• Unipolar depressive disorders or
• Anxiety disorders rather than bipolar disorders.

2 weeks duration although most episodes are considerably longer.

Disruptive Mood Dysregulation Disorder

Diagnostic Criteria

 DMDD can coexist with other disorders including: MDD, ADHD, CD, and substance use disorders.  

Individuals whose symptoms meet criteria for both DMDD and ODD should only be given the diagnosis of DMDD.  If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.  

• Chronic, severe, persistent irritability.
• Frequent temper outbursts and angry, irritable mood between outbursts

1. Frequent temper outbursts
2. Irritable or angry mood that is present between temper outbursts- must be charachteristic of the child, being present most of the day, nearly every day, and noticable by others in the child's environment.

Rates are expected to be higher in males and school-age children than in females and adolescents.

Major Depressive Disorder

(MDD)

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.

  1. Depressed mood most of the day, nearly every day, as indicated by either subjective 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).

  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 inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without 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 impairment in social, occupational, 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 represents a major depressive episode.

   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 sadness, 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 understandable 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.

D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E.  There has never been a manic 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 medical condition.

• Distinguishing depression from grief.
• Period of at least 2 weeks with either depressed mood or the loss of interest/pleasure in nearly all activities.

• Depressed
• Sad
• Hopless
• "Down in the dumps"
• Blah
• Having no feelings
• Anxious
• Somatic complaints: bodily aches/pains
• Increased irritability

Mortality rate. 

Persistent Depressive Disorder (Dysthymia)

(Diagnostic Criteria)

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 individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.

D. Criteria for a MDD 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 PDD (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years bit will not meet criteria for PDD. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of MDD.  Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted. 

Specify If:

   With anxious distress

   With mixed features

   With melancholic features

   With atypical features

   With mood-congruent psychotic  features

   With mood-incongruent psychotic features

Specify If:   

   In partial remission

   In full remission

Specify If:

   Early onset: if onset is before age 21

   Late onset: if onset is at 21 years or older

Specify If:

   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 episode 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 criteria 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

    Moderate

    Severe

Persistent Depressive Disorder

(Dysthymia)

• 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 or adolescents)
• Individuals whose symptoms meet MDD criteria for 2 yeats should be MDD and PDD.

Premenstrual Dysphoric Disorder

(Diagnostic Criteria)

A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset before menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses. 

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 increased sensitivity to rejection). 

 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 makred 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, joing or muscle pain, a physical 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 activities, or relationships with others (e.g., avoidance of social activities, decreased productivity and efficiency at work, school, or home).

E. The disturbance is nor merely an exacerbation of the symptoms of another disorder such as MDD, panic disorder, PDD, or a personality disorder (although it may co-occur with any of these disorders).

F. Criteria A should be confirmed by prospective daily ratings during at least two symptomatic 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., hyperthyriodism). 

• The expression of mood lability, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the premenstrual phase of the cycle and remit around the onset of menses or shortly thereafter. 
• Symptoms must occur in most cycles in the past year.

Substance/Medication-Induced Depressive Disorder

(Diagnostic Criteria)

A. A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by 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 Criterion 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 include 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; there is other evidence suggesting the existence of an independent non-substance/medication-induced depressive disorder (e.g., a history of recurrent non-substance/medication-related episodes).

D. The disturbance does not occur exlusively durng the course of delirium.

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Note: The diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms of Criterion A predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention. 

Specify if: 

  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. 

• Stimulants
• Steroids
• L-dopa
• Antibiotics
• CNS drugs
• Dermatalogical agents
• Chemotherapeutic drugs
• Immunological agents

Depressive Disorder Due to Another Medical Condition

(Diagnostic Criteria)

A. A prominent and persistent period of depressed mood or markedly diminished intrest 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 condition. 

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, occupational, or other important areas of functioning.  

Specify if:

 With depressive features: Full criteria are not met for a major depressive episode.

 With major depressive-like episode: Full criteria are met (except Criterion C) for a major depressive episode.

 With mixed features: Symptoms of mania or hypomania are also present byt do not predominate in the clinical picture. 

Why does the DSM have a specification of 

Other Specified Depressive Disorder?

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. 

1. Recurrent Brief Depression: Concurrent presence of depressed mood and at least four other symptoms of depresseion for 2-13 days at least once per month (not associated 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 disoder.

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 any other depressive or bipolar disorder, does not currently meet or residual criteria for any psychotic disorder, 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 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. 

Separation Anxiety Disorder

(diagnostic criteria)

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 sparation from home or from major attachment figures.

 2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters or death. 

 3. Persistnet and excessive worry about experiencing an untoward event (e.g.,  getting lost, being kidnapped, having an accident, becoming ill) that causes seperation from a major 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. Persistnet reluctance or refusal to sleep away from home or to go to sleeo 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, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.

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, academic, 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 GAD; or concerns about having an illness in illness anxiety disorder.

• Excessive fear/anxiety over separation from home or attachment figures- beyond what is expected for developmental level.
• At least 4 weeks in children and adolescents (under 18) ant at least 6 months in adults (some flexibility in adults).
• Social withdrawal, apathy, sadness, difficulty concentrating.

• Being unable/uncomfortable traveling independently
• Repeated nightmares: e.g., destruction of the family through fire, murder, catastrophe.
• Physical symptoms: Cardiovascular: dizziness, feeling faint, palpations.

• Specific Phobia
• PTSD
• Panic disorder
• GAD
• Social anxiety disorder
• Agoraphobia
• OCD
• Personality disorders

Selective Mutism

(diagnostic criteria)

A. Consistent failure to speak in specific social situations in which there is an expectaation for speaking (e.g., 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.

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, etc.)

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, anxity, 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 OCD); reminders of traumatic events (as in PTSD); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

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)

  300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed spaces)

  300.28 (F40.298) Other (e.g., situations may lead to choking/vomiting; in children, e.g., loud sounds or costumed characters).

• The fear or anxiety is circumscribed to the presence of a particular situation or object.
• The individual actively avoids a situation.
• Anxiety in the presence of a certain stimuli; evoked nearly everytime the stimulus is present.
• The fear is disproportionate to the stimulus.

What is the prevalence for specific phobia in the U.S.?

Which gender is more likely to be affected?

7%-9% Rates vary across stimuli.

Females 2:1

The percentage goes down over time in age. 

Social Anxiety Disorder (Social Phobia)

(diagnostic criteria)

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., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others. Note: In children, the anxiety must occur in peer settings and not just during interactions 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 embarassing; will lead to rejection or offending 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. 

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 substance (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.

• Marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others; for children this must occur in peer settings, not just in the presence of adults.
• In children, must occur with peers and adults
• Fear is disproportionate to actual risk of being evaluated.
• Typically at least 6 months.

13yrs old

75% of individuals have an onset between 8 and 15yrs.

"Interpersonal Fear Disorder" in Japanese

• Syndrome characterized by anxiety and avoidance of interpersonal situations due to the thought, feeling, or conviction that one's appearance and actions in social interactions are inadequate or offensive to others. 
• Individuals tend to focus on the impact of their symptoms and behaviors on others.
• Is a broader construct than social anxiety disorder (social phobia). 

"Sensitive Type"

  Extreme social sensitivity and anxiety about

  interpersonal interactions.

"Offensive Type"

  The major concern is offending others.

Panic Disorder

(diagnostic criteria)

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of 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 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. Parethesias (numbness or tingling sensations)

 11. Derealization (feelings of unreality) or depersonalization

      (detached from onself).

 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.

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). 

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, cardiopulmonary disorders). 

D. The disturbance is not better explained by another mental disorder (e.g., the panic attcks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions as in OCD; in response to reminders of traumatic events, as in PTSD; or in response to separation from attachment figures, as in separation anxiety disorder). 

Panic Attack Specifier

Criteria

Pg. 214

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 disorders, PTSD, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g., "PTSD 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. 

Note:The abrupt surge can occur from a calm state or an anxious state

1. Palpations, 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 sensation.

10. Paresthesias (numbness or tingling sensations).

11. Derealization (feelings of unreality) or depersonalization (being detachment from onself).

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.

Waking from sleep in a state of panic. 

Related to a higher rate of suicide attempts and suicidal ideation even when comobidity and other suicide risks are taken into account

Agoraphobia

(diagnostic criteria)

A. Marked fear or anxiety about two (or more) of the following five situations.

 1. Using public transportation (e.g. autos, 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 symptoms or other incapacitating or embarassing symptoms (e.g., fear of falling in the elderly; 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 persistant, typically lasting for 6 months or more. 

G. The fear, anxiety, or avoidance causes clinically significantdistress or impairment in social, occupational, or other important areas of functioning. 

H. If another medical condition (e.g., IBS, 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 mental 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 related exclusively to obsessions (as in OCD), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders in traumatic events (as in PTSD), or fear of separation (as in separation anxiety disorder). 

Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder.  If an individual;s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned. 

Generalized Anxiety Disorder

GAD

(diagnostic criteria)

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 symptoms (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 restlessness, unsatisfying sleep). 

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment 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 anxiety disorder [social phobia], contamination or other obsessions in OCD, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in PTSD, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder). 

• The excessive anxiety and worry that is spread to a number of events or activities.
• Difficult to control worry and it interferes with activities.
• Accompanied by at least 3 additional symptoms.

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 Criterion 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 existnce of an independent non-substance/medication-induced anxiety disorder (e.g., a history of recurrent non-substance/medication-related episodes). 

  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. 

• Prominent symptoms of panic or anxiety that are judged to be due to the effects of a substance.
• Symptoms developed during or soon after intoxication or withdrawal or after exposure to a medication.
• The substances must be capable of producing symptoms.

Reactive Attachment Disorder

(diagnostic criteria)

A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:

 1. The child rarely or minimally seeks comfort when distressed.

 2. The child rarely or minimally respons to comfort when distressed.

B. A persistent social and emotional disturbance characterize by at least two of the following:

 1. Minimal social and emotional responsiveness to others.

 2. Limited positive affect.

 3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.

C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following. 

 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.

 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). 

 3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios). 

D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C). 

E. The criteria are not met for autism spectrum disorder.

F. The disturbance is evident before the age of 5 years. 

G. The child has a developmental age of at least 9 months. 

Specify if:

  Persistent: The disorder has been present for more than 12 months.

Specify current severity:

  Reactive attachment disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

Disinhibited Social Engagement Disorder

(diagnostic criteria)

no stranger danger

A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:

 1. Reduced or absent reticence in approaching and interacting with unfamiliar adults.

 2. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and age-appropriate social boundaries). 

 3. Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.

 4. Willingness to go off with an unfamiliar adult with minimal or no hesitation. 

B. The behaviors in Criterion A are not limited to impulsivity (as in ADHD) but include socially disinhibited behavior.

C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:

 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.

 2. Repeated changes of primary caregivers that limit opportunitiesto form stable attachments (e.g., frequent changes in foster care).

 3. Rearing in unusual settings that severly limit opportunities to form selective attachments (e.g., institutions with high child-to-caregivers ratio).

D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).

E. The child has a developmental age of at least 9 months.

Specify if:

  Persistent: The disorder has been present for more than 12 months

Specify if:

  Disinhibited social engagement disorder is specified as severe when the child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

20%

The condition is rarely seen in clinical populations.

Posttraumatic Stress Disorder

(diagnostic criteria)

Adults/Adolescents/Children 6+

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways.

 1. Directly experiencing the traumatic events.

 2. Witnessing, in person, the event(s) as it occurred to others.

 3. Learning that the traumatic even(s) occurred to a close family member or close friend.  In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers exposed to details of child abuse).

  Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.  

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: in children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. 

 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: in children, there may be frightening dreams without recognizable content. 

 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings). Note: In children, trauma-specific reenactment may occur in play.

 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

C. Present avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidence by one or both of the following:

 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

 2. Avoidance of or efforts to avoid external reminders (people, places, conversatoins, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 

D. Negative alterations in cognitions and mood association with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidened by two (or more) of the following:

 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). 

 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., 'I am bad', 'No one can be trusted,' 'the world is completely dangerous,' 'My whole nervous system is completely ruined').

 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

 5. Markedly diminished interest or participation in significantactivities

 6. Feelings of detachment or estrangement from others

 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

 2. Reckless or self-destructive behavior.

 3. Hypervigilance

 4. Exaggerated startle response

 5. Problems with concentration

 6. Sleep disturbance (e.g., difficulty falling asleep or staying asleep or restless sleep).

F. Duration of the disturbance (Criterion B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medicaion, alcohol) or another medical condition.

Specify whether:

  With dissociative symptoms: The individual's symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

  1. Depersonalization: Persistent or recurrent experiences of feeling detached from and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).

  2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world aruond the individual is experienced as unreal, dreamlike, distant, or distorted). Note: to use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackuots, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). 

Specify if:

  With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate). 

Posttraumatic Stress Disorder

diagnostic criteria

Children 6 Years and Younger

A. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 

 1. Directly experiencing the traumatic event(s)

 2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers. Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures.

 3. Learning the traumatic event(s) occurred to a parent or caregiving figure.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment. 

 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: It may npt be possible to ascertain that the frightening content is related to the traumatic event. 

 3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-specific reenactment may occur in play.

 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). 

 5. Marked physiological reactions to reminders of the traumatic event(s). 

C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s):

  Persistent Avoidance of Stimuli

  1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s). 

  2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s). 

  Negative Alterations in Cognitions

  3. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion). 

  4. Markedly diminished interest or participation in significant activities, including constriction of play. 

  5. Socially withdrawn behavior. 

  6. Persistent reduction in expression of positive emotions.

D. Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s)occurred, as evidenced by two (or more) of the following:

 1. irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums). 

 2. Hypervigilance

 3. Exaggerated startle response.

 4. Problems with concentration

 5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). 

E. The duration of the disturbance is more than 1 month. 

F. The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behavior. 

G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition.

Specify whether:

  With dissociative symptoms: The individua's symptoms meet the criteria for posttraumatic stress disorder, and the individual experiences persistent or recurrent symptoms of either of the following:

 1. Depersonalization: Persistent or recurrent experiences of feeling detached from and as if one were an outside observer of, one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly). 

 2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). 

Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures). 

Specify if:

  With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate). 

Acute Stress Disorder

(diagnostic criteria)

A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways:

 1. Directly experiencing the traumatic event(s).

 2. Witnessing, in person, the event(s) as it occurred to others.

 3. Learning that the event(s) occurred to a close family member or close friend. Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains, police officers repeatedly exposed to details of child abuse). Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related. 

B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

 Intrusion Symptoms

  1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitve play may occur in which themes or aspects of the traumatic event(s) are expressed.

  2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content.

  3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum with the most extreme expression being a complete loss of awareness of present surroundings). Note: In children, trauma-specific reenactment may occur in play. 

  4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the trauma.

 Negative Mood

  5. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

 Dissociative Symptoms

  6. An altered sense of the reality of one's surroundings or oneself (e.g., seeing oneself from another's perspective; being in a daze, time slowing).

  7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol or drugs). 

 Avoidance Symptoms

  8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

  9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). 

 Arousal Symptoms

  10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).

  11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.

  12. Hypervigilance.

  13. Problems with concentration. 

  14. Exaggerated startle response. 

C. Duration of disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure. Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria. 

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

E. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not better explained by brief psychotic disorder. 

• Khyal
• Ataque de nervios

Adjustment Disorders

(diagnostic criteria)

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:

 1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation. 

 2. Significant impairment in social, occupational, or other important areas of functioning. 

C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbationof a preexisting mental disorder.

D. The symptoms do not represent normal bereavement.

E. Once the stressor its consequences have terminated, the symptoms do not persist for more than an additional 6 months. 

Specify whether: 

  309.0 (F43.21) With Depressed Mood: Low mood, tearfulness, or feelings of hopelessness are predominant.

  309.24 (F43.22) With Anxiety: Nervousness, worry, jitterness, or separation anxiety is predominant

  309.28 (F43.23) With Mixed Anxiety and Depressed Mood: A combination of depression and anxiety is predominant. 

  309.3 (F43.24) With Disturbance of Conduct: Disturbance of conduct is predominant.

  309.4 (F43.25) With Mixed Disturbance of emotions and Conduct: Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant.

  309.9 (F43.20) Unspecified: For maladaptive reactions that are not classifiable as one of the specific subtypes of adjustment disorder. 

Belief that one is going to be harmed, harassed, and so forth by an individual, organization, or other group.

Disorganized Thinking

Typically inferred from the individual's speech.

1. Diminished emotional expression
2. Avolition

Schizotypal (Personality) Disorder

(diagnostic criteria)

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 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 brieft relative to the duration of the delusional periods. 

E. The disturbance is not attributable to the physiological effects of a substance or another 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 involves 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. 

 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 specidic types (e.g., referential delusions 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 belief that a stranger has removed his or her internal organs and replaced them with someone else's organs without leaving any wounds or scars). 

Specify if:

 The following course specifiers are only to be used after 1 year duration of the disorder: 

  First episode, currently in acute episode: First manifestation of the disorder meeting the defining diagnostic symptom and time criteria.  An acute episode is a time period in which the symptom criteria are fulfilled. 

  First episode, currently in partial remission: Partial remission is a time period during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partialy 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 being 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 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). Note: Diagnosis of delusional disorder can be made without using this severity specifier.

Brief Psychotic Disorder

(diagnostic criteria)

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.

  With marked stressor(s): If symptoms fo not occur in response to events that singly or together, would be markedly stressful to almost anyone in similar circumstances 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 disorder)

Specify Current severity

  Severity is rated by quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, 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).  

 Schizophreniform Disorder

(diagnostic criteria)

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. 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 "provisional."

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 or concurrently with the 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; and absense 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 disorder)

Specify current severity:

  Severity is rated by quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms......

Schizophrenia

(diagnostic criteria)

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 functioning 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 Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attentuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been rules 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 childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month.

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 manifestion of the disorder meeting the defining diagnostic symptom and time criteria.  An acute episode is a time period in which the symptom criteria is fulfilled. 

  First episode, currently in partial remission: Partial remission is a period of time during which an improvement after a previous episode 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 determined 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 being very relative to the overall course. 

  Unspecified

Specify if:

  With catatonia (refer to the criteria for catatonia associated with another mental disorder)

Specify current severity

Schizoaffective Disorder

(diagnostic criteria)

A. An uninterupted period of illness during which there is a major mood episode (depressive or manic) concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include Criterion A1: Depressed Mood. 

B. Delusions or hallucinatons for 2 or more weeks in the absence of a major mood episode (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 medicaion) or another medical condition). 

Specify whether: 

  295.70 (F25.0): Bipolar Type: This subtype applies if a manic episode is part of the presentations. Major depresive episodes may also occur. 

  295.70 (F25.1): Depressive Type: This subtype applies if only major depressive episodes are part of the presentation. 

Specify if:

  With catatonia (refer to the criteria for catatonia associated with another medical disorder)

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 meeting the defining diagnostic symptom and time criteria.  An acute episode is a period of time in which the symptom criteria are fulfilled. 

  First episode, currently in partial remission: Partial remission is a time period during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfillled. 

  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 may be determined 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, currenly 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 being very brief relative to the overall course.

  Unspecified

Specify current severity

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 Criterion 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 include 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 independent non-substance/medication-induced psychotic 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, occupational, 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. 

Specify if: 

 With onset during intoxication: If the criteria are met for intoxication with the substance and the symptoms develop during intoxication. 

 With onset during withdrawal: If the criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after withdrawal. 

Specify current severity

What are the classes of substances in which a psychotic disorder can occur in association with? 

What are the classes of substances a psychotic disorder can occur in association with a withdrawal from?

In Association With:

  Alcohol

  Cannabis

  Halucinogens (including phencyclidine and related sub.)

  Inhalents

  Sedatives, hypnotics, and anxiolytics

  Stimulants (including cocaine)

  Other

In Assoc. with Withdrawal From

  Alcohol

  Sedatives, hypnotics, and anxiolytics

  Other

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 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, occupational, 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. 

Specify current severity

Catatonia Specifier

Catonia Associated with Another Mental Disorder

(diagnostic criteria)

A. The clinical picture is dominated by three (or more) of the following symptoms.

  1. Stuppor (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. Stererotypy (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)

Catatonic Disorder due to Another Medical Condition

(diagnostic criteria)

A. The clinical picture is dominated by three (or more) of the following symptoms.

  1. Stuppor (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. Stererotypy (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 spisode). 

D. The disturbance does not occur exclusively during the course of a delirium. 

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

(diagnostic criteria)

This category applies to presentations in which symptoms characteristic of a schizophrenia spectrum and other psychotic 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 schizophrenia spectrum and other psychotic 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 schizophrenia spectrum and other psychotic disorder.  This is done by recording "other specified schizophrenia spectrum and other psychotic disorder" followed by the specific reason (e.g., persistent auditory hallucinations). 

Examples:

 1. Persistent auditory hallucinations: occuring in the absence of 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 criteria for delusional disorder. 

Manic Episode

(diagnostic criteria)

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistentlyt increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day, (or any duration if hospitalization is necessary)

B. During the period of mood disturbance and increased energy or activiry, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant 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 pressured to keep talking

 4. Flight of ideas or subjective experience that thoughts are racing.

 5. Distractability (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 consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). 

C. The mood disturbance is suffiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, 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 antidepresent treatment (e.g., medication, ECT) 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 consitutes a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I. 

Hypomanic Episode

(diagnostic criteria)

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 consequtive 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, represent a noticable 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 presure to keep talking.

 4. Flight of ideas or subjective experience that thoughts are racing. 

 5. Distractability (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 

 6. Increased 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 consequences (e.g., engaging in unrestrained buying sprees, sexual indescretions, or foolish business investments). 

C. the episode is associated with an unequivocal change in functioning that is uncharacteristic 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 occupational 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 medicaiton, other treatment). Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, ECT) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence of a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficent for daignosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis. 

Note: Criteria A-F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I but are not required for the diagnosis of bipolar I disorder.

Major Depressive Episode

(diagnostic criteria)

Major Depressive Disorder

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 subjective report (e.g., feels sad, empty, hopeless) or observation made my 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. Significannt weight loss when not dieting or weight gain (e.g., a change of more than 5% 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 delusional) nearly every day (not merely self-reproach or guilt about being sick).

 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

 9. Recurrent thoughts of death (not just fear of dying, recurrent suicidal ideation without 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, occupational, 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 consitute a major depressive episode. Major depressive episodes are common in bipolar I bute are not required for the diagnosis of bipolar I.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses froma natural disaster, a serious medical illness, or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Althought such symptoms may be understandable 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 inevitable 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

Bipolar I Disorder

(diagnostic criteria)

A. Criteria have been met for at least one manic episode (Criteria A-D under Manic Episode).

B. The occurance of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. 

Specify:

 With anxious distress

 With mixed features

 With rapid cycling

 With melancholic features

 With atypical features

 With mood-congruent psychotic features

 With mood-incontruent psychotic features

 With catatonia

 With peripartum onset

 With seasonal pattern

Bipolar II Disorder

(diagnostic criteria)

A. Criteria have been met for at least one hypomanic episode (Criteria A-F under Hypomanic Episode) and at least one major depressive episode (Criteria A-C under Major Depressive Episode). 

B. There has never been a manic episode. 

C. The occurance of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform 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 between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

Specify current or most recent episode:

 Hypomanic

 Depressed 

Specify if:

 With anxious distress

 With mixed features

 With rapid cycling

 With mood-congruent psychotic features 

 With mood-incongruent psychotic features

 With catatonia

 With peripartum onset

 With seasonal pattern

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 

Cyclothymic Disorder

(diagnostic criteria)

A. For at least 2 years (at least 1 in children and adolescents) there have been numerous 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 sumptoms for more than 2 months at a time. 

C. Criteria for a major depressive, manic, or hypomanic episode has never been met.

D. The symptoms in criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other unspecified or unspecified schizophrenia spectrum and other psychotic disorder.

E. The symptoms are not attributable to the physiolotical effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). 

F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

Specify if:

  With anxious distress

Obsessive Compulsive Disorder

OCD

(diagnostic criteria)

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., handwashing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform 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 distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: young children may not be able to articulate the aims of these behaviors or mental acts.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. 

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in GAD; preoccupation with appearance, as in body dysmorphyic disorder; difficulty discarding or parting with posessions, as in hoarding disorder; hair pulling, as in trichotillomania; skin picking, as in excoriation disorder; stereotypies as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in distuptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder). 

Specify if:

 With good or fair insight: the individual recognizes that OCD beliefs are definitely or probably not true or that they may or may not be true.

 With poor insight: The individual thinks OCD beliefs are probably true.

 With absent insight/delusional beliefs: The individual is completely convinced that OCD beliefs are true.

Specify if:

 Tic-related: The individual has a current or past history of a tic disorder. 

Body Dysmorphic Disorder

(diagnostic criteria)

A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. 

B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others in response to the appearance concerns.

C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Specify if:

 With muscle dysmorphia: The individual is preoccupied with the idea that his or her build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case. 

Specify if:

Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., "I look ugly" or "I look deformed"). 

 With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true.

 With poor insight: the individual thinks that the body dysmorphic disorder beliefs are probably true. 

 With absent insight/delusional beliefs: The individual is completely convinced that the body dysmorphic disorder beliefs are true. 

Hoarding Disorder

(diagnostic criteria)

A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.

B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. 

C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compormises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities). 

D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). 

E. The hoarding is not attributable to another emdical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome). 

F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in OCD, decreased energy in MDD, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder). 

Specify if:

 With excessive aquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. 

Specify if:

 With good or fair insight: The individual recognizes that hoarding-related beliefs are behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. 

 With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. 

 With absent insight/delusional beliefs: the individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

Trichotillomania

(diagnostic criteria)

A. Recurrent pulling out of one's hair, resulting in hair loss.

B. Repeated attempts to decrease or stop hair pulling.

C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. the hair pulling or hair loss is not attributable to another medical disorder (e.g., a dermatological disorder). 

E. The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder). 

Skin-picking disorder

Excoriation Disorder

(diagnostic criteria)

A. Recurrent skin picking resulting in skin lesions

B. Repeated attempts to decrease or stop skin picking

C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies).

E. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury).

Disociative Identity Disorder

(DID)

(diagnostic criteria)

A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of posession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, congnition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.

B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.

E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). 

Dissociative Amnesia

(diagnostic crtieria)

A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or drug of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/traumatic brain injury, other neurological disorder).

D. The disturbance is not better explained by DID, PTSD, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.

Specify if:

 With dissociative fugue: Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information. 

Depersonalization/Derealization Disorder

(diagnostic criteria)

A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:

  1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one's thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing.

  2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted). 

B. During the depersonalization or derealization experiences, reality testing remains intact.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other areas of important functioning. 

D. The disturbance is not attributable to the physiological effects of a subtstance (e.g., a drug of choice, a medication) or another medical condition (e.g., seizures). 

E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, MDD, acute stress disorder, PTSD, or another dissociative disorder. 

Somatic Symptom Disorder

(diagnostic criteria)

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life. 

B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

 1. Disproportionate and persistent thoughts about the seriousness of one's symptoms

 2. Persistently high level of anxiety about health or symptoms

 3. Excessive time and energy devoted to these symptoms or health concerns.

C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). 

Specify if: 

  With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain.

Specify if: 

  Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months). 

Specify current severity:

  Mild: Only one of the symptoms specified in Criterion B is fulfilled.

  Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.

  Severe: Two or more of the symptoms specified in Criterion B are fulfillled, plus there are multiple somatic complaints (or one very severe somatic symptom). 

Illness Anxiety Disorder

(diagnostic criteria)

A. Preoccupation with having or acquiring a serious illness.

B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.

C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.

D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).

E. Illness preoccupation has been present fr at least 6 months, but the specific illness that is feared may change over that period of time.

F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, GAD, body dysmorphic disorder, OCD, or delusional disorder, somatic type. 

Specify whether:

  Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used.

  Care-avoidant type: Medical care is rarely used.

Hypochondriasis

Being a hypochondriac

Conversion Disorder

(Functional Neurological Symptom Disorder)

(diagnostic criteria)

A. One or more symptoms of altered voluntary motor or sensory function.

B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.

C. the symptom or deficit is not better explained by another medical or mental disorder.

D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Specify symptom type:

  (F44.4) With weakness or paralysis

  (F44.4) With abnormal movement

  (F44.4) With swallowing symptoms

  (F44.4) With speech symptoms

  (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: Symptoms present for less than 6 months

  Persistent: Symptoms occuring for 6 months or more.

Specify if:

  With psychological stressor (specify stressor)

  Without psychological stressor

Psychological Factors Affecting Other Medical Conditions

(diagnostic criteria)

A. A medical symptom or condition (other than a mental disorder) is present.

B. Psychological or behavioral factors adversely affect the medical condition in one of the following ways:

 1. The factors have influenced the course of the medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from the medical condition.

 2. The factors interfere with the treatment of the medical condition (e.g., poor adherence).

 3. The factors constitute additional well-established health risks for the individual.

 4. The factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention.

C. The psychological and behavioral factors in Criterion B are not better explained by another mental disorder (e.g., panic disorder, MDD, PTSD). 

Specify current severity:

 Mild: Increases medical risk (e.g., inconsistent adherence with antihypertension treatment).

 Moderate: Aggravates underlying medical condition (e.g., anxiety aggravating asthma).

 Severe: Results in medical hospitalization or emergency room visit.

 Extreme: Results in severe, life-threatening risk (e.g., ignoring heart-attack symptoms). 

Factitious Disorder

(diagnostic criteria)

Imposed on Self

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.

B. The individual presents himself or herself to others as ill, impaired, or injured.

C. The deceptive behavior is evident even in the absence of obvious external rewards.

D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder. 

Specify:

 Single episode

 Recurrent episodes (two or more events of falsification of illness and/or induction of injury).

Factitious Disorder

(diagnostic criteria)

Imposed on Another

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.

B. The individual presents another individual (victim) to others as ill, impaired, or injured.

C. The deceptive behavior is evident even in the absence of obvious external rewards.

D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Note: The perpetrator, not the victim, receives this diagnosis. 

Specify:

  Single episode

  Recurrent episodes (two or more events of falsification of illness and/or induction of injury). 

Pica

(diagnostic criteria)

A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.

B. The eating of nonnutritive, non food substances is inappropriate to the developmental level of the individual.

C. The eating behavior is not part of a culturally supported or socially normative practice.

D. If the eating behavior occurs in the context of another mental disorder(e.g., intellectual disability [intellectual developmental disorder], autism spectrum disorder, schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to warrant additional clinical attention.

Specify if:

  In remission: After full criteria for pica were previously met, the criteria have not been met for a sustained period of time.

Rumination Disorder

(diagnostic criteria)

A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out.

B. the repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., ggastroesophegeal reflux, pyloric stenosis). 

C. The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, bing-eating disorder, or avoidant/restrictive food intake disorder.

D. If the symptoms occur in the context of another mental disorder (e.g., intellectual disability [intellextual developmental disorder] or another neurodevelopmental disorder), they are sufficiently severe to warrant additional clinical attention. 

Specify if:

 In remission: After full criteria for rumination disorder were previously met, the criteria have not been met for a sustained period of time. 

Avoidant/Restrictive Food Intake Disorder

(diagnostic criteria)

A. Aneating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:

 1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).

 2. Significant nutritional defeciency.

 3. Dependence on enteral feeding or oral nutritional supplements.

 4. Marked interference with psychosocial functioning. 

B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.

C. The eating disturbance does not occur exclusively during the course of anorexia or bulimia nervosa, and there is no evidence of a disturbance in the way in which one's body weight or shape is experienced.

D. The eating disturbance is not attributable to a concurrent medical condition or better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.

Specify if:

  In remission: After full criteria for avoidant/restrictive food intake disorder were previously met, the criteria have not been met for a sustained period of time.

Anorexia Nervosa

(diagnostic criteria)

A. Restriction of energy intake relatve to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight, 

C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Specify whether:

  (F50.01) Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the mis-use of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. 

  (F50.02) Binge-eating/Purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). 

Specify if:

  In partial permission: After full criteria for anorexia nervosa were previously met, Criterion A (low body weight) has not been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behavior that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met.

  In full remission: After full criteria for anorexia nervosa was previously met, none of the criteria have been met for a sustained period of time.

Specify current severity:

The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or, for children and adolescents, on BMI percentile. The rantes below are detived from World Health Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision.

  Mild: BMI ≥ 17 kg/m²

  Moderate: BMI 16-16.99 kg/m²

  Severe: BMI 15-15.99 kg/m²

  Extreme: BMI < 15 kg/m²

Significantly Low Weight

(definition)

Bulimia Nervosa

(diagnostic criteria)

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

  1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.

  2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). 

B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify if:

  In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time.

  In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time. 

Specify current severity:

The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability.

  Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week.

  Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week. 

  Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week. 

  Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week. 

Binge-Eating Disorder

(diagnostic criteria)

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

  1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is larger than what most people would eat in a similar period of time under similar circumstances.

  2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). 

B. The binge-eating episodes are associated with three (or more) of the following:

 1. Eating much more rapidly than normal.

 2. Eating until feeling uncomfortably full.

 3. Eating large amounts of food when not feeling physically hungry.

 4. Eating alone because of feeling embarassed by how much one is eating.

 5. Feeling disgusted with oneself,depressed, or very guilty afterward

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least once/week, for 3 months.

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Specify if:

  In partial remission: After full criteria for binge-eating disorder were previously met, binge eating occurs at an average frequency of less tan one episode per week for a sustained period of time. 

  In full remission: After full criteria for binge-eating disorder were previously met, none of the criteria have been met for a sustained period of time.

Specify current severity:

The minimum level of severity is based on the frequency of episodes of binge eating (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability. 

  Mild: 1-3 binge-eating episodes per week.

  Moderate: 4-7 binge-eating episodes per week.

  Severe: 8-13 binge-eating episodes per week.

  Extreme: 24 or more binge-eating episodes per week. 

Enuresis

(diagnostic criteria)

A. Repeated voiding of urine into bed or clothes, whether voluntary or involuntary.

B. The behavior is clinically significant as manifested by either a frequency of at least twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. 

C. Chronological age is at least 5 years (or equivalent developmental level).

D. The behavior is not attributable to the physiological effects of a substance (e.g., a diuretic, an antipsychotic medication) or another medical condition (e.g., diabetes, spina bifida, a seizure disorder).

Specify whether:

  Nocturnal only: Passage of urine only during nighttime sleep.

  Diurnal only: Passaage of urine only during waking hours.

  Nocturnal and Diurnal: A combination of the two subtypes.

Encopresis

(diagnostic criteria)

A. Repeated passage of feces into inappropriate places (e.g., clothing, floor), whether involuntary or intentional. 

B. At least one such event occurs each month for at least 3 months.

C. Chronological age is at least 4 years (or equivalent developmental level).

D. The behavior is not attributable to the physiological effects of a substance (e.g., laxatives) or another medical condition except through a mechanism involving constipation.

Specify whether:

  With constipation and overflow incontinence: Ther is evidence of constipation on physical examination or by history.

  Without constipation and overflow inconinence: There is no evidence of constipation on physical examination or by history.

Insomnia Disorder

(diagnostic criteria)

A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:

 1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)

 2. difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)

 3. Early-morning awakening with inability to return to sleep.

B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning. 

C. The sleep difficulty occurs at least 3 nights per week.

D. The sleep difficulty is present for at least 3 months.

E. The sleep difficulty occurs despite adequate opportunity for sleep.

F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia). 

G. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication). 

H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

Specify if:

  With non-sleep disorder mental comorbidity, including substance use disorders

  With other medical comorbidity

  With other sleep disorder

Specify if:

  Episodic: Symptoms last at least 1 month but less than 3 months.

  Persistent: Symptoms last 3 months or longer.

  Recurrent: Two (or more) episodes within the space of 1 year.

Note: Acute and short-term insomnia (i.e., symptoms lasting less than 3 months but otherwise meeting all crtieria with regard to frequency, intensity, distress, and/or impairment) should be coded as an other specified insomnia disorder.

Hypersomnolence Disorder

(diagnostic criteria)

A. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:

 1. Recurrent periods of sleep or lapses into sleep within the same day.

 2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing).

 3. Difficulty being fully awake after abrupt awakening.

B. The hypersomnolence occurs at least three times per week, for at least 3 months.

C. The hypersomnolence is accompanied by significant distress or impairment in cognitive, social, occupational, or other important areas of functioning.

D. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder (e.g., narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or a parasomnia). 

E. The hypersomnolence is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication). 

F. Coexisting mental and medical disorders do not adequately explain the predominant complaint of hypersomnolence.

Specify if:

  With mental disorder, including substance use disorders.

  With medical condition

  With another sleep disorder

Specify if:

  Acute: Duration of less than 1 month

  Subacute: Duration of 1-3 months

  Persistent: Duration of more than 3 months

Specify current severity:

Specify severity based on degree of difficulty maintaining daytime alertness as manifested by the occurrence of multiple attacks of irresistible sleepiness within any given day occurring, for example, while sedentary, driving, visiting with friends, or working. 

Narcolepsy

(diagnostic criteria)

A. Recurrent periods of an irrepressible need to sleep, or napping occurring within the same day. These must have been occurring at least three times per week over the past 3 months.

B. The presence of at least one of the following:

 1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times per month:

   a. Individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking.

   b. In children or individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers.

 2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretin-1 immunoreactivity values (less than or equal to one-third of values obtained in healthy subjects tested using the same assay, or less than or equal to 110 pg/mL). Low CSF levels of hypocretin-1 must not be observed in the context of acute brain injury, inflammation, or infection.

 3. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep latency less than or equal to 8 minutes and two or more sleep-onset REM periods.

Specify whether:

 347.00 (G47.419): Narcolepsy without cataplexy but with hypocretin deficiency: Criterion B requirements of low CSF hypocretin-1 levels and positive polysomnogrophy/multiple sleep latency test are met, but no cataplexy is present (Criterion B1 not met).

 347.01 (G47.411): Narcolepsy with cataplexy but without hypocretin deficiency: In this rare subtype (less than 5% of narcolepsy cases), Criterion B requirments of cataplexy and positive polysomnography/multiple sleep latency tests are met, but CSF hypocretin-1 levels are normal (Criterion B2 not met).

 347.00 (G47.419): Autosomal dominant cerebellar ataxia, deafness, and narcolepsy: This subtype is caused by exon 21 DNA (cytosine-5)-methyltransferase-1 mutations and is characterized by late-onset (age 30-40 years) narcolepsy (with low or intermediate CSF hypocretin-1 levels), deafness, cerebellar ataxia, and eventually dementia.

 347.00 (G47.19): Autosomal dominant narcolepsy, obesity, and type 2 diabetes: Narcolepsy, obesity, and type 2 diabetes and low CSF hypocretin-1 levels have been described in rare cases and are associated with a mutation in the myelin oligodendrocyte glycoprotein gene.

 347.10 (G47.429): Narcolepsy secondary to another medical condition: This subtype is for narcolepsy that develops secondary to medical conditions that cause infectious (e.g., Whipple's disease, sarcoidosis), traumatic, or tumoral destruction of hypocretin neurons.

Specify current severity:

  Mild: Infrequent cataplexy (less than once per week), need for naps only once or twice per day, and less disturbed nocturnal sleep.

  Moderate: Cataplexy once daily or every few days, distrubed nocturnal sleep, and need for multiple naps daily.

  Severe: Drug-resistant cataplexy with multiple attacks daily, nearly constant sleepiness, and disturbed nocturnal sleep (i.e., movements, insomnia, and vivid dreaming). 

• Obstructive Sleep Apnea Hypopnea
• Central Sleep Apnea
• Sleep-related Hypoventalation

Obstructive Sleep Apnea Hypopnea

(diagnostic criteria)

A. Either (1) or (2):

 1. Evidenced by polysomnography of at least five obstructive apneas or hypopneas per hour of sleep and either of the following sleep symptoms:

   a. Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses during sleep.

   b. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that is not better explained by another mental disorder (including a sleep disorder) and is not attributable to another medical condition.

 2. Evidenced by polysomnography of 15 or more obstructive apnease and/or hypopneas per hour of sleep regardless of accompanying symptoms.

Specify current severity: 

  Mild: Apnea hypopnea index is less than 15.

  Moderate: Apnea hypopnea index is 15-30.

  Severe: Apnea hypopnea index is greater than 30.

Central Sleep Apnea

(diagnostic criteria)

A. Evidence by polysomnography of five or more central apneas per hour of sleep.

B. The disorder is not better explained by another current sleep disorder.

Specify whether:

  327.21 (G47.31): Idiopathic central sleep apnea: Characterized by repeated episodes of apneas and hypopneas during sleep caused by variability in respiratory effort but without evidence of airway obstruction.

  786.04 (R06.3): Cheyne-Stokes breathing: A pattern of periodic crescendo-decrescendo variation in tidal volume that results in central apneas and hypopneas at a frequency of at least five events per hour, accompanied by frequent arousal.

  780.57 (G47.37): Central sleep apnea comorbid with opioid use: The pathogenesis of this subtype is attributed to the effects of opioids on the respiratory rhythm generators in the medulla as well as the differential effects on hypoxic versus hypercapnic respiratory drive. 

Specify current severity:

Severity of central sleep apnea is graded according to the frequency of the breathing disturbances as well as the extent of associated oxygen desaturation and sleep fragmentation that occur as a consequence of repetitive respiratory disturbances.

Sleep-Related Hypoventilation

(diagnostic criteria)

A. Polysomnography demonstrates episodes of decreased respiration associated with elevated CO₂ levels. (Note: In the absence of objective measurement of CO₂, persistent low levels of hemoglobin oxygen saturation unassociated with apneic/hypopneic events may indicate hypoventilation).

B. The disturbance is not better explained by another current sleep disorder.

Specify whether: 

  327.24 (G47.34): Idiopathic hypoventilation: This subtype is not attributable to any readily identifiable condition.

  327.25 (G47.35): Congenital central alveolar hypoventilation: This subtype is a rare congenital disorder in which the individual typically presents in the perinatal period with shallow breathing, or cyanosis and apnea during sleep.

  327.26 (G47.36): Comorbid sleep-related hypoventilation: This subtype occurs as a consequence of a medical condition, such as a pulmonary disorder (e.g., interstitial lung disease, chronic obstructive pulmonary disease) or a neuromuscular or chest wall disorder (e.g., muscular dystrophies, postpolio syndrome, cervical spinal cord injury, kyphoscoliosis), or medications (e.g., benzodiazepines, opiates). It also occurs with obesity (obesity hypoventilation disorder), where it reflects a combination of increased work of breathing  due to reduced  chest wall compliance and ventilation-perfusion mismatch and variably reduced ventilatory drive. Such individuals usually are characterized by body mass index of greater than 30 and hypercapnia during wakefulness (with a pCO₂ of greater than 45), without evidence of hypoventilation. 

Specify current severity:

 Severity is graded according to the degree of hypoxemia and hypercarbia present during sleep and evidence of end organ impairment due to these abnormalities (e.g., right sided heart failure). The presence of blood gas abnormalities during wakefulness is an indicator of greater severity.

Circadian Rhythm Sleep-Wake Disorders

(diagnostic criteria)

A. A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual's physical environment or social or professional schedule.

B. The sleep disruption leads to excessive sleepiness or insomnia, or both. 

C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning.

Specify whether:

  307.45 (G47.21) Delayed sleep phase type: A pattern of delayed sleep onset and awakening times, with an inability to fall asleep and awaken at a desired or conventionally acceptable earlier time.

  Specify if:

     Familial: A history of delayed sleep is phase present.

  Specify if:

     Overlapping with non-24-hour-sleep-wake type: Delayed sleep phase type may overlap with another circadian rhythm sleep-wake-disorder, non-24-hour sleep-wake-type.

  307.45 (G47.22) Advanced sleep phase type: A pattern of advanced sleep onset and awakening times, with an inability to remain awake or asleep until the desired or conventionally acceptable later sleep or wake times.

   Specify if:

     Familial: A family history of advanced sleep phase is present.

  307.45 (G47.23): Irregular sleep-wake type: A temporally disorganized sleep-wake pattern, such that the timing of sleep and wake periods is variable throughout the 24-hour period.

  307.45 (G47.24): Non-24-hour sleep-wake type: A pattern of sleep-wake cycles that is not synchronized to the 24-hour environment, with a consistent daily drift (usually to later and later times) of sleep onset and wake times.

  307.45 (G47.24): Shift work type: Insomnia during the major sleep period and/or excessive sleepiness (including inadvertent sleep) during the major awake period associated with a shift work schedule (i.e., requiring unconventional work hours). 

  307.45 (G47.20): Unspecified type

Specify if:

  Episodic: Symptoms last at least 1 month but less than 3 months.

  Persistent: Symptoms last 3 months or longer.

  Recurrent: Two or more episodes occur within the space of 1 year

Non-Rapid Eye Movement Sleep Arousal Disorders

(diagnostic criteria)

A. Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either one of the following:

 1. Sleepwalking: Repeated episodes of rising from bed during sleep and walking about. While sleepwalking, the individual has a blank, staring face; is relatively unresponsive to the efforts of others to communicate with him or her; and can be awakened only with great difficulty.

 2. Sleep terrors: Recurrent episodes of abrupt terror arousals from sleep, usually beginning with a panicky scream. There is intense fear and signs of autonomic arousal, such as mydriasis, tachychardia, rapid breathing, and sweating, during each episode. There is relative unresponsiveness to efforts of others to comfort the individual during the episodes.

B. No or little (e.g., only a single visual scene) dream imagery is recalled.

C. Amnesia for the episodes is present.

D. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The distubance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

F. Coexisting mental and medical disorders do not explain the episodes of sleepwalking or sleep terrors.

Specify whether:

  307.46 (F51.3) Sleepwalking type

   Specify if:

     With sleep-related eating

     With sleep-related sexual behavior (sexomnia)

  307.46 (F51.4) Sleep terror type

Nightmare Disorder

(diagnostic criteria)

A. Repeated occurences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode.

B. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.

C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The nightmare symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

E. Coexisting mental and medical disorders do not adequately explain the predominant complaint of dysphoric dreams.

Specify if:

 During sleep onset

Specify if:

 With associated nonsleep disorder, inc. substance use disorder

 With associated other medical condition

 With associated other sleep disorder

Specify if:

 Acute: Duratin of period of nightmares is less than 1 month

 Subacute: Duration of period of nightmares is longer than 1 month but less than 6 months

 Persistent: Duration of period of nightmares is 6 months or greater

Specify current severity:

 Severity can be rated by the frequency with which the nightmares occur.

  Mild: Less than one episode per week.

  Moderate: One or more episodes per week but less than nightly.

  Severe: Episodes nightly.

Rapid Eye Movement Sleep Behavior Disorder

(diagnostic criteria)

A. Repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors.

B. These behaviors arise during rapid eye movement (REM) sleep and therefore usually occur more than 90 minutes after sleep onset, are more frequent during the later portions of the sleep period, and uncommonly occur during daytime naps.

C. Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented.

D. Either of the following:

 1. REM sleep without atonia on polysomnographic.

 2. A history suggestive of REM sleep behavior disorder and an established synucleinopathy diagnosis (e.g., Parkinson's disease, multiple system atrophy).

E. the behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (which may include injury to self or the med partner).

F. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

G. Coexisting mental and medical disorders do not explain the episodes.

Restless Leg Syndrome

(diagnostic criteria)

A. An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, characterized by the following:

 1. The urge to move the legs begins or worsens during periods of rest or inactivity.

 2. The urge to move the legs is partially or totally relieved by movement.

 3. The urge to move the legs is worse in the evening or at night than during the day, or occurs only in the evening or at night.

B. The symptoms in Criterion A occur at least 3 times per week and have persisted for at least 3 months.

C. The symptoms in Criterion A are accompanied by significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.

D. The symptoms in Criterion A are not attributable to another mental disorder or medical condition (e.g., arthritis, leg edema, peripheral ischemia, leg cramps) and are not better explained by a behavioral condition (e.g., positional discomfort, habbitual foot tapping).

E. The symptoms are not attributable to the physiological effects of a drug of abuse or medication (e.g., akathisia).

Delayed Ejaculation

(diagnostic criteria)

A. Either of the following symptoms must be experienced on almost all or all occasions (approx. 75-100%) of partnered sexual activity (in identified situational contexts or, if generalized, in all contexts), and without the individual desiring delay:

  1. Marked delay in ejaculation

  2. Marked infrequency or absence of ejaculation.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify whether:

  Lifelong: The disturbance has been present since the individual became sexually active.

  Acquired: The disturbance began after a period of relatively normal sexual function. 

Specify whether:

  Generalized: Not limited to certain types of stimulation, situations, or partners.

  Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity:

  Mild: Evidence of mild distress over the symptoms in Criterion A

  Moderate: Evidence of moderate distress over the symptoms of Criterion A.

  Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.

Erectile Disorder

(diagnostic criteria)

A. At least one of the three following symptoms must be experienced on almost all or all (approx. 75-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts).

 1. Marked difficulty in obtaining an erection during sexual activity.

 2. Marked difficulty in maintaining an erection until completion of sexual activity.

 3. Marked decrease in erectile rigidity.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in the individual.

D. the sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify whether:

 Lifelong: The disturbance has been present since the individual became sexually active.

 Acquired: The disturbance began after a period of relatively normal sexual function. 

Specify whether:

 Generalized: Not limited to certain types of stimulation, situations, or partners.

 Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity:

 Mild: Evidence of mild distress over the symptoms in Criterion A.

 Moderate: Evidence of moderate distress over the symptoms in Criterion A.

 Severe: Evidence of severe or extreme distress over the symptoms in Criterion A. 

Female Orgasmic Disorder

(diagnostic criteria)

A. Presence of either of the following symptoms and experienced on almost all or all (approximately 75-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts):

 1. Marked delay in, marked infrequency of, or absence of orgasm.

 2. Markedly reduced intensity of orgasmic sensations.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify whether:

 Lifelong: The disturbance has been present since the individual became sexually active.

 Acquired: The disturbance began after a period of relatively normal sexual function.

Specify whether:

 Generalized: Not limited to certain types of stimulation, situations, or partners.

 Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify if:

 Never experienced an orgasm under any situation.

Specify current severity:

 Mild: Evidence of mild distress over the symptoms in Criterion A.

 Moderate: Evidence of moderate distress over the symptoms in Criterion A.

 Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.

Female Sexual Interest/Arousal Disorder

(diagnostic criteria)

A. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following:

 1. Absent/reduced interest in sexual activity.

 2. Absent/reduced sexual/erotic thoughts or fantasies.

 3. No/reduced initiation of sexual activity, and typically unreceptive to a partner's attempts to initiate.

 4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approx. 75-100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts). 

 5. Absent/reduced sexual interest/arousal in response to any internal or external sexual erotic cues (e.g., written, verbal, visual).

 6. Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approx. 75-100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts). 

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify whether:

 Lifelong: The disturbance has been present since the individual became sexually active. 

 Acquired: The disturbance began after a period of relatively normal sexual function.

Specify whether:

 Generalized: Not limited to certain types of stimulation, situations, or partners.

 Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity:

 Mild: Evidence of mild distress over the symptoms in Criterion A.

 Moderate: Evidence of moderate distress over the symptoms in Criterion A.

 Severe: Evidence of severe or extreme distress over the symptoms in Criterion A. 

Genito-Pelvic Pain/Penetration Disorder

(diagnostic criteria)

A. Persistent or recurrent difficulties with one (or more) of the following:

 1. Vaginal penetration during intercourse.

 2. Marked vulvovaginal or pelvic pain during intercourse or penetration attempts.

 3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration.

 4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Crition A causes clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of a severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify whether:

 Lifelong: The disturbance has been present since the individual became sexually active.

 Acquired: The disturbance began after a period of relatively normal sexual function.

Specify current severity:

 Mild: Evidence of mild distress over the symptoms in Criterion A. 

 Moderate: Evidence of moderate distress over the symptoms in Criterion A.

 Severe: Evidence of severe or extreme distress over the symptoms in Criterion A. 

Male Hypoactive Sexual Desire Disorder

(diagnostic criteria)

A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The judgment of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and sociocultural contexts of the individual's life.

B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant distressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify whether:

 Lifelong: The disturbance has been present since the individual became sexually active.

 Acquired: The disturbance began after a period of relatively normal sexual function.

Specify whether:

 Generalized: Not limited to certain types of stimulation, situations, or partners.

 Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity:

 Mild: Evidence of mild distress over the symptoms in Criterion A.

 Moderate: Evidence of moderate distress over the symptoms in Criterion A.

 Severe: Evidence of severe to extreme distress over the symptoms in Criterion A.

Premature (Early) Ejaculation

(diagnostic criteria)

A. A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1minute following vaginal penetration and before the individual wishes it. Note: Although the diagnosis of premature (early) ejaculation may be applied to individuals engaged in nonvaginal sexual activities, specific duration criteria have not been established for these activities. 

B. The symptom in Criterion A must have been present for at least 6 months and must be experienced on all or almost all (approx. 75-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts). 

C. The symptom in Criterion A causes clinically significant distress in the individual.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify whether:

 Lifelong: The disturbance has been present since the individual became sexually active.

 Acquired: The disturbance began after a period of relatively normal sexual function. 

Specify whether:

 Generalized: Not limited to certain types of stimulation, situations, or partners.

 Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity:

 Mild: Ejaculation occurring within approximately 30seconds to 1 minute of vaginal penetration. 

 Moderate: Ejaculation occuring within approximately 15-30seconds of vaginal penetration.

 Severe: Ejaculation occuring prior to sexual activity, at the start of sexual activity, or within approximately 15 seconds of vaginal penetration. 

Gender Dysphoria

(diagnostic criteria)

In Children

A. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 month's duration, as manifested by at least six of the following (one of which must be Criterion A1):

 1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one's assigned gender).

 2. In boys (assigned gender), a stronger preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for weating only typical masculine clothing and a strong resistance to wearing of typical feminine clothing. 

 3. A strong preference for cross-gender roles in make-believe play or fantasy play. 

 4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.

 5. A strong preference for playmates of the other gender.

 6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.

 7. A strong dislike of one's sexual anatomy.

 8. A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender.

B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Specify if:

  With a disorder of sex development: (e.g., a congenital andrenoegnital disorder such as 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensitivity syndrom).

Gender Dysphoria

(diagnostic criteria)

In Adolescents and Adults

A. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least two of the following:

 1. A marked oncongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).

 2. A strong desire to be rid of one's primary and/or seconday sex characteristics because of a marked incongruence with one's experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).

 3. A strong desire for the primary and/or secondary sex characteristics of the other gender.

 4. A strong desire to be of the other gender (or some alternative gender different from one's assigned gender).

 5. A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender).

 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender). 

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

  With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensitivity syndrome)

Specify if: 

  Posttransition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen- namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in a natal female). 

Oppositional Defiant Disorder

(diagnostic criteria)

A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

 Angry/Irritable Mood

  1. Often loses temper.

  2. Is often touchy or easily annoyed.

  3. Is often angry and resentful.

 Argumentative/Defiant Behavior

  4. Often argues with authority figures or, for children and adolescents, with adults. 

  5. Often actively defies or refuses to comply with requests from authority figures or with rules.

  6. Often deliberately annoys others.

  7. Often blames others for his or her mistakes or misbehavior.

 Vindictiveness

  8. Has been spiteful or vindictive at least twice within the past 6months. 

Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise noted (Criterion A8). For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless otherwise noted (Criterion A8). While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual's developmental level, gender, and culture.

B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning.

C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.

Specify if:

 Mild: Symptoms are confined to only one setting (e.g., home, school, work, with peers). 

 Moderate: Some symptoms are present in at least two settings.

 Severe: Some symptoms are present in thee or more settings.

Intermittent Explosive Disorder

(diagnostic criteria)

IED

A. Recurrent behavioral outbursts representing a failure to control aggressive impulsives as manifested by either of the following:

 1. Verbal agression (e.g., temper tantrums, tirafes, verbal arguments, or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical affression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.

 2. Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12 month period. 

B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors. 

C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (e.g., money, power, intimidation). 

D. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupaitonal or interpersonal functioning, or are associated with financial or legal consequences.

E. Chronological age is at least 6 years (or equivalent dev. level).

F. The recurrent aggressive outbursts are not better explained by another mental disorder (e.g., MDD, bipolar disorder, DMDD, a psychotic disorder, antisocial personality disorder, BPD) and are not attributable to another medical condition (e.g., head trauma, Alzheimer's disease) or to the physiological effects of a substance (e.g., a drug of abuse, a medication). For children 6-18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis.

Note: This diagnosis can be made in addition to the diagnosis of ADHD, CD, ODD, or autism spectrum disorder when recurrent impulsive aggressive outbursts are in excess of those usually seen in these disorders and warrant independent clinical attention. 

Conduct Disorder

(diagnostic criteria)

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least 3 of the following:

 Aggression to People and Animals

  1. Often bullies, threatens, or intimidates others.

  2. Often initiates physical fights.

  3. Has used a weapon that can cause serious physical harm (e.g., bat, brick, broken bottle, knife, gun).

  4. Has been physically cruel to people.

  5. Has been physically cruel to animals.

  6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).

  7. Has forced someone into sexual activity.

 Destruction of Property

  8. Has deliberately engaged in fire setting with the intention of causing serious damage.

  9. Has deliberately destroyed others' property (other than by fire setting).

 Deceitfulness or Theft

  10. Has broken into someone else's house, building, or car.

  11. Often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others).

  12. Has stolen items of nontivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

 Serious Violations of Rules

  13. Often stays out at night despite parental prohibitions, beginning before age 13 years.

  14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.

  15. Is often truant from school, beginning before age 13.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. If the individual is age 18 years or older, criteria are not met for antisocial personality order.

Specify whether:

 312.81 (F91.1) Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years.

 312.82 (F91.2) Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder prior to age 10 years.

 312.89 (F91.9) Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years.

Specify if:

 With limited prosocial emotions: To qualify for this specifier, an individual must have displayed at least two of the following characteristics persistently over at last 12 months and in multiple relationships and settings. These characteristics reflect the individual's typical pattern of interpersonal and emotional functioning over this period and not just occasional occurences in some situations. Thus, to assess the criteria for the specifier, multiple information sources are necessary. In addition to the individual's self-report, it is necessary to consider reports by others who have known the individual for extended periods of time (e.g., parents, teachers, co-workers, extended family members, peers).

  Lack of remorse or guilt: Does not feel bad or guilty when he or she does something wrong (exclude remorse when expressed only when caught and/or facing punishment). The individual shows a general lack of concern about the negative consequences of his or her actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules.

  Callous-lack of empathy: Disregards and is unconcerned about the feelings of others. The individual is described as cold and uncaring. The person appears more concerned about the effects of his or her actions on himself or herself, rather than their effects on others, even when they result in substantial harm to others.

  Unconcerned about performance: Does not show concern about poor/problematic performance at school, at work, or in other important activities. The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others for his or her poor performance.

  Shallow or deficient affect: Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial (e.g., actions contradict the emotion displayed; can turn emotions "on" or "off" quickly) or when emotional expressions are used for gain (e.g., emotions displayed to manipulate or intimidate others).

Specify current severity:

 Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to oghers (e.g., lying, truancy, staying out after dark without permission, other rule breaking). 

 Moderate: The number of conduct problems and the effect on others are intermediate between those specified in "mild" and those in "severe" (e.g., stealing without confronting a victim, vandalism).

 Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering).

Pyromania

(diagnostic criteria)

A. Deliberate and purposeful fire setting on more than one occasion.

B. Tension or affective arousal before the act.

C. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences).

D. Pleasure, gratification, or releif when setting fires or when witnessing or participating in their aftermath.

E. The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one's living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., in major neurocognitive disorder, intellectual disability [intellectual developmental disorder], substance intoxication).

F. The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Kleptomania

(diagnostic criteria)

A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.

B. Increasing sense of tension immediately before committing the theft.

C. Pleasure, gratification, or relief at the time of committing the theft.

D. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.

E. The stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

Substance/Medication-Induced Mental Disorders

(diagnostic criteria)

A. The disorder represents a clinically significant symptomatic presentation of a relevant mental disorder.

B. There is evidence from the history, physical examination, or laboratory findings of both the following:

 1. The disorder developed during or within 1 month of a substance intoxication or withdrawal or taking a medication; and

 2. The involved substance/medication is capable of producing the mental disorder.

C. The disorder is not better explained by an independent mental disorder (i.e., one that is not substance- or medication-induced). Such evidence of an independent mental disorder could include the following:

 1. The disorder preceded the onset of severe intoxication or withdrawal or exposure to the medication; or

 2. The full mental disorder persisted for a substantial period of time (e.g., at least 1 month) after the cessation of acute withdrawal or severe intoxication or taking the medication. This criterion does not apply to substance-induced neurocognitive disorders or hallucinogen persisting perception disorder, which persist beyond the cessation of acute intoxication or withdrawal.

D. The disorder does not occur exclusively during the course of a delirium.

E. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Alcohol Use Disorder

(diagnostic criteria)

A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12 month period:

 1. Alcohol is often taken in larger amounts or over a longer period than was intended.

 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 

 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

 4. Craving, or a strong desire or urge to use alcohol.

 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

 8. Recurrent alcohol use in situations in which it is physically hazardous.

 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

 10. Tolerance, as defined by either of the following:

   a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

   b. A markedly diminished effect with continued use of the same amount of alcohol.

 11. Withdrawal, as manifested by either of the following:

   a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal).

   b. Alcohol (or a closely related substance, such as benzodiaxepine) is taken to relieve or avoid withdrawal symptoms.

Specify if:

 In early remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met for at least 3 months but for less than 12 months, (with the exception that Criterion A4, "Craving, or a strong desire or urge to use alcohol," may be met).

 In sustained remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, "Craving, or a strong desire or urge to use alcohol," may be met).

Specify if: 

 In a controlled environment: This additional specifier is used if the individual is in an environment where access to alcohol is restricted.

Specify current severity:

 305.00 (F10.10) Mild: Presence of 2-3 symptoms.

 303.90 (F10.20) Moderate: Presence of 4-5 symptoms.

 303.90 (F10.20) Severe: Presence of 6 or more symptoms.

Alcohol Intoxication

(diagnostic criteria)

A. Recent ingestion of alcohol.

B. Clinically significant problematic behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, alcohol ingestion.

C. One (or more) of the following signs or symptoms developing during, or shortly after, alcohol use:

 1. Slurred speech.

 2. Incoordination.

 3. Unsteady gait.

 4. Nystagmus.

 5. Impairment in attention or memory.

 6. Stupor or coma.

D. The signs or symptoms are not attributable to another emdical condition and are not better explained by another mental disorder, including intoxication with another substance.

Caffeine Intoxication

(diagnostic criteria)

A. Recent consumption of caffeine (typically a high dose well in excess of 250mg).

B. Five (or more) of the following signs or symptoms developing during, or shortly after, caffeine use:

 1. Restlessness.

 2. Nervousness.

 3. Excitement.

 4. Insomnia.

 5. Flushed face.

 6. Diuresis.

 7. Gastrointestinal disturbance.

 8. Muscle twitching.

 9. Rambling flow of thought and speech.

 10. Tachycardia or cardiac arrhythmia.

 11. Periods of inexhaustibility.

 12. Psychomotor agitation. 

C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.

Caffeine Withdrawal

(diagnostic criteria)

A. Prolonged daily use of caffeine

B. Abrupt cessation of or reduction in caffeine use, followed within 24 hours by 3 (or more) of the following signs or symptoms:

 1. Headache.

 2. Marked fatigue or drowsiness.

 3. Dysphoric mood, depressed mood, or irritability.

 4. Difficulty concentrating.

 5. Flu-like symptoms.

C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other areas of functioning.

D. The signs or symptoms are not associated with the physiological effects of another medical condition (e.g., migraine, viral illness) and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Cannabis Intoxication

(diagnostic criteria)

A. Recent use of cannabis.

B. Clinically significant problematic behavioral or psychological changes (e.g., impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that develop during, or shortly after, cannabis use.

C. Two (or more) of the following signs or symptoms developing within 2 hours of cannabis use.

 1. Conjunctival injection.

 2. Increased appetite.

 3. Dry mouth.

 4. Tachycardia.

D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.

Specify if:

 With perceptual disturbances: Hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. 

Phencyclidine Intoxication

(diagnostic criteria)

A. Recent use of phencyclidine (or a pharmacologically similar substance).

B. Clinically significant problematic behavioral changes (e.g., belligerence, assaultiveness, impulsiveness, unpredictability, psychomotor agitation, impaired judgment) that developed during, or shortly after, phencyclidine use.

C. Within 1 hour, two (or more) of the following signs or symptoms:

Note: When the drug is smoked, "snorted," or used intravenously, the onset may be particularly rapid.

 1. Vertical or horizontal nystagmus.

 2. Hypertension or tachycardia.

 3. Numbness or diminished responsivenss to pain.

 4. Ataxia

 5. Dysarthria

 6. Muscle rigidity

 7. Seizures or coma

 8. Hyperacusis

D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.

Other Hallucinogen Intoxication

(diagnostic criteria)

A. Recent use of a hallucinogen (other than phencyclidine).

B. Clinically significant problematic behavioral or psychological changes (e.g., marked anxiety or depression, ideas of reference, fear of "losing one's mind," paranoid ideation, impaired judgment) that developed during, or shortly after, hallucinogen use.

C. Perceptual changes occurring in a state of full wakefulness and alertness (e.g., subjective intensification of perceptions, depersonalization, derealization, illusions, hallucinations, synthesias) that developed during, or shortly after, hallucinogen use.

D. Two (or more) of the following signs developed during, or shortly after, hallucinogen use:

 1. Pupillary dilation.

 2. Tachycardia.

 3. Sweating.

 4. Palpitations.

 5. Blurring of vision.