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fatal overdoses. Taken to the extreme, the wide-

spread illicit manufacture and use of designer drugs

with unknown toxicity could result in millions of

people ingesting the drug before the toxic effects

are known, potentially producing an epidemic of

neurodegenerative disorders and fatalities.

See also Controlled Substances Act of 1970; MDMA; MPTP.

B I B L I O G R A P H Y

Barnett, G., & Rapaka, R. S. (1989). Designer drugs: An

overview. In K. K. Redda, C. A. Walker, & G. Barnett

(Eds.), Cocaine, marijuana, designer drugs: Chemistry,

pharmacology, and behavior (pp. 163–174). Boca

Raton, FL: CRC Press.

Beebe, D. K., & Walley, E. (1991). Substance abuse: The designer drugs. American Family Physician, 43(5), 1689–1698.

Christophersen, A. S. (2000). Amphetamine designer drugs: An overview and epidemiology. Toxicology Let- ters, 112–113, 127–131.

de Boer, D., Bosman, I. J., Hidvégi, E., Manzoni, C., Benkö, A. A., dos Reys, L. J., et al. (2001). Pipera- zine-like compounds: A new group of designer drugs- of-abuse on the European market. Forensic Science International, 121(1–2), 47–56.

Klein, M., & Kramer, F. (2004). Rave drugs: Pharmaco- logical considerations. AANA Journal, 72(1), 61–67.

Maurer, H. H., Kraemer, T., Springer, D., & Staack, R. F. (2004). Chemistry, pharmacology, toxicology, and hepatic metabolism of designer drugs of the amphet- amine (ecstasy), piperazine, and pyrrolidinophenone types: A synopsis. Therapeutic Drug Monitoring, 26(2), 127–131.

Nichols, D. E. (1989). Substituted amphetamine controlled substance analogues. In K. K. Redda, C. A. Walker & G. Barnett (Eds.), Cocaine, marijuana, designer drugs: Chemistry, pharmacology, and behavior (pp. 175–185). Boca Raton, FL: CRC Press.

Soine, W. H. (1986). Clandestine drug synthesis. Medicinal Research Reviews, 6(1), 41–47.

Staack, R. F., & Maurer, H. H. (2005). Metabolism of designer drugs of abuse. Currents in Drug Metabolism, 6(3), 259–274.

Trevor, A., Castagnoli, N., Jr., & Singer, T. P. (1989). Pharmacology and toxicology of MPTP: A neurotoxic by-product of illicit designer drug chemistry. In K. K. Redda, C. A. Walker & G. Barnett (Eds.), Cocaine, marijuana, designer drugs: Chemistry, pharmacology, and behavior (pp. 187–200). Boca Raton, FL: CRC Press.

Ziporyn, T. (1986). A growing industry and menace: Makeshift laboratory’s designer drugs. Journal of the American Medical Association, 256(22), 3061–3063.

NICHOLAS E. GOEDERS

n

DEXTROAMPHETAMINE. This is the d-isomer of amphetamine. It is classified as a psy- chomotor stimulant drug and is three to four times as potent as the l-isomer in eliciting central nervous system (CNS) excitatory effects. It is also more potent than the l-isomer in its anorectic (appetite suppressant) activity, but slightly less potent in its cardiovascular actions. It is prescribed in the treat- ment of narcolepsy and obesity, although care must be taken in such prescribing because of the sub- stantial abuse liability.

High-dose chronic use of dextroamphetamine can lead to the development of a toxic psychosis as well as to other physiological and behavioral prob- lems. This toxicity became a problem in the United States in the 1960s, when substantial amounts of the drug were being taken for nonmedical reasons. Although still abused by some, dextroamphet- amine is no longer the stimulant of choice for most psychomotor stimulant abusers.

See also Amphetamine Epidemics, International; Coca/ Cocaine, International.

B I B L I O G R A P H Y

de Wit, H., et al (2002). Acute administration of d-amphet- amine decreases impulsivity in healthy volunteers. Neu- ropsychopharmacology, 27, 813–825.

Schmetzer, A. D. (2004). The psychostimulants. Annals of the American Psychotherapy Association, 7, 31–32.

MARIAN W. FISCHMAN

n

DIAGNOSIS OF SUBSTANCE USE DISORDERS: DIAGNOSTIC CRI- TERIA. Diagnosis is the process of identifying and labeling specific disease conditions. The signs and symptoms used to classify a sick person as having a disease are called diagnostic criteria. Diag- nostic criteria and classification systems are useful for making clinical decisions, estimating disease

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prevalence, understanding the causes of disease, and facilitating scientific communication.

Diagnostic classification provides the treating clinician with a basis for retrieving information about a patient’s probable symptoms, the likely course of an illness, and the biological or psychological processes that underlie the disorder. For example, the Diagnostic and Statistical Manual (DSM) of the American Psy- chiatric Association is a classification of mental disor- ders that provides the clinician with a systematic description of each disorder in terms of essential fea- tures, age of onset, probable course, predisposing fac- tors, associated features, and differential diagnosis. Mental health professionals can use this system to diagnose substance use disorders in terms of the fol- lowing categories: acute intoxication, abuse, depend- ence, withdrawal, delirium, and other disorders. In contrast to screening, diagnosis typically involves a broader evaluation of signs, symptoms, and laboratory data as these relate to the patient’s illness. The purpose of diagnosis is to provide the clinician with a logical basis for planning treatment and estimating prognosis.

Another purpose of classification is the collec- tion of statistical information on a national and international scale. The primary purpose of the World Health Organization’s International Classi- fication of Diseases (ICD), for example, is the enu- meration of morbidity and mortality data for public health planning. In addition, a good classification will facilitate communication among scientists and provide the basic concepts needed for theory devel- opment. Both the DSM and ICD have also been used extensively to classify persons for scientific research. Classification thus provides a common frame of reference in communicating scientific findings.

Diagnosis may also serve a variety of adminis- trative purposes. When a patient is suspected of having a substance use disorder, diagnostic proce- dures are needed to exclude ‘‘false positives’’ (i.e., people who appear to have the disorder but who really do not) and borderline cases. Insurance reim- bursement for medical treatment increasingly demands that a formal diagnosis be confirmed according to standard procedures or criteria. The need for uniform reporting of statistical data, as well as the generation of prevalence estimates for epidemiological research, often requires a diagnos- tic classification of the patient.

CLASSIFICATION SYSTEMS

Alcoholism and drug addiction have been variously defined as medical diseases, mental disorders, social problems, and behavioral conditions. In some cases, they are considered the symptom of an underlying mental disorder (Babor, 1992). Some of these definitions permit the classification of alco- holism and drug dependence within standard nomenclatures such as the DSM and ICD. The most recent revisions of both of these diagnostic systems—DSM-IV (1994) and ICD-10 (1992)— have resulted in a high degree of compatibility between the classification criteria used in the United States and those used internationally. Both systems now diagnose dependence according to the elements first proposed by Edwards and Gross (1976). They also include a residual category (harmful alcohol use [ICD-10]; alcohol abuse [DSM-IV]) that allows classification of psycholog- ical, social, and medical consequences directly related to substance use.

HISTORY TAKING

Obtaining accurate information from patients with alcohol and drug problems is often difficult because of the stigma associated with substance abuse and the fear of legal consequences. At times, these individuals want help for the medical compli- cations of substance use (such as injuries or depres- sion) but are ambivalent about giving up alcohol or drug use entirely. It is often the case that these patients are evasive and attempt to conceal or min- imize the extent of their alcohol or drug use. Acquiring accurate information about the presence, severity, duration, and effects of alcohol and drug use therefore requires a considerable amount of clinical skill.

The medical model for history taking is the most widely used approach to diagnostic evalua- tion. This model consists of identifying the chief complaint, evaluating the present illness, reviewing past history, conducting a review of biological sys- tems (e.g., gastrointestinal, cardiovascular), asking about family history of similar disorders, and dis- cussing the patient’s psychological and social func- tioning. A history of the present illness begins with questions on the use of alcohol, drugs, and tobacco. The questions should cover prescription drugs as well as illicit drugs, with additional elabo- ration of the kinds of drugs, the amount used, and

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the mode of administration (e.g., smoking, injec- tion). Questions about alcohol use should refer specifically to the amount and frequency of using the major beverage types (wine, spirits, and beer). A thorough physical examination is important because each substance has specific pathological effects on certain organs and body systems. For example, alcohol commonly affects the liver, stom- ach, cardiovascular system, and nervous system, while drugs often produce abnormalities in ‘‘vital signs’’ such as temperature, pulse, and blood pressure.

A mental status examination frequently gives

evidence of substance use disorders, which can be

signaled by poor personal hygiene, inappropriate

affect (e.g., sad, euphoric, irritable, anxious), illog-

ical or delusional thought processes, and memory

problems. The physical examination can be supple-

mented by laboratory tests, which sometimes aid in

early diagnosis before severe or irreversible damage

has taken place. Laboratory tests are useful in two

ways: (1) alcohol and drugs can be measured

directly in blood, urine, or exhaled air; (2) bio-

chemical and psychological functions known to be

affected by substance use can be assessed. Many

drugs can be detected in the urine for 12 to 48

hours after their consumption. An estimate of

blood alcohol concentration (BAC) can be made

directly by blood test or indirectly by means of a

breath or saliva test. Elevations of the liver enzyme

gamma-glutamyl transpeptidase (GGTP) or the

protein carbohydrate-deficient transferrin (CDT)

are sensitive indicators of chronic and heavy alco-

hol intake. However, while these tests can detect

recent use of a wide variety of psychoactive sub-

stances (e.g., opioids, cannabis, stimulants, barbi-

turates), they are not able to detect alcohol or

drug dependence.

In addition to the physical examination and labo- ratory tests, a variety of diagnostic interview proce- dures have been developed to provide objective, empirically based, reliable diagnoses of substance use disorders in various clinical populations. One type, exemplified by the Diagnostic Interview Schedule (DIS; see Robins et al., 1981) and the Composite International Diagnostic Interview (CIDI; see Robins et al., 1988), is highly structured and requires a minimum of clinical judgment by the interviewer. These interviews provide information not only about

substance use disorders, but also about physical con- ditions and psychiatric disorders that are commonly associated with substance abuse. Because of its stand- ardized questioning procedures, the CIDI has been used by the World Health Organization to estimate the prevalence of mental disorders, including sub- stance use disorders, in the general populations of countries throughout the world (Haro et al., 2006). In the United States, the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV) has been used extensively in popu- lation surveys, including the National Epidemiologic Survey on Alcohol and Related Conditions (Grant et al., 2003). It covers alcohol consumption, tobacco use, family history of depression, and selected DSM- IV Axis I and II psychiatric disorders.

A second type of diagnostic interview is exempli-

fied by the Structured Clinical Interview for DSM-IV (SCID), which is designed for use by mental health

professionals (Spitzer et al., 1992; First et al., 2002).

The SCID assesses the most commonly occurring

psychiatric disorders described in DSM-IV, including mood disorders, schizophrenia, and substance use

disorders. A similar clinical interview designed for

international use is the Schedules for Clinical Assess-

ment in Neuropsychiatry (SCAN; see Wing et al.,

1990). The SCID and SCAN interviews allow the

experienced clinician to tailor questions to fit the

patient’s understanding, to ask additional questions

that clarify ambiguities, to challenge inconsistencies,

and to make clinical judgments about the seriousness

of symptoms. Both are modeled on the standard

medical history practiced by many mental health

professionals. Questions about the chief complaint,

past episodes of psychiatric disturbance, treatment

history, and current functioning all contribute to a

thorough and orderly psychiatric history that is

extremely useful for diagnosing substance use disor-

ders. The Psychiatric Research Interview for Sub-

stance and Mental Disorders (PRISM; Hasin et al.,

2006) is another semistructured diagnostic inter-

view. It is designed to deal with the problems of

psychiatric diagnosis when subjects or patients drink

heavily or use drugs. The PRISM is used for making a

number of DSM-IV Axis I and Axis II diagnoses, including alcohol and drug use disorders, in a way

that allows differentiation of psychiatric disorders

from substance-induced disorders and from the

expected effects of intoxication and withdrawal.

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In recent years, there has been interest in devel- oping better methods to obtain accurate information from patients with substance use disorders, both for diagnostic purposes and for the measurement of treatment outcomes. It has been assumed that infor- mation obtained from alcohol and drug users cannot be trusted, because they often unconsciously deny that they have a problem or deliberately lie about their substance use to avoid the embarrassment of being labeled as an alcoholic or a drug addict. Another factor is clinical suspicion that individuals with substance use disorders often are not capable of reporting their symptoms accurately, due to the cog- nitive effects of chronic substance use.

With advances in the technology of psychiatric

interviewing, questionnaire design, and psycholog-

ical measurement, it is now possible to obtain valid

measurement at the symptom level and to improve

classification accuracy at the syndrome level (Haro

et al., 2006). According to one systematic review of

methodological studies, self-report measures using

questionnaires and interviews tend to be valid and

reliable in the aggregate under most circumstances

(Del Boca & Noll, 2000). Nevertheless, patients

may bias their responses in a socially desirable

direction when they do not understand the pur-

pose of the questions, feel threatened by the possi-

ble outcome of the diagnostic evaluation (e.g.,

being labeled as having a psychiatric disorder), have

cognitive disabilities that affect memory and recall,

or have personality characteristics (e.g., psychopa-

thy) that increase the chances of deliberate lying.

DIAGNOSIS OF ABUSE AND HARMFUL USE

A major diagnostic category that has received

increasing attention in research and clinical practice

is substance abuse—in contrast to dependence.

This category permits the classification of malad-

aptive patterns of alcohol or drug use that do not

meet criteria for dependence. The diagnosis of

abuse is designed primarily for persons who have

recently begun to experience alcohol or drug prob-

lems, as well as for chronic users whose substance-

related consequences develop in the absence of

marked dependence symptoms. Examples of situa-

tions in which this category would be appropriate

include: (1) a pregnant woman who keeps drinking

alcohol even though her physician has told her that

it could cause fetal damage; (2) a college student

whose weekend binges result in missed classes,

poor grades, and alcohol-related traffic accidents;

(3) a middle-aged beer drinker regularly consum-

ing a six-pack each day who develops high blood

pressure and fatty liver in the absence of alcohol-

dependence symptoms; and (4) an occasional mar-

ijuana smoker who has an accidental injury while

intoxicated.

In the fourth revision of the Diagnostic and Statistical Manual (American Psychiatric Associa- tion, 1994), substance abuse is defined as a malad- aptive pattern of alcohol or drug use leading to clinically significant impairment or distress, as man- ifested by one or more of the symptoms listed in Table 1. (For comparative purposes, the table also lists the criteria for harmful use in ICD-10.) To assure that the diagnosis is based on clinically meaningful symptoms, rather than the results of an occasional excess, the duration criterion specifies how long the symptoms must be present to qualify for a diagnosis.

In ICD-10, the term harmful use refers to a pattern of using one or more psychoactive substan- ces that causes damage to health. The damage may be: (1) physical (physiological)—such as pancreati- tis from alcohol or hepatitis from needle-injected drugs; or (2) mental (psychological)—such as depression related to heavy drinking or drug use. Adverse social consequences often accompany sub- stance use, but they are not in themselves sufficient to result in a diagnosis of harmful use. The key issue in the definition of this term is the distinction between perceptions of adverse effects (e.g., wife complaining about husband’s drinking) and actual health consequences (e.g., trauma due to accidents during drug intoxication). Since the purpose of ICD is to classify diseases, injuries, and causes of death, harmful use is defined as a pattern of use already causing damage to health.

Harmful patterns of use are often criticized by others, and they are sometimes legally prohibited by governments. However, the fact that alcohol or drug intoxication is disapproved by another person or by the user’s culture is not in itself evidence of harmful use, unless socially negative consequences have actually occurred at dosage levels that also result in psychological and physical consequences. This is the major difference that distinguishes

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ICD-10’s harmful use from DSM-IV ’s substance abuse—the latter category includes social conse- quences in the diagnosis of abuse.

THE DEPENDENCE SYNDROME CONCEPT

The diagnosis of substance use disorders in ICD-10

and DSM-IV is based on the concept of a ‘‘depend-

ence syndrome,’’ which is distinguished from dis-

abilities caused by substance use (Edwards, Arif, &

Hodgson, 1981). An important diagnostic issue is

the extent to which dependence is sufficiently dis-

tinct from abuse or harmful use to be considered a

separate condition. In DSM-IV, substance abuse is a

residual category that allows the clinician to classify

clinically meaningful aspects of a patient’s behavior

when that behavior is not clearly associated with a

dependence syndrome. In ICD-10, harmful sub-

stance use implies identifiable substance-induced

medical or psychiatric consequences that occur in

the absence of a dependence syndrome. In both

classification systems, dependence is conceived as

an underlying condition that has much greater

clinical significance because of its implications for

understanding etiology, predicting course, and

planning treatment.

The dependence syndrome is seen as an interre-

lated cluster of cognitive, behavioral, and physiolog-

ical symptoms. Table 2 summarizes the criteria used

to diagnose dependence in ICD-10 and DSM-IV. A

diagnosis of dependence in all systems is made if

three or more of the criteria have been experienced

at some time in the previous twelve months.

The dependence syndrome may be present for a specific substance (e.g., tobacco, alcohol,

or diazepam), for a class of substances (e.g., opioid drugs), or for a wider range of various substances. A diagnosis of dependence does not necessarily imply the presence of physical, psychological, or social consequences, although some form of harm is usually present. There are some differences among these classification systems, but the criteria are very similar, making it unlikely that a patient diagnosed in one system would be diagnosed differently in the other.

The syndrome concept implicit in the diagnosis of alcohol and drug dependence in ICD and DSM is a way of describing the nature and severity of addic- tion (Babor, 1992). Table 2 describes four depend- ence syndrome elements (salience, impaired control, tolerance, withdrawal, and withdrawal relief) in rela- tion to the criteria for DSM-IV, and ICD-10. The same elements apply to the diagnosis of dependence on all psychoactive substances, including alcohol, marijuana, opioids, cocaine, sedatives, phencyclidine, other hallucinogens, and tobacco. The elements repre- sent biological, psychological (cognitive), and behavio- ral processes. This helps to explain the linkages and interrelationships that account for the coherence of signs and symptoms. The co-occurrence of signs and symptoms is the essential feature of a syndrome. If three or more criteria occur repeatedly during the same period, it is likely that dependence is responsible for the amount, frequency, and pattern of the per- son’s substance use.

Salience. Salience means that drinking or drug use is given a higher priority than other activities in spite of its negative consequences. This is reflected in the emergence of substance use as the preferred activity from a set of available alternative activities. In addi- tion, the individual does not respond well to the

ICD-10 Criteria for Harmful Use DSM-IV Criteria for Abuse

Symptom Criteria

The pattern of use has persisted for at least 1 month or has occurred repeatedly over the previous 12 months

Clear evidence that alcohol or drug use is responsible for causing actual psychological or physical harm to the user

A maladaptive pattern of alcohol or drug use indicated by at least one of the following: (1) failure to fulfill major role obligations at work, school, or home (e.g., neglect of children or household); (2) use in situations in which it is physically hazardous (e.g., driving an automobile); (3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct); (4) continued substance use despite having recurrent social or interpersonal problems

Duration Criterion One or more symptoms has occurred during the same 12-month period

Table 1. Diagnostic Criteria for Harmful Use (IDC-10) and Substance Abuse (DSM-III-R, DSM-IV). ILLUSTRATION BY GGS INFORMATION

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normal processes of social control. For example, when drinking to intoxication goes against the tacit social rules governing the time, place, or amount typically expected by the user’s family or friends, this may indicate increased salience.

One indication of salience is the amount of

time or effort devoted to obtaining, using, or

recovering from substance use. For example, peo-

ple who spend a great deal of time at parties, bars,

or business lunches give evidence of the increased

salience of drinking over nondrinking activities.

Chronic drinking and drug intoxication interfere

with the person’s ability to conform to tacit social

rules governing daily activities—such as keeping

appointments, caring for children, or performing a

job properly—that are typically expected by the per-

son’s reference group. Substance use also results in

mental and medical consequences. Thus, a key aspect

of the dependence syndrome is the persistence of

substance use in spite of social, psychological, or

physical harm—such as loss of employment, marital

problems, depressive symptoms, accidents, and liver

disease. This indicates that substance use is given a

higher priority than other activities, in spite of its

negative consequences.

One explanation for the salience of drug- and alco- hol-seeking behaviors despite negative consequences is the relative reinforcement value of immediate and long-

term consequences. For many alcoholics and drug abusers, the immediate positive reinforcing effects of the substance, such as euphoria or stimulation, far out- weigh any delayed negative consequences, which may occur either infrequently or inconsistently.

Impaired Control. The main characteristic of

impaired control is the lack of success in limiting

the amount or frequency of substance use. For

example, the alcoholic wants to stop drinking, but

repeated attempts to do so have been unsuccessful.

Typically, rules and other stratagems are used to

avoid alcohol entirely or to limit the frequency of

drinking. A resumption of heavy drinking after

receiving professional help for a drinking problem

is evidence of lack of success. The symptom is

considered present if the drinker has repeatedly

failed to abstain or has only been able to control

drinking with the help of treatment, mutual-help

groups, or removal to a controlled environment

(e.g., prison).

In addition to an inability to abstain, impaired control is also reflected in the failure to regulate the amount of alcohol or drug consumed on a given occasion. The cocaine addict vows to snort only a small amount but then continues until the entire supply is used up. For the alcoholic, impaired control includes an inability to prevent the spontaneous

onset of drinking bouts, as well as a failure to stop

Dependence element

Salience

Impaired control

Tolerance

Withdrawal and withdrawal relief

Diagnostic level

Cognitive, behavioral

Behavioral

Behavioral, cognitive

Behavioral

Biological, behavioral

Behavioral, biological, cognitive

ICD-10 symptoms

Progressive neglect of alternative activities in favor of substance use Persistence with substance use despite harmful consequences

A strong desire or sense of compulsion to drink or use drugs Evidence of impaired capacity to control substance use in terms of its onset, termination, or levels of use

Increased doses of substance are required to achieve effects originally produced by lower doses

A physiological withdrawal state Use to relieve or avoid withdrawal symptoms and subjective awareness that this strategy is effective

DSM-IV symptoms

Important social, occupational, or recreational activities given up Continued use despite psychological or physical problems

Substance often taken in larger amounts or over a longer period than intended Any unsuccessful effort or a persistent desire to cut down or control substance use

Either (a) increased amounts needed to achieve desired effect; or (b) markedly diminished effect with continued use

Either (a) characteristic withdrawal syndrome for substance; or (b) the same substance taken to relieve or avoid symptoms

Table 2. ICD and DSM Diagnostic Criteria for Dependence (labeled according to diagnostic level—physiological, cognitive, and

behavioral—and underlying dependence elements). ILLUSTRATION BY GGS INFORMATION SERVICES. GALE, CENGAGE LEARNING

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drinking before intoxication. This behavior should be

distinguished from situations in which the drinker’s

‘‘control’’ over the onset or amount of drinking is

regulated by social or cultural factors, such as during

college beer parties or fiesta drinking occasions. One

way to judge the degree of impaired control is to

determine whether the drinker or drug user has made

repeated attempts to limit the quantity of substance

use by making rules or imposing limits on his or

her access to alcohol or drugs. The more these

attempts have failed, the more the impaired control is

present.

Tolerance. Tolerance is a decrease in response to a psychoactive substance that occurs with continued use. For example, increased doses of heroin are required to achieve effects originally produced by lower doses. Tolerance may be physical, behavioral, or psychological. Physical tolerance is a change in cellular functioning. The effects of a dependence- producing substance are reduced, even though the cells normally affected by the substance are subjected to the same concentration. A clear example is the finding that alcoholics can drink amounts of alcohol (e.g., a quart of vodka) that would be sufficient to incapacitate or kill nontolerant drinkers.

Tolerance may also develop at the psycholog-

ical and behavioral levels, independent of the bio-

logical adaptation that takes place. Psychological

tolerance occurs when a marijuana smoker or her-

oin user no longer experiences a ‘‘high’’ after the

initial dose of the substance. Behavioral tolerance is

a change in the effect of a substance because the

person has learned to compensate for the impair-

ment caused by a substance. Some alcoholics, for

example, can operate machinery at moderate doses

of alcohol without impairment.

Withdrawal Signs and Symptoms. A ‘‘with-

drawal state’’ is a group of symptoms occurring

after cessation of substance use. It usually occurs

after repeated, and usually prolonged, drinking or

drug use. Both the onset of and course of with-

drawal symptoms are related to the type of sub-

stance and the dose being used immediately

prior to abstinence. Table 3 lists some common

withdrawal symptoms associated with different psy-

choactive substances. Some drugs, such as halluci-

nogens, do not typically produce a withdrawal syn-

drome after cessation of use. Although generally

thought of as not being characterized by with-

drawal symptoms, recent evidence supports the

Symptom

Craving

Tremor

Sweating, fever

Nausea or vomiting

Malaise, fatigue

Hyperactivity, restlessness

Headache

Insomnia

Hallucinations

Convulsions

Delirium

Irritability

Anxiety

Depression

Difficulty concentrating

Gastrointestinal disturbance

Increased appetite

Diarrhea

Alcohol

X

X

X

X

X

X

X

X

X

X

X

X

X

Amphetamine

X

X

X

X

Caffeine

X

X

X

X

Cocaine

X

X

X

X

X

Opioids

X

X

X

X

X

Nicotine

X

X

X

X

X

X

Table 3. Withdrawal symptoms associated with different psychoactive substances. ILLUSTRATION BY GGS INFORMATION SERVICES. GALE,

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existence of a cannabis (marijuana) withdrawal syn-

drome (Agrawal et al., 2008).

Alcohol withdrawal symptoms follow within

hours of the cessation or reduction of prolonged

heavy drinking. These symptoms include tremor,

hyperactive reflexes, rapid heartbeat, hypertension,

general malaise, nausea, and vomiting. Seizures and

convulsions may occur, particularly in people with a

preexisting seizure disorder. Patients may have hal-

lucinations, illusions, or vivid nightmares, and sleep

is usually disturbed. In addition to physical with-

drawal symptoms, anxiety and depression are also

common. Some chronic drinkers never have a long

enough period of abstinence to permit withdrawal

to occur.

The use of a substance with the intention of

relieving withdrawal symptoms and with aware-

ness that this strategy is effective are cardinal

symptoms of dependence. Morning drinking to

relieve nausea or the ‘‘shakes’’ is one of the most

common manifestations of physical dependence in

alcoholics.

Other Features of Dependence. To be labeled

dependence, symptoms must have persisted for at

least one month or must have occurred repeatedly

(two or more times) over a longer period of time.

The patient does not need to be using the sub-

stance continually to have recurrent or persistent

problems. Some symptoms (e.g., craving) may

occur repeatedly whether the person is using the

substance or not.

Many patients with a history of dependence

experience a rapid reinstatement of the syndrome

following resumption of substance use after a

period of abstinence. Rapid reinstatement is a

powerful diagnostic indicator of dependence. It

points to the impairment of control over substance

use, the rapid development of tolerance, and fre-

quently, physical withdrawal symptoms.

Patients who receive opiates or other drugs for

pain relief following surgery (or for a malignant

disease such as cancer) sometimes show signs of a

withdrawal state when the use of these drugs is

terminated. The great majority of these individuals

have no desire to continue taking such drugs, and

they therefore do not fulfill the criteria for

dependence. The presence of a physical withdrawal

syndrome in these patients does not necessarily

indicate dependence, but rather a state of neuro-

adaptation to the drug that was being administered.

It is commonly assumed that severe dependence is

not reversible, and this assumption is supported by

the rapid reinstatement of dependence symptoms

when drinking or drug use is resumed after a period

of detoxification.

CATEGORICAL VERSUS DIMENSIONAL

APPROACHES TO DIAGNOSIS

Clinical decision-making often requires the classifi-

cation of a patient’s condition into discrete catego-

ries reflecting whether a disorder such as alcohol

dependence is present or absent. This kind of cat-

egorical thinking is convenient for the diagnostician

and consistent with the way in which physical diseases

are diagnosed, but it may not fit the way in which

substance use disorders are manifested in clinical

practice. Typically, people with substance use disor-

ders vary widely in the severity of their symptoms,

with no clear demarcation between mild, moderate,

and severe cases. This makes it difficult to diagnose

patients whose problems with substance use are at

the threshold between mild and moderate severity.

For this reason, it has been proposed that the fifth

revision of the Diagnostic and Statistical Manual

(DSM-V) include the option of rating patients’ sub-

stance use disorders along a continuum that reflects

the actual severity of their dependence or abuse

(Helzer et al., 2006). The concept of a continuum

of alcohol dependence with various levels of severity

is consistent with the original formulation of the

dependence syndrome (Edwards et al., 1981), and

it has been supported empirically by psychometric

studies (Hasin, Liu, et al., 2006).

MAKING A DISTINCTION BETWEEN ABUSE

AND DEPENDENCE

Questions have been raised about whether two diag-

noses are needed for substance use disorders, or

whether one diagnosis that combines abuse and

dependence criteria in some form could be more

efficient while still being reliable and valid. A number

of studies using factor analysis have shown that two

factors are generally found to fit existing data better

than a single factor, but that the two factors are very

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highly correlated (Hasin, Hatzenbuehler, et al.,

2006). In the first decade of the twenty-first century,

investigators have used Item Response Theory (IRT)

analysis to examine alcohol abuse and dependence

criteria in general population data (Saha et al.,

2006). These investigators found that alcohol abuse

and dependence criteria appear to combine well into

a single continuum of severity, with some abuse cri-

teria (e.g., interpersonal problems related to drinking,

failure to perform in major roles) actually indicating

more severe aspects of dependence than some of the

currently used dependence criteria (e.g., drinking

more or longer than intended). However, whether

these findings will extend to other substances remains

a question to be answered by further research.

See also Addiction: Concepts and Definitions; Alcohol- ism: Origin of the Term; Blood Alcohol Concen- tration; Computerized Diagnostic Interview Schedule for DSM-IV (C DIS-IV); Diagnostic and Statistical Manual (DSM); International Classifica- tion of Diseases (ICD); Models of Alcoholism and Drug Abuse; Physical Dependence; Risk Factors for Substance Use, Abuse, and Dependence: An Over- view; Structured Clinical Interview for DSM-IV (SCID); Tolerance and Physical Dependence; Wikler’s Conditioning Theory of Drug Addiction.

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THOMAS F. BABOR

n

DIAGNOSTIC AND STATISTICAL MANUAL (DSM). The Diagnostic and Stat- istical Manual of Mental Disorders (DSM) is the most widely accepted psychiatric diagnostic system in the United States, although psychiatric disorders are also included in the International Classification of Diseases (ICD). First published by the Ameri- can Psychiatric Association (APA) in 1952, the DSM is used by medical professionals, insurance

companies, the pharmaceutical industry, and the court system to diagnose and define mental ill- nesses and disorders, including substance abuse and dependence. In fact, the diagnosis code assigned to a case often determines insurance reimburse- ment for treatment. The book is also an important indicator of societal mores: Until 1973 homosex- uality was defined as a mental disorder. This sug- gests that at least some psychiatric disorders are experienced because of the way in which a society reacts to an individual’s behavior, and what is con- sidered deviant in some cultures may be normative in others.

The first tabulation of mental illness in the United States appeared in the 1840 census, when the categories idiots and insane were first counted. By the 1880 census seven types of mental illness were recognized, including epilepsy. In 1917 the Ameri- can Medico-Psychological Association (now the APA), in conjunction with the National Commission on Mental Hygiene, further enlarged its categories of mental illness. This broader list, while certainly of greater clinical use, was still chiefly designed to count the numbers and types of patients in mental hospitals. Several years after this tabulation, the newly renamed APA released a compendium of nationally recognized psychiatric terms—most of which applied to psy- chotic disorders and severe neurological impair- ments—that would become part of the American Medical Association’s standard classified nomencla- ture of disease.

After the end of World War II, the Veterans Administration (VA) added many more diagnoses to the APA inventory, incorporating the various psychological disorders exhibited by servicemen. This expanded compilation proved to be influen- tial, for shortly after its publication, the World Health Organization (WHO) published the sixth edition of its ICD, which for the first time included information on mental disorders, much of it based on the VA classifications.

The first edition of the DSM (DSM-I) was little more than a pamphlet where symptoms were not specified in detail. Its importance, however, lay in its description and definition of the approximately 100 diagnostic categories then recognized by clini- cians. The seventh and eighth editions of ICD heavily influenced DSM-I, like its successor, DSM-II. Until the publication of DSM-III, the American

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D I A G N O S T I C A N D S T A T I S T I C A L M A N U A L ( D S M )