Within the next year, most insurance providers will be expecting all claims to include the new DSM-5 nomenclature. It is imperative for all mental health professionals to be comfortable with the new diagnostic criteria and recording procedures. This presentation provides participants with a clear understanding of the revisions made in the category of Substance - Related and Addictive Disorders from the DSM-IV to the DSM-5. Topics presented by Nick Lessa, CEO of Inter-Care: an addiction treatment program in New York City. Includes: Changes in the diagnostic criteria from the DSM–IV to the DSM-5 The distinction between Substance Use Disorders and the Substance - Induced Disorders Recording procedures for Substance Related Disorders

1. DSM-5 Update:
Substance-Related and
Addictive Disorders
{
Presented by:
Nick Lessa, LCSW, MA, CASAC
Nlessa@inter-care.com

2. DSM- 5 Update
0 A guide in the diagnosis of mental disorders
0 Recently updated after 13 years since the DSM-IV-
TR was released in 2000.
0 22 separate classifications involving 13 work groups

3. Changes in Substance-Related
Disorders Section from DSM-IV
0 Removal of Substance Abuse and Substance
Dependence.
0 Severity of disorder (mild to severe) based on the
number of symptom criteria met:
0 Mild: 2-3 symptoms
0 Moderate: 4-5 symptoms
0 Severe: 6 or more symptoms

4. Changes in Substance-Related
Disorders Section from DSM-IV
0 The word “addiction” is omitted due to its “uncertain
definition and its potentially negative connotation.”
0 “Craving or strong desire” replaces “preoccupation”
0 Items deleted: “recurrent legal problems”,
polysubstance category, physiological subtype

5. Substance-Related and
Addictive Disorders
Encompasses 10 separate classes of drugs:
1. Alcohol
2. Caffeine
3. Cannabis
4. Hallucinogens
5. Inhalants
6. Opioids
7. Sedatives, hypnotics,& anxiolytics
8. Stimulants
9. Tobacco
10. Other (or unknown) substances

6. Addictive Disorders
0 Includes Gambling Disorder
0 Other potential behavioral addictions (internet
addiction, sex addiction, exercise addiction,
shopping addiction, etc.) not included due to
“insufficient peer-reviewed evidence to establish the
diagnostic criteria and course descriptions…”

7. Substance-Related Disorders
0 Divided into two groups
0 Substance-Induced Disorders: includes
conditions of intoxication or withdrawal and other
induced mental disorders
0 Substance-Use Disorders: relates to pathological
patterns of behaviors related to the use of a
particular substance

8. Substance-Induced Disorders
0 Essential Feature – “the development of a
reversible substance-specific syndrome due to the
recent ingestion of a substance.”
0 Includes intoxication, withdrawal, and other
substance/medication-induced mental disorders

9. Substance Intoxication
0 Substance intoxication can occur in individuals
without a Substance Use Disorder
0 Substance intoxication must include problematic
behavior
0 Substance intoxication does not apply to tobacco.
(may explain society’s liberal view of use –
nonproblematic)

10. Substance Withdrawal
0 Essential Feature – “the development of substance-
specific problematic behavioral change, with
physiological and cognitive concomitants, that is
due to the cessation of, or reduction in, heavy and
prolonged substance use.”

11. Substance/Medication-Induced
Mental Disorders
0 The substance/medication-induced mental
disorders are potentially severe, usually temporary,
but sometimes persisting CNS syndromes that
develop in the context of the effects of substances
of abuse, medications, or several toxins
0 Likely to improve in a matter of days to weeks of
abstinence

12. Substance/Medication-Induced
Mental Disorders
0 The disorder developed within 1 month of
substance intoxication or withdrawal or taking a
medication
0 The disorder did not proceed the onset of severe
intoxication, withdrawal or exposure to a medication
0 The disorder not likely to be better explained by an
independent mental condition
0 Likely to disappear within 1 month of cessation of
withdrawal, intoxication or use of meds

13. Substance/Medication-Induced
Mental Disorders
Exception to the 1 month rule includes:
0 Alcohol-induced, inhalant-induced, and
sedative/hypnotic/anxiolytic-induced neurocognitive
disorders
0 Hallucinogen Persisting Perception Disorder (e.g.,
“flashbacks”)

14. Substance Use Disorders
0 The Essential Feature – continued use despite
significant substance-related problems
0 Changes in brain circuits may persist, exhibited in
repeated relapses & intense drug cravings
0 Criteria include impaired control, social impairment,
risky use, and pharmacological symptoms
(withdrawal/tolerance)

15. Substance Use Disorders
0 11 diagnostic criteria (some classes of substances
have 10 criteria)
0 2 or more within a 12-month period
0 Must include a pattern of use leading to clinically
significant impairment or distress

16. Substance Use Disorders:
Diagnostic Criteria
1. Substance often taken in larger amounts or over a
longer period of time than intended (impaired
control)
2. A persistent desire or unsuccessful efforts to cut
down or control use (impaired control)
3. A great deal of time spent in activities necessary
to obtain the substance, use it, or recover from its
effects (impaired control)
4. Craving, or strong desire or urge to use (impaired
control) (New criteria)

17. Substance Use Disorders:
Diagnostic Criteria
5. Recurrent use resulting in failure to fulfill major role
obligations at work, school, or home (social
impairment)
6. Continued use despite having persistent or
recurrent social/interpersonal problems caused or
exacerbated by use (social impairment)
7. Important social, occupational, or recreational
activities given up or reduced because of use (social
impairment)

18. Substance Use Disorders:
Diagnostic Criteria
8. Recurrent use in situations which is physically
hazardous (risky use)
9. Use is continued despite knowledge of having a
persistent or recurrent physical/psychological problem
likely to have been caused or exacerbated by use
(risky use)

19. Substance Use Disorders:
Diagnostic Criteria
10. Tolerance: the need for markedly increased
amounts of substance to achieve intoxication or
desired effect, or a markedly diminished effect with
continued use of same amount (pharmacological)
11. Withdrawal: a characteristic syndrome, or use to
relieve or avoid withdrawal (pharmacological)

20. Recording Procedures for
Substance Related Disorders
0 New recording procedures to occur by 10/14
0 Use the code for the class of substances, but record
the specific substance
0 Severity determined by # of symptom criteria
0 Mild (2-3); Moderate (4-5); Severe (6 or more)
0 Severity can change over the course of time by
reductions or increases
0 Record for each individual substance disorder

21. Recording Procedures for
Substance Related Disorders
Course Specifiers
0 “in early remission” (3-11 months)
0 “in sustained remission” (12 mos. or longer)
0 None of the criteria met for that duration with
exception of craving
0 “on maintenance therapy” (for opioids, tobacco)
0 “in a controlled environment” (access to substance
is restricted)

22. Alcohol-Related Disorders
0 Prevalence – 12% of males and 4.6% of females 18
and older. Significantly drops after age 65.
0 Lifetime risk of major depressive disorders – 40%
0 Can lead to persisting neurocognitive disorders
0 Alcohol Intoxication includes 1 or more symptoms
of: slurred speech, incoordination, unsteady gait,
nystagmus (involuntary eye movement),
attention/memory impairment, stupor/coma

23. Alcohol Use Disorders
0 Alcohol Withdrawal includes 2 or more of following after
cessation of or reduction in alcohol use:
0 Autonomic hyperactivity (sweating or pulse > 100)
0 Increased hand tremor
0 Insomnia
0 Nausea or vomiting
0 Transient visual, tactile, auditory hallucinations
0 Psychomotor agitation
0 Anxiety
0 Seizures

24. Caffeine-Related Disorders
0 More than 85% of children and adults consume
caffeine regularly
0 Most widely used drug in the world
0 Symptoms include tolerance and withdrawal
0 No Caffeine Use Disorder (data unavailable yet);
only Caffeine Intoxication and Withdrawal
0 Significant growth in energy drinks with young
individuals
0 Taking oral contraceptives decreases elimination of
caffeine (Increased risk of intoxication)

25. Caffeine Intoxication
0 Intoxication must be in excess of 250 mg. & cause distress or impairment
0 5 or more of following:
0 Restlessness
0 Nervousness
0 Excitement
0 Insomnia
0 Flushed face
0 Diuresis
0 Gastrointestinal disturbance
0 Muscle twitching
0 Rambling flow of thought and speech
0 Tachycardia or cardiac arrhythmia
0 Periods of inexhaustibility
0 Psychomotor agitation

26. Caffeine Withdrawal
0 Following cessation of or reduction in use within 24
hours by 3 or more of following:
0 Headache (the hallmark feature)
0 Marked fatigue or drowsiness
0 Dysphoric mood, depressed mood, or irritability
0 Difficulty concentrating
0 Flu-like symptoms (nausea, vomiting, muscle pain)

27. Cannabis Related Disorders
0 Most widely used illicit substance in the U.S.
0 Prevalence of disorder - 3% of adolescents and 1.5% of
adults
0 Prevalence drops after age 65
0 More common for males than females
0 Cannabis use disorders have increased over past
decade
0 Difficult to distinguish between problem use and nonproblematic use
0 Few clear medical conditions associated with use
0 60% of adolescents also have Conduct D/O or AD/HD

28. Cannabis Use Disorder
0 At least 2 of the 11 symptom criteria
0 Includes tolerance and withdrawal

29. Cannabis Intoxication
0 Can lead to substance-induced psychotic or anxiety
D/O’s, sleep disorders, or delirium
0 Problematic behavioral or psychological changes (e.g.,
impaired judgment, motor coordination, social
withdrawal, euphoria, anxiety, sensation of slowed time)
and,
0 2 or more of the following:
0
0
0
0
Conjunctival injection (red eyes)
Increased appetite
Dry mouth
Tachycardia

30. Cannabis Withdrawal
0 After heavy or prolonged use
0 3 or more of the following developing within a week:
0 Irritability, anger, or aggression
0 Nervousness or anxiety
0 Sleep difficulty (insomnia or disturbing dreams)
0 Decreased appetite or weight loss
0 Restlessness
0 Depressed mood
0 Physical symptoms (sweating, fever, chills, headache,
shakiness/tremors, or stomach pain)

31. Hallucinogen-Related Disorders
0 Separate criteria for Phencyclidine Disorders (e.g.,
PCP, “angel dust”, ketamine, cyclohexamine,
dizocilpine) and,
0 Other Hallucinogen Disorders (e.g., LSD, MDMA,
DMT, psilocybin, mescaline, peyote, morning glory
seeds, jimsonweed)

32. Phencyclidine Use Disorder
0 10 symptom criteria (excludes withdrawal
symptoms)
0 Previously in the category of Dissociative
Anesthetics
0 Prevalence primarily in the African-American (49%)
and Hispanic (29%) cultures. Only .5% of young
Caucasians.

33. Other Hallucinogen Use
Disorder
0 10 symptom criteria (excludes withdrawal
symptoms)
0 Hallucinogen Use Disorder is one of the rarest. (.5%
among adolescents and .2% in adults)
0 Those who have this disorder have higher rates of
other SUD’s as well
0 Can lead to psychotic-induced, bipolar-induced,
depressive-induced, anxiety-induced disorders and
delirium

34. Phencyclidine Intoxication
0 Problematic behavior (e.g., belligerent, assaultive,
impulsive, unpredictable, agitated, impaired judgment)
and, 2 or more of the following:
1. Vertical or horizontal nystagmus (involuntary eye
movement)
2. Hypertension or tachycardia
3. Numbness or diminished response to pain
4. Ataxia (lack of muscle coordination)
5. Dysarthria (difficulty articulating)
6. Muscle rigidity
7. Seizures or coma
8. Hyperacusis (sensitivity to loud noises)

35. Other Hallucinogen Intoxication
0 Problem behavior or psychological changes (e.g.,
anxiety, depression, ideas of reference, “losing
one’s mind”, paranoia, impaired judgment)
0 Perceptual changes (e.g., intensified perceptions,
illusions, hallucinations, derealization) and, 2 or
more of the following:
0 Pupillary dilation, tachycardia, sweating,
palpitations, blurred vision, tremors, incoordination

36. Hallucinogen Persisting
Perception Disorder
0 Following cessation of hallucinogen use, the
reexperiencing of one or more of the perceptual
symptoms that were experienced when intoxicated
(e.g., trails, color flashes, geometric hallucinations,
false perceptions of movement, intensified colors)
0 Cause significant distress or impairment in
important areas of functioning

37. Inhalant Related Disorders
0 Involves any hydrocarbon-based substances (e.g., toxic
gases from glues, fuels, paints, and other volatile
substances)
0 No diagnosis of inhalant withdrawal
0 Standard drug screens do not detect inhalants.
Detection is costly
0 Prevalence is about 0.2%. Rare among females and a
preponderance of European American males
0 Prevalence declines after adolescence
0 Common with adolescent Conduct Disorder. Adult use
strongly associated with suicidality

38. Inhalant Use Disorder
0 10 of the 11 standard symptom criteria. No
withdrawal criteria.
0 When possible, name the particular substance
involved

39. Inhalant Intoxication
0 Problematic behavioral or psychological changes
(e.g., belligerence, assaultive, apathy, impaired
judgment)
0 2 or more of following: dizziness, nystagmus,
incoordination, slurred speech, unsteady gait,
lethargy, depressed reflexes, psychomotor
retardation, tremor, muscle weakness, blurred
vision, stupor/coma, and euphoria.

40. Opioid-Related Disorders
0 Prevalence is about 0.37% of adults
0 Lowest among African Americans, highest among
Native Americans
0 Hepatitis A, B, and C virus found in 80%-90% of
injection opioid users
0 HIV infection up to 60% of heroin users
0 A heightened risk for accidental and deliberate
overdoses

41. Opioid Use Disorder
0 Includes all 11 standard, symptom criteria
0 Include the specifier “On maintenance therapy”
when individual is taking a “prescribed” agonist
medication (e.g., methadone, buprenorphine) or
antagonist (e.g., naltrexone, Vivitrol)

42. Opioid Intoxication
0 Problem behavior or psychological changes (e.g.,
euphoria followed by apathy, dysphoria,
psychomotor agitation or retardation, impaired
judgment)
0 Pupillary constriction (or dilation due to severe
overdose) and,
0 One or more of the following: drowsiness/coma,
slurred speech, impairment in attention or memory

43. Opioid Withdrawal
0 3 or more of the following within minutes to several
days after cessation of use or administration of an
antagonist:
0 Dysphoric mood, nausea/vomiting, muscle aches,
lacrimation/rhinorrhea, pupillary dilation,
piloerection/sweating, diarrhea, yawning, fever, and
insomnia.

44. Opioid Withdrawal
0 Short-acting drugs (e.g., heroin) begin to have
withdrawal symptoms within 6-12 hours after last
dose
0 Longer-acting drugs (e.g., methadone,
buprenorphine) may take 2-4 days for symptoms to
emerge
0 Less acute withdrawal symptoms ( e.g., anxiety,
insomnia, dysphoria, anhedonia) can last for weeks
to months

45. Sedative-, Hypnotic-, or
Anxiolytic-Related Disorders
0 Includes benzodiazepines, benzodiazepine-like
drugs (e.g., ambien, sonata), carbamates,
barbiturates (e.g., secobarbital), and barbiturate-like
hypnotics (e.g., quaalude)
0 Also includes all prescription sleeping medications
and almost all prescription anti-anxiety medications

46. Sedative-, Hypnotic-, or
Anxiolytic-Related Disorders
0 0.3% prevalence rate among adolescents and 0.2%
among adults
0 Females appear to be at a higher risk for
prescription drug misuse of this class of substances
0 Can be detected in tox screens for up to a week
0 At high doses, can be lethal especially when mixed
with alcohol

47. Sedative, Hypnotic, or Anxiolytic
Intoxication
0 Problem behavior or psychological changes (e.g.,
inappropriate sexual or aggressive behavior, mood
lability, and impaired judgment) and,
0 One or more of the following: slurred speech,
incoordination, unsteady gait, nystagmus,
impairment in cognition (attention, memory),
stupor/coma

48. Sedative, Hypnotic, or Anxiolytic
Withdrawal
0 Two or more of the following developing within several
hours to a few days after cessation:
1.
2.
3.
4.
5.
6.
7.
8.
Autonomic hyperactivity (sweating, pulse rate > 100
bpm)
Hand tremor
Insomnia
Nausea or vomiting
Transient hallucinations or illusions
Psychomotor agitation
Anxiety
Grand mal seizures

49. Sedative, Hypnotic, or Anxiolytic
Withdrawal
0 Grand mal seizures may occur in as many as 20-
30% of cases undergoing untreated withdrawal
0 In severe withdrawal, visual, tactile, or auditory
hallucinations or illusions can occur
0 Withdrawal from shorter-acting substances can
begin within hours, longer-acting within 1-2 days

50. Stimulant Use Disorder
0 Prevalence rate for cocaine use disorder for adults
is 0.3%
0 Greatest for 18-29 year-olds (0.6%)
0 Cocaine use disorder is virtually absent among
Native Americans and Alaska natives
0 Childhood conduct disorder and adult ASPD are
associated with later development of stimulantrelated disorders

51. Stimulant Use Disorder
0 Stimulant-use disorder is associated with PTSD,
ASPD, ADHD, and gambling disorder
0 66% of those with methamphetamine use disorders
are non-Hispanic white, 21% Hispanic, 3% AfricanAmerican
0 Hair samples can detect the presence of stimulants
for up to 90 days

52. Stimulant Use Disorder
0 Use leading to significant impairment or distress
over a 12-month period
0 Two or more of the 11 symptom criteria

53. Stimulant Intoxication
0 Problem behavioral or psychological changes (e.g.,
euphoria or affective blunting; changes in sociability;
hypervigilance; interpersonal sensitivity; anxiety, tension,
or anger; stereotyped behaviors; impaired judgment) &
0 Two or more of the following: tachycardia/bradycardia,
pupillary dilation, elevated or lowered BP,
perspiration/chills, nausea/vomiting, weight loss,
psychomotor change, muscular weakness, respiratory
depression, chest pain, cardiac arrhythmias, confusion,
seizures, involuntary muscle movements, coma

54. Stimulant Withdrawal
0 Dysphoric mood and 2 or more of the following
developing within a few hours to several days after
cessation:
0 Fatigue
0 Vivid, unpleasant dreams
0 Insomnia or hypersomnia
0 Increased appetite
0 Psychomotor retardation or agitation

55. Tobacco-Related Disorders
0 Includes daily cigarette use or smokeless tobacco
0 Features often include smoking within 30 minutes of
waking, daily use, waking at night to smoke
0 Nicotine dependence in about 13% of U.S. adults
0 Nicotine dependence in about 50% of daily smokers

56. Tobacco-Related Disorders
0 Initiation of smoking after age 21 is rare
0 Those who quit usually do so after age 30
0 Non-daily smoking has become more prevalent in
the past decade especially among younger
individuals
0 More common among those with AD/HD, conduct
d/o, mood, anxiety, personality, psychotic or other
SUD’s

57. Tobacco-Related Disorders
0 Individuals with low incomes and low educational
levels are more likely to initiate tobacco use and
less likely to stop
0 50% of smokers who do not stop using tobacco will
die early from a tobacco-related illness
0 There is no Tobacco Intoxication Disorder

58. Tobacco Use Disorder
0 Problematic pattern of use leading to significant
impairment or distress as manifested by 2 or more
of the 11 symptom criteria
0 Includes the specifier “on maintenance therapy” for
those taking a nicotine replacement aid or a tobacco
cessation medication

59. Tobacco Withdrawal
0 Cessation or reduction followed within 24 hours by 4
or more of the following:
0 Irritability, frustration, or anger
0 Anxiety
0 Difficulty concentrating
0 Increased appetite
0 Restlessness
0 Depressed mood
0 Insomnia

60. Other (or Unknown) Substance
Use Disorder
0 Problematic use of an “intoxicating substance” not
able to be classified within the other categories
0 Meets at least two or more of the 11 symptom
criteria within a 12-month period

61. Other (or Unknown) Substance
Use Disorder
0 Other includes anabolic steroids; non-steroidal anti-
inflammatory drugs; cortisol; antiparkinsonian
medications; antihistamines; nitrous oxide; amyl-,
butyl-, or isobutyl-nitrates; betel nut; kava; and khat
0 Unknown – when a substance is unknown
0 Also, includes the categories Intoxication and
Withdrawal

62. Gambling Disorder
0 Previously known as “Pathological Gambling” and
was in category of Impulse Control Disorders
0 Problematic gambling leading to significant
impairment or distress
0 Leading to four or more of the following symptoms
over a 12-month period

63. Gambling Disorder Diagnostic
Criteria
1. Needs to gamble with increasing amounts of
2.
3.
4.
5.
money for desired excitement
Is restless or irritable when attempting to cut
down or stop gambling
Repeated unsuccessful efforts to control, cut
back, or stop gambling
Often preoccupied with gambling
Gambles when feeling distressed (helpless, guilty,
anxious, depressed)

64. Gambling Disorder Diagnostic
Criteria
6. After losing money gambling, often returns
another day to get even
7. Lies to conceal the extent of involvement with
gambling
8. Jeopardized or lost a significant relationship, job, or
career opportunity due to gambling
9. Relies on others to provide money to relieve
financial situations caused by gambling

65. Gambling Disorder Diagnostic
Criteria
0 Removal of the criteria “has committed acts of
forgery, fraud, theft, or embezzlement to finance
gambling”
0 Can be specified as either “Episodic” or “Persistent”
and “In early remission” or “In sustained remission”

66. Gambling Disorder Severity
Rating
0 Mild: 4-5 criteria
0 Moderate: 6-7 criteria
0 Severe: 8-9 criteria

67. Gambling Disorder
0 About 0.2%-0.3% of general population
0 3x more likely in males
0 Highest in African Americans (0.9%), whites (0.4%),
Hispanics (0.3%)
0 For females, the progression is more rapid
0 About 17% commit suicide
0 Often associated with SUDs and impulse –control
disorders (males) & mood/ anxiety D/O (females)