gression characterized by the diagnostic criter ia is proactive and predatory. Aggression in
oppositional defiant disorder is typically char acterized by temper ta ntrums and verbal ar-
guments with authority figures, whereas impu lsive aggressive outbursts in intermittent
explosive disorder are in response to a broader array of provocation and include physical
assault. The level of impulsive aggression in individuals with a history of one or more of
these disorders has been reported as lower than that in comparab le individuals whose
symptoms also meet intermitte nt explosive disorder Criteria  A through E. Accordingly, if
Criteria A through E are also met, and the impulsive aggressive out bursts warrant inde-
pendent clinical attention, a diagnosis of intermittent expl osive disorder may be given.
Comorbidity
Depressive disorders, anxiet y disorders, and substance us e disorders are most commonly
comorbid with intermittent explosive disord er. In addition, individuals with antisocial
personality disorder or borderline personality disorder, and individuals with a history of
disorders with disruptive beha viors (e.g., ADHD, conduct di sorder, oppositional defiant
disorder), are at greater risk for como rbid intermittent explosive disorder.
Conduct Disorder
Diagnostic Criteria
A. A repetitive and persistent pattern of behavior in which the basic rights of others or ma-
jor age-appropriate societal norms or rules ar e violated, as manifested by the presence
of at least three of the following 15 criteria in the past 12 months from any of the cate-
gories below, with at least one criter ion present in the past 6 months:
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others.
2. Often initiates physical fights.


2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical harm to others (e.g., a bat,
brick, broken bottle, knife, gun).


470 Disruptive, Impulse-Control, and Conduct Disorders
4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion,
armed robbery).
7. Has forced someone into sexual activity.
Destruction of Property
8. Has deliberately engaged in fire setting with the intention of causing serious damage.
9. Has deliberately destroyed others’ property (other than by fire setting).
Deceitfulness or Theft
10. Has broken into someone else’s house, building, or car.
11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting,
but without breaking and entering; forgery).
Serious Violations of Rules
13. Often stays out at night despite parental prohibitions, beginning before age 13 years.
14. Has run away from home overnight at least twice while living in the parental or pa-
rental surrogate home, or once without returning for a lengthy period.
15. Is often truant from school, beginning before age 13 years.
B. The disturbance in behavior causes clinically significant impairment in social, aca-
demic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial personality
disorder.
Specify whether:
312.81 (F91.1) Childhood-onset type:  Individuals show at least one symptom char-
acteristic of conduct disorder prior to age 10 years.
312.82 (F91.2) Adolescent-onset type:  Individuals show no symptom characteristic
of conduct disorder prior to age 10 years.


of conduct disorder prior to age 10 years.
312.89 (F91.9) Unspecified onset:  Criteria for a diagnosis of conduct disorder are
met, but there is not enough information available to determine whether the onset of
the first symptom was before or after age 10 years.
Specify if:
With limited prosocial emotions:  To qualify for this specifier, an individual must have dis-
played at least two of the following characteristics persistently over at least 12 months and
in multiple relationships and settings. These characteristics reflect the individual’s typical
pattern of interpersonal and emotional functioning over this period and not just occasional
occurrences in some situations. Thus, to assess the criteria for the specifier, multiple infor-
mation sources are necessary. In addition to the individual’s self-report, it is necessary to
consider reports by others who have know n the individual for extended periods of time
(e.g., parents, teachers, co-workers, extended family members, peers).
Lack of remorse or guilt:  Does not feel bad or guilty when he or she does some-
thing wrong (exclude remorse when expre ssed only when caught and/or facing
punishment). The individual shows a general  lack of concern about the negative
consequences of his or her actions. For ex ample, the individual is not remorseful
after hurting someone or does not care about the consequences of breaking rules.
Callous—lack of empathy:  Disregards and is unconcerned about the feelings of
others. The individual is described as cold and uncaring. The person appears more
concerned about the effects of his or her actions on himself or herself, rather than
their effects on others, even when they result in substantial harm to others.


Conduct Disorder 471
Unconcerned about performance: Does not show concern about poor/problem-
atic performance at school, at work, or in other important activities. The individual
does not put forth the effort necessary to perform well, even when expectations are
clear, and typically blames other s for his or her poor performance.
Shallow or deficient affect:  Does not express feelings or show emotions to others,
except in ways that seem shallow, insincere,  or superficial (e.g., actions contradict the
emotion displayed; can turn emotions “on” or “off” quickly) or when emotional expres-
sions are used for gain (e.g., emotions displayed to manipulate or intimidate others).
Specify current severity:
Mild:  Few if any conduct problems in excess of those required to make the diagnosis
are present, and conduct problems cause relatively minor harm to others (e.g., lying,
truancy, staying out after dark without permission, other rule breaking).
Moderate: The number of conduct problems and the effect on others are intermediate
between those specified in “mild” and those in “severe” (e.g., stealing without confront-
ing a victim, vandalism).
Severe:  Many conduct problems in excess of those required to make the diagnosis are
present, or conduct problems cause considerable harm to others (e.g., forced sex, physical
cruelty, use of a weapon, stealing while c onfronting a victim, breaking and entering).
Subtypes
Three subtypes of conduct disorder are provided based on the age at onset of the disorder.
Onset is most accurately estimated with information from both the youth and the care-
giver; estimates are often 2 years later than actu al onset. Both subtypes can occur in a mild,
moderate, or severe form. An unspecified-onse t subtype is designated when there is in-


sufficient information to determine age at onset.
In childhood-onset conduct disorder, indivi duals are usually male, frequently display
physical aggression toward others, have disturbed peer rela tionships, may have had op-
positional defiant disorder during early ch ildhood, and usually have symptoms that meet
full criteria for conduct disord er prior to puberty. Many children with this subtype also
have concurrent attention-deficit/hyperactiv ity disorder (ADHD) or other neurodevel-
opmental difficulties. Individuals with childho od-onset type are more  likely to have per-
sistent conduct disorder into adulthood than are those with adolescent-onset type. As
compared with individuals with childhood-ons et type, individuals with adolescent-onset
conduct disorder are less likely to display a ggressive behaviors and tend to have more
normative peer relationships (although they often display conduct problems in the com-
pany of others). These individuals are less lik ely to have conduct disorder that persists into
adulthood. The ratio of males to  females with conduct disorder is more balanced for the
adolescent-onset type than for the childhood-onset type.
Specifiers
A minority of individuals with conduct disorder exhibit characteristics that qualify for the
“with limited prosocial emotions” specifier. The indicators of  this specifier are those that
have often been labeled as callous and unemot ional traits in research. Other personality
features, such as thrill seeking, fearlessness, and insensitivity to punishment, may also dis-
tinguish those with characteri stics described in the specifier. Individuals with character-
istics described in this specifier may be mo re likely than other individuals with conduct
disorder to engage in aggression that is planned for instrumental gain. Individuals with
conduct disorder of any subtype or any level of  severity can have characteristics that qual-


conduct disorder of any subtype or any level of  severity can have characteristics that qual-
ify for the specifier “with limited prosocial em otions,” although individuals with the spec-
ifier are more likely to have childhood-onset ty pe and a severity specifier rating of severe.


472 Disruptive, Impulse-Control, and Conduct Disorders
Although the validity of self-report to assess the presence of the specifier has been sup-
ported in some research contexts, individual s with conduct disorder with this specifier
may not readily admit to the traits in a clinical interview. Thus, to assess the criteria for the
specifier, multiple information sources are ne cessary. Also, because the indicators of the
specifier are characteristics that reflect the in dividual’s typical pattern of interpersonal and
emotional functioning, it is important to co nsider reports by others who have known the
individual for extended periods of time an d across relationships and settings (e.g., par-
ents, teachers, co-workers, extended family members, peers).
Diagnostic Features
The essential feature of conduct disorder is a repetitive and persistent pattern of behavior
in which the basic rights of others or major age-appropriate societal norms or rules are vi-
olated (Criterion A). These be haviors fall into four main groupings: aggressive conduct
that causes or threatens physical harm to other people or animals (Criteria A1–A7); non-
aggressive conduct that causes property loss or damage (Criteria A8–A9); deceitfulness or
theft (Criteria A10–A12); and serious violations  of rules (Criteria A13–A15). Three or more
characteristic behaviors must ha ve been present during the pa st 12 months, with at least
one behavior present in the past 6 months. The disturbance in behavior causes clinically
significant impairment in social, academic, or  occupational functioning (Criterion B). The
behavior pattern is usually pres ent in a variety of settings, su ch as home, at school, or in
the community. Because individu als with conduct disorder ar e likely to minimize their
conduct problems, the clinician often must rely on additional informants. However, infor-


conduct problems, the clinician often must rely on additional informants. However, infor-
mants’ knowledge of the individual’s conduct problems may be limited if they have inad-
equately supervised the individual or the individual has concealed symptom behaviors.
Individuals with conduct disorder often initiate aggressive behavior and react aggres-
sively to others. They may display bullying, th reatening, or intimidating behavior (includ-
ing bullying via messaging on Web-based social  media) (Criterion A1); initiate frequent
physical fights (Criteri on A2); use a weapon that can caus e serious physical harm (e.g., a bat,
brick, broken bottle, knife, gun) (Criterion A3);  be physically cruel to people (Criterion A4)
or animals (Criterion A5); steal while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery) (Criterion A6); or force someone into sexual activity (Criterion A7).
Physical violence may take the form of rape, assault, or, in rare cases, homicide. Deliberate
destruction of others’ property may include delibe rate fire setting with the intention of caus-
ing serious damage (Criterion A8) or deliberate destroying of  other people’s property in
other ways (e.g., smashing car windows, vandal izing school property) (C riterion A9). Acts of
deceitfulness or theft may include breaking into someone else’s house, building, or car (Crite-
rion A10); frequently lying or breaking promises  to obtain goods or favors or to avoid debts
or obligations (e.g., “conning” other individual s) (Criterion A11); or stealing items of non-
trivial value without confronting the victim (e.g.,  shoplifting, forgery, fraud) (Criterion A12).


Individuals with conduct diso rder may also frequently commit serious violations of
rules (e.g., school, parental, workplace). Children with cond uct disorder often have a pat-
tern, beginning before age 13 years, of stay ing out late at night despite parental prohi-
bitions (Criterion A13). Children may also show a pattern of running away from home
overnight (Criterion A14). To be considered  a symptom of conduct disorder, the running
away must have occurred at le ast twice (or only once if the individual did not return for a


overnight (Criterion A14). To be considered  a symptom of conduct disorder, the running
away must have occurred at le ast twice (or only once if the individual did not return for a
lengthy period). Runaway episodes that occur as a direct consequence of physical or sex-
ual abuse do not typically qualify for this criterion. Children with conduct disorder may
often be truant from school, beginning prior to age 13 years (Criterion A15).
Associated Features Supporting Diagnosis
Especially in ambiguous situ ations, aggressive individual s with conduct disorder fre-
quently misperceive the intentio ns of others as more hostile  and threatening than is the


Conduct Disorder 473
case and respond with aggression that they th en feel is reasonable and justified. Person-
ality features of trait negative emotionality and poor self-control, including poor frustra-
tion tolerance, irritability, temper outbursts,  suspiciousness, insens itivity to punishment,
thrill seeking, and recklessnes s, frequently co-occur with conduct disorder. Substance
misuse is often an associated fe ature, particularly in adolescent females. Suicidal ideation,
suicide attempts, and completed suicide occur at  a higher-than-expected rate in individu-
als with conduct disorder.
Prevalence
One-year population prevalence estimates range from 2% to more than 10%, with a median
of 4%. The prevalence of conduct disorder a ppears to be fairly consistent across various
countries that differ in race and ethnicity. Pr evalence rates rise from  childhood to adoles-
cence and are higher among males than amon g females. Few children with impairing con-
duct disorder receive treatment.
Development and Course
The onset of conduct disorder may occur as ea rly as the preschool years, but the first sig-
nificant symptoms usually emerge during the period from middle childhood through
middle adolescence. Oppositi onal defiant disorder is a common precursor to the child-
hood-onset type of conduct disorder. Conduct disorder may be diagnosed in adults, how-
ever, symptoms of conduct di sorder usually emerge in ch ildhood or adol escence, and
onset is rare after age 16 years. The course of  conduct disorder after onset is variable. In a
majority of individuals, the disorder remits by adulthood. Many individuals with conduct
disorder—particularly those with adolescent-onset type and those with few and milder


disorder—particularly those with adolescent-onset type and those with few and milder
symptoms—achieve adequate social and occupa tional adjustment as adults. However, the
early-onset type predicts a worse prognosis and an increased risk of criminal behavior,
conduct disorder, and substance-related disord ers in adulthood. Individuals with conduct
disorder are at risk for later mood disorders, anxiety disorders, posttraumatic stress dis-
order, impulse-control disord ers, psychotic disorders, so matic symptom disorders, and
substance-related disorders as adults.
Symptoms of the disorder vary with age as the individual develops increased physical
strength, cognitive abilities, and sexual ma turity. Symptom behaviors that emerge first
tend to be less serious (e.g., lying, shoplifti ng), whereas conduct problems that emerge last
tend to be more severe (e.g., rape, theft wh ile confronting a victim ). However, there are
wide differences among individuals, with some enga ging in the more damaging behaviors
at an early age (which is predictive of a worse prognosis). When individuals with conduct
disorder reach adulthood, symptoms of aggres sion, property destruction, deceitfulness,
and rule violation, including violence against co-workers, partners, and children, may be ex-
hibited in the workplace and the home, such that antisocial personality disorder may be
considered.
Risk and Prognostic Factors
Temperamental. Temperamental risk factors include a difficult undercontrolled infant
temperament and lower-than-average intelligence , particularly with regard to verbal IQ.
Environmental. Family-level risk factors include parental rejection and neglect, inconsis-
tent child-rearing practices, harsh discipline, physical or sexual abuse, lack of supervision,
early institutional living, freque nt changes of caregivers, large family size, parental criminal-


early institutional living, freque nt changes of caregivers, large family size, parental criminal-
ity, and certain kinds of familial psychopath ology (e.g., substance-related disorders). Com-
munity-level risk factors include peer rejection, association with a delinquent peer group,
and neighborhood exposure to violence. Both types of risk factors te nd to be more common
and severe among individuals with the child hood-onset su btype of conduct disorder.


474 Disruptive, Impulse-Control, and Conduct Disorders
Genetic and physiological. Conduct disorder is influenced by both genetic and envi-
ronmental factors. The risk is increased in child ren with a biological or adoptive parent or
a sibling with conduct disorder. The disorder also appears to be more common in children
of biological parents with severe alcohol us e disorder, depressive and bipolar disorders, or
schizophrenia or biological parents who have  a history of ADHD or conduct disorder.
Family history particularly characterizes in dividuals with the childhood-onset subtype of
conduct disorder. Slower resting heart rate has been reliably noted in individuals with
conduct disorder compared with those without the disorder, and this marker is not char-
acteristic of any other mental  disorder. Reduced autonomic fe ar conditioning, particularly
low skin conductance, is also well documented. However, these psychophysiological find-
ings are not diagnostic of the disorder. Structural and functional differences in brain areas
associated with affect regulation and affect processing, particularly frontotemporal-limbic
connections involving the brain’s ventral pref rontal cortex and amygdala, have been con-
sistently noted in individuals with conduct d isorder compared with those without the dis-
order. However, neuroimaging findings are not diagnostic of the disorder.
Course modifiers. Persistence is more likely for indi viduals with behaviors that meet
criteria for the childhood-onset subtype and qualify for the specifier “with limited pro-
social emotions”. The risk that conduct disorder will persist is also increased by co-occurring
ADHD and by substance abuse.
Culture-Related Diagnostic Issues
Conduct disorder diagnosis may at times be potentially misapplied to individuals in set-
tings where patterns of disruptive behavior are viewed as near-normative (e.g., in very


tings where patterns of disruptive behavior are viewed as near-normative (e.g., in very
threatening, high-crime areas or war zones). Therefore, the context in which the undesir-
able behaviors have occurr ed should be considered.
Gender-Related Diagnostic Issues
Males with a diagnosis of conduct disorder frequently exhibit fighting, stealing, vandalism,
and school discipline problems. Females with a diagnosis of conduct disorder are more likely
to exhibit lying, truancy, running away, subs tance use, and prostitution. Whereas males tend
to exhibit both physical aggression and relation al aggression (behavior that harms social re-
lationships of others), females tend to exhibit relatively more relational aggression.
Functional Consequences  of Conduct Disorder
Conduct disorder behaviors may lead to sch ool suspension or expulsion, problems in
work adjustment, legal difficulties, sexually  transmitted diseases, unplanned pregnancy,
and physical injury from accidents or fights . These problems may preclude attendance in
ordinary schools or living in a parental or foster home. Conduct disorder is often associ-
ated with an early onset of sexual behavior, alcohol use, to bacco smoking, use of illegal
substances, and reckless and risk-taking acts. Ac cident rates appear to be higher among in-
dividuals with conduct disord er compared with those without the disorder. These func-
tional consequences of conduct disorder may predict health difficulties when individuals
reach midlife. It is not uncommon for individu als with conduct disorder to come into con-
tact with the criminal justice system for engaging in illegal behavior. Conduct disorder is
a common reason for treatment referral and is frequently diagnosed in mental health fa-
cilities for children, especially in forensic practice. It is associated with impairment that is
more severe and chronic than that expe rienced by other clinic-referred children.
Differential Diagnosis


Differential Diagnosis
Oppositional defiant disorder. Conduct disorder and oppositi onal defiant disorder are
both related to symptoms that bring the indi vidual in conflict with adults and other au-


Conduct Disorder 475
thority figures (e.g., parents, teachers, work supervisors). The behaviors of oppositional
defiant disorder are typically of a less severe nature than those of individuals with conduct
disorder and do not include aggression towa rd individuals or animals, destruction of
property, or a pattern of theft or deceit. Fu rthermore, oppositional defiant disorder in-
cludes problems of emotional dysregulation (i.e ., angry and irritable mood) that are not in-
cluded in the definition of conduct disorder. When criteria are met for both oppositional
defiant disorder and conduct disord er, both diagnoses can be given.
Attention-deficit/hyperactivity disorder. Although children with  ADHD often exhibit
hyperactive and impulsive behavior that may be disruptive, this behavior does not by it-
self violate societal norms or the rights of others and therefore does not usually meet cri-
teria for conduct disorder. When criteria are met for both ADHD and conduct disorder, both
diagnoses should be given.
Depressive and bipolar disorders. Irritability, aggression, and conduct problems can
occur in children or adolescents with a majo r depressive disorder, a bipolar disorder, or
disruptive mood dysregulation disorder. The behaviorial problems associated with these
mood disorders can usually be distinguished from the pattern of conduct problems seen in
conduct disorder based on their course. Spec ifically, persons with conduct disorder will
display substantial levels of aggressive or non-aggressive conduct problems during peri-
ods in which there is no mood disturbance, ei ther historically (i.e., a history of conduct
problems predating the onset of  the mood disturbance) or concurrently (i.e., display of
some conduct problems that ar e premeditated and do not occur during periods of intense


some conduct problems that ar e premeditated and do not occur during periods of intense
emotional arousal). In those cases in which cr iteria for conduct disorder and a mood dis-
order are met, both diagnoses can be given.
Intermittent explosive disorder. Both conduct disorder and intermittent explosive dis-
order involve high rates of aggression. However, the aggression in individuals with inter-
mittent explosive disorder is limited to impu lsive aggression and is not premeditated, and
it is not committed in order to achieve some tangible objectiv e (e.g., money, power, intim-
idation). Also, the definition of intermittent  explosive disorder does not include the non-
aggressive symptoms of conduct disorder. If criteria for both  disorders are met, the diag-
nosis of intermittent explosive disorder sh ould be given only when  the recurrent impul-
sive aggressive outbursts warrant in dependent clinical attention.
Adjustment disorders. The diagnosis of an adjustment di sorder (with disturbance of con-
duct or with mixed disturbance of emotions an d conduct) should be co nsidered if clinically
significant conduct problems that  do not meet the criteria for another specific disorder de-
velop in clear association with the onset of a psychosocial stressor and do not resolve within
6 months of the termination of the stressor (o r its consequences). Cond uct disorder is diag-
nosed only when the conduct problems represen t a repetitive and pers istent pattern that is
associated with impairment in social, academic, or occupational functioning.
Comorbidity
ADHD and oppositional defiant disorder are both common in individuals with conduct
disorder, and this comorbid presentation pr edicts worse outcomes.  Individuals who show
the personality features associated with anti social personality disorder often violate the


the personality features associated with anti social personality disorder often violate the
basic rights of others or violate major age-appr opriate societal norms, and as a result their
pattern of behavior often meets criteria fo r conduct disorder. Conduct disorder may also
co-occur with one or more of the following me ntal disorders: specif ic learning disorder,
anxiety disorders, depressive or bipolar diso rders, and substance-related disorders. Aca-


co-occur with one or more of the following me ntal disorders: specif ic learning disorder,
anxiety disorders, depressive or bipolar diso rders, and substance-related disorders. Aca-
demic achievement, particularly in reading an d other verbal skills, is often below the level
expected on the basis of age and intelligence and may justify the additional diagnosis of
specific learning disorder or a communication disorder.


476 Disruptive, Impulse-Control, and Conduct Disorders
Antisocial Personality Disorder
Criteria and text for antisocial personality disorder can be found in the chapter “Person-
ality Disorders.” Because this disorder is closely connected to the spectrum of “external-
izing” conduct disorders in this chapter, as we ll as to the disorders in the adjoining chapter
“Substance-Related and Addictiv e Disorders,” it is dual code d here as well as in the chap-
ter “Personality Disorders.”
Pyromania
Diagnostic Criteria 312.33 (F63.1)
A. Deliberate and purposeful fire setting on more than one occasion.
B. Tension or affective arousal before the act.
C. Fascination with, interest in, curiosity about, or attraction to fire and its situational con-
texts (e.g., paraphernalia, uses, consequences).
D. Pleasure, gratification, or relief when setting fires or when witnessing or participating
in their aftermath.
E. The fire setting is not done for monetary gain, as an expression of sociopolitical ideol-
ogy, to conceal criminal activity, to express anger or vengeance, to improve one’s living
circumstances, in response to a delusion or hallucination, or as a result of impaired
judgment (e.g., in major neurocognitive disorder, intellectual disability [intellectual de-
velopmental disorder], substance intoxication).
F. The fire setting is not better explained by conduct disorder, a manic episode, or anti-
social personality disorder.
Diagnostic Features
The essential feature of pyromania is the pres ence of multiple episodes of deliberate and
purposeful fire setting (Criterion A). Individuals with this disorder experience tension or af-
fective arousal before setting a fi re (Criterion B). There is a f ascination with, interest in, cu-


riosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses,
consequences) (Criterion C). Individuals with this disorder are often regular “watchers” at
fires in their neig hborhoods, may set off false alarms, and derive pleasure from institutions,
equipment, and personnel associat ed with fire. They may spend time at the local fire depart-
ment, set fires to be affiliated with the fire department, or even beco me firefighters. Individ-
uals with this disorder experi ence pleasure, gratification, or relief when setting the fire,
witnessing its effects, or participating in its aftermath (Criterion D). The fire setting is not
done for monetary gain, as an expression of so ciopolitical ideology, to conceal criminal ac-
tivity, to express anger or vengeance, to impr ove one’s living circumstances, or in response
to a delusion or a hallucination (Criterion E). The fire setting does not result from impaired
judgment (e.g., in major neurocog nitive disorder or intellectual disability [intellectual devel-
opmental disorder]). The diagnosis is not made if the fire setting is better explained by con-
duct disorder, a manic episode, or antiso cial personality disorder (Criterion F).
Associated Features Supporting Diagnosis
Individuals with pyromania may make considerable advance preparation for starting a
fire. They may be indifferent to  the consequences to life or property caused by the fire, or


Pyromania 477
they may derive satisfaction from the resulting property destruction. The behaviors may
lead to property damage, legal co nsequences, or injury or loss of  life to the fire setter or to
others. Individuals who impulsively set fires (who may or may not have pyromania) often
have a current or past history of alcohol use disorder.
Prevalence
The population prevalence of pyromania is no t known. The lifetime prevalence of fire set-
ting, which is just one component of pyromania and not sufficient for a diagnosis by itself,
was reported as 1.13% in a population sample, but the mo st common como rbidities were
antisocial personality disorder, substance use disorder, bipolar disorder, and pathological
gambling (gambling disorder). In contrast, pyromania as a primary diagnosis appears to
be very rare. Among a sample of persons reachi ng the criminal system with repeated fire
setting, only 3.3% had symptoms th at met full criteria  for pyromania.
Development and Course
There are insufficient data to establish a typi cal age at onset of pyromania. The relation-
ship between fire setting in childhood and pyromania in adulthood has not been docu-
mented. In individuals with pyromania, fire -setting incidents are episodic and may wax
and wane in frequency. Longitudinal course is unknown. Although fire setting is a major
problem in children and adolescents (over 40% of  those arrested for arson offenses in the
United States are younger than 18 years), pyromania in childhood appears to be rare. Ju-
venile fire setting is usually associated with  conduct disorder, attention-deficit/hyperac-
tivity disorder, or an  adjustment disorder.
Gender-Related Diagnostic Issues


tivity disorder, or an  adjustment disorder.
Gender-Related Diagnostic Issues
Pyromania occurs much more often in males, es pecially those with poorer social skills and
learning difficulties.
Differential Diagnosis
Other causes of intentional fire setting. It is important to rule out other causes of fire
setting before giving the diagnosis of pyroma nia. Intentional fire setting may occur for
profit, sabotage, or revenge; to  conceal a crime; to make a po litical statement (e.g., an act of
terrorism or protest); or to attract attention or recognition (e.g., setting a fire in order to dis-
cover it and save the day). Fire setting may also occur as part of developmental experi-
mentation in childhood (e.g., playing with matches, lighters, or fire).
Other mental disorders. A separate diagnosis of pyromania is not given when fire set-
ting occurs as part of conduct disorder, a mani c episode, or antisocial personality disorder,
or if it occurs in response to a delusion or a hallucination (e.g., in schizophrenia) or is at-
tributable to the physiological effects of anot her medical condition (e.g., epilepsy). The di-
agnosis of pyromania should also not be gi ven when fire setting results from impaired
judgment associated with major neurocognitive  disorder, intellectual disability, or sub-
stance intoxication.
Comorbidity
There appears to be a high co-occurrence of substance use disorders,  gambling disorder,
depressive and bipolar disorder s, and other disruptive, impu lse-control, and conduct dis-
orders with pyromania.


478 Disruptive, Impulse-Control, and Conduct Disorders
Kleptomania
Diagnostic Criteria 312.32 (F63.2)
A. Recurrent failure to resist impulses to steal objects that are not needed for personal
use or for their monetary value.
B. Increasing sense of tension immediately before committing the theft.
C. Pleasure, gratification, or relief at the time of committing the theft.
D. The stealing is not committed to express anger or vengeance and is not in response
to a delusion or a hallucination.
E. The stealing is not better explained by conduct disorder, a manic episode, or antisocial
personality disorder.
Diagnostic Features
The essential feature of kleptomania is the recurrent failure to resist impulses to steal items
even though the items are not ne eded for personal use or for their monetary value (Criterion
A). The individual experiences a rising subjective  sense of tension before  the theft (Criterion B)
and feels pleasure, gratification, or relief when  committing the theft (Criterion C). The stealing
is not committed to express anger or vengeance, is not done in response to a delusion or hal-
lucination (Criterion D), and is  not better explained by conduc t disorder, a manic episode, or
antisocial personality disorder (Criterion E). The objects are stolen despite the fact that they are
typically of little value to the individual, who could have afforded to pay for them and often
gives them away or discards them. Occasionally  the individual may hoard the stolen objects or
surreptitiously return them. Al though individuals with this disorder will generally avoid
stealing when immediate arrest is probable (e.g., in full view of a po lice officer), they usually
do not preplan the thefts or fully take into ac count the chances of apprehension. The stealing is


done without assistance from, or collaboration with, others.
Associated Features Supporting Diagnosis
Individuals with kleptomania typically attempt to resist the impulse to steal, and they are
aware that the act is wrong and senseless. The individual frequently fears being appre-
hended and often feels depressed or guilty  about the thefts. Neurotransmitter pathways
associated with behavioral addictions, includ ing those associated with  the serotonin, do-
pamine, and opioid systems,  appear to play a role in kleptomania as well.
Prevalence
Kleptomania occurs in about 4%–24% of indivi duals arrested for shoplifting. Its preva-
lence in the general population is very rare, at approximately 0.3%–0.6%. Females outnum-
ber males at a ratio of 3:1.
Development and Course
Age at onset of kleptomania is variable, but th e disorder often begins in adolescence. How-
ever, the disorder may begin in childhood, adolescence, or adulthood, and in rare cases
in late adulthood. There is little systematic information on the course of kleptomania, but
three typical courses have been described: sp oradic with brief episodes and long periods
of remission; episodic with protracted peri ods of stealing and periods of remission; and
chronic with some degree of fluctuation. Th e disorder may continue for years, despite
multiple convictions for shoplifting.


Other Specified Disruptive, Impulse-Control, and Conduct Disorder 479
Risk and Prognostic Factors
Genetic and physiological. There are no controlled family history studies of kleptoma-
nia. However, first-degree relatives of in dividuals with klepto mania may have higher
rates of obsessive-compulsive disorder than the general population. There also appears to
be a higher rate of substance use disorders, including alcohol use disorder, in relatives of
individuals with kleptomania than in the general population.
Functional Consequenc es of Kleptomania
The disorder may cause legal, family , career, and personal difficulties.
Differential Diagnosis
Ordinary theft. Kleptomania should be distinguishe d from ordinary acts of theft or
shoplifting. Ordinary theft (whether planned or impulsive) is deliberate and is motivated
by the usefulness of the object or its monetary  worth. Some individuals, especially adoles-
cents, may also steal on a dare, as an act of re bellion, or as a rite of passage. The diagnosis
is not made unless other characteristic featur es of kleptomania are also present. Klepto-
mania is exceedingly rare, whereas sh oplifting is relatively common.
Malingering. In malingering, individuals may simulate the symptoms of kleptomania to
avoid criminal prosecution.
Antisocial personality disorder and conduct disorder. Antisocial personality disorder
and conduct disorder are distinguished from kleptomania by a general pattern of antiso-
cial behavior.
Manic episodes, psychotic episodes, and major neurocognitive disorder. Kleptomania
should be distinguished from intentional or inadvertent stealing that may occur during a
manic episode, in response to delusions or ha llucinations (as in, e.g. , schizophrenia), or as


a result of a major neurocognitive disorder.
Comorbidity
Kleptomania may be associated with compulsive  buying as well as with depressive and
bipolar disorders (especially major depressive disorder), anxiety disorders, eating disor-
ders (particularly bulimia ner vosa), personality disorders, substance use disorders (espe-
cially alcohol use disorder), and other disruptive, impulse-control, and conduct disorders.
Other Specified Disruptive, Impulse-Control,
and Conduct Disorder
312.89 (F91.8)
This category applies to presentations in which symptoms characteristic of a disruptive,
impulse-control, and conduct disorder that cause clinically significant distress or impair-
ment in social, occupational, or other impor tant areas of functioning predominate but do
not meet the full criteria for any of the disor ders in the disruptive, impulse-control, and con-
duct disorders diagnostic class. The other specified disruptive, impulse-control, and con-
duct disorder category is used in situations in which the clinician chooses to communicate
the specific reason that the presentation does not meet the criteria for any specific disrup-
tive, impulse-control, and conduct disorder. This  is done by recording “other specified dis-
ruptive, impulse-control, and conduct disorder” followed by the specific reason (e.g.,
“recurrent behavioral outbursts of insufficient frequency”).


480 Disruptive, Impulse-Control, and Conduct Disorders
Unspecified Disruptive, Impulse-Control,
 and Conduct Disorder
312.9 (F91.9)
This category applies to presentations in which symptoms characteristic of a disruptive,
impulse-control, and conduct disorder that cause clinically significant distress or impair-
ment in social, occupational, or other impor tant areas of functioning predominate but do
not meet the full criteria for any of the disorders in the disruptive, impulse-control, and con-
duct disorders diagnostic class. The unspecif ied disruptive, impulse-control, and conduct
disorder category is used in situations in which the clinician chooses not to specify the rea-
son that the criteria are not met for a specific disruptive, impulse-control, and conduct dis-
order, and includes presentations in which there is insufficient information to make a more
specific diagnosis (e.g., in emergency room settings).


481Substance-Related and
Addictive Disorders
The substance-related  disorders encompass 10 separate classes of drugs: alco-
hol; caffeine; cannabis; hallucinogens (with separate categories for phencyclidine [or sim-
ilarly acting arylcyclohexylamines] and ot her hallucinogens); inhalants; opioids;
sedatives, hypnotics, and anxiolytics; stimul ants (amphetamine-type substances, cocaine,
and other stimulants); tobacco ; and other (or unknown) subs tances. These 10 classes are
not fully distinct. All drugs that are taken in excess have in common direct activation of
the brain reward system, which is involved in  the reinforcement of behaviors and the pro-
duction of memories. They produce such an in tense activation of the reward system that
normal activities may be neglected. Inst ead of achieving reward system activation
through adaptive behaviors, drugs of abuse directly activate the reward pathways. The
pharmacological mechanisms by which each class  of drugs produces reward are different,
but the drugs typically activate the system and produce feelings of pleasure, often re-
ferred to as a “high.” Furthe rmore, individuals with lower levels of self-control, which
may reflect impairments of brain inhibitory mechanisms, may be particularly predisposed
to develop substance use disord ers, suggesting that the root s of substance use disorders
for some persons can be seen in behaviors long before the onset of actual substance use
itself.
In addition to the substance-related disorders, this chapter also includes gambling dis-
order, reflecting evidence that gambling be haviors activate reward systems similar to
those activated by drugs of abuse and produce some behavi oral symptoms that appear
comparable to those produced by the substa nce use disorders. Other excessive behavioral


comparable to those produced by the substa nce use disorders. Other excessive behavioral
patterns, such as Internet gaming, have also been described, but the research on these and
other behavioral syndromes is less clear. Thus, groups of repetitive behaviors, which some
term behavioral addictions,  with such subcategories as “sex addiction,” “exercise addiction,”
or “shopping addiction,” are not included becaus e at this time there is insufficient peer-re-
viewed evidence to establish the diagnostic criteria and co urse descriptions needed to
identify these behaviors as mental disorders.
The substance-related disorder s are divided into two groups: substance use disorders
and substance-induced disorders. The followi ng conditions may be classified as sub-
stance-induced: intoxication, withdrawal, an d other substance/medication-induced men-
tal disorders (psychotic disord ers, bipolar and related disorders, depressive disorders,
anxiety disorders, obsessive-compulsive and re lated disorders, sleep disorders, sexual dys-
functions, delirium, and neurocognitive disorders).
The current section begins with a general di scussion of criteria sets for a substance
use disorder, substance intoxication and withdrawal, and other substance/medication-
induced mental disorders, at  least some of which are a pplicable across classes of sub-
stances. Reflecting some unique  aspects of the 10 substance classes relevant to this chapter,
the remainder of the chapter is  organized by the class of substance and describes their
unique aspects. To facilitate differential diagnosis, the text and criteria for the remaining
substance/medication-induced mental disorder s are included with disorders with which
they share phenomenology (e.g ., substance/medication-induced depressive disorder is in
the chapter “Depressive Disorder s”). The broad diagnostic cate gories associated with each
specific group of substances are shown in Table 1.


482 Substance-Related and Addictive DisordersTABLE 1 Diagnoses associated with substance class
 Psychotic
disordersBipolar
disordersDepres-
sive
disordersAnxiety
disordersObsessive-
compulsive
and related
disordersSleep
disordersSexual
dysfunc-
tions DeliriumNeuro-
cognitive
disordersSubstance
use
disordersSub-
stance
intoxi-
cationSub-
stance
with-
drawal
Alcohol I/W I/W I/W I/W I/W I/W I/W I/W/P X X X
Caffeine     I   I/W       X X
Cannabis I   I   I/W   I X X X
Hallucinogens
Phencyclidine I I I I     I X X
Other hallucino-
gensI* I I I     I X X
Inhalants I I  I        I I/P X X
Opioids I/W W   I/W I/W I/W X X X
Sedatives,
hypnotics, or
anxiolyticsI/W I/W I/W W I/W I/W I/W I/W/P X X X
Stimulants** I I/W I/W I/W I/W I/W I I X X X
Tobacco         W     X   X
Other (or
unknown)I/W I/W I/W I/W I/W I/W I/W I/W I/W/P X X X
Note.  X = The category is recognized in DSM-5.
I = The specifier “with onset during intoxication” may be noted for the category.
W = The specifier “with onset during with drawal” may be noted for the category.


W = The specifier “with onset during with drawal” may be noted for the category.
I/W = Either “with onset during intoxication” or “with onset during withdrawal” may be noted for the category.
P = The disorder is persisting.
*Also hallucinogen persisting perception disorder (flashbacks).
**Includes amphetamine-type substances, coca ine, and other or unspecified stimulants.


Substance Use Disorders 483
Substance-Related Disorders
Substance Use Disorders
Features
The essential feature of a substance use disorder  is a cluster of cognitive, behavioral, and
physiological symptoms indicating that the individual continues using the substance de-
spite significant substance-related problems. As seen in Table 1, the diagnosis of a sub-
stance use disorder can be applied to all 10 cl asses included in this chapter except caffeine.
For certain classes some symptoms are less sa lient, and in a few instances not all symptoms
apply (e.g., withdrawal symptoms are not sp ecified for phencyclidin e use disorder, other
hallucinogen use disorder, or  inhalant use disorder).
An important characteristic of substance use disorders is an underlying change in brain cir-
cuits that may persist beyond detoxification, part icularly in individuals with severe disorders.
The behavioral effect s of these brain changes may be exhibited in the repeated relapses and in-
tense drug craving when the individuals are exposed to drug-related stimuli. These persistent
drug effects may benefit from long-term approaches to treatment.
Overall, the diagnosis of a su bstance use disorder is based on a pathological pattern of
behaviors related to use of the substance. To as sist with organization, Criterion A criteria can
be considered to fit within overall groupings of impaired control,  social impairment,  risky use,
and pharmacological criteria.  Impaired control over substance use is the first criteria grouping
(Criteria 1–4). The individual may take the substance in larger amounts or over a longer pe-
riod than was originally intended (Criterion 1). The individual may express a persistent de-
sire to cut down or regulate substance use and may report multiple unsuccessful efforts to


sire to cut down or regulate substance use and may report multiple unsuccessful efforts to
decrease or discontinue use (Cri terion 2). The individual may sp end a great deal of time ob-
taining the substance, using the substance, or recovering from  its effects (Criterion 3). In
some instances of more severe substance use disorders, virtually all of the individual’s daily
activities revolve around  the substance. Craving (Criterion 4) is manifested by an intense de-
sire or urge for the drug that may occur at an y time but is more likely when in an environ-
ment where the drug previous ly was obtained or used. Cr aving has also been shown to
involve classical conditioning and is associated with activation of specific reward structures
in the brain. Craving is queried by asking if there has ever been a time when they had such
strong urges to take the drug th at they could not think of anythi ng else. Current craving is of-
ten used as a treatment outcome measure becaus e it may be a signal of impending relapse.
Social impairment is the second grouping of  criteria (Criteria 5–7) . Recurrent substance
use may result in a failure to fulfill major role obligations at work, sc hool, or home (Crite-
rion 5). The individual may continue substanc e use despite having persistent or recurrent
social or interpersonal problems caused or ex acerbated by the effects of the substance (Cri-
terion 6). Important social, occupational, or re creational activities ma y be given up or re-
duced because of substance us e (Criterion 7). The individual may withdraw from family
activities and hobbies in order to use the substance.
Risky use of the substance is the third grouping of criteria (Criteria 8–9). This may take


the form of recurrent substanc e use in situations in which it is physically hazardous (Cri-
terion 8). The individual may continue substance use despite knowledge of having a per-
sistent or recurrent physical or psychological problem that is likely to have been caused or
exacerbated by the substance (Criterion 9). The key issue in evaluating this criterion is not
the existence of the problem, but rather the in dividual’s failure to abstain from using the
substance despite the difficulty it is causing.


484 Substance-Related and Addictive Disorders
Pharmacological criteria are the final grouping (Criteria 10 and 11). Tolerance (Crite-
rion 10) is signaled by requiring a markedly in creased dose of the substance to achieve the
desired effect or a markedly reduced effect when the usual dose is consumed. The degree
to which tolerance develops varies greatly across different individuals as well as across
substances and may involve a va riety of central nervous system  effects. For example, tol-
erance to respiratory depression and tolerance to sedating and motor coordination may
develop at different rates, depending on the substance. Tolerance ma y be difficult to de-
termine by history alone, and la boratory tests may be helpful (e .g., high blood levels of the
substance coupled with little evidence of into xication suggest that tolerance is likely). Tol-
erance must also be distinguished from indi vidual variability in the initial sensitivity to
the effects of particular substances. For exam ple, some first-time alcohol drinkers show
very little evidence of intoxication with thre e or four drinks, whereas others of similar
weight and drinking histories have slurred speech and incoordination.
Withdrawal (Criterion 11) is a syndrome th at occurs when blood or tissue concentra-
tions of a substance decline in an individual who had maintained prolonged heavy use of
the substance. After developi ng withdrawal symptoms, the individual is likely to con-
sume the substance to relieve the symptoms . Withdrawal symptoms vary greatly across
the classes of substances, and separate criter ia sets for withdrawal are provided for the
drug classes. Marked and generally easily me asured physiological signs of withdrawal are
common with alcohol, opioids, and sedatives, hypnotics, and anxiolytics. Withdrawal


signs and symptoms with stimulants (amphetamines and cocaine), as well as tobacco and
cannabis, are often present but may be le ss apparent. Significant withdrawal has not been
documented in humans after repeated use of  phencyclidine, other hallucinogens, and in-
halants; therefore, this criterion is not incl uded for these substances. Neither tolerance nor
withdrawal is necessary for a diagnosis of a substance use disorder. However, for most
classes of substances, a past history of withdraw al is associated with a more severe clinical
course (i.e., an earlier onset of a substance us e disorder, higher levels of substance intake,
and a greater number of substance-related problems).
Symptoms of tolerance and withdrawal occurring during appropriate medical treat-
ment with prescribed medications (e.g., opio id analgesics, sedatives, stimulants) are spe-
cifically not counted when diagnosing a substance use disorder. The appearance of normal,
expected pharmacological  tolerance and withdrawal during the course of medical treat-
ment has been known to lead to an erroneou s diagnosis of “addiction” even when these
were the only symptoms pr esent. Indivi duals whose only symptoms are those that occur
as a result of medical treatment (i.e., tolera nce and withdrawal as part of medical care
when the medications are taken as prescribed) sh ould not receive a diagnosis solely on the
basis of these symptoms. However, prescripti on medications can be used inappropriately,
and a substance use disorder can be correc tly diagnosed when there are other symptoms
of compulsive, drug-seeking behavior.
Severity and Specifiers
Substance use disorders occur in a broad range of severity, from mild  to severe, with se-
verity based on the number of symptom criteria endorsed. As a general estimate of sever-


verity based on the number of symptom criteria endorsed. As a general estimate of sever-
ity, a mild substance use disorder is suggested by the presence of two to three symptoms,
moderate  by four to five symptoms, and severe by six or more symptoms. Changing severity
across time is also reflected by reductions or increases in the fr equency and/or dose of
substance use, as assessed by the individual’s  own report, report of knowledgeable others,


across time is also reflected by reductions or increases in the fr equency and/or dose of
substance use, as assessed by the individual’s  own report, report of knowledgeable others,
clinician’s observations, and biological testing. The following course specifiers and descrip-
tive features specifiers are a lso available for substance use di sorders: “in early remission,”
“in sustained remission,” “on maintenance th erapy,” and “in a cont rolled environment.”
Definitions of each are provided within respective criteria sets.


Substance Use Disorders 485
Recording Procedures for Substance Use Disorders
The clinician should use the code that applies to the class of substances but record the
name of the specific substance.  For example, the clinician should record 304.10 (F13.20)
moderate alprazolam use disorder  (rather than moderate seda tive, hypnotic, or anxiolytic
use disorder) or 305.70 (F15.10) mild methamphetamine use disorder (rather than mild
stimulant use disorder). For substances that do not fit into any of the classes (e.g., anabolic
steroids), the appropriate code for “other su bstance use disorder” should be used and the
specific substance indicated (e.g., 305.90 [F19.10] mild anabolic steroid use disorder). If the
substance taken by the individual is unknown, the code for the class “other (or unknown)”
should be used (e.g., 304.90 [F 19.20] severe unknown substance use disorder). If criteria
are met for more than one substance use diso rder, all should be diagnosed (e.g., 304.00
[F11.20] severe heroin use disorder; 304.20 [F14.20] moderate cocaine use disorder).
The appropriate ICD-10-CM code for a subs tance use disorder depends on whether
there is a comorbid substance-induced disorder  (including intoxication and withdrawal). In
the above example, the diagnostic code for moderate alprazolam use disorder, F13.20, re-
flects the absence of a comorbid alprazolam -induced mental disorder. Because ICD-10-CM
codes for substance-induced disorders indicate both the presence (or absence) and severity


codes for substance-induced disorders indicate both the presence (or absence) and severity
of the substance use disorder, ICD-10-CM co des for substance use disorders can be used
only in the absence of a substance-induced di sorder. See the individu al substance-specific
sections for additional coding information.
Note that the word addiction  is not applied as a diagnostic term in this classification,
although it is in common usage in many countr ies to describe severe problems related to
compulsive and habitual use of substances. The more neutral term substance use disorder  is
used to describe the wide range of the disorder , from a mild form to a severe state of chron-
ically relapsing, compulsive drug taking. So me clinicians will choose to use the word ad-
diction  to describe more extreme presentations, but the word is omitted from the official
DSM-5 substance use disorder diagnostic term inology because of its uncertain definition
and its potentially negative connotation.
Substance-Induced Disorders
The overall category of subs tance-induced disorders includ es intoxication, withdrawal,
and other substance/medication-induced ment al disorders (e.g., substance-induced psy-
chotic disorder, substance-in duced depressive disorder).
Substance Intoxication and Withdrawal
Criteria for substance intoxica tion are included within the substance-specific sections of
this chapter. The essential fe ature is the development of a reversible substance-specific
syndrome due to the recent ingestion of a subs tance (Criterion A). The clinically significant
problematic behavioral or psychological changes associated with intoxication (e.g., bellig-
erence, mood lability, impaired judgment) are attributable to the phy siological effects of
the substance on the central nervous system and develop during or shortly after use of the
substance (Criterion B). The symptoms are not attributable to another medical condition


substance (Criterion B). The symptoms are not attributable to another medical condition
and are not better explained by another mental  disorder (Criterion D). Substance intoxi-
cation is common among those with a substance use disorder but also occurs frequently in
individuals without a substance use disorder. This category does not apply to tobacco.
The most common changes in intoxication involve disturba nces of perception, wake-
fulness, attention, thinking, judgment, psychomotor behavi or, and interpersonal behav-
ior. Short-term, or “acute,” intoxications may have different signs and symptoms than


486 Substance-Related and Addictive Disorders
sustained, or “chronic,” intoxications. For example, moderate cocaine doses may initially
produce gregariousness, but social withdrawal  may develop if such doses are frequently
repeated over days or weeks.
When used in the physiological sense, the term intoxication  is broader than substance
intoxication as defined here. Many substances may produce physiological or psychologi-
cal changes that are not necessarily problematic. For example, an individual with tachy-
cardia from substance use has a physiological effe ct, but if this is the only symptom in the
absence of problematic behavior, the diagnosis of intoxication would not apply. Intoxica-
tion may sometimes persist beyond the time when the substance is detectable in the body.
This may be due to enduring central nervous system effects,  the recovery of which takes
longer than the time for elimination of the su bstance. These longer-term effects of intoxi-
cation must be distinguished from withdraw al (i.e., symptoms initiated by a decline in
blood or tissue concentrat ions of a substance).
Criteria for substance withdrawal are included within the su bstance-specific sections of
this chapter. The essential feat ure is the development of a subs tance-specific problematic be-
havioral change, with physiologic al and cognitive concomitants, that is due to the cessation of,
or reduction in, heavy and prolonged substance use (Criterion A). The substance-specific syn-
drome causes clinically significant distress or impairment in social, oc cupational, or other im-
portant areas of functioning (Criterion C). The symptoms are not due to another medical
condition and are not better explained by anot her mental disorder (Criterion D). Withdrawal
is usually, but not always, as sociated with a substance use disorder. Most individuals with


is usually, but not always, as sociated with a substance use disorder. Most individuals with
withdrawal have an urge to re-administe r the substance to reduce the symptoms.
Route of Administration and Speed of Substance Effects
Routes of administration that produce more rapid and efficient absorption into the blood-
stream (e.g., intravenous, smoking, intranasal “snorting”) te nd to result in a more intense
intoxication and an increased likelihood of an escalating pattern of substance use leading
to withdrawal. Similarly, rapi dly acting substances are more likely than slower-acting
substances to produce immediate intoxication.
Duration of Effects
Within the same drug category, relatively sh ort-acting substances tend to have a higher
potential for the development of withdrawal th an do those with a longer duration of ac-
tion. However, longer-acting substances tend to have longer withdrawal duration. The
half-life of the substance parallels aspects of wi thdrawal: the longer the duration of action,
the longer the time between cessation and th e onset of withdrawal symptoms and the lon-
ger the withdrawal duration. In general, the longer the acute withdrawal period, the less
intense the syndrome tends to be.
Use of Multiple Substances
Substance intoxication and withdrawal often involve several substances used simultane-
ously or sequentially. In these cases, each diagnosis should be recorded separately.
Associated Laboratory Findings
Laboratory analyses of blood and urine samples can help determine recent use and the specific
substances involved. However, a positive laboratory test result do es not by itself indicate that
the individual has a pattern of substance use that  meets criteria for a substance-induced or sub-
stance use disorder, and a negative test result does not by  itself rule out a diagnosis.
Laboratory tests can be useful in identify ing withdrawal. If the individual presents


Laboratory tests can be useful in identify ing withdrawal. If the individual presents
with withdrawal from an unknown substance, laboratory tests may help identify the sub-
stance and may also be helpful in differentiating withdrawal from other mental disorders.


Substance-Induced Disorders 487
In addition, normal functionin g in the presence of high bl ood levels of a substance sug-
gests considerable tolerance.
Development and Course
Individuals ages 18–24 years have relatively hi gh prevalence rates for the use of virtually
every substance. Intoxication is usually the initial substance-related disorder and often be-
gins in the teens. Withdrawal can occur at any age as long as the relevant drug has been
taken in sufficient doses over an extended period of time.
Recording Procedures for Intoxication and Withdrawal
The clinician should use the code that applies to the class of substances but record the
name of the specific substance.  For example, the clinician sh ould record 292. 0 (F13.239) seco-
barbital withdrawal (rather than sedative, hypnotic, or anxiolytic withdrawal) or 292.89
(F15.129) methamphetamine intoxication (rathe r than stimulant intoxication). Note that
the appropriate ICD-10-CM diagnostic code fo r intoxication depends on whether there is
a comorbid substance use diso rder. In this case, the F15.129 code for methamphetamine in-
dicates the presence of a comorbid mild methamphetamine use disorder. If there had been
no comorbid methamphetamine use disorder , the diagnostic code would have been
F15.929. ICD-10-CM coding rules require th at all withdrawal codes imply a comorbid
moderate to severe substance use disorder fo r that substance. In the above case, the code
for secobarbital withdrawal (F13.239) indicates the comorbid presence of a moderate to se-
vere secobarbital use disorder . See the coding note for the substance-specific intoxication


vere secobarbital use disorder . See the coding note for the substance-specific intoxication
and withdrawal syndromes for the actual coding options.
For substances that do not fit into any of the cl asses (e.g., anabolic steroids), the appropriate
code for “other substance intoxication” should be used and the specific substance indicated
(e.g., 292.89 [F19.929] anabolic steroid intoxication). If the substance taken by the individual is
unknown, the code for the class “other (or unknown)” should be used (e.g., 292.89 [F19.929]
unknown substance intoxication). If there are sy mptoms or problems associated with a partic-
ular substance but criteria are not met for any of  the substance-specific disorders, the unspec-
ified category can be used (e.g., 292.9 [F12.99] unspecified cannabis-related disorder).
As noted above, the substance-related codes in ICD-10-CM combine the substance use dis-
order aspect of the clinical picture and the su bstance-induced aspect into a single combined
code. Thus, if both heroin withdrawal and modera te heroin use disorder are present, the single
code F11.23 is given to cover both presentati ons. In ICD-9-CM, separate diagnostic codes
(292.0 and 304.00) are given to indicate withdr awal and a moderate heroin use disorder, re-
spectively. See the individual substance-specific  sections for additional coding information.
Substance/Medication-Induced Mental Disorders
The substance/medication-induced mental di sorders are potentially severe, usually tem-
porary, but sometimes persisti ng central nervous system (C NS) syndromes that develop
in the context of the effects of substances of abuse, medications, or several toxins. They are


in the context of the effects of substances of abuse, medications, or several toxins. They are
distinguished from the substance use disorder s, in which a cluster of cognitive, behav-
ioral, and physiological symptoms contribute to the continued use of a substance despite
significant substance-related problems. The substance/medication-induced mental disor-
ders may be induced by the 10 classes of subs tances that produce su bstance use disorders,
or by a great variety of other medications used in medical treatment. Each substance-
induced mental disorder is desc ribed in the relevant chapter (e.g., “Depressive Disorders,”
“Neurocognitive Disorders”), an d therefore, only a brief description is offered here. All
substance/medication-induced disorders share common characte ristics. It is important to


“Neurocognitive Disorders”), an d therefore, only a brief description is offered here. All
substance/medication-induced disorders share common characte ristics. It is important to
recognize these common features to aid in th e detection of these disorders. These features
are described as follows:


488 Substance-Related and Addictive Disorders
A. The disorder represents a clinically signif icant symptomatic presentation of a relevant
mental disorder.
B. There is evidence from the history, physical  examination, or laboratory findings of
both of the following:
1. The disorder developed during or within  1 month of a substance intoxication or
withdrawal or taking a medication; and
2. The involved substance/medication is ca pable of producing th e mental disorder.
C. The disorder is not better explained by an in dependent mental disorder (i.e., one that is
not substance- or medication-induced). Such  evidence of an independent mental dis-
order could include the following:
1. The disorder preceded the onset of severe  intoxication or withdrawal or exposure
to the medication; or
2. The full mental disorder persisted for a substa ntial period of time (e.g., at least 1 month)
after the cessation of acute withdrawal or severe intoxication or taking the medica-
tion. This criterion does not apply to su bstance-induced neurocognitive disorders
or hallucinogen persisting perception disorder, which persist beyond the cessation
of acute intoxication or withdrawal.
D. The disorder does not occur exclusiv ely during the course of a delirium.
E. The disorder causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
Features
Some generalizations can be made  regarding the categories of substances capable of produc-
ing clinically relevant substance-induced mental disorders. In general, the more sedating
drugs (sedative, hypnotics, or anxiolytics, and alcohol) can produce prominent and clini-
cally significant depressive disorders during in toxication, while anxiet y conditions are likely


cally significant depressive disorders during in toxication, while anxiet y conditions are likely
to be observed during withdrawal syndromes from these substances. Also, during intoxica-
tion, the more stimulating substances (e.g., am phetamines and cocaine) are likely to be as-
sociated with substance-induced psychoti c disorders and substance-induced anxiety
disorders, with substance-indu ced major depressive episodes observed during withdrawal.
Both the more sedating and mo re stimulating drugs are likely to produce significant but
temporary sleep and sexual dist urbances. An overview of the relationship between specific
categories of substanc es and specific psychiatric syndromes is presented in Table 1.
The medication-induced conditions includ e what are often idiosyncratic CNS reac-
tions or relatively extreme examples of side effects for a wide range of medications taken
for a variety of medical concerns. These includ e neurocognitive complications of anesthet-
ics, antihistamines, antihypertensives, and a variety of other medications and toxins (e.g.,
organophosphates, insecticides, carbon monoxi de), as described in the chapter on neuro-
cognitive disorders. Psychotic syndromes may be temporarily experienced in the context
of anticholinergic, cardiovascul ar, and steroid drugs, as well  as during use of stimulant-
like and depressant-like prescription or over-the-counter drugs. Temporary but severe
mood disturbances can be observed with a wi de range of medications, including steroids,
antihypertensives, disulfiram, and any prescription or over-the- counter depressant or
stimulant-like substances. A similar range of medications can be associated with tempo-
rary anxiety syndromes, sexual dysfunct ions, and conditions of disturbed sleep.


rary anxiety syndromes, sexual dysfunct ions, and conditions of disturbed sleep.
In general, to be considered a substance/ medication-induced mental disorder, there
must be evidence that the diso rder being observed is not likely to be better explained by an
independent mental condition. The latter are most likely to be seen if the mental disorder
was present before the severe intoxication or withdrawal or medication administration, or,
with the exception of several substance-induced persisting disorders listed in Table 1, con-
tinued more than 1 month after cessation of acute withdrawal, severe intoxication, or use


Substance-Induced Disorders 489
of the medications. When symptoms are only  observed during a delirium (e.g., alcohol
withdrawal delirium), the mental disorder sh ould be diagnosed as a delirium, and the
psychiatric syndrome occurring during the delirium should not also be diagnosed sepa-
rately, as many symptoms (including disturba nces in mood, anxiety, and reality testing)
are commonly seen during agitated, confused states. The features associated with each rel-
evant major mental disorder are similar whether observed with independent or sub-
stance/medication-induced mental disorders. However, individuals with substance/
medication-induced mental disorders are lik ely to also demonstrate the associated fea-
tures seen with the specific category of subs tance or medication, as listed in other subsec-
tions of this chapter.
Development and Course
Substance-induced mental disord ers develop in the context of  intoxication or withdrawal
from substances of abuse, and medication-i nduced mental disorders are seen with pre-
scribed or over-the-counter medications that are taken at the suggest ed doses. Both condi-
tions are usually temporary and li kely to disappear with in 1 month or so of cessation of acute
withdrawal, severe intoxication, or use of th e medication. Exceptions to these generaliza-
tions occur for certain long-d uration substance-in duced disorders: substance-associated
neurocognitive disorders that relate to conditions such as alcohol- induced neurocognitive
disorder, inhalant-induced neurocognitive disord er, and sedative-, hypnotic-, or anxiolytic-
induced neurocognitive disorder; and hallucinogen persisting perception disorder (“flash-
backs”; see the section “Hallucinogen-Related Disorders” later in this chapter). However,


most other substance/medication -induced mental disorders, re gardless of the severity of
the symptoms, are likely to impr ove relatively quickly with ab stinence and unlikely to re-
main clinically relevant for more than 1 month after complete cessation of use.
As is true of many consequences of heavy substance use, some individuals are more
and others less prone toward specific substance-induced disorders. Similar types of pre-
dispositions may make some individuals more likely to develop psychiatric side effects of
some types of medications, but not others. However, it is unclear whether individuals
with family histories or personal prior hist ories with independent psychiatric syndromes
are more likely to develop the induced synd rome once the consideration is made as to
whether the quantity and frequency of the substance was sufficient to lead to the devel-
opment of a substanc e-induced syndrome.
There are indications that the intake of su bstances of abuse or some medications with
psychiatric side effects in the context of a pree xisting mental disorder is likely to result in
an intensification of the preexisting indepe ndent syndrome. The risk for substance/med-
ication-induced mental disorders is likely to increase with both the quantity and the fre-
quency of consumption of  the relevant substance.
The symptom profiles for the substance/medication-induced mental disorders resem-
ble independent mental disorders. While the symptoms of substance/medication-in-
duced mental disorders can be identical to those of independent mental disorders (e.g.,
delusions, hallucinations, psychoses, major de pressive episodes, anxiety syndromes), and
although they can have the same severe conseq uences (e.g., suicide) , most induced mental
disorders are likely to improve in a matt er of days to weeks of abstinence.


disorders are likely to improve in a matt er of days to weeks of abstinence.
The substance/medication-induced mental di sorders are an important part of the dif-
ferential diagnoses for the independent psychiatric conditions. The importance of recog-
nizing an induced mental disorder is similar to the relevance of identifying the possible
role of some medical conditions and medication reaction s before diagnosing an indepen-


nizing an induced mental disorder is similar to the relevance of identifying the possible
role of some medical conditions and medication reaction s before diagnosing an indepen-
dent mental disorder. Symptoms of substanc e- and medication-induced mental disorders
may be identical cross-sectionally to those of  independent mental disorders but have dif-
ferent treatments and prognoses from the independent condition.


490 Substance-Related and Addictive Disorders
Functional Consequences of Substance/Medication-
Induced Mental Disorders
The same consequences related to the relevant  independent mental disorder (e.g., suicide
attempts) are likely to apply to the substance/medi cation-induced mental disorders, but
these are likely to disappear within 1 month after abstinence. Similarly, the same func-
tional consequences associated with the relevant substance use disorder are likely to be seen
for the substance-indu ced mental disorders.
Recording Procedures fo r Substance/Medication-
Induced Mental Disorders
Coding notes and separate recording procedures for ICD-9-CM and ICD-10-CM codes for
other specific substance/medi cation-induced mental diso rders are provided in other
chapters of the manual with disorders with  which they share phenomenology (see the sub-
stance/medication-indu ced mental disorders in these chapters: “Schizophrenia Spectrum
and Other Psychotic Disorders,” “Bipolar and Related Disorders,” “Depressive Disor-
ders,” “Anxiety Disorders,” “Obsessive-Compulsive and Related Disorders,” “Sleep-
Wake Disorders,” “Sexual Dysfunctions,” and “Neurocognitive Disorders”). Generally,
for ICD-9-CM, if a mental disorder is induced by a substance use disorder, a separate di-
agnostic code is given for the specific substance use disorder, in addition  to the code for the
substance/medication-induced mental disord er. For ICD-10-CM, a single code combines
the substance-induced mental disorder with the substance use disorder. A separate diag-
nosis of the comorbid substance use disorder is  not given, although the name and severity
of the specific substance use disorder (whe n present) are used when recording the sub-


of the specific substance use disorder (whe n present) are used when recording the sub-
stance/medication-induced mental disorder. ICD-10-CM codes are also provided for sit-
uations in which the substance/ medication-induced mental di sorder is not induced by a
substance use disorder (e.g., when a disorder is induced by one-time use of a substance or
medication). Additional  information needed to record the diagnostic name of the sub-
stance/medication-induce d mental disorder is provided in the sect ion “Recording Proce-
dures” for each substance/medication-induced mental disorder in its respective chapter.
Alcohol-Related Disorders
Alcohol Use Disorder
Alcohol Intoxication
Alcohol Withdrawal
Other Alcohol-Induced Disorders
Unspecified Alcohol-Related Disorder
Alcohol Use Disorder
Diagnostic Criteria
A. A problematic pattern of alcohol use leading to clinically significant impairment or dis-
tress, as manifested by at least two of the following, occurring within a 12-month period:
1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.


Alcohol Use Disorder 491
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol,
or recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work,
school, or home.
6. Continued alcohol use despite having persist ent or recurrent social or interpersonal
problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreat ional activities are given up or reduced be-
cause of alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is  likely to have been caused or exacerbated
by alcohol.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to achieve intoxication or de-
sired effect.
b. A markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome fo r alcohol (refer to Criteria A and B of
the criteria set for alcohol withdrawal, pp. 499–500).
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to
relieve or avoid withdrawal symptoms.
Specify if:
In early remission:  After full criteria for alcohol us e disorder were previously met,
none of the criteria for alcohol use disorder have been met for at least 3 months but for
less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire
or urge to use alcohol,” may be met).


or urge to use alcohol,” may be met).
In sustained remission:  After full criteria for alcohol  use disorder were previously
met, none of the criteria for alcohol use disorder have been met at any time during a
period of 12 months or longer (with the exception that Criterion A4, “Craving, or a
strong desire or urge to use alcohol,” may be met).
Specify if:
In a controlle d environment:  This additional specifier is used if the individual is in an
environment where access to alcohol is restricted.
Code based on current severity:  Note for ICD-10-CM codes: If an alcohol intoxication,
alcohol withdrawal, or another alcohol-induced m ental disorder is also present, do not use
the codes below for alcohol use disorder. Instead, the comorbid alcohol use disorder is
indicated in the 4th character of the alco hol-induced disorder code (see the coding note
for alcohol intoxication, alcohol withdrawal, or a specific alcohol-induced mental disorder).
For example, if there is comorbid alcohol intoxication and alcohol use disorder, only the
alcohol intoxication code is given, with the 4th character indicating whether the comorbid
alcohol use disorder is mild, moderate, or severe: F10.129 for mild alcohol use disorder
with alcohol intoxication or F10.229 for a moderat e or severe alcohol use disorder with al-
cohol intoxication.
Specify current severity:
305.00 (F10.10) Mild:  Presence of 2–3 symptoms.
303.90 (F10.20) Moderate: Presence of 4–5 symptoms.
303.90 (F10.20) Severe:  Presence of 6 or more symptoms.


492 Substance-Related and Addictive Disorders
Specifiers
“In a controlled environment” app lies as a further specifier of remission if the individual is
both in remission and in a controlled environm ent (i.e., in early remission in a controlled
environment or in sustained remission in a controlled environmen t). Examples of these
environments are closely supe rvised and substanc e-free jails, therapeutic communities,
and locked hospital units.
Severity of the disorder is based on the number of diagno stic criteria endorsed. For a
given individual, changes in severity of alcoho l use disorder across ti me are also reflected
by reductions in the frequency (e.g., days of  use per month) and/or dose (e.g., number of
standard drinks consumed per day) of alcohol used, as assessed by the individual’s self-
report, report of knowledgeabl e others, clinician observations, and, when practical, bio-
logical testing (e.g., elevations in blood test s as described in the section “Diagnostic Mark-
ers” for this disorder).
Diagnostic Features
Alcohol use disorder is defined by a cluste r of behavioral and physical symptoms, which
can include withdrawal, tolerance, and cravin g. Alcohol withdrawal  is characterized by
withdrawal symptoms that de velop approximately 4–12 hours after the reduction of in-
take following prolonged, heavy alcohol inge stion. Because withdrawal from alcohol can
be unpleasant and intense, individuals may continue to consume alcohol despite adverse
consequences, often to avoid or to relieve withdrawal symptoms. Some withdrawal symp-
toms (e.g., sleep problems) can persist at lower intensities for months and can contribute to
relapse. Once a pattern of re petitive and intense use develo ps, individuals with alcohol
use disorder may devote substantial periods of time to obtaining and consuming alcoholic


use disorder may devote substantial periods of time to obtaining and consuming alcoholic
beverages.
Craving for alcohol is indicated by a strong desire to drink that makes it difficult to
think of anything else and that often results in the onset of drinking. School and job per-
formance may also suffer either from the aftereffects of drinking or from actual intoxica-
tion at school or on the job; child care or household responsibilities may be neglected; and
alcohol-related absences may o ccur from school or work. The individual may use alcohol
in physically hazardous circumstances (e.g., driving an automobile, swimming, operating
machinery while intoxicated). Finally, individu als with an alcohol use disorder may con-
tinue to consume alco hol despite the knowledge that continued consumption poses sig-
nificant physical (e.g., blackouts, liver disease ), psychological (e.g., depression), social, or
interpersonal problems (e.g., violent argume nts with spouse while intoxicated, child
abuse).
Associated Features Supporting Diagnosis
Alcohol use disorder is often associated wi th problems similar to  those associated with
other substances (e.g., cannabis ; cocaine; heroin; amphetamin es; sedatives, hypnotics, or
anxiolytics). Alcohol may be used to alleviate the unwanted effects of these other
substances or to substitute for them when they are not av ailable. Symptoms of conduct
problems, depression, anxiety, and insomnia frequently accompany heavy drinking and
sometimes precede it.
Repeated intake of high doses of alcohol can affect nearly every organ system, espe-
cially the gastrointestinal tract, cardiovasc ular system, and the central and peripheral ner-
vous systems. Gastrointestinal effects includ e gastritis, stomach or duodenal ulcers, and,


in about 15% of individuals who use alcohol he avily, liver cirrhosis and/or pancreatitis.
There is also an increased rate of cancer of the esophagus, stomach, and other parts of the
gastrointestinal tract. One of the most comm only associated conditions is low-grade hy-
pertension. Cardiomyopathy and other myopat hies are less common but occur at an in-


Alcohol Use Disorder 493
creased rate among those who drink very he avily. These factors, along with marked
increases in levels of triglycerides and low- density lipoprotein cholesterol, contribute to
an elevated risk of heart disease. Periphe ral neuropathy may be evidenced by muscular
weakness, paresthesias, and decreased peripher al sensation. More persistent central ner-
vous system effects include cognitive deficits, severe memory impairment, and degener-
ative changes in the cerebellum. These effects are related to the direct effects of alcohol or
of trauma and to vitamin deficiencies (parti cularly of the B vitamins, including thiamine).
One devastating central nervous system e ffect is the relatively rare alcohol-induced per-
sisting amnestic disorder, or Wernicke-Korsakoff syndrome, in which the ability to encode
new memory is severely impaired. This condition would now be described within the chap-
ter “Neurocognitive Disorder s” and would be termed a substance/medicati on-induced neuro-
cognitive disorder.
Alcohol use disorder is an important contribu tor to suicide risk du ring severe intoxi-
cation and in the context of a temporary alco hol-induced depressive and bipolar disorder.
There is an increased rate of suicidal behavior as well as of completed suicide among in-
dividuals with the disorder.
Prevalence
Alcohol use disorder is a common disorder. In  the United States, the 12-month prevalence
of alcohol use disorder is estimated to be 4.6% among 12- to 17-year-olds and 8.5% among
adults age 18 years and older in the United St ates. Rates of the disorder are greater among
adult men (12.4%) than among adult women (4 .9%). Twelve-month prevalence of alcohol


use disorder among adults decreases in midd le age, being greatest among individuals 18-
to 29-years-old (16.2%) and lowest among individuals age 65 years and older (1.5%).
Twelve-month prevalence varies markedly  across race/ethnic subgroups of the U.S.
population. For 12- to 17-year-olds, rates ar e greatest among Hispanics (6.0%) and Native
Americans and Alaska Natives (5.7%) relative to whites (5.0%), Afri can Americans (1.8%),
and Asian Americans and Pacific Islanders (1.6 %). In contrast, amon g adults, the 12-month
prevalence of alcohol use di sorder is clearly greater among Native Americans and Alaska
Natives (12.1%) than among whites (8.9%), Hispanics (7.9%), African Americans (6.9%),
and Asian Americans and Pacific Islanders (4.5%).
Development and Course
The first episode of alcohol into xication is likely to occur during the mid-teens. Alcohol-
related problems that do not m eet full criteria for a use disord er or isolated problems may
occur prior to age 20 years, but the age at onse t of an alcohol use disorder with two or more
of the criteria clustered together peaks in th e late teens or early to mid 20s. The large ma-
jority of individuals who develop alcohol-relate d disorders do so by their late 30s. The first
evidence of withdrawal is not likely to appear until after many other aspects of an alcohol
use disorder have developed. An  earlier onset of alcohol use disorder is observed in ado-
lescents with preexisting conduct problems and those with an earlier onset of intoxication.
Alcohol use disorder has a variable course th at is characterized by periods of remission


Alcohol use disorder has a variable course th at is characterized by periods of remission
and relapse. A decision to stop drinking, often in response to a crisis, is likely to be followed
by a period of weeks or more of abstinence , which is often followed by limited periods of
controlled or nonproblematic drinking. However,  once alcohol intake resumes, it is highly
likely that consumption will rapidly escalate and that severe problems will once again
develop.
Alcohol use disorder is often erroneously pe rceived as an intractable condition, per-
haps based on the fact that individuals who present for treatment typically have a history
of many years of severe alco hol-related problems. However, these most severe cases rep-


haps based on the fact that individuals who present for treatment typically have a history
of many years of severe alco hol-related problems. However, these most severe cases rep-
resent only a small proportion of individuals with this disorder, and the typical individual
with the disorder has a much more promising prognosis.


494 Substance-Related and Addictive Disorders
Among adolescents, conduct disorder and repeated antisocial behavior often co-occur
with alcohol- and with other substance-relate d disorders. While most  individuals with al-
cohol use disorder develop the condition be fore age 40 years, perhaps 10% have later
onset. Age-related physical changes in older individuals result in increased brain suscep-
tibility to the depressant effect s of alcohol; decreased rates of  liver metabolism of a variety
of substances, including alcohol; and decrease d percentages of body water. These changes
can cause older people to develop more seve re intoxication and su bsequent problems at
lower levels of consumption. Al cohol-related problems in older people are also especially
likely to be associated with  other medical complications.
Risk and Prognostic Factors
Environmental. Environmental risk and prognostic factors may include cultural atti-
tudes toward drinking and intoxication, the availability of alcohol (including price),
acquired personal experiences with alcohol, and stress levels. Additional potential medi-
ators of how alcohol problems develop in predisposed individuals include heavier peer
substance use, exaggerated positive expectations  of the effects of alcohol, and suboptimal
ways of coping with stress.
Genetic and physiological. Alcohol use disorder runs in families, with 40%–60% of the
variance of risk explained by genetic influenc es. The rate of this condition is three to four
times higher in close relatives of individuals with alcohol use disorder, with values highest
for individuals with a greater nu mber of affected relatives, closer genetic relationships to
the affected person, and higher severity of the alcohol-related problems in those relatives.
A significantly higher rate of alcohol use disorders exists in the monozygotic twin than in
the dizygotic twin of an individual with the condition. A three- to fourfold increase in risk


has been observed in children of individuals with alcohol use disorder, even when these
children were given up for adoption at birth and raised by adoptive parents who did not
have the disorder.
Recent advances in our understanding of  genes that operate through intermediate
characteristics (or phe notypes) to affect the risk of alco hol use disorder can help to identify
individuals who might be at pa rticularly low or high risk for alcohol use disorder. Among
the low-risk phenotypes are the acute alcohol-related skin flush (seen most prominently in
Asians). High vulnerability is associated with  preexisting schizophrenia or bipolar disor-
der, as well as impulsivity (producing enha nced rates of all substance use disorders and
gambling disorder), and a high risk specifically for alcohol use disorder is associated with
a low level of response (low sensitivity) to alcohol. A number of gene variations may ac-
count for low response to alcohol or modulate the dopamine reward systems; it is impor-
tant to note, however, that any one gene variat ion is likely to explain only 1%–2% of the risk
for these disorders.
Course modifiers. In general, high levels of impulsivity are associated with an earlier
onset and more severe alcohol use disorder.
Culture-Related Diagnostic Issues
In most cultures, alcohol is the most frequently used intoxicating substance and contrib-
utes to considerable morbidity and mortality. An estimate d 3.8% of all global deaths and
4.6% of global disability-adjusted life-years are attribut able to alcohol. In the United States,
80% of adults (age 18 years and older) have co nsumed alcohol at some  time in their lives,
and 65% are current drinkers (last 12 months).  An estimated 3.6% of the world population


(15–64 years old) has a current (12-month) alcohol use disorder, with a lower prevalence
(1.1%) found in the Afri can region, a higher rate  (5.2%) found in the Am erican region (North,
South, and Central America and the Caribbean) , and the highest rate (10.9%) found in the


(1.1%) found in the Afri can region, a higher rate  (5.2%) found in the Am erican region (North,
South, and Central America and the Caribbean) , and the highest rate (10.9%) found in the
Eastern Europe region.


Alcohol Use Disorder 495
Polymorphisms of genes for the alcohol- metabolizing enzymes alcohol dehydroge-
nase and aldehyde dehydrogenase are most ofte n seen in Asians and affect the response to
alcohol. When consuming alcoho l, individuals with these gene variations can experience a
flushed face and palpitations, reactions that ca n be so severe as to lim it or preclude future
alcohol consumption and diminish the risk fo r alcohol use disorder. These gene variations
are seen in as many as 40% of Japanese, Chinese, Korean, and related groups worldwide
and are related to lower risks for the disorder.
Despite small variations regarding individual criterion items, the diagnostic criteria
perform equally well across mo st race/ethnicity groups.
Gender-Related Diagnostic Issues
Males have higher rates of drinking and rela ted disorders than fema les. However, because
females generally weigh less than males, have more fat and less water in their bodies, and
metabolize less alcohol in their esophagus and stomach, they are likely to develop higher
blood alcohol levels per drink than males. Females who drink heavily may also be more
vulnerable than males to some of the physical consequences associated with alcohol, in-
cluding liver disease.
Diagnostic Markers
Individuals whose heavier drinking places them  at elevated risk for alcohol use disorder
can be identified both through standardized qu estionnaires and by elevations in blood test
results likely to be seen with regular heavie r drinking. These measures do not establish a
diagnosis of an alcohol-related disorder but can be useful in highlighting individuals for
whom more information should be gathered. Th e most direct test available to measure al-
cohol consumption cross-sectionally is blood alcohol concentration,  which can also be used to


cohol consumption cross-sectionally is blood alcohol concentration,  which can also be used to
judge tolerance to alcohol. For example, an individual with a conc entration of 150 mg of
ethanol per deciliter (dL) of blood who does not show signs of intoxication can be pre-
sumed to have acquired at le ast some degree of tolerance to  alcohol. At 200 mg/dL, most
nontolerant individuals demons trate severe intoxication.
Regarding laboratory tests, one sensitive la boratory indicator of heavy drinking is a
modest elevation or high-normal levels (>35  units) of gamma-glutamyltransferase (GGT).
This may be the only laboratory  finding. At least 70% of indi viduals with a high GGT level
are persistent heavy drinkers (i.e., consuming ei ght or more drinks daily on a regular basis).
A second test with comparable or even higher levels of sensitivity and specificity is carbo-
hydrate-deficient transferrin (CDT), with levels of  20 units or higher us eful in identifying in-
dividuals who regularly consum e eight or more drinks daily. Since both GGT and CDT
levels return toward normal within days to weeks of stopping drinking, both state markers
may be useful in monitoring abstinence, espe cially when the clinician observes increases,
rather than decreases, in thes e values over time—a finding indicating that the person is
likely to have returned to heavy drinking. The combination of tests for CDT and GGT may
have even higher levels of sens itivity and specificity than eith er test used alone. Additional
useful tests include the mean corpuscular volume (MCV), whic h may be elevated to high-
normal values in individuals who drink heavily— a change that is due to the direct toxic ef-


normal values in individuals who drink heavily— a change that is due to the direct toxic ef-
fects of alcohol on erythropoiesis. Although the MCV can be used  to help identify those who
drink heavily, it is a poor method of monitori ng abstinence because of the long half-life of
red blood cells. Liver function tests (e.g., alanine aminotransfe rase [ALT] and alkaline phos-
phatase) can reveal liver injury that is a co nsequence of heavy drinking. Other potential
markers of heavy drinking that are more nons pecific for alcohol but can help the clinician
think of the possible effects of alcohol include elevations in blood levels or lipids (e.g., tri-


markers of heavy drinking that are more nons pecific for alcohol but can help the clinician
think of the possible effects of alcohol include elevations in blood levels or lipids (e.g., tri-
glycerides and high-density li poprotein cholesterol) and high -normal levels of uric acid.
Additional diagnostic markers relate to sign s and symptoms that reflect the consequences
often associated with persistent heavy drinki ng. For example, dyspepsia, nausea, and bloat-