Opioid-induced anxiety disorder

Essential (Required) Features:

• The presentation is characterized by anxiety symptoms (e.g., apprehension or worry, fear, physiological symptoms of excessive autonomic arousal, panic attacks, avoidance behaviour) that develop during or soon after intoxication with or withdrawal from opioids.
• The intensity or duration of the anxiety symptoms is substantially in excess of anxiety symptoms that are characteristic of Opioid Intoxication or Opioid Withdrawal.
• The symptoms are not better accounted for by another mental disorder such as an Anxiety or Fear-Related Disorder, a Depressive Disorder with prominent anxiety symptoms, or Post-Traumatic Stress Disorder. Evidence supporting a diagnosis of another mental disorder would include anxiety symptoms preceding the onset of opioid use, the symptoms persisting for a substantial period of time after cessation of opioids or withdrawal (e.g., 1 month or more), or other evidence of a pre-existing mental disorder with anxiety symptoms (e.g., a history of prior episodes not associated with opioid use).
• The symptoms are not a manifestation of another medical condition.
• The symptoms cause significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

When making a diagnosis of Opioid-Induced Anxiety Disorder, an additional diagnosis indicating the related pattern of opioid use should also be assigned. These include Episode of Harmful Use of Opioids, Harmful Pattern of Use of Opioids, and Opioid Dependence. A diagnosis of Opioid Intoxication or Opioid Withdrawal may also be assigned if applicable.

Additional Clinical Features:

• Opioid-Induced Anxiety Disorder may present with patterns of symptoms that vary according to the characteristics of the user (e.g., genetics, metabolism, personality factors). Opioids use in higher amounts or over longer periods of time is more likely to be associated with the development of an Opioid-Induced Anxiety Disorder.
• Symptoms of Opioid-Induced Anxiety Disorder usually resolve or improve after sustained cessation of opioid use.
• The duration of Substance Withdrawal for some substances can be protracted. For substances with more protracted withdrawal periods, the onset of symptoms of Substance-Induced Anxiety Disorder can occur up to several weeks after the cessation of substance use. Substance-Induced Anxiety Disorder symptoms related to substances with more protracted withdrawal periods may also last for correspondingly longer periods of time.
• In cases in which multiple psychoactive substance are used, it is often challenging to distinguish which substance is the cause of the Substance-Induced Anxiety Disorder. When the specific etiological substance cannot be determined, a diagnosis of Substance-Induced Anxiety Disorder Due to Multiple Specified Psychoactive Substances including Medications may assigned. In cases of multiple psychoactive substance use in which more than one specific substance can be identified as a cause of the Substance-Induced Anxiety Disorder, the corresponding specific Substance-Induced Anxiety Disorder diagnoses should be given instead.

Boundary with Normality (Threshold):

• Symptoms of Opioid-Induced Anxiety Disorders should be differentiated from transient physiological aftereffects of intoxication (‘hangover effect’). The duration or severity of the symptoms in Opioid-Induced Anxiety Disorders must be in excess of ‘hangover effects’ of Opioids and result in significant distress or impairment of functioning.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Opioid Intoxication and Opioid Withdrawal: Mental or behavioural symptoms that occur during Opioid Intoxication or Opioid Withdrawal should only be used as a basis for diagnosing an Opioid-Induced Anxiety Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of Opioid Intoxication or Opioid Withdrawal and the symptoms are sufficiently severe to warrant specific clinical attention.
• Boundary with Episode of Harmful Use of Opioids, Harmful Pattern of Use of Opioids, or Opioid Dependence: The impact of repeated or continuous use of opioids characteristic of Harmful Pattern of Use of Opioids and Opioids Dependence may include Opioid-Induced Anxiety Disorder. Opioid-Induced Anxiety Disorders can also be associated with a single episode of opioid use. In such cases, an Opioid-Induced Anxiety Disorder should be diagnosed together with a primary diagnosis of Episode of Harmful Use of Opioids, Harmful Pattern of Use of Opioids, or Opioid Dependence.
• Boundary with mental disorders not induced by opioids: Opioid-Induced Anxiety Disorders are differentiated from mental disorders with similar features that are not induced by opioids on the basis of their onset, course and clinical features. A diagnosis of Opioid-Induced Anxiety Disorder requires evidence from history, physical or mental examination, or laboratory findings of recent opioid use, intoxication or withdrawal. Most Opioid-Induced Mental Disorders resolve or improve within several weeks of cessation of opioid use. Mental disorders not induced by opioids may precede the onset of opioid use or may continue to be symptomatic during periods of sustained abstinence. The co-occurrence of opioid use or withdrawal and onset of symptoms of mental disorders should not be taken as evidence for a presumptive diagnosis of an Opioid-Induced Anxiety Disorder. Some people use substances to suppress symptoms of mental disorders (e.g., Schizophrenia and Other Primary Psychotic Disorders, Mood Disorders, Anxiety and Fear-Related Disorders, Personality Disorders) and full symptomatic presentations only emerge upon cessation or reduction in substance use. Furthermore, opioid use can exacerbate symptoms or precipitate an episode of a pre-existing mental disorder. Finally, opioid use may be associated with but not aetiologic for new onset of symptoms of a mental disorder. Although a diagnosis of an Opioid-Induced Anxiety Disorder should not be assigned under these circumstances, an additional diagnosis of Episode of Harmful Use of Opioids, Harmful Pattern of Use of Opioids, or Opioid Dependence may still be appropriate.