Substance-Related Disorders
Core Concept
Occurrence of adverse social, behavioral,
psychological, & physiological effects caused by 1 or
more of the following abused substances:
1) Alcohol
2) Inhalants
3) Amphetamines
4) Nicotine
5) Caffeine
6) Opioids
7) Cannabis
8) Phencyclidine
9) Cocaine
10) Sedatives, Hypnotics, or Anxiolytics
11) Hallucinogens
12) Other or Unknown Substances
Categories for Substance-Related Disorders:
Substance Use Disorders (generic criteria sets):

Substance Dependence

Substance Abuse
Substance-Induced Disorders (specific criteria sets):

Substance Intoxication

Substance Withdrawal

Substance-Induced Psychiatric Syndromes
Substance Dependence & Abuse
Criteria for Substance Dependence and Abuse:
exactly the same for all 12 classes of substances
Names for specific Dx: e.g. Alcohol Dependence,
Alcohol Abuse
Polysubstance Dependence: a pattern of
maladaptive use of at least 3 classes of
substances; meet the full criteria for Substance
Dependence for substances considered as a
group, but not for any single substance
Substance Dependence
A maladaptive pattern of substance use, leading to clinically
significant impairment or distress, as manifested by 3+ of the
following, at any time in a 12-month period:
Tolerance
 A need for markedly increased amounts of substance
to achieve intoxication or desired effect
 Markedly diminished effect with continued use of the
same amount of substance
Withdrawal
 Characteristic withdrawal syndrome for substance
 The same or a closely related substance taken to
relieve or avoid withdrawal symptoms
Substance taken in larger amounts or over longer period
than intended.
Substance Dependence
Symptoms (continued):
Persistent desire or unsuccessful efforts to cut down or
control substance use.
A great deal of time is spent in activities necessary to obtain
or use the substance or recover from its effects.
Important social, occupational, or recreational activities are
given up or reduced because of substance use.
Substance use is continued despite having a persistent or
recurrent physical or psychological problem that is likely to
have been caused or exacerbated by the substance.
Specifiers:
With Physiological Dependence – evidence of tolerance or
withdrawal.
Without Physiological Dependence – no evidence of
tolerance or withdrawal
Substance Dependence
Course Modifiers:
Early Full Remission: no criteria for dependence or abuse
have been met at any time for the last 1-12 months
 Early Partial Remission: 1 or more, but not full, criteria for
dependence or abuse have been met for last 1-12 months
 Sustained Full Remission: no criteria for dependence or
abuse have been met at any time for the last 12+ months
 Sustained Partial Remission: 1 or more, but not full,
criteria for dependence or abuse have been met for the last
12+ months
 In a Controlled Environment: no criteria for abuse or
dependence have been met for at least the past month
 On Agonist Therapy: no criteria for abuse or dependence
have been met for at least the past month

Substance Abuse
A. Maladaptive pattern of substance use, leading to clinically
significant impairment or distress, as manifested by 1 or more
of the following, occurring in a 12-month period:
Recurrent substance use resulting in a failure to fulfill major
role obligations at work, school, or home
Recurrent substance use in situations in which it is
physically hazardous (e.g. driving while impaired)
Recurrent substance-related legal problems (e.g. disorderly
conduct)
Recurrent substance use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance (e.g. arguments
with significant other about substance use, physical fights)
B. Symptoms have never met the criteria for Substance
Dependence for this class of substance.
Differential Diagnosis of Substance
Dependence & Abuse
Continuum of Substance Use: Recreational Use 
Problematic Use  Substance Abuse  Substance
Dependence
Substance Dependence: adverse consequences &
tolerance, withdrawal, compulsive use.
Substance Abuse: adverse consequences, but absence of
tolerance, withdrawal, or compulsive use.
Consider factors such as age, sex, culture, and health.
Once person has met criteria for Substance Dependence
for a substance, they can never be given dx of Substance
Abuse for that substance.
Substance Intoxication
The development of a reversible substancespecific syndrome, due to recent ingestion of, or
exposure to, a substance.
B. Clinically significant maladaptive behavioral or
psychological changes develop during or shortly
after use of the substance due to the effect of
the substance on the central nervous system.
C. The symptoms are not due to a general medical
condition and are not better accounted for by
another disorder.
A.
Substance Withdrawal
Development of a substance-specific
syndrome due to the cessation of, or
reduction in, substance use that has been
heavy & prolonged.
B. The substance-specific syndrome causes
clinically significant distress or impairment in
social, occupational, or other important areas
of functioning.
C. Symptoms aren’t due to a general medical
condition and aren’t better accounted for by
another mental disorder.
A.
Necessary Clinical Information
Current substance use
History of substance use
History of substance use emergencies & treatment
Cognitive impairment, e.g. confusion, disorientation,
impaired attention, rambling thoughts, drowsiness
Physiological signs, e.g. tachycardia, hypertension,
hypotension, dilation or constriction of pupils
Neurological signs, e.g. slurred speech, lack of
coordination, ataxia, dystonia, tremor, seizure, etc.
Psychomotor agitation or retardation
Changes in personality, mood, anxiety
Urine drug screening, blood alcohol level
Changes in social or family life
Current and past legal problems
Making a Diagnosis
Identification of abused substance(s):



Patient admits to using substance(s)
Substance is detected in urine or blood
Patient has characteristic physiological, behavioral, or
psychological signs & Sx of intoxication or withdrawal from
substance
Current pattern of use: dependence or abuse
Abnormal physiological symptoms or signs: current
intoxication or withdrawal
History of substance abuse
Experiencing recent related legal problems: intoxication,
abuse, or dependence
Maladaptive behavioral or psychological changes:
intoxication, withdrawal, abuse, or dependence
Treatment Planning
Detoxification (for severe withdrawal)
Inpatient treatment programs (substance
dependence)
Outpatient treatment programs
Groups: psychoeducation, 12-step recovery,
support groups, relapse prevention
Evaluate social system (family situation, significant
relationships, friendships, support network) &
coping skills
Prevention strategies: stressing the need for
abstinence for those with a strong family Hx of
alcoholism or their own Hx of alcohol or substance
dependence
Alcohol, Sedative, Hypnotic, or Anxiolytic Intoxication
Behavioral & Psychological Changes:
Inappropriate sexual/aggressive behavior
Mood lability
Impaired judgment
Impaired social/occupational functioning
Clinical Signs & Symptoms:
Slurred speech
Lack of coordination
Unsteady gait
Nystagmus
Impaired attention and memory
Stupor or coma
Alcohol, Sedative, Hypnotic, or Anxiolytic Withdrawal
Autonomic hyperactivity, e.g. sweating, pulse
greater than 100
Increased hand tremor
Insomnia
Nausea or vomiting
Transient visual, tactile, or auditory
hallucinations or illusions
Psychomotor agitation
Anxiety
Grand mal seizures
Amphetamine or Cocaine Intoxication
Behavioral & Psychological Changes:
Euphoria or affective blunting
Changes in sociability
Hypervigilance
Interpersonal sensitivity
Anxiety, tension, or anger
Stereotyped behaviors
Impaired judgment
Impaired social/occupational functioning
Amphetamine or Cocaine Intoxication
Clinical Signs & Symptoms:
Tachycardia or bradycardia
Pupil dilation
Elevated or lowered blood pressure
Perspiration or chills
Nausea or vomiting
Weight loss
Psychomotor agitation or retardation
Muscular weakness, respiratory depression, chest pain,
cardiac arrhythmias
Confusion, seizures, dyskinesias, dystonias, or coma
Amphetamine or Cocaine Withdrawal
Dysphoric mood
Fatigue
Vivid, unpleasant dreams
Insomnia or hypersomnia
Increased appetite
Psychomotor retardation or agitation
Caffeine Intoxication
Clinical Signs & Symptoms:
Restlessness
Nervousness
Excitement
Insomnia
Flushed face
Diuresis
Gastrointestinal disturbance
Muscle twitching
Rambling flow of thought and speech
Tachycardia or cardiac arrhythmia
Periods or inexhaustibility
Psychomotor agitation
Nicotine Withdrawal
Dysphoric or depressed mood
Insomnia
Irritability, frustration, anger
Anxiety
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite or weight gain
Cannabis Intoxication
Behavioral & Psychological Changes:
Impaired motor coordination
Euphoria
Anxiety
Sensation of slowed time
Impaired judgment
Social withdrawal
Clinical Signs & Symptoms:
Conjuctival injection
Increased appetite
Tachycardia
Dry mouth
Hallucinogen Intoxication
Behavioral & Psychological Changes:
Marked anxiety or depression
Ideas of reference
Fear of losing one’s mind
Paranoid ideation
Impaired judgment
Impaired social/occupational functioning
Clinical Signs & Symptoms:
Pupillary dilation
Tachycardia
Sweating
Palpitations
Blurring of vision
Tremors
Lack of coordination
Hallucinogen Persisting Perception Disorder
Individuals who have previously used a hallucinogen
reexperience one or more of the perceptual symptoms that
they experienced while intoxicated with the hallucinogen:
Geometric hallucinations
False perceptions of movement in peripheral visual fields
Flashes of color
Intensified colors
Trials of images of moving objects
Positive afterimages
Halos around objects
Macropsia
Micropsia
Inhalant Intoxication
Clinical Signs & Symptoms:
Dizziness
Blurred vision or diplopia
Nystagmus
Stupor or coma
Incoordination
Euphoria
Slurred speech
Tremor
Unsteady gait
Lethargy
Depressed reflexes
Generalized muscle weakness
Psychomotor retardation
Behavioral & Psychological Changes:
Belligerence
Impaired judgment
Assaultiveness
Impaired social/occupational functioning
Apathy
Opioid Intoxication
Behavioral & Psychological Changes:
Initial euphoria followed by apathy
Dysphoria
Psychomotor agitation or retardation
Impaired judgment
Impaired social/occupational functioning
Clinical Signs & Symptoms:
Pupillary constriction
Drowsiness or coma
Slurred speech
Impaired attention or memory
Opioid Withdrawal
Dysphoric mood
Nausea or vomiting
Muscle aches
Lacrimation or rhinorrhea
Pupillary dilation, piloerection, or sweating
Diarrhea
Yawning
Fever
Insomnia
Phencyclidine Intoxication
Behavioral &
Clinical Signs & Sx:
Psychological Changes:
Vertical or horizontal
Belligerence
nystagmus
assaultiveness
Hypertension or tachycardia
Impulsiveness
Numbness or diminished
responsiveness to pain
Unpredictability
Ataxia
Psychomotor agitation
Dysarthria
Impaired judgment
Muscle rigidity
Impaired social/
occupational functioning
Seizure or coma
Hyperacusis
Substance-Induced
Psychiatric Syndromes
There is evidence that psychiatric symptoms
developed during or within a month of significant
substance intoxication or withdrawal.
Every class of abused substances, except
nicotine, has the capacity to produce psychiatric
symptoms during intoxication or withdrawal.
Specific diagnosis should specify the name of the
abused substance, the psychiatric syndrome, &
whether the onset occurred during withdrawal or
intoxication, e.g. Alcohol-Induced Anxiety Disorder
with onset during withdrawal.
Substance-Induced
Psychiatric Syndromes
Delirium
Persisting Dementia
Persisting Amnestic
Disorder
Psychotic Disorder
with Delusions
Psychotic Disorder
with Hallucinations
Mood Disorder
Anxiety Disorder
Sexual Dysfunction
Sleep Disorder