DSM-III

Other Specified Substance Dependence

This category should be used when the individual is dependent on a substance that cannot be classified in any of the previous categories, e.g., codeine or corticosteroids.

Unspecified Substance Dependence

This diagnosis can be used as an initial diagnosis in cases in which the specific substance is not yet known.

DSM-IV

Diagnostic Criteria

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  1. tolerance, as defined by either of the following:
    • a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect
    • b. markedly diminished effect with continued use of the same amount of the substance
  2. withdrawal, as manifested by either of the following:
    • a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
    • b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  3. the substance is often taken in larger amounts or over a longer period than was intended
  4. there is a persistent desire or unsuccessful efforts to cut down or control substance use
  5. a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
  6. important social, occupational, or recreational activities are given up or reduced because of substance use
  7. the substance use is continued despite knowledge of having a persistent or recurent physical or phychosocial problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Specify if:

  • With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present)
  • Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)

Course specifiers (see text for definitions):

  • Early Full Remission
  • Early Partial Remission
  • Sustained Full Remission
  • Sustained Partial Remission
  • On Agonist Therapy
  • In a Controlled Environment

Specifiers

Tolerance and withdrawal may be associated with a higher risk for immediate general medical problems and a higher relapse rate. Specifiers are provided to note their presence or absence:

With Physiological Dependence

This specifier should be used when Substance Dependence is accompanied by evidence of tolerance or withdrawal.

Without Physiological Dependence

This specifier should be used when there is no evidence of tolerance or withdrawal. In these individuals, Substance Dependence is characterized by a pattern of compulsive use.

Course Specifiers

Six course specifiers are available for Substance Dependence. The four Remission specifiers can be applied only after none of the criteria for Substance Dependence or Substance Abuse have been present for at least 1 month. The definition of these four types of Remission is based on the interval of time that has elapsed since the cessation of Dependence (Early versus Sustained Remission) and whether there is continued presence of one or more of the items included in the criteria sets for Dependence or Abuse (Partial versus Full Remission). Because the first 12 months following Dependence is a time of particularly high risk for relapse, this period is designated Early Remission. After 12 months of Early Remission have passed without relapse to Dependence, the person enters into Sustained Remission. For both Early Remission and Sustained Remission, a further designation of Full is given if no criteria for Dependence or Abuse have been met during the period of remission; a designation of Partial is given if at least one of the criteria for Dependence or Abuse has been met, intermittently or continuously, during the period of remission. The differentiation of Sustained Full Remission from recovered (no current Substance Use Disorder) requires consideration of the length of time since the last period of disturbance, the total duration of the disturbance, and the need for continued evaluation. If, after a period of remission or recovery, the individual again becomes dependent, the application of the Early Remission specifier requires that there again be at least 1 month in which no criteria for Dependence or Abuse are met. Two additional specifiers have been provided: On Agonist Therapy and In a Controlled Environment. or an individual to qualify for Early Remission after cessation of agonist therapy or release from a controlled environment, there must be a 1-month period in which none of the criteria for Dependence or Abuse are met.

The following Remission specifiers can be applied only after no criteria for Dependence or Abuse have been met for at least 1 month. Note that these specifiers do not apply if the individual is on agonist therapy or in a controlled environment (see below).

Early Full Remission

This specifier is used if, for at least 1 month, but for less than 12 months, no criteria for Dependence or Abuse have been met.

Early Partial Remission

This specifier is used if, for at least 1 month, but less than 12 months, one or more criteria for Dependence or Abuse have been met (but the full criteria for Dependence have not been met).

Sustained Full Remission

This specifier is used if none of the criteria for Dependence or Abuse have been met at any time during a period of 12 months or longer.

Sustained Partial Remission

This specifier is used if full criteria for Dependence have not been met for a period of 12 months or longer; however, one or more criteria for Dependence or Abuse have been met.

The following specifiers apply if the individual is on agonist therapy or in a controlled environment:

On Agonist Therapy

This specifier is used if the individual is on a prescribed agonist medication, and no criteria for Dependence or Abuse have been met for that class of medication for at least the past month (except tolerance to, or withdrawal from, the agonist). This category also applies to those being treated for Dependence using a partial agonist or an agonist/antagonist.

In a Controlled Environment

This specifier is used if the individual is in an environment where access to alcohol and controlled substances is restricted, and no criteria for Dependence or Abuse have been met for at least the past month. Examples of these environments are closely supervised and substance-free jails, therapeutic communities, or locked hospital units.

DSM-5

See Substance-Related Disorders

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