Substance-related and addictive disorders

What are gender differences associated with alcohol intoxication?

Historically, in many Western societies, acceptance of drinking and drunkenness is more tolerated for males, but such gender differences may be much less prominent in recent years, especially during adolescence and young adulthood.

What is a common course modifier in gambling disorder?

Many individuals, including adolescents and young adults, are likely to resolve their problems with gambling disorder over time, although a strong predictor of future gambling problems is prior gambling problems.

How can alcohol withdrawal symptoms be relieved?

Symptoms can be relieved by administering alcohol or benzodiazepines (e.g., diazepam). The withdrawal symptoms typically begin when blood concentrations of alcohol decline sharply (i.e., within 4-12 hours) after alcohol use has been stopped or reduced. Reflecting the relatively fast metabolism of alcohol, symptoms of alcohol withdrawal usually peak in intensity during the second day of abstinence and are likely to improve markedly by the fourth or fifth day. Following acute withdrawal, however, symptoms of anxiety, insomnia, and autonomic dysfunction may persist for up to 3-6 months at lower levels of intensity.

When should the specifier of "In a controlled environment" be used?

"In a controlled environment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these environments are closely supervised and substance-free jails, therapeutic communities, and locked hospital units.

What does the specifier With perceptual disturbances refer to?

Hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium.

When is the specifier "in a controlled environment" applied?

"In a controlled environment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these environments are closely supervised and substance-free jails, therapeutic communities, and locked hospital units.

What are the temperamental risk factors for cannabis use?

A history of conduct disorder in childhood or adolescence and antisocial personality disorder are risk factors for the development of many substance-related disorders, including cannabis-related disorders. Other risk factors include externalizing or internalizing disorders during childhood or adolescence. Youths with high behavioral disinhibition scores show early-onset substance use disorders, including cannabis use dis order, multiple substance involvement, and early conduct problems.

What are some of the behaviour patterns in gambling disorder?

A pattern of "chasing one's losses" may develop, with an urgent need to keep gambling (often with the placing of larger bets or the taking of greater risks) to undo a loss or series of losses. The individual may abandon his or her gambling strategy and try to win back losses all at once. Although many gamblers may "chase" for short periods of time, it is the frequent, and often long-term, "chase" that is characteristic of gambling disorder (Criterion A6). Individuals may lie to family members, therapists, or others to conceal the extent of involvement with gambling; these instances of deceit may also include, but are not limited to, covering up illegal behaviors such as forgery, fraud, theft, or embezzlement to obtain money with which to gamble (Criterion A7). Individuals may also engage in "bailout" behavior, turning to family or others for help with a desperate financial situation that w,as caused by gambling (Criterion A9).

What are the diagnostic criteria of Alcohol Use Disorder

A. 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: 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. 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. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of alcohol. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for alcohol b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

What are the criteria for Cannabis Use Disorder?

A. A problematic pattern of cannabis use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Cannabis is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control cannabis use. 3. A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects. 4. Craving, or a strong desire or urge to use cannabis. 5. Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cannabis. 7. Important social, occupational, or recreational activities are given up or reduced because of cannabis use. 8. Recurrent cannabis use in situations in which it is physically hazardous. 9. Cannabis 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 cannabis. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of cannabis to achieve intoxication or desired effect. b. Markedly diminished effect with continued use of the same amount of cannabis. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for cannabis b. Cannabis (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

What are the diagnostic criteria for Alcohol Withdrawal?

A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A: 1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm). 2. Increased hand tremor. 3. Insomnia. 4. Nausea or vomiting. 5. Transient visual, tactile, or auditory hallucinations or illusions. 6. Psychomotor agitation. 7. Anxiety. 8. Generalized tonic-clonic seizures. C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

What are the symptoms of Cannabis Withdrawal?

A. Cessation of cannabis use tliat lias been heavy and prolonged (i.e., usually daily or almost daily use over a period of at least a few months). B. Three (or more) of the following signs and symptoms develop within approximately 1 week after Criterion A: 1. Irritability, anger, or aggression. 2. Nervousness or anxiety. 3. Sleep difficulty (e.g., insomnia, disturbing dreams). 4. Decreased appetite or weight loss. 5. Restlessness. 6. Depressed mood. 7. At least one of the following physical symptoms causing significant discomfort: ab dominal pain, shakiness/tremors, sweating, fever, chills, or headache. C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

What are the symptoms of Gambling Disorder?

A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the fol lowing in a 12-month period: 1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement. 2. Is restless or irritable when attempting to cut down or stop gambling. 3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling. 4. 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). 5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed). 6. After losing money gambling, often returns another day to get even ("chasing"one's losses). 7. Lies to conceal the extent of involvement with gambling. 8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling. 9. Relies on others to provide money to relieve desperate financial situations caused by gambling. B. The gambling behavior is not better explained by a manic episode

What are the symptoms of opioid Withdrawal

A. Presence of either of the following; 1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e., several weeks or longer). 2. Administration of an opioid antagonist after a period of opioid use. B. Three (or more) of the following developing within minutes to several days after CriterionA: 1. Dysphoric mood. 2. Nausea or vomiting. 3. Muscle aches. 4. Lacrimation or rhinorrhea. 5. Pupillary dilation, piloerection, or sweating. 6. Diarrhea. 7. Yawning. 8. Fever. 9. Insomnia.

What are the criteria for alcohol intoxication?

A. Recent ingestion of alcohol. B. Clinically significant problematic behavioral or psychological changes (e.g.,inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, alcohol ingestion. C. One (or more) of the following signs or symptoms developing during, or shortly after, alcohol use: 1. Slurred speech. 2. Incoordination. 3. Unsteady gait. 4. Nystagmus. 5. Impairment in attention or memory. 6. Stupor or coma. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.

What are the criteria for Cannabis Intoxication?

A. Recent use of cannabis. B. Clinically significant problematic behavioral or psychological changes (e.g., impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that developed during, or shortly after, cannabis use. C. Two (or more) of the following signs or symptoms developing within 2 hours of cannabis use: 1. Conjunctival injection. 2. Increased appetite. 3. Dry mouth. 4. Tachycardia. D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.

What are the criteria for Substance/Medication-Induced Mental Disorders?

A. The disorder represents a clinically significant symptomatic presentation of a relevant mental disorder. B. There is evidence from the history, physical examination, or laboratory findings of both of the following: 1. The disorder developed during or within 1 month of a substance intoxication or withdrawal or taking a medication; and 2. The involved substance/medication is capable of producing the mental disorder. C. The disorder is not better explained by an independent mental disorder (i.e., one that is not substance- or medication-induced). Such evidence of an independent mental dis order could include the following: 1. The disorder preceded the onset of severe intoxication or withdrawal or exposure to the medication; or 2. The full mental disorder persisted for a substantial period of time (e.g., at least 1 month) after the cessation of acute withdrawal or severe intoxication or taking the medication. This criterion does not apply to substance-induced neurocognitive disorders or hallucinogen persisting perception disorder, which persist beyond the cessation of acute intoxication or withdrawal. D. The disorder does not occur exclusively during the course of a delirium.

How common is alcohol withdrawal in people under 30?

Acute alcohol withdrawal occurs as an episode usually lasting 4-5 days and only after extended periods of heavy drinking. Withdrawal is relatively rare in individuals younger than 30 years, and the risk and severity increase with increasing age.

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Additional diagnostic markers relate to signs and symptoms that reflect the consequences often associated with persistent heavy drinking. For example, dyspepsia, nausea, and bloating can accompany gastritis, and hepatomegaly, esophageal varices, and hemorrhoids may reflect alcohol-induced changes in the liver. Other physical signs of heavy drinking include tremor, unsteady gait, insomnia, and erectile dysfunction. Males with chronic alcohol use dis order may exhibit decreased testicular size and feminizing effects associated with reduced testosterone levels. Repeated heavy drinking in females is associated with menstrual irregu larities and, during pregnancy, spontaneous abortion and fetal alcohol syndrome. Individu als with preexisting histories of epilepsy or severe head trauma are more likely to develop alcohol-related seizures. Alcohol withdrawal may be associated with nausea, vomiting, gas tritis, hematemesis, dry mouth, puffy blotchy complexion, and mild peripheral edema.

What is the social impact of alcohol intoxication?

Alcohol intoxication contributes to the more than 30,000 alcohol-related drinking deaths in the United States each year. In addition, intoxication with this drug contributes to huge costs associated with drunk driving, lost time from school or work, as well as interpersonal arguments and physical fights.

What is the effect of alcohol intoxication on suicide?

Alcohol intoxication is an important contributor to suicidal behavior. There appears to be an increased rate of suicidal behavior, as well as of completed suicide, among persons intoxicated by alcohol.

What is alcohol intoxication sometimes associated with?

Alcohol intoxication is sometimes associated with amnesia for the events that occurred during the course of the intoxication ("blackouts"). This phenomenon may be related to the presence of a high blood alcohol level and, perhaps, to the rapidity with which this level is reached. During even mild alcohol intoxication, different symptoms are likely to be at different time points. Evidence of mild intoxication with alcohol can be seen in most individuals after approximately two drinks (each standard drink is approximately 10-12 grams of ethanol and raises the blood alcohol concentration approximately 20mg/ dL). Early in the drinking period, when blood alcohol levels are rising, symptoms often include talkativeness, a sensation of well-being, and a bright, expansive mood. Later, especially when blood alcohol levels are falling, the individual is likely to become progres sively more depressed, withdrawn, and cognitively impaired. At very high blood alcohol levels (e.g., 200-300 mg/dL), an individual who has not developed tolerance for alcohol is likely to fall asleep and enter a first stage of anesthesia. Higher blood alcohol levels (e.g., in excess of 300-400 mg/dL) can cause inhibition of respiration and pulse and even death in nontolerant individuals. The duration of intoxication depends on how much alcohol was consumed over what period of time. In general, the body is able to metabolize approximately one drink per hour, so that the blood alcohol level generally decreases at a rate of 15-20 mg/dL per hour. Signs and symptoms of intoxication are likely to be more intense when the blood alcohol level is rising than when it is falling.

What substances does alcohol intoxication occur comorbidly with?

Alcohol intoxication may occur comorbidly with other substance intoxication, especially in individuals with conduct disorder or antisocial personality disorder.

What is the development course of alcohol use disorder?

Alcohol use disorder has a variable course that is characterized by periods of remission and relapse. A decision to stop drinking, often in response to a crisis, is likely to be followed by a period of weeks or more of abstinence, which is often followed by limited periods of controlled or non-problematic drinking. However, once alcohol intake resumes, it is highly likely that consumption will rapidly escalate and that severe problems will once again develop.

What is the prevalence of alcohol use disorder?

Alcohol use disorder is a common disorder. In the United States, the 12-month prevalence of alcohol use disorder is estimated to be - 4.6% among 12- to 17-year-olds and - 8.5% among adults age 18 years and older in the United States. Rates of the disorder are greater among adult men (12.4%) than among adult women (4.9%). Twelve-month prevalence of alcohol use disorder among adults decreases in middle age, being greatest among individuals 18- to 29-years-old (16.2%) and lowest among individuals age 65 years and older (1.5%). Twelve-month prevalence varies markedly across race/ethnic subgroups of the U.S. population. For 12- to 17-year-olds, rates are greatest among Hispanics (6.0%) and Native Americans and Alaska Natives (5.7%) relative to whites (5.0%), African Americans (1.8%), and Asian Americans and Pacific Islanders (1.6%). In contrast, among adults, the 12-month prevalence of alcohol use disorder is clearly greater among Native Americans and Alaska Natives (12.1%) than among whites (8.9%), Hispanics (7.9%), African Americans (6.9%), and Asian Americans and Pacific Islanders (4.5%).

Does alcohol use contribute to suicide risk?

Alcohol use disorder is an important contributor to suicide risk during severe intoxication and in the context of a temporary alcohol-induced depressive and bipolar disorder. There is an increased rate of suicidal behavior as well as of completed suicide among individuals with the disorder.

What are the consequences of alcohol use disorder?

Alcohol use disorder is associated with a significant increase in the risk of accidents, violence, and suicide. It is estimated that one in five intensive care unit admissions in some urban hospitals is related to alcohol and that 40% of individuals in the United States experience an alcohol-related adverse event at some time in their lives, with alcohol accounting for up to 55% of fatal driving events. Severe alcohol use disorder, especially in individuals with antisocial personality disorder, is associated with the commission of criminal acts, including homicide. Severe problematic alcohol use also contributes to disinhibition and feelings of sadness and irritability, which contribute to suicide attempts and completed suicides.

What symptom groups are included in the cluster of behavioural and physical symptoms?

Alcohol use disorder is defined by a cluster of behavioral and physical symptoms, which can include withdrawal, tolerance, and craving. Alcohol withdrawal is characterized by withdrawal symptoms that develop approximately 4-12 hours after the reduction of in take following prolonged, heavy alcohol ingestion. Because withdrawal from alcohol can be unpleasant and intense, individuals may continue to consume alcohol despite adverse consequences, often to avoid or to relieve withdrawal symptoms. Some withdrawal symptoms (e.g., sleep problems) can persist at lower intensities for months and can contribute to relapse. Once a pattern of repetitive and intense use develops, individuals with alcohol use disorder may devote substantial periods of time to obtaining and consuming alcoholic beverages.

What problems are often associated with alcohol used disorder?

Alcohol use disorder is often associated with problems similar to those associated with other substances (e.g., cannabis; cocaine; heroin; amphetamines; sedatives, hypnotics, or anxiolytics). Alcohol may be used to alleviate the unwanted effects of these other substances or to substitute for them when they are not available. Symptoms of conduct problems, depression, anxiety, and insomnia frequently accompany heavy drinking and sometimes precede it.

What is the common perception about alcohol use disorder?

Alcohol use disorder is often erroneously perceived as an intractable condition, perhaps based on the fact that individuals who present for treatment typically have a history of many years of severe alcohol-related problems. These most severe cases represent only a small proportion of individuals with this disorder, and the typical individual with the disorder has a much more promising prognosis

What are some of the genetic and physiological risk factors?

Alcohol use disorder runs in families, with 40%-60% of the variance of risk explained by genetic influences. The rate of this condition is three to four times higher in close relatives of individuals with alcohol use disorder, with values highest for individuals with a greater number of affected relatives, closer genetic relationships to the affected person, and higher severity of the alcohol-related problems in those relatives. A significantly higher rate of alcohol use disorders exists in the monozygotic twin than in the dizygotic twin of an individual with the condition. A three- to fourfold increase in risk has been observed in children of individuals with alcohol use disorder, even when these children were given up for adoption at birth and raised by adoptive parents who did not have the disorder.

What is the impact of conduct disorder in childhood and adult antisocial personality disorder and alcohol use disorder?

Alcohol use disorder, along with other substance use disorders, is seen in the majority of individuals with antisocial personality and preexisting conduct disorder. Because these diagnoses are associated with an early onset of alcohol use disorder as well as a worse prognosis, it is important to establish both conditions.

What do drugs taken in excess do?

All drugs that are taken in excess have in common direct activation of the brain reward system, which is involved in the reinforcement of behaviors and the production of memories. They produce such an intense activation of the reward system that normal activities may be neglected. Instead of achieving reward system activation through adaptive behaviors, drugs of abuse directly activate the reward pathways.

What are the health effects of cannabis use?

Although cannabis use can impact multiple aspects of normal human functioning, including the cardiovascular, immune, neuromuscular, ocular, reproductive, and respiratory systems, as well as appetite and cognition/perception, there are few clear medical conditions that commonly co-occur with cannabis use disorder. The most significant health effects of cannabis involve the respiratory system, and chronic cannabis smokers exhibit high rates of respiratory symptoms of bronchitis, sputum production, shortness of breath, and wheezing.

Are confusion and changes in consciousness present in alcohol withdrawal?

Although confusion and changes in consciousness are not core criteria for alcohol withdrawal, alcohol withdrawal delirium may occur in the context of withdrawal. As is true for any agitated, confused state, regardless of the cause, in addition to a disturbance of consciousness and cognition, withdrawal delirium can include visual, tactile, or (rarely) auditory hallucinations (delirium tremens). When alcohol withdrawal delirium develops, it is likely that a clinically relevant medical condition may be present (e.g., liver failure, pneumonia, gastrointestinal bleeding, sequelae of head trauma, hypoglycemia, an electrolyte imbalance, postoperative status).

What are some age specific impacts of alcohol use disorder?

Among adolescents, conduct disorder and repeated antisocial behavior often co-occur with alcohol- and with other substance-related disorders. While most individuals with alcohol use disorder develop the condition before age 40 years, perhaps 10% have later onset. Age-related physical changes in older individuals result in - increased brain susceptibility to the depressant effects of alcohol; - decreased rates of liver metabolism of a variety of substances, including alcohol; and - decreased percentages of body water. These changes can cause older people to develop more severe intoxication and subsequent problems at lower levels of consumption. Alcohol-related problems in older people are also especially likely to be associated with other medical complications.

How common is a secondary or tertiary substance used with cannabis?

Among those seeking treatment for a cannabis use disorder, 74% report problematic use of a secondary or tertiary substance: alcohol (40%), cocaine (12%), methamphetamine (6%), and heroin or other opiates (2%). Among those younger than 18 years, 61% reported problematic use of a secondary substance: alcohol (48%), cocaine (4%), methamphetamine (2%), and heroin or other opiates (2%).

What are the functional consequences of gambling disorder?

Areas of psychosocial, health, and mental health functioning may be adversely affected by gambling disorder. Specifically, individuals with gambling disorder may, because of their involvement with gambling, jeopardize or lose important relationships with family members or friends. Such problems may occur from repeatedly lying to others to cover up the extent of gambling or from requesting money that is used for gambling or to pay off gambling debts. Employment or educational activities may likewise be adversely impacted by gambling disorder; absenteeism or poor work or school performance can occur with gambling disorder, as individuals may gamble during work or school hours or be preoccupied with gambling or its adverse consequence when they should be working or studying. Individuals with gambling disorder have poor general health and utilize medical services at high rates.

What are some of the factors of Substance/Medication-Induced Mental Disorders?

As is true of many consequences of heavy substance use, some individuals are more and others less prone toward specific substance-induced disorders. Similar types of pre-dispositions may make some individuals more likely to develop psychiatric side effects of some types of medications, but not others. However, it is unclear whether individuals with family histories or personal prior histories with independent psychiatric syndromes are more likely to develop the induced syndrome once the consideration is made as to whether the quantity and frequency of the substance was sufficient to lead to the development of a substance-induced syndrome

What are some signs of chronic use of cannabis?

As with other substances, experienced users of cannabis develop behavioral and pharmacological tolerance such that it can be difficult to detect when they are under the influence. Signs of acute and chronic use include red eyes (conjunctival injection), cannabis odor on clothing, yellowing of finger tips (from smoking joints), chronic cough, burning of incense (to hide the odor), and exaggerated craving and impulse for specific foods, sometimes at unusual times of the day or night.

What are some of the physiological risks of alcohol withdrawal?

Autonomic hyperactivity in the context of moderately high but falling blood alcohol levels and a history of prolonged heavy drinking indicate a likelihood of alcohol withdrawal.

Why should there be a careful evaluation to ensure that the symptoms of cannabis withdrawal are not better explained by cessation from an other substance?

Because many of the symptoms of cannabis withdrawal are also symptoms of other sub stance withdrawal syndromes or of depressive or bipolar disorders, careful evaluation should focus on ensuring that the symptoms are not better explained by cessation from an other substance (e.g., tobacco or alcohol withdrawal), another mental disorder (generalized anxiety disorder, major depressive disorder), or another medical condition.

Why can the effects of cannabis intoxication reoccur for 12-24 hours?

Because most cannabinoids, including delta-9-tetrahydrocannabinol (delta-9-THC), are fat soluble, the effects of cannabis or hashish may occasionally persist or reoccur for 12-24 hours because of the slow re lease of psychoactive substances from fatty tissue or to enterohepatic circulation.

How can cannabis use be detected?

Biological tests for cannabinoid metabolites are useful for determining if an individual has recently used cannabis. Such testing is helpful in making a diagnosis, particularly in milder cases if an individual denies using while others (family, work, school) purport concern about a substance use problem. Because cannabinoids are fat soluble, they persist in bodily fluids for extended periods of time and are excreted slowly. Expertise in urine testing methods is needed to reliably interpret results.

What disorders are associated with a markedly increased rate of alcohol use disorder?

Bipolar disorders, schizophrenia, and antisocial personality disorder are associated with a markedly increased rate of alcohol use disorder, and several anxiety and depressive disorders may relate to alcohol use disorder as well. At least a part of the reported association between depression and i^oderate to severe alcohol use disorder may be attributable to temporary, al cohol-induced comorbid depressive symptoms resulting from the acute effects of intoxication or withdrawal. Severe, repeated alcohol intoxication may also suppress immune mechanisms and predispose individuals to infections and increase the risk for cancers.

What is the prevalence of cannabis use (in US)?

Cannabinoids, especially cannabis, are the most widely used illicit psychoactive sub stances in the United States. The 12-month prevalence of cannabis use disorder (DSM-IV abuse and dependence rates combined) is approximately -3.4% among 12- to 17-year-olds and -1.5% among adults age 18 years and older. Rates of cannabis use disorder are greater among adult males (2.2%) than among adult females (0.8%) and among 12- to 17-year-old males (3.8%) than among 12- to 17-year-old females (3.0%). Twelve-month prevalence rates of cannabis use disorder among adults decrease with age, with rates highest among 18- to 29-year-olds (4.4%) and lowest among individuals age 65 years and older (0.01%). The high prevalence of cannabis use disorder likely reflects the much more widespread use of cannabis relative to other illicit drugs rather than greater addictive potential.

What other disorders does cannabis disorder have a high comorbidity with?

Cannabis has been commonly thought of as a "gateway" drug because individuals who frequently use cannabis have a much greater lifetime probability than nonusers of using what are commonly considered more dangerous substances, like opioids or cocaine. Cannabis use and cannabis use disorder are highly comorbid with other substance use disorders.

In what way does cannabis intoxication resemble other substance intoxication and what distinguishes them?

Cannabis intoxication may resemble intoxication with other types of substances. However, in contrast to cannabis intoxication, alcohol intoxication and sedative, hypnotic, or anxiolytic intoxication frequently decrease appetite, in crease aggressive behavior, and produce nystagmus or ataxia. Hallucinogens in low doses may cause a clinical picture that resembles cannabis intoxication. Phencyclidine, like cannabis, can be smoked and also causes perceptual changes, but phencyclidine intoxication is much more likely to cause ataxia and aggressive behavior.

How is cannabis used?

Cannabis is most commonly smoked via a variety of methods: pipes, water pipes (bongs or hookahs), cigarettes (joints or reefers), or, most recently, in the paper from hollowed out cigars (blunts). Cannabis is also sometimes ingested orally, typically by mixing it into food. More recently, devices have been developed in which cannabis is "vaporized." Vaporization involves heating the plant material to release psychoactive cannabinoids for inhalation. As with other psychoactive substances, smoking (and vaporization) typically produces more rapid onset and more intense experiences of the desired effects.

How common is cannabis use?

Cannabis is probably the world's most commonly used illicit substance. Occurrence of cannabis use disorder across countries is unknown, but the prevalence rates are likely similar among developed countries. It is frequently among the first drugs of experimentation (often in the teens) of all cultural groups in the United States.

What are some common patterns of cannabis use in adults?

Cannabis use disorder among adults typically involves well-established patterns of daily cannabis use that continue despite clear psychosocial or medical problems. Many adults have experienced repeated desire to stop or have failed at repeated cessation attempts. Milder adult cases may resemble the more common adolescent cases in that cannabis use is not as frequent or heavy but continues despite potential significant consequences of sustained use. The rate of use among middle-age and older adults appears to be increasing, likely because of a cohort effect resulting from high prevalence of use in the late 1960s and the 1970s.

How is severity of cannabis use determined?

Cannabis use disorder among preteens, adolescents, and young adults is typically expressed as excessive use with peers that is a component of a pattern of other delinquent behaviors usually associated with conduct problems. Milder cases primarily reflect continued use despite clear problems related to disapproval of use by other peers, school ad ministration, or family, which also places the youth at risk for physical or behavioral consequences. In more severe cases, there is a progression to using alone or using through out the day such that use interferes with daily functioning and takes the place of previously established, prosocial activities.

What is included in the cannabis use disorder section?

Cannabis use disorder and the other cannabis-related disorders include problems that are associated with substances derived from the cannabis plant and chemically similar synthetic compounds. Over time, this plant material has accumulated many names (e.g., weed, pot, herb, grass, reefer, mary jane, dagga, dope, bhang, skunk, boom, gangster, kif, and ganja). A concentrated extraction of the cannabis plant that is also commonly used is hashish. Cannabis is the generic and perhaps the most appropriate scientific term for the psychoactive substance(s) derived from the plant, and as such it is used in this manual to refer to all forms of cannabis-like substances, including synthetic cannabinoid compounds

How often is cannabis use disorder observed as a secondary problem?

Cannabis use disorder is also often observed as a secondary problem among those with a primary diagnosis of other substance use disorders, with approximately 25%-80% of those in treatment for another substance use disorder reporting use of cannabis.

What are some of the difficulties associated with cannabis withdrawal?

Cannabis users report using cannabis to relieve withdrawal symptoms, suggesting that withdrawal might contribute to ongoing expression of cannabis use disorder. Worse outcomes may be associated with greater withdrawal. A substantial proportion of adults and adolescents in treatment for moderate to severe cannabis use disorder acknowledge moderate to severe withdrawal symptoms, and many complain that these symptoms make cessation more difficult. Cannabis users report having relapsed to cannabis use or initiating use of other drugs (e.g., tranquilizers) to provide relief from cannabis withdrawal symptoms. Last, individuals living with cannabis users observe significant withdrawal effects, suggesting that such symptoms are disruptive to daily living.

Who is cannabis withdrawal observed in?

Cannabis withdrawal is commonly observed in individuals seeking treatment for cannabis use as well as in heavy cannabis users who are not seeking treatment. Among individuals who have used cannabis regularly during some period of their lifetime, up to one- third report having experienced cannabis withdrawal. Among adults and adolescents en rolled in treatment or heavy cannabis users, 50%-95% report cannabis withdrawal. These findings indicate that cannabis withdrawal occurs among a substantial subset of regular cannabis users who try to quit.

What other disorders are common in cannabis use disorder?

Co-occurring mental conditions are common in cannabis use disorder. Cannabis use has been associated with poorer life satisfaction; increased mental health treatment and hospitalization; and higher rates of depression, anxiety disorders, suicide attempts, and conduct disorder. Individuals with past-year or lifetime cannabis use disorder have high rates of alcohol use disorder (greater than 50%) and tobacco use disorder (53%). Rates of other substance use disorders are also likely to be high among individuals with cannabis use disorder.

How is craving manifested? What type of conditioning does craving involved?

Craving (Criterion 4) is manifested by an intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug previously was obtained or used. Craving has also been shown to involve classical conditioning and is associated with activation of specific reward structures in the brain. Craving is queried by asking if there has ever been a time when they had such strong urges to take the drug that they could not think of anything else. Current craving is of ten used as a treatment outcome measure because it may be a signal of impending relapse.

How is craving for alcohol defined?

Craving for alcohol is indicated by a strong desire to drink that makes it difficult to think of anything else and that often results in the onset of drinking. School and job performance may also suffer either from the aftereffects of drinking or from actual intoxication at school or on the job; child care or household responsibilities may be neglected; and alcohol-related absences may occur from school or work. The individual may use alcohol in physically hazardous circumstances (e.g., driving an automobile, swimming, operating machinery while intoxicated). Finally, individuals with an alcohol use disorder may continue to consume alcohol despite the knowledge that continued consumption poses significant physical (e.g., blackouts, liver disease), psychological (e.g., depression), social, or interpersonal problems (e.g., violent arguments with spouse while intoxicated, child abuse).

What are some of the problems associated with gambling disorder?

Distortions in thinking (e.g., denial, superstitions, a sense of power and control over the outcome of chance events, overconfidence) may be present in individuals with gambling disorder. Many individuals with gambling disorder believe that money is both the cause of and the solution to their problems. Some individuals with gambling disorder are impulsive, competitive, energetic, restless, and easily bored; they may be overly concerned with the approval of others and may be generous to the point of extravagance when winning. Other individuals with gambling disorder are depressed and lonely, and they may gamble when feeling helpless, guilty, or depressed. Up to half of individuals in treatment for gambling disorder have suicidal ideation, and about 17% have attempted suicide.

What is the repartition across gender of gambling disorder?

Early expression of gambling disorder is more common among males than among females. Individuals who begin gambling in youth often do so with family members or friends Development of early-life gambling disorder appears to be associated with impulsivity and substance abuse. Many high school and college students who develop gambling disorder grow out of the disorder over time, although it remains a lifelong problem for some. Mid- and later-life onset of gambling disorder is more common among females than among males.

What does early onset of cannabis use a predictor of?

Early onset of cannabis use (e.g., prior to age 15 years) is a robust predictor of the development of cannabis use disorder and other types of substance use disorders and mental disorders during young adulthood. Such early onset is likely related to concurrent other externalizing problems, most notably conduct disorder symptoms. However, early onset is also a predictor of internalizing problems and as such probably reflects a general risk factor for the development of mental health disorders.

What are some of the environmental risk factors?

Environmental risk and prognostic factors may include cultural attitudes toward drinking and intoxication, the availability of alcohol (including price), acquired personal experiences with alcohol, and stress levels. Additional potential mediators of how alcohol problems develop in predisposed individuals include heavier peer substance use, exaggerated positive expectations of the effects of alcohol, and suboptimal ways of coping with stress.

What are the environmental risk factors for alcohol intoxication?

Episodes of alcohol intoxication increase with a heavy drinking environment.

What are the temparamental risk factors for alcohol intoxication?

Episodes of alcohol intoxication increase with personality characteristics of sensation seeking and impulsivity.

What are the two specifiers for severity of gambling disorder?

Episodic: Meeting diagnostic criteria at more than one time point, with symptoms subsiding between periods of gambling disorder for at least several months. Persistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple years.

What is the ethnic and racial prevalence of cannabis use (in US)?

Ethnic and racial differences in prevalence are moderate. Twelve-month prevalences of cannabis use disorder vary markedly across racial-ethnic subgroups in the United States. For 12- to 17-year-olds, rates are highest among Native American and Alaska Natives (7.1%) compared with Hispanics (4.1%), whites (3.4%), African Americans (2.7%), and Asian Americans and Pacific Islanders (0.9%). Among adults, the prevalence of cannabis use disorder is also highest among Native Americans and Alaska Natives (3.4%) relative to rates among African Americans (1.8%), whites (1.4%), Hispanics (1.2%), and Asian and Pacific Islanders (1.2%). During the past decade the prevalence of cannabis use disorder has increased among adults and adolescents. Gender differences in cannabis use disorder generally are concordant with those in other substance use disorders. Cannabis use disorder is more commonly observed in males, although the magnitude of this difference is less among adolescents.

What percentage of individuals will develop dramatic alcohol withdrawal symptoms?

Fewer than 10% of individuals who develop alcohol withdrawal will ever develop dramatic symptoms (e.g., severe autonomic hyperactivity, tremors, alcohol withdrawal delirium). Tonic-clonic seizures occur in fewer than 3% of individuals.

What are the functional consequences of cannabis use and how important are they in diagnosing cannabis use disorder?

Functional consequences of cannabis use disorder are part of the diagnostic criteria. Many areas of psychosocial, cognitive, and health functioning may be compromised in relation to cannabis use disorder. Cognitive function, particularly higher executive function, appears to be compromised in cannabis users, and this relationship appears to be dose dependent (both acutely and chronically). This may contribute to increased difficulty at school or work. Cannabis use has been related to a reduction in prosocial goal-directed activity, which some have labeled an amotivational syndrome, that manifests itself in poor school performance and employment problems. These problems may be related to pervasive intoxication or recovery from the effects of intoxication. Similarly, cannabis-associated problems with social relationships are commonly reported in those with cannabis use dis order. Accidents due to engagement in potentially dangerous behaviors while under the influence (e.g., driving, sport, recreational or employment activities) are also of concern. Cannabis smoke contains high levels of carcinogenic compounds that place chronic users at risk for respiratory illnesses similar to those experienced by tobacco smokers. Chronic cannabis use may contribute to the onset or exacerbation of many other mental disorders. In particular, concern has been raised about cannabis use as a causal factor in schizophrenia and other psychotic disorders. Cannabis use can contribute to the onset of an acute psychottic episode, can exacerbate some symptoms, and can adversely affect treatment of a major psychotic illness.

What are the genetic and physiological risk factors for gambling disorder?

Gambling disorder can aggregate in families, and this effect appears to relate to both environmental and genetic factors. Gambling problems are more frequent in monozygotic than in dizygotic twins. Gambling disorder is also more prevalent among first-degree relatives of individuals with moderate to severe alcohol use dis order than among the general population.

What are some of the disorders that are frequently comorbid with gambling disorder?

Gambling disorder is associated with poor general health. In addition, some specific medical diagnoses, such as tachycardia and angina, are more common among individuals with gambling disorder than in the general population, even when other substance use disorders, including tobacco use disorder, are controlled for. Individuals with gambling disorder have high rates of comorbidity with other mental disorders, such as substance use disorders, depressive disorders, anxiety disorders, and personality disorders. In some individuals, other mental disorders may precede gambling disorder and be either absent or present during the manifestation of gambling disorder. Gambling disorder may also occur prior to the onset of other mental disorders, especially anxiety disorders and substance use disorders.

How do gambling disorder and nondisorder gamling differ?

Gambling disorder must be distinguished from professional and social gambling. In professional gambling, risks are limited and discipline is central. Social gambling typically occurs with friends or colleagues and lasts for a limited period of time, with acceptable losses. Some individuals can experience problems associated with gambling (e.g., short-term chasing behavior and loss of control) that do not meet the full criteria for gambling disorder.

What are the essential features of gambling disorder?

Gambling involves risking something of value in the hopes of obtaining something of greater value. In many cultures, individuals gamble on games and events, and most do so without experiencing problems. However, some individuals develop substantial impairment related to their gambling behaviors. The essential feature of gambling disorder is persistent and recurrent maladaptive gambling behavior that disrupts personal, family, and/or vocational pursuits (Criterion A). Gambling disorder is defined as a cluster of four or more of the symptoms listed in Criterion A occurring at any time in the same 12-month period.

What patterns are common in gambling disorder?

Gambling patterns may be regular or episodic, and gambling disorder can be persistent or in remission. Gambling can increase during periods of stress or depression and during periods of substance use or abstinence. There may be periods of heavy gambling and severe problems, times of total abstinence, and periods of non-problematic gambling. Gambling disorder is sometimes associated with spontaneous, long-term remissions. Nevertheless, some individuals underestimate their vulnerability to develop gambling disorder or to return to gambling disorder following remission. When in a period of remission, they may incorrectly assume that they will have no problem regulating gambling and that they may gamble on some forms non-problematically, only to experience a return to gambling disorder.

What are the temperamental risk factors for gambling disorder?

Gambling that begins in childhood or early adolescence is associated with increased rates of gambling disorder. Gambling disorder also appears to aggregate with antisocial personality disorder, depressive and bipolar disorders, and other sub stance use disorders, particularly with alcohol disorders.

What factors likely contribute to the potential rapid transition from cannabis use to a cannabis use disorder?

Generally, cannabis use disorder develops over an extended period of time, although the progression appears to be more rapid in adolescents, particularly those with pervasive conduct problems. Most people who develop a cannabis use disorder typically establish a pattern of cannabis use that gradually increases in both frequency and amount. Cannabis, along with tobacco and alcohol, is traditionally the first substance that adolescents try. Many perceive cannabis use as less harmful than alcohol or tobacco use, and this perception likely contributes to increased use. Moreover, cannabis intoxication does not typically result in as severe behavioral and cognitive dysfunction as does significant alcohol intoxication, which may increase the probability of more frequent use in more diverse situations than with alcohol. These factors likely contribute to the potential rapid transition from cannabis use to a cannabis use disorder among some adolescents and the common pattern of using throughout the day that is commonly observed among those with more severe carmabis use disorder.

What are the genetic and physiological risk factors for cannabis use?

Genetic influences contribute to the development of cannabis use disorders. Heritable factors contribute between 30% and 80% of the total variance in risk of cannabis use disorders. It should be noted that common genetic and shared environmental influences between cannabis and other types of substance use disorders suggest a common genetic basis for adolescent substance use and conduct problems.

What are the functional consequences of cannabis intoxication?

Impairment from cannabis intoxication may have serious consequences, including dysfunction at work or school, social indiscretions, failure to fulfill role obligations, traffic accidents, and having unprotected sex. In rare cases, cannabis intoxication may precipitate a psychosis that may vary in duration.

Why are gambling disorders included?

In addition to the substance-related disorders, this chapter also includes gambling disorder, reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse and produce some behavioral symptoms that appear comparable to those produced by the substance use disorders.

What is the criteria for the early remission specifier?

In early remission: After full criteria for cannabis use disorder were previously met, none of the criteria for cannabis use disorder have been met for at least 3 months but for less than 12 months

What is the effect of high impulsivity on alcohol use disorder?

In general, high levels of impulsivity are associated with an earlier onset and more severe alcohol use disorder.

What evidence should there be to be considered a Substance/Medication-Induced Mental Disorders?

In general, to be considered a substance/medication-induced mental disorder, there must be evidence that the disorder being observed is not likely to be better explained by an independent mental condition. The latter are most likely to be seen if the mental disorder was present before the severe intoxication or withdrawal or medication administration, or, with the exception of several substance-induced persisting disorders, continued more than 1 month after cessation of acute withdrawal, severe intoxication, or use of the medications. When symptoms are only observed during a delirium (e.g., alcohol withdrawal del|rium), the mental disorder should be diagnosed as a delirium, and the psychiatric syndrome occurring during the delirium should not also be diagnosed sepa rately, as many symptoms (including disturbances in mood, anxiety, and reality testing) are commonly seen during agitated, conhised states. The features associated with each rel evant major mental disorder are similar whether observed with independent or sub stance/medication-induced mental disorders. However, individuals with substance/ medication-induced mental disorders are likely to also demonstrate the associated fea tures seen with the specific category of substance or medication, as listed in other subsec tions of this chapter.

What is the cultural distribution of alcohol use?

In most cultures, alcohol is the most frequently used intoxicating substance and contributes to considerable morbidity and mortality. An estimated 3.8% of all global deaths and 4.6% of global disability-adjusted life-years are attributable to alcohol. In the United States, 80% of adults (age 18 years and older) have consumed alcohol at some time in their lives, and 65% are current drinkers (last 12 months). An estimated 3.6% of the world population (15-64 years old) has a current (12-month) alcohol use disorder, with a lower prevalence (1.1%) found in the African region, a higher rate (5.2%) found in the American region (North, South, and Central America and the Caribbean), and the highest rate (10.9%) found in the Eastern Europe region.

What is the criteria for the sustained remission specifier?

In sustained remission; After full criteria for cannabis use disorder were previously met, none of the criteria for cannabis use disorder have been met at any time during a period of 12 months or longer.

What is the prevalence of gambling disorder in the general population and across ethnicities in the US?

In the general population, the lifetime prevalence rate is about 0.4%-1.0%. For females, the lifetime prevalence rate of gambling disorder is about 0.2%, and for males it is about 0.6%. The lifetime prevalence of pathological gambling among African Americans is about 0.9%, among whites about 0.4%, and among Hispanics about 0.3%.

What age group has a high prevalence rate for virtually every substance?

Individuals ages 18-24 years have relatively high prevalence rates for the use of virtually every substance. Intoxication is usually the initial substance-related disorder and often be gins in the teens. Withdrawal can occur at any age as long as the relevant drug has been taken in sufficient doses over an extended period of time.

What are cultural differences of gambling disorder?

Individuals from specific cultures and races/ethnicities are more likely to participate in some types of gambling activities than others (e.g., pai gow, cockfights, blackjack, horse racing). Prevalence rates of gambling disorder are higher among African Americans than among European Americans, with rates for Hispanic Americans similar to those of Euro pean Americans. Indigenous populations have high prevalence rates of gambling disorder.

Can individuals who regularly use cannabis develop the diagnostic features of a substance use disorder?

Individuals who regularly use cannabis can develop all the general diagnostic features of a substance use disorder. Cannabis use disorder is commonly observed as the only substance use disorder experienced by the individual; however, it also frequently occurs concurrently with other types of substance use disorders (i.e., alcohol, cocaine, opioid). In cases for which multiple types of substances are used, many times the individual may minimize the symptoms related to cannabis, as the symptoms may be less severe or cause less harm than those directly related to the use of the other substances. Pharmacological and behavioral tolerance to most of the effects of cannabis has been reported in individuals who use cannabis persistently. Generally, tolerance is lost when cannabis use is discontinued for a significant period of time (i.e., for at least several months).

What do individuals who use cannabis report using it for?

Individuals who regularly use cannabis often report that it is being used to cope with mood, sleep, pain, or other physiological or psychological problems, and those diagnosed with cannabis use disorder frequently do have concurrent other mental disorders. Careful assessment typically reveals reports of cannabis use contributing to exacerbation of these same symptoms, as well as other reasons for frequent use (e.g., to experience euphoria, to forget about problems, in response to anger, as an enjoyable social activity). Related to this issue, some individuals who use cannabis multiple times per day for the aforementioned reasons do not perceive themselves as (and thus do not report) spending an excessive amount of time under the influence or recovering from the effects of cannabis, despite being intoxicated on cannabis or coming down from it effects for the majority of most days. An important marker of a substance use disorder diagnosis, particularly in milder cases, is continued use despite a clear risk of negative consequences to other valued activities or relationships (e.g., school, work, sport activity, partner or parent relationship).

How is heavy drinking determined?

Individuals whose heavier drinking places them at elevated risk for alcohol use disorder can be identified both through standardized questionnaires and by elevations in blood test results likely to be seen with regular heavier drinking. These measures do not establish a diagnosis of an alcohol-related disorder but can be useful in highlighting individuals for whom more information should be gathered. The most direct test available to measure alcohol consumption cross-sectionally is blood alcohol concentration, which can also be used to judge tolerance to alcohol. For example, an individual with a concentration of 150 mg of ethanol per deciliter (dL) of blood who does not show signs of intoxication can be presumed to have acquired at least some degree of tolerance to alcohol. At 200 mg/dL, most nontolerant individuals demonstrate severe intoxication.

When should a diagnosis not be made?

Individuals whose only symptoms are those that occur as a result of medical treatment (i.e., tolerance and withdrawal as part of medical care when the medications are taken as prescribed) should not receive a diagnosis solely on the basis of these symptoms. Prescription medications can be used inappropriately, and a substance use disorder can be correctly diagnosed when there are other symptoms of compulsive, drug-seeking behavior.

What is the pattern of cannabis use and how does it affect the individual (socially)?

Individuals with cannabis use disorder may use cannabis throughout the day over a period of months or years, and thus may spend many hours a day under the influence. Others may use less frequently, but their use causes recurrent problems related to family, school, work, or other important activities (e.g., repeated absences at work; neglect of fam ily obligations). Periodic cannabis use and intoxication can negatively affect behavioral and cognitive functioning and thus interfere with optimal performance at work or school, or place the individual at increased physical risk when performing activities that could be physically hazardous (e.g., driving a car; playing certain sports; performing manual work activities, including operating machinery). Arguments with spouses or parents over the use of cannabis in the home, or its use in the presence of children, can adversely impact family functioning and are common features of those with cannabis use disorder. Last, individuals with cannabis use disorder may continue using despite knowledge of physical problems (e.g., chronic cough related to smoking) or psychological problems (e.g., excessive sedation or exacerbation of other mental health problems) associated with its use.

How common are concurrent mental disorders in individuals with cannabis use disorder?

Individuals with past-year or lifetime diagnoses of cannabis use disorder also have high rates of concurrent mental disorders other than substance use disorders. Major depressive disorder (11%), any anxiety disorder (24%), and bipolar I disorder (13%) are quite common among individuals with a past-year diagnosis of a cannabis use disorder, as are antisocial (30%), obsessive-compulsive, (19%), and paranoid (18%) personality disorders. Approximately 33% of adolescents with cannabis use disorder have internalizing disorders (e.g., anxiety, depression, posttraumatic stress disorder), and 60% have externalizing disorders (e.g., conduct disorder, attention-deficit/hyperactivity disorder).

What are the symptoms of cannabis intoxication?

Intoxication develops within minutes if the cannabis is smoked but may take a few hours to develop if the cannabis is ingested orally. The effects usually last 3-4 hours, with the duration being somewhat longer when the substance is ingested orally. The magnitude of the behavioral and physiological changes depends on the dose, the method of adminis tration, and the characteristics of the individual using the substance, such as rate of absorp tion, tolerance, and sensitivity to the effects of the substance.

How is alcohol intoxication established?

Intoxication is usually established by observing an individual's behavior and smelling alcohol on the breath. The degree of intoxication increases with an individual's blood or breath alcohol level and with the ingestion of other substances, especially those with sedating effects.

When does intoxication occur, and what is the impact of an early onset of regular intoxication?

Intoxication usually occurs as an episode usually developing over minutes to hours and typically lasting several hours. In the United States, the average age at first intoxication is approximately 15 years, with the highest prevalence at approximately 18-25 years. Frequency and intensity usually decrease with further advancing age. The earlier the onset of regular intoxication, the greater the likelihood the individual will go on to develop alcohol use disorder.

How can sedative, hypnotic, or anxiolytic intoxication be differentiated from alcohol intoxication?

Intoxication with sedative, hypnotic, or anxiolytic drugs or with other sedating substances (e.g., antihistamines, anticholinergic drugs) can be mistaken for alcohol intoxication. The differential requires observing alcohol on the breath, measuring blood or breath alcohol levels, ordering a medical workup, and gathering a good history. The signs and symptoms of sedative-hypnotic intoxication are very similar to those observed with alcohol and include similar problematic behavioral or psychological changes. These changes are accompanied by evidence of impaired functioning and judgment—which, if intense, can result in a life-threatening coma—and levels of inco-ordination that can interfere with driving abilities and with performing usual activities. However, there is no smell as there is with alcohol, but there is likely to be evidence of misuse of the depressant drug in the blood or urine toxicology analyses.

What percentage of individuals with alcohol use disorder experience alcohol withdrawal syndrome?

It is estimated that approximately 50% of middle-class, highly functional individuals with alcohol use disorder have ever experienced a full alcohol withdrawal syndrome. Among individuals with alcohol use disorder who are hospitalized or homeless, the rate of alcohol withdrawal may be greater than 80%. Less than 10% of individuals in withdrawal ever demonstrate alcohol withdrawal delirium or withdrawal seizures.

What can laboratory analyses of blood and urine samples can help determine?

Laboratory analyses of blood and urine samples can help determine recent use and the specific substances involved. A positive laboratory test result does not by itself indicate that the individual has a pattern of substance use that meets criteria for a substance-induced or sub stance use disorder, and a negative test result does not by itself rule out a diagnosis. Laboratory tests can be useful in identifying withdrawal. If the individual presents with withdrawal from an unknown substance, laboratory tests may help identify the sub stance and may also be helpful in differentiating withdrawal from other mental disorders

What is the relationship between gambling disorder and manic episodes and what should be considered when making a diagnosis?

Loss of judgment and excessive gambling may occur during a manic episode. An additional diagnosis of gambling disorder should be given only if the gambling behavior is not better explained by manic episodes (e.g., a history of maladaptive gambling behavior at times other than during a manic episode). Alternatively, an individual with gambling disorder may, during a period of gambling, exhibit behavior that resembles a manic episode, but once the individual is away from the gambling, these manic-like features dissipate.

How are males and females likely to develop gambling disorder?

Males are more likely to begin gambling earlier in life and to have a younger age at on set of gambling disorder than females, who are more likely to begin gambling later in life and to develop gambling disorder in a shorter time frame. Females with gambling disorder are more likely than males with gambling disorder to have depressive, bipolar, and anxiety disorders. Females also have a later age at onset of the disorder and seek treatment sooner, although rates of treatment seeking are low (<10%) among individuals with gambling disorder regardless of gender.

What type of gambling do males and females favour?

Males develop gambling disorder at higher rates than females, although this gender gap may be narrowing. Males tend to wager on different forms of gambling than females, with cards, sports, and horse race gambling more prevalent among males, and slot machine and bingo gambling more common among females.

What is the distribution of alcohol use disorder in males and females?

Males have higher rates of drinking and related disorders than females. However, because females generally weigh less than males, have more fat and less water in their bodies, and metabolize less alcohol in their esophagus and stomach, they are likely to develop higher blood alcohol levels per drink than males. Females who drink heavily may also be more vulnerable than males to some of the physical consequences associated with alcohol, including liver disease.

What are the environmental risk factors of cannabis withdrawal?

Most likely, the prevalence and severity of cannabis withdrawal are greater among heavier cannabis users, and particularly among those seeking treatment for cannabis use disorders. Withdrawal severity also appears to be positively related to the severity of comorbid symptoms of mental disorders.

What are the symptoms of cannabis withdrawal?

New to DSM-5 is the recognition that abrupt cessation of daily or near-daily cannabis use often results in the onset of a cannabis withdrawal syndrome. Common symptoms of withdrawal include irritability, anger or aggression, anxiety, depressed mood, restlessness, sleep difficulty, and decreased appetite or weight loss. Although typically not as severe as alcohol or opiate withdrawal, the cannabis withdrawal syndrome can cause significant distress and contribute to difficulty quitting or relapse among those trying to abstain.

What other nonsubstance related disorders are listed in DSM?

Note: Although some behavioral conditions that do not involve ingestion of substances have similarities to substance-related disorders, only one disorder—gambling disorder— has sufficient data to be included in this section.

Why are other non-substance addictions not included?

Other excessive behavioral patterns, such as Internet gaming, have also been described, but the research on these and other behavioral syndromes is less clear. Thus, groups of repetitive behaviors, which some term behavioral addictions, with such subcategories as "sex addiction," "exercise addiction," or "shopping addiction," are not included because at this time there is insufficient peer-re viewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders.

How does cannabis use disorder differ from other mental disorders?

Other mental disorders. Cannabis-induced disorder may be characterized by symptoms (e.g., anxiety) that resemble primary mental disorders (e.g., generalized anxiety disorder vs. cannabis-induced anxiety disorder, with generalized anxiety, with onset during intoxication). Chronic intake of cannabis can produce a lack of motivation that resembles persistent depressive disorder (dysthymia). Acute adverse reactions to cannabis should be differentiated from the symptoms of panic disorder, major depressive disorder, delusional disorder, bipolar disorder, or schizophrenia, paranoid type. Physical examination will usually show an increased pulse and conjunctival injection. Urine toxicological testing can be helpful in making a diagnosis.

What is included in pharmacological criteria?

Pharmacological criteria are the final grouping (Criteria 10 and 11). Tolerance (Criterion 10) is signaled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed. The degree to which tolerance develops varies greatly across different individuals as well as across substances and may involve a variety of central nervous system effects. For example, tolerance to respiratory depression and tolerance to sedating and motor coordination may develop at different rates, depending on the substance. Tolerance may be difficult to determine by history alone, and laboratory tests may be helpful (e.g., high blood levels of the substance coupled with little evidence of intoxication suggest that tolerance is likely). Tol erance must also be distinguished from individual variability in the initial sensitivity to the effects of particular substances. For example, some first-time alcohol drinkers show very little evidence of intoxication with three or four drinks, whereas others of similar weight and drinking histories have slurred speech and incoordination.

What are some genetic factors for alcohol use disorder?

Polymorphism of genes for the alcohol-metabolizing enzymes alcohol dehydroge nase and aldehyde dehydrogenase are most often seen in Asians and affect the response to alcohol. When consuming alcohol, individuals with these gene variations can experience a flushed face and palpitations, reactions that can be so severe as to limit or preclude future alcohol consumption and diminish the risk for alcohol use disorder. These gene variations are seen in as many as 40% of Japanese, Chinese, Korean, and related groups worldwide and are related to lower risks for the disorder. Despite small variations regarding individual criterion items, the diagnostic criteria perform equally well across most race/ethnicity groups.

What is the lifetime risk for major depressive episodes in individuals with alcohol use disorder?

Rates of alcohol-induced disorders vary somewhat by diagnostic category. For example, the lifetime risk for major depressive episodes in individuals with alcohol use disorder is approximately 40%, but only about one-third to one-half of these represent independent major depressive syndromes observed outside the context of intoxication. Similar rates of alcohol-induced sleep and anxiety conditions are likely, but alcohol-induced psychotic episodes are fairly rare.

What are additional genetic factors associated with alcohol use disorder?

Recent advances in our understanding of genes that operate through intermediate characteristics (or phenotypes) to affect the risk of alcohol use disorder can help to identify individuals who might be at particularly low or high risk for alcohol use disorder. Among the low-risk phenotypes are the acute alcohol-related skin flush (seen most prominently in Asians). High vulnerability is associated with preexisting schizophrenia or bipolar disorder, as well as impulsivity (producing enhanced rates of all substance use disorders and gambling disorder), and a high risk specifically for alcohol use disorder is associated with a low level of response (low sensitivity) to alcohol. A number of gene variations may ac count for low response to alcohol or modulate the dopamine reward systems; it is important to note, however, that any one gene variation is likely to explain only l% -2% of the risk for these disorders.

What are the laboratory tests used

Regarding laboratory tests, one sensitive laboratory indicator of heavy drinking is a modest elevation or high-normal levels (>35 units) of gamma-glutamyltransferase (GGT). This may be the only laboratory finding. At least 70% of individuals with a high GGT level are persistent heavy drinkers (i.e., consuming eight or more drinks daily on a regular basis). A second test with comparable or even higher levels of sensitivity and specificity is carbo hydrate-deficient transferrin (CDT), with levels of 20 units or higher useful in identifying individuals who regularly consume eight or more drinks daily. Since both GGT and CDT levels return toward normal within days to weeks of stopping drinking, both state markers may be useful in monitoring abstinence, especially when the clinician observes increases, rather than decreases, in these values over time—a finding indicating that the person is likely to have returned to heavy drinking. The combination of tests for CDT and GGT may have even higher levels of sensitivity and specificity than either test used alone. Additional useful tests include the mean corpuscular volume (MCV), which may be elevated to high normal values in individuals who drink heavily—a change that is due to the direct toxic effects of alcohol on erythropoiesis. Although the MCV can be used to help identify those who drink heavily, it is a poor method of monitoring abstinence because of the long half-life of red blood cells. Liver function tests (e.g., alanine aminotransferase [ALT] and alkaline phosphatase) can reveal liver injury that is a consequence of heavy drinking. Other potential markers of heavy drinking that are more nonspecific for alcohol but can help the clinician think of the possible effects of alcohol include elevations in blood levels or lipids (e.g., triglycerides and high-density lipoprotein cholesterol) and high-normal levels of uric acid

What are the physical effect of repeated intake of high doses of alcohol

Repeated intake of high doses of alcohol can affect nearly every organ system, especially the gastrointestinal tract, cardiovascular system, and the central and peripheral nervous systems. Gastrointestinal effects include gastritis, stomach or duodenal ulcers, and, in about 15% of individuals who use alcohol heavily, liver cirrhosis and/or pancreatitis. There is also an increased rate of cancer of the esophagus, stomach, and other parts of the gastrointestinal tract. One of the most commonly associated conditions is low-grade hypertension. Cardiomyopathy and other myopathies are less common but occur at an increased rate among those who drink very heavily. These factors, along with marked increases in levels of triglycerides and low-density lipoprotein cholesterol, contribute to an elevated risk of heart disease. Peripheral neuropathy may be evidenced by muscular weakness, paresthesias, and decreased peripheral sensation. More persistent central nervous system effects include cognitive deficits, severe memory impairment, and degenerative changes in the cerebellum. These effects are related to the direct effects of alcohol or of trauma and to vitamin deficiencies (particularly of the B vitamins, including thiamine). One devastating central nervous system effect is the relatively rare alcohol-induced persisting amnestic disorder, or Wemicke-Korsakoff syndrome, in which the ability to encode new memory is severely impaired. This condition would now be described within the chapter "Neurocognitive Disorders" and would be termed a substance/medication-induced neuro- cognitive disorder.

What are the environmental risk factors for cannabis use?

Risk factors include academic failure, tobacco smoking, unstable or abusive family situation, use of cannabis among immediate family members, a family history of a substance use disorder, and low socioeconomic status. As with all substances of abuse, the ease of availability of the substance is a risk factor; cannabis is relatively easy to obtain in most cultures, which increases the risk of developing a cannabis use disorder.

What is included in risky use?

Risky use of the substance is the third grouping of criteria (Criteria 8-9). This may take the form of recurrent substance use in situations in which it is physically hazardous (Criterion 8). The individual may continue substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (Criterion 9). The key issue in evaluating this criterion is not the existence of the problem, but rather the individual's failure to abstain from using the substance despite the difficulty it is causing.

What difference does the route of administration make?

Routes of administration that produce more rapid and efficient absorption into the blood stream (e.g., intravenous, smoking, intranasal "snorting") tend to result in a more intense intoxication and an increased likelihood of an escalating pattern of substance use leading to withdrawal. Similarly, rapidly acting substances are more likely than slower-acting substances to produce immediate intoxication.

What do Sedative, hypnotic, or anxiolytic withdrawal and alcohol withdrawal have in common?

Sedative, hypnotic, or anxiolytic withdrawal produces a syndrome very similar to that of alcohol withdrawal.

What other medical conditions resemble alcohol intoxication?

Several medical (e.g., diabetic acidosis) and neurological conditions (e.g., cerebellar ataxia, multiple sclerosis) can temporarily resemble alcohol intoxication.

How is severity determined in gambling disorder?

Severity is based on the number of criteria endorsed. Individuals with mild gambling disorder may exhibit only 4-5 of the criteria, with the most frequently endorsed criteria usually related to preoccupation with gambling and "chasing" losses. Individuals with moderately severe gambling disorder exhibit more of the criteria (i.e., 6-7). Individuals with the most severe form will exhibit all or most of the nine criteria (i.e., 8-9). Jeopardiing relationships or career opportunities due to gambling and relying on others to provide money for gambling losses are typically the least often endorsed criteria and most often oc cur among those with more severe gambling disorder. Furthermore, individuals presenting for treatment of gambling disorder typically have moderate to severe forms of the disorder.

How is the severity of the disorder determined?

Severity of the disorder is based on the number of diagnostic criteria endorsed. For a given individual, changes in severity of alcohol use disorder across time are also reflected by reductions in the frequency (e.g., days of use per month) and/or dose (e.g., number of standard drinks consumed per day) of alcohol used, as assessed by the individual's self report, report of knowledgeable others, clinician observations, and, when practical, bio logical testing (e.g., elevations in blood tests as described in the section "Diagnostic Mark ers" for this disorder).

What substances has withdrawal not been documented in?

Significant withdrawal has not been documented in humans after repeated use of phencyclidine, other hallucinogens, and in halants; therefore, this criterion is not included for these substances. Neither tolerance nor withdrawal is necessary for a diagnosis of a substance use disorder. However, for most classes of substances, a past history of withdrawal is associated with a more severe clinical course (i.e., an earlier onset of a substance use disorder, higher levels of substance intake, and a greater number of substance-related problems).

What is included in social impairment?

Social impairment is the second grouping of criteria (Criteria 5-7). Recurrent substance use may result in a failure to fulfill major role obligations at work, school, or home (Criterion 5). The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (Criterion 6). Important social, occupational, or recreational activities may be given up or reduced because of substance use (Criterion 7). The individual may withdraw from family activities and hobbies in order to use the substance.

What generalizations can be made regarding the categories of substances capable of Substance/Medication-Induced Mental Disorders

Some generalizations can be made regarding the categories of substances capable of producing clinically relevant substance-induced mental disorders. In general, the more sedating drugs (sedative, hypnotics, or anxiolytics, and alcohol) can produce prominent and clinically significant depressive disorders during intoxication, while anxiety conditions are likely to be observed during withdrawal syndromes from these substances. Also, during intoxication, the more stimulating substances (e.g., amphetamines and cocaine) are likely to be associated with substance-induced psychotic disorders and substance-induced anxiety disorders, with substance-induced major depressive episodes observed during withdrawal. Both the more sedating and more stimulating drugs are likely to produce significant but temporary sleep and sexual disturbances.

What medications and conditions can trigger an urge to gamle?

Some patients taking dopaminergic medications (e.g., for Parkinson's disease) may experience urges to gamble. If such symptoms dissipate when dopaminergic medications are reduced in dosage or ceased, then a diagnosis of gambling disorder would not be indicated.

How many symptoms are required for severity?

Specify current severity: Mild: 4-5 criteria met. iModerate: 6-7 criteria met. Severe: 8-9 criteria met.

How is the severity level determined?

Substance use disorders occur in a broad range of severity, from mild to severe, with severity based on the number of symptom criteria endorsed. As a general estimate of severity, a mild substance use disorder is suggested by the presence of two to three symptoms, moderate by four to five symptoms, and severe by six or more symptoms. Changing severity across time is also reflected by reductions or increases in the frequency and/or dose of substance use, as assessed by the individual's own report, report of knowledgeable others, clinician's observations, and biological testing. The following course specifiers and descriptive features specifiers are also available for substance use disorders: "in early remission," "in sustained remission," "on maintenance therapy," and "in a controlled environment." Definitions of each are provided within respective criteria set

How many classes of drugs do substance-abuse related disorders encompass?

Substance-abuse related disorders encompass 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens (with separate categories for phencyclidine [or similarly acting arylcyclohexylamines] and other hallucinogens); inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants (amphetamine-type substances, cocaine, and other stimulants); tobacco; and other (or unknown) substances. These 10 classes are not fully distinct.

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Substance-induced mental disorders develop in the context of intoxication or withdrawal from substances of abuse, and medication-induced mental disorders are seen with pre scribed or over-the-counter medications that are taken at the suggested doses. Both conditions are usually temporary and likely to disappear within 1 month or so of cessation of acute withdrawal, severe intoxication, or use of the medication. Exceptions to these generalizations occur for certain long-duration substance-induced disorders: substance-associated neurocognitive disorders that relate to conditions such as alcohol-induced neurocognitive disorder, inhalant-induced neurocognitive disorder, and sedative-, hypnotic-, or anxiolytic- induced neurocognitive disorder; and hallucinogen persisting perception disorder ("flash backs"; see the section "Hallucinogen-Related Disorders" later in this chapter). However, most other substance/medication-induced mental disorders, regardless of the severity of the symptoms, are likely to improve relatively quickly with abstinence and unlikely to re main clinically relevant for more than 1 month after complete cessation of use.

What substances are tolerance and withdrawal not counted?

Symptoms of tolerance and withdrawal occurring during appropriate medical treatment with prescribed medications (e.g., opioid analgesics, sedatives, stimulants) are specifically not counted when diagnosing a substance use disorder. The appearance of normal, expected pharmacological tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of "addiction" even when these were the only symptoms present.

What are some of the consequences of alcohol withdrawal?

Symptoms of withdrawal may serve to perpetuate drinking behaviors and contribute to relapse, resulting in persistently impaired social and occupational functioning. Symptoms requiring medically supervised detoxification result in hospital utilization and loss of work productivity. Overall, the presence of withdrawal is associated with greater func tional impairment and poor prognosis.

What conditions is cannabis prescribed for?

Synthetic oral formulations (pill/capsules) of delta-9-tetrahydrocannabinol (delta-9- THC) are available by prescription for a number of approved medical indications (e.g., for nausea and vomiting caused by chemotherapy; for anorexia and weight loss in individuals with AIDS). Other synthetic cannabinoid compounds have been manufactured and distributed for nonmedical use in the form of plant material that has been sprayed with a cannabinoid formulation (e.g., K2, Spice, JWH-018, JWH-073).

What group of people experience more severe withdrawal?

The amount, duration, and frequency of cannabis smoking that is required to produce an associated withdrawal disorder during a quit attempt are unknown. Most symptoms have their onset within the first 24-72 hours of cessation, peak within the first week, and last approximately 1-2 weeks. Sleep difficulties may last more than 30 days. Cannabis withdrawal has been documented among adolescents and adults. Withdrawal tends to be more common and severe among adults, most likely related to the more persistent and greater frequency and quantity of use among adults.

What is the effect of cannabinoids on the brain?

The cannabinoids have diverse effects in the brain, prominent among which are actions on CBl and CB2 cannabinoid receptors that are found throughout the central nervous system. Endogenous ligands for these receptors behave essentially like neurotransmitters. The potency of cannabis (delta-9-THC concentration) that is generally available varies greatly, ranging from 1% to approximately 15% in typical cannabis plant material and 10%-20% in hashish. During the past two decades, a steady increase in the potency of seized cannabis has been observed.

What is the diagnosis of a substance use disorder based on?

The diagnosis of a substance use disorder is based on a pathological pattern of behaviors related to use of the substance. To assist with organization. Criterion A criteria can be considered to fit within overall groupings of impaired control, social impairment, risky use, and pharmacological criteria. Impaired control over substance use is the first criteria grouping (Criteria 1-4).

What is the functional impact of alcohol use disorder

The diagnostic features of alcohol use disorder highlight major areas of life functioning likely to be impaired. These include driving and operating machinery, school and work, interpersonal relationships and communication, and health. Alcohol-related disorders contribute to absenteeism from work, job-related accidents, and low employee productivity. Rates are elevated in homeless individuals, perhaps reflecting a downward spiral in social and occupational functioning, although most individuals with alcohol use disorder continue to live with their families and function within their jobs.

How does nonproblematic use of cannabis differ from cannabis use disorder?

The distinction between nonproblematic use of can nabis and cannabis use disorder can be difficult to make because social, behavioral, or psychological problems may be difficult to attribute to the substance, especially in the context of use of other substances. Also, denial of heavy cannabis use and the attribution that cannabis is related to or causing substantial problems are common among individuals who are referred to treatment by others (i.e., school, family, employer, criminal justice system).

What are the essential features of Substance Intoxication and Withdrawal?

The essential feature is the development of a reversible substance-specific syndrome due to the recent ingestion of a substance (Criterion A). The clinically significant problematic behavioral or psychological changes associated with intoxication (e.g., belligerence, mood lability, impaired judgment) are attributable to the physiological effects of the substance on the central nervous system and develop during or shortly after use of the substance (Criterion B). The symptoms are not attributable to another medical condition and are not better explained by another mental disorder (Criterion D). Substance intoxication is common among those with a substance use disorder but also occurs frequently in individuals without a substance use disorder. This category does not apply to tobacco.

What is the essential feature for substance withdrawal?

The essential feature is the development of a 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 (Criterion A). The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The symptoms are not due to another medical condition and are not better explained by another mental disorder (Criterion D). Withdrawal is usually, but not always, associated with a substance use disorder. Most individuals with withdrawal have an urge to re-administer the substance to reduce the symptoms.

What is the essential feature of a substance use disorder?

The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance de spite significant substance-related problems. The diagnosis of a sub stance use disorder can be applied to all 10 classes included in this chapter except caffeine. For certain classes some symptoms are less salient, and in a few instances not all symptoms apply (e.g., withdrawal symptoms are not specified for phencyclidine use disorder, other hallucinogen use disorder, or inhalant use disorder).

What is the essential feature of alcohol intoxication?

The essential feature of alcohol intoxication is the presence of clinically significant problematic behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning) that develop during, or shortly after, alcohol ingestion (Criterion B). These changes are accompanied by evidence of impaired functioning and judgment and, if intoxication is intense, can result in a life-threatening coma. The symptoms must not be attributable to another medical condition (e.g., diabetic ketoacidosis), are not a reflection of conditions such as delirium, and are not related to intoxication with other depressant drugs (e.g., benzodiazepines) (Criterion D). The levels of incoordination can interfere with driving abilities and performance of usual activities to the point of causing accidents. Evidence of alcohol use can be obtained by smelling alcohol on the individual's breath, eliciting a history from the individual or another observer, and, when needed, having the individual provide breath, blood, or urine samples for toxicology analyses.

What is the essential feature of alcohol withdrawal?

The essential feature of alcohol withdrawal is the presence of a characteristic withdrawal syndrome that develops within several hours to a few days after the cessation of (or reduction in) heavy and prolonged alcohol use (Criteria A and B). The withdrawal syndrome includes two or more of the symptoms reflecting autonomic hyperactivity and anxiety listed in Criterion B, along with gastrointestinal symptoms.

What is the essential feature of cannabis withdrawal?

The essential feature of cannabis withdrawal is the presence of a characteristic withdrawal syndrome that develops after the cessation of or substantial reduction in heavy and pro longed cannabis use. In addition to the symptoms in Criterion B, the following may also be observed post-abstinence: - fatigue, - yawning, - difficulty concentrating, and - rebound periods of increased appetite and hypersomnia that follow initial periods of loss of appetite and insomnia. For the diagnosis, withdrawal symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). Many cannabis users report smoking cannabis or taking other substances to help relieve withdrawal symptoms, and many report that withdrawal symptoms make quitting difficult or have contributed to relapse. The symptoms typically are not of sufficient severity to require medical attention, but medication or behavioral strategies may help alleviate symptoms and improve prognosis in those trying to quit using cannabis.

What is the onset and progression of alcohol use?

The first episode of alcohol intoxication is likely to occur during the mid-teens. Alcohol- related problems that do not meet full criteria for a use disorder or isolated problems may occur prior to age 20years, but the age at onset of an alcohol use disorder with two or more of the criteria clustered together peaks in the late teens or early to mid 20s. The large majority of individuals who develop alcohol-related disorders do so by their late 30s. The first evidence of withdrawal is not likely to appear until after many other aspects of an alcohol use disorder have developed. An earlier onset of alcohol use disorder is observed in adolescents with preexisting conduct problems and those with an earlier onset of intoxication.

Why is it important to recognize alcohol induced disorder before diagnosing a mental disorder?

The importance of recognizing an alcohol-induced disorder is similar to the relevance of identifying the possible role of some endocrine conditions and medication reactions before diagnosing an independent mental disorder. In light of the high prevalence of alcohol use disorders worldwide, it is important that these alcohol-induced diagnoses be considered before independent mental disorders are diagnosed.

What are the criteria for a substance use disorder

The individual may take the substance in larger amounts or over a longer period than was originally intended (Criterion 1). The individual may express a persistent desire to cut down or regulate substance use and may report multiple unsuccessful efforts to decrease or discontinue use (Criterion 2). The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects (Criterion 3). In some instances of more severe substance use disorders, virtually all of the individual's daily activities revolve around the substance.

What are Nonpathological use of alcohol?

The key element of alcohol use disorder is the use of heavy doses of alcohol with resulting repeated and significant distress or impaired functioning. While most drinkers sometimes consume enough alcohol to feel intoxicated, only a minority (less than 20%) ever develop alcohol use disorder. Therefore, drinking, even daily, in low doses and occasional intoxication do not by themselves make this diagnosis.

What is the percentage of alcohol consumers who report intoxication at one time?

The large majority of alcohol consumers are likely to have been intoxicated to some degree at some point in their lives. For example, in 2010, 44% of 12th-grade students admitted to having been "drunk in the past year," with more than 70% of college students reporting the same.

What are the cultural factors related to alcohol intoxication?

The major issues parallel the cultural differences regarding the use of alcohol overall. Thus, college fraternities and sororities may encourage alcohol intoxication. This condition is also frequent on certain dates of cultural significance (e.g.. New Year's Eve) and, for some subgroups, during specific events (e.g., wakes following funerals). Other subgroups encourage drinking at religious celebrations (e.g., Jewish and Catholic holidays), while still others strongly discourage all drinking or intoxication (e.g., some religious groups, such as Mormons, fundamentalist Christians, and Muslims).

what do Substance/Medication-Induced Mental Disorders include?

The medication-induced conditions include what are often idiosyncratic CNS reactions or relatively extreme examples of side effects for a wide range of medications taken for a variety of medical concerns. These include neurocognitive complications of anesthetics, antihistamines, antihypertensives, and a variety of other medications and toxins (e.g., organophosphates, insecticides, carbon monoxide), as described in the chapter on neurocognitive disorders. Psychotic syndromes may be temporarily experienced in the context of anticholinergic, cardiovascular, and steroid drugs, as well as during use of stimulant like and depressant-like prescription or over-the-counter drugs. Temporary but severe mood disturbances can be observed with a wide range of medications, including steroids, antihypertensives, disulfiram, and any prescription or over-the-counter depressant or stimulant-like substances. A similar range of medications can be associated with tempo rary anxiety syndromes, sexual dysfunctions, and conditions of disturbed sleep.

What are the most common changes in intoxication?

The most common changes in intoxication involve disturbances of perception, wake fulness, attention, thinking, judgment, psychomotor behavior, and interpersonal behavior. Short-term, or "acute," intoxications may have different signs and symptoms than sustained, or "chronic," intoxications. For example, moderate cocaine doses may initially produce gregariousness, but social withdrawal may develop if such doses are frequently repeated over days or weeks.

What is the onset period of cannabis use?

The onset of cannabis use disorder can occur at any time during or following adolescence, but onset is most commonly during adolescence or young adulthood. Although much less frequent, onset of cannabis use disorder in the preteen years or in the late 20s or older can occur. Recent acceptance by some of the use and availability of "medical marijuana" may increase the rate of onset of cannabis use disorder among older adults.

What is the onset and frequency of gambling disorder?

The onset of gambling disorder can occur during adolescence or young adulthood, but in other individuals it manifests during middle or even older adulthood. Generally, gambling disorder develops over the course of years, although the progression appears to be more rapid in females than in males. Most individuals who develop a gambling disorder evidence a pattern of gambling that gradually increases in both frequency and amount of wagering. Certainly, milder forms can develop into more severe cases. Most individuals with gambling disorder report that one or two types of gambling are most problematic for them, although some individuals participate in many forms of gambling. Individuals are likely to engage in certain types of gambling (e.g., buying scratch tickets daily) more frequently than others (e.g., playing slot machines or blackjack at the casino weekly). Frequency of gambling can be related more to the type of gambling than to the severity of the overall gambling disorder. For example, purchasing a single scratch ticket each day may not be problematic, while less frequent casino, sports, or card gambling may be part of a gambling disorder. Similarly, amounts of money spent wagering are not in themselves indicative of gambling disorder. Some individuals can wager thousands of dollars per month and not have a problem with gambling, while others may wager much smaller amounts but experience substantial gambling-related difficulties.

What is included in the substance-induced disorders?

The overall category of substance-induced disorders includes intoxication, withdrawal, and other substance/medication-induced mental disorders (e.g., substance-induced psychotic disorder, substance-induced depressive disorder).

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The pharmacological mechanisms by which each class of drugs produces reward are different, but the drugs typically activate the system and produce feelings of pleasure, often referred to as a ''high." Furthermore, individuals with lower levels of self-control, which may reflect impairments of brain inhibitory mechanisms, may be particularly predisposed to develop substance use disorders, suggesting that the roots of substance use disorders for some persons can be seen in behaviors long before the onset of actual substance use itself.

What are environmental risk factors for alcohol withdrawal?

The probability of developing alcohol withdrawal increases with the quantity and frequency of alcohol consumption. Most individuals with this condition are drinking daily, consuming large amounts (approximately more than eight drinks per day) for multiple days. However, there are large inter-individual differences, with enhanced risks for individuals with concurrent medical conditions, those with family histories of alcohol withdrawal (i.e., a genetic component), those with prior withdrawals, and individuals who consume sedative, hypnotic, or anxiolytic drugs.

What consequences are likely to apply to substance/medication-induced mental disorders?

The same consequences related to the relevant independent mental disorder (e.g., suicide attempts) are likely to apply to the substance/medication-induced mental disorders, but these are likely to disappear within 1 month after abstinence. Similarly, the same functional consequences associated with the relevant substance use disorder are likely to be seen for the substance-induced mental disorders.

What is the relationship between sedative, hypnotic, or anxiolytic use disorder and alcohol use disorder?

The signs and symptoms of alcohol use disorder are similar to those seen in sedative, hypnotic, or anxiolytic use disorder. The two must be distinguished, however, because the course may be different, especially in relation to medical problems.

What two groups are substance-related disorders are divided into?

The substance-related disorders are divided into two groups: substance use disorders and substance-induced disorders. The following conditions may be classified as sub stance-induced: intoxication, withdrawal, and other substance/medication-induced mental disorders (psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders).

Why is it important to recognizing a substance/medication-induced mental disorders?

The substance/medication-induced mental disorders are an important part of the differential diagnoses for the independent psychiatric conditions. The importance of recognizing an induced mental disorder is similar to the relevance of identifying the possible role of some medical conditions and medication reactions before diagnosing an independent mental disorder. Symptoms of substance- and medication-induced mental disorders may be identical cross-sectionally to those of independent mental disorders but have different treatments and prognoses from the independent condition

How are substance/medication-induced mental disorders distinguished?

The substance/medication-induced mental disorders are potentially severe, usually temporary, but sometimes persisting central nervous system (CNS) syndromes that develop in the context of the effects of substances of abuse, medications, or several toxins. They are distinguished from the substance use disorders, in which a cluster of cognitive, behavioral, and physiological symptoms contribute to the continued use of a substance despite significant substance-related problems.

Which classes can induce Substance/Medication-Induced Mental Disorders?

The substance/medication-induced mental disorders may be induced by the 10 classes of substances that produce substance use disorders, or by a great variety of other medications used in medical treatment. Each substance- induced mental disorder is described in the relevant chapter (e.g., "Depressive Disorders," "Neurocognitive Disorders"), and therefore, only a brief description is offered here. All substance/medication-induced disorders share common characteristics. It is important to recognize these common features to aid in the detection of these disorders.

What are the symptom profiles?

The symptom profiles for the substance/medication-induced mental disorders resemble independent mental disorders. While the symptoms of substance/medication-induced mental disorders can be identical to those of independent mental disorders (e.g., delusions, hallucinations, psychoses, major depressive episodes, anxiety syndromes), and although they can have the same severe consequences (e.g., suicide), most induced mental disorders are likely to improve in a matter of days to weeks of abstinence.

What other medical conditions can mimic alcohol withdrawal?

The symptoms of alcohol withdrawal can also be mimicked by some medical conditions (e.g., hypoglycemia and diabetic ketoacidosis). Essential tremor, a disorder that frequently runs in families, may erroneously suggest the tremulousness associated with alcohol withdrawal.

What are the age and gender variations of gambling disorder?

There are age and gender variations in the type of gambling activities and the prevalence rates of gambling disorder. Gambling disorder is more common among younger and middle-age persons than among older adults. Among adolescents and young adults, the disorder is more prevalent in males than in females. Younger individuals prefer different forms of gambling (e.g., sports betting), while older adults are more likely to develop problems with slot machine and bingo gambling. Although the proportions of individuals who seek treatment for gambling disorder are low across all age groups, younger individuals are especially unlikely to present for treatment.

What is the effect of abuse of some medications in the context of a preexisting mental disorder?

There are indications that the intake of substances of abuse or some medications with psychiatric side effects in the context of a preexisting mental disorder is likely to result in an intensification of the preexisting independent syndrome. The risk for substance/medication-induced mental disorders is likely to increase with both the quantity and the frequency of consumption of the relevant substance.

When does the specifier "with perceptual disturbances" apply?

This specifier applies in the rare instance when hallucinations (usually visual or tactile) occur with intact reality testing, or auditory, visual, or tactile illusions occur in the absence of a delirium.

What is a possible impact of unanticipated alcohol withdrawal?

Unanticipated alcohol withdrawal in hospitalized individuals for whom a diagnosis of alcohol use disorder has been overlooked can add to the risks and costs of hospitalization and to time spent in the hospital.

What are physiological changes of intoxication?

When used in the physiological sense, the term intoxication is broader than substance intoxication as defined here. Many substances may produce physiological or psychological changes that are not necessarily problematic. For example, an individual with tachycardia from substance use has a physiological effect, but if this is the only symptom in the absence of problematic behavior, the diagnosis of intoxication would not apply. Intoxication may sometimes persist beyond the time when the substance is detectable in the body. This may be due to enduring central nervous system effects, the recovery of which takes longer than the time for elimination of the substance. These longer-term effects of intoxication must be distinguished from withdrawal (i.e., symptoms initiated by a decline in blood or tissue concentrations of a substance).

What are some common patterns of cannabis use in adolescents?

With adolescent users, changes in mood stability, energy level, and eating patterns are commonly observed. These signs and symptoms are likely due to the direct effects of cannabis use (intoxication) and the subsequent effects following acute intoxication (coming down), as well as attempts to conceal use from others. School-related problems are commonly associated with cannabis use disorder in adolescents, particularly a dramatic drop in grades, truancy, and reduced interest in general school activities and outcomes.

What is withdrawal?

Withdrawal (Criterion 11) is a syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing withdrawal symptoms, the individual is likely to consume the substance to relieve the symptoms. Withdrawal symptoms vary greatly across the classes of substances, and separate criteria sets for withdrawal are provided for the drug classes. Marked and generally easily measured physiological signs of withdrawal are common with alcohol, opioids, and sedatives, hypnotics, and anxiolytics. Withdrawal signs and symptoms with stimulants (amphetamines and cocaine), as well as tobacco and cannabis, are often present but may be less apparent.

Who is most likely to experience alcohol withdrawal?

Withdrawal is more likely to occur with heavier alcohol intake, and that might be most often observed in individuals with conduct disorder and antisocial personality disorder. Withdrawal states are also more severe in older individuals, individuals who are also dependent on other depressant drugs (sedative-hypnotics), and individuals who have had more alcohol withdrawal experiences in the past.

What are the impact of withdrawal symptoms?

Withdrawal symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The symptoms must not be attributable to another medical condition and are not better explained by another mental disorder (e.g., generalized anxiety disorder), including intoxication or withdrawal from another substance (e.g., sedative, hypnotic, or anxiolytic withdrawal) (Criterion D).

What effect does short and long acting substances have on withdrawal?

Within the same drug category, relatively short-acting substances tend to have a higher potential for the development of withdrawal than do those with a longer duration of action. However, longer-acting substances tend to have longer withdrawal duration. The half-life of the substance parallels aspects of withdrawal: the longer the duration of action, the longer the time between cessation and the onset of withdrawal symptoms and the longer the withdrawal duration. In general, the longer the acute withdrawal period, the less intense the syndrome tends to be.

How is the specifier "in early remission" and "In sustained remission" described?

in early remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, "Craving, or a strong desire or urge to use alcohol," may be met). In sustained remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, "Craving, or a strong desire or urge to use alcohol," may be met).

What specifiers are also used in diagnosing gambling disorder?

in early remission: After full criteria for gambling disorder were previously met, none of the criteria for gambling disorder have been met for at least 3 months but for less than 12 months. in sustained remission: After full criteria for gambling disorder were previously met, none of the criteria for gambling disorder have been met during a period of 12 months or longer.