MDMA or related drug withdrawal, including MDA

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 MDMA or related drugs in individuals who have developed dependence on MDMA or related drugs or have used MDMA or related drugs for a prolonged period or in large amounts.
• Presenting features of MDMA or Related Drug Withdrawal may include fatigue, lethargy, hypersomnia or insomnia, depressed mood, anxiety, irritability, craving, difficulty in concentrating, and appetite disturbance.
• The symptoms are not better accounted for by another medical condition or another mental disorder.

Additional Clinical Features:

• The essential features above primarily concern withdrawal from MDMA. There is insufficient information on the features and course of the withdrawal state from drugs related to MDMA, including MDA, to fully characterize the associated withdrawal states.
• MDMA Withdrawal is uncommon, reflecting the comparative rarity of MDMA Dependence.
• Onset of MDMA Withdrawal typically occurs within 12-24 hours after last use, as blood concentrations decline. The features vary in type, severity, onset and duration according to the amount, frequency and duration of MDMA use prior to cessation of use.
• The duration of MDMA Withdrawal may be up to 10 days. Craving for MDMA may be prominent during the later stages.
• Characteristic features of MDMA or Related Drug Withdrawal are opposite to the acute pharmacological effects of MDMA or related drugs.
• MDMA or Related Drug 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):

• MDMA or Related Drug Withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of MDMA or related drugs. Recent cessation or reduction of use and the presence of various non-specific transient symptoms is not sufficient to make the diagnosis of MDMA or Related Drug 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 MDMA or related drugs 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 MDMA or Related Drug Dependence may experience symptoms similar to those of MDMA or Related Drug 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 MDMA or related drug use. These symptoms are more transient than those observed during MDMA or Related Drug Withdrawal and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of MDMA or Related Drug Withdrawal should not be assigned under these circumstances.

Course Features:

• MDMA or Related Drug Withdrawal is time-limited. Factors that influence the features and time course of MDMA or Related Drug Withdrawal include: (1) the severity of MDMA or Related Drug Dependence, if present, (2) the dose, frequency of use, and duration of MDMA or related drug use prior to cessation or reduction of that use, (3) the half-life and duration of action of MDMA or related drugs, 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 MDMA or related drugs. 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 MDMA or Related Drug Dependence, including MDA: Many individuals with MDMA or Related Drug Dependence develop MDMA or Related Drug Withdrawal upon cessation or reduction in the amount of the substance. In such cases, both MDMA or Related Drug Dependence and MDMA or Related Drug Withdrawal should be diagnosed. However, MDMA or Related Drug Withdrawal can be diagnosed in the absence of a diagnosis of MDMA or Related Drug Dependence.
• Boundary with MDMA or Related Drug Intoxication, including MDA: The onset of MDMA or Related Drug Intoxication occurs immediately or shortly after the consumption of MDMA or related drugs. In contrast, MDMA or Related Drug Withdrawal occurs upon cessation or reduction in the amount of MDMA or related drugs in the context of MDMA or Related Drug Dependence or when MDMA or related drugs have been taken for a prolonged period or in large amounts. For MDMA or related drugs, the intoxication and withdrawal syndromes are typically distinct.
• Boundary with other MDMA or Related Drug-Induced Mental Disorders, including MDA: Mental or behavioural symptoms that arise during MDMA or Related Drug Withdrawal should only be used as a basis for diagnosing a MDMA or Related Drug-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the MDMA or Related Drug Withdrawal and the symptoms are sufficiently severe to warrant specific clinical attention. In such cases, if the withdrawal syndrome is ongoing, diagnoses of both MDMA or Related Drug Withdrawal and a MDMA or Related Drug-Induced Mental Disorder may be assigned.
• Boundary with other mental disorders: Various symptoms associated with MDMA or Related Drug Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of MDMA or Related Drug Withdrawal occur in specific temporal relationship to the cessation of use of MDMA or related drugs and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of MDMA or related drug use, the symptoms persisting for a substantial period of time after cessation of MDMA or related drugs 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 MDMA or related drug use).
• Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with MDMA or Related Drug Withdrawal (e.g., fatigue, lethargy, difficulty concentrating, sleep disruption) and those that are characteristic of other medical conditions. Symptoms of MDMA or Related Drug Withdrawal occur in specific temporal relationship to the cessation of use of MDMA or related drugs and diminish with the passage of time.