154 - Substance induced impulse control disorders

Substance-induced impulse control disorders

495 Disorders due to substance use or addictive behaviours more depending on the specific substance), or other evidence of a pre-existing mental disorder with obsessive-compulsive or related symptoms (e.g. a history of prior episodes not associated with substance use). • The symptoms and behaviours are not a manifestation of another medical condition. • The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort. Substance-induced impulse control disorders Available categories by substance class 6C45.73 Cocaine-induced impulse control disorder 6C46.73 Stimulant-induced impulse control disorder, including amfetamines, methamfetamine and methcathinone 6C47.73 Synthetic cathinone-induced impulse control disorder 6C4E.73 Impulse control disorder induced by other specified psychoactive substance 6C4F.73 Impulse control disorder induced by multiple specified psychoactive substances 6C4G.73 Impulse control disorder induced by unknown or unspecified psychoactive substances Essential (required) features • The presentation is characterized by persistently repeated behaviours in which there is recurrent failure to resist an impulse, drive or urge to perform an act that is rewarding to the person – at least in the short term – despite longer-term harm either to the individual or to others (e.g. fire setting or stealing without apparent motive, repetitive sexual behaviour, aggressive outbursts), or by behaviours similar to those seen in disorders due to addictive behaviours (i.e. excessive gambling or gaming). • The disturbance in impulse control develops during or soon after intoxication with or withdrawal from a specified substance, or use or discontinuation of a psychoactive medication. • The intensity or duration of the disturbance in impulse control is substantially in excess of impulse control disturbances that are characteristic of intoxication or withdrawal due to the specified substance. • The specified substance, as well as the amount and duration of its use, is known to be capable of producing disturbances in impulse control (see the list above and Table 6.14, p. 454). • The symptoms and behaviours are not better accounted for by another mental disorder such as an impulse control disorder or a disorder due to addictive behaviours. Evidence supporting a diagnosis of another mental disorder would include an impulse control disturbance preceding the onset of the substance use, the disturbance persisting for a substantial period of time after cessation of the substance or medication use or withdrawal (e.g. 1 month or more depending on the specific substance), or other evidence of a preSubstance-induced impulse control disorders

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders existing mental disorder with impulse control disturbance (e.g. a history of prior episodes not associated with substance use). • The symptoms and behaviours are not a manifestation of another medical condition. • The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort. Additional clinical features for substance-induced mental disorders • Substance-induced mental disorders may present with varying patterns of symptoms, depending on the specific substance used as well as characteristics of the user (e.g. genetics, metabolism, personality factors). Substance use in higher amounts or over longer periods of time is more likely to be associated with the development of a substance-induced mental disorder. • Symptoms of substance-induced mental disorder usually resolve or improve after sustained cessation of substance use. Longer-lasting and in some cases permanent changes can occur in amnestic disorder due to psychoactive substances, including medications, and in dementia due to psychoactive substances, including medications. Perceptual disturbances that last for weeks, months or years (e.g. trails of images of moving objects, geometric illusions) can also occur as a result of hallucinogen use – primarily LSD – and are referred to as “posthallucinogen perception disorder” or “hallucinogen-induced persisting perception disorder”. • The duration of substance withdrawal for some substances can be protracted. For substances with more protracted withdrawal periods, the onset of symptoms of substanceinduced mental disorder can occur up to several weeks after the cessation of substance use. Substance-induced mental disorder symptoms related to substances with more protracted withdrawal periods may also last for correspondingly longer periods of time. • In cases in which multiple psychoactive substances are used, it is often challenging to distinguish which substance is the cause of the substance-induced mental disorder. When the specific etiological substance cannot be determined, a diagnosis of substance-induced mental disorder due to multiple specified psychoactive substances, including medications, may assigned. In cases of multiple psychoactive substance use in which more than one specific substance can be identified as a cause of the substance-induced mental disorder, the corresponding specific substance-induced mental disorder diagnoses should be given instead. Boundary with normality (threshold) for substance-induced mental disorders • Symptoms of substance-induced mental disorders should be differentiated from known side-effects of psychoactive medication that are not significantly impairing or distressing, and from transient physiological aftereffects of intoxication (“hangover effects”). The duration or severity of the symptoms in substance-induced mental disorders must be Substance-induced impulse control disorders

497 Disorders due to substance use or addictive behaviours in excess of side-effects (e.g. transient jitteriness as a side-effect of methylphenidate) or hangover effects (e.g. transient low mood following alcohol use) of the specified substance, and result in significant distress or impairment of functioning. Boundaries with other disorders and conditions (differential diagnosis) for substance-induced mental disorders Boundary with substance intoxication and substance withdrawal Mental or behavioural symptoms that occur during substance intoxication or substance withdrawal should only be used as a basis for diagnosing a substance-induced mental disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of substance intoxication or substance withdrawal due to the specified substance (see Table 6.16, p. 484), and the symptoms are sufficiently severe to warrant specific clinical attention. Boundary with episode of harmful psychoactive substance use, harmful pattern of psychoactive substance use or substance dependence The impact of repeated or continuous use of substances characteristic of harmful pattern of substance use and substance dependence may include substance-induced mental disorders. Substance-induced mental disorders can also be associated with a single episode of substance use. In such cases, a substance-induced mental disorder should be diagnosed together with a primary diagnosis of episode of harmful psychoactive substance use, harmful pattern of psychoactive substance use or substance dependence. Boundary with mental disorders not induced by substances Substance-induced mental disorders are differentiated from mental disorders with similar features that are not induced by substances on the basis of their onset, course and clinical features. A diagnosis of substance-induced mental disorder requires evidence from history, physical or mental examination, or laboratory findings of recent substance use, intoxication or withdrawal. Most substance-induced mental disorders resolve or improve within several weeks of cessation of substance use. Mental disorders not induced by substances may precede the onset of substance use or may continue to be symptomatic during periods of sustained abstinence. The co-occurrence of substance use or withdrawal and onset of symptoms of mental disorders should not be taken as evidence for a presumptive diagnosis of a substance-induced mental disorder. Some people use substances to suppress symptoms of mental disorders (e.g. schizophrenia and other primary psychotic disorders, mood disorders, anxiety and fear-related disorders, personality disorders), and full symptomatic presentations only emerge upon cessation or reduction in substance use. Furthermore, substance use can exacerbate symptoms or precipitate an episode of a pre-existing mental disorder. Finally, substance use may be associated with – but not etiological for – new onset of symptoms of a mental disorder. Although a diagnosis of a substance-induced mental disorder should not be assigned under these circumstances, an additional diagnosis of episode of harmful psychoactive substance use, harmful pattern of psychoactive substance use or substance dependence may still be appropriate. Substance-induced impulse control disorders