Cocaine withdrawal

Essential (Required) Features:

• The presence of a clinically significant cluster of symptoms, behaviours, and/or physiological features that occurs upon cessation or reduction in the use of cocaine in individuals who have developed dependence on cocaine or have used cocaine for a prolonged period or in large amounts.
• Presenting features of Cocaine Withdrawal may include depressed or dysphoric mood, irritability, fatigue, psychomotor agitation or retardation, vivid unpleasant dreams, insomnia or hypersomnia, increased appetite, anxiety, and craving for cocaine.
• The symptoms are not better accounted for by another medical condition or another mental disorder.

Additional Clinical Features:

• Initial symptoms of Cocaine Withdrawal include a dysphoric and low energy state manifested as depressed or dysphoric mood, irritability, fatigue, inertia and hypersomnia. This typically occurs within 6 to 24 hours of cessation of cocaine use.
• The withdrawal state may last up to 7 days. Craving for cocaine is prominent in the later stages.
• Suicidal ideation may occur, especially when dysphoric mood is marked.
• At the onset of Cocaine Withdrawal there may be features that persist from the intoxicating effects of cocaine such as hyperactivity, paranoid ideation and auditory hallucinations.
• Characteristic features of Cocaine Withdrawal are opposite to the acute pharmacological effects of cocaine.
• Cocaine Withdrawal symptoms become more severe with repeated episodes of withdrawal (termed ‘kindling’), with aging, or in the presence of comorbid medical conditions.

Boundary with Normality (Threshold):

• Cocaine Withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of cocaine. Recent cessation or reduction of use and the presence of various non-specific transient symptoms is not sufficient to make the diagnosis of Cocaine Withdrawal.
• Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (‘hangover effect’).
• Some individuals who have previously had Cocaine Dependence may experience symptoms similar to those of Cocaine Withdrawal months after the last use of the substance, particularly when the individual encounters stimuli (e.g., drug paraphernalia) and contexts (e.g., location where use was frequent) previously associated with past cocaine use. These symptoms are more transient than those observed during Cocaine Withdrawal and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of Cocaine Withdrawal should not be assigned under these circumstances.

Course Features:

• Cocaine Withdrawal is time-limited. Factors that influence the features and time course of Cocaine Withdrawal include: (1) the severity of Cocaine Dependence, if present, (2) the dose, frequency of use, and duration of cocaine use prior to cessation or reduction of that use, (3) the half-life and duration of action of cocaine, and (4) the presence of comorbid medical conditions (e.g., metabolic disturbances).

Culture-Related Features:

• Symptoms of withdrawal depend largely on the psychotropic characteristics of cocaine. However, specific cultures may emphasize certain symptoms of withdrawal over others, making it more difficult to conduct a differential diagnosis. In addition, vernacular terms for withdrawal vary greatly.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Cocaine Dependence: Many individuals with Cocaine Dependence develop Cocaine Withdrawal upon cessation or reduction in the amount of the substance. In such cases, both Cocaine Dependence and Cocaine Withdrawal should be diagnosed. However, Cocaine Withdrawal can be diagnosed in the absence of a diagnosis of Cocaine Dependence.
• Boundary with Cocaine Intoxication: The onset of Cocaine Intoxication occurs immediately or shortly after the consumption of cocaine. In contrast, Cocaine Withdrawal occurs upon cessation or reduction in the amount of cocaine in the context of Cocaine Dependence or when cocaine has been taken for a prolonged period or in large amounts. For cocaine, the intoxication and withdrawal syndromes are typically distinct.
• Boundary with other Cocaine-Induced Mental Disorders: Mental or behavioural symptoms that arise during Cocaine Withdrawal should only be used as a basis for diagnosing a Cocaine-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the Cocaine Withdrawal and the symptoms are sufficiently severe to warrant specific clinical attention. In such cases, if the withdrawal syndrome is ongoing, diagnoses of both Cocaine Withdrawal and a Cocaine-Induced Mental Disorder may be assigned.
• Boundary with other mental disorders: Various symptoms associated with Cocaine Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of Cocaine Withdrawal occur in specific temporal relationship to the cessation of use of cocaine and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of cocaine use, the symptoms persisting for a substantial period of time after cessation of cocaine or withdrawal (e.g., 1 month or more, depending on the substance), or other evidence of a pre-existing mental disorder (e.g., a history of prior episodes not associated with cocaine use).
• Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with Cocaine Withdrawal (e.g., psychomotor agitation or retardation, increased appetite, hypersomnia) and those that are characteristic of other medical conditions. Symptoms of Cocaine Withdrawal occur in specific temporal relationship to the cessation of use of cocaine and diminish with the passage of time.
• Boundary with Foetus or Newborn Affected by Maternal Use of Tobacco, Alcohol, or Other Drugs of Addiction: The ICD-11 chapter on Certain Conditions Arising During the Perinatal Period contains categories for ‘Foetus or newborn affected by maternal use of tobacco, alcohol, and other drugs.’ A neonate exhibiting signs of Cocaine Withdrawal may also be Cocaine Withdrawal diagnosis in order to guide treatment together with appropriate diagnosis from the chapter on Certain Conditions Originating in the Perinatal Period.