"In a controlled environment" applies as a further specifier of remission if the individual is both in remission and in a controlled environment (i.e., in early remission in a controlled environment or in sustained remission in a controlled environment). Examples of these environments are closely supervised and substance—free jails, therapeutic communities, and locked hospital units.
Hallucinogens comprise a diverse group of substances that, despite having different chem— ical structures and possibly involving different molecular mechanisms, produce similar alterations of perception, mood, and cognition in users. Hallucinogens included are phenyl- alkylamines (e.g., mescaline, DOM [2,5-dimethoxy—4-methylamphetamine], and MDMA [3,4—methylenedioxymethamphetamine; also called "ecstasy”]); the indoleamines, includ- ing psilocybin (i.e., psilocin) and dimethyltryptamine (DMT); and the ergolines, such as LSD (lysergic acid diethylamide) and morning glory seeds. In addition, miscellaneous other ethnobotanical compounds are classified as "hallucinogens," of which Salviu divinorum and jimsonweed are two examples. Excluded from the hallucinogen group are cannabis and its active compound, delta-9—tetrahydrocannabinol (THC) (see the section "Cannabis-Related
Disorders”). These substances can have hallucinogenic effects but are diagnosed separately because of significant differences in their psychological and behavioral effects.
Hallucinogens are usually taken orally, although some forms are smoked (e.g., DMT, salvia) or (rarely) taken intranasally or by injection (e.g., ecstasy). Duration of effects varies across types of hallucinogens. Some of these substances (i.e., LSD, MDMA) have a long half-life and extended duration such that users may spend hours to days using and / or re- covering from the effects of these drugs. However, other hallucinogenic drugs (e.g., DMT, salvia) are short acting. Tolerance to hallucinogens develops with repeated use and has been reported to have both autonomic and psychological effects. Cross-tolerance exists be- tween LSD and other hallucinogens (e.g., psilocybin, mescaline) but does not extend to other drug categories such as amphetamines and cannabis.
MDMA /ecstasy as a hallucinogen may have distinctive effects attributable to both its hal— lucinogenic and its stimulant properties. Among heavy ecstasy users, continued use despite physical or psychological problems, tolerance, hazardous use, and spending a great deal of time obtaining the substance are the most commonly reported criteria—over 50% in adults and over 30% in a younger sample, while legal problems related to substance use and persis- tent desire/inability to quit are rarely reported. As found for other substances, diagnostic cri- teria for other hallucinogen use disorder are arrayed along a single continuum of severity.
One of the generic criteria for substance use disorders, a clinically significant with— drawal syndrome, has not been consistently documented in humans, and therefore the di- agnosis of hallucinogen withdrawal syndrome is not included in DSM-5. However, there is evidence of withdrawal from MDMA, with endorsement of two or more withdrawal symptoms observed in 59%—98% in selected samples of ecstasy users. Both psychological and physical problems have been commonly reported as withdrawal problems.
The characteristic symptom features of some of the hallucinogens can aid in diagnosis if urine or blood toxicology results are not available. For example, individuals who use LSD tend to experience visual hallucinations that can be frightening. Individuals intoxicated with hallucinogens may exhibit a temporary increase in suicidality.