Other specified psychoactive substance 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 other specified psychoactive drugs in individuals who have developed dependence on other specified psychoactive drugs or have used other specified psychoactive drugs for a prolonged period or in large amounts.
• The symptoms are not better accounted for by another medical condition or another mental disorder.

Specifiers for clinical presentation:

Because of clinically important variation in their withdrawal syndromes, the following specifiers can be applied to the Withdrawal syndrome for Other Specified (6C4E.4) Psychoactive Substance Categories.

6C4E.40 Other Specified Psychoactive Drug Withdrawal, uncomplicated

All diagnostic requirements for Other Specified Psychoactive Drug Withdrawal are met and the withdrawal state is not accompanied by perceptual disturbances or seizures.

6C4E.41 Other Specified Psychoactive Drug Withdrawal, with perceptual disturbances

All diagnostic requirements for Other Specified Psychoactive Drug Withdrawal are met and the withdrawal state is accompanied by perceptual disturbances (e.g., visual or tactile hallucinations or illusions) with intact reality testing. There is no evidence of confusion and other diagnostic requirements for Delirium are not met. The withdrawal state is not accompanied by seizures.

6C4E.42 Other Specified Psychoactive Drug Withdrawal, with seizures

All diagnostic requirements for Other Specified Psychoactive Drug Withdrawal are met and the withdrawal state is accompanied by seizures (i.e., generalized tonic-clonic seizures) but not by perceptual disturbances.

6C4E.43 Other Specified Psychoactive Drug Withdrawal, with perceptual disturbances and seizures

All diagnostic requirements for Other Specified Psychoactive Drug Withdrawal are met and the withdrawal state is accompanied by both seizures (i.e., generalized tonic-clonic seizures) and perceptual disturbances (e.g., visual or tactile hallucinations or illusions) with intact reality testing. Diagnostic requirements for Delirium are not met.

6C4E.4Z Other Specified Psychoactive Drug Withdrawal, unspecified

Additional Clinical Features:

• Characteristic features of Other Specified Psychoactive Drug Withdrawal are opposite to the acute pharmacological effects of other specified psychoactive drugs.
• Other Specified Psychoactive 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):

• Other Specified Psychoactive Drug Withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of other specified psychoactive drugs. Recent cessation or reduction of use and the presence of various non-specific transient symptoms is not sufficient to make the diagnosis of Other Specified Psychoactive Drug Withdrawal.
• Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (‘hangover effect’).
• Some individuals who have previously had Other Specified Psychoactive Drug Dependence may experience symptoms similar to those of Other Specified Psychoactive 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 other specified psychoactive drug use. These symptoms are more transient than those observed during Other Specified Psychoactive Drug Withdrawal and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of Other Specified Psychoactive Drug Withdrawal should not be assigned under these circumstances.

Course Features:

• Other Specified Psychoactive Drug Withdrawal is time-limited. Factors that influence the features and time course of Other Specified Psychoactive Drug Withdrawal include: (1) the severity of Other Specified Psychoactive Drug Dependence, if present, (2) the dose, frequency of use, and duration of other specified psychoactive drug use prior to cessation or reduction of that use, (3) the half-life and duration of action of other specified psychoactive 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 other specified psychoactive 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 Other Specified Psychoactive Drug Dependence: Many individuals with Other Specified Psychoactive Drug Dependence develop Other Specified Psychoactive Drug Withdrawal upon cessation or reduction in the amount of the substance. In such cases, both Other Specified Psychoactive Drug Dependence and Other Specified Psychoactive Drug Withdrawal should be diagnosed. However, Other Specified Psychoactive Drug Withdrawal can be diagnosed in the absence of a diagnosis of Other Specified Psychoactive Drug Dependence.
• Boundary with Other Specified Psychoactive Drug Intoxication: The onset of Other Specified Psychoactive Drug Intoxication occurs immediately or shortly after the consumption of other specified psychoactive drugs. In contrast, Other Specified Psychoactive Drug Withdrawal occurs upon cessation or reduction in the amount of other specified psychoactive drugs in the context of Other Specified Psychoactive Drug Dependence or when other specified psychoactive drugs have been taken for a prolonged period or in large amounts. For other specified psychoactive drugs, the intoxication and withdrawal syndromes are typically distinct.
• Boundary with Other Specified Psychoactive Drug-Induced Delirium: Delirium is characterized by disturbances in attention, orientation, and awareness that develop within a short period of time with symptoms that are transient and may fluctuate depending on the underlying etiology. Delirium often includes disturbance of behaviour and emotion, and may include impairment in multiple cognitive domains. Disturbance of the sleep-wake cycle may also be present. Delirium may occur as an aspect of Other Specified Psychoactive Drug Withdrawal, particularly during later stages of withdrawal. In such cases, diagnoses of both Substance Withdrawal and Other Specified Psychoactive Drug-Induced Delirium should be assigned.
• Boundary with Other Specified Psychoactive Drug-Induced Mental Disorders: Mental or behavioural symptoms that arise during Other Specified Psychoactive Drug Withdrawal should only be used as a basis for diagnosing an Other Specified Psychoactive Drug-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the Other Specified Psychoactive 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 Other Specified Psychoactive Drug Withdrawal and an Other Specified Psychoactive Drug-Induced Mental Disorder may be assigned.
• Boundary with other mental disorders: Various symptoms associated with Other Specified Psychoactive Drug Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of Other Specified Psychoactive Drug Withdrawal occur in specific temporal relationship to the cessation of use of other specified psychoactive drugs and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of other specified psychoactive drug use, the symptoms persisting for a substantial period of time after cessation of other specified psychoactive 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 other specified psychoactive drug use).
• Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with Other Specified Psychoactive Drug Withdrawal (e.g., nausea, retching or vomiting, seizures, abdominal cramps, diarrhea, perspiration, postural hypotension, decreased or increased heart rate, cough, sleep disruption) and those that are characteristic of other medical conditions. Symptoms of Other Specified Psychoactive Drug Withdrawal occur in specific temporal relationship to the cessation of use of other specified psychoactive drugs 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 Other Specified Psychoactive Drug Withdrawal may also be Other Specified Psychoactive Drug Withdrawal diagnosis in order to guide treatment together with appropriate diagnosis from the chapter on Certain Conditions Originating in the Perinatal Period.