DSM-5 ™ in Action: Diagnostic and Treatment Implications Section 2, Chapters 5–13 PART 2 of Section 2 Chapters 8–16 by Sophia F. Dziegielewski, PhD, LCSW © 2014 S. Dziegielewski

Chapter 12: Substance-Related and Addictive Disorders © 2014 S. Dziegielewski

 Substance Abuse: viewed as the less severe, continued use knowing it is causing harm, does not apply to caffeine and nicotine  Substance Dependence: taking larger amounts with unsuccessful attempts to quit  Substance Intoxication: the development of a substance-specific (reversible) syndrome, condition related to recent ingestion of psychoactive substance  Substance Withdrawal: follows termination of a psychoactive substance (Abstinence Syndrome) © 2014 S. Dziegielewski

Types of Substances Include: alcohol, amphetamines, cocaine, caffeine, hallucinogens, inhalants, nicotine, opioids, phencyclidine (PCP), cannabis, and sedatives-hypnotics-anxiolytics  Be sure the relationship between dependence and withdrawal is noted  Almost always when dependence is an issue treat the substance first © 2014 S. Dziegielewski

DSM-IV-TR, Polysubstance  Dependence Intoxication Withdrawal  No such diagnosis of polysubstance abuse  Uses at least THREE different classes of substances indiscriminately and does not have a favorite drug that qualifies for dependence alone.  All three used in the same 12-month period.  Polysubstance dependence use only when the pattern of multiple drug use is such that it fails to meet the criteria for dependence on any one class of drug. In such settings, the only way to assign a diagnosis of dependence is to consider all the substances that the person uses taken together as a whole. © 2014 S. Dziegielewski

An individual for a year or more has the pattern:  Smokes crack  Illegal sedative use regularly  Smokes several joints a day to level out This diagnosed is reserved for:  Uses at least three substances indiscriminately together, no drug of choice, none predominate  Meets criteria for substance dependence when taken together as a whole, not separately  Use over a 12-month period © 2014 S. Dziegielewski

 The work group retitled the category Substance-Related and Addictive Disorders.  The work group had extensive discussions on the use of the word addiction and the phrase Medical Necessity for Chronic Pain. © 2014 S. Dziegielewski

 Alcohol-Related Disorders  Caffeine-Related Disorders  Cannabis-Related Disorders  Hallucinogen-Related Disorders  Inhalant-Related Disorders  Opioid-Related Disorders  Sedative- Hypnotic- or Anxiolytic-Related Disorders  Stimulant-Related Disorders  Tobacco-Related Disorders  Other (or Unknown) Substance-Related Disorders  Non-Substance-Related Disorders—Gambling Disorder © 2014 S. Dziegielewski

 Want to avoid using the label “dependence” when compulsive, out-of-control drug use remains problematic.  Clients with normal tolerance and withdrawal are often labeled addicts.  This has resulted in withholding adequate doses of opioids for severe pain because of fear of producing addiction. © 2014 S. Dziegielewski

 If medically prescribed as part of pain management it will not be considered a substance disorder.  The presence of tolerance and withdrawal symptoms (numbers 10 and 11 of the criteria) will not be counted for the diagnosis of substance use disorder when occurring in the context of appropriate medical treatment with prescribed medications. © 2014 S. Dziegielewski

 The word dependence will be limited to physiological dependence only, recognizing this is often a normal response to repeated doses of many medications, including beta- blockers, antidepressants, opioids, antianxiety agents, and other drugs.  Tolerance and withdrawal symptoms are NOT counted as symptoms for the diagnosis of substance use disorder when occurring in the context of appropriate medical treatment with prescribed medications. © 2014 S. Dziegielewski

 Combine Abuse and Dependence into one category —Substance Use Disorders.  This new category will have graded clinical severity.  Elimination of “Legal Problems Criterion for Substance Use Disorder Diagnosis.”  Add criteria for CRAVING— defined as a strong desire for a substance, tending to be present on the severe end of the severity spectrum. © 2014 S. Dziegielewski

 Can include all 10 substances except Caffeine  Alcohol  Cannabis  Hallucinogens (Phencyclidine, other hallucinogens)  Inhalants  Opioids  Sedatives/hypnotics/anxiolytics  Stimulants (cocaine, etc.)  Tobacco  Other or Unknown © 2014 S. Dziegielewski

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by two (or more) of the following, occurring within a 12-month period: There are 11 areas identified, and the individual must have two or more. (SERIES OF SLIDES TO FOLLOW WILL SHOW 11 AREAS.) Identify the Severity specifiers: ◦ Mild 2 or 3 of the 11 criteria are positive ◦ Moderate 4 or 5 of the 11 criteria are positive ◦ Severe 6 or more © 2014 S. Dziegielewski

Noted over four areas: ◦ Impaired Control (Numbers 1-4) ◦ Social Impairment (Numbers 5-7) ◦ Risky Use (Numbers 8-9) ◦ Pharmacological Criteria (10-11) © 2014 S. Dziegielewski

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by two (or more) of the following, occurring within a 12-month period: © 2014 S. Dziegielewski

1. The individual may take the substance in larger amounts or over a longer period of time than originally intended. 2. A persistent desire to cut down or regulate the substance with multiple unsuccessful attempts to regulate, decrease of discontinued use. © 2014 S. Dziegielewski

3. Excessive time obtaining the substance, using the substance, or recovering from its effects. 4. In more severe substance use, virtually all of the individual’s daily activities revolve around the substance; craving is manifested with an intense desire or urge for the drug that may occur at any time but more likely when in an environment where the drug previously was obtained or used. © 2014 S. Dziegielewski

5. Recurrent substance use may result in a failure to fulfill major role obligations at work, school, or home. 6. Continues using despite recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance. 7. Important social or occupational recreational activities may be given up or reduced because of substance use. © 2014 S. Dziegielewski

8. May take the form of recurrent substance use in situations where it is physically hazardous. 9. The individual my continue substance use despite knowledge of having physical/ psychological problems that are likely to be caused or exacerbated by the substance. © 2014 S. Dziegielewski

10. Tolerance, as defined by either of the following: ◦ A need for markedly increased amounts of the substance to achieve intoxication or desired effect. ◦ Markedly diminished effect with continued use of the same amount of the substance. (Does not include medications taken under medical supervision.) © 2014 S. Dziegielewski

11. Withdrawal, as manifested by either of the following:  A syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who has maintained prolonged heavy use of the substance.  Needs to consume the substance to relieve the symptoms. a. The characteristic withdrawal syndrome for the substance as defined in each class can vary across the substance used. b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms (Note: Does not include medications taken under medical supervision.) © 2014 S. Dziegielewski

Severity specifiers: Mild: 2 or 3 criteria positive Moderate: 4 or 5 criteria positive Severe: 6 or 7 criteria positive © 2014 S. Dziegielewski

 In early remission  In sustained remission  In a controlled environment  With perpetual disturbances © 2014 S. Dziegielewski

 Further breakdown to ensure each drug will have its own category  Discontinuation syndromes: related to TCAs and the SSRIs © 2014 S. Dziegielewski

Nonsubstance Addictions to be added include:  Gambling disorder (currently called pathological gambling, under impulse control disorders).  Internet Gaming Disorder is in Section 3 for further study. © 2014 S. Dziegielewski

 Uses increasingly higher amounts of the drugs over time in order to achieve the same drug effect  Finds that the same amount of the drug has much less of an effect over time than before.  After using several different drugs regularly, an individual may find that he or she needs to use at least 50% more of the amount he or she began using in order to get the same effect © 2014 S. Dziegielewski

 Interference with Daily Activities: Reduction because of drug use affecting the amount of time involved in recreational activities, social activities, or occupational activities. Uses drugs instead of engaging in hobbies, spending time with friends, or going to work.  Inability to Stop Using: Unsuccessfully attempted to cut down or stop using the drugs or persistent desire to stop using. Despite efforts to stop using drugs on weekdays, he or she is unable to do so. © 2014 S. Dziegielewski

Clearly identify the addictive disorder *Note severity of the disorder and how it interferes with functioning. Gather a comprehensive history *Note medical factors, risk behaviors, and peer family and social supports. Identify problems or factors to ensure client safety. Formulate a plan of action to address the problem areas. Establish a plan for monitoring and follow-up. Develop a support system that will assist in addressing problem behaviors. © 2014 S. Dziegielewski

Axis I Alcohol dependence with physiological dependence Cocaine dependence Cannabis abuse Axis II:V71.09 No diagnosis. Axis III:Liver cirrhosis, history of seizures, Allergy to sulfa drugs. Axis IV: 1.Multiple legal problems with possible incarceration. 2.Medical concerns, chronic and debilitating conditions. 3.Occupational difficulties with loss of career and current unemployment. 4.Inadequate support system, with substance-using peers. 5.Marital conflict with current separation of 1 year. 6.Social isolation. 7.Lack of housing. Axis V: 45 (current). © 2014 S. Dziegielewski

 How to document in DSM-5 © 2014 S. Dziegielewski

Substance Use Disorders  Record the specific substance.  When using other substance use disorder, document the substance in brackets.  (e.g., mild anabolic steroids)  If unknown substance, code it unknown.  The word addiction is deleted from the “use” category (not recommended, although some use it to document severe forms) © 2014 S. Dziegielewski

Alcohol Use Disorder (principal diagnosis) Cocaine Use Disorder (principal diagnosis?) Liver Cirrhosis (another medical condition) History of Seizures (patient self-report). List Relevant V or Z Codes © 2014 S. Dziegielewski

 Alcohol Use (F10.20) Moderate (has 4-5 symptoms) (principal diagnosis)  Cocaine (Stimulant Use Disorder) (F14.10) Mild (has2-3 symptoms)  Cannabis Use Disorder (F12.10) Mild (has 2-3 symptoms)  Any Other Conditions That May Be the Focus of Clinical Attention © 2014 S. Dziegielewski