Chapter 9
Substance-Related and Addictive Disorders
After my husband died, I drank more and more to numb the pain. It started out with a few glasses of wine a day, which then turned into a few bottles. I would wake up in the middle of the night and have a glass of wine. I would drink before work and during lunch. That was before I stopped going to work altogether. My family and friends wanted me to get help, but I didn't care. The only thing that made me feel better was drinking. —Susan
Substance-related disorders include 10 classes of drugs (alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants; tobacco; and other/unknown substances) that activate the brain's reward system (APA, 2013a). Use of these substances often leads to impairments in multiple areas of functioning that occur at a clinical level and represent diagnosable disorders. There are three classifications: use, intoxication, and withdrawal (APA, 2013a). Prevalence rates of substance use are extremely high, with 22.6 million individuals in the United States reporting use of illegal substances within the past month; this represents 8.9% of the total population over 12 years of age (SAMHSA, 2011b). Additionally, according to SAMHSA (2011b), a staggering 131.3 million people (51.8%) ages 12 and older had used alcohol and 69.6 million (27.4%) had used tobacco in the past month. During the same year, 23.5 million people ages 12 or older needed treatment for an illicit drug or alcohol abuse problem; this represents 9.3% of the U.S. population age 12 or older (SAMHSA, 2011b).
According to the American Society of Addictive Medicine (ASAM, 2013),
Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. (para. 1)
Addiction is ongoing and often cyclical, with many negative effects on psychological and physiological wellness. Addiction is present and problematic within and across social, cultural, and economic groups (ASAM, 2013; SAMHSA, 2011b). The cost of addiction is enormous, with a price tag of $559 billion annually for illegal substances, alcohol, and tobacco (National Institute on Drug Abuse, 2011).
Because of the devastating impact and high prevalence rates of individuals with diagnosable substance-related and addictive disorders, virtually all counselors—regardless of their professional settings—will work directly with this population or provide services for the family members and loved ones of individuals with the disorders. Substance-related and addictive disorders appear throughout the life span in people of all socioeconomic status levels, educational attainment, gender, culture, ethnicity, and religion. It is critical that counselors possess a strong understanding of criteria for substance-related disorders. To help establish this framework, the following section provides an overview of the changes from the DSM-IV-TR to the DSM-5.
Major Changes From DSM-IV-TR to DSM-5
The DSM-5 includes significant restructuring to the categorization of substance-related disorders. One of the biggest changes in the DSM-5 is removal of the distinction between abuse and dependence. The prior classification of abuse and dependence was based on the notion that there is a biaxial difference between the two and that abuse was a less severe form of dependence. The bimodal theory did not hold true in research and practice, so the classification was revised to address substance use disorders as existing on a fluid, continuous spectrum (APA, 2013a; Dawson, Goldstein, & Grant, 2013; Keyes, Krueger, Grant, & Hasin, 2011). This resulted in the new substance use disorders section.
Once clinicians note the presence of a substance use disorder, they may specify severity of the addiction using ratings of mild, moderate, and severe. Research supports an increasing spectrum of severity across addictions and addictive behaviors that occurs as a continuous variable; this represents the predominant reason for the move from abuse versus dependence to severity ratings (APA, 2013a; Dawson et al., 2013; Keyes et al., 2011). In addition, the removal of the terms abuse and dependence supports the fluid and progressive nature of substance use disorders as conceptualized in the manual.
It is important to note that concerns related to specific substances in the Substance-Related and Addictive Disorders chapter of the DSM-5 (and enumerated in this chapter) are viewed as distinctive disorders. For example, caffeine-related disorders are separate from cannabis-related disorders. However, despite being distinctly separate diagnoses, all substance use disorders are based on the same criteria. Substance use criteria are also separate from substance-specific intoxication and withdrawal criteria. For example, there is alcohol use disorder, alcohol intoxication, and alcohol withdrawal, which are all coded separately. The only exception is hallucinogen-related and inhalant-related disorders, because symptoms of withdrawal have not been sufficiently documented for these substances so the withdrawal criterion has been eliminated. All other criteria for hallucinogen-related and inhalant-related disorders are the same. This modification in the diagnostic process for substance use disorders represents one of the most substantive changes to a diagnostic category in the DSM-5.
As discussed in Chapter 2, unlike the discrete categories in the DSM-IV-TR, many disorders within the DSM-5 were revised to represent a continuum. In the Substance-Related and Addictive Disorders chapter of the DSM-5, this continuum is represented by replacing distinct categories of substance abuse and dependence with 11 standard enumerated criteria for substance use disorders (APA, 2013a). Two to three criteria must be present for the severity indicator of mild, four to five for moderate, and six or more for severe. Additionally, craving has been included as a criterion, and legal difficulties has been excluded as a criterion.
The APA Substance-Related Disorders Work Group found research that collaborates the development of the substance use spectrum (APA, 2013a). According to Compton, Dawson, Goldstein, and Grant (2013), 80.5% of individuals who met the criteria for alcohol dependence in the DSM-IV-TR also met the criteria for alcohol use disorder (moderate to severe) in the DSM-5. Dawson et al. (2013) and Keyes et al. (2011) also found support for this new unimodal, fluid approach.
A second substantive change is that other addictive disorders have been included as part of this chapter, although at this time the DSM-5 only includes gambling disorder in this category. Pathological gambling was listed in the DSM-IV-TR in the Impulse-Control Disorders Not Elsewhere Classified section but has now been relabeled and classified with substance-related disorders. The addition of gambling disorder represents the first time a process-related addictive behavior has been included alongside use of substances. This is due to an abundance of research that shows that gambling activates the brain's reward system in ways that are consistent with substance use (APA, 2013a; Ko et al., 2013; Moran, 2013). The symptoms of gambling disorder also hold similarities to substance use disorders, and gambling disorder possesses similar etiology in terms of presentation, biological underpinnings, and treatment.
Internet gaming disorder, listed in Section III of the DSM-5 under the chapter Conditions for Further Study, may be added as an addictive disorder to subsequent iterations of the manual. Other types of “behavioral addictions” such as exercise, shopping, or sex addictions have not yet been shown to identify a diagnostic profile or similar developmental course. These may also be considered for inclusion in future editions of the manual (APA, 2013a; Ko et al., 2013; Moran, 2013).
Some scholars have taken umbrage with the wordsmithing of the chapter title, pointing out that Substance-Related and Addictive Disorders implies that being diagnosed with a substance use disorder means the client has an addiction (Kaminer & Winters, 2012). There has also been concern over the removal of the abuse category. Kaminer and Winters (2012) posited that the category of abuse is particularly applicable for adolescents; they discussed a body of knowledge coined the “biobehavioral developmental perspective” that asserts the course of the substance use is heterogeneously progressive and fits a categorical model of abuse versus dependence. The authors worried that removal of the abuse category in the DSM-5 will affect treatment services for this population. However, other scholars believed modifications will increase access to services (Dawson et al., 2013; Keyes et al., 2011; Mewton, Slade, McBride, Grove, & Teeson, 2011).
Several other changes are reflected in the Substance-Related and Addictive Disorders chapter. Specifically, early remission is now defined as at least 3 but not more than 12 months' absence of meeting diagnostic criteria for substance use disorders. Craving can still be present as a symptom, even with remission, because individuals continue to experience craving, or a strong desire, for the substance. The specifier with physiological dependence is not included in the DSM-5 nor is the diagnosis of polysubstance dependence. Newly included codable disorders are caffeine withdrawal and cannabis withdrawal (APA, 2013a).
Substance-Related Disorders
The DSM-5 includes specific criteria sets for each substance and applicable disorders related to that substance (e.g., use, intoxication, and withdrawal). All diagnostic labels include the name of the specific substance, such as cannabis use disorder, cannabis intoxication, and cannabis withdrawal. If an individual meets the criteria for multiple substance-related diagnoses, they are all listed. The manual is explicit in noting the likelihood of comorbidity of substance-related disorders (APA, 2013a; SAMHSA, 2011b).
Essential Features
According to APA (2013a), “a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems” (p. 483). In severe and long-term use, these changes may be observed through underlying changes in brain circuits (Agrawal et al., 2012). The first four criteria for substance use disorders encompass impaired control, social impairment, risky use, and pharmacological criteria. Criteria 5 to 7 cover social, occupational, and interpersonal problems. Criteria 8 and 9 focus on risk taking surrounding use of the substance, and Criteria 10 and 11 are tolerance and withdrawal, respectively. Assuming an individual meets the general requirement for “clinically significant impairment or distress” related to pattern of use, just two specific criteria must be met to justify assignment of a clinical diagnosis.
The predominant change to the overall diagnostic criteria for substance use disorder is the inclusion of craving and the exclusion of recurrent legal problems. Craving is included in ICD-10 criteria (WHO, 2007) and has been supported through epidemiological studies as a highly prominent and core feature of substance use disorders (Kavanaugh, 2013; Keyes et al., 2011; Ko et al., 2013; Mewton et al., 2011; Sinha, 2013). Functional magnetic resonance imaging (fMRI) has shown that there are certain brain regions directly related to craving (Ko et al., 2013). Presence of cues, negative moods, and stress reactions often lead to an increase in craving. Mindfulness training has been shown to reduce craving in that it can address awareness of the emotion and redirection of thoughts.
Diagnostic Criteria (Alcohol Use Disorder Example)
- A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period.
- Alcohol 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 alcohol use.
- A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
- Craving, or a strong desire to use alcohol.
- Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
- Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
- Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
- Recurrent alcohol use in situations in which it is physically hazardous.
- Alcohol 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 alcohol.
- Tolerance, as defined by either of the following:
- A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
- A markedly diminished effect with continued use of the same amount of alcohol.
- Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal, pp. 499–500).
- Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
From Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013, pp. 490–491. Copyright 2013 by the American Psychiatric Association. All rights reserved. Reprinted with permission.
Note
The diagnostic criteria for alcohol use disorder are used as an example because the criteria are identical for all of the disorders with the exception of Criterion 11, which does not apply to hallucinogen-related and inhalant-related use disorders.
Substance Intoxication and Withdrawal
Substance intoxication is a syndrome that develops temporarily after ingestion of a substance. The subsequent psychological changes result from the physiological effects of the substance. Intoxication often includes alterations in attention, thinking, judgment, perception, interpersonal behavior, psychomotor behavior, and wakefulness. The diagnosis of substance intoxication is separate from substance use disorder, and the specific substance of intoxication is listed in the disorder. The DSM-5 includes criteria sets specific to intoxication for each substance category. ICD-10-CM coding will change on the basis of the comorbidity of a substance use disorder. For example, there are different codes for alcohol intoxication with comorbid alcohol use disorder, mild (F10.129), than for alcohol intoxication with comorbid alcohol use disorder, moderate (F10.229), or alcohol intoxication without comorbid alcohol use disorder (F10.929).
Substance withdrawal includes physiological and psychological effects from stopping or reducing substance utilization after significant, prolonged use. Withdrawal can be distinctly unpleasant and trigger a cycle of renewed use to counterbalance the deleterious effects of the withdrawal. An individual can become intoxicated by, and have withdrawal from, more than one substance concomitantly. The DSM-5 includes criteria sets specific to withdrawal from each substance; generally, withdrawal criteria are opposite what one would expect with substance intoxication for the substance. As with substance intoxication, the diagnosis of substance withdrawal can occur with or without the comorbid diagnosis of a substance use disorder (APA, 2013a).
Coding, Recording, and Specifiers
There are separate diagnostic codes for all substance-related disorders (see list below). In making a diagnosis for a substance-related disorder, counselors must identify specifiers accurately. In addition to specification of substance use disorders as mild, moderate, or severe as discussed earlier, specifiers include in early remission, in sustained remission, on maintenance therapy, and in a controlled environment, with the last being an additional specifier for remission. Jails, locked hospital units, and therapeutic living settings are examples of controlled environments.
Counselors use the codes that apply to the specific substances with the name of the specific substance included, for example, alcohol use disorder, mild (ICD-9-CM, 305.00; ICD-10-CM, F10.10). Other substance use disorder should be used if a substance does not fit into one of the enumerated classes. It should be noted that there are separate codes for use and withdrawal for ICD-9-CM, whereas there is one unified code for ICD-10-CM.
Diagnostic Codes for Substance Use Disorders
Alcohol-Related Disorders
| 305.00 (F10.10) | Alcohol use disorder, mild |
| 303.90 (F10.20) | Alcohol use disorder, moderate |
| 303.90 (F10.20) | Alcohol use disorder, severe |
| 303.00 (F10.129) | Alcohol intoxication with use disorder, mild |
| 303.00 (F10.229) | Alcohol intoxication with use disorder, moderate or severe |
| 303.00 (F10.929) | Alcohol intoxication without use disorder |
| 291.81 (F10.239) | Alcohol withdrawal without perceptual disturbances |
| 291.81 (F10.232) | Alcohol withdrawal with perceptual disturbances |
| 291.9 (F10.99) | Unspecified alcohol-related disorders |
Caffeine-Related Disorders
| 305.90 (F15.92) | Caffeine intoxication |
| 292.0 (F15.33) | Caffeine withdrawal |
| 292.9 (F15.99) | Unspecified caffeine-related disorder |
Cannabis-Related Disorders
| 305.20 (F12.10) | Cannabis use disorder, mild |
| 303.90 (F12.20) | Cannabis use disorder, moderate |
| 303.90 (F12.20) | Cannabis use disorder, severe |
| 292.89 (F12.129) | Cannabis intoxication without perceptual disturbance with use disorder, mild |
| 292.89 (F10.229) | Cannabis intoxication without perceptual disturbance with use disorder, moderate or severe |
| 292.89 (F10.929) | Cannabis intoxication without perceptual disturbance without use disorder |
| 292.89 (F12.122) | Cannabis intoxication with perceptual disturbance with use disorder, mild |
| 292.89 (F12.222) | Cannabis intoxication with perceptual disturbance with use disorder, moderate or severe |
| 292.89 (F12.922) | Cannabis intoxication with perceptual disturbance without use disorder |
| 292.0 (F12.288) | Cannabis withdrawal |
| 292.9 (F12.99) | Unspecified cannabis-related disorders |
Hallucinogen-Related Disorders
| 305.90 (F16.10) | Phencyclidine use disorder, mild |
| 304.60 (F16.20) | Phencyclidine use disorder, moderate |
| 304.60 (F16.20) | Phencyclidine use disorder, severe |
| 305.30 (F16.10) | Other hallucinogen use disorder, mild |
| 304.50 (F16.20) | Other hallucinogen use disorder, moderate |
| 304.50 (F16.20) | Other hallucinogen use disorder, severe |
| 292.89 (F16.129) | Phencyclidine intoxication with use disorder, mild |
| 292.89 (F16.229) | Phencyclidine intoxication with use disorder, moderate or severe |
| 292.89 (F16.929) | Phencyclidine intoxication without use disorder |
| 292.89 (F16.129) | Other hallucinogen intoxication with use disorder, mild |
| 292.89 (F16.229) | Other hallucinogen intoxication with use disorder, moderate or severe |
| 292.89 (F16.929) | Other hallucinogen intoxication without use disorder |
| 292.89 (F16.983) | Hallucinogen persisting perception disorder |
| 292.9 (F16.99) | Unspecified phencyclidine-related disorder |
| 292.9 (F16.99) | Unspecified hallucinogen-related disorder |
Inhalant-Related Disorders
Specify the particular inhalant
| 305.90 (F18.10) | Inhalant use disorder, mild |
| 304.60 (F18.20) | Inhalant use disorder, moderate |
| 304.60 (F18.20) | Inhalant use disorder, severe |
| 292.89 (F18.129) | Inhalant intoxication with use disorder, mild |
| 292.89 (F18.229) | Inhalant intoxication with use disorder, moderate or severe |
| 292.89 (F18.929) | Inhalant intoxication without use disorder |
| 292.9 (F18.99) | Unspecified inhalant-related disorders |
Opioid-Related Disorders
Specify if on maintenance therapy or in a controlled environment
| 305.50 (F11.10) | Opioid use disorder, mild |
| 304.00 (F11.20) | Opioid use disorder, moderate |
| 304.00 (F11.20) | Opioid use disorder, severe |
| 292.89 (F11.129) | Opioid intoxication without perceptual disturbance with use disorder, mild |
| 292.89 (F11.229) | Opioid intoxication without perceptual disturbance with use disorder, moderate or severe |
| 292.89 (F11.929) | Opioid intoxication without perceptual disturbance without use disorder |
| 292.89 (F11.122) | Opioid intoxication with perceptual disturbance with use disorder, mild |
| 292.89 (F11.222) | Opioid intoxication with perceptual disturbance with use disorder, moderate or severe |
| 292.89 (F11.922) | Opioid intoxication with perceptual disturbance without use disorder |
| 292.0 (F11.23) | Opioid withdrawal |
| 292.9 (F11.99) | Unspecified opioid-related disorders |
Sedative-, Hypnotic-, or Anxiolytic-Related Disorders
| 305.40 (F13.10) | Sedative, hypnotic, or anxiolytic use disorder, mild |
| 304.10 (F13.20) | Sedative, hypnotic, or anxiolytic use disorder, moderate |
| 304.10 (F13.20) | Sedative, hypnotic, or anxiolytic use disorder, severe |
| 292.89 (F13.129) | Sedative, hypnotic, or anxiolytic intoxication with use disorder, mild |
| 292.89 (F13.229) | Sedative, hypnotic, or anxiolytic intoxication with use disorder, moderate or severe |
| 292.89 (F13.929) | Sedative, hypnotic, or anxiolytic intoxication without use disorder |
| 292.0 (F13.239) | Sedative, hypnotic, or anxiolytic withdrawal without perceptual disturbance |
| 292.0 (F13.232) | Sedative, hypnotic, or anxiolytic withdrawal with perceptual disturbance |
| 292.9 (F13.99) | Unspecified sedative-, hypnotic-, or anxiolytic- related disorder |
Stimulant-Related Disorders
| 305.70 (F15.10) | Amphetamine-type substance use disorder, mild |
| 304.40 (F15.20) | Amphetamine-type substance use disorder, moderate |
| 304.40 (F15.20) | Amphetamine-type substance use disorder, severe |
| 305.60 (F14.10) | Cocaine use disorder, mild |
| 304.20 (F14.20) | Cocaine use disorder, moderate |
| 304.20 (F14.20) | Cocaine use disorder, severe |
| 305.70 (F15.10) | Other or unspecified stimulant use disorder, mild |
| 304.40 (F15.20) | Other or unspecified stimulant use disorder, moderate |
| 304.40 (F15.20) | Other or unspecified stimulant use disorder, severe |
| 292.89 (F15.129) | Amphetamine or other stimulant intoxication without perceptual disturbance with use disorder, mild |
| 292.89 (F15.229) | Amphetamine or other stimulant intoxication without perceptual disturbance with use disorder, moderate or severe |
| 292.89 (F15.929) | Amphetamine or other stimulant intoxication without perceptual disturbance without use disorder |
| 292.89 (F14.129) | Cocaine intoxication without perceptual disturbance with use disorder, mild |
| 292.89 (F14.229) | Cocaine intoxication without perceptual disturbance with use disorder, moderate or severe |
| 292.89 (F14.929) | Cocaine intoxication without perceptual disturbance without use disorder |
| 292.89 (F15.122) | Amphetamine or other stimulant intoxication with perceptual disturbance with use disorder, mild |
| 292.89 (F15.222) | Amphetamine or other stimulant intoxication with perceptual disturbance with use disorder, moderate or severe |
| 292.89 (F15.922) | Amphetamine or other stimulant intoxication with perceptual disturbance without use disorder |
| 292.89 (F14.122) | Cocaine intoxication with perceptual disturbance with use disorder, mild |
| 292.89 (F14.222) | Cocaine intoxication with perceptual disturbance with use disorder, moderate or severe |
| 292.89 (F14.922) | Cocaine intoxication with perceptual disturbance without use disorder |
| 292.0 (F15.23) | Amphetamine or other stimulant withdrawal |
| 292.0 (F14.23) | Cocaine withdrawal |
| 292.9 (F15.99) | Unspecified amphetamine or other stimulant-related disorders |
| 292.9 (F14.99) | Unspecified cocaine-related disorders |
Tobacco-Related Disorders
Specify if on maintenance therapy or in a controlled environment
| 305.1 (Z72.0) | Tobacco use disorder, mild |
| 305.1 (F17.200) | Tobacco use disorder, moderate |
| 305.1 (F17.200) | Tobacco use disorder, severe |
| 292.0 (F17.203) | Tobacco withdrawal |
| 292.9 (F17.209) | Unspecified tobacco-related disorder |
Other (or Unknown) Substance-Related Disorders
| 305.90 (F19.10) | Other (or unknown) substance use disorder, mild |
| 304.90 (F19.20) | Other (or unknown) substance use disorder, moderate |
| 304.90 (F19.20) | Other (or unknown) substance use disorder, severe |
| 292.89 (F19.129) | Other (or unknown) substance intoxication with use disorder, mild |
| 292.89 (F19.229) | Other (or unknown) substance intoxication with use disorder, moderate or severe |
| 292.89 (F19.929) | Other (or unknown) substance intoxication without use disorder |
| 292.0 (F19.239) | Other (or unknown) substance withdrawal |
| 292.9 (F19.99) | Unspecified other (or unknown) substance-related disorder |
Implications for Counselors
The removal of the abuse and dependence categories allows counselors to assess severity on three levels, which lends to enhanced and tailored treatment options. The mild level of severity for substance use disorders (two to three criteria met) provides early intervention opportunities; individuals who present with moderate (four or five symptoms) or severe (six of more symptoms) substance use disorders may require more intensive treatments. In a study addressing the comparability of diagnoses between the DSM-IV-TR substance dependence and DSM-5 substance use disorders, Compton et al. (2013) found excellent correspondence with alcohol, cocaine, cannabis, and opioid use disorders.
Initial substance use typically takes place during the mid-teens for most individuals, and conduct disorder is often comorbid with substance use disorders in adolescents (Crowley, 2007; Vandrey, Budney, Kamon, & Stanger, 2005). Considering the negative psychological, physiological, and environmental effects of substance-related disorders, it is critical to assess thoroughly and engage in treatment modalities early in the course of the disorder.
An important area for counselors to address in treatment is the lingering symptom of substance craving that can present a challenge for client relapse prevention. The desire and yearning for a specific substance or substances is a common symptom that can exist well beyond cessation of use (Sinha, 2013). Instillation of adaptive coping mechanisms and substitution of positive behaviors can be important elements of treatment in working with clients' residual craving. Mindfulness training has also been shown to be beneficial in treatment for substance-related disorders (Brewer, Elwafi, & Davis, 2013).
Specific Substance-Related Disorders Overview
The following sections provide brief descriptions and key elements of substance-related disorders outlined in the DSM-5. The manual also contains a section for other (or unknown) substance-related disorders that encompasses substances that fall outside of the specific types enumerated below.
Alcohol-Related Disorders
There is a high prevalence of alcohol use disorder in the United States, with approximately 12.4% of adult men and 4.9% of adult women afflicted (APA, 2013a). The highest prevalence is among Native Americans and Alaska Natives (12.1%) and the lowest is among Asian Americans and Pacific Islanders (4.5%). Age of onset peaks in the late teens, and most individuals who will develop alcohol use disorder do so by their late 30s (APA, 2013a).
Alcohol use and criminal activity are linked, with up to 40% of state prisoners reporting that they were under the influence of alcohol during commission of the crime for which they were incarcerated. Agrawal et al. (2012) found that genetic factors can contribute to alcohol craving, which makes certain individuals particularly vulnerable to alcohol use disorder since craving often exists after cessation of alcohol use (even after it is in sustained remission).
From an environmental standpoint, individuals living in cultures where alcohol availability and use are widespread are more prone to the development of the disorder. This is especially true if there are genetic predispositions to alcohol use disorder as is the case in almost 50% of individuals who develop the disorder. From a physiological standpoint, individuals with bipolar disorder, schizophrenia, and general impulsivity concerns have a heightened risk for alcohol-related disorders (APA, 2013a; Keyes et al., 2011).
Caffeine-Related Disorders
The DSM-5 does not identify caffeine use disorder. Although evidence supports caffeine use as a condition, there is not yet sufficient information supporting impairment resulting from a problematic pattern of caffeine use. The United States has a high number of caffeine users—more than 85% of adults use caffeine regularly; among those, the average caffeine consumption is about 280 milligrams (two to three small cups of coffee) per day. Thus, caffeine use disorder is included in Section III of the manual as a condition for further study. The DSM-5 includes caffeine intoxication and withdrawal as diagnosable disorders (APA, 2013a).
Caffeine withdrawal is a newly diagnosable condition and requires stopping caffeine use after prolonged daily consumption, with physical symptoms of headache, fatigue, dysphoric mood, difficulty concentrating, and possible flu-like symptoms that cause clinically significant distress. This is similar to withdrawal criteria for substance-related disorders listed in this chapter. It is interesting to note that excessive caffeine use is often seen in individuals with mental health disorders (e.g., eating disorders and other substance-related disorders) and incarcerated individuals (APA, 2013a). The growing popularity of energy drinks with high caffeine content poses a concern, especially because young people are frequent consumers of those beverages.
Cannabis-Related Disorders
Cannabis, or marijuana, has been known to be a “gateway” drug. According to the United Nations Office on Drugs and Crime (Leggett, 2006), cannabis is used more than any other illegal drug, with a definitive link found between cannabis use and mood disorders (Lyns key, Glowinski, & Todorov, 2004). Cannabis use is widespread in the United States, and the number of users is projected to increase over the next decade (Alexander & Leung, 2011).
Cannabis withdrawal is new to the DSM-5 and includes physical symptoms arising after cessation of heavy use, which is defined as daily or almost daily use for a minimum of several months (APA, 2013a). Irritability, anger, aggression, nervousness, restlessness, and sleep disturbance are a few of the symptoms. The inclusion of cannabis withdrawal reflects the plethora of supportive empirical research (e.g., Budney, Hughes, Moore, & Vandrey, 2004; Budney, Moore, Vandrey, & Hughes, 2003; Crowley, 2007; Vandrey et al., 2005). Additionally, genetic factors can contribute to cannabis use and withdrawal, thus providing further rationale for their enumeration in the manual (Verweij et al., 2013).
Hallucinogen-Related Disorders
Hallucinogens are a heterogeneous grouping of substances that can have the same type of alterations of cognition and perception in users. These are most often taken orally, although some are smoked or injected. These types of drugs (e.g., ecstasy; lysergic acid diethylamide [LSD]; 3,4-methylenedioxy-methamphetamine [MDMA or ecstasy]; and psychedelic mushrooms) have a long half-life that can extend from hours to days. Hallucinogen use disorder has an annual prevalence rate of 0.1% in adults, with men more likely than women to engage in use (APA, 2013a). Hallucinogens can have long-term effects on brain functioning. In diagnosing hallucinogen use disorder, counselors should identify the specific substance (e.g., “ecstasy use disorder” rather than the more general “hallucinogen use disorder”). Because withdrawal from hallucinogens has not been clearly documented, the withdrawal criterion is not present for hallucinogen use disorder (APA, 2013a; Kerridge et al., 2011).
Hallucinogens are sometimes used in religious practices (i.e., peyote in the Native American Church). Controlled use during religious observances is not to be considered a diagnosable condition. As with the diagnosis of any mental health disorder, cultural factors must be taken into account during assessment (Pettet, Lu, & Narrow, 2011).
Inhalant-Related Disorders
Inhalants such as glues, paints, fuels, and other “volatile hydrocarbons” are all included in this diagnostic classification. A small percentage (0.4%) of adolescents between the ages of 12 and 17 meet the criteria for inhalant use disorder, although usage rates for young people may be as high as 10% (Dinwiddie, 1994). This disorder is typically not seen in older children or adults (APA, 2013a).
Kerridge et al. (2011) used data from the National Epidemiological Survey on Alcohol and Related Conditions to assess fit for the unidimensional model of substance use disorders for inhalants. Their study found support for the DSM-5 elimination of abuse and dependence for inhalants. Because of a dearth of documented physiological and psychological effects related to cessation of use, inhalant withdrawal is not included in the manual (APA, 2013a).
Inhalant use is quite dangerous and can be fatal. One author of this Learning Companion had a childhood friend who died of inhalant poisoning at 18 years of age. It is important for counselors to effectively identify inhalant-related disorders, especially counselors specializing in adolescent treatment. Counselors should be very concerned about reports of inhalant use. Even reports of “experimentation” can be fatal, as 22% of inhalant abusers who died of sudden sniffing death syndrome (i.e., cardiac arrest) were first-time users (J. F. Williams & Storck, 2007). This problem afflicts children from all socioeconomic backgrounds and from families with both high and low levels of parental education.
Opioid-Related Disorders
Opioid use has multiple deleterious physical effects. Because opioids are frequently injected, there are many risks for infection and disease. Common opioids include morphine, oxycodone, and heroin (APA, 2013a). Counselors must be aware of the risks of needle sharing, which puts opioid users at higher risk for HIV, hepatitis, and tuberculosis. There is a heightened suicide risk and high mortality rate for opioid users (up to 2% yearly). Jim Morrison, Janis Joplin, John Belushi, Chris Farley, River Phoenix, Heath Ledger, and, most recently, Corey Monteith were all young, famous people who died from opioid overdoses. Even prescribed opioid use can be a problem; from 1999 to 2007, the rate of fatal prescription opioid overdoses in the United States increased by 124% (Bohnert et al., 2011).
Opioid use disorder typically develops in early adulthood and spans many years. Rates of opioid use are higher in males than females (APA, 2013a). Problems first occur in adolescence and early adulthood. Opioid use disorder is seen across ethnicities; tolerance and withdrawal are commonly evident criteria. Babies born to mothers who have used opioids during their pregnancy can be born physiologically dependent (APA, 2013a). The severity of negative health effects underscores the need for early and effective interventions for opioid users.
Sedative, Hypnotic, or Anxiolytic-Related Disorders
This class of substances includes all prescription sleeping medications and almost all anxiety medications. One great danger is the swift build-up of tolerance and withdrawal for these substances, often resulting in craving. Individuals in adolescence and early adulthood are at the highest prevalence for the disorder and often engage in concomitant use of other substances (APA, 2013a).
If sedatives, hypnotics, or anxiolytics are prescribed for specific medical purposes and the medication is taken as prescribed, an individual would not meet diagnostic criteria for the use disorder. Sometimes, individuals who receive a prescription will build tolerance and seek out additional access through use of multiple physicians; thus, counselors should be careful to assess for patterns of use even for clients who report accessing substances through medical providers. Sedative, hypnotic, or anxiolytic-related disorders are often comorbid with alcohol and tobacco use disorders, personality disorders, depressive disorders, anxiety disorders, and bipolar disorders (APA, 2013a).
Stimulant-Related Disorders
Substances included in this section include, but are not limited to, amphetamine, dextroamphetamine, methamphetamine, and cocaine. Stimulants can be taken orally, injected, or smoked and typically result in drastic changes in behavior and a concomitant feeling of subjective well-being. Violent and aggressive behavior occurs with stimulant use and can lead to interpersonal and legal difficulties. Withdrawal can cause significant depressive symptoms as well as medical conditions. Examples include cardiac difficulties, seizures, neurocognitive impairment, and respiratory problems, just to name a few. Stimulant-related disorders are likely to co-occur with other substance-related disorders and gambling disorder. It is notable that amphetamines are sometimes medically prescribed to treat ADHD, obesity, and narcolepsy (APA, 2013a).
There has been research supporting a higher diagnostic inclusion of individuals with stimulant-related disorders based on the revised diagnostic spectrum. This can help accurately identify those individuals in need of treatment for stimulant use disorders. Specifically, Proctor, Kopak, and Hoffmann (2012) found that the new criteria assist with inclusivity in meeting the needs of those with cocaine-related disorders.
Tobacco-Related Disorders
Approximately one in five adolescents in the United States will use tobacco on a regular basis; most individuals will develop tobacco use disorder prior to the age of 21. Many tobacco users attempt to quit, with most making multiple attempts before successfully stopping usage (APA, 2013a). Tobacco is linked to a plethora of physical health problems and accounts for approximately one in every five deaths in the United States. Tobacco smokers have a life-span projection that is about 10 years shorter than nonsmokers (CDC, 2008).
Tobacco intoxication is not included in the DSM-5. Tobacco withdrawal is a new diagnosis in DSM-5 and involves symptoms of irritability, anxiety, difficulty concentrating, increased appetite, restlessness, depressed mood, and insomnia. There is a significant comorbidity (22% to 32%) of alcohol, anxiety, depressive, bipolar, and personality disorders (APA, 2013a).
Tobacco use has declined in the United States since the 1960s, in part from heightened awareness of the health risks and restrictions on smoking accessibility. However, the African American and Hispanic populations have seen less of a decline. Those from lower socioeconomic backgrounds are more likely to begin smoking tobacco and less likely to quit successfully (APA, 2013a; CDC, 2008).
Case Example
Maria is a 33-year old Latino American, heterosexual married mother of two young children. Previously employed as a bank manager, Maria has been working as a homemaker since the birth of her second child 2 years ago. Although a social drinker throughout her early adulthood, she began consuming alcohol on a daily basis about a year and a half ago. She started out drinking only wine but quickly progressed to vodka. For close to a year, Maria has been consuming in excess of seven drinks daily.
Maria hides her alcohol use from her family and friends. There have been times when she tried to quit drinking for several days, but those attempts were unsuccessful. Maria often thinks about drinking and admits to driving multiple times under the effects of alcohol, although she denies any impairment or risk. She often starts drinking first thing in the morning several days of the week to get rid of hangover symptoms.
Maria feels stressed by her responsibilities in parenting her two small children and maintaining the household. She also feels unfulfilled in her life and believes that she has wasted her career potential. As a devout Catholic, she also feels her drinking and lying are sinful. This makes her sad and leads to her drinking more to numb the pain.
Maria presents for counseling as a result of her husband confronting her about her drinking. She verbalizes that she loves her husband and family, which is why she sought help from counseling. She denies having a problem and states that she has “everything under control” and can “stop drinking anytime.”
Diagnostic Questions
- Do Maria's presenting symptoms meet the criteria for alcohol use disorder?
- Based on your answer to Question 1, what severity specifier would you assign to Maria's diagnosis?
- What would be the reason(s), if any, a counselor may not diagnose Maria with an alcohol use disorder?
- Would Maria be more accurately diagnosed with a mood or personality disorder? If so, why? If not, why not?
- What rule-outs would you consider for Maria's case?
- What other information may be needed to make an accurate clinical diagnosis?
312.31 Gambling Disorder (F63.0)
It was like my whole life revolved around being in the casino. I would spend all day there and then dream about it at night. It didn't matter how much money I lost because I just knew that the next time I pulled the slot, I would hit the jackpot. I quit caring about my relationships or the fact that I had been fired from another job. —Johi
Gambling disorder is the only non-substance-related disorder included in the Substance-Related and Addictive Disorders chapter of the DSM-5. It replaces pathological gambling from the DSM-IV-TR, which was listed in the Impulse-Control Disorders Not Elsewhere Classified section. With criteria almost identical to the previous manual, its movement to this section of the DSM-5 reflects the similarities in neurocircuitry related to brain reward systems and behavior patterns (APA, 2013a; King & Delfabbro, 2013).
The behavior of gambling activates the brain reward system. It has been posited that most addictions involve the development of a delivery mechanism of some kind; that is, gambling addiction can involve addiction to poker or roulette, which provides the conduit for receiving rewards (King & Delfabbro, 2013). As noted in the DSM-5, “gambling involves risking something of value in the hopes of obtaining something of greater value” (APA, 2013a, p. 586). The earlier gambling behaviors begin, the more likely an individual is to develop the disorder. Cultural, environmental, and genetic factors can lead an individual to be at higher risk for the development of gambling disorder. Animal and human research supports a strong neurological basis of addiction, including twin studies that have uncovered a higher prevalence in identical versus fraternal twins.
Cultural Considerations
Males are more likely to develop gambling disorder than females and tend to engage in different types of gambling (APA, 2013a). Playing cards and betting on sports and horse racing are more prevalent gambling activities in males, whereas playing bingo and using slot machines are more common gambling activities for females. Gambling patterns often increase during times of stress or personal difficulty (Moran, 2013).
There is a higher prevalence of gambling disorder among African Americans compared with European Americans and Hispanic Americans; Native Americans have the highest prevalence rates of the disorder (APA, 2013a). Gambling disorder can manifest throughout the life span with occurrences from adolescence through older adulthood (APA, 2013a).
Differential Diagnosis
Nondisordered gambling, manic episodes, personality disorders, and other medical conditions should all be considered as possible differential diagnoses. Examples of nondisordered gambling are professional and social gambling. Discipline and control with minimal and acceptable losses are key elements for professional and social gambling. Gambling issues can be seen in individuals with personality disorders (e.g., antisocial personality disorder, borderline personality disorder). If an individual with a diagnosable personality disorder meets the criteria for gambling disorder, both can be diagnosed (APA, 2013a; Potenza et al., 2013).
Certain medications can enhance urges to gamble (e.g., dopaminergic medications prescribed for Parkinson's disease). Additionally, it is important to rule out disordered gambling that occurs during the course of a manic episode. Manic episodes are often characterized by impaired impulse control, loss of judgment, and engagement in excessive pleasurable activity; for some, gambling may result (APA, 2013a).
Diagnostic Criteria for Gambling Disorder 312.31 (F63.0)
- Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual meeting four (or more) of the following in a 12-month period:
- Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
- Is restless or irritable when attempting to cut down or stop gambling.
- Has made repeated unsuccessful efforts to cut down, control, or stop gambling.
- Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).
- Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).
- After losing money gambling, often returns the next day to get even (“chasing” one's losses).
- Lies to conceal the extent of involvement with gambling.
- Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.
- Relies on others to provide money to relieve desperate financial situations caused by gambling.
- The gambling behavior is not better explained by a manic episode.
From Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013, p. 585. Copyright 2013 by the American Psychiatric Association. All rights reserved. Reprinted with permission.
Coding, Recording, and Specifiers
There is only one diagnostic code for gambling disorder: 312.31 (F63.0). Specifiers for gambling disorder are episodic, which mean symptoms meet diagnostic criteria with amelioration of symptoms for at least several months, and persistent, which means symptoms are continuous and ongoing over the course of several years or more. There are both early remission and sustained remission with duration of 3 months and 12 months, respectively. Levels of severity are mild (four to five criteria met), moderate (six to seven criteria met), and severe (eight to nine criteria met).
Implications for Counselors
The inclusion of gambling disorder as an addictive disorder in the DSM-5 brings with it a reconceptualization for counselors working with clients who struggle with problematic gambling. Because of its convergent etiology with substance-related disorders, it is important for counselors to be aware of the sequelae of the diagnosis and its psychosocial impact. Clients with gambling disorder frequently face impairment in multiple facets of their lives and often have specific financial hardship as a result of their behaviors (Moran, 2013).
Counselors across settings should be aware of treatment needs, comorbidity, and differential diagnoses for these clients. Lifestyle modifications will often need to be made to alleviate temptation and negative peer influences. If there is a comorbid disorder, the special clinical needs of those clients should be taken into account. Addressing the impact on family members is an important part of treatment because relationships are frequently frayed as a result of the destructive gambling behaviors (Brewer et al., 2013; Moran, 2013; Potenza et al., 2013)
The inclusion of gambling disorder as a nonsubstance addiction holds the potential to assist people with access to treatment. Several treatment modalities have proved efficacious with this population of clients. These include mindfulness training, CBT, behavior modification, contingency management, and motivational interviewing (Brewer et al., 2013; Potenza et al., 2013)
Although gambling disorder is the only non-substance-related disorder in the Substance-Related and Addictive Disorders chapter of the DSM-5, Section III of the manual includes Internet gaming disorder as a condition for further study. Internet gaming has been shown to activate the parahippocampus indicated by fMRI scans (Ko et al., 2013). Its inclusion in Section III of the manual reflects the growing body of research showing that excessive engagement with games on the Internet can lead to significant interpersonal challenges and cause impairment in various aspects of one's life. At this time, other potentially addictive behaviors, such as sex, shopping, and exercise addictions, are not included in the manual as codable disorders or conditions for further study (APA, 2013a).
It is important for counselors working across client populations and clinical settings to be aware of the diagnostic criteria, functional impairments, and effective treatment modalities for clients with gambling disorder and Internet gaming difficulties. Counselors who do not work directly with clients who have process addictions may still witness the pervasive and negative impact on family members and loved ones across clinical settings. As with substance-related disorders, gambling disorder (and potentially Internet gaming) has wide-reaching negative consequences.
Case Example
Akule is a single, Native American, 26-year-old male graduate student living in a metropolitan area. Akule has been a full-time student for all of his adult life and has had to support himself through employment and student financial aid because his family does not have the means to provide financial support. Akule considers himself close to his parents and siblings, although over the last year, he has been avoiding contact with them because he has been “too busy.”
Akule originally started gambling during a vacation with a group of friends. Excited by initial winnings and the accolades of his peers, Akule began gambling regularly upon his return home. At first, he was on a lucky streak and was able to pay some bills with his winnings. That soon changed, and he began losing. Over the course of the past year, Akule started gambling multiple days per week, often missing class because he stayed out late at the casino. He would grow irritable and anxious in the days following a string of losses; this began to affect his friendships and his relationship with his girlfriend. She tired of his being out late at night and his irritability. After catching him in a lie about how much money he lost gambling, she broke up with him.
After the break-up, at risk of being put on academic probation, and facing about $10,000 in debt, Akule seeks counseling services. Akule states that he is anxious and depressed but minimizes his gambling behavior, shrugging and saying that it is “not really a problem.”
Diagnostic Questions
- Do Akule's presenting symptoms meet the criteria for gambling disorder?
- Based on the disorder identified in Question 1, what severity specifier would you assign for Akule's diagnosis?
- What would be the reason(s) a counselor may not diagnose Akule with a personality disorder?
- Would Akule be more accurately diagnosed with bipolar disorder? If so, why? If not, why not?
- What rule-outs would you consider for Akule's case?
- What other information may be needed to make an accurate clinical diagnosis?