Substance-Related and Addictive Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), no
longer uses the terms substance abuse and substance dependence, rather it refers to substance
use disorders, which are defined as mild, moderate, or severe to indicate the level of severity,
which is determined by the number of diagnostic criteria met by an individual. Substance use
disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally
significant impairment, such as health problems, disability, and failure to meet major
responsibilities at work, school, or home. According to the DSM-5, a diagnosis of substance use
disorder is based on evidence of impaired control, social impairment, risky use, and
pharmacological criteria.

Substance-Related Disorders
Substance Use Disorders
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.
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.

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.
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).

Substance/Medication-Induced Mental Disorders

Diagnostic Criteria
A. The disorder represents a clinically significant symptomatic presentation of a relevant mental
disorder.
B. There is evidence from the history, physical examination, or laboratory findings of both of the
following:
1. The disorder developed during or within 1 month of a substance intoxication or withdrawal or
taking a medication; and
2. The involved substance/medication is capable of producing the mental disorder.
C. 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:
1. The disorder preceded the onset of severe intoxication or withdrawal or exposure to the
medication; or
2. 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.
D. The disorder does not occur exclusively during the course of a delirium.
E. The disorder causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.

Alcohol-Related Disorders
Alcohol-related disorders include alcohol-use disorder, alcohol intoxication, and alcohol
withdrawal. Alcohol-use disorder, or alcoholism, refers to a problematic pattern of alcohol use
leading to significant impairment or distress. Alcohol intoxication refers to recent ingestion of
alcohol with problematic behavioral or psychological changes developed during, or shortly after,
drinking. Alcohol withdrawal refers to the symptoms that may develop when a person who has
been drinking excessive amounts of alcohol on a regular basis suddenly stops drinking.

Alcohol Use Disorder

Alcohol use disorder (which includes a level that's sometimes called alcoholism) is a
pattern of alcohol use that involves problems controlling your drinking, being preoccupied with
alcohol, continuing to use alcohol even when it causes problems, having to drink more to get the
same effect, or having withdrawal symptoms when you rapidly decrease or stop drinking.
Characteristics
When a person has a dependency on alcohol, they feel continuous cravings for drinking,
and may suffer light to severe withdrawal symptoms if they stop. They also feel the need to
drink ever-increasing amounts in order to get a "buzz" or get drunk. Even with the realisation
that drinking is affecting their health or their relationship with others, they will still drink, because
stopping could cause them to experience anything from insomnia, nauseous feelings, break out
in sweats, to seizures, and even to hallucinate.

These withdrawal symptoms can be overcome with treatment, but the lasting health
problems can be much worse if treatment is not sought and drinking is not stopped. Chronic
drinking can cause problems with the heart, the liver, brain function, and increase the risks of
cancer and nerve damage. It can also cause birth defects if someone pregnant drinks.

Clinical Signs and Symptoms

 Being unable to limit the amount of alcohol you drink

 Wanting to cut down on how much you drink or making unsuccessful attempts to do so
 Spending a lot of time drinking, getting alcohol or recovering from alcohol use
 Feeling a strong craving or urge to drink alcohol
 Failing to fulfill major obligations at work, school or home due to repeated alcohol use
 Continuing to drink alcohol even though you know it's causing physical, social or
interpersonal problems
 Giving up or reducing social and work activities and hobbies
 Using alcohol in situations where it's not safe, such as when driving or swimming
 Developing a tolerance to alcohol so you need more to feel its effect or you have a reduced
effect from the same amount
 Experiencing withdrawal symptoms — such as nausea, sweating and shaking — when you
don't drink, or drinking to avoid these symptoms

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, pp. 499-500).
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or
avoid withdrawal symptoms.

Alcohol Intoxication
Alcohol intoxication results as the amount of alcohol in your blood stream increases. The
higher the blood alcohol concentration is, the more impaired you become.

Characteristics

Alcohol intoxication causes behavior problems and mental changes. These may include
inappropriate behavior, unstable moods, impaired judgment, slurred speech, impaired attention
or memory, and poor coordination. You can also have periods called "blackouts," where you
don't remember events. Very high blood alcohol levels can lead to coma or even death.

Clinical Signs and Symptoms

 Confusion
 Vomiting
 Seizures
 Slow breathing (less than eight breaths a minute)
 Irregular breathing (a gap of more than 10 seconds between breaths)
 Blue-tinged skin or pale skin
 Low body temperature (hypothermia)
 Passing out (unconsciousness) and can't be awakened

Diagnostic Criteria
A. Recent ingestion of alcohol.
B. Clinically significant problematic behavioral or psychological changes (e.g., inappropriate
sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or
shortly after, alcohol ingestion.
C. One (or more) of the following signs or symptoms developing during, or shortly after, alcohol
use:
1. Slurred speech.
2. Incoordination.
3. Unsteady gait.
4. Nystagmus.
5. Impairment in attention or 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 substance.

Alcohol Withdrawal
Alcohol withdrawal can occur when alcohol use has been heavy and prolonged and is
then stopped or greatly reduced. It can occur within several hours to four or five days later.
Symptoms include sweating, rapid heartbeat, hand tremors, problems sleeping, nausea and
vomiting, hallucinations, restlessness and agitation, anxiety, and occasionally seizures.
Symptoms can be severe enough to impair your ability to function at work or in social situations.

Characteristics
Alcohol withdrawal occurs most often in adults. But, it may occur in teenagers or
children. The more you drink regularly, the more likely you are to develop alcohol withdrawal
symptoms when you stop drinking. You may have more severe withdrawal symptoms if you
have certain other medical problems.

Clinical Signs and Symptoms

 Anxiety or nervousness
 Depression
 Fatigue
 Irritability
 Jumpiness or shakiness
 Mood swings
 Nightmares
 Not thinking clearly

Other symptoms may include:

 Sweating, clammy skin

 Enlarged (dilated) pupils
 Headache
 Insomnia (sleeping difficulty)
 Loss of appetite
 Nausea and vomiting
 Pallor
 Rapid heart rate
 Tremor of the hands or other body parts

A severe form of alcohol withdrawal called delirium tremens can cause:

 Agitation
  Fever
 Seeing or feeling things that aren't there (hallucinations)
 Seizures
 Severe confusion

Diagnostic Criteria
A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. Two (or more) of the following, developing within several hours to a few days after the
cessation of (or reduction in) alcohol use described in Criterion A:
1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
2. Increased hand tremor.
3. Insomnia.
4. Nausea or vomiting.
5. Transient visual, tactile, or auditory hallucinations or illusions.
6. Psychomotor agitation.
7. Anxiety.
8. Generalized tonic-clonic 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.

Caffeine-Related Disorders
While not technically a diagnosable condition, caffeine-related disorder, or caffeine-use
disorder is listed in the DSM-5 as a condition that warrants further study, because the
stimulating effects and side effects of caffeine can mimic those of recreational drugs. In fact,
some people, particularly adolescents, are known to use and abuse caffeinated products such
as energy drinks to achieve a "high" and to combine caffeine and alcohol for more
effect. Caffeine-related disorders include caffeine intoxication and caffeine withdrawal.

Caffeine Intoxication
Caffeine intoxication usually occurs with consumption above 250mg (equivalent to about
2 1/2 cups of coffee). Caffeine is a central nervous system stimulant and may be taken to help
restore mental alertness when unusual tiredness, weakness or drowsiness occurs. Caffeine's
use as an alertness aid should be only occasional. It is not intended to replace sleep and
should not be used regularly for this purpose.

Characteristics
A caffeine overdose occurs when you take in too much caffeine through drinks, foods, or
medications. However, some people can ingest well above the daily recommended amount
each day without issue. This isn’t recommended because high caffeine doses can cause major
health issues, including irregular heartbeat and seizures. Consuming high caffeine doses on a
regular basis can also possibly lead to hormonal imbalances.
Clinical Signs and Symptoms

 dizziness
 diarrhea
 increased thirst
 insomnia
 headache
 fever
 irritability

Other symptoms are more severe and call for immediate medical treatment. These more
serious symptoms of caffeine overdose include:

 trouble breathing
 vomiting
 hallucinations
 confusion
 chest pain
 irregular or fast heartbeat
 uncontrollable muscle movements
 convulsions

Diagnostic Criteria
A. Recent consumption of caffeine (typically a high dose well in excess of 250 mg).
B. Five (or more) of the following signs or symptoms developing during, or shortly after, caffeine
use:
1. Restlessness.
2. Nervousness.
3. Excitement.
4. Insomnia.
5. Flushed face.
6. Diuresis.
7. Gastrointestinal disturbance.
8. Muscle twitching.
9. Rambling flow of thought and speech.
10. Tachycardia or cardiac arrhythmia.
11. Periods of inexhaustibility.
12. Psychomotor 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 with another substance.

Caffeine Withdrawal
Caffeine is a stimulant and can be chemically addictive. Although it doesn’t necessarily
jeopardize health the same way other drugs do, it is possible to develop a dependence. Quitting
caffeine abruptly, especially if you’ve been consuming two or more cups of coffee a day, can cause
physical, psychological, and emotional symptoms. In fact, caffeine intoxication and caffeine
withdrawal are classified as mental disorders in the American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders (DSM) when either one interferes with daily life.
Characteristics
Withdrawal can occur with abstinence from daily doses as low as 100 mg a day, but the
likelihood and severity of symptoms increases with higher amounts. There is even a genetic
propensity toward caffeine withdrawal, so if someone in your family has experienced the effects,
you might need to take extra precautions when cutting back.
Clinical Signs and Symptoms

 headache
 fatigue
 anxiety
 irritability
 depressed mood
 difficulty concentrating

Diagnostic Criteria
A. Prolonged daily use of caffeine.
B. Abrupt cessation of or reduction in caffeine use, followed within 24 hours by three (or more)
of the following signs or symptoms:
1. Headache.
2. Marked fatigue or drowsiness.
3. Dysphoric mood, depressed mood, or irritability.
4. Difficulty concentrating.
5. Flu-like symptoms (nausea, vomiting, or muscle pain/stiffness).
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 associated with the physiological effects of another medical
condition (e.g., migraine, viral illness) and are not better explained by another mental disorder,
including intoxication or withdrawal from another substance.
Cannabis-Related Disorders
Cannabis, more commonly called marijuana, refers to the several varieties of Cannabis sativa ,
or Indian hemp plant, that contains the psychoactive drug delta-9-tetrahydrocannabinol (THC).
Cannabis-related disorders refer to problems associated with the use of substances derived
from this plant.
Cannabis Use Disorder

Characteristics
Cannabis Use Disorder is a condition characterized by the harmful consequences of
repeated cannabis use, a pattern of compulsive cannabis use, and (sometimes) physiological
dependence on cannabis (i.e., tolerance and/or symptoms of withdrawal). This disorder is only
diagnosed when cannabis use becomes persistent and causes significant academic,
occupational or social impairment.

Clinical Signs and Symptoms

 distorted perceptions
 impaired coordination
 difficulty in thinking and problem solving
 ongoing problems with learning and memory

Additionally, several other signs of marijuana abuse are frequently visible in users:

 red, blurry, bloodshot eyes

 constant, mucus-filled cough
 rapid heartbeat
 hunger, referred to as munchies
 dry mouth
 anxiety, paranoia, or fear
 poor memory
 poor coordination
 slow reaction time
 loss of control
 addiction

Diagnostic Criteria
A. A problematic pattern of cannabis use leading to clinically significant impairment or distress,
as manifested by at least two of the following, occurring within a 12-month period:
1. Cannabis 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 cannabis use.
3. A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or
recover from its effects.
4. Craving, or a strong desire or urge to use cannabis.
5. Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or
home.
6. Continued cannabis use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of cannabis.
7. Important social, occupational, or recreational activities are given up or reduced because of
cannabis use.
8. Recurrent cannabis use in situations in which it is physically hazardous.
9. Cannabis 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 cannabis.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of cannabis to achieve intoxication or desired effect.
b. Markedly diminished effect with continued use of the same amount of cannabis.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for cannabis (refer to Criteria A and B of the criteria
set for cannabis withdrawal, pp. 517-518).
b. Cannabis (or a closely related substance) is tal<en to relieve or avoid withdrawal symptoms.

Cannabis Intoxication
The direct effects of acute cannabis use and reactions that accompany it such as feeling
"high," euphoria, sleepiness, lethargy, impairment in short-term memory, stimulated appetite,
impaired judgment, distorted sensory perceptions, impaired motor performance, and other
symptoms.

Characteristics
Cannabis (marijuana) intoxication develops rapidly. It usually begins with a feeling of
euphoria (a "high"). It then leads to anxiety; a lack of coordination; reduced judgment; memory
problems; decreased alertness; and difficulty engaging in social interactions. Because people
intoxicated on cannabis have impaired memory, they tend to lose their own train of thought.
They cannot follow a conversation very well. Thus, their attempts at conversation can be
disjointed and sometimes nonsensical. Cannabis intoxication may also lead to increased
appetite (the "munchies"); dry mouth ("cottonmouth"); persistent cough; reduced heart rate; and
red, blood-shot eyes.

Clinical Signs and Symptoms

The intoxicating effects of marijuana include relaxation, sleepiness, and mild euphoria (getting
high).

Smoking marijuana leads to fast and predictable signs and symptoms. Eating marijuana can
cause slower, and sometimes less predictable effects.

Marijuana can cause undesirable side effects, which increase with higher doses. These side
effects include:

 Decreased short-term memory

 Dry mouth
 Impaired perception and motor skills
 Red eyes

More serious side effects include panic, paranoia, or acute psychosis, which may be more
common with new users or in those who already have a psychiatric disease.
The degree of these side effects varies from person to person, as well as with the amount of
marijuana used.

Marijuana is often cut with hallucinogens and other, more dangerous drugs that have more
serious side effects than marijuana. These side effects may include:

 Sudden high blood pressure with headache

  Chest pain and heart rhythm disturbances
 Extreme hyperactivity and physical violence
 Heart attack
 Seizures
 Stroke
 Sudden collapse (cardiac arrest)

Diagnostic Criteria
A. Recent use of cannabis.
B. Clinically significant problematic behavioral or psychological changes (e.g., impaired motor
coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal)
that developed during, or shortly after, cannabis use.
C. Two (or more) of the following signs or symptoms developing within 2 hours of cannabis use:
1. Conjunctival injection.
2. Increased appetite.
3. Dry mouth.
4. Tachycardia.
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 substance.

Cannabis Withdrawal

If cannabis use is discontinued after prolonged (daily or almost daily) use, over a period
of several months, withdrawal may occur.

Characteristics
Cannabis Withdrawal occurs after the cessation of (or reduction in) heavy and prolonged
cannabis use. This withdrawal syndrome includes three or more of the following: irritability,
anger or aggression; nervousness or anxiety; insomnia or disturbing dreams; decreased
appetite or weight loss; restlessness; depressed mood; at least one of: abdominal pain,
shakiness/tremors, sweating, fever, chills, or headache. These withdrawal symptoms typically
don't require medical attention; however, they make quitting cannabis difficult.

Clinical Signs and Symptoms

 Anxiety
 Depression
 Mood changes
 Irritability
 Stomach pains
 Loss of appetite
 Nausea
 Insomnia
At least one physical symptom is required for diagnosis such as fever, chills, tremors, sweating,
and abdominal pain.

Diagnostic Criteria
A. Cessation of cannabis use that has been heavy and prolonged (i.e., usually daily or almost
daily use over a period of at least a few months).
B. Three (or more) of the following signs and symptoms develop within approximately 1 week
after Criterion A:
1. Irritability, anger, or aggression.
2. Nervousness or anxiety.
3. Sleep difficulty (e.g., insomnia, disturbing dreams).
4. Decreased appetite or weight loss.
5. Restlessness.
6. Depressed mood.
7. At least one of the following physical symptoms causing significant discomfort: abdominal
pain, shakiness/tremors, sweating, fever, chills, or headache.
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.

Hallucinogen-Related Disorders
Hallucinogens are a chemically diverse group of drugs that cause changes in a person's
thought processes, perceptions of the physical world, and sense of time passing. Hallucinogens
can be found naturally in some plants, and can be synthesized in the laboratory. Most
hallucinogens are abused as recreational drugs. Hallucinogens are also called psychedelic
drugs.
Characteristics

Clinical Signs and Symptoms

Although the primary effects of hallucinogens are on perceptions, some physical effects do
occur. Physical symptoms include:

 increased blood pressure

 increased heart rate
 nausea and vomiting (especially with psilocybin and mescaline)
 blurred vision which can last after the drug has worn off
 poor coordination
 enlarged pupils
 sweating
 diarrhea (plant hallucinogens)
 restlessness
 muscle cramping (especially clenched jaws with MDMA)
 dehydration (MDMA)
 serious increase in body temperature leading to seizures (MDMA)
Phencyclidine Use Disorder
Phencyclidine (PCP) and related substances (such as ketamine) are taken orally,
intravenously, nasally, or smoked. Street names include angel dust, super grass, boat, tic-tac,
zoom, and shermans. PCP use disorders are more common in males between the ages of 20
and 40.

Characteristics

People who use PCP describe having strong cravings. These powerful urges to use may
contribute to their continued use. This use continues despite both psychological and physical
problems. Many people with phencyclidine use disorders regularly use other drugs as well.

Clinical Signs and Symptoms

 Euphoria.
 Reduced sensitivity to pain.
 Feelings of super strength.
 Sense of invulnerability.
 Apathy.

Diagnostic Criteria
A. A pattern of phencyclidine (or a pharmacologically similar substance) use leading to clinically
significant impairment or distress, as manifested by at least two of the following, occurring within
a 12-month period:
1. Phencyclidine 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 phencyclidine use.
3. A great deal of time is spent in activities necessary to obtain phencyclidine, use the
phencyclidine, or recover from its effects.
4. Craving, or a strong desire or urge to use phencyclidine.
5. Recurrent phencyclidine use resulting in a failure to fulfill major role obligations at work,
school, or home (e.g., repeated absences from work or poor work performance related to
phencyclidine use; phencyclidine-related absences, suspensions, or expulsions from school;
neglect of children or household).
6. Continued phencyclidine use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of the phencyclidine (e.g., arguments with a
spouse about consequences of intoxication; physical fights).
7. Important social, occupational, or recreational activities are given up or reduced because of
phencyclidine use.
8. Recurrent phencyclidine use in situations in which it is physically hazardous (e.g., driving an
automobile or operating a machine when impaired by a phencyclidine).
9. Phencyclidine 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
phencyclidine.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of the phencyclidine to achieve intoxication or
desired effect.
b. A markedly diminished effect with continued use of the same amount of the phencyclidine.
Other Hallucinogen Use Disorder
Other Hallucinogen Use Disorder is a diagnosis which is documented in the fifth edition
of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. The "Other" in the title
distinguishes the hallucinogens causing the disorder from phencyclidine and pharmacologically
similar substances, which has its own disorder, known as Phencyclidine Use Disorder, and
cannabis, which also has its own disorder, Cannabis Use Disorder, which also includes the
psychoactive ingredients of cannabis such as THC.

The drugs associated with Other Hallucinogen Use Disorder include phenylalkylaines,
such as mescaline, DOM, MDMA or ecstasy, the indoleamines including psilocybin and psilocin,
which are the psychoactive ingredient in magic mushrooms, DMT, the ergolines such as LSD or
acid, and morning glory seeds. Various other plant compounds with hallucinogenic effects are
also included.

Characteristics
Other Hallucinogen Use Disorder is a condition characterized by the harmful
consequences of repeated hallucinogen use (other than phencyclidine), a pattern of compulsive
use of these drugs, and (sometimes) physiological dependence on these drugs (i.e., tolerance).
This disorder is only diagnosed when the use of these drugs becomes persistent and causes
significant academic, occupational, social or medical impairment.

Diagnostic Criteria
A. A problematic pattern of hallucinogen (other than phencyclidine) use leading to clinically
significant impairment or distress, as manifested by at least two of the following, occurring within
a 12-month period:
1. The hallucinogen 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 hallucinogen use.
3. A great deal of time is spent in activities necessary to obtain the hallucinogen, use the
hallucinogen, or recover from its effects.
4. Craving, or a strong desire or urge to use the hallucinogen.
5. Recurrent hallucinogen use resulting in a failure to fulfill major role obligations at work,
school, or home (e.g., repeated absences from work or poor work performance related to
hallucinogen use; hallucinogen-related absences, suspensions, or expulsions from school;
neglect of children or household).
6. Continued hallucinogen use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of the hallucinogen (e.g., arguments with a
spouse about consequences of intoxication; physical fights).
7. Important social, occupational, or recreational activities are given up or reduced because of
hallucinogen use.
8. Recurrent hallucinogen use in situations in which it is physically hazardous (e.g., driving an
automobile or operating a machine when impaired by the hallucinogen).
9. Hallucinogen 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 hallucinogen.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of the hallucinogen to achieve intoxication or desired
effect.
b. A markedly diminished effect with continued use of the same amount of the hallucinogen.

Phencyclidine Intoxication

Characteristics
Phencyclidine Intoxication typically includes behavioral changes. This may include
impulsivity, belligerence, hallucinations, and impaired functioning. Violent behavior can occur
during use as intoxicated persons may believe they are being attacked. These perceptual
distortions, coupled with a reduced threshold for pain, are a recipe for dangerous behavior.

Clinical Signs and Symptoms

 disorientation
 confusion without hallucinations
 hallucinations or delusion
 a catatonic-like state
 coma

Some people become belligerent, violent, impulsive, and unpredictable and have impaired
judgment. Physical symptoms include rapid heartbeat, uncontrolled eye movements, numbness,
and a loss of control of body movements. At high doses, these drugs can cause stupor and
coma in users. Intoxication typically lasts for several hours but can persist for several days or
longer.

Diagnostic Criteria
A. Recent use of phencyclidine (or a pharmacologically similar substance).
B. Clinically significant problematic behavioral changes (e.g., belligerence, assaultiveness,
impulsiveness, unpredictability, psychomotor agitation, impaired judgment) that developed
during, or shortly after, phencyclidine use.
C. Within 1 hour, two (or more) of the following signs or symptoms:
Note: When the drug is smoked, “snorted,” or used intravenously, the onset may be particularly
rapid.
1. Vertical or horizontal nystagmus.
2. Hypertension or tachycardia.
3. Numbness or diminished responsiveness to pain.
4. Ataxia.
5. Dysarthria.
6. Muscle rigidity.
7. Seizures or coma.
8. Hyperacusis.
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 substance.

Other Hallucinogen Intoxication

 Other hallucinogen intoxication should be differentiated from intoxication
with amphetamines, cocaine, or other stimulants; anticholinergics; inhalants; and phencyclidine.
Toxicological tests are useful in making this distinction, and determining the route of
administration may be useful.

Diagnostic Criteria
A. Recent use of a hallucinogen (other than phencyclidine).
B. Clinically significant problematic behavioral or psychological changes (e.g., marked anxiety or
depression, ideas of reference, fear of “losing one’s mind,” paranoid ideation, impaired
judgment) that developed during, or shortly after, hallucinogen use.
C. Perceptual changes occurring in a state of full wakefulness and alertness (e.g., subjective
intensification of perceptions, depersonalization, derealization, illusions, hallucinations,
synesthesias) that developed during, or shortly after, hallucinogen use.
D. Two (or more) of the following signs developing during, or shortly after, hallucinogen use:
1. Pupillary dilation.
2. Tachycardia.
3. Sweating.
4. Palpitations.
5. Blurring of vision.
6. Tremors.
7. Incoordination.
E. 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.

Hallucinogen Persisting Perception Disorder

Characteristics
Hallucinogen persisting perception disorder (HPPD), commonly known as flashback, is
diagnosed when a sober person re-experiences the perceptual disturbances, typically visual,
that occurred when previously intoxicated with a hallucinogen.

Clinical Signs and Symptoms

The mostly visual symptoms of HPPD, or flashbacks, include false perceptions of
movement in the peripheral vision fields, flashes of color, or trails of images of moving objects.
While short-term flashbacks may reoccur, they are generally benign and described as pleasant
events. HPPD, on the other hand, is a long-lasting condition that can persist for years and can
cause great distress.

Diagnostic Criteria
A. Following cessation of use of a hallucinogen, the reexperiencing of one or more of the
perceptual symptoms that were experienced while intoxicated with the hallucinogen
(e.g., geometric hallucinations, false perceptions of movement in the peripheral visual fields,
flashes of color, intensified colors, trails of images of moving objects, positive afterimages, halos
around objects, macropsia and micropsia).
B. The symptoms in Criterion A cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
C. The symptoms are not attributable to another medical condition (e.g., anatomical lesions and
infections of the brain, visual epilepsies) and are not better explained by another mental
disorder (e.g., delirium, major neurocognitive disorder, schizophrenia) or hypnopompic
hallucinations.

Inhalant Related Disorder

Inhalants are substances that contain mind-altering properties when inhaled. Inhalants
are breathed in through the mouth (commonly known as huffing) or sniffed or snorted through
the nose, and the high that people experience typically lasts only for several minutes. The most
commonly used substances include glue, aerosol sprays, shoe polish, gasoline, lighter fluids,
leather cleaner, room odorizer, paint thinners, spray paints, and even felt-tip markers. Inhaling
these substances can cause seizures, comas, and even death. Although addiction to inhalants
is uncommon, it is possible.

Inhalant Use Disorder

It develops in people who frequently use inhalants as a recreational drug. Inhalants are a
range of different substances, including volatile hydrocarbons, which are toxic gasses typically
found in household products such as glue, paint thinners, white-out, and various cleaning
products, leading to the term "glue sniffing." The substance may be inhaled from a bag to
intensify the effect, which is known as "huffing."

Characteristics

 Inhalant Use Disorder is a psychological condition that applies to the deliberate use of
inhalants, not to the accidental inhalation of toxic or psychoactive substances, even if
they are the same substances that are people inhale when they have Inhalant Use
Disorder, and even if they produce identical effects.
 Inhalants are mostly used by younger people, mainly because they can access inhalants
more easily than other drugs, and because they are not aware of the dangers of these
drugs. Unfortunately, use of inhalants is one of the most acutely dangerous forms of
substance use, and can result in sudden sniffing death even the first time they are used.
However, Inhalant Use Disorder refers to a problematic pattern of inhalant use over time,
not the acute effects of inhalants, even if they are life-threatening.

Clinical Signs and Symptoms

 Slurred speech.
 Jerky reactions.
 Mild highs.
 A general loss of motor control.
 Users will look like they're drunk.
 Nausea and vomiting.
 Sedation.
 Hallucinations.
 Dilated pupils.
  Loss of appetite.
 Facial rash where the inhalant blistered the skin.
 You'll often notice a strange smell—a distinctive chemical-like smell that reminds you of
fresh paint.
 Users might also have marks around their mouth and noses, particularly if they're
sniffing paint.

Diagnostic Criteria

An individual diagnosed with Inhalant Use Disorder needs to meet all of the following criteria:

A. A problematic pattern of use of a hydrocarbon-based inhalant substance leading to clinically

significant impairment or distress, as manifested by at least two of the following, occurring
within a 12-month period:
1. The inhalant 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
inhalant substance.
3. A great deal of time is spent in activities necessary to obtain the inhalant substance,
use it, or recover from its effects.
4. Craving, or a strong desire or urge to use the inhalant substance.
5. Recurrent use of the inhalant substance resulting in a failure to fulfill major role
obligations at work, school, or home.
6. Continued use of the inhalant substance despite having persistent or recurrent social
or interpersonal problems caused or exacerbated by the effects of its use.
7. Important social, occupational, or recreational activities are given up or reduced
because of use of the inhalant substance.
8. Recurrent use of the inhalant substance in situations in which it is physically
hazardous.
9. Use of the inhalant substance 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 substance.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of the inhalant substance to achieve
intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of the
inhalant substance.

Inhalant Intoxication
Inhalant intoxication is an inhalant-related, clinically significant mental disorder that
develops during, or immediately after, intended or unintended inhalation of a volatile
hydrocarbon substance. Volatile hydrocarbons are toxic gases from glues, fuels, paints, and
other volatile compounds. When it is possible to do so, the particular substance involved should
be named (e.g., toluene intoxication). Among those who do, the intoxication clears within a few
minutes to a few hours after the exposure ends. Thus, inhalant intoxication usually occurs in
brief episodes that may recur.
Characteristics

 The chemicals found in solvents, aerosol sprays, and gases can produce a variety of
additional effects during or shortly after use. These effects are related to inhalant
intoxication and may include belligerence, apathy, impaired judgment, and impaired
functioning in work or social situations; nausea and vomiting are other common side
effects. Exposure to high doses can cause confusion and delirium. In addition, inhalant
abusers may experience dizziness, drowsiness, slurred speech, lethargy, depressed
reflexes, general muscle weakness, and stupor. For example, research shows that
toluene can produce headache, euphoria, giddy feelings, and the inability to coordinate
movements.

Sniffing - Inhaling vapors from an open container

Huffing - Soaking a rag or sock with substance and placing it over the mouth and nose

Bagging - Spraying or pouring the substance into a paper or plastic bag and inhaling the vapors
by placing the bag over the face or over the head

Clinical Signs and Symptoms

 Slurred speech.
 Jerky reactions.
 Mild highs.
 A general loss of motor control.
 Users will look like they're drunk.
 Nausea and vomiting.
 Sedation.
 Hallucinations.
 Dilated pupils.
 Loss of appetite.
 Facial rash where the inhalant blistered the skin.
 You'll often notice a strange smell—a distinctive chemical-like smell that reminds you of
fresh paint.
 Users might also have marks around their mouth and noses, particularly if they're
sniffing paint.

Diagnostic Criteria

A. Recent intended or unintended short-term, high-dose exposure to inhalants

substances, including volatile hydrocarbons such as toluene or gasoline.

B. Clinically significant problematic behavioral or psychological changes (e.g.,

belligerence, assaultiveness, apathy, impaired judgment) that developed during, or
shortly after, use of or exposure to inhalants.

C. Two (or more) of the following signs or symptoms developing during, or shortly after,
inhalant use or exposure:
 1. Dizziness
2. nystagmus
3. incoordination
4. slurred speech
5. unsteady gait
6. lethargy
7. depressed reflexes
8. psychomotor retardation
9. tremor
10. generalized muscle weakness
11. blurred vision or diplopia
12. stupor or coma
13. euphoria

D. The signs or symptoms are not attributable to another medical condition and are not
better explained for by another mental disorder, including intoxication with another
substance.

Opioid-Related Disorders
Opioid Use Disorder
Opioid use disorder (OUD) - can involve misuse of prescribed opioid medications, use of
diverted opioid medications, or use of illicitly obtained heroin. OUD is typically a chronic,
relapsing illness, associated with significantly increased rates of morbidity and mortality.
Opioids, used medically for pain relief, have analgesic and central nervous system (CNS)
depressant effects as well as the potential to cause euphoria.

Characteristics

 includes signs and symptoms that reflect compulsive, prolonged self administration of
opioid substances that are used for no legitimate medical purpose or, if another medical
condition is present that requires opioid treatment, that are used in doses greatly in
excess of the amount needed for that medical condition.
 Individuals with opioid use disorder tend to develop such regular patterns of compulsive
drug use that daily activities are planned around obtaining and administering opioids.
Opioids are usually purchased on the illegal market but may also be obtained from
physicians by falsifying or exaggerating general medical problems or by receiving
simultaneous prescriptions from several physicians. Health care professionals with
opioid use disorder will often obtain opioids by writing prescriptions for themselves or by
diverting opioids that have been prescribed for patients or from pharmacy supplies.
 Most individuals with opioid use disorder have significant levels of tolerance and will
experience withdrawal on abrupt discontinuation of opioid substances. Individuals with
opioid use disorder often develop conditioned responses to drug-related stimuli (e.g.,
craving on seeing any heroin powder-like substance)— a phenomenon that occurs with
most drugs that cause intense psychological changes.
 leading to clinically significant impairment or distress and occurring within a 1 2-month
period.
Clinical Signs and Symptoms

 feeling of warmth
 heaviness of the extremities
 dry mouth
 itchy face (especially the nose)
 facial flushing.

Diagnostic Criteria
A. A problematic pattern of opioid use leading to clinically significant impairment or distress,
as manifested by at least two of the following, occurring within a 12-month period:

1. Opioids are 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 opioid use.
3. A great deal of time is spent in activities necessary to obtain the opioid, use the
opioid, or recover from its effects.
4. Craving, or a strong desire or urge to use opioids.
5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work,
school, or home.
6. Continued opioid use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of opioids.
7. Important social, occupational, or recreational activities are given up or reduced
because of opioid use.
8. Recurrent opioid use in situations in which it is physically hazardous.
9. Continued opioid 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.
10. Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of opioids to achieve intoxication or

desired effect.
b. A markedly diminished effect with continued use of the same amount of an
opioid. (Note: This criterion is not considered to be met for those taking opioids
solely under appropriate medical supervision.)

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

a. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of

the criteria set for opioid withdrawal).
b. Opioids (or a closely related substance) are taken to relieve or avoid
withdrawal symptoms. (Note: This criterion is not considered to be met for
those individuals taking opioids solely under appropriate medical
supervision.)

Note: This criterion is not considered to be met for those individuals taking opioids solely under
appropriate medical supervision.
Opioid Intoxication
Opioid intoxication occurs when you take too much of an opioid drug. Your level of
intoxication depends on how much of the drug you take.

Characteristics

Opioid intoxication can occur if you:

1. accidentally overdose
2. mix opioids together
3. abuse the drugs (take them without a prescription or for long periods of time)

Heroin and methadone are the most commonly abused opioids.

Clinical Signs and Symptoms

 small, or constricted, pupils

 slowed breathing or absent breathing
 extreme fatigue
 changes in heart rate
 loss of alertness

Diagnostic Criteria

A. Recent use of an opioid.

B. Clinically significant problematic behavioral or psychological changes (e.g., initial euphoria

followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment) that
developed during, or shortly after, opioid use.

C. Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or
more) of the following signs or symptoms developing during, or shortly after, opioid use:

1. drowsiness or coma
2. slurred speech
3. impairment in attention or memory

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 substance.

Opioid Withdrawal
When an individual stops or decrease the amount of opioid take.

Characteristics
 During withdrawal, indirect dangers of opiate withdrawal can emerge, including strong
cravings for more drugs and severe depression. If someone restarts opioid use due to cravings,
they put themselves at greater risk of a fatal overdose—especially if their opioid tolerance has
decreased significantly over the abstinent period. Also, the severe depression related to the
later stages of withdrawal can place the individual at risk of self-injury or suicide.

Clinical Signs and Symptoms

Early Withdrawal Symptoms

These usually start within 6-12 hours for short-acting opiates, and they start within 30 hours for
longer-acting ones

 Tearing up
 Muscle aches
 Agitation
 Trouble falling and staying asleep
 Excessive yawning
 Anxiety
 Nose running
 Sweats
 Racing heart
 Hypertension
 Fever

Late Withdrawal Symptoms

These peak within 72 hours and usually last a week or so:

 Nausea and vomiting

 Diarrhea
 Goosebumps
 Stomach cramps
 Depression
 Drug cravings
 Dilated pupils.

Diagnostic Criteria

A. Presence of either of the following:

 cessation of (or reduction in) opioid use that has been heavy and prolonged (several
weeks or longer)
 administration of an opioid antagonist after a period of opioid use

B. Three (or more) of the following, developing within minutes to several days after Criterion A:

1. dysphoric moods
 2. nausea or vomiting
3. muscle aches
4. lacrimation or rhinorrhea
5. pupillary dilation, piloerection, or sweating
6. diarrhea
7. yawning
8. fever
9. insomnia

C. The 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 due to another medical condition and are not better
accounted for by another mental disorder, including intoxication or withdrawal from another
substance.

Sedative-, Hypnotic-, or Anxiolytic-

Related Disorders
Sedatives, hypnotics, and anxiolytics are often prescribed for a number of physical and
psychological medical conditions. These substances that reduce arousal and stimulation in
various areas of the brain. As a result, the user may experience a sense of calm or sedation,
sleep, respiratory depression, or coma. This class of substances includes all prescription
sleeping medications and almost all prescription anti-anxiety medications (tranquilizers).
Sedative, hypnotic, or anxiolytic substances are available by prescription and can also be
obtained illegally. Sedative-, hypnotic-, or anxiolytic- (SHA-) related disorders include SHA
intoxication, SHA-use disorder and SHA withdrawal.

Sedative, Hypnotic, or Anxiolytic Use Disorder

Sedative-hypnotic drugs — sometimes called "depressants" — and anxiolytic
(antianxiety) drugs slow down the activity of the brain.
Sedative, hypnotic, or anxiolytic use disorder is the continued use of these substances despite
clinically significant distress or impairment. It typically includes a strong desire to take these
substances, difficulties in controlling their use, persisting in their use despite harmful
consequences, a higher priority given to the use of these substances than to other activities and
obligations, increased tolerance, and a physical withdrawal state.

Characteristics

 Benzodiazepines (Ativan, Halcion, Librium, Valium, Xanax, Rohypnol) are the best
known. An older class of drugs, called barbiturates (Amytal, Nembutal, Seconal,
phenobarbital) fit into this broad category. Other drugs in this group include chloral
hydrate (which when mixed with alcohol was once known as "knockout drops" or a
"Mickey Finn"), glutethimide, methaqualone (Quaalude, Sopor, "ludes") and
meprobamate (Equanil, Miltown and other brand names).
  Benzodiazepines are a good treatment for anxiety and are also useful in sleep
disorders. Barbiturates are used to treat seizures and for anesthesia during major
surgery.
 Sedative, hypnotic, or anxiolytic substances are available both by prescription and
illegally. Some individuals who obtain thesesubstances by prescription will develop a
sedative, hypnotic, or anxiolytic use disorder, while others who misuse these
substances or use them for intoxication will not develop a use disorder. In particular,
sedatives, hypnotics, or anxiolytics with rapid onset and/or short to intermediate
lengths of action may be taken for intoxication purposes, although longer acting
substances in this class may be taken for intoxication as well.

Clinical Signs and Symptoms

 A craving for the drug, often with unsuccessful attempts to cut down on its use
 Physical dependence (development of physical withdrawal symptoms when a person
stops taking the depressant)
 A continued need to take the drug despite drug-related psychological, interpersonal or
physical problems

Diagnostic Criteria

A. A problematic pattern of sedative, hypnotic, or anxiolytic use leading to clinically significant

impairment or distress, as manifested by at least two of the following, occurring within a 12-
month period:
1. Sedatives, hypnotics, or anxiolytics are 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 sedative,
hypnotic, or anxiolytic use.
3. A great deal of time is spent in activities necessary to obtain the sedative, hypnotic, or
anxiolytic, use the sedative, hypnotic, or anxiolytic, or recover from its effects.
4. Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic.
5. Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure to fulfill major role
obligations at work, school, or home.
6. Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the effects of sedatives,
hypnotics, or anxiolytics (e.g. arguments with a spouse about consequences of
intoxication; physical fights).
7. Important social, occupational, or recreational activities are given up or reduced because
of sedative, hypnotic, or anxiolytic use.
8. Recurrent sedative, hypnotic, or anxiolytic use in situations in which it is physically
hazardous.
9. Sedative, hypnotic, or anxiolytic 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 sedative, hypnotic, or anxiolytic.
10. Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to

achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of the
sedative, hypnotic, or anxiolytic.
Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or
anxiolytics under medical supervision.

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

a. The characteristic withdrawal syndrome for sedatives, hypnotics, or anxiolytics: (refer to
Criteria A and B of the criteria set for sedative, hypnotic, or anxiolytic withdrawal, pp.
557-558).
b. Sedatives, hypnotics, or anxiolytics (or a closely related substance, such as alcohol) are
taken to relieve or avoid withdrawal symptoms.

Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or
anxiolytics under medical supervision.

Sedative, Hypnotic, or Anxiolytic Intoxication

The essential feature of sedative, hypnotic, or anxiolytic intoxication is the presence of

clinically significant maladaptive behavioral or psychological changes (e.g., inappropriate sexual
or aggressive behavior, mood lability, impaired judgment, impaired social or occupational
functioning) that develop during, or shortly after, use of a sedative, hypnotic, or anxiolytic

Characteristics

The intoxication syndromes induced by all these drugs are similar, and include
incoordination, dysarthria, nystagmus, impaired memory, gait disturbance, and in severe cases
stupor, coma, or death. The diagnosis of intoxication by one of this class of substances is best
confirmed by obtaining a blood sample for substance screening.

Clinical Signs and Symptoms

Physical signs

 slurred speech
 nystagmus
 a lack of coordination
 impaired memory
 decreased blood pressure and pulse
 possibly coma

Diagnostic Criteria
A. Recent use of a sedative, hypnotic, or anxiolytic.

B. Clinically significant maladaptive behavioral or psychological changes (e.g., inappropriate

sexual or aggressive behavior, mood lability, impaired judgment, impaired social or
occupational functioning) that developed during, or shortly after, sedative, hypnotic, or
anxiolytic use.

C. One (or more) of the following signs, developing during, or shortly after, sedative hypnotic,
or anxiolytic use:
 (1) slurred speech
(2) incoordination
(3) unsteady gait
(4) nystagmus
(5) impairment in attention or 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 substance.

Sedative, Hypnotic, or Anxiolytic Withdrawal

The essential feature of sedative, hypnotic, or anxiolytic withdrawal is the presence of a
characteristic syndrome that develops after a marked decrease in or cessation of intake after
several weeks or more of regular use.

Characteristics
This withdrawal syndrome is characterized by two or more symptoms (similar to alcohol
withdrawal) that include autonomic 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.

Clinical Signs and Symptoms

 autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
increased hand tremor
 Insomnia
 nausea or vomiting
 transient visual, tactile, or auditory hallucinations or illusions
 psychomotor agitation
 anxiety
 grand mal seizures

Diagnostic Criteria

A. Cessation of (or reduction in) sedative, hypnotic, or anxiolytic use that has been heavy
and prolonged.

B. Two (or more) of the following, developing within several hours to a few days after
Criterion A:

(1) autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
(2) increased hand tremor
(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 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.

Stimulant-Related Disorders
Stimulants include a wide range of drugs such as amphetamines, methamphetamine,
and cocaine. These drugs increase energy, attention, and alertness and have a wide range of
effects on the body, such as increased respiration and heart rate. Stimulants may be prescribed
to treat obesity, attention-deficit/hyperactivity disorder, narcolepsy, and depression. Stimulant-
related disorders include stimulant intoxication, stimulant-use disorder, and stimulant
withdrawal.

Stimulant Use Disorder

Amphetamines are stimulant drugs. The most commonly known drug in this class is
methamphetamine or "crystal meth" (also known as crank). Other amphetamine drugs include
dextroamphetamine, and appetite suppressants. Street names are speed, bennies, black
beauties, and dexies. People take these drugs orally, intravenously, or nasally. In some cases
they are smoked.

Characteristics

 People obtain prescriptions for amphetamines for conditions such as obesity,

narcolepsy, and attention-deficit/hyperactivity disorder. When people use a drug
correctly, as prescribed, this does not meet the diagnostic criteria for a substance
use disorder. However, if someone exceeds the prescribed dose and frequency, then
a diagnosis of amphetamine use disorder may be used.
 These substances are usually taken orally or intravenously, although
methamphetamine is also taken by the nasal route. In addition to the synthetic
amphetamine-type compounds, there are naturally occurring, plant-derivedstimulants
such as khat.
 Consequently, prescribed stimulants may be diverted into the illegal market.
 Individuals exposed to amphetamine-type stimulants or cocaine can develop
stimulant use disorder as rapidly as 1 week, although the onset is not always this
rapid. Regardless of the route of administration, tolerance occurs with repeated use.

Clinical Signs and Symptoms

 decrease in appetite
 an increase in physical activity and alertness
 convulsions
 an elevated body temperature
 increased respiration
 irregular heart beat
 increased blood pressure
Diagnostic Criteria

A. A problematic 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 following, occurring within a 12-month period:
1. The stimulant 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 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 persistent or recurrent social or interpersonal

problems caused or exacerbated by the effects of the stimulant.

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

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
stimulant.

Note: This criterion is not considered to be met for those taking stimulant
medications solely under appropriate medical supervision, such as medications
for attention-deficit/hyperactivity disorder or narcolepsy.

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

 The characteristic withdrawal syndrome for the stimulant:

a. The characteristic withdrawal syndrome for 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
withdrawal symptoms.

Note: This criterion is not considered to be met for those taking stimulant
 medications solely under appropriate medical supervision, such as
medications for attention-deficit/hyperactivity disorder or narcolepsy.

Stimulant Intoxication
The diagnostic criteria for stimulant intoxication emphasize behavioral and physical signs
and symptoms of stimulant use.

Characteristics

Persons use stimulants for their characteristic effects of elation, euphoria, heightened
self-esteem, and perceived improvement on mental and physical tasks. With high doses,
symptoms of intoxication include agitation, irritability, impaired judgment, impulsive and
potentially dangerous sexual behavior, aggression, a generalized increase in psychomotor
activity, and potentially, symptoms of mania. The major associated physical symptoms are
tachycardia, hypertension, and mydriasis.

Clinical Signs and Symptoms

 New or worsening mental health symptoms (anxiety, panic, hallucinations, paranoia)

 Alertness, hypervigiliance, impulsivity
 Euphoria, confidence, excitement
 Agitation, irritability, anger, hostility
 Psychomotor agitation (pacing, restlessness), repetitive movements, tremor
 Rapid/ pressured speech
 Decreased appetite/need for sleep
 Flushed cheeks, sweating, dry mouth
 Teeth grinding, jaw clenching
 Dilated pupils or sluggish light reflex
 Hypersexuality, at risk sexual behaviours
 Hypertension, tachycardia
 signs of recent physical injury (head injury)
 Injecting sites for signs of infection

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 develop 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:

 Tachycardia or bradycardia
 Pupillary dilatation
 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

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 substance.

Stimulant Withdrawal
When a person stops using stimulants, they may experience a series of unpleasant
withdrawal symptoms.

Characteristics

 Withdrawal symptoms for many drugs can be so intense and so uncomfortable that it
makes it impossible for the person to break their addiction.
 The onset of stimulant withdrawal symptoms will vary- the withdrawal period is
determined by the person’s physical makeup, the strength of their addiction abuse and
by the type of stimulant being abused. The entire withdrawal process can take only one
or two weeks; however, if the person is abusing multiple drugs, it can take much longer.
 A person suffering from stimulant withdrawal will find themselves having difficulty
sleeping or getting a full nights rest. They will become even more irritable and will be
depressed, especially since they are no longer experiencing the intense highs and
increased mental activity that stimulants produce. They may even feel physical effects
like muscle pain or tremors.

Clinical Signs and Symptoms

 Jittery reactions
 Anxiety
 Chills
 Dehydration
 Dulled senses
 Slowed speech
 Loss of interest
 Slowed movements
 Slow heart rate
 Irritability
 Hallucinations
 Paranoia
 Fatigue
 Depression
 Increased appetite
 Impaired memory
 Weight loss or gaunt appearance
 Insomnia or hypersomnia
 Body aches
  Drug cravings
 Unpleasant dreams

Diagnostic Criteria

A. Cessation of (or reduction in) amphetamine (or a related substance) use that has been
heavy and prolonged.

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 symptoms in Criterion B cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

D. The symptoms are not due to a general medical condition and are not better accounted
for by another mental disorder.

Tobacco-Related Disorders
Tobacco products contain many harmful substances, including nicotine, a highly
addictive chemical that causes changes in the brain that result in cravings for more nicotine use
and leads to tobacco-related disorders. Tobacco-related disorders include tobacco-use disorder
and tobacco withdrawal. Those with tobacco-use disorder continue to use tobacco even though
they know it is harmful. Tobacco-use disorder is not only the most common substance use
disorder in the U.S., it is also the most preventable cause of disability and early death. Exposure
to tobacco smoke can also cause early death in nonsmokers.

Tobacco Use Disorder

When an individual is dependent upon nicotine, which is found in tobacco. A
psychoactive drug (affects the mind), nicotine is a highly addictive, central nervous system
stimulant. The addictive nature of nicotine includes drug-reinforced behavior, obsessive use and
reoccurring use after abstaining from it, as well as physical dependence and tolerance.

Characteristics

 Inability to quit or lessen the amount of tobacco use in spite of efforts to do so.
 Excessive amount of time spent on attaining or using tobacco.
 Desire (cravings) for tobacco.
 Relinquish responsibilities because of the tobacco use.
 Use of tobacco persists in spite of its negative impacts both socially and in relationships.
 Abandon career, social and other activities to use tobacco.
 Use tobacco in harmful situations/settings.
  Use is persistent even in the face of physical or emotional difficulties that are related to
the use of tobacco.

Clinical Signs and Symptoms

 Facial wrinkles (prematurely)

 Breathe odor.
 Decreased sense of smell and taste.
 Staining on teeth and fingers.
 Odor is left on the skin, clothes and hair.
 Tobacco use is a costly habit.
 Residue from chewing tobacco gets stuck between the teeth.
 Tobacco smoke threatens the health of others, because smoke from cigarettes is
composed of toxic chemicals, such as nicotine, arsenic, cyanide, tar and nicotine.

Diagnostic Criteria

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

distress, 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 interpersonal

problems caused or exacerbated by the effects of tobacco (e.g., arguments with others
about tobacco use).

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

of tobacco use.

8. Recurrent tobacco use in situations in which it is physically hazardous (e.g., smoking 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 continued use of the same amount of tobacco.
 11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal 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.

Tobacco Withdrawal
Withdrawal symptoms impair the ability to stop tobacco use.

Characteristics

The symptoms after abstinence 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 withdrawal is common among daily tobacco users who stop or
reduce but can also occur among nondaily users.
Clinical sign and symptoms

Physical Symptoms.

 Tingling in the hands and feet

 Sweating
 Intestinal disorders (cramps, nausea)
 Headaches
 Sore throat, coughing, and signs of a cold

Mental and Emotional Symptoms.

 Temper tantrums, intense needs, feelings of dependency, and a state of near paralysis
 Insomnia
 Mental confusion, vagueness, or difficulty concentrating
 Irritability, restlessness, impatience, or anger
 Anxiety
 Depression

Diagnostic Criteria
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 better
explained by another mental disorder, including intoxication or withdrawal from another
substance.