1. Jennifer E. Kaufman
Pre-Doctoral Candidate
The George Washington University
From the DSM IV TR to the DSM V

2. Presentation Major Sections
D
• KEY CHANGES
• Reasoning Behind The Changes
S
• SPECIFIC CHANGES WITHIN IN EACH OVER ARCHING DISORDER
M
• TOP CHANGED D/O’S DIAGNOSTIC CRITERIA
• FAST FACT/DID YOU KNOW?
• DIAGNOSTIC INTERVIEWING FOR SUD
V
• ACTIVITIES?
• REFERENCES
• RESOURCES FOR CLINICIANS
SUBSTANCE RELATED DISORDERS IN THE DSM V

3. THE MAJOR CHANGES
1. “Gambling Disorder” & “Tobacco Use Disorder” were added
2. “Substance Abuse Disorder” & “Substance Dependence” have
been combined into a SINGLE Substance Use Disorder specific to
each individual substance of abuse within a “Addictions & Related
Disorders” category.
3. “Recurrent legal problems” was deleted
4. “Craving or strong desire or urge to use a substance” was added to
the criteria.
5. In addition, the threshold for substance use disorder diagnosis in
DSM-5 is set at two or more criteria, in contrast to a threshold of
one or more criteria for a diagnosis of DSM-IV substance abuse and
three or more for DSM-IV substance dependence.
6. Severity was added- “Mild” to “Severe” depending on the number
of criteria that is met.
7. Criteria was added for “Cannabis Withdrawal” & “Caffeine
Withdrawal”.
8. New specifiers were added- “Early Remission” & “Sustained
In Substance-Related and Addictive Disorders in the DSM V

4. Reasons For The Changes
Provide treatment
according to
severity
To denote the
difference between
prescribed
dependence and
abuse
Infrequency of legal
problems
(Many ppl never
experience legal
issues but that
doesn't’t mean they
don’t have a SUD)
The connotation with
the word dependence
(ppl who take
medication can form
dependence)

5. “Eliminating the category of dependence will better differentiate
between the compulsive drug-seeking behavior of addiction
and normal responses of tolerance and withdrawal that some
patients experience when using prescribed medications that
affect the central nervous system” And O’Brien said the term
‘abuse’ is clinically meaningless, noting that “abuse,
dependence, and addiction are all one continuous variable.”

6. DSM IV TR DSM V
Alcohol-Related Disorders Same
Amphetamine-Related Disorders Stimulant-Related Disorders
Caffeine-Related Disorders Same
Cannabis-Related Disorders Same
Cocaine-Related Disorders Added to Amphetamine-Related D/Os
Hallucinogen-Related Disorders Same
Inhalant-Related Disorders Same
Nicotine-Related Disorders Tobacco-Related Disorders
Opioid-Related Disorders Same
Phencyclidine Related Disorders Added to Hallucinogen-Related Disorders
Sedative-, Hypnotic-, OR Anxiolytic-
Related Disorders
Same

7. Dimensional
Assessment
• Dimensional assessments allow systematic evaluation of
patients on the full range of symptoms they may be
experiencing.
• Important information about depressed mood, anxiety level,
sleep quality and substance use included regardless of
diagnosis.
• Will allow clinicians to rate both the presents and the severity
of the symptoms.
• Ratings allow tracking of a patient's progress.
• Improvements can be described even if the symptoms are still
present to some degree.
• Clinicians will document all of the patient's symptoms and not

8. Substance Use Disorders
Criteria
1. Taking the substance in larger amounts or for longer than the you
meant to
2. Wanting to cut down or stop using the substance but not
managing to
3. Spending a lot of time getting, using, or recovering from use of the
substance
4. Cravings and urges to use the substance
5. Not managing to do what you should at work, home or school,
because of substance use
6. Continuing to use, even when it causes problems in relationships
7. Giving up important social, occupational or recreational activities
because of substance use
8. Using substances again and again, even when it puts the you in
danger
9. Continuing to use, even when the you know you have a physical or
psychological problem that could have been caused or made worse

9. The DSM 5 allows clinicians to specify how severe the
substance use disorder is, depending on how many
symptoms are identified.
2 to 3 symptoms = a mild substance use disorder
4 to 5 symptoms = a moderate substance use disorder
6+symptoms = a severe substance use disorder.
Clinicians can also add “in early remission,” “in sustained
remission,” “on maintenance therapy,” and “in a controlled
environment.”

10. Early remission: The abstinence will three months or more of no
symptoms except craving
Full remission: No symptoms at all for 12 months – except
cravings

11. In Remission Specifiers
On maintenance therapy: The individual is taking a
long-term maintenance medication, such as nicotine
replacement medication, and no criteria for tobacco use
disorder have been met for that class of medication
(except tolerance to, or withdrawal from, the nicotine
replacement medication).
In a controlled environment: This additional specifier is
used if the individual is in an environment where access
to tobacco is restricted.

12. DSM V Severity Specifiers
305.00 (F10.10) Mild: Presence of 2-3 symptoms
303.90 (F10.20) Moderate: Presence of 4-5 symptoms
303.90 (F10.20) Severe: Presence of 6 or more symptoms

13. The Most Changed SUDs
Alcohol
Related
Disorders
Cannabis
Withdrawal
Nicotine
Withdrawal
Gambling
Disorder
Diagnostic Criteria

14. DSM IV TR: Alcohol Related Disorders DSM V: Alcohol Related Disorder
Alcohol Use Disorder
303.90 Alcohol Dependence
305.00 Alcohol Abuse
Alcohol-Induced Disorders
Specify
With Onset During Intoxication/With Onset During Withdrawal
303.00 Alcohol Intoxication
291.81 Alcohol Withdrawal
291.0 Alcohol Intoxication Delirium
291.0 Alcohol Withdrawal Delirium
291.2 Alcohol-Induced Persisting Dementia
291.1 Alcohol-Induced Persisting Amnestic Disorder
291.X Alcohol-Induced Psychotic Disorder (with
Delusions/with Hallucinations)
291.89 Alcohol-Induced Mood disorder
291.89 Alcohol Induced Anxiety disorder
291.89 Alcohol-Induced Sexual Dysfunction
291.89 Alcohol-Induced Sleep Disorder
291.9 Alcohol-Related Disorder NOS
Alcohol Use Disorder
Specify:
305.00 Mild
303.90 Moderate
303.90 Severe
303.00 Alcohol Intoxication
- With use disorder, mild
- With use disorder, moderate/severe
- Without use disorder
291.81 Alcohol Withdrawal
- Without perceptual disturbances
- With perceptual disturbances
Other Alcohol-Induced Disorders
291.19 Unspecified Alcohol-Related Disorder

15. 305.90 (F15.929) Caffeine Intoxication
292.0 (F15.93) Caffeine Withdrawal
Other Caffeine-Induced Behaviors
292.9 (F15.99) Unspecified Caffeine-Related Disorders

16. Caffeine Withdrawal
A: Prolonged daily use of caffeine
B: Abrupt cessation of or reduction in caffeine use, followed within 24 hours
by 3 (or more) of the following signs or symptoms
– headache
– marked fatigue or drowsiness
– dysphonic or depressed mood, or irritability
- difficulty concentrating
- flu like symptoms
C: Signs and symptoms in Criterion B cause clinically significant distress or
impairment in social, occupational or other important areas of functioning
D: The signs and symptoms are not due to the direct physiological effects of
a general medical condition

17. *305.20 Cannabis Abuse
*304.30, Cannabis
Dependence With
Physiological Dependence
*304.30, Cannabis
Dependence, Without
Physiological Dependence

18. A. Had recently stopped using marijuana after having used it heavily for a long time
B: Experiences at least 3 of the following withdrawal symptoms within several days of stopping
marijuana use:
Anger, irritability or feelings of aggression
Depressed mood
Feelings of restlessness
loss of appetite (or weight loss)
Insomnia or other sleeping problems
Feelings of anxiety or nervousness
Physical symptoms of withdrawal, such as headache, stomach pains, increased sweating, fever, chills or
shakiness. To count as a symptoms of withdrawal at least one of the above listed physical symptoms must be
present and the severity of the symptom(s) must be great enough to cause substantial discomfort
C: The symptoms of withdrawal are severe enough to cause the person substantial problems with
functioning at work or in social situations – or significant impairment in functioning in other important
areas
D: The symptoms of withdrawal cannot be better explained by another physical or mental health
condition2
DIAGNOSTIC CRITERIA
Cannabis Withdrawal

19. Tobacco-Use Disorder
305.1 (Z72.0) Mild
305.1 (F17.200) Moderate
305.1 (F17.200) Severe
292.0 (F17.203) Tobacco Withdrawal
292.9 (F17.209) Unspecified Tobacco-Related Disorder

20. Tobacco Withdrawal
Diagnostic Criteria
A: Daily use of tobacco for at least several weeks
B: Abrupt cessation of tobacco use, or reduction in the amount of tobacco used,
followed within 24 hours by four (ormore) of the following signs or symptoms:
1. Irritability, frustration, or anger
2. anxiety
3. Difficulty concentrating
4. Increased appetite
5. Restlessness
6. Depressed mood
7. Insomnia
C: Signs and symptoms in Criterion B cause clinically significant distress or impairment
in social, occupational or other important areas of functioning
D: The signs and symptoms are not due to the direct physiological effects of a general
medical condition

21. Gambling Disorder
• An important departure from past diagnostic manuals is
that the substance-related disorders chapter has been
expanded to include gambling disorder.
• This change reflects the increasing and consistent
evidence that some behaviors, such as gambling, activate
the brain reward system with effects similar to those of
drugs of abuse and that gambling disorder symptoms
resemble substance use disorders to a certain extent.
Reason For Addition to The DSM 5

22. 312.31 (F63.0)Gambling Disorder
Persistent recurrent problematic gambling behavior as
indicated by four or more of the following in a 12 month period:
• Needs to gamble with increasingly amounts of money in order to achieve the
desired excitement
• Restlessness or irritable when attempting to cut down or stop
gambling
• Repeated unsuccessful efforts to control, cutback, or stop gambling
• Often preoccupied with gambling
• Gambles often when feelings distressed
• After losing money gambling, often returns another day to get even
• Lies to conceal the extent of involvement with gambling
• Has jeopardized or lost a significant relationship, job, or
educational or career opportunity because of gambling
• Relies on others to provide money to relieve desperate
financial situation caused by gambling
Diagnostic Criteria

23. Gambling Differential Diagnosis
1. Nondisordered Gambling
1. Manic Episode
1. Personality Disorder
1. Other Medical Conditions

24. SCREENING FOR SUD
1. How often do you drink alcohol?
2. On days when you have at least one drink, how many
do you typically have?
3. Have you had any problems as a result of drinking?
4. When you stop drinking, do you go through withdrawal?
Alcohol Related Questions

25. 1. Have you ever experimented with illicit or prescription
drugs?
2. How often do you use drugs?
3. Have you ever had any problems as a result of using
drugs?
4. When you don’t use drugs, do you experience any
withdrawal?
For Illicit & Prescription Drug Use

26. Screening For SUD
1. Do you bet, wager, or gamble in a way that interferes
with your life?
If yes, ask:
Did these experiences ever cause you
significant trouble with your friends or family, at
work, or in another setting?
Questions for Gambling

27. Screening For SUD
*If person reports problems with substance use, proceed to
Substance Use criteria for the particular substance
*If person presents with substance intoxication, proceed to
the Substance Intoxication criteria for particular
substance
*If person reports problems with substance withdrawal,
proceed to the Substance Withdrawal criteria for the
particular substance
*If person reports problems with gambling, proceed to
Gambling Disorder criteria
Where to go from here…

28. Newer Drugs Not Included In The DSM 5
BathSalts
Legal
Similar to cocaine
and
amphetamines
Headaches to
seizures to liver
failure, heart
attack, violent
behavior and
even death
SyntheticMarijuana
K2
Acute psychosis,
worsening of
previously stable
psychotic
disorders, and it
may trigger a
chronic psychotic
disorder
“BlackDahlia”
or Fentanyl
a synthetic, opioid
drug that is up to
five times more
powerful than
heroin. The drug
can be smoked,
snorted, injected
or taken orally.
2CEorSmiles
A rapid heart
beat, high body
temperatures,
and
hallucinations
that can last up
to 24 hours.
Bought legally

29. Resources for Practitioners
Websites
o www.medicalnewstoday.com
o www.recoverytoday.net
o http://www.medscape.com/viewarticle/803884_11
Books
o Buzzed By Kuhn, Swartzwelder & Wilson
o The Addictive Person By Craig Nakken
o Understanding the Alcoholics Mind By Ludwig
o Why Cant They Just Stop? Addiction By Hoffman and Froemke
Journals
Behavioral Neuroscience
Alcoholism: Clinical & Experimental Research
Journal of Studies on Alcohol and Drugs
Other
The National Institute of Health/ NIAAA/NIDA
Ameircan Psychiatric Association
American Psychological Association

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