Disclaimer: Nothing in this document should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care.
I’ve been thinking a lot lately about the basic inadequacy of counting up how many DSM-5-TR SUD criteria are met by the person served – and stopping right there to understand their addiction illness.
One reason this has been a sustained meditation for me is the increasing percentage of medical records I see over time that are check-listed, plus little else if anything at all, concerning the patient’s personal addiction illness.
As a response to this lack, I have prepared a document that outlines a way of thinking that adds the consideration of two other areas simultaneously:
- Basic factors in personality function (reality testing, defense mechanisms, and identity integration) outlined by Otto Kernberg.
- The Big 5 SUD criteria outlined by Norman Hoffmann.
To me, these three specific areas of personality function (reality testing, defense mechanisms, and identity integration) seem especially relevant to addiction illness in particular – aside from their general use by Kernberg in understanding broad clinical mental health populations.
The document I have prepared shows how these contributions from Kernberg and Hoffmann can be considered simultaneously, along with the DSM-5-TR criteria count and the resulting severity rating (mild, moderate, and severe).
Questions:
- Are all SUDs that are mild to be understood in the same way?
- Are the SUDs of all people who are “moderate” to be understood the same way?
- Or severe?
Hoffmann’s weighting of the 11 DSM SUD criteria can give us an added perspective. And Kernberg’s work on these 3 areas of personality function can as well.
Looking back, my initial academic training was during the DSM-III-R era. At that time and the subsequent DSM-IV era, we were required by the DSM to use the multi-axial diagnostic system, rather than just list diagnoses. The five axes, taken together, provided something closer to the person’s specific form and context of their difficulties. Am I the only one that misses the multi-axial system that was removed in the DSM-5?
For those that want a little more on this topic, the document I prepared is immediately below in PDF format. It’s only 3 pages long, but the style is more academic and technical.
A link to one suggested reading is below the PDF.
Suggested Reading:
Coon, B. (June 8, 2026). Addiction and Alcoholism: The Form of the Disorder. Recovery Review.
