DSM – 5 Substance-Related and Addictive Disorders Michael Ryan, LCSW, CASAC October 2013

Use of the Manual The primary purpose of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) is to assist trained clinicians in the diagnosis of their patients’ mental disorders as part of a case formulation assessment that leads to a fully informed treatment plan for each individual.

The symptoms contained in the respective diagnostic criteria sets do not constitute comprehensive definitions of underlying disorders, which encompass cognitive, emotional, behavioral, and physiological processes that are far more complex than can be described in these brief summaries. Rather, they are intended to summarize characteristics syndromes of signs and symptoms that point to an underlying disorder.

Substance-Related and Addictive Disorders In the fifth addition of the Diagnostic and Statistical manual of Mental Disorders (DSM-5), the revised chapter of “Substance-Related and Addictive Disorders” includes substantive changes to the disorders grouped plus changes to the criteria of certain conditions.

Substance Use Disorders The DSM-5 Substance-Related Disorders Work Group has proposed eliminating two categories in the current DSM-IV. Substance use disorder in the DSM-5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe.

Each specific substance (other than caffeine, which cannot be diagnosed as a substance use disorder) is addressed as a separate use disorder (e.g. alcohol use disorder, stimulant use disorder, etc.), but nearly all substances are diagnosed based on the same overarching criteria. In this overarching disorder, the criteria have not only been combined, but strengthened.

Whereas a diagnosis of substance abuse previously required only one symptom, mild substance use disorder in DSM-5 requires two to three symptoms from a list of 11. Drug craving will be added to the list, and problems with law enforcement will be eliminated because of cultural considerations that make the criteria difficult to apply internationally.

In the DSM-IV, the distinction between abuse and dependence was based on the concept of abuse as a mild or early phase and dependence as the more severe manifestation. In practice, the abuse criteria were sometimes quite severe. The revised substance use disorder, a single diagnosis, will better match the symptoms that the patients experience. Additionally, the diagnosis of dependence caused much confusion. Most people link dependence with “addiction” when in fact dependence can be a normal body response to a substance.

Addictive Disorders The chapter also includes gambling disorder as the sole condition in a new category on behavioral addictions. DSM-IV listed pathological gambling but in a different chapter. This new term and its location in the new manual reflect research findings that gambling disorder is similar to substance-related disorders in clinical expression, brain origin, co-morbidity, physiology, and treatment.

Substance-Related and Addictive Disorders The DSM-5 Substance-Related Disorders has eliminated two categories in the current DSM-IV; Substance Dependence and Substance Abuse now under one category called Substance-Use Disorders. Substance-related Disorders

The Substance-Related Disorders encompass 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens (with separate categories for phencyclidine or similarly acting arylcyclohexylamines and other hallucinogens); inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants (amphetamine-type substances, cocaine, and other stimulants); tobacco; and other (or unknown) substances.

These 10 classes are not fully distinct These 10 classes are not fully distinct. All drugs that are taken in excess have in common direct activation of the brain reward system, which is involved in the reinforcement of behaviors and the production of memories. They produce such an intense activation of the reward system that normal activities may be neglected.

In addition to substance-related disorders, this chapter also includes gambling disorder, reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse and produce some behavioral symptoms that appear comparable to the substance use disorders.

The substance-related disorders are divided into two groups: Substance use disorders and substance-induced disorders The following conditions may be classified as substance-induced disorders: intoxication, withdrawal, and other substance/medication-induced mental disorders (psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders.

Substance Use Disorders In the substance use disorder chapter the biggest change from the dependence and abuse diagnosis is the move to Mild, Moderate, and Severe. To determine the severity of the disorder, a criteria 1-11 has been established. The presence of 2-3 symptoms out of the 11 is defined as Mild. The presence of 4-5 symptoms is defined as Moderate. The presence of 6 or more symptoms is defined as Severe.

Substance Use Disorder A. A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12 month period: 1. The substance 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 the substance use.

3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from it’s effects. 4. Craving, or a strong desire or urge to use the substance. 5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued Substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

7. Important social, occupational, or recreational activities are given up or reduced because of substance use. 8. Recurrent substance use in situations in which it is physically hazardous. 9. Substance 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 the substance.

10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the substance to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of the substance.

11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the substance (refer to criteria A and B of the criteria set for alcohol or other substances withdrawal) b. Substance (or closely related substance, such as benzodiazepine with alcohol) is taken to relieve or avoid withdrawal symptoms.

Specify With physiological dependence: evidence of tolerance or withdrawal (i.e. either item 4 or 5 is present. Without physiological dependence: no evidence of tolerance or withdrawal (i.e. neither item 4 or 5 is present.

Early Remission – After full criteria for substance use disorder were previously met, none of the criteria for the substance use disorder have been met for at least 3 months but for less than 12 months (with the exception that criterion A4 “craving, or strong desire or urge to use substance).

In Sustained Remission – After full criteria for substance use disorder were previously met, none of the criteria for substance use disorder have been met at any time during a period of 12 months or longer (with the exception that criterion A4, craving, or strong desire or urge to use the substance).

In a Controlled Environment – This additional specifier is used if the individual is in an environment where access to the substance is restricted. On Maintenance Therapy – This additional specifier is used if the individual is taking prescribed agonist medication such as methadone or buprenorphine and none of the criteria for opioid use disorder have been met for that class of medication (except tolerance to, or withdrawal from, the agonist). This category also applies to those individuals being maintained on partial agonist, an agonist/antagonist, or a full antagonist such as oral naltrexone or depot naltrexone.

ICD-10-CMCodes Alcohol 305.00 Mild (2-3) 303.90 Moderate (4-5) 303.90 Severe (6 or more) Cannabis 305.20 Mild (2-3) 304.30 Moderate (4-5) 304.30 Severe (6 - more)

Phencyclidine 305.90 Mild (2-3) 304.60 Moderate (4-5) 304.60 Severe (6 or more) Other Hallucinogen 305.30 Mild (3-3 304.50 Moderate (4-5) 304.50 Severe (6 - more)

Inhalant Mild 305.90 (2-3) Moderate 304.60 (4-5) Severe 304.60 (6 - more) Opioid Mild 305.50 9 (2-3) Moderate 304.00 (4-5) Severe 304.00 (6 - more)

Sedative-, Hypnotic-, or Anxiolytic-Related Disorders: 305.40 Mild (2-3) 304.10 Moderate (4-5) 304.10 Severe (6 or more)

Stimulant – Related Disorders Mild: Presence 0f 2-3 symptoms 305.70 Amphetamine-type substance 305.60 Cocaine 305.70 Other or unspecified stimulant Moderate Presence o4 4-5 symptoms 304.40 Amphetamine-type substance 304.20 Cocaine 304.40 Other or unspecified stimulant

Severe: presence of 6 or more symptoms 304.40 Amphetamine-type substance 304.20 Cocaine 304.40 Other or unspecified stimulant Tobacco (Nicotine) 305.1 Mild (2-3) 305.1 Moderate (4-5) 305.1 (Severe 6 or more)

Non-Substance Related disorder Gambling Disorder 312.31 Specify criteria: Mild (4-5) Moderate (6-7) Severe (8-9)

Substance Use Disorders The clinician should use the code that applies to the class of substances but record the name of the specific substance. For example, the clinician should record 304.10 moderate alprazolam use disorder (rather than moderate sedative, hypnotic, or anxiolytic use disorder). If the substance does not fit into any of the classes (e.g., anabolic steroids), the appropriate code for ‘other substance use 305.90 mild anabolic steroid use disorder.

If the substance taken by the individual is unknown, code for the class “other (or unknown) should be used (e.g. 304.90 severe unknown substance use disorder.