Dependence
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Dependence is a foundational concept in addiction. It is a physiological and psychological component of addictive disease. Dependence is also an interpersonal dynamic common in individuals with addictive disorders and their significant others.
Substance Dependence is a psychiatric diagnosis given to denote the chronic form of a Substance Use Disorder commonly called “addiction”. Substance Dependence involves an array of cognitive, behavioral and physiological symptoms. These symptoms are experienced during the continued use of a substance despite negative consequences of that use.
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Substances That Can Cause Substance Dependence
Substance Dependence can occur with the use of illicit substances, prescribed medications and over-the-counter medications.
Some of the illicit substances that can cause Substance Dependence are:
• cannabis
• cocaine
• heroin
• inhalants
• methamphetamine
• hallucinogens
Some of the prescribed medications that may cause Substance Dependence are:
• analgesics
• anti-anxiety medications
• antihistamines
• muscle relaxants
• psycho-stimulants
• sedatives
• hypnotics
Some of the over-the-counter-medications that may cause Substance Dependence are:
• cold remedies
• analgesics
• sleep aids
• diet aids
The diagnosis of dependence is given in relationship to the following classes of substances:
• alcohol
• amphetamine
• cannabis
• cocaine
• hallucinogen
• inhalant
• nicotine
• opioid
• phencyclidine
• sedative
• hypnotic
• anxiolytics
The diagnosis of Substance Dependence can include other mood-altering substances not categorized in these major classes. Examples are anabolic steroids, nitrous oxide, antihistamines and anti-cholinergics.
Diagnosis of Dependence in Use of Multiple Substances
The diagnosis of Polysubstance Dependence is given when an individual has repeatedly used substances from at least three classes of substances without predominant use of any one substance.
Some individuals will meet the diagnostic criteria for Polysubstance Dependence as well as the criteria for other substance-related dependencies. An individual may receive the diagnosis of Polysubstance Dependence as well as, for example, Alcohol Dependence.
Diagnostic Criteria for Substance Dependence
Diagnostic criteria for Substance Dependence as given in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) are as follows:
• a maladaptive pattern of substance use which results in clinically significant impairments or distress
• the presence of three or more of the following indicators of impairment and/or distress related to substance use over a 12 month period:
o the development of tolerance
o withdrawal symptoms
o use in greater amounts than intended or over a longer period than intended
o a persistent desire or unsuccessful efforts to reduce or control use
o significant time spent in obtaining the substance, using the substance or recovering from its effects
o giving up or reducing important social, occupational or recreational activities because of use
o continuing to use the substance despite knowledge of persistent or recurrent problems caused or exacerbated by the use
Physiological Dependence
Physiological dependence is defined by the presence of tolerance for a substance and withdrawal symptoms when the substance is abruptly discontinued or decreased. The presence of physiological dependence can indicate a Substance Disorder; however, a Substance Dependence can exist without physiological dependence upon the substance used. Physiological dependence upon a substance can occur in the use of administered and addictive medications without the presence of a Substance Dependence Disorder.
Diagnostic Specifiers
The exact diagnosis of Substance Dependence is further clarified with the addition of diagnostic specifiers. Two of these specifiers are used to denote the presence or absence of physiological dependence and are written as:
• Substance Dependence With Physiological Dependence
• Substance Dependence Without Physiological Dependence
Other specifiers are added to clarify the current phase of recovery from Substance Dependence. These specifiers are appended to the main body of the diagnosis. These specifiers are:
• Early Full Remission— no symptoms of dependence or abuse for at least one month, but less than one year
• Early Partial Remission -- one of more symptoms of dependence or abuse present for at least one month, but less than one year
• Sustained Full Remission -- no symptoms of dependence or abuse at any time during one year
• Sustained Partial Remission -- no return to the full diagnostic criteria for dependence in one year or longer, but one or more symptoms of dependence or abuse present in that time
Examples of the diagnosis written with these appended markers of remission are:
• Substance Dependence With Physiological Dependence In Early Full Remission
• Substance Dependence Without Physiological Dependence And Sustained Partial Remission
Two specifiers are added to clarify atypical conditions under which remission from Substance Dependence is achieved. These are:
• On Agonist Therapy
• In A Controlled Environment
Examples of the full diagnosis written with appended markers of remission and exceptional conditions of remission are:
• Substance Dependence With Physiological Dependence In Early Full Remission In A Controlled Environment
• Substance Dependence With Physiological Dependence And Sustained Full Remission On Agonist Therapy
The diagnosis of Substance Dependence is typically written to denote the specific class of substance used. The name of the specific class is substituted for the word “substance” as illustrated in the following examples:
• Cocaine Dependence
• Cannabis Dependence
Specific substances which have a pharmaceutical name may be indicated in the diagnosis. Some examples are:
• Diazepam Dependency
• Oxycodone Dependency
Psychological Dependence
Psychological dependence upon a substance occurs when an individual has come to rely upon the effects of the substance used. Psychological dependence can occur when using substances without physiological tolerance or physiological withdrawal. Abrupt cessation or decreased use of substances upon which there is a psychological dependence may induce a psychological ‘withdrawal’ syndrome. Mood alterations and anxiety are common symptoms of psychological withdrawal.
Interpersonal Dependence in Substance Disorders
Interpersonal dependence is a social dynamic common between persons with a substance disorder and their significant others. Substance dependent individuals often have relationships that compensate for the impairments incurred by their substance disorders and come to depend upon them for coping in daily life. Codependence describes such relationships, and the dynamics of relationship, between substance dependent people and those who care for them. Codependent relationships enable the person with a substance disorder to continue in the addictive disease process while their significant others suppress or deny their own needs.
