DSM – 5 Substance-Related and Addictive Disorders

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
• 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
• 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
• 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. DSMIV 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, comorbidity, physiology, and treatment.
Substance-Related and Addictive
• 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
• 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. 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
• 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
• The substance-related disorders are divided into
two groups: Substance use disorders and
substance-induced disorders The following
conditions may be classified as substanceinduced 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
• 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
• 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
• 5. Recurrent substance use resulting in a failure
to fulfill major role obligations at work, school, or
• 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
• 10. Tolerance, as defined by either of the
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
• 11. Withdrawal, as manifested by either of the
a. The characteristic withdrawal syndrome
for the substance (refer to criteria A and B of the
criteria set for alcohol or other substances
b. Substance (or closely related substance,
such as benzodiazepine with alcohol) is taken to
relieve or avoid withdrawal symptoms.
• 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
• 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.
• 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
• 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
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.

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