Substance Related Disorders

●​ The substance-related disorders encompass 10 separate classes of

drugs: alcohol; caffeine; cannabis; hallucinogens (with separate
categories for phencyclidine [or similarly acting
arylcyclohexylamines] and other hallucinogens); inhalants; opioids;
sedatives, hypnotics, or anxiolytics; stimulants (amphetamine-type
substances, cocaine, and other stimulants); tobacco; and other (or
unknown) substances.
●​ These 10 classes are not fully distinct. All drugs that are taken in
excess have in common the ability to directly activate the brain
reward systems, which are involved in the reinforcement of
behaviors and establishment of memories.
●​ Instead of achieving reward system activation through adaptive
behaviors, these substances produce such an intense activation of
the reward system that normal activities may be neglected.
●​ The substance-related disorders are divided into two groups:
substance use disorders and substance-induced disorders.
●​ The following conditions may be classified as substance-induced:
substance intoxication, substance withdrawal, and
substance/medication-induced mental disorders (diagnostic criteria
and text are provided in this manual for substance/medication
induced psychotic disorders, bipolar and related disorders,
depressive disorders, anxiety disorders, obsessive-compulsive and
related disorders, sleep disorders, sexual dysfunctions, delirium,
and neurocognitive disorders)
●​ Substance/medication-induced mental disorder refers to
symptomatic presentations that are due to the physiological effects
of an exogenous substance on the central nervous system and
includes typical intoxicants (e.g., alcohol, inhalants, cocaine),
psychotropic medications (e.g., stimulants, sedative-hypnotics)
other medications, (e.g., steroids), and environmental toxins (e.g.,
organophosphate insecticides).
Substance Use Disorders

●​ The term substance use disorder is used to describe the wide range
of the disorder, from a mild form to a severe state of chronically
relapsing, compulsive pattern of drug taking.
●​ The essential feature of a substance use disorder is a cluster of
cognitive, behavioral, and physiological symptoms indicating that the
individual continues using the substance despite significant
substance-related problems.
●​ Overall, the diagnosis of a substance use disorder is based on a
pathological pattern of behaviors related to use of the substance.

❖​ Criterion A can be considered to fit within overall groupings of

impaired control, social impairment, risky use, and pharmacological
criteria.
❖​ Impaired control over substance use is the first criteria grouping
(Criteria 1–4).
❖​ (Criterion 1) The individual may take the substance in larger
amounts or over a longer period than was originally intended.
❖​ (Criterion 2) The individual may express a persistent desire to cut
down or regulate substance use and may report multiple
unsuccessful efforts to decrease or discontinue use.
❖​ (Criterion 3) The individual may spend a great deal of time obtaining
the substance, using the substance, or recovering from its effects.
In some instances of more severe substance use disorders, virtually
all of the individual’s daily activities revolve around the substance.
❖​ (Criterion 4) Craving is manifested by an intense desire or urge for
the drug that may occur at any time but is more likely when in an
environment where the drug previously was obtained or used.
❖​ Craving has also been shown to involve classical conditioning and is
associated with activation of specific reward structures in the
brain.
❖​ Craving might be queried by asking if there has ever been a time
when there were such strong urges to take the drug that the
individual could not think of anything else. Current craving is often
used as a treatment outcome measure because it may be a signal of
impending relapse.

❖​ Social impairment is the second grouping of criteria (Criteria 5–7).

❖​ Criterion 5: Recurrent substance use may result in a failure to
fulfill major role obligations at work, school, or home.
❖​ Criterion 6: The individual may continue substance use despite
having persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of the substance.
❖​ Criterion 7: Important social, occupational, or recreational
activities may be given up or reduced because of substance use. The
individual may withdraw from family activities and hobbies in order
to use the substance.

❖​ Risky use of the substance is the third grouping of criteria (Criteria

8–9).
❖​ Criterion 8: This may take the form of recurrent substance use in
situations in which it is physically hazardous.
❖​ Criterion 9: The individual may continue substance use despite
knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or
exacerbated by the substance.
❖​ The key issue in evaluating this criterion is not the existence of the
problem, but rather the individual’s failure to abstain from using
the substance despite the difficulty it is causing.

❖​ Pharmacological criteria are the final grouping (Criteria 10 and 11).

❖​ Criterion 10: Tolerance
●​ Tolerance is signaled by requiring a markedly increased dose of the
substance to achieve the desired effect or a markedly reduced
effect when the usual dose is consumed.
●​ The degree to which tolerance develops varies greatly across
different individuals as well as across substances and may involve a
variety of central nervous system effects.
●​ For example, tolerance to respiratory depression and tolerance to
sedating and motor coordination may develop at different rates,
depending on the substance.
●​ Tolerance may be difficult to determine by history alone, and
laboratory tests may be helpful (e.g., high blood levels of the
substance coupled with little evidence of intoxication suggest that
tolerance is likely).
●​ Tolerance must also be distinguished from individual variability in
the initial sensitivity to the effects of particular substances.
○​ For example, some first-time alcohol drinkers show very little
evidence of intoxication with three or four drinks, whereas
others of similar weight and drinking histories have slurred
speech and incoordination.
❖​ Criterion 11: Withdrawal
❖​ Withdrawal is a syndrome that occurs when blood or tissue
concentrations of a substance decline in an individual who had
maintained prolonged, heavy use of the substance.
❖​ After developing withdrawal symptoms, the individual is likely to
consume the substance to relieve the symptoms.
❖​ Withdrawal symptoms vary greatly across the classes of
substances, and separate criteria sets for withdrawal are provided
for the drug classes.
❖​ Marked and generally easily measured physiological signs of
withdrawal are common with alcohol, opioids, and sedatives,
hypnotics, and anxiolytics.
 ❖​ Withdrawal signs and symptoms with stimulants (amphetamine-type
substances, cocaine, other or unspecified stimulants), as well as
tobacco and cannabis, are often present but may be less apparent.
❖​ Significant withdrawal has not been documented in humans after
repeated use of phencyclidine, other hallucinogens, and inhalants;
therefore, this criterion is not included for these substances.
❖​ Neither tolerance nor withdrawal is necessary for a diagnosis of a
substance use disorder.
❖​ However, for most classes of substances, a past history of
withdrawal is associated with a more severe clinical course (i.e., an
earlier onset of a substance use disorder, higher levels of
substance intake, and a greater number of substance-related
problems).

Tolerance and Withdrawal During Medical Treatment

●​ Symptoms of tolerance and withdrawal occurring during appropriate

use of prescribed medications given as part of medical treatment
(e.g., opioid analgesics, sedatives, stimulants) are specifically not
counted when diagnosing a substance use disorder.
●​ The appearance of normal, expected pharmacological tolerance and
withdrawal during the course of medical treatment has been known
to lead to an erroneous diagnosis of “addiction” even when these
were the only symptoms present.
●​ Individuals whose only symptoms are those that occur as a result of
medical treatment (i.e., tolerance and withdrawal as part of medical
care when the medications are taken as prescribed) should not
receive a diagnosis solely on the basis of these symptoms.
●​ However, prescription medications can be used inappropriately, and
a substance use disorder can be correctly diagnosed when there are
other symptoms of compulsive, drug-seeking behavior.
Alcohol Related Disorders- 4 C’s Control, Compulsions, Cravings,
Consequences

Alcohol Use Disorder

Diagnostic Criteria

A. A problematic pattern of alcohol use leading to clinically significant impairment or

distress, as manifested by at least two of the following, occurring within a 12 month period:

1. Alcohol 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 alcohol use.

3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its
effects.

4. Craving, or a strong desire or urge to use alcohol.

5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

6. Continued alcohol use despite having persistent or recurrent social or

interpersonal problems caused or exacerbated by the effects of alcohol.

7. Important social, occupational, or recreational activities are given up or

reduced because of alcohol use.

8. Recurrent alcohol use in situations in which it is physically hazardous.

9. Alcohol 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 alcohol.

10. Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

b. A markedly diminished effect with continued use of the same amount of alcohol.

11. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for
alcohol withdrawal).

b. Alcohol (or a closely related substance, such as a benzodiazepine) is

taken to relieve or avoid withdrawal symptoms.

Specify if:

In early remission: After full criteria for alcohol use disorder were
previously met, none of the criteria for alcohol 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 desire or urge to use alcohol,” may
be met).

In sustained remission: After full criteria for alcohol use disorder were
previously met, none of the criteria for alcohol 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
alcohol,” may be met).

Specify if: In a controlled environment: This additional specifier is used if

the individual is in an environment where access to alcohol is restricted.
“In a controlled environment” applies as a further specifier of remission
if the individual is both in remission and in a controlled environment (i.e.,
in early remission in a controlled environment or in sustained remission in
a controlled environment). Examples of these environments are closely
supervised and substance-free jails, therapeutic communities, and locked
hospital units. Severity of the disorder is based on the number of
diagnostic criteria endorsed. For a given individual, changes in severity of
alcohol use disorder across time are also reflected by reductions in the
frequency (e.g., days of use per month) or dose (e.g., number of standard
drinks consumed per day) of alcohol used, as assessed by the individual’s
self-report, report of knowledgeable others, clinician observations, and,
when practical, biological testing (e.g., elevations in blood tests)
Of course! Here's the **same content** you provided, now
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points** for better clarity—**no paraphrasing or omissions**.

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## **Diagnostic Features of Alcohol Use Disorder**

Alcohol use disorder is defined by a cluster of behavioral and

physical symptoms, such as withdrawal, tolerance, and craving.

### **Withdrawal**
- Characterized by symptoms that develop approximately 4–12 hours
after the reduction of intake following prolonged, heavy alcohol
ingestion.
- Because withdrawal can be unpleasant and intense, individuals may
continue to consume alcohol despite adverse consequences—often to
avoid or relieve withdrawal symptoms.
- Some withdrawal symptoms (e.g., sleep problems) can persist at
lower intensities for months and contribute to relapse.

### **Behavioral Patterns**

- Once repetitive and intense use develops, individuals may devote
substantial periods of time to obtaining and consuming alcoholic
beverages.

### **Craving**
- Craving for alcohol is indicated by a strong desire to drink that
makes it difficult to think of anything else.
- Often results in the onset of drinking.

### **Functional Impairment**

- School and job performance may suffer due to:
 - Aftereffects of drinking
- Actual intoxication at school or work
- Child care or household responsibilities may be neglected.
- Alcohol-related absences may occur from school or work.

### **Risky Use**

- The individual may use alcohol in physically hazardous
circumstances (e.g., driving, swimming, or operating machinery while
intoxicated).

### **Continued Use Despite Harm**

- Individuals may continue to consume alcohol despite knowledge
that it poses significant:
- Physical problems (e.g., blackouts, liver disease)
- Psychological problems (e.g., depression)
- Social or interpersonal problems (e.g., violent arguments with
spouse, child abuse)

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## **Associated Features**

### **Polysubstance Use**

- Alcohol use disorder is often associated with problems seen in
other substance use disorders (e.g., cannabis, cocaine, heroin,
amphetamines, sedatives, hypnotics, anxiolytics).
- Alcohol may be used to:
- Alleviate unwanted effects of other substances
- Substitute when other substances are unavailable

### **Comorbid Symptoms**

- Symptoms frequently accompanying heavy drinking:
- Conduct problems
 - Depression
- Anxiety
- Insomnia
- These symptoms can sometimes precede alcohol use.

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## **Medical Complications**

### **Organ System Effects**

- **Gastrointestinal**:
- Gastritis
- Stomach or duodenal ulcers
- Liver cirrhosis (in ~15% of heavy users)
- Pancreatitis
- Increased rate of gastrointestinal cancers (e.g., esophagus,
stomach)

- **Cardiovascular**:
- Low-grade hypertension
- Cardiomyopathy and other myopathies (less common but
increased in heavy drinkers)
- Elevated risk of heart disease due to:
- Increased triglycerides
- Increased low-density lipoprotein (LDL) cholesterol

- **Peripheral Nervous System**:

- Peripheral neuropathy:
- Muscular weakness
- Paresthesias
- Decreased peripheral sensation

- **Central Nervous System**:

 - Cognitive deficits (e.g., severe memory impairment)
- Degenerative changes in the cerebellum
- Caused by:
- Direct effects of alcohol
- Trauma
- Vitamin deficiencies (especially B vitamins like thiamine)

- **Severe Neurocognitive Disorders**:

- Alcohol-induced persisting amnestic disorder, or
**Wernicke-Korsakoff syndrome**
- Involves severely impaired ability to encode new memory
- Now classified under “Neurocognitive Disorders” as a
**substance/medication-induced neurocognitive disorder**

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## **Suicide Risk**

- Alcohol use disorder is a major contributor to suicide risk:

- During severe intoxication
- In the context of temporary alcohol-induced depressive or
bipolar disorder
- Increased rate of:
- Suicidal behavior
- Completed suicide among individuals with the disorder

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Would you like me to organize the DSM-5 diagnostic criteria for

any other substance-related or addictive disorders as well?