Anxiety Disorders

New changes in DSM:

- Selective mutism & separation anxiety disorder added to adult DSM (no longer childhood dz)
- Changed: social phobia  social anxiety disorder
- Removed: panic attack as a specifier for agoraphobia
- Added: “panic attack” to list of specifiers for other DSM-5 dxs

Each anxiety disorder shares features of fear & anxiety

 Anxiety: intense apprehension, uncertainty or fear resulting from anticipation of threatening

event/situation  18% Adults (40 M) in U.S.
 Fear: emotional response to real or perceived threat

 Most common disorders in youth  median age of onset = 11 years old

 Diagnoses are frequently made in counseling setting or by counselors
 50% of individuals diagnosed w/ anxiety also meet criteria for depressive disorder
o Depressive disorders sometimes viewed as “anxious misery”
o Severe anxiety is a risk factor for SUICIDE *

Characteristics:
- Physiological Sxs:
o Muscle tension
o Heart palpitations
o Sweating
o Dizziness
o SOB
- Emotional Sxs:
o Sense of restlessness
o Sense of impending doom
o Fear of dying
o Fear of embarrassment or humiliation
o Fear of something terrible happening
- Shares sxs w/ depression:
o Sleep disturbance
o Overall fatigue
o Difficulty w/ concentration

Separation Anxiety: (M.C. anxiety disorder in children)

- No longer required to diagnose before age 18  can now be dx in adults
- Duration: 1 month in children & at least 6 months in adults
- MC in children (4%), then adolescents (1.6%), then adults (0.9-1.9%)
- Functionality at school, work, or in social settings is often impaired
- May exhibit anger

Selective Mutism:
- Refusal to verbally communicate outside home or w/ people other than family/caregivers
- Sometimes communicate w/ nonverbal gestures
- Onset: typically, under 5 years old & often noticed in school settings

Specific Phobia:
- Intense fear & anxiety in presence of specific stimulation or object  “phobic stimulus”
o Can occur after/witnessing a trauma
- Median age of onset: 13 years old; Lifetime Prevalence: 9.4-12.5%
- 75% of pts diagnosed w/ specific phobia fear more than one object
- May include sxs of a panic attack & should be added to dx
Social Anxiety Disorder (SAD):
- Ongoing fear & worry surrounding social situations
o Fear negative evaluation (humiliation, rejection, etc.) by others in their performance,
interaction, or observation situations.
o Can have “performance only” SAD  added as specifier (MIN Req. 6 mo duration)
 Ex. anxiety specific to speaking or performing in public
 Often affects pts in their occupation & in school
- One of the M.C. mental disorders  Lifetime prevalence >10%
- Majority of diagnoses occur in childhood or early adolescence

- Often seen in conjunction w/:

o Major depressive disorders
o Anxiety disorders
o Substance use disorders

Panic Disorder:
- Defined as recurrent, unexpected panic attacks
- Median age of onset range from 20-24 years old; 2-3x more common in women
- Small % first diagnosed in childhood; not usually first diagnosed over the age of 45
- Annual Prevalence: 2.1-2.8%; U.S. has highest prevalence rate worldwide
- Common differentials: any other unspecified anxiety disorder or disorder w/ panic attack feature
(ex. substance/med induces anxiety disorder, illness anxiety)
o Illness anxiety formerly known as hypochondriasis – often occurs w/ panic disorder

- Must have at least one of the following for at least 1 month

o Panic attacks often followed by concern about future attacks
o Worry about implication or consequence of attacks
o Significant change in behavior related to the attacks

- Characteristics:
o Persistent fear or concern
o Inappropriate fear responses w/ recurrent & unexpected/expected panic attacks
 Includes physiological changes: (must have 4 out of 13)
 Accelerated heart rate
 Sweating
 Dizziness
 Trembling
 Chest pain
- Tx: Long term: Cognitive Behavior Therapy, SSRI (1st line medical tx) Acute: Benzodiazepines

Panic Attacks: (NOT a disorder)

- Ex: Social Anxiety Disorder, w/ Panic Attack
- Panic attack: abrupt surges of intense fear that can occur w/ other mental disorders such as
depressive & anxiety disorders; usually last less than 60 min
- Specifier for both mental & physical disorders
- Annual Prevalence: 11.2%
- NOT a specifier for panic disorder – elements of panic attack already contained in criteria
- Must include a minimum of 4 out of 13 specific symptoms.
- Tx: Benzo = 1st line (lorazepam, alprazolam)
Agoraphobia:
- Defined as anxiety about being in places or situations from which escape may be difficult (ex.
open spaces, enclosed spaces, crowds, public transportation or outside of the home alone).
- Happens every time person is exposed to situation or event
- May include cognitive & behavioral aspects such as avoidance
- Agoraphobia seen as separate entity from panic disorders & can occur w/ other disorders.

Generalized Anxiety Disorder:

- One of the M.C. mental disorders; Annual Prevalence: 2.9%
- Onset = early 20s
- Excessive worry/anxiety about many things that occurs on most days (not episodic or situational)
- Must occur for at least 6 months
- Must experience at least three of the following sxs:
o Restlessness or on edge feeling
o Easily fatigued
o Difficulty concentrating or mild going blank
o Irritability
o Muscle tension
o Sleep disturbance
- DDx: OCD, PTSD, adjustment disorder, depressive disorder, & psychotic disorders

Substance-Induced Anxiety Disorder:

- Anxiety caused by use of substance (primary criteria)
- Must have developed soon or after substance/medication usage (more than expected S/E)
- Low prevalence rate: (0.002%)

Anxiety Disorder Due to Another Medical Condition:

- Must cause clinically significant distress
- Unclear prevalence rates
- Important to rule out other ddx before claiming this dx
- Essential features:
o Anxiety must be attributed to physiological effects of the existing medical condition
o Can parallel the course of illness
o Ex. endocrine, cardiovascular, respiratory, metabolic, & neurological disorders

Post-Traumatic Stress Disorder:

- Induced by severe/catastrophic traumatic event affecting pt or someone close to pt (war, natural
disaster, rape, accident, etc.)
- Prevalence: 1-3% of general population – 30% of Vietnam Veterans have it
- Dx: Symptoms must last for more than 1 month (can last for years in chronic form)
- Sxs:
o Anxiety
o Recurrent nightmares
o Flashbacks
o Social withdrawal
o Numbing of affective responses
o Survivors guilt
o Dissociative symptoms
- DIFFERENTIAL: If sxs last less than 1 month  dx is considered Acute Stress Disorder
- Conditions associated w/ PTSD: (all lack presence of traumatic event)
o Substance abuse
o Borderline personality
o Malingering
o Generalized anxiety disorder
o Factitious disorder
 - Tx
o Psychotherapy, support groups & group therapy initiated as soon as possible after the
traumatic event is very helpful
o No good pharmacologic tx. Some drugs have been tried w/ some success:
 Antidepressants – TCAs – Imipramine (Tofranil)150 –300 mg/day
 SSRIs – Prozac 40 – 60 mg/day or MAOIs – Nardil 45 – 75 mg/day
 Carbamazepine 400 – 600 mg/day (particularly for flashbacks/nightmares)
o 50% completely recover within 3 months
o Many have symptoms for years

Anti-Anxiety Txs:
- Anxiety disorders tend to be chronic – but are responsive to psychotherapeutic tx
- Cognitive-behavior Therapy (CBT) & Behavior Therapy (BT) considered the most effective tx (along
w/ relaxation therapy)– positive tx outcomes maintained longer for these individuals
- Pharmacologic tx:
o Benzodiazepines (intermediate length of action)
o Buspirone (Bu Spar) 15-60 mg/day
 Most useful in pts never been treated w/ or can’t use benzos
 2-3 weeks to become effective
o TCAs
o Beta Blockers (propanalol 80-160mg)
 Primarily for autonomic symptoms of anxiety
- Tx needed indefinitely for chronic cases (50% of pts)
- Other 50% become asymptomatic within a few years

Classification Agent (Duration) Dose Clinical use

(mg/day)
Lorazepam (Ativan) [short] 2 -6 Psychotic agitation

Oxazepam (Serax) [short] 30 – 120 Alcohol withdrawal

Chlordiazepoxide (Librium) [long] 15 – 100

Benzodiazepine Triazolam (Halcion) [short] 15 – 30 Insomnia

Temazepam (Restoril) 15 – 30
[intermediate] 15 – 30
Flurazepam (Dalmane) [long]

Alprazolam (Xanax) [intermediate] 0.5 – 6 Antidepressant, panic

disorder, social phobia

Clonazepam (Klonopin) [long] 0.5 – 10 Seizures, mania, social

phobia, panic disorder
Diazepam (Valium) [long] 2 – 60 Muscle relaxation,
analgesia, anticonvulsant
Carbamate Meprobamate (Miltown) 1200 – 1600 Intolerance of
benzodiazepines
Azapirone Buspirone (BuSpar) 15 – 60 Anxiety in the elderly; low
abuse potential; no
sedation
Feeding & Eating Disorders
- Persistent disturbance of eating & eating related behaviors that alter consumption & impair
physical health & psychosocial functioning

Pica:
- Criteria:
o Eating of nonfood substances  at least 1 month
o Inappropriate behavior to developmental level of the individual
o Eating behavior not part of culturally/socially accepted practice
o Considered severe & warrant medical attention if eating behavior occurs in the context of
another metal disorder or medical illness.

- Childhood onset is M.C., can also occur in adolescence or adulthood.

o Can occur in normally developing children
o More often associated w/ mental disorder or intellectual disability in adults
- Can also manifest in pregnancy  cravings such as chalk or ice

Rumination Disorder:
- Repeated regurgitation of food  at least 1 month duration
- Regurgitated food may be re-chewed, re-swallowed, or spit out.
- Not attributable to an associated GI or other medical condition (e.g., GERD, achalasia)
- Does not occur exclusively during the course of another eating disorder
- Considered severe if symptoms occur in the context of another mental/medical disorder

Avoidant/Restrictive Food Intake Disorder:

- Diagnostic Criteria:

A. Apparent lack of interest in eating or food; avoidance based on sensory characteristics of food or
concern about aversive consequences of eating;
- Associated w/ one (or more) of the following:
o Significant weight loss or faltering growth (failure to achieve expected weight gain)
o Significant nutritional deficiency.
o Dependence on enteral feeding or oral nutritional supplements.
o Marked interference w/ psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by an associated culturally
sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia
nervosa, & there is no evidence of body dysmorphia
D. Not attributable to a concurrent medical condition or not better explained by another mental
disorder.

Anorexia Nervosa (highest mortality rate)

- Admitted if they reach less than 85% ideal body weight (BMI <17.5)
- Often occurs w/ body dysmorphic disorder

- Diagnostic Criteria:
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in
the context of age, sex, developmental trajectory, & physical health. Significantly low weight is
defined as a weight that is less than minimally normal or, for children & adolescents, less than that
minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes w/ weight
gain, even though at a significantly low weight.
 C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of
body weight or shape on self- evaluation, or persistent lack of recognition of the seriousness of the
current low body weight.
- Subtypes
o Most individuals w/ the binge- eating/purging type of anorexia nervosa who binge eat also
purge through self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
 Some individuals w/ this subtype of anorexia nervosa do not binge eat but do
regularly purge after the consumption of small amounts of food.
o Crossover between the subtypes over the course of the disorder is not uncommon;
therefore, subtype description should be used to describe current symptoms rather than
longitudinal course.

Bulimia Nervosa
- Diagnostic Criteria:
A. Recurrent episodes of binge eating.
- An episode of binge eating is characterized by both of the following:
a. Binge eating an excessively large amount of food in a short period of time (2-hour period),
b. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot
stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors to prevent weight gain  self-induced vomiting,
misuse of laxatives, diuretics (or other meds), fasting, excessive exercise, chewing & spitting
C. Binge-eating & compensatory behaviors occur at least once a week for 3 months.
D. Self-evaluation is influenced by body shape & weight; pts often normal or overweight
E. The disturbance does not occur exclusively during episodes of anorexia nervosa

- Specify if in Remission:
o Partial remission: Some, but not all, criteria have been met for a sustained period of time.
o Full remission: None of the criteria have been met for a sustained period of time.

- Specify Severity if Current:

o Mild: Average of 1-3 episodes of inappropriate compensatory behaviors per week.
o Moderate: Average of 4-7 episodes of inappropriate compensatory behaviors per week.
o Severe: Average of 8-13 episodes of inappropriate compensatory behaviors per week.
o Extreme: Average of 14+ episodes of inappropriate compensatory behaviors per week.

Binge-Eating Disorder
- Diagnostic Criteria:
A. Recurrent episodes of binge eating characterized by both of the following:
a. Binge eating an excessively large amount of food in a short period of time (2-hour period)
b. Sense of lack of control over eating during the episode (feeling one cannot stop)
B. The binge-eating episodes are associated w/ three (or more) of the following:
a. Eating much more rapidly than normal.
b. Eating until feeling uncomfortably full.
c. Eating large amounts of food when not feeling physically hungry.
d. Eating alone because of feeling embarrassed by how much one is eating.
e. Feeling disgusted w/ oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated w/ the recurrent use of inappropriate compensatory behavior as
in bulimia & doesn’t occur exclusively during course of bulimia or anorexia

- Specify if in Remission:
o In partial remission: After full criteria were previously met, binge eating occurs at an average
frequency of less than one episode per week for a sustained period of time.
o In full remission: None of the criteria have been met for a sustained period of time.
 - Specify current severity:
o Mild: 1-3 binge-eating episodes per week.
o Moderate: 4-7 binge-eating episodes per week.
o Severe: 8-13 binge-eating episodes per week.
o Extreme: 14 or more binge-eating episodes per week.

“OTHER SPECIFIED FEEDING OR EATING DISORDER”

- This category applies to presentations in which symptoms characteristic of a feeding & eating
disorders predominate but do not meet the full criteria for any of the disorders.
- Clinician can document specific reason why presentation doesn’t meet criteria for any specific
disorder  “other specified feeding/eating disorder; bulimia nervosa of low frequency”

- Presentations that can be specified as “other specified” include the following:

o ATYPICAL
 Atypical anorexia nervosa: All criteria met, except that despite significant weight
loss, the individual’s weight is within or above the normal range.
 Bulimia nervosa (low frequency &/or limited duration): All criteria met, except that
binge eating & compensatory behaviors occur, less than 1x a week &/or <3 mo
 Binge-eating disorder (of low frequency &/or limited duration): All criteria met,
except that binge eating occurs, less than 1x a week &/or < 3 mos.
 Purging disorder: Recurrent purging behavior to influence weight or shape (self-
induced vomiting: misuse of laxatives, diuretics/meds in absence of binge eating.
 Night eating syndrome: Recurrent episodes of night eating, as manifested by eating
after awakening from sleep or by excessive food consumption after evening meal.
 There Is awareness & recall of the eating
 Not explained by changes in the individual’s sleep-wake cycle, local social
norms, or another disorder such as binge-eating, substance use, or med S/E
 Causes significant distress &/or impairment in functioning.

“Unspecified Feeding or Eating Disorder”

- Applies to presentations in which symptoms characteristic of a feeding & eating disorder cause
significant distress/impairment in social, occupational, or other important areas of functioning
predominate but do not meet the full criteria for any of the disorders
- Clinician may choose not to specify the reason that the criteria are not met for a specific feeding
& eating disorder; can include presentation of dz (e.g., in emergency room settings).
SEXUAL DISORDERS

3 CATEGORIES:
1. Paraphilias
2. Gender Dysphoria
3. Sexual Dysfunction

PARAPHILIAS:
- Paraphilia means” love” (philia) “beyond the usual” (para).
o Recurrent, sexually arousing fantasies, urges, &/or behaviors that generally involve:
 Nonhuman objects
 The suffering or humiliation of oneself or one’s partner
 Children or other nonconsenting persons.

- Unknown cause  Some experts believe it is:

o Caused by a childhood trauma, such as sexual abuse or
o Objects/situations become arousing due to frequent associated w/ sexual activity.

- In most cases, the individual has difficulty developing personal & sexual relationships w/ others.
- Many paraphilias begin during adolescence & continue into adulthood.
- Intensity & occurrence vary w/ the individual, but usually decrease as the person ages.

A. Fetishistic Disorder
o Refers to the association of sexual arousal w/ nonliving objects.
o Range of object is unlimited -- women’s underwear, shoes/feet, rubber or leather.
o People w/ fetishism typically masturbate while holding, rubbing, or smelling the object

B. Transvestic Fetishism
o Heterosexual men who experience recurrent, intense sexual fantasies, urges, or behaviors
that involve cross‐dressing as a female & experience significant distress or impairment
o Onset: generally during adolescence & involve masturbation while wearing female clothing
o Blanchard  said psychological motivation of most heterosexual transvestites includes
o Autogynephilia: paraphilic sexual arousal by the thought or fantasy of being a
woman.
 Not all men w/ transvestic fetishism show clear evidence of autogynephilia
o Magnus Hirschfeld  identified a class of cross dressing men who are sexually aroused “not
by the woman outside them, but by the woman inside them”
.
C. Voyeuristic Disorder
o Recurrent, intense sexual fantasies, urges or behaviors involving the observation of
unsuspecting persons who are undressing or of couples engaging in sexual activity
o Frequently, such individuals masturbate during their peeping activity.
o “Peeping Tom” commit these offenses primarily as young men
o Voyeur  gets pleasure, especially sexual pleasure from secretly watching others
o Voyeurism is probably the most common illegal sexual activity.

D. Exhibitionistic Disorder (indecent exposure in legal terms)

o Recurrent, intense urges, fantasies, or behaviors that involve exposing genitals to others
(usually strangers) in inappropriate circumstances & w/out their consent
o Frequently the element of shock in the victim is highly arousing to these individuals.
o Exposure can be accompanied by suggestive gestures or masturbation, but more often
there is only exposure.
 E. Frotteuristic Disorder
o Sexual excitement at rubbing one’s genitals against or touching the body of a
nonconsenting person.
o Common occurrence in crowded areas such as buses or subway trains

F. Sexual Sadism Disorder

o Marquis de Sade (1740‐1814)  Sadist; eventually committed as insane. Named after him
o For dx, person must have recurrent, fantasies, urges, or behaviors that involve inflicting
psychological or physical pain or another individual; often include themes of dominance,
control & humiliation.

G. Sexual Masochism Disorder

o Novelist Leopold V. Sacher‐Masoch (1836‐1895): fictional characters dwelt lovingly on the
sexual pleasure of pain. Named after him
o Person experiences recurrent, intense sexual stimulation & gratification from the experience
of pain & degradation; often involves act of being humiliated, beaten, bound or otherwise
made to suffer.

H. Pedophilic Disorder
- Diagnosed when an adult has recurrent, fantasies about sexual activity w/ a prepubertal child
- Pedophiles’ sexual interaction w/ children involves manual or oral contact w/ a child’s genitals;
penetrative anal or vaginal sex = rarer.
- Nearly all individuals w/ pedophilia are male
- 2/3 of pedophilic offenders victims are girls typically between the ages of 8 & 11.

Other Types of Paraphilias:

Tx of Paraphilias:

- Most cases treated w/ counseling & therapy to help modify behavior.

- Medications may help to decrease the compulsiveness associated w/ paraphilia & reduce number
of deviant sexual fantasies & behaviors.
o In some cases, hormones are prescribed for individuals who experience frequent
occurrences of abnormal or dangerous sexual behavior. Many of these medications work
by reducing the individual's sex drive (pedophiles often given estrogen)

GENDER DYSPHORIA
- Has replaced Gender Identity Disorder.
- Define as discomfort w/ one’s sex, physical characteristics, or w/ one’s assigned gender
- Can be diagnosed at two different life stages, either childhood/adolescence or adulthood.
- Causal Factors:
o Psychiatric & biological causes:
  Traditionally thought to be a psychiatric condition or mental ailment. Now there is
evidence that the disease may not have origins in the brain alone.
 Studies suggest that gender dysphoria may have biological causes associated w/
the development gender identity before birth.
 More research is needed before the causes of gender dysphoria can be fully
understood.

o Genetic causes of biological sex:

 Research suggests development that determines biological sex happens in womb.
 Anatomical sex is determined by chromosomes that contain the genes & DNA.
 Each individual has two sex chromosomes. One of the chromosomes is from the
father & the other from the mother.
 A normal man has XY sex chromosome & a normal woman has two XX

- Tx for Children:
o Family therapy
o Individual child psychotherapy
o Parental support or counselling
o Group work for young people & their parents

- Tx for Adults:
o Mental health support, such as counselling
o Speech & language therapy – to help alter your voice, to sound more typical of your
gender identity
o Peer support groups, to meet other people w/ gender dysphoria
o Relatives' support groups, for your family

SEXUAL DYSFUNCTIONS
- Impairment either in the desire for sexual gratification or in the ability to achieve it.
- Four different phases of human sexual response (Masters & Johnson & Kaplan)
o According to DSM‐ 5, disorders can occur in any of the first three phases:

1. DESIRE PHASE: consist of fantasies about sexual activity or sense of desire to have sexual activity.
2. EXCITEMENT (arousal) PHASE: subjective sense of sexual pleasure & physiological changes,
including penile erection, vaginal lubrication & clitoral enlargement.
3. ORGASM PHASE: release of sexual tension & a peaking of sexual pleasure.
4. RESOLUTION PHASE: sense of relaxation & well‐ being.

IN MEN:
A. Male Hypoactive Sexual Desire Disorder
o Defined in terms of subjective experiences, such as lack of sexual fantasies & lack of interest
in sexual experiences  for at least 6 months
o Pt distressed or impaired due to low levels of sexual thoughts, desires, or fantasies.
o Causal Factors:
 Problem emanating from partners
 Cultural beliefs or attitudes
 Personal vulnerabilities (e.g. poor body image)

B. Male Erectile Disorder

o Persistent/recurrent inability to attain, or maintain erection until completion of sexual act
o Causal Factors:
 Anxiety about sexual performance
 Cognitive distractions
 Decreased blood flow to penis or diminished ability to maintain blood (older men)
 Lifestyle factors (e.g. smoking, obesity, alcohol abuse)
 o Txs:
 Medications that promote erections like Viagra, Levitra, & Cialis.
C. Premature (Early) Ejaculation
o In DSM‐5 it is called early ejaculation disorder.
o Persistent & recurrent onset of orgasm & ejaculation w/ minimal sexual stimulation.
o May occur before, on, or shortly after penetration & before the man wants it to
 Average duration is 15 seconds or 15 thrusts of intercourse

o What are the consequences if a man has this kind of sexual dysfunction?
 Include failure of the partner to achieve satisfaction
 Often acute embarrassment for the early ejaculating man, w/ disruptive anxiety
about recurrence on future occasions.

o Txs:
 Behavioral therapy
 Pause‐&‐squeeze technique – Masters & Johnson (1970)
 This technique requires squeezing head of the penis for a few moments until
the feeling of pending ejaculation passes, stopping as many times as needed
 Initial reports suggest it is approximately 60-90% effective.
 Pharmacological Intervention:
 Anti‐depressant (SSRIs):
o Paroxetine (Pexil)
o Sertraline (Zoloft)
o Fluoxetine (Prozac)
o Dapoxetine (Priligy)

D. Delayed Ejaculation Disorder

o Persistent inability to ejaculate during intercourse.
o Occurs in only 3 -10% of men. Men who are completely unable to ejaculate are rare.
o Tx:
 Psychological txs: couples therapy  man tries to get used to having orgasms
through intercourse w/ a partner rather than via masturbation.
IN FEMALE:

A. Female Sexual Interest/Arousal Disorder

o Combination of two previous disorders, Sexual Aversion & Sexual Arousal Disorders.
o Sexual Aversion Disorder: persistent or recurrent extreme aversion to, & avoidance of, all (or
almost all) genital sexual contact.
o Sexual Arousal Disorder: persistent or recurrent inability to attain/maintain arousal or
adequate lubrication‐swelling response  female counterpart of erectile disorder for men.
 Formerly known as “frigidity”

* Note:
o Elimination of sexual aversion disorder  has been argued that sexual aversion disorder
should be considered an anxiety disorder similar to simple phobias rather than as a
sexual dysfunction.

o Causal Factors:
 Biological Factors –basis remains controversial
 Psychological Factors
 Prior/current depression or anxiety may contribute to many desire disorders
 Physical Factors (e.g. Age of a person)

o Txs:
 Pharmacological Intervention:
  Bupropion (atypical antidepressant) to improve sexual arousability
 Flibanserin (“female Viagra”)
 Psychotherapy
 Focus on education
 Communication training
 Cognitive restructuring of dysfunctional beliefs about sexuality
 Sexual fantasy training
 Sensual focus training  teach couples to focus on pleasurable sensation
brought about w/out the goal of actually having intercourse or orgasm.

B. Genito‐Pelvic Pain/Penetration Disorde

o Previously called in DSM‐IV‐TR Sexual Pain Disorders:
 Dyspareunia
 Vaginismus

o Dyspareunia‐ recurrent or persistent genital pain associated w/ sexual intercourse in either a

male or female. Considered to be much more common in women.
o Vaginismus‐ recurrent or persistent involuntary spasm & pain of the outer third of the vagina
that interferes w/ sexual intercourse  not reliably diagnosed
o Both can come w/ anxiety before & after sex

* Note: combined in DSM‐5 because research did not support their distinction

o Causal Factors:
 Physical Causes:
 Acute or chronic infections or inflammations of the vagina
 Vaginal atrophy that occurs w/ aging
 Scars from vaginal tearing
 Insufficiency of sexual arousal
 Psychological Factors
 Fear & anxiety

o Txs:
 Cognitive‐Behavioral Interventions:
 Education about sexuality
 Identifying & correcting maladaptive cognition
 Graduated vaginal dilation exercises to facilitate vaginal penetration, &
progressive muscle relaxation.
 Medical Txs:
 Surgical removal of the vulvar vestibule can be very successful

C. Female Orgasmic Disorder

o Diagnosed in women who show persistent or recurrent delay in or absence of orgasm
following a normal sexual excitement phase & who are distressed by this.

o Causal Factors:
 Some women feel fearful & inadequate in sexual relations.

o Txs:
 Cognitive‐Behavioral Txs
 Usually involves education about female sexuality & female sexual anatomy
Sleep Disorders:

o Sleep disorders can be classified into the following:

1. Dyssomnia: disorder of the quantity or timing of sleep; includes:
 Insomnia (disturbance in quantity/quality of sleep)
 Hypersomnia (excessive sleepiness)

a. Breathing related sleep disorder

b. Circadian rhythm sleep disorder
c. Narcolepsy
d. Primary insomnia
e. Primary hypersomnia
f. Dyssomnia not otherwise specified

2. During sleep or during the transition between sleep & wakefulness:

a. Nightmare disorder
b. Sleep terror disorder
c. Sleepwalking disorder
d. Parasomnia not otherwise specified
e. Sleep disorder related to another mental disorder
f. Other sleep disorders

o Assessment of Sleep Disorders

o Require detailed medical & psychiatric history from the pt.
o Crucial to perform a more in-depth assessment of the sleep disturbance

o The following questions should be asked during assessment:

 Daytime:
 Do you feel sleepy during the day?
 Do you take routine naps during the day?
 Do you find yourself having difficulties w/ concentration during the day?
 Night-time:
 Could you describe a typical night of sleep (in terms of the # of hours you get,
the quality of sleep etc.)?
 Do you find yourself having difficulties w/ falling asleep?
 Do you sleep well?
 Do you find yourself awake during the night? If so, what is the reason?
o Going to toilet 2x night is considered normal & not a sleep disturbance
 Do you find yourself waking up much earlier in the morning?
 Past Management:
 Have you sought help for your sleep problems? (e.g.GP, psychiatrist,
acupuncturist, traditional medicine practitioner)
 Are you on any chronic long-term medications to help yourself fall sleep (e.g.
sleeping pills)? Where do you get these medications?
 The following questions should be asked to partner:
 Have you noticed any change in your partner’s sleeping habits?
 Have you noticed that your partner has been snoring during his sleep?
 Any abnormal movements (e.g. kicking) during sleep?
 Have you ever been injured by these movements?

1. Dyssomnia

 Insomnia: diagnosed when the main problem is difficulty in initiating/maintaining sleep

o Important that other physical & mental conditions have been ruled out.
o Diagnostic Criteria:
 At least 3 nights per week, for 3 months.
o These sleep difficulties include:
 Difficulties associated w/ initiation of sleep
 Difficulties w/ maintaining sleep
 Early morning awakening & inability to return back to sleep
 These sleep difficulties must have occurred despite adequate opportunities for rest.
o Epidemiology
 Insomnia has been estimated to affect at least 30% of the general population, w/
women being more affected as compared to men.
 The incidence rate is higher among the elderly.
 Mahendran et al (2007) studied 141 pts seen at the Insomnia Clinic at IMH & found
the following:
 Primary insomnia: 47.5%
 Primary dx of a psychiatric disorder: 52.5%
 Of whom further diagnosed w/ comorbid psychiatric disorders: 41.1%
 Substance abuse problems: 4.3%
o Etiology
 Intrinsic causes:
 Idiopathic/primary insomnia
 Sleep apnea syndrome (OSA)
 Periodic limb movement disorder
 Restless leg syndrome
 Extrinsic causes:
 Poor sleep hygiene
 Environmental
 Adjustment
 Altitude
 Substance-related
 Circadian rhythm disorders
 Medical disorders:
 Chronic pain
 Pulmonary diseases (e.g. COPD)
 Neurological disorders (e.g. Parkinson disease)
 Endocrine disorders
 Iron deficiency
 Restless leg syndrome
 Sleep apnea
 Psychiatric disorders:
 Generalized anxiety disorder
 Depression
 Bipolar affective disorder
 Chronic pain disorders
 Post-traumatic stress disorder
 Anorexia nervosa
 Somatoform disorder
 Schizophrenia
o Management
 Non-pharmacological
 Sleep education:
o various stages of sleep
o typical sleep cycle
o sleep cycle changes w/ age
 Allow pts to gain insight into characteristics of the sleep issue they are seeking
tx for
 o Sleep hygiene: considered to be useful in all pts.
o Ensure sleep environment is familiar, comfortable, dark & quiet.
o Ensure regular bedtime routines w/ consistent bedtime & waking up
time
o Reinforce going to bed only when tired
o Avoid factors associated w/ insomnia including overexcitement prior
to going to bed, late evening exercises, consuming drinks w/ caffeine
late in the day, excessive smoking/alcohol, excessive daytime
sleeping, late meals prior to bedtime
 Stimulus control:
 Individuals should go to sleep only when tired
 Get up & focus on relaxing activities before attempting to go to bed again if
there are difficulties w/ sleep
 Sleep restriction:
 Must have high intrinsic motivation
 Reduce total time spent in bed
 Enable improvement in quality of sleep via consolidation
 Pharmacological
 Principles: Prescription of hypnotics should be considered as the last option for
the tx of insomnia
 Underlying cause of insomnia should be worked up prior to commencement of
hypnotic tx
 First-line:
o Hydroxyzine (Atarax) 25-50mg QHS
 Anti-histamine
 Main side effect: drowsiness in the morning
o Mirtazapine (Remeron) 15mg QHS
 Sedative antidepressant
 Main side effect: weight gain
o Agomelatine (Valdoxan) 25mg QHS
 Novel antidepressant targeting melatonin receptors to regulate
sleep-wake cycle
 Main side effect: giddiness
 Second-line:
o Zopiclone (Imovane) 7.5-15mg QHS
 Half-life: 6 hours
 Main side effect: metallic taste
o Zolpidem CR (Stilnox CR) 10mg QHS
 Half-life 2-3 hours (non-CR form), longer in CR form
 High risk of dependence
 Associated w/ less day time sedation
o Benzodiazepines: short periods (< 2 weeks)  prevent dependence
 Common benzodiazepines:
 Alprazolam (Xanax) 0.25mg
o Indication: anxiolytic use
o Half-life: ~11 hours
 Clonazepam 0.5mg
o Indication: anxiolytic & REM-movement disorder
o Half-life: ~25 hours
 Lorazepam (Ativan) 0.5mg QHS
o Intramuscular form: calm pt w/ acute agitation
o Half-life: ~10 hours
 Diazepam (Valium) 5mg QHS
o Per-rectum use: epilepsy
o Half-life: ~30 hours.
  Hypersomnia
o Individuals suffering from hypersomnia tend to present w/ recurrent sleep attacks during the
day, poor concentration & difficulties w/ transiting from a rested state to full arousal &
wakefulness.
o To fulfil the diagnostic criteria, such episodes must have lasted for several months & must
have significant impacts on their physical & psychosocial life.
o Hypersomnia tends to affect 10-15% of the general population.

o DSM-5 Diagnostic Criteria

 There must be excessive sleepiness that occurs at least 3 times per week, for the past
3 months. This excessive sleepiness is characterized by:
 Recurrent periods of sleep or lapses back to sleep even within the same day
 Prolonged sleep episodes of more than 9 hours that are not restorative
 Difficulties associated w/ being fully awake after abrupt awakening
 These sleep difficulties must have occurred despite adequate opportunities for rest.

o Etiology
 Drug effects e.g. long acting benzodiazepine
 Poor sleep routines e.g. playing online games through the night
 Circadian rhythm sleep disorders
 Chronic physical illness
 Frequent parasomnia
 Insufficient night-time rest
 Kleine-Levin Syndrome
 Narcolepsy
 Obstructive sleep apnea (commonest cause of secondary hypersomnia)
 Psychiatric disorders e.g. melancholic depression

Narcolepsy
o Narcolepsy is a hypersomnia characterized by excessive daytime sleepiness & falling asleep at
inappropriate times.

o DSM-5 Diagnostic Criteria

o There must be repeated episodes during which there is a need to fall back into sleep, or
nap occasionally within the same day. This must have occurred at least 3 times per week
over the past 3 months.
o In addition, there must be the presence of at least one of the following symptoms:
 Episodes of sudden bilateral loss of muscular tone w/ maintained consciousness
precipitated by laughter/joking
 Lack of hypocretin (is a neuropeptide that regulates arousal, wakefulness, &
appetite)
 REM sleep latency less than or equal to 15 minutes
o Epidemiology
o Prevalence: 5 per 10,000
o Age: 10-20 years
o Gender: M:F = 1:1
o Etiology
o HLA-DR2 is the candidate gene for this condition
o Hypocretin (hypothalamic neuropeptide transmitter which regulates sleep-wake cycles) is
involved; concentrations of hypocretin-1 & hypocretin-2 are reduced in narcoleptic pts
o Clinical Features
o Cataplexy: sudden & brief episodes of paralysis w/ loss of muscular tone
o Excessive sleepiness
o Hypnagogic hallucinations (hypnopompic hallucinations are less common but can still
occur)
 o Sleep paralysis
o Management
o Non-pharmacological
 Encourage regimen of regular naps in the daytime x
o Pharmacological
 Modafinil (Provigil): helps reduce number of sleep attacks; better side effect profile
than traditional psychostimulants
 SSRIs (e.g. fluoxetine) help suppress REM and reduce cataplexy

Breathing Related Sleep Disorder

o Breathing disturbances which can occur during sleep include apnea & hypopnea.
o Obstructive sleep apnea
o Epidemiology
 Common cause of breathing related sleep disorder
 Affects at least 4% of the male population
 Clinical features
 Apnea at least five times per hour for greater than a 10-second period as a
result of upper airway obstruction
 Sleep is fragmented by short arousals following apnea & there is unrefreshed
sleep
 Risk factors
o Middle aged overweight males who snore loudly
 Management
o Weight loss
o Continuous positive pressure ventilation (CPAP) via face mask at night

Kleine-Levin Syndrome (Sleeping Beauty Syndrome)

o Epidemiology
o Rare in prevalence
o Largely affects male adolescents
o Clinical Features
o Symptoms
 Episodes of excessive sleepiness
 Increased appetite
 Episodes of sexual disinhibition & other co-morbid psychiatric symptoms
o Duration
 Often lasts for days or weeks w/ long intervals
 Free from attacks in between episodes
o Management
 Stimulatory SSRIs (e.g. fluoxetine)
 Psychostimulants: can be used but usually only effect for a short period of time

Circadian Rhythm Sleep Disorder

o Pts w/ circadian rhythm sleep disorder have abnormal sleep-wake patterns, leading to excessive
daytime sleepiness & impairment in social or occupational functioning.

o There are two main types of circadian rhythm sleep disorder:

o Advanced sleep phase syndrome: early onset of sleep w/ early morning awakening
o Delayed sleep phase syndrome: delayed onset of sleep (2am); total sleep time is normal
o Etiology
o Time zone changes
o Shift work (e.g. security guards)
o Irregular sleep-wake pattern
o Management
 o Non-pharmacological
 Sleep education: stages of sleep, assist establishment of good sleep habits
 Shift-workers: advised to try & have regular sleep cycles, & attempt to nap if
necessary, to compensate for the absolute number of sleep hours lost
o Pharmacological
 Agomelatine or melatonin: reset circadian rhythm
 Hypnotics e.g. short acting benzodiazepines

Parasomnia
o Parasomnia is classified into the following subtypes:
o Arousal disorders:
 Confusional arousals
 Sleep-terrors, sleep-walking
o Sleep-wake transition disorders:
 nocturnal leg cramps,
 sleep-talking,
 rhythmic movement disorder
o Parasomnia associated w/ REM sleep:
 nightmares,
 sleep paralysis
o Other parasomnia:
 Sleep bruxism (teeth grinding)
 Sleep enuresis
o Other parasomnia not otherwise stated

Somnambulism (Sleep-Walking)
o Epidemiology
o Prevalent among both children & adults
 Children: up to 17% affected, higher incidence among 4-8-year-olds
 Adults: up to 10% affected
o Clinical Features
 Complex & automatic behaviors e.g. wandering w/out purpose, attempting to dress
or undress
 Episodes tend to occur in the initial stages of sleep, usually 15-120 minutes after
individuals fall asleep
 Usually able to get back to bed & continue w/ sleep after the event has taken place
 Usually do not recall exact incidents that happen
 Appear to be disorientated & confused if awakened during somnambulism
o Management
 Supportive therapy, sleep hygiene, psychoeducation & reassurance are useful
 Protective measures: locking doors/windows, installation of window bars/frames to
prevent accidents e.g. fall from height
 Antidepressants: imipramine & paroxetine are useful

Sleep Terrors (Night Terrors)

o Epidemiology
o Children: 3%
o Adults: 1%
o Gender: M>F
o Clinical Features
o Sudden awakening during sleep w/ loud terrified screaming
o Physiological changes: tachycardia, diaphoresis, mydriasis
o Each episode is estimated to last around 10-15 minutes
o Similar to sleep-walking, confused and disoriented if awakened during sleep terror
o Usually unable to recollect events in detail
 o Management
o Supportive therapy, sleep hygiene, psychoeducation and reassurance are useful

Nightmares
o Definition
o Awakening from REM sleep to full consciousness w/ detailed dream recall ability
o Epidemiology
o Common especially among children between the ages of 5 to 6 years old
o Management
o No specific tx is usually required
o Agents that help to suppress REM sleep can be used e.g. tricyclic drugs & SSRIs

Periodic Limb Movement Disorder

o Epidemiology
o More common in elderly, pregnant women, patients with vertebral degenerative disorders
o Etiology
o B12 deficiency
o Iron deficiency
o Chronic renal disease
o Parkinson disease
o Clinical Features
o Repeated leg twitching during sleep
o Investigations
o B12 & ferritin levels
o Management
o Vitamin B12 & iron tablets

Random Eye Movement (REM) & Non-Random Eye Movement (NREM) Sleep Disorders
o Sleep comprises of periods of NREM & REM sleep alternating through the night; the deepest stages
of NREM occur in the first part of the night, & episodes of REM sleep are longer as the night
progresses.
SUBSTANCE USE DISORDERS
- Cluster of Cognitive, behavioral and physiological symptoms indicating that the individual
continues using the substance despite significant substance related problems.
- Pathological pattern of behaviors related to the use of the substance.
- Underlying change in brain circuits that exist/persist beyond intoxication (repeated releases,
intense cravings)

- Impaired control:
o Use in larger quantities or longer period
o May express persistent desire or failed attempts to reduce use
o Excess of time to obtain, use, or recover
o Cravings: (classical conditioning/reward center)
- Social Impairment:
o Recurrent use results in work, school or home role failures
o Continued use regardless of social/interpersonal problems as a result of use
o Important activities abandoned in lieu of use (interpersonal withdrawal)
- Risky use:
o Use in potentially hazardous situations
o Use knowing physical/psychological issues as a result
- Pharmacological criteria:
o Tolerance – continued use in which and individual requires greater doses to achieve the
same effect
o Withdrawal – syndrome when blood or tissue concentrations of a substance decline in an
individual who maintained prolonged heavy use of the substance

- Modifiers
o Severity
 Mild Substance Use Disorder (2-3 symptoms)
 Moderate Substance Use Disorder (4-5 symptoms)
 Severe Substance Use Disorder (6 or more symptoms)
o Specifiers
 In early remission
 In sustained remission
 On maintenance therapy
 In a controlled environments

Alcohol Related Disorders

1. Alcohol Use Disorder
2. Alcohol Intoxication
3. Alcohol Withdrawal
4. Other Alcohol Induced Disorders
5. Unspecified Alcohol-Related Disorder

- The presence of at least 2 of these symptoms occurring within a 12-month period indicates an:
- Alcohol Use Disorder (AUD):
1. Alcohol is often taken in larger amounts or over a longer period of time than intended.
2. There is a persistent desire or unsuccessful effort to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover
from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or
home.
 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced because of
alcohol use.
8. Recurrent alcohol use in situations where it is physically dangerous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by alcohol.

10. Tolerance as defined by either of the following:

a. Need for markedly increased amounts of alcohol to achieve intoxication/desired effect
b. A markedly diminished effect with continued use of the same amount of alcohol.

11. Withdrawal as manifested by either of the following:

a. The characteristic withdrawal syndrome for alcohol
b. Alcohol (or a closely related substance, such as a benzodiazepine)
c. Taken to relieve or avoid withdrawal symptoms.

- Alcohol Intoxication is the direct result of alcohol consumption.

- Clinically significant behavioral or psychological changes that occur after drinking alcohol.
- Common symptoms:
o Slurred speech
o Poor balance
o Dizziness
o Headache
o Nausea.

(DSM-5) Alcohol Withdrawal Syndrome (AWS)

A. Cessation of or reduction in alcohol intake, which has previously been prolonged/heavy.
B. Criterion A, plus any 2 of the following symptoms developing within several hours to a few days:
o Autonomic hyperactivity
o Worsening tremor
o Insomnia
o Vomiting and nausea
o Hallucinations
o Psychomotor agitation
o Anxiety
o Generalized tonic-clonic seizures.
C. The above symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
D. The above symptoms are not attributable to other causes; for example, another mental disorder,
intoxication, or withdrawal from another substance.

**Specify if hallucinations (usually visual or tactile) occur with intact reality testing, or if auditory, visual,
or tactile illusions occur in the absence of a delirium.**

Diagnostic Criteria for Delirium Tremens:

- Decreased attention and awareness  changes from normal level and fluctuates in severity during
the day.
- Disturbance in memory, orientation, language, visuospatial ability, or perception.
- No evidence of coma or other evolving neurocognitive disorder severity during the day.
- History indicates that the disturbance is attributable to alcohol withdrawal.
Caffeine-Related Disorders
1. Caffeine Intoxication
2. Caffeine Withdrawal
3. Other Caffeine-Indicated Disorders
4. Unspecified Caffeine-related Disorder

- Caffeine intoxication is an over-stimulation of the central nervous system caused by a high dose of
caffeine
- Caffeine, the most consumed psychoactive drug in the world, is highly addictive and can cause:
physical, mental, and psychomotor impairments.
- Coffee is the most common source of a high intake of caffeine.
- Other sources of caffeine are:
o Tea, energy drinks, soda, chocolate, analgesics, and cold remedies.

- Caffeine overdose  person must ingest more than 250 mg

o An 6-8 oz energy drink has 70-180 mg
o An energy shot 171 mg
o Mega 24-oz coffee can have as high as 500 mg of caffeine.
o A cup of coffee contains 100-200 mg

- Most common withdrawal symptom is headache—it throbs and is sensitive to any movement (may
last as long as 21 days).
- Many of the symptoms start between 12 -24 hours after caffeine is stopped (last up to 9 days):
o Mood changes, including depression and anxiety
o Trouble concentrating
o Fatigue
o Nausea, vomiting and achiness—symptoms like the flu.
o Cravings for caffeine.
o Increase in appetite.

Cannabis-Related Disorders
1. Cannabis Use Disorder
2. Cannabis Intoxication
3. Cannabis Withdrawal
4. Other Cannabis-Induced Disorders
5. Unspecified Cannabis-Related Disorder

- Cannabis intoxication refers to the side effects seen as a result of the active ingredient found in
cannabis known as delta-9-tetrohydrocannabinol or THC
- Forms: flower, resin and the hash oil.
- The most widely consumed form of cannabis is marijuana, which contains the most amount of THC.
- Cannabis is the most commonly used illicit drug in the United States and globally
- Hyper-cannabinoid emesis syndrome  allergy to THC (morning sickness type nausea/vomiting)

- Signs of Intoxication:
o Increased hunger
o Sleepiness
o Impaired cognition and perception
o Disorientation
o Acute psychosis

- Recent history of cannabis

- Behavioral or psychological changes (euphoria, impaired judgment, and motor skills)
- At least two within 2 hours of use:
o Redeyes, dry mouth, increased appetite, tachycardia,
Hallucinogen-Related Disorders AKA ‘psychedelics’

1. Phencyclidine Use Disorder

2. Other Hallucinogen Use Disorder
3. Phencyclidine Intoxication
4. Other Hallucinogen Intoxication
5. Hallucinogen Persisting Perception Disorder
6. Other Phencyclidine-Induced Disorders
7. Other Hallucinogen-Induced Disorders
8. Unspecified Phencyclidine-Related Disorder
9. Unspecified Hallucinogen-Related Disorder

- Hallucinogens can be chemically synthesized (as with lysergic acid diethylamide or LSD) or may
occur naturally (as with psilocybin mushrooms, peyote).
- Both synthesized and natural substances can produce visual and auditory detachment from one’s
environment and oneself, and distortions in time and hallucinations, feelings of perception.

- Examples:
o LSD (Lysergic Acid Diethylamide)
o PCP (Phencyclidine)
o Magic Mushrooms (Psilocybin)
o Ketamine
o Mescaline (Peyote Cactus)
o Morning Glory Seeds
o Datura

Opioid-Related Disorders
1. Opioid Use Disorder
2. Opioid Intoxication
3. Opioid Withdrawal
4. Other Opioid-Induced Disorders
5. Unspecified Opioid-Related Disorder

- Opioids: reduce the perception of pain, produce drowsiness, mental confusion, euphoria, nausea,
constipation, can depress respiration  Illegal – Heroin  Legal - Oxycodone and Hydrocodone

Sedative, Hypnotic, Or Anxiolytic Use Disorder

1. Sedative, Hypnotic, or Anxiolytic Use Disorder
2. Sedative, Hypnotic, or Anxiolytic Intoxication
3. Sedative, Hypnotic, or Anxiolytic Withdrawal
4. Other Sedative, Hypnotic, or Anxiolytic-Induced Disorders
5. Unspecified Sedative, Hypnotic, or Anxiolytic-Related Disorder

- Potential Signs of Sedative Intoxication:

o Reduced mental alertness
o Reduced attention span
o Sensations of floating or being out of the body
o Depressed heartbeat
o Depressed breathing
o Sleepiness and drowsiness
o Confusion and disorientation
o Jitters and having shaky hands
Stimulant Use Disorder
1. Stimulant Use Disorder
2. Stimulant Intoxication
3. Stimulant Withdrawal
4. Other Stimulant-Induced Disorders
5. Unspecified Stimulant-Related Disorder

- Stimulant intoxication:
o Recent exposure to a stimulant
o Behavioral or psychological changes:
 Euphoria
 Hyper-vigilance
 Anger
 Interpersonal sensitivity
 Auditory hallucinations
 Paranoid thoughts
 and/or repetitive movement.

o Physical symptoms
o Abnormally fast or slow heartbeat
o Dilation of the pupils
o Elevated or lowered blood pressure
o Sweating or chills
o Nausea or vomiting
o Weight loss
o and/or muscle weakness.

Tobacco-Related Disorders
1. Tobacco Use Disorder
2. Tobacco Withdrawal
3. Other Tobacco-Induced Disorders
4. Unspecified Tobacco-Related Disorder

OTHER (OR UNKNOWN) SUBSTANCE-RELATED DISORDERS

1. Other (or Unknown) Substance Use Disorder
2. Other (or Unknown) Substance Intoxication
3. Other (or Unknown) Substance Withdrawal
4. Other (or Unknown) Substance-Induced Disorders
5. Unspecified Other (or Unknown) Substance-Related Disorder

- Solvents, fuels, paints, and other substances that produce intoxicating gases are readily and legally
available.
- Inhalant use disorder is most prevalent amongst adolescents and young adults who do not have
access to alcohol or other illegal substances.