Substance-Related Disorders

1. Substance-Related Disorders Core Concept Occurrence of adverse social, behavioral, psychological, & physiological effects caused by 1 or more of the following abused substances: 1) Alcohol 7) Cannabis 2) Inhalants 8) Phencyclidine 3) Amphetamines 9) Cocaine 4) Nicotine 10) Sedatives, Hypnotics, or Anxiolytics 5) Caffeine 11) Hallucinogens 6) Opioids 12) Other or Unknown Substances

2. Categories for Substance-Related Disorders: • Substance Use Disorders (generic criteria sets): • Substance Dependence • Substance Abuse • Substance-Induced Disorders (specific criteria sets): • Substance Intoxication • Substance Withdrawal • Substance-Induced Psychiatric Syndromes

3. Substance Dependence & Abuse • Criteriafor Substance Dependence and Abuse: exactly the same for all 12 classes of substances • Names for specific Dx: e.g. Alcohol Dependence, Alcohol Abuse • Polysubstance Dependence: a pattern of maladaptive use of at least 3 classes of substances; meet the full criteria for Substance Dependence for substances considered as a group, but not for any single substance

4. Substance Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3+ of the following, at any time in a 12-month period: • Tolerance • A need for markedly increased amounts of substance to achieve intoxication or desired effect • Markedly diminished effect with continued use of the same amount of substance • Withdrawal • Characteristic withdrawal syndrome for substance • The same or a closely related substance taken to relieve or avoid withdrawal symptoms • Substance taken in larger amounts or over longer period than intended.

5. Substance Dependence Symptoms (continued): • Persistent desire or unsuccessful efforts to cut down or control substance use. • A great deal of time is spent in activities necessary to obtain or use the substance or recover from its effects. • Important social, occupational, or recreational activities are given up or reduced because of substance use. • Substance use is continued despite having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. Specifiers: • With Physiological Dependence – evidence of tolerance or withdrawal. • Without Physiological Dependence – no evidence of tolerance or withdrawal

6. Substance Dependence Course Modifiers: • Early Full Remission: no criteria for dependence or abuse have been met at any time for the last 1-12 months • Early Partial Remission: 1 or more, but not full, criteria for dependence or abuse have been met for last 1-12 months • Sustained Full Remission: no criteria for dependence or abuse have been met at any time for the last 12+ months • Sustained Partial Remission: 1 or more, but not full, criteria for dependence or abuse have been met for the last 12+ months • In a Controlled Environment: no criteria for abuse or dependence have been met for at least the past month • On Agonist Therapy: no criteria for abuse or dependence have been met for at least the past month

7. Substance Abuse A. Maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 1 or more of the following, occurring in a 12-month period: • Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home • Recurrent substance use in situations in which it is physically hazardous (e.g. driving while impaired) • Recurrent substance-related legal problems (e.g. disorderly conduct) • Recurrent substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g. arguments with significant other about substance use, physical fights) B. Symptoms have never met the criteria for Substance Dependence for this class of substance.

8. Differential Diagnosis of Substance Dependence & Abuse • Continuum of Substance Use: Recreational Use  Problematic Use  Substance Abuse  Substance Dependence • Substance Dependence: adverse consequences & tolerance, withdrawal, compulsive use. • Substance Abuse: adverse consequences, but absence of tolerance, withdrawal, or compulsive use. • Consider factors such as age, sex, culture, and health. • Once person has met criteria for Substance Dependence for a substance, they can never be given dx of Substance Abuse for that substance.

9. Substance Intoxication • The development of a reversible substance-specific syndrome, due to recent ingestion of, or exposure to, a substance. • Clinically significant maladaptive behavioral or psychological changes develop during or shortly after use of the substance due to the effect of the substance on the central nervous system. • The symptoms are not due to a general medical condition and are not better accounted for by another disorder.

10. Substance Withdrawal • Development of a substance-specific syndrome due to the cessation of, or reduction in, substance use that has been heavy & prolonged. • The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • Symptoms aren’t due to a general medical condition and aren’t better accounted for by another mental disorder.

11. Necessary Clinical Information • Current substance use • History of substance use • History of substance use emergencies & treatment • Cognitive impairment, e.g. confusion, disorientation, impaired attention, rambling thoughts, drowsiness • Physiological signs, e.g. tachycardia, hypertension, hypotension, dilation or constriction of pupils • Neurological signs, e.g. slurred speech, lack of coordination, ataxia, dystonia, tremor, seizure, etc. • Psychomotor agitation or retardation • Changes in personality, mood, anxiety • Urine drug screening, blood alcohol level • Changes in social or family life • Current and past legal problems

12. Making a Diagnosis • Identification of abused substance(s): • Patient admits to using substance(s) • Substance is detected in urine or blood • Patient has characteristic physiological, behavioral, or psychological signs & Sx of intoxication or withdrawal from substance • Current pattern of use: dependence or abuse • Abnormal physiological symptoms or signs: current intoxication or withdrawal • History of substance abuse • Experiencing recent related legal problems: intoxication, abuse, or dependence • Maladaptive behavioral or psychological changes: intoxication, withdrawal, abuse, or dependence

13. Treatment Planning • Detoxification (for severe withdrawal) • Inpatient treatment programs (substance dependence) • Outpatient treatment programs • Groups: psychoeducation, 12-step recovery, support groups, relapse prevention • Evaluate social system (family situation, significant relationships, friendships, support network) & coping skills • Prevention strategies: stressing the need for abstinence for those with a strong family Hx of alcoholism or their own Hx of alcohol or substance dependence

14. Alcohol, Sedative, Hypnotic, or Anxiolytic Intoxication Behavioral & Psychological Changes: • Inappropriate sexual/aggressive behavior • Mood lability • Impaired judgment • Impaired social/occupational functioning Clinical Signs & Symptoms: • Slurred speech • Lack of coordination • Unsteady gait • Nystagmus • Impaired attention and memory • Stupor or coma

15. Alcohol, Sedative, Hypnotic, or Anxiolytic Withdrawal • Autonomic hyperactivity, e.g. sweating, pulse greater than 100 • Increased hand tremor • Insomnia • Nausea or vomiting • Transient visual, tactile, or auditory hallucinations or illusions • Psychomotor agitation • Anxiety • Grand mal seizures

16. Amphetamine or Cocaine Intoxication Behavioral & Psychological Changes: • Euphoria or affective blunting • Changes in sociability • Hypervigilance • Interpersonal sensitivity • Anxiety, tension, or anger • Stereotyped behaviors • Impaired judgment • Impaired social/occupational functioning

17. Amphetamine or Cocaine Intoxication Clinical Signs & Symptoms: • Tachycardia or bradycardia • Pupil dilation • Elevated or lowered blood pressure • Perspiration or chills • Nausea or vomiting • Weight loss • Psychomotor agitation or retardation • Muscular weakness, respiratory depression, chest pain, cardiac arrhythmias • Confusion, seizures, dyskinesias, dystonias, or coma

18. Amphetamine or Cocaine Withdrawal • Dysphoric mood • Fatigue • Vivid, unpleasant dreams • Insomnia or hypersomnia • Increased appetite • Psychomotor retardation or agitation

19. Caffeine Intoxication Clinical Signs & Symptoms: • Restlessness • Nervousness • Excitement • Insomnia • Flushed face • Diuresis • Gastrointestinal disturbance • Muscle twitching • Rambling flow of thought and speech • Tachycardia or cardiac arrhythmia • Periods or inexhaustibility • Psychomotor agitation

20. Nicotine Withdrawal • Dysphoric or depressed mood • Insomnia • Irritability, frustration, anger • Anxiety • Difficulty concentrating • Restlessness • Decreased heart rate • Increased appetite or weight gain

21. Cannabis Intoxication Behavioral & Psychological Changes: • Impaired motor coordination • Euphoria • Anxiety • Sensation of slowed time • Impaired judgment • Social withdrawal Clinical Signs & Symptoms: • Conjuctival injection • Increased appetite • Tachycardia • Dry mouth

22. Hallucinogen Intoxication Behavioral & Psychological Changes: • Marked anxiety or depression • Ideas of reference • Fear of losing one’s mind • Paranoid ideation • Impaired judgment • Impaired social/occupational functioning Clinical Signs & Symptoms: • Pupillary dilation • Tachycardia • Sweating • Palpitations • Blurring of vision • Tremors • Lack of coordination

23. Hallucinogen Persisting Perception Disorder Individuals who have previously used a hallucinogen reexperience one or more of the perceptual symptoms that they experienced while intoxicated with the hallucinogen: • Geometric hallucinations • False perceptions of movement in peripheral visual fields • Flashes of color • Intensified colors • Trials of images of moving objects • Positive afterimages • Halos around objects • Macropsia • Micropsia

24. Inhalant Intoxication Clinical Signs & Symptoms: Dizziness Blurred vision or diplopia Nystagmus Stupor or coma Incoordination Euphoria Slurred speech Tremor Unsteady gait Lethargy Depressed reflexes Generalized muscle weakness Psychomotor retardation Behavioral & Psychological Changes: Belligerence Impaired judgment Assaultiveness Impaired social/occupational functioning Apathy

25. Opioid Intoxication Behavioral & Psychological Changes: • Initial euphoria followed by apathy • Dysphoria • Psychomotor agitation or retardation • Impaired judgment • Impaired social/occupational functioning Clinical Signs & Symptoms: • Pupillary constriction • Drowsiness or coma • Slurred speech • Impaired attention or memory

26. Opioid Withdrawal • Dysphoric mood • Nausea or vomiting • Muscle aches • Lacrimation or rhinorrhea • Pupillary dilation, piloerection, or sweating • Diarrhea • Yawning • Fever • Insomnia

27. Behavioral & Psychological Changes: Belligerence assaultiveness Impulsiveness Unpredictability Psychomotor agitation Impaired judgment Impaired social/ occupational functioning Clinical Signs & Sx: Vertical or horizontal nystagmus Hypertension or tachycardia Numbness or diminished responsiveness to pain Ataxia Dysarthria Muscle rigidity Seizure or coma Hyperacusis Phencyclidine Intoxication

28. Substance-Induced Psychiatric Syndromes • There is evidence that psychiatric symptoms developed during or within a month of significant substance intoxication or withdrawal. • Every class of abused substances, except nicotine, has the capacity to produce psychiatric symptoms during intoxication or withdrawal. • Specific diagnosis should specify the name of the abused substance, the psychiatric syndrome, & whether the onset occurred during withdrawal or intoxication, e.g. Alcohol-Induced Anxiety Disorder with onset during withdrawal.

29. Delirium Persisting Dementia Persisting Amnestic Disorder Psychotic Disorder with Delusions Psychotic Disorder with Hallucinations Mood Disorder Anxiety Disorder Sexual Dysfunction Sleep Disorder Substance-Induced Psychiatric Syndromes