Problems with the 2/11 algorithm must be understood in the context of the DSM-5 draft criteria, some of which are mild, not necessarily indicative of pathology, or are commonly misunderstood and over-endorsed, particularly among youth. Tolerance can present without significant harm, and alcohol tolerance is normative in adolescence and young adulthood (O'Neill & Sher, 2000). The symptom of hazardous use, usually given due to intoxicated driving, can reflect simple heedlessness rather than disorder. Although not problematic conceptually, the symptoms of using more or longer than intended (larger /longer) and persistent desire or repeated attempts to quit or cut down (quit/cut down) have proven difficult to operationalize, and standard wording is frequently misunderstood. These criteria are often incorrectly endorsed by drinkers for social reasons (e.g. conformity) rather than compulsion-based reasons (Chung & Martin, 2005; Caetano & Babor, 2006). Given the nature of these four symptoms, a 2/11 threshold means that many diagnosed cases may have mild levels of substance involvement and no meaningful pathology.
