DSM-5 Update:

Substance-Related and
Addictive Disorders
{
 DSM- 5 Update

0 A guide in the diagnosis of mental disorders

0 Recently updated after 13 years since the DSM-IV-TR

was released in 2000.

0 22 separate classifications involving 13 work groups

 Changes in Substance-Related
Disorders Section from DSM-IV
0 Removal of Substance Abuse and Substance
Dependence.

0 Severity of disorder (mild to severe) based on the number

of symptom criteria met:
0 Mild: 2-3 symptoms
0 Moderate: 4-5 symptoms
0 Severe: 6 or more symptoms
 Changes in Substance-Related
Disorders Section from DSM-IV
0 The word “addiction” is omitted due to its “uncertain
definition and its potentially negative connotation.”

0 “Craving or strong desire” replaces “preoccupation”

0 Items deleted: “recurrent legal problems”, polysubstance

category, physiological subtype
Substance-Related and Addictive
Disorders
Encompasses 10 separate classes of drugs:
1. Alcohol
2. Caffeine
3. Cannabis
4. Hallucinogens
5. Inhalants
6. Opioids
7. Sedatives, hypnotics,& anxiolytics
8. Stimulants
9. Tobacco
10. Other (or unknown) substances
 Addictive Disorders
0 Includes Gambling Disorder

0 Other potential behavioral addictions (internet addiction,

sex addiction, exercise addiction, shopping addiction,
etc.) not included due to “insufficient peer-reviewed
evidence to establish the diagnostic criteria and course
descriptions…”
Substance-Related Disorders
0 Divided into two groups

0 Substance-Induced Disorders: includes conditions of

intoxication or withdrawal and other induced mental
disorders

0 Substance-Use Disorders: relates to pathological

patterns of behaviors related to the use of a particular
substance
Substance-Induced Disorders
0 Essential Feature – “the development of a reversible
substance-specific syndrome due to the recent ingestion
of a substance.”

0 Includes intoxication, withdrawal, and other

substance/medication-induced mental disorders
 Substance Intoxication
0 Substance intoxication can occur in individuals without a
Substance Use Disorder

0 Substance intoxication must include problematic

behavior

0 Substance intoxication does not apply to tobacco. (may

explain society’s liberal view of use – nonproblematic)
 Substance Withdrawal
0 Essential Feature – “the development of substance-
specific problematic behavioral change, with
physiological and cognitive concomitants, that is due to
the cessation of, or reduction in, heavy and prolonged
substance use.”
Substance/Medication-Induced
Mental Disorders
0 The substance/medication-induced mental disorders are
potentially severe, usually temporary, but sometimes
persisting CNS syndromes that develop in the context of
the effects of substances of abuse, medications, or several
toxins
0 Likely to improve in a matter of days to weeks of
abstinence
Substance/Medication-Induced
Mental Disorders
0 The disorder developed within 1 month of substance
intoxication or withdrawal or taking a medication
0 The disorder did not proceed the onset of severe
intoxication, withdrawal or exposure to a medication
0 The disorder not likely to be better explained by an
independent mental condition
0 Likely to disappear within 1 month of cessation of
withdrawal, intoxication or use of meds
Substance/Medication-Induced
Mental Disorders
Exception to the 1 month rule includes:
0 Alcohol-induced, inhalant-induced, and
sedative/hypnotic/anxiolytic-induced neurocognitive
disorders
0 Hallucinogen Persisting Perception Disorder (e.g.,
“flashbacks”)
 Substance Use Disorders
0 The Essential Feature – continued use despite significant
substance-related problems
0 Changes in brain circuits may persist, exhibited in
repeated relapses & intense drug cravings
0 Criteria include impaired control, social impairment,
risky use, and pharmacological symptoms
(withdrawal/tolerance)
 Substance Use Disorders
0 11 diagnostic criteria (some classes of substances have
10 criteria)

0 2 or more within a 12-month period

0 Must include a pattern of use leading to clinically

significant impairment or distress
 Substance Use Disorders: Diagnostic
Criteria

1. Substance often taken in larger amounts or over a

longer period of time than intended (impaired control)
2. A persistent desire or unsuccessful efforts to cut down
or control use (impaired control)
3. A great deal of time spent in activities necessary to
obtain the substance, use it, or recover from its effects
(impaired control)
4. Craving, or strong desire or urge to use (impaired
control) (New criteria)
 Substance Use Disorders:
Diagnostic Criteria
5. Recurrent use resulting in failure to fulfill major role
obligations at work, school, or home (social impairment)
6. Continued use despite having persistent or recurrent
social/interpersonal problems caused or exacerbated by use
(social impairment)
7. Important social, occupational, or recreational activities
given up or reduced because of use (social impairment)
 Substance Use Disorders:
Diagnostic Criteria
8. Recurrent use in situations which is physically
hazardous (risky use)

9. Use is continued despite knowledge of having a

persistent or recurrent physical/psychological problem
likely to have been caused or exacerbated by use (risky
use)
 Substance Use Disorders:
Diagnostic Criteria
10. Tolerance: the need for markedly increased amounts of
substance to achieve intoxication or desired effect, or a
markedly diminished effect with continued use of same
amount (pharmacological)
11. Withdrawal: a characteristic syndrome, or use to relieve
or avoid withdrawal (pharmacological)
 Recording Procedures for
Substance Related Disorders
0 New recording procedures to occur by 10/14
0 Use the code for the class of substances, but record the
specific substance
0 Severity determined by # of symptom criteria
0 Mild (2-3); Moderate (4-5); Severe (6 or more)
0 Severity can change over the course of time by
reductions or increases
0 Record for each individual substance disorder
 Recording Procedures for
Substance Related Disorders
Course Specifiers
0 “in early remission” (3-11 months)
0 “in sustained remission” (12 mos. or longer)
0 None of the criteria met for that duration with exception
of craving
0 “on maintenance therapy” (for opioids, tobacco)
0 “in a controlled environment” (access to substance is
restricted)
 Alcohol-Related Disorders
0 Prevalence – 12% of males and 4.6% of females 18 and
older. Significantly drops after age 65.
0 Lifetime risk of major depressive disorders – 40%
0 Can lead to persisting neurocognitive disorders
0 Alcohol Intoxication includes 1 or more symptoms of:
slurred speech, incoordination, unsteady gait, nystagmus
(involuntary eye movement), attention/memory
impairment, stupor/coma
 Alcohol Use Disorders
0 Alcohol Withdrawal includes 2 or more of following
after cessation of or reduction in alcohol use:
0 Autonomic hyperactivity (sweating or pulse > 100)
0 Increased hand tremor
0 Insomnia
0 Nausea or vomiting
0 Transient visual, tactile, auditory hallucinations
0 Psychomotor agitation
0 Anxiety
0 Seizures
 Caffeine-Related Disorders
0 More than 85% of children and adults consume caffeine
regularly
0 Most widely used drug in the world
0 Symptoms include tolerance and withdrawal
0 No Caffeine Use Disorder (data unavailable yet); only
Caffeine Intoxication and Withdrawal
0 Significant growth in energy drinks with young
individuals
0 Taking oral contraceptives decreases elimination of
caffeine (Increased risk of intoxication)
 Caffeine Intoxication
0 Intoxication must be in excess of 250 mg. & cause distress or impairment
0 5 or more of following:
0 Restlessness
0 Nervousness
0 Excitement
0 Insomnia
0 Flushed face
0 Diuresis
0 Gastrointestinal disturbance
0 Muscle twitching
0 Rambling flow of thought and speech
0 Tachycardia or cardiac arrhythmia
0 Periods of inexhaustibility
0 Psychomotor agitation
 Caffeine Withdrawal
0 Following cessation of or reduction in use within 24
hours by 3 or more of following:
0 Headache (the hallmark feature)
0 Marked fatigue or drowsiness
0 Dysphoric mood, depressed mood, or irritability
0 Difficulty concentrating
0 Flu-like symptoms (nausea, vomiting, muscle pain)
 Cannabis Related Disorders
0 Most widely used illicit substance in the U.S.
0 Prevalence of disorder - 3% of adolescents and 1.5% of
adults
0 Prevalence drops after age 65
0 More common for males than females
0 Cannabis use disorders have increased over past decade
0 Difficult to distinguish between problem use and non-
problematic use
0 Few clear medical conditions associated with use
0 60% of adolescents also have Conduct D/O or AD/HD
 Cannabis Use Disorder
0 At least 2 of the 11 symptom criteria

0 Includes tolerance and withdrawal

 Cannabis Intoxication
0 Can lead to substance-induced psychotic or anxiety D/O’s,
sleep disorders, or delirium
0 Problematic behavioral or psychological changes (e.g.,
impaired judgment, motor coordination, social withdrawal,
euphoria, anxiety, sensation of slowed time) and,
0 2 or more of the following:
0 Conjunctival injection (red eyes)
0 Increased appetite
0 Dry mouth
0 Tachycardia
 Cannabis Withdrawal
0 After heavy or prolonged use
0 3 or more of the following developing within a week:
0 Irritability, anger, or aggression
0 Nervousness or anxiety
0 Sleep difficulty (insomnia or disturbing dreams)
0 Decreased appetite or weight loss
0 Restlessness
0 Depressed mood
0 Physical symptoms (sweating, fever, chills, headache,
shakiness/tremors, or stomach pain)
Hallucinogen-Related Disorders
0 Separate criteria for Phencyclidine Disorders (e.g., PCP,
“angel dust”, ketamine, cyclohexamine, dizocilpine) and,

0 Other Hallucinogen Disorders (e.g., LSD, MDMA,

DMT, psilocybin, mescaline, peyote, morning glory
seeds, jimsonweed)
 Phencyclidine Use Disorder
0 10 symptom criteria (excludes withdrawal symptoms)
0 Previously in the category of Dissociative Anesthetics
0 Prevalence primarily in the African-American (49%) and
Hispanic (29%) cultures. Only .5% of young
Caucasians.
 Other Hallucinogen Use
Disorder
0 10 symptom criteria (excludes withdrawal symptoms)
0 Hallucinogen Use Disorder is one of the rarest. (.5%
among adolescents and .2% in adults)
0 Those who have this disorder have higher rates of other
SUD’s as well
0 Can lead to psychotic-induced, bipolar-induced,
depressive-induced, anxiety-induced disorders and
delirium
 Phencyclidine Intoxication
0 Problematic behavior (e.g., belligerent, assaultive, impulsive,
unpredictable, agitated, impaired judgment) and, 2 or more of
the following:
1. Vertical or horizontal nystagmus (involuntary eye movement)
2. Hypertension or tachycardia
3. Numbness or diminished response to pain
4. Ataxia (lack of muscle coordination)
5. Dysarthria (difficulty articulating)
6. Muscle rigidity
7. Seizures or coma
8. Hyperacusis (sensitivity to loud noises)
Other Hallucinogen Intoxication
0 Problem behavior or psychological changes (e.g.,
anxiety, depression, ideas of reference, “losing one’s
mind”, paranoia, impaired judgment)
0 Perceptual changes (e.g., intensified perceptions,
illusions, hallucinations, derealization) and, 2 or more of
the following:
0 Pupillary dilation, tachycardia, sweating, palpitations,
blurred vision, tremors, incoordination
 Hallucinogen Persisting
Perception Disorder
0 Following cessation of hallucinogen use, the
reexperiencing of one or more of the perceptual
symptoms that were experienced when intoxicated (e.g.,
trails, color flashes, geometric hallucinations, false
perceptions of movement, intensified colors)
0 Cause significant distress or impairment in important
areas of functioning
 Inhalant Related Disorders
0 Involves any hydrocarbon-based substances (e.g., toxic gases
from glues, fuels, paints, and other volatile substances)
0 No diagnosis of inhalant withdrawal
0 Standard drug screens do not detect inhalants. Detection is
costly
0 Prevalence is about 0.2%. Rare among females and a
preponderance of European American males
0 Prevalence declines after adolescence
0 Common with adolescent Conduct Disorder. Adult use
strongly associated with suicidality
 Inhalant Use Disorder
0 10 of the 11 standard symptom criteria. No withdrawal
criteria.

0 When possible, name the particular substance involved

 Inhalant Intoxication
0 Problematic behavioral or psychological changes (e.g.,
belligerence, assaultive, apathy, impaired judgment)
0 2 or more of following: dizziness, nystagmus,
incoordination, slurred speech, unsteady gait, lethargy,
depressed reflexes, psychomotor retardation, tremor,
muscle weakness, blurred vision, stupor/coma, and
euphoria.
 Opioid-Related Disorders
0 Prevalence is about 0.37% of adults
0 Lowest among African Americans, highest among Native
Americans
0 Hepatitis A, B, and C virus found in 80%-90% of
injection opioid users
0 HIV infection up to 60% of heroin users
0 A heightened risk for accidental and deliberate overdoses
 Opioid Use Disorder
0 Includes all 11 standard, symptom criteria

0 Include the specifier “On maintenance therapy” when

individual is taking a “prescribed” agonist medication
(e.g., methadone, buprenorphine) or antagonist (e.g.,
naltrexone, Vivitrol)
 Opioid Intoxication
0 Problem behavior or psychological changes (e.g.,
euphoria followed by apathy, dysphoria, psychomotor
agitation or retardation, impaired judgment)
0 Pupillary constriction (or dilation due to severe overdose)
and,
0 One or more of the following: drowsiness/coma, slurred
speech, impairment in attention or memory
 Opioid Withdrawal
0 3 or more of the following within minutes to several days
after cessation of use or administration of an antagonist:

0 Dysphoric mood, nausea/vomiting, muscle aches,

lacrimation/rhinorrhea, pupillary dilation,
piloerection/sweating, diarrhea, yawning, fever, and
insomnia.
 Opioid Withdrawal
0 Short-acting drugs (e.g., heroin) begin to have
withdrawal symptoms within 6-12 hours after last dose
0 Longer-acting drugs (e.g., methadone, buprenorphine)
may take 2-4 days for symptoms to emerge
0 Less acute withdrawal symptoms ( e.g., anxiety,
insomnia, dysphoria, anhedonia) can last for weeks to
months
 Sedative-, Hypnotic-, or
Anxiolytic-Related Disorders
0 Includes benzodiazepines, benzodiazepine-like drugs
(e.g., ambien, sonata), carbamates, barbiturates (e.g.,
secobarbital), and barbiturate-like hypnotics (e.g.,
quaalude)
0 Also includes all prescription sleeping medications and
almost all prescription anti-anxiety medications
 Sedative-, Hypnotic-, or
Anxiolytic-Related Disorders
0 0.3% prevalence rate among adolescents and 0.2%
among adults
0 Females appear to be at a higher risk for prescription
drug misuse of this class of substances
0 Can be detected in tox screens for up to a week
0 At high doses, can be lethal especially when mixed with
alcohol
 Sedative, Hypnotic, or
Anxiolytic Intoxication
0 Problem behavior or psychological changes (e.g.,
inappropriate sexual or aggressive behavior, mood
lability, and impaired judgment) and,
0 One or more of the following: slurred speech,
incoordination, unsteady gait, nystagmus, impairment in
cognition (attention, memory), stupor/coma
 Sedative, Hypnotic, or
Anxiolytic Withdrawal
0 Two or more of the following developing within several
hours to a few days after cessation:
1. Autonomic hyperactivity (sweating, pulse rate > 100 bpm)
2. Hand tremor
3. Insomnia
4. Nausea or vomiting
5. Transient hallucinations or illusions
6. Psychomotor agitation
7. Anxiety
8. Grand mal seizures
 Sedative, Hypnotic, or
Anxiolytic Withdrawal
0 Grand mal seizures may occur in as many as 20-30% of
cases undergoing untreated withdrawal
0 In severe withdrawal, visual, tactile, or auditory
hallucinations or illusions can occur
0 Withdrawal from shorter-acting substances can begin
within hours, longer-acting within 1-2 days
 Stimulant Use Disorder
0 Prevalence rate for cocaine use disorder for adults is
0.3%
0 Greatest for 18-29 year-olds (0.6%)
0 Cocaine use disorder is virtually absent among Native
Americans and Alaska natives
0 Childhood conduct disorder and adult ASPD are
associated with later development of stimulant-related
disorders
 Stimulant Use Disorder
0 Stimulant-use disorder is associated with PTSD, ASPD,
ADHD, and gambling disorder
0 66% of those with methamphetamine use disorders are
non-Hispanic white, 21% Hispanic, 3% African-
American
0 Hair samples can detect the presence of stimulants for up
to 90 days
 Stimulant Use Disorder
0 Use leading to significant impairment or distress over a
12-month period

0 Two or more of the 11 symptom criteria

 Stimulant Intoxication
0 Problem behavioral or psychological changes (e.g.,
euphoria or affective blunting; changes in sociability;
hypervigilance; interpersonal sensitivity; anxiety, tension,
or anger; stereotyped behaviors; impaired judgment) &
0 Two or more of the following: tachycardia/bradycardia,
pupillary dilation, elevated or lowered BP,
perspiration/chills, nausea/vomiting, weight loss,
psychomotor change, muscular weakness, respiratory
depression, chest pain, cardiac arrhythmias, confusion,
seizures, involuntary muscle movements, coma
 Stimulant Withdrawal
0 Dysphoric mood and 2 or more of the following
developing within a few hours to several days after
cessation:
0 Fatigue
0 Vivid, unpleasant dreams
0 Insomnia or hypersomnia
0 Increased appetite
0 Psychomotor retardation or agitation
 Tobacco-Related Disorders
0 Includes daily cigarette use or smokeless tobacco
0 Features often include smoking within 30 minutes of
waking, daily use, waking at night to smoke
0 Nicotine dependence in about 13% of U.S. adults
0 Nicotine dependence in about 50% of daily smokers
 Tobacco-Related Disorders
0 Initiation of smoking after age 21 is rare
0 Those who quit usually do so after age 30
0 Non-daily smoking has become more prevalent in the
past decade especially among younger individuals
0 More common among those with AD/HD, conduct d/o,
mood, anxiety, personality, psychotic or other SUD’s
 Tobacco-Related Disorders
0 Individuals with low incomes and low educational levels
are more likely to initiate tobacco use and less likely to
stop
0 50% of smokers who do not stop using tobacco will die
early from a tobacco-related illness
0 There is no Tobacco Intoxication Disorder
 Tobacco Use Disorder
0 Problematic pattern of use leading to significant
impairment or distress as manifested by 2 or more of the
11 symptom criteria
0 Includes the specifier “on maintenance therapy” for those
taking a nicotine replacement aid or a tobacco cessation
medication
 Tobacco Withdrawal
0 Cessation or reduction followed within 24 hours by 4 or
more of the following:
0 Irritability, frustration, or anger
0 Anxiety
0 Difficulty concentrating
0 Increased appetite
0 Restlessness
0 Depressed mood
0 Insomnia
Other (or Unknown) Substance
Use Disorder
0 Problematic use of an “intoxicating substance” not able
to be classified within the other categories
0 Meets at least two or more of the 11 symptom criteria
within a 12-month period
Other (or Unknown) Substance
Use Disorder
0 Other includes anabolic steroids; non-steroidal anti-
inflammatory drugs; cortisol; antiparkinsonian
medications; antihistamines; nitrous oxide; amyl-, butyl-,
or isobutyl-nitrates; betel nut; kava; and khat
0 Unknown – when a substance is unknown
0 Also, includes the categories Intoxication and
Withdrawal
 Gambling Disorder
0 Previously known as “Pathological Gambling” and was
in category of Impulse Control Disorders

0 Problematic gambling leading to significant impairment

or distress

0 Leading to four or more of the following symptoms over

a 12-month period
Gambling Disorder Diagnostic
Criteria
1. Needs to gamble with increasing amounts of money
for desired excitement
2. Is restless or irritable when attempting to cut down or
stop gambling
3. Repeated unsuccessful efforts to control, cut back, or
stop gambling
4. Often preoccupied with gambling
5. Gambles when feeling distressed (helpless, guilty,
anxious, depressed)
Gambling Disorder Diagnostic
Criteria
6. After losing money gambling, often returns another
day to get even
7. Lies to conceal the extent of involvement with gambling
8. Jeopardized or lost a significant relationship, job, or
career opportunity due to gambling
9. Relies on others to provide money to relieve financial
situations caused by gambling
Gambling Disorder Diagnostic
Criteria
0 Removal of the criteria “has committed acts of forgery,
fraud, theft, or embezzlement to finance gambling”

0 Can be specified as either “Episodic” or “Persistent” and

“In early remission” or “In sustained remission”
 Gambling Disorder Severity
Rating
0 Mild: 4-5 criteria

0 Moderate: 6-7 criteria

0 Severe: 8-9 criteria

 Gambling Disorder
0 About 0.2%-0.3% of general population
0 3x more likely in males
0 Highest in African Americans (0.9%), whites (0.4%),
Hispanics (0.3%)
0 For females, the progression is more rapid
0 About 17% commit suicide
0 Often associated with SUDs and impulse –control
disorders (males) & mood/ anxiety D/O (females)