Clinical Intervention (Psychology)

Clinical Intervention II

Psychosocial Case Study

Assignment

Overview

You will review the case study provided to develop a biopsychosocial, determine the mental status examination, and apply a diagnosis using the DSM V. You must use the following outline to write-out the biopsychosocial:

I. Presenting Problem

II. Background Information/History

III. Medical History

IV. Education

V. Employment History

VI. Substance Abuse History

VII. Mental Status Examination

Diagnostic Impression

You will use the DSM V to diagnose the identified client. You write put your diagnosis in bold with the proper ICD code. What is the primary, secondary, and tertiary diagnosis you would give this client? Why? You need to use DSM V citation(s) to justify the reason for your diagnosis. What is your diagnostic impression of this client? You will need to use three literature (journals or books) to justify your clinical impressions.

You must use APA 7th edition writing style to correctly highlight the subtitle of the biopsychosocial and diagnostic impression. This paper will be 6-7 pages double space in 12 size fonts.

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(Note: This case study is based on many actual cases. All the names used are made up, and

any relation to actual people or events is purely accidental and coincidental.)

PSYCHOSOCIAL CASE STUDY

Marci has smoked cigarettes since age 16 and currently smokes one pack daily. Marci

stopped smoking cigarettes for six months one year ago, but she presently does not plan to cut

down or quit.

She has five prescription pills (Xanax) for depression and anxiety that were given to

her by a college classmate (for whom they were prescribed). Marci shared that she had been

struggling with feelings of sadness and worrying too much about two months ago. She hasn’t

taken them yet but has considered trying them.

Marci first experimented with marijuana during her senior year of high school (age 17),

with her use becoming more regular after she entered college. Marci was first introduced to

marijuana by her high school boyfriend, who used it every day along with alcohol on the

weekends. Marci has never been in an in-patient nor an out-patient program. When her parents

first discovered her marijuana use, they insisted that she seek professional help for what they

perceived to be a drug problem. Although they even threatened to call her college academic

dean because of her dropping grades, Marci refused help and began to discuss quitting school.

While she started drinking wine with her family when she was 13, she started to

“seriously” drink starting around 18-years-old. She currently drinks four or more alcoholic

beverages (usually wine or wine coolers; sometimes beer) three to four times a week and had

been smoking marijuana two to three times a week for one year. Her usual pattern was to go

on weekend binges, starting to drink and smoke on Friday evenings until 2:00 a.m. She

would then have a glass or two of wine around lunchtime on Saturday, smoking a joint or two

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with a couple of friends during Saturday afternoons prior to attending college sporting or

social events. She would then go to parties with friends on Saturday evenings, typically

consuming six to seven cans/bottles/cups of beer and sharing several joints of marijuana with

others. She had also started to consume energy drinks (Red Bull, Monster, etc.) when she

drank beer at these parties to get an added “boost” to her high.

During the past two months, she has sometimes had one to two glasses of wine (she

also used to smoke half a joint of marijuana with it) when alone on school nights. On the

mornings after she used alcohol, Marci tended to sleep in and cut class, but not every week.

Her recreational and social interests had increasingly involved the use of alcohol and

marijuana, now since her arrest, it is mainly alcohol (although she still desires to smoke

cannabis). Recently, Marci has begun to express concern to her friends about “feeling

depressed and anxious,” but she reports no suicidal ideation or panic attacks. She is also

concerned since she has missed her period.

Marci does not admit to any physical problems. She says she was not hurt in her

accidents other than a few bumps and bruises. She says she did not hit her head or lose

consciousness from the accidents. She says she has been sexually active for the past two

years with her “semi-permanent” boyfriend of two years. She thought she was pregnant about

one year ago, but it turned out to be a “false alarm.” She says every now and then, especially

during allergy season, she tends to get a “dry, hacky cough.”

Marci is the oldest of three children (one brother, Jacob, 17-years-old; and one sister,

Sarah, 14-years-old) and continues to live at home while attending college. Her mother, Joan,

is a successful attorney, and her father, John, is a school administrator. Her family has always

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attended weekly services at their church and have, on a couple of occasions, gone as a family on

church-sponsored humanitarian missions to Latin America. Marci and her siblings were always

very active in the youth groups, and helping with various church ministries, such as the nursery

and pre-school child-care Sunday schools. From taking these trips, the family started

incorporating drinking wine with their evening dinners, similar to some of the local customs

observed in these countries. This started when Marci was around 13-years-old. Marci’s parents

found out about her use of marijuana six months prior to her arrest. Marci’s parents found out

about her use of marijuana six months prior to her arrest. After her DUI, her parents sat her down

and expressed their concern about the amount she was drinking and want her to stop.

Since their confrontation and her arrest, she did cut down somewhat on her use of both alcohol

and marijuana, and (when pressed by her parents) she would abstain for several weeks at a time.

As one consequence, her parents stopped giving her permission to drive a family car and were

concerned about her influence on her younger siblings.

Neither her brother nor her sister currently drink or use substances. Her brother Jacob

admits to “drinking a beer with his friends” when he was 16-years-old, but did not like it. He

also admitted to trying his mother’s (Joan) cigarettes several times (about 10 of them) when he

15-years-old, but since he wanted to play sports, he stopped. Her sister Sarah says she has never

used and does not want to try any of it because she “hates the smell of all of it, and sees from

Marci’s example how much trouble it causes.”

Her father (45-years-old) drank alcohol to the point of inebriation many times when he

was younger (being arrested once for Public Intoxication when he was 19), but stopped when he

met and married Joan 25 years ago when they were both 20-years-old. He has not drank alcohol

regularly since then (other than the glass of wine at dinner). He has not had any particular

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problem with mood disorders, although he says he “worries from time-to-time about problems at

work and providing for his family.” He says both his parents struggled with depression and

anxiety, but never (to his knowledge) used any prescription or illegal drugs. He says his dad

drank occasionally, and John got his first taste of liquor from the stash his dad kept in the

workshop when he was around 12-years-old. John’s mother never drank, but she told John her

father (John’s grandfather) was an alcoholic most of John’s life until his death 42 years ago.

John is an only child.

Marci’s mother (45-years-old) says she used marijuana growing up (“like everyone my

age at the time”) and has struggled off-and-on with depression and anxiety since she was quite

young. She never drank when she was younger but has enjoyed the practice of drinking a glass

of wine with dinner. She says she occasionally will have another glass or two “to help her

sleep.” Joan says she was addicted to tobacco, and smoked cigarettes for over 30 years before

beginning to quit about three years ago using nicotine gum and patches. She has now cut the

gum and patch use down considerably and has not had a cigarette for two weeks. Joan says her

father drank excessively all her life and was quite violent when he was drunk. She says that her

father would beat up her mother frequently, and put her in the hospital at least once that she

remembers for two days. Her father could also be verbally abusive to her two brothers and two

sisters (Joan is the youngest). Joan’s father died from a car accident 10 years ago, and alcohol is

thought to have been a factor. Joan’s mother also drank, but not to the excess of her father, and

could get “acid-tongued” to the father and all the children. Joan reports that she and the two

sisters do not have a good relationship with their mother, but the two brothers seem to have an

okay relationship. At this time, Joan’s oldest brother drinks excessively, and seems to be

following in her father’s footsteps. The other brother has never touched alcohol as far as Joan

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knows. (Interestingly, both brothers blame the use and non-use of alcohol on the example of

their father.) Joan says she is very close to the younger brother, but she has a “love-hate”

relationship with the older brother, since he reminds her so much of her dad and his abuse. Both

of Joan’s sisters drank and smoked a little when they were younger but stopped once they

married and had children (though the oldest sister’s first-born son displays some symptoms of

Fetal Alcohol Syndrome). She does not know anything about her grandparents since they died

(on both sides) before she was born, although there were “family rumors” that there was a lot of

drinking that took place on both maternal and paternal sides.

Marci is currently unemployed. In the past she has worked as a waitress, and when she

turned 21, as a part-time bartender for the extra money. Her longest place of employment was

waitressing for six months. Over the past four years, she has been fired or left three other places

of employment due to excessive absenteeism and once for destruction of property.

Marci was arrested five months ago for Driving While Impaired (DWI) with a blood

alcohol level of 0.13. She was also charged with possession of 1 gram of marijuana. Her license

was suspended, but she has driving privileges to get to school/work and back. Over the past

three years she has had two accidents that occurred while she was intoxicated with alcohol and

marijuana, but no other people or vehicles were involved, and no charges were filed against her.

In the first one (30 months ago), she backed into a light pole in the mall parking lot. In the other

(13 months ago), she slid into a ditch when making a moderate curve on a road under normal

road conditions, suffering some cuts to her face and bruises to her chest, sides, and knees, and

needing to call a friend to pull her car out of the ditch. She also had one “destruction of

property” count two years ago, where she was placed on six months of probation and ordered to

pay reparations to the owner, which she did.

6

Marci is a 22-year-old female college student who was arrested five months ago for

driving while impaired with a blood alcohol level of 0.13. She was also charged with possession

of a small amount (about 1 gram) of marijuana. Her license was suspended, but she has driving

privileges to get to school/work and back.

Marci admits that, since she began smoking marijuana, her previously good and trusting

relationship with her parents has soured. She had begun to hide and lied to them about using, and

had felt increasingly negative about herself, especially as her grades have suffered and her general

interests have narrowed. On several occasions she tried cocaine, and on another, LSD, but she

found the experiences unpleasant. It was not until her arrest that she began to feel some guilt and

remorse over the fact that her drinking and especially her marijuana use was negatively impacting

her relationship with her parents, and interfering with her desire to be an attorney. She had also

become gradually aware that marijuana had been affecting her motivation, her schoolwork, and her

spiritual life, but she has not expressed concerns about her use of alcohol.

Marci achieved normal milestones and performed well in high school, generally

achieving A’s and B’s. She is in her junior year of college. She wanted to live away from home

during college, but her parents resisted the idea because of financial pressures and their tendency

to be overprotective. Although she has always been a good student, her grades have begun to go

down and she is not meeting her academic potential.

Marci is neatly dressed, and displays a compliant manner. Her grooming was

appropriate. She was cooperative in the interview answering all questions politely. Her mood

seemed somewhat anxious and depressed.

Her affect was appropriate, and she was not overly emotional but appears torn between

embarrassment and anger at being forced to attend counseling. Her rate of speech was somewhat

rapid when addressing her substance using history and seemed pressured at times, but otherwise

appeared normal. Her tone modulated from high when discussing subjects that made her anxious

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(such as failing school, getting arrested), and low when discussing subjects that were depressing

to her (problems with her parents trusting her). Her thought processes were logical, and she

Page 8 of 9

demonstrated proper insight to her own actions, how they contributed to her situation, and her

continued lack of feeling the need to stop marijuana and alcohol consumption. She was oriented

x 4 (to person, place, time, reason why she is being assessed). She had no problem answering

the mental status questions or doing “serial sevens.”

She states that, although she has not used marijuana since she was arrested, she still has

doubts about its harmfulness. Her use of alcohol has not changed. She says that she finds

marijuana pleasurable and relaxing and that, if she could find a way to not get caught, she would

like to continue using it. She believes that both alcohol and marijuana have helped her feel better

about not achieving the high goals she had set for herself and not fulfilling the expectations her

parents have for her.

Marci shows no evidence of a thought disorder, and her content of thought appeared

normal. She did not demonstrate any psychotic symptoms, and denied any past or current

hallucinations or delusions. She admitted to feeling paranoid at times when she was using

marijuana. She denied any obsessions or compulsions. She reports that she has been depressed

and anxious at times but that these feelings have never been lasting (although they have been

more frequent over the past month). Her memory did not seem impaired, and her intelligence

appeared above average. She has only a few problems regarding sleeping (trouble sleeping

soundly, getting up too late), but no eating problems, history of panic attacks or agoraphobia,

cognitive deficits, or learning disability. She denies any suicidal and homicidal ideations.

Page 9 of 9

DIAGNOSTIC AND STATISTICAL
MANUAL OF

MENTAL DISORDERS
F I F T H E D I T I O N

DSM-5™

American Psychiatric Association

Officers 2012–2013
PRESIDENT DILIP V. JESTE, M.D.

PRESIDENT-ELECT JEFFREY A. LIEBERMAN, M.D.
TREASURER DAVID FASSLER, M.D.
SECRETARY ROGER PEELE, M.D.

Assembly
SPEAKER R. SCOTT BENSON, M.D.

SPEAKER-ELECT MELINDA L. YOUNG, M.D.

Board of Trustees
JEFFREY AKAKA, M.D.

CAROL A. BERNSTEIN, M.D.
BRIAN CROWLEY, M.D.

ANITA S. EVERETT, M.D.
JEFFREY GELLER, M.D., M.P.H.

MARC DAVID GRAFF, M.D.
JAMES A. GREENE, M.D.

JUDITH F. KASHTAN, M.D.
MOLLY K. MCVOY, M.D.
JAMES E. NININGER, M.D.
JOHN M. OLDHAM, M.D.

ALAN F. SCHATZBERG, M.D.
ALIK S. WIDGE, M.D., PH.D.

ERIK R. VANDERLIP, M.D.,
MEMBER-IN-TRAINING TRUSTEE-ELECT

Washington, DC
London, England

DIAGNOSTIC AND STATISTICAL
MANUAL OF

MENTAL DISORDERS
F I F T H E D I T I O N

DSM-5™

Copyright © 2013 American Psychiatric Association

DSM and DSM-5 are trademarks of the American Psychiatric Association. Use of these terms
is prohibited without permission of the American Psychiatric Association.

ALL RIGHTS RESERVED. Unless authorized in writing by the APA, no part of this book may
be reproduced or used in a manner inconsistent with the APA’s copyright. This prohibition
applies to unauthorized uses or reproductions in any form, including electronic applications.

Correspondence regarding copyright permissions should be directed to DSM Permissions,
American Psychiatric Publishing, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-
3901.

Manufactured in the United States of America on acid-free paper.

ISBN 978-0-89042-554-1 (Hardcover) 2nd printing June 2013

ISBN 978-0-89042-555-8 (Paperback) 2nd printing June 2013

American Psychiatric Association
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.psych.org

The correct citation for this book is American Psychiatric Association: Diagnostic and Statisti-
cal Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Associa-
tion, 2013.

Library of Congress Cataloging-in-Publication Data
Diagnostic and statistical manual of mental disorders : DSM-5. — 5th ed.

p. ; cm.
DSM-5
DSM-V
Includes index.
ISBN 978-0-89042-554-1 (hardcover : alk. paper) — ISBN 978-0-89042-555-8 (pbk. : alk. paper)
I. American Psychiatric Association. II. American Psychiatric Association. DSM-5 Task Force.
III. Title: DSM-5. IV. Title: DSM-V.
[DNLM: 1. Diagnostic and statistical manual of mental disorders. 5th ed. 2. Mental Disorders—
classification. 3. Mental Disorders—diagnosis. WM 15]
RC455.2.C4
616.89’075—dc23

2013011061

British Library Cataloguing in Publication Data
A CIP record is available from the British Library.

Text Design—Tammy J. Cordova

Manufacturing—R. R. Donnelley

Contents

DSM-5 Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xli

Section I
DSM-5 Basics

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Use of the Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Cautionary Statement for Forensic Use of DSM-5 . . . . . . . . . . . .25

Section II
Diagnostic Criteria and Codes

Neurodevelopmental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Schizophrenia Spectrum and Other Psychotic Disorders . . . . . .87

Bipolar and Related Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . .123

Depressive Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155

Anxiety Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189

Obsessive-Compulsive and Related Disorders . . . . . . . . . . . . .235

Trauma- and Stressor-Related Disorders . . . . . . . . . . . . . . . . . .265

Dissociative Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .291

Somatic Symptom and Related Disorders . . . . . . . . . . . . . . . . .309

Feeding and Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . .329

Elimination Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .355

Sleep-Wake Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .361

Sexual Dysfunctions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .423

Gender Dysphoria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .451

Disruptive, Impulse-Control, and Conduct Disorders . . . . . . . . 461

Substance-Related and Addictive Disorders . . . . . . . . . . . . . . . 481

Neurocognitive Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591

Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645

Paraphilic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685

Other Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707

Medication-Induced Movement Disorders
and Other Adverse Effects of Medication . . . . . . . . . . . . . . . . 709

Other Conditions That May Be a Focus of Clinical Attention . . 715

Section III
Emerging Measures and Models

Assessment Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733

Cultural Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 749

Alternative DSM-5 Model for Personality Disorders . . . . . . . . . 761

Conditions for Further Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783

Appendix
Highlights of Changes From DSM-IV to DSM-5 . . . . . . . . . . . . . 809

Glossary of Technical Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . 817

Glossary of Cultural Concepts of Distress . . . . . . . . . . . . . . . . . 833

Alphabetical Listing of DSM-5 Diagnoses and Codes
(ICD-9-CM and ICD-10-CM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839

Numerical Listing of DSM-5 Diagnoses and Codes
(ICD-9-CM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863

Numerical Listing of DSM-5 Diagnoses and Codes
(ICD-10-CM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877

DSM-5 Advisors and Other Contributors . . . . . . . . . . . . . . . . . . 897

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 917

DSM-5 Task Force
DAVID J. KUPFER, M.D.

Task Force Chair
DARREL A. REGIER, M.D., M.P.H.

Task Force Vice-Chair
William E. Narrow, M.D., M.P.H.,

Research Director
Susan K. Schultz, M.D., Text Editor
Emily A. Kuhl, Ph.D., APA Text Editor

Dan G. Blazer, M.D., Ph.D., M.P.H.
Jack D. Burke Jr., M.D., M.P.H.
William T. Carpenter Jr., M.D.
F. Xavier Castellanos, M.D.
Wilson M. Compton, M.D., M.P.E.
Joel E. Dimsdale, M.D.
Javier I. Escobar, M.D., M.Sc.
Jan A. Fawcett, M.D.
Bridget F. Grant, Ph.D., Ph.D. (2009–)
Steven E. Hyman, M.D. (2007–2012)
Dilip V. Jeste, M.D. (2007–2011)
Helena C. Kraemer, Ph.D.
Daniel T. Mamah, M.D., M.P.E.
James P. McNulty, A.B., Sc.B.
Howard B. Moss, M.D. (2007–2009)

Charles P. O’Brien, M.D., Ph.D.
Roger Peele, M.D.
Katharine A. Phillips, M.D.
Daniel S. Pine, M.D.
Charles F. Reynolds III, M.D.
Maritza Rubio-Stipec, Sc.D.
David Shaffer, M.D.
Andrew E. Skodol II, M.D.
Susan E. Swedo, M.D.
B. Timothy Walsh, M.D.
Philip Wang, M.D., Dr.P.H. (2007–2012)
William M. Womack, M.D.
Kimberly A. Yonkers, M.D.
Kenneth J. Zucker, Ph.D.
Norman Sartorius, M.D., Ph.D., Consultant

APA Division of Research Staff on DSM-5
Darrel A. Regier, M.D., M.P.H.,

Director, Division of Research
William E. Narrow, M.D., M.P.H.,

Associate Director
Emily A. Kuhl, Ph.D., Senior Science

Writer; Staff Text Editor
Diana E. Clarke, Ph.D., M.Sc., Research

Statistician

Lisa H. Greiner, M.S.S.A., DSM-5 Field
Trials Project Manager

Eve K. Moscicki, Sc.D., M.P.H.,
Director, Practice Research Network

S. Janet Kuramoto, Ph.D. M.H.S.,
Senior Scientific Research Associate,
Practice Research Network

Amy Porfiri, M.B.A.
Director of Finance and Administration

Jennifer J. Shupinka, Assistant Director,
DSM Operations

Seung-Hee Hong, DSM Senior Research
Associate

Anne R. Hiller, DSM Research Associate
Alison S. Beale, DSM Research Associate
Spencer R. Case, DSM Research Associate

Joyce C. West, Ph.D., M.P.P.,
Health Policy Research Director, Practice
Research Network

Farifteh F. Duffy, Ph.D.,
Quality Care Research Director, Practice
Research Network

Lisa M. Countis, Field Operations
Manager, Practice Research Network

Christopher M. Reynolds,
Executive Assistant

APA Office of the Medical Director
JAMES H. SCULLY JR., M.D.

Medical Director and CEO

Editorial and Coding Consultants
Michael B. First, M.D. Maria N. Ward, M.Ed., RHIT, CCS-P

DSM-5 Work Groups

ADHD and Disruptive Behavior Disorders
DAVID SHAFFER, M.D.

Chair

F. XAVIER CASTELLANOS, M.D.
Co-Chair

Paul J. Frick, Ph.D., Text Coordinator
Glorisa Canino, Ph.D.
Terrie E. Moffitt, Ph.D.
Joel T. Nigg, Ph.D.

Luis Augusto Rohde, M.D., Sc.D.
Rosemary Tannock, Ph.D.
Eric A. Taylor, M.B.
Richard Todd, Ph.D., M.D. (d. 2008)

Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic,
and Dissociative Disorders

KATHARINE A. PHILLIPS, M.D.
Chair

Michelle G. Craske, Ph.D., Text
Coordinator

J. Gavin Andrews, M.D.
Susan M. Bögels, Ph.D.
Matthew J. Friedman, M.D., Ph.D.
Eric Hollander, M.D. (2007–2009)
Roberto Lewis-Fernández, M.D., M.T.S.
Robert S. Pynoos, M.D., M.P.H.

Scott L. Rauch, M.D.
H. Blair Simpson, M.D., Ph.D.
David Spiegel, M.D.
Dan J. Stein, M.D., Ph.D.
Murray B. Stein, M.D.
Robert J. Ursano, M.D.
Hans-Ulrich Wittchen, Ph.D.

Childhood and Adolescent Disorders
DANIEL S. PINE, M.D.

Chair

Ronald E. Dahl, M.D.
E. Jane Costello, Ph.D. (2007–2009)
Regina Smith James, M.D.
Rachel G. Klein, Ph.D.

James F. Leckman, M.D.
Ellen Leibenluft, M.D.
Judith H. L. Rapoport, M.D.
Charles H. Zeanah, M.D.

Eating Disorders
B. TIMOTHY WALSH, M.D.

Chair

Stephen A. Wonderlich, Ph.D.,
Text Coordinator

Evelyn Attia, M.D.
Anne E. Becker, M.D., Ph.D., Sc.M.
Rachel Bryant-Waugh, M.D.
Hans W. Hoek, M.D., Ph.D.

Richard E. Kreipe, M.D.
Marsha D. Marcus, Ph.D.
James E. Mitchell, M.D.
Ruth H. Striegel-Moore, Ph.D.
G. Terence Wilson, Ph.D.
Barbara E. Wolfe, Ph.D. A.P.R.N.

Mood Disorders
JAN A. FAWCETT, M.D.

Chair

Ellen Frank, Ph.D., Text Coordinator
Jules Angst, M.D. (2007–2008)
William H. Coryell, M.D.
Lori L. Davis, M.D.
Raymond J. DePaulo, M.D.
Sir David Goldberg, M.D.
James S. Jackson, Ph.D.

Kenneth S. Kendler, M.D.
(2007–2010)

Mario Maj, M.D., Ph.D.
Husseini K. Manji, M.D. (2007–2008)
Michael R. Phillips, M.D.
Trisha Suppes, M.D., Ph.D.
Carlos A. Zarate, M.D.

Neurocognitive Disorders
DILIP V. JESTE, M.D. (2007–2011)

Chair Emeritus

DAN G. BLAZER, M.D., PH.D., M.P.H.
Chair

RONALD C. PETERSEN, M.D., PH.D.
Co-Chair

Mary Ganguli, M.D., M.P.H.,
Text Coordinator

Deborah Blacker, M.D., Sc.D.
Warachal Faison, M.D. (2007–2008)

Igor Grant, M.D.
Eric J. Lenze, M.D.
Jane S. Paulsen, Ph.D.
Perminder S. Sachdev, M.D., Ph.D.

Neurodevelopmental Disorders
SUSAN E. SWEDO, M.D.

Chair

Gillian Baird, M.A., M.B., B.Chir.,
Text Coordinator

Edwin H. Cook Jr., M.D.
Francesca G. Happé, Ph.D.
James C. Harris, M.D.
Walter E. Kaufmann, M.D.
Bryan H. King, M.D.
Catherine E. Lord, Ph.D.

Joseph Piven, M.D.
Sally J. Rogers, Ph.D.
Sarah J. Spence, M.D., Ph.D.
Rosemary Tannock, Ph.D.
Fred Volkmar, M.D. (2007–2009)
Amy M. Wetherby, Ph.D.
Harry H. Wright, M.D.

Personality and Personality Disorders1

ANDREW E. SKODOL, M.D.
Chair

JOHN M. OLDHAM, M.D.
Co-Chair

Robert F. Krueger, Ph.D., Text
Coordinator

Renato D. Alarcon, M.D., M.P.H.
Carl C. Bell, M.D.
Donna S. Bender, Ph.D.

Lee Anna Clark, Ph.D.
W. John Livesley, M.D., Ph.D. (2007–2012)
Leslie C. Morey, Ph.D.
Larry J. Siever, M.D.
Roel Verheul, Ph.D. (2008–2012)

1 The members of the Personality and Personality Disorders Work Group are responsible for the
alternative DSM-5 model for personality disorders that is included in Section III. The Section II
personality disorders criteria and text (with updating of the text) are retained from DSM-IV-TR.

Psychotic Disorders
WILLIAM T. CARPENTER JR., M.D.

Chair

Deanna M. Barch, Ph.D., Text
Coordinator

Juan R. Bustillo, M.D.
Wolfgang Gaebel, M.D.
Raquel E. Gur, M.D., Ph.D.
Stephan H. Heckers, M.D.

Dolores Malaspina, M.D., M.S.P.H.
Michael J. Owen, M.D., Ph.D.
Susan K. Schultz, M.D.
Rajiv Tandon, M.D.
Ming T. Tsuang, M.D., Ph.D.
Jim van Os, M.D.

Sexual and Gender Identity Disorders
KENNETH J. ZUCKER, PH.D.

Chair

Lori Brotto, Ph.D., Text Coordinator
Irving M. Binik, Ph.D.
Ray M. Blanchard, Ph.D.
Peggy T. Cohen-Kettenis, Ph.D.
Jack Drescher, M.D.
Cynthia A. Graham, Ph.D.

Martin P. Kafka, M.D.
Richard B. Krueger, M.D.
Niklas Långström, M.D., Ph.D.
Heino F.L. Meyer-Bahlburg, Dr. rer. nat.
Friedemann Pfäfflin, M.D.
Robert Taylor Segraves, M.D., Ph.D.

Sleep-Wake Disorders
CHARLES F. REYNOLDS III, M.D.

Chair

Ruth M. O’Hara, Ph.D., Text Coordinator
Charles M. Morin, Ph.D.
Allan I. Pack, Ph.D.

Kathy P. Parker, Ph.D., R.N.
Susan Redline, M.D., M.P.H.
Dieter Riemann, Ph.D.

Somatic Symptom Disorders
JOEL E. DIMSDALE, M.D.

Chair

James L. Levenson, M.D., Text
Coordinator

Arthur J. Barsky III, M.D.
Francis Creed, M.D.
Nancy Frasure-Smith, Ph.D. (2007–2011)

Michael R. Irwin, M.D.
Francis J. Keefe, Ph.D. (2007–2011)
Sing Lee, M.D.
Michael Sharpe, M.D.
Lawson R. Wulsin, M.D.

Substance-Related Disorders
CHARLES P. O’BRIEN, M.D., PH.D.

Chair

THOMAS J. CROWLEY, M.D.
Co-Chair

Wilson M. Compton, M.D., M.P.E.,
Text Coordinator

Marc Auriacombe, M.D.
Guilherme L. G. Borges, M.D., Dr.Sc.
Kathleen K. Bucholz, Ph.D.
Alan J. Budney, Ph.D.
Bridget F. Grant, Ph.D., Ph.D.
Deborah S. Hasin, Ph.D.

Thomas R. Kosten, M.D. (2007–2008)
Walter Ling, M.D.
Spero M. Manson, Ph.D. (2007-2008)
A. Thomas McLellan, Ph.D. (2007–2008)
Nancy M. Petry, Ph.D.
Marc A. Schuckit, M.D.
Wim van den Brink, M.D., Ph.D.

(2007–2008)

DSM-5 Study Groups

Diagnostic Spectra and DSM/ICD Harmonization
STEVEN E. HYMAN, M.D.

Chair (2007–2012)

William T. Carpenter Jr., M.D.
Wilson M. Compton, M.D., M.P.E.
Jan A. Fawcett, M.D.
Helena C. Kraemer, Ph.D.
David J. Kupfer, M.D.

William E. Narrow, M.D., M.P.H.
Charles P. O’Brien, M.D., Ph.D.
John M. Oldham, M.D.
Katharine A. Phillips, M.D.
Darrel A. Regier, M.D., M.P.H.

Lifespan Developmental Approaches
ERIC J. LENZE, M.D.

Chair

SUSAN K. SCHULTZ, M.D.
Chair Emeritus

DANIEL S. PINE, M.D.
Chair Emeritus

Dan G. Blazer, M.D., Ph.D., M.P.H.
F. Xavier Castellanos, M.D.
Wilson M. Compton, M.D., M.P.E.

Daniel T. Mamah, M.D., M.P.E.
Andrew E. Skodol II, M.D.
Susan E. Swedo, M.D.

Gender and Cross-Cultural Issues
KIMBERLY A. YONKERS, M.D.

Chair

ROBERTO LEWIS-FERNÁNDEZ, M.D., M.T.S.
Co-Chair, Cross-Cultural Issues

Renato D. Alarcon, M.D., M.P.H.
Diana E. Clarke, Ph.D., M.Sc.
Javier I. Escobar, M.D., M.Sc.
Ellen Frank, Ph.D.
James S. Jackson, Ph.D.
Spiro M. Manson, Ph.D. (2007–2008)
James P. McNulty, A.B., Sc.B.

Leslie C. Morey, Ph.D.
William E. Narrow, M.D., M.P.H.
Roger Peele, M.D.
Philip Wang, M.D., Dr.P.H. (2007–2012)
William M. Womack, M.D.
Kenneth J. Zucker, Ph.D.

Psychiatric/General Medical Interface
LAWSON R. WULSIN, M.D.

Chair

Ronald E. Dahl, M.D.
Joel E. Dimsdale, M.D.
Javier I. Escobar, M.D., M.Sc.
Dilip V. Jeste, M.D. (2007–2011)
Walter E. Kaufmann, M.D.

Richard E. Kreipe, M.D.
Ronald C. Petersen, Ph.D., M.D.
Charles F. Reynolds III, M.D.
Robert Taylor Segraves, M.D., Ph.D.
B. Timothy Walsh, M.D.

Impairment and Disability
JANE S. PAULSEN, PH.D.

Chair

J. Gavin Andrews, M.D.
Glorisa Canino, Ph.D.
Lee Anna Clark, Ph.D.
Diana E. Clarke, Ph.D., M.Sc.
Michelle G. Craske, Ph.D.

Hans W. Hoek, M.D., Ph.D.
Helena C. Kraemer, Ph.D.
William E. Narrow, M.D., M.P.H.
David Shaffer, M.D.

Diagnostic Assessment Instruments
JACK D. BURKE JR., M.D., M.P.H.

Chair

Lee Anna Clark, Ph.D.
Diana E. Clarke, Ph.D., M.Sc.
Bridget F. Grant, Ph.D., Ph.D.

Helena C. Kraemer, Ph.D.
William E. Narrow, M.D., M.P.H.
David Shaffer, M.D.

DSM-5 Research Group
WILLIAM E. NARROW, M.D., M.P.H.

Chair

Jack D. Burke Jr., M.D., M.P.H.
Diana E. Clarke, Ph.D., M.Sc.
Helena C. Kraemer, Ph.D.

David J. Kupfer, M.D.
Darrel A. Regier, M.D., M.P.H.
David Shaffer, M.D.

Course Specifiers and Glossary
WOLFGANG GAEBEL, M.D.

Chair

Ellen Frank, Ph.D.
Charles P. O’Brien, M.D., Ph.D.
Norman Sartorius, M.D., Ph.D.,

Consultant
Susan K. Schultz, M.D.

Dan J. Stein, M.D., Ph.D.
Eric A. Taylor, M.B.
David J. Kupfer, M.D.
Darrel A. Regier, M.D., M.P.H.

xiii

DSM-5
Classification

Before each disorder name, ICD-9-CM codes are provided, followed by ICD-10-CM codes
in parentheses. Blank lines indicate that either the ICD-9-CM or the ICD-10-CM code is not
applicable. For some disorders, the code can be indicated only according to the subtype or
specifier.

ICD-9-CM codes are to be used for coding purposes in the United States through Sep-
tember 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014.

Following chapter titles and disorder names, page numbers for the corresponding text
or criteria are included in parentheses.

Note for all mental disorders due to another medical condition: Indicate the name of
the other medical condition in the name of the mental disorder due to [the medical condi-
tion]. The code and name for the other medical condition should be listed first immedi-
ately before the mental disorder due to the medical condition.

Neurodevelopmental Disorders (31)

Intellectual Disabilities (33)

___.__ (___.__) Intellectual Disability (Intellectual Developmental Disorder) (33)
Specify current severity:

317 (F70) Mild
318.0 (F71) Moderate
318.1 (F72) Severe
318.2 (F73) Profound

315.8 (F88) Global Developmental Delay (41)

319 (F79) Unspecified Intellectual Disability (Intellectual Developmental
Disorder) (41)

Communication Disorders (41)
315.32 (F80.2) Language Disorder (42)

315.39 (F80.0) Speech Sound Disorder (44)

315.35 (F80.81) Childhood-Onset Fluency Disorder (Stuttering) (45)
Note: Later-onset cases are diagnosed as 307.0 (F98.5) adult-onset fluency

disorder.

315.39 (F80.89) Social (Pragmatic) Communication Disorder (47)

307.9 (F80.9) Unspecified Communication Disorder (49)

xiv DSM-5 Classification

Autism Spectrum Disorder (50)
299.00 (F84.0) Autism Spectrum Disorder (50)

Specify if: Associated with a known medical or genetic condition or envi-
ronmental factor; Associated with another neurodevelopmental, men-
tal, or behavioral disorder

Specify current severity for Criterion A and Criterion B: Requiring very
substantial support, Requiring substantial support, Requiring support

Specify if: With or without accompanying intellectual impairment, With
or without accompanying language impairment, With catatonia (use
additional code 293.89 [F06.1])

Attention-Deficit/Hyperactivity Disorder (59)

___.__ (___.__) Attention-Deficit/Hyperactivity Disorder (59)
Specify whether:

314.01 (F90.2) Combined presentation
314.00 (F90.0) Predominantly inattentive presentation
314.01 (F90.1) Predominantly hyperactive/impulsive presentation

Specify if: In partial remission
Specify current severity: Mild, Moderate, Severe

314.01 (F90.8) Other Specified Attention-Deficit/Hyperactivity Disorder (65)

314.01 (F90.9) Unspecified Attention-Deficit/Hyperactivity Disorder (66)

Specific Learning Disorder (66)

___.__ (___.__) Specific Learning Disorder (66)
Specify if:

315.00 (F81.0) With impairment in reading (specify if with word reading
accuracy, reading rate or fluency, reading comprehension)

315.2 (F81.81) With impairment in written expression (specify if with spelling
accuracy, grammar and punctuation accuracy, clarity or
organization of written expression)

315.1 (F81.2) With impairment in mathematics (specify if with number sense,
memorization of arithmetic facts, accurate or fluent
calculation, accurate math reasoning)

Specify current severity: Mild, Moderate, Severe

Motor Disorders (74)
315.4 (F82) Developmental Coordination Disorder (74)

307.3 (F98.4) Stereotypic Movement Disorder (77)
Specify if: With self-injurious behavior, Without self-injurious behavior
Specify if: Associated with a known medical or genetic condition, neuro-

developmental disorder, or environmental factor
Specify current severity: Mild, Moderate, Severe

Tic Disorders

307.23 (F95.2) Tourette’s Disorder (81)

307.22 (F95.1) Persistent (Chronic) Motor or Vocal Tic Disorder (81)
Specify if: With motor tics only, With vocal tics only

DSM-5 Classification xv

307.21 (F95.0) Provisional Tic Disorder (81)

307.20 (F95.8) Other Specified Tic Disorder (85)

307.20 (F95.9) Unspecified Tic Disorder (85)

Other Neurodevelopmental Disorders (86)
315.8 (F88) Other Specified Neurodevelopmental Disorder (86)

315.9 (F89) Unspecified Neurodevelopmental Disorder (86)

Schizophrenia Spectrum
and Other Psychotic Disorders (87)

The following specifiers apply to Schizophrenia Spectrum and Other Psychotic Disorders
where indicated:
aSpecify if: The following course specifiers are only to be used after a 1-year duration of the dis-

order: First episode, currently in acute episode; First episode, currently in partial remission;
First episode, currently in full remission; Multiple episodes, currently in acute episode; Mul-
tiple episodes, currently in partial remission; Multiple episodes, currently in full remission;
Continuous; Unspecified

bSpecify if: With catatonia (use additional code 293.89 [F06.1])
cSpecify current severity of delusions, hallucinations, disorganized speech, abnormal psycho-

motor behavior, negative symptoms, impaired cognition, depression, and mania symptoms

301.22 (F21) Schizotypal (Personality) Disorder (90)

297.1 (F22) Delusional Disordera, c (90)
Specify whether: Erotomanic type, Grandiose type, Jealous type, Persecu-

tory type, Somatic type, Mixed type, Unspecified type
Specify if: With bizarre content

298.8 (F23) Brief Psychotic Disorderb, c (94)
Specify if: With marked stressor(s), Without marked stressor(s), With

postpartum onset

295.40 (F20.81) Schizophreniform Disorderb, c (96)
Specify if: With good prognostic features, Without good prognostic fea-

tures

295.90 (F20.9) Schizophreniaa, b, c (99)

___.__ (___.__) Schizoaffective Disordera, b, c (105)
Specify whether:

295.70 (F25.0) Bipolar type
295.70 (F25.1) Depressive type

___.__ (___.__) Substance/Medication-Induced Psychotic Disorderc (110)
Note: See the criteria set and corresponding recording procedures for

substance-specific codes and ICD-9-CM and ICD-10-CM coding.
Specify if: With onset during intoxication, With onset during withdrawal

___.__ (___.__) Psychotic Disorder Due to Another Medical Conditionc (115)
Specify whether:

293.81 (F06.2) With delusions
293.82 (F06.0) With hallucinations

xvi DSM-5 Classification

293.89 (F06.1) Catatonia Associated With Another Mental Disorder (Catatonia
Specifier) (119)

293.89 (F06.1) Catatonic Disorder Due to Another Medical Condition (120)

293.89 (F06.1) Unspecified Catatonia (121)
Note: Code first 781.99 (R29.818) other symptoms involving nervous and

musculoskeletal systems.

298.8 (F28) Other Specified Schizophrenia Spectrum and Other Psychotic
Disorder (122)

298.9 (F29) Unspecified Schizophrenia Spectrum and Other Psychotic
Disorder (122)

Bipolar and Related Disorders (123)
The following specifiers apply to Bipolar and Related Disorders where indicated:
aSpecify: With anxious distress (specify current severity: mild, moderate, moderate-severe, severe);

With mixed features; With rapid cycling; With melancholic features; With atypical features;
With mood-congruent psychotic features; With mood-incongruent psychotic features; With
catatonia (use additional code 293.89 [F06.1]); With peripartum onset; With seasonal pattern

___.__ (___.__) Bipolar I Disordera (123)
___.__ (___.__) Current or most recent episode manic
296.41 (F31.11) Mild
296.42 (F31.12) Moderate
296.43 (F31.13) Severe
296.44 (F31.2) With psychotic features
296.45 (F31.73) In partial remission
296.46 (F31.74) In full remission
296.40 (F31.9) Unspecified
296.40 (F31.0) Current or most recent episode hypomanic
296.45 (F31.71) In partial remission
296.46 (F31.72) In full remission
296.40 (F31.9) Unspecified
___.__ (___.__) Current or most recent episode depressed
296.51 (F31.31) Mild
296.52 (F31.32) Moderate
296.53 (F31.4) Severe
296.54 (F31.5) With psychotic features
296.55 (F31.75) In partial remission
296.56 (F31.76) In full remission
296.50 (F31.9) Unspecified
296.7 (F31.9) Current or most recent episode unspecified

296.89 (F31.81) Bipolar II Disordera (132)
Specify current or most recent episode: Hypomanic, Depressed
Specify course if full criteria for a mood episode are not currently met: In

partial remission, In full remission
Specify severity if full criteria for a mood episode are currently met:

Mild, Moderate, Severe

DSM-5 Classification xvii

301.13 (F34.0) Cyclothymic Disorder (139)
Specify if: With anxious distress

___.__ (___.__) Substance/Medication-Induced Bipolar and Related Disorder (142)
Note: See the criteria set and corresponding recording procedures for

substance-specific codes and ICD-9-CM and ICD-10-CM coding.
Specify if: With onset during intoxication, With onset during withdrawal

293.83 (___.__) Bipolar and Related Disorder Due to Another Medical Condition
(145)

Specify if:
(F06.33) With manic features
(F06.33) With manic- or hypomanic-like episode
(F06.34) With mixed features

296.89 (F31.89) Other Specified Bipolar and Related Disorder (148)

296.80 (F31.9) Unspecified Bipolar and Related Disorder (149)

Depressive Disorders (155)
The following specifiers apply to Depressive Disorders where indicated:
aSpecify: With anxious distress (specify current severity: mild, moderate, moderate-severe,

severe); With mixed features; With melancholic features; With atypical features; With mood-
congruent psychotic features; With mood-incongruent psychotic features; With catatonia
(use additional code 293.89 [F06.1]); With peripartum onset; With seasonal pattern

296.99 (F34.8) Disruptive Mood Dysregulation Disorder (156)

___.__ (___.__) Major Depressive Disordera (160)
___.__ (___.__) Single episode
296.21 (F32.0) Mild
296.22 (F32.1) Moderate
296.23 (F32.2) Severe
296.24 (F32.3) With psychotic features
296.25 (F32.4) In partial remission
296.26 (F32.5) In full remission
296.20 (F32.9) Unspecified
___.__ (___.__) Recurrent episode
296.31 (F33.0) Mild
296.32 (F33.1) Moderate
296.33 (F33.2) Severe
296.34 (F33.3) With psychotic features
296.35 (F33.41) In partial remission
296.36 (F33.42) In full remission
296.30 (F33.9) Unspecified

300.4 (F34.1) Persistent Depressive Disorder (Dysthymia)a (168)
Specify if: In partial remission, In full remission
Specify if: Early onset, Late onset
Specify if: With pure dysthymic syndrome; With persistent major depres-

sive episode; With intermittent major depressive episodes, with current

xviii DSM-5 Classification

episode; With intermittent major depressive episodes, without current
episode

Specify current severity: Mild, Moderate, Severe

625.4 (N94.3) Premenstrual Dysphoric Disorder (171)

___.__ (___.__) Substance/Medication-Induced Depressive Disorder (175)
Note: See the criteria set and corresponding recording procedures for

substance-specific codes and ICD-9-CM and ICD-10-CM coding.
Specify if: With onset during intoxication, With onset during withdrawal

293.83 (___.__) Depressive Disorder Due to Another Medical Condition (180)
Specify if:

(F06.31) With depressive features
(F06.32) With major depressive-like episode
(F06.34) With mixed features

311 (F32.8) Other Specified Depressive Disorder (183)

311 (F32.9) Unspecified Depressive Disorder (184)

Anxiety Disorders (189)

309.21 (F93.0) Separation Anxiety Disorder (190)

313.23 (F94.0) Selective Mutism (195)

300.29 (___.__) Specific Phobia (197)
Specify if:

(F40.218) Animal
(F40.228) Natural environment
(___.__) Blood-injection-injury
(F40.230) Fear of blood
(F40.231) Fear of injections and transfusions
(F40.232) Fear of other medical care
(F40.233) Fear of injury
(F40.248) Situational
(F40.298) Other

300.23 (F40.10) Social Anxiety Disorder (Social Phobia) (202)
Specify if: Performance only

300.01 (F41.0) Panic Disorder (208)

___.__ (___.__) Panic Attack Specifier (214)

300.22 (F40.00) Agoraphobia (217)

300.02 (F41.1) Generalized Anxiety Disorder (222)

___.__ (___.__) Substance/Medication-Induced Anxiety Disorder (226)
Note: See the criteria set and corresponding recording procedures for

substance-specific codes and ICD-9-CM and ICD-10-CM coding.
Specify if: With onset during intoxication, With onset during withdrawal,

With onset after medication use

DSM-5 Classification xix

293.84 (F06.4) Anxiety Disorder Due to Another Medical Condition (230)

300.09 (F41.8) Other Specified Anxiety Disorder (233)

300.00 (F41.9) Unspecified Anxiety Disorder (233)

Obsessive-Compulsive and Related Disorders (235)
The following specifier applies to Obsessive-Compulsive and Related Disorders where indicated:
aSpecify if: With good or fair insight, With poor insight, With absent insight/delusional beliefs

300.3 (F42) Obsessive-Compulsive Disordera (237)
Specify if: Tic-related

300.7 (F45.22) Body Dysmorphic Disordera (242)
Specify if: With muscle dysmorphia

300.3 (F42) Hoarding Disordera (247)
Specify if: With excessive acquisition

312.39 (F63.3) Trichotillomania (Hair-Pulling Disorder) (251)

698.4 (L98.1) Excoriation (Skin-Picking) Disorder (254)

___.__ (___.__) Substance/Medication-Induced Obsessive-Compulsive and
Related Disorder (257)

Note: See the criteria set and corresponding recording procedures for
substance-specific codes and ICD-9-CM and ICD-10-CM coding.

Specify if: With onset during intoxication, With onset during withdrawal,
With onset after medication use

294.8 (F06.8) Obsessive-Compulsive and Related Disorder Due to Another
Medical Condition (260)

Specify if: With obsessive-compulsive disorder–like symptoms, With
appearance preoccupations, With hoarding symptoms, With hair-
pulling symptoms, With skin-picking symptoms

300.3 (F42) Other Specified Obsessive-Compulsive and Related Disorder
(263)

300.3 (F42) Unspecified Obsessive-Compulsive and Related Disorder (264)

Trauma- and Stressor-Related Disorders (265)

313.89 (F94.1) Reactive Attachment Disorder (265)
Specify if: Persistent
Specify current severity: Severe

313.89 (F94.2) Disinhibited Social Engagement Disorder (268)
Specify if: Persistent
Specify current severity: Severe

309.81 (F43.10) Posttraumatic Stress Disorder (includes Posttraumatic Stress
Disorder for Children 6 Years and Younger) (271)

Specify whether: With dissociative symptoms
Specify if: With delayed expression

308.3 (F43.0) Acute Stress Disorder (280)

xx DSM-5 Classification

___.__ (___.__) Adjustment Disorders (286)
Specify whether:

309.0 (F43.21) With depressed mood
309.24 (F43.22) With anxiety
309.28 (F43.23) With mixed anxiety and depressed mood
309.3 (F43.24) With disturbance of conduct
309.4 (F43.25) With mixed disturbance of emotions and conduct
309.9 (F43.20) Unspecified

309.89 (F43.8) Other Specified Trauma- and Stressor-Related Disorder (289)

309.9 (F43.9) Unspecified Trauma- and Stressor-Related Disorder (290)

Dissociative Disorders (291)

300.14 (F44.81) Dissociative Identity Disorder (292)

300.12 (F44.0) Dissociative Amnesia (298)
Specify if:

300.13 (F44.1) With dissociative fugue

300.6 (F48.1) Depersonalization/Derealization Disorder (302)

300.15 (F44.89) Other Specified Dissociative Disorder (306)

300.15 (F44.9) Unspecified Dissociative Disorder (307)

Somatic Symptom and Related Disorders (309)

300.82 (F45.1) Somatic Symptom Disorder (311)
Specify if: With predominant pain
Specify if: Persistent
Specify current severity: Mild, Moderate, Severe

300.7 (F45.21) Illness Anxiety Disorder (315)
Specify whether: Care seeking type, Care avoidant type

300.11 (___.__) Conversion Disorder (Functional Neurological Symptom
Disorder) (318)

Specify symptom type:
(F44.4) With weakness or paralysis
(F44.4) With abnormal movement
(F44.4) With swallowing symptoms
(F44.4) With speech symptom
(F44.5) With attacks or seizures
(F44.6) With anesthesia or sensory loss
(F44.6) With special sensory symptom
(F44.7) With mixed symptoms

Specify if: Acute episode, Persistent
Specify if: With psychological stressor (specify stressor), Without psycho-

logical stressor

DSM-5 Classification xxi

316 (F54) Psychological Factors Affecting Other Medical Conditions (322)
Specify current severity: Mild, Moderate, Severe, Extreme

300.19 (F68.10) Factitious Disorder (includes Factitious Disorder Imposed on Self,
Factitious Disorder Imposed on Another) (324)

Specify Single episode, Recurrent episodes

300.89 (F45.8) Other Specified Somatic Symptom and Related Disorder (327)

300.82 (F45.9) Unspecified Somatic Symptom and Related Disorder (327)

Feeding and Eating Disorders (329)

The following specifiers apply to Feeding and Eating Disorders where indicated:
aSpecify if: In remission
bSpecify if: In partial remission, In full remission
cSpecify current severity: Mild, Moderate, Severe, Extreme

307.52 (___.__) Picaa (329)
(F98.3) In children
(F50.8) In adults

307.53 (F98.21) Rumination Disordera (332)

307.59 (F50.8) Avoidant/Restrictive Food Intake Disordera (334)

307.1 (___.__) Anorexia Nervosab, c (338)
Specify whether:

(F50.01) Restricting type
(F50.02) Binge-eating/purging type

307.51 (F50.2) Bulimia Nervosab, c (345)

307.51 (F50.8) Binge-Eating Disorderb, c (350)

307.59 (F50.8) Other Specified Feeding or Eating Disorder (353)

307.50 (F50.9) Unspecified Feeding or Eating Disorder (354)

Elimination Disorders (355)

307.6 (F98.0) Enuresis (355)
Specify whether: Nocturnal only, Diurnal only, Nocturnal and diurnal

307.7 (F98.1) Encopresis (357)
Specify whether: With constipation and overflow incontinence, Without

constipation and overflow incontinence

___.__ (___.__) Other Specified Elimination Disorder (359)
788.39 (N39.498) With urinary symptoms
787.60 (R15.9) With fecal symptoms

___.__ (___.__) Unspecified Elimination Disorder (360)
788.30 (R32) With urinary symptoms
787.60 (R15.9) With fecal symptoms

xxii DSM-5 Classification

Sleep-Wake Disorders (361)
The following specifiers apply to Sleep-Wake Disorders where indicated:
aSpecify if: Episodic, Persistent, Recurrent
bSpecify if: Acute, Subacute, Persistent
cSpecify current severity: Mild, Moderate, Severe

307.42 (F51.01) Insomnia Disordera (362)
Specify if: With non–sleep disorder mental comorbidity, With other

medical comorbidity, With other sleep disorder

307.44 (F51.11) Hypersomnolence Disorderb, c (368)
Specify if: With mental disorder, With medical condition, With another

sleep disorder

___.__ (___.__) Narcolepsyc (372)
Specify whether:

347.00 (G47.419) Narcolepsy without cataplexy but with hypocretin deficiency
347.01 (G47.411) Narcolepsy with cataplexy but without hypocretin deficiency
347.00 (G47.419) Autosomal dominant cerebellar ataxia, deafness, and

narcolepsy
347.00 (G47.419) Autosomal dominant narcolepsy, obesity, and type 2 diabetes
347.10 (G47.429) Narcolepsy secondary to another medical condition

Breathing-Related Sleep Disorders (378)
327.23 (G47.33) Obstructive Sleep Apnea Hypopneac (378)

___.__ (___.__) Central Sleep Apnea (383)
Specify whether:

327.21 (G47.31) Idiopathic central sleep apnea
786.04 (R06.3) Cheyne-Stokes breathing
780.57 (G47.37) Central sleep apnea comorbid with opioid use

Note: First code opioid use disorder, if present.
Specify current severity

___.__ (___.__) Sleep-Related Hypoventilation (387)
Specify whether:

327.24 (G47.34) Idiopathic hypoventilation
327.25 (G47.35) Congenital central alveolar hypoventilation
327.26 (G47.36) Comorbid sleep-related hypoventilation

Specify current severity

___.__ (___.__) Circadian Rhythm Sleep-Wake Disordersa (390)
Specify whether:

307.45 (G47.21) Delayed sleep phase type (391)
Specify if: Familial, Overlapping with non-24-hour sleep-wake type

307.45 (G47.22) Advanced sleep phase type (393)
Specify if: Familial

307.45 (G47.23) Irregular sleep-wake type (394)
307.45 (G47.24) Non-24-hour sleep-wake type (396)

DSM-5 Classification xxiii

307.45 (G47.26) Shift work type (397)
307.45 (G47.20) Unspecified type

Parasomnias (399)

___.__ (__.__) Non–Rapid Eye Movement Sleep Arousal Disorders (399)
Specify whether:

307.46 (F51.3) Sleepwalking type
Specify if: With sleep-related eating, With sleep-related sexual

behavior (sexsomnia)
307.46 (F51.4) Sleep terror type

307.47 (F51.5) Nightmare Disorderb, c (404)
Specify if: During sleep onset
Specify if: With associated non–sleep disorder, With associated other

medical condition, With associated other sleep disorder

327.42 (G47.52) Rapid Eye Movement Sleep Behavior Disorder (407)

333.94 (G25.81) Restless Legs Syndrome (410)

___.__ (___.__) Substance/Medication-Induced Sleep Disorder (413)
Note: See the criteria set and corresponding recording procedures for

substance-specific codes and ICD-9-CM and ICD-10-CM coding.
Specify whether: Insomnia type, Daytime sleepiness type, Parasomnia

type, Mixed type
Specify if: With onset during intoxication, With onset during discontinua-

tion/withdrawal

780.52 (G47.09) Other Specified Insomnia Disorder (420)

780.52 (G47.00) Unspecified Insomnia Disorder (420)

780.54 (G47.19) Other Specified Hypersomnolence Disorder (421)

780.54 (G47.10) Unspecified Hypersomnolence Disorder (421)

780.59 (G47.8) Other Specified Sleep-Wake Disorder (421)

780.59 (G47.9) Unspecified Sleep-Wake Disorder (422)

Sexual Dysfunctions (423)
The following specifiers apply to Sexual Dysfunctions where indicated:
aSpecify whether: Lifelong, Acquired
bSpecify whether: Generalized, Situational
cSpecify current severity: Mild, Moderate, Severe

302.74 (F52.32) Delayed Ejaculationa, b, c (424)

302.72 (F52.21) Erectile Disordera, b, c (426)

302.73 (F52.31) Female Orgasmic Disordera, b, c (429)
Specify if: Never experienced an orgasm under any situation

302.72 (F52.22) Female Sexual Interest/Arousal Disordera, b, c (433)

302.76 (F52.6) Genito-Pelvic Pain/Penetration Disordera, c (437)

xxiv DSM-5 Classification

302.71 (F52.0) Male Hypoactive Sexual Desire Disordera, b, c (440)

302.75 (F52.4) Premature (Early) Ejaculationa, b, c (443)

___.__ (___.__) Substance/Medication-Induced Sexual Dysfunctionc (446)
Note: See the criteria set and corresponding recording procedures for

substance-specific codes and ICD-9-CM and ICD-10-CM coding.
Specify if: With onset during intoxication, With onset during withdrawal,

With onset after medication use

302.79 (F52.8) Other Specified Sexual Dysfunction (450)

302.70 (F52.9) Unspecified Sexual Dysfunction (450)

Gender Dysphoria (451)

___.__ (__.__) Gender Dysphoria (452)
302.6 (F64.2) Gender Dysphoria in Children

Specify if: With a disorder of sex development
302.85 (F64.1) Gender Dysphoria in Adolescents and Adults

Specify if: With a disorder of sex development
Specify if: Posttransition

Note: Code the disorder of sex development if present, in addition to
gender dysphoria.

302.6 (F64.8) Other Specified Gender Dysphoria (459)

302.6 (F64.9) Unspecified Gender Dysphoria (459)

Disruptive, Impulse-Control, and Conduct Disorders (461)

313.81 (F91.3) Oppositional Defiant Disorder (462)
Specify current severity: Mild, Moderate, Severe

312.34 (F63.81) Intermittent Explosive Disorder (466)

___.__ (__.__) Conduct Disorder (469)
Specify whether:

312.81 (F91.1) Childhood-onset type
312.82 (F91.2) Adolescent-onset type
312.89 (F91.9) Unspecified onset

Specify if: With limited prosocial emotions
Specify current severity: Mild, Moderate, Severe

301.7 (F60.2) Antisocial Personality Disorder (476)

312.33 (F63.1) Pyromania (476)

312.32 (F63.2) Kleptomania (478)

312.89 (F91.8) Other Specified Disruptive, Impulse-Control, and Conduct
Disorder (479)

312.9 (F91.9) Unspecified Disruptive, Impulse-Control, and Conduct Disorder
(480)

DSM-5 Classification xxv

Substance-Related and Addictive Disorders (481)

The following specifiers and note apply to Substance-Related and Addictive Disorders where
indicated:
aSpecify if: In early remission, In sustained remission
bSpecify if: In a controlled environment
cSpecify if: With perceptual disturbances
dThe ICD-10-CM code indicates the comorbid presence of a moderate or severe substance use

disorder, which must be present in order to apply the code for substance withdrawal.

Substance-Related Disorders (483)

Alcohol-Related Disorders (490)

___.__ (___.__) Alcohol Use Disordera, b (490)
Specify current severity:

305.00 (F10.10) Mild
303.90 (F10.20) Moderate
303.90 (F10.20) Severe

303.00 (___.__) Alcohol Intoxication (497)
(F10.129) With use disorder, mild
(F10.229) With use disorder, moderate or severe
(F10.929) Without use disorder

291.81 (___.__) Alcohol Withdrawalc, d (499)
(F10.239) Without perceptual disturbances
(F10.232) With perceptual disturbances

___.__ (___.__) Other Alcohol-Induced Disorders (502)

291.9 (F10.99) Unspecified Alcohol-Related Disorder (503)

Caffeine-Related Disorders (503)

305.90 (F15.929) Caffeine Intoxication (503)

292.0 (F15.93) Caffeine Withdrawal (506)

___.__ (___.__) Other Caffeine-Induced Disorders (508)

292.9 (F15.99) Unspecified Caffeine-Related Disorder (509)

Cannabis-Related Disorders (509)

___.__ (___.__) Cannabis Use Disordera, b (509)
Specify current severity:

305.20 (F12.10) Mild
304.30 (F12.20) Moderate
304.30 (F12.20) Severe

xxvi DSM-5 Classification

292.89 (___.__) Cannabis Intoxicationc (516)
Without perceptual disturbances

(F12.129) With use disorder, mild
(F12.229) With use disorder, moderate or severe
(F12.929) Without use disorder

With perceptual disturbances
(F12.122) With use disorder, mild
(F12.222) With use disorder, moderate or severe
(F12.922) Without use disorder

292.0 (F12.288) Cannabis Withdrawald (517)

___.__ (___.__) Other Cannabis-Induced Disorders (519)

292.9 (F12.99) Unspecified Cannabis-Related Disorder (519)

Hallucinogen-Related Disorders (520)

___.__ (___.__) Phencyclidine Use Disordera, b (520)
Specify current severity:

305.90 (F16.10) Mild
304.60 (F16.20) Moderate
304.60 (F16.20) Severe

___.__ (___.__) Other Hallucinogen Use Disordera, b (523)
Specify the particular hallucinogen
Specify current severity:

305.30 (F16.10) Mild
304.50 (F16.20) Moderate
304.50 (F16.20) Severe

292.89 (___.__) Phencyclidine Intoxication (527)
(F16.129) With use disorder, mild
(F16.229) With use disorder, moderate or severe
(F16.929) Without use disorder

292.89 (___.__) Other Hallucinogen Intoxication (529)
(F16.129) With use disorder, mild
(F16.229) With use disorder, moderate or severe
(F16.929) Without use disorder

292.89 (F16.983) Hallucinogen Persisting Perception Disorder (531)

___.__ (___.__) Other Phencyclidine-Induced Disorders (532)

___.__ (___.__) Other Hallucinogen-Induced Disorders (532)

292.9 (F16.99) Unspecified Phencyclidine-Related Disorder (533)

292.9 (F16.99) Unspecified Hallucinogen-Related Disorder (533)

Inhalant-Related Disorders (533)

___.__ (___.__) Inhalant Use Disordera, b (533)
Specify the particular inhalant
Specify current severity:

305.90 (F18.10) Mild

DSM-5 Classification xxvii

304.60 (F18.20) Moderate
304.60 (F18.20) Severe

292.89 (___.__) Inhalant Intoxication (538)
(F18.129) With use disorder, mild
(F18.229) With use disorder, moderate or severe
(F18.929) Without use disorder

___.__ (___.__) Other Inhalant-Induced Disorders (540)

292.9 (F18.99) Unspecified Inhalant-Related Disorder (540)

Opioid-Related Disorders (540)

___.__ (___.__) Opioid Use Disordera (541)
Specify if: On maintenance therapy, In a controlled environment
Specify current severity:

305.50 (F11.10) Mild
304.00 (F11.20) Moderate
304.00 (F11.20) Severe

292.89 (___.__) Opioid Intoxicationc (546)
Without perceptual disturbances

(F11.129) With use disorder, mild
(F11.229) With use disorder, moderate or severe
(F11.929) Without use disorder

With perceptual disturbances
(F11.122) With use disorder, mild
(F11.222) With use disorder, moderate or severe
(F11.922) Without use disorder

292.0 (F11.23) Opioid Withdrawald (547)

___.__ (___.__) Other Opioid-Induced Disorders (549)

292.9 (F11.99) Unspecified Opioid-Related Disorder (550)

Sedative-, Hypnotic-, or Anxiolytic-Related Disorders (550)

___.__ (___.__) Sedative, Hypnotic, or Anxiolytic Use Disordera, b (550)
Specify current severity:

305.40 (F13.10) Mild
304.10 (F13.20) Moderate
304.10 (F13.20) Severe

292.89 (___.__) Sedative, Hypnotic, or Anxiolytic Intoxication (556)
(F13.129) With use disorder, mild
(F13.229) With use disorder, moderate or severe
(F13.929) Without use disorder

292.0 (___.__) Sedative, Hypnotic, or Anxiolytic Withdrawalc, d (557)
(F13.239) Without perceptual disturbances
(F13.232) With perceptual disturbances

xxviii DSM-5 Classification

___.__ (___.__) Other Sedative-, Hypnotic-, or Anxiolytic-Induced Disorders
(560)

292.9 (F13.99) Unspecified Sedative-, Hypnotic-, or Anxiolytic-Related Disorder
(560)

Stimulant-Related Disorders (561)

___.__ (___.__) Stimulant Use Disordera, b (561)
Specify current severity:

___.__ (___.__) Mild
305.70 (F15.10) Amphetamine-type substance
305.60 (F14.10) Cocaine
305.70 (F15.10) Other or unspecified stimulant
___.__ (___.__) Moderate
304.40 (F15.20) Amphetamine-type substance
304.20 (F14.20) Cocaine
304.40 (F15.20) Other or unspecified stimulant
___.__ (___.__) Severe
304.40 (F15.20) Amphetamine-type substance
304.20 (F14.20) Cocaine
304.40 (F15.20) Other or unspecified stimulant

292.89 (___.__) Stimulant Intoxicationc (567)
Specify the specific intoxicant

292.89 (___.__) Amphetamine or other stimulant, Without perceptual
disturbances

(F15.129) With use disorder, mild
(F15.229) With use disorder, moderate or severe
(F15.929) Without use disorder

292.89 (___.__) Cocaine, Without perceptual disturbances
(F14.129) With use disorder, mild
(F14.229) With use disorder, moderate or severe
(F14.929) Without use disorder

292.89 (___.__) Amphetamine or other stimulant, With perceptual
disturbances

(F15.122) With use disorder, mild
(F15.222) With use disorder, moderate or severe
(F15.922) Without use disorder

292.89 (___.__) Cocaine, With perceptual disturbances
(F14.122) With use disorder, mild
(F14.222) With use disorder, moderate or severe
(F14.922) Without use disorder

292.0 (___.__) Stimulant Withdrawald (569)
Specify the specific substance causing the withdrawal syndrome

(F15.23) Amphetamine or other stimulant
(F14.23) Cocaine

___.__ (___.__) Other Stimulant-Induced Disorders (570)

DSM-5 Classification xxix

292.9 (___.__) Unspecified Stimulant-Related Disorder (570)
(F15.99) Amphetamine or other stimulant
(F14.99) Cocaine

Tobacco-Related Disorders (571)

___.__ (___.__) Tobacco Use Disordera (571)
Specify if: On maintenance therapy, In a controlled environment
Specify current severity:

305.1 (Z72.0) Mild
305.1 (F17.200) Moderate
305.1 (F17.200) Severe

292.0 (F17.203) Tobacco Withdrawald (575)

___.__ (___.__) Other Tobacco-Induced Disorders (576)

292.9 (F17.209) Unspecified Tobacco-Related Disorder (577)

Other (or Unknown) Substance–Related Disorders (577)

___._ (___.__) Other (or Unknown) Substance Use Disordera, b (577)
Specify current severity:

305.90 (F19.10) Mild
304.90 (F19.20) Moderate
304.90 (F19.20) Severe

292.89 (___.__) Other (or Unknown) Substance Intoxication (581)
(F19.129) With use disorder, mild
(F19.229) With use disorder, moderate or severe
(F19.929) Without use disorder

292.0 (F19.239) Other (or Unknown) Substance Withdrawald (583)

___.__ (___.__) Other (or Unknown) Substance–Induced Disorders (584)

292.9 (F19.99) Unspecified Other (or Unknown) Substance–Related Disorder (585)

Non-Substance-Related Disorders (585)
312.31 (F63.0) Gambling Disordera (585)

Specify if: Episodic, Persistent
Specify current severity: Mild, Moderate, Severe

Neurocognitive Disorders (591)

___.__ (___.__) Delirium (596)
aNote: See the criteria set and corresponding recording procedures for

substance-specific codes and ICD-9-CM and ICD-10-CM coding.
Specify whether:

___.__ (___.__) Substance intoxication deliriuma

___.__ (___.__) Substance withdrawal deliriuma

292.81 (___.__) Medication-induced deliriuma

293.0 (F05) Delirium due to another medical condition

xxx DSM-5 Classification

293.0 (F05) Delirium due to multiple etiologies
Specify if: Acute, Persistent
Specify if: Hyperactive, Hypoactive, Mixed level of activity

780.09 (R41.0) Other Specified Delirium (602)

780.09 (R41.0) Unspecified Delirium (602)

Major and Mild Neurocognitive Disorders (602)
Specify whether due to: Alzheimer’s disease, Frontotemporal lobar degeneration, Lewy body

disease, Vascular disease, Traumatic brain injury, Substance/medication use, HIV infection,
Prion disease, Parkinson’s disease, Huntington’s disease, Another medical condition, Multi-
ple etiologies, Unspecified

aSpecify Without behavioral disturbance, With behavioral disturbance. For possible major neuro-
cognitive disorder and for mild neurocognitive disorder, behavioral disturbance cannot be coded but
should still be indicated in writing.

bSpecify current severity: Mild, Moderate, Severe. This specifier applies only to major neurocogni-
tive disorders (including probable and possible).

Note: As indicated for each subtype, an additional medical code is needed for probable major
neurocognitive disorder or major neurocognitive disorder. An additional medical code should
not be used for possible major neurocognitive disorder or mild neurocognitive disorder.

Major or Mild Neurocognitive Disorder Due to Alzheimer’s Disease (611)

___.__ (___.__) Probable Major Neurocognitive Disorder Due to Alzheimer’s
Diseaseb

Note: Code first 331.0 (G30.9) Alzheimer’s disease.
294.11 (F02.81) With behavioral disturbance
294.10 (F02.80) Without behavioral disturbance

331.9 (G31.9) Possible Major Neurocognitive Disorder Due to Alzheimer’s
Diseasea, b

331.83 (G31.84) Mild Neurocognitive Disorder Due to Alzheimer’s Diseasea

Major or Mild Frontotemporal Neurocognitive Disorder (614)

___.__ (___.__) Probable Major Neurocognitive Disorder Due to Frontotemporal
Lobar Degenerationb

Note: Code first 331.19 (G31.09) frontotemporal disease.
294.11 (F02.81) With behavioral disturbance
294.10 (F02.80) Without behavioral disturbance

331.9 (G31.9) Possible Major Neurocognitive Disorder Due to Frontotemporal
Lobar Degenerationa, b

331.83 (G31.84) Mild Neurocognitive Disorder Due to Frontotemporal Lobar
Degenerationa

Major or Mild Neurocognitive Disorder With Lewy Bodies (618)

___.__ (___.__) Probable Major Neurocognitive Disorder With Lewy Bodiesb

Note: Code first 331.82 (G31.83) Lewy body disease.
294.11 (F02.81) With behavioral disturbance
294.10 (F02.80) Without behavioral disturbance

DSM-5 Classification xxxi

331.9 (G31.9) Possible Major Neurocognitive Disorder With Lewy Bodiesa, b

331.83 (G31.84) Mild Neurocognitive Disorder With Lewy Bodiesa

Major or Mild Vascular Neurocognitive Disorder (621)

___.__ (___.__) Probable Major Vascular Neurocognitive Disorderb

Note: No additional medical code for vascular disease.
290.40 (F01.51) With behavioral disturbance
290.40 (F01.50) Without behavioral disturbance

331.9 (G31.9) Possible Major Vascular Neurocognitive Disordera, b

331.83 (G31.84) Mild Vascular Neurocognitive Disordera

Major or Mild Neurocognitive Disorder Due to Traumatic Brain Injury (624)

___.__ (___.__) Major Neurocognitive Disorder Due to Traumatic Brain Injuryb

Note: For ICD-9-CM, code first 907.0 late effect of intracranial injury without
skull fracture. For ICD-10-CM, code first S06.2X9S diffuse traumatic brain
injury with loss of consciousness of unspecified duration, sequela.

294.11 (F02.81) With behavioral disturbance
294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to Traumatic Brain Injurya

Substance/Medication-Induced Major or Mild Neurocognitive Disordera (627)
Note: No additional medical code. See the criteria set and corresponding recording procedures
for substance-specific codes and ICD-9-CM and ICD-10-CM coding.
Specify if: Persistent

Major or Mild Neurocognitive Disorder Due to HIV Infection (632)

___.__ (___.__) Major Neurocognitive Disorder Due to HIV Infectionb

Note: Code first 042 (B20) HIV infection.
294.11 (F02.81) With behavioral disturbance
294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to HIV Infectiona

Major or Mild Neurocognitive Disorder Due to Prion Disease (634)

___.__ (___.__) Major Neurocognitive Disorder Due to Prion Diseaseb

Note: Code first 046.79 (A81.9) prion disease.
294.11 (F02.81) With behavioral disturbance
294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to Prion Diseasea

Major or Mild Neurocognitive Disorder Due to Parkinson’s Disease (636)

___.__ (___.__) Major Neurocognitive Disorder Probably Due to Parkinson’s
Diseaseb

Note: Code first 332.0 (G20) Parkinson’s disease.
294.11 (F02.81) With behavioral disturbance
294.10 (F02.80) Without behavioral disturbance

xxxii DSM-5 Classification

331.9 (G31.9) Major Neurocognitive Disorder Possibly Due to Parkinson’s
Diseasea, b

331.83 (G31.84) Mild Neurocognitive Disorder Due to Parkinson’s Diseasea

Major or Mild Neurocognitive Disorder Due to Huntington’s Disease (638)

___.__ (___.__) Major Neurocognitive Disorder Due to Huntington’s Diseaseb

Note: Code first 333.4 (G10) Huntington’s disease.
294.11 (F02.81) With behavioral disturbance
294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to Huntington’s Diseasea

Major or Mild Neurocognitive Disorder Due to Another Medical Condition (641)

___.__ (___.__) Major Neurocognitive Disorder Due to Another Medical
Conditionb

Note: Code first the other medical condition.
294.11 (F02.81) With behavioral disturbance
294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to Another Medical
Conditiona

Major or Mild Neurocognitive Disorder Due to Multiple Etiologies (642)

___.__ (___.__) Major Neurocognitive Disorder Due to Multiple Etiologiesb

Note: Code first all the etiological medical conditions (with the exception
of vascular disease).

294.11 (F02.81) With behavioral disturbance
294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to Multiple Etiologiesa

Unspecified Neurocognitive Disorder (643)

799.59 (R41.9) Unspecified Neurocognitive Disordera

Personality Disorders (645)

Cluster A Personality Disorders
301.0 (F60.0) Paranoid Personality Disorder (649)

301.20 (F60.1) Schizoid Personality Disorder (652)

301.22 (F21) Schizotypal Personality Disorder (655)

Cluster B Personality Disorders
301.7 (F60.2) Antisocial Personality Disorder (659)

301.83 (F60.3) Borderline Personality Disorder (663)

301.50 (F60.4) Histrionic Personality Disorder (667)

301.81 (F60.81) Narcissistic Personality Disorder (669)

DSM-5 Classification xxxiii

Cluster C Personality Disorders
301.82 (F60.6) Avoidant Personality Disorder (672)

301.6 (F60.7) Dependent Personality Disorder (675)

301.4 (F60.5) Obsessive-Compulsive Personality Disorder (678)

Other Personality Disorders
310.1 (F07.0) Personality Change Due to Another Medical Condition (682)

Specify whether: Labile type, Disinhibited type, Aggressive type, Apathetic
type, Paranoid type, Other type, Combined type, Unspecified type

301.89 (F60.89) Other Specified Personality Disorder (684)

301.9 (F60.9) Unspecified Personality Disorder (684)

Paraphilic Disorders (685)
The following specifier applies to Paraphilic Disorders where indicated:
aSpecify if: In a controlled environment, In full remission

302.82 (F65.3) Voyeuristic Disordera (686)

302.4 (F65.2) Exhibitionistic Disordera (689)
Specify whether: Sexually aroused by exposing genitals to prepubertal

children, Sexually aroused by exposing genitals to physically mature
individuals, Sexually aroused by exposing genitals to prepubertal chil-
dren and to physically mature individuals

302.89 (F65.81) Frotteuristic Disordera (691)

302.83 (F65.51) Sexual Masochism Disordera (694)
Specify if: With asphyxiophilia

302.84 (F65.52) Sexual Sadism Disordera (695)

302.2 (F65.4) Pedophilic Disorder (697)
Specify whether: Exclusive type, Nonexclusive type
Specify if: Sexually attracted to males, Sexually attracted to females, Sexu-

ally attracted to both
Specify if: Limited to incest

302.81 (F65.0) Fetishistic Disordera (700)
Specify: Body part(s), Nonliving object(s), Other

302.3 (F65.1) Transvestic Disordera (702)
Specify if: With fetishism, With autogynephilia

302.89 (F65.89) Other Specified Paraphilic Disorder (705)

302.9 (F65.9) Unspecified Paraphilic Disorder (705)

Other Mental Disorders (707)

294.8 (F06.8) Other Specified Mental Disorder Due to Another Medical
Condition (707)

294.9 (F09) Unspecified Mental Disorder Due to Another Medical Condition
(708)

300.9 (F99) Other Specified Mental Disorder (708)

300.9 (F99) Unspecified Mental Disorder (708)

xxxiv DSM-5 Classification

Medication-Induced Movement Disorders and
Other Adverse Effects of Medication (709)

332.1 (G21.11) Neuroleptic-Induced Parkinsonism (709)

332.1 (G21.19) Other Medication-Induced Parkinsonism (709)

333.92 (G21.0) Neuroleptic Malignant Syndrome (709)

333.72 (G24.02) Medication-Induced Acute Dystonia (711)

333.99 (G25.71) Medication-Induced Acute Akathisia (711)

333.85 (G24.01) Tardive Dyskinesia (712)

333.72 (G24.09) Tardive Dystonia (712)

333.99 (G25.71) Tardive Akathisia (712)

333.1 (G25.1) Medication-Induced Postural Tremor (712)

333.99 (G25.79) Other Medication-Induced Movement Disorder (712)

___.__ (___.__) Antidepressant Discontinuation Syndrome (712)
995.29 (T43.205A) Initial encounter
995.29 (T43.205D) Subsequent encounter
995.29 (T43.205S) Sequelae

___.__ (___.__) Other Adverse Effect of Medication (714)
995.20 (T50.905A) Initial encounter
995.20 (T50.905D) Subsequent encounter
995.20 (T50.905S) Sequelae

Other Conditions That May Be a Focus
of Clinical Attention (715)

Relational Problems (715)

Problems Related to Family Upbringing (715)

V61.20 (Z62.820) Parent-Child Relational Problem (715)

V61.8 (Z62.891) Sibling Relational Problem (716)

V61.8 (Z62.29) Upbringing Away From Parents (716)

V61.29 (Z62.898) Child Affected by Parental Relationship Distress (716)

Other Problems Related to Primary Support Group (716)

V61.10 (Z63.0) Relationship Distress With Spouse or Intimate Partner (716)

V61.03 (Z63.5) Disruption of Family by Separation or Divorce (716)

V61.8 (Z63.8) High Expressed Emotion Level Within Family (716)

V62.82 (Z63.4) Uncomplicated Bereavement (716)

DSM-5 Classification xxxv

Abuse and Neglect (717)

Child Maltreatment and Neglect Problems (717)

Child Physical Abuse (717)

Child Physical Abuse, Confirmed (717)
995.54 (T74.12XA) Initial encounter
995.54 (T74.12XD) Subsequent encounter

Child Physical Abuse, Suspected (717)
995.54 (T76.12XA) Initial encounter
995.54 (T76.12XD) Subsequent encounter

Other Circumstances Related to Child Physical Abuse (718)
V61.21 (Z69.010) Encounter for mental health services for victim of child abuse

by parent
V61.21 (Z69.020) Encounter for mental health services for victim of nonparental

child abuse
V15.41 (Z62.810) Personal history (past history) of physical abuse in childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental

child abuse
V62.83 (Z69.021) Encounter for mental health services for perpetrator of

nonparental child abuse

Child Sexual Abuse (718)
Child Sexual Abuse, Confirmed (718)
995.53 (T74.22XA) Initial encounter
995.53 (T74.22XD) Subsequent encounter

Child Sexual Abuse, Suspected (718)
995.53 (T76.22XA) Initial encounter
995.53 (T76.22XD) Subsequent encounter

Other Circumstances Related to Child Sexual Abuse (718)
V61.21 (Z69.010) Encounter for mental health services for victim of child sexual

abuse by parent
V61.21 (Z69.020) Encounter for mental health services for victim of nonparental

child sexual abuse
V15.41 (Z62.810) Personal history (past history) of sexual abuse in childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental

child sexual abuse
V62.83 (Z69.021) Encounter for mental health services for perpetrator of

nonparental child sexual abuse

Child Neglect (718)
Child Neglect, Confirmed (718)
995.52 (T74.02XA) Initial encounter
995.52 (T74.02XD) Subsequent encounter

xxxvi DSM-5 Classification

Child Neglect, Suspected (719)
995.52 (T76.02XA) Initial encounter
995.52 (T76.02XD) Subsequent encounter

Other Circumstances Related to Child Neglect (719)
V61.21 (Z69.010) Encounter for mental health services for victim of child neglect

by parent
V61.21 (Z69.020) Encounter for mental health services for victim of nonparental

child neglect
V15.42 (Z62.812) Personal history (past history) of neglect in childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental

child neglect
V62.83 (Z69.021) Encounter for mental health services for perpetrator of

nonparental child neglect

Child Psychological Abuse (719)

Child Psychological Abuse, Confirmed (719)
995.51 (T74.32XA) Initial encounter
995.51 (T74.32XD) Subsequent encounter

Child Psychological Abuse, Suspected (719)
995.51 (T76.32XA) Initial encounter
995.51 (T76.32XD) Subsequent encounter

Other Circumstances Related to Child Psychological Abuse (719)
V61.21 (Z69.010) Encounter for mental health services for victim of child

psychological abuse by parent
V61.21 (Z69.020) Encounter for mental health services for victim of nonparental

child psychological abuse
V15.42 (Z62.811) Personal history (past history) of psychological abuse in

childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental

child psychological abuse
V62.83 (Z69.021) Encounter for mental health services for perpetrator of

nonparental child psychological abuse

Adult Maltreatment and Neglect Problems (720)

Spouse or Partner Violence, Physical (720)

Spouse or Partner Violence, Physical, Confirmed (720)
995.81 (T74.11XA) Initial encounter
995.81 (T74.11XD) Subsequent encounter

Spouse or Partner Violence, Physical, Suspected (720)
995.81 (T76.11XA) Initial encounter
995.81 (T76.11XD) Subsequent encounter

Other Circumstances Related to Spouse or Partner Violence, Physical (720)
V61.11 (Z69.11) Encounter for mental health services for victim of spouse or

partner violence, physical

DSM-5 Classification xxxvii

V15.41 (Z91.410) Personal history (past history) of spouse or partner violence,
physical

V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse
or partner violence, physical

Spouse or Partner Violence, Sexual (720)

Spouse or Partner Violence, Sexual, Confirmed (720)
995.83 (T74.21XA) Initial encounter
995.83 (T74.21XD) Subsequent encounter

Spouse or Partner Violence, Sexual, Suspected (720)
995.83 (T76.21XA) Initial encounter
995.83 (T76.21XD) Subsequent encounter

Other Circumstances Related to Spouse or Partner Violence, Sexual (720)
V61.11 (Z69.81) Encounter for mental health services for victim of spouse or

partner violence, sexual
V15.41 (Z91.410) Personal history (past history) of spouse or partner violence,

sexual
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse

or partner violence, sexual

Spouse or Partner, Neglect (721)

Spouse or Partner Neglect, Confirmed (721)
995.85 (T74.01XA) Initial encounter
995.85 (T74.01XD) Subsequent encounter

Spouse or Partner Neglect, Suspected (721)
995.85 (T76.01XA) Initial encounter
995.85 (T76.01XD) Subsequent encounter

Other Circumstances Related to Spouse or Partner Neglect (721)
V61.11 (Z69.11) Encounter for mental health services for victim of spouse or

partner neglect
V15.42 (Z91.412) Personal history (past history) of spouse or partner neglect
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse

or partner neglect

Spouse or Partner Abuse, Psychological (721)

Spouse or Partner Abuse, Psychological, Confirmed (721)
995.82 (T74.31XA) Initial encounter
995.82 (T74.31XD) Subsequent encounter

Spouse or Partner Abuse, Psychological, Suspected (721)
995.82 (T76.31XA) Initial encounter
995.82 (T76.31XD) Subsequent encounter

Other Circumstances Related to Spouse or Partner Abuse, Psychological (721)
V61.11 (Z69.11) Encounter for mental health services for victim of spouse or

partner psychological abuse

xxxviii DSM-5 Classification

V15.42 (Z91.411) Personal history (past history) of spouse or partner
psychological abuse

V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse
or partner psychological abuse

Adult Abuse by Nonspouse or Nonpartner (722)

Adult Physical Abuse by Nonspouse or Nonpartner, Confirmed (722)
995.81 (T74.11XA) Initial encounter
995.81 (T74.11XD) Subsequent encounter

Adult Physical Abuse by Nonspouse or Nonpartner, Suspected (722)
995.81 (T76.11XA) Initial encounter
995.81 (T76.11XD) Subsequent encounter

Adult Sexual Abuse by Nonspouse or Nonpartner, Confirmed (722)
995.83 (T74.21XA) Initial encounter
995.83 (T74.21XD) Subsequent encounter

Adult Sexual Abuse by Nonspouse or Nonpartner, Suspected (722)
995.83 (T76.21XA) Initial encounter
995.83 (T76.21XD) Subsequent encounter

Adult Psychological Abuse by Nonspouse or Nonpartner, Confirmed (722)
995.82 (T74.31XA) Initial encounter
995.82 (T74.31XD) Subsequent encounter

Adult Psychological Abuse by Nonspouse or Nonpartner, Suspected (722)
995.82 (T76.31XA) Initial encounter
995.82 (T76.31XD) Subsequent encounter

Other Circumstances Related to Adult Abuse by Nonspouse or Nonpartner (722)
V65.49 (Z69.81) Encounter for mental health services for victim of nonspousal

adult abuse
V62.83 (Z69.82) Encounter for mental health services for perpetrator of

nonspousal adult abuse

Educational and Occupational Problems (723)

Educational Problems (723)

V62.3 (Z55.9) Academic or Educational Problem (723)

Occupational Problems (723)

V62.21 (Z56.82) Problem Related to Current Military Deployment Status (723)

V62.29 (Z56.9) Other Problem Related to Employment (723)

Housing and Economic Problems (723)

Housing Problems (723)

V60.0 (Z59.0) Homelessness (723)

V60.1 (Z59.1) Inadequate Housing (723)

DSM-5 Classification xxxix

V60.89 (Z59.2) Discord With Neighbor, Lodger, or Landlord (723)

V60.6 (Z59.3) Problem Related to Living in a Residential Institution (724)

Economic Problems (724)

V60.2 (Z59.4) Lack of Adequate Food or Safe Drinking Water (724)

V60.2 (Z59.5) Extreme Poverty (724)

V60.2 (Z59.6) Low Income (724)

V60.2 (Z59.7) Insufficient Social Insurance or Welfare Support (724)

V60.9 (Z59.9) Unspecified Housing or Economic Problem (724)

Other Problems Related to the Social Environment (724)
V62.89 (Z60.0) Phase of Life Problem (724)

V60.3 (Z60.2) Problem Related to Living Alone (724)

V62.4 (Z60.3) Acculturation Difficulty (724)

V62.4 (Z60.4) Social Exclusion or Rejection (724)

V62.4 (Z60.5) Target of (Perceived) Adverse Discrimination or Persecution (724)

V62.9 (Z60.9) Unspecified Problem Related to Social Environment (725)

Problems Related to Crime or Interaction With the Legal System (725)
V62.89 (Z65.4) Victim of Crime (725)

V62.5 (Z65.0) Conviction in Civil or Criminal Proceedings Without
Imprisonment (725)

V62.5 (Z65.1) Imprisonment or Other Incarceration (725)

V62.5 (Z65.2) Problems Related to Release From Prison (725)

V62.5 (Z65.3) Problems Related to Other Legal Circumstances (725)

Other Health Service Encounters for Counseling and Medical Advice (725)
V65.49 (Z70.9) Sex Counseling (725)

V65.40 (Z71.9) Other Counseling or Consultation (725)

Problems Related to Other Psychosocial, Personal, and Environmental
Circumstances (725)
V62.89 (Z65.8) Religious or Spiritual Problem (725)

V61.7 (Z64.0) Problems Related to Unwanted Pregnancy (725)

V61.5 (Z64.1) Problems Related to Multiparity (725)

V62.89 (Z64.4) Discord With Social Service Provider, Including Probation
Officer, Case Manager, or Social Services Worker (725)

V62.89 (Z65.4) Victim of Terrorism or Torture (725)

V62.22 (Z65.5) Exposure to Disaster, War, or Other Hostilities (725)

V62.89 (Z65.8) Other Problem Related to Psychosocial Circumstances (725)

V62.9 (Z65.9) Unspecified Problem Related to Unspecified Psychosocial
Circumstances (725)

xl DSM-5 Classification

Other Circumstances of Personal History (726)
V15.49 (Z91.49) Other Personal History of Psychological Trauma (726)

V15.59 (Z91.5) Personal History of Self-Harm (726)

V62.22 (Z91.82) Personal History of Military Deployment (726)

V15.89 (Z91.89) Other Personal Risk Factors (726)

V69.9 (Z72.9) Problem Related to Lifestyle (726)

V71.01 (Z72.811) Adult Antisocial Behavior (726)

V71.02 (Z72.810) Child or Adolescent Antisocial Behavior (726)

Problems Related to Access to Medical and Other Health Care (726)

V63.9 (Z75.3) Unavailability or Inaccessibility of Health Care Facilities (726)

V63.8 (Z75.4) Unavailability or Inaccessibility of Other Helping Agencies (726)

Nonadherence to Medical Treatment (726)

V15.81 (Z91.19) Nonadherence to Medical Treatment (726)

278.00 (E66.9) Overweight or Obesity (726)

V65.2 (Z76.5) Malingering (726)

V40.31 (Z91.83) Wandering Associated With a Mental Disorder (727)

V62.89 (R41.83) Borderline Intellectual Functioning (727)

xli

Preface

The American Psychiatric Association’s Diagnostic and Statistical Manual of
Mental Disorders (DSM) is a classification of mental disorders with associated criteria de-
signed to facilitate more reliable diagnoses of these disorders. With successive editions
over the past 60 years, it has become a standard reference for clinical practice in the mental
health field. Since a complete description of the underlying pathological processes is not
possible for most mental disorders, it is important to emphasize that the current diagnos-
tic criteria are the best available description of how mental disorders are expressed and
can be recognized by trained clinicians. DSM is intended to serve as a practical, functional,
and flexible guide for organizing information that can aid in the accurate diagnosis and
treatment of mental disorders. It is a tool for clinicians, an essential educational resource
for students and practitioners, and a reference for researchers in the field.

Although this edition of DSM was designed first and foremost to be a useful guide to
clinical practice, as an official nomenclature it must be applicable in a wide diversity of
contexts. DSM has been used by clinicians and researchers from different orientations (bi-
ological, psychodynamic, cognitive, behavioral, interpersonal, family/systems), all of
whom strive for a common language to communicate the essential characteristics of men-
tal disorders presented by their patients. The information is of value to all professionals
associated with various aspects of mental health care, including psychiatrists, other
physicians, psychologists, social workers, nurses, counselors, forensic and legal special-
ists, occupational and rehabilitation therapists, and other health professionals. The criteria
are concise and explicit and intended to facilitate an objective assessment of symptom pre-
sentations in a variety of clinical settings—inpatient, outpatient, partial hospital, consul-
tation-liaison, clinical, private practice, and primary care—as well in general community
epidemiological studies of mental disorders. DSM-5 is also a tool for collecting and com-
municating accurate public health statistics on mental disorder morbidity and mortality
rates. Finally, the criteria and corresponding text serve as a textbook for students early in
their profession who need a structured way to understand and diagnose mental disorders
as well as for seasoned professionals encountering rare disorders for the first time. Fortu-
nately, all of these uses are mutually compatible.

These diverse needs and interests were taken into consideration in planning DSM-5.
The classification of disorders is harmonized with the World Health Organization’s Inter-
national Classification of Diseases (ICD), the official coding system used in the United States,
so that the DSM criteria define disorders identified by ICD diagnostic names and code
numbers. In DSM-5, both ICD-9-CM and ICD-10-CM codes (the latter scheduled for adop-
tion in October 2014) are attached to the relevant disorders in the classification.

Although DSM-5 remains a categorical classification of separate disorders, we recog-
nize that mental disorders do not always fit completely within the boundaries of a single
disorder. Some symptom domains, such as depression and anxiety, involve multiple di-
agnostic categories and may reflect common underlying vulnerabilities for a larger group
of disorders. In recognition of this reality, the disorders included in DSM-5 were reordered
into a revised organizational structure meant to stimulate new clinical perspectives. This
new structure corresponds with the organizational arrangement of disorders planned for
ICD-11 scheduled for release in 2015. Other enhancements have been introduced to pro-
mote ease of use across all settings:

xlii Preface

• Representation of developmental issues related to diagnosis. The change in chapter
organization better reflects a lifespan approach, with disorders more frequently diag-
nosed in childhood (e.g., neurodevelopmental disorders) at the beginning of the man-
ual and disorders more applicable to older adulthood (e.g., neurocognitive disorders)
at the end of the manual. Also, within the text, subheadings on development and course
provide descriptions of how disorder presentations may change across the lifespan.
Age-related factors specific to diagnosis (e.g., symptom presentation and prevalence
differences in certain age groups) are also included in the text. For added emphasis,
these age-related factors have been added to the criteria themselves where applicable
(e.g., in the criteria sets for insomnia disorder and posttraumatic stress disorder, spe-
cific criteria describe how symptoms might be expressed in children). Likewise, gender
and cultural issues have been integrated into the disorders where applicable.

• Integration of scientific findings from the latest research in genetics and neuroimag-
ing. The revised chapter structure was informed by recent research in neuroscience and
by emerging genetic linkages between diagnostic groups. Genetic and physiological
risk factors, prognostic indicators, and some putative diagnostic markers are high-
lighted in the text. This new structure should improve clinicians’ ability to identify di-
agnoses in a disorder spectrum based on common neurocircuitry, genetic vulnerability,
and environmental exposures.

• Consolidation of autistic disorder, Asperger’s disorder, and pervasive developmen-
tal disorder into autism spectrum disorder. Symptoms of these disorders represent a
single continuum of mild to severe impairments in the two domains of social commu-
nication and restrictive repetitive behaviors/interests rather than being distinct disor-
ders. This change is designed to improve the sensitivity and specificity of the criteria for
the diagnosis of autism spectrum disorder and to identify more focused treatment tar-
gets for the specific impairments identified.

• Streamlined classification of bipolar and depressive disorders. Bipolar and depres-
sive disorders are the most commonly diagnosed conditions in psychiatry. It was there-
fore important to streamline the presentation of these disorders to enhance both clinical
and educational use. Rather than separating the definition of manic, hypomanic, and
major depressive episodes from the definition of bipolar I disorder, bipolar II disorder,
and major depressive disorder as in the previous edition, we included all of the com-
ponent criteria within the respective criteria for each disorder. This approach will facil-
itate bedside diagnosis and treatment of these important disorders. Likewise, the
explanatory notes for differentiating bereavement and major depressive disorders will
provide far greater clinical guidance than was previously provided in the simple be-
reavement exclusion criterion. The new specifiers of anxious distress and mixed fea-
tures are now fully described in the narrative on specifier variations that accompanies
the criteria for these disorders.

• Restructuring of substance use disorders for consistency and clarity. The categories
of substance abuse and substance dependence have been eliminated and replaced with
an overarching new category of substance use disorders—with the specific substance
used defining the specific disorders. “Dependence” has been easily confused with the
term “addiction” when, in fact, the tolerance and withdrawal that previously defined
dependence are actually very normal responses to prescribed medications that affect
the central nervous system and do not necessarily indicate the presence of an addiction.
By revising and clarifying these criteria in DSM-5, we hope to alleviate some of the
widespread misunderstanding about these issues.

• Enhanced specificity for major and mild neurocognitive disorders. Given the explo-
sion in neuroscience, neuropsychology, and brain imaging over the past 20 years, it was
critical to convey the current state-of-the-art in the diagnosis of specific types of disor-
ders that were previously referred to as the “dementias” or organic brain diseases. Bi-
ological markers identified by imaging for vascular and traumatic brain disorders and

Preface xliii

specific molecular genetic findings for rare variants of Alzheimer’s disease and Hun-
tington’s disease have greatly advanced clinical diagnoses, and these disorders and
others have now been separated into specific subtypes.

• Transition in conceptualizing personality disorders. Although the benefits of a more
dimensional approach to personality disorders have been identified in previous edi-
tions, the transition from a categorical diagnostic system of individual disorders to one
based on the relative distribution of personality traits has not been widely accepted. In
DSM-5, the categorical personality disorders are virtually unchanged from the previous
edition. However, an alternative “hybrid” model has been proposed in Section III to
guide future research that separates interpersonal functioning assessments and the ex-
pression of pathological personality traits for six specific disorders. A more dimensional
profile of personality trait expression is also proposed for a trait-specified approach.

• Section III: new disorders and features. A new section (Section III) has been added to
highlight disorders that require further study but are not sufficiently well established to
be a part of the official classification of mental disorders for routine clinical use. Dimen-
sional measures of symptom severity in 13 symptom domains have also been incorpo-
rated to allow for the measurement of symptom levels of varying severity across all
diagnostic groups. Likewise, the WHO Disability Assessment Schedule (WHODAS), a
standard method for assessing global disability levels for mental disorders that is based
on the International Classification of Functioning, Disability and Health (ICF) and is ap-
plicable in all of medicine, has been provided to replace the more limited Global As-
sessment of Functioning scale. It is our hope that as these measures are implemented
over time, they will provide greater accuracy and flexibility in the clinical description of
individual symptomatic presentations and associated disability during diagnostic as-
sessments.

• Online enhancements. DSM-5 features online supplemental information.
Additional cross-cutting and diagnostic severity measures are available online
(www.psychiatry.org/dsm5), linked to the relevant disorders. In addition, the Cul-
tural Formulation Interview, Cultural Formulation Interview—Informant Version, and
supplementary modules to the core Cultural Formulation Interview are also included
online at www.psychiatry.org/dsm5.

These innovations were designed by the leading authorities on mental disorders in the
world and were implemented on the basis of their expert review, public commentary, and
independent peer review. The 13 work groups, under the direction of the DSM-5 Task
Force, in conjunction with other review bodies and, eventually, the APA Board of Trust-
ees, collectively represent the global expertise of the specialty. This effort was supported
by an extensive base of advisors and by the professional staff of the APA Division of Re-
search; the names of everyone involved are too numerous to mention here but are listed in
the Appendix. We owe tremendous thanks to those who devoted countless hours and in-
valuable expertise to this effort to improve the diagnosis of mental disorders.

We would especially like to acknowledge the chairs, text coordinators, and members of
the 13 work groups, listed in the front of the manual, who spent many hours in this vol-
unteer effort to improve the scientific basis of clinical practice over a sustained 6-year pe-
riod. Susan K. Schultz, M.D., who served as text editor, worked tirelessly with Emily A.
Kuhl, Ph.D., senior science writer and DSM-5 staff text editor, to coordinate the efforts of
the work groups into a cohesive whole. William E. Narrow, M.D., M.P.H., led the research
group that developed the overall research strategy for DSM-5, including the field trials,
that greatly enhanced the evidence base for this revision. In addition, we are grateful to
those who contributed so much time to the independent review of the revision proposals,
including Kenneth S. Kendler, M.D., and Robert Freedman, M.D., co-chairs of the Scien-
tific Review Committee; John S. McIntyre, M.D., and Joel Yager, M.D., co-chairs of the
Clinical and Public Health Committee; and Glenn Martin, M.D., chair of the APA Assem-

xliv Preface

bly review process. Special thanks go to Helena C. Kraemer, Ph.D., for her expert statistical
consultation; Michael B. First, M.D., for his valuable input on the coding and review of cri-
teria; and Paul S. Appelbaum, M.D., for feedback on forensic issues. Maria N. Ward,
M.Ed., RHIT, CCS-P, also helped in verifying all ICD coding. The Summit Group, which
included these consultants, the chairs of all review groups, the task force chairs, and the
APA executive officers, chaired by Dilip V. Jeste, M.D., provided leadership and vision in
helping to achieve compromise and consensus. This level of commitment has contributed
to the balance and objectivity that we feel are hallmarks of DSM-5.

We especially wish to recognize the outstanding APA Division of Research staff—
identified in the Task Force and Work Group listing at the front of this manual—who
worked tirelessly to interact with the task force, work groups, advisors, and reviewers to
resolve issues, serve as liaisons between the groups, direct and manage the academic and
routine clinical practice field trials, and record decisions in this important process. In par-
ticular, we appreciate the support and guidance provided by James H. Scully Jr., M.D.,
Medical Director and CEO of the APA, through the years and travails of the development
process. Finally, we thank the editorial and production staff of American Psychiatric Pub-
lishing—specifically, Rebecca Rinehart, Publisher; John McDuffie, Editorial Director; Ann
Eng, Senior Editor; Greg Kuny, Managing Editor; and Tammy Cordova, Graphics Design
Manager—for their guidance in bringing this all together and creating the final product. It
is the culmination of efforts of many talented individuals who dedicated their time, exper-
tise, and passion that made DSM-5 possible.

David J. Kupfer, M.D.
DSM-5 Task Force Chair

Darrel A. Regier, M.D., M.P.H.
DSM-5 Task Force Vice-Chair

December 19, 2012

SECTION I
DSM-5 Basics

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Use of the Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Cautionary Statement for Forensic Use of DSM-5 . . . . . . . . . . . . . . . . . . 25

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This section is a basic orientation to the purpose, structure, content, and
use of DSM-5. It is not intended to provide an exhaustive account of the evo-
lution of DSM-5, but rather to give readers a succinct overview of its key ele-
ments. The introductory section describes the public, professional, and expert
review process that was used to extensively evaluate the diagnostic criteria
presented in Section II. A summary of the DSM-5 structure, harmonization with
ICD-11, and the transition to a non-axial system with a new approach to as-
sessing disability is also presented. “Use of the Manual” includes “Definition of
a Mental Disorder,” forensic considerations, and a brief overview of the diag-
nostic process and use of coding and recording procedures.

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5

Introduction

The creation of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) was a massive undertaking that involved hundreds of people working toward a
common goal over a 12-year process. Much thought and deliberation were involved in
evaluating the diagnostic criteria, considering the organization of every aspect of the man-
ual, and creating new features believed to be most useful to clinicians. All of these efforts
were directed toward the goal of enhancing the clinical usefulness of DSM-5 as a guide in
the diagnosis of mental disorders.

Reliable diagnoses are essential for guiding treatment recommendations, identifying
prevalence rates for mental health service planning, identifying patient groups for clinical
and basic research, and documenting important public health information such as mor-
bidity and mortality rates. As the understanding of mental disorders and their treatments
has evolved, medical, scientific, and clinical professionals have focused on the character-
istics of specific disorders and their implications for treatment and research.

While DSM has been the cornerstone of substantial progress in reliability, it has been well
recognized by both the American Psychiatric Association (APA) and the broad scientific com-
munity working on mental disorders that past science was not mature enough to yield fully
validated diagnoses—that is, to provide consistent, strong, and objective scientific validators
of individual DSM disorders. The science of mental disorders continues to evolve. However,
the last two decades since DSM-IV was released have seen real and durable progress in such
areas as cognitive neuroscience, brain imaging, epidemiology, and genetics. The DSM-5 Task
Force overseeing the new edition recognized that research advances will require careful, iter-
ative changes if DSM is to maintain its place as the touchstone classification of mental disor-
ders. Finding the right balance is critical. Speculative results do not belong in an official
nosology, but at the same time, DSM must evolve in the context of other clinical research ini-
tiatives in the field. One important aspect of this transition derives from the broad recognition
that a too-rigid categorical system does not capture clinical experience or important scientific
observations. The results of numerous studies of comorbidity and disease transmission in fam-
ilies, including twin studies and molecular genetic studies, make strong arguments for what
many astute clinicians have long observed: the boundaries between many disorder “catego-
ries” are more fluid over the life course than DSM-IV recognized, and many symptoms as-
signed to a single disorder may occur, at varying levels of severity, in many other disorders.
These findings mean that DSM, like other medical disease classifications, should accommo-
date ways to introduce dimensional approaches to mental disorders, including dimensions
that cut across current categories. Such an approach should permit a more accurate description
of patient presentations and increase the validity of a diagnosis (i.e., the degree to which diag-
nostic criteria reflect the comprehensive manifestation of an underlying psychopathological
disorder). DSM-5 is designed to better fill the need of clinicians, patients, families, and re-
searchers for a clear and concise description of each mental disorder organized by explicit di-
agnostic criteria, supplemented, when appropriate, by dimensional measures that cross
diagnostic boundaries, and a brief digest of information about the diagnosis, risk factors, as-
sociated features, research advances, and various expressions of the disorder.

Clinical training and experience are needed to use DSM for determining a diagnosis. The
diagnostic criteria identify symptoms, behaviors, cognitive functions, personality traits, phys-
ical signs, syndrome combinations, and durations that require clinical expertise to differenti-
ate from normal life variation and transient responses to stress. To facilitate a thorough

6 Introduction

examination of the range of symptoms present, DSM can serve clinicians as a guide to identify
the most prominent symptoms that should be assessed when diagnosing a disorder. Although
some mental disorders may have well-defined boundaries around symptom clusters, scien-
tific evidence now places many, if not most, disorders on a spectrum with closely related dis-
orders that have shared symptoms, shared genetic and environmental risk factors, and
possibly shared neural substrates (perhaps most strongly established for a subset of anxiety
disorders by neuroimaging and animal models). In short, we have come to recognize that the
boundaries between disorders are more porous than originally perceived.

Many health profession and educational groups have been involved in the development
and testing of DSM-5, including physicians, psychologists, social workers, nurses, counselors,
epidemiologists, statisticians, neuroscientists, and neuropsychologists. Finally, patients, fam-
ilies, lawyers, consumer organizations, and advocacy groups have all participated in revising
DSM-5 by providing feedback on the mental disorders described in this volume. Their moni-
toring of the descriptions and explanatory text is essential to improve understanding, reduce
stigma, and advance the treatment and eventual cures for these conditions.

A Brief History
The APA first published a predecessor of DSM in 1844, as a statistical classification of in-
stitutionalized mental patients. It was designed to improve communication about the
types of patients cared for in these hospitals. This forerunner to DSM also was used as a
component of the full U.S. census. After World War II, DSM evolved through four major
editions into a diagnostic classification system for psychiatrists, other physicians, and
other mental health professionals that described the essential features of the full range of
mental disorders. The current edition, DSM-5, builds on the goal of its predecessors (most
recently, DSM-IV-TR, or Text Revision, published in 2000) of providing guidelines for di-
agnoses that can inform treatment and management decisions.

DSM-5 Revision Process
In 1999, the APA launched an evaluation of the strengths and weaknesses of DSM based on
emerging research that did not support the boundaries established for some mental disor-
ders. This effort was coordinated with the World Health Organization (WHO) Division of
Mental Health, the World Psychiatric Association, and the National Institute of Mental
Health (NIMH) in the form of several conferences, the proceedings of which were published
in 2002 in a monograph entitled A Research Agenda for DSM-V. Thereafter, from 2003 to 2008,
a cooperative agreement with the APA and the WHO was supported by the NIMH, the Na-
tional Institute on Drug Abuse (NIDA), and the National Institute on Alcoholism and Alco-
hol Abuse (NIAAA) to convene 13 international DSM-5 research planning conferences,
involving 400 participants from 39 countries, to review the world literature in specific diag-
nostic areas to prepare for revisions in developing both DSM-5 and the International Classi-
fication of Diseases, 11th Revision (ICD-11). Reports from these conferences formed the basis
for future DSM-5 Task Force reviews and set the stage for the new edition of DSM.

In 2006, the APA named David J. Kupfer, M.D., as Chair and Darrel A. Regier, M.D.,
M.P.H., as Vice-Chair of the DSM-5 Task Force. They were charged with recommending
chairs for the 13 diagnostic work groups and additional task force members with a multi-
disciplinary range of expertise who would oversee the development of DSM-5. An addi-
tional vetting process was initiated by the APA Board of Trustees to disclose sources of
income and thus avoid conflicts of interest by task force and work group members. The full
disclosure of all income and research grants from commercial sources, including the phar-
maceutical industry, in the previous 3 years, the imposition of an income cap from all com-
mercial sources, and the publication of disclosures on a Web site set a new standard for the

Introduction 7

field. Thereafter, the task force of 28 members was approved in 2007, and appointments of
more than 130 work group members were approved in 2008. More than 400 additional
work group advisors with no voting authority were also approved to participate in the pro-
cess. A clear concept of the next evolutionary stage for the classification of mental disorders
was central to the efforts of the task force and the work groups. This vision emerged as the
task force and work groups recounted the history of DSM-IV’s classification, its current
strengths and limitations, and strategic directions for its revision. An intensive 6-year pro-
cess involved conducting literature reviews and secondary analyses, publishing research
reports in scientific journals, developing draft diagnostic criteria, posting preliminary
drafts on the DSM-5 Web site for public comment, presenting preliminary findings at pro-
fessional meetings, performing field trials, and revising criteria and text.

Proposals for Revisions
Proposals for the revision of DSM-5 diagnostic criteria were developed by members of the
work groups on the basis of rationale, scope of change, expected impact on clinical man-
agement and public health, strength of the supporting research evidence, overall clarity,
and clinical utility. Proposals encompassed changes to diagnostic criteria; the addition of
new disorders, subtypes, and specifiers; and the deletion of existing disorders.

In the proposals for revisions, strengths and weaknesses in the current criteria and no-
sology were first identified. Novel scientific findings over the previous two decades were
considered, leading to the creation of a research plan to assess potential changes through
literature reviews and secondary data analyses. Four principles guided the draft revisions:
1) DSM-5 is primarily intended to be a manual to be used by clinicians, and revisions must
be feasible for routine clinical practice; 2) recommendations for revisions should be guided
by research evidence; 3) where possible, continuity should be maintained with previous
editions of DSM; and 4) no a priori constraints should be placed on the degree of change
between DSM-IV and DSM-5.

Building on the initial literature reviews, work groups identified key issues within
their diagnostic areas. Work groups also examined broader methodological concerns,
such as the presence of contradictory findings within the literature; development of a re-
fined definition of mental disorder; cross-cutting issues relevant to all disorders; and the
revision of disorders categorized in DSM-IV as “not otherwise specified.” Inclusion of a
proposal for revision in Section II was informed by consideration of its advantages and
disadvantages for public health and clinical utility, the strength of the evidence, and the
magnitude of the change. New diagnoses and disorder subtypes and specifiers were sub-
ject to additional stipulations, such as demonstration of reliability (i.e., the degree to which
two clinicians could independently arrive at the same diagnosis for a given patient). Dis-
orders with low clinical utility and weak validity were considered for deletion. Placement
of conditions in “Conditions for Further Study” in Section III was contingent on the
amount of empirical evidence generated on the diagnosis, diagnostic reliability or valid-
ity, presence of clear clinical need, and potential benefit in advancing research.

DSM-5 Field Trials
The use of field trials to empirically demonstrate reliability was a noteworthy improvement in-
troduced in DSM-III. The design and implementation strategy of the DSM-5 Field Trials rep-
resent several changes over approaches used for DSM-III and DSM-IV, particularly in
obtaining data on the precision of kappa reliability estimates (a statistical measure that assesses
level of agreement between raters that corrects for chance agreement due to prevalence rates)
in the context of clinical settings with high levels of diagnostic comorbidity. For DSM-5, field
trials were extended by using two distinctive designs: one in large, diverse medical-academic
settings, and the other in routine clinical practices. The former capitalized on the need for large
sample sizes to test hypotheses on reliability and clinical utility of a range of diagnoses in a

8 Introduction

variety of patient populations; the latter supplied valuable information about how proposed
revisions performed in everyday clinical settings among a diverse sample of DSM users. It is
anticipated that future clinical and basic research studies will focus on the validity of the re-
vised categorical diagnostic criteria and the underlying dimensional features of these disor-
ders (including those now being explored by the NIMH Research Domain Criteria initiative).

The medical-academic field trials were conducted at 11 North American medical-academic
sites and assessed the reliability, feasibility, and clinical utility of select revisions, with priority
given to those that represented the greatest degree of change from DSM-IV or those potentially
having the greatest public health impact. The full clinical patient populations coming to each
site were screened for DSM-IV diagnoses or qualifying symptoms likely to predict several spe-
cific DSM-5 disorders of interest. Stratified samples of four to seven specific disorders, plus a
stratum containing a representative sample of all other diagnoses, were identified for each site.
Patients consented to the study and were randomly assigned for a clinical interview by a cli-
nician blind to the diagnosis, followed by a second interview with a clinician blind to previous
diagnoses. Patients first filled out a computer-assisted inventory of cross-cutting symptoms in
more than a dozen psychological domains. These inventories were scored by a central server,
and results were provided to clinicians before they conducted a typical clinical interview (with
no structured protocol). Clinicians were required to score the presence of qualifying criteria on
a computer-assisted DSM-5 diagnostic checklist, determine diagnoses, score the severity of the
diagnosis, and submit all data to the central Web-based server. This study design allowed the
calculation of the degree to which two independent clinicians could agree on a diagnosis (us-
ing the intraclass kappa statistic) and the agreement of a single patient or two different clini-
cians on two separate ratings of cross-cutting symptoms, personality traits, disability, and
diagnostic severity measures (using intraclass correlation coefficients) along with information
on the precision of these estimates of reliability. It was also possible to assess the prevalence
rates of both DSM-IV and DSM-5 conditions in the respective clinical populations.

The routine clinical practice field trials involved recruitment of individual psychiatrists
and other mental health clinicians. A volunteer sample was recruited that included gener-
alist and specialty psychiatrists, psychologists, licensed clinical social workers, counselors,
marriage and family therapists, and advanced practice psychiatric mental health nurses.
The field trials provided exposure of the proposed DSM-5 diagnoses and dimensional mea-
sures to a wide range of clinicians to assess their feasibility and clinical utility.

Public and Professional Review
In 2010, the APA launched a unique Web site to facilitate public and professional input into
DSM-5. All draft diagnostic criteria and proposed changes in organization were posted on
www.dsm5.org for a 2-month comment period. Feedback totaled more than 8,000 submis-
sions, which were systematically reviewed by each of the 13 work groups, whose members,
where appropriate, integrated questions and comments into discussions of draft revisions
and plans for field trial testing. After revisions to the initial draft criteria and proposed
chapter organization, a second posting occurred in 2011. Work groups considered feedback
from both Web postings and the results of the DSM-5 Field Trials when drafting proposed
final criteria, which were posted on the Web site for a third and final time in 2012. These
three iterations of external review produced more than 13,000 individually signed com-
ments on the Web site that were received and reviewed by the work groups, plus thousands
of organized petition signers for and against some proposed revisions, all of which allowed
the task force to actively address concerns of DSM users, as well as patients and advocacy
groups, and ensure that clinical utility remained a high priority.

Expert Review
The members of the 13 work groups, representing expertise in their respective areas, col-
laborated with advisors and reviewers under the overall direction of the DSM-5 Task

Introduction 9

Force to draft the diagnostic criteria and accompanying text. This effort was supported by
a team of APA Division of Research staff and developed through a network of text coor-
dinators from each work group. The preparation of the text was coordinated by the text
editor, working in close collaboration with the work groups and under the direction of the
task force chairs. The Scientific Review Committee (SRC) was established to provide a sci-
entific peer review process that was external to that of the work groups. The SRC chair,
vice-chair, and six committee members were charged with reviewing the degree to which
the proposed changes from DSM-IV could be supported with scientific evidence. Each
proposal for diagnostic revision required a memorandum of evidence for change pre-
pared by the work group and accompanied by a summary of supportive data organized
around validators for the proposed diagnostic criteria (i.e., antecedent validators such as
familial aggregation, concurrent validators such as biological markers, and prospective
validators such as response to treatment or course of illness). The submissions were re-
viewed by the SRC and scored according to the strength of the supportive scientific data.
Other justifications for change, such as those arising from clinical experience or need or
from a conceptual reframing of diagnostic categories, were generally seen as outside the
purview of the SRC. The reviewers’ scores, which varied substantially across the different
proposals, and an accompanying brief commentary were then returned to the APA Board
of Trustees and the work groups for consideration and response.

The Clinical and Public Health Committee (CPHC), composed of a chair, vice-chair, and
six members, was appointed to consider additional clinical utility, public health, and log-
ical clarification issues for criteria that had not yet accumulated the type or level of evi-
dence deemed sufficient for change by the SRC. This review process was particularly
important for DSM-IV disorders with known deficiencies for which proposed remedies
had neither been previously considered in the DSM revision process nor been subjected to
replicated research studies. These selected disorders were evaluated by four to five exter-
nal reviewers, and the blinded results were reviewed by CPHC members, who in turn
made recommendations to the APA Board of Trustees and the work groups.

Forensic reviews by the members of the APA Council on Psychiatry and Law were con-
ducted for disorders frequently appearing in forensic environments and ones with high
potential for influencing civil and criminal judgments in courtroom settings. Work groups
also added forensic experts as advisors in pertinent areas to complement expertise pro-
vided by the Council on Psychiatry and Law.

The work groups themselves were charged with the responsibility to review the entire re-
search literature surrounding a diagnostic area, including old, revised, and new diagnostic cri-
teria, in an intensive 6-year review process to assess the pros and cons of making either small
iterative changes or major conceptual changes to address the inevitable reification that occurs
with diagnostic conceptual approaches that persist over several decades. Such changes in-
cluded the merger of previously separate diagnostic areas into more dimensional spectra, such
as that which occurred with autism spectrum disorder, substance use disorders, sexual dys-
functions, and somatic symptom and related disorders. Other changes included correcting
flaws that had become apparent over time in the choice of operational criteria for some disor-
ders. These types of changes posed particular challenges to the SRC and CPHC review pro-
cesses, which were not constructed to evaluate the validity of DSM-IV diagnostic criteria.
However, the DSM-5 Task Force, which had reviewed proposed changes and had responsi-
bility for reviewing the text describing each disorder contemporaneously with the work
groups during this period, was in a unique position to render an informed judgment on the sci-
entific merits of such revisions. Furthermore, many of these major changes were subject to field
trial testing, although comprehensive testing of all proposed changes could not be accommo-
dated by such testing because of time limitations and availability of resources.

A final recommendation from the task force was then provided to the APA Board of
Trustees and the APA Assembly’s Committee on DSM-5 to consider some of the clinical
utility and feasibility features of the proposed revisions. The assembly is a deliberative

10 Introduction

body of the APA representing the district branches and wider membership that is com-
posed of psychiatrists from throughout the United States who provide geographic, prac-
tice size, and interest-based diversity. The Committee on DSM-5 is a committee made up
of a diverse group of assembly leaders.

Following all of the preceding review steps, an executive “summit committee” session
was held to consolidate input from review and assembly committee chairs, task force
chairs, a forensic advisor, and a statistical advisor, for a preliminary review of each disor-
der by the assembly and APA Board of Trustees executive committees. This preceded a
preliminary review by the full APA Board of Trustees. The assembly voted, in November
2012, to recommend that the board approve the publication of DSM-5, and the APA Board
of Trustees approved its publication in December 2012. The many experts, reviewers, and
advisors who contributed to this process are listed in the Appendix.

Organizational Structure
The individual disorder definitions that constitute the operationalized sets of diagnostic
criteria provide the core of DSM-5 for clinical and research purposes. These criteria have
been subjected to scientific review, albeit to varying degrees, and many disorders have un-
dergone field testing for interrater reliability. In contrast, the classification of disorders (the
way in which disorders are grouped, which provides a high-level organization for the man-
ual) has not generally been thought of as scientifically significant, despite the fact that judg-
ments had to be made when disorders were initially divided into chapters for DSM-III.

DSM is a medical classification of disorders and as such serves as a historically deter-
mined cognitive schema imposed on clinical and scientific information to increase its com-
prehensibility and utility. Not surprisingly, as the foundational science that ultimately led
to DSM-III has approached a half-century in age, challenges have begun to emerge for cli-
nicians and scientists alike that are inherent in the DSM structure rather than in the de-
scription of any single disorder. These challenges include high rates of comorbidity within
and across DSM chapters, an excessive use of and need to rely on “not otherwise specified”
(NOS) criteria, and a growing inability to integrate DSM disorders with the results of ge-
netic studies and other scientific findings.

As the APA and the WHO began to plan their respective revisions of the DSM and the
International Classification of Disorders (ICD), both considered the possibility of improving
clinical utility (e.g., by helping to explain apparent comorbidity) and facilitating scientific
investigation by rethinking the organizational structures of both publications in a linear
system designated by alphanumeric codes that sequence chapters according to some ra-
tional and relational structure. It was critical to both the DSM-5 Task Force and the WHO
International Advisory Group on the revision of the ICD-10 Section on Mental and Behav-
ioral Disorders that the revisions to the organization enhance clinical utility and remain
within the bounds of well-replicated scientific information. Although the need for reform
seemed apparent, it was important to respect the state of the science as well as the chal-
lenge that overly rapid change would pose for the clinical and research communities. In
that spirit, revision of the organization was approached as a conservative, evolutionary di-
agnostic reform that would be guided by emerging scientific evidence on the relationships
between disorder groups. By reordering and regrouping the existing disorders, the re-
vised structure is meant to stimulate new clinical perspectives and to encourage research-
ers to identify the psychological and physiological cross-cutting factors that are not bound
by strict categorical designations.

The use of DSM criteria has the clear virtue of creating a common language for com-
munication between clinicians about the diagnosis of disorders. The official criteria and
disorders that were determined to have accepted clinical applicability are located in Sec-
tion II of the manual. However, it should be noted that these diagnostic criteria and their

Introduction 11

relationships within the classification are based on current research and may need to be
modified as new evidence is gathered by future research both within and across the do-
mains of proposed disorders. “Conditions for Further Study,” described in Section III, are
those for which we determined that the scientific evidence is not yet available to support
widespread clinical use. These diagnostic criteria are included to highlight the evolution
and direction of scientific advances in these areas to stimulate further research.

With any ongoing review process, especially one of this complexity, different viewpoints
emerge, and an effort was made to consider various viewpoints and, when warranted, ac-
commodate them. For example, personality disorders are included in both Sections II and
III. Section II represents an update of the text associated with the same criteria found in
DSM-IV-TR, whereas Section III includes the proposed research model for personality dis-
order diagnosis and conceptualization developed by the DSM-5 Personality and Personality
Disorders Work Group. As this field evolves, it is hoped that both versions will serve clin-
ical practice and research initiatives.

Harmonization With ICD-11
The groups tasked with revising the DSM and ICD systems shared the overarching goal of
harmonizing the two classifications as much as possible, for the following reasons:

• The existence of two major classifications of mental disorders hinders the collection and
use of national health statistics, the design of clinical trials aimed at developing new
treatments, and the consideration of global applicability of the results by international
regulatory agencies.

• More broadly, the existence of two classifications complicates attempts to replicate sci-
entific results across national boundaries.

• Even when the intention was to identify identical patient populations, DSM-IV and
ICD-10 diagnoses did not always agree.

Early in the course of the revisions, it became apparent that a shared organizational
structure would help harmonize the classifications. In fact, the use of a shared framework
helped to integrate the work of DSM and ICD work groups and to focus on scientific is-
sues. The DSM-5 organization and the proposed linear structure of the ICD-11 have been
endorsed by the leadership of the NIMH Research Domain Criteria (RDoC) project as con-
sistent with the initial overall structure of that project.

Of course, principled disagreements on the classification of psychopathology and on
specific criteria for certain disorders were expected given the current state of scientific
knowledge. However, most of the salient differences between the DSM and the ICD classi-
fications do not reflect real scientific differences, but rather represent historical by-products
of independent committee processes.

To the surprise of participants in both revision processes, large sections of the content
fell relatively easily into place, reflecting real strengths in some areas of the scientific lit-
erature, such as epidemiology, analyses of comorbidity, twin studies, and certain other ge-
netically informed designs. When disparities emerged, they almost always reflected the
need to make a judgment about where to place a disorder in the face of incomplete—or,
more often, conflicting—data. Thus, for example, on the basis of patterns of symptoms, co-
morbidity, and shared risk factors, attention-deficit/hyperactivity disorder (ADHD) was
placed with neurodevelopmental disorders, but the same data also supported strong ar-
guments to place ADHD within disruptive, impulse-control, and conduct disorders.
These issues were settled with the preponderance of evidence (most notably validators ap-
proved by the DSM-5 Task Force). The work groups recognize, however, that future dis-
coveries might change the placement as well as the contours of individual disorders and,
furthermore, that the simple and linear organization that best supports clinical practice

12 Introduction

may not fully capture the complexity and heterogeneity of mental disorders. The revised
organization is coordinated with the mental and behavioral disorders chapter (Chapter V)
of ICD-11, which will utilize an expanded numeric–alphanumeric coding system. How-
ever, the official coding system in use in the United States at the time of publication of this
manual is that of the International Classification of Diseases, Ninth Revision, Clinical Modifica-
tion (ICD-9-CM)—the U.S. adaptation of ICD-9. International Classification of Diseases, Tenth
Revision, Clinical Modification (ICD-10-CM), adapted from ICD-10, is scheduled for imple-
mentation in the United States in October 2014. Given the impending release of ICD-11, it
was decided that this iteration, and not ICD-10, would be the most relevant on which to focus
harmonization. However, given that adoption of the ICD-9-CM coding system will remain
at the time of the DSM-5 release, it will be necessary to use the ICD-9-CM codes. Further-
more, given that DSM-5’s organizational structure reflects the anticipated structure of
ICD-11, the eventual ICD-11 codes will follow the sequential order of diagnoses in the
DSM-5 chapter structure more closely. At present, both the ICD-9-CM and the ICD-10-CM
codes have been indicated for each disorder. These codes will not be in sequential order
throughout the manual because they were assigned to complement earlier organizational
structures.

Dimensional Approach to Diagnosis
Structural problems rooted in the basic design of the previous DSM classification, con-
structed of a large number of narrow diagnostic categories, have emerged in both clinical
practice and research. Relevant evidence comes from diverse sources, including studies of
comorbidity and the substantial need for not otherwise specified diagnoses, which repre-
sent the majority of diagnoses in areas such as eating disorders, personality disorders, and
autism spectrum disorder. Studies of both genetic and environmental risk factors, whether
based on twin designs, familial transmission, or molecular analyses, also raise concerns
about the categorical structure of the DSM system. Because the previous DSM approach
considered each diagnosis as categorically separate from health and from other diagnoses,
it did not capture the widespread sharing of symptoms and risk factors across many dis-
orders that is apparent in studies of comorbidity. Earlier editions of DSM focused on ex-
cluding false-positive results from diagnoses; thus, its categories were overly narrow, as is
apparent from the widespread need to use NOS diagnoses. Indeed, the once plausible goal
of identifying homogeneous populations for treatment and research resulted in narrow di-
agnostic categories that did not capture clinical reality, symptom heterogeneity within dis-
orders, and significant sharing of symptoms across multiple disorders. The historical
aspiration of achieving diagnostic homogeneity by progressive subtyping within disorder
categories no longer is sensible; like most common human ills, mental disorders are het-
erogeneous at many levels, ranging from genetic risk factors to symptoms.

Related to recommendations about alterations in the chapter structure of DSM-5, mem-
bers of the diagnostic spectra study group examined whether scientific validators could
inform possible new groupings of related disorders within the existing categorical frame-
work. Eleven such indicators were recommended for this purpose: shared neural sub-
strates, family traits, genetic risk factors, specific environmental risk factors, biomarkers,
temperamental antecedents, abnormalities of emotional or cognitive processing, symptom
similarity, course of illness, high comorbidity, and shared treatment response. These indi-
cators served as empirical guidelines to inform decision making by the work groups and
the task force about how to cluster disorders to maximize their validity and clinical utility.

A series of papers was developed and published in a prominent international journal
(Psychological Medicine, Vol. 39, 2009) as part of both the DSM-5 and the ICD-11 develop-
mental processes to document that such validators were most useful for suggesting large
groupings of disorders rather than for “validating” individual disorder diagnostic criteria.
The regrouping of mental disorders in DSM-5 is intended to enable future research to en-

Introduction 13

hance understanding of disease origins and pathophysiological commonalities between
disorders and provide a base for future replication wherein data can be reanalyzed over
time to continually assess validity. Ongoing revisions of DSM-5 will make it a “living doc-
ument,” adaptable to future discoveries in neurobiology, genetics, and epidemiology.

On the basis of the published findings of this common DSM-5 and ICD-11 analysis, it
was demonstrated that clustering of disorders according to what has been termed internal-
izing and externalizing factors represents an empirically supported framework. Within both
the internalizing group (representing disorders with prominent anxiety, depressive, and
somatic symptoms) and the externalizing group (representing disorders with prominent
impulsive, disruptive conduct, and substance use symptoms), the sharing of genetic and
environmental risk factors, as shown by twin studies, likely explains much of the system-
atic comorbidities seen in both clinical and community samples. The adjacent placement of
“internalizing disorders,” characterized by depressed mood, anxiety, and related physio-
logical and cognitive symptoms, should aid in developing new diagnostic approaches, in-
cluding dimensional approaches, while facilitating the identification of biological markers.
Similarly, adjacencies of the “externalizing group,” including disorders exhibiting antiso-
cial behaviors, conduct disturbances, addictions, and impulse-control disorders, should en-
courage advances in identifying diagnoses, markers, and underlying mechanisms.

Despite the problem posed by categorical diagnoses, the DSM-5 Task Force recognized
that it is premature scientifically to propose alternative definitions for most disorders. The
organizational structure is meant to serve as a bridge to new diagnostic approaches with-
out disrupting current clinical practice or research. With support from DSM-associated
training materials, the National Institutes of Health other funding agencies, and scientific
publications, the more dimensional DSM-5 approach and organizational structure can fa-
cilitate research across current diagnostic categories by encouraging broad investigations
within the proposed chapters and across adjacent chapters. Such a reformulation of re-
search goals should also keep DSM-5 central to the development of dimensional approaches
to diagnosis that will likely supplement or supersede current categorical approaches in
coming years.

Developmental and Lifespan Considerations
To improve clinical utility, DSM-5 is organized on developmental and lifespan consider-
ations. It begins with diagnoses thought to reflect developmental processes that manifest
early in life (e.g., neurodevelopmental and schizophrenia spectrum and other psychotic
disorders), followed by diagnoses that more commonly manifest in adolescence and
young adulthood (e.g., bipolar, depressive, and anxiety disorders), and ends with diagno-
ses relevant to adulthood and later life (e.g., neurocognitive disorders). A similar approach
has been taken, where possible, within each chapter. This organizational structure facili-
tates the comprehensive use of lifespan information as a way to assist in diagnostic deci-
sion making.

The proposed organization of chapters of DSM-5, after the neurodevelopmental disor-
ders, is based on groups of internalizing (emotional and somatic) disorders, externalizing
disorders, neurocognitive disorders, and other disorders. It is hoped that this organization
will encourage further study of underlying pathophysiological processes that give rise to
diagnostic comorbidity and symptom heterogeneity. Furthermore, by arranging disorder
clusters to mirror clinical reality, DSM-5 should facilitate identification of potential diag-
noses by non–mental health specialists, such as primary care physicians.

The organizational structure of DSM-5, along with ICD harmonization, is designed to
provide better and more flexible diagnostic concepts for the next epoch of research and to
serve as a useful guide to clinicians in explaining to patients why they might have received
multiple diagnoses or why they might have received additional or altered diagnoses over
their lifespan.

14 Introduction

Cultural Issues
Mental disorders are defined in relation to cultural, social, and familial norms and values.
Culture provides interpretive frameworks that shape the experience and expression of the
symptoms, signs, and behaviors that are criteria for diagnosis. Culture is transmitted, re-
vised, and recreated within the family and other social systems and institutions. Diagnostic
assessment must therefore consider whether an individual’s experiences, symptoms, and
behaviors differ from sociocultural norms and lead to difficulties in adaptation in the cul-
tures of origin and in specific social or familial contexts. Key aspects of culture relevant to di-
agnostic classification and assessment have been considered in the development of DSM-5.

In Section III, the “Cultural Formulation” contains a detailed discussion of culture and
diagnosis in DSM-5, including tools for in-depth cultural assessment. In the Appendix, the
“Glossary of Cultural Concepts of Distress” provides a description of some common cul-
tural syndromes, idioms of distress, and causal explanations relevant to clinical practice.

The boundaries between normality and pathology vary across cultures for specific types
of behaviors. Thresholds of tolerance for specific symptoms or behaviors differ across cul-
tures, social settings, and families. Hence, the level at which an experience becomes prob-
lematic or pathological will differ. The judgment that a given behavior is abnormal and
requires clinical attention depends on cultural norms that are internalized by the individual
and applied by others around them, including family members and clinicians. Awareness of
the significance of culture may correct mistaken interpretations of psychopathology, but cul-
ture may also contribute to vulnerability and suffering (e.g., by amplifying fears that main-
tain panic disorder or health anxiety). Cultural meanings, habits, and traditions can also
contribute to either stigma or support in the social and familial response to mental illness.
Culture may provide coping strategies that enhance resilience in response to illness, or sug-
gest help seeking and options for accessing health care of various types, including alterna-
tive and complementary health systems. Culture may influence acceptance or rejection of a
diagnosis and adherence to treatments, affecting the course of illness and recovery. Culture
also affects the conduct of the clinical encounter; as a result, cultural differences between the
clinician and the patient have implications for the accuracy and acceptance of diagnosis as
well as for treatment decisions, prognostic considerations, and clinical outcomes.

Historically, the construct of the culture-bound syndrome has been a key interest of
cultural psychiatry. In DSM-5, this construct has been replaced by three concepts that offer
greater clinical utility:

1. Cultural syndrome is a cluster or group of co-occurring, relatively invariant symptoms
found in a specific cultural group, community, or context (e.g., ataque de nervios). The
syndrome may or may not be recognized as an illness within the culture (e.g., it might
be labeled in various ways), but such cultural patterns of distress and features of illness
may nevertheless be recognizable by an outside observer.

2. Cultural idiom of distress is a linguistic term, phrase, or way of talking about suffering
among individuals of a cultural group (e.g., similar ethnicity and religion) referring to
shared concepts of pathology and ways of expressing, communicating, or naming es-
sential features of distress (e.g., kufungisisa). An idiom of distress need not be associated
with specific symptoms, syndromes, or perceived causes. It may be used to convey a
wide range of discomfort, including everyday experiences, subclinical conditions, or
suffering due to social circumstances rather than mental disorders. For example, most
cultures have common bodily idioms of distress used to express a wide range of suf-
fering and concerns.

3. Cultural explanation or perceived cause is a label, attribution, or feature of an explanatory
model that provides a culturally conceived etiology or cause for symptoms, illness, or
distress (e.g., maladi moun). Causal explanations may be salient features of folk classi-
fications of disease used by laypersons or healers.

Introduction 15

These three concepts (for which discussion and examples are provided in Section III
and the Appendix) suggest cultural ways of understanding and describing illness experi-
ences that can be elicited in the clinical encounter. They influence symptomatology, help
seeking, clinical presentations, expectations of treatment, illness adaptation, and treat-
ment response. The same cultural term often serves more than one of these functions.

Gender Differences
Sex and gender differences as they relate to the causes and expression of medical conditions
are established for a number of diseases, including selected mental disorders. Revisions to
DSM-5 included review of potential differences between men and women in the expression
of mental illness. In terms of nomenclature, sex differences are variations attributable to an
individual’s reproductive organs and XX or XY chromosomal complement. Gender differ-
ences are variations that result from biological sex as well as an individual’s self-represen-
tation that includes the psychological, behavioral, and social consequences of one’s
perceived gender. The term gender differences is used in DSM-5 because, more commonly,
the differences between men and women are a result of both biological sex and individual
self-representation. However, some of the differences are based on only biological sex.

Gender can influence illness in a variety of ways. First, it may exclusively determine
whether an individual is at risk for a disorder (e.g., as in premenstrual dysphoric disor-
der). Second, gender may moderate the overall risk for development of a disorder as
shown by marked gender differences in the prevalence and incidence rates for selected
mental disorders. Third, gender may influence the likelihood that particular symptoms of
a disorder are experienced by an individual. Attention-deficit/hyperactivity disorder is
an example of a disorder with differences in presentation that are most commonly expe-
rienced by boys or girls. Gender likely has other effects on the experience of a disorder that
are indirectly relevant to psychiatric diagnosis. It may be that certain symptoms are more
readily endorsed by men or women, and that this contributes to differences in service pro-
vision (e.g., women may be more likely to recognize a depressive, bipolar, or anxiety dis-
order and endorse a more comprehensive list of symptoms than men).

Reproductive life cycle events, including estrogen variations, also contribute to gender
differences in risk and expression of illness. Thus, a specifier for postpartum onset of mania
or major depressive episode denotes a time frame wherein women may be at increased risk
for the onset of an illness episode. In the case of sleep and energy, alterations are often nor-
mative postpartum and thus may have lower diagnostic reliability in postpartum women.

The manual is configured to include information on gender at multiple levels. If there
are gender-specific symptoms, they have been added to the diagnostic criteria. A gender-
related specifier, such as perinatal onset of a mood episode, provides additional informa-
tion on gender and diagnosis. Finally, other issues that are pertinent to diagnosis and gen-
der considerations can be found in the section “Gender-Related Diagnostic Issues.”

Use of Other Specified and Unspecified Disorders
To enhance diagnostic specificity, DSM-5 replaces the previous NOS designation with two
options for clinical use: other specified disorder and unspecified disorder. The other specified
disorder category is provided to allow the clinician to communicate the specific reason
that the presentation does not meet the criteria for any specific category within a diagnos-
tic class. This is done by recording the name of the category, followed by the specific rea-
son. For example, for an individual with clinically significant depressive symptoms
lasting 4 weeks but whose symptomatology falls short of the diagnostic threshold for a
major depressive episode, the clinician would record “other specified depressive disorder,
depressive episode with insufficient symptoms.” If the clinician chooses not to specify the

16 Introduction

reason that the criteria are not met for a specific disorder, then “unspecified depressive
disorder” would be diagnosed. Note that the differentiation between other specified and
unspecified disorders is based on the clinician’s decision, providing maximum flexibility
for diagnosis. Clinicians do not have to differentiate between other specified and unspec-
ified disorders based on some feature of the presentation itself. When the clinician deter-
mines that there is evidence to specify the nature of the clinical presentation, the other
specified diagnosis can be given. When the clinician is not able to further specify and de-
scribe the clinical presentation, the unspecified diagnosis can be given. This is left entirely
up to clinical judgment.

For a more detailed discussion of how to use other specified and unspecified designa-
tions, see “Use of the Manual” in Section I.

The Multiaxial System
Despite widespread use and its adoption by certain insurance and governmental agencies,
the multiaxial system in DSM-IV was not required to make a mental disorder diagnosis. A
nonaxial assessment system was also included that simply listed the appropriate Axis I, II,
and III disorders and conditions without axial designations. DSM-5 has moved to a nonax-
ial documentation of diagnosis (formerly Axes I, II, and III), with separate notations for
important psychosocial and contextual factors (formerly Axis IV) and disability (formerly
Axis V). This revision is consistent with the DSM-IV text that states, “The multiaxial dis-
tinction among Axis I, Axis II, and Axis III disorders does not imply that there are funda-
mental differences in their conceptualization, that mental disorders are unrelated to
physical or biological factors or processes, or that general medical conditions are unrelated
to behavioral or psychosocial factors or processes.” The approach of separately noting di-
agnosis from psychosocial and contextual factors is also consistent with established WHO
and ICD guidance to consider the individual’s functional status separately from his or her
diagnoses or symptom status. In DSM-5, Axis III has been combined with Axes I and II.
Clinicians should continue to list medical conditions that are important to the understand-
ing or management of an individual’s mental disorder(s).

DSM-IV Axis IV covered psychosocial and environmental problems that may affect the
diagnosis, treatment, and prognosis of mental disorders. Although this axis provided
helpful information, even if it was not used as frequently as intended, the DSM-5 Task
Force recommended that DSM-5 should not develop its own classification of psychosocial
and environmental problems, but rather use a selected set of the ICD-9-CM V codes and
the new Z codes contained in ICD-10-CM. The ICD-10 Z codes were examined to deter-
mine which are most relevant to mental disorders and also to identify gaps.

DSM-IV Axis V consisted of the Global Assessment of Functioning (GAF) scale, repre-
senting the clinician’s judgment of the individual’s overall level of “functioning on a hy-
pothetical continuum of mental health–illness.” It was recommended that the GAF be
dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., in-
cluding symptoms, suicide risk, and disabilities in its descriptors) and questionable psy-
chometrics in routine practice. In order to provide a global measure of disability, the WHO
Disability Assessment Schedule (WHODAS) is included, for further study, in Section III of
DSM-5 (see the chapter “Assessment Measures”). The WHODAS is based on the Interna-
tional Classification of Functioning, Disability and Health (ICF) for use across all of medicine
and health care. The WHODAS (version 2.0), and a modification developed for children/
adolescents and their parents by the Impairment and Disability Study Group were in-
cluded in the DSM-5 field trial.

Introduction 17

Online Enhancements
It was challenging to determine what to include in the print version of DSM-5 to be most
clinically relevant and useful and at the same time maintain a manageable size. For this
reason, the inclusion of clinical rating scales and measures in the print edition is limited to
those considered most relevant. Additional assessment measures used in the field trials
are available online (www.psychiatry.org/dsm5), linked to the relevant disorders. The
Cultural Formulation Interview, Cultural Formulation Interview—Informant Version, and
supplementary modules to the core Cultural Formulation Interview are also available on-
line at www.psychiatry.org/dsm5.

DSM-5 is available as an online subscription at PsychiatryOnline.org as well as an e-
book. The online component contains modules and assessment tools to enhance the diag-
nostic criteria and text. Also available online is a complete set of supportive references as
well as additional helpful information. The organizational structure of DSM-5, its use of
dimensional measures, and compatibility with ICD codes will allow it to be readily adapt-
able to future scientific discoveries and refinements in its clinical utility. DSM-5 will be an-
alyzed over time to continually assess its validity and enhance its value to clinicians.

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19

Use of the Manual

The introduction contains much of the history and developmental process of the
DSM-5 revision. This section is designed to provide a practical guide to using DSM-5, par-
ticularly in clinical practice. The primary purpose of DSM-5 is to assist trained clinicians
in the diagnosis of their patients’ mental disorders as part of a case formulation assess-
ment that leads to a fully informed treatment plan for each individual. The symptoms con-
tained in the respective diagnostic criteria sets do not constitute comprehensive
definitions of underlying disorders, which encompass cognitive, emotional, behavioral,
and physiological processes that are far more complex than can be described in these brief
summaries. Rather, they are intended to summarize characteristic syndromes of signs and
symptoms that point to an underlying disorder with a characteristic developmental his-
tory, biological and environmental risk factors, neuropsychological and physiological cor-
relates, and typical clinical course.

Approach to Clinical Case Formulation
The case formulation for any given patient must involve a careful clinical history and con-
cise summary of the social, psychological, and biological factors that may have contrib-
uted to developing a given mental disorder. Hence, it is not sufficient to simply check off
the symptoms in the diagnostic criteria to make a mental disorder diagnosis. Although a
systematic check for the presence of these criteria as they apply to each patient will assure
a more reliable assessment, the relative severity and valence of individual criteria and
their contribution to a diagnosis require clinical judgment. The symptoms in our diagnos-
tic criteria are part of the relatively limited repertoire of human emotional responses to in-
ternal and external stresses that are generally maintained in a homeostatic balance without
a disruption in normal functioning. It requires clinical training to recognize when the com-
bination of predisposing, precipitating, perpetuating, and protective factors has resulted
in a psychopathological condition in which physical signs and symptoms exceed normal
ranges. The ultimate goal of a clinical case formulation is to use the available contextual
and diagnostic information in developing a comprehensive treatment plan that is in-
formed by the individual’s cultural and social context. However, recommendations for the
selection and use of the most appropriate evidence-based treatment options for each dis-
order are beyond the scope of this manual.

Although decades of scientific effort have gone into developing the diagnostic criteria
sets for the disorders included in Section II, it is well recognized that this set of categorical
diagnoses does not fully describe the full range of mental disorders that individuals ex-
perience and present to clinicians on a daily basis throughout the world. As noted previ-
ously in the introduction, the range of genetic/environmental interactions over the course
of human development affecting cognitive, emotional and behavioral function is virtually
limitless. As a result, it is impossible to capture the full range of psychopathology in the
categorical diagnostic categories that we are now using. Hence, it is also necessary to in-
clude “other specified/unspecified” disorder options for presentations that do not fit
exactly into the diagnostic boundaries of disorders in each chapter. In an emergency de-
partment setting, it may be possible to identify only the most prominent symptom ex-
pressions associated with a particular chapter—for example, delusions, hallucinations,

20 Use of the Manual

mania, depression, anxiety, substance intoxication, or neurocognitive symptoms—so that
an “unspecified” disorder in that category is identified until a fuller differential diagnosis
is possible.

Definition of a Mental Disorder
Each disorder identified in Section II of the manual (excluding those in the chapters enti-
tled “Medication-Induced Movement Disorders and Other Adverse Effects of Medica-
tion” and “Other Conditions That May Be a Focus of Clinical Attention”) must meet the
definition of a mental disorder. Although no definition can capture all aspects of all dis-
orders in the range contained in DSM-5, the following elements are required:

A mental disorder is a syndrome characterized by clinically significant distur-
bance in an individual’s cognition, emotion regulation, or behavior that reflects
a dysfunction in the psychological, biological, or developmental processes un-
derlying mental functioning. Mental disorders are usually associated with signif-
icant distress or disability in social, occupational, or other important activities.
An expectable or culturally approved response to a common stressor or loss,
such as the death of a loved one, is not a mental disorder. Socially deviant be-
havior (e.g., political, religious, or sexual) and conflicts that are primarily be-
tween the individual and society are not mental disorders unless the deviance
or conflict results from a dysfunction in the individual, as described above.

The diagnosis of a mental disorder should have clinical utility: it should help clinicians
to determine prognosis, treatment plans, and potential treatment outcomes for their pa-
tients. However, the diagnosis of a mental disorder is not equivalent to a need for treat-
ment. Need for treatment is a complex clinical decision that takes into consideration
symptom severity, symptom salience (e.g., the presence of suicidal ideation), the patient’s
distress (mental pain) associated with the symptom(s), disability related to the patient’s
symptoms, risks and benefits of available treatments, and other factors (e.g., psychiatric
symptoms complicating other illness). Clinicians may thus encounter individuals whose
symptoms do not meet full criteria for a mental disorder but who demonstrate a clear need
for treatment or care. The fact that some individuals do not show all symptoms indicative
of a diagnosis should not be used to justify limiting their access to appropriate care.

Approaches to validating diagnostic criteria for discrete categorical mental disorders
have included the following types of evidence: antecedent validators (similar genetic mark-
ers, family traits, temperament, and environmental exposure), concurrent validators (simi-
lar neural substrates, biomarkers, emotional and cognitive processing, and symptom
similarity), and predictive validators (similar clinical course and treatment response). In
DSM-5, we recognize that the current diagnostic criteria for any single disorder will not nec-
essarily identify a homogeneous group of patients who can be characterized reliably with all
of these validators. Available evidence shows that these validators cross existing diagnostic
boundaries but tend to congregate more frequently within and across adjacent DSM-5 chap-
ter groups. Until incontrovertible etiological or pathophysiological mechanisms are identi-
fied to fully validate specific disorders or disorder spectra, the most important standard for
the DSM-5 disorder criteria will be their clinical utility for the assessment of clinical course
and treatment response of individuals grouped by a given set of diagnostic criteria.

This definition of mental disorder was developed for clinical, public health, and re-
search purposes. Additional information is usually required beyond that contained in the
DSM-5 diagnostic criteria in order to make legal judgments on such issues as criminal re-
sponsibility, eligibility for disability compensation, and competency (see “Cautionary
Statement for Forensic Use of DSM-5” elsewhere in this manual).

Use of the Manual 21

Criterion for Clinical Significance
There have been substantial efforts by the DSM-5 Task Force and the World Health Orga-
nization (WHO) to separate the concepts of mental disorder and disability (impairment in
social, occupational, or other important areas of functioning). In the WHO system, the In-
ternational Classification of Diseases (ICD) covers all diseases and disorders, while the In-
ternational Classification of Functioning, Disability and Health (ICF) provides a separate
classification of global disability. The WHO Disability Assessment Schedule (WHODAS)
is based on the ICF and has proven useful as a standardized measure of disability for men-
tal disorders. However, in the absence of clear biological markers or clinically useful mea-
surements of severity for many mental disorders, it has not been possible to completely
separate normal and pathological symptom expressions contained in diagnostic criteria.
This gap in information is particularly problematic in clinical situations in which the pa-
tient’s symptom presentation by itself (particularly in mild forms) is not inherently path-
ological and may be encountered in individuals for whom a diagnosis of “mental
disorder” would be inappropriate. Therefore, a generic diagnostic criterion requiring dis-
tress or disability has been used to establish disorder thresholds, usually worded “the dis-
turbance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.” The text following the revised definition of a mental
disorder acknowledges that this criterion may be especially helpful in determining a pa-
tient’s need for treatment. Use of information from family members and other third parties
(in addition to the individual) regarding the individual’s performance is recommended
when necessary.

Elements of a Diagnosis
Diagnostic Criteria and Descriptors
Diagnostic criteria are offered as guidelines for making diagnoses, and their use should be
informed by clinical judgment. Text descriptions, including introductory sections of each
diagnostic chapter, can help support diagnosis (e.g., providing differential diagnoses; de-
scribing the criteria more fully under “Diagnostic Features”).

Following the assessment of diagnostic criteria, clinicians should consider the applica-
tion of disorder subtypes and/or specifiers as appropriate. Severity and course specifiers
should be applied to denote the individual’s current presentation, but only when the full
criteria are met. When full criteria are not met, clinicians should consider whether the
symptom presentation meets criteria for an “other specified” or “unspecified” designa-
tion. Where applicable, specific criteria for defining disorder severity (e.g., mild, moder-
ate, severe, extreme), descriptive features (e.g., with good to fair insight; in a controlled
environment), and course (e.g., in partial remission, in full remission, recurrent) are pro-
vided with each diagnosis. On the basis of the clinical interview, text descriptions, criteria,
and clinician judgment, a final diagnosis is made.

The general convention in DSM-5 is to allow multiple diagnoses to be assigned for
those presentations that meet criteria for more than one DSM-5 disorder.

Subtypes and Specifiers
Subtypes and specifiers (some of which are coded in the fourth, fifth, or sixth digit) are
provided for increased specificity. Subtypes define mutually exclusive and jointly exhaus-
tive phenomenological subgroupings within a diagnosis and are indicated by the instruc-
tion “Specify whether” in the criteria set. In contrast, specifiers are not intended to be
mutually exclusive or jointly exhaustive, and as a consequence, more than one specifier
may be given. Specifiers are indicated by the instruction “Specify” or “Specify if” in the cri-
teria set. Specifiers provide an opportunity to define a more homogeneous subgrouping of

22 Use of the Manual

individuals with the disorder who share certain features (e.g., major depressive disorder,
with mixed features) and to convey information that is relevant to the management of the
individual’s disorder, such as the “with other medical comorbidity” specifier in sleep-
wake disorders. Although a fifth digit is sometimes assigned to code a subtype or specifier
(e.g., 294.11 [F02.81] major neurocognitive disorder due to Alzheimer’s disease, with be-
havioral disturbance) or severity (296.21 [F32.0] major depressive disorder, single episode,
mild), the majority of subtypes and specifiers included in DSM-5 cannot be coded within
the ICD-9-CM and ICD-10-CM systems and are indicated only by including the subtype or
specifier after the name of the disorder (e.g., social anxiety disorder [social phobia], per-
formance type). Note that in some cases, a specifier or subtype is codable in ICD-10-CM
but not in ICD-9-CM. Accordingly, in some cases the 4th or 5th character codes for the sub-
types or specifiers are provided only for the ICD-10-CM coding designations.

A DSM-5 diagnosis is usually applied to the individual’s current presentation; previ-
ous diagnoses from which the individual has recovered should be clearly noted as such.
Specifiers indicating course (e.g., in partial remission, in full remission) may be listed after
the diagnosis and are indicated in a number of criteria sets. Where available, severity spec-
ifiers are provided to guide clinicians in rating the intensity, frequency, duration, symptom
count, or other severity indicator of a disorder. Severity specifiers are indicated by the in-
struction “Specify current severity” in the criteria set and include disorder-specific defini-
tions. Descriptive features specifiers have also been provided in the criteria set and convey
additional information that can inform treatment planning (e.g., obsessive-compulsive
disorder, with poor insight). Not all disorders include course, severity, and/or descriptive
features specifiers.

Medication-Induced Movement Disorders and Other
Conditions That May Be a Focus of Clinical Attention
In addition to important psychosocial and environmental factors (see “The Multiaxial Sys-
tem” in the “Introduction” elsewhere in this manual), these chapters in Section II also con-
tain other conditions that are not mental disorders but may be encountered by mental
health clinicians. These conditions may be listed as a reason for clinical visit in addition to,
or in place of, the mental disorders listed in Section II. A separate chapter is devoted to
medication-induced disorders and other adverse effects of medication that may be as-
sessed and treated by clinicians in mental health practice such as akathisia, tardive dyski-
nesia, and dystonia. The description of neuroleptic malignant syndrome is expanded from
that provided in DSM-IV-TR to highlight the emergent and potentially life-threatening na-
ture of this condition, and a new entry on antidepressant discontinuation syndrome is pro-
vided. An additional chapter discusses other conditions that may be a focus of clinical
attention. These include relational problems, problems related to abuse and neglect, prob-
lems with adherence to treatment regimens, obesity, antisocial behavior, and malingering.

Principal Diagnosis
When more than one diagnosis for an individual is given in an inpatient setting, the prin-
cipal diagnosis is the condition established after study to be chiefly responsible for occa-
sioning the admission of the individual. When more than one diagnosis is given for an
individual in an outpatient setting, the reason for visit is the condition that is chiefly re-
sponsible for the ambulatory care medical services received during the visit. In most cases,
the principal diagnosis or the reason for visit is also the main focus of attention or treat-
ment. It is often difficult (and somewhat arbitrary) to determine which diagnosis is the
principal diagnosis or the reason for visit, especially when, for example, a substance-
related diagnosis such as alcohol use disorder is accompanied by a non-substance-related
diagnosis such as schizophrenia. For example, it may be unclear which diagnosis should

Use of the Manual 23

be considered “principal” for an individual hospitalized with both schizophrenia and al-
cohol use disorder, because each condition may have contributed equally to the need for
admission and treatment. The principal diagnosis is indicated by listing it first, and the re-
maining disorders are listed in order of focus of attention and treatment. When the prin-
cipal diagnosis or reason for visit is a mental disorder due to another medical condition
(e.g., major neurocognitive disorder due to Alzheimer’s disease, psychotic disorder due to
malignant lung neoplasm), ICD coding rules require that the etiological medical condition
be listed first. In that case, the principal diagnosis or reason for visit would be the mental
disorder due to the medical condition, the second listed diagnosis. In most cases, the dis-
order listed as the principal diagnosis or the reason for visit is followed by the qualifying
phrase “(principal diagnosis)” or “(reason for visit).”

Provisional Diagnosis
The specifier “provisional” can be used when there is a strong presumption that the full
criteria will ultimately be met for a disorder but not enough information is available to
make a firm diagnosis. The clinician can indicate the diagnostic uncertainty by recording
“(provisional)” following the diagnosis. For example, this diagnosis might be used when
an individual who appears to have a major depressive disorder is unable to give an ade-
quate history, and thus it cannot be established that the full criteria are met. Another use of
the term provisional is for those situations in which differential diagnosis depends exclu-
sively on the duration of illness. For example, a diagnosis of schizophreniform disorder re-
quires a duration of less than 6 months but of at least 1 month and can only be given
provisionally if assigned before remission has occurred.

Coding and Reporting Procedures
Each disorder is accompanied by an identifying diagnostic and statistical code, which is
typically used by institutions and agencies for data collection and billing purposes. There
are specific recording protocols for these diagnostic codes (identified as coding notes in
the text) that were established by WHO, the U.S. Centers for Medicare and Medicaid Ser-
vices (CMS), and the Centers for Disease Control and Prevention’s National Center for
Health Statistics to ensure consistent international recording of prevalence and mortality
rates for identified health conditions. For most clinicians, the codes are used to identify the
diagnosis or reason for visit for CMS and private insurance service claims. The official
coding system in use in the United States as of publication of this manual is ICD-9-CM. Of-
ficial adoption of ICD-10-CM is scheduled to take place on October 1, 2014, and these
codes, which are shown parenthetically in this manual, should not be used until the offi-
cial implementation occurs. Both ICD-9-CM and ICD-10-CM codes have been listed 1) pre-
ceding the name of the disorder in the classification and 2) accompanying the criteria set
for each disorder. For some diagnoses (e.g., neurocognitive and substance/medication-
induced disorders), the appropriate code depends on further specification and is listed
within the criteria set for the disorder, as coding notes, and, in some cases, further clarified
in a section on recording procedures. The names of some disorders are followed by alter-
native terms enclosed in parentheses, which, in most cases, were the DSM-IV names for
the disorders.

Looking to the Future:
Assessment and Monitoring Tools

The various components of DSM-5 are provided to facilitate patient assessment and to aid
in developing a comprehensive case formulation. Whereas the diagnostic criteria in Sec-
tion II are well-established measures that have undergone extensive review, the assess-

24 Use of the Manual

ment tools, a cultural formulation interview, and conditions for further study included in
Section III are those for which we determined that the scientific evidence is not yet avail-
able to support widespread clinical use. These diagnostic aids and criteria are included to
highlight the evolution and direction of scientific advances in these areas and to stimulate
further research.

Each of the measures in Section III is provided to aid in a comprehensive assessment of
individuals that will contribute to a diagnosis and treatment plan tailored to the individ-
ual presentation and clinical context. Where cultural dynamics are particularly important
for diagnostic assessment, the cultural formulation interview should be considered as a
useful aid to communication with the individual. Cross-cutting symptom and diagnosis-
specific severity measures provide quantitative ratings of important clinical areas that are
designed to be used at the initial evaluation to establish a baseline for comparison with rat-
ings on subsequent encounters to monitor changes and inform treatment planning.

The use of such measures will undoubtedly be facilitated by digital applications, and
the measures are included in Section III to provide for further evaluation and develop-
ment. As with each DSM edition, the diagnostic criteria and the DSM-5 classification of
mental disorders reflect the current consensus on the evolving knowledge in our field.

25

Cautionary Statement for
Forensic Use of DSM-5

Although the DSM-5 diagnostic criteria and text are primarily designed to assist
clinicians in conducting clinical assessment, case formulation, and treatment planning,
DSM-5 is also used as a reference for the courts and attorneys in assessing the forensic con-
sequences of mental disorders. As a result, it is important to note that the definition of
mental disorder included in DSM-5 was developed to meet the needs of clinicians, public
health professionals, and research investigators rather than all of the technical needs of the
courts and legal professionals. It is also important to note that DSM-5 does not provide
treatment guidelines for any given disorder.

When used appropriately, diagnoses and diagnostic information can assist legal deci-
sion makers in their determinations. For example, when the presence of a mental disorder
is the predicate for a subsequent legal determination (e.g., involuntary civil commitment),
the use of an established system of diagnosis enhances the value and reliability of the de-
termination. By providing a compendium based on a review of the pertinent clinical and
research literature, DSM-5 may facilitate legal decision makers’ understanding of the rel-
evant characteristics of mental disorders. The literature related to diagnoses also serves as
a check on ungrounded speculation about mental disorders and about the functioning of a
particular individual. Finally, diagnostic information about longitudinal course may im-
prove decision making when the legal issue concerns an individual’s mental functioning
at a past or future point in time.

However, the use of DSM-5 should be informed by an awareness of the risks and lim-
itations of its use in forensic settings. When DSM-5 categories, criteria, and textual descrip-
tions are employed for forensic purposes, there is a risk that diagnostic information will be
misused or misunderstood. These dangers arise because of the imperfect fit between the
questions of ultimate concern to the law and the information contained in a clinical diagno-
sis. In most situations, the clinical diagnosis of a DSM-5 mental disorder such as intellec-
tual disability (intellectual developmental disorder), schizophrenia, major neurocognitive
disorder, gambling disorder, or pedophilic disorder does not imply that an individual
with such a condition meets legal criteria for the presence of a mental disorder or a speci-
fied legal standard (e.g., for competence, criminal responsibility, or disability). For the latter,
additional information is usually required beyond that contained in the DSM-5 diagnosis,
which might include information about the individual’s functional impairments and how
these impairments affect the particular abilities in question. It is precisely because impair-
ments, abilities, and disabilities vary widely within each diagnostic category that assign-
ment of a particular diagnosis does not imply a specific level of impairment or disability.

Use of DSM-5 to assess for the presence of a mental disorder by nonclinical, nonmed-
ical, or otherwise insufficiently trained individuals is not advised. Nonclinical decision
makers should also be cautioned that a diagnosis does not carry any necessary implica-
tions regarding the etiology or causes of the individual’s mental disorder or the individ-
ual’s degree of control over behaviors that may be associated with the disorder. Even
when diminished control over one’s behavior is a feature of the disorder, having the diag-
nosis in itself does not demonstrate that a particular individual is (or was) unable to con-
trol his or her behavior at a particular time.

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SECTION II
Diagnostic Criteria and Codes

Neurodevelopmental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Schizophrenia Spectrum and Other Psychotic Disorders . . . . . . . . . . . . 87

Bipolar and Related Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Depressive Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Obsessive-Compulsive and Related Disorders. . . . . . . . . . . . . . . . . . . . 235

Trauma- and Stressor-Related Disorders . . . . . . . . . . . . . . . . . . . . . . . . 265

Dissociative Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Somatic Symptom and Related Disorders . . . . . . . . . . . . . . . . . . . . . . . 309

Feeding and Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329

Elimination Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355

Sleep-Wake Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

Sexual Dysfunctions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423

Gender Dysphoria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451

Disruptive, Impulse-Control, and Conduct Disorders. . . . . . . . . . . . . . . 461

Substance-Related and Addictive Disorders . . . . . . . . . . . . . . . . . . . . . 481

Neurocognitive Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591

Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645

Paraphilic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685

Other Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707

Medication-Induced Movement Disorders and
Other Adverse Effects of Medication. . . . . . . . . . . . . . . . . . . . . . . . . . 709

Other Conditions That May Be a Focus of Clinical Attention . . . . . . . . . 715

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This section contains the diagnostic criteria approved for routine clinical
use along with the ICD-9-CM codes (ICD-10 codes are shown parenthetically).
For each mental disorder, the diagnostic criteria are followed by descriptive
text to assist in diagnostic decision making. Where needed, specific recording
procedures are presented with the diagnostic criteria to provide guidance in
selecting the most appropriate code. In some cases, separate recording pro-
cedures for ICD-9-CM and ICD-10-CM are provided. Although not considered
as official DSM-5 disorders, medication-induced movement disorders and other
adverse effects of medication, as well as other conditions that may be a focus
of clinical attention (including additional ICD-9-CM V codes and forthcoming
ICD-10-CM Z codes), are provided to indicate other reasons for a clinical visit
such as environmental factors and relational problems. These codes are adapted
from ICD-9-CM and ICD-10-CM and were neither reviewed nor approved as
official DSM-5 diagnoses, but can provide additional context for a clinical for-
mulation and treatment plan. These three components—the criteria and their
descriptive text, the medication-induced movement disorders and other ad-
verse effects of medication, and the descriptions of other conditions that may
be a focus of clinical attention—represent the key elements of the clinical di-
agnostic process and thus are presented together.

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31

Neurodevelopmental
Disorders

The neurodevelopmental disorders are a group of conditions with onset in the
developmental period. The disorders typically manifest early in development, often be-
fore the child enters grade school, and are characterized by developmental deficits that
produce impairments of personal, social, academic, or occupational functioning. The
range of developmental deficits varies from very specific limitations of learning or control
of executive functions to global impairments of social skills or intelligence. The neurode-
velopmental disorders frequently co-occur; for example, individuals with autism spec-
trum disorder often have intellectual disability (intellectual developmental disorder), and
many children with attention-deficit/hyperactivity disorder (ADHD) also have a specific
learning disorder. For some disorders, the clinical presentation includes symptoms of ex-
cess as well as deficits and delays in achieving expected milestones. For example, autism
spectrum disorder is diagnosed only when the characteristic deficits of social communi-
cation are accompanied by excessively repetitive behaviors, restricted interests, and insis-
tence on sameness.

Intellectual disability (intellectual developmental disorder) is characterized by deficits
in general mental abilities, such as reasoning, problem solving, planning, abstract thinking,
judgment, academic learning, and learning from experience. The deficits result in impair-
ments of adaptive functioning, such that the individual fails to meet standards of personal
independence and social responsibility in one or more aspects of daily life, including com-
munication, social participation, academic or occupational functioning, and personal inde-
pendence at home or in community settings. Global developmental delay, as its name
implies, is diagnosed when an individual fails to meet expected developmental milestones
in several areas of intellectual functioning. The diagnosis is used for individuals who are
unable to undergo systematic assessments of intellectual functioning, including children
who are too young to participate in standardized testing. Intellectual disability may result
from an acquired insult during the developmental period from, for example, a severe head
injury, in which case a neurocognitive disorder also may be diagnosed.

The communication disorders include language disorder, speech sound disorder, so-
cial (pragmatic) communication disorder, and childhood-onset fluency disorder (stutter-
ing). The first three disorders are characterized by deficits in the development and use of
language, speech, and social communication, respectively. Childhood-onset fluency dis-
order is characterized by disturbances of the normal fluency and motor production of
speech, including repetitive sounds or syllables, prolongation of consonants or vowel
sounds, broken words, blocking, or words produced with an excess of physical tension.
Like other neurodevelopmental disorders, communication disorders begin early in life
and may produce lifelong functional impairments.

Autism spectrum disorder is characterized by persistent deficits in social communica-
tion and social interaction across multiple contexts, including deficits in social reciprocity,
nonverbal communicative behaviors used for social interaction, and skills in developing,
maintaining, and understanding relationships. In addition to the social communication
deficits, the diagnosis of autism spectrum disorder requires the presence of restricted, re-
petitive patterns of behavior, interests, or activities. Because symptoms change with de-
velopment and may be masked by compensatory mechanisms, the diagnostic criteria may

32 Neurodevelopmental Disorders

be met based on historical information, although the current presentation must cause sig-
nificant impairment.

Within the diagnosis of autism spectrum disorder, individual clinical characteristics
are noted through the use of specifiers (with or without accompanying intellectual impair-
ment; with or without accompanying structural language impairment; associated with a
known medical/genetic or environmental/acquired condition; associated with another
neurodevelopmental, mental, or behavioral disorder), as well as specifiers that describe
the autistic symptoms (age at first concern; with or without loss of established skills; sever-
ity). These specifiers provide clinicians with an opportunity to individualize the diagnosis
and communicate a richer clinical description of the affected individuals. For example, many
individuals previously diagnosed with Asperger’s disorder would now receive a diagnosis
of autism spectrum disorder without language or intellectual impairment.

ADHD is a neurodevelopmental disorder defined by impairing levels of inattention, dis-
organization, and/or hyperactivity-impulsivity. Inattention and disorganization entail inabil-
ity to stay on task, seeming not to listen, and losing materials, at levels that are inconsistent
with age or developmental level. Hyperactivity-impulsivity entails overactivity, fidgeting, in-
ability to stay seated, intruding into other people’s activities, and inability to wait—symptoms
that are excessive for age or developmental level. In childhood, ADHD frequently overlaps
with disorders that are often considered to be “externalizing disorders,” such as oppositional
defiant disorder and conduct disorder. ADHD often persists into adulthood, with resultant
impairments of social, academic and occupational functioning.

The neurodevelopmental motor disorders include developmental coordination disor-
der, stereotypic movement disorder, and tic disorders. Developmental coordination dis-
order is characterized by deficits in the acquisition and execution of coordinated motor
skills and is manifested by clumsiness and slowness or inaccuracy of performance of mo-
tor skills that cause interference with activities of daily living. Stereotypic movement dis-
order is diagnosed when an individual has repetitive, seemingly driven, and apparently
purposeless motor behaviors, such as hand flapping, body rocking, head banging, self-
biting, or hitting. The movements interfere with social, academic, or other activities. If the
behaviors cause self-injury, this should be specified as part of the diagnostic description.
Tic disorders are characterized by the presence of motor or vocal tics, which are sudden,
rapid, recurrent, nonrhythmic, sterotyped motor movements or vocalizations. The dura-
tion, presumed etiology, and clinical presentation define the specific tic disorder that is di-
agnosed: Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, provisional
tic disorder, other specified tic disorder, and unspecified tic disorder. Tourette’s disorder
is diagnosed when the individual has multiple motor and vocal tics that have been present
for at least 1 year and that have a waxing-waning symptom course.

Specific learning disorder, as the name implies, is diagnosed when there are specific defi-
cits in an individual’s ability to perceive or process information efficiently and accurately. This
neurodevelopmental disorder first manifests during the years of formal schooling and is
characterized by persistent and impairing difficulties with learning foundational academic
skills in reading, writing, and/or math. The individual’s performance of the affected academic
skills is well below average for age, or acceptable performance levels are achieved only with
extraordinary effort. Specific learning disorder may occur in individuals identified as intellec-
tually gifted and manifest only when the learning demands or assessment procedures (e.g.,
timed tests) pose barriers that cannot be overcome by their innate intelligence and compensa-
tory strategies. For all individuals, specific learning disorder can produce lifelong impairments
in activities dependent on the skills, including occupational performance.

The use of specifiers for the neurodevelopmental disorder diagnoses enriches the clin-
ical description of the individual’s clinical course and current symptomatology. In addi-
tion to specifiers that describe the clinical presentation, such as age at onset or severity
ratings, the neurodevelopmental disorders may include the specifier “associated with a
known medical or genetic condition or environmental factor.” This specifier gives clini-

Intellectual Disability (Intellectual Developmental Disorder) 33

cians an opportunity to document factors that may have played a role in the etiology of the
disorder, as well as those that might affect the clinical course. Examples include genetic
disorders, such as fragile X syndrome, tuberous sclerosis, and Rett syndrome; medical con-
ditions such as epilepsy; and environmental factors, including very low birth weight and
fetal alcohol exposure (even in the absence of stigmata of fetal alcohol syndrome).

Intellectual Disabilities

Intellectual Disability
(Intellectual Developmental Disorder)

Diagnostic Criteria

Intellectual disability (intellectual developmental disorder) is a disorder with onset during
the developmental period that includes both intellectual and adaptive functioning deficits
in conceptual, social, and practical domains. The following three criteria must be met:
A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract

thinking, judgment, academic learning, and learning from experience, confirmed by
both clinical assessment and individualized, standardized intelligence testing.

B. Deficits in adaptive functioning that result in failure to meet developmental and socio-
cultural standards for personal independence and social responsibility. Without ongo-
ing support, the adaptive deficits limit functioning in one or more activities of daily life,
such as communication, social participation, and independent living, across multiple
environments, such as home, school, work, and community.

C. Onset of intellectual and adaptive deficits during the developmental period.

Note: The diagnostic term intellectual disability is the equivalent term for the ICD-11 diag-
nosis of intellectual developmental disorders. Although the term intellectual disability is
used throughout this manual, both terms are used in the title to clarify relationships with
other classification systems. Moreover, a federal statute in the United States (Public Law
111-256, Rosa’s Law) replaces the term mental retardation with intellectual disability, and
research journals use the term intellectual disability. Thus, intellectual disability is the
term in common use by medical, educational, and other professions and by the lay public
and advocacy groups.

Specify current severity (see Table 1):
317 (F70) Mild
318.0 (F71) Moderate
318.1 (F72) Severe
318.2 (F73) Profound

Specifiers
The various levels of severity are defined on the basis of adaptive functioning, and not IQ
scores, because it is adaptive functioning that determines the level of supports required.
Moreover, IQ measures are less valid in the lower end of the IQ range.

3
4

N
e

u
ro

d
e

ve
lo

p
m

e
n

ta
l D

iso
rd

e
rs

TABLE 1 Severity levels for intellectual disability (intellectual developmental disorder)

Severity
level Conceptual domain Social domain Practical domain

Mild For preschool children, there
may be no obvious conceptual
differences. For school-age
children and adults, there are
difficulties in learning aca-
demic skills involving reading,
writing, arithmetic, time, or
money, with support needed
in one or more areas to meet
age-related expectations. In
adults, abstract thinking, exec-
utive function (i.e., planning,
strategizing, priority setting,
and cognitive flexibility), and
short-term memory, as well as
functional use of academic
skills (e.g., reading, money
management), are impaired.
There is a somewhat concrete
approach to problems and
solutions compared with
age-mates.

Compared with typically developing age-
mates, the individual is immature in social
interactions. For example, there may be diffi-
culty in accurately perceiving peers’ social
cues. Communication, conversation, and lan-
guage are more concrete or immature than
expected for age. There may be difficulties reg-
ulating emotion and behavior in age-appropri-
ate fashion; these difficulties are noticed by
peers in social situations. There is limited
understanding of risk in social situations;
social judgment is immature for age, and
the person is at risk of being manipulated
by others (gullibility).

The individual may function age-appropriately in
personal care. Individuals need some support with
complex daily living tasks in comparison to peers. In
adulthood, supports typically involve grocery shop-
ping, transportation, home and child-care organiz-
ing, nutritious food preparation, and banking and
money management. Recreational skills resemble
those of age-mates, although judgment related to
well-being and organization around recreation
requires support. In adulthood, competitive
employment is often seen in jobs that do not empha-
size conceptual skills. Individuals generally need
support to make health care decisions and legal
decisions, and to learn to perform a skilled vocation
competently. Support is typically needed to raise a
family.

In
te

lle
ctu

a
l D

isa
b

ility (In
te

lle
ctu

a
l D

e
ve

lo
p

m
e
n

ta
l D

iso
rd

e
r)

3
5

Moderate All through development, the
individual’s conceptual skills
lag markedly behind those of
peers. For preschoolers, lan-
guage and pre-academic skills
develop slowly. For school-age
children, progress in reading,
writing, mathematics, and
understanding of time and
money occurs slowly across
the school years and is mark-
edly limited compared with
that of peers. For adults, aca-
demic skill development is
typically at an elementary
level, and support is required
for all use of academic skills in
work and personal life. Ongo-
ing assistance on a daily basis
is needed to complete concep-
tual tasks of day-to-day life,
and others may take over these
responsibilities fully for the
individual.

The individual shows marked differences from
peers in social and communicative behavior
across development. Spoken language is typi-
cally a primary tool for social communication
but is much less complex than that of peers.
Capacity for relationships is evident in ties to
family and friends, and the individual may
have successful friendships across life and
sometimes romantic relations in adulthood.
However, individuals may not perceive or
interpret social cues accurately. Social judg-
ment and decision-making abilities are lim-
ited, and caretakers must assist the person
with life decisions. Friendships with typically
developing peers are often affected by com-
munication or social limitations. Significant
social and communicative support is needed
in work settings for success.

The individual can care for personal needs involving
eating, dressing, elimination, and hygiene as an
adult, although an extended period of teaching and
time is needed for the individual to become indepen-
dent in these areas, and reminders may be needed.
Similarly, participation in all household tasks can be
achieved by adulthood, although an extended
period of teaching is needed, and ongoing supports
will typically occur for adult-level performance.
Independent employment in jobs that require lim-
ited conceptual and communication skills can be
achieved, but considerable support from co-work-
ers, supervisors, and others is needed to manage
social expectations, job complexities, and ancillary
responsibilities such as scheduling, transportation,
health benefits, and money management. A variety
of recreational skills can be developed. These typi-
cally require additional supports and learning
opportunities over an extended period of time.
Maladaptive behavior is present in a significant
minority and causes social problems.

TABLE 1 Severity levels for intellectual disability (intellectual developmental disorder) (continued)

Severity
level Conceptual domain Social domain Practical domain

3
6

N
e

u
ro

d
e

ve
lo

p
m

e
n

ta
l D

iso
rd

e
rs

Severe Attainment of conceptual skills
is limited. The individual gen-
erally has little understanding
of written language or of con-
cepts involving numbers,
quantity, time, and money.
Caretakers provide extensive
supports for problem solving
throughout life.

Spoken language is quite limited in terms of
vocabulary and grammar. Speech may be sin-
gle words or phrases and may be supple-
mented through augmentative means. Speech
and communication are focused on the here
and now within everyday events. Language is
used for social communication more than for
explication. Individuals understand simple
speech and gestural communication. Relation-
ships with family members and familiar others
are a source of pleasure and help.

The individual requires support for all activities of
daily living, including meals, dressing, bathing, and
elimination. The individual requires supervision at
all times. The individual cannot make responsible
decisions regarding well-being of self or others. In
adulthood, participation in tasks at home, recre-
ation, and work requires ongoing support and assis-
tance. Skill acquisition in all domains involves long-
term teaching and ongoing support. Maladaptive
behavior, including self-injury, is present in a signif-
icant minority. 

Profound Conceptual skills generally
involve the physical world
rather than symbolic pro-
cesses. The individual may use
objects in goal-directed fashion
for self-care, work, and recre-
ation. Certain visuospatial
skills, such as matching and
sorting based on physical char-
acteristics, may be acquired.
However, co-occurring motor
and sensory impairments may
prevent functional use of
objects.

The individual has very limited understanding
of symbolic communication in speech or ges-
ture. He or she may understand some simple
instructions or gestures. The individual
expresses his or her own desires and emotions
largely through nonverbal, nonsymbolic com-
munication. The individual enjoys relation-
ships with well-known family members,
caretakers, and familiar others, and initiates
and responds to social interactions through
gestural and emotional cues. Co-occurring
sensory and physical impairments may pre-
vent many social activities.

The individual is dependent on others for all aspects of
daily physical care, health, and safety, although he or
she may be able to participate in some of these activi-
ties as well. Individuals without severe physical
impairments may assist with some daily work tasks at
home, like carrying dishes to the table. Simple actions
with objects may be the basis of participation in some
vocational activities with high levels of ongoing sup-
port. Recreational activities may involve, for example,
enjoyment in listening to music, watching movies,
going out for walks, or participating in water activi-
ties, all with the support of others. Co-occurring
physical and sensory impairments are frequent
barriers to participation (beyond watching) in home,
recreational, and vocational activities. Maladaptive
behavior is present in a significant minority.

TABLE 1 Severity levels for intellectual disability (intellectual developmental disorder) (continued)

Severity
level Conceptual domain Social domain Practical domain

Intellectual Disability (Intellectual Developmental Disorder) 37

Diagnostic Features
The essential features of intellectual disability (intellectual developmental disorder) are
deficits in general mental abilities (Criterion A) and impairment in everyday adaptive
functioning, in comparison to an individual’s age-, gender-, and socioculturally matched
peers (Criterion B). Onset is during the developmental period (Criterion C). The diagnosis
of intellectual disability is based on both clinical assessment and standardized testing of
intellectual and adaptive functions.

Criterion A refers to intellectual functions that involve reasoning, problem solving,
planning, abstract thinking, judgment, learning from instruction and experience, and
practical understanding. Critical components include verbal comprehension, working
memory, perceptual reasoning, quantitative reasoning, abstract thought, and cognitive ef-
ficacy. Intellectual functioning is typically measured with individually administered and
psychometrically valid, comprehensive, culturally appropriate, psychometrically sound
tests of intelligence. Individuals with intellectual disability have scores of approximately
two standard deviations or more below the population mean, including a margin for mea-
surement error (generally +5 points). On tests with a standard deviation of 15 and a mean
of 100, this involves a score of 65–75 (70 ± 5). Clinical training and judgment are required
to interpret test results and assess intellectual performance.

Factors that may affect test scores include practice effects and the “Flynn effect’ (i.e.,
overly high scores due to out-of-date test norms). Invalid scores may result from the use of
brief intelligence screening tests or group tests; highly discrepant individual subtest scores
may make an overall IQ score invalid. Instruments must be normed for the individual’s so-
ciocultural background and native language. Co-occurring disorders that affect communi-
cation, language, and/or motor or sensory function may affect test scores. Individual
cognitive profiles based on neuropsychological testing are more useful for understanding
intellectual abilities than a single IQ score. Such testing may identify areas of relative
strengths and weaknesses, an assessment important for academic and vocational planning.

IQ test scores are approximations of conceptual functioning but may be insufficient to
assess reasoning in real-life situations and mastery of practical tasks. For example, a per-
son with an IQ score above 70 may have such severe adaptive behavior problems in social
judgment, social understanding, and other areas of adaptive functioning that the person’s
actual functioning is comparable to that of individuals with a lower IQ score. Thus, clinical
judgment is needed in interpreting the results of IQ tests.

Deficits in adaptive functioning (Criterion B) refer to how well a person meets community
standards of personal independence and social responsibility, in comparison to others of sim-
ilar age and sociocultural background. Adaptive functioning involves adaptive reasoning in
three domains: conceptual, social, and practical. The conceptual (academic) domain involves
competence in memory, language, reading, writing, math reasoning, acquisition of practical
knowledge, problem solving, and judgment in novel situations, among others. The social do-
main involves awareness of others’ thoughts, feelings, and experiences; empathy; interper-
sonal communication skills; friendship abilities; and social judgment, among others. The
practical domain involves learning and self-management across life settings, including personal
care, job responsibilities, money management, recreation, self-management of behavior, and
school and work task organization, among others. Intellectual capacity, education, motivation,
socialization, personality features, vocational opportunity, cultural experience, and coexisting
general medical conditions or mental disorders influence adaptive functioning.

Adaptive functioning is assessed using both clinical evaluation and individualized,
culturally appropriate, psychometrically sound measures. Standardized measures are
used with knowledgeable informants (e.g., parent or other family member; teacher; coun-
selor; care provider) and the individual to the extent possible. Additional sources of infor-
mation include educational, developmental, medical, and mental health evaluations.
Scores from standardized measures and interview sources must be interpreted using clin-
ical judgment. When standardized testing is difficult or impossible, because of a variety of

38 Neurodevelopmental Disorders

factors (e.g., sensory impairment, severe problem behavior), the individual may be diag-
nosed with unspecified intellectual disability. Adaptive functioning may be difficult to
assess in a controlled setting (e.g., prisons, detention centers); if possible, corroborative in-
formation reflecting functioning outside those settings should be obtained.

Criterion B is met when at least one domain of adaptive functioning—conceptual, so-
cial, or practical—is sufficiently impaired that ongoing support is needed in order for the
person to perform adequately in one or more life settings at school, at work, at home, or in
the community. To meet diagnostic criteria for intellectual disability, the deficits in adap-
tive functioning must be directly related to the intellectual impairments described in Cri-
terion A. Criterion C, onset during the developmental period, refers to recognition that
intellectual and adaptive deficits are present during childhood or adolescence.

Associated Features Supporting Diagnosis
Intellectual disability is a heterogeneous condition with multiple causes. There may be
associated difficulties with social judgment; assessment of risk; self-management of behav-
ior, emotions, or interpersonal relationships; or motivation in school or work environments.
Lack of communication skills may predispose to disruptive and aggressive behaviors. Gull-
ibility is often a feature, involving naiveté in social situations and a tendency for being easily
led by others. Gullibility and lack of awareness of risk may result in exploitation by others
and possible victimization, fraud, unintentional criminal involvement, false confessions,
and risk for physical and sexual abuse. These associated features can be important in crim-
inal cases, including Atkins-type hearings involving the death penalty.

Individuals with a diagnosis of intellectual disability with co-occurring mental disor-
ders are at risk for suicide. They think about suicide, make suicide attempts, and may die
from them. Thus, screening for suicidal thoughts is essential in the assessment process. Be-
cause of a lack of awareness of risk and danger, accidental injury rates may be increased.

Prevalence
Intellectual disability has an overall general population prevalence of approximately 1%,
and prevalence rates vary by age. Prevalence for severe intellectual disability is approxi-
mately 6 per 1,000.

Development and Course
Onset of intellectual disability is in the developmental period. The age and characteristic
features at onset depend on the etiology and severity of brain dysfunction. Delayed motor,
language, and social milestones may be identifiable within the first 2 years of life among
those with more severe intellectual disability, while mild levels may not be identifiable un-
til school age when difficulty with academic learning becomes apparent. All criteria (in-
cluding Criterion C) must be fulfilled by history or current presentation. Some children
under age 5 years whose presentation will eventually meet criteria for intellectual disabil-
ity have deficits that meet criteria for global developmental delay.

When intellectual disability is associated with a genetic syndrome, there may be a char-
acteristic physical appearance (as in, e.g., Down syndrome). Some syndromes have a
behavioral phenotype, which refers to specific behaviors that are characteristic of particular
genetic disorder (e.g., Lesch-Nyhan syndrome). In acquired forms, the onset may be
abrupt following an illness such as meningitis or encephalitis or head trauma occurring
during the developmental period. When intellectual disability results from a loss of pre-
viously acquired cognitive skills, as in severe traumatic brain injury, the diagnoses of in-
tellectual disability and of a neurocognitive disorder may both be assigned.

Although intellectual disability is generally nonprogressive, in certain genetic disor-
ders (e.g., Rett syndrome) there are periods of worsening, followed by stabilization, and in

Intellectual Disability (Intellectual Developmental Disorder) 39

others (e.g., San Phillippo syndrome) progressive worsening of intellectual function. After
early childhood, the disorder is generally lifelong, although severity levels may change
over time. The course may be influenced by underlying medical or genetic conditions and
co-occurring conditions (e.g., hearing or visual impairments, epilepsy). Early and ongoing in-
terventions may improve adaptive functioning throughout childhood and adulthood. In
some cases, these result in significant improvement of intellectual functioning, such that
the diagnosis of intellectual disability is no longer appropriate. Thus, it is common practice
when assessing infants and young children to delay diagnosis of intellectual disability un-
til after an appropriate course of intervention is provided. For older children and adults,
the extent of support provided may allow for full participation in all activities of daily liv-
ing and improved adaptive function. Diagnostic assessments must determine whether im-
proved adaptive skills are the result of a stable, generalized new skill acquisition (in which
case the diagnosis of intellectual disability may no longer be appropriate) or whether the
improvement is contingent on the presence of supports and ongoing interventions (in
which case the diagnosis of intellectual disability may still be appropriate).

Risk and Prognostic Factors
Genetic and physiological. Prenatal etiologies include genetic syndromes (e.g., se-
quence variations or copy number variants involving one or more genes; chromosomal
disorders), inborn errors of metabolism, brain malformations, maternal disease (including
placental disease), and environmental influences (e.g., alcohol, other drugs, toxins, terato-
gens). Perinatal causes include a variety of labor and delivery-related events leading to
neonatal encephalopathy. Postnatal causes include hypoxic ischemic injury, traumatic
brain injury, infections, demyelinating disorders, seizure disorders (e.g., infantile spasms),
severe and chronic social deprivation, and toxic metabolic syndromes and intoxications
(e.g., lead, mercury).

Culture-Related Diagnostic Issues
Intellectual disability occurs in all races and cultures. Cultural sensitivity and knowledge
are needed during assessment, and the individual’s ethnic, cultural, and linguistic back-
ground, available experiences, and adaptive functioning within his or her community and
cultural setting must be taken into account.

Gender-Related Diagnostic Issues
Overall, males are more likely than females to be diagnosed with both mild (average
male:female ratio 1.6:1) and severe (average male:female ratio 1.2:1) forms of intellectual
disability. However, gender ratios vary widely in reported studies. Sex-linked genetic fac-
tors and male vulnerability to brain insult may account for some of the gender differences.

Diagnostic Markers
A comprehensive evaluation includes an assessment of intellectual capacity and adaptive
functioning; identification of genetic and nongenetic etiologies; evaluation for associated
medical conditions (e.g., cerebral palsy, seizure disorder); and evaluation for co-occurring
mental, emotional, and behavioral disorders. Components of the evaluation may include
basic pre- and perinatal medical history, three-generational family pedigree, physical exam-
ination, genetic evaluation (e.g., karyotype or chromosomal microarray analysis and testing
for specific genetic syndromes), and metabolic screening and neuroimaging assessment.

Differential Diagnosis
The diagnosis of intellectual disability should be made whenever Criteria A, B, and C are
met. A diagnosis of intellectual disability should not be assumed because of a particular

40 Neurodevelopmental Disorders

genetic or medical condition. A genetic syndrome linked to intellectual disability should
be noted as a concurrent diagnosis with the intellectual disability.

Major and mild neurocognitive disorders. Intellectual disability is categorized as a neu-
rodevelopmental disorder and is distinct from the neurocognitive disorders, which are
characterized by a loss of cognitive functioning. Major neurocognitive disorder may co-
occur with intellectual disability (e.g., an individual with Down syndrome who develops
Alzheimer’s disease, or an individual with intellectual disability who loses further cogni-
tive capacity following a head injury). In such cases, the diagnoses of intellectual disability
and neurocognitive disorder may both be given.

Communication disorders and specific learning disorder. These neurodevelopmental
disorders are specific to the communication and learning domains and do not show defi-
cits in intellectual and adaptive behavior. They may co-occur with intellectual disability.
Both diagnoses are made if full criteria are met for intellectual disability and a communi-
cation disorder or specific learning disorder.

Autism spectrum disorder. Intellectual disability is common among individuals with
autism spectrum disorder. Assessment of intellectual ability may be complicated by so-
cial-communication and behavior deficits inherent to autism spectrum disorder, which
may interfere with understanding and complying with test procedures. Appropriate as-
sessment of intellectual functioning in autism spectrum disorder is essential, with reas-
sessment across the developmental period, because IQ scores in autism spectrum disorder
may be unstable, particularly in early childhood.

Comorbidity
Co-occurring mental, neurodevelopmental, medical, and physical conditions are frequent
in intellectual disability, with rates of some conditions (e.g., mental disorders, cerebral
palsy, and epilepsy) three to four times higher than in the general population. The prognosis
and outcome of co-occurring diagnoses may be influenced by the presence of intellectual
disability. Assessment procedures may require modifications because of associated disor-
ders, including communication disorders, autism spectrum disorder, and motor, sensory,
or other disorders. Knowledgeable informants are essential for identifying symptoms
such as irritability, mood dysregulation, aggression, eating problems, and sleep problems,
and for assessing adaptive functioning in various community settings.

The most common co-occurring mental and neurodevelopmental disorders are atten-
tion-deficit/hyperactivity disorder; depressive and bipolar disorders; anxiety disorders;
autism spectrum disorder; stereotypic movement disorder (with or without self-injurious
behavior); impulse-control disorders; and major neurocognitive disorder. Major depres-
sive disorder may occur throughout the range of severity of intellectual disability. Self-
injurious behavior requires prompt diagnostic attention and may warrant a separate di-
agnosis of stereotypic movement disorder. Individuals with intellectual disability, partic-
ularly those with more severe intellectual disability, may also exhibit aggression and
disruptive behaviors, including harm of others or property destruction.

Relationship to Other Classifications
ICD-11 (in development at the time of this publication) uses the term intellectual develop-
mental disorders to indicate that these are disorders that involve impaired brain functioning
early in life. These disorders are described in ICD-11 as a metasyndrome occurring in the
developmental period analogous to dementia or neurocognitive disorder in later life.
There are four subtypes in ICD-11: mild, moderate, severe, and profound.

The American Association on Intellectual and Developmental Disabilities (AAIDD)
also uses the term intellectual disability with a similar meaning to the term as used in this

Global Developmental Delay 41

manual. The AAIDD’s classification is multidimensional rather than categorical and is
based on the disability construct. Rather than listing specifiers as is done in DSM-5, the
AAIDD emphasizes a profile of supports based on severity.

Global Developmental Delay
315.8 (F88)

This diagnosis is reserved for individuals under the age of 5 years when the clinical severity
level cannot be reliably assessed during early childhood. This category is diagnosed when
an individual fails to meet expected developmental milestones in several areas of intellec-
tual functioning, and applies to individuals who are unable to undergo systematic assess-
ments of intellectual functioning, including children who are too young to participate in
standardized testing. This category requires reassessment after a period of time.

Unspecified Intellectual Disability
(Intellectual Developmental Disorder)

319 (F79)

This category is reserved for individuals over the age of 5 years when assessment of the
degree of intellectual disability (intellectual developmental disorder) by means of locally
available procedures is rendered difficult or impossible because of associated sensory or
physical impairments, as in blindness or prelingual deafness; locomotor disability; or pres-
ence of severe problem behaviors or co-occurring mental disorder. This category should
only be used in exceptional circumstances and requires reassessment after a period of time.

Communication Disorders

Disorders of communication include deficits in language, speech, and communication.
Speech is the expressive production of sounds and includes an individual’s articulation,
fluency, voice, and resonance quality. Language includes the form, function, and use of a
conventional system of symbols (i.e., spoken words, sign language, written words, pic-
tures) in a rule-governed manner for communication. Communication includes any verbal
or nonverbal behavior (whether intentional or unintentional) that influences the behavior,
ideas, or attitudes of another individual. Assessments of speech, language and communi-
cation abilities must take into account the individual’s cultural and language context,
particularly for individuals growing up in bilingual environments. The standardized mea-
sures of language development and of nonverbal intellectual capacity must be relevant for
the cultural and linguistic group (i.e., tests developed and standardized for one group may
not provide appropriate norms for a different group). The diagnostic category of commu-
nication disorders includes the following: language disorder, speech sound disorder,
childhood-onset fluency disorder (stuttering), social (pragmatic) communication disor-
der, and other specified and unspecified communication disorders.

42 Neurodevelopmental Disorders

Language Disorder
Diagnostic Criteria 315.32 (F80.2)

A. Persistent difficulties in the acquisition and use of language across modalities (i.e.,
spoken, written, sign language, or other) due to deficits in comprehension or produc-
tion that include the following:

1. Reduced vocabulary (word knowledge and use).
2. Limited sentence structure (ability to put words and word endings together to form

sentences based on the rules of grammar and morphology).
3. Impairments in discourse (ability to use vocabulary and connect sentences to ex-

plain or describe a topic or series of events or have a conversation).

B. Language abilities are substantially and quantifiably below those expected for age, re-
sulting in functional limitations in effective communication, social participation, aca-
demic achievement, or occupational performance, individually or in any combination.

C. Onset of symptoms is in the early developmental period.
D. The difficulties are not attributable to hearing or other sensory impairment, motor dys-

function, or another medical or neurological condition and are not better explained by in-
tellectual disability (intellectual developmental disorder) or global developmental delay.

Diagnostic Features
The core diagnostic features of language disorder are difficulties in the acquisition and use
of language due to deficits in the comprehension or production of vocabulary, sentence
structure, and discourse. The language deficits are evident in spoken communication,
written communication, or sign language. Language learning and use is dependent on
both receptive and expressive skills. Expressive ability refers to the production of vocal, ges-
tural, or verbal signals, while receptive ability refers to the process of receiving and com-
prehending language messages. Language skills need to be assessed in both expressive
and receptive modalities as these may differ in severity. For example, an individual’s ex-
pressive language may be severely impaired, while his receptive language is hardly im-
paired at all.

Language disorder usually affects vocabulary and grammar, and these effects then
limit the capacity for discourse. The child’s first words and phrases are likely to be delayed
in onset; vocabulary size is smaller and less varied than expected; and sentences are
shorter and less complex with grammatical errors, especially in past tense. Deficits in com-
prehension of language are frequently underestimated, as children may be good at using
context to infer meaning. There may be word-finding problems, impoverished verbal def-
initions, or poor understanding of synonyms, multiple meanings, or word play appro-
priate for age and culture. Problems with remembering new words and sentences are
manifested by difficulties following instructions of increasing length, difficulties rehears-
ing strings of verbal information (e.g., remembering a phone number or a shopping list),
and difficulties remembering novel sound sequences, a skill that may be important for
learning new words. Difficulties with discourse are shown by a reduced ability to provide
adequate information about the key events and to narrate a coherent story.

The language difficulty is manifest by abilities substantially and quantifiably below
that expected for age and significantly interfering with academic achievement, occupa-
tional performance, effective communication, or socialization (Criterion B). A diagnosis of
language disorder is made based on the synthesis of the individual’s history, direct clinical
observation in different contexts (i.e., home, school, or work), and scores from standard-
ized tests of language ability that can be used to guide estimates of severity.

Language Disorder 43

Associated Features Supporting Diagnosis
A positive family history of language disorders is often present. Individuals, even chil-
dren, can be adept at accommodating to their limited language. They may appear to be shy
or reticent to talk. Affected individuals may prefer to communicate only with family mem-
bers or other familiar individuals. Although these social indicators are not diagnostic of a
language disorder, if they are notable and persistent, they warrant referral for a full lan-
guage assessment. Language disorder, particularly expressive deficits, may co-occur with
speech sound disorder.

Development and Course
Language acquisition is marked by changes from onset in toddlerhood to the adult level of
competency that appears during adolescence. Changes appear across the dimensions of
language (sounds, words, grammar, narratives/expository texts, and conversational
skills) in age-graded increments and synchronies. Language disorder emerges during the
early developmental period; however, there is considerable variation in early vocabulary
acquisition and early word combinations, and individual differences are not, as single
indicators, highly predictive of later outcomes. By age 4 years, individual differences in
language ability are more stable, with better measurement accuracy, and are highly pre-
dictive of later outcomes. Language disorder diagnosed from 4 years of age is likely to be
stable over time and typically persists into adulthood, although the particular profile of
language strengths and deficits is likely to change over the course of development.

Risk and Prognostic Factors
Children with receptive language impairments have a poorer prognosis than those with
predominantly expressive impairments. They are more resistant to treatment, and diffi-
culties with reading comprehension are frequently seen.

Genetic and physiological. Language disorders are highly heritable, and family mem-
bers are more likely to have a history of language impairment.

Differential Diagnosis
Normal variations in language. Language disorder needs to be distinguished from nor-
mal developmental variations, and this distinction may be difficult to make before 4 years
of age. Regional, social, or cultural/ethnic variations of language (e.g., dialects) must be
considered when an individual is being assessed for language impairment.

Hearing or other sensory impairment. Hearing impairment needs to be excluded as the
primary cause of language difficulties. Language deficits may be associated with a hearing
impairment, other sensory deficit, or a speech-motor deficit. When language deficits are in
excess of those usually associated with these problems, a diagnosis of language disorder
may be made.

Intellectual disability (intellectual developmental disorder). Language delay is often the
presenting feature of intellectual disability, and the definitive diagnosis may not be made
until the child is able to complete standardized assessments. A separate diagnosis is not
given unless the language deficits are clearly in excess of the intellectual limitations.

Neurological disorders. Language disorder can be acquired in association with neuro-
logical disorders, including epilepsy (e.g., acquired aphasia or Landau-Kleffner syndrome).

Language regression. Loss of speech and language in a child younger than 3 years may
be a sign of autism spectrum disorder (with developmental regression) or a specific neuro-
logical condition, such as Landau-Kleffner syndrome. Among children older than 3 years,
language loss may be a symptom of seizures, and a diagnostic assessment is necessary to
exclude the presence of epilepsy (e.g., routine and sleep electroencephalogram).

44 Neurodevelopmental Disorders

Comorbidity
Language disorder is strongly associated with other neurodevelopmental disorders in
terms of specific learning disorder (literacy and numeracy), attention-deficit/hyperactiv-
ity disorder, autism spectrum disorder, and developmental coordination disorder. It is
also associated with social (pragmatic) communication disorder. A positive family history
of speech or language disorders is often present.

Speech Sound Disorder
Diagnostic Criteria 315.39 (F80.0)

A. Persistent difficulty with speech sound production that interferes with speech intelligi-
bility or prevents verbal communication of messages.

B. The disturbance causes limitations in effective communication that interfere with social
participation, academic achievement, or occupational performance, individually or in
any combination.

C. Onset of symptoms is in the early developmental period.
D. The difficulties are not attributable to congenital or acquired conditions, such as cere-

bral palsy, cleft palate, deafness or hearing loss, traumatic brain injury, or other medi-
cal or neurological conditions.

Diagnostic Features
Speech sound production describes the clear articulation of the phonemes (i.e., individual
sounds) that in combination make up spoken words. Speech sound production requires both
the phonological knowledge of speech sounds and the ability to coordinate the movements of
the articulators (i.e., the jaw, tongue, and lips,) with breathing and vocalizing for speech. Chil-
dren with speech production difficulties may experience difficulty with phonological knowl-
edge of speech sounds or the ability to coordinate movements for speech in varying degrees.
Speech sound disorder is thus heterogeneous in its underlying mechanisms and includes pho-
nological disorder and articulation disorder. A speech sound disorder is diagnosed when
speech sound production is not what would be expected based on the child’s age and devel-
opmental stage and when the deficits are not the result of a physical, structural, neurological,
or hearing impairment. Among typically developing children at age 4 years, overall speech
should be intelligible, whereas at age 2 years, only 50% may be understandable.

Associated Features Supporting Diagnosis
Language disorder, particularly expressive deficits, may be found to co-occur with speech
sound disorder. A positive family history of speech or language disorders is often present.

If the ability to rapidly coordinate the articulators is a particular aspect of difficulty,
there may be a history of delay or incoordination in acquiring skills that also utilize the
articulators and related facial musculature; among others, these skills include chewing,
maintaining mouth closure, and blowing the nose. Other areas of motor coordination may
be impaired as in developmental coordination disorder. Verbal dyspraxia is a term also
used for speech production problems.

Speech may be differentially impaired in certain genetic conditions (e.g., Down syn-
drome, 22q deletion, FoxP2 gene mutation). If present, these should also be coded.

Development and Course
Learning to produce speech sounds clearly and accurately and learning to produce con-
nected speech fluently are developmental skills. Articulation of speech sounds follows a

Childhood-Onset Fluency Disorder (Stuttering) 45

developmental pattern, which is reflected in the age norms of standardized tests. It is not
unusual for typically developing children to use developmental processes for shortening
words and syllables as they are learning to talk, but their progression in mastering speech
sound production should result in mostly intelligible speech by age 3 years. Children with
speech sound disorder continue to use immature phonological simplification processes
past the age when most children can produce words clearly.

Most speech sounds should be produced clearly and most words should be pronounced
accurately according to age and community norms by age 7 years. The most frequently mis-
articulated sounds also tend to be learned later, leading them to be called the “late eight” (l, r,
s, z, th, ch, dzh, and zh). Misarticulation of any of these sounds by itself could be considered
within normal limits up to age 8 years. When multiple sounds are involved, it may be appro-
priate to target some of those sounds as part of a plan to improve intelligibility prior to the age
at which almost all children can produce them accurately. Lisping (i.e., misarticulating sibi-
lants) is particularly common and may involve frontal or lateral patterns of airstream direc-
tion. It may be associated with an abnormal tongue-thrust swallowing pattern.

Most children with speech sound disorder respond well to treatment, and speech dif-
ficulties improve over time, and thus the disorder may not be lifelong. However, when a
language disorder is also present, the speech disorder has a poorer prognosis and may be
associated with specific learning disorders.

Differential Diagnosis
Normal variations in speech. Regional, social, or cultural/ethnic variations of speech
should be considered before making the diagnosis.

Hearing or other sensory impairment. Hearing impairment or deafness may result in
abnormalities of speech. Deficits of speech sound production may be associated with a
hearing impairment, other sensory deficit, or a speech-motor deficit. When speech deficits
are in excess of those usually associated with these problems, a diagnosis of speech sound
disorder may be made.

Structural deficits. Speech impairment may be due to structural deficits (e.g., cleft palate).

Dysarthria. Speech impairment may be attributable to a motor disorder, such as cerebral
palsy. Neurological signs, as well as distinctive features of voice, differentiate dysarthria
from speech sound disorder, although in young children (under 3 years) differentiation
may be difficult, particularly when there is no or minimal general body motor involve-
ment (as in, e.g., Worster-Drought syndrome).

Selective mutism. Limited use of speech may be a sign of selective mutism, an anxiety
disorder that is characterized by a lack of speech in one or more contexts or settings. Se-
lective mutism may develop in children with a speech disorder because of embarassment
about their impairments, but many children with selective mutism exhibit normal speech
in “safe” settings, such as at home or with close friends.

Childhood-Onset Fluency Disorder (Stuttering)
Diagnostic Criteria 315.35 (F80.81)

A. Disturbances in the normal fluency and time patterning of speech that are inappropri-
ate for the individual’s age and language skills, persist over time, and are characterized
by frequent and marked occurrences of one (or more) of the following: 

1. Sound and syllable repetitions.
2. Sound prolongations of consonants as well as vowels.

46 Neurodevelopmental Disorders

3. Broken words (e.g., pauses within a word).
4. Audible or silent blocking (filled or unfilled pauses in speech).
5. Circumlocutions (word substitutions to avoid problematic words).
6. Words produced with an excess of physical tension.
7. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”).

B. The disturbance causes anxiety about speaking or limitations in effective communica-
tion, social participation, or academic or occupational performance, individually or in
any combination.

C. The onset of symptoms is in the early developmental period. (Note: Later-onset cases
are diagnosed as 307.0 [F98.5] adult-onset fluency disorder.)

D. The disturbance is not attributable to a speech-motor or sensory deficit, dysfluency as-
sociated with neurological insult (e.g., stroke, tumor, trauma), or another medical con-
dition and is not better explained by another mental disorder.

Diagnostic Features
The essential feature of childhood-onset fluency disorder (stuttering) is a disturbance in
the normal fluency and time patterning of speech that is inappropriate for the individual’s
age. This disturbance is characterized by frequent repetitions or prolongations of sounds
or syllables and by other types of speech dysfluencies, including broken words (e.g.,
pauses within a word), audible or silent blocking (i.e., filled or unfilled pauses in speech),
circumlocutions (i.e., word substitutions to avoid problematic words), words produced
with an excess of physical tension, and monosyllabic whole-word repetitions (e.g., “I-I-I-I
see him”). The disturbance in fluency interferes with academic or occupational achieve-
ment or with social communication. The extent of the disturbance varies from situation to
situation and often is more severe when there is special pressure to communicate (e.g., giv-
ing a report at school, interviewing for a job). Dysfluency is often absent during oral read-
ing, singing, or talking to inanimate objects or to pets.

Associated Features Supporting Diagnosis
Fearful anticipation of the problem may develop. The speaker may attempt to avoid dys-
fluencies by linguistic mechanisms (e.g., altering the rate of speech, avoiding certain
words or sounds) or by avoiding certain speech situations, such as telephoning or public
speaking. In addition to being features of the condition, stress and anxiety have been
shown to exacerbate dysfluency.

Childhood-onset fluency disorder may also be accompanied by motor movements
(e.g., eye blinks, tics, tremors of the lips or face, jerking of the head, breathing movements,
fist clenching). Children with fluency disorder show a range of language abilities, and the
relationship between fluency disorder and language abilities is unclear.

Development and Course
Childhood-onset fluency disorder, or developmental stuttering, occurs by age 6 for 80%–
90% of affected individuals, with age at onset ranging from 2 to 7 years. The onset can be
insidious or more sudden. Typically, dysfluencies start gradually, with repetition of initial
consonants, first words of a phrase, or long words. The child may not be aware of dysflu-
encies. As the disorder progresses, the dysfluencies become more frequent and interfering,
occurring on the most meaningful words or phrases in the utterance. As the child becomes
aware of the speech difficulty, he or she may develop mechanisms for avoiding the dys-
fluencies and emotional responses, including avoidance of public speaking and use of
short and simple utterances. Longitudinal research shows that 65%–85% of children re-

Social (Pragmatic) Communication Disorder 47

cover from the dysfluency, with severity of fluency disorder at age 8 years predicting re-
covery or persistence into adolescence and beyond.

Risk and Prognostic Factors
Genetic and physiological. The risk of stuttering among first-degree biological rela-
tives of individuals with childhood-onset fluency disorder is more than three times the
risk in the general population.

Functional Consequences of
Childhood-Onset Fluency Disorder (Stuttering)
In addition to being features of the condition, stress and anxiety can exacerbate dysflu-
ency. Impairment of social functioning may result from this anxiety.

Differential Diagnosis
Sensory deficits. Dysfluencies of speech may be associated with a hearing impairment
or other sensory deficit or a speech-motor deficit. When the speech dysfluencies are in ex-
cess of those usually associated with these problems, a diagnosis of childhood-onset flu-
ency disorder may be made.

Normal speech dysfluencies. The disorder must be distinguished from normal dysflu-
encies that occur frequently in young children, which include whole-word or phrase rep-
etitions (e.g., “I want, I want ice cream”), incomplete phrases, interjections, unfilled
pauses, and parenthetical remarks. If these difficulties increase in frequency or complexity
as the child grows older, a diagnosis of childhood-onset fluency disorder is appropriate.

Medication side effects. Stuttering may occur as a side effect of medication and may be
detected by a temporal relationship with exposure to the medication.

Adult-onset dysfluencies. If onset of dysfluencies is during or after adolescence, it is an
“adult-onset dysfluency” rather than a neurodevelopmental disorder. Adult-onset dysflu-
encies are associated with specific neurological insults and a variety of medical conditions
and mental disorders and may be specified with them, but they are not a DSM-5 diagnosis.

Tourette’s disorder. Vocal tics and repetitive vocalizations of Tourette’s disorder
should be distinguishable from the repetitive sounds of childhood-onset fluency disorder
by their nature and timing.

Social (Pragmatic) Communication Disorder
Diagnostic Criteria 315.39 (F80.89)

A. Persistent difficulties in the social use of verbal and nonverbal communication as man-
ifested by all of the following:

1. Deficits in using communication for social purposes, such as greeting and sharing
information, in a manner that is appropriate for the social context.

2. Impairment of the ability to change communication to match context or the needs of
the listener, such as speaking differently in a classroom than on a playground, talk-
ing differently to a child than to an adult, and avoiding use of overly formal language.

3. Difficulties following rules for conversation and storytelling, such as taking turns in
conversation, rephrasing when misunderstood, and knowing how to use verbal and
nonverbal signals to regulate interaction.

48 Neurodevelopmental Disorders

4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and
nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors,
multiple meanings that depend on the context for interpretation).

B. The deficits result in functional limitations in effective communication, social participa-
tion, social relationships, academic achievement, or occupational performance, indi-
vidually or in combination.

C. The onset of the symptoms is in the early developmental period (but deficits may not
become fully manifest until social communication demands exceed limited capacities).

D. The symptoms are not attributable to another medical or neurological condition or to low
abilities in the domains of word structure and grammar, and are not better explained by
autism spectrum disorder, intellectual disability (intellectual developmental disorder),
global developmental delay, or another mental disorder.

Diagnostic Features
Social (pragmatic) communication disorder is characterized by a primary difficulty with
pragmatics, or the social use of language and communication, as manifested by deficits in
understanding and following social rules of verbal and nonverbal communication in nat-
uralistic contexts, changing language according to the needs of the listener or situation,
and following rules for conversations and storytelling. The deficits in social communica-
tion result in functional limitations in effective communication, social participation, devel-
opment of social relationships, academic achievement, or occupational performance. The
deficits are not better explained by low abilities in the domains of structural language or
cognitive ability.

Associated Features Supporting Diagnosis
The most common associated feature of social (pragmatic) communication disorder is lan-
guage impairment, which is characterized by a history of delay in reaching language mile-
stones, and historical, if not current, structural language problems (see “Language Disorder”
earlier in this chapter). Individuals with social communication deficits may avoid social inter-
actions. Attention-deficit/hyperactivity disorder (ADHD), behavioral problems, and specific
learning disorders are also more common among affected individuals.

Development and Course
Because social (pragmatic) communication depends on adequate developmental progress
in speech and language, diagnosis of social (pragmatic) communication disorder is rare
among children younger than 4 years. By age 4 or 5 years, most children should possess
adequate speech and language abilities to permit identification of specific deficits in social
communication. Milder forms of the disorder may not become apparent until early ado-
lescence, when language and social interactions become more complex.

The outcome of social (pragmatic) communication disorder is variable, with some chil-
dren improving substantially over time and others continuing to have difficulties persist-
ing into adulthood. Even among those who have significant improvements, the early
deficits in pragmatics may cause lasting impairments in social relationships and behavior
and also in acquisition of other related skills, such as written expression.

Risk and Prognostic Factors
Genetic and physiological. A family history of autism spectrum disorder, communica-
tion disorders, or specific learning disorder appears to increase the risk for social (prag-
matic) communication disorder.

Unspecified Communication Disorder 49

Differential Diagnosis
Autism spectrum disorder. Autism spectrum disorder is the primary diagnostic con-
sideration for individuals presenting with social communication deficits. The two disor-
ders can be differentiated by the presence in autism spectrum disorder of restricted/
repetitive patterns of behavior, interests, or activities and their absence in social (prag-
matic) communication disorder. Individuals with autism spectrum disorder may only dis-
play the restricted/repetitive patterns of behavior, interests, and activities during the early
developmental period, so a comprehensive history should be obtained. Current absence of
symptoms would not preclude a diagnosis of autism spectrum disorder, if the restricted
interests and repetitive behaviors were present in the past. A diagnosis of social (prag-
matic) communication disorder should be considered only if the developmental history
fails to reveal any evidence of restricted/repetitive patterns of behavior, interests, or ac-
tivities.

Attention-deficit/hyperactivity disorder. Primary deficits of ADHD may cause impair-
ments in social communication and functional limitations of effective communication, so-
cial participation, or academic achievement.

Social anxiety disorder (social phobia). The symptoms of social communication disor-
der overlap with those of social anxiety disorder. The differentiating feature is the timing
of the onset of symptoms. In social (pragmatic) communication disorder, the individual
has never had effective social communication; in social anxiety disorder, the social com-
munication skills developed appropriately but are not utilized because of anxiety, fear, or
distress about social interactions.

Intellectual disability (intellectual developmental disorder) and global developmental
delay. Social communication skills may be deficient among individuals with global de-
velopmental delay or intellectual disability, but a separate diagnosis is not given unless
the social communication deficits are clearly in excess of the intellectual limitations.

Unspecified Communication Disorder
307.9 (F80.9)

This category applies to presentations in which symptoms characteristic of communication
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for com-
munication disorder or for any of the disorders in the neurodevelopmental disorders diag-
nostic class. The unspecified communication disorder category is used in situations in
which the clinician chooses not to specify the reason that the criteria are not met for com-
munication disorder or for a specific neurodevelopmental disorder, and includes presen-
tations in which there is insufficient information to make a more specific diagnosis.

50 Neurodevelopmental Disorders

Autism Spectrum Disorder

Autism Spectrum Disorder
Diagnostic Criteria 299.00 (F84.0)

A. Persistent deficits in social communication and social interaction across multiple con-
texts, as manifested by the following, currently or by history (examples are illustrative,
not exhaustive; see text):

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social
approach and failure of normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging,
for example, from poorly integrated verbal and nonverbal communication; to abnor-
malities in eye contact and body language or deficits in understanding and use of
gestures; to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for ex-
ample, from difficulties adjusting behavior to suit various social contexts; to difficulties
in sharing imaginative play or in making friends; to absence of interest in peers.

Specify current severity:
Severity is based on social communication impairments and restricted, re-
petitive patterns of behavior (seeTable 2).

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at
least two of the following, currently or by history (examples are illustrative, not exhaus-
tive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple
motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic
phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of
verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties
with transitions, rigid thinking patterns, greeting rituals, need to take same route or
eat same food every day).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g.,
strong attachment to or preoccupation with unusual objects, excessively circum-
scribed or perseverative interests).

4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of
the environment (e.g., apparent indifference to pain/temperature, adverse re-
sponse to specific sounds or textures, excessive smelling or touching of objects,
visual fascination with lights or movement).

Specify current severity:
Severity is based on social communication impairments and restricted, re-
petitive patterns of behavior (see Table 2).

C. Symptoms must be present in the early developmental period (but may not become
fully manifest until social demands exceed limited capacities, or may be masked by
learned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other im-
portant areas of current functioning.

Autism Spectrum Disorder 51

E. These disturbances are not better explained by intellectual disability (intellectual devel-
opmental disorder) or global developmental delay. Intellectual disability and autism
spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spec-
trum disorder and intellectual disability, social communication should be below that ex-
pected for general developmental level.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s
disorder, or pervasive developmental disorder not otherwise specified should be given the
diagnosis of autism spectrum disorder. Individuals who have marked deficits in social
communication, but whose symptoms do not otherwise meet criteria for autism spectrum
disorder, should be evaluated for social (pragmatic) communication disorder.

Specify if:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Associated with a known medical or genetic condition or environmental factor
(Coding note: Use additional code to identify the associated medical or genetic condition.)
Associated with another neurodevelopmental, mental, or behavioral disorder
(Coding note: Use additional code[s] to identify the associated neurodevelopmental,
mental, or behavioral disorder[s].)
With catatonia (refer to the criteria for catatonia associated with another mental dis-
order, pp. 119–120, for definition) (Coding note: Use additional code 293.89 [F06.1]
catatonia associated with autism spectrum disorder to indicate the presence of the co-
morbid catatonia.)

Recording Procedures
For autism spectrum disorder that is associated with a known medical or genetic condition
or environmental factor, or with another neurodevelopmental, mental, or behavioral dis-
order, record autism spectrum disorder associated with (name of condition, disorder, or
factor) (e.g., autism spectrum disorder associated with Rett syndrome). Severity should be
recorded as level of support needed for each of the two psychopathological domains in
Table 2 (e.g., “requiring very substantial support for deficits in social communication and
requiring substantial support for restricted, repetitive behaviors”). Specification of “with
accompanying intellectual impairment” or “without accompanying intellectual impair-
ment” should be recorded next. Language impairment specification should be recorded
thereafter. If there is accompanying language impairment, the current level of verbal func-
tioning should be recorded (e.g., “with accompanying language impairment—no intelligi-
ble speech” or “with accompanying language impairment—phrase speech”). If catatonia is
present, record separately “catatonia associated with autism spectrum disorder.”

Specifiers
The severity specifiers (see Table 2) may be used to describe succinctly the current symp-
tomatology (which might fall below level 1), with the recognition that severity may vary by
context and fluctuate over time. Severity of social communication difficulties and re-
stricted, repetitive behaviors should be separately rated. The descriptive severity categories
should not be used to determine eligibility for and provision of services; these can only be
developed at an individual level and through discussion of personal priorities and targets.

Regarding the specifier “with or without accompanying intellectual impairment,” un-
derstanding the (often uneven) intellectual profile of a child or adult with autism spectrum
disorder is necessary for interpreting diagnostic features. Separate estimates of verbal and
nonverbal skill are necessary (e.g., using untimed nonverbal tests to assess potential
strengths in individuals with limited language).

5
2

N
e

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ro

d
e

ve
lo

p
m

e
n

ta
l D

iso
rd

e
rs

TABLE 2 Severity levels for autism spectrum disorder

Severity level Social communication Restricted, repetitive behaviors

Level 3

“Requiring very substantial support”

Severe deficits in verbal and nonverbal social com-
munication skills cause severe impairments in func-
tioning, very limited initiation of social
interactions, and minimal response to social over-
tures from others. For example, a person with few
words of intelligible speech who rarely initiates
interaction and, when he or she does, makes
unusual approaches to meet needs only and
responds to only very direct social approaches.

Inflexibility of behavior, extreme difficulty coping
with change, or other restricted/repetitive behav-
iors markedly interfere with functioning in all
spheres. Great distress/difficulty changing focus
or action.

Level 2

“Requiring substantial support”

Marked deficits in verbal and nonverbal social com-
munication skills; social impairments apparent
even with supports in place; limited initiation of
social interactions; and reduced or abnormal
responses to social overtures from others. For
example, a person who speaks simple sentences,
whose interaction is limited to narrow special inter-
ests, and who has markedly odd nonverbal com-
munication.

Inflexibility of behavior, difficulty coping with
change, or other restricted/repetitive behaviors
appear frequently enough to be obvious to the
casual observer and interfere with functioning
in a variety of contexts. Distress and/or difficulty
changing focus or action.

Level 1

“Requiring support”

Without supports in place, deficits in social communi-
cation cause noticeable impairments.
Difficulty initiating social interactions, and clear
examples of atypical or unsuccessful responses to
social overtures of others. May appear to have
decreased interest in social interactions. For example,
a person who is able to speak in full sentences and
engages in communication but whose to-and-fro con-
versation with others fails, and whose attempts to
make friends are odd and typically unsuccessful.

Inflexibility of behavior causes significant interfer-
ence with functioning in one or more contexts. Dif-
ficulty switching between activities. Problems of
organization and planning hamper independence.

Autism Spectrum Disorder 53

To use the specifier “with or without accompanying language impairment,” the cur-
rent level of verbal functioning should be assessed and described. Examples of the specific
descriptions for “with accompanying language impairment” might include no intelligible
speech (nonverbal), single words only, or phrase speech. Language level in individuals
“without accompanying language impairment” might be further described by speaks in
full sentences or has fluent speech. Since receptive language may lag behind expressive
language development in autism spectrum disorder, receptive and expressive language
skills should be considered separately.

The specifier “associated with a known medical or genetic condition or environmental fac-
tor” should be used when the individual has a known genetic disorder (e.g., Rett syndrome,
Fragile X syndrome, Down syndrome), a medical disorder (e.g. epilepsy), or a history of envi-
ronmental exposure (e.g., valproate, fetal alcohol syndrome, very low birth weight).

Additional neurodevelopmental, mental or behavioral conditions should also be noted
(e.g., attention-deficit/hyperactivity disorder; developmental coordination disorder; dis-
ruptive behavior, impulse-control, or conduct disorders; anxiety, depressive, or bipolar
disorders; tics or Tourette’s disorder; self-injury; feeding, elimination, or sleep disorders).

Diagnostic Features
The essential features of autism spectrum disorder are persistent impairment in reciprocal
social communication and social interaction (Criterion A), and restricted, repetitive pat-
terns of behavior, interests, or activities (Criterion B). These symptoms are present from
early childhood and limit or impair everyday functioning (Criteria C and D). The stage at
which functional impairment becomes obvious will vary according to characteristics of
the individual and his or her environment. Core diagnostic features are evident in the
developmental period, but intervention, compensation, and current supports may mask
difficulties in at least some contexts. Manifestations of the disorder also vary greatly de-
pending on the severity of the autistic condition, developmental level, and chronological age;
hence, the term spectrum. Autism spectrum disorder encompasses disorders previously re-
ferred to as early infantile autism, childhood autism, Kanner’s autism, high-functioning
autism, atypical autism, pervasive developmental disorder not otherwise specified, child-
hood disintegrative disorder, and Asperger’s disorder.

The impairments in communication and social interaction specified in Criterion A are
pervasive and sustained. Diagnoses are most valid and reliable when based on multiple
sources of information, including clinician’s observations, caregiver history, and, when
possible, self-report. Verbal and nonverbal deficits in social communication have varying
manifestations, depending on the individual’s age, intellectual level, and language ability,
as well as other factors such as treatment history and current support. Many individuals
have language deficits, ranging from complete lack of speech through language delays,
poor comprehension of speech, echoed speech, or stilted and overly literal language. Even
when formal language skills (e.g., vocabulary, grammar) are intact, the use of language for
reciprocal social communication is impaired in autism spectrum disorder.

Deficits in social-emotional reciprocity (i.e., the ability to engage with others and share
thoughts and feelings) are clearly evident in young children with the disorder, who may
show little or no initiation of social interaction and no sharing of emotions, along with re-
duced or absent imitation of others’ behavior. What language exists is often one-sided,
lacking in social reciprocity, and used to request or label rather than to comment, share
feelings, or converse. In adults without intellectual disabilities or language delays, deficits
in social-emotional reciprocity may be most apparent in difficulties processing and re-
sponding to complex social cues (e.g., when and how to join a conversation, what not to
say). Adults who have developed compensation strategies for some social challenges still
struggle in novel or unsupported situations and suffer from the effort and anxiety of con-
sciously calculating what is socially intuitive for most individuals.

54 Neurodevelopmental Disorders

Deficits in nonverbal communicative behaviors used for social interaction are mani-
fested by absent, reduced, or atypical use of eye contact (relative to cultural norms), ges-
tures, facial expressions, body orientation, or speech intonation. An early feature of autism
spectrum disorder is impaired joint attention as manifested by a lack of pointing, showing,
or bringing objects to share interest with others, or failure to follow someone’s pointing or
eye gaze. Individuals may learn a few functional gestures, but their repertoire is smaller
than that of others, and they often fail to use expressive gestures spontaneously in com-
munication. Among adults with fluent language, the difficulty in coordinating nonverbal
communication with speech may give the impression of odd, wooden, or exaggerated
“body language” during interactions. Impairment may be relatively subtle within indi-
vidual modes (e.g., someone may have relatively good eye contact when speaking) but
noticeable in poor integration of eye contact, gesture, body posture, prosody, and facial ex-
pression for social communication.

Deficits in developing, maintaining, and understanding relationships should be
judged against norms for age, gender, and culture. There may be absent, reduced, or atyp-
ical social interest, manifested by rejection of others, passivity, or inappropriate ap-
proaches that seem aggressive or disruptive. These difficulties are particularly evident in
young children, in whom there is often a lack of shared social play and imagination (e.g.,
age-appropriate flexible pretend play) and, later, insistence on playing by very fixed rules.
Older individuals may struggle to understand what behavior is considered appropriate in
one situation but not another (e.g., casual behavior during a job interview), or the different
ways that language may be used to communicate (e.g., irony, white lies). There may be an
apparent preference for solitary activities or for interacting with much younger or older
people. Frequently, there is a desire to establish friendships without a complete or realistic
idea of what friendship entails (e.g., one-sided friendships or friendships based solely on
shared special interests). Relationships with siblings, co-workers, and caregivers are also
important to consider (in terms of reciprocity).

Autism spectrum disorder is also defined by restricted, repetitive patterns of behavior,
interests, or activities (as specified in Criterion B), which show a range of manifestations
according to age and ability, intervention, and current supports. Stereotyped or repetitive
behaviors include simple motor stereotypies (e.g., hand flapping, finger flicking), repeti-
tive use of objects (e.g., spinning coins, lining up toys), and repetitive speech (e.g., echola-
lia, the delayed or immediate parroting of heard words; use of “you” when referring to
self; stereotyped use of words, phrases, or prosodic patterns). Excessive adherence to rou-
tines and restricted patterns of behavior may be manifest in resistance to change (e.g., dis-
tress at apparently small changes, such as in packaging of a favorite food; insistence on
adherence to rules; rigidity of thinking) or ritualized patterns of verbal or nonverbal be-
havior (e.g., repetitive questioning, pacing a perimeter). Highly restricted, fixated interests
in autism spectrum disorder tend to be abnormal in intensity or focus (e.g., a toddler
strongly attached to a pan; a child preoccupied with vacuum cleaners; an adult spending
hours writing out timetables). Some fascinations and routines may relate to apparent hy-
per- or hyporeactivity to sensory input, manifested through extreme responses to specific
sounds or textures, excessive smelling or touching of objects, fascination with lights or
spinning objects, and sometimes apparent indifference to pain, heat, or cold. Extreme re-
action to or rituals involving taste, smell, texture, or appearance of food or excessive food
restrictions are common and may be a presenting feature of autism spectrum disorder.

Many adults with autism spectrum disorder without intellectual or language disabili-
ties learn to suppress repetitive behavior in public. Special interests may be a source of
pleasure and motivation and provide avenues for education and employment later in life.
Diagnostic criteria may be met when restricted, repetitive patterns of behavior, interests,
or activities were clearly present during childhood or at some time in the past, even if
symptoms are no longer present.

Autism Spectrum Disorder 55

Criterion D requires that the features must cause clinically significant impairment in so-
cial, occupational, or other important areas of current functioning. Criterion E specifies that
the social communication deficits, although sometimes accompanied by intellectual disabil-
ity (intellectual developmental disorder), are not in line with the individual’s developmental
level; impairments exceed difficulties expected on the basis of developmental level.

Standardized behavioral diagnostic instruments with good psychometric properties,
including caregiver interviews, questionnaires and clinician observation measures, are
available and can improve reliability of diagnosis over time and across clinicians.

Associated Features Supporting Diagnosis
Many individuals with autism spectrum disorder also have intellectual impairment and/or
language impairment (e.g., slow to talk, language comprehension behind production). Even
those with average or high intelligence have an uneven profile of abilities. The gap between
intellectual and adaptive functional skills is often large. Motor deficits are often present, in-
cluding odd gait, clumsiness, and other abnormal motor signs (e.g., walking on tiptoes). Self-
injury (e.g., head banging, biting the wrist) may occur, and disruptive/challenging behav-
iors are more common in children and adolescents with autism spectrum disorder than
other disorders, including intellectual disability. Adolescents and adults with autism spec-
trum disorder are prone to anxiety and depression. Some individuals develop catatonic-like
motor behavior (slowing and “freezing” mid-action), but these are typically not of the mag-
nitude of a catatonic episode. However, it is possible for individuals with autism spectrum
disorder to experience a marked deterioration in motor symptoms and display a full cata-
tonic episode with symptoms such as mutism, posturing, grimacing and waxy flexibility.
The risk period for comorbid catatonia appears to be greatest in the adolescent years.

Prevalence
In recent years, reported frequencies for autism spectrum disorder across U.S. and non-
U.S. countries have approached 1% of the population, with similar estimates in child and
adult samples. It remains unclear whether higher rates reflect an expansion of the diag-
nostic criteria of DSM-IV to include subthreshold cases, increased awareness, differences
in study methodology, or a true increase in the frequency of autism spectrum disorder.

Development and Course
The age and pattern of onset also should be noted for autism spectrum disorder. Symptoms
are typically recognized during the second year of life (12–24 months of age) but may be seen
earlier than 12 months if developmental delays are severe, or noted later than 24 months if
symptoms are more subtle. The pattern of onset description might include information
about early developmental delays or any losses of social or language skills. In cases where
skills have been lost, parents or caregivers may give a history of a gradual or relatively
rapid deterioration in social behaviors or language skills. Typically, this would occur be-
tween 12 and 24 months of age and is distinguished from the rare instances of developmen-
tal regression occurring after at least 2 years of normal development (previously described
as childhood disintegrative disorder).

The behavioral features of autism spectrum disorder first become evident in early
childhood, with some cases presenting a lack of interest in social interaction in the first
year of life. Some children with autism spectrum disorder experience developmental pla-
teaus or regression, with a gradual or relatively rapid deterioration in social behaviors or
use of language, often during the first 2 years of life. Such losses are rare in other disor-
ders and may be a useful “red flag” for autism spectrum disorder. Much more unusual
and warranting more extensive medical investigation are losses of skills beyond social
communication (e.g., loss of self-care, toileting, motor skills) or those occurring after the

56 Neurodevelopmental Disorders

second birthday (see also Rett syndrome in the section “Differential Diagnosis” for this
disorder).

First symptoms of autism spectrum disorder frequently involve delayed language de-
velopment, often accompanied by lack of social interest or unusual social interactions (e.g.,
pulling individuals by the hand without any attempt to look at them), odd play patterns
(e.g., carrying toys around but never playing with them), and unusual communication
patterns (e.g., knowing the alphabet but not responding to own name). Deafness may be
suspected but is typically ruled out. During the second year, odd and repetitive behaviors
and the absence of typical play become more apparent. Since many typically developing
young children have strong preferences and enjoy repetition (e.g., eating the same foods,
watching the same video multiple times), distinguishing restricted and repetitive behav-
iors that are diagnostic of autism spectrum disorder can be difficult in preschoolers. The
clinical distinction is based on the type, frequency, and intensity of the behavior (e.g., a
child who daily lines up objects for hours and is very distressed if any item is moved).

Autism spectrum disorder is not a degenerative disorder, and it is typical for learning
and compensation to continue throughout life. Symptoms are often most marked in early
childhood and early school years, with developmental gains typical in later childhood in
at least some areas (e.g., increased interest in social interaction). A small proportion of in-
dividuals deteriorate behaviorally during adolescence, whereas most others improve.
Only a minority of individuals with autism spectrum disorder live and work indepen-
dently in adulthood; those who do tend to have superior language and intellectual abilities
and are able to find a niche that matches their special interests and skills. In general, indi-
viduals with lower levels of impairment may be better able to function independently.
However, even these individuals may remain socially naive and vulnerable, have difficul-
ties organizing practical demands without aid, and are prone to anxiety and depression.
Many adults report using compensation strategies and coping mechanisms to mask their
difficulties in public but suffer from the stress and effort of maintaining a socially accept-
able facade. Scarcely anything is known about old age in autism spectrum disorder.

Some individuals come for first diagnosis in adulthood, perhaps prompted by the diagno-
sis of autism in a child in the family or a breakdown of relations at work or home. Obtaining de-
tailed developmental history in such cases may be difficult, and it is important to consider self-
reported difficulties. Where clinical observation suggests criteria are currently met, autism
spectrum disorder may be diagnosed, provided there is no evidence of good social and com-
munication skills in childhood. For example, the report (by parents or another relative) that the
individual had ordinary and sustained reciprocal friendships and good nonverbal communi-
cation skills throughout childhood would rule out a diagnosis of autism spectrum disorder;
however, the absence of developmental information in itself should not do so.

Manifestations of the social and communication impairments and restricted/repeti-
tive behaviors that define autism spectrum disorder are clear in the developmental period.
In later life, intervention or compensation, as well as current supports, may mask these dif-
ficulties in at least some contexts. However, symptoms remain sufficient to cause current
impairment in social, occupational, or other important areas of functioning.

Risk and Prognostic Factors
The best established prognostic factors for individual outcome within autism spectrum
disorder are presence or absence of associated intellectual disability and language impair-
ment (e.g., functional language by age 5 years is a good prognostic sign) and additional
mental health problems. Epilepsy, as a comorbid diagnosis, is associated with greater in-
tellectual disability and lower verbal ability.

Environmental. A variety of nonspecific risk factors, such as advanced parental age, low
birth weight, or fetal exposure to valproate, may contribute to risk of autism spectrum dis-
order.

Autism Spectrum Disorder 57

Genetic and physiological. Heritability estimates for autism spectrum disorder have
ranged from 37% to higher than 90%, based on twin concordance rates. Currently, as many
as 15% of cases of autism spectrum disorder appear to be associated with a known genetic
mutation, with different de novo copy number variants or de novo mutations in specific
genes associated with the disorder in different families. However, even when an autism
spectrum disorder is associated with a known genetic mutation, it does not appear to be
fully penetrant. Risk for the remainder of cases appears to be polygenic, with perhaps hun-
dreds of genetic loci making relatively small contributions.

Culture-Related Diagnostic Issues
Cultural differences will exist in norms for social interaction, nonverbal communication,
and relationships, but individuals with autism spectrum disorder are markedly impaired
against the norms for their cultural context. Cultural and socioeconomic factors may affect
age at recognition or diagnosis; for example, in the United States, late or underdiagnosis of
autism spectrum disorder among African American children may occur.

Gender-Related Diagnostic Issues
Autism spectrum disorder is diagnosed four times more often in males than in females. In
clinic samples, females tend to be more likely to show accompanying intellectual disabil-
ity, suggesting that girls without accompanying intellectual impairments or language
delays may go unrecognized, perhaps because of subtler manifestation of social and com-
munication difficulties.

Functional Consequences of Autism Spectrum Disorder
In young children with autism spectrum disorder, lack of social and communication abil-
ities may hamper learning, especially learning through social interaction or in settings
with peers. In the home, insistence on routines and aversion to change, as well as sensory
sensitivities, may interfere with eating and sleeping and make routine care (e.g., haircuts,
dental work) extremely difficult. Adaptive skills are typically below measured IQ. Ex-
treme difficulties in planning, organization, and coping with change negatively impact
academic achievement, even for students with above-average intelligence. During adult-
hood, these individuals may have difficulties establishing independence because of con-
tinued rigidity and difficulty with novelty.

Many individuals with autism spectrum disorder, even without intellectual disability,
have poor adult psychosocial functioning as indexed by measures such as independent
living and gainful employment. Functional consequences in old age are unknown, but so-
cial isolation and communication problems (e.g., reduced help-seeking) are likely to have
consequences for health in older adulthood.

Differential Diagnosis
Rett syndrome. Disruption of social interaction may be observed during the regressive
phase of Rett syndrome (typically between 1–4 years of age); thus, a substantial proportion
of affected young girls may have a presentation that meets diagnostic criteria for autism
spectrum disorder. However, after this period, most individuals with Rett syndrome im-
prove their social communication skills, and autistic features are no longer a major area of
concern. Consequently, autism spectrum disorder should be considered only when all di-
agnostic criteria are met.

Selective mutism. In selective mutism, early development is not typically disturbed.
The affected child usually exhibits appropriate communication skills in certain contexts
and settings. Even in settings where the child is mute, social reciprocity is not impaired,
nor are restricted or repetitive patterns of behavior present.

58 Neurodevelopmental Disorders

Language disorders and social (pragmatic) communication disorder. In some forms
of language disorder, there may be problems of communication and some secondary so-
cial difficulties. However, specific language disorder is not usually associated with abnor-
mal nonverbal communication, nor with the presence of restricted, repetitive patterns of
behavior, interests, or activities.

When an individual shows impairment in social communication and social interactions
but does not show restricted and repetitive behavior or interests, criteria for social (prag-
matic) communication disorder, instead of autism spectrum disorder, may be met. The di-
agnosis of autism spectrum disorder supersedes that of social (pragmatic) communication
disorder whenever the criteria for autism spectrum disorder are met, and care should be
taken to enquire carefully regarding past or current restricted/repetitive behavior.

Intellectual disability (intellectual developmental disorder) without autism spectrum
disorder. Intellectual disability without autism spectrum disorder may be difficult to
differentiate from autism spectrum disorder in very young children. Individuals with in-
tellectual disability who have not developed language or symbolic skills also present a
challenge for differential diagnosis, since repetitive behavior often occurs in such individ-
uals as well. A diagnosis of autism spectrum disorder in an individual with intellectual
disability is appropriate when social communication and interaction are significantly im-
paired relative to the developmental level of the individual’s nonverbal skills (e.g., fine
motor skills, nonverbal problem solving). In contrast, intellectual disability is the appropri-
ate diagnosis when there is no apparent discrepancy between the level of social-commu-
nicative skills and other intellectual skills.

Stereotypic movement disorder. Motor stereotypies are among the diagnostic charac-
teristics of autism spectrum disorder, so an additional diagnosis of stereotypic movement
disorder is not given when such repetitive behaviors are better explained by the presence
of autism spectrum disorder. However, when stereotypies cause self-injury and become a
focus of treatment, both diagnoses may be appropriate.

Attention-deficit/hyperactivity disorder. Abnormalities of attention (overly focused or
easily distracted) are common in individuals with autism spectrum disorder, as is hy-
peractivity. A diagnosis of attention-deficit/hyperactivity disorder (ADHD) should be
considered when attentional difficulties or hyperactivity exceeds that typically seen in in-
dividuals of comparable mental age.

Schizophrenia. Schizophrenia with childhood onset usually develops after a period of
normal, or near normal, development. A prodromal state has been described in which so-
cial impairment and atypical interests and beliefs occur, which could be confused with the
social deficits seen in autism spectrum disorder. Hallucinations and delusions, which are
defining features of schizophrenia, are not features of autism spectrum disorder. How-
ever, clinicians must take into account the potential for individuals with autism spectrum
disorder to be concrete in their interpretation of questions regarding the key features of
schizophrenia (e.g., “Do you hear voices when no one is there?” ”Yes [on the radio]”).

Comorbidity
Autism spectrum disorder is frequently associated with intellectual impairment and struc-
tural language disorder (i.e., an inability to comprehend and construct sentences with proper
grammar), which should be noted under the relevant specifiers when applicable. Many in-
dividuals with autism spectrum disorder have psychiatric symptoms that do not form part of
the diagnostic criteria for the disorder (about 70% of individuals with autism spectrum dis-
order may have one comorbid mental disorder, and 40% may have two or more comorbid
mental disorders). When criteria for both ADHD and autism spectrum disorder are met, both
diagnoses should be given. This same principle applies to concurrent diagnoses of autism
spectrum disorder and developmental coordination disorder, anxiety disorders, depressive

Attention-Deficit/Hyperactivity Disorder 59

disorders, and other comorbid diagnoses. Among individuals who are nonverbal or have
language deficits, observable signs such as changes in sleep or eating and increases in chal-
lenging behavior should trigger an evaluation for anxiety or depression. Specific learning dif-
ficulties (literacy and numeracy) are common, as is developmental coordination disorder.
Medical conditions commonly associated with autism spectrum disorder should be noted
under the “associated with a known medical/genetic or environmental/acquired condition”
specifier. Such medical conditions include epilepsy, sleep problems, and constipation.
Avoidant-restrictive food intake disorder is a fairly frequent presenting feature of autism
spectrum disorder, and extreme and narrow food preferences may persist.

Attention-Deficit/Hyperactivity
Disorder

Attention-Deficit/Hyperactivity Disorder
Diagnostic Criteria

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with
functioning or development, as characterized by (1) and/or (2):

1. Inattention: Six (or more) of the following symptoms have persisted for at least
6 months to a degree that is inconsistent with developmental level and that nega-
tively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defi-
ance, hostility, or failure to understand tasks or instructions. For older adolescents
and adults (age 17 and older), at least five symptoms are required.

a. Often fails to give close attention to details or makes careless mistakes in
schoolwork, at work, or during other activities (e.g., overlooks or misses details,
work is inaccurate).

b. Often has difficulty sustaining attention in tasks or play activities (e.g., has diffi-
culty remaining focused during lectures, conversations, or lengthy reading).

c. Often does not seem to listen when spoken to directly (e.g., mind seems else-
where, even in the absence of any obvious distraction).

d. Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and
is easily sidetracked).

e. Often has difficulty organizing tasks and activities (e.g., difficulty managing se-
quential tasks; difficulty keeping materials and belongings in order; messy, dis-
organized work; has poor time management; fails to meet deadlines).

f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained
mental effort (e.g., schoolwork or homework; for older adolescents and adults,
preparing reports, completing forms, reviewing lengthy papers).

g. Often loses things necessary for tasks or activities (e.g., school materials, pen-
cils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

h. Is often easily distracted by extraneous stimuli (for older adolescents and
adults, may include unrelated thoughts).

i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older
adolescents and adults, returning calls, paying bills, keeping appointments).

60 Neurodevelopmental Disorders

2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have per-
sisted for at least 6 months to a degree that is inconsistent with developmental level
and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defi-
ance, hostility, or a failure to understand tasks or instructions. For older adolescents
and adults (age 17 and older), at least five symptoms are required.

a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves

his or her place in the classroom, in the office or other workplace, or in other
situations that require remaining in place).

c. Often runs about or climbs in situations where it is inappropriate. (Note: In ad-
olescents or adults, may be limited to feeling restless.)

d. Often unable to play or engage in leisure activities quietly.
e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or un-

comfortable being still for extended time, as in restaurants, meetings; may be
experienced by others as being restless or difficult to keep up with).

f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g., com-

pletes people’s sentences; cannot wait for turn in conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or

activities; may start using other people’s things without asking or receiving per-
mission; for adolescents and adults, may intrude into or take over what others
are doing).

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age
12 years.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more set-
tings (e.g., at home, school, or work; with friends or relatives; in other activities).

D. There is clear evidence that the symptoms interfere with, or reduce the quality of, so-
cial, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality disorder, substance intox-
ication or withdrawal).

Specify whether:
314.01 (F90.2) Combined presentation: If both Criterion A1 (inattention) and Crite-
rion A2 (hyperactivity-impulsivity) are met for the past 6 months.
314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention)
is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.
314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hy-
peractivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months.

Specify if:
In partial remission: When full criteria were previously met, fewer than the full criteria
have been met for the past 6 months, and the symptoms still result in impairment in
social, academic, or occupational functioning.

Specify current severity:
Mild: Few, if any, symptoms in excess of those required to make the diagnosis are
present, and symptoms result in no more than minor impairments in social or occupa-
tional functioning.
Moderate: Symptoms or functional impairment between “mild” and “severe” are present.

Attention-Deficit/Hyperactivity Disorder 61

Severe: Many symptoms in excess of those required to make the diagnosis, or several
symptoms that are particularly severe, are present, or the symptoms result in marked
impairment in social or occupational functioning.

Diagnostic Features
The essential feature of attention-deficit/hyperactivity disorder (ADHD) is a persistent
pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or
development. Inattention manifests behaviorally in ADHD as wandering off task, lacking
persistence, having difficulty sustaining focus, and being disorganized and is not due to
defiance or lack of comprehension. Hyperactivity refers to excessive motor activity (such as
a child running about) when it is not appropriate, or excessive fidgeting, tapping, or talk-
ativeness. In adults, hyperactivity may manifest as extreme restlessness or wearing others
out with their activity. Impulsivity refers to hasty actions that occur in the moment without
forethought and that have high potential for harm to the individual (e.g., darting into the
street without looking). Impulsivity may reflect a desire for immediate rewards or an in-
ability to delay gratification. Impulsive behaviors may manifest as social intrusiveness
(e.g., interrupting others excessively) and/or as making important decisions without con-
sideration of long-term consequences (e.g., taking a job without adequate information).

ADHD begins in childhood. The requirement that several symptoms be present before
age 12 years conveys the importance of a substantial clinical presentation during child-
hood. At the same time, an earlier age at onset is not specified because of difficulties in es-
tablishing precise childhood onset retrospectively. Adult recall of childhood symptoms
tends to be unreliable, and it is beneficial to obtain ancillary information.

Manifestations of the disorder must be present in more than one setting (e.g., home and
school, work). Confirmation of substantial symptoms across settings typically cannot be
done accurately without consulting informants who have seen the individual in those set-
tings. Typically, symptoms vary depending on context within a given setting. Signs of the
disorder may be minimal or absent when the individual is receiving frequent rewards for
appropriate behavior, is under close supervision, is in a novel setting, is engaged in espe-
cially interesting activities, has consistent external stimulation (e.g., via electronic screens),
or is interacting in one-on-one situations (e.g., the clinician’s office).

Associated Features Supporting Diagnosis
Mild delays in language, motor, or social development are not specific to ADHD but often co-
occur. Associated features may include low frustration tolerance, irritability, or mood lability.
Even in the absence of a specific learning disorder, academic or work performance is often im-
paired. Inattentive behavior is associated with various underlying cognitive processes, and in-
dividuals with ADHD may exhibit cognitive problems on tests of attention, executive
function, or memory, although these tests are not sufficiently sensitive or specific to serve as di-
agnostic indices. By early adulthood, ADHD is associated with an increased risk of suicide at-
tempt, primarily when comorbid with mood, conduct, or substance use disorders.

No biological marker is diagnostic for ADHD. As a group, compared with peers, chil-
dren with ADHD display increased slow wave electroencephalograms, reduced total
brain volume on magnetic resonance imaging, and possibly a delay in posterior to anterior
cortical maturation, but these findings are not diagnostic. In the uncommon cases where
there is a known genetic cause (e.g., Fragile X syndrome, 22q11 deletion syndrome), the
ADHD presentation should still be diagnosed.

Prevalence
Population surveys suggest that ADHD occurs in most cultures in about 5% of children
and about 2.5% of adults.

62 Neurodevelopmental Disorders

Development and Course
Many parents first observe excessive motor activity when the child is a toddler, but symp-
toms are difficult to distinguish from highly variable normative behaviors before age 4
years. ADHD is most often identified during elementary school years, and inattention be-
comes more prominent and impairing. The disorder is relatively stable through early ad-
olescence, but some individuals have a worsened course with development of antisocial
behaviors. In most individuals with ADHD, symptoms of motoric hyperactivity become
less obvious in adolescence and adulthood, but difficulties with restlessness, inattention,
poor planning, and impulsivity persist. A substantial proportion of children with ADHD
remain relatively impaired into adulthood.

In preschool, the main manifestation is hyperactivity. Inattention becomes more prom-
inent during elementary school. During adolescence, signs of hyperactivity (e.g., running
and climbing) are less common and may be confined to fidgetiness or an inner feeling of
jitteriness, restlessness, or impatience. In adulthood, along with inattention and restless-
ness, impulsivity may remain problematic even when hyperactivity has diminished.

Risk and Prognostic Factors
Temperamental. ADHD is associated with reduced behavioral inhibition, effortful con-
trol, or constraint; negative emotionality; and/or elevated novelty seeking. These traits
may predispose some children to ADHD but are not specific to the disorder.

Environmental. Very low birth weight (less than 1,500 grams) conveys a two- to three-
fold risk for ADHD, but most children with low birth weight do not develop ADHD. Al-
though ADHD is correlated with smoking during pregnancy, some of this association
reflects common genetic risk. A minority of cases may be related to reactions to aspects of
diet. There may be a history of child abuse, neglect, multiple foster placements, neurotoxin
exposure (e.g., lead), infections (e.g., encephalitis), or alcohol exposure in utero. Exposure
to environmental toxicants has been correlated with subsequent ADHD, but it is not
known whether these associations are causal.

Genetic and physiological. ADHD is elevated in the first-degree biological relatives of
individuals with ADHD. The heritability of ADHD is substantial. While specific genes
have been correlated with ADHD, they are neither necessary nor sufficient causal factors.
Visual and hearing impairments, metabolic abnormalities, sleep disorders, nutritional de-
ficiencies, and epilepsy should be considered as possible influences on ADHD symptoms.

ADHD is not associated with specific physical features, although rates of minor phys-
ical anomalies (e.g., hypertelorism, highly arched palate, low-set ears) may be relatively
elevated. Subtle motor delays and other neurological soft signs may occur. (Note that
marked co-occurring clumsiness and motor delays should be coded separately [e.g., de-
velopmental coordination disorder].)

Course modifiers. Family interaction patterns in early childhood are unlikely to cause
ADHD but may influence its course or contribute to secondary development of conduct
problems.

Culture-Related Diagnostic Issues
Differences in ADHD prevalence rates across regions appear attributable mainly to differ-
ent diagnostic and methodological practices. However, there also may be cultural varia-
tion in attitudes toward or interpretations of children’s behaviors. Clinical identification
rates in the United States for African American and Latino populations tend to be lower
than for Caucasian populations. Informant symptom ratings may be influenced by cul-
tural group of the child and the informant, suggesting that culturally appropriate practices
are relevant in assessing ADHD.

Attention-Deficit/Hyperactivity Disorder 63

Gender-Related Diagnostic Issues
ADHD is more frequent in males than in females in the general population, with a ratio of
approximately 2:1 in children and 1.6:1 in adults. Females are more likely than males to
present primarily with inattentive features.

Functional Consequences of
Attention-Deficit/Hyperactivity Disorder
ADHD is associated with reduced school performance and academic attainment, social re-
jection, and, in adults, poorer occupational performance, attainment, attendance, and
higher probability of unemployment as well as elevated interpersonal conflict. Children
with ADHD are significantly more likely than their peers without ADHD to develop con-
duct disorder in adolescence and antisocial personality disorder in adulthood, conse-
quently increasing the likelihood for substance use disorders and incarceration. The risk of
subsequent substance use disorders is elevated, especially when conduct disorder or an-
tisocial personality disorder develops. Individuals with ADHD are more likely than peers
to be injured. Traffic accidents and violations are more frequent in drivers with ADHD.
There may be an elevated likelihood of obesity among individuals with ADHD.

Inadequate or variable self-application to tasks that require sustained effort is often in-
terpreted by others as laziness, irresponsibility, or failure to cooperate. Family relation-
ships may be characterized by discord and negative interactions. Peer relationships are
often disrupted by peer rejection, neglect, or teasing of the individual with ADHD. On av-
erage, individuals with ADHD obtain less schooling, have poorer vocational achievement,
and have reduced intellectual scores than their peers, although there is great variability. In
its severe form, the disorder is markedly impairing, affecting social, familial, and scholas-
tic/occupational adjustment.

Academic deficits, school-related problems, and peer neglect tend to be most associ-
ated with elevated symptoms of inattention, whereas peer rejection and, to a lesser extent,
accidental injury are most salient with marked symptoms of hyperactivity or impulsivity.

Differential Diagnosis
Oppositional defiant disorder. Individuals with oppositional defiant disorder may re-
sist work or school tasks that require self-application because they resist conforming to
others’ demands. Their behavior is characterized by negativity, hostility, and defiance.
These symptoms must be differentiated from aversion to school or mentally demanding
tasks due to difficulty in sustaining mental effort, forgetting instructions, and impulsivity
in individuals with ADHD. Complicating the differential diagnosis is the fact that some
individuals with ADHD may develop secondary oppositional attitudes toward such tasks
and devalue their importance.

Intermittent explosive disorder. ADHD and intermittent explosive disorder share high
levels of impulsive behavior. However, individuals with intermittent explosive disorder
show serious aggression toward others, which is not characteristic of ADHD, and they do
not experience problems with sustaining attention as seen in ADHD. In addition, intermit-
tent explosive disorder is rare in childhood. Intermittent explosive disorder may be diag-
nosed in the presence of ADHD.

Other neurodevelopmental disorders. The increased motoric activity that may occur in
ADHD must be distinguished from the repetitive motor behavior that characterizes stereo-
typic movement disorder and some cases of autism spectrum disorder. In stereotypic
movement disorder, the motoric behavior is generally fixed and repetitive (e.g., body rock-
ing, self-biting), whereas the fidgetiness and restlessness in ADHD are typically general-
ized and not characterized by repetitive stereotypic movements. In Tourette’s disorder,

64 Neurodevelopmental Disorders

frequent multiple tics can be mistaken for the generalized fidgetiness of ADHD. Prolonged
observation may be needed to differentiate fidgetiness from bouts of multiple tics.

Specific learning disorder. Children with specific learning disorder may appear inat-
tentive because of frustration, lack of interest, or limited ability. However, inattention in
individuals with a specific learning disorder who do not have ADHD is not impairing out-
side of academic work.

Intellectual disability (intellectual developmental disorder). Symptoms of ADHD are
common among children placed in academic settings that are inappropriate to their intel-
lectual ability. In such cases, the symptoms are not evident during non-academic tasks. A
diagnosis of ADHD in intellectual disability requires that inattention or hyperactivity be
excessive for mental age.

Autism spectrum disorder. Individuals with ADHD and those with autism spectrum
disorder exhibit inattention, social dysfunction, and difficult-to-manage behavior. The so-
cial dysfunction and peer rejection seen in individuals with ADHD must be distinguished
from the social disengagement, isolation, and indifference to facial and tonal communica-
tion cues seen in individuals with autism spectrum disorder. Children with autism spec-
trum disorder may display tantrums because of an inability to tolerate a change from their
expected course of events. In contrast, children with ADHD may misbehave or have a tan-
trum during a major transition because of impulsivity or poor self-control.

Reactive attachment disorder. Children with reactive attachment disorder may show
social disinhibition, but not the full ADHD symptom cluster, and display other features
such as a lack of enduring relationships that are not characteristic of ADHD.

Anxiety disorders. ADHD shares symptoms of inattention with anxiety disorders. Indi-
viduals with ADHD are inattentive because of their attraction to external stimuli, new
activities, or preoccupation with enjoyable activities. This is distinguished from the inat-
tention due to worry and rumination seen in anxiety disorders. Restlessness might be seen
in anxiety disorders. However, in ADHD, the symptom is not associated with worry and
rumination.

Depressive disorders. Individuals with depressive disorders may present with inabil-
ity to concentrate. However, poor concentration in mood disorders becomes prominent
only during a depressive episode.

Bipolar disorder. Individuals with bipolar disorder may have increased activity, poor
concentration, and increased impulsivity, but these features are episodic, occurring sev-
eral days at a time. In bipolar disorder, increased impulsivity or inattention is accompa-
nied by elevated mood, grandiosity, and other specific bipolar features. Children with
ADHD may show significant changes in mood within the same day; such lability is dis-
tinct from a manic episode, which must last 4 or more days to be a clinical indicator of bi-
polar disorder, even in children. Bipolar disorder is rare in preadolescents, even when
severe irritability and anger are prominent, whereas ADHD is common among children
and adolescents who display excessive anger and irritability.

Disruptive mood dysregulation disorder. Disruptive mood dysregulation disorder is
characterized by pervasive irritability, and intolerance of frustration, but impulsiveness
and disorganized attention are not essential features. However, most children and adoles-
cents with the disorder have symptoms that also meet criteria for ADHD, which is diag-
nosed separately.

Substance use disorders. Differentiating ADHD from substance use disorders may be
problematic if the first presentation of ADHD symptoms follows the onset of abuse or fre-
quent use. Clear evidence of ADHD before substance misuse from informants or previous
records may be essential for differential diagnosis.

Other Specified Attention-Deficit/Hyperactivity Disorder 65

Personality disorders. In adolescents and adults, it may be difficult to distinguish ADHD
from borderline, narcissistic, and other personality disorders. All these disorders tend to
share the features of disorganization, social intrusiveness, emotional dysregulation, and
cognitive dysregulation. However, ADHD is not characterized by fear of abandonment,
self-injury, extreme ambivalence, or other features of personality disorder. It may take
extended clinical observation, informant interview, or detailed history to distinguish im-
pulsive, socially intrusive, or inappropriate behavior from narcissistic, aggressive, or dom-
ineering behavior to make this differential diagnosis.

Psychotic disorders. ADHD is not diagnosed if the symptoms of inattention and hyperac-
tivity occur exclusively during the course of a psychotic disorder.

Medication-induced symptoms of ADHD. Symptoms of inattention, hyperactivity, or
impulsivity attributable to the use of medication (e.g., bronchodilators, isoniazid, neuro-
leptics [resulting in akathisia], thyroid replacement medication) are diagnosed as other
specified or unspecified other (or unknown) substance–related disorders.

Neurocognitive disorders. Early major neurocognitive disorder (dementia) and/or
mild neurocognitive disorder are not known to be associated with ADHD but may present
with similar clinical features. These conditions are distinguished from ADHD by their late
onset.

Comorbidity
In clinical settings, comorbid disorders are frequent in individuals whose symptoms meet
criteria for ADHD. In the general population, oppositional defiant disorder co-occurs with
ADHD in approximately half of children with the combined presentation and about a
quarter with the predominantly inattentive presentation. Conduct disorder co-occurs in
about a quarter of children or adolescents with the combined presentation, depending on
age and setting. Most children and adolescents with disruptive mood dysregulation dis-
order have symptoms that also meet criteria for ADHD; a lesser percentage of children
with ADHD have symptoms that meet criteria for disruptive mood dysregulation disor-
der. Specific learning disorder commonly co-occurs with ADHD. Anxiety disorders and
major depressive disorder occur in a minority of individuals with ADHD but more often
than in the general population. Intermittent explosive disorder occurs in a minority of
adults with ADHD, but at rates above population levels. Although substance use disor-
ders are relatively more frequent among adults with ADHD in the general population, the
disorders are present in only a minority of adults with ADHD. In adults, antisocial and
other personality disorders may co-occur with ADHD. Other disorders that may co-occur
with ADHD include obsessive-compulsive disorder, tic disorders, and autism spectrum
disorder.

Other Specified Attention-Deficit/
Hyperactivity Disorder

314.01 (F90.8)

This category applies to presentations in which symptoms characteristic of attention-
deficit/hyperactivity disorder that cause clinically significant distress or impairment in so-
cial, occupational or other important areas of functioning predominate but do not meet the
full criteria for attention-deficit/hyperactivity disorder or any of the disorders in the neuro-
developmental disorders diagnostic class. The other specified attention-deficit/hyperactiv-
ity disorder category is used in situations in which the clinician chooses to communicate

66 Neurodevelopmental Disorders

the specific reason that the presentation does not meet the criteria for attention-deficit/
hyperactivity disorder or any specific neurodevelopmental disorder. This is done by re-
cording “other specified attention-deficit/hyperactivity disorder” followed by the specific
reason (e.g., “with insufficient inattention symptoms”).

Unspecified Attention-Deficit/
Hyperactivity Disorder

314.01 (F90.9)

This category applies to presentations in which symptoms characteristic of attention-
deficit/hyperactivity disorder that cause clinically significant distress or impairment in so-
cial, occupational, or other important areas of functioning predominate but do not meet the
full criteria for attention-deficit/hyperactivity disorder or any of the disorders in the neuro-
developmental disorders diagnostic class. The unspecified attention-deficit/hyperactivity
disorder category is used in situations in which the clinician chooses not to specify the rea-
son that the criteria are not met for attention-deficit/hyperactivity disorder or for a specific
neurodevelopmental disorder, and includes presentations in which there is insufficient in-
formation to make a more specific diagnosis.

Specific Learning Disorder

Specific Learning Disorder
Diagnostic Criteria

A. Difficulties learning and using academic skills, as indicated by the presence of at least
one of the following symptoms that have persisted for at least 6 months, despite the
provision of interventions that target those difficulties:

1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incor-
rectly or slowly and hesitantly, frequently guesses words, has difficulty sounding
out words).

2. Difficulty understanding the meaning of what is read (e.g., may read text accurately
but not understand the sequence, relationships, inferences, or deeper meanings of
what is read).

3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).
4. Difficulties with written expression (e.g., makes multiple grammatical or punctua-

tion errors within sentences; employs poor paragraph organization; written expres-
sion of ideas lacks clarity).

5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor
understanding of numbers, their magnitude, and relationships; counts on fingers to
add single-digit numbers instead of recalling the math fact as peers do; gets lost in
the midst of arithmetic computation and may switch procedures).

6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying math-
ematical concepts, facts, or procedures to solve quantitative problems).

Specific Learning Disorder 67

B. The affected academic skills are substantially and quantifiably below those expected
for the individual’s chronological age, and cause significant interference with academic
or occupational performance, or with activities of daily living, as confirmed by individu-
ally administered standardized achievement measures and comprehensive clinical
assessment. For individuals age 17 years and older, a documented history of impairing
learning difficulties may be substituted for the standardized assessment.

C. The learning difficulties begin during school-age years but may not become fully man-
ifest until the demands for those affected academic skills exceed the individual’s lim-
ited capacities (e.g., as in timed tests, reading or writing lengthy complex reports for a
tight deadline, excessively heavy academic loads).

D. The learning difficulties are not better accounted for by intellectual disabilities, uncor-
rected visual or auditory acuity, other mental or neurological disorders, psychosocial
adversity, lack of proficiency in the language of academic instruction, or inadequate
educational instruction.

Note: The four diagnostic criteria are to be met based on a clinical synthesis of the indi-
vidual’s history (developmental, medical, family, educational), school reports, and psycho-
educational assessment.

Coding note: Specify all academic domains and subskills that are impaired. When more
than one domain is impaired, each one should be coded individually according to the fol-
lowing specifiers.

Specify if:
315.00 (F81.0) With impairment in reading:

Word reading accuracy
Reading rate or fluency
Reading comprehension

Note: Dyslexia is an alternative term used to refer to a pattern of learning difficulties
characterized by problems with accurate or fluent word recognition, poor decoding,
and poor spelling abilities. If dyslexia is used to specify this particular pattern of dif-
ficulties, it is important also to specify any additional difficulties that are present,
such as difficulties with reading comprehension or math reasoning.

315.2 (F81.81) With impairment in written expression:

Spelling accuracy
Grammar and punctuation accuracy
Clarity or organization of written expression

315.1 (F81.2) With impairment in mathematics:

Number sense
Memorization of arithmetic facts
Accurate or fluent calculation
Accurate math reasoning

Note: Dyscalculia is an alternative term used to refer to a pattern of difficulties char-
acterized by problems processing numerical information, learning arithmetic facts,
and performing accurate or fluent calculations. If dyscalculia is used to specify this
particular pattern of mathematic difficulties, it is important also to specify any addi-
tional difficulties that are present, such as difficulties with math reasoning or word rea-
soning accuracy.

Specify current severity:
Mild: Some difficulties learning skills in one or two academic domains, but of mild enough
severity that the individual may be able to compensate or function well when provided with
appropriate accommodations or support services, especially during the school years.

68 Neurodevelopmental Disorders

Moderate: Marked difficulties learning skills in one or more academic domains, so that
the individual is unlikely to become proficient without some intervals of intensive and
specialized teaching during the school years. Some accommodations or supportive
services at least part of the day at school, in the workplace, or at home may be needed
to complete activities accurately and efficiently.
Severe: Severe difficulties learning skills, affecting several academic domains, so that
the individual is unlikely to learn those skills without ongoing intensive individualized
and specialized teaching for most of the school years. Even with an array of appropri-
ate accommodations or services at home, at school, or in the workplace, the individual
may not be able to complete all activities efficiently.

Recording Procedures
Each impaired academic domain and subskill of specific learning disorder should be re-
corded. Because of ICD coding requirements, impairments in reading, impairments in writ-
ten expression, and impairments in mathematics, with their corresponding impairments in
subskills, must be coded separately. For example, impairments in reading and mathematics
and impairments in the subskills of reading rate or fluency, reading comprehension, accu-
rate or fluent calculation, and accurate math reasoning would be coded and recorded as
315.00 (F81.0) specific learning disorder with impairment in reading, with impairment in
reading rate or fluency and impairment in reading comprehension; 315.1 (F81.2) specific
learning disorder with impairment in mathematics, with impairment in accurate or fluent
calculation and impairment in accurate math reasoning.

Diagnostic Features
Specific learning disorder is a neurodevelopmental disorder with a biological origin that is
the basis for abnormalities at a cognitive level that are associated with the behavioral signs
of the disorder. The biological origin includes an interaction of genetic, epigenetic, and en-
vironmental factors, which affect the brain’s ability to perceive or process verbal or non-
verbal information efficiently and accurately.

One essential feature of specific learning disorder is persistent difficulties learning key-
stone academic skills (Criterion A), with onset during the years of formal schooling (i.e., the de-
velopmental period). Key academic skills include reading of single words accurately and
fluently, reading comprehension, written expression and spelling, arithmetic calculation, and
mathematical reasoning (solving mathematical problems). In contrast to talking or walking,
which are acquired developmental milestones that emerge with brain maturation, academic
skills (e.g., reading, spelling, writing, mathematics) have to be taught and learned explicitly.
Specific learning disorder disrupts the normal pattern of learning academic skills; it is not sim-
ply a consequence of lack of opportunity of learning or inadequate instruction. Difficulties
mastering these key academic skills may also impede learning in other academic subjects (e.g.,
history, science, social studies), but those problems are attributable to difficulties learning the
underlying academic skills. Difficulties learning to map letters with the sounds of one’s lan-
guage—to read printed words (often called dyslexia)—is one of the most common manifesta-
tions of specific learning disorder. The learning difficulties manifest as a range of observable,
descriptive behaviors or symptoms (as listed in Criteria A1–A6). These clinical symptoms may
be observed, probed by means of the clinical interview, or ascertained from school reports, rat-
ing scales, or descriptions in previous educational or psychological assessments. The learning
difficulties are persistent, not transitory. In children and adolescents, persistence is defined as
restricted progress in learning (i.e., no evidence that the individual is catching up with class-
mates) for at least 6 months despite the provision of extra help at home or school. For example,
difficulties learning to read single words that do not fully or rapidly remit with the provision of
instruction in phonological skills or word identification strategies may indicate a specific

Specific Learning Disorder 69

learning disorder. Evidence of persistent learning difficulties may be derived from cumulative
school reports, portfolios of the child’s evaluated work, curriculum-based measures, or clinical
interview. In adults, persistent difficulty refers to ongoing difficulties in literacy or numeracy
skills that manifest during childhood or adolescence, as indicated by cumulative evidence
from school reports, evaluated portfolios of work, or previous assessments.

A second key feature is that the individual’s performance of the affected academic skills is
well below average for age (Criterion B). One robust clinical indicator of difficulties learning
academic skills is low academic achievement for age or average achievement that is sustain-
able only by extraordinarily high levels of effort or support. In children, the low academic skills
cause significant interference in school performance (as indicated by school reports and
teacher’s grades or ratings). Another clinical indicator, particularly in adults, is avoidance of
activities that require the academic skills. Also in adulthood, low academic skills interfere with
occupational performance or everyday activities requiring those skills (as indicated by self-re-
port or report by others). However, this criterion also requires psychometric evidence from an
individually administered, psychometrically sound and culturally appropriate test of aca-
demic achievement that is norm-referenced or criterion-referenced. Academic skills are dis-
tributed along a continuum, so there is no natural cutpoint that can be used to differentiate
individuals with and without specific learning disorder. Thus, any threshold used to specify
what constitutes significantly low academic achievement (e.g., academic skills well below age
expectation) is to a large extent arbitrary. Low achievement scores on one or more standard-
ized tests or subtests within an academic domain (i.e., at least 1.5 standard deviations [SD] be-
low the population mean for age, which translates to a standard score of 78 or less, which is
below the 7th percentile) are needed for the greatest diagnostic certainty. However, precise
scores will vary according to the particular standardized tests that are used. On the basis of
clinical judgment, a more lenient threshold may be used (e.g., 1.0–2.5 SD below the pop-
ulation mean for age), when learning difficulties are supported by converging evidence
from clinical assessment, academic history, school reports, or test scores. Moreover, since
standardized tests are not available in all languages, the diagnosis may then be based in
part on clinical judgment of scores on available test measures.

A third core feature is that the learning difficulties are readily apparent in the early
school years in most individuals (Criterion C). However, in others, the learning difficulties
may not manifest fully until later school years, by which time learning demands have in-
creased and exceed the individual’s limited capacities.

Another key diagnostic feature is that the learning difficulties are considered “spe-
cific,” for four reasons. First, they are not attributable to intellectual disabilities (intellec-
tual disability [intellectual developmental disorder]); global developmental delay;
hearing or vision disorders, or neurological or motor disorders) (Criterion D). Specific
learning disorder affects learning in individuals who otherwise demonstrate normal lev-
els of intellectual functioning (generally estimated by an IQ score of greater than about 70
[± 5 points allowing for measurement error]). The phrase “unexpected academic under-
achievement” is often cited as the defining characteristic of specific learning disorder in
that the specific learning disabilities are not part of a more general learning difficulty as
manifested in intellectual disability or global developmental delay. Specific learning dis-
order may also occur in individuals identified as intellectually “gifted.” These individuals
may be able to sustain apparently adequate academic functioning by using compensatory
strategies, extraordinarily high effort, or support, until the learning demands or assess-
ment procedures (e.g., timed tests) pose barriers to their demonstrating their learning or
accomplishing required tasks. Second, the learning difficulty cannot be attributed to more
general external factors, such as economic or environmental disadvantage, chronic absen-
teeism, or lack of education as typically provided in the individual’s community context.
Third, the learning difficulty cannot be attributed to a neurological (e.g., pediatric stroke)
or motor disorders or to vision or hearing disorders, which are often associated with prob-
lems learning academic skills but are distinguishable by presence of neurological signs.

70 Neurodevelopmental Disorders

Finally, the learning difficulty may be restricted to one academic skill or domain (e.g., read-
ing single words, retrieving or calculating number facts).

Comprehensive assessment is required. Specific learning disorder can only be diagnosed
after formal education starts but can be diagnosed at any point afterward in children, adoles-
cents, or adults, providing there is evidence of onset during the years of formal schooling (i.e.,
the developmental period). No single data source is sufficient for a diagnosis of specific learn-
ing disorder. Rather, specific learning disorder is a clinical diagnosis based on a synthesis of
the individual’s medical, developmental, educational, and family history; the history of the
learning difficulty, including its previous and current manifestation; the impact of the diffi-
culty on academic, occupational, or social functioning; previous or current school reports;
portfolios of work requiring academic skills; curriculum-based assessments; and previous or
current scores from individual standardized tests of academic achievement. If an intellectual,
sensory, neurological, or motor disorder is suspected, then the clinical assessment for specific
learning disorder should also include methods appropriate for these disorders. Thus, compre-
hensive assessment will involve professionals with expertise in specific learning disorder and
psychological/cognitive assessment. Since specific learning disorder typically persists into
adulthood, reassessment is rarely necessary, unless indicated by marked changes in the learn-
ing difficulties (amelioration or worsening) or requested for specific purposes.

Associated Features Supporting Diagnosis
Specific learning disorder is frequently but not invariably preceded, in preschool years, by
delays in attention, language, or motor skills that may persist and co-occur with specific
learning disorder. An uneven profile of abilities is common, such as above-average abili-
ties in drawing, design, and other visuospatial abilities, but slow, effortful, and inaccurate
reading and poor reading comprehension and written expression. Individuals with spe-
cific learning disorder typically (but not invariably) exhibit poor performance on psycho-
logical tests of cognitive processing. However, it remains unclear whether these cognitive
abnormalities are the cause, correlate, or consequence of the learning difficulties. Also, al-
though cognitive deficits associated with difficulties learning to read words are well doc-
umented, those associated with other manifestations of specific learning disorder (e.g.,
reading comprehension, arithmetic computation, written expression) are underspecified
or unknown. Moreover, individuals with similar behavioral symptoms or test scores are
found to have a variety of cognitive deficits, and many of these processing deficits are also
found in other neurodevelopmental disorders (e.g., attention-deficit/hyperactivity disor-
der [ADHD], autistic spectrum disorder, communication disorders, developmental coor-
dination disorder). Thus, assessment of cognitive processing deficits is not required for
diagnostic assessment. Specific learning disorder is associated with increased risk for sui-
cidal ideation and suicide attempts in children, adolescents, and adults.

There are no known biological markers of specific learning disorder. As a group, indi-
viduals with the disorder show circumscribed alterations in cognitive processing and
brain structure and function. Genetic differences are also evident at the group level. But
cognitive testing, neuroimaging, or genetic testing are not useful for diagnosis at this time.

Prevalence
The prevalence of specific learning disorder across the academic domains of reading, writ-
ing, and mathematics is 5%–15% among school-age children across different languages
and cultures. Prevalence in adults is unknown but appears to be approximately 4%.

Development and Course
Onset, recognition, and diagnosis of specific learning disorder usually occurs during the
elementary school years when children are required to learn to read, spell, write, and learn

Specific Learning Disorder 71

mathematics. However, precursors such as language delays or deficits, difficulties in
rhyming or counting, or difficulties with fine motor skills required for writing commonly
occur in early childhood before the start of formal schooling. Manifestations may be be-
havioral (e.g., a reluctance to engage in learning; oppositional behavior). Specific learning
disorder is lifelong, but the course and clinical expression are variable, in part depending
on the interactions among the task demands of the environment, the range and severity of
the individual’s learning difficulties, the individual’s learning abilities, comorbidity, and
the available support systems and intervention. Nonetheless, problems with reading flu-
ency and comprehension, spelling, written expression, and numeracy skills in everyday life
typically persist into adulthood.

Changes in manifestation of symptoms occur with age, so that an individual may have
a persistent or shifting array of learning difficulties across the lifespan.

Examples of symptoms that may be observed among preschool-age children include a lack
of interest in playing games with language sounds (e.g., repetition, rhyming), and they may
have trouble learning nursery rhymes. Preschool children with specific learning disorder may
frequently use baby talk, mispronounce words, and have trouble remembering names of let-
ters, numbers, or days of the week. They may fail to recognize letters in their own names and
have trouble learning to count. Kindergarten-age children with specific learning disorder may
be unable to recognize and write letters, may be unable to write their own names, or may use
invented spelling. They may have trouble breaking down spoken words into syllables (e.g.,
“cowboy” into “cow” and “boy”) and trouble recognizing words that rhyme (e.g., cat, bat, hat).
Kindergarten-age children also may have trouble connecting letters with their sounds (e.g., let-
ter b makes the sound /b/) and may be unable to recognize phonemes (e.g., do not know
which in a set of words [e.g., dog, man, car] starts with the same sound as “cat”).

Specific learning disorder in elementary school–age children typically manifests as
marked difficulty learning letter-sound correspondence (particularly in English-speaking
children), fluent word decoding, spelling, or math facts; reading aloud is slow, inaccurate,
and effortful, and some children struggle to understand the magnitude that a spoken or
written number represents. Children in primary grades (grades 1–3) may continue to have
problems recognizing and manipulating phonemes, be unable to read common one-sylla-
ble words (such as mat or top), and be unable recognize common irregularly spelled
words (e.g., said, two). They may commit reading errors that indicate problems in con-
necting sounds and letters (e.g., “big” for “got”) and have difficulty sequencing numbers
and letters. Children in grades 1-3 also may have difficulty remembering number facts or
arithmetic procedures for adding, subtracting, and so forth, and may complain that read-
ing or arithmetic is hard and avoid doing it. Children with specific learning disorder in the
middle grades (grades 4–6) may mispronounce or skip parts of long, multisyllable words
(e.g., say “conible” for “convertible,” “aminal” for “animal”) and confuse words that
sound alike (e.g., “tornado” for “volcano”). They may have trouble remembering dates,
names, and telephone numbers and may have trouble completing homework or tests on
time. Children in the middle grades also may have poor comprehension with or without
slow, effortful, and inaccurate reading, and they may have trouble reading small function
words (e.g., that, the, an, in). They may have very poor spelling and poor written work.
They may get the first part of a word correctly, then guess wildly (e.g., read “clover” as
“clock”), and may express fear of reading aloud or refuse to read aloud.

By contrast, adolescents may have mastered word decoding, but reading remains slow
and effortful, and they are likely to show marked problems in reading comprehension and
written expression (including poor spelling) and poor mastery of math facts or mathemat-
ical problem solving. During adolescence and into adulthood, individuals with specific
learning disorder may continue to make numerous spelling mistakes and read single
words and connected text slowly and with much effort, with trouble pronouncing multi-
syllable words. They may frequently need to reread material to understand or get the main
point and have trouble making inferences from written text. Adolescents and adults may

72 Neurodevelopmental Disorders

avoid activities that demand reading or arithmetic (reading for pleasure, reading instruc-
tions). Adults with specific learning disorder have ongoing spelling problems, slow and
effortful reading, or problems making important inferences from numerical information
in work-related written documents. They may avoid both leisure and work-related activ-
ities that demand reading or writing or use alternative approaches to access print (e.g.,
text-to-speech/speech-to-text software, audiobooks, audiovisual media).

An alternative clinical expression is that of circumscribed learning difficulties that per-
sist across the lifespan, such as an inability to master the basic sense of number (e.g., to
know which of a pair of numbers or dots represents the larger magnitude), or lack of pro-
ficiency in word identification or spelling. Avoidance of or reluctance to engage in activi-
ties requiring academic skills is common in children, adolescents, and adults. Episodes of
severe anxiety or anxiety disorders, including somatic complaints or panic attacks, are
common across the lifespan and accompany both the circumscribed and the broader ex-
pression of learning difficulties.

Risk and Prognostic Factors
Environmental. Prematurity or very low birth weight increases the risk for specific
learning disorder, as does prenatal exposure to nicotine.

Genetic and physiological. Specific learning disorder appears to aggregate in families,
particularly when affecting reading, mathematics, and spelling. The relative risk of spe-
cific learning disorder in reading or mathematics is substantially higher (e.g., 4–8 times
and 5–10 times higher, respectively) in first-degree relatives of individuals with these
learning difficulties compared with those without them. Family history of reading diffi-
culties (dyslexia) and parental literacy skills predict literacy problems or specific learning
disorder in offspring, indicating the combined role of genetic and environmental factors.

There is high heritability for both reading ability and reading disability in alphabetic and
nonalphabetic languages, including high heritability for most manifestations of learning abil-
ities and disabilities (e.g., heritability estimate values greater than 0.6). Covariation between
various manifestations of learning difficulties is high, suggesting that genes related to one
presentation are highly correlated with genes related to another manifestation.

Course modifiers. Marked problems with inattentive behavior in preschool years is pre-
dictive of later difficulties in reading and mathematics (but not necessarily specific learn-
ing disorder) and nonresponse to effective academic interventions. Delay or disorders in
speech or language, or impaired cognitive processing (e.g., phonological awareness,
working memory, rapid serial naming) in preschool years, predicts later specific learning
disorder in reading and written expression. Comorbidity with ADHD is predictive of
worse mental health outcome than that associated with specific learning disorder without
ADHD. Systematic, intensive, individualized instruction, using evidence-based interven-
tions, may improve or ameliorate the learning difficulties in some individuals or promote
the use of compensatory strategies in others, thereby mitigating the otherwise poor out-
comes.

Culture-Related Diagnostic Issues
Specific learning disorder occurs across languages, cultures, races, and socioeconomic
conditions but may vary in its manifestation according to the nature of the spoken and
written symbol systems and cultural and educational practices. For example, the cognitive
processing requirements of reading and of working with numbers vary greatly across or-
thographies. In the English language, the observable hallmark clinical symptom of diffi-
culties learning to read is inaccurate and slow reading of single words; in other alphabetic
languages that have more direct mapping between sounds and letters (e.g., Spanish, Ger-
man) and in non-alphabetic languages (e.g., Chinese, Japanese), the hallmark feature is

Specific Learning Disorder 73

slow but accurate reading. In English-language learners, assessment should include con-
sideration of whether the source of reading difficulties is a limited proficiency with Eng-
lish or a specific learning disorder. Risk factors for specific learning disorder in English-
language learners include a family history of specific learning disorder or language delay
in the native language, as well as learning difficulties in English and failure to catch up
with peers. If there is suspicion of cultural or language differences (e.g., as in an English-
language learner), the assessment needs to take into account the individual’s language
proficiency in his or her first or native language as well as in the second language (in this
example, English). Also, assessment should consider the linguistic and cultural context in
which the individual is living, as well as his or her educational and learning history in the
original culture and language.

Gender-Related Diagnostic Issues
Specific learning disorder is more common in males than in females (ratios range from
about 2:1 to 3:1) and cannot be attributed to factors such as ascertainment bias, definitional
or measurement variation, language, race, or socioeconomic status.

Functional Consequences of
Specific Learning Disorder
Specific learning disorder can have negative functional consequences across the lifespan,
including lower academic attainment, higher rates of high school dropout, lower rates of
postsecondary education, high levels of psychological distress and poorer overall mental
health, higher rates of unemployment and under-employment, and lower incomes. School
dropout and co-occurring depressive symptoms increase the risk for poor mental health
outcomes, including suicidality, whereas high levels of social or emotional support predict
better mental health outcomes.

Differential Diagnosis
Normal variations in academic attainment. Specific learning disorder is distinguished
from normal variations in academic attainment due to external factors (e.g., lack of edu-
cational opportunity, consistently poor instruction, learning in a second language), be-
cause the learning difficulties persist in the presence of adequate educational opportunity
and exposure to the same instruction as the peer group, and competency in the language of
instruction, even when it is different from one’s primary spoken language.

Intellectual disability (intellectual developmental disorder). Specific learning disorder
differs from general learning difficulties associated with intellectual disability, because the
learning difficulties occur in the presence of normal levels of intellectual functioning (i.e.,
IQ score of at least 70 ± 5). If intellectual disability is present, specific learning disorder can
be diagnosed only when the learning difficulties are in excess of those usually associated
with the intellectual disability.

Learning difficulties due to neurological or sensory disorders. Specific learning dis-
order is distinguished from learning difficulties due to neurological or sensory disorders
(e.g., pediatric stroke, traumatic brain injury, hearing impairment, vision impairment), be-
cause in these cases there are abnormal findings on neurological examination.

Neurocognitive disorders. Specific learning disorder is distinguished from learning
problems associated with neurodegenerative cognitive disorders, because in specific
learning disorder the clinical expression of specific learning difficulties occurs during the
developmental period, and the difficulties do not manifest as a marked decline from a for-
mer state.

74 Neurodevelopmental Disorders

Attention-deficit/hyperactivity disorder. Specific learning disorder is distinguished from
the poor academic performance associated with ADHD, because in the latter condition the
problems may not necessarily reflect specific difficulties in learning academic skills but
rather may reflect difficulties in performing those skills. However, the co-occurrence of
specific learning disorder and ADHD is more frequent than expected by chance. If criteria
for both disorders are met, both diagnoses can be given.

Psychotic disorders. Specific learning disorder is distinguished from the academic and
cognitive-processing difficulties associated with schizophrenia or psychosis, because with
these disorders there is a decline (often rapid) in these functional domains.

Comorbidity
Specific learning disorder commonly co-occurs with neurodevelopmental (e.g., ADHD,
communication disorders, developmental coordination disorder, autistic spectrum disor-
der) or other mental disorders (e.g., anxiety disorders, depressive and bipolar disorders).
These comorbidities do not necessarily exclude the diagnosis specific learning disorder
but may make testing and differential diagnosis more difficult, because each of the co-
occurring disorders independently interferes with the execution of activities of daily liv-
ing, including learning. Thus, clinical judgment is required to attribute such impairment to
learning difficulties. If there is an indication that another diagnosis could account for the
difficulties learning keystone academic skills described in Criterion A, specific learning
disorder should not be diagnosed.

Motor Disorders

Developmental Coordination Disorder
Diagnostic Criteria 315.4 (F82)

A. The acquisition and execution of coordinated motor skills is substantially below that ex-
pected given the individual’s chronological age and opportunity for skill learning and
use. Difficulties are manifested as clumsiness (e.g., dropping or bumping into objects)
as well as slowness and inaccuracy of performance of motor skills (e.g., catching an
object, using scissors or cutlery, handwriting, riding a bike, or participating in sports).

B. The motor skills deficit in Criterion A significantly and persistently interferes with activ-
ities of daily living appropriate to chronological age (e.g., self-care and self-mainte-
nance) and impacts academic/school productivity, prevocational and vocational
activities, leisure, and play.

C. Onset of symptoms is in the early developmental period.
D. The motor skills deficits are not better explained by intellectual disability (intellectual devel-

opmental disorder) or visual impairment and are not attributable to a neurological condi-
tion affecting movement (e.g., cerebral palsy, muscular dystrophy, degenerative disorder).

Diagnostic Features
The diagnosis of developmental coordination disorder is made by a clinical synthesis of the
history (developmental and medical), physical examination, school or workplace report, and
individual assessment using psychometrically sound and culturally appropriate standardized
tests. The manifestation of impaired skills requiring motor coordination (Criterion A) varies

Developmental Coordination Disorder 75

with age. Young children may be delayed in achieving motor milestones (i.e., sitting, crawling,
walking), although many achieve typical motor milestones. They also may be delayed in de-
veloping skills such as negotiating stairs, pedaling, buttoning shirts, completing puzzles, and
using zippers. Even when the skill is achieved, movement execution may appear awkward,
slow, or less precise than that of peers. Older children and adults may display slow speed or in-
accuracy with motor aspects of activities such as assembling puzzles, building models, playing
ball games (especially in teams), handwriting, typing, driving, or carrying out self-care skills.

Developmental coordination disorder is diagnosed only if the impairment in motor
skills significantly interferes with the performance of, or participation in, daily activities in
family, social, school, or community life (Criterion B). Examples of such activities include
getting dressed, eating meals with age-appropriate utensils and without mess, engaging
in physical games with others, using specific tools in class such as rulers and scissors, and
participating in team exercise activities at school. Not only is ability to perform these ac-
tions impaired, but also marked slowness in execution is common. Handwriting compe-
tence is frequently affected, consequently affecting legibility and/or speed of written output
and affecting academic achievement (the impact is distinguished from specific learning
difficulty by the emphasis on the motoric component of written output skills). In adults,
everyday skills in education and work, especially those in which speed and accuracy are
required, are affected by coordination problems.

Criterion C states that the onset of symptoms of developmental coordination disorder
must be in the early developmental period. However, developmental coordination disorder is
typically not diagnosed before age 5 years because there is considerable variation in the age at
acquisition of many motor skills or a lack of stability of measurement in early childhood (e.g.,
some children catch up) or because other causes of motor delay may not have fully manifested.

Criterion D specifies that the diagnosis of developmental coordination disorder is
made if the coordination difficulties are not better explained by visual impairment or at-
tributable to a neurological condition. Thus, visual function examination and neurological
examination must be included in the diagnostic evaluation. If intellectual disability (intel-
lectual developmental disorder) is present, the motor difficulties are in excess of those ex-
pected for the mental age; however, no IQ cut-off or discrepancy criterion is specified.

Developmental coordination disorder does not have discrete subtypes; however, indi-
viduals may be impaired predominantly in gross motor skills or in fine motor skills, in-
cluding handwriting skills.

Other terms used to describe developmental coordination disorder include childhood
dyspraxia, specific developmental disorder of motor function, and clumsy child syndrome.

Associated Features Supporting Diagnosis
Some children with developmental coordination disorder show additional (usually sup-
pressed) motor activity, such as choreiform movements of unsupported limbs or mirror
movements. These “overflow” movements are referred to as neurodevelopmental immaturities or
neurological soft signs rather than neurological abnormalities. In both current literature and
clinical practice, their role in diagnosis is still unclear, requiring further evaluation.

Prevalence
The prevalence of developmental coordination disorder in children ages 5–11 years is 5%–
6% (in children age 7 years, 1.8% are diagnosed with severe developmental coordination
disorder and 3% with probable developmental coordination disorder). Males are more of-
ten affected than females, with a male:female ratio between 2:1 and 7:1.

Development and Course
The course of developmental coordination disorder is variable but stable at least to 1 year
follow-up. Although there may be improvement in the longer term, problems with coor-

76 Neurodevelopmental Disorders

dinated movements continue through adolescence in an estimated 50%–70% of children.
Onset is in early childhood. Delayed motor milestones may be the first signs, or the disor-
der is first recognized when the child attempts tasks such as holding a knife and fork, but-
toning clothes, or playing ball games. In middle childhood, there are difficulties with
motor aspects of assembling puzzles, building models, playing ball, and handwriting, as
well as with organizing belongings, when motor sequencing and coordination are re-
quired. In early adulthood, there is continuing difficulty in learning new tasks involving
complex/automatic motor skills, including driving and using tools. Inability to take notes
and handwrite quickly may affect performance in the workplace. Co-occurrence with
other disorders (see the section “Comorbidity” for this disorder) has an additional impact
on presentation, course, and outcome.

Risk and Prognostic Factors
Environmental. Developmental coordination disorder is more common following pre-
natal exposure to alcohol and in preterm and low-birth-weight children.

Genetic and physiological. Impairments in underlying neurodevelopmental processes—
particularly in visual-motor skills, both in visual-motor perception and spatial mentalizing—
have been found and affect the ability to make rapid motoric adjustments as the complexity of
the required movements increases. Cerebellar dysfunction has been proposed, but the neural
basis of developmental coordination disorder remains unclear. Because of the co-occurrence of
developmental coordination disorder with attention-deficit/hyperactivity disorder (ADHD),
specific learning disabilities, and autism spectrum disorder, shared genetic effect has been pro-
posed. However, consistent co-occurrence in twins appears only in severe cases.

Course modifiers. Individuals with ADHD and with developmental coordination dis-
order demonstrate more impairment than individuals with ADHD without developmen-
tal coordination disorder.

Culture-Related Diagnostic Issues
Developmental coordination disorder occurs across cultures, races, and socioeconomic
conditions. By definition, “activities of daily living” implies cultural differences necessi-
tating consideration of the context in which the individual child is living as well as
whether he or she has had appropriate opportunities to learn and practice such activities.

Functional Consequences of
Developmental Coordination Disorder
Developmental coordination disorder leads to impaired functional performance in activ-
ities of daily living (Criterion B), and the impairment is increased with co-occurring con-
ditions. Consequences of developmental coordination disorder include reduced
participation in team play and sports; poor self-esteem and sense of self-worth; emotional
or behavior problems; impaired academic achievement; poor physical fitness; and re-
duced physical activity and obesity.

Differential Diagnosis
Motor impairments due to another medical condition. Problems in coordination may
be associated with visual function impairment and specific neurological disorders (e.g.,
cerebral palsy, progressive lesions of the cerebellum, neuromuscular disorders). In such
cases, there are additional findings on neurological examination.

Intellectual disability (intellectual developmental disorder). If intellectual disability is
present, motor competences may be impaired in accordance with the intellectual disabil-

Stereotypic Movement Disorder 77

ity. However, if the motor difficulties are in excess of what could be accounted for by the
intellectual disability, and criteria for developmental coordination disorder are met, de-
velopmental coordination disorder can be diagnosed as well.

Attention-deficit/hyperactivity disorder. Individuals with ADHD may fall, bump into
objects, or knock things over. Careful observation across different contexts is required to
ascertain if lack of motor competence is attributable to distractibility and impulsiveness
rather than to developmental coordination disorder. If criteria for both ADHD and devel-
opmental coordination disorder are met, both diagnoses can be given.

Autism spectrum disorder. Individuals with autism spectrum disorder may be uninter-
ested in participating in tasks requiring complex coordination skills, such as ball sports,
which will affect test performance and function but not reflect core motor competence. Co-
occurrence of developmental coordination disorder and autism spectrum disorder is com-
mon. If criteria for both disorders are met, both diagnoses can be given.

Joint hypermobility syndrome. Individuals with syndromes causing hyperextensible
joints (found on physical examination; often with a complaint of pain) may present with
symptoms similar to those of developmental coordination disorder.

Comorbidity
Disorders that commonly co-occur with developmental coordination disorder include
speech and language disorder; specific learning disorder (especially reading and writing);
problems of inattention, including ADHD (the most frequent coexisting condition, with
about 50% co-occurrence); autism spectrum disorder; disruptive and emotional behavior
problems; and joint hypermobility syndrome. Different clusters of co-occurrence may be
present (e.g., a cluster with severe reading disorders, fine motor problems, and handwriting
problems; another cluster with impaired movement control and motor planning). Presence
of other disorders does not exclude developmental coordination disorder but may make
testing more difficult and may independently interfere with the execution of activities of
daily living, thus requiring examiner judgment in ascribing impairment to motor skills.

Stereotypic Movement Disorder
Diagnostic Criteria 307.3 (F98.4)

A. Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand
shaking or waving, body rocking, head banging, self-biting, hitting own body).

B. The repetitive motor behavior interferes with social, academic, or other activities and
may result in self-injury.

C. Onset is in the early developmental period.
D. The repetitive motor behavior is not attributable to the physiological effects of a sub-

stance or neurological condition and is not better explained by another neurodevel-
opmental or mental disorder (e.g., trichotillomania [hair-pulling disorder], obsessive-
compulsive disorder).

Specify if:
With self-injurious behavior (or behavior that would result in an injury if preventive
measures were not used)
Without self-injurious behavior

Specify if:
Associated with a known medical or genetic condition, neurodevelopmental dis-
order, or environmental factor (e.g., Lesch-Nyhan syndrome, intellectual disability
[intellectual developmental disorder], intrauterine alcohol exposure)

78 Neurodevelopmental Disorders

Coding note: Use additional code to identify the associated medical or genetic
condition, or neurodevelopmental disorder.

Specify current severity:
Mild: Symptoms are easily suppressed by sensory stimulus or distraction.
Moderate: Symptoms require explicit protective measures and behavioral modification.
Severe: Continuous monitoring and protective measures are required to prevent seri-
ous injury.

Recording Procedures
For stereotypic movement disorder that is associated with a known medical or genetic
condition, neurodevelopmental disorder, or environmental factor, record stereotypic
movement disorder associated with (name of condition, disorder, or factor) (e.g., stereo-
typic movement disorder associated with Lesch-Nyhan syndrome).

Specifiers
The severity of non-self-injurious stereotypic movements ranges from mild presentations
that are easily suppressed by a sensory stimulus or distraction to continuous movements
that markedly interfere with all activities of daily living. Self-injurious behaviors range in se-
verity along various dimensions, including the frequency, impact on adaptive functioning,
and severity of bodily injury (from mild bruising or erythema from hitting hand against
body, to lacerations or amputation of digits, to retinal detachment from head banging).

Diagnostic Features
The essential feature of stereotypic movement disorder is repetitive, seemingly driven,
and apparently purposeless motor behavior (Criterion A). These behaviors are often
rhythmical movements of the head, hands, or body without obvious adaptive function.
The movements may or may not respond to efforts to stop them. Among typically devel-
oping children, the repetitive movements may be stopped when attention is directed to
them or when the child is distracted from performing them. Among children with neuro-
developmental disorders, the behaviors are typically less responsive to such efforts. In
other cases, the individual demonstrates self-restraining behaviors (e.g., sitting on hands,
wrapping arms in clothing, finding a protective device).

The repertoire of behaviors is variable; each individual presents with his or her own in-
dividually patterned, “signature” behavior. Examples of non-self-injurious stereotypic
movements include, but are not limited to, body rocking, bilateral flapping or rotating
hand movements, flicking or fluttering fingers in front of the face, arm waving or flapping,
and head nodding. Stereotyped self-injurious behaviors include, but are not limited to, re-
petitive head banging, face slapping, eye poking, and biting of hands, lips, or other body
parts. Eye poking is particularly concerning; it occurs more frequently among children
with visual impairment. Multiple movements may be combined (e.g., cocking the head,
rocking the torso, waving a small string repetitively in front of the face).

Stereotypic movements may occur many times during a day, lasting a few seconds to
several minutes or longer. Frequency can vary from many occurrences in a single day to
several weeks elapsing between episodes. The behaviors vary in context, occurring when
the individual is engrossed in other activities, when excited, stressed, fatigued, or bored.
Criterion A requires that the movements be “apparently” purposeless. However, some
functions may be served by the movements. For example, stereotypic movements might
reduce anxiety in response to external stressors.

Criterion B states that the stereotypic movements interfere with social, academic, or
other activities and, in some children, may result in self-injury (or would if protective mea-
sures were not used). If self-injury is present, it should be coded using the specifier. Onset

Stereotypic Movement Disorder 79

of stereotypic movements is in the early developmental period (Criterion C). Criterion D
states that the repetitive, stereotyped behavior in stereotypic movement disorder is not at-
tributable to the physiological effects of a substance or neurological condition and is not
better explained by another neurodevelopmental or mental disorder. The presence of
stereotypic movements may indicate an undetected neurodevelopmental problem, espe-
cially in children ages 1–3 years.

Prevalence
Simple stereotypic movements (e.g., rocking) are common in young typically developing chil-
dren. Complex stereotypic movements are much less common (occurring in approximately
3%–4%). Between 4% and 16% of individuals with intellectual disability (intellectual develop-
mental disorder) engage in stereotypy and self-injury. The risk is greater in individuals with
severe intellectual disability. Among individuals with intellectual disability living in res-
idential facilities, 10%–15% may have stereotypic movement disorder with self-injury.

Development and Course
Stereotypic movements typically begin within the first 3 years of life. Simple stereotypic move-
ments are common in infancy and may be involved in acquisition of motor mastery. In chil-
dren who develop complex motor stereotypies, approximately 80% exhibit symptoms before
24 months of age, 12% between 24 and 35 months, and 8% at 36 months or older. In most typ-
ically developing children, these movements resolve over time or can be suppressed. Onset of
complex motor stereotypies may be in infancy or later in the developmental period. Among
individuals with intellectual disability, the stereotyped, self-injurious behaviors may persist
for years, even though the typography or pattern of self-injury may change.

Risk and Prognostic Factors
Environmental. Social isolation is a risk factor for self-stimulation that may progress to
stereotypic movements with repetitive self-injury. Environmental stress may also trigger
stereotypic behavior. Fear may alter physiological state, resulting in increased frequency
of stereotypic behaviors.

Genetic and physiological. Lower cognitive functioning is linked to greater risk for stereo-
typic behaviors and poorer response to interventions. Stereotypic movements are more fre-
quent among individuals with moderate-to-severe/profound intellectual disability, who by
virtue of a particular syndrome (e.g., Rett syndrome) or environmental factor (e.g., an environ-
ment with relatively insufficient stimulation) seem to be at higher risk for stereotypies. Repet-
itive self-injurious behavior may be a behavioral phenotype in neurogenetic syndromes. For
example, in Lesch-Nyhan syndrome, there are both stereotypic dystonic movements and self-
mutilation of fingers, lip biting, and other forms of self-injury unless the individual is re-
strained, and in Rett syndrome and Cornelia de Lange syndrome, self-injury may result from
the hand-to-mouth stereotypies. Stereotypic behaviors may result from a painful medical con-
dition (e.g., middle ear infection, dental problems, gastroesophageal reflux).

Culture-Related Diagnostic Issues
Stereotypic movement disorder, with or without self-injury, occurs in all races and cultures.
Cultural attitudes toward unusual behaviors may result in delayed diagnosis. Overall cultural
tolerance and attitudes toward stereotypic movement vary and must be considered.

Differential Diagnosis
Normal development. Simple stereotypic movements are common in infancy and early
childhood. Rocking may occur in the transition from sleep to awake, a behavior that usu-

80 Neurodevelopmental Disorders

ally resolves with age. Complex stereotypies are less common in typically developing
children and can usually be suppressed by distraction or sensory stimulation. The indi-
vidual’s daily routine is rarely affected, and the movements generally do not cause the
child distress. The diagnosis would not be appropriate in these circumstances.

Autism spectrum disorder. Stereotypic movements may be a presenting symptom of
autism spectrum disorder and should be considered when repetitive movements and be-
haviors are being evaluated. Deficits of social communication and reciprocity manifesting
in autism spectrum disorder are generally absent in stereotypic movement disorder, and
thus social interaction, social communication, and rigid repetitive behaviors and interests
are distinguishing features. When autism spectrum disorder is present, stereotypic move-
ment disorder is diagnosed only when there is self-injury or when the stereotypic behav-
iors are sufficiently severe to become a focus of treatment.

Tic disorders. Typically, stereotypies have an earlier age at onset (before 3 years) than
do tics, which have a mean age at onset of 5–7 years. They are consistent and fixed in their
pattern or topography compared with tics, which are variable in their presentation. Ste-
reotypies may involve arms, hands, or the entire body, while tics commonly involve eyes,
face, head, and shoulders. Stereotypies are more fixed, rhythmic, and prolonged in dura-
tion than tics, which, generally, are brief, rapid, random, and fluctuating. Tics and stereo-
typic movements are both reduced by distraction.

Obsessive-compulsive and related disorders. Stereotypic movement disorder is dis-
tinguished from obsessive-compulsive disorder (OCD) by the absence of obsessions, as
well as by the nature of the repetitive behaviors. In OCD the individual feels driven to per-
form repetitive behaviors in response to an obsession or according to rules that must be ap-
plied rigidly, whereas in stereotypic movement disorder the behaviors are seemingly
driven but apparently purposeless. Trichotillomania (hair-pulling disorder) and excoria-
tion (skin-picking) disorder are characterized by body-focused repetitive behaviors (i.e.,
hair pulling and skin picking) that may be seemingly driven but that are not apparently
purposeless, and that may not be patterned or rhythmical. Furthermore, onset in tricho-
tillomania and excoriation disorder is not typically in the early developmental period, but
rather around puberty or later.

Other neurological and medical conditions. The diagnosis of stereotypic movements
requires the exclusion of habits, mannerisms, paroxysmal dyskinesias, and benign he-
reditary chorea. A neurological history and examination are required to assess features
suggestive of other disorders, such as myoclonus, dystonia, tics, and chorea. Involuntary
movements associated with a neurological condition may be distinguished by their signs
and symptoms. For example, repetitive, stereotypic movements in tardive dyskinesia can
be distinguished by a history of chronic neuroleptic use and characteristic oral or facial
dyskinesia or irregular trunk or limb movements. These types of movements do not result
in self-injury. A diagnosis of stereotypic movement disorder is not appropriate for repet-
itive skin picking or scratching associated with amphetamine intoxication or abuse (e.g.,
patients are diagnosed with substance/medication-induced obsessive-compulsive and re-
lated disorder) and repetitive choreoathetoid movements associated with other neurolog-
ical disorders.

Comorbidity
Stereotypic movement disorder may occur as a primary diagnosis or secondary to another
disorder. For example, stereotypies are a common manifestation of a variety of neuro-
genetic disorders, such as Lesch-Nyhan syndrome, Rett syndrome, fragile X syndrome,
Cornelia de Lange syndrome, and Smith-Magenis syndrome. When stereotypic move-
ment disorder co-occurs with another medical condition, both should be coded.

Tic Disorders 81

Tic Disorders
Diagnostic Criteria

Note: A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.

Tourette’s Disorder 307.23 (F95.2)
A. Both multiple motor and one or more vocal tics have been present at some time during

the illness, although not necessarily concurrently.
B. The tics may wax and wane in frequency but have persisted for more than 1 year since

first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., co-

caine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).

Persistent (Chronic) Motor or Vocal Tic Disorder 307.22 (F95.1)
A. Single or multiple motor or vocal tics have been present during the illness, but not both

motor and vocal.
B. The tics may wax and wane in frequency but have persisted for more than 1 year since

first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., co-

caine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder.

Specify if:
With motor tics only
With vocal tics only

Provisional Tic Disorder 307.21 (F95.0)
A. Single or multiple motor and/or vocal tics.
B. The tics have been present for less than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., co-

caine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or

vocal tic disorder.

Specifiers
The “motor tics only” or “vocal tics only” specifier is only required for persistent (chronic)
motor or vocal tic disorder.

Diagnostic Features
Tic disorders comprise four diagnostic categories: Tourette’s disorder, persistent (chronic)
motor or vocal tic disorder, provisional tic disorder, and the other specified and unspecified
tic disorders. Diagnosis for any tic disorder is based on the presence of motor and/or vocal
tics (Criterion A), duration of tic symptoms (Criterion B), age at onset (Criterion C), and ab-
sence of any known cause such as another medical condition or substance use (Criterion D).
The tic disorders are hierarchical in order (i.e., Tourette’s disorder, followed by persistent
[chronic] motor or vocal tic disorder, followed by provisional tic disorder, followed by the

82 Neurodevelopmental Disorders

other specified and unspecified tic disorders), such that once a tic disorder at one level of the
hierarchy is diagnosed, a lower hierarchy diagnosis cannot be made (Criterion E).

Tics are sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations. An
individual may have various tic symptoms over time, but at any point in time, the tic rep-
ertoire recurs in a characteristic fashion. Although tics can include almost any muscle group
or vocalization, certain tic symptoms, such as eye blinking or throat clearing, are common
across patient populations. Tics are generally experienced as involuntary but can be vol-
untarily suppressed for varying lengths of time.

Tics can be either simple or complex. Simple motor tics are of short duration (i.e., milli-
seconds) and can include eye blinking, shoulder shrugging, and extension of the extrem-
ities. Simple vocal tics include throat clearing, sniffing, and grunting often caused by
contraction of the diaphragm or muscles of the oropharynx. Complex motor tics are of lon-
ger duration (i.e., seconds) and often include a combination of simple tics such as simul-
taneous head turning and shoulder shrugging. Complex tics can appear purposeful, such
as a tic-like sexual or obscene gesture (copropraxia) or a tic-like imitation of someone else’s
movements (echopraxia). Similarly, complex vocal tics include repeating one’s own sounds
or words (palilalia), repeating the last-heard word or phrase (echolalia), or uttering socially
unacceptable words, including obscenities, or ethnic, racial, or religious slurs (coprolalia).
Importantly, coprolalia is an abrupt, sharp bark or grunt utterance and lacks the prosody
of similar inappropriate speech observed in human interactions.

The presence of motor and/or vocal tics varies across the four tic disorders (Criterion
A). For Tourette’s disorder, both motor and vocal tics must be present, whereas for per-
sistent (chronic) motor or vocal tic disorder, only motor or only vocal tics are present. For
provisional tic disorder, motor and/or vocal tics may be present. For other specified or un-
specified tic disorders, the movement disorder symptoms are best characterized as tics but
are atypical in presentation or age at onset, or have a known etiology.

The 1-year minimum duration criterion (Criterion B) assures that individuals diag-
nosed with either Tourette’s disorder or persistent (chronic) motor or vocal tic disorder
have had persistent symptoms. Tics wax and wane in severity, and some individuals may
have tic-free periods of weeks to months; however, an individual who has had tic symp-
toms of greater than 1 year’s duration since first tic onset would be considered to have per-
sistent symptoms regardless of duration of tic-free periods. For an individual with motor
and/or vocal tics of less than 1 year since first tic onset, a provisional tic disorder diagnosis
can be considered. There is no duration specification for other specified and unspecified tic
disorders. The onset of tics must occur prior to age 18 years (Criterion C). Tic disorders
typically begin in the prepubertal period, with an average age at onset between 4 and 6
years, and with the incidence of new-onset tic disorders decreasing in the teen years. New
onset of tic symptoms in adulthood is exceedingly rare and is often associated with expo-
sures to drugs (e.g., excessive cocaine use) or is a result of a central nervous system insult
(e.g., postviral encephalitis). Although tic onset is uncommon in teenagers and adults, it is
not uncommon for adolescents and adults to present for an initial diagnostic assessment
and, when carefully evaluated, provide a history of milder symptoms dating back to child-
hood. New-onset abnormal movements suggestive of tics outside of the usual age range
should result in evaluation for other movement disorders or for specific etiologies.

Tic symptoms cannot be attributable to the physiological effects of a substance or an-
other medical condition (Criterion D). When there is strong evidence from the history,
physical examination, and/or laboratory results to suggest a plausible, proximal, and
probable cause for a tic disorder, a diagnosis of other specified tic disorder should be used.

Having previously met diagnostic criteria for Tourette’s disorder negates a possible di-
agnosis of persistent (chronic) motor or vocal tic disorder (Criterion E). Similarly, a previ-
ous diagnosis of persistent (chronic) motor or vocal tic disorder negates a diagnosis of
provisional tic disorder or other specified or unspecified tic disorder (Criterion E).

Tic Disorders 83

Prevalence
Tics are common in childhood but transient in most cases. The estimated prevalence of
Tourette’s disorder ranges from 3 to 8 per 1,000 in school-age children. Males are more
commonly affected than females, with the ratio varying from 2:1 to 4:1. A national survey
in the United States estimated 3 per 1,000 for the prevalence of clinically identified cases.
The frequency of identified cases was lower among African Americans and Hispanic
Americans, which may be related to differences in access to care.

Development and Course
Onset of tics is typically between ages 4 and 6 years. Peak severity occurs between ages 10
and 12 years, with a decline in severity during adolescence. Many adults with tic disorders
experience diminished symptoms. A small percentage of individuals will have persis-
tently severe or worsening symptoms in adulthood.

Tic symptoms manifest similarly in all age groups and across the lifespan. Tics wax and
wane in severity and change in affected muscle groups and vocalizations over time. As
children get older, they begin to report their tics being associated with a premonitory
urge—a somatic sensation that precedes the tic—and a feeling of tension reduction follow-
ing the expression of the tic. Tics associated with a premonitory urge may be experienced
as not completely “involuntary” in that the urge and the tic can be resisted. An individual
may also feel the need to perform a tic in a specific way or repeat it until he or she achieves
the feeling that the tic has been done “just right.”

The vulnerability toward developing co-occurring conditions changes as individuals
pass through the age of risk for various co-occurring conditions. For example, prepubertal
children with tic disorders are more likely to experience attention-deficit/hyperactivity
disorder (ADHD), obsessive-compulsive disorder (OCD), and separation anxiety disorder
than are teenagers and adults, who are more likely to experience the new onset of major
depressive disorder, substance use disorder, or bipolar disorder.

Risk and Prognostic Factors
Temperamental. Tics are worsened by anxiety, excitement, and exhaustion and are better
during calm, focused activities. Individuals may have fewer tics when engaged in schoolwork
or tasks at work than when relaxing at home after school or in the evening. Stressful/exciting
events (e.g., taking a test, participating in exciting activities) often make tics worse.

Environmental. Observing a gesture or sound in another person may result in an indi-
vidual with a tic disorder making a similar gesture or sound, which may be incorrectly
perceived by others as purposeful. This can be a particular problem when the individual is
interacting with authority figures (e.g., teachers, supervisors, police).

Genetic and physiological. Genetic and environmental factors influence tic symptom
expression and severity. Important risk alleles for Tourette’s disorder and rare genetic
variants in families with tic disorders have been identified. Obstetrical complications,
older paternal age, lower birth weight, and maternal smoking during pregnancy are as-
sociated with worse tic severity.

Culture-Related Diagnostic Issues
Tic disorders do not appear to vary in clinical characteristics, course, or etiology by race,
ethnicity, and culture. However, race, ethnicity, and culture may impact how tic disorders
are perceived and managed in the family and community, as well as influencing patterns
of help seeking, and choices of treatment.

84 Neurodevelopmental Disorders

Gender-Related Diagnostic Issues
Males are more commonly affected than females, but there are no gender differences in the
kinds of tics, age at onset, or course. Women with persistent tic disorders may be more
likely to experience anxiety and depression.

Functional Consequences of Tic Disorders
Many individuals with mild to moderate tic severity experience no distress or impairment
in functioning and may even be unaware of their tics. Individuals with more severe symp-
toms generally have more impairment in daily living, but even individuals with moderate
or even severe tic disorders may function well. The presence of a co-occurring condition,
such as ADHD or OCD, can have greater impact on functioning. Less commonly, tics dis-
rupt functioning in daily activities and result in social isolation, interpersonal conflict,
peer victimization, inability to work or to go to school, and lower quality of life. The indi-
vidual also may experience substantial psychological distress. Rare complications of Tou-
rette’s disorder include physical injury, such as eye injury (from hitting oneself in the face),
and orthopedic and neurological injury (e.g., disc disease related to forceful head and neck
movements).

Differential Diagnosis
Abnormal movements that may accompany other medical conditions and stereotypic
movement disorder. Motor stereotypies are defined as involuntary rhythmic, repetitive,
predictable movements that appear purposeful but serve no obvious adaptive function or
purpose and stop with distraction. Examples include repetitive hand waving/rotating,
arm flapping, and finger wiggling. Motor stereotypies can be differentiated from tics based
on the former’s earlier age at onset (younger than 3 years), prolonged duration (seconds to
minutes), constant repetitive fixed form and location, exacerbation when engrossed in ac-
tivities, lack of a premonitory urge, and cessation with distraction (e.g., name called or
touched). Chorea represents rapid, random, continual, abrupt, irregular, unpredictable,
nonstereotyped actions that are usually bilateral and affect all parts of the body (i.e., face,
trunk, and limbs). The timing, direction, and distribution of movements vary from mo-
ment to moment, and movements usually worsen during attempted voluntary action. Dys-
tonia is the simultaneous sustained contracture of both agonist and antagonist muscles,
resulting in a distorted posture or movement of parts of the body. Dystonic postures are of-
ten triggered by attempts at voluntary movements and are not seen during sleep.

Substance-induced and paroxysmal dyskinesias. Paroxysmal dyskinesias usually oc-
cur as dystonic or choreoathetoid movements that are precipitated by voluntary move-
ment or exertion and less commonly arise from normal background activity.

Myoclonus. Myoclonus is characterized by a sudden unidirectional movement that is
often nonrhythmic. It may be worsened by movement and occur during sleep. Myoclonus
is differentiated from tics by its rapidity, lack of suppressibility, and absence of a premon-
itory urge.

Obsessive-compulsive and related disorders. Differentiating obsessive-compulsive
behaviors from tics may be difficult. Clues favoring an obsessive-compulsive behavior in-
clude a cognitive-based drive (e.g., fear of contamination) and the need to perform the ac-
tion in a particular fashion a certain number of times, equally on both sides of the body, or
until a “just right” feeling is achieved. Impulse-control problems and other repetitive be-
haviors, including persistent hair pulling, skin picking, and nail biting, appear more goal
directed and complex than tics.

Other Specified Tic Disorder 85

Comorbidity
Many medical and psychiatric conditions have been described as co-occurring with tic disor-
ders, with ADHD and obsessive-compulsive and related disorders being particularly com-
mon. The obsessive-compulsive symptoms observed in tic disorder tend to be characterized
by more aggressive symmetry and order symptoms and poorer response to pharmacotherapy
with selective serotonin reuptake inhibitors. Children with ADHD may demonstrate disrup-
tive behavior, social immaturity, and learning difficulties that may interfere with academic
progress and interpersonal relationships and lead to greater impairment than that caused by a
tic disorder. Individuals with tic disorders can also have other movement disorders and other
mental disorders, such as depressive, bipolar, or substance use disorders.

Other Specified Tic Disorder
307.20 (F95.8)

This category applies to presentations in which symptoms characteristic of a tic disorder
that cause clinically significant distress or impairment in social, occupational, or other im-
portant areas of functioning predominate but do not meet the full criteria for a tic disorder
or any of the disorders in the neurodevelopmental disorders diagnostic class. The other
specified tic disorder category is used in situations in which the clinician chooses to com-
municate the specific reason that the presentation does not meet the criteria for a tic disor-
der or any specific neurodevelopmental disorder. This is done by recording “other specified
tic disorder” followed by the specific reason (e.g., “with onset after age 18 years”).

Unspecified Tic Disorder
307.20 (F95.9)

This category applies to presentations in which symptoms characteristic of a tic disorder
that cause clinically significant distress or impairment in social, occupational, or other im-
portant areas of functioning predominate but do not meet the full criteria for a tic disorder
or for any of the disorders in the neurodevelopmental disorders diagnostic class. The un-
specified tic disorder category is used in situations in which the clinician chooses not to
specify the reason that the criteria are not met for a tic disorder or for a specific neurode-
velopmental disorder, and includes presentations in which there is insufficient information
to make a more specific diagnosis.

86 Neurodevelopmental Disorders

Other Neurodevelopmental Disorders

Other Specified Neurodevelopmental Disorder
315.8 (F88)

This category applies to presentations in which symptoms characteristic of a neurodevel-
opmental disorder that cause impairment in social, occupational, or other important areas
of functioning predominate but do not meet the full criteria for any of the disorders in the
neurodevelopmental disorders diagnostic class. The other specified neurodevelopmental
disorder category is used in situations in which the clinician chooses to communicate the
specific reason that the presentation does not meet the criteria for any specific neurode-
velopmental disorder. This is done by recording “other specified neurodevelopmental dis-
order” followed by the specific reason (e.g., “neurodevelopmental disorder associated with
prenatal alcohol exposure”).

An example of a presentation that can be specified using the “other specified” desig-
nation is the following:

Neurodevelopmental disorder associated with prenatal alcohol exposure: Neu-
rodevelopmental disorder associated with prenatal alcohol exposure is characterized
by a range of developmental disabilities following exposure to alcohol in utero.

Unspecified Neurodevelopmental Disorder
315.9 (F89)

This category applies to presentations in which symptoms characteristic of a neurodevel-
opmental disorder that cause impairment in social, occupational, or other important areas
of functioning predominate but do not meet the full criteria for any of the disorders in the
neurodevelopmental disorders diagnostic class. The unspecified neurodevelopmental dis-
order category is used in situations in which the clinician chooses not to specify the reason
that the criteria are not met for a specific neurodevelopmental disorder, and includes pre-
sentations in which there is insufficient information to make a more specific diagnosis
(e.g., in emergency room settings).

87

Schizophrenia Spectrum and
Other Psychotic Disorders

Schizophrenia spectrum and other psychotic disorders include schizophrenia,
other psychotic disorders, and schizotypal (personality) disorder. They are defined by ab-
normalities in one or more of the following five domains: delusions, hallucinations, disor-
ganized thinking (speech), grossly disorganized or abnormal motor behavior (including
catatonia), and negative symptoms.

Key Features That Define the Psychotic Disorders
Delusions
Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence.
Their content may include a variety of themes (e.g., persecutory, referential, somatic, reli-
gious, grandiose). Persecutory delusions (i.e., belief that one is going to be harmed, harassed,
and so forth by an individual, organization, or other group) are most common. Referential
delusions (i.e., belief that certain gestures, comments, environmental cues, and so forth are
directed at oneself) are also common. Grandiose delusions (i.e., when an individual believes
that he or she has exceptional abilities, wealth, or fame) and erotomanic delusions (i.e., when
an individual believes falsely that another person is in love with him or her) are also seen.
Nihilistic delusions involve the conviction that a major catastrophe will occur, and somatic
delusions focus on preoccupations regarding health and organ function.

Delusions are deemed bizarre if they are clearly implausible and not understandable to
same-culture peers and do not derive from ordinary life experiences. An example of a bi-
zarre delusion is the belief that an outside force has removed his or her internal organs and
replaced them with someone else’s organs without leaving any wounds or scars. An ex-
ample of a nonbizarre delusion is the belief that one is under surveillance by the police, de-
spite a lack of convincing evidence. Delusions that express a loss of control over mind or
body are generally considered to be bizarre; these include the belief that one’s thoughts
have been “removed” by some outside force (thought withdrawal), that alien thoughts have
been put into one’s mind (thought insertion), or that one’s body or actions are being acted on
or manipulated by some outside force (delusions of control). The distinction between a de-
lusion and a strongly held idea is sometimes difficult to make and depends in part on the
degree of conviction with which the belief is held despite clear or reasonable contradictory
evidence regarding its veracity.

Hallucinations
Hallucinations are perception-like experiences that occur without an external stimulus.
They are vivid and clear, with the full force and impact of normal perceptions, and not
under voluntary control. They may occur in any sensory modality, but auditory halluci-
nations are the most common in schizophrenia and related disorders. Auditory hallucina-
tions are usually experienced as voices, whether familiar or unfamiliar, that are perceived
as distinct from the individual’s own thoughts. The hallucinations must occur in the con-
text of a clear sensorium; those that occur while falling asleep (hypnagogic) or waking up

88 Schizophrenia Spectrum and Other Psychotic Disorders

(hypnopompic) are considered to be within the range of normal experience. Hallucinations
may be a normal part of religious experience in certain cultural contexts.

Disorganized Thinking (Speech)
Disorganized thinking (formal thought disorder) is typically inferred from the individual’s
speech. The individual may switch from one topic to another (derailment or loose associa-
tions). Answers to questions may be obliquely related or completely unrelated (tangential-
ity). Rarely, speech may be so severely disorganized that it is nearly incomprehensible and
resembles receptive aphasia in its linguistic disorganization (incoherence or “word salad”).
Because mildly disorganized speech is common and nonspecific, the symptom must be se-
vere enough to substantially impair effective communication. The severity of the impair-
ment may be difficult to evaluate if the person making the diagnosis comes from a
different linguistic background than that of the person being examined. Less severe dis-
organized thinking or speech may occur during the prodromal and residual periods of
schizophrenia.

Grossly Disorganized or Abnormal Motor Behavior
(Including Catatonia)
Grossly disorganized or abnormal motor behavior may manifest itself in a variety of ways,
ranging from childlike “silliness” to unpredictable agitation. Problems may be noted in
any form of goal-directed behavior, leading to difficulties in performing activities of daily
living.

Catatonic behavior is a marked decrease in reactivity to the environment. This ranges
from resistance to instructions (negativism); to maintaining a rigid, inappropriate or bi-
zarre posture; to a complete lack of verbal and motor responses (mutism and stupor). It can
also include purposeless and excessive motor activity without obvious cause (catatonic
excitement). Other features are repeated stereotyped movements, staring, grimacing,
mutism, and the echoing of speech. Although catatonia has historically been associated
with schizophrenia, catatonic symptoms are nonspecific and may occur in other mental
disorders (e.g., bipolar or depressive disorders with catatonia) and in medical conditions
(catatonic disorder due to another medical condition).

Negative Symptoms
Negative symptoms account for a substantial portion of the morbidity associated with
schizophrenia but are less prominent in other psychotic disorders. Two negative symp-
toms are particularly prominent in schizophrenia: diminished emotional expression and
avolition. Diminished emotional expression includes reductions in the expression of emo-
tions in the face, eye contact, intonation of speech (prosody), and movements of the hand,
head, and face that normally give an emotional emphasis to speech. Avolition is a decrease
in motivated self-initiated purposeful activities. The individual may sit for long periods of
time and show little interest in participating in work or social activities. Other negative
symptoms include alogia, anhedonia, and asociality. Alogia is manifested by diminished
speech output. Anhedonia is the decreased ability to experience pleasure from positive
stimuli or a degradation in the recollection of pleasure previously experienced. Asociality
refers to the apparent lack of interest in social interactions and may be associated with avo-
lition, but it can also be a manifestation of limited opportunities for social interactions.

Disorders in This Chapter
This chapter is organized along a gradient of psychopathology. Clinicians should first con-
sider conditions that do not reach full criteria for a psychotic disorder or are limited to one

Schizophrenia Spectrum and Other Psychotic Disorders 89

domain of psychopathology. Then they should consider time-limited conditions. Finally,
the diagnosis of a schizophrenia spectrum disorder requires the exclusion of another con-
dition that may give rise to psychosis.

Schizotypal personality disorder is noted within this chapter as it is considered within
the schizophrenia spectrum, although its full description is found in the chapter “Person-
ality Disorders.” The diagnosis schizotypal personality disorder captures a pervasive pat-
tern of social and interpersonal deficits, including reduced capacity for close relationships;
cognitive or perceptual distortions; and eccentricities of behavior, usually beginning by
early adulthood but in some cases first becoming apparent in childhood and adolescence.
Abnormalities of beliefs, thinking, and perception are below the threshold for the diagno-
sis of a psychotic disorder.

Two conditions are defined by abnormalities limited to one domain of psychosis: delu-
sions or catatonia. Delusional disorder is characterized by at least 1 month of delusions but
no other psychotic symptoms. Catatonia is described later in the chapter and further in this
discussion.

Brief psychotic disorder lasts more than 1 day and remits by 1 month. Schizophreni-
form disorder is characterized by a symptomatic presentation equivalent to that of schizo-
phrenia except for its duration (less than 6 months) and the absence of a requirement for a
decline in functioning.

Schizophrenia lasts for at least 6 months and includes at least 1 month of active-phase
symptoms. In schizoaffective disorder, a mood episode and the active-phase symptoms of
schizophrenia occur together and were preceded or are followed by at least 2 weeks of de-
lusions or hallucinations without prominent mood symptoms.

Psychotic disorders may be induced by another condition. In substance/medication-
induced psychotic disorder, the psychotic symptoms are judged to be a physiological con-
sequence of a drug of abuse, a medication, or toxin exposure and cease after removal of the
agent. In psychotic disorder due to another medical condition, the psychotic symptoms
are judged to be a direct physiological consequence of another medical condition.

Catatonia can occur in several disorders, including neurodevelopmental, psychotic, bi-
polar, depressive, and other mental disorders. This chapter also includes the diagnoses
catatonia associated with another mental disorder (catatonia specifier), catatonic disorder
due to another medical condition, and unspecified catatonia, and the diagnostic criteria for
all three conditions are described together.

Other specified and unspecified schizophrenia spectrum and other psychotic disor-
ders are included for classifying psychotic presentations that do not meet the criteria for
any of the specific psychotic disorders, or psychotic symptomatology about which there is
inadequate or contradictory information.

Clinician-Rated Assessment of Symptoms and
Related Clinical Phenomena in Psychosis

Psychotic disorders are heterogeneous, and the severity of symptoms can predict impor-
tant aspects of the illness, such as the degree of cognitive or neurobiological deficits. To
move the field forward, a detailed framework for the assessment of severity is included in
Section III “Assessment Measures,” which may help with treatment planning, prognostic
decision making, and research on pathophysiological mechanisms. Section III “Assess-
ment Measures” also contains dimensional assessments of the primary symptoms of psy-
chosis, including hallucinations, delusions, disorganized speech (except for substance/
medication-induced psychotic disorder and psychotic disorder due to another medical
condition), abnormal psychomotor behavior, and negative symptoms, as well as dimen-
sional assessments of depression and mania. The severity of mood symptoms in psychosis
has prognostic value and guides treatment. There is growing evidence that schizoaffective

90 Schizophrenia Spectrum and Other Psychotic Disorders

disorder is not a distinct nosological category. Thus, dimensional assessments of depres-
sion and mania for all psychotic disorders alert clinicians to mood pathology and the need
to treat where appropriate. The Section III scale also includes a dimensional assessment of
cognitive impairment. Many individuals with psychotic disorders have impairments in a
range of cognitive domains that predict functional status. Clinical neuropsychological as-
sessment can help guide diagnosis and treatment, but brief assessments without formal
neuropsychological assessment can provide useful information that can be sufficient for
diagnostic purposes. Formal neuropsychological testing, when conducted, should be ad-
ministered and scored by personnel trained in the use of testing instruments. If a formal
neuropsychological assessment is not conducted, the clinician should use the best avail-
able information to make a judgment. Further research on these assessments is necessary
in order to determine their clinical utility; thus, the assessments available in Section III
should serve as a prototype to stimulate such research.

Schizotypal (Personality) Disorder
Criteria and text for schizotypal personality disorder can be found in the chapter “Person-
ality Disorders.” Because this disorder is considered part of the schizophrenia spectrum of
disorders, and is labeled in this section of ICD-9 and ICD-10 as schizotypal disorder, it is
listed in this chapter and discussed in detail in the DSM-5 chapter “Personality Disorders.”

Delusional Disorder
Diagnostic Criteria 297.1 (F22)

A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A for schizophrenia has never been met.

Note: Hallucinations, if present, are not prominent and are related to the delusional
theme (e.g., the sensation of being infested with insects associated with delusions of
infestation).

C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly
impaired, and behavior is not obviously bizarre or odd.

D. If manic or major depressive episodes have occurred, these have been brief relative
to the duration of the delusional periods.

E. The disturbance is not attributable to the physiological effects of a substance or an-
other medical condition and is not better explained by another mental disorder, such
as body dysmorphic disorder or obsessive-compulsive disorder.

Specify whether:
Erotomanic type: This subtype applies when the central theme of the delusion is that
another person is in love with the individual.
Grandiose type: This subtype applies when the central theme of the delusion is the
conviction of having some great (but unrecognized) talent or insight or having made
some important discovery.
Jealous type: This subtype applies when the central theme of the individual’s delusion
is that his or her spouse or lover is unfaithful.
Persecutory type: This subtype applies when the central theme of the delusion in-
volves the individual’s belief that he or she is being conspired against, cheated, spied
on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in
the pursuit of long-term goals.
Somatic type: This subtype applies when the central theme of the delusion involves
bodily functions or sensations.

Delusional Disorder 91

Mixed type: This subtype applies when no one delusional theme predominates.
Unspecified type: This subtype applies when the dominant delusional belief cannot
be clearly determined or is not described in the specific types (e.g., referential delu-
sions without a prominent persecutory or grandiose component).

Specify if:
With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not
understandable, and not derived from ordinary life experiences (e.g., an individual’s be-
lief that a stranger has removed his or her internal organs and replaced them with some-
one else’s organs without leaving any wounds or scars).

Specify if:
The following course specifiers are only to be used after a 1-year duration of the disorder:

First episode, currently in acute episode: First manifestation of the disorder meet-
ing the defining diagnostic symptom and time criteria. An acute episode is a time pe-
riod in which the symptom criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a time period dur-
ing which an improvement after a previous episode is maintained and in which the de-
fining criteria of the disorder are only partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a
previous episode during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are
remaining for the majority of the illness course, with subthreshold symptom periods be-
ing very brief relative to the overall course.
Unspecified

Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor be-
havior, and negative symptoms. Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present)
to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom
Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of delusional disorder can be made without using this severity specifier.

Subtypes
In erotomanic type, the central theme of the delusion is that another person is in love with
the individual. The person about whom this conviction is held is usually of higher status
(e.g., a famous individual or a superior at work) but can be a complete stranger. Efforts to
contact the object of the delusion are common. In grandiose type, the central theme of the de-
lusion is the conviction of having some great talent or insight or of having made some im-
portant discovery. Less commonly, the individual may have the delusion of having a
special relationship with a prominent individual or of being a prominent person (in which
case the actual individual may be regarded as an impostor). Grandiose delusions may
have a religious content. In jealous type, the central theme of the delusion is that of an un-
faithful partner. This belief is arrived at without due cause and is based on incorrect infer-
ences supported by small bits of “evidence” (e.g., disarrayed clothing). The individual
with the delusion usually confronts the spouse or lover and attempts to intervene in the
imagined infidelity. In persecutory type, the central theme of the delusion involves the in-

92 Schizophrenia Spectrum and Other Psychotic Disorders

dividual’s belief of being conspired against, cheated, spied on, followed, poisoned, mali-
ciously maligned, harassed, or obstructed in the pursuit of long-term goals. Small slights
may be exaggerated and become the focus of a delusional system. The affected individual
may engage in repeated attempts to obtain satisfaction by legal or legislative action. Indi-
viduals with persecutory delusions are often resentful and angry and may resort to vio-
lence against those they believe are hurting them. In somatic type, the central theme of the
delusion involves bodily functions or sensations. Somatic delusions can occur in several
forms. Most common is the belief that the individual emits a foul odor; that there is an in-
festation of insects on or in the skin; that there is an internal parasite; that certain parts of
the body are misshapen or ugly; or that parts of the body are not functioning.

Diagnostic Features
The essential feature of delusional disorder is the presence of one or more delusions that
persist for at least 1 month (Criterion A). A diagnosis of delusional disorder is not given if
the individual has ever had a symptom presentation that met Criterion A for schizophre-
nia (Criterion B). Apart from the direct impact of the delusions, impairments in psychoso-
cial functioning may be more circumscribed than those seen in other psychotic disorders
such as schizophrenia, and behavior is not obviously bizarre or odd (Criterion C). If mood
episodes occur concurrently with the delusions, the total duration of these mood episodes
is brief relative to the total duration of the delusional periods (Criterion D). The delusions
are not attributable to the physiological effects of a substance (e.g., cocaine) or another
medical condition (e.g., Alzheimer’s disease) and are not better explained by another men-
tal disorder, such as body dysmorphic disorder or obsessive-compulsive disorder (Crite-
rion E).

In addition to the five symptom domain areas identified in the diagnostic criteria, the
assessment of cognition, depression, and mania symptom domains is vital for making crit-
ically important distinctions between the various schizophrenia spectrum and other psy-
chotic disorders.

Associated Features Supporting Diagnosis
Social, marital, or work problems can result from the delusional beliefs of delusional dis-
order. Individuals with delusional disorder may be able to factually describe that others
view their beliefs as irrational but are unable to accept this themselves (i.e., there may be
“factual insight” but no true insight). Many individuals develop irritable or dysphoric
mood, which can usually be understood as a reaction to their delusional beliefs. Anger and
violent behavior can occur with persecutory, jealous, and erotomanic types. The individ-
ual may engage in litigious or antagonistic behavior (e.g., sending hundreds of letters of
protest to the government). Legal difficulties can occur, particularly in jealous and eroto-
manic types.

Prevalence
The lifetime prevalence of delusional disorder has been estimated at around 0.2%, and the
most frequent subtype is persecutory. Delusional disorder, jealous type, is probably more
common in males than in females, but there are no major gender differences in the overall
frequency of delusional disorder.

Development and Course
On average, global function is generally better than that observed in schizophrenia. Al-
though the diagnosis is generally stable, a proportion of individuals go on to develop

Delusional Disorder 93

schizophrenia. Delusional disorder has a significant familial relationship with both
schizophrenia and schizotypal personality disorder. Although it can occur in younger age
groups, the condition may be more prevalent in older individuals.

Culture-Related Diagnostic Issues
An individual’s cultural and religious background must be taken into account in evaluat-
ing the possible presence of delusional disorder. The content of delusions also varies
across cultural contexts.

Functional Consequences of Delusional Disorder
The functional impairment is usually more circumscribed than that seen with other psy-
chotic disorders, although in some cases, the impairment may be substantial and include
poor occupational functioning and social isolation. When poor psychosocial functioning is
present, delusional beliefs themselves often play a significant role. A common character-
istic of individuals with delusional disorder is the apparent normality of their behavior
and appearance when their delusional ideas are not being discussed or acted on.

Differential Diagnosis
Obsessive-compulsive and related disorders. If an individual with obsessive-compul-
sive disorder is completely convinced that his or her obsessive-compulsive disorder beliefs
are true, then the diagnosis of obsessive-compulsive disorder, with absent insight/delu-
sional beliefs specifier, should be given rather than a diagnosis of delusional disorder.
Similarly, if an individual with body dysmorphic disorder is completely convinced that
his or her body dysmorphic disorder beliefs are true, then the diagnosis of body dysmor-
phic disorder, with absent insight/delusional beliefs specifier, should be given rather than
a diagnosis of delusional disorder.

Delirium, major neurocognitive disorder, psychotic disorder due to another medical con-
dition, and substance/medication-induced psychotic disorder. Individuals with these
disorders may present with symptoms that suggest delusional disorder. For example, sim-
ple persecutory delusions in the context of major neurocognitive disorder would be di-
agnosed as major neurocognitive disorder, with behavioral disturbance. A substance/
medication-induced psychotic disorder cross-sectionally may be identical in symptom-
atology to delusional disorder but can be distinguished by the chronological relationship
of substance use to the onset and remission of the delusional beliefs.

Schizophrenia and schizophreniform disorder. Delusional disorder can be distinguished
from schizophrenia and schizophreniform disorder by the absence of the other character-
istic symptoms of the active phase of schizophrenia.

Depressive and bipolar disorders and schizoaffective disorder. These disorders may
be distinguished from delusional disorder by the temporal relationship between the mood
disturbance and the delusions and by the severity of the mood symptoms. If delusions oc-
cur exclusively during mood episodes, the diagnosis is depressive or bipolar disorder with
psychotic features. Mood symptoms that meet full criteria for a mood episode can be su-
perimposed on delusional disorder. Delusional disorder can be diagnosed only if the total
duration of all mood episodes remains brief relative to the total duration of the delusional
disturbance. If not, then a diagnosis of other specified or unspecified schizophrenia spec-
trum and other psychotic disorder accompanied by other specified depressive disorder,
unspecified depressive disorder, other specified bipolar and related disorder, or unspeci-
fied bipolar and related disorder is appropriate.

94 Schizophrenia Spectrum and Other Psychotic Disorders

Brief Psychotic Disorder
Diagnostic Criteria 298.8 (F23)

A. Presence of one (or more) of the following symptoms. At least one of these must be
(1), (2), or (3):

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.

Note: Do not include a symptom if it is a culturally sanctioned response.
B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with

eventual full return to premorbid level of functioning.
C. The disturbance is not better explained by major depressive or bipolar disorder with

psychotic features or another psychotic disorder such as schizophrenia or catatonia,
and is not attributable to the physiological effects of a substance (e.g., a drug of abuse,
a medication) or another medical condition.

Specify if:
With marked stressor(s) (brief reactive psychosis): If symptoms occur in response to
events that, singly or together, would be markedly stressful to almost anyone in similar
circumstances in the individual’s culture.
Without marked stressor(s): If symptoms do not occur in response to events that,
singly or together, would be markedly stressful to almost anyone in similar circum-
stances in the individual’s culture.
With postpartum onset: If onset is during pregnancy or within 4 weeks postpartum.

Specify if:
With catatonia (refer to the criteria for catatonia associated with another mental dis-
order, pp. 119–120, for definition)

Coding note: Use additional code 293.89 (F06.1) catatonia associated with brief
psychotic disorder to indicate the presence of the comorbid catatonia.

Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor be-
havior, and negative symptoms. Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present)
to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom
Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of brief psychotic disorder can be made without using this severity
specifier.

Diagnostic Features
The essential feature of brief psychotic disorder is a disturbance that involves the sudden
onset of at least one of the following positive psychotic symptoms: delusions, hallucina-
tions, disorganized speech (e.g., frequent derailment or incoherence), or grossly abnormal
psychomotor behavior, including catatonia (Criterion A). Sudden onset is defined as
change from a nonpsychotic state to a clearly psychotic state within 2 weeks, usually with-
out a prodrome. An episode of the disturbance lasts at least 1 day but less than 1 month,
and the individual eventually has a full return to the premorbid level of functioning (Cri-

Brief Psychotic Disorder 95

terion B). The disturbance is not better explained by a depressive or bipolar disorder with
psychotic features, by schizoaffective disorder, or by schizophrenia and is not attributable
to the physiological effects of a substance (e.g., a hallucinogen) or another medical condi-
tion (e.g., subdural hematoma) (Criterion C).

In addition to the five symptom domain areas identified in the diagnostic criteria, the
assessment of cognition, depression, and mania symptom domains is vital for making crit-
ically important distinctions between the various schizophrenia spectrum and other psy-
chotic disorders.

Associated Features Supporting Diagnosis
Individuals with brief psychotic disorder typically experience emotional turmoil or over-
whelming confusion. They may have rapid shifts from one intense affect to another.
Although the disturbance is brief, the level of impairment may be severe, and supervision
may be required to ensure that nutritional and hygienic needs are met and that the indi-
vidual is protected from the consequences of poor judgment, cognitive impairment, or act-
ing on the basis of delusions. There appears to be an increased risk of suicidal behavior,
particularly during the acute episode.

Prevalence
In the United States, brief psychotic disorder may account for 9% of cases of first-onset
psychosis. Psychotic disturbances that meet Criteria A and C, but not Criterion B, for brief
psychotic disorder (i.e., duration of active symptoms is 1–6 months as opposed to remis-
sion within 1 month) are more common in developing countries than in developed coun-
tries. Brief psychotic disorder is twofold more common in females than in males.

Development and Course
Brief psychotic disorder may appear in adolescence or early adulthood, and onset can oc-
cur across the lifespan, with the average age at onset being the mid 30s. By definition, a
diagnosis of brief psychotic disorder requires a full remission of all symptoms and an
eventual full return to the premorbid level of functioning within 1 month of the onset of the
disturbance. In some individuals, the duration of psychotic symptoms may be quite brief
(e.g., a few days).

Risk and Prognostic Factors
Temperamental. Preexisting personality disorders and traits (e.g., schizotypal person-
ality disorder; borderline personality disorder; or traits in the psychoticism domain, such
as perceptual dysregulation, and the negative affectivity domain, such as suspiciousness)
may predispose the individual to the development of the disorder.

Culture-Related Diagnostic Issues
It is important to distinguish symptoms of brief psychotic disorder from culturally sanc-
tioned response patterns. For example, in some religious ceremonies, an individual may
report hearing voices, but these do not generally persist and are not perceived as abnormal
by most members of the individual’s community. In addition, cultural and religious back-
ground must be taken into account when considering whether beliefs are delusional.

Functional Consequences of Brief Psychotic Disorder
Despite high rates of relapse, for most individuals, outcome is excellent in terms of social
functioning and symptomatology.

96 Schizophrenia Spectrum and Other Psychotic Disorders

Differential Diagnosis
Other medical conditions. A variety of medical disorders can manifest with psychotic
symptoms of short duration. Psychotic disorder due to another medical condition or a de-
lirium is diagnosed when there is evidence from the history, physical examination, or lab-
oratory tests that the delusions or hallucinations are the direct physiological consequence
of a specific medical condition (e.g., Cushing’s syndrome, brain tumor) (see “Psychotic
Disorder Due to Another Medical Condition” later in this chapter).

Substance-related disorders. Substance/medication-induced psychotic disorder, sub-
stance-induced delirium, and substance intoxication are distinguished from brief psychotic
disorder by the fact that a substance (e.g., a drug of abuse, a medication, exposure to a toxin)
is judged to be etiologically related to the psychotic symptoms (see “Substance/Medication-
Induced Psychotic Disorder” later in this chapter). Laboratory tests, such as a urine drug
screen or a blood alcohol level, may be helpful in making this determination, as may a care-
ful history of substance use with attention to temporal relationships between substance in-
take and onset of the symptoms and to the nature of the substance being used.

Depressive and bipolar disorders. The diagnosis of brief psychotic disorder cannot be
made if the psychotic symptoms are better explained by a mood episode (i.e., the psychotic
symptoms occur exclusively during a full major depressive, manic, or mixed episode).

Other psychotic disorders. If the psychotic symptoms persist for 1 month or longer, the
diagnosis is either schizophreniform disorder, delusional disorder, depressive disorder
with psychotic features, bipolar disorder with psychotic features, or other specified or un-
specified schizophrenia spectrum and other psychotic disorder, depending on the other
symptoms in the presentation. The differential diagnosis between brief psychotic disorder
and schizophreniform disorder is difficult when the psychotic symptoms have remitted be-
fore 1 month in response to successful treatment with medication. Careful attention should
be given to the possibility that a recurrent disorder (e.g., bipolar disorder, recurrent acute ex-
acerbations of schizophrenia) may be responsible for any recurring psychotic episodes.

Malingering and factitious disorders. An episode of factitious disorder, with predomi-
nantly psychological signs and symptoms, may have the appearance of brief psychotic
disorder, but in such cases there is evidence that the symptoms are intentionally produced.
When malingering involves apparently psychotic symptoms, there is usually evidence
that the illness is being feigned for an understandable goal.

Personality disorders. In certain individuals with personality disorders, psychosocial
stressors may precipitate brief periods of psychotic symptoms. These symptoms are usu-
ally transient and do not warrant a separate diagnosis. If psychotic symptoms persist for at
least 1 day, an additional diagnosis of brief psychotic disorder may be appropriate.

Schizophreniform Disorder
Diagnostic Criteria 295.40 (F20.81)

A. Two (or more) of the following, each present for a significant portion of time during a
1-month period (or less if successfully treated). At least one of these must be (1), (2),
or (3):

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition).

Schizophreniform Disorder 97

B. An episode of the disorder lasts at least 1 month but less than 6 months. When the
diagnosis must be made without waiting for recovery, it should be qualified as “provi-
sional.”

C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have
been ruled out because either 1) no major depressive or manic episodes have occurred
concurrently with the active-phase symptoms, or 2) if mood episodes have occurred dur-
ing active-phase symptoms, they have been present for a minority of the total duration
of the active and residual periods of the illness.

D. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition.

Specify if:
With good prognostic features: This specifier requires the presence of at least two
of the following features: onset of prominent psychotic symptoms within 4 weeks of the
first noticeable change in usual behavior or functioning; confusion or perplexity; good
premorbid social and occupational functioning; and absence of blunted or flat affect.
Without good prognostic features: This specifier is applied if two or more of the
above features have not been present.

Specify if:
With catatonia (refer to the criteria for catatonia associated with another mental disor-
der, pp. 119–120, for definition).

Coding note: Use additional code 293.89 (F06.1) catatonia associated with schizo-
phreniform disorder to indicate the presence of the comorbid catatonia.

Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor be-
havior, and negative symptoms. Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present)
to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom
Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of schizophreniform disorder can be made without using this severity
specifier.

Note: For additional information on Associated Features Supporting Diagnosis, Develop-
ment and Course (age-related factors), Culture-Related Diagnostic Issues, Gender-Related
Diagnostic Issues, Differential Diagnosis, and Comorbidity, see the corresponding sec-
tions in schizophrenia.

Diagnostic Features
The characteristic symptoms of schizophreniform disorder are identical to those of schizo-
phrenia (Criterion A). Schizophreniform disorder is distinguished by its difference in du-
ration: the total duration of the illness, including prodromal, active, and residual phases, is
at least 1 month but less than 6 months (Criterion B). The duration requirement for schizo-
phreniform disorder is intermediate between that for brief psychotic disorder, which lasts
more than 1 day and remits by 1 month, and schizophrenia, which lasts for at least 6 months.
The diagnosis of schizophreniform disorder is made under two conditions. 1) when an ep-
isode of illness lasts between 1 and 6 months and the individual has already recovered,
and 2) when an individual is symptomatic for less than the 6 months’ duration required for
the diagnosis of schizophrenia but has not yet recovered. In this case, the diagnosis should
be noted as “schizophreniform disorder (provisional)” because it is uncertain if the indi-
vidual will recover from the disturbance within the 6-month period. If the disturbance per-
sists beyond 6 months, the diagnosis should be changed to schizophrenia.

98 Schizophrenia Spectrum and Other Psychotic Disorders

Another distinguishing feature of schizophreniform disorder is the lack of a criterion
requiring impaired social and occupational functioning. While such impairments may po-
tentially be present, they are not necessary for a diagnosis of schizophreniform disorder.

In addition to the five symptom domain areas identified in the diagnostic criteria, the
assessment of cognition, depression, and mania symptom domains is vital for making crit-
ically important distinctions between the various schizophrenia spectrum and other psy-
chotic disorders.

Associated Features Supporting Diagnosis
As with schizophrenia, currently there are no laboratory or psychometric tests for schizo-
phreniform disorder. There are multiple brain regions where neuroimaging, neuropa-
thological, and neurophysiological research has indicated abnormalities, but none are
diagnostic.

Prevalence
Incidence of schizophreniform disorder across sociocultural settings is likely similar to
that observed in schizophrenia. In the United States and other developed countries, the in-
cidence is low, possibly fivefold less than that of schizophrenia. In developing countries,
the incidence may be higher, especially for the specifier “with good prognostic features”;
in some of these settings schizophreniform disorder may be as common as schizophrenia.

Development and Course
The development of schizophreniform disorder is similar to that of schizophrenia. About
one-third of individuals with an initial diagnosis of schizophreniform disorder (provi-
sional) recover within the 6-month period and schizophreniform disorder is their final di-
agnosis. The majority of the remaining two-thirds of individuals will eventually receive a
diagnosis of schizophrenia or schizoaffective disorder.

Risk and Prognostic Factors
Genetic and physiological. Relatives of individuals with schizophreniform disorder
have an increased risk for schizophrenia.

Functional Consequences of
Schizophreniform Disorder
For the majority of individuals with schizophreniform disorder who eventually receive a
diagnosis of schizophrenia or schizoaffective disorder, the functional consequences are
similar to the consequences of those disorders. Most individuals experience dysfunction in
several areas of daily functioning, such as school or work, interpersonal relationships, and
self-care. Individuals who recover from schizophreniform disorder have better functional
outcomes.

Differential Diagnosis
Other mental disorders and medical conditions. A wide variety of mental and medical
conditions can manifest with psychotic symptoms that must be considered in the differ-
ential diagnosis of schizophreniform disorder. These include psychotic disorder due to
another medical condition or its treatment; delirium or major neurocognitive disorder;
substance/medication-induced psychotic disorder or delirium; depressive or bipolar
disorder with psychotic features; schizoaffective disorder; other specified or unspecified bi-
polar and related disorder; depressive or bipolar disorder with catatonic features; schizophre-

Schizophrenia 99

nia; brief psychotic disorder; delusional disorder; other specified or unspecified schizo-
phrenia spectrum and other psychotic disorder; schizotypal, schizoid, or paranoid
personality disorders; autism spectrum disorder; disorders presenting in childhood with
disorganized speech; attention-deficit/hyperactivity disorder; obsessive-compulsive dis-
order; posttraumatic stress disorder; and traumatic brain injury.

Since the diagnostic criteria for schizophreniform disorder and schizophrenia differ
primarily in duration of illness, the discussion of the differential diagnosis of schizophre-
nia also applies to schizophreniform disorder.

Brief psychotic disorder. Schizophreniform disorder differs in duration from brief psy-
chotic disorder, which has a duration of less than 1 month.

Schizophrenia
Diagnostic Criteria 295.90 (F20.9)

A. Two (or more) of the following, each present for a significant portion of time during a
1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition).

B. For a significant portion of the time since the onset of the disturbance, level of function-
ing in one or more major areas, 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, there is failure to achieve expected level of interpersonal, academic,
or occupational functioning).

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period
must include at least 1 month of symptoms (or less if successfully treated) that meet Cri-
terion A (i.e., active-phase symptoms) and may include periods of prodromal or residual
symptoms. During these prodromal or residual periods, the signs of the disturbance may
be manifested by only negative symptoms or by two or more symptoms listed in Criterion
A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features
have been ruled out because either 1) no major depressive or manic episodes have
occurred concurrently with the active-phase symptoms, or 2) if mood episodes have
occurred during active-phase symptoms, they have been present for a minority of the
total duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition.

F. If there is a history of autism spectrum disorder or a communication disorder of child-
hood onset, the additional diagnosis of schizophrenia is made only if prominent delu-
sions or hallucinations, in addition to the other required symptoms of schizophrenia,
are also present for at least 1 month (or less if successfully treated).

Specify if:
The following course specifiers are only to be used after a 1-year duration of the disorder
and if they are not in contradiction to the diagnostic course criteria.

First episode, currently in acute episode: First manifestation of the disorder meet-
ing the defining diagnostic symptom and time criteria. An acute episode is a time pe-
riod in which the symptom criteria are fulfilled.

100 Schizophrenia Spectrum and Other Psychotic Disorders

First episode, currently in partial remission: Partial remission is a period of time
during which an improvement after a previous episode is maintained and in which the
defining criteria of the disorder are only partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a
previous episode during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode: Multiple episodes may be deter-
mined after a minimum of two episodes (i.e., after a first episode, a remission and a
minimum of one relapse).
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are
remaining for the majority of the illness course, with subthreshold symptom periods be-
ing very brief relative to the overall course.
Unspecified

Specify if:
With catatonia (refer to the criteria for catatonia associated with another mental disorder,
pp. 119–120, for definition).

Coding note: Use additional code 293.89 (F06.1) catatonia associated with
schizophrenia to indicate the presence of the comorbid catatonia.

Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor be-
havior, and negative symptoms. Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present)
to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom
Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of schizophrenia can be made without using this severity specifier.

Diagnostic Features
The characteristic symptoms of schizophrenia involve a range of cognitive, behavioral, and
emotional dysfunctions, but no single symptom is pathognomonic of the disorder. The di-
agnosis involves the recognition of a constellation of signs and symptoms associated with
impaired occupational or social functioning. Individuals with the disorder will vary sub-
stantially on most features, as schizophrenia is a heterogeneous clinical syndrome.

At least two Criterion A symptoms must be present for a significant portion of time
during a 1-month period or longer. At least one of these symptoms must be the clear pres-
ence of delusions (Criterion A1), hallucinations (Criterion A2), or disorganized speech
(Criterion A3). Grossly disorganized or catatonic behavior (Criterion A4) and negative
symptoms (Criterion A5) may also be present. In those situations in which the active-
phase symptoms remit within a month in response to treatment, Criterion A is still met if the
clinician estimates that they would have persisted in the absence of treatment.

Schizophrenia involves impairment in one or more major areas of functioning (Crite-
rion B). If the disturbance begins in childhood or adolescence, the expected level of func-
tion is not attained. Comparing the individual with unaffected siblings may be helpful. The
dysfunction persists for a substantial period during the course of the disorder and does not
appear to be a direct result of any single feature. Avolition (i.e., reduced drive to pursue
goal-directed behavior; Criterion A5) is linked to the social dysfunction described under
Criterion B. There is also strong evidence for a relationship between cognitive impairment
(see the section “Associated Features Supporting Diagnosis” for this disorder) and func-
tional impairment in individuals with schizophrenia.

Schizophrenia 101

Some signs of the disturbance must persist for a continuous period of at least 6 months
(Criterion C). Prodromal symptoms often precede the active phase, and residual symp-
toms may follow it, characterized by mild or subthreshold forms of hallucinations or
delusions. Individuals may express a variety of unusual or odd beliefs that are not of de-
lusional proportions (e.g., ideas of reference or magical thinking); they may have unusual
perceptual experiences (e.g., sensing the presence of an unseen person); their speech may
be generally understandable but vague; and their behavior may be unusual but not grossly
disorganized (e.g., mumbling in public). Negative symptoms are common in the pro-
dromal and residual phases and can be severe. Individuals who had been socially active
may become withdrawn from previous routines. Such behaviors are often the first sign of
a disorder.

Mood symptoms and full mood episodes are common in schizophrenia and may be con-
current with active-phase symptomatology. However, as distinct from a psychotic mood dis-
order, a schizophrenia diagnosis requires the presence of delusions or hallucinations in the
absence of mood episodes. In addition, mood episodes, taken in total, should be present for
only a minority of the total duration of the active and residual periods of the illness.

In addition to the five symptom domain areas identified in the diagnostic criteria, the
assessment of cognition, depression, and mania symptom domains is vital for making crit-
ically important distinctions between the various schizophrenia spectrum and other psy-
chotic disorders.

Associated Features Supporting Diagnosis
Individuals with schizophrenia may display inappropriate affect (e.g., laughing in the ab-
sence of an appropriate stimulus); a dysphoric mood that can take the form of depression,
anxiety, or anger; a disturbed sleep pattern (e.g., daytime sleeping and nighttime activity);
and a lack of interest in eating or food refusal. Depersonalization, derealization, and so-
matic concerns may occur and sometimes reach delusional proportions. Anxiety and pho-
bias are common. Cognitive deficits in schizophrenia are common and are strongly linked
to vocational and functional impairments. These deficits can include decrements in declar-
ative memory, working memory, language function, and other executive functions, as well
as slower processing speed. Abnormalities in sensory processing and inhibitory capacity,
as well as reductions in attention, are also found. Some individuals with schizophrenia
show social cognition deficits, including deficits in the ability to infer the intentions of
other people (theory of mind), and may attend to and then interpret irrelevant events or
stimuli as meaningful, perhaps leading to the generation of explanatory delusions. These
impairments frequently persist during symptomatic remission.

Some individuals with psychosis may lack insight or awareness of their disorder (i.e.,
anosognosia). This lack of “insight” includes unawareness of symptoms of schizophrenia
and may be present throughout the entire course of the illness. Unawareness of illness is
typically a symptom of schizophrenia itself rather than a coping strategy. It is comparable
to the lack of awareness of neurological deficits following brain damage, termed anoso-
gnosia. This symptom is the most common predictor of non-adherence to treatment, and it
predicts higher relapse rates, increased number of involuntary treatments, poorer psycho-
social functioning, aggression, and a poorer course of illness.

Hostility and aggression can be associated with schizophrenia, although spontaneous
or random assault is uncommon. Aggression is more frequent for younger males and for
individuals with a past history of violence, non-adherence with treatment, substance
abuse, and impulsivity. It should be noted that the vast majority of persons with schizo-
phrenia are not aggressive and are more frequently victimized than are individuals in the
general population.

Currently, there are no radiological, laboratory, or psychometric tests for the disorder.
Differences are evident in multiple brain regions between groups of healthy individuals

102 Schizophrenia Spectrum and Other Psychotic Disorders

and persons with schizophrenia, including evidence from neuroimaging, neuropatholog-
ical, and neurophysiological studies. Differences are also evident in cellular architecture,
white matter connectivity, and gray matter volume in a variety of regions such as the pre-
frontal and temporal cortices. Reduced overall brain volume has been observed, as well as
increased brain volume reduction with age. Brain volume reductions with age are more
pronounced in individuals with schizophrenia than in healthy individuals. Finally, indi-
viduals with schizophrenia appear to differ from individuals without the disorder in eye-
tracking and electrophysiological indices.

Neurological soft signs common in individuals with schizophrenia include impairments
in motor coordination, sensory integration, and motor sequencing of complex movements;
left-right confusion; and disinhibition of associated movements. In addition, minor phys-
ical anomalies of the face and limbs may occur.

Prevalence
The lifetime prevalence of schizophrenia appears to be approximately 0.3%–0.7%, al-
though there is reported variation by race/ethnicity, across countries, and by geographic
origin for immigrants and children of immigrants. The sex ratio differs across samples and
populations: for example, an emphasis on negative symptoms and longer duration of dis-
order (associated with poorer outcome) shows higher incidence rates for males, whereas
definitions allowing for the inclusion of more mood symptoms and brief presentations
(associated with better outcome) show equivalent risks for both sexes.

Development and Course
The psychotic features of schizophrenia typically emerge between the late teens and the
mid-30s; onset prior to adolescence is rare. The peak age at onset for the first psychotic ep-
isode is in the early- to mid-20s for males and in the late-20s for females. The onset may be
abrupt or insidious, but the majority of individuals manifest a slow and gradual develop-
ment of a variety of clinically significant signs and symptoms. Half of these individuals
complain of depressive symptoms. Earlier age at onset has traditionally been seen as a pre-
dictor of worse prognosis. However, the effect of age at onset is likely related to gender,
with males having worse premorbid adjustment, lower educational achievement, more
prominent negative symptoms and cognitive impairment, and in general a worse out-
come. Impaired cognition is common, and alterations in cognition are present during de-
velopment and precede the emergence of psychosis, taking the form of stable cognitive
impairments during adulthood. Cognitive impairments may persist when other symptoms
are in remission and contribute to the disability of the disease.

The predictors of course and outcome are largely unexplained, and course and outcome
may not be reliably predicted. The course appears to be favorable in about 20% of those
with schizophrenia, and a small number of individuals are reported to recover completely.
However, most individuals with schizophrenia still require formal or informal daily living
supports, and many remain chronically ill, with exacerbations and remissions of active
symptoms, while others have a course of progressive deterioration.

Psychotic symptoms tend to diminish over the life course, perhaps in association with
normal age-related declines in dopamine activity. Negative symptoms are more closely re-
lated to prognosis than are positive symptoms and tend to be the most persistent. Further-
more, cognitive deficits associated with the illness may not improve over the course of the
illness.

The essential features of schizophrenia are the same in childhood, but it is more diffi-
cult to make the diagnosis. In children, delusions and hallucinations may be less elaborate
than in adults, and visual hallucinations are more common and should be distinguished
from normal fantasy play. Disorganized speech occurs in many disorders with childhood
onset (e.g., autism spectrum disorder), as does disorganized behavior (e.g., attention-deficit/

Schizophrenia 103

hyperactivity disorder). These symptoms should not be attributed to schizophrenia with-
out due consideration of the more common disorders of childhood. Childhood-onset cases
tend to resemble poor-outcome adult cases, with gradual onset and prominent negative
symptoms. Children who later receive the diagnosis of schizophrenia are more likely to
have experienced nonspecific emotional-behavioral disturbances and psychopathology,
intellectual and language alterations, and subtle motor delays.

Late-onset cases (i.e., onset after age 40 years) are overrepresented by females, who
may have married. Often, the course is characterized by a predominance of psychotic
symptoms with preservation of affect and social functioning. Such late-onset cases can still
meet the diagnostic criteria for schizophrenia, but it is not yet clear whether this is the
same condition as schizophrenia diagnosed prior to mid-life (e.g., prior to age 55 years).

Risk and Prognostic Factors
Environmental. Season of birth has been linked to the incidence of schizophrenia, in-
cluding late winter/early spring in some locations and summer for the deficit form of the
disease. The incidence of schizophrenia and related disorders is higher for children grow-
ing up in an urban environment and for some minority ethnic groups.

Genetic and physiological. There is a strong contribution for genetic factors in deter-
mining risk for schizophrenia, although most individuals who have been diagnosed with
schizophrenia have no family history of psychosis. Liability is conferred by a spectrum of
risk alleles, common and rare, with each allele contributing only a small fraction to the to-
tal population variance. The risk alleles identified to date are also associated with other
mental disorders, including bipolar disorder, depression, and autism spectrum disorder.

Pregnancy and birth complications with hypoxia and greater paternal age are associated
with a higher risk of schizophrenia for the developing fetus. In addition, other prenatal
and perinatal adversities, including stress, infection, malnutrition, maternal diabetes, and
other medical conditions, have been linked with schizophrenia. However, the vast major-
ity of offspring with these risk factors do not develop schizophrenia.

Culture-Related Diagnostic Issues
Cultural and socioeconomic factors must be considered, particularly when the individual
and the clinician do not share the same cultural and socioeconomic background. Ideas that
appear to be delusional in one culture (e.g., witchcraft) may be commonly held in another.
In some cultures, visual or auditory hallucinations with a religious content (e.g., hearing
God’s voice) are a normal part of religious experience. In addition, the assessment of dis-
organized speech may be made difficult by linguistic variation in narrative styles across
cultures. The assessment of affect requires sensitivity to differences in styles of emotional
expression, eye contact, and body language, which vary across cultures. If the assessment
is conducted in a language that is different from the individual’s primary language, care
must be taken to ensure that alogia is not related to linguistic barriers. In certain cultures,
distress may take the form of hallucinations or pseudo-hallucinations and overvalued
ideas that may present clinically similar to true psychosis but are normative to the pa-
tient’s subgroup.

Gender-Related Diagnostic Issues
A number of features distinguish the clinical expression of schizophrenia in females and
males. The general incidence of schizophrenia tends to be slightly lower in females, par-
ticularly among treated cases. The age at onset is later in females, with a second mid-life
peak as described earlier (see the section “Development and Course” for this disorder).
Symptoms tend to be more affect-laden among females, and there are more psychotic
symptoms, as well as a greater propensity for psychotic symptoms to worsen in later life.

104 Schizophrenia Spectrum and Other Psychotic Disorders

Other symptom differences include less frequent negative symptoms and disorganization.
Finally, social functioning tends to remain better preserved in females. There are, how-
ever, frequent exceptions to these general caveats.

Suicide Risk
Approximately 5%–6% of individuals with schizophrenia die by suicide, about 20% attempt
suicide on one or more occasions, and many more have significant suicidal ideation. Suicidal
behavior is sometimes in response to command hallucinations to harm oneself or others.
Suicide risk remains high over the whole lifespan for males and females, although it may be
especially high for younger males with comorbid substance use. Other risk factors include
having depressive symptoms or feelings of hopelessness and being unemployed, and the
risk is higher, also, in the period after a psychotic episode or hospital discharge.

Functional Consequences of Schizophrenia
Schizophrenia is associated with significant social and occupational dysfunction. Making
educational progress and maintaining employment are frequently impaired by avolition
or other disorder manifestations, even when the cognitive skills are sufficient for the tasks
at hand. Most individuals are employed at a lower level than their parents, and most, par-
ticularly men, do not marry or have limited social contacts outside of their family.

Differential Diagnosis
Major depressive or bipolar disorder with psychotic or catatonic features. The distinc-
tion between schizophrenia and major depressive or bipolar disorder with psychotic
features or with catatonia depends on the temporal relationship between the mood distur-
bance and the psychosis, and on the severity of the depressive or manic symptoms. If de-
lusions or hallucinations occur exclusively during a major depressive or manic episode,
the diagnosis is depressive or bipolar disorder with psychotic features.

Schizoaffective disorder. A diagnosis of schizoaffective disorder requires that a major
depressive or manic episode occur concurrently with the active-phase symptoms and that
the mood symptoms be present for a majority of the total duration of the active periods.

Schizophreniform disorder and brief psychotic disorder. These disorders are of shorter
duration than schizophrenia as specified in Criterion C, which requires 6 months of symp-
toms. In schizophreniform disorder, the disturbance is present less than 6 months, and in
brief psychotic disorder, symptoms are present at least 1 day but less than 1 month.

Delusional disorder. Delusional disorder can be distinguished from schizophrenia by
the absence of the other symptoms characteristic of schizophrenia (e.g., delusions, prom-
inent auditory or visual hallucinations, disorganized speech, grossly disorganized or cata-
tonic behavior, negative symptoms).

Schizotypal personality disorder. Schizotypal personality disorder may be distinguished
from schizophrenia by subthreshold symptoms that are associated with persistent person-
ality features.

Obsessive-compulsive disorder and body dysmorphic disorder. Individuals with
obsessive-compulsive disorder and body dysmorphic disorder may present with poor or
absent insight, and the preoccupations may reach delusional proportions. But these
disorders are distinguished from schizophrenia by their prominent obsessions, compul-
sions, preoccupations with appearance or body odor, hoarding, or body-focused repeti-
tive behaviors.

Posttraumatic stress disorder. Posttraumatic stress disorder may include flashbacks that
have a hallucinatory quality, and hypervigilance may reach paranoid proportions. But a trau-

Schizoaffective Disorder 105

matic event and characteristic symptom features relating to reliving or reacting to the event
are required to make the diagnosis.

Autism spectrum disorder or communication disorders. These disorders may also have
symptoms resembling a psychotic episode but are distinguished by their respective defi-
cits in social interaction with repetitive and restricted behaviors and other cognitive and
communication deficits. An individual with autism spectrum disorder or communication
disorder must have symptoms that meet full criteria for schizophrenia, with prominent
hallucinations or delusions for at least 1 month, in order to be diagnosed with schizophre-
nia as a comorbid condition.

Other mental disorders associated with a psychotic episode. The diagnosis of schizo-
phrenia is made only when the psychotic episode is persistent and not attributable to the
physiological effects of a substance or another medical condition. Individuals with a de-
lirium or major or minor neurocognitive disorder may present with psychotic symptoms,
but these would have a temporal relationship to the onset of cognitive changes consistent
with those disorders. Individuals with substance/medication-induced psychotic disorder
may present with symptoms characteristic of Criterion A for schizophrenia, but the sub-
stance/medication-induced psychotic disorder can usually be distinguished by the chron-
ological relationship of substance use to the onset and remission of the psychosis in the
absence of substance use.

Comorbidity
Rates of comorbidity with substance-related disorders are high in schizophrenia. Over
half of individuals with schizophrenia have tobacco use disorder and smoke cigarettes
regularly. Comorbidity with anxiety disorders is increasingly recognized in schizophre-
nia. Rates of obsessive-compulsive disorder and panic disorder are elevated in individuals
with schizophrenia compared with the general population. Schizotypal or paranoid per-
sonality disorder may sometimes precede the onset of schizophrenia.

Life expectancy is reduced in individuals with schizophrenia because of associated
medical conditions. Weight gain, diabetes, metabolic syndrome, and cardiovascular and
pulmonary disease are more common in schizophrenia than in the general population.
Poor engagement in health maintenance behaviors (e.g., cancer screening, exercise) in-
creases the risk of chronic disease, but other disorder factors, including medications, life-
style, cigarette smoking, and diet, may also play a role. A shared vulnerability for
psychosis and medical disorders may explain some of the medical comorbidity of schizo-
phrenia.

Schizoaffective Disorder
Diagnostic Criteria

A. An uninterrupted period of illness during which there is a major mood episode (major
depressive or manic) concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A1: Depressed mood.

B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood epi-
sode (depressive or manic) during the lifetime duration of the illness.

C. Symptoms that meet criteria for a major mood episode are present for the majority of
the total duration of the active and residual portions of the illness.

D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse,
a medication) or another medical condition.

106 Schizophrenia Spectrum and Other Psychotic Disorders

Specify whether:
295.70 (F25.0) Bipolar type: This subtype applies if a manic episode is part of the pre-
sentation. Major depressive episodes may also occur.
295.70 (F25.1) Depressive type: This subtype applies if only major depressive epi-
sodes are part of the presentation.

Specify if:
With catatonia (refer to the criteria for catatonia associated with another mental disorder,
pp. 119–120, for definition).

Coding note: Use additional code 293.89 (F06.1) catatonia associated with
schizoaffective disorder to indicate the presence of the comorbid catatonia.

Specify if:
The following course specifiers are only to be used after a 1-year duration of the disorder
and if they are not in contradiction to the diagnostic course criteria.

First episode, currently in acute episode: First manifestation of the disorder meet-
ing the defining diagnostic symptom and time criteria. An acute episode is a time pe-
riod in which the symptom criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a time period dur-
ing which an improvement after a previous episode is maintained and in which the de-
fining criteria of the disorder are only partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a
previous episode during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode: Multiple episodes may be deter-
mined after a minimum of two episodes (i.e., after a first episode, a remission and a
minimum of one relapse).
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are
remaining for the majority of the illness course, with subthreshold symptom periods be-
ing very brief relative to the overall course.
Unspecified

Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor be-
havior, and negative symptoms. Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present)
to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom
Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of schizoaffective disorder can be made without using this severity
specifier.

Note: For additional information on Development and Course (age-related factors), Risk
and Prognostic Factors (environmental risk factors), Culture-Related Diagnostic Issues,
and Gender-Related Diagnostic Issues, see the corresponding sections in schizophrenia,
bipolar I and II disorders, and major depressive disorder in their respective chapters.

Diagnostic Features
The diagnosis of schizoaffective disorder is based on the assessment of an uninterrupted
period of illness during which the individual continues to display active or residual symp-
toms of psychotic illness. The diagnosis is usually, but not necessarily, made during the
period of psychotic illness. At some time during the period, Criterion A for schizophrenia

Schizoaffective Disorder 107

has to be met. Criteria B (social dysfunction) and F (exclusion of autism spectrum disorder
or other communication disorder of childhood onset) for schizophrenia do not have to be
met. In addition to meeting Criterion A for schizophrenia, there is a major mood episode
(major depressive or manic) (Criterion A for schizoaffective disorder). Because loss of in-
terest or pleasure is common in schizophrenia, to meet Criterion A for schizoaffective dis-
order, the major depressive episode must include pervasive depressed mood (i.e., the
presence of markedly diminished interest or pleasure is not sufficient). Episodes of de-
pression or mania are present for the majority of the total duration of the illness (i.e., after
Criterion A has been met) (Criterion C for schizoaffective disorder). To separate schizoaf-
fective disorder from a depressive or bipolar disorder with psychotic features, delusions
or hallucinations must be present for at least 2 weeks in the absence of a major mood epi-
sode (depressive or manic) at some point during the lifetime duration of the illness (Cri-
terion B for schizoaffective disorder). The symptoms must not be attributable to the effects
of a substance or another medical condition (Criterion D for schizoaffective disorder).

Criterion C for schizoaffective disorder specifies that mood symptoms meeting criteria
for a major mood episode must be present for the majority of the total duration of the ac-
tive and residual portion of the illness. Criterion C requires the assessment of mood symp-
toms for the entire course of a psychotic illness, which differs from the criterion in DSM-IV,
which required only an assessment of the current period of illness. If the mood symptoms
are present for only a relatively brief period, the diagnosis is schizophrenia, not schizoaf-
fective disorder. When deciding whether an individual’s presentation meets Criterion C,
the clinician should review the total duration of psychotic illness (i.e., both active and re-
sidual symptoms) and determine when significant mood symptoms (untreated or in need
of treatment with antidepressant and/or mood-stabilizing medication) accompanied the
psychotic symptoms. This determination requires sufficient historical information and
clinical judgment. For example, an individual with a 4-year history of active and residual
symptoms of schizophrenia develops depressive and manic episodes that, taken together,
do not occupy more than 1 year during the 4-year history of psychotic illness. This presen-
tation would not meet Criterion C.

In addition to the five symptom domain areas identified in the diagnostic criteria, the
assessment of cognition, depression, and mania symptom domains is vital for making crit-
ically important distinctions between the various schizophrenia spectrum and other psy-
chotic disorders.

Associated Features Supporting Diagnosis
Occupational functioning is frequently impaired, but this is not a defining criterion (in
contrast to schizophrenia). Restricted social contact and difficulties with self-care are as-
sociated with schizoaffective disorder, but negative symptoms may be less severe and less
persistent than those seen in schizophrenia. Anosognosia (i.e., poor insight) is also com-
mon in schizoaffective disorder, but the deficits in insight may be less severe and perva-
sive than those in schizophrenia. Individuals with schizoaffective disorder may be at
increased risk for later developing episodes of major depressive disorder or bipolar disor-
der if mood symptoms continue following the remission of symptoms meeting Criterion A
for schizophrenia. There may be associated alcohol and other substance-related disorders.

There are no tests or biological measures that can assist in making the diagnosis of
schizoaffective disorder. Whether schizoaffective disorder differs from schizophrenia
with regard to associated features such as structural or functional brain abnormalities,
cognitive deficits, or genetic risk factors is not clear.

Prevalence
Schizoaffective disorder appears to be about one-third as common as schizophrenia. Life-
time prevalence of schizoaffective disorder is estimated to be 0.3%. The incidence of

108 Schizophrenia Spectrum and Other Psychotic Disorders

schizoaffective disorder is higher in females than in males, mainly due to an increased in-
cidence of the depressive type among females.

Development and Course
The typical age at onset of schizoaffective disorder is early adulthood, although onset can
occur anywhere from adolescence to late in life. A significant number of individuals diag-
nosed with another psychotic illness initially will receive the diagnosis schizoaffective dis-
order later when the pattern of mood episodes has become more apparent. With the
current diagnostic Criterion C, it is expected that the diagnosis for some individuals will
convert from schizoaffective disorder to another disorder as mood symptoms become less
prominent. The prognosis for schizoaffective disorder is somewhat better than the prog-
nosis for schizophrenia but worse than the prognosis for mood disorders.

Schizoaffective disorder may occur in a variety of temporal patterns. The following is
a typical pattern: An individual may have pronounced auditory hallucinations and per-
secutory delusions for 2 months before the onset of a prominent major depressive episode.
The psychotic symptoms and the full major depressive episode are then present for 3 months.
Then, the individual recovers completely from the major depressive episode, but the psy-
chotic symptoms persist for another month before they too disappear. During this period
of illness, the individual’s symptoms concurrently met criteria for a major depressive ep-
isode and Criterion A for schizophrenia, and during this same period of illness, auditory
hallucinations and delusions were present both before and after the depressive phase. The
total period of illness lasted for about 6 months, with psychotic symptoms alone present
during the initial 2 months, both depressive and psychotic symptoms present during the
next 3 months, and psychotic symptoms alone present during the last month. In this in-
stance, the duration of the depressive episode was not brief relative to the total duration of
the psychotic disturbance, and thus the presentation qualifies for a diagnosis of schizoaf-
fective disorder.

The expression of psychotic symptoms across the lifespan is variable. Depressive or
manic symptoms can occur before the onset of psychosis, during acute psychotic episodes,
during residual periods, and after cessation of psychosis. For example, an individual
might present with prominent mood symptoms during the prodromal stage of schizo-
phrenia. This pattern is not necessarily indicative of schizoaffective disorder, since it is the
co-occurrence of psychotic and mood symptoms that is diagnostic. For an individual with
symptoms that clearly meet the criteria for schizoaffective disorder but who on further fol-
low-up only presents with residual psychotic symptoms (such as subthreshold psychosis
and/or prominent negative symptoms), the diagnosis may be changed to schizophrenia,
as the total proportion of psychotic illness compared with mood symptoms becomes more
prominent. Schizoaffective disorder, bipolar type, may be more common in young adults,
whereas schizoaffective disorder, depressive type, may be more common in older adults.

Risk and Prognostic Factors
Genetic and physiological. Among individuals with schizophrenia, there may be an in-
creased risk for schizoaffective disorder in first-degree relatives. The risk for schizoaffec-
tive disorder may be increased among individuals who have a first-degree relative with
schizophrenia, bipolar disorder, or schizoaffective disorder.

Culture-Related Diagnostic Issues
Cultural and socioeconomic factors must be considered, particularly when the individual
and the clinician do not share the same cultural and economic background. Ideas that ap-
pear to be delusional in one culture (e.g., witchcraft) may be commonly held in another.
There is also some evidence in the literature for the overdiagnosis of schizophrenia com-

Schizoaffective Disorder 109

pared with schizoaffective disorder in African American and Hispanic populations, so
care must be taken to ensure a culturally appropriate evaluation that includes both psy-
chotic and affective symptoms.

Suicide Risk
The lifetime risk of suicide for schizophrenia and schizoaffective disorder is 5%, and the
presence of depressive symptoms is correlated with a higher risk for suicide. There is ev-
idence that suicide rates are higher in North American populations than in European,
Eastern European, South American, and Indian populations of individuals with schizo-
phrenia or schizoaffective disorder.

Functional Consequences of Schizoaffective Disorder
Schizoaffective disorder is associated with social and occupational dysfunction, but dys-
function is not a diagnostic criterion (as it is for schizophrenia), and there is substantial
variability between individuals diagnosed with schizoaffective disorder.

Differential Diagnosis
Other mental disorders and medical conditions. A wide variety of psychiatric and med-
ical conditions can manifest with psychotic and mood symptoms that must be considered
in the differential diagnosis of schizoaffective disorder. These include psychotic disorder
due to another medical condition; delirium; major neurocognitive disorder; substance/
medication-induced psychotic disorder or neurocognitive disorder; bipolar disorders
with psychotic features; major depressive disorder with psychotic features; depressive or
bipolar disorders with catatonic features; schizotypal, schizoid, or paranoid personality
disorder; brief psychotic disorder; schizophreniform disorder; schizophrenia; delusional
disorder; and other specified and unspecified schizophrenia spectrum and other psychotic
disorders. Medical conditions and substance use can present with a combination of psy-
chotic and mood symptoms, and thus psychotic disorder due to another medical condition
needs to be excluded. Distinguishing schizoaffective disorder from schizophrenia and
from depressive and bipolar disorders with psychotic features is often difficult. Criterion
C is designed to separate schizoaffective disorder from schizophrenia, and Criterion B is
designed to distinguish schizoaffective disorder from a depressive or bipolar disorder
with psychotic features. More specifically, schizoaffective disorder can be distinguished
from a depressive or bipolar disorder with psychotic features due to the presence of prom-
inent delusions and/or hallucinations for at least 2 weeks in the absence of a major mood
episode. In contrast, in depressive or bipolar disorders with psychotic features, the psy-
chotic features primarily occur during the mood episode(s). Because the relative propor-
tion of mood to psychotic symptoms may change over time, the appropriate diagnosis
may change from and to schizoaffective disorder (e.g., a diagnosis of schizoaffective dis-
order for a severe and prominent major depressive episode lasting 3 months during the
first 6 months of a persistent psychotic illness would be changed to schizophrenia if active
psychotic or prominent residual symptoms persist over several years without a recurrence
of another mood episode).

Psychotic disorder due to another medical condition. Other medical conditions and
substance use can manifest with a combination of psychotic and mood symptoms, and
thus psychotic disorder due to another medical condition needs to be excluded.

Schizophrenia, bipolar, and depressive disorders. Distinguishing schizoaffective dis-
order from schizophrenia and from depressive and bipolar disorders with psychotic fea-
tures is often difficult. Criterion C is designed to separate schizoaffective disorder from
schizophrenia, and Criterion B is designed to distinguish schizoaffective disorder from a

110 Schizophrenia Spectrum and Other Psychotic Disorders

depressive or bipolar disorder with psychotic features. More specifically, schizoaffective
disorder can be distinguished from a depressive or bipolar disorder with psychotic features
based on the presence of prominent delusions and/or hallucinations for at least 2 weeks in
the absence of a major mood episode. In contrast, in depressive or bipolar disorder with
psychotic features, the psychotic features primarily occur during the mood episode(s). Be-
cause the relative proportion of mood to psychotic symptoms may change over time, the
appropriate diagnosis may change from and to schizoaffective disorder. (For example, a
diagnosis of schizoaffective disorder for a severe and prominent major depressive episode
lasting 3 months during the first 6 months of a chronic psychotic illness would be changed
to schizophrenia if active psychotic or prominent residual symptoms persist over several
years without a recurrence of another mood episode.)

Comorbidity
Many individuals diagnosed with schizoaffective disorder are also diagnosed with other
mental disorders, especially substance use disorders and anxiety disorders. Similarly, the
incidence of medical conditions is increased above base rate for the general population
and leads to decreased life expectancy.

Substance/Medication-Induced
Psychotic Disorder

Diagnostic Criteria

A. Presence of one or both of the following symptoms:

1. Delusions.
2. Hallucinations.

B. There is evidence from the history, physical examination, or laboratory findings of both
(1) and (2):

1. The symptoms in Criterion A developed during or soon after substance intoxication
or withdrawal or after exposure to a medication.

2. The involved substance/medication is capable of producing the symptoms in Crite-
rion A.

C. The disturbance is not better explained by a psychotic disorder that is not substance/
medication-induced. Such evidence of an independent psychotic disorder could in-
clude the following:

The symptoms preceded the onset of the substance/medication use; the symptoms
persist for a substantial period of time (e.g., about 1 month) after the cessation of
acute withdrawal or severe intoxication; or there is other evidence of an indepen-
dent non-substance/medication-induced psychotic disorder (e.g., a history of recur-
rent non-substance/medication-related episodes).

D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-

tional, or other important areas of functioning.

Note: This diagnosis should be made instead of a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical
picture and when they are sufficiently severe to warrant clinical attention.

Substance/Medication-Induced Psychotic Disorder 111

Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific substance/medica-
tion]-induced psychotic disorders are indicated in the table below. Note that the ICD-10-
CM code depends on whether or not there is a comorbid substance use disorder present
for the same class of substance. If a mild substance use disorder is comorbid with the sub-
stance-induced psychotic disorder, the 4th position character is “1,” and the clinician should
record “mild [substance] use disorder” before the substance-induced psychotic disorder
(e.g., “mild cocaine use disorder with cocaine-induced psychotic disorder”). If a moderate or
severe substance use disorder is comorbid with the substance-induced psychotic disor-
der, the 4th position character is “2,” and the clinician should record “moderate [substance]
use disorder” or “severe [substance] use disorder,” depending on the severity of the co-
morbid substance use disorder. If there is no comorbid substance use disorder (e.g., after
a one-time heavy use of the substance), then the 4th position character is “9,” and the cli-
nician should record only the substance-induced psychotic disorder.

Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for diag-
noses associated with substance class):

With onset during intoxication: If the criteria are met for intoxication with the sub-
stance and the symptoms develop during intoxication.
With onset during withdrawal: If the criteria are met for withdrawal from the sub-
stance and the symptoms develop during, or shortly after, withdrawal.

Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, abnormal psychomotor behavior, and negative
symptoms. Each of these symptoms may be rated for its current severity (most severe
in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and
severe). (See Clinician-Rated Dimensions of Psychosis Symptom Severity in the chap-
ter “Assessment Measures.”)
Note: Diagnosis of substance/medication-induced psychotic disorder can be made
without using this severity specifier.

ICD-10-CM

ICD-9-CM

With use
disorder,

mild

With use
disorder,
moderate
or severe

Without
use

disorder

Alcohol 291.9 F10.159 F10.259 F10.959

Cannabis 292.9 F12.159 F12.259 F12.959

Phencyclidine 292.9 F16.159 F16.259 F16.959

Other hallucinogen 292.9 F16.159 F16.259 F16.959

Inhalant 292.9 F18.159 F18.259 F18.959

Sedative, hypnotic, or
anxiolytic

292.9 F13.159 F13.259 F13.959

Amphetamine (or other
stimulant)

292.9 F15.159 F15.259 F15.959

Cocaine 292.9 F14.159 F14.259 F14.959

Other (or unknown) substance 292.9 F19.159 F19.259 F19.959

112 Schizophrenia Spectrum and Other Psychotic Disorders

Recording Procedures
ICD-9-CM. The name of the substance/medication-induced psychotic disorder begins
with the specific substance (e.g., cocaine, dexamethasone) that is presumed to be causing
the delusions or hallucinations. The diagnostic code is selected from the table included in
the criteria set, which is based on the drug class. For substances that do not fit into any of
the classes (e.g., dexamethasone), the code for “other substance” should be used; and in
cases in which a substance is judged to be an etiological factor but the specific class of sub-
stance is unknown, the category “unknown substance” should be used.

The name of the disorder is followed by the specification of onset (i.e., onset during in-
toxication, onset during withdrawal). Unlike the recording procedures for ICD-10-CM,
which combine the substance-induced disorder and substance use disorder into a single
code, for ICD-9-CM a separate diagnostic code is given for the substance use disorder. For
example, in the case of delusions occurring during intoxication in a man with a severe co-
caine use disorder, the diagnosis is 292.9 cocaine-induced psychotic disorder, with onset
during intoxication. An additional diagnosis of 304.20 severe cocaine use disorder is also
given. When more than one substance is judged to play a significant role in the development
of psychotic symptoms, each should be listed separately (e.g., 292.9 cannabis-induced psy-
chotic disorder with onset during intoxication, with severe cannabis use disorder; 292.9
phencyclidine-induced psychotic disorder, with onset during intoxication, with mild
phencyclidine use disorder).

ICD-10-CM. The name of the substance/medication-induced psychotic disorder begins
with the specific substance (e.g., cocaine, dexamethasone) that is presumed to be causing
the delusions or hallucinations. The diagnostic code is selected from the table included in
the criteria set, which is based on the drug class and presence or absence of a comorbid
substance use disorder. For substances that do not fit into any of the classes (e.g., dexa-
methasone), the code for “other substance” with no comorbid substance use should be
used; and in cases in which a substance is judged to be an etiological factor but the specific
class of substance is unknown, the category “unknown substance” with no comorbid sub-
stance use should be used.

When recording the name of the disorder, the comorbid substance use disorder (if any)
is listed first, followed by the word “with,” followed by the name of the substance-induced
psychotic disorder, followed by the specification of onset (i.e., onset during intoxication,
onset during withdrawal). For example, in the case of delusions occurring during intoxi-
cation in a man with a severe cocaine use disorder, the diagnosis is F14.259 severe cocaine
use disorder with cocaine-induced psychotic disorder, with onset during intoxication. A
separate diagnosis of the comorbid severe cocaine use disorder is not given. If the sub-
stance-induced psychotic disorder occurs without a comorbid substance use disorder
(e.g., after a one-time heavy use of the substance), no accompanying substance use disor-
der is noted (e.g., F16.959 phencyclidine-induced psychotic disorder, with onset during in-
toxication). When more than one substance is judged to play a significant role in the
development of psychotic symptoms, each should be listed separately (e.g., F12.259 severe
cannabis use disorder with cannabis-induced psychotic disorder, with onset during intox-
ication; F16.159 mild phencyclidine use disorder with phencyclidine-induced psychotic
disorder, with onset during intoxication).

Diagnostic Features
The essential features of substance/medication-induced psychotic disorder are prominent
delusions and/or hallucinations (Criterion A) that are judged to be due to the physiolog-
ical effects of a substance/medication (i.e., a drug of abuse, a medication, or a toxin expo-
sure) (Criterion B). Hallucinations that the individual realizes are substance/medication-
induced are not included here and instead would be diagnosed as substance intoxication

Substance/Medication-Induced Psychotic Disorder 113

or substance withdrawal with the accompanying specifier “with perceptual disturbances”
(applies to alcohol withdrawal; cannabis intoxication; sedative, hypnotic, or anxiolytic
withdrawal; and stimulant intoxication).

A substance/medication-induced psychotic disorder is distinguished from a primary
psychotic disorder by considering the onset, course, and other factors. For drugs of abuse,
there must be evidence from the history, physical examination, or laboratory findings of
substance use, intoxication, or withdrawal. Substance/medication-induced psychotic
disorders arise during or soon after exposure to a medication or after substance intoxica-
tion or withdrawal but can persist for weeks, whereas primary psychotic disorders may
precede the onset of substance/medication use or may occur during times of sustained ab-
stinence. Once initiated, the psychotic symptoms may continue as long as the substance/
medication use continues. Another consideration is the presence of features that are atyp-
ical of a primary psychotic disorder (e.g., atypical age at onset or course). For example, the
appearance of delusions de novo in a person older than 35 years without a known history
of a primary psychotic disorder should suggest the possibility of a substance/medication-
induced psychotic disorder. Even a prior history of a primary psychotic disorder does not
rule out the possibility of a substance/medication-induced psychotic disorder. In contrast,
factors that suggest that the psychotic symptoms are better accounted for by a primary
psychotic disorder include persistence of psychotic symptoms for a substantial period of
time (i.e., a month or more) after the end of substance intoxication or acute substance with-
drawal or after cessation of medication use; or a history of prior recurrent primary psy-
chotic disorders. Other causes of psychotic symptoms must be considered even in an
individual with substance intoxication or withdrawal, because substance use problems are
not uncommon among individuals with non-substance/medication-induced psychotic
disorders.

In addition to the four symptom domain areas identified in the diagnostic criteria, the
assessment of cognition, depression, and mania symptom domains is vital for making crit-
ically important distinctions between the various schizophrenia spectrum and other psy-
chotic disorders.

Associated Features Supporting Diagnosis
Psychotic disorders can occur in association with intoxication with the following classes of
substances: alcohol; cannabis; hallucinogens, including phencyclidine and related sub-
stances; inhalants; sedatives, hypnotics, and anxiolytics; stimulants (including cocaine);
and other (or unknown) substances. Psychotic disorders can occur in association with with-
drawal from the following classes of substances: alcohol; sedatives, hypnotics, and anxio-
lytics; and other (or unknown) substances.

Some of the medications reported to evoke psychotic symptoms include anesthetics
and analgesics, anticholinergic agents, anticonvulsants, antihistamines, antihypertensive
and cardiovascular medications, antimicrobial medications, antiparkinsonian medica-
tions, chemotherapeutic agents (e.g., cyclosporine, procarbazine), corticosteroids, gastro-
intestinal medications, muscle relaxants, nonsteroidal anti-inflammatory medications,
other over-the-counter medications (e.g., phenylephrine, pseudoephedrine), antidepres-
sant medication, and disulfiram. Toxins reported to induce psychotic symptoms include
anticholinesterase, organophosphate insecticides, sarin and other nerve gases, carbon
monoxide, carbon dioxide, and volatile substances such as fuel or paint.

Prevalence
Prevalence of substance/medication-induced psychotic disorder in the general popula-
tion is unknown. Between 7% and 25% of individuals presenting with a first episode of
psychosis in different settings are reported to have substance/medication-induced psy-
chotic disorder.

114 Schizophrenia Spectrum and Other Psychotic Disorders

Development and Course
The initiation of the disorder may vary considerably with the substance. For example,
smoking a high dose of cocaine may produce psychosis within minutes, whereas days or
weeks of high-dose alcohol or sedative use may be required to produce psychosis. Alco-
hol-induced psychotic disorder, with hallucinations, usually occurs only after prolonged,
heavy ingestion of alcohol in individuals who have moderate to severe alcohol use disorder,
and the hallucinations are generally auditory in nature.

Psychotic disorders induced by amphetamine and cocaine share similar clinical fea-
tures. Persecutory delusions may rapidly develop shortly after use of amphetamine or a
similarly acting sympathomimetic. The hallucination of bugs or vermin crawling in or un-
der the skin (formication) can lead to scratching and extensive skin excoriations. Cannabis-
induced psychotic disorder may develop shortly after high-dose cannabis use and usually
involves persecutory delusions, marked anxiety, emotional lability, and depersonalization.
The disorder usually remits within a day but in some cases may persist for a few days.

Substance/medication-induced psychotic disorder may at times persist when the offend-
ing agent is removed, such that it may be difficult initially to distinguish it from an indepen-
dent psychotic disorder. Agents such as amphetamines, phencyclidine, and cocaine have been
reported to evoke temporary psychotic states that can sometimes persist for weeks or longer
despite removal of the agent and treatment with neuroleptic medication. In later life, poly-
pharmacy for medical conditions and exposure to medications for parkinsonism, cardiovas-
cular disease, and other medical disorders may be associated with a greater likelihood of
psychosis induced by prescription medications as opposed to substances of abuse.

Diagnostic Markers 
With substances for which relevant blood levels are available (e.g., blood alcohol level,
other quantifiable blood levels such as digoxin), the presence of a level consistent with tox-
icity may increase diagnostic certainty.

Functional Consequences of
Substance/Medication-Induced Psychotic Disorder
Substance/medication-induced psychotic disorder is typically severely disabling and
consequently is observed most frequently in emergency rooms, as individuals are often
brought to the acute-care setting when it occurs. However, the disability is typically self-
limited and resolves upon removal of the offending agent.

Differential Diagnosis
Substance intoxication or substance withdrawal. Individuals intoxicated with stimu-
lants, cannabis, the opioid meperidine, or phencyclidine, or those withdrawing from alco-
hol or sedatives, may experience altered perceptions that they recognize as drug effects. If
reality testing for these experiences remains intact (i.e., the individual recognizes that the
perception is substance induced and neither believes in nor acts on it), the diagnosis is not
substance/medication-induced psychotic disorder. Instead, substance intoxication or
substance withdrawal, with perceptual disturbances, is diagnosed (e.g., cocaine intoxica-
tion, with perceptual disturbances). “Flashback” hallucinations that can occur long after
the use of hallucinogens has stopped are diagnosed as hallucinogen persisting perception
disorder. If substance/medication-induced psychotic symptoms occur exclusively during
the course of a delirium, as in severe forms of alcohol withdrawal, the psychotic symptoms
are considered to be an associated feature of the delirium and are not diagnosed sepa-
rately. Delusions in the context of a major or mild neurocognitive disorder would be di-
agnosed as major or mild neurocognitive disorder, with behavioral disturbance.

Psychotic Disorder Due to Another Medical Condition 115

Primary psychotic disorder. A substance/medication-induced psychotic disorder is
distinguished from a primary psychotic disorder, such as schizophrenia, schizoaffective
disorder, delusional disorder, brief psychotic disorder, other specified schizophrenia
spectrum and other psychotic disorder, or unspecified schizophrenia spectrum and other
psychotic disorder, by the fact that a substance is judged to be etiologically related to the
symptoms.

Psychotic disorder due to another medical condition. A substance/medication-induced
psychotic disorder due to a prescribed treatment for a mental or medical condition must
have its onset while the individual is receiving the medication (or during withdrawal, if
there is a withdrawal syndrome associated with the medication). Because individuals with
medical conditions often take medications for those conditions, the clinician must con-
sider the possibility that the psychotic symptoms are caused by the physiological conse-
quences of the medical condition rather than the medication, in which case psychotic
disorder due to another medical condition is diagnosed. The history often provides the
primary basis for such a judgment. At times, a change in the treatment for the medical con-
dition (e.g., medication substitution or discontinuation) may be needed to determine em-
pirically for that individual whether the medication is the causative agent. If the clinician
has ascertained that the disturbance is attributable to both a medical condition and sub-
stance/medication use, both diagnoses (i.e., psychotic disorder due to another medical
condition and substance/medication-induced psychotic disorder) may be given.

Psychotic Disorder
Due to Another Medical Condition

Diagnostic Criteria

A. Prominent hallucinations or delusions.
B. There is evidence from the history, physical examination, or laboratory findings that the

disturbance is the direct pathophysiological consequence of another medical condi-
tion.

C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-

tional, or other important areas of functioning.

Specify whether:
Code based on predominant symptom:

293.81 (F06.2) With delusions: If delusions are the predominant symptom.
293.82 (F06.0) With hallucinations: If hallucinations are the predominant symptom.

Coding note: Include the name of the other medical condition in the name of the mental
disorder (e.g., 293.81 [F06.2] psychotic disorder due to malignant lung neoplasm, with de-
lusions). The other medical condition should be coded and listed separately immediately
before the psychotic disorder due to the medical condition (e.g., 162.9 [C34.90] malignant
lung neoplasm; 293.81 [F06.2] psychotic disorder due to malignant lung neoplasm, with
delusions).

Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, abnormal psychomotor behavior, and negative
symptoms. Each of these symptoms may be rated for its current severity (most severe
in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and

116 Schizophrenia Spectrum and Other Psychotic Disorders

severe). (See Clinician-Rated Dimensions of Psychosis Symptom Severity in the chap-
ter “Assessment Measures.”)
Note: Diagnosis of psychotic disorder due to another medical condition can be made
without using this severity specifier.

Specifiers
In addition to the symptom domain areas identified in the diagnostic criteria, the assess-
ment of cognition, depression, and mania symptom domains is vital for making critically
important distinctions between the various schizophrenia spectrum and other psychotic
disorders.

Diagnostic Features
The essential features of psychotic disorder due to another medical condition are promi-
nent delusions or hallucinations that are judged to be attributable to the physiological ef-
fects of another medical condition and are not better explained by another mental disorder
(e.g., the symptoms are not a psychologically mediated response to a severe medical con-
dition, in which case a diagnosis of brief psychotic disorder, with marked stressor, would
be appropriate).

Hallucinations can occur in any sensory modality (i.e., visual, olfactory, gustatory, tac-
tile, or auditory), but certain etiological factors are likely to evoke specific hallucinatory
phenomena. Olfactory hallucinations are suggestive of temporal lobe epilepsy. Hallucina-
tions may vary from simple and unformed to highly complex and organized, depending
on etiological and environmental factors. Psychotic disorder due to another medical con-
dition is generally not diagnosed if the individual maintains reality testing for the hallu-
cinations and appreciates that they result from the medical condition. Delusions may have
a variety of themes, including somatic, grandiose, religious, and, most commonly, perse-
cutory. On the whole, however, associations between delusions and particular medical
conditions appear to be less specific than is the case for hallucinations.

In determining whether the psychotic disturbance is attributable to another medical
condition, the presence of a medical condition must be identified and considered to be the
etiology of the psychosis through a physiological mechanism. Although there are no
infallible guidelines for determining whether the relationship between the psychotic distur-
bance and the medical condition is etiological, several considerations provide some guidance.
One consideration is the presence of a temporal association between the onset, exacerba-
tion, or remission of the medical condition and that of the psychotic disturbance. A second
consideration is the presence of features that are atypical for a psychotic disorder (e.g.,
atypical age at onset or presence of visual or olfactory hallucinations). The disturbance must
also be distinguished from a substance/medication-induced psychotic disorder or an-
other mental disorder (e.g., an adjustment disorder).

Associated Features Supporting Diagnosis
The temporal association of the onset or exacerbation of the medical condition offers the
greatest diagnostic certainty that the delusions or hallucinations are attributable to a med-
ical condition. Additional factors may include concomitant treatments for the underlying
medical condition that confer a risk for psychosis independently, such as steroid treatment
for autoimmune disorders.

Prevalence
Prevalence rates for psychotic disorder due to another medical condition are difficult to es-
timate given the wide variety of underlying medical etiologies. Lifetime prevalence has

Psychotic Disorder Due to Another Medical Condition 117

been estimated to range from 0.21% to 0.54%. When the prevalence findings are stratified
by age group, individuals older than 65 years have a significantly greater prevalence of
0.74% compared with those in younger age groups. Rates of psychosis also vary according
to the underlying medical condition; conditions most commonly associated with psy-
chosis include untreated endocrine and metabolic disorders, autoimmune disorders (e.g.,
systemic lupus erythematosus, N-methyl-D-aspartate (NMDA) receptor autoimmune en-
cephalitis), or temporal lobe epilepsy. Psychosis due to epilepsy has been further differ-
entiated into ictal, postictal, and interictal psychosis. The most common of these is postictal
psychosis, observed in 2%–7.8% of epilepsy patients. Among older individuals, there may
be a higher prevalence of the disorder in females, although additional gender-related fea-
tures are not clear and vary considerably with the gender distributions of the underlying
medical conditions.

Development and Course
Psychotic disorder due to another medical condition may be a single transient state or it
may be recurrent, cycling with exacerbations and remissions of the underlying medical
condition. Although treatment of the underlying medical condition often results in a res-
olution of the psychosis, this is not always the case, and psychotic symptoms may persist
long after the medical event (e.g., psychotic disorder due to focal brain injury). In the con-
text of chronic conditions such as multiple sclerosis or chronic interictal psychosis of epi-
lepsy, the psychosis may assume a long-term course.

The expression of psychotic disorder due to another medical condition does not differ
substantially in phenomenology depending on age at occurrence. However, older age
groups have a higher prevalence of the disorder, which is most likely due to the increasing
medical burden associated with advanced age and the cumulative effects of deleterious
exposures and age-related processes (e.g., atherosclerosis). The nature of the underlying
medical conditions is likely to change across the lifespan, with younger age groups more
affected by epilepsy, head trauma, autoimmune, and neoplastic diseases of early to mid-
life, and older age groups more affected by stroke disease, anoxic events, and multiple sys-
tem comorbidities. Underlying factors with increasing age, such as preexisting cognitive
impairment as well as vision and hearing impairments, may incur a greater risk for psy-
chosis, possibly by serving to lower the threshold for experiencing psychosis.

Risk and Prognostic Factors
Course modifiers. Identification and treatment of the underlying medical condition has
the greatest impact on course, although preexisting central nervous system injury may
confer a worse course outcome (e.g., head trauma, cerebrovascular disease).

Diagnostic Markers
The diagnosis of psychotic disorder due to another medical condition depends on the clin-
ical condition of each individual, and the diagnostic tests will vary according to that con-
dition. A variety of medical conditions may cause psychotic symptoms. These include
neurological conditions (e.g., neoplasms, cerebrovascular disease, Huntington’s disease,
multiple sclerosis, epilepsy, auditory or visual nerve injury or impairment, deafness,
migraine, central nervous system infections), endocrine conditions (e.g., hyper- and hypo-
thyroidism, hyper- and hypoparathyroidism, hyper- and hypoadrenocorticism), metabolic
conditions (e.g., hypoxia, hypercarbia, hypoglycemia), fluid or electrolyte imbalances,
hepatic or renal diseases, and autoimmune disorders with central nervous system involve-
ment (e.g., systemic lupus erythematosus). The associated physical examination findings,
laboratory findings, and patterns of prevalence or onset reflect the etiological medical
condition.

118 Schizophrenia Spectrum and Other Psychotic Disorders

Suicide Risk
Suicide risk in the context of psychotic disorder due to another medical condition is not
clearly delineated, although certain conditions such as epilepsy and multiple sclerosis are
associated with increased rates of suicide, which may be further increased in the presence
of psychosis.

Functional Consequences of Psychotic Disorder
Due to Another Medical Condition
Functional disability is typically severe in the context of psychotic disorder due to another
medical condition but will vary considerably by the type of condition and likely improve
with successful resolution of the condition.

Differential Diagnosis
Delirium. Hallucinations and delusions commonly occur in the context of a delirium;
however, a separate diagnosis of psychotic disorder due to another medical condition is
not given if the disturbance occurs exclusively during the course of a delirium. Delusions
in the context of a major or mild neurocognitive disorder would be diagnosed as major or
mild neurocognitive disorder, with behavioral disturbance.

Substance/medication-induced psychotic disorder. If there is evidence of recent or
prolonged substance use (including medications with psychoactive effects), withdrawal
from a substance, or exposure to a toxin (e.g., LSD [lysergic acid diethylamide] intoxica-
tion, alcohol withdrawal), a substance/medication-induced psychotic disorder should be
considered. Symptoms that occur during or shortly after (i.e., within 4 weeks) of substance
intoxication or withdrawal or after medication use may be especially indicative of a sub-
stance-induced psychotic disorder, depending on the character, duration, or amount of
the substance used. If the clinician has ascertained that the disturbance is due to both a
medical condition and substance use, both diagnoses (i.e., psychotic disorder due to an-
other medical condition and substance/medication-induced psychotic disorder) can be
given.

Psychotic disorder. Psychotic disorder due to another medical condition must be distin-
guished from a psychotic disorder (e.g., schizophrenia, delusional disorder, schizoaffective
disorder) or a depressive or bipolar disorder, with psychotic features. In psychotic disor-
ders and in depressive or bipolar disorders, with psychotic features, no specific and direct
causative physiological mechanisms associated with a medical condition can be demon-
strated. Late age at onset and the absence of a personal or family history of schizophrenia
or delusional disorder suggest the need for a thorough assessment to rule out the diagno-
sis of psychotic disorder due to another medical condition. Auditory hallucinations that
involve voices speaking complex sentences are more characteristic of schizophrenia than
of psychotic disorder due to a medical condition. Other types of hallucinations (e.g., vi-
sual, olfactory) commonly signal a psychotic disorder due to another medical condition or
a substance/medication-induced psychotic disorder.

Comorbidity
Psychotic disorder due to another medical condition in individuals older than 80 years is
associated with concurrent major neurocognitive disorder (dementia).

Catatonia Associated With Another Mental Disorder (Catatonia Specifier) 119

Catatonia

Catatonia can occur in the context of several disorders, including neurodevelopmental,
psychotic, bipolar, depressive disorders, and other medical conditions (e.g., cerebral folate
deficiency, rare autoimmune and paraneoplastic disorders. The manual does not treat
catatonia as an independent class but recognizes a) catatonia associated with another men-
tal disorder (i.e., a neurodevelopmental, psychotic disorder, a bipolar disorder, a depres-
sive disorder, or other mental disorder), b) catatonic disorder due to another medical
condition, and c) unspecified catatonia.

Catatonia is defined by the presence of three or more of 12 psychomotor features in the
diagnostic criteria for catatonia associated with another mental disorder and catatonic dis-
order due to another medical condition. The essential feature of catatonia is a marked psy-
chomotor disturbance that may involve decreased motor activity, decreased engagement
during interview or physical examination, or excessive and peculiar motor activity. The
clinical presentation of catatonia can be puzzling, as the psychomotor disturbance may
range from marked unresponsiveness to marked agitation. Motoric immobility may be se-
vere (stupor) or moderate (catalepsy and waxy flexibility). Similarly, decreased engage-
ment may be severe (mutism) or moderate (negativism). Excessive and peculiar motor
behaviors can be complex (e.g., stereotypy) or simple (agitation) and may include echola-
lia and echopraxia. In extreme cases, the same individual may wax and wane between de-
creased and excessive motor activity. The seemingly opposing clinical features and
variable manifestations of the diagnosis contribute to a lack of awareness and decreased
recognition of catatonia. During severe stages of catatonia, the individual may need care-
ful supervision to avoid self-harm or harming others. There are potential risks from mal-
nutrition, exhaustion, hyperpyrexia and self-inflicted injury.

Catatonia Associated With Another
Mental Disorder (Catatonia Specifier)

293.89 (F06.1)

A. The clinical picture is dominated by three (or more) of the following symptoms: 

1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
2. Catalepsy (i.e., passive induction of a posture held against gravity).
3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]).
5. Negativism (i.e., opposition or no response to instructions or external stimuli).
6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
9. Agitation, not influenced by external stimuli.

10. Grimacing.
11. Echolalia (i.e., mimicking another’s speech).
12. Echopraxia (i.e., mimicking another’s movements).

Coding note: Indicate the name of the associated mental disorder when recording the
name of the condition (i.e., 293.89 [F06.1] catatonia associated with major depressive dis-
order). Code first the associated mental disorder (e.g., neurodevelopmental disorder, brief

120 Schizophrenia Spectrum and Other Psychotic Disorders

psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder,
bipolar disorder, major depressive disorder, or other mental disorder) (e.g., 295.70 [F25.1]
schizoaffective disorder, depressive type; 293.89 [F06.1] catatonia associated with
schizoaffective disorder).

Diagnostic Features
Catatonia associated with another mental disorder (catatonia specifier) may be used when
criteria are met for catatonia during the course of a neurodevelopmental, psychotic, bipo-
lar, depressive, or other mental disorder. The catatonia specifier is appropriate when the
clinical picture is characterized by marked psychomotor disturbance and involves at least
three of the 12 diagnostic features listed in Criterion A. Catatonia is typically diagnosed in
an inpatient setting and occurs in up to 35% of individuals with schizophrenia, but the ma-
jority of catatonia cases involve individuals with depressive or bipolar disorders. Before
the catatonia specifier is used in neurodevelopmental, psychotic, bipolar, depressive, or
other mental disorders, a wide variety of other medical conditions need to be ruled out;
these conditions include, but are not limited to, medical conditions due to infectious, met-
abolic, or neurological conditions (see “Catatonic Disorder Due to Another Medical Con-
dition”). Catatonia can also be a side effect of a medication (see the chapter “Medication-
Induced Movement Disorders and Other Adverse Effects of Medication”). Because of the
seriousness of the complications, particular attention should be paid to the possibility that
the catatonia is attributable to 333.92 (G21.0) neuroleptic malignant syndrome.

Catatonic Disorder Due to
Another Medical Condition

Diagnostic Criteria 293.89 (F06.1)

A. The clinical picture is dominated by three (or more) of the following symptoms: 

1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
2. Catalepsy (i.e., passive induction of a posture held against gravity).
3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
4. Mutism (i.e., no, or very little, verbal response [Note: not applicable if there is an

established aphasia]).
5. Negativism (i.e., opposition or no response to instructions or external stimuli).
6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
9. Agitation, not influenced by external stimuli.

10. Grimacing.
11. Echolalia (i.e., mimicking another’s speech).
12. Echopraxia (i.e., mimicking another’s movements).

B. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condition.

C. The disturbance is not better explained by another mental disorder (e.g., a manic episode).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-

tional, or other important areas of functioning.

Unspecified Catatonia 121

Coding note: Include the name of the medical condition in the name of the mental disor-
der (e.g., 293.89 [F06.1]) catatonic disorder due to hepatic encephalopathy). The other
medical condition should be coded and listed separately immediately before the cata-
tonic disorder due to the medical condition (e.g., 572.2 [K71.90] hepatic encephalopathy;
293.89 [F06.1] catatonic disorder due to hepatic encephalopathy).

Diagnostic Features
The essential feature of catatonic disorder due to another medical condition is the presence
of catatonia that is judged to be attributed to the physiological effects of another medical
condition. Catatonia can be diagnosed by the presence of at least three of the 12 clinical fea-
tures in Criterion A. There must be evidence from the history, physical examination, or
laboratory findings that the catatonia is attributable to another medical condition (Crite-
rion B). The diagnosis is not given if the catatonia is better explained by another mental
disorder (e.g., manic episode) (Criterion C) or if it occurs exclusively during the course of
a delirium (Criterion D).

Associated Features Supporting Diagnosis
A variety of medical conditions may cause catatonia, especially neurological conditions
(e.g., neoplasms, head trauma, cerebrovascular disease, encephalitis) and metabolic con-
ditions (e.g., hypercalcemia, hepatic encephalopathy, homocystinuria, diabetic ketoacido-
sis). The associated physical examination findings, laboratory findings, and patterns of
prevalence and onset reflect those of the etiological medical condition.

Differential Diagnosis
A separate diagnosis of catatonic disorder due to another medical condition is not given if
the catatonia occurs exclusively during the course of a delirium or neuroleptic malignant
syndrome. If the individual is currently taking neuroleptic medication, consideration
should be given to medication-induced movement disorders (e.g., abnormal positioning
may be due to neuroleptic-induced acute dystonia) or neuroleptic malignant syndrome
(e.g., catatonic-like features may be present, along with associated vital sign and/or labo-
ratory abnormalities). Catatonic symptoms may be present in any of the following five
psychotic disorders: brief psychotic disorder, schizophreniform disorder, schizophrenia,
schizoaffective disorder, and substance/medication-induced psychotic disorder. It may
also be present in some of the neurodevelopmental disorders, in all of the bipolar and de-
pressive disorders, and in other mental disorders.

Unspecified Catatonia

This category applies to presentations in which symptoms characteristic of catatonia
cause clinically significant distress or impairment in social, occupational, or other impor-
tant areas of functioning but either the nature of the underlying mental disorder or other
medical condition is unclear, full criteria for catatonia are not met, or there is insufficient
information to make a more specific diagnosis (e.g., in emergency room settings).

Coding note: Code first 781.99 (R29.818) other symptoms involving nervous and muscu-
loskeletal systems, followed by 293.89 (F06.1) unspecified catatonia.

122 Schizophrenia Spectrum and Other Psychotic Disorders

Other Specified Schizophrenia Spectrum and
Other Psychotic Disorder

298.8 (F28)

This category applies to presentations in which symptoms characteristic of a schizophre-
nia spectrum and other psychotic disorder that cause clinically significant distress or im-
pairment in social, occupational, or other important areas of functioning predominate but
do not meet the full criteria for any of the disorders in the schizophrenia spectrum and other
psychotic disorders diagnostic class. The other specified schizophrenia spectrum and oth-
er psychotic disorder category is used in situations in which the clinician chooses to com-
municate the specific reason that the presentation does not meet the criteria for any
specific schizophrenia spectrum and other psychotic disorder. This is done by recording “oth-
er specified schizophrenia spectrum and other psychotic disorder” followed by the specific
reason (e.g., “persistent auditory hallucinations”).

Examples of presentations that can be specified using the “other specified” designation
include the following:
1. Persistent auditory hallucinations occurring in the absence of any other features.
2. Delusions with significant overlapping mood episodes: This includes persistent

delusions with periods of overlapping mood episodes that are present for a substantial
portion of the delusional disturbance (such that the criterion stipulating only brief mood
disturbance in delusional disorder is not met).

3. Attenuated psychosis syndrome: This syndrome is characterized by psychotic-like
symptoms that are below a threshold for full psychosis (e.g., the symptoms are less
severe and more transient, and insight is relatively maintained).

4. Delusional symptoms in partner of individual with delusional disorder: In the
context of a relationship, the delusional material from the dominant partner provides
content for delusional belief by the individual who may not otherwise entirely meet cri-
teria for delusional disorder.

Unspecified Schizophrenia Spectrum and
Other Psychotic Disorder

298.9 (F29)

This category applies to presentations in which symptoms characteristic of a schizophre-
nia spectrum and other psychotic disorder that cause clinically significant distress or im-
pairment in social, occupational, or other important areas of functioning predominate but
do not meet the full criteria for any of the disorders in the schizophrenia spectrum and oth-
er psychotic disorders diagnostic class. The unspecified schizophrenia spectrum and oth-
er psychotic disorder category is used in situations in which the clinician chooses not to
specify the reason that the criteria are not met for a specific schizophrenia spectrum and
other psychotic disorder, and includes presentations in which there is insufficient informa-
tion to make a more specific diagnosis (e.g., in emergency room settings).

123

Bipolar and
Related Disorders

Bipolar and related disorders are separated from the depressive disorders in
DSM-5 and placed between the chapters on schizophrenia spectrum and other psychotic
disorders and depressive disorders in recognition of their place as a bridge between the
two diagnostic classes in terms of symptomatology, family history, and genetics. The di-
agnoses included in this chapter are bipolar I disorder, bipolar II disorder, cyclothymic
disorder, substance/medication-induced bipolar and related disorder, bipolar and relat-
ed disorder due to another medical condition, other specified bipolar and related disor-
der, and unspecified bipolar and related disorder.

The bipolar I disorder criteria represent the modern understanding of the classic
manic-depressive disorder or affective psychosis described in the nineteenth century, dif-
fering from that classic description only to the extent that neither psychosis nor the lifetime
experience of a major depressive episode is a requirement. However, the vast majority of
individuals whose symptoms meet the criteria for a fully syndromal manic episode also
experience major depressive episodes during the course of their lives.

Bipolar II disorder, requiring the lifetime experience of at least one episode of major de-
pression and at least one hypomanic episode, is no longer thought to be a “milder” condition
than bipolar I disorder, largely because of the amount of time individuals with this con-
dition spend in depression and because the instability of mood experienced by individuals
with bipolar II disorder is typically accompanied by serious impairment in work and social
functioning.

The diagnosis of cyclothymic disorder is given to adults who experience at least 2 years
(for children, a full year) of both hypomanic and depressive periods without ever fulfilling
the criteria for an episode of mania, hypomania, or major depression.

A large number of substances of abuse, some prescribed medications, and several
medical conditions can be associated with manic-like phenomena. This fact is recognized
in the diagnoses of substance/medication-induced bipolar and related disorder and bipo-
lar and related disorder due to another medical condition.

The recognition that many individuals, particularly children and, to a lesser extent, ad-
olescents, experience bipolar-like phenomena that do not meet the criteria for bipolar I, bi-
polar II, or cyclothymic disorder is reflected in the availability of the other specified
bipolar and related disorder category. Indeed, specific criteria for a disorder involving
short-duration hypomania are provided in Section III in the hope of encouraging further
study of this disorder.

Bipolar I Disorder
Diagnostic Criteria

For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic
episode. The manic episode may have been preceded by and may be followed by hypo-
manic or major depressive episodes.

124 Bipolar and Related Disorders

Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood

and abnormally and persistently increased goal-directed activity or energy, lasting at
least 1 week and present most of the day, nearly every day (or any duration if hospi-
talization is necessary).

B. During the period of mood disturbance and increased energy or activity, three (or
more) of the following symptoms (four if the mood is only irritable) are present to a sig-
nificant degree and represent a noticeable change from usual behavior:

1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external

stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or

psychomotor agitation (i.e., purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful conse-

quences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments).

C. The mood disturbance is sufficiently severe to cause marked impairment in social or
occupational functioning or to necessitate hospitalization to prevent harm to self or oth-
ers, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication, other treatment) or to another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medi-
cation, electroconvulsive therapy) but persists at a fully syndromal level beyond the
physiological effect of that treatment is sufficient evidence for a manic episode and,
therefore, a bipolar I diagnosis.

Note: Criteria A–D constitute a manic episode. At least one lifetime manic episode is re-
quired for the diagnosis of bipolar I disorder.

Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood

and abnormally and persistently increased activity or energy, lasting at least 4 consec-
utive days and present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy and activity, three (or
more) of the following symptoms (four if the mood is only irritable) have persisted, rep-
resent a noticeable change from usual behavior, and have been present to a significant
degree:

1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external

stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or

psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful conse-

quences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments).

Bipolar I Disorder 125

C. The episode is associated with an unequivocal change in functioning that is uncharac-
teristic of the individual when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupa-

tional functioning or to necessitate hospitalization. If there are psychotic features, the
episode is, by definition, manic.

F. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication, other treatment).
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level beyond
the physiological effect of that treatment is sufficient evidence for a hypomanic episode
diagnosis. However, caution is indicated so that one or two symptoms (particularly in-
creased irritability, edginess, or agitation following antidepressant use) are not taken
as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bi-
polar diathesis.

Note: Criteria A–F constitute a hypomanic episode. Hypomanic episodes are common in
bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2-week

period and represent a change from previous functioning; at least one of the symptoms
is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condi-
tion.

1. Depressed mood most of the day, nearly every day, as indicated by either subjec-
tive report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g.,
appears tearful). (Note: In children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the
day, nearly every day (as indicated by either subjective account or observation).

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 gain.)

4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others; not

merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delu-

sional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei-

ther by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with-

out a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or another
medical condition.

Note: Criteria A–C constitute a major depressive episode. Major depressive episodes are
common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a
natural disaster, a serious medical illness or disability) may include the feelings of intense

126 Bipolar and Related Disorders

sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Cri-
terion A, which may resemble a depressive episode. Although such symptoms may be un-
derstandable or considered appropriate to the loss, the presence of a major depressive
episode in addition to the normal response to a significant loss should also be carefully
considered. This decision inevitably requires the exercise of clinical judgment based on
the individual’s history and the cultural norms for the expression of distress in the context
of loss.1

Bipolar I Disorder
A. Criteria have been met for at least one manic episode (Criteria A–D under “Manic Ep-

isode” above).
B. The occurrence of the manic and major depressive episode(s) is not better explained

by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional dis-
order, or other specified or unspecified schizophrenia spectrum and other psychotic
disorder.

Coding and Recording Procedures
The diagnostic code for bipolar I disorder is based on type of current or most recent epi-
sode and its status with respect to current severity, presence of psychotic features, and
remission status. Current severity and psychotic features are only indicated if full criteria
are currently met for a manic or major depressive episode. Remission specifiers are only
indicated if the full criteria are not currently met for a manic, hypomanic, or major depres-
sive episode. Codes are as follows:

1 In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in
grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent
depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is
likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of
grief. These waves tend to be associated with thoughts or reminders of the deceased. The
depressed mood of a MDE is more persistent and not tied to specific thoughts or preoccupations.
The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic
of the pervasive unhappiness and misery characteristic of a major depressive episode. The
thought content associated with grief generally features a preoccupation with thoughts and
memories of the deceased, rather than the self-critical or pessimistic ruminations seen in a MDE.
In grief, self-esteem is generally preserved, whereas in a MDE, feelings of worthlessness and self-
loathing are common. If self-derogatory ideation is present in grief, it typically involves per-
ceived failings vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the
deceased how much he or she was loved). If a bereaved individual thinks about death and dying,
such thoughts are generally focused on the deceased and possibly about “joining” the deceased,
whereas in a major depressive episode such thoughts are focused on ending one’s own life
because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.

Bipolar I disorder

Current or
most recent

episode
manic

Current or
most recent

episode
hypomanic*

Current or
most recent

episode
depressed

Current or
most recent

episode
unspecified**

Mild (p. 154) 296.41
(F31.11)

NA 296.51
(F31.31)

NA

Moderate (p. 154) 296.42
(F31.12)

NA 296.52
(F31.32)

NA

Severe (p. 154) 296.43
(F31.13)

NA 296.53
(F31.4)

NA

Bipolar I Disorder 127

In recording the name of a diagnosis, terms should be listed in the following order: bipolar
I disorder, type of current or most recent episode, severity/psychotic/remission specifiers,
followed by as many specifiers without codes as apply to the current or most recent epi-
sode.

Specify:
With anxious distress (p. 149)
With mixed features (pp. 149–150)
With rapid cycling (pp. 150–151)
With melancholic features (p. 151)
With atypical features (pp. 151–152)
With mood-congruent psychotic features (p. 152)
With mood-incongruent psychotic features (p. 152)
With catatonia (p. 152). Coding note: Use additional code 293.89 (F06.1).
With peripartum onset (pp. 152–153)
With seasonal pattern (pp. 153–154)

Diagnostic Features
The essential feature of a manic episode is a distinct period during which there is an ab-
normally, persistently elevated, expansive, or irritable mood and persistently increased
activity or energy that is present for most of the day, nearly every day, for a period of at
least 1 week (or any duration if hospitalization is necessary), accompanied by at least three
additional symptoms from Criterion B. If the mood is irritable rather than elevated or ex-
pansive, at least four Criterion B symptoms must be present.

Mood in a manic episode is often described as euphoric, excessively cheerful, high, or
“feeling on top of the world.” In some cases, the mood is of such a highly infectious quality
that it is easily recognized as excessive and may be characterized by unlimited and hap-
hazard enthusiasm for interpersonal, sexual, or occupational interactions. For example,
the individual may spontaneously start extensive conversations with strangers in public.
Often the predominant mood is irritable rather than elevated, particularly when the indi-
vidual’s wishes are denied or if the individual has been using substances. Rapid shifts in
mood over brief periods of time may occur and are referred to as lability (i.e., the alterna-

With psychotic
features***
(p. 152)

296.44
(F31.2)

NA 296.54
(F31.5)

NA

In partial
remission (p. 154)

296.45
(F31.73)

296.45
(F31.71)

296.55
(F31.75)

NA

In full remission
(p. 154)

296.46
(F31.74)

296.46
(F31.72)

296.56
(F31.76)

NA

Unspecified 296.40
(F31.9)

296.40
(F31.9)

296.50
(F31.9)

NA

*Severity and psychotic specifiers do not apply; code 296.40 (F31.0) for cases not in remission.
**Severity, psychotic, and remission specifiers do not apply. Code 296.7 (F31.9).
***If psychotic features are present, code the “with psychotic features” specifier irrespective of epi-
sode severity.

Bipolar I disorder

Current or
most recent

episode
manic

Current or
most recent

episode
hypomanic*

Current or
most recent

episode
depressed

Current or
most recent

episode
unspecified**

128 Bipolar and Related Disorders

tion among euphoria, dysphoria, and irritability). In children, happiness, silliness and
“goofiness” are normal in the context of special occasions; however, if these symptoms are
recurrent, inappropriate to the context, and beyond what is expected for the developmen-
tal level of the child, they may meet Criterion A. If the happiness is unusual for a child (i.e.,
distinct from baseline), and the mood change occurs at the same time as symptoms that
meet Criterion B for mania, diagnostic certainty is increased; however, the mood change
must be accompanied by persistently increased activity or energy levels that are obvious
to those who know the child well.

During the manic episode, the individual may engage in multiple overlapping new
projects. The projects are often initiated with little knowledge of the topic, and nothing seems
out of the individual’s reach. The increased activity levels may manifest at unusual hours of
the day.

Inflated self-esteem is typically present, ranging from uncritical self-confidence to marked
grandiosity, and may reach delusional proportions (Criterion B1). Despite lack of any partic-
ular experience or talent, the individual may embark on complex tasks such as writing a novel
or seeking publicity for some impractical invention. Grandiose delusions (e.g., of having a
special relationship to a famous person) are common. In children, overestimation of abilities
and belief that, for example, they are the best at a sport or the smartest in the class is normal;
however, when such beliefs are present despite clear evidence to the contrary or the child at-
tempts feats that are clearly dangerous and, most important, represent a change from the
child’s normal behavior, the grandiosity criterion should be considered satisfied.

One of the most common features is a decreased need for sleep (Criterion B2) and is
distinct from insomnia in which the individual wants to sleep or feels the need to sleep but
is unable. The individual may sleep little, if at all, or may awaken several hours earlier than
usual, feeling rested and full of energy. When the sleep disturbance is severe, the individ-
ual may go for days without sleep, yet not feel tired. Often a decreased need for sleep her-
alds the onset of a manic episode.

Speech can be rapid, pressured, loud, and difficult to interrupt (Criterion B3). Individ-
uals may talk continuously and without regard for others’ wishes to communicate, often
in an intrusive manner or without concern for the relevance of what is said. Speech is
sometimes characterized by jokes, puns, amusing irrelevancies, and theatricality, with
dramatic mannerisms, singing, and excessive gesturing. Loudness and forcefulness of
speech often become more important than what is conveyed. If the individual’s mood is
more irritable than expansive, speech may be marked by complaints, hostile comments, or
angry tirades, particularly if attempts are made to interrupt the individual. Both Criterion
A and Criterion B symptoms may be accompanied by symptoms of the opposite (i.e., de-
pressive) pole (see “with mixed features” specifier, pp. 149–150).

Often the individual’s thoughts race at a rate faster than they can be expressed through
speech (Criterion B4). Frequently there is flight of ideas evidenced by a nearly continuous flow
of accelerated speech, with abrupt shifts from one topic to another. When flight of ideas is se-
vere, speech may become disorganized, incoherent, and particularly distressful to the individ-
ual. Sometimes thoughts are experienced as so crowded that it is very difficult to speak.

Distractibility (Criterion B5) is evidenced by an inability to censor immaterial external
stimuli (e.g., the interviewer’s attire, background noises or conversations, furnishings in
the room) and often prevents individuals experiencing mania from holding a rational con-
versation or attending to instructions.

The increase in goal-directed activity often consists of excessive planning and partici-
pation in multiple activities, including sexual, occupational, political, or religious activi-
ties. Increased sexual drive, fantasies, and behavior are often present. Individuals in a manic
episode usually show increased sociability (e.g., renewing old acquaintances or calling or
contacting friends or even strangers), without regard to the intrusive, domineering, and
demanding nature of these interactions. They often display psychomotor agitation or rest-
lessness (i.e., purposeless activity) by pacing or by holding multiple conversations simulta-

Bipolar I Disorder 129

neously. Some individuals write excessive letters, e-mails, text messages, and so forth, on
many different topics to friends, public figures, or the media.

The increased activity criterion can be difficult to ascertain in children; however, when
the child takes on many tasks simultaneously, starts devising elaborate and unrealistic
plans for projects, develops previously absent and developmentally inappropriate sexual
preoccupations (not accounted for by sexual abuse or exposure to sexually explicit mate-
rial), then Criterion B might be met based on clinical judgment. It is essential to determine
whether the behavior represents a change from the child’s baseline behavior; occurs most
of the day, nearly every day for the requisite time period; and occurs in temporal associa-
tion with other symptoms of mania.

The expansive mood, excessive optimism, grandiosity, and poor judgment often lead
to reckless involvement in activities such as spending sprees, giving away possessions,
reckless driving, foolish business investments, and sexual promiscuity that is unusual for
the individual, even though these activities are likely to have catastrophic consequences
(Criterion B7). The individual may purchase many unneeded items without the money to
pay for them and, in some cases, give them away. Sexual behavior may include infidelity
or indiscriminate sexual encounters with strangers, often disregarding the risk of sexually
transmitted diseases or interpersonal consequences.

The manic episode must result in marked impairment in social or occupational func-
tioning or require hospitalization to prevent harm to self or others (e.g., financial losses, il-
legal activities, loss of employment, self-injurious behavior). By definition, the presence of
psychotic features during a manic episode also satisfies Criterion C.

Manic symptoms or syndromes that are attributable to the physiological effects of a
drug of abuse (e.g., in the context of cocaine or amphetamine intoxication), the side effects
of medications or treatments (e.g., steroids, L-dopa, antidepressants, stimulants), or an-
other medical condition do not count toward the diagnosis of bipolar I disorder. However,
a fully syndromal manic episode that arises during treatment (e.g., with medications, elec-
troconvulsive therapy, light therapy) or drug use and persists beyond the physiological ef-
fect of the inducing agent (i.e., after a medication is fully out of the individual’s system or
the effects of electroconvulsive therapy would be expected to have dissipated completely)
is sufficient evidence for a manic episode diagnosis (Criterion D). Caution is indicated so
that one or two symptoms (particularly increased irritability, edginess, or agitation follow-
ing antidepressant use) are not taken as sufficient for diagnosis of a manic or hypomanic
episode, nor necessarily an indication of a bipolar disorder diathesis. It is necessary to
meet criteria for a manic episode to make a diagnosis of bipolar I disorder, but it is not re-
quired to have hypomanic or major depressive episodes. However, they may precede or
follow a manic episode. Full descriptions of the diagnostic features of a hypomanic epi-
sode may be found within the text for bipolar II disorder, and the features of a major de-
pressive episode are described within the text for major depressive disorder.

Associated Features Supporting Diagnosis
During a manic episode, individuals often do not perceive that they are ill or in need of treat-
ment and vehemently resist efforts to be treated. Individuals may change their dress, makeup,
or personal appearance to a more sexually suggestive or flamboyant style. Some perceive a
sharper sense of smell, hearing, or vision. Gambling and antisocial behaviors may accompany
the manic episode. Some individuals may become hostile and physically threatening to others
and, when delusional, may become physically assaultive or suicidal. Catastrophic conse-
quences of a manic episode (e.g., involuntary hospitalization, difficulties with the law, serious
financial difficulties) often result from poor judgment, loss of insight, and hyperactivity.

Mood may shift very rapidly to anger or depression. Depressive symptoms may occur
during a manic episode and, if present, may last moments, hours, or, more rarely, days (see
“with mixed features” specifier, pp. 149–150).

130 Bipolar and Related Disorders

Prevalence
The 12-month prevalence estimate in the continental United States was 0.6% for bipolar I
disorder as defined in DSM-IV. Twelve-month prevalence of bipolar I disorder across 11
countries ranged from 0.0% to 0.6%. The lifetime male-to-female prevalence ratio is ap-
proximately 1.1:1.

Development and Course
Mean age at onset of the first manic, hypomanic, or major depressive episode is approxi-
mately 18 years for bipolar I disorder. Special considerations are necessary to detect the di-
agnosis in children. Since children of the same chronological age may be at different
developmental stages, it is difficult to define with precision what is “normal” or “ex-
pected” at any given point. Therefore, each child should be judged according to his or her
own baseline. Onset occurs throughout the life cycle, including first onsets in the 60s or
70s. Onset of manic symptoms (e.g., sexual or social disinhibition) in late mid-life or late-
life should prompt consideration of medical conditions (e.g., frontotemporal neurocogni-
tive disorder) and of substance ingestion or withdrawal.

More than 90% of individuals who have a single manic episode go on to have recurrent
mood episodes. Approximately 60% of manic episodes occur immediately before a major
depressive episode. Individuals with bipolar I disorder who have multiple (four or more)
mood episodes (major depressive, manic, or hypomanic) within 1 year receive the speci-
fier “with rapid cycling.”

Risk and Prognostic Factors
Environmental. Bipolar disorder is more common in high-income than in low-income
countries (1.4 vs. 0.7%). Separated, divorced, or widowed individuals have higher rates of
bipolar I disorder than do individuals who are married or have never been married, but
the direction of the association is unclear.

Genetic and physiological. A family history of bipolar disorder is one of the strongest and
most consistent risk factors for bipolar disorders. There is an average 10-fold increased risk
among adult relatives of individuals with bipolar I and bipolar II disorders. Magnitude of
risk increases with degree of kinship. Schizophrenia and bipolar disorder likely share a ge-
netic origin, reflected in familial co-aggregation of schizophrenia and bipolar disorder.

Course modifiers. After an individual has a manic episode with psychotic features, subse-
quent manic episodes are more likely to include psychotic features. Incomplete inter-
episode recovery is more common when the current episode is accompanied by mood-
incongruent psychotic features.

Culture-Related Diagnostic Issues
Little information exists on specific cultural differences in the expression of bipolar I dis-
order. One possible explanation for this may be that diagnostic instruments are often
translated and applied in different cultures with no transcultural validation. In one U.S.
study, 12-month prevalence of bipolar I disorder was significantly lower for Afro-Carib-
beans than for African Americans or whites.

Gender-Related Diagnostic Issues
Females are more likely to experience rapid cycling and mixed states, and to have patterns of
comorbidity that differ from those of males, including higher rates of lifetime eating disor-
ders. Females with bipolar I or II disorder are more likely to experience depressive symptoms
than males. They also have a higher lifetime risk of alcohol use disorder than are males and a
much greater likelihood of alcohol use disorder than do females in the general population.

Bipolar I Disorder 131

Suicide Risk
The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least
15 times that of the general population. In fact, bipolar disorder may account for one-quar-
ter of all completed suicides. A past history of suicide attempt and percent days spent de-
pressed in the past year are associated with greater risk of suicide attempts or completions.

Functional Consequences of Bipolar I Disorder
Although many individuals with bipolar disorder return to a fully functional level be-
tween episodes, approximately 30% show severe impairment in work role function. Func-
tional recovery lags substantially behind recovery from symptoms, especially with respect
to occupational recovery, resulting in lower socioeconomic status despite equivalent lev-
els of education when compared with the general population. Individuals with bipolar I
disorder perform more poorly than healthy individuals on cognitive tests. Cognitive im-
pairments may contribute to vocational and interpersonal difficulties and persist through
the lifespan, even during euthymic periods.

Differential Diagnosis
Major depressive disorder. Major depressive disorder may also be accompanied by hy-
pomanic or manic symptoms (i.e., fewer symptoms or for a shorter duration than required
for mania or hypomania). When the individual presents in an episode of major depression,
one must depend on corroborating history regarding past episodes of mania or hypoma-
nia. Symptoms of irritability may be associated with either major depressive disorder or
bipolar disorder, adding to diagnostic complexity.

Other bipolar disorders. Diagnosis of bipolar I disorder is differentiated from bipolar II
disorder by determining whether there have been any past episodes of mania. Other spec-
ified and unspecified bipolar and related disorders should be differentiated from bipolar I
and II disorders by considering whether either the episodes involving manic or hypo-
manic symptoms or the episodes of depressive symptoms fail to meet the full criteria for
those conditions.

Bipolar disorder due to another medical condition may be distinguished from bipolar
I and II disorders by identifying, based on best clinical evidence, a causally related medical
condition.

Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or other
anxiety disorders. These disorders need to be considered in the differential diagnosis as
either the primary disorder or, in some cases, a comorbid disorder. A careful history of
symptoms is needed to differentiate generalized anxiety disorder from bipolar disorder,
as anxious ruminations may be mistaken for racing thoughts, and efforts to minimize anx-
ious feelings may be taken as impulsive behavior. Similarly, symptoms of posttraumatic
stress disorder need to be differentiated from bipolar disorder. It is helpful to assess the ep-
isodic nature of the symptoms described, as well as to consider symptom triggers, in mak-
ing this differential diagnosis.

Substance/medication-induced bipolar disorder. Substance use disorders may mani-
fest with substance.medication-induced manic symptoms that must be distinguished
from bipolar I disorder; response to mood stabilizers during a substance/medication-
induced mania may not necessarily be diagnostic for bipolar disorder. There may be sub-
stantial overlap in view of the tendency for individuals with bipolar I disorder to overuse
substances during an episode. A primary diagnosis of bipolar disorder must be estab-
lished based on symptoms that remain once substances are no longer being used.

Attention-deficit/hyperactivity disorder. This disorder may be misdiagnosed as bipolar
disorder, especially in adolescents and children. Many symptoms overlap with the symp-

132 Bipolar and Related Disorders

toms of mania, such as rapid speech, racing thoughts, distractibility, and less need for
sleep. The “double counting” of symptoms toward both ADHD and bipolar disorder can
be avoided if the clinician clarifies whether the symptom(s) represents a distinct episode.

Personality disorders. Personality disorders such as borderline personality disorder
may have substantial symptomatic overlap with bipolar disorders, since mood lability
and impulsivity are common in both conditions. Symptoms must represent a distinct ep-
isode, and the noticeable increase over baseline required for the diagnosis of bipolar dis-
order must be present. A diagnosis of a personality disorder should not be made during an
untreated mood episode.

Disorders with prominent irritability. In individuals with severe irritability, particularly
children and adolescents, care must be taken to apply the diagnosis of bipolar disorder
only to those who have had a clear episode of mania or hypomania—that is, a distinct time
period, of the required duration, during which the irritability was clearly different from
the individual’s baseline and was accompanied by the onset of Criterion B symptoms.
When a child’s irritability is persistent and particularly severe, the diagnosis of disruptive
mood dysregulation disorder would be more appropriate. Indeed, when any child is being
assessed for mania, it is essential that the symptoms represent a clear change from the
child’s typical behavior.

Comorbidity
Co-occurring mental disorders are common, with the most frequent disorders being any
anxiety disorder (e.g., panic attacks, social anxiety disorder [social phobia], specific pho-
bia), occurring in approximately three-fourths of individuals; ADHD, any disruptive, im-
pulse-control, or conduct disorder (e.g., intermittent explosive disorder, oppositional
defiant disorder, conduct disorder), and any substance use disorder (e.g., alcohol use dis-
order) occur in over half of individuals with bipolar I disorder. Adults with bipolar I dis-
order have high rates of serious and/or untreated co-occurring medical conditions.
Metabolic syndrome and migraine are more common among individuals with bipolar dis-
order than in the general population. More than half of individuals whose symptoms meet
criteria for bipolar disorder have an alcohol use disorder, and those with both disorders
are at greater risk for suicide attempt.

Bipolar II Disorder
Diagnostic Criteria 296.89 (F31.81)

For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a cur-
rent or past hypomanic episode and the following criteria for a current or past major de-
pressive episode:

Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood

and abnormally and persistently increased activity or energy, lasting at least 4 consec-
utive days and present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy and activity, three (or more)
of the following symptoms have persisted (four if the mood is only irritable), represent a no-
ticeable change from usual behavior, and have been present to a significant degree:

1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.

Bipolar II Disorder 133

4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external

stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or

psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful conse-

quences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments).

C. The episode is associated with an unequivocal change in functioning that is uncharac-
teristic of the individual when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupa-

tional functioning or to necessitate hospitalization. If there are psychotic features, the
episode is, by definition, manic.

F. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication or other treatment).
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level beyond
the physiological effect of that treatment is sufficient evidence for a hypomanic episode
diagnosis. However, caution is indicated so that one or two symptoms (particularly in-
creased irritability, edginess, or agitation following antidepressant use) are not taken
as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bi-
polar diathesis.

Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2-week

period and represent a change from previous functioning; at least one of the symptoms
is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to a medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjec-
tive report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g.,
appears tearful). (Note: In children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the
day, nearly every day (as indicated by either subjective account or observation).

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 gain.)

4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others; not

merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delu-

sional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei-

ther by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with-

out a specific plan, a suicide attempt, or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or another
medical condition.

134 Bipolar and Related Disorders

Note: Criteria A–C above constitute a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a nat-
ural disaster, a serious medical illness or disability) may include the feelings of intense sad-
ness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion
A, which may resemble a depressive episode. Although such symptoms may be under-
standable or considered appropriate to the loss, the presence of a major depressive episode
in addition to the normal response to a significant loss should be carefully considered. This
decision inevitably requires the exercise of clinical judgment based on the individual’s history
and the cultural norms for the expression of distress in the context of loss.1

Bipolar II Disorder
A. Criteria have been met for at least one hypomanic episode (Criteria A–F under “Hypo-

manic Episode” above) and at least one major depressive episode (Criteria A–C under
“Major Depressive Episode” above).

B. There has never been a manic episode.
C. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not

better explained by schizoaffective disorder, schizophrenia, schizophreniform disor-
der, delusional disorder, or other specified or unspecified schizophrenia spectrum and
other psychotic disorder.

D. The symptoms of depression or the unpredictability caused by frequent alternation be-
tween periods of depression and hypomania causes clinically significant distress or im-
pairment in social, occupational, or other important areas of functioning.

Coding and Recording Procedures
Bipolar II disorder has one diagnostic code: 296.89 (F31.81). Its status with respect to cur-
rent severity, presence of psychotic features, course, and other specifiers cannot be
coded but should be indicated in writing (e.g., 296.89 [F31.81] bipolar II disorder, current
episode depressed, moderate severity, with mixed features; 296.89 [F31.81] bipolar II dis-
order, most recent episode depressed, in partial remission).

Specify current or most recent episode:
Hypomanic
Depressed

Specify if:
With anxious distress (p. 149)
With mixed features (pp. 149–150)

1 In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief
the predominant affect is feelings of emptiness and loss, while in a MDE it is persistent depressed
mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to
decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These
waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of a
MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may
be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhap-
piness and misery characteristic of a MDE. The thought content associated with grief generally fea-
tures a preoccupation with thoughts and memories of the deceased, rather than the self-critical or
pessimistic ruminations seen in a MDE. In grief, self-esteem is generally preserved, whereas in a
MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present
in grief, it typically involves perceived failings vis-à-vis the deceased (e.g., not visiting frequently
enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks
about death and dying, such thoughts are generally focused on the deceased and possibly about
“’joining” the deceased, whereas in a MDE such thoughts are focused on ending one’s own life
because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.

Bipolar II Disorder 135

With rapid cycling (pp. 150–151)
With mood-congruent psychotic features (p. 152)
With mood-incongruent psychotic features (p. 152)
With catatonia (p. 152). Coding note: Use additional code 293.89 (F06.1).
With peripartum onset (pp. 152–153)
With seasonal pattern (pp. 153–154): Applies only to the pattern of major depressive
episodes.

Specify course if full criteria for a mood episode are not currently met:
In partial remission (p. 154)
In full remission (p. 154)

Specify severity if full criteria for a mood episode are currently met:
Mild (p. 154)
Moderate (p. 154)
Severe (p. 154)

Diagnostic Features
Bipolar II disorder is characterized by a clinical course of recurring mood episodes con-
sisting of one or more major depressive episodes (Criteria A–C under “Major Depressive
Episode”) and at least one hypomanic episode (Criteria A–F under “Hypomanic Epi-
sode”). The major depressive episode must last at least 2 weeks, and the hypomanic epi-
sode must last at least 4 days, to meet the diagnostic criteria. During the mood episode(s),
the requisite number of symptoms must be present most of the day, nearly every day, and
represent a noticeable change from usual behavior and functioning. The presence of a
manic episode during the course of illness precludes the diagnosis of bipolar II disorder
(Criterion B under “Bipolar II Disorder”). Episodes of substance/medication-induced de-
pressive disorder or substance/medication-induced bipolar and related disorder (repre-
senting the physiological effects of a medication, other somatic treatments for depression,
drugs of abuse, or toxin exposure) or of depressive and related disorder due to another
medical condition or bipolar and related disorder due to another medical condition do not
count toward a diagnosis of bipolar II disorder unless they persist beyond the physiolog-
ical effects of the treatment or substance and then meet duration criteria for an episode. In
addition, the episodes must not be better accounted for by schizoaffective disorder and are
not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or
other specified or unspecified schizophrenia spectrum or other psychotic disorders (Cri-
terion C under “Bipolar II Disorder”). The depressive episodes or hypomanic fluctuations
must cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning (Criterion D under “Bipolar II Disorder”); however, for hy-
pomanic episodes, this requirement does not have to be met. A hypomanic episode that
causes significant impairment would likely qualify for the diagnosis of manic episode and,
therefore, for a lifetime diagnosis of bipolar I disorder. The recurrent major depressive ep-
isodes are often more frequent and lengthier than those occurring in bipolar I disorder.

Individuals with bipolar II disorder typically present to a clinician during a major de-
pressive episode and are unlikely to complain initially of hypomania. Typically, the hy-
pomanic episodes themselves do not cause impairment. Instead, the impairment results
from the major depressive episodes or from a persistent pattern of unpredictable mood
changes and fluctuating, unreliable interpersonal or occupational functioning. Individu-
als with bipolar II disorder may not view the hypomanic episodes as pathological or dis-
advantageous, although others may be troubled by the individual’s erratic behavior.
Clinical information from other informants, such as close friends or relatives, is often use-
ful in establishing the diagnosis of bipolar II disorder.

136 Bipolar and Related Disorders

A hypomanic episode should not be confused with the several days of euthymia and re-
stored energy or activity that may follow remission of a major depressive episode. Despite the
substantial differences in duration and severity between a manic and hypomanic episode, bi-
polar II disorder is not a “milder form” of bipolar I disorder. Compared with individuals with
bipolar I disorder, individuals with bipolar II disorder have greater chronicity of illness and
spend, on average, more time in the depressive phase of their illness, which can be severe and/
or disabling. Depressive symptoms co-occurring with a hypomanic episode or hypomanic
symptoms co-occurring with a depressive episode are common in individuals with bipolar II
disorder and are overrepresented in females, particularly hypomania with mixed features. In-
dividuals experiencing hypomania with mixed features may not label their symptoms as hy-
pomania, but instead experience them as depression with increased energy or irritability.

Associated Features Supporting Diagnosis
A common feature of bipolar II disorder is impulsivity, which can contribute to suicide at-
tempts and substance use disorders. Impulsivity may also stem from a concurrent person-
ality disorder, substance use disorder, anxiety disorder, another mental disorder, or a
medical condition. There may be heightened levels of creativity in some individuals with
a bipolar disorder. However, that relationship may be nonlinear; that is, greater lifetime
creative accomplishments have been associated with milder forms of bipolar disorder, and
higher creativity has been found in unaffected family members. The individual’s attach-
ment to heightened creativity during hypomanic episodes may contribute to ambivalence
about seeking treatment or undermine adherence to treatment.

Prevalence
The 12-month prevalence of bipolar II disorder, internationally, is 0.3%. In the United
States, 12-month prevalence is 0.8%. The prevalence rate of pediatric bipolar II disorder is
difficult to establish. DSM-IV bipolar I, bipolar II, and bipolar disorder not otherwise spec-
ified yield a combined prevalence rate of 1.8% in U.S. and non-U.S. community samples,
with higher rates (2.7% inclusive) in youths age 12 years or older.

Development and Course
Although bipolar II disorder can begin in late adolescence and throughout adulthood, av-
erage age at onset is the mid-20s, which is slightly later than for bipolar I disorder but ear-
lier than for major depressive disorder. The illness most often begins with a depressive
episode and is not recognized as bipolar II disorder until a hypomanic episode occurs; this
happens in about 12% of individuals with the initial diagnosis of major depressive disor-
der. Anxiety, substance use, or eating disorders may also precede the diagnosis, compli-
cating its detection. Many individuals experience several episodes of major depression
prior to the first recognized hypomanic episode.

The number of lifetime episodes (both hypomanic and major depressive episodes)
tends to be higher for bipolar II disorder than for major depressive disorder or bipolar I
disorder. However, individuals with bipolar I disorder are actually more likely to experi-
ence hypomanic symptoms than are individuals with bipolar II disorder.The interval
between mood episodes in the course of bipolar II disorder tends to decrease as the indi-
vidual ages. While the hypomanic episode is the feature that defines bipolar II disorder,
depressive episodes are more enduring and disabling over time. Despite the predomi-
nance of depression, once a hypomanic episode has occurred, the diagnosis becomes bi-
polar II disorder and never reverts to major depressive disorder.

Approximately 5%–15% of individuals with bipolar II disorder have multiple (four or
more) mood episodes (hypomanic or major depressive) within the previous 12 months. If

Bipolar II Disorder 137

this pattern is present, it is noted by the specifier “with rapid cycling.” By definition, psy-
chotic symptoms do not occur in hypomanic episodes, and they appear to be less frequent
in the major depressive episodes in bipolar II disorder than in those of bipolar I disorder.

Switching from a depressive episode to a manic or hypomanic episode (with or with-
out mixed features) may occur, both spontaneously and during treatment for depression.
About 5%–15% of individuals with bipolar II disorder will ultimately develop a manic ep-
isode, which changes the diagnosis to bipolar I disorder, regardless of subsequent course.

Making the diagnosis in children is often a challenge, especially in those with irritabil-
ity and hyperarousal that is nonepisodic (i.e., lacks the well-demarcated periods of altered
mood). Nonepisodic irritability in youth is associated with an elevated risk for anxiety dis-
orders and major depressive disorder, but not bipolar disorder, in adulthood. Persistently
irritable youths have lower familial rates of bipolar disorder than do youths who have bi-
polar disorder. For a hypomanic episode to be diagnosed, the child’s symptoms must ex-
ceed what is expected in a given environment and culture for the child’s developmental
stage. Compared with adult onset of bipolar II disorder, childhood or adolescent onset of
the disorder may be associated with a more severe lifetime course. The 3-year incidence
rate of first-onset bipolar II disorder in adults older than 60 years is 0.34%. However, dis-
tinguishing individuals older than 60 years with bipolar II disorder by late versus early
age at onset does not appear to have any clinical utility.

Risk and Prognostic Factors
Genetic and physiological. The risk of bipolar II disorder tends to be highest among rel-
atives of individuals with bipolar II disorder, as opposed to individuals with bipolar I dis-
order or major depressive disorder. There may be genetic factors influencing the age at
onset for bipolar disorders.

Course modifiers. A rapid-cycling pattern is associated with a poorer prognosis. Return
to previous level of social function for individuals with bipolar II disorder is more likely
for individuals of younger age and with less severe depression, suggesting adverse effects
of prolonged illness on recovery. More education, fewer years of illness, and being mar-
ried are independently associated with functional recovery in individuals with bipolar
disorder, even after diagnostic type (I vs. II), current depressive symptoms, and presence
of psychiatric comorbidity are taken into account.

Gender-Related Diagnostic Issues
Whereas the gender ratio for bipolar I disorder is equal, findings on gender differences in
bipolar II disorder are mixed, differing by type of sample (i.e., registry, community, or
clinical) and country of origin. There is little to no evidence of bipolar gender differences,
whereas some, but not all, clinical samples suggest that bipolar II disorder is more com-
mon in females than in males, which may reflect gender differences in treatment seeking
or other factors.

Patterns of illness and comorbidity, however, seem to differ by gender, with females
being more likely than males to report hypomania with mixed depressive features and a
rapid-cycling course. Childbirth may be a specific trigger for a hypomanic episode, which
can occur in 10%–20% of females in nonclinical populations and most typically in the early
postpartum period. Distinguishing hypomania from the elated mood and reduced sleep
that normally accompany the birth of a child may be challenging. Postpartum hypomania
may foreshadow the onset of a depression that occurs in about half of females who expe-
rience postpartum “highs.” Accurate detection of bipolar II disorder may help in estab-
lishing appropriate treatment of the depression, which may reduce the risk of suicide and
infanticide.

138 Bipolar and Related Disorders

Suicide Risk
Suicide risk is high in bipolar II disorder. Approximately one-third of individuals with bi-
polar II disorder report a lifetime history of suicide attempt. The prevalence rates of life-
time attempted suicide in bipolar II and bipolar I disorder appear to be similar (32.4% and
36.3%, respectively). However, the lethality of attempts, as defined by a lower ratio of at-
tempts to completed suicides, may be higher in individuals with bipolar II disorder com-
pared with individuals with bipolar I disorder. There may be an association between
genetic markers and increased risk for suicidal behavior in individuals with bipolar dis-
order, including a 6.5-fold higher risk of suicide among first-degree relatives of bipolar II
probands compared with those with bipolar I disorder.

Functional Consequences of Bipolar II Disorder
Although many individuals with bipolar II disorder return to a fully functional level be-
tween mood episodes, at least 15% continue to have some inter-episode dysfunction, and
20% transition directly into another mood episode without inter-episode recovery. Func-
tional recovery lags substantially behind recovery from symptoms of bipolar II disorder,
especially in regard to occupational recovery, resulting in lower socioeconomic status de-
spite equivalent levels of education with the general population. Individuals with bipolar
II disorder perform more poorly than healthy individuals on cognitive tests and, with the
exception of memory and semantic fluency, have similar cognitive impairment as do in-
dividuals with bipolar I disorder. Cognitive impairments associated with bipolar II disor-
der may contribute to vocational difficulties. Prolonged unemployment in individuals
with bipolar disorder is associated with more episodes of depression, older age, increased
rates of current panic disorder, and lifetime history of alcohol use disorder.

Differential Diagnosis
Major depressive disorder. Perhaps the most challenging differential diagnosis to con-
sider is major depressive disorder, which may be accompanied by hypomanic or manic
symptoms that do not meet full criteria (i.e., either fewer symptoms or a shorter duration
than required for a hypomanic episode). This is especially true in evaluating individuals
with symptoms of irritability, which may be associated with either major depressive dis-
order or bipolar II disorder.

Cyclothymic disorder. In cyclothymic disorder, there are numerous periods of hypo-
manic symptoms and numerous periods of depressive symptoms that do not meet symp-
tom or duration criteria for a major depressive episode. Bipolar II disorder is distinguished
from cyclothymic disorder by the presence of one or more major depressive episodes. If a
major depressive episode occurs after the first 2 years of cyclothymic disorder, the addi-
tional diagnosis of bipolar II disorder is given.

Schizophrenia spectrum and other related psychotic disorders. Bipolar II disorder must
be distinguished from psychotic disorders (e.g., schizoaffective disorder, schizophrenia,
and delusional disorder). Schizophrenia, schizoaffective disorder, and delusional disor-
der are all characterized by periods of psychotic symptoms that occur in the absence of
prominent mood symptoms. Other helpful considerations include the accompanying
symptoms, previous course, and family history.

Panic disorder or other anxiety disorders. Anxiety disorders need to be considered in
the differential diagnosis and may frequently be present as co-occurring disorders.

Substance use disorders. Substance use disorders are included in the differential diag-
nosis.

Attention-deficit/hyperactivity disorder. Attention-deficit/hyperactivity disorder (ADHD)
may be misdiagnosed as bipolar II disorder, especially in adolescents and children. Many

Cyclothymic Disorder 139

symptoms of ADHD, such as rapid speech, racing thoughts, distractibility, and less need
for sleep, overlap with the symptoms of hypomania. The double counting of symptoms to-
ward both ADHD and bipolar II disorder can be avoided if the clinician clarifies whether
the symptoms represent a distinct episode and if the noticeable increase over baseline re-
quired for the diagnosis of bipolar II disorder is present.

Personality disorders. The same convention as applies for ADHD also applies when
evaluating an individual for a personality disorder such as borderline personality disor-
der, since mood lability and impulsivity are common in both personality disorders and bi-
polar II disorder. Symptoms must represent a distinct episode, and the noticeable increase
over baseline required for the diagnosis of bipolar II disorder must be present. A diagnosis
of a personality disorder should not be made during an untreated mood episode unless
the lifetime history supports the presence of a personality disorder.

Other bipolar disorders. Diagnosis of bipolar II disorder should be differentiated from
bipolar I disorder by carefully considering whether there have been any past episodes of
mania and from other specified and unspecified bipolar and related disorders by confirm-
ing the presence of fully syndromal hypomania and depression.

Comorbidity
Bipolar II disorder is more often than not associated with one or more co-occurring mental
disorders, with anxiety disorders being the most common. Approximately 60% of individ-
uals with bipolar II disorder have three or more co-occurring mental disorders; 75% have
an anxiety disorder; and 37% have a substance use disorder. Children and adolescents
with bipolar II disorder have a higher rate of co-occurring anxiety disorders compared
with those with bipolar I disorder, and the anxiety disorder most often predates the bi-
polar disorder. Anxiety and substance use disorders occur in individuals with bipolar II
disorder at a higher rate than in the general population. Approximately 14% of individuals
with bipolar II disorder have at least one lifetime eating disorder, with binge-eating dis-
order being more common than bulimia nervosa and anorexia nervosa.

These commonly co-occurring disorders do not seem to follow a course of illness that
is truly independent from that of the bipolar disorder, but rather have strong associations
with mood states. For example, anxiety and eating disorders tend to associate most with
depressive symptoms, and substance use disorders are moderately associated with manic
symptoms.

Cyclothymic Disorder
Diagnostic Criteria 301.13 (F34.0)

A. For at least 2 years (at least 1 year in children and adolescents) there have been nu-
merous periods with hypomanic symptoms that do not meet criteria for a hypomanic
episode and numerous periods with depressive symptoms that do not meet criteria for
a major depressive episode.

B. During the above 2-year period (1 year in children and adolescents), the hypomanic
and depressive periods have been present for at least half the time and the individual
has not been without the symptoms for more than 2 months at a time.

C. Criteria for a major depressive, manic, or hypomanic episode have never been met.
D. The symptoms in Criterion A are not better explained by schizoaffective disorder,

schizophrenia, schizophreniform disorder, delusional disorder, or other specified or un-
specified schizophrenia spectrum and other psychotic disorder.

E. The symptoms are not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

140 Bipolar and Related Disorders

F. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.

Specify if:
With anxious distress (see p. 149)

Diagnostic Features
The essential feature of cyclothymic disorder is a chronic, fluctuating mood disturbance
involving numerous periods of hypomanic symptoms and periods of depressive symp-
toms that are distinct from each other (Criterion A). The hypomanic symptoms are of
insufficient number, severity, pervasiveness, or duration to meet full criteria for a hypo-
manic episode, and the depressive symptoms are of insufficient number, severity, perva-
siveness, or duration to meet full criteria for a major depressive episode. During the initial
2-year period (1 year for children or adolescents), the symptoms must be persistent (pres-
ent more days than not), and any symptom-free intervals last no longer than 2 months
(Criterion B). The diagnosis of cyclothymic disorder is made only if the criteria for a major
depressive, manic, or hypomanic episode have never been met (Criterion C).

If an individual with cyclothymic disorder subsequently (i.e., after the initial 2 years in
adults or 1 year in children or adolescents) experiences a major depressive, manic, or hy-
pomanic episode, the diagnosis changes to major depressive disorder, bipolar I disorder,
or other specified or unspecified bipolar and related disorder (subclassified as hypomanic
episode without prior major depressive episode), respectively, and the cyclothymic disor-
der diagnosis is dropped.

The cyclothymic disorder diagnosis is not made if the pattern of mood swings is better
explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delu-
sional disorder, or other specified and unspecified schizophrenia spectrum and other
psychotic disorders (Criterion D), in which case the mood symptoms are considered asso-
ciated features of the psychotic disorder. The mood disturbance must also not be attribut-
able to the physiological effects of a substance (e.g., a drug of abuse, a medication) or
another medical condition (e.g., hyperthyroidism) (Criterion E). Although some individ-
uals may function particularly well during some of the periods of hypomania, over the
prolonged course of the disorder, there must be clinically significant distress or impair-
ment in social, occupational, or other important areas of functioning as a result of the
mood disturbance (Criterion F). The impairment may develop as a result of prolonged pe-
riods of cyclical, often unpredictable mood changes (e.g., the individual may be regarded
as temperamental, moody, unpredictable, inconsistent, or unreliable).

Prevalence
The lifetime prevalence of cyclothymic disorder is approximately 0.4%–1%. Prevalence in
mood disorders clinics may range from 3% to 5%. In the general population, cyclothymic
disorder is apparently equally common in males and females. In clinical settings, females
with cyclothymic disorder may be more likely to present for treatment than males.

Development and Course
Cyclothymic disorder usually begins in adolescence or early adult life and is sometimes
considered to reflect a temperamental predisposition to other disorders in this chapter.
Cyclothymic disorder usually has an insidious onset and a persistent course. There is a
15%–50% risk that an individual with cyclothymic disorder will subsequently develop bi-
polar I disorder or bipolar II disorder. Onset of persistent, fluctuating hypomanic and de-
pressive symptoms late in adult life needs to be clearly differentiated from bipolar and

Cyclothymic Disorder 141

related disorder due to another medical condition and depressive disorder due to another
medical condition (e.g., multiple sclerosis) before the cyclothymic disorder diagnosis is as-
signed. Among children with cyclothymic disorder, the mean age at onset of symptoms is
6.5 years of age.

Risk and Prognostic Factors
Genetic and physiological. Major depressive disorder, bipolar I disorder, and bipolar II
disorder are more common among first-degree biological relatives of individuals with cyclo-
thymic disorder than in the general population. There may also be an increased familial risk of
substance-related disorders. Cyclothymic disorder may be more common in the first-degree
biological relatives of individuals with bipolar I disorder than in the general population.

Differential Diagnosis
Bipolar and related disorder due to another medical condition and depressive disorder
due to another medical condition. The diagnosis of bipolar and related disorder due to
another medical condition or depressive disorder due to another medical condition is
made when the mood disturbance is judged to be attributable to the physiological effect of
a specific, usually chronic medical condition (e.g., hyperthyroidism). This determination
is based on the history, physical examination, or laboratory findings. If it is judged that the
hypomanic and depressive symptoms are not the physiological consequence of the med-
ical condition, then the primary mental disorder (i.e., cyclothymic disorder) and the med-
ical condition are coded. For example, this would be the case if the mood symptoms are
considered to be the psychological (not the physiological) consequence of having a chronic
medical condition, or if there is no etiological relationship between the hypomanic and de-
pressive symptoms and the medical condition.

Substance/medication-induced bipolar and related disorder and substance/medica-
tion-induced depressive disorder. Substance/medication-induced bipolar and related
disorder and substance/medication-induced depressive disorder are distinguished from
cyclothymic disorder by the judgment that a substance/medication (especially stimu-
lants) is etiologically related to the mood disturbance. The frequent mood swings in these
disorders that are suggestive of cyclothymic disorder usually resolve following cessation
of substance/medication use.

Bipolar I disorder, with rapid cycling, and bipolar II disorder, with rapid cycling.
Both disorders may resemble cyclothymic disorder by virtue of the frequent marked shifts
in mood. By definition, in cyclothymic disorder the criteria for a major depressive, manic,
or hypomanic episode has never been met, whereas the bipolar I disorder and bipolar II
disorder specifier “with rapid cycling” requires that full mood episodes be present.

Borderline personality disorder. Borderline personality disorder is associated with
marked shifts in mood that may suggest cyclothymic disorder. If the criteria are met for
both disorders, both borderline personality disorder and cyclothymic disorder may be di-
agnosed.

Comorbidity
Substance-related disorders and sleep disorders (i.e., difficulties in initiating and main-
taining sleep) may be present in individuals with cyclothymic disorder. Most children
with cyclothymic disorder treated in outpatient psychiatric settings have comorbid mental
conditions; they are more likely than other pediatric patients with mental disorders to
have comorbid attention-deficit/hyperactivity disorder.

142 Bipolar and Related Disorders

Substance/Medication-Induced
Bipolar and Related Disorder

Diagnostic Criteria

A. A prominent and persistent disturbance in mood that predominates in the clinical picture
and is characterized by elevated, expansive, or irritable mood, with or without depressed
mood, or markedly diminished interest or pleasure in all, or almost all, activities.

B. There is evidence from the history, physical examination, or laboratory findings of both
(1) and (2):

1. The symptoms in Criterion A developed during or soon after substance intoxication
or withdrawal or after exposure to a medication.

2. The involved substance/medication is capable of producing the symptoms in Crite-
rion A.

C. The disturbance is not better explained by a bipolar or related disorder that is not sub-
stance/medication-induced. Such evidence of an independent bipolar or related disor-
der could include the following:

The symptoms precede the onset of the substance/medication use; the symptoms per-
sist for a substantial period of time (e.g., about 1 month) after the cessation of acute
withdrawal or severe intoxication; or there is other evidence suggesting the existence
of an independent non-substance/medication-induced bipolar and related disorder
(e.g., a history of recurrent non-substance/medication-related episodes).

D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-

tional, or other important areas of functioning.

Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific substance/medication]-
induced bipolar and related disorders are indicated in the table below. Note that the ICD-10-
CM code depends on whether or not there is a comorbid substance use disorder present for
the same class of substance. If a mild substance use disorder is comorbid with the substance-
induced bipolar and related disorder, the 4th position character is “1,” and the clinician should
record “mild [substance] use disorder” before the substance-induced bipolar and related dis-
order (e.g., “mild cocaine use disorder with cocaine-induced bipolar and related disorder”). If a
moderate or severe substance use disorder is comorbid with the substance-induced bipolar
and related disorder, the 4th position character is “2,” and the clinician should record “moder-
ate [substance] use disorder” or “severe [substance] use disorder,” depending on the severity
of the comorbid substance use disorder. If there is no comorbid substance use disorder (e.g.,
after a one-time heavy use of the substance), then the 4th position character is “9,” and the
clinician should record only the substance-induced bipolar and related disorder.

ICD-10-CM

ICD-9-CM

With use
disorder,

mild

With use
disorder,
moderate
or severe

Without
use

disorder

Alcohol 291.89 F10.14 F10.24 F10.94

Phencyclidine 292.84 F16.14 F16.24 F16.94

Other hallucinogen 292.84 F16.14 F16.24 F16.94

Substance/Medication-Induced Bipolar and Related Disorder 143

Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for di-
agnoses associated with substance class):

With onset during intoxication: If the criteria are met for intoxication with the sub-
stance and the symptoms develop during intoxication.
With onset during withdrawal: If criteria are met for withdrawal from the substance
and the symptoms develop during, or shortly after, withdrawal.

Recording Procedures
ICD-9-CM. The name of the substance/medication-induced bipolar and related disor-
der begins with the specific substance (e.g., cocaine, dexamethasone) that is presumed to
be causing the bipolar mood symptoms. The diagnostic code is selected from the table in-
cluded in the criteria set, which is based on the drug class. For substances that do not fit
into any of the classes (e.g., dexamethasone), the code for “other substance” should be
used; and in cases in which a substance is judged to be an etiological factor but the specific
class of substance is unknown, the category “unknown substance” should be used.

The name of the disorder is followed by the specification of onset (i.e., onset during in-
toxication, onset during withdrawal). Unlike the recording procedures for ICD-10-CM,
which combine the substance-induced disorder and substance use disorder into a single
code, for ICD-9-CM a separate diagnostic code is given for the substance use disorder. For
example, in the case of irritable symptoms occurring during intoxication in a man with a
severe cocaine use disorder, the diagnosis is 292.84 cocaine-induced bipolar and related
disorder, with onset during intoxication. An additional diagnosis of 304.20 severe cocaine
use disorder is also given. When more than one substance is judged to play a significant
role in the development of bipolar mood symptoms, each should be listed separately (e.g.,
292.84 methylphenidate-induced bipolar and related disorder, with onset during intoxi-
cation; 292.84 dexamethasone-induced bipolar and related disorder, with onset during in-
toxication).

ICD-10-CM. The name of the substance/medication-induced bipolar and related disor-
der begins with the specific substance (e.g., cocaine, dexamethasone) that is presumed to
be causing the bipolar mood symptoms. The diagnostic code is selected from the table in-
cluded in the criteria set, which is based on the drug class and presence or absence of a co-
morbid substance use disorder. For substances that do not fit into any of the classes (e.g.,
dexamethasone), the code for “other substance” should be used; and in cases in which a
substance is judged to be an etiological factor but the specific class of substance is un-
known, the category “unknown substance” should be used.

When recording the name of the disorder, the comorbid substance use disorder (if any)
is listed first, followed by the word “with,” followed by the name of the substance-induced

Sedative, hypnotic, or anxiolytic 292.84 F13.14 F13.24 F13.94

Amphetamine (or other
stimulant)

292.84 F15.14 F15.24 F15.94

Cocaine 292.84 F14.14 F14.24 F14.94

Other (or unknown) substance 292.84 F19.14 F19.24 F19.94

ICD-10-CM

ICD-9-CM

With use
disorder,

mild

With use
disorder,
moderate
or severe

Without
use

disorder

144 Bipolar and Related Disorders

bipolar and related disorder, followed by the specification of onset (i.e., onset during in-
toxication, onset during withdrawal). For example, in the case of irritable symptoms oc-
curring during intoxication in a man with a severe cocaine use disorder, the diagnosis is
F14.24 severe cocaine use disorder with cocaine-induced bipolar and related disorder,
with onset during intoxication. A separate diagnosis of the comorbid severe cocaine use
disorder is not given. If the substance-induced bipolar and related disorder occurs without
a comorbid substance use disorder (e.g., after a one-time heavy use of the substance), no
accompanying substance use disorder is noted (e.g., F15.94 amphetamine-induced bipolar
and related disorder, with onset during intoxication). When more than one substance is
judged to play a significant role in the development of bipolar mood symptoms, each
should be listed separately (e.g., F15.24 severe methylphenidate use disorder with meth-
ylphenidate-induced bipolar and related disorder, with onset during intoxication; F19.94
dexamethasone-induced bipolar and related disorder, with onset during intoxication).

Diagnostic Features
The diagnostic features of substance/medication-induced bipolar and related disorder are es-
sentially the same as those for mania, hypomania, or depression. A key exception to the diag-
nosis of substance/medication-induced bipolar and related disorder is the case of hypomania
or mania that occurs after antidepressant medication use or other treatments and persists be-
yond the physiological effects of the medication. This condition is considered an indicator of
true bipolar disorder, not substance/medication-induced bipolar and related disorder. Simi-
larly, individuals with apparent electroconvulsive therapy–induced manic or hypomanic ep-
isodes that persist beyond the physiological effects of the treatment are diagnosed with
bipolar disorder, not substance/medication-induced bipolar and related disorder.

Side effects of some antidepressants and other psychotropic drugs (e.g., edginess, ag-
itation) may resemble the primary symptoms of a manic syndrome, but they are funda-
mentally distinct from bipolar symptoms and are insufficient for the diagnosis. That is, the
criterion symptoms of mania/hypomania have specificity (simple agitation is not the same
as excess involvement in purposeful activities), and a sufficient number of symptoms
must be present (not just one or two symptoms) to make these diagnoses. In particular, the
appearance of one or two nonspecific symptoms—irritability, edginess, or agitation during
antidepressant treatment—in the absence of a full manic or hypomanic syndrome should
not be taken to support a diagnosis of a bipolar disorder.

Associated Features Supporting Diagnosis
Etiology (causally related to the use of psychotropic medications or substances of abuse
based on best clinical evidence) is the key variable in this etiologically specified form of bi-
polar disorder. Substances/medications that are typically considered to be associated
with substance/medication-induced bipolar and related disorder include the stimulant
class of drugs, as well as phencyclidine and steroids; however, a number of potential sub-
stances continue to emerge as new compounds are synthesized (e.g., so-called bath salts).
A history of such substance use may help increase diagnostic certainty.

Prevalence
There are no epidemiological studies of substance/medication-induced mania or bipolar
disorder. Each etiological substance may have its own individual risk of inducing a bipo-
lar (manic/hypomanic) disorder.

Development and Course
In phencyclidine-induced mania, the initial presentation may be one of a delirium with af-
fective features, which then becomes an atypically appearing manic or mixed manic state.

Bipolar and Related Disorder Due to Another Medical Condition 145

This condition follows the ingestion or inhalation quickly, usually within hours or, at the
most, a few days. In stimulant-induced manic or hypomanic states, the response is in min-
utes to 1 hour after one or several ingestions or injections. The episode is very brief and
typically resolves over 1–2 days. With corticosteroids and some immunosuppressant
medications, the mania (or mixed or depressed state) usually follows several days of in-
gestion, and the higher doses appear to have a much greater likelihood of producing bi-
polar symptoms.

Diagnostic Markers
Determination of the substance of use can be made through markers in the blood or urine
to corroborate diagnosis.

Differential Diagnosis
Substance/medication-induced bipolar and related disorder should be differentiated
from other bipolar disorders, substance intoxication or substance-induced delirium, and
medication side effects (as noted earlier). A full manic episode that emerges during anti-
depressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully
syndromal level beyond the physiological effect of that treatment is sufficient evidence for
a bipolar I diagnosis. A full hypomanic episode that emerges during antidepressant treat-
ment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level
beyond the physiological effect of that treatment is sufficient evidence for a bipolar II di-
agnosis only if preceded by a major depressive episode.

Comorbidity
Comorbidities are those associated with the use of illicit substances (in the case of illegal
stimulants or phencyclidine) or diversion of prescribed stimulants. Comorbidities related
to steroid or immunosuppressant medications are those medical indications for these
preparations. Delirium can occur before or along with manic symptoms in individuals in-
gesting phencyclidine or those who are prescribed steroid medications or other immuno-
suppressant medications.

Bipolar and Related Disorder
Due to Another Medical Condition

Diagnostic Criteria

A. A prominent and persistent period of abnormally elevated, expansive, or irritable mood
and abnormally increased activity or energy that predominates in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings that the dis-
turbance is the direct pathophysiological consequence of another medical condition.

C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-

tional, or other important areas of functioning, or necessitates hospitalization to pre-
vent harm to self or others, or there are psychotic features.

Coding note: The ICD-9-CM code for bipolar and related disorder due to another medical
condition is 293.83, which is assigned regardless of the specifier. The ICD-10-CM code
depends on the specifier (see below).

146 Bipolar and Related Disorders

Specify if:
(F06.33) With manic features: Full criteria are not met for a manic or hypomanic ep-
isode.
(F06.33) With manic- or hypomanic-like episode: Full criteria are met except Crite-
rion D for a manic episode or except Criterion F for a hypomanic episode.
(F06.34) With mixed features: Symptoms of depression are also present but do not
predominate in the clinical picture.

Coding note: Include the name of the other medical condition in the name of the mental
disorder (e.g., 293.83 [F06.33] bipolar disorder due to hyperthyroidism, with manic fea-
tures). The other medical condition should also be coded and listed separately immedi-
ately before the bipolar and related disorder due to the medical condition (e.g., 242.90
[E05.90] hyperthyroidism; 293.83 [F06.33] bipolar disorder due to hyperthyroidism, with
manic features).

Diagnostic Features
The essential features of bipolar and related disorder due to another medical condition are
presence of a prominent and persistent period of abnormally elevated, expansive, or irri-
table mood and abnormally increased activity or energy predominating in the clinical pic-
ture that is attributable to another medical condition (Criterion B). In most cases the manic
or hypomanic picture may appear during the initial presentation of the medical condition
(i.e., within 1 month); however, there are exceptions, especially in chronic medical condi-
tions that might worsen or relapse and herald the appearance of the manic or hypomanic
picture. Bipolar and related disorder due to another medical condition would not be diag-
nosed when the manic or hypomanic episodes definitely preceded the medical condition,
since the proper diagnosis would be bipolar disorder (except in the unusual circumstance
in which all preceding manic or hypomanic episodes—or, when only one such episode has
occurred, the preceding manic or hypomanic episode—were associated with ingestion of
a substance/medication). The diagnosis of bipolar and related disorder due to another
medical condition should not be made during the course of a delirium (Criterion D). The
manic or hypomanic episode in bipolar and related disorder due to another medical con-
dition must cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning to qualify for this diagnosis (Criterion E).

Associated Features Supporting Diagnosis
Etiology (i.e., a causal relationship to another medical condition based on best clinical ev-
idence) is the key variable in this etiologically specified form of bipolar disorder. The list-
ing of medical conditions that are said to be able to induce mania is never complete, and
the clinician’s best judgment is the essence of this diagnosis. Among the best known of the
medical conditions that can cause a bipolar manic or hypomanic condition are Cushing’s
disease and multiple sclerosis, as well as stroke and traumatic brain injuries.

Development and Course
Bipolar and related disorder due to another medical condition usually has its onset acutely
or subacutely within the first weeks or month of the onset of the associated medical con-
dition. However, this is not always the case, as a worsening or later relapse of the associ-
ated medical condition may precede the onset of the manic or hypomanic syndrome. The
clinician must make a clinical judgment in these situations about whether the medical con-
dition is causative, based on temporal sequence as well as plausibility of a causal relation-

Bipolar and Related Disorder Due to Another Medical Condition 147

ship. Finally, the condition may remit before or just after the medical condition remits,
particularly when treatment of the manic/hypomanic symptoms is effective.

Culture-Related Diagnostic Issues
Culture-related differences, to the extent that there is any evidence, pertain to those asso-
ciated with the medical condition (e.g., rates of multiple sclerosis and stroke vary around
the world based on dietary, genetic factors, and other environmental factors).

Gender-Related Diagnostic Issues
Gender differences pertain to those associated with the medical condition (e.g., systemic
lupus erythematosus is more common in females; stroke is somewhat more common in
middle-age males compared with females).

Diagnostic Markers
Diagnostic markers pertain to those associated with the medical condition (e.g., steroid
levels in blood or urine to help corroborate the diagnosis of Cushing’s disease, which can
be associated with manic or depressive syndromes; laboratory tests confirming the diag-
nosis of multiple sclerosis).

Functional Consequences of Bipolar and Related
Disorder Due to Another Medical Condition
Functional consequences of the bipolar symptoms may exacerbate impairments associ-
ated with the medical condition and may incur worse outcomes due to interference with
medical treatment. In general, it is believed, but not established, that the illness, when in-
duced by Cushing’s disease, will not recur if the Cushing’s disease is cured or arrested.
However, it is also suggested, but not established, that mood syndromes, including de-
pressive and manic/hypomanic ones, may be episodic (i.e., recurring) with static brain in-
juries and other central nervous system diseases.

Differential Diagnosis
Symptoms of delirium, catatonia, and acute anxiety. It is important to differentiate
symptoms of mania from excited or hypervigilant delirious symptoms; from excited cata-
tonic symptoms; and from agitation related to acute anxiety states.

Medication-induced depressive or manic symptoms. An important differential diag-
nostic observation is that the other medical condition may be treated with medications
(e.g., steroids or alpha-interferon) that can induce depressive or manic symptoms. In these
cases, clinical judgment using all of the evidence in hand is the best way to try to separate
the most likely and/or the most important of two etiological factors (i.e., association with
the medical condition vs. a substance/medication-induced syndrome). The differential di-
agnosis of the associated medical conditions is relevant but largely beyond the scope of the
present manual.

Comorbidity
Conditions comorbid with bipolar and related disorder due to another medical condition
are those associated with the medical conditions of etiological relevance. Delirium can oc-
cur before or along with manic symptoms in individuals with Cushing’s disease.

148 Bipolar and Related Disorders

Other Specified Bipolar and Related Disorder
296.89 (F31.89)

This category applies to presentations in which symptoms characteristic of a bipolar and
related disorder that cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning predominate but do not meet the full criteria
for any of the disorders in the bipolar and related disorders diagnostic class. The other
specified bipolar and related disorder category is used in situations in which the clinician
chooses to communicate the specific reason that the presentation does not meet the cri-
teria for any specific bipolar and related disorder. This is done by recording “other speci-
fied bipolar and related disorder” followed by the specific reason (e.g., “short-duration
cyclothymia”).

Examples of presentations that can be specified using the “other specified” designation
include the following:
1. Short-duration hypomanic episodes (2–3 days) and major depressive episodes: A

lifetime history of one or more major depressive episodes in individuals whose presenta-
tion has never met full criteria for a manic or hypomanic episode but who have experienced
two or more episodes of short-duration hypomania that meet the full symptomatic criteria
for a hypomanic episode but that only last for 2–3 days. The episodes of hypomanic symp-
toms do not overlap in time with the major depressive episodes, so the disturbance does
not meet criteria for major depressive episode, with mixed features.

2. Hypomanic episodes with insufficient symptoms and major depressive epi-
sodes: A lifetime history of one or more major depressive episodes in individuals
whose presentation has never met full criteria for a manic or hypomanic episode but
who have experienced one or more episodes of hypomania that do not meet full symp-
tomatic criteria (i.e., at least 4 consecutive days of elevated mood and one or two of
the other symptoms of a hypomanic episode, or irritable mood and two or three of the
other symptoms of a hypomanic episode). The episodes of hypomanic symptoms do
not overlap in time with the major depressive episodes, so the disturbance does not
meet criteria for major depressive episode, with mixed features.

3. Hypomanic episode without prior major depressive episode: One or more hypo-
manic episodes in an individual whose presentation has never met full criteria for a ma-
jor depressive episode or a manic episode. If this occurs in an individual with an
established diagnosis of persistent depressive disorder (dysthymia), both diagnoses
can be concurrently applied during the periods when the full criteria for a hypomanic
episode are met.

4. Short-duration cyclothymia (less than 24 months): Multiple episodes of hypomanic
symptoms that do not meet criteria for a hypomanic episode and multiple episodes of de-
pressive symptoms that do not meet criteria for a major depressive episode that persist
over a period of less than 24 months (less than 12 months for children or adolescents)
in an individual whose presentation has never met full criteria for a major depressive,
manic, or hypomanic episode and does not meet criteria for any psychotic disorder. Dur-
ing the course of the disorder, the hypomanic or depressive symptoms are present for
more days than not, the individual has not been without symptoms for more than 2 months
at a time, and the symptoms cause clinically significant distress or impairment.

Unspecified Bipolar and Related Disorder 149

Unspecified Bipolar and Related Disorder
296.80 (F31.9)

This category applies to presentations in which symptoms characteristic of a bipolar and
related disorder that cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning predominate but do not meet the full criteria
for any of the disorders in the bipolar and related disorders diagnostic class. The unspec-
ified bipolar and related disorder category is used in situations in which the clinician choos-
es not to specify the reason that the criteria are not met for a specific bipolar and related
disorder, and includes presentations in which there is insufficient information to make a
more specific diagnosis (e.g., in emergency room settings).

Specifiers for Bipolar and Related Disorders
Specify if:

With anxious distress: The presence of at least two of the following symptoms during
the majority of days of the current or most recent episode of mania, hypomania, or de-
pression:

1. Feeling keyed up or tense.
2. Feeling unusually restless.
3. Difficulty concentrating because of worry.
4. Fear that something awful may happen.
5. Feeling that the individual might lose control of himself or herself.

Specify current severity:
Mild: Two symptoms.
Moderate: Three symptoms.
Moderate-severe: Four or five symptoms.
Severe: Four or five symptoms with motor agitation.

Note: Anxious distress has been noted as a prominent feature of both bipolar and
major depressive disorder in both primary care and specialty mental health set-
tings. High levels of anxiety have been associated with higher suicide risk, longer
duration of illness, and greater likelihood of treatment nonresponse. As a result, it
is clinically useful to specify accurately the presence and severity levels of anxious
distress for treatment planning and monitoring of response to treatment.

With mixed features: The mixed features specifier can apply to the current manic, hy-
pomanic, or depressive episode in bipolar I or bipolar II disorder:

Manic or hypomanic episode, with mixed features:

A. Full criteria are met for a manic episode or hypomanic episode, and at least
three of the following symptoms are present during the majority of days of the
current or most recent episode of mania or hypomania:

1. Prominent dysphoria or depressed mood as indicated by either subjective
report (e.g., feels sad or empty) or observation made by others (e.g., ap-
pears tearful).

2. Diminished interest or pleasure in all, or almost all, activities (as indicated by
either subjective account or observation made by others).

3. Psychomotor retardation nearly every day (observable by others; not merely
subjective feelings of being slowed down).

150 Bipolar and Related Disorders

4. Fatigue or loss of energy.
5. Feelings of worthlessness or excessive or inappropriate guilt (not merely

self-reproach or guilt about being sick).
6. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ide-

ation without a specific plan, or a suicide attempt or a specific plan for com-
mitting suicide.

B. Mixed symptoms are observable by others and represent a change from the
person’s usual behavior.

C. For individuals whose symptoms meet full episode criteria for both mania and
depression simultaneously, the diagnosis should be manic episode, with mixed
features, due to the marked impairment and clinical severity of full mania.

D. The mixed symptoms are not attributable to the physiological effects of a sub-
stance (e.g., a drug of abuse, a medication, other treatment).

Depressive episode, with mixed features:

A. Full criteria are met for a major depressive episode, and at least three of the fol-
lowing manic/hypomanic symptoms are present during the majority of days of
the current or most recent episode of depression:

1. Elevated, expansive mood.
2. Inflated self-esteem or grandiosity.
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Increase in energy or goal-directed activity (either socially, at work or school,

or sexually).
6. Increased or excessive involvement in activities that have a high potential

for painful consequences (e.g., engaging in unrestrained buying sprees,
sexual indiscretions, or foolish business investments).

7. Decreased need for sleep (feeling rested despite sleeping less than usual;
to be contrasted with insomnia).

B. Mixed symptoms are observable by others and represent a change from the
person’s usual behavior.

C. For individuals whose symptoms meet full episode criteria for both mania and
depression simultaneously, the diagnosis should be manic episode, with mixed
features.

D. The mixed symptoms are not attributable to the physiological effects of a sub-
stance (e.g., a drug of abuse, a medication, or other treatment).

Note: Mixed features associated with a major depressive episode have been found
to be a significant risk factor for the development of bipolar I or bipolar II disorder.
As a result, it is clinically useful to note the presence of this specifier for treatment
planning and monitoring of response to treatment.

With rapid cycling (can be applied to bipolar I or bipolar II disorder): Presence of at
least four mood episodes in the previous 12 months that meet the criteria for manic,
hypomanic, or major depressive episode.

Note: Episodes are demarcated by either partial or full remissions of at least 2 months
or a switch to an episode of the opposite polarity (e.g., major depressive episode to
manic episode).

Note: The essential feature of a rapid-cycling bipolar disorder is the occurrence of
at least four mood episodes during the previous 12 months. These episodes can
occur in any combination and order. The episodes must meet both the duration and

Specifiers for Bipolar and Related Disorders 151

symptom number criteria for a major depressive, manic, or hypomanic episode and
must be demarcated by either a period of full remission or a switch to an episode
of the opposite polarity. Manic and hypomanic episodes are counted as being on
the same pole. Except for the fact that they occur more frequently, the episodes that
occur in a rapid-cycling pattern are no different from those that occur in a non-rapid-
cycling pattern. Mood episodes that count toward defining a rapid-cycling pattern
exclude those episodes directly caused by a substance (e.g., cocaine, corticoste-
roids) or another medical condition.

With melancholic features:

A. One of the following is present during the most severe period of the current episode:

1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even

temporarily, when something good happens).

B. Three (or more) of the following:

1. A distinct quality of depressed mood characterized by profound despondency,
despair, and/or moroseness or by so-called empty mood.

2. Depression that is regularly worse in the morning.
3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
4. Marked psychomotor agitation or retardation.
5. Significant anorexia or weight loss.
6. Excessive or inappropriate guilt.

Note: The specifier “with melancholic features” is applied if these features are pres-
ent at the most severe stage of the episode. There is a near-complete absence of
the capacity for pleasure, not merely a diminution. A guideline for evaluating the
lack of reactivity of mood is that even highly desired events are not associated with
marked brightening of mood. Either mood does not brighten at all, or it brightens
only partially (e.g., up to 20%–40% of normal for only minutes at a time). The “dis-
tinct quality” of mood that is characteristic of the “with melancholic features” speci-
fier is experienced as qualitatively different from that during a nonmelancholic
depressive episode. A depressed mood that is described as merely more severe,
longer lasting, or present without a reason is not considered distinct in quality. Psy-
chomotor changes are nearly always present and are observable by others.

Melancholic features exhibit only a modest tendency to repeat across episodes
in the same individual. They are more frequent in inpatients, as opposed to outpa-
tients; are less likely to occur in milder than in more severe major depressive epi-
sodes; and are more likely to occur in those with psychotic features.

With atypical features: This specifier can be applied when these features predomi-
nate during the majority of days of the current or most recent major depressive epi-
sode.

A. Mood reactivity (i.e., mood brightens in response to actual or potential positive
events).

B. Two (or more) of the following features:

1. Significant weight gain or increase in appetite.
2. Hypersomnia.
3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
4. A long-standing pattern of interpersonal rejection sensitivity (not limited to epi-

sodes of mood disturbance) that results in significant social or occupational
impairment.

152 Bipolar and Related Disorders

C. Criteria are not met for “with melancholic features” or “with catatonia” during the
same episode.

Note: “Atypical depression” has historical significance (i.e., atypical in contradis-
tinction to the more classical agitated, “endogenous” presentations of depression
that were the norm when depression was rarely diagnosed in outpatients and al-
most never in adolescents or younger adults) and today does not connote an un-
common or unusual clinical presentation as the term might imply.

Mood reactivity is the capacity to be cheered up when presented with positive
events (e.g., a visit from children, compliments from others). Mood may become
euthymic (not sad) even for extended periods of time if the external circumstances
remain favorable. Increased appetite may be manifested by an obvious increase in
food intake or by weight gain. Hypersomnia may include either an extended period
of nighttime sleep or daytime napping that totals at least 10 hours of sleep per day
(or at least 2 hours more than when not depressed). Leaden paralysis is defined as
feeling heavy, leaden, or weighted down, usually in the arms or legs. This sensation
is generally present for at least an hour a day but often lasts for many hours at a
time. Unlike the other atypical features, pathological sensitivity to perceived inter-
personal rejection is a trait that has an early onset and persists throughout most of
adult life. Rejection sensitivity occurs both when the person is and is not depressed,
though it may be exacerbated during depressive periods.

With psychotic features: Delusions or hallucinations are present at any time in the
episode. If psychotic features are present, specify if mood-congruent or mood-incon-
gruent:

With mood-congruent psychotic features: During manic episodes, the con-
tent of all delusions and hallucinations is consistent with the typical manic
themes of grandiosity, invulnerability, etc., but may also include themes of sus-
piciousness or paranoia, especially with respect to others’ doubts about the in-
dividual’s capacities, accomplishments, and so forth.
With mood-incongruent psychotic features: The content of delusions and
hallucinations is inconsistent with the episode polarity themes as described
above, or the content is a mixture of mood-incongruent and mood-congruent
themes.

With catatonia: This specifier can apply to an episode of mania or depression if cata-
tonic features are present during most of the episode. See criteria for catatonia asso-
ciated with a mental disorder in the chapter “Schizophrenia Spectrum and Other
Psychotic Disorders.”
With peripartum onset: This specifier can be applied to the current or, if the full crite-
ria are not currently met for a mood episode, most recent episode of mania, hypoma-
nia, or major depression in bipolar I or bipolar II disorder if onset of mood symptoms
occurs during pregnancy or in the 4 weeks following delivery.

Note: Mood episodes can have their onset either during pregnancy or postpartum.
Although the estimates differ according to the period of follow-up after delivery, be-
tween 3% and 6% of women will experience the onset of a major depressive epi-
sode during pregnancy or in the weeks or months following delivery. Fifty percent
of “postpartum” major depressive episodes actually begin prior to delivery. Thus,
these episodes are referred to collectively as peripartum episodes. Women with
peripartum major depressive episodes often have severe anxiety and even panic
attacks. Prospective studies have demonstrated that mood and anxiety symptoms
during pregnancy, as well as the “baby blues,” increase the risk for a postpartum
major depressive episode.

Specifiers for Bipolar and Related Disorders 153

Peripartum-onset mood episodes can present either with or without psychotic
features. Infanticide is most often associated with postpartum psychotic episodes
that are characterized by command hallucinations to kill the infant or delusions that
the infant is possessed, but psychotic symptoms can also occur in severe postpar-
tum mood episodes without such specific delusions or hallucinations.

Postpartum mood (major depressive or manic) episodes with psychotic features
appear to occur in from 1 in 500 to 1 in 1,000 deliveries and may be more common
in primiparous women. The risk of postpartum episodes with psychotic features is
particularly increased for women with prior postpartum mood episodes but is also
elevated for those with a prior history of a depressive or bipolar disorder (especially
bipolar I disorder) and those with a family history of bipolar disorders.

Once a woman has had a postpartum episode with psychotic features, the risk
of recurrence with each subsequent delivery is between 30% and 50%. Postpartum
episodes must be differentiated from delirium occurring in the postpartum period,
which is distinguished by a fluctuating level of awareness or attention. The postpar-
tum period is unique with respect to the degree of neuroendocrine alterations and
psychosocial adjustments, the potential impact of breast-feeding on treatment plan-
ning, and the long-term implications of a history of postpartum mood disorder on sub-
sequent family planning.

With seasonal pattern: This specifier applies to the lifetime pattern of mood episodes.
The essential feature is a regular seasonal pattern of at least one type of episode (i.e.,
mania, hypomania, or depression). The other types of episodes may not follow this pat-
tern. For example, an individual may have seasonal manias, but his or her depressions
do not regularly occur at a specific time of year.

A. There has been a regular temporal relationship between the onset of manic, hypo-
manic, or major depressive episodes and a particular time of the year (e.g., in the
fall or winter) in bipolar I or bipolar II disorder.

Note: Do not include cases in which there is an obvious effect of seasonally related
psychosocial stressors (e.g., regularly being unemployed every winter).

B. Full remissions (or a change from major depression to mania or hypomania or vice
versa) also occur at a characteristic time of the year (e.g., depression disappears
in the spring).

C. In the last 2 years, the individual’s manic, hypomanic, or major depressive episodes
have demonstrated a temporal seasonal relationship, as defined above, and no
non-seasonal episodes of that polarity have occurred during that 2-year period.

D. Seasonal manias, hypomanias, or depressions (as described above) substantially
outnumber any nonseasonal manias, hypomanias, or depressions that may have
occurred over the individual’s lifetime.

Note: This specifier can be applied to the pattern of major depressive episodes in
bipolar I disorder, bipolar II disorder, or major depressive disorder, recurrent. The
essential feature is the onset and remission of major depressive episodes at char-
acteristic times of the year. In most cases, the episodes begin in fall or winter and
remit in spring. Less commonly, there may be recurrent summer depressive epi-
sodes. This pattern of onset and remission of episodes must have occurred during
at least a 2-year period, without any nonseasonal episodes occurring during this
period. In addition, the seasonal depressive episodes must substantially outnum-
ber any nonseasonal depressive episodes over the individual’s lifetime.

This specifier does not apply to those situations in which the pattern is better ex-
plained by seasonally linked psychosocial stressors (e.g., seasonal unemployment
or school schedule). Major depressive episodes that occur in a seasonal pattern

154 Bipolar and Related Disorders

are often characterized by prominent energy, hypersomnia, overeating, weight
gain, and a craving for carbohydrates. It is unclear whether a seasonal pattern is
more likely in recurrent major depressive disorder or in bipolar disorders. However,
within the bipolar disorders group, a seasonal pattern appears to be more likely in
bipolar II disorder than in bipolar I disorder. In some individuals, the onset of manic
or hypomanic episodes may also be linked to a particular season.

The prevalence of winter-type seasonal pattern appears to vary with latitude,
age, and sex. Prevalence increases with higher latitudes. Age is also a strong pre-
dictor of seasonality, with younger persons at higher risk for winter depressive epi-
sodes.

Specify if:
In partial remission: Symptoms of the immediately previous manic, hypomanic, or
depressive episode are present, but full criteria are not met, or there is a period lasting
less than 2 months without any significant symptoms of a manic, hypomanic, or major
depressive episode following the end of such an episode.
In full remission: During the past 2 months, no significant signs or symptoms of the
disturbance were present.

Specify current severity:
Severity is based on the number of criterion symptoms, the severity of those symptoms,
and the degree of functional disability.

Mild: Few, if any, symptoms in excess of those required to meet the diagnostic criteria
are present, the intensity of the symptoms is distressing but manageable, and the
symptoms result in minor impairment in social or occupational functioning.
Moderate: The number of symptoms, intensity of symptoms, and/or functional impair-
ment are between those specified for “mild” and “severe.”
Severe: The number of symptoms is substantially in excess of those required to make
the diagnosis, the intensity of the symptoms is seriously distressing and unmanage-
able, and the symptoms markedly interfere with social and occupational functioning.

155

Depressive
Disorders

Depressive disorders include disruptive mood dysregulation disorder, major
depressive disorder (including major depressive episode), persistent depressive disorder
(dysthymia), premenstrual dysphoric disorder, substance/medication-induced depres-
sive disorder, depressive disorder due to another medical condition, other specified de-
pressive disorder, and unspecified depressive disorder. Unlike in DSM-IV, this chapter
“Depressive Disorders” has been separated from the previous chapter “Bipolar and Re-
lated Disorders.” The common feature of all of these disorders is the presence of sad,
empty, or irritable mood, accompanied by somatic and cognitive changes that signifi-
cantly affect the individual’s capacity to function. What differs among them are issues of
duration, timing, or presumed etiology.

In order to address concerns about the potential for the overdiagnosis of and treatment
for bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder,
referring to the presentation of children with persistent irritability and frequent episodes
of extreme behavioral dyscontrol, is added to the depressive disorders for children up to
12 years of age. Its placement in this chapter reflects the finding that children with this
symptom pattern typically develop unipolar depressive disorders or anxiety disorders,
rather than bipolar disorders, as they mature into adolescence and adulthood.

Major depressive disorder represents the classic condition in this group of disorders. It
is characterized by discrete episodes of at least 2 weeks’ duration (although most episodes
last considerably longer) involving clear-cut changes in affect, cognition, and neurovege-
tative functions and inter-episode remissions. A diagnosis based on a single episode is
possible, although the disorder is a recurrent one in the majority of cases. Careful consid-
eration is given to the delineation of normal sadness and grief from a major depressive ep-
isode. Bereavement may induce great suffering, but it does not typically induce an episode
of major depressive disorder. When they do occur together, the depressive symptoms and
functional impairment tend to be more severe and the prognosis is worse compared with
bereavement that is not accompanied by major depressive disorder. Bereavement-related
depression tends to occur in persons with other vulnerabilities to depressive disorders,
and recovery may be facilitated by antidepressant treatment.

A more chronic form of depression, persistent depressive disorder (dysthymia), can be
diagnosed when the mood disturbance continues for at least 2 years in adults or 1 year in
children. This diagnosis, new in DSM-5, includes both the DSM-IV diagnostic categories of
chronic major depression and dysthymia.

After careful scientific review of the evidence, premenstrual dysphoric disorder has
been moved from an appendix of DSM-IV (“Criteria Sets and Axes Provided for Further
Study”) to Section II of DSM-5. Almost 20 years of additional of research on this condition
has confirmed a specific and treatment-responsive form of depressive disorder that begins
sometime following ovulation and remits within a few days of menses and has a marked
impact on functioning.

A large number of substances of abuse, some prescribed medications, and several
medical conditions can be associated with depression-like phenomena. This fact is recog-
nized in the diagnoses of substance/medication-induced depressive disorder and depres-
sive disorder due to another medical condition.

156 Depressive Disorders

Disruptive Mood Dysregulation Disorder
Diagnostic Criteria 296.99 (F34.8)

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or be-
haviorally (e.g., physical aggression toward people or property) that are grossly out of
proportion in intensity or duration to the situation or provocation.

B. The temper outbursts are inconsistent with developmental level.
C. The temper outbursts occur, on average, three or more times per week.
D. The mood between temper outbursts is persistently irritable or angry most of the day,

nearly every day, and is observable by others (e.g., parents, teachers, peers).
E. Criteria A–D have been present for 12 or more months. Throughout that time, the indi-

vidual has not had a period lasting 3 or more consecutive months without all of the
symptoms in Criteria A–D.

F. Criteria A and D are present in at least two of three settings (i.e., at home, at school,
with peers) and are severe in at least one of these.

G. The diagnosis should not be made for the first time before age 6 years or after age 18
years.

H. By history or observation, the age at onset of Criteria A–E is before 10 years.
I. There has never been a distinct period lasting more than 1 day during which the full

symptom criteria, except duration, for a manic or hypomanic episode have been met.
Note: Developmentally appropriate mood elevation, such as occurs in the context of a
highly positive event or its anticipation, should not be considered as a symptom of ma-
nia or hypomania.

J. The behaviors do not occur exclusively during an episode of major depressive disorder
and are not better explained by another mental disorder (e.g., autism spectrum disor-
der, posttraumatic stress disorder, separation anxiety disorder, persistent depressive
disorder [dysthymia]).
Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent ex-
plosive disorder, or bipolar disorder, though it can coexist with others, including major
depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and
substance use disorders. Individuals whose symptoms meet criteria for both disruptive
mood dysregulation disorder and oppositional defiant disorder should only be given the
diagnosis of disruptive mood dysregulation disorder. If an individual has ever experi-
enced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation
disorder should not be assigned.

K. The symptoms are not attributable to the physiological effects of a substance or to an-
other medical or neurological condition.

Diagnostic Features
The core feature of disruptive mood dysregulation disorder is chronic, severe persistent ir-
ritability. This severe irritability has two prominent clinical manifestations, the first of
which is frequent temper outbursts. These outbursts typically occur in response to frus-
tration and can be verbal or behavioral (the latter in the form of aggression against prop-
erty, self, or others). They must occur frequently (i.e., on average, three or more times per
week) (Criterion C) over at least 1 year in at least two settings (Criteria E and F), such as in
the home and at school, and they must be developmentally inappropriate (Criterion B).
The second manifestation of severe irritability consists of chronic, persistently irritable or
angry mood that is present between the severe temper outbursts. This irritable or angry
mood must be characteristic of the child, being present most of the day, nearly every day,
and noticeable by others in the child’s environment (Criterion D).

Disruptive Mood Dysregulation Disorder 157

The clinical presentation of disruptive mood dysregulation disorder must be carefully
distinguished from presentations of other, related conditions, particularly pediatric bi-
polar disorder. In fact, disruptive mood dysregulation disorder was added to DSM-5 to
address the considerable concern about the appropriate classification and treatment of
children who present with chronic, persistent irritability relative to children who present
with classic (i.e., episodic) bipolar disorder.

Some researchers view severe, non-episodic irritability as characteristic of bipolar dis-
order in children, although both DSM-IV and DSM-5 require that both children and adults
have distinct episodes of mania or hypomania to qualify for the diagnosis of bipolar I dis-
order. During the latter decades of the 20th century, this contention by researchers that
severe, nonepisodic irritability is a manifestation of pediatric mania coincided with an up-
surge in the rates at which clinicians assigned the diagnosis of bipolar disorder to their
pediatric patients. This sharp increase in rates appears to be attributable to clinicians com-
bining at least two clinical presentations into a single category. That is, both classic, epi-
sodic presentations of mania and non-episodic presentations of severe irritability have
been labeled as bipolar disorder in children. In DSM-5, the term bipolar disorder is explicitly
reserved for episodic presentations of bipolar symptoms. DSM-IV did not include a diagno-
sis designed to capture youths whose hallmark symptoms consisted of very severe, non-
episodic irritability, whereas DSM-5, with the inclusion of disruptive mood dysregulation
disorder, provides a distinct category for such presentations.

Prevalence
Disruptive mood dysregulation disorder is common among children presenting to pedi-
atric mental health clinics. Prevalence estimates of the disorder in the community are un-
clear. Based on rates of chronic and severe persistent irritability, which is the core feature
of the disorder, the overall 6-month to 1-year period-prevalence of disruptive mood dys-
regulation disorder among children and adolescents probably falls in the 2%–5% range.
However, rates are expected to be higher in males and school-age children than in females
and adolescents.

Development and Course
The onset of disruptive mood dysregulation disorder must be before age 10 years, and the
diagnosis should not be applied to children with a developmental age of less than 6 years.
It is unknown whether the condition presents only in this age-delimited fashion. Because
the symptoms of disruptive mood dysregulation disorder are likely to change as children
mature, use of the diagnosis should be restricted to age groups similar to those in which
validity has been established (7–18 years). Approximately half of children with severe,
chronic irritability will have a presentation that continues to meet criteria for the condition
1 year later. Rates of conversion from severe, nonepisodic irritability to bipolar disorder
are very low. Instead, children with chronic irritability are at risk to develop unipolar de-
pressive and/or anxiety disorders in adulthood.

Age-related variations also differentiate classic bipolar disorder and disruptive mood
dysregulation disorder. Rates of bipolar disorder generally are very low prior to adoles-
cence (<1%), with a steady increase into early adulthood (1%–2% prevalence). Disruptive
mood dysregulation disorder is more common than bipolar disorder prior to adolescence,
and symptoms of the condition generally become less common as children transition into
adulthood.

Risk and Prognostic Factors
Temperamental. Children with chronic irritability typically exhibit complicated psy-
chiatric histories. In such children, a relatively extensive history of chronic irritability is

158 Depressive Disorders

common, typically manifesting before full criteria for the syndrome are met. Such predi-
agnostic presentations may have qualified for a diagnosis of oppositional defiant disorder.
Many children with disruptive mood dysregulation disorder have symptoms that also
meet criteria for attention-deficit/hyperactivity disorder (ADHD) and for an anxiety dis-
order, with such diagnoses often being present from a relatively early age. For some chil-
dren, the criteria for major depressive disorder may also be met.

Genetic and physiological. In terms of familial aggregation and genetics, it has been
suggested that children presenting with chronic, non-episodic irritability can be differen-
tiated from children with bipolar disorder in their family-based risk. However, these two
groups do not differ in familial rates of anxiety disorders, unipolar depressive disorders,
or substance abuse. Compared with children with pediatric bipolar disorder or other men-
tal illnesses, those with disruptive mood dysregulation disorder exhibit both commonal-
ities and differences in information-processing deficits. For example, face-emotion
labeling deficits, as well as perturbed decision making and cognitive control, are present in
children with bipolar disorder and chronically irritable children, as well as in children
with some other psychiatric conditions. There is also evidence for disorder-specific dys-
function, such as during tasks assessing attention deployment in response to emotional
stimuli, which has demonstrated unique signs of dysfunction in children with chronic ir-
ritability.

Gender-Related Diagnostic Issues
Children presenting to clinics with features of disruptive mood dysregulation disorder are
predominantly male. Among community samples, a male preponderance appears to be
supported. This difference in prevalence between males and females differentiates disrup-
tive mood dysregulation disorder from bipolar disorder, in which there is an equal gender
prevalence.

Suicide Risk
In general, evidence documenting suicidal behavior and aggression, as well as other se-
vere functional consequences, in disruptive mood dysregulation disorder should be noted
when evaluating children with chronic irritability.

Functional Consequences of
Disruptive Mood Dysregulation Disorder
Chronic, severe irritability, such as is seen in disruptive mood dysregulation disorder, is
associated with marked disruption in a child’s family and peer relationships, as well as in
school performance. Because of their extremely low frustration tolerance, such children
generally have difficulty succeeding in school; they are often unable to participate in the
activities typically enjoyed by healthy children; their family life is severely disrupted by
their outbursts and irritability; and they have trouble initiating or sustaining friendships.
Levels of dysfunction in children with bipolar disorder and disruptive mood dysregulation
disorder are generally comparable. Both conditions cause severe disruption in the lives of
the affected individual and their families. In both disruptive mood dysregulation disorder
and pediatric bipolar disorder, dangerous behavior, suicidal ideation or suicide attempts,
severe aggression, and psychiatric hospitalization are common.

Differential Diagnosis
Because chronically irritable children and adolescents typically present with complex histo-
ries, the diagnosis of disruptive mood dysregulation disorder must be made while consid-
ering the presence or absence of multiple other conditions. Despite the need to consider

Disruptive Mood Dysregulation Disorder 159

many other syndromes, differentiation of disruptive mood dysregulation disorder from bi-
polar disorder and oppositional defiant disorder requires particularly careful assessment.

Bipolar disorders. The central feature differentiating disruptive mood dysregulation disor-
der and bipolar disorders in children involves the longitudinal course of the core symptoms. In
children, as in adults, bipolar I disorder and bipolar II disorder manifest as an episodic illness
with discrete episodes of mood perturbation that can be differentiated from the child’s typical
presentation. The mood perturbation that occurs during a manic episode is distinctly different
from the child’s usual mood. In addition, during a manic episode, the change in mood must be
accompanied by the onset, or worsening, of associated cognitive, behavioral, and physical
symptoms (e.g., distractibility, increased goal-directed activity), which are also present to a de-
gree that is distinctly different from the child’s usual baseline. Thus, in the case of a manic ep-
isode, parents (and, depending on developmental level, children) should be able to identify a
distinct time period during which the child’s mood and behavior were markedly different
from usual. In contrast, the irritability of disruptive mood dysregulation disorder is persistent
and is present over many months; while it may wax and wane to a certain degree, severe irri-
tability is characteristic of the child with disruptive mood dysregulation disorder. Thus, while
bipolar disorders are episodic conditions, disruptive mood dysregulation disorder is not. In
fact, the diagnosis of disruptive mood dysregulation disorder cannot be assigned to a child
who has ever experienced a full-duration hypomanic or manic episode (irritable or euphoric)
or who has ever had a manic or hypomanic episode lasting more than 1 day. Another central
differentiating feature between bipolar disorders and disruptive mood dysregulation disorder
is the presence of elevated or expansive mood and grandiosity. These symptoms are common
features of mania but are not characteristic of disruptive mood dysregulation disorder.

Oppositional defiant disorder. While symptoms of oppositional defiant disorder typi-
cally do occur in children with disruptive mood dysregulation disorder, mood symptoms
of disruptive mood dysregulation disorder are relatively rare in children with opposi-
tional defiant disorder. The key features that warrant the diagnosis of disruptive mood
dysregulation disorder in children whose symptoms also meet criteria for oppositional de-
fiant disorder are the presence of severe and frequently recurrent outbursts and a persis-
tent disruption in mood between outbursts. In addition, the diagnosis of disruptive mood
dysregulation disorder requires severe impairment in at least one setting (i.e., home,
school, or among peers) and mild to moderate impairment in a second setting. For this rea-
son, while most children whose symptoms meet criteria for disruptive mood dysregula-
tion disorder will also have a presentation that meets criteria for oppositional defiant
disorder, the reverse is not the case. That is, in only approximately 15% of individuals with
oppositional defiant disorder would criteria for disruptive mood dysregulation disorder
be met. Moreover, even for children in whom criteria for both disorders are met, only the
diagnosis of disruptive mood dysregulation disorder should be made. Finally, both the
prominent mood symptoms in disruptive mood dysregulation disorder and the high risk
for depressive and anxiety disorders in follow-up studies justify placement of disruptive
mood dysregulation disorder among the depressive disorders in DSM-5. (Oppositional
defiant disorder is included in the chapter “Disruptive, Impulse-Control, and Conduct
Disorders.”) This reflects the more prominent mood component among individuals with
disruptive mood dysregulation disorder, as compared with individuals with oppositional
defiant disorder. Nevertheless, it also should be noted that disruptive mood dysregulation
disorder appears to carry a high risk for behavioral problems as well as mood problems.

Attention-deficit/hyperactivity disorder, major depressive disorder, anxiety disorders,
and autism spectrum disorder. Unlike children diagnosed with bipolar disorder or op-
positional defiant disorder, a child whose symptoms meet criteria for disruptive mood
dysregulation disorder also can receive a comorbid diagnosis of ADHD, major depressive
disorder, and/or anxiety disorder. However, children whose irritability is present only in
the context of a major depressive episode or persistent depressive disorder (dysthymia)

160 Depressive Disorders

should receive one of those diagnoses rather than disruptive mood dysregulation disor-
der. Children with disruptive mood dysregulation disorder may have symptoms that also
meet criteria for an anxiety disorder and can receive both diagnoses, but children whose ir-
ritability is manifest only in the context of exacerbation of an anxiety disorder should re-
ceive the relevant anxiety disorder diagnosis rather than disruptive mood dysregulation
disorder. In addition, children with autism spectrum disorders frequently present with
temper outbursts when, for example, their routines are disturbed. In that instance, the
temper outbursts would be considered secondary to the autism spectrum disorder, and
the child should not receive the diagnosis of disruptive mood dysregulation disorder.

Intermittent explosive disorder. Children with symptoms suggestive of intermittent
explosive disorder present with instances of severe temper outbursts, much like children
with disruptive mood dysregulation disorder. However, unlike disruptive mood dysreg-
ulation disorder, intermittent explosive disorder does not require persistent disruption in
mood between outbursts. In addition, intermittent explosive disorder requires only 3 months
of active symptoms, in contrast to the 12-month requirement for disruptive mood dys-
regulation disorder. Thus, these two diagnoses should not be made in the same child. For
children with outbursts and intercurrent, persistent irritability, only the diagnosis of dis-
ruptive mood dysregulation disorder should be made.

Comorbidity
Rates of comorbidity in disruptive mood dysregulation disorder are extremely high. It is
rare to find individuals whose symptoms meet criteria for disruptive mood dysregulation
disorder alone. Comorbidity between disruptive mood dysregulation disorder and other
DSM-defined syndromes appears higher than for many other pediatric mental illnesses;
the strongest overlap is with oppositional defiant disorder. Not only is the overall rate of
comorbidity high in disruptive mood dysregulation disorder, but also the range of comor-
bid illnesses appears particularly diverse. These children typically present to the clinic
with a wide range of disruptive behavior, mood, anxiety, and even autism spectrum
symptoms and diagnoses. However, children with disruptive mood dysregulation disor-
der should not have symptoms that meet criteria for bipolar disorder, as in that context,
only the bipolar disorder diagnosis should be made. If children have symptoms that meet
criteria for oppositional defiant disorder or intermittent explosive disorder and disruptive
mood dysregulation disorder, only the diagnosis of disruptive mood dysregulation disor-
der should be assigned. Also, as noted earlier, the diagnosis of disruptive mood dysregu-
lation disorder should not be assigned if the symptoms occur only in an anxiety-
provoking context, when the routines of a child with autism spectrum disorder or obses-
sive-compulsive disorder are disturbed, or in the context of a major depressive episode.

Major Depressive Disorder
Diagnostic Criteria

A. Five (or more) of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning; at least one of the symptoms
is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjec-
tive report (e.g., feels sad, empty, hopeless) or observation made by others (e.g.,
appears tearful). (Note: In children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the
day, nearly every day (as indicated by either subjective account or observation).

Major Depressive Disorder 161

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 gain.)

4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not

merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delu-

sional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei-

ther by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with-

out a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to another
medical condition.

Note: Criteria A–C represent a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a nat-
ural disaster, a serious medical illness or disability) may include the feelings of intense sad-
ness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A,
which may resemble a depressive episode. Although such symptoms may be understand-
able or considered appropriate to the loss, the presence of a major depressive episode in
addition to the normal response to a significant loss should also be carefully considered. This
decision inevitably requires the exercise of clinical judgment based on the individual’s history
and the cultural norms for the expression of distress in the context of loss.1

D. The occurrence of the major depressive episode is not better explained by schizoaf-
fective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or
other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.
Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes
are substance-induced or are attributable to the physiological effects of another med-
ical condition.

1 In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in
grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent
depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is
likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of
grief. These waves tend to be associated with thoughts or reminders of the deceased. The
depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations.
The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic
of the pervasive unhappiness and misery characteristic of MDE. The thought content associated
with grief generally features a preoccupation with thoughts and memories of the deceased,
rather than the self-critical or pessimistic ruminations seen in MDE. In grief, self-esteem is gener-
ally preserved, whereas in MDE feelings of worthlessness and self-loathing are common. If self-
derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the
deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was
loved). If a bereaved individual thinks about death and dying, such thoughts are generally
focused on the deceased and possibly about “joining” the deceased, whereas in MDE such
thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life,
or unable to cope with the pain of depression.

162 Depressive Disorders

Coding and Recording Procedures
The diagnostic code for major depressive disorder is based on whether this is a single or
recurrent episode, current severity, presence of psychotic features, and remission status.
Current severity and psychotic features are only indicated if full criteria are currently met
for a major depressive episode. Remission specifiers are only indicated if the full criteria
are not currently met for a major depressive episode. Codes are as follows:

In recording the name of a diagnosis, terms should be listed in the following order: major
depressive disorder, single or recurrent episode, severity/psychotic/remission specifiers,
followed by as many of the following specifiers without codes that apply to the current
episode.

Specify:
With anxious distress (p. 184)
With mixed features (pp. 184–185)
With melancholic features (p. 185)
With atypical features (pp. 185–186)
With mood-congruent psychotic features (p. 186)
With mood-incongruent psychotic features (p. 186)
With catatonia (p. 186). Coding note: Use additional code 293.89 (F06.1).
With peripartum onset (pp. 186–187)
With seasonal pattern (recurrent episode only) (pp. 187–188)

Diagnostic Features
The criterion symptoms for major depressive disorder must be present nearly every day to
be considered present, with the exception of weight change and suicidal ideation. De-
pressed mood must be present for most of the day, in addition to being present nearly ev-
ery day. Often insomnia or fatigue is the presenting complaint, and failure to probe for
accompanying depressive symptoms will result in underdiagnosis. Sadness may be de-
nied at first but may be elicited through interview or inferred from facial expression and
demeanor. With individuals who focus on a somatic complaint, clinicians should de-
termine whether the distress from that complaint is associated with specific depressive
symptoms. Fatigue and sleep disturbance are present in a high proportion of cases; psy-
chomotor disturbances are much less common but are indicative of greater overall sever-
ity, as is the presence of delusional or near-delusional guilt.

Severity/course specifier Single episode Recurrent episode*

Mild (p. 188) 296.21 (F32.0) 296.31 (F33.0)

Moderate (p. 188) 296.22 (F32.1) 296.32 (F33.1)

Severe (p. 188) 296.23 (F32.2) 296.33 (F33.2)

With psychotic features** (p. 186) 296.24 (F32.3) 296.34 (F33.3)

In partial remission (p. 188) 296.25 (F32.4) 296.35 (F33.41)

In full remission (p. 188) 296.26 (F32.5) 296.36 (F33.42)

Unspecified 296.20 (F32.9) 296.30 (F33.9)

*For an episode to be considered recurrent, there must be an interval of at least 2 consecutive months
between separate episodes in which criteria are not met for a major depressive episode. The defini-
tions of specifiers are found on the indicated pages.
**If psychotic features are present, code the “with psychotic features” specifier irrespective of epi-
sode severity.

Major Depressive Disorder 163

The essential feature of a major depressive episode is a period of at least 2 weeks during
which there is either depressed mood or the loss of interest or pleasure in nearly all activi-
ties (Criterion A). In children and adolescents, the mood may be irritable rather than sad.
The individual must also experience at least four additional symptoms drawn from a list
that includes changes in appetite or weight, sleep, and psychomotor activity; decreased en-
ergy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making deci-
sions; or recurrent thoughts of death or suicidal ideation or suicide plans or attempts. To
count toward a major depressive episode, a symptom must either be newly present or must
have clearly worsened compared with the person’s pre-episode status. The symptoms
must persist for most of the day, nearly every day, for at least 2 consecutive weeks. The ep-
isode must be accompanied by clinically significant distress or impairment in social, occu-
pational, or other important areas of functioning. For some individuals with milder
episodes, functioning may appear to be normal but requires markedly increased effort.

The mood in a major depressive episode is often described by the person as depressed,
sad, hopeless, discouraged, or “down in the dumps” (Criterion A1). In some cases, sadness
may be denied at first but may subsequently be elicited by interview (e.g., by pointing out
that the individual looks as if he or she is about to cry). In some individuals who complain
of feeling “blah,” having no feelings, or feeling anxious, the presence of a depressed mood
can be inferred from the person’s facial expression and demeanor. Some individuals em-
phasize somatic complaints (e.g., bodily aches and pains) rather than reporting feelings of
sadness. Many individuals report or exhibit increased irritability (e.g., persistent anger, a
tendency to respond to events with angry outbursts or blaming others, an exaggerated
sense of frustration over minor matters). In children and adolescents, an irritable or cranky
mood may develop rather than a sad or dejected mood. This presentation should be dif-
ferentiated from a pattern of irritability when frustrated.

Loss of interest or pleasure is nearly always present, at least to some degree. Individ-
uals may report feeling less interested in hobbies, “not caring anymore,” or not feeling any
enjoyment in activities that were previously considered pleasurable (Criterion A2). Family
members often notice social withdrawal or neglect of pleasurable avocations (e.g., a for-
merly avid golfer no longer plays, a child who used to enjoy soccer finds excuses not to
practice). In some individuals, there is a significant reduction from previous levels of sex-
ual interest or desire.

Appetite change may involve either a reduction or increase. Some depressed individ-
uals report that they have to force themselves to eat. Others may eat more and may crave
specific foods (e.g., sweets or other carbohydrates). When appetite changes are severe (in
either direction), there may be a significant loss or gain in weight, or, in children, a failure
to make expected weight gains may be noted (Criterion A3).

Sleep disturbance may take the form of either difficulty sleeping or sleeping exces-
sively (Criterion A4). When insomnia is present, it typically takes the form of middle in-
somnia (i.e., waking up during the night and then having difficulty returning to sleep) or
terminal insomnia (i.e., waking too early and being unable to return to sleep). Initial in-
somnia (i.e., difficulty falling asleep) may also occur. Individuals who present with over-
sleeping (hypersomnia) may experience prolonged sleep episodes at night or increased
daytime sleep. Sometimes the reason that the individual seeks treatment is for the dis-
turbed sleep.

Psychomotor changes include agitation (e.g., the inability to sit still, pacing, hand-
wringing; or pulling or rubbing of the skin, clothing, or other objects) or retardation (e.g.,
slowed speech, thinking, and body movements; increased pauses before answering;
speech that is decreased in volume, inflection, amount, or variety of content, or muteness)
(Criterion A5). The psychomotor agitation or retardation must be severe enough to be ob-
servable by others and not represent merely subjective feelings.

Decreased energy, tiredness, and fatigue are common (Criterion A6). A person may re-
port sustained fatigue without physical exertion. Even the smallest tasks seem to require

164 Depressive Disorders

substantial effort. The efficiency with which tasks are accomplished may be reduced. For
example, an individual may complain that washing and dressing in the morning are ex-
hausting and take twice as long as usual.

The sense of worthlessness or guilt associated with a major depressive episode may in-
clude unrealistic negative evaluations of one’s worth or guilty preoccupations or rumina-
tions over minor past failings (Criterion A7). Such individuals often misinterpret neutral
or trivial day-to-day events as evidence of personal defects and have an exaggerated sense
of responsibility for untoward events. The sense of worthlessness or guilt may be of delu-
sional proportions (e.g., an individual who is convinced that he or she is personally re-
sponsible for world poverty). Blaming oneself for being sick and for failing to meet
occupational or interpersonal responsibilities as a result of the depression is very common
and, unless delusional, is not considered sufficient to meet this criterion.

Many individuals report impaired ability to think, concentrate, or make even minor
decisions (Criterion A8). They may appear easily distracted or complain of memory diffi-
culties. Those engaged in cognitively demanding pursuits are often unable to function. In
children, a precipitous drop in grades may reflect poor concentration. In elderly individ-
uals, memory difficulties may be the chief complaint and may be mistaken for early signs
of a dementia (“pseudodementia”). When the major depressive episode is successfully
treated, the memory problems often fully abate. However, in some individuals, particu-
larly elderly persons, a major depressive episode may sometimes be the initial presenta-
tion of an irreversible dementia.

Thoughts of death, suicidal ideation, or suicide attempts (Criterion A9) are common.
They may range from a passive wish not to awaken in the morning or a belief that others
would be better off if the individual were dead, to transient but recurrent thoughts of com-
mitting suicide, to a specific suicide plan. More severely suicidal individuals may have put
their affairs in order (e.g., updated wills, settled debts), acquired needed materials (e.g., a
rope or a gun), and chosen a location and time to accomplish the suicide. Motivations for
suicide may include a desire to give up in the face of perceived insurmountable obstacles,
an intense wish to end what is perceived as an unending and excruciatingly painful emo-
tional state, an inability to foresee any enjoyment in life, or the wish to not be a burden to
others. The resolution of such thinking may be a more meaningful measure of diminished
suicide risk than denial of further plans for suicide.

The evaluation of the symptoms of a major depressive episode is especially difficult
when they occur in an individual who also has a general medical condition (e.g., cancer,
stroke, myocardial infarction, diabetes, pregnancy). Some of the criterion signs and symp-
toms of a major depressive episode are identical to those of general medical conditions
(e.g., weight loss with untreated diabetes; fatigue with cancer; hypersomnia early in preg-
nancy; insomnia later in pregnancy or the postpartum). Such symptoms count toward a
major depressive diagnosis except when they are clearly and fully attributable to a general
medical condition. Nonvegetative symptoms of dysphoria, anhedonia, guilt or worthless-
ness, impaired concentration or indecision, and suicidal thoughts should be assessed with
particular care in such cases. Definitions of major depressive episodes that have been mod-
ified to include only these nonvegetative symptoms appear to identify nearly the same in-
dividuals as do the full criteria.

Associated Features Supporting Diagnosis
Major depressive disorder is associated with high mortality, much of which is accounted
for by suicide; however, it is not the only cause. For example, depressed individuals ad-
mitted to nursing homes have a markedly increased likelihood of death in the first year. In-
dividuals frequently present with tearfulness, irritability, brooding, obsessive rumination,
anxiety, phobias, excessive worry over physical health, and complaints of pain (e.g., head-
aches; joint, abdominal, or other pains). In children, separation anxiety may occur.

Major Depressive Disorder 165

Although an extensive literature exists describing neuroanatomical, neuroendocrino-
logical, and neurophysiological correlates of major depressive disorder, no laboratory test
has yielded results of sufficient sensitivity and specificity to be used as a diagnostic tool for
this disorder. Until recently, hypothalamic-pituitary-adrenal axis hyperactivity had been
the most extensively investigated abnormality associated with major depressive episodes,
and it appears to be associated with melancholia, psychotic features, and risks for eventual
suicide. Molecular studies have also implicated peripheral factors, including genetic vari-
ants in neurotrophic factors and pro-inflammatory cytokines. Additionally, functional
magnetic resonance imaging studies provide evidence for functional abnormalities in spe-
cific neural systems supporting emotion processing, reward seeking, and emotion regula-
tion in adults with major depression.

Prevalence
Twelve-month prevalence of major depressive disorder in the United States is approximately
7%, with marked differences by age group such that the prevalence in 18- to 29-year-old indi-
viduals is threefold higher than the prevalence in individuals age 60 years or older. Females ex-
perience 1.5- to 3-fold higher rates than males beginning in early adolescence.

Development and Course
Major depressive disorder may first appear at any age, but the likelihood of onset in-
creases markedly with puberty. In the United States, incidence appears to peak in the 20s;
however, first onset in late life is not uncommon.

The course of major depressive disorder is quite variable, such that some individuals
rarely, if ever, experience remission (a period of 2 or more months with no symptoms, or
only one or two symptoms to no more than a mild degree), while others experience many
years with few or no symptoms between discrete episodes. It is important to distinguish
individuals who present for treatment during an exacerbation of a chronic depressive ill-
ness from those whose symptoms developed recently. Chronicity of depressive symptoms
substantially increases the likelihood of underlying personality, anxiety, and substance
use disorders and decreases the likelihood that treatment will be followed by full symp-
tom resolution. It is therefore useful to ask individuals presenting with depressive symp-
toms to identify the last period of at least 2 months during which they were entirely free of
depressive symptoms.

Recovery typically begins within 3 months of onset for two in five individuals with ma-
jor depression and within 1 year for four in five individuals. Recency of onset is a strong
determinant of the likelihood of near-term recovery, and many individuals who have been
depressed only for several months can be expected to recover spontaneously. Features as-
sociated with lower recovery rates, other than current episode duration, include psychotic
features, prominent anxiety, personality disorders, and symptom severity.

The risk of recurrence becomes progessively lower over time as the duration of re-
mission increases. The risk is higher in individuals whose preceding episode was severe,
in younger individuals, and in individuals who have already experienced multiple epi-
sodes. The persistence of even mild depressive symptoms during remission is a powerful
predictor of recurrence.

Many bipolar illnesses begin with one or more depressive episodes, and a substantial
proportion of individuals who initially appear to have major depressive disorder will
prove, in time, to instead have a bipolar disorder. This is more likely in individuals with
onset of the illness in adolescence, those with psychotic features, and those with a family
history of bipolar illness. The presence of a “with mixed features” specifier also increases
the risk for future manic or hypomanic diagnosis. Major depressive disorder, particularly
with psychotic features, may also transition into schizophrenia, a change that is much
more frequent than the reverse.

166 Depressive Disorders

Despite consistent differences between genders in prevalence rates for depressive disor-
ders, there appear to be no clear differences by gender in phenomenology, course, or treat-
ment response. Similarly, there are no clear effects of current age on the course or treatment
response of major depressive disorder. Some symptom differences exist, though, such that
hypersomnia and hyperphagia are more likely in younger individuals, and melancholic
symptoms, particularly psychomotor disturbances, are more common in older individuals.
The likelihood of suicide attempts lessens in middle and late life, although the risk of com-
pleted suicide does not. Depressions with earlier ages at onset are more familial and more
likely to involve personality disturbances. The course of major depressive disorder within
individuals does not generally change with aging. Mean times to recovery appear to be sta-
ble over long periods, and the likelihood of being in an episode does not generally increase
or decrease with time.

Risk and Prognostic Factors
Temperamental. Neuroticism (negative affectivity) is a well-established risk factor for the
onset of major depressive disorder, and high levels appear to render individuals more likely
to develop depressive episodes in response to stressful life events.

Environmental. Adverse childhood experiences, particularly when there are multiple
experiences of diverse types, constitute a set of potent risk factors for major depressive dis-
order. Stressful life events are well recognized as precipitants of major depressive epi-
sodes, but the presence or absence of adverse life events near the onset of episodes does
not appear to provide a useful guide to prognosis or treatment selection.

Genetic and physiological. First-degree family members of individuals with major de-
pressive disorder have a risk for major depressive disorder two- to fourfold higher than
that of the general population. Relative risks appear to be higher for early-onset and re-
current forms. Heritability is approximately 40%, and the personality trait neuroticism ac-
counts for a substantial portion of this genetic liability.

Course modifiers. Essentially all major nonmood disorders increase the risk of an indi-
vidual developing depression. Major depressive episodes that develop against the back-
ground of another disorder often follow a more refractory course. Substance use, anxiety,
and borderline personality disorders are among the most common of these, and the pre-
senting depressive symptoms may obscure and delay their recognition. However, sus-
tained clinical improvement in depressive symptoms may depend on the appropriate
treatment of underlying illnesses. Chronic or disabling medical conditions also increase
risks for major depressive episodes. Such prevalent illnesses as diabetes, morbid obesity,
and cardiovascular disease are often complicated by depressive episodes, and these epi-
sodes are more likely to become chronic than are depressive episodes in medically healthy
individuals.

Culture-Related Diagnostic Issues
Surveys of major depressive disorder across diverse cultures have shown sevenfold dif-
ferences in 12-month prevalence rates but much more consistency in female-to-male ratio,
mean ages at onset, and the degree to which presence of the disorder raises the likelihood
of comorbid substance abuse. While these findings suggest substantial cultural differences
in the expression of major depressive disorder, they do not permit simple linkages be-
tween particular cultures and the likelihood of specific symptoms. Rather, clinicians
should be aware that in most countries the majority of cases of depression go unrecog-
nized in primary care settings and that in many cultures, somatic symptoms are very likely
to constitute the presenting complaint. Among the Criterion A symptoms, insomnia and
loss of energy are the most uniformly reported.

Major Depressive Disorder 167

Gender-Related Diagnostic Issues
Although the most reproducible finding in the epidemiology of major depressive disorder
has been a higher prevalence in females, there are no clear differences between genders in
symptoms, course, treatment response, or functional consequences. In women, the risk for
suicide attempts is higher, and the risk for suicide completion is lower. The disparity in
suicide rate by gender is not as great among those with depressive disorders as it is in the
population as a whole.

Suicide Risk
The possibility of suicidal behavior exists at all times during major depressive episodes.
The most consistently described risk factor is a past history of suicide attempts or threats,
but it should be remembered that most completed suicides are not preceded by unsuccess-
ful attempts. Other features associated with an increased risk for completed suicide
include male sex, being single or living alone, and having prominent feelings of hopeless-
ness. The presence of borderline personality disorder markedly increases risk for future
suicide attempts.

Functional Consequences of
Major Depressive Disorder
Many of the functional consequences of major depressive disorder derive from individual
symptoms. Impairment can be very mild, such that many of those who interact with the af-
fected individual are unaware of depressive symptoms. Impairment may, however, range
to complete incapacity such that the depressed individual is unable to attend to basic self-
care needs or is mute or catatonic. Among individuals seen in general medical settings,
those with major depressive disorder have more pain and physical illness and greater de-
creases in physical, social, and role functioning.

Differential Diagnosis
Manic episodes with irritable mood or mixed episodes. Major depressive episodes
with prominent irritable mood may be difficult to distinguish from manic episodes with
irritable mood or from mixed episodes. This distinction requires a careful clinical evalua-
tion of the presence of manic symptoms.

Mood disorder due to another medical condition. A major depressive episode is the
appropriate diagnosis if the mood disturbance is not judged, based on individual history,
physical examination, and laboratory findings, to be the direct pathophysiological conse-
quence of a specific medical condition (e.g., multiple sclerosis, stroke, hypothyroidism).

Substance/medication-induced depressive or bipolar disorder. This disorder is distin-
guished from major depressive disorder by the fact that a substance (e.g., a drug of abuse,
a medication, a toxin) appears to be etiologically related to the mood disturbance. For ex-
ample, depressed mood that occurs only in the context of withdrawal from cocaine would
be diagnosed as cocaine-induced depressive disorder.

Attention-deficit/hyperactivity disorder. Distractibility and low frustration tolerance
can occur in both attention-deficit/ hyperactivity disorder and a major depressive epi-
sode; if the criteria are met for both, attention-deficit/hyperactivity disorder may be diag-
nosed in addition to the mood disorder. However, the clinician must be cautious not to
overdiagnose a major depressive episode in children with attention-deficit/hyperactivity
disorder whose disturbance in mood is characterized by irritability rather than by sadness
or loss of interest.

168 Depressive Disorders

Adjustment disorder with depressed mood. A major depressive episode that occurs in
response to a psychosocial stressor is distinguished from adjustment disorder with de-
pressed mood by the fact that the full criteria for a major depressive episode are not met in
adjustment disorder.

Sadness. Finally, periods of sadness are inherent aspects of the human experience.
These periods should not be diagnosed as a major depressive episode unless criteria are
met for severity (i.e., five out of nine symptoms), duration (i.e., most of the day, nearly ev-
ery day for at least 2 weeks), and clinically significant distress or impairment. The diagno-
sis other specified depressive disorder may be appropriate for presentations of depressed
mood with clinically significant impairment that do not meet criteria for duration or se-
verity.

Comorbidity
Other disorders with which major depressive disorder frequently co-occurs are substance-
related disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, buli-
mia nervosa, and borderline personality disorder.

Persistent Depressive Disorder (Dysthymia)
Diagnostic Criteria 300.4 (F34.1)

This disorder represents a consolidation of DSM-IV-defined chronic major depressive dis-
order and dysthymic disorder.
A. Depressed mood for most of the day, for more days than not, as indicated by either

subjective account or observation by others, for at least 2 years.

Note: In children and adolescents, mood can be irritable and duration must be at least
1 year.

B. Presence, while depressed, of two (or more) of the following:

1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.

C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individ-
ual has never been without the symptoms in Criteria A and B for more than 2 months at a
time.

D. Criteria for a major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode, and criteria have

never been met for cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective disorder,

schizophrenia, delusional disorder, or other specified or unspecified schizophrenia
spectrum and other psychotic disorder.

G. The symptoms are not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition (e.g. hypothyroidism).

H. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.

Note: Because the criteria for a major depressive episode include four symptoms that are
absent from the symptom list for persistent depressive disorder (dysthymia), a very limited

Persistent Depressive Disorder (Dysthymia) 169

number of individuals will have depressive symptoms that have persisted longer than 2 years
but will not meet criteria for persistent depressive disorder. If full criteria for a major de-
pressive episode have been met at some point during the current episode of illness, they
should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other
specified depressive disorder or unspecified depressive disorder is warranted.

Specify if:
With anxious distress (p. 184)
With mixed features (pp. 184–185)
With melancholic features (p. 185)
With atypical features (pp. 185–186)
With mood-congruent psychotic features (p. 186)
With mood-incongruent psychotic features (p. 186)
With peripartum onset (pp. 186–187)

Specify if:
In partial remission (p. 188)
In full remission (p. 188)

Specify if:
Early onset: If onset is before age 21 years.
Late onset: If onset is at age 21 years or older.

Specify if (for most recent 2 years of persistent depressive disorder):
With pure dysthymic syndrome: Full criteria for a major depressive episode have not
been met in at least the preceding 2 years.
With persistent major depressive episode: Full criteria for a major depressive epi-
sode have been met throughout the preceding 2-year period.
With intermittent major depressive episodes, with current episode: Full criteria for
a major depressive episode are currently met, but there have been periods of at least
8 weeks in at least the preceding 2 years with symptoms below the threshold for a full
major depressive episode.
With intermittent major depressive episodes, without current episode: Full crite-
ria for a major depressive episode are not currently met, but there has been one or
more major depressive episodes in at least the preceding 2 years.

Specify current severity:
Mild (p. 188)
Moderate (p. 188)
Severe (p. 188)

Diagnostic Features
The essential feature of persistent depressive disorder (dysthymia) is a depressed mood
that occurs for most of the day, for more days than not, for at least 2 years, or at least 1 year
for children and adolescents (Criterion A). This disorder represents a consolidation of
DSM-IV-defined chronic major depressive disorder and dysthymic disorder. Major de-
pression may precede persistent depressive disorder, and major depressive episodes may
occur during persistent depressive disorder. Individuals whose symptoms meet major de-
pressive disorder criteria for 2 years should be given a diagnosis of persistent depressive
disorder as well as major depressive disorder.

Individuals with persistent depressive disorder describe their mood as sad or “down
in the dumps.” During periods of depressed mood, at least two of the six symptoms from
Criterion B are present. Because these symptoms have become a part of the individual’s
day-to-day experience, particularly in the case of early onset (e.g., “I’ve always been this

170 Depressive Disorders

way”), they may not be reported unless the individual is directly prompted. During the 2-year
period (1 year for children or adolescents), any symptom-free intervals last no longer than
2 months (Criterion C).

Prevalence
Persistent depressive disorder is effectively an amalgam of DSM-IV dysthymic disorder and
chronic major depressive episode. The 12-month prevalence in the United States is approxi-
mately 0.5% for persistent depressive disorder and 1.5% for chronic major depressive disorder.

Development and Course
Persistent depressive disorder often has an early and insidious onset (i.e., in childhood,
adolescence, or early adult life) and, by definition, a chronic course. Among individuals
with both persistent depressive disorder and borderline personality disorder, the covari-
ance of the corresponding features over time suggests the operation of a common mecha-
nism. Early onset (i.e., before age 21 years) is associated with a higher likelihood of
comorbid personality disorders and substance use disorders.

When symptoms rise to the level of a major depressive episode, they are likely to sub-
sequently revert to a lower level. However, depressive symptoms are much less likely to
resolve in a given period of time in the context of persistent depressive disorder than they
are in a major depressive episode.

Risk and Prognostic Factors
Temperamental. Factors predictive of poorer long-term outcome include higher levels
of neuroticism (negative affectivity), greater symptom severity, poorer global functioning,
and presence of anxiety disorders or conduct disorder.

Environmental. Childhood risk factors include parental loss or separation.

Genetic and physiological. There are no clear differences in illness development, course,
or family history between DSM-IV dysthymic disorder and chronic major depressive dis-
order. Earlier findings pertaining to either disorder are therefore likely to apply to per-
sistent depressive disorder. It is thus likely that individuals with persistent depressive
disorder will have a higher proportion of first-degree relatives with persistent depressive
disorder than do individuals with major depressive disorder, and more depressive disor-
ders in general.

A number of brain regions (e.g., prefrontal cortex, anterior cingulate, amygdala, hip-
pocampus) have been implicated in persistent depressive disorder. Possible polysomno-
graphic abnormalities exist as well.

Functional Consequences of
Persistent Depressive Disorder
The degree to which persistent depressive disorder impacts social and occupational func-
tioning is likely to vary widely, but effects can be as great as or greater than those of major
depressive disorder.

Differential Diagnosis
Major depressive disorder. If there is a depressed mood plus two or more symptoms
meeting criteria for a persistent depressive episode for 2 years or more, then the diagnosis of
persistent depressive disorder is made. The diagnosis depends on the 2-year duration,
which distinguishes it from episodes of depression that do not last 2 years. If the symptom

Premenstrual Dysphoric Disorder 171

criteria are sufficient for a diagnosis of a major depressive episode at any time during this pe-
riod, then the diagnosis of major depression should be noted, but it is coded not as a separate
diagnosis but rather as a specifier with the diagnosis of persistent depressive disorder. If the
individual’s symptoms currently meet full criteria for a major depressive episode, then the
specifier of “with intermittent major depressive episodes, with current episode” would be
made. If the major depressive episode has persisted for at least a 2-year duration and re-
mains present, then the specifier “with persistent major depressive episode” is used. When
full major depressive episode criteria are not currently met but there has been at least one
previous episode of major depression in the context of at least 2 years of persistent depres-
sive symptoms, then the specifier of “with intermittent major depressive episodes, without
current episode” is used. If the individual has not experienced an episode of major depres-
sion in the last 2 years, then the specifier “with pure dysthymic syndrome” is used.

Psychotic disorders. Depressive symptoms are a common associated feature of chronic
psychotic disorders (e.g., schizoaffective disorder, schizophrenia, delusional disorder). A
separate diagnosis of persistent depressive disorder is not made if the symptoms occur
only during the course of the psychotic disorder (including residual phases).

Depressive or bipolar and related disorder due to another medical condition. Persistent
depressive disorder must be distinguished from a depressive or bipolar and related dis-
order due to another medical condition. The diagnosis is depressive or bipolar and related
disorder due to another medical condition if the mood disturbance is judged, based on his-
tory, physical examination, or laboratory findings, to be attributable to the direct patho-
physiological effects of a specific, usually chronic, medical condition (e.g., multiple
sclerosis). If it is judged that the depressive symptoms are not attributable to the physiolog-
ical effects of another medical condition, then the primary mental disorder (e.g., persistent
depressive disorder) is recorded, and the medical condition is noted as a concomitant med-
ical condition (e.g., diabetes mellitus).

Substance/medication-induced depressive or bipolar disorder. A substance/medi-
cation-induced depressive or bipolar and related disorder is distinguished from persis-
tent depressive disorder when a substance (e.g., a drug of abuse, a medication, a toxin) is
judged to be etiologically related to the mood disturbance.

Personality disorders. Often, there is evidence of a coexisting personality disturbance.
When an individual’s presentation meets the criteria for both persistent depressive disor-
der and a personality disorder, both diagnoses are given.

Comorbidity
In comparison to individuals with major depressive disorder, those with persistent de-
pressive disorder are at higher risk for psychiatric comorbidity in general, and for anxiety
disorders and substance use disorders in particular. Early-onset persistent depressive dis-
order is strongly associated with DSM-IV Cluster B and C personality disorders.

Premenstrual Dysphoric Disorder
Diagnostic Criteria 625.4 (N94.3)

A. In the majority of menstrual cycles, at least five symptoms must be present in the final
week before the onset of menses, start to improve within a few days after the onset of
menses, and become minimal or absent in the week postmenses.

B. One (or more) of the following symptoms must be present:

1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or in-
creased sensitivity to rejection).

172 Depressive Disorders

2. Marked irritability or anger or increased interpersonal conflicts.
3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.

C. One (or more) of the following symptoms must additionally be present, to reach a total
of five symptoms when combined with symptoms from Criterion B above.

1. Decreased interest in usual activities (e.g., work, school, friends, hobbies).
2. Subjective difficulty in concentration.
3. Lethargy, easy fatigability, or marked lack of energy.
4. Marked change in appetite; overeating; or specific food cravings.
5. Hypersomnia or insomnia.
6. A sense of being overwhelmed or out of control.
7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a

sensation of “bloating,” or weight gain.

Note: The symptoms in Criteria A–C must have been met for most menstrual cycles that
occurred in the preceding year.
D. The symptoms are associated with clinically significant distress or interference with

work, school, usual social activities, or relationships with others (e.g., avoidance of so-
cial activities; decreased productivity and efficiency at work, school, or home).

E. The disturbance is not merely an exacerbation of the symptoms of another disorder,
such as major depressive disorder, panic disorder, persistent depressive disorder
(dysthymia), or a personality disorder (although it may co-occur with any of these dis-
orders).

F. Criterion A should be confirmed by prospective daily ratings during at least two symptom-
atic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.)

G. The symptoms are not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication, other treatment) or another medical condition (e.g., hy-
perthyroidism).

Recording Procedures
If symptoms have not been confirmed by prospective daily ratings of at least two symp-
tomatic cycles, “provisional” should be noted after the name of the diagnosis (i.e., “pre-
menstrual dysphoric disorder, provisional”).

Diagnostic Features
The essential features of premenstrual dysphoric disorder are the expression of mood la-
bility, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the pre-
menstrual phase of the cycle and remit around the onset of menses or shortly thereafter.
These symptoms may be accompanied by behavioral and physical symptoms. Symptoms
must have occurred in most of the menstrual cycles during the past year and must have an
adverse effect on work or social functioning. The intensity and/or expressivity of the ac-
companying symptoms may be closely related to social and cultural background charac-
teristics of the affected female, family perspectives, and more specific factors such as
religious beliefs, social tolerance, and female gender role issues.

Typically, symptoms peak around the time of the onset of menses. Although it is not
uncommon for symptoms to linger into the first few days of menses, the individual must
have a symptom-free period in the follicular phase after the menstrual period begins.
While the core symptoms include mood and anxiety symptoms, behavioral and somatic
symptoms commonly also occur. However, the presence of physical and/or behavioral
symptoms in the absence of mood and/or anxious symptoms is not sufficient for a diag-

Premenstrual Dysphoric Disorder 173

nosis. Symptoms are of comparable severity (but not duration) to those of another mental
disorder, such as a major depressive episode or generalized anxiety disorder. In order to
confirm a provisional diagnosis, daily prospective symptom ratings are required for at
least two symptomatic cycles.

Associated Features Supporting Diagnosis
Delusions and hallucinations have been described in the late luteal phase of the menstrual
cycle but are rare. The premenstrual phase has been considered by some to be a risk period
for suicide.

Prevalence
Twelve-month prevalence of premenstrual dysphoric disorder is between 1.8% and 5.8%
of menstruating women. Estimates are substantially inflated if they are based on retro-
spective reports rather than prospective daily ratings. However, estimated prevalence
based on a daily record of symptoms for 1–2 months may be less representative, as indi-
viduals with the most severe symptoms may be unable to sustain the rating process. The
most rigorous estimate of premenstrual dysphoric disorder is 1.8% for women whose
symptoms meet the full criteria without functional impairment and 1.3% for women
whose symptoms meet the current criteria with functional impairment and without co-oc-
curring symptoms from another mental disorder.

Development and Course
Onset of premenstrual dysphoric disorder can occur at any point after menarche. Inci-
dence of new cases over a 40-month follow-up period is 2.5% (95% confidence interval =
1.7–3.7). Anecdotally, many individuals, as they approach menopause, report that symp-
toms worsen. Symptoms cease after menopause, although cyclical hormone replacement
can trigger the re-expression of symptoms.

Risk and Prognostic Factors
Environmental. Environmental factors associated with the expression of premenstrual
dysphoric disorder include stress, history of interpersonal trauma, seasonal changes, and
sociocultural aspects of female sexual behavior in general, and female gender role in par-
ticular.

Genetic and physiological. Heritability of premenstrual dysphoric disorder is unknown.
However, for premenstrual symptoms, estimates for heritability range between 30% and
80%, with the most stable component of premenstrual symptoms estimated to be about
50% heritable.

Course modifiers. Women who use oral contraceptives may have fewer premenstrual
complaints than do women who do not use oral contraceptives.

Culture-Related Diagnostic Issues
Premenstrual dysphoric disorder is not a culture-bound syndrome and has been observed
in individuals in the United States, Europe, India, and Asia. It is unclear as to whether rates
differ by race. Nevertheless, frequency, intensity, and expressivity of symptoms and help-
seeking patterns may be significantly influenced by cultural factors.

Diagnostic Markers
As indicated earlier, the diagnosis of premenstrual dysphoric disorder is appropriately
confirmed by 2 months of prospective symptom ratings. A number of scales, including the

174 Depressive Disorders

Daily Rating of Severity of Problems and the Visual Analogue Scales for Premenstrual
Mood Symptoms, have undergone validation and are commonly used in clinical trials for
premenstrual dysphoric disorder. The Premenstrual Tension Syndrome Rating Scale has a
self-report and an observer version, both of which have been validated and used widely to
measure illness severity in women who have premenstrual dysphoric disorder.

Functional Consequences of
Premenstrual Dysphoric Disorder
Symptoms must be associated with clinically meaningful distress and/or an obvious and
marked impairment in the ability to function socially or occupationally in the week prior
to menses. Impairment in social functioning may be manifested by marital discord and
problems with children, other family members, or friends. Chronic marital or job prob-
lems should not be confused with dysfunction that occurs only in association with pre-
menstrual dysphoric disorder.

Differential Diagnosis
Premenstrual syndrome. Premenstrual syndrome differs from premenstrual dysphoric
disorder in that a minimum of five symptoms is not required, and there is no stipulation of
affective symptoms for individuals who have premenstrual syndrome. This condition
may be more common than premenstrual dysphoric disorder, although the estimated
prevalence of premenstrual syndrome varies. While premenstrual syndrome shares the
feature of symptom expression during the premenstrual phase of the menstrual cycle, it is
generally considered to be less severe than premenstrual dysphoric disorder. The pres-
ence of physical or behavioral symptoms in the premenstruum, without the required
affective symptoms, likely meets criteria for premenstrual syndrome and not for premen-
strual dysphoric disorder.

Dysmenorrhea. Dysmenorrhea is a syndrome of painful menses, but this is distinct from a
syndrome characterized by affective changes. Moreover, symptoms of dysmenorrhea begin
with the onset of menses, whereas symptoms of premenstrual dysphoric disorder, by defini-
tion, begin before the onset of menses, even if they linger into the first few days of menses.

Bipolar disorder, major depressive disorder, and persistent depressive disorder
(dysthymia). Many women with (either naturally occurring or substance/medication-
induced) bipolar or major depressive disorder or persistent depressive disorder believe
that they have premenstrual dysphoric disorder. However, when they chart symptoms,
they realize that the symptoms do not follow a premenstrual pattern. Women with an-
other mental disorder may experience chronic symptoms or intermittent symptoms that
are unrelated to menstrual cycle phase. However, because the onset of menses constitutes
a memorable event, they may report that symptoms occur only during the premenstruum
or that symptoms worsen premenstrually. This is one of the rationales for the requirement
that symptoms be confirmed by daily prospective ratings. The process of differential di-
agnosis, particularly if the clinician relies on retrospective symptoms only, is made more
difficult because of the overlap between symptoms of premenstrual dysphoric disorder
and some other diagnoses. The overlap of symptoms is particularly salient for differenti-
ating premenstrual dysphoric disorder from major depressive episodes, persistent de-
pressive disorder, bipolar disorders, and borderline personality disorder. However, the
rate of personality disorders is no higher in individuals with premenstrual dysphoric dis-
order than in those without the disorder.

Use of hormonal treatments. Some women who present with moderate to severe pre-
menstrual symptoms may be using hormonal treatments, including hormonal contracep-
tives. If such symptoms occur after initiation of exogenous hormone use, the symptoms

Substance/Medication-Induced Depressive Disorder 175

may be due to the use of hormones rather than to the underlying condition of premen-
strual dysphoric disorder. If the woman stops hormones and the symptoms disappear,
this is consistent with substance/medication-induced depressive disorder.

Comorbidity
A major depressive episode is the most frequently reported previous disorder in individuals
presenting with premenstrual dysphoric disorder. A wide range of medical (e.g., migraine,
asthma, allergies, seizure disorders) or other mental disorders (e.g., depressive and bipolar
disorders, anxiety disorders, bulimia nervosa, substance use disorders) may worsen in the
premenstrual phase; however, the absence of a symptom-free period during the postmen-
strual interval obviates a diagnosis of premenstrual dysphoric disorder. These conditions
are better considered premenstrual exacerbation of a current mental or medical disorder. Al-
though the diagnosis of premenstrual dysphoric disorder should not be assigned in situa-
tions in which an individual only experiences a premenstrual exacerbation of another
mental or physical disorder, it can be considered in addition to the diagnosis of another men-
tal or physical disorder if the individual experiences symptoms and changes in level of func-
tioning that are characteristic of premenstrual dysphoric disorder and markedly different
from the symptoms experienced as part of the ongoing disorder.

Substance/Medication-Induced
Depressive Disorder

Diagnostic Criteria

A. A prominent and persistent disturbance in mood that predominates in the clinical pic-
ture and is characterized by depressed mood or markedly diminished interest or plea-
sure in all, or almost all, activities.

B. There is evidence from the history, physical examination, or laboratory findings of both
(1) and (2):

1. The symptoms in Criterion A developed during or soon after substance intoxication
or withdrawal or after exposure to a medication.

2. The involved substance/medication is capable of producing the symptoms in Crite-
rion A.

C. The disturbance is not better explained by a depressive disorder that is not substance/
medication-induced. Such evidence of an independent depressive disorder could in-
clude the following:

The symptoms preceded the onset of the substance/medication use; the symptoms
persist for a substantial period of time (e.g., about 1 month) after the cessation of acute
withdrawal or severe intoxication; or there is other evidence suggesting the existence
of an independent non-substance/medication-induced depressive disorder (e.g., a his-
tory of recurrent non-substance/medication-related episodes).

D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-

tional, or other important areas of functioning.

Note: This diagnosis should be made instead of a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical
picture and when they are sufficiently severe to warrant clinical attention.

Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific substance/medica-
tion]-induced depressive disorders are indicated in the table below. Note that the ICD-10-

176 Depressive Disorders

CM code depends on whether or not there is a comorbid substance use disorder present for
the same class of substance. If a mild substance use disorder is comorbid with the substance-
induced depressive disorder, the 4th position character is “1,” and the clinician should record
“mild [substance] use disorder” before the substance-induced depressive disorder (e.g.,
“mild cocaine use disorder with cocaine-induced depressive disorder”). If a moderate or se-
vere substance use disorder is comorbid with the substance-induced depressive disorder,
the 4th position character is “2,” and the clinician should record “moderate [substance] use
disorder” or “severe [substance] use disorder,” depending on the severity of the comorbid
substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-
time heavy use of the substance), then the 4th position character is “9,” and the clinician should
record only the substance-induced depressive disorder.

Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for di-
agnoses associated with substance class):

With onset during intoxication: If criteria are met for intoxication with the substance
and the symptoms develop during intoxication.
With onset during withdrawal: If criteria are met for withdrawal from the substance
and the symptoms develop during, or shortly after, withdrawal.

Recording Procedures
ICD-9-CM. The name of the substance/medication-induced depressive disorder begins
with the specific substance (e.g., cocaine, dexamethasone) that is presumed to be causing
the depressive symptoms. The diagnostic code is selected from the table included in the
criteria set, which is based on the drug class. For substances that do not fit into any of the
classes (e.g., dexamethasone), the code for “other substance” should be used; and in cases
in which a substance is judged to be an etiological factor but the specific class of substance
is unknown, the category “unknown substance” should be used.

The name of the disorder is followed by the specification of onset (i.e., onset during in-
toxication, onset during withdrawal). Unlike the recording procedures for ICD-10-CM,
which combine the substance-induced disorder and substance use disorder into a single

ICD-10-CM

ICD-9-CM

With use
disorder,

mild

With use
disorder,
moderate
or severe

Without
use

disorder

Alcohol 291.89 F10.14 F10.24 F10.94

Phencyclidine 292.84 F16.14 F16.24 F16.94

Other hallucinogen 292.84 F16.14 F16.24 F16.94

Inhalant 292.84 F18.14 F18.24 F18.94

Opioid 292.84 F11.14 F11.24 F11.94

Sedative, hypnotic, or anxiolytic 292.84 F13.14 F13.24 F13.94

Amphetamine (or other
stimulant)

292.84 F15.14 F15.24 F15.94

Cocaine 292.84 F14.14 F14.24 F14.94

Other (or unknown) substance 292.84 F19.14 F19.24 F19.94

Substance/Medication-Induced Depressive Disorder 177

code, for ICD-9-CM a separate diagnostic code is given for the substance use disorder. For
example, in the case of depressive symptoms occurring during withdrawal in a man with
a severe cocaine use disorder, the diagnosis is 292.84 cocaine-induced depressive disorder,
with onset during withdrawal. An additional diagnosis of 304.20 severe cocaine use dis-
order is also given. When more than one substance is judged to play a significant role in
the development of depressive mood symptoms, each should be listed separately (e.g.,
292.84 methylphenidate-induced depressive disorder, with onset during withdrawal;
292.84 dexamethasone-induced depressive disorder, with onset during intoxication).

ICD-10-CM. The name of the substance/medication-induced depressive disorder begins
with the specific substance (e.g., cocaine, dexamethasone) that is presumed to be causing
the depressive symptoms. The diagnostic code is selected from the table included in the
criteria set, which is based on the drug class and presence or absence of a comorbid sub-
stance use disorder. For substances that do not fit into any of the classes (e.g., dexameth-
asone), the code for “other substance” should be used; and in cases in which a substance is
judged to be an etiological factor but the specific class of substance is unknown, the category
“unknown substance” should be used.

When recording the name of the disorder, the comorbid substance use disorder (if any) is
listed first, followed by the word “with,” followed by the name of the substance-induced de-
pressive disorder, followed by the specification of onset (i.e., onset during intoxication, onset
during withdrawal). For example, in the case of depressive symptoms occurring during with-
drawal in a man with a severe cocaine use disorder, the diagnosis is F14.24 severe cocaine use
disorder with cocaine-induced depressive disorder, with onset during withdrawal. A separate
diagnosis of the comorbid severe cocaine use disorder is not given. If the substance-induced
depressive disorder occurs without a comorbid substance use disorder (e.g., after a one-time
heavy use of the substance), no accompanying substance use disorder is noted (e.g., F16.94
phencyclidine-induced depressive disorder, with onset during intoxication). When more than
one substance is judged to play a significant role in the development of depressive mood
symptoms, each should be listed separately (e.g., F15.24 severe methylphenidate use disorder
with methylphenidate-induced depressive disorder, with onset during withdrawal; F19.94
dexamethasone-induced depressive disorder, with onset during intoxication).

Diagnostic Features
The diagnostic features of substance/medication-induced depressive disorder include the
symptoms of a depressive disorder, such as major depressive disorder; however, the de-
pressive symptoms are associated with the ingestion, injection, or inhalation of a sub-
stance (e.g., drug of abuse, toxin, psychotropic medication, other medication), and the
depressive symptoms persist beyond the expected length of physiological effects, intoxi-
cation, or withdrawal period. As evidenced by clinical history, physical examination, or
laboratory findings, the relevant depressive disorder should have developed during or
within 1 month after use of a substance that is capable of producing the depressive disor-
der (Criterion B1). In addition, the diagnosis is not better explained by an independent
depressive disorder. Evidence of an independent depressive disorder includes the de-
pressive disorder preceded the onset of ingestion or withdrawal from the substance; the
depressive disorder persists beyond a substantial period of time after the cessation of sub-
stance use; or other evidence suggests the existence of an independent non-substance/
medication-induced depressive disorder (Criterion C). This diagnosis should not be made
when symptoms occur exclusively during the course of a delirium (Criterion D). The de-
pressive disorder associated with the substance use, intoxication, or withdrawal must
cause clinically significant distress or impairment in social, occupational, or other impor-
tant areas of functioning to qualify for this diagnosis (Criterion E).

Some medications (e.g., stimulants, steroids, L-dopa, antibiotics, central nervous
system drugs, dermatological agents, chemotherapeutic drugs, immunological agents)

178 Depressive Disorders

can induce depressive mood disturbances. Clinical judgment is essential to determine
whether the medication is truly associated with inducing the depressive disorder or
whether a primary depressive disorder happened to have its onset while the person was
receiving the treatment. For example, a depressive episode that developed within the first
several weeks of beginning alpha-methyldopa (an antihypertensive agent) in an individ-
ual with no history of major depressive disorder would qualify for the diagnosis of med-
ication-induced depressive disorder. In some cases, a previously established condition
(e.g., major depressive disorder, recurrent) can recur while the individual is coincidentally
taking a medication that has the capacity to cause depressive symptoms (e.g., L-dopa, oral
contraceptives). In such cases, the clinician must make a judgment as to whether the med-
ication is causative in this particular situation.

A substance/medication-induced depressive disorder is distinguished from a primary
depressive disorder by considering the onset, course, and other factors associated with the
substance use. There must be evidence from the history, physical examination, or labora-
tory findings of substance use, abuse, intoxication, or withdrawal prior to the onset of the
depressive disorder. The withdrawal state for some substances can be relatively pro-
tracted, and thus intense depressive symptoms can last for a long period after the cessation
of substance use.

Prevalence
In a nationally representative U.S. adult population, the lifetime prevalence of substance/
medication-induced depressive disorder is 0.26%.

Development and Course
A depressive disorder associated with the use of substance (i.e., alcohol, illicit drugs, or a
prescribed treatment for a mental disorder or another medical condition) must have its on-
set while the individual is using the substance or during withdrawal, if there is a with-
drawal syndrome associated with the substance. Most often, the depressive disorder has
its onset within the first few weeks or 1 month of use of the substance. Once the substance
is discontinued, the depressive symptoms usually remit within days to several weeks, de-
pending on the half-life of the substance/medication and the presence of a withdrawal
syndrome. If symptoms persist 4 weeks beyond the expected time course of withdrawal of
a particular substance/medication, other causes for the depressive mood symptoms
should be considered.

Although there are a few prospective controlled trials examining the association of de-
pressive symptoms with use of a medication, most reports are from postmarketing sur-
veillance studies, retrospective observational studies, or case reports, making evidence of
causality difficult to determine. Substances implicated in medication-induced depressive
disorder, with varying degrees of evidence, include antiviral agents (efavirenz), cardio-
vascular agents (clonidine, guanethidine, methyldopa, reserpine), retinoic acid deriva-
tives (isotretinoin), antidepressants, anticonvulsants, anti-migraine agents (triptans),
antipsychotics, hormonal agents (corticosteroids, oral contraceptives, gonadotropin-
releasing hormone agonists, tamoxifen), smoking cessation agents (varenicline), and im-
munological agents (interferon). However, other potential substances continue to emerge
as new compounds are synthesized. A history of such substance use may help increase di-
agnostic certainty.

Risk and Prognostic Factors
Temperamental. Factors that appear to increase the risk of substance/medication-
induced depressive disorder can be conceptualized as pertaining to the specific type of
drug or to a group of individuals with underlying alcohol or drug use disorders. Risk fac-

Substance/Medication-Induced Depressive Disorder 179

tors common to all drugs include history of major depressive disorder, history of drug-
induced depression, and psychosocial stressors.

Environmental. There are also risks factors pertaining to a specific type of medication
(e.g., increased immune activation prior to treatment for hepatitis C associated with inter-
feron-alfa-induced depression); high doses (greater than 80 mg/day prednisone-equiva-
lents) of corticosteroids or high plasma concentrations of efavirenz; and high estrogen/
progesterone content in oral contraceptives.

Course modifiers. In a representative U.S. adult population, compared with individuals
with major depressive disorder who did not have a substance use disorder, individuals
with substance-induced depressive disorder were more likely to be male, to be black, to
have at most a high school diploma, to lack insurance, and to have lower family income.
They were also more likely to report higher family history of substance use disorders and
antisocial behavior, higher 12-month history of stressful life events, and a greater number
of DSM-IV major depressive disorder criteria. They were more likely to report feelings of
worthlessness, insomnia/hypersomnia, and thoughts of death and suicide attempts, but
less likely to report depressed mood and parental loss by death before age 18 years.

Diagnostic Markers
Determination of the substance of use can sometimes be made through laboratory assays
of the suspected substance in the blood or urine to corroborate the diagnosis.

Suicide Risk
Drug-induced or treatment-emergent suicidality represents a marked change in thoughts
and behavior from the person’s baseline, is usually temporally associated with initiation of
a substance, and must be distinguished from the underlying primary mental disorders.

In regard to the treatment-emergent suicidality associated with antidepressants, a U.S.
Food and Drug Administration (FDA) advisory committee considered meta-analyses of
99,839 participants enrolled in 372 randomized clinical trials of antidepressants in trials for
mental disorders. The analyses showed that when the data were pooled across all adult
age groups, there was no perceptible increased risk of suicidal behavior or ideation. How-
ever, in age-stratified analyses, the risk for patients ages 18–24 years was elevated, albeit
not significantly (odds ratio [OR] = 1.55; 95% confidence interval [CI] = 0.91–2.70). The
FDA meta-analyses reveal an absolute risk of suicide in patients taking investigational an-
tidepressants of 0.01%. In conclusion, suicide is clearly an extremely rare treatment-emer-
gent phenomenon, but the outcome of suicide was serious enough to prompt the FDA to
issue an expanded black-box warning in 2007 regarding the importance of careful moni-
toring of treatment-emergent suicidal ideation in patients receiving antidepressants.

Differential Diagnosis
Substance intoxication and withdrawal. Depressive symptoms occur commonly in sub-
stance intoxication and substance withdrawal, and the diagnosis of the substance-specific
intoxication or withdrawal will usually suffice to categorize the symptom presentation. A
diagnosis of substance-induced depressive disorder should be made instead of a diag-
nosis of substance intoxication or substance withdrawal when the mood symptoms are
sufficiently severe to warrant independent clinical attention. For example, dysphoric
mood is a characteristic feature of cocaine withdrawal. Substance/medication-induced
depressive disorder should be diagnosed instead of cocaine withdrawal only if the mood
disturbance is substantially more intense or longer lasting than what is usually encountered
with cocaine withdrawal and is sufficiently severe to be a separate focus of attention and
treatment.

180 Depressive Disorders

Primary depressive disorder. A substance/medication-induced depressive disorder is
distinguished from a primary depressive disorder by the fact that a substance is judged to
be etiologically related to the symptoms, as described earlier (see section “Development
and Course” for this disorder).

Depressive disorder due to another medical condition. Because individuals with other
medical conditions often take medications for those conditions, the clinician must consider the
possibility that the mood symptoms are caused by the physiological consequences of the med-
ical condition rather than the medication, in which case depressive disorder due to another
medical condition is diagnosed. The history often provides the primary basis for such a judg-
ment. At times, a change in the treatment for the other medical condition (e.g., medication sub-
stitution or discontinuation) may be needed to determine empirically whether the medication
is the causative agent. If the clinician has ascertained that the disturbance is a function of both
another medical condition and substance use or withdrawal, both diagnoses (i.e., depressive
disorder due to another medical condition and substance/medication-induced depressive
disorder) may be given. When there is insufficient evidence to determine whether the depres-
sive symptoms are associated with substance (including a medication) ingestion or with-
drawal or with another medical condition or are primary (i.e., not a function of either a
substance or another medical condition), a diagnosis of other specified depressive disorder or
unspecified depressive disorder would be indicated.

Comorbidity
Compared with individuals with major depressive disorder and no comorbid substance
use disorder, those with substance/medication-induced depressive disorder have higher
rates of comorbidity with any DSM-IV mental disorder; are more likely to have specific
DSM-IV disorders of pathological gambling and paranoid, histrionic, and antisocial per-
sonality disorders; and are less likely to have persistent depressive disorder (dysthymia).
Compared with individuals with major depressive disorder and a comorbid substance use
disorder, individuals with substance/medication-induced depressive disorder are more
likely to have alcohol use disorder, any other substance use disorder, and histrionic per-
sonality disorder; however, they are less likely to have persistent depressive disorder.

Depressive Disorder
Due to Another Medical Condition

Diagnostic Criteria

A. A prominent and persistent period of depressed mood or markedly diminished interest
or pleasure in all, or almost all, activities that predominates in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condi-
tion.

C. The disturbance is not better explained by another mental disorder (e.g., adjustment
disorder, with depressed mood, in which the stressor is a serious medical condition).

D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-

tional, or other important areas of functioning.

Coding note: The ICD-9-CM code for depressive disorder due to another medical condi-
tion is 293.83, which is assigned regardless of the specifier. The ICD-10-CM code de-
pends on the specifier (see below).

Depressive Disorder Due to Another Medical Condition 181

Specify if:
(F06.31) With depressive features: Full criteria are not met for a major depressive
episode.
(F06.32) With major depressive–like episode: Full criteria are met (except Criterion
C) for a major depressive episode.
(F06.34) With mixed features: Symptoms of mania or hypomania are also present but
do not predominate in the clinical picture.

Coding note: Include the name of the other medical condition in the name of the mental dis-
order (e.g., 293.83 [F06.31] depressive disorder due to hypothyroidism, with depressive fea-
tures). The other medical condition should also be coded and listed separately immediately
before the depressive disorder due to the medical condition (e.g., 244.9 [E03.9] hypothyroid-
ism; 293.83 [F06.31] depressive disorder due to hypothyroidism, with depressive features).

Diagnostic Features
The essential feature of depressive disorder due to another medical condition is a promi-
nent and persistent period of depressed mood or markedly diminished interest or plea-
sure in all, or almost all, activities that predominates in the clinical picture (Criterion A)
and that is thought to be related to the direct physiological effects of another medical con-
dition (Criterion B). In determining whether the mood disturbance is due to a general
medical condition, the clinician must first establish the presence of a general medical con-
dition. Further, the clinician must establish that the mood disturbance is etiologically re-
lated to the general medical condition through a physiological mechanism. A careful and
comprehensive assessment of multiple factors is necessary to make this judgment. Al-
though there are no infallible guidelines for determining whether the relationship
between the mood disturbance and the general medical condition is etiological, several
considerations provide some guidance in this area. One consideration is the presence of a
temporal association between the onset, exacerbation, or remission of the general medical
condition and that of the mood disturbance. A second consideration is the presence of fea-
tures that are atypical of primary Mood Disorders (e.g., atypical age at onset or course or
absence of family history). Evidence from the literature that suggests that there can be a di-
rect association between the general medical condition in question and the development
of mood symptoms can provide a useful context in the assessment of a particular situation.

Associated Features Supporting Diagnosis
Etiology (i.e., a causal relationship to another medical condition based on best clinical ev-
idence) is the key variable in depressive disorder due to another medical condition. The
listing of the medical conditions that are said to be able to induce major depression is never
complete, and the clinician’s best judgment is the essence of this diagnosis.

There are clear associations, as well as some neuroanatomical correlates, of depression
with stroke, Huntington’s disease, Parkinson’s disease, and traumatic brain injury. Among
the neuroendocrine conditions most closely associated with depression are Cushing’s dis-
ease and hypothyroidism. There are numerous other conditions thought to be associated
with depression, such as multiple sclerosis. However, the literature’s support for a causal
association is greater with some conditions, such as Parkinson’s disease and Huntington’s
disease, than with others, for which the differential diagnosis may be adjustment disorder,
with depressed mood.

Development and Course
Following stroke, the onset of depression appears to be very acute, occurring within 1 day
or a few days of the cerebrovascular accident (CVA) in the largest case series. However, in

182 Depressive Disorders

some cases, onset of the depression is weeks to months following the CVA. In the largest
series, the duration of the major depressive episode following stroke was 9–11 months on
average. Similarly, in Huntington’s disease the depressive state comes quite early in the
course of the illness. With Parkinson’s disease and Huntington’s disease, it often precedes
the major motor impairments and cognitive impairments associated with each condition.
This is more prominently the case for Huntington’s disease, in which depression is con-
sidered to be the first neuropsychiatric symptom. There is some observational evidence
that depression is less common as the dementia of Huntington’s disease progresses.

Risk and Prognostic Factors
The risk of acute onset of a major depressive disorder following a CVA (within 1 day to a
week of the event) appears to be strongly correlated with lesion location, with greatest risk
associated with left frontal strokes and least risk apparently associated with right frontal
lesions in those individuals who present within days of the stroke. The association with
frontal regions and laterality is not observed in depressive states that occur in the 2–6 months
following stroke.

Gender-Related Diagnostic Issues
Gender differences pertain to those associated with the medical condition (e.g., systemic
lupus erythematosus is more common in females; stroke is somewhat more common in
middle-age males compared with females).

Diagnostic Markers
Diagnostic markers pertain to those associated with the medical condition (e.g., steroid
levels in blood or urine to help corroborate the diagnosis of Cushing’s disease, which can
be associated with manic or depressive syndromes).

Suicide Risk
There are no epidemiological studies that provide evidence to differentiate the risk of sui-
cide from a major depressive episode due to another medical condition compared with the
risk from a major depressive episode in general. There are case reports of suicides in
association with major depressive episodes associated with another medical condition.
There is a clear association between serious medical illnesses and suicide, particularly
shortly after onset or diagnosis of the illness. Thus, it would be prudent to assume that the
risk of suicide for major depressive episodes associated with medical conditions is not less
than that for other forms of major depressive episode, and might even be greater.

Functional Consequences of Depressive Disorder
Due to Another Medical Condition
Functional consequences pertain to those associated with the medical condition. In gen-
eral, it is believed, but not established, that a major depressive episode induced by Cush-
ing’s disease will not recur if the Cushing’s disease is cured or arrested. However, it is also
suggested, but not established, that mood syndromes, including depressive and manic/
hypomanic ones, may be episodic (i.e., recurring) in some individuals with static brain in-
juries and other central nervous system diseases.

Differential Diagnosis
Depressive disorders not due to another medical condition. Determination of whether
a medical condition accompanying a depressive disorder is causing the disorder depends
on a) the absence of an episode(s) of depressive episodes prior to the onset of the medical

Other Specified Depressive Disorder 183

condition, b) the probability that the associated medical condition has a potential to pro-
mote or cause a depressive disorder, and c) a course of the depressive symptoms shortly
after the onset or worsening of the medical condition, especially if the depressive symp-
toms remit near the time that the medical disorder is effectively treated or remits.

Medication-induced depressive disorder. An important caveat is that some medical con-
ditions are treated with medications (e.g., steroids or alpha-interferon) that can induce depres-
sive or manic symptoms. In these cases, clinical judgment, based on all the evidence in hand, is
the best way to try to separate the most likely and/or the most important of two etiological fac-
tors (i.e., association with the medical condition vs. a substance-induced syndrome).

Adjustment disorders. It is important to differentiate a depressive episode from an ad-
justment disorder, as the onset of the medical condition is in itself a life stressor that could
bring on either an adjustment disorder or an episode of major depression. The major dif-
ferentiating elements are the pervasiveness the depressive picture and the number and
quality of the depressive symptoms that the patient reports or demonstrates on the mental
status examination. The differential diagnosis of the associated medical conditions is rel-
evant but largely beyond the scope of the present manual.

Comorbidity
Conditions comorbid with depressive disorder due to another medical condition are those
associated with the medical conditions of etiological relevance. It has been noted that de-
lirium can occur before or along with depressive symptoms in individuals with a variety
of medical conditions, such as Cushing’s disease. The association of anxiety symptoms,
usually generalized symptoms, is common in depressive disorders, regardless of cause.

Other Specified Depressive Disorder
311 (F32.8)

This category applies to presentations in which symptoms characteristic of a depressive
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for any of
the disorders in the depressive disorders diagnostic class. The other specified depressive
disorder category is used in situations in which the clinician chooses to communicate the
specific reason that the presentation does not meet the criteria for any specific depressive
disorder. This is done by recording “other specified depressive disorder” followed by the
specific reason (e.g., “short-duration depressive episode”).

Examples of presentations that can be specified using the “other specified” designation
include the following:
1. Recurrent brief depression: Concurrent presence of depressed mood and at least

four other symptoms of depression for 2–13 days at least once per month (not associ-
ated with the menstrual cycle) for at least 12 consecutive months in an individual
whose presentation has never met criteria for any other depressive or bipolar disorder
and does not currently meet active or residual criteria for any psychotic disorder.

2. Short-duration depressive episode (4–13 days): Depressed affect and at least four
of the other eight symptoms of a major depressive episode associated with clinically
significant distress or impairment that persists for more than 4 days, but less than 14 days,
in an individual whose presentation has never met criteria for any other depressive or
bipolar disorder, does not currently meet active or residual criteria for any psychotic dis-
order, and does not meet criteria for recurrent brief depression.

3. Depressive episode with insufficient symptoms: Depressed affect and at least one
of the other eight symptoms of a major depressive episode associated with clinically

184 Depressive Disorders

significant distress or impairment that persist for at least 2 weeks in an individual
whose presentation has never met criteria for any other depressive or bipolar disorder,
does not currently meet active or residual criteria for any psychotic disorder, and does
not meet criteria for mixed anxiety and depressive disorder symptoms.

Unspecified Depressive Disorder
311 (F32.9)

This category applies to presentations in which symptoms characteristic of a depressive dis-
order that cause clinically significant distress or impairment in social, occupational, or other im-
portant areas of functioning predominate but do not meet the full criteria for any of the disorders
in the depressive disorders diagnostic class. The unspecified depressive disorder category is
used in situations in which the clinician chooses not to specify the reason that the criteria are
not met for a specific depressive disorder, and includes presentations for which there is insuf-
ficient information to make a more specific diagnosis (e.g., in emergency room settings).

Specifiers for Depressive Disorders
Specify if:

With anxious distress: Anxious distress is defined as the presence of at least two of
the following symptoms during the majority of days of a major depressive episode or
persistent depressive disorder (dysthymia):

1. Feeling keyed up or tense.
2. Feeling unusually restless.
3. Difficulty concentrating because of worry.
4. Fear that something awful may happen.
5. Feeling that the individual might lose control of himself or herself.

Specify current severity:
Mild: Two symptoms.
Moderate: Three symptoms.
Moderate-severe: Four or five symptoms.
Severe: Four or five symptoms and with motor agitation.

Note: Anxious distress has been noted as a prominent feature of both bipolar and ma-
jor depressive disorder in both primary care and specialty mental health settings. High
levels of anxiety have been associated with higher suicide risk, longer duration of ill-
ness, and greater likelihood of treatment nonresponse. As a result, it is clinically useful
to specify accurately the presence and severity levels of anxious distress for treatment
planning and monitoring of response to treatment.

With mixed features:

A. At least three of the following manic/hypomanic symptoms are present nearly every
day during the majority of days of a major depressive episode:

1. Elevated, expansive mood.
2. Inflated self-esteem or grandiosity.
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Increase in energy or goal-directed activity (either socially, at work or school, or

sexually).

Specifiers for Depressive Disorders 185

6. Increased or excessive involvement in activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees, sexual in-
discretions, foolish business investments).

7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be
contrasted with insomnia).

B. Mixed symptoms are observable by others and represent a change from the per-
son’s usual behavior.

C. For individuals whose symptoms meet full criteria for either mania or hypomania,
the diagnosis should be bipolar I or bipolar II disorder.

D. The mixed symptoms are not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication or other treatment).

Note: Mixed features associated with a major depressive episode have been found
to be a significant risk factor for the development of bipolar I or bipolar II disorder.
As a result, it is clinically useful to note the presence of this specifier for treatment
planning and monitoring of response to treatment.

With melancholic features:

A. One of the following is present during the most severe period of the current epi-
sode:

1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even

temporarily, when something good happens).

B. Three (or more) of the following:

1. A distinct quality of depressed mood characterized by profound despondency,
despair, and/or moroseness or by so-called empty mood.

2. Depression that is regularly worse in the morning.
3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
4. Marked psychomotor agitation or retardation.
5. Significant anorexia or weight loss.
6. Excessive or inappropriate guilt.

Note: The specifier “with melancholic features” is applied if these features are present
at the most severe stage of the episode. There is a near-complete absence of the ca-
pacity for pleasure, not merely a diminution. A guideline for evaluating the lack of reac-
tivity of mood is that even highly desired events are not associated with marked
brightening of mood. Either mood does not brighten at all, or it brightens only partially
(e.g., up to 20%–40% of normal for only minutes at a time). The “distinct quality” of mood
that is characteristic of the “with melancholic features” specifier is experienced as qual-
itatively different from that during a nonmelancholic depressive episode. A depressed
mood that is described as merely more severe, longer lasting, or present without a rea-
son is not considered distinct in quality. Psychomotor changes are nearly always pres-
ent and are observable by others.

Melancholic features exhibit only a modest tendency to repeat across episodes in the
same individual. They are more frequent in inpatients, as opposed to outpatients; are
less likely to occur in milder than in more severe major depressive episodes; and are
more likely to occur in those with psychotic features.

With atypical features: This specifier can be applied when these features predomi-
nate during the majority of days of the current or most recent major depressive episode
or persistent depressive disorder.

A. Mood reactivity (i.e., mood brightens in response to actual or potential positive
events).

186 Depressive Disorders

B. Two (or more) of the following:

1. Significant weight gain or increase in appetite.
2. Hypersomnia.
3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
4. A long-standing pattern of interpersonal rejection sensitivity (not limited to epi-

sodes of mood disturbance) that results in significant social or occupational im-
pairment.

C. Criteria are not met for “with melancholic features” or “with catatonia” during the
same episode.

Note: “Atypical depression” has historical significance (i.e., atypical in contradistinction
to the more classical agitated, “endogenous” presentations of depression that were the
norm when depression was rarely diagnosed in outpatients and almost never in ado-
lescents or younger adults) and today does not connote an uncommon or unusual clin-
ical presentation as the term might imply.

Mood reactivity is the capacity to be cheered up when presented with positive events
(e.g., a visit from children, compliments from others). Mood may become euthymic (not
sad) even for extended periods of time if the external circumstances remain favorable.
Increased appetite may be manifested by an obvious increase in food intake or by
weight gain. Hypersomnia may include either an extended period of nighttime sleep or
daytime napping that totals at least 10 hours of sleep per day (or at least 2 hours more
than when not depressed). Leaden paralysis is defined as feeling heavy, leaden, or
weighted down, usually in the arms or legs. This sensation is generally present for at
least an hour a day but often lasts for many hours at a time. Unlike the other atypical
features, pathological sensitivity to perceived interpersonal rejection is a trait that has
an early onset and persists throughout most of adult life. Rejection sensitivity occurs
both when the person is and is not depressed, though it may be exacerbated during
depressive periods.

With psychotic features: Delusions and/or hallucinations are present.

With mood-congruent psychotic features: The content of all delusions and hal-
lucinations is consistent with the typical depressive themes of personal inade-
quacy, guilt, disease, death, nihilism, or deserved punishment.
With mood-incongruent psychotic features: The content of the delusions or hal-
lucinations does not involve typical depressive themes of personal inadequacy,
guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture
of mood-incongruent and mood-congruent themes.

With catatonia: The catatonia specifier can apply to an episode of depression if cata-
tonic features are present during most of the episode. See criteria for catatonia asso-
ciated with a mental disorder (for a description of catatonia, see the chapter
“Schizophrenia Spectrum and Other Psychotic Disorders”).

With peripartum onset: This specifier can be applied to the current or, if full criteria
are not currently met for a major depressive episode, most recent episode of major de-
pression if onset of mood symptoms occurs during pregnancy or in the 4 weeks follow-
ing delivery.

Note: Mood episodes can have their onset either during pregnancy or postpartum.
Although the estimates differ according to the period of follow-up after delivery, be-
tween 3% and 6% of women will experience the onset of a major depressive epi-
sode during pregnancy or in the weeks or months following delivery. Fifty percent
of “postpartum” major depressive episodes actually begin prior to delivery. Thus,
these episodes are referred to collectively as peripartum episodes. Women with
peripartum major depressive episodes often have severe anxiety and even panic

Specifiers for Depressive Disorders 187

attacks. Prospective studies have demonstrated that mood and anxiety symptoms
during pregnancy, as well as the “baby blues,” increase the risk for a postpartum
major depressive episode.

Peripartum-onset mood episodes can present either with or without psychotic
features. Infanticide is most often associated with postpartum psychotic episodes
that are characterized by command hallucinations to kill the infant or delusions that
the infant is possessed, but psychotic symptoms can also occur in severe postpar-
tum mood episodes without such specific delusions or hallucinations.

Postpartum mood (major depressive or manic) episodes with psychotic features
appear to occur in from 1 in 500 to 1 in 1,000 deliveries and may be more common
in primiparous women. The risk of postpartum episodes with psychotic features is
particularly increased for women with prior postpartum mood episodes but is also
elevated for those with a prior history of a depressive or bipolar disorder (especially
bipolar I disorder) and those with a family history of bipolar disorders.

Once a woman has had a postpartum episode with psychotic features, the risk
of recurrence with each subsequent delivery is between 30% and 50%. Postpartum
episodes must be differentiated from delirium occurring in the postpartum period,
which is distinguished by a fluctuating level of awareness or attention. The postpar-
tum period is unique with respect to the degree of neuroendocrine alterations and
psychosocial adjustments, the potential impact of breast-feeding on treatment
planning, and the long-term implications of a history of postpartum mood disorder
on subsequent family planning.

With seasonal pattern: This specifier applies to recurrent major depressive disorder.
A. There has been a regular temporal relationship between the onset of major depres-

sive episodes in major depressive disorder and a particular time of the year (e.g.,
in the fall or winter).
Note: Do not include cases in which there is an obvious effect of seasonally related
psychosocial stressors (e.g., regularly being unemployed every winter).

B. Full remissions (or a change from major depression to mania or hypomania) also
occur at a characteristic time of the year (e.g., depression disappears in the spring).

C. In the last 2 years, two major depressive episodes have occurred that demonstrate
the temporal seasonal relationships defined above and no nonseasonal major de-
pressive episodes have occurred during that same period.

D. Seasonal major depressive episodes (as described above) substantially outnum-
ber the nonseasonal major depressive episodes that may have occurred over the
individual’s lifetime.

Note: The specifier “with seasonal pattern” can be applied to the pattern of major de-
pressive episodes in major depressive disorder, recurrent. The essential feature is the
onset and remission of major depressive episodes at characteristic times of the year.
In most cases, the episodes begin in fall or winter and remit in spring. Less commonly,
there may be recurrent summer depressive episodes. This pattern of onset and remis-
sion of episodes must have occurred during at least a 2-year period, without any non-
seasonal episodes occurring during this period. In addition, the seasonal depressive
episodes must substantially outnumber any nonseasonal depressive episodes over
the individual’s lifetime.

This specifier does not apply to those situations in which the pattern is better ex-
plained by seasonally linked psychosocial stressors (e.g., seasonal unemployment or
school schedule). Major depressive episodes that occur in a seasonal pattern are often
characterized by prominent energy, hypersomnia, overeating, weight gain, and a crav-
ing for carbohydrates. It is unclear whether a seasonal pattern is more likely in recur-
rent major depressive disorder or in bipolar disorders. However, within the bipolar
disorders group, a seasonal pattern appears to be more likely in bipolar II disorder than

188 Depressive Disorders

in bipolar I disorder. In some individuals, the onset of manic or hypomanic episodes
may also be linked to a particular season.

The prevalence of winter-type seasonal pattern appears to vary with latitude, age,
and sex. Prevalence increases with higher latitudes. Age is also a strong predictor of
seasonality, with younger persons at higher risk for winter depressive episodes.

Specify if:
In partial remission: Symptoms of the immediately previous major depressive episode
are present, but full criteria are not met, or there is a period lasting less than 2 months
without any significant symptoms of a major depressive episode following the end of
such an episode.
In full remission: During the past 2 months, no significant signs or symptoms of the
disturbance were present.

Specify current severity:
Severity is based on the number of criterion symptoms, the severity of those symptoms,
and the degree of functional disability.

Mild: Few, if any, symptoms in excess of those required to make the diagnosis are
present, the intensity of the symptoms is distressing but manageable, and the symp-
toms result in minor impairment in social or occupational functioning.
Moderate: The number of symptoms, intensity of symptoms, and/or functional impair-
ment are between those specified for “mild” and “severe.”
Severe: The number of symptoms is substantially in excess of that required to make
the diagnosis, the intensity of the symptoms is seriously distressing and unmanage-
able, and the symptoms markedly interfere with social and occupational functioning.

189

Anxiety
Disorders

Anxiety disorders include disorders that share features of excessive fear and anxi-
ety and related behavioral disturbances. Fear is the emotional response to real or per-
ceived imminent threat, whereas anxiety is anticipation of future threat. Obviously, these
two states overlap, but they also differ, with fear more often associated with surges of au-
tonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape
behaviors, and anxiety more often associated with muscle tension and vigilance in prep-
aration for future danger and cautious or avoidant behaviors. Sometimes the level of fear
or anxiety is reduced by pervasive avoidance behaviors. Panic attacks feature prominently
within the anxiety disorders as a particular type of fear response. Panic attacks are not lim-
ited to anxiety disorders but rather can be seen in other mental disorders as well.

The anxiety disorders differ from one another in the types of objects or situations that
induce fear, anxiety, or avoidance behavior, and the associated cognitive ideation. Thus,
while the anxiety disorders tend to be highly comorbid with each other, they can be dif-
ferentiated by close examination of the types of situations that are feared or avoided and
the content of the associated thoughts or beliefs.

Anxiety disorders differ from developmentally normative fear or anxiety by being ex-
cessive or persisting beyond developmentally appropriate periods. They differ from tran-
sient fear or anxiety, often stress-induced, by being persistent (e.g., typically lasting 6 months
or more), although the criterion for duration is intended as a general guide with allowance
for some degree of flexibility and is sometimes of shorter duration in children (as in sepa-
ration anxiety disorder and selective mutism). Since individuals with anxiety disorders
typically overestimate the danger in situations they fear or avoid, the primary determina-
tion of whether the fear or anxiety is excessive or out of proportion is made by the clinician,
taking cultural contextual factors into account. Many of the anxiety disorders develop in
childhood and tend to persist if not treated. Most occur more frequently in females than in
males (approximately 2:1 ratio). Each anxiety disorder is diagnosed only when the symp-
toms are not attributable to the physiological effects of a substance/medication or to another
medical condition or are not better explained by another mental disorder.

The chapter is arranged developmentally, with disorders sequenced according to the
typical age at onset. The individual with separation anxiety disorder is fearful or anxious
about separation from attachment figures to a degree that is developmentally inappro-
priate. There is persistent fear or anxiety about harm coming to attachment figures and
events that could lead to loss of or separation from attachment figures and reluctance to go
away from attachment figures, as well as nightmares and physical symptoms of distress. Al-
though the symptoms often develop in childhood, they can be expressed throughout adult-
hood as well.

Selective mutism is characterized by a consistent failure to speak in social situations in
which there is an expectation to speak (e.g., school) even though the individual speaks in
other situations. The failure to speak has significant consequences on achievement in aca-
demic or occupational settings or otherwise interferes with normal social communication.

Individuals with specific phobia are fearful or anxious about or avoidant of circum-
scribed objects or situations. A specific cognitive ideation is not featured in this disorder,
as it is in other anxiety disorders. The fear, anxiety, or avoidance is almost always imme-

190 Anxiety Disorders

diately induced by the phobic situation, to a degree that is persistent and out of proportion
to the actual risk posed. There are various types of specific phobias: animal; natural envi-
ronment; blood-injection-injury; situational; and other situations.

In social anxiety disorder (social phobia), the individual is fearful or anxious about or
avoidant of social interactions and situations that involve the possibility of being scruti-
nized. These include social interactions such as meeting unfamiliar people, situations in
which the individual may be observed eating or drinking, and situations in which the in-
dividual performs in front of others. The cognitive ideation is of being negatively evalu-
ated by others, by being embarrassed, humiliated, or rejected, or offending others.

In panic disorder, the individual experiences recurrent unexpected panic attacks and is
persistently concerned or worried about having more panic attacks or changes his or her
behavior in maladaptive ways because of the panic attacks (e.g., avoidance of exercise or of
unfamiliar locations). Panic attacks are abrupt surges of intense fear or intense discomfort
that reach a peak within minutes, accompanied by physical and/or cognitive symptoms.
Limited-symptom panic attacks include fewer than four symptoms. Panic attacks may be
expected, such as in response to a typically feared object or situation, or unexpected, meaning
that the panic attack occurs for no apparent reason. Panic attacks function as a marker and
prognostic factor for severity of diagnosis, course, and comorbidity across an array of dis-
orders, including, but not limited to, the anxiety disorders (e.g., substance use, depressive
and psychotic disorders). Panic attack may therefore be used as a descriptive specifier for
any anxiety disorder as well as other mental disorders.

Individuals with agoraphobia are fearful and anxious about two or more of the follow-
ing situations: using public transportation; being in open spaces; being in enclosed places;
standing in line or being in a crowd; or being outside of the home alone in other situations.
The individual fears these situations because of thoughts that escape might be difficult or
help might not be available in the event of developing panic-like symptoms or other inca-
pacitating or embarrassing symptoms. These situations almost always induce fear or anx-
iety and are often avoided and require the presence of a companion.

The key features of generalized anxiety disorder are persistent and excessive anxiety
and worry about various domains, including work and school performance, that the indi-
vidual finds difficult to control. In addition, the individual experiences physical symptoms,
including restlessness or feeling keyed up or on edge; being easily fatigued; difficulty con-
centrating or mind going blank; irritability; muscle tension; and sleep disturbance.

Substance/medication-induced anxiety disorder involves anxiety due to substance in-
toxication or withdrawal or to a medication treatment. In anxiety disorder due to another
medical condition, anxiety symptoms are the physiological consequence of another med-
ical condition.

Disorder-specific scales are available to better characterize the severity of each anxiety
disorder and to capture change in severity over time. For ease of use, particularly for in-
dividuals with more than one anxiety disorder, these scales have been developed to have
the same format (but different focus) across the anxiety disorders, with ratings of behav-
ioral symptoms, cognitive ideation symptoms, and physical symptoms relevant to each
disorder.

Separation Anxiety Disorder
Diagnostic Criteria 309.21 (F93.0)

A. Developmentally inappropriate and excessive fear or anxiety concerning separation from
those to whom the individual is attached, as evidenced by at least three of the following:

1. Recurrent excessive distress when anticipating or experiencing separation from
home or from major attachment figures.

Separation Anxiety Disorder 191

2. Persistent and excessive worry about losing major attachment figures or about pos-
sible harm to them, such as illness, injury, disasters, or death.

3. Persistent and excessive worry about experiencing an untoward event (e.g., getting
lost, being kidnapped, having an accident, becoming ill) that causes separation
from a major attachment figure.

4. Persistent reluctance or refusal to go out, away from home, to school, to work, or
elsewhere because of fear of separation.

5. Persistent and excessive fear of or reluctance about being alone or without major
attachment figures at home or in other settings.

6. Persistent reluctance or refusal to sleep away from home or to go to sleep without
being near a major attachment figure.

7. Repeated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nau-

sea, vomiting) when separation from major attachment figures occurs or is antici-
pated.

B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and
adolescents and typically 6 months or more in adults.

C. The disturbance causes clinically significant distress or impairment in social, aca-
demic, occupational, or other important areas of functioning.

D. The disturbance is not better explained by another mental disorder, such as refusing
to leave home because of excessive resistance to change in autism spectrum disorder;
delusions or hallucinations concerning separation in psychotic disorders; refusal to go
outside without a trusted companion in agoraphobia; worries about ill health or other
harm befalling significant others in generalized anxiety disorder; or concerns about
having an illness in illness anxiety disorder.

Diagnostic Features
The essential feature of separation anxiety disorder is excessive fear or anxiety concerning
separation from home or attachment figures. The anxiety exceeds what may be expected
given the person’s developmental level (Criterion A). Individuals with separation anxiety
disorder have symptoms that meet at least three of the following criteria: They experience
recurrent excessive distress when separation from home or major attachment figures is an-
ticipated or occurs (Criterion A1). They worry about the well-being or death of attachment
figures, particularly when separated from them, and they need to know the whereabouts
of their attachment figures and want to stay in touch with them (Criterion A2). They also
worry about untoward events to themselves, such as getting lost, being kidnapped, or
having an accident, that would keep them from ever being reunited with their major at-
tachment figure (Criterion A3). Individuals with separation anxiety disorder are reluctant
or refuse to go out by themselves because of separation fears (Criterion A4). They have
persistent and excessive fear or reluctance about being alone or without major attachment
figures at home or in other settings. Children with separation anxiety disorder may be un-
able to stay or go in a room by themselves and may display “clinging” behavior, staying
close to or “shadowing” the parent around the house, or requiring someone to be with
them when going to another room in the house (Criterion A5). They have persistent reluc-
tance or refusal to go to sleep without being near a major attachment figure or to sleep
away from home (Criterion A6). Children with this disorder often have difficulty at bed-
time and may insist that someone stay with them until they fall asleep. During the night,
they may make their way to their parents’ bed (or that of a significant other, such as a sib-
ling). Children may be reluctant or refuse to attend camp, to sleep at friends’ homes, or to
go on errands. Adults may be uncomfortable when traveling independently (e.g., sleeping
in a hotel room). There may be repeated nightmares in which the content expresses the in-

192 Anxiety Disorders

dividual’s separation anxiety (e.g., destruction of the family through fire, murder, or other
catastrophe) (Criterion A7). Physical symptoms (e.g., headaches, abdominal complaints,
nausea, vomiting) are common in children when separation from major attachment fig-
ures occurs or is anticipated (Criterion A8). Cardiovascular symptoms such as palpitations,
dizziness, and feeling faint are rare in younger children but may occur in adolescents and
adults.

The disturbance must last for a period of at least 4 weeks in children and adolescents
younger than 18 years and is typically 6 months or longer in adults (Criterion B). However,
the duration criterion for adults should be used as a general guide, with allowance for
some degree of flexibility. The disturbance must cause clinically significant distress or im-
pairment in social, academic, occupational, or other important areas of functioning (Cri-
terion C).

Associated Features Supporting Diagnosis
When separated from major attachment figures, children with separation anxiety disorder
may exhibit social withdrawal, apathy, sadness, or difficulty concentrating on work or
play. Depending on their age, individuals may have fears of animals, monsters, the dark,
muggers, burglars, kidnappers, car accidents, plane travel, and other situations that are
perceived as presenting danger to the family or themselves. Some individuals become
homesick and uncomfortable to the point of misery when away from home. Separation
anxiety disorder in children may lead to school refusal, which in turn may lead to academic
difficulties and social isolation. When extremely upset at the prospect of separation, chil-
dren may show anger or occasionally aggression toward someone who is forcing separa-
tion. When alone, especially in the evening or the dark, young children may report unusual
perceptual experiences (e.g., seeing people peering into their room, frightening creatures
reaching for them, feeling eyes staring at them). Children with this disorder may be de-
scribed as demanding, intrusive, and in need of constant attention, and, as adults, may ap-
pear dependent and overprotective. The individual’s excessive demands often become a
source of frustration for family members, leading to resentment and conflict in the family.

Prevalence
The 12-month prevalence of separation anxiety disorder among adults in the United States
is 0.9%–1.9%. In children, 6- to 12-month prevalence is estimated to be approximately 4%.
In adolescents in the United States, the 12-month prevalence is 1.6%. Separation anxiety
disorder decreases in prevalence from childhood through adolescence and adulthood and
is the most prevalent anxiety disorder in children younger than 12 years. In clinical sam-
ples of children, the disorder is equally common in males and females. In the community,
the disorder is more frequent in females.

Development and Course
Periods of heightened separation anxiety from attachment figures are part of normal early
development and may indicate the development of secure attachment relationships (e.g.,
around 1 year of age, when infants may suffer from stranger anxiety). Onset of separation
anxiety disorder may be as early as preschool age and may occur at any time during child-
hood and more rarely in adolescence. Typically there are periods of exacerbation and re-
mission. In some cases, both the anxiety about possible separation and the avoidance of
situations involving separation from the home or nuclear family (e.g., going away to col-
lege, moving away from attachment figures) may persist through adulthood. However,
the majority of children with separation anxiety disorder are free of impairing anxiety dis-
orders over their lifetimes. Many adults with separation anxiety disorder do not recall a
childhood onset of separation anxiety disorder, although they may recall symptoms.

Separation Anxiety Disorder 193

The manifestations of separation anxiety disorder vary with age. Younger children are
more reluctant to go to school or may avoid school altogether. Younger children may not
express worries or specific fears of definite threats to parents, home, or themselves, and the
anxiety is manifested only when separation is experienced. As children age, worries
emerge; these are often worries about specific dangers (e.g., accidents, kidnapping, mug-
ging, death) or vague concerns about not being reunited with attachment figures. In adults,
separation anxiety disorder may limit their ability to cope with changes in circumstances
(e.g., moving, getting married). Adults with the disorder are typically overconcerned about
their offspring and spouses and experience marked discomfort when separated from them.
They may also experience significant disruption in work or social experiences because of
needing to continuously check on the whereabouts of a significant other.

Risk and Prognostic Factors
Environmental. Separation anxiety disorder often develops after life stress, especially a
loss (e.g., the death of a relative or pet; an illness of the individual or a relative; a change of
schools; parental divorce; a move to a new neighborhood; immigration; a disaster that in-
volved periods of separation from attachment figures). In young adults, other examples of
life stress include leaving the parental home, entering into a romantic relationship, and be-
coming a parent. Parental overprotection and intrusiveness may be associated with sepa-
ration anxiety disorder.

Genetic and physiological. Separation anxiety disorder in children may be heritable.
Heritability was estimated at 73% in a community sample of 6-year-old twins, with higher
rates in girls. Children with separation anxiety disorder display particularly enhanced
sensitivity to respiratory stimulation using CO2-enriched air.

Culture-Related Diagnostic Issues
There are cultural variations in the degree to which it is considered desirable to tolerate
separation, so that demands and opportunities for separation between parents and chil-
dren are avoided in some cultures. For example, there is wide variation across countries
and cultures with respect to the age at which it is expected that offspring should leave the
parental home. It is important to differentiate separation anxiety disorder from the high
value some cultures place on strong interdependence among family members.

Gender-Related Diagnostic Issues
Girls manifest greater reluctance to attend or avoidance of school than boys. Indirect ex-
pression of fear of separation may be more common in males than in females, for example,
by limited independent activity, reluctance to be away from home alone, or distress when
spouse or offspring do things independently or when contact with spouse or offspring is
not possible.

Suicide Risk
Separation anxiety disorder in children may be associated with an increased risk for sui-
cide. In a community sample, the presence of mood disorders, anxiety disorders, or sub-
stance use has been associated with suicidal ideation and attempts. However, this
association is not specific to separation anxiety disorder and is found in several anxiety
disorders.

Functional Consequences of Separation Anxiety Disorder
Individuals with separation anxiety disorder often limit independent activities away from
home or attachment figures (e.g., in children, avoiding school, not going to camp, having

194 Anxiety Disorders

difficulty sleeping alone; in adolescents, not going away to college; in adults, not leaving the
parental home, not traveling, not working outside the home).

Differential Diagnosis
Generalized anxiety disorder. Separation anxiety disorder is distinguished from gener-
alized anxiety disorder in that the anxiety predominantly concerns separation from attach-
ment figures, and if other worries occur, they do not predominate the clinical picture.

Panic disorder. Threats of separation may lead to extreme anxiety and even a panic at-
tack. In separation anxiety disorder, in contrast to panic disorder, the anxiety concerns the
possibility of being away from attachment figures and worry about untoward events be-
falling them, rather than being incapacitated by an unexpected panic attack.

Agoraphobia. Unlike individuals with agoraphobia, those with separation anxiety dis-
order are not anxious about being trapped or incapacitated in situations from which es-
cape is perceived as difficult in the event of panic-like symptoms or other incapacitating
symptoms.

Conduct disorder. School avoidance (truancy) is common in conduct disorder, but anx-
iety about separation is not responsible for school absences, and the child or adolescent
usually stays away from, rather than returns to, the home.

Social anxiety disorder. School refusal may be due to social anxiety disorder (social pho-
bia). In such instances, the school avoidance is due to fear of being judged negatively by oth-
ers rather than to worries about being separated from the attachment figures.

Posttraumatic stress disorder. Fear of separation from loved ones is common after trau-
matic events such as a disasters, particularly when periods of separation from loved ones
were experienced during the traumatic event. In posttraumatic stress disorder (PTSD), the
central symptoms concern intrusions about, and avoidance of, memories associated with
the traumatic event itself, whereas in separation anxiety disorder, the worries and avoid-
ance concern the well-being of attachment figures and separation from them.

Illness anxiety disorder. Individuals with illness anxiety disorder worry about specific
illnesses they may have, but the main concern is about the medical diagnosis itself, not
about being separated from attachment figures.

Bereavement. Intense yearning or longing for the deceased, intense sorrow and emo-
tional pain, and preoccupation with the deceased or the circumstances of the death are ex-
pected responses occurring in bereavement, whereas fear of separation from other
attachment figures is central in separation anxiety disorder.

Depressive and bipolar disorders. These disorders may be associated with reluctance
to leave home, but the main concern is not worry or fear of untoward events befalling at-
tachment figures, but rather low motivation for engaging with the outside world. How-
ever, individuals with separation anxiety disorder may become depressed while being
separated or in anticipation of separation.

Oppositional defiant disorder. Children and adolescents with separation anxiety disor-
der may be oppositional in the context of being forced to separate from attachment figures.
Oppositional defiant disorder should be considered only when there is persistent opposi-
tional behavior unrelated to the anticipation or occurrence of separation from attachment
figures.

Psychotic disorders. Unlike the hallucinations in psychotic disorders, the unusual per-
ceptual experiences that may occur in separation anxiety disorder are usually based on a
misperception of an actual stimulus, occur only in certain situations (e.g., nighttime), and
are reversed by the presence of an attachment figure.

Selective Mutism 195

Personality disorders. Dependent personality disorder is characterized by an indis-
criminate tendency to rely on others, whereas separation anxiety disorder involves con-
cern about the proximity and safety of main attachment figures. Borderline personality
disorder is characterized by fear of abandonment by loved ones, but problems in identity,
self-direction, interpersonal functioning, and impulsivity are additionally central to that
disorder, whereas they are not central to separation anxiety disorder.

Comorbidity
In children, separation anxiety disorder is highly comorbid with generalized anxiety dis-
order and specific phobia. In adults, common comorbidities include specific phobia,
PTSD, panic disorder, generalized anxiety disorder, social anxiety disorder, agoraphobia,
obsessive-compulsive disorder, and personality disorders. Depressive and bipolar disor-
ders are also comorbid with separation anxiety disorder in adults.

Selective Mutism
Diagnostic Criteria 313.23 (F94.0)

A. Consistent failure to speak in specific social situations in which there is an expectation
for speaking (e.g., at school) despite speaking in other situations.

B. The disturbance interferes with educational or occupational achievement or with social
communication.

C. The duration of the disturbance is at least 1 month (not limited to the first month of
school).

D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the
spoken language required in the social situation.

E. The disturbance is not better explained by a communication disorder (e.g., childhood-
onset fluency disorder) and does not occur exclusively during the course of autism
spectrum disorder, schizophrenia, or another psychotic disorder.

Diagnostic Features
When encountering other individuals in social interactions, children with selective mut-
ism do not initiate speech or reciprocally respond when spoken to by others. Lack of
speech occurs in social interactions with children or adults. Children with selective mut-
ism will speak in their home in the presence of immediate family members but often not
even in front of close friends or second-degree relatives, such as grandparents or cousins.
The disturbance is often marked by high social anxiety. Children with selective mutism of-
ten refuse to speak at school, leading to academic or educational impairment, as teachers
often find it difficult to assess skills such as reading. The lack of speech may interfere with
social communication, although children with this disorder sometimes use nonspoken or
nonverbal means (e.g., grunting, pointing, writing) to communicate and may be willing or
eager to perform or engage in social encounters when speech is not required (e.g., nonver-
bal parts in school plays).

Associated Features Supporting Diagnosis
Associated features of selective mutism may include excessive shyness, fear of social em-
barrassment, social isolation and withdrawal, clinging, compulsive traits, negativism,
temper tantrums, or mild oppositional behavior. Although children with this disorder
generally have normal language skills, there may occasionally be an associated commu-

196 Anxiety Disorders

nication disorder, although no particular association with a specific communication dis-
order has been identified. Even when these disorders are present, anxiety is present as
well. In clinical settings, children with selective mutism are almost always given an addi-
tional diagnosis of another anxiety disorder—most commonly, social anxiety disorder (so-
cial phobia).

Prevalence
Selective mutism is a relatively rare disorder and has not been included as a diagnostic cat-
egory in epidemiological studies of prevalence of childhood disorders. Point prevalence
using various clinic or school samples ranges between 0.03% and 1% depending on the set-
ting (e.g., clinic vs. school vs. general population) and ages of the individuals in the sample.
The prevalence of the disorder does not seem to vary by sex or race/ethnicity. The disor-
der is more likely to manifest in young children than in adolescents and adults.

Development and Course
The onset of selective mutism is usually before age 5 years, but the disturbance may not
come to clinical attention until entry into school, where there is an increase in social inter-
action and performance tasks, such as reading aloud. The persistence of the disorder is
variable. Although clinical reports suggest that many individuals “outgrow” selective
mutism, the longitudinal course of the disorder is unknown. In some cases, particularly in
individuals with social anxiety disorder, selective mutism may disappear, but symptoms
of social anxiety disorder remain.

Risk and Prognostic Factors
Temperamental. Temperamental risk factors for selective mutism are not well identi-
fied. Negative affectivity (neuroticism) or behavioral inhibition may play a role, as may
parental history of shyness, social isolation, and social anxiety. Children with selective
mutism may have subtle receptive language difficulties compared with their peers, al-
though receptive language is still within the normal range.

Environmental. Social inhibition on the part of parents may serve as a model for social
reticence and selective mutism in children. Furthermore, parents of children with selective
mutism have been described as overprotective or more controlling than parents of chil-
dren with other anxiety disorders or no disorder.

Genetic and physiological factors. Because of the significant overlap between selective
mutism and social anxiety disorder, there may be shared genetic factors between these
conditions.

Culture-Related Diagnostic Issues
Children in families who have immigrated to a country where a different language is spo-
ken may refuse to speak the new language because of lack of knowledge of the language.
If comprehension of the new language is adequate but refusal to speak persists, a diagno-
sis of selective mutism may be warranted.

Functional Consequences of Selective Mutism
Selective mutism may result in social impairment, as children may be too anxious to en-
gage in reciprocal social interaction with other children. As children with selective mutism
mature, they may face increasing social isolation. In school settings, these children may
suffer academic impairment, because often they do not communicate with teachers re-
garding their academic or personal needs (e.g., not understanding a class assignment, not

Specific Phobia 197

asking to use the restroom). Severe impairment in school and social functioning, including
that resulting from teasing by peers, is common. In certain instances, selective mutism
may serve as a compensatory strategy to decrease anxious arousal in social encounters.

Differential Diagnosis
Communication disorders. Selective mutism should be distinguished from speech dis-
turbances that are better explained by a communication disorder, such as language
disorder, speech sound disorder (previously phonological disorder), childhood-onset
fluency disorder (stuttering), or pragmatic (social) communication disorder. Unlike selec-
tive mutism, the speech disturbance in these conditions is not restricted to a specific social
situation.

Neurodevelopmental disorders and schizophrenia and other psychotic disorders.
Individuals with an autism spectrum disorder, schizophrenia or another psychotic disor-
der, or severe intellectual disability may have problems in social communication and be
unable to speak appropriately in social situations. In contrast, selective mutism should be
diagnosed only when a child has an established capacity to speak in some social situations
(e.g., typically at home).

Social anxiety disorder (social phobia). The social anxiety and social avoidance in so-
cial anxiety disorder may be associated with selective mutism. In such cases, both diagno-
ses may be given.

Comorbidity
The most common comorbid conditions are other anxiety disorders, most commonly so-
cial anxiety disorder, followed by separation anxiety disorder and specific phobia. Oppo-
sitional behaviors have been noted to occur in children with selective mutism, although
oppositional behavior may be limited to situations requiring speech. Communication de-
lays or disorders also may appear in some children with selective mutism.

Specific Phobia
Diagnostic Criteria

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals,
receiving an injection, seeing blood).

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing,
or clinging.

B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object

or situation and to the sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.
G. The disturbance is not better explained by the symptoms of another mental disorder,

including fear, anxiety, and avoidance of situations associated with panic-like symptoms
or other incapacitating symptoms (as in agoraphobia); objects or situations related to
obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in
posttraumatic stress disorder); separation from home or attachment figures (as in sep-
aration anxiety disorder); or social situations (as in social anxiety disorder).

198 Anxiety Disorders

Specify if:
Code based on the phobic stimulus:

300.29 (F40.218) Animal (e.g., spiders, insects, dogs).
300.29 (F40.228) Natural environment (e.g., heights, storms, water).
300.29 (F40.23x) Blood-injection-injury (e.g., needles, invasive medical procedures).

Coding note: Select specific ICD-10-CM code as follows: F40.230 fear of blood;
F40.231 fear of injections and transfusions; F40.232 fear of other medical care; or
F40.233 fear of injury.

300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed places).
300.29 (F40.298) Other (e.g., situations that may lead to choking or vomiting; in chil-
dren, e.g., loud sounds or costumed characters).

Coding note: When more than one phobic stimulus is present, code all ICD-10-CM codes
that apply (e.g., for fear of snakes and flying, F40.218 specific phobia, animal, and
F40.248 specific phobia, situational).

Specifiers
It is common for individuals to have multiple specific phobias. The average individual with
specific phobia fears three objects or situations, and approximately 75% of individuals with
specific phobia fear more than one situation or object. In such cases, multiple specific phobia
diagnoses, each with its own diagnostic code reflecting the phobic stimulus, would need to be
given. For example, if an individual fears thunderstorms and flying, then two diagnoses
would be given: specific phobia, natural environment, and specific phobia, situational.

Diagnostic Features
A key feature of this disorder is that the fear or anxiety is circumscribed to the presence of a
particular situation or object (Criterion A), which may be termed the phobic stimulus. The cat-
egories of feared situations or objects are provided as specifiers. Many individuals fear objects
or situations from more than one category, or phobic stimulus. For the diagnosis of specific
phobia, the response must differ from normal, transient fears that commonly occur in the pop-
ulation. To meet the criteria for a diagnosis, the fear or anxiety must be intense or severe (i.e.,
“marked”) (Criterion A). The amount of fear experienced may vary with proximity to the
feared object or situation and may occur in anticipation of or in the actual presence of the object
or situation. Also, the fear or anxiety may take the form of a full or limited symptom panic at-
tack (i.e., expected panic attack). Another characteristic of specific phobias is that fear or anxi-
ety is evoked nearly every time the individual comes into contact with the phobic stimulus
(Criterion B). Thus, an individual who becomes anxious only occasionally upon being con-
fronted with the situation or object (e.g., becomes anxious when flying only on one out of every
five airplane flights) would not be diagnosed with specific phobia. However, the degree of fear
or anxiety expressed may vary (from anticipatory anxiety to a full panic attack) across different
occasions of encountering the phobic object or situation because of various contextual factors
such as the presence of others, duration of exposure, and other threatening elements such as
turbulence on a flight for individuals who fear flying. Fear and anxiety are often expressed dif-
ferently between children and adults. Also, the fear or anxiety occurs as soon as the phobic ob-
ject or situation is encountered (i.e., immediately rather than being delayed).

The individual actively avoids the situation, or if he or she either is unable or decides
not to avoid it, the situation or object evokes intense fear or anxiety (Criterion C). Active
avoidance means the individual intentionally behaves in ways that are designed to prevent
or minimize contact with phobic objects or situations (e.g., takes tunnels instead of bridges
on daily commute to work for fear of heights; avoids entering a dark room for fear of spi-
ders; avoids accepting a job in a locale where a phobic stimulus is more common). Avoid-

Specific Phobia 199

ance behaviors are often obvious (e.g., an individual who fears blood refusing to go to the
doctor) but are sometimes less obvious (e.g., an individual who fears snakes refusing to
look at pictures that resemble the form or shape of snakes). Many individuals with specific
phobias have suffered over many years and have changed their living circumstances in
ways designed to avoid the phobic object or situation as much as possible (e.g., an indi-
vidual diagnosed with specific phobia, animal, who moves to reside in an area devoid of
the particular feared animal). Therefore, they no longer experience fear or anxiety in their
daily life. In such instances, avoidance behaviors or ongoing refusal to engage in activities
that would involve exposure to the phobic object or situation (e.g., repeated refusal to ac-
cept offers for work-related travel because of fear of flying) may be helpful in confirming
the diagnosis in the absence of overt anxiety or panic.

The fear or anxiety is out of proportion to the actual danger that the object or situation
poses, or more intense than is deemed necessary (Criterion D). Although individuals with
specific phobia often recognize their reactions as disproportionate, they tend to overesti-
mate the danger in their feared situations, and thus the judgment of being out of propor-
tion is made by the clinician. The individual’s sociocultural context should also be taken
into account. For example, fears of the dark may be reasonable in a context of ongoing
violence, and fear of insects may be more disproportionate in settings where insects are
consumed in the diet. The fear, anxiety, or avoidance is persistent, typically lasting for
6 months or more (Criterion E), which helps distinguish the disorder from transient fears
that are common in the population, particularly among children. However, the duration
criterion should be used as a general guide, with allowance for some degree of flexibility.
The specific phobia must cause clinically significant distress or impairment in social, oc-
cupational, or other important areas of functioning in order for the disorder to be diag-
nosed (Criterion F).

Associated Features Supporting Diagnosis
Individuals with specific phobia typically experience an increase in physiological arousal
in anticipation of or during exposure to a phobic object or situation. However, the physi-
ological response to the feared situation or object varies. Whereas individuals with situa-
tional, natural environment, and animal specific phobias are likely to show sympathetic
nervous system arousal, individuals with blood-injection-injury specific phobia often
demonstrate a vasovagal fainting or near-fainting response that is marked by initial brief
acceleration of heart rate and elevation of blood pressure followed by a deceleration of
heart rate and a drop in blood pressure. Current neural systems models for specific phobia
emphasize the amygdala and related structures, much as in other anxiety disorders.

Prevalence
In the United States, the 12-month community prevalence estimate for specific phobia is
approximately 7%–9%. Prevalence rates in European countries are largely similar to those
in the United States (e.g., about 6%), but rates are generally lower in Asian, African, and
Latin American countries (2%–4%). Prevalence rates are approximately 5% in children and
are approximately 16% in 13- to 17-year-olds. Prevalence rates are lower in older individ-
uals (about 3%–5%), possibly reflecting diminishing severity to subclinical levels. Females
are more frequently affected than males, at a rate of approximately 2:1, although rates vary
across different phobic stimuli. That is, animal, natural environment, and situational spe-
cific phobias are predominantly experienced by females, whereas blood-injection-injury
phobia is experienced nearly equally by both genders.

Development and Course
Specific phobia sometimes develops following a traumatic event (e.g., being attacked by
an animal or stuck in an elevator), observation of others going through a traumatic event (e.g.,

200 Anxiety Disorders

watching someone drown), an unexpected panic attack in the to be feared situation (e.g.,
an unexpected panic attack while on the subway), or informational transmission (e.g., ex-
tensive media coverage of a plane crash). However, many individuals with specific phobia
are unable to recall the specific reason for the onset of their phobias. Specific phobia usu-
ally develops in early childhood, with the majority of cases developing prior to age 10
years. The median age at onset is between 7 and 11 years, with the mean at about 10 years.
Situational specific phobias tend to have a later age at onset than natural environment, an-
imal, or blood-injection-injury specific phobias. Specific phobias that develop in child-
hood and adolescence are likely to wax and wane during that period. However, phobias
that do persist into adulthood are unlikely to remit for the majority of individuals.

When specific phobia is being diagnosed in children, two issues should be considered.
First, young children may express their fear and anxiety by crying, tantrums, freezing,
or clinging. Second, young children typically are not able to understand the concept of
avoidance. Therefore, the clinician should assemble additional information from parents,
teachers, or others who know the child well. Excessive fears are quite common in young
children but are usually transitory and only mildly impairing and thus considered devel-
opmentally appropriate. In such cases a diagnosis of specific phobia would not be made.
When the diagnosis of specific phobia is being considered in a child, it is important to
assess the degree of impairment and the duration of the fear, anxiety, or avoidance, and
whether it is typical for the child’s particular developmental stage.

Although the prevalence of specific phobia is lower in older populations, it remains
one of the more commonly experienced disorders in late life. Several issues should be con-
sidered when diagnosing specific phobia in older populations. First, older individuals
may be more likely to endorse natural environment specific phobias, as well as phobias of
falling. Second, specific phobia (like all anxiety disorders) tends to co-occur with medical
concerns in older individuals, including coronary heart disease and chronic obstructive
pulmonary disease. Third, older individuals may be more likely to attribute the symptoms
of anxiety to medical conditions. Fourth, older individuals may be more likely to manifest
anxiety in an atypical manner (e.g., involving symptoms of both anxiety and depression)
and thus be more likely to warrant a diagnosis of unspecified anxiety disorder. Addition-
ally, the presence of specific phobia in older adults is associated with decreased quality of
life and may serve as a risk factor for major neurocognitive disorder.

Although most specific phobias develop in childhood and adolescence, it is possible for a
specific phobia to develop at any age, often as the result of experiences that are traumatic. For
example, phobias of choking almost always follow a near-choking event at any age.

Risk and Prognostic Factors
Temperamental. Temperamental risk factors for specific phobia, such as negative affec-
tivity (neuroticism) or behavioral inhibition, are risk factors for other anxiety disorders as
well.

Environmental. Environmental risk factors for specific phobias, such as parental over-
protectiveness, parental loss and separation, and physical and sexual abuse, tend to pre-
dict other anxiety disorders as well. As noted earlier, negative or traumatic encounters
with the feared object or situation sometimes (but not always) precede the development of
specific phobia.

Genetic and physiological. There may be a genetic susceptibility to a certain category of
specific phobia (e.g., an individual with a first-degree relative with a specific phobia of an-
imals is significantly more likely to have the same specific phobia than any other category
of phobia). Individuals with blood-injection-injury phobia show a unique propensity to
vasovagal syncope (fainting) in the presence of the phobic stimulus.

Specific Phobia 201

Culture-Related Diagnostic Issues
In the United States, Asians and Latinos report significantly lower rates of specific phobia
than non-Latino whites, African Americans, and Native Americans. In addition to having
lower prevalence rates of specific phobia, some countries outside of the United States, par-
ticularly Asian and African countries, show differing phobia content, age at onset, and
gender ratios.

Suicide Risk
Individuals with specific phobia are up to 60% more likely to make a suicide attempt than
are individuals without the diagnosis. However, it is likely that these elevated rates are
primarily due to comorbidity with personality disorders and other anxiety disorders.

Functional Consequences of Specific Phobia
Individuals with specific phobia show similar patterns of impairment in psychosocial
functioning and decreased quality of life as individuals with other anxiety disorders and
alcohol and substance use disorders, including impairments in occupational and inter-
personal functioning. In older adults, impairment may be seen in caregiving duties and
volunteer activities. Also, fear of falling in older adults can lead to reduced mobility and
reduced physical and social functioning, and may lead to receiving formal or informal
home support. The distress and impairment caused by specific phobias tend to increase
with the number of feared objects and situations. Thus, an individual who fears four ob-
jects or situations is likely to have more impairment in his or her occupational and social
roles and a lower quality of life than an individual who fears only one object or situation.
Individuals with blood-injection-injury specific phobia are often reluctant to obtain med-
ical care even when a medical concern is present. Additionally, fear of vomiting and chok-
ing may substantially reduce dietary intake.

Differential Diagnosis
Agoraphobia. Situational specific phobia may resemble agoraphobia in its clinical pre-
sentation, given the overlap in feared situations (e.g., flying, enclosed places, elevators). If
an individual fears only one of the agoraphobia situations, then specific phobia, situa-
tional, may be diagnosed. If two or more agoraphobic situations are feared, a diagnosis of
agoraphobia is likely warranted. For example, an individual who fears airplanes and ele-
vators (which overlap with the “public transportation” agoraphobic situation) but does
not fear other agoraphobic situations would be diagnosed with specific phobia, situa-
tional, whereas an individual who fears airplanes, elevators, and crowds (which overlap
with two agoraphobic situations, “using public transportation” and “standing in line and
or being in a crowd”) would be diagnosed with agoraphobia. Criterion B of agoraphobia
(the situations are feared or avoided “because of thoughts that escape might be difficult or
help might not be available in the event of developing panic-like symptoms or other inca-
pacitating or embarrassing symptoms”) can also be useful in differentiating agoraphobia
from specific phobia. If the situations are feared for other reasons, such as fear of being
harmed directly by the object or situations (e.g., fear of the plane crashing, fear of the an-
imal biting), a specific phobia diagnosis may be more appropriate.

Social anxiety disorder. If the situations are feared because of negative evaluation, so-
cial anxiety disorder should be diagnosed instead of specific phobia.

Separation anxiety disorder. If the situations are feared because of separation from a
primary caregiver or attachment figure, separation anxiety disorder should be diagnosed
instead of specific phobia.

202 Anxiety Disorders

Panic disorder. Individuals with specific phobia may experience panic attacks when con-
fronted with their feared situation or object. A diagnosis of specific phobia would be given if
the panic attacks only occurred in response to the specific object or situation, whereas a di-
agnosis of panic disorder would be given if the individual also experienced panic attacks
that were unexpected (i.e., not in response to the specific phobia object or situation).

Obsessive-compulsive disorder. If an individual’s primary fear or anxiety is of an ob-
ject or situation as a result of obsessions (e.g., fear of blood due to obsessive thoughts about
contamination from blood-borne pathogens [i.e., HIV]; fear of driving due to obsessive im-
ages of harming others), and if other diagnostic criteria for obsessive-compulsive disorder
are met, then obsessive-compulsive disorder should be diagnosed.

Trauma- and stressor-related disorders. If the phobia develops following a traumatic
event, posttraumatic stress disorder (PTSD) should be considered as a diagnosis. How-
ever, traumatic events can precede the onset of PTSD and specific phobia. In this case, a di-
agnosis of specific phobia would be assigned only if all of the criteria for PTSD are not met.

Eating disorders. A diagnosis of specific phobia is not given if the avoidance behavior is
exclusively limited to avoidance of food and food-related cues, in which case a diagnosis
of anorexia nervosa or bulimia nervosa should be considered.

Schizophrenia spectrum and other psychotic disorders. When the fear and avoidance
are due to delusional thinking (as in schizophrenia or other schizophrenia spectrum and
other psychotic disorders), a diagnosis of specific phobia is not warranted.

Comorbidity
Specific phobia is rarely seen in medical-clinical settings in the absence of other psycho-
pathology and is more frequently seen in nonmedical mental health settings. Specific pho-
bia is frequently associated with a range of other disorders, especially depression in older
adults. Because of early onset, specific phobia is typically the temporally primary disorder.
Individuals with specific phobia are at increased risk for the development of other dis-
orders, including other anxiety disorders, depressive and bipolar disorders, substance-
related disorders, somatic symptom and related disorders, and personality disorders (par-
ticularly dependent personality disorder).

Social Anxiety Disorder (Social Phobia)
Diagnostic Criteria 300.23 (F40.10)

A. Marked fear or anxiety about one or more social situations in which the individual is
exposed to possible scrutiny by others. Examples include social interactions (e.g., hav-
ing a conversation, meeting unfamiliar people), being observed (e.g., eating or drink-
ing), and performing in front of others (e.g., giving a speech).

Note: In children, the anxiety must occur in peer settings and not just during interac-
tions with adults.

B. The individual fears that he or she will act in a way or show anxiety symptoms that will
be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection
or offend others).

C. The social situations almost always provoke fear or anxiety.

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing,
clinging, shrinking, or failing to speak in social situations.

D. The social situations are avoided or endured with intense fear or anxiety.

Social Anxiety Disorder (Social Phobia) 203

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation
and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a sub-

stance (e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another

mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum
disorder.

J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns
or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specify if:
Performance only: If the fear is restricted to speaking or performing in public.

Specifiers
Individuals with the performance only type of social anxiety disorder have performance
fears that are typically most impairing in their professional lives (e.g., musicians, dancers,
performers, athletes) or in roles that require regular public speaking. Performance fears
may also manifest in work, school, or academic settings in which regular public presenta-
tions are required. Individuals with performance only social anxiety disorder do not fear
or avoid nonperformance social situations.

Diagnostic Features
The essential feature of social anxiety disorder is a marked, or intense, fear or anxiety of so-
cial situations in which the individual may be scrutinized by others. In children the fear or
anxiety must occur in peer settings and not just during interactions with adults (Criterion
A). When exposed to such social situations, the individual fears that he or she will be neg-
atively evaluated. The individual is concerned that he or she will be judged as anxious,
weak, crazy, stupid, boring, intimidating, dirty, or unlikable. The individual fears that
he or she will act or appear in a certain way or show anxiety symptoms, such as blushing,
trembling, sweating, stumbling over one’s words, or staring, that will be negatively eval-
uated by others (Criterion B). Some individuals fear offending others or being rejected as
a result. Fear of offending others—for example, by a gaze or by showing anxiety symp-
toms—may be the predominant fear in individuals from cultures with strong collectivistic
orientations. An individual with fear of trembling of the hands may avoid drinking, eat-
ing, writing, or pointing in public; an individual with fear of sweating may avoid shaking
hands or eating spicy foods; and an individual with fear of blushing may avoid public per-
formance, bright lights, or discussion about intimate topics. Some individuals fear and
avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or
“shy bladder syndrome”).

The social situations almost always provoke fear or anxiety (Criterion C). Thus, an in-
dividual who becomes anxious only occasionally in the social situation(s) would not be di-
agnosed with social anxiety disorder. However, the degree and type of fear and anxiety
may vary (e.g., anticipatory anxiety, a panic attack) across different occasions. The antici-
patory anxiety may occur sometimes far in advance of upcoming situations (e.g., worrying
every day for weeks before attending a social event, repeating a speech for days in advance).
In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, or
shrinking in social situations. The individual will often avoid the feared social situations.
Alternatively, the situations are endured with intense fear or anxiety (Criterion D). Avoid-

204 Anxiety Disorders

ance can be extensive (e.g., not going to parties, refusing school) or subtle (e.g., overpre-
paring the text of a speech, diverting attention to others, limiting eye contact).

The fear or anxiety is judged to be out of proportion to the actual risk of being nega-
tively evaluated or to the consequences of such negative evaluation (Criterion E). Some-
times, the anxiety may not be judged to be excessive, because it is related to an actual
danger (e.g., being bullied or tormented by others). However, individuals with social anx-
iety disorder often overestimate the negative consequences of social situations, and thus
the judgment of being out of proportion is made by the clinician. The individual’s socio-
cultural context needs to be taken into account when this judgment is being made. For ex-
ample, in certain cultures, behavior that might otherwise appear socially anxious may be
considered appropriate in social situations (e.g., might be seen as a sign of respect).

The duration of the disturbance is typically at least 6 months (Criterion F). This dura-
tion threshold helps distinguish the disorder from transient social fears that are com-
mon, particularly among children and in the community. However, the duration criterion
should be used as a general guide, with allowance for some degree of flexibility. The fear,
anxiety, and avoidance must interfere significantly with the individual’s normal routine,
occupational or academic functioning, or social activities or relationships, or must cause
clinically significant distress or impairment in social, occupational, or other important ar-
eas of functioning (Criterion G). For example, an individual who is afraid to speak in pub-
lic would not receive a diagnosis of social anxiety disorder if this activity is not routinely
encountered on the job or in classroom work, and if the individual is not significantly dis-
tressed about it. However, if the individual avoids, or is passed over for, the job or educa-
tion he or she really wants because of social anxiety symptoms, Criterion G is met.

Associated Features Supporting Diagnosis
Individuals with social anxiety disorder may be inadequately assertive or excessively sub-
missive or, less commonly, highly controlling of the conversation. They may show overly
rigid body posture or inadequate eye contact, or speak with an overly soft voice. These in-
dividuals may be shy or withdrawn, and they may be less open in conversations and dis-
close little about themselves. They may seek employment in jobs that do not require social
contact, although this is not the case for individuals with social anxiety disorder, perfor-
mance only. They may live at home longer. Men may be delayed in marrying and having
a family, whereas women who would want to work outside the home may live a life as
homemaker and mother. Self-medication with substances is common (e.g., drinking be-
fore going to a party). Social anxiety among older adults may also include exacerbation of
symptoms of medical illnesses, such as increased tremor or tachycardia. Blushing is a hall-
mark physical response of social anxiety disorder.

Prevalence
The 12-month prevalence estimate of social anxiety disorder for the United States is ap-
proximately 7%. Lower 12-month prevalence estimates are seen in much of the world us-
ing the same diagnostic instrument, clustering around 0.5%–2.0%; median prevalence in
Europe is 2.3%. The 12-month prevalence rates in children and adolescents are comparable
to those in adults. Prevalence rates decrease with age. The 12-month prevalence for older
adults ranges from 2% to 5%. In general, higher rates of social anxiety disorder are found
in females than in males in the general population (with odds ratios ranging from 1.5 to
2.2), and the gender difference in prevalence is more pronounced in adolescents and
young adults. Gender rates are equivalent or slightly higher for males in clinical samples,
and it is assumed that gender roles and social expectations play a significant role in ex-
plaining the heightened help-seeking behavior in male patients. Prevalence in the United
States is higher in American Indians and lower in persons of Asian, Latino, African Amer-
ican, and Afro-Caribbean descent compared with non-Hispanic whites.

Social Anxiety Disorder (Social Phobia) 205

Development and Course
Median age at onset of social anxiety disorder in the United States is 13 years, and 75% of
individuals have an age at onset between 8 and 15 years. The disorder sometimes emerges
out of a childhood history of social inhibition or shyness in U.S. and European studies. On-
set can also occur in early childhood. Onset of social anxiety disorder may follow a stress-
ful or humiliating experience (e.g., being bullied, vomiting during a public speech), or it
may be insidious, developing slowly. First onset in adulthood is relatively rare and is more
likely to occur after a stressful or humiliating event or after life changes that require new
social roles (e.g., marrying someone from a different social class, receiving a job promo-
tion). Social anxiety disorder may diminish after an individual with fear of dating marries
and may reemerge after divorce. Among individuals presenting to clinical care, the disor-
der tends to be particularly persistent.

Adolescents endorse a broader pattern of fear and avoidance, including of dating,
compared with younger children. Older adults express social anxiety at lower levels but
across a broader range of situations, whereas younger adults express higher levels of so-
cial anxiety for specific situations. In older adults, social anxiety may concern disability
due to declining sensory functioning (hearing, vision) or embarrassment about one’s ap-
pearance (e.g., tremor as a symptom of Parkinson’s disease) or functioning due to medical
conditions, incontinence, or cognitive impairment (e.g., forgetting people’s names). In the
community approximately 30% of individuals with social anxiety disorder experience re-
mission of symptoms within 1 year, and about 50% experience remission within a few
years. For approximately 60% of individuals without a specific treatment for social anxiety
disorder, the course takes several years or longer.

Detection of social anxiety disorder in older adults may be challenging because of sev-
eral factors, including a focus on somatic symptoms, comorbid medical illness, limited
insight, changes to social environment or roles that may obscure impairment in social
functioning, or reticence about describing psychological distress.

Risk and Prognostic Factors
Temperamental. Underlying traits that predispose individuals to social anxiety disor-
der include behavioral inhibition and fear of negative evaluation.

Environmental. There is no causative role of increased rates of childhood maltreatment or
other early-onset psychosocial adversity in the development of social anxiety disorder. How-
ever, childhood maltreatment and adversity are risk factors for social anxiety disorder.

Genetic and physiological. Traits predisposing individuals to social anxiety disorder,
such as behavioral inhibition, are strongly genetically influenced. The genetic influence is
subject to gene-environment interaction; that is, children with high behavioral inhibition
are more susceptible to environmental influences, such as socially anxious modeling by
parents. Also, social anxiety disorder is heritable (but performance-only anxiety less so).
First-degree relatives have a two to six times greater chance of having social anxiety dis-
order, and liability to the disorder involves the interplay of disorder-specific (e.g., fear of
negative evaluation) and nonspecific (e.g., neuroticism) genetic factors.

Culture-Related Diagnostic Issues
The syndrome of taijin kyofusho (e.g., in Japan and Korea) is often characterized by social-
evaluative concerns, fulfilling criteria for social anxiety disorder, that are associated with
the fear that the individual makes other people uncomfortable (e.g., “My gaze upsets peo-
ple so they look away and avoid me”), a fear that is at times experienced with delusional
intensity. This symptom may also be found in non-Asian settings. Other presentations
of taijin kyofusho may fulfill criteria for body dysmorphic disorder or delusional disorder.

206 Anxiety Disorders

Immigrant status is associated with significantly lower rates of social anxiety disorder in
both Latino and non-Latino white groups. Prevalence rates of social anxiety disorder may
not be in line with self-reported social anxiety levels in the same culture—that is, societies
with strong collectivistic orientations may report high levels of social anxiety but low prev-
alence of social anxiety disorder.

Gender-Related Diagnostic Issues
Females with social anxiety disorder report a greater number of social fears and comorbid
depressive, bipolar, and anxiety disorders, whereas males are more likely to fear dating,
have oppositional defiant disorder or conduct disorder, and use alcohol and illicit drugs to
relieve symptoms of the disorder. Paruresis is more common in males.

Functional Consequences of Social Anxiety Disorder
Social anxiety disorder is associated with elevated rates of school dropout and with de-
creased well-being, employment, workplace productivity, socioeconomic status, and quality
of life. Social anxiety disorder is also associated with being single, unmarried, or divorced
and with not having children, particularly among men. In older adults, there may be impair-
ment in caregiving duties and volunteer activities. Social anxiety disorder also impedes lei-
sure activities. Despite the extent of distress and social impairment associated with social
anxiety disorder, only about half of individuals with the disorder in Western societies ever
seek treatment, and they tend to do so only after 15–20 years of experiencing symptoms. Not
being employed is a strong predictor for the persistence of social anxiety disorder.

Differential Diagnosis
Normative shyness. Shyness (i.e., social reticence) is a common personality trait and is
not by itself pathological. In some societies, shyness is even evaluated positively. How-
ever, when there is a significant adverse impact on social, occupational, and other impor-
tant areas of functioning, a diagnosis of social anxiety disorder should be considered, and
when full diagnostic criteria for social anxiety disorder are met, the disorder should be di-
agnosed. Only a minority (12%) of self-identified shy individuals in the United States have
symptoms that meet diagnostic criteria for social anxiety disorder.

Agoraphobia. Individuals with agoraphobia may fear and avoid social situations (e.g., go-
ing to a movie) because escape might be difficult or help might not be available in the event of
incapacitation or panic-like symptoms, whereas individuals with social anxiety disorder are
most fearful of scrutiny by others. Moreover, individuals with social anxiety disorder are likely
to be calm when left entirely alone, which is often not the case in agoraphobia.

Panic disorder. Individuals with social anxiety disorder may have panic attacks, but the
concern is about fear of negative evaluation, whereas in panic disorder the concern is
about the panic attacks themselves.

Generalized anxiety disorder. Social worries are common in generalized anxiety disorder,
but the focus is more on the nature of ongoing relationships rather than on fear of negative
evaluation. Individuals with generalized anxiety disorder, particularly children, may have ex-
cessive worries about the quality of their social performance, but these worries also pertain to
nonsocial performance and when the individual is not being evaluated by others. In social anx-
iety disorder, the worries focus on social performance and others’ evaluation.

Separation anxiety disorder. Individuals with separation anxiety disorder may avoid
social settings (including school refusal) because of concerns about being separated from
attachment figures or, in children, about requiring the presence of a parent when it is not
developmentally appropriate. Individuals with separation anxiety disorder are usually
comfortable in social settings when their attachment figure is present or when they are at

Social Anxiety Disorder (Social Phobia) 207

home, whereas those with social anxiety disorder may be uncomfortable when social sit-
uations occur at home or in the presence of attachment figures.

Specific phobias. Individuals with specific phobias may fear embarrassment or humil-
iation (e.g., embarrassment about fainting when they have their blood drawn), but they do
not generally fear negative evaluation in other social situations.

Selective mutism. Individuals with selective mutism may fail to speak because of fear of
negative evaluation, but they do not fear negative evaluation in social situations where no
speaking is required (e.g., nonverbal play).

Major depressive disorder. Individuals with major depressive disorder may be con-
cerned about being negatively evaluated by others because they feel they are bad or not
worthy of being liked. In contrast, individuals with social anxiety disorder are worried
about being negatively evaluated because of certain social behaviors or physical symptoms.

Body dysmorphic disorder. Individuals with body dysmorphic disorder are preoccu-
pied with one or more perceived defects or flaws in their physical appearance that are not
observable or appear slight to others; this preoccupation often causes social anxiety and
avoidance. If their social fears and avoidance are caused only by their beliefs about their
appearance, a separate diagnosis of social anxiety disorder is not warranted.

Delusional disorder. Individuals with delusional disorder may have nonbizarre delu-
sions and/or hallucinations related to the delusional theme that focus on being rejected by
or offending others. Although extent of insight into beliefs about social situations may
vary, many individuals with social anxiety disorder have good insight that their beliefs are
out of proportion to the actual threat posed by the social situation.

Autism spectrum disorder. Social anxiety and social communication deficits are hall-
marks of autism spectrum disorder. Individuals with social anxiety disorder typically
have adequate age-appropriate social relationships and social communication capacity,
although they may appear to have impairment in these areas when first interacting with
unfamiliar peers or adults.

Personality disorders. Given its frequent onset in childhood and its persistence into and
through adulthood, social anxiety disorder may resemble a personality disorder. The most
apparent overlap is with avoidant personality disorder. Individuals with avoidant person-
ality disorder have a broader avoidance pattern than those with social anxiety disorder.
Nonetheless, social anxiety disorder is typically more comorbid with avoidant personality
disorder than with other personality disorders, and avoidant personality disorder is more
comorbid with social anxiety disorder than with other anxiety disorders.

Other mental disorders. Social fears and discomfort can occur as part of schizophrenia,
but other evidence for psychotic symptoms is usually present. In individuals with an eat-
ing disorder, it is important to determine that fear of negative evaluation about eating
disorder symptoms or behaviors (e.g., purging and vomiting) is not the sole source of so-
cial anxiety before applying a diagnosis of social anxiety disorder. Similarly, obsessive-
compulsive disorder may be associated with social anxiety, but the additional diagnosis of
social anxiety disorder is used only when social fears and avoidance are independent of
the foci of the obsessions and compulsions.

Other medical conditions. Medical conditions may produce symptoms that may be em-
barrassing (e.g. trembling in Parkinson’s disease). When the fear of negative evaluation
due to other medical conditions is excessive, a diagnosis of social anxiety disorder should
be considered.

Oppositional defiant disorder. Refusal to speak due to opposition to authority figures
should be differentiated from failure to speak due to fear of negative evaluation.

208 Anxiety Disorders

Comorbidity
Social anxiety disorder is often comorbid with other anxiety disorders, major depressive
disorder, and substance use disorders, and the onset of social anxiety disorder generally
precedes that of the other disorders, except for specific phobia and separation anxiety dis-
order. Chronic social isolation in the course of a social anxiety disorder may result in major
depressive disorder. Comorbidity with depression is high also in older adults. Substances
may be used as self-medication for social fears, but the symptoms of substance intoxica-
tion or withdrawal, such as trembling, may also be a source of (further) social fear. Social
anxiety disorder is frequently comorbid with bipolar disorder or body dysmorphic disor-
der; for example, an individual has body dysmorphic disorder concerning a preoccupa-
tion with a slight irregularity of her nose, as well as social anxiety disorder because of a
severe fear of sounding unintelligent. The more generalized form of social anxiety disor-
der, but not social anxiety disorder, performance only, is often comorbid with avoidant
personality disorder. In children, comorbidities with high-functioning autism and selec-
tive mutism are common.

Panic Disorder
Diagnostic Criteria 300.01 (F41.0)

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear
or intense discomfort that reaches a peak within minutes, and during which time four
(or more) of the following symptoms occur:

Note: The abrupt surge can occur from a calm state or an anxious state.

1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.

10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from one-

self).
12. Fear of losing control or “going crazy.”
13. Fear of dying.

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrol-
lable screaming or crying) may be seen. Such symptoms should not count as one of
the four required symptoms.

B. At least one of the attacks has been followed by 1 month (or more) of one or both of
the following:

1. Persistent concern or worry about additional panic attacks or their consequences
(e.g., losing control, having a heart attack, “going crazy”).

2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors
designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar
situations).

Panic Disorder 209

C. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, car-
diopulmonary disorders).

D. The disturbance is not better explained by another mental disorder (e.g., the panic at-
tacks do not occur only in response to feared social situations, as in social anxiety dis-
order; in response to circumscribed phobic objects or situations, as in specific phobia;
in response to obsessions, as in obsessive-compulsive disorder; in response to re-
minders of traumatic events, as in posttraumatic stress disorder; or in response to sep-
aration from attachment figures, as in separation anxiety disorder).

Diagnostic Features
Panic disorder refers to recurrent unexpected panic attacks (Criterion A). A panic attack is
an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes,
and during which time four or more of a list of 13 physical and cognitive symptoms occur.
The term recurrent literally means more than one unexpected panic attack. The term unex-
pected refers to a panic attack for which there is no obvious cue or trigger at the time of oc-
currence—that is, the attack appears to occur from out of the blue, such as when the
individual is relaxing or emerging from sleep (nocturnal panic attack). In contrast, expected
panic attacks are attacks for which there is an obvious cue or trigger, such as a situation in
which panic attacks typically occur. The determination of whether panic attacks are ex-
pected or unexpected is made by the clinician, who makes this judgment based on a com-
bination of careful questioning as to the sequence of events preceding or leading up to the
attack and the individual’s own judgment of whether or not the attack seemed to occur for
no apparent reason. Cultural interpretations may influence the assignment of panic at-
tacks as expected or unexpected (see section “Culture-Related Diagnostic Issues” for this
disorder). In the United States and Europe, approximately one-half of individuals with
panic disorder have expected panic attacks as well as unexpected panic attacks. Thus, the
presence of expected panic attacks does not rule out the diagnosis of panic disorder. For
more details regarding expected versus unexpected panic attacks, see the text accompa-
nying panic attacks (pp. 214–217).

The frequency and severity of panic attacks vary widely. In terms of frequency, there
may be moderately frequent attacks (e.g., one per week) for months at a time, or short
bursts of more frequent attacks (e.g., daily) separated by weeks or months without any at-
tacks or with less frequent attacks (e.g., two per month) over many years. Persons who
have infrequent panic attacks resemble persons with more frequent panic attacks in terms
of panic attack symptoms, demographic characteristics, comorbidity with other disorders,
family history, and biological data. In terms of severity, individuals with panic disorder
may have both full-symptom (four or more symptoms) and limited-symptom (fewer than
four symptoms) attacks, and the number and type of panic attack symptoms frequently
differ from one panic attack to the next. However, more than one unexpected full-symp-
tom panic attack is required for the diagnosis of panic disorder.

The worries about panic attacks or their consequences usually pertain to physical con-
cerns, such as worry that panic attacks reflect the presence of life-threatening illnesses
(e.g., cardiac disease, seizure disorder); social concerns, such as embarrassment or fear of
being judged negatively by others because of visible panic symptoms; and concerns about
mental functioning, such as “going crazy” or losing control (Criterion B). The maladaptive
changes in behavior represent attempts to minimize or avoid panic attacks or their conse-
quences. Examples include avoiding physical exertion, reorganizing daily life to ensure
that help is available in the event of a panic attack, restricting usual daily activities, and
avoiding agoraphobia-type situations, such as leaving home, using public transportation,
or shopping. If agoraphobia is present, a separate diagnosis of agoraphobia is given.

210 Anxiety Disorders

Associated Features Supporting Diagnosis
One type of unexpected panic attack is a nocturnal panic attack (i.e., waking from sleep in
a state of panic, which differs from panicking after fully waking from sleep). In the United
States, this type of panic attack has been estimated to occur at least one time in roughly
one-quarter to one-third of individuals with panic disorder, of whom the majority also
have daytime panic attacks. In addition to worry about panic attacks and their conse-
quences, many individuals with panic disorder report constant or intermittent feelings of
anxiety that are more broadly related to health and mental health concerns. For example,
individuals with panic disorder often anticipate a catastrophic outcome from a mild phys-
ical symptom or medication side effect (e.g., thinking that they may have heart disease or
that a headache means presence of a brain tumor). Such individuals often are relatively in-
tolerant of medication side effects. In addition, there may be pervasive concerns about
abilities to complete daily tasks or withstand daily stressors, excessive use of drugs (e.g.,
alcohol, prescribed medications or illicit drugs) to control panic attacks, or extreme behav-
iors aimed at controlling panic attacks (e.g., severe restrictions on food intake or avoidance
of specific foods or medications because of concerns about physical symptoms that pro-
voke panic attacks).

Prevalence
In the general population, the 12-month prevalence estimate for panic disorder across the
United States and several European countries is about 2%–3% in adults and adolescents. In
the United States, significantly lower rates of panic disorder are reported among Latinos,
African Americans, Caribbean blacks, and Asian Americans, compared with non-Latino
whites; American Indians, by contrast, have significantly higher rates. Lower estimates
have been reported for Asian, African, and Latin American countries, ranging from 0.1%
to 0.8%. Females are more frequently affected than males, at a rate of approximately 2:1. The
gender differentiation occurs in adolescence and is already observable before age 14 years.
Although panic attacks occur in children, the overall prevalence of panic disorder is low
before age 14 years (<0.4%). The rates of panic disorder show a gradual increase during ad-
olescence, particularly in females, and possibly following the onset of puberty, and peak dur-
ing adulthood. The prevalence rates decline in older individuals (i.e., 0.7% in adults over
the age of 64), possibly reflecting diminishing severity to subclinical levels.

Development and Course
The median age at onset for panic disorder in the United States is 20–24 years. A small
number of cases begin in childhood, and onset after age 45 years is unusual but can occur.
The usual course, if the disorder is untreated, is chronic but waxing and waning. Some in-
dividuals may have episodic outbreaks with years of remission in between, and others
may have continuous severe symptomatology. Only a minority of individuals have full
remission without subsequent relapse within a few years. The course of panic disorder
typically is complicated by a range of other disorders, in particular other anxiety disor-
ders, depressive disorders, and substance use disorders (see section “Comorbidity” for
this disorder).

Although panic disorder is very rare in childhood, first occurrence of “fearful spells” is
often dated retrospectively back to childhood. As in adults, panic disorder in adolescents
tends to have a chronic course and is frequently comorbid with other anxiety, depressive,
and bipolar disorders. To date, no differences in the clinical presentation between adoles-
cents and adults have been found. However, adolescents may be less worried about addi-
tional panic attacks than are young adults. Lower prevalence of panic disorder in older
adults appears to be attributable to age-related “dampening” of the autonomic nervous
system response. Many older individuals with “panicky feelings” are observed to have a
“hybrid” of limited-symptom panic attacks and generalized anxiety. Also, older adults

Panic Disorder 211

tend to attribute their panic attacks to certain stressful situations, such as a medical pro-
cedure or social setting. Older individuals may retrospectively endorse explanations for
the panic attack (which would preclude the diagnosis of panic disorder), even if an attack
might actually have been unexpected in the moment (and thus qualify as the basis for a
panic disorder diagnosis). This may result in under-endorsement of unexpected panic at-
tacks in older individuals. Thus, careful questioning of older adults is required to assess
whether panic attacks were expected before entering the situation, so that unexpected
panic attacks and the diagnosis of panic disorder are not overlooked.

While the low rate of panic disorder in children could relate to difficulties in symptom
reporting, this seems unlikely given that children are capable of reporting intense fear or
panic in relation to separation and to phobic objects or phobic situations. Adolescents
might be less willing than adults to openly discuss panic attacks. Therefore, clinicians
should be aware that unexpected panic attacks do occur in adolescents, much as they do in
adults, and be attuned to this possibility when encountering adolescents presenting with
episodes of intense fear or distress.

Risk and Prognostic Factors
Temperamental. Negative affectivity (neuroticism) (i.e., proneness to experiencing neg-
ative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of
anxiety are harmful) are risk factors for the onset of panic attacks and, separately, for
worry about panic, although their risk status for the diagnosis of panic disorder is un-
known. History of “fearful spells” (i.e., limited-symptom attacks that do not meet full cri-
teria for a panic attack) may be a risk factor for later panic attacks and panic disorder.
Although separation anxiety in childhood, especially when severe, may precede the later
development of panic disorder, it is not a consistent risk factor.

Environmental. Reports of childhood experiences of sexual and physical abuse are more
common in panic disorder than in certain other anxiety disorders. Smoking is a risk factor
for panic attacks and panic disorder. Most individuals report identifiable stressors in the
months before their first panic attack (e.g., interpersonal stressors and stressors related to
physical well-being, such as negative experiences with illicit or prescription drugs, dis-
ease, or death in the family).

Genetic and physiological. It is believed that multiple genes confer vulnerability to panic
disorder. However, the exact genes, gene products, or functions related to the genetic re-
gions implicated remain unknown. Current neural systems models for panic disorder em-
phasize the amygdala and related structures, much as in other anxiety disorders. There is
an increased risk for panic disorder among offspring of parents with anxiety, depressive,
and bipolar disorders. Respiratory disturbance, such as asthma, is associated with panic
disorder, in terms of past history, comorbidity, and family history.

Culture-Related Diagnostic Issues
The rate of fears about mental and somatic symptoms of anxiety appears to vary across
cultures and may influence the rate of panic attacks and panic disorder. Also, cultural ex-
pectations may influence the classification of panic attacks as expected or unexpected. For
example, a Vietnamese individual who has a panic attack after walking out into a windy
environment (trúng gió; “hit by the wind”) may attribute the panic attack to exposure to
wind as a result of the cultural syndrome that links these two experiences, resulting in clas-
sification of the panic attack as expected. Various other cultural syndromes are associated
with panic disorder, including ataque de nervios (“attack of nerves”) among Latin Ameri-
cans and khyâl attacks and “soul loss” among Cambodians. Ataque de nervios may involve
trembling, uncontrollable screaming or crying, aggressive or suicidal behavior, and deper-
sonalization or derealization, which may be experienced longer than the few minutes typical

212 Anxiety Disorders

of panic attacks. Some clinical presentations of ataque de nervios fulfill criteria for condi-
tions other than panic attack (e.g., other specified dissociative disorder). These syndromes
impact the symptoms and frequency of panic disorder, including the individual’s attribu-
tion of unexpectedness, as cultural syndromes may create fear of certain situations, rang-
ing from interpersonal arguments (associated with ataque de nervios), to types of exertion
(associated with khyâl attacks), to atmospheric wind (associated with trúng gió attacks).
Clarification of the details of cultural attributions may aid in distinguishing expected and
unexpected panic attacks. For more information regarding cultural syndromes, refer to the
“Glossary of Cultural Concepts of Distress” in the Appendix.

The specific worries about panic attacks or their consequences are likely to vary from
one culture to another (and across different age groups and gender). For panic disorder,
U.S. community samples of non-Latino whites have significantly less functional impair-
ment than African Americans. There are also higher rates of objectively defined severity in
non-Latino Caribbean blacks with panic disorder, and lower rates of panic disorder over-
all in both African American and Afro-Caribbean groups, suggesting that among individ-
uals of African descent, the criteria for panic disorder may be met only when there is
substantial severity and impairment.

Gender-Related Diagnostic Issues
The clinical features of panic disorder do not appear to differ between males and females.
There is some evidence for sexual dimorphism, with an association between panic disor-
der and the catechol-O-methyltransferase (COMT) gene in females only.

Diagnostic Markers
Agents with disparate mechanisms of action, such as sodium lactate, caffeine, isoprotere-
nol, yohimbine, carbon dioxide, and cholecystokinin, provoke panic attacks in individuals
with panic disorder to a much greater extent than in healthy control subjects (and in some
cases, than in individuals with other anxiety, depressive, or bipolar disorders without
panic attacks). Also, for a proportion of individuals with panic disorder, panic attacks are
related to hypersensitive medullary carbon dioxide detectors, resulting in hypocapnia and
other respiratory irregularities. However, none of these laboratory findings are consid-
ered diagnostic of panic disorder.

Suicide Risk
Panic attacks and a diagnosis of panic disorder in the past 12 months are related to a higher
rate of suicide attempts and suicidal ideation in the past 12 months even when comorbid-
ity and a history of childhood abuse and other suicide risk factors are taken into account.

Functional Consequences of Panic Disorder
Panic disorder is associated with high levels of social, occupational, and physical disabil-
ity; considerable economic costs; and the highest number of medical visits among the anx-
iety disorders, although the effects are strongest with the presence of agoraphobia.
Individuals with panic disorder may be frequently absent from work or school for doctor
and emergency room visits, which can lead to unemployment or dropping out of school.
In older adults, impairment may be seen in caregiving duties or volunteer activities. Full-
symptom panic attacks typically are associated with greater morbidity (e.g., greater health
care utilization, more disability, poorer quality of life) than limited-symptom attacks.

Differential Diagnosis
Other specified anxiety disorder or unspecified anxiety disorder. Panic disorder should
not be diagnosed if full-symptom (unexpected) panic attacks have never been experienced. In

Panic Disorder 213

the case of only limited-symptom unexpected panic attacks, an other specified anxiety dis-
order or unspecified anxiety disorder diagnosis should be considered.

Anxiety disorder due to another medical condition. Panic disorder is not diagnosed if
the panic attacks are judged to be a direct physiological consequence of another medical
condition. Examples of medical conditions that can cause panic attacks include hyperthy-
roidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure dis-
orders, and cardiopulmonary conditions (e.g., arrhythmias, supraventricular tachycardia,
asthma, chronic obstructive pulmonary disease [COPD]). Appropriate laboratory tests
(e.g., serum calcium levels for hyperparathyroidism; Holter monitor for arrhythmias) or
physical examinations (e.g., for cardiac conditions) may be helpful in determining the eti-
ological role of another medical condition.

Substance/medication-induced anxiety disorder. Panic disorder is not diagnosed if
the panic attacks are judged to be a direct physiological consequence of a substance. In-
toxication with central nervous system stimulants (e.g., cocaine, amphetamines, caffeine)
or cannabis and withdrawal from central nervous system depressants (e.g., alcohol, bar-
biturates) can precipitate a panic attack. However, if panic attacks continue to occur out-
side of the context of substance use (e.g., long after the effects of intoxication or withdrawal
have ended), a diagnosis of panic disorder should be considered. In addition, because
panic disorder may precede substance use in some individuals and may be associated
with increased substance use, especially for purposes of self-medication, a detailed history
should be taken to determine if the individual had panic attacks prior to excessive sub-
stance use. If this is the case, a diagnosis of panic disorder should be considered in addition
to a diagnosis of substance use disorder. Features such as onset after age 45 years or the
presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness,
loss of bladder or bowel control, slurred speech, amnesia) suggest the possibility that an-
other medical condition or a substance may be causing the panic attack symptoms.

Other mental disorders with panic attacks as an associated feature (e.g., other anxiety
disorders and psychotic disorders). Panic attacks that occur as a symptom of other anx-
iety disorders are expected (e.g., triggered by social situations in social anxiety disorder, by
phobic objects or situations in specific phobia or agoraphobia, by worry in generalized anx-
iety disorder, by separation from home or attachment figures in separation anxiety disorder)
and thus would not meet criteria for panic disorder. (Note: Sometimes an unexpected panic
attack is associated with the onset of another anxiety disorder, but then the attacks become
expected, whereas panic disorder is characterized by recurrent unexpected panic attacks.) If
the panic attacks occur only in response to specific triggers, then only the relevant anxiety
disorder is assigned. However, if the individual experiences unexpected panic attacks as
well and shows persistent concern and worry or behavioral change because of the attacks,
then an additional diagnosis of panic disorder should be considered.

Comorbidity
Panic disorder infrequently occurs in clinical settings in the absence of other psychopa-
thology. The prevalence of panic disorder is elevated in individuals with other disorders,
particularly other anxiety disorders (and especially agoraphobia), major depression, bipo-
lar disorder, and possibly mild alcohol use disorder. While panic disorder often has an ear-
lier age at onset than the comorbid disorder(s), onset sometimes occurs after the comorbid
disorder and may be seen as a severity marker of the comorbid illness.

Reported lifetime rates of comorbidity between major depressive disorder and panic
disorder vary widely, ranging from 10% to 65% in individuals with panic disorder. In ap-
proximately one-third of individuals with both disorders, the depression precedes the on-
set of panic disorder. In the remaining two-thirds, depression occurs coincident with or
following the onset of panic disorder. A subset of individuals with panic disorder develop
a substance-related disorder, which for some represents an attempt to treat their anxiety

214 Anxiety Disorders

with alcohol or medications. Comorbidity with other anxiety disorders and illness anxiety
disorder is also common.

Panic disorder is significantly comorbid with numerous general medical symptoms
and conditions, including, but not limited to, dizziness, cardiac arrhythmias, hyperthy-
roidism, asthma, COPD, and irritable bowel syndrome. However, the nature of the asso-
ciation (e.g., cause and effect) between panic disorder and these conditions remains
unclear. Although mitral valve prolapse and thyroid disease are more common among in-
dividuals with panic disorder than in the general population, the differences in prevalence
are not consistent.

Panic Attack Specifier

Note: Symptoms are presented for the purpose of identifying a panic attack; however,
panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the
context of any anxiety disorder as well as other mental disorders (e.g., depressive disor-
ders, posttraumatic stress disorder, substance use disorders) and some medical condi-
tions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic
attack is identified, it should be noted as a specifier (e.g., “posttraumatic stress disorder
with panic attacks”). For panic disorder, the presence of panic attack is contained within
the criteria for the disorder and panic attack is not used as a specifier.
An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes,
and during which time four (or more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.

1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.

10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable
screaming or crying) may be seen. Such symptoms should not count as one of the four
required symptoms.

Features
The essential feature of a panic attack is an abrupt surge of intense fear or intense discomfort
that reaches a peak within minutes and during which time four or more of 13 physical and cog-
nitive symptoms occur. Eleven of these 13 symptoms are physical (e.g., palpitations, sweat-
ing), while two are cognitive (i.e., fear of losing control or going crazy, fear of dying). “Fear of
going crazy” is a colloquialism often used by individuals with panic attacks and is not in-
tended as a pejorative or diagnostic term. The term within minutes means that the time to peak

Panic Attack Specifier 215

intensity is literally only a few minutes. A panic attack can arise from either a calm state or an
anxious state, and time to peak intensity should be assessed independently of any preceding
anxiety. That is, the start of the panic attack is the point at which there is an abrupt increase in
discomfort rather than the point at which anxiety first developed. Likewise, a panic attack can
return to either an anxious state or a calm state and possibly peak again. A panic attack is dis-
tinguished from ongoing anxiety by its time to peak intensity, which occurs within minutes; its
discrete nature; and its typically greater severity. Attacks that meet all other criteria but have
fewer than four physical and/or cognitive symptoms are referred to as limited-symptom attacks.

There are two characteristic types of panic attacks: expected and unexpected. Expected
panic attacks are attacks for which there is an obvious cue or trigger, such as situations in
which panic attacks have typically occurred. Unexpected panic attacks are those for which
there is no obvious cue or trigger at the time of occurrence (e.g., when relaxing or out of
sleep [nocturnal panic attack]). The determination of whether panic attacks are expected
or unexpected is made by the clinician, who makes this judgment based on a combination
of careful questioning as to the sequence of events preceding or leading up to the attack
and the individual’s own judgment of whether or not the attack seemed to occur for no ap-
parent reason. Cultural interpretations may influence their determination as expected or
unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncon-
trollable screaming or crying) may be seen; however, such symptoms should not count as
one of the four required symptoms. Panic attacks can occur in the context of any mental
disorder (e.g., anxiety disorders, depressive disorders, bipolar disorders, eating disorders,
obsessive-compulsive and related disorders, personality disorders, psychotic disorders,
substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibu-
lar, gastrointestinal), with the majority never meeting criteria for panic disorder. Recur-
rent unexpected panic attacks are required for a diagnosis of panic disorder.

Associated Features
One type of unexpected panic attack is a nocturnal panic attack (i.e., waking from sleep in a
state of panic), which differs from panicking after fully waking from sleep. Panic attacks
are related to a higher rate of suicide attempts and suicidal ideation even when comorbid-
ity and other suicide risk factors are taken into account.

Prevalence
In the general population, 12-month prevalence estimates for panic attacks in the United
States is 11.2% in adults. Twelve-month prevalence estimates do not appear to differ sig-
nificantly among African Americans, Asian Americans, and Latinos. Lower 12-month
prevalence estimates for European countries appear to range from 2.7% to 3.3%. Females
are more frequently affected than males, although this gender difference is more pro-
nounced for panic disorder. Panic attacks can occur in children but are relatively rare until
the age of puberty, when the prevalence rates increase. The prevalence rates decline in
older individuals, possibly reflecting diminishing severity to subclinical levels.

Development and Course
The mean age at onset for panic attacks in the United States is approximately 22–23 years
among adults. However, the course of panic attacks is likely influenced by the course of
any co-occurring mental disorder(s) and stressful life events. Panic attacks are uncommon,
and unexpected panic attacks are rare, in preadolescent children. Adolescents might be
less willing than adults to openly discuss panic attacks, even though they present with ep-
isodes of intense fear or discomfort. Lower prevalence of panic attacks in older individuals
may be related to a weaker autonomic response to emotional states relative to younger in-
dividuals. Older individuals may be less inclined to use the word “fear” and more inclined

216 Anxiety Disorders

to use the word “discomfort” to describe panic attacks. Older individuals with “panicky
feelings” may have a hybrid of limited-symptom attacks and generalized anxiety. In
addition, older individuals tend to attribute panic attacks to certain situations that are
stressful (e.g., medical procedures, social settings) and may retrospectively endorse expla-
nations for the panic attack even if it was unexpected in the moment. This may result in un-
der-endorsement of unexpected panic attacks in older individuals.

Risk and Prognostic Factors
Temperamental. Negative affectivity (neuroticism) (i.e., proneness to experiencing neg-
ative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of
anxiety are harmful) are risk factors for the onset of panic attacks. History of “fearful
spells” (i.e., limited-symptom attacks that do not meet full criteria for a panic attack) may
be a risk factor for later panic attacks.

Environmental. Smoking is a risk factor for panic attacks. Most individuals report iden-
tifiable stressors in the months before their first panic attack (e.g., interpersonal stressors
and stressors related to physical well-being, such as negative experiences with illicit or
prescription drugs, disease, or death in the family).

Culture-Related Diagnostic Issues
Cultural interpretations may influence the determination of panic attacks as expected or
unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and un-
controllable screaming or crying) may be seen; however, such symptoms should not count
as one of the four required symptoms. Frequency of each of the 13 symptoms varies cross-
culturally (e.g., higher rates of paresthesias in African Americans and of dizziness in sev-
eral Asian groups). Cultural syndromes also influence the cross-cultural presentation of
panic attacks, resulting in different symptom profiles across different cultural groups. Ex-
amples include khyâl (wind) attacks, a Cambodian cultural syndrome involving dizziness,
tinnitus, and neck soreness; and trúng gió (wind-related) attacks, a Vietnamese cultural
syndrome associated with headaches. Ataque de nervios (attack of nerves) is a cultural syn-
drome among Latin Americans that may involve trembling, uncontrollable screaming or
crying, aggressive or suicidal behavior, and depersonalization or derealization, and which
may be experienced for longer than only a few minutes. Some clinical presentations of
ataque de nervios fulfill criteria for conditions other than panic attack (e.g., other specified
dissociative disorder). Also, cultural expectations may influence the classification of panic
attacks as expected or unexpected, as cultural syndromes may create fear of certain situa-
tions, ranging from interpersonal arguments (associated with ataque de nervios), to types of
exertion (associated with khyâl attacks), to atmospheric wind (associated with trúng gió at-
tacks). Clarification of the details of cultural attributions may aid in distinguishing ex-
pected and unexpected panic attacks. For more information about cultural syndromes, see
“Glossary of Cultural Concepts of Distress” in the Appendix to this manual.

Gender-Related Diagnostic Issues
Panic attacks are more common in females than in males, but clinical features or symp-
toms of panic attacks do not differ between males and females.

Diagnostic Markers
Physiological recordings of naturally occurring panic attacks in individuals with panic
disorder indicate abrupt surges of arousal, usually of heart rate, that reach a peak within
minutes and subside within minutes, and for a proportion of these individuals the panic
attack may be preceded by cardiorespiratory instabilities.

Agoraphobia 217

Functional Consequences of Panic Attacks
In the context of co-occurring mental disorders, including anxiety disorders, depressive
disorders, bipolar disorder, substance use disorders, psychotic disorders, and personality
disorders, panic attacks are associated with increased symptom severity, higher rates of
comorbidity and suicidality, and poorer treatment response. Also, full-symptom panic at-
tacks typically are associated with greater morbidity (e.g., greater health care utilization,
more disability, poorer quality of life) than limited-symptom attacks.

Differential Diagnosis
Other paroxysmal episodes (e.g., “anger attacks”). Panic attacks should not be diag-
nosed if the episodes do not involve the essential feature of an abrupt surge of intense fear
or intense discomfort, but rather other emotional states (e.g., anger, grief).

Anxiety disorder due to another medical condition. Medical conditions that can cause
or be misdiagnosed as panic attacks include hyperthyroidism, hyperparathyroidism, pheo-
chromocytoma, vestibular dysfunctions, seizure disorders, and cardiopulmonary con-
ditions (e.g., arrhythmias, supraventricular tachycardia, asthma, chronic obstructive
pulmonary disease). Appropriate laboratory tests (e.g., serum calcium levels for hyperpara-
thyroidism; Holter monitor for arrhythmias) or physical examinations (e.g., for cardiac con-
ditions) may be helpful in determining the etiological role of another medical condition.

Substance/medication-induced anxiety disorder. Intoxication with central nervous
system stimulants (e.g., cocaine, amphetamines, caffeine) or cannabis and withdrawal
from central nervous system depressants (e.g., alcohol, barbiturates) can precipitate a
panic attack. A detailed history should be taken to determine if the individual had panic
attacks prior to excessive substance use. Features such as onset after age 45 years or the
presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness,
loss of bladder or bowel control, slurred speech, or amnesia) suggest the possibility that a
medical condition or a substance may be causing the panic attack symptoms.

Panic disorder. Repeated unexpected panic attacks are required but are not sufficient for
the diagnosis of panic disorder (i.e., full diagnostic criteria for panic disorder must be met).

Comorbidity
Panic attacks are associated with increased likelihood of various comorbid mental dis-
orders, including anxiety disorders, depressive disorders, bipolar disorders, impulse-
control disorders, and substance use disorders. Panic attacks are associated with increased
likelihood of later developing anxiety disorders, depressive disorders, bipolar disorders,
and possibly other disorders.

Agoraphobia
Diagnostic Criteria 300.22 (F40.00)

A. Marked fear or anxiety about two (or more) of the following five situations:

1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.

B. The individual fears or avoids these situations because of thoughts that escape might
be difficult or help might not be available in the event of developing panic-like symp-

218 Anxiety Disorders

toms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the el-
derly; fear of incontinence).

C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion,

or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic

situations and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.
H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease)

is present, the fear, anxiety, or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another men-

tal disorder—for example, the symptoms are not confined to specific phobia, situational
type; do not involve only social situations (as in social anxiety disorder); and are not re-
lated exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects
or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic
events (as in posttraumatic stress disorder), or fear of separation (as in separation anx-
iety disorder).

Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an indi-
vidual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses
should be assigned.

Diagnostic Features
The essential feature of agoraphobia is marked, or intense, fear or anxiety triggered by the
real or anticipated exposure to a wide range of situations (Criterion A). The diagnosis re-
quires endorsement of symptoms occurring in at least two of the following five situations:
1) using public transporation, such as automobiles, buses, trains, ships, or planes; 2) being
in open spaces, such as parking lots, marketplaces, or bridges; 3) being in enclosed spaces,
such as shops, theaters, or cinemas; 4) standing in line or being in a crowd; or 5) being out-
side of the home alone. The examples for each situation are not exhaustive; other situations
may be feared. When experiencing fear and anxiety cued by such situations, individuals
typically experience thoughts that something terrible might happen (Criterion B). Individ-
uals frequently believe that escape from such situations might be difficult (e.g., “can’t get
out of here”) or that help might be unavailable (e.g., “there is nobody to help me”) when
panic-like symptoms or other incapacitating or embarrassing symptoms occur. “Panic-like
symptoms” refer to any of the 13 symptoms included in the criteria for panic attack, such as
dizziness, faintness, and fear of dying. “Other incapacitating or embarrassing symptoms”
include symptoms such as vomiting and inflammatory bowel symptoms, as well as, in
older adults, a fear of falling or, in children, a sense of disorientation and getting lost.

The amount of fear experienced may vary with proximity to the feared situation and
may occur in anticipation of or in the actual presence of the agoraphobic situation. Also,
the fear or anxiety may take the form of a full- or limited-symptom panic attack (i.e., an ex-
pected panic attack). Fear or anxiety is evoked nearly every time the individual comes into
contact with the feared situation (Criterion C). Thus, an individual who becomes anxious
only occasionally in an agoraphobic situation (e.g., becomes anxious when standing in line
on only one out of every five occasions) would not be diagnosed with agoraphobia. The in-
dividual actively avoids the situation or, if he or she either is unable or decides not to avoid
it, the situation evokes intense fear or anxiety (Criterion D). Active avoidance means the in-
dividual is currently behaving in ways that are intentionally designed to prevent or min-
imize contact with agoraphobic situations. Avoidance can be behavioral (e.g., changing

Agoraphobia 219

daily routines, choosing a job nearby to avoid using public transportation, arranging for
food delivery to avoid entering shops and supermarkets) as well as cognitive (e.g., using
distraction to get through agoraphobic situations) in nature. The avoidance can become so
severe that the person is completely homebound. Often, an individual is better able to con-
front a feared situation when accompanied by a companion, such as a partner, friend, or
health professional.

The fear, anxiety, or avoidance must be out of proportion to the actual danger posed by
the agoraphobic situations and to the sociocultural context (Criterion E). Differentiating
clinically significant agoraphobic fears from reasonable fears (e.g., leaving the house dur-
ing a bad storm) or from situations that are deemed dangerous (e.g., walking in a parking
lot or using public transportation in a high-crime area) is important for a number of reasons.
First, what constitutes avoidance may be difficult to judge across cultures and sociocultural
contexts (e.g., it is socioculturally appropriate for orthodox Muslim women in certain parts
of the world to avoid leaving the house alone, and thus such avoidance would not be con-
sidered indicative of agoraphobia). Second, older adults are likely to overattribute their
fears to age-related constraints and are less likely to judge their fears as being out of pro-
portion to the actual risk. Third, individuals with agoraphobia are likely to overestimate
danger in relation to panic-like or other bodily symptoms. Agoraphobia should be diag-
nosed only if the fear, anxiety, or avoidance persists (Criterion F) and if it causes clinically
significant distress or impairment in social, occupational, or other important areas of func-
tioning (Criterion G). The duration of “typically lasting for 6 months or more” is meant to
exclude individuals with short-lived, transient problems. However, the duration criterion
should be used as a general guide, with allowance for some degree of flexibility.

Associated Features Supporting Diagnosis
In its most severe forms, agoraphobia can cause individuals to become completely home-
bound, unable to leave their home and dependent on others for services or assistance to pro-
vide even for basic needs. Demoralization and depressive symptoms, as well as abuse of
alcohol and sedative medication as inappropriate self-medication strategies, are common.

Prevalence
Every year approximately 1.7% of adolescents and adults have a diagnosis of agoraphobia.
Females are twice as likely as males to experience agoraphobia. Agoraphobia may occur in
childhood, but incidence peaks in late adolescence and early adulthood. Twelve-month
prevalence in individuals older than 65 years is 0.4%. Prevalence rates do not appear to
vary systematically across cultural/racial groups.

Development and Course
The percentage of individuals with agoraphobia reporting panic attacks or panic disorder
preceding the onset of agoraphobia ranges from 30% in community samples to more than
50% in clinic samples. The majority of individuals with panic disorder show signs of anx-
iety and agoraphobia before the onset of panic disorder.

In two-thirds of all cases of agoraphobia, initial onset is before age 35 years. There is a
substantial incidence risk in late adolescence and early adulthood, with indications for
a second high incidence risk phase after age 40 years. First onset in childhood is rare. The
overall mean age at onset for agoraphobia is 17 years, although the age at onset without
preceding panic attacks or panic disorder is 25–29 years.

The course of agoraphobia is typically persistent and chronic. Complete remission is
rare (10%), unless the agoraphobia is treated. With more severe agoraphobia, rates of full
remission decrease, whereas rates of relapse and chronicity increase. A range of other dis-
orders, in particular other anxiety disorders, depressive disorders, substance use disor-
ders, and personality disorders, may complicate the course of agoraphobia. The long-term

220 Anxiety Disorders

course and outcome of agoraphobia are associated with substantially elevated risk of sec-
ondary major depressive disorder, persistent depressive disorder (dysthymia), and sub-
stance use disorders.

The clinical features of agoraphobia are relatively consistent across the lifespan, although
the type of agoraphobic situations triggering fear, anxiety, or avoidance, as well as the type of
cognitions, may vary. For example, in children, being outside of the home alone is the most fre-
quent situation feared, whereas in older adults, being in shops, standing in line, and being in
open spaces are most often feared. Also, cognitions often pertain to becoming lost (in children),
to experiencing panic-like symptoms (in adults), to falling (in older adults).

The low prevalence of agoraphobia in children could reflect difficulties in symptom re-
porting, and thus assessments in young children may require solicitation of information
from multiple sources, including parents or teachers. Adolescents, particularly males,
may be less willing than adults to openly discuss agoraphobic fears and avoidance; how-
ever, agoraphobia can occur prior to adulthood and should be assessed in children and
adolescents. In older adults, comorbid somatic symptom disorders, as well as motor dis-
turbances (e.g., sense of falling or having medical complications), are frequently men-
tioned by individuals as the reason for their fear and avoidance. In these instances, care is
to be taken in evaluating whether the fear and avoidance are out of proportion to the real
danger involved.

Risk and Prognostic Factors
Temperamental. Behavioral inhibition and neurotic disposition (i.e., negative affectivity
[neuroticism] and anxiety sensitivity) are closely associated with agoraphobia but are rel-
evant to most anxiety disorders (phobic disorders, panic disorder, generalized anxiety dis-
order). Anxiety sensitivity (the disposition to believe that symptoms of anxiety are
harmful) is also characteristic of individuals with agoraphobia.

Environmental. Negative events in childhood (e.g., separation, death of parent) and other
stressful events, such as being attacked or mugged, are associated with the onset of agorapho-
bia. Furthermore, individuals with agoraphobia describe the family climate and child-rearing
behavior as being characterized by reduced warmth and increased overprotection.

Genetic and physiological. Heritability for agoraphobia is 61%. Of the various phobias,
agoraphobia has the strongest and most specific association with the genetic factor that
represents proneness to phobias.

Gender-Related Diagnostic Issues
Females have different patterns of comorbid disorders than males. Consistent with gender
differences in the prevalence of mental disorders, males have higher rates of comorbid
substance use disorders.

Functional Consequences of Agoraphobia
Agoraphobia is associated with considerable impairment and disability in terms of role
functioning, work productivity, and disability days. Agoraphobia severity is a strong de-
terminant of the degree of disability, irrespective of the presence of comorbid panic disor-
der, panic attacks, and other comorbid conditions. More than one-third of individuals
with agoraphobia are completely homebound and unable to work.

Differential Diagnosis
When diagnostic criteria for agoraphobia and another disorder are fully met, both diagnoses
should be assigned, unless the fear, anxiety, or avoidance of agoraphobia is attributable to the
other disorder. Weighting of criteria and clinical judgment may be helpful in some cases.

Agoraphobia 221

Specific phobia, situational type. Differentiating agoraphobia from situational specific
phobia can be challenging in some cases, because these conditions share several symptom
characteristics and criteria. Specific phobia, situational type, should be diagnosed versus ago-
raphobia if the fear, anxiety, or avoidance is limited to one of the agoraphobic situations.
Requiring fears from two or more of the agoraphobic situations is a robust means for differen-
tiating agoraphobia from specific phobias, particularly the situational subtype. Additional dif-
ferentiating features include the cognitive ideation. Thus, if the situation is feared for reasons
other than panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fears
of being directly harmed by the situation itself, such as fear of the plane crashing for individ-
uals who fear flying), then a diagnosis of specific phobia may be more appropriate.

Separation anxiety disorder. Separation anxiety disorder can be best differentiated
from agoraphobia by examining cognitive ideation. In separation anxiety disorder, the
thoughts are about detachment from significant others and the home environment (i.e.,
parents or other attachment figures), whereas in agoraphobia the focus is on panic-like
symptoms or other incapacitating or embarrassing symptoms in the feared situations.

Social anxiety disorder (social phobia). Agoraphobia should be differentiated from so-
cial anxiety disorder based primarily on the situational clusters that trigger fear, anxiety,
or avoidance and the cognitive ideation. In social anxiety disorder, the focus is on fear of
being negatively evaluated.

Panic disorder. When criteria for panic disorder are met, agoraphobia should not be di-
agnosed if the avoidance behaviors associated with the panic attacks do not extend to avoid-
ance of two or more agoraphobic situations.

Acute stress disorder and posttraumatic stress disorder. Acute stress disorder and
posttraumatic stress disorder (PTSD) can be differentiated from agoraphobia by examin-
ing whether the fear, anxiety, or avoidance is related only to situations that remind the
individual of a traumatic event. If the fear, anxiety, or avoidance is restricted to trauma re-
minders, and if the avoidance behavior does not extend to two or more agoraphobic situ-
ations, then a diagnosis of agoraphobia is not warranted.

Major depressive disorder. In major depressive disorder, the individual may avoid leav-
ing home because of apathy, loss of energy, low self-esteem, and anhedonia. If the avoid-
ance is unrelated to fears of panic-like or other incapacitating or embarrassing symptoms,
then agoraphobia should not be diagnosed.

Other medical conditions. Agoraphobia is not diagnosed if the avoidance of situations
is judged to be a physiological consequence of a medical condition. This determination is
based on history, laboratory findings, and a physical examination. Other relevant medical
conditions may include neurodegenerative disorders with associated motor disturbances
(e.g., Parkinson’s disease, multiple sclerosis), as well as cardiovascular disorders. Individ-
uals with certain medical conditions may avoid situations because of realistic concerns
about being incapacitated (e.g., fainting in an individual with transient ischemic attacks)
or being embarrassed (e.g., diarrhea in an individual with Crohn’s disease). The diagnosis
of agoraphobia should be given only when the fear or avoidance is clearly in excess of that
usually associated with these medical conditions.

Comorbidity
The majority of individuals with agoraphobia also have other mental disorders. The most
frequent additional diagnoses are other anxiety disorders (e.g., specific phobias, panic dis-
order, social anxiety disorder), depressive disorders (major depressive disorder), PTSD,
and alcohol use disorder. Whereas other anxiety disorders (e.g., separation anxiety disor-
der, specific phobias, panic disorder) frequently precede onset of agoraphobia, depressive
disorders and substance use disorders typically occur secondary to agoraphobia.

222 Anxiety Disorders

Generalized Anxiety Disorder
Diagnostic Criteria 300.02 (F41.1)

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than
not for at least 6 months, about a number of events or activities (such as work or school
performance).

B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symp-

toms (with at least some symptoms having been present for more days than not for the
past 6 months):

Note: Only one item is required in children.

1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying

sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impair-
ment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another mental disorder (e.g., anxiety or
worry about having panic attacks in panic disorder, negative evaluation in social anxi-
ety disorder [social phobia], contamination or other obsessions in obsessive-compul-
sive disorder, separation from attachment figures in separation anxiety disorder,
reminders of traumatic events in posttraumatic stress disorder, gaining weight in an-
orexia nervosa, physical complaints in somatic symptom disorder, perceived appear-
ance flaws in body dysmorphic disorder, having a serious illness in illness anxiety
disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Diagnostic Features
The essential feature of generalized anxiety disorder is excessive anxiety and worry (ap-
prehensive expectation) about a number of events or activities. The intensity, duration, or
frequency of the anxiety and worry is out of proportion to the actual likelihood or impact
of the anticipated event. The individual finds it difficult to control the worry and to keep
worrisome thoughts from interfering with attention to tasks at hand. Adults with gener-
alized anxiety disorder often worry about everyday, routine life circumstances, such as
possible job responsibilities, health and finances, the health of family members, misfor-
tune to their children, or minor matters (e.g., doing household chores or being late for ap-
pointments). Children with generalized anxiety disorder tend to worry excessively about
their competence or the quality of their performance. During the course of the disorder,
the focus of worry may shift from one concern to another.

Several features distinguish generalized anxiety disorder from nonpathological anxiety.
First, the worries associated with generalized anxiety disorder are excessive and typically in-
terfere significantly with psychosocial functioning, whereas the worries of everyday life
are not excessive and are perceived as more manageable and may be put off when more
pressing matters arise. Second, the worries associated with generalized anxiety disorder are

Generalized Anxiety Disorder 223

more pervasive, pronounced, and distressing; have longer duration; and frequently occur
without precipitants. The greater the range of life circumstances about which a person
worries (e.g., finances, children’s safety, job performance), the more likely his or her symp-
toms are to meet criteria for generalized anxiety disorder. Third, everyday worries are much
less likely to be accompanied by physical symptoms (e.g., restlessness or feeling keyed up
or on edge). Individuals with generalized anxiety disorder report subjective distress due
to constant worry and related impairment in social, occupational, or other important areas
of functioning.

The anxiety and worry are accompanied by at least three of the following additional
symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty
concentrating or mind going blank, irritability, muscle tension, and disturbed sleep, al-
though only one additional symptom is required in children.

Associated Features Supporting Diagnosis
Associated with muscle tension, there may be trembling, twitching, feeling shaky, and
muscle aches or soreness. Many individuals with generalized anxiety disorder also expe-
rience somatic symptoms (e.g., sweating, nausea, diarrhea) and an exaggerated startle re-
sponse. Symptoms of autonomic hyperarousal (e.g., accelerated heart rate, shortness of
breath, dizziness) are less prominent in generalized anxiety disorder than in other anxiety
disorders, such as panic disorder. Other conditions that may be associated with stress (e.g.,
irritable bowel syndrome, headaches) frequently accompany generalized anxiety disorder.

Prevalence
The 12-month prevalence of generalized anxiety disorder is 0.9% among adolescents and
2.9% among adults in the general community of the United States. The 12-month preva-
lence for the disorder in other countries ranges from 0.4% to 3.6%. The lifetime morbid risk
is 9.0%. Females are twice as likely as males to experience generalized anxiety disorder. The
prevalence of the diagnosis peaks in middle age and declines across the later years of life.

Individuals of European descent tend to experience generalized anxiety disorder more
frequently than do individuals of non-European descent (i.e., Asian, African, Native
American and Pacific Islander). Furthermore, individuals from developed countries are
more likely than individuals from nondeveloped countries to report that they have expe-
rienced symptoms that meet criteria for generalized anxiety disorder in their lifetime.

Development and Course
Many individuals with generalized anxiety disorder report that they have felt anxious and
nervous all of their lives. The median age at onset for generalized anxiety disorder is 30
years; however, age at onset is spread over a very broad range. The median age at onset is
later than that for the other anxiety disorders. The symptoms of excessive worry and anx-
iety may occur early in life but are then manifested as an anxious temperament. Onset of
the disorder rarely occurs prior to adolescence. The symptoms of generalized anxiety dis-
order tend to be chronic and wax and wane across the lifespan, fluctuating between syn-
dromal and subsyndromal forms of the disorder. Rates of full remission are very low.

The clinical expression of generalized anxiety disorder is relatively consistent across
the lifespan. The primary difference across age groups is in the content of the individual’s
worry. Children and adolescents tend to worry more about school and sporting perfor-
mance, whereas older adults report greater concern about the well-being of family or their
own physical heath. Thus, the content of an individual’s worry tends to be age appropri-
ate. Younger adults experience greater severity of symptoms than do older adults.

The earlier in life individuals have symptoms that meet criteria for generalized anxiety
disorder, the more comorbidity they tend to have and the more impaired they are likely to

224 Anxiety Disorders

be. The advent of chronic physical disease can be a potent issue for excessive worry in the
elderly. In the frail elderly, worries about safety—and especially about falling—may limit
activities. In those with early cognitive impairment, what appears to be excessive worry
about, for example, the whereabouts of things is probably better regarded as realistic
given the cognitive impairment.

In children and adolescents with generalized anxiety disorder, the anxieties and wor-
ries often concern the quality of their performance or competence at school or in sporting
events, even when their performance is not being evaluated by others. There may be ex-
cessive concerns about punctuality. They may also worry about catastrophic events, such
as earthquakes or nuclear war. Children with the disorder may be overly conforming, per-
fectionist, and unsure of themselves and tend to redo tasks because of excessive dissatis-
faction with less-than-perfect performance. They are typically overzealous in seeking
reassurance and approval and require excessive reassurance about their performance and
other things they are worried about.

Generalized anxiety disorder may be overdiagnosed in children. When this diagnosis
is being considered in children, a thorough evaluation for the presence of other childhood
anxiety disorders and other mental disorders should be done to determine whether the
worries may be better explained by one of these disorders. Separation anxiety disorder, so-
cial anxiety disorder (social phobia), and obsessive-compulsive disorder are often accom-
panied by worries that may mimic those described in generalized anxiety disorder. For
example, a child with social anxiety disorder may be concerned about school performance
because of fear of humiliation. Worries about illness may also be better explained by sep-
aration anxiety disorder or obsessive-compulsive disorder.

Risk and Prognostic Factors
Temperamental. Behavioral inhibition, negative affectivity (neuroticism), and harm
avoidance have been associated with generalized anxiety disorder.

Environmental. Although childhood adversities and parental overprotection have been
associated with generalized anxiety disorder, no environmental factors have been identi-
fied as specific to generalized anxiety disorder or necessary or sufficient for making the di-
agnosis.

Genetic and physiological. One-third of the risk of experiencing generalized anxiety
disorder is genetic, and these genetic factors overlap with the risk of neuroticism and are
shared with other anxiety and mood disorders, particularly major depressive disorder.

Culture-Related Diagnostic Issues
There is considerable cultural variation in the expression of generalized anxiety disorder.
For example, in some cultures, somatic symptoms predominate in the expression of the
disorder, whereas in other cultures cognitive symptoms tend to predominate. This differ-
ence may be more evident on initial presentation than subsequently, as more symptoms
are reported over time. There is no information as to whether the propensity for excessive
worrying is related to culture, although the topic being worried about can be culture spe-
cific. It is important to consider the social and cultural context when evaluating whether
worries about certain situations are excessive.

Gender-Related Diagnostic Issues
In clinical settings, generalized anxiety disorder is diagnosed somewhat more frequently
in females than in males (about 55%–60% of those presenting with the disorder are
female). In epidemiological studies, approximately two-thirds are female. Females and
males who experience generalized anxiety disorder appear to have similar symptoms but

Generalized Anxiety Disorder 225

demonstrate different patterns of comorbidity consistent with gender differences in the
prevalence of disorders. In females, comorbidity is largely confined to the anxiety disor-
ders and unipolar depression, whereas in males, comorbidity is more likely to extend to
the substance use disorders as well.

Functional Consequences of
Generalized Anxiety Disorder
Excessive worrying impairs the individual’s capacity to do things quickly and efficiently,
whether at home or at work. The worrying takes time and energy; the associated symp-
toms of muscle tension and feeling keyed up or on edge, tiredness, difficulty concentrat-
ing, and disturbed sleep contribute to the impairment. Importantly the excessive worrying
may impair the ability of individuals with generalized anxiety disorder to encourage con-
fidence in their children.

Generalized anxiety disorder is associated with significant disability and distress that is
independent of comorbid disorders, and most non-institutionalized adults with the disorder
are moderately to seriously disabled. Generalized anxiety disorder accounts for 110 mil-
lion disability days per annum in the U.S. population.

Differential Diagnosis
Anxiety disorder due to another medical condition. The diagnosis of anxiety disorder
associated with another medical condition should be assigned if the individual’s anxiety
and worry are judged, based on history, laboratory findings, or physical examination, to
be a physiological effect of another specific medical condition (e.g., pheochromocytoma,
hyperthyroidism).

Substance/medication-induced anxiety disorder. A substance/medication-induced
anxiety disorder is distinguished from generalized anxiety disorder by the fact that a sub-
stance or medication (e.g., a drug of abuse, exposure to a toxin) is judged to be etiologically
related to the anxiety. For example, severe anxiety that occurs only in the context of heavy
coffee consumption would be diagnosed as caffeine-induced anxiety disorder.

Social anxiety disorder. Individuals with social anxiety disorder often have anticipa-
tory anxiety that is focused on upcoming social situations in which they must perform or
be evaluated by others, whereas individuals with generalized anxiety disorder worry,
whether or not they are being evaluated.

Obsessive-compulsive disorder. Several features distinguish the excessive worry of
generalized anxiety disorder from the obsessional thoughts of obsessive-compulsive dis-
order. In generalized anxiety disorder the focus of the worry is about forthcoming prob-
lems, and it is the excessiveness of the worry about future events that is abnormal. In
obsessive-compulsive disorder, the obsessions are inappropriate ideas that take the form of
intrusive and unwanted thoughts, urges, or images.

Posttraumatic stress disorder and adjustment disorders. Anxiety is invariably pres-
ent in posttraumatic stress disorder. Generalized anxiety disorder is not diagnosed if the
anxiety and worry are better explained by symptoms of posttraumatic stress disorder.
Anxiety may also be present in adjustment disorder, but this residual category should be
used only when the criteria are not met for any other disorder (including generalized anx-
iety disorder). Moreover, in adjustment disorders, the anxiety occurs in response to an
identifiable stressor within 3 months of the onset of the stressor and does not persist for
more than 6 months after the termination of the stressor or its consequences.

Depressive, bipolar, and psychotic disorders. Generalized anxiety/worry is a common
associated feature of depressive, bipolar, and psychotic disorders and should not be di-

226 Anxiety Disorders

agnosed separately if the excessive worry has occurred only during the course of these
conditions.

Comorbidity
Individuals whose presentation meets criteria for generalized anxiety disorder are likely
to have met, or currently meet, criteria for other anxiety and unipolar depressive disor-
ders. The neuroticism or emotional liability that underpins this pattern of comorbidity is
associated with temperamental antecedents and genetic and environmental risk factors
shared between these disorders, although independent pathways are also possible. Co-
morbidity with substance use, conduct, psychotic, neurodevelopmental, and neurocogni-
tive disorders is less common.

Substance/Medication-Induced
Anxiety Disorder

Diagnostic Criteria

A. Panic attacks or anxiety is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings of both

(1) and (2):

1. The symptoms in Criterion A developed during or soon after substance intoxication
or withdrawal or after exposure to a medication.

2. The involved substance/medication is capable of producing the symptoms in Crite-
rion A.

C. The disturbance is not better explained by an anxiety disorder that is not substance/
medication-induced. Such evidence of an independent anxiety disorder could include
the following:

The symptoms precede the onset of the substance/medication use; the symptoms
persist for a substantial period of time (e.g., about 1 month) after the cessation of
acute withdrawal or severe intoxication; or there is other evidence suggesting the
existence of an independent non-substance/medication-induced anxiety disorder
(e.g., a history of recurrent non-substance/medication-related episodes).

D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-

tional, or other important areas of functioning.

Note: This diagnosis should be made instead of a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical
picture and they are sufficiently severe to warrant clinical attention.
Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific substance/medica-
tion]-induced anxiety disorders are indicated in the table below. Note that the ICD-10-CM
code depends on whether or not there is a comorbid substance use disorder present for
the same class of substance. If a mild substance use disorder is comorbid with the sub-
stance-induced anxiety disorder, the 4th position character is “1,” and the clinician should
record “mild [substance] use disorder” before the substance-induced anxiety disorder
(e.g., “mild cocaine use disorder with cocaine-induced anxiety disorder”). If a moderate or
severe substance use disorder is comorbid with the substance-induced anxiety disorder,
the 4th position character is “2,” and the clinician should record “moderate [substance] use
disorder” or “severe [substance] use disorder,” depending on the severity of the comorbid
substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-

Substance/Medication-Induced Anxiety Disorder 227

time heavy use of the substance), then the 4th position character is “9,” and the clinician
should record only the substance-induced anxiety disorder.

Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for di-
agnoses associated with substance class):

With onset during intoxication: This specifier applies if criteria are met for intoxica-
tion with the substance and the symptoms develop during intoxication.
With onset during withdrawal: This specifier applies if criteria are met for withdrawal
from the substance and the symptoms develop during, or shortly after, withdrawal.
With onset after medication use: Symptoms may appear either at initiation of medi-
cation or after a modification or change in use.

Recording Procedures
ICD-9-CM. The name of the substance/medication-induced anxiety disorder begins
with the specific substance (e.g., cocaine, salbutamol) that is presumed to be causing the
anxiety symptoms. The diagnostic code is selected from the table included in the criteria
set, which is based on the drug class. For substances that do not fit into any of the classes
(e.g., salbutamol), the code for “other substance” should be used; and in cases in which
a substance is judged to be an etiological factor but the specific class of substance is un-
known, the category “unknown substance” should be used.

The name of the disorder is followed by the specification of onset (i.e., onset during in-
toxication, onset during withdrawal, with onset during medication use). Unlike the record-
ing procedures for ICD-10-CM, which combine the substance-induced disorder and
substance use disorder into a single code, for ICD-9-CM a separate diagnostic code is given
for the substance use disorder. For example, in the case of anxiety symptoms occurring dur-
ing withdrawal in a man with a severe lorazepam use disorder, the diagnosis is 292.89 loraz-
epam-induced anxiety disorder, with onset during withdrawal. An additional diagnosis of
304.10 severe lorazepam use disorder is also given. When more than one substance is judged
to play a significant role in the development of anxiety symptoms, each should be listed sep-

ICD-10-CM

ICD-9-CM

With use
disorder,

mild

With use
disorder,
moderate
or severe

Without
use

disorder

Alcohol 291.89 F10.180 F10.280 F10.980

Caffeine 292.89 F15.180 F15.280 F15.980

Cannabis 292.89 F12.180 F12.280 F12.980

Phencyclidine 292.89 F16.180 F16.280 F16.980

Other hallucinogen 292.89 F16.180 F16.280 F16.980

Inhalant 292.89 F18.180 F18.280 F18.980

Opioid 292.89 F11.188 F11.288 F11.988

Sedative, hypnotic, or anxiolytic 292.89 F13.180 F13.280 F13.980

Amphetamine (or other
stimulant)

292.89 F15.180 F15.280 F15.980

Cocaine 292.89 F14.180 F14.280 F14.980

Other (or unknown) substance 292.89 F19.180 F19.280 F19.980

228 Anxiety Disorders

arately (e.g., 292.89 methylphenidate-induced anxiety disorder, with onset during intoxica-
tion; 292.89 salbutamol-induced anxiety disorder, with onset after medication use).

ICD-10-CM. The name of the substance/medication-induced anxiety disorder begins
with the specific substance (e.g., cocaine, salbutamol) that is presumed to be causing the
anxiety symptoms. The diagnostic code is selected from the table included in the criteria
set, which is based on the drug class and presence or absence of a comorbid substance use
disorder. For substances that do not fit into any of the classes (e.g., salbutamol), the code
for “other substance” should be used; and in cases in which a substance is judged to be an
etiological factor but the specific class of substance is unknown, the category “unknown
substance” should be used.

When recording the name of the disorder, the comorbid substance use disorder (if any)
is listed first, followed by the word “with,” followed by the name of the substance-induced
anxiety disorder, followed by the specification of onset (i.e., onset during intoxication,
onset during withdrawal, with onset during medication use). For example, in the case of
anxiety symptoms occurring during withdrawal in a man with a severe lorazepam use dis-
order, the diagnosis is F13.280 severe lorazepam use disorder with lorazepam-induced
anxiety disorder, with onset during withdrawal. A separate diagnosis of the comorbid se-
vere lorazepam use disorder is not given. If the substance-induced anxiety disorder occurs
without a comorbid substance use disorder (e.g., after a one-time heavy use of the substance),
no accompanying substance use disorder is noted (e.g., F16.980 psilocybin-induced anxi-
ety disorder, with onset during intoxication). When more than one substance is judged to
play a significant role in the development of anxiety symptoms, each should be listed sep-
arately (e.g., F15.280 severe methylphenidate use disorder with methylphenidate-induced
anxiety disorder, with onset during intoxication; F19.980 salbutamol-induced anxiety dis-
order, with onset after medication use).

Diagnostic Features
The essential features of substance/medication-induced anxiety disorder are prominent
symptoms of panic or anxiety (Criterion A) that are judged to be due to the effects of a sub-
stance (e.g., a drug of abuse, a medication, or a toxin exposure). The panic or anxiety symp-
toms must have developed during or soon after substance intoxication or withdrawal or
after exposure to a medication, and the substances or medications must be capable of pro-
ducing the symptoms (Criterion B2). Substance/medication-induced anxiety disorder
due to a prescribed treatment for a mental disorder or another medical condition must
have its onset while the individual is receiving the medication (or during withdrawal, if a
withdrawal is associated with the medication). Once the treatment is discontinued, the
panic or anxiety symptoms will usually improve or remit within days to several weeks to
a month (depending on the half-life of the substance/medication and the presence of with-
drawal). The diagnosis of substance/medication-induced anxiety disorder should not be
given if the onset of the panic or anxiety symptoms precedes the substance/medication in-
toxication or withdrawal, or if the symptoms persist for a substantial period of time (i.e.,
usually longer than 1 month) from the time of severe intoxication or withdrawal. If the
panic or anxiety symptoms persist for substantial periods of time, other causes for the
symptoms should be considered.

The substance/medication-induced anxiety disorder diagnosis should be made in-
stead of a diagnosis of substance intoxication or substance withdrawal only when the
symptoms in Criterion A are predominant in the clinical picture and are sufficiently severe
to warrant independent clinical attention.

Associated Features Supporting Diagnosis
Panic or anxiety can occur in association with intoxication with the following classes of sub-
stances: alcohol, caffeine, cannabis, phencyclidine, other hallucinogens, inhalants, stimu-

Substance/Medication-Induced Anxiety Disorder 229

lants (including cocaine), and other (or unknown) substances. Panic or anxiety can occur in
association with withdrawal from the following classes of substances: alcohol; opioids; sed-
atives, hypnotics, and anxiolytics; stimulants (including cocaine); and other (or unknown)
substances. Some medications that evoke anxiety symptoms include anesthetics and anal-
gesics, sympathomimetics or other bronchodilators, anticholinergics, insulin, thyroid prep-
arations, oral contraceptives, antihistamines, antiparkinsonian medications, corticosteroids,
antihypertensive and cardiovascular medications, anticonvulsants, lithium carbonate, an-
tipsychotic medications, and antidepressant medications. Heavy metals and toxins (e.g.,
organophosphate insecticide, nerve gases, carbon monoxide, carbon dioxide, volatile sub-
stances such as gasoline and paint) may also cause panic or anxiety symptoms.

Prevalence
The prevalence of substance/medication-induced anxiety disorder is not clear. General
population data suggest that it may be rare, with a 12-month prevalence of approximately
0.002%. However, in clinical populations, the prevalence is likely to be higher.

Diagnostic Markers
Laboratory assessments (e.g., urine toxicology) may be useful to measure substance intox-
ication as part of an assessment for substance/medication-induced anxiety disorder.

Differential Diagnosis
Substance intoxication and substance withdrawal. Anxiety symptoms commonly oc-
cur in substance intoxication and substance withdrawal. The diagnosis of the substance-
specific intoxication or substance-specific withdrawal will usually suffice to categorize the
symptom presentation. A diagnosis of substance/medication-induced anxiety disorder
should be made in addition to substance intoxication or substance withdrawal when the
panic or anxiety symptoms are predominant in the clinical picture and are sufficiently se-
vere to warrant independent clinical attention. For example, panic or anxiety symptoms
are characteristic of alcohol withdrawal.

Anxiety disorder (i.e., not induced by a substance/medication). Substance/medication-
induced anxiety disorder is judged to be etiologically related to the substance/medication.
Substance/medication-induced anxiety disorder is distinguished from a primary anxiety
disorder based on the onset, course, and other factors with respect to substances/medica-
tions. For drugs of abuse, there must be evidence from the history, physical examination, or
laboratory findings for use, intoxication, or withdrawal. Substance/medication-induced
anxiety disorders arise only in association with intoxication or withdrawal states, whereas
primary anxiety disorders may precede the onset of substance/medication use. The pres-
ence of features that are atypical of a primary anxiety disorder, such as atypical age at onset
(e.g., onset of panic disorder after age 45 years) or symptoms (e.g., atypical panic attack
symptoms such as true vertigo, loss of balance, loss of consciousness, loss of bladder con-
trol, headaches, slurred speech) may suggest a substance/medication-induced etiology. A
primary anxiety disorder diagnosis is warranted if the panic or anxiety symptoms persist
for a substantial period of time (about 1 month or longer) after the end of the substance in-
toxication or acute withdrawal or there is a history of an anxiety disorder.

Delirium. If panic or anxiety symptoms occur exclusively during the course of delirium,
they are considered to be an associated feature of the delirium and are not diagnosed sep-
arately.

Anxiety disorder due to another medical condition. If the panic or anxiety symptoms
are attributed to the physiological consequences of another medical condition (i.e., rather
than to the medication taken for the medical condition), anxiety disorder due to another

230 Anxiety Disorders

medical condition should be diagnosed. The history often provides the basis for such a
judgment. At times, a change in the treatment for the other medical condition (e.g., med-
ication substitution or discontinuation) may be needed to determine whether the medica-
tion is the causative agent (in which case the symptoms may be better explained by
substance/medication-induced anxiety disorder). If the disturbance is attributable to both
another medical condition and substance use, both diagnoses (i.e., anxiety disorder due to
another medical condition and substance/medication-induced anxiety disorder) may be
given. When there is insufficient evidence to determine whether the panic or anxiety symp-
toms are attributable to a substance/medication or to another medical condition or are pri-
mary (i.e., not attributable to either a substance or another medical condition), a diagnosis
of other specified or unspecified anxiety disorder would be indicated.

Anxiety Disorder Due to
Another Medical Condition

Diagnostic Criteria 293.84 (F06.4)

A. Panic attacks or anxiety is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the dis-

turbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-

tional, or other important areas of functioning.

Coding note: Include the name of the other medical condition within the name of the men-
tal disorder (e.g., 293.84 [F06.4] anxiety disorder due to pheochromocytoma). The other
medical condition should be coded and listed separately immediately before the anxiety
disorder due to the medical condition (e.g., 227.0 [D35.00] pheochromocytoma; 293.84
[F06.4] anxiety disorder due to pheochromocytoma.

Diagnostic Features
The essential feature of anxiety disorder due to another medical condition is clinically signifi-
cant anxiety that is judged to be best explained as a physiological effect of another medical con-
dition. Symptoms can include prominent anxiety symptoms or panic attacks (Criterion A).
The judgment that the symptoms are best explained by the associated physical condition must
be based on evidence from the history, physical examination, or laboratory findings (Criterion
B). Additionally, it must be judged that the symptoms are not better accounted for by another
mental disorder, in particular, adjustment disorder, with anxiety, in which the stressor is the
medical condition (Criterion C). In this case, an individual with adjustment disorder is espe-
cially distressed about the meaning or the consequences of the associated medical condition.
By contrast, there is often a prominent physical component to the anxiety (e.g., shortness of
breath) when the anxiety is due to another medical condition. The diagnosis is not made if the
anxiety symptoms occur only during the course of a delirium (Criterion D). The anxiety symp-
toms must cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning (Criterion E).

In determining whether the anxiety symptoms are attributable to another medical con-
dition, the clinician must first establish the presence of the medical condition. Further-
more, it must be established that anxiety symptoms can be etiologically related to the
medical condition through a physiological mechanism before making a judgment that this
is the best explanation for the symptoms in a specific individual. A careful and compre-

Anxiety Disorder Due to Another Medical Condition 231

hensive assessment of multiple factors is necessary to make this judgment. Several aspects
of the clinical presentation should be considered: 1) the presence of a clear temporal asso-
ciation between the onset, exacerbation, or remission of the medical condition and the anx-
iety symptoms; 2) the presence of features that are atypical of a primary anxiety disorder
(e.g., atypical age at onset or course); and 3) evidence in the literature that a known phys-
iological mechanism (e.g., hyperthyroidism) causes anxiety. In addition, the disturbance
must not be better explained by a primary anxiety disorder, a substance/medication-
induced anxiety disorder, or another primary mental disorder (e.g., adjustment disorder).

Associated Features Supporting Diagnosis
A number of medical conditions are known to include anxiety as a symptomatic manifes-
tation. Examples include endocrine disease (e.g., hyperthyroidism, pheochromocytoma,
hypoglycemia, hyperadrenocortisolism), cardiovascular disorders (e.g., congestive heart
failure, pulmonary embolism, arrhythmia such as atrial fibrillation), respiratory illness
(e.g., chronic obstructive pulmonary disease, asthma, pneumonia), metabolic distur-
bances (e.g., vitamin B12 deficiency, porphyria), and neurological illness (e.g., neoplasms,
vestibular dysfunction, encephalitis, seizure disorders). Anxiety due to another medical
condition is diagnosed when the medical condition is known to induce anxiety and when
the medical condition preceded the onset of the anxiety.

Prevalence
The prevalence of anxiety disorder due to another medical condition is unclear. There ap-
pears to be an elevated prevalence of anxiety disorders among individuals with a variety
of medical conditions, including asthma, hypertension, ulcers, and arthritis. However, this
increased prevalence may be due to reasons other than the anxiety disorder directly caus-
ing the medical condition.

Development and Course
The development and course of anxiety disorder due to another medical condition gen-
erally follows the course of the underlying illness. This diagnosis is not meant to include
primary anxiety disorders that arise in the context of chronic medical illness. This is im-
portant to consider with older adults, who may experience chronic medical illness and
then develop independent anxiety disorders secondary to the chronic medical illness.

Diagnostic Markers
Laboratory assessments and/or medical examinations are necessary to confirm the diag-
nosis of the associated medical condition.

Differential Diagnosis
Delirium. A separate diagnosis of anxiety disorder due to another medical condition is
not given if the anxiety disturbance occurs exclusively during the course of a delirium.
However, a diagnosis of anxiety disorder due to another medical condition may be given
in addition to a diagnosis of major neurocognitive disorder (dementia) if the etiology of
anxiety is judged to be a physiological consequence of the pathological process causing the
neurocognitive disorder and if anxiety is a prominent part of the clinical presentation.

Mixed presentation of symptoms (e.g., mood and anxiety). If the presentation includes
a mix of different types of symptoms, the specific mental disorder due to another medical
condition depends on which symptoms predominate in the clinical picture.

Substance/medication-induced anxiety disorder. If there is evidence of recent or pro-
longed substance use (including medications with psychoactive effects), withdrawal from

232 Anxiety Disorders

a substance, or exposure to a toxin, a substance/medication-induced anxiety disorder
should be considered. Certain medications are known to increase anxiety (e.g., corticoste-
roids, estrogens, metoclopramide), and when this is the case, the medication may be the
most likely etiology, although it may be difficult to distinguish whether the anxiety is at-
tributable to the medications or to the medical illness itself. When a diagnosis of substance-
induced anxiety is being made in relation to recreational or nonprescribed drugs, it may be
useful to obtain a urine or blood drug screen or other appropriate laboratory evaluation.
Symptoms that occur during or shortly after (i.e., within 4 weeks of) substance intoxication
or withdrawal or after medication use may be especially indicative of a substance/medi-
cation-induced anxiety disorder, depending on the type, duration, or amount of the sub-
stance used. If the disturbance is associated with both another medical condition and
substance use, both diagnoses (i.e., anxiety disorder due to another medical condition and
substance/medication-induced anxiety disorder) can be given. Features such as onset af-
ter age 45 years or the presence of atypical symptoms during a panic attack (e.g., vertigo,
loss of consciousness, loss of bladder or bowel control, slurred speech, amnesia) suggest
the possibility that another medical condition or a substance may be causing the panic at-
tack symptoms.

Anxiety disorder (not due to a known medical condition). Anxiety disorder due to an-
other medical condition should be distinguished from other anxiety disorders (especially
panic disorder and generalized anxiety disorder). In other anxiety disorders, no specific
and direct causative physiological mechanisms associated with another medical condition
can be demonstrated. Late age at onset, atypical symptoms, and the absence of a personal
or family history of anxiety disorders suggest the need for a thorough assessment to rule
out the diagnosis of anxiety disorder due to another medical condition. Anxiety disorders
can exacerbate or pose increased risk for medical conditions such as cardiovascular events
and myocardial infarction and should not be diagnosed as anxiety disorder due to another
medical condition in these cases.

Illness anxiety disorder. Anxiety disorder due to another medical condition should be
distinguished from illness anxiety disorder. Illness anxiety disorder is characterized by
worry about illness, concern about pain, and bodily preoccupations. In the case of illness
anxiety disorder, individuals may or may not have diagnosed medical conditions. Al-
though an individual with illness anxiety disorder and a diagnosed medical condition is
likely to experience anxiety about the medical condition, the medical condition is not
physiologically related to the anxiety symptoms.

Adjustment disorders. Anxiety disorder due to another medical condition should be
distinguished from adjustment disorders, with anxiety, or with anxiety and depressed
mood. Adjustment disorder is warranted when individuals experience a maladaptive re-
sponse to the stress of having another medical condition. The reaction to stress usually
concerns the meaning or consequences of the stress, as compared with the experience of
anxiety or mood symptoms that occur as a physiological consequence of the other medical
condition. In adjustment disorder, the anxiety symptoms are typically related to coping
with the stress of having a general medical condition, whereas in anxiety disorder due to
another medical condition, individuals are more likely to have prominent physical symp-
toms and to be focused on issues other than the stress of the illness itself.

Associated feature of another mental disorder. Anxiety symptoms may be an associ-
ated feature of another mental disorder (e.g., schizophrenia, anorexia nervosa).

Other specified or unspecified anxiety disorder. This diagnosis is given if it cannot be
determined whether the anxiety symptoms are primary, substance-induced, or associated
with another medical condition.

Other Specified Anxiety Disorder 233

Other Specified Anxiety Disorder
300.09 (F41.8)

This category applies to presentations in which symptoms characteristic of an anxiety dis-
order that cause clinically significant distress or impairment in social, occupational, or oth-
er important areas of functioning predominate but do not meet the full criteria for any of the
disorders in the anxiety disorders diagnostic class. The other specified anxiety disorder
category is used in situations in which the clinician chooses to communicate the specific
reason that the presentation does not meet the criteria for any specific anxiety disorder.
This is done by recording “other specified anxiety disorder” followed by the specific reason
(e.g., “generalized anxiety not occurring more days than not”).

Examples of presentations that can be specified using the “other specified” designation
include the following:
1. Limited-symptom attacks.
2. Generalized anxiety not occurring more days than not.
3. Khyâl cap (wind attacks): See “Glossary of Cultural Concepts of Distress” in the Ap-

pendix.
4. Ataque de nervios (attack of nerves): See “Glossary of Cultural Concepts of Distress”

in the Appendix.

Unspecified Anxiety Disorder
300.00 (F41.9)

This category applies to presentations in which symptoms characteristic of an anxiety dis-
order that cause clinically significant distress or impairment in social, occupational, or oth-
er important areas of functioning predominate but do not meet the full criteria for any of the
disorders in the anxiety disorders diagnostic class. The unspecified anxiety disorder cate-
gory is used in situations in which the clinician chooses not to specify the reason that the
criteria are not met for a specific anxiety disorder, and includes presentations in which
there is insufficient information to make a more specific diagnosis (e.g., in emergency room
settings).

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235

Obsessive-Compulsive and
Related Disorders

Obsessive-compulsive and related disorders include obsessive-compulsive
disorder (OCD), body dysmorphic disorder, hoarding disorder, trichotillomania (hair-
pulling disorder), excoriation (skin-picking) disorder, substance/medication-induced ob-
sessive-compulsive and related disorder, obsessive-compulsive and related disorder due
to another medical condition, and other specified obsessive-compulsive and related dis-
order and unspecified obsessive-compulsive and related disorder (e.g., body-focused re-
petitive behavior disorder, obsessional jealousy).

OCD is characterized by the presence of obsessions and/or compulsions. Obsessions
are recurrent and persistent thoughts, urges, or images that are experienced as intrusive
and unwanted, whereas compulsions are repetitive behaviors or mental acts that an indi-
vidual feels driven to perform in response to an obsession or according to rules that must
be applied rigidly. Some other obsessive-compulsive and related disorders are also char-
acterized by preoccupations and by repetitive behaviors or mental acts in response to the
preoccupations. Other obsessive-compulsive and related disorders are characterized pri-
marily by recurrent body-focused repetitive behaviors (e.g., hair pulling, skin picking) and
repeated attempts to decrease or stop the behaviors.

The inclusion of a chapter on obsessive-compulsive and related disorders in DSM-5 re-
flects the increasing evidence of these disorders’ relatedness to one another in terms of a
range of diagnostic validators as well as the clinical utility of grouping these disorders in
the same chapter. Clinicians are encouraged to screen for these conditions in individuals
who present with one of them and be aware of overlaps between these conditions. At the
same time, there are important differences in diagnostic validators and treatment ap-
proaches across these disorders. Moreover, there are close relationships between the anx-
iety disorders and some of the obsessive-compulsive and related disorders (e.g., OCD),
which is reflected in the sequence of DSM-5 chapters, with obsessive-compulsive and re-
lated disorders following anxiety disorders.

The obsessive-compulsive and related disorders differ from developmentally norma-
tive preoccupations and rituals by being excessive or persisting beyond developmentally
appropriate periods. The distinction between the presence of subclinical symptoms and a
clinical disorder requires assessment of a number of factors, including the individual’s
level of distress and impairment in functioning.

The chapter begins with OCD. It then covers body dysmorphic disorder and hoarding
disorder, which are characterized by cognitive symptoms such as perceived defects or
flaws in physical appearance or the perceived need to save possessions, respectively. The
chapter then covers trichotillomania (hair-pulling disorder) and excoriation (skin-picking)
disorder, which are characterized by recurrent body-focused repetitive behaviors. Finally,
it covers substance/medication-induced obsessive-compulsive and related disorder,
obsessive-compulsive and related disorder due to another medical condition, and other
specified obsessive-compulsive and related disorder and unspecified obsessive-compul-
sive and related disorder.

While the specific content of obsessions and compulsions varies among individuals,
certain symptom dimensions are common in OCD, including those of cleaning (contami-
nation obsessions and cleaning compulsions); symmetry (symmetry obsessions and repeat-

236 Obsessive-Compulsive and Related Disorders

ing, ordering, and counting compulsions); forbidden or taboo thoughts (e.g., aggressive,
sexual, and religious obsessions and related compulsions); and harm (e.g., fears of harm to
oneself or others and related checking compulsions). The tic-related specifier of OCD is
used when an individual has a current or past history of a tic disorder.

Body dysmorphic disorder is characterized by preoccupation with one or more per-
ceived defects or flaws in physical appearance that are not observable or appear only slight
to others, and by repetitive behaviors (e.g., mirror checking, excessive grooming, skin
picking, or reassurance seeking) or mental acts (e.g., comparing one’s appearance with that
of other people) in response to the appearance concerns. The appearance preoccupations
are not better explained by concerns with body fat or weight in an individual with an eat-
ing disorder. Muscle dysmorphia is a form of body dysmorphic disorder that is character-
ized by the belief that one’s body build is too small or is insufficiently muscular.

Hoarding disorder is characterized by persistent difficulty discarding or parting with
possessions, regardless of their actual value, as a result of a strong perceived need to save
the items and to distress associated with discarding them. Hoarding disorder differs from
normal collecting. For example, symptoms of hoarding disorder result in the accumula-
tion of a large number of possessions that congest and clutter active living areas to the ex-
tent that their intended use is substantially compromised. The excessive acquisition form
of hoarding disorder, which characterizes most but not all individuals with hoarding dis-
order, consists of excessive collecting, buying, or stealing of items that are not needed or
for which there is no available space.

Trichotillomania (hair-pulling disorder) is characterized by recurrent pulling out of
one’s hair resulting in hair loss, and repeated attempts to decrease or stop hair pulling.
Excoriation (skin-picking) disorder is characterized by recurrent picking of one’s skin re-
sulting in skin lesions and repeated attempts to decrease or stop skin picking. The body-
focused repetitive behaviors that characterize these two disorders are not triggered by ob-
sessions or preoccupations; however, they may be preceded or accompanied by various
emotional states, such as feelings of anxiety or boredom. They may also be preceded by an
increasing sense of tension or may lead to gratification, pleasure, or a sense of relief when
the hair is pulled out or the skin is picked. Individuals with these disorders may have vary-
ing degrees of conscious awareness of the behavior while engaging in it, with some indi-
viduals displaying more focused attention on the behavior (with preceding tension and
subsequent relief) and other individuals displaying more automatic behavior (with the be-
haviors seeming to occur without full awareness).

Substance/medication-induced obsessive-compulsive and related disorder consists of
symptoms that are due to substance intoxication or withdrawal or to a medication. Obses-
sive-compulsive and related disorder due to another medical condition involves symptoms
characteristic of obsessive-compulsive and related disorders that are the direct pathophysio-
logical consequence of a medical disorder. Other specified obsessive-compulsive and related
disorder and unspecified obsessive-compulsive and related disorder consist of symptoms
that do not meet criteria for a specific obsessive-compulsive and related disorder because of
atypical presentation or uncertain etiology; these categories are also used for other specific
syndromes that are not listed in Section II and when insufficient information is available to di-
agnose the presentation as another obsessive-compulsive and related disorder. Examples of
specific syndromes not listed in Section II, and therefore diagnosed as other specified obses-
sive-compulsive and related disorder or as unspecified obsessive-compulsive and related
disorder include body-focused repetitive behavior disorder and obsessional jealousy.

Obsessive-compulsive and related disorders that have a cognitive component have in-
sight as the basis for specifiers; in each of these disorders, insight ranges from “good or fair
insight” to “poor insight” to “absent insight/delusional beliefs” with respect to disorder-
related beliefs. For individuals whose obsessive-compulsive and related disorder symp-
toms warrant the “with absent insight/delusional beliefs” specifier, these symptoms
should not be diagnosed as a psychotic disorder.

Obsessive-Compulsive Disorder 237

Obsessive-Compulsive Disorder
Diagnostic Criteria 300.3 (F42)

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some
time during the disturbance, as intrusive and unwanted, and that in most individuals
cause marked anxiety or distress.

2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to
neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,
praying, counting, repeating words silently) that the individual feels driven to per-
form in response to an obsession or according to rules that must be applied rigidly.

2. The behaviors or mental acts are aimed at preventing or reducing anxiety or dis-
tress, or preventing some dreaded event or situation; however, these behaviors or
mental