1. Example of the Multi-Axial DSM-IV-TR Recording System
Diagnostic Impression Based on the DSM-IV-TR:
Axis I: , 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: , 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

2. 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.”

3. 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?“

4. Substance Use Disorders Substance Use Disorders
Removed
Polysubstance-Related Disorder
DSM-IV-TR pages
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

5. 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

6. 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

7. 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:
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.

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

9. 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

10. 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

11. 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:
Ref. Page 497

12. 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

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

14. 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

15. 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

16. 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