Substance-induced mental disorders included elsewhere in the manual
Substance-Induced Mental Disorders Included Elsewhere in the Manual
Substance-Induced Disorders cause a variety of symptoms that are characteristic of other mental disorders (see Table 1, p. 193). To facilitate differential diagnosis, the text and criteria for these other Substance-Induced Disorders are included in the sections of the manual with disorders with which they share phenomenology:
- Substance-Induced Delirium (see p. 143) is included in the "Delirium, Dementia, and Amnestic and Other Cognitive Disorders" section.
- Substance-Induced Persisting Dementia (see p. 168) is included in the "Delirium, Dementia, and Amnestic and Other Cognitive Disorders" section.
- Substance-Induced Persisting Amnestic Disorder (see p. 177) is included in the "Delirium, Dementia, and Amnestic and Other Cognitive Disorders" section.
- Substance-Induced Psychotic Disorder (see p. 338) is included in the "Schizophrenia and Other Psychotic Disorders" section. (In DSM-III-R these disorders were classified as "organic hallucinosis" and "organic delusional disorder.")
- Substance-Induced Mood Disorder (see p. 405) is included in the "Mood Disorders" section.
- Substance-Induced Anxiety Disorder (see p. 479) is included in the "Anxiety Disorders" section.
- Substance-Induced Sexual Dysfunction (see p. 562) is included in the "Sexual and Gender Identity Disorders" section.
- Substance-Induced Sleep Disorder (see p. 655) is included in the "Sleep Disorders" section.
In addition, Hallucinogen Persisting Perception Disorder (Flashbacks) (p. 253) is included under "Hallucinogen-Related Disorders" in this section.
In DSM-III-R, the Substance-Induced Disorders and the Mental Disorders Due to a General Medical Condition were called "organic" disorders and were listed together in a single section. This differentiation of "organic" mental disorders as a separate class implied that "nonorganic" or "functional" mental disorders were somehow unrelated to physical or biological factors or processes. DSM-IV eliminates the term organic and distinguishes those mental disorders that are substance induced from those that are due to a general medical condition and those that have no specified etiology. The term primary mental disorder is used as a shorthand to indicate those mental disorders that are not substance induced and that are not due to a general medical condition.
The context in which a Substance-Induced Disorder develops can have important management implications. Substance-Induced Disorders can develop in the context of Substance Intoxication or Substance Withdrawal, or they can persist long after the substance has been eliminated from the body (Substance-Induced Persisting Disorders). Substance-induced presentations that develop in the context of Substance Intoxication can be indicated by using the specifier With Onset During Intoxication. Substance-induced presentations that develop in the context of Substance Withdrawal can be indicated by the specifier With Onset During Withdrawal. It should be noted that a diagnosis of a Substance-Induced Disorder, With Onset During Intoxication or Withdrawal, should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome that is characteristic of the particular substance and when they are sufficiently severe to warrant independent clinical attention. For example, depression and fatigue that develop after stopping cocaine use following a prolonged period of daily intake are ordinarily diagnosed as Cocaine Withdrawal, since these symptoms are typical features of the withdrawal syndrome. Severe depression accompanied by a suicide attempt is usually diagnosed as Cocaine-Induced Mood Disorder, With Depressive Features, With Onset During Withdrawal, since a suicidal depression is in excess of what is usually seen in Cocaine Withdrawal and would warrant independent clinical attention.
Three Substance-Induced Persisting Disorders are included: Substance-Induced Persisting Dementia (see p. 168) and Substance-Induced Persisting Amnestic Disorder (see p. 177) in the "Delirium, Dementia, and Amnestic and Other Cognitive Disorders" section and Hallucinogen Persisting Perception Disorder under "Hallucinogen-Related Disorders" in this section (see p. 253). The essential feature of a Substance-Induced Persisting Disorder is prolonged or permanent persistence of substance-related symptoms that continue long after the usual course of Intoxication or Withdrawal has ended.
For drugs of abuse, a diagnosis of a Substance-Induced Mental Disorder requires that there be evidence from the history, physical examination, or laboratory findings of Substance Intoxication or Substance Withdrawal. In evaluating whether the symptoms of a mental disorder are the direct physiological effect of substance use, it is important to note the temporal relationship between the onset and offset of substance use and the onset and offset of the symptoms or the full syndrome. If the symptoms precede the onset of substance use or persist during extended periods of abstinence from the substance, it is likely that the symptoms are not substance induced. As a rule of thumb, symptoms that persist for more than 4 weeks after the cessation of acute Intoxication or Withdrawal should be considered to be manifestations of an independent non-substance-induced mental disorder or of a Substance-Induced Persisting Disorder. Clinical judgment is necessary in making this distinction, particularly because different substances have different characteristic durations of intoxication and withdrawal and varying relationships with symptoms of mental disorders. Because the withdrawal state for some substances can be relatively protracted, it is useful to carefully observe the course of symptoms for an extended period of time (e.g., 4 weeks or more) after the cessation of acute Intoxication or Withdrawal, making all possible efforts to maintain the individual's abstinence. This can be accomplished in various ways, including inpatient hospitalization or residential treatment, requiring frequent follow-up visits, recruiting friends and family members to help keep the person substance free, regularly evaluating urine or blood for the presence of substances, and, if alcohol is involved, routinely evaluating changes in state markers of heavy drinking such as gamma-glutamyltransferase (GGT).
Another consideration in differentiating a primary mental disorder from a Substance-Induced Disorder is the presence of features that are atypical of the primary disorder (e.g., atypical age at onset or course). For example, the onset of a Manic Episode after age 45 years may suggest a substance-induced etiology. In contrast, factors that suggest that the symptoms are better accounted for by a primary mental disorder include a history of prior episodes of the disturbance that were not substance induced. Finally, the presence or absence of the substance-specific physiological and behavioral features of Intoxication or Withdrawal should be considered. For example, the presence of paranoid delusions would not be surprising in the context of Amphetamine Intoxication, but would be unusual with Sedative Intoxication, increasing the likelihood that a primary Psychotic Disorder accounts for the symptoms. Furthermore, the dosage of the substance used should be taken into account. For example, the presence of paranoid delusions would be unusual after a single puff of marijuana, but might be compatible with high doses of hashish.
Substance-Induced Disorders can also occur as a side effect of a medication or from exposure to a toxin. Substance-Induced Disorders due to a prescribed treatment for a mental disorder or general medical condition must have their onset while the person is receiving the medication (or during withdrawal if the medication is associated with a withdrawal syndrome). Once the treatment is discontinued, the symptoms will usually remit within days but may persist for up to 4 weeks or so (depending on the half-life of the substance, the presence of a withdrawal syndrome, and individual variability). If symptoms persist, a primary mental disorder (not related to a medication) should be considered. Because individuals with general medical conditions often take medications for those conditions, the clinician must consider the possibility that the symptoms are caused by the physiological consequences of the general medical condition rather than the medication, in which case Mental Disorder Due to a General Medical Condition is diagnosed. The history may provide a basis for making this judgment, but a change in the treatment for the general medical condition (e.g., medication substitution or discontinuation) may be needed to determine empirically for that person whether or not the medication is the causative agent.
Recording Procedures for Substance-Induced Mental Disorders Included Elsewhere in the Manual
The name of the diagnosis begins with the specific substance (e.g., cocaine, diazepam, dexamethasone) that is presumed to be causing the symptoms. The diagnostic code is selected from the listing of classes of substances provided in the criteria sets for the particular Substance-Induced Disorder. For substances that do not fit into any of the classes (e.g., dexamethasone), the code for "Other Substance" should be used. In addition, for medications prescribed at therapeutic doses, the specific medication can be indicated by listing the appropriate E-code on Axis I (see Appendix G). The name of the disorder (e.g., Cocaine-Induced Psychotic Disorder; Diazepam-Induced Anxiety Disorder) is followed by the specification of the predominant symptom presentation and the context in which the symptoms developed (e.g., 292.11 Cocaine-Induced Psychotic Disorder, With Delusions, With Onset During Intoxication; 292.89 Diazepam-Induced Anxiety Disorder, With Onset During Withdrawal). When more than one substance is judged to play a significant role in the development of symptoms, each should be listed separately. If a substance is judged to be the etiological factor, but the specific substance or class of substances is unknown, the class "Unknown Substance" should be used.