Substance dependence and non-dependence in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD): can an identical conceptualization be achieved?


John B. Saunders MD, FRACP, Professor of Alcohol and Drug Studies, School of Medicine, University of Queensland, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia. E-mail:


Background  This review summarizes the history of the development of diagnostic constructs that apply to repetitive substance use, and compares and contrasts the nature, psychometric performance and utility of the major diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD) diagnostic systems.

Methods  The available literature was reviewed with a particular focus on diagnostic concepts that are relevant for clinical and epidemiological practice, and so that research questions could be generated that might inform the development of the next generation of DSM and ICD diagnoses.

Results  The substance dependence syndrome is a psychometrically robust and clinically useful construct, which applies to a range of psychoactive substances. The differences between the DSM fourth edition (DSM-IV) and the ICD tenth edition (ICD-10) versions are minimal and could be resolved. DSM-IV substance abuse performs moderately well but, being defined essentially by social criteria, may be culture-dependent. ICD-10 harmful substance use performs poorly as a diagnostic entity. 

Conclusions  There are good prospects for resolving many of the differences between the DSM and ICD systems. A new non-dependence diagnosis is required. There would also be advantages in a subthreshold diagnosis of hazardous or risky substance use being incorporated into the two systems. Biomedical research can be drawn upon to define a psychophysiological ‘driving force’ which could underpin a broad spectrum of substance use disorders.