Substance Use Disorder

ABNORMAL PSYCHOLOGY II PSY 4121 Lecture
FINAL COMPONENT - FIRST SEMESTER, AY 2023-2024
SUBSTANCE-RELATED DISORDERS persistent or recurrent physical

or psychological problems.
➢ Pharmacological criteria
SUBSTANCE USE DISORDERS
○ Tolerance
○ Withdrawal
DIAGNOSTIC FEATURES
SEVERITY AND SPECIFIERS
➢ Impaired control
○ Taking substance in larger ➢ Mild
amounts or over a longer period ○ 2 to 3 symptoms
than was originally intended. ➢ Moderate
○ Experience persistent desire to ○ 4 to 5 symptoms
cut down or regulate substance ➢ Severe
use and may report multiple ○ 6 or more symptoms
unsuccessful efforts to decrease
or discontinue use.
○ May spend a great deal of time SUBSTANCE-INDUCED DISORDERS
obtaining the substance, using
the substance, or recovering SUBSTANCE INTOXICATION AND
from its effects. SUBSTANCE WITHDRAWAL
○ Craving
➢ Social impairment
○ Failure to fulfill major role CRITERIA
obligations at work, school, or
home. ➢ Development of a reversible
○ May continue substance use substance-specific syndrome due to the
despite having persistent or recent ingestion of a substance.
recurrent social or interpersonal ➢ Significant problematic behavioral or
problems caused or psychological changes associated with
exacerbated by the effects of intoxication attributable to the
the substance. physiological effects of the substance.
○ Important social, occupational, ➢ Substance-specific signs and symptoms
or recreational activities may be
given up or reduced because of
ROUTE OF ADMINISTRATION AND SPEED
substance use. OF SUBSTANCE EFFECTS
○ Withdraw from family activities
and hobbies in order to use the
➢ Routes of administration that produce
substance.
more rapid and efficient absorption into
➢ Risky use
the bloodstream tend to result in a more
○ Recurrent substance use in
intense intoxication and an increased
situations in which it is
likelihood of an escalating pattern of
physically hazardous.
substance use leading to withdrawal.
○ May continue substance use
○ Intravenous
despite knowledge of having
○ Smoking
TRANS BY and FOR Arante, K. G., & Viarino, N. F. G., BS Psychology 4 | University of San Carlos
○ Intranasal “snorting” SUBSTANCE/MEDICATION-INDUCED
➢ Rapidly acting substances are more DISORDERS
likely than slower-acting substances to
produce immediate intoxication.
DIAGNOSTIC AND ASSOCIATED
FEATURES
DURATION
➢ More sedating drugs can produce

➢ Short-acting substances tend to have
prominent and clinically significant
higher potential for the development of
depressive disorder during intoxication,
withdrawal than do those with a longer
while anxiety conditions are likely to be
duration of action.
observed during withdrawal symptoms
➢ Longer-acting substances tend to have
from these substances.
a longer duration of withdrawal
○ Sedative
symptoms.
○ Hypnotics
➢ The longer the acute withdrawal period,
○ Anxiolytics
the less intense the syndrome tends to
○ Alcohol
be.
➢ During intoxication, the more stimulating
substances are likely to be associated
ASSOCIATED LABORATORY FINDINGS with substance-induced psychotic
disorders and substance-induced
➢ Laboratory analyses of blood and urine anxiety disorders, and with
samples can help determine recent use substance-induced major depressive
and the specific substances involved. episodes observed during withdrawal.
➢ Positive test result does not indicate a ○ e.g. amphetamines, cocaine
pattern of substance use. ➢ Sedating and more stimulating produce
➢ Laboratory tests may help identify the significant but temporary sleep and
substance and differentiate withdrawal sexual disturbances.
from other mental disorders. ➢ There must be evidence that the
➢ Normal functioning in the presence of symptoms being observed are not likely
high blood levels of a substance to be better explained by an
suggests considerable tolerance. independent mental disorder.
DEVELOPMENT AND COURSE DEVELOPMENT AND COURSE
➢ 18-24 year old individuals have ➢ Most of these disorders, regardless of

relatively high prevalence rates for the the severity of symptoms, are likely to
use of virtually every substance. improve relatively quickly with
➢ Intoxication is usually the initial abstinence and unlikely to remain
substance-related disorder and often clinically relevant for more than 1 month
begins in the teens. after complete cessation of use.
➢ Withdrawal can occur at any age as ➢ Likely to increase with both the quantity
long as the relevant drug has been and the frequency of consumption of the
taken in sufficient doses over an relevant substance.
extended period of time. ➢ Symptom profiles of this disorder
resemble independent mental disorder.
frequently accompany heavy drinking
IMPORTANT NOTES
and sometimes precede it.
➢ Repeated intake of high doses of
SUBSTANCE - MEDICATION - alcohol can affect nearly every organ
INDUCED INDUCED system, especially the gastrointestinal
tract, cardiovascular system, and the
Develop in the Seen with prescribed
central and peripheral nervous systems.
context of intoxication or OTC medications
or withdrawal from that are taken at the ○ Korsakoff syndrome
substances of abuse suggested doses. ■ Inability to encode new
memory
➢ Both are usually temporary and likely to
disappear within 1 month or so of DEVELOPMENT AND COURSE
cessation of acute withdrawal, severe
intoxication, or use of the medication. ➢ First episode of alcohol intoxication
likely to occur during mid-teens.
ALCOHOL-RELATED DISORDER ➢ Large majority of the individuals who
develop alcohol-related disorders do so
ALCOHOL USE DISORDER by their late 30s.
➢ Alcohol-related problems in older people
are also especially likely to be
CRITERIA associated with other medical
complications.
➢ Repeated use of alcohol in a way that
leads to harmful consequences. PREVALENCE & SEX AND GENDER
➢ At least 2 of the following: RELATED DIAGNOSTIC ISSUES
○ Excessive use
○ Impaired control ➢ AUD is common
○ Craving ➢ 29.1% lifetime prevalence rates in the
○ social/occupational problems U.S.
○ Risky use ➢ Greater in men
○ Tolerance ➢ Females are more likely to develop
○ Withdrawal blood alcohol levels per drink than
males.
➢ Drinking during pregnancy may be a
DURATION sign of an AUD.
➢ Within a 12-month period. DIFFERENTIAL DIAGNOSIS
ASSOCIATED FEATURES NONPATHOLOGICAL USE OF ALCOHOL
➢ Alcohol may be used to alleviate the

unwanted effects of other substances or ➢ Drinking even daily, in low doses and
to substitute for them when they are not occasional intoxication do not by
available. themselves make this diagnosis.
➢ Symptoms of conduct problems,
depression, anxiety, and insomnia
ALCOHOL INTOXICATION, ALCOHOL ➢ Suboptimal ways of coping with stress
WITHDRAWAL, AND ALCOHOL-INDUCED
MENTAL DISORDERS GENETIC AND PHYSIOLOGICAL
➢ AUD describes a problematic pattern of ➢ Runs in families, 40%-60% of the

alcohol use that involves impaired variance of risk explained by genetic
control, social impairment, and risky use influences.
➢ Three- to fourfold increase in risk has
over alcohol use, whereas alcohol
been observed in children of individuals
intoxication, withdrawal, -induced mental with AUD.
disorders describe psychiatric
syndromes that develop in the context of COURSE MODIFIERS
heavy use.
SEDATIVE, HYPNOTIC, OR ANXIOLYTIC USE ➢ High levels of impulsivity are associated

DISORDER with an earlier onset and more severe
alcohol use disorder
➢ Share similar symptoms. The two must

be distinguished, however, because the IMPORTANT NOTES
course may be different, especially in
relation to medical problems. ➢ Associated with a significant increase
risk of accidents, violence, and suicide.
CONDUCT DISORDER IN CHILDHOOD AND ➢ Comorbid with
ANTISOCIAL PERSONALITY DISORDER ○ Bipolar disorders
○ Schizophrenia
○ Antisocial PD
○ Most anxiety and depressive
➢ Because these diagnoses are
disorders
associated with an early onset of AUD
as well as a worse prognosis, it is
important to establish both conditions. ALCOHOL INTOXICATION
RISK AND PROGNOSTIC FACTORS CRITERIA
ENVIRONMENTAL
➢ Recent ingestion of alcohol
➢ Clinically significant problematic
➢ Poverty behavioral or psychological changes
➢ Discrimination ➢ 1 or more of the following signs or
➢ Unemployment symptoms developing during, or shortly
➢ Low levels of education after, alcohol use
➢ Cultural attitudes toward drinking and ○ Slurred speech
intoxication ○ Incoordination
➢ Availability of alcohol (price) ○ Unsteady gait
➢ Acquired personal experiences with ○ Nystagmus
alcohol ○ Impairment in attention or
➢ Stress levels memory
➢ Heavier peer substance use ○ Stupor or coma
➢ Exaggerated positive expectations of
the effects of alcohol
DURATION DIFFERENTIAL DIAGNOSIS
➢ Depends on how much alcohol was OTHER MEDICAL CONDITIONS

consumed over what period of time.
➢ Blood alcohol level generally decreases
at a rate of 15-20 mg/dL per hour. ➢ Several medical and neurological
conditions can temporarily resemble
alcohol intoxication.
ASSOCIATED FEATURES
ALCOHOL-INDUCED MENTAL DISORDERS
➢ Signs and symptoms are likely to be
intense when the blood alcohol level is
rising and when it is falling. ➢ Symptoms are in excess of those
➢ When blood alcohol levels are rising usually associated with AI, predominate
early in the drinking, symptoms often in the clinical presentation, and are
reflect stimulation. severe enough to warrant clinical
➢ When blood levels are falling, attention.
individuals are likely to become
SEDATIVE, HYPNOTIC, OR ANXIOLYTIC
progressively more depressed,
INTOXICATION
withdrawn, and cognitively impaired.
➢ Associated with amnesia.
➢ Important contributor to interpersonal ➢ Differential requires observing alcohol
violence and suicidal behavior. on breath, measuring blood or breath
alcohol levels, ordering a medical
DEVELOPMENT AND COURSE workup, and gathering a good history.
➢ Usually occurs as an episode RISK AND PROGNOSTIC FACTORS

developing over minutes to hours and
typically lasting several hours. TEMPERAMENTAL
➢ Frequency and intensity usually
decrease with further advancing age.
➢ The earlier onset of regular intoxication, ➢ Episodes of alcohol intoxication
the greater the likelihood the individual increase with personality characteristics
will go on to develop AUD. of sensation seeking and impulsivity
ENVIRONMENTAL
PREVALENCE & SEX AND GENDER
RELATED DIAGNOSTIC ISSUES
➢ Heavy-drinking peers
➢ Beliefs that heavy drinking is an
➢ Large majority of alcohol consumers are
important component of having fun.
likely to have been intoxicated to some ➢ Using alcohol with stress
degree at some point in their lives.
➢ More tolerated for men
IMPORTANT NOTES
➢ Intoxication is usually established by

observing an individual's behavior and
smelling alcohol on the breath.
➢ Comorbid with conduct disorder or only after extended periods of heavy
antisocial PD. drinking.
➢ Withdrawal is relatively rare in
ALCOHOL WITHDRAWAL individuals younger than 30 years, and
the risk and severity increase with
increasing age.
CRITERIA

➢ Cessation of alcohol use that has been RELATED DIAGNOSTIC ISSUES
heavy and prolonged.
➢ 2 or more of the following ➢ Approximately 50% of middle-class,
○ Autonomic hyperactivity highly functional individuals with AUD in
○ Increased hand tremor the U.S. have ever experienced a full
○ Insomnia alcohol withdrawal syndrome.
○ Nausea or vomiting
○ Transient visual, or auditory
hallucinations or illusions DIFFERENTIAL DIAGNOSIS
○ Psychomotor agitation
○ Anxiety OTHER MEDICAL CONDITIONS
○ Generalized tonic-clonic
seizures
➢ Distress or impairment in social, ➢ Symptoms of AW can also be mimicked
occupational, or other important areas of by some medical conditions.
functioning. ➢ Essential tremor, a disorder that
frequently runs in families, may
erroneously suggest the tremulousness
DURATION
associated with alcohol withdrawal.
➢ Within several hours to a few days after ALCOHOL-INDUCED MENTAL DISORDERS

the cessation of heavy and prolonged
alcohol use.
➢ Symptoms are in excess of those
usually associated with AW,
ASSOCIATED FEATURES predominate in the clinical presentation,
and are severe enough to warrant
➢ Alcohol withdrawal delirium may occur in clinical attention.
the context of a withdrawal.
○ Visual,tactile, or (rarely) auditory
hallucinations (delirium
tremens). SEDATIVE, HYPNOTIC, OR ANXIOLYTIC
WITHDRAWAL
○ When AWD develops, it is likely
that a clinically significant
relevant medical condition may ➢ Produces a syndrome very similar to
be present. that of AW.
DEVELOPMENT AND COURSE
➢ Acute alcohol withdrawal occurs as an

episode usually lasting 4-5 days and
RISK AND PROGNOSTIC FACTORS CAFFEINE-RELATED DISORDER
ENVIRONMENTAL CAFFEINE INTOXICATION
➢ Quantity and frequency of alcohol CRITERIA

consumption.
➢ Concurrent medical conditions
➢ Recent consumption of caffeine (in
➢ Family histories of alcohol withdrawal
excess of 250mg).
➢ Those with prior withdrawals
➢ Five or more of the following
➢ Those who consume sedative, hypnotic,
○ Restlessness
or anxiolytic drugs.
○ Nervousness
○ Excitement
IMPORTANT NOTES ○ Insomnia
○ Flushed face
➢ Withdrawal may serve to perpetuate ○ Diuresis
drinking behaviors and contribute to ○ Gastrointestinal disturbance
relapse, resulting in persistently ○ Muscle twitching
impaired social and occupational ○ Rambling flow or thought and
functioning. speech
○ Tachycardia or cardiac
ALCOHOL-INDUCED MENTAL DISORDERS arrhythmia
○ Period of inexhaustibility
DIAGNOSTIC AND ASSOCIATED
➢ Clinically significant distress or
FEATURES
impairment in social, occupational, or
other important areas of functioning.
➢ Differentiated based on the temporal
relationship between the alcohol use
ASSOCIATED FEATURES
and the psychiatric symptoms.
➢ Likely to demonstrate the associated
features seen with AUD. ➢ Mild sensory disturbances in high doses
of caffeine
○ Ringing in the ears
○ Flashes of light
➢ Caffeine blood level may provide
➢ Symptoms of A-IMD are likely to remain important information for diagnosis.
clinically relevant as long as the
individual continues to experience
severe intoxication or withdrawal.
➢ Likely to improve relatively quickly and
unlikely to remain clinically relevant for ➢ Caffeine intoxication symptoms usually
more than a month after cessation of remit within the first day or so and do
severe intoxication and/or withdrawal. not have any known long-lasting
consequences.
➢ With advancing age, individuals are
UNSPECIFIED ALCOHOL-RELATED
likely to demonstrate increasingly
DISORDER
intense reactions to caffeine, with
greater complaints of interference with ➢ Genetic factors may affect risk of
sleep or feelings of hyperarousal. caffeine intoxication.
➢ Children and adolescents may be at
increased risk for caffeine intoxication. IMPORTANT NOTES
PREVALENCE & SEX AND GENDER ➢ Associated with

RELATED DIAGNOSTIC ISSUES ○ Depressive disorders
○ Bipolar disorders
➢ In the U.S.,7% of individuals of the ○ Eating disorders
population may experience 5 or more ○ Psychotic disorders
symptoms along with functional ○ Sleep disorders
impairment consistent with a diagnosis ○ Substance-related disorders
of caffeine intoxication. ➢ Individuals with anxiety disorders are
➢ Adolescents and young adults in more likely to avoid caffeine.
high-income countries.
CAFFEINE WITHDRAWAL
DIFFERENTIAL DIAGNOSIS
CRITERIA
INDEPENDENT MENTAL DISORDERS
➢ Prolonged daily use of caffeine.

➢ Symptoms must not be associated with ➢ Abrupt cessation of or reduction in
another medical condition or another caffeine use, followed within 24 hours by
mental disorder. 3 or more of the following
○ Headache
CAFFEINE-INDUCED MENTAL DISORDERS ○ Marked fatigue or drowsiness
○ Dysphoric mood, depressed
mood, or irritability
➢ Differentiated with onset during
○ Difficulty concentrating
intoxication.
○ Flu-like symptoms
■ Nausea
RISK AND PROGNOSTIC FACTORS ■ Vomiting
■ Muscle pain/stiffness
ENVIRONMENTAL ➢ Clinically significant distress or
➢ Among individuals who use caffeine less
frequently or in those who have recently
DURATION
increased their caffeine intake by a
substantial amount.
➢ Oral contraceptives significantly ➢ Symptoms usually begin 12-24 hours
decrease the elimination of caffeine and after the last caffeine dose and peak
consequently may increase the risk of after 1-2 days of abstinence.
intoxication. ➢ Lasts for 2-9 days, with the possibility of
withdrawal headaches occurring for up
GENETIC AND PHYSIOLOGICAL to 21 days.
ASSOCIATED FEATURES
CAFFEINE-INDUCED SLEEP DISORDER
➢ Impaired behavioral and cognitive

performance ➢ Sleep symptoms are in excess of those
➢ Increase total sleep time usually associated with caffeine
➢ Sleep efficiency withdrawal, predominate in the clinical
➢ Slow-wave sleep presentation, and are severe enough to
➢ Increase in theta power and decreases warrant clinical attention.
in beta-2 power
➢ Decreased motivation to work and RISK AND PROGNOSTIC FACTORS
decreased sociability
➢ Increased analgesic use
TEMPERAMENTAL

➢ Individuals with mental disorders,
including eating disorders and alcohol
➢ Symptoms usually remit rapidly (within
and other substance use disorders
30-60 minutes) after re-ingestion of
➢ Cigarette smokers
caffeine.
➢ Incarcerated individuals
➢ Overall level of caffeine consumption
increases with age.
ENVIRONMENTAL
➢ Use of highly caffeinated energy drinks
is increasing in young people, which
could increase the risk of caffeine ➢ Unavailability of caffeine
withdrawal. ➢ Restriction of caffeine
GENETIC AND PHYSIOLOGICAL

➢ Genetic factors appear to increase
➢ Unclear incidence and prevalence. vulnerability to caffeine withdrawal, but
➢ More than 70% of individuals reported at no specific genes have been identified.
least one caffeine withdrawal symptom.
➢ Metabolism in caffeine is slower in IMPORTANT NOTES
females who use oral contraceptives
and in the luteal phase of menstrual
➢ May be associated with
cycle.
○ Major depressive disorder
○ Moderate to severe AUD
DIFFERENTIAL DIAGNOSIS ○ Cannabis and cocaine use
OTHER MEDICAL CONDITIONS AND CAFFEINE-INDUCED MENTAL DISORDERS

MEDICATION SIDE EFFECT
UNSPECIFIED CAFFEINE-RELATED
➢ Determination of the pattern and amount DISORDER
consumed, the time interval between
caffeine abstinence and onset of
symptoms, and the particular clinical
features presented by the individual.
CANNABIS-RELATED DISORDER gradually increases in frequency and
amount.
➢ Early onset of cannabis use is a robust
CANNABIS USE DISORDER
predictor of the development of CUS
and other types of substance use
CRITERIA disorders and mental disorders during
young adulthood.
➢ Repeated use of cannabis in a way that

leads to harmful consequences. PREVALENCE & SEX AND GENDER
➢ At least 2 of the following:
○ Excessive use
○ Impaired control ➢ Cannabinoids, especially cannabis, are
○ Craving the most widely used illicit psychoactive
○ social/occupational problems substances in the U.S.
○ Risky use ➢ 2.5% among adults
○ Tolerance ➢ Women report more severe cannabis
○ Withdrawal withdrawal symptoms.
DURATION
NONPROBLEMATIC USE OF CANNABIS
➢ 12-month period
➢ Differentiating nonproblematic use of

ASSOCIATED FEATURES
cannabis and CUS can be challenging
because individuals may not attribute
➢ Using it to cope with mood, insomnia, cannabis-related social, behavioral, or
anger, pain, or other physiological or psychological problems to the
psychological problems. substance, especially in the context of
➢ Individuals have other concurrent polysubstance use.
mental disorders.
➢ Red eyes (conjunctival injection) CANNABIS INTOXICATION, CANNABIS
➢ Cannabis odor on clothes WITHDRAWAL, AND CANNABIS-INDUCED
➢ Yellowing of fingertips MENTAL DISORDERS
➢ Chronic cough
➢ Burning of incense
➢ Exaggerated craving ➢ Cannabis intoxication, cannabis
➢ Craving for specific food, sometimes at withdrawal, and cannabis-induced
odd times. mental disorders describe psychiatric
syndromes that develop in the context of
heavy use.
➢ Can occur at any age but is common

during adolescence or young adulthood.
➢ Most individuals who develop a CUS
establish a pattern of cannabis use that
RISK AND PROGNOSTIC FACTORS CANNABIS INTOXICATION
TEMPERAMENTAL
CRITERIA
➢ A history of conduct disorder in ➢ Recent use of cannabis

childhood or adolescence and antisocial ➢ Clinically significant problematic
PD are risk factors for the development behavioral or psychological changes
of many substance use disorders, that developed during, or shortly after,
including CUS. cannabis use.
➢ 2 or more of the following developing
ENVIRONMENTAL
within 2 hours of cannabis use
○ Conjunctival injection
➢ Unstable or abusive family situations ○ Increased appetite
➢ Use of cannabis among immediate ○ Dry mouth
family members ○ Tachycardia
➢ Childhood history of emotional or
physical abuse
➢ Violent death of a close family member DURATION
or friend
➢ Family history of substance use ➢ Developing within 2 hours of cannabis
disorders use.
➢ Low socioeconomic status
➢ Effects usually last 3-4 hours, with
duration longer when the substance is
GENETIC AND PHYSIOLOGICAL ingested orally.

➢ Heritable factors contribute between
30% and 80% of the total variance in
risk of CUS.
➢ Unknown prevalence of episodes of
cannabis intoxication.
IMPORTANT NOTES ➢ Probable that most individuals using
cannabis would at some time
➢ Detection of experience symptoms that meet criteria
11-nor-9-carboxy-delta-9-tetrahydrocann for cannabis intoxication.
abinol (THCCOOH) in urine is often
used as a biological marker of cannabis
use. DIFFERENTIAL DIAGNOSIS
➢ Co-occurring with major depressive
disorder, bipolar I and II disorders,
anxiety disorders, PTSD, and PDs. ➢ If the clinical presentation includes
hallucination in the absence of intact
reality testing, a diagnosis of
substance/medication-induced
-psychotic disorder should be
considered.
OTHER SUBSTANCE INTOXICATION
DURATION
➢ Other substance intoxication frequently ➢ Typically occurs within 24-48 hours after
decreases appetite, increases cessation of use.
aggressive behavior, and produces ➢ Peaks within 2-5 days and revolves
nystagmus or ataxia. within 1-2 weeks
CANNABIS-INDUCED MENTAL DISORDERS

ASSOCIATED FEATURES
➢ Distinguished in excess of those usually ➢ Observed fatigue

associated with CI, predominant in the ➢ Yawning
clinical presentation, and are severe ➢ Difficulty concentrating
enough to warrant independent clinical ➢ Rebound periods of increased appetite
attention. ➢ hypersomnia
CANNABIS WITHDRAWAL DEVELOPMENT AND COURSE
➢ More chronic and frequent cannabis use

CRITERIA
is associated with greater quantity and
severity of withdrawal symptoms.
➢ Cessation of cannabis use that has ➢ Can occur in adults and adolescents.
been heavy and prolonged
➢ 3 or more of the following develop within
approximately 1 week after criterion A RELATED DIAGNOSTIC ISSUES
○ Irritability, anger, or aggression
○ Nervousness or anxiety
○ Sleep difficulty ➢ Among adult regular cannabis uses in
○ Decreased appetite or weight the general population, 12% reported
loss signs and symptoms that met criteria
○ Restlessness for the full syndrome of DSM-5 CW.
○ Depressed mood ➢ Women may experience more severe
○ At least 1 of the following cannabis withdrawal symptoms than
physical symptoms cause men.
significant discomfort
■ Abdominal pain DIFFERENTIAL DIAGNOSIS
■ shakiness/tremors
■ Sweating ➢ Careful evaluation should focus on
■ Fever ensuring that the symptoms are not
■ Chills better explained by cessation of another
■ Headache substance, mental disorders, or medical
➢ Clinically significant distress or condition.
RISK AND PROGNOSTIC FACTORS
➢ Moderately heritable, indicating genetic

influences.
IMPORTANT NOTES PREVALENCE & SEX AND GENDER
➢ Comorbid depression, anxiety, and
antisocial PD. ➢ Unavailable data on PUD, rates appear
to be low.
CANNABIS-INDUCED MENTAL ➢ 0.3% of admitted individuals endorsed
DISORDERS phencyclidine as their primary drug.
○ 62% of facility admission
endorsing it as their primary
UNSPECIFIED CANNABIS-RELATED drug were men.
DISORDER
HALLUCINOGEN-RELATED DISORDER
OTHER SUBSTANCE USE DISORDERS

PHENCYCLIDINE USE DISORDER
➢ Phencyclidine can be an additive to

CRITERIA
other substances.
➢ Repeated use of PCP in a way that PHENCYCLIDINE INTOXICATION AND

leads to harmful consequences. PHENCYCLIDINE-INDUCED MENTAL
DISORDERS
○ Excessive use
○ Impaired control ➢ Phencyclidine intoxication and
○ Craving phencyclidine-induced mental disorders
○ social/occupational problems describe psychiatric syndromes that
○ Risky use occur in the context of heavy use.
○ Tolerance
○ Withdrawal INDEPENDENT MENTAL DISORDERS
DURATION ➢ Some of the effects of phencyclidine use

may resemble symptoms of
independent mental disorder, such as
➢ Within a 12-month period
psychosis, low mood, and violent,
aggressive behaviors.
ASSOCIATED FEATURES

➢ Likely to produce dissociative
symptoms, analgesia, nystagmus, risk of
➢ Ketamine users are more likely to be
hypertension/hypotension and shock,
mean and to have consumed more than
euphoria, visual/auditory hallucinations,
11 standard drinks per day.
derealization, and unusual thought
content.
➢ Violent behavior
➢ 0.1% of individuals age 12 or older
IMPORTANT NOTES
endorsed the symptoms of past
12-month hallucinogen use disorder in
➢ Phencyclidine is present in the urine in 2018.
intoxicated individuals up to 8 days after ➢ Boys have greater 12-month prevalence
ingestion. rates.
➢ Conduct disorder in adolescents and
antisocial PD may be associated with
phencyclidine use. DIFFERENTIAL DIAGNOSIS
OTHER SUBSTANCE DISORDERS

OTHER HALLUCINOGEN USE DISORDER
➢ Must be distinguished from those of

CRITERIA
other substances, especially because
contamination of the hallucinogens with
➢ Problem use of hallucinogens (except other drugs is relatively common.
PCP) causing impairment or distress.
● At least 2 or more of: HALLUCINOGEN INTOXICATION AND
○ Excessive use HALLUCINOGEN-INDUCED MENTAL
○ Impaired control DISORDERS
○ Craving
○ Social/occupational problems
○ Risky use ➢ Hallucinogen intoxication and
○ Tolerance hallucinogen-induced mental disorders
○ Withdrawal symptoms describe psychiatric syndromes that
occur in the context of heavy use.
DURATION INDEPENDENT MENTAL DISORDERS

➢ Discerning whether symptoms occurred
before the intake of the drug is important
ASSOCIATED FEATURES in the differentiation of acute drug
effects from a preexisting mental
➢ Individuals who use LSD tent to disorder.
experience visual hallucinations that can
be frightening.
DEVELOPMENT AND COURSE TEMPERAMENTAL
➢ The disorder is not often persistent and

is concentrated in young adults. ➢ Use of specific hallucinogens has been
linked with high sensation-seeking.
PREVALENCE & SEX AND GENDER ENVIRONMENTAL

➢ Rare ➢ Higher income

➢ Lower education
➢ Being never married
➢ Residing in urban areas
➢ Peer use
GENETIC AND PHYSIOLOGICAL OTHER SUBSTANCE INTOXICATION
➢ Among male twins, total variance due to ➢ Nystagmus and bizarre and violent
additive genetics has been estimated to behavior may distinguish intoxication
range from 26% to 79%, with due to phencyclidine from that due to
inconsistent evidence forshared other substances.
environmental influences.
PHENCYCLIDINE-INDUCED MENTAL
DISORDERS
IMPORTANT NOTES
➢ Associated with cocaine use disorder, ➢ Symptoms are in excess of those

stimulant use disorder, other substance usually associated with phencyclidine
use disorder, tobacco use disorder, any intoxication, predominate in the clinical
PD, PTSD, and panic attacks.
presentation, and are severe enough to
warrant clinical attention.
PHENCYCLIDINE INTOXICATION
OTHER MEDICAL CONDITIONS
CRITERIA
➢ Medical conditions to be considered
➢ Recent use of phencyclidine include certain metabolic disorders like
➢ Clinically significant problematic hypoglycemia and hyponatremia,
behavioral changes that developed central nervous system tumors, seizure
during, or shortly after, phencyclidine disorders, sepsis, neuroleptic malignant
use. syndrome, and vascular insults.
➢ Within 1 hour, 2 or more of the following
○ Vertical or horizontal nystagmus OTHER HALLUCINOGEN INTOXICATION
○ Hypertension or tachycardia
○ Numbness or diminished
responsiveness to pain CRITERIA
○ Ataxia
○ Dysarthria ➢ Recent use of hallucinogen
○ Muscle rigidity ➢ Clinically significant problematic
○ Seizure or coma behavioral or psychological changes
○ Hyperacusis that developed during, or shortly after,
hallucinogen use.
PREVALENCE & SEX AND GENDER ➢ Perceptual changes occurring in a state
RELATED DIAGNOSTIC ISSUES of full wakefulness and alertness that
developed during, or shortly after,
➢ Phencyclidine use is rare hallucinogen use.
➢ 1.2% among 12th graders and 0.5% ➢ 2 or more of the following
among young adults, ages 28-28 years. ○ Pupillary dilation
○ Tachycardia
○ Sweating
○ Palpitations
○ Blurring of vision in the clinical presentation, and are
○ Tremors severe enough to warrant independent
○ Incoordination clinical attention.
PREVALENCE & SEX AND GENDER IMPORTANT NOTES

➢ Other hallucinogen intoxication may
➢ Not fully known but may be lead to increased suicidal thoughts or
approximated based on the prevalence behavior, although suicide is rare among
of use of the substances. individuals who use hallucinogens.
➢ Higher for boys and men in every age
group. OTHER HALLUCINOGEN INTOXICATION
DIFFERENTIAL DIAGNOSIS CRITERIA
OTHER SUBSTANCE INTOXICATION ➢ Recent use of hallucinogen

behavioral or psychological changes
➢ Toxicological tests are useful in making
that developed during, or shortly after,
this distinction, and determining the
hallucinogen use.
route of administration may also be
➢ Perceptual changes occurring in a state
useful.
of full wakefulness and alertness that
developed during, or shortly after,
OTHER CONDITIONS
hallucinogen use.
➢ 2 or more of the following
➢ Other disorders and conditions to be ○ Pupillary dilation
considered include schizophrenia, ○ Tachycardia
depression, withdrawal from other ○ Sweating
drugs, certain metabolic disorders, ○ Palpitations
seizure disorders, tumors of CNS, and ○ Blurring of vision
vascular insults. ○ Tremors
○ Incoordination
HALLUCINOGEN PERSISTING PERCEPTION
DISORDER HALLUCINOGEN PERSISTING
PERCEPTION DISORDER
➢ Symptoms continue episodically or
continuously for weeks (or longer) after CRITERIA
the most recent intoxication.
➢ Following cessation of use of a
HALLUCINOGEN-INDUCED MENTAL hallucinogen, the re-experiencing of 1 or
DISORDERS more of the perceptual symptoms that
were experienced while intoxicated with
the hallucinogen.
➢ Symptoms are in excess of those ➢ Clinically significant distress or
usually associated with other impairment in social, occupational, or
hallucinogen intoxication, predominate other important areas of functioning.
ASSOCIATED FEATURES PHENCYCLIDINE-INDUCED MENTAL
DISORDERS
➢ Reality testing remains intact in
individuals with hallucinogen persisting HALLUCINOGEN-INDUCED MENTAL
perception disorder. DISORDERS

UNSPECIFIED PHENCYCLIDINE-RELATED
DISORDER
➢ Persistent, lasting for weeks, months, or
even years in certain individuals.
UNSPECIFIED HALLUCINOGEN-RELATED
DISORDER
PREVALENCE & SEX ANDGENDER
INHALANT-RELATED DISORDER
➢ Prevalence estimates approximately
4.2%. INHALANT USE DISORDER
DIFFERENTIAL DIAGNOSIS CRITERIA
➢ Conditions to be ruled out ➢ Repeated use of inhalants in a way that

○ Schizophrenia leads to harmful consequences.
○ Other drug effects ➢ At least 2 of the following:
○ Neurodegenerative disorders ○ Excessive use
○ Stroke ○ Impaired control
○ Brain tumors ○ Craving
○ Infections ○ social/occupational problems
○ Head trauma ○ Risky use
○ Tolerance
RISK AND PROGNOSTIC FACTORS ○ Withdrawal
➢ Genetic factors have been suggested as

a possible explanation underlying the DURATION
susceptibility to LSD effects in this
condition. ➢ Within a 12-month period
IMPORTANT NOTES ASSOCIATED FEATURES
➢ Comorbid with panic disorders, alcohol ➢ Recurring episodes of intoxication with

use disorder, major depressive disorder, negative results in standard drug
bipolar 1 disorder, and schizophrenia screens.
spectrum disorders. ➢ Possession, or lingering odors, of
inhalant substance.
➢ Peri-oral or peri-nasal “glue sniffer” rash
➢ Association with other individuals known
to use inhalants.
➢ Easy access to certain inhalant INHALANT INTOXICATION, WITHOUT
substances. MEETING CRITERIA FOR INHALANT USE
➢ Paraphernalia possession DISORDER
➢ Presence of disorder’s characteristic
medical conditions complications.
➢ Inhalant intoxication occurs frequently
➢ Presence of multiple substance use
during inhalant use disorder but also
disorders.
may occur among individuals whose use
➢ Pernicious anemia
does not meet criteria for inhalant use
➢ Subacute combined degeneration of the
disorder.
spinal cord
➢ Major or mild NCD
INHALANT INTOXICATION MEETING
➢ Brain atrophy CRITERIA FOR INHALANT USE DISORDER,
➢ Leukoencephalopathy AND INHALANT-INDUCED MENTAL
DISORDERS
➢ Inhalant intoxication and
➢ Disorder usually remits in early inhalant-induced mental disorders
adulthood. describe psychiatric syndromes that
➢ Rare in prepubertal children, most develop in the context of heavy use.
common in adolescents and young
adults, and uncommon in older persons. OTHER SUBSTANCE USE DISORDERS,
ESPECIALLY THOSE INVOLVING SEDATING
SUBSTANCES
➢ Inquire about which symptoms persisted
➢ About 2.3% of American youth ages during periods when some of the
12-17 years have used inhalants in the substances were not being used.
past 12-months, with 0.1% having a
pattern of use that meets criteria for RISK AND PROGNOSTIC FACTORS
inhalant use disorder.
➢ Disorder is very rare among adult
TEMPERAMENTAL
women.
DIFFERENTIAL DIAGNOSIS ➢ Predictors of inhalant use disorder

include sensation seeking and
impulsivity.
INHALANT EXPOSURE (UNINTENTIONAL)
FROM INDUSTRIAL OR OTHER ACCIDENTS
ENVIRONMENTAL
➢ A diagnosis of inhalant use disorder only

➢ Inhalant gases are widely and legally
applies if the inhalant exposure is available, increasing the risk of misuse.
intentional.
ASSOCIATED FEATURES
➢ Youths with strong behavioral ➢ Evidence of possession, or lingering

disinhibition show risk factors for odors, of inhalant substances
inhalant use disorder. ➢ Euphoria
➢ Relaxation
➢ Headache
IMPORTANT NOTES
➢ Rapid heartbeat
➢ Confusion
➢ Urine, breath, or saliva tests may be ➢ Talkativeness
valuable for assessing concurrent use of ➢ Blurred vision
non-inhalant substances by individuals ➢ Amnesia
with inhalant use disorder. ➢ Slurred speech
➢ Irritability
INHALANT INTOXICATION ➢ Nausea
➢ Fatigue
➢ Burning in eyes or throat
CRITERIA ➢ Grandiosity
➢ Chest pain
➢ Recent intended or unintended ➢ Auditory or visual hallucinations
short-term, high dose exposure to ➢ Dissociation
inhalant substances, including volatile
hydrocarbons such as toluene or PREVALENCE & SEX AND GENDER
gasoline RELATED DIAGNOSTIC ISSUES
➢ Probable that a majority of inhalant
users would at some time exhibit
exposure to inhalants.
and symptoms that would meet criteria
○ Dizziness
for inhalant intoxication.
○ Nystagmus
➢ Unknown gender differences
○ Incoordination
○ Slurred speech
○ Unsteady gait DIFFERENTIAL DIAGNOSIS
○ Lethargy
○ Depressed reflexes INTOXICATION FROM OTHER SUBSTANCES,
○ Psychomotor retardation ESPECIALLY FROM SEDATING
○ Tremor SUBSTANCES
○ Generalized muscle weakness
○ Blurred vision or diplopia
➢ Differentiating the source of the
○ Stupor or coma
intoxication may involve discerning
○ Euphoria
evidence of inhalant exposure as
described for inhalant use disorder.
DURATION
➢ Intoxication clears within a few minutes

to a few hours after the exposure ends.
INHALANT-INDUCED MENTAL DISORDERS
ASSOCIATED FEATURES
➢ Symptoms are in excess of those ➢ Fatal or nonfatal opioid overdose.

usually associated with inhalant ○ Unconsciousness
intoxication, predominate in the clinical ○ Respiratory depression
presentation, and are severe enough to ○ Pinpoint pupils
warrant independent clinical attention. ➢ History of drug-related crimes
➢ Marital difficulties
OTHER TOXIC, TRAUMATIC, NEOPLASTIC, ➢ Unemployment or irregular employment
OR INFECTIOUS DISORDERS THAT IMPAIR
BRAIN FUNCTION AND COGNITION
➢ Numerous neurological and other ➢ Can begin at any age

medical conditions may produce the ➢ First observed in the late teens or early
clinically significant behavioral or 20s.
psychological changes that also
characterize inhalant intoxication.
INHALANT-INDUCED MENTAL DISORDERS
➢ Prescription opioid use disorder among
UNSPECIFIED INHALANT-RELATED U.S. adults age 18 and older is 4.1% -
DISORDER 4.7%.
➢ 26,8 million cases of DSM-IV opioid
dependence.
OPIOID-RELATED DISORDER ➢ Women are more likely to have initiated
opioid use in response to sexual abuse
OPIOID USE DISORDER and violence, and mare more likely to
be introduced to the drug by a partner.
CRITERIA
➢ Repeated use of opioids in a way that

OPIOID INTOXICATION, OPIOID
leads to harmful consequences. WITHDRAWAL, AND OPIOID-INDUCED
➢ At least 2 of the following: MENTAL DISORDERS
○ Excessive use
○ Impaired control
○ Craving ➢ Opioid intoxication, opioid withdrawal,
○ social/occupational problems opioid-induced mental disorders
○ Risky use describe psychiatric syndromes that
○ Tolerance occur in the context of heavy use.
○ Withdrawal
DURATION
➢ Diagnosis can usually be made based
on the absence of pupillary constriction
or the lack of a response to naloxone ➢ Clinically significant problematic
challenge. behavioral or psychological changes
OTHER WITHDRAWAL DISORDERS opioid use.
➢ Pupillary constriction and 1 more of the
following
➢ Opioid withdrawal is accompanied by
○ Drowsiness or coma
rhinorrhea, lacrimation, and pupillary
○ Slurred speech
dilation, which are not seen in
○ Impairment in attention or
sedative-type withdrawal.
memory
INDEPENDENT MENTAL DISORDERS ASSOCIATED FEATURES
➢ Decreases in respiratory rate and blood

➢ Opioids are less likely to produce
pressure
symptoms of mental disturbances than
➢ Mild hypothermia
most other drugs of abuse.
➢ Fatal or nonfatal opioid overdose

➢ Other substance use disorders

➢ Can occur in an individual who is opioid
➢ Novelty-seeking
naive, an individual who uses opioids
➢ Impulsivity
sporadically, and an individual who is
➢ Disinhibition
physically dependent on opioids
➢ Family, peer, and social environmental
➢ Individuals often report that the
factors
qualitative pleasurable experience of
➢ Strong genetic contribution
opioid intoxication diminishes after
repeated use of an opioid..
IMPORTANT NOTES
➢ Routine urine toxicology test results are
often positive for opioid drugs in
individuals with opioid use disorder. OTHER SUBSTANCE INTOXICATION
○ Remains positive for 12-36
hours after administration.
➢ A diagnosis of alcohol or
➢ Heightened risk for suicide attempts and
sedative-hypnotic intoxication can
suicide.
usually be made based on the absence
➢ Comorbid with viral and bacterial
of pupillary constriction or the lack of a
infections.
response to a naloxone challenge.
OPIOID INTOXICATION OPIOID-INDUCED MENTAL DISORDERS
CRITERIA ➢ Symptoms are in excess of those

usually associated with opioid
➢ Recent use of an opioid intoxication, predominate in the clinical
presentations, and are severe enough to
➢ More chronic symptoms can last for

OPIOID WITHDRAWAL weeks to months.
➢ The course of withdrawal can be part of
an escalating pattern in which an opioid
CRITERIA
is used to reduce withdrawal symptoms,
in turn leading to recurrent episodes of
➢ Cessation of opioid use that has been withdrawal at a later time.
heavy and prolonged.
➢ Administration of an opioid antagonist
after a period of opioid use. PREVALENCE & SEX AND GENDER
○ Dysphoric mood
○ Nausea or vomiting ➢ From various U.S. clinical settings,
○ Muscle aches opioid withdrawal occurred in 60% of
○ Lacrimation or rhinorrhea individuals who had used heroin at least
○ Pupillary dilation, piloerection, or once in the prior 12 months.
sweating
○ Diarrhea DIFFERENTIAL DIAGNOSIS
○ Yawning
○ Fever
OTHER WITHDRAWAL DISORDERS
○ Insomnia
impairment in social, occupational, or ➢ Opioid withdrawal is also accompanied
other important areas of functioning. by rhinorrhea, lacrimation,, and pupillary
dilation, which are not seen in
DURATION sedative-type withdrawal.

➢ Symptoms may take 2-4 days to emerge
in the case of longer-acting drugs such
as methadone or buprenorphine. ➢ Other signs or symptoms of opioid
➢ Short-acting drugs: 6-12 hours withdrawal, such as nausea, vomiting,
diarrhea, abdominal cramps, rhinorrhea,
ASSOCIATED FEATURES and lacrimation, are not present.
OPIOID-INDUCED MENTAL DISORDERS

➢ May occur in individuals without opioid
use disorder and should not be
confused with it. ➢ Symptoms are in excess of those
➢ Males with opioid withdrawal may usually associated with opioid
experience piloerection, sweating, and withdrawal, predominate in the clinical
spontaneous ejaculations while awake. presentation, and are severe enough to
OPIOID-INDUCED MENTAL DISORDERS DEVELOPMENT AND COURSE
➢ Usual course involves individuals in their

OPIOID-INDUCED MENTAL DISORDERS
teens or 20s who escalate their
occasional use of sedative, hypnotic, or
SEDATIVE-, HYPNOTIC-, OR anxiolytic agents to the point at which
ANXIOLYTIC-RELATED DISORDER they develop problems that meet criteria
for a diagnosis.
SEDATIVE, HYPNOTIC, OR ANXIOLYTIC ➢ Tolerance can reach high levels, and
USE DISORDER withdrawal may occur.

CRITERIA
➢ Repeated use of sedative, hypnotic, or ➢ 0.3% among adolescents aged 12-17

anxiolytic in a way that leads to harmful years and adults aged 18 years and
consequences. older.
➢ At least 2 of the following: ➢ No gender differences
○ Excessive use
○ Craving DIFFERENTIAL DIAGNOSIS
○ social/occupational problems
○ Risky use SEDATIVE, HYPNOTIC, OR ANXIOLYTIC
○ Tolerance INTOXICATION; SEDATIVE, HYPNOTIC, OR
○ Withdrawal ANXIOLYTIC WITHDRAWAL; AND
SEDATIVE-, HYPNOTIC-, OR
ANXIOLYTIC-INDUCED MENTAL DISORDERS
DURATION
➢ These describe psychiatric syndromes
➢ Within a 12-month period that occur in the context of heavy use.
OTHER MEDICAL CONDITIONS

ASSOCIATED FEATURES
➢ Associated with other substance use ➢ The slurred speech, incoordination, and
disorders. other associated features characteristics
➢ Tolerance develops to the sedative of a sedative, hypnotic, or anxiolytic
effects, and a progressively higher dose intoxication could be the result of
is used. another medical condition of a prior
➢ As the individual takes more substance head trauma.
to achieve euphoria or other desired
ALCOHOL USE DISORDER
effects, there may be a sudden onset of
respiratory depression and hypotension,
which may result in death. ➢ Differential diagnosis is determined
mostly through clinical history.
CLINICALLY APPROPRIATE USE OF
USE INTOXICATION
MEDICATIONS
CRITERIA
➢ Even if physiological signs of tolerance
or withdrawal are manifested, many of
these individuals do not develop ➢ Recent use of sedative, hypnotic, or
symptoms that meet the criteria but they anxiolytic.
are not preoccupied with obtaining the ➢ Clinically significant maladaptive
substance and it use does not interfere behavioral or psychological changes
with their performance of usual social or that developed during, or shortly after
occupational roles. sedative, hypnotic, or anxiolytic use.
○ Slurred speech
○ Incoordination
○ Unsteady gait
TEMPERAMENTAL
○ Nystagmus
○ Impairment in cognition
➢ Impulsivity and novelty seeking ○ Stupor or coma
➢ Personality disorders
ASSOCIATED FEATURES
ENVIRONMENTAL
➢ Taking more medication than prescribed
➢ Availability of substances ➢ Taking multiple different medications
➢ Mixing sedative, hypnotic, or anxiolytic
GENETIC AND PHYSIOLOGICAL agents with alcohol

➢ Genetic factors play a particularly
important role both directly and
indirectly.
➢ Unknown prevalence
COURSE MODIFIERS
➢ Early onset of use is associated with
greater likelihood for developing a ALCOHOL USE DISORDER
sedative, hypnotic, or anxiolytic use
disorder.
➢ Require evidence for recent ingestion of
sedative, hypnotic, anxiolytic
IMPORTANT NOTES medications by self-report, informant
report, or toxicological testing.
➢ Can be identified through laboratory
evaluations of urine or blood. ALCOHOL INTOXICATION
➢ May be distinguished by the smell of

alcohol on the breath.
SEDATIVE-, HYPNOTIC-, OR
ANXIOLYTIC-INDUCED MENTAL DISORDERS ASSOCIATED FEATURES
➢ The longer the substance has been

➢ Symptoms are in excess of those taken and the higher the dosages used,
usually associated with sedative, the more likely there will be severe
hypnotic or anxiolytic intoxication; withdrawal.
predominate in the clinical presentation;
clinical attention.
NEUROCOGNITIVE DISORDERS
➢ Based on predominant syndrome.
WITHDRAWAL OTHER MEDICAL CONDITIONS
CRITERIA
➢ If seizures are a feature of the sedative,
hypnotic, or anxiolytic withdrawal, the
➢ Cessation of sedative, hypnotic, or differential diagnosis includes the
anxiolytic use that has been prolonged. various causes of seizures.
○ Autonomic hyperactivity ESSENTIAL TREMOR
○ Hand tremor
○ Insomnia
➢ Essential tremor, a neurological
○ Nausea or vomiting
condition that frequently runs in families,
○ Transient visual, tactile, or
may erroneously suggest the
auditory hallucinations or
tremulousness associated with sedative,
illusions
hypnotic, or anxiolytic withdrawal.
○ Anxiety
ALCOHOL WITHDRAWAL
○ Grand mal seizures
impairment in social, occupational, or ➢ Differential diagnosis is determined
other important areas of functioning. mostly through clinical history.
DURATION SEDATIVE-, HYPNOTIC-, OR

ANXIOLYTIC-INDUCED MENTAL DISORDERS
➢ Withdrawal from short-acting

substances, no active metabolites ➢ Symptoms are in excess of those
○ Within hours after the substance usually associated with sedative,
is stopped hypnotic, or anxiolytic withdrawal;
➢ From long-acting metabolites predominate in the clinical presentation;
○ May not begin for 1-2 days or and are severe enough to warrant
longer. clinical attention.
ANXIETY DISORDERS
ASSOCIATED FEATURES
➢ Withdrawal would be suspected with an ➢ Individuals with stimulant use disorder

abrupt reduction in the dosage of a often develop conditioned responses to
sedative, hypnotic, or anxiolytic drug-related stimuli.
medication. ➢ Depressive symptoms with suicidal
thoughts or behavior can occur and are
generally the most serious problems
IMPORTANT NOTES
seen during stimulant withdrawal.
➢ Seizures and autonomic instability in the

setting of a history of prolonged DEVELOPMENT AND COURSE
exposure to sedative, hypnotic, or
anxiolytic medications suggest a high ➢ More common among individuals ages
likelihood of sedative, hypnotic, or 18-25 years compared with individuals
anxiolytic withdrawal. ages 12-17 or 26 years and older.
➢ Some persons begin stimulant use to
SEDATIVE-, HYPNOTIC-, OR control weight or to improve
ANXIOLYTIC-INDUCED MENTAL performance in school, work, or
DISORDERS athletics.
➢ Patterns of stimulant administration
include episodic or daily use.
UNSPECIFIED SEDATIVE-, HYPNOTIC-, OR
ANXIOLYTIC-RELATED DISORDERS
STIMULANT-RELATED DISORDERS
STIMULANT USE DISORDER:
STIMULANT USE DISORDER AMPHETAMINE-TYPE SUBSTANCES
CRITERIA ➢ 0.4% among individuals 12 years and

older.
➢ 0.5% for men and 0.2% for women.
➢ Repeated use of stimulants in a way
that leads to harmful consequences. STIMULANT USE DISORDER: COCAINE
○ Excessive use
○ Impaired control ➢ 0.4% among individuals 12 years and
○ Craving older.
○ social/occupational problems ➢ 0.5% for men and 0.2% for women.
○ Risky use
○ Tolerance
○ Withdrawal
PHENCYCLIDINE INTOXICATION
DURATION
➢ May cause a similar clinical picture and
➢ Within a 12-month period can only be distinguished from stimulant
intoxication by the presence of cocaine
IMPORTANT NOTES
or amphetamine-type substance
metabolites in a urine or plasma sample.
➢ Benzoylecgonine, a metabolite of
cocaine, typically remains in the urine
STIMULANT INTOXICATION, STIMULANT
for 1-3 days after a single dose and may
WITHDRAWAL, AND STIMULANT-INDUCED
be present for 7-12 days in individuals
MENTAL DISORDERS
using repeated high doses.
➢ Comorbid with other substance use
disorders, especially those involving
➢ Stimulant intoxication, stimulant substances with sedative properties.
withdrawal, and stimulant-induced
mental disorders describe psychiatric
STIMULANT INTOXICATION
syndromes that occur in the context of
heavy use.
CRITERIA
INDEPENDENT MENTAL DISORDERS
➢ Recent use of an amphetamine-type

➢ Discerning whether these behaviors substance, cocaine, or other stimulant.
occurred before the intake of the drug is ➢ Clinically significant problematic
important in the differentiation of acute behavioral or psychological changes
drug effects from a preexisting mental that developed during, or shortly after,
disorder. use of a stimulant.
RISK AND PROGNOSTIC FACTORS ○ Tachycardia or bradycardia
○ Pupillary dilation
○ Elevated or lowered blood
TEMPERAMENTAL
pressure
○ Perspiration or chills
➢ Comorbid bipolar disorder, ○ Nausea or vomiting
schizophrenia, antisocial PD, and other ○ Evidence of weight loss
substance use disorders. ○ Psychomotor agitation or
➢ Higher stress reactivity retardation
➢ Male, cluster B PD ○ Muscular weakness, respiratory
➢ Family history of substance use disorder depression, chest pain, or
➢ Being separated, divorced, or widowed cardiac arrhythmias
○ Confusion, seizures,
ENVIRONMENTAL dyskinesias, dystonias, or coma.
ASSOCIATED FEATURES
➢ Prenatal cocaine exposure
➢ Postnatal cocaine use by parents
➢ Exposure to community violence during ➢ Stimulant effects such as euphoria,
childhood increased pulse and blood pressure,
➢ Exposure to intimate partner violence and psychomotor activity are most
➢ Childhood mistreatment
commonly seen.
➢ Food insecurity
➢ Depressant effects such as sadness,
bradycardia, decreased blood pressure,
and decreased psychomotor activity are
less common and generally emerge only ○ Psychomotor retardation or
with chronic high-dose use. agitation
RELATED DIAGNOSTIC ISSUES other important areas of functioning.
➢ Not known but prevalence of stimulation ASSOCIATED FEATURES

use can be used as a proxy.
➢ Cocaine use: 2.2% for individuals age ➢ Acute withdrawal symptoms (crash) are
12 and older. often seen after periods of repetitive
➢ Methamphetamine use: 0.6% for high-dose use (runs or binges).
individuals age 12 and older. ➢ Depressive symptoms with suicidal
thoughts or behavior can occur and are
generally the mosts serious roblems
seen during “crashing” or other forms of
stimulant withdrawal.
STIMULANT-INDUCED MENTAL DISORDERS
➢ Symptoms are in excess of those
usually seen in stimulant intoxication, STIMULANT-INDUCED MENTAL DISORDERS
predominate in the clinical presentation,
and meet full criteria for the relevant
disorder. ➢ Symptoms in excess of those usually
associated with stimulant withdrawal,
INDEPENDENT MENTAL DISORDERS predominate in the clinical presentation,
clinical attention.
➢ Salient mental disturbances associated
with stimulant intoxication should be
distinguished from the symptoms of STIMULANT-INDUCED MENTAL
DISORDERS
schizophrenia, bipolar and depressive
disorders, GAD, and panic disorder as
described in this manual. UNSPECIFIED STIMULANT-RELATED
DISORDER
STIMULANT WITHDRAWAL
TOBACCO-RELATED DISORDERS
CRITERIA
TOBACCO USE DISORDER
➢ Cessation of prolonged
amphetamine-type substance, cocaine, CRITERIA
or other stimulant use.
➢ Dysphoric mood and 2 or more of the
➢ Repeated use of tobacco in a way that
following:
leads to harmful consequences.
○ Fatigue
○ Vivid, unpleasant dreams
○ Excessive use
○ Insomnia or hypersomnia
○ Increased appetite
○ Craving ➢ Adults with depressive, bipolar, anxiety,
○ social/occupational problems personality, psychotic, or other
○ Risky use substance use disorders are at higher
○ Tolerance risk for starting and continuing tobacco
○ Withdrawal use and of tobacco use disorder.
ENVIRONMENTAL
DURATION
➢ Persons with low incomes and low
➢ Within a 12-month period educational levels are more likely to
initiate tobacco use and are less likely to
to stop.
ASSOCIATED FEATURES
➢ Smoking within 30 minutes of waking, GENETIC AND PHYSIOLOGICAL

smoking daily, smoking cigarettes per
day, and waking at night to smoke are ➢ Genetic factors contribute to the onset
associated with tobacco use disorder. of tobacco use, the continuation of
➢ Lung and other cancers, cardiac and tobacco use, and the development of
pulmonary disease, perinatal problems, tobacco use disorder, with a degree of
cough, shortness of breath, and heritability equivalent to that observed
accelerated skin aging. with other substance use disorders.
IMPORTANT NOTES
➢ Comorbid with cardiovascular illnesses,

➢ Among adolescents who smoke chronic obstructive pulmonary disease,
cigarettes at least monthly, most of and cancers.
these individuals will become daily
tobacco users in the future.
TOBACCO WITHDRAWAL
PREVALENCE & SEX GENDER RELATED
DIAGNOSTIC ISSUES
CRITERIA
➢ Cigarettes are the most commonly used
tobacco product. ➢ Daily use of tobacco for at least several
➢ 19% of adults in the U.S used a tobacco weeks.
product in the last year. ➢ Abrupt cessation of tobacco use, or
➢ Men to women ratio, 1.4:1 reduction in the amount of tobacco
➢ Fewer men are smoking as age used, followed within 24 hours or more
increases. of the following
○ Irritability, frustration, or anger
RISK AND PROGNOSTIC FACTORS ○ Anxiety
○ Difficulty concentrating
TEMPERAMENTAL ○ Increased appetite
○ Restlessness
○ Depressed mood
➢ Externalizing personality traits ○ insomnia
➢ Children with ADHD or conduct disorder
DURATION
➢ Usually begins within 24 hours of ➢ Genotype can influence the probability

stopping or cutting down use. of withdrawal upon abstinence.
➢ Peaks at 2-3 days after abstinence, and
usually lasts 2-3 weeks. TOBACCO-INDUCED MENTAL DISORDERS
ASSOCIATED FEATURES UNSPECIFIED TOBACCO-RELATED

DISORDER
➢ Craving for tobacco or nicotine is very
common during abstinence and has a OTHER (OR UNKNOWN)
large effect on the ability to remain
SUBSTANCE-RELATED DISORDERS
abstinent.
➢ Smoking increases the metabolism of
many medications used to treat mental OTHER (OR UNKNOWN) SUBSTANCE USE
disorders. DISORDER
DEVELOPMENT AND COURSE CRITERIA
➢ Tobacco withdrawal symptoms can ➢ Problematic use of unknown or unlisted

occur among adolescent tobacco users, substances causing impairment or
even prior to daily tobacco use. distress.
➢ At least two of:
PREVALENCE & SEX AND GENDER ○ Excessive use
RELATED DIAGNOSTIC ISSUES ○ Impaired control
○ Craving
➢ 50% of daily smokers who quit for 2 or ○ Social/work problems
more days will have four or more ○ Risky use despite harm
symptoms of tobacco withdrawal. ○ Tolerance
○ Withdrawal symptoms
DURATION
➢ Reduction in symptoms with the use of
nicotine confirms the diagnosis. ➢ Within a 12-month period
RISK AND PROGNOSTIC FACTORS ASSOCIATED FEATURES
TEMPERAMENTAL
➢ Reported use of a substance that is not
among the nine classes listed.
➢ Depressive disorders ➢ Membership in certain populations may
➢ Bipolar disorders be associated with frequent use of the
➢ Anxiety disorders nitrous oxide and possibly with a
➢ ADHD diagnosis of nitrous oxide use disorder.
➢ Other substance use disorders
➢ Use of amyl-. Butyl-, and isobutyl- nitrite
gases is prevalent among homosexual
men and some adolescents, especially
➢ Presence of any other substance use
those with conduct disorder.
disorders
➢ Conduct disorder
DEVELOPMENT AND COURSE ➢ Antisocial PD in the individual or family
➢ Early onset of substance problems
➢ Easy availability of the substance in the
➢ No single pattern of development of individual’s environment
course characterized the ➢ Childhood maltreatment and trauma
pharmacologically varied other ➢ Evidence of limited early self-control and
substance use disorders. behavioral disinhibition
OTHER (OR UNKNOWN) SUBSTANCE

INTOXICATION
➢ Likely lower than that of use disorders CRITERIA

involving the nine substance classes.
➢ Development of a reversible
DIFFERENTIAL DIAGNOSIS substance-specific syndrome,
attributable to recent ingestion of a
USE OF OTHER OR UNKNOWN substance that is not listed elsewhere,
SUBSTANCES WITHOUT MEETING CRITERIA or is unknown.
FOR OTHER (OR UNKNOWN) SUBSTANCE ➢ Clinically significant problematic,
USE DISORDER behavioral or psychological changes
that are attributable to the effect of the
substance on the central nervous
➢ Most use does not meet the diagnostic
system and develop, during or shortly,
standard of 2 or more criteria for other
after use of the substance.
(or unknown) substance use disorder in
a 12-month period.
DURATION
SUBSTANCE USE DISORDERS
➢ Intoxication usually appears and then
peaks minutes to hours after use of the
➢ Inquire about which symptoms persisted substance, but the onset and course
during periods when some of the vary with the substance and the route of
substances were not being used. administration.

INTOXICATION, OTHER (OR UNKNOWN) DEVELOPMENT AND COURSE
SUBSTANCE WITHDRAWAL, AND OTHER
(OR UNKNOWN) SUBSTANCE-INDUCED
MENTAL DISORDERS ➢ Generally substances used by
pulmonary insulation and intravenous
injection, have the most rapid onset of
➢ Describes psychiatric syndromes that action, whereas those ingested by
occur in the context of heavy use. mouth and requiring metabolism to an
active product are much slower.
➢ Intoxication effects usually resolve within
hours to a few days. However, the body WITHDRAWAL
may completely eliminate an anesthetic
gas such as nitrous oxide just minutes
after use ends. CRITERIA
PREVALENCE & SEX AND GENDER ➢ Cessation of use of a substance that

RELATED DIAGNOSTIC ISSUES has been heavy and prolonged.
➢ The development of a
➢ Unknown prevalence substance-specific syndrome, shortly
after the cessation of substance use.
impairment in social, occupational or
USE OF OTHER OR UNKNOWN SUBSTANCE, ➢ Cannot be classified under any of the
WITHOUT MEETING CRITERIA FOR OTHER other substance categories, or is
(OR UNKNOWN) SUBSTANCE
unknown.
➢ The individual used an other or DURATION

unknown substances, but the dose was
insufficient to produce symptoms that
meet the diagnostic criteria required for ➢ Commonly appears some hours after
the diagnosis. use of the substance is terminated, but
the onset and course vary greatly,
SUBSTANCE INTOXICATION OR OTHER depending on the dose typically used
SUBSTANCE/MEDICATION-INDUCED and the rate of elimination of the specific
MENTAL DISORDERS substance from the body.
➢ Symptoms are in excess of those DEVELOPMENT AND COURSE

usually associated with the specific
substance intoxication, predominate in ➢ Withdrawal symptoms slowly abate over
the clinical presentation, and are severe this weeks or months, depending on the
enough to warrant clinical attention. particular drug and doses to which the
individual became tolerant.
OTHER TOXIC, METABOLIC, TRAUMATIC,
NEOPLASTIC, BASCULAR, OR INFECTIOUS
DISORDERS THAT IMPAIR BRAIN FUNCTION PREVALENCE & SEX AND GENDER
AND COGNITION RELATED DIAGNOSTIC ISSUES
➢ Paradoxically, drug withdrawals must be
ruled out; for example: lethargy may
indicate withdrawal from one drug or DIFFERENTIAL DIAGNOSIS
intoxication with another substance.
DOSE REDUCTION AFTER EXTENDED
DOSING, BUT NOT MEETING THE CRITERIA
FOR OTHER (OR UNKNOWN) SUBSTANCE
WITHDRAWAL
➢ The individual used other (or unknown) ○ Restless/irritable when trying to
substances, but the dose that was used cut back.
was insufficient to produce symptoms ○ Preoccupation with gambling.
that meet the criteria required for the ○ Gambles when distressed.
withdrawal diagnosis. ○ Chases losses.
○ Lies to conceal gambling.
SUBSTANCE USE WITHDRAWAL OR OTHER ○ Jeopardizes relationships or
SUBSTANCE/MEDICATION-INDUCED opportunities.
MENTAL DISORDERS
○ Relies on others for financial
support.
➢ In excess of symptoms (if known)
usually associated with the specific
substance withdrawal, predominate in DURATION
the clinical presentation, and are severe
enough to wear clinical attention.
OTHER TOXIC, METABOLIC, TRAUMATIC,
ENOPLASTIC, VASCULAR, OR INFECTIOUS ASSOCIATED FEATURES
DISORDER THAT IMPAIR BRAIN FUNCTION
AND COGNITION
➢ Distortions in thinking
➢ Believe money is both the cause of and
➢ Paradoxically, drug withdrawals must be the solution to their problems.
ruled out; for example: lethargy may ➢ Impulsive, competitive, energetic,
indicate withdrawal from one drug or restless, and easily bored.
intoxication with another substance. ➢ Overly concerned with the approval of
others.
OTHER (OR UNKNOWN) ➢ Gamble when feeling helpless, guilty, or
SUBSTANCE-INDUCED MENTAL depressed.
DISORDERS
UNSPECIFIED OTHER (OR UNKNOWN)
SUBSTANCE-RELATED DISORDER ➢ The onset of gambling disorder can
occur during adolescence or young
adulthood, but in other individuals it
NON-SUBSTANCE-RELATED manifests during middle or even older
DISORDERS adulthood.
➢ Progression appears to be more rapid in
women than in men.
GAMBLING DISORDER ➢ Gambling patterns may be regular, or
episodic and gambling disorder can be
CRITERIA persistent or in remission.

➢ Recurrent problematic gambling causing
harm.
➢ At least 4 of the following
○ Needs increasing amounts to ➢ 0.2%-0.3% in the general U.S.
feel the excitement. population.
➢ Men develop gambling disorder at ➢ Depressive and bipolar disorders
higher rates. ➢ Other substance use disorders,
particularly alcohol use disorder.
NONDISORDERED GAMBLING
➢ Frequent in monozygotic than in
dizygotic twins.
➢ In professional gambling, risks are ➢ First-degree relatives of individuals with
limited and discipline is central. Social moderate to severe alcohol use disorder
than among the general population.
gambling typically occurs with friends or
colleagues and lasts for a limited period COURSE MODIFIERS
of time with acceptable losses.
MANIC EPISODE ➢ ADHD

➢ Anxiety disorders
➢ An additional diagnosis of gambling

disorder should be given only if the
gambling behavior is not better
explained by manic episodes.
PERSONALITY DISORDERS
➢ Problems with gambling may occur in

individuals with antisocial personality
disorder and other personal disorders. If
the criteria are met for both disorders,
both can be diagnosed.
GAMBLING SYMPTOMS DUE TO

DOPAMINERGIC MEDICATIONS
➢ Some individuals taking dopaminergic

medications may experience urges to
gamble that might be distressing or
impairing enough to meet criteria for
gambling disorder. In such cases, a
diagnosis of gambling disorder would be
warranted.
TEMPERAMENTAL
➢ Antisocial PD
SUBSTANCE KINDS KEYWORDS
ALCOHOL ➢ Beer ➢ Intoxication

➢ Wine ➢ Impaired coordination
➢ Liquor ➢ Memory
➢ Spirits problem
s
➢ Dependence
➢ Risky behavior
CAFFEINE ➢ Coffee ➢ Alertness

➢ Tea ➢ Energy
➢ Energy drinks ➢ Focus
➢ Soda ➢ Restlessness
➢ Anxiety
➢ Insomnia
CANNABIS ➢ Marrijuana ➢ Euphoria

➢ Hashish ➢ Relaxation
➢ THC ➢ Altered perception
➢ CBD ➢ Impaired memory
➢ Anxiety
➢ Paranoia
PCP ➢ Phencyclidine ➢ Dissociation

“angel dust” ➢ Hallucinations
➢ Bizarre behavior
➢ Aggression
➢ Self-harm
HALLUCINOGENS ➢ LSD ➢ Visual/auditory hallucinations

➢ Psilocybin ➢ Altered perception
➢ DMT ➢ Euphoria
➢ Mescaline ➢ Anxiety
➢ Paranoia
INHALANTS ➢ Glue ➢ Intoxication

➢ Paint thinner ➢ Dizziness
➢ Gasoline ➢ Euphoria
➢ Nitrous oxide ➢ Impaired coordination
➢ Risky behavior
OPIOIDS ➢ Heroin ➢ Pain relief

➢ Morphine ➢ Drowsiness
➢ Oxycodone ➢ Euphoria
➢ Fentanyl ➢ Dependence
➢ Respiratory depression
SEDATIVES, HYPNOTICS, ➢ Benzodiazepine ➢ Drowsiness

OR ANXIOLYTICS s ➢ Relaxation
➢ Barbiturates ➢ Anxiety reduction
➢ Zolpidem ➢ Dependence
➢ Eszopiclone
STIMULANTS ➢ Cocaine ➢ Alertness
➢ Amphetamines ➢ Energy
➢ Methamphetami ➢ Mood boost
ne ➢ Decreased appetite
➢ Ritali ➢ Anxiety
➢ Psychosis
TOBACCO ➢ Cigarettes ➢ Addiction

➢ E-cigarettes ➢ Nicotine dependence
➢ Lung cancer
➢ Heart disease
➢ Respiratory problems
OTHER (OR UNKNOWN) ➢ Kratom ➢ Mimic known drugs

➢ Kava kava ➢ Potential overdose
➢ Synthetic
cannabinoids

Substance Use Disorder

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Substance Use Disorder

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ABNORMAL PSYCHOLOGY II PSY 4121 Lecture

FINAL COMPONENT - FIRST SEMESTER, AY 2023-2024

SUBSTANCE-RELATED DISORDERS persistent or recurrent physical

➢ More sedating drugs can produce

DEVELOPMENT AND COURSE DEVELOPMENT AND COURSE

➢ 18-24 year old individuals have ➢ Most of these disorders, regardless of

➢ Within a 12-month period. DIFFERENTIAL DIAGNOSIS

ASSOCIATED FEATURES NONPATHOLOGICAL USE OF ALCOHOL

➢ Alcohol may be used to alleviate the

➢ AUD describes a problematic pattern of ➢ Runs in families, 40%-60% of the

SEDATIVE, HYPNOTIC, OR ANXIOLYTIC USE ➢ High levels of impulsivity are associated

➢ Share similar symptoms. The two must

RISK AND PROGNOSTIC FACTORS CRITERIA

➢ Depends on how much alcohol was OTHER MEDICAL CONDITIONS

➢ Usually occurs as an episode RISK AND PROGNOSTIC FACTORS

➢ Intoxication is usually established by

PREVALENCE & SEX AND GENDER

➢ Within several hours to a few days after ALCOHOL-INDUCED MENTAL DISORDERS

DEVELOPMENT AND COURSE

➢ Acute alcohol withdrawal occurs as an

ENVIRONMENTAL CAFFEINE INTOXICATION

➢ Quantity and frequency of alcohol CRITERIA

PREVALENCE & SEX AND GENDER ➢ Associated with

➢ Prolonged daily use of caffeine.

➢ Impaired behavioral and cognitive

DEVELOPMENT AND COURSE

GENETIC AND PHYSIOLOGICAL

OTHER MEDICAL CONDITIONS AND CAFFEINE-INDUCED MENTAL DISORDERS

➢ Repeated use of cannabis in a way that

➢ Differentiating nonproblematic use of

➢ Can occur at any age but is common

➢ A history of conduct disorder in ➢ Recent use of cannabis

PREVALENCE & SEX AND GENDER

CANNABIS-INDUCED MENTAL DISORDERS

➢ Distinguished in excess of those usually ➢ Observed fatigue

CANNABIS WITHDRAWAL DEVELOPMENT AND COURSE

➢ More chronic and frequent cannabis use

➢ Moderately heritable, indicating genetic

OTHER SUBSTANCE USE DISORDERS

➢ Phencyclidine can be an additive to

➢ Repeated use of PCP in a way that PHENCYCLIDINE INTOXICATION AND

DURATION ➢ Some of the effects of phencyclidine use

RISK AND PROGNOSTIC FACTORS

OTHER SUBSTANCE DISORDERS

➢ Must be distinguished from those of

DURATION INDEPENDENT MENTAL DISORDERS

➢ Within a 12-month period

DEVELOPMENT AND COURSE TEMPERAMENTAL

➢ The disorder is not often persistent and

PREVALENCE & SEX AND GENDER ENVIRONMENTAL

➢ Rare ➢ Higher income

GENETIC AND PHYSIOLOGICAL OTHER SUBSTANCE INTOXICATION

➢ Associated with cocaine use disorder, ➢ Symptoms are in excess of those

PREVALENCE & SEX AND GENDER IMPORTANT NOTES

DIFFERENTIAL DIAGNOSIS CRITERIA

OTHER SUBSTANCE INTOXICATION ➢ Recent use of hallucinogen

DEVELOPMENT AND COURSE

DIFFERENTIAL DIAGNOSIS CRITERIA

➢ Conditions to be ruled out ➢ Repeated use of inhalants in a way that

➢ Genetic factors have been suggested as

IMPORTANT NOTES ASSOCIATED FEATURES

➢ Comorbid with panic disorders, alcohol ➢ Recurring episodes of intoxication with