A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
Tolerance, as defined by either of the following:
A need for markedly increased amounts of the substance to achieve intoxication or desired effect
Markedly diminished effect with continued use of the same amount of the substance
Withdrawal, as manifested by either of the following:
The characteristic withdrawal syndrome for the substance (refer to criteria A and B of the criteria sets for Withdrawal from the specific substances)
The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
The substance is often taken in larger amounts or over a longer period than was intended
There is a persistent desire or unsuccessful efforts to cut down or control substance use
A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain smoking), or recover from its effects
Important social, occupational, or recreational activities are given up or reduced because of substance use
The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
Specify if:
With Physiological Dependence: Evidence of tolerance or withdrawal (i.e., either item 1 or 2 is present)
Without Physiological Dependence: No evidence of tolerance or withdrawal (i.e., neither item 1 nor 2 is present)
Course specifiers (see text for definitions):
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment
*Used with permission from the American Psychiatric Association. Adapted from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washiongton, DC: American Psychiatric Association, 1994. Copyright 1994 by the American Psychiatric Association.
Six course specifiers are available for Substance Dependence.
The four Remission specifiers can be applied only after none of the criteria for Substance Dependence or Substance Abuse have been present for at least 1 month.
The definition of these four types of Remission is based on the interval of time that has elapsed since the cessation of Dependence (Early versus Sustained Remission) and whether there is continued presence of one or more of the items included in the criteria sets for Dependence or Abuse (Partial versus Full Remission).
A diagnosis of Substance Abuse is preempted by the diagnosis of Substance Dependence if the individual's pattern of substance use has ever met the criteria for Dependence for that class of substances.
Early Remission: Because the first 12 months following Dependence is a time of particularly high risk for relapse, this period is designated Early Remission.
There are two categories:
Early Full Remission: This specifier is used if, for at least 1 month, but for less than 12 months, no criteria for Dependence or Abuse have been met.
Early Partial Remission: This specifier is used if, for at least 1 month, but less than 12 months, one or more criteria for Dependence or Abuse have been met (but the full criteria for Dependence have not been met).
Sustained Remission: After 12 months of Early Remission have passed without relapse to Dependence, the person enters into Sustained Remission.
There are two categories:
Sustained Full Remission: This specifier is use, if none of the criteria for Dependence or Abuse have been met at any time during a period of 12 months or longer.
Sustained Partial Remission: This specifier is used if full criteria for Dependence have not been met for a period of 12 months or longer; however, one or more criteria for Dependence or Abuse have been met.
The following specifiers apply if the individual is on agonist therapy or in a controlled environment:
On Agonist Therapy: This specifier is used if the individual is on a prescribed agonist medication, and no criteria for Dependence or Abuse have been met for that class of medication for at least the past month (except tolerance to, or withdrawal from, the agonist).
This category also applies to those being treated for dependence using a partial agonist or an agonist/antagonist.
In a Controlled Environment: This specifier is used if the individual is in an environment where access to alcohol and controlled substances is restricted, and no criteria for Dependence or Abuse have been met for at least the past month.
Examples of these environments are closely supervised and substance-free jails, therapeutic communities, or locked hospital units.
Note: For an individual to qualify for Early Remission after cessation of agonist therapy or release from a controlled environment, there must be a 1-month period in which none of the criteria for Dependence or Abuse are met.
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
Recurrent substance use resulting in
a failure to fulfill major role obligations
at work, school, or home (e.g., repeated
absences or poor work performance
related to substance use; substance-
related absences, suspensions, or
expulsions from school; neglect of
children or household)
Recurrent substance use in situations
in which it is physically hazardous
(e.g., driving an automobile or operating
a machine when impaired by substance
use)
Recurrent substance-related legal
problems (e.g., arrests for substance-related disorderly conduct)
Continued substance use despite
having persistent or recurrent social or
interpersonal problems caused or
exacerbated by the effects of the
substance (e.g., arguments with spouse
about consequences of intoxication,
physical fights)
The symptoms have never met the criteria
for Substance Dependence for this class
of substance
The development of a reversible substance-specific
syndrome due to recent ingestion of, or exposure to, a substance. (Note: Different substances may produce similar or identical syndromes.)
Clinically significant maladaptive behavioral or psychological
changes that are due to the effect of the substance on the central nervous system (e.g., belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) and
develop during or shortly after use of the substance.
The symptoms are not due to a general medical condition
and are not better accounted for by another mental disorder.
Clinically significant maladaptive behavioral or psychological
changes (e.g., euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviors; impaired judgment; or impaired
social or occupational functioning) that developed during, or shortly after, use of cocaine.
Two (or more) of the following, developing during, or shortly after,
use:
Tachycardia or bradycardia
Pupillary dilation
Elevated or lowered blood pressure
Perspiration or chills
Nausea or vomiting
Evidence of weight loss
Psychomotor agitation or retardation,
Muscular weakness, respiratory depression, chest pain, or cardiac
arrhythmias
Confusion, seizures, dyskinesias, dystonias, or coma
The symptoms are not due to a general medical condition and are
not better accounted for by another mental disorder.
Specify if with perceptual disturbances: Hallucinations
with intact reality testing or auditory, visual, or tactile illusions
that occur in the absence of a delirium.
Clinically significant maladaptive behavioral or psychological
changes (e.g., initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment, or impaired social or occupational functioning) that developed during, or shortly after, opioid use.
Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one (or more) of the following signs, developing during, or shortly after, opioid use:
Drowsiness or coma
Slurred speech
Impairment in attention or memory
The symptoms are not due to a general medical condition
and are not better accounted for by another mental disorder
Specify ifwith perceptual disturbances: hallucinations
with intact reality testing or auditory, visual, or tactile illusions
that occur in the absence of a delirium.
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