Example of the Multi-Axial DSM-IV-TR Recording System Diagnostic Impression Based on the DSM-IV-TR: Axis I: 296.52, Bipolar I Disorder, most recent episode depressed, moderate (even though never treated) 300.01, Panic Disorder, With and Without Agoraphobia 309.81, Post Traumatic Stress Disorder, Chronic 300.02, Generalized Anxiety Disorder 300.29, Specific Phobia 303.93D, Alcohol Dependence, in full remission 307.51, Bulimia Nervosa, in full remission Axis II: 301.83, Borderline Personality Disorder Axis III: Chronic migraine headaches, severe insomnia, asthma, obesity Axis IV: Stressors: Multiple Family Issues Axis V: Global Assessment of Functioning: GAF: 54  

Substance-Related and Addictive Disorders Charles O'Brien, M.D., Ph.D. Chair, Substance-Related Disorders Work Group 1. “diagnosed with a clinical interview” 2. “abuse not milder than dependence” 3. “dependence does not = addiction as long as follow doctor’s orders” Substance-Related and Addictive Disorders “Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system” And O’Brien said the term ‘abuse’ is clinically meaningless, noting that “abuse, dependence, and addiction are all one continuous variable.”

Substance Use Disorders Abuse and Dependence combined into Use Continued use despite significant substance-related problems “Pathological patterns, significant problems, repeated relapses, intense drug cravings” Criteria Removed: recurrent legal problems criterion Added: craving or a strong desire or urge to use a substance Craving involves classical conditioning and associated with activation of specific brain reward structures Relapse prediction and treatment outcome measure DSM-IV: “Although not specifically listed as a criterion item, ‘craving’ (a strong subjective drive to use the substance) is likely to be experienced by most (if not all) individuals with Substance Dependence.” (p. 192) "Have you ever wanted alcohol so badly you couldn't think of anything else?“ "Have you ever felt a strong desire or urge to drink?“

Substance Use Disorders Substance Use Disorders Removed Polysubstance-Related Disorder DSM-IV-TR pages 293-294 Specifier for a physiological subtype Cocaine and Amphetamine Added Stimulant Use Disorder Caffeine Withdrawal Cannabis Withdrawal Changed Nicotine to Tobacco On agonist therapy to on maintenance therapy Substance Use Disorders Miscellaneous classification Synthetic cannabinoid compounds Ecstasy and ketamine Other/Unknown Substance Use Disorder Bath salts (“synthetic chemical derivatives”) Anabolic steroids New, black market drugs Nitrous oxide

Substance-Related and Addictive Disorders Substance Use Disorders Threshold = 2 of 11 symptoms Impaired control criteria 1-4 Social impairment criteria 5-7 Risky use criteria 8-9 Pharmacological criteria 10-11 Tolerance and withdrawal: Symptoms vary between drug classes Appropriate medical treatment w/ prescribed medications Substance Use Disorders Severity ratings 2–3 criteria indicate = a mild disorder An important marker is continued use despite a clear risk of negative consequences to other valued activities or relationships 4–5 criteria = moderate disorder 6 or more = a severe disorder

Substance Use Disorders Remission specifiers Early at least 3 but less than 12 months w/o substance use disorder criteria (except craving) Sustained at least 12 months w/o criteria (except craving) Sample DSM-5 diagnosis Severe Opioid Use Disorder, On Maintenance Therapy, In Controlled Environment (principle diagnosis); Moderate Cannabis Use Disorder (synthetic cannabinoid); Mild Stimulant Use Disorder (cocaine type) Early Remission Substance-Induced Disorders Substance Intoxication and Withdrawal Intoxication does not apply to Tobacco Substance/Medication-Induced Mental Disorders Mood disturbances Anxiety syndromes Psychotic symptoms Suicide attempts Sexual dysfunctions Disturbed sleep

Results: Conclusions: Latest research Compton, W. M., Dawson, D. A., Goldstein, R. B., & Grant, B. F. (2013). Crosswalk between DSM-IV dependence and DSM-5 substance use disorders for opioids, cannabis, cocaine and alcohol. Drug and Alcohol Dependence, doi:http://dx.doi.org/10.1016/j.drugalcdep.2013.02.036 Results: For DSM-IV alcohol, cocaine and opioid dependence, optimal concordance occurred when 4+DSM-5 criteria were endorsed, corresponding to the threshold for moderate DSM-5. Maximal concordance of DSM-IV cannabis dependence and DSM-5 cannabis use disorder occurred when 6+ criteria were endorsed, corresponding to the threshold for severe DSM-5. Sensitivity and specificity, generally exceeded 85%(>75% for cannabis). Conclusions: Overall, excellent correspondence of DSM-IV dependence with DSM-5 substance use disorders.

DSM-5 Alcohol-Related Disorders Alcohol Use Disorder Alcohol Intoxication Alcohol Withdrawal Other Alcohol-Induced Disorders Unspecified Alcohol-Related Disorder Ref. Page 490

DSM-5 Alcohol Use Disorder1 Diagnostic Criteria: A problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least TWO of the following within a twelve(12) month period. Alcohol is often taken in larger amounts or over a longer period than was intended. Persistent desire or unsuccessful efforts to cut down or control alcohol use. Spending a great deal of time in activities necessary to obtain alcohol use or recover from its effects. Craving or a strong desire or urge to use alcohol. Recurrent alcohol use resulting in the failure to fulfill major role obligations. Continued alcohol use despite persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of alcohol. Important social, occupational or recreational activities are given up or reduced because of alcohol use. Recurrent use in situations in which it is physically hazardous. Alcohol use continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. Tolerance as defined by either of the following: Need for markedly increased amounts of alcohol to achieve intoxication or the desired effect. Markedly diminished effect with continued use of the same amount of alcohol. Withdrawal: Classic withdrawal syndrome, specifically described. Alcohol (or closely related substance) is taken to relive or avoid withdrawal symptoms. Ref. Page 490

DSM-5 Alcohol Use Disorder Specifiers2 Subtype: Specify whether: Mild = 2-3 symptoms of 11 symptoms Moderate = 4-5 symptoms Severe = 6 or more symptoms Specify if: In Early Remission = after full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met for at least 3 months but less than 12 months. In Sustained Remission = after full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met at anytime during a period of 12 months or longer (except for “craving”.) In a controlled environment Ref. Page 491

DSM-5 Alcohol Intoxication Criterion A: Recent Ingestion of alcohol Criterion B: Clinically significant problematic behavior or psychological changes that developed during, or shortly after, alcohol intoxication. Criterion C: ONE or more of the following during or shortly after alcohol use. Slurred speech Incoordination Unsteady Gait Nystagmus Impairment in attention or memory Stupor or coma Has a specific code: 303.00 Ref. Page 497

DSM-5 Alcohol Withdrawal Criterion A: Cessation of (or reduction in) alcohol use that has been heavy and prolonged. Criterion B: TWO (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A. Autonomic hyperactivity (sweating, pulse > 100 bpm) Increased hand tremor Insomnia Nausea or vomiting Transient visual, tactile or auditory hallucinations or illusions Psychomotor agitation Anxiety Generalized tonic- clonic seizures Criterion C: Clinically significant distress/impairment Criterion D: Not attributable to another. Specify if: with perceptual disturbances Ref. Page 499

DSM-5 Caffeine-Related Disorder No Caffeine Use Disorder Caffeine Intoxication Caffeine Withdrawal Other Caffeine-Inducted Disorders Unspecified Caffeine-Related Disorder Ref. Page 503

DSM-5 Caffeine Intoxication Criterion A: Recent consumption of caffeine (typically > 250mg.) Criterion B: FIVE (or more developing during, or shortly after, caffeine use): Restlessness Nervousness Excitement Insomnia Flushed Face Diuresis GI disturbance Muscle twitching Rambling flow of thought and speech Tachycardia or cardiac arrhythmia Psychomotor agitation Ref. Page 508

DSM-5 Caffeine Withdrawal Criterion A: Prolonged daily use of caffeine Criterion B: Abrupt cessation of, or reduction in caffeine use, followed within 24 hours by THREE (or more) of the following signs or symptoms: Headache Marked fatigue or drowsiness Dysphoric mood, depressed mood or irritability Difficulty concentrating Flu-like symptoms (nausea, vomiting, or muscle pain / stiffness) Ref. Page 506

DSM-5 Non-Substance-Related (Addictive) Disorder: Gambling Criterion A: Persistent and recurrent problematic gambling behavior leading to clinical significant impairment or distress as indicated by FOUR (or more) of the following during a 12-month period. Needs to gamble with increasing amounts of money to achieve the desired excitement. Is restless or irritable when attempting to cut down or stop gambling. Has made repeated unsuccessful efforts to control, cut back or stop gambling. Often preoccupied with gambling. Often gambles when feeling distressed. After losing money gambling, often returns another day to get even. Lies to conceal the extent of involvement with gambling. Has jeopardized or lost a significant relationship, job or education or career opportunity because of gambling Relies on others to provide money to relieve desperate financial situations caused by gambling. Criterion B: The gambling is not better explained by a manic episode. Specify whether (subtypes): Current Severity: Mild = 4 – 5 symptoms above Moderate = 6 – 7 symptoms above Severe = 8 – 9 symptoms above Specify if: Episodic = symptoms meeting criteria for at least 7 months. Persistent = continuous symptoms meeting criteria for multiple years. Early remission = after full criteria for gambling disorder were previously met, NONE of the criteria for gambling disorder have been met for at least three (3) months but for less than 12 months. Sustained remission = After full criteria for gambling disorder were previously met, NONE of the criteria for gambling disorder have been met during a period of twelve (12) months or longer. Ref. Page 585