Substance-Related Disorders

Contents of this page:

Substance Dependence        Substance Withdrawal          Course Specifiers

Substance Abuse               Substance Intoxication        Alcohol

             Amphetamines               Caffeine              Cannabis               Cocaine      

               Hallucinogens             Inhalants               Nicotine

          Opioids           Phencyclidine          Sedative

Return to Home Page

Generic Criteria for Substance Dependence

• The patient's maladaptive pattern of substance use leads to clinically important distress or impairment as shown in a single 12-month period by 3 or more of the following:
  -Tolerance, shown by either of:
     - markedly increased intake of the substance is needed to achieve the same effect or
     -with continued use, the same amount of the substance has markedly less effect
  -Withdrawal, shown by either of:
      -the substance's characteristic withdrawal syndrome or
      -the substance (or one closely related) is used to avoid or relieve withdrawal symptoms
  -The amount or duration of use is often greater than intended.
  -The patient repeatedly tries without success to control or reduce substance use.
  -The patient spends much time using the substance, recovering from its effects or trying to obtain it.
  -The patient reduces or abandons important social, occupational or recreational activities because of substance use.
  -The patient continues to use the substance, despite knowing that it has probably caused physical or psychological problems.

Specify whether:
With Physiological Dependence. There is evidence of tolerance or withdrawal (see above).
Without Physiological Dependence.

Choose one or none to specify course:
Early Full Remission (months 2 through 12)
Early Partial Remission (months 2 through 12)
Sustained Full Remission (months 13+)
Sustained Partial Remission (months 13+)

Specify one, either or both of:

On Agonist Therapy (does not apply to Cannabis, Hallucinogens, Inhalants, PCP)
In a Controlled Environment (does not apply to Nicotine)

Generic Criteria for Substance Withdrawal

• A syndrome specific to a substance develops when someone who has used it frequently and for a long time suddenly stops or markedly reduces its intake.

• This syndrome causes clinically important distress or impairs work, social or personal functioning.

• This syndrome is neither the result of a general medical condition nor better explained by a different mental disorder.

Substance Dependence Course Specifiers

Course modifiers only refer to the criteria for dependence. This is because there is still not enough information to feel confident about the typical course for patients who abuse a given substance but are not dependent on it.

Remission

No patient can be said to be in any sort of remission until there have been no symptoms of either dependence or abuse for one month or more. [Note that the criteria for remission include all the symptoms of both dependence and abuse.]

To add any course modifier for substance dependence, the patient must have: for at least one month, no use of the substance and no problems from its use. A person who has stopped using but is still trying to get a drug, for example, would not qualify for any type of remission.

All remissions can be divided in two ways: into full versus partial and early versus sustained.

Early remission. This period comprises months 2-12 after the patient last experienced problems with the substance. This period of time was singled out because most patients are especially vulnerable to relapse during the first year of sobriety.

Sustained remission. After the first year, the patient is said to be in sustained remission.

During both of these time periods, a patient will be in partial or full remission:

Full remission. There have been no symptoms of dependence or of abuse. During months 2-12 this would be called early full remission; after the first year is termed sustained full remission.

Partial remission. The patient has met at least one criterion for either dependence or abuse, but does not fully qualify for either of these diagnoses. The terms early partial and sustained partial remission apply, as above.

On Agonist Therapy

This term describes patients who (1) have previously met criteria for dependence, (2) have not met criteria for dependence or abuse for at least one month and (3) are currently taking medication to block the effects of the substance in question. Examples: An alcohol-dependent patient takes disulfiram (Antabuse); a heroin-dependent patient takes methadone.

In A Controlled Environment

Patients who are in remission but live in an environment where it would be very difficult to obtain the substance may merit the modifier "in a controlled environment." Such an environment would include a therapeutic community or a jail or locked hospital ward with good control of contraband. This term would not be applied during the first month.

Coding Note

Some patients may qualify for both "On Agonist Therapy" and "In a Controlled Environment." An example of the full coding for such a heroin-dependent patient might read: "Opioid Dependence, Early Partial Remission On Agonist Therapy In a Controlled Environment."

Generic Criteria for Substance Abuse

• The patient's maladaptive substance use pattern causes clinically important distress or impairment as shown in a single 12-month period by 1 or more of the following:
  -Because of repeated use, the patient fails to carry out major obligations at work or at home.
  -The patient uses substances even when it is physically dangerous.
  -The patient repeatedly has legal problems from substance use.
  -Despite knowing that it has caused or worsened social or interpersonal problems, the patient continues to use the substance.
• For this class of substance, the patient has never fulfilled criteria for Substance Dependence.

Substance Intoxication

• The patient develops a reversible syndrome due to recent use of or exposure to a substance.

• During or shortly after using the substance, the patient develops clinically important behavioral or psychological changes that are maladaptive.

• This condition is neither the result of a general medical condition nor better explained by a different mental disorder.

Coding Note

Although DSM-IV specifies that the symptoms and behavioral and psychological changes of intoxication are "substance-specific," it notes that various substances can produce syndromes of intoxication that are similar, or even identical.

Alcohol

Alcohol Withdrawal

• A patient who has been drinking heavily and for a long time suddenly stops or markedly reduces its intake.

• Within a few hours to several days of reducing intake, 2 or more of the following develop:
  -autonomic overactivity (sweating or rapid heartbeat)
  -worsened tremor of hands
  -insomnia
  -nausea or vomiting
  -short-lived hallucinations or illusions (visual, tactile or auditory)
  -psychomotor agitation
  -anxiety
  -grand mal seizures

• These symptoms cause clinically important distress or impair work, social or personal functioning.

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.*

Coding Notes

If the patient meets criteria for Alcohol Withdrawal Delirium, do not also code 291.8 Alcohol Withdrawal.

*Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggest a diagnosis of Substance-Induced Psychotic Disorder.

Alcohol Intoxication

• The patient has recently drunk alcohol.

• During or shortly after drinking, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include inappropriate sexuality or aggression, lability of mood, impaired judgment and impaired job or social functioning.

• Shortly after drinking, 1 or more of:
  -slurred speech
  -poor coordination
  -unsteady walking
  -nystagmus
  -impaired attention or memory
  -stupor or coma

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Amphetamines

Amphetamine Intoxication

• The patient has recently used amphetamine or a related substance.

• During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include blunted affect, hypervigilance, interpersonal sensitivity, anger, anxiety or tension, changes in sociability, stereotyped behaviors, impaired judgment and impaired job or social functioning.

• Shortly after use, 2 or more of:
  -slowed or rapid heart rate
  -dilated pupils
  -raised or lowered blood pressure
  -chills or sweating
  -nausea or vomiting
  -weight loss
  -psychomotor agitation or retardation
  -muscle weakness, shallow or slowed breathing, chest pain or heart arrhythmias
  -coma, confusion, dyskinesias, dystonias or seizures

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.*

Coding Note

*Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggest a diagnosis of Amphetamine-Induced Psychotic Disorder.

Amphetamine Withdrawal

• A patient who has been using an amphetamine or a similar substance heavily and for a long time suddenly stops or markedly reduces its intake.

• Within a few hours to several days of reducing intake, the patient develops dysphoric mood and 2 or more of the following:
  -fatigue
  -unpleasant, vivid dreams
  -hypersomnia or insomnia
  -increased appetite
  -psychomotor agitation or retardation

• These symptoms cause clinically important distress or impaired work, social or personal functioning.

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Caffeine

Caffeine Intoxication

• The patient has recently consumed caffeine (usually, more than 250 mg, or 2-3 cups of coffee).

• Beginning during or shortly after ingestion, 5 or more of:
  -restlessness
  -nervousness
  -excitement
  -insomnia
  -red face
  -increased urination
  -gastrointestinal upset
  -muscle twitching
  -rambling speech
  -rapid or irregular heart beat
  -periods of tirelessness
  -psychomotor agitation

• These symptoms cause clinically important distress or impair work , social or personal functioning.

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Cannabis

Cannabis Intoxication

• The patient has recently used cannabis.

• During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include anxiety, euphoria, impaired judgment, social withdrawal and the sensation that time has slowed down.

• Within 2 hours of use, 2 or more of:
  -red eyes
  -increased appetite
  -dry mouth
  -rapid heart rate

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.*

Coding Note

*Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggest a diagnosis of Cannabis-Induced Psychotic Disorder.

Cocaine

Cocaine Intoxication

• The patient has recently used cocaine.

• During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These would include blunted affect, hypervigilance, interpersonal sensitivity, anger, anxiety or tension, changes in sociability, stereotyped behaviors, impaired judgment and impaired job or social functioning.

• Shortly after use, 2 or more of:
  -slowed or rapid heart rate
  -dilated pupils
  -raised or lowered blood pressure
  -chills or sweating
  -nausea or vomiting
  -weight loss
  -psychomotor agitation or retardation
  -muscle weakness, shallow or slowed breathing, chest pain or cardiac arrhythmias
  -coma, confusion, dyskinesias, dystonias or seizures

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.*

Coding Note

*Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggest a diagnosis of Cocaine-Induced Psychotic Disorder.

Cocaine Withdrawal

• A patient who has been using cocaine heavily and for a long time suddenly stops or markedly reduces its intake.

• Within a few hours to several days of reducing intake, the patient has dysphoric mood and 2 or more of the following:
  -fatigue
  -unpleasant, vivid dreams
  -hypersomnia or insomnia
  -increased appetite
  -psychomotor agitation or retardation

• These symptoms cause clinically important distress or impair work, social or personal functioning.

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Hallucinogens

Hallucinogen Intoxication

• The patient has recently used a hallucinogen.

• During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include severe depression or anxiety, ideas of reference, fear of becoming insane, persecutory ideas, impaired judgment and impaired job or social functioning.

• During or shortly after use, while fully alert the patient has perceptual changes (depersonalization, derealization, illusions, hallucinations, synesthesias or subjective intensification of experience).

• Shortly after use, 2 or more of:
  -dilated pupils
  -rapid heart rate
  -sweating
  -irregular heartbeat
  -blurred vision
  -tremors
  -incoordination

• These symptoms are neither the direct result of a general medical condition nor better explained by a different mental disorder.

Hallucinogen Persisting Perception Disorder (Flashbacks)

• After stopping the use of a hallucinogen, the patient reexperiences at least one of the symptoms of perception that occurred during intoxication. These could include flashes of color, trails of images, afterimages, halos, macropsia, micropsia, geometric hallucinations and false peripheral perception of movement.

• These symptoms cause clinically important distress or impair work, social or personal functioning.

• These symptoms are neither the result of a general medical condition nor better explained by hypnopompic hallucinations or a different mental disorder such as Schizophrenia or dementia.

Inhalants

Inhalant Intoxication

• Recently the patient has intentionally used volatile inhalants or has had brief, high-dose exposure to them.

• During or shortly after this experience, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include apathy, assaultiveness or belligerence, impaired judgment and impaired job or social functioning.

• During or shortly after this experience, 2 or more of:
  -dizziness
  -nystagmus
  -incoordination
  -slurred speech
  -unsteady walking
  -lethargy
  -diminished reflexes
  -psychomotor retardation
  -blurred or double vision
  -tremors
  -generalized muscle weakness
  -stupor or coma
  -euphoria

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Coding Notes

Do not include anesthetic gasses or short-acting vasodilators in this category. They are coded under Other Substance-Related Disorders (page 112).

Because most commercial products contain a number of different gasses and other volatile substances, it is often impossible to determine which have produced the toxic effects observed. That is why, in coding, it is often necessary to use the generic term "Inhalant Intoxication."

Nicotine

Nicotine Withdrawal

• The patient has used nicotine daily for several weeks or more.

• Within 24 hours of abruptly reducing nicotine intake, the patient develops 4 or more of:
  -dysphoria or depression
  -insomnia
  -anger, frustration or irritability
  -anxiety
  -trouble concentrating
  -restlessness
  -slowed heart rate
  -increased appetite or weight

• These symptoms cause clinically important distress or impair work, social or personal functioning.

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Opioids

Opioid Intoxication

• The patient has recently used an opioid.

• During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These could include euphoria leading to apathy, depression or anxiety, psychomotor agitation or retardation, impaired judgment and impaired job or social functioning.

• During or shortly after use, the patient develops constricted pupils (or dilation due to brain damage following a severe overdose) and 1 or more of:
  -drowsiness or coma
  -slurred speech
  -impaired memory or attention

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.*

Coding Note

*Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggest a diagnosis of Opioid-Induced Psychotic Disorder.

Opioid Withdrawal

• The patient has either:
  -Recently stopped or reduced use of opioids after heavy, prolonged use (at least several weeks) or
  -Been given an opioid antagonist after using opioids for some time

• Within minutes to several days after this experience, the patient develops 3 or more of:
  -dysphoria
  -nausea or vomiting
  -aching muscles
  -tearing or runny nose
  -dilated pupils, piloerection or sweating
  -diarrhea
  -yawning
  -fever
  -insomnia

• These symptoms cause clinically important distress or impair work, social or personal functioning.

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Phencyclidine

Phencyclidine (or Related Substance) Intoxication

• The patient has recently used PCP or a related substance.

• During or shortly after its use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These would include assault, belligerence, impulsivity, agitation, unpredictability, impaired judgment and impaired job or social functioning.

• Within an hour of use (less, if snorted, smoked or used IV), the patient develops 2 or more of:
  -nystagmus
  -rapid heartbeat or high blood pressure
  -numbness or decreased response to pain
  -trouble walking
  -trouble speaking
  -rigid muscles
  -coma or seizures
  -abnormally acute hearing

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.*

Coding Note

*Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without this insight suggests a diagnosis of Phencyclidine-Induced Psychotic.

Sedative, Hypnotic or Anxiolytic

Sedative, Hypnotic or Anxiolytic Intoxication

• The patient has recently used a sedative, hypnotic or anxiolytic drug.

• During or shortly after use, the patient develops clinically important behavioral or psychological changes that are maladaptive. These would include inappropriate sexuality or aggression, lability of mood, impaired judgment and impaired job or social functioning.

• Shortly after use, 1 or more of:
  -slurred speech
  -incoordination
  -unsteady walking
  -nystagmus
  -impaired attention or memory
  -stupor or coma

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Sedative, Hypnotic or Anxiolytic Withdrawal

• A patient who has been using one or more of these drugs heavily and for a long time suddenly markedly reduces its intake.

• Within a few hours to several days, 2 or more of the following develop:
  -autonomic overactivity (sweating, rapid heartbeat)
  -worsened tremor of hands
  -insomnia
  -nausea or vomiting
  -short-lived hallucinations or illusions (visual, tactile or auditory)
  -psychomotor agitation
  -anxiety
  -grand mal seizures

• These symptoms cause clinically important distress or impair work, social or personal functioning.

• These symptoms are neither the result of a general medical condition nor better explained by a different mental disorder.

Specify if: With Perceptual Disturbances. The patient has altered perceptions: auditory, tactile or visual illusions or hallucinations with intact insight.*

Coding Note

*Intact insight implies that the patient recognizes that the symptoms are unreal, caused by the substance use. Hallucinations without insight suggest a diagnosis of Phencyclidine-Induced Psychotic Disorder.

Return to Top