Diagnosing Substance Use Disorders

Ethical Diagnosing

Read through the Diagnosing Unit from the Conceptualizing Class.

Diagnosing Ethics Exploration Questions

1. What are your personal views regarding mental health diagnoses?
2. What sort of client might benefit from receiving a mental health diagnosis?
3. When might you avoid diagnosing a client?

Understanding Diagnostic Codes

Note that the diagnostic codes used by the DSM-5 and ICD-10 are made up of several different parts. The letter "F" indicates that it is a Mental and behavioral disorder. For substance related diagnoses, the number after the "F", but before the decimal place describes which type of substance a client is using. The DSM-5 specifies that categories are not always mutually exclusive. The numbers after the decimal place are used to specify which diagnosis a client will receive, and any additional features associated with the diagnosis.

Substance Related Diagnostic Codes

• F10: Alcohol
• F11: Opioids
• F12: Cannabinoids (e.g., marijuana)
• F13: Sedatives or hypnotics
• F14: Cocaine
• F15: Other stimulants, including caffeine (Caffeine Use Disorder is not included as a DSM-5 diagnosis, although it is under review for inclusion in future versions of the DSM).
• F16: Hallucinogens
• F17: Tobacco
• F18: Volatile solvents
• F19: Multiple drugs or other psychoactive substances

(World Health Organization, 1992)

Specifiers

The DSM-5 and ICD 10 use digits to the right of the decimal point in the diagnostic code to specify additional diagnostic information. For example, the following diagnosis (note the format that the diagnosis is written in):

"F10.21 Alcohol dependence syndrome, currently abstinent in a protected environment"

In this diagnosis:

• The "F" is used to indicate the diagnosis is a mental/behavioral health disorder.
• The "10" indicates it is a disorder due to alcohol use.
• The ".2" is for dependence syndrome.
• The last digit, "1", is the specifier: abstinent in a protected environment.

DSM-5 Diagnostic Criteria

Spend some time familiarizing yourself with the layout and organization of the DSM-5. Once you are familiar with the book, read through the Substance-Related and Addictive Disorders in Section II. Note that the diagnostic criteria are relatively consistent for many of the substances. Also, note that the DSM-5 provides diagnostic criteria for use disorders, intoxication, and withdrawal for many of the substances. Also note that Gambling Disorder is included with the Substance-Related and Addictive Disorders, because "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" (APA, 2013, p. 481).

After you read through the disorders in Section II, look at the Conditions for Further Study in Section III. Pay particular attention to Caffeine Use Disorder and Internet Gaming Disorder.

DSM-5 Substance Related Diagnoses

The DSM-5 has multiple diagnoses that can be applied across multiple substances. Clients who have problematic use patterns will likely be diagnosed with a Use Disorder, while clients who are going through withdrawals will be diagnosed with a Withdrawal disorder. Clients who are using substances while engaging with treatment will likely meet the criteria for Intoxication.

Use Disorders

Use disorders generally apply to clients who are using substances in ways that interfere with their daily life. The DSM-5 provides diagnostic criteria for use disorders related to many substances. For example, a client who uses marijuana may meet the criteria for Cannabis Use Disorder:

1. 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:
       1. A need for markedly increased amounts of cannabis to achieve intoxication or desired effect.
       2. Markedly diminished effect with continued use of the same amount of cannabis.
   11. Withdraw, as manifested by either of the following:
       1. The characteristic withdrawal syndrome for cannabis (refer to Criteria A and B of the criteria set for cannabis withdrawal, pp. 517-518).
       2. Cannabis (or a closely related substance) is taken to relieve or avoid withdrawal symptoms.

(American Psychiatric Association, 2013, p. )

Intoxication

Intoxication diagnoses are used with clients who are actively using substances and are intoxicated as a result of their substance use. The diagnostic criteria for Cannabis Intoxication are:

1. Recent use of cannabis.
2. Clinically significant problematic behavioral or psychological change (e.g., impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that developed during, or shortly after, cannabis use.
3. 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.
4. 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.

(American Psychiatric Association, 2013, p. )

Withdrawal Disorders

Withdrawing from substances can have imminent health consequences, and counselors working with clients who may experience withdrawals are encouraged to collaborate with physical health providers, who can monitor health during the withdrawal period. The DSM-5 has specific diagnoses for clients who are withdrawing from substances. The diagnostic criteria for Cannabis Withdrawal are:

1. Cessation of cannabis use that has been heavy and prolonged (i.e., usually daily or almost daily use over a period of at least a few months).
2. 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: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache.
3. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. 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.

(American Psychiatric Association, 2013, p. )

DSM-5 Exploration Questions

1. In what ways is the information in the DSM-5 congruent with the information you found in the Introduction to Commonly Used Substances Unit?
2. How might you assess a client to see if they meet the diagnostic criteria for one or more of the substance use disorders?
3. What additional information do you need to feel comfortable using the DSM-5 to diagnose clients?

ICD-10 Diagnostic Criteria

The tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) is published by the World Health Organization (WHO), and it is available for free online. Unlike the DSM-5, the ICD-10 contains physical as well as mental health diagnoses. Spend some time familiarizing yourself with the ICD-10, paying particular attention to Section V Mental and behavioural disorders. Diagnostic codes F10-F19 are used for disorders due to psychoactive substance use.

The complete ICD-10 diagnostic criteria for substance use can be downloaded here. This excerpt is taken directly from the ICD-10 Blue Book, which is a .pdf version of the ICD-10.

What's in a Name: ICD-10 v. DSM-5

The ICD-10 uses different terms for diagnoses than the DSM-5. For example, The DSM-5 uses the diagnostic code F10.10 for Alcohol Use Disorder (mild), while the ICD-10 used the code F10.10 for Harmful Alcohol Use. Similarly, the DSM-5 uses the diagnostic code F10.20 for either a moderate or severe alcohol use disorder, while F10.20 in the ICD-10 refers to Alcohol Dependence Syndrome.

ICD-10 Exploration Questions

1. In what ways is the ICD-10 similar to or different from the DSM-5?
2. Do you prefer the layout of the ICD-10 or the DSM-5? How come?

The Addictions Neuroclinical Assessment: The Future of Substance Use Diagnosing

Recent developments in neuroscience and genetics enable researchers to better understand the roles of brain chemistry and genetics in substance use disorders. Scientists at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) are developing a new diagnostic instrument that would incorporate genetic, physiological, and behavioral measures.

A revolution in understanding the neurobiologic basis of addiction has not been translated into the clinic. Translation of neuroscience to practice would identify the etiologic factors and functional outcomes that unify people addicted to different agents and that differentiate people addicted to the same agent.

(Kwako, Momenan, Litten, Koob, & Goldman, 2016, p. 179)

Similarly, in 2013, the previous Director of the National Institute of Mental Health (NIMH) wrote an online post emphasizing that the NIMH is moving away from DSM and ICD diagnoses, as they are based on symptom categories, rather than research.

...the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure... symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as... symptoms alone rarely indicate the best choice of treatment.

(Insel, 2013)

These efforts are rooted in precision medicine which is...

...an emerging approach for disease treatment and prevention that takes into account individual variability in environment, lifestyle and genes for each person.

(National Institutes of Health, n.d.)

The Future of Diagnosing Exploration Questions

1. Do you think that using categories of symptoms is the best way to diagnose mental health disorders?
   • Why or why not?
2. What research do you think is needed to develop a new diagnostic system that incorporates genetic, behavioral, cognitive, and emotional factors?