Comparison of demographic characteristics and psychiatric comorbidity among methamphetamine-, heroin- and methamphetamine-heroin co- dependent males in Hunan, China

Background There is little research of psychiatric comorbidity differences among people with different types of drug dependence in Chinese population. We explored demographic and comorbid psychiatric differences among methamphetamine- dependent males (MDs), heroin-dependent males (HDs) and methamphetamine and heroin co-dependent males (M/HDs) in Hunan province, China. Methods A cross-sectional, structured and clinical interview method was used to examine differences in DSM-IV-TR Axis I Disorders among 346 MDs, 698 HDs and 247 M/HDs from three compulsory rehabilitation centers and two voluntary rehabilitation centers in Hunan. Results MDs and M/HDs were younger, more likely to choose inhalation administration, less likely to have a family history of substance use, less likely to have undergone detoxification treatment, had higher incomes and shorter duration of drug use than HDs. Overall, methamphetamine-dependence related to higher rates of current and lifetime psychotic disorders, lifetime hallucinogen use disorders. Heroin-dependence related to higher rates of current and lifetime substance-induced mood disorders, sedative/hypnotic/anxiolytic and other drug use disorders and current alcohol use disorder. For M/HDs, they were more likely to have any other lifetime substance use disorders than MDs and HDs. Conclusions There were substantial differences in epidemiological characteristics and comorbidity among MD, HD and M/HD groups, which highlights the urgent need to develop treatment services and policies for drug-specific users in China. Electronic supplementary material The online version of this article (doi:10.1186/s12888-017-1346-7) contains supplementary material, which is available to authorized users.

argument with family members).

71
If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument), no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind In school work). 70 61 Some mild symptoms (e.g., depressed mood and mild Insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. 60 51 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with co-workers). 50 41 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). 40 31 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, Is defiant at home, and is failing at school).

21
Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes Incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends) 20 11 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death, frequently violent, manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute) 10 1 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicide act with clear expectation of death

Depression Criteria
Now I would like to ask you some more specific questions about (TIME PERIOD FOR SUSPECTED DEPRESSIVE EPISODE).
A. Five or more of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms was either (1) depressed mood or (2) loss of interest or pleasure.
During this time, (TIME PERIOD FOR SUSPECTED DEPRESSIVE EPISODE) were you depressed or down, most of the day nearly every day? (What was that like?) IF YES: When was that? How long did it last? As long as two weeks?
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observations made by others (e.g., appears tearful). Note: in children and adolescents, can be irritable mood. IF YES: When was that? Was that nearly every day How long did it last? As long as two weeks?
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day ( ...did you lose or gain any weight? (How much? Were you trying to lose weight?) IF NO: How was your appetite? What about compared to your usual appetite? Did you have to force yourself to eat? Eat (less/more) than usual? Was that nearly every day?
(3) significant weight loss when not dieting, or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains. Just before this began, were you physically ill?
Just before this began, were you drinking or taking any street drugs?
IF YES: Any change in the amount you were taking?
Just before this began, were you taking any medications?
IF YES: Any change in the amount you were taking? C. Not due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or to a general medical condition (e.g., hypothyroidism) During this episode of depression did you also experience any of the following symptoms?
Over activity, such as running around, having many projects, or feeling physically agitated?

Depression Criteria
Now I would like to ask you some more specific questions about (TIME PERIOD FOR SUSPECTED DEPRESSIVE EPISODE).
A. Five or more of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms was either (1) depressed mood or (2) loss of interest or pleasure.
During this time, (TIME PERIOD FOR SUSPECTED DEPRESSIVE EPISODE) were you depressed or down, most of the day nearly every day? (What was that like?) IF YES: When was that? How long did it last? As long as two weeks?
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observations made by others (e.g., appears tearful). Note: in children and adolescents, can be irritable mood. (3) significant weight loss when not dieting, or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains. Just before this began, were you physically ill?
Just before this began, were you drinking or taking any street drugs?
IF YES: Any change in the amount you were taking?
C. Not due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or to a general medical condition (e.g., hypothyroidism)

Depression Criteria
Now I would like to ask you some more specific questions about (TIME PERIOD FOR SUSPECTED DEPRESSIVE EPISODE).
A. Five or more of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms was either (1) depressed mood or (2) loss of interest or pleasure.
During this time, (TIME PERIOD FOR SUSPECTED DEPRESSIVE EPISODE) were you depressed or down, most of the day nearly every day? (What was that like?) IF YES: When was that? How long did it last? As long as two weeks?
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observations made by others (e.g., appears tearful). Note: in children and adolescents, can be irritable mood. Did you lose interest or pleasure in things you usually enjoyed? (What was that like?) IF YES: When was that? Was that nearly every day How long did it last? As long as two weeks?
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated either by subjective account or observation made by others) (3) significant weight loss when not dieting, or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains. Just before this began, were you physically ill?
Just before this began, were you drinking or taking any street drugs?
IF YES: Any change in the amount you were taking?
Just before this began, were you taking any medications?
IF YES: Any change in the amount you were taking?
C. Not due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or to a general medical condition (e.g., hypothyroidism)

Depression Criteria
Now I would like to ask you some more specific questions about (TIME PERIOD FOR SUSPECTED DEPRESSIVE EPISODE).
A. Five or more of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms was either (1) depressed mood or (2) loss of interest or pleasure.
During this time, (TIME PERIOD FOR SUSPECTED DEPRESSIVE EPISODE) were you depressed or down, most of the day nearly every day? (What was (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observations made by IF YES: When was that? How long did it last? As long as two weeks?
others (e.g., appears tearful). Note: in children and adolescents, can be irritable mood.
Did you lose interest or pleasure in things you usually enjoyed? (What was that like?) IF YES: When was that? Was that nearly every day How long did it last? As long as two weeks?
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated either by subjective account or observation made by others) (3) significant weight loss when not dieting, or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains. Did this begin soon after someone close to you died?
D. Not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms or psychomotor retardation.

Depression Criteria
Now I would like to ask you some more specific questions about (TIME PERIOD FOR SUSPECTED DEPRESSIVE EPISODE).
A. Five or more of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms was either (1) depressed mood or (2) loss of interest or pleasure.
During this time, (TIME PERIOD FOR SUSPECTED DEPRESSIVE EPISODE) were you depressed or down, most of the day nearly every day? (What was that like?) IF YES: When was that? How long did it last? As long as two weeks?
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observations made by others (e.g., appears tearful). Note: in children and adolescents, can be irritable mood. (3) significant weight loss when not dieting, or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains.

D. (Mania) F. (Hypomania)
Just before this began, were you physically ill?
Just before this began, were you drinking or taking any street drugs?
IF YES: Any change in the amount you were taking?
Just before this began, were you taking any medications ,other than antidepressants?
IF YES: Any change in the amount you were taking? D/F. Not due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or to a general medical condition IF GENERAL MEDICAL CONDITION OR SUBSTANCE THAT CAN BE ETIOLOGICALLY ASSOCIATED WITH MANIA/HYPOMANIA, GO TO *GMC/SUBSTANCE,* A.51 AND RETURN HERE TO MAKE RATING OF "1" OR "3" Etiological general medical conditions include: degenerative neurological illnesses (e.g., Huntington's disease, multiple sclerosis), cerebrovascular disease (e.g., stroke), metabolic conditions (e.g., Vitamin B-12 deficiency, Wilson's disease), endocrine conditions (e.g., hyperthyroidism), viral or other infections, and certain cancers (e.g., cerebral neoplasms).

D. (Mania) F. (Hypomania)
Just before this began, were you physically ill?
Just before this began, were you drinking or taking any street drugs? D/F. Not due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or to a general medical condition IF YES: Any change in the amount you were taking?
Just before this began, were you taking any medications ,other than antidepressants?
(3) leaden paralysis (i.e., heavy, leaden feeling in arms or legs) During that period, was your mood ever normal for more than two months in a row-that is, two months when you were not sad, blue, down, or high?
B. During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.

HYPERTHYMIC TEMPERAMENT (FOR GENETICS STUDY, SCORE PAST AND CURRENT EPISODES)
INTERVIEWER: If subject reported episodes of mania or hypomania, distinguish these from the less severe periods of hyperthymia by beginning the questions with: "Other than the severe episodes you mentioned" . .

HYPERTHYMIC TEMPERAMENT CRITERIA
A. pervasive pattern of energetic, cheerful, and/or irritable mood present in a variety of contexts, as indicated by at least three (or more) of the following:

IF NEVER HAD A DELUSION AND THERE IS NO SUSPICION OF ANY PSYCHOTIC FEATURES, CHECK HERE AND GO TO HALLUCINATIONS.
O Check Here Did you ever feel that someone or something outside yourself was controlling your thoughts or actions against your will?
Did you ever feel that certain thoughts that were not your own were put into your head? removed and replaced with someone else's brain) DESCRIBE:

HALLUCINATIONS (PSYCHOTIC)
A sensory perception that has the compelling sense of reality of a true perception but occurs without external stimulation of the relevant sensory organ. (CODE "2" FOR HALLUCINATIONS THAT ARE SO TRANSIENT AS TO BE WITHOUT DIAGNOSTIC SIGNIFICANCE) Disorganized speech: frequent derailment (loosening of associations) or incoherence; derailment is a pattern of speech in which the ideas slip off the track onto another that is completely unrelated or only obliquely related. The person may shift the topic idiosyncratically from one frame of reference to another and things may be said in juxtaposition that lack a meaningful relationship. Incoherence is speech that is essentially incomprehensible to others because words or phrases are joined together without a logical or meaningful connection. Alogia: Impoverishment in thinking that is inferred from observing speech and language behavior. There may be restriction in the amount of spontaneous speech and brief and concrete replies to questions (poverty of speech). Sometimes the speech is adequate in amount but conveys little information because it is over-concrete, over-abstract, repetitive, or stereotyped (poverty of content). C. Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms that meet criterion A (i.e., active phase symptoms), and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of disturbance may be manifested by only negative sxs (i.e., affective flattening, alogia, avolition) or two or more symptoms listed in criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences, ideas of reference). B. For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations or self-care is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement). E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or to a general medical condition.

AUDITORY HALLUCINATIONS CRITERIA
Etiological general medical conditions include: neurological conditions (e.g., neoplasms, cerebrovascular disease, Huntington's disease epilepsy, auditory nerve injury, deafness, migraine, central nervous system infections); endocrine conditions (e.g., hyper-and hypo-parathyroidism, hypocortisolism); metabolic conditions (e.g., hypoxia, hypercarbia, hypoglycemia); fluid or electrolyte imbalances; hepatic or renal diseases; and autoimmune disorders with central nervous system involvement (e.g., systemic lupus erythematosis). This specifier may be noted if the psychotic symptoms develop shortly after and apparently in response to one or more events that, singly or together, wouild be markedly stressful to almost anyone in similar circumstances in that person's culture. The precipitating event(s) may be any major stress, such as the loss of a loved one or the psychological trauma of combat. Determining whether a specific stressor was a precipitant or a consequence of the illness may sometimes be clinically difficult. In such instances, the decision will depend on related factors such as the temporal relationship between the stressor and the onset of the symptoms, ancillary information from a spouse or friend about the level of functioning prior to the stressor, and history of similar responses to stressful events in the past. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. CONSIDERED AND SUPPORT THE  CONCLUSION THAT THE GMC IS ETIOLOGIC  TO THE PSYCHOTIC SYMPTOMS: 1) There is evidence from the literature of a well-established association between the GMC and psychotic symptoms.

THE FOLLOWING FACTORS SHOULD BE
2) There is a close temporal relationship between the course of the psychotic symptoms and the course of the general medical condition.
3) The psychotic symptoms are characterized by unusual presenting features (e.g., late age at onset).
4) The absence of alternative explanations. 1) The psychotic symptoms precede the onset of the Substance Abuse or Dependence (or medication use).
2) The psychotic symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication.
3) The psychotic symptoms are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use.
4) There is evidence suggesting the existence of an independent non-substance-induced Psychotic Disorder (e.g., a history of recurrent non-substance-related psychotic episodes).

BIPOLAR I DISORDER DIAGNOSTIC SPECIFIERS LIFETIME SEVERITY:
(Additional questions regarding impairment may be necessary.) O Mild: (GAF = 61-80) Minimum symptom criteria are met for a Manic Episode or few, if any, symptoms in excess of those required to make the diagnosis and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others. Either mild disability is present or substantial or unusual effort is needed to function normally.
O Moderate: (GAF = 51-60) Extreme increase in activity or impairment in judgment; intermediate between "mild" and "severe." O Severe: (GAF = 50) Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others. Almost continual supervision is required during many episodes in order to prevent physical harm to self or others.

PSYCHOTIC FEATURES:
(This rating refers to Bipolar I Disorder over the subject's lifetime. Psychotic symptom ratings in Module A refer to the actual depression and manic episodes as opposed to the diagnosis as a whole.) O Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with either the typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person, or the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.
O Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve either typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person or typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas/themes or to depressivethemes), thought insertion, thought broadcasting, and delusions of being controlled. O Currently Symptomatic: Symptoms are present but full criteria are not met. This differs from Partial Remission in that it does not immediately follow a period of illness (i.e., there was a symptom-free period of at least two months before the current symptoms began). O Severe: (GAF = 50) Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others. Almost continual supervision is required during many episodes in order to prevent physical harm to self or others.

PSYCHOTIC FEATURES:
(This rating refers to Bipolar II Disorder over the subject's lifetime. Psychotic symptom ratings in Module A refer to the actual depression and manic episodes as opposed to the diagnosis as a whole.) O Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with either the typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person, or the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.
O Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve either typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person or typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas/themes or to depressivethemes), thought insertion, thought broadcasting, and delusions of being controlled. The symptoms are not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

MAJOR DEPRESSIVE DISORDER DIAGNOSTIC SPECIFIERS LIFETIME SEVERITY:
(Additional questions regarding impairment may be necessary.) O Mild: (GAF = 61-80) Minimum symptom criteria are met for a Depressive Episode or few, if any, symptoms in excess of those required to make the diagnosis and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others. Either mild disability is present or substantial or unusual effort is needed to function normally.
O Moderate: (GAF = 51-60) Intermediate between "mild" and "severe." O Severe: (GAF = 50) Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.

SUBSTANCE-INDUCED MOOD DISORDER DIFFERENTIAL CRITERIA
There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): (1) The mood symptoms developed during, or within a month of, Substance Intoxication or Withdrawal.
(2) Medication use is etiologically related to the disturbance. The symptoms are not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). O Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with either the typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person, or the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.
O Mood-Incongruent Psychotic Features: Delusions or hallucinations whose content does not involve either typical manic themes of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person or typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to grandiose ideas/themes or to depressivethemes), thought insertion, thought broadcasting, and delusions of being controlled. O Currently Symptomatic: Symptoms are present but full criteria are not met. This differs from Partial Remission in that it does not immediately follow a period of illness (i.e., there was a symptom-free period of at least two months before the current symptoms began).

Module E: Subtance Use Disorders
ALCOHOL USE SCREENING (LIFETIME) What are your drinking habits like? (How much do you drink? Has there ever been a time in your life when you had five or more drinks on one occasion?)

CURRENT ALCOHOL USE:
When in your life were you drinking the most? (How long did that period last?)

RECORD DATE OF HEAVIEST USE AND DESCRIBE PATTERN:
During that time, how often were you drinking?
What were you drinking? How much?
During that time, did your drinking cause problems for you?
Did anyone object to your drinking?

ALCOHOL ABUSE CRITERIA
Let me ask you a few more questions about your drinking habits.
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a twelve month period: Have you ever missed work or school because you were intoxicated, high, or very hung over? (How often? What about doing a bad job at work or failing courses at school because of your drinking?)

LIFETIME SEVERITY:
(Additional questions regarding impairment may be necessary.) O Mild: (GAF = 61-80) Minimum symptom criteria are met or few, if any, symptoms in excess of those required to make the diagnosis and/or symptoms result in only minimal interference in normal functioning. Either mild disability is present or substantial or unusual effort is needed to function normally.
O Moderate: (GAF = 51-60) Intermediate between "mild" and "severe." O Severe: (GAF = 50) Several symptoms in excess of those required to make the diagnosis and/or symptoms result in only limited functioning in most aspects of life almost all the time.

CURRENT STATE:
O In Remission: This specifier is used if, for at least one month, but less than 12 months, one or more criteria for Dependence or Abuse have been met (but the full criteria for Dependence have not been met). A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following occurring at any time in the same twelve month period: Have you often found that when you started drinking you ended up drinking much more than you were planning to?
IF NO: What about drinking for a much longer period of time than you were planning to? 1) alcohol is often taken in larger amounts OR over a longer period than intended Have you found that you needed to drink a lot more than you did when you first started drinking in order to get the feeling you wanted?
IF YES: How much more?
IF NO: What about finding that when you drank the same amount, it had much less effect than before? 6) tolerance, as defined by either of the following: a) a need for markedly increased amounts of alcohol to achieve intoxication or desired effect b) markedly diminished effect with continued use of the same amount of alcohol How about having a seizure or seeing, feeling, or hearing things that weren't really there?
IF NO: Have you ever started the day with a drink, or did you often drink or take some other drug or medication to keep yourself from getting the shakes or becoming sick?
(e.g., sweating or pulse rate greater than 100) -increased hand tremor -insomnia -nausea or vomiting -psychomotor agitation -anxiety -grand mal seizures -transient visual, tactile, or auditory hallucinations or illusions. b) alcohol (or a substance from the sedative/hypnotic/anxiolytic class) taken to relieve or avoid withdrawal symptoms (The following remission specifiers can be applied only after no criteria for dependence or abuse have been met for at least one month in the past. Note: These specifiers do not apply if the individual is On Agonist Therapy or In a Controlled Environment (next page).
O Early Partial Remission: This specifier is used if, for at least one month, but less than 12 months, one or more criteria for Dependence or Abuse have been met (but the full criteria for Dependence have not been met O On Agonist Therapy: The individual is on a prescribed agonist medication (e.g., valium) and no criteria for Dependence or Abuse have been met for that class of medication for at least the past month (except tolerance to, or withdrawal from, the agonist). This category also applies to those being treated for Dependence using a partial agonist or a mixed agonist/antagonist. Have you ever taken any of these to get high, sleep better, lose weight, or change your mood?

GUIDELINES FOR RATING LEVEL OF DRUG USE
ASK FOR EACH DRUG GROUP EVER USED: IF STREET DRUG: When were you using (DRUG) the most? Has there ever been a time when you used it at least ten times in a one-month period of time?
IF PRESCRIBED: Did you ever get hooked (BECOME DEPENDENT) on (PRESCRIBED DRUG) or take much more of it than was prescribed?
Either (1) or (2) (1) has ever taken street drug more than ten times in a one-month period (2) reports becoming dependent on a prescribed drug OR using much more of it than was prescribed  ANY DRUG GROUPS CODED "2" OR "3" false IF NO DRUG CLASSES WERE CODED "3" ON PREVIOUS PAGE (I.E., "2"S ONLY), GO TO *SUBSTANCE ABUSE*. You've told me that you've used (DRUG). Was there a period when you were using a lot of different drugs at the same time and it did not matter what you were taking as long as you could get high?

ASK EACH OF THE FOLLOWING SUBSTANCE DEPENDENCE QUESTIONS FOR EACH DRUG
Behavior during the same 12-month period in which the person was repeatedly using at least three groups of substance (not including caffeine and nicotine), but no single substance predominated. Further, during this period, the Dependence criteria were (likely) met for substances as a group but not for any specific substance. Now I'm going to ask you some specific questions about your use of (DRUGS CODED "3").

SUBSTANCE DEPENDENCE CRITERIA
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: Have you often found that when you started using (DRUG) you ended up using much more of it than you were planning to?
IF NO: What about using it over a much longer period of time than you were planning to? Have you found that you needed to use a lot more (DRUG) in order to get high than you did when you first started using it?
IF YES: How much more?
IF NO: What about finding that when you used the same amount, it had much less effect than before? (1) Tolerance, as defined by either of the following: (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect. (b) markedly diminished effect with continued use of the same amount of this substance. LIST OF WITHDRAWAL SYMPTOMS (FROM DSM-IV CRITERIA) Listed below are the characteristic withdrawal symptoms for those classes of psychoactive substances for which a withdrawal syndrome has been identified. (NOTE: A specific withdrawal syndrome has not been identified for CANNABIS AND HALLUCINOGENS/PCP). Withdrawal symptoms may occur following the cessation of prolonged moderate or heavy use of a psychoactive substance or a reduction in the amount used. For polysubstance use, ask about each applicable category.

SEDATIVES, HYPNOTICS, AND ANXIOLYTICS:
Two (or more) of the following, developing within several hours to a few days after cessation (or reduction) of sedative, hypnotic, or anxiolytic use, which has been heavy and prolonged: O autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)

STIMULANTS/COCAINE:
Dysphoric mood AND two (or more) of the following physiological changes, developing within a few hours to several days after cessation (or reduction of substance use which has been heavy and prolonged):

OPIOIDS:
Three (or more) of the following, developing within minutes to several days after cessation (or reduction) of opioid use which has been heavy and prolonged (several weeks or longer) or after administration of an opioid antagonist (after a period of opioid use): Other CURRENT STATE: Sedatives (The following remission specifiers can be applied only after no criteria for dependence or abuse have been met for at least one month in the past. Note: These specifiers do not apply if the individual is On Agonist Therapy or In a Controlled Environment (next page).

Stimulants
Opioids O Early Partial Remission: This specifier is used if, for at least one month, but less than 12 months, one or more criteria for Dependence or Abuse have been met (but the full criteria for Dependence have not been met

SUBSTANCE ABUSE CRITERIA
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring at any time in the same 12-month period: Have you ever missed work or school because you were intoxicated, high, or very hung over? ( (2) At least one of the attacks has been followed by a month (or more) of one (or more) of the following: (b) worry about the implications of the attack or its consequences(e.g., losing control, having a heart attack, "going crazy") (a) persistent concern about having additional attacks (c) a significant change in behavior related to the attacks (1) Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms.
Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile. (3) The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).  Etiological substances include intoxication with central nervous stimulants (e.g., cocaine, amphetamines, caffeine) or cannabis, hallucinogens, PCP, or alcohol, or withdrawal from central nervous system depressants (e.g., alcohol, sedatives, hypnotics) or from cocaine.
D. If an associated general medical condition is present, the fear described in criterion A is clearly in excess of that usually associated with the condition. O Currently Meets Full Criteria: Full Criteria for an illness must be met at the time of the interview O Currently Symptomatic: Symptoms are present but full criteria are not met. This differs fromPartial Remission in that it does not immediately follow a period of illness (i.e., there was a symptom-free period of at least two months before the current symptoms began A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. GMC OR SUBSTANCE, GO TO *GMC/SUBSTANCE,* F36, AND RETURN HERE TO MAKE A RATING OF "1" OR "3." Etiological general medical conditions include: hyper-and hypo-thyroidism, hypoglycemia, hyperparathyroidism, pheochromocytoma, congestive heart failure, arrhythmias, pulmonary embolism, chronic obstructive pulmonary disease, pneumonia, hyperventilation, B-12 deficiency, porphyria, CNS neoplasms, vestibular dysfunction, encephalitis.
Etiological substances include: intoxication with central nervous stimulants (e.g., cocaine, amphetamines, caffeine) or cannabis, hallucinogens, PCP, or alcohol, or withdrawal from central nervous system depressants (e.g., alcohol, sedatives, hypnotics) or from cocaine. H. If a general medical condition or other mental disorder is present, the fear in A is unrelated to it, e.g., the fear is not of stuttering, trembling (in Parkinson's disease) or exhibiting abnormal eating behavior (in Anorexia Nervosa or Bulimia Nervosa). O Mild: (GAF = 61-80) Minimum symptom criteria are met or few, if any, symptoms in excess of those required to make the diagnosis and/or symptoms result in only minimal interference in normal functioning. Either mild disability is present or substantial or unusual effort is needed to function normally.  (1) and (2): Was there ever anything that you had to do over and over again and couldn't resist doing, like washing your hands again and again, counting up to a certain number, or checking something several times to make sure that you'd done it right? What did you have to do?
(1) Repetitive behaviors (e.g., handwashing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly A. The person has been exposed to a traumatic event in which both of the following were present: IF MORE THAN ONE TRAUMA WAS REPORTED: Which of these do you think affected you the most?
(1) The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others Have you stayed away from things or people that reminded you of (TRAUMA)?
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma IF YES: How many? Were you using (SUBSTANCES) at those times?
C. The disturbance is NOT better accounted for by an Anxiety Disorder that is not substance-induced.
Guidelines for Primary Anxiety: Evidence that the symptoms are better accounted for by a primary (i.e., non-substance-induced) Anxiety Disorder may include any (or all) of the following: (1) the anxiety symptoms precede the onset of the Substance Abuse or Dependence (or medication use) (2) the anxiety symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication (3) the anxiety symptoms are substantially in excess of what would be expected given the character, duration, or amount of the substance used (4) there is evidence suggesting the existence of an independent non-substance-induced Anxiety Disorder (e.g., a history of recurrent non-substance-related panic attacks) O Mild: (GAF = 61-80) Minimum symptom criteria are met or few, if any, symptoms in excess of those required to make the diagnosis and/or symptoms result in only minimal interference in normal functioning. Either mild disability is present or substantial or unusual effort is needed to function normally.
O Moderate: (GAF = 51-60) Intermediate between "mild" and "severe." O Severe: (GAF = 50) Several symptoms in excess of those required to make the diagnosis and/or symptoms result in only limited functioning in most aspects of life almost all the time.

CURRENT STATE:
O In Partial Remission: Symptoms are present but full criteria are not met, or there is a period withoutany significant symptoms lasting less than two months following the end of the episode.
O In Full Remission: During the past two months no significant signs or symptoms of the disturbance.
O Currently Meets Full Criteria: Full Criteria for an illness must be met at the time of the interview O Currently Symptomatic: Symptoms are present but full criteria are not met. This differs fromPartial Remission in that it does not immediately follow a period of illness (i.e., there was a symptom-free period of at least two months before the current symptoms began). Just before you began having this anxiety, were you taking any drugs, stimulants or medicines?

O No Information
(How much coffee, tea, or caffeinated soda do you drink a day)?
Just before these problems began, were you physically ill? (What did the doctor say?) amphetamines, caffeine) or cannabis, hallucinogens, PCP, or alcohol, or withdrawal from central nervous system depressants (e.g., alcohol, sedatives, hypnotics) or from cocaine.

LIFETIME SEVERITY:
(Additional questions regarding impairment may be necessary.) O Mild: (GAF = 61-80) Minimum symptom criteria are met or few, if any, symptoms in excess of those required to make the diagnosis and/or symptoms result in only minimal interference in normal functioning. Either mild disability is present or substantial or unusual effort is needed to function normally.
O Moderate: (GAF = 51-60) Intermediate between "mild" and "severe." O Severe: (GAF = 50) Several symptoms in excess of those required to make the diagnosis and/or symptoms result in only limited functioning in most aspects of life almost all the time.

CURRENT STATE:
O In Partial Remission: Symptoms are present but full criteria are not met, or there is a period withoutany significant symptoms lasting less than two months following the end of the episode.
O In Full Remission: During the past two months no significant signs or symptoms of the disturbance.
O Currently Meets Full Criteria: Full Criteria for an illness must be met at the time of the interview O Currently Symptomatic: Symptoms are present but full criteria are not met. This differs fromPartial Remission in that it does not immediately follow a period of illness (i.e., there was a symptom-free period of at least two months before the current symptoms began). Have you ever had a time when you weighed much less than other people thought you ought to weigh?
A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected) At your lowest weight, did you still feel too fat or that part of your body was too fat? IF NO: Did you need to be very thin in order to feel good about yourself? IF NOT AND LOW WEIGHT IS MEDICALLY SERIOUS: When you were that thin, did anybody tell you it could be dangerous to your health to be that thin? What did you think? C. Disturbance in the way in which one's body weight or shape is experienced; undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight (Additional questions regarding impairment may be necessary.) O Mild: (GAF = 61-80) Minimum symptom criteria are met or few, if any, symptoms in excess of those required to make the diagnosis and/or symptoms result in only minimal interference in normal functioning. Either mild disability is present or substantial or unusual effort is needed to function normally.
O Moderate: (GAF = 51-60) Intermediate between "mild" and "severe." O Severe: (GAF symptoms result in only limited functioning in most aspects of life almost all the time.

CURRENT STATE:
O In Partial Remission: Symptoms are present but full criteria are not met, or there is a periodwithout any significant symptoms lasting less than two months following the end of the episode.
O In Full Remission: During the past two months no significant signs or symptoms of thedisturbance. A. Recurrent episodes of binge eating. An episode of binge eating is characterized by BOTH of the following: (2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) (Additional questions regarding impairment may be necessary.) O Mild: (GAF = 61-80) Minimum symptom criteria are met or few, if any, symptoms in excess of those required to make the diagnosis and/or symptoms result in only minimal interference in normal functioning. Either mild disability is present or substantial or unusual effort is needed to function normally.
O Moderate: (GAF = 51-60) Intermediate between "mild" and "severe." O Severe: (GAF symptoms result in only limited functioning in most aspects of life almost all the time.

CURRENT STATE:
O In Partial Remission: Symptoms are present but full criteria are not met, or there is a periodwithout any significant symptoms lasting less than two months following the end of the episode.
O In Full Remission: During the past two months no significant signs or symptoms of thedisturbance. O Nonpurging Type: This subtype describes presentations in which the person has used otherinappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularlyengaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the courseof illness. (Additional questions regarding impairment may be necessary.) O Mild: (GAF = 61-80) Minimum symptom criteria are met or few, if any, symptoms in excess of those required to make the diagnosis and/or symptoms result in only minimal interference in normal functioning. Either mild disability is present or substantial or unusual effort is needed to function normally.
O Moderate: (GAF = 51-60) Intermediate between "mild" and "severe. O Less Frequent: This subtype describes presentations in which all the criteria for Bulimia Nervosaare met except that the binge eating and inappropriate compensatory mechanisms occur at afrequency of less than twice a week for a duration of less than three months.
O Small Amounts: The regular use of inappropriate compensatory behavior by an individual ofnormal body weight after eating small amounts of food (e.g., self-induced vomiting after theconsumption of two cookies Have you had this kind of reaction many times before? Were you having these (SYMPTOMS) even before (STRESSOR) happened?
C. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a pre-existing Axis I or Axis II disorder. How long has it been now since (STRESSOR AND COMPLICA-TIONS ARISING FROM THE STRESSOR) was over?
E. Once the stressor (or its consequen-ces) has terminated, the symptoms do not persist for more than an additional 6 months. O Chronic: This specifier can be used to indicate persistence of full symptoms for 6 months or longer.By definition, symptoms cannot persist for more than 6 months after the termination of the stressor orits consequences. The Chronic specifier therefore applies when the duration of the disturbance islonger than 6 months in response to a chronic stressor or to a stressor that has enduringconsequences. When you were age 13 or younger, was there ever a time when you had a lot of difficulty staying seated when you were supposed to or a time when you got into trouble because you didn't think before you acted?

ADHD Criteria
When you were age 13 or younger, was there ever a six month period when you often did any of the following: A. Either (1) or (2)

Inattention
(1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity
(2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Did you have a hard time keeping your arms and legs still or did people often tell you to sit still, to stop moving, or to stop squirming in your seat?
(a) Often fidgets with hands or feet or squirms in seat (Additional questions regarding impairment may be necessary.) O Mild: (GAF = 61-80) Minimum symptom criteria are met or few, if any, symptoms in excess of those required to make the diagnosis and/or symptoms result in only minimal interference in normal functioning. Either mild disability is present or substantial or unusual effort is needed to function normally.
O Moderate: (GAF = 51-60) Intermediate between "mild" and "severe." O Severe: (GAF symptoms result in only limited functioning in most aspects of life almost all the time.

CURRENT STATE:
O In Partial Remission: This specifier applies when there has been a period of ADHD symptoms, and some clinically significant residual symptoms remain for less than two months following the end of the episode.
O In Full Remission: This specifier applies when there has been a period of ADHD synptoms, and no clinically significant residual symptoms remain for the past two months.
O Prior History: This specifier applies when there is a history of the criteria having been met for thedisorder but the individual is considered to have recovered from it.
O Currently Meets Full Criteria: Full Criteria for an illness must be met at the time of the interview.
O Currently Symptomatic: Symptoms are present but full criteria are not met. This differs fromPartial Remission in that it does not immediately follow a period of illness (i.e., there was asymptom-free period of at least two months before the current symptoms began

REMEMBER TO ALWAYS RATE THE ITEM AND NOT THE QUESTION.
Frequently the subject will say yes to a question but your clinical judgment will be that the item should be coded "1"or "2". Equally, the subject may say no to a question but there is evidence to the contrary. A rating of "3" should be given only if the subject provided a convincing elaboration or example or there is clear evidence from behavior during interview or from other sources that the item is true.
START by asking the indicated question and follow-up questions as needed. In addition to the questions noted, use probes like: Give me an extreme example?
Does that happen in a lot of different situations?
Have you always been that way?
Do you think you are more this way than most people?