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Substance-Related and Addictive Disorders

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Example of the Multi-Axial DSM-IV-TR Recording SystemDiagnostic Impression Based on the DSM-IV-TR:Axis I: 296.52, Bipolar I Disorder, most recentepisodedepressed, moderate (even thoughnever treated)300.01, Panic Disorder, With and Without Agoraphobia309.81, Post Traumatic Stress Disorder, Chronic300.02, Generalized Anxiety Disorder300.29, Specific Phobia303.93D, AlcoholDependence, in full remission307.51, Bulimia Nervosa, in full remissionAxisII: 301.83, Borderline Personality DisorderAxisIII: Chronicmigraine headaches, severeinsomnia, asthma, obesityAxis IV: Stressors:Multiple Family IssuesAxis V: GlobalAssessment ofFunctioning:GAF: 54
Charles O'Brien,M.D., Ph.D.Chair, Substance-Related Disorders WorkGroup1. “diagnosed with a clinical interview”2. “abuse not milder than dependence”3. “dependence does not = addiction as long as follow doctor’s orders”
“Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system” And O’Brien saidthe term ‘abuse’ is clinically meaningless, noting that “abuse, dependence, and addiction are all one continuous variable.”
Substance-Related and Addictive Disorders
Substance Use DisordersAbuseandDependencecombined intoUseContinued use despite significant substance-related problems“Pathological patterns, significant problems, repeated relapses, intense drug cravings”CriteriaRemoved: recurrentlegal problems criterionAdded:cravingor a strong desire or urge to use asubstanceCraving involvesclassical conditioningand associated with activation of specific brainreward structuresRelapse prediction and treatment outcome measureDSM-IV: “Although not specifically listed as a criterion item, ‘craving’ (a strong subjective drive to use the substance) is likely to be experienced by most (if not all) individuals with Substance Dependence.” (p. 192)"Have you ever wanted alcoholso badly you couldn't thinkof anything else?“"Have you ever felt a strong desire orurgetodrink?“
Substance UseDisordersRemovedPolysubstance-Related DisorderDSM-IV-TRpages 293-294Specifier for a physiological subtypeCocaine and AmphetamineAddedStimulant Use DisorderCaffeine WithdrawalCannabis WithdrawalChangedNicotine to TobaccoOnagonisttherapy to onmaintenancetherapy
Substance Use DisordersMiscellaneous classificationSyntheticcannabinoid compoundsEcstasy and ketamineOther/Unknown SubstanceUse DisorderBath salts (“synthetic chemical derivatives”)Anabolic steroidsNew, black market drugsNitrousoxide
Substance-Related and Addictive Disorders
Substance Use DisordersThreshold=2 of11symptomsImpairedcontrolcriteria 1-4Socialimpairmentcriteria 5-7Riskyusecriteria 8-9Pharmacologicalcriteria 10-11Tolerance and withdrawal:Symptoms vary between drug classesAppropriate medical treatment w/ prescribedmedications
Substance Use DisordersSeverity ratings2–3 criteria indicate = amilddisorderAn important marker iscontinued use despite a clear riskof negative consequences to other valued activities or relationships4–5 criteria =moderatedisorder6 or more = aseveredisorder
Substance Use DisordersRemission specifiersEarlyat least 3 but less than 12 months w/o substance use disorder criteria (except craving)Sustainedat least 12 months w/o criteria (except craving)SampleDSM-5 diagnosisSevereOpioid Use Disorder, On Maintenance Therapy, In Controlled Environment(principle diagnosis);ModerateCannabis Use Disorder (synthetic cannabinoid);MildStimulant UseDisorder (cocainetype)EarlyRemission
Substance-Induced DisordersSubstanceIntoxication and WithdrawalIntoxication doesnot apply toTobaccoSubstance/Medication-Induced Mental DisordersMood disturbancesAnxiety syndromesPsychotic symptomsSuicide attemptsSexual dysfunctionsDisturbed sleep
LatestresearchCompton,W.M., Dawson,D.A., Goldstein,R.B., & Grant, B.F.(2013).Crosswalkbetween DSM-IV dependence and DSM-5 substance use disorders for opioids, cannabis, cocaine and alcohol.Drugand Alcohol Dependence,doi: alcohol, cocaine and opioid dependence,optimal concordance occurred when 4+DSM-5 criteriawere endorsed, corresponding to the threshold formoderateDSM-5.Maximalconcordance of DSM-IV cannabis dependence and DSM-5 cannabis usedisorderoccurred when 6+ criteriawere endorsed, corresponding to the threshold forsevereDSM-5.Sensitivity and specificity, generallyexceeded 85%(>75% for cannabis).Conclusions:Overall, excellent correspondence of DSM-IV dependence with DSM-5 substance usedisorders.

DSM-5 Alcohol-Related DisordersAlcohol Use DisorderAlcohol IntoxicationAlcohol WithdrawalOther Alcohol-Induced DisordersUnspecified Alcohol-Related DisorderRef. Page490

DSM-5 Alcohol Use Disorder1Diagnostic Criteria: A problematic pattern of alcohol use leading to clinically significant impairmentordistress as manifested by at leastTWOof the following within a twelve(12) month period.Alcohol is often taken in larger amountsorover a longer period than was intended.Persistent desireorunsuccessful efforts to cut down or control alcohol use.Spending a great deal of time in activities necessary to obtain alcohol use or recover from its effects.Craving or a strong desireorurge to use alcohol.Recurrent alcohol use resulting in the failure to fulfill major role obligations.Continued alcohol use despite persistent or recurrent social or interpersonal problems caused byorexacerbated by the effects of alcohol.Important social, occupational or recreational activities are given up or reduced because of alcohol use.Recurrent use in situations in which it is physically hazardous.Alcohol use continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.Tolerance as defined by either of the following:Need for markedly increased amounts of alcohol to achieve intoxication or the desired effect.Markedly diminished effect with continued use of the same amount of alcohol.Withdrawal:Classic withdrawal syndrome, specifically described.Alcohol (or closely related substance) is taken to relive or avoid withdrawal symptoms.Ref. Page490

DSM-5 Alcohol Use Disorder Specifiers2Subtype: Specify whether:Mild = 2-3 symptoms of 11 symptomsModerate = 4-5 symptomsSevere = 6 or more symptomsSpecify if:In EarlyRemission= after full criteria for alcohol use disorder were previously met,none of the criteria for alcohol use disorder have been met for at least 3 monthsbutlessthan 12 months.In Sustained Remission=after full criteria for alcohol use disorder were previously met,noneof the criteria for alcohol use disorder have been met at anytime during a periodof12 months orlonger (except for “craving”.)Specify if:In a controlled environmentRef.Page 491

DSM-5 Alcohol IntoxicationCriterion A:Recent Ingestion of alcoholCriterionB: Clinically significant problematic behaviororpsychological changes that developed during, or shortly after, alcohol intoxication.CriterionC:ONEor more of the following during or shortly after alcohol use.Slurred speechIncoordinationUnsteady GaitNystagmusImpairment in attention or memoryStupor or comaHas a specific code: 303.00Ref. Page497

DSM-5 Alcohol WithdrawalCriterionA:Cessation of (or reduction in) alcohol use that has beenheavy and prolonged.CriterionB:TWO(or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A.Autonomic hyperactivity (sweating, pulse > 100 bpm)Increased hand tremorInsomniaNausea or vomitingTransient visual, tactile or auditory hallucinations or illusionsPsychomotor agitationAnxietyGeneralized tonic- clonic seizuresCriterion C:Clinically significant distress/impairmentCriterion D:Not attributable to another.Specify if:with perceptual disturbancesRef. Page499

DSM-5 Caffeine-Related DisorderNo Caffeine UseDisorderCaffeine IntoxicationCaffeine WithdrawalOther Caffeine-Inducted DisordersUnspecified Caffeine-Related DisorderRef. Page503

DSM-5 Caffeine IntoxicationCriterionA:Recent consumption of caffeine (typically > 250mg.)Criterion B:FIVE(or more developing during, or shortly after, caffeine use):RestlessnessNervousnessExcitementInsomniaFlushed FaceDiuresisGI disturbanceMuscle twitchingRambling flow of thought and speechTachycardia or cardiac arrhythmiaPsychomotor agitationRef. Page508

DSM-5 Caffeine WithdrawalCriterionA:Prolonged daily use of caffeineCriterion B:Abrupt cessation of, or reduction in caffeine use, followed within 24 hours byTHREE(or more) of the following signs or symptoms:HeadacheMarked fatigue or drowsinessDysphoric mood, depressed mood or irritabilityDifficulty concentratingFlu-like symptoms (nausea, vomiting, or muscle pain / stiffness)Ref. Page506

DSM-5 Non-Substance-Related (Addictive) Disorder: GamblingCriterionA:Persistent and recurrent problematic gambling behavior leading to clinical significant impairmentordistress as indicated byFOUR(or more) of the following during a12-month period.Needs to gamble with increasing amounts of money to achieve the desired excitement.Is restless or irritable when attempting to cut down or stop gambling.Has made repeated unsuccessful efforts to control, cut back or stop gambling.Often preoccupied with gambling.Often gambles when feeling distressed.After losing money gambling, often returns another day to get even.Lies to conceal the extent of involvement with gambling.Has jeopardized or lost a significant relationship, job or education or career opportunity because of gamblingRelies on others to provide money to relieve desperate financial situations caused by gambling.Criterion B:The gambling is not better explained by a manic episode.Specify whether (subtypes):Current Severity: Mild= 4 – 5symptoms aboveModerate = 6 – 7 symptoms aboveSevere= 8 – 9symptoms aboveSpecify if:Episodic = symptoms meeting criteria for at least 7 months.Persistent = continuous symptoms meeting criteria for multiple years.Specify if:Early remission = after full criteria for gambling disorder were previously met,NONEof the criteriafor gambling disorder have been met for at leastthree (3) monthsbut for less than 12 months.Sustained remission = After full criteria for gambling disorder were previously met,NONEof thecriteria for gambling disorder have been met during a period of twelve (12) monthsor longer.Ref.Page 585





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Substance-Related and Addictive Disorders