492 Substance-Related and Addictive Disorders
Specifiers
“In a controlled environment” app lies as a further specifier of remission if the individual is
both in remission and in a controlled environm ent (i.e., in early remission in a controlled
environment or in sustained remission in a controlled environmen t). Examples of these
environments are closely supe rvised and substanc e-free jails, therapeutic communities,
and locked hospital units. 
Severity of the disorder is based on the number of diagno stic criteria endorsed. For a
given individual, changes in severity of alcoho l use disorder across ti me are also reflected
by reductions in the frequency (e.g., days of  use per month) and/or dose (e.g., number of
standard drinks consumed per day) of alcohol used, as assessed by the individual’s self-
report, report of knowledgeabl e others, clinician observations, and, when practical, bio-
logical testing (e.g., elevations in blood test s as described in the section “Diagnostic Mark-
ers” for this disorder).
Diagnostic Features
Alcohol use disorder is defined by a cluste r of behavioral and physical symptoms, which
can include withdrawal, tolerance, and cravin g. Alcohol withdrawal  is characterized by
withdrawal symptoms that de velop approximately 4–12 hours after the reduction of in-
take following prolonged, heavy alcohol inge stion. Because withdrawal from alcohol can
be unpleasant and intense, individuals may continue to consume alcohol despite adverse
consequences, often to avoid or to relieve withdrawal symptoms. Some withdrawal symp-
toms (e.g., sleep problems) can persist at lower intensities for months and can contribute to
relapse. Once a pattern of re petitive and intense use develo ps, individuals with alcohol
use disorder may devote substantial periods of time to obtaining and consuming alcoholic