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I I I I I I I I I I I I I I I DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FOURTH EDITION D SM-TVTM PUBLISHED BY THE AMERICAN PSYCHIATRIC ASSOCIATION WASHINGTON, DC I

17G Substance-Related Disorders I I I ~ I I I 11 I I I I I I I I symptoms can take weeks or months and may require treatment. The Substance-Related Disorders are divided into two groups: the Substance Use Disorders (Substance Dependence and Substance Abuse) and the Substance-Induced Disorders (Substance Intoxication, Substance Withdrawal, Substance-Induced Delirium, Substance-Induced Persisting Dementia, Substance-Induced Persisting Amnestic Disor- der, Substance-Induced Psychotic Disorder, Substance-Induced Mood Disorder, Sub- stance-Induced Anxiety Disorder, Substance-Induced Sexual Dysfunction, and Substance-Induced Sleep Disorder). The section begins with the text and criteria sets for Substance Dependence, Abuse, Intoxication, and Withdrawal that are applicable across classes of substances. This is followed by general comments concerning associated features; culture, age, and gender features; course; impairment and complications; familial pattern; differential diagnosis; and recording procedures that apply to all substance classes. The remainder of the section is organized by class of substance and describes the specific aspects of Dependence, Abuse, Intoxication, and Withdrawal for each of the 11 classes of substances. To facilitate differential diagnosis, the text and criteria for the remaining Substance-Induced Disorders are included in the sections of the manual with disorders with which they share phenomenology (e.g., Substance- Induced Mood Disorder is included in the "Mood Disorders" section). The diagnoses associated with each specific group of substances are shown in Table 1. Features Substance Use Disorders Substance Dependence The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated self- administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior. A diagnosis of Substance Dependence can be applied to every class of substances except caffeine. The symptoms of Dependence are similar across the various categories of substances, but for certain classes some symptoms are less salient, and in a few instances not all symptoms apply (e.g., withdrawal symptoms are not specified for Hallucinogen Dependence). Although not specifically listed as a criterion item, "craving" (a strong subjective drive to use the substance) is likely to be experienced by most (if not all) individuals with Substance Dependence. Dependence is defined as a cluster of three or more of the symptoms listed below occurring at any time in the same 12-month period. Tolerance (Criterion 1) is the need for greatly increased amounts of the substance to achieve intoxication (or the desired effect) or a markedly diminished effect with continued use of the same amount of the substance. The degree to which tolerance develops varies greatly across substances. Individuals with heavy use of opioids and stimulants can develop substantial (e.g., tenfold) levels of tolerance, often to a dosage that would be lethal to a nonuser. Alcohol tolerance can also be pronounced, but is usually much less extreme than for amphetamine. Many individuals who smoke I

Table 1. Diagnoses associated with class of substances Intoxi- With- Sexual Depen- Intoxi- With- cation drawal Amnestic Psychotic Mood Anxiety Dysfunc- Sleep dence Abuse cation drawal Delirium Deliriurn Dementia Disorder Disorders Disorders Disorders tions Disorders Alcohol X X X X I W 1' 1' 1/W 1/W 1/W I 1/W Amphetamines X X X X I I VW I I I/W Caffeine X I I Cannabis X X X I I I Cocaine X X X X I I 1/W I/W I 1/W Hallucinogens X X X I I~ I I Inhalants X X X I I' I I I Nicotine X X ~ C Opioids X X X X I I I 1 I/W ~ Phencyclidine X X X I I I I ~ A SeQatives, Lqpnotics, or anxiolytics 1'olysubstance X X X X X I W 1' 1' 1/W I/W W I I/W d ~rD tb .'7 a Other X X X X I W 1' P I/\Ci I/W 1/W I I/W ~ •Also Hallucinogen Persisting Perception Disorder (Flashbacks). Note: X, 1, W, I/W, or P indicates that the category is recognized in DSM-IV. In addition, /indicates that the specifier With Onset 1)uring Intoxication may be noted for the category (except for lntoxication Delirium); W indicates that the specifier With Onset I)uring Withdrawal may be noted for the category (except for Withdrawat Delirium); and UW indicates that either With Onset During Intoxication or With Onset During Withdrawal may be noted for the category. Pindicates that the disorder is Persisting. A 84886£9M

1'18 Substance-Related Disorders I t I I I I I I I I I I I I I I I cigarettes consume more than 20 cigarettes a day, an amount that would have produced symptoms of toxicity when they first started smoking. Individuals with heavy use of cannabis are generally not aware of having developed tolerance (although it has been demonstrated in animal studies and in some individuals). It is uncertain whether any tolerance develops to phencyclidine (PCP). Tolerance may be difficult to determine by history alone when the substance used is illegal and perhaps mixed with various diluents or with other substances. In such situations, laboratory tests may be helpful (e.g., high blood levels of the substance coupled with little evidence of intoxication suggest that tolerance is likely). Tolerance must also be distinguished from individual variabiliry in the initial sensitivity to the effects of particular substances. For example, some first-time drinkers show very little evidence of intoxication with three or four drinks, whereas others of similar weight and drinking histories have slurred speech and incoordi- nation. Withdrawal (Criterion 2a) is a maladaptive behavioral change, with physiological and cognitive concomitants, that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing unpleasant withdrawal symptoms, the person is likely to take the substance to relieve or to avoid those symptoms (Criterion 2b), typically using the substance throughout the day beginning soon after awakening. Withdrawal symp- toms vary greatly across the classes of substances, and separate criteria sets for Withdrawal are provided for most of the classes. Marked and generally easily measured physiological signs of withdrawal are common with alcohol, opioids, and sedatives, hypnotics, and anxiolytics. Withdrawal signs and symptoms are often present, but may be less apparent, with stimulants such as amphetamines and cocaine, as well as with nicotine. No significant withdrawal is seen even after repeated use of hallucinogens. Withdrawal from phencyclidine and related substances has not yet been described in humans (although it has been demonstrated in animals). Neither tolerance nor withdrawal is necessary or sufficient for a diagnosis of Substance Dependence. Some individuals (e.g., those with Cannabis Dependence) show a pattern of compulsive use without any signs of tolerance or withdrawal. Conversely, some postsurgical patients without Opioid Dependence may develop a tolerance to prescribed opioids and experience withdrawal symptoms without showing any signs of compulsive use. The specifiers With Physiological Dependence and Without Physiolog- ical Dependence are provided to indicate the presence or absence of tolerance or withdrawal. The following items describe the pattern of compulsive substance use that is characteristic of Dependence. The individual may take the substance in larger amounts or over a longer period than was originally intended (e.g., continuing to drink until severely intoxicated despite having set a limit of only one drink) (Criterion 3). The individual may express a persistent desire to cut down or regulate substance use. Often, there have been many unsuccessful efforts to decrease or discontinue use (Criterion 4). The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects (Criterion 5). In some instances of Substance Dependence, virtually all of the person's daily activities revolve around the substance. Important social, occupational, or recreational activities may be given up or reduced because of substance use (Criterion 6). The individual may withdraw from family activities and hobbies in order to use the substance in private or to spend more time with substance-using friends. Despite recognizing the contributing role of the substance to a psychological or physical problem (e.g.. severe depressive symptoms or damage to I

I I Substance Dependence 179 that would have produced Ii~duals with heavy use of nce (although it has been L is uncertain whether any ~ e difficult to determine by ixed with various diluenu may be helpful (e.g., high )f intoxication suggest that I m individual variabilitv in r example, some first-time :e or four drinks, whereas ed speech and incoordi- 9 _hange, with physiological issue conc ti entra ons of a ~ longed heavy use of the ns, the person is likely to riterion 2b), typically using ~kening. Withdrawal symp- separate criteria sets for generally easily measured C, opioids, and sedatives, are often present, but may cocaine, as well as with ated use of hallucinogens. ~ not yet been described in ficient for a diagnosis of nnabis Dependence) show ~ >r withdrawal. Conversely, ay develop a tolerance to chout showing any signs of Ice and Without Physiolog- r absence of tolerance or rve substance use that is ~ ibstance in larger amounts continuing to drink until drink) (Criterion 3). The ulate substance use• Often, ,continue use (Criterion 4). I I the substance, using the me instances of Substance )lve around the substance• y be given up or reduced iay withdraw from familY ,ite or to spend more time )uting role of the substance ve symptoms or damage to systems), the person continues to use the substance (Criterion 7). The key issue evaluating this criterion is not the existence of the problem, but rather the individual's ure to abstain from using the substance despite having evidence of the difficulty it is using. ecifters olerance and withdrawal may be associated with a higher risk for immediate general edical problems and a higher relapse rate. Specifiers are provided to note their presence absence: With Physiological Dependence. This specifier should be used when Sub- stance Dependence is accompanied by evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). Without Physiological Dependence. This specifier should be used when there is no evidence of tolerance (Criterion 1) or withdrawal (Criterion 2). In these individuals, Substance Dependence is characterized by a pattern of compulsive use (at least three items from Criteria 3-7). rse Specif'iers course specifiers are available for Substance Dependence. The four Remission lers can be applied only after none of the criteria for Substance Dependence or ce Abuse have been present for at least 1 month. The definition of these four of Remission is based on the interval of time that has elapsed since the cessation ndence (Early versus Sustained Remission) and whether there is continued nce of one or more of the items included in the criteria sets for Dependence or (Partial versus Full Remission). Because the first 12 months following Dependence time of particularly high risk for relapse, this period is designated Early Remission. 12 months of Early Remission have passed without relapse to Dependence, the n enters into Sustained Remission. For both Early Remission and Sustained ion, a further designation of Full is given if no criteria for Dependence or Abuse been met during the period of remission; a designation of Partial is given if at least the criteria for Dependence or Abuse has been met, intermittently or continuously, the period of remission. The differentiation of Sustained Full Remission from ered (no current Substance Use Disorder) requires consideration of the length of since the last period of disturbance, the total duration of the disturbance, and the for continued evaluation. If, after a period of remission or recovery, the individual becomes dependent, the application of the Early Remission specifier requires that again be at least 1 month in which no criteria for Dependence or Abuse are met. additional specifiers have been provided: On Agonist Therapy and In a Controlled nment. For an individual to qualify for Early Remission after cessation of agonist Py or release from a controlled environment, there must be a 1-month period in none of the criteria for Dependence or Abuse are met. Me following Remission specifiers can be applied only after no criteria for F_ dence or Abuse have been met for at least 1 month. Note that these specifiers do :aPPly if the individual is on agonist therapy or in a conuolled environment (see ),

I I I I I I I I I I I I I 242 Substance-Related Disorders Differential Diagnosis For aoeneral di,cussion of the differer.tial diagnosis of Substance-Related Disorders, see p. 190. Inhalant-Induced Disorders may be characterized b}• symptoms (e.g., depressed mood) that resemble priman- mental disorders (e.,.. Major Depressive Disorder versus Inhalant-Induced Mood Disorder, With Depressive Features. With Onset During Intoxication). See p. 193 for a discussion of this differential diagnosis. The symptoms of mild to moder<ue Inhalant Intoxication can be similar to those of Alcohol Intoxication and Sedative, Hypnotic, or An.iiolytic Intoxication. Breath odor or residues on body or clothing mav be important differentiating clues, but should not be relied on exclusivelr. Individuals who chronicallv use inhalants are likely to use other substances frequently and heavily, further complicating the diagnostic picture. Concomitant use of alcohol may also make the differentiation difficult. History of the drug used and characteristic findings (includint; odor of solvent or paint residue) may differentiate Inhalant Intoxication from other substance intoxications; additionally, symptoms may subside faster with Inhalant Intoxication than with other substance intoxications. Rapid onset and resolution may also differentiate Inhalant Intoxication from other mental disorders and neurological conditions. Inhalant Intoxication is distinguished from the other Inhalant-Induced Disorders (e.g., Inhalant-Induced :'vlood Disorder, %Vith Onset During Intoxic:uion) because the symptoms in these latter disorders are in excess of those usuall~, associated with Inhalant Intoxication and are severe enough to warrant independent clinical attention. Industrial workers may occasionally be accidentally exposed to volatile chemi- cals and suffer physiological intoxication. The category -Other Substance-Related Disorders" should be used for such toxin exposures. 292.9 Inhalant-Related Disorder Not Otherwise Specified The Inhalant-Related Disorder \bt Otherwise Specified category is for disorders associ- ated with the use of inhalants that are not classifiable as Inhalant Dependence, Inhalant Abuse, Inhalant Intoxication, Inhalant Intoxication Delirium, Inhalant-Induced Persisting Dementia. Inhalant-Induced Psvchotic Disorder. Inhalant-Induced :kfood Disorder, or Inhalant-Induced Anxiety Disorder. Nicotine-Related Disorders Nicotine Dependence and Withdrawal can develop with use of all forms of tobacco (cigarettes. chewing tobacco, snuff, pipes, and cigars) and with prescription medications (nicotine gum and patch). The relative ability of these products to produce Dependence or to induce Withdrawal is associated with the rapidlty characteristic of the route of administration (smoked over oral over tr.tnsdermal) and the nicotine content of the product. This section contains discussions specific to the Nicotine-Related Disorders. Texts and criteria sets have already been provided to define the generic aspects of Substance Dependence (p. 176) that apply across all substances. Text specific to Nicotine Dependence is provided helow. Nicotine intoxication and nicotine abuse are not I

I I I I Nicotine-Related Disorders 2-f3 included in DSM-I%'; nicotine intoxication rarelt' occurs and has not been ~vell studied, and nicotine abuse is not likelv to be observed in the absence of Dependence. A specific text and criteria set for Nicotine «'ithdra%val is also provided below. Listed below are the Nicotine-Related Disorders. Nicotine Use Disorder 305.10 Nicotine Dependence (see p. 243) Nicotine-Induced Disorder 292.0 Nicotine Withdrawal (see p. 244) 292.9 Nicotine-Related Disorder Not Otherwise Specified (see p. 2 i"') Nicotine Use Disorder 305.10 Nicotine Dependence I I I I I I I I I Also refer to the text and criteria for Substance Dependence (see p. 176). Some of the generic Dependence criteria do not appear to apply to nicotine, whereas others require further explanation. Tolerance to nicotine is manifested by the absence of nausea, dizziness, and other characteristic symptoms despite using substantial amounts of nicotine or a diminished effect observed %vith continued use of the same amount of nicotine-containing products. Cessation of nicotine use produces awel1-defined with- drawal syndrome that is described below. iVtany individuals who use nicotine take nicotine to relieve or to avoid withdrawal symptoms when they wake up in the morning or after being in a situation where use is restricted (e.g., at work or on an airplane). Individuals who smoke and other individuals who use nicotine are likely to find that they use up their supply of cigarettes or other nicotine-containing products faster than originally intended. Although over 80% of individuals who smoke express a desire to stop smoking and 35% try to stop each year, less than 5% are successful in unaided attempts to quit. Spending a great deal of time in using the substance is best exemplified by chain-smoking. Because nicotine sources are readily and legally available, spending a great deal of time attempting to procure nicotine would he rare. Giving up important social, occupational, or recreational activities can occur when an individual forgoes an activity because it occurs in smoking-restricted areas. Continued use despite knov.•ledge of medical problems related to smoking is a particularly important health problem (e.g., an individual who continues to smoke despice having a tobacco-induced general medical condition such as bronchitis or chronic obstructive lung disease). Speciers The following specifiers may be applied to a diagnosis of Nicotine Dependence (see p. 179 for more details): With Physiological Dependence Without Physiological Dependence I

I I I I I I I I I I I I I I I I 244 Substance-Related Disorders Early Full Remission Early Partial Remission Sustained Full Remission Sustained Partial Remission On Agonist Therapy Nicotine-Induced Disorder 292.0 Nicotine Withdrawal Also refer,to the text and criteria for Substance Withdra~'al (see p. 1S-i). The essential feature of Nicotine \Vithdran•al is the presence of a characteristic n•ithdrawal syndrome that develops after the abript cessation of, or reduction in. the use of nicotine-containing products follon-ing a prolonged period (at least several cveeks) of daily use (Criteria A and B). The withdran,al syndrome includes four or more of the follo~.in-: dysphoric or depressed mood; insomnia: irritabilitv, fristration. or anger: anxiet}•: difficulty concen- trating; restlessness or impatience; decreased heart rate: and increased appetite or weight gain. The withdrawal symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioninc, (Criterion C). The symptoms must not be due to a general medical condition and are not better accounted for by another mental disorder (Criterion D). These symptoms are in large part due to nicotine deprivation and are typically more intense among individuals n•ho smoke cigarettes than among individuals who use other nicotine-containing products. The more rapid onset of nicotine effects with cigarette smokino leads to a more intensive habit pattern that is more ~lifficult to give up because of the frequency and rapidity of reinforcement and the greater physical dependence on nicotine. In individuals -who smoke cioarettes, heart rate decreases hy 5 to 12 beats per minute in the first few days after stopping smoking, and %veight increases an average of 2-3 kg over the first year after stopping smoking. IMild symptoms of withdrawal may occur after switching to low-tar/nicotine cigarettes and after stopping the use of smokeless (chewing) tobacco, nicotine gum, or nicotine patches. / Diagnostic criteria for 292.0 Nicotine Withdrawal A. Daily use of nicotine for at least several \veeks. B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed R-ithin 24 hours by four (or more) of the follon•inu sions: (1) dysphoric or depressed mood (2) insomnia (3) irritability, frustration, or anger (4) anxiety (5) difficulty concentrating (contintied) I

I I I I I I I I I I I I I I I I I Nicotine-Related Disorders 245 0 Diagnostic criteria for 292.0 Nicotine Withdrawal (continued) (6) restlessness (7) decreased heart rate (8) increased appetite or n•ei;ht gain C. The symptoms in Criterion B cause clinically significant distress or impairment in social. occupational, or other unportant areas of functioning. D. The svmptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Additional Information on Nicotine-Related Disorders Associated Features and Disorders Associated descriptive features and mental disorders. Craving is an important element in Nicotine Withdrawal and may account for the difficulty that individuals have in giving up nicotine-containing products. Other symptoms associated with Nicotine tVithdraR•al include a desire for sweets and impaired performance on tasks requiring vigilance. Several features associatecl with Nicotine Dependence appear to predict a greater level of difficulty in stopping nicotine use: smoking soon after ,~vakinn, smoking n•hen ill, difficulty refraining from smoking, reporting the first cigarette of the day to be the one most difficult to give up, and smoking more in the morning than in the afternoon. The number of cigarettes smoked per day, the nicotine yield of the ci'arette, and the number of pack-years also are related to the likelihood of an individual stopping smoking. Nicotine Dependence is more common among indivicluals with other mental disorders. Depending on the population stucliecl, from 55% to 90% of individuals with other mental disorders smoke, compared to 30% in the general population. Mood. Anxiety, and other Substance-Related Disorders may he more common in individuals who smoke than in those who are ex-smokers and those vvho have never smoked. Associated laboratory findings. Withdrawal svmptoms are associated with a slon•- ing on EEG, decreases in catecholamine and cortisol levels, r,tpid eye movement (REM) changes, impairment on neuropsychological testing, and decreased metabolic rate. Smoking increases the metabolism of many medications prescribed for the treatment of mental disorders and of other substances. Thus, cessation of smokin~ can increase the • blood levels of these medications and other substances, sometimes to a clinicall% significant degree. This effect does not appear to be due to nicotine but rather to other compounds in tobacco. Nicotine and its metabolite cotinine can be measured in blood. saliva, or urine. Persons who smoke also often have diminished pulmonaty function tests and increased mean corpuscular volume (MCti'). I

I -1 I I I I I I I I I I 246 Substance-Related Disorders Associated physical examination findings and general medical conditions. Nicotine %t'ithdra,~val may be associated with a dn• or productive cough, decreased heart rate, increased appetite or weight gain. and a dampened orthostatic response. The most common siens of Nicotine Dependence are tobacco odor, cough, evidence of chronic obstructive pulmonary disease, and excessive skin crrinkling. Tobacco stains on the fingers can occur but are rare. Tobacco use can markedly increase the risk of lung. oral, and other cancers; cardiovascular and cerebrovascular conditions: chronic obstructive and other lung diseases; ulcers; maternal and fetal complications; and other conditions. Although most of these problems appear to be caused by the carcinogens and carbon monoxide in tobacco smoke rather than by nicotine itself. nicotine may increase the risk for cardiovascular events. Those who have never smoked but are chronically exposed to tobacco smoke appear to be at increased risk for conditions such as lung cancer and heart disease. Specic Culture, Age, and Gender Features The prevalence of smoking is decreasing in most industrialized nations, but is increasing 0 in the developing areas. In the United States, the prevalence of smoking is slightly higher in males than in females; however, the prevalence of smoking is decreasing more rapidly in males than in females. In other countries, smoking is often much more prevalent among males. Prevalence In the United States, approximately 45% of the general population have never smoked. The remainder fall into one or more of the following categories: 25% are ex-smokers, 30% currently smoke cigarettes, 4% use pipes or cigars, and 3% use smokeless tobacco. In the United States, the prevalence of smoking has been decreasing approximately 0.7tYo-1.0°/u per year. The lifetime prevalence of Nicotine Dependence in the general population is estimated to be 20%. In the United States, between 50% and 80% of individuals who currently smoke have Nicotine Dependence. Lifetime prevalence of Nicotine \`j/ithdrtwal among persons who smoke appears to be about 50%. Prospectively, it is estimated that about 50% of those who quit smoking on their own and about 75% of those in treatment programs experience Nicotine Withdrawal when they stop smoking. Course ~ Smoking usually begins in the early teens. How quickly dependence develops is unclear. # Among those who continue to smoke through age 20 years, 95% become regular, daily smokers. Of those who successfully quit, less than 25% quit on their first attempt. Most ~ individuals who smoke have 3-4 failures before they stop smoking for good. In the w United States, about 45% of those who have ever smoked eventually stop smoking. Withdrawal symptoms can begin within a few hours of cessation, typically peak in 1-4 days, and last for 3-4 weeks. Depressive symptoms postcessation may be associated ~ with a relapse to smoking. Whether other Nicotine Withdrawal symptoms play a major ~ role in relapse to smoking is debatable. Increased hunger and weight gain often persist ~ for at least 6 months. Six months postcessation, 50% of individuals who have quit ~ ~ smoking report having had a desire for a cigarette in the last 24 hours. ~ CD 00 Cn I