Withdrawal due to unknown or unspecified psychoactive substance

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 unknown or unspecified psychoactive substances in individuals who have developed dependence on unknown or unspecified psychoactive substances or have used unknown or unspecified 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 Unspecified (6C4G.4) Psychoactive Substance Categories.

###6C4G.40 Withdrawal due to Unknown or Unspecified Psychoactive Substance, uncomplicated

All diagnostic requirements for Withdrawal due to Unknown or Unspecified Psychoactive Substance are met and the withdrawal state is not accompanied by perceptual disturbances or seizures.

6C4G.41 Withdrawal due to Unknown or Unspecified Psychoactive Substance, with perceptual disturbances

All diagnostic requirements for Withdrawal due to Unknown or Unspecified Psychoactive Substance 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.

6C4G.42 Withdrawal due to Unknown or Unspecified Psychoactive Substance, with seizures

All diagnostic requirements for Withdrawal due to Unknown or Unspecified Psychoactive Substance are met and the withdrawal state is accompanied by seizures (i.e., generalized tonic-clonic seizures) but not by perceptual disturbances.

6C4G.43 Withdrawal due to Unknown or Unspecified Psychoactive Substance, with perceptual disturbances and seizures

All diagnostic requirements for Withdrawal due to Unknown or Unspecified Psychoactive Substance 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.

6C4G.4Z Withdrawal due to Unknown or Unspecified Psychoactive Substance, unspecified

Additional Clinical Features:

• For some substances, characteristic features of Withdrawal due to Unknown or Unspecified Psychoactive Substance are opposite to the acute pharmacological effects of unknown or unspecified psychoactive substances.
• Withdrawal due to Unknown or Unspecified Psychoactive Substance symptoms become more severe with repeated episodes of withdrawal (termed ‘kindling’), with aging, or in the presence of comorbid medical conditions.
• A diagnosis of Withdrawal due to Unknown or Unspecified Psychoactive Substance can be assigned if the substance consumed is initially unknown. As more information becomes available (e.g., laboratory results, report from a collateral informant) the diagnosis should be changed to indicate the substance responsible for the withdrawal symptoms.

Boundary with Normality (Threshold):

• Withdrawal due to Unknown or Unspecified Psychoactive Substance should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of unknown or unspecified 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 Withdrawal due to Unknown or Unspecified Psychoactive Substance.
• Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (‘hangover effect’).
• Some individuals who have previously had Unknown or Unspecified Psychoactive Substance Dependence may experience symptoms similar to those of Withdrawal due to Unknown or Unspecified Psychoactive Substance 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 unknown or unspecified psychoactive substance use. These symptoms are more transient than those observed during Withdrawal due to Unknown or Unspecified Psychoactive Substance and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of Withdrawal due to Unknown or Unspecified Psychoactive Substance should not be assigned under these circumstances.

Course Features:

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