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Appendix C Diagnostic Criteria for Psychoactive Substance Dependence TABLE C.1 Diagnostic Criteria for Psychoactive Substance Dependence (DSM-III-R) A. At least three of the following: 1. substance often taken in larger amounts or over a longer period than the person intended persistent desire or one or more unsuccessful efforts to cut down or control substance use 3. a great deal of time spent in activities necessary to get the substance (e.g., theft), taking the substance (e.g., chain smoking), or recovering from its effects frequent intoxication or withdrawal symptoms when expected to fulfill major role obligations at work, school, or home (e.g., does not go to work because hung over, goes to school or work "high", intoxicated while taking care of his or her children), or when substance use is physically hazardous (e.g., drives when intoxicated) important social, occupational, or recreational activities given up or reduced because of substance use 6. continued substance use despite knowledge of having a persistent or recurrent social, physiological, or physical problem that is caused or exacerbated by the use of the substance (e.g., keeps heroin despite family arguments about it, cocaine- induced depression, or having an ulcer made worse by drinking) (continued) 211

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212 TABLE C.1 Continued DEVELOPMENT OF MEDICATIONS marked tolerance: need for markedly increased amounts of the substance (i.e.' at least a 50 percent increase) in order to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount Note: The following items may not apply to cannabis, hallucinogens, or phencyclidine (PCP): 8. characteristic withdrawal symptoms (see specific withdrawal syndromes under Psychoactive Substance-induced Organic Mental Disorders) 9. substance often taken to relieve or avoid withdrawal symptoms B. Some symptoms of the disturbance have persisted for at least 1 month, or have occurred repeatedly over a longer period of time. Criteria for severity of psychoactive substance dependence Mild: Few, if any, symptoms in excess of those required to make the diagnosis, and the symptoms result in no more than mild impairment in occupational functioning or in usual social activities or relationships with others. Moderate: Symptoms or functional impairment between "mild" and "severe" Severe: Many symptoms in excess of those required to make the diagnosis, and the symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.a In Partial Remission: During the past six months, some use of the substance and some symptoms of dependence In Full Remission: During the past six months, either no use of the substance, or use of the substance and no symptoms of dependence. Because of the availability of cigarettes and other nicotine-containing substances and the absence of a clinically significant nicotine intoxication syndrome, impairment in occupational or social functioning is not necessary for a rating of severe Nicotine Dependence. SOURCE: American Psychiatric Association. 1987. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. revised (DSM-III-R). Washington, DC: American Psychiatric Association.

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APPENDIX C TABLE C.2 Diagnostic Criteria for Psychoactive Substance Abuse (ICD-10 Draft) Fix. 2 Dependence syndrome 213 A cluster of physiological, behavioral and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than the other behaviors that once had higher value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take drugs (which may or may not have been medically prescribed), alcohol or tobacco. There may be evidence that return to substance use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with non-dependent individuals. Diagnostic guidelines A definite diagnosis of dependence should usually only be made if three or more of the following have been experienced or exhibited at some time during the previous year: (i, (ii, (iii, A strong desire or sense of compulsion to take the substance. An impaired capacity to control substance-taking behavior in terms of its onset, termination, or levels of use. Substance use with the intention of relieving withdrawal symptoms and with awareness that this strategy is effective. (iv) A physiological withdrawal state (see .4 and .5) (v) (vi) (viii) Evidence of tolerance such that increased doses of the substance are required in order to achieve effects originally produced by lower doses. (Clear examples of this are found in alcohol and opiate dependent individuals who may take daily doses of the substance sufficient to incapacitate or kill non-tolerant users.) A narrowing of the personal repertoire of patterns of substance use (e.g., a tendency to drink alcoholic drinks in the same way on weekdays and weekends and whatever the social constraints regarding appropriate drinking behavior). (vii) Progressive neglect of alternative pleasures or interests in favor of substance use. Persisting with substance use despite clear evidence of overtly harmful consequences. (Adverse consequences may be medical as with ha. to the liver through excessive drinking, social as in the case of loss of a job through drug-related impairment of performance, or psychological as in the case of depressive mood states consequent to periods of heavy substance use). (continued)

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214 TABLE C.2 (continued) DEVELOPMENT OF MEDICATIONS It is an essential characteristic of the dependence syndrome that either substance taking or a desire to take a particular substance should be present, the subjective awareness of compulsion to use drugs is most commonly seen during attempts to stop or control substance use. This diagnostic requirement would exclude, for instance, surgical patients given opiate drugs for the relief of pain and who may show signs of an opiate withdrawal state when drugs are not given, but who have no desire to continue taking drugs. The dependence syndrome may be present for a specific substance (e.g., tobacco or diazepam), for a class of substances (e.g., opiate and opioid drugs); or for a wider range of different substances (as for those individuals who feel a sense of compulsion regularly to use whatever drugs are available and who show distress, agitation, and/or physical signs of a withdrawal stat upon abstinence). Includes: chronic alcoholism; dipsomania; drug addiction NOS. The diagnosis of the dependence syndrome may be further specified by the following fifth character codes: Flx.20 Flx.2 1 Flx.22 Flx.23 Flx.24 Flx.25 Flx.26 Currently abstinent Currently abstinent, but in a protected environment (e.g., in hospital, in a therapeutic community, in prison, etc.) Currently on a clinically supervised maintenance or replacement regime (e.g., with methadone; nicotine-gum or patch) Currently abstinent, but receiving aversive treatment on aversive blocking drugs (e.g. naltrexone or disulfiram) Currently using the substance Continuous use Episodic use (dipsomania) SOURCE: World Health Organization. 1990. Draft of chapter V: mental and behavioural disorders. Clinical descriptions and diagnostic guidelines. International Classification of Diseases, 10th rev. Geneva: WHO. As cited in: O'Brien CP, Jaffe JH, eds. Addictive States. New York: Raven Press.