The 11 Symptoms of a Substance Use Disorder

Alright, folks, let's do a little test. All right, let's see. See if this is working. Alright, folks, here we are. Another live another day. Today I thought we would talk about a question that I get quite frequently. And this is about substance use disorders, right. Some may say, am I an alcoholic? Is someone else an alcoholic? Are they an addict? Right. So I thought I would go through and talk about from a mental health perspective, what do we professionals look at what constitutes someone being an addict or alcoholic?

And I put that in parentheses because those aren't technical terms, right. Saying someone is an addict or alcoholic is more we call colloquial. Right. It's something that most of us know about, but we talk more about what's called a substance use disorder. So that's the technical term. And the question then is someone, do they meet criteria for a substance use disorder? And this is essentially the same as any other mental health disorder, whether it's depression, how we diagnose something is essentially based on a list of symptoms of common symptoms, right?

So unfortunately for most mental health, or just about any mental health disorder, it's really hard to say objectively, definitively. You know, unlike other medical disorders, it's hard to, let's say, do a blood test and send it to the lab and see if it comes back positive. We could do that for like a urine test or something to see if they've been using. But, you know, that doesn't really give us a diagnosis. So, you know, whether it's addiction, depression, bipolar, autism, these are all things that are diagnosed from observing.

Okay? So you know us as a clinician, sometimes we get info, you know, sometimes we get info from family members, friends. Right? We call that collateral information. Sometimes that helps us as well. So I thought we would spend today and go through the eleven symptoms, right? So when we, as an addiction professional, when someone is doing assessment, essentially we look at eleven symptoms and I'll break it down a little further. It's not always just like a check mark, yes or no. In some ways it is, but I'm going to give you a peek behind the curtain here.

So I'm going to pull it up because usually I could, I know all of them, but I voice correct, I know all of them, but usually when I try to pull them off of the top of my head, I always miss one or two. So I'm just like, I'm just going to pull this up. Recall. So the first symptom that we look at is well before we even go into the symptoms, right? So the question is what is, like, the time frame, right. So this is like a problematic pattern of substance use leading to clinically significant impairment.

Distress is manifested by at least two of the following occurring within a twelve month period. All right? And so when we go through that, it's just because you have some of these symptoms, it has to be a couple of things, one recurring and it has to be significant. So just because you have one of these occurrences or something, it has to, like, have a negative impact on your life, right? It can't just be like, oh, I had this thing happen or one bad thing happen, one consequence, and that's it, right.

It has to be a recurring pattern. So there's that. All right, so let's go ahead and let's go through them. The first is the alcohol. And I'm just pulling up alcohol, and there's, you know, every other substance, you know, and they just kind of break it down. So we'll just say, I'll just try to change it. So the substance is taken in larger amounts over a longer period of time than intended, right. So a lot of times, you see when folks struggle, right, with control over their use is that they say something like, you know, and probably we've all been there to a degree where it's like, okay, I'm gonna go out tonight.

I'm only gonna have two drinks, right? But then all of a sudden you find you had five, you had seven, and then bad things potentially happen. You have a hangover. Right? And I feel like everyone has been there, and that's why we have to differentiate a little bit. But the question is, does this happen all the time? Right? How often does this happen? And when it does happen, how bad is it? Is it like, oh, I had two instead of one? Or is it more like I had five instead of one? Or often it's. I'm planning on not drinking today.

All right, I'm not gonna drink. I'm gonna go out. But then you do it anyway. So sometimes it's just the yes or no thing. So that is one of the things that we look for. And then let's see, the next is a persistent desire or unsuccessful efforts to cut down or control alcohol. So this is in a similar vein, right? This kind of comes down to control. How much control do I have over it? Because most people who don't have an issue with substances, for the most part, aren't going to have trouble controlling, right.

I drink or use when I want, and then when I don't want, I don't do it. Maybe sometimes I indulge a little more than I'd like to. You know, maybe I'm on a diet or I'm doing a cleanse. And, you know, I'm just trying to be healthy. Right. That doesn't really count. You know, you're like, but I had a few drinks anyway, right? Now, this is, like, persistent. Right? That's the key word of persistent and unsuccessful. So I try to do it multiple times, yet still it doesn't work. So, you know, that's unfortunate for a lot of people now.

So, yeah, persistent desire. Right? And a lot of times people will have, as we look at, like, relapse. And now a lot of people, let's say they acknowledge that they have an issue, right? And they get sober, clean, in recovery for days, weeks, months, years. But then they end up going back and they do this recurrently. Right. Persistent. Recurrent and significant. Right. So that's another one of the symptoms. That's number three. Number four is a craving or strong desire, urge to use. Right. So again, a lot of these could be seen as, like, kind of normal.

It's like, oh, man, I just got off a hard day at work. It'd be nice to have a drink. Oh, it's a beautiful summer day. I'm sitting, I'm, you know, at my cabin or whatever, and then you find that you're like, oh, man, a drink would be really quite nice right now. Okay, so that would be kind of within a normal range. Now, abnormal is. Would be like, you have these just really strong, intense urges. Cravings to drink and going back even when you don't want to. Like, I really wish I didn't. But a craving is, like, very physical.

It's not just like I want to. It's just like, I feel like I need to. So that's like a differentiator that I would look at versus, like, desire versus craving. It says here, craving more strong desire. The next number five is recurrent alcohol use, resulting in a failure to fulfill major role obligations at work, school, or home. Right. So this is, you know, we all have, you know, different responsibilities. Yeah. So we all have different obligations. Responsibilities. I'm a mother, I'm a father, I'm an employee, I'm a boss.

Right? And so we try to manage these things, and it's not always easy, but when directly it is impacted by substances or the result of using substances. Right. Where it's like, I have a hangover, I don't have energy, then that would be something that this recurs again and again and it's affecting your ability. Work, school, home, then that may be an issue, right? And a lot of times when we're looking at this as well, again, this within a normal. When I say normal, I mean average. Within an average range of someone who drinks, right?

Again, maybe they go a little too hard one night, they have a hangover and they miss work. Okay? It happens to the best of us, but when this is recurring and it keeps happening, another thing I forgot to mention is this is all in the category of consequences. So if I'm having consequences yet, I continue to do it. That's one of, like, the better, is that I have consequences, yet I continue to do it either way. So we have that. Let's see what else we got. Continued alcohol use despite having a persistent or recurrent social or interpersonal problems or exacerbated by the effects of alcohol, right?

So sometimes we use this, like, clinical language. So let's simplify. So let's see here. Continued. Use this by having a persistent recurrence, social. Right? So this is basically problems in relationships, right? This is causing issues in multiple relationships or in one primary relationship over and over again. And this is one that gets a little tricky because let's say someone else isn't really a fan of my drinking, but maybe they're a bit of a Puritan or something like that, right? So that's within normal range, or maybe someone doesn't approve of it, right?

So these are examples of how maybe you could have these things, but yet still not be a huge problem. However, you do find that when folks have an issue with substances, right? These are all corollaries. Very often, it's going to have a negative impact on the relationships. Right. When you see some of these consequences happening, the people who love, care about you, or more equally importantly, rely on you, right? They are going to take issue with it, right? I found out, like most people, you know, they don't necessarily care that you drink or sometimes use them.

If it's something hard like meth or heroin, it's like, you know, those are substances that very rarely people use recreationally and not have a problem with them. But I think most people aren't like, oh, I want you to not drink. A very high percentage of people drink, and they want you to be able to drink, drink normally and to, you know, be able to share a drink with them. But when they start to have a problem with it is usually because it has taken too far, and then they're like, okay, I don't want you to continue using because of the consequences.

I see. And again, yet if they continue, then that is an indicator that, you know, in fact, this may be an issue for that person. So the other one is social, occupational or recreational activities are given up or reduced because of alcohol. Useaurate. I think of it like, the more you drink or use, the more time and energy and bandwidth it takes. Right. So when you start to feed an addiction, right. It takes your energy to do that, and then you have to sacrifice something else. Right. I view addiction like it's like a fire that you have to keep going in order to keep it going.

You have to take whatever energy logs and throw it in there instead of putting it in, let's say, a fire of health. Right. Or putting it towards things that are more productive. Like, you have these logs and you can either build a deck with it or you could throw it into this fire, right. And so an example of those logs would be like, here are the things that I like to do. I like golfing, although people drink and golf all the time. But whatever that hobby activity, things you used to love, instead you find yourself using more and more.

Maybe it's a money thing. Maybe it's time. Maybe it's just desire. Maybe it's from depression, from using that. You just are giving up those things that you once loved. So that's an indicator as well. And that one's an indicator of a lot of other things, like depression. Yeah. So that's the social recreational. Then another one is recurrent alcohol use. Again, substance use in situations that are physically hazardous. So drinking and driving, putting yourself, for some people, it's like putting themselves in dangerous situations around dangerous people, perhaps that kind of criminal type situations.

So really kind of sacrificing and risking your health. And sometimes, too, that could be like, if you have a medical condition and your doctor's like, yeah, if you drink, your livers could tick out at any minute and you're done and you drink anyway. Well, that would be considered a hazardous situation. So those are just a couple examples. And it's interesting because in the old way, we diagnosed it in the. Well, now it is two versions ago since the new DSM came out, but the DSM four. One of the symptoms that they removed was legal issues.

Right. Which we're kind of mixed on. I see why they did that. But if someone is having multiple duis, right. A lot of, actually, a very high percentage of people get duis, right? And it's not because they're alcoholics or anything like that. They. Right. I mean, you have one too many, you don't know. You get pulled over, you smell like alcohol a little bit, and you're just over the limit. And so it happens to people who aren't. But when you start having it happen multiple times. So that's why I feel like it could or should be left in there.

Because if you're having multiple, right, not just one, maybe even two times. So I don't know if I agree with that. But usually if that person has a use disorder, you can justify it in other ways. They're going to have other symptoms. So it's not like the legal is going to make or break it, but that's a related one. So this one is. So alcohol is alcohol or substance 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.

Kind of like what I was talking about before, knowing you have a physical or mental health condition. Or it could just be that alcohol, drugs affect your overall happiness and well being, yet you do it anyway, right? It affects you physically, yet you do it anyway. So recurring problems and drinking, using, knowing that you have those, knowing that it has a negative consequence on those things, and then too, just knowing you have the addiction itself. Let's say you've acknowledged in the past that you have an addiction, yet you continue to do it anyway.

So it could be from a past addiction as well, or a past diagnosis. These things could be ongoing. A lot of people I assess have already been assessed before and deemed substance dependent or substance use disorder, as we call it now. And that used to be the old categories of substance dependence or abuse. And we'll talk about that at the end of the changes there. And then, what is the outcome of having this many symptoms? So we'll get there in a bit. So the next one is tolerance is defined by a need for markedly increased amounts of alcohol to achieve intoxication or desired effect or a markedly diminished effect.

Continued use of the same amount of alcohol. This one I have, I want to say, take a little issue too, because no matter what, if you drink and you continue to drink or use, you build up a tolerance and you build up a tolerance to caffeine, right. I used to be able to drink one cup and I'd be flying, but now I need like five cups. That's just how the body works. So most people who drink heavily use heavily, they're going to naturally build up a tolerance. So the question is, when is this more addictive and when is it not?

And I feel like that's kind of hard to separate out, and I have a lot of trouble. Like, now, again, this is a very real thing, and if you have an addiction, you're going to have a tolerance. However, you can make the argument that tolerance is going to happen almost no matter what if you are a regular drinker. So a lot of people who could drink maybe every day and not meet the criteria for a use disorder, that one or two, because at the end of the day, right, we're not. You'll see that there's nothing in here.

We're already at ten. There's nothing in here. And if you drink this much or use this much, if you drink every day, do you drink first thing in the morning? Right. Those are some indicators, but that's not part of it. So I tell folks it's not about the amount. Of course, that's correlated. If you have an addiction, you're probably going to drink or use more, but it's more about the consequences. And that gives you a little wiggle room as well, because some people are more binge drinkers or users, they don't use every day.

But when they do buckle up, then the last one, which is probably the most, um, indicative and probably one of the most just glaring, severe symptoms would be withdrawal. And every substance does it differently, has different levels of withdrawal. Some have very little, even some of the harder ones. But, you know, withdrawal, basically, when you build that tolerance up and then all of a sudden you stop using, then all of a sudden, well, you know, your body has an equal, opposite reaction, right? So for every action, there's an equal, opposite reaction.

So if the action is using or drinking heavily, when I stop, I don't go back to that baseline. All right, so an upper, let's say, like, let's say I'm doing cocaine or meth and I'm bringing my nervous system up here. When I stop, it just doesn't go back to normal. It goes lower than it did, and then eventually it'll go back up over time if you stop using. But then you feel like crap. So then that's kind of the trap people fall into. It's like, oh, I feel like crap, and then I go up, but then eventually you don't go up as high, right.

So you kind of are, like, working your way down, and that's when it becomes less and less pleasurable, and you kind of get stuck in that tolerance trap, you know, with withdrawal. Like withdrawal is like a punishment, right? It feels horrible, you know, something like heroin, benzodiazepines any kind of opiate, even things like cannabis, you know, weed actually have like pretty significant withdrawal if you use it enough. With meth, usually kind of get over it pretty quick, but you still have that.

And with meth, you do have a lot more of the psychological. It's almost like cigarettes over time, maybe you don't have that nicotine withdrawal, but there's something like a mental obsession about it that brings it back. So withdrawal happens differently for different drugs, but that is a big indicator. All right, so now that's the eleven symptoms. So let's say I go through, I'm assessing someone. What I do is I find examples. If I'm trying to make the case that the person does or does not have a use disorder, especially if they do, I'm trying to find some examples.

It's like the burden of proof is on me to prove they have a use disorder. If I'm going that direction, I try to go in without bias. Siri, we're not talking to you. So if I'm trying to diagnose, the burden of proof is on me. So I'm going to say, okay, this person meets the criteria for symptom one, two, 4511, you know, whatever those are. And then I give examples. Here are some examples of how that shows up in that person's life. And then I count them up, right? And then if they have two to three, we say it's a mild use disorder, four to five, moderate, six and above, that's severe.

So that's how we code it. Do you have a mild, moderate or severe? Sometimes I think like the taco bell hot sauces, you know, like mild, medium hot. But that's not how we have it, unfortunately. So we have that so we can make that diagnosis. There's other things to consider. So what if somebody had all of these in the past, or maybe the recent past, however, they stopped using or decreased their use, and over the last three months, they have not had any of these symptoms, then what do I do? Well, then we would code that in early remission so they do not meet the criteria that they did before.

Now, if they go back and use happens again while they're back in use disorder category, if they go for a year or more without having that again, then that is sustained remission. So those are the different ones that you'll see. So mild, moderate, severe, is it in remission, is it not? So it's really a number of symptoms. Now there is some wiggle room, at least in my opinion. No one's really policing me on this. But, you know, sometimes I look at, let's say someone only has three, but the severity is just way more than average.

Right? Like, you know, they have issues in real life, but they have horrible. I had this recently with someone who, you know, they would drink and have just horrible, like anger. I mean, it was just really, really intense. So that would kind of elicit me to maybe bump that up to a higher level of concern because of the severity I would have to, you know, I have some leeway. I mean, someone could argue that, well, no, this is the criteria, you know, but I could also diagnose someone with unspecified and say, why that's unspecified.

So before we had these three categories, it was two categories. It was abuse or dependence and it was pretty much the same symptoms. But it was like. I can't remember. Cause this was like very early in my career. But, you know, let's just say it was like less than five, then that would be abuse and more than that would be dependence. And I actually kind of like that. And one of the reasons why, I mean, I like the levels, but I also like the binary there just because a lot of people come with substance use issues and it's not an ongoing progressive disease, right.

They get one too many duis. They've been stressed, their drinking goes up, and it kind of comes into problem zone. But, you know, it doesn't take all that much intervention, maybe a little bit of therapy, you know, just like these small episodes or episode in their life, than to say, you are substance dependent, you are severe, you are even mild. To even give them a use disorder, that kind of implies more of a dependence. It doesn't differentiate. So I kind of wish there was still the abuse category.

Like, maybe instead of mild, they called it abuse, but then they had moderate. Maybe then they had moderate. If I were doing it, I would do this. I would do my. I would do abuse, then mild, but make the mild moderate, make the moderate severe and make the severe even more severe. That's what I would do. As I think about it now, because it is easy to have two. All you have to have is two of those symptoms recurring to have a use disorder. And now that's on your medical charts and stuff. So I think.

I don't think it's horrible the way we do it, but I think that there are some. Some issues, some ethical issues there. So I try to be really careful with that of, you know, giving somebody a diagnosis who may not have it quite as severe. So, yeah, I mean, that's really the overarching of how we look at it, how we diagnose it. It's not perfect. None of these criteria for any disorders are perfect, but it's the best we got, because, again, I can't do a blood test unless your blood alcohol is really high.

But even then, I can't say that you have an addiction or use disorder. So the question then, I guess, is, what do you do? And I've done some videos on this in the past, and perhaps in a live stream if you look back. But what do you do? And just like I'm telling you now about how I do this as an assessment, I think that's the best next step is to get an assessment from an addiction professional, because then I'm not gonna open this bag of worms. But based on how severe it is, we then look at, you know, levels of care, which is basically, do I do nothing?

Do I do maybe some outpatient individual therapy? Do I do outpatient intensive outpatient treatments? So, like, on average, three days a week, 3 hours in a group setting doing some individual two, or do I go inpatient? Right. 30, 60, 90 days, where I go and stay there, live there. So I'm like, kind of what you typically think of as rehab, right? And the highest would be like, all right, we need to go to detox right now. Your hands are shaking because with some of those withdrawals, they can be deadly.

Not just uncomfortable, but deadly. Like alcohol and benzodiazepines, there could be some very significant withdrawal symptoms that could result in seizures and other medical conditions. And people. People can die from that. So it's like, all right, we got to skip all the other things. We got to go right to detox before we can recommend anything else because it's a safety issue. So that's really what the assessment is about, is I'm assessing for a substance use disorder? If so, what level of care is most appropriate?

So, hopefully, that gives you a better idea and lightens. Anything for you. If you're. If this was a question you had pad for yourself or a loved one. Now, there's a lot of other canwarms we could open if someone doesn't want to go get an assessment and all that. But I have some videos out on that as well. So, anyway, as always, folks, it's good checking in. I hope you have a great rest of your evening, and until then, I will see you next time, dear.