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A DSM 5 Update: Substance - Related And Addictive Disorders

Within the next year, most insurance providers will be expecting all claims to include the new DSM-5 nomenclature. It is imperative for all mental health professionals to be comfortable with the new diagnostic criteria and recording procedures. This presentation provides participants with a clear understanding of the revisions made in the category of Substance - Related and Addictive Disorders from the DSM-IV to the DSM-5.

Topics presented by Nick Lessa, CEO of Inter-Care: an addiction treatment program in New York City.


Changes in the diagnostic criteria from the DSM–IV to the DSM-5
The distinction between Substance Use Disorders and the Substance - Induced Disorders
Recording procedures for Substance Related Disorders

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A DSM 5 Update: Substance - Related And Addictive Disorders

  1. 1. DSM-5 Update: Substance-Related and Addictive Disorders { Presented by: Nick Lessa, LCSW, MA, CASAC
  2. 2. DSM- 5 Update 0 A guide in the diagnosis of mental disorders 0 Recently updated after 13 years since the DSM-IV- TR was released in 2000. 0 22 separate classifications involving 13 work groups
  3. 3. Changes in Substance-Related Disorders Section from DSM-IV 0 Removal of Substance Abuse and Substance Dependence. 0 Severity of disorder (mild to severe) based on the number of symptom criteria met: 0 Mild: 2-3 symptoms 0 Moderate: 4-5 symptoms 0 Severe: 6 or more symptoms
  4. 4. Changes in Substance-Related Disorders Section from DSM-IV 0 The 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
  5. 5. Substance-Related and Addictive Disorders Encompasses 10 separate classes of drugs: 1. Alcohol 2. Caffeine 3. Cannabis 4. Hallucinogens 5. Inhalants 6. Opioids 7. Sedatives, hypnotics,& anxiolytics 8. Stimulants 9. Tobacco 10. Other (or unknown) substances
  6. 6. Addictive Disorders 0 Includes Gambling Disorder 0 Other 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…”
  7. 7. Substance-Related Disorders 0 Divided into two groups 0 Substance-Induced Disorders: includes conditions of intoxication or withdrawal and other induced mental disorders 0 Substance-Use Disorders: relates to pathological patterns of behaviors related to the use of a particular substance
  8. 8. Substance-Induced Disorders 0 Essential 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
  9. 9. Substance Intoxication 0 Substance intoxication can occur in individuals without a Substance Use Disorder 0 Substance intoxication must include problematic behavior 0 Substance intoxication does not apply to tobacco. (may explain society’s liberal view of use – nonproblematic)
  10. 10. Substance Withdrawal 0 Essential 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.”
  11. 11. Substance/Medication-Induced Mental Disorders 0 The 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 0 Likely to improve in a matter of days to weeks of abstinence
  12. 12. Substance/Medication-Induced Mental Disorders 0 The disorder developed within 1 month of substance intoxication or withdrawal or taking a medication 0 The disorder did not proceed the onset of severe intoxication, withdrawal or exposure to a medication 0 The disorder not likely to be better explained by an independent mental condition 0 Likely to disappear within 1 month of cessation of withdrawal, intoxication or use of meds
  13. 13. Substance/Medication-Induced Mental Disorders Exception to the 1 month rule includes: 0 Alcohol-induced, inhalant-induced, and sedative/hypnotic/anxiolytic-induced neurocognitive disorders 0 Hallucinogen Persisting Perception Disorder (e.g., “flashbacks”)
  14. 14. Substance Use Disorders 0 The Essential Feature – continued use despite significant substance-related problems 0 Changes in brain circuits may persist, exhibited in repeated relapses & intense drug cravings 0 Criteria include impaired control, social impairment, risky use, and pharmacological symptoms (withdrawal/tolerance)
  15. 15. Substance Use Disorders 0 11 diagnostic criteria (some classes of substances have 10 criteria) 0 2 or more within a 12-month period 0 Must include a pattern of use leading to clinically significant impairment or distress
  16. 16. 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)
  17. 17. 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)
  18. 18. 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)
  19. 19. 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)
  20. 20. Recording Procedures for Substance Related Disorders 0 New recording procedures to occur by 10/14 0 Use the code for the class of substances, but record the specific substance 0 Severity determined by # of symptom criteria 0 Mild (2-3); Moderate (4-5); Severe (6 or more) 0 Severity can change over the course of time by reductions or increases 0 Record for each individual substance disorder
  21. 21. Recording Procedures for Substance Related Disorders Course Specifiers 0 “in early remission” (3-11 months) 0 “in sustained remission” (12 mos. or longer) 0 None of the criteria met for that duration with exception of craving 0 “on maintenance therapy” (for opioids, tobacco) 0 “in a controlled environment” (access to substance is restricted)
  22. 22. Alcohol-Related Disorders 0 Prevalence – 12% of males and 4.6% of females 18 and older. Significantly drops after age 65. 0 Lifetime risk of major depressive disorders – 40% 0 Can lead to persisting neurocognitive disorders 0 Alcohol Intoxication includes 1 or more symptoms of: slurred speech, incoordination, unsteady gait, nystagmus (involuntary eye movement), attention/memory impairment, stupor/coma
  23. 23. 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 tremor 0 Insomnia 0 Nausea or vomiting 0 Transient visual, tactile, auditory hallucinations 0 Psychomotor agitation 0 Anxiety 0 Seizures
  24. 24. Caffeine-Related Disorders 0 More than 85% of children and adults consume caffeine regularly 0 Most widely used drug in the world 0 Symptoms include tolerance and withdrawal 0 No Caffeine Use Disorder (data unavailable yet); only Caffeine Intoxication and Withdrawal 0 Significant growth in energy drinks with young individuals 0 Taking oral contraceptives decreases elimination of caffeine (Increased risk of intoxication)
  25. 25. Caffeine Intoxication 0 Intoxication must be in excess of 250 mg. & cause distress or impairment 0 5 or more of following: 0 Restlessness 0 Nervousness 0 Excitement 0 Insomnia 0 Flushed face 0 Diuresis 0 Gastrointestinal disturbance 0 Muscle twitching 0 Rambling flow of thought and speech 0 Tachycardia or cardiac arrhythmia 0 Periods of inexhaustibility 0 Psychomotor agitation
  26. 26. Caffeine Withdrawal 0 Following cessation of or reduction in use within 24 hours by 3 or more of following: 0 Headache (the hallmark feature) 0 Marked fatigue or drowsiness 0 Dysphoric mood, depressed mood, or irritability 0 Difficulty concentrating 0 Flu-like symptoms (nausea, vomiting, muscle pain)
  27. 27. Cannabis Related Disorders 0 Most widely used illicit substance in the U.S. 0 Prevalence of disorder - 3% of adolescents and 1.5% of adults 0 Prevalence drops after age 65 0 More common for males than females 0 Cannabis use disorders have increased over past decade 0 Difficult to distinguish between problem use and nonproblematic use 0 Few clear medical conditions associated with use 0 60% of adolescents also have Conduct D/O or AD/HD
  28. 28. Cannabis Use Disorder 0 At least 2 of the 11 symptom criteria 0 Includes tolerance and withdrawal
  29. 29. 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 0 0 0 Conjunctival injection (red eyes) Increased appetite Dry mouth Tachycardia
  30. 30. Cannabis Withdrawal 0 After heavy or prolonged use 0 3 or more of the following developing within a week: 0 Irritability, anger, or aggression 0 Nervousness or anxiety 0 Sleep difficulty (insomnia or disturbing dreams) 0 Decreased appetite or weight loss 0 Restlessness 0 Depressed mood 0 Physical symptoms (sweating, fever, chills, headache, shakiness/tremors, or stomach pain)
  31. 31. Hallucinogen-Related Disorders 0 Separate 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)
  32. 32. Phencyclidine Use Disorder 0 10 symptom criteria (excludes withdrawal symptoms) 0 Previously in the category of Dissociative Anesthetics 0 Prevalence primarily in the African-American (49%) and Hispanic (29%) cultures. Only .5% of young Caucasians.
  33. 33. Other Hallucinogen Use Disorder 0 10 symptom criteria (excludes withdrawal symptoms) 0 Hallucinogen Use Disorder is one of the rarest. (.5% among adolescents and .2% in adults) 0 Those who have this disorder have higher rates of other SUD’s as well 0 Can lead to psychotic-induced, bipolar-induced, depressive-induced, anxiety-induced disorders and delirium
  34. 34. 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 tachycardia 3. Numbness or diminished response to pain 4. Ataxia (lack of muscle coordination) 5. Dysarthria (difficulty articulating) 6. Muscle rigidity 7. Seizures or coma 8. Hyperacusis (sensitivity to loud noises)
  35. 35. Other Hallucinogen Intoxication 0 Problem behavior or psychological changes (e.g., anxiety, depression, ideas of reference, “losing one’s mind”, paranoia, impaired judgment) 0 Perceptual changes (e.g., intensified perceptions, illusions, hallucinations, derealization) and, 2 or more of the following: 0 Pupillary dilation, tachycardia, sweating, palpitations, blurred vision, tremors, incoordination
  36. 36. Hallucinogen Persisting Perception Disorder 0 Following 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) 0 Cause significant distress or impairment in important areas of functioning
  37. 37. 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 withdrawal 0 Standard drug screens do not detect inhalants. Detection is costly 0 Prevalence is about 0.2%. Rare among females and a preponderance of European American males 0 Prevalence declines after adolescence 0 Common with adolescent Conduct Disorder. Adult use strongly associated with suicidality
  38. 38. Inhalant Use Disorder 0 10 of the 11 standard symptom criteria. No withdrawal criteria. 0 When possible, name the particular substance involved
  39. 39. Inhalant Intoxication 0 Problematic behavioral or psychological changes (e.g., belligerence, assaultive, apathy, impaired judgment) 0 2 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.
  40. 40. Opioid-Related Disorders 0 Prevalence is about 0.37% of adults 0 Lowest among African Americans, highest among Native Americans 0 Hepatitis A, B, and C virus found in 80%-90% of injection opioid users 0 HIV infection up to 60% of heroin users 0 A heightened risk for accidental and deliberate overdoses
  41. 41. 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)
  42. 42. Opioid Intoxication 0 Problem behavior or psychological changes (e.g., euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment) 0 Pupillary constriction (or dilation due to severe overdose) and, 0 One or more of the following: drowsiness/coma, slurred speech, impairment in attention or memory
  43. 43. Opioid Withdrawal 0 3 or more of the following within minutes to several days after cessation of use or administration of an antagonist: 0 Dysphoric mood, nausea/vomiting, muscle aches, lacrimation/rhinorrhea, pupillary dilation, piloerection/sweating, diarrhea, yawning, fever, and insomnia.
  44. 44. Opioid Withdrawal 0 Short-acting drugs (e.g., heroin) begin to have withdrawal symptoms within 6-12 hours after last dose 0 Longer-acting drugs (e.g., methadone, buprenorphine) may take 2-4 days for symptoms to emerge 0 Less acute withdrawal symptoms ( e.g., anxiety, insomnia, dysphoria, anhedonia) can last for weeks to months
  45. 45. 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) 0 Also includes all prescription sleeping medications and almost all prescription anti-anxiety medications
  46. 46. Sedative-, Hypnotic-, or Anxiolytic-Related Disorders 0 0.3% prevalence rate among adolescents and 0.2% among adults 0 Females appear to be at a higher risk for prescription drug misuse of this class of substances 0 Can be detected in tox screens for up to a week 0 At high doses, can be lethal especially when mixed with alcohol
  47. 47. Sedative, Hypnotic, or Anxiolytic Intoxication 0 Problem behavior or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, and impaired judgment) and, 0 One or more of the following: slurred speech, incoordination, unsteady gait, nystagmus, impairment in cognition (attention, memory), stupor/coma
  48. 48. Sedative, Hypnotic, or Anxiolytic Withdrawal 0 Two or more of the following developing within several hours to a few days after cessation: 1. 2. 3. 4. 5. 6. 7. 8. Autonomic hyperactivity (sweating, pulse rate > 100 bpm) Hand tremor Insomnia Nausea or vomiting Transient hallucinations or illusions Psychomotor agitation Anxiety Grand mal seizures
  49. 49. Sedative, Hypnotic, or Anxiolytic Withdrawal 0 Grand 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 0 Withdrawal from shorter-acting substances can begin within hours, longer-acting within 1-2 days
  50. 50. Stimulant Use Disorder 0 Prevalence rate for cocaine use disorder for adults is 0.3% 0 Greatest for 18-29 year-olds (0.6%) 0 Cocaine use disorder is virtually absent among Native Americans and Alaska natives 0 Childhood conduct disorder and adult ASPD are associated with later development of stimulantrelated disorders
  51. 51. Stimulant Use Disorder 0 Stimulant-use disorder is associated with PTSD, ASPD, ADHD, and gambling disorder 0 66% of those with methamphetamine use disorders are non-Hispanic white, 21% Hispanic, 3% AfricanAmerican 0 Hair samples can detect the presence of stimulants for up to 90 days
  52. 52. Stimulant Use Disorder 0 Use leading to significant impairment or distress over a 12-month period 0 Two or more of the 11 symptom criteria
  53. 53. 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
  54. 54. Stimulant Withdrawal 0 Dysphoric mood and 2 or more of the following developing within a few hours to several days after cessation: 0 Fatigue 0 Vivid, unpleasant dreams 0 Insomnia or hypersomnia 0 Increased appetite 0 Psychomotor retardation or agitation
  55. 55. Tobacco-Related Disorders 0 Includes daily cigarette use or smokeless tobacco 0 Features often include smoking within 30 minutes of waking, daily use, waking at night to smoke 0 Nicotine dependence in about 13% of U.S. adults 0 Nicotine dependence in about 50% of daily smokers
  56. 56. Tobacco-Related Disorders 0 Initiation of smoking after age 21 is rare 0 Those who quit usually do so after age 30 0 Non-daily smoking has become more prevalent in the past decade especially among younger individuals 0 More common among those with AD/HD, conduct d/o, mood, anxiety, personality, psychotic or other SUD’s
  57. 57. Tobacco-Related Disorders 0 Individuals with low incomes and low educational levels are more likely to initiate tobacco use and less likely to stop 0 50% of smokers who do not stop using tobacco will die early from a tobacco-related illness 0 There is no Tobacco Intoxication Disorder
  58. 58. Tobacco Use Disorder 0 Problematic 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
  59. 59. Tobacco Withdrawal 0 Cessation or reduction followed within 24 hours by 4 or more of the following: 0 Irritability, frustration, or anger 0 Anxiety 0 Difficulty concentrating 0 Increased appetite 0 Restlessness 0 Depressed mood 0 Insomnia
  60. 60. Other (or Unknown) Substance Use Disorder 0 Problematic use of an “intoxicating substance” not able to be classified within the other categories 0 Meets at least two or more of the 11 symptom criteria within a 12-month period
  61. 61. Other (or Unknown) Substance Use Disorder 0 Other includes anabolic steroids; non-steroidal anti- inflammatory drugs; cortisol; antiparkinsonian medications; antihistamines; nitrous oxide; amyl-, butyl-, or isobutyl-nitrates; betel nut; kava; and khat 0 Unknown – when a substance is unknown 0 Also, includes the categories Intoxication and Withdrawal
  62. 62. Gambling Disorder 0 Previously known as “Pathological Gambling” and was in category of Impulse Control Disorders 0 Problematic gambling leading to significant impairment or distress 0 Leading to four or more of the following symptoms over a 12-month period
  63. 63. Gambling Disorder Diagnostic Criteria 1. Needs to gamble with increasing amounts of 2. 3. 4. 5. money for desired excitement Is restless or irritable when attempting to cut down or stop gambling Repeated unsuccessful efforts to control, cut back, or stop gambling Often preoccupied with gambling Gambles when feeling distressed (helpless, guilty, anxious, depressed)
  64. 64. Gambling Disorder Diagnostic Criteria 6. After losing money gambling, often returns another day to get even 7. Lies to conceal the extent of involvement with gambling 8. Jeopardized or lost a significant relationship, job, or career opportunity due to gambling 9. Relies on others to provide money to relieve financial situations caused by gambling
  65. 65. Gambling Disorder Diagnostic Criteria 0 Removal of the criteria “has committed acts of forgery, fraud, theft, or embezzlement to finance gambling” 0 Can be specified as either “Episodic” or “Persistent” and “In early remission” or “In sustained remission”
  66. 66. Gambling Disorder Severity Rating 0 Mild: 4-5 criteria 0 Moderate: 6-7 criteria 0 Severe: 8-9 criteria
  67. 67. Gambling Disorder 0 About 0.2%-0.3% of general population 0 3x more likely in males 0 Highest in African Americans (0.9%), whites (0.4%), Hispanics (0.3%) 0 For females, the progression is more rapid 0 About 17% commit suicide 0 Often associated with SUDs and impulse –control disorders (males) & mood/ anxiety D/O (females)