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10 separate classes of drugs in the DSM-5-TR

• Alcohol
• Caffeine

CHAPTER 4 • Cannabis
• Hallucinogens
• Inhalants
• Opioids
Chapter 4
• Sedatives Hypnotics, or anxiolytics
Assessment of Substance
Abuse, Dependence, and • Stimulants (cocaine)
Addiction
• Stimulants (amphetamine-type substances, and other stimulants)
• Tobacco
• Other or unspecified

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Challenges
• Differentiating those individuals who fall in the gray
area between occasional, or nonproblematic, use of
alcohol/drugs from those who use excessively and/or
have an alcohol/drug problem.
• People strongly deny problems with alcohol and
drugs.
• Individual, family, and societal perceptions of
alcohol/drugs are distorted by this denial system.
1. Substance-Related Disorders: Substance Use
Disorders
Diagnostic Features
• A cluster of cognitive, behavioral, and physiological
symptoms indicating that the individual continues using the
substance despite significant substance-related problems.
• The diagnosis of a substance use disorder can be applied
to all 10 substance classes included in the DSM-5-tr except
caffeine.

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Diagnostic Categories (DSM 5tr)

Substance-related disorders are divided into two major categories:

Substance Use Disorders
1. Substance use disorders.
• Dependence & Abuse
• Impaired control (Items 1, 2, 3, 4)
*** Were separate in DSM IV but combined by DSM 5 under substance
use disorders title. • Social impairment (Items 5, 6, 7)
2. Substance induced disorders.
• Risky use of the substance (Items 8,9)
• Intoxication.
• Withdrawal. • Pharmacological criteria (Items 10, 11)
• Substance/medication-induced mental disorders (listed in other
chapters)
*** Addiction is not being used as a diagnostic category.

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Severity
• Severity is based on the number of symptom criteria
endorsed:
• Mild substance use disorder; presence of two to
three symptoms,
• Moderate; four to five symptoms,
• Severe; by six or more symptoms
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Specifiers
The following course specifiers and descriptive features
specifiers are also available for substance use disorders:
• "in early remission," "in sustained remission," "on
maintenance therapy," and "in a controlled environment."
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Alcohol Use Disorder: Diagnostic Criteria
A problematic pattern of alcohol use leading to clinically significant impairment or
distress, as manifested by at least two of the following, occurring within a 12-month
period:
1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts 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.
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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 in which it is
physically hazardous.
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. A need for markedly increased amounts of alcohol to achieve
intoxication or 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 (refer to Criteria A
and B of the criteria set for alcohol withdrawal).
b. Alcohol (or a closely related substance, such as a benzodiazepine) is
taken to relieve or avoid withdrawal symptoms.
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2. Substance-Induced disorders: Substance Intoxication

2. Substance-Induced Disorders: Substance Withdrawal

A. Development of a reversible substance-specific syndrome due to

the recent ingestion of a substance
B. The clinically significant problematic behavioral or psychological
changes associated with intoxication (e.g., belligerence, mood
lability, impaired judgment)
C. are accompanied by substance-specific signs and symptoms
D. The symptoms are not attributable to another medical condition and
are not better explained by another mental disorder
A. Development of a 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
B. The substance-specific syndrome causes clinically significant
distress or impairment in social, occupational, or other important
areas of functioning
C. The symptoms are not due to another medical condition and are not
better explained by another mental disorder
D. Withdrawal is usually, but not always, associated with a substance
use disorder.

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Alcohol Withdrawal Diagnostic Criteria

A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. 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:

Substance intoxication is common among • 1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).

individuals with a substance use disorder but also • 2. Increased hand tremor.

• 3. Insomnia.
occurs frequently in persons who use substances
• 4. Nausea or vomiting.
but do not have a substance use disorder. This • 5. Transient visual, tactile, or auditory hallucinations or illusions.
category does not apply to tobacco. • 6. Psychomotor agitation.

• 7. Anxiety.

• 8. Generalized tonic-clonic seizures.

C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition and are not better explained
by another mental disorder, including intoxication or withdrawal from another substance.
Specify if:
With perceptual disturbances

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Alcohol Intoxication: Diagnostic Criteria 2. Substance-Induced Disorders: Substance-induced mental disorders

A. Recent ingestion of alcohol.

B. Clinically significant problematic behavioral or psychological changes (e.g.,
inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that Will not be covered here.
developed during, or shortly after, alcohol ingestion.
C. One (or more) of the following signs or symptoms developing during, or shortly Are presented in the relevant sections not under the substances section
after, alcohol use:
1. Slurred speech.
2. Incoordination.
3. Unsteady gait.
4. Nystagmus.
5. Impairment in attention or memory.
6. Stupor or coma.
D. The signs or symptoms are not attributable to another medical condition and are
not better explained by another mental disorder, including intoxication with another
substance.

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Behavioral Definition of Addiction Table 4.1: Phases of Cocaine Addiction

• Compulsion: Obsession with alcohol/drugs.

• Control: Inability to stop using alcohol/drugs.
• Consequences: Continued use despite adverse consequences.
Phase Progressive Themes
Initial contact "Isn't this a great drug?"
Experimentation "It's sure expensive, but it's worth it."
Excessive use "I really should cut down."
Addiction "I know I have to stop, but I can't."
SOURCE: Rawson 1989.

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Set and Setting Table 4.2: Early and Late Stages of Alcohol or Drug Use

• Determine the individual’s reaction to alcohol/drugs.

• Set: Psychological and emotional frame of mind of a person when
using alcohol/drugs. Early Stage Late Stage
• Setting: Involves physical, social, and interpersonal environment. More freedom Lack of freedom
Fewer risks and less damage More damage
Possible abuse Present abuse
No illness State of illness
Linear operating factors Vicious cycles

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Figure 4.1: Stages of Alcohol/Drug Use Vulnerability to Relapse

• At each stage of recovery, individuals are vulnerable to relapse.

• Chemical dependency treatment programs must address relapse
issues.
• Longer term inpatient or residential program is much needed.
• No criteria or descriptions of the different types of relapses exist.

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Denial
Can stand for “I Don’t Even Know I Am Lying.”
By individuals who have drug problems, family and friends, and society.
Defense mechanisms used to deny problems with alcohol and drugs.
• Minimization and rationalization.
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Consequences of Minimization and Rationalization
• Neglect and emotional, physical, or sexual abuse.
• Loss—death, trauma, divorce, separation.
• Numerous relocations and unstable home environment.
• Parental dysfunction, creating feelings of parental unavailability and/or
feelings of abandonment, rejection, or shame.
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Screening & Assessment
Screening: A process for evaluating the possible presence of a particular
problem. The outcome is normally a simple “yes” or “no”.
Assessment: A process for defining the nature of that problem, determining
a diagnosis, and developing specific treatment recommendations for
addressing the problem or diagnosis
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Screening
Often the initial contact with the treatment system
– client forms first impression
Sensitivity and engagement- sets the tone of
treatment and begins the relationship with the
client
Clinician discomfort can discourage the client from
endorsing screening items
• Can target aspects of addiction such as
hangovers, likeliness to have problems with
withdrawal, confidence in implementing change
Does not result in a diagnosis
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CAGE & CAGE - AID
CAGE: Brief screening used to determine if further alcohol use assessment
is warranted
CAGE – AID: CAGE adapted to include drugs
Questions:
Have you felt you ought to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning to steady
your nerves or to get rid of a hangover (eye-opener)?
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Assessment
There is no single gold-standard assessment tool
Many tools are developed with specific focuses:
• Determining amount and type of use to drive diagnosis
• Determining readiness to change
• Integrated assessments that look at various disorders
Assessment is a process that involves engagement, identification of
collateral contacts and supports, diagnosis, identification of problems and
needs, staging, treatment recommendations
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Alcohol/Drug Assessment Psychological Consequences of Alcohol or Drug Use

• Age of initial drug and alcohol use. • Irritability and short temper.
• Frequency of use, amounts used, set and setting of use. • Panic attacks.
• Patterns of use, binges, periods of nonuse. • Violent thoughts.
• Stage of current use. • Severe depression.
• History of negative consequences. • Memory problems.
• Medical history. • Paranoia and suspiciousness.
• Use of coffee, cigarettes, and medication. • Suicidal thoughts.

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Identification of Adolescent Alcohol/Drug Problems Sexual Consequences of Alcohol or Drug Use

• Mood. • Lying, stealing, and cheating. • Loss of sex drive.

• Changes. • Community. • Sex with strangers.
• Responsibility. • Criminal justice problems. • Sexuality out of control.
• Motivation. • Physical signs. • Sexual obsession or preoccupation.
• School. • Parents. • Risking of AIDS through sexual behavior.
• Negative activities.

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Physical Consequences of Alcohol/Drug Use Relationship or Social Consequences of Alcohol/Drug Use

• Convulsions with loss of consciousness. • Arguments with spouse or mate.

• Nasal sores and bleeding. • Thrown out of household.
• Chest congestion and wheezing. • Loss of friends.
• Hepatitis or other liver problems. • Arguments with parents, brothers, or sisters.
• Severe or frequent headaches. • Spouse or mate has threatened to leave or has already left.
• Drug overdose requiring treatment in an emergency room or hospital. • Social isolation.
• Coughing up black phlegm.
• Severe weight loss (without dieting).
• Sinus problems.
• Ulcers or other stomach problems.
• Heart palpitations.

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Financial Consequences of Alcohol/Drug Use

• In jeopardy of losing the job.

• Late to work.
• Less productive at work.
• In debt.
• Already lost at least one job.
• Missed days of work.
• Missed opportunity for promotion or raise.
• Behind in paying bills.

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Legal Consequences of Alcohol/Drug Use

Arrested for:

• Possession and sale of illicit substances.

• Forging prescriptions and violent or disorderly conduct.
• Assaulting someone.
• Embezzlement or check forgery.
• D W I or D U I.
• Theft or robbery.

Auto accident while driving under the influence.

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