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Classification, Substance misuse or abuse (DSM / ICD)

Substance misuse or abuse is frequently classified as experimental, recreational, or dependant that may result in adverse physical and/or psychological effects (i.e. harmful use). This represents a wide-ranging spectrum of the use of therapeutic drugs or substances with physiological and psycho-active effects on the body or mind which are out with legal or medical guidelines.

Drug misuse is defined as the use of a substance for a purpose not consistent with legal or medical guidelines (WHO, 2006). A further definition by the Royal College of Psychiatrists states “… any taking of a drug which harms or threatens to harm the physical or mental health or social well-being of an individual or other individuals or society at large, or which is illegal” (Royal College of Psychiatrists, 1987).

Care should be taken when defining drug use in terms of addiction or dependence as these terms are not necessarily used with consistent meaning and also have social and cultural implications to their use. Definitions are provided below from the two most recognised disease classification systems - the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Fourth edition Text Revision (2000) – usually referred to as DSM-IV-TR - and the International Classification of Diseases (ICD-10) coding system published by the World Health Organisation (2007) in order to clearly describe the processes of substance abuse an dependence.

Diagnostic and Statistical Manual of Mental Disorders 4th Edition Text Revision (DSM-IV-TR) Classification
DSM-IV-TR Substance Abuse
The term Substance Abuse is used when an individual will repeatedly consume an illicit substance but the pattern of this abuse does not lead to addiction or compulsive behaviour, nor withdrawal symptoms.
DSM-IV-TR describes substance abuse as: a ‘maladaptive’ pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following within a 12 month period:
1. Recurrent use leading to failure to fulfil major role obligations (work, home, school, etc.)
2. Recurrent use in situations where it is physically hazardous (e.g. drunk driving)
3. Repeated substance related legal problems (repeated disorderly conduct while drunk)
4. Persistent use despite recurrent social/interpersonal problems caused or exacerbated by the effects of a substance (e.g. arguments with spouse or physical fights)

Alternatively, the symptoms have never met the criteria for substance dependence for this class of substance.

DSM- IV-TR Substance Dependence
The term Substance Dependence is used when an individual compulsively and repetitively consumes an illicit drug despite problems related to the consumption of that drug, possible tolerance to the effects of the drug, and possible withdrawal symptoms should the drug use be reduced or stopped altogether.

DSM-IV-TR describes Substance dependence as a: ‘maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three (or more) of the following within a 12 month period:
1. Tolerance: a need for increased amounts of a substance to achieve the desired effect or a diminished effect with ongoing use of the same amount of substance
2. Withdrawal symptoms
3. The substance taken in larger amounts over longer periods than was intended
4. Persistent desire or unsuccessful efforts to cut down or control use
5. A great deal of time spent in activities relating to obtaining the substance, using the substance or recovering from use
6. Significant social, occupational or recreational activities are given up or reduced because of use
7. Use continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance’

DSM-IV criteria for substance dependence include several specifiers, one of which outlines whether substance dependence is:
• With physiologic dependence (evidence of tolerance or withdrawal) or
• Without physiologic dependence (no evidence of tolerance or withdrawal).

In addition, remission categories are classified into four subtypes: (1) full, (2) early partial, (3) sustained, and (4) sustained partial; on the basis of whether any of the criteria for abuse or dependence have been met and over what time frame. The remission category can also be used for patients receiving agonist therapy (such as methadone maintenance) or for those living in a controlled, drug-free environment.
[(American Psychiatric Association, 2000) From BearingPoint et al. (2013) Substance and drug dependency]

World Health Organisation: International Classification of Diseases 10th Edition (ICD-10) Classification
ICD-10 classifies substance abuse mainly under the code F10-F19 Mental and behavioural disorders due to psychoactive substance use. However, an additional code exists for non-dependence producing substances such as aspirin.
The codes in this range represent an individual diagnostic code for different substances.
• F10. – Mental and behavioural disorders due to use of alcohol
• F11. – Mental and behavioural disorders due to use of opioids
• F12. – Mental and behavioural disorders due to use of cannabinoids
• F13. – Mental and behavioural disorders due to use of sedative hypnotics
• F14. – Mental and behavioural disorders due to use of cocaine
• F15. – Mental and behavioural disorders due to use of other stimulants, including caffeine
• F16. – Mental and behavioural disorders due to use of hallucinogens
• F17. – Mental and behavioural disorders due to use of tobacco
• F18. – Mental and behavioural disorders due to use of volatile solvents
• F19. – Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances
• F55 – abuse of non-dependence-producing substances (e.g laxatives or Aspirin)

See also WHO ICD-10 Version:2010

BearingPoint et al. (2013) Substance and drug dependency