____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
• A great deal of time spent in activities necessary to obtain the substance, use the substance, or recover from its effects • Important social, occupational, or recreational activities given up or reduced • Continuation of substance use despite knowledge of having a persistent or recurrent physical or psychological problem caused or exacerbated by the substance • Craving or a strong desire or urge to use a specific substance (a new criterion for DSM-5 ) The DSM-IV criterion of recurrent substance-related legal problems, which was a part of the diagnosis of substance abuse, has been eliminated. What has been added is a severity specifier based on how many criteria on the foregoing list the individual meets: no disorder (0-1), mild disorder (2-3), moderate disorder (4-5), or severe disorder (6 criteria or more). The higher end of severity is equivalent to the DSM-IV substance dependence diagnosis (Straussner, 2013). However, it should be noted that an increasing number of symptoms does not necessarily cor- relate with decreased functionality. It is entirely conceivable that a person could meet four or five criteria (moderate) and be completely nonfunctional, while another person might meet six or more criteria (severe) and function fairly well. The DSM-5-TR diagnosis of SUD uses one of six “course speci- fiers” delineating the longer-term outcome of these disorders. These specifiers can be assigned only after the individual has completely stopped using a given substance for at least 3 months (a change from the DSM-IV requirement of 1 month of abstinence) and does not show any symptoms, with the exception of “craving.” The course specifiers include early full remission , defined as not meeting criteria for the disorder for more than 3 months but less than 12 months; early partial remis- sion , whereby the individual resumes some use of a substance (sometimes referred to as having a “slip”) and subsequently exhibits some problematic symptoms within the first year of recovery; sustained full remission , defined as not meeting criteria for the disorder for 12 months or more; and sustained partial remission , in which the individual resumes substance use after 12 months of not having any symptoms and then meets at least one criterion related to the SUD. The two final specifiers are on maintenance therapy , which refers to the use of agonist or antagonist medication to treat the substance of choice, such as using methadone as a replacement for opiates or using bupropion as a substitute for tobacco, and in a controlled envi- ronment , indicating that the individual is not using a substance because he or she is living in a substance-free environment, such as a therapeutic community or a prison. Each SUD is diagnosed separately and has its own category of “disorder not elsewhere classified” (for example, “opioid-induced disorder not elsewhere classified”). Since each substance has its own category, there is no diagnosis of “polysubstance” use disorder (Straussner, 2013).
In addition to SUDs, the manual includes nine substance- induced disorders (SIDs), which cover both physiological and psychiatric symptoms. As the term implies, SIDs include those disorders that are caused or induced by the use of a substance; these disorders range from substance intoxication or withdrawal symptoms to substance-induced mood, anxiety, psychotic, or sleeping disorders. A list of SIDs, excluding intoxication and withdrawal, is presented in Box 1.
Box 1. Substance-Induced Disorders • Substance-induced psychotic disorder • Substance-induced bipolar disorder • Substance-induced depressive disorder • Substance-induced anxiety disorder • Substance-induced obsessive-compulsive or related disorders • Substance-induced sleep-wake disorder • Substance-induced sexual dysfunction • Substance-induced delirium • Substance-induced neurocognitive disorder
It is assumed that once a person stops his or her abuse of or dependence on the substance, the SID will disappear within a relatively short time. Individuals whose psychiatric symptoms do not disappear over time are likely to receive additional diag- noses, variously referred to as coexisting , co-occurring , comorbid , or, to use an older term, MICA (an acronym for “mentally ill, chemically addicted”)—all of which refer to individuals who suffer from major mental illness, including personality disorders, along with a SUD. The differential effects of sub- stances on cognitions, mood, and behavior make it imperative to conduct thorough screening, assessment, and appropriate evidence-based treatment. Several of the side effects or with- drawal symptoms can be misconstrued as a mental health disorder if substance use is not considered in the assessment process. Therefore, prior to developing a treatment plan, it is essential to conduct a thorough assessment of substance use and withdrawal symptoms (Straussner, 2014). TREATMENT APPROACHES Although fewer than one fourth of those individuals who need help for their substance abuse or dependence ever get treatment, individuals who do obtain treatment do get better, with outcomes that are similar to those of other chronic health conditions (National Center on Addiction and Substance Abuse at Columbia University, 2012). It is important to note, however, that many people recover on their own, as a result of what is referred to as the maturation process or spontaneous recovery (Mignon, 2015).
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