Stimulant-Related Disorders

Stimulant Use Disorder Stimulant Intoxication Stimulant Withdrawal Other Stimulant-Induced Disorders Unspecified Stimulant-Related Disorder

Stimulant Use Disorder

Diagnostic Criteria A. A 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 ta en in larger amounts or o!er a longer period than was it ended. 2. There is a persistent desire or unsuccessful efforts to cut down or control stimulant use. ". A great deal of time is spent in acti!ities necessary to obtain the stimulant, use the stimulant, or reco!er from its effects. #. Cra!ing, or a strong desire or urge to use the stimulant. $. %ecurrent stimulant use resulting in a failure to fulfill ma&or role obligations at wor , school, or home. '. Continued stimulant use despite ha!ing persistent or recurrent social or interpersonal problems caused or e(acerbated by the effects of the stimulant. ). *mportant social, occupational, or recreational acti!ities are gi!en up or reduced because of stimulant use. +. %ecurrent stimulant use in situations in which it is physically ha,ardous. -. .timulant use is continued despite nowledge of ha!ing a persistent or recurrent *** physical or psychological problem that is li ely to ha!e been caused or e(acerbated by the stimulant. 1/. Tolerance, as defined by either of the following: a. A need for mar edly increased amounts of the stimulant to achie!e into(ication or desired effect. b. A mar edly diminished effect with continued use of the same amount of the 1

stimulant. 0ote: This criterion is not considered to be met for those ta ing stimulant medications solely under appropriate medical super!ision, such as medications for attention-deficit1hyperacti!ity disorder or narcolepsy. 11. 2ithdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the stimulant 3refer to Criteria A and 4 of the criteria set for stimulant withdrawal, p. $'-5. b. The stimulant 3or a closely related substance5 is ta en to relie!e or a!oid withdrawal symptoms. 0ote: This criterion is not considered to be met for those ta ing stimulant medical tions solely under appropriate medical super!ision, such as medications for attenttiondeficit1hyperacti!ity disorder or narcolepsy. .pecify if: In early remission: After full criteria for stimulant use disorder were pre!iously met none of the criteria for stimulant use disorder ha!e been met for at least " months but for less than 12 months 3with the e(ception that Criterion A#, 6Cra!ing, or a strong desire or urge to use the stimulant,6 may be met5. In sustained remission: After full criteria for stimulant use disorder were pre!iously met, none of the criteria for stimulant use disorder ha!e been met at any time during a period of 12 months or longer 3with the e(ception that Criterion A#, 6Cra!ing, or a strong desire or urge to use the stimulant,6 may be met5. .pecify if: In a controlled environment: This additional specifier is used if the indi!idual is in an en!ironment where access to stimulants is restricted. Coding ased on current severity: 0ote for *CD-1/-C7 codes: *f an amphetamine into(ication, amphetamine withdrawal, or another amphetamine-induced mental disorder is also present, do not use the codes below for amphetamine use disorder. *nstead, the comorbid amphetamine use disorder is indicated in the #th character of the amphetamineinduced disorder code 3see the coding note for amphetamine into(ication, amphetamine withdrawal, or a specific amphetamine-induced mental disorder5. 8or e(ample, if there is comorbid amphetamine-type or other stimulant-induced depressi!e disorder and amphetamine-type or other stimulant use disorder, only the amphetamine-type or other stimulant2

induced depressi!e disorder code is gi!en, with the #th character indicating whether the comorbid amphetamine-type or other stimulant use disorder is mild, moderate, or se!ere9 81$.1# for mild amphetamine-type or other stimulant use disorder with amphetamine-type or other stimulant-induced depressi!e disorder or 81$.2# for a moderate or se!ere am- * phetamine-type or other stimulant use disorder with amphetamine-type or other stimulantinduced depressi!e disorder. .imilarly, if there is comorbid cocaine-induced depressi!e disorder and cocaine use disorder, only the cocaine-induced depressi!e disorder code is gi!en, with the #th character indicating whether the comorbid cocaine use disorder is mid moderate, or se!ere: 81#.1# for mild cocaine use disorder with cocaine-induced depressi!e disorder or 81#.2# for a moderate or se!ere cocaine use disorder with cocaineinduced depressi!e disorder. .pecify current se!erity: !ild " :resence of 2-" symptoms. #$%&'$ ()*%&*$+ Amphetamine-type substance #$%&,$ ()*-&*$+ Cocaine #$%&'$ ()*%&*$+ ;ther or unspecified stimulant !oderate : :resence of #-$ symptoms. #$-&-$ ()*%&.$+ Amphetamine-type substance #$-&.$ ()*-&.$+ Cocaine #$-&-$ ()*%&.$+ ;ther or unspecified stimulant Severe : :resence of ' or more symptoms. #$-&-$ ()*%&.$+ Amphetamine-type substance #$-&.$ ()*-&.$+ Cocaine #$-&-$ ()*%&.$+ ;ther or unspecified stimulant Specifiers 9*na controlled en!ironment6 applies as a further specifier of remission if the indi!idual is both in remission and in a controlled en!ironment 3i.e., in early remission in a controlled en!ironment or in sustained remission in a controlled en!ironment5. <(amples of these en!ironments are closely super!ised and substance-free &ails, therapeutic communities, and loc ed hospital units. Diagnostic )eatures The amphetamine and amphetamine-type stimulants include substances with a substituted-phenylethylamine structure, such as amphetamine, de(troamphetamine, and "

meth- amphetamine. Also included are those substances that are structurally different but ha!e similar effects, such as methylphenidate. These substances are usually ta en orally or intra!enously, although methamphetamine is also ta en by the nasal route. *n addition to the synthetic amphetamine-type compounds, there are naturally occurring, plant-deri!ed stimulants such as 7at. Amphetamines and other stimulants may be obtained by prescription for the treatment of obesity, attention-deficit1hyperacti!ity disorder, and narcolepsy. Conse=uently, prescribed stimulants may be di!erted into the illegal mar et. The effects of amphetamines and amphetamine-li e drugs are similar to those of cocaine, such that the criteria for stimulant use disorder are presented here as a single disorder with the ability to specify the particular stimulant used by the indi!idual. Cocaine may be consumed in se!eral preparations 3e.g., coca lea!es, coca paste, cocaine hydrochloride, and cocaine al aloids such as freebase and crac 5 that differ in potency because of !arying le!els of purity and speed of onset. >owe!er, in all forms of the substance, cocaine is the acti!e ingredient. Cocaine hydrochloride powder is usually 6snorted6 through the nostrils or dissol!ed in water and in&ected intra!enously. *ndi!iduals e(posed to amphetamine-type stimulants or cocaine can de!elop stimulant use disorder as rapidly as 1 wee , although the onset is not always this rapid. %egardless of the route of administration, tolerance occurs with repeated use. 2ithdrawal symptoms, particularly hypersomnia, increased appetite, and dysphoria, can occur and can enhance cra!ing. 7ost indi!iduals with stimulant use disorder ha!e e(perienced tolerance or withdrawal. ?se patterns and course are similar for disorders in!ol!ing amphetamine-type stimulants and cocaine, as both substances are potent central ner!ous system stimulants with similar psychoacti!e and sympathomimetic effects. Amphetamine-type stimulants are longer acting than cocaine and thus are used fewer times per day. ?sage may be chronic or episodic, with binges punctuated by brief non-use periods. Aggressi!e or !iolent beha!ior is common when high doses are smo ed, ingested, or administered intra!enously. *ntense temporary an(iety resembling panic disorder or generali,ed an(iety disorder, as well as paranoid ideation and psychotic episodes that resemble schi,ophrenia, is seen with highdose use. 2ithdrawal states are associated with temporary but intense depressi!e symptoms that can resemble a ma&or depressi!e episode@ the depressi!e symptoms usually resol!e within 1 wee . Tolerance to amphetamine-type stimulants de!elops and leads to escalation of the dose. Con!ersely, some users of amphetamine-type stimulants de!elop sensiti,ation, #

characteri,ed by enhanced effects. /ssociated )eatures Supporting Diagnosis 2hen in&ected or smo ed, stimulants typically produce an instant feeling of wellbeing, confidence, and euphoria. Dramatic beha!ioral changes can rapidly de!elop with stimulant use disorder. Chaotic beha!ior, social isolation, aggressi!e beha!ior, and se(ual dysfunction can result from long-term stimulant use disorder. *ndi!iduals with acute into(ication may present with rambling speech, headache, transient ideas of reference, and tinnitus. There may be paranoid ideation, auditory hallucinations in a clear sensorium, and tactile hallucinations, which the indi!idual usually recogni,es as drug effects. Threats or acting out of aggressi!e beha!ior may occur. Depression, suicidal ideation, irritability, anhedonia, emotional lability, or disturbances in attention and concentration commonly occur during withdrawal. 7ental disturbances associated with cocaine use usually resol!e hours to days after cessation of use but can persist for 1 month. :hysiological changes during stimulant withdrawal are opposite to those of the into(ication phase, sometimes including bradycardia. Temporary depressi!e symptoms may meet symptomatic and duration criteria for ma&or depressi!e episode. >istories consistent with repeated panic attac s, social an(iety disorder 3social phobia5li e beha!ior, and generali,ed an(iety-li e syndromes are common, as are eating disorders. ;ne e(treme instance of stimulant to(icity is stimulant-induced psychotic disorder, a disorder that resembles schi,ophrenia, with delusions and hallucinations. *ndi!iduals with stimulant use disorder often de!elop conditioned responses to drug- related stimuli 3e.g., cra!ing on seeing any white powderli e substance5. These responses contribute to relapse, are difficult to e(tinguish, and persist after deto(ification. Depressi!e symptoms with suicidal ideation or beha!ior can occur and are generally the most serious problems seen during stimulant withdrawal. 0revalence .timulant use disorder amphetamine-type stimulants. <stimated 12-month pre!alence of amphetamine-type stimulant use disorder in the ?nited .tates is /.2A among 12- to 1)year-olds and /.2A among indi!iduals 1+ years and older. %ates are similar among adult males and females 3/.2A5, but among 12- to 1)-year-olds, the rate for females 3/."A5 is greater than that for males 3/.1A5. *ntra!enous stimulant use has a maleto-female ratio of ":1 or #:1, but rates are more balanced among non-in&ecting users, with males representing $#A of primary treatment admissions. Twel!e-month pre!alence is $

greater among 1+- to 2--year-olds 3/.#A5 compared with #$- to '#-year-olds 3/.1.1/5. 8or 12- to 1)-year-olds, rates are highest among whites and African Americans 3/."A5 compared with >ispanics 3/.1A5 and Asian Americans and :acific *slanders 3/./1A5, with amphetamine-type stimulant use disorder !irtually absent among 0ati!e Americans. Among adults, rates are highest among 0ati!e Americans and Alas a 0ati!es 3/.'A5 compared with whites 3/.2A5 and >ispanics 3/.2A5, with amphetamine-type stimulant use disorder !irtually absent among African Americans and Asian Americans and :acific *slanders. :ast-year nonprescribed use of prescription stimulants occurred among $A--A of children through high school, with $A-"$A of college-age persons reporting past-year use. .timulant use disorder cocaine. <stimated 12-month pre!alence of cocaine use disorder in the ?nited .tates is /.2A among 12- to 1) year olds and /."A among indi!iduals 1+ years and older. %ates are higher among males 3/.#A5 than among females 3/.1A5. %ates are highest among 1+- to 2--year-olds 3/.'A5 and lowest among #$- to '#year-olds 3/.1.1/5. Among adults, rates are greater among 0ati!e Americans 3/.+A5 compared with African Amen- cans 3/.#A5, >ispanics 3/."A5, whites 3/.2A5, and Asian Americans and :acific *slanders 3/.1A5. *n contrast, for 12- to 1)-year-olds, rates are similar among >ispanics 3/.2A5, whites 3/.2A5, and Asian Americans and :acific *slanders 3/.2A5@ and lower among African Americans 3/./2A5@ with cocaine use disorder !irtually absent among 0ati!e Americans and Alas a 0ati!es. Development and Course .timulant use disorders occur throughout all le!els of society and are more common among indi!iduals ages 12-2$ years compared with indi!iduals 2' years and older. 8irst regular use among indi!iduals in treatment occurs, on a!erage, at appro(imately age 2" years. 8or methamphetamine primary treatment admissions, the a!erage age is "1 years. .ome indi!iduals begin stimulant use to control weight or to impro!e performance in ,school, wor , or athletics. This includes obtaining medications such as methylphenidate or amphetamine salts prescribed to others for the treatment of attention deficit1hyperacti!y disorder. .timulant use disorder can de!elop rapidly with intra!enous or smo ed administration@ among primary admissions for amphetamine-type stimulant use, ''A reported smo ing, 1+A reported in&ecting, and 1/A reported snorting.

'

Ris1 and 0rognostic )actors amperamental. Comorbid bipolar disorder, schi,ophrenia, antisocial personality disorder and other substance use disorders are ris factors for de!eloping stimulant use disorder aid for relapse to cocaine use in treatment samples. Also, impulsi!ity and similar personality arts may affect treatment outcomes. Childhood conduct disorder and adult antisocial personality disorder are associated with the later de!elopment of stimulantrelated disorders. <n!ironmental. :redictors of cocaine use among teenagers include prenatal cocaine e(posure, postnatal cocaine use by parents, and e(posure to community !iolence during dhood. 8or youths, especially females, ris factors include li!ing in an unstable home <n!ironment, ha!ing a psychiatric condition, and associating with dealers and users. Culture-Related Diagnostic Issues .timulant use attendant disorders affect all racial1ethnic, socioeconomic, age, and gender coups. Diagnostic issues may be related to societal conse=uences 3e.g., arrest, school suspensions, employment suspension5. Despite small !ariations, cocaine and other stimulant ale disorder diagnostic criteria perform e=ually across gender and race1ethnicity groups. americans Appro(imately ''A of indi!iduals admitted for primary methamphetamine1amphetamine related disorders are non->ispanic white, followed by 21A of >ispanic origin, "A Asian and :acific *slander, and "A non->ispanic blac . Diagnostic !ar1ers 4en,oylecgonine, a metabolite of cocaine, typically remains in the urine for 1-" days after a single dose and may be present for )-12 days in indi!iduals using repeated high doses. midly ele!ated li!er function tests can be present in cocaine in&ectors or users with concomitant alcohol use. There are no neurobiological mar ers of diagnostic utility. Disconsituation of chronic cocaine use may be associated with electroencephalographic changes, suggesting persistent abnormalities@ alterations in secretion patterns of prolactin@ and down regulation of dopamine receptors. .hort-half-life amphetamine-type stimulants 37D7A B",#-methylenedio(y-0methylamphetamine5, methamphetamine5 can be detected for 1-" days, and possibly up to # days depending on dosage and metabolism. >air samples can be used to detect presence of amphetamine type stimulants for up to -/ days. ;ther laboratory findings, as well as )

physical findings and other medical conditions 3e.g., weight loss, malnutrition@ poor hygiene5, art similar for both cocaine and amphetamine-type stimulant use disorder. )unctional Conse2uences of Stimulant Use Disorder Carious medical conditions may occur depending on the route of administration. *ntranasal users often de!elop sinusitis, irritation, bleeding of the nasal mucosa, and a perforated nasal septum. *ndi!iduals who smo e the drugs are at increased ris for respiratory problems 3egg., coughing, bronchitis, and pneumonitis5. *n&ectors ha!e puncture mar s and 6trac s,6 most commonly on their forearms. %is of >*C infection increases with fre=uent intra!enous in&ections and unsafe se(ual acti!ity. ;ther se(ually transmitted diseases hepatitis, and tuberculosis and other lung infections are also seen. 2eight loss and malnutrition are common. Chest pain may be a common symptom during stimulant into(ication. 7yocardial infarction, palpitations and arrhythmias, sudden death from respiratory or cardiac arrest and stro e ha!e been associated with stimulant use among young and otherwise healthy indi!iduals. .ei,ures can occur with stimulant use. :neumothora( can result from forming Calsal!a-li e maneu!ers done to better absorb inhaled smo e. Traumatic in&uries due to !iolent beha!ior are common among indi!iduals traffic ing drugs. Cocaine use , associated with irregularities in placental blood flow, abruptio placentae, premature labor and deli!ery, and an increased pre!alence of infants with !ery low birth weights. *ndi!iduals with stimulant use disorder may become in!ol!ed in theft, prostitution, drug dealing in order to ac=uire drugs or money for drugs. 0eurocogniti!e impairment is common among methamphetamine users. ;ral healD problems include 6meth mouth6 with gum disease, tooth decay, and mouth sores relater9 to the to(ic effects of smo ing the drug and to bru(ism while into(icated. Ad!erse pu*monary effects appear to be less common for amphetamine-type stimulants because they are smo ed fewer times per day. <mergency department !isits are common for stimulant-related mental disorder symptoms, in&ury, s in infections, and dental pathology. Differential Diagnosis :rimary mental disorders. .timulant-induced disorders may resemble primary mend disorders 3e.g., ma&or depressi!e disorder5 3for discussion of this differential diagnosis, see 6.timulant 2ithdrawal65. The mental disturbances resulting from the effects of stimulants should be distinguished from the symptoms of schi,ophrenia@ depressi!e and bipolar orders@ generali,ed an(iety disorder@ and panic disorder. +

:hencyclidine into(ication. *nto(ication with phencyclidine 36:C:6 or 6angel dust65 or synthetic 6designer drugs6 such as mephedrone 3 nown by different names, including 6bath salts65 may cause a similar clinical picture and can only be distinguished from stimulant into(ication by the presence of cocaine or amphetamine-type substance metaboliteE in a urine or plasma sample. .timulant into(ication and withdrawal. .timulant into(ication and withdrawal are di, distinguished from the other stimulant-induced disorders 3e.g., an(iety disorder, with on., during into(ication5 because the symptoms in the latter disorders predominate the clinic. presentation and are se!ere enough to warrant independent clinical attention. Comor idity .timulant-related disorders often co-occur with other substance use disorders, especially those in!ol!ing substances with sedati!e properties, which are often ta en to reduce insomnia, ner!ousness, and other unpleasant side effects. Cocaine users often use alcohol, while amphetamine-type stimulant users often use cannabis. .timulant use disorder may :e associated with posttraumatic stress disorder, antisocial personality disorder, attention deficit1hyperacti!ity disorder, and gambling disorder. Cardiopulmonary problems ire often present in indi!iduals see ing treatment for cocaine-related problems, with chest pain being the most common. 7edical problems occur in response to adulterants used as 9cutting6 agents. Cocaine users who ingest cocaine cut with le!amisole, an antimicrobial and !eterinary medication, may e(perience agranulocytosis and febrile neutropenia.

Stimulant Intoxication
Diagnostic Criteria A 4 %ecent use of an amphetamine-type substance, cocaine, or other stimulant. Clinically significant problematic beha!ioral or psychological changes 3e.g., euphoria or affecti!e blunting@ changes in sociability@ hyper!igilance@ interpersonal sensiti!ity@ an(iety, tension, or anger@ stereotyped beha!iors@ impaired &udgment5 that de!eloped during, or shortly after, use of a stimulant. C Two 3or more5 of the following signs or symptoms, de!eloping during, or shortly after, stimulant use: 1. Tachycardia or bradycardia. -

2. :apillary dilation. ". <le!ated or lowered blood pressure. #. :erspiration or chills. $. 0ausea or !omiting. '. <!idence of weight loss. ). :sychomotor agitation or retardation. +. 7uscular wea ness, respiratory depression, chest pain, or cardiac arrhythmias. -. Confusion, sei,ures, dys inesias, dystonias, or coma. D. The signs or symptoms are not attributable to another medical condition and are not better e(plained by another mental disorder, including into(ication with another substance. specify the specific into(icant 3i e., amphetamine-type substance, cocaine, or other stimulant5. .pecify if: With perceptual distur ances: This specifier may be noted when hallucinations with intact reality testing or auditory, !isual, or tactile illusions occur in the absence of a de- actual. Coding note" The *CD---C7 code is 2-2.+-. The *CD-1/-C7 code depends on whether be stimulant is an amphetamine, cocaine, or other stimulant@ whether there is a comorbid amphetamine, cocaine, or other stimulant use disorder@ and whether or not there are perceptual disturbances. 8or amphetamine, cocaine, or other stimulant into(ication, without perceptual disturbances: *f a mild amphetamine or other stimulant use disorder is comorbid, the *CD1/C7 code is 81$.12-, and if a moderate or se!ere amphetamine or other stimulant use disorder is comorbid, the *CD-1/-C7 code is 81$.22-. *f there is no comorbid amphetamine or other stimulant use disorder, then the *CD-1/-C7 code is 81$.-2-. .imilarly, if a mild cocaine use disorder is comorbid, the *CD-1/-C7 code is 81#.12-, and if a moderate or se!ere cocaine use disorder is comorbid, the *CD-1/-C7 code is 81#.22-. *f there is no comorbid cocaine use disorder, then the *CD-1/-C7 code is 81#.-2-. 8or amphetamine, cocaine, or other stimulant into(ication, with perceptual disturbances: *f a mild amphetamine or other stimulant use disorder is comorbid, the *CD-1/C7 code is 81$.122, and if a moderate or se!ere amphetamine or other stimulant use disorder is comorbid, the *CD-1/-C7 code is 81$.222. *f there is no comorbid amphetamine or other stimulant use disorder, then the *CD-1/-C7 code is 81$.-22. .imilarly, * a 1/

mild cocaine use disorder is comorbid, the *CD-1/-C7 code is 81#.122, and if a moderate or se!ere cocaine use disorder is comorbid, the *CD-1/-C7 code is 81#.222. 1 there is no comorbid cocaine use disorder, then the *CD-1/-C7 code is 81#.-22. Diagnostic )eatures The essential feature of stimulant into(ication, related to amphetamine-type stimulants and cocaine, is the presence of clinically significant beha!ioral or psychological changes that de!elop during, or shortly after, use of stimulants 3Criteria A and 45. Auditory hallucinations may be prominent, as may paranoid ideation, and these symptoms must be distinguished from an independent psychotic disorder such as schi,ophrenia. .timulant into(ication usually begins with a 6high6 feeling and includes one or more of the following: euphoria with enhanced !igor, gregariousness, hyperacti!ity, restlessness, hyper!igilance, interpersonal sensiti!ity, tal ati!eness, an(iety, tension, alertness, grandiosity, stereotyped and repetiti!e beha!ior, anger, impaired &udgment, and, in the case of chronic into(ication, affecti!e blunting with fatigue or sadness and social withdrawal. These beha!ioral and psychological changes are accompanied by two or more of the following signs and symptoms that de!elop during or shortly after stimulant use: tachycardia or bradycardia@ pupillary dilation@ ele!ated or lowered blood pressure@ perspiration or chills@ nausea or !omiting@ e!idence of weight loss@ psychomotor agitation or retardation@ muscular wea ness, respiratory depression, chest pain, or cardiac arrhythmias@ and confusion, sei,ures, dys inesias, dystonias, or coma 3Criterion C5. *nto(ication, either acute or chronic, is often associated with impaired social or occupational functioning. .e!ere into(ication can lead to con!ulsions, cardiac arrhythmias, hyperpyre(ia, and death. 8or the diagnosis of stimulant into(ication to be made, the symptoms must not be attributable to another medical condition and not better e(plained by another mental disorder 3Criterion D5. 2hile stimulant into(ication occurs in indi!iduals with stimulant use disorders, into(ication is not a criterion for stimulant use disorder, which is confirmed by the presence of two of the 11 diagnostic criteria for use disorder. /ssociated )eatures Supporting Diagnosis The magnitude and direction of the beha!ioral and physiological changes depend on many !ariables, including the dose used and the characteristics of the indi!idual using the substance or the conte(t 3e.g., tolerance, rate of absorption, chronicity of use, conte(t in which it is ta en5. .timulant effects such as euphoria, increased pulse and blood 11

pressure, and psychomotor acti!ity are most commonly seen. Depressant effects such as sadness, bradycardia, decreased blood pressure, and decreased psychomotor acti!ity are less common and generally emerge only with chronic high-dose use. Differential Diagnosis .timulant-induced disorders. .timulant into(ication is distinguished from the other stimulant-induced disorders 3e.g., stimulant-induced depressi!e disorder, bipolar disorder, psychotic disorder, an(iety disorder5 because the se!erity of the into(ication symptoms e(ceeds that associated with the stimulant-induced disorders, and the symptoms warrant independent clinical attention. .timulant into(ication delirium would be distinguished by a disturbance in le!el of awareness and change in cognition. /ssociated )eatures Supporting Diagnosis Acute withdrawal symptoms 36a crash65 are often seen after periods of repetiti!e high-due. use 36runs6 or 6binges65. These periods are characteri,ed by intense and unpleasant feeling lassitude and depression and increased appetite, generally re=uiring se!eral days of rest a. recuperation. Depressi!e symptoms with suicidal ideation or beha!ior can occur and are genorally the most serious problems seen during 6crashing6 or other forms of stimulant withdrawal. The ma&ority of indi!iduals with stimulant use disorder e(perience a withdraw. syndrome at some point, and !irtually all indi!iduals with the disorder report tolerance. Differential Diagnosis .timulant use disorder and other stimulant-induced disorders. .timulant withdrawal is distinguished from stimulant use disorder and from the other stimulantinduced dicer ders 3e.g., stimulant-induced into(ication delirium, depressi!e disorder, bipolar disorder psychotic disorder, an(iety disorder, se(ual dysfunction, sleep disorder5 because symptoms of withdrawal predominate the clinical presentation and are se!ere enough warrant independent clinical attention.

Other Stimulant-Induced Disorders

The following stimulant-induced disorders 3which include amphetamine-, cocaine-, apt other stimulant-induced disorders5 are described in other chapters of the manual with dieorders with which they share phenomenology 3see the substance1medication inducet mental disorders in these chapters5: stimulant-induced psychotic disorder 36.chi,ophrenia .pectrum and ;ther :sychotic Disorders65@ stimulant12

induced bipolar disorder 364ipolar and %elated Disorders65@ stimulant-induced depressi!e disorder 36Depressi!e Disorders9@ stimulant-induced an(iety disorder 36An(iety Disorders65@ stimulant-induced obsessi!e compulsi!e disorder 36;bsessi!e-Compulsi!e and %elated Disorders65@ stimulant induced sleep disorder 36.leep-2a e Disorders65@ and stimulant-induced se(ual dysfunction 36.e(ual Dysfunctions65. 8or stimulant into(ication delirium, see the criteria and discussion of delirium in the chapter 60eurocogniti!e Disorders.6 These stimulant-induced disorder are diagnosed instead of stimulant into(ication or stimulant withdrawal only when the symptoms are sufficiently se!ere to warrant independent clinical attention.

Unspecified Stimulant-Related Disorder

This category applies to presentations in which symptoms characteristic of a stimulant related disorder that cause clinically significant distress or impairment in social, occupe tional, or other important areas of functioning predominate but do not meet the full criteria. for any specific stimulant-related disorder or any of the disorders in the substance related and addicti!e disorders diagnostic class. Coding note" The *CD---C7 code is 2-2.-. The *CD-1/-C7 code depends on whether the stimulant is an amphetamine, cocaine, or another stimulant. The *CD-1/-C7 code for an unspecified amphetamine- or other stimulant-related disorder is 81$.--. The *CD-1/C7 code for an unspecified cocaine-related disorder is 81#.--.

3o acco-Related Disorders
3o acco Use Disorder 3o acco Withdrawal Other 3o acco-Induced Disorders Unspecified 3o acco-Related Disorder

3o acco Use Disorder

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"

1. Tobacco is often ta en in larger amounts or o!er a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control tobacco use. ". A great deal of time is spent in acti!ities necessary to obtain or use tobacco. #. Cra!ing, or a strong desire or urge to use tobacco. $. %ecurrent tobacco use resulting in a failure to fulfill ma&or role obligations at wor , school, or home 3e.g., interference with wor 5. '. Continued tobacco use despite ha!ing persistent or recurrent social or interpersonal problems caused or e(acerbated by the effects of tobacco 3e.g., arguments with others about tobacco use5. ). *mportant social, occupational, or recreational acti!ities are gi!en up or reduced because of tobacco use. +. %ecurrent tobacco use in situations in which it is physically ha,ardous 3e.g., smo ing in bed5. -. Tobacco use is continued despite nowledge of ha!ing a persistent or recurrent physical or psychological problem that is li ely to ha!e been caused or e(acerbated by tobacco. 1/.Tolerance, as defined by either of the following: a. A need for mar edly increased amounts of tobacco to achie!e the desired effect. b. A mar edly diminished effect with continued use of the same amount of tobacco. 11. 2ithdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for tobacco 3refer to Criteria A and 4 of the criteria set for tobacco withdrawal5. b. Tobacco 3or a closely related substance, such as nicotine5 is ta en to relie!e or a!oid withdrawal symptoms. .pecify if: In early remission" After full criteria for tobacco use disorder were pre!iously met, none of the criteria for tobacco use disorder ha!e been met for at least " months but for less than 12 months 3with the e(ception that Criterion A#, 6Cra!ing, or a strong desire or urge to use tobacco,6 may be met5. In sustained remission" After full criteria for tobacco use disorder were pre!iously met, none of the criteria for tobacco use disorder ha!e been met at any time during a period of 12 months or longer 3with the e(ception that Criterion A#, 6Cra!ing, or a strong desire or urge to use tobacco,6 may be met5. .pecify if: 1#

On maintenance therapy" The indi!idual is ta ing a long-term maintenance medication, such as nicotine replacement medication, and no criteria for tobacco use disorder ha!e been met for that class of medication 3e(cept tolerance to, or withdrawal from, the nicotine replacement medication5. In a controlled environment" This additional specifier is used if the indi!idual is in an en!ironment where access to tobacco is restricted. Coding based on current se!erity: 0ote for *CD-1/-C7 codes: *f a tobacco withdrawal to tobacco-induced sleep disorder is also present, do not use the codes below for tobacco use disorder. *nstead, the comorbid tobacco use disorder is indicated in the #th character of the tobacco-induced disorder code 3see the coding note for tobacco withdrawal or tobacco. induced sleep disorder5. 8or e(ample, if there is comorbid tobacco-induced sleep disorder and tobacco use disorder, only the tobacco-induced sleep disorder code is gi!en, with the #th character indicating whether the comorbid tobacco use disorder is moderate or se!ere: 81).2/+ for moderate or se!ere tobacco use disorder with tobacco-induced sleep disorder. *t is not permissible to code a comorbid mild tobacco use disorder with a tobacco-induced sleep disorder. .pecify current se!erity: #$%&* (4'.&$+ 7ild: :resence of 2-" symptoms. #$%&* ()*'&.$$+ 7oderate: :resence of #-$ symptoms. #$%&* ()*'&.$$+ .e!ere: :resence of ' or more symptoms. Specifiers 6;n maintenance therapy6 applies as a further specifier to indi!iduals being maintained on other tobacco cessation medication 3e.g., bupropion, !arenicline5 and as a further specifier of remission if the indi!idual is both in remission and on maintenance therapy. 6*n a controlled en!ironment6 applies as a further specifier of remission if the indi!idual is both in remission and in a controlled en!ironment 3i.e., in early remission in a controlled en!ironment or in sustained remission in a controlled en!ironment5. <(amples of these en!ironments are closely super!ised and substance-free &ails, therapeutic communities, and loc ed hospital units. Diagnostic )eatures Tobacco use disorder is common among indi!iduals who use cigarettes and smo eless tobacco daily and is uncommon among indi!iduals who do not use tobacco daily or who use 1$

nicotine medications. Tolerance to tobacco is e(emplified by the disappearance of nausea and di,,iness after repeated inta e and with a more intense effect of tobacco the first time it is used during the day. Cessation of tobacco use can produce a well-defined withdrawal syndrome. 7any indi!iduals with tobacco use disorder use tobacco to relie!e or to a!oid withdrawal symptoms 3e.g., after being in a situation where use is restricted5. 7any indi!iduals who use tobacco ha!e tobacco-related physical symptoms or diseases and continue to smo e. The large ma&ority report cra!ing when they do not smo e for se!eral hours. .pending e(cessi!e time using tobacco can be e(emplified by chain-smo ing 3i.e., smo ing one cigarette after another with no time between cigarettes5. 4ecause tobacco sources are readily and legally a!ailable, and because nicotine into(ication is !ery rare, spending a great deal of time attempting to procure tobacco or reco!ering from its effects is uncommon. Fi!ing up important social, occupational, or recreational acti!ities can occur when an indi!idual forgoes an acti!ity because it occurs in tobacco useGrestricted areas. ?se of tobacco rarely results in failure to fulfill ma&or role obligations 3e.g., interference with wor , interference with home obligations5, but persistent social or interpersonal problems 3e.g., ha!ing arguments with others about tobacco use, a!oiding social situations because of others9 disappro!al of tobacco use5 or use that is physically ha,ardous 3e.g., smo ing in bed, smo ing around flammable chemicals5 occur at an intermediate pre!alence. Although these criteria are less often endorsed by tobacco users, if endorsed, they can indicate a more se!ere disorder. /ssociated )eatures Supporting Diagnosis .mo ing within "/ minutes of wa ing, smo ing daily, smo ing more cigarettes per day, and wa ing at night to smo e are associated with tobacco use disorder. <n!ironmental cues can e!o e cra!ing and withdrawal. .erious medical conditions, such as lung and other cancers, cardiac and pulmonary disease, perinatal problems, cough, shortness of breath, and accelerated s in aging, often occur. 0revalence Cigarettes are the most commonly used tobacco product, representing o!er -/A of tobacco1nicotine use. *n the ?nited .tates, $)A of adults ha!e ne!er been smo ers, 22A are former smo ers, and 21A are current smo ers. Appro(imately 2/.1/ of current ?... smo ers are nondaily smo ers. The pre!alence of smo eless tobacco use is less than $A, and the pre!alence of tobacco use in pipes and cigars is less than 1A. 1'

D.7-*C nicotine dependence criteria can be used to estimate the pre!alence of tobacco use disorder, but since they are a subset of tobacco use disorder criteria, the pre!alence of tobacco use disorder will be somewhat greater. The 12-month pre!alence of D.7-*C nicotine dependence in the ?nited .tates is 1"A among adults age 1+ years and older. %ates are similar among adult males 31#A5 and females 312A5 and decline in age from 1)A among 1+- to 2--year-olds to #A among indi!iduals age '$ years and older. The pre!alence of current nicotine dependence is greater among 0ati!e American and Alas a 0ati!es 32"A5 than among whites 31#A5 but is less among African Americans 31/A5, Asian Americans and :acific *slanders 3'A5, and >ispanics 3'A5. The pre!alence among current daily smo ers is appro(imately $/A. *n many de!eloping nations, the pre!alence of smo ing is much greater in males than in females, but this is not the case in de!eloped nations. >owe!er, there often is a lag in the demographic transition such that smo ing increases in females at a later time. Development and Course The ma&ority of ?... adolescents e(periment with tobacco use, and by age 1+ years, about 2/A smo e at least monthly. 7ost of these indi!iduals become daily tobacco users. *nitiation of smo ing after age 21 years is rare. *n general, some of the tobacco use disorder criteria symptoms occur soon after beginning tobacco use, and many indi!iduals9 pattern of use meets current tobacco use disorder criteria by late adolescence. 7ore than +/A of indi!iduals who use tobacco attempt to =uit at some time, but '/A relapse within 1 wee and less than $A remain abstinent for life. >owe!er, most indi!iduals who use tobacco ma e multiple attempts such that one-half of tobacco users e!entually abstain. *ndi!iduals who use tobacco who do =uit usually do not do so until after age "/ years. Although non- daily smo ing in the ?nited .tates was pre!iously rare, it has become more pre!alent in the last decade, especially among younger indi!iduals who use tobacco. Ris1 and 0rognostic )actors 3emperamental& *ndi!iduals with e(ternali,ing personality traits are more li ely to initiate tobacco use. Children with attention-deficit1hyperacti!ity disorder or conduct disorder, and adults with depressi!e, bipolar, an(iety, personality, psychotic, or other substance use disorders, are at higher ris of starting and continuing tobacco use and of tobacco use disorder. 5nvironmental. *ndi!iduals with low incomes and low educational le!els are 1)

more li ely to initiate tobacco use and are less li ely to stop. 6enetic and physiological. Fenetic factors contribute, to the onset of tobacco use, the continuation of tobacco use, and the de!elopment of tobacco use disorder, with a degree of heritability e=ui!alent to that obser!ed with other substance use disorders 3i.e., about $/A5. .ome of this ris is specific to tobacco, and some is common with the !ulnerability to de!eloping any substance use disorder. Culture-Related Diagnostic Issues Cultures and subcultures !ary widely in their acceptance of the use of tobacco. The pre!alence of tobacco use declined in the ?nited .tates from the 1-'/s through the 1--/s, but this decrease has been less e!ident in African American and >ispanic populations. Also. smo ing in de!eloping countries is more pre!alent than in de!eloped nations. The degree to which these cultural differences are due to income, education, and tobacco control acti!ities in a country is unclear. 0on->ispanic white smo ers appear to be more li ely to de!elop tobacco use disorder than are smo ers. .ome ethnic differences may be biologically based. African American males tend to ha!e higher nicotine blood le!els for a gi!er number of cigarettes, and this might contribute to greater difficulty in =uitting. Also, the speed of nicotine metabolism is significantly different for whites compared with African Americans and can !ary by genotypes associated with ethnicities. Diagnostic !ar1ers Carbon mono(ide in the breath, and nicotine and its metabolite cotinine in blood, sali!a, or urine, can be used to measure the e(tent of current tobacco or nicotine use@ howe!er, these are only wea ly related to tobacco use disorder. )unctional Conse2uences of 3o acco Use Disorder 7edical conse=uences of tobacco use often begin when tobacco users are in their #/s and usually become progressi!ely more debilitating o!er time. ;ne-half of smo ers who do not stop using tobacco will die early from a tobacco-related illness, and smo ingrelated morbidity occurs in more than one-half of tobacco users. 7ost medical conditions result from e(posure to carbon mono(ide, tars, and other non-nicotine components of tobacco The ma&or predictor of re!ersibility is duration of smo ing. .econdhand smo e increaseE the ris of heart disease and cancer by "/A. Hong-term use of nicotine medications does not appear to cause medical harm. 1+

Comor idity The most common medical diseases from smo ing are cardio!ascular illnesses, chronic obstructi!e pulmonary disease, and cancers. .mo ing also increases perinatal problems, such as low birth weight and miscarriage. The most common psychiatric comorbidities are alcohol1substance, depressi!e, bipolar, an(iety, personality, and attention deficit1hyperacti!ity disorders. *n indi!iduals with current tobacco use disorder, the pre!alence of current alcohol, drug, an(iety, depressi!e, bipolar, and personality disorders ranges from 22A to "2A. 0icotine-dependent smo ers are 2.)-+.1 times more li ely to ha!e these disorders than nondependent smo ers, ne!er-smo ers, or e(-smo ers.

3o acco Withdrawal
.7.&$()1).2/"5 Diagnostic Criteria A 4 Daily use of tobacco for at least se!eral wee s. Abrupt cessation of tobacco use, or reduction in the amount of tobacco used, followed within 2# hours by four 3or more5 of the following signs or symptoms: 1. *rritability, frustration, or anger. 2. An(iety. ". Difficulty concentrating. #. *ncreased appetite. $. %estlessness. '. Depressed mood. ). *nsomnia. C. The signs or symptoms in Criterion 4 cause clinically significant distress orimpairment 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 e(plained by another mental disorder, including into(ication or withdrawal from another substance. Coding note" The *CD---C7 code is 2-2./. The *CD-1/-C7 code for tobacco withdrawal is 81).2/". 0ote that the *CD-1/-C7 code indicates the comorbid presence of a moderate or se!ere tobacco use disorder, reflecting the fact that tobacco withdrawal can only occur at *re presence of a moderate or se!ere tobacco use disorder. *t is not permissible to code a 1-

comorbid mild tobacco use disorder with tobacco withdrawal. Diagnostic )eatures 2ithdrawal symptoms impair the ability to stop tobacco use. The symptoms after abstice from tobacco are in large part due to nicotine depri!ation. .ymptoms are much re intense among indi!iduals who smo e cigarettes or use smo eless tobacco than song those who use nicotine medications. This difference in symptom intensity is li ely to the more rapid onset and higher le!els of nicotine with cigarette smo ing. Tobacco withdrawal is common among daily tobacco users who stop or reduce but can also occur r among nondaily users. Typically, heart rate decreases by $-12 beats per minute in the first few days after stopping smo ing, and weight increases an a!erage of #-) lb 32-" g5 o!er first year after stopping smo ing. Tobacco withdrawal can produce clinically significant mood changes and functional impairment. /ssociated )eatures Supporting Diagnosis Cra!ing for sweet or sugary foods and impaired performance on tas s re=uiring !igilance associated with tobacco withdrawal. Abstinence can increase constipation, coughing, di,,iness, dreaming1nightmares, nausea, and sore throat. .mo ing increases the metabolism of many medications used to treat mental disorders@ thus, cessation of smo ing can acrease the blood le!els of these medications, and this can produce clinically significant :outcomes. This effect appears to be due not to nicotine but rather to other compounds in. 0revalence Appro(imately $/A of tobacco users who =uit for 2 or more days will ha!e symptoms that meet criteria for tobacco withdrawal. The most commonly endorsed signs and symptoms are an(iety, irritability, and difficulty concentrating. The least commonly endorsed symptoms are depression and insomnia. Development and Course Tobacco withdrawal usually begins within 2# hours of stopping or cutting down on tobacco use, pea s at 2-" days after abstinence, and lasts 2-" wee s. Tobacco withdrawal symptoms can occur among adolescent tobacco users, e!en prior to daily tobacco use. :rolonged symptoms beyond 1 month are uncommon. 2/

Ris1 and 0rognostic )actors 3emperamental& .mo ers with depressi!e disorders, bipolar disorders, an(iety disorders, attention-deficit1hyperacti!ity disorder, and other substance use disorders ha!e more se!ere withdrawal. 6enetic and physiological. Fenotype can influence the probability of withdrawal upon abstinence. Diagnostic !ar1ers Carbon mono(ide in the breath, and nicotine and its metabolite cotinine in blood, sali!a, or urine, can be used to measure the e(tent of tobacco or nicotine use but are only wea ly related to tobacco withdrawal. )unctional Conse2uences of 3o acco Withdrawal Abstinence from cigarettes can cause clinically significant distress. 2ithdrawal impairs the ability to stop or control tobacco use. 2hether tobacco withdrawal can prompt a new mental disorder or recurrence of a mental disorder is debatable, but if this occurs, it would be in a small minority of tobacco users. Differential Diagnosis The symptoms of tobacco withdrawal o!erlap with those of other substance withdrawal syndromes 3e.g., alcohol withdrawal@ sedati!e, hypnotic, or an(iolytic withdrawal@ stimulant withdrawal@ caffeine withdrawal@ opioid withdrawal5@ caffeine into(ication@ an(iety, depressi!e, bipolar, and sleep disorders@ and medication-induced a athisia. Admission to smo e-free inpatient units or !oluntary smo ing cessation can induce withdrawal symptoms that mimic, intensify, or disguise other disorders or ad!erse effects of medications used to treat mental disorders 3e.g., irritability thought to be due to alcohol withdrawal could be due to tobacco withdrawal5. %eduction in symptoms with the use of nicotine medications confirms the diagnosis. Other 3o acco-Induced Disorders Tobacco-induced sleep disorder is discussed in the chapter 6.leep-2a e Disorders6 3see 6.ubstance17edication-*nduced .leep Disorder65.

21

Unspecified 3o acco-Related Disorder

.7.&7 ()*'&.$7+ This category applies to presentations in which symptoms characteristic of a tobacco related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any specific tobacco-related disorder or any of the disorders in the substancerelated and addicti!e disorders diagnostic class.

Other (or Un1nown+ Su stance-Related Disorders

Other (or Un1nown+ Su stance Use Disorder Other (or Un1nown+ Su stance Intoxication Other (or Un1nown+ Su stance Withdrawal Other (or Un1nown+ Su stance8Induced Disorders Unspecified Other (or Un1nown+ Su stance8Related Disorder

Other (or Un1nown+ Su stance Use Disorder

Diagnostic Criteria A. A problematic pattern of use of an into(icating substance not able to be classified within the alcohol@ caffeine@ cannabis@ hallucinogen 3phencyclidine and others5@ inhalant@ opioid@ sedati!e, hypnotic, or an(iolytic@ stimulant@ or tobacco categories and leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. The substance is often ta en in larger amounts or o!er a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control use of the substance. ". A great deal of time is spent in acti!ities necessary to obtain the substance, use the substance, or reco!er from its effects. #. Cra!ing, or a strong desire or urge to use the substance. 22

$. %ecurrent use of the substance resulting in a failure to fulfill ma&or role obligations at wor , school, or home. '. Continued use of the substance despite ha!ing persistent or recurrent social or interpersonal problems caused or e(acerbated by the effects of its use. ). *mportant social, occupational, or recreational acti!ities are gi!en up or reduced because of use of the substance. +. %ecurrent use of the substance in situations in which it is physically ha,ardous. -. ?se of the substance is continued despite nowledge of ha!ing a persistent or recurrent physical or psychological problem that is li ely to ha!e been caused or e(acerbated by the substance. 1/. Tolerance, as defined by either of the following: a. A need for mar edly increased amounts of the substance to achie!e into(ication or desired effect. b. A mar edly diminished effect with continued use of the same amount of the substance. 11. 2ithdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for other 3or un nown5 substance 3refer to Criteria A and 4 of the criteria sets for other Bor un nownI substance withdrawal, p. $+"5. b. The substance 3or a closely related substance5 is ta en to relie!e or a!oid withdrawal symptoms. .pecify if: *n early remission: After full criteria for other 3or un nown5 substance use disorder were pre!iously met, none of the criteria for other 3or un nown5 substance use disorder ha!e been met for at least " months but for less than 12 months 3with the e(ception that Criterion A#, 6Cra!ing, or a strong desire or urge to use the substance,6 may be met5. *n sustained remission: After full criteria for other 3or un nown5 substance use disorder were pre!iously met, none of the criteria for other 3or un nown5 substance use disorder ha!e been met at any time during a period of 12 months or longer 3with the e(ception that Criterion A#, 6Cra!ing, or a strong desire or urge to use the substance,9 may be met5. .pecify if: *n a controlled en!ironment: This additional specifier is used if the indi!idual is if air en!ironment where access to the substance is restricted. 2"

Coding ased on current severity: 0ote for *CD-1/-C7 codes: *f an other 3or un nown5 substance into(ication, other 3or un nown5 substance withdrawal, or another other 3or un nown substance-induced mental disorder is present, do not use the codes below for other 3or un nown5 substance use disorder. *nstead, the comorbid other 3or un nown5 substance use disorder is indicated in the #th character of the other 3or un nown5 substance-induced disorder code 3see the coding note for other 3or un nown5 substance into(ication, other 3or un nown5 substance withdrawal, or specific other 3or un nown5 substance-induced mental disorder 8or e(ample, if there is comorbid other 3or un nown5 substance-induced depressi!e disorder and other 3or un nown5 substance use disorder, only the other 3or un nown5 substance- induced depressi!e disorder code is gi!en, with the #th character indicating whether the co- morbid other 3or un nown5 substance use disorder is mild, moderate, or se!ere: 81-.1# for other 3or un nown5 substance use disorder with other 3or un nown5 substance-induced de pressi!e disorder or 81-.2# for a moderate or se!ere other 3or un nown5 substance use disorder with other 3or un nown5 substance-induced depressi!e disorder. .pecify current se!erity: #$%&7$ ()*7&*$+ 7ild: :resence of 2-" symptoms& #$-&7$ ()*7&.$+ 7oderate: :resence of #-$ symptoms. #$-&7$ ()*7&.$+ .e!ere: :resence of ' or more symptoms. Specifiers 6*n a controlled en!ironment6 applies as a further specifier of remission if the indi!idual is both in remission and in a controlled en!ironment 3i.e., in early remission in a controlled en!ironment or in sustained remission in a controlled en!ironment5. <(amples of these en!ironments are closely super!ised and substance-free &ails, therapeutic communities, and loc ed hospital units. Diagnostic )eatures The diagnostic class other 3or un nown5 substance use and related disorders comprises aubstance-related disorders unrelated to alcohol@ caffeine@ cannabis@ hallucinogens 3phencyclidine and others5@ inhalants@ opioids@ sedati!e, hypnotics, or an(iolytics@ stimulants 3including amphetamine and cocaine5@ or tobacco. .uch substances include anabolic steroids@ nonsteroidal anti-inflammatory drugs@ cortisol@ antipar insonian medications@ and ..histamines@ nitrous o(ide@ amyl-, butyl-, or isobutyl nitrites@ betel nut, 2#

which is chewed many cultures to produce mild euphoria and a floating sensation@ a!a 3from a .outh :acific pepper plant5, which produces sedation, incoordination, weight loss, mild hepatis, and lung abnormalities@ or cathinones 3including hat plant agents and synthetic chemical deri!ati!es5 that produce stimulant effects. ?n nown substance-related disorders are associated with unidentified substances, such as into(ications in which the indi!idual cannot identify the ingested drug, or substance use disorders in!ol!ing either new, blac mar et drugs not yet identified or familiar drugs illegally sold under false names. ;ther 3or un nown5 substance use disorder is a mental disorder in which repeated use ,fan other or un nown substance typically continues, despite the indi!idual9s nowing that the substance is causing serious problems for the indi!idual. Those problems are reflected in the diagnostic criteria. 2hen the substance is nown, it should be reflected in the :awe of the disorder upon coding 3e.g., nitrous o(ide use disorder5. /ssociated )eatures Supporting Diagnosis A diagnosis of other 3or un nown5 substance use disorder is supported by the indi!idual9s statment that the substance in!ol!ed is not among the nine classes listed in this chapter@ by recurring episodes of into(ication with negati!e results in standard drug screens 3which may not detect new or rarely used substances5@ or by the presence of symptoms characteristic of an unidentified substance that has newly appeared in the indi!idual9s community. 4ecause of increased access to nitrous o(ide 36laughing gas65, membership in certain populations is associated with diagnosis of nitrous o(ide use disorder. The role of this gas m an anesthetic agent leads to misuse by some medical and dental professionals. *ts use as a propellant for commercial products 3e.g., whipped cream dispensers5 contributes to misuse by food ser!ice wor ers. 2ith recent widespread a!ailability of the substance in 9whippet6 cartridges for use in home whipped cream dispensers, nitrous o(ide misuse by adolescents and young adults is significant, especially among those who also inhale !olatile hydrocarbons. .ome continuously using indi!iduals, inhaling from as many as 2#/ whippets per day, may present with serious medical complications and mental conditions, including myeloneuropathy, spinal cord subacute combined degeneration, peripheral neuropathy, and psychosis. These conditions are also associated with a diagnosis of nitrous o(ide use disorder. ?se of amyl-, butyl-, and isobutyl nitrite gases has been obser!ed among homose(ual men 2$

and some adolescents, especially those with conduct disorder. 7embership in these populations may be associated with a diagnosis of amyl-, butyl-, or isobutyl nitrite use disorder. >owe!er, it has not been determined that these substances produce a substance use disorder. Despite tolerance, these gases may not alter beha!ior through central effects, and they may be used only for their peripheral effects. .ubstance use disorders generally are associated with ele!ated ris s of suicide, but there is no e!idence of uni=ue ris factors for suicide with other 3or un nown5 substance use disorder. 0revalence 4ased on e(tremely limited data, the pre!alence of other 3or un nown5 substance use disorder is li ely lower than that of use disorders in!ol!ing the nine substance classes in this chapter. Development and Course 0o single pattern of de!elopment or course characteri,es the pharmacologically !aried other 3or un nown5 substance use disorders. ;ften un nown substance use disorders will be reclassified when the un nown substance e!entually is identified. Ris1 and 0rognostic )actors %is and prognostic factors for other 3or un nown5 substance use disorders are thought to be similar to those for most substance use disorders and include the presence of any other substance use disorders, conduct disorder, or antisocial personality disorder in the indi!idual or the indi!idual9s family@ early onset of substance problems@ easy a!ailability of the substance in the indi!idual9s en!ironment@ childhood maltreatment or trauma@ and e!idence of limited early self-control and beha!ioral disinhibition. Culture-Related Diagnostic Issues Certain cultures may be associated with other 3or un nown5 substance use disorders in!ol!ing specific indigenous substances within the cultural region, such as betel nut. Diagnostic !ar1ers ?rine, breath, or sali!a tests may correctly identify a commonly used substance falsely sold as a no!el product. >owe!er, routine clinical tests usually cannot identify 2'

truly unusual or new substances, which may re=uire testing in speciali,ed laboratories. Differential Diagnosis ?se of other or un nown substances without meeting criteria for other 3or un nown. substance use disorder. ?se of un nown substances is not rare among adolescents, most use does not meet the diagnostic standard of two or more criteria for other 3or un nown5 substance use disorder in the past year. .ubstance use disorders. ;ther 3or un nown5 substance use disorder may co-occur with !arious substance use disorders, and the symptoms of the disorders may be similar and o!erlapping. To disentangle symptom patterns, it is helpful to in=uire about which symptoms persisted during periods when some of the substances were not being used. ;ther 3or un nown5 substance1medication-induced disorder. This diagnosis should be differentiated from instances when the indi!idual9s symptoms meet full criteria for ore of the following disorders, and that disorder is caused by an other or un nown substance delirium, ma&or or mild neurocogniti!e disorder, psychotic disorder, depressi!e disorder an(iety disorder, se(ual dysfunction, or sleep disorder. ;ther medical conditions. *ndi!iduals with substance use disorders, including other 3or un nown5 substance use disorder, may present with symptoms of many medical deorders. These disorders also may occur in the absence of other 3or un nown5 substance use disorder. A history of little or no use of other or un nown substances helps to e(clude. other 3or un nown5 substance use disorder as the source of these problems. Comor idity .ubstance use disorders, including other 3or un nown5 substance use disorder, are cot.- monly comorbid with one another, with adolescent conduct disorder and adult antisocial personality disorder, and with suicidal ideation and suicide attempts.

2)