Substance-Related and Addictive Disorders (Presentation)

PSY 70303
Substance-Related
and Addictive
Disorders
Lee Shu En 0331901
Ng Wei Yee 0353499
Ryan Wong Kar Wai 0353807
Substance-Related Disorders
DSM-5 TR (2022)
Encompass 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens;

inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants; tobacco; and other (or
unknown) substances
“Drug addiction” is omitted from the official DSM-5 because of its uncertain definition and its
potentially negative connotation
Divided into two groups: substance use disorders and substance-induced disorders
(substance intoxication, substance withdrawal, and substance/medication-induced mental
disorders)
Substance-use disorder : a cluster of cognitive, behavioral, and physiological symptoms
indicating that the individual continues using the substance despite significant substance-
related problems (Also known as substance-dependence in ICD-11 (WHO, 2019)
Substance-induced disorder: development of a reversible substance-specific syndrome due
to the recent ingestion of a substance
Diagnostic criteria
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
❖ The diagnosis of a substance use disorder can be applied ❖ Under category of substance dependence for each
to all 10 substance classes except caffeine substance class
A problematic pattern of substance use leading to clinically

significant impairment or distress
Occurring within a 12- month period ∙ Features of dependence are usually evident over a period
of at least 12 months but the diagnosis may be made if
substance use is continuous (daily or almost daily) for at
least 1 month
Manifested by at least two of the following criteria
1. Substance is often taken in larger amounts or over a ∙ Disorder of regulation of substance use arising from
longer period than was intended repeated or continuous use of substance
2. Persistent desire or unsuccessful efforts to cut down ∙ Impaired ability to control use of substance
or control substance use.
Diagnostic criteria (2)
3. A great deal of time is spent in activities necessary to ∙ Increasing priority given to use substance over other
obtain, use or recover from substance activities
4. Craving, or a strong desire or urge to use substance ∙ Strong internal drive to use substance
∙ Subjective sensation of urge or craving to use cannabis
5. Recurrent substance use resulting in a failure to fulfill ∙ Substance use continues or escalates despite the
major role obligations at work, school, or home. occurrence of harm or negative consequences (e.g.,
repeated relationship disruption, occupational or
scholastic consequences, negative impact on health)
6. Continued substance use despite having persistent or ∙ Substance use continues or escalates despite the
recurrent social or interpersonal problems caused or occurrence of harm or negative consequences (e.g.,
exacerbated by the effects of substance repeated relationship disruption, occupational or
scholastic consequences, negative impact on health)
7. Important social, occupational, or recreational

activities are given up or reduced because of
substance use
8. Recurrent substance use in physically hazardous ∙ Harmful pattern use of substance : Harm can occur due to
situations intoxication behavior, toxic effects or harmful route
of administration
9. Continued substance use despite knowing persistent ∙ Persistence of use despite harm or negative
or recurrent physical or psychological problem is consequences
likely to have been caused or exacerbated by substance
10. Tolerance – defined either: ∙ Tolerance to the effects of cannabis

- need for markedly increased amounts for desired effect
- markedly diminished effect with continued use same
amount
11. Withdrawal ∙ Withdrawal symptoms following cessation or reduction in

use of substance
Specifiers
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
∙ In early remission: ∙ Substance dependence - early full remission

After full criteria for substance use disorder were previously After a diagnosis of substance dependence, and often
met, none of the criteria for substance use disorder have following a treatment episode or other intervention
been met for at least 3 months but for less than 12 (including self-help intervention), the individual has been
months abstinent from substance during a period lasting from
between 1 and 12 months.
∙ In sustained remission: ∙ Substance dependence - sustained partial remission

After full criteria for substance use disorder were previously After a diagnosis of substance dependence, and often
met, none of the criteria for substance use disorder have following a treatment episode or other intervention (including
been met at any time during a period of 12 months or self-help intervention), there is a significant reduction in
longer substance consumption for more than 12 months, such that
even though substance use has occurred during this period,
the definitional requirements for dependence have not
been met.
∙ Substance dependence - sustained full remission

After a diagnosis of substance dependence, and often
following a treatment episode or other intervention (including
self-intervention), the person has been abstinent from
substance for 12 months or longer
∙ In a controlled environment:
This additional specifier is used if the individual is in an
environment where access to substance is restricted
Substance Intoxication
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
∙ No tobacco intoxication ∙ There is tobacco intoxication
A. Recent ingestion of a substance ∙
B. Clinically significant problematic behavioral or ∙ Clinically significant transient condition that develops during or
psychological changes associated with intoxication shortly after the consumption of substance that is
developed during or shortly after use of the substance characterised by disturbances in consciousness,
cognition, perception, affect, behaviour, or coordination
C. Substance-specific signs and symptoms ∙ Substance-specific signs and symptoms
D. The symptoms are not attributable to another medical ∙ Symptoms are not better accounted for by another
condition and are not better explained by another medical condition or another mental disorder
mental disorder
∙ These disturbances are caused by the known
pharmacological effects of substance and their intensity is
closely related to the amount of substance consumed.
∙ They are time-limited and abate as substance is cleared from
the body.
Substance Withdrawal
DSM-5 TR (APA, 2019) ICD-11 (WHO, 2019)
A. Cessation or reduction in substance use that has been ∙ Occurs upon cessation or reduction of use of substance in
heavy and prolonged individuals who have developed Cannabis dependence or
have used substance for a prolonged period or in large
amounts.
B. Substance-specific syndrome ∙ Substance-specific syndrome
C. Symptoms in Criterion B cause clinically significant

distress or impairment in social, occupational, or other
important areas of functioning
D. Symptoms are not due to another medical condition ∙ The symptoms are not better accounted for by another
and are not better explained by another mental disorder medical condition or another mental disorder
Unspecified Substance-Related Disorder
DSM-5 TR ICD-11
❖ No description/detail for unspecified substance-related

disorder
❖ 6C41.Z Disorders due to use of cannabis,
unspecified
∙ Symptoms characteristic of a substance-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

substance-related disorder or any of the disorders
in the substance-related and addictive disorders
diagnostic class
Alcohol Use Disorder
Alcohol- Alcohol Intoxication

Alcohol Withdrawal
related Alcohol-Induced Mental
disorders Disorders
Unspecified Alcohol-
DSM-5 TR (APA, 2022)
Related Disorder
Alcohol Use
Alcohol
Diagnostic marker: 35 units and higher for gamma-
glutamyltransferase (CGT); persistent heavy
Disorder drinkers (i.e., consuming eight or more drinks daily
Use
on a regular basis). A second test with comparable
or even higher levels of sensitivity and specificity is
carbohydrate-deficient transferrin (CDT), with levels
disorder of 20 units or higher useful in identifying individuals

who regularly consume eight or more drinks daily
(APA, 2022).
Coded as : 6C40.2 (alcohol dependance) in ICD-11.

In Malaysia,alcohol
In United States, 29.1% consumption in the general
overall with severity of population ranges from 2 to
8.6% mild, 6.6% 5%. The prevalence of binge
drinking in Malaysia is at 6%
Alcohol Use
moderate and 13.9% severe
(APA, 2022). ;lower than the global
prevalence (Mutalip et al.,2013).
Disorder - Among adults, the 12-month
Prevalence
In Malaysia: an increased use of
prevalence of DSM-5 alcohol use
alcohol (8.9% to 10.2%) among
disorder; 14.4% in African
adolescents from 2012 to 2017
Americans, 14.0% in non-Hispanic
{National Health and Morbidity
Whites, 13.6% in Hispanics, and
Survey (NHMS) 2017,
10.6% in Asian Americans and
Adolescent Health Survey 2017,
Pacific Islanders based in United
Ministry of Health Kuala
Stated population study (APA,
Lumpur, Malaysia}.
2022).
Alcohol Use Disorder - Onset
Peaks in the late teens or early to mid 20s but majority

develop alcohol-related disorders by their late 30s.

Alcohol Use Disorder - Risk Factors
Environment Genetic and physiological
Poverty
Discrimination ● 40%-60% is by genetic influences
● Cultural attitude towards drinking
● Unemployment
Availability of alcohol ● Higher rate of alcohol use disorder among
● Peer substanceLow educational level
abuse monozygotic twin than dizygotic twin
● Suboptimal way personal
Acquired of coping experiences
with stress with ● High vulnerability with pre-existing
alcohol schizophrenia, bipolar disorder or
impulsivity
Availability of alcohol
● Low response level towards alcohol
Stress level

Bipolar disorders, schizophrenia, and antisocial
personality disorder (APA, 2022)
Northeast England : 40% lifetime comorbidity between bipolar II
and alcohol use disorder with little difference between female
(38%) and male (43%) (Scott et al., 2015).
Alcohol Use Panic disorder

Disorder - 2.4 times higher than that in the general
population (Smith & Randall, 2010).
Comorbidity Anxiety and depressive disorders (APA,

2022)
Females are more common for major depressive
disorder (Nagendrappa et al., 2018).
Alcohol Use Disorder - Differential
Diagnosis
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
● Sedative, hypnotic or anxiolytic use ● Boundary with Alcohol Intoxication

disorder ● Boundary with Alcohol Withdrawal
● Conduct disorder ● Boundary with Alcohol-Induced
● Antisocial personality disorder Mental Disorders
The Alcohol Use Disorder
Identification Test
(AUDIT): Interview
Version
Developed by World Health Organisation (1983)
Scores between 8 and 15: at ris k
Score more than 20: s erious alcohol abus e (Babor et
al., 2001).
The Alcohol Use
Disorder Identification
Test (AUDIT): Self
Report version
Cut-off s cores for hazardous drinking : >3 to >5
Cut-off s cores for harmful drinking: >5 to >16
Cut-off s cores for dependent drinking: >7 to >24
for low & middle-income countries
(Nadkarni et al., 2019)
The Alcohol Use Disorder Identification
Test (AUDIT): Malay version
● Reliability Cronbach α coefficient for
total AUDIT-M: 0.823
● Correlation between the AUDIT and AUDIT-
M scores ρ: 0.979, p<0.01
● Test–retest reliability coefficient ρ:
0.955, p<0.01
(Yee et al., 2015)

The Michigan Alcoholism Screening Test (MAST)
Developed by Selzer in 1971.

Average internal cons is tency
coefficient among clinical
s amples : 0.85 while the coefficient
for non- clinical s amples : 0.82
(Minnich et al., 2018).
Tes t–retes t reliability coefficient of
0.95 for a 7-day retes t interval
(Teitelbaum & Carey,2000)
Sens itivity: 0.70, s pecificity:
0.83 and optimal cut-off s core:
8 (Minnich et al., 2018).
The Michigan Alcoholism Screening Test (MAST)
Lack of a validity and

s ocial des irability
s ubs cale: not
knowing the examinee is
res ponding to ques tions
hones tly or attempting to
give pos itive or negative
impres s ion (Minnich et al.,
2018).
Minnesota Multiphasic Personality Inventory-2
{(MMPI-2),1989}
● Contain 567 items.
● Translated into over 40 languages and used in over 90% of parental evaluations in
child custody disputes (Ackerman& Pritzl, 2011).
● 10 clinical scales: Hypochondriasis (Hs), Depression (D), Hysteria (Hy), Psychopathic
Deviate (Pd), Masculinity–Femininity (Mf), Paranoia (Pa), Psychasthenia (Pt),
Schizophrenia (Sc), Hypomania (Ma), and Social Introversion (Si).
● 3 supplementary scales: MacAndrew Alcoholism Scale Revised (MAC -R), the
Addiction Admission Scale (AAS) and the Addiction Potential Scale (APS) ; firm
understanding and diagnostic classification of substance -related disorders
(Cooper-Hakim & Viswesvaran, 2002; Graham, 2006; Shin & Min, 2012).
Increase in the 4-2/2-4 code type in
AUD patients , s imilar to patients with
heroin, cocaine, and other s ubs tance
addiction (Cho et al., 2020).
Minnesota Multiphasic
Personality Inventory-2
{(MMPI-2),1989}
Alcohol Intoxication
Substance - Specific Signs and Symptoms
DSM-5 TR ICD-11
Criteria C: One (or more) of the following signs

● Impaired attention
or symptoms developing during, or shortly ● Inappropriate or aggressive behaviour
after, alcohol use: ● Lability of mood and emotions
1. Slurred speech. ● Impaired judgment
2. Incoordination. ● Poor coordination
● Unsteady gait
3. Unsteady gait.
● Slurred speech
4. Nystagmus. ● Stupor or coma
5. Impairment in attention or memory.
6. Stupor or coma.
*The risk of suicide attempt, with each drink

increased by 30%.
In Malaysia, 36% of men aged 16-24
The 12-month prevalence of
had drunk more than 4 units on at
high-risk drinking in U.S. adults :
least one day compared with 20% of
17.4% for Native Americans,
men aged 65 and over.
15.1% for African Americans, Among young women, 37% of
Alcohol
13.5% for Latinx, 12.3% for non- those aged 16-24 had exceeded 3
Latinx Whites and 7.2% for units on at least one day compared
Asians and Pacific Islanders. with only 11% of those aged 65 and
Intoxication -
(APA, 2022). over (Sekaran, 2003).
Prevalence Intoxication: 4 or more

standard drinks on any day for
women and 5 or more on any
day for men (APA, 2022).
Alcohol Intoxication - Onset
An episode lasting over minutes to hours and typically

several hours with an average age at first intoxication of
approximately 15 years, with the highest prevalence at
approximately 18–25 years old (APA, 2022).
Alcohol Intoxication - Risk Factors
Environmental Genetic and sex-and-gender related
Heavy-drinking peers • Temperament (sensation-seeking

Coping mechanism of stress & impulsivity)
Cultural differences (festivals) • Women are less tolerant of the
same amount of alcohol than men

Alcohol Conduct disorder or antisocial personality
Intoxication -
disorder (APA, ,2022).
Comorbidity
Alcohol Intoxication- Differential
Diagnosis
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
● Other medical conditions ● Boundary with Alcohol Dependence

● Alcohol-induced mental ● Boundary with Alcohol Withdrawal
disorders ● Boundary with other Alcohol-Induced
● Sedative, hypnotic or Mental Disorders
anxiolytic intoxication ● Boundary with Alcohol-induced Delirium
● Boundary with other medical conditions
● Boundary with Overdose
Alcohol Withdrawal
Substance-Specific Signs and Symptoms
Criteria B. Two (or more) of the following, developing within
several hours to a few days after the cessation of (or reduction
in) alcohol use that has been heavy and prolonged:
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.
Alcohol
50% of middle-class, highly
functional individuals with
alcohol use disorder in the
Withdrawal - United States experienced a full
alcohol withdrawal syndrome
Prevalence (APA, 2022).
Alcohol Withdrawal - Onset
Lasting for 4–5 days and only after extended periods of heavy
drinking(DSM-5 TR, 2022).
Typically occurs within 6 to 12 hours after last use, as blood alcohol
concentrations decline (WHO, 2019).
Alcohol Withdrawal - Risk Factors
Environmental Physiological
Quantity and frequency of alcohol Alcohol withdrawal delirium Prior

consumption Histories of severe withdrawal
syndromes
Low blood potassium levels
Decreased platelet counts
Systolic hypertension

Alcohol Withdrawal -
Differential Diagnosis
ICD-11 (WHO, 2019)
● Other medical conditions ● Boundary with Alcohol Dependence

● Alcohol-induced mental ● Boundary with Alcohol Intoxication
disorders ● Boundary with other Alcohol-Induced
● Sedative, hypnotic or Mental Disorders
anxiolytic withdrawal ● Boundary with other mental disorders
● Boundary with Foetus or Newborn
Affected by Maternal Use of Tobacco,
Alcohol, or Other Drugs of Addiction
The Clinical Institute Withdrawal Assessment
for Alcohol – Revised (CIWA-Ar,1989)
● National Institute for Health and Care Excellence (NICE)

and the National Institutes of Health (NIH) recommend the
CIWA-Ar as the gold standard.
● Items:nausea, vomiting, tremor, paroxysmal sweats,

perceptual (tactile, visual or auditory) disturbances,
anxiety, agitation, headache and disturbances of
orientation and/or consciousness (Sullivan et al., 1989).
● Scores of 0–8, 9–15 and 16 or more indicate mild,

moderate, and severe withdrawal syndrome, respectively
(Saitz & O’Malley, 1997).
Alcohol-Induced Mental Disorders
● Alcohol-induced mental disorders disappear within several days to 1 month after
cessation of severe intoxication and/or withdrawal, even without psychotropic
medications (APA, ,2022).
● 6C40.5 Alcohol-induced delirium, 6C40.60 alcohol-induced psychotic disorder with

hallucinations, 6C40.61 alcohol-induced disorder with delusions,6C40.62 alcohol-
induced disorder with mixed psychotic symptoms (WHO, 2019).
Unspecified Alcohol - Related Disorder
Coded as F10.99 (APA, ,2022).

6C40.1Z Harmful pattern of use of alcohol, unspecified (ICD-11,2019).
This category applies to presentations in which symptoms characteristic of an

alcohol-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 alcohol-related disorder or any of the
disorders in the substance-related and addictive disorders diagnostic class.
Caffeine-related disorders
Caffeine Intoxication
Caffeine Withdrawal
Caffeine-Induced Mental Disorders
Unspecified Caffeine-Related Disorder

Caffeine Intoxication
Caffeine Intoxication - Diagnostic Criteria
A. Recent consumption of caffeine (typically a high dose C. The signs or symptoms in Criterion B
cause clinically significant distress or
well in excess of 250 mg).
impairment in social, occupational, or other
B. Five (or more) of the following signs or symptoms important areas of functioning.
developing during, or shortly after, caffeine use:
D. The signs or symptoms are not
1. Restlessness
9. Rambling flow of thought and attributable to another medical condition and
2. Nervousness are not better explained by another mental
speech.
3. Excitement disorder, including intoxication with another
10. Tachycardia or cardiac arrhythmia.
4. Insomnia substance.
11. Periods of inexhaustibility.
5. Flushed face
6. Diuresis
7. Gastrointestinal disturbance
8. Muscle twitching

Caffeine Intoxication - Prevalence
● Unclear
● In US, approximately 7% of individuals in the population may experience 5 or more symptoms along
with functional impairment consistent with a diagnosis of caffeine intoxication
● Consumption of caffeinated energy drinks, often together with alcohol, has increased among
adolescents and young adults in high-income countries.

Caffeine Intoxication - Development & Course
● Consistent with a half-life of caffeine of approximately 4–6 hours, caffeine intoxication symptoms usually remit
within the first day or so and do not have any known long-lasting consequences.
● individuals who consume very high doses of caffeine (i.e., 5–10 g) can leads to lethal
● With advancing age, individuals are likely to demonstrate increasingly intense reactions to caffeine, with greater
complaints of interference with sleep or feelings of hyperarousal.
● Children and adolescents may be at increased risk for caffeine intoxication because of low body weight, lack of
tolerance, and lack of knowledge about the pharmacological effects of caffeine.

Caffeine Intoxication - Risk & Prognostic factors
1. Environmental
○ Caffeine intoxication is often seen among individuals who use caffeine less frequently or in those
who have recently increased their caffeine intake by a substantial amount. Furthermore, oral
contraceptives significantly decrease the elimination of caffeine and consequently may increase
the risk of intoxication.
2. Genetic & Physiological
○ Genetic factors may affect risk of caffeine intoxication

Caffeine Intoxication - Differential Diagnosis
Independent Mental Disorder
● Caffeine intoxication may be characterized by symptoms (e.g., panic attacks) that resemble independent mental
disorders.
● To meet criteria, symptoms must not be associated with another medical condition or another mental disorder, such
as an anxiety disorder
● Manic episodes; panic disorder; generalized anxiety disorder; amphetamine intoxication; sedative, hypnotic, or
anxiolytic withdrawal or tobacco withdrawal; sleep disorders; and medication-induced side effects (e.g., akathisia)
can cause a clinical picture that is similar to that of caffeine intoxication
Caffeine-induced mental disorders

● The temporal relationship of the symptoms to increased caffeine use or to abstinence from caffeine helps to
establish the diagnosis.

Caffeine Intoxication - Comorbidity
● Typical dietary doses of caffeine have not been consistently associated with medical problems
● Heavy use (e.g., > 400 mg) can cause or exacerbate anxiety and somatic symptoms and gastrointestinal distress
● With acute, extremely high doses of caffeine, grand mal seizures & respiratory failure may result in death
● Excessive caffeine use is associated with depressive disorders, bipolar disorders, eating disorders, psychotic
disorders, sleep disorders, and substance related disorders
● Individuals with anxiety disorders are more likely to avoid caffeine

Caffeine Withdrawal
Caffeine Withdrawal - Diagnostic Criteria
A. Prolonged daily use of caffeine
C. The signs or symptoms in Criterion B cause clinically
B. Abrupt cessation of or reduction in caffeine use,
significant distress or impairment in social, occupational, or
followed within 24 hours by three (or more) of the
other important areas of functioning.
following signs or symptoms:
D. The signs or symptoms are not associated with the
1. Headache
physiological effects of another medical condition (e.g.,
2. Marked fatigue or drowsiness
migraine, viral illness) and are not better explained by another
3. Dysphoric mood, depressed mood, or irritability
mental disorder, including intoxication or withdrawal from
4. Difficulty concentrating
another substance
5. Flu-like symptoms (nausea, vomiting, or muscle
pain/stiffness)
Caffeine Withdrawal - Prevalence
● More than 85% of adults and children in the US regularly consume caffeine, with adult caffeine consumers ingesting
about 280 mg/day on average.
● The incidence and prevalence of the caffeine withdrawal syndrome in the general population are unclear
● In US, headache may occur in approximately 50% of cases of caffeine abstinence
● In attempts to permanently stop caffeine use, more than 70% of individuals in a U.S. metropolitan county reported
at least one caffeine withdrawal symptom (47% experienced headache), and 24% experienced headache plus one
or more other symptoms as well as functional impairment due to withdrawal.
● Among individuals who abstained from caffeine for at least 24 hours but were not trying to permanently stop
caffeine use, 11% experienced headache plus one or more other symptoms as well as functional impairment
● Caffeine consumers can decrease the incidence of caffeine withdrawal by using caffeine daily or only infrequently
(e.g., no more than 2 consecutive days).
● Gradual reduction in caffeine over a period of days or weeks may decrease the incidence and severity of caffeine
withdrawal
Caffeine Withdrawal - Development & Course
● Symptoms usually begin 12–24 hours after the last caffeine dose and peak after 1–2 days of abstinence.
● Caffeine withdrawal symptoms last for 2–9 days, with the possibility of withdrawal headaches occurring for up to 21
days.
● Symptoms usually remit rapidly (within 30–60 minutes) after re-ingestion of caffeine.
● Doses of caffeine significantly less than the individual’s usual daily dose may be sufficient to prevent or attenuate
caffeine withdrawal symptoms (e.g., consumption of 25 mg by an individual who typically consumes 300 mg).
● Caffeine is unique in that it is a behaviorally active drug that is consumed by individuals of nearly all ages
● Although caffeine withdrawal among children and adolescents has been documented, relatively little is known about
risk factors for caffeine withdrawal among this age group
● The use of highly caffeinated energy drinks is increasing in young people, which could increase the risk for caffeine
withdrawal.

Caffeine Withdrawal - Risk & Prognostic Factors
1. Temperamental
● Heavy caffeine use has been observed among individuals with mental disorders, including eating
disorders and alcohol and other substance use disorders, as well as among individuals who smoke
cigarettes and those who are incarcerated.
● At higher risk for caffeine withdrawal upon acute caffeine abstinence
1. Environmental
● The unavailability of caffeine are risk factor for incipient withdrawal symptoms.
● While caffeine is legal and usually widely available, there are conditions in which caffeine use may be
restricted, such as during medical procedures, pregnancy, hospitalizations, religious observances,
wartime, travel, and research participation
1. Genetic & physiological
● Genetic factors appear to increase vulnerability to caffeine withdrawal, but no specific genes have been
identified

Culture related diagnostic issues
● Habitual caffeine consumers who fast for religious reasons may be at increased risk for caffeine withdrawal
Sex- and Gender-Related Diagnostic Issues
● Metabolism of caffeine is slower in females who use oral contraceptives and in the luteal phase of the menstrual cycle, and
caffeine metabolism becomes progressively slower in the second and third trimesters of pregnancy compared with the first
trimester and the nonpregnant state.
● These features reduce the rate of clearance and may diminish withdrawal, although they can also lengthen the duration of
caffeine-associated adverse symptoms. It is unlikely that doses < 300mg/day are associated with adverse reproductive
outcomes in pregnancy
Functional Consequences of Caffeine Withdrawal
● Caffeine withdrawal symptoms can vary from mild to extreme, at times causing functional impairment in normal daily activities.
● Rates of functional impairment in the US range from 10% to 55% (median 13%), with rates as high as 73% found among
individuals who also show other problematic features of caffeine use

Caffeine Withdrawal - Differential Diagnosis
1. Other medical conditions and medication side effects

● Caffeine withdrawal can mimic migraine and other headache disorders, viral illnesses, sinus conditions,
tension, other drug withdrawal states (e.g., from amphetamines, cocaine), and medication side effects
● The final determination of caffeine withdrawal should rest on a determination of the pattern and
amount consumed, the time interval between caffeine abstinence and onset of symptoms, and the
particular clinical features presented by the individual
● A challenge dose of caffeine followed by symptom remission may be used to confirm the diagnosis
1. Caffeine-induced sleep disorder
● Caffeine withdrawal is distinguished from caffeine-induced sleep disorder (e.g., caffeine-induced sleep
disorder, insomnia type, with onset during withdrawal) because the sleep symptoms are in excess of
those usually associated caffeine withdrawal, predominate in the clinical presentation, and are severe
enough to warrant clinical attention
Caffeine Withdrawal - Comorbidity
Caffeine withdrawal may be associated with major depressive disorder, generalized anxiety disorder,
panic disorder, antisocial personality disorder, moderate to severe alcohol use disorder, and cannabis and
cocaine use.

Caffeine-Induced Mental Disorders
● Caffeine-induced anxiety disorder (“Anxiety Disorders”)
● Caffeine-induced sleep disorder (“Sleep-Wake Disorders”)
● These caffeine-induced mental disorders are diagnosed instead of caffeine intoxication or caffeine
withdrawal only when the symptoms are sufficiently severe to warrant independent clinical attention.

Unspecified-Caffeine Related Disorder
Coded as F15.99.
This category applies to presentations in which symptoms characteristic of a caffeine-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 caffeine-related disorder or any of the disorders in
the substance-related and addictive disorders diagnostic class.

Assessment
● Caffeine Use Disorder Questionnaire (CUDQ) (Urbán; Richman & Demetrovics, 2018)
● Caffeine Withdrawal Symptom Questionnaire (CWSQ) (Julliano et al., 2012)

Cannabis- Cannabis-use disorder
Related Cannabis Intoxication
Disorder Cannabis Withdrawal
DSM-5 TR (APA, 2022) Cannabis Induced Mental
Disorder
● The most widely used illicit psychoactive substances in the United
States
● According to age, the prevalence of cannabis use disorder in the
United States is highest among individuals ages 18–29 years
(6.9%) and lowest among individuals age 45 years and older
Cannabis Use (0.8%)
● During the past decade, the prevalence of cannabis use disorder has
Disorder - decreased among adolescent

● among adults, some studies suggest that the prevalence has either
remained stable or increased
Prevalance ● According to age, the prevalence of cannabis use disorder in the
United States is highest among individuals ages 18–29 years
DSM-5 TR (APA, 2022) (6.9%) and lowest among individuals age 45 years and older
(0.8%)
Cannabis Use Disorder - Onset
Onset of cannabis use disorder can occur at

any age but is most common during
adolescence or young adulthood

Cannabis Use Disorder - Development &
Course
● Impacted by acceptability and availability of medical and

recreational marijuana
● Preteen, adolescents, young adults - novelty-seeking, risk-taking,
norm-violating or other illegal behaviors, and conduct disorder
● Middle-age and older adults - “baby boomer” cohort effect (usage
among those who were young adults in the late 1960s and the 1970s)
● Early onset of cannabis use (e.g., prior to age 15 years) is a
robust predictor of the development of cannabis use disorder

Environmental Culture-Related Diagnostic
Cannabis Use ● Unstable or abusive family
Issues
Disorder - Risk situations

● Childhood history of emotional
● Acceptability varies across
cultural context
and Prognostic or physical abuse
● Family history of substance use
● Influence from ethnicity, religion,
and sociocultural practices
Factors disorders
● Low socioeconomic status
Temperamental Genetic and physiological Sex- and Gender-Related

Diagnostic Issues
● History of conduct disorder in ● Heritable factors contribute
childhood between 30% and 80% of the ● Women report more severe
● Youth with high behavioral total variance in risk cannabis withdrawal symptoms
disinhibition show early-onset ● Lower use in pregnant compared
substance use disorders with nonpregnant women
Cannabis Use Disorder -
Comorbidity
• Highly comorbid with other substance use
disorders and increases risk for any other
substance disorder
• Co-occurring mental disorders are common including major depressive disorder,
anxiety disorders and personality disorders
• Cannabis used in critical periods is consistently associated with a threefold increase in the
risk for psychosis
• Cannabinoid hyperemesis syndrome (nausea and cyclic vomiting )
• Respiratory disorders (e.g., asthma, pneumonia) are associated with regular cannabis
inhalation

Cannabis Use Disorder -
Cannabis intoxication, cannabis
withdrawal, and cannabis-induced mental
Nonproblematic use of cannabis
disorders
• Majority do not have problems
related to its use • Cannabis use disorder concerns
problematic pattern of cannabis use
• Differentiating nonproblematic use
while cannabis intoxication, cannabis
of cannabis and cannabis use
withdrawal, and cannabis-induced mental
disorder can be challenging because
disorders related to psychiatric
individuals may not attribute
syndromes that develop in the context
cannabis-related to the
of heavy use
substance
• Occur frequently in individuals with
cannabis use disorder
DSM-5 TR (2022)
Cannabis Intoxication - Substance - Specific
Signs and Symptoms
Diagnostic Criteria (APA, 2022) Diagnostic Requirements (WHO, 2019)
Criterion C ○ Inappropriate euphoria

○ Impaired attention, judgment or
memory
Two (or more) of the following signs ○ Perceptual alterations
or symptoms developing within 2
○ Increased appetite
hours of cannabis use:
○ Changes in sociability
1. Conjunctival injection. ○ Anxiety
2. Increased appetite. ○ Intensification of ordinary experiences
3. Dry mouth. ○ Conjunctival injection
4. Tachycardia. ○ Dry mouth
○ Tachycardia
Prevalence (APA, 2022) Comorbidity (APA, 2022)
Prevalence is unknown Overlap of cannabis intoxication
Prevalence of individuals using
with cannabis use disorder
cannabis and the prevalence of
individuals experiencing
cannabis intoxication are likely
Cannabis similar
Intoxication –
Course & Onset (WHO, 2019)
Prevalence, Course
● Onset varies according to
& Comorbidity pharmacokinetic factors
● Duration of intoxication depend on
multiple factors including dosage, half-
life and formulation of the substance
taken
● Intensity of intoxication lessens with
time after reaching a peak of absorption
● Effects usually disappear in the absence
of further use
Cannabis Intoxication -
)
Other substance intoxication Cannabis-induced mental
disorders
Resemble intoxication with other types
of substances ● Symptoms are in excess of those
associated with cannabis
Hallucinogens in low doses may
intoxication and are severe
resemble cannabis intoxication enough to warrant independent
Phencyclidine intoxication also causes clinical attention
perceptual changes, but more likely to cause
ataxia and aggressive behavior

Cannabis Withdrawal - Substance-
Specific Signs and Symptoms
Criterion B - Three (or more) of the following signs Irriitability, anger or aggressive
and symptoms develop within approximately 1
behaviour,
week after Criterion A:
Shakiness, Insomnia,
1. Irritability, anger, or aggression.
2. Nervousness or anxiety. Restlessness,
3. Sleep difficulty Anxiety,
4. Decreased appetite or weight loss. Depressed or dysphoric mood,
5. Restlessness. Decreased appetite and weight loss,
6. Depressed mood.
Headache,
7. At least one of the following physical
symptoms causing significant discomfort: Sweating or chills,
abdominal pain, shakiness/tremors, sweating, Abdominal cramps
fever, chills, or headache. Muscle aches

Cannabis Withdrawal -
Prevalence & Course
Prevalence Course & Onset
Prevalence vary widely due to differences ● Onset occurs within 24-48 hours
in samples after cessation
Substantial differences in prevalence among ● Peaks within 2–5 days
non-Latinx Whites (10%), African Americans ● Resolves within 1–2
(15.3%), and Asian Americans, Native Hawai weeks
ans, and Pacific Islanders (31%) ● More chronic & frequent use = more
Occurs among a substantial subset of severe
regular cannabis users who try to quit. ● Women may experience more severe
symptoms

Cannabis Withdrawal - Comorbidity
● Associated with comorbid depression, anxiety,

and antisocial personality disorder
● Overlap with cannabis-use disorder

Cannabis Withdrawal -
Same symptoms with other substance
withdrawal, depressive or bipolar disorders
Regular cannabis users experiencing cannabis
withdrawal may not realize that their
withdrawal symptoms are due to the effects
of cannabis wearing out

Cannabis-Induced Mental Disorders
6C41.6 Cannabis-induced psychotic disorder
Diagnostic Criteria (APA, 2022)
(WHO,2019)
• Cannabis-induced psychotic • Psychotic symptoms (e.g., delusions, hallucinations, or
disorder (“Schizophrenia Spectrum disorganized thinking or behaviour) during/after
and Other Psychotic Disorders”); intoxication/withdrawal
• Cannabis-induced anxiety • Intensity and duration substantially in excess of psychotic-
disorder (“Anxiety Disorders”); like disturbances during intoxication/withdrawal
• Cannabis-induced sleep disorder • Symptoms are not better accounted for by another
mental disorder or medical condition
(“Sleep-Wake Disorders”)
• Cannabis intoxication 6C41.5 Cannabis-induced delirium (WHO, 2019)
delirium • Requirements for 6D70 Delirium are met
• Diagnosed instead of • Evidence that neurocognitive disturbance is caused by
intoxication or withdrawal the cannabis use
when the symptoms are • Duration & severity is substantially in excess of
sufficiently severe to intoxication/withdrawal symptoms
warrant independent • Diagnostic requirements for 6D70.2 Delirium Due to
clinical attention Multiple Etiological Factors are not met
Assessments
The 47-item Marijuana Craving Marijuana Withdrawal 19-item Marijuana Problem
Questionnaire, MCQ (Heishman et Checklist, MWCQ (Budney et Scale, MPS
al., 2001) al., 1999) (Stephens et al., 2000)
Measures: Lists 22 symptoms that users Measures potential negative

may report when they abstain effects of marijuana on
Compulsivity (inability to from marijuana use, with each social relationships, self-
control marijuana use), symptom rated as absent, esteem, motivation and
Emotionality (expecting use to mild, moderate, or severe productivity, work and
reduce negative emotion); finances, physical health,
Expectancy (expecting use to memory impairment, and
have positive outcomes), and legal problems
Purposefulness (intention and
planning to use for positive
outcomes).
Phencyclidine Use Disorder
Other Hallucinogen Use Disorder
Phencyclidine Intoxication
Hallucinogen- Other Hallucinogen Intoxication

Hallucinogen Persisting Perception
related
Disorder
Phencyclidine-Induced Mental Disorders
Hallucinogen-Induced Mental Disorders
disorders Unspecified Phencyclidine-Related

Disorder
Unspecified Hallucinogen-Related Disorder

● Ketamine, cyclohexylamine
phencyclidine (angel dust)
Phencyclidine Use (APA,2022).
Disorder ● Coded as 6C4D.2 Dissociative

Drug Dependence, including
Ketamine and PCP in ICD-11
(WHO, 2019).
0.1% among individuals aged 12
years old and older in the United
Phencyclidine Use States (APA, 2022).
Disorder - 0.8% between the ages of 15 and

40 years in Malaysia (Ismail et al.,
Prevalence 2022).
Phencyclidine Use Disorder - Onset
Detected in urine for up to 8 days or even longer at

very high doses and hallucinogenic effect can last for
weeks among vulnerable individuals (APA, 2022).
Phencyclidine Use
Disorder - Risk Factors
Gender and
Physiological (APA, 2022)
● 62% are men

● Presence of nystagmus, analgesia,
prominent hypertension
Phencyclidine Conduct disorder, antisocial personality
Use Disorder - disorder or other substance-abuse

disorders (APA, 2022).
Comorbidity
Phencyclidine Use Disorder -
● Other substance use disorders
● Phencyclidine intoxication and
phencyclidine-induced mental
disorders
● Independent mental disorders
(schizophrenia, major depressive
disorder, conduct disorder)

Other Hallucinogen Use Disorder/Hallucinogen
Dependence
● Phenylalkylamines (e.g., mescaline, DOM
● Coded as 6C49.2 Hallucinogen
[2,5-dimethoxy-4- methylamphetamine] Dependence in ICD-11.
● MDMA [3,4 ● Usually taken orally (DMT) or
methylenedioxymethamphetamine; also injection (ecstasy).
called “ecstasy” or “molly”]
● Psilocin, the compound primarily responsible
for the psychedelic effects of hallucinogenic
mushrooms
● Dimethyltryptamine (DMT)
● LSD (lysergic acid diethylamide)
● Morning glory seeds
● In United States, 0.2%
among those ages 12–17
Other Hallucinogens years old. 0.4% among those
ages 18–25, and < 0.1%
Use Disorder - among those age 26 and
older.
Prevalence

Other Hallucinogens Use Disorder -
Risk Factors
Environmental Genetic & Physiological
Higher income 26% to 79% influenced by genetics

Lower education level
Being never married
Life transition
Religious or spiritual practices (Mexico
& South America)

Other Cocaine use disorder, stimulant use
disorder, other substance use disorder,
Hallucinogens tobacco (nicotine) use disorder, any
Use Disorder - personality disorder, posttraumatic stress

disorder and panic attacks (APA, 2022).
Comorbidity
Other Hallucinogens Use Disorder -
● Other substance use disorders

● Schizophrenia
● Other mental disorders or medical
conditions

Phencyclidine Intoxication
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
Criteria C:
● Hallucinations
Within 1 hour, two (or more) of the following signs
● Illusions
or symptoms: ● Perceptual changes such as depersonalization,
derealization, synesthesias (blending of senses,
Note: When the drug is smoked, “snorted,” or such as a visual stimulus evoking a smell)
used intravenously, the onset may be particularly ● Anxiety
rapid. ● Depressed or dysphoric mood
● Ideas of reference
● Paranoid ideation
Vertical or horizontal nystagmus. ● Impaired judgment
Hypertension or tachycardia. ● Palpitations
Numbness or diminished responsiveness to pain. ● Sweating
● Blurred vision
Ataxia.
● Tremors
Dysarthria. ● Lack of coordination
Muscle rigidity. ● Tachycardia
Seizures or coma. ● Elalvated blood pressure
Hyperacusis. ● Pupillary dilatation
1.2% among 12th graders and
0.5% among young adults, ages 19
Phencyclidine to 28 years old in United States
Intoxication - (APA, 2022).
Prevalence
Phencyclidine Intoxication -
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
● Other substance use disorders ● Boundary with Dissociative Drug

● Hallucinogen intoxication and Dependence, including Ketamine and
hallucinogen-induced mental PCP
disorders ● Boundary with Dissociative Drug-
● Independent mental disorders Induced Delirium
(schizophrenia, major depressive ● Boundary with other Dissociative Drug-
Induced Mental Disorders, including
disorder, conduct disorder)
Ketamine and PCP
● Boundary with other medical
conditions
● Boundary with overdose
Other Hallucinogen Intoxication
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
Criteria D: Two (or more) of the following signs
developing during, or shortly after, hallucinogen
use: ● Aggression.
● Impulsiveness.
1. Pupillary dilation. ● Unpredictable behaviour.
● Anxiety.
1. Tachycardia.
● Psychomotor agitation.
1. Sweating.
● Impaired judgment.
● Numbness or diminished
1. Palpitations. responsiveness to pain.
● Tachycardia.
1. Blurring of vision.
● Elevated blood pressure.
1. Tremors. ● Ataxia.
● Muscle rigidity.
1. Incoordination.
● 6.9% for individuals ages 18-25,
1.3% for among those aged 26 or
Other Hallucinogen older in United States (APA,
Intoxication - 2022).
● 13.58% in Malaysia (Abdalrazak
Prevalence et al., 2019).
Other Hallucinogen Intoxication - Risk
Factors
Environmental (APA, 2022)
Other drug use

Childhood depression
Lifetime psychedelic use
Other Panic disorder, alcohol use disorder, major
depressive disorder, bipolar I disorder, and
Hallucinogen schizophrenia spectrum disorders (APA,
2022).
Intoxication -
Comorbidity
Other Hallucinogen Intoxication -
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
● Other substance intoxication ● Boundary with Dissociative Drug

● Hallucinogen persisting perception Dependence, including Ketamine and
disorder PCP
● Other hallucinogen-induced disorders ● Boundary with Dissociative Drug-
Induced Delirium
● Boundary with other Dissociative Drug-
Induced Mental Disorders, including
Ketamine and PCP
● Boundary with other medical
conditions
Hallucinogen Persisting Perception Disorder (APA,
2022)
Hallucinogen Persisting Perception
Disorder -Differential diagnosis
● Schizophrenia
● Stroke
● Brain tumors
● Head trauma

Phencyclidine-Induced
Mental Disorders
Hallucinogen-Induced
Mental Disorders

Unspecified Phencyclidine- Related Disorder/Disorder Due to Use of Dissociative
Drugs including Ketamine and PCP, Unspecified
(F16.99/6C4D.Z)
This category applies to presentations in which symptoms characteristic of a phencyclidine-

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 phencyclidine-related disorder or any of the disorders in the
substance-related and addictive disorders diagnostic class.

Unspecified Hallucinogen-Related Disorder/Disorders due to
use of hallucinogens, unspecified

Inhalant-Related Disorders
● Inhalant Use Disorder

● Inhalant Intoxication
● Inhalant-Induced Mental Disorders
● Unspecified Inhalant-Related Disorder
Inhalant Use Disorder - Prevalence
● About 2.3% of American youth ages 12–17 years have used inhalants in the past 12 months, with 0.1% having a
pattern of use that meets criteria for inhalant use disorder.
● Among U.S. adults, age 18 years and older, past 12-month prevalence of inhalant use is about 0.21%, with 0.04%
having a pattern of use that meets criteria for an inhalant use disorder.

Inhalant Use Disorder - Development & Course
● The declining prevalence in the US of inhalant use and inhalant use disorder after adolescence (from 2.3%
during adolescence to 0.1% in early adulthood for inhalant use and from 0.1% to 0.04% for inhalant use
disorder) indicates that the disorder usually remits in early adulthood.
● Inhalant use disorder is rare in prepubertal children, most common in adolescents and young adults, and
uncommon in older persons.
● Those with inhalant use disorder extending into adulthood demonstrate earlier onset of inhalant use, use of
multiple inhalants, and more frequent inhalant use.
DSM-5 TR ( APA, 2022)

Inhalant Use Disorder - Risk & Prognostic Factors
● Temperamental.
○ Predictors of inhalant use disorder include sensation seeking and impulsivity.
● Environmental.
○ Inhalant gases are widely and legally available, increasing the risk of misuse.
○ Childhood maltreatment or trauma also is associated with youthful progression from inhalant non-use to inhalant use disorder.
● Genetic and physiological
○ Behavioral disinhibition is a highly heritable general propensity to not constrain behavior in socially acceptable ways, to break
social norms and rules, and to take dangerous risks, pursuing rewards excessively despite dangers of adverse consequences.
○ Youths with strong behavioral disinhibition show risk factors for inhalant use disorder:
i. early-onset substance use disorder,
ii. multiple substance involvement, and
iii. early conduct problems.
iv. behavioral disinhibition is under strong genetic influence, youths in families with substance use and antisocial behaviors
are at elevated risk for inhalant use disorder
● Culture-Related Diagnostic Issues
○ In some low- and middle-income countries, groups of homeless children living on the streets have extensive inhalant use
problems because of the effects of poverty and the availability and affordability of the substances, and as a way to cope with
homelessness.
● Sex- and Gender-Related Diagnostic Issues
○ Although the past 12-month prevalence of inhalant use disorder in the United States is almost identical among adolescent boys
and girls, the disorder is very rare among adult women.

Inhalant Use Disorder - Differential Diagnosis
● Inhalant use disorder is differentiated from inhalant intoxication and inhalant-induced mental disorders in that
inhalant use disorder describes a problematic pattern of inhalant use that involves impaired control over inhalant
use, social impairment attributable to inhalant use, risky inhalant use, and pharmacological symptoms.
● Inhalant intoxication and inhalant-induced mental disorders occur frequently in individuals with inhalant use
disorder.
● Inhalant use disorder commonly co-occurs with other substance use disorders, and the symptoms of the disorders
may be similar and overlapping

Inhalant Use Disorder- Comorbidity
● Individuals with inhalant use disorder receiving clinical care often have numerous other substance use, mood,
anxiety, and personality disorders.
● Inhalant use disorder commonly co- occurs with conduct disorder in adolescents and with antisocial personality
disorder.
● Individuals with inhalant use disorder may have comorbid symptoms of hepatic or renal damage, rhabdomyolysis,
methemoglobinemia, or symptoms of other gastrointestinal, cardiovascular, or pulmonary diseases.

Inhalant Intoxication
Inhalant Intoxication - Signs & symptoms
DSM- 5 TR (APA, 2022)
ICD-11 (WHO,2019)
Two (or more) of the following signs or symptoms 1. Euphoria

developing during, or shortly after, inhalant use or 2. Impaired judgment
exposure: 3. Aggression
1. Dizziness 4. Somnolence
2. Nystagmus 5. Stupor or coma
3. Incoordination 6. Dizziness
4. Slurred speech 7. Tremor
5. Unsteady gait 8. Lack of coordination
6. Lethargy 9. Slurred speech
7. Depressed reflexes 10. Unsteady gait
8. Psychomotor retardation 11. Lethargy and apathy
9. Tremor 12. Psychomotor retardation
10. Generalized muscle weakness 13. Visual disturbance
11. Blurred vision or diplopia
12. Stupor or coma
13. Euphoria
Inhalant Intoxication - Development and
Course, Risk and Prognostic Factors
● Refer to Inhalant Use Disorder
Inhalant Intoxication - Comorbidity

● Overlap of Inhalant Intoxication with Inhalant Use Disorder

Inhalant Intoxication - Prevalence
● Unknown
● A majority of inhalant users would at some time exhibit behavioral or psychological changes and symptoms that
would meet criteria for inhalant intoxication.
● In 2017, inhalant use in the past year was reported by 0.6% of all Americans older than 12 years
○ highest in younger age groups
○ 2.3% for individuals ages 12 –17 years
○ 1.6% for individuals ages 18–25 years
○ 0.3% for individuals age 26 and older
● Sex- and Gender-Related Diagnostic Issues
○ Gender differences remain unknown
○ In US, 0.8% of boys/men older than 12 years and 0.5% of girls/women older than 12 years have used
inhalants in the previous year,
○ In younger age groups differences are minimal or girls may have slightly higher prevalence (e.g., among
adolescents ages 12–17 years, 2.4% of girls and 2.2% of boys have used inhalants in the past year)

Inhalant Intoxication - Differential Diagnosis
Intoxication from other substances, especially from sedating substances (e.g., alcohol, benzodiazepines,
barbiturates)
● May have similar signs and symptoms
● Intoxication attributable to other intoxicants may be identified via a toxicology screen
● A diagnosis of inhalant intoxication may be suggested by possession or lingering odors
● of inhalant substances
○ Glue
○ Paint thinner
○ Gasoline
○ Butane lighters
○ Paraphernalia possession (e.g., rags or bags for concentrating glue fumes)
○ perioral or perinasal “glue-sniffer’s rash”
Inhalant-induced mental disorders

● Inhalant intoxication is distinguished from inhalant-induced mental disorders because the symptoms in these latter
disorders are in excess of those usually associated with inhalant intoxication, predominate in the clinical
presentation, and are severe enough to warrant independent clinical attention.
Inhalant-Induced Mental Disorders
6C4B.5 Volatile inhalant-induced delirium (WHO,
2019)
● Substance/medication-induced mental disorder ● Volatile inhalant-induced delirium is characterised by
● inhalant-induced psychotic disorder (Schizophrenia
an acute state of disturbed attention and awareness
Spectrum and Other Psychotic Disorders)
● Inhalant-induced depressive disorder (Depressive with specific features of delirium that develops during
Disorders) or soon after substance intoxication or withdrawal or
● inhalant-induced anxiety disorder (Anxiety during the use of volatile inhalants.
Disorders)
● Duration or severity of the symptoms is substantially in
● Inhalant-induced major or mild neurocognitive
disorder (Neurocognitive Disorders) excess of the characteristic syndrome of Volatile
Inhalant Intoxication
DSM-5 TR (APA, 2022); ICD-11 (WHO,2019)

Unspecified Inhalant-Related Disorder
Coded as F18.99.
This category applies to presentations in which symptoms characteristic of an inhalant-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 inhalant-related disorder or any of the disorders in
the substance-related and addictive disorders diagnostic class.

Assessment
1. Physical and behavioural signs and symptoms

2. Urine screening and lab tests
3. General substance use screeners
4. Inhalant specific interviews and inventories
a. The Volatile Solvent Screening Inventory (VSSI; Howard et al., 2008)
b. Comprehensive Solvent Assessment Interview (CSAI; Howard et al., 2008)
(Nguyen; O’Brien & Schapp,2016)

Opioid- Opioid-use disorder
Related Opioid Intoxication
Opioid Withdrawal
Disorder Opioid Induced Mental
Disorder
Opioid Use
● U.S. adults age 18 and older (DSM-IV or DSM-5
criteria) is 0.6%–0.9%,
● Among those ages 12–17, prevalence is 0.4%
Disorder - ● In the United States, higher among men than
women, young adults than older adults, and
Prevalance among those with lower income or education

● Globally in 2016, there were 26.8 million cases of
DSM-IV opioid dependence
Opioid Use Disorder -
Development & Course
● Can begin at any age
● Most commonly first observed in the late teens or early 20s
● Early use can reflect a desire for relief from life stressors or
psychological pain
● Long term studies show that once an opioid use disorder develops, it can
continue over many years, with brief periods of abstinence in some
individuals but long-term abstinence only in a minority

Culture-Related Diagnostic Issues
● Highly associated with
externalizing traits such as ● Opioid use disorder has become
novelty-seeking, impulsivity, and more common among White
disinhibition individuals
● Family, peer, and social ● Criteria for opioid use disorder
environmental factors all perform equally well across
increase the risk ethnoracial groups
Opioid Use
Disorder - Risks & Sex- and Gender-Related Diagnostic Issues
Prognostic ● Women more likely than men to have
Factors initiated opioid use in response to sexual
abuse and violence
DSM-5 TR (APA, 2022) ● Women more likely than men to be
introduced to the drug by a partner.
● Women progress to disorder more
quickly than men after first use
Opioid Use Disorder - Comorbidity
● Most common medical comorbidities associated with opioid use disorder are viral (e.g., HIV,
hepatitis C virus) and bacterial infections – related to method of administration
● Often associated with other substance use disorders (tobacco, alcohol and cannabis)
● Risk developing persistent depressive disorder or major depressive disorder
● Symptoms may represent an opioid-induced depressive disorder
● Insomnia is common especially during withdrawal.
● Opioid use disorder is also associated with bipolar I disorder, posttraumatic stress
disorder, and antisocial personality disorder

Opioid Use Disorder - Differential
Diagnosis
Opioid intoxication, opioid withdrawal, and Other substance intoxication
opioid-induced mental disorders
● Alcohol intoxication and sedative,
● Opioid use disorder describes a problematic hypnotic, or anxiolytic intoxication can
pattern of opioid use whereas opioid cause a clinical picture that resembles that of
intoxication, opioid withdrawal, and opioid- opioid intoxication
induced mental disorders describe psychiatric ● A diagnosis of alcohol or sedative, hypnotic, or
syndromes. anxiolytic intoxication can usually be made
based on the absence of pupillary
constriction or the lack of a response to
naloxone challenge

Opioid Intoxication - Substance-Specific
Signs and Symptoms
Criterion C
● Somnolence
● Stupor
Pupillary constriction and one (or more) of the
● Mood changes (e.g. euphoria followed by
following signs or symptoms developing during, or
apathy and dysphoria)
shortly after, opioid use:
● Psychomotor retardation
•Drowsiness or coma
● Impaired judgment
•Slurred speech
•Impairment in attention or memory. ● Respiratory depression
● Slurred speech
● Impairment of memory and attention
● Pupillary constriction
Opioid Intoxication – Prevalence, Course
& Comorbidity
Prevalence (APA, 2022) Development & Course Comorbidity (APA, 2022)
(WHO, 2019)
● Prevalence is ● Overlap of cannabis
● Opioid intoxication can occur in an
unknown intoxication with
individual who is opioid naïve,
cannabis use disorder
who uses opioids occasionally,
and physically dependent on
opioids.
● The dose of opioid consumed
relative to the likelihood of
experiencing opioid intoxication will
vary as a function of the status
and history of the individual’s
opioid exposure (i.e., tolerance).
Other substance intoxication
● Alcohol intoxication and sedative-hypnotic intoxication can
Opioid cause a clinical picture that resembles opioid intoxication.

● A diagnosis of alcohol or sedative-hypnotic intoxication can usually
Intoxication –
be made based on the absence of pupillary constriction or the
lack of a response to a naloxone challenge
Differential
Diagnosis Opioid-induced mental disorders
DSM-5 TR (APA, 2022) ● Symptoms in opioid-induced mental disorders are in excess of

those usually associated with opioid intoxication and are
severe enough to warrant clinical attention
Opioid Withdrawal - Substance-Specific Signs and
Symptoms
Criterion B ● Depressed or dysphoric mood

● Craving for an opioid
● Anxiety
Three (or more) of the following developing within
● Nausea or vomiting
minutes to several days after Criterion A:
● Abdominal cramps
• Dysphoric mood
● Muscle aches
• Nausea or vomiting.
● Yawning
• Muscle aches
● Perspiration
• Lacrimation or rhinorrhea
● Hot and cold flashes
• Pupillary dilation, piloerection, or sweating
● Hypersomnia (typically in the initial phase) or
• Diarrhea
Insomnia
• Yawning
● Diarrhoea
• Fever
● Piloerection
• Insomnia
● Pupillary dilation

Opioid Withdrawal - Prevalence & Course &
Comorbidity
Prevalence Course & Onset Comorbidity
● Prevalence vary widely due to ● Onset occurs within 24-48 ● Overlap of opioid
differences in samples hours after cessation withdrawal with opioid
● Substantial differences in ● Peaks within 2–5 days use disorder
prevalence among non-Latinx ● Resolves within 1–2 weeks
Whites (10%), African ● More chronic & frequent use =
Americans (15.3%), and Asian more severe
Americans, Native Hawaiians, ● Women may experience more
and Pacific Islanders (31%) severe symptoms
● Occurs among a substantial
subset of regular cannabis
users who try to quit.

Opioid Withdrawal - Differential Diagnosis
Other withdrawal disorders Other substance intoxication Opioid-induced mental

disorders
● Anxiety and restlessness ● Dilated pupils are also seen
associated with opioid in hallucinogen intoxication ● Opioid withdrawal is
withdrawal resemble symptoms and stimulant intoxication distinguished from opioid-
seen in sedative-hypnotic ● Other signs or symptoms of induced mental disorders
withdrawal opioid withdrawal, such as because the symptoms in
● Opioid withdrawal is also nausea, vomiting, diarrhea, latter disorders are in
accompanied by rhinorrhea, abdominal cramps, excess of those usually
lacrimation, and pupillary rhinorrhea, and associated with opioid
dilation, which are not seen in lacrimation, are not withdrawal, and are
sedative type withdrawal. present severe enough to warrant
clinical attention

Opioid-Induced Mental Disorders
6C43.6 Opioid-induced psychotic disorder (WHO,2019)
● Psychotic symptoms (e.g., delusions, hallucinations, or
● Opioid-induced depressive disorder disorganized thinking or behaviour) during/after
(“Depressive Disorders”) intoxication/withdrawal
● Opioid-induced anxiety disorder ● Intensity and duration substantially in excess of psychotic-
(“Anxiety Disorders”) like disturbances during intoxication/withdrawal
● Opioid-induced sleep disorder ● Symptoms are not better accounted for by another
(“Sleep-Wake Disorders”) mental disorder or medical condition
● Opioid-induced sexual dysfunction
(“Sexual Dysfunctions”) 6C43.5 Opioid-induced delirium (WHO, 2019)
● Diagnosed instead of toxication or ● Requirements for 6D70 Delirium are met
withdrawal when the symptoms ● Evidence that neurocognitive disturbance is caused by the
are sufficiently severe to cannabis use
warrant independent clinical ● Duration & severity is substantially in excess of
attention intoxication/withdrawal symptoms
● Diagnostic requirements for 6D70.2 Delirium Due to
Multiple Etiological Factors are not met
Opioid Risk Tool (ORT) Current Opioid Misuse Measure
(Webster & Webster, 2005) (COMM) (Butler et al., 2010)
● A brief, self-report screening tool ● A 17 item self administered

● To assess risk for opioid abuse questionnaire designed to detect signs
among individuals prescribed of opioid misuse within the past 30
opioids for treatment of chronic days in chronic pain patients
pain
Assessments
Clinical Opiate Withdrawal Scale
(COWS) (Wesson & Ling, 2003)
● 11-item scale
● Rate common signs and symptoms of
opiate withdrawal
● Used to help clinicians determine the
stage or severity of opiate withdrawal
and assess the level of physical
dependence on opioids
SEDATIVE,HYPNOTIC AND ANXIOLYTIC RELATED
DISORDERS
● Sedative, Hypnotic, or Anxiolytic Use Disorder

● Sedative, Hypnotic, or Anxiolytic Intoxication
● Sedative, Hypnotic, or Anxiolytic Withdrawal
● Sedative-, Hypnotic-, or Anxiolytic-Induced Mental
Disorders
● Unspecified Sedative-, Hypnotic-, or Anxiolytic-Related
Disorder
SEDATIVE,
HYPNOTIC, OR
ANXIOLYTIC USE
DISORDER
● Benzodiazepines,
● Benzodiazepine-like drugs (e.g., ● Coded as 6C44.2 Sedative, Hypnotic, or
zolpidem, zaleplon). Anxiolytic Dependence in ICD-11 (WHO, 2019).
● Carbamates (e.g., glutethimide,
meprobamate).
● Barbiturates (e.g., secobarbital)
Barbiturate-like hypnotics (e.g.,
glutethimide, methaqualone,
● propofol).
SEDATIVE, HYPNOTIC, OR ANXIOLYTIC USE
DISORDER- Risk Factors
Peer factors
Availability of the Novelty
substances, both through Genetics seeking
an individual’s own Impulsivity
prescriptions and from
prescriptions dispensed to
family and friends.
ENVIRONMENTAL GENETICS & PHYSIOLOGICAL TEMPERAMENT

DISORDER-PREVALENCE
0.3% among adolescents ages 12–17 years and adults age 18 years old and older, in
United States(DSM-5 TR, 2022).

DISORDER-COMORBIDITY
Alcohol use disorder, tobacco use disorder, antisocial personality disorder,
depressive, bipolar, and anxiety disorders; and drug use(DSM-5 TR,2022).
DISORDER- Differential Diagnosis
● Alcohol Use disorder

● Other mental or medical conditions
● Clinically appropriate use of sedative,
hypnotic or anxiolytic medications
TEMPERAMENT
DSM-5 TR APA, (2022)

SEDATIVE, HYPNOTIC, OR ANXIOLYTIC
INTOXICATION
Substance-Specific Signs and Symptoms
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
Criteria C. One (or more) of the following ● Somnolence
signs or symptoms developing during, or ● Impaired judgment
shortly after, sedative, hypnotic, or anxiolytic ● Inappropriate behaviour (including sexual
use: behaviour or aggression)
● Slurred speech
1. Slurred speech. ● Impaired motor coordination
2. Incoordination. ● Unsteady gait
3. Unsteady gait. ● Mood changes
4. Nystagmus. ● impaired memory, attention and concentration.
5. Impairment in cognition (attention, Nystagmus
memory). ● Stupor or coma
6. Stupor or coma.
SEDATIVE, HYPNOTIC, OR ANXIOLYTIC INTOXICATION
DSM-5 TR (APA, 2019) ICD-11 (WHO, 2019)
● Alcohol use disorders ● Boundary with Sedative, Hypnotic

or Anxiolytic-Induced Delirium
● Alcohol intoxication
● Boundary with other Sedative,
● Other sedative, Hypnotic or Anxiolytic-Induced
hypnotic, or anxiolytic- Mental Disorders
induced disorders ● Boundary with other medical
conditions
● Neurocognitive ● Boundary with overdose
disorders
TEMPERAMENT
SEDATIVE, HYPNOTIC, OR
ANXIOLYTIC WITHDRAWAL
Substance-specific Signs and
Symptoms
Criteria B. Two (or more) of the following, developing within

several hours to a few days after the cessation of (or reduction in)
sedative, hypnotic, or anxiolytic use:
1.Autonomic hyperactivity (e.g., sweating or pulse rate greater

than 100 bpm).
2. Hand tremor.
3. Insomnia.
4. Nausea or vomiting.
5. Transient visual, tactile, or auditory hallucinations or illusions.
7. Anxiety.
8. Grand mal seizures. DSM-5 TR (APA, 2022)
Withdrawal from substances with long-acting
metabolites (e.g., diazepam) may not begin for
1–2 days or longer.
Medications whose actions typically last about SEDATIVE,
10 hours or less (e.g., lorazepam, oxazepam,
temazepam) produce withdrawal symptoms HYPNOTIC, OR
within 6–8 hours and peak in intensity on the
2nd day. ANXIOLYTIC
100 mg of diazepam are more likely to be
followed by withdrawal seizures or delirium. WITHDRAWAL

www.reallygreatsite.com
SEDATIVE, HYPNOTIC, OR ANXIOLYTIC
WITHDRAWAL
ICD-11 (WHO, 2019)
● Alcohol withdrawal ● Boundary with Sedative, Hypnotic or Anxiolytic

● Other sedative-hypnotic, or anxiolytic Dependence
induced disorders ● Boundary with Sedative, Hypnotic or Anxiolytic
● Anxiety disorders Intoxication
● Boundary with Sedative, Hypnotic or Anxiolytic-
Induced Delirium
● Boundary with other Sedative, Hypnotic or
Anxiolytic-Induced Mental Disorders
● Boundary with other mental disorders
● Boundary with Foetus or Newborn Affected by
Maternal Use of Tobacco, Alcohol, or Other
Drugs of Addiction TEMPERAMENT
SEDATIVE,
HYPNOTIC, OR
ANXIOLYTIC
INDUCED
MENTAL
DISORDER

This category applies to presentations in
which symptoms characteristic of a
UNSPECIFIED SEDATIVE-, sedative-, hypnotic-, or anxiolytic-related
disorder that cause clinically significant
HYPNOTIC-, OR ANXIOLYTIC- distress or impairment in social,
RELATED DISORDER (F13.99) occupational, or other important areas of
functioning predominate but do not meet
/ DISORDER DUE TO USE OF the full criteria for any specific sedative-,
SEDATIVES, HYPNOTICS, OR hypnotic-, or anxiolytic-related disorder or
any of the disorders in the substance-
ANXIOLYTICS, UNSPECIFIED related and addictive
(6C44.Z) disorders diagnostic class.

OTHER (OR UNKNOWN) SUBSTANCE–RELATED
DISORDERS
● Other (or Unknown) Substance Use Disorder

● Other (or Unknown) Substance Intoxication
● Other (or Unknown) Substance Withdrawal
● Other (or Unknown) Substance–Induced Mental
Disorders
● Unspecified Other (or Unknown) Substance–Related
Disorder

OTHER (OR
UNKNOWN)
SUBSTANCE
USE DISORDER
Anabolic steroids
Nonsteroidal anti-inflammatory drugs
Corticosteroids
Antiparkinsonian medications
Antihistamines
Nitrous oxide
Amyl-, butyl-, or isobutyl-nitrites
Betel nut
Kava DSM-5 TR (APA, 2022)
OTHER (OR UNKNOWN) SUBSTANCE USE DISORDER
PREVALENCE
Lifetime prevalence in the United States: Individuals aged 12 years and older ; at 4.6%
for nitrous oxide and 2.5% for nitrites (APA, 2022).
OTHER (OR UNKNOWN) SUBSTANCE USE DISORDER-

COMORBIDITY
Substance use disorder,conduct disorder, antisocial personality disorder with
suicidal ideation and attempts (APA,2022).
OTHER (OR UNKNOWN) SUBSTANCE USE
DISORDER-Risk Factors
● Easy availability of the

● Limited early self-
substance in the individual’s
control.
environment.
● Behavioral disinhibition
● Childhood maltreatment or
trauma.
ENVIRONMENTAL TEMPERAMENT

OTHER (OR UNKNOWN) SUBSTANCE USE DISORDER -
● Substance use disorders

● Other (or unknown)
susbtance/medication
induced disorder
● Other medical conditions

OTHER (OR UNKNOWN) SUBSTANCE
INTOXICATION
Substance-specific Signs and Symptoms
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
Criteria B: Clinically significant problematic ● The symptoms must be compatible

behavioral or psychological changes that are with the known pharmacological effects
attributable to the effect of the substance on the of unknown or unspecified
central nervous system (e.g: impaired motor psychoactive substances, and their
coordination, psychomotor agitation or retardation, intensity is closely related to the
euphoria, anxiety, belligerence, mood lability, amount of unknown or unspecified
cognitive impairment, impaired judgment, social psychoactive substances consumed.
withdrawal) and develop during, or shortly after,
use of the substance.
INTOXICATION-Risk Factors
● Easy availability of the

● Limited early self-
substance in the individual’s
control.
environment.
● Behavioral disinhibition
● Childhood maltreatment or
trauma.
ENVIRONMENTAL TEMPERAMENT

OTHER (OR UNKNOWN) SUBSTANCE INTOXICATION-
PREVALENCE
Unknown(APA, 2022).

COMORBIDITY
Substance use disorder,conduct disorder, antisocial personality disorder with
suicidal ideation and attempts (APA,2022).
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
● Substance intoxication or other ● Boundary with Unknown or Unspecified

substance/medication induced Psychoactive Substance Dependence
disorders ● Boundary with Unknown or Unspecified
● Different types of other (unknown) Psychoactive Substance Withdrawal
substance related disorders ● Boundary with Unknown or Unspecified
● Other toxic, metabolic, traumatic, Psychoactive Substance-Induced Delirium
neoplastic,vascular or infectious ● Boundary with other Unknown or Unspecified
disorders Psychoactive Substance-Induced Mental
Disorders
OTHER (OR
UNKNOWN)
SUBSTANCE
WITHDRAWAL

WITHDRAWAL-PREVALENCE
Unknown(APA, 2022).
OTHER (OR UNKNOWN) SUBSTANCE WITHDRAWAL-

COMORBIDITY
Substance use disorder,conduct disorder, antisocial personality disorder and
co-oocur with other substance abuse withdrawal (APA,2022).
OTHER(OR UNKNOWN) SUBSTANCE WITHDRAWAL
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
● Substance withdrawal or other ● Boundary with Unknown or Unspecified

susbtance/medication-induced Psychoactive Substance Dependence
disorders ● Boundary with Unknown or Unspecified
● Different types of other (unknown) Psychoactive Substance Intoxication
substance related disorders ● Boundary with Unknown or Unspecified
● Other toxic, metabolic, traumatic, Psychoactive Substance-Induced Delirium
neoplastic,vascular or infectious ● Boundary with other Unknown or Unspecified
disorders Psychoactive Substance-Induced Mental
Disorders
OTHER (OR
UNKNOWN)
SUBSTANCE–
INDUCED
MENTAL
DISORDERS

UNSPECIFIED OTHER (OR
UNKNOWN) SUBSTANCE–
RELATED DISORDER This category applies to presentations in which
symptoms characteristic of an other (or
(F19.99) / DISORDER DUE unknown) substance–related disorder that cause
TO USE OF NON- clinically significant distress or impairment in
social, occupational, or other important areas of
PSYCHOACTIVE functioning predominate but do not meet the
SUBSTANCES, UNSPECIFIED full criteria for any specific other (or unknown)
substance–related disorder or any of the
(6C4H.Z ) disorders in the substance- related disorders
diagnostic class.

Stimulant-Related Disorders
Stimulant Use Disorder

Stimulant Intoxication
Stimulant Withdrawal
Stimulant-Induced Mental Disorders
Unspecified Stimulant-Related Disorder
Stimulant Use Disorder - Prevalence
Stimulant use disorder: amphetamine-type substances

● Amphetamine-type substance use disorder in the US is 0.4% among individuals 12 years and older (12 months)
● 0.1% among individuals ages 12–17 years, 0.5% among those ages 18–25, and 0.4% among those age 26 and older (12
months)
● 0.5% for men and 0.2% for women.
● Among U.S. adults, 6.6% (annual average) used prescription stimulants overall; 4.5% used without misuse, 1.9% misused
without use disorders, and 0.2% had use disorders
Stimulant use disorder: cocaine
● Estimated 12-month prevalence of cocaine use disorder in the US is 0.4% among individuals 12 years and older
● 0.1% among individuals ages 12–17 years, 0.7% among those ages 18–25 years, and 0.3% among those age 26 and older
● 0.5% for men and 0.2% for women

Stimulant Use Disorder - Development & Course
● In US, stimulant use disorder occurs throughout all levels of society and is more common among individuals ages
18–25 years compared with individuals ages 12–17 or 26 years and older
● First regular use among individuals in treatment occurs at approximately age 23 years.
● Methamphetamine treatment admissions, the average age is 34 years
● Primary cocaine treatment admissions, the average age is 44 years
● Stimulant smoking and intravenous use are associated with rapid progression to severe-level stimulant use disorder,
often occurring over weeks to months.
● Intranasal use of cocaine and oral use of amphetamine-type substances result in more gradual progression occurring
over months to years.

Stimulant Use Disorder - Risk & Prognostic Factors
1. Temperamental
○ Comorbid bipolar disorder, schizophrenia, antisocial personality disorder, and other substance use disorders
○ Conduct disorder in childhood and antisocial personality disorder are associated with the development of stimulant-
related disorders
2. Environmental
○ Predictors of cocaine use among a cohort of U.S. teenagers include prenatal cocaine exposure, postnatal cocaine use by
parents, and exposure to community violence during childhood
○ women followed up longitudinally, socioeconomic status, including food insecurity, had a dose-dependent effect on risk
of stimulant use
Culture-Related Diagnostic Issues

● Cocaine use in the US increased between 2001–2002 & 2012– 2013 among non-Latinx Whites, African Americans, and Latinx,
but the prevalence of cocaine use disorder increased only among Whites.
● cocaine and other stimulant use disorder diagnostic criteria perform equally across gender and ethnoracial groups.
Sex and Gender-Related Diagnosis Issues

● In the US, women with cocaine use disorder more frequently have comorbid psychiatric disorders, such as depression and
posttraumatic stress disorder (PTSD), compared with men
DSM-5 TR (APA,2022)
Stimulant Use Disorder - Differential Diagnosis
● Phencyclidine intoxication
○ Intoxication with phencyclidine (PCP or “angel dust”) or synthetic “designer drugs” such as mephedrone (known by
different names, including “bath salts”) may cause a similar clinical picture and can only be distinguished from stimulant
intoxication by the presence of cocaine or amphetamine-type substance metabolites in a urine or plasma sample.
● Stimulant intoxication, stimulant withdrawal, and stimulant-induced mental disorders.
○ Stimulant use disorder is differentiated from stimulant intoxication, stimulant withdrawal, and stimulant induced mental
disorders
● Independent mental disorder
○ Some of the effects of stimulant use may resemble symptoms of independent mental disorders
Stimulant Use Disorder - Comorbidity

● Stimulant-related disorders often co-occur with other substance use disorders, especially those involving substances with
sedative properties, which are often taken to reduce insomnia, nervousness, and other unpleasant side effects
● Stimulant use disorder may be associated with posttraumatic stress disorder, antisocial personality disorder, attention deficit/
hyperactivity disorder, and gambling disorder

Stimulant Intoxication
Stimulant Intoxication - Signs & Symptoms
DSM-5 TR (APA, 2022) ICD-11 (WHO,2019)
● B. Clinically significant problematic behavioral or psychological
changes (e.g.,euphoria or affective blunting; changes in ● Anxiety
sociability; hypervigilance; interpersonal sensitivity; anxiety, ● Anger
tension, or anger; stereotyped behaviors; impaired judgment) ● Impaired attention
that developed during, or shortly after, use of a stimulant. ● Hypervigilance
● C. Two (or more) of the following signs or symptoms, ● Psychomotor agitation
developing during, or shortly after, stimulant use: ● Paranoid ideation (possibly of delusional
1. Tachycardia or bradycardia. intensity)
2. Pupillary dilation. ● Transient auditory hallucinations
3. Elevated or lowered blood pressure. ● Transient confusion
4. Perspiration or chills. ● Changes in sociability
5. Nausea or vomiting. ● Physical signs include tachycardia, elevated
6. Evidence of weight loss. blood pressure, pupillary dilatation,
7. Psychomotor agitation or retardation. dyskinesia and dystonia, and skin sores.
8. Muscular weakness, respiratory depression, chest pain,
or cardiac arrhythmias.
9. Confusion, seizures, dyskinesias, dystonias, or coma.
Stimulant Intoxication-Prevalence
● Unknown
● Estimated 12-month prevalence of cocaine use in the United States is 2.2% for individuals age 12 and older
● 3% of men/boys and 1.4% of women/girls
Stimulant Intoxication-Differential Diagnosis

● Stimulant intoxication is distinguished from stimulant-induced mental disorders because the symptoms in the latter
disorders are in excess of those usually seen in stimulant intoxication, predominate in the clinical presentation, and
meet full criteria for the relevant disorder.
● Salient mental disturbances associated with stimulant intoxication should be distinguished from the symptoms of
schizophrenia, bipolar and depressive disorders, generalized anxiety disorder, and panic disorder.
Stimulant Intoxication-Comorbidity
● Overlap of stimulant intoxication with stimulant use disorder
“

Stimulant Withdrawal
(DSM-5 TR, 2022) ICD-11 (WHO,2019)
● Presenting features of Stimulant

B. Dysphoric mood and two (or more) of the following
Withdrawal may include:
physiological changes, developing within a few hours to
○ Depressed or dysphoric mood
several days after Criterion A:
○ Irritability, fatigue
1. Fatigue
○ Insomnia or (more commonly)
2. Vivid, unpleasant dreams
hypersomnia
3. Insomnia or hypersomnia
○ Vivid and unpleasant dreams
4. Increased appetite
5. Psychomotor retardation or agitation ○ Increased appetite
○ Psychomotor agitation or retardation,
○ Craving for amphetamine and related
stimulants
Stimulant Withdrawal-Differential Diagnosis
● Stimulant-induced mental disorders
○ Stimulant withdrawal is distinguished from stimulant-induced mental disorders
Stimulant Withdrawal-Comorbidity
● Overlap of stimulant withdrawal with stimulant use disorder

Stimulant - Induced Mental Disorder
● Stimulant-induced psychotic disorder (“Schizophrenia Spectrum and Other Psychotic Disorders”)
● Stimulant-induced bipolar and related disorder (“Bipolar and Related Disorders”)
● Stimulant-induced depressive disorder (“Depressive Disorders”)
● Stimulant-induced anxiety disorder (“Anxiety Disorders”)
● Stimulant induced obsessive-compulsive disorder (“Obsessive-Compulsive and Related Disorders”)
● Stimulant-induced sleep disorder (“Sleep-Wake Disorders”)
● Stimulant-induced sexual dysfunction (“Sexual Dysfunctions”)
● Stimulant-induced mild neurocognitive disorder (“Neurocognitive Disorders”)

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, occupational, 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
addictive disorders diagnostic class.

Assessments
● Cocaine Selective Severity Assessment (CSSA) (Kampman et al., 1998)
● Methamphetamine Selective Severity Assessment (MSSA) (Mancino et al., 2011)
Tobacco-use disorder
Tobacco- Tobacco Intoxication
Related Tobacco Withdrawal
Tobacco Induced
Disorder Mental Disorder
Diagnostic Features
● Tobacco use disorder can develop with use of all forms of tobacco (e.g., cigarettes,
chewing tobacco, snuff, pipes, cigars, electronic nicotine delivery devices such as
electronic cigarettes [ecigarettes]) and with prescription nicotine-containing
medications (nicotine gum and patch).
● Ability of these products to produce tobacco use disorder or to induce withdrawal is
associated with the rapidity of the route of administration
● The name of this substance category was changed from “nicotine” in prior
editions of DSM to “tobacco” in DSM-5 on the basis of harms from addiction
being associated mostly with tobacco and much less with nicotine

● The 12-month prevalence of DSM-5 tobacco use
Tobacco Use
disorder in the United States in 2012–2013 was 20%
among adults age 18 years and older
● The prevalence among current daily smokers is
Disorder - approximately 50%.
● Prevalence was higher among men; those who
Prevalence were young, unmarried, less educated, poor, or

residing in the southern United States; and those
with almost any psychiatric disorder
Tobacco Use ● Among adolescents who smoke cigarettes at
Disorder -
least monthly, most of these individuals will
become daily tobacco users in the future
Development
● Addiction process sometimes begins with
initial use; however, fulfilling DSM criteria
and Course
usually occurs over several years

Culture-Related Diagnostic Issues Sex- and Gender-Related
● Acceptance of tobacco use varies Diagnostic Issues
Tobacco Use across cultures
● Liver enzyme polymorphisms that
● Ratio of men to women among U.S.
smokers is approximately 1.4:1
Disorder - Risk vary across ethnoracial groups can
affect nicotine metabolism
● Negative reinforcement (i.e., that
smoking relieves negative affect) is a
and Prognostic ● Associated with exposure to racism,
ethnic discrimination & sexual
greater motivator in women than in
men
Factors orientation–related discrimination ● Pregnant females smoke at a lower

rate but relapse after delivery
Temperamental Genetic and physiological Environmental

● Externalizing personality traits ● Contribute to the onset, the
● Children with attention- continuation, and the development ● Low incomes
deficit/hyperactivity disorder or of tobacco use disorder ● Low educational levels
conduct disorder ● A degree of heritability equivalent
● Adults with depressive, bipolar, to that observed with other
anxiety, personality, psychotic, or substance use disorders (i.e., about
other substance use disorders 50%)

Tobacco Use Disorder -
Comorbidity
● Common medical conditions: cardiovascular illnesses, chronic obstructive
pulmonary disease, cancers, perinatal problems
● Prevalence of smoking is almost twice as high in individuals with major
depressive disorder
● The most common psychiatric comorbidities associated with smoking are
alcohol and other substance, depressive, bipolar, anxiety, personality, and
attention-deficit/hyperactivity disorders

Tobacco Use Disorder - Differential
Diagnosis
Boundary with Nicotine Boundary with Nicotine
Boundary with Harmful Use of
Intoxication Withdrawal
Nicotine
● Episodic or continuous ● Many individuals with Nicotine

● In the absence of the Essential
intoxication with nicotine is a Dependence develop
Features of Nicotine Dependence,
typical feature of Nicotine Nicotine Withdrawal upon
a diagnosis of Harmful Use of
Dependence, but is not an nicotine cessation or reduction
Nicotine can be given when there
Essential Feature ● Nicotine Withdrawal can be
has been demonstrable harm to
● If all diagnostic requirements of diagnosed in the absence of a
the individual’s physical or mental
both conditions are met for the diagnosis of Nicotine
health or that of others
same episode of care, Nicotine Dependence
● Harmful Pattern of Use of
Dependence should be Nicotine and Nicotine
assigned as the primary Dependence should not be
diagnosis, with an associated diagnosed together
diagnosis of Nicotine Intoxication
ICD-11 (WHO, 2019)

Tobacco Intoxication - Substance-
specific signs and symptoms
ICD-11 (WHO, 2019)
● Clinically significant disturbances in cognition,
● No tobacco intoxication is affect, behaviour, or coordination that develop during
provided or shortly after the consumption of nicotine
● Tobacco intoxication is very rare ● Restlessness, psychomotor agitation, anxiety, cold
sweats, headache, insomnia, palpitations,
paresthesias, nausea or vomiting, abdominal cramps,
confusion, bizarre dreams, burning sensations in the
mouth, and salivation
● Time-limited and abate as nicotine is cleared from
the body
● Symptoms not better accounted for by another
medical condition or another mental disorder
Tobacco No information is provided in both
Intoxication - DSM-5 and ICD-11
Prevalence
Tobacco (Nicotine) Intoxication –
Course & Onset
● The onset varies according to the route, absorption other pharmacokinetic factors
● Inhalation (smoking) and intravenous injecting routes lead to more rapid onset of intoxication
● Duration of intoxication depending on multiple factors including:
(1) the dose of the substance taken,
(2) the half-life and duration of action of the particular substance
(3) the formulation of the substance taken
● The intensity of intoxication lessens with time after reaching a peak of absorption
● The effects eventually disappear in the absence of further use of the substance
● Naïve users including adolescents can show features of intoxication at lower levels of use,
reflecting lower physical and learned tolerance
ICD-11 (WHO, 2019)

Tobacco Other medical conditions
(Nicotine) ● Evidence of nicotine use (e.g., positive

laboratory results) does not rule out the
Intoxication -
possibility of a comorbid medical condition
● If it is determined that Nicotine Intoxication is
Comorbidity
comorbid with a medical condition, both
diagnoses should be assigned
ICD-11 (WHO, 2019)

Boundary with Episode of Harmful Boundary with Nicotine Withdrawal
Use of Nicotine and Harmful Pattern
of Use of Nicotine ● Nicotine Withdrawal occurs upon
cessation or reduction of nicotine
● Consumption of nicotine results in or when nicotine has been taken for a
damage to the person’s physical prolonged period or in large
health or in behaviour leading to amounts.
● Onset of Nicotine Intoxication occurs
Tobacco harm to the health of others.
immediately or shortly after the
(Nicotine) consumption of nicotine
Intoxication –
Differential Boundary with Nicotine Dependence Boundary with other medical
conditions
Diagnosis ● Episodic or continuous intoxication
with nicotine is a typical feature of ● Symptoms of intoxication that persist
Nicotine Dependence. after they can no longer be
ICD-11 (WHO, 2019)
● If all diagnostic requirements of both reasonably attributed to the
conditions are met for the same episode pharmacological effects of nicotine may
of care, Nicotine Dependence should suggest the presence of another medical
be assigned as the primary condition
diagnosis, with an associated diagnosis
of Nicotine Intoxication
Tobacco Withdrawal - Substance-Specific
Signs and Symptoms
Diagnostic Criteria (APA, 2022) Diagnostic requirement (WHO, 2019)
Criterion B ● Depressed or dysphoric mood

● Insomnia
Abrupt cessation of tobacco use, or reduction ● Irritability
in the amount of tobacco used, followed within ● Anger
24 hours by four (or more) of the following ● Anxiety
signs or symptoms: ● Difficulty concentrating
● Irritability, frustration, or anger. ● Restlessness
● Anxiety ● Bradycardia
● Difficulty concentrating. ● Increased appetite
● Increased appetite. ● Craving for tobacco or other nicotine-containing
● Restlessness. products
● Depressed mood. ● Increased cough
● Insomnia ● Mouth ulceration
● Approximately 50% of daily smokers who quit for 2
Tobacco or more days will have four or more symptoms of
tobacco withdrawal.
Withdrawal - ● The most commonly endorsed signs and symptoms

are anxiety, irritability, and difficulty concentrating.
Prevalence
● The least commonly endorsed symptoms are
depression and insomnia.
DSM-5 TR (APA,2022)
● Tobacco withdrawal usually begins
within 24 hours of stopping or cutting
Tobacco down tobacco use
● Peaks at 2–3 days after abstinence
Withdrawal – ● Usually lasts 2–3 weeks.
● Tobacco withdrawal symptoms can occur
Course & Onset among adolescent tobacco users,
even prior to daily tobacco use.
● Prolonged symptoms beyond 1 month
can occur but are uncommon
Temperamental
● Smokers with depressive disorders,

bipolar disorders, anxiety disorders,
attention-deficit/hyperactivity
disorder, and other substance use
disorders have more severe withdrawal
Tobacco Withdrawal
– Risk and
Prognostic Factors Genetic and physiological

● Genotype can influence the
probability of withdrawal upon
abstinence
Typical overlap of tobacco
Tobacco Withdrawal withdrawal with tobacco use
– Comorbidity disorder

Boundary with Nicotine Boundary with other medical
Tobacco Intoxication conditions
Withdrawal – ● Onset of Nicotine Intoxication

occurs immediately or shortly
● Symptoms of Nicotine Withdrawal
occur in specific temporal
Differential after the consumption of nicotine

● Nicotine Withdrawal occurs upon
relationship to the cessation of
use of nicotine and diminish with
Diagnosis cessation or reduction in the

amount of nicotine
the passage of time
Boundary with Nicotine Boundary with other mental Boundary with Foetus or
Dependence disorders Newborn Affected by Maternal
Use of Tobacco, Alcohol, or
● Many individuals with Nicotine ● Evidence for mental disorder Other Drugs of Addiction
diagnosis would include the
Dependence develop Nicotine
symptoms preceding the onset
Withdrawal upon nicotine ● A neonate exhibiting signs of
of nicotine use, the symptoms
cessation or reduction persisting for a substantial
Nicotine Withdrawal may also be
● Nicotine Withdrawal can be period after cessation of nicotine Nicotine Withdrawal diagnosis
diagnosed in the absence of a or evidence of a pre-existing
diagnosis of Nicotine Dependence mental disorder
ICD-11 (WHO, 2019)
● Tobacco-induced sleep
Tobacco - disorder
Induced Mental
Disorders
Assessments
Fagerstrom Test For Nicotine Hooked on Nicotine Checklist Nicotine Dependence
Dependence (FTND) (HONC) (Wellman et al., Syndrome Scale (NDSS)
(Heatherton et al., 1991) 2005) (Shiffman et al., 2004)
● Instrument for assessing the ● A 10-item screening tool to ● A 19-item questionnaire

intensity of physical addiction determine the onset and ● Multi-dimensional measure of
to nicotine strength of tobacco nicotine dependence, yielding
● To provide an ordinal measure dependence five scores for different aspects
of nicotine dependence ● Identify the point at which an of dependence as well as a
● Contains six items that adolescent has lost full total score
evaluate the quantity of autonomy over their use of ● Five separate aspects of
cigarette consumption, the tobacco nicotine dependence: drive,
compulsion to use, and priority, tolerance, continuity,
dependence and stereotypy
● Behaviors that activate reward systems similar to those
activated by drugs and produce behavioral symptoms that
Non-Substance- appear comparable to those produced by the substance

use disorders
Related
● Gambling disorder is currently the only non- substance-
related disorder
● Internet gaming disorder is under “Conditions for Further
Disorders Study” due to issues like lack of a standard definition –
however, high prevalence rates, both in Asian countries and
DSM-5 TR (APA, 2022) in the West, justified inclusion of this disorder
F63- Gambling Disorder (APA,2015)
6C50 - Gambling disorder (WHO,2019)
Gambling disorder-Diagnostic Criteria
DSM-5 TR (APA,2022)
● Persistent and recurrent problematic gambling behavior ICD-11 (WHO,2019)
leading to clinically significant impairment or distress, as
indicated by the individual exhibiting four (or more) of ● A persistent pattern of gambling behaviour, which may
the following in a 12-month period be predominantly online (i.e., over the internet or similar
electronic networks) or offline, manifested by all of the
1. increasing amounts of money to achieve the desired following:
excitement. ○ Impaired control over gambling behaviour
2. restless or irritable when attempting to cut down or stop ○ Increasing priority given to gambling behaviour
gambling. to the extent that gambling takes precedence
3. Repeated unsuccessful efforts to control, cut back, or over other life interests and daily activities
stop gambling. ○ Continuation or escalation of gambling behaviour
4. Often preoccupied with gambling despite negative consequences
5. Often gambles when feeling distressed ● The pattern of gambling behaviour may be continuous or
6. After losing money gambling, often returns another day episodic and recurrent but is manifested over an
to get even extended period of time (e.g., 12 months).
7. Lies to conceal the extent of involvement with gambling.
8. Has jeopardized or lost a significant relationship, job, or
educational or career opportunity
9. Relies on others to provide money to relieve desperate
financial situations
Gambling disorder-Prevalence
● In past-year, about 0.2%–0.3% in the United States general population
● For women, it’s about 0.2%, and for men it is about 0.6%
Gambling disorder-Onset
● Occur during adolescence or young adulthood, but in other individuals it manifests during middle or
even older adulthood

Gambling disorder-Course
● The course of Gambling Disorder is variable with recovery a common outcome, even in the absence of
intervention, especially for adolescents and young adults. However, for many, Gambling Disorder
persists across the lifespan.
Gambling disorder-Development
● Early onset is associated with higher levels of impulsivity.
● Prevalence of Gambling Disorder among adolescents tends to be higher than in adults
ICD-11 (WHO,2019)
Gambling disorder- Risk & Prognostic factors
Temperamental
● Gambling disorder also appears to aggregate with antisocial personality disorder, depressive and bipolar disorders,
and other substance use disorders, particularly alcohol use disorder.
Course modifiers
● Attention deficit/hyperactivity and anxiety disorders, has been found to be associated with increased risk of onset of
gambling disorder among those who gamble and with persistence of gambling disorder symptoms over time.
Sex & gender Diagnostic issues
● Men develop gambling disorder at higher rates than women.

Gambling disorder- Differential Diagnostic
Nondisordered gambling
● Gambling disorder must be distinguished from professional and social gambling.
Manic Episode
● Loss of judgment and excessive gambling may occur during a manic episode.
● An additional diagnosis of gambling disorder should be given only if the gambling behavior is not better
explained by manic episodes (e.g., a history of maladaptive gambling behavior at times other than during a
manic episode)
Personality disorder
● Antisocial personality disorder and other personality disorders.
● If the criteria are met for both disorders, both can be diagnosed
Gambling symptoms due to dopaminergic medications
● Some individuals taking dopaminergic medications (e.g., for Parkinson‘s disease) may experience urges to
gamble that might be distressing or impairing enough to meet criteria for gambling disorder

Gambling disorder-Comorbidity
● Some specific medical conditions, such as tachycardia and angina, are more common among individuals
with gambling disorder
● individuals with gambling disorder have high rates of comorbidity with other mental disorders, such as
substance use disorders, depressive disorders, anxiety disorders, and personality disorders

Screening & Assessment
Screening
1. South Oaks Gambling Screen (SOGS)
Assessment
1. Gambling Treatment Outcome Monitoring System (GAMTOMS)
(Rash & Petry, 2014; Hodgins; Stea &

Grant, 2011)
Internet Gaming Disorder (APA, 2015)
6C51 Gaming disorder (WHO, 2019)
Diagnostic criteria
DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)
Proposed criteria
Persistent and recurrent use of the Internet to ● Persistent pattern of gaming which may be
engage in games leading to clinically significant online or offline
impairment or distress as indicated by five (or more) ● Significant distress or impairment in personal,
of the following in a 12-month period family, social, educational, occupational, or other
important areas of functioning
Preoccupation with Internet games. (The individual

thinks gaming activity or anticipates playing next game;
dominant activity in daily life.)
Withdrawal symptoms when Internet gaming is taken

away. (These symptoms are typically described as
irritability, anxiety, or sadness, but no physical signs
of pharmacological withdrawal.)
Tolerance—the need to spend increasing amounts of
time engaged in Internet games.
Unsuccessful attempts to control the participation in Impaired control over gaming

Internet games.
Loss of interests in previous hobbies and Increasing priority given to gaming to the extent that
entertainment with the exception of Internet games. gaming takes precedence over other life interests
and daily activities
Continued excessive use of Internet games despite Continuation or escalation of gaming despite negative
knowledge of psychosocial problems consequences (e.g., family, academic, health)
Has deceived family members, therapists, or others

regarding the amount of Internet gaming.
Use of Internet games to escape or relieve a negative
mood
Has jeopardized or lost a significant relationship, job,

or educational or career opportunity
The pattern of gaming behaviour may be continuous or

episodic and recurrent but is manifested over an
extended period of time (e.g., 12 months)
The gaming behaviour is not better accounted for by

another mental disorder (e.g., Manic Episode) and is
not due to the effects of a substance or medication
Internet Gaming Disorder - Prevalence
● Mean prevalence of 12-month Internet gaming disorder is estimated as 4.7% across
multiple countries
● Research using the DSM-5 proposed criteria suggests that prevalence is similar in
Asian and Western countries
● An international meta-analysis of 16 studies found a pooled prevalence of Internet
gaming disorder among adolescents of 4.6%
● Adolescent boys/men generally reporting a higher prevalence rate (6.8%) than
adolescent girls/women (1.3%)

Course
● Course is typically progressive, as the individual increasingly

prioritizes gaming at the expense of other activities
Gaming Disorder Developmental features
- Course & ● Most prevalent among adolescent and young adult males aged 12
to 20 years
Development ● Among adolescents, ithas been associated with elevated levels of
externalizing (e.g., antisocial behaviour, anger control) and
ICD-11 (WHO, 2019)
internalizing (e.g., emotional distress, lower self-esteem) problems
● Among adults, Gaming Disorder has been associated with greater
levels of depressive and anxiety symptoms
● Adolescents with may be at increased risk for academic
underachievement, school failure/drop-out, and psychosocial and
sleep problems
Environmental Genetic and physiological
● Computer availability ● Adolescent male seem to be at

● Internet connection greatest risk
Internet Gaming
Disorder - Risks Sex- and Gender-Related Diagnostic Issues
& Prognostic ● More common in adolescent and young adult
Factors men
● Adolescent boys ages 12–15 years also may be at
DSM-5 TR (2022) greater risk of adverse effects of disordered
gaming (e.g., lower school grades, loneliness
● Adolescent boys often choose action, fighting,
strategy, and role-playing games that may
have greater addictive potential
Internet ● Health may be neglected due to compulsive
gaming
Gaming
Disorder - ● Other diagnoses that may be associated
with Internet gaming disorder include
Comorbidity major depressive disorder, ADHD, and
obsessive-compulsive disorder
Boundary with Hazardous Gaming Boundary with Gambling Disorder
● Hazardous gaming refers to a pattern of ● If gaming behaviour is focused

gaming that appreciably increases the on wagers , Gambling Disorder may
risk of harmful physical or mental be a more appropriate diagnosis
health consequences to the
individual or to others around the
Gaming individual that may require some
intervention or monitoring but is not
Disorder - considered to constitute a disorder
Differential Boundary with Bipolar and Related Disorders

Boundary with Obsessive-Compulsive
Diagnosis ● Increased goal-directed activity including

Disorder
impaired ability to control gaming behaviour
can occur during Manic, Mixed, or Hypomanic ● Compulsions observed in Obsessive-
ICD-11 (WHO, 2019)
Episodes Compulsive Disorder are almost never
● A diagnosis of Gaming Disorder should only be experienced as inherently
assigned if there is evidence of a persistent pleasurable and typically occur in
pattern of gaming behaviour that meets all response to, unwanted obsessions,
diagnostic requirements for the disorder which is not the case with gaming
and occurs outside of Mood Episodes behaviour in Gaming Disorder
Assessments
Internet Gaming Disorder Game Addiction Inventory for Problematic Online Gaming
Scale–Short-Form (IGDS9-SF) Adults (GAIA) (Wong & Questionnaire (POGQ)
(Pontes & Griffiths, 2015) Hodgins, 2014) (Demetrovics et al., 2012)
● Psychometric tool based on the ● 31-item video game addiction ● 18-item questionnaire
nine core criteria defining IGD scale ● Assess the degree of
as suggested by the DSM-5. ● Consists of five addiction-related problematic online gaming
● Assesses symptoms and subscales: loss of control and ● Six dimension: preoccupation,
prevalence by examining both consequences, agitated overuse, immersion, social
online and/or offline gaming withdrawal, coping, mournful isolation, interpersonal conflicts,
activities occurring over a 12- withdrawal, and shame and withdrawal
month period
General
Assessments
Montreal Cognitive Assessment (MoCA, 1995)
Assess the changes in cognitive

function from alcohol detoxification
(Pelletier et al., 2016).
8 cognitive domains :
vis uos patial/executive ability, naming,
memory, attention, language,
abs traction, delayed recall and
orientation.
Cut-off s core is ≥26 (Gagnon et al.,
2013).
Sens itivity:80% and s pecificity: 75% ,
reliability alpha coefficient of : 0.88
Mini-Mental State
Examination
(1975)
Measures vis uos patial, language,

concentration, working memory, memory
recall and orientation (Ramirez et al., 2010).
Alcohol us ers : additional deficits in learning,
memory and ps ychomotor s peed. Heavy
cannabis us ers : s pecific deficits in
epis odic memory and attention (Kroon et
al.,2020).
Mini-Mental State
Examination
(1975)
Drug Abuse Screening Test(DAST-20,1982)
Internal consistency ranged from 0.74 to

0.95 (Shirinbayan et al., 2020).
Cronbach’s alpha of Mandarin vers ion, DAST-
20 : 0.88 (Liao,Chi & Guo, 2017).
Treatments
Pharmacotherapy
Treatments Psychotherapy
Functional Magnetic Resonance

Imaging (Suckling & Nestor,
2017).
Pharmacotherapy
Disulfiram (Alcohol use Naltrexone (Alcohol Flumazenil (Benzodiazepine Diazepam (Alcohol &
disorder) & opioid use intoxication ) hallucinogen
● Recommended average disorder) withdrawal)
Diazepam (Alcohol &
maintenance dose of 250 mg ● Side effects: mild ● Recommended dose: (2 hallucinogen withdrawal)
daily(Douaihy, Kelly & nausea, mg/24 )in a continuous
Sullivan (2013). headache,sleep manner for 96 hours (4
● Disulfiram administration only disturbance,diarrhea, days) with oxazepam • Mild withdrawal symptoms
after abstinence from alcohol abdominal cramps tapering (Hood et al., take benzodiazepines orally
for at least 12 hours. (Stokes while those with moderate or
(Toljan& Vrooman, 2009).
& Abdijadid, 2021). severe symptoms
2018). intravenously (Sachdeva et
● Side effects: nausea, vomiting,
headache, chest pain, al., 2015).
weakness, blurred vision
• Benzodiazepines usage should
not be longer than one month
(Colin, Emmanuel &
(Johnson & Streltzer, 2013).
Marilyn,2017).
\
Pharmacotherapy
Buprenorphine & Delta-9- Varenicline (Tobacco-
Methadone (Opioid- tetrahydrocannabinol related disorder) (Ebbert et
related disorder) (Coffa & (THC) (Cannabis- al., 2010)
Snyder, 2019) related disorder)
(Sherman &
McRae‐Clark, 2016) ● Effectively helps smokers
● Reduce cravings and quit by reducing
preventing intoxication if withdrawal symptoms and
the patient resumes ● Oral THC 10 mg blocking the reward
administered 5 times mechanism of smoking
opioid use.
daily decreased both
● Treat and prevent
withdrawal symptoms
withdrawal
and cannabis craving
Pharmacotherapy
Medications (Stimulant
Baclofen (Inhalant Related
Related Disorder) (Ronsley
Disorder) (Muralidharan et al.,
at al., 2020)
2008)
● Topiramate ● Treating craving and

● Modafinil withdrawal symptoms in
● Methylphenidate patients with inhalant
● N-acetylcysteine
dependence
Mindfulness-Based Multisystemic Therapy
Cognitive Therapy Problem-focused treatment
components tailored to the individual
Mindfulness reduces substance
child and family (Henggeler et al.
misuse and craving, improve 2009). Cognitive-behavioral
emotion dysregulation and strategies, parent management
mood state (Garland & training and systemic family therapy
Fredrickson, 2019). may be applied (Henggeler,1999).
3-5 months with 60 hours of direct
contact with each family (heather &
Psychotherapy
Rachel,2013)
Cognitive Dialectical
Behavioural therapy Behavioural
Motivational interviewing;
Therapy
CBT approach; targets the Weekly individual and group
ambivalence patients feel skills sessions, with phone
towards their behavioral coaching on substance
changes (Merlo et al., 2010) abuse-specific skills
(Stotts&Northup,2015).
Conclusion
Thank You!
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Substance-Related and Addictive Disorders (Presentation)

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PSY 70303

Encompass 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens;

A problematic pattern of substance use leading to clinically

Manifested by at least two of the following criteria

7. Important social, occupational, or recreational

10. Tolerance – defined either: ∙ Tolerance to the effects of cannabis

11. Withdrawal ∙ Withdrawal symptoms following cessation or reduction in

∙ In early remission: ∙ Substance dependence - early full remission

∙ In sustained remission: ∙ Substance dependence - sustained partial remission

∙ Substance dependence - sustained full remission

A. Recent ingestion of a substance ∙

C. Substance-specific signs and symptoms ∙ Substance-specific signs and symptoms

B. Substance-specific syndrome ∙ Substance-specific syndrome

C. Symptoms in Criterion B cause clinically significant

❖ No description/detail for unspecified substance-related

∙ Symptoms characteristic of a substance-related

∙ BUT do not meet the full criteria for any specific

Alcohol- Alcohol Intoxication

disorder of 20 units or higher useful in identifying individuals

Coded as : 6C40.2 (alcohol dependance) in ICD-11.

Disorder - Among adults, the 12-month

Peaks in the late teens or early to mid 20s but majority

DSM-5 TR (APA, 2022)

Environment Genetic and physiological

DSM-5 TR (APA, 2022)

Alcohol Use Panic disorder

Comorbidity Anxiety and depressive disorders (APA,

● Sedative, hypnotic or anxiolytic use ● Boundary with Alcohol Intoxication

(Yee et al., 2015)

Developed by Selzer in 1971.

Lack of a validity and

Criteria C: One (or more) of the following signs

*The risk of suicide attempt, with each drink

Prevalence Intoxication: 4 or more

An episode lasting over minutes to hours and typically

Heavy-drinking peers • Temperament (sensation-seeking

DSM-5 TR (APA, 2022)

DSM-5 TR (APA, 2022) ICD-11 (WHO, 2019)

● Other medical conditions ● Boundary with Alcohol Dependence

Quantity and frequency of alcohol Alcohol withdrawal delirium Prior

DSM-5 TR (APA, 2022)

● Other medical conditions ● Boundary with Alcohol Dependence

● National Institute for Health and Care Excellence (NICE)

● Items:nausea, vomiting, tremor, paroxysmal sweats,

● Scores of 0–8, 9–15 and 16 or more indicate mild,

● 6C40.5 Alcohol-induced delirium, 6C40.60 alcohol-induced psychotic disorder with

Coded as F10.99 (APA, ,2022).

This category applies to presentations in which symptoms characteristic of an

Caffeine-Induced Mental Disorders

Unspecified Caffeine-Related Disorder

DSM-5 TR (APA, 2022)

with functional impairment consistent with a diagnosis of caffeine intoxication

adolescents and young adults in high-income countries.

DSM-5 TR (APA, 2022)

DSM-5 TR (APA, 2022)

DSM-5 TR (APA, 2022)

Caffeine-induced mental disorders

DSM-5 TR (APA, 2022)

DSM-5 TR (APA, 2022)

DSM-5 TR (APA, 2022)

DSM-5 TR (APA, 2022)

Sex- and Gender-Related Diagnostic Issues

trimester and the nonpregnant state.