disorder and the devel-opmental aspects of disorder in young adults [10,11],including the consequences. Mental disorder diagnosis isconsidering the development of a quantitative, empiri-cally based model of psychopathology [7,12]. This is asignificant improvement, because existing diagnostic cat-egories are often heterogeneous, they overlap andcomorbidity is common [6]. We can argue the theory, thefun is in the data—give us the data that the new criteriaare indeed more valid, if you ‘dare’.

Declaration of interests

None.

Keywords Addiction, diagnosis, diagnostic criteria,DSM5, nosology, substance use disorder.

MAREE TEESSON1, ANDREW J BAILLIE2 & TIM SLADE3

University of New South Wales, Centre of Research

Excellence in Mental Health and Substance Use, National

Drug and Alcohol Research Centre, Sydney, New South

Wales, Australia,1 Centre for Emotional Health, Psychology

Department, Macquarie University, Sydney, Australia2 and

National Drug and Alcohol Research Centre, University of

New South Wales, Randwick, New South Wales, Australia3.

E-mail: m.teesson@unsw.edu.au

References

1. Martin C. S., Langenbucher J. W., Chung T., Sher K. J. Truthor consequences in the diagnosis of substance use disorders.Addiction 2014; 109: 1773–8.

2. Saha T. D., Chou S. P., Grant B. F. Toward an alcohol usedisorder continuum using item response theory: resultsfrom the National Epidemiologic Survey on Alcohol andRelated Conditions. Psychol Med 2006; 36: 931–41.

3. Baillie A. J., Teesson M. Continuous, categorical and mixturemodels of DSM-IV alcohol and cannabis use disorders in theAustralian community. Addiction 2010; 105: 1246–53.

4. Mewton L., Teesson M., Slade T. ‘Youthful epidemic’ or diag-nostic bias? Differential item functioning of DSM-IV canna-bis use criteria in an Australian general population survey.Addict Behav 2010; 35: 408–13.

5. Proudfoot H., Baillie A. J., Teesson M. The structure ofalcohol dependence in the community. Drug Alcohol Depend2006; 81: 21–6.

6. McBride O., Teesson M., Baillie A., Slade T. Assessing thedimensionality of lifetime DSM-IV alcohol use disorders anda quantity–frequency alcohol use criterion in the Australianpopulation: a factor mixture modelling approach. AlcoholAlcohol 2011; 46: 333–41.

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7. Wright A. G., Krueger R. F., Hobbs M. J., Markon K. E., EatonN. R., Slade T. The structure of psychopathology: toward anexpanded quantitative empirical model. J Abnorm Psychol2013; 122: 281–94.

8. Teesson M., Lynskey M., Manor B., Baillie A. The structureof cannabis dependence in the community. Drug AlcoholDepend 2002; 68: 255–62.

9. Mewton L., Slade T., Memedovic S., Teesson M. Alcohol usein hazardous situations: implications for DSM-IV andDSM-5 alcohol use disorders. Alcohol Clin Exp Res 2013; 37:E228–36.

10. Slade T., Teesson M., Mewton L., Memedovic S., Krueger R.F. Do young adults interpret the DSM diagnostic criteria foralcohol use disorders as intended? A cognitive interviewingstudy. Alcohol Clin Exp Res 2013; 37: 1001–7.

11. Hickie I. B., Scott J., Hermens D. F. et al. Clinical classificationin mental health at the cross-roads: which direction next?BMC Med 2013; 11: 125.

12. Andrews G., Goldberg D. P., Krueger R. F. et al. Exploring thefeasibility of a meta-structure for DSM-V and ICD-11: couldit improve utility and validity? Psychol Med 2009; 39:1993–2000.

RESPONSE TO COMMENTARIES

We thank Borges [1], Caetano [2], Hasin [3] and Teessonet al. [4] for their comments. Our principal points—thatconsequence-related criteria are accessory to substanceuse disorders (SUDs), and introduce systematic biases todiagnosis—were meant to help frame a future researchagenda, but not present the fruits of a completed one, asBorges [1] and Teesson et al. [4] desired. Our brief discus-sion of possible alternatives to consequences was meantto highlight novel candidate criteria that deserve furtherstudy (e.g. [5–7]).

We do not support a bi-axial approach to SUD diagno-sis, such that consequences form a separate illness cat-egory. To the contrary, we agree with Hasin [3] on thispoint, and have long called for the use of a single criterionset to diagnose SUDs [8]. Our primary concern is that theitems in this single criterion array should minimize, to theextent possible, systematic biases due to age, gender,culture and socio-economic status, as these degrade diag-nostic validity.

If a symptom loads on a unidimensional SUD factor,this is not by itself good evidence that it is valid. If thiswere the case we could include many non-substanceexternalizing behaviors as SUD symptoms [9], but thisdoes not make sense conceptually or practically. Diagnos-tic validity must also be based on conceptual coherenceand evidence that a criterion performs similarly invarious demographic groups. There are already consider-able data showing the bias produced by consequence-related criteria. Substance-related medical problems aredevelopmentally biased [10,11]. Both ‘hazardous use’

(e.g. intoxicated driving) and ‘legal problems’ show agreat deal of demographic and policy-related bias [12–14], which compromises their validity. Retaining hazard-ous use confers on driving under the influence (DUI)policy the ability to strongly influence the prevalence of amental disorder, even though the two should not be con-flated [15].

Caetano [2] and Hasin [3] note that non-consequencesymptoms can be influenced by context, and we stronglyagree. For example, craving is influenced by cues [3].However, our use of the term ‘context’ was meant toemphasize systematic biases that are unrelated to basicaddictive processes. In contrast, craving is probably agood example of an addictive phenomenon that occursregularly among most heavy drug users, across drug,country, gender culture, race and age. The same cannotbe said for consequences. Similarly, tolerance and with-drawal are moderated by genetics [3], but this is a farcry from the numerous moderating influences on, forexample, intoxicated driving. Indeed, the fact that toler-ance and withdrawal occur in non-human animals indi-cates that these addiction constructs can be measuredrelatively independently of human cultural influences.

As noted in our commentary and reaffirmed byTeesson et al. [4], symptoms defined by ‘continued usedespite’ consequences can indicate compulsive drug use.However, the way in which these symptoms are defined isproblematic: compulsive use is implied rather thandirectly described, the compound nature of the criteriamakes it easy for interviewers and respondents to focuson consequences rather than compulsion, and the crite-ria are conditioned on problem recognition and the attri-bution of a causal role to drug use. More generally,compulsive drug use can occur in the absence of conse-quences. There is a need for better assessment of compul-sive use without consequences in our diagnostic systems.

Hasin [3] states that DSM-5 provides a ‘standard set ofreliable, valid, evidence-based criteria’. Regarding reli-ability, current evidence is limited [16], but existing dataare cause for concern [17]. Regarding validity, researchhas identified important limitations of both consequence-related and non-consequence-related DSM-IV SUD symp-toms [8], yet none of the symptoms that were retainedin DSM-5 were revised in any way. We continue to believethat diagnostic systems should become better alignedwith modern neurobehavioral theories of addiction,although Caetano [2] is correct that this is a difficult andcomplex undertaking. We should attempt to developdiagnostic systems that better distinguish addiction fromimprudence, culture, and public policy.

Declaration of interests

None.

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