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DSM-5 Update: Substance-Related and Addictive Disorders
Presented by:Nick Lessa, LCSW, MA, [email protected]
DSM- 5 Update
0A guide in the diagnosis of mental disorders
0Recently updated after 13 years since the DSM-IV-TR was released in 2000.
022 separate classifications involving 13 work groups
Changes in Substance-Related Disorders Section from DSM-IV
0Removal of Substance Abuse and Substance Dependence.
0Severity of disorder (mild to severe) based on the number of symptom criteria met: 0 Mild: 2-3 symptoms0 Moderate: 4-5 symptoms 0 Severe: 6 or more symptoms
Changes in Substance-Related Disorders Section from DSM-IV
0The word “addiction” is omitted due to its “uncertain definition and its potentially negative connotation.”
0 “Craving or strong desire” replaces “preoccupation”
0 Items deleted: “recurrent legal problems”, polysubstance category, physiological subtype
Substance-Related and Addictive Disorders
Encompasses 10 separate classes of drugs:1. Alcohol2. Caffeine3. Cannabis4. Hallucinogens5. Inhalants6. Opioids7. Sedatives, hypnotics,& anxiolytics8. Stimulants9. Tobacco10. Other (or unknown) substances
Addictive Disorders
0 Includes Gambling Disorder
0Other potential behavioral addictions (internet addiction, sex addiction, exercise addiction, shopping addiction, etc.) not included due to “insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions…”
Substance-Related Disorders
0Divided into two groups
0Substance-Induced Disorders: includes conditions of intoxication or withdrawal and other induced mental disorders
0Substance-Use Disorders: relates to pathological patterns of behaviors related to the use of a particular substance
Substance-Induced Disorders
0Essential Feature – “the development of a reversible substance-specific syndrome due to the recent ingestion of a substance.”
0 Includes intoxication, withdrawal, and other substance/medication-induced mental disorders
Substance Intoxication
0Substance intoxication can occur in individuals without a Substance Use Disorder
0Substance intoxication must include problematic behavior
0Substance intoxication does not apply to tobacco. (may explain society’s liberal view of use – nonproblematic)
Substance Withdrawal
0Essential Feature – “the development of substance-specific problematic behavioral change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use.”
Substance/Medication-Induced Mental Disorders0The substance/medication-induced mental
disorders are potentially severe, usually temporary, but sometimes persisting CNS syndromes that develop in the context of the effects of substances of abuse, medications, or several toxins
0Likely to improve in a matter of days to weeks of abstinence
Substance/Medication-Induced Mental Disorders0The disorder developed within 1 month of
substance intoxication or withdrawal or taking a medication
0The disorder did not proceed the onset of severe intoxication, withdrawal or exposure to a medication
0The disorder not likely to be better explained by an independent mental condition
0Likely to disappear within 1 month of cessation of withdrawal, intoxication or use of meds
Substance/Medication-Induced Mental Disorders Exception to the 1 month rule includes:0Alcohol-induced, inhalant-induced, and
sedative/hypnotic/anxiolytic-induced neurocognitive disorders
0Hallucinogen Persisting Perception Disorder (e.g., “flashbacks”)
Substance Use Disorders
0The Essential Feature – continued use despite significant substance-related problems
0Changes in brain circuits may persist, exhibited in repeated relapses & intense drug cravings
0Criteria include impaired control, social impairment, risky use, and pharmacological symptoms (withdrawal/tolerance)
Substance Use Disorders
011 diagnostic criteria (some classes of substances have 10 criteria)
0 2 or more within a 12-month period
0Must include a pattern of use leading to clinically significant impairment or distress
Substance Use Disorders: Diagnostic Criteria
1. Substance often taken in larger amounts or over a longer period of time than intended (impaired control)
2. A persistent desire or unsuccessful efforts to cut down or control use (impaired control)
3. A great deal of time spent in activities necessary to obtain the substance, use it, or recover from its effects (impaired control)
4. Craving, or strong desire or urge to use (impaired control) (New criteria)
Substance Use Disorders: Diagnostic Criteria
5. Recurrent use resulting in failure to fulfill major role obligations at work, school, or home (social impairment)6. Continued use despite having persistent or recurrent social/interpersonal problems caused or exacerbated by use (social impairment)7. Important social, occupational, or recreational activities given up or reduced because of use (social impairment)
Substance Use Disorders: Diagnostic Criteria
8. Recurrent use in situations which is physically hazardous (risky use)
9. Use is continued despite knowledge of having a persistent or recurrent physical/psychological problem likely to have been caused or exacerbated by use (risky use)
Substance Use Disorders: Diagnostic Criteria
10. Tolerance: the need for markedly increased amounts of substance to achieve intoxication or desired effect, or a markedly diminished effect with continued use of same amount (pharmacological)11. Withdrawal: a characteristic syndrome, or use to relieve or avoid withdrawal (pharmacological)
Recording Procedures for Substance Related Disorders
0New recording procedures to occur by 10/140Use the code for the class of substances, but
record the specific substance0Severity determined by # of symptom criteria0Mild (2-3); Moderate (4-5); Severe (6 or more)0Severity can change over the course of time
by reductions or increases0Record for each individual substance disorder
Recording Procedures for Substance Related Disorders
Course Specifiers0“in early remission” (3-11 months)0“in sustained remission” (12 mos. or longer)0None of the criteria met for that duration with
exception of craving0“on maintenance therapy” (for opioids, tobacco)0“in a controlled environment” (access to
substance is restricted)
Alcohol-Related Disorders
0Prevalence – 12% of males and 4.6% of females 18 and older. Significantly drops after age 65.
0Lifetime risk of major depressive disorders – 40%0Can lead to persisting neurocognitive disorders0Alcohol Intoxication includes 1 or more symptoms
of: slurred speech, incoordination, unsteady gait, nystagmus (involuntary eye movement), attention/memory impairment, stupor/coma
Alcohol Use Disorders
0 Alcohol Withdrawal includes 2 or more of following after cessation of or reduction in alcohol use:0 Autonomic hyperactivity (sweating or pulse > 100)0 Increased hand tremor0 Insomnia0 Nausea or vomiting0 Transient visual, tactile, auditory hallucinations0 Psychomotor agitation0 Anxiety0 Seizures
Caffeine-Related Disorders
0More than 85% of children and adults consume caffeine regularly
0Most widely used drug in the world0Symptoms include tolerance and withdrawal0No Caffeine Use Disorder (data unavailable yet);
only Caffeine Intoxication and Withdrawal0Significant growth in energy drinks with young
individuals0Taking oral contraceptives decreases elimination
of caffeine (Increased risk of intoxication)
Caffeine Intoxication0 Intoxication must be in excess of 250 mg. & cause distress or
impairment0 5 or more of following:
0 Restlessness0 Nervousness0 Excitement0 Insomnia0 Flushed face0 Diuresis0 Gastrointestinal disturbance0 Muscle twitching0 Rambling flow of thought and speech0 Tachycardia or cardiac arrhythmia0 Periods of inexhaustibility0 Psychomotor agitation
Caffeine Withdrawal
0Following cessation of or reduction in use within 24 hours by 3 or more of following:0 Headache (the hallmark feature)0 Marked fatigue or drowsiness0 Dysphoric mood, depressed mood, or irritability0 Difficulty concentrating0 Flu-like symptoms (nausea, vomiting, muscle
pain)
Cannabis Related Disorders
0 Most widely used illicit substance in the U.S.0 Prevalence of disorder - 3% of adolescents and 1.5%
of adults0 Prevalence drops after age 650 More common for males than females0 Cannabis use disorders have increased over past
decade0 Difficult to distinguish between problem use and
non-problematic use0 Few clear medical conditions associated with use0 60% of adolescents also have Conduct D/O or AD/HD
Cannabis Use Disorder
0At least 2 of the 11 symptom criteria
0 Includes tolerance and withdrawal
Cannabis Intoxication
0 Can lead to substance-induced psychotic or anxiety D/O’s, sleep disorders, or delirium
0 Problematic behavioral or psychological changes (e.g., impaired judgment, motor coordination, social withdrawal, euphoria, anxiety, sensation of slowed time) and,
0 2 or more of the following:0 Conjunctival injection (red eyes)0 Increased appetite0 Dry mouth0 Tachycardia
Cannabis Withdrawal
0 After heavy or prolonged use0 3 or more of the following developing within a
week:0 Irritability, anger, or aggression0 Nervousness or anxiety0 Sleep difficulty (insomnia or disturbing dreams)0 Decreased appetite or weight loss0 Restlessness0 Depressed mood0 Physical symptoms (sweating, fever, chills,
headache, shakiness/tremors, or stomach pain)
Hallucinogen-Related Disorders
0Separate criteria for Phencyclidine Disorders (e.g., PCP, “angel dust”, ketamine, cyclohexamine, dizocilpine) and,
0 Other Hallucinogen Disorders (e.g., LSD, MDMA, DMT, psilocybin, mescaline, peyote, morning glory seeds, jimsonweed)
Phencyclidine Use Disorder
010 symptom criteria (excludes withdrawal symptoms)
0Previously in the category of Dissociative Anesthetics
0Prevalence primarily in the African-American (49%) and Hispanic (29%) cultures. Only .5% of young Caucasians.
Other Hallucinogen Use Disorder
010 symptom criteria (excludes withdrawal symptoms)
0Hallucinogen Use Disorder is one of the rarest. (.5% among adolescents and .2% in adults)
0Those who have this disorder have higher rates of other SUD’s as well
0Can lead to psychotic-induced, bipolar-induced, depressive-induced, anxiety-induced disorders and delirium
Phencyclidine Intoxication
0 Problematic behavior (e.g., belligerent, assaultive, impulsive, unpredictable, agitated, impaired judgment) and, 2 or more of the following:
1. Vertical or horizontal nystagmus (involuntary eye movement)
2. Hypertension or tachycardia3. Numbness or diminished response to pain4. Ataxia (lack of muscle coordination)5. Dysarthria (difficulty articulating)6. Muscle rigidity7. Seizures or coma8. Hyperacusis (sensitivity to loud noises)
Other Hallucinogen Intoxication
0Problem behavior or psychological changes (e.g., anxiety, depression, ideas of reference, “losing one’s mind”, paranoia, impaired judgment)
0Perceptual changes (e.g., intensified perceptions, illusions, hallucinations, derealization) and, 2 or more of the following:
0Pupillary dilation, tachycardia, sweating, palpitations, blurred vision, tremors, incoordination
Hallucinogen Persisting Perception Disorder
0Following cessation of hallucinogen use, the reexperiencing of one or more of the perceptual symptoms that were experienced when intoxicated (e.g., trails, color flashes, geometric hallucinations, false perceptions of movement, intensified colors)
0Cause significant distress or impairment in important areas of functioning
Inhalant Related Disorders
0 Involves any hydrocarbon-based substances (e.g., toxic gases from glues, fuels, paints, and other volatile substances)
0 No diagnosis of inhalant withdrawal0 Standard drug screens do not detect inhalants.
Detection is costly0 Prevalence is about 0.2%. Rare among females
and a preponderance of European American males0 Prevalence declines after adolescence0 Common with adolescent Conduct Disorder. Adult
use strongly associated with suicidality
Inhalant Use Disorder
010 of the 11 standard symptom criteria. No withdrawal criteria.
0When possible, name the particular substance involved
Inhalant Intoxication
0Problematic behavioral or psychological changes (e.g., belligerence, assaultive, apathy, impaired judgment)
02 or more of following: dizziness, nystagmus, incoordination, slurred speech, unsteady gait, lethargy, depressed reflexes, psychomotor retardation, tremor, muscle weakness, blurred vision, stupor/coma, and euphoria.
Opioid-Related Disorders
0Prevalence is about 0.37% of adults0Lowest among African Americans, highest
among Native Americans0Hepatitis A, B, and C virus found in 80%-90%
of injection opioid users0HIV infection up to 60% of heroin users0A heightened risk for accidental and
deliberate overdoses
Opioid Use Disorder
0 Includes all 11 standard, symptom criteria
0 Include the specifier “On maintenance therapy” when individual is taking a “prescribed” agonist medication (e.g., methadone, buprenorphine) or antagonist (e.g., naltrexone, Vivitrol)
Opioid Intoxication
0Problem behavior or psychological changes (e.g., euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment)
0Pupillary constriction (or dilation due to severe overdose) and,
0One or more of the following: drowsiness/coma, slurred speech, impairment in attention or memory
Opioid Withdrawal
03 or more of the following within minutes to several days after cessation of use or administration of an antagonist:
0Dysphoric mood, nausea/vomiting, muscle aches, lacrimation/rhinorrhea, pupillary dilation, piloerection/sweating, diarrhea, yawning, fever, and insomnia.
Opioid Withdrawal
0Short-acting drugs (e.g., heroin) begin to have withdrawal symptoms within 6-12 hours after last dose
0Longer-acting drugs (e.g., methadone, buprenorphine) may take 2-4 days for symptoms to emerge
0Less acute withdrawal symptoms ( e.g., anxiety, insomnia, dysphoria, anhedonia) can last for weeks to months
Sedative-, Hypnotic-, or Anxiolytic-Related Disorders
0 Includes benzodiazepines, benzodiazepine-like drugs (e.g., ambien, sonata), carbamates, barbiturates (e.g., secobarbital), and barbiturate-like hypnotics (e.g., quaalude)
0Also includes all prescription sleeping medications and almost all prescription anti-anxiety medications
Sedative-, Hypnotic-, or Anxiolytic-Related Disorders
00.3% prevalence rate among adolescents and 0.2% among adults
0Females appear to be at a higher risk for prescription drug misuse of this class of substances
0Can be detected in tox screens for up to a week
0At high doses, can be lethal especially when mixed with alcohol
Sedative, Hypnotic, or Anxiolytic Intoxication
0Problem behavior or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, and impaired judgment) and,
0One or more of the following: slurred speech, incoordination, unsteady gait, nystagmus, impairment in cognition (attention, memory), stupor/coma
Sedative, Hypnotic, or Anxiolytic Withdrawal
0 Two or more of the following developing within several hours to a few days after cessation:
1. Autonomic hyperactivity (sweating, pulse rate > 100 bpm)
2. Hand tremor3. Insomnia4. Nausea or vomiting5. Transient hallucinations or illusions6. Psychomotor agitation7. Anxiety8. Grand mal seizures
Sedative, Hypnotic, or Anxiolytic Withdrawal
0Grand mal seizures may occur in as many as 20-30% of cases undergoing untreated withdrawal
0 In severe withdrawal, visual, tactile, or auditory hallucinations or illusions can occur
0Withdrawal from shorter-acting substances can begin within hours, longer-acting within 1-2 days
Stimulant Use Disorder
0Prevalence rate for cocaine use disorder for adults is 0.3%
0Greatest for 18-29 year-olds (0.6%)0Cocaine use disorder is virtually absent
among Native Americans and Alaska natives0Childhood conduct disorder and adult ASPD
are associated with later development of stimulant-related disorders
Stimulant Use Disorder
0Stimulant-use disorder is associated with PTSD, ASPD, ADHD, and gambling disorder
066% of those with methamphetamine use disorders are non-Hispanic white, 21% Hispanic, 3% African-American
0Hair samples can detect the presence of stimulants for up to 90 days
Stimulant Use Disorder
0Use leading to significant impairment or distress over a 12-month period
0Two or more of the 11 symptom criteria
Stimulant Intoxication
0 Problem behavioral or psychological changes (e.g., euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviors; impaired judgment) &
0 Two or more of the following: tachycardia/bradycardia, pupillary dilation, elevated or lowered BP, perspiration/chills, nausea/vomiting, weight loss, psychomotor change, muscular weakness, respiratory depression, chest pain, cardiac arrhythmias, confusion, seizures, involuntary muscle movements, coma
Stimulant Withdrawal
0Dysphoric mood and 2 or more of the following developing within a few hours to several days after cessation:0 Fatigue0 Vivid, unpleasant dreams0 Insomnia or hypersomnia0 Increased appetite0 Psychomotor retardation or agitation
Tobacco-Related Disorders
0 Includes daily cigarette use or smokeless tobacco
0Features often include smoking within 30 minutes of waking, daily use, waking at night to smoke
0Nicotine dependence in about 13% of U.S. adults
0Nicotine dependence in about 50% of daily smokers
Tobacco-Related Disorders
0 Initiation of smoking after age 21 is rare0Those who quit usually do so after age 300Non-daily smoking has become more
prevalent in the past decade especially among younger individuals
0More common among those with AD/HD, conduct d/o, mood, anxiety, personality, psychotic or other SUD’s
Tobacco-Related Disorders
0 Individuals with low incomes and low educational levels are more likely to initiate tobacco use and less likely to stop
050% of smokers who do not stop using tobacco will die early from a tobacco-related illness
0There is no Tobacco Intoxication Disorder
Tobacco Use Disorder
0Problematic pattern of use leading to significant impairment or distress as manifested by 2 or more of the 11 symptom criteria
0 Includes the specifier “on maintenance therapy” for those taking a nicotine replacement aid or a tobacco cessation medication
Tobacco Withdrawal
0Cessation or reduction followed within 24 hours by 4 or more of the following:0 Irritability, frustration, or anger0 Anxiety0 Difficulty concentrating0 Increased appetite0 Restlessness0 Depressed mood0 Insomnia
Other (or Unknown) Substance Use Disorder
0Problematic use of an “intoxicating substance” not able to be classified within the other categories
0Meets at least two or more of the 11 symptom criteria within a 12-month period
Other (or Unknown) Substance Use Disorder
0Other includes anabolic steroids; non-steroidal anti-inflammatory drugs; cortisol; antiparkinsonian medications; antihistamines; nitrous oxide; amyl-, butyl-, or isobutyl-nitrates; betel nut; kava; and khat
0Unknown – when a substance is unknown0Also, includes the categories Intoxication and
Withdrawal
Gambling Disorder
0Previously known as “Pathological Gambling” and was in category of Impulse Control Disorders
0Problematic gambling leading to significant impairment or distress
0Leading to four or more of the following symptoms over a 12-month period
Gambling Disorder Diagnostic Criteria
1. Needs to gamble with increasing amounts of money for desired excitement
2. Is restless or irritable when attempting to cut down or stop gambling
3. Repeated unsuccessful efforts to control, cut back, or stop gambling
4. Often preoccupied with gambling5. Gambles when feeling distressed (helpless,
guilty, anxious, depressed)
Gambling Disorder Diagnostic Criteria
6. After losing money gambling, often returns another day to get even7. Lies to conceal the extent of involvement with gambling8. Jeopardized or lost a significant relationship, job, or career opportunity due to gambling9. Relies on others to provide money to relieve financial situations caused by gambling
Gambling Disorder Diagnostic Criteria
0Removal of the criteria “has committed acts of forgery, fraud, theft, or embezzlement to finance gambling”
0Can be specified as either “Episodic” or “Persistent” and “In early remission” or “In sustained remission”
Gambling Disorder Severity Rating
0Mild: 4-5 criteria
0Moderate: 6-7 criteria
0Severe: 8-9 criteria
Gambling Disorder
0About 0.2%-0.3% of general population03x more likely in males0Highest in African Americans (0.9%), whites
(0.4%), Hispanics (0.3%)0For females, the progression is more rapid0About 17% commit suicide0Often associated with SUDs and impulse –
control disorders (males) & mood/ anxiety D/O (females)
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