Multiple specified psychoactive substances 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 multiple specified psychoactive substances in individuals who have developed dependence on multiple specified psychoactive substances or have used multiple specified psychoactive substances 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 (Multiple Specified (6C4F.4) Psychoactive Substance Categories.

6C4F.40 Multiple Specified Psychoactive Substances Withdrawal, uncomplicated

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

6C4F.41 Multiple Specified Psychoactive Substances Withdrawal, with perceptual disturbances

All diagnostic requirements for Multiple Specified Psychoactive Substances 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.

6C4F.42 Multiple Specified Psychoactive Substances Withdrawal, with seizures

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

6C4F.43 Multiple Specified Psychoactive Substances Withdrawal, with perceptual disturbances and seizures

All diagnostic requirements for Multiple Specified Psychoactive Substances 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.

6C4F.4Z Multiple Specified Psychoactive Substances Withdrawal, unspecified

Additional Clinical Features:

• Characteristic features of Multiple Specified Psychoactive Substances Withdrawal are opposite to the acute pharmacological effects of multiple specified psychoactive substances.
• Multiple Specified Psychoactive Substances 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):

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

Course Features:

• Multiple Specified Psychoactive Substances Withdrawal is time-limited. Factors that influence the features and time course of Multiple Specified Psychoactive Substances Withdrawal include: (1) the severity of Multiple Specified Psychoactive Substances Dependence, if present, (2) the dose, frequency of use, and duration of multiple specified psychoactive substance use prior to cessation or reduction of that use, (3) the half-life and duration of action of multiple specified psychoactive substances, 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 multiple specified psychoactive substances. 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 Multiple Specified Psychoactive Substances Dependence: Many individuals with Multiple Specified Psychoactive Substances Dependence develop Multiple Specified Psychoactive Substances Withdrawal upon cessation or reduction in the amount of the substance. In such cases, both Multiple Specified Psychoactive Substances Dependence and Multiple Specified Psychoactive Substances Withdrawal should be diagnosed. However, Multiple Specified Psychoactive Substances Withdrawal can be diagnosed in the absence of a diagnosis of Multiple Specified Psychoactive Substances Dependence.
• Boundary with Multiple Specified Psychoactive Substances Intoxication: The onset of Multiple Specified Psychoactive Substances Intoxication occurs immediately or shortly after the consumption of multiple specified psychoactive substances. In contrast, Multiple Specified Psychoactive Substances Withdrawal occurs upon cessation or reduction in the amount of multiple specified psychoactive substances in the context of Multiple Specified Psychoactive Substances Dependence or when multiple specified psychoactive substances have been taken for a prolonged period or in large amounts. For multiple specified psychoactive substances, the intoxication and withdrawal syndromes are typically distinct.
• Boundary with Multiple Specified Psychoactive Substances-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 Multiple Specified Psychoactive Substances Withdrawal, particularly during later stages of withdrawal. In such cases, diagnoses of both Substance Withdrawal and Multiple Specified Psychoactive Substances-Induced Delirium should be assigned.
• Boundary with other Multiple Specified Psychoactive Substances-Induced Mental Disorders: Mental or behavioural symptoms that arise during Multiple Specified Psychoactive Substances Withdrawal should only be used as a basis for diagnosing a Multiple Specified Psychoactive Substances-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the Multiple Specified Psychoactive Substances Withdrawal and the symptoms are sufficiently severe to warrant specific clinical attention. In such cases, if the withdrawal syndrome is ongoing, diagnoses of both Multiple Specified Psychoactive Substances Withdrawal and a Multiple Specified Psychoactive Substances-Induced Mental Disorder may be assigned.
• Boundary with other mental disorders: Various symptoms associated with Multiple Specified Psychoactive Substances Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of Multiple Specified Psychoactive Substances Withdrawal occur in specific temporal relationship to the cessation of use of multiple specified psychoactive substances and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of multiple specified psychoactive substance use, the symptoms persisting for a substantial period of time after cessation of multiple specified psychoactive substances 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 multiple specified psychoactive substance use).
• Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with Multiple Specified Psychoactive Substances 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 Multiple Specified Psychoactive Substances Withdrawal occur in specific temporal relationship to the cessation of use of multiple specified psychoactive substances 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 Multiple Specified Psychoactive Substances Withdrawal may also be Multiple Specified Psychoactive Substances Withdrawal diagnosis in order to guide treatment together with appropriate diagnosis from the chapter on Certain Conditions Originating in the Perinatal Period.