magnus919_agent-skills/dsm5/references/25-substance-framework-alcohol.md

Substance Use Disorder Framework and Alcohol

Part of the Substance-Related and Addictive Disorders chapter reference — index: 25-substance-related-and-addictive-disorders.md

Summarized and paraphrased from DSM-5-TR (American Psychiatric Association, 2022). This file is for orientation and education; verify exact criteria wording, codes, and recording procedures against the official DSM-5-TR before any formal clinical, legal, insurance, or research use.

General framework: Substance Use Disorder

Core features

The essential feature is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. The diagnosis applies to all 10 classes except caffeine. For some classes certain symptoms are less salient or do not apply (no withdrawal criterion for phencyclidine, other hallucinogens, or inhalants; caffeine has no use disorder category at all). A diagnosis is based on a pathological pattern of behaviors related to use, organized into four groupings: impaired control, social impairment, risky use, and pharmacological criteria (tolerance and withdrawal).

Diagnostic criteria (summarized)

• Criterion A: A problematic pattern of substance use leading to clinically significant impairment or distress, manifested by at least two of the following within a 12-month period (wording adapted per class; the 11 generic criteria):
  1. Substance often taken in larger amounts or over a longer period than intended (impaired control).
  2. Persistent desire or unsuccessful efforts to cut down or control use.
  3. A great deal of time spent obtaining, using, or recovering from the substance.
  4. Craving — a strong desire or urge to use (often queried as: "has there been a time when urges were so strong you could not think of anything else?").
  5. Recurrent use resulting in failure to fulfill major role obligations at work, school, or home (social impairment).
  6. Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the substance.
  7. Important social, occupational, or recreational activities given up or reduced because of use.
  8. Recurrent use in situations in which it is physically hazardous (risky use).
  9. Continued use despite knowledge of a persistent or recurrent physical or psychological problem likely caused or exacerbated by the substance — the key is failure to abstain despite the difficulty it causes.
  10. Tolerance: markedly increased amounts needed to achieve the desired effect, or a markedly diminished effect with the same amount (pharmacological).
  11. Withdrawal: the characteristic withdrawal syndrome for the class, or use of the substance (or a closely related one) to relieve or avoid withdrawal. Withdrawal is not included for phencyclidine, other hallucinogens, or inhalants; neither tolerance nor withdrawal is necessary for the diagnosis.
• No separate Criteria B/C exist; impairment or distress is embedded in Criterion A.
• Exclusions/rule-outs: Tolerance and withdrawal during appropriate medical treatment (prescribed opioid analgesics, sedatives, stimulants taken as directed) are not counted; a use disorder requires additional compulsive drug-seeking symptoms.

Severity and specifiers

• Severity is based on the number of criteria endorsed: mild = 2-3 symptoms; moderate = 4-5; severe = 6 or more. Changes over time are reflected in reductions or increases in frequency and/or dose, assessed by self-report, report of knowledgeable others, clinician observation, and biological testing.
• In early remission: after full criteria were previously met, none of the criteria have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, craving, may be met).
• In sustained remission: none of the criteria have been met at any time during a period of 12 months or longer (craving may be met).
• On maintenance therapy: the individual is taking a prescribed agonist (e.g., methadone or buprenorphine) or is maintained on a partial agonist, agonist/antagonist, or full antagonist (e.g., oral or depot naltrexone), and no criteria have been met for that class of medication except tolerance/withdrawal from the agonist. This specifier is printed for opioids and tobacco.
• In a controlled environment: access to the substance is restricted (e.g., closely supervised, substance-free jails; therapeutic communities; locked hospital units). Applies as a further specifier of early or sustained remission.

Recording procedures

• Code by substance class but record the name of the specific substance (e.g., "F13.20 moderate alprazolam use disorder," "F15.10 mild methamphetamine use disorder"). Substances not fitting any class (e.g., anabolic steroids) use the other (or unknown) codes (e.g., F19.10); unknown substances likewise use F19 codes.
• If criteria are met for more than one substance use disorder, each is diagnosed separately.
• The ICD-10-CM code for a substance use disorder is used only in the absence of a comorbid substance-induced disorder; when intoxication, withdrawal, or an induced mental disorder is present, the single combined code for the induced disorder indicates the comorbid use-disorder severity in its 4th character (e.g., F10.129 = mild alcohol use disorder with alcohol intoxication).

Substance Intoxication and Substance Withdrawal (general)

• Intoxication: the development of a reversible substance-specific syndrome due to recent ingestion of a substance (Criterion A); clinically significant problematic behavioral or psychological changes (e.g., belligerence, mood lability, impaired judgment) attributable to the substance's physiological CNS effects, developing during or shortly after use (Criterion B), accompanied by substance-specific signs and symptoms (Criterion C); not attributable to another medical condition and not better explained by another mental disorder (Criterion D). Intoxication is common in use disorder but also occurs in users without a use disorder. This category does not apply to tobacco. Physiological effects alone (e.g., tachycardia without problematic behavior) do not meet criteria. Intoxication may outlast detection of the substance because CNS recovery can take longer than elimination.
• Withdrawal: a substance-specific problematic behavioral change with physiological and cognitive concomitants due to cessation of, or reduction in, heavy and prolonged use (Criterion A); the specific syndrome (Criterion B) causes clinically significant distress or impairment (Criterion C); not due to another medical condition and not better explained by another mental disorder (Criterion D). Withdrawal is usually, but not always, associated with a use disorder, and most affected individuals have an urge to readminister the substance to relieve symptoms. Withdrawal symptoms during appropriate prescribed medical treatment are not counted toward a use disorder.
• Multiple substances used simultaneously or sequentially are recorded as separate diagnoses. Laboratory tests help confirm recent use but neither a positive nor a negative test by itself establishes or rules out a diagnosis; high blood levels with little intoxication suggest tolerance.
• Recording: use the class code but name the specific substance (e.g., "F13.230 secobarbital withdrawal," "F15.120 methamphetamine intoxication"). F15.120 indicates comorbid mild methamphetamine use disorder; with no comorbid use disorder (and no perceptual disturbances) the code is F15.920. If symptoms are associated with a substance but no criteria are met, the unspecified category can be used (e.g., F12.99 unspecified cannabis-related disorder).

Substance/Medication-Induced Mental Disorders

A potentially severe, usually temporary, sometimes persisting CNS syndrome developing in the context of substances of abuse, medications, or toxins, distinguished from use disorders (which concern a pattern of continued use despite problems). Full criteria appear in the chapters with which each disorder shares phenomenology.

• Criterion A: A clinically significant presentation of symptoms characteristic of the relevant diagnostic class predominates in the clinical picture.
• Criterion B: Evidence from history, physical examination, or laboratory findings of both (1) symptom onset during or soon after intoxication, withdrawal, or exposure to/withdrawal from a medication, and (2) that the substance/medication is capable of producing the symptoms.
• Criterion C: Not better explained by an independent mental disorder. Evidence of independence includes symptoms that preceded the onset of severe intoxication, withdrawal, or medication exposure, or that persisted a substantial period (at least 1 month) after cessation of acute withdrawal/severe intoxication/medication. This criterion does not apply to substance-induced neurocognitive disorders or hallucinogen persisting perception disorder, which persist beyond acute intoxication or withdrawal.
• Criterion D: The disturbance does not occur exclusively during the course of a delirium (during a substance-induced delirium, only the delirium is diagnosed).
• Criterion E: Clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Generalizations: more sedating drugs (sedatives/hypnotics/anxiolytics and alcohol) commonly produce depressive syndromes during intoxication and anxiety syndromes during withdrawal; more stimulating drugs (amphetamines, cocaine) are linked to psychotic and anxiety disorders during intoxication and depressive episodes during withdrawal; both types of drugs commonly produce temporary sleep and sexual disturbances. Onset specifiers "with onset during intoxication" and "with onset during withdrawal" are noted per class (Table 1 of the chapter). Most induced disorders improve within days to weeks of abstinence and are unlikely to remain clinically relevant more than 1 month after complete cessation, except alcohol-/inhalant-/ sedative-induced neurocognitive disorders and hallucinogen persisting perception disorder. Recording: a single diagnosis reflects the substance, the induced disorder, and the severity of any comorbid use disorder (e.g., "cocaine-induced psychotic disorder with severe cocaine use disorder"); without a comorbid use disorder, only the induced disorder is recorded (e.g., "corticosteroid-induced depressive disorder").

The following table summarizes, per class, which substance-induced mental disorders are recognized and the onset specifiers printed in Table 1 of the chapter (I = with onset during intoxication; W = with onset during withdrawal; delirium entries come from the class narrative text).

Class	Induced mental disorders (onset specifier)
Alcohol	Psychotic (I/W), bipolar (I/W), depressive (I/W), anxiety (I/W), sleep (I/W), sexual dysfunction (I/W), major/mild neurocognitive; intoxication and withdrawal delirium
Caffeine	Anxiety (I), sleep (I/W)
Cannabis	Psychotic (I), anxiety (I), sleep (I/W); intoxication delirium
Phencyclidine	Psychotic (I), bipolar (I), depressive (I), anxiety (I); intoxication delirium
Other hallucinogens	Psychotic (I), bipolar (I), depressive (I), anxiety (I); hallucinogen persisting perception disorder; intoxication delirium
Inhalants	Psychotic (I), depressive (I), anxiety (I), major/mild neurocognitive; intoxication delirium
Opioids	Depressive (I/W), anxiety (W), sleep (I/W), sexual dysfunction (I/W); intoxication and withdrawal delirium
Sedatives, hypnotics, or anxiolytics	Psychotic (I/W), bipolar (I/W), depressive (I/W), anxiety (W), sleep (I/W), sexual dysfunction (I/W), major/mild neurocognitive; intoxication and withdrawal delirium
Stimulants (amphetamine-type, cocaine, other)	Psychotic (I), bipolar (I/W), depressive (I/W), anxiety (I/W), obsessive-compulsive (I/W), sleep (I/W), sexual dysfunction (I), mild neurocognitive; intoxication delirium
Tobacco	Sleep (W)
Other (or unknown)	Psychotic (I/W), bipolar (I/W), depressive (I/W), anxiety (I/W), obsessive-compulsive (I/W), sleep (I/W), sexual dysfunction (I/W), major/mild neurocognitive; intoxication and withdrawal delirium

Verify cell-level onset specifiers against the manual: the source table's column alignment was partly lost in text extraction, so the I/W letters above are best-effort readings of the printed Table 1.

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Alcohol-Related Disorders (F10.x)

The alcohol-related disorders comprise alcohol use disorder, alcohol intoxication, alcohol withdrawal, alcohol-induced mental disorders, and unspecified alcohol-related disorder. Alcohol is a CNS depressant; its use disorder is defined by a cluster of behavioral and physical symptoms including withdrawal, tolerance, and craving.

Alcohol Use Disorder

Diagnostic criteria (summarized)

• Criterion A: A problematic pattern of alcohol use causing clinically significant impairment or distress, with at least two of the standard 11 criteria (larger amounts/longer than intended; desire or failed efforts to cut down; time spent obtaining/using/recovering; craving; failure to fulfill role obligations; continued use despite social/interpersonal problems; giving up important activities; hazardous use; continued use despite known physical or psychological problems; tolerance; withdrawal — or taking alcohol or a closely related substance such as a benzodiazepine to relieve or avoid withdrawal) within a 12-month period.
• Specifiers: in early remission (3 to <12 months without criteria, craving may be met); in sustained remission (12 months or longer); in a controlled environment (restricted access to alcohol; applies as a further specifier of remission).
• Codes (current severity/remission): F10.10 mild (2-3 symptoms); F10.11 mild in early or sustained remission; F10.20 moderate (4-5) or severe (6+); F10.21 moderate or severe in early or sustained remission. When alcohol intoxication, withdrawal, or another alcohol-induced disorder is present, the combined induced-disorder code is used instead (e.g., F10.129 mild AUD with alcohol intoxication; F10.229 moderate or severe AUD with alcohol intoxication).

Core features and associated features

Craving is a strong desire to drink that makes it hard to think of anything else and often results in drinking. Withdrawal symptoms develop approximately 4-12 hours after reduction following prolonged, heavy ingestion; some withdrawal symptoms (e.g., sleep problems) can persist at lower intensity for months and contribute to relapse. Repeated high-dose intake can affect nearly every organ system: gastritis, stomach or duodenal ulcers, and in about 15% of heavy drinkers liver cirrhosis and/or pancreatitis; increased rates of cancer of the esophagus, stomach, and other GI sites; low-grade hypertension; cardiomyopathy and other myopathies; elevated triglycerides and LDL; peripheral neuropathy; and CNS effects including severe memory impairment and cerebellar degeneration. Wernicke-Korsakoff syndrome (alcohol-induced persisting amnestic disorder) is a relatively rare condition with severe impairment of new-memory encoding; it is now described as a substance/medication-induced neurocognitive disorder in the Neurocognitive Disorders chapter. Alcohol use disorder is an important contributor to suicide risk during severe intoxication and in the context of a temporary alcohol-induced depressive or bipolar disorder.

Onset, prevalence, course

• First intoxication typically occurs in the mid-teens; AUD with clustered criteria peaks in the late teens to early/mid-20s; most develop the disorder by their late 30s (perhaps 10% have later onset). Withdrawal usually appears only after many other features of AUD have developed. Course is variable, with periods of remission and relapse; resumption of drinking often escalates rapidly.
• US lifetime prevalence of DSM-5 AUD among adults: 29.1% overall (8.6% mild, 6.6% moderate, 13.9% severe); men 36.0%, women 22.7%. Australian adults: 31.0% lifetime. Twelve-month prevalence of DSM-IV alcohol use disorders in the US: 4.6% (ages 12-17), 16.2% (ages 18-29), 1.5% (65+). Among adults, 12-month DSM-5 AUD was 14.4% in African Americans, 14.0% in non-Hispanic Whites, 13.6% in Hispanics, and 10.6% in Asian Americans and Pacific Islanders. Globally, 2.8 million deaths are attributed to alcohol (2.2% of age-standardized deaths among women, 6.8% among men); an estimated 237 million men and 46 million women have AUD.
• Only a minority (< 20%) of drinkers ever develop AUD; drinking, even daily, in low doses and occasional intoxication do not by themselves make the diagnosis.

Risk and prognostic factors

• Environmental: poverty and discrimination (including structural inequities such as differential incarceration and differential access to addiction medications), unemployment, low education, cultural attitudes toward drinking, alcohol availability and price, stress, heavier peer substance use, positive expectations, poor coping.
• Genetic/physiological: 40%-60% of variance explained by genetic influences; rate is three to four times higher in close relatives; higher in monozygotic than dizygotic twins; three- to fourfold risk in children of affected individuals even when adopted at birth. Low-risk phenotype: acute alcohol-related skin flush (more common in persons of Asian descent; alcohol-metabolizing enzyme polymorphisms seen in up to 40% of Japanese, Chinese, and Korean individuals). High vulnerability: preexisting schizophrenia or bipolar disorder, impulsivity (raises risk of all substance use disorders and gambling disorder), and low level of response (low sensitivity) to alcohol. Any single gene variant likely explains only 1%-2% of risk.
• Course modifiers: high impulsivity is associated with earlier onset and more severe AUD.

Differential diagnosis

• Nonpathological use of alcohol: the key is repeated, significant distress or impaired functioning from heavy use; fewer than 20% of drinkers develop AUD.
• Alcohol intoxication, withdrawal, and alcohol-induced mental disorders: these are syndromes that develop in the context of heavy use, diagnosed in addition to AUD (the code then carries the AUD severity).
• Sedative, hypnotic, or anxiolytic use disorder: similar signs/symptoms; courses differ, especially regarding medical problems (see sedatives section below).
• Conduct disorder in childhood and antisocial personality disorder: alcohol use disorder is seen in the majority of individuals with these conditions; both diagnoses should be established because they mark early onset and worse prognosis (see 24-disruptive-impulse-control-and-conduct-disorders.md).

Comorbidity

Bipolar disorders, schizophrenia, and antisocial personality disorder, as well as most anxiety and depressive disorders, are associated with AUD. Part of the reported depression-AUD association may reflect temporary alcohol-induced depressive symptoms from acute intoxication or withdrawal. Severe, repeated intoxication may suppress immune mechanisms, predispose to infections, and increase cancer risk.

Alcohol Intoxication

Diagnostic criteria (summarized)

• Criterion A: Recent ingestion of alcohol.
• Criterion B: Clinically significant problematic behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment) developing during or shortly after ingestion.
• Criterion C: One or more of: slurred speech; incoordination; unsteady gait; nystagmus; impairment in attention or memory; stupor or coma.
• Criterion D: Not attributable to another medical condition (e.g., diabetic ketoacidosis) and not better explained by another mental disorder, including intoxication with another substance.
• Codes: F10.120 with mild comorbid AUD; F10.220 with moderate or severe AUD; F10.920 with no comorbid AUD.

Course, features, risks

Intoxication usually develops over minutes to hours and lasts several hours; the body metabolizes about one drink per hour (blood alcohol falls 15-20 mg/dL per hour; each standard drink, ~10-12 g ethanol, raises BAC ~20 mg/dL). Symptoms are more intense while blood alcohol is rising; early effects often feel stimulating, and later effects (when levels fall) are depressant, with withdrawal and cognitive impairment. Amnesia ("blackouts") can occur at relatively high BACs. At 200-300 mg/dL a nontolerant person may fall asleep and enter a first stage of anesthesia; above 300-400 mg/dL, respiratory and pulse inhibition can cause death. Alcohol intoxication contributes to interpersonal violence and suicidal behavior. In 2018, 43% of US 12th graders reported having been drunk at least once; high-risk drinking (4+ drinks/day for women, 5+ for men) in the past 12 months was reported by 17.4% of Native Americans, 15.1% of African Americans, 13.5% of Latinx, 12.3% of non-Latinx Whites, and 7.2% of Asians and Pacific Islanders. Intoxication contributed to more than 95,000 US deaths and 2.8 million years of potential life lost per year (2011-2015), shortening lives by an average of 30 years.

Differential diagnosis

Other medical/neurological conditions that can mimic intoxication (e.g., diabetic acidosis, cerebellar ataxia, multiple sclerosis); alcohol-induced mental disorders (symptoms in excess of those usually seen with intoxication and severe enough to warrant independent attention); and sedative, hypnotic, or anxiolytic intoxication (very similar presentation but no alcohol odor; toxicology distinguishes).

Alcohol Withdrawal

Diagnostic criteria (summarized)

• Criterion A: Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
• Criterion B: Two or more of the following developing within several hours to a few days after cessation/reduction:
  1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
  2. Increased hand tremor.
  3. Insomnia.
  4. Nausea or vomiting.
  5. Transient visual, tactile, or auditory hallucinations or illusions.
  6. Psychomotor agitation.
  7. Anxiety.
  8. Generalized tonic-clonic seizures.
• Criterion C: The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Criterion D: Not attributable to another medical condition and not better explained by another mental disorder, including intoxication or withdrawal from another substance.
• Specifier — with perceptual disturbances: applies in the rare instance when hallucinations (usually visual or tactile) occur with intact reality testing, or auditory, visual, or tactile illusions occur in the absence of a delirium.
• Codes: without perceptual disturbances: F10.130 (mild AUD), F10.230 (moderate or severe AUD), F10.930 (no comorbid AUD); with perceptual disturbances: F10.132, F10.232, F10.932.

Onset, course, features, risks

Withdrawal typically begins when blood alcohol declines sharply, within 4-12 hours after stopping or reducing; symptoms usually peak during the second day of abstinence and improve markedly by the fourth or fifth day. Anxiety, insomnia, and autonomic dysfunction may persist at lower intensity for up to 3-6 months. Symptoms can be relieved by alcohol or benzodiazepines. Fewer than 10% of individuals in withdrawal develop dramatic symptoms (severe autonomic hyperactivity, tremors, withdrawal delirium); tonic-clonic seizures occur in fewer than 3%. Alcohol withdrawal delirium (delirium tremens) — disturbance of consciousness and cognition with visual, tactile, or rarely auditory hallucinations — may be accompanied by a relevant medical condition (liver failure, pneumonia, GI bleeding, head-trauma sequelae, hypoglycemia, electrolyte imbalance, postoperative status). About 50% of middle-class, highly functional US individuals with AUD have ever experienced a full withdrawal syndrome; among hospitalized or homeless individuals with AUD the rate may exceed 80%. Withdrawal is relatively rare before age 30 and risk/severity increase with age. Predictors of severe withdrawal: prior withdrawal delirium, prior severe withdrawal, low blood potassium, decreased platelet counts, systolic hypertension. Diagnostic markers include autonomic hyperactivity with moderately high but falling blood alcohol and a history of prolonged heavy drinking. GGT (>35 units) and CDT (≥20 units) elevations can flag heavy drinking (at least 70% of individuals with high GGT are persistent heavy drinkers, i.e., 8+ drinks daily), as can elevated MCV and liver function tests.

Differential diagnosis

Medical mimics (hypoglycemia, diabetic ketoacidosis); essential tremor (familial, may mimic withdrawal tremulousness); alcohol-induced mental disorders (symptoms in excess of those of withdrawal, warranting independent attention); sedative, hypnotic, or anxiolytic withdrawal (very similar syndrome; distinguished by history).

Alcohol-Induced Mental Disorders

Recognized for alcohol: alcohol-induced psychotic disorder; alcohol-induced bipolar and related disorder; alcohol-induced depressive disorder; alcohol-induced anxiety disorder; alcohol-induced sleep disorder; alcohol-induced sexual dysfunction; and alcohol-induced major or mild neurocognitive disorder (all described in their respective chapters), plus alcohol intoxication delirium and alcohol withdrawal delirium (Neurocognitive Disorders chapter). They are diagnosed instead of intoxication or withdrawal only when symptoms are severe enough to warrant independent clinical attention. The lifetime risk for major depressive episodes in individuals with AUD is approximately 40%, but only about one-third to one-half of these represent independent depressive syndromes outside intoxication; alcohol-induced psychotic episodes occur in less than 5% of individuals with AUD. All alcohol-induced disorders except alcohol-induced neurocognitive disorder (amnestic confabulatory type) are likely to improve within days to about 1 month of cessation of severe intoxication and/or withdrawal.

Unspecified Alcohol-Related Disorder (F10.99)

Applies when symptoms characteristic of an alcohol-related disorder cause clinically significant distress or impairment but do not meet full criteria for any specific alcohol-related disorder.

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