Chapter 24
Alcohol and Substance Misuse
200
, Chapter 24: Alcohol and Substance Misuse
ICD-10 classification of mental and behavioural disorders due to psychoactive substance misuse
1. Acute intoxication.
2. Harmful use.
3. Dependence syndrome.
4. Withdrawal state.
5. Withdrawal state with delirium.
6. Psychotic disorder.
7. Amnestic syndrome.
8. Residual and late onset psychotic disorder.
1. Acute intoxication
ICD-10 criteria
A transient condition following the administration of alcohol or other psychoactive substance, resulting in
disturbances in the level of consciousness, cognition, perception, affect or behaviour, or other
psychophysiological functions and responses.
Intensity of intoxication lessens with time, and the effects eventually disappear in the absence of further use of
the substance.
Recovery is complete except where tissue damage or other complication has arisen.
2. Harmful use
ICD-10 criteria
A pattern of psychoactive substance use which causes damage to health.
The damage may be physical (e.g. hepatitis from the self-administration of injected drugs) or mental (e.g.
episodes of depressive disorder secondary to heavy consumption of alcohol).
3. Dependence syndrome
ICD-10 criteria
A cluster of physiological, behavioural and cognitive phenomena in which the use of a substance or a class of
substances takes on a much higher priority for a given individual than other behaviours that once had
greater value.
A definite diagnosis of dependence should usually be made only if three or more of the following have been
present together at some time during the previous year:
o A strong desire or sense of compulsion to take the substance.
o Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use.
o A physiological withdrawal state when the substance use has ceased or been reduced as evidenced by
the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance
with the intention of relieving or avoiding withdrawal symptoms.
o Evidence of tolerance, such that increased doses of the psychoactive substances are required in order to
achieve effects originally produced by lower doses (clear examples of this are found in alcohol dependent
and opiate dependent individuals who may take daily doses sufficient to incapacitate or kill non-tolerant
users).
o Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased
amount of time necessary to obtain or take the substance or to recover from its effects.
o Persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the
liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or
drug-related impairment of cognitive functioning.
Narrowing of the personal repertoire of patterns of psychoactive substance use has also been described as a
characteristic feature (e.g. a tendency to drink alcoholic drinks in the same way on weekends, regardless of
social constraints that determine appropriate drinking behaviour).
4. Withdrawal state
ICD-10 criteria
A group of symptoms of variable clustering and severity, occurring on absolute or relative withdrawal of a
substance after repeated and usually prolonged and/or high dose use of that substance.
Physical symptoms vary according to the substance being used.
Psychological disturbances (e.g. anxiety, depression and sleep disorders) are also common features of withdrawal.
Typically, the patient is likely to report that withdrawal symptoms are relieved by further substance
use.
201
, 5. Withdrawal state with delirium (includes delirium tremens)
ICD-10 criteria
A condition in which the withdrawal state is complicated by delirium.
Delirium tremens
o Is a short-lived, but occasionally life-threatening, toxic confusional state with accompanying somatic
disturbance.
o It is usually a consequence of absolute or relative withdrawal of alcohol in severely dependent users with a
long history of use.
o Onset usually occurs after withdrawal of alcohol.
o Prodromal symptoms typically include insomnia, tremulousness and fear.
o Onset may also be preceded by withdrawal convulsions.
o The classical triad of symptoms includes clouding of consciousness and confusion, vivid
hallucinations and illusions affecting any sensory modality, and marked tremor.
o Delusions, agitation, insomnia or sleep cycle reversal, and autonomic over-activity are usually also present.
6. Psychotic disorder (includes alcoholic hallucinosis)
ICD-10 criteria
A cluster of psychotic phenomena that occur during or immediately after psychoactive substance use (usually
within 48 hours).
The disorder typically resolves at least partially within one month and fully within six months.
Characterised by:
o Vivid hallucinations (typically auditory but often in more than one sensory modality).
o Misidentifications.
o Delusions and/or ideas of reference (often of a paranoid or persecutory nature).
o Psychomotor disturbances (excitement or stupor).
o Abnormal affect (ranging from intense fear to ecstasy).
o Consciousness is usually clear.
7. Amnestic syndrome
ICD-10 criteria
Impairment in learning recent material (learning of new material).
Disturbance of time sense (rearrangements of chronological sequence, telescoping of repeated events into one).
Absence of defect in immediate recall.
Absence of impairment of consciousness and of generalised cognitive impairment.
History or objective evidence of chronic (and particularly high-dose) use of alcohol or drugs.
8. Residual and late-onset psychotic disorder
ICD-10 criteria
Onset of the disorder should be directly related to the use of alcohol or a psychoactive substance.
The disorder should persist beyond any period of time during which direct effects of the psychoactive
substance might be assumed to be operative.
202
Alcohol and Substance Misuse
200
, Chapter 24: Alcohol and Substance Misuse
ICD-10 classification of mental and behavioural disorders due to psychoactive substance misuse
1. Acute intoxication.
2. Harmful use.
3. Dependence syndrome.
4. Withdrawal state.
5. Withdrawal state with delirium.
6. Psychotic disorder.
7. Amnestic syndrome.
8. Residual and late onset psychotic disorder.
1. Acute intoxication
ICD-10 criteria
A transient condition following the administration of alcohol or other psychoactive substance, resulting in
disturbances in the level of consciousness, cognition, perception, affect or behaviour, or other
psychophysiological functions and responses.
Intensity of intoxication lessens with time, and the effects eventually disappear in the absence of further use of
the substance.
Recovery is complete except where tissue damage or other complication has arisen.
2. Harmful use
ICD-10 criteria
A pattern of psychoactive substance use which causes damage to health.
The damage may be physical (e.g. hepatitis from the self-administration of injected drugs) or mental (e.g.
episodes of depressive disorder secondary to heavy consumption of alcohol).
3. Dependence syndrome
ICD-10 criteria
A cluster of physiological, behavioural and cognitive phenomena in which the use of a substance or a class of
substances takes on a much higher priority for a given individual than other behaviours that once had
greater value.
A definite diagnosis of dependence should usually be made only if three or more of the following have been
present together at some time during the previous year:
o A strong desire or sense of compulsion to take the substance.
o Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use.
o A physiological withdrawal state when the substance use has ceased or been reduced as evidenced by
the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance
with the intention of relieving or avoiding withdrawal symptoms.
o Evidence of tolerance, such that increased doses of the psychoactive substances are required in order to
achieve effects originally produced by lower doses (clear examples of this are found in alcohol dependent
and opiate dependent individuals who may take daily doses sufficient to incapacitate or kill non-tolerant
users).
o Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased
amount of time necessary to obtain or take the substance or to recover from its effects.
o Persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the
liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or
drug-related impairment of cognitive functioning.
Narrowing of the personal repertoire of patterns of psychoactive substance use has also been described as a
characteristic feature (e.g. a tendency to drink alcoholic drinks in the same way on weekends, regardless of
social constraints that determine appropriate drinking behaviour).
4. Withdrawal state
ICD-10 criteria
A group of symptoms of variable clustering and severity, occurring on absolute or relative withdrawal of a
substance after repeated and usually prolonged and/or high dose use of that substance.
Physical symptoms vary according to the substance being used.
Psychological disturbances (e.g. anxiety, depression and sleep disorders) are also common features of withdrawal.
Typically, the patient is likely to report that withdrawal symptoms are relieved by further substance
use.
201
, 5. Withdrawal state with delirium (includes delirium tremens)
ICD-10 criteria
A condition in which the withdrawal state is complicated by delirium.
Delirium tremens
o Is a short-lived, but occasionally life-threatening, toxic confusional state with accompanying somatic
disturbance.
o It is usually a consequence of absolute or relative withdrawal of alcohol in severely dependent users with a
long history of use.
o Onset usually occurs after withdrawal of alcohol.
o Prodromal symptoms typically include insomnia, tremulousness and fear.
o Onset may also be preceded by withdrawal convulsions.
o The classical triad of symptoms includes clouding of consciousness and confusion, vivid
hallucinations and illusions affecting any sensory modality, and marked tremor.
o Delusions, agitation, insomnia or sleep cycle reversal, and autonomic over-activity are usually also present.
6. Psychotic disorder (includes alcoholic hallucinosis)
ICD-10 criteria
A cluster of psychotic phenomena that occur during or immediately after psychoactive substance use (usually
within 48 hours).
The disorder typically resolves at least partially within one month and fully within six months.
Characterised by:
o Vivid hallucinations (typically auditory but often in more than one sensory modality).
o Misidentifications.
o Delusions and/or ideas of reference (often of a paranoid or persecutory nature).
o Psychomotor disturbances (excitement or stupor).
o Abnormal affect (ranging from intense fear to ecstasy).
o Consciousness is usually clear.
7. Amnestic syndrome
ICD-10 criteria
Impairment in learning recent material (learning of new material).
Disturbance of time sense (rearrangements of chronological sequence, telescoping of repeated events into one).
Absence of defect in immediate recall.
Absence of impairment of consciousness and of generalised cognitive impairment.
History or objective evidence of chronic (and particularly high-dose) use of alcohol or drugs.
8. Residual and late-onset psychotic disorder
ICD-10 criteria
Onset of the disorder should be directly related to the use of alcohol or a psychoactive substance.
The disorder should persist beyond any period of time during which direct effects of the psychoactive
substance might be assumed to be operative.
202
