id
stringlengths 14
14
| page_content
stringlengths 10
2.06k
| source
stringclasses 1
value |
|---|---|---|
5d3c5dac9159-1 | timated to be 0.3% among 12- to 17-year-ol ds and 0.2% among adults age 18 years and
older. Rates of DSM-IV sedative, hypnotic, or anxiolytic use disorder are slightly greater
among adult males (0.3%) than among adult fe males, but for 12- to 17-year-olds, the rate
for females (0.4%) exceeds that for males (0.2%). The 12-month prevalence of DSM-IV
sedative, hypnotic, or anxiolytic use disorder decreases as a function of age and is great-
est among 18- to 29-year-olds (0.5%) and lo west among individuals 65 years and older
(0.04%).
Twelve-month prevalence of se dative, hypnotic, or anxiolytic use disorder varies across
racial/ethnic subgroups of the U.S. population . For 12- to 17-year-olds, rates are greatest
among whites (0.3%) relative to African Amer icans (0.2%), Hispanics (0.2%), Native Amer-
icans (0.1%), and Asian Americans and Pacifi c Islanders (0.1%). Among adults, 12-month
prevalence is greatest amon g Native Americans and Alaska Natives (0.8%), with rates of
approximately 0.2% among African Americans, whites, and Hispanics and 0.1% among
Asian Americans and Pacific Islanders.
Development and Course
The usual course of sedative, hypnotic, or anxiolytic use disorder involves individuals in
their teens or 20s who escalate their occasional use of seda tive, hypnotic, or anxiolytic
agents to the point at which they develop prob lems that meet criteria for a diagnosis. This | dsm5.pdf |
5d3c5dac9159-2 | pattern may be especially likely among indi viduals who have other substance use disor-
ders (e.g., alcohol, opioids, stimulants). An in itial pattern of intermit tent use socially (e.g.,
at parties) can lead to daily use and high leve ls of tolerance. Once this occurs, an increasing
level of interpersonal difficulties, as well as increasingly severe episodes of cognitive dys-
function and physiological wi thdrawal, can be expected.
The second and less frequently observed clinical course begins with an individual who
originally obtained the medication by prescrip tion from a physician, usually for the treat-
ment of anxiety, insomnia, or somatic complain ts. As either tolerance or a need for higher
doses of the medication develops, there is a gr adual increase in the dose and frequency of | dsm5.pdf |
374a746e3997-0 | ment of anxiety, insomnia, or somatic complain ts. As either tolerance or a need for higher
doses of the medication develops, there is a gr adual increase in the dose and frequency of
self-administration. The individu al is likely to continue to justify use on the basis of his or
her original symptoms of anxiety or insomn ia, but substance-seeking behavior becomes | dsm5.pdf |
5ecd762a4c4c-0 | 554 Substance-Related and Addictive Disorders
more prominent, and the individual may seek out multiple physicians to obtain sufficient
supplies of the medication. Tolerance can reach high levels, and withdrawal (including
seizures and withdrawal delirium) may occur.
As with many substance use disorders, sedati ve, hypnotic, or anxiol ytic use disorder gen-
erally has an onset during adolescence or early adult life. There is an increased risk for misuse
and problems from many psychoactive substances as individuals age. In particular, cognitive
impairment increases as a side effect with ag e, and the metabolism of sedatives, hypnotics, or
anxiolytics decreases with age among older indi viduals. Both acute and chronic toxic effects
of these substances, especially effects on co gnition, memory, and motor coordination, are
likely to increase with age as a consequence of pharmacodynamic and pharmacokinetic age-
related changes. Individuals with major neuroc ognitive disorder (dementia) are more likely
to develop intoxication and impaired phy siological functioning at lower doses.
Deliberate intoxication to achieve a “high” is most likely to be observed in teenagers
and individuals in their 20s. Problems associate d with sedatives, hypnotics, or anxiolytics
are also seen in individuals in their 40s and older who escalate the dose of prescribed med-
ications. In older individuals, intoxicati on can resemble a progressive dementia.
Risk and Prognostic Factors
Temperamental. Impulsivity and novelty seeking are in dividual temperaments that re-
late to the propensity to develop a substanc e use disorder but may themselves be geneti-
cally determined.
Environmental. Since sedatives, hypnotics, or anxiolytics are all pharmaceuticals, a key | dsm5.pdf |
5ecd762a4c4c-1 | risk factor relates to availability of the substances. In the United States, the historical pat-
terns of sedative, hypn otic, or anxiolytic misuse relate to the broad prescribing patterns.
For instance, a marked decrease in prescription of barbiturates was associated with an in-
crease in benzodiazepine pres cribing. Peer factors may rela te to genetic predisposition in
terms of how individuals select their environment. Other individuals at heightened risk
might include those with alcohol use disorder who may receive repeated prescriptions in
response to their complaints of al cohol-related anxiety or insomnia.
Genetic and physiological. As for other substance use diso rders, the risk for sedative,
hypnotic, or anxiolytic use disorder can be re lated to individual, family, peer, social, and
environmental factors. Within these domains, genetic factors play a particularly important
role both directly and indirectly. Overall, ac ross development, genetic factors seem to play
a larger role in the onset of sedative, hypnotic, or anxiolytic use disorder as individuals age
through puberty into adult life.
Course modifiers. Early onset of use is associated with greater likelihood for develop-
ing a sedative, hypnotic, or anxiolytic use disorder.
Culture-Related Diagnostic Issues
There are marked variations in prescription patt erns (and availability) of this class of sub-
stances in different countries, which may lead to variations in prevalence of sedative, hyp-
notic, or anxiolytic use disorders.
Gender-Related Diagnostic Issues
Females may be at higher risk than males for prescription drug mi suse of sedative, hyp-
notic, or anxiolytic substances.
Diagnostic Markers | dsm5.pdf |
5ecd762a4c4c-2 | notic, or anxiolytic substances.
Diagnostic Markers
Almost all sedative, hypnotic, or anxiolytic substances can be identified through labora-
tory evaluations of urine or blood (the latter of which can quantify the amounts of these | dsm5.pdf |
2b048318a8a9-0 | Sedative, Hypnotic, or Anxiolytic Use Disorder 555
agents in the body). Urine tests are likely to remain positive for up to approximately 1 week
after the use of long-acting substa nces, such as diazepam or flurazepam.
Functional Consequences of
Sedative, Hypnotic, or Anxiolytic Use Disorder
The social and interpersonal co nsequences of sedative, hypnot ic, or anxiolytic use disorder
mimic those of alcohol in terms of the potentia l for disinhibited behavior. Accidents, interper-
sonal difficulties (such as argume nts or fights), and interference with work or school perfor-
mance are all common outcomes. Physical examinat ion is likely to reveal evidence of a mild
decrease in most aspects of autonomic nervous system functioning, including a slower pulse,
a slightly decreased respiratory rate, and a slight drop in blood pressure (most likely to occur
with postural changes). At high doses, sedative, hypnotic, or an xiolytic substances can be le-
thal, particularly when mixed with alcohol, al though the lethal dosage varies considerably
among the specific substances. Overdoses may be associated with a deterioration in vital signs
that signals an impending medical emergency (e .g., respiratory arrest from barbiturates).
There may be consequences of trauma (e.g., internal bleeding or a subdural hematoma) from
accidents that occur while intoxicated. Intraven ous use of these substances can result in med-
ical complications related to the use of contaminated needles (e.g., hepatitis and HIV).
Acute intoxication can result in accidental injuries and automobile accidents. For elderly
individuals, even short-term use of these sedati ng medications at prescr ibed doses can be as- | dsm5.pdf |
2b048318a8a9-1 | sociated with an increased risk for cognitive problems and falls. The disinhibiting effects of
these agents, like alcohol, may potentially cont ribute to overly aggressive behavior, with sub-
sequent interpersonal and legal problems. Accide ntal or deliberate overdoses, similar to those
observed for alcohol use disorder or repeated alcohol intoxication, can occur. In contrast to
their wide margin of safety when used alone, benzodiazepines taken in combination with al-
cohol can be particularly dangerous, and accidental overdoses are reported commonly. Acci-
dental overdoses have also been reported in individuals who deliberately misuse barbiturates
and other nonbenzodiazepine sedatives (e.g., me thaqualone), but since these agents are much
less available than the benzodiazepines, the freq uency of overdosing is low in most settings.
Differential Diagnosis
Other mental disorders or medical conditions. Individuals with se dative-, hypnotic-,
or anxiolytic-induced disorders may present with symptoms (e.g., anxiety) that resemble
primary mental disorders (e.g., generalized an xiety disorder vs. sedative-, hypnotic-, or
anxiolytic-induced anxiety disorder, with on set during withdrawal). The slurred speech,
incoordination, and other associa ted features characteristic of sedative, hypnotic, or anx-
iolytic intoxication could be the result of an other medical condition (e .g., multiple sclero-
sis) or of a prior head trauma (e.g., a subdural hematoma).
Alcohol use disorder. Sedative, hypnotic, or anxiolytic use disorder must be differenti-
ated from alcohol use disorder.
Clinically appropriate use of sedative, hypnotic, or anxiolytic medications. Individuals | dsm5.pdf |
2b048318a8a9-2 | Clinically appropriate use of sedative, hypnotic, or anxiolytic medications. Individuals
may continue to take benzodiazepine medication according to a physician’s direction for a
legitimate medical indication over extended pe riods of time. Even if physiological signs of
tolerance or withdrawal are manifested, many of these individuals do not develop symp-
toms that meet the criteria for sedative, hypnotic, or anxiolytic use disorder because they
are not preoccupied with obtaining the substanc e and its use does not interfere with their
performance of usual social or occupational roles.
Comorbidity
Nonmedical use of sedative, hypnotic, or anxi olytic agents is associated with alcohol use | dsm5.pdf |
5fdd81aef979-0 | performance of usual social or occupational roles.
Comorbidity
Nonmedical use of sedative, hypnotic, or anxi olytic agents is associated with alcohol use
disorder, tobacco use disorder, and, generally, illicit drug use. There may also be an over- | dsm5.pdf |
456d5af61c8f-0 | 556 Substance-Related and Addictive Disorders
lap between sedative, hypnotic, or anxiolytic use disorder an d antisocial personality dis-
order; depressive, bipolar, and anxiety disorders; and other substance use disorders, such
as alcohol use disorder and illicit drug use disorders. Antisocial behavior and antisocial
personality disorder are especially associated with sedative, hypnotic, or anxiolytic use
disorder when the substances are obtained illegally.
Sedative, Hypnotic, or Anxiolytic Intoxication
Diagnostic Criteria
A. Recent use of a sedative, hypnotic, or anxiolytic.
B. Clinically significant maladaptive behavioral or psychological changes (e.g., inappro-
priate sexual or aggressive behavior, m ood lability, impaired judgment) that developed
during, or shortly after, sedative, hypnotic, or anxiolytic use.
C. One (or more) of the following signs or symptoms developing during, or shortly after,
sedative, hypnotic, or anxiolytic use:
1. Slurred speech.
2. Incoordination.
3. Unsteady gait.
4. Nystagmus.
5. Impairment in cognition (e.g., attention, memory).
6. Stupor or coma.
D. The signs or symptoms are not attributable to another medical condition and are not
better explained by another mental disorder, including intoxication with another sub-
stance.
Coding note: The ICD-9-CM code is 292.89. The ICD-10-CM code depends on whether
there is a comorbid sedative, hypnotic, or anxiolytic use disorder. If a mild sedative, hyp- | dsm5.pdf |
456d5af61c8f-1 | notic, or anxiolytic use disorder is comorbid, the ICD-10-CM code is F13.129, and if a mod-
erate or severe sedative, hypnotic, or anxio lytic use disorder is comorbid, the ICD-10-CM
code is F13.229. If there is no comorbid sedative, hypnotic, or anxiolytic use disorder, then
the ICD-10-CM code is F13.929.
Note: For information on Developm ent and Course; Risk and Prognostic Factors; Culture-
Related Diagnostic Issues; Diagnostic Marker s; Functional Consequences of Sedative,
Hypnotic, or Anxiolytic Intoxication; and Co morbidity, see the corre sponding sections in
sedative, hypnotic, or anxiolytic use disorder.
Diagnostic Features
The essential feature of sedative, hypnotic, or anxiolytic intoxication is the presence of clini-
cally significant maladaptive behavioral or ps ychological changes (e.g ., inappropriate sexual
or aggressive behavior, mood lability, impair ed judgment, impaired social or occupational
functioning) that develo p during, or shortly after, use of a sedative, hypnotic, or anxiolytic
(Criteria A and B). As with other brain depressants, such as alcohol, these behaviors may be ac-
companied by slurred speech, incoordination (at le vels that can interfere with driving abilities
and with performing usual activities to the poin t of causing falls or automobile accidents), an
unsteady gait, nystagmus, impairment in cogn ition (e.g., attentional or memory problems), | dsm5.pdf |
456d5af61c8f-2 | and stupor or coma (Criterion C). Memory impa irment is a prominent feature of sedative, hyp-
notic, or anxiolytic intoxication and is most often characterized by an anterograde amnesia that
resembles “alcoholic blackouts,” which can be disturbing to the individual. The symptoms
must not be attributable to another medical co ndition and are not better explained by another | dsm5.pdf |
f5cc83286908-0 | Sedative, Hypnotic, or Anxiolytic Withdrawal 557
mental disorder (Criterion D). Intoxication ma y occur in individuals who are receiving these
substances by prescription, are borrowing the medi cation from friends or relatives, or are de-
liberately taking the substance to achieve intoxication.
Associated Features Supporting Diagnosis
Associated features include taking more medi cation than prescribed, taking multiple dif-
ferent medications, or mixing sedative, hypnotic, or anxiolytic agents with alcohol, which
can markedly increase the effects of these agents.
Prevalence
The prevalence of sedative, hypnotic, or anxi olytic intoxication in the general population
is unclear. However, it is probable that most nonmedical users of sedatives, hypnotics, or
anxiolytics would at some time have signs or symptoms that meet criteria for sedative,
hypnotic, or anxiolytic intoxication; if so, then the prevalence of nonmedical sedative,
hypnotic, or anxiolytic use in the general po pulation may be simila r to the prevalence of
sedative, hypnotic, or anxiolytic intoxicati on. For example, tranquilizers are used non-
medically by 2.2% of Amer icans older than 12 years.
Differential Diagnosis
Alcohol use disorders. Since the clinical presentations may be identical, distinguishing sed-
ative, hypnotic, or anxiolytic intoxication from alcohol use disorders requires evidence for re-
cent ingestion of sedative, hypnot ic, or anxiolytic medications by self-report, informant report,
or toxicological testing. Many individuals who misuse sedatives, hypnotics, or anxiolytics may | dsm5.pdf |
f5cc83286908-1 | also misuse alcohol and other su bstances, and so multiple intoxi cation diagnoses are possible.
Alcohol intoxication. Alcohol intoxication may be distin guished from sedative, hypnotic,
or anxiolytic intoxication by the smell of al cohol on the breath. Otherwise, the features of
the two disorders may be similar.
Other sedative-, hypnotic-, or anxiolytic-induced disorders. Sedative, hypnotic, or anx-
iolytic intoxication is distin guished from the other sedative-, hypnotic-, or anxiolytic-
induced disorders (e.g., sedative-, hypnotic-, or anxiolytic-induced anxiety disorder, with
onset during withdrawal) because the sympto ms in the latter disorders predominate in
the clinical presentation and are severe enough to warrant clinical attention.
Neurocognitive disorders. In situations of cognitive im pairment, traumatic brain in-
jury, and delirium from other causes, sedative s, hypnotics, or anxiolytics may be intoxi-
cating at quite low dosages. The differential diagnosis in these complex settings is based
on the predominant syndrome. An additional diagnosis of sedative, hypnotic, or anxio-
lytic intoxication may be appropriate even if the substance has been ingested at a low dos-
age in the setting of these other (o r similar) co-occu rring conditions.
Sedative, Hypnotic, or Anxiolytic Withdrawal
Diagnostic Criteria
A. Cessation of (or reduction in) sedative, hypnotic, or anxiolytic use that has been pro-
longed.
B. Two (or more) of the following, developing within several hours to a few days after the ces- | dsm5.pdf |
f5cc83286908-2 | sation of (or reduction in) sedative, hypnotic, or anxiolytic use described in Criterion A:
1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
2. Hand tremor. | dsm5.pdf |
632aa0fdeec7-0 | 558 Substance-Related and Addictive Disorders
3. Insomnia.
4. Nausea or vomiting.
5. Transient visual, tactile, or auditory hallucinations or illusions.
6. Psychomotor agitation.
7. Anxiety.
8. Grand mal seizures.
C. The signs or symptoms in Criterion B cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition and are not
better explained by another mental disorder, including intoxication or withdrawal from
another substance.
Specify if:
With perceptual disturbances: This specifier may be noted when hallucinations with in-
tact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium.
Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code for sedative, hypnotic,
or anxiolytic withdrawal depends on whether or not there is a comorbid moderate or se-
vere sedative, hypnotic, or anxiolytic use di sorder and whether or not there are perceptual
disturbances. For sedative, hypnotic, or anxiolytic withdrawal without perceptual distur-
bances, the ICD-10-CM code is F13.239. For sedative, hypnotic, or anxiolytic withdrawal
with perceptual disturbances, the ICD-10-CM code is F13.232. Note that the ICD-10-CM
codes indicate the comorbid presence of a moderate or severe sedative, hypnotic, or anx-
iolytic use disorder, reflecting the fact that sedative, hypnotic, or anxiolytic withdrawal can | dsm5.pdf |
632aa0fdeec7-1 | only occur in the presence of a moderate or severe sedative, hypnotic, or anxiolytic use
disorder. It is not permissible to code a comorbid mild sedative, hypnotic, or anxiolytic use
disorder with sedative, hypnotic, or anxiolytic withdrawal.
Note: For information on Developm ent and Course; Risk and Prognostic Factors; Culture-
Related Diagnostic Issues; Functional Conseq uences of Sedative, Hypnotic, or Anxiolytic
Withdrawal; and Comorbidity, see the corresp onding sections in sedative, hypnotic, or
anxiolytic use disorder.
Diagnostic Features
The essential feature of sedative, hypnotic, or anxiolytic withdrawal is the presence of a char-
acteristic syndrome that develops after a marked decrease in or cessation of intake after several
weeks or more of regular use (C riteria A and B). This withdrawal syndrome is characterized by
two or more symptoms (similar to alcohol with drawal) that include au tonomic hyperactivity
(e.g., increases in heart rate, respiratory rate, blood pressure, or body temperature, along with
sweating); a tremor of the hands; insomnia ; nausea, sometimes accompanied by vomiting;
anxiety; and psychomotor agitation. A grand mal seizure may occur in perhaps as many as
20%–30% of individuals undergoing untreated withdrawal from these substances. In severe
withdrawal, visual, tactile, or auditory hallucinations or illus ions can occur but are usually in
the context of a delirium. If the individual’s rea lity testing is intact (i.e., he or she knows the
substance is causing the hallucinations) and the illusions occur in a clear sensorium, the spec- | dsm5.pdf |
632aa0fdeec7-2 | ifier “with perceptual disturbances” can be note d. When hallucinations occur in the absence of
intact reality testing, a diagnosis of substanc e/medication-induced ps ychotic disorder should
be considered. The symptoms cause clinically si gnificant distress or impairment in social, oc-
cupational, or other important areas of functioning (Criterion C). The symptoms must not be
attributable to anothe r medical condition and are not bette r explained by an other mental dis-
order (e.g., alcohol withdrawal or generalized anxiety disorder) (Criterion D). Relief of with-
drawal symptoms with admini stration of any sedative-hypnotic agent would support a
diagnosis of sedative, hypnotic, or anxiolytic withdrawal. | dsm5.pdf |
441bcce87705-0 | Sedative, Hypnotic, or Anxiolytic Withdrawal 559
Associated Features Supporting Diagnosis
The timing and severity of the withdrawal sy ndrome will differ depending on the specific
substance and its pharmacokinetics and ph armacodynamics. For example, withdrawal
from shorter-acting substances that are rapidl y absorbed and that have no active metabo-
lites (e.g., triazolam) can begi n within hours after the subs tance is stopped; withdrawal
from substances with long-acting metabolites (e.g., diazepam) may not begin for 1–2 days
or longer. The withdrawal syndrome produced by substances in this class may be charac-
terized by the development of a delirium that can be life-threatening. There may be evi-
dence of tolerance and withdr awal in the absence of a diagnosis of a substance use
disorder in an individual who has abruptly discontinued benzodiazepines that were taken
for long periods of time at prescribed and therapeutic doses. Howe ver, ICD-10-CM codes
only allow a diagnosis of seda tive, hypnotic, or anxiolytic withdrawal in the presence of
comorbid moderate to severe sedative, hypnotic, or anxiolytic use disorder.
The time course of the withdr awal syndrome is generally predicted by the half-life of
the substance. Medications whose actions typica lly last about 10 hours or less (e.g., loraz-
epam, oxazepam, temazepam) produce withdr awal symptoms within 6–8 hours of de-
creasing blood levels that peak in intensity on the second day and improve markedly by
the fourth or fifth day. For substances with longer half-lives (e .g., diazepam), symptoms | dsm5.pdf |
441bcce87705-1 | may not develop for more than 1 week, peak in intensity during the second week, and de-
crease markedly during the third or fourth week. There may be additional longer-term
symptoms at a much lower level of inte nsity that persist for several months.
The longer the substance has been taken and the higher the dosages used, the more likely
it is that there will be severe withdrawal. However, withdrawal has been reported with as little
as 15 mg of diazepam (or its eq uivalent in other benzodiazepines) when taken daily for several
months. Doses of approximately 40 mg of diazepa m (or its equivalent) daily are more likely to
produce clinically relevant withdrawal symptoms, and even higher doses (e.g., 100 mg of di-
azepam) are more likely to be followed by withdrawal seizures or delirium. Sedative, hyp-
notic, or anxiolytic withdrawal delirium is ch aracterized by disturbances in consciousness and
cognition, with visual, tactile, or auditory ha llucinations. When present, sedative, hypnotic, or
anxiolytic withdrawal delirium should be diagnosed instead of withdrawal.
Prevalence
The prevalence of sedative, hypnotic, or anxiolytic withdrawal is unclear.
Diagnostic Markers
Seizures and autonomic instability in the setting of a history of prolonged exposure to sed-
ative, hypnotic, or anxiolytic medications su ggest a high likelihood of sedative, hypnotic,
or anxiolytic withdrawal.
Differential Diagnosis
Other medical disorders. The symptoms of sedative, hypnotic, or anxiolytic with-
drawal may be mimicked by other medical cond itions (e.g., hypoglyc emia, diabetic keto- | dsm5.pdf |
441bcce87705-2 | acidosis). If seizures are a feature of the seda tive, hypnotic, or anxi olytic withdrawal, the
differential diagnosis includes the various causes of seizures (e.g., infections, head injury,
poisonings).
Essential tremor. Essential tremor, a disorder that frequently runs in families, may
erroneously suggest the tremulousness associat ed with sedative, hypnotic, or anxiolytic
withdrawal.
Alcohol withdrawal. Alcohol withdrawal produces a sy ndrome very similar to that of
sedative, hypnotic, or anxiolytic withdrawal. | dsm5.pdf |
65504de9d269-0 | 560 Substance-Related and Addictive Disorders
Other sedative-, hypnotic-, or anxiolytic-induced disorders. Sedative, hypnotic, or anx-
iolytic withdrawal is distingu ished from the other sedative-, hypnotic-, or anxiolytic-
induced disorders (e.g., sedative-, hypnotic-, or anxiolytic-induced anxiety disorder, with
onset during withdrawal) beca use the symptoms in the latter disorders predominate in
the clinical presentation and are severe enough to warrant clinical attention.
Anxiety disorders. Recurrence or worsening of an underlying anxiety disorder pro-
duces a syndrome similar to sedative, hypnotic, or anxiolytic withdrawal. Withdrawal
would be suspected with an abrupt reduction in the dosage of a sedative, hypnotic, or anx-
iolytic medication. When a taper is under wa y, distinguishing the withdrawal syndrome
from the underlying anxiety disorder can be difficult. As with alco hol, lingering with-
drawal symptoms (e.g., anxiety, moodiness, and trouble sleeping) can be mistaken for
non-substance/medication-induc ed anxiety or depr essive disorders (e.g., generalized
anxiety disorder).
Other Sedative-, Hypnotic-,
or Anxiolytic-Induced Disorders
The following sedative-, hypnotic-, or anxiolyt ic-induced disorders are described in other
chapters of the manual with disorders with which they share phenomenology (see the sub-
stance/medication-induced mental disorders in these chapters): sedative-, hypnotic-, or
anxiolytic-induced psychotic disorder (“Schizophrenia Spectrum and Other Psychotic
Disorders”); sedative-, hypnotic-, or anxiolytic -induced bipolar disord er (“Bipolar and Re- | dsm5.pdf |
65504de9d269-1 | lated Disorders”); sedative-, hypnotic-, or anxiolytic-induced depressive disorder (“De-
pressive Disorders”); sedative-, hypnotic-, or anxiolytic-induced anxiety disorder
(“Anxiety Disorders”); sedative-, hypnotic-, or anxiolytic-induced sleep disorder (“Sleep-
Wake Disorders”); sedative-, hypnotic-, or anxiolytic-induc ed sexual dysfunction (“Sex-
ual Dysfunctions”); and sedative-, hypnotic-, or anxiolytic-induced major or mild neuro-
cognitive disorder (“Neurocog nitive Disorders”). For seda tive, hypnotic, or anxiolytic
intoxication delirium and sedative, hypnotic, or anxiolytic withdrawal delirium, see the
criteria and discussion of delirium in the chapter “Neurocognitive Disorders.” These sed-
ative-, hypnotic-, or anxiolytic-induced disorders are diagnosed inst ead of sedative, hyp-
notic, or anxiolytic intoxication or sedative, hypnotic, or anxiolytic withdrawal only when
the symptoms are sufficiently severe to warrant independent clinical attention.
Unspecified Sedative-, Hypnotic-,
or Anxiolytic-Related Disorder
292.9 (F13.99)
This category applies to presentations in which symptoms characteristic of a sedative-,
hypnotic-, or anxiolytic-related disorder that cause clinically significant distress or impair-
ment in social, occupational, or other impor tant areas of functioning predominate but do
not meet the full criteria for any specific s edative-, hypnotic-, or anxiolytic-related disorder
or any of the disorders in the substance-related and addictive disorders diagnostic class. | dsm5.pdf |
87fcca424143-0 | Stimulant Use Disorder 561
Stimulant-Related Disorders
Stimulant Use Disorder
Stimulant Intoxication
Stimulant Withdrawal
Other Stimulant-Induced Disorders
Unspecified Stimulant-Related Disorder
Stimulant Use Disorder
Diagnostic Criteria
A. A pattern of amphetamine-type substance, cocaine, or other stimulant use leading to
clinically significant impairment or distress, as manifested by at least two of the follow-
ing, occurring within a 12-month period:
1. The stimulant is often taken in larger amounts or over a longer period than was in-
tended.
2. There is a persistent desire or unsuccessful efforts to cut down or control stimulant use.
3. A great deal of time is spent in activities necessary to obtain the stimulant, use the
stimulant, or recover from its effects.
4. Craving, or a strong desire or urge to use the stimulant.
5. Recurrent stimulant use resulting in a failure to fulfill major role obligations at work,
school, or home.
6. Continued stimulant use despite having persi stent or recurrent social or interper-
sonal problems caused or exacerbated by the effects of the stimulant.
7. Important social, occupational, or recreat ional activities are given up or reduced be-
cause of stimulant use.
8. Recurrent stimulant use in situations in which it is physically hazardous.
9. Stimulant 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 stimulant.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of the stimulant to achieve intoxication
or desired effect.
b. A markedly diminished effect with continued use of the same amount of the | dsm5.pdf |
87fcca424143-1 | b. A markedly diminished effect with continued use of the same amount of the
stimulant.
Note: This criterion is not considered to be met for those taking stimulant medica-
tions solely under appropriate medical supervision, such as medications for atten-
tion-deficit/hyperactivity disorder or narcolepsy.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome fo r the stimulant (refer to Criteria A and
B of the criteria set for stimulant withdrawal, p. 569).
b. The stimulant (or a closely related substance) is taken to relieve or avoid with-
drawal symptoms. | dsm5.pdf |
416e351c1bbf-0 | 562 Substance-Related and Addictive Disorders
Note: This criterion is not considered to be met for those taking stimulant medica-
tions solely under appropriate medical supervision, such as medications for atten-
tion-deficit/hyperactivity disorder or narcolepsy.
Specify if:
In early remission: After full criteria for stimulant use disorder were previously met,
none of the criteria for stimulant use disorder have been met for at least 3 months but
for less than 12 months (with the exception that Criterion A4, “Craving, or a strong de-
sire or urge to use the stimulant,” may be met).
In sustained remission: After full criteria for stimulant use disorder were previously
met, none of the criteria for stimulant use disorder have been met at any time during a
period of 12 months or longer (with the exception that Criterion A4, “Craving, or a
strong desire or urge to use the stimulant,” may be met).
Specify if:
In a controlled environment: This additional specifier is used if the individual is in an
environment where access to stimulants is restricted.
Coding based on current severity: Note for ICD-10-CM codes: If an amphetamine in-
toxication, amphetamine withdrawal, or anot her amphetamine-induced mental disorder is
also present, do not use the codes below for amphetamine use disorder. Instead, the co-
morbid amphetamine use disorder is indicat ed in the 4th character of the amphetamine-
induced disorder code (see the coding note for amphetamine intoxication, amphetamine
withdrawal, or a specific amphetamine-induced m ental disorder). For example, if there is
comorbid amphetamine-type or other stimulant-induced depressive disorder and amphet- | dsm5.pdf |
416e351c1bbf-1 | comorbid amphetamine-type or other stimulant-induced depressive disorder and amphet-
amine-type or other stimulant use disorder, only the amphetamine-type or other stimulant-
induced depressive disorder code is given, with the 4th character indicating whether the
comorbid amphetamine-type or other stimulant use disorder is mild, moderate, or severe:
F15.14 for mild amphetamine-type or other st imulant use disorder with amphetamine-type
or other stimulant-induced depressive disorder or F15.24 for a moderate or severe am-
phetamine-type or other stimulant use disorder with amphetamine-type or other stimulant-
induced depressive disorder. Similarly, if there is comorbid cocaine-induced depressive
disorder and cocaine use disorder, only the cocaine-induced depressive disorder code is
given, with the 4th character indicating whether the comorbid cocaine use disorder is mild,
moderate, or severe: F14.14 for mild cocaine use disorder with cocaine-induced depressive
disorder or F14.24 for a moderate or severe cocaine use disorder with cocaine-induced
depressive disorder.
Specify current severity:
Mild: Presence of 2–3 symptoms.
305.70 (F15.10) Amphetamine-type substance
305.60 (F14.10) Cocaine
305.70 (F15.10) Other or unspecified stimulant
Moderate: Presence of 4–5 symptoms.
304.40 (F15.20) Amphetamine-type substance
304.20 (F14.20) Cocaine
304.40 (F15.20) Other or unspecified stimulant
Severe: Presence of 6 or more symptoms.
304.40 (F15.20) Amphetamine-type substance
304.20 (F14.20) Cocaine | dsm5.pdf |
416e351c1bbf-2 | 304.20 (F14.20) Cocaine
304.40 (F15.20) Other or unspecified stimulant | dsm5.pdf |
cd991c573a21-0 | Stimulant Use Disorder 563
Specifiers
“In a controlled environment” app lies as a further specifier of remission if the individual is
both in remission and in a controlled environm ent (i.e., in early remission in a controlled
environment or in sustained remission in a controlled environment). Examples of these
environments are closely supe rvised and substanc e-free jails, therapeutic communities,
and locked hospital units.
Diagnostic Features
The amphetamine and amphetamine-type stimul ants include substances with a substi-
tuted-phenylethylamine struct ure, such as amphetamine, dextroamphetamine, and meth-
amphetamine. Also included are those substanc es that are structura lly different but have
similar effects, such as methylphenidate. These substances are usually taken orally or in-
travenously, although methamphetamine is also taken by the nasal route. In addition to
the synthetic amphetamine-type compounds, th ere are naturally occurring, plant-derived
stimulants such as khât. Amphetamines and other stimulants may be obtained by prescrip-
tion for the treatment of obesity, attention-deficit/hyperactivity disorder, and narcolepsy.
Consequently, prescribed stimul ants may be diverted into the illegal market. The effects of
amphetamines and amphetamine-like drugs are sim ilar to those of cocaine, such that the
criteria for stimulant use disord er are presented here as a sing le disorder with the ability to
specify the particular stimulant used by the individual. Cocaine may be consumed in sev-
eral preparations (e.g., coca leaves, coca pa ste, cocaine hydrochloride, and cocaine alka-
loids such as freebase and crack) that differ in potency because of varying levels of purity | dsm5.pdf |
cd991c573a21-1 | and speed of onset. However, in all forms of the substance, cocaine is the active ingredient.
Cocaine hydrochloride powder is usually “snorted” through the nostrils or dissolved in
water and injected intravenously.
Individuals exposed to amphetamine-type stimulants or cocaine can develop stimu-
lant use disorder as rapidly as 1 week, although the onset is not always th is rapid. Re-
gardless of the route of administration, tole rance occurs with repeated use. Withdrawal
symptoms, particularly hypersomnia, increa sed appetite, and dysphoria, can occur and
can enhance craving. Most individuals with stimulant use disorder have experienced tol-
erance or withdrawal.
Use patterns and course are similar for di sorders involving amphetamine-type stimu-
lants and cocaine, as both substances are po tent central nervous system stimulants with
similar psychoactive and sympathomimetic effects. Amphetamine-type stimulants are
longer acting than cocaine and thus are used fewer times per day. Usage may be chronic or
episodic, with binges punctuated by brief no n-use periods. Aggressive or violent behavior
is common when high doses are smoked, ingested, or administered intravenously. Intense
temporary anxiety resembling panic disorder or generalized anxiety disorder, as well as
paranoid ideation and psychotic episodes that resemble schizophrenia, is seen with high-
dose use.
Withdrawal states are associated with temporary but intense depressive symptoms that
can resemble a major depressive episode; the depressive symptoms usually resolve within
1 week. Tolerance to amphetamine -type stimulants develops and leads to escalation of the
dose. Conversely, some users of amphetami ne-type stimulants develop sensitization,
characterized by enhanced effects.
Associated Features Supporting Diagnosis | dsm5.pdf |
cd991c573a21-2 | characterized by enhanced effects.
Associated Features Supporting Diagnosis
When injected or smoked, stimulants typica lly produce an instant feeling of well-being,
confidence, and euphoria. Dramatic behavior al changes can rapidly develop with stimu-
lant use disorder. Chaotic behavior, social is olation, aggressive behavior, and sexual dys-
function can result from long -term stimulant use disorder. | dsm5.pdf |
2255e87c1cc0-0 | 564 Substance-Related and Addictive Disorders
Individuals with acute intoxication may pr esent with rambling speech, headache, tran-
sient ideas of reference, and tinnitus. There may be paranoid ideati on, auditory halluci-
nations in a clear sensorium, and tactile hallucinations, which the individual usually
recognizes as drug effects. Thre ats or acting out of aggressive behavior may occur. Depres-
sion, suicidal ideation, irritability, anhedonia, emotional lability, or disturbances in atten-
tion and concentration commonly occur during withdrawal. Mental disturbances associated
with cocaine use usually resolve hours to days after cessation of use but can persist for
1 month. Physiological changes during stimulant withdrawal ar e opposite to those of the
intoxication phase, sometimes including bradycardia. Temporary depressive symptoms
may meet symptomatic and duration criteria for major depressive episode. Histories con-
sistent with repeated panic attacks, social an xiety disorder (social phobia)–like behavior,
and generalized anxiety–like syndromes are co mmon, as are eating disorders. One ex-
treme instance of stimulant toxicity is st imulant-induced psychotic disorder, a disorder
that resembles schizophrenia, with delusions and hallucinations.
Individuals with stimulant use disorder of ten develop conditioned responses to drug-
related stimuli (e.g., craving on seeing an y white powderlike substance). These responses
contribute to relapse, are difficult to extinguish, and persist after detoxification.
Depressive symptoms with su icidal ideation or behavior can occur and are generally
the most serious problems seen during stimulant withdrawal.
Prevalence
Stimulant use disorder: amphetamine-type stimulants. Estimated 12-month prevalence | dsm5.pdf |
2255e87c1cc0-1 | Stimulant use disorder: amphetamine-type stimulants. Estimated 12-month prevalence
of amphetamine-type stimulant use disorder in the United States is 0.2% among 12- to 17-
year-olds and 0.2% among individuals 18 year s and older. Rates are similar among adult
males and females (0.2%), but among 12- to 17- year-olds, the rate for females (0.3%) is
greater than that for males (0.1%). Intravenou s stimulant use has a male-to-female ratio of
3:1 or 4:1, but rates are more balanced amon g non-injecting users, with males representing
54% of primary treatment admissions. Twelve -month prevalence is greater among 18- to
29-year-olds (0.4%) compared with 45- to 64-ye ar-olds (0.1%). For 12- to 17-year-olds, rates
are highest among whites and African Americans (0.3%) compared with Hispanics (0.1%)
and Asian Americans and Pacific Islanders (0.01%), with amphetamine-type stimulant use
disorder virtually absent among Native Americans. Among adults, rates are highest among
Native Americans and Alaska Natives (0.6%) compared with whites (0.2%) and Hispanics
(0.2%), with amphetamine-type stimulant use disorder virtually absent among African
Americans and Asian Americans and Pacific Islanders. Past-year nonprescribed use of
prescription stimulants occu rred among 5%–9% of children through high school, with
5%–35% of college-age persons reporting past-year use.
Stimulant use disorder: cocaine. Estimated 12-month prevalence of cocaine use disorder | dsm5.pdf |
2255e87c1cc0-2 | Stimulant use disorder: cocaine. Estimated 12-month prevalence of cocaine use disorder
in the United States is 0.2% among 12- to 17- year-olds and 0.3% amon g individuals 18 years
and older. Rates are higher among males (0 .4%) than among females (0.1%). Rates are
highest among 18- to 29-year-olds (0.6%) and lo west among 45- to 64-year-olds (0.1%). Among
adults, rates are greater among Native Amer icans (0.8%) compared with African Ameri-
cans (0.4%), Hispanics (0.3%), whites (0.2%) , and Asian Americans and Pacific Islanders
(0.1%). In contrast, for 12- to 17-year-olds, rates are similar among Hispanics (0.2%), whites
(0.2%), and Asian Americans and Pacific Islanders (0.2%); and lower among African Amer-
icans (0.02%); with cocaine use disorder vi rtually absent among Native Americans and
Alaska Natives.
Development and Course
Stimulant use disorders occur throughout all levels of society and are more common among | dsm5.pdf |
d20ea3b23bf6-0 | Alaska Natives.
Development and Course
Stimulant use disorders occur throughout all levels of society and are more common among
individuals ages 12–25 years compared with indi viduals 26 years and olde r. First regular use | dsm5.pdf |
1e6813e80fe2-0 | Stimulant Use Disorder 565
among individuals in treatment occurs, on average, at approximately age 23 years. For pri-
mary methamphetamine–primary treatment admissions, the average age is 31 years.
Some individuals begin stimulant use to control weight or to improve performance in
school, work, or athlet ics. This includes obtaining medications such as methylphenidate or
amphetamine salts prescribed to others for the treatment of attention-deficit/hyperac-
tivity disorder. Stimulant use disorder can develop rapidly with intravenous or smoked
administration; among primary admissions fo r amphetamine-type stimulant use, 66% re-
ported smoking, 18% reported inje cting, and 10% reported snorting.
Patterns of stimulant administration include episodic or daily (or almost daily) use.
Episodic use tends to be separated by 2 or more days of non-use (e.g., intense use over a
weekend or on one or more weekdays). “Bin ges” involve continuous high-dose use over
hours or days and are often associated with physical dependence. Binges usually termi-
nate only when stimulant supplies are deplet ed or exhaustion ensues. Chronic daily use
may involve high or low doses, often with an increase in dose over time.
Stimulant smoking and intravenous use are a ssociated with rapid progression to se-
vere-level stimulant use disorder, often occu rring over weeks to months. Intranasal use of
cocaine and oral use of amphetamine-type stim ulants result in more gradual progression
occurring over months to years. With continui ng use, there is a diminution of pleasurable
effects due to tolerance and an increase in dysphoric effects.
Risk and Prognostic Factors | dsm5.pdf |
1e6813e80fe2-1 | Risk and Prognostic Factors
Temperamental. Comorbid bipolar disorder, schizophrenia, antisocial personality disor-
der, and other substance use disorders are risk factors for developing stimulant use disorder
and for relapse to cocaine use in treatment samp les. Also, impulsivity and similar personality
traits may affect treatment outcomes. Childhood conduct disorder and adult antisocial per-
sonality disorder are associated with the la ter development of stim ulant-related disorders.
Environmental. Predictors of cocaine use among teenagers include prenatal cocaine ex-
posure, postnatal cocaine use by parents, and exposure to community violence during
childhood. For youths, especially females, risk factors include living in an unstable home
environment, having a psychiatric conditio n, and associating with dealers and users.
Culture-Related Diagnostic Issues
Stimulant use–attendant disorders affect all ra cial/ethnic, socioeconomic, age, and gender
groups. Diagnostic issues may be related to societal consequenc es (e.g., arrest, school sus-
pensions, employment suspension). Despite sm all variations, cocaine and other stimulant
use disorder diagnostic criteria perform eq ually across gender and race/ethnicity groups.
Chronic use of cocaine impairs cardiac left ventricular function in African Americans.
Approximately 66% of individuals admitt ed for primary methamphetamine/amphet-
amine-related disorders are non-Hispanic whit e, followed by 21% of Hispanic origin, 3%
Asian and Pacific Islander, and 3% non-Hispanic black.
Diagnostic Markers
Benzoylecgonine, a metabolite of cocaine, typi cally remains in the urine for 1–3 days after
a single dose and may be present for 7–12 days in individuals using repeated high doses. | dsm5.pdf |
1e6813e80fe2-2 | Mildly elevated liver function tests can be pr esent in cocaine injectors or users with con-
comitant alcohol use. There are no neurobiological markers of diagnostic utility. Discon-
tinuation of chronic cocaine use may be asso ciated with electroencephalographic changes,
suggesting persistent abnormalit ies; alterations in secretion patterns of prolactin; and
downregulation of dopamine receptors.
Short-half-life amphetamine-type stim ulants (MDMA [3,4-methylenedioxy- N-methyl-
amphetamine], methamphetamine) can be detected for 1–3 days, and possibly up to 4 days | dsm5.pdf |
f6e98fbf0313-0 | 566 Substance-Related and Addictive Disorders
depending on dosage and metabolism. Hair sampl es can be used to detect presence of am-
phetamine-type stimulants for up to 90 days. Other laboratory findings, as well as physical
findings and other medical conditions (e.g., weight loss, malnutrition; poor hygiene), are
similar for both cocaine and amphet amine-type stimulant use disorder.
Functional Consequences of Stimulant Use Disorder
Various medical conditions may occur dependin g on the route of administration. Intrana-
sal users often develop sinusitis, irritation, bl eeding of the nasal mucosa, and a perforated
nasal septum. Individuals who smoke the drugs are at increased risk for respiratory prob-
lems (e.g., coughing, bronchitis, and pneumonitis). Injectors have puncture marks and
“tracks,” most commonly on their forearms. Ri sk of HIV infection increases with frequent
intravenous injections and unsafe sexual acti vity. Other sexually transmitted diseases,
hepatitis, and tuberculosis and other lung infections are also seen . Weight loss and mal-
nutrition are common.
Chest pain may be a common symptom during stimulant intoxication. Myocardial in-
farction, palpitations and arrhythmias, sudden death from respiratory or cardiac arrest,
and stroke have been associated with stimulant use among young and otherwise healthy
individuals. Seizures can occur with stimulant use. Pneumothorax can result from per-
forming Valsalva-like maneuvers done to better absorb inhaled smoke. Traumatic injuries
due to violent behavior are common among in dividuals trafficking drugs. Cocaine use is
associated with irregularities in placental bl ood flow, abruptio placentae, premature labor
and delivery, and an increased prevalence of infants with very low birth weights. | dsm5.pdf |
f6e98fbf0313-1 | and delivery, and an increased prevalence of infants with very low birth weights.
Individuals with stimulant use disorder may become involved in theft, prostitution, or
drug dealing in order to acquire drugs or money for drugs.
Neurocognitive impairment is common am ong methamphetamine users. Oral health
problems include “meth mouth” with gum dise ase, tooth decay, and mouth sores related
to the toxic effects of smoking the drug and to bruxism while intoxicated. Adverse pulmo-
nary effects appear to be le ss common for amphetamine-type stimulants because they are
smoked fewer times per day. Emergency department visits are common for stimulant-re-
lated mental disorder symptoms, injury, skin infections, and dental pathology.
Differential Diagnosis
Primary mental disorders. Stimulant-induced disorders may resemble primary mental
disorders (e.g., major depressive disorder) (for discussion of th is differential diagnosis, see
“Stimulant Withdrawal”). The mental disturbanc es resulting from the effects of stimulants
should be distinguished from the symptoms of schizophrenia; depressive and bipolar dis-
orders; generalized anxiety disorder; and panic disorder.
Phencyclidine intoxication. Intoxication with phencyclidine (“PCP” or “angel dust”) or
synthetic “designer drugs” such as mephedrone (known by different names, including
“bath salts”) may cause a similar clinical pict ure and can only be di stinguished from stim-
ulant intoxication by the presence of coca ine or amphetamine-type substance metabolites
in a urine or plasma sample.
Stimulant intoxication and withdrawal. Stimulant intoxication and withdrawal are dis-
tinguished from the other stimulant-induced di sorders (e.g., anxiety disorder, with onset | dsm5.pdf |
f6e98fbf0313-2 | during intoxication) because the symptoms in the latter disorders predominate the clinical
presentation and are severe enough to warrant independent clinical attention.
Comorbidity
Stimulant-related disorders often co-occur wi th other substance use disorders, especially
those involving substances with sedative properties, which are often taken to reduce in- | dsm5.pdf |
ec63b2c8876f-0 | Stimulant Intoxication 567
somnia, nervousness, and other unpleasant side effects. Cocaine users often use alcohol,
while amphetamine-type stimulant users ofte n use cannabis. Stimulant use disorder may
be associated with posttraumatic stress diso rder, antisocial personality disorder, atten-
tion-deficit/hyperacti vity disorder, and gambling di sorder. Cardiopulmonary problems
are often present in individuals seeking treatm ent for cocaine-related problems, with chest
pain being the most common. Medical problems occur in response to adulterants used as
“cutting” agents. Cocaine users who ingest co caine cut with levamisole, an antimicrobial
and veterinary medication, may experience agranulocytosis and febrile neutropenia.
Stimulant Intoxication
Diagnostic Criteria
A. Recent use of an amphetamine-type substance, cocaine, or other stimulant.
B. Clinically significant problematic behavioral or psychological changes (e.g., euphoria
or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity;
anxiety, tension, or anger; stereotyped behaviors; impaired judgment) that developed
during, or shortly after, use of a stimulant.
C. Two (or more) of the following signs or symptoms, developing during, or shortly after,
stimulant use:
1. Tachycardia or bradycardia.
2. Pupillary dilation.
3. Elevated or lowered blood pressure.
4. Perspiration or chills.
5. Nausea or vomiting.
6. Evidence of weight loss.
7. Psychomotor agitation or retardation.
8. Muscular weakness, respiratory depression , chest pain, or cardiac arrhythmias. | dsm5.pdf |
ec63b2c8876f-1 | 8. Muscular weakness, respiratory depression , chest pain, or cardiac arrhythmias.
9. Confusion, seizures, dyskinesias, dystonias, or coma.
D. The signs or symptoms are not attributable to another medical condition and are not
better explained by another mental disorder, including intoxication with another sub-
stance.
Specify the specific intoxicant (i.e., amphetamine-type substance, cocaine, or other
stimulant).
Specify if:
With perceptual disturbances: This specifier may be noted when hallucinations with
intact reality testing or auditory, visual, or tactile illusions occur in the absence of a de-
lirium.
Coding note: The ICD-9-CM code is 292.89. The ICD-10-CM code depends on whether
the stimulant is an amphetamine, cocaine, or other stimulant; whether there is a comorbid
amphetamine, cocaine, or other stimulant use disorder; and whether or not there are per-
ceptual disturbances.
For amphetamine, cocaine, or other stimulant intoxication, without perceptual dis-
turbances: If a mild amphetamine or other stimulant use disorder is comorbid, the ICD-
10-CM code is F15.129, and if a moderate or severe amphetamine or other stimulant use
disorder is comorbid, the ICD-10-CM code is F15.229. If there is no comorbid amphet-
amine or other stimulant use disorder, then the ICD-10-CM code is F15.929. Similarly, if
a mild cocaine use disorder is comorbid, the ICD-10-CM code is F14.129, and if a mod- | dsm5.pdf |
ec63b2c8876f-2 | erate or severe cocaine use disorder is comorbid, the ICD-10-CM code is F14.229. If
there is no comorbid cocaine use disorder, then the ICD-10-CM code is F14.929. | dsm5.pdf |
bbba0afea597-0 | 568 Substance-Related and Addictive Disorders
For amphetamine, cocaine, or other stimulant intoxication, with perceptual distur-
bances: If a mild amphetamine or other stimulant use disorder is comorbid, the ICD-10-
CM code is F15.122, and if a moderate or severe amphetamine or other stimulant use
disorder is comorbid, the ICD-10-CM code is F15.222. If there is no comorbid amphet-
amine or other stimulant use disorder, then the ICD-10-CM code is F15.922. Similarly, if
a mild cocaine use disorder is comorbid, the ICD-10-CM code is F14.122, and if a mod-
erate or severe cocaine use disorder is comorbid, the ICD-10-CM code is F14.222. If
there is no comorbid cocaine use disorder, then the ICD-10-CM code is F14.922.
Diagnostic Features
The essential feature of stimulant intoxicati on, related to amphetamine-type stimulants
and cocaine, is the presence of clinically significant behavioral or psychological changes
that develop during, or shortly after, use of stimulants (Criteria A and B). Auditory hallu-
cinations may be prominent, as may paranoid ideation, and these symptoms must be dis-
tinguished from an independent psychotic disorder such as schizophrenia. Stimulant
intoxication usually begins with a “high” f eeling and includes one or more of the follow-
ing: euphoria with enhanced vigor, gregarious ness, hyperactivity, restlessness, hypervig-
ilance, interpersonal sensitivity, talkativenes s, anxiety, tension, alertness, grandiosity, | dsm5.pdf |
bbba0afea597-1 | stereotyped and repetitive behavior, anger, impaired judgment, and, in the case of chronic
intoxication, affective blunting with fatigue or sadness and social withdrawal. These be-
havioral and psychological changes are acco mpanied by two or more of the following
signs and symptoms that develop during or sh ortly after stimulant us e: tachycardia or bra-
dycardia; pupillary dilation; el evated or lowered blood pressu re; perspiration or chills;
nausea or vomiting; evidence of weight loss ; psychomotor agitation or retardation; mus-
cular weakness, respiratory depression, chest pain, or card iac arrhythmias; and confu-
sion, seizures, dyskinesias, dystonias, or coma (Criterion C). Intoxi cation, either acute or
chronic, is often associated with impaired so cial or occupational functioning. Severe in-
toxication can lead to convulsions, cardiac arrhythmias, hyperpyrexia, and death. For the
diagnosis of stimulant intoxica tion to be made, the symptoms must not be attributable
to another medical condition and not better explained by anot her mental disorder (Crite-
rion D). While stimulant intoxica tion occurs in individuals with stimulant use disorders, in-
toxication is not a criterion for stimulant us e disorder, which is confirmed by the presence
of two of the 11 diagnostic criteria for use disorder.
Associated Features Supporting Diagnosis
The magnitude and direction of the behavioral and physiological changes depend on many
variables, including the dose used and the ch aracteristics of the individual using the sub-
stance or the context (e.g., tolerance, rate of absorption, chronicity of use, context in which | dsm5.pdf |
bbba0afea597-2 | it is taken). Stimulant effects such as eupho ria, increased pulse an d blood pressure, and
psychomotor activity are most commonly seen . Depressant effects such as sadness, brady-
cardia, decreased blood pressure, and decr eased psychomotor activity are less common
and generally emerge only wi th chronic high-dose use.
Differential Diagnosis
Stimulant-induced disorders. Stimulant intoxication is distinguished from the other
stimulant-induced disorders (e.g., stimulant- induced depressive di sorder, bipolar disor-
der, psychotic disorder, anxiety disorder) because the severity of the intoxication symp-
toms exceeds that associated with the stim ulant-induced disorders, and the symptoms
warrant independent clinical attention. Stimulant intoxication delirium would be distin-
guished by a disturbance in level of awareness and change in cognition. | dsm5.pdf |
5ef83f118f9e-0 | Stimulant Withdrawal 569
Other mental disorders. Salient mental disturbances associated with stimulant intoxi-
cation should be distinguished from the symptoms of schizophrenia, paranoid type; bi-
polar and depressive disorders; generalized anxiety disorder; and panic disorder as
described in DSM-5.
Stimulant Withdrawal
Diagnostic Criteria
A. Cessation of (or reduction in) prolonged amphetamine-type substance, cocaine, or
other stimulant use.
B. Dysphoric mood and two (or more) of the following physiological changes, developing
within a few hours to several days after Criterion A:
1. Fatigue.
2. Vivid, unpleasant dreams.
3. Insomnia or hypersomnia.
4. Increased appetite.
5. Psychomotor retardation or agitation.
C. The signs or symptoms in Criterion B cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition and are not
better explained by another mental disorder, including intoxication or withdrawal from
another substance.
Specify the specific substance that causes the withdrawal syndrome (i.e., amphet-
amine-type substance, cocaine, or other stimulant).
Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code depends on whether
the stimulant is an amphetamine, cocaine, or other stimulant. The ICD-10-CM code for
amphetamine or an other stimulant withdrawal is F15.23, and the ICD-10-CM for cocaine
withdrawal is F14.23. Note that the ICD-10-CM code indicates the comorbid presence of
a moderate or severe amphetamine, cocaine, or other stimulant use disorder, reflecting | dsm5.pdf |
5ef83f118f9e-1 | a moderate or severe amphetamine, cocaine, or other stimulant use disorder, reflecting
the fact that amphetamine, cocaine, or other stimulant withdrawal can only occur in the
presence of a moderate or severe amphetamine, cocaine, or other stimulant use disorder.
It is not permissible to code a comorbid mild amphetamine, cocaine, or other stimulant use
disorder with amphetamine, cocaine, or other stimulant withdrawal.
Diagnostic Features
The essential feature of stimulant withdrawal is the presence of a characteristic with-
drawal syndrome that develops within a few hours to several days after the cessation of
(or marked reduction in) stimulant use (genera lly high dose) that has been prolonged (Cri-
terion A). The withdrawal syndrome is char acterized by the development of dysphoric
mood accompanied by two or more of the fo llowing physiological changes: fatigue, vivid
and unpleasant dreams, insomnia or hypers omnia, increased appetite, and psychomotor
retardation or agitation (Crite rion B). Bradycardia is often present and is a reliable mea-
sure of stimulant withdrawal.
Anhedonia and drug craving can often be pres ent but are not part of the diagnostic cri-
teria. These symptoms cause clinically signif icant distress or impairment in social, occu-
pational, or other important areas of functioning (Criterion C). The symptoms must not be
attributable to another medica l condition and are not better explained by another mental
disorder (Criterion D). | dsm5.pdf |
fb0affb37449-0 | 570 Substance-Related and Addictive Disorders
Associated Features Supporting Diagnosis
Acute withdrawal symptoms (“a crash”) are ofte n seen after periods of repetitive high-dose
use (“runs” or “binges”). These periods are char acterized by intense and unpleasant feelings of
lassitude and depression and increased appetite, generally requiring several days of rest and
recuperation. Depressive symptoms with suicidal ideation or behavior can occur and are gen-
erally the most serious problems seen during “crashing” or other forms of stimulant with-
drawal. The majority of individuals with st imulant use disorder experience a withdrawal
syndrome at some point, and virtually all in dividuals with the diso rder report tolerance.
Differential Diagnosis
Stimulant use disorder and other stimulant-induced disorders. Stimulant withdrawal
is distinguished from stimulan t use disorder and from the other stimulant-induced disor-
ders (e.g., stimulant-induced intoxication delirium, depressi ve disorder, bipolar disorder,
psychotic disorder, anxiety disorder, sexual dysfunction, sleep disorder) because the
symptoms of withdrawal predominate the clin ical presentation and are severe enough to
warrant independent clinical attention.
Other Stimulant-Induced Disorders
The following stimulant-induced disorders (w hich include amphetamine-, cocaine-, and
other stimulant–induced disorder s) are described in other chapters of the manual with dis-
orders with which they share phenomenol ogy (see the substance/medication-induced
mental disorders in these chapters): stimulan t-induced psychotic disorder (“Schizophrenia
Spectrum and Other Psychotic Disorders”); st imulant-induced bipolar disorder (“Bipolar
and Related Disorders”); stimulant-induced de pressive disorder (“De pressive Disorders”); | dsm5.pdf |
fb0affb37449-1 | and Related Disorders”); stimulant-induced de pressive disorder (“De pressive Disorders”);
stimulant-induced anxiety disorder (“Anxiet y Disorders”); stimulant-induced obsessive-
compulsive disorder (“Obsessive-Compulsive and Related Disorders”); stimulant-induced
sleep disorder (“Sleep-Wake Disorders”); and stimulant-induced sexual dysfunction (“Sex-
ual Dysfunctions”). For stimulant intoxication delirium, see the criteria and discussion of
delirium in the chapter “Neurocognitive Disorders.” These stimulant-induced disorders
are diagnosed instead of stimulant intoxication or stimulant withdrawal only when the
symptoms are sufficiently severe to wa rrant independent clinical attention.
Unspecified Stimulant-Related Disorder
This category applies to presentations in which symptoms characteristic of a stimulant-
related disorder that cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning predominate but do not meet the full criteria
for any specific stimulant-related disorder or any of the disorders in the substance-related
and addictive disorders diagnostic class.
Coding note: The ICD-9-CM code is 292.9. The ICD-10-CM code depends on whether
the stimulant is an amphetamine, cocaine, or another stimulant. The ICD-10-CM code for
an unspecified amphetamine- or other stimulant-related disorder is F15.99. The ICD-10-
CM code for an unspecified cocaine-related disorder is F14.99. | dsm5.pdf |
6966dc13fcb0-0 | Tobacco Use Disorder 571
Tobacco-Related Disorders
Tobacco Use Disorder
Tobacco Withdrawal
Other Tobacco-Ind uced Disorders
Unspecified Tobacco-Related Disorder
Tobacco Use Disorder
Diagnostic Criteria
A. A problematic pattern of tobacco use leading to clinically significant impairment or dis-
tress, as manifested by at least two of the following, occurring within a 12-month period:
1. Tobacco 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 tobacco use.
3. A great deal of time is spent in activities necessary to obtain or use tobacco.
4. Craving, or a strong desire or urge to use tobacco.
5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work,
school, or home (e.g., interference with work).
6. Continued tobacco use despite having persistent or recurrent social or interper-
sonal problems caused or exacerbated by the effects of tobacco (e.g., arguments
with others about tobacco use).
7. Important social, occupational, or recreat ional activities are given up or reduced be-
cause of tobacco use.
8. Recurrent tobacco use in situations in which it is physically hazardous (e.g., smok-
ing in bed).
9. Tobacco 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 tobacco.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of tobacco to achieve the desired effect.
b. A markedly diminished effect with conti nued use of the same amount of tobacco.
11. Withdrawal, as manifested by either of the following: | dsm5.pdf |
6966dc13fcb0-1 | 11. Withdrawal, as manifested by either of the following:
a. The characteristic withdraw al syndrome for tobacco (refer to Criteria A and B of
the criteria set for tobacco withdrawal).
b. Tobacco (or a closely related substance, such as nicotine) is taken to relieve or
avoid withdrawal symptoms.
Specify if:
In early remission: After full criteria for tobacco use disorder were previously met,
none of the criteria for tobacco use disorder have been met for at least 3 months but
for less than 12 months (with the exception that Criterion A4, “Craving, or a strong de-
sire or urge to use tobacco,” may be met).
In sustained remission: After full criteria for tobacco use disorder were previously
met, none of the criteria for tobacco use disorder have been met at any time during a
period of 12 months or longer (with the exception that Criterion A4, “Craving, or a
strong desire or urge to use tobacco,” may be met). | dsm5.pdf |
f5893c1a8e34-0 | 572 Substance-Related and Addictive Disorders
Specify if:
On maintenance therapy: The individual is taking a long-term maintenance medica-
tion, such as nicotine replacement medication, and no criteria for tobacco use disorder
have been met for that class of medication (except tolerance to, or withdrawal from,
the nicotine replacement medication).
In a controlled environment: This additional specifier is used if the individual is in an
environment where access to tobacco is restricted.
Coding based on current severity: Note for ICD-10-CM codes: If a tobacco withdrawal or
tobacco-induced sleep disorder is also present, do not use the codes below for tobacco use
disorder. Instead, the comorbid tobacco use disorder is indicated in the 4th character of the
tobacco-induced disorder code (see the coding note for tobacco withdrawal or tobacco-
induced sleep disorder). For example, if ther e is comorbid tobacco-induced sleep disorder and
tobacco use disorder, only the tobacco-induced sleep disorder code is given, with the 4th char-
acter indicating whether the comorbid tobacco use disorder is moderate or severe: F17.208
for moderate or severe tobacco use disorder with tobacco-induced sleep disorder. It is not per-
missible to code a comorbid mild tobacco use disorder with a tobacco-induced sleep disorder.
Specify current severity:
305.1 (Z72.0) Mild: Presence of 2–3 symptoms.
305.1 (F17.200) Moderate: Presence of 4–5 symptoms.
305.1 (F17.200) Severe: Presence of 6 or more symptoms.
Specifiers
“On maintenance therapy” applies as a further specifier to individuals being maintained on
other tobacco cessation me dication (e.g., bupropio n, varenicline) and as a further specifier of | dsm5.pdf |
f5893c1a8e34-1 | remission if the individual is both in remissi on and on maintenance therapy. “In a controlled
environment” applies as a further specifier of re mission if the individual is both in remission
and in a controlled environment (i.e., in early remission in a controlled environment or in sus-
tained remission in a controlled environment). Examples of these environments are closely su-
pervised and substance-free jails, therapeutic communities, and locked hospital units.
Diagnostic Features
Tobacco use disorder is common among individu als who use cigarettes and smokeless to-
bacco daily and is uncommon among individuals who do not use tobacco daily or who use
nicotine medications. Tolerance to tobacco is exemplified by the disappearance of nausea
and dizziness after repeated intake and with a more intense effect of tobacco the first time
it is used during the day. Cessation of to bacco use can produce a well-defined withdrawal
syndrome. Many individuals with tobacco use disorder use tobacco to relieve or to avoid
withdrawal symptoms (e.g., after being in a sit uation where use is restricted). Many indi-
viduals who use tobacco have tobacco-relat ed physical symptoms or diseases and con-
tinue to smoke. The large majority report crav ing when they do not smoke for several hours.
Spending excessive time usin g tobacco can be exemplified by chain-smoking (i.e., smok-
ing one cigarette after another with no time between cigarettes). Because tobacco sources
are readily and legally available, and because nicotine intoxication is very rare, spending a
great deal of time attempting to procure toba cco or recovering from its effects is uncom-
mon. Giving up important social, occupational , or recreational acti vities can occur when
an individual forgoes an activity because it occurs in tobacco use–restricted areas. Use of | dsm5.pdf |
f5893c1a8e34-2 | an individual forgoes an activity because it occurs in tobacco use–restricted areas. Use of
tobacco rarely results in failu re to fulfill major role obligat ions (e.g., in terference with
work, interference with home obligations), bu t persistent social or interpersonal problems
(e.g., having arguments with others about to bacco use, avoiding social situations because
of others’ disapproval of tobacco use) or use that is physically hazardous (e.g., smoking in | dsm5.pdf |
91613cc283f7-0 | Tobacco Use Disorder 573
bed, smoking around flammable chemicals) oc cur at an intermediate prevalence. Although
these criteria are less often endorsed by toba cco users, if endorsed, they can indicate a
more severe disorder.
Associated Features Supporting Diagnosis
Smoking within 30 minutes of waking, smoking daily, smoking more cigarettes per day,
and waking at night to smoke are associated with tobacco use di sorder. Environmental
cues can evoke craving and withdrawal. Serious medical conditions, such as lung and
other cancers, cardiac and pulmonary disease , perinatal problems, cough, shortness of
breath, and accelerated skin aging, often occur.
Prevalence
Cigarettes are the most commonly used toba cco product, representing over 90% of to-
bacco/nicotine use. In the United States, 57% of adults have never been smokers, 22% are
former smokers, and 21% are current smokers. Approximately 20% of current U.S. smok-
ers are nondaily smokers. The prevalence of sm okeless tobacco use is less than 5%, and the
prevalence of tobacco use in pipes and cigars is less than 1%.
DSM-IV nicotine dependence criteria can be used to estimate the prevalence of tobacco
use disorder, but since they are a subset of to bacco use disorder criteria, the prevalence of
tobacco use disorder will be somewhat greater. The 12-month prevalence of DSM-IV nic-
otine dependence in the United States is 13% among adults age 18 years and older. Rates
are similar among adult males (14%) and fe males (12%) and decline in age from 17%
among 18- to 29-year-old s to 4% among individuals age 65 years and older. The prevalence | dsm5.pdf |
91613cc283f7-1 | of current nicotine dependence is greate r among Native American and Alaska Natives
(23%) than among whites (14%) but is less am ong African Americans (10%), Asian Amer-
icans and Pacific Islanders (6%), and Hispan ics (6%). The prevalence among current daily
smokers is approximately 50%.
In many developing nations, the prevalence of smoking is much greater in males than
in females, but this is not the case in develope d nations. However, ther e often is a lag in the
demographic transition such that smoking increases in females at a later time.
Development and Course
The majority of U.S. adolescents experiment with tobacco use, and by age 18 years, about
20% smoke at least monthly. Most of these in dividuals become daily tobacco users. Initi-
ation of smoking after age 21 years is rare. In general, some of the to bacco use disorder cri-
teria symptoms occur soon after beginning to bacco use, and many individuals’ pattern of
use meets current tobacco use diso rder criteria by late adolescence. More than 80% of in-
dividuals who use tobacco atte mpt to quit at some time, but 60% relapse within 1 week
and less than 5% remain abstinent for life . However, most indivi duals who use tobacco
make multiple attempts such that one-half of tobacco users eventually abstain. Individuals
who use tobacco who do quit usually do not do so until after age 30 years. Although non-
daily smoking in the United States was previ ously rare, it has beco me more prevalent in
the last decade, especially among younger individuals who use tobacco.
Risk and Prognostic Factors
Temperamental. Individuals with externalizing pers onality traits are more likely to | dsm5.pdf |
91613cc283f7-2 | Temperamental. Individuals with externalizing pers onality traits are more likely to
initiate tobacco use. Children with attentio n-deficit/hyperactivity disorder or conduct
disorder, and adults with depr essive, bipolar, anxiety, pers onality, psychotic, or other
substance use disorders, are at higher risk of starting and continuing tobacco use and of to-
bacco use disorder. | dsm5.pdf |
1da9fb2422d1-0 | 574 Substance-Related and Addictive Disorders
Environmental. Individuals with low incomes and low educational levels are more likely
to initiate tobacco use an d are less likely to stop.
Genetic and physiological. Genetic factors contribute to the onset of tobacco use, the
continuation of tobacco use, and the developm ent of tobacco use disorder, with a degree of
heritability equivalent to that observed with other substance use disorders (i.e., about
50%). Some of this risk is specific to toba cco, and some is common with the vulnerability to
developing any substance use disorder.
Culture-Related Diagnostic Issues
Cultures and subcultures vary widely in their acceptance of the use of tobacco. The prev-
alence of tobacco use declined in the United States from the 1960s through the 1990s, but
this decrease has been less evident in Africa n American and Hispanic populations. Also,
smoking in developing countries is more prev alent than in developed nations. The degree
to which these cultural differences are due to income, education, and tobacco control ac-
tivities in a country is unclear. Non-Hispan ic white smokers appear to be more likely to
develop tobacco use disorder than are smoker s. Some ethnic differences may be biologi-
cally based. African American males tend to have higher nicotine blood levels for a given
number of cigarettes, and this might contribute to greater difficulty in quitting. Also, the
speed of nicotine metabolism is significantly different for whites compared with African
Americans and can vary by genotypes associated with ethnicities.
Diagnostic Markers
Carbon monoxide in the breath, and nicotine and its metabolite cotinine in blood, saliva, or
urine, can be used to measure the extent of cu rrent tobacco or nicotine use; however, these
are only weakly related to tobacco use disorder. | dsm5.pdf |
1da9fb2422d1-1 | are only weakly related to tobacco use disorder.
Functional Consequences of Tobacco Use Disorder
Medical consequences of tobacco use often be gin when tobacco users are in their 40s and
usually become progressively more debilitat ing over time. One-half of smokers who do
not stop using tobacco will die early from a tobacco-related illness, and smoking-related
morbidity occurs in more than one-half of tobacco users. Most medical conditions result
from exposure to carbon monoxide, tars, an d other non-nicotine components of tobacco.
The major predictor of reversibility is duration of smoking. Secondhand smoke increases
the risk of heart disease and cancer by 30%. Long-term use of nicotine medications does
not appear to cause medical harm.
Comorbidity
The most common medical diseases from smoking are cardiovascular illnesses, chronic
obstructive pulmonary disease, and cancers. Smoking also increases perinatal problems,
such as low birth weight and miscarriage. Th e most common psychiat ric comorbidities are
alcohol/substance, depressive, bipolar, anxiet y, personality, and attention-deficit/hyper-
activity disorders. In individuals with curren t tobacco use disorder, the prevalence of cur-
rent alcohol, drug, anxiety, depressive, bi polar, and personality disorders ranges from
22% to 32%. Nicotine-dependent smokers are 2.7–8.1 times more likely to have these dis-
orders than nondependent smokers, never-smokers, or ex-smokers. | dsm5.pdf |
527028b211c4-0 | Tobacco Withdrawal 575
Tobacco Withdrawal
Diagnostic Criteria 292.0 (F17.203)
A. Daily use of tobacco for at least several weeks.
B. Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed
within 24 hours by four (or more) of the following signs or symptoms:
1. Irritability, frustration, or anger.
2. Anxiety.
3. Difficulty concentrating.
4. Increased appetite.
5. Restlessness.
6. Depressed mood.
7. Insomnia.
C. The signs or symptoms in Criterion B cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributed to another medical condition and are not bet-
ter explained by another mental disorder, including intoxication or withdrawal from an-
other substance.
Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code for tobacco withdrawal
is F17.203. Note that the ICD-10-CM code indicates the comorbid presence of a moderate
or severe tobacco use disorder, reflecting the fact that tobacco withdrawal can only occur
in the presence of a moderate or severe toba cco use disorder. It is not permissible to code
a comorbid mild tobacco use disorder with tobacco withdrawal.
Diagnostic Features
Withdrawal symptoms impair the ability to st op tobacco use. The symptoms after absti-
nence from tobacco are in large part due to nicotine deprivation. Symptoms are much
more intense among individuals who smoke cigarettes or use smokeless tobacco than
among those who use nicotine medications. This difference in symptom intensity is likely
due to the more rapid onset and higher levels of nicotine with cigarette smoking. Tobacco | dsm5.pdf |
527028b211c4-1 | due to the more rapid onset and higher levels of nicotine with cigarette smoking. Tobacco
withdrawal is common among daily tobacco users who stop or reduce but can also occur
among nondaily users. Typically, heart rate decreases by 5–12 beats per minute in the first
few days after stopping smoking, and weight increases an average of 4–7 lb (2–3 kg) over
the first year after stopping smoking. Tobacco withdrawal can produce clinically signifi-
cant mood changes and functional impairment.
Associated Features Supporting Diagnosis
Craving for sweet or sugary foods and impaired performance on tasks requiring vigilance
are associated with tobacco withdrawal. Abstinence can increase constipation, coughing,
dizziness, dreaming/nightmare s, nausea, and sore throat. Smoking increases the metab-
olism of many medications used to treat mental disorders; thus, cessation of smoking can
increase the blood levels of these medications, and this can produce clinically significant
outcomes. This effect appears to be due not to nicotine but rather to other compounds in
tobacco. | dsm5.pdf |
8e09707e96cf-0 | 576 Substance-Related and Addictive Disorders
Prevalence
Approximately 50% of tobacco users who quit for 2 or more days will have symptoms that
meet criteria for tobacco withdrawal. The most commonly endorsed signs and symptoms
are anxiety, irritability, and difficulty concentrating. The least commonly endorsed symp-
toms are depression and insomnia.
Development and Course
Tobacco withdrawal usually begins within 24 hours of stopping or cutting down on to-
bacco use, peaks at 2–3 days after abstinence, and lasts 2–3 weeks. Tobacco withdrawal
symptoms can occur among adolescent tobacco users, even prior to daily tobacco use. Pro-
longed symptoms beyond 1 month are uncommon.
Risk and Prognostic Factors
Temperamental. Smokers with depressive disorders, bipolar disorders, anxiety disor-
ders, attention-deficit/hypera ctivity disorder, and other substance use disorders have
more severe withdrawal.
Genetic and physiological. Genotype can influence the probability of withdrawal upon
abstinence.
Diagnostic Markers
Carbon monoxide in the breath, and nicotine and its metabolite cotinine in blood, saliva, or
urine, can be used to measure the extent of tobacco or nicotine use but are only weakly re-
lated to tobacco withdrawal.
Functional Consequences of Tobacco Withdrawal
Abstinence from cigarettes can cause clinically significant distress. Withdrawal impairs
the ability to stop or control tobacco use. Whether tobacco withdraw al can prompt a new
mental disorder or recurrence of a mental disorder is debatable, but if this occurs, it would
be in a small minority of tobacco users.
Differential Diagnosis
The symptoms of tobacco with drawal overlap with those of other substance withdrawal | dsm5.pdf |
8e09707e96cf-1 | Differential Diagnosis
The symptoms of tobacco with drawal overlap with those of other substance withdrawal
syndromes (e.g., alcohol withdrawal; sedative, hypnotic, or anxiolytic withdrawal; stim-
ulant withdrawal; caffeine withdrawal; opioid withdrawal); caffeine intoxication; anxiety,
depressive, bipolar, and sleep disorders; an d medication-induced akathisia. Admission to
smoke-free inpatient units or voluntary smoking cessation ca n induce withdrawal symp-
toms that mimic, intensify, or disguise othe r disorders or adverse effects of medications
used to treat mental disorders (e.g., irritabi lity thought to be du e to alcohol withdrawal
could be due to tobacco with drawal). Reduction in sympto ms with the use of nicotine
medications confirms the diagnosis.
Other Tobacco-Induced Disorders
Tobacco-induced sleep disorder is discussed in the chapter “Sleep -Wake Disorders” (see
“Substance/Medication-In duced Sleep Disorder”). | dsm5.pdf |
b752852695aa-0 | Unspecified Tobacco-Related Disorder 577
Unspecified Tobacco-Related Disorder
292.9 (F17.209)
This category applies to presentations in which symptoms characteristic of a tobacco-
related disorder that cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning predominate but do not meet the full criteria
for any specific tobacco-related disorder or any of the disorders in the substance-related
and addictive disorders diagnostic class.
Other (or Unknown)
Substance–Related Disorders
Other (or Unknown) Su bstance Use Disorder
Other (or Unknown) Substance Intoxication
Other (or Unknown) Substance Withdrawal
Other (or Unknown) Subs tance–Induced Disorders
Unspecified Other (or Unknown) Substance–Related Disorder
Other (or Unknown) Substance Use Disorder
Diagnostic Criteria
A. A problematic pattern of use of an intoxicating substance not able to be classified
within the alcohol; caffeine; cannabis; hallucinogen (phencyclidine and others); inhal-
ant; opioid; sedative, hypnotic, or anxiolytic; stimulant; or tobacco categories and lead-
ing 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 use of the
substance.
3. A great deal of time is spent in activities necessary to obtain the substance, use the
substance, or recover from its effects.
4. Craving, or a strong desire or urge to use the substance.
5. Recurrent use of the substance resulting in a failure to fulfill major role obligations
at work, school, or home. | dsm5.pdf |
b752852695aa-1 | at work, school, or home.
6. Continued use of the substance despite having persistent or recurrent social or in-
terpersonal problems caused or exacerbated by the effects of its use.
7. Important social, occupational, or recreat ional activities are given up or reduced be-
cause of use of the substance.
8. Recurrent use of the substance in situations in which it is physically hazardous.
9. Use of the substance is continued despite knowledge of having a persistent or re-
current physical or psychological problem that is likely to have been caused or ex-
acerbated by the substance. | dsm5.pdf |
791eecf6e49a-0 | 578 Substance-Related and Addictive Disorders
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 sub-
stance.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome fo r other (or unknown) substance (refer to
Criteria A and B of the criteria sets fo r other [or unknown] substance withdrawal,
p. 583).
b. The substance (or a closely related substance) is taken to relieve or avoid with-
drawal symptoms.
Specify if:
In early remission: After full criteria for other (or unknown) substance use disorder were
previously met, none of the criteria for other (or unknown) substance use disorder have
been met for at least 3 months but for less than 12 months (with the exception that Cri-
terion A4, “Craving, or a strong desire or urge to use the substance,” may be met).
In sustained remission: After full criteria for other (or unknown) substance use disor-
der were previously met, none of the criteria for other (or unknown) substance use dis-
order have been met at any time during a period of 12 months or longer (with the
exception that Criterion A4, “Craving, or a strong desire or urge to use the substance,”
may be met).
Specify if:
In a controlled environment: This additional specifier is used if the individual is in an
environment where access to the substance is restricted.
Coding based on current severity: Note for ICD-10-CM codes: If an other (or unknown) sub- | dsm5.pdf |
791eecf6e49a-1 | stance intoxication, other (or unknown) substance withdrawal, or another other (or unknown)
substance–induced mental disorder is present, do not use the codes below for other (or un-
known) substance use disorder. Instead, the comorbid other (or unknown) substance use dis-
order is indicated in the 4th character of the other (or unknown) substance–induced disorder
code (see the coding note for other (or unknown) substance intoxication, other (or unknown)
substance withdrawal, or specific other (or unknown) substance–induced mental disorder).
For example, if there is comorbid other (or unknown) substance–induced depressive disorder
and other (or unknown) substance use disorder, only the other (or unknown) substance–
induced depressive disorder code is given, with the 4th character indicating whether the co-
morbid other (or unknown) substance use disorder is mild, moderate, or severe: F19.14 for
other (or unknown) substance use disorder with other (or unknown) substance–induced de-
pressive disorder or F19.24 for a moderate or severe other (or unknown) substance use dis-
order with other (or unknown) substance–induced depressive disorder.
Specify current severity:
305.90 (F19.10) Mild: Presence of 2–3 symptoms.
304.90 (F19.20) Moderate: Presence of 4–5 symptoms.
304.90 (F19.20) Severe: Presence of 6 or more symptoms.
Specifiers
“In a controlled environment” app lies as a further specifier of remission if the individual is
both in remission and in a controlled environm ent (i.e., in early remission in a controlled | dsm5.pdf |
791eecf6e49a-2 | environment or in sustained remission in a controlled environmen t). Examples of these
environments are closely supe rvised and substanc e-free jails, therapeutic communities,
and locked hospital units. | dsm5.pdf |
03f5cda4e20b-0 | Other (or Unknown) Substance Use Disorder 579
Diagnostic Features
The diagnostic class other (or unknown) su bstance use and related disorders comprises
substance-related disorders unrelated to alco hol; caffeine; cannabis; hallucinogens (phen-
cyclidine and others); inhalants; opioids; sedative, hypnotics, or anxiolytics; stimulants
(including amphetamine and cocaine); or tobacco. Such substances include anabolic ste-
roids; nonsteroidal anti-inflammatory drugs; cortisol; antiparkinsoni an medications; an-
tihistamines; nitrous oxide; amyl-, butyl-, or isobutyl-nitrites; betel nut, which is chewed
in many cultures to produce mild euphoria an d a floating sensation; kava (from a South
Pacific pepper plant), which produces sedation , incoordination, weight loss, mild hepati-
tis, and lung abnormalities; or cathinones (including khât plant agents and synthetic chem-
ical derivatives) that produce stimulant effe cts. Unknown substance- related disorders are
associated with unidentified substances, such as intoxications in which the individual can-
not identify the ingested drug, or substance use disorders involving either new, black mar-
ket drugs not yet identified or familia r drugs illegally sold under false names.
Other (or unknown) substance use disorder is a mental disorder in which repeated use
of an other or unknown substance typically continues, despite the individual’s knowing
that the substance is causing serious problems for the individual. Th ose problems are re-
flected in the diagnostic criteria . When the substance is known, it should be reflected in the
name of the disorder upon coding (e.g., nitrous oxide use disorder).
Associated Features Supporting Diagnosis | dsm5.pdf |
03f5cda4e20b-1 | Associated Features Supporting Diagnosis
A diagnosis of other (or unknown) substance us e disorder is supporte d by the individual’s
statement that the substance involved is not among the nine classes listed in this chapter; by re-
curring episodes of intoxication with negative results in standard drug screens (which may not
detect new or rarely used substances); or by the presence of symptoms characteristic of an un-
identified substance that has newly appeared in the individual’s community.
Because of increased access to nitrous oxide (“laughing ga s”), membership in certain
populations is associated with diagnosis of ni trous oxide use disorder. The role of this gas
as an anesthetic agent leads to misuse by so me medical and dental professionals. Its use as
a propellant for commercial products (e.g., whipped cream dispensers) contributes to
misuse by food service workers. With recent widespread availability of the substance in
“whippet” cartridges for use in home whipped cream dispensers, ni trous oxide misuse by
adolescents and young adults is significant, especially among those who also inhale vola-
tile hydrocarbons. Some continuously usin g individuals, inhaling from as many as 240
whippets per day, may present with serious medical complications and mental conditions,
including myeloneuropathy, spinal cord su bacute combined degeneration, peripheral
neuropathy, and psychosis. These conditions are also associated with a diagnosis of ni-
trous oxide use disorder.
Use of amyl-, butyl-, and iso butyl nitrite gases has been observed among homosexual
men and some adolescents, especially those with conduct disorder. Membership in these
populations may be associated with a diagnosis of amyl-, butyl-, or is obutyl-nitrite use dis-
order. However, it has not been determined that these substances produce a substance use | dsm5.pdf |
03f5cda4e20b-2 | order. However, it has not been determined that these substances produce a substance use
disorder. Despite tolerance, these gases may no t alter behavior through central effects, and
they may be used only for their peripheral effects.
Substance use disorders generall y are associated with elevated risks of suicide, but there
is no evidence of unique risk factors for suicide with other (or unknown) substance use
disorder.
Prevalence
Based on extremely limited data, the prevalence of other (or unknown) substance use disorder | dsm5.pdf |
d8e875f5a3ab-0 | disorder.
Prevalence
Based on extremely limited data, the prevalence of other (or unknown) substance use disorder
is likely lower than that of use disorders involv ing the nine substance classes in this chapter. | dsm5.pdf |
1eeb74a18418-0 | 580 Substance-Related and Addictive Disorders
Development and Course
No single pattern of development or course characterizes the pharmacologically varied
other (or unknown) substance use disorders. Often unknown substance use disorders will
be reclassified when the unknown substance eventually is identified.
Risk and Prognostic Factors
Risk and prognostic factors for other (or un known) substance use disorders are thought to
be similar to those for most substance use disorders and include the presence of any other
substance use disorders, conduct disorder, or antisocial personality disorder in the indi-
vidual or the individual’s family; early onse t of substance problems ; easy availability of
the substance in the individual’s environment; childhood maltreatment or trauma; and ev-
idence of limited early self-control and behavioral disinhibition.
Culture-Related Diagnostic Issues
Certain cultures may be associated with ot her (or unknown) substance use disorders in-
volving specific indigenous substances with in the cultural region, such as betel nut.
Diagnostic Markers
Urine, breath, or saliva tests may correctly identify a commonly used substance falsely
sold as a novel product. However, routine clin ical tests usually cannot identify truly un-
usual or new substances, which may requir e testing in specialized laboratories.
Differential Diagnosis
Use of other or unknown substances without meeting criteria for other (or unknown)
substance use disorder. Use of unknown substances is not rare among adolescents, but
most use does not meet the diag nostic standard of two or mo re criteria for other (or un-
known) substance use disorder in the past year.
Substance use disorders. Other (or unknown) substanc e use disorder may co-occur
with various substance use diso rders, and the symptoms of the disorders may be similar | dsm5.pdf |
1eeb74a18418-1 | with various substance use diso rders, and the symptoms of the disorders may be similar
and overlapping. To disentangle symptom pattern s, it is helpful to inquire about which
symptoms persisted during periods when some of the substances were not being used.
Other (or unknown) substance/medication-induced disorder. This diagnosis should
be differentiated from instances when the indi vidual’s symptoms meet full criteria for one
of the following disorders, and that disorder is caused by an other or unknown substance:
delirium, major or mild neurocognitive disorder, psychoti c disorder, depressive disorder,
anxiety disorder, sexual dysf unction, or sleep disorder.
Other medical conditions. Individuals with substance us e disorders, including other
(or unknown) substance use disorder, may present with symptoms of many medical dis-
orders. These disorders also may occur in the absence of other (or unknown) substance use
disorder. A history of little or no use of ot her or unknown substances helps to exclude
other (or unknown) substance use disord er as the source of these problems.
Comorbidity
Substance use disorders, including other (o r unknown) substance use disorder, are com-
monly comorbid with one another, with adol escent conduct disorder and adult antisocial
personality disorder, and with suicid al ideation and suicide attempts. | dsm5.pdf |
fc476ed28421-0 | Other (or Unknown) Substance Intoxication 581
Other (or Unknown) Substance Intoxication
Diagnostic Criteria
A. The development of a reversible substance-specific syndrome attributable to recent in-
gestion of (or exposure to) a substance that is not listed elsewhere or is unknown.
B. Clinically significant problematic behavioral or psychological changes that are attribut-
able to the effect of the substance on the central nervous system (e.g., impaired motor
coordination, psychomotor agitation or retardation, euphoria, anxiety, belligerence,
mood lability, cognitive impairment, impaired judgment, social withdrawal) and develop
during, or shortly after, use of the substance.
C. The signs or symptoms are not attributable to another medical condition and are not bet-
ter explained by another mental disorder, in cluding intoxication with another substance.
Coding note: The ICD-9-CM code is 292.89. The ICD-10-CM code depends on whether
there is a comorbid other (or unknown) substance use disorder involving the same sub-
stance. If a mild other (or unknown) substance use disorder is comorbid, the ICD-10-CM
code is F19.129, and if a moderate or severe other (or unknown) substance use disorder is
comorbid, the ICD-10-CM code is F19.229. If there is no comorbid other (or unknown) sub-
stance use disorder involving the same substance, then the ICD-10-CM code is F19.929.
Note: For information on Risk and Prognostic Factors, Culture-Related Diagnostic Issues,
and Diagnostic Markers, see the correspondin g sections in other (or unknown) substance
use disorder.
Diagnostic Features | dsm5.pdf |
fc476ed28421-1 | use disorder.
Diagnostic Features
Other (or unknown) substance intoxication is a clinically significant mental disorder that
develops during, or immediately after, use of either a) a substance not elsewhere ad-
dressed in this chapter (i.e., alcohol; caff eine; cannabis; phencyclidine and other halluci-
nogens; inhalants; opioids; sedatives, hypnotics , or anxiolytics; stimulants; or tobacco) or
b) an unknown substance. If the substance is known, it should be reflected in the name of
the disorder upon coding.
Application of the diagnostic criteria for other (or unknow n) substance intoxication is
very challenging. Criterion A requires development of a reversible “substance-specific
syndrome,” but if the substance is unknown, that syndrome usually will be unknown. To
resolve this conflict, clinicians may ask the in dividual or obtain co llateral history as to
whether the individual has experienced a similar episode after using substances with the
same “street” name or from the same source . Similarly, hospital emergency departments
sometimes recognize over a few days numerous presentations of a severe, unfamiliar in-
toxication syndrome from a newly available, previously unknown substance. Because of
the great variety of intoxicating substances, Criterion B can provide only broad examples
of signs and symptoms from some intoxications, with no threshold for the number of
symptoms required for a diagnosis; clinical judgment guides those decisions. Criterion C
requires ruling out other medical conditio ns, mental disorders, or intoxications.
Prevalence
The prevalence of other (or unknown) substance intoxication is unknown.
Development and Course
Intoxications usually appear and then peak minu tes to hours after use of the substance, but
the onset and course vary with the substanc e and the route of administration. Generally, | dsm5.pdf |
745a5c209b0f-0 | 582 Substance-Related and Addictive Disorders
substances used by pulmonary inhalation and intravenous injection have the most rapid
onset of action, while those ingested by mouth and requiring metabolism to an active
product are much slower. (For example, after ingestion of certain mushrooms, the first
signs of an eventually fatal intoxication may not appear for a few days.) Intoxication ef-
fects usually resolve within hours to a very few days. However, the body may completely
eliminate an anesthetic gas such as nitrous ox ide just minutes after use ends. At the other
extreme, some “hit-and-run” intoxicating su bstances poison systems, leaving permanent
impairments. For example, MPTP (1-methyl- 4-phenyl-1,2,3,6-tetrahydropyridine), a con-
taminating by-product in the synthesis of a certain opioid, kills dopaminergic cells and in-
duces permanent parkinsonism in user s who sought opioid intoxication.
Functional Consequences of
Other (or Unknown) Substance Intoxication
Impairment from intoxication with any subs tance may have serious consequences, includ-
ing dysfunction at work, social indiscretions, problems in interpersonal relationships, fail-
ure to fulfill role obligations, traffic accide nts, fighting, high-risk behaviors (i.e., having
unprotected sex), and substance or medication overdose. The pattern of consequences will
vary with the particular substance.
Differential Diagnosis
Use of other or unknown substance, without meeting criteria for other (or unknown)
substance intoxication. The individual used an other or unknown substance(s), but the
dose was insufficient to produce symptoms that meet the diag nostic criteria required for
the diagnosis. | dsm5.pdf |
745a5c209b0f-1 | the diagnosis.
Substance intoxication or other subs tance/medication-induced disorders. Familiar sub-
stances may be sold in the black market as novel products, and individuals may experience
intoxication from those substances. History, to xicology screens, or chemical testing of the
substance itself may help to identify it.
Different types of other (or unknown) substance–related disorders. Episodes of other
(or unknown) substance intoxication may occur during, but are distinct from, other (or un-
known) substance use disorder, unspecified other (or unknown) substance–related disor-
der, and other (or unknown) substance–induced disorders.
Other toxic, metabolic, traumatic, neoplastic, vascular, or infectious disorders that impair
brain function and cognition. Numerous neurological and other medical conditions may
produce rapid onset of signs and symptoms mimi cking those of intoxica tions, including the
examples in Criterion B. Parado xically, drug withdrawals also must be ruled out, because, for
example, lethargy may indicate withdrawal from one drug or intoxication with another drug.
Comorbidity
As with all substance-related disorders, adolescent conduct disorder, adult antisocial per-
sonality disorder, and other subs tance use disorders tend to co-occur with other (or un-
known) substance intoxication. | dsm5.pdf |
2aacc0763f6d-0 | Other (or Unknown) Substance Withdrawal 583
Other (or Unknown) Substance Withdrawal
Diagnostic Criteria 292.0 (F19.239)
A. Cessation of (or reduction in) use of a substance that has been heavy and prolonged.
B. The development of a substance-specific syndrome shortly after the cessation of (or
reduction in) substance use.
C. The substance-specific syndrome causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
D. The symptoms are not attributable to anot her medical condition and are not better ex-
plained by another mental disorder, including withdrawal from another substance.
E. The substance involved cannot be classified under any of the other substance catego-
ries (alcohol; caffeine; cannabis; opioids; sedatives, hypnotics, or anxiolytics; stimu-
lants; or tobacco) or is unknown.
Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code for other (or unknown) sub-
stance withdrawal is F19.239. Note that the ICD-10-CM code indicates the comorbid presence
of a moderate or severe other (or unknown) substance use disorder. It is not permissible to
code a comorbid mild other (or unknown) substance use disorder with other (or unknown) sub-
stance withdrawal.
Note: For information on Risk and Prognostic Fa ctors and Diagnostic Markers, see the cor-
responding sections in other (or unknown) substance use disorder.
Diagnostic Features
Other (or unknown) substance withdrawal is a clinically significant mental disorder that
develops during, or within a few hours to days after, reducing or terminating dosing with
a substance (Criteria A and B). Although recent dose reduction or termination usually is | dsm5.pdf |
2aacc0763f6d-1 | a substance (Criteria A and B). Although recent dose reduction or termination usually is
clear in the history, other diagnostic procedur es are very challenging if the drug is un-
known. Criterion B requires development of a “substance-specific syndrome” (i.e., the in-
dividual’s signs and sympto ms must correspond with th e known withdrawal syndrome
for the recently stopped drug)—a requirement that rarely can be met with an unknown
substance. Consequently, clinical judgment must guide such decisions when information
is this limited. Criterion D requ ires ruling out other medical conditions, mental disorders,
or withdrawals from familiar substances. When the substance is known, it should be re-
flected in the name of the disorder upon coding (e.g., betel nut withdrawal).
Prevalence
The prevalence of other (or unknown) substance withdrawal is unknown.
Development and Course
Withdrawal signs commonly appe ar some hours after use of the substance is terminated,
but the onset and course vary greatly, depending on the dose typically used by the person
and the rate of elimination of the specific su bstance from the body. At peak severity, with-
drawal symptoms from some substances involve only mode rate levels of discomfort,
whereas withdrawal from other substances may be fatal. Withdrawal-associated dyspho-
ria often motivates relapse to substance us e. Withdrawal symptoms slowly abate over
days, weeks, or months, depending on the particular drug and dose s to which the indi-
vidual became tolerant.
Culture-Related Diagnostic Issues
Culture-related issues in diagnosis will vary with the particular substance. | dsm5.pdf |
baf74c81d598-0 | 584 Substance-Related and Addictive Disorders
Functional Consequences of
Other (or Unknown) Substance Withdrawal
Withdrawal from any substance may have serious consequences, including physical signs
and symptoms (e.g., malaise, vi tal sign changes, abdominal distress, headache), intense
drug craving, anxiety, depre ssion, agitation, psychotic symp toms, or cognitive impairments.
These consequences may lead to problems such as dysfunction at work, problems in in-
terpersonal relationships, failure to fulfill role obligations, traffic accidents, fighting, high-
risk behavior (e.g., having unprotected sex), suicide attempts, and substance or medica-
tion overdose. The pattern of consequences will vary with the particular substance.
Differential Diagnosis
Dose reduction after extended dosing, but no t meeting the criteria for other (or un-
known) substance withdrawal. The individual used other (or unknown) substances,
but the dose that was used was insufficient to produce symptoms that meet the criteria re-
quired for the diagnosis.
Substance withdrawal or other substance/medication-induced disorders. Familiar
substances may be sold in the black market as novel products, and individuals may expe-
rience withdrawal when discontinuing those substances. History, toxicology screens, or
chemical testing of the substance itself may help to identify it.
Different types of other (or unknown) substance–related disorders. Episodes of other
(or unknown) substance withdrawal may occur during, but are distinct from, other (or un-
known) substance use disorder, unspecified other (or unknown) substance–related disor-
der, and unspecified other (or unkn own) substance–induced disorders.
Other toxic, metabolic, traumatic, neoplastic, vascular, or infectious disorders that im-
pair brain function and cognition. Numerous neurological and other medical condi- | dsm5.pdf |
baf74c81d598-1 | pair brain function and cognition. Numerous neurological and other medical condi-
tions may produce rapid onset of signs and symptoms mimi cking those of withdrawals.
Paradoxically, drug intoxications also must be ruled out, because, for example, lethargy
may indicate withdrawal from one drug or intoxication with another drug.
Comorbidity
As with all substance-related disorders, adolescent conduct disorder, adult antisocial per-
sonality disorder, and other substance use disorders likely co-occur with other (or un-
known) substance withdrawal.
Other (or Unknown)
Substance–Induced Disorders
Because the category of other or unknown subs tances is inherently ill-defined, the extent
and range of induced disorders are uncertain. Nevertheless, othe r (or unknown) sub-
stance–induced disorders are possible and are described in other chapters of the manual
with disorders with which they share phenomenology (see the substance/medication-
induced mental disorders in these chapters): other (or unknown) substance–induced psy-
chotic disorder (“Schizophren ia Spectrum and Other Psychotic Disorders”); other (or un-
known substance–induced bipolar disorder (“ Bipolar and Related Disorders”); other (or
unknown) substance–induced depressive diso rder (“Depressive Disorders”); other (or
unknown) substance–induced anxiety disorders (“Anxiety Disorders”); other (or un-
known) substance–induced obsessive-compu lsive disorder (“Obsessive-Compulsive and
Related Disorders”); other (or unknown) substance–indu ced sleep disorder (“Sleep-Wake | dsm5.pdf |
a6c2b6b28fcf-0 | Unspecified Other (or Unknown) Substance–Related Disorder 585
Disorders”); other (or unknown) substance–induced sexual dysfunction (“Sexual Dys-
functions”); and other (or un known) substance/me dication–induced major or mild neu-
rocognitive disorder (“Neurocognitive Diso rders”). For other (or unknown) substance–
induced intoxication delirium and other (o r unknown) substance–induced withdrawal
delirium, see the criteria and discussion of delirium in the chapter “Neurocognitive Dis-
orders.” These other (or unknown) substanc e–induced disorders are diagnosed instead of
other (or unknown) substance intoxication or other (or unknown) substance withdrawal
only when the symptoms are sufficiently seve re to warrant independent clinical attention.
Unspecified Other (or Unknown)
Substance–Related Disorder
292.9 (F19.99)
This category applies to presentations in which symptoms characteristic of an other (or un-
known) substance–related disorder that cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning predominate but do not
meet the full criteria for any specific other (or unknown) substance–related disorder or any
of the disorders in the substance-related disorders diagnostic class.
Non-Substance-Related Disorders
Gambling Disorder
Diagnostic Criteria 312.31 (F63.0)
A. Persistent and recurrent problematic gambling behavior leading to clinically significant
impairment or distress, as indicated by the individual exhibiting four (or more) of the fol-
lowing in a 12-month period:
1. Needs to gamble with increasing amounts of money in order to achieve the desired
excitement.
2. Is restless or irritable when attempting to cut down or stop gambling. | dsm5.pdf |
a6c2b6b28fcf-1 | 2. Is restless or irritable when attempting to cut down or stop gambling.
3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past
gambling experiences, handicapping or planni ng the next venture, thinking of ways
to get money with which to gamble).
5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).
6. After losing money gambling, often returns another day to get even (“chasing” one’s
losses).
7. Lies to conceal the extent of involvement with gambling.
8. Has jeopardized or lost a significant rela tionship, job, or educational or career op-
portunity because of gambling.
9. Relies on others to provide money to relieve desperate financial situations caused
by gambling.
B. The gambling behavior is not better explained by a manic episode. | dsm5.pdf |
18b27b425ac5-0 | 586 Substance-Related and Addictive Disorders
Specify if:
Episodic: Meeting diagnostic criteria at more than one time point, with symptoms sub-
siding between periods of gambling disorder for at least several months.
Persistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple
years.
Specify if:
In early remission: After full criteria for gambling disorder were previously met, none
of the criteria for gambling disorder have been met for at least 3 months but for less
than 12 months.
In sustained remission: After full criteria for gambling disorder were previously met,
none of the criteria for gambling disorder have been met during a period of 12 months
or longer.
Specify current severity:
Mild: 4–5 criteria met.
Moderate: 6–7 criteria met.
Severe: 8–9 criteria met.
Note: Although some behavioral conditions th at do not involve in gestion of substances
have similarities to substance-related disorders, only one disord er—gambling disorder—
has sufficient data to be included in this section.
Specifiers
Severity is based on the number of criteria endorsed. Individuals with mild gambling dis-
order may exhibit only 4–5 of the criteria, with the most frequently endorsed criteria usu-
ally related to preoccupation with gamb ling and “chasing” losses. Individuals with
moderately severe gambli ng disorder exhibit more of the criteria (i.e., 6–7). Individuals
with the most severe form will exhibit all or mo st of the nine criteria (i.e., 8–9). Jeopardiz-
ing relationships or career o pportunities due to gambling and relying on others to provide
money for gambling losses are typically the least often endorsed criteria and most often oc- | dsm5.pdf |
18b27b425ac5-1 | money for gambling losses are typically the least often endorsed criteria and most often oc-
cur among those with more severe gambling disorder. Furthermore, individuals present-
ing for treatment of gambling disorder typically have moderate to severe forms of the
disorder.
Diagnostic Features
Gambling involves risking something of value in the hopes of obtaining something of
greater value. In many cultur es, individuals gamble on game s and events, and most do so
without experiencing problems. However, so me individuals develo p substantial impair-
ment related to their gambling behaviors. Th e essential feature of gambling disorder is
persistent and recurrent maladaptive gambling behavior that disrupts personal, family,
and/or vocational pursuits (Criterion A). Gamb ling disorder is defined as a cluster of four
or more of the symptoms listed in Criterion A occurring at any time in the same 12-month
period.
A pattern of “chasing one’s losses” may deve lop, with an urgent need to keep gam-
bling (often with the placing of larger bets or the taking of greater risks) to undo a loss or
series of losses. The individual may abandon his or her gambling strategy and try to win
back losses all at once. Although many gamblers may “chase” for short periods of time, it
is the frequent, and often long-term, “chase” that is characteristic of gambling disorder
(Criterion A6). Individuals may lie to family members, therapists, or others to conceal the
extent of involvement with gambling; these instances of deceit may also include, but
are not limited to, covering up illegal behaviors such as forgery, fraud, theft, or embez-
zlement to obtain money with which to gamble (Criterion A7). Individuals may also en- | dsm5.pdf |
bebf16bca4ae-0 | Gambling Disorder 587
gage in “bailout” behavior, turning to family or others for help with a desperate financial
situation that was caused by gambling (Criterion A9).
Associated Features Supporting Diagnosis
Distortions in thinking (e.g., denial, superstitions, a sense of power and control over the
outcome of chance events, overconfidence) ma y be present in individuals with gambling
disorder. Many individuals with gambling diso rder believe that money is both the cause
of and the solution to their problems. Some individuals with gambling disorder are im-
pulsive, competitive, energetic, restless, an d easily bored; they may be overly concerned
with the approval of others and may be gene rous to the point of extravagance when win-
ning. Other individuals with gambling disord er are depressed and lonely, and they may
gamble when feeling helpless, guilty, or depres sed. Up to half of individuals in treatment
for gambling disorder have suicidal ideati on, and about 17% have attempted suicide.
Prevalence
The past-year prevalence rate of gambling di sorder is about 0.2%–0.3% in the general pop-
ulation. In the general population, the lifetim e prevalence rate is about 0.4%–1.0%. For fe-
males, the lifetime prevalence rate of gambling disorder is about 0.2%, and for males it is
about 0.6%. The lifetime prevalence of path ological gambling among African Americans is
about 0.9%, among whites about 0.4% , and among Hispanics about 0.3%.
Development and Course
The onset of gambling disorder can occur du ring adolescence or young adulthood, but in
other individuals it manifests during middle or even older adulthood. Generally, gam- | dsm5.pdf |
bebf16bca4ae-1 | other individuals it manifests during middle or even older adulthood. Generally, gam-
bling disorder develops over the course of years, although the progression appears to be
more rapid in females than in males. Most individuals who develop a gambling disorder
evidence a pattern of gambling that gradually increases in both frequency and amount of
wagering. Certainly, milder fo rms can develop into more severe cases. Most individuals
with gambling disorder report that one or tw o types of gambling are most problematic for
them, although some individuals participate in many forms of gambling. Individuals are
likely to engage in certain types of gambling (e.g., buying scratch tickets daily) more fre-
quently than others (e.g., playing slot machin es or blackjack at the casino weekly). Fre-
quency of gambling can be related more to the type of gambling than to the severity of the
overall gambling disorder. For example, purcha sing a single scratch ticket each day may
not be problematic, while less frequent casino , sports, or card gambling may be part of a
gambling disorder. Similarly, amounts of money spent wagering are not in themselves in-
dicative of gambling disorder. Some individuals can wager thousands of dollars per
month and not have a problem with gambling, while others may wager much smaller
amounts but experience substantia l gambling-related difficulties.
Gambling patterns may be regular or episod ic, and gambling disorder can be persis-
tent or in remission. Gambling can increase during periods of stress or depression and
during periods of substance use or abstinen ce. There may be periods of heavy gambling
and severe problems, times of total abstin ence, and periods of nonproblematic gambling.
Gambling disorder is some times associated with spontaneous, long-term remissions.
Nevertheless, some individual s underestimate their vulner ability to develop gambling | dsm5.pdf |
bebf16bca4ae-2 | Nevertheless, some individual s underestimate their vulner ability to develop gambling
disorder or to return to gamb ling disorder following remission. When in a period of re-
mission, they may incorrectly assume that th ey will have no problem regulating gambling
and that they may gamble on some forms no nproblematically, only to experience a return
to gambling disorder.
Early expression of gambling disorder is mo re common among males than among fe-
males. Individuals who begin gambling in yo uth often do so with family members or | dsm5.pdf |
9bd8ed7b5711-0 | 588 Substance-Related and Addictive Disorders
friends. Development of early-life gambling diso rder appears to be associated with impul-
sivity and substance abuse. Many high scho ol and college students who develop gambling
disorder grow out of the disorder over time , although it remains a lifelong problem for
some. Mid- and later-life onse t of gambling disorder is more common among females than
among males.
There are age and gender variations in the type of gambling activities and the preva-
lence rates of gambling disorder. Gambling d isorder is more common among younger and
middle-age persons than among older adults . Among adolescents and young adults, the
disorder is more prevalent in males than in females. Younger indivi duals prefer different
forms of gambling (e.g., sports betting), while older adults are more likely to develop
problems with slot machine and bingo gamblin g. Although the proportions of individuals
who seek treatment for gambling disorder ar e low across all age groups, younger individ-
uals are especially unlikely to present for treatment.
Males are more likely to begin gambling earlie r in life and to have a younger age at on-
set of gambling disorder than females, who ar e more likely to begin gambling later in life
and to develop gambling disorder in a shorte r time frame. Females with gambling disor-
der are more likely than males with gambling disorder to have depressive, bipolar, and
anxiety disorders. Females also have a later age at onset of the disorder and seek treatment
sooner, although rates of treatment seekin g are low (<10%) among individuals with gam-
bling disorder regardless of gender.
Risk and Prognostic Factors
Temperamental. Gambling that begins in childhood or early adolescence is associated
with increased rates of gambling disorder. Gambling disorder also appears to aggregate | dsm5.pdf |
9bd8ed7b5711-1 | with increased rates of gambling disorder. Gambling disorder also appears to aggregate
with antisocial personality disorder, depre ssive and bipolar disorders, and other sub-
stance use disorders, particul arly with alcohol disorders.
Genetic and physiological. Gambling disorder can aggregate in families, and this effect
appears to relate to both environmental and genetic factors. Gambling problems are more
frequent in monozygotic than in dizygotic twins. Gambling disorder is also more preva-
lent among first-degree relati ves of individuals with modera te to severe alcohol use dis-
order than among the general population.
Course modifiers. Many individuals, including adolesce nts and young adults, are likely to
resolve their problems with gambling disorder over time, although a strong predictor of
future gambling problems is prior gambling problems.
Culture-Related Diagnostic Issues
Individuals from specific cultures and races/ethnicities are more likely to participate in
some types of gambling activities than others (e.g., pai gow, cockfights , blackjack, horse rac-
ing). Prevalence rates of gambling disorder are higher among African Americans than
among European Americans, with rates for Hi spanic Americans similar to those of Euro-
pean Americans. Indigenous populations have high prevalence rates of gambling disorder.
Gender-Related Diagnostic Issues
Males develop gambling disorder at higher rates than females, alth ough this gender gap
may be narrowing. Males tend to wager on di fferent forms of gambling than females, with
cards, sports, and horse race gambling more prevalent among males, and slot machine and
bingo gambling more common among females. | dsm5.pdf |
c597cdce75e3-0 | Gambling Disorder 589
Functional Consequences of Gambling Disorder
Areas of psychosocial, health, and mental heal th functioning may be adversely affected by
gambling disorder. Specifically, individuals with gambling disorder may, because of their
involvement with gambling, jeopardize or lo se important relationships with family mem-
bers or friends. Such problems may occur from repeatedly lying to others to cover up the
extent of gambling or from requesting money that is used for gambling or to pay off gam-
bling debts. Employment or educational activities may likewise be adversely impacted by
gambling disorder; absenteeism or poor work or school performance can occur with gam-
bling disorder, as individuals may gamble duri ng work or school h ours or be preoccupied
with gambling or its adverse co nsequence when they should be working or studying. In-
dividuals with gambling disorder have poor general health and utilize medical services at
high rates.
Differential Diagnosis
Nondisordered gambling. Gambling disorder must be distinguished from professional
and social gambling. In professional gambling , risks are limited and discipline is central.
Social gambling typically occurs with friends or colleagues and lasts for a limited period of
time, with acceptable losses. Some individu als can experience problems associated with
gambling (e.g., short-term chasin g behavior and loss of control) that do not meet the full
criteria for gambling disorder.
Manic episode. Loss of judgment and excessive gambling may occur during a manic ep-
isode. An additional diagnosis of gambling d isorder should be given only if the gambling
behavior is not better explained by manic ep isodes (e.g., a histor y of maladaptive gam-
bling behavior at times other than during a manic episode). Alternatively, an individual
with gambling disorder may, during a period of gambling, exhibit behavior that resembles | dsm5.pdf |
c597cdce75e3-1 | with gambling disorder may, during a period of gambling, exhibit behavior that resembles
a manic episode, but once the individual is away from the gambling, these manic-like fea-
tures dissipate.
Personality disorders. Problems with gambling may occur in individuals with antisocial
personality disorder and other personality disorders. If the criteria are met for both disor-
ders, both can be diagnosed.
Other medical conditions. Some patients taking dopaminergic medications (e.g., for
Parkinson‘s disease) may expe rience urges to gamble. If such symptoms dissipate when
dopaminergic medications are reduced in dosag e or ceased, then a diagnosis of gambling
disorder would not be indicated.
Comorbidity
Gambling disorder is associated with poor general health. In addition, some specific med-
ical diagnoses, such as tachycardia and an gina, are more common among individuals with
gambling disorder than in the general popula tion, even when other substance use disor-
ders, including tobacco use disorder, are cont rolled for. Individuals with gambling disor-
der have high rates of comorbidity with ot her mental disorders, such as substance use
disorders, depressive d isorders, anxiety disorders, and personality disorders. In some in-
dividuals, other mental disorders may preced e gambling disorder and be either absent or
present during the manifestat ion of gambling disorder. Gamb ling disorder may also occur
prior to the onset of other ment al disorders, especially anxi ety disorders and substance use
disorders. | dsm5.pdf |
e44a7d7977f4-0 | This page intentionally left blank | dsm5.pdf |
bd4fffb98008-0 | 591Neurocognitive
Disorders
The neurocognitive disorders (NCDs) (referred to in DSM-IV as “Dementia,
Delirium, Amnestic, and Other Cognitive Di sorders”) begin with delirium, followed by
the syndromes of major NCD, mild NCD, an d their etiological su btypes. The major or
mild NCD subtypes are NCD due to Alzheimer’s disease; vascular NCD; NCD with Lewy
bodies; NCD due to Parkinso n’s disease; frontotemporal NCD; NCD due to traumatic
brain injury; NCD due to HIV infection; su bstance/medication-induced NCD; NCD due
to Huntington’s disease; NC D due to prion disease; NCD du e to another medical condi-
tion; NCD due to multiple etiologies; and unspecified NCD. The NCD category encom-
passes the group of disorders in which the primar y clinical deficit is in cognitive function,
and that are acquired rather than developmental. Although cognitive deficits are present
in many if not all mental disorders (e.g., schizophrenia, bipolar diso rders), only disorders
whose core features are cognitive are includ ed in the NCD category. The NCDs are those
in which impaired cognition has not been present since birth or very early life, and thus
represents a decline from a previou sly attained level of functioning.
The NCDs are unique among DSM-5 categories in that these are syndromes for which
the underlying pathology, and frequently the etiology as well, can potentially be deter-
mined. The various underlying disease entities have all been the subject of extensive re-
search, clinical experience, and expert consen sus on diagnostic crit eria. The DSM-5 criteria | dsm5.pdf |
bd4fffb98008-1 | for these disorders have been developed in close consultation with the expert groups for
each of the disease entities and align as closely as possible with the current consensus cri-
teria for each of them. The potential utility of biomarkers is also discussed in relation to
diagnosis. Dementia is subsumed under the newly named entity major neurocognitive dis-
order , although the term dementia is not precluded from use in the etiological subtypes in
which that term is standard. Furthermore, DSM-5 recognizes a less severe level of cogni-
tive impairment, mild neurocognitive disorder, which can also be a focus of care, and which
in DSM-IV was subsumed under “Cognitive Disorder Not Otherwise Specified.” Diagnos-
tic criteria are provided for both these synd romic entities, followed by diagnostic criteria
for the different etiological subtypes. Several of the NCDs frequently coexist with one an-
other, and their relationships may be multip ly characterized under different chapter sub-
headings, including “Differential Diagnosis” (e.g., NCD due to Alzheimer’s disease vs.
vascular NCD), “Risk and Prognostic Factors” (e.g., vascular path ology increasing the
clinical expression of Alzheimer’s disease), and/or “Comorbidity” (e.g., mixed Alzhei-
mer’s disease–vascular pathology).
The term dementia is retained in DSM-5 for contin uity and may be used in settings
where physicians and patients are accustomed to this term. Although dementia is the cus-
tomary term for disorders like the degenerative dementias that usually affect older adults,
the term neurocognitive disorder is widely used and often preferred for conditions affect-
ing younger individuals, such as impairment secondary to traumatic brain injury or HIV | dsm5.pdf |
bd4fffb98008-2 | ing younger individuals, such as impairment secondary to traumatic brain injury or HIV
infection. Furthermore, the major NCD definition is some what broader than the term
dementia, in that individuals with substantial decline in a single domain can receive this di-
agnosis, most notably the DSM-IV category of “Amnestic Disorder,” which would now be
diagnosed as major NCD due to another medical condition and for which the term demen-
tia would not be used. | dsm5.pdf |
Subsets and Splits