DSM-IV

In DSM-IV, this disorder is called Substance-Induced Sexual Dysfunction

Diagnostic Criteria

A. Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty predominates in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings that the sexual dysfunction is fully explained by substance use as manifested by either (1) or (2):

  1. the symptoms in Criterion A developed during, or within a month of, Substance Intoxication
  2. medication use is etiologically related to the disturbance

C. The disturbance is not better accounted for by a Sexual Dysfunction that is not substance induced. Evidence that the symptoms are better accounted for by a Sexual Dysfunction that is not substance induced might include the following:

  • the symptoms precede the onset of the substance use or dependence (or medication use)
  • the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use
  • there is other evidence that suggests the existence of an independent non-substance-induced Sexual Dysfunction (e.g., a history of recurrent non-substance-related episodes).

Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication only when the sexual dysfunction is in excess of that usually associated with the intoxication syndrome and when the dysfunction is sufficiently severe to warrant independent clinical attention.

Specify if:

  • With Impaired Desire
  • With Impaired Arousal
  • With Impaired Orgasm
  • With Sexual Pain

Specify if:

  • With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome

Specifiers

The following specifiers for Substance-Induced Sexual Dysfunction are selected based on the predominant sexual dysfunction. Although the clinical presentation of the sexual dysfunction may resemble one of the specific primary Sexual Dysfunctions, the full criteria for one of these disorders need not be met.

With Impaired Desire

This specifier is used if deficient or absent sexual desire is the predominant feature.

With Impaired Arousal

This specifier is used if impaired sexual arousal (e.g., erectile dysfunction, impaired lubrication) is the predominant feature.

With Impaired Orgasm

This specifier is used if impaired orgasm is the predominant feature.

With Sexual Pain

This specifier is used if pain associated with intercourse is the predominant feature.

With Onset During Intoxication

Substance-Induced Sexual Dysfunctions usually have their onset during Substance Intoxication, and this may be indicated by noting With Onset During Intoxication.

Recording Procedures

The name of the Substance-Induced Sexual Dysfunction begins with the specific substance (e.g., alcohol, fluoxetine) that is presumed to be causing the sexual dysfunction. The name of the disorder is followed by the specification of predominant symptom presentation (e.g., Cocaine-Induced Sexual Dysfunction, With Impaired Arousal). When more than one substance is judged to play a significant role in the development of the sexual dysfunction, each should be listed separately (e.g., Alcohol-Induced Sexual Dysfunction, With Impaired Arousal; Fluoxetine-Induced Sexual Dysfunction, With Impaired Orgasm). If a substance is judged to be the etiological factor, but the specific substance or class of substances is unknown, the category Unknown Substance-Induced Sexual Dysfunction may be used.

Specific Substances

Sexual Dysfunctions can occur in association with intoxication with the following classes of substances: alcohol; amphetamine and related substances; cocaine; opioids; sedatives, hypnotics, and anxiolytics; and other or unknown substances. Acute intoxication with or chronic abuse of substances of abuse has been reported to decrease sexual interest and cause arousal problems in both sexes. A decrease in sexual interest (both sexes), arousal disorders (both sexes), and orgasmic disorders (more common in men) may also be caused by prescribed medications including antihypertensives, histamine H2 receptor antagonists, antidepressants, neuroleptics, anxiolytics, anabolic steroids, and antiepileptics. Painful orgasm has been reported with fluphenazine, thioridazine, and amoxapine. Priapism has been reported with use of chlorpromazine, trazodone, and clozapine and following penile injections of papaverine or prostaglandin. Serotonin reuptake blockers may cause decreased sexual desire or arousal disorders. Medications such as antihypertensive agents or anabolic steroids may also promote depressed or irritable mood in addition to the sexual dysfunction, and an additional diagnosis of Substance-Induced Mood Disorder may be warranted. Current clinical experience strongly suggests that Substance-Induced Sexual Dysfunction is usually generalized.

Differential Diagnosis

Substance Intoxication

Sexual dysfunctions commonly occur in Substance Intoxication. The diagnosis of the substance-specific Intoxication will usually suffice to categorize the symptom presentation. A diagnosis of Substance-Induced Sexual Dysfunction should be made instead of a diagnosis of Substance Intoxication only when the dysfunction is judged to be in excess of that usually associated with the intoxication syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention. If psychological factors also play a role in the onset, severity, exacerbation, or maintenance of a sexual dysfunction, the diagnosis is the primary Sexual Dysfunction (with the subtype Due to Combined Factors).

Primary Sexual Dysfunction

A Substance-Induced Sexual Dysfunction is distinguished from a primary Sexual Dysfunction by the fact that the symptoms are judged to be fully explained by the direct effects of a substance.

A Substance-Induced Sexual Dysfunction due to a prescribed treatment for a mental disorder or general medical condition must have its onset while the person is receiving the medication (e.g., antihypertensive medication). Once the treatment is discontinued, the sexual dysfunction will remit within days to several weeks (depending on the half-life of the substance). If the sexual dysfunction persists, other causes for the dysfunction should be considered. Side effects of prescribed medications that affect sexual function may lead individuals to be noncompliant with the medication regimen if they value sexual performance over the benefits of the medication.

Sexual Dysfunction Due to a General Medical Condition

Because individuals with general medical conditions often take medications for those conditions, the clinician must consider the possibility that the sexual dysfunction is caused by the physiological consequences of the general medical condition rather than the medication, in which case Sexual Dysfunction Due to a General Medical Condition is diagnosed. The history often provides the primary basis for such a judgement. At times, a change in the treatment for the general medical condition (e.g., medication substitution or discontinuation) may be needed to determine empirically for that person whether the medication is the causative agent. If the clinician has ascertained that the dysfunction is due to both a general medical condition and substance use, both diagnoses (i.e., Sexual Dysfunction Due to a General Medical Condition and Substance-Induced Sexual Dysfunction) are given. When there is insufficient evidence to determine whether the Sexual Dysfunction is due to a substance (including a medication) or to a general medical condition or is primary (i.e., not due to either a substance or a general medical condition), Sexual Dysfunction Not Otherwise Specified would be indicated.

DSM-5

Diagnostic Criteria

A. A clinically significant disturbance in sexual function is predominant in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):

  1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
  2. The involved substance/medication is capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by a sexual dysfunction that is not substance/medication-induced. Such evidence of an independent sexual dysfunction could include the following:

  • The symptoms precede the onset of the substance/medication use.
  • The symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication.
  • There is other evidence suggesting the existence of an independent non-substance/medication-induced sexual dysfunction (e.g., a history of recurrent non-substance/medication-related episodes).

D. The disturbance does not occur exclusively during the course of a delirium.

E. The disturbance causes clinically significant distress in the individual.

Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to warrant clinical attention.

Note: If a mild substance use disorder is comorbid with the substance-induced sexual dysfunction, the clinician should record "mild [substance] use disorder" before the substance-induced sexual dysfunction (e.g., "mild cocaine use disorder with cocaine-induced sexual dysfunction"). If a moderate or severe substance use disorder is comorbid with the substance-induced sexual dysfunction, the clinician should record "moderate [substance] use disorder" or "severe [substance] use disorder," depending on the severity of the comorbid substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-time heavy use of the substance), then the clinician should record only the substance-induced sexual dysfunction.

Specify if:

  • With onset during intoxication: If the criteria are met for intoxication with the substance and the symptoms develop during intoxication.
  • With onset during withdrawal: If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal.
  • With onset after medication use: Symptoms may appear either at initiation of medication or after a modification or change in use.

Specify current severity:

  • Mild: Occurs on 25%-50% of occasions of sexual activity.
  • Moderate: Occurs on 50%-75% of occasions of sexual activity.
  • Severe: Occurs on 75% or more occasions of sexual activity.

Recording Procedures

The name of the substance/medication-induced sexual dysfunction begins with the specific substance (e.g., alcohol, fluoxetine) that is presumed to be causing the sexual dysfunction. In cases in which a substance is judged to be an etiological factor but the specific class of substance is unknown, the category "unknown substance" should be used.

When recording the name of the disorder, the comorbid substance use disorder (if any) is listed first, followed by the word "with," followed by the name of the substance-induced sexual dysfunction, followed by the specification of onset (i.e., onset during intoxication, onset during withdrawal, with onset after medication use), followed by the severity specifier (e.g., mild, moderate, severe). For example, in the case of erectile dysfunction occurring during intoxication in a man with a severe alcohol use disorder, the diagnosis is moderate alcohol use disorder with alcohol-induced sexual dysfunction, with onset during intoxication, moderate. A separate diagnosis of the comorbid severe alcohol use disorder is not given. If the substance-induced sexual dysfunction occurs without a comorbid substance use disorder (e.g., after a one-time heavy use of the substance), no accompanying substance use disorder is noted (e.g., amphetamine-induced sexual dysfunction, with onset during intoxication). When more than one substance is judged to play a significant role in the development of the sexual dysfunction, each should be listed separately (e.g., mild cocaine use disorder with cocaine-induced sexual dysfunction, with onset during intoxication, moderate; fluoxetine-induced sexual dysfunction, with onset after medication use, moderate).

Differential Diagnosis

Non-substance/medication-induced sexual dysfunctions

Many mental conditions, such as depressive, bipolar, anxiety, and psychotic disorders, are associated with disturbances of sexual dysfunction. Thus, differentiating a substance/medication-induced sexual dysfunction from a manifestation of the underlying mental disorder can be quite difficult. The diagnosis is usually established if a close relationship between substance/medication initiation or discontinuation is observed. A clear diagnosis can be established if the problem occurs after substance/medication initiation, dissipates with substance/medication discontinuation, and recurs with introduction of the same agent. Most substance/medication-induced side effects occur shortly after initiation or discontinuation. Sexual side effects that only occur after chronic use of a substance/medication may be extremely difficult to diagnosis with certainty.

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