Substance-Use Disorder in DSM-5

Borough Market, big cheese

If a clinician expects to use the label of substance-use disorder, and if the substance being used is a drug, the Diagnostic and Statistical Manual offers a list of symptoms to consider. The purpose of the list is to diagnose not only the presence, but the magnitude, of the substance-use disorder.

Two or three checkmarks means a mild disorder, four or five means moderate, and six or seven checkmarks means severe. Could any of these hallmark symptoms ever apply to a morbidly obese person who cannot stop overeating? Let’s call this person Wally, whose “drug of choice” is cheese, though he’s not that picky, really. In fact, he’ll eat anything that doesn’t run away. But let’s keep it simple.

Q. Does Wally continue to eat cheese, despite negative personal consequences?
A. Yes, he does.

Q. Is he messing up at work, at school, or in the domestic realm because of his cheese consumption?
A. Due at least in part to size discrimination, Wally has been unable to find work. He dropped out of college because the desks were too small. His mother is about to throw him out because her whole house smells of the cheese he hides everywhere.

Q. Does he recurrently use the substance in physically hazardous situations?
A. Crossing the street, Wally was nearly hit by a car because his attention was focused on unwrapping a package of cheese.

Q. Does he keep on doing it, even though it causes social and interpersonal problems or makes existing problems worse?
A. Sadly, the answer to this is also yes.

Q. Does he have to eat more to feel as happy as he used to feel with less?
A. You guessed it. Wally used to buy the 8-ounce packages, but now he buys cheese by the pound. The only reason he doesn’t buy a wheel is his mother’s temper.

Q. Does he avoid the possibility of experiencing withdrawal?
A. Indeed. Wally will no longer attend any social gathering that does not either provide cheese or allow him to bring his own supply and munch freely.

Q. Does he use greater amounts, or over a longer time period than he had intended?
A. Well just an ounce or two will not help Wally to feel better, will it? Of course he uses bigger amounts – he buys it by the pound, remember? And he’s been meaning to quit for years.

Q. Does he want to cut down or quit? Has he tried and tried and tried?
A. Yes, yes, and yes.

Q. And when he tries to quit, does he experience cravings for the substance?
A. Good heavens, affirmative. Cheese haunts his dreams.

Q. Does he spend a lot of time obtaining, using, or recovering from the substance?
A. If Wally sneaks some cheese into the shopping cart, his eagle-eyed mother puts it right back in the cooling case. He has to make an excuse that he’s going to the library, and return to the grocery store on his own. It takes up an enormous amount of time – though the walk does him some good.

Q. Has he quit or reduced his attendance at social, occupational, or recreational activities?
A. Obviously, unemployed Wally has no work-related functions to attend. Mostly, he stays in his room. Recreational – are you kidding?

Q. Does he consistently use the substance “despite acknowledgement of persistent or recurrent physical or psychological difficulties from it”?
A. Yes! That’s the frustrating part, he knows better! Wally isn’t stupid. He knows it’s not good for him and he’ll probably die young, and he just keeps on eating cheese!

In the official accounting, the “severe” rating only goes up to 7. There must be a category above “severe,” because we see how easy it is for an actual human to fulfill all the criteria for a substance-use disorder. And food is not even officially considered to be a substance of abuse.

Your responses and feedback are welcome!

Source: “DSM-5 Substance Use Disorder,”, Undated
Image by Stephanie Watson


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About Dr. Robert A. Pretlow

Dr. Robert A. Pretlow is a pediatrician and childhood obesity specialist. He has been researching and spreading awareness on the childhood obesity epidemic in the US for more than a decade.
You can contact Dr. Pretlow at:


Dr. Pretlow’s invited presentation at the American Society of Animal Science 2020 Conference
What’s Causing Obesity in Companion Animals and What Can We Do About It

Dr. Pretlow’s invited presentation at the World Obesity Federation 2019 Conference:
Food/Eating Addiction and the Displacement Mechanism

Dr. Pretlow’s Multi-Center Clinical Trial Kick-off Speech 2018:
Obesity: Tackling the Root Cause

Dr. Pretlow’s 2017 Workshop on
Treatment of Obesity Using the Addiction Model

Dr. Pretlow’s invited presentation for
TEC and UNC 2016

Dr. Pretlow’s invited presentation at the 2015 Obesity Summit in London, UK.

Dr. Pretlow’s invited keynote at the 2014 European Childhood Obesity Group Congress in Salzburg, Austria.

Dr. Pretlow’s presentation at the 2013 European Congress on Obesity in Liverpool, UK.

Dr. Pretlow’s presentation at the 2011 International Conference on Childhood Obesity in Lisbon, Portugal.

Dr. Pretlow’s presentation at the 2010 Uniting Against Childhood Obesity Conference in Houston, TX.

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