Stimulant withdrawal including amphetamines, methamphetamine or methcathinone

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 stimulants in individuals who have developed dependence on stimulants or have used stimulants for a prolonged period or in large amounts. Note: Stimulant Withdrawal can occur when prescribed stimulants (e.g., methylphenidate) have been used in standard therapeutic doses.
• Presenting features of Stimulant Withdrawal may include depressed or dysphoric mood, irritability, fatigue, insomnia or (more commonly) hypersomnia, vivid and unpleasant dreams, increased appetite, psychomotor agitation or retardation, and craving for amphetamine and related stimulants.
• The severity and duration of the withdrawal state is widely variable based on the type of stimulant taken and the amount, frequency and duration of such use prior to its cessation.
• The symptoms are not better accounted for by another medical condition or another mental disorder.

Additional Clinical Features:

• Stimulant Withdrawal typically occurs within 24 hours to 4 days of cessation of stimulant use and is characterized by a dysphoric and low energy state manifested by depressed or dysphoric mood, irritability, fatigue, inertia and hypersomnia.
• In the first phase of Stimulant Withdrawal, which typically lasts for 7 to 14 days, low mood, lethargy and hypersomnia predominate. After this phase, irritability and craving for stimulants are prominent and may persist for 6 to 8 weeks.
• At the onset of Stimulant Withdrawal there may be features that persist from the intoxicating effects of the stimulant such as hyperactivity, paranoid ideation and auditory hallucinations.
• Characteristic features of Stimulant Withdrawal are opposite to the acute pharmacological effects of stimulants.
• Stimulant 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):

• Stimulant Withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of stimulants. Recent cessation or reduction of use and the presence of various non-specific transient symptoms is not sufficient to make the diagnosis of Stimulant Withdrawal.
• Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (‘hangover effect’). For example, if low mood and reduction in energy are reported following use of stimulants and other characteristic features of Substance Withdrawal are not present, a diagnosis of Substance Withdrawal should not be assigned.
• Some individuals who have previously had Stimulant Dependence may experience symptoms similar to those of Stimulant 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 stimulant use. These symptoms are more transient than those observed during Stimulant Withdrawal and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of Stimulant Withdrawal should not be assigned under these circumstances.

Course Features:

• Stimulant Withdrawal is time-limited. Factors that influence the features and time course of Stimulant Withdrawal include: (1) the severity of Stimulant Dependence, if present, (2) the dose, frequency of use, and duration of stimulant use prior to cessation or reduction of that use, (3) the half-life and duration of action of stimulants, 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 stimulants. 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 Stimulant Dependence, including Amphetamines, Methamphetamine and Methcathinone: Many individuals with Stimulant Dependence develop Stimulant Withdrawal upon cessation or reduction in the amount of the substance. In such cases, both Stimulant Dependence and Stimulant Withdrawal should be diagnosed. However, Stimulant Withdrawal can be diagnosed in the absence of a diagnosis of Stimulant Dependence, for example in response to cessation of medically appropriate treatment with stimulants (e.g., methylphenidate), when the other Essential Features of Substance Dependence are not present.
• Boundary with Stimulant Intoxication, including Amphetamines, Methamphetamine and Methcathinone: The onset of Stimulant Intoxication occurs immediately or shortly after the consumption of stimulants. In contrast, Stimulant Withdrawal occurs upon cessation or reduction in the amount of stimulants in the context of Stimulant Dependence or when stimulants have been taken for a prolonged period or in large amounts. For stimulants, the intoxication and withdrawal syndromes are typically distinct.
• Boundary with other Stimulant-Induced Mental Disorders: Mental or behavioural symptoms that arise during Stimulant Withdrawal should only be used as a basis for diagnosing a Stimulant-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the Stimulant Withdrawal and the symptoms are sufficiently severe to warrant specific clinical attention. In such cases, if the withdrawal syndrome is ongoing, diagnoses of both Stimulant Withdrawal and a Stimulant-Induced Mental Disorder may be assigned.
• Boundary with other mental disorders: Various symptoms associated with Stimulant Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of Stimulant Withdrawal occur in specific temporal relationship to the cessation of use of stimulants and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of stimulant use, the symptoms persisting for a substantial period of time after cessation of stimulants 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 stimulant use).
• Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with Stimulant Withdrawal (e.g., increased appetite, psychomotor agitation or retardation sleep disruption) and those that are characteristic of other medical conditions. Symptoms of Stimulant Withdrawal occur in specific temporal relationship to the cessation of use of stimulants 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 Stimulant Withdrawal may also be Stimulant Withdrawal diagnosis in order to guide treatment together with appropriate diagnosis from the chapter on Certain Conditions Originating in the Perinatal Period.