Substance-Related and Addictive Disorders
Assignment: Assessing and Diagnosing Patients With Substance-Related and Addictive Disorders
Many individuals seeking treatment meet the criteria for both mental health and substance-related disorders. Regardless of whether you specialize in substance-related disorders, all advanced practice nurses should know their signs and symptoms and how to assess and diagnose them. There are assessment and screening tools available to clinicians, and a plethora of information can be obtained through the diagnostic interview. It takes time and experience to know what types of questions to ask to gain the most information, in addition to a basic knowledge of the substances and behaviors you are trying to assess. It can be complicated to sort out substance use disorders from other mental health disorders, but most clients seeking treatment have comorbidities. Substance-Related and Addictive Disorders
- Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information
- Formulate differential diagnoses using DSM-5 criteria for patients with substance-related and addictive disorders across the lifespan
An important consideration when working with patients is their cultural background. Understanding an individual’s culture and personal experiences provides insight into who the person is and where he or she may progress in the future. Culture helps to establish a sense of identity, as well as to set values, behaviors, and purpose for individuals within a society. Culture may also contribute to a divide between specific interpretations of cultural behavior and societal norms. What one culture may deem as appropriate another culture may find inappropriate. As a result, it is important for advanced practice nurses to remain aware of cultural considerations and interpretations of behavior for diagnosis, especially with reference to substance-related disorders. At the same time, PMHNPs must balance their professional and legal responsibilities for assessment and diagnosis with such cultural considerations and interpretations.
- Consider what history would be necessary to collect from this patient.
- Consider what interview questions you would need to ask this patient.
- Identify at least three possible differential diagnoses for the patient. Substance-Related and Addictive Disorders
CASE STUDY
Name: Lisa Pittman Gender: female Age: 29 years old T- 99.8 P- 101 R 20 178/94 Ht 5’6 Wt 140lbs Background: Lisa is in a West Palm Beach, FL detox facility thinking about long term rehab. She has been smoking crack cocaine, approximately $100 daily. She admits to cannabis 1–2 times weekly (“I have a medical card”), and 2–3 alcohol drinks once weekly. She has past drug possession and theft convictions; currently on 2 yr probation with randomized drug screens. She tries to find the pattern for the calls in order not to test dirty urine. Her admission labs abnormal for ALT 168 AST 200 ALK 250; bilirubin 2.5, albumin 3.0; her GGT is 59; UDS positive for cocaine, THC. Negative for alcohol or other drugs. BAL 0; other labs within normal ranges. She reports sexual abuse as child ages 5–7, perpetrator being her father who went to prison for the abuse and drug charges. She is estranged from him. Mother lives in Alabama, hx of anxiety, benzodiazepine use. Older brother has not contact with family in last 10 years, hx of opioid use. Sleeps 4-5 hrs, appetite decreased, prefers to get high instead of eating. Allergies: amoxicillin She is considering treatment for her Hep C+ but needs to get clean first.
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00:00:00TRANSCRIPT OF VIDEO FILE:
00:00:00______________________________________________________________________________
00:00:00BEGIN TRANSCRIPT:
00:00:00[sil.]
00:00:20LISA Well I had to be here in this hospital if that answers your question.
00:00:25OFF CAMERA Yes, thank you. Can I get you a drink of water or something else to drink? Anything?
00:00:35LISA A drink isn’t going to convince me, right? You’re going to have to convince me.
00:00:40OFF CAMERA What is you want me to persuade you to do?
00:00:45LISA Going to rehab.
00:00:50OFF CAMERA What worries you about going to rehab? Substance-Related and Addictive Disorders
00:00:55[sil.]
00:01:00LISA Everything.
00:01:00OFF CAMERA Okay. I tell you what let’s go back a little bit and tell me about how you’re feeling today.
00:01:10LISA Scared.
00:01:15OFF CAMERA Can you tell me more about that feeling of being scared?
00:01:20LISA Well, I don’t want to be. I don’t want to be what people say I am because if I say it and I’m not going to say it because I ain’t going to change. I can’t.
00:01:35OFF CAMERA What do people say you are?
00:01:40LISA And I’m not.
00:01:45OFF CAMERA What don’t you want to be?
00:01:45LISA An addict.
00:01:50OFF CAMERA Do you use drugs and alcohol?
00:01:50LISA Yeah sometimes I have a drink. You know with friends [inaudible] but it doesn’t matter. I’m in control.
00:02:00OFF CAMERA Do you feel in control now?
00:02:05LISA Maybe I could just get that drink [inaudible].
00:02:10OFF CAMERA Sure. Sure. Here you go.
00:02:15LISA Thank you.
00:02:20[sil.]
00:02:30LISA You know what I just think I should leave.
00:02:30OFF CAMERA You keep saying you should leave. You said that earlier but do you really want to leave?
00:02:40LISA No.
00:02:45OFF CAMERA Okay. Tell me why you are here.
00:02:45LISA Because I’m scared.
00:02:50OFF CAMERA You said that earlier. You think if you could — then I could figure out together why you’re scared and maybe we can come up to a plan. Up with a plan and if we do that, then maybe your fears will disappear.
00:03:05LISA No not these fears [inaudible] because it’s over.
00:03:10OFF CAMERA What’s over?
00:03:10LISA Everything. The business.
00:03:15OFF CAMERA What do you mean?
00:03:20LISA Jeremy.
00:03:25OFF CAMERA Who is Jeremy?
00:03:25LISA He’s my boyfriend. I saw him naked with Alisa [assumed spelling] with the same fucking name as me. We now have the same fucking boyfriend. In my office, he was screwing that fucking cunk.
00:03:45OFF CAMERA So you’re the one who caught Jeremy cheating?
00:03:55LISA Yeah. Cheating? Yeah that’s a clever word shrinks use.
00:04:05OFF CAMERA So you and Jeremy share an office?
00:04:05LISA Yeah we do commercials for local businesses, you know, build websites, that kind of stuff. We started a business together. He moved in with me.
00:04:15OFF CAMERA How long ago was that?
00:04:20LISA Nine months.
00:04:20OFF CAMERA Do you have any children? Substance-Related and Addictive Disorders
00:04:20LISA Not with that fucking asshole.
00:04:25[sil.]
00:04:30LISA I have a daughter, Sarah. Gosh, she’s beautiful. She stays with some friends. She’s not related to Jeremy, thank God.
00:04:45OFF CAMERA And where are you staying?
00:04:45LISA I’m renting a place far away from here. You know I ran down to the bank to empty both our bank accounts.
00:04:55OFF CAMERA Business accounts?
00:04:55LISA Yeah. And do you know that asshole has been draining them for 4 months? I swear.
00:05:05OFF CAMERA Taking money out of your account without your knowledge.
00:05:05LISA Yeah. For his buys.
00:05:10OFF CAMERA Buys?
00:05:10LISA Yeah, to payoff his debts with my money.
00:05:20OFF CAMERA Or crack cocaine?
00:05:25LISA Yeah for crack.
00:05:25OFF CAMERA How long have you know he’s been smoking crack?
00:05:30LISA Ever since I saw him with that — every since I saw with her naked. The both of them naked.
00:05:40OFF CAMERA What was that like seeing Jeremy and Alisa naked and smoking crack?
00:05:40LISA Well have you ever seen someone you love naked smoking crack?
00:05:45OFF CAMERA No.
00:05:50LISA Yeah no I didn’t think so.
00:05:50OFF CAMERA So what has that been like for you knowing Jeremy’s smoking crack?
00:05:55LISA Well, I’ve never seen him do drugs before. You know he drinks a lot, smokes weed, but crack cocaine. I mean God have mercy.
00:06:15OFF CAMERA What are you thinking about?
00:06:20LISA Everyone’s going to know.
00:06:25OFF CAMERA Know what?
00:06:30LISA That I was getting high to stay in this hospital and get cleaned up.
00:06:35OFF CAMERA You mean rather than go to rehab.
00:06:40LISA Rehab, man they’re fucking dirty places and I’m sick and tired of dirty places.
00:06:45OFF CAMERA No, no, no this rehab place is very clean. I’ve seen it. There are a lot of nice people there. People who feel like they get much better help than here in the hospital. In fact, I can call someone for you and let you talk with them.
00:06:55LISA No, no, no, no, no, no, no, no, don’t do that.
00:07:00OFF CAMERA You’re really fearful of going to rehab.
00:07:05LISA Well if everyone finds out that I’ve been to rehab, I won’t get a job. I won’t be hired anyway.
00:07:10OFF CAMERA Plus if people are fearful of the stigma and fearful of what people will think of them.
00:07:20LISA Yeah, but he says that I’m not addicted. It’s just — you know something wrong with my personality.
00:07:25OFF CAMERA Who says there’s something wrong with your personality?
00:07:30LISA Jeremy.
00:07:30OFF CAMERA When did he tell you that?
00:07:35LISA Lots of times.
00:07:35OFF CAMERA I thought you said you and Jeremy split up after you caught him cheating.
00:07:40LISA I —
00:07:45OFF CAMERA It’s okay. Take your time.
00:07:50LISA Well yeah he moved back in.
00:07:50OFF CAMERA Into your new home?
00:07:55LISA Yeah. What changed that you two decided to get back together?
00:08:00OFF CAMERA Well he said he was sorry and he begged me. He’s done it before so I took him back.
00:08:10LISA And how has that been being back with Jeremy?
00:08:15OFF CAMERA Well I love Jeremy. I do and don’t want to go out and find another boyfriend. I mean we lost 80,000 dollars on that business. And he promised me that he would make it all back.
00:08:30LISA So is that why you took him back? Has Jeremy continued smoking crack?
00:08:45OFF CAMERA Yeah a little but he’s not addicted. He says that it calms him down. Me too.
00:09:05LISA You too? Substance-Related and Addictive Disorders
00:09:05OFF CAMERA So do you smoke crack with Jeremy?
00:09:15LISA Yeah we — he made me try it.
00:09:25[sil.]
00:09:30[ Crying ]
00:09:40LISA And then he tried just once. We did it together. [Inaudible] I could.
00:09:55[ Crying ]
00:10:00LISA Hit me like a bullet. And it felt so good. I felt so good. And real fast.
00:10:20[sil.]
00:10:25LISA Have you ever felt like you were dancing with butterflies?
00:10:30OFF CAMERA Dancing with butterflies? No I have not.
00:10:40[sil.]
00:10:45LISA But he says it’s not addictive, Jeremy.
00:10:50OFF CAMERA What do you think?
00:10:55LISA Well I know I can’t get enough.
00:11:00[ Crying ]
00:11:10LISA And I know I don’t want to go back to feeling horrible again because when I don’t smoke it I get worse. And when I have it, I feel good. And then it’s gone. And then I know that I’m going to be needing another hit.
00:11:45OFF CAMERA That sounds a lot like addiction.
00:11:55LISA Yeah but I know I don’t want it to be.
00:12:00OFF CAMERA It sounds like you are very scared of getting help and yet at the same very time, it sounds like you know you need that help.
00:12:15LISA I know I don’t need help. I don’t need anything. Jeremy promised me that everything is going to be okay. And when you love someone like I do, you got to believe him. Right?
00:12:45[sil.]
00:12:45END TRANSCRIPT
Substance-Related and Addictive Disorders
The substance-related disorders encompass 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens (with separate categories for phencyclidine [or similarly acting arylcyclohexylamines] and other hallucinogens); inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants (amphetamine-type substances, cocaine, and other stimulants); tobacco; and other (or unknown) substances. These 10 classes are not fully distinct. All drugs that are taken in excess have in common direct activation of the brain reward system, which is involved in the reinforcement of behaviors and the production of memories. They produce such an intense activation of the reward system that normal activities may be neglected. Instead of achieving reward system activation through adaptive behaviors, drugs of abuse directly activate the reward pathways(Koob 2006). The pharmacological mechanisms by which each class of drugs produces reward are different, but the drugs typically activate the system and produce feelings of pleasure, often referred to as a “high.” Furthermore, individuals with lower levels of self-control, which may reflect impairments of brain inhibitory mechanisms, may be particularly predisposed to develop substance use disorders, suggesting that the roots of substance use disorders for some persons can be seen in behaviors long before the onset of actual substance use itself(Moffitt et al. 2011).
In addition to the substance-related disorders, this chapter also includes gambling disorder, reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse and produce some behavioral symptoms that appear comparable to those produced by the substance use disorders. Other excessive behavioral patterns, such as Internet gaming, have also been described, but the research on these and other behavioral syndromes is less clear. Thus, groups of repetitive behaviors, which some term behavioral addictions, with such subcategories as “sex addiction,” “exercise addiction,” or “shopping addiction,” are not included because at this time there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders. Substance-Related and Addictive Disorders
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: intoxication, withdrawal, and other substance/medication-induced mental disorders (psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders).
The current section begins with a general discussion of criteria sets for a substance use disorder, substance intoxication and withdrawal, and other substance/medication-induced mental disorders, at least some of which are applicable across classes of substances. Reflecting some unique aspects of the 10 substance classes relevant to this chapter, the remainder of the chapter is organized by the class of substance and describes their unique aspects. To facilitate differential diagnosis, the text and criteria for the remaining substance/medication-induced mental disorders are included with disorders with which they share phenomenology (e.g., substance/medication-induced depressive disorder is in the chapter “Depressive Disorders”).
Features
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. As seen in Table, the diagnosis of a substance use disorder can be applied to all 10 classes included in this chapter except caffeine. For certain classes some symptoms are less salient, and in a few instances not all symptoms apply (e.g., withdrawal symptoms are not specified for phencyclidine use disorder, other hallucinogen use disorder, or inhalant use disorder).
An important characteristic of substance use disorders is an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. The behavioral effects of these brain changes may be exhibited in the repeated relapses and intense drug craving when the individuals are exposed to drug-related stimuli. These persistent drug effects may benefit from long-term approaches to treatment(McLellan et al. 2000).
Overall, the diagnosis of a substance use disorder is based on a pathological pattern of behaviors related to use of the substance. To assist with organization, Criterion A criteria 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). The individual may take the substance in larger amounts or over a longer period than was originally intended (Criterion 1). 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 2). The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects (Criterion 3). In some instances of more severe substance use disorders, virtually all of the individual’s daily activities revolve around the substance. Craving (Criterion 4) 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 is queried by asking if there has ever been a time when they had such strong urges to take the drug that they 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(Miller et al. 1996).
Social impairment is the second grouping of criteria (Criteria 5–7). Recurrent substance use may result in a failure to fulfill major role obligations at work, school, or home (Criterion 5). 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 6). Important social, occupational, or recreational activities may be given up or reduced because of substance use (Criterion 7). 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). This may take the form of recurrent substance use in situations in which it is physically hazardous (Criterion 8). 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 (Criterion 9). 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). Tolerance (Criterion 10) 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(Schuckit et al. 2011). Substance-Related and Addictive Disorders.
Withdrawal (Criterion 11) 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 (amphetamines and cocaine), 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)(Chen et al. 2009).
Symptoms of tolerance and withdrawal occurring during appropriate medical treatment with prescribed medications (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.
Severity and Specifiers
Substance use disorders occur in a broad range of severity, from mild to severe, with severity based on the number of symptom criteria endorsed. As a general estimate of severity, a mild substance use disorder is suggested by the presence of two to three symptoms, moderate by four to five symptoms, and severe by six or more symptoms. Changing severity across time is also reflected by reductions or increases in the frequency and/or dose of substance use, as assessed by the individual’s own report, report of knowledgeable others, clinician’s observations, and biological testing. The following course specifiers and descriptive features specifiers are also available for substance use disorders: “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.” Definitions of each are provided within respective criteria sets.
Recording Procedures for Substance Use Disorders
The clinician should use the code that applies to the class of substances but record the name of the specific substance. For example, the clinician should record 304.10 (F13.20) moderate alprazolam use disorder (rather than moderate sedative, hypnotic, or anxiolytic use disorder) or 305.70 (F15.10) mild methamphetamine use disorder (rather than mild stimulant use disorder). For substances that do not fit into any of the classes (e.g., anabolic steroids), the appropriate code for “other substance use disorder” should be used and the specific substance indicated (e.g., 305.90 [F19.10] mild anabolic steroid use disorder). If the substance taken by the individual is unknown, the code for the class “other (or unknown)” should be used (e.g., 304.90 [F19.20] severe unknown substance use disorder). If criteria are met for more than one substance use disorder, all should be diagnosed (e.g., 304.00 [F11.20] severe heroin use disorder; 304.20 [F14.20] moderate cocaine use disorder).
The appropriate ICD-10-CM code for a substance use disorder depends on whether there is a comorbid substance-induced disorder (including intoxication and withdrawal). In the above example, the diagnostic code for moderate alprazolam use disorder, F13.20, reflects the absence of a comorbid alprazolam-induced mental disorder. Because ICD-10-CM codes for substance-induced disorders indicate both the presence (or absence) and severity of the substance use disorder, ICD-10-CM codes for substance use disorders can be used only in the absence of a substance-induced disorder. See the individual substance-specific sections for additional coding information.
Note that the word addiction is not applied as a diagnostic term in this classification, although it is in common usage in many countries to describe severe problems related to compulsive and habitual use of substances. The more neutral 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 drug taking. Some clinicians will choose to use the word addiction to describe more extreme presentations, but the word is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation.Substance-Related and Addictive Disorders
Substance-Induced Disorders
The overall category of substance-induced disorders includes intoxication, withdrawal, and other substance/medication-induced mental disorders (e.g., substance-induced psychotic disorder, substance-induced depressive disorder).
Substance Intoxication and Withdrawal
Criteria for substance intoxication are included within the substance-specific sections of this chapter. The essential feature is the development of a reversible substance-specific syndrome due to the recent ingestion of a substance (Criterion A). The clinically significant problematic behavioral or psychological changes associated with intoxication (e.g., belligerence, mood lability, impaired judgment) are attributable to the physiological effects of the substance on the central nervous system and develop during or shortly after use of the substance (Criterion B). The symptoms are not attributable to another medical condition and are not better explained by another mental disorder (Criterion D). Substance intoxication is common among those with a substance use disorder but also occurs frequently in individuals without a substance use disorder. This category does not apply to tobacco.
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The most common changes in intoxication involve disturbances of perception, wakefulness, attention, thinking, judgment, psychomotor behavior, and interpersonal behavior. Short-term, or “acute,” intoxications may have different signs and symptoms than sustained, or “chronic,” intoxications. For example, moderate cocaine doses may initially produce gregariousness, but social withdrawal may develop if such doses are frequently repeated over days or weeks(O’Brien 2011).
When used in the physiological sense, the term intoxication is broader than substance intoxication as defined here. Many substances may produce physiological or psychological changes that are not necessarily problematic. For example, an individual with tachycardia from substance use has a physiological effect, but if this is the only symptom in the absence of problematic behavior, the diagnosis of intoxication would not apply. Intoxication may sometimes persist beyond the time when the substance is detectable in the body. This may be due to enduring central nervous system effects, the recovery of which takes longer than the time for elimination of the substance. These longer-term effects of intoxication must be distinguished from withdrawal (i.e., symptoms initiated by a decline in blood or tissue concentrations of a substance).
Criteria for substance withdrawal are included within the substance-specific sections of this chapter. The essential feature is the development of a substance-specific problematic behavioral change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use (Criterion A). The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The symptoms are not due to another medical condition and are not better explained by another mental disorder (Criterion D). Withdrawal is usually, but not always, associated with a substance use disorder. Most individuals with withdrawal have an urge to re-administer the substance to reduce the symptoms.
Route of Administration and Speed of Substance Effects
Routes of administration that produce more rapid and efficient absorption into the bloodstream (e.g., intravenous, smoking, intranasal “snorting”) tend to result in a more intense intoxication and an increased likelihood of an escalating pattern of substance use leading to withdrawal. Similarly, rapidly acting substances are more likely than slower-acting substances to produce immediate intoxication(O’Brien 2011).
Duration of Effects
Within the same drug category, relatively short-acting substances tend to have a higher potential for the development of withdrawal than do those with a longer duration of action. However, longer-acting substances tend to have longer withdrawal duration. The half-life of the substance parallels aspects of withdrawal: the longer the duration of action, the longer the time between cessation and the onset of withdrawal symptoms and the longer the withdrawal duration. In general, the longer the acute withdrawal period, the less intense the syndrome tends to be(O’Brien 2011). Substance-Related and Addictive Disorders
Use of Multiple Substances
Substance intoxication and withdrawal often involve several substances used simultaneously or sequentially. In these cases, each diagnosis should be recorded separately.
Associated Laboratory Findings
Laboratory analyses of blood and urine samples can help determine recent use and the specific substances involved. However, a positive laboratory test result does not by itself indicate that the individual has a pattern of substance use that meets criteria for a substance-induced or substance use disorder, and a negative test result does not by itself rule out a diagnosis.
Laboratory tests can be useful in identifying withdrawal. If the individual presents with withdrawal from an unknown substance, laboratory tests may help identify the substance and may also be helpful in differentiating withdrawal from other mental disorders. In addition, normal functioning in the presence of high blood levels of a substance suggests considerable tolerance.
Development and Course
Individuals ages 18–24 years have relatively high prevalence rates for the use of virtually every substance. Intoxication is usually the initial substance-related disorder and often begins in the teens. Withdrawal can occur at any age as long as the relevant drug has been taken in sufficient doses over an extended period of time.
Recording Procedures for Intoxication and Withdrawal
The clinician should use the code that applies to the class of substances but record the name of the specific substance. For example, the clinician should record 292.0 (F13.239) secobarbital withdrawal (rather than sedative, hypnotic, or anxiolytic withdrawal) or 292.89 (F15.129) methamphetamine intoxication (rather than stimulant intoxication). Note that the appropriate ICD-10-CM diagnostic code for intoxication depends on whether there is a comorbid substance use disorder. In this case, the F15.129 code for methamphetamine indicates the presence of a comorbid mild methamphetamine use disorder. If there had been no comorbid methamphetamine use disorder, the diagnostic code would have been F15.929. ICD-10-CM coding rules require that all withdrawal codes imply a comorbid moderate to severe substance use disorder for that substance. In the above case, the code for secobarbital withdrawal (F13.239) indicates the comorbid presence of a moderate to severe secobarbital use disorder. See the coding note for the substance-specific intoxication and withdrawal syndromes for the actual coding options.
For substances that do not fit into any of the classes (e.g., anabolic steroids), the appropriate code for “other substance intoxication” should be used and the specific substance indicated (e.g., 292.89 [F19.929] anabolic steroid intoxication). If the substance taken by the individual is unknown, the code for the class “other (or unknown)” should be used (e.g., 292.89 [F19.929] unknown substance intoxication). If there are symptoms or problems associated with a particular substance but criteria are not met for any of the substance-specific disorders, the unspecified category can be used (e.g., 292.9 [F12.99] unspecified cannabis-related disorder).
As noted above, the substance-related codes in ICD-10-CM combine the substance use disorder aspect of the clinical picture and the substance-induced aspect into a single combined code. Thus, if both heroin withdrawal and moderate heroin use disorder are present, the single code F11.23 is given to cover both presentations. In ICD-9-CM, separate diagnostic codes (292.0 and 304.00) are given to indicate withdrawal and a moderate heroin use disorder, respectively. See the individual substance-specific sections for additional coding information.
Substance/Medication-Induced Mental Disorders
The substance/medication-induced mental disorders are potentially severe, usually temporary, but sometimes persisting central nervous system (CNS) syndromes that develop in the context of the effects of substances of abuse, medications, or several toxins. They are distinguished from the substance use disorders, in which a cluster of cognitive, behavioral, and physiological symptoms contribute to the continued use of a substance despite significant substance-related problems. The substance/medication-induced mental disorders may be induced by the 10 classes of substances that produce substance use disorders, or by a great variety of other medications used in medical treatment. Each substance-induced mental disorder is described in the relevant chapter (e.g., “Depressive Disorders,” “Neurocognitive Disorders”), and therefore, only a brief description is offered here. All substance/medication-induced disorders share common characteristics. It is important to recognize these common features to aid in the detection of these disorders. These features are described as follows: Substance-Related and Addictive Disorders
- The disorder represents a clinically significant symptomatic presentation of a relevant mental disorder.
- There is evidence from the history, physical examination, or laboratory findings of both of the following:
- The disorder developed during or within 1 month of a substance intoxication or withdrawal or taking a medication; and
- The involved substance/medication is capable of producing the mental disorder.
- The disorder is not better explained by an independent mental disorder (i.e., one that is not substance- or medication-induced). Such evidence of an independent mental disorder could include the following:
- The disorder preceded the onset of severe intoxication or withdrawal or exposure to the medication; or
- The full mental disorder persisted for a substantial period of time (e.g., at least 1 month) after the cessation of acute withdrawal or severe intoxication or taking the medication. This criterion does not apply to substance-induced neurocognitive disorders or hallucinogen persisting perception disorder, which persist beyond the cessation of acute intoxication or withdrawal.
- The disorder does not occur exclusively during the course of a delirium.
- The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Features
Some generalizations can be made regarding the categories of substances capable of producing clinically relevant substance-induced mental disorders. In general, the more sedating drugs (sedative, hypnotics, or anxiolytics, and alcohol) can produce prominent and clinically significant depressive disorders during intoxication, while anxiety conditions are likely to be observed during withdrawal syndromes from these substances(Schuckit 2006a). Also, during intoxication, the more stimulating substances (e.g., amphetamines and cocaine) are likely to be associated with substance-induced psychotic disorders and substance-induced anxiety disorders (McLellan et al. 1979), with substance-induced major depressive episodes observed during withdrawal. Both the more sedating and more stimulating drugs are likely to produce significant but temporary sleep and sexual disturbances(Van Reen et al. 2006). An overview of the relationship between specific categories of substances and specific psychiatric syndromes is presented in Table.
The medication-induced conditions include what are often idiosyncratic CNS reactions or relatively extreme examples of side effects for a wide range of medications taken for a variety of medical concerns. These include neurocognitive complications of anesthetics, antihistamines, antihypertensives, and a variety of other medications and toxins (e.g., organophosphates, insecticides, carbon monoxide), as described in the chapter on neurocognitive disorders. Psychotic syndromes may be temporarily experienced in the context of anticholinergic, cardiovascular, and steroid drugs, as well as during use of stimulant-like and depressant-like prescription or over-the-counter drugs. Temporary but severe mood disturbances can be observed with a wide range of medications, including steroids, antihypertensives, disulfiram, and any prescription or over-the-counter depressant or stimulant-like substances. A similar range of medications can be associated with temporary anxiety syndromes, sexual dysfunctions, and conditions of disturbed sleep.
In general, to be considered a substance/medication-induced mental disorder, there must be evidence that the disorder being observed is not likely to be better explained by an independent mental condition. The latter are most likely to be seen if the mental disorder was present before the severe intoxication or withdrawal or medication administration, or, with the exception of several substance-induced persisting disorders listed in Table, continued more than 1 month after cessation of acute withdrawal, severe intoxication, or use of the medications(Caton et al. 2005; Hasin et al. 2002; Schuckit 2006a). When symptoms are only observed during a delirium (e.g., alcohol withdrawal delirium), the mental disorder should be diagnosed as a delirium, and the psychiatric syndrome occurring during the delirium should not also be diagnosed separately, as many symptoms (including disturbances in mood, anxiety, and reality testing) are commonly seen during agitated, confused states. The features associated with each relevant major mental disorder are similar whether observed with independent or substance/medication-induced mental disorders. However, individuals with substance/medication-induced mental disorders are likely to also demonstrate the associated features seen with the specific category of substance or medication, as listed in other subsections of this chapter. Substance-Related and Addictive Disorders
Development and Course
Substance-induced mental disorders develop in the context of intoxication or withdrawal from substances of abuse, and medication-induced mental disorders are seen with prescribed or over-the-counter medications that are taken at the suggested doses. Both conditions are usually temporary and likely to disappear within 1 month or so of cessation of acute withdrawal, severe intoxication, or use of the medication. Exceptions to these generalizations occur for certain long-duration substance-induced disorders: substance-associated neurocognitive disorders that relate to conditions such as alcohol-induced neurocognitive disorder, inhalant-induced neurocognitive disorder, and sedative-, hypnotic-, or anxiolytic-induced neurocognitive disorder; and hallucinogen persisting perception disorder (“flashbacks”; see the section “Hallucinogen-Related Disorders” later in this chapter). However, most other substance/medication-induced mental disorders, regardless of the severity of the symptoms, are likely to improve relatively quickly with abstinence and unlikely to remain clinically relevant for more than 1 month after complete cessation of use.
As is true of many consequences of heavy substance use, some individuals are more and others less prone toward specific substance-induced disorders(Alia-Klein et al. 2011; Fu et al. 2002; Nunes et al. 2006; Nurnberger et al. 2004). Similar types of predispositions may make some individuals more likely to develop psychiatric side effects of some types of medications, but not others. However, it is unclear whether individuals with family histories or personal prior histories with independent psychiatric syndromes are more likely to develop the induced syndrome once the consideration is made as to whether the quantity and frequency of the substance was sufficient to lead to the development of a substance-induced syndrome.
There are indications that the intake of substances of abuse or some medications with psychiatric side effects in the context of a preexisting mental disorder is likely to result in an intensification of the preexisting independent syndrome(Fu et al. 2002; Swendsen et al. 2010). The risk for substance/medication-induced mental disorders is likely to increase with both the quantity and the frequency of consumption of the relevant substance.
The symptom profiles for the substance/medication-induced mental disorders resemble independent mental disorders(Caton et al. 2005; Hasin et al. 2006; Regier et al. 1990; Schuckit et al. 1997). While the symptoms of substance/medication-induced mental disorders can be identical to those of independent mental disorders (e.g., delusions, hallucinations, psychoses, major depressive episodes, anxiety syndromes), and although they can have the same severe consequences (e.g., suicide)(Aharonovich et al. 2002), most induced mental disorders are likely to improve in a matter of days to weeks of abstinence(Brown et al. 1995; Gilder et al. 2004; Nunes and Rounsaville 2006; Schuckit et al. 2007).
The substance/medication-induced mental disorders are an important part of the differential diagnoses for the independent psychiatric conditions. The importance of recognizing an induced mental disorder is similar to the relevance of identifying the possible role of some medical conditions and medication reactions before diagnosing an independent mental disorder. Symptoms of substance- and medication-induced mental disorders may be identical cross-sectionally to those of independent mental disorders but have different treatments and prognoses from the independent condition.
Functional Consequences of Substance/Medication-Induced Mental Disorders
The same consequences related to the relevant independent mental disorder (e.g., suicide attempts) are likely to apply to the substance/medication-induced mental disorders, but these are likely to disappear within 1 month after abstinence. Similarly, the same functional consequences associated with the relevant substance use disorder are likely to be seen for the substance-induced mental disorders.
Recording Procedures for Substance/Medication-Induced Mental Disorders
Coding notes and separate recording procedures for ICD-9-CM and ICD-10-CM codes for other specific substance/medication-induced mental disorders are provided in other chapters of the manual with disorders with which they share phenomenology (see the substance/medication-induced mental disorders in these chapters: “Schizophrenia Spectrum and Other Psychotic Disorders,” “Bipolar and Related Disorders,” “Depressive Disorders,” “Anxiety Disorders,” “Obsessive-Compulsive and Related Disorders,” “Sleep-Wake Disorders,” “Sexual Dysfunctions,” and “Neurocognitive Disorders”). Generally, for ICD-9-CM, if a mental disorder is induced by a substance use disorder, a separate diagnostic code is given for the specific substance use disorder, in addition to the code for the substance/medication-induced mental disorder. For ICD-10-CM, a single code combines the substance-induced mental disorder with the substance use disorder. A separate diagnosis of the comorbid substance use disorder is not given, although the name and severity of the specific substance use disorder (when present) are used when recording the substance/medication-induced mental disorder. ICD-10-CM codes are also provided for situations in which the substance/medication-induced mental disorder is not induced by a substance use disorder (e.g., when a disorder is induced by one-time use of a substance or medication). Additional information needed to record the diagnostic name of the substance/medication-induced mental disorder is provided in the section “Recording Procedures” for each substance/medication-induced mental disorder in its respective chapter. Substance-Related and Addictive Disorders
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Stimulant Intoxication
Diagnostic Criteria
- Recent use of an amphetamine-type substance, cocaine, or other stimulant.
- 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.
- Two (or more) of the following signs or symptoms, developing during, or shortly after, stimulant use:
- Tachycardia or bradycardia.
- Pupillary dilation.
- Elevated or lowered blood pressure.
- Perspiration or chills.
- Nausea or vomiting.
- Evidence of weight loss.
- Psychomotor agitation or retardation.
- Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias.
- Confusion, seizures, dyskinesias, dystonias, or coma.
- The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.
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 delirium.
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 perceptual disturbances.
- For amphetamine, cocaine, or other stimulant intoxication, without perceptual disturbances:If a mild amphetamine or other stimulant use disorder is comorbid, the ICD-10-CM code is 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 amphetamine 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 moderate 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.
- For amphetamine, cocaine, or other stimulant intoxication, with perceptual disturbances:If a mild amphetamine or other stimulant use disorder is comorbid, the ICD-10-CM code is 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 amphetamine 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 moderate 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 intoxication, 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 hallucinations may be prominent, as may paranoid ideation, and these symptoms must be distinguished from an independent psychotic disorder such as schizophrenia. Stimulant intoxication usually begins with a “high” feeling and includes one or more of the following: euphoria with enhanced vigor, gregariousness, hyperactivity, restlessness, hypervigilance, interpersonal sensitivity, talkativeness, anxiety, tension, alertness, grandiosity, stereotyped and repetitive behavior, anger, impaired judgment, and, in the case of chronic intoxication, affective blunting with fatigue or sadness and social withdrawal. Substance-Related and Addictive Disorders. These behavioral and psychological changes are accompanied by two or more of the following signs and symptoms that develop during or shortly after stimulant use: tachycardia or bradycardia; pupillary dilation; elevated or lowered blood pressure; perspiration or chills; nausea or vomiting; evidence of weight loss; psychomotor agitation or retardation; muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias; and confusion, seizures, dyskinesias, dystonias, or coma (Criterion C). Intoxication, either acute or chronic, is often associated with impaired social or occupational functioning. Severe intoxication can lead to convulsions, cardiac arrhythmias, hyperpyrexia, and death. For the diagnosis of stimulant intoxication to be made, the symptoms must not be attributable to another medical condition and not better explained by another mental disorder (Criterion D). While stimulant intoxication occurs in individuals with stimulant use disorders, intoxication is not a criterion for stimulant use 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 characteristics of the individual using the substance or the context (e.g., tolerance, rate of absorption, chronicity of use, context in which it is taken). Stimulant effects such as euphoria, increased pulse and blood pressure, and psychomotor activity are most commonly seen. Depressant effects such as sadness, bradycardia, decreased blood pressure, and decreased psychomotor activity are less common and generally emerge only with chronic high-dose use.
Differential Diagnosis
Stimulant-induced disorders
Stimulant intoxication is distinguished from the other stimulant-induced disorders (e.g., stimulant-induced depressive disorder, bipolar disorder, psychotic disorder, anxiety disorder) because the severity of the intoxication symptoms exceeds that associated with the stimulant-induced disorders, and the symptoms warrant independent clinical attention. Stimulant intoxication delirium would be distinguished by a disturbance in level of awareness and change in cognition.
Other mental disorders
Salient mental disturbances associated with stimulant intoxication should be distinguished from the symptoms of schizophrenia, paranoid type; bipolar and depressive disorders; generalized anxiety disorder; and panic disorder as described in DSM-5.
Stimulant Withdrawal
Diagnostic Criteria
- Cessation of (or reduction in) prolonged amphetamine-type substance, cocaine, or other stimulant use.
- Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criterion A: Substance-Related and Addictive Disorders
- Vivid, unpleasant dreams.
- Insomnia or hypersomnia.
- Increased appetite.
- Psychomotor retardation or agitation.
- The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- 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., amphetamine-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 other stimulant withdrawal occurring in the presence of moderate or severe amphetamine or other stimulant use disorder is 23, and the ICD-10-CM code for cocaine withdrawal occurring in the presence of moderate or severe cocaine use disorder is F14.23. For amphetamine or other stimulant withdrawal occurring in the absence of an amphetamine or other stimulant use disorder (e.g., in a patient taking amphetamines solely under appropriate medical supervision), the ICD-10-CM code is F15.93. 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 withdrawal syndrome that develops within a few hours to several days after the cessation of (or marked reduction in) stimulant use (generally high dose) that has been prolonged (Criterion A). The withdrawal syndrome is characterized by the development of dysphoric mood accompanied by two or more of the following physiological changes: fatigue, vivid and unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor retardation or agitation (Criterion B). Bradycardia is often present and is a reliable measure of stimulant withdrawal(Ahmadi et al. 2008; Ahmadi et al. 2009; McGregor et al. 2005).
Anhedonia and drug craving can often be present but are not part of the diagnostic criteria. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The symptoms must not be attributable to another medical condition and are not better explained by another mental disorder (Criterion D).
Associated Features Supporting Diagnosis
Acute withdrawal symptoms (“a crash”) are often seen after periods of repetitive high-dose use (“runs” or “binges”). These periods are characterized 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 generally the most serious problems seen during “crashing” or other forms of stimulant withdrawal. The majority of individuals with stimulant use disorder experience a withdrawal syndrome at some point, and virtually all individuals with the disorder report tolerance.
Differential Diagnosis
Stimulant use disorder and other stimulant-induced disorders
Stimulant withdrawal is distinguished from stimulant use disorder and from the other stimulant-induced disorders (e.g., stimulant-induced intoxication delirium, depressive disorder, bipolar disorder, psychotic disorder, anxiety disorder, sexual dysfunction, sleep disorder) because the symptoms of withdrawal predominate the clinical presentation and are severe enough to warrant independent clinical attention. Substance-Related and Addictive Disorders
