Diagnostic and Statistical Manual of Mental Disorders: Dsm-5 [5° ed.] 9780890425541, 089042554X

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DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FI FTH

EDITION

DSM-5

TM

American Psychiatric Association Officers 2012-2013 P resident D ilip V. J este , M.D. P resident -E lect J effrey A. L ieberm an , M.D. T reasurer D avid F assler , M.D. S ecretary R cxser P eele , M.D.

Assembly S peaker R. Scott B enson , M.D. S peaker -E lect M elinda L. Y oung , M.D.

Board of Trustees J effrey A kaka , M.D. C arol A. B ernstein , M.D. B rL·^^ C row ley , M.D. A nita S. E verett , M.D. J effrey G eller , M.D., M.P.H. M ^ c D avid G raff , M.D. 'J ^

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G i^ eneVM.D.

J udith F. K ashtan , M.D. M olly K. M c V oy , M.D. J am es E. N ininger , M.D. J ohn M. O ldham , M.D. A lan F. S chatzberg , M.D. A lik s . W idge , M.D., P h .D. E rik R. V anderlip , M.D., M em ber - in -T raining T rustee -E lect

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS7 FI FTH

EDITION

DSM-5

TM

New School Library

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Amcriccin

O svchiatric ADivi«ono(AmCT»MlVhijtiKAModn

W ashington, DC London, England

Copyright © 2013 American Psychiatric Association DSM and DSM-5 are trademarks of the American Psychiatric Association. Use of these terms is prohibited without permission of the American Psychiatric Association. ALL RIGHTS RESERVED. Unless authorized in writing by the APA, no part of this book may be reproduced or used in a manner inconsistent with the APA's copyright. This prohibition apphes to unauthorized uses or reproductions in any form, including electronic applications. Correspondence regarding copyright permissions should be directed to DSM Permissions, American Psychiatric Publishing, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209­ 3901. Manufactured in the United States of America on acid-free paper. ISBN 978-0-89042-554-1 (Hardcover) ISBN 978-0-89042-555-8 (Paperback) American Psychiatric Association 1000 Wilson Boulevard Arlington, VA 22209-3901 www.psych.org The correct citation for this book is American Psychiatric Association: Diagnostic and Statisti­ cal Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Associa­ tion, 2013. Library of Congress Cataloging-in-Publication Data Diagnostic and statistical manual of mental disorders : DSM-5. — 5th ed. p. ; cm. DSM-5 DSM-V Includes index. ISBN 978-0-89042-554-1 (hardcover : alk. paper) — ISBN 978-0-89042-555-8 (pbk. : alk. paper) I. American Psychiatric Association. II. American Psychiatric Association. DSM-5 Task Force, m. Title: DSM-5. IV. Title: DSM-V. [DNLM: 1. Diagnostic and statistical manual of mental disorders. 5th ed. 2. Mental Disorders— classification. 3. Mental Disorders—diagnosis. WM 15] RC455.2.C4 616.89Ό75—dc23 2013011061 British Library Cataloguing in Publication Data A CIP record is available from the British Library.

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Text Design—Tammy J. Cordova Manufacturing—Edwards Brothers Malloy

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Contents

DSM-5 Classification..................................................................xiii Preface......................................................................................... xli

Section I DSM-5 Basics Introduction................................................................................... 5 Use of the Manual........................................................................19 Cautionary Statement for Forensic Use of DSM-5..................... 25

Section II Diagnostic Criteria and Codes Neurodevelopmental Disorders.................................................. 31 Schizophrenia Spectrum and Other Psychotic Disorders..........87 Bipolar and Related Disorders.................................................. 123 Depressive Disorders................................................................155 Anxiety Disorders........................................................................189 Obsessive-Compulsive and Related Disorders....................... 235 Trauma- and Stressor-Related Disorders................................. 265 Dissociative Disorders.............................................................. 291 Somatic Symptom and Related Disorders............................... 309 Feeding and Eating Disorders.................................................. 329 Elimination Disorders................................................................355 Sleep-Wake Disorders................................................................361 Sexual Dysfunctions..................................................................423 Gender Dysphoria......................................................................451

Disruptive, Impulse-Control, and Conduct Disorders..............461 Substance-Related and Addictive Disorders........................... 481 Neurocognitive Disorders.......................................................... 591 Personality Disorders................................................................ 645 Paraphilic Disorders..................................................................685 Other Mental Disorders............................................................ 707 Medication-Induced Movement Disorders and Other Adverse Effects of Medication............................. 709 Other Conditions That May Be a Focus of Clinical Attention .. 715

Section III Emerging Measures and Models Assessment Measures.............................................................. 733 Cultural Formulation..................................................................749 Alternative DSM-5 Model for Personality Disorders................761 Conditions for Further Study.................................................... 783

Appendix Highlights of Changes From DSM-IV to DSM-5....................... 809 Glossary of Technical Terms.................................................... 817 Glossary of Cultural Concepts of Distress............................... 833 Alphabetical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM and ICD-10-CM).................................................... 839 Numerical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM)............................................................................. 863 Numerical Listing of DSM-5 Diagnoses and Codes (ICD-10-CM)............................................................................877 DSM-5 Advisors and Other Contributors................................. 897 Index........................................................................................... 917

DSM-5 Task Force D avid J. K upfer , M.D.

Task Force Chair D arrel A. R egier , M.D., M.P.H.

Task Force Vice-Chair William E. Narrow, M.D., Research Director

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

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

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

APA Division of Research Staff on DSIVI-5 Darrel A. Regier, M.D., M.P.H., Director, Division o f Research William E. Narrow, M.D., M.P.H., Associate Director Emily A. Kuhl, Ph.D., Senior Science Writer; Staff Text Editor Diana E. Clarke, Ph.D., M.Sc., Research Statistician

Jennifer J. Shupinka, Assistant Director, DSM Operations Seung-Hee Hong, DSM Senior Research Associate Anne R. Hiller, DSM Research Associate Alison S. Beale, DSM Research Associate Spencer R. Case, DSM Research Associate

Lisa H. Greiner, M.S.S.A., DSM-5 Field Trials Project Manager Eve K. Moscicki, Sc.D., M.P.H., Director, Practice Research Network S. Janet Kuramoto, Ph.D. M.H.S., Senior Scientific Research Associate, Practice Research Network

Joyce C. West, Ph.D., M.P.P., Health Policy Research Director, Practice Research Network Farifteh F. Duffy, Ph.D., Quality Care Research Director, Practice Research Network Lisa M. Countis, Field Operations Manager, Practice Research Network

Amy Porfiri, M.B.A. Director o f Finance and Administration

Christopher M. Reynolds, Executive Assistant

APA Office of the IVIedlcal Director Jam es H. S c u lly Jr., M.D. Medical Director and CEO

Editorial and Coding Consultants Michael B. First, M.D.

Maria N. Ward, M.Ed., RHIT, CCS-P

DSM-5 Work Groups ADHD and Disruptive Behavior Disorders D avid S haffer , M.D. Chair F. X avier C astellanos , M.D. Co-Chair Paul J. Frick, Ph.D., Text Coordinator Glorisa Canino, Ph.D. Terrie E. Moffitt, Ph.D. Joel T. Nigg, Ph.D.

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

Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders K atharine A. P hillips , M.D. Chair Michelle G. Craske, Ph.D., Text Coordinator J. Gavin Andrews, M.D. Susan M. Bögels, Ph.D. Matthew J. Friedman, M.D., Ph.D. Eric Hollander, M.D. (2007-2009) Roberto Lewis-Fernandez, M.D., M.T.S. Robert S. Pynoos, M.D., M.P.H.

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

Childhood and Adolescent Disorders D aniel S. Pine , M.D. Chair Ronald E. Dahl, M.D. E. Jane Costello, Ph.D. (2007-2009) Regina Smith James, M.D. Rachel G. Klein, Ph.D.

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

Eating Disorders B. T imothy W alsh , M.D. Chair Stephen A. Wonderlich, Ph.D., Text Coordinator Evelyn Attia, M.D. Anne E. Becker, M.D., Ph.D., Sc.M. Rachel Bryant-Waugh, M.D. Hans W. Hoek, M.D., Ph.D.

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

Mood Disorders Ja n a . F a w c e tt, M.D. Chair Ellen Frank, Ph.D., Text Coordinator Jules Angst, M.D. (2007-2008) William H. Coryell, M.D. Lori L. Davis, M.D. Raymond J. DePaulo, M.D. Sir David Goldberg, M.D. James S. Jackson, Ph.D.

Kenneth S. Kendler, M.D., Ph.D. (2007-2010) Mario Maj, M.D., Ph.D. Husseini K. Manji, M.D. (2007-2008) Michael R. Phillips, M.D. Trisha Suppes, M.D., Ph.D. Carlos A. Zarate, M.D.

Neurocognitive Disorders Dilip V. Jeste, M.D. (2007-2011) Chair Emeritus D an G. B lazer , M.D., P h .D., M.P.H. Chair R o n a ld C. P etersen , M.D., Ph.D. Co-Chair Mary Ganguli, M.D., M.P.H., Text Coordinator Deborah Blacker, M.D., Sc.D. Warachal Faison, M.D. (2007-2008)

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

Neurodevelopmental Disorders S usan E. S w edo , M.D. Chair Gillian Baird, M.A., M.B., B.Chir., Text Coordinator Edwin H. Cook Jr., M.D. Francesca G. Happé, Ph.D. James C. Harris, M.D. Walter E. Kaufmann, M.D. Bryan H. King, M.D.

Catherine E. Lord, Ph.D. Joseph Piven, M.D. Sally J. Rogers, Ph.D. Sarah J. Spence, M.D., Ph.D. Fred Volkmar, M.D. (2007-2009) Amy M. Wetherby, Ph.D. Harry H. Wright, M.D.

Personality and Personality Disorders^ A ndrew E. S kodol , M.D. Chair J ohn M. O ldham , M.D. Co-Chair Robert F. Krueger, Ph.D., Text Coordinator Renato D. Alarcon, M.D., M.P.H. Carl C. Bell, M.D. Donna S. Bender, Ph.D.

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

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

Psychotic Disorders W illiam T. C arpenter J r ., M.D. Chair Deanna M. Barch, Ph.D., Text Coordinator Juan R. Bustillo, M.D. Wolfgang Gaebel, M.D. Raquel E. Gur, M.D., Ph.D. Stephan H. Heckers, M.D.

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

Sexual and Gender Identity Disorders K enneth J. Z ucker , P h .D. Chair Lori Brotto, Ph.D., Text Coordinator Irving M. Binik, Ph.D. Ray M. Blanchard, Ph.D. Peggy T. Cohen-Kettenis, Ph.D. Jack Drescher, M.D. Cynthia A. Graham, Ph.D.

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

Sleep-Wake Disorders C harles F. R eynolds III, M.D. Chair Ruth M. O'Hara, Ph.D., Text Coordinator Charles M. Morin, Ph.D. Allan I. Pack, Ph.D.

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

Somatic Symptom Disorders J oel E. D im sdale , M.D. Chair James L. Levenson, M.D., Text Coordinator Arthur J. Barsky III, M.D. Francis Creed, M.D. Nancy Frasure-Smith, Ph.D. (2007-2011)

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

Substance-Related Disorders C harles P. O 'B rien , M.D., P h .D. Chair T homas J. C row ley , M.D. Co-Chair Wilson M. Compton, M.D., M.P.E., Text Coordinator Marc Auriacombe, M.D. Guilherme L. G. Borges, M.D., Dr .Sc. Kathleen K. Bucholz, Ph.D. Alan J. Budney, Ph.D. Bridget F. Grant, Ph.D., Ph.D. Deborah S. Hasin, Ph.D.

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

DSM-5 Study Groups Diagnostic Spectra and DSM/ICD Harmonization S teven E. H ym an , M.D. Chair (2007-2012) William T. Carpenter Jr., M.D. Wilson M. Compton, M.D., M.P.E. Jan A. Fawcett, M.D. Helena C. Kraemer, Ph.D. David J. Kupfer, M.D.

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

Lifespan Developmental Approaches E ric J. L enze , M.D. Chair S usan K. S chultz , M.D. Chair Emeritus D aniel S. P ine , M.D. Chair Emeritus Dan G. Blazer, M.D., Ph.D., M.P.H. F. Xavier Castellanos, M.D. Wilson M. Compton, M.D., M.P.E.

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

Gender and Cross-Cultural Issues K imberly A. Y onkers , M.D. Chair R oberto L ewis -F ernândez , M.D., M.T.S. Co-Chair, Cross-Cultural Issues Renato D. Alarcon, M.D., M.P.H. Diana E. Clarke, Ph.D., M.Sc. Javier I. Escobar, M.D., M.Sc. Ellen Frank, Ph.D. James S. Jackson, Ph.D. Spiro M. Manson, Ph.D. (2007-2008) James P. McNulty, A.B., Sc.B.

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

Psychiatric/General Medical Interface L awson R. W ulsin , M.D. Chair Ronald E. Dahl, M.D. Joel E. Dimsdale, M.D. Javier I. Escobar, M.D., M.Sc. Dilip V. Jeste, M.D. (2007-2011) Walter E. Kaufmann, M.D.

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

Impairment and Disability Ja n e S. P a u lse n , Ph.D. Chair J. Gavin Andrews, M.D. Glorisa Canino, Ph.D. Lee Anna Clark, Ph.D. Diana E. Clarke, Ph.D., M.Sc. Michelle G. Craske, Ph.D.

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

Diagnostic Assessment Instruments J ack D. B urke J r ., M.D., M.P.H. Chair Lee Anna Clark, Ph.D. Diana E. Clarke, Ph.D., M.Sc. Bridget F. Grant, Ph.D., Ph.D.

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

DSM-5 Research Group W illiam E. N arrow , M.D., M.P.H. Chair Jack D. Burke Jr., M.D., M.P.H. Diana E. Clarke, Ph.D., M.Sc. Helena C. Kraemer, Ph.D.

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

Course Specifiers and Glossary W olfgang G aebel , M.D. Chair Ellen Frank, Ph.D. Charles P. O'Brien, M.D., Ph.D. Norman Sartorius, M.D., Ph.D., Consultant Susan K. Schultz, M.D.

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

Before each disorder name, ICD-9-CM codes are provided, followed by ICD-IO-CM codes in parentheses. Blank lines indicate that either the ICD-9-CM or the ICD-IO-CM code is not applicable. For some disorders, the code can be indicated only according to the subtype or specifier. ICD-9-CM codes are to be used for coding purposes in the United States through Sep­ tember 30,2014. ICD-IO-CM codes are to be used starting October 1,2014. Following chapter titles and disorder names, page numbers for the corresponding text or criteria are included in parentheses. Note for all mental disorders due to another medical condition: Indicate the name of the other medical condition in the name of the mental disorder due to [the medical condi­ tion]. The code and name for the other medical condition should be listed first immedi­ ately before the mental disorder due to the medical condition.

Neurodevelopmental Disorders (31) Intellectual Disabilities (33) 319

(___.__) (F70)

Intellectual Disability (Intellectual Developmental Disorder) (33) Specify current severity; Mild

(F71)

Moderate

(F72)

Severe

(F73)

Profound

315.8 (F88)

Global Developmental Delay (41)

319

Unspecified Intellectual Disability (Intellectual Developmental Disorder) (41)

(F79)

Communication Disorders (41) 315.39 (F80.9)

Language Disorder (42)

315.39 (F80.0)

Speech Sound Disorder (44)

315.35 (F80.81)

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

315.39 (F80.89)

Social (Pragmatic) Communication Disorder (47)

307.9 (F80.9)

Unspecified Communication Disorder (49)

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

Autism Spectrum Disorder (50) Specify if: Associated with a known medical or genetic condition or envi­ ronmental factor; Associated with another neurodevelopmental, men­ tal, or behavioral disorder Specify current severity for Criterion A and Criterion B: Requiring very substantial support. Requiring substantial support. Requiring support Specify if: With or without accompanying intellectual impairment. With or without accompanying language impairment. With catatonia (use additional code 293.89 [F06.1])

Attention-Deficit/Hyperactivity Disorder (59) ___.__ (__ .__) 314.01 (F90.2)

Attention-Deficit/Hyperactivity Disorder (59) Specify whether: Combined presentation

314.00 (F90.0)

Predominantly inattentive presentation

314.01 (F90.1)

Predominantly hyperactive/impulsive presentation Specify if: In partial remission Specify current severity: Mild, Moderate, Severe

314.01 (F90.8)

Other Specified Attention-Deficit/Hyperactivity Disorder (65)

314.01 (F90.9)

Unspecified Attention-Deficit/Hyperactivity Disorder (66)

Specific Learning Disorder (66) ___.__ (___.__) 315.00 (F81.0) 315.2 (F81.81 )

315.1 (F81.2)

Specific Learning Disorder (66) Specify if: With impairment in reading {specify if with word reading accuracy, reading rate or fluency, reading comprehension) With impairment in written expression {specify if with spelling accuracy, grammar and punctuation accuracy, clarity or organization of written expression) With impairment in mathematics {specify if with number sense, memorization of arithmetic facts, accurate or fluent calculation, accurate math reasoning) Specify current severity: Mild, Moderate, Severe

Motor Disorders (74) 315.4 (F82)

Developmental Coordination Disorder (74)

307.3 (F98.4)

Stereotypic Movement Disorder (77) Specify if: With self-injurious behavior. Without self-injurious behavior Specify if: Associated with a known medical or genetic condition, neuro­ developmental disorder, or environmental factor Specify current severity: Mild, Moderate, Severe

Tic Disorders 307.23 (F95.2)

Tourette's Disorder (81)

307.22 (F95.1)

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

307.21 (F95.0)

Provisional Tic Disorder (81)

307.20 (F95.8),

Other Specified Tic Disorder (85)

307.20 (F95.9)

Urispecified Tic Disorder (85)

Other Neurodevelopmental Disorders (86) 315.8 (FSB)

Other Specified Neurodevelopmental Disorder (86)

315.9 (F89)

Unspecified Neurodevelopmental Disorder (86)

Schizophrenia Spectrum and Other Psychotic Disorders (87) The following specifiers apply to Schizophrenia Spectrum and Other Psychotic Disorders where indicated: ^Specify if: The following course specifiers are only to be used after a 1-year duration of the dis­ order: First episode, currently in acute episode; First episode, currently in partial remission; First episode, currently in full remission; Multiple episodes, currently in acute episode; Mul­ tiple episodes, currently in partial remission; Multiple episodes, currently in full remission; Continuous; Unspecified ^Specify if: With catatonia (use additional code 293.89 [F06.1]) ^Specify current severity of delusions, hallucinations, disorganized speech, abnormal psycho­ motor behavior, negative symptoms, impaired cognition, depression, and mania symptoms 301.22 (F21)

Schizotypal (Personality) Disorder (90)

297.1

(F22)

Delusional Disorder^' ^ (90) Specify whether: Erotomanie type. Grandiose type. Jealous type. Persecu­ tory type. Somatic type. Mixed type. Unspecified type Specify if: With bizarre content

298.8 (F23)

Brief Psychotic Disorder^' ^ (94) Specify if: With marked stressor(s). Without marked stressor(s). With postpartum onset

295.40 (F20.81)

Schizophreniform Disorder^' ^ (96) Specify if: With good prognostic features. Without good prognostic fea­ tures

295.90 (F20.9)

Schizophrenia^'

295.70 (F25.0)

Schizoaffective Disorder^' Specify whether: Bipolar type

295.70 (F25.1)

^ (99) ^ (105)

Depressive type Substance/Medication-Induced Psychotic Disorder^ (110) Note: See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-IO-CM coding. Specify if: With onset during intoxication. With onset during withdrawal

293.81 (F06.2) 293.82 (F06.0)

Psychotic Disorder Due to Another Medical Condition^ (115) Specify whether: With delusions With hallucinations

293.89 (F06.1)

Catatonia Associated With Another Mental Disorder (Catatonia Specifier) (119)

293.89 (F06.1)

Catatonic Disorder Due to Another Medical Condition (120)

293.89 (F06.1)

Unspecified Catatonia (121) Note: Code first 781.99 (R29.818) other symptoms involving nervous and musculoskeletal systems.

298.8

(F28)

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder (122)

298.9

(F29)

Unspecified Schizophrenia Spectrum and Other Psychotic Disorder (122)

Bipolar and Related Disorders (123) The following specifiers apply to Bipolar and Related Disorders where indicated: ^Specify: With anxious distress (specify current severity: mild, moderate, moderate-severe, severe); With mixed features; With rapid cycling; With melancholic features; With atypical features; With mood-congruent psychotic features; With mood-incongruent psychotic features; With catatonia (use additional code 293.89 [F06.1]); With péripartum onset; With seasonal pattem Bipolar I Disorder® (123) 296.41 296.42 296.43 296.44 296.45 296.46 296.40

(F31.11) (F31.12) (F31.13) (F31.2) (F31.73) (F31.74) (F31.9)

Current or most recent episode manic Mild Moderate Severe With psychotic features In partial remission In full remission Unspecified

296.40 296.45 296.46 296.40

(F31.0) (F31.73) (F31.74) (F31.9)

Current or most recent episode hypomanie In partial remission In kill remission Unspecified

296.51 296.52 296.53 296.54 296.55 296.56 296.50

(F31.31) (F31.32) (F31.4) (F31.5) (F31.75) (F31.76) (F31.9)

Current or most recent episode depressed Mild Moderate Severe With psychotic features In partial remission In full remission Unspecified

296.7

(F31.9)

Current or most recent episode unspecified

296.89 (F31.81)

Bipolar II Disorder® (132) Specify current or most recent episode: Hypomanie, Depressed Specify course if full criteria for a mood episode are not currently met: In partial remission. In full remission Specify severity if full criteria for a mood episode are not currently met: Mild, Moderate, Severe

301.13 (F34.0) y

Cyclothymic Disorder (139) Specify if: With anxious distress Substance/Medication-Induced Bipolar and Related Disorder (142) Note: See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-IO-CM coding. Specify if: With onset during intoxication. With onset during withdrawal

293.83 (__ ._ )

(F06.33)

Bipolar and Related Disorder Due to Another Medical Condition (145) Specify if: With manic features

(F06.33)

With manic- or hypomanic-like episode

(F06.34)

With mixed features

296.89 (F31.89)

Other Specified Bipolar and Related Disorder (148)

296.80 (F31.9)

Unspecified Bipolar and Related Disorder (149)

Depressive Disorders (155) The following specifiers apply to Depressive Disorders where indicated: ^Specify: With anxious distress (specify current severity: mild, moderate, moderate-severe, severe); With mixed features; With melancholic features; With atypical features; With moodcongruent psychotic features; With mood-incongruent psychotic features; With catatonia (use additional code 293.89 [F06.1]); With péripartum onset; With seasonal pattern 296.99 (F34.8) .

(_ ■

)

Disruptive Mood Dysregulation Disorder (156) Major Depressive Disorder® (160)

. 296.21 296.22 296.23 296.24 296.25 296.26 296.20

(_ . ) (F32.0) (F32.1) (F32.2) (F32.3) (F32.4) (F32.5) (F32.9)

Single episode Mild Moderate Severe With psychotic features In partial remission In full remission Unspecified

. 296.31 296.32 296.33 296.34 296.35 296.36 296.30

(_ · ) (F33.0) (F33.1) (F33.2) (F33.3) (F33.41) (F33.42) (F33.9)

Recurrent episode Mild Moderate Severe With psychotic features In partial remission In full remission Unspecified

300.4

(F34.1)

Persistent Depressive Disorder (Dysthymia)® (168) Specify if: In partial remission. In full remission Specify if: Early onset. Late onset Specify if: With pure dysthymic syndrome; With persistent major depres­ sive episode; With intermittent major depressive episodes, with current

episode; With intermittent major depressive episodes, without current episode Specify current severity: Mild, Moderate, Severe 625.4

(N94.3)

Premenstrual Dysphoric Disorder (171)

(__■ _)

Substance/Medication-Induced Depressive Disorder (175) Note: See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-IO-CM coding. Specify if: With onset during intoxication. With onset during withdrawal

293.83 (__ ._ ) (F06.31)

Depressive Disorder Due to Another Medical Condition (180) Specify if: With depressive features

(F06.32)

With major depressive-like episode

(F06.34)

With mixed features

311

(F32.8)

Other Specified Depressive Disorder (183)

311

(F32.9)

Unspecified Depressive Disorder (184)

Anxiety Disorders (189) 309.21 (F93.0)

Separation Anxiety Disorder (190)

312.23 (F94.0)

Selective Mutism (195)

300.29 (__ ._ )

Specific Phobia (197) Specify if: Animal

(F40.218) (F40.228)

Natural environment

(_ ·_ ) (F40.230) (F40.231) (F40.232) (F40.233)

Blood-injection-injury Fear of blood Fear of injections and transfusions Fear of other medical care Fear of injury

(F40.248)

Situational Other

(F40.298) 300.23 (F40.10)

Social Anxiety Disorder (Social Phobia) (202) Specify if: Performance only

300.01 (F41.0)

Panic Disorder (208) Panic Attack Specifier (214)

300.22 (F40.00)

Agoraphobia (217)

300.02 (F41.1)

Generalized Anxiety Disorder (222) Substance/Medication-Induced Anxiety Disorder (226) Note: See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-IO-CM coding. Specify if: With onset during intoxication. With onset during withdrawal. With onset after medication use

293.84 (F06.4)

Anxiety Disorder Due to Another Medical Condition (230)

300.09 (F41.8) \

Other Specified Anxiety Disorder (233)

300.00 (F41.9)

Unspecified Anxiety Disorder (233)

Obsessive-Compulsive and Related Disorders (235) The following specifier applies to Obsessive-Compulsive and Related Disorders where indicated: ^Specify if: With good or fair insight. With poor insight. With absent insight/delusional beliefs 300.3

(F42)

Obsessive-Compulsive Disorder^ (237) Specify if: Tic-related

300.7

(F45.22)

Body Dysmorphic Disorder^ (242) Specify if: With muscle dysmorphia

300.3

(F42)

Hoarding Disorder^ (247) Specify if: With excessive acquisition

312.39 (F63.2)

Trichotillomania (Hair-Pulling Disorder) (251)

698.4

(L98.1)

Excoriation (Skin-Picking) Disorder (254)

(_._J

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder (257) Note: See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-IO-CM coding. Specify if: With onset during intoxication. With onset during withdrawal. With onset after medication use

294.8

(F06.8)

Obsessive-Compulsive and Related Disorder Due to Another Medical Condition (260) Specify if: With obsessive-compulsive disorder-like symptoms. With appearance preoccupations. With hoarding symptoms. With hairpulling symptoms. With skin-picking symptoms

300.3

(F42)

Other Specified Obsessive-Compulsive and Related Disorder (263)

300.3

(F42)

Unspecified Obsessive-Compulsive and Related Disorder (264)

Trauma- and Stressor-Related Disorders (265) 313.89 (F94.1)

Reactive Attachment Disorder (265) Specify if: Persistent Specify current severity: Severe

313.89 (F94.2)

Disinhibited Social Engagement Disorder (268) Specify if: Persistent Specify current severity: Severe

309.81 (F43.10)

Posttraumatic Stress Disorder (includes Posttraumatic Stress Disorder for Children 6 Years and Younger) (271) Specify whether: With dissociative symptoms Specify if: With delayed expression

308.3

Acute Stress Disorder (280)

(F43.0)

DSM-5 Classification

XX

( 309.0

■_)

(F43.21)

Adjustment Disorders (286) Specify whether: With depressed mood

309.24 (F43.22)

With anxiety

309.28 (F43.23)

With mixed anxiety and depressed mood

309.3

(F43.24)

With disturbance of conduct

309.4

(F43.25)

With mixed disturbance of emotions and conduct

309.9

(F43.20)

Unspecified

309.89 (F43.8)

Other Specified Trauma- and Stressor-Related Disorder (289)

309.9

Unspecified Trauma- and Stressor-Related Disorder (290)

(F43.9)

Dissociative Disorders (291) 300.14 (F44.81)

Dissociative Identity Disorder (292)

300.12 (F44.0) 300.13 (F44.1)

Dissociative Amnesia (298) Specify if: With dissociative fugue

300.6

Depersonalization/Derealization Disorder (302)

(F48.1)

300.15 {F44.89)

Other Specified Dissociative Disorder (306)

300.15 (F44.9)

Unspecified Dissociative Disorder (307)

Somatic Symptom and Related Disorders (309) 300.82 (F45.1)

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

300.7

Illness Anxiety Disorder (315) Specify whether: Care seeking type. Care avoidant type

(F45.21)

300.11 (

._ )

(F44.4)

Conversion Disorder (Functional Neurological Symptom Disorder) (318) Specify symptom type: With weakness or paralysis

(F44.4)

With abnormal movement

(F44.4)

With swallowing symptoms

(F44.4)

With speech symptom

{F44.5)

With attacks or seizures

(F44.6)

With anesthesia or sensory loss

(F44.6)

With special sensory symptom

(F44.7)

With mixed symptoms Specify if: Acute episode, Persistent Specify if: With psychological stressor (specify stressor). Without psycho­ logical stressor

316

(F54)

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

300.19 (F68.10)

Factitious Disorder (includes Factitious Disorder Imposed on Self, Factitious Disorder Imposed on Another) (324) Specify Single episode. Recurrent episodes

300.89 (F45.8)

Other Specified Somatic Symptom and Related Disorder (327)

300.82 (F45.9)

Unspecified Somatic Symptom and Related Disorder (327)

Feeding and Eating Disorders (329) The following specifiers apply to Feeding and Eating Disorders where indicated: ^Specify if: In remission ^Specify if: In partial remission, In full remission ^Specify current severity: Mild, Moderate, Severe, Extreme 307.52 (

. )

Pica® (329)

(F98.3)

In children

(F50.8)

In adults

307.53 (F98.21)

Rumination Disorder^ (332)

307.59 {F50.8)

Avoidant/Restrictive Food Intake Disorder^ (334)

307.1

(

. )

(F50.01) (F50.02)

Anorexia Nervosa^' ^ (338) Specify whether: Restricting type Binge-eating/purging type

307.51 (F50.2)

Bulimia Nervosa^' ^ (345)

307.51 (F50.8)

Binge-Eating Disorder^' ^ (350)

307.59 (F50.8)

Other Specified Feeding or Eating Disorder (353)

307.50 (F50.9)

Unspecified Feeding or Eating Disorder (354)

Elimination Disorders (355) 307.6

(F98.0)

Enuresis (355) Specify whether: Nocturnal only. Diurnal only. Nocturnal and diurnal

307.7

(F98.1)

Encopresis (357) Specify whether: With constipation and overflow incontinence. Without constipation and overflow incontinence

Other Specified Elimination Disorder (359) . (_ . ) 788.39 (N39.498) With urinary symptoms 787.60 (R15.9) . ( . ) 788.30 (R32) 787.60 (R15.9)

With fecal symptoms Unspecified Elimination Disorder (360) With urinary symptoms With fecal symptoms

Sleep-Wake Disorders (361) The following specifiers apply to Sleep-Wake Disorders where indicated: ^Specify if: Episodic, Persistent, Recurrent ^Specify if: Acute, Subacute, Persistent ^Specify current severity: Mild, Moderate, Severe 780.52 (G47.00)

Insomnia Disorder^ (362) Specify if: With non-sleep disorder mental comorbidity. With other medical comorbidity. With other sleep disorder

780.54 (G47.10)

Hypersoninolence Disorder^' ^ (368) Specify if: With mental disorder. With medical condition. With another sleep disorder

Narcolepsy^ (372) Specify whether: Narcolepsy v^ithout cataplexy but with hypocretin deficiency 347.00 (G47.419) 347.01 (G47.411)

Narcolepsy with cataplexy but without hypocretin deficiency

347.00 (G47.419)

Autosomal dominant cerebellar ataxia, deafness, and narcolepsy

347.00 (G47.419)

Autosomal dominant narcolepsy, obesity, and type 2 diabetes

347.10 (G47.429)

Narcolepsy secondary to another medical condition

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

Obstructive Sleep Apnea Hypopnea^ (378)

327.21 (G47.31)

Central Sleep Apnea (383) Specify whether: Idiopathic central sleep apnea

786.04 (R06.3)

Cheyne-Stokes breathing

780.57 (G47.37)

Central sleep apnea comorbid with opioid use Note: First code opioid use disorder, if present. Specify current severity

327.24 (G47.34)

Sleep-Related Hypoventilation (387) Specify whether: Idiopathic hypoventilation

327.25 (G47.35)

Congenital central alveolar hypoventilation

327.26 (G47.36)

Comorbid sleep-related hypoventilation Specify current severity

307.45 (G47.21) 307.45 (G47.22) 307.45 (G47.23) 307.45 (G47.24)

Circadian Rhythm Sleep-Wake Disorders^ (390) Specify whether: Delayed sleep phase type (391) Specify if: Familial, Overlapping with non-24-hour sleep-wake type Advanced sleep phase type (393) Specify if: Familial Irregular sleep-wake type (394) Non-24-hour sleep-wake type (396)

307.45 (G47.26)

Shift work type (397)

307.45 (G47.20)

Unspecified type

Parasomnias (399)

307.46 (F51.3)

307.46 (F51.4)

Non-Rapid Eye Movement Sleep Arousal Disorders (399) Specify whether: Sleepwalking type Specify if: With sleep-related eating. With sleep-related sexual behavior (sexsomnia) Sleep terror type

307.47 (F51.5)

Nightmare Disorder^' ^ (404) Specify if: During sleep onset Specify if: With associated non-sleep disorder. With associated other medical condition. With associated other sleep disorder

327.42 (G47.52)

Rapid Eye Movement Sleep Behavior Disorder (407)

333.94 (025.81)

Restless Legs Syndrome (410)

(_ ._ )

Substance/Medication-Induced Sleep Disorder (413) Note: See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-IO-CM coding. Specify whether: Insomnia type. Daytime sleepiness type, Parasomnia type. Mixed type Specify if: With onset during intoxication. With onset during discontinua­ tion/withdrawal

780.52 (G47.09)

Other Specified Insomnia Disorder (420)

780.52 (G47.00)

Unspecified Insonmia Disorder (420)

780.54 (G47.19)

Other Specified Hypersomnolence Disorder (421)

780.54 (G47.10)

Unspecified Hypersomnolence Disorder (421)

780.59 (G47.8)

Other Specified Sleep-Wake Disorder (421)

780.59 (G47.9)

Unspecified Sleep-Wake Disorder (422)

Sexual Dysfunctions (423) The following specifiers apply to Sexual Dysfunctions where indicated: ^Specify whether: Lifelong, Acquired ^Specify whether: Generalized, Situational ^Specify current severity: Mild, Moderate, Severe 302.74 (F52.32)

Delayed Ejaculation®'

^ (424)

302.72 (F52.21)

Erectile Disorder®'

302.73 (F52.31)

Female Orgasmic Disorder®' *^' (429) Specify if: Never experienced an orgasm under any situation

302.72 (F52.22)

Female Sexual Interest/Arousal Disorder®'

302.76 (F52.6)

Genito-Pelvic Pain/Penetration Disorder®' ^ (437)

(426)

(433)

302.71 (F52.0)

Male Hypoactive Sexual Desire Disorder^'

302.75 (F52.4)

Premature (Early) Ejaculation^'

^ (440)

^ (443)

Substance/Medication-Induced Sexual Dysfunction^ (446) Note: See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-IO-CM coding. Specify if: With onset during intoxication. With onset during withdrawal. With onset after medication use 302.79 (F52.8)

Other Specified Sexual Dysfunction (450)

302.70 (F52.9)

Unspecified Sexual Dysfunction (450)

Gender Dysplioria (451) . 302.6

{ · ) (F64.2)

302.85 (F64.1)

Gender Dysphoria (452) Gender Dysphoria in Children Specify if: With a disorder of sex development Gender Dysphoria in Adolescents and Adults Specify if: With a disorder of sex development Specify if: Posttransition Note: Code the disorder of sex development if present, in addition to gender dysphoria.

302.6

(F64.8)

Other Specified Gender Dysphoria (459)

302.6

(F64.9)

Unspecified Gender Dysphoria (459)

Disruptive, impuise-Control, and Conduct Disorders (461) 313.81 (F91.3)

Oppositional Defiant Disorder (462) Specify current severity: Mild, Moderate, Severe

312.34 (F63.81)

Intermittent Explosive Disorder (466)

312.81 (F91.1)

Conduct Disorder (469) Specify whether: Childhood-onset type

312.32 (F91.2)

Adolescent-onset type

■

'

312.89 (F91.9)

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

301.7

Antisocial Personality Disorder (476)

(F60.2)

312.33 {F63.1)

Pyromania (476)

312.32 (F63.3)

Kleptomania (478)

312.89 (F91.8)

Other Specified Disruptive, Impulse-Control, and Conduct Disorder (479)

312.9

Unspecified Disruptive, Impulse-Control, and Conduct Disorder (480)

(F91.9)

Substance-Related and Addictive Disorders (481) The following specifiers and note apply to Substance-Related and Addictive Disorders where indicated: ^Specify if: In early remission. In sustained remission ^Specify if: In a controlled environment ^Specify if: With perceptual disturbances ^The ICD-IO-CM code indicates the comorbid presence of a moderate or severe substance use disorder, which must be present in order to apply the code for substance withdrawal.

Substance-Related Disorders (483) Alcohol-Related Disorders (490) .

(

. )

305.00 (F10.10)

Alcohol Use Disorder®' (490) Specify current severity: Mild

303.90 (FI 0.20)

Moderate

303.90 (F10.20)

Severe

303.00 (

. )

With use disorder, mild

(F10.229)

With use disorder, moderate or severe

(F10.929)

Without use disorder

291.81 (

. 291.9

Alcohol Intoxication (497)

(F10.129)

._ )

Alcohol Withdrawal^' ^ (499)

(FI0.239)

Without perceptual disturbances

(FI 0.232)

With perceptual disturbances

(

._ )

(FI 0.99)

Other Alcohol-Induced Disorders (502) Unspecified Alcohol-Related Disorder (503)

Caffeine-Related Disorders (503) 305.90 (F15.929)

Caffeine Intoxication (503)

292.0

(F15.93)

Caffeine Withdrawal (506)

(_ ·

Other Caffeine-Induced Disorders (508)

. 292.9

)

(FI 5.99)

Unspecified Caffeine-Related Disorder (509)

Cannabis-Related Disorders (509) .

(

■ )

305.20 (F12.10)

Cannabis Use Disorder^' ^ (509) Specify current severity: Mild

304.30 (F12.20)

Moderate

304.30 (F12.20)

Severe

292.89 (__

292.0

292.9

Cannabis Intoxication‘s (516)

(F12.129) (Fl 2.229) (F12.929)

Without perceptual disturbances With use disorder, mild With use disorder, moderate or severe Without use disorder

(F12.122) (F12.222) (F12.922)

With perceptual disturbances With use disorder, mild With use disorder, moderate or severe Without use disorder

(F12.288)

Cannabis Withdrawal*^ (517)

(_ ._ )

Other Cannabis-Induced Disorders (519)

(F12.99)

Unspecified Cannabis-Related Disorder (519)

Hallucinogen-Related Disorders (520)

305.90 (F16.10)

Phencyclidine Use Disorder®' (520) Specify current severity: Mild

304.60 (F16.20)

Moderate

304.60 (F16.20)

Severe

(_ ■ _ )

305.30 (F16.10)

Other Hallucinogen Use Disorder®' Specify the particular hallucinogen Specify current severity; Mild

304.50 (F16.20)

Moderate

304.50 (F16.20)

Severe

292.89 (__ ._ )

(523)

Phencyclidine Intoxication (527)

(F16.129)

With use disorder, mild

(F16.229)

With use disorder, moderate or severe

(F16.929)

Without use disorder

292.89 (__ ._ )

Other Hallucinogen Intoxication (529)

(F16.129)

With use disorder, mild

(F16.229)

With use disorder, moderate or severe

(F16.929)

Without use disorder

292.89 (F16.983) (_ ._ )

Hallucinogen Persisting Perception Disorder (531) Other Phencyclidine-Induced Disorders (532) Other Hallucinogen-Induced Disorders (532)

292.9

(F16.99)

Unspecified Phencyclidine-Related Disorder (533)

292.9

(F16.99)

Unspecified Hallucinogen-Related Disorder (533)

Inhalant-Related Disorders (533) ___. _

(__ ._ )

305.90 (F18.10)

Inhalant Use Disorder®' (533) Specify the particular inhalant Specify current severity: Mild

304.60 (F18.20)

Moderate

304.60 (F18.20)

Severe

292.89 (__ ._ )

292.9

Inhalant Intoxication (538)

(F18.129)

With use disorder, mild

(F18.229)

With use disorder, moderate or severe

(F18.929)

Without use disorder

(_ ■ _ )

Other Inhalant-Induced Disorders (540)

(F18.99)

Unspecified Inhalant-Related Disorder (540)

Opioid-Related Disorders (540) ___.__ (___.__)

305.50 (F11.10)

Opioid Use Disorder® (541) Specify if: On maintenance therapy, In a controlled environment Specify current severity: Mild

304.00 (F11.20)

Moderate

304.00 (F11.20)

Severe

292.89 (

292.0 . 292.9

. )

Opioid Intoxication‘s (546)

(F11.129) (F11.229) (F11.929)

Without perceptual disturbances With use disorder, mild With use disorder, moderate or severe Without use disorder

(F11.122) (F11.222) (F11.922)

With perceptual disturbances With use disorder, mild With use disorder, moderate or severe Without use disorder

(F11.23)

Opioid Withdrawal‘s (547)

(

Other Opioid-Induced Disorders (549)

■ )

(F11.99)

Unspecified Opioid-Related Disorder (550)

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

(

- )

305.40 (F13.10)

Sedative, Hypnotic, or Anxiolytic Use Disorder^' ^ (550) Specify current severity: Mild

304.10 (F13.20)

Moderate

304.10 (F13.20)

Severe

292.89 (

292.0

. )

Sedative, Hypnotic, or Anxiolytic Intoxication (556)

(F13.129)

With use disorder, mild

(F13.229)

With use disorder, moderate or severe

(F13.929)

Without use disorder

(

. )

Sedative, Hypnotic, or Anxiolytic Withdrawal^' ^ (557)

(FI 3.239)

Without perceptual disturbances

(F13.232)

With perceptual disturbances

___.__ (__ .__)

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

292.9

Unspecified Sedative-, Hypnotic-, or Anxiolytic-Related Disorder (560)

(F13.99)

Stimulant-Related Disorders (561)

(_ ■ _ ) 305.70 (F15.10) 305.60 (F14.10) 305.70 (F15.10)

Stimulant Use Disorder®'*^ (561) Specify current severity: Mild Amphetamine-t)φe substance Cocaine Other or unspecified stimulant

(_ ■ _ ) 304.40 (F15.20) 304.20 (F14.20) 304.40 (F15.20)

Moderate Amphetamine-type substance Cocaine Other or unspecified stimulant

(_ ._ ) 304.40 (F15.20) 304.20 (F14.20) 304.40 (F15.20)

Severe Amphetamine-type substance Cocaine Other or unspecified stimulant

292.89 (__ ._ ) 292.89 (__ ._ ) (F15.129) (F15.229) (F15.929)

Stimulant Intoxication‘s (567) Specify the specific intoxicant Amphetamine or other stimulant. Without perceptual disturbances With use disorder, mild With use disorder, moderate or severe Without use disorder

292.89 (__ ._J (F14.129) (F14.229) (F14.929)

Cocaine, Without perceptual disturbances With use disorder, mild With use disorder, moderate or severe Without use disorder

292.89 (__ ._ )

Amphetamine or other stimulant. With perceptual disturbances With use disorder, mild With use disorder, moderate or severe Without use disorder

(F15.122) (F15.222) (F15.922) 292.89 (__ ._ ) (F14.122) (F14.222) (F14.922) 292.0

(__ ._ ) (F15.23) (FI 4.23) (_ ._ )

Cocaine, With perceptual disturbances With use disorder, mild With use disorder, moderate or severe Without use disorder Stimulant Withdrawal*^ (569) Specify the specific substance causing the withdrawal syndrome Amphetamine or other stimulant Cocaine Other Stimulant-Induced Disorders (570)

292.9

(__ .__)

Unspecified Stimulant-Related Disorder (570)

(FI 5.9^9)

Amphetamine or other stimulant

(FI 4.99)

Cocaine

Tobacco-Related Disorders (571) ■

(

._ )

Tobacco Use Disorder® (571) Specify if: On maintenance therapy. In a controlled environment Specify current severity: Mild

305.1

(Z72.0)

305.1

(F17.200)

Moderate

305.1

(F17.200)

Severe

292.0

(F17.203)

Tobacco Withdrawal*^ (575)

(

Other Tobacco-Induced Disorders (576)

■

292.9

. )

(FI 7.209)

Unspecified Tobacco-Related Disorder (577)

Other (or Unknown) Substance-Related Disorders (577) — ■-

(_ _ .

)

305.90 (F19.10)

Other (or Unknown) Substance Use Disorder®' (577) Specify current severity: Mild

304.90 (F19.20)

Moderate

304.90 (F19.20)

Severe

292.89 ( _ . ) (FI 9.129)

292.0 ■

292.9

Other (or Unknown) Substance Intoxication (581) With use disorder, mild

(F19.229)

With use disorder, moderate or severe

(F19.929)

Without use disorder

(F19.239)

Other (or Unknown) Substance Withdrawal*^ (583)

(

Other (or Unknown) Substance-Induced Disorders (584)

._ )

(F19.99)

Unspecified Other (or Unknovm) Substance-Related Disorder (585)

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

Gambling Disorder^ (585) Specify if: Episodic, Persistent Specify current severity: Mild, Moderate, Severe

Neurocognitive Disorders (591) Delirium (596) ^Note: See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-IO-CM coding. Specify whether: Substance intoxication delirium^ Substance withdrawal delirium^ 292.81 (__ ._J

Medication-induced delirium^

293.0

Delirium due to another medical condition

(F05)

293.0

(F05)

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

780.09 (R41.0)

Other Specified Delirium (602)

780.09 (R41.0)

Unspecified Delirium (602)

Major and Mild Neurocognitive Disorders (602) Specify whether due to: Alzheimer's disease, Frontotemporal lobar degeneration, Lewy body disease. Vascular disease. Traumatic brain injury. Substance/medication use, HIV infection. Prion disease, Parkinson's disease, Huntington's disease. Another medical condition. Multi­ ple etiologies. Unspecified ^Specify Without behavioral disturbance. With behavioral disturbance. For possible major neuro­ cognitive disorder and for mild neurocognitive disorder, behavioral disturbance cannot be coded but should still be indicated in writing. ^Specify current severity: Mild, Moderate, Severe. This specifier applies only to major neurocogni­ tive disorders (including probable and possible). Note: As indicated for each subtype, an additional medical code is needed for probable major neurocognitive disorder or major neurocognitive disorder. An additional medical code should not be used for possible major neurocognitive disorder or mild neurocognitive disorder. Major or Mild Neurocognitive Disorder Due to Alzheimer’s Disease (611) ___.__ (___.__)

294.11 (F02.81 ) 294.10 (F02.80) 331.9

(G31.9)

331.83 (G31.84)

Probable Major Neurocognitive Disorder Due to Alzheimer's Disease^ Note: Code first 331.0 (G30.9) Alzheimer's disease. With behavioral disturbance Without behavioral disturbance Possible Major Neurocognitive Disorder Due to Alzheimer's Disease^' ^ Mild Neurocognitive Disorder Due to Alzheimer's Disease^

Major or Mild Frontotemporal Neurocognitive Disorder (614) ___.__ (__ .__)

294.11 (F02.81 ) 294.10 (F02.80) 331.9

(G31.9)

331.83 (G31,84)

Probable Major Neurocognitive Disorder Due to Frontotemporal Lobar Degeneration^ Note: Code first 331.19 (G31.09) frontotemporal disease. With behavioral disturbance Without behavioral disturbance Possible Major Neurocognitive Disorder Due to Frontotemporal Lobar Degeneration^' ^ Mild Neurocognitive Disorder Due to Frontotemporal Lobar Degeneration^

Major or Mild Neurocognitive Disorder With Lewy Bodies (618) ___.__ (__ .__) 294.11 (F02.81 ) 294.10 (F02.80)

Probable Major Neurocognitive Disorder With Lew^y Bodies^ Note: Code first 331.82 (G31.83) Lewy body disease. With behavioral disturbance Without behavioral disturbance

331.9

(G31.9)

331 -83 (G31.84)

Possible Major Neurocognitive Disorder With Lewy Bodies^' ^ Mild Neurocognitive Disorder With Lewy Bodies^

Major or Mild Vascular Neurocognitive Disorder (621) — ■— (

·_ )

290.40 (FOI .51) 290.40 (FOI .50) 331.9

(G31.9)

331.83 (G31.84)

Probable Major Vascular Neurocognitive Disorder^ Note: No additional medical code for vascular disease. With behavioral disturbance Without behavioral disturbance Possible Major Vascular Neurocognitive Disorder^' ^ Mild Vascular Neurocognitive Disorder^

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

294.11 (F02.81 ) 294.10 (F02.80) 331.83 (G31.84)

Major Neurocognitive Disorder Due to Traumatic Brain Injury^ Note: For ICD-9-CM, code first 907.0 late effect of intracranial injury without skull fracture. For ICD-IO-CM, code first S06.2X9S diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela. With behavioral disturbance Without behavioral disturbance Mild Neurocognitive Disorder Due to Traumatic Brain Injury^

Substance/Medication-Induced Major or Mild Neurocognitive Disorder^ (627) Note: No additional medical code. See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-IO-CM coding. Specify if: Persistent Major or Mild Neurocognitive Disorder Due to HIV Infection (632) ---- ■— (

._ )

294.11 (F02.81) 294.10 (F02.80) 331.83 (G31.84)

Major Neurocognitive Disorder Due to HIV Infection^ Note: Code first 042 (B20) HIV infection. With behavioral disturbance Without behavioral disturbance Mild Neurocognitive Disorder Due to HIV Infection^

Major or Mild Neurocognitive Disorder Due to Prion Disease (634) ___.__ (___.__) 294.11 (F02.81 ) 294.10 (F02.80) 331.83 (G31.84)

Major Neurocognitive Disorder Due to Prion Disease^ Note: Code first 046.79 (A81.9) prion disease. With behavioral disturbance Without behavioral disturbance Mild Neurocognitive Disorder Due to Prion Disease^

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

294.11 (F02.81 ) 294.10 (F02.80)

Major Neurocognitive Disorder Probably Due to Parkinson's Disease^ Note: Code first 332.0 (G20) Parkinson's disease. With behavioral disturbance Without behavioral disturbance

331.9

(G31.9)

331.83 (G31.84)

Major Neurocognitive Disorder Possibly Due to Parkir\son's Disease®' ^ Mild Neurocognitive Disorder Due to Parkinson's Disease®

Major or Mild Neurocognitive Disorder Due to Huntington’s Disease (638) ___.__ (__ .__) 294.11 (F02.81 ) 294.10 (F02.80) 331 -83 (G31.84)

Major Neurocognitive Disorder Due to Huntington's Disease*’ Note: Code first 333.4 (GIO) Huntington's disease. With behavioral disturbance Without behavioral disturbance Mild Neurocognitive Disorder Due to Huntington's Disease^

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

294.11 (F02.81 ) 294.10 (F02.80) 331.83 (G31.84)

Major Neurocognitive Disorder Due to Another Medical Condition^ Note: Code first the other medical condition. With behavioral disturbance Without behavioral disturbance Mild Neurocognitive Disorder Due to Another Medical Condition^

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

294.11 (F02.81 ) 294.10 (F02.80) 331.83 (G31.84)

Major Neurocognitive Disorder Due to Multiple Etiologies^ Note: Code first all the etiological medical conditions (with the exception of vascular disease). With behavioral disturbance Without behavioral disturbance Mild Neurocognitive Disorder Due to Multiple Etiologies^

Unspecified Neurocognitive Disorder (643) 799.59 (R41.9)

Unspecified Neurocognitive Disorder^

Personality Disorders (645) Cluster A Personality Disorders (F60.0)

Paranoid Personality Disorder (649)

301.20 (F60.1)

Schizoid Personality Disorder (652)

301.22 (F21)

Schizotypal Personality Disorder (655)

301.0

Cluster B Personality Disorders (F60.2)

Antisocial Personality Disorder (659)

301.83 (F60.3)

Borderline Personality Disorder (663)

301.50 (F60.4)

Histrionic Personality Disorder (667)

301.81 (F60.81)

Narcissistic Personality Disorder (669)

301.7

Cluster C Personality Disorders 301.82 (F60.6V

Avoidant Personality Disorder (672)

301.6

(F60.7)

Dependent Personality Disorder (675)

301.4

(F60.5)

Obsessive-Compulsive Personality Disorder (678)

Other Personality Disorders 310.1

(F07.0)

Personality Change Due to Another Medical Condition (682) Specify whether: Labile type, Disinhibited type. Aggressive type, Apathetic type. Paranoid type. Other type. Combined type. Unspecified type

301.89 (F60.89)

Other Specified Personality Disorder (684)

301.9

Unspecified Personality Disorder (684)

(F60.9)

Paraphilic Disorders (685) The following specifier applies to Paraphilic Disorders where indicated: ^Specify if: In a controlled environment. In full remission 302.82 (F65.3)

Voyeuristic Disorder® (686)

302.4

Exhibitionistic Disorder® (689) Specify whether: Sexually aroused by exposing genitals to prepubertal children. Sexually aroused by exposing genitals to physically mature individuals. Sexually aroused by exposing genitals to prepubertal chil­ dren and to physically mature individuals

(F65.2)

302.89 (F65.81)

Frotteuristic Disorder® (691)

302.83 (F65.51)

Sexual Masochism Disorder® (694) Specify if: With asphyxiophilia

302.84 (F65.52)

Sexual Sadism Disorder® (695)

302.2 (F65.4)

Pedophilic Disorder (697) Specify whether: Exclusive type. Nonexclusive type Specify if: Sexually attracted to males. Sexually attracted to females. Sexu­ ally attracted to both Specify if: Limited to incest

302.81 (F65.0)

Fetishistic Disorder® (700) Specify: Body part(s). Nonliving object(s). Other

302.3 (F65.1)

Transvestic Disorder® (702) Specify if: With fetishism. With autogynephilia

302.89 (F65.89)

Other Specified Paraphilic Disorder (705)

302.9 (F65.9)

Unspecified Paraphilic Disorder (705)

Other Mental Disorders (707) 294.8

(F06.8)

Other Specified Mental Disorder Due to Another Medical Condition (707)

294.9

(F09)

Unspecified Mental Disorder Due to Another Medical Condition (708)

300.9

(F99)

Other Specified Mental Disorder (708)

300.9

(F99)

Unspecified Mental Disorder (708)

Medication-Induced iVlovement Disorders and Other Adverse Effects of iVledication (709) 332.1

(G21.11)

Neuroleptic-Induced Parkinsonism (709)

332.1

(G21.19)

Other Medication-Induced Parkinsonism (709)

333.92 (G21.0)

Neuroleptic Malignant Syndrome (709)

333.72 (G24.02)

Medication-Induced Acute Dystonia (711)

333.99 (G25.71)

Medication-Induced Acute Akathisia (711)

333.85 (G24.01)

Tardive Dyskinesia (712)

333.72 (G24.09)

Tardive Dystonia (712)

333.99 (G25.71)

Tardive Akathisia (712)

333.1

Medication-Induced Postural Tremor (712)

(G25.1)

333.99 (G25.79)

Other Medication-Induced Movement Disorder (712)

Antidepressant Discontinuation Syndrome (712) . ( . ) 995.29 (T43.205A) Initial encounter 995.29 (T43.205D)

Subsequent encounter

995.29 (T43.205S)

Sequelae

Other Adverse Effect of Medication (714) . ( ■ ) 995.20 (T50.905A) Initial encounter 995.20 (T50.905D)

Subsequent encounter

995.20 (T50.905S)

Sequelae

Other Conditions That iVlay Be a Focus of Ciinicai Attention (715) Relational Problems (715) Problems Related to Family Upbringing (715) V61.20 (Z62.820)

Parent-Child Relational Problem (715)

V61.8 (Z62.891 ) Sibling Relational Problem (716) V61.8 (Z62.29)

Upbringing Away From Parents (716)

V61.29 (Z62.898)

Child Affected by Parental Relationship Distress (716)

Other Problems Related to Primary Support Group (716) V61.10 (Z63.0)

Relationship Distress With Spouse or Intimate Partner (716)

V61.03 (Z63.5)

Disruption of Family by Separation or Divorce (716)

V61.8

High Expressed Emotion Level Within Family (716)

(Z63.8)

V62.82 (Z63.4)

Uncomplicated Bereavement (716)

Abuse and Neglect (717) Child ΜβΙίΓ63ίφ6ηΙ and Neglect Problems (717) Child Physical Abuse (717) Child Physical Abuse, Confirmed (717) 995.54 (T74.12XA) Initialencounter 995.54 {T74.12XD)

Subsequent encounter

Child Physical Abuse, Suspected (717) 995.54 (T76.12XA) Initialencounter 995.54 (T76.12XD)

Subsequent encounter

Other Circumstances Related to Child Physical Abuse (718) V61.21 (Z69.010) Encounter for mental health services for victim of child abuse by parent V61.21 (Z69.020)

Encounter for mental health services for victim of nonparental child abuse

VI 5.41 (Z62.810)

Personal history (past history) of physical abuse in childhood

V61.22 (Z69.011)

Encounter for mental health services for perpetrator of parental child abuse

V62.83 (Z69.021)

Encounter for mental health services for perpetrator of nonparental child abuse

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

Subsequent encounter

Child Sexual Abuse, Suspected (718) 995.53 (T76.22XA) Initialencounter 995.53 (T76.22XD)

Subsequent encounter

Other Circumstances Related to Child Sexual Abuse (718) V61.21 (Z69.010) Encounter for mental health services for victim of child sexual abuse by parent V61.21 (Z69.020)

Encounter for mental health services for victim of nonparental child sexual abuse

V15.41 (Z62.810)

Personal history (past history) of sexual abuse in childhood

V61.22 (Z69.011)

Encounter for mental health services for perpetrator of parental child sexual abuse

V62.83 (Z69.021)

Encounter for mental health services for perpetrator of nonparental child sexual abuse

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

Subsequent encounter

Child Neglect, Suspected (719) 995.52 (T76.02XA) Initialencounter 995.52 (T76.02XD)

Subsequent encounter

Other Circumstances Related to Child Neglect (719) V61.21 (Z69.010) Encounter for mental health services for victim of child neglect by parent V61.21 (Z69.020)

Encounter for mental health services for victim of nonparental child neglect

VI 5.42 (Z62.812)

Personal history (past history) of neglect in childhood

V61.22 (Z69.011)

Encounter for mental health services for perpetrator of parental child neglect

V62.83 (Z69.021)

Encounter for mental health services for perpetrator of nonparental child neglect

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

Subsequent encounter

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

Subsequent encounter

Other Circumstances Related to Child Psychological Abuse (719) V61.21 (Z69.010) Encounter for mental health services for victim of child psychological abuse by parent V61.21 (Z69.020)

Encounter for mental health services for victim of nonparental child psychological abuse

VI 5.42 (Z62.811)

Personal history (past history) of psychological abuse in childhood

V61.22 (Z69.011)

Encounter for mental health services for perpetrator of parental child psychological abuse

V62.83 (Z69.021)

Encounter for mental health services for perpetrator of nonparental child psychological abuse

Adult Maltreatment and Neglect Problems (720)

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

Subsequent encounter

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

Subsequent encounter

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

V15.41 (Z91.410)

Personal history (past history) of spouse or partner violence, physical

V61.12 (Z69.12)

Encounter for mental health services for perpetrator of spouse or partner violence, physical

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

Subsequent encounter

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

Subsequent encounter

Other Circumstances Related to Spouse or Partner Violence, Sexual (720) V61.11 (Z69.81 ) Encounter for mental health services for victim of spouse or partner violence, sexual VI 5.41 (Z91.410)

Personal history (past history) of spouse or partner violence, sexual

V61.12 (Z69.12)

Encounter for mental health services for perpetrator of spouse or partner violence, sexual

Spouse or Partner, Neglect (721) Spouse or Partner Neglect, Confirmed (721) 995.85 (T74.01XA) Initialencounter 995.85 (T74.01XD)

Subsequent encounter

Spouse or Partner Neglect, Suspected (721) 995.85 (T76.01XA) Initialencounter 995.85 (T76.01XD)

Subsequent encounter

Other Circumstances Related to Spouse or Partner Neglect (721) V61.11 (Z69.11) Encounter for mental health services for victim of spouse or partner neglect VI 5.42 (Z91.412)

Personal history (past history) of spouse or partner neglect

V61.12 (Z69.12)

Encounter for mental health services for perpetrator of spouse or partner neglect

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

Subsequent encounter

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

Subsequent encounter

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

V15.42 (Z91.411)

Personal history (past history) of spouse or partner psychological abuse

V61.12 (Z69.12)

Encounter for mental health services for perpetrator of spouse or partner psychological abuse

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

Subsequent encounter

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

Subsequent encounter

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

Subsequent encounter

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

Subsequent encounter

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

Subsequent encounter

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

Subsequent encounter

Other Circumstances Related to Adult Abuse by Nonspouse or Nonpartner (722) V65.49 (Z69.81) Encoxmter for mental health services for victim of nonspousal adult abuse V62.83 (Z69.82)

Encovmter for mental health services for perpetrator of nonspousal adult abuse

Educational and Occupational Problems (723) Educational Problems (723) V62.3

(Z55.9)

Academic or Educational Problem (723)

Occupational Problems (723) V62.21 (Z56.82)

Problem Related to Current Military Deployment Status (723)

V62.29 (Z56.9)

Other Problem Related to Employment (723)

Housing and Economic Problems (723) Housing Problems (723) V60.0 (Z59.0)

Homelessness (723)

V60.1

Inadequate Housing (723)

(Z59.1)

V60.89 (Z59.2)

Discord With Neighbor, Lodger, or Landlord (723)

V60.6

Problem Related to Living in a Residential Institution (724)

(Z59.3V

Economic Problems (724) V60.2

(Z59.4)

Lack of Adequate Food or Safe Drinking Water (724)

V60.2

(Z59.5)

Extreme Poverty (724)

V60.2

(Z59.6)

Low Income (724)

V60.2

(Z59.7)

Insufficient Social Insurance or Welfare Support (724)

V60.9

(Z59.9)

Unspecified Housing or Economic Problem (724)

Other Problems Related to the Social Environment (724) V62.89 (Z60.0)

Phase of Life Problem (724)

V60.3

(Z60.2)

Problem Related to Living Alone (724)

V62.4

(Z60.3)

Acculturation Difficulty (724)

V62.4

(Z60.4)

Social Exclusion or Rejection (724)

V62.4

(Z60.5)

Target of (Perceived) Adverse Discrimination or Persecution (724)

V62.9

(Z60.9)

Unspecified Problem Related to Social Environment (725)

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

Victim of Crime (725)

V62.5

(Z65.0)

Conviction in Civil or Criminal Proceedings Without Imprisonment (725)

V62.5

(Z65.1)

Imprisonment or Other Incarceration (725)

V62.5

(Z65.2)

Problems Related to Release From Prison (725)

V62.5

(Z65.3)

Problems Related to Other Legal Circumstances (725)

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

Sex Counseling (725)

V65.40 (271.9)

Other Counseling or Consultation (725)

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

Religious or Spiritual Problem (725)

V61.7

(Z64.0)

Problems Related to Unwanted Pregnancy (725)

V61.5

(Z64.1)

Problems Related to Multiparity (725)

V62.89 (Z64.4)

Discord With Social Service Provider, Including Probation Officer, Case Manager, or Social Services Worker (725)

V62.89 (Z65.4)

Victim of Terrorism or Torture (725)

V62.22 (Z65.5)

Exposure to Disaster, War, or Other Hostilities (725)

V62.89 (Z65.8)

Other Problem Related to Psychosocial Circumstances (725)

V62.9

Unspecified Problem Related to Unspecified Psychosocial Circumstances (725)

(Z65.9)

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

Other Personal History of Psychological Trauma (726)

V15.59 (Z91.5)

Personal History of Self-Harm (726)

V62.22 (Z91.82)

Personal History of Military Deployment (726)

V15.89 (Z91.89)

Other Personal Risk Factors (726)

V69.9

Problem Related to Lifestyle (726)

(Z72.9)

V71.01 (Z72.811)

Adult Antisocial Behavior (726)

V71.02 (Z72.810)

Child or Adolescent Antisocial Behavior (726)

Problems Related to Access to Medical and Other Health Care (726) V63.9

(Z75.3)

Unavailability or Inaccessibility of Health Care Facilities (726)

V63.8

(Z75.4)

Unavailability or Inaccessibility of Other Helping Agencies (726)

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

Nonadherence to Medical Treatment (726)

278.00 (E66.9)

Overweight or Obesity (726)

V65.2 (Z76.5)

Malingering (726)

V40.31 (Z91.83)

Wandering Associated With a Mental Disorder (727)

V62.89 (R41.83)

Borderline Intellectual Functioning (727)

Preface ΤΙΊΘ A m G riC S n P s y c h i â t r i c Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification of mental disorders with associated criteria de­ signed to facilitate more reliable diagnoses of these disorders. With successive editions over the past 60 years, it has become a standard reference for clinical practice in the mental health field. Since a complete description of the underlying pathological processes is not possible for most mental disorders, it is important to emphasize that the current diagnos­ tic criteria are the best available description of how mental disorders are expressed and can be recognized by trained clinicians. DSM is intended to serve as a practical, functional, and flexible guide for organizing information that can aid in the accurate diagnosis and treatment of mental disorders. It is a tool for clinicians, an essential educational resource for students and practitioners, and a reference for researchers in the field. Although this edition of DSM was designed first and foremost to be a useful guide to clinical practice, as an official nomenclature it must be applicable in a wide diversity of contexts. DSM has been used by clinicians and researchers from different orientations (bi­ ological, psychodynamic, cognitive, behavioral, interpersonal, family/systems), all of whom strive for a common language to communicate the essential characteristics of men­ tal disorders presented by their patients. The information is of value to all professionals associated with various aspects of mental health care, including psychiatrists, other physicians, psychologists, social workers, nurses, counselors, forensic and legal special­ ists, occupational and rehabilitation therapists, and other health professionals. The criteria are concise and explicit and intended to facilitate an objective assessment of symptom pre­ sentations in a variety of clinical settings—inpatient, outpatient, partial hospital, consul­ tation-liaison, clinical, private practice, and primary care—as well in general community epidemiological studies of mental disorders. DSM-5 is also a tool for collecting and com­ municating accurate public health statistics on mental disorder morbidity and mortality rates. Finally, the criteria and corresponding text serve as a textbook for students early in their profession who need a structured way to understand and diagnose mental disorders as well as for seasoned professionals encountering rare disorders for the first time. Fortu­ nately, all of these uses are mutually compatible. These diverse needs and interests were taken into consideration in planning DSM-5. The classification of disorders is harmonized with the World Health Organization's Inter­ national Classification of Diseases (ICD), the official coding system used in the United States, so that the DSM criteria define disorders identified by ICD diagnostic names and code numbers. In DSM-5, both ICD-9-CM and ICD-IO-CM codes (the latter scheduled for adop­ tion in October 2014) are attached to the relevant disorders in the classification. Although DSM-5 remains a categorical classification of separate disorders, we recog­ nize that mental disorders do not always fit completely within the boundaries of a single disorder. Some symptom domains, such as depression and anxiety, involve multiple di­ agnostic categories and may reflect common underlying vulnerabilities for a larger group of disorders. In recognition of this reality, the disorders included in DSM-5 were reordered into a revised organizational structure meant to stimulate new clinical perspectives. This new structure corresponds with the organizational arrangement of disorders planned for ICD-11 scheduled for release in 2015. Other enhancements have been introduced to pro­ mote ease of use across all settings:

xli

• Representation of developmental issues related to diagnosis. The change in chapter organization better reflects a lifespan approach, with disorders more frequently diag­ nosed in childhood (e.g., neurodevelopmental disorders) at the beginning of the man­ ual and disorders more applicable to older adulthood (e.g., neurocognitive disorders) at the end of the manual. Also, within the text, subheadings on development and course provide descriptions of how disorder presentations may change across the lifespan. Age-related factors specific to diagnosis (e.g., symptom presentation and prevalence differences in certain age groups) are also included in the text. For added emphasis, these age-related factors have been added to the criteria themselves where applicable (e.g., in the criteria sets for insomnia disorder and posttraumatic stress disorder, spe­ cific criteria describe how symptoms might be expressed in children). Likewise, gender and cultural issues have been integrated into the disorders where applicable. • Integration of scientific findings from the latest research in genetics and neuroimag­ ing. The revised chapter structure was informed by recent research in neuroscience and by emerging genetic linkages between diagnostic groups. Genetic and physiological risk factors, prognostic indicators, and some putative diagnostic markers are high­ lighted in the text. This new structure should improve clinicians' ability to identify di­ agnoses in a disorder spectrum based on common neurocircuitry, genetic vulnerability, and environmental exposures. • Consolidation of autistic disorder, Asperger's disorder, and pervasive developmen­ tal disorder into autism spectrum disorder. Symptoms of these disorders represent a single continuum of mild to severe impairments in the two domains of social commu­ nication and restrictive repetitive behaviors/interests rather than being distinct disor­ ders. This change is designed to improve the sensitivity and specificity of the criteria for the diagnosis of autism spectrum disorder and to identify more focused treatment tar­ gets for the specific impairments identified. • Streamlined classification of bipolar and depressive disorders. Bipolar and depres­ sive disorders are the most commonly diagnosed conditions in psychiatry. It was there­ fore important to streamline the presentation of these disorders to enhance both clinical and educational use. Rather than separating the definition of manic, hypomanie, and major depressive episodes from the definition of bipolar I disorder, bipolar II disorder, and major depressive disorder as in the previous edition, we included all of the com­ ponent criteria within the respective criteria for each disorder. This approach will facil­ itate bedside diagnosis and treatment of these important disorders. Likewise, the explanatory notes for differentiating bereavement and major depressive disorders will provide far greater clinical guidance than was previously provided in the simple be­ reavement exclusion criterion. The new specifiers of anxious distress and mixed fea­ tures are now fully described in the narrative on specifier variations that accompanies the criteria for these disorders. • Restructuring of substance use disorders for consistency and clarity. The categories of substance abuse and substance dependence have been eliminated and replaced with an overarching new category of substance use disorders—with the specific substance used defining the specific disorders. "Dependence" has been easily confused with the term "addiction" when, in fact, the tolerance and withdrawal that previously defined dependence are actually very normal responses to prescribed medications that affect the central nervous system and do not necessarily indicate the presence of an addiction. By revising and clarifying these criteria in DSM-5, we hope to alleviate some of the widespread misunderstanding about these issues. • Enhanced specificity for major and mild neurocognitive disorders. Given the explo­ sion in neuroscience, neuropsychology, and brain imaging over the past 20 years, it was critical to convey the current state-of-the-art in the diagnosis of specific types of disor­ ders that were previously referred to as the "dementias" or organic brain diseases. Bi­ ological markers identified by imaging for vascular and traumatic brain disorders and

specific molecular genetic findings for rare variants of Alzheimer's disease and Hun­ tington's disease have greatly advanced clinical diagnoses, and these disorders and others have now been separated into specific subtypes. • Transition in conceptualizing personality disorders. Although the benefits of a more dimensional approach to personality disorders have been identified in previous edi­ tions, the transition from a categorical diagnostic system of individual disorders to one based on the relative distribution of personality traits has not been widely accepted. In DSM-5, the categorical personality disorders are virtually unchanged from the previous edition. However, an alternative "hybrid" model has been proposed in Section III to guide future research that separates interpersonal functioning assessments and the ex­ pression of pathological personality traits for six specific disorders. A more dimensional profile of personality trait expression is also proposed for a trait-specified approach. • Section III: new disorders and features. A new section (Section III) has been added to highlight disorders that require further study but are not sufficiently well established to be a part of the official classification of mental disorders for routine clinical use. Dimen­ sional measures of symptom severity in 13 symptom domains have also been incorpo­ rated to allow for the measurement of symptom levels of varying severity across all diagnostic groups. Likewise, the WHO Disability Assessment Schedule (WHODAS), a standard method for assessing global disability levels for mental disorders that is based on the International Classification of Functioning, Disability and Health (ICF) and is ap­ plicable in all of medicine, has been provided to replace the more limited Global As­ sessment of Functioning scale. It is our hope that as these measures are implemented over time, they will provide greater accuracy and flexibility in the clinical description of individual symptomatic presentations and associated disability during diagnostic as­ sessments. • Online enhancements. DSM-5 features online supplemental information. Additional cross-cutting and diagnostic severity measures are available online (www.psychiatry.org/dsm5), linked to the relevant disorders. In addition, the Cul­ tural Formulation Interview, Cultural Formulation Interview—Informant Version, and supplementary modules to the core Cultural Formulation Interview are also included online at www.psychiatry.org/dsm5. These innovations were designed by the leading authorities on mental disorders in the world and were implemented on the basis of their expert review, public commentary, and independent peer review. The 13 work groups, under the direction of the DSM-5 Task Force, in conjunction with other review bodies and, eventually, the APA Board of Trust­ ees, collectively represent the global expertise of the specialty. This effort was supported by an extensive base of advisors and by the professional staff of the APA Division of Re­ search; the names of everyone involved are too numerous to mention here but are listed in the Appendix. We owe tremendous thanks to those who devoted countless hours and in­ valuable expertise to this effort to improve the diagnosis of mental disorders. We would especially like to acknowledge the chairs, text coordinators, and members of the 13 work groups, listed in the front of the manual, who spent many hours in this vol­ unteer effort to improve the scientific basis of clinical practice over a sustained 6-year pe­ riod. Susan K. Schultz, M.D., who served as text editor, worked tirelessly with Emily A. Kuhl, Ph.D., senior science writer and DSM-5 staff text editor, to coordinate the efforts of the work groups into a cohesive whole. William E. Narrow, M.D., M.P.H., led the research group that developed the overall research strategy for DSM-5, including the field trials, that greatly enhanced the evidence base for this revision. In addition, we are grateful to those who contributed so much time to the independent review of the revision proposals, including Kenneth S. Kendler, M.D., and Robert Freedman, M.D., co-chairs of the Scien­ tific Review Committee; John S. McIntyre, M.D., and Joel Yager, M.D., co-chairs of the Clinical and Public Health Committee; and Glenn Martin, M.D., chair of the APA Assem­

bly review process. Special thanks go to Helena C. Kraemer, Ph.D., for her expert statistical consultation; Michael B. First, M.D., for his valuable input on the coding and review of cri­ teria; and Paul S. Appelbaum, M.D., for feedback on forensic issues. Maria N. Ward, M.Ed., RHIT, CCS-P, also helped in verifying all ICD coding. The Summit Group, which included these consultants, the chairs of all review groups, the task force chairs, and the APA executive officers, chaired by Dilip V. Jeste, M.D., provided leadership and vision in helping to achieve compromise and consensus. This level of commitment has contributed to the balance and objectivity that we feel are hallmarks of DSM-5. We especially wish to recognize the outstanding APA Division of Research staff— identified in the Task Force and Work Group listing at the front of this manual—who worked tirelessly to interact with the task force, work groups, advisors, and reviewers to resolve issues, serve as liaisons between the groups, direct and manage the academic and routine clinical practice field trials, and record decisions in this important process. In par­ ticular, we appreciate the support and guidance provided by James H. Scully Jr., M.D., Medical Director and CEO of the APA, through the years and travails of the development process. Finally, we thank the editorial and production staff of American Psychiatric Pub­ lishing—specifically, Rebecca Rinehart, Publisher; John McDuffie, Editorial Director; Ann Eng, Senior Editor; Greg Kuny, Managing Editor; and Tammy Cordova, Graphics Design Manager—for their guidance in bringing this all together and creating the final product. It is the culmination of efforts of many talented individuals who dedicated their time, exper­ tise, and passion that made DSM-5 possible. David J. Kupfer, M.D. DSM-5 Task Force Chair Darrel A. Regier, M.D., M.P.H. DSM-5 Task Force Vice-Chair December 19, 2012

Introduction.................................................................................................. 5 Use of the Manual .................................................................................... 19 Cautionary Statement for Forensic Use of DSM-5.................................. 25

This section

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

Introduction ΤΙΊΘ C rG â tio n of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was a massive undertaking that involved hundreds of people working toward a common goal over a 12-year process. Much thought and deliberation were involved in evaluating the diagnostic criteria, considering the organization of every aspect of the man­ ual, and creating new features believed to be most useful to clinicians. All of these efforts were directed toward the goal of enhancing the clinical usefulness of DSM-5 as a guide in the diagnosis of mental disorders. Reliable diagnoses are essential for guiding treatment recommendations, identifying prevalence rates for mental health service planning, identifying patient groups for clinical and basic research, and documenting important public health information such as mor­ bidity and mortality rates. As the understanding of mental disorders and their treatments has evolved, medical, scientific, and clinical professionals have focused on the character­ istics of specific disorders and their implications for treatment and research. While DSM has been the cornerstone of substantial progress in reliability, it has been well recognized by both the American Psychiatric Association (APA) and the broad scientific com­ munity working on mental disorders that past science was not mature enough to yield fully validated diagnoses—that is, to provide consistent, strong, and objective scientific validators of individual DSM disorders. The science of mental disorders continues to evolve. However, the last two decades since DSM-IV was released have seen real and durable progress in such areas as cognitive neuroscience, brain imaging, epidemiology, and genetics. The DSM-5 Task Force overseeing the new edition recognized that research advances will require careful, iter­ ative changes if DSM is to maintain its place as the touchstone classification of mental disor­ ders. Finding the right balance is critical. Speculative results do not belong in an official nosology, but at the same time, DSM must evolve in the context of other clinical research ini­ tiatives in the field. One important aspect of this transition derives from the broad recognition that a too-rigid categorical system does not capture clinical experience or important scientific observations. The results of numerous studies of comorbidity and disease transmission in fam­ ilies, including twin studies and molecular genetic studies, make strong arguments for what many astute clinicians have long observed: the boundaries between many disorder "catego­ ries" are more fluid over the life course than DSM-IV recognized, and many symptoms as­ signed to a single disorder may occur, at varying levels of severity, in many other disorders. These findings mean that DSM, like other medical disease classifications, should accommo­ date ways to introduce dimensional approaches to mental disorders, including dimensions that cut across current categories. Such an approach should permit a more accurate description of patient presentations and increase the validity of a diagnosis (i.e., the degree to which diag­ nostic criteria reflect the comprehensive manifestation of an underlying psychopathological disorder). DSM-5 is designed to better fill the need of clinicians, patients, families, and re­ searchers for a clear and concise description of each mental disorder organized by explicit di­ agnostic criteria, supplemented, when appropriate, by dimensional measures that cross diagnostic boundaries, and a brief digest of information about the diagnosis, risk factors, as­ sociated features, research advances, and various expressions of the disorder. Clinical training and experience are needed to use DSM for determining a diagnosis. The diagnostic criteria identify symptoms, behaviors, cognitive functions, personality traits, phys­ ical signs, syndrome combinations, and durations that require clinical expertise to differenti­ ate from normal life variation and transient responses to stress. To facilitate a thorough

examination of the range of symptoms present, DSM can serve clinicians as a guide to identify the most prominent symptoms that should be assessed when diagnosing a disorder. Although some mental disorders may have well-defined boundaries around symptom clusters, scien­ tific evidence now places many, if not most, disorders on a spectrum with closely related dis­ orders that have shared symptoms, shared genetic and environmental risk factors, and possibly shared neural substrates (perhaps most strongly established for a subset of anxiety disorders by neuroimaging and animal models). In short, we have come to recognize that the boundaries between disorders are more porous than originally perceived. Many health profession and educational groups have been involved in the development and testing of DSM-5, including physicians, psychologists, social workers, nurses, counselors, epidemiologists, statisticians, neuroscientists, and neuropsychologists. Finally, patients, fam­ ilies, lawyers, consumer organizations, and advocacy groups have all participated in revising DSM-5 by providing feedback on the mental disorders described in this volume. Their moni­ toring of the descriptions and explanatory text is essential to improve understanding, reduce stigma, and advance the treatment and eventual cures for these conditions.

A Brief History The APA first published a predecessor of DSM in 1844, as a statistical classification of in­ stitutionalized mental patients. It was designed to improve communication about the types of patients cared for in these hospitals. This forerunner to DSM also was used as a component of the full U.S. census. After World War II, DSM evolved through four major editions into a diagnostic classification system for psychiatrists, other physicians, and other mental health professionals that described the essential features of the full range of mental disorders. The current edition, DSM-5, builds on the goal of its predecessors (most recently, DSM-IV-TR, or Text Revision, published in 2000) of providing guidelines for di­ agnoses that can inform treatment and management decisions.

DSM-5 Revision Process In 1999, the APA launched an evaluation of the strengths and weaknesses of DSM based on emerging research that did not support the boundaries established for some mental disor­ ders. This effort was coordinated with the World Health Organization (WHO) Division of Mental Health, the World Psychiatric Association, and the National Institute of Mental Health (NIMH) in the form of several conferences, the proceedings of which were published in 2002 in a monograph entitled A Research Agenda for DSM-V. Thereafter, from 2003 to 2008, a cooperative agreement with the APA and the WHO was supported by the NIMH, the Na­ tional Institute on Drug Abuse (NIDA), and the National Institute on Alcoholism and Alco­ hol Abuse (NI AAA) to convene 13 international DSM-5 research planning conferences, involving 400 participants from 39 countries, to review the world literature in specific diag­ nostic areas to prepare for revisions in developing both DSM-5 and the International Classi­ fication of Diseases, 11th Revision (ICD-11). Reports from these conferences formed the basis for future DSM-5 Task Force reviews and set the stage for the new edition of DSM. In 2006, the APA named David J. Kupfer, M.D., as Chair and Darrel A. Regier, M.D., M.P.H., as Vice-Chair of the DSM-5 Task Force. They were charged with recommending chairs for the 13 diagnostic work groups and additional task force members with a multi­ disciplinary range of expertise who would oversee the development of DSM-5. An addi­ tional vetting process was initiated by the APA Board of Trustees to disclose sources of income and thus avoid conflicts of interest by task force and work group members. The full disclosure of all income and research grants from commercial sources, including the phar­ maceutical industry, in the previous 3 years, the imposition of an income cap from all com­ mercial sources, and the publication of disclosures on a Web site set a new standard for the

field. Thereafter, the task force of 28 members was approved in 2007, and appointments of more than 130 work group members were approved in 2008. More than 400 additional work group advisors with no voting authority were also approved to participate in the pro­ cess. A clear concept of the next evolutionary stage for the classification of mental disorders was central to the efforts of the task force and the work groups. This vision emerged as the task force and work groups recounted the history of DSM-IV's classification, its current strengths and limitations, and strategic directions for its revision. An intensive 6-year pro­ cess involved conducting literature reviews and secondary analyses, publishing research reports in scientific journals, developing draft diagnostic criteria, posting preliminary drafts on the DSM-5 Web site for public comment, presenting preliminary findings at pro­ fessional meetings, performing field trials, and revising criteria and text.

Proposals for Revisions Proposals for the revision of DSM-5 diagnostic criteria were developed by members of the work groups on the basis of rationale, scope of change, expected impact on clinical man­ agement and public health, strength of the supporting research evidence, overall clarity, and clinical utility. Proposals encompassed changes to diagnostic criteria; the addition of new disorders, subtypes, and specifiers; and the deletion of existing disorders. In the proposals for revisions, strengths and weaknesses in the current criteria and no­ sology were first identified. Novel scientific findings over the previous two decades were considered, leading to the creation of a research plan to assess potential changes through literature reviews and secondary data analyses. Four principles guided the draft revisions: 1) DSM-5 is primarily intended to be a manual to be used by clinicians, and revisions must be feasible for routine clinical practice; 2) recommendations for revisions should be guided by research evidence; 3) where possible, continuity should be maintained with previous editions of DSM; and 4) no a priori constraints should be placed on the degree of change between DSM-IV and DSM-5. Building on the initial literature reviews, work groups identified key issues within their diagnostic areas. Work groups also examined broader methodological concerns, such as the presence of contradictory findings within the literature; development of a re­ fined definition of mental disorder; cross-cutting issues relevant to all disorders; and the revision of disorders categorized in DSM-IV as '"not otherwise specified." Inclusion of a proposal for revision in Section II was informed by consideration of its advantages and disadvantages for public health and clinical utility, the strength of the evidence, and the magnitude of the change. New diagnoses and disorder subtypes and specifiers were sub­ ject to additional stipulations, such as demonstration of reliability (i.e., the degree to which two clinicians could independently arrive at the same diagnosis for a given patient). Dis­ orders with low clinical utility and weak validity were considered for deletion. Placement of conditions in ''Conditions for Further Study" in Section III was contingent on the amount of empirical evidence generated on the diagnosis, diagnostic reliability or valid­ ity, presence of clear clinical need, and potential benefit in advancing research.

DSIVI-5 Fieid Triais The use of field trials to empirically demonstrate reliability was a noteworthy improvement in­ troduced in DSM-III. The design and implementation strategy of the DSM-5 Field Trials rep­ resent several changes over approaches used for DSM-III and DSM-IV, particularly in obtaining data on the precision of kappa reliability estimates (a statistical measure that assesses level of agreement between raters that corrects for chance agreement due to prevalence rates) in the context of clinical settings with high levels of diagnostic comorbidity. For DSM-5, field trials were extended by using two distinctive designs: one in large, diverse medical-academic settings, and the other in routine clinical practices. The former capitalized on the need for large sample sizes to test hypotheses on reliability and clinical utility of a range of diagnoses in a

variety of patient populations; the latter supplied valuable information about how proposed revisions performed in everyday clinical settings among a diverse sample of DSM users. It is anticipated that future clinical and basic research studies will focus on the validity of the re­ vised categorical diagnostic criteria and the underlying dimensional features of these disor­ ders (including those now being explored by the NIB/IH Research Domain Criteria initiative). The medical-academic field trials were conducted at 11 North American medical-academic sites and assessed the reliability, feasibility, and clinical utility of select revisions, with priority given to those that represented the greatest degree of change from DSM-IV or those potentially having the greatest public health impact. The full clinical patient populations coming to each site were screened for DSM-IV diagnoses or qualifying symptoms likely to predict several spe­ cific DSM-5 disorders of interest. Stratified samples of four to seven specific disorders, plus a stratum containing a representative sample of all other diagnoses, were identified for each site. Patients consented to the study and were randomly assigned for a clinical interview by a cli­ nician blind to the diagnosis, followed by a second interview with a clinician blind to previous diagnoses. Patients first filled out a computer-assisted inventory of cross-cutting symptoms in more than a dozen psychological domains. These inventories were scored by a central server, and results were provided to cliniciai\s before they conducted a typical clinical interview (with no structured protocol). Clinicians were required to score the presence of qualifying criteria on a computer-assisted DSM-5 diagnostic checklist, determine diagnoses, score the severity of the diagnosis, and submit all data to the central Web-based server. This study design allowed the calculation of the degree to which two independent clinicians could agree on a diagnosis (us­ ing the intraclass kappa statistic) and the agreement of a single patient or two different clini­ cians on two separate ratings of cross-cutting symptoms, personality traits, disability, and diagnostic severity measures (using intraclass correlation coefficients) along with information on tiie precision of these estimates of reliability. It was also possible to assess the prevalence rates of both DSM-IV and DSM-5 conditions in the respective clinical populations. The routine clinical practice field trials involved recruitment of individual psychiatrists and other mental health clinicians. A volunteer sample was recruited that included gener­ alist and specialty psychiatrists, psychologists, licensed clinical social workers, counselors, marriage and family therapists, and advanced practice psychiatric mental health nurses. The field trials provided exposure of the proposed DSM-5 diagnoses and dimensional mea­ sures to a wide range of clinicians to assess their feasibility and clinical utility.

Public and Professional Review In 2010, the APA launched a unique Web site to facilitate public and professional input into DSM-5. All draft diagnostic criteria and proposed changes in organization were posted on www.dsm5.org for a 2-month comment period. Feedback totaled more than 8,000 submis­ sions, which were systematically reviewed by each of the 13 work groups, whose members, where appropriate, integrated questions and comments into discussions of draft revisions and plans for field trial testing. After revisions to the initial draft criteria and proposed chapter organization, a second posting occurred in 2011. Work groups considered feedback from both Web postings and the results of the DSM-5 Field Trials when drafting proposed final criteria, which were posted on the Web site for a third and final time in 2012. These three iterations of external review produced more than 13,000 individually signed com­ ments on the Web site that were received and reviewed by the work groups, plus thousands of organized petition signers for and against some proposed revisions, all of which allowed the task force to actively address concerns of DSM users, as well as patients and advocacy groups, and ensure that clinical utility remained a high priority.

Expert Review The members of the 13 work groups, representing expertise in their respective areas, col­ laborated with advisors and reviewers under the overall direction of the DSM-5 Task

Force to draft the diagnostic criteria and accompanying text. This effort was supported by a team of APA Division of Research staff and developed through a network of text coor­ dinators from each work group. The preparation of the text was coordinated by the text editor, working in close collaboration with the work groups and under the direction of the task force chairs. The Scientific Review Committee (SRC) was established to provide a sci­ entific peer review process that was external to that of the work groups. The SRC chair, vice-chair, and six committee members were charged with reviewing the degree to which the proposed changes from DSM-IV could be supported with scientific evidence. Each proposal for diagnostic revision required a memorandum of evidence for change pre­ pared by the work group and accompanied by a summary of supportive data organized around validators for the proposed diagnostic criteria (i.e., antecedent validators such as familial aggregation, concurrent validators such as biological markers, and prospective validators such as response to treatment or course of illness). The submissions were re­ viewed by the SRC and scored according to the strength of the supportive scientific data. Other justifications for change, such as those arising from clinical experience or need or from a conceptual reframing of diagnostic categories, were generally seen as outside the purview of the SRC. The reviewers' scores, which varied substantially across the different proposals, and an accompanying brief commentary were then returned to the APA Board of Trustees and the work groups for consideration and response. The Clinical and Public Health Committee (CPHC), composed of a chair, vice-chair, and six members, was appointed to consider additional clinical utility, public health, and log­ ical clarification issues for criteria that had not yet accumulated the type or level of evi­ dence deemed sufficient for change by the SRC. This review process was particularly important for DSM-IV disorders with known deficiencies for which proposed remedies had neither been previously considered in the DSM revision process nor been subjected to replicated research studies. These selected disorders were evaluated by four to five exter­ nal reviewers, and the blinded results were reviewed by CPHC members, who in turn made recommendations to the APA Board of Trustees and the work groups. Forensic reviews by the members of the APA Council on Psychiatry and Law were con­ ducted for disorders frequently appearing in forensic environments and ones with high potential for influencing civil and criminal judgments in courtroom settings. Work groups also added forensic experts as advisors in pertinent areas to complement expertise pro­ vided by the Council on Psychiatry and Law. The work groups themselves were charged with the responsibility to review the entire re­ search literature surrounding a diagnostic area, including old, revised, and new diagnostic cri­ teria, in an intensive 6-year review process to assess the pros and cons of making either small iterative changes or major conceptual changes to address the inevitable reification that occurs with diagnostic conceptual approaches that persist over several decades. Such changes in­ cluded the merger of previously separate diagnostic areas into more dimensional spectra, such as that which occurred with autism spectrum disorder, substance use disorders, sexual dys­ functions, and somatic symptom and related disorders. Other changes included correcting flaws that had become apparent over time in the choice of operational criteria for some disor­ ders. These types of changes posed particular challenges to the SRC and CPHC review pro­ cesses, which were not constructed to evaluate the validity of DSM-IV diagnostic criteria. However, the DSM-5 Task Force, which had reviewed proposed changes and had responsi­ bility for reviewing the text describing each disorder contemporaneously with the work groups during this period, was in a unique position to render an ir\formed judgment on the sci­ entific merits of such revisions. Furthermore, many of these major changes were subject to field trial testing, although comprehensive testing of all proposed changes could not be accommo­ dated by such testing because of time limitations and availability of resources. A final recommendation from the task force was then provided to the APA Board of Trustees and the APA Assembly's Committee on DSM-5 to consider some of the clinical utility and feasibility features of the proposed revisions. The assembly is a deliberative

body of the APA representing the district branches and wider membership that is com­ posed of psychiatrists from throughout the United States who provide geographic, prac­ tice size, and interest-based diversity. The Committee on DSM-5 is a committee made up of a diverse group of assembly leaders. Following all of the preceding review steps, an executive "summit committee" session was held to consolidate input from review and assembly committee chairs, task force chairs, a forensic advisor, and a statistical advisor, for a preliminary review of each disor­ der by the assembly and APA Board of Trustees executive committees. This preceded a preliminary review by the full APA Board of Trustees. The assembly voted, in November 2012, to recommend that the board approve the publication of DSM-5, and the APA Board of Trustees approved its publication in December 2012. The many experts, reviewers, and advisors who contributed to this process are listed in the Appendix.

Organizational Structure The individual disorder definitions that constitute the operationalized sets of diagnostic criteria provide the core of DSM-5 for clinical and research purposes. These criteria have been subjected to scientific review, albeit to varying degrees, and many disorders have un­ dergone field testing for interrater reliability. In contrast, the classification of disorders (the way in which disorders are grouped, which provides a high-level organization for the man­ ual) has not generally been thought of as scientifically significant, despite the fact that judg­ ments had to be made when disorders were initially divided into chapters for DSM-III. DSM is a medical classification of disorders and as such serves as a historically deter­ mined cognitive schema imposed on clinical and scientific information to increase its com­ prehensibility and utility. Not surprisingly, as the foundational science that ultimately led to DSM-III has approached a half-century in age, challenges have begun to emerge for cli­ nicians and scientists alike that are inherent in the DSM structure rather than in the de­ scription of any single disorder. These challenges include high rates of comorbidity within and across DSM chapters, an excessive use of and need to rely on "not otherwise specified" (NOS) criteria, and a growing inability to integrate DSM disorders with the results of ge­ netic studies and other scientific findings. As the APA and the WHO began to plan their respective revisions of the DSM and the International Classification of Disorders (ICD), both considered the possibility of improving clinical utility (e.g., by helping to explain apparent comorbidity) and facilitating scientific investigation by rethinking the organizational structures of both publications in a linear system designated by alphanumeric codes that sequence chapters according to some ra­ tional and relational structure. It was critical to both the DSM-5 Task Force and the WHO International Advisory Group on the revision of the ICD-10 Section on Mental and Behav­ ioral Disorders that the revisions to the organization enhance clinical utility and remain within the bounds of well-replicated scientific information. Although the need for reform seemed apparent, it was important to respect the state of the science as well as the chal­ lenge that overly rapid change would pose for the clinical and research communities. In that spirit, revision of the organization was approached as a conservative, evolutionary di­ agnostic reform that would be guided by emerging scientific evidence on the relationships between disorder groups. By reordering and regrouping the existing disorders, the re­ vised structure is meant to stimulate new clinical perspectives and to encourage research­ ers to identify the psychological and physiological cross-cutting factors that are not bound by strict categorical designations. The use of DSM criteria has the clear virtue of creating a common language for com­ munication between clinicians about the diagnosis of disorders. The official criteria and disorders that were determined to have accepted clinical applicability are located in Sec­ tion II of the manual. However, it should be noted that these diagnostic criteria and their

relationships within the classification are based on current research and may need to be modified as new evidence is gathered by future research both within and across the do­ mains of proposed disorders. "Conditions for Further Study," described in Section III, are those for which we determined that the scientific evidence is not yet available to support widespread clinical use. These diagnostic criteria are included to highlight the evolution and direction of scientific advances in these areas to stimulate further research. With any ongoing review process, especially one of this complexity, different viewpoints emerge, and an effort was made to consider various viewpoints and, when warranted, ac­ commodate them. For example, personality disorders are included in both Sections II and III. Section II represents an update of the text associated with the same criteria found in DSM-IV-TR, whereas Section III includes the proposed research model for personality dis­ order diagnosis and conceptualization developed by the DSM-5 Personality and Personality Disorders Work Group. As this field evolves, it is hoped that both versions will serve clin­ ical practice and research initiatives.

Harmonization With ICD-11 The groups tasked with revising the DSM and ICD systems shared the overarching goal of harmonizing the two classifications as much as possible, for the following reasons: • The existence of two major classifications of mental disorders hinders the collection and use of national health statistics, the design of clinical trials aimed at developing new treatments, and the consideration of global applicability of the results by international regulatory agencies. • More broadly, the existence of two classifications complicates attempts to replicate sci­ entific results across national boundaries. • Even when the intention was to identify identical patient populations, DSM-IV and ICD-10 diagnoses did not always agree. Early in the course of the revisions, it became apparent that a shared organizational structure would help harmonize the classifications. In fact, the use of a shared framework helped to integrate the work of DSM and ICD work groups and to focus on scientific is­ sues. The DSM-5 organization and the proposed linear structure of the ICD-11 have been endorsed by the leadership of the NIMH Research Domain Criteria (RDoC) project as con­ sistent with the initial overall structure of that project. Of course, principled disagreements on the classification of psychopathology and on specific criteria for certain disorders were expected given the current state of scientific knowledge. However, most of the salient differences between the DSM and the ICD classi­ fications do not reflect real scientific differences, but rather represent historical by-products of independent committee processes. To the surprise of participants in both revision processes, large sections of the content fell relatively easily into place, reflecting real strengths in some areas of the scientific lit­ erature, such as epidemiology, analyses of comorbidity, twin studies, and certain other ge­ netically informed designs. When disparities emerged, they almost always reflected the need to make a judgment about where to place a disorder in the face of incomplete—or, more often, conflicting—data. Thus, for example, on the basis of patterns of symptoms, co­ morbidity, and shared risk factors, attention-deficit/hyperactivity disorder (ADHD) was placed with neurodevelopmental disorders, but the same data also supported strong ar­ guments to place ADHD within disruptive, impulse-control, and conduct disorders. These issues were settled with the preponderance of evidence (most notably validators ap­ proved by the DSM-5 Task Force). The work groups recognize, however, that future dis­ coveries might change the placement as well as the contours of individual disorders and, furthermore, that the simple and linear organization that best supports clinical practice

may not fully capture the complexity and heterogeneity of mental disorders. The revised organization is coordinated with the mental and behavioral disorders chapter (Chapter V) of ICD-11, which will utilize an expanded numeric-alphanumeric coding system. How­ ever, the official coding system in use in the United States at the time of publication of this manual is that of the International Classification of Diseases, Ninth Revision, Clinical Modifica­ tion (ICD-9-CM)—the U.S. adaptation of ICD-9. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-IO-CM), adapted from ICD-10, is scheduled for imple­ mentation in the United States in October 2014. Given the impending release of ICD-11, it was decided that this iteration, and not ICD-10, would be the most relevant on which to focus harmonization. However, given that adoption of the ICD-9-CM coding system will remain at the time of the DSM-5 release, it will be necessary to use the ICD-9-CM codes. Further­ more, given that DSM-5's organizational structure reflects the anticipated structure of ICD-11, the eventual ICD-11 codes will follow the sequential order of diagnoses in the DSM-5 chapter structure more closely. At present, both the ICD-9-CM and the ICD-IO-CM codes have been indicated for each disorder. These codes will not be in sequential order throughout the manual because they were assigned to complement earlier organizational structures.

Dimensional Approach to Diagnosis Structural problems rooted in the basic design of the previous DSM classification, con­ structed of a large number of narrow diagnostic categories, have emerged in both clinical practice and research. Relevant evidence comes from diverse sources, including shidies of comorbidity and the substantial need for not otherwise specified diagnoses, which repre­ sent the majority of diagnoses in areas such as eating disorders, personality disorders, and autism spectrum disorder. Studies of both genetic and environmental risk factors, whether based on twin designs, familial transmission, or molecular analyses, also raise concerns about the categorical structure of the DSM system. Because the previous DSM approach considered each diagnosis as categorically separate from health and from other diagnoses, it did not capture the widespread sharing of symptoms and risk factors across many dis­ orders that is apparent in studies of comorbidity. Earlier editions of DSM focused on ex­ cluding false-positive results from diagnoses; thus, its categories were overly narrow, as is apparent from the widespread need to use NOS diagnoses. Indeed, the once plausible goal of identifying homogeneous populations for treatment and research resulted in narrow di­ agnostic categories that did not capture clinical reality, symptom heterogeneity within dis­ orders, and significant sharing of symptoms across multiple disorders. The historical aspiration of achieving diagnostic homogeneity by progressive subtyping within disorder categories no longer is sensible; like most common human ills, mental disorders are het­ erogeneous at many levels, ranging from genetic risk factors to symptoms. Related to recommendations about alterations in the chapter structure of DSM-5, mem­ bers of the diagnostic spectra study group examined whether scientific validators could inform possible new groupings of related disorders within the existing categorical frame­ work. Eleven such indicators were recommended for this purpose: shared neural sub­ strates, family traits, genetic risk factors, specific environmental risk factors, biomarkers, temperamental antecedents, abnormalities of emotional or cognitive processing, symptom similarity, course of illness, high comorbidity, and shared treatment response. These indi­ cators served as empirical guidelines to inform decision making by the work groups and the task force about how to cluster disorders to maximize their validity and clinical utility. A series of papers was developed and published in a prominent international journal (Psychological Medicine, Vol. 39,2009) as part of both the DSM-5 and the ICD-11 develop­ mental processes to document that such validators were most useful for suggesting large groupings of disorders rather than for "validating" individual disorder diagnostic criteria. The regrouping of mental disorders in DSM-5 is intended to enable future research to en-

hance understanding of disease origins and pathophysiological commonalities between disorders and provide a base for future replication wherein data can be reanalyzed over time to continually assess validity. Ongoing revisions of DSM-5 will make it a ''living doc­ ument," adaptable to future discoveries in neurobiology, genetics, and epidemiology. On the basis of the published findings of this common DSM-5 and ICD-11 analysis, it was demonstrated that clustering of disorders according to what has been termed internal­ izing and externalizing factors represents an empirically supported framework. Within both the internalizing group (representing disorders with prominent anxiety, depressive, and somatic symptoms) and the externalizing group (representing disorders with prominent impulsive, disruptive conduct, and substance use symptoms), the sharing of genetic and environmental risk factors, as shown by twin studies, likely explains much of the system­ atic comorbidities seen in both clinical and community samples. The adjacent placement of "internalizing disorders," characterized by depressed mood, anxiety, and related physio­ logical and cognitive symptoms, should aid in developing new diagnostic approaches, in­ cluding dimensional approaches, while facilitating the identification of biological markers. Similarly, adjacencies of the "externalizing group," including disorders exhibiting antiso­ cial behaviors, conduct disturbances, addictions, and impulse-control disorders, should en­ courage advances in identifying diagnoses, markers, and underlying mechanisms. Despite the problem posed by categorical diagnoses, the DSM-5 Task Force recognized that it is premature scientifically to propose alternative definitions for most disorders. The organizational structure is meant to serve as a bridge to new diagnostic approaches with­ out disrupting current clinical practice or research. With support from DSM-associated training materials, the National Institutes of Health other funding agencies, and scientific publications, the more dimensional DSM-5 approach and organizational structure can fa­ cilitate research across current diagnostic categories by encouraging broad investigations within the proposed chapters and across adjacent chapters. Such a reformulation of re­ search goals should also keep DSM-5 central to the development of dimensional approaches to diagnosis that will likely supplement or supersede current categorical approaches in coming years.

Developmental and Lifespan Considerations To improve clinical utility, DSM-5 is organized on developmental and lifespan consider­ ations. It begins with diagnoses thought to reflect developmental processes that manifest early in life (e.g., neurodevelopmental and schizophrenia spectrum and other psychotic disorders), followed by diagnoses that more commonly manifest in adolescence and young adulthood (e.g., bipolar, depressive, and anxiety disorders), and ends with diagno­ ses relevant to adulthood and later life (e.g., neurocognitive disorders). A similar approach has been taken, where possible, within each chapter. This organizational structure facili­ tates the comprehensive use of lifespan information as a way to assist in diagnostic deci­ sion making. The proposed organization of chapters of DSM-5, after the neurodevelopmental disor­ ders, is based on groups of internalizing (emotional and somatic) disorders, externalizing disorders, neurocognitive disorders, and other disorders. It is hoped that this organization will encourage further study of underlying pathophysiological processes that give rise to diagnostic comorbidity and symptom heterogeneity. Furthermore, by arranging disorder clusters to mirror clinical reality, DSM-5 should facilitate identification of potential diag­ noses by non-mental health specialists, such as primary care physicians. The organizational structure of DSM-5, along with ICD harmonization, is designed to provide better and more flexible diagnostic concepts for the next epoch of research and to serve as a useful guide to clinicians in explaining to patients why they might have received multiple diagnoses or why they might have received additional or altered diagnoses over their lifespan.

Cultural Issues Mental disorders are defined in relation to cultural, social, and familial norms and values. Culture provides interpretive frameworks that shape the experience and expression of the symptoms, signs, and behaviors that are criteria for diagnosis. Culture is transmitted, re­ vised, and recreated within the family and other social systems and institutions. Diagnostic assessment must therefore consider whether an individual's experiences, symptoms, and behaviors differ from sociocultural norms and lead to difficulties in adaptation in the cul­ tures of origin and in specific social or familial contexts. Key aspects of culture relevant to di­ agnostic classification and assessment have been considered in the development of DSM-5. In Section III, the "Cultural Formulation" contains a detailed discussion of culture and diagnosis in DSM-5, including tools for in-depth cultural assessment. In the Appendix, the "Glossary of Cultural Concepts of Distress" provides a description of some common cul­ tural syndromes, idioms of distress, and causal explanations relevant to clinical practice. The boundaries between normality and pathology vary across cultures for specific types of behaviors. Thresholds of tolerance for specific symptoms or behaviors differ across cul­ tures, social settings, and families. Hence, the level at which an experience becomes prob­ lematic or pathological will differ. The judgment that a given behavior is abnormal and requires clinical attention depends on cultural norms that are internalized by the individual and applied by others around them, including family members and clinicians. Awareness of the significance of culture may correct mistaken interpretations of psychopathology, but cul­ ture may also contribute to vulnerability and suffering (e.g., by amplifying fears that main­ tain panic disorder or health anxiety). Cultural meanings, habits, and traditions can also contribute to either stigma or support in the social and familial response to mental illness. Culture may provide coping strategies that enhance resilience in response to illness, or sug­ gest help seeking and options for accessing health care of various types, including alterna­ tive and complementary health systems. Culture may influence acceptance or rejection of a diagnosis and adherence to treatments, affecting the course of illness and recovery. Culture also affects the conduct of the clinical encounter; as a result, cultural differences between the clinician and the patient have implications for the accuracy and acceptance of diagnosis as well as for treatment decisions, prognostic considerations, and clinical outcomes. Historically, the construct of the culture-bound syndrome has been a key interest of cultural psychiatry. In DSM-5, this construct has been replaced by three concepts that offer greater clinical utility: 1. Cultural syndrome is a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context (e.g., ataque de nervios). The syndrome may or may not be recognized as an illness within the culture (e.g., it might be labeled in various ways), but such cultural patterns of distress and features of illness may nevertheless be recognizable by an outside observer. 2. Cultural idiom of distress is a linguistic term, phrase, or way of talking about suffering among individuals of a cultural group (e.g., similar ethnicity and religion) referring to shared concepts of pathology and ways of expressing, communicating, or naming es­ sential features of distress (e.g., kufiingisisa). An idiom of distress need not be associated with specific symptoms, syndromes, or perceived causes. It may be used to convey a wide range of discomfort, including everyday experiences, subclinical conditions, or suffering due to social circumstances rather than mental disorders. For example, most cultures have common bodily idioms of distress used to express a wide range of suf­ fering and concerns. 3. Cultural explanation or perceived cause is a label, attribution, or feature of an explanatory model that provides a culturally conceived etiology or cause for symptoms, illness, or distress (e.g., maladi moun). Causal explanations may be salient features of folk classi­ fications of disease used by laypersons or healers.

These three concepts (for which discussion and examples are provided in Section III and the Appenc^ix) suggest cultural ways of understanding and describing illness experi­ ences that can be elicited in the clinical encounter. They influence symptomatology, help seeking, clinical presentations, expectations of treatment, illness adaptation, and treat­ ment response. The same cultural term often serves more than one of these functions.

Gender Differences Sex and gender differences as they relate to the causes and expression of medical conditions are established for a number of diseases, including selected mental disorders. Revisions to DSM-5 included review of potential differences between men and women in the expression of mental illness. In terms of nomenclature, sex differences are variations attributable to an individual's reproductive organs and XX or XY chromosomal complement. Gender differ­ ences are variations that result from biological sex as well as an individual's self-represen­ tation that includes the psychological, behavioral, and social consequences of one's perceived gender. The term gender differences is used in DSM-5 because, more commonly, the differences between men and women are a result of both biological sex and individual self-representation. However, some of the differences are based on only biological sex. Gender can influence illness in a variety of ways. First, it may exclusively determine whether an individual is at risk for a disorder (e.g., as in premenstrual dysphoric disor­ der). Second, gender may moderate the overall risk for development of a disorder as shown by marked gender differences in the prevalence and incidence rates for selected mental disorders. Third, gender may influence the likelihood that particular symptoms of a disorder are experienced by an individual. Attention-deficit/hyper activity disorder is an example of a disorder with differences in presentation that are most commonly expe­ rienced by boys or girls. Gender likely has other effects on the experience of a disorder that are indirectly relevant to psychiatric diagnosis. It may be that certain symptoms are more readily endorsed by men or women, and that this contributes to differences in service pro­ vision (e.g., women may be more likely to recognize a depressive, bipolar, or anxiety dis­ order and endorse a more comprehensive list of symptoms than men). Reproductive life cycle events, including estrogen variations, also contribute to gender differences in risk and expression of illness. Thus, a specifier for postpartum onset of mania or major depressive episode denotes a time frame wherein women may be at increased risk for the onset of an illness episode. In the case of sleep and energy, alterations are often nor­ mative postpartum and thus may have lower diagnostic reliability in postpartum women. The manual is configured to include information on gender at multiple levels. If there are gender-specific symptoms, they have been added to the diagnostic criteria. A genderrelated specifier, such as perinatal onset of a mood episode, provides additional informa­ tion on gender and diagnosis. Finally, other issues that are pertinent to diagnosis and gen­ der considerations can be found in the section "Gender-Related Diagnostic Issues."

Use of Other Specified and Unspecified Disorders To enhance diagnostic specificity, DSM-5 replaces the previous NOS designation with two options for clinical use: other specified disorder and unspecified disorder. The other specified disorder category is provided to allow the clinician to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnos­ tic class. This is done by recording the name of the category, followed by the specific rea­ son. For example, for an individual with clinically significant depressive symptoms lasting 4 weeks but whose symptomatology falls short of the diagnostic threshold for a major depressive episode, the clinician would record "other specified depressive disorder, depressive episode with insufficient symptoms." If the clinician chooses not to specify the

reason that the criteria are not met for a specific disorder, then "unspecified depressive disorder" would be diagnosed. Note that the differentiation between other specified and unspecified disorders is based on the clinician's decision, providing maximum flexibility for diagnosis. Clinicians do not have to differentiate between other specified and unspec­ ified disorders based on some feature of the presentation itself. When the clinician deter­ mines that there is evidence to specify the nature of the clinical presentation, the other specified diagnosis can be given. When the clinician is not able to further specify and de­ scribe the clinical presentation, the unspecified diagnosis can be given. This is left entirely up to clinical judgment. For a more detailed discussion of how to use other specified and unspecified designa­ tions, see "Use of the Manual" in Section I.

The Multiaxial System Despite widespread use and its adoption by certain insurance and governmental agencies, the multiaxial system in DSM-IV was not required to make a mental disorder diagnosis. A nonaxial assessment system was also included that simply listed the appropriate Axis I, II, and III disorders and conditions without axial designations. DSM-5 has moved to a nonax­ ial documentation of diagnosis (formerly Axes I, II, and III), with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V). This revision is consistent with the DSM-IV text that states, "The multiaxial dis­ tinction among Axis I, Axis II, and Axis III disorders does not imply that there are funda­ mental differences in their conceptualization, that mental disorders are unrelated to physical or biological factors or processes, or that general medical conditions are unrelated to behavioral or psychosocial factors or processes." The approach of separately noting di­ agnosis from psychosocial and contextual factors is also consistent with established WHO and ICD guidance to consider the individual's functional status separately from his or her diagnoses or symptom status. In DSM-5, Axis III has been combined with Axes I and II. Clinicians should continue to list medical conditions that are important to the understand­ ing or management of an individual's mental disorder(s). DSM-IV Axis IV covered psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders. Although this axis provided helpful information, even if it was not used as frequently as intended, the DSM-5 Task Force recommended that DSM-5 should not develop its own classification of psychosocial and environmental problems, but rather use a selected set of the ICD-9-CM V codes and the new Z codes contained in ICD-IO-CM. The ICD-10 Z codes were examined to deter­ mine which are most relevant to mental disorders and also to identify gaps. DSM-IV Axis V consisted of the Global Assessment of Functioning (GAF) scale, repre­ senting the clinician's judgment of the individual's overall level of "functioning on a hy­ pothetical continuum of mental health-illness." It was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., in­ cluding symptoms, suicide risk, and disabilities in its descriptors) and questionable psy­ chometrics in routine practice. In order to provide a global measure of disability, the WHO Disability Assessment Schedule (WHODAS) is included, for further study, in Action III of DSM-5 (see the chapter "Assessment Measures"). The WHODAS is based on the Interna­ tional Classification of Functioning, Disability and Health (ICF) for use across all of medicine and health care. The WHODAS (version 2.0), and a modification developed for children/ adolescents and their parents by the Impairment and Disability Study Group were in­ cluded in the DSM-5 field trial.

Online Enhancements It was challenging to determine what to include in the print version of DSM-5 to be most clinically relevant and useful and at the same time maintain a manageable size. For this reason, the inclusion of clinical rating scales and measures in the print edition is limited to those considered most relevant. Additional assessment measures used in the field trials are available online (www.psychiatry.org/dsm5), linked to the relevant disorders. The Cultural Formulation Interview, Cultural Formulation Interview—Informant Version, and supplementary modules to the core Cultural Formulation Interview are also available on­ line at www.psychiatry.org/dsm5. DSM-5 is available as an online subscription at PsychiatryOnline.org as well as an e­ book. The online component contains modules and assessment tools to enhance the diag­ nostic criteria and text. Also available online is a complete set of supportive references as well as additional helpful information. The organizational structure of DSM-5, its use of dimensional measures, and compatibility with ICD codes will allow it to be readily adapt­ able to future scientific discoveries and refinements in its clinical utility. DSM-5 will be an­ alyzed over time to continually assess its validity and enhance its value to clinicians.

Use of the Manual T h e in t r o d u c t io n contains much of the history and developmental process of the DSM-5 revision. This section is designed to provide a practical guide to using DSM-5, par­ ticularly in clinical practice. The primary purpose of DSM-5 is to assist trained clinicians in the diagnosis of their patients' mental disorders as part of a case formulation assess­ ment that leads to a fully informed treatment plan for each individual. The symptoms con­ tained in the respective diagnostic criteria sets do not constitute comprehensive definitions of underlying disorders, which encompass cognitive, emotional, behavioral, and physiological processes that are far more complex than can be described in these brief summaries. Rather, they are intended to summarize characteristic syndromes of signs and symptoms that point to an underlying disorder with a characteristic developmental his­ tory, biological and environmental risk factors, neuropsychological and physiological cor­ relates, and typical clinical course.

Approach to Clinical Case Formulation The case formulation for any given patient must involve a careful clinical history and con­ cise summary of the social, psychological, and biological factors that may have contrib­ uted to developing a given mental disorder. Hence, it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis. Although a systematic check for the presence of these criteria as they apply to each patient will assure a more reliable assessment, the relative severity and valence of individual criteria and their contribution to a diagnosis require clinical judgment. The symptoms in our diagnos­ tic criteria are part of the relatively limited repertoire of human emotional responses to in­ ternal and external stresses that are generally maintained in a homeostatic balance without a disruption in normal functioning. It requires clinical training to recognize when the com­ bination of predisposing, precipitating, perpetuating, and protective factors has resulted in a psychopathological condition in which physical signs and symptoms exceed normal ranges. The ultimate goal of a clinical case formulation is to use the available contextual and diagnostic information in developing a comprehensive treatment plan that is in­ formed by the individual's cultural and social context. However, recommendations for the selection and use of the most appropriate evidence-based treatment options for each dis­ order are beyond the scope of this manual. Although decades of scientific effort have gone into developing the diagnostic criteria sets for the disorders included in Section II, it is well recognized that this set of categorical diagnoses does not fully describe the full range of mental disorders that individuals ex­ perience and present to clinicians on a daily basis throughout the world. As noted previ­ ously in the introduction, the range of genetic/environmental interactions over the course of human development affecting cognitive, emotional and behavioral function is virtually limitless. As a result, it is impossible to capture the full range of psychopathology in the categorical diagnostic categories that we are now using. Hence, it is also necessary to in­ clude "other specified/unspecified" disorder options for presentations that do not fit exactly into the diagnostic boundaries of disorders in each chapter. In an emergency de­ partment setting, it may be possible to identify only the most prominent symptom ex­ pressions associated with a particular chapter—for example, delusions, hallucinations.

mania, depression, anxiety, substance intoxication, or neurocognitive symptoms—so that an "unspecified" disorder in that category is identified until a fuller differential diagnosis is possible.

Definition of a Mental Disorder Each disorder identified in Section II of the manual (excluding those in the chapters enti­ tled "Medication-Induced Movement Disorders and Other Adverse Effects of Medica­ tion" and "Other Conditions That May Be a Focus of Clinical Attention") must meet the definition of a mental disorder. Although no definition can capture all aspects of all dis­ orders in the range contained in DSM-5, the following elements are required: A mental disorder is a syndrome characterized by clinically significant distur­ bance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes un­ derlying mental functioning. Mental disorders are usually associated with signif­ icant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant be­ havior (e.g., political, religious, or sexual) and conflicts that are primarily be­ tween the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. The diagnosis of a mental disorder should have clinical utility: it should help clinicians to determine prognosis, treatment plans, and potential treatment outcomes for their pa­ tients. However, the diagnosis of a mental disorder is not equivalent to a need for treat­ ment. Need for treatment is a complex clinical decision that takes into consideration symptom severity, symptom salience (e.g., the presence of suicidal ideation), the patient's distress (mental pain) associated with the symptom(s), disability related to the patient's symptoms, risks and benefits of available treatments, and other factors (e.g., psychiatric symptoms complicating other illness). Clinicians may thus encounter individuals whose symptoms do not meet full criteria for a mental disorder but who demonstrate a clear need for treatment or care. The fact that some individuals do not show all symptoms indicative of a diagnosis should not be used to justify limiting their access to appropriate care. Approaches to validating diagnostic criteria for discrete categorical mental disorders have included the following types of evidence: antecedent validators (similar genetic mark­ ers, family traits, temperament, and environmental exposure), concurrent validators (simi­ lar neural substrates, biomarkers, emotional and cognitive processing, and symptom similarity), and predictive validators (similar clinical course and treatment response). In DSM-5, we recognize that the current diagnostic criteria for any single disorder will not nec­ essarily identify a homogeneous group of patients who can be characterized reliably with all of these validators. Available evidence shows that these validators cross existing diagnostic boundaries but tend to congregate more frequently within and across adjacent DSM-5 chap­ ter groups. Until incontrovertible etiological or pathophysiological mechanisms are identi­ fied to fully validate specific disorders or disorder spectra, the most important standard for the DSM-5 disorder criteria will be their clinical utility for the assessment of clinical course and treatment response of individuals grouped by a given set of diagnostic criteria. This definition of mental disorder was developed for clinical, public health, and re­ search purposes. Additional information is usually required beyond that contained in the DSM-5 diagnostic criteria in order to make legal judgments on such issues as criminal re­ sponsibility, eligibility for disability compensation, and competency (see "Cautionary Statement for Forensic Use of DSM-5" elsewhere in this manual).

Criterion for Ciinical Significance There have beeh substantial efforts by the DSM-5 Task Force and the World Health Orga­ nization (WHO) to separate the concepts of mental disorder and disability (impairment in social, occupational, or other important areas of functioning). In the WHO system, the In­ ternational Classification of Diseases (ICD) covers all diseases and disorders, while the In­ ternational Classification of Functioning, Disability and Health (ICF) provides a separate classification of global disability. The WHO Disability Assessment Schedule (WHODAS) is based on the ICF and has proven useful as a standardized measure of disability for men­ tal disorders. However, in the absence of clear biological markers or clinically useful mea­ surements of severity for many mental disorders, it has not been possible to completely separate normal and pathological symptom expressions contained in diagnostic criteria. This gap in information is particularly problematic in clinical situations in which the pa­ tient's symptom presentation by itself (particularly in mild forms) is not inherently path­ ological and may be encountered in individuals for whom a diagnosis of "mental disorder" would be inappropriate. Therefore, a generic diagnostic criterion requiring dis­ tress or disability has been used to establish disorder thresholds, usually worded "the dis­ turbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning." The text following the revised definition of a mental disorder acknowledges that this criterion may be especially helpful in determining a pa­ tient's need for treatment. Use of information from family members and other third parties (in addition to the individual) regarding the individual's performance is recommended when necessary.

Elements of a Diagnosis Diagnostic Criteria and Descriptors Diagnostic criteria are offered as guidelines for making diagnoses, and their use should be informed by clinical judgment. Text descriptions, including introductory sections of each diagnostic chapter, can help support diagnosis (e.g., providing differential diagnoses; de­ scribing the criteria more fully under "Diagnostic Features"). Following the assessment of diagnostic criteria, clinicians should consider the applica­ tion of disorder subtypes and/or specifiers as appropriate. Severity and course specifiers should be applied to denote the individual's current presentation, but only when the full criteria are met. When full criteria are not met, clinicians should consider whether the symptom presentation meets criteria for an "other specified" or "unspecified" designa­ tion. Where applicable, specific criteria for defining disorder severity (e.g., mild, moder­ ate, severe, extreme), descriptive features (e.g., with good to fair insight; in a controlled environment), and course (e.g., in partial remission, in full remission, recurrent) are pro­ vided with each diagnosis. On the basis of the clinical interview, text descriptions, criteria, and clinician judgment, a final diagnosis is made. The general convention in DSM-5 is to allow multiple diagnoses to be assigned for those presentations that meet criteria for more than one DSM-5 disorder.

Subtypes and Specifiers Subtypes and specifiers (some of which are coded in the fourth, fifth, or sixth digit) are provided for increased specificity. Subtypes define mutually exclusive and jointly exhaus­ tive phenomenological subgroupings within a diagnosis and are indicated by the instruc­ tion "Specify whether" in the criteria set. In contrast, specifiers are not intended to be mutually exclusive or jointly exhaustive, and as a consequence, more than one specifier may be given. Specifiers are indicated by the instruction "Specify" or "Specify if" in the cri­ teria set. Specifiers provide an opportunity to define a more homogeneous subgrouping of

individuals with the disorder who share certain features (e.g., major depressive disorder, with mixed features) and to convey information that is relevant to the management of the individual's disorder, such as the "with other medical comorbidity" specifier in sleepwake disorders. Although a fifth digit is sometimes assigned to code a subtype or specifier (e.g., 294.11 [F02.81] major neurocognitive disorder due to Alzheimer's disease, with be­ havioral disturbance) or severity (296.21 [F32.0] major depressive disorder, single episode, mild), the majority of subtypes and specifiers included in DSM-5 cannot be coded within the ICD-9-CM and ICD-IO-CM systems and are indicated only by including the subtype or specifier after the name of the disorder (e.g., social anxiety disorder [social phobia], per­ formance type). Note that in some cases, a specifier or subtype is codable in ICD-IO-CM but not in ICD-9-CM. Accordingly, in some cases the 4th or 5th character codes for the sub­ types or specifiers are provided only for the ICD-IO-CM coding designations. A DSM-5 diagnosis is usually applied to the individual's current presentation; previ­ ous diagnoses from which the individual has recovered should be clearly noted as such. Specifiers indicating course (e.g., in partial remission, in full remission) may be listed after the diagnosis and are indicated in a number of criteria sets. Where available, severity spec­ ifiers are provided to guide clinicians in rating the intensity, frequency, duration, symptom count, or other severity indicator of a disorder. Severity specifiers are indicated by the in­ struction "Specify current severity" in the criteria set and include disorder-specific defini­ tions. Descriptive features specifiers have also been provided in the criteria set and convey additional information that can inform treatment planning (e.g., obsessive-compulsive disorder, with poor insight). Not all disorders include course, severity, and/or descriptive features specifiers.

Medication-Induced iVlovement Disorders and Other Conditions That iViay Be a Focus of Ciinicai Attention In addition to important psychosocial and environmental factors (see "The Multiaxial Sys­ tem" in the "Introduction" elsewhere in this manual), these chapters in Section II also con­ tain other conditions that are not mental disorders but may be encountered by mental health clinicians. These conditions may be listed as a reason for clinical visit in addition to, or in place of, the mental disorders listed in Section II. A separate chapter is devoted to medication-induced disorders and other adverse effects of medication that may be as­ sessed and treated by clinicians in mental health practice such as akathisia, tardive dyski­ nesia, and dystonia. The description of neuroleptic malignant syndrome is expanded from that provided in DSM-IV-TR to highlight the emergent and potentially life-threatening na­ ture of this condition, and a new entry on antidepressant discontinuation syndrome is pro­ vided. An additional chapter discusses other conditions that may be a focus of clinical attention. These include relational problems, problems related to abuse and neglect, prob­ lems with adherence to treatment regimens, obesity, antisocial behavior, and malingering.

Principal Diagnosis When more than one diagnosis for an individual is given in an inpatient setting, the prin­ cipal diagnosis is the condition established after study to be chiefly responsible for occa­ sioning the admission of the individual. When more than one diagnosis is given for an individual in an outpatient setting, the reason for visit is the condition that is chiefly re­ sponsible for the ambulatory care medical services received during the visit. In most cases, the principal diagnosis or the reason for visit is also the main focus of attention or treat­ ment. It is often difficult (and somewhat arbitrary) to determine which diagnosis is the principal diagnosis or the reason for visit, especially when, for example, a substancerelated diagnosis such as alcohol use disorder is accompanied by a non-substance-related diagnosis such as schizophrenia. For example, it may be unclear which diagnosis should

be considered "principal" for an individual hospitalized with both schizophrenia and al­ cohol use disorder, because each condition may have contributed equally to the need for admission and treatment. The principal diagnosis is indicated by listing it first, and the re­ maining disorders are listed in order of focus of attention and treatment. When the prin­ cipal diagnosis or reason for visit is a mental disorder due to another medical condition (e.g., major neurocognitive disorder due to Alzheimer's disease, psychotic disorder due to malignant lung neoplasm), ICD coding rules require that the etiological medical condition be listed first. In that case, the principal diagnosis or reason for visit would be the mental disorder due to the medical condition, the second listed diagnosis. In most cases, the dis­ order listed as the principal diagnosis or the reason for visit is followed by the qualifying phrase "(principal diagnosis)" or "(reason for visit)."

Provisional Diagnosis The specifier "provisional" can be used when there is a strong presumption that the full criteria will ultimately be met for a disorder but not enough information is available to make a firm diagnosis. The clinician can indicate the diagnostic uncertainty by recording "(provisional)" following the diagnosis. For example, this diagnosis might be used when an individual who appears to have a major depressive disorder is unable to give an ade­ quate history, and thus it cannot be established that the full criteria are met. Another use of the term provisional is for those situations in which differential diagnosis depends exclu­ sively on the duration of illness. For example, a diagnosis of schizophreniform disorder re­ quires a duration of less than 6 months but of at least 1 month and can only be given provisionally if assigned before remission has occurred.

Coding and Reporting Procedures Each disorder is accompanied by an identifying diagnostic and statistical code, which is typically used by institutions and agencies for data collection and billing purposes. There are specific recording protocols for these diagnostic codes (identified as coding notes in the text) that were established by WHO, the U.S. Centers for Medicare and Medicaid Ser­ vices (CMS), and the Centers for Disease Control and Prevention's National Center for Health Statistics to ensure consistent international recording of prevalence and mortality rates for identified health conditions. For most clinicians, the codes are used to identify the diagnosis or reason for visit for CMS and private insurance service claims. The official coding system in use in the United States as of publication of this manual is ICD-9-CM. Of­ ficial adoption of ICD-IO-CM is scheduled to take place on October 1, 2014, and these codes, which are shown parenthetically in this manual, should not be used until the offi­ cial implementation occurs. Both ICD-9-CM and ICD-IO-CM codes have been listed 1) pre­ ceding the name of the disorder in the classification and 2) accompanying the criteria set for each disorder. For some diagnoses (e.g., neurocognitive and substance/medicationinduced disorders), the appropriate code depends on further specification and is listed within the criteria set for the disorder, as coding notes, and, in some cases, further clarified in a section on recording procedures. The names of some disorders are followed by alter­ native terms enclosed in parentheses, which, in most cases, were the DSM-IV names for the disorders.

Looking to the Future: Assessment and Monitoring Tools The various components of DSM-5 are provided to facilitate patient assessment and to aid in developing a comprehensive case formulation. Whereas the diagnostic criteria in Sec­ tion II are well-established measures that have undergone extensive review, the assess-

ment tools, a cultural formulation interview, and conditions for further study included in Section III are those for which we determined that the scientific evidence is not yet avail­ able to support widespread clinical use. These diagnostic aids and criteria are included to highlight the evolution and direction of scientific advances in these areas and to stimulate further research. Each of the measures in Section III is provided to aid in a comprehensive assessment of individuals that will contribute to a diagnosis and treatment plan tailored to the individ­ ual presentation and clinical context. Where cultural dynamics are particularly important for diagnostic assessment, the cultural formulation interview should be considered as a useful aid to communication with the individual. Cross-cutting symptom and diagnosisspecific severity measures provide quantitative ratings of important clinical areas that are designed to be used at the initial evaluation to establish a baseline for comparison with rat­ ings on subsequent encounters to monitor changes and inform treatment planning. The use of such measures will undoubtedly be facilitated by digital apphcations, and the measures are included in Section III to provide for further evaluation and develop­ ment. As with each DSM edition, the diagnostic criteria and the DSM-5 classification of mental disorders reflect the current consensus on the evolving knowledge in our field.

Cautionary Statement for Forensic Use of DSiVi-5 A lt h o u g h t h e D S M - 5 diagnostic criteria and text are primarily designed to assist clinicians in conducting clinical assessment, case formulation, and treatment planning, DSM-5 is also used as a reference for the courts and attorneys in assessing the forensic con­ sequences of mental disorders. As a result, it is important to note that the definition of mental disorder included in DSM-5 was developed to meet the needs of clinicians, public health professionals, and research investigators rather than all of the technical needs of the courts and legal professionals. It is also important to note that DSM-5 does not provide treatment guidelines for any given disorder. When used appropriately, diagnoses and diagnostic information can assist legal deci­ sion makers in their determinations. For example, when the presence of a mental disorder is the predicate for a subsequent legal determination (e.g., involuntary civil commitment), the use of an established system of diagnosis enhances the value and reliability of the de­ termination. By providing a compendium based on a review of the pertinent clinical and research literature, DSM-5 may facilitate legal decision makers' understanding of the rel­ evant characteristics of mental disorders. The literature related to diagnoses also serves as a check on ungrounded speculation about mental disorders and about the functioning of a particular individual. Finally, diagnostic information about longitudinal course may im­ prove decision making when the legal issue concerns an individual's mental functioning at a past or future point in time. However, the use of DSM-5 should be informed by an awareness of the risks and lim­ itations of its use in forensic settings. When DSM-5 categories, criteria, and textual descrip­ tions are employed for forensic purposes, there is a risk that diagnostic information will be misused or misunderstood. These dangers arise because of the imperfect fit between the questions of ultimate concern to the law and the information contained in a clinical diagno­ sis. In most situations, the clinical diagnosis of a DSM-5 mental disorder such as intellec­ tual disability (intellectual developmental disorder), schizophrenia, major neurocognitive disorder, gambling disorder, or pedophilic disorder does not imply that an individual with such a condition meets legal criteria for the presence of a mental disorder or a speci­ fied legal standard (e.g., for competence, criminal responsibility, or disability). For the latter, additional information is usually required beyond that contained in the DSM-5 diagnosis, which might include information about the individual's functional impairments and how these impairments affect the particular abilities in question. It is precisely because impair­ ments, abilities, and disabilities vary widely within each diagnostic category that assign­ ment of a particular diagnosis does not imply a specific level of impairment or disability. Use of DSM-5 to assess for the presence of a mental disorder by nonclinical, nonmed­ ical, or otherwise insufficiently trained individuals is not advised. Nonclinical decision makers should also be cautioned that a diagnosis does not carry any necessary implica­ tions regarding the etiology or causes of the individual's mental disorder or the individ­ ual's degree of control over behaviors that may be associated with the disorder. Even when diminished control over one's behavior is a feature of the disorder, having the diag­ nosis in itself does not demonstrate that a particular individual is (or was) unable to con­ trol his or her behavior at a particular time.

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Diagnostic '

Neurodevelopmental Disorders................................................................ 31 Schizophrenia Spectrum and Other Psychotic Disorders...................... 87 Bipolar and Related Disorders................................................................ 123 Depressive Disorders.............................................................................. 155 Anxiety Disorders.................................................................................... 189 Obsessive-Compulsive and Related Disorders...................................... 235 Trauma- and Stressor-Related Disorders.............................................. 265 Dissociative Disorders............................................................................ 291 Somatic Symptom and Related Disorders............................................ 309 Feeding and Eating Disorders................................................................ 329 Elimination Disorders.............................................................................. 355 Sleep-Wake Disorders............................................................................ 361 Sexual Dysfunctions................................................................................ 423 Gender Dysphoria.................................................................................... 451 Disruptive, Impulse-Control, and Conduct Disorders............................ 461 Substance-Related and Addictive Disorders........................................ 481 Neurocognitive Disorders........................................................................ 591 Personality Disorders.............................................................................. 645 Paraphilic Disorders................................................................................ 685 Other Mental Disorders.......................................................................... 707 Medication-Induced Movement Disorders and Other Adverse Effects of Medication.................................................. 709 Other Conditions That May Be a Focus of Clinical Attention................ 715

I his s e c tio n contains the diagnostic criteria approved for routine clinical use along with the ICD-9-CM codes (ICD-10 codes are shown parenthetically). For each mental disorder, the diagnostic criteria are followed by descriptive text to assist in diagnostic decision making. Where needed, specific recording procedures are presented with the diagnostic criteria to provide guidance in selecting the most appropriate code. In some cases, separate recording pro­ cedures for ICD-9-CM and ICD-10-CM are provided. Although not considered as official DSM-5 disorders, medication-induced movement disorders and other adverse effects of medication, as well as other conditions that may be a focus of clinical attention (including additional ICD-9-CM V codes and forthcoming ICD-10-CM Z codes), are provided to indicate other reasons for a clinical visit such as environmental factors and relational problems. These codes are adapted from ICD-9-CM and 1CD-10-CM and were neither reviewed nor approved as official DSM-5 diagnoses, but can provide additional context for a clinical for­ mulation and treatment plan. These three components—^the criteria and their descriptive text, the medication-induced movement disorders and other ad­ verse effects of medication, and the descriptions of other conditions that may be a focus of clinical attention—represent the key elements of the clinical di­ agnostic process and thus are presented together.

ΤΙί Θ Π θυΓΟ όθνθΙορΓΠ Θ Π ΐά Ι disorders are a group of conditions with onset in the developmental period. The disorders typically manifest early in development, often be­ fore the child enters grade school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning. The range of developmental deficits varies from very specific limitations of learning or control of executive functions to global impairments of social skills or intelligence. The neurodevelopmental disorders frequently co-occur; for example, individuals with autism spec­ trum disorder often have intellectual disability (intellectual developmental disorder), and many children with attention-deficit/hyperactivity disorder (ADHD) also have a specific learning disorder. For some disorders, the clinical presentation includes symptoms of ex­ cess as well as deficits and delays in achieving expected milestones. For example, autism spectrum disorder is diagnosed only when the characteristic deficits of social communi­ cation are accompanied by excessively repetitive behaviors, restricted interests, and insis­ tence on sameness. Intellectual disability (intellectual developmental disorder) is characterized by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience. The deficits result in impair­ ments of adaptive functioning, such that the individual fails to meet standards of personal independence and social responsibility in one or more aspects of daily life, including commimication, social participation, academic or occupational functioning, and personal inde­ pendence at home or in community settings. Global developmental delay, as its name implies, is diagnosed when an individual fails to meet expected developmental milestones in several areas of intellectual functioning. The diagnosis is used for individuals who are imable to undergo systematic assessments of intellectual functioning, including children who are too young to participate in standardized testing. Intellectual disability may result from an acquired insult during the developmental period from, for example, a severe head injury, in which case a neurocognitive disorder also may be diagnosed. Tlie communication disorders include language disorder, speech sound disorder, so­ cial (pragmatic) communication disorder, and childhood-onset fluency disorder (stutter­ ing). The first three disorders are characterized by deficits in the development and use of language, speech, and social communication, respectively. Childhood-onset fluency dis­ order is characterized by disturbances of the normal fluency and motor production of speech, including repetitive sounds or syllables, prolongation of consonants or vowel sounds, broken words, blocking, or words produced with an excess of physical tension. Like other neurodevelopmental disorders, communication disorders begin early in life and may produce lifelong functional impairments. Autism spectrum disorder is characterized by persistent deficits in social communica­ tion and social interaction across multiple contexts, including deficits in social reciprocity, nonverbal communicative behaviors used for social interaction, and skills in developing, maintaining, and understanding relationships. In addition to the social communication deficits, the diagnosis of autism spectrum disorder requires the presence of restricted, re­ petitive patterns of behavior, interests, or activities. Because symptoms change with de­ velopment and may be masked by compensatory mechanisms, the diagnostic criteria may

be met based on historical information, although the current presentation must cause sig­ nificant impairment. Within the diagnosis of autism spectrum disorder, individual clinical characteristics are noted through the use of specifiers (with or without accompanying intellectual impair­ ment; with or without accompanying structural language impairment; associated with a known medical/genetic or environmental/acquired condition; associated with another neurodevelopmental, mental, or behavioral disorder), as well as specifiers that describe the autistic symptoms (age at first concern; with or without loss of established skills; sever­ ity). These specifiers provide clinicians with an opportunity to individualize the diagnosis and communicate a richer clinical description of the affected individuals. For example, many individuals previously diagnosed with Asperger's disorder would now receive a diagnosis of autism spectrum disorder without language or intellectual impairment. ADHD is a neurodevelopmental disorder defined by impairing levels of inattention, dis­ organization, and/or hyperactivity-impulsivity. Inattention and disorganization entail inabil­ ity to stay on task, seeming not to listen, and losing materials, at levels that are inconsistent with age or developmental level. Hyperactivity-impulsivity entails overactivity, fidgeting, in­ ability to stay seated, intruding into other people's activities, and inability to wait—symptoms that are excessive for age or developmental level. In childhood, ADHD frequently overlaps with disorders that are often considered to be "externalizing disorders," such as oppositional defiant disorder and conduct disorder. ADHD often persists into adulthood, witii resultant impairments of social, academic and occupational functioning. The neurodevelopmental motor disorders include developmental coordination disor­ der, stereotypic movement disorder, and tic disorders. Developmental coordination dis­ order is characterized by deficits in the acquisition and execution of coordinated motor skills and is manifested by clumsiness and slowness or inaccuracy of performance of mo­ tor skills that cause interference with activities of daily living. Stereotypic movement dis­ order is diagnosed when an individual has repetitive, seemingly driven, and apparently purposeless motor behaviors, such as hand flapping, body rocking, head banging, selfbiting, or hitting. The movements interfere with social, academic, or other activities. If the behaviors cause self-injury, this should be specified as part of the diagnostic description. Tic disorders are characterized by the presence of motor or vocal tics, which are sudden, rapid, recurrent, nonrhythmic, sterotyped motor movements or vocalizations. The dura­ tion, presumed etiology, and clinical presentation define the specific tic disorder that is di­ agnosed: Tourette's disorder, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder. Tourette's disorder is diagnosed when the individual has multiple motor and vocal tics that have been present for at least 1 year and that have a waxing-waning symptom course. Specific learning disorder, as the name implies, is diagnosed when there are specific defi­ cits in an individual's ability to perceive or process information efficiently and accurately. This neurodevelopmental disorder first manifests during the years of formal schooling and is characterized by persistent and impairing difficulties with learning foimdational academic skills in reading, writing, and/or math. The individual's performance of the affected academic skills is well below average for age, or acceptable performance levels are achieved only with extraordinary effort. Specific learning disorder may occur in individuals identified as intellec­ tually gifted and manifest only when the learning demands or assessment procedures (e.g., timed tests) pose barriers that cannot be overcome by their innate intelligence and compensa­ tory strategies. For all individuals, specific learning disorder can produce lifelong impairments in activities dependent on the skills, including occupational performance. The use of specifiers for the neurodevelopmental disorder diagnoses enriches the clin­ ical description of the individual's clinical course and current symptomatology. In addi­ tion to specifiers that describe the clinical presentation, such as age at onset or severity ratings, the neurodevelopmental disorders may include the specifier "associated with a known medical or genetic condition or environmental factor." This specifier gives clini­

cians an opportunity to document factors that may have played a role in the etiology of the disorder, as v^^ll as those that might affect the clinical course. Examples include genetic disorders, such as fragile X syndrome, tuberous sclerosis, and Rett syndrome; medical con­ ditions such as epilepsy; and environmental factors, including very low birth weight and fetal alcohol exposure (even in the absence of stigmata of fetal alcohol syndrome).

Intellectual Disabilities Intellectual Disability (Intellectual Developmental Disorder) Diagnostic Criteria Intellectual disability (intellectual developmental disorder) is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains. The following three criteria must be met: A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing. B. Deficits in adaptive functioning that result in failure to meet developmental and socio­ cultural standards for personal independence and social responsibility. Without ongo­ ing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, across multiple environments, such as home, school, work, and community. C. Onset of intellectual and adaptive deficits during the developmental period. Note: The diagnostic term intellectual disability is the equivalent term for the ICD-11 diag­ nosis of intellectual developmental disorders. Although the term intellectual disability is

used throughout this manual, both terms are used in the title to clarify relationships with other classification systems. Moreover, a federal statute in the United States (Public Law 111 -256, Rosa’s Law) replaces the term mental retardation with intellectual disability, and research journals use the term intellectual disability. Thus, intellectual disability is the term in common use by medical, educational, and other professions and by the lay public and advocacy groups. Coding note: The ICD-9-CM code for intellectual disability (intellectual developmental disorder) is 319, which is assigned regardless of the severity specifier. The ICD-10-CM code depends on the severity specifier (see below). Specify current severity (see Table 1): (F70) Mild (F71) lUloderate (F72) Severe (F73) Profound

Specifiers The various levels of severity are defined on the basis of adaptive functioning, and not IQ scores, because it is adaptive functioning that determines the level of supports required. Moreover, IQ measures are less valid in the lower end of the IQ range.

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Diagnostic Features The essential fèatures of intellectual disability (intellectual developmental disorder) are deficits in general mental abilities (Criterion A) and impairment in everyday adaptive functioning, in comparison to an individual's age-, gender-, and socioculturally matched peers (Criterion B). Onset is during the developmental period (Criterion C). The diagnosis of intellectual disability is based on both clinical assessment and standardized testing of intellectual and adaptive functions. Criterion A refers to intellectual functions that involve reasoning, problem solving, planning, abstract thinking, judgment, learning from instruction and experience, and practical understanding. Critical components include verbal comprehension, working memory, perceptual reasoning, quantitative reasoning, abstract thought, and cognitive ef­ ficacy. Intellectual functioning is typically measured with individually administered and psychometrically valid, comprehensive, culturally appropriate, psychometrically sound tests of intelligence. Individuals with intellectual disability have scores of approximately two standard deviations or more below the population mean, including a margin for mea­ surement error (generally +5 points). On tests with a standard deviation of 15 and a mean of 100, this involves a score of 65-75 (70 ± 5). Clinical training and judgment are required to interpret test results and assess intellectual performance. Factors that may affect test scores include practice effects and the "Flynn effect' (i.e., overly high scores due to out-of-date test norms). Invalid scores may result from the use of brief intelligence screening tests or group tests; highly discrepant individual subtest scores may make an overall IQ score invalid. Instruments must be normed for the individual's so­ ciocultural background and native language. Co-occurring disorders that affect communi­ cation, language, and/or motor or sensory function may affect test scores. Individual cognitive profiles based on neuropsychological testing are more useful for understanding intellectual abilities than a single IQ score. Such testing may identify areas of relative strengths and weaknesses, an assessment important for academic and vocational planning. IQ test scores are approximations of conceptual functioning but may be insufficient to assess reasoning in real-life situations and mastery of practical tasks. For example, a per­ son with an IQ score above 70 may have such severe adaptive behavior problems in social judgment, social understanding, and other areas of adaptive functioning that the person's actual functioning is comparable to that of individuals with a lower IQ score. Thus, clinical judgment is needed in interpreting the results of IQ tests. Deficits in adaptive functioning (Criterion B) refer to how well a person meets community standards of personal independence and social responsibility, in comparison to others of sim­ ilar age and sociocultural background. Adaptive functioning involves adaptive reasoning in three domains: conceptual, social, and practical. The conceptual (academic) domain involves competence in memory, language, reading, writing, math reasoning, acquisition of practical knowledge, problem solving, and judgment in novel situations, among others. The social do­ main involves awareness of others' thoughts, feelings, and experiences; empathy; interper­ sonal communication skills; friendship abilities; and social judgment, among others. The practical domain involves learning and self-management across life settings, including personal care, job responsibilities, money management, recreation, self-management of behavior, and school and work task organization, among others. Intellectual capacity, education, motivation, socialization, personality features, vocational opportunity, cultural experience, and coexisting general medical conditions or mental disorders influence adaptive functioning. Adaptive functioning is assessed using both clinical evaluation and individualized, culturally appropriate, psychometrically sound measures. Standardized measures are used with knowledgeable informants (e.g., parent or other family member; teacher; coun­ selor; care provider) and the individual to the extent possible. Additional sources of infor­ mation include educational, developmental, medical, and mental health evaluations. Scores from standardized measures and interview sources must be interpreted using clin­ ical judgment. When standardized testing is difficult or impossible, because of a variety of

factors (e.g., sensory impairment, severe problem behavior), the individual may be diag­ nosed with unspecified intellectual disability. Adaptive functioning may be difficult to assess in a controlled setting (e.g., prisons, detention centers); if possible, corroborative in­ formation reflecting functioning outside those settings should be obtained. Criterion B is met when at least one domain of adaptive functioning—conceptual, so­ cial, or practical—is sufficiently impaired that ongoing support is needed in order for the person to perform adequately in one or more life settings at school, at work, at home, or in the community. To meet diagnostic criteria for intellectual disability, the deficits in adap­ tive functioning must be directly related to the intellectual impairments described in Cri­ terion A. Criterion C, onset during the developmental period, refers to recognition that intellectual and adaptive deficits are present during childhood or adolescence.

Associated Features Supporting Diagnosis Intellectual disability is a heterogeneous condition with multiple causes. There may be associated difficulties with social judgment; assessment of risk; self-management of behav­ ior, emotions, or interpersonal relationships; or motivation in school or work environments. Lack of communication skills may predispose to disruptive and aggressive behaviors. Gull­ ibility is often a feature, involving naiveté in social situations and a tendency for being easily led by others. Gullibility and lack of awareness of risk may result in exploitation by others and possible victimization, fraud, unintentional criminal involvement, false confessions, and risk for physical and sexual abuse. These associated features can be important in crim­ inal cases, including Atkins-type hearings involving the death penalty. Individuals with a diagnosis of intellectual disability with co-occurring mental disor­ ders are at risk for suicide. They think about suicide, make suicide attempts, and may die from them. Thus, screening for suicidal thoughts is essential in the assessment process. Be­ cause of a lack of awareness of risk and danger, accidental injury rates may be increased.

Prevalence Intellectual disability has an overall general population prevalence of approximately 1%, and prevalence rates vary by age. Prevalence for severe intellectual disability is approxi­ mately 6 per 1,000.

Deveiopment and Course Onset of intellectual disability is in the developmental period. The age and characteristic features at onset depend on the etiology and severity of brain dysfunction. Delayed motor, language, and social milestones may be identifiable within the first 2 years of life among those with more severe intellectual disability, while mild levels may not be identifiable un­ til school age when difficulty with academic learning becomes apparent. All criteria (in­ cluding Criterion C) must be fulfilled by history or current presentation. Some children under age 5 years whose presentation will eventually meet criteria for intellectual disabil­ ity have deficits that meet criteria for global developmental delay. When intellectual disability is associated with a genetic syndrome, there may be a char­ acteristic physical appearance (as in, e.g.. Down syndrome). Some syndromes have a behavioral phenotype, which refers to specific behaviors that are characteristic of particular genetic disorder (e.g., Lesch-Nyhan syndrome). In acquired forms, the onset may be abrupt following an illness such as meningitis or encephalitis or head trauma occurring during the developmental period. When intellectual disability results from a loss of pre­ viously acquired cognitive skills, as in severe traumatic brain injury, the diagnoses of in­ tellectual disability and of a neurocognitive disorder may both be assigned. Although intellectual disability is generally nonprogressive, in certain genetic disor­ ders (e.g., Rett syndrome) there are periods of worsening, followed by stabilization, and in

others (e.g., San Phillippo syndrome) progressive worsening of intellectual function. After early childhood^ the disorder is generally lifelong, although severity levels may change over time. The course may be influenced by underlying medical or genetic conditions and co-occurring conditions (e.g., hearing or visual impairments, epilepsy). Early and ongoing in­ terventions may improve adaptive functioning throughout childhood and adulthood. In some cases, these result in significant improvement of intellectual functioning, such that the diagnosis of intellectual disability is no longer appropriate. Thus, it is common practice when assessing infants and young children to delay diagnosis of intellectual disability un­ til after an appropriate course of intervention is provided. For older children and adults, the extent of support provided may allow for full participation in all activities of daily liv­ ing and improved adaptive function. Diagnostic assessments must determine whether im­ proved adaptive skills are the result of a stable, generalized new skill acquisition (in which case the diagnosis of intellectual disability may no longer be appropriate) or whether the improvement is contingent on the presence of supports and ongoing interventions (in which case the diagnosis of intellectual disability may still be appropriate).

Risk and Prognostic Factors Genetic and physiological. Prenatal etiologies include genetic syndromes (e.g., se­ quence variations or copy number variants involving one or more genes; chromosomal disorders), inborn errors of metabolism, brain malformations, maternal disease (including placental disease), and environmental influences (e.g., alcohol, other drugs, toxins, terato­ gens). Perinatal causes include a variety of labor and delivery-related events leading to neonatal encephalopathy. Postnatal causes include hypoxic ischemic injury, traumatic brain injury, infections, demyelinating disorders, seizure disorders (e.g., infantile spasms), severe and chronic social deprivation, and toxic metabolic syndromes and intoxications (e.g., lead, mercury).

Culture-Reiated Diagnostic issues Intellectual disability occurs in all races and cultures. Cultural sensitivity and knowledge are needed during assessment, and the individual's ethnic, cultural, and linguistic back­ ground, available experiences, and adaptive functioning within his or her community and cultural setting must be taken into account.

Gender-Reiated Diagnostic issues Overall, males are more likely than females to be diagnosed with both mild (average maleifemale ratio 1.6:1) and severe (average male:female ratio 1.2:1) forms of intellectual disability. However, gender ratios vary widely in reported studies. Sex-linked genetic fac­ tors and male vulnerability to brain insult may accoimt for some of the gender differences.

Diagnostic iVlaricers A comprehensive evaluation includes an assessment of intellectual capacity and adaptive functioning; identification of genetic and nongenetic etiologies; evaluation for associated medical conditions (e.g., cerebral palsy, seizure disorder); and evaluation for co-occurring mental, emotional, and behavioral disorders. Components of the evaluation may include basic pre- and perinatal medical history, three-generational family pedigree, physical exam­ ination, genetic evaluation (e.g., karyotype or chromosomal microarray analysis and testing for specific genetic syndromes), and metabolic screening and neuroimaging assessment.

Differential Diagnosis The diagnosis of intellectual disability should be made whenever Criteria A, B, and C are met. A diagnosis of intellectual disability should not be assumed because of a particular

genetic or medical condition. A genetic syndrome linked to intellectual disability should be noted as a concurrent diagnosis with the intellectual disability. Major and mild neurocognitive disorders. Intellectual disability is categorized as a neu­ rodevelopmental disorder and is distinct from the neurocognitive disorders, which are characterized by a loss of cognitive functioning. Major neurocognitive disorder may co­ occur with intellectual disability (e.g., an individual with Down syndrome who develops Alzheimer's disease, or an individual with intellectual disability who loses further cogni­ tive capacity following a head injury). In such cases, the diagnoses of intellectual disability and neurocognitive disorder may both be given. Communication disorders and specific learning disorder. These neurodevelopmental disorders are specific to the communication and learning domains and do not show defi­ cits in intellectual and adaptive behavior. They may co-occur with intellectual disability. Both diagnoses are made if full criteria are met for intellectual disability and a communi­ cation disorder or specific learning disorder. Autism spectrum disorder. Intellectual disability is common among individuals with autism spectrum disorder. Assessment of intellectual ability may be complicated by social-communication and behavior deficits inherent to autism spectrum disorder, which may interfere with understanding and complying with test procedures. Appropriate as­ sessment of intellectual functioning in autism spectrum disorder is essential, with reas­ sessment across the developmental period, because IQ scores in autism spectrum disorder may be unstable, particularly in early childhood.

Comorbidity Co-occurring mental, neurodevelopmental, medical, and physical conditions are frequent in intellectual disability, with rates of some conditions (e.g., mental disorders, cerebral palsy, and epilepsy) three to four times higher than in the general population. The prognosis and outcome of co-occurring diagnoses may be influenced by the presence of intellectual disability. Assessment procedures may require modifications because of associated disor­ ders, including communication disorders, autism spectrum disorder, and motor, sensory, or other disorders. Knowledgeable informants are essential for identifying symptoms such as irritability, mood dysregulation, aggression, eating problems, and sleep problems, and for assessing adaptive functioning in various community settings. The most common co-occurring mental and neurodevelopmental disorders are attention-deficit/hyperactivity disorder; depressive and bipolar disorders; anxiety disorders; autism spectrum disorder; stereotypic movement disorder (with or without self-injurious behavior); impulse-control disorders; and major neurocognitive disorder. Major depres­ sive disorder may occur throughout the range of severity of intellectual disability. Selfinjurious behavior requires prompt diagnostic attention and may warrant a separate di­ agnosis of stereotypic movement disorder. Individuals with intellectual disability, partic­ ularly those with more severe intellectual disability, may also exhibit aggression and disruptive behaviors, including harm of others or property destruction.

Reiationship to Other Classifications ICD-11 (in development at the time of this publication) uses the term intellectual develop­ mental disorders to indicate that these are disorders that involve impaired brain functioning early in life. These disorders are described in ICD-11 as a metasyndrome occurring in the developmental period analogous to dementia or neurocognitive disorder in later life. There are four subtypes in ICD-11: mild, moderate, severe, and profound. The American Association on Intellectual and Developmental Disabilities (AAIDD) also uses the term intellectual disability with a similar meaning to the term as used in this

manual. The AAIDD's classification is multidimensional rather than categorical and is based on the disability construct. Rather than listing specifiers as is done in DSM-5, the AAIDD emphasizes a profile of supports based on severity.

Global Developmental Delay 315.8 (F88) This diagnosis is reserved for individuals under the age of 5 years when the clinical severity level cannot be reliably assessed during early childhood. This category is diagnosed when an individual fails to meet expected developmental milestones in several areas of intellec­ tual functioning, and applies to individuals who are unable to undergo systematic assess­ ments of intellectual functioning, including children who are too young to participate in standardized testing. This category requires reassessment after a period of time.

Unspecified Intellectual Disability (Intellectual Developmental Disorder) 319 (F79) This category is reserved for individuals over the age of 5 years when assessment of the degree of intellectual disability (intellectual developmental disorder) by means of locally available procedures is rendered difficult or impossible because of associated sensory or physical impairments, as in blindness or prelingual deafness; locomotor disability; or pres­ ence of severe problem behaviors or co-occurring mental disorder. This category should only be used in exceptional circumstances and requires reassessment after a period of time.

Communication Disorders Disorders of communication include deficits in language, speech, and communication. Speech is the expressive production of sounds and includes an individual's articulation, fluency, voice, and resonance quality. Language includes the form, function, and use of a conventional system of symbols (i.e., spoken words, sign language, written words, pic­ tures) in a rule-governed manner for communication. Communication includes any verbal or nonverbal behavior (whether intentional or unintentional) that influences the behavior, ideas, or attitudes of another individual. Assessments of speech, language and communi­ cation abilities must take into account the individual’s cultural and language context, particularly for individuals growing up in bilingual environments. The standardized mea­ sures of language development and of nonverbal intellectual capacity must be relevant for the cultural and linguistic group (i.e., tests developed and standardized for one group may not provide appropriate norms for a different group). The diagnostic category of commu­ nication disorders includes the following: language disorder, speech sound disorder, childhood-onset fluency disorder (stuttering), social (pragmatic) communication disor­ der, and other specified and unspecified communication disorders.

Language Disorder Diagnostic Criteria

315.39 (F80.9)

A. Persistent difficulties in the acquisition and use of language across modalities (i.e., spoken, written, sign language, or other) due to deficits in comprehension or produc­ tion that include the following: 1. Reduced vocabulary (word knowledge and use). 2. Limited sentence structure (ability to put words and word endings together to form sentences based on the rules of grammar and morphology). 3. Impairments in discourse (ability to use vocabulary and connect sentences to ex­ plain or describe a topic or series of events or have a conversation). B. Language abilities are substantially and quantifiably below those expected for age, re­ sulting in functional limitations in effective communication, social participation, aca­ demic achievement, or occupational performance, individually or in any combination. C. Onset of symptoms is in the early developmental period. D. The difficulties are not attributable to hearing or other sensory impairment, motor dys­ function, or another medical or neurological condition and are not better explained by in­ tellectual disability (intellectual developmental disorder) or global developmental delay.

Diagnostic Features The core diagnostic features of language disorder are difficulties in the acquisition and use of language due to deficits in the comprehension or production of vocabulary, sentence structure, and discourse. The language deficits are evident in spoken communication, written communication, or sign language. Language learning and use is dependent on both receptive and expressive skills. Expressive ability refers to the production of vocal, ges­ tural, or verbal signals, while receptive ability refers to the process of receiving and com­ prehending language messages. Language skills need to be assessed in both expressive and receptive modalities as these may differ in severity. For example, an individual's ex­ pressive language may be severely impaired, while his receptive language is hardly im­ paired at all. Language disorder usually affects vocabulary and grammar, and these effects then limit the capacity for discourse. The child's first words and phrases are likely to be delayed in onset; vocabulary size is smaller and less varied than expected; and sentences are shorter and less complex with grammatical errors, especially in past tense. Deficits in com­ prehension of language are frequently underestimated, as children may be good at using context to infer meaning. There may be word-finding problems, impoverished verbal def­ initions, or poor understanding of synonyms, multiple meanings, or word play appro­ priate for age and culture. Problems with remembering new words and sentences are manifested by difficulties following instructions of increasing length, difficulties rehears­ ing strings of verbal information (e.g., remembering a phone number or a shopping list), and difficulties remembering novel sound sequences, a skill that may be important for learning new words. Difficulties with discourse are shown by a reduced ability to provide adequate information about the key events and to narrate a coherent story. The language difficulty is manifest by abilities substantially and quantifiably below that expected for age and significantly interfering with academic achievement, occupa­ tional performance, effective communication, or socialization (Criterion B). A diagnosis of language disorder is made based on the synthesis of the individual's history, direct clinical observation in different contexts (i.e., home, school, or work), and scores from standard­ ized tests of language ability that can be used to guide estimates of severity.

Associated Features Supporting Diagnosis A positive family history of language disorders is often present. Individuals, even chil­ dren, can be adept at accommodating to their limited language. They may appear to be shy or reticent to talk. Affected individuals may prefer to communicate only with family mem­ bers or other familiar individuals. Although these social indicators are not diagnostic of a language disorder, if they are notable and persistent, they warrant referral for a full lan­ guage assessment. Language disorder, particularly expressive deficits, may co-occur with speech sound disorder.

Deveiopment and Course Language acquisition is marked by changes from onset in toddlerhood to the adult level of competency that appears during adolescence. Changes appear across the dimensions of language (sounds, words, grammar, narratives/expository texts, and conversational skills) in age-graded increments and synchronies. Language disorder emerges during the early developmental period; however, there is considerable variation in early vocabulary acquisition and early word combinations, and individual differences are not, as single indicators, highly predictive of later outcomes. By age 4 years, individual differences in language ability are more stable, with better measurement accuracy, and are highly pre­ dictive of later outcomes. Language disorder diagnosed from 4 years of age is likely to be stable over time and typically persists into adulthood, although the particular profile of language strengths and deficits is likely to change over the course of development.

Risic and Prognostic Factors Children with receptive language impairments have a poorer prognosis than those with predominantly expressive impairments. They are more resistant to treatment, and diffi­ culties with reading comprehension are frequently seen. Genetic and physiological. Language disorders are highly heritable, and family mem­ bers are more likely to have a history of language impairment.

Differentiai Diagnosis Normal variations in language. Language disorder needs to be distinguished from nor­ mal developmental variations, and this distinction may be difficult to make before 4 years of age. Regional, social, or cultural/ethnic variations of language (e.g., dialects) must be considered when an individual is being assessed for language impairment. Hearing or other sensory impairment. Hearing impairment needs to be excluded as the primary cause of language difficulties. Language deficits may be associated with a hearing impairment, other sensory deficit, or a speech-motor deficit. When language deficits are in excess of those usually associated with these problems, a diagnosis of language disorder may be made. Intellectual disability (intellectual developmental disorder). Language delay is often the presenting feature of intellectual disability, and the definitive diagnosis may not be made until the child is able to complete standardized assessments. A separate diagnosis is not given unless the language deficits are clearly in excess of the intellectual limitations. Neurological disorders. Language disorder can be acquired in association with neuro­ logical disorders, including epilepsy (e.g., acquired aphasia or Landau-Kleffner syndrome). Language regression. Loss of speech and language in a child younger than 3 years may be a sign of autism spectrum disorder (with developmental regression) or a specific neuro­ logical condition, such as Landau-Kleffner syndrome. Among children older than 3 years, language loss may be a symptom of seizures, and a diagnostic assessment is necessary to exclude the presence of epilepsy (e.g., routine and sleep electroencephalogram).

Comorbidity Language disorder is strongly associated with other neurodevelopmental disorders in terms of specific learning disorder (literacy and numeracy), attention-deficit/hyperactiv­ ity disorder, autism spectrum disorder, and developmental coordination disorder. It is also associated with social (pragmatic) communication disorder. A positive family history of speech or language disorders is often present.

Speech Sound Disorder Diagnostic Criteria

315.39 (F80.0)

A. Persistent difficulty with speech sound production that interferes with speech intelligi­ bility or prevents verbal communication of messages. B. The disturbance causes limitations in effective communication that interfere with social participation, academic achievement, or occupational performance, individually or in any combination. C. Onset of symptoms is in the early developmental period. D. The difficulties are not attributable to congenital or acquired conditions, such as cere­ bral palsy, cleft palate, deafness or hearing loss, traumatic brain injury, or other medi­ cal or neurological conditions.

Diagnostic Features Speech sound production describes the clear articulation of the phonemes (i.e., individual sounds) that in combination make up spoken words. Speech sound production requires both the phonological knowledge of speech sounds and the ability to coordinate the movements of the articulators (i.e., the jaw, tongue, and lips,) with breathing and vocalizing for speech. Chil­ dren with speech production difficulties may experience difficulty with phonological knowl­ edge of speech sounds or the ability to coordinate movements for speech in varying degrees. Speech sound disorder is thus heterogeneous in its underlying mechanisms and includes pho­ nological disorder and articulation disorder. A speech sound disorder is diagnosed when speech sound production is not what would be expected based on the child's age and devel­ opmental stage and when the deficits are not the result of a physical, structural, neurological, or hearing impairment. Among typically developing children at age 4 years, overall speech should be intelligible, whereas at age 2 years, only 50% may be understandable.

Associated Features Supporting Diagnosis Language disorder, particularly expressive deficits, may be found to co-occur with speech sound disorder. A positive family history of speech or language disorders is often present. If the ability to rapidly coordinate the articulators is a particular aspect of difficulty, there may be a history of delay or incoordination in acquiring skills that also utilize the articulators and related facial musculature; among others, these skills include chewing, maintaining mouth closure, and blowing the nose. Other areas of motor coordination may be impaired as in developmental coordination disorder. Verbal dyspraxia is a term also used for speech production problems. Speech may be differentially impaired in certain genetic conditions (e.g.. Down syn­ drome, 22q deletion, FoxPZ gene mutation). If present, these should also be coded.

Deveiopment and Course Learning to produce speech sounds clearly and accurately and learning to produce con­ nected speech fluently are developmental skills. Articulation of speech sounds follows a

developmental pattern, which is reflected in the age norms of standardized tests. It is not unusual for typically developing children to use developmental processes for shortening words and syllables as they are learning to talk, but their progression in mastering speech sound production should result in mostly inteUigible speech by age 3 years. Children with speech sound disorder continue to use immature phonological simplification processes past the age when most children can produce words clearly. Most speech sounds should be produced clearly and most words should be pronounced accurately according to age and community norms by age 7 years. The most frequently misarticulated sounds also tend to be learned later, leading them to be called the ''late eight" (/, r, s, z, th, ch, dzh, and zh). Misarticulation of any of these sounds by itself could be considered within normal limits up to age 8 years. When multiple sounds are involved, it may be appro­ priate to target some of those sounds as part of a plan to improve intelligibility prior to the age at which almost all children can produce them accurately. Lisping (i.e., misarticulating sibi­ lants) is particularly common and may involve frontal or lateral patterns of airstream direc­ tion. It may be associated with an abnormal tongue-thrust swallowing pattern. Most children with speech sound disorder respond well to treatment, and speech dif­ ficulties improve over time, and thus the disorder may not be lifelong. However, when a language disorder is also present, the speech disorder has a poorer prognosis and may be associated with specific learning disorders.

Differential Diagnosis Normal variations in speech. Regional, social, or cultural/ethnic variations of speech should be considered before making the diagnosis. Hearing or other sensory impairment. Hearing impairment or deafness may result in abnormalities of speech. Deficits of speech sound production may be associated with a hearing impairment, other sensory deficit, or a speech-motor deficit. When speech deficits are in excess of those usually associated with these problems, a diagnosis of speech sound disorder may be made. Structural deficits.

Speech impairment may be due to structural deficits (e.g., cleft palate).

Dysarthria. Speech impairment may be attributable to a motor disorder, such as cerebral palsy. Neurological signs, as well as distinctive features of voice, differentiate dysarthria from speech sound disorder, although in young children (under 3 years) differentiation may be difficult, particularly when there is no or minimal general body motor involve­ ment (as in, e.g., Worster-Drought syndrome). Selective mutism. Limited use of speech may be a sign of selective mutism, an anxiety disorder that is characterized by a lack of speech in one or more contexts or settings. Se­ lective mutism may develop in children with a speech disorder because of embarassment about their impairments, but many children with selective mutism exhibit normal speech in "safe" settings, such as at home or with close friends.

Childhood-Onset Fluency Disorder (Stuttering) Diagnostic Criteria

315.35 (F80.81)

A. Disturbances in the normal fluency and time patterning of speech that are inappropri­ ate for the individual’s age and language skills, persist over time, and are characterized by frequent and marked occurrences of one (or more) of the following: 1. Sound and syllable repetitions. 2. Sound prolongations of consonants as well as vowels.

3. 4. 5. 6. 7.

Broken words (e.g., pauses within a word). Audible or silent blocking (filled or unfilled pauses in speech). Circumlocutions (word substitutions to avoid problematic words). Words produced with an excess of physical tension. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”).

B. The disturbance causes anxiety about speaking or limitations in effective communica­ tion, social participation, or academic or occupational performance, individually or in any combination. C. The onset of symptoms is in the early developmental period. (Note: Later-onset cases are diagnosed as 307.0 [F98.5] adult-onset fluency disorder.) D. The disturbance is not attributable to a speech-motor or sensory deficit, dysfluency as­ sociated with neurological insult (e.g., stroke, tumor, trauma), or another medical con­ dition and is not better explained by another mental disorder.

Diagnostic Features The essential feature of childhood-onset fluency disorder (stuttering) is a disturbance in the normal fluency and time patterning of speech that is inappropriate for the individual's age. This disturbance is characterized by frequent repetitions or prolongations of sounds or syllables and by other types of speech dysfluencies, including broken words (e.g., pauses within a word), audible or silent blocl^g (i.e., filled or unfilled pauses in speech), circumlocutions (i.e., word substitutions to avoid problematic words), words produced with an excess of physical tension, and monosyllabic whole-word repetitions (e.g., 'T-I-I-I see him"). The disturbance in fluency interferes with academic or occupational achieve­ ment or with social communication. The extent of the disturbance varies from situation to situation and often is more severe when there is special pressure to communicate (e.g., giv­ ing a report at school, interviewing for a job). Dysfluency is often absent during oral read­ ing, singing, or talking to inanimate objects or to pets.

Associated Features Supporting Diagnosis Fearful anticipation of the problem may develop. The speaker may attempt to avoid dys­ fluencies by linguistic mechanisms (e.g., altering the rate of speech, avoiding certain words or sounds) or by avoiding certain speech situations, such as telephoning or public speaking. In addition to being features of the condition, stress and anxiety have been shown to exacerbate dysfluency. Childhood-onset fluency disorder may also be accompanied by motor movements (e.g., eye blinks, tics, tremors of the lips or face, jerking of the head, breathing movements, fist clenching). Children with fluency disorder show a range of language abilities, and the relationship between fluency disorder and language abilities is unclear.

Deveiopment and Course Childhood-onset fluency disorder, or developmental stuttering, occurs by age 6 for 80%90% of affected individuals, with age at onset ranging from 2 to 7 years. The onset can be insidious or more sudden. Typically, dysfluencies start gradually, with repetition of initial consonants, first words of a phrase, or long words. The child may not be aware of dysflu­ encies. As the disorder progresses, the dysfluencies become more frequent and interfering, occurring on the most meaningful words or phrases in the utterance. As the child becomes aware of the speech difficulty, he or she may develop mechanisms for avoiding the dys­ fluencies and emotional responses, including avoidance of public speaking and use of short and simple utterances. Longitudinal research shows that 65%-85% of children re­

cover from the dysfluency, with severity of fluency disorder at age 8 years predicting re­ covery or persisjence into adolescence and beyond.

Risk and Prognostic Factors Genetic and physiological. The risk of stuttering among first-degree biological rela­ tives of individuals with childhood-onset fluency disorder is more than three times the risk in the general population.

Functional Consequences of Childhood-Onset Fiuency Disorder (Stuttering) In addition to being features of the condition, stress and anxiety can exacerbate dysflu­ ency. Impairment of social functioning may result from this anxiety.

Differential Diagnosis Sensory deficits. Dysfluencies of speech may be associated with a hearing impairment or other sensory deficit or a speech-motor deficit. When the speech dysfluencies are in ex­ cess of those usually associated with these problems, a diagnosis of childhood-onset flu­ ency disorder may be made. Normal speech dysfluencies. The disorder must be distinguished from normal dysflu­ encies that occur frequently in young children, which include whole-word or phrase rep­ etitions (e.g., 'T want, I want ice cream"), incomplete phrases, interjections, unfilled pauses, and parenthetical remarks. If these difficulties increase in frequency or complexity as the child grows older, a diagnosis of childhood-onset fluency disorder is appropriate. Medication side effects. Stuttering may occur as a side effect of medication and may be detected by a temporal relationship with exposure to the medication. Adult-onset dysfluencies. If onset of dysfluencies is during or after adolescence, it is an "adult-onset dysfluency" rather than a neurodevelopmental disorder. Adult-onset dysflu­ encies are associated with specific neurological insults and a variety of medical conditions and mental disorders and may be specified with them, but they are not a DSM-5 diagnosis. Tourette’s disorder. Vocal tics and repetitive vocalizations of Tourette's disorder should be distinguishable from the repetitive sounds of childhood-onset fluency disorder by their nature and timing.

Social (Pragmatic) Communication Disorder Diagnostic Criteria

315.39 (F80.89)

A. Persistent difficulties in the social use of verbal and nonverbal communication as man­ ifested by all of the following: 1. Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context. 2. Impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talk­ ing differently to a child than to an adult, and avoiding use of overly formal language. 3. Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction.

4. Difficulties understanding wliat is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation). B. The deficits result in functional limitations in effective communication, social participa­ tion, social relationships, academic achievement, or occupational performance, indi­ vidually or in combination. C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities). D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder.

Diagnostic Features Social (pragmatic) communication disorder is characterized by a primary difficulty with pragmatics, or the social use of language and communication, as manifested by deficits in understanding and following social rules of verbal and nonverbal communication in nat­ uralistic contexts, changing language according to the needs of the listener or situation, and following rules for conversations and storytelling. The deficits in social communica­ tion result in functional limitations in effective communication, social participation, devel­ opment of social relationships, academic achievement, or occupational performance. The deficits are not better explained by low abilities in the domains of structural language or cognitive abihty.

Associated Features Supporting Diagnosis The most common associated feature of social (pragmatic) communication disorder is lan­ guage impairment, which is characterized by a history of delay in reaching language mile­ stones, and historical, if not current, structural language problems (see ''Language Disorder" earlier in this chapter). Individuals with social communication deficits may avoid social inter­ actions. Attention-deficit/hyperactivity disorder (ADHD), behavioral problems, and specific learning disorders are also more common among affected individuals.

Development and Course Because social (pragmatic) communication depends on adequate developmental progress in speech and language, diagnosis of social (pragmatic) communication disorder is rare among children younger than 4 years. By age 4 or 5 years, most children should possess adequate speech and language abilities to permit identification of specific deficits in social communication. Milder forms of the disorder may not become apparent until early ado­ lescence, when language and social interactions become more complex. The outcome of social (pragmatic) communication disorder is variable, with some chil­ dren improving substantially over time and others continuing to have difficulties persist­ ing into adulthood. Even among those who have significant improvements, the early deficits in pragmatics may cause lasting impairments in social relationships and behavior and also in acquisition of other related skills, such as written expression.

Risic and Prognostic Factors Genetic and physiological. A family history of autism spectrum disorder, communica­ tion disorders, or specific learning disorder appears to increase the risk for social (prag­ matic) communication disorder.

Differential Diagnosis Autism spectrum disorder. Autism spectrum disorder is the primary diagnostic con­ sideration for individuals presenting with social communication deficits. The two disor­ ders can be differentiated by the presence in autism spectrum disorder of restricted/ repetitive patterns of behavior, interests, or activities and their absence in social (prag­ matic) communication disorder. Individuals with autism spectrum disorder may only dis­ play the restricted/repetitive patterns of behavior, interests, and activities during the early developmental period, so a comprehensive history should be obtained. Current absence of symptoms would not preclude a diagnosis of autism spectrum disorder, if the restricted interests and repetitive behaviors were present in the past. A diagnosis of social (prag­ matic) communication disorder should be considered only if the developmental history fails to reveal any evidence of restricted/repetitive patterns of behavior, interests, or ac­ tivities. Attention-deficit/hyperactivity disorder. Primary deficits of ADHD may cause impair­ ments in social communication and functional limitations of effective communication, so­ cial participation, or academic achievement. Social anxiety disorder (social phobia). The symptoms of social communication disor­ der overlap with those of social anxiety disorder. The differentiating feature is the timing of the onset of symptoms. In social (pragmatic) communication disorder, the individual has never had effective social communication; in social anxiety disorder, the social com­ munication skills developed appropriately but are not utilized because of anxiety, fear, or distress about social interactions. Intellectual disability (intellectual developmental disorder) and global developmental delay. Social communication skills may be deficient among individuals with global de­ velopmental delay or intellectual disability, but a separate diagnosis is not given unless the social communication deficits are clearly in excess of the intellectual limitations.

Unspecified Communication Disorder 307.9 (F80.9) This category applies to presentations in which symptoms characteristic of communication disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for com­ munication disorder or for any of the disorders in the neurodevelopmental disorders diag­ nostic class. The unspecified communication disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for com­ munication disorder or for a specific neurodevelopmental disorder, and includes presen­ tations in which there is insufficient information to make a more specific diagnosis.

Autism Spectrum Disorder Autism Spectrum Disorder Diagnostic Criteria

299.00 (F84.0)

A. Persistent deficits in social communication and social interaction across multiple con­ texts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text): 1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnor­ malities in eye contact and body language or deficits in understanding and use of gestures: to a total lack of facial expressions and nonverbal communication. 3. Deficits in developing, maintaining, and understanding relationships, ranging, for ex­ ample, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. Specify current severity: Severity is based on social communication impairments and restricted, re­ petitive patterns of behavior (seeTable 2).

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaus­ tive; see text): 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). 3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circum­ scribed or perseverative interests). 4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse re­ sponse to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). Specify current severity: Severity is based on social communication impairments and restricted, re­ petitive patterns of behavior (see Table 2).

C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other im­ portant areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual devel­ opmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spec­ trum disorder and intellectual disability, social communication should be below that ex­ pected for general developmental level. Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not othenwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder. Specify if; With or without accompanying inteliectual impairment With or without accompanying language impairment Associated with a icnown medicai or genetic condition or environmental factor (Coding note: Use additional code to identify the associated medical or genetic condition.) Associated with another neurodevelopmental, mental, or behavioral disorder (Coding note: Use additional code[s] to identify the associated neurodevelopmental,

mental, or behavioral disorder[s].) With catatonia (refer to the criteria for catatonia associated with another mental dis­ order, pp. 119-120, for definition) (Coding note: Use additional code 293.89 [F06.1]

catatonia associated with autism spectrum disorder to indicate the presence of the co­ morbid catatonia.)

Recording Procedures For autism spectrum disorder that is associated with a known medical or genetic condition or environmental factor, or with another neurodevelopmental, mental, or behavioral dis­ order, record autism spectrum disorder associated with (name of condition, disorder, or factor) (e.g., autism spectrum disorder associated with Rett syndrome). Severity should be recorded as level of support needed for each of the two psychopathological domains in Table 2 (e.g., "requiring very substantial support for deficits in social communication and requiring substantial support for restricted, repetitive behaviors"). Specification of "with accompanying intellectual impairment" or "without accompanying intellectual impair­ ment" should be recorded next. Language impairment specification should be recorded thereafter. If there is accompanying language impairment, the current level of verbal func­ tioning should be recorded (e.g., "with accompanying language impairment—no intelligi­ ble speech" or "with accompanying language impairment—phrase speech"). If catatonia is present, record separately "catatonia associated with autism spectrum disorder."

Specifiers The severity specifiers (see Table 2) may be used to describe succinctly the current symp­ tomatology (which might fall below level 1), with the recognition that severity may vary by context and fluctuate over time. Severity of social communication difficulties and re­ stricted, repetitive behaviors should be separately rated. The descriptive severity categories should not be used to determine eligibility for and provision of services; these can only be developed at an individual level and through discussion of personal priorities and targets. Regarding the specifier "with or without accompanying intellectual impairment," un­ derstanding the (often uneven) intellectual profile of a child or adult with autism spectrum disorder is necessary for interpreting diagnostic features. Separate estimates of verbal and nonverbal skill are necessary (e.g., using untimed nonverbal tests to assess potential strengths in individuals with limited language).

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^ > 90%). They may have difficulty waking up in the morning, sometimes appearing confused, combative, or ataxic. This prolonged impairment of alert­ ness at the sleep-wake transition is often referred to as sleep inertia (i.e., sleep drunkenness). It can also occur upon awakening from a daytime nap. During that period, the individual appears awake, but there is a decline in motor dexterity, behavior may be very inappro­ priate, and memory deficits, disorientation in time and space, and feelings of grogginess may occur. This period may last some minutes to hours. The persistent need for sleep can lead to automatic behavior (usually of a very routine, low-complexity type) that the individual carries out with little or no subsequent recall. For example, individuals may find themselves having driven several miles from where they thought they were, unaware of the "automatic" driving they did in the preceding minutes. For some individuals with hypersomnolence disorder, the major sleep episode (for most individuals, nocturnal sleep) has a duration of 9 hours or more. However, the sleep is often nonrestorative and is followed by difficulty awakening in the morning. For other individ­ uals with hypersomnolence disorder, the major sleep episode is of normal nocturnal sleep duration (6-9 hours). In these cases, the excessive sleepiness is characterized by several un­ intentional daytime naps. These daytime naps tend to be relatively long (often lasting 1 hour or more), are experienced as nonrestorative (i.e., unrefreshing), and do not lead to improved alertness. Individuals with hypersomnolence have daytime naps nearly everyday regard­ less of the nocturnal sleep duration. Subjective sleep quality may or may not be reported as good. Individuals typically feel sleepiness developing over a period of time, rather than

experiencing a sudden sleep "attack." Unintentional sleep episodes typically occur in lowstimulation and low-activity situations (e.g., while attending lectures, reading, watching television, or driving long distances), but in more severe cases they can manifest in highattention situations such as at work, in meetings, or at social gatherings.

Associated Features Supporting Diagnosis Nonrestorative sleep, automatic behavior, difficulties awakening in the morning, and sleep inertia, although common in hypersomnolence disorder, may also be seen in a variety of conditions, including narcolepsy. Approximately 80% of individuals with hyper­ somnolence report that their sleep is nonrestorative, and as many have difficulties awak­ ening in the morning. Sleep inertia, though less common (i.e., observed in 36%-50% of individuals with hypersomnolence disorder), is highly specific to h)φersomnolence. Short naps (i.e., duration of less than 30 minutes) are often unrefreshing. Individuals with hy­ persomnolence often appear sleepy and may even fall asleep in the clinician's waiting area. A subset of individuals with hypersomnolence disorder have a family history of hy­ persomnolence and also have symptoms of autonomic nervous system dysfunction, in­ cluding recurrent vascular-type headaches, reactivity of the peripheral vascular system (Raynaud's phenomenon), and fainting.

Prevaience Approximately 5%-10% of individuals who consult in sleep disorders clinics with com­ plaints of daytime sleepiness are diagnosed as having hypersomnolence disorder. It is es­ timated that about 1% of the European and U.S. general population has episodes of sleep inertia. Hypersomnolence occurs with relatively equal frequency in males and females.

Deveiopment and Course Hypersomnolence disorder has a persistent course, with a progressive evolution in the se­ verity of symptoms. In most extreme cases, sleep episodes can last up to 20 hours. How­ ever, the average nighttime sleep duration is around 9Vi hours. While many individuals with hypersomnolence are able to reduce their sleep time during working days, weekend and holiday sleep is greatly increased (by up to 3 hours). Awakenings are very difficult and accompanied by sleep inertia episodes in nearly 40% of cases. Hypersomnolence fully manifests in most cases in late adolescence or early adulthood, with a mean age at onset of 17-24 years. Individuals with hypersomnolence disorder are diagnosed, on average, 10-15 years after the appearance of the first symptoms. Pediatric cases are rare. Hypersomnolence has a progressive onset, with symptoms beginning between ages 15 and 25 years, with a gradual progression over weeks to months. For most individuals, the course is then persistent and stable, unless treatment is initiated. The development of other sleep disorders (e.g., breathing-related sleep disorder) may worsen the degree of sleepi­ ness. Although hyperactivity may be one of the presenting signs of daytime sleepiness in children, voluntary napping increases with age. This normal phenomenon is distinct from hypersomnolence.

Risic and Prognostic Factors Environmental. Hypersomnolence can be increased temporarily by psychological stress and alcohol use, but they have not been documented as environmental precipitating factors. Viral infections have been reported to have preceded or accompanied hyper­ somnolence in about 10% of cases. Viral infections, such as HIV pneumonia, infectious mononucleosis, and Guillain-Barré syndrome, can also evolve into hypersomnolence within

months after the infection. Hypersomnolence can also appear within 6-18 months follow­ ing a head traum;^. Genetic and physiological. Hypersomnolence may be familial, with an autosomal­ dominant mode of inheritance.

Diagnostic iVlarlcers Nocturnal polysomnography demonstrates a normal to prolonged sleep duration, short sleep latency, and normal to increased sleep continuity. The distribution of rapid eye movement (REM) sleep is also normal. Sleep efficiency is mostly greater than 90%. Some individuals with hypersomnolence disorder have increased amounts of slow-wave sleep. The multiple sleep latency test documents sleep tendency, typically indicated by mean sleep latency values of less than 8 minutes. In hypersomnolence disorder, the mean sleep latency is typically less than 10 minutes and frequently 8 minutes or less. Sleep-onset REM periods (SOREMPs; i.e., the occurrence of REM sleep within 20 minutes of sleep onset) may be present but occur less than two times in four to five nap opportunities.

Functional Consequences of Hypersomnoience Disorder The low level of alertness that occurs while an individual fights the need for sleep can lead to reduced efficiency, diminished concentration, and poor memory during daytime activ­ ities. Hypersomnoience can lead to significant distress and dysfunction in work and social relationships. Prolonged nocturnal sleep and difficulty awakening can result in difficulty in meeting morning obligations, such as arriving at work on time. Unintentional daytime sleep episodes can be embarrassing and even dangerous, if, for instance, the individual is driving or operating machinery when the episode occurs.

Differential Diagnosis Normative variation in sleep. "Normal" sleep duration varies considerably in the general population. "Long sleepers" (i.e., individuals who require a greater than average amount of sleep) do not have excessive sleepiness, sleep inertia, or automatic behavior when they obtain their required amount of nocturnal sleep. Sleep is reported to be refreshing. If social or occupational demands lead to shorter nocturnal sleep, daytime symptoms may appear. In hypersomnoience disorder, by contrast, symptoms of excessive sleepiness occur regard­ less of nocturnal sleep duration. An inadequate amount of nocturnal sleep, or behaviorally induced insufficient sleep syndrome, can produce symptoms of daytime sleepiness very similar to those of hypersomnoience. An average sleep duration of fewer than 7 hours per night strongly suggests inadequate nocturnal sleep, and an average of more than 9-10 hours of sleep per 24-hour period suggests hypersomnoience. Individuals with inadequate noctur­ nal sleep typically "catch up" with longer sleep durations on days when they are free from social or occupational demands or on vacations. Unlike hypersomnoience, insufficient nocturnal sleep is unlikely to persist unabated for decades. A diagnosis of hypersomno­ ience disorder should not be made if there is a question regarding the adequacy of noctur­ nal sleep duration. A diagnostic and therapeutic trial of sleep extension for 10-14 days can often clarify the diagnosis. Poor sleep quality and fatigue. Hypersomnoience disorder should be distinguished from excessive sleepiness related to insufficient sleep quantity or quality and fatigue (i.e., tiredness not necessarily relieved by increased sleep and unrelated to sleep quantity or quality). Excessive sleepiness and fatigue are difficult to differentiate and may overlap considerably. Breathing-related sleep disorders. Individuals with hypersomnoience and breathingrelated sleep disorders may have similar patterns of excessive sleepiness. Breathing-

related sleep disorders are suggested by a history of loud snoring, pauses in breathing during sleep, brain injury, or cardiovascular disease and by the presence of obesity, oro­ pharyngeal anatomical abnormalities, hypertension, or heart failure on physical examina­ tion. Polysomnographie studies can confirm the presence of apneic events in breathingrelated sleep disorder (and their absence in hypersomnolence disorder). Circadian rhythm sleep-wake disorders. Circadian rhythm sleep-wake disorders are often characterized by daytime sleepiness. A history of an abnormal sleep-wake schedule (with shifted or irregular hours) is present in individuals with a circadian rhythm sleepwake disorder. Parasomnias. Parasomnias rarely produce the prolonged, undisturbed nocturnal sleep or daytime sleepiness characteristic of hypersomnolence disorder. Other mental disorders. Hypersomnolence disorder must be distinguished from mental disorders that include hypersomnolence as an essential or associated feature. In particular, complaints of daytime sleepiness may occur in a major depressive episode, with atypical fea­ tures, and in the depressed phase of bipolar disorder. Assessment for other mental disorders is essential before a diagnosis of hypersomnolence disorder is considered. A diagnosis of hyper­ somnolence disorder can be made in the presence of another current or past mental disorder.

Comorbidity H)φersomnolence can be associated with depressive disorders, bipolar disorders (during a depressive episode), and major depressive disorder, with seasonal pattern. Many individu­ als with hypersomnolence disorder have symptoms of depression that may meet criteria for a depressive disorder. This presentation may be related to the psychosocial consequences of persistent increased sleep need. Individuals with hyper somnolence disorder are also at risk for substance-related disorders, particularly related to self-medication with stimulants. This general lack of specificity may contribute to very heterogeneous profiles among indi­ viduals whose symptoms meet the same diagnostic criteria for hypersomnolence disorder. Neurodegenerative conditions, such as Alzheimer's disease, Parkinson's disease, and mul­ tiple system atrophy, may also be associated with hypersomnolence.

Reiationship to internatlonai Classification of Sleep Disorders The International Classification of Sleep Disorders, 2nd Edition (ICSD-2), differentiates nine subtypes of "hypersomnias of central origin," including recurrent hypersomnia (Kleine­ Levin syndrome).

Narcolepsy Diagnostic Criteria A. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping oc­ curring 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. In 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 in 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 la­ tency less than or equal to 15 minutes, or a multiple sleep latency test showing a mean 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: Cri­ terion B requirements of low CSF hypocretin-1 levels and positive polysomnography/ 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 requirements of cataplexy and positive polysomnography/multiple sleep latency test are met, but CSF hypocretin-1 levels are normal (Criterion B2 not met). 347.00 (G47.419) Autosomal dominant cerebellar ataxia, deafness, and narco­ lepsy: This subtype is caused by exon 21 DNA (cytosine-5)-methyltransferase-1 mu­

tations and is characterized by late-onset (age 30-40 years) narcolepsy (with low or intermediate CSF hypocretin-1 levels), deafness, cerebellar ataxia, and eventually de­ mentia. 347.00 (G47.419) 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 oligodendro­ cyte glycoprotein gene. 347.10 (G47.429) Narcolepsy secondary to another medical condition: This sub­ type is for narcolepsy that develops secondary to medical conditions that cause infec­ tious (e.g., Whipple’s disease, sarcoidosis), traumatic, or tumoral destruction of hypocretin neurons. Coding note (for ICD-9-CM code 347.10 only): Code first the underlying medical con­

dition (e.g., 040.2 Whipple’s disease; 347.10 narcolepsy secondary to Whipple’s dis­ ease). Specify current severity: IMild: 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, disturbed nocturnal sleep, and need for multiple naps daily. Severe: Drug-resistant cataplexy with multiple attacks daily, nearly constant sleepi­ ness, and disturbed noctumal sleep (i.e., movements, insomnia, and vivid dreaming).

Subtypes In narcolepsy without cataplexy but with hypocretin deficiency, unclear ''cataplexy-like" symptoms may be reported (e.g., the symptoms are not triggered by emotions and are un­ usually long lasting). In extremely rare cases, cerebrospinal fluid (CSF) levels of hypocre­ tin-1 are low, and polysomnographic/multiple sleep latency test (MSLT) results are negative: repeating the test is advised before establishing the subtype diagnosis. In narco­

lepsy with cataplexy but without hypocretin deficiency, test results for human leukocyte antigen (HLA) DQBl’^06:02 may be negative. Seizures, falls of other origin, and conversion disorder (functional neurological symptom disorder) should be excluded. In narcolepsy secondary to infectious (e.g., Whipple's disease, sarcoidosis), traumatic, or tumoral de­ struction of hypocretin neurons, test results for HLA DQBl *06:02 may be positive and may result from the insult triggering the autoimmune process. In other cases, the destruction of hypocretin neurons may be secondary to trauma or hypothalamic surgery. Head trauma or infections of the central nervous system can, however, produce transitory decreases in CSF hypocretin-1 levels without hypocretin cell loss, complicating the diagnosis.

Diagnostic Features The essential features of sleepiness in narcolepsy are recurrent daytime naps or lapses into sleep. Sleepiness typically occurs daily but must occur at a minimum three times a week for at least 3 months (Criterion A). Narcolepsy generally produces cataplexy, which most commonly presents as brief episodes (seconds to minutes) of sudden, bilateral loss of mus­ cle tone precipitated by emotions, typically laughing and joking. Muscles affected may include those of the neck, jaw, arms, legs, or whole body, resulting in head bobbing, jaw dropping, or complete falls. Individuals are awake and aware during cataplexy. To meet Criterion Bl(a), cataplexy must be triggered by laughter or joking and must occur at least a few times per month when the condition is untreated or in the past. Cataplexy should not be confused with ''weakness" occurring in the context of athletic activities (physiological) or exclusively after unusual emotional triggers such as stress or anxiety (suggesting possible psychopathology). Episodes lasting hours or days, or those not triggered by emotions, are unlikely to be cataplexy, nor is rolling on the floor while laugh­ ing hysterically. In children close to onset, genuine cataplexy can be atypical, affecting primarily the face, causing grimaces or jaw opening with tongue thrusting ("cataplectic faces"). Alter­ natively, cataplexy may present as low-grade continuous hypotonia, yielding a wobbling walk. In these cases. Criterion Bl(b) can be met in children or in individuals within 6months of a rapid onset. Narcolepsy-cataplexy nearly always results from the loss of hypothalamic hypocretin (orexin)-producing cells, causing hypocretin deficiency (less than or equal to one-third of control values, or 110 pg/mL in most laboratories). Cell loss is likely autoimmune, and ap­ proximately 99% of affected individuals carry HLA-DQBl*06:02 (vs. 12%-38% of control subjects). Thus, checking for the presence of DQB1*06:02 prior to a lumbar puncture for eval­ uation of CSF hypocretin-1 immunoreactivity may be useful. Rarely, low CSF levels of hypo­ cretin-1 occur without cataplexy, notably in youths who may develop cataplexy later. CSF hypocretin-1 measurement represents the gold standard, excepting associated severe con­ ditions (neurological, inflammatory, infectious, trauma) that can interfere with the assay. A nocturnal polysonrmographic sleep study followed by an MSLT can also be used to confirm the diagnosis (Criterion B3). These tests must be performed after the individual has stopped all psychotropic medications, following 2 weeks of adequate sleep time (as documented with sleep diaries, actigraphy). Short rapid eye movement (REM) latency (sleep-onset REM period, REM latency less than or equal to 15 minutes) during polysom­ nography is sufficient to confirm the diagnosis and meets Criterion B3. Alternatively, the MSLT result must be positive, showing a mean sleep latency of less than or equal to 8min­ utes and two or more sleep-onset REM periods in four to five naps.

Associated Features Supporting Diagnosis When sleepiness is severe, automatic behaviors may occur, with the individual continuing his or her activities in a semi-automatic, hazelike fashion without memory or conscious­ ness. Approximately 20%-60% of individuals experience vivid hypnagogic hallucinations

before or upon falling asleep or hypnopompic hallucinations just after awakening. These hallucinations are distinct from the less vivid, nonhallucinatory dreamlike mentation at sleep onset that occurs in normal sleepers. Nightmares and vivid dreaming are also fre­ quent in narcolepsy, as is REM sleep behavior disorder. Approximately 20%-60% of indi­ viduals experience sleep paralysis upon falling asleep or awakening, leaving them awake but unable to move or speak. However, many normal sleepers also report sleep paralysis, especially with stress or sleep deprivation. Nocturnal eating may occur. Obesity is com­ mon. Nocturnal sleep disruption with frequent long or short awakenings is common and can be disabling. Individuals may appear sleepy or fall asleep in the waiting area or during clinical ex­ amination. During cataplexy, individuals may slump in a chair and have slurred speech or drooping eyelids. If the clinician has time to check reflexes during cataplexy (most attacks are less than 10 seconds), reflexes are abolished—an important finding distinguishing gen­ uine cataplexy from conversion disorder.

Prevalence Narcolepsy-cataplexy affects 0.02%-0.04% of the general population in most countries. Narcolepsy affects both genders, with possibly a slight male preponderance.

Development and Course Onset is typically in children and adolescents/young adults but rarely in older adults. Two peaks of onset are suggested, at ages 15-25 years and ages 30-35 years. Onset can be abrupt or progressive (over years). Severity is highest when onset is abrupt in children, and then decreases with age or with treatment, so that symptoms such as cataplexy can oc­ casionally disappear. Abrupt onset in young, prepubescent children can be associated with obesity and premature puberty, a phenotype more frequently observed since 2009. In adolescents, onset is more difficult to pinpoint. Onset in adults is often unclear, with some individuals reporting having had excessive sleepiness since birth. Once the disorder has manifested, the course is persistent and lifelong. In 90% of cases, the first symptom to manifest is sleepiness or increased sleep, followed by cataplexy (within 1 year in 50% of cases, within 3 years in 85%). Sleepiness, hypnagogic hallucinations, vivid dreaming, and REM sleep behavior disorder (excessive movements during REM sleep) are early symptoms. Excessive sleep rapidly progresses to an inability to stay awake during the day, and to maintain good sleep at night, without a clear increase in total 24-hour sleep needs. In the first months, cataplexy may be atypical, especially in children. Sleep paralysis usually develops around puberty in children with prepubertal onset. Exacerbations of symptoms suggest lack of compliance with medications or devel­ opment of a concurrent sleep disorder, notably sleep apnea. Young children and adolescents with narcolepsy often develop aggression or behav­ ioral problems secondary to sleepiness and/or nighttime sleep disruption. Workload and social pressure increase through high school and college, reducing available sleep time at night. Pregnancy does not seem to modify symptoms consistently. After retirement, indi­ viduals typically have more opportunity for napping, reducing the need for stimulants. Maintaining a regular schedule benefits individuals at all ages.

Risk and Prognostic Factors Temperamental. Parasomnias, such as sleepwalking, bruxism, REM sleep behavior dis­ order, and enuresis, may be more common in individuals who develop narcolepsy. Indi­ viduals commonly report that they need more sleep than other family members. Environmental. Group A streptococcal throat infection, influenza (notably pandemic H lN l 2009), or other winter infections are likely triggers of the autoimmune process, pro­

ducing narcolepsy a few months later. Head trauma and abrupt changes in sleep-wake patterns (e.g., job changes, stress) may be additional triggers. Genetic and physiological. Monozygotic twins are 25%-32% concordant for narcolepsy. The prevalence of narcolepsy is l% -2% in first-degree relatives (a 10- to 40-fold increase overall). Narcolepsy is strongly associated with DQB1*06:02 (99% vs. 12%-38% in control subjects of various ethnic groups; 25% in the general U.S. population). DQB1*03:01 in­ creases, while DQBl’OSiOl, DQBl’OôiOl, and DQB1*06:03 reduce risk in the presence of DQB1’^06:02, but the effect is small. Polymorphisms within the T-cell receptor alpha gene and other immune modulating genes also modulate risk slightly.

Culture-Related Diagnostic issues Narcolepsy has been described in all ethnic groups and in many cultures. Among African Americans, more cases present without cataplexy or with atypical cataplexy, complicating diagnosis, especially in the presence of obesity and obstructive sleep apnea.

Diagnostic Markers Functional imaging suggests impaired hypothalamic responses to humorous stimuli. Nocturnal polysomnography followed by an MSLT is used to confirm the diagnosis of narcolepsy, especially when the disorder is first being diagnosed and before treatment has begun, and if hypocretin deficiency has not been documented biochemically. The poly­ somnography/MSLT should be performed after the individual is no longer taking any psychotropic drugs and after regular sleep-wake patterns, without shift work or sleep de­ privation, have been documented. A sleep-onset REM period during the polysomnography (REM sleep latency less than or equal to 15 minutes) is highly specific (approximately 1% positive in control subjects) but moderately sensitive (approximately 50%). A positive MSLT result displays an aver­ age sleep latency of less than or equal to 8 minutes, and sleep-onset REM periods in two or more naps on a four- or five-nap test. The MSLT result is positive in 90%-95% of individ­ uals with narcolepsy versus 2%-4% of control subjects or individuals with other sleep dis­ orders. Additional polysomnographic findings often include frequent arousals, decreased sleep efficiency, and increased stage 1 sleep. Periodic limb movements (found in about 40% of individuals with narcolepsy) and sleep apnea are often noted. Hypocretin deficiency is demonstrated by measuring CSF hypocretin-1 immunoreactivity. The test is particularly useful in individuals with suspected conversion disorder and those without typical cataplexy, or in treatment-refractory cases. The diagnostic value of the test is not affected by medications, sleep deprivation, or circadian time, but the find­ ings are uninteφretable when the individual is severely ill with a concurrent infection or head trauma or is comatose. CSF cytology, protein, and glucose are within normal range even when sampled within weeks of rapid onset. CSF hypocretin-1 in these incipient cases is typically already very diminished or undetectable.

Functional Consequences of Narcolepsy Driving and working are impaired, and individuals with narcolepsy should avoid jobs that place themselves (e.g., working with machinery) or others (e.g., bus driver, pilot) in danger. Once the narcolepsy is controlled with therapy, patients can usually drive, al­ though rarely long distances alone. Untreated individuals are also at risk for social isola­ tion and accidental injury to themselves or others. Social relations may suffer as these individuals strive to avert cataplexy by exerting control over emotions.

Differential Diagnosis Other hypersomnias. Hypersomnolence and narcolepsy are similar with respect to the degree of daytime sleepiness, age at onset, and stable course over time but can be distin­

guished based on distinctive clinical and laboratory features. Individuals with hypersom­ nolence typically have longer and less disrupted nocturnal sleep, greater difficulty awakening, more persistent daytime sleepiness (as opposed to more discrete "sleep at­ tacks" in narcolepsy), longer and less refreshing daytime sleep episodes, and little or no dreaming during daytime naps. By contrast, individuals with narcolepsy have cataplexy and recurrent intrusions of elements of REM sleep into the transition between sleep and wakefulness (e.g., sleep-related hallucinations and sleep paralysis). The MSLT typically demonstrates shorter sleep latencies (i.e., greater physiological sleepiness) as well as the presence of multiple sleep-onset REM periods in individuals with narcolepsy. Sleep deprivation and insufficient nocturnal sleep. Sleep deprivation and insufficient nocturnal sleep are common in adolescents and shift workers. In adolescents, difficulties falling asleep at night are common, causing sleep deprivation. The MSLT result may be positive if conducted while the individual is sleep deprived or while his or her sleep is phase delayed. Sleep apnea syndromes. Sleep apneas are especially likely in the presence of obesity. Because obstructive sleep apnea is more frequent than narcolepsy, cataplexy may be over­ looked (or absent), and the individual is assumed to have obstructive sleep apnea unre­ sponsive to usual therapies. Major depressive disorder. Narcolepsy or hypersomnia may be associated or confused with depression. Cataplexy is not present in depression. The MSLT results are most often normal, and there is dissociation between subjective and objective sleepiness, as measured by the mean sleep latency during the MSLT. Conversion disorder (functional neurological symptom disorder). Atypical features, such as long-lasting cataplexy or unusual triggers, may be present in conversion disorder (functional neurological symptom disorder). Individuals may report sleeping and dream­ ing, yet the MSLT does not show the characteristic sleep-onset REM period. Full-blown, long-lasting pseudocataplexy may occur during consultation, allowing the examining physician enough time to verify reflexes, which remain intact. Attention-deficit/hyperactivity disorder or other behavioral problems. In children and adolescents, sleepiness can cause behavioral problems, including aggressiveness and in­ attention, leading to a misdiagnosis of attention-deficit/hyperactivity disorder. Seizures. In young children, cataplexy can be misdiagnosed as seizures. Seizures are not conmionly triggered by emotions, and when they are, the trigger is not usually laughing or joking. During a seizure, individuals are more likely to hurt themselves when falling. Sei­ zures characterized by isolated atonia are rarely seen in isolation of other seizures, and they also have signatures on the electroencephalogram. Chorea and movement disorders. In young children, cataplexy can be misdiagnosed as chorea or pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, especially in the context of a strep throat infection and high antistreptolysin O antibody levels. Some children may have an overlapping movement disorder close to on­ set of the cataplexy. Schizophrenia. In the presence of florid and vivid hypnagogic hallucinations, individuals may think these experiences are real—a feature that suggests schizophrenia. Similarly, with stimulant treatment, persecutory delusions may develop. If cataplexy is present, the clinician should first assume that these symptoms are secondary to narcolepsy before con­ sidering a co-occurring diagnosis of schizophrenia.

Comorbidity Narcolepsy can co-occur with bipolar, depressive, and anxiety disorders, and in rare cases with schizophrenia. Narcolepsy is also associated with increased body mass index or obe­

sity, especially when the narcolepsy is untreated. Rapid weight gain is common in young children with a sudden disease onset. Comorbid sleep apnea should be considered if there is a sudden aggravation of preexisting narcolepsy.

Relationship to international Classification of Sleep Disorders The International Classification of Sleep Disorders, 2nd Edition (ICSD-2), differentiates five subtypes of narcolepsy.

Breathing-Related Sleep Disorders The breathing-related sleep disorders category encompasses three relatively distinct dis­ orders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypo­ ventilation.

Obstructive Sleep Apnea Hypopnea Diagnostic Criteria

327.23 (G47.33)

A. Either (1) or (2): 1. Evidence 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 opportuni­ ties to sleep that is not better explained by another mental disorder (including a sleep disorder) and is not attributable to another medical condition. 2. Evidence by polysomnography of 15 or more obstructive apneas 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.

Specifiers Disease severity is measured by a count of the number of apneas plus hypopneas per hour of sleep (apnea hypopnea index) using polysomnography or other overnight monitoring. Overall severity is also informed by levels of nocturnal desaturation and sleep fragmen­ tation (measured by brain cortical arousal frequency and sleep stages) and degree of as­ sociated symptoms and daytime impairment. However, the exact number and thresholds may vary according to the specific measurement techniques used, and these numbers may change over time. Regardless of the apnea hypopnea index (count) per se, the disorder is considered to be more severe when apneas and hypopneas are accompanied by significant oxygen hemoglobin desaturation (e.g., when more than 10% of the sleep time is spent at desaturation levels of less than 90%) or when sleep is severely fragmented as shown by an

elevated arousal index (arousal index greater than 30) or reduced stages in deep sleep (e.g., percentage stage N3 [slow-v^ave sleep] less than 5%).

Diagnostic Features Obstructive sleep apnea hypopnea is the most common breathing-related sleep disorder. It is characterized by repeated episodes of upper (pharyngeal) airw^ay obstruction (apneas and hypopneas) during sleep. Apnea refers to the total absence of airflow, and hypopnea re­ fers to a reduction in airflow. Each apnea or hypopnea represents a reduction in breathing of at least 10 seconds in duration in adults or two missed breaths in children and is typi­ cally associated with drops in oxygen saturation of 3% or greater and/or an electroencephalographic arousal. Both sleep-related (nocturnal) and wake-time symptoms are common. The cardinal symptoms of obstructive sleep apnea hypopnea are snoring and daytime sleepiness. Obstructive sleep apnea hypopnea in adults is diagnosed on the basis of polysomnographic findings and symptoms. The diagnosis is based on symptoms of 1) nocturnal breathing disturbances (i.e., snoring, snorting/gasping, breathing pauses during sleep), or 2) daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that are not better explained by another mental disorder and not attributable to an­ other medical condition, along with 3) evidence by polysomnography of five or more ob­ structive apneas or hypopneas per hour of sleep (Criterion Al). Diagnosis can be made in the absence of these symptoms if there is evidence by polysomnography of 15 or more ob­ structive apneas and/or hypopneas per hour of sleep (Criterion A2). Specific attention to disturbed sleep occurring in association with snoring or breathing pauses and physical findings that increase risk of obstructive sleep apnea hypopnea (e.g., central obesity, crowded pharyngeal airway, elevated blood pressure) is needed to reduce the chance of misdiagnosing this treatable condition.

Associated Features Supporting Diagnosis Because of the frequency of nocturnal awakenings that occur with obstructive sleep apnea hypopnea, individuals may report symptoms of insomnia. Other common, though non­ specific, symptoms of obstructive sleep apnea hypopnea are heartburn, nocturia, morning headaches, dry mouth, erectile dysfunction, and reduced libido. Rarely, individuals may complain of difficulty breathing while lying supine or sleeping. Hypertension may occur in more than 60% of individuals with obstructive sleep apnea hypopnea.

Prevalence Obstructive sleep apnea hypopnea is a very common disorder, affecting at least l% -2% of children, 2%-15% of middle-age adults, and more than 20% of older individuals. In the general community, prevalence rates of undiagnosed obstructive sleep apnea hypopnea may be very high in elderly individuals. Since the disorder is strongly associated with obe­ sity, increases in obesity rates are likely to be accompanied by an increased prevalence of this disorder. Prevalence may be particularly high among males, older adults, and certain racial/ethnic groups. In adults, the male-to-female ratio of obstructive sleep apnea hypop­ nea ranges from 2:1 to 4:1. Gender differences decline in older age, possibly because of an increased prevalence in females after menopause. There is no gender difference among prepubertal children.

Deveiopment and Course The age distribution of obstructive sleep apnea hypopnea likely follows a J-shaped distri­ bution. There is a peak in children ages 3-8 years when the nasopharynx may be compro­ mised by a relatively large mass of tonsillar tissue compared with the size of the upper

airway. With growth of the airway and regression of lymphoid tissue during later child­ hood, there is reduction in prevalence. Then, as obesity prevalence increases in midlife and females enter menopause, obstructive sleep apnea hypopnea again increases. The course in older age is unclear; the disorder may level off after age 65 years, but in other individ­ uals, prevalence may increase with aging. Because there is some age dependency of the oc­ currence of apneas and hypopneas, polysomnographic results must be interpreted in light of other clinical data. In particular, significant clinical symptoms of insomnia or hyper­ somnia should be investigated regardless of the individual's age. Obstructive sleep apnea hypopnea usually has an insidious onset, gradual progression, and persistent course. Typically the loud snoring has been present for many years, often since childhood, but an increase in its severity may lead the individual to seek evaluation. Weight gain may precipitate an increase in symptoms. Although obstructive sleep apnea hypopnea can occur at any age, it most commonly manifests among individuals ages 40-60 years. Over 4-5 years, the average apnea hypopnea index increases in adults and older individuals by ap­ proximately two apneas/hypopneas per hour. The apnea hypopnea index is increased and in­ cident obstructive sleep apnea hypopnea is greater among individuals who are older, who are male, or who have a higher baseline body mass index (BMI) or increase their BMI over time. Spontaneous resolution of obstructive sleep apnea hypopnea has been reported with weight loss, particularly after bariatric surgery. In children, seasonal variation in obstructive sleep ap­ nea hypopnea has been observed, as has improvement with overall growth. In young children, the signs and symptoms of obstructive sleep apnea hypopnea may be more subtle than in adults, making diagnosis more difficult to establish. Polysomnography is useful in confirming diagnosis. Evidence of fragmentation of sleep on the polysomnogram may not be as apparent as in studies of older individuals, possibly because of the high homeo­ static drive in young individuals. Symptoms such as snoring are usually parent-reported and thus have reduced sensitivity. Agitated arousals and unusual sleep postures, such as sleeping on the hands and knees, may occur. Nocturnal enuresis also may occur and should raise the suspicion of obstructive sleep apnea hypopnea if it recurs in a child who was previously dry at night. Children may also manifest excessive daytime sleepiness, although this is not as com­ mon or pronounced as in adults. Daytime mouth breathing, difficulty in swallowing, and poor speech articulation are also common features in children. Children younger than 5 years more often present with nighttime symptoms, such as observed apneas or labored breathing, than with l^havioral symptoms (i.e., the nighttime symptoms are more noticeable and more often bring the child to clinical attention). In children older than 5 years, daytime symptoms such as sleepiness and behavioral problems (e.g., impulsivity and hyperactivity), attention-deficit/ hyperactivity disorder, learning difficulties, and morning headaches are more often the focus of concern. Children with obstructive sleep apnea hypopnea also may present with failure to thrive and developmental delays. In young children, obesity is a less common risk factor, while delayed growth and "failure to thrive" may be present.

Risk and Prognostic Factors Genetic and physiological. The major risk factors for obstructive sleep apnea hypopnea are obesity and male gender. Others include maxillary-mandibular retrognathia or micro­ gnathia, positive family history of sleep apnea, genetic syndromes that reduce upper airway patency (e.g., Down's syndrome, Treacher Collin's syndrome), adenotonsillar hy­ pertrophy (especially in young children), menopause (in females), and various endocrine syndromes (e.g., acromegaly). Compared with premenopausal females, males are at in­ creased risk for obstructive sleep apnea hypopnea, possibly reflecting the influences of sex hormones on ventilatory control and body fat distribution, as well as because of gender differences in airway structure. Medications for mental disorders and medical conditions that tend to induce somnolence may worsen the course of apnea symptoms if these med­ ications are not managed carefully.

Obstructive sleep apnea hypopnea has a strong genetic basis, as evidenced by the sig­ nificant familial aggregation of the apnea hypopnea index. The prevalence of obstructive sleep apnea hypopnea is approximately twice as high among the first-degree relatives of probands with obstructive sleep apnea hypopnea as compared with members of control families. One-third of the variance in the apnea hypopnea index is explained by shared fa­ milial factors. Although genetic markers with diagnostic or prognostic value are not yet available for use, eliciting a family history of obstructive sleep apnea hypopnea should in­ crease the clinical suspicion for the disorder.

Culture-Related Diagnostic Issues There is a potential for sleepiness and fatigue to be reported differently across cultures. In some groups, snoring may be considered a sign of health and thus may not trigger con­ cerns. Individuals of Asian ancestry may be at increased risk for obstructive sleep apnea hypopnea despite relatively low BMI, possibly reflecting the influence of craniofacial risk factors that narrow the nasopharynx.

Gender-Related Issues Females may more commonly report fatigue rather than sleepiness and may underreport snoring.

Diagnostic Markers Polysomnography provides quantitative data on frequency of sleep-related respiratory disturbances and associated changes in oxygen saturation and sleep continuity. Polysom­ nographie findings in children differ from those in adults in that children demonstrate labored breathing, partial obstructive hypoventilation with cyclical desaturations, hypercapnia and paradoxical movements. Apnea hypopnea index levels as low as 2 are used to define thresholds of abnormality in children. Arterial blood gas measurements while the individual is awake are usually normal, but some individuals can have waking hypoxemia or hypercapnia. This pattern should alert the clinician to the possibility of coexisting lung disease or hypoventilation. Imaging procedures may reveal narrowing of the upper airway. Cardiac testing may show evidence of impaired ventricular function. Individuals with severe nocturnal oxygen desaturation may also have el­ evated hemoglobin or hematocrit values. Validated sleep measures (e.g., multiple sleep la­ tency test [MSLT], maintenance of wakefulness test) may identify sleepiness.

Functional Consequences of Obstructive Sleep Apnea Hypopnea More than 50% of individuals with moderate to severe obstructive sleep apnea hypopnea report symptoms of daytime sleepiness. A twofold increased risk of occupational accidents has been reported in association with symptoms of snoring and sleepiness. Motor vehicle crashes also have been reported to be as much as sevenfold higher among individuals with elevated apnea hypopnea index values. Clinicians should be cognizant of state govern­ ment requirements for reporting this disorder, especially in relationship to commercial drivers. Reduced scores on measures of health-related quality of life are common in individ­ uals with obstructive sleep apnea hypopnea, with the largest decrements observed in the physical and vitality subscales.

Differential Diagnosis Primary snoring and other sleep disorders. Individuals with obstructive sleep apnea hypopnea must be differentiated from individuals with primary snoring (i.e., otherwise

asjnnptomatic individuals who snore and do not have abnormalities on overnight polysom­ nography). Individuals with obstructive sleep apnea hypopnea may additionally report nocturnal gasping and choking. The presence of sleepiness or other daytime symptoms not explained by other etiologies suggests the diagnosis of obstructive sleep apnea hypop­ nea, but this differentiation requires polysomnography. Definitive differential diagnosis between hypersomnia, central sleep apnea, sleep-related hypoventilation, and obstructive sleep apnea hypopnea also requires polysomnographic studies. Obstructive sleep apnea hypopnea must be differentiated from other causes of sleepi­ ness, such as narcolepsy, hypersonmia, and circadian rhythm sleep disorders. Obstructive sleep apnea hypopnea can be differentiated from narcolepsy by the absence of cataplexy, sleep-related hallucinations, and sleep paralysis and by the presence of loud snoring, gasping during sleep, or observed apneas in sleep. Daytime sleep episodes in narcolepsy are characteristically shorter, more refreshing, and more often associated with dreaming. Obstructive sleep apnea hypopnea shows characteristic apneas and hypopneas and oxy­ gen desaturation during nocturnal polysomnographic studies. Narcolepsy results in mul­ tiple sleep-onset rapid eye movement (REM) periods during the MSLT. Narcolepsy, like obstructive sleep apnea hypopnea, may be associated with obesity, and some individuals have concurrent narcolepsy and obstructive sleep apnea hypopnea. A diagnosis of narco­ lepsy does not exclude the diagnosis of obstructive sleep apnea hypopnea, as the two con­ ditions may co-occur. Insomnia disorder. For individuals complaining of difficulty initiating or maintaining sleep or early-moming awakenings, insomnia disorder can be differentiated from obstruc­ tive sleep apnea hypopnea by the absence of snoring and the absence of the history, signs, and symptoms characteristic of the latter disorder. However, insomnia and obstructive sleep apnea hypopnea may coexist, and if so, both disorders may need to be addressed concurrently to improve sleep. Panic attacks. Nocturnal panic attacks may include symptoms of gasping or choking during sleep that may be difficult to distinguish clinically from obstructive sleep apnea hy­ popnea. However, the lower frequency of episodes, intense autonomic arousal, and lack of excessive sleepiness differentiate nocturnal panic attacks from obstructive sleep apnea hy­ popnea. Polysomnography in individuals with nocturnal panic attacks does not reveal the typical pattern of apneas or oxygen desaturation characteristic of obstructive sleep apnea hypopnea. Individuals with obstructive sleep apnea hypopnea do not provide a history of daytime panic attacks. Attention-deficit/hyperactivity disorder. Attention-defidt/hyperactivity disorder in chil­ dren may include symptoms of inattention, academic impairment, hyperactivity, and in­ ternalizing behaviors, all of which may also be symptoms of childhood obstructive sleep apnea hypopnea. The presence of other symptoms and signs of childhood obstructive sleep apnea hypopnea (e.g., labored breathing or snoring during sleep and adenotonsillar hypertrophy) would suggest the presence of obstructive sleep apnea hypopnea. Obstruc­ tive sleep apnea hypopnea and attention-deficit/hyperactivity disorder may commonly co-occur, and there may be causal links between them; therefore, risk factors such as en­ larged tonsils, obesity, or a family history of sleep apnea may help alert the clinician to their co-occurrence. Substance/medication-induced insomnia or hypersomnia. Substance use and substance withdrawal (including medications) can produce insomnia or hypersomnia. A careful his­ tory is usually sufficient to identify the relevant substance/medication, and follow-up shows improvement of the sleep disturbance after discontinuation of the substance/med­ ication. In other cases, the use of a substance/medication (e.g., alcohol, barbiturates, ben­ zodiazepines, tobacco) has been shown to exacerbate obstructive sleep apnea hypopnea. An individual with symptoms and signs consistent with obstructive sleep apnea hypop-

nea should receive that diagnosis, even in the presence of concurrent substance use that is exacerbating the condition. \

Comorbidity Systemic hypertension, coronary artery disease, heart failure, stroke, diabetes, and increased mortality are consistently associated with obstructive sleep apnea hypopnea. Risk esti­ mates vary from 30% to as much as 300% for moderate to severe obstructive sleep apnea hypopnea. Evidence of pulmonary hypertension and right heart failure (e.g., cor pulmo­ nale, ankle edema, hepatic congestion) are rare in obstructive sleep apnea hypopnea and when present indicate either very severe disease or associated hypoventilation or cardio­ pulmonary comorbidities. Obstructive sleep apnea hypopnea also may occur with in­ creased frequency in association with a number of medical or neurological conditions (e.g., cerebrovascular disease, Parkinson's disease). Physical findings reflect the co-occurrence of these conditions. As many as one-third of individuals referred for evaluation of obstructive sleep apnea hypopnea report symptoms of depression, with as many of 10% having depression scores consistent with moderate to severe depression. Severity of obstructive sleep apnea hypop­ nea, as measured by the apnea hypopnea index, has been foimd to be correlated w i^ se­ verity of symptoms of depression. This association may be stronger in males than in females.

Reiationsliip to internationai Ciassification of Sieep Disorders The International Classification of Sleep Disorders, 2nd Edition (ICSD-2), differentiates 11 sub­ types of "sleep-related breathing disorders," including primary central sleep apnea, ob­ structive sleep apnea, and sleep-related hypoventilation.

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 epi­

sodes of apneas and hypopneas during sleep caused by variability in respiratory effort but without evidence of ainway obstruction. 786.04 (R06.3) Clieyne-Stokes breathing: A pattern of periodic crescendodecrescendo 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 genera­ tors in the medulla as well as the differential effects on hypoxic versus hypercapnic re­ spiratory drive. Coding note (for 780.57 [G47.37] code only): When an opioid use disorder is present, first

code the opioid use disorder: 305.50 (F11.10) mild opioid use disorder or 304.00 (F11.20) moderate or severe opioid use disorder; then code 780.57 (G47.37) central sleep apnea comorbid with opioid use. When an opioid use disorder is not present (e.g., after a one­ time heavy use of the substance), code only 780.57 (G47.37) central sleep apnea comor­ bid with opioid use.

Note: See the section “Diagnostic Features” in text. 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 frag­ mentation that occur as a consequence of repetitive respiratory disturbances.

Subtypes Idiopathic central sleep apnea and Cheyne-Stokes breathing are characterized by increased gain of the ventilatory control system, also referred to as high loop gain, which leads to in­ stability in ventilation and PaC02 levels. This instability is termed periodic breathing and can be recognized by hyperventilation alternating with hypoventilation. Individuals with these disorders typically have pC02 levels while awake that are slightly hypocapneic or normocapneic. Central sleep apnea may also manifest during initiation of treatment of ob­ structive sleep apnea hypopnea or may occur in association with obstructive sleep apnea hypopnea syndrome (termed complex sleep apnea). The occurrence of central sleep apnea in association with obstructive sleep apnea is also considered to be due to high loop gain. In contrast, the pathogenesis of central sleep apnea comorbid with opioid use has been at­ tributed to the effects of opioids on the respiratory rhythm generators in the medulla as well as to its differential effects on hypoxic versus hypercapneic respiratory drive. These individuals may have elevated pC02 levels while awake. Individuals receiving chronic methadone maintenance therapy have been noted to have increased sonmolence and de­ pression, although the role of breathing disorders associated with opioid medication in caus­ ing these problems has not been studied.

Specifiers An increase in the central apnea index (i.e., number of central apneas per hour of sleep) re­ flects an increase in severity of central sleep apnea. Sleep continuity and quality may be markedly impaired with reductions in restorative stages of non-rapid eye movement (REM) sleep (i.e., decreased slow-wave sleep [stage N3]). In individuals with severe CheyneStokes breathing, the pattern can also be observed during resting wakefulness, a finding that is thought to be a poor prognostic marker for mortality.

Diagnostic Features Central sleep apnea disorders are characterized by repeated episodes of apneas and hypopneas during sleep caused by variability in respiratory effort. These are disorders of ventilatory control in which respiratory events occur in a periodic or intermittent pattern. Idiopathic central sleep apnea is characterized by sleepiness, insomnia, and awakenings due to dyspnea in association with five or more central apneas per hour of sleep. Central sleep apnea occurring in individuals with heart failure, stroke, or renal failure typically have a breathing pattern called Cheyne-Stokes breathing, which is characterized by a pattern of periodic crescendo-decrescendo variation in tidal volume that results in central apneas and hypopneas occurring at a frequency of at least five events per hour that are accompa­ nied by frequent arousals. Central and obstructive sleep apneas may coexist; the ratio of central to obstructive apneas/hypopneas may be used to identify which condition is pre­ dominant. Alterations in neuromuscular control of breathing can occur in association with med­ ications or substances used in individuals with mental health conditions, which can cause or exacerbate impairments of respiratory rhythm and ventilation. Individuals taking these medications have a sleep-related breathing disorder that could contribute to sleep distur­ bances and symptoms such as sleepiness, confusion, and depression. Specifically, chronic

use of long-acting opioid medications is often associated with impairment of respiratory con­ trol leading to central sleep apnea.

Associated Features Supporting Diagnosis Individuals with central sleep apnea hypopneas can manifest with sleepiness or insomnia. There can be complaints of sleep fragmentation, including awakening with dyspnea. Some individuals are asymptomatic. Obstructive sleep apnea hypopnea can coexist with Cheyne-Stokes breathing, and thus snoring and abruptly terminating apneas may be ob­ served during sleep.

Prevaience The prevalence of idiopathic central sleep apnea is unknown but thought to be rare. The prevalence of Cheyne-Stokes breathing is high in individuals with depressed cardiac ven­ tricular ejection fraction. In individuals with an ejection fraction of less than 45%, the prev­ alence has been reported to be 20% or higher. The male-to-female ratio for prevalence is even more highly skewed toward males than for obstructive sleep apnea hypopnea. Prev­ alence increases with age, and most patients are older than 60 years. Cheyne-Stokes breath­ ing occurs in approximately 20% of individuals with acute stroke. Central sleep apnea comorbid with opioid use occurs in approximately 30% of individuals taking chronic opi­ oids for nonmalignant pain and similarly in individuals receiving methadone mainte­ nance therapy.

Development and Course The onset of Cheyne-Stokes breathing appears tied to the development of heart failure. The Cheyne-Stokes breathing pattern is associated with oscillations in heart rate, blood pres­ sure and oxygen desaturation, and elevated sympathetic nervous system activity that can promote progression of heart failure. The clinical significance of Cheyne-Stokes breathing in the setting of stroke is not known, but Cheyne-Stokes breathing may be a transient find­ ing that resolves with time after acute stroke. Central sleep apnea comorbid with opioid use has been documented with chronic use (i.e., several months).

Risic and Prognostic Factors Genetic and physiological. Cheyne-Stokes breathing is frequently present in individu­ als with heart failure. The coexistence of atrial fibrillation further increases risk, as do older age and male gender. Cheyne-Stokes breathing is also seen in association with acute stroke and possibly renal failure. The underlying ventilatory instability in the setting of heart fail­ ure has been attributed to increased ventilatory chemosensitivity and hyperventilation due to pulmonary vascular congestion and circulatory delay. Central sleep apnea is seen in individuals taking long-acting opioids.

Diagnostic l\/larl(ers Physical findings seen in individuals with a Cheyne-Stokes breathing pattern relate to its risk factors. Findings consistent with heart failure, such as jugular venous distension, S3 heart sound, lung crackles, and lower extremity edema, may be present. Polysonmography is used to characterize the breathing characteristics of each breathing-related sleep disorder subtype. Central sleep apneas are recorded when periods of breathing cessation for longer than 10 seconds occur. Cheyne-Stokes breathing is characterized by a pattern of periodic crescendo-decrescendo variation in tidal volume that results in central apneas and hypopneas occurring at a frequency of at least five events per hour that are accompa­ nied by frequent arousals. The cycle length of Cheyne-Stokes breathing (or time from end of one central apnea to the end of the next apnea) is about 60 seconds.

Functional Consequences of Central Sleep Apnea Idiopathic central sleep apnea has been reported to cause symptoms of disrupted sleep, in­ cluding insomnia and sleepiness. Cheyne-Stokes breathing with comorbid heart failure has been associated with excessive sleepiness, fatigue, and insomnia, although many in­ dividuals may be asymptomatic. Coexistence of heart failure and Cheyne-Stokes breath­ ing may be associated with increased cardiac arrhythmias and increased mortality or cardiac transplantation. Individuals with central sleep apnea comorbid with opioid use may present with symptoms of sleepiness or insomnia.

Differential Diagnosis Idiopathic central sleep apnea must be distinguished from other breathing-related sleep disorders, other sleep disorders, and medical conditions and mental disorders that cause sleep fragmentation, sleepiness, and fatigue. This is achieved using polysomnography. Other breathing-related sleep disorders and sleep disorders. Central sleep apnea can be distinguished from obstructive sleep apnea hypopnea by the presence of at least five central apneas per hour of sleep. These conditions may co-occur, but central sleep apnea is considered to predominate when the ratio of central to obstructive respiratory events ex­ ceeds 50%. Cheyne-Stokes breathing can be distinguished from other mental disorders, including other sleep disorders, and other medical conditions that cause sleep fragmentation, sleep­ iness, and fatigue based on the presence of a predisposing condition (e.g., heart failure or stroke) and signs and polysomnographic evidence of the characteristic breathing pattern. Polysomnographie respiratory findings can help distinguish Cheyne-Stokes breathing from insomnia due to other medical conditions. High-altitude periodic breathing has a pattern that resembles Cheyne-Stokes breathing but has a shorter cycle time, occurs only at high altitude, and is not associated with heart failure. Central sleep apnea comorbid with opioid use can be differentiated from other types of breathing-related sleep disorders based on the use of long-acting opioid medications in conjunction with polysomnographic evidence of central apneas and periodic or ataxic breathing. It can be distinguished from insomnia due to drug or substance use based on polysomnographic evidence of central sleep apnea.

Comorbidity Central sleep apnea disorders are frequently present in users of long-acting opioids, such as methadone. Individuals taking these medications have a sleep-related breathing disor­ der that could contribute to sleep disturbances and symptoms such as sleepiness, confu­ sion, and depression. While the individual is asleep, breathing patterns such as central apneas, periodic apneas, and ataxic breathing may be observed. Obstructive sleep apnea hypopnea may coexist with central sleep apnea, and features consistent with this condi­ tion can also be present (see 'Obstructive Sleep Apnea Hypopnea" earlier in this chapter). Cheyne-Stokes breathing is more commonly observed in association with conditions that include heart failure, stroke, and renal failure and is seen more frequently in individuals with atrial fibrillation. Individuals with Cheyne-Stokes breathing are more likely to be older, to be male, and to have lower weight than individuals with obstructive sleep apnea hypopnea.

Sleep-Related Hypoventilation --------------------1-------------------------------------------------------------------------------------------

Diagnostic Criteria A. Polysomnograpy demonstrates episodes of decreased respiration associated with el­ evated 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 liypoventilation: This subtype is not attributable to any

readily identified 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 mis­ match and variably reduced ventilatory drive. Such individuals usually are character­ ized by body mass index of greater than 30 and hypercapnia during wakefulness (with a PCO2 of greater than 45), without other evidence of hypoventilation. Specify current severity:

Severity is graded according to the degree of hypoxemia and hypercarbia present dur­ ing 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.

Subtypes Regarding obesity hypoventilation disorder, the prevalence of obesity hypoventilation in the general population is not known but is thought to be increasing in association with the increased prevalence of obesity and extreme obesity.

Diagnostic Features Sleep-related hypoventilation can occur independently or, more frequently, comorbid with medical or neurological disorders, medication use, or substance use disorder. Al­ though symptoms are not mandatory to make this diagnosis, individuals often report excessive daytime sleepiness, frequent arousals and awakenings during sleep, morning headaches, and insomnia complaints.

Associated Features Supporting Diagnosis Individuals with sleep-related hypoventilation can present with sleep-related complaints of insomnia or sleepiness. Episodes of orthopnea can occur in individuals with diaphragm weakness. Headaches upon awakening may be present. During sleep, episodes of shallow breathing may be observed, and obstructive sleep apnea hypopnea or central sleep apnea may coexist. Consequences of ventilatory insufficiency, including pulmonary hyperten­ sion, cor pulmonale (right heart failure), polycythemia, and neurocognitive dysfunction.

can be present. With progression of ventilatory insufficiency, blood gas abnormalities ex­ tend into wakefulness. Features of the medical condition causing sleep-related hypoven­ tilation can also be present. Episodes of hypoventilation may be associated with frequent arousals or bradytachycardia. Individuals may complain of excessive sleepiness and in­ somnia or morning headaches or may present with findings of neurocognitive dysfunction or depression. Hypoventilation may not be present during wakefulness.

Prevalence Idiopathic sleep-related hypoventilation in adults is very uncommon. The prevalence of congenital central alveolar hypoventilation is unknown, but the disorder is rare. Comorbid sleep-related hypoventilation (i.e., hypoventilation comorbid with other conditions, such as chronic obstructive pulmonary disease [COPD], neuromuscular disorders, or obe­ sity) is more common.

Development and Course Idiopathic sleep-related hypoventilation is thought to be a slowly progressive disorder of respiratory impairment. When this disorder occurs comorbidly with other disorders (e.g., COPD, neuromuscular disorders, obesity), disease severity reflects the severity of the un­ derlying condition, and the disorder progresses as the condition worsens. Complications such as pulmonary hypertension, cor pulmonale, cardiac dysrhythmias, polycythemia, neurocognitive dysfunction, and worsening respiratory failure can develop with increas­ ing severity of blood gas abnormalities. Congenital central alveolar hypoventilation usually manifests at birth with shallow, erratic, or absent breathing. This disorder can also manifest during infancy, childhood, and adulthood because of variable penetrance of the PHOX2B mutation. Children with congenital central alveolar hypoventilation are more likely to have disorders of the auto­ nomic nervous system, Hirschsprung's disease, neural crest tumors, and characteristic box­ shaped face (i.e., the face is short relative to its width).

Risk and Prognostic Factors Environmental. Ventilatory drive can be reduced in individuals using central nervous system depressants, including benzodiazepines, opiates, and alcohol. Genetic and physiological. Idiopathic sleep-related hypoventilation is associated with reduced ventilatory drive due to a blunted chemoresponsiveness to CO2 (reduced respi­ ratory drive; i.e., "won't breathe"), reflecting underlying neurological deficits in centers governing the control of ventilation. More commonly, sleep-related hypoventilation is co­ morbid with another medical condition, such as a pulmonary disorder, a neuromuscular or chest wall disorder, or hypothyroidism, or with use of medications (e.g., benzodiaze­ pines, opiates). In these conditions, the hypoventilation may be a consequence of in­ creased work of breathing and/or impairment of respiratory muscle function (i.e., "can't breathe") or reduced respiratory drive (i.e., "won't breathe"). Neuromuscular disorders influence breathing through impairment of respiratory mo­ tor innervation or respiratory muscle function. They include conditions such as amyo­ trophic lateral sclerosis, spinal cord injury, diaphragmatic paralysis, myasthenia gravis, Lambert-Eaton syndrome, toxic or metabolic myopathies, postpolio syndrome, and Charcot-Marie-Tooth syndrome. Congenital central alveolar hypoventilation is a genetic disorder attributable to muta­ tions of PH0X2B, a gene that is crucial for the development of the embryonic autonomic nervous system and neural crest derivatives. Children with congenital central alveolar hy­ poventilation show blunted ventilatory responses to hypercapnia, especially in non-rapid eye movement sleep.

Gender-Related Diagnostic Issues Gender distributions for sleep-related hypoventilation occurring in association with comorbid conditions reflect the gender distributions of the comorbid conditions. For exam­ ple, COPD is more frequently present in males and with increasing age.

Diagnostic Markers Sleep-related hypoventilation is diagnosed using polysomnography showing sleep-related hypoxemia and hypercapnia that is not better explained by another breathing-related sleep disorder. The documentation of increased arterial pC02 levels to greater than 55 mmHg during sleep or a 10 mmHg or greater increase in pC02 levels (to a level that also exceeds 50 mmHg) during sleep in comparison to awake supine values, for 10 minutes or longer, is the gold standard for diagnosis. However, obtaining arterial blood gas determinations dur­ ing sleep is impractical, and non-invasive measures of pC02 have not been adequately val­ idated during sleep and are not widely used during polysomnography in adults. Prolonged and sustained decreases in oxygen saturation (oxygen saturation of less than 90% for more than 5 minutes with a nadir of at least 85%, or oxygen saturation of less than 90% for at least 30% of sleep time) in the absence of evidence of upper airway obstruction are often used as an indication of sleep-related hypoventilation; however, this finding is not specific, as there are other potential causes of hypoxemia, such as that due to lung disease.

Functional Consequences of Sleep-Related Hypoventilation The consequences of sleep-related hypoventilation are related to the effects of chronic ex­ posure to hypercapnia and hypoxemia. These blood gas derangements cause vasocon­ striction of the pulmonary vasculature leading to pulmonary hypertension, which, if severe, can result in right-sided heart failure (cor pulmonale). Hypoxemia can lead to dys­ function of organs such as the brain, blood, and heart, leading to outcomes such as cog­ nitive dysfunction, polycythemia, and cardiac arrhythmias. Hypercapnia can depress ventilatory drive, leading to progressive respiratory failure.

Differential Diagnosis Other medical conditions affecting ventilation. In adults, the idiopathic variety of sleeprelated hypoventilation is very uncommon and is determined by excluding the presence of lung diseases, skeletal malformations, neuromuscular disorders, and other medical and neurological disorders or medications that affect ventilation. Sleep-related hypoventila­ tion must be distinguished from other causes of sleep-related hypoxemia, such as that due to lung disease. Other breathing-related sleep disorders. Sleep-related hypoventilation can be distin­ guished from obstructive sleep apnea hypopnea and central sleep apnea based on clinical features and findings on polysomnography. Sleep-related hypoventilation typically shows more sustained periods of oxygen desaturation rather that the periodic episodes seen in obstructive sleep apnea hypopnea and central sleep apnea. Obstructive sleep apnea hy­ popnea and central sleep apnea also show a pattern of discrete episodes of repeated air­ flow decreases that can be absent in sleep-related hypoventilation.

Comorbidity Sleep-related hypoventilation often occurs in association with a pulmonary disorder (e.g., in­ terstitial lung disease, COPD), with a neuromuscular or chest wall disorder (e.g., muscular dystrophies, post-polio syndrome, cervical spinal cord injury, obesity, kyphoscoliosis), or.

most relevant to the mental health provider, with medication use (e.g., benzodiazepines, opi­ ates). Congenital central alveolar hypoventilation often occurs in association with autonomic dysfunction and may occur in association with Hirschsprung's disease. COPD, a disorder of lower airway obstruction usually associated with cigarette smoking, can result in sleeprelated hypoventilation and hypoxemia. The presence of coexisting obstructive sleep apnea hypopnea is thought to exacerbate hypoxemia and hypercapnia during sleep and wakeful­ ness. The relationship between congenital central alveolar hypoventilation and idiopathic sleep-related hypoventilation is unclear; in some individuals, idiopathic sleep-related hy­ poventilation may represent cases of late-onset congenital central alveolar hypoventilation.

Relationship to internationai Ciassification of Sieep Disorders The International Classification of Sleep Disorders, 2nd Edition (ICSD-2), combines sleeprelated hypoventilation and sleep-related hypoxemia under the category of sleep-related hypoventilation/hypoxemic syndromes. This approach to classification reflects the fre­ quent co-occurrence of disorders that lead to hypoventilation and hypoxemia. In contrast, the classification used in DSM-5 reflects evidence that there are distinct sleep-related pathogenetic processes leading to hypoventilation.

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, oc­ cupational, and other important areas of functioning. Coding note: For ICD-9-CM, code 307.45 for all subtypes. For ICD-10-CM, code is based

on subtype. 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 convention­ ally acceptable earlier time. Specify if: Familial: A family history of delayed sleep phase is 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 con­ ventionally acceptable later sleep or wake times. Specify if: Familial: A family history of advanced sleep phase is present. 307.45 (G47.23) Irregular sleep-walte type: A temporally disorganized sleep-wake

pattern, such that the timing of sleep and wake periods is variable throughout the 24hour period.

307.45 (G47.24) Non-24-hour sleep-wake type: A pattern of sleep-wal400 mg) can cause or exacerbate anxiety and somatic symptoms and gastrointestinal distress. With acute, extremely high doses of caffeine, grand mal seizures and respiratory failure may result in death. Excessive caffeine use is as­ sociated with depressive disorders, bipolar disorders, eating disorders, psychotic disor­ ders, sleep disorders, and substance-related disorders, whereas individuals with anxiety disorders are more likely to avoid caffeine.

Caffeine Withdrawal Diagnostic Criteria

292.0 (F15.93)

A. Prolonged daily use of caffeine. B. Abrupt cessation of or reduction in caffeine use, followed within 24 hours by three (or more) of the following signs or symptoms: 1. 2. 3. 4. 5.

Headache. Marked fatigue or drowsiness. Dysphoric mood, depressed mood, or irritability. Difficulty concentrating. Flu-like symptoms (nausea, vomiting, or muscle pain/stiffness).

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 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.

Diagnostic Features The essential feature of caffeine withdrawal is the presence of a characteristic withdrawal syndrome that develops after the abrupt cessation of (or substantial reduction in) pro­ longed daily caffeine ingestion (Criterion B). The caffeine withdrawal syndrome is indi­ cated by three or more of the following (Criterion B): headache; marked fatigue or drowsiness; dysphoric mood, depressed mood, or irritability; difficulty concentrating; and flu-hke symptoms (nausea, vomiting, or muscle pain/stiffness). The withdrawal syn­ drome causes clinical significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The symptoms must not be associated with the physiological effects of another medical condition and are not better explained by an­ other mental disorder (Criterion D). Headache is the hallmark feature of caffeine withdrawal and may be diffuse, gradual in development, throbbing, severe, and sensitive to movement. However, other symptoms of caffeine withdrawal can occur in the absence of headache. Caffeine is the most widely used behaviorally active drug in the world and is present in many different types of bev­ erages (e.g., coffee, tea, maté, soft drinks, energy drinks), foods, energy aids, medications, and dietary supplements. Because caffeine ingestion is often integrated into social customs and daily rituals (e.g., coffee break, tea time), some caffeine consumers may be unaware of their physical dependence on caffeine. Thus, caffeine withdrawal symptoms could be un­ expected and misattributed to other causes (e.g., the flu, migraine). Furthermore, caffeine withdrawal symptoms may occur when individuals are required to abstain from foods and beverages prior to medical procedures or when a usual caffeine dose is missed be­ cause of a change in routine (e.g., during travel, weekends).

The probability and severity of caffeine withdrawal generally increase as a function of usual daily caffeine dose. However, there is large variability among individuals and within individuals across different episodes in the incidence, severity, and time course of withdrawal symptoms. Caffeine withdrawal symptoms may occur after abrupt cessation of relatively low chronic daily doses of caffeine (i.e., 100 mg).

Associated Features Supporting Diagnosis Caffeine abstinence has been shown to be associated with impaired behavioral and cogni­ tive performance (e.g., sustained attention). Electroencephalographic studies have shown that caffeine withdrawal symptoms are significantly associated with increases in theta power and decreases in beta-2 power. Decreased motivation to work and decreased socia­ bility have also been reported during caffeine withdrawal. Increased analgesic use during caffeine withdrawal has been documented.

Prevaience More than 85% of adults and children in the United States regularly consume caffeine, with adult caffeine consumers ingesting about 280 mg/day on average. The incidence and prevalence of the caffeine withdrawal syndrome in the general population are unclear. In the United States, headache may occur in approximately 50% of cases of caffeine absti­ nence. In attempts to permanently stop caffeine use, more than 70% of individuals may ex­ perience at least one caffeine withdrawal symptom (47% may experience headache), and 24% may experience headache plus one or more other symptoms as well as functional impairment due to withdrawal. Among individuals who abstain from caffeine for at least 24 hours but are not trying to permanently stop caffeine use, 11% may experience head­ ache plus one or more other symptoms as well as functional impairment. Caffeine con­ sumers can decrease the incidence of caffeine withdrawal by using caffeine daily or only infrequently (e.g., no more than 2 consecutive days). Gradual reduction in caffeine over a period of days or weeks may decrease the incidence and severity of caffeine withdrawal.

Deveiopment and Course Symptoms usually begin 12-24 hours after the last caffeine dose and peak after 1-2 days of abstinence. Caffeine withdrawal symptoms last for 2-9 days, with the possibility of withdrawal headaches occurring for up to 21 days. Symptoms usually remit rapidly (within 30-60 minutes) after re-ingestion of caffeine. Caffeine is unique in that it is a behaviorally active drug that is consumed by individ­ uals of nearly all ages. Rates of caffeine consumption and overall level of caffeine con­ sumption increase with age until the early to mid-30s and then level off. Although caffeine withdrawal among children and adolescents has been documented, relatively little is known about risk factors for caffeine withdrawal among this age group. The use of highly caffeinated energy drinks is increasing with in young individuals, which could increase the risk for caffeine withdrawal.

Risic and Prognostic Factors Temperamental. Heavy caffeine use has been observed among individuals with mental disorders, including eating disorders; smokers; prisoners; and drug and alcohol abusers. Thus, these individuals could be at higher risk for caffeine withdrawal upon acute caffeine abstinence. Environmental. The unavailability of caffeine is an environmental risk factor for incipi­ ent withdrawal symptoms. While caffeine is legal and usually widely available, there are conditions in which caffeine use may be restricted, such as during medical procedures, pregnancy, hospitalizations, religious observances, wartime, travel, and research partici­

pation. These external environmental circumstances may precipitate a withdrawal syn­ drome in vulnerable individuals. Genetic and physiological factors. Genetic factors appear to increase vulnerability to caffeine withdrawal, but no specific genes have been identified. Course modifiers. Caffeine withdrawal symptoms usually remit within 30-60 minutes of reexposure to caffeine. Doses of caffeine significantly less than one's usual daily dose may be sufficient to prevent or attenuate caffeine withdrawal symptoms (e.g., consump­ tion of 25 mg by an individual who typically consumes 300 mg).

Culture-Related Diagnostic Issues Habitual caffeine consumers who fast for religious reasons may be at increased risk for caf­ feine withdrawal.

Functional Consequences of Caffeine Withdrawal Disorder Caffeine withdrawal symptoms can vary from mild to extreme, at times causing functional impairment in normal daily activities. Rates of functional impairment range from 10% to 55% (median 13%), with rates as high as 73% found among individuals who also show other problematic features of caffeine use. Examples of functional impairment include be­ ing unable to work, exercise, or care for children; staying in bed all day; missing religious services; ending a vacation early; and cancelling a social gathering. Caffeine withdrawal headaches may be described by individuals as "the worst headaches" ever experienced. Decrements in cognitive and motor performance have also been observed.

Differential Diagnosis Other medical disorders and medical side effects. Several disorders should be consid­ ered in the differential diagnosis of caffeine withdrawal. Caffeine withdrawal can mimic migraine and other headache disorders, viral illnesses, sinus conditions, tension, other drug withdrawal states (e.g., from amphetamines, cocaine), and medication side effects. The final determination of caffeine withdrawal should rest on a determination of the pat­ tern and amount consumed, the time interval between caffeine abstinence and onset of symptoms, and the particular clinical features presented by the individual. A challenge dose of caffeine followed by symptom remission may be used to confirm the diagnosis.

Comorbidity Caffeine withdrawal may be associated with major depressive disorder, generalized anx­ iety disorder, panic disorder, antisocial personality disorder in adults, moderate to severe alcohol use disorder, and cannabis and cocaine use.

Other Caffeine-Induced Disorders The following caffeine-induced disorders are described in other chapters of the manual with disorders with which they share phenomenology (see the substance/medicationinduced mental disorders in these chapters): caffeine-induced anxiety disorder ("Anxiety Disorders") and caffeine-induced sleep disorder ("Sleep-Wake Disorders"). These caf­ feine-induced disorders are diagnosed instead of caffeine intoxication or caffeine with­ drawal only when the symptoms are sufficiently severe to warrant independent clinical attention.

Unspecified Caffeine-Related Disorder

____________ \______________________________________________________

______________________________________ 292.9 (F15.99) This category applies to presentations in whicfi symptoms characteristic of a caffeinerelated disorder that cause clinically significant distress or impairment in social, occupa­ tional, or other important areas of functioning predominate but do not meet the full criteria for any specific caffeine-related disorder or any of the disorders in the substance-related and addictive disorders diagnostic class.

Cannabis-Related Disorders Cannabis Use Disorder Cannabis Intoxication Cannabis Withdrawal Other Cannabis-Induced Disorders Unspecified Cannabis-Related Disorder

Cannabis Use Disorder Diagnostic Criteria A. A problematic pattern of cannabis use leading to clinically significant impairment or dis­ tress, as manifested by at least two of the following, occurring within a 12-month period: 1. Cannabis 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 cannabis use. 3. A great deal of time is spent in activities necessary to obtain cannabis, use canna­ bis, or recover from its effects. 4. Craving, or a strong desire or urge to use cannabis. 5. Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued cannabis use despite having persistent or recurrent social or interper­ sonal problems caused or exacerbated by the effects of cannabis. 7. Important social, occupational, or recreational activities are given up or reduced be­ cause of cannabis use. 8. Recurrent cannabis use in situations in which it is physically hazardous. 9. Cannabis 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 cannabis. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of cannabis to achieve intoxication or desired effect. b. Markedly diminished effect with continued use of the same amount of cannabis. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for cannabis (refer to Criteria A and B of the criteria set for cannabis withdrawal, pp. 517-518).

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TABLE 3

Dc^finitions of DSM-5 personality disorder trait domains and facets

DOMAINS (Polar Opposites) and Facets Definitions NEGATIVEAFFECTIVITY (vs. Emotional Stability)

Emotional lability

Anxiousness

Separation insecurity

Submissiveness

Hostility

Perseveration

Depressivity Suspiciousness Restricted affectivity (lack of)

DETACHMENT (vs. Extraversion)

Withdrawal

Intimacy avoidance Anhedonia Depressivity

Restricted affectivity

Suspiciousness

Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/ shame, worry, anger) and their behavioral (e.g., self-harm) and interpersonal (e.g., dependency) manifestations. Instability of emotional experiences and mood; emotions that are easily aroused, intense, and/or out of proportion to events and cir­ cumstances. Feelings of nervousness, tenseness, or panic in reaction to diverse situa­ tions; frequent worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful and apprehensive about uncertainty; expecting the worst to happen. Fears of being alone due to rejection by—and/or separation from— significant others, based in a lack of confidence in one's ability to care for oneself, both physically and emotionally. Adaptation of one's behavior to the actual or perceived interests and desires of others even when doing so is antithetical to one's own interests, needs, or desires. Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior. See also Antagonism. Persistence at tasks or in a particular way of doing things long after the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures or clear reasons for stopping. See Detachment. See Detachment. The lack o/this facet characterizes low levels of Negative Affectivity. See Detachment for definition of this facet.

Avoidance of socioemotional experience, including both withdrawal from interpersonal interactions (ranging from casual, daily interac­ tions to friendships to intimate relationships) and restricted affective experience and expression, particularly limited hedonic capacity. Preference for being alone to being with others; reticence in social sit­ uations; avoidance of social contacts and activity; lack of initiation of social contact. Avoidance of close or romantic relationships, interpersonal attach­ ments, and intimate sexual relationships. Lack of enjoyment from, engagement in, or energy for life's experiences; deficits in the capacity to feel pleasure and take interest in things. Feelings of being down, nüserable, and/or hopeless; difficulty recov­ ering from such moods; pessimism about the future; pervasive shame and/or guilt; feelings of inferior self-worth; thoughts of sui­ cide and suicidal behavior. Little reaction to emotionally arousing situations; constricted emo­ tional experience and expression; indifference and aloofness in nor­ matively engaging situations. Expectations of—and sensitivity to—signs of inteφersonal illintent or harm; doubts about loyalty and fidelity of others; feelings of being mistreated, used, and/or persecuted by others.

TA BLE 3

Definitions of DSIVI-S personality disorder trait domains and facets (continued)

DOMAINS (Polar Opposites) and Facets Definitions ANTAGONISM (vs. Agreeableness)

Manipulativeness Deceitfulness Grandiosity

Attention seeking Callousness

Hostility

DISINHIBITION (vs. Conscientiousness)

Irresponsibility

Impulsivity

Distractibility

Risk taking

Rigid perfectionism (lack of)

Behaviors that put the individual at odds with other people, includ­ ing an exaggerated sense of self-importance and a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both an unawareness of others' needs and feelings and a readiness to use others in the service of self-enhancement. Use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one's ends. Dishonesty and fraudulence; misrepresentation of self; embellish­ ment or fabrication when relating events. Believing that one is superior to others and deserves special treat­ ment; self-centeredness; feelings of entitlement; condescension toward others. Engaging in behavior designed to attract notice and to make oneself the focus of others' attention and admiration. Lack of concern for the feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one's actions on others. See Negative Affectivity. Orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stim­ uli, without regard for past learning or consideration of future consequences. Disregard for—and failure to honor—financial and other obliga­ tions or commitments; lack of respect for—and lack of followthrough on—agreements and promises; carelessness with others' property. Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans; a sense of urgency and self-harming behavior under emotional distress. Difficulty concentrating and focusing on tasks; attention is easily diverted by extraneous stimuli; difficulty maintaining goalfocused behavior, including both planning and completing tasks. Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one's limitations and denial of the reality of per­ sonal danger; reckless pursuit of goals regardless of the level of risk involved. Rigid insistence on everything being flawless, perfect, and without errors or faults, including one's own and others' performance; sac­ rificing of timeliness to ensure correctness in every detail; believ­ ing that there is only one right way to do things; difficulty changing ideas and/or viewpoint; preoccupation with details, organization, and order. The lac k o/this facet characterizes low levels of Disinhibition.

TA BLE 3

Definitions of DSM-5 personality disorder trait domains and facets (continued)

DOMAINS (Polar Opposites) and Facets Definitions PSYCHOTICISM (vs. Lucidity) Unusual beliefs and experiences Eccentricity

Cognitive and perceptual dysregulation

Exhibiting a wide range of culturally incongruent odd, eccentric, or unusual behaviors and cognitions, including both process (e.g., perception, dissociation) and content (e.g., beliefs). Belief that one has unusual abilities, such as mind reading, telekine­ sis, thought-action fusion, unusual experiences of reality, includ­ ing hallucination-like experiences. Odd, unusual, or bizarre behavior, appearance, and/or speech; having strange and unpredictable thoughts; saying unusual or inappropriate things. Odd or unusual thought processes and experiences, including depersonalization, derealization, and dissociative experiences; mixed sleep-wake state experiences; thought-control experiences.

P r o p o s e d C r ite riâ sets are presented for conditions on which future research is en­ couraged. The specific items, thresholds, and durations contained in these research crite­ ria sets were set by expert consensus—informed by literature review, data reanalysis, and field trial results, where available—and are intended to provide a common language for researchers and clinicians who are interested in studying these disorders. It is hoped that such research will allow the field to better understand these conditions and will inform decisions about possible placement in forthcoming editions of DSM. The DSM-5 Task Force and Work Groups subjected each of these proposed criteria sets to a careful empir­ ical review and invited wide commentary from the field as well as from the general public. The Task Force determined that there was insufficient evidence to warrant inclusion of these proposals as official mental disorder diagnoses in Section II. These proposed criteria sets are n o t intended f o r clinical use; o n ly the criteHa sets and disorders in Section I I o f D S M -5 are o fficially recognized and can be used f o r clin ica l purposes.

Attenuated Psychosis Syndrome Proposed Criteria A. At least one of the following symptoms is present in attenuated form, with relatively in­ tact reality testing, and is of sufficient severity or frequency to warrant clinical attention: 1. Delusions. 2. Hallucinations. 3. Disorganized speech. B. Symptom(s) must have been present at least once per week for the past month. C. Symptom(s) must have begun or worsened in the past year. D. Symptom(s) is sufficiently distressing and disabling to the individual to warrant clinical attention. E. Symptom(s) is not better explained by another mental disorder, including a depressive or bipolar disorder with psychotic features, and is not attributable to the physiological effects of a substance or another medical condition. F. Criteria for any psychotic disorder have never been met._______________________

Diagnostic Features Attenuated psychotic symptoms, as defined in Criterion A, are psychosis-like but below the threshold for a full psychotic disorder. Compared with psychotic disorders, the symptoms are less severe and more transient, and insight is relatively maintained. A diagnosis of atten­ uated psychosis syndrome requires state psychopathology associated with functional impairment rather than long-standing trait pathology. The psychopathology has not pro­ gressed to full psychotic severity. Attenuated psychosis syndrome is a disorder based on the manifest pathology and impaired function and distress. Changes in experiences and behav-

iors are noted by the individual and/or others, suggesting a change in mental state (i.e., the symptoms are of sufficient severity or frequency to warrant clinical attention) (Criterion A). Attenuated delusions (Criterion Al) may have suspiciousness/persecutory ideational con­ tent, including persecutory ideas of reference. The individual may have a guarded, distrust­ ful attitude. When the delusions are moderate in severity, the individual views others as untrustworthy and may be hypervigilant or sense ill will in others. When the delusions are severe but still within the attenuated range, the individual entertains loosely organized be­ liefs about danger or hostile intention, but the delusions do not have the fixed nature that is necessary for the diagnosis of a psychotic disorder. Guarded behavior in the interview can interfere with the ability to gather information. Reality testing and perspective can be elic­ ited with nonconfirming evidence, but the propensity for viewing the world as hostile and dangerous remains strong. Attenuated delusions may have grandiose content presenting as an unrealistic sense of superior capacity. When the delusions are moderate, the individual harbors notions of being gifted, influential, or special. When the delusions are severe, the in­ dividual has beliefs of superiority that often alienate friends and worry relatives. Thoughts of being special may lead to unrealistic plans and investments, yet skepticism about these at­ titudes can be elicited with persistent questioning and confrontation. Attenuated hallucinations (Criterion A2) include alterations in sensory perceptions, usually auditory and/or visual. When the hallucinations are moderate, the sounds and images are often unformed (e.g., shadows, trails, halos, murmurs, rumbling), and they are experienced as unusual or puzzling. When the hallucinations are severe, these experiences become more vivid and frequent (i.e., recurring illusions or hallucinations that capture at­ tention and affect thinking and concentration). These perceptual abnormalities may dis­ rupt behavior, but skepticism about their reality can still be induced. Disorganized communication (Criterion A3) may manifest as odd speech (vague, meta­ phorical, overelaborate, stereotyped), unfocused speech (confused, muddled, too fast or too slow, wrong words, irrelevant context, off track), or meandering speech (circumstantial, tan­ gential). When the disorganization is moderately severe, the individual frequently gets into irrelevant topics but responds easily to clarifying questions. Speech may be odd but under­ standable. At the moderately severe level, speech becomes meandering and circumstantial, and when the disorganization is severe, the individual fails to get to the point without external guidance (tangential). At the severe level, some thought blocking and/or loose as­ sociations may occur infrequently, especially when the individual is under pressure, but re­ orienting questions quickly return structure and organization to the conversation. The individual realizes that changes in mental state and/or in relationships are taking place. He or she maintains reasonable insight into the psychotic-like experiences and gen­ erally appreciates that altered perceptions are not real and magical ideation is not compel­ ling. The individual must experience distress and/or impaired performance in social or role functioning (Criterion D), and the individual or responsible others must note the changes and express concern, such that clinical care is sought (Criterion A).

Associated Features Supporting Diagnosis The individual may experience magical thinking, perceptual aberrations, difficulty in con­ centration, some disorganization in thought or behavior, excessive suspiciousness, anxi­ ety, social withdrawal, and disruption in sleep-wake cycle. Impaired cognitive function and negative symptoms are often observed. Neuroimaging variables distinguish cohorts with attenuated psychosis syndrome from normal control cohorts with patterns similar to, but less severe than, that observed in schizophrenia. However, neuroimaging data is not diagnostic at the individual level.

Prevalence The prevalence of attenuated psychosis syndrome is unknown. Symptoms in Criterion A are not uncommon in the non-help-seeking population, ranging from 8%-13% for hallu­

cinatory experiences and delusional thinking. There appears to be a slight male prepon­ derance for attei^uated psychosis syndrome.

Development and Course Onset of attenuated psychosis syndrome is usually in mid-to-late adolescence or early adulthood. It may be preceded by normal development or evidence for impaired cogni­ tion, negative symptoms, and/or impaired social development. In help-seeking cohorts, approximately 18% in 1 year and 32% in 3 years may progress symptomatically and met criteria for a psychotic disorder. In some cases, the syndrome may transition to a depres­ sive or bipolar disorder with psychotic features, but development to a schizophrenia spec­ trum disorder is more frequent. It appears that the diagnosis is best applied to individuals ages 15-35 years. Long-term course is not yet described beyond 7-12 years.

Risk and Prognostic Factors Temperamental. Factors predicting prognosis of attenuated psychosis syndrome have not been definitively characterized, but the presence of negative symptoms, cognitive im­ pairment, and poor functioning are associated with poor outcome and increase risk of transition to psychosis. Genetic and physiological. A family history of psychosis places the individual with at­ tenuated psychosis syndrome at increased risk for developing a full psychotic disorder. Structural, functional, and neurochemical imaging data are associated with increased risk of transition to psychosis.

Functional Consequences of Attenuated Psycliosis Syndrome Many individuals may experience functional impairments. Modest-to-moderate impair­ ment in social and role functioning may persist even with abatement of symptoms. A sub­ stantial portion of individuals with the diagnosis will improve over time; many continue to have mild symptoms and impairment, and many others will have a full recovery.

Differential Diagnosis Brief psychotic disorder. When symptoms of attenuated psychosis syndrome initially manifest, they may resemble symptoms of brief psychotic disorder. However, in attenu­ ated psychosis syndrome, the symptoms do not cross the psychosis threshold and reality testing/insight remains intact. Schizotypal personality disorder. Schizotypal personality disorder, although having symptomatic features that are similar to those of attenuated psychosis syndrome, is a rel­ atively stable trait disorder not meeting the state-dependent aspects (Criterion C) of atten­ uated psychosis syndrome. In addition, a broader array of symptoms is required for schizotypal personality disorder, although in the early stages of presentation it may re­ semble attenuated psychosis syndrome. Depressive or bipolar disorders. Reality distortions that are temporally limited to an episode of a major depressive disorder or bipolar disorder and are descriptively more characteristic of those disorders do not meet Criterion E for attenuated psychosis syn­ drome. For example, feelings of low self-esteem or attributions of low regard from others in the context of major depressive disorder would not qualify for comorbid attenuated psychosis syndrome. Anxiety disorders. Reality distortions that are temporally limited to an episode of an anxiety disorder and are descriptively more characteristic of an anxiety disorder do not

meet Criterion E for attenuated psychosis syndrome. For example, a feeling of being the focus of undesired attention in the context of social anxiety disorder would not qualify for comorbid attenuated psychosis syndrome. Bipolar II disorder. Reality distortions that are temporally limited to an episode of ma­ nia or hypomania and are descriptively more characteristic of bipolar disorder do not meet Criterion E for attenuated psychosis syndrome. For example, inflated self-esteem in the context of pressured speech and reduced need for sleep would not qualify for comorbid at­ tenuated psychosis syndrome. Borderline personality disorder. Reality distortions that are concomitant with border­ line personality disorder and are descriptively more characteristic of it do not meet Crite­ rion E for attenuated psychosis syndrome. For example, a sense of being unable to experience feelings in the context of an intense fear of real or imagined abandonment and recurrent self-mutilation would not qualify for comorbid attenuated psychosis syndrome. Adjustment reaction of adolescence. Mild, transient symptoms typical of normal de­ velopment and consistent with the degree of stress experienced do not qualify for attenu­ ated psychosis syndrome. Extreme end of perceptual aberration and magical thinking in the non-ill population. This diagnostic possibility should be strongly entertained when reality distortions are not associated with distress and functional impairment and need for care. Substance/medication-induced psychotic disorder. Substance use is common among individuals whose symptoms meet attenuated psychosis syndrome criteria. When other­ wise qualifying characteristic symptoms are strongly temporally related to substance use episodes. Criterion E for attenuated psychosis syndrome may not be met, and a diagnosis of substance/medication-induced psychotic disorder may be preferred. Attention-deficit/hyperactivity disorder. A history of attentional impairment does not exclude a current attenuated psychosis syndrome diagnosis. Earlier attentional impair­ ment may be a prodromal condition or comorbid attention-deficit/hyperactivity disorder.

Comorbidity Individuals with attenuated psychosis syndrome often experience anxiety and/or depres­ sion. Some individuals with an attenuated psychosis syndrome diagnosis will progress to another diagnosis, including anxiety, depressive, bipolar, and personality disorders. In such cases, the psychopathology associated with the attenuated psychosis syndrome diagnosis is reconceptualized as the prodromal phase of another disorder, not a comorbid condition.

Depressive Episodes With Short-Duration Hypomania Proposed Criteria Lifetime experience of at least one major depressive episode meeting the foiiowing criteria:

A. Five (or more) of the following criteria have been present during the same 2-week pe­ riod and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (Note: Do not include symptoms that are clearly attributable to a medical condition.) 1. Depressed mood most of the day, nearly every day, as indicated by either subjec­ tive report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of bqdy weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delu­ sional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei­ ther by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with­ out a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupa­ tional, or other important areas of functioning. C. The disturbance is not attributable to the physiological effects of a substance or an­ other medical condition. D. The disturbance is not better explained by schizoaffective disorder and is not superim­ posed on schizophrenia, schizophreniform disorder, delusional disorder, or other spec­ ified or unspecified schizophrenia spectrum and other psychotic disorder. At least two lifetime episodes of hypomanie periods that involve the required crite­ rion symptoms below but are of insufficient duration (at least 2 days but less than 4 consecutive days) to meet criteria for a hypomanie episode. The criterion sym p­ tom s are as follows:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy. B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a no­ ticeable change from usual behavior, and have been present to a significant degree: 1. 2. 3. 4. 5.

Inflated self-esteem or grandiosity. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). More talkative than usual or pressured to keep talking. Flight of ideas or subjective experience that thoughts are racing. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. 7. Excessive involvement in activities that have a high potential for painful conse­ quences (e.g., the individual engages in unrestrained buying sprees, sexual indis­ cretions, or foolish business investments).

C. The episode is associated with an unequivocal change in functioning that is uncharac­ teristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupa­ tional functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment).

Diagnostic Features Individuals with short-duration hypomania have experienced at least one major depres­ sive episode as well as at least two episodes of 2-3 days' duration in which criteria for a hy­ pomanie episode were met (except for symptom duration). These episodes are of sufficient intensity to be categorized as a hypomanie episode but do not meet the 4-day duration re­ quirement. Symptoms are present to a significant degree, such that they represent a no­ ticeable change from the individual's normal behavior. An individual with a history of a syndromal hypomanie episode and a major depres­ sive episode by definition has bipolar II disorder, regardless of current duration of hypomanic symptoms.

Associated Features Supporting Diagnosis Individuals who have experienced both short-duration hypomania and a major depres­ sive episode, with their increased comorbidity with substance use disorders and a greater family history of bipolar disorder, more closely resemble individuals with bipolar disor­ der than those with major depressive disorder. Differences have also been found between individuals with short-duration hypomania and those with syndromal bipolar disorder. Work impairment was greater for individuals with syndromal bipolar disorder, as was the estimated average number of episodes. Indi­ viduals with short-duration hypomania may exhibit less severity than individuals with syndromal hypomanie episodes, including less mood lability.

Prevalence The prevalence of short-duration hypomania is unclear, since the criteria are new as of this edition of the manual. Using somewhat different criteria, however, it has been estimated that short-duration hypomania occurs in 2.8% of the population (compared with hypoma­ nia or mania in 5.5% of the population). Short-duration hypomania may be more common in females, who may present with more features of atypical depression.

R is k

and Prognostic Factors

Genetic and physiological. A family history of mania is two to three times more common in individuals with short-duration hypomania compared with the general population, but less than half as common as in individuals with a history of syndromal mania or hypomania.

Suicide Risic Individuals with short-duration hypomania have higher rates of suicide attempts than healthy individuals, although not as high as the rates in individuals with syndromal bipo­ lar disorder.

Functional Consequences of Short-Duration Hypomania Functional impairments associated specifically with short-duration hypomania are as yet not fully determined. However, research suggests that individuals with this disorder have less work impairment than individuals with syndromal bipolar disorder but more comorbid substance use disorders, particularly alcohol use disorder, than individuals with major depressive disorder.

Differential Diagnosis Bipolar II disorder. Bipolar II disorder is characterized by a period of at least 4 days of hypomanie symptoms, whereas short-duration hypomania is characterized by periods of

2-3 days of hypomanie symptoms. Once an individual has experienced a hypomanie ep­ isode (4 days oi* more), the diagnosis becomes and remains bipolar II disorder regardless of future duration of hypomanie symptom periods. Major depressive disorder. Major depressive disorder is also characterized by at least one lifetime major depressive episode. However, the additional presence of at least two life­ time periods of 2-3 days of hypomanie symptoms leads to a diagnosis of short-duration hypomania rather than to major depressive disorder. Major depressive disorder with mixed features. Both major depressive disorder with mixed features and short-duration hypomania are characterized by the presence of some hypomanie symptoms and a major depressive episode. However, major depressive disor­ der with mixed features is characterized by hypomanie features present concurrently with a major depressive episode, while individuals with short-duration hypomania experience subsyndromal hypomania and fully syndromal major depression at different times. Bipolar I disorder. Bipolar I disorder is differentiated from short-duration hypomania by at least one lifetime manic episode, which is longer (at least 1 week) and more severe (causes more impaired social functioning) than a hypomanie episode. An episode (of any duration) that involves psychotic symptoms or necessitates hospitalization is by definition a manic episode rather than a hypomanie one. Cyclothymic disorder. While cyclothymic disorder is characterized by periods of de­ pressive symptoms and periods of hypomanie symptoms, the lifetime presence of a major depressive episode precludes the diagnosis of cyclothymic disorder.

Comorbidity Short-duration hypomania, similar to full hypomanie episodes, has been associated with higher rates of comorbid anxiety disorders and substance use disorders than are found in the general population.

Persistent Confiplex Bereavement Disorder Proposed Criteria A. The individual experienced the death of someone with whom he or she had a close re­ lationship. B. Since the death, at least one of the following symptoms is experienced on more days than not and to a clinically significant degree and has persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children: 1. Persistent yearning/longing for the deceased. In young children, yearning may be expressed in play and behavior, including behaviors that reflect being separated from, and also reuniting with, a caregiver or other attachment figure. 2. Intense sorrow and emotional pain in response to the death. 3. Preoccupation with the deceased. 4. Preoccupation with the circumstances of the death. In children, this preoccupation with the deceased may be expressed through the themes of play and behavior and may extend to preoccupation with possible death of others close to them. C. Since the death, at least six of the following symptoms are experienced on more days than not and to a clinically significant degree, and have persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children:

Reactive distress to the death

1. Marked difficulty accepting the death. In children, this is dependent on the child’s capacity to comprehend the meaning and permanence of death. 2. Experiencing disbelief or emotional numbness over the loss. 3. Difficulty with positive reminiscing about the deceased. 4. Bitterness or anger related to the loss. 5. Maladaptive appraisals about oneself in relation to the deceased or the death (e.g., self-blame). 6. Excessive avoidance of reminders of the loss (e.g., avoidance of individuals, places, or situations associated with the deceased; in children, this may include avoidance of thoughts and feelings regarding the deceased). Social/identity disruption

7. 8. 9. 10.

A desire to die in order to be with the deceased. Difficulty trusting other individuals since the death. Feeling alone or detached from other individuals since the death. Feeling that life is meaningless or empty without the deceased, or the belief that one cannot function without the deceased. 11. Confusion about one’s role in life, or a diminished sense of one’s identity (e.g., feel­ ing that a part of oneself died with the deceased). 12. Difficulty or reluctance to pursue interests since the loss or to plan for the future (e.g., friendships, activities).

D. The disturbance causes clinically significant distress or impairment in social, occupa­ tional, or other important areas of functioning. E. The bereavement reaction is out of proportion to or inconsistent with cultural, religious, or age-appropriate norms. Specify if: With traumatic bereavement: Bereavement due to homicide or suicide with persis­

tent distressing preoccupations regarding the traumatic nature of the death (often in re­ sponse to loss reminders), including the deceased’s last moments, degree of suffering and mutilating injury, or the malicious or intentional nature of the death.

Diagnostic Features Persistent complex bereavement disorder is diagnosed only if at least 12 months (6months in children) have elapsed since the death of someone with whom the bereaved had a close relationship (Criterion A). This time frame discriminates normal grief from persistent grief. The condition typically involves a persistent yearning/longing for the deceased (Criterion Bl), which may be associated with intense sorrow and frequent crying (Crite­ rion B2) or preoccupation with the deceased (Criterion B3). The individual may also be preoccupied with the manner in which the person died (Criterion B4). Six additional symptoms are required, including marked difficulty accepting that the in­ dividual has died (Criterion Cl) (e.g. preparing meals for them), disbelief that the individual is dead (Criterion C2), distressing memories of the deceased (Criterion C3), anger over the loss (Criterion C4), maladaptive appraisals about oneself in relation to the deceased or the death (Criterion C5), and excessive avoidance of reminders of the loss (Criterion C6). Individuals may also report a desire to die because they wish to be with the deceased (Criterion C7); be dis­ trustful of others (Criterion C8); feel isolated (Criterion C9); believe that life has no meaning or purpose without the deceased (Criterion CIO); experience a diminished sense of identity in which they feel a part of themselves has died or been lost (Criterion C ll); or have difficulty en­ gaging in activities, pursuing relationships, or planning for the future (Criterion C12).

Persistent complex bereavement disorder requires clinically significant distress or im­ pairment in psychosocial functioning (Criterion D). The nature and severity of grief must be beyond expected norms for the relevant cultural setting, religious group, or develop­ mental stage (Criterion E). Although there are variations in how grief can manifest, the symptoms of persistent complex bereavement disorder occur in both genders and in di­ verse social and cultural groups.

Associated Features Supporting Diagnosis Some individuals with persistent complex bereavement disorder experience hallucina­ tions of the deceased (auditory or visual) in which they temporarily perceive the deceased's presence (e.g., seeing the deceased sitting in his or her favorite chair). They may also ex­ perience diverse somatic complaints (e.g., digestive complaints, pain, fatigue), including symptoms experienced by the deceased.

Prevaience The prevalence of persistent complex bereavement disorder is approximately 2A%-4.S%. The disorder is more prevalent in females than in males.

Deveiopment and Course Persistent complex bereavement disorder can occur at any age, begirming after the age of 1 year. Symptoms usually begin within the initial months after the death, although there may be a delay of months, or even years, before the full syndrome appears. Although grief responses commonly appear immediately following bereavement, these reactions are not diagnosed as persistent complex bereavement disorder unless the symptoms persist be­ yond 12 months (6 months for children). Young children may experience the loss of a primary caregiver as traumatic, given the disorganizing effects the caregiver's absence can have on a child's coping response. In chil­ dren, the distress may be expressed in play and behavior, developmental regressions, and anxious or protest behavior at times of separation and reunion. Separation distress may be predominant in younger children, and social/identity distress and risk for comorbid de­ pression can increasingly manifest in older children and adolescents.

Risic and Prognostic Factors Environmental. Risk for persistent complex bereavement disorder is heightened by in­ creased dependency on the deceased person prior to the death and by the death of a child. Disturbances in caregiver support increase the risk for bereaved children. Genetic and physiological. ual being female.

Risk for the disorder is heightened by the bereaved individ­

Cuiture-Reiated Diagnostic issues The symptoms of persistent complex bereavement disorder are observed across cultural settings, but grief responses may manifest in culturally specific ways. Diagnosis of the dis­ order requires that the persistent and severe responses go beyond cultural norms of grief responses and not be better explained by culturally specific mourning rituals.

Suicide Risic Individuals with persistent complex bereavement disorder frequently report suicidal ideation.

Functional Consequences of Persistent Compiex Bereavement Disorder Persistent complex bereavement disorder is associated with deficits in work and social func­ tioning and with harmful health behaviors, such as increased tobacco and alcohol use. It is also associated with marked increases in risks for serious medical conditions, including cardiac dis­ ease, hypertension, cancer, immunological deficiency, and reduced quality of life.

Differential Diagnosis Normal grief. Persistent complex bereavement disorder is distinguished from normal grief by the presence of severe grief reactions that persist at least 12 months (or 6 months in children) after the death of the bereaved. It is only when severe levels of grief response per­ sist at least 12 months following the death and interfere with the individual's capacity to function that persistent complex bereavement disorder is diagnosed. Depressive disorders. Persistent complex bereavement disorder, major depressive dis­ order, and persistent depressive disorder (dysthymia) share sadness, crying, and suicidal thinking. Whereas major depressive disorder and persistent depressive disorder can share depressed mood with persistent complex bereavement disorder, the latter is characterized by a focus on the loss. Posttraumatic stress disorder. Individuals who experience bereavement as a result of trau­ matic death may develop both posttraumatic stress disorder (PTSD) and persistent complex bereavement disorder. Both conditions can involve intrusive thoughts and avoidance. Whereas intrusions in PTSD revolve around the traumatic event, intrusive memories in per­ sistent complex bereavement disorder focus on thoughts about many aspects of the relation­ ship with the deceased, including positive aspects of the relationship and distress over the separation. In individuals with the traumatic bereavement specifier of persistent complex be­ reavement disorder, the distressing thoughts or feelings may be more overtly related to the manner of death, with distressing fantasies of what happened. Both persistent complex be­ reavement disorder and PTSD can involve avoidance of reminders of distressing events. Whereas avoidance in PTSD is characterized by consistent avoidance of internal and external reminders of the traumatic experience, in persistent complex bereavement disorder, there is also a preoccupation with the loss and yearning for the deceased, which is absent in PTSD. Separation anxiety disorder. Separation anxiety disorder is characterized by anxiety about separation from current attachment figures, whereas persistent complex bereavement disorder involves distress about separation from a deceased individual.

Comorbidity The most common comorbid disorders with persistent complex bereavement disorder are major depressive disorder, PTSD, and substance use disorders. PTSD is more frequently comorbid with persistent complex bereavement disorder when the death occurred in trau­ matic or violent circumstances.

Caffeine Use Disorder Proposed Criteria A problematic pattern of caffeine use leading to clinically significant impainnent or distress, as manifested by at least the first three of the following criteria occurring within a 12-month period: 1. A persistent desire or unsuccessful efforts to cut down or control caffeine use. 2. Continued caffeine use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by caffeine.

3. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndronne for caffeine. b. Caffeine (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. 4. Caffeine is often taken in larger amounts or over a longer period than was intended. 5. Recurrent caffeine use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated tardiness or absences from work or school related to caffeine use or withdrawal). 6. Continued caffeine use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of caffeine (e.g., arguments with spouse about consequences of use, medical problems, cost). 7. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of caffeine to achieve desired effect. b. Markedly diminished effect with continued use of the same amount of caffeine. 8. A great deal of time is spent in activities necessary to obtain caffeine, use caffeine, or recover from its effects. 9. Craving or a strong desire or urge to use caffeine. A diagnosis of substance dependence due to caffeine is recognized by the World Health Organization in ICD-10. Since the publication of DSM-IV in 1994, considerable research on caffeine dependence has been published, and several recent review^s provide a current analysis of this literature. There is now sufficient evidence to warrant inclusion of caffeine use disorder as a research diagnosis in DSM-5 to encourage additional research. The work­ ing diagnostic algorithm proposed for the study of caffeine use disorder differs from that of the other substance use disorders, reflecting the need to identify only cases that have sufficient clinical importance to warrant the labeling of a mental disorder. A key goal of in­ cluding caffeine use disorder in this section of DSM-5 is to stimulate research that will determine the reliability, validity, and prevalence of caffeine use disorder based on the proposed diagnostic schema, with particular attention to the association of the diagnosis with functional impairments as part of validity testing. The proposed criteria for caffeine use disorder reflect the need for a diagnostic thresh­ old higher than that used for the other substance use disorders. Such a threshold is in­ tended to prevent overdiagnosis of caffeine use disorder due to the high rate of habitual nonproblematic daily caffeine use in the general population.

Diagnostic Features Caffeine use disorder is characterized by the continued use of caffeine and failure to con­ trol use despite negative physical and/or psychological consequences. In a survey of the general population, 14% of caffeine users met the criterion of use despite harm, with most reporting that a physician or counselor had advised them to stop or reduce caffeine use within the last year. Medical and psychological problems attributed to caffeine included heart, stomach, and urinary problems, and complaints of anxiety, depression, insomnia, irritability, and difficulty thinking. In the same survey, 45% of caffeine users reported de­ sire or unsuccessful efforts to control caffeine use, 18% reported withdrawal, 8% reported tolerance, 28% used more than intended, and 50% reported spending a great deal of time using caffeine. In addition, 19% reported a strong desire for caffeine that they could not re­ sist, and less than 1% reported that caffeine had interfered with social activities. Among those seeking treatment for quitting problematic caffeine use, 88% reported having made prior serious attempts to modify caffeine use, and 43% reported having been advised by a medical professional to reduce or eliminate caffeine. Ninety-three percent endorsed signs and symptoms meeting DSM-IV criteria for caffeine dependence, with the

most commonly endorsed criteria being withdrawal (96%), persistent desire or unsuccess­ ful efforts to control use (89%), and use despite knowledge of physical or psychological problems caused by caffeine (87%). The most common reasons for wanting to modify caf­ feine use were health-related (59%) and a desire to not be dependent on caffeine (35%). The DSM-5 discussion of caffeine withdrawal in the Section II chapter "SubstanceRelated and Addictive Disorders" provides information on the features of the withdrawal criterion. It is well documented that habitual caffeine users can experience a well-defined withdrawal syndrome upon acute abstinence from caffeine, and many caffeine-dependent individuals report continued use of caffeine to avoid experiencing withdrawal symptoms.

Prevalence The prevalence of caffeine use disorder in the general population is unclear. Based on all seven generic DSM-IV-TR criteria for dependence, 30% of current caffeine users may have met DSM-IV criteria for a diagnosis of caffeine dependence, with endorsement of three or more dependence criteria, during the past year. When only four of the seven criteria (the three primary criteria proposed above plus tolerance) are used, the prevalence appears to drop to 9%. Thus, the expected prevalence of caffeine use disorder among regular caffeine users is likely less than 9%. Given that approximately 75%-80% of the general population uses caffeine regularly, the estimated prevalence would be less than 7%. Among regular caffeine drinkers at higher risk for caffeine use problems (e.g., high school and college stu­ dents, individuals in drug treatment, and individuals at pain clinics who have recent his­ tories of alcohol or illicit drug misuse), approximately 20% may have a pattern of use that meets all three of the proposed criteria in Criterion A.

Development and Course Individuals whose pattern of use meets criteria for a caffeine use disorder have shown a wide range of daily caffeine intake and have been consumers of various types of caffeinated products (e.g., coffee, soft drinks, tea) and medications. A diagnosis of caffeine use disorder has been shown to prospectively predict a greater incidence of caffeine reinforce­ ment and more severe withdrawal. There has been no longitudinal or cross-sectional lifespan research on caffeine use dis­ order. Caffeine use disorder has been identified in both adolescents and adults. Rates of caffeine consumption and overall level of caffeine consumption tend to increase with age until the early to mid-30s and then level off. Age-related factors for caffeine use disorder are unknown, although concern is growing related to excessive caffeine consumption among adolescents and young adults through use of caffeinated energy drinks.

Risk and Prognostic Factors Genetic and physiological. Heritabilities of heavy caffeine use, caffeine tolerance, and caffeine withdrawal range from 35% to 77%. For caffeine use, alcohol use, and cigarette smoking, a common genetic factor (polysubstance use) underlies the use of these three substances, with 28% ^1% of the heritable effects of caffeine use (or heavy use) shared with alcohol and smoking. Caffeine and tobacco use disorders are associated and substan­ tially influenced by genetic factors unique to these licit drugs. The magnitude of heritability for caffeine use disorder markers appears to be similar to that for alcohol and tobacco use disorder markers.

Functional Consequences of Caffeine Use Disorder Caffeine use disorder may predict greater use of caffeine during pregnancy. Caffeine with­ drawal, a key feature of caffeine use disorder, has been shown to produce functional im-

pairment in normal daily activities. Caffeine intoxication may include symptoms of nausea and vomijing, as well as impairment of normal activities. Significant disruptions in normal daily activities may occur during caffeine abstinence.

Differential Diagnosis Nonproblematic use of caffeine. The distinction between nonproblematic use of caf­ feine and caffeine use disorder can be difficult to make because social, behavioral, or psy­ chological problems may be difficult to attribute to the substance, especially in the context of use of other substances. Regular, heavy caffeine use that can result in tolerance and with­ drawal is relatively common, which by itself should not be sufficient for making a diagnosis. Other stimulant use disorder. Problems related to use of other stimulant medications or substances may approximate the features of caffeine use disorder. Anxiety disorders. Chronic heavy caffeine use may mimic generalized anxiety disorder, and acute caffeine consumption may produce and mimic panic attacks.

Comorbidity There may be comorbidity between caffeine use disorder and daily cigarette smoking, a family or personal history of alcohol use disorder. Features of caffeine use disorder (e.g., tolerance, caffeine withdrawal) may be positively associated with several diagnoses: ma­ jor depression, generalized anxiety disorder, panic disorder, adult antisocial personality disorder, and alcohol, cannabis, and cocaine use disorders.

Internet Gaming Disorder Proposed Criteria Persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by five (or more) of the following in a 12-month period: 1. Preoccupation with Internet games. (The individual thinks about previous gaming activity or anticipates playing the next game; Internet gaming becomes the dominant activity in daily life). Note: This disorder is distinct from Internet gambling, which is included under gam­ bling disorder. 2. Withdrawal symptoms when Internet gaming is taken away. (These symptoms are typ­ ically described as irritability, anxiety, or sadness, but there are no physical signs of pharmacological withdrawal.) 3. Tolerance—the need to spend increasing amounts of time engaged in Internet games. 4. Unsuccessful attempts to control the participation in Internet games. 5. Loss of interests in previous hobbies and entertainment as a result of, and with the ex­ ception of, Internet games. 6. Continued excessive use of Internet games despite knowledge of psychosocial problems. 7. Has deceived family members, therapists, or others regarding the amount of Internet gaming. 8. Use of Internet games to escape or relieve a negative mood (e.g., feelings of helpless­ ness, guilt, anxiety). 9. Has jeopardized or lost a significant relationship, job, or educational or career oppor­ tunity because of participation in Internet games.

Note: Only nongambling Internet games are included in this disorder. Use of the Internet for required activities in a business or profession is not included; nor is the disorder intend­ ed to include other recreational or social Internet use. Similarly, sexual Internet sites are excluded. Specify current severity:

Internet gaming disorder can be mild, moderate, or severe depending on the degree of disruption of normal activities. Individuals with less severe Internet gaming disorder may exhibit fewer symptoms and less disruption of their lives. Those with severe Inter­ net gaming disorder will have more hours spent on the computer and more severe loss of relationships or career or school opportunities.

Subtypes There are no well-researched subtypes for Internet gaming disorder to date. Internet gam­ ing disorder most often involves specific Internet games, but it could involve non-Intemet computerized games as well, although these have been less researched. It is likely that pre­ ferred games will vary over time as new games are developed and popularized, and it is unclear if behaviors and consequence associated with Internet gaming disorder vary by game type.

Diagnostic Features Gambling disorder is currently the only non-substance-related disorder proposed for in­ clusion with DSM-5 substance-related and addictive disorders. However, there are other behavioral disorders that show some similarities to substance use disorders and gambling disorder for which the word addiction is commonly used in nonmedical settings, and the one condition with a considerable literature is the compulsive playing of Internet games. Internet gaming has been reportedly defined as an "addiction" by the Chinese govern­ ment, and a treatment system has been set up. Reports of treatment of this condition have appeared in medical journals, mostly from Asian countries and some in the United States. The DSM-5 work group reviewed more than 240 articles and found some behavioral similarities of Internet gaming to gambling disorder and to substance use disorders. The literature suffers, however, from lack of a standard definition from which to derive prev­ alence data. An understanding of the natural histories of cases, with or without treatment, is also missing. The literature does describe many underlying similarities to substance ad­ dictions, including aspects of tolerance, withdrawal, repeated unsuccessful attempts to cut back or quit, and impairment in normal functioning. Further, the seemingly high preva­ lence rates, both in Asian countries and, to a lesser extent, in the West, justified inclusion of this disorder in Section III of DSM-5. Internet gaming disorder has significant public health importance, and additional re­ search may eventually lead to evidence that Internet gaming disorder (also commonly re­ ferred to as Internet use disorder, Internet addiction, or gaming addiction) has merit as an independent disorder. As with gambling disorder, there should be epidemiological stud­ ies to determine prevalence, clinical course, possible genetic influence, and potential bio­ logical factors based on, for example, brain imaging data. Internet gaming disorder is a pattern of excessive and prolonged Internet gaming that re­ sults in a cluster of cognitive and behavioral symptoms, including progressive loss of control over gaming, tolerance, and withdrawal symptoms, analogous to the symptoms of sub­ stance use disorders. As with substance-related disorders, individuals with Internet gaming disorder continue to sit at a computer and engage in gaming activities despite neglect of other activities. They typically devote 8-10 hours or more per day to this activity and at least 30 hours per week. If they are prevented from using a computer and returning to the game, they become agitated and angry. They often go for long periods without food or sleep. Nor-

mal obligations, such as school or work, or family obligations are neglected. This condition is separate from gambling disorder involving the Internet because money is not at risk. The essential feature of Internet gaming disorder is persistent and recurrent participa­ tion in computer gaming, typically group games, for many hours. These games involve competition between groups of players (often in different global regions, so that duration of play is encouraged by the time-zone independence) participating in complex structured activities that include a significant aspect of social interactions during play. Team aspects appear to be a key motivation. Attempts to direct the individual toward schoolwork or in­ terpersonal activities are strongly resisted. Thus personal, family, or vocational pursuits are neglected. When individuals are asked, the major reasons given for using the com­ puter are more likely to be "avoiding boredom" rather than commimicating or searching for information. The description of criteria related to this condition is adapted from a study in China. Un­ til the optimal criteria and threshold for diagnosis are determined empirically, conserva­ tive definitions ought to be used, such that diagnoses are considered for endorsement of five or more of nine criteria.

Associated Features Supporting Diagnosis No consistent personality types associated with Internet gaming disorder have been iden­ tified. Some authors describe associated diagnoses, such as depressive disorders, attention-deficit/hyperactivity disorder (ADHD), or obsessive-compulsive disorder (OCD). Individuals with compulsive Internet gaming have demonstrated brain activation in spe­ cific regions triggered by exposure to the Internet game but not limited to reward system structures

Prevalence The prevalence of Internet gaming disorder is unclear because of the varying question­ naires, criteria and thresholds employed, but it seems to be highest in Asian countries and in male adolescents 12-20 years of age. There is an abundance of reports from Asian coun­ tries, especially China and South Korea, but fewer from Europe and North America, from which prevalence estimates are highly variable. The point prevalence in adolescents (ages 15-19 years) in one Asian study using a threshold of five criteria was 8.4% for males and 4.5% for females.

R is k

and Prognostic Factors

Environmental. Computer availability with Internet connection allows access to the types of games with which Internet gaming disorder is most often associated. Genetic and physiological. Adolescent males seem to be at greatest risk of developing Internet gaming disorder, and it has been speculated that Asian environmental and/or ge­ netic background is another risk factor, but this remains unclear.

Functional Consequences of Internet Gaming Disorder Internet gaming disorder may lead to school failure, job loss, or marriage failure. The com­ pulsive gaming behavior tends to crowd out normal social, scholastic, and family activities. Students may show declining grades and eventually failure in school. Family responsibil­ ities may be neglected.

Differential Diagnosis Excessive use of the Internet not involving playing of online games (e.g., excessive use of social media, such as Facebook; viewing pornography online) is not considered analogous

to Internet gaming disorder, and future research on other excessive uses of the Internet would need to follow similar guidelines as suggested herein. Excessive gambling online may qualify for a separate diagnosis of gambling disorder.

Comorbidity Health may be neglected due to compulsive gaming. Other diagnoses that may be associ­ ated with Internet gaming disorder include major depressive disorder, ADHD, and OCD.

Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure Proposed Criteria A. More than minimal exposure to alcohol during gestation, including prior to pregnancy recognition. Confirmation of gestational exposure to alcohol may be obtained from ma­ ternal self-report of alcohol use in pregnancy, medical or other records, or clinical ob­ servation. B. Impaired neurocognitive functioning as manifested by one or more of the following: 1. Impairment in global intellectual performance (i.e., IQ of 70 or below, or a standard score of 70 or below on a comprehensive developmental assessment). 2. Impairment in executive functioning (e.g., poor planning and organization; inflexi­ bility: difficulty with behavioral inhibition). 3. Impairment in learning (e.g., lower academic achievement than expected for intel­ lectual level; specific learning disability). 4. Memory impairment (e.g., problems remembering information learned recently; repeatedly making the same mistakes; difficulty remembering lengthy verbal in­ structions). 5. Impairment in visual-spatial reasoning (e.g., disorganized or poorly planned draw­ ings or constructions; problems differentiating left from right). C. Impaired self-regulation as manifested by one or more of the following: 1. Impairment in mood or behavioral regulation (e.g., mood lability; negative affect or irritability; frequent behavioral outbursts). 2. Attention deficit (e.g., difficulty shifting attention; difficulty sustaining mental effort). 3. Impairment in impulse control (e.g., difficulty waiting turn; difficulty complying with rules). D. Impairment in adaptive functioning as manifested by two or more of the following, one of which must be (1) or (2): 1. Communication deficit (e.g., delayed acquisition of language; difficulty understand­ ing spoken language). 2. Impainnent in social communication and interaction (e.g., overly friendly with strang­ ers; difficulty reading social cues; difficulty understanding social consequences). 3. Impairment in daily living skills (e.g., delayed toileting, feeding, or bathing; difficulty managing daily schedule). 4. Impairment in motor skills (e.g., poor fine motor development; delayed attainment of gross motor milestones or ongoing deficits in gross motor function; deficits in co­ ordination and balance). E. Onset of the disorder (symptoms in Criteria B, C, and D) occurs in childhood.

F. The disturbance causes clinically significant distress or impairment in social, aca­ demic, occupational, or other important areas of functioning. G. The disorder is not better explained by the direct physiological effects associated with postnatal use of a substance (e.g., a medication, alcohol or other drugs), a general medical condition (e.g., traumatic brain injury, delirium, dementia), another known te­ ratogen (e.g., fetal hydantoin syndrome), a genetic condition (e.g., Williams syndrome, Down syndrome, Cornelia de Lange syndrome), or environmental neglect. Alcohol is a neurobehavioral teratogen, and prenatal alcohol exposure has teratogenic effects oil central nervous system (CNS) development and subsequent fimction. Neurobe­ havioral disorder associated with prenatal alcohol exposure (ND-PAE) is a new clarifying term, intended to encompass the full range of developmental disabilities associated with expo­ sure to alcohol in utero. The current diagnostic guidelines allow ND-PAE to be diagnosed both in the absence and in the presence of the physical effects of prenatal alcohol exposure (e.g., facial dysmorphology required for a diagnosis of fetal alcohol syndrome).

Diagnostic Features The essential features of ND-PAE are the manifestation of impairment in neurocognitive, behavioral, and adaptive functioning associated with prenatal alcohol exposure. Impair­ ment can be documented based on past diagnostic evaluations (e.g., psychological or ed­ ucational assessments) or medical records, reports by the individual or informants, and/ or observation by a clinician. A clinical diagnosis of fetal alcohol syndrome, including specific prenatal alcoholrelated facial dysmorphology and growth retardation, can be used as evidence of signifi­ cant levels of prenatal alcohol exposure. Although both animal and human studies have documented adverse effects of lower levels of drinking, identifying how much prenatal exposure is needed to significantly impact neurodevelopmental outcome remains chal­ lenging. Data suggest that a history of more than minimal gestational exposure (e.g., more than light drinking) prior to pregnancy recognition and/or following pregnancy recogni­ tion may be required. Light drinking is defined as 1-13 drinks per month during preg­ nancy with no more than 2 of these drinks consumed on any 1 drinking occasion. Identifying a minimal threshold of drinking during pregnancy will require consideration of a variety of factors known to affect exposure and/or interact to influence developmental outcomes, including stage of prenatal development, gestational smoking, maternal and fetal genet­ ics, and maternal physical status (i.e., age, health, and certain obstetric problems). Symptoms of ND-PAE include marked impairment in global intellectual performance (IQ) or neurocognitive impairments in any of the following areas: executive functioning, learning, memory, and/or visual-spatial reasoning. Impairments in self-regulation are pres­ ent and may include impairment in mood or behavioral regulation, attention deficit, or impairment in impulse control. Finally, impairments in adaptive functioning include com­ munication deficits and impairment in social communication and interaction. Impairment in daily living (self-help) skills and impairment in motor skills may be present. As it may be difficult to obtain an accurate assessment of the neurocognitive abilities of very young chil­ dren, it is appropriate to defer a diagnosis for children 3 years of age and younger.

Associated Features Supporting Diagnosis Associated features vary depending on age, degree of alcohol exposure, and the individ­ ual's environment. An individual can be diagnosed with this disorder regardless of socio­ economic or cultural background. However, ongoing parental alcohol/substance misuse, parental mental illness, exposure to domestic or community violence, neglect or abuse, disrupted caregiving relationships, multiple out-of-home placements, and lack of conti­ nuity in medical or mental health care are often present.

Prevalence The prevalence rates of ND-PAE are unknown. However, estimated prevalence rates of clini­ cal conditions associated with prenatal alcohol exposure are 2%-5% in the United States.

Development and Course Among individuals with prenatal alcohol exposure, evidence of CNS dysfunction varies according to developmental stage. Although about one-half of young children prenatally exposed to alcohol show marked developmental delay in the first 3 years of life, other chil­ dren affected by prenatal alcohol exposure may not exhibit signs of CNS dysfunction until they are preschool- or school-age. Additionally, impairments in higher order cognitive processes (i.e., executive functioning), which are often associated with prenatal alcohol ex­ posure, may be more easily assessed in older children. When children reach school age, learning difficulties, impairment in executive function, and problems with integrative lan­ guage functions usually emerge more clearly, and both social skills deficits and challeng­ ing behavior may become more evident. In particular, as school and other requirements become more complex, greater deficits are noted. Because of this, the school years repre­ sent the ages at which a diagnosis of ND-PAE would be most likely.

Suicide Risic Suicide is a high-risk outcome, with rates increasing significantly in late adolescence and early adulthood.

Functional Consequences of Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure The CNS dysfunction seen in individuals with ND-PAE often leads to decrements in adap­ tive behavior and to maladaptive behavior with lifelong consequences. Individuals affected by prenatal alcohol exposure have a higher prevalence of disrupted school expe­ riences, poor employment records, trouble with the law, confinement (legal or psychiat­ ric), and dependent living conditions.

Differential Diagnosis Disorders that are attributable to the physiological effects associated with postnatal use of a substance, another medical condition, or environmental neglect. Other consid­ erations include the physiological effects of postnatal substance use, such as a medication, alcohol, or other substances; disorders due to another medical condition, such as traumatic brain injury or other neurocognitive disorders (e.g., delirium, major neurocognitive dis­ order [dementia]); or environmental neglect. Genetic and teratogenic conditions. Genetic conditions such as Williams syndrome. Down syndrome, or Cornelia de Lange syndrome and other teratogenic conditions such as fetal hydantoin syndrome and maternal phenylketonuria may have similar physical and behavioral characteristics. A careful review of prenatal exposure history is needed to clar­ ify the teratogenic agent, and an evaluation by a clinical geneticist may be needed to dis­ tinguish physical characteristics associated with these and other genetic conditions.

Comorbidity Mental health problems have been identified in more than 90% of individuals with histo­ ries of significant prenatal alcohol exposure. The most common co-occurring diagnosis is attention-deficit/hyperactivity disorder, but research has shown that individuals with ND-PAE differ in neuropsychological characteristics and in their responsiveness to phar­

macological interventions. Other high- probability co-occurring disorders include oppo­ sitional defiant disorder and conduct disorder, but the appropriateness of these diagnoses should be weighed in the context of the significant impairments in general intellectual and executive functioning that are often associated with prenatal alcohol exposure. Mood symptoms, including symptoms of bipolar disorder and depressive disorders, have been described. History of prenatal alcohol exposure is associated with an increased risk for later tobacco, alcohol, and other substance use disorders.

Suicidal Behavior Disorder Proposed Criteria A. Within the last 24 months, the individual has made a suicide attempt. Note: A suicide attempt is a self-initiated sequence of behaviors by an individual who, at the time of initiation, expected that the set of actions would lead to his or her own death. The “time of initiation” is the time when a behavior took place that involved ap­ plying the method.) B. The act does not meet criteria for nonsuicidal self-injury—that is, it does not involve self-injury directed to the surface of the body undertaken to induce relief from a nega­ tive feeling/cognitive state or to achieve a positive mood state. C. The diagnosis is not applied to suicidal ideation or to preparatory acts. D. The act was not initiated during a state of delirium or confusion. E. The act was not undertaken solely for a political or religious objective. Specify if: Current: Not more than 12 months since the last attempt. In early remission: 12-24 months since the last attempt.

Specifiers Suicidal behavior is often categorized in terms of violence of the method. Generally, over­ doses with legal or illegal substances are considered nonviolent in method, whereas jump­ ing, gunshot wounds, and other methods are considered violent. Another dimension for classification is medical consequences of the behavior, with high-lethality attempts being defined as those requiring medical hospitalization beyond a visit to an emergency depart­ ment. An additional dimension considered includes the degree of planning versus impul­ siveness of the attempt, a characteristic that might have consequences for the medical outcome of a suicide attempt. If the suicidal behavior occurred 12-24 months prior to evaluation, the condition is considered to be in early remission. Individuals remain at higher risk for further suicide at­ tempts and death in the 24 months after a suicide attempt, and the period 12-24 months af­ ter the behavior took place is specified as "early remission."

Diagnostic Features The essential manifestation of suicidal behavior disorder is a suicide attempt. A suicide at­ tempt is a behavior that the individual has undertaken with at least some intent to die. The behavior might or might not lead to injury or serious medical consequences. Several fac­ tors can influence the medical consequences of the suicide attempt, including poor plan­ ning, lack of knowledge about the lethality of the method chosen, low intentionality or ambivalence, or chance intervention by others after the behavior has been initiated. These should not be considered in assigning the diagnosis.

Determining the degree of intent can be challenging. Individuals might not acknowl­ edge intent, especially in situations where doing so could result in hospitalization or cause distress to loved ones. Markers of risk include degree of planning, including selection of a time and place to minimize rescue or interruption; the individual's mental state at the time of the behavior, with acute agitation being especially concerning; recent discharge from inpatient care; or recent discontinuation of a mood stabilizer such as lithium or an anti­ psychotic such as clozapine in the case of schizophrenia. Examples of environmental ''trig­ gers" include recently learning of a potentially fatal medical diagnosis such as cancer, experiencing the sudden and unexpected loss of a close relative or partner, loss of employ­ ment, or displacement from housing. Conversely, features such as talking to others about future events or preparedness to sign a contract for safety are less reliable indicators. In order for the criteria to be met, the individual must have made at least one suicide at­ tempt. Suicide attempts can include behaviors in which, after initiating the suicide attempt, the individual changed his or her mind or someone intervened. For example, an individual might intend to ingest a given amount of medication or poison, but either stop or be stopped by another before ingesting the full amount. If the individual is dissuaded by another or changes his or her mind before initiating the behavior, the diagnosis should not be made. The act must not meet criteria for nonsuicidal self-injury—that is, it should not involve re­ peated (at least five times within the past 12 months) self-injurious episodes undertaken to induce relief from a negative feeling/cognitive state or to achieve a positive mood state. The act should not have been initiated during a state of delirium or confusion. If the individual deliberately became intoxicated before initiating the behavior, to reduce anticipatory anxi­ ety and to minimize interference with the intended behavior, the diagnosis should be made.

Development and Course Suicidal behavior can occur at any time in the lifespan but is rarely seen in children under the age of 5. In prepubertal children, the behavior will often consist of a behavior (e.g., sit­ ting on a ledge) that a parent has forbidden because of the risk of accident. Approximately 25%-30% of persons who attempt suicide will go on to make more attempts.There is sig­ nificant variability in terms of frequency, method, and lethality of attempts. However, this is not different from what is observed in other illnesses, such as major depressive disorder, in which frequency of episode, subtype of episode, and impairment for a given episode can vary significantly.

Culture-Related Diagnostic issues Suicidal behavior varies in frequency and form across cultures. Cultural differences might be due to method availability (e.g., poisoning with pesticides in developing countries; gunshot wounds in the southwestern United States) or the presence of culturally specific syndromes (e.g., ataques de nervios, which in some Latino groups might lead to behaviors that closely resemble suicide attempts or might facilitate suicide attempts).

Diagnostic IVIarkers Laboratory abnormalities consequent to the suicidal attempt are often evident. Suicidal behavior that leads to blood loss can be accompanied by anemia, hypotension, or shock. Overdoses might lead to coma or obtundation and associated laboratory abnormalities such as electrolyte imbalances.

Functional Consequences of Suicidal Behavior Disorder Medical conditions (e.g., lacerations or skeletal trauma, cardiopulmonary instability, in­ halation of vomit and suffocation, hepatic failure consequent to use of paracetamol) can occur as a consequence of suicidal behavior.

Comorbidity Suicidal behavior is seen in the context of a variety of mental disorders, most commonly bipo­ lar disorder, major depressive disorder, schizophrenia, schizoaffective disorder, anxiety dis­ orders (in particular, panic disorders associated with catastrophic content and PTSD flashbacks), substance use disorders (especially alcohol use disorders), borderline personality disorder, antisocial personality disorder, eating disorders, and adjustment disorders. It is rarely manifested by individuals with no discernible pathology, unless it is undertaken be­ cause of a painful medical condition with the intention of drawing attention to martyrdom for political or religious reasons, or in partners in a suicide pact, both of which are excluded from this diagnosis, or when third-party informants wish to conceal the nature of the behavior.

Nonsuicidal Self-lnjuiy Proposed Criteria A. In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain (e.g., cutting, buming, stabbing, hitting, excessive rubbing), with the expectation that the injury will lead to only minor or moderate physical harm (i.e., there is no suicidal intent). Note: The absence of suicidal intent has either been stated by the individual or can be inferred by the individual’s repeated engagement in a behavior that the individual knows, or has learned, is not likely to result in death. B. The individual engages in the self-injurious behavior with one or more of the following expectations: 1. To obtain relief from a negative feeling or cognitive state. 2. To resolve an interpersonal difficulty. 3. To induce a positive feeling state. Note: The desired relief or response is experienced during or shortly after the self­ injury, and the individual may display patterns of behavior suggesting a dependence on repeatedly engaging in it. C. The intentional self-injury is associated with at least one of the following: 1. Interpersonal difficulties or negative feelings or thoughts, such as depression, anx­ iety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act. 2. Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to control. 3. Thinking about self-injury that occurs frequently, even when it is not acted upon. D. The behavior is not socially sanctioned (e.g., body piercing, tattooing, part of a religious or cultural ritual) and is not restricted to picking a scab or nail biting. E. The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning. F. The behavior does not occur exclusively during psychotic episodes, delirium, sub­ stance intoxication, or substance withdrawal. In individuals with a neurodevelopmental disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior is not better explained by another mental disorder or medical condition (e.g., psychotic disorder, autism spectrum disorder, intellectual disability, Lesch-Nyhan syndrome, ste­ reotypic movement disorder with self-injury, trichotillomania [hair-pulling disorder], ex­ coriation [skin-picking] disorder).

Diagnostic Features The essential feature of nonsuicidal self-injury is that the individual repeatedly inflicts shallow, yet painful injuries to the surface of his or her body. Most commonly, the purpose is to reduce negative emotions, such as tension, anxiety, and self-reproach, and/or to re­ solve an interpersonal difficulty. In some cases, the injury is conceived of as a deserved self-punishment. The individual will often report an immediate sensation of relief that oc­ curs during the process. When the behavior occurs frequently, it might be associated with a sense of urgency and craving, the resultant behavioral pattern resembling an addiction. The inflicted wounds can become deeper and more numerous. The injury is most often inflicted with a knife, needle, razor, or other shaφ object. Com­ mon areas for injury include the frontal area of the thighs and the dorsal side of the forearm. A single session of injury might involve a series of superficial, parallel cuts—separated by 1 or 2 centimeters—on a visible or accessible location. The resulting cuts will often bleed and will eventually leave a characteristic pattern of scars. Other methods used include stabbing an area, most often the upper arm, with a needle or sharp, pointed knife; inflicting a superficial bum with a lit cigarette end; or burning the skin by repeated rubbing with an eraser. Engagement in nonsuicidal self-injury with mul­ tiple methods is associated with more severe psychopathology, including engagement in suicide attempts. The great majority of individuals who engage in nonsuicidal self-injury do not seek clinical attention. It is not known if this reflects frequency of engagement in the disorder, because accurate reporting is seen as stigmatizing, or because the behaviors are experi­ enced positively by the individual who engages in them, who is unmotivated to receive treatment. Young children might experiment with these behaviors but not experience re­ lief. In such cases, youths often report that the procedure is painful or distressing and might then discontinue the practice.

Development and Course Nonsuicidal self-injury most often starts in the early teen years and can continue for many years. Admission to hospital for nonsuicidal self-injury reaches a peak at 20-29 years of age and then declines. However, research that has examined age at hospitalization did not provide information on age at onset of the behavior, and prospective research is needed to outline the natural history of nonsuicidal self-injury and the factors that promote or in­ hibit its course. Individuals often leam of the behavior on the recommendation or observa­ tion of another. Research has shown that when an individual who engages in nonsuicidal self-injury is admitted to an inpatient unit, other individuals may begin to engage in the behavior.

Risic and Prognostic Factors Male and female prevalence rates of nonsuicidal self-injury are closer to each other than in suicidal behavior disorder, in which the female-to-male ratio is about 3:1 or 4:1. Two theories of psychopathology—^based on functional behavioral analyses—have been proposed: In the first, based on learning theory, either positive or negative reinforcement sustains the behavior. Positive reinforcement might result from punishing oneself in a way that the individual feels is deserved, with the behavior inducing a pleasant and relaxed state or generating attention and help from a significant other, or as an expression of anger. Neg­ ative reinforcement results from affect regulation and the reduction of unpleasant emotions or avoiding distressing thoughts, including thinking about suicide. In the second theory, nonsuicidal self-injury is thought to be a form of self-punishment, in which self-punitive ac­ tions are engaged in to make up for acts that caused distress or harm to others.

Functional Consequences of Nonsuicidal Self-lnjuiy The act of cutting\might be performed with shared implements, raisiiig the possibility of blood-borne disease transmission.

Differential Diagnosis Borderline personality disorder. As indicated, nonsuicidal self-injury has long been re­ garded as a "symptom" of borderline personality disorder, even though comprehensive clinical evaluations have found that most individuals with nonsuicidal self-injury have symptoms that also meet criteria for other diagnoses, with eating disorders and substance use disorders being especially common. Historically, nonsuicidal self-injury was regarded as pathognomonic of borderline personality disorder. Both conditions are associated with several other diagnoses. Although frequently associated, borderline personality disorder is not invariably found in individuals with nonsuicidal self-injury. The two conditions dif­ fer in several ways. Individuals with borderline personality disorder often manifest dis­ turbed aggressive and hostile behaviors, whereas nonsuicidal self-injury is more often associated with phases of closeness, collaborative behaviors, and positive relationships. At a more fundamental level, there are differences in the involvement of different neurotrans­ mitter systems, but these will not be apparent on clinical examination. Suicidal behavior disorder. The differentiation between nonsuicidal self-injury and sui­ cidal behavior disorder is based either on the stated goal of the behavior being a wish to die (suicidal behavior disorder) or, in nonsuicidal self-injury, to experience relief as de­ scribed in the criteria. Depending on the circumstances, individuals may provide reports of convenience, and several studies report high rates of false intent declaration. Individu­ als with a history of frequent nonsuicidal self-injury episodes have learned that a session of cutting, while painful, is, in the short-term, largely benign. Because individuals with nonsuicidal self-injury can and do attempt and commit suicide, it is important to check past history of suicidal behavior and to obtain information from a third party concerning any recent change in stress exposure and mood. Likelihood of suicide intent has been as­ sociated with the use of multiple previous methods of self-harm. In a follow-up study of cases of "self-harm" in males treated at one of several multiple emergency centers in the United Kingdom, individuals with nonsuicidal self-injury were significantly more likely to commit suicide than other teenage individuals drawn from the same cohort. Studies that have examined the relationship between nonsuicidal self-injury and suicidal behavior disorder are limited by being retrospective and failing to obtain ver­ ified accounts of the method used during previous "attempts." A significant proportion of those who engage in nonsuicidal self-injury have responded positively when asked if they have ever engaged in self-cutting (or their preferred means of self-injury) with an intention to die. It is reasonable to conclude that nonsuicidal self-injury, while not presenting a high risk for suicide when first manifested, is an especially dangerous form of self-injurious behavior. This conclusion is also supported by a multisite study of depressed adolescents who had previously failed to respond to antidepressant medication, which noted that those with pre­ vious nonsuicidal self-injury did not respond to cognitive-behavioral therapy, and by a study that found that nonsuicidal self-injury is a predictor of substance use/misuse. Trichotillomania (hair-pulling disorder). Trichotillomania is an injurious behavior con­ fined to pulling out one's own hair, most commonly from the scalp, eyebrows, or eyelashes. The behavior occurs in "sessions" that can last for hours. It is most likely to occur during a period of relaxation or distraction.

Stereotypic self-injury. Stereotypic self-injury, which can include head banging, selfbiting, or self-hitting, is usually associated with intense concentration or under conditions of low external stimulation and might be associated with developmental delay. Excoriation (skin-picking) disorder. Excoriation disorder occurs mainly in females and is usually directed to picking at an area of the skin that the individual feels is unsightly or a blemish, usually on the face or the scalp. As in nonsuicidal self-injury, the picking is often preceded by an urge and is experienced as pleasurable, even though the individual real­ izes that he or she is harming himself or herself. It is not associated with the use of any im­ plement.

Highlights of Changes From DSIVI-IV to DSIVI-5.................................... 809 Glossary of Technical Terms.................................................................. 817 Glossary of Cultural Concepts of Distress............................................ 833 Alphabetical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM and ICD-10-CM)................................................................ 839 Numerical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM).......... 863 Numerical Listing of DSM-5 Diagnoses and Codes (ICD-10-CM)........ 877 DSM-5 Advisors and Other Contributors................................................ 897

Highlights of Changes FiNiii DSiVi-IV to D Ü * i ChsngGS msdG to DSM’ 5 diagnostic criteria and texts are outlined in this chapter in the same order in which they appear in the DSM-5 classification. This abbreviated descrip­ tion is intended to orient readers to only the most significant changes in each disorder cate­ gory. An expanded description of nearly all changes (e.g., except minor text or wording changes needed for clarity) is available online (www.psychiatry.org/dsm5). It should also be noted that Section I contains a description of changes pertaining to the chapter organization in DSM-5, the multiaxial system, and the introduction of dimensional assessments.

Neurodevelopmental Disorders The term mental retardation was used in DSM-IV. However, intellectual disability (intel­ lectual developmental disorder) is the term that has come into common use over the past two decades among medical, educational, and other professionals, and by the lay public and advocacy groups. Diagnostic criteria emphasize the need for an assessment of both cognitive capacity (IQ) and adaptive functioning. Severity is determined by adaptive func­ tioning rather than IQ score. The communication disorders, which are newly named from DSM-IV phonological dis­ order and stuttering, respectively, include language disorder (which combines the previous expressive and mixed receptive-expressive language disorders), speech sound disorder (pre­ viously phonological disorder), and childhood-onset fluency disorder (previously stutter­ ing). Also included is social (pragmatic) commimication disorder, a new condition involving persistent difficulties in the social uses of verbal and nonverbal communication. Autism spectrum disorder is a new DSM-5 disorder encompassing the previous DSMIV autistic disorder (autism), Asperger's disorder, childhood disintegrative disorder, Rett's disorder, and pervasive developmental disorder not otherwise specified. It is char­ acterized by deficits in two core domains: 1) deficits in social communication and social in­ teraction and 2) restricted repetitive patterns of behavior, interests, and activities. Several changes have been made to the diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD). Examples have been added to the criterion items to facilitate application across the life span; the age at onset description has been changed (from "some hyperactiveimpulsive or inattentive symptoms that caused impairment were present before age 7 years" to "Several inattentive or hyperactive-impulsive symptoms were present prior to age 12"); subtypes have been replaced with presentation specifiers that map directly to the prior sub­ types; a comorbid diagnosis with autism spectrum disorder is now allowed; and a symptom tlu-eshold change has been made for adults, to reflect the substantial evidence of clinically sig­ nificant ADHD impairment, with the cutoff for ADHD of five symptoms, instead of six re­ quired for younger persons, both for inattention and for hyperactivity and impulsivity. Specific learning disorder combines the DSM-IV diagnoses of reading disorder, math­ ematics disorder, disorder of written expression, and learning disorder not otherwise specified. Learning deficits in the areas of reading, written expression, and mathematics are coded as separate specifiers. Acknowledgment is made in the text that specific types of reading deficits are described internationally in various ways as dyslexia and specific types of mathematics deficits as dyscalculia.

The following motor disorders are included in DSM-5: developmental coordination disor­ der, stereotypic movement disorder, Tourette's disorder, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder. The tic criteria have been standardized across all of these disorders in this chapter.

Schizophrenia Spectrum and Other Psychotic Disorders Two changes were made to Criterion A for schizophrenia: 1) the elimination of the special at­ tribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing), leading to the requirement of at least two Criterion A symptoms for any diagnosis of schizophrenia, and 2) the addition of the requirement that at least one of the Criterion A symptoms must be delusions, hallucinations, or disorganized speech. The DSM-IV subtypes of schizophrenia were eliminated due to their limited diagnostic stability, low reli­ ability, and poor validity. Instead, a dimensional approach to rating severity for the core symp­ toms of schizophrenia is included in DSM-5 Section ΠΙ to capture the important heterogeneity in symptom type and severity expressed across individuals with psychotic disorders. Schizoaffective disorder is reconceptualized as a longitudinal instead of a cross-sectional di­ agnosis—more comparable to schizophrenia, bipolar disorder, and major depressive disorder, which are bridged by this condition—and requires that a major mood episode be present for a majority of the total disorder's duration after Criterion A has been met. Criterion A for delu­ sional disorder no longer has the requirement that the delusions must be nonbizarre; a spec­ ifier is now included for bizarre type delusions to provide continuity with DSM-IV. Criteria for catatonia are described uniformly across DSM-5. Furthermore, catatonia may be diagnosed with a specifier (for depressive, bipolar, and psychotic disorders, including schizophrenia), in the context of a known medical condition, or as an other specified diagnosis.

Bipolar and Related Disorders Diagnostic criteria for bipolar disorders now include both changes in mood and changes in activity or energy. The DSM-IV diagnosis of bipolar I disorder, mixed episodes—requiring that the individual simultaneously meet full criteria for both mania and major depressive ep­ isode—is replaced with a new specifier "with mixed features." Particular conditions can now be diagnosed under other specified bipolar and related disorder, including categori­ zation for individuals with a past history of a major depressive disorder whose symptoms meet all criteria for hypomania except the duration criterion is not met (i.e., the episode lasts only 2 or 3 days instead of the required 4 consecutive days or more). A second condition con­ stituting an other specified bipolar and related disorder variant is that too few symptoms of hypomania are present to meet criteria for the full bipolar II syndrome, although the dura­ tion, at least 4 consecutive days, is sufficient. Finally, in both this chapter and in the chapter "Depressive Disorders," an anxious distress specifier is delineated.

Depressive Disorders To address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is included for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behav­ ioral dyscontrol. Premenstrual dysphoric disorder is now promoted from Appendix B, "Cri­ teria Sets and Axes Provided for Further Study," in DSM-IV to the main body of DSM-5. What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive disorder, which includes both chronic major depressive disorder and the previous dysthymic disorder. The coexistence within a major depressive episode of at least three manic symp­ toms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier

"with mixed features." In DSM-IV, there was an exclusion criterion for a major depressive ep­ isode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons, including the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss, and can add an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer medical health, and worse interpersonal and work functioning. It was critical to remove the implication that bereavement typically lasts only 2 months, when both physi­ cians and grief counselors recognize that the duration is more commonly 1-2 years. A detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive disorder. Finally, a new specifier to indicate the presence of mixed symptoms has been added across both the bipolar and the depressive disorders.

Anxiety Disorders The chapter on anxiety disorders no longer includes obsessive-compulsive disorder (which is in the new chapter "Obsessive-Compulsive and Related Disorders") or posttraumatic stress disorder (PTSD) and acute stress disorder (which are in the new chapter "Traumaand Stressor-Related Disorders"). Changes in criteria for specific phobia and social anxiety disorder (social phobia) include deletion of the requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable. Instead, the anxiety must be out of proportion to the actual danger or threat in the situation, after cultural contextual fac­ tors are taken into account. In addition, the 6-month duration is now extended to all ages. Panic attacks can now be listed as a specifier that is applicable to all DSM-5 disorders. Panic disorder and agoraphobia are unlinked in DSM-5. Thus, the former DSM-IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses, panic disorder and ag­ oraphobia, each with separate criteria. The "generalized" specifier for social anxiety disor­ der has been deleted and replaced with a "performance only" specifier. Separation anxiety disorder and selective mutism are now classified as anxiety disorders. The wording of the criteria is modified to more adequately represent the expression of separation anxiety symp­ toms in adulthood. Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that onset must be before age 18 years, and a duration statement—"typically lasting for 6 months or more"—has been added for adults to miiumize overdiagnosis of transient fears.

Obsessive-Compulsive and Related Disorders The chapter "Obsessive-Compulsive and Related Disorders" is new in DSM-5. New disor­ ders include hoarding disorder, excoriation (skin-picking) disorder, substance/medica­ tion-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. The DSM-IV diagnosis of trichotillo­ mania is now termed trichotillomania (hair-pulling disorder) and has been moved from a DSM-IV classification of impulse-control disorders not elsewhere classified to obsessivecompulsive and related disorders in DSM-5. The DSM-IV "with poor insight" specifier for obsessive-compulsive disorder has been refined to allow a distinction between individuals with good or fair insight, poor insight, and "absent insight/delusional" obsessive-compul­ sive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). Analogous "insight" specifiers have been included for body dysmorphic disorder and hoarding disorder. A "tic-related" specifier for obsessive-compulsive disorder has also been added, because presence of a comorbid tic disorder may have important clinical im­ plications. A "muscle dysmoφhia" specifier for body dysmorphic disorder is added to re­ flect a growing literature on the diagnostic validity and clinical utility of making this

distinction in individuals with body dysmorphic disorder. The delusional variant of body dysmorphic disorder (which identifies individuals who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delu­ sional disorder, somatic type, and body dysmorphic disorder; in DSM-5, this presentation is designated only as body dysmoφhic disorder with the absent insight/delusional specifier. Individuals can also be diagnosed with other specified obsessive-compulsive and related disorder, which can include conditions such as body-focused repetitive behavior disorder and obsessional jealousy, or unspecified obsessive-compulsive and related disorder.

Trauma- and Stressor-Related Disorders For a diagnosis of acute stress disorder, qualifying traumatic events are now explicit as to whether they were experienced directly, witnessed, or experienced indirectly. Also, the DSM-IV Criterion A2 regarding the subjective reaction to the traumatic event (e.g., expe­ riencing '"fear, helplessness, or horror") has been eliminated. Adjustment disorders are reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event, rather than as a residual cat­ egory for individuals who exhibit clinically significant distress but whose symptoms do not meet criteria for a more discrete disorder (as in DSM-IV). DSM-5 criteria for PTSD differ significantly from the DSM-IV criteria. The stressor cri­ terion (Criterion A) is more explicit with regard to events that qualify as "traumatic" ex­ periences. Also, DSM-IV Criterion A2 (subjective reaction) has been eliminated. Whereas there were three major symptom clusters in DSM-IV—reexperiencing, avoidance/numb­ ing, and arousal—there are now four symptom clusters in DSM-5, because the avoidance/ numbing cluster is divided into two distinct clusters: avoidance and persistent negative al­ terations in cognitions and mood. This latter category, which retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as persistent negative emotional states. The final cluster—alterations in arousal and reactivity—retains most of the DSM-IV arousal symptoms. It also includes irritable behavior or angry out­ bursts and reckless or self-destructive behavior. PTSD is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder. The DSM-IV childhood diagnosis reactive attachment disorder had two subtypes: emotionally withdrawn/inhibited and indiscriminately social/disinhibited. In DSM-5, these subtypes are defined as distinct disorders: reactive attachment disorder and disin-

hibited social engagement disorder.

Dissociative Disorders Major changes in dissociative disorders in DSM-5 include the following: 1) derealization is included in the name and symptom structure of what previously was called depersonali­ zation disorder (depersonalization/derealization disorder); 2) dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis, and 3) the criteria for dissociative identity disorder have been changed to indicate that symptoms of disruption of identity may be reported as well as observed, and that gaps in the recall of events may occur for everyday and not just traumatic events. Also, experiences of pathological pos­ session in some cultures are included in the description of identity disruption.

Somatic Symptom and Related Disorders In DSM-5, somatoform disorders are now referred to as somatic symptom and related dis­ orders. The DSM-5 classification reduces the number of these disorders and subcategories to avoid problematic overlap. Diagnoses of somatization disorder, hypochondriasis, pain dis­ order, and undifferentiated somatoform disorder have been removed. Individuals previ­

ously diagnosed with somatization disorder will usually have symptoms that meet DSM-5 criteria for somatic symptom disorder, but only if they have the maladaptive thoughts, feel­ ings, and behaviors that define the disorder, in addition to their somatic symptoms. Because the distinction between somatization disorder and undifferentiated somatoform disorder was arbitrary, they are merged in DSM-5 under somatic symptom disorder. Individuals pre­ viously diagnosed with hypochondriasis who have high health anxiety but no somatic symp­ toms would receive a DSM-5 diagnosis of illness anxiety disorder (unless their health anxiety was better explained by a primary anxiety disorder, such as generalized anxiety dis­ order). Some individuals with chronic pain would be appropriately diagnosed as having so­ matic symptom disorder, with predominant pain. For otiiers, psychological factors affecting other medical conditions or an adjustment disorder would be more appropriate. Psychological factors affecting other medical conditions is a new mental disorder in DSM-5, having formerly been listed in the DSM-IV chapter "Other Conditions That May Be a Focus of Clinical Attention." This disorder and factitious disorder are placed among the somatic symptom and related disorders because somatic symptoms are predominant in both disorders, and both are most often encountered in medical settings. The variants of psychological factors affecting other medical conditions are removed in favor of the stem diagnosis. Criteria for conversion disorder (functional neurological symptom disorder) have been modified to emphasize the essential importance of the neurological examina­ tion, and in recognition that relevant psychological factors may not be demonstrable at the time of diagnosis. Other specified somatic symptom disorder, other specified illness anx­ iety disorder, and pseudocyesis are now the only exemplars of the other specified somatic symptom and related disorder classification.

Feeding and Eating Disorders Because of the elimination of the DSM-IV-TR chapter "Disorders Usually First Diagnosed During Infancy, Childhood, or Adolescence," this chapter describes several disorders found in the DSM-IV section "Feeding and Eating Disorders of Infancy or Early Childhood," such as pica and rumination disorder. The DSM-IV category feeding disorder of infancy or early childhood has been renamed avoidant/restrictive food intake disorder, and the criteria are significantly expanded. The core diagnostic criteria for anorexia nervosa are conceptually un­ changed from E)SM-rV with one exception: the requirement for amenorrhea is eliminated. As in DSM-IV, individuals with this disorder are required by Criterion A to be at a significantly low body weight for their developmental stage. The wording of the criterion is changed for clarification, and guidance regarding how to judge whether an individual is at or below a sig­ nificantly low weight is provided in the text. In DSM-5, Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behavior that interferes with weight gain. The only change in the DSM-IV criteria for bulimia nervosa is a reduction in the required minimum average frequency of binge eating and inappropriate compensatory be­ havior frequency from twice to once weekly. The extensive research that followed the prom­ ulgation of preliminary criteria for binge-eating disorder in Appendix B of DSM-IV documented the clinical utility and validity of binge-eating disorder. The only significant dif­ ference from the preliminary criteria is that the minimum average frequency of binge eating re­ quired for diagnosis is once weekly over the last 3 months, identical to the frequency criterion for bulimia nervosa (rather than at least 2 days a week for 6 months in DSM-IV).

Elimination Disorders There have been no significant changes in this diagnostic class from DSM-IV to DSM-5. The disorders in this chapter were previously classified under disorders usually first di­ agnosed in infancy, childhood, or adolescence in DSM-IV and exist now as an independent classification in DSM-5.

Sleep-Wake Disorders In DSM-5, the DSM-IV diagnoses named sleep disorder related to another mental disorder and sleep disorder related to another medical condition have been removed, and instead greater specification of coexisting conditions is provided for each sleep-wake disorder. The diagnosis of primary insomnia has been renamed insomnia disorder to avoid the differen­ tiation between primary and secondary insomnia. DSM-5 also distinguishes narcolepsy— now known to be associated with hypocretin deficiency—from other forms of hypersomno­ lence (hypersomnolence disorder). Finally, throughout the DSM-5 classification of sleepwake disorders, pediatric and developmental criteria and text are integrated where existing science and considerations of clinical utility support such integration. Breathing-related sleep disorders are divided into three relatively distinct disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. The subtypes of circadian rhythm sleep disorders are expanded to include advanced sleep phase type and irregular sleep-wake type, whereas the jet lag type has been removed. The use of the former "not oth­ erwise specified" diagnoses in DSM-IV have been reduced by elevating rapid eye move­ ment sleep behavior disorder and restless legs syndrome to independent disorders.

Sexual Dysfunctions In DSM-5, some gender-specific sexual dysfunctions have been added, and, for females, sexual desire and arousal disorders have been combined into one disorder: female sexual interest/arousal disorder. All of the sexual dysfunctions (except substance/medication-in­ duced sexual dysfunction) now require a minimum duration of approximately 6months and more precise severity criteria. Genito-pelvic pain/penetration disorder has been added to DSM-5 and represents a merging of vaginismus and dyspareunia, which were highly comorbid and difficult to distinguish. The diagnosis of sexual aversion disorder has been re­ moved due to rare use and lack of supporting research. There are now only two subtypes for sexual dysfunctions: lifelong versus acquired and generalized versus situational. To indicate the presence and degree of medical and other nonmedical correlates, the following associated features have been added to the text: partner factors, relationship factors, individual vulnerability factors, cultural or religious factors, and medical factors.

Gender Dysplioria Gender dysphoria is a new diagnostic class in DSM-5 and reflects a change in conceptual­ ization of the disorder's defining features by emphasizing the phenomenon of "gender in­ congruence" rather than cross-gender identification per se, as was the case in DSM-IV gender identity disorder. Gender dysphoria includes separate sets of criteria: for children and for adults and adolescents. For the adolescents and adults criteria, the previous Criterion A (cross-gender identification) and Criterion B (aversion toward one's gender) are merged. In the wording of the criteria, "the other sex" is replaced by "the other gender" (or "some alter­ native gender")." Gender instead of sex is used systematically because the concept "sex" is in­ adequate when referring to individuals with a disorder of sex development. In the child criteria, "strong desire to be of the other gender" replaces the previous "repeatedly stated de­ sire to be...the other sex" to capture the situation of some children who, in a coercive envi­ ronment, may not verbalize the desire to be of another gender. For children. Criterion A1 ("a strong desire to be of the other gender or an insistence that he or she is the other gender...)" is now necessary (but not sufficient), which makes the diagnosis more restrictive and conser­ vative. The subtyping on the basis of sexual orientation is removed because the distinction is no longer considered clinically useful. A posttransition specifier has been added to identify

individuals who have undergone at least one medical procedure or treatment to support the new gender assignment (e.g., cross-sex hormone treatment). Although the concept of post­ transition is modeled on the concept of full or partial remission, the term remission has impli­ cations in terms of symptom reduction that do not apply directly to gender dysphoria.

Disruptive, Impulse-Control, and Conduct Disorders The chapter "Disruptive, Impulse-Control, and Conduct Disorders" is new to DSM-5 and combines disorders that were previously included in the chapter "Disorders Usually First Di­ agnosed in Infancy, Childhood, or Adolescence" (i.e., oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified, now categorized as other specified and unspecified disruptive, impulse-control, and conduct disorders) and the chap­ ter "Impulse-Control Disorders Not Elsewhere Classified" (i.e., intermittent explosive disor­ der, pyromania, and kleptomania). These disorders are all characterized by problems in emotional and behavioral self-control. Notably, ADHD is frequently comorbid with the dis­ orders in this chapter but is listed with the neurodevelopmental disorders. Because of its close association with conduct disorder, antisocial personality disorder is listed both in this chapter and in the chapter "Personality Disorders," where it is described in detail. The criteria for oppositional defiant disorder are now grouped into three types: an­ gry/irritable mood, argumentative/defiant behavior, and vindictiveness. Additionally, the exclusionary criterion for conduct disorder has been removed. The criteria for conduct disorder include a descriptive features specifier for individuals who meet full criteria for the disorder but also present with limited prosocial emotions. The primary change in in­ termittent explosive disorder is in the type of aggressive outbursts that should be consid­ ered: DSM-IV required physical aggression, whereas in DSM-5 verbal aggression and nondestructive/noninjurious physical aggression also meet criteria. DSM-5 also provides more specific criteria defining frequency needed to meet the criteria and specifies that the aggressive outbursts are impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences. Furthermore, a minimum age of 6 years (or equivalent developmental level) is now required.

Substance-Related and Addictive Disorders An important departure from past diagnostic manuals is that the chapter on substance-related disorders has been expanded to include gambling disorder. Another key change is that DSM-5 does not separate the diagnoses of substance abuse and dependence as in DSM-IV. Rather criteria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, substance-induced disorders, and unspecified substance-related disorders, where relevant. Within substance use disorders, the DSM-IV recurrent substance-related legal problems criterion has been deleted from DSM-5, and a new criterion—craving, or a strong de­ sire or urge to use a substance—^has been added. In addition, the threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria, in contrast to a threshold of one or more criteria for a diagnosis of DSM-IV substance abuse and three or more for DSM-IV depen­ dence. Cannabis withdrawal and caffeine withdrawal are new disorders (the latter was in DSM-IV Appendbc B, "Criteria Sets and Axes Provided for Further Study"). Severity of the DSM-5 substance use disorders is based on the number of criteria en­ dorsed. The DSM-IV specifier for a physiological subtype is eliminated in DSM-5, as is the DSM-IV diagnosis of polysubstance dependence. Early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without meeting substance use disorder criteria (except craving), and sustained remission is defined as at least 12 months without meeting criteria (except craving). Additional new DSM-5 specifiers include "in a controlled environment" and "on maintenance therapy" as the situation warrants.

Neurocognitive Disorders The DSM-IV diagnoses of dementia and amnestic disorder are subsumed under the newly named entity major neurocognitive disorder (NCD). The term dementia is not precluded from use in the etiological subtypes where that term is standard. Furthermore, DSM-5 now recog­ nizes a less severe level of cognitive impairment, mild NCD, which is a new disorder that per­ mits the diagnosis of less disabling syndromes that may nonetheless be the focus of concern and treatment. Diagnostic criteria are provided for both of these disorders, followed by diag­ nostic criteria for different etiological subtypes. In DSM-IV, individual diagnoses were desig­ nated for dementia of the Alzheimer's type, vascular dementia, and substance-induced dementia, whereas the other neurodegenerative disorders were classified as dementia due to another medical condition, with HIV, head trauma, Parkinson's disease, Huntington's disease. Pick's disease, Creutzfeldt-Jakob disease, and other medical conditions specified. In DSM-5, major or mild NCD due to Alzheimer's disease and major or mild vascular NCD have been re­ tained, while new separate criteria are now presented for major or mild frontotemporal NCD, NCD with Lewy bodies, and NCDs due to traumatic brain injury, a substance/medication, HIV infection, prion disease, Parkinson's disease, Huntington's disease, another medical con­ dition, and multiple etiologies, respectively. Unspecified NCD is also included as a diagnosis.

Personality Disorders The criteria for personality disorders in Section II of DSM-5 have not changed from those in DSM-IV. An alternative approach to the diagnosis of personality disorders was developed for DSM-5 for further study and can be found in Section III (see "Alternative DSM-5 Model for Personality Disorders"). For the general criteria for personality disorder, presented in Section III, a revised personality functioning criterion (Criterion A) has been developed based on a literature review of reliable clinical measures of core impairments central to per­ sonality pathology. A diagnosis of personality disorder—trait specified, based on moderate or greater impairment in personality functioning and the presence of pathological personal­ ity traits, replaces personality disorder not otherwise specified and provides a much more in­ formative diagnosis for individuals who are not optimally described as having a specific personality disorder. A greater emphasis on personality functioning and trait-based criteria increases the stability and empirical bases of the disorders. Personality functioning and per­ sonality traits also can be assessed whether or not the individual has a personality disor­ der—a feature that provides clinically useful information about all individuals.

Paraphilic Disorders An overarching change from DSM-IV is the addition of the course specifiers "in a controlled environment" and "in remission" to the diagnostic criteria sets for all the paraphilic disor­ ders. These specifiers are added to indicate important changes in an individual's status. In DSM-5, paraphilias are not ipsofacto mental disorders. There is a distinction between paraphil­ ias and paraphilic disorders. A paraphilic disorder is a paraphilia that is currently causing dis­ tress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. A paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not automatically justify or require clinical intervention. The distinction between paraphilias and paraphilic disorders was im­ plemented without making any changes to the basic structure of the diagnostic criteria as they had existed since DSM-III-R. The change proposed for DSM-5 is that individuals who meet both Criterion A and Criterion B would now be diagnosed as having a paraphilic disorder. A diagnosis would not be given to individuals whose symptoms meet Criterion A but not Cri­ terion B—that is, to individuals who have a paraphilia but not a paraphilic disorder.

Glossa Technical Terms affect A pattern of observable behaviors that is the expression of a subjectively experi­ enced feeling state (emotion). Examples of affect include sadness, elation, and anger. In contrast to mood, which refers to a pervasive and sustained emotional "climate," ajfect refers to more fluctuating changes in emotional "weather." What is considered the nor­ mal range of the expression of affect varies considerably, both within and among dif­ ferent cultures. Disturbances in affect include blunted Significant reduction in the intensity of emotional expression. flat Absence or near absence of any sign of affective expression. inappropriate Discordance between affective expression and the content of speech or ideation. labile Abnormal variability in affect with repeated, rapid, and abrupt shifts in af­ fective expression. restricted or constricted Mild reduction in the range and intensity of emotional ex­ pression. affective blunting

See AFFECT.

agitation (psychomotor)

See PSYCHOMOTOR AGITATION.

agnosia Loss of ability to recognize objects, persons, sounds, shapes, or smells that occurs in the absence of either impairment of the specific sense or significant memory loss. alogia An impoverishment in thinking that is inferred from observing speech and lan­ guage behavior. There may be brief and concrete replies to questions and restriction in the amount of spontaneous speech (termed poverty of speech). Sometimes the speech is adequate in amoimt but conveys little information because it is overconcrete, overab­ stract, repetitive, or stereotyped (termed poverty of content). amnesia An inability to recall important autobiographical information that is inconsis­ tent with ordinary forgetting. anhedonia Lack of enjoyment from, engagement in, or energy for life's experiences; def­ icits in the capacity to feel pleasure and take interest in things. Anhedonia is a facet of the broad personality trait domain DETACHMENT. anosognosia A condition in which a person with an illness seems unaware of the exis­ tence of his or her illness. antagonism Behaviors that put an individual at odds with other people, such as an ex­ aggerated sense of self-importance with a concomitant expectation of special treat­ ment, as well as a callous antipathy toward others, encompassing both unawareness of others' needs and feelings, and a readiness to use others in the service of self-enhance­ ment. Antagonism is one of the five broad PERSONALITY TRAIT DOMAINS defined in Sec­ tion III "Alternative DSM-5 Model for Personality Disorders." Small caps indicate term found elsewhere in this glossary. Glossary definitions were informed by

DSM-5 Work Groups, publicly available Internet sources, and previously published glossaries for mental disorders (World Health Organization and American Psychiatric Association).

antidepressant discontinuation syndrome A set of symptoms that can occur after abrupt cessation, or marked reduction in dose, of an antidepressant medication that had been taken continuously for at least 1 month.

anxiety The apprehensive anticipation of future danger or misfortune accompanied by a feeling of worry, distress, and/or somatic symptoms of tension. The focus of antici­ pated danger may be internal or external.

anxiousness Feelings of nervousness or tenseness in reaction to diverse situations; frequent v^orry about the negative effects of past unpleasant experiences and future negative possi­ bilities; feeling fearful and apprehensive about uncertainty; expecting the worst to happen. Anxiousness is a facet of the broad personality trait domain NEGATIVE AFFECnviTY.

arousal The physiological and psychological state of being awake or reactive to stimuli. asociality A reduced initiative for interacting with other people. attention The ability to focus in a sustained manner on a particular stimulus or activity. A disturbance in attention may be manifested by easy DISTRACTIBILITY or difficulty in finishing tasks or in concentrating on work.

attention seeking Engaging in behavior designed to attract notice and to make oneself the focus of others' attention and admiration. Attention seeking is a facet of the broad personality trait domain ANTAGONISM.

autogynephilia Sexual arousal of a natal male associated with the idea or image of being a woman.

avoidance The act of keeping away from stress-related circumstances; a tendency to cir­ cumvent cues, activities, and situations that remind the individual of a stressful event experienced.

avolition An inability to initiate and persist in goal-directed activities. When severe enough to be considered pathological, avolition is pervasive and prevents the person from com­ pleting many different types of activities (e.g., work, intellectual pursuits, self-care).

bereavement The state of having lost through death someone with whom one has had a close relationship. This state includes a range of grief and mourning responses.

biological rhythms See CIRCADIAN RHYTHMS. callousness Lack of concern for the feelings or problems of others; lack of guilt or re­ morse about the negative or harmful effects of one's actions on others. Callousness is a facet of the broad personality trait domain ANTAGONISM.

catalepsy Passive induction of a posture held against gravity. Compare with WAXY FLEX­ IBILITY.

cataplexy Episodes of sudden bilateral loss of muscle tone resulting in the individual collapsing, often occurring in association with intense emotions such as laughter, an­ ger, fear, or surprise.

circadian rhythms Cyclical variations in physiological and biochemical function, level of sleep-wake activity, and emotional state. Circadian rhythms have a cycle of about 24 hours, ultradian rhythms have a cycle that is shorter than 1 day, and infradian rhythms have a cycle that may last weeks or months.

cognitive and perceptual dysregulation Odd or unusual thought processes and experi­ ences, including DEPERSONALIZAΉON, DEREALIZATON, and DISSOCIATON; mixed sleepwake state experiences; and thought-control experiences. Cognitive and perceptual dysregulation is a facet of the broad personality trait domain PSYCHOTICISM.

coma State of complete loss of consciousness.

compulsion Repetitive behaviors (e.g., hand washing, 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 rig­ idly. The behaviors or mental acts are aimed at preventing or reducing anxiety or dis­ tress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutral­ ize or prevent or are clearly excessive.

conversion symptom A loss of, or alteration in, voluntary motor or sensory functioning, with or without apparent impairment of consciousness. The symptom is not fully ex­ plained by a neurological or another medical condition or the direct effects of a sub­ stance and is not intentionally produced or feigned.

deceitfulness Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events. Deceitfulness is a facet of the broad personality trait domain ANTAGONISM.

defense mechanism Mechanisms that mediate the individual's reaction to emotional conflicts and to external stressors. Some defense mechanisms (e.g., projection, splitting, acting out) are almost invariably maladaptive. Others (e.g., suppression, denial) may be either maladaptive or adaptive, depending on their severity, their inflexibility, and the context in which they occur.

delusion A false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and despite what constitutes incontro­ vertible and obvious proof or evidence to the contrary. The belief is not ordinarily ac­ cepted by other members of the person's culture or subculture (i.e., it is not an article of religious faith). When a false belief involves a value judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility. Delusional conviction can sometimes be inferred from an overvalued idea (in which case the individual has an un­ reasonable belief or idea but does not hold it as firmly as is the case with a delusion). De­ lusions are subdivided according to their content. Common types are listed below:

bizarre A delusion that involves a phenomenon that the person's culture would re­ gard as physically impossible.

delusional jealousy A delusion that one's sexual partner is unfaithful. érotomanie A delusion that another person, usually of higher status, is in love with the individual.

grandiose A delusion of inflated worth, power, knowledge, identity, or special re­ lationship to a deity or famous person.

mixed type Delusions of more than one type (e.g., EROTOMANIC, GRANDIOSE, PERSE­ CUTORY, SOMATIC) in which no one theme predominates.

mood-congruent See MOOD-CONGRUENT PSYCHOTIC FEATURES. mood-incongruent See MOOD-INCONGRUENT PSYCHOΉC FEATURES. of being controlled A delusion in which feelings, impulses, thoughts, or actions are experienced as being under the control of some external force rather than be­ ing under one's own control. of reference A delusion in which events, objects, or other persons in one's immedi­ ate environment are seen as having a particular and unusual significance. These delusions are usually of a negative or pejorative nature but also may be grandiose in content. A delusion of reference differs from an idea of reference, in which the false belief is not as firmly held nor as fully organized into a true belief. persecutory A delusion in which the central theme is that one (or someone to whom one is close) is being attacked, harassed, cheated, persecuted, or conspired against.

somatic A delusion whose main content pertains to the appearance or functioning of one's body.

thought broadcasting A delusion that one's thoughts are being broadcast out loud so that they can be perceived by others.

thought insertion A delusion that certain of one's thoughts are not one's own, but rather are inserted into one's mind.

depersonalization The experience of feeling detached from, and as if one is an outside observer of, one's mental processes, body, or actions (e.g., feeling like one is in a dream; a sense of unreality of self, perceptual alterations; emotional and/or physical numbing; temporal distortions; sense of unreality).

depressivity Feelings of being intensely sad, miserable, and/or hopeless. Some patients describe an absence of feelings and/or dysphoria; difficulty recovering from such moods; pessimism about the future; pervasive shame and/or guilt; feelings of inferior self-worth; and thoughts of suicide and suicidal behavior. Depressivity is a facet of the broad personality trait domain DETACHMENT.

derealization The experience of feeling detached from, and as if one is an outside ob­ server of, one's surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).

detachment Avoidance of socioemotional experience, including both WITHDRAWAL from interpersonal interactions (ranging from casual, daily interactions to friendships and inti­ mate relationships [i.e., INTIMACY AVOIDANCE]) and RESTRICTED AFFECTWITY, particularly limited hedonic capacity. Detachment is one of the five pathological PERSONALITY TRAIT DOMAINS defined in Section ΙΠ "Alternative DSM-5 Model for Personality Disorders."

disinhibition Orientation toward immediate gratification, leading to impulsive behav­ ior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences. RIGID PERFECTIONISM, the opposite pole of this domain, reflects excessive constraint of impulses, risk avoidance, hyper­ responsibility, hyperperfectionism, and rigid, rule-governed behavior. Disinhibition is one of the five pathological PERSONALITY TRAIT DOMAINS defined in Section III "Al­ ternative DSM-5 Model for Personality Disorders."

disorder of sex development Condition of significant inborn somatic deviations of the reproductive tract from the norm and/or of discrepancies among the biological indica­ tors of male and female.

disorientation Confusion about the time of day, date, or season (time); where one is (place); or who one is (person).

dissociation The splitting off of clusters of mental contents from conscious awareness. Dissociation is a mechanism central to dissociative disorders. The term is also used to describe the separation of an idea from its emotional significance and affect, as seen in the inappropriate affect in schizophrenia. Often a result of psychic trauma, dissociation may allow the individual to maintain allegiance to two contradictory truths while re­ maining unconscious of the contradiction. An extreme manifestation of dissociation is dissociative identity disorder, in which a person may exhibit several independent per­ sonalities, each unaware of the others.

distractibility Difficulty concentrating and focusing on tasks; attention is easily divert­ ed by extraneous stimuli; difficulty maintaining goal-focused behavior, including both planning and completing tasks. Distractibility is a facet of the broad personality trait domain DiSlNHlBmON.

dysarthria A disorder of speech sound production due to structural or motor impair­ ment affecting the articulatory apparatus. Such disorders include cleft palate, muscle

disorders, cranial nerve disorders, and cerebral palsy affecting bulbar structures (i.e., lower and upper motor neuron disorders). Distortion of voluntary movements with involuntary muscle activity.

dyskinesia

A condition in which a person experiences intense feelings of depression, discontent, and in some cases indifference to the world around them.

dysphoria (dysphoric mood)

dyssomnias Primary disorders of sleep or wakefulness characterized by INSOMNIA or HYPERSOMNIA as the major presenting symptom. Dyssomnias are disorders of the amount, quality, or timing of sleep. Compare with PARASOMNIAS.

Presence, while depressed, of two or more of the following: 1) poor appetite or overeating, 2) insomnia or hypersonnnia, 3) low energy or fatigue, 4) low self-esteem, 5) poor concentration or difficulty making decisions, or 6) feelings of hopelessness.

dysthymia

dystonia

Disordered tonicity of muscles.

eccentricity Odd, unusual, or bizarre behavior, appearance, and/or speech having strange and unpredictable thoughts; saying unusual or inappropriate things. Eccentric­ ity is a facet of the broad personality trait domain PSYCHOTICISM.

The pathological, parrotlike, and apparently senseless repetition (echoing) of a word or phrase just spoken by another person.

echolalia

echopraxia

Mimicking the movements of another.

Instability of emotional experiences and mood; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances. Emo­ tional lability is a facet of the broad personality trait domain NEGATIVE AFFECTIVITY.

emotional lability

Comprehension and appreciation of others' experiences and motivations; tol­ erance of differing perspectives; understanding the effects of own behavior on others.

empathy

A specified duration of time during which the patient has developed or experienced symptoms that meet the diagnostic criteria for a given mental disorder. De­ pending on the type of mental disorder, episode may denote a certain number of symptoms or a specified severity or frequency of symptoms. Episodes may be further differentiated as a single (first) episode or a recurrence or relapse of multiple episodes if appropriate.

episode (episodic)

A mental and emotional condition in which a person experiences intense feel­ ings of well-being, elation, happiness, excitement, and joy.

euphoria

fatigability

Tendency to become easily fatigued. See also FATIGUE.

A state (also called exhaustion, tiredness, lethargy, languidness, languor, lassi­ tude, and listlessness) usually associated with a weakening or depletion of one's phys­ ical and/or mental resources, ranging from a general state of lethargy to a specific, work-induced burning sensation within one's muscles. Physical fatigue leads to an in­ ability to continue functioning at one's normal level of activity. Although widespread in everyday life, this state usually becomes particularly noticeable during heavy exer­ cise. Mental fatigue, by contrast, most often manifests as SOMNOLENCE (sleepiness).

fatigue

An emotional response to perceived imminent threat or danger associated with urges to flee or fight.

fear

A dissociative state during which aspects of a traumatic event are reexperi­ enced as though they were occurring at that moment.

flashback

A nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations, distracting stimuli, or plays on words. When the condition is severe, speech may be disorganized and incoherent.

flight of ideas

gender The public (and usually legally recognized) lived role as boy or girl, man or woman. Biological factors are seen as contributing in interaction with social and psy­ chological factors to gender development.

gender assignment The initial assignment as male or female, which usually occurs at birth and is subsequently referred to as the "natal gender."

gender dysphoria Distress that accompanies the incongruence between one's experi­ enced and expressed gender and one's assigned or natal gender.

gender experience The unique and personal ways in which individuals experience their gender in the context of the gender roles provided by their societies.

gender expression The specific ways in which individuals enact gender roles provided in their societies.

gender identity A category of social identity that refers to an individual's identification as male, female or, occasionally, some category other than male or female.

gender reassignment A change of gender that can be either medical (hormones, sur­ gery) or legal (government recognition), or both. In case of medical interventions, often referred to as sex reassignment.

geometric hallucination See HALLUCINATION. grandiosity Believing that one is superior to others and deserves special treatment; selfcenteredness; feelings of entitlement; condescension toward others. Grandiosity is a facet of the broad personality trait domain ANTAGONISM.

grimace (grimacing) Odd and inappropriate facial expressions unrelated to situation (as seen in individuals with CATATONIA).

hallucination A perception-like experience with the clarity and impact of a true percep­ tion but without the external stimulation of the relevant sensory organ. Hallucinations should be distinguished from ILLUSIONS, in which an actual external stimulus is misperceived or misinteφreted. The person may or may not have insight into the nonveridical nature of the hallucination. One hallucinating person may recognize the false sensory experience, whereas another may be convinced that the experience is grounded in reality. The term hallucination is not ordinarily applied to the false perceptions that occur during dreaming, while falling asleep (hypnagogic), or upon awakening (hypnopompic). Transient hallucinatory experiences may occur without a mental disorder.

auditory A hallucination involving the perception of sound, most commonly of voice.

geometric Visual hallucinations involving geometric shapes such as tunnels and funnels, spirals, lattices, or cobwebs.

gustatory A hallucination involving the perception of taste (usually unpleasant). mood-congruent See MOOD-CONGRUENT PSYCHOTIC FEATURES. mood-incongruent See MOOD-INCONGRUENT PSYCHOTIC FEATURES. olfactory A hallucination involving the perception of odor, such as of burning rub­ ber or decaying fish.

somatic A hallucination involving the perception of physical experience localized within the body (e.g., a feeling of electricity). A somatic hallucination is to be dis­ tinguished from physical sensations arising from an as-yet-undiagnosed general medical condition, from hypochondriacal preoccupation with normal physical sensations, or from a tactile hallucination.

tactile A hallucination involving the perception of being touched or of something being under one's skin. The most common tactile hallucinations are the sensation

of electric shocks and formication (the sensation of something creeping or crawl­ ing on pr under the skin). visual A hallucination involving sight, which may consist of formed images, such as of people, or of unformed images, such as flashes of light. Visual hallucinations should be distinguished from ILLUSIONS, which are misperceptions of real external stimuli. hostility Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior. Hostility is a facet of the broad personality trait domain ANTAGONISM. hyperacusis

Increased auditory perception.

hyperorality

A condition in which inappropriate objects are placed in the mouth.

hypersexuality

A stronger than usual urge to have sexual activity.

hypersomnia Excessive sleepiness, as evidenced by prolonged nocturnal sleep, difficul­ ty maintaining an alert awake state during the day, or undesired daytime sleep epi­ sodes. See also SOMNOLENCE. hypervigilance An enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompa­ nied by a state of increased anxiety which can cause exhaustion. Other symptoms include abnormally increased arousal, a high responsiveness to stimuli, and a continual scanning of the environment for threats. In hypervigilance, there is a perpetual scanning of the envi­ ronment to search for sights, sounds, people, behaviors, smells, or anything else that is rem­ iniscent of threat or trauma. The individual is placed on high alert in order to be certain danger is not near. Hypervigilance can lead to a variety of obsessive behavior patterns, as well as producing difficulties with social interaction and relationships. hypomania

An abnormality of mood resembling mania but of lesser intensity. See also

MANIA.

hypopnea

Episodes of overly shallow breathing or an abnormally low respiratory rate.

ideas of reference The feeling that causal incidents and external events have a particu­ lar and unusual meaning that is specific to the person. An idea of reference is to be dis­ tinguished from a DELUSION OF REFERENCE, in which there is a belief that is held with delusional conviction. identity Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regu­ late, a range of emotional experience. illusion A misperception or misinterpretation of a real external stimulus, such as hear­ ing the rustling of leaves as the sound of voices. See also HALLUCINATION. impulsivity Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establish­ ing and following plans; a sense of urgency and self-harming behavior under emotion­ al distress. Impulsivity is a facet of the broad personality trait domain DiSlNHlBmON. incoherence Speech or thinking that is essentially incomprehensible to others because word or phrases are joined together without a logical or meaningful connection. This disturbance occurs within clauses, in contrast to derailment, in which the disturbance is between clauses. This has sometimes been referred to a "word salad" to convey the degree of linguistic disorganization. Mildly ungrammatical constructions or idiomatic usages characteristic of a particular regional or cultural backgrounds, lack of educa­ tion, or low intelligence should not be considered incoherence. The term is generally not applied when there is evidence that the disturbance in speech is due to an aphasia. insomnia

A subjective complaint of difficulty falling or staying asleep or poor sleep quality.

intersex condition A condition in which individuals have conflicting or ambiguous bi­ ological indicators of sex.

intimacy Depth and duration of connection with others; desire and capacity for close­ ness; mutuality of regard reflected in interpersonal behavior.

intimacy avoidance Avoidance of close or romantic relationships, interpersonal attach­ ments, and intimate sexual relationships. Intimacy avoidance is a facet of the broad personality trait domain DETACHMENT.

irresponsibility Disregard for—and failure to honor—financial and other obligations or commitments; lack of respect for—and lack of follow-through on—agreements and promises; carelessness with others' property. Irresponsibility is a facet of the broad per­ sonality trait domain DiSINHIBmON.

language pragmatics The understanding and use of language in a given context. For example, the warning "Watch your hands" when issued to a child who is dirty is in­ tended not only to prompt the child to look at his or her hands but also to communicate the admonition "Don't get anything dirty."

lethargy A state of decreased mental activity, characterized by sluggishness, drowsi­ ness, inactivity, and reduced alertness.

macropsia The visual perception that objects are larger than they actually are. Compare with MICROPSIA.

magical thinking The erroneous belief that one's thoughts, words, or actions will cause or prevent a specific outcome in some way that defies commonly understood laws of cause and effect. Magical thinking may be a part of normal child development.

mania A mental state of elevated, expansive, or irritable mood and persistently in­ creased level of activity or energy. See also HYPOMANIA.

manipulativeness Use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one's ends. Manipulativeness is a facet of the broad personality trait domain ANTAGONISM.

mannerism A peculiar and characteristic individual style of movement, action, thought, or speech.

melancholia (melancholic)

A mental state characterized by very severe depression.

micropsia The visual perception that objects are smaller than they actually are. Com­ pare with MACROPSIA.

mixed symptoms The specifier "with mixed features" is applied to mood episodes during which subthreshold symptoms from the opposing pole are present. Whereas these con­ current "mixed" symptoms are relatively simultaneous, they may also occur closely juxtaposed in time as a waxing and waning of individual symptoms of the opposite pole (i.e., depressive symptoms during hypomanie or manic episodes, and vice versa).

mood A pervasive and sustained emotion that colors the perception of the world. Com­ mon examples of mood include depression, elation, anger, and anxiety. In contrast to affect, which refers to more fluctuating changes in emotional "weather," mood refers to a pervasive and sustained emotional "climate." Types of mood include

dysphoric An unpleasant mood, such as sadness, anxiety, or irritability. elevated An exaggerated feeling of well-being, or euphoria or elation. A person with elevated mood may describe feeling "high," "ecstatic," "on top of the world," or "up in the clouds."

euthymie Mood in the "normal" range, which implies the absence of depressed or elevated mood.

expansive Lack of restraint in expressing one's feelings, frequently with an overvaluatipn of one's significance or importance. irritable Easily annoyed and provoked to anger. mood-congruent psychotic features Delusions or hallucinations whose content is en­ tirely consistent with the typical themes of a depressed or manic mood. If the mood is depressed, the content of the delusions or hallucinations would involve themes of per­ sonal inadequacy, guilt, disease, death, nihilism, or deserved punishment. The content of the delusion may include themes of persecution if these are based on self-derogatory concepts such as deserved punishment. If the mood is manic, the content of the delusions or hallucinations would involve themes of inflated worth, power, knowledge, or iden­ tity, or a special relationship to a deity or a famous person. The content of the delusion may include themes of persecution if these are based on concepts such as inflated worth or deserved punishment. mood-incongruent psychotic features Delusions or hallucinations whose content is not consistent with the typical themes of a depressed or manic mood. In the case of depres­ sion, the delusions or hallucinations would not involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. In the case of mania, the delu­ sions or hallucinations would not involve themes of inflated worth, power, knowledge, or identity, or a special relationship to a deity or a famous person. multiple sleep latency test Polysomnographie assessment of the sleep-onset period, with several short sleep-wake cycles assessed during a single session. The test repeat­ edly measures the time to daytime sleep onset ("sleep latency") and occurrence of and time to onset of the rapid eye movement sleep phase. mutism

No, or very little, verbal response (in the absence of known aphasia).

narcolepsy Sleep disorder characterized by periods of extreme drowsiness and frequent daytime lapses into sleep (sleep attacks). These must have been occurring at least three times per week over the last 3 months (in the absence of treatment). negative affectivity Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/shame, worry, anger), and their be­ havioral (e.g., self-harm) and interpersonal (e.g., dependency) manifestations. Nega­ tive Affectivity is one of the five pathological PERSONALITY TRAIT DOMAINS defined in Section III "Alternative DSM-5 Model for Personality Disorders." negativism Opposition to suggestion or advice; behavior opposite to that appropriate to a specific situation or against the wishes of others, including direct resistance to efforts to be moved. night eating syndrome Recurrent episodes of night eating, as manifested by eating after awakening from sleep or excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better accounted for by ex­ ternal influences such as changes in the individual's sleep-wake cycle or by local social norms. nightmare disorder Repeated occurrences of extended, extremely dysphoric, and wellremembered 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. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert. nonsubstance addiction(s) Behavioral disorder (also called behavioral addiction) not re­ lated to any substance of abuse that shares some features with substance-induced addiction.

obsession Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted and that in most individ­ uals cause marked anxiety or distress. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or ac­ tion (i.e., by performing a compulsion).

overeating Eating too much food too quickly. overvalued idea An unreasonable and sustained belief that is maintained with less than delusional intensity (i.e., the person is able to acknowledge the possibility that the be­ lief may not be true). The belief is not one that is ordinarily accepted by other members of the person's culture or subculture.

panic attacks Discrete periods of sudden onset of intense fear or terror, often associated with feelings of impending doom. During these attacks there are symptoms such as shortness of breath or smothering sensations; palpitations, pounding heart, or acceler­ ated heart rate; chest pain or discomfort; choking; and fear of going crazy or losing con­ trol. Panic attacks may be unexpected, in which the onset of the attack is not associated with an obvious trigger and instead occurs "out of the blue," or expected, in which the panic attack is associated with an obvious trigger, either internal or external.

paranoid ideation Ideation, of less than delusional proportions, involving suspicious­ ness or the belief that one is being harassed, persecuted, or unfairly treated.

parasomnias Disorders of sleep involving abnormal behaviors or physiological events occurring during sleep or sleep-wake transitions. Compare with DYSSOMNIAS.

perseveration Persistence at tasks or in particular way of doing things long after the be­ havior has ceased to be functional or effective; continuance of the same behavior de­ spite repeated failures or clear reasons for stopping. Perseveration is a facet of the broad personality trait domain NEGATIVE A ffectivity .

personality Enduring patterns of perceiving, relating to, and thinking about the envi­ ronment and oneself. PERSONALITY TRAITS are prominent aspects of personality that are exhibited in relatively consistent ways across time and across situations. Personality traits influence self and interpersonal functioning. Depending on their severity, im­ pairments in personality functioning and personality trait expression may reflect the presence of a personality disorder.

personality disorder—trait specified In Section III "Alternative DSM-5 Model for Per­ sonality Disorders," a proposed diagnostic category for use when a personality disor­ der is considered present but the criteria for a specific disorder are not met. Personality disorder—trait specified (PD-TS) is defined by significant impairment in personality functioning, as measured by the Level of Personality Functioning Scale and one or more pathological PERSONALITY TRAIT DOMAINS or PERSONALITY TRAIT FACETS. PD-TS is proposed in DSM-5 Section III for further study as a possible future replacement for other specified personality disorder and unspecified personality disorder.

personality functioning Cognitive models of self and others that shape patterns of emo­ tional and affiliative engagement.

personality trait A tendency to behave, feel, perceive, and think in relatively consistent ways across time and across situations in which the trait may be manifest.

personality trait facets Specific personality components that make up the five broad per­ sonality trait domains in the dimensional taxonomy of Section III "Alternative DSM-5 Model for Personality Disorders." For example, the broad domain antagonism has the following component facets: MANIPULAΉVENESS, DECEITFULNESS, GRANDIOSITY, ATTENΉΟΝ SEEKING, CALLOUSNESS, and HOSTILITY.

personality trait domains In the dimensional taxonomy of Section III ''Alternative DSM5 Model for Personality Disorders," personality traits are organized into five broad do­ mains: N egative A ffectivity , Detachment , A ntagonism , DisiNHiBmoN, and P syCHOTICISM. Within these five broad trait domains are 25 specific personality trait facets (e.g., IMPULSIVITY, RIGID PERFECTIONISM).

phobia A persistent fear of a specific object, activity, or situation (i.e., the phobic stimu­ lus) out of proportion to the actual danger posed by the specific object or situation that results in a compelling desire to avoid it. If it cannot be avoided, the phobic stimulus is endured with marked distress.

pica Persistent eating of nonnutritive nonfood substances over a period of at least 1 month. The eating of nonnutritive nonfood substances is inappropriate to the developmental level of the individual (a minimum age of 2 years is suggested for diagnosis). The eat­ ing behavior is not part of a culturally supported or socially normative practice.

polysomnography Polysomnography (PSG), also known as a sleep study, is a multiparametric test used in the study of sleep and as a diagnostic tool in sleep medicine. The test result is called a polysomnogram, also abbreviated PSG. PSG monitors many body functions, including brain (electroencephalography), eye movements (electro-oculog­ raphy), muscle activity or skeletal muscle activation (electromyography), and heart rhythm (electrocardiography).

posturing Spontaneous and active maintenance of a posture against gravity (as seen in Abnormal posturing may also be a sign of certain injuries to the brain or spinal cord, including the following:

catatonia ).

decerebrate posture The arms and legs are out straight and rigid, the toes point downward, and the head is arched backward.

decorticate posture The body is rigid, the arms are stiff and bent, the fists are tight, and the legs are straight out.

opisthotonus The back is rigid and arching, and the head is thrown backward. An affected person may alternate between different postures as the condition changes.

pressured speech Speech that is increased in amount, accelerated, and difficult or impossi­ ble to interrupt. Usually it is also loud and emphatic. Frequently the person talks without any social stimulation and may continue to talk even though no one is listening.

prodrome An early or premonitory sign or symptom of a disorder. pseudocyesis A false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy.

psychological distress A range of symptoms and experiences of a person's internal life that are commonly held to be troubling, confusing, or out of the ordinary.

psychometric measures Standardized instruments such as scales, questionnaires, tests, and assessments that are designed to measure human knowledge, abilities, attitudes, or personality traits.

psychomotor agitation Excessive motor activity associated with a feeling of inner tension. The activity is usuaUy nonproductive and repetitious and consists of behaviors such as pac­ ing, fidgeting, wringing of the hands, pulling of clothes, and inability to sit still.

psychomotor retardation Visible generalized slowing of movements and speech. psychotic features Features characterized by delusions, hallucinations, and formal thought disorder.

psychoticism Exhibiting a wide range of culturally incongruent odd, eccentric, or un­ usual behaviors and cognitions, including both process (e.g., perception, dissociation)

and content (e.g., beliefs). Psychoticism is one of the five broad PERSONALITY TRAIT DO­ MAINS defined in Section III "Alternative DSM-5 Model for Personality Disorders." purging disorder Eating disorder characterized by recurrent purging behavior to influ­ ence weight or shape, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, in the absence of binge eating. racing thoughts A state in which the mind uncontrollably brings up random thoughts and memories and switches between them very quickly. Sometimes the thoughts are related, with one thought leading to another; other times they are completely random. A person experiencing an episode of racing thoughts has no control over them and is unable to focus on a single topic or to sleep. rapid cycling Term referring to bipolar disorder characterized by the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, or major depressive episode. Episodes are demarcated either by partial or full remissions of at least 2 months or by a switch to an episode of the opposite polarity (e.g., major depressive episode to manic episode). The rapid cycling specifier can be ap­ plied to bipolar I or bipolar II disorder. rapid eye movement (REM) A behavioral sign of the phase of sleep during which the sleeper is likely to be experiencing dreamlike mental activity. repetitive speech

Morphologically heterogeneous iterations of speech.

residual phase Period after an episode of schizophrenia that has partly or completed re­ mitted but in which some symptoms may remain, and symptoms such as listlessness, problems with concentrating, and withdrawal from social activities may predominate. restless legs syndrome An urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs (for pediatric restless legs syn­ drome, the description of these symptoms should be in the child's own words). The symptoms begin or worsen during periods of rest or inactivity. Symptoms are partially or totally relieved by movement. Symptoms are worse in the evening or at night than during the day or occur only in the night/evening. restricted affectivity Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference and aloofness in normatively engaging situations. Restricted affectivity is a facet of the broad personality trait domain DETACH­ MENT.

rigid perfectionism Rigid insistence on everything being flawless, perfect, and without errors or faults, including one's own and others' performance; sacrificing of timeliness to ensure correctness in every detail; believing that there is only one right way to do things; difficulty changing ideas and/or viewpoint; preoccupation with details, orga­ nization, and order. Lack of rigid perfectionism is a facet of the broad personality trait domain DisiNHiBmON. risk taking Engagement in dangerous, risky, and potentially self-damaging activities, un­ necessarily and without regard to consequences; lack of concern for one's limitations and denial of the reality of personal danger; reckless pursuit of goals regardless of the level of risk involved. Risk taking is a facet of the broad personality trait domain DiSlNHlBmON. rumination (rumination disorders) Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out. In rumination disorders, there is no evidence that an associated gastrointestinal or an­ other medical condition (e.g., gastroesophageal reflux) is sufficient to account for the repeated regurgitation.

seasonal pattern A pattern of the occurrence of a specific mental disorder in selected seasons of thç year.

self-directedness, self-direction Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively.

separation insecurity Fears of being alone due to rejection by and/or separation from significant others, based in a lack of confidence in one's ability to care for oneself, both physically and emotionally. Separation insecurity is a facet of the broad personality trait domain NEGATIVE A ffectivity .

sex Biological indication of male and female (understood in the context of reproductive capacity), such as sex chromosomes, gonads, sex hormones, and nonambiguous inter­ nal and external genitalia.

sign An objective manifestation of a pathological condition. Signs are observed by the examiner rather than reported by the affected individual. Compare with SYMPTOM.

sleep-onset REM Occurrence of the rapid eye movement (REM) phase of sleep within minutes after falling asleep. Usually assessed by a polysomnographic MULTIPLE SLEEP LATENCY TEST.

sleep terrors Recurrent episodes of abrupt terror arousals from sleep, usually occurring during the first third of the major sleep episode and beginning with a panicky scream. There is intense fear and signs of autonomic arousal, such as mydriasis, tachycardia, rapid breathing, and sweating, during each episode.

sleepwalking Repeated episodes of rising from bed during sleep and walking about, usually occurring during the first third of the major sleep episode. While sleepwalking, the person 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.

somnolence (or "drowsiness") A state of near-sleep, a strong desire for sleep, or sleep­ ing for unusually long periods. It has two distinct meanings, referring both to the usual state preceding falling asleep and to the chronic condition that involves being in that state independent of a circadian rhythm. Compare with HYPERSOMNIA.

specific food cravings Irresistible desire for special types of food. startle response (or "startle reaction") An involuntary (reflexive) reaction to a sudden unexpected stimulus, such as a loud noise or sharp movement.

stereotypies, stereotyped behaviors/movements Repetitive, abnormally frequent, non­ goal-directed movements, seemingly driven, and nonfunctional motor behavior (e.g., hand shaking or waving, body rocking, head banging, self-biting).

stress The pattern of specific and nonspecific responses a person makes to stimulus events that disturb his or her equilibrium and tax or exceed his or her ability to cope.

stressor Any emotional, physical, social, economic, or other factor that disrupts the nor­ mal physiological, cognitive, emotional, or behavioral balance of an individual.

stressor, psychological Any life event or life change that may be associated temporally (and perhaps causally) with the onset, occurrence, or exacerbation of a mental disorder.

stupor Lack of psychomotor activity, which may range from not actively relating to the environment to complete immobility.

submissiveness Adaptation of one's behavior to the actual or perceived interests and desires of others even when doing so is antithetical to one's own interests, needs, or desires. Submissiveness is a facet of the broad personality trait domain NEGATIVE Af­ fectivity .

Below a specified level or threshold required to qualify for a particular condition. Subsyndromal conditions (formes frustes) are medical conditions that do not meet full criteria for a diagnosis—for example, because the symptoms are fewer or less severe than a defined syndrome—but that nevertheless can be identified and related to the "'full-blown" syndrome.

subsyndromal

Thoughts about self-harm, with deliberate consider­ ation or planning of possible techniques of causing one's own death.

suicidal ideas (suicidal ideation) suicide

The act of intentionally causing one's own death.

suicide attempt

An attempt to end one's own life, which may lead to one's death.

Expectations of—and sensitivity to—signs of interpersonal ill intent or harm; doubts about loyalty and fidelity of others; feelings of being mistreated, used, and/or persecuted by others. Suspiciousness is a facet of the broad personality trait do­ main Detachment.

suspiciousness

A subjective manifestation of a pathological condition. Symptoms are reported by the affected individual rather than observed by the examiner. Compare with SIGN.

symptom

A grouping of signs and symptoms, based on their frequent co-occurrence that may suggest a common underlying pathogenesis, course, familial pattern, or treat­ ment selection.

syndrome

A condition in which stimulation of one sensory or cognitive pathway leads to automatic, involuntary experiences in a second sensory or cognitive pathway.

synesthesias

An emotional outburst (also called a "tantrum"), usually associated with children or those in emotional distress, and typically characterized by stubborn­ ness, crying, screaming, defiance, angry ranting, a resistance to attempts at pacifica­ tion, and in some cases hitting. Physical control may be lost, the person may be unable to remain still, and even if the "goal" of the person is met, he or she may not be calmed.

temper outburst

thought-action fusion tic

The tendency to treat thoughts and actions as equivalent.

An involuntary, sudden, rapid, recurrent, nonrhythmic motor movement or vocal­ ization. A situation that occurs with continued use of a drug in which an individual requires greater dosages to achieve the same effect.

tolerance

The broad spectrum of individuals who transiently or permanently identify with a gender different from their natal gender.

transgender

An individual who seeks, or has undergone, a social transition from male to female or female to male, which in many, but not all cases may also involve a somatic transition by cross-sex hormone treatment and genital surgery ("sex reassignment surgery").

transsexual

Any event (or events) that may cause or threaten death, serious injury, or sexual violence to an individual, a close family member, or a close friend.

traumatic stressor

unusual beliefs and experiences Belief that one has unusual abilities, such as mind reading, telekinesis, or THOUGHT-ACTION FUSION; unusual experiences of reality, in­

cluding hallucinatory experiences. In general, the unusual beliefs are not held at the same level of conviction as DELUSIONS. Unusual beliefs and experiences are a facet of the personality trait domain PSYCHOTICISM. waxy flexibility ALEPSY.

Slight, even resistance to positioning by examiner. Compare with CAT­

withdrawal, social Preference for being alone to being with others; reticence in social situations; AVpiDANCE of social contacts and activity; lack of initiation of social contact. Social withdrawal is a facet of the broad personality trait domain DETACHMENT. worry Unpleasant or uncomfortable thoughts that cannot be consciously controlled by trying to turn the attention to other subjects. The worrying is often persistent, repeti­ tive, and out of proportion to the topic worried about (it can even be about a triviality).

Glossary of Culltai^l Concepts of Distréii Ataque de nervios Ataque de nervios ("attack of nerves") is a syndrome among individuals of Latino descent, characterized by symptoms of intense emotional upset, including acute anxiety, anger, or grief; screaming and shouting uncontrollably; attach of crying; trembling; heat in the chest rising into the head; and becoming verbally and physically aggressive. Dissociative experi­ ences (e.g., depersonalization, derealization, amnesia), seizure-like or fainting episodes, and suicidal gestures are prominent in some ataques but absent in others. A general feature of an ataque de nervios is a sense of being out of control. Attacks frequently occur as a direct result of a stressful event relating to the family, such as news of the death of a close relative, con­ flicts with a spouse or children, or witnessing an accident involving a family member. For a minority of individuals, no particular social event triggers their ataques; instead, their vul­ nerability to losing control comes from the accumulated experience of suffering. No one-to-one relationship has been found between ataque and any specific psychiatric dis­ order, although several disorders, including panic disorder, other specified or unspecified dis­ sociative disorder, and conversion disorder, have symptomatic overlap with ataque. In community samples, ataque is associated with suicidal ideation, disability, and out­ patient psychiatric utilization, after adjustment for psychiatric diagnoses, traumatic expo­ sure, and other covariates. However, some ataques represent normative expressions of acute distress (e.g., at a funeral) without clinical sequelae. The term ataque de nervios may also refer to an idiom of distress that includes any "fit"-like paroxysm of emotionality (e.g., hysterical laughing) and may be used to indicate an episode of loss of control in response to an intense stressor. Related conditions in other cultural contexts: Indisposition in Haiti, blacking out in the Southern United States, and falling out in the West Indies. Related conditions in DSM-5: Panic attack, panic disorder, other specified or unspec­ ified dissociative disorder, conversion (functional neurologic symptom) disorder, inter­ mittent explosive disorder, other specified or unspecified anxiety disorder, other specified or unspecified trauma and stressor-related disorder.

Dhat syndrome Dhat syndrome is a term that was coined in South Asia little more than half a century ago to account for common clinical presentations of young male patients who attributed their various symptoms to semen loss. Despite the name, it is not a discrete syndrome but rather a cultural explanation of distress for patients who refer to diverse symptoms, such as anx­ iety, fatigue, weakness, weight loss, impotence, other multiple somatic complaints, and depressive mood. The cardinal feature is anxiety and distress about the loss of dhat in the absence of any identifiable physiological dysfunction. Dhat was identified by patients as a white discharge that was noted on defecation or urination. Ideas about this substance are related to the concept of dhatu (semen) described in the Hindu system of medicine, Ayurveda, as one of seven essential bodily fluids whose balance is necessary to maintain health.

Although dhat syndrome was formulated as a cultural guide to local clinical practice, related ideas about the harmful effects of semen loss have been shown to be widespread in the general population, suggesting a cultural disposition for explaining health problems and symptoms with reference to dhat syndrome. Research in health care settings has yielded diverse estimates of the syndrome's prevalence (e.g., 64% of men attending psychiatric clinics in India for sexual complaints; 30% of men attending general medical clinics in Pakistan). Although dhat syndrome is most commonly identified with young men from lower socioeconomic backgrounds, mid­ dle-aged men may also be affected. Comparable concerns about white vaginal discharge (leukorrhea) have been associated with a variant of the concept for women. Related conditions in other cultural contexts: koro in Southeast Asia, particularly Sin­ gapore and shen-k'uei ("kidney deficiency") in China. Related conditions in DSM-5: Major depressive disorder, persistent depressive disor­ der (dysthymia), generalized anxiety disorder, somatic symptom disorder, illness anxiety disorder, erectile disorder, early (premature) ejaculation, other specified or unspecified sexual dysfunction, academic problem.

Khyâl cap "Khyal attacks" (khyâl cap), or "wind attacks," is a syndrome found among Cambodians in the United States and Cambodia. Common symptoms include those of panic attacks, such as dizziness, palpitations, shortness of breath, and cold extremities, as well as other symp­ toms of anxiety and autonomic arousal (e.g., tinnitus and neck soreness). Khyâl attacks in­ clude catastrophic cognitions centered on the concern that khyâl (a windlike substance) may rise in the body—along with blood—and cause a range of serious effects (e.g., com­ pressing the lungs to cause shortness of breath and asphyxia; entering the cranium to cause tinnitus, dizziness, blurry vision, and a fatal syncope). Khyâl attacks may occur with­ out warning, but are frequently brought about by triggers such as worrisome thoughts, standing up (i.e., orthostasis), specific odors with negative associations, and agoraphobictype cues like going to crowded spaces or riding in a car. Khyâl attacks usually meet panic attack criteria and may shape the experience of other anxiety and trauma- and stressorrelated disorders. Khyâl attacks may be associated with considerable disability. Related conditions in other cultural contexts: Laos (pen lom), Tibet (srog rlunggi nad), Sri Lanka (vata), and Korea (hwa byung). Related conditions in DSM-5: Panic attack, panic disorder, generalized anxiety disor­ der, agoraphobia, posttraumatic stress disorder, illness anxiety disorder.

Kufungisisa Kufungisisa ("thinking too much" in Shona) is an idiom of distress and a cultural explana­ tion among the Shona of Zimbabwe. As an explanation, it is considered to be causative of anxiety, depression, and somatic problems (e.g., "my heart is painful because I think too much"). As an idiom of psychosocial distress, it is indicative of interpersonal and social difficulties (e.g., marital problems, having no money to take care of children). Kufungisisa involves ruminating on upsetting thoughts, particularly worries. Kufungisisa is associated with a range of psychopathology, including anxiety symp­ toms, excessive worry, panic attacks, depressive symptoms, and irritability. In a study of a random community sample, two-thirds of the cases identified by a general psychopathol­ ogy measure were of this complaint. In many cultures, "thinking too much" is considered to be damaging to the mind and body and to cause specific symptoms like headache and dizziness. "Thinking too much" may also be a key component of cultural syndromes such as "brain fag" in Nigeria. In the case of brain fag, "thinking too much" is primarily attributed to excessive study, which is considered to damage the brain in particular, with symptoms including feelings of heat or crawling sensations in the head.

Related conditions in other cultural contexts: "'Thinking too much" is a common id­ iom of distress ^nd cultural explanation across many countries and ethnic groups. It has been described in Africa, the Caribbean and Latin America, and among East Asian and Native American groups. Related conditions in DSM-5: Major depressive disorder, persistent depressive disorder (dysthymia), generalized anxiety disorder, posttraumatic stress disorder, obsessive-compul­ sive disorder, persistent complex bereavement disorder (see "Conditions for Further Study").

Maladi moun Maladi moun (literally "humanly caused illness," also referred to as "sent sickness") is a cultural explanation in Haitian communities for diverse medical and psychiatric disor­ ders. In this explanatory model, interpersonal envy and malice cause people to harm their enemies by sending illnesses such as psychosis, depression, social or academic failure, and inability to perform activities of daily living. The etiological model assumes that illness may be caused by others' envy and hatred, provoked by the victim's economic success as evidenced by a new job or expensive purchase. One person's gain is assumed to produce another person's loss, so visible success makes one vulnerable to attack. Assigning the la­ bel of sent sickness depends on mode of onset and social status more than presenting symptoms. The acute onset of new symptoms or an abrupt behavioral change raises sus­ picions of a spiritual attack. Someone who is attractive, intelligent, or wealthy is perceived as especially vulnerable, and even young healthy children are at risk. Related conditions in other cultural contexts: Concerns about illness (typically, phys­ ical illness) caused by envy or social conflict are common across cultures and often ex­ pressed in the form of "evil eye" (e.g. in Spanish, mal de ojo, in Italian, mal'occhiu). Related conditions in DSM-5: Delusional disorder, persecutory type; schizophrenia with paranoid features.

Nervios Nervios ("nerves") is a common idiom of distress among Latinos in the United States and Latin America. Nervios refers to a general state of vulnerability to stressful life experiences and to difficult life circumstances. The term nervios includes a wide range of symptoms of emotional distress, somatic disturbance, and inability to function. The most common symptoms attributed to nervios include headaches and "brain aches" (occipital neck ten­ sion), irritability, stomach disturbances, sleep difficulties, nervousness, easy tearfulness, inability to concentrate, trembling, tingling sensations, and mareos (dizziness with occa­ sional vertigo-like exacerbations). Nervios is a broad idiom of distress that spans the range of severity from cases with no mental disorder to presentations resembling adjustment, anxiety, depressive, dissociative, somatic symptom, or psychotic disorders. "Being ner­ vous since childhood" appears to be more of a trait and may precede social anxiety disor­ der, while "being ill with nerves" is more related than other forms of nervios to psychiatric problems, especially dissociation and depression. Related conditions in other cultural contexts: Nevra among Greeks in North America, nierbi among Sicilians in North America, and nerves among whites in Appalachia and Newfoundland. Related conditions in DSM-5: Major depressive disorder, peristent depressive disor­ der (dysthymia), generalized anxiety disorder, social anxiety disorder, other specified or unspecified dissociative disorder, somatic symptom disorder, schizophrenia.

Shenjing shuairuo Shenjing shuairuo ("weakness of the nervous system" in Mandarin Chinese) is a cultural syndrome that integrates conceptual categories of traditional Chinese medicine with the

Western diagnosis of neurasthenia. In the second, revised edition of the Chinese Classifica­ tion of Mental Disorders (CCMD-2-R), shenjing shuairuo is defined as a syndrome composed of three out of five nonhierarchical symptom clusters: weakness (e.g., mental fatigue), emotions (e.g., feeling vexed), excitement (e.g., increased recollections), nervous pain (e.g., headache), and sleep (e.g., insomnia). Fan nao (feeling vexed) is a form of irritability mixed with worry and distress over conflicting thoughts and unfulfilled desires. The third edi­ tion of the CCMD retains shenjing shuairuo as a somatoform diagnosis of exclusion. Salient précipitants of shenjing shuairuo include work- or family-related stressors, loss of face {mianzi, lianzi), and an acute sense of failure (e.g., in academic performance). Shenjing sh­ uairuo is related to traditional concepts of weakness (xu) and health imbalances related to deficiencies of a vital essence (e.g., the depletion of qi [vital energy] following overstrain­ ing or stagnation of qi due to excessive worry). In the traditional interpretation, shenjing shuairuo results when bodily channels (jing) conveying vital forces (shen) become dysreg­ ulated as a result of various social and interpersonal stressors, such as the inability to change a chronically frustrating and distressing situation. Various psychiatric disorders are associated with shenjing shuairuo, notably mood, anxiety, and somatic symptom disor­ ders. In medical clinics in China, however, up to 45% of patients with shenjing shuairuo do not meet criteria for any DSM-IV disorder. Related conditions in other cultural contexts: Neurasthenia-spectrum idioms and syndromes are present in India (ashaktapanna) and Japan (shinkei-suijaku), among other set­ tings. Other conditions, such as brain fag syndrome, burnout syndrome, and chronic fa­ tigue syndrome, are also closely related. Related conditions in DSM-5: Major depressive disorder, persistent depressive disor­ der (dysthymia), generalized anxiety disorder, somatic symptom disorder, social anxiety disorder, specific phobia, posttraumatic stress disorder.

Susto Susto ("fright") is a cultural explanation for distress and misfortune prevalent among some Latinos in the United States and among people in Mexico, Central America, and South America. It is not recognized as an illness category among Latinos from the Carib­ bean. Susto is an illness attributed to a frightening event that causes the soul to leave the body and results in unhappiness and sickness, as well as difficulties functioning in key social roles. Symptoms may appear any time from days to years after the fright is experi­ enced. In extreme cases, susto may result in death. There are no specific defining symp­ toms for susto; however, symptoms that are often reported by people with susto include appetite disturbances, inadequate or excessive sleep, troubled sleep or dreams, feelings of sadness, low self-worth or dirtiness, interpersonal sensitivity, and lack of motivation to do anything. Somatic symptoms accompanying susto may include muscle aches and pains, cold in the extremities, pallor, headache, stomachache, and diarrhea. Precipitating events are diverse, and include natural phenomena, animals, interpersonal situations, and super­ natural agents, among others. Three syndromic types of susto (referred to as cibih in the local Zapotec language) have been identified, each having different relationships with psychiatric diagnoses. An interper­ sonal susto characterized by feelings of loss, abandonment, and not being loved by family, with accompanying symptoms of sadness, poor self-image, and suicidal ideation, seemed to be closely related to major depressive disorder. When susto resulted from a traumatic event that played a major role in shaping symptoms and in emotional processing of the experience, the diagnosis of posttraumatic stress disorder appeared more appropriate. Susto character­ ized by various recurrent somatic symptoms—for which the person sought health care from several practitioners—was thought to resemble a somatic symptom disorder. Related conditions in other cultural contexts: Similar etiological concepts and symp­ tom configurations are found globally. In the Andean region, susto is referred to as espanto.

Related conditions in DSM-5: Major depressive disorder, posttraumatic stress disor­ der, other specified or unspecified trauma and stressor-related disorder, somatic symp­ tom disorders.

Taijin kyofusho Taijin kyofusho ("interpersonal fear disorder" in Japanese) is a cultural syndrome charac­ terized by anxiety about and avoidance of interpersonal situations due to the thought, feel­ ing, or conviction that one's appearance and actions in social interactions are inadequate or offensive to others. In the United States, the variant involves having an offensive body odor and is termed olfactory reference syndrome. Individuals with taijin kyofusho tend to focus on the impact of their symptoms and behaviors on others. Variants include major concerns about facial blushing (erythrophobia), having an offensive body odor (olfactory reference syndrome), inappropriate gaze (too much or too little eye contact), stiff or awkward facial expression or bodily movements (e.g., stiffening, trembling), or body deformity. Taijin kyofusho is a broader construct than social anxiety disorder in DSM-5. In addition to performance anxiety, taijin kyofusho includes two culture-related forms: a "sensitive type," with extreme social sensitivity and anxiety about interpersonal interactions, and an "of­ fensive type," in which the major concern is offending others. As a category, taijin kyofusho thus includes syndromes with features of body dysmorphic disorder as well as delusional disorder. Concerns may have a delusional quality, responding poorly to simple reassurance or counterexample. The distinctive symptoms of taijin kyofusho occur in specific cultural contexts and, to some extent, with more severe social anxiety across cultures. Similar syndromes are found in Korea and other societies that place a strong emphasis on the self-conscious mainte­ nance of appropriate social behavior in hierarchical interpersonal relationships. Taijin kyofushoAike symptoms have also been described in other cultural contexts, including the United States, Australia, and New Zealand. Related conditions in other cultural contexts: Taein kong po in Korea. Related conditions in DSM-5: Social anxiety disorder, body dysmorphic disorder, de­ lusional disorder, obsessive-compulsive disorder, olfactory reference syndrome (a type of other specified obsessive-compulsive and related disorder). Olfactory reference syndrome is related specifically to the jikoshu-kyofu variant of taijin kyofusho, whose core symptom is the concern that the person emits an offensive body odor. This presentation is seen in var­ ious cultures outside Japan.

Alphabetical Listing of DSIM-5 Diagnoses and Codes (iCD-9-CIVi and iCD-IO-CIM) ICD-9-CM codes are to be used for coding purposes in the United States through September 30, 2014. ICD-IO-CM codes are to be used starting October 1,2014.

ICD-9-CM ICD-10-CM Disorder, condition, or problem V62.3 V62.4 308.3

Z55.9 Z60.3 F43.0

309.24 309.0 309.3 309.28 309.4 309.9 V71.01 307.0

F43.22 F43.21 F43.24 F43.23 F43.25 F43.20 Z72.811 F98.5

995.81 995.81

T74.11XA T74.11XD

995.81 995.81

T76.11XA T76.11XD

995.82 995.82

T74.31XA T74.31XD

995.82 995.82

T76.31XA T76.31XD

995.83 995.83

T74.21XA T74.21XD

995.83 995.83

T76.21XA T76.21XD

Academic or educational problem Acculturation difficulty Acute stress disorder Adjustment disorders With anxiety With depressed mood With disturbance of conduct With mixed anxiety and depressed mood With mixed disturbance of emotions and conduct Unspecified Adult antisocial behavior Adult-onset fluency disorder Adult physical abuse by nonspouse or nonpartner. Confirmed Initial encounter Subsequent encounter Adult physical abuse by nonspouse or nonpartner. Suspected Initial encounter Subsequent encounter Adult psychological abuse by nonspouse or nonpartner. Confirmed Initial encounter Subsequent encounter Adult psychological abuse by nonspouse or nonpartner. Suspected Initial encounter Subsequent encounter Adult sexual abuse by nonspouse or nonpartner. Confirmed Initial encounter Subsequent encounter Adult sexual abuse by nonspouse or nonpartner, Suspected Initial encounter Subsequent encounter

300.22 291.89

F40.00 F10.180 F10.280 F10.980

291.89 F10.14 F10.24 F10.94 291.89 F10.14 F10.24 F10.94 291.1 F10.26 F10.96 291.2 F10.27 F10.97 291.89 F10.288 F10.988 291.9 F10.159 F10.259 F10.959 291.89 F10.181 F10.281 F10.981 291.82 F10.182 F10.282 F10.982 303.00 F10.129 F10.229 F10.929 F10.121 F10.221 F10.921

Agoraphobia Alcohol-induced anxiety disorder With mild use disorder With moderate or severe use disorder Without use disorder Alcohol-induced bipolar and related disorder With mild use disorder With moderate or severe use disorder Without use disorder Alcohol-induced depressive disorder With mild use disorder With moderate or severe use disorder Without use disorder Alcohol-induced major neurocognitive disorder. Amnestic confabulatory type With moderate or severe use disorder Without use disorder Alcohol-induced major neurocognitive disorder, Nonamnestic confabulatory type With moderate or severe use disorder Without use disorder Alcohol-induced mild neurocognitive disorder With moderate or severe use disorder Without use disorder Alcohol-induced psychotic disorder With mild use disorder With moderate or severe use disorder Without use disorder Alcohol-induced sexual dysfunction With mild use disorder With moderate or severe use disorder Without use disorder Alcohol-induced sleep disorder With mild use disorder With moderate or severe use disorder Without use disorder Alcohol intoxication With mild use disorder With moderate or severe use disorder Without use disorder Alcohol intoxication delirium With mild use disorder With moderate or severe use disorder Without use disorder

Alcohol use disorder 305.00 303.90 303.90 291.81

291.0 292.89

FIO.IO F10.20 F10.20 F10.232 F10.239 F10.231 F15.180 F15.280 F15.980

292.84 F15.14 F15.24 F15.94 F15.921 292.84 F15.14 F15.24 F15.94 292.89 F15.188 F15.288 F15.988 292.9 F15.159 F15.259 F15.959 292.89 F15.181 F15.281 F15.981 292.85 F15.182 F15.282 F15.982 292.89

F15.122 FI5.222 F15.922

Mild Moderate Severe Alcohol withdrawal With perceptual disturbances Without perceptual disturbances Alcohol withdrawal delirium Amphetamine (or other stimulant)-induced anxiety disorder With mild use disorder With moderate or severe use disorder Without use disorder Amphetamine (or other stimulant)-induced bipolar and related disorder With mild use disorder With moderate or severe use disorder Without use disorder Amphetamine (or other stimulant)-induced delirium Amphetamine (or other stimulant)-induced depressive disorder With mild use disorder With moderate or severe use disorder Without use disorder Amphetamine (or other stimulant)-induced obsessive-compulsive and related disorder With mild use disorder With moderate or severe use disorder Without use disorder Amphetamine (or other stimulant)-induced psychotic disorder With mild use disorder With moderate or severe use disorder Without use disorder Amphetamine (or other stimulant)-induced sexual dysfunction With mild use disorder With moderate or severe use disorder Without use disorder Amphetamine (or other stimulant)-induced sleep disorder With mild use disorder With moderate or severe use disorder Without use disorder Amphetamine or other stimulant intoxication Amphetamine or other stimulant intoxication. With perceptual disturbances With mild use disorder With moderate or severe use disorder Without use disorder

ICD-9-CM ICD-10-CM Disorder, condition, or problem

F15.129 F15.229 F15.929 292.81

292.0 305.70 304.40 304.40 307.1

F15.121 F15.221 F15.921 F15.23 F15.10 F15.20 F15.20 F50.02 F50.01

995.29 995.29 995.29 301.7 293.84

T43.205A T43.205S T43.205D F60.2 F06.4

314.01 314.01 314.00 299.00 301.82 307.59 307.51

F90.2 F90.1 F90.0 F84.0 F60.6 F50.8 F50.8

296.56 296.55 296.51 296.52 296.53 296.54 296.50 296.40 296.46 296.45 296.40

F31.76 F31.75 F31.31 F31.32 F31.4 F31.5 F31.9 F31.0 F31.74 F31.73 F31.9

Amphetamine or other stimulant intoxication. Without perceptual disturbances With mild use disorder With moderate or severe use disorder Without use disorder Amphetamine (or other stimulant) intoxication delirium With mild use disorder With moderate or severe use disorder Without use disorder Amphetamine or other stimulant withdrawal Amphetamine-type substance use disorder Mild Moderate Severe Anorexia nervosa Binge-eating/purging type Restricting type Antidepressant discontinuation syndrome Initial encounter Sequelae Subsequent encounter Antisocial personality disorder Anxiety disorder due to another medical condition Attention-deficit/hyperactivity disorder Combined presentation Predominantly hyperactive/impulsive presentation Predominantly inattentive presentation Autism spectrum disorder Avoidant personality disorder Avoidant/restrictive food intake disorder Binge-eating disorder Bipolar I disorder. Current or most recent episode depressed In full remission In partial remission Mild Moderate Severe With psychotic features Unspecified Bipolar I disorder. Current or most recent episode hypomanie In full remission In partial remission Unspecified

ICD-9-CM ICD-10-CM Disorder, condition, or problem 296.46 296.45 296.41 296.42 296.43 296.44 296.40 296.7 296.89 293.83

300.7 V62.89 301.83 298.8 307.51 292.89

F31.74 F31.73 F31.il F31.12 F31.13 F31.2 F31.9 F31.9 F31.81 F06.33 F06.33 F06.34 F45.22 R41.83 F60.3 F23 F50.2 F15.180 F15.280 F15.980

292.85

305.90 292.0 292.89

F15.182 F15.282 F15.982 F15.929 F15.93 F12.180 F12.280 F12.980

292.9 F12.159 F12.259 F12.959 292.85 F12.188 F12.288 F12.988

Bipolar I disorder. Current or most recent episode manic In full remission In partial remission Mild Moderate Severe With psychotic features Unspecified Bipolar I disorder. Current or most recent episode unspecified Bipolar II disorder Bipolar and related disorder due to another medical condition With manic features With manic- or hypomanic-like episodes With mixed features Body dysmorphic disorder Borderline intellectual functioning Borderline personality disorder Brief psychotic disorder Bulimia nervosa Caffeine-induced anxiety disorder With mild use disorder With moderate or severe use disorder Without use disorder Caffeine-induced sleep disorder With mild use disorder With moderate or severe use disorder Without use disorder Caffeine intoxication Caffeine withdrawal Cannabis-induced anxiety disorder With mild use disorder With moderate or severe use disorder Without use disorder Cannabis-induced psychotic disorder With mild use disorder With moderate or severe use disorder Without use disorder Cannabis-induced sleep disorder With mild use disorder With moderate or severe use disorder Without use disorder

ICD-9-CM ICD-10-CM Disorder, condition, or problem F12.122 F12.222 F12.922 F12.129 F12.229 F12.929 292.81 F12.121 F12.221 F12.921 305.20 304.30 304.30 292.0 293.89

F12.10 F12.20 F12.20 F12.288 F06.1

293.89

F06.1

780.57 786.04 327.21 V61.29

G47.37 R06.3 G47.31 Z62.898

995.52 995.52

T74.02XA T74.02XD

995.52 995.52 V71.02

T76.02XA T76.02XD Z72.810

995.54 995.54

T74.12XA T74.12XD

995.54 995.54

T76.12XA T76.12XD

995.51 995.51

T74.32XA T74.32XD

995.51 995.51

T76.32XA T76.32XD

Cannabis intoxication. With perceptual disturbances With mild use disorder With moderate or severe use disorder Without use disorder Carmabis intoxication. Without perceptual disturbances With mild use disorder With moderate or severe use disorder Without use disorder Cannabis intoxication delirium With mild use disorder With moderate or severe use disorder Without use disorder Cannabis use disorder Mild Moderate Severe Cannabis withdrawal Catatonia associated with another mental disorder (catatonia specifier) Catatonic disorder due to another medical condition Central sleep apnea Central sleep apnea comorbid with opioid use Cheyne-Stokes breathing Idiopathic central sleep apnea Child affected by parental relationship distress Child neglect. Confirmed Initial encounter Subsequent encounter Child neglect. Suspected Initial encounter Subsequent encounter Child or adolescent antisocial behavior Child physical abuse. Confirmed Initial encounter Subsequent encounter Child physical abuse. Suspected Initial encounter Subsequent encounter Child psychological abuse. Confirmed Initial encounter Subsequent encounter Child psychological abuse. Suspected Initial encounter Subsequent encounter

ICD-9-CM ICD-10-CM Disorder, condition, or problem 995.53 995.53

T74.22XA T74.22XD

995.53 995.53 315.35

T76.22XA T76.22XD F80.81

307.45 307.45 307.45 307.45 307.45 307.45 292.89

G47.22 G47.21 G47.23 G47.24 G47.26 G47.20 F14.180 F14.280 F14.980

292.84 F14.14 F14.24 F14.94 292.84 F14.14 F14.24 F14.94 292.89 F14.188 F14.288 F14.988 292.9 F14.159 F14.259 F14.959 292.89 F14.181 F14.281 F14.981 292.85 F14.182 F14.282 F14.982

Child sexual abuse. Confirmed Initial encounter Subsequent encounter Child sexual abuse. Suspected Initial encounter Subsequent encounter Childhood-onset fluency disorder (stuttering) Circadian rhythm sleep-wake disorders Advanced sleep phase type Delayed sleep phase type Irregular sleep-wake type Non-24-hour sleep-wake type Shift work type Unspecified type Cocaine-induced anxiety disorder With mild use disorder With moderate or severe use disorder Without use disorder Cocaine-induced bipolar and related disorder With mild use disorder With moderate or severe use disorder Without use disorder Cocaine-induced depressive disorder With mild use disorder With moderate or severe use disorder Without use disorder Cocaine-induced obsessive-compulsive and related disorder With mild use disorder With moderate or severe use disorder Without use disorder Cocaine-induced psychotic disorder With mild use disorder With moderate or severe use disorder Without use disorder Cocaine-induced sexual dysfunction With mild use disorder With moderate or severe use disorder Without use disorder Cocaine-induced sleep disorder With mild use disorder With moderate or severe use disorder Without use disorder

ICD-9-CM ICD-10-CM Disorder, condition, or problem 292.89 F14.122 F14.222 F14.922 F14.129 F14.229 F14.929 292.81 F14.121 F14.221 F14.921 305.60 304.20 304.20 292.0

F14.10 F14.20 F14.20 F14.23

312.32 312.81 312.89 300.11

F91.2 F91.1 F91.9

V62.5 301.13 302.74 293.0 293.0 292.81

F44.4 F44.6 F44.5 F44.7 F44.6 F44.4 F44.4 F44.4 Z65.0 F34.0 F52.32 F05 F05

Cocaine intoxication Cocaine intoxication. With perceptual disturbances With mild use disorder With moderate or severe use disorder Without use disorder Cocaine intoxication. Without perceptual disturbances With mild use disorder With moderate or severe use disorder Without use disorder Cocaine intoxication delirium With mild use disorder With moderate or severe use disorder Without use disorder Cocaine use disorder Mild Moderate Severe Cocaine withdrawal Conduct disorder Adolescent-onset type Childhood-onset type Unspecified onset Conversion disorder (functional neurological symptom disorder) With abnormal movement With anesthesia or sensory loss With attacks or seizures With mixed symptoms With special sensory symptoms With speech symptoms With swallowing symptoms With weakness/paralysis Conviction in civil or criminal proceedings without imprisonment Cyclothymic disorder Delayed ejaculation Delirium Delirium due to another medical condition Delirium due to multiple etiologies Medication-induced delirium (for ICD-IO-CM codes, see specific substances)

297.1 301.6

F22 F60.7

Substance intoxication delirium (see specific substances for codes) Substance withdrawal delirium (see specific substances fo r codes) Delusional disorder Dependent personality disorder

ICD-9-CM ICD-10-CM \ 300.6 F48.1 293.83 F06.31 F06.32 F06.34 315.4 F82 Z59.2 V60.89 Z64.4 V62.89 313.89 V61.03 296.99 300.12 300.13 300.14 307.7 307.6 302.72 698.4 302.4 V62.22 V60.2 300.19 302.73 302.72 302.81 302.89 312.31 302.85 302.6 300.02 302.76 315.8 292.89 V61.8 301.50 300.3 V60.0 780.54 300.7 V62.5 V60.1

F94.2 Z63.5 F34.8 F44.0 F44.1 F44.81 F98.1 F98.0 F52.21 L98.1 F65.2 Z65.5 Z59.5 F68.10 F52.31 F52.22 F65.0 F65.81 F63.0 F64.1 F64.2 F41.1 F52.6 F88 F16.983 Z63.8 F60.4 F42 Z59.0 G47.10 F45.21 Z65.1 Z59.1

Disorder, condition, or problem Depersonalization/derealization disorder Depressive disorder due to another medical condition With depressive features With major depressive-like episode With mixed features Developmental coordination disorder Discord with neighbor, lodger, or landlord Discord with social service provider, including probation officer, case manager, or social services worker Disinhibited social engagement disorder Disruption of family by separation or divorce Disruptive mood dysregulation disorder Dissociative amnesia Dissociative amnesia, with dissociative fugue Dissociative identity disorder Encopresis Enuresis Erectile disorder Excoriation (skin-picking) disorder Exhibitionistic disorder Exposure to disaster, war, or other hostilities Extreme poverty Factitious disorder Female orgasmic disorder Female sexual interest/arousal disorder Fetishistic disorder Frotteuristic disorder Gambling disorder Gender dysphoria in adolescents and adults Gender dysphoria in children Generalized anxiety disorder Genito-pelvic pain/penetration disorder Global developmental delay Hallucinogen persisting perception disorder High expressed emotion level within family Histrionic personality disorder Hoarding disorder Homelessness Hypersomnolence disorder Illness anxiety disorder Imprisonment or other incarceration Inadequate housing

ICD-9-CM ICD-10-CM Disorder, condition, or problem 292.89 F18.180 F18.280 F18.980 292.84 F18.14 F18.24 F18.94 292.82 F18.17 F18.27 F18.97 292.89 F18.188 F18.288 F18.988 292.9 F18.159 F18.259 F18.959 292.89 F18.129 F18.229 F18.929 292.81 F18.121 F18.221 F18.921 305.90 304.60 304.60 780.52 V60.2 319

312.34 312.32 V60.2 315.39 V60.2

F18.10 F18.20 F18.20 G47.00 Z59.7 F70 F71 F73 F72 F63.81 F63.3 Z59.4 F80.9 Z59.6

Inhalant-induced anxiety disorder With mild use disorder With moderate or severe use disorder Without use disorder Inhalant-induced depressive disorder With mild use disorder With moderate or severe use disorder Without use disorder Inhalant-induced major neurocognitive disorder With mild use disorder With moderate or severe use disorder Without use disorder Inhalant-induced mild neurocognitive disorder With mild use disorder With moderate or severe use disorder Without use disorder Inhalant-induced psychotic disorder With mild use disorder With moderate or severe use disorder Without use disorder Inhalant intoxication With mild use disorder With moderate or severe use disorder Without use disorder Inhalant intoxication delirium With mild use disorder With moderate or severe use disorder Without use disorder Inhalant use disorder Mild Moderate Severe Insomnia disorder Insufficient social insurance or welfare support Intellectual disability (intellectual developmental disorder) Mild Moderate Profound Severe Intermittent explosive disorder Kleptomania Lack of adequate food or safe drinking water Language disorder Low income

ICD-9-CM ICD-10-CM Disorder, condition, or problem \ Major depressive disorder. Recurrent episode In full remission 296.36 F33.42 296.35 F33.41 In partial remission 296.31 F33.0 Mild 296.32 F33.1 Moderate 296.33 F33.2 Severe 296.34 F33.3 With psychotic features 296.30 F33.9 Unspecified Major depressive disorder. Single episode In full remission 296.26 F32.5 F32.4 296.25 In partial remission 296.21 F32.0 Mild 296.22 F32.1 Moderate F32.2 Severe 296.23 296.24 F32.3 With psychotic features 296.20 F32.9 Unspecifed 331.9 G31.9 Major frontotemporal neurocognitive disorder. Possible Major frontotemporal neurocognitive disorder. Probable (codefirst 331.19 [G31.09] frontotemporal disease) 294.11 F02.81 With behavioral disturbance Without behavioral disturbance 294.10 F02.80 Major neurocognitive disorder due to Alzheimer's disease. Possible G31.9 331.9 Major neurocognitive disorder due to Alzheimer's disease. Probable {code first 331.0 [G30.9] Alzheimer's disease) 294.11 F02.81 With behavioral disturbance Without behavioral disturbance 294.10 F02.80 Major neurocognitive disorder due to another medical condition With behavioral disturbance 294.11 F02.81 F02.80 Without behavioral disturbance 294.10 Major neurocognitive disorder due to HTV infection (code first 042 [B20] HIV infection) With behavioral disturbance 294.11 F02.81 Without behavioral disturbance F02.80 294.10 Major neurocognitive disorder due to Huntington's disease (code first 333.4 [GIO] Huntington's disease) With behavioral disturbance 294.11 F02.81 Without behavioral disturbance 294.10 F02.80 G31.9 Major neurocognitive disorder with Lewy bodies. Possible 331.9 Major neurocognitive disorder with Lewy bodies. Probable (code first 331.82 [G31.83] Lewy body disease) With behavioral disturbance 294.11 F02.81 Without behavioral disturbance 294.10 F02.80 Major neurocognitive disorder due to multiple etiologies With behavioral disturbance 294.11 F02.81 294.10 F02.80 Without behavioral disturbance

ICD-9-CM ICD-10-CM Disorder, condition, or problem 331.9

G31.9

294.11 294.10

F02.81 F02.80

294.11 294.10

F02.81 F02.80

294.11 294.10 331.9

F02.81 F02.80 G31.9

290.40 290.40 302.71 V65.2 333.99 333.72 292.81

F01.51 F01.50 F52.0 Z76.5 G25.71 G24.02

333.1 331.83 331.83 331.83 331.83 331.83 331.83 331.83 331.83 331.83 331.83 331.83 301.81

G25.1 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 F60.81

347.00

G47.419

347.00 347.10 347.01 347.00 332.1

G47.419 G47.429 G47.411 G47.419 G21.il

Major neurocognitive disorder due to Parkinson's disease. Possible Major neurocognitive disorder due to Parkinson's disease. Probable (code first 332.0 [G20] Parkinson's disease) With behavioral disturbance Without behavioral disturbance Major neurocognitive disorder due to prion disease {code first 046.79 [A81.9] prion disease) With behavioral disturbance Without behavioral disturbance Major neurocognitive disorder due to traumatic brain injury {code first 907.0 late effect of intracranial injury without skull fracture [S06.2X9S diffuse traumatic brain injury with loss of conscious­ ness of unspecified duration, sequela]) With behavioral disturbance Without behavioral disturbance Major vascular neurocognitive disorder. Possible Major vascular neurocognitive disorder. Probable With behavioral disturbance Without behavioral disturbance Male hypoactive sexual desire disorder Malingering Medication-induced acute akathisia Medication-induced acute dystonia Medication-induced dehrium (for ICD-IO-CM codes, see specific substances) Medication-induced postural tremor Mild frontotemporal neurocognitive disorder Mild neurocognitive disorder due to Alzheimer's disease Mild neurocognitive disorder due to another medical condition Mild neurocognitive disorder due to HIV infection Mild neurocognitive disorder due to Huntington's disease Mild neurocognitive disorder due to multiple etiologies Mild neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to prion disease Mild neurocognitive disorder due to traumatic brain injury Mild neurocognitive disorder with Lewy bodies Mild vascular neurocognitive disorder Narcissistic personality disorder Narcolepsy Autosomal dominant cerebellar ataxia, deafness, and narcolepsy Autosomal dominant narcolepsy, obesity, and type 2 diabetes Narcolepsy secondary to another medical condition Narcolepsy with cataplexy but without hypocretin deficiency Narcolepsy without cataplexy but with hypocretin deficiency Neuroleptic-induced parkinsonism

ICD-9-CM ICD-10-CM \ 333.92 G21.0 307.47 F51.5 V15.81 Z91.19 307.46 307.46 300.3 301.4 294.8

F51.4 F51.3 F42 F60.5 F06.8

327.23 292.89

G47.33 F11.188 F11.288 F11.988 F11.921

292.84 F11.14 F11.24 FI 1.94 292.89 F11.181 FI 1.281 F11.981 292.85 F11.182 F11.282 FI 1.982 292.89 F11.122 FI 1.222 F11.922 F11.129 FI 1.229 F11.929 292.81 F11.121 FI 1.221 FI 1.921 305.50 304.00 304.00

Fll.lO FI 1.20 FI 1.20

Disorder, condition, or problem Neuroleptic malignant syndrome Nightmare disorder Nonadherence to medical treatment Non-rapid eye movement sleep arousal disorders Sleep terror type Sleepwalking type Obsessive-compulsive disorder Obsessive-compulsive personality disorder Obsessive-compulsive and related disorder due to another medical condition Obstructive sleep apnea hypopnea Opioid-induced anxiety disorder With mild use disorder With moderate or severe use disorder Without use disorder Opioid-induced delirium Opioid-induced depressive disorder With mild use disorder With moderate or severe use disorder Without use disorder Opioid-induced sexual dysfunction With mild use disorder With moderate or severe use disorder Without use disorder Opioid-induced sleep disorder With mild use disorder With moderate or severe use disorder Without use disorder Opioid intoxication Opioid intoxication. With perceptual disturbances With mild use disorder With moderate or severe use disorder Without use disorder Opioid intoxication. Without perceptual disturbances With mild use disorder With moderate or severe use disorder Without use disorder Opioid intoxication delirium With mild use disorder With moderate or severe use disorder Without use disorder Opioid use disorder Mild Moderate Severe

ICD-9-CM ICD-10-CM Disorder, condition, or problem 292.0 292.0 313.81

FI 1.23 F11.23 F91.3

995.20 995.20 995.20

T50.905A T50.905S T50.905D

V62.83

Z69.82

V65.49

Z69.81

Opioid withdrawal Opioid withdrawal delirium Oppositional defiant disorder Other adverse effect of medication Initial encounter Sequelae Subsequent encounter Other circumstances related to adult abuse by nonspouse or nonpartner

Encounter for mental health services for perpetrator of nonspousal adult abuse Encounter for mental health services for victim of nonspousal adult abuse Other circumstances related to child neglect

V62.83

Z69.021

V61.22

Z69.011

V61.21

Z69.010

V61.21

Z69.020

V15.42

Z62.812

V62.83

Z69.021

V61.22

Z69.011

V61.21

Z69.010

V61.21

Z69.020

V15.41

Z62.810

V62.83

Z69.021

V61.22

Z69.011

V61.21

Z69.010

V61.21

Z69.020

V15.42

Z62.811

V62.83

Z69.021

V61.22

Z69.011

Encounter for mental health services for perpetrator of nonparental child neglect Encounter for mental health services for peφetrator of parental child neglect Encounter for mental health services for victim of child neglect by parent Encounter for mental health services for victim of nonparental child neglect Personal history (past history) of neglect in childhood Other circumstances related to child physical abuse

Encounter for mental health services for perpetrator of nonparental child abuse Encounter for mental health services for perpetrator of parental child abuse Encounter for mental health services for victim of child abuse by parent Encounter for mental health services for victim of nonparental child abuse Personal history (past history) of physical abuse in childhood Other circumstances related to child psychological abuse

Encounter for mental health services for perpetrator of nonparental child psychological abuse Encounter for mental health services for perpetrator of parental child psychological abuse Encounter for mental health services for victim of child psychological abuse by parent Encounter for mental health services for victim of nonparental child psychological abuse Personal history (past history) of psychological abuse in childhood Other circumstances related to child sexual abuse

Encounter for mental health services for perpetrator of nonparental child sexual abuse Encounter for mental health services for perpetrator of parental

V61.21

Z69.010

V61.21

Z69.020

V15.41

Z62.810

Encounter for mental health services for victim of child sexual abuse by parent Encounter for mental health services for victim of nonparental child sexual abuse Personal history (past history) of sexual abuse in childhood Other circumstances related to spouse or partner abuse, Psychological

V61.12

Z69.12

V61.ll

Z69.ll

V15.42

Z91.411

V61.12

Z69.12

V61.ll

Z69.ll

V15.42

Z91.412

Encounter for mental health services for perpetrator of spouse or partner psychological abuse Encounter for mental health services for victim of spouse or partner psychological abuse Personal history (past history) of spouse or partner psychological abuse Other circumstances related to spouse or partner neglect

Encounter for mental health services for perpetrator of spouse or partner neglect Encounter for mental health services for victim of spouse or partner neglect Personal history (past history) of spouse or partner neglect Other circumstances related to spouse or partner violence, Physical

V61.12

Z69.12

V61.ll

Z69.ll

V15.41

Z91.410

V61.12

Z69.12

V61.ll

Z69.81

V15.41

Z91.410

V65.40 292.89

Z71.9

Encounter for mental health services for perpetrator of spouse or partner violence. Physical Encounter for mental health services for victim of spouse or partner violence. Physical Personal history (past history) of spouse or partner violence. Physical Other circumstances related to spouse or partner violence, Sexual

F16.180 F16.280 F16.980 292.84 F16.14 F16.24 F16.94 292.84 F16.14 F16.24 F16.94

Encounter for mental health services for peφetrator of spouse or partner violence. Sexual Encounter for mental health services for victim of spouse or partner violence. Sexual Personal history (past history) of spouse or partner violence. Sexual Other counseling or consultation Other hallucinogen-induced anxiety disorder With mild use disorder With moderate or severe use disorder Without use disorder Other hallucinogen-induced bipolar and related disorder With mild use disorder With moderate or severe use disorder Without use disorder Other hallucinogen-induced depressive disorder With mild use disorder With moderate or severe use disorder Without use disorder

ICD-9-CM ICD-10-CM Disorder, condition, or problem 292.9 F16.159 F16.259 F16.959 292.89 F16.129 F16.229 F16.929 292.81 F16.121 F16.221 F16.921 305.30 304.50 304.50 333.99 332.1 V15.49 V15.89 V62.29 V62.89 300.09 314.01 296.89 780.09 311 312.89 300.15

F16.10 F16.20 F16.20 G25.79 G21.19 Z91.49 Z91.89 Z56.9 Z65.8 F41.8 F90.8 F31.89 R41.0 F32.8 F91.8 F44.89

787.60 788.39 307.59 302.6 780.54 780.52 300.9 294.8 315.8 300.3 302.89 301.89 298.8 302.79

R15.9 N39.498 F50.8 F64.8 G47.19 G47.09 F99 F06.8 F88 F42 F65.89 F60.89 F28 F52.8

Other hallucinogen-induced psychotic disorder With mild use disorder With moderate or severe use disorder Without use disorder Other hallucinogen intoxication With mild use disorder With moderate or severe use disorder Without use disorder Other hallucinogen intoxication delirium With mild use disorder With moderate or severe use disorder Without use disorder Other hallucinogen use disorder Mild Moderate Severe Other medication-induced movement disorder Other medication-induced parkinsonism Other personal history of psychological trauma Other personal risk factors Other problem related to employment Other problem related to psychosocial circumstances Other specified anxiety disorder Other specified attention-deficit/hyperactivity disorder Other specified bipolar and related disorder Other specified delirium Other specified depressive disorder Other specified disruptive, impulse-control, and conduct disorder Other specified dissociative disorder Other specified elimination disorder With fecal symptoms With urinary symptoms Other specified feeding or eating disorder Other specified gender dysphoria Other specified hypersomnolence disorder Other specified insomnia disorder Other specified mental disorder Other specified mental disorder due to another medical condition Other specified neurodevelopmental disorder Other specified obsessive-compulsive and related disorder Other specified paraphilic disorder Other specified personality disorder Other specified schizophrenia spectrum and other psychotic disorder Other specified sexual dysfunction

ICD-9-CM ICD-10-CM Disorder, condition, or problem 780.59 300.89 307.20 309.89 292.89

G47.8 F45.8 F95.8 F43.8 F19.180 F19.280 F19.980

292.84 F19.14 F19.24 F19.94 F19.921 292.84 F19.14 F19.24 F19.94 292.82 F19.17 F19.27 F19.97 292.89 F19.188 F19.288 F19.988 292.89 F19.188 F19.288 F19.988 292.9 F19.159 F19.259 F19.959 292.89 F19.181 F19.281 F19.981 292.85 F19.182 F19.282 F19.982

Other specified sleep-wake disorder Other specified somatic symptom and related disorder Other specified tic disorder Other specified trauma- and stressor-related disorder Other (or unknown) substance-induced anxiety disorder With mild use disorder With moderate or severe use disorder Without use disorder Other (or unknown) substance-induced bipolar and related disorder With mild use disorder With moderate or severe use disorder Without use disorder Other (or unknown) substance-induced delirium Other (or unknown) substance-induced depressive disorder With mild use disorder With moderate or severe use disorder Without use disorder Other (or unknown) substance-induced major neurocognitive disorder With mild use disorder With moderate or severe use disorder Without use disorder Other (or unknown) substance-induced mild neurocognitive disorder With mild use disorder With moderate or severe use disorder Without use disorder Other (or unknown) substance-induced obsessive-compulsive and related disorder With mild use disorder With moderate or severe use disorder Without use disorder Other (or unknown) substance-induced psychotic disorder With mild use disorder With moderate or severe use disorder Without use disorder Other (or unknown) substance-induced sexual dysfunction With mild use disorder With moderate or severe use disorder Without use disorder Other (or unknown) substance-induced sleep disorder With mild use disorder With moderate or severe use disorder Without use disorder

ICD-9-CM ICD-10-CM Disorder, condition, or problem 292.89 F19.129 F19.229 F19.929 292.81 F19.121 F19.221 F19.921 305.90 304.90 304.90 292.0 292.0

F19.10 F19.20 F19.20 F19.239 F19.231

305.70 304.40 304.40 278.00

F15.10 F15.20 F15.20 E66.9

300.01 301.0 V61.20 302.2 307.22 300.4 V62.22 V15.59 310.1 V62.89 292.89

F41.0 F60.0 Z62.820 F65.4 F95.1 F34.1 Z91.82 Z91.5 F07.0 Z60.0 F16.180 F16.280 F16.980

292.84 F16.14 F16.24 F16.94 292.84 F16.14 F16.24 F16.94

Other (or unknown) substance intoxication With mild use disorder With moderate or severe use disorder Without use disorder Other (or unknown) substance intoxication delirium With mild use disorder With moderate or severe use disorder Without use disorder Other (or unknown) substance use disorder Mild Moderate Severe Other (or unknown) substance withdrawal Other (or unknown) substance withdrawal delirium Other or unspecified stimulant use disorder Mild Moderate Severe Overweight or obesity Panic attack specifier Panic disorder Paranoid personahty disorder Parent-child relational problem Pedophilic disorder Persistent (chronic) motor or vocal tic disorder Persistent depressive disorder (dysthymia) Personal history of military deployment Personal history of self-harm Personality change due to another medical condition Phase of life problem Phencyclidine-induced anxiety disorder With mild use disorder With moderate or severe use disorder Without use disorder Phencyclidine-induced bipolar and related disorder With mild use disorder With moderate or severe use disorder Without use disorder Phencyclidine-induced depressive disorder With mild use disorder With moderate or severe use disorder Without use disorder

ICD-9-CM ICD-10-CM \ 292.9 F16.159 F16.259 F16.959 292.89 F16.129 F16.229 F16.929 292.81 F16.121 F16.221 F16.921 305.90 304.60 304.60 307.52

F16.10 F16.20 F16.20

309.81 302.75 625.4 V62.21 V69.9 V60.3 V60.6 V61.5 V62.5 V62.5 V61.7 307.21 316

F50.8 F98.3 F43.10 F52.4 N94.3 Z56.82 Z72.9 Z60.2 Z59.3 Z64.1 Z65.3 Z65.2 Z64.0 F95.0 F54

293.81 293.82 312.33 327.42 313.89 V61.10 V62.89 333.94 307.53

F06.2 F06.0 F63.1 G47.52 F94.1 Z63.0 Z65.8 G25.81 F98.21

Disorder, condition, or problem Phencyclidine-induced psychotic disorder With mild use disorder With moderate or severe use disorder Without use disorder Phencyclidine intoxication With mild use disorder With moderate or severe use disorder Without use disorder Phencyclidine intoxication delirium With mild use disorder With moderate or severe use disorder Without use disorder Phencyclidine use disorder Mild Moderate Severe Pica In adults In children Posttraumatic stress disorder Premature (early) ejaculation Premenstrual dysphoric disorder Problem related to current military deployment status Problem related to lifestyle Problem related to living alone Problem related to living in a residential institution Problems related to multiparity Problems related to other legal circumstances Problems related to release from prison Problems related to unwanted pregnancy Provisional tic disorder Psychological factors affecting other medical conditions Psychotic disorder due to another medical condition With delusions With hallucinations Pyromania Rapid eye movement sleep behavior disorder Reactive attachment disorder Relationship distress with spouse or intimate partner Religious or spiritual problem Restless legs syndrome Rumination disorder

295.70 295.70 301.20 295.90 295.40 301.22 292.89

F25.0 F25.1 F60.1 F20.9 F20.81 F21 F13.180 F13.280 F13.980

292.84 F13.14 F13.24 F13.94 F13.921 292.84 F13.14 F13.24 F13.94 292.82 F13.27 F13.97 292.89 F13.288 F13.988 292.9 F13.159 F13.259 F13.959 292.89 F13.181 F13.281 F13.981 292.85 F13.182 F13.282 F13.982 292.89 F13.129 FI3.229 F13.929

Schizoaffective disorder Bipolar type Depressive type Schizoid personality disorder Schizophrenia Schizophreniform disorder Schizotypal personality disorder Sedative-, hypnotic-, or anxiolytic-induced anxiety disorder With mild use disorder With moderate or severe use disorder Without use disorder Sedative-, hypnotic-, or anxiolytic-induced bipolar and related disorder With mild use disorder With moderate or severe use disorder Without use disorder Sedative-, hypnotic-, or anxiolytic-induced delirium Sedative-, hypnotic-, or anxiolytic-induced depressive disorder With mild use disorder With moderate or severe use disorder Without use disorder Sedative-, hypnotic-, or anxiolytic-induced major neurocognitive disorder With moderate or severe use disorder Without use disorder Sedative-, hypnotic-, or anxiolytic-induced mild neurocognitive disorder With moderate or severe use disorder Without use disorder Sedative-, hypnotic-, or anxiolytic-induced psychotic disorder With mild use disorder With moderate or severe use disorder Without use disorder Sedative-, hypnotic-, or anxiolytic-induced sexual dysfunction With mild use disorder With moderate or severe use disorder Without use disorder Sedative-, hypnotic-, or anxiolytic-induced sleep disorder With mild use disorder With moderate or severe use disorder Without use disorder Sedative, hypnotic, or anxiolytic intoxication With mild use disorder With moderate or severe use disorder Without use disorder

F13.121 F13.221 F13.921 305.40 304.10 304.10 292.0

F13.10 F13.20 F13.20

292.0 312.23 309.21 V65.49 302.83 302.84 V61.8

F13.232 F13.239 F13.231 F94.0 F93.0 Z70.9 F65.51 F65.52 Z62.891

327.26 327.25 327.24 300.23 V62.4 315.39 300.82

G47.36 G47.35 G47.34 F40.10 Z60.4 F80.89 F45.1

315.1 315.00 315.2

F81.2 F81.0 F81.81

300.29 300.29

F40.218

300.29 300.29 300.29 315.39

F40.230 F40.231 F40.233 F40.232 F40.228 F40.298 F40.248 F80.0

995.82 995.82

T74.31XA T74.31XD

With mild use disorder With moderate or severe use disorder Without use disorder Sedative, hypnotic, or anxiolyhc use disorder Mild Moderate Severe Sedative, hypnotic, or anxiolytic withdrawal With perceptual disturbances Without perceptual disturbances Sedative, hypnotic, or anxiolytic withdrawal delirium Selective mutism Separation anxiety disorder Sex counseling Sexual masochism disorder Sexual sadism disorder Sibling relational problem Sleep-related hypoventilation Comorbid sleep-related hypoventilation Congenital central alveolar hypoventilation Idiopathic hypoventilation Social anxiety disorder (social phobia) Social exclusion or rejection Social (pragmatic) communication disorder Somatic symptom disorder Specific learning disorder With impairment in mathematics With impairment in reading With impairment in written expression Specific phobia Animal Blood-injection-injury Fear of blood Fear of injections and transfusions Fear of injury Fear of other medical care Natural environment Other Situational Speech sound disorder Spouse or partner abuse. Psychological, Confirmed Initial encounter Subsequent encounter

995.82 995.82

T76.31XA T76.31XD

995.85 995.85

T74.01XA T74.01XD

995.85 995.85

T76.01XA T76.01XD

995.81 995.81

T74.11XA T74.11XD

995.81 995.81

T76.11XA T76.11XD

995.83 995.83

T74.21XA T74.21XD

995.83 995.83 307.3

T76.21XA T76.21XD F98.4

Spouse or partner abuse. Psychological, Suspected Initial encounter Subsequent encounter Spouse or partner neglect. Confirmed Initial encounter Subsequent encounter Spouse or partner neglect. Suspected Initial encounter Subsequent encounter Spouse or partner violence. Physical, Confirmed Initial encounter Subsequent encounter Spouse or partner violence. Physical, Suspected Initial encounter Subsequent encounter Spouse or partner violence. Sexual, Confirmed Initial encounter Subsequent encounter Spouse or partner violence. Sexual, Suspected Initial encounter Subsequent encounter Stereotypic movement disorder Stimulant intoxication (see amphetamine or cocaine intoxication fo r specific codes)

Stimulant use disorder (see amphetamine or cocaine use disorder fo r specific codes)

Stimulant withdrawal (see amphetamine or cocaine withdrawal for specific codes)

Substance intoxication delirium (see specific substances fo r codes) Substance withdrawal delirium (see specific substances fo r codes) Substance/medication-induced anxiety disorder (see specific substances fo r codes)

Substance/medication-induced bipolar and related disorder (see specific substances fo r codes)

Substance/medication-induced depressive disorder (see specific substances for codes)

Substance/medication-induced major or mild neurocognitive disorder (see specific substances fo r codes) Substance/medication-induced obsessive-compulsive and related disorder (see specific substances for codes) Substance/medication-induced psychotic disorder (see specific substances fo r codes)

Substance/medication-induced sexual dysfunction (see specific substances fo r codes)

Substance/medication-induced sleep disorder (see specific substances fo r codes)

ICD-9-CM ICD-10-CM Disorder, condition, or problem 333.99 333.85 333.72 V62.4 292.85

G25.71 G24.01 G24.09 Z60.5 F17.208

305.1 305.1 305.1 292.0 307.23 302.3 312.39 V63.9 V63.8 V62.82 291.9 300.00 314.01 296.80 292.9 292.9 293.89

Z72.0 F17.200 F17.200 F17.203 F95.2 F65.1 F63.2 Z75.3 Z75.4 Z63.4 F10.99 F41.9 F90.9 F31.9 F15.99 F12.99 F06.1

307.9 780.09 311 312.9 300.15

F80.9 R41.0 F32.9 F91.9 F44.9

787.60 788.30 307.50 302.6 292.9 V60.9 780.54 292.9 780.52 319

R15.9 R32 F50.9 F64.9 F16.99 Z59.9 G47.10 F18.99 G47.00 F79

300.9 294.9 799.59

F99 F09 R41.9

Tardive akathisia Tardive dyskinesia Tardive dystonia Target of (perceived) adverse discrimination or persecution Tobacco-induced sleep disorder With moderate or severe use disorder Tobacco use disorder Mild Moderate Severe Tobacco withdrawal Tourette's disorder Transvestic disorder Trichotillomania (hair-pulling disorder) Unavailability or inaccessibility of health care facilities Unavailability or inaccessibility of other helping agencies Uncomplicated bereavement Unspecified alcohol-related disorder Unspecified anxiety disorder Unspecified attention-deficit/hyperactivity disorder Unspecified bipolar and related disorder Unspecified caffeine-related disorder Unspecified cannabis-related disorder Unspecified catatonia {code first 781.99 [R29.818] other symptoms involving nervous and musculoskeletal systems) Unspecified communication disorder Unspecified delirium Unspecified depressive disorder Unspecified disruptive, impulse-control, and conduct disorder Unspecified dissociative disorder Unspecified elimination disorder With fecal symptoms With urinary symptoms Unspecified feeding or eating disorder Unspecified gender dysphoria Unspecified hallucinogen-related disorder Unspecified housing or economic problem Unspecified hypersomnolence disorder Unspecified inhalant-related disorder Unspecified insomnia disorder Unspecified intellectual disability (intellectual developmental disorder) Unspecified mental disorder Unspecified mental disorder due to another medical condition Unspecified neurocognitive disorder

ICD-9-CM ICD-10-CM Disorder, condition, or problem 315.9 300.3 292.9 292.9 302.9 301.9 292.9 V62.9 V62.9

F89 F42 FI 1.99 F19.99 F65.9 F60.9 F16.99 Z60.9 Z65.9

298.9 292.9 302.70 780.59 300.82 292.9

F29 F13.99 F52.9 G47.9 F45.9

307.20 292.9 309.9 V61.8 V62.89 V62.89 302.82 V40.31

F15.99 F14.99 F95.9 F17.209 F43.9 Z62.29 Z65.4 Z65.4 F65.3 Z91.83

Unspecified neurodevelopmental disorder Unspecified obsessive-compulsive and related disorder Unspecified opioid-related disorder Unspecified other (or unknown) substance-related disorder Unspecified paraphilic disorder Unspecified personality disorder Unspecified phencyclidine-related disorder Unspecified problem related to social environment Unspecified problem related to imspecified psychosocial circumstances Unspecified schizophrenia spectrum and other psychotic disorder Unspecified sedative-, hypnotic-, or anxiolytic-related disorder Unspecified sexual dysfunction Unspecified sleep-wake disorder Unspecified somatic symptom and related disorder Unspecified stimulant-related disorder Unspecified amphetamine or other stimulant-related disorder Unspecified cocaine-related disorder Unspecified tic disorder Unspecified tobacco-related disorder Unspecified trauma- and stressor-related disorder Upbringing away from parents Victim of crime Victim of terrorism or torture Voyeuristic disorder Wandering associated with a mental disorder

Numerical Listing of DSIVi-5 Diagnoses and Codes (ICD-9-CM) ICD-9-CM codes are to be used for coding purposes in the United States through September 30,2014.

ICD-9-CM

Disorder, condition, or problem

278.00 290.40 290.40

Overweight or obesity Probable major vascular neurocognitive disorder. With behavioral disturbance Probable major vascular neurocognitive disorder. Without behavioral disturbance Alcohol intoxication delirium Alcohol withdrawal delirium Alcohol-induced major neurocognitive disorder. Amnestic confabulatory type Alcohol-induced major neurocognitive disorder, Nonamnestic confabulatory type Alcohol withdrawal Alcohol-induced sleep disorder Alcohol-induced anxiety disorder Alcohol-induced bipolar and related disorder Alcohol-induced depressive disorder Alcohol-induced mild neurocognitive disorder Alcohol-induced sexual dysfunction Alcohol-induced psychotic disorder Unspecified alcohol-related disorder Amphetamine or other stimulant withdrawal Caffeine withdrawal Cannabis withdrawal Cocaine withdrawal Opioid withdrawal Opioid withdrawal delirium Other (or unknown) substance withdrawal Other (or unknown) substance withdrawal delirium Sedative, hypnotic, or anxiolytic withdrawal Sedative, hypnotic, or anxiolytic withdrawal delirium Tobacco withdrawal Amphetamine (or other stimulant) intoxication delirium Cannabis intoxication delirium Cocaine intoxication delirium

291.0 291.0 291.1 291.2 291.81 291.82 291.89 291.89 291.89 291.89 291.89 291.9 291.9 292.0 292.0 292.0 292.0 292.0 292.0 292.0 292.0 292.0 292.0 292.0 292.81 292.81 292.81

292.81 292.81 292.81 292.81 292.81 292.81 292.81 292.82 292.82 292.82 292.84 292.84 292.84 292.84 292.84 292.84 292.84 292.84 292.84 292.84 292.84 292.84 292.84 292.84 292.85 292.85 292.85 292.85 292.85 292.85 292.85 292.85 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89

Inhalant intoxication delirium Medication-induced delirium Opioid intoxication delirium Other hallucinogen intoxication delirium Other (or unknown) substance intoxication delirium Phencyclidine intoxication delirium Sedative, hypnotic, or anxiolytic intoxication delirium Inhalant-induced major neurocognitive disorder Other (or unknown) substance-induced major neurocognitive disorder Sedative-, hypnotic-, or anxiolytic-induced major neurocognitive disorder Amphetamine (or other stimulant)-induced bipolar and related disorder Amphetamine (or other stimulant)-induced depressive disorder Cocaine-induced bipolar and related disorder Cocaine-induced depressive disorder Inhalant-induced depressive disorder Opioid-induced depressive disorder Other hallucinogen-induced bipolar and related disorder Other hallucinogen-induced depressive disorder Other (or unknown) substance-induced bipolar and related disorder Other (or unknown) substance-induced depressive disorder Phencyclidine-induced bipolar and related disorder Phencyclidine-induced depressive disorder Sedative-, hypnotic-, or anxiolytic-induced bipolar and related disorder Sedative-, hypnotic-, or anxiolytic-induced depressive disorder Amphetamine (or other stimulant)-induced sleep disorder Caffeine-induced sleep disorder Cannabis-induced sleep disorder Cocaine-induced sleep disorder Opioid-induced sleep disorder Other (or unknown) substance-induced sleep disorder Sedative-, hypnotic-, or anxiolytic-induced sleep disorder Tobacco-induced sleep disorder Amphetamine (or other stimulant)-induced anxiety disorder Amphetamine (or other stimulant)-induced obsessive-compulsive and related disorder Amphetamine (or other stimulant)-induced sexual dysfunction Amphetamine or other stimulant intoxication Caffeine-induced anxiety disorder Cannabis-induced anxiety disorder Cannabis intoxication Cocaine-induced anxiety disorder Cocaine-induced obsessive-compulsive and related disorder Cocaine-induced sexual dysfunction Cocaine intoxication Hallucinogen persisting perception disorder

292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.89 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 292.9 293.0 293.0 293.81 293.82 293.83 293.83 293.84 293.89

Inhalant-induced anxiety disorder Inhalant-induced mild neurocognitive disorder Inhalant intoxication Opioid-induced anxiety disorder Opioid-induced sexual dysfunction Opioid intoxication Other hallucinogen-induced anxiety disorder Other hallucinogen intoxication Other (or unknown) substance-induced anxiety disorder Other (or unknown) substance-induced mild neurocognitive disorder Other (or unknown) substance-induced obsessive-compulsive and related disorder Other (or unknown) substance-induced sexual dysfunction Other (or unknown) substance intoxication Phencyclidine-induced anxiety disorder Phencyclidine intoxication Sedative-, hypnotic-, or anxiolytic-induced anxiety disorder Sedative-, hypnotic-, or anxiolytic-induced mild neurocognitive disorder Sedative-, hypnotic-, or anxiolytic-induced sexual dysfunction Sedative, hypnotic, or anxiolytic intoxication Amphetamine (or other stimulant)-induced psychotic disorder Cannabis-induced psychotic disorder Cocaine-induced psychotic disorder Inhalant-induced psychotic disorder Other hallucinogen-induced psychotic disorder Other (or ui^cnown) substance-induced psychotic disorder Phencyclidine-induced psychotic disorder Sedative-, hypnotic-, or anxiolytic-induced psychotic disorder Unspecified caffeine-related disorder Unspecified cannabis-related disorder Unspecified hallucinogen-related disorder Unspecified inhalant-related disorder Unspecified opioid-related disorder Unspecified other (or unknown) substance-related disorder Unspecified phencyclidine-related disorder Unspecified sedative-, hypnotic-, or anxiolytic-related disorder Unspecified stimulant-related disorder Unspecified tobacco-related disorder Delirium due to another medical condition Delirium due to multiple etiologies Psychotic disorder due to another medical condition. With delusions Psychotic disorder due to another medical condition. With hallucinations Bipolar and related disorder due to another medical condition Depressive disorder due to another medical condition Anxiety disorder due to another medical condition Catatonia associated with another mental disorder (catatonia specifier)

ICD-9-CM

Disorder, condition, or problem

293.89 293.89

Catatonic disorder due to another medical condition Unspecified catatonia (codefirst 781.99 other symptoms involving nervous and musculoskeletal systems) Major neurocognitive disorder due to another medical condition. Without behavioral disturbance Major neurocognitive disorder due to HIV infection. Without behavioral disturbance (code first 042 HIV infection) Major neurocognitive disorder due to Huntington's disease. Without behavioral disturbance (code first 333.4 Huntington's disease) Major neurocognitive disorder due to multiple etiologies. Without behavioral disturbance Major neurocognitive disorder probably due to Parkinson's disease. Without behavioral disturbance (code first 332.0 Parkinson's disease) Major neurocognitive disorder due to prion disease. Without behavioral disturbance (code first 046.79 prion disease) Major neurocognitive disorder due to traumatic brain injury. Without behavioral disturbance (code first 907.0 late effect of intracranial injury without skull fracture) Probable major frontotemporal neurocognitive disorder. Without behavioral disturbance (code first 331.19 frontotemporal disease) Probable major neurocognitive disorder due to Alzheimer's disease. Without behavioral disturbance (code first 331.0 Alzheimer's disease) Probable major neurocognitive disorder with Lewy bodies. Without behavioral disturbance (code first 331.82 Lewy body disease) Major neurocognitive disorder due to another medical condition. With behavioral disturbance Major neurocognitive disorder due to HIV infection. With behavioral disturbance (code first 042 HIV infection) Major neurocognitive disorder due to Huntington's disease. With behavioral disturbance (code first 333.4 Huntington's disease) Major neurocognitive disorder due to multiple etiologies. With behavioral disturbance Major neurocognitive disorder probably due to Parkinson's disease. With behavioral disturbance (code first 332.0 Parkinson's disease) Major neurocognitive disorder due to prion disease. With behavioral disturbance (code first 046.79 prion disease) Major neurocognitive disorder due to traumatic brain injury. With behavioral disturbance (code first 907.0 late effect of intracranial injury without skull fracture) Probable major frontotemporal neurocognitive disorder. With behavioral disturbance (code first 331.19 frontotemporal disease) Probable major neurocognitive disorder due to Alzheimer's disease. With behavioral disturbance (code first 331.0 Alzheimer's disease) Probable major neurocognitive disorder with Lewy bodies. With behavioral disturbance (code first 331.82 Lewy body disease) Obsessive-compulsive and related disorder due to another medical condition Other specified mental disorder due to another medical condition Unspecified mental disorder due to another medical condition

294.10 294.10 294.10 294.10 294.10 294.10 294.10

294.10 294.10 294.10 294.11 294.11 294.11 294.11 294.11 294.11 294.11

294.11 294.11 294.11 294.8 294.8 294.9

295.40 295.70 295.70 295.90 296.20 296.21 296.22 296.23 296.24 296.25 296.26 296.30 296.31 296.32 296.33 296.34 296.35 296.36 296.40 296.40 296.40 296.41 296.42 296.43 296.44 296.45 296.45 296.46 296.46 296.50 296.51 296.52 296.53 296.54 296.55 296.56 296.7 296.80 296.89 296.89 296.99 297.1 298.8 298.8

Schizophreniform disorder Schizoaffective disorder. Bipolar type Schizoaffective disorder. Depressive type Schizophrenia Major depressive disorder. Single episode, Unspecifed Major depressive disorder. Single episode. Mild Major depressive disorder. Single episode. Moderate Major depressive disorder. Single episode. Severe Major depressive disorder. Single episode. With psychotic features Major depressive disorder. Single episode. In partial remission Major depressive disorder. Single episode. In full remission Major depressive disorder. Recurrent episode. Unspecified Major depressive disorder. Recurrent episode. Mild Major depressive disorder. Recurrent episode. Moderate Major depressive disorder. Recurrent episode. Severe Major depressive disorder. Recurrent episode. With psychotic features Major depressive disorder. Recurrent episode. In partial remission Major depressive disorder. Recurrent episode. In full remission Bipolar I disorder. Current or most recent episode hypomanie Bipolar I disorder. Current or most recent episode hypomanie. Unspecified Bipolar I disorder. Current or most recent episode manic. Unspecified Bipolar I disorder. Current or most recent episode manic. Mild Bipolar I disorder. Current or most recent episode manic. Moderate Bipolar I disorder. Current or most recent episode manic. Severe Bipolar I disorder. Current or most recent episode manic. With psychotic features Bipolar I disorder. Current or most recent episode hypomanie. In partial remission Bipolar I disorder. Current or most recent episode manic. In partial remission Bipolar I disorder. Current or most recent episode hypomanie. In full remission Bipolar I disorder. Current or most recent episode manic. In full remission Bipolar I disorder. Current or most recent episode depressed. Unspecified Bipolar I disorder. Current or most recent episode depressed. Mild Bipolar I disorder. Current or most recent episode depressed. Moderate Bipolar I disorder. Current or most recent episode depressed. Severe Bipolar I disorder. Current or most recent episode depressed. With psychotic features Bipolar I disorder. Current or most recent episode depressed. In partial remission Bipolar I disorder. Current or most recent episode depressed. In full remission Bipolar I disorder. Current or most recent episode unspecified Unspecified bipolar and related disorder Bipolar II disorder Other specified bipolar and related disorder Disruptive mood dysregulation disorder Delusional disorder Brief psychotic disorder Other specified schizophrenia spectrum and other psychotic disorder

298.9 299.00 300.00 300.01 300.02 300.09 300.11 300.12 300.13 300.14 300.15 300.15 300.19 300.22 300.23 300.29 300.29 300.29 300.29 300.29 300.3 300.3 300.3 300.3 300.4 300.6 300.7 300.7 300.82 300.82 300.89 300.9 300.9 301.0 301.13 301.20 301.22 301.4 301.50 301.6 301.7 301.81 301.82 301.83 301.89

Unspecified schizophrenia spectrum and other psychotic disorder Autism spectrum disorder Unspecified anxiety disorder Panic disorder Generalized anxiety disorder Other specified anxiety disorder Conversion disorder (functional neurological symptom disorder) Dissociative amnesia Dissociative amnesia. With dissociative fugue Dissociative identity disorder Other specified dissociative disorder Unspecified dissociative disorder Factitious disorder Agoraphobia Social anxiety disorder (social phobia) Specific phobia. Animal Specific phobia, Blood-injection-injury Specific phobia. Natural environment Specific phobia. Other Specific phobia. Situational Hoarding disorder Obsessive-compulsive disorder Other specified obsessive-compulsive and related disorder Unspecified obsessive-compulsive and related disorder Persistent depressive disorder (dysthymia) Depersonalization/derealization disorder Body dysmorphic disorder Illness anxiety disorder Somatic symptom disorder Unspecified somatic symptom and related disorder Other specified somatic symptom and related disorder Other specified mental disorder Unspecified mental disorder Paranoid personality disorder Cyclothymic disorder Schizoid personality disorder Schizotypal personality disorder Obsessive-compulsive personality disorder Histrionic personality disorder Dependent personality disorder Antisocial personality disorder Narcissistic personality disorder Avoidant personality disorder Borderline personality disorder Other specified personality disorder

301.9 302.2 302.3 302.4 302.6 302.6 302.6 302.70 302.71 302.72 302.72 302.73 302.74 302.75 302.76 302.79 302.81 302.82 302.83 302.84 302.85 302.89 302.89 302.9 303.00 303.90 303.90 304.00 304.00 304.10 304.10 304.20 304.20 304.30 304.30 304.40 304.40 304.40 304.40 304.50 304.50 304.60 304.60 304.60 304.60

Unspecified personality disorder Pedophilic disorder Transvestic disorder Exhibitionistic disorder Gender dysphoria in children Other specified gender dysphoria Unspecified gender dysphoria Unspecified sexual dysfunction Male hypoactive sexual desire disorder Erectile disorder Female sexual interest/arousal disorder Female orgasmic disorder Delayed ejaculation Premature (early) ejaculation Genito-pelvic pain/penetration disorder Other specified sexual dysfunction Fetishistic disorder Voyeuristic disorder Sexual masochism disorder Sexual sadism disorder Gender dysphoria in adolescents and adults Frotteuristic disorder Other specified paraphilic disorder Unspecified paraphilic disorder Alcohol intoxication Alcohol use disorder. Moderate Alcohol use disorder. Severe Opioid use disorder. Moderate Opioid use disorder. Severe Sedative, hypnotic, or anxiolytic use disorder. Moderate Sedative, hypnotic, or anxiolytic use disorder. Severe Cocaine use disorder. Moderate Cocaine use disorder. Severe Cannabis use disorder. Moderate Cannabis use disorder. Severe Amphetamine-type substance use disorder. Moderate Amphetamine-type substance use disorder. Severe Other or unspecified stimulant use disorder. Moderate Other or unspecified stimulant use disorder. Severe Other hallucinogen use disorder. Moderate Other hallucinogen use disorder. Severe Inhalant use disorder. Moderate Inhalant use disorder. Severe Phencyclidine use disorder. Moderate Phencyclidine use disorder. Severe

304.90 304.90 305.00 305.1 305.1 305.1 305.20 305.30 305.40 305.50 305.60 305.70 305.70 305.90 305.90 305.90 305.90 307.0 307.1 307.20 307.20 307.21 307.22 307.23 307.3 307.45 307.45 307.45 307.45 307.45 307.45 307.46 307.46 307.47 307.50 307.51 307.51 307.52 307.53 307.59 307.59 307.6 307.7 307.9 308.3

Other (or unknown) substance use disorder. Moderate Other (or unknown) substance use disorder. Severe Alcohol use disorder. Mild Tobacco use disorder. Mild Tobacco use disorder. Moderate Tobacco use disorder. Severe Cannabis use disorder. Mild Other hallucinogen use disorder. Mild Sedative, hypnotic, or anxiolytic use disorder. Mild Opioid use disorder. Mild Cocaine use disorder. Mild Amphetamine-type substance use disorder. Mild Other or unspecified stimulant use disorder. Mild Caffeine intoxication Inhalant use disorder. Mild Other (or unknown) substance use disorder. Mild Phencyclidine use disorder. Mild Adult-onset fluency disorder Anorexia nervosa Other specified tic disorder Unspecified tic disorder Provisional tic disorder Persistent (chronic) motor or vocal tic disorder Tourette's disorder Stereotypic movement disorder Circadian rhythm sleep-wake disorders. Advanced sleep phase type Circadian rhythm sleep-wake disorders. Delayed sleep phase type Circadian rhythm sleep-wake disorders. Irregular sleep-wake type Circadian rhythm sleep-wake disorders, Non-24-hour sleep-wake type Circadian rhythm sleep-wake disorders. Shift work type Circadian rhythm sleep-wake disorders. Unspecified type Non-rapid eye movement sleep arousal disorders. Sleep terror type Non-rapid eye movement sleep arousal disorders. Sleepwalking type Nightmare disorder Unspecified feeding or eating disorder Binge-eating disorder Bulimia nervosa Pica Rumination disorder Avoidant/restrictive food intake disorder Other specified feeding or eating disorder Enuresis Encopresis Unspecified communication disorder Acute stress disorder

309.0 309.21 309.24 309.28 309.3 309.4 309.81 309.89 309.9 309.9 310.1 311 311 312.23 312.31 312.32 312.32 312.33 312.34 312.39 312.81 312.89 312.89 312.9 313.81 313.89 313.89 314.00 314.01 314.01 314.01 314.01 315.00 315.1 315.2 315.35 315.39 315.39 315.39 315.4 315.8 315.8 315.9 316

Adjustment disorders. With depressed mood Separation anxiety disorder Adjustment disorders. With anxiety Adjustment disorders. With mixed anxiety and depressed mood Adjustment disorders. With disturbance of conduct Adjustment disorders. With mixed disturbance of emotions and conduct Posttraumatic stress disorder Other specified trauma- and stressor-related disorder Adjustment disorders. Unspecified Unspecified trauma- and stressor-related disorder Personality change due to another medical condition Other specified depressive disorder Unspecified depressive disorder Selective mutism Gambling disorder Conduct disorder, Adolescent-onset type Kleptomania Pyromania Intermittent explosive disorder Trichotillomania (hair-pulling disorder) Conduct disorder, Childhood-onset type Conduct disorder. Unspecified onset Other specified disruptive, impulse-control, and conduct disorder Unspecified disruptive, impulse-control, and conduct disorder Oppositional defiant disorder Disinhibited social engagement disorder Reactive attachment disorder Attention-deficit/hyperactivity disorder. Predominantly inattentive presentation Attention-deficit/hyperactivity disorder. Combined presentation Attention-deficit/hyperactivity disorder. Predominantly hyperactive/ impulsive presentation Other specified attention-deficit/hyperactivity disorder Unspecified attention-deficit/hyperactivity disorder Specific learning disorder. With impairment in reading Specific learning disorder. With impairment in mathematics Specific learning disorder. With impairment in written expression Childhood-onset fluency disorder (stuttering) Language disorder Social (pragmatic) communication disorder Speech sound disorder Developmental coordination disorder Global developmental delay Other specified neurodevelopmental disorder Unspecified neurodevelopmental disorder Psychological factors affecting other medical conditions

319 319 327.21 327.23 327.24 327.25 327.26 327.42 331.83 331.83 331.83 331.83 331.83 331.83 331.83 331.83 331.83 331.83 331.83 331.9 331.9 331.9 331.9 331.9 333.1 332.1 332.1 333.72 333.72 333.85 333.92 333.94 333.99 333.99 333.99 347.00 347.00 347.00 347.01 347.10 625.4 698.4 780.09 780.09 780.52

Intellectual disability (intellectual developmental disorder) Unspecified intellectual disability (intellectual developmental disorder) Central sleep apnea. Idiopathic central sleep apnea Obstructive sleep apnea hypopnea Sleep-related hypoventilation. Idiopathic hypoventilation Sleep-related hypoventilation. Congenital central alveolar hypoventilation Sleep-related hypoventilation, Comorbid sleep-related hypoventilation Rapid eye movement sleep behavior disorder Mild frontotemporal neurocognitive disorder Mild neurocognitive disorder due to Alzheimer's disease Mild neurocognitive disorder due to another medical condition Mild neurocognitive disorder due to HIV infection Mild neurocognitive disorder due to Huntington's disease Mild neurocognitive disorder with Lewy bodies Mild neurocognitive disorder due to multiple etiologies Mild neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to prion disease Mild neurocognitive disorder due to traumatic brain injury Mild vascular neurocognitive disorder Major neurocognitive disorder possibly due to Parkinson's disease Possible major frontotemporal neurocognitive disorder Possible major neurocognitive disorder due to Alzheimer's disease Possible major neurocognihve disorder with Lewy bodies Possible major vascular neurocognitive disorder Medication-induced postural tremor Neuroleptic-induced parkinsonism Other medication-induced parkinsonism Medication-induced acute dystonia Tardive dystonia Tardive dyskinesia Neuroleptic malignant syndrome Restless legs syndrome Medication-induced acute akathisia Other medication-induced movement disorder Tardive akathisia Autosomal dominant cerebellar ataxia, deafness, and narcolepsy Autosomal dominant narcolepsy, obesity, and type 2 diabetes Narcolepsy without cataplexy but with hypocretin deficiency Narcolepsy with cataplexy but without hypocretin deficiency Narcolepsy secondary to another medical condition Premenstrual dysphoric disorder Excoriation (skin-picking) disorder Other specified delirium Unspecified delirium Insomnia disorder

780.52 780.52 780.54 780.54 780.54 780.57 780.59 780.59 786.04 787.60 787.60 788.30 788.39 799.59 995.20 995.20 995.20 995.29 995.29 995.29 995.51 995.51 995.51 995.51 995.52 995.52 995.52 995.52 995.53 995.53 995.53 995.53 995.54 995.54 995.54 995.54 995.81 995.81 995.81 995.81 995.81 995.81 995.81

Other specified insomnia disorder Unspecified insomnia disorder Hypersomnolence disorder Other specified hypersomnolence disorder Unspecified hypersomnolence disorder Central sleep apnea. Central sleep apnea comorbid with opioid use Other specified sleep-wake disorder Unspecified sleep-wake disorder Central sleep apnea, Cheyne-Stokes breathing Other specified elimination disorder. With fecal symptoms Unspecified elimination disorder. With fecal symptoms Unspecified elimination disorder. With urinary symptoms Other specified elimination disorder. With urinary symptoms Unspecified neurocognitive disorder Other adverse effect of medication. Initial encounter Other adverse effect of medication. Sequelae Other adverse effect of medication. Subsequent encounter Antidepressant discontinuation syndrome. Initial encounter Antidepressant discontinuation syndrome. Sequelae Antidepressant discontinuation syndrome. Subsequent encounter Child psychological abuse. Confirmed, Initial encounter Child psychological abuse. Confirmed, Subsequent encounter Child psychological abuse. Suspected, Initial encounter Child psychological abuse. Suspected, Subsequent encounter Child neglect. Confirmed, Initial encounter Child neglect. Confirmed, Subsequent encounter Child neglect. Suspected, Initial encounter Child neglect. Suspected, Subsequent encounter Child sexual abuse. Confirmed, Initial encounter Child sexual abuse. Confirmed, Subsequent encounter Child sexual abuse. Suspected, Initial encounter Child sexual abuse. Suspected, Subsequent encounter Child physical abuse. Confirmed, Initial encounter Child physical abuse. Confirmed, Subsequent encounter Child physical abuse. Suspected, Initial encounter Child physical abuse. Suspected, Subsequent encounter Adult physical abuse by nonspouse or nonpartner. Confirmed, Initial encounter Adult physical abuse by nonspouse or nonpartner. Confirmed, Subsequent encounter Adult physical abuse by nonspouse or nonpartner. Suspected, Initial encounter Adult physical abuse by nonspouse or nonpartner. Suspected, Subsequent encounter Spouse or partner violence. Physical, Confirmed, Initial encounter Spouse or partner violence. Physical, Confirmed, Subsequent encounter Spouse or partner violence. Physical, Suspected, Initial encounter

995.81 995.82 995.82 995.82 995.82 995.82 995.82 995.82 995.82 995.83 995.83 995.83 995.83 995.83 995.83 995.83 995.83 995.85 995.85 995.85 995.85 V15.41 V15.41 VI5.41 V15.41 V15.42 V15.42 V15.42 V15.42 VI5.49 V15.59 V15.81 VI5.89 V40.31 V60.0 V60.1 V60.2 V60.2 V60.2 V60.2

Spouse or partner violence. Physical, Suspected, Subsequent encounter Adult psychological abuse by nonspouse or nonpartner. Confirmed, Initial encounter Adult psychological abuse by nonspouse or nonpartner. Confirmed, Subsequent encounter Adult psychological abuse by nonspouse or nonpartner, Suspected, Initial encounter Adult psychological abuse by nonspouse or nonpartner. Suspected, Subsequent encounter Spouse or partner abuse. Psychological, Confirmed, Initial encounter Spouse or partner abuse. Psychological, Confirmed, Subsequent encounter Spouse or partner abuse. Psychological, Suspected, Initial encounter Spouse or partner abuse. Psychological, Suspected, Subsequent encounter Adult sexual abuse by nonspouse or nonpartner. Confirmed, Initial encounter Adult sexual abuse by nonspouse or nonpartner. Confirmed, Subsequent encounter Adult sexual abuse by nonspouse or nonpartner. Suspected, Initial encounter Adult sexual abuse by nonspouse or nonpartner. Suspected, Subsequent encounter Spouse or partner violence. Sexual, Confirmed, Initial encounter Spouse or partner violence. Sexual, Confirmed, Subsequent encounter Spouse or partner violence. Sexual, Suspected, Initial encounter Spouse or partner violence. Sexual, Suspected, Subsequent encounter Spouse or partner neglect. Confirmed, Initial encounter Spouse or partner neglect. Confirmed, Subsequent encounter Spouse or partner neglect. Suspected, Initial encounter Spouse or partner neglect. Suspected, Subsequent encounter Personal history (past history) of physical abuse in childhood Personal history (past history) of sexual abuse in childhood Personal history (past history) of spouse or partner violence. Physical Personal history (past history) of spouse or partner violence. Sexual Personal history (past history) of neglect in childhood Personal history (past history) of psychological abuse in childhood Personal history (past history) of spouse or partner neglect Personal history (past history) of spouse or partner psychological abuse Other personal history of psychological trauma Personal history of self-harm Nonadherence to medical treatment Other personal risk factors Wandering associated with a mental disorder Homelessness Inadequate housing Extreme poverty Insufficient social insurance or welfare support Lack of adequate food or safe drinking water Low income

V60.3 V60.6 V60.89 V60.9 V61.03 V61.10 V61.ll V61.ll V61.ll V61.ll V61.12 V61.12 V61.12 V61.12 V61.20 V61.21 V61.21 V61.21 V61.21 V61.21 V61.21 V61.21 V61.21 V61.22 V61.22 V61.22 V61.22 V61.29 V61.5 V61.7 V61.8 V61.8 V61.8 V62.21 V62.22

Problem related to living alone Problem related to living in a residential institution Discord with neighbor, lodger, or landlord Unspecified housing or economic problem Disruption of family by separation or divorce Relationship distress with spouse or intimate partner Encounter for mental health services for victim of spouse or partner neglect Encounter for mental health services for victim of spouse or partner psychological abuse Encounter for mental health services for victim of spouse or partner violence. Physical Encounter for mental health services for victim of spouse or partner violence. Sexual Encounter for mental health services for perpetrator of spouse or partner neglect Encounter for mental health services for perpetrator of spouse or partner psychological abuse Encounter for mental health services for perpetrator of spouse or partner violence, Physical Encounter for mental health services for perpetrator of spouse or partner violence. Sexual Parent-child relational problem Encounter for mental health services for victim of child abuse by parent Encounter for mental health services for victim of child neglect by parent Encounter for mental health services for victim of child psychological abuse by parent Encounter for mental health services for victim of child sexual abuse by parent Encounter for mental health services for victim of nonparental child abuse Encounter for mental health services for victim of nonparental child neglect Encounter for mental health services for victim of nonparental child psychological abuse Encounter for mental health services for victim of nonparental child sexual abuse Encounter for mental health services for perpetrator of parental child abuse Encounter for mental health services for perpetrator of parental child neglect Encounter for mental health services for perpetrator of parental child psychological abuse Encounter for mental health services for perpetrator of parental child sexual abuse Child affected by parental relationship distress Problems related to multiparity Problems related to unwanted pregnancy High expressed emotion level within family Sibling relational problem Upbringing away from parents Problem related to current military deployment status Exposure to disaster, war, or other hostilities

V62.22 V62.29 V62.3 V62.4 V62.4 V62.4 V62.5 V62.5 V62.5 V62.5 V62.82 V62.83 V62.83 V62.83 V62.83 V62.83 V62.89 V62.89 V62.89 V62.89 V62.89 V62.89 V62.89 V62.9 V62.9 V63.8 V63.9 V65.2 V65.40 V65.49 V65.49 V69.9 V71.01 V71.02

Personal history of military deployment Other problem related to employment Academic or educational problem Acculturation difficulty Social exclusion or rejection Target of (perceived) adverse discrimination or persecution Conviction in civil or criminal proceedings without imprisonment Imprisonment or other incarceration Problems related to other legal circumstances Problems related to release from prison Uncomplicated bereavement Encounter for mental health services for perpetrator of nonparental child abuse Encounter for mental health services for perpetrator of nonparental child neglect Encounter for mental health services for perpetrator of nonparental child psychological abuse Encounter for mental health services for perpetrator of nonparental child sexual abuse Encounter for mental health services for perpetrator of nonspousal adult abuse Borderline intellectual functioning Discord with social service provider, including probation officer, case manager, or social services worker Other problem related to psychosocial circumstances Phase of life problem Religious or spiritual problem Victim of crime Victim of terrorism or torture Unspecified problem related to social environment Unspecified problem related to unspecified psychosocial circumstances Unavailability or inaccessibility of other helping agencies Unavailability or inaccessibility of health care facilities Malingering Other counseling or consultation Encounter for mental health services for victim of nonspousal adult abuse Sex counseling Problem related to lifestyle Adult antisocial behavior Child or adolescent antisocial behavior

Numerical Listing of DSIVi-5 Diagnoses and Codes (iCD-10-CIM) ICD-IO-CM codes are to be used for coding purposes in the United States starting October 1, 2014.

ICD-10-CM Disorder, condition, or problem E66.9 FOl .50 F01.51 F02.80 F02.80 F02.80 F02.80 F02.80 F02.80 F02.80

F02.80 F02.80 F02.80 F02.81 F02.81 F02.81 F02.81

Overweight or obesity Probable major vascular neurocognitive disorder. Without behavioral disturbance Probable major vascular neurocognitive disorder. With behavioral disturbance Major neurocognitive disorder due to another medical condition. Without behavioral disturbance Major neurocognitive disorder due to HIV infection. Without behavioral disturbance (code first B20 HIV infection) Major neurocognitive disorder due to Huntington's disease. Without behavioral disturbance (code first GIO Huntington's disease) Major neurocognitive disorder due to multiple etiologies. Without behavioral disturbance Major neurocognitive disorder probably due to Parkinson's disease. Without behavioral disturbance (code first G20 Parkinson's disease) Major neurocognitive disorder due to prion disease. Without behavioral disturbance (code first A81.9 prion disease) Major neurocognitive disorder due to traumatic brain injury. Without behavioral disturbance (code first S06.2X9S diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela) Probable major frontotemporal neurocognitive disorder. Without behavioral disturbance (code first G31.09 frontotemporal disease) Probable major neurocognitive disorder due to Alzheimer's disease. Without behavioral disturbance (code first G30.9 Alzheimer's disease) Probable major neurocognitive disorder with Lewy bodies. Without behavioral disturbance (code first G31.83 Lewy body disease) Major neurocognitive disorder due to another medical condition. With behavioral disturbance Major neurocognitive disorder due to HIV infection. With behavioral disturbance (code first B20 HIV infection) Major neurocognitive disorder due to Huntington's disease. With behavioral disturbance (code first GIO Huntington's disease) Major neurocognitive disorder due to multiple etiologies. With behavioral disturbance

F02.81 F02.81 F02.81

F02.81 F02.81 F02.81 F05 F05 F06.0 F06.1 F06.1 F06.1 F06.2 F06.31 F06.32 F06.33 F06.33 F06.34 F06.34 F06.4 F06.8 F06.8 F07.0 F09 FIO.IO F10.121 F10.129 F10.14 F10.14 FI0.159 F10.180 F10.181 F10.182 FI 0.20 FI0.20 F10.221

Major neurocognitive disorder probably due to Parkinson's disease. With behavioral disturbance (code first G20 Parkinson's disease) Major neurocognitive disorder due to prion disease. With behavioral disturbance {code first A81.9 prion disease) Major neurocognitive disorder due to traumatic brain injury. With behavioral disturbance {code first S06.2X9S diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela) Probable major frontotemporal neurocognitive disorder. With behavioral disturbance {code first G31.09 frontotemporal disease) Probable major neurocognitive disorder due to Alzheimer's disease. With behavioral disturbance {code first G30.9 Alzheimer's disease) Probable major neurocognitive disorder with Lewy bodies. With behavioral disturbance {code first G31.83 Lewy body disease) Delirium due to another medical condition Delirium due to multiple etiologies Psychotic disorder due to another medical condition. With hallucinations Catatonia associated with another mental disorder (catatonia specifier) Catatonic disorder due to another medical condition Unspecified catatonia {code first R29.818 other symptoms involving nervous and musculoskeletal systems) Psychotic disorder due to another medical condition. With delusions Depressive disorder due to another medical condition. With depressive features Depressive disorder due to another medical condition. With major depressive-like episode Bipolar and related disorder due to another medical condition. With manic features Bipolar and related disorder due to another medical condition. With manic- or hypomanic-like episodes Bipolar and related disorder due to another medical condition. With mixed features Depressive disorder due to another medical condition. With mixed features Anxiety disorder due to another medical condition Obsessive-compulsive and related disorder due to another medical condition Other specified mental disorder due to another medical condition Personality change due to another medical condition Unspecified mental disorder due to another medical condition Alcohol use disorder. Mild Alcohol intoxication delirium. With mild use disorder Alcohol intoxication. With mild use disorder Alcohol-induced bipolar and related disorder. With mild use disorder Alcohol-induced depressive disorder. With mild use disorder Alcohol-induced psychotic disorder. With mild use disorder Alcohol-induced anxiety disorder. With mild use disorder Alcohol-induced sexual dysfunction. With mild use disorder Alcohol-induced sleep disorder. With mild use disorder Alcohol use disorder. Moderate Alcohol use disorder. Severe Alcohol intoxication delirium. With moderate or severe use disorder

F10.229 F10.231 F10.232 FI0.239 F10.24 FI0.24 F10.259 F10.26 F10.27 F10.280 F10.281 FI0.282 F10.288 F10.921 F10.929 F10.94 FI0.94 F10.959 F10.96 F10.97 F10.980 F10.981 FI0.982 FI0.988 F10.99 FI 1.10 FI 1.121 FI 1.122 FI 1.129 FI 1.14 F11.181 F11.182 FI 1.188 FI 1.20 FI 1.20 FI 1.221 FI 1.222 FI 1.229 FI 1.23

Alcohol intoxication. With moderate or severe use disorder Alcohol withdrawal delirium Alcohol withdrawal. With perceptual disturbances Alcohol withdrawal. Without perceptual disturbances Alcohol-induced bipolar and related disorder. With moderate or severe use disorder Alcohol-induced depressive disorder. With moderate or severe use disorder Alcohol-induced psychotic disorder. With moderate or severe use disorder Alcohol-induced major neurocognitive disorder. Amnestic confabulatory type. With moderate or severe use disorder Alcohol-induced major neurocognitive disorder, Nonamnestic confabulatory type. With moderate or severe use disorder Alcohol-induced anxiety disorder. With moderate or severe use disorder Alcohol-induced sexual dysfunction. With moderate or severe use disorder Alcohol-induced sleep disorder. With moderate or severe use disorder Alcohol-induced mild neurocognitive disorder. With moderate or severe use disorder Alcohol intoxication delirium. Without use disorder Alcohol intoxication. Without use disorder Alcohol-induced bipolar and related disorder. Without use disorder Alcohol-induced depressive disorder. Without use disorder Alcohol-induced psychotic disorder. Without use disorder Alcohol-induced major neurocognitive disorder. Amnestic confabulatory type. Without use disorder Alcohol-induced major neurocognitive disorder, Nonanmestic confabulatory type. Without use disorder Alcohol-induced anxiety disorder. Without use disorder Alcohol-induced sexual dysfunction. Without use disorder Alcohol-induced sleep disorder. Without use disorder Alcohol-induced mild neurocognitive disorder. Without use disorder Unspecified alcohol-related disorder Opioid use disorder. Mild Opioid intoxication delirium. With mild use disorder Opioid intoxication. With perceptual disturbances. With mild use disorder Opioid intoxication. Without perceptual disturbances. With mild use disorder Opioid-induced depressive disorder. With mild use disorder Opioid-induced sexual dysfunction. With mild use disorder Opioid-induced sleep disorder. With mild use disorder Opioid-induced anxiety disorder. With mild use disorder Opioid use disorder. Moderate Opioid use disorder. Severe Opioid intoxication delirium. With moderate or severe use disorder Opioid intoxication. With perceptual disturbances. With moderate or severe use disorder Opioid intoxication. Without perceptual disturbances. With moderate or severe use disorder Opioid withdrawal

FI 1.23 FI 1.24 FI 1.281 FI 1.282 FI 1.288 FI 1.921 FI 1.921 FI 1.922 FI 1.929 FI 1.94 FI 1.981 FI 1.982 FI 1.988 FI 1.99 F12.10 F12.121 F12.122 F12.129 F12.159 F12.180 F12.188 F12.20 FI 2.20 F12.221 F12.222 F12.229 F12.259 F12.280 F12.288 F12.288 FI2.921 F12.922 F12.929 F12.959 F12.980 F12.988 F12.99 FI3.10 F13.121 F13.129 F13.14 F13.14

Opioid withdrawal delirium Opioid-induced depressive disorder. With moderate or severe use disorder Opioid-induced sexual dysfunction. With moderate or severe use disorder Opioid-induced sleep disorder. With moderate or severe use disorder Opioid-induced anxiety disorder. With moderate or severe use disorder Opioid-induced delirium Opioid intoxication delirium. Without use disorder Opioid intoxication. With perceptual disturbances. Without use disorder Opioid intoxication. Without perceptual disturbances. Without use disorder Opioid-induced depressive disorder. Without use disorder Opioid-induced sexual dysfunction. Without use disorder Opioid-induced sleep disorder. Without use disorder Opioid-induced anxiety disorder. Without use disorder Unspecified opioid-related disorder Cannabis use disorder. Mild Cannabis intoxication delirium. With mild use disorder Cannabis intoxication. With perceptual disturbances. With mild use disorder Cannabis intoxication. Without perceptual disturbances. With mild use disorder Cannabis-induced psychotic disorder. With mild use disorder Cannabis-induced anxiety disorder. With mild use disorder Cannabis-induced sleep disorder. With mild use disorder Cannabis use disorder. Moderate Cannabis use disorder. Severe Cannabis intoxication delirium. With moderate or severe use disorder Cannabis intoxication. With perceptual disturbances. With moderate or severe use disorder Cannabis intoxication. Without perceptual disturbances. With moderate or severe use disorder Cannabis-induced psychotic disorder. With moderate or severe use disorder Cannabis-induced anxiety disorder. With moderate or severe use disorder Cannabis-induced sleep disorder. With moderate or severe use disorder Cannabis withdrawal Cannabis intoxication delirium. Without use disorder Cannabis intoxication. With perceptual disturbances. Without use disorder Cannabis intoxication. Without perceptual disturbances. Without use disorder Cannabis-induced psychotic disorder. Without use disorder Cannabis-induced anxiety disorder. Without use disorder Cannabis-induced sleep disorder. Without use disorder Unspecified cannabis-related disorder Sedative, hypnotic, or anxiolytic use disorder. Mild Sedative, hypnotic, or anxiolytic intoxication delirium. With mild use disorder Sedative, hypnotic, or anxiolytic intoxication. With mild use disorder Sedative-, hypnotic-, or anxiolytic-induced bipolar and related disorder. With mild use disorder Sedative-, hypnotic-, or anxiolytic-induced depressive disorder. With mild use disorder

F13.159 F13.180 F13.181 F13.182 FI3.20 F13.20 F13.221 FI3.229 FI3.231 F13.232 F13.239 F13.24 F13.24 F13.259 F13.27 F13.280 F13.281 F13.282 F13.288 F13.921 F13.921 FI3.929 F13.94 F13.94 F13.959 F13.97 FI3.980 F13.981 F13.982 F13.988

Sedative-, hypnotic-, or anxiolytic-induced psychotic disorder. With mild use disorder Sedative-, hypnotic-, or anxiolytic-induced anxiety disorder. With mild use disorder Sedative-, hypnotic-, or anxiolytic-induced sexual dysfunction. With mild use disorder Sedative-, hypnotic-, or anxiolytic-induced sleep disorder. With mild use disorder Sedative, hypnotic, or anxiolytic use disorder. Moderate Sedative, hypnotic, or anxiolytic use disorder. Severe Sedative, hypnotic, or anxiolytic intoxication delirium. With moderate or severe use disorder Sedative, hypnotic, or aiOdolytic intoxication. With moderate or severe use disorder Sedative, hypnotic, or anxiolytic withdrawal delirium Sedative, hypnotic, or anxiolytic withdrawal. With perceptual disturbances Sedative, hypnotic, or anxiolytic withdrawal. Without perceptual disturbances Sedative-, hypnotic-, or anxiolytic-induced bipolar and related disorder. With moderate or severe use disorder Sedative-, hypnotic-, or anxiolytic-induced depressive disorder. With moderate or severe use disorder Sedative-, hypnotic-, or anxiolytic-induced psychotic disorder. With moderate or severe use disorder Sedative-, hypnotic-, or anxiolytic-induced major neurocognitive disorder. With moderate or severe use disorder Sedative-, hypnotic-, or anxiolytic-induced anxiety disorder. With moderate or severe use disorder Sedative-, hypnotic-, or anxiolytic-induced sexual dysfunction. With moderate or severe use disorder Sedative-, hypnotic-, or anxiolytic-induced sleep disorder. With moderate or severe use disorder Sedative-, hypnotic-, or anxiolytic-induced mild neurocognitive disorder. With moderate or severe use disorder Sedative-, hypnotic-, or anxiolytic-induced delirium Sedative, hypnotic, or anxiolytic intoxication delirium. Without use disorder Sedative, hypnotic, or anxiolytic intoxication. Without use disorder Sedative-, hypnotic-, or anxiolytic-induced bipolar and related disorder. Without use disorder Sedative-, hypnotic-, or anxiolytic-induced depressive disorder. Without use disorder Sedative-, hypnotic-, or anxiolytic-induced psychotic disorder. Without use disorder Sedative-, hypnotic-, or anxiolytic-induced major neurocognitive disorder. Without use disorder Sedative-, hypnotic-, or anxiolytic-induced anxiety disorder. Without use disorder Sedative-, hypnotic-, or anxiolytic-induced sexual dysfunction. Without use disorder Sedative-, hypnotic-, or anxiolytic-induced sleep disorder. Without use disorder Sedative-, hypnotic-, or anxiolytic-induced mild neurocognitive disorder. Without use disorder

F13.99 F14.10 F14.121 F14.122 F14.129 F14.14 F14.14 F14.159 F14.180 F14.181 F14.182 F14.188 F14.20 F14.20 FI4.221 F14.222 F14.229 F14.23 F14.24 F14.24 F14.259 F14.280 F14.281 F14.282 F14.288 F14.921 F14.922 F14.929 F14.94 F14.94 F14.959 F14.980 F14.981 F14.982 F14.988 F14.99 F15.10 F15.10 F15.121 F15.122

Unspecified sedative-, hypnotic-, or anxiolytic-related disorder Cocaine use disorder. Mild Cocaine intoxication delirium. With mild use disorder Cocaine intoxication. With perceptual disturbances. With mild use disorder Cocaine intoxication. Without perceptual disturbances. With mild use disorder Cocaine-induced bipolar and related disorder. With mild use disorder Cocaine-induced depressive disorder. With mild use disorder Cocaine-induced psychotic disorder. With mild use disorder Cocaine-induced anxiety disorder. With mild use disorder Cocaine-induced sexual dysfunction. With mild use disorder Cocaine-induced sleep disorder. With mild use disorder Cocaine-induced obsessive-compulsive and related disorder. With mild use disorder Cocaine use disorder. Moderate Cocaine use disorder. Severe Cocaine intoxication delirium. With moderate or severe use disorder Cocaine intoxication. With perceptual disturbances. With moderate or severe use disorder Cocaine intoxication. Without perceptual disturbances. With moderate or severe use disorder Cocaine withdrawal Cocaine-induced bipolar and related disorder. With moderate or severe use disorder Cocaine-induced depressive disorder. With moderate or severe use disorder Cocaine-induced psychotic disorder. With moderate or severe use disorder Cocaine-induced anxiety disorder. With moderate or severe use disorder Cocaine-induced sexual dysfunction. With moderate or severe use disorder Cocaine-induced sleep disorder. With moderate or severe use disorder Cocaine-induced obsessive-compulsive and related disorder. With moderate or severe use disorder Cocaine intoxication delirium. Without use disorder Cocaine intoxication. With perceptual disturbances. Without use disorder Cocaine intoxication. Without perceptual disturbances. Without use disorder Cocaine-induced bipolar and related disorder. Without use disorder Cocaine-induced depressive disorder. Without use disorder Cocaine-induced psychotic disorder. Without use disorder Cocaine-induced anxiety disorder. Without use disorder Cocaine-induced sexual dysfunction. Without use disorder Cocaine-induced sleep disorder. Without use disorder Cocaine-induced obsessive-compulsive and related disorder. Without use disorder Unspecified stimulant-related disorder. Unspecified Cocaine-related disorder Amphetamine-type substance use disorder. Mild Other or unspecified stimulant use disorder. Mild Amphetamine (or other stimulant) intoxication delirium. With mild use disorder Amphetamine or other stimulant intoxication. With perceptual disturbances. With mild use disorder

F15.129 F15.14 F15.14 F15.159 F15.180 F15.180 F15.181 F15.182 F15.182 F15.188 F15.20 FI5.20 F15.20 F15.20 F15.221 F15.222 F15.229 FI5.23 F15.24 F15.24 F15.259 F15.280 F15.280 F15.281 F15.282 F15.282 F15.288 F15.921 F15.921 F15.922

Amphetamine or other stimulant intoxication. Without perceptual disturbances. With mild use disorder Amphetamine (or other stimulant)-induced bipolar and related disorder. With mild use disorder Amphetamine (or other stimulant)-induced depressive disorder. With mild use disorder Amphetamine (or other stimulant)-induced psychotic disorder. With mild use disorder Amphetamine (or other stimulant)-induced anxiety disorder. With mild use disorder Caffeine-induced anxiety disorder. With mild use disorder Amphetamine (or other stimulant)-induced sexual dysfunction. With mild use disorder Amphetamine (or other stimulant)-induced sleep disorder. With mild use disorder Caffeine-induced sleep disorder. With mild use disorder Amphetamine (or other stimulant)-induced obsessive-compulsive and related disorder. With mild use disorder Amphetamine-type substance use disorder. Moderate Amphetamine-type substance use disorder. Severe Other or unspecified stimulant use disorder. Moderate Other or unspecified stimulant use disorder. Severe Amphetamine (or other stimulant) intoxication delirium. With moderate or severe use disorder Amphetamine or other stimulant intoxication. With perceptual disturbances. With moderate or severe use disorder Amphetamine or other stimulant intoxication. Without perceptual disturbances. With moderate or severe use disorder Amphetamine or other stimulant withdrawal Amphetamine (or other stimulant)-induced bipolar and related disorder. With moderate or severe use disorder Amphetamine (or other stimulant)-induced depressive disorder. With moderate or severe use disorder Amphetamine (or other stimulant)-induced psychotic disorder. With moderate or severe use disorder Amphetamine (or other stimulant)-induced anxiety disorder. With moderate or severe use disorder Caffeine-induced anxiety disorder. With moderate or severe use disorder Amphetamine (or other stimulant)-induced sexual dysfunction. With moderate or severe use disorder Amphetamine (or other stimulant)-induced sleep disorder. With moderate or severe use disorder Caffeine-induced sleep disorder. With moderate or severe use disorder Amphetamine (or other stimulant)-induced obsessive-compulsive and related disorder. With moderate or severe use disorder Amphetamine (or other stimulant)-induced delirium Amphetamine (or other stimulant) intoxication delirium. Without use disorder Amphetamine or other stimulant intoxication. With perceptual disturbances. Without use disorder

FI5.929 F15.929 FI5.93 F15.94 FI5.94 FI5.959 F15.980 FI5.980 F15.981 FI5.982 F15.982 FI5.988 F15.99 FI5.99 F16.10 FI 6.10 F16.121 F16.121 F16.129 F16.129 FI6.14 F16.14 FI 6.14 F16.14 F16.159 F16.159 F16.180 F16.180 F16.20 FI6.20 F16.20 FI6.20 FI6.221 F16.221 F16.229 FI6.229 F16.24

Amphetamine or other stimulant intoxication. Without perceptual disturbances. Without use disorder Caffeine intoxication Caffeine withdrawal Amphetamine (or other stimulant)-induced bipolar and related disorder. Without use disorder Amphetamine (or other stimulant)-induced depressive disorder. Without use disorder Amphetamine (or other stimulant)-induced psychotic disorder. Without use disorder Amphetamine (or other stimulant)-induced anxiety disorder. Without use disorder Caffeine-induced anxiety disorder. Without use disorder Amphetamine (or other stimulant)-induced sexual dysfunction. Without use disorder Amphetamine (or other stimulant)-induced sleep disorder. Without use disorder Caffeine-induced sleep disorder. Without use disorder Amphetamine (or other stimulant)-induced obsessive-compulsive and related disorder. Without use disorder Unspecified amphetamine or other stimulant-related disorder Unspecified caffeine-related disorder Other hallucinogen use disorder. Mild Phencyclidine use disorder. Mild Other hallucinogen intoxication delirium. With mild use disorder Phencyclidine intoxication delirium. With mild use disorder Other hallucinogen intoxication. With mild use disorder Phencyclidine intoxication. With mild use disorder Other hallucinogen-induced bipolar and related disorder. With mild use disorder Other hallucinogen-induced depressive disorder. With mild use disorder Phencyclidine-induced bipolar and related disorder. With mild use disorder Phencychdine-induced depressive disorder. With mild use disorder Other hallucinogen-induced psychotic disorder. With mild use disorder Phencyclidine-induced psychotic disorder. With mild use disorder Other hallucinogen-induced anxiety disorder. With mild use disorder Phencyclidine-induced anxiety disorder. With mild use disorder Other hallucinogen use disorder. Moderate Other hallucinogen use disorder. Severe Phencyclidine use disorder. Moderate Phencyclidine use disorder. Severe Other hallucinogen intoxication delirium. With moderate or severe use disorder Phencyclidine intoxication delirium. With moderate or severe use disorder Other hallucinogen intoxication. With moderate or severe use disorder Phencyclidine intoxication. With moderate or severe use disorder Other hallucinogen-induced bipolar and related disorder. With moderate or severe use disorder

FI 6.24 FI6.24 FI6.24 F16.259 FI6.259 FI6.280 FI6.280 F16.921 F16.921 FI6.929 FI6.929 FI6.94 FI 6.94 F16.94 FI 6.94 FI6.959 F16.959 F16.980 F16.980 FI6.983 FI 6.99 FI6.99 FI7.200 F17.200 F17.203 FI7.208 FI7.209 F18.10 F18.121 F18.129 F18.14 F18.159 F18.17 FI8.180 F18.188 FI 8.20 F18.20 F18.221 F18.229 FI8.24 FI8.259

Other hallucinogen-induced depressive disorder. With moderate or severe use disorder Phencyclidine-induced bipolar and related disorder. With moderate or severe use disorder Phencyclidine-induced depressive disorder. With moderate or severe use disorder Other hallucinogen-induced psychotic disorder. With moderate or severe use disorder Phencyclidine-induced psychotic disorder. With moderate or severe use disorder Other hallucinogen-induced anxiety disorder. With moderate or severe use disorder Phencyclidine-induced anxiety disorder. With moderate or severe use disorder Other hallucinogen intoxication delirium. Without use disorder Phencyclidine intoxication delirium. Without use disorder Other hallucinogen intoxication. Without use disorder Phencyclidine intoxication. Without use disorder Other hallucinogen-induced bipolar and related disorder. Without use disorder Other hallucinogen-induced depressive disorder. Without use disorder Phencyclidine-induced bipolar and related disorder. Without use disorder Phencyclidine-induced depressive disorder. Without use disorder Other hallucinogen-induced psychotic disorder. Without use disorder Phencyclidine-induced psychotic disorder. Without use disorder Other hallucinogen-induced anxiety disorder. Without use disorder Phencyclidine-induced anxiety disorder. Without use disorder Hallucinogen persisting perception disorder Unspecified hallucinogen-related disorder Unspecified phencyclidine-related disorder Tobacco use disorder, Moderate Tobacco use disorder. Severe Tobacco withdrawal Tobacco-induced sleep disorder. With moderate or severe use disorder Unspecified tobacco-related disorder Inhalant use disorder. Mild Inhalant intoxication delirium. With mild use disorder Inhalant intoxication. With mild use disorder Inhalant-induced depressive disorder. With mild use disorder Inhalant-induced psychotic disorder. With mild use disorder Inhalant-induced major neurocognitive disorder. With mild use disorder Inhalant-induced anxiety disorder. With mild use disorder Inhalant-induced mild neurocognitive disorder. With mild use disorder Inhalant use disorder. Moderate Inhalant use disorder. Severe Inhalant intoxication delirium. With moderate or severe use disorder Inhalant intoxication. With moderate or severe use disorder Inhalant-induced depressive disorder. With moderate or severe use disorder Inhalant-induced psychotic disorder, With moderate or severe use disorder

FI8.27 F18.280 F18.288 F18.921 FI8.929 F18.94 F18.959 FI8.97 F18.980 FI8.988 F18.99 F19.10 FI9.121 FI9.129 F19.14 F19.14 F19.159 F19.17 F19.180 F19.181 F19.182 F19.188 F19.188 F19.20 FI9.20 F19.221 F19.229 FI9.231 FI9.239 F19.24 F19.24 F19.259 F19.27

Inhalant-induced major neurocognitive disorder. With moderate or severe use disorder Inhalant-induced anxiety disorder. With moderate or severe use disorder Inhalant-induced mild neurocognitive disorder. With moderate or severe use disorder Inhalant intoxicahon delirium. Without use disorder Inhalant intoxication. Without use disorder Inhalant-induced depressive disorder. Without use disorder Inhalant-induced psychotic disorder. Without use disorder Inhalant-induced major neurocognitive disorder. Without use disorder Inhalant-induced anxiety disorder. Without use disorder Inhalant-induced mild neurocognitive disorder. Without use disorder Unspecified inhalant-related disorder Other (or unknown) substance use disorder. Mild Other (or unknown) substance intoxication delirium. With mild use disorder Other (or unknown) substance intoxication. With mild use disorder Other (or unknown) substance-induced bipolar and related disorder. With mild use disorder Other (or unknown) substance-induced depressive disorder. With mild use disorder Other (or unknown) substance-induced psychotic disorder. With mild use disorder Other (or unknown) substance-induced major neurocognitive disorder. With mild use disorder Other (or unknown) substance-induced anxiety disorder. With mild use disorder Other (or unknown) substance-induced sexual dysfunction. With mild use disorder Other (or unknown) substance-induced sleep disorder. With mild use disorder Other (or unknown) substance-induced mild neurocognitive disorder. With mild use disorder Other (or unknown) substance-induced obsessive-compulsive and related disorder. With mild use disorder Other (or unknown) substance use disorder. Moderate Other (or unknown) substance use disorder. Severe Other (or unknown) substance intoxication delirium. With moderate or severe use disorder Other (or unknown) substance intoxication. With moderate or severe use disorder Other (or unknown) substance withdrawal delirium Other (or unknown) substance withdrawal Other (or unknown) substance-induced bipolar and related disorder. With moderate or severe use disorder Other (or unknown) substance-induced depressive disorder. With moderate or severe use disorder Other (or unknown) substance-induced psychotic disorder. With moderate or severe use disorder Other (or unknown) substance-induced major neurocognitive disorder. With moderate or severe use disorder

F19.280 F19.281 F19.282 F19.288 F19.288 FI9.921 F19.921 F19.929 F19.94 F19.94 FI9.959 FI9.97 FI9.980 F19.981 F19.982 FI9.988 F19.988 F19.99 F20.81 F20.9 F21 F22 F23 F25.0 F25.1 F28 F29 F31.0 F31.il F31.12 F31.13 F31.2 F31.31 F31.32 F31.4 F31.5

Othei· (or unknown) substance-induced anxiety disorder. With moderate or severe use disorder Other (or unknown) substance-induced sexual dysfunction. With moderate or severe use disorder Other (or unknown) substance-induced sleep disorder. With moderate or severe use disorder Other (or unknown) substance-induced mild neurocognitive disorder. With moderate or severe use disorder Other (or unknown) substance-induced obsessive-compulsive and related disorder. With moderate or severe use disorder Other (or unknown) substance-induced delirium Other (or unknown) substance intoxication delirium. Without use disorder Other (or unknown) substance intoxication. Without use disorder Other (or unknown) substance-induced bipolar and related disorder. Without use disorder Other (or unknown) substance-induced depressive disorder. Without use disorder Other (or unknown) substance-induced psychotic disorder. Without use disorder Other (or unknown) substance-induced major neurocognitive disorder. Without use disorder Other (or unknown) substance-induced anxiety disorder. Without use disorder Other (or unknown) substance-induced sexual dysfunction. Without use disorder Other (or unknown) substance-induced sleep disorder. Without use disorder Other (or unknown) substance-induced mild neurocognitive disorder. Without use disorder Other (or unknown) substance-induced obsessive-compulsive and related disorder. Without use disorder Unspecified other (or unknown) substance-related disorder Schizophreniform disorder Schizophrenia Schizotypal personality disorder Delusional disorder Brief psychotic disorder Schizoaffective disorder. Bipolar type Schizoaffective disorder. Depressive type Other specified schizophrenia spectrum and other psychotic disorder Unspecified schizophrenia spectrum and other psychotic disorder Bipolar I disorder. Current or most recent episode hypomanie Bipolar I disorder. Current or most recent episode manic. Mild Bipolar I disorder, Current or most recent episode manic. Moderate Bipolar I disorder. Current or most recent episode manic. Severe Bipolar I disorder. Current or most recent episode manic. With psychotic features Bipolar I disorder. Current or most recent episode depressed. Mild Bipolar I disorder, Current or most recent episode depressed. Moderate Bipolar I disorder, Current or most recent episode depressed. Severe Bipolar I disorder. Current or most recent episode depressed. With psychotic features

F31.73 F31.73 F31.74 F31.74 F31.75 F31.76 F31.81 F31.89 F31.9 F31.9 F31.9 F31.9 F31.9 F32.0 F32.1 F32.2 F32.3 F32.4 F32.5 F32.8 F32.9 F32.9 F33.0 F33.1 F33.2 F33.3 F33.41 F33.42 F33.9 F34.0 F34.1 F34.8 F40.00 F40.10 F40.218 F40.228 F40.230 F40.231 F40.232 F40.233 F40.248 F40.298 F41.0 F41.1 F41.8

Bipolar I disorder. Current or most recent episode hypomanie. In partial remission Bipolar I disorder. Current or most recent episode manic. In partial remission Bipolar I disorder. Current or most recent episode hypomanie. In full remission Bipolar I disorder. Current or most recent episode manic. In full remission Bipolar I disorder. Current or most recent episode depressed. In partial remission Bipolar I disorder. Current or most recent episode depressed. In full remission Bipolar II disorder Other specified bipolar and related disorder Bipolar I disorder. Current or most recent episode depressed. Unspecified Bipolar I disorder. Current or most recent episode hypomanie. Unspecified Bipolar I disorder. Current or most recent episode manic. Unspecified Bipolar I disorder. Current or most recent episode unspecified Unspecified bipolar and related disorder Major depressive disorder. Single episode. Mild Major depressive disorder. Single episode. Moderate Major depressive disorder. Single episode. Severe Major depressive disorder. Single episode. With psychotic features Major depressive disorder. Single episode. In partial remission Major depressive disorder. Single episode. In full remission Other specified depressive disorder Major depressive disorder. Single episode, Unspecifed Unspecified depressive disorder Major depressive disorder. Recurrent episode. Mild Major depressive disorder. Recurrent episode. Moderate Major depressive disorder. Recurrent episode. Severe Major depressive disorder. Recurrent episode. With psychotic features Major depressive disorder. Recurrent episode. In partial remission Major depressive disorder. Recurrent episode. In full remission Major depressive disorder. Recurrent episode. Unspecified Cyclothymic disorder Persistent depressive disorder (dysthymia) Disruptive mood dysregulation disorder Agoraphobia Social anxiety disorder (social phobia) Specific phobia. Animal Specific phobia. Natural environment Specific phobia. Fear of blood Specific phobia. Fear of injections and transfusions Specific phobia. Fear of other medical care Specific phobia. Fear of injury Specific phobia. Situational Specific phobia. Other Panic disorder Generalized anxiety disorder Other specified anxiety disorder

F41.9 F42 F42 F42 F42 F43.0 F43.10 F43.20 F43.21 F43.22 F43.23 F43.24 F43.25 F43.8 F43.9 F44.0 F44.1 F44.4 F44.4 F44.4 F44.4 F44.5 F44.6 F44.6 F44.7 F44.81 F44.89 F44.9 F45.1 F45.21 F45.22 F45.8 F45.9 F48.1 F50.01 F50.02 F50.2 F50.8

Unspecified anxiety disorder Hoarding disorder Obsessive-compulsive disorder Other specified obsessive-compulsive and related disorder Unspecified obsessive-compulsive and related disorder Acute stress disorder Posttraumatic stress disorder Adjustment disorders. Unspecified Adjustment disorders. With depressed mood Adjustment disorders. With anxiety Adjustment disorders. With mixed anxiety and depressed mood Adjustment disorders. With disturbance of conduct Adjustment disorders. With mixed disturbance of emotions and conduct Other specified trauma- and stressor-related disorder Unspecified trauma- and stressor-related disorder Dissociative amnesia Dissociative amnesia. With dissociative fugue Conversion disorder (functional neurological symptom disorder). With abnormal movement Conversion disorder (functional neurological symptom disorder). With speech symptoms Conversion disorder (functional neurological symptom disorder). With swallowing symptoms Conversion disorder (functional neurological symptom disorder). With weakness /paralysis Conversion disorder (functional neurological symptom disorder). With attacks or seizures Conversion disorder (functional neurological symptom disorder). With anesthesia or sensory loss Conversion disorder (functional neurological symptom disorder). With special sensory symptoms Conversion disorder (functional neurological symptom disorder). With mixed symptoms Dissociative identity disorder Other specified dissociative disorder Unspecified dissociative disorder Somatic symptom disorder Illness anxiety disorder Body dysmorphic disorder Other specified somatic symptom and related disorder Unspecified somatic symptom and related disorder Depersonalization/derealization disorder Anorexia nervosa. Restricting type Anorexia nervosa. Binge-eating/purging type Bulimia nervosa Avoidant/restrictive food intake disorder

F50.8 F50.8 F50.8 F50.9 F51.3 F51.4 ¥51.5 F52.0 F52.21 F52.22 F52.31 F52.32 F52.4 F52.6 F52.8 F52.9 F54 F60.0 F60.1 F60.2 F60.3 F60.4 F60.5 F60.6 F60.7 F60.81 F60.89 F60.9 F63.0 F63.1 F63.2 F63.3 F63.81 F64.1 F64.2 F64.8 F64.9 F65.0 F65.1 F65.2 F65.3 F65.4 F65.51 F65.52 F65.81

Binge-eating disorder Other specified feeding or eating disorder Pica, in adults Unspecified feeding or eating disorder Non-rapid eye movement sleep arousal disorders. Sleepwalking type Non-rapid eye movement sleep arousal disorders. Sleep terror type Nightmare disorder Male hypoactive sexual desire disorder Erectile disorder Female sexual interest/arousal disorder Female orgasmic disorder Delayed ejaculation Premature (early) ejaculation Genito-pelvic pain/penetration disorder Other specified sexual dysfunction Unspecified sexual dysfunction Psychological factors affecting other medical conditions Paranoid personality disorder Schizoid personality disorder Antisocial personality disorder Borderline personality disorder Histrionic personality disorder Obsessive-compulsive personality disorder Avoidant personality disorder Dependent personality disorder Narcissistic personality disorder Other specified personality disorder Unspecified personality disorder Gambling disorder Pyromania Trichotillomania (hair-pulling disorder) Kleptomania Intermittent explosive disorder Gender dysphoria in adolescents and adults Gender dysphoria in children Other specified gender dysphoria Unspecified gender dysphoria Fetishistic disorder Transvestic disorder Exhibitionistic disorder Voyeurishc disorder Pedophilic disorder Sexual masochism disorder Sexual sadism disorder Frotteuristic disorder

F65.89 F65.9 F68.10 F70 F71 F72 F73 F79 F80.0 F80.81 F80.89 F80.9 F80.9 F81.0 F81.2 F81.81 F82 F84.0 F88 F88 F89 F90.0 F90.1 F90.2 F90.8 F90.9 F91.1 F91.2 F91.3 F91.8 F91.9 F91.9 F93.0 F94.0 F94.1 F94.2 F95.0 F95.1 F95.2 F95.8 F95.9 F98.0 F98.1 F98.21

Other specified paraphilic disorder Unspecified paraphilic disorder Factitious disorder Intellectual disability (intellectual developmental disorder). Mild Intellectual disability (intellectual developmental disorder). Moderate Intellectual disability (intellectual developmental disorder). Severe Intellectual disability (intellectual developmental disorder). Profound Unspecified intellectual disability (intellectual developmental disorder) Speech sound disorder Childhood-onset fluency disorder (stuttering) Social (pragmatic) communication disorder Language disorder Unspecified communication disorder Specific learning disorder. With impairment in reading Specific learning disorder. With impairment in mathematics Specific learning disorder. With impairment in written expression Developmental coordination disorder Autism spectrum disorder Global developmental delay Other specified neurodevelopmental disorder Unspecified neurodevelopmental disorder Attention-deficit/hyperactivity disorder. Predominantly inattentive presentation Attention-deficit/hyperactivity disorder. Predominantly hyperactive/ impulsive presentation Attention-deficit/hyperactivity disorder. Combined presentation Other specified attention-deficit/hyperactivity disorder Unspecified attention-deficit/hyperactivity disorder Conduct disorder, Childhood-onset type Conduct disorder, Adolescent-onset type Oppositional defiant disorder Other specified disruptive, impulse-control, and conduct disorder Conduct disorder. Unspecified onset Unspecified disruptive, impulse-control, and conduct disorder Separation anxiety disorder Selective mutism Reactive attachment disorder Disinhibited social engagement disorder Provisional tic disorder Persistent (chronic) motor or vocal tic disorder Tourette's disorder Other specified tic disorder Unspecified tic disorder Enuresis Encopresis Rumination disorder

F98.3 F98.4 F98.5 F99 F99 G21.0 G21.il G21.19 G24.01 G24.02 G24.09 G25.1 G25.71 G25.71 G25.79 G25.81 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 G31.84 G31.9 G31.9 G31.9 G31.9 G31.9 G47.00 G47.00 G47.09 G47.10 G47.10 G47.19 G47.20 G47.21 G47.22 G47.23 G47.24 G47.26 G47.31

Pica, in children Stereotypic movement disorder Adult-onset fluency disorder Other specified mental disorder Unspecified mental disorder Neuroleptic malignant syndrome Neuroleptic-induced parkinsonism Other medication-induced parkinsonism Tardive dyskinesia Medication-induced acute dystonia Tardive dystonia Medication-induced postural tremor Medication-induced acute akathisia Tardive akathisia Other medication-induced movement disorder Restless legs syndrome Mild frontotemporal neurocognitive disorder Mild neurocognitive disorder due to Alzheimer's disease Mild neurocognitive disorder due to another medical condition Mild neurocognitive disorder due to HIV infection Mild neurocognitive disorder due to Huntington's disease Mild neurocognitive disorder with Lev^y bodies Mild neurocognitive disorder due to multiple etiologies Mild neurocognitive disorder due to Parkinson's disease Mild neurocognitive disorder due to prion disease Mild neurocognitive disorder due to traumatic brain injury Mild vascular neurocognitive disorder Major neurocognitive disorder possibly due to Parkinson's disease Possible major frontotemporal neurocognitive disorder Possible major neurocognitive disorder due to Alzheimer's disease Possible major neurocognitive disorder with Lewy bodies Possible major vascular neurocognitive disorder Insomnia disorder Unspecified insomnia disorder Other specified insomnia disorder Hypersonrmolence disorder Unspecified hypersomnolence disorder Other specified hypersomnolence disorder Circadian rhythm sleep-wake disorders. Unspecified type Circadian rhythm sleep-wake disorders. Delayed sleep phase type Circadian rhythm sleep-wake disorders. Advanced sleep phase type Circadian rhythm sleep-wake disorders, Irregular sleep-wake type Circadian rhythm sleep-wake disorders, Non-24-hour sleep-wake type Circadian rhythm sleep-wake disorders. Shift work type Central sleep apnea. Idiopathic central sleep apnea

G47.33

Ot^structive sleep apnea hypopnea

G47.34

Sleep-related hypoventilation. Idiopathic hypoventilation

G47.35

Sleep-related hypoventilation. Congenital central alveolar hypoventilation

G47.36

Sleep-related hypoventilation, Comorbid sleep-related hypoventilation

G47.37

Central sleep apnea comorbid with opioid use

G47.411

Narcolepsy with cataplexy but without hypocretin deficiency

G47.419

Autosomal dominant cerebellar ataxia, deafness, and narcolepsy

G47.419

Autosomal dominant narcolepsy, obesity, and type 2 diabetes

G47.419

Narcolepsy without cataplexy but with hypocretin deficiency

G47.429

Narcolepsy secondary to another medical condition

G47.52

Rapid eye movement sleep behavior disorder

G47.8

Other specified sleep-wake disorder

G47.9

Unspecified sleep-wake disorder

L98.1

Excoriation (skin-picking) disorder

N39.498

Other specified elimination disorder. With urinary symptoms

N94.3

Premenstrual dysphoric disorder

R06.3

Central sleep apnea, Cheyne-Stokes breathing

R15.9

Other specified elimination disorder. With fecal symptoms

R15.9

Unspecified elimination disorder. With fecal symptoms

R32

Unspecified elimination disorder, With urinary symptoms

R41.0

Other specified delirium

R41.0

Unspecified delirium

R41.83

Borderline intellectual functioning

R41.9

Unspecified neurocognitive disorder

T43.205A

Antidepressant discontinuation syndrome. Initial encounter

T43.205D

Antidepressant discontinuation syndrome. Subsequent encounter

T43.205S

Antidepressant discontinuation syndrome. Sequelae

T50.905A

Other adverse effect of medication. Initial encounter

T50.905D

Other adverse effect of medication. Subsequent encounter

T50.905S

Other adverse effect of medication. Sequelae

T74.01XA

Spouse or partner neglect. Confirmed, Initial encounter

T74.01XD

Spouse or partner neglect. Confirmed, Subsequent encounter

T74.02XA

Child neglect. Confirmed, Initial encounter

T74.02XD

Child neglect. Confirmed, Subsequent encounter

T74.11XA

Adult physical abuse by nonspouse or nonpartner. Confirmed, Initial encounter

T74.11XA

Spouse or partner violence. Physical, Confirmed, Initial encounter

T74.11XD

Adult physical abuse by nonspouse or nonpartner. Confirmed, Subsequent encounter

T74.11XD

Spouse or partner violence. Physical, Confirmed, Subsequent encounter

T74.12XA

Child physical abuse. Confirmed, Initial encounter

T74.12XD

Child physical abuse. Confirmed, Subsequent encounter

T74.21XA

Adult sexual abuse by nonspouse or nonpartner. Confirmed, Initial encounter

T74.21XA

Spouse or partner violence. Sexual, Confirmed, Initial encounter

T74.21XD

Adult sexual abuse by nonspouse or nonpartner. Confirmed, Subsequent encounter

T74.21XD

Spouse or partner violence. Sexual, Confirmed, Subsequent encounter

T74.22XA

Child sexual abuse. Confirmed, Initial encounter

T74.22XD

Child sexual abuse. Confirmed, Subsequent encounter

T74.31XA

Adult psychological abuse by nonspouse or nonpartner. Confirmed, Initial encounter

T74.31XA

Spouse or partner abuse. Psychological, Confirmed, Initial encounter

T74.31XD

Adult psychological abuse by nonspouse or nonpartner. Confirmed, Subsequent encounter

T74.31XD

Spouse or partner abuse. Psychological, Confirmed, Subsequent encounter

T74.32XA

Child psychological abuse. Confirmed, Initial encounter

T74.32XD

Child psychological abuse. Confirmed, Subsequent encounter

T76.01XA

Spouse or partner neglect. Suspected, Initial encounter

T76.01XD

Spouse or partner neglect. Suspected, Subsequent encounter

T76.02XA

Child neglect. Suspected, Initial encounter

T76.02XD

Child neglect. Suspected, Subsequent encounter

T76.11XA

Adult physical abuse by nonspouse or nonpartner. Suspected, Initial encounter

T76.11XA

Spouse or partner violence. Physical, Suspected, Initial encounter

T76.11XD

Adult physical abuse by nonspouse or nonpartner. Suspected, Subsequent encounter

T76.11XD

Spouse or partner violence. Physical, Suspected, Subsequent encounter

T76.12XA

Child physical abuse. Suspected, Initial encounter

T76.12XD

Child physical abuse. Suspected, Subsequent encounter

T76.21XA

Adult sexual abuse by nonspouse or nonpartner. Suspected, Initial encounter

T76.21XA

Spouse or partner violence. Sexual, Suspected, Initial encounter

T76.21XD

Adult sexual abuse by nonspouse or nonpartner. Suspected, Subsequent encounter

T76.21XD

Spouse or partner violence. Sexual, Suspected, Subsequent encounter

T76.22XA

Child sexual abuse. Suspected, Initial encounter

T76.22XD

Child sexual abuse. Suspected, Subsequent encounter

T76.31XA

Adult psychological abuse by nonspouse or nonpartner. Suspected, Initial encounter

T76.31XA

Spouse or partner abuse. Psychological, Suspected, Initial encounter

T76.31XD

Adult psychological abuse by nonspouse or nonpartner. Suspected, Subsequent encounter

T76.31XD

Spouse or partner abuse. Psychological, Suspected, Subsequent encounter

T76.32XA

Child psychological abuse. Suspected, Initial encounter

T76.32XD

Child psychological abuse. Suspected, Subsequent encounter

Z55.9

Academic or educational problem

Z56.82

Problem related to current military deployment status

Z56.9

Other problem related to employment

Z59.0

Homelessness

Z59.1

Inadequate housing

Z59.2

Discord with neighbor, lodger, or landlord

Z59.3

Problem related to living in a residential institution

Z59.4

Lack of adequate food or safe drinking water

Z59.5

Extreme poverty

Z59.6

Low income

Z59.7

Insufficient social insurance or welfare support

Z59.9

Unspecified housing or economic problem

Z60.0

Phase of life problem

Z60.2

Problem related to living alone

Z60.3

Acculturation difficulty

Z60.4

Social exclusion or rejection

Z60.5

Target of (perceived) adverse discrimination or persecution

Z60.9

Unspecified problem related to social environment

Z62.29

Upbringing away from parents

Z62.810

Personal history (past history) of physical abuse in childhood

Z62.810

Personal history (past history) of sexual abuse in childhood

Z62.811

Personal history (past history) of psychological abuse in childhood

Z62.812

Personal history (past history) of neglect in childhood

Z62.820

Parent-child relational problem

Z62.891

Sibling relational problem

Z62.898

Child affected by parental relationship distress

Z63.0

Relationship distress with spouse or intimate partner

Z63.4

Uncomplicated bereavement

Z63.5

Disruption of family by separation or divorce

Z63.8

High expressed emotion level within family

Z64.0

Problems related to unwanted pregnancy

Z64.1

Problems related to multiparity

Z64.4

Discord with social service provider, including probation officer, case manager, or social services worker

Z65.0

Conviction in civil or criminal proceedings without imprisonment

Z65.1

Imprisonment or other incarceration

Z65.2

Problems related to release from prison

Z65.3

Problems related to other legal circumstances

Z65.4

Victim of crime

Z65.4

Victim of terrorism or torture

Z65.5

Exposure to disaster, war, or other hostilities

Z65.8

Other problem related to psychosocial circumstances

Z65.8

Religious or spiritual problem

Z65.9

Unspecified problem related to unspecified psychosocial circumstances

Z69.010

Encounter for mental health services for victim of child abuse by parent

Z69.010

Encounter for mental health services for victim of child neglect by parent

Z69.010

Encounter for mental health services for victim of child psychological abuse by parent

Z69.010

Encounter for mental health services for victim of child sexual abuse by parent

Z69.011

Encounter for mental health services for perpetrator of parental child abuse

Z69.011

Encounter for mental health services for perpetrator of parental child neglect

Z69.011

Encounter for mental health services for perpetrator of parental child psychological abuse

Z69.011

Encounter for mental health services for peφetrator of parental child sexual abuse

Z69.020

Encounter for mental health services for victim of nonparental child abuse

Z69.020

Encounter for mental health services for victim of nonparental child neglect

Z69.020

Encounter for mental health services for victim of nonparental child psycho­ logical abuse

Z69.020

Encounter for mental health services for victim of nonparental child sexual abuse

Z69.021

Encounter for mental health services for perpetrator of nonparental child abuse

Z69.021

Encounter for mental health services for perpetrator of nonparental child neglect

Z69.021

Encounter for mental health services for perpetrator of nonparental child psychological abuse

Z69.021

Encounter for mental health services for perpetrator of nonparental child sexual abuse

Z 69.ll

Encounter for mental health services for victim of spouse or partner neglect

Z 69.ll

Encounter for mental health services for victim of spouse or partner psychological abuse

Z 69.ll

Encounter for mental health services for victim of spouse or partner violence. Physical

Z69.12

Encounter for mental health services for peφetrator of spouse or partner neglect

Z69.12

Encounter for mental health services for perpetrator of spouse or partner psychological abuse

Z69.12

Encounter for mental health services for perpetrator of spouse or partner violence. Physical

Z69.12

Encounter for mental health services for perpetrator of spouse or partner violence. Sexual

Z69.81

Encounter for mental health services for victim of nonspousal adult abuse

Z69.81

Encounter for mental health services for victim of spouse or partner violence. Sexual

Z69.82

Encounter for mental health services for peφetΓator of nonspousal adult abuse

Z70.9

Sex counseling

Z71.9

Other counseling or consultation

Z72.0

Tobacco use disorder, mild

Z72.810

Child or adolescent antisocial behavior

Z72.811

Adult antisocial behavior

Z72.9

Problem related to lifestyle

Z75.3

Unavailability or inaccessibility of health care facilities

Z75.4

Unavailability or inaccessibility of other helping agencies

Z76.5

Malingering

Z91.19

Nonadherence to medical treatment

Z91.410

Personal history (past history) of spouse or partner violence. Physical

Z91.410

Personal history (past history) of spouse or partner violence. Sexual

Z91.411

Personal history (past history) of spouse or partner psychological abuse

Z91.412

Personal history (past history) of spouse or partner neglect

Z91.49

Other personal history of psychological trauma

Z91.5

Personal history of self-harm

Z91.82

Personal history of military deployment

Z91.83

Wandering associated with a mental disorder

Z91.89

Other personal risk factors

IW I^iravisörö^nä Other Contributor APA Board of Trustees DSM-5 Review Committees Scientific Review Committee (SRC) Kenneth S. Kendler, M.D. (Chair) Robert Freedman, M.D. (Co-chair) Dan G. Blazer, M.D., Ph.D., M.P.H. David Brent, M.D. (2011-) Ellen Leibenluft, M.D. Sir Michael Rutter, M.D. (-2011) Paul S. Summergrad, M.D. Robert J. Ursano, M.D. (-2011) Myrna Weissman, Ph.D. (2011-) Joel Yager, M.D. Jill L. Opalesky M.S. (Administrative Support)

Clinical and Public Health Review Committee (CPHC) John s. McIntyre, M.D. (Chair) Joel Yager, M.D. (Co-chair) Anita Everett M.D. Cathryn A. Galanter, M.D. Jeffrey M. Lyness, M.D. James E. Nininger, M.D. Victor I. Reus, M.D. Michael J. Vergäre, M.D. Ann Miller (Administrative Support)

Oversight Committee Carolyn Robinowitz, M.D. (Chair) Mary Badaracco, M.D. Ronald Burd, M.D. Robert Freedman, M.D. Jeffrey A. Lieberman, M.D. Kyla Pope, M.D. Victor I. Reus, M.D. Daniel K. Winstead, M.D. Joel Yager, M.D.

APA Assembly DSM-5 Review Committee Glenn A. Martin, M.D. (Chair) R. Scott Benson, M.D. (Speaker of the Assembly) William Cardasis, M.D. John M. de Figueiredo, M.D. Lawrence S. Gross, M.D. Brian S. Hart, M.D.

Stephen A. McLeod Bryant, M.D. Gregory A. Miller, M.D. Roger Peele, M.D. Charles S. Price, M.D. Deepika Sastry, M.D. John P.D. Shemo, M.D. Eliot Sorel, M.D.

DSM-5 Summit Group Dilip V. Jeste, M.D. (Chair) R. Scott Benson, M.D. Kenneth S. Kendler, M.D. Helena C. Kraemer, Ph.D. David J. Kupfer, M.D. Jeffrey A. Lieberman, M.D. Glenn A. Martin, M.D. John S. McIntyre, M.D. John M. Oldham, M.D. Roger Peele, M.D. Darrel A. Regier, M.D., M.P.H. James H. Scully Jr., M.D. Joel Yager, M.D. Paul S. Appelbaum, M.D. (Consultant) Michael B. First, M.D. (Consultant)

DSM-5 Field Trials Review Robert D. Gibbons, Ph.D. Craig Nelson, M.D.

DSM-5 Forensic Review Paul S. Appelbaum, M.D. Lama Bazzi, M.D. Alec W. Buchanan, M.D., Ph.D. Carissa Caban Aleman, M.D. Michael Champion, M.D. Jeffrey C. Eisen, M.D. Elizabeth Ford, M.D. Daniel T. Hackman, M.D. Mark Hauser, M.D. Steven K. Hoge, M.D., M.B.A. Debra A. Pinals, M.D. Guillermo Portillo, M.D. Patricia Recupero, M.D., J.D. Robert Weinstock, M.D. Cheryl Wills, M.D. Howard V. Zonana, M.D.

Past DSM-5 APA Staff Erin J. Dalder-Alpher Kristin Edwards Leah I. Engel

Lenna Jawdat Elizabeth C. Martin Rocio J. Salvador

Work Group Advisors ADHD and Disruptive Behavior Disorders Emil F. Coccaro, M.D. Deborah Dabrick, Ph.D. Prudence W. Fisher, Ph.D. Benjamin B. Lahey, Ph.D. Salvatore Mannuzza, Ph.D. Mary Solanto, Ph.D. J. Blake Turner, Ph.D. Eric Youngstrom, Ph.D.

Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Lynn E. Alden, Ph.D. David B. Arciniegas, M.D. David H. Barlow, Ph.D. Katja Beesdo-Baum, Ph.D. Chris R. Brewin, Ph.D. Richard J. Brown, Ph.D. Timothy A. Brown, Ph.D. Richard A. Bryant, Ph.D. Joan M. Cook, Ph.D. Joop de Jong, M.D., Ph.D. Paul F. Dell, Ph.D. Damiaan Denys, M.D. Bruce P. Dohrenwend, Ph.D. Brian A. Fallon, M.D., M.P.H. Edna B. Foa, Ph.D. Martin E. Franklin, Ph.D. Wayne K. Goodman, M.D. Jon E. Grant, J.D., M.D. Bonnie L. Green, Ph.D. Richard G. Heimberg, Ph.D. Judith L. Herman, M.D. Devon E. Hinton, M.D., Ph.D. Stefan G. Hofmann, Ph.D. Charles W. Hoge, M.D. Terence M. Keane, Ph.D. Nancy J. Keuthen, Ph.D. Dean G. Kilpatrick, Ph.D. Katharina Kircanski, Ph.D. Laurence J. Kirmayer, M.D. Donald F. Klein, M.D., D.Sc. Amaro J. Laria, Ph.D. Richard T. LeBeau, M.A. Richard J. Loewenstein, M.D. David Mataix-Cols, Ph.D. Thomas W. McAllister, M.D.

Harrison G. Pope, M.D., M.P.H. Ronald M. Rapee, Ph.D. Steven A. Rasmussen, M.D. Patricia A. Resick, Ph.D. Vedat Sar, M.D. Sanjaya Saxena, M.D. Paula P. Schnurr, Ph.D. M. Katherine Shear, M.D. Daphne Simeon, M.D. Harvey S. Singer, M.D. Melinda A. Stanley, Ph.D. James J. Strain, M.D. Kate Wolitzky Taylor, Ph.D. Onno van der Hart, Ph.D. Eric Vermetten, M.D., Ph.D. John T. Walkup, M.D. Sabine Wilhelm, Ph.D. Douglas W. Woods, Ph.D. Richard E. Zinbarg, Ph.D. Joseph Zohar, M.D.

Childhood and Adolescent Disorders Adrian Angold, Ph.D. Deborah Beidel, Ph.D. David Brent, M.D. John Campo, M.D. Gabrielle Carlson, M.D. Prudence W. Fisher, Ph.D. David Klonsky, Ph.D. Matthew Nock, Ph.D. J. Blake Turner, Ph.D.

Eating Disorders Michael J. Devlin, M.D. Denise E. Wilfley, Ph.D. Susan Z. Yanovski, M.D.

Mood Disorders Boris Birmaher, M.D. Yeates Conwell, M.D. Ellen B. Dennehy, Ph.D. S. Ann Hartlage, Ph.D. Jack M. Hettema, M.D., Ph.D. Michael C. Neale, Ph.D. Gordon B. Parker, M.D., Ph.D., D.Sc. Roy H. Perlis, M.D. M.Sc. Holly G. Prigerson, Ph.D. Norman E. Rosenthal, M.D. Peter J. Schmidt, M.D.

Mort M. Silverman, M.D. Meir Steiner, M.D., Ph.D. Mauricio Tohen, M,D., Dr.P.H., M.B.A. Sidney Zisook, M.D.

Neurocognitive Disorders Jiska Cohen-Mansfield, Ph.D. Vladimir Hachinski, M.D., C.M., D.Sc. Sharon Inouye, M.D., M.P.H. Grant Iverson, Ph.D. Laura Marsh, M.D. Bruce Miller, M.D. Jacobo Mintzer, M.D., M.B.A. Bruce Pollock, M.D., Ph.D. George Prigatano, Ph.D. Ron Ruff, Ph.D. Ingmar Skoog, M.D., Ph.D. Robert Sweet, M.D. Paula Trzepacz, M.D.

Neurodevelopmental Disorders Ari Ne'eman Nickola Nelson, Ph.D. Diane Paul, Ph.D. Eva Petrova, Ph.D. Andrew Pickles, Ph.D. Jan Piek, Ph.D. Helene Polatajko, Ph.D. Alya Reeve, M.D. Mabel Rice, Ph.D. Joseph Sergeant, Ph.D. Bennett Shaywitz, M.D. Sally Shaywitz, M.D. Audrey Thurm, Ph.D. Keith Widaman, Ph.D. Warren Zigman, Ph.D.

Personality and Personality Disorders Eran Chemerinski, M.D. Thomas N. Crawford, Ph.D. Harold W. Koenigsberg, M.D. Kristian E. Markon, Ph.D. Rebecca L. Shiner, Ph.D. Kenneth R. Silk, M.D. Jennifer L. Tackett, Ph.D. David Watson, Ph.D.

Psychotic Disorders Kamaldeep Bhui, M.D. Manuel J. Cuesta, M.D., Ph.D. Richard Douyon, M.D. Paolo Fusar-Poli, Ph.D. John H. Krystal, M.D. Thomas H. McGlashan, M.D. Victor Peralta, M.D., Ph.D. Anita Riecher-Rössler, M.D. Mary V. Seeman, M.D.

Sexual and Gender Identity Disorders Stan E. Althof, Ph.D. Richard Balon, M.D. John H.J. Bancroft, M.D., M.A., D.P.M. Howard E. Barbaree, Ph.D., M.A. Rosemary J. Basson, M.D. Sophie Bergeron, Ph.D. Anita L. Clayton, M.D. David L. Delmonico, Ph.D. Domenico Di Ceglie, M.D. Esther Gomez-Gil, M.D. Jamison Green, Ph.D. Richard Green, M.D, J.D. R. Karl Hanson, Ph.D. Lawrence Hartmann, M.D. Stephen J. Hucker, M.B. Eric S. Janus, J.D. Patrick M. Jem, Ph.D. Megan S. Kaplan, Ph.D. Raymond A. Knight, Ph.D. Ellen T.M. Laan, Ph.D. Stephen B. Levine, M.D. Christopher G. McMahon, M.B. Marta Meana, Ph.D. Michael H. Miner, Ph.D., M.A. William T. O'Donohue, Ph.D. Michael A. Perelman, Ph.D. Caroline F. Pukall, Ph.D. Robert E. Pyke, M.D., Ph.D. Vernon L. Quinsey, Ph.D. M.Sc. David L. Rowland, Ph.D., M.A. Michael Sand, Ph.D., M.P.H. Leslie R. Schover, Ph.D., M.A. Paul Stem, B.S, J.D. David Thomton, Ph.D. Leonore Tiefer, Ph.D. Douglas E. Tucker, M.D. Jacques van Lankveld, Ph.D. Marcel D. Waldinger, M.D., Ph.D.

Sleep-Wake Disorders Donald L. Bliwise, Ph.D. Daniel J. Buysse, M.D. Vishesh K. Kapur, M.D., M.P.H. Sanjeeve V. Kothare, M.D. Kenneth L. Lichstein, Ph.D. Mark W. Mahowald, M.D. Rachel Manber, Ph.D. Emmanuel Mignot, M.D., Ph.D. Timothy H. Monk, Ph.D., D.Sc. Thomas C. Neylan, M.D. Maurice M. Ohayon, M.D., D.Sc., Ph.D. Judith Owens, M.D., M.P.H. Daniel L. Picchietti, M.D. Stuart F. Quan, M.D. Thomas Roth, Ph.D. Daniel Weintraub, M.D.

Theresa B. Young, Ph.D. Phyllis C. Zee, M.D., Ph.D.

Somatic Symptom Disorders Brenda Bursch, Ph.D. Kurt Kroenke, M.D. W. Curt LaFrance, Jr., M.D., M.P.H. Jon Stone, M.B., Ch.B., Ph.D. Lynn M. Wegner, M.D.

Substance-Related Disorders Raymond F. Anton, Jr., M.D. Deborah A. Dawson, Ph.D. Roland R. Griffiths, Ph.D. Dorothy K. Hatsukami, Ph.D. John E. Heizer, M.D. Marilyn A. Huestis, Ph.D. John R. Hughes, M.D. Thomas R. Kosten, M.D. Nora D. Volkow, M.D.

DSM-5 Study Group and Other DSM-5 Group Advisors Lifespan Developmental Approaches Christina Bryant, Ph.D. Amber Gum, Ph.D. Thomas Meeks, M.D. Jan Mohlman, Ph.D. Steven Thorp, Ph.D. Julie Wetherell, Ph.D.

Gender and Cross-Cultural Issues Neil K. Aggarwal, M.D., M.B.A., M.A. Sofie Bäämhielm, M.D., Ph.D. José J. Bauermeister, Ph.D. James Boehnlein, M.D., M.Sc. Jaswant Guzder, M.D. Alejandro Interian, Ph.D. Sushrut S. Jadhav, M.B.B.S., M.D., Ph.D. Laurence J. Kirmayer, M.D. Alex J. Kopelowicz, M.D. Amaro J. Laria, Ph.D. Steven R. Lopez, Ph.D. Kwame J. McKenzie, M.D. John R. Peteet, M.D.

Hans Q.G.B.M.) Rohlof, M.D. Cecile Rousseau, M.D. Mitchell G. Weiss, M.D., Ph.D.

Psychiatric/General Medical Interface Daniel L. Coury, M.D. Bernard P. Dreyer, M.D. Danielle Laraque, M.D. Lynn M. Wegner, M.D.

Impairment and Disability Prudence W. Fisher, Ph.D. Martin Prince, M.D., M.Sc. Michael R. Von Korff, Sc.D.

Diagnostic Assessment Instruments Prudence W. Fisher, Ph.D. Robert D. Gibbons, Ph.D. Ruben Gur, Ph.D. John E. Heizer, M.D. John Houston, M.D., Ph.D. Kurt Kroenke, M.D.

Other Contributors/Consultants ADHD and Disruptive Behavior Disorders

Childhood and Adolescent Disorders

Patrick E. Shrout, Ph.D. Erik Willcutt, Ph.D.

Grace T. Baranek, Ph.D. Colleen Jacobson, Ph.D. Maria Oquendo, M.D. Sir Michael Rutter, M.D.

Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Eric Hollander, M.D. Charlie Marmar, M.D. Mark W. Miller, Ph.D. Mark H. Pollack, M.D. Heidi S. Resnick, Ph.D.

Eating Disorders Nancy L. Zucker, Ph.D.

Mood Disorders Keith Hawton, M.Sc. David A. Jobes, Ph.D. Maria A. Oquendo, M.D.

Neurocognitive Disorders J. Eric Ahlskog, M.D, Ph.D. Allen J. Aksamit, M.D. Marilyn Albert, Ph.D. Guy Mckhann, M.D. Bradley Boeve, M.D. Helena Chui, M.D. Sureyya Dikmen, Ph.D. Douglas Galasko, M.D. Harvey Levin, Ph.D. Mark Lovell, Ph.D. Jeffery Max, M.B.B.Ch. Ian McKeith, M.D. Cynthia Munro, Ph.D. Marlene Oscar-Berman, Ph.D. Alexander Tröster, Ph.D.

Sally M. Anderson, Ph.D. Julie A. Kable, Ph.D. Christopher Martin, Ph.D. Sarah N. Mattson, Ph.D. Edward V. Nunes, Jr., M.D. Mary J. O'Connor, Ph.D. Heather Carmichael Olson, Ph.D. Blair Paley, Ph.D. Edward P. Riley, Ph.D. Tulshi D. Saha, Ph.D. Wim van den Brink, M.D., Ph.D. George E. Woody, M.D.

Neurodevelopmental Disorders

Bruce Cuthbert, Ph.D.

Arma Barnett, Ph.D. Martha Denckla, M.D. Jack M. Fletcher, Ph.D. Dido Green, Ph.D. Stephen Greenspan, Ph.D. Bruce Pennington, Ph.D. Ruth Shalev, M.D. Larry B. Silver, M.D. Lauren Swineford, Ph.D. Michael Von Aster, M.D.

Lifespan Developmental Approaches

Personality and Personality Disorders Patricia R. Cohen, Ph.D. Jaime L. Derringer, Ph.D. Lauren Helm, M.D. Christopher J. Patrick, Ph.D. Anthony Pinto, Ph.D.

Psychotic Disorders Scott W. Woods, M.D.

Sexual and Gender Identity Disorders Alan J. Riley, M.Sc. Ray C. Rosen, Ph.D.

Sleep-Wake Disorders Jack D. Edinger, Ph.D. David Gozal, M.D. Hochang B. Lee, M.D. Tore A. Nielsen, Ph.D. Michael J. Sateia, M.D. Jamie M. Zeitzer, Ph.D.

Somatic Symptom Disorders Chuck V. Ford, M.D. Patricia L Rosebush, M.Sc.N., M.D.

Diagnostic Spectra and DSM/ICD Harmonization

Aartjan Beekman Ph.D. Alistair Flint, M.B. David Sultzer, M.D. Ellen Whyte, M.D.

Gender and Cross-Cultural Issues Sergio Aguilar-Gaxiola, M.D., Ph.D. Kavoos G. Bassiri, M.S. Venkataramana Bhat, M.D. Marit Boiler, M.P.H. Denise Canso, M.Sc. Smita N. Deshpande, M.D., D.P.M. Ravi DeSilva, M.D. Esperanza Diaz, M.D. Byron J. Good, Ph.D. Simon Groen, M.A. Ladson Hinton, M.D. Lincoln L Khasakhala, Ph.D. Francis G. Lu, M.D. Athena Madan, M.A. Arme W. Mbwayo, Ph.D. Oanh Meyer, Ph.D. Victoria N. Mutiso, Ph.D., D.Sc. David M. Ndetei, M.D. Andel V. Nicasio, M.S.Ed. Vasudeo Paralikar, M.D., Ph.D. Kanak Patil, M.A. Filipa L Santos, H.B.Sc. Sanjeev B. Sarmukaddam, Ph.D., M.Sc. Monica Z. Scalco, M.D., Ph.D. Katie Thompson, M.A. Hendry Ton, M.D., M.Sc. Rob C.J. van Dijk, M.Sc. Johann M. Vega-Dienstmaier, M.D. Joseph Westermeyer, M.D., Ph.D.

Psychiatric/General Medical Interface

Other Conditions That May Be a Focus of Clinical Attention

Daniel J. Balog, M.D. Charles C. Engel M.D., M.P.H. Charles D. Motsinger, M.D.

William E. Narrow, M.D., M.P.H., Chair Roger Peele, M.D. Lawson R. Wulsin, M.D. Charles H. Zeanah, M.D. Prudence W. Fisher, Ph.D., Advisor Stanley N. Caroff, M.D., Contributor/Consultant James B. Lohr, M.D., Contributor/Consultant Marianne Wambolt, Ph.D., Contributor/Consultant

Impairment and Disability Cille Kennedy, Ph.D.

Diagnostic Assessment Instruments

DSM-5 Research Group Allan Dormer, Ph.D.

Paul J. Pikonis, Ph.D.

CPHC Peer Reviewers Kenneth Altshuler, M.D. Pedro G. Alvarenga, M.D. Diana J. Antonacci, M.D. Richard Balon, M.D. David H. Barlow, Ph.D. L. Jarrett Banihill, M.D. Katja Beesdo-Baum, Ph.D. Marty Boman, Ed.D. James Bourgeois, M.D. David Braff, M.D. Harry Brandt, M.D. Kirk Brower, M.D. Rachel Bryant-Waugh, Ph.D. Jack D. Burke Jr., M.D., M.P.H. Brenda Bursch, Ph.D. Joseph Camilleri, M.D. Patricia Casey, M.D. F. Xavier Castellanos, M.D. Eran Chemerinski, M.D. Wai Chen, M.D. Elie Cheniaux, M.D., D.Sc. Cheryl Chessick, M.D, J. Richard Ciccone, M.D. Anita H. Clayton, M.D. Tihalia J. Coleman, Ph.D. John Csemansky, M.D. Manuel J. Cuesta M.D., Ph.D. Joanne L. Davis, M.D. David L. Delmonico, Ph.D. Ray J. DePaulo, M.D. Dinnitris Dikeos, M.D. Ina E. Djonlagic, M.D. C. Neill Epperson, M.D. Javier I. Escobar, M.D., M.Sc. Spencer Eth, M.D. David Fassler, M.D. Giovanni A. Fava, M.D. Robert Feinstein, M.D. Molly Finnerty, M.D. Mark H. Fleisher, M.D. Alessio Florentini, M.D.

Laura Fochtmann, M.D. Marshal Forstein, M.D. William French, M.D. MaximiUian Gahr, M.D. Cynthia Geppert, M.D. Ann Germaine, Ph.D. Marcia Goin, M.D. David A. Gorelick, M.D., Ph.D. David Graeber, M.D. Cynthia A. Graham, Ph.D. Andreas Hartmann, M.D. Victoria Hendrick, M.D. Merrill Herman, M.D. David Herzog, M.D. Mardi Horowitz, M.D. Ya-fen Huang, M.D. Anthony Kales, M.D Niranjan S. Karnik, M.D., Ph.D. Jeffrey Katzman, M.D. Bryan King, M.D. Cecilia Kjellgren, M.D. Harold W. Koenigsberg, M.D. Richard B. Krueger, M.D. Steven Lamberti, M.D. Ruth A. Lanius, M.D. John Lauriello, M.D. Anthony Lehman, M.D. Michael Linden, M.D. MarkW. Mahowald, M.D. Marsha D. Marcus, Ph.D. Stephen Marder, M.D. Wendy Marsh, M.D. Michael S. McCloskey, Ph.D. Jeffrey Metzner, M.D. Robert Michels, M.D. Laura Miller, M.D. Michael C. Miller, M.D. Frederick Moeller, M.D. Peter T. Morgan, M.D., Ph.D. Madhav Muppa, M.D. Philip Muskin, M.D.

Joachim Nitschke, M.D. Abraham Nussbaum, M.D. Ann Olincy, M.D. ^ Mark Onslow, Ph.D. Sally Ozonoff, Ph.D. John R. Peteet, M.D. Ismene L. Petrakis, M.D. Christophe M. Pfeiffer, M.D. Karen Pierce, M.D. Belinda Plattner, M.D. Franklin Putnam, M.D. Stuart F. Quan, M.D. John Racy, M.D. Phillip Resnick, M.D. Michele Riba, M.D. Jerold Rosenbaum, M.D. Stephen Ross, M.D. Lawrence Scahill, M.S.N., Ph.D. Daniel Schechter, M.D. Mary V. Seeman, M.D. Alessandro Serretti, M.D. Jianhua Shen, M.D.

Ravi Kumar R. Singareddy, M.D. Ingmar Skoog, M.D., Ph.D. Gary Small, M.D. Paul Soloff, M.D. Christina Stadler, M.D., Ph.D. Nada Stotland, M.D. Neil Swerdlow, M.D. Kim Tillery, Ph.D. David Tolin, Ph.D. Jayne Trachman, M.D. Luke Tsai, M.D. Ming T. Tsuang, M.D., Ph.D. Richard Tuch, M.D. Johan Verhulst, M.D. B. Timothy Walsh, M.D. Michael Weissberg, M.D. Godehard Weniger, M.D. Keith Widaman, Ph.D. Thomas Wise, M.D. George E. Woods, M.D. Kimberly A. Yonkers, M.D. Alexander Young, M.D.

DSM-5 Field Trials in Academic Clinical Centers— Adult Samples David Geffen School of Medicine, University of California, Los Angeles Investigator Helen Lavretsky, M.D., Principal Investigator

Referring and Interviewing Clinicians Jessica Brommelhoff, Ph.D. Xavier Cagigas, Ph.D. Paul Cemin, Ph.D. Linda Ercoli, Ph.D. Randall Espinoza, M.D.

Helen Lavretsky, M.D. Jeanne Kim, Ph.D. David Merrill, M.D. Karen Miller, Ph.D. Christopher Nunez, Ph.D.

Research Coordinators Natalie St. Cyr, M.A., Lead Research Coordinator Nora Nazarian, B.A. Colin Shinn, M.A.

Centre for Addiction and Mental Health, Toronto, Ontario, Canada Investigators Bruce G. Pollock, M.D., Ph.D., Lead Principal Investigator R. Michael Bagby, Ph.D., Principal Investigator Kwame J. McKenzie, M.D., Principal Investigator Tony P. George, M.D., Co-investigator Lena C. Quilty, Ph.D., Co-investigator Peter Voore, M.D., Co-investigator

Referring and Interviewing Clinicians Donna E. Akman, Ph.D. R. Michael Bagby, Ph.D. Wayne C. V. Baici, M.D. Crystal Baluyut, M.D.

Eva W. C. Chow, M.D., J.D., M.P.H. Z. J. Daskalakis, M.D., Ph.D. Pablo Diaz-Hermosillo, M.D. George Foussias, M.Sc., M.D. Paul A. Frewen, Ph.D. Ariel Graff-Guerrero, M.D., M.Sc., Ph.D. Margaret K. Hahn, M.D. Lorena Hsu, Ph.D. Justine Joseph, Ph.D. Sean Kidd, Ph.D. Kwame J. McKenzie, M.D. Mahesh Menon, Ph.D. Romina Mizrahi, M.D., Ph.D. Daniel J. Mueller, M.D., Ph.D. Lena C. Quilty, Ph.D. Anthony C. Ruocco, Ph.D.

Jorge Soni, M.D. Aristotle N. Voineskos, M.D., Ph.D. George Voineskos, M.D. Peter Voore, Ph.D. Chris Watson, Ph.D.

Referring Clinicians Ofer Agid, M.D. Ash Bender, M.D. Patricia Cavanagh, M.D. Sarah Colman, M.D. Vincenzo Deluca, M.D. Justin Geagea, M.D. David S. Goldbloom, M.D. Daniel Greben, M.D. Malati Gupta, M.D. Ken Harrison, M.D. Imraan Jeeva, M.D. Joel Jeffries, M.B. Judith Laposa, Ph.D.

Jan Malat, M.D. Shelley McMain, Ph.D. Bruce Pollock, M.D., Ph.D. Andriy V. Samokhvalov, M.D., Ph.D. Martin Strassnig, M.D. Albert H. C. Wong, M.D., Ph.D.

Research Coordinators Gloria I. Leo, M.A., Lead Research Coordinator Anissa D. Bachan, B.A. Bahar Haji-Khamneh, M.A. Olga Likhodi, M.Sc. Eleanor J. Liu, Ph.D. Sarah A. McGee Ng, B.B.A.

other Research Staff Susan E. Dickens, M.A., Clinical Research Manager Sandy Richards, B.Sc.N., Schizophrenia Research Manager

Dallas VA Medical Center, Dallas, Texas Investigators Carol S. North, M.D., M.P.E., Principal Investigator Alina Suris, Ph.D., A.B.P.P., Principal Investigator

Referring and Interviewing Clinicians Barry Ardolf, Psy.D. Abila Awan, M.D. Joel Baskin, M.D. John Black, Ph.D. Jeffrey Dodds, Ph.D. Gloria Emmett, Ph.D. Karma Hudson, M.D. Jamylah Jackson, Ph.D., A.B.P.P. Lynda Kirkland-Culp, Ph.D., A.B.P.P. Heidi Koehler, Ph.D., A.B.P.P. Elizabeth Lewis, Psy.D. Aashish Parikh, M.D. Reed Robinson, Ph.D. Jheel Shah, M.D. Geetha Shivakumar, M.D. Sarah Spain, Ph.D., A.B.P.P.

Lisa Thoman, Ph.D. Lia Thomas, M.D. Jamie Zabukovec, Psy.D. Mustafa Zaidi, M.D. Andrea Zartman, Ph.D.

General Referral Sources Robert Blake, L.M.S.W. Evelyn Gibbs, L.M.S.W. Michelle King-Thompson, L.M.S.W.

Research Coordinators Jeannie B. Whitman, Ph.D., Lead Research Coordinator Sunday Adewuyi, M.D. Elizabeth Anderson, B.A. Solaleh Azimipour, B.S. Carissa Barney, B.S. Kristie Cavazos, B.A. Robert Devereaux, B.S. Dana Downs, M.S., M.S.W. Sharjeel Farooqui, M.D. Julia Smith, Psy.D. Kun-Ying H. Sung, B.S.

School of Medicine, The University of Texas San Antonio, San Antonio, Texas Investigator Mauricio Tohen, M.D., Dr.P.H., M.B.A., Principal Investigator

Referring and Interviewing Clinicians Suman Baddam, Psy.D. Charles L. Bowden, M.D.

Nancy Diazgranados, M.D., M.S. Craig A. Dike, Psy.D. Dianne E. Dunn, Psy.D., M.P.H. Elena Gherman, M.D. Jodi M. Gonzalez, Ph.D. Pablo Gonzalez, M.D. Phillip Lai, Psy.D.

Natalie Maples-Aguilar, M.A., L.P.A. Marlon P. Quinones, M.D. Jeslina J. Raj, Psy.D. David L. Roberts, Ph.D. Nancy Sandusky, R.N., F.P.M.H.N.P.-B.C., D.N.P.-C. Donna S. Stutes, M.S., L.P.C. Mauricio Tohen, M.D., Dr.PH, M.B.A. Dawn I. Velligan, Ph.D. Weiran Wu, M.D., Ph.D.

Referring Clinicians Albana Dassori, M.D. Megan Frederick, M.A.

Robert Gonzalez, M.D. Uma Kasinath, M.D. Camis Milam, M.D. Vivek Singh, M.D. Peter Thompson, M.D.

Research Coordinators Melissa Hernandez, B.A., Lead Research Coordinator Fermin Alejandro Carrizales, B.A. Martha Dahl, R.N., B.S.N. Patrick M. Smith, B.A. Nicole B. Watson, M.A.

Michael E. DeBakey VA Medical Center and the Menninger Clinic, Houston, Texas (Joint Study Site) Michael E. DeBakey VA Medical Center Investigator

Referring Clinicians

Laura Marsh, M.D., Principal Investigator

Sara Allison, M.D. Leonard Denney, L.C.S.W. Catherine Flores, L.C.S.W. Nathalie Marie, M.D. Christopher Martin, M.D. Sanjay Mathev^, M.D. Erica Montgomery, M.D. Gregory Scholl, P.A. Jocelyn Ulanday, M.D., M.P.H.

Referring and Interviewing Clinicians Shalini Aggarwal, M.D. Su Bailey, Ph.D. Minnete (Helen) Beckner, Ph.D. Crystal Clark, M.D. Charles Dejohn, M.D. Robert Garza, M.D. Aruna Gottumakkla, M.D. Janet Hickey, M.D. James Ireland, M.D. Mary Lois Lacey, A.P.R.N. Wendy Leopoulos, M.D. Laura Marsh, M.D. Deleene Menefee, Ph.D. Brian I. Miller, Ph.D. Candy Smith, Ph.D. Avila Steele, Ph.D. Jill Wanner, Ph.D. Rachel Wells, Ph.D. Kaki York-Ward, Ph.D.

Research Coordinators Sarah Neely Torres, B.S., Lead Research Coordinator Kathleen Grout, M.A. Lea Kiefer, M.P.H. Jana Tran, M.A.

Volunteer Research Assistants Catherine Clark Linh Hoang

Menninger Clinic Investigator Efrain Bleiberg, M.D., Principal Investigator

Refening and Interviewing Clinicians Jennifer Baumgardner, Ph.D. Elizabeth Dodd Conaway, L.C.S.W., B.C.D. Warren Christianson, D.O. Wesley Clayton, L.M.S.W. J. Christopher Fowler, Ph.D. Michael Groat, Ph.D. Edythe Harvey, M.D. Denise Kagan, Ph.D. Hans Meyer, L.C.S.W.

Segundo Robert-Ibarra, M.D. Sandhya Trivedi, M.D. Rebecca Wagner, Ph.D. Harrell Woodson, Ph.D. Amanda Yoder, L.C.S.W.

Referring Clinicians James Flack, M.D. David Ness, M.D.

Research Coordinators Steve Herrera, B.S., M.T., Lead Research Coordinator Allison Kalpakci, B.A.

Mayo Clinic, Rochester, Minnesota Investigators Mark A. Frye, M.D., Principal Iiwestigator Glenn E. Smith, Ph.D., Principal Investigator Jeffrey P. Staab M.D., M.S., Principal Investigator

Referring and Interviewing Clinicians Osama Abulseoud, M.D. Jane Cerhan, Ph.D. Julie Fields, Ph.D. Mark A. Frye, M.D. Manuel Fuentes, M.D. Yonas Geda, M.D. Maria Harmandayan, M.D. Reba King, M.D. Simon Kung, M.D. Mary Machuda, Ph.D. Donald McAlpine, M.D. Alastair McKean, M.D. Juliana Moraes, M.D. Teresa Rummans, M.D.

James R. Rundell, M.D. Richard Seime, Ph.D. Glenn E. Smith, Ph.D. Christopher Sola, D.O. Jeffrey P. Staab M.D., M.S. Marin Veldic, M.D. Mark D. Williams, M.D. Maya Yustis, Ph.D.

Research Coordinators Lisa Seymour, B.S., Lead Research Coordinator Scott Feeder, M.S. Lee Gunderson, B.S. Sherrie Hanna, M.A., L.P. Kelly Harper, B.A. Katie Mingo, B.A. Cynthia Stoppel, A.S.

other Study Staff Anna Frye Andrea Hogan

Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania Investigators Mahendra T. Bhati, M.D., Principal Investigator Mama S. Barrett, Ph.D., Co-investigator Michael E. Thase, M.D., Co-investigator

Referring and Interviewing Clinicians Peter B. Bloom, M.D. Nicole K Chalmers L.C.S.W. Torrey A. Creed, Ph.D. Mario Cristancho, M.D. Amy Cunningham, Psy.D. John P. Dennis, Ph.D. Josephine Elia, M.D. Peter Gariti, Ph.D., L.C.S.W. Philip Gehrman, Ph.D. Laurie Gray, M.D. Emily A.P. Haigh, Ph.D. Nora J. Johnson, M.B.A., M.S., Psy.D. Paulo Knapp, M.D. Yong-Tong Li, M.D. Bill Mace, Ph.D. Kevin S. McCarthy, Ph.D. Dimitri Perivoliotis, Ph.D. Luke Schultz, Ph.D. Tracy Steen, Ph.D. Chris Tjoa, M.D. Nancy A. Wintering, L.C.S.W.

Referring Clinicians Eleanor Ainslie, M.D. Kelly C. Allison, Ph.D.

Rebecca Aspden, M.D. Claudia F. Baldassano, M.D. Vijayta Bansal, M.D. Rachel A. Bennett, M.D. Richard Bollinger, Ph.D. Andrea Bowen, M.D. Karla Campanella, M.D. Anthony Carlino, M.D. Noah Carroll, M.S.S. Alysia Cirona, M.D. Samuel Collier, M.D. Andreea Crauciuc, L.C.S.W. Pilar Cristancho, M.D. Traci D'Almeida, M.D. Kathleen Diller, M.D. Benoit Dube, M.D. Jon Dukes, M.S.W. Lauren Elliott, M.D. Mira Elwell, B.A. Mia Everett, M.D. Lucy F. Faulconbridge, Ph.D. Patricia Furlan, Ph.D. Joanna Goldstein, L.C.S.W. Paul Grant, Ph.D. Jillian Graves, L.C.S.W. Tamar Gur, M.D., Ph.D. Alisa Gutman, M.D., Ph.D. Nora Hymowitz, M.D. Sofia Jensen, M.D. Tiffany King, M.S.W. Katherine Levine, M.D.

Alice Li, M.D. Janet Light, L.C.S.W. John Listerud, M.Dy, Ph.D. Emily Malcoun, Ph.D. Donovan Maust, M.D. Adam Meadows, M.D. Michelle Moyer, M.D. Rebecca Naugle, L.C.S.W. Cory Newman, Ph.D. John Northrop, M.D., Ph.D. Elizabeth A. ElUs Ohr, Psy.D. John O'Reardon, M.D. Abraham Pachikara, M.D. Andrea Perelman, M.S.W. Diana Perez, M.S.W. Bianca Previdi, M.D. J. Russell Ramsay, Ph.D. Jorge Rivera-Colon, M.D. Jan Smedley, L.C.S.W. Katie Struble, M.S.W. Aita Susi, M.D. Yekaterina Tatarchuk, M.D. Ellen Tarves, M.A. Allison Tweedie, M.D. Holly Valerio, M.D.

Thomas A. Wadden, Ph.D. Joseph Wright, Ph.D. Yan Xuan, M.D. David Yusko, Psy.D.

Research Coordinators Jordan A. Coello, B.A., Lead Research Coordinator Eric Wang, B.S.E.

Volunteer Research Assistants/ Interns Jeannine Barker, M.A., A.T.R. Jacqueline Baron Kelsey Bogue Alexandra Ciomek Martekuor Dodoo, B.A. Julian Domanico Laura Heller, B.A. Leah Hull-Rawson, B.A. Jacquelyn Klehm, B.A. Christina Lam Dante Proetto, B.S. Molly Roy Casey Shannon

Stanford University Scliool of Medicine, Stanford, California Investigators Carl Feinstein, M.D., Principal Investigator Debra Safer, M.D., Principal Investigator

Referring and Interviewing Clinicians Kari Berquist, Ph.D. Eric Clausell, Ph.D. Danielle Colbom, Ph.D. Whitney Daniels, M.D. Ahson Darcy, Ph.D. Krista Fielding, M.D. Mina Fisher, M.D. Kara Fitzpatrick, Ph.D. Wendy Froehlich, M.D. Grace Gengoux, Ph.D. Anna Cassandra Golding, Ph.D. Lisa Groesz, Ph.D. Kyle Hinman, M.D. Rob Holaway, Ph.D. Matthew Holve, M.D. Rex Huang, M.D. Nina Kirz, M.D. Megan Klabunde, Ph.D. John Leckie, Ph.D. Naomi Leslie, M.D. Adrianne Lona, M.D. Ranvinder Rai, M.D. Rebecca Rialon, Ph.D. Beverly Rodriguez, M.D., Ph.D. Debra Safer, M.D. Mary Sanders, Ph.D.

Jamie Scaletta, Ph.D. Norah Simpson, Ph.D. Manpreet Singh, M.D. Maria-Christina Stewart, Ph.D. Melissa Valias, M.D. Patrick Whalen, Ph.D. Sanno Zack, Ph.D.

Referring Clinicians Robin Apple, Ph.D. Victor Carrion, M.D. Carl Feinstein, M.D. Qhristine Gray, Ph.D. Antonio Hardan, M.D. Megan Jones, Psy.D. Linda Lotspeich, M.D. Lauren Mikula, Psy.D. Brandyn Street, Ph.D. Violeta Tan, M.D. Heather Taylor, Ph.D. Jacob Towery, M.D. Sharon Williams, Ph.D.

Research Coordinators Kate Amow, B.A., Lead Research Coordinator Nandini Datta, B.S. Stephanie Manasse, B.A.

Volunteer Research Assistants/ Interns Arianna Martin, M.S. Adriana Nevado, B.A.

Children’s Hospital Colorado, Aurora, Colorado Investigator Marianne Wamboldt, M.D., Principal Investigator

Referring and Interviewing Clinicians Galia Abadi, M.D. Steven Behling, Ph.D. Jamie Blume, Ph.D. Adam Burstein, M.D. Debbie Carter, M.D. Kelly Caywood, Ph.D. Meredith Chapman, M.D. Paulette Christian, A.P.P.M.H.N. Mary Cook, M.D. Anthony Cordaro, M.D. Audrey Dumas, M.D. Guido Frank, M.D. Karen Frankel, Ph.D. Darryl Graham, Ph.D. Yael Granader, Ph.D. Isabelle Guillemet, M.D. Patrece Hairston, Ph.D. Charles Harrison, Ph.D. Tammy Herckner, L.C.S.W. Cassie Karlsson, M.D. Kimberly Kelsay, M.D. David Kieval, Ph.D. Megan Klabunde, Ph.D. Jaimelyn Kost, L.C.S.W. Harrison Levine, M.D. Raven Lipmanson, M.D. Susan Lurie, M.D. Asa Marokus, M.D. Idalia Massa, Ph.D. Christine McDunn, Ph.D. Scot McKay, M.D. Marissa Murgolo, L.C.S.W. Alyssa Oland, Ph.D. Lina Patel, Ph.D. Rheena Pineda, Ph.D. Gautam Rajendran, M.D. Diane Reichmuth, Ph.D Michael Rollin, M.D.

Marlena Romero, L.C.S.W. Michelle Roy, Ph.D. Celeste St. John-Larkin, M.D. Elise Sannar, Ph.D. Daniel Savin, M.D. Claire Dean Sinclair, Ph.D. Ashley Smith, L.C.S.W. Mindy Solomon, Ph.D. Sally Tarbell, Ph.D. Helen Thilly, L.C.S.W. Sara Tlustos-Carter, Ph.D. Holly Vause, A.P.P.M.H.N Mariarme Wamboldt, M.D. Angela Ward, L.C.S.W. Jason Williams, Ph.D. Jason Willoughby, Ph.D. Brennan Young, Ph.D.

Referring Clinicians Kelly Bhatnagar, Ph.D. Jeffery Dolgan, Ph.D. Jennifer Eichberg, L.C.S.W. Jennifer Hagman, M.D. James Masterson, L.C.S.W. Hy Gia Park, M.D. Tami Roblek, Ph.D. Wendy Smith, Ph.D. David Williams, M.D.

Research Coordinators Laurie Burnside, M.S.M., C.C.R.C., Lead Research Coordinator Darci Anderson, B.A., C.C.R.C. Heather Kennedy, M.P.H. Amanda Millar, B.A. Vanessa Waruinge, B.S. Elizabeth Wallace, B.A.

Volunteer Research Assistants/ Interns Wisdom Amouzou Ashley Anderson Michael Richards Mateya Whyte

Baystate Medioal Center, Springfield, Massachusetts Investigators

Referring and Interviewing Clinicians

Bruce Waslick, M.D., Principal Investigator Cheryl Bonica, Ph.D., Co-investigator John Fanton, M.D., Co-investigator Barry Sarvet, M.D., Co-investigator

Julie Bermant, R.N., M.S.N., N.P. Cheryl Bonica, Ph.D. Jodi Devine, L.I.C.S.W. William Fahey, Ph.D. John Fanton, M.D.

Sarah Marcotte, L.C.S.W. Patricia Rogowski, R.N., C.N.S.

Stephane Jacobus, Ph.D. Barry Sarvet, M.D. Peter Thunfors, Ph,.D. Bruce Waslick, M.D. Vicki Weld, L.I.C.S.W. Sara Wiener, L.I.C.S.W. Shadi Zaghloul, M.D.

Research Coordinators Julie Kingsbury, C.C.R.P., Lead Research Coordinator Brenda Martin, B.A.

Referring Clinicians Sarah Detenber, L.I.C.S.W. Gordon Garrison, L.I.C.S.W. Jacqueline Humpreys, L.I.C.S.W. Noreen McGirr, L.I.C.S.W.

Volunteer Research Assistant/ Intern Liza Detenber

New York state Psychiatric Institute, New York, N.Y., Weill Cornell Medical College, Payne Whitney and Westchester Divisions, New York and White Plains, N.Y., and North Shore Child and Family Guidance Center, Roslyn Heights, N.Y. (Joint Study Site) Investigator

Volunteers

Prudence W. Fisher, Ph.D., Principal Investigator

Preeya Desai Samantha Keller Jeremy Litfin, M.A. Sarah L. Pearlstein, B.A. Cedilla Sacher

Research Coordinators Julia K. Carmody, B.A., Lead Research Coordinator Zvi R. Shapiro, B.A., Lead Research Coordinator

New York State Psychiatric Institute Refening and Interviewing Clinicians Michele Cohen, L.C.S.W. Eduvigis Cruz-Arrieta, Ph.D. Miriam Ehrensaft, Ph.D. Laurence Greenhill, M.D. Schuyler Henderson, M.D., M.P.H. Sharlene Jackson, Ph.D. Lindsay Moskowitz, M.D. Sweene C. Oscar, Ph.D. Xenia Protopopescu, M.D. James Rodriguez, Ph.D. Gregory Tau, M.D. Melissa Tebbs, L.C.S.W. Carolina Velez-Grau, L.C.S.W. Khadijah Booth Watkins, M.D.

Referring Clinicians George Alvarado, M.D. Alison Baker, M.D. Elena Baron, Psy.D. Lincoln Bickford, M.D., Ph.D. Zachary Blumkin, Psy.D. Colleen Cullen, L.C.S.W. Chyristianne DeAlmeida, Ph.D. Matthew Ehrlich, M.D.

Eve Friedl, M.D. Clare Gaskins, Ph.D. Alice Greenfield, L.C.S.W. Liora Hoffman, M.D. Kathleen Jung, M.D. Karimi Mailutha, M.D., M.P.H. Valentina Nikulina, Ph.D. Tal Reis, Ph.D. Moira Rynn, M.D. Jasmine Sawhney, M.D. Sarajbit Singh, M.D. Katherine Stratigos, M.D. Oliver Stroeh, M.D. Russell Tobe, M.D. Meghan Tomb, Ph.D. Michelle Tricamo, M.D.

Research Coordinators Angel A. Caraballo, M.D. Erica M. Chin, Ph.D. Daniel T. Chrzanowski, M.D. Tess Dougherty, B.A. Stephanie Hundt, M.A. Moira A. Rynn, M.D. Deborah Stedge, R.N.

Weill Cornell Medical College, Payne Whitney and Westchester Divisions Referring and Interviewing Clinicians Archana Basu, Ph.D. Shannon M. Bennett, M.D. Maria De Pena-Nowak, M.D. Jill Feldman, L.M.S.W. Dennis Gee, M.D. Jo R. Hariton, Ph.D. Lakshmi P. Reddy, M.D. Margaret Yoon, M.D.

Jodi Gold, M.D. Tejal Kaur, M.D. Aaron Krasner, M.D. Amy Miranda, L.C.S.W. Cynthia Pfeffer, M.D. James Rebeta, Ph.D. Sharon Skariah, M.D. Jeremy Stone, Ph.D. Dirk Winter, M.D.

Referring Clinicians

Research Coordinators

Margo Benjamin, M.D. Vanessa Bobb, M.D. Elizabeth Bochtler, M.D. Katie Cave, L.C.S.W. Maalobeeka Gangopadhyay, M.D.

Alex Eve Keller, B.S., Lead Research Coordinator Nomi Bodner (volunteer) Barbara L. Flye, Ph.D. Jamie S. Neiman (volunteer) Rebecca L. Rendleman, M.D.

North Shore Child and Family Guidance Center Referring and Interviewing Clinicians Casye Brachfeld-Launer, L.C.S.W. Susan Klein Cohen, Ph.D. Amy Gelb, L.C.S.W.-R. Jodi Glasser, L.C.S.W. Elizabeth Goulding-Tag, L.C.S.W. Deborah B. Kassimir, L.C.S.W. Margo Posillico Messina, L.C.S.W. Andréa Moullin-Heddle, L.M.S.W. Lisa Pineda, L.C.S.W. Elissa Smilowitz, L.C.S.W.

Referring Clinicians Regina Barros-Rivera, L.C.S.W.-R. Assistant Executive Director Maria Christiansen, B.S. Amy Davies-Hollander, L.M.S.W. Eartha Hackett, M.S.Ed., M.Sc., B.Sc.

Bruce Kaufstein, L.C.S.W.-R, Director of Clinical Services Kathy Knaust, L.C.S.W. John Levinson, L.C.S.W.-R, B.C.D. Andrew Maleckoff, L.C.S.W., Executive Director/CEO Sarah Rosen, L.C.S.W.-R, A.C.S.W. Abigail Rothenberg, L.M.S.W. Christine Scotten, A.C.S.W. Michelle Spatano, L.C.S.W.-R. Diane Straneri, M.S., R.N., C.S. Rosara Torrisi, L.M.S.W. Rob Vichnis, L.C.S.W.

Research Coordinators Toni Kolb-Papetti, L.C.S.W. Sheena M. Dauro (volunteer)

DSM-5 Field Trials Pilot Study, Johns Hopkins Medical institution, Baltimore, Maryland A d u lt S a m p le

Community Psychiatry Outpatient Program, Department of Psychiatry and Behavioral Sciences Main Campus Investigators

Referring and Interviewing Clinicians

Emily Lorensen, L.C.S.W.-C. Kathleen Malloy, L.C.P.C. Gary Pilarchik, L.C.S.W.-C Holly Slater, L.C.P.C. Stanislav Spivak, M.D. Tarcia Spencer Turner, L.C.P.C. Nicholas Seldes Windt, L.C.S.W.-C.

Bernadette Cullen, M.B., B.Ch., B.A.O. Shane Grant, L.C.S.W.-C. Charee Green, L.C.P.C.

Mellisha McKitty, B.A. Alison Newcomer, M.H.S.

Bernadette Cullen, M.B., B.Ch., B.A.O., Principal Investigator Holly C. Wilcox, Ph.D., Principal Investigator

Research Coordinators

P e d ia tric S a m p le

Child and Adölescent Outpatient Program, Department of Psycliiatry and Behavioral Sciences Bayview Medical Center Investigators Joan P. Gerring, M.D., Principal Investigator Leslie Miller, M.D., Principal Investigator Holly C. Wilcox, Ph.D., Co-investigator

Referring and Interviewing Clinicians Shannon Barnett, M.D. Gwen Condon, L.C.P.C. Brijan Fellows, L.C.S.W.-C. Heather Gamer, L.C.S.W.-C. Joan P. Gerring, M.D.

Anna Gonzaga, M.D. Debra Jenkins, L.C.S.W.-C. Paige N. Johnston, L.C.P.C. Brenda Memel, D.N.P., R.N. Leslie Miller, M.D. Ryan Moore, L.C.S.W.-C. Shauna Reinblatt, M.D. Monique Vardi, L.C.P.C.

Research Coordinators Mellisha McKitty, B.A. Alison Newcomer, M.H.S.

DSM-5 Field Trials in Routine Clinical Practice Settings: Collaborating Investigators Archil Abashidze, M.D. Francis R. Abueg, Ph.D. Jennifer Louise Accuardi, M.S. Balkozar S. Adam, M.D. Miriam E. Adams, Sc.D., M.S.W., L.I.C.S.W. Suzanna C. Adams, M.A. Lawrence Adler, M.D. Rownak Afroz, M.D. Khalid I. Afzal, M.D. Joseph Alimasuya, M.D. Emily Allen, M.S. Katherine A. Allen, L.M.F.T., M.A. William D. Allen, M.S. Jafar AlMashat, M.D. Anthony T. Alonzo, D.M.F.T. Guillermo Alvarez, B.A., M.A. Angela Amoia-Lutz, L.M.F.T. Krista A. Anderson, M.A., L.M.F.T. Lisa R. Anderson, M.Ed., L.C.P.C. Pamela M. Anderson, L.M.F.T. Shannon N. Anderson, M.A., L.P.C., N.C.C. Eric S. Andrews, M.A. Vicki Arbuckle, M.S., Nursing(N.P.) Namita K. Arora, M.D. Darryl Arrington, M.A. Bearlyn Y. Ash, M.S. Wylie J. Bagley, Ph.D. Kumar D. Bahl, M.D. Deborah C. Bailey, M.A., M.S., Ph.D. Carolyn Baird, D.N.P., M.B.A., R.N.-B.C., C.A.R.N.-A.P., I.C.C.D.P.D. Joelle Bangsund M.S.W. Maria Baratta, M.S.W., Ph.D. Stan Barnard, M.S.W. Deborah Barnes, M.S.

Margaret L. Barnes, Ph.D. David Bamum, Ph.D. Raymond M. Baum, M.D. Edward Wescott Beal, M.D. Michelle Beaudoin, M.A. Ernest E. Beckham, Ph.D. Lori L. Beckwith, M.Ed Emmet Bellville, M.A. Randall E. Bennett, M.A. Lynn Benson, Ph.D. Robert Scott Benson, M.D. Linda Benton, M.S.W. Ditza D. Berger, Ph.D. Louise I. Bertman, Ph.D. Robin Bieber, M.S., L.M.F.T. Diana M. Bigham, M.A. David R. Blackburn, Ph.D. Kelley Blackwell, L.M.F.T. Lancia Blatchley, B.A., L.M.F.T. Stacey L. Block, L.M.S.W., A.C.S.W. Karen J. Bloodworth, M.S., N.C.C., L.P.C. Lester Bloomenstiel, M.S. Christine M. Blue, D.O. Marina Bluvshtein, Ph.D. Callie Gray Bobbitt, M.S.W., L.C.S.W. Moses L. Boone, Jr., L.M.S.W., B.C.D. Steffanie Boudreau-Thomas, M.A.-L.P.C. Jay L. Boulter, M.A. Aaron Daniel Bourne, M.A. Helen F. Bowden, Ph.D. Aryn Bowley-Safranek, B.S., M.S. Elizabeth Boyajian, Ph.D. Beth K. Boyarsky, M.D. Gail M. Boyd, Ph.D. Jeffrey M. Brandler, Ed.S., C.A.S., S.A.P.

Sandra L. Branton, Ed.D. Karen J. Brocco-Kish, M.D. Kristin Brooks, P.M.H.N.P. Ann Marie Brown, M.S.W. Philip Brown, M.S.W. Kellie Buckner, Ed.S. Richard Bunt, M.D. Neil P. Buono, D.Min. Janice Bureau, M.S.W., L.C.S.W. Kimlee Butterfield, M.S.W. Claudia Byrne, Ph.D. Quinn Callicott, M.S.W., L.C.S.W. Alvaro Camacho, M.D., M.P.H. Sandra Cambra, Ph.D. Heather Campbell, M.A. Nancy Campbell, Ph.D., M.S.W. Karen Ranee Canada, L.M.F.T. Joseph P. Cannavo, M.D. Catherine P. Caporale, Ph.D. Frederick Capps, Ph.D., M.S. Rebecca J. Carney, M.B.A., M.A., L.M.H.C. Kelly J. Carroll, M.S.W. Richard W. Carroll, Ph.D., L.P.C., A.C.S. Sherry Casper, Ph.D. Joseph A. Catania, L.I.S.W.S., L.C.D.C. Ill Manisha P. Cavendish, Ph.D. Kenneth M. Certa, M.D. Shambhavi Chandraiah, M.D. Calvin Chatlos, M.D. Daniel C. Chen, M.D. Darlene Cheryl, M.S.W. Matthew R. Chirman, M.S. Carole A. Chisholm, M.S.W. Shobha A. Chottera, M.D. Joseph Logue Christenson, M.D. Pamela Christy, Psy.D. Sharon M. Freeman Clevenger, Ph.D., P.M.H.C.N.S.-B.C. Mary Ann Cohen, M.D. Mitchell J. Cohen, M.D. Diego L. Coira, M.D. Melinda A. Lawless Coker, Psy.D. Carol Cole, M.S.W., L.C.S.W. Caron Collins, M.A., L.M.F.T. Wanda Collins, M.S.N. Linda Cook Cason, M.A. Ayanna Cooke-Chen, M.D., Ph.D. Heidi B. Cooperstein, D.O. Ileana Corbelle, M.S.W. Kimberly Corbett, Ph.D. Angelina Cordova, M.A.Ed. Jennifer Carol Cox, L.P.C. Sheree Cox, M.A., R.N., N.C.C., D.C.C., L.M.H.C. William Frederick Cox, M.D. Sally M. Cox, M.S.Ed. Debbie Herman Crane, M.S.W. Arthur Ray Crawford, III, Ph.D.

Roula Creighton, M.D. John R. Crossfield, L.M.H.C. Sue Cutbirth, R.N., M.S.N, C.S., P.M.H.N.P. Marco Antonio Cuyar, M.S. Rebecca Susan Daily, M.D. Lori S. Danenberg, Ph.D. Chan Dang-Vu, M.D. Mary Hynes Danielak, Psy.D. Cynthia A. Darby, M.Ed., Ed.S. Douglas Darnall, Ph.D. Christopher Davidson, M.D. Doreen Davis, Ph.D., L.C.S.W. Sandra Davis, Ph.D., L.M.H.C., N.C.C. Walter Pitts Davis, M.Th. Christian J. Dean, Ph.D. Kent Dean, Ph.D. Elizabeth Dear, M.A. Shelby DeBause, M.A. Rebecca B. DeLaney, M.S.S.W., L.C.S.W., B.C.D. John R. Delatorre, M.A. Frank DeLaurentis, M.D. Eric Denner, M.A., M.B.A. Mary Dennihan, L.M.F.T. Kenny Dennis, M.A. Pamela L. Detrick, Ph.D., M.S., F.N.P.-B.C., P.M.H.N.P.-B.C., R.N.-B.C., C.A.P., G.C.A.C. Robert Detrinis, M.D. Daniel A. Deutschman, M.D. Tania Diaz, Psy.D. Sharon Dobbs, M.S.W., L.C.S.W. David Doreau, M.Ed. Gayle L. Dosher, M.A. D’Ann Downey, Ph.D., M.S.W. Beth Doyle, M.A. Amy J. Driskill, M.S., L.C.M.F.T. James Drury, M.D. Brenda-Lee Duarte, M.Ed. Shane E. Dulemba, M.S.N. Nancy R. G. Dunbar, M.D. Cathy Duncan, M.A. Rebecca S. Dunn, M.S.N., A.R.N.P. Debbie Earnshaw, M.A. Shawna Eddy-Kissell, M.A. Momen El Nesr, M.D. Jeffrey Bruce Elliott, Psy.D. Leslie Ellis, Ph.D. Donna M. Emfield, L.C.P.C. Gretchen S. Enright, M.D. John C. Espy, Ph.D. Renuka Evani, M.B.B.S., M.D. Heather Evans, M.S.Ed, L.P.C.N.C.C. Cesar A. Fabiani, M.D. Fahim Fahim, M.D. Samuel Fam, M.D. Edward H. Fankhanel, Ph.D., Ed.D. Tamara Farmer, M.S.N, A.R.N.P. Farida Farzana, M.D.

Philip Fast, M.S. Patricia Feltrup-Exum, M.A.M.F.T. Hector J. Femandez-Barillas, Ph.D. Julie Ferry, M.S.W., L.I.C.S.W. Jane Fink, Ph.D., M.S.S.A. Kathy Finkle, L.P.C.M.H. Steven Finlay, Ph.D. Rik Fire, M.S.W., L.C.S.W. Ann Flood, Ph.D. Jeanine Lee Foreman, M.S. Thyra Fossum, Ph.D. Karen S. Franklin, L.I.C.S.W. Sherre K. Franklin, M.A. Helen R. Frey, M.A., E.D. Michael L. Freytag, B.S., M.A. Beth Gagnon, M.S.W. Patrice L.R. Gallagher, Ph.D. Angela J. Gallien, M.A. Robert Gallo, M.S.W. Mario Galvarino, M.D. Vladimir L Gasca, M.D. Joshua Gates, Ph.D. Anthony Gaudioso, Ph.D. Michelle S. Gauthier, A.P.R.N., M.S.N, P.M.H.N.P.-B.C. Rachel E. Gearhart, L.C.S.W. Stephen D. Gelfond, M.D. Nancy S. Gerow, M.S. Michael J. Gerson, Ph.D. Susan M. A. Geyer, L.M.S.W. Lorrie Gfeller-Strouts, Ph.D. Shubu Ghosh, M.D. Richard Dorsey Gillespie, M.Div. Stuart A. Gitlin, M.S.S.A. Jeannette E. Given, Ph.D. Frances Gizzi, L.C.S.W. Stephen L Glicksman, Ph.D. Martha Glisky, Ph.D. Sonia Godbole, M.D. Howard M. Goldfischer, Psy.D. Mary Jane Gonzalez-Huss, Ph.D. Michael L Good, M.D. Dawn Goodman-Martin, M.A.-L.M.H.C. Robert Gorkin, Ph.D., M.D. JeffGorski, M.S.W. Linda O. Graf, M.Ed., L.C.P.C. Ona Graham, Psy.D. Aubrie M. Graves, L.M.S.W., C.A.S.A.C. Howard S. Green, M.D. Karen Torry Green, M.S.W. Gary Greenberg, Ph.D. Marjorie Greenhut, M.A. James L. Greenstone, Ed.D., J.D. Raymond A. Griffin, Ph.D. Joseph Grillo, Ph.D. Janeane M. Grisez, A.A., B.A. Lawrence S. Gross, M.D. Robert J. Gross, M.D.

Sally J. Grosscup, Ph.D. Philip A. Grossi, M.D. Gabrielle Guedet, Ph.D. Nicholas Guenzel, B.A., B.S., M.S.N. Mary G. Hales, M.A. Tara C. Haley, M.S., L.M.F.T. John D. Hall, M.D. Amy Hammer, M.S.W. Michael S. Hanau, M.D. Linda K.W. Hansen, M.A., L.P. Genevieve R. Hansler, M.S.W. Mary T. Harrington, L.C.S.W. Lois Hartman, Ph.D. Steven Lee Hartsock, Ph.D., M.S.W. Victoria Ann Harwood, M.S.W., L.C.S.W. Rossi A. Hassad, Ph.D., M.P.H. Erin V. Hatcher, M.S.N. Richard L. Hauger, M.D. Kimberly M. Haverly, M.A. Gale Eisner Heater, M.S., M.F.T. Katlin Hecox, M.A. Brenda Heideman, M.S.W. Melinda Heinen, M.Sc. Marie-Therese Heitkamp, M.S. Melissa B. Held, M.A. Jessica Hellings, M.D. Bonnie Helmick-O'Brien, M.A., L.M.F.T. MaLinda T. Henderson, M.S.N, F.P.M.H.N.P. Gwenn Herman, M.S.W. Martha W. Hernandez, M.S.N, A.P.R.N., P.M.H.C.N.S. Robin L. Hewitt, M.S. Kenneth Hoffman, Ph.D. Patricia E. Hogan, D.O. Peggy Holcomb, Ph.D. Garland H. Holloman, Jr., M.D. Kimberly Huegel, M.S.W., L.C.S.W. Jason Hughes, L.P.C.-S., N.C.C. Jennifer C. Hughes, Ph.D., M.S.W., L.LS.W.-S. Michelle K. Humke, M.A. Judith G. Hunt, L.M.F.T. Tasneem Hussainee, M.D. Sharlene J. Hutchinson, M.S.N. Muhammad Ikram, M.D. Sunday Ilechukwu, M.D., D.Psy. Cli. Douglas H. Ingram, M.D. Marilynn Irvine, Ph.D. Marjorie Isaacs, Psy.D. Raymond Isackila, Ed.S., P.C.C.-S., L.I.C.D.C. Mohammed A. Issa, M.D. John L. Jankord, M.A. Barbara P. Jannah, L.C.S.W. C. Stuart Johnson, M.S. Dawn M. Johnson, M.A. Deanna V. Johnson, M.S., A^P.R.N., B.C. Eric C. Johnson, M.F.T. Joy Johnson, Ph.D., L.C.S.W. Willard Johnson, Ph.D.

Xenia Johnson-Bhembe, M.D. Vann S. Joines, Ph.D. Margaret Jones, Psy.D. Patricia Jorgenson, M.S.W. Steven M. Joseph, M.D. Taylere Joseph, M.A. Jeanette M. Joyner-Craddock, M.S.S.W. Melissa Kachapis, M.A. Charles T. Kaelber, M.D. Aimee C. Kaempf, M.D. Peter Andrew Kahn, M.D. Robert P. Kahn-Rose, M.D. Maher Karam-Hage, M.D. Todd H. Kasdan, Ph.D. Karen Kaufman, M.S., L.M.F.T. Rhesa Kaulia, M.A., M.F.T. Debbie Lynn Kelly, M.S.N, P.M.H.N.P.-B.C. W. Stephen Kelly, Ph.D. Selena Kennedy, M.A. Judith A. Kenney, M.S., L.P.C. Mark Patrick Kerekes, M.D. Alyse Kerr, M.S., N.C.C., N.A.D.D.-C.C., L.P.C. Karen L. Kerschmann, L.C.S.W. Marcia Kesner, M.S. Ashan Khan, Ph.D. Shaukat Khan, M.D. Audrey Khatchikian, Ph.D. Laurie B. Kimmel, M.S.W. Jason H. King, Ph.D. Nancy Leigh King, M.S.W., L.C.S.W., L.C.A.S. Kyle Kinne, M.S.C Cassandra M. Klyman, M.D. David R. Knapp, L.C.S.W. Margaret Knerr, M.S. Michael R. Knox, Ph.D. Carolyn Koblin, M.S. Valerie Kolbert, M.S., A.R.N.P.-B.C. Heather Koontz, M.S.W. Faye Koop, Ph.D., L.C.M.F.T. Fern M. Kopakin, M.S.W., L.C.S.W. Joel Kotin, M.D. Sharlene K. Kraemer, M.S.E. Marjorie Vego Krausz, M.A., Ed.D. Nancy J. Krell, M.S.W. Mindy E. Kronenberg, Ph.D. EHvayne Kruse, M.S., M.F.T. Ajay S. Kuchibhatla, M.D. Shubha N. Kumar, M.D. Helen H. Kyomen, M.D., M.S. Rebecca M. Lachut, M.Ed., Ed.S. Alexis Lake, M.S.S. Ramaswamy Lakshmanan, M.D. Brigitta Lalone, L.C.S.W.-R John W. Lancaster, Ph.D. Patience R. Land, L.I.C.S.W., M.S.W., M.P.A. Amber Lange, M.A., Ph.D. Jeff K. Larsen, M.A. Nathan E. Lavid, M.D.

Michelle Leader, Ph.D. Stephen E. Lee, M.D. Cathryn L. Leff, Ph.D., L.M.F.T. Rachael Kollar Leombruno, L.M.F.T. Arlene I. Lev, M.S.W., L.C.S.W.-R Gregory K. Lewis, M.A.-L.M.F.T. Jane Hart Lewis, M.S. Melissa S. Lewis, M.S.W., L.I.C.S.W. Norman Gerald Lewis, F.R.A.N.Z.C.P. Robin Joy Lewis, Ph.D. Ryan Michael Ley, M.D. Tammy R. Lias, M.A. Russell F. Lim, M.D. Jana Lincoln, M.D. Ted Lindberg, L.M.S.W., L.M.F.T., M.S.W. Peggy Solow Liss, M.S.W. Andrea Loeb, Psy.D. William David Lohr, M.D. Mary L. Ludy, M.A., L.M.H.C., L.M.F.T. Nathan Lundin, M.A., L.P.C. Veena Luthra, M.D. Patti Lyerly, L.C.S.W. Denise E. Maas, M.A. Silvia MacAllister, L.M.F.T. Nicola MacCallum, M.S., M.F.C. Therapy Colin N. MacKenzie, M.D. Cynthia Mack-Emsdorff, Ph.D. John R. Madsen-Bibeau, M.S., M.Div Christopher J. Maglio, Ph.D. Deepak Mahajan, M.D. Debra Majewski, M.A. Harish Kumar Malhotra, M.D. Pamela Marcus, R.N., M.S. Mary P. Marshall, Ph.D. Flora Lynne Martin, M.A., L.P.C., A.D.C. Robert S. Martin, M.D. Jennifer L. Martinez, M.S. Ninfa Martinez-Aguilar, M.A., M.F.T. Emily Martinsen, M.S.W. Farhan A. Matin, M.D. Janus Maybee, P.M.H.N.P. Karen Mazarin-Stanek, M.A. Eben L. McClenahan, M.D., M.S. Jerlyn C. McCleod, M.D. Susan E. McCue, M.S.W., L.C.S.W. Kent D. McDonald, M.S. Daniel McDonnell, M.S.N, P.M.H.-N.P. Robert McElhose, Ph.D. Lisa D. McGrath, Ph.D. Mark McGrosky, M.S.W. Katherine M. McKay, Ph.D. Darren D. McKinnis, M.S.W. Mona McNelis-Broadley, M.S.W., L.C.S.W. Rick McQuistion, Ph.D. Susan Joy Mendelsohn, Psy.D. Barbara S. Menninga, M.Ed. Hindi Mermelstein, M.D., F.A.P.M. Rachel B. Michaelsen, M.S.W.

Thomas F. Micka, M.D. Tonya Miles, Psy.D. Matthew Miller, M.S. Michael E. Miller, M.D. Noel Miller, L.M.S.W., M.B.A., M.P.S. Kalpana Miriyala, M.D. Sandra Moenssens, M.S. Erin Mokhtar, M.A. Robert E. Montgomery, M.Ed. Susan Moon, M.A. Theresa K. Moon, M.D. David B. Moore, B.A., M.Div., M.S.S.W., Ph.D. Joanne M. Moore, M.S. Peter I. M. Moran, M.B.B.Ch. Anna Moriarty, M.P.S., L.P.C., L.M.H.C. Richard Dean Morris, M.A. Michael M. Morrison, M.A. Carlton E. Munson, Ph.D. Timothy A. Murphy, M.D. Beth L. Murphy, Psy.D. Melissa A. Myers, M.D. Stefan Nawab, M.D. Allyson Matney Neal, D.N.P. Steven Nicholas, M.A. Aurelian N. Niculescu, M.D. Earl S. Nielsen, Ph.D. Terry Oleson, Ph.D. Julianne R. Oliver, B.S., M.S., Ph.D. Robert O. Olsen, M.D. Amy O’Neill, M.D. Oscar H. Oo, Psy.D., A.B.P.P. Laurie Orlando, J.D., M.A. Jill Osborne, M.S., Ed.S. Kimberly Overlie, M.S. L. Kola Oyev^umi, Ph.D. Zachary J. Pacha, M.S.W. Suzette R. Papadakis, M.S. Amanda C. Parsons, M.A., L.P.C.C. Lee R. Pate, B.A., M.A. Eric L. Patterson, L.P.C. Sherri Paulson, M.Ed., L.S.C.W. Peter Dennis Pautz, B.A., M.S.W. Malinda J. Perkins, M.S.W., L.C.S.W. Eleanor F. Perlman, M.S.W. Deborah K. Perry, M.S.W. Amanda Peterman, L.M.F.T. Shawn Pflugardt, Psy.D. Robert J. Dean Phillips, M.S. Laura Pieper, M.S.W., L.C.S.W. Lori D. Pink, M.S.W., B.C.D Michael G. Pipich, M.S., L.M.F.T. Cynthia G. Pizzulli, M.S.W., Ph.D. Kathy C. Points, M.A. Marya E. Pollack, M.D., M.P.H. Sanford E. Pomerantz, M.D. Eva Ponder, M.S.W., Psy.D. Ernest Poortinga, M.D. David Post, M.D.

Laura L. Post, M.D., Ph.D., J.D. Patrick W. Powell, Ed.D. Beth M. Prewett, Psy.D. Robert Price, D.C.C., M.Ed. John Pruett, M.D. Aneita S. Radov, M.A. Dawn M. Raffa, Ph.D. Kavitha Raja, M.D. Ranjit Ram, M.D. Mohamed Ibrahim Ramadan, M.D., M.S. Christopher S. Randolph, M.D. Nancy Rappaport, M.Ed. John Moir Rauenhorst, M.D. Laurel Jean Rebenstock, L.M.S.W. Edwin Renaud, Ph.D. Heather J. Rhodes, M.A. Jennifer S. Ritchie-Goodline, Psy.D. Daniel G. Roberts, M.A. Brenda Rohren, M.A., M.F.S., L.LM.H.P., L.A.D.C., M.A.C. Donna G. Rolin-Kenny, Ph.D., A.P.R.N., P.M.H.C.N.S.-B.C. Sylvia E. Rosario, M.Ed. Mindy S. Rosenbloom, M.D. Harvey A. Rosenstock, M.D. Thalia Ross, M.S.S.W. Fernando Rosso, M.D. Barry H. Roth, M.D. Thomas S. Rue, M.A., L.M.H.C. Elizabeth Ruegg, L.C.S.W. Diane Rullo, Ph.D. Angie Rumaldo, Ph.D. Eric Rutberg, M.A., D.H.Ed. Joseph A. Sabella, L.M.H.C. Kemal Sagduyu, M.D. Adam H. Saltz, M.S.W. Jennifer A. Samardak, L.LS.W.-S. George R. Samuels, M.A., M.S.W. Carmen Sanjurjo, M.A. John S. Saroyan, Ed.D. Brigid Kathleen Sboto, M.A., M.F.T. Lori Cluff Schade, M.S. Joan E. Schaper, M.S.N. Rae J. Schilling, Ph.D. Larry Schor, Ph.D. Donna J. Schwartz, M.S.W., L.I.C.S.W. Amy J. Schwarzenbart, P.M.H.-C.N.S., B.C., A.P.N.P. John V. Scialli, M.D. Chad Scott, Ph.D., L.P.C.C. Sabine Sell, M.F.T. Minal Shah, N.S., N.C.C., L.P.C. Lynn Shell, M.S.N. Dharmesh Navin Sheth, M.D. S. Christopher Shim, M.D. Marta M. Shinn, Ph.D. Andreas Sidiropoulos, M.D., Ph.D. Michael Siegell, M.D.

Michael G. Simonds, Psy.D. Gagandeep Singh, M.D. Melissa Rae Skrzypchak, M.S.S.W., L.C.S.W. Paula Slater, M.D. WiUiam Bill Slaughter, M.D., M.A. Aki Smith, Ph.D. Deborah L. Smith, Ed.M. Diane E. Smith, M.A., L.M.F.T. James S. Sommer, M.S. J. Richard Spatafora, M.D. Judy Splittgerber, M.S.N., C.S., N.P. Thiruneermalai T.G. Sriram, M.D. Martha W. St. John, M.D. Sybil Stafford, Ph.D. Timothy Stambaugh, M.A. Laura A. Stamboni, M.S.W. Carol L. R. Stark, M.D. Stephanie Steinman, M.S. Claudia M. Stevens, M.S.W. Jennifer Boyer Stevens, Psy.D. Dominique Stevens-Young, M.S.W., L.C.S.W. Kenneth Stewart, Ph.D. Daniel Storch, M.D. Suzanne Straebler, A.P.R.N. Dawn Stremel, M.A., L.M.F.T. Emel Stroup, Psy.D. John W. Stump, M.S., L.M.F.T. Thomas G. Suk, M.A. Elizabeth Sunzeri, M.S. Linnea Swanson, M.A., Psy.D. Patricia Swanson, M.A. Fereidoon Taghizadeh, M.D. Bonnie L. Tardif, L.M.H.C., N.C.C., B.C.P.C.C. Joan Tavares, M.S.W. Ann Taylor, M.S.W. Dawn O'Dwyer Taylor, Ph.D. Chanel V. Tazza, L.M.H.C. Martha H. Teater, M.A. Clark D. Terrell, M.D. Mark R. Thelen, Psy.D. Norman E. Thibault, M.S., Ph.D. Tojuana L. Thomason, Ph.D. Paula Thomson, Psy.D. D. Chadwick Thompson, M.A. Susan Thome-Devin, A.M. Jean Eva Thumm, M.A.P.C., M.A.T., L.M.F.T., B.C.C. James E. Tille, Ph.D., D.Min. Jacalyn G. Tippey, Ph.D. Saraswathi Tirumalasetty, M.D. Jacqueline A. Torrance, M.S. Terrence Trobaugh, M.S. Louisa V. Troemel, Psy.D., L.M.F.T.

Susan Ullman, M.S.W. Jennifer M. Underwood, M.S.W., L.C.S.W. Rodney Dale Veldhuizen, M.A. Michelle Voegels, B.S.N., M.S.N., B.C. Wess Vogt, M.D. R. Christopher Votolato, Psy.D. John W. Waid, Ph.D. Christa A. Wallis, M.A. Dominique Walmsley, M.A. Bhupinder Singh Waraich, M.D. Joseph Ward, N.C.C., L.P.C. M.Ed. Robert Ward, M.S.W. Marilee L. M. Wasell, Ph.D. Gannon J. Watts, L.P.C.-S., L.A.C., N.C.C., N.C.S.C., A.A.D.C., LC.A.A.D.C. Sheila R. Webster, M.A., M.S.S.A. Burton Weiss, M.D. Dennis V. Weiss, M.D. Jonathan S. Weiss, M.D. Richard Wendel, Ph.D. Paul L. West, Ed.D. Kris Sandra Wheatley, M.A., L.P.C., N.C.C. Leneigh White, M.A. Danny R. Whitehead, L.I.C.S.W. Jean Whitinger, M.A. Peter D. Wilk, M.D. Vanessa Wilkinson, L.P.C. Tim F. Willia, M.S., M.A.Ed., L.P.C. Cathy E. Willis, M.A., L.M.F.T., C.A.D.C. Jeffery John Wilson, M.D. Jacquie Wilson, M.Ed. David D. Wines, M.S.W. Barbara A. Wirebaugh, M.S.W. Daniel L. Wise, Ph.D. Christina Wong, M.S.W., L.C.S.W. Susanna Wood, M.S.W., L.C.S.W. Linda L. Woodall, M.D. Leoneen Woodard-Faust, M.D. Sheryl E. Woodhouse, L.M.F.T. Gregory J. Worthington, Psy.D. Tanya Wozniak, M.D. Kimberly Isaac Wright, M.A. Peter Yamamoto, M.D. Maria Ruiza Ang Yee, M.D. Michael B. Zafrani, M.D. Jafet E. Gonzalez Zakarchenco, M.D. John Zibert, Ph.D. Karen Zilberstein, M.S.W. Cathi Zillmann, C.P.N.P., N.P.P. Gerald A. Zimmerman, Ph.D. Michele Zimmerman, M.A., P.M.H.C.N.S.-B.C. Judith A. Zink, M.A.

Vanderbilt University REDCap Team Paul Harris, Ph.D. Sudah Kashyap, B.E. Brenda Minor

Jon Scherdin, M.A. Rob Taylor, M.A. Janey Wang, M.S.

Index Page numbers printed in boldface type refer to tables. Abuse and neglect, 22 ,7V7-722 adult maltreatment and neglect problems, 720-722 child maltreatment and neglect problems, 717-719 Access to medical and other health care, problems related to, 726 Acute dissociative reactions to stressful events, 306-307 Acute stress disorder, 265,280-286 associated features supporting diagnosis of, 283-284 culture-related diagnostic issues in, 285 development and course of, 284 diagnostic criteria for, 280-281 diagnostic features of, 281-283 differential diagnosis of, 285-286 functional consequences of, 285 gender-related diagnostic issues in, 285 prevalence of, 284 risk and prognostic factors for, 284-285 Addiction. See Substance-related and addictive disorders ADHD. See Attention-deficit/hyperactivity disorder Adjustment disorders, 265, 286-289 comorbidity with, 289 culture-related diagnostic issues in, 288 development and course of, 287 diagnostic criteria for, 286-287 diagnostic features of, 287 differential diagnosis of, 288-289 functional consequences of, 288 prevalence of, 287 risk and prognostic factors for, 288 Adjustment-like disorders, 289 Adult maltreatment and neglect problems, 720­ 722 adult abuse by nonspouse or nonpartner, 722 spouse or partner abuse, psychological, 721­ 722 spouse or partner neglect, 721 spouse or partner violence, physical, 720 spouse or partner violence, sexual, 720

Agoraphobia, 190,217-221 associated features supporting diagnosis of, 219 comorbidity with, 221 development and course of, 219-220 diagnostic criteria for, 217-218 diagnostic features of, 218-219 differential diagnosis of, 220-221 functional consequences of, 220 gender-related diagnostic issues in, 220 prevalence of, 219 risk and prognostic factors for, 220 Akathisia, medication-induced, 22 acute, 711 tardive, 712 Alcohol intoxication, 497-499 associated features supporting diagnosis of, 497-498 comorbidity with, 499 culture-related diagnostic issues in, 498 development and course of, 498 diagnostic criteria for, 497 diagnostic features of, 497 diagnostic markers for, 499 differential diagnosis of, 499 functional consequences of, 499 gender-related diagnostic issues in, 498 prevalence of, 498 risk and prognostic factors for, 498 Alcohol-related disorders, 481,490-503 alcohol intoxication, 497-499 alcohol use disorder, 490-497 alcohol withdrawal, 484,499-501 diagnoses associated with, 482 other alcohol-induced disorders, 502-503 development and course of, 502-503 features of, 502 unspecified alcohol-related disorder, 503 Alcohol use disorder, 490-497 associated features supporting diagnosis of, 492-193 comorbidity with, 496-497 culture-related diagnostic issues in, 494-495 development and course of, 493-494

Alcohol use disorder (continued) diagnostic criteria for, 49CM91 diagnostic features of, 492 diagnostic markers for, 495-496 differential diagnosis of, 496 functional consequences of, 496 prevalence of, 493 risk and prognostic factors for, 494 specifiers for, 492 Alcohol withdrawal, 499-501 associated features supporting diagnosis of, 500 comorbidity with, 501 development and course of, 501 diagnostic criteria for, 499-500 diagnostic features of, 500 diagnostic markers for, 501 differential diagnosis of, 501 functional consequences of, 501 prevalence of, 501 risk and prognostic factors for, 501 specifiers for, 500 Alzheimer's disease, major or mild neurocognitive disorder due to, 591, 603, 611-614 associated features supporting diagnosis of, 612 comorbidity with, 614 culture-related diagnostic issues in, 613 development and course of, 612-613 diagnostic criteria for, 611-612 diagnostic features of, 612 diagnostic markers for, 613 differential diagnosis of, 614 functional consequences of, 614 prevalence of, 612 risk and prognostic factors for, 613 American Psychiatric Association (APA), 5-7 Anorexia nervosa, 329,338-345 associated features supporting diagnosis of, 341 atypical, 353 comorbidity with, 344-345 culture-related diagnostic issues in, 342 development and course of, 341-342 diagnostic criteria for, 338-339 diagnostic features of, 339-340 diagnostic markers for, 342-343 differential diagnosis of, 344 functional consequences of, 343 prevalence of, 341 risk and prognostic factors for, 342 subtypes of, 339 suicide risk in, 343 Antidepressant discontinuation syndrome, 22, 712-714 comorbidity with, 714 course and development of, 713

diagnostic features of, 713 differential diagnosis of, 713-714 prevalence of, 713 Antisocial personality disorder, 461,476, 645, 646, 659-663 associated features supporting diagnosis of, 660-661 culture-related diagnostic issues in, 662 development and course of, 661 diagnostic criteria for, 659 diagnostic features of, 659-660 differential diagnosis of, 662-663 features and criteria in alternative DSM-5 model for personality disorders, 763, 764-765 gender-related diagnostic issues in, 662 prevalence of, 661 risk and prognostic factors for, 661-662 Aruciety disorder due to another medical condition, 190,230-232 associated features supporting diagnosis of, 231 development and course of, 231 diagnostic criteria for, 230 diagnostic features of, 230-231 diagnostic markers for, 231 differential diagnosis of, 231-232 prevalence of, 231 Anxiety disorders, 189-264 agoraphobia, 190,217-221 anxiety disorder due to another medical condition, 190,230-232 generalized anxiety disorder, 190, 222-226 highlights of changes from DSM-IV to DSM-5, 811 other specified anxiety disorder, 233 panic attack specifier, 214-217 panic disorder, 190,208-214 selective mutism, 189,195-197 separation anxiety disorder, 189,190-195 social anxiety disorder (social phobia), 190, 202-208 specific phobia, 189-190,197-202 substance/medication-induced anxiety disorder, 190, 226-230 unspecified anxiety disorder, 233 APA (American Psychiatric Association), 5-7 Assessment measures, 23-24, 733-748 cross-cutting symptom measures, 733-741 DSM-5 Level 1 Cross-Cutting Symptom Measure, 734-736, 738-741 DSM-5 Level 2 Cross-Cutting Symptom Measures, 734, 735, 736, 737 frequency of use of, 737 severity measures, 733, 742

Clinician-Rated Dimensions of Psychosis Symptom Severity, 742-744 frequency of use of, 742 scoring and interpretation of, 742 WHO Disability Assessment Schedule (WHODAS), 16,21, 734, 745-748 Ataque de nervios, 14,211-212,233,833 Attention-deficit /hyperactivity disorder (ADHD), 11,32,59-66 associated features supporting diagnosis of, 61 comorbidity with, 65 culture-related diagnostic issues in, 62 development and course of, 61 diagnostic criteria for, 59-61 diagnostic features of, 61 differential diagnosis of, 63-65 functional consequences of, 63 gender-related diagnostic issues in, 63 medication-induced symptoms of, 65 other specified attention-deficit/hyperactivity disorder, 65-66 prevalence of, 61 risk and prognostic factors for, 62 unspecified attention-deficit/hyperactivity disorder, 66 Attenuated psychosis syndrome, 122, 783-786 associated features supporting diagnosis of, 784 comorbidity with, 786 development and course of, 785 diagnostic features of, 783-784 differential diagnosis of, 785-786 functional consequences of, 785 prevalence of, 784-785 proposed criteria for, 783 risk and prognostic factors for, 785 Autism spectrum disorder, 31-32,50-59 associated features supporting diagnosis of, 55 comorbidity with, 58-59 culture-related diagnostic issues in, 57 development and course of, 55-56 diagnostic criteria for, 50-51 diagnostic features of, 53-55 differential diagnosis of, 57-58 functional consequences of, 57 gender-related diagnostic issues in, 57 prevalence of, 55 recording procedures for, 51 risk and prognostic factors for, 56-57 specifiers for, 51-53, 52 Avoidant personality disorder, 645,646, 672-675 associated features supporting diagnosis of, 673-674 culture-related diagnostic issues in, 674 development and course of, 674 diagnostic criteria for, 672-673

diagnostic features of, 673 differential diagnosis of, 674-675 features and criteria in alternative DSM-5 model for personality disorders, 763, 765-766 gender-related diagnostic issues in, 674 prevalence of, 674 Avoidant/restrictive food intake disorder, 329, 334-338 associated features supporting diagnosis of, 335 comorbidity with, 338 culture-related diagnostic issues in, 336 development and course of, 335-336 diagnostic criteria for, 334 diagnostic features of, 334-335 diagnostic markers for, 336 differential diagnosis of, 336-338 functional consequences of, 336 gender-related diagnostic issues in, 336 risk and prognostic factors for, 336 Bereavement, 125-126,134,155,161,194 persistent complex, 289, 789-792 Binge-eating disorder, 329, 350-353 associated features supporting diagnosis of, 351 comorbidity with, 353 culture-related diagnostic issues in, 352 development and course of, 352 diagnostic criteria for, 350 diagnostic features of, 350-351 differential diagnosis of, 352-353 functional consequences of, 352 of low frequency and/or limited duration, 353 prevalence of, 351 risk and prognostic factors for, 352 Bipolar I disorder, 123-132 associated features supporting diagnosis of, 129 comorbidity with, 132 culture-related diagnostic issues in, 130 development and course of, 130 diagnostic criteria for, 123-127 diagnostic features of, 127-129 differential diagnosis of, 131-132 functional consequences of, 131 gender-related diagnostic issues in, 130 prevalence of, 130 risk and prognostic factors for, 130 suicide risk and, 131 Bipolar II disorder, 123,132-139 associated features supporting diagnosis of, 136 comorbidity with, 139 development and course of, 136-137 diagnostic criteria for, 132-135 diagnostic features of, 135-136 differential diagnosis of, 138-139

Bipolar II disorder (continued) functional consequences of, 138 gender-related diagnostic issues in, 137 prevalence of, 136 risk and prognostic factors for, 137 suicide risk in, 138 Bipolar and related disorder due to another medical condition, 123,145-147 associated features supporting diagnosis of, 146 comorbidity with, 147 culture-related diagnostic issues in, 147 development and course of, 146-147 diagnostic criteria for, 145-146 diagnostic features of, 146 diagnostic markers for, 147 differential diagnosis of, 147 functional consequences of, 147 gender-related diagnostic issues in, 147 Bipolar and related disorders, 123-154 bipolar I disorder, 123-132 bipolar II disorder, 123,132-139 bipolar and related disorder due to another medical condition, 123,145-147 cyclothymic disorder, 123,139-141 highlights of changes from DSM-IV to DSM-5, 810 other specified bipolar and related disorder, 123,148 specifiers for, 149-154 substance/medication-induced bipolar and related disorder, 123,142-145 unspecified bipolar and related disorder, 149 Body dysmorphic disorder, 235, 236, 242-247 associated features supporting diagnosis of, 244 comorbidity with, 247 culture-related diagnostic issues in, 245 development and course of, 244 diagnostic criteria for, 242-243 diagnostic features of, 243-244 differential diagnosis of, 245-247 functional consequences of, 245 gender-related diagnostic issues in, 245 prevalence of, 244 risk and prognostic factors for, 245 suicide risk and, 245 Body dysmorphic-like disorder with actual flaws, 263 Body dysmorphic-like disorder without repetitive behaviors, 263 Body-focused repetitive behavior disorder, 235, 263-264 Borderline personality disorder, 645, 646, 663-666 associated features supporting diagnosis of, 665 culture-related diagnostic issues in, 665-666 development and course of, 665

diagnostic criteria for, 663 diagnostic features of, 663-664 differential diagnosis of, 666 features and criteria in alternative DSM-5 model for personality disorders, 763, 766-767 gender-related diagnostic issues in, 666 prevalence of, 665 risk and prognostic factors for, 665 Breathing-related sleep disorders, 361,378-390 central sleep apnea, 383-386 obstructive sleep apnea hypopnea, 378-383 sleep-related hypoventilation, 387-390 Brief illness anxiety disorder, 327 Brief psychotic disorder, 94-96 associated features supporting diagnosis of, 95 culture-related diagnostic issues in, 95 development and course of, 95 diagnostic criteria for, 94 diagnostic features of, 94-95 differential diagnosis of, 96 duration of, 89,94, 99 functional consequences of, 95 prevalence of, 95 risk and prognostic factors for, 95 Brief somatic symptom disorder, 327 Bulimia nervosa, 329, 345-350 associated features supporting diagnosis of, 347 comorbidity with, 349-350 culture-related diagnostic issues in, 348 development and course of, 347-348 diagnostic criteria for, 345 diagnostic features of, 345-347 diagnostic markers for, 348 differential diagnosis of, 349 functional consequences of, 349 gender-related diagnostic issues in, 348 of low frequency and/or limited duration, 353 prevalence of, 347 risk and prognostic factors for, 348 suicide risk in, 349 Caffeine intoxication, 503-506 associated features supporting diagnosis of, 504 comorbidity with, 506 development and course of, 505 diagnostic criteria for, 503-504 diagnostic features of, 504 differential diagnosis of, 505 functional consequences of, 505 prevalence of, 505 risk and prognostic factors for, 505 Caffeine-related disorders, 481, 503-509 caffeine intoxication, 503-506 caffeine withdrawal, 506-508

diagnoses associated with, 482 other caffeine-induced disorders, 508 unspecified caffeine-related disorder, 509 Caffeine use disorder, 792-795 comorbidity with, 795 development and course of, 794 diagnostic features of, 793-794 differential diagnosis of, 795 functional consequences of, 794-795 prevalence of, 794 proposed criteria for, 792-793 risk and prognostic factors for, 794 Caffeine withdrawal, 506-508 associated features supporting diagnosis of, 507 comorbidity with, 508 culture-related diagnostic issues in, 508 development and course of, 507 diagnostic criteria for, 506 diagnostic features of, 506-507 differential diagnosis of, 508 functional consequences of, 508 prevalence of, 507 risk and prognostic factors for, 507-508 Cannabis intoxication, 516-517 diagnostic criteria for, 516 diagnostic features of, 516-517 differential diagnosis of, 517 functional consequences of, 517 prevalence of, 517 specifiers for, 516 Cannabis-related disorders, 481,509-519 cannabis intoxication, 516-517 cannabis use disorder, 509-516 cannabis withdrawal, 484, 517-519 diagnoses associated with, 482 other cannabis-induced disorders, 519 unspecified cannabis-related disorder, 519 Cannabis use disorder, 509-516 associated features supporting diagnosis of, 512 comorbidity with, 515-516 culture-related diagnostic issues in, 514 development and course of, 513 diagnostic criteria for, 509-510 diagnostic features of, 510-512 diagnostic markers for, 514 functional consequences of, 514-515 prevalence of, 512 risk and prognostic factors for, 513-514 specifiers for, 510 Cannabis withdrawal, 517-519 development and course of, 518 diagnostic criteria for, 517-518 diagnostic features of, 518 differential diagnosis of, 519 risk and prognostic factors for, 519

Case formulation, 19-20 cultural, 749-759 {See also Cultural formulation) Catatonia, 89,119-121 associated with another mental disorder (catatonia specifier), 119-120 diagnostic criteria for, 119-120 diagnostic features of, 120 unspecified, 89,121 Catatonic disorder due to another medical condition, 120-121 associated features supporting diagnosis of, 121 diagnostic criteria for, 120-121 diagnostic features of, 121 differential diagnosis of, 121 Central sleep apnea, 383-386 associated features supporting diagnosis of, 385 comorbidity with, 386 development and course of, 385 diagnostic criteria for, 383-384 diagnostic features of, 384-385 diagnostic markers for, 385 differential diagnosis of, 386 functional consequences of, 386 prevalence of, 385 risk and prognostic factors for, 385 specifiers for, 384 subtypes of, 384 CFI. See Cultural Formulation Interview Cheyne-Stokes breathing, 383-386. See also Central sleep apnea Childhood-onset fluency disorder (stuttering), 31,

45^7 associated features supporting diagnosis of, 46 development and course of, 46-47 diagnostic criteria for, 45-46 diagnostic features of, 46 differential diagnosis of, 47 functional consequences of, 47 risk and prognostic factors for, 47 Child maltreatment and neglect problems, 717-719 child neglect, 718-719 child physical abuse, 717-718 child psychological abuse, 719 child sexual abuse, 718 Circadian rhythm sleep-wake disorders, 361, 390-398 advanced sleep phase type, 393-394 associated features supporting diagnosis of, 393 comorbidity with, 394 culture-related diagnostic issues in, 394 development and course of, 393 diagnostic features of, 393 diagnostic markers for, 394

Circadian rhythm sleep-wake disorders (continued) advanced sleep phase type (continued) differential diagnosis of, 394 functional consequences of, 394 prevalence of, 393 risk and prognostic factors for, 394 specifiers for, 393 delayed sleep phase type, 391-392 associated features supporting diagnosis of, 391 comorbidity with, 392 development and course of, 391 diagnostic features of, 391 diagnostic markers for, 392 differential diagnosis of, 392 functional consequences of, 392 prevalence of, 391 risk and prognostic factors for, 392 diagnostic criteria for, 390-391 irregular sleep-wake type, 394-396 associated features supporting diagnosis of, 395 comorbidity with, 396 development and course of, 395 diagnostic features of, 394-395 diagnostic markers for, 395 differential diagnosis of, 395 functional consequences of, 395 prevalence of, 395 risk and prognostic factors for, 395 non-24-hour sleep-wake type, 396-397 associated features supporting diagnosis of, 396 comorbidity with, 397 development and course of, 396 diagnostic features of, 396 diagnostic markers for, 397 differential diagnosis of, 397 functional consequences of, 397 prevalence of, 396 risk and prognostic factors for, 396-397 relationship to International Classification of Sleep Disorders, 398 shift work type, 397-398 comorbidity with, 398 development and course of, 398 diagnostic features of, 397 diagnostic markers for, 398 differential diagnosis of, 398 functional consequences of, 398 prevalence of, 397 risk and prognostic factors for, 398 Clinician-Rated Dimensions of Psychosis Symptom Severity, 742-744

Coding and reporting procedures, 12,16, 22, 23, 29 Cognitive disorders. See Neurocognitive disorders Communication disorders, 31, 41-49 childhood-onset fluency disorder (stuttering), 45-47 language disorder, 42-44 social (pragmatic) communication disorder, 47-i9 speech sound disorder, 44 -45 unspecified communication disorder, 49 Comorbidity, 5 Compulsions, 235-236, 239. See also Obsessivecompulsive and related disorders Conditions for further study, 7,11, 24, 783-806 attenuated psychosis syndrome, 783-786 caffeine use disorder, 792-795 depressive episodes with short-duration hypomania, 786-789 Internet gaming disorder, 795-798 neurobehavioral disorder associated with prenatal alcohol exposure, 798-801 nonsuicidal self-injury, 803-805 persistent complex bereavement disorder, 789-792 suicidal behavior disorder, 801-803 Conduct disorder, 32, 461, 469-475 associated features supporting diagnosis of, 472-473 comorbidity with, 475 culture-related diagnostic issues in, 474 development and course of, 473 diagnostic criteria for, 469-471 diagnostic features of, 472 differential diagnosis of, 474-^75 functional consequences of, 474 gender-related diagnostic issues in, 474 prevalence of, 473 risk and prognostic factors for, 473-474 specifiers for, 471^72 subtypes of, 471 Conversion disorder (functional neurological symptom disorder), 309, 310, 318-321 associated features supporting diagnosis of, 319-320 comorbidity with, 321 culture-related diagnostic issues in, 320 development and course of, 320 diagnostic criteria for, 318-319 diagnostic features of, 319 differential diagnosis of, 321 functional consequences of, 321 gender-related diagnostic issues in, 320 prevalence of, 320 risk and prognostic factors for, 320

Creutzfeldt-Jakob disease. See Prion disease, major or mild neurocognitive disorder due to Crime or interactioh with the legal system, problems related to, 725 Criterion for clinical significance, 21 Cross-cutting symptom measures, 733-741 DSM-5 Level 1 Cross-Cutting Symptom Measure, 734-736, 738-741 DSM-5 Level 2 Cross-Cutting Symptom Measures, 734, 735, 736, 737 frequency of use of, 737 Cultural concepts of distress, 750,758,759,833-837 Cultural explanations or perceived causes, 14, 758 Cultural formulation, 749-759 definitions related to, 749 diagnostic importance of, 758-759 outline for, 749-750 relationship to DSM-5 nosology, 758 Cultural Formulation Interview (CFI), 17, 24, 749, 750-757 domains of assessment, 751 indications for, 751 Informant Version, 755-757 supplementary modules of, 751 Cultural idioms of distress, 14, 758 Cultural issues, 14-15, 749-759 in anxiety disorders generalized anxiety disorder, 224 panic attacks, 216 panic disorder, 211-212 selective mutism, 196 separation anxiety disorder, 193 social anxiety disorder (social phobia), 205-206 specific phobia, 201 in bipolar and related disorders bipolar I disorder, 130 bipolar and related disorder due to another medical condition, 147 in depressive disorders major depressive disorder, 166 premenstrual dysphoric disorder, 173 in disruptive, impulse-control, and conduct disorders conduct disorder, 474 intermittent explosive disorder, 468 oppositional defiant disorder, 465 in dissociative disorders depersonalization/derealization disorder, 304 dissociative amnesia, 300 dissociative identity disorder, 295 in enuresis, 357 in feeding and eating disorders anorexia nervosa, 342

avoidant/restrictive food intake disorder, 336 binge-eating disorder, 352 bulimia nervosa, 348 pica, 331 in fetishistic disorder, 701 in gender dysphoria, 457 in neurocognitive disorders, 609 due to Alzheimer's disease, 613 in neurodevelopmental disorders attention-deficit/hyperactivity disorder, 62 autism spectrum disorder, 57 developmental coordination disorder, 76 intellectual disability (intellectual developmental disorder), 39 specific learning disorder, 72-73 stereotypic movement disorder, 79 tic disorders, 83 in obsessive-compulsive and related disorders body dysmoφhic disorder, 245 hoarding disorder, 250 obsessive-compulsive disorder, 240 trichotillomania (hair-pulling disorder), 253 in personality disorders, 648 antisocial personality disorder, 662 avoidant personality disorder, 674 borderline personality disorder, 665-666 dependent personality disorder, 677 histrionic personality disorder, 668 obsessive-compulsive personality disorder, 681 paranoid personality disorder, 651 schizoid personality disorder, 654 schizotypal personality disorder, 657 in schizophrenia spectrum and other psychotic disorders brief psychotic disorder, 95 delusional disorder, 93 schizoaffective disorder, 108-109 schizophrenia, 103 in sexual dysfunctions, 423 delayed ejaculation, 425 erectile disorder, 428 female orgasmic disorder, 432 female sexual interest/arousal disorder, 435-436 genito-pelvic pain/penetration disorder, 439 male hypoactive sexual desire disorder, 442 premature (early) ejaculation, 445 substance/medication-induced sexual dysfunction, 449

Cultural issues (continued) in sleep-wake disorders central sleep apnea hypopnea, 381 circadian rhythm sleep-wake disorders, advanced sleep phase type, 394 narcolepsy, 376 nightmare disorder, 406 substance/medication-induced sleep disorder, 418 in somatic symptoms and related disorders conversion disorder (functional neurological symptom disorder), 320 illness anxiety disorder, 317 psychological factors affecting other medical conditions, 323 somatic symptom disorder, 313 in substance-related and addictive disorders alcohol intoxication, 498 alcohol use disorder, 495 caffeine withdrawal, 508 cannabis use disorder, 514 gambling disorder, 588 inhalant use disorder, 536 opioid use disorder, 544 other hallucinogen use disorder, 526 other (or unknown) substance use disorder, 580 other (or unknown) substance withdrawal, 580 phencyclidine use disorder, 522 sedative, hypnotic, or anxiolytic use disorder, 554 stimulant use disorder, 565 tobacco use disorder, 574 in suicidal behavior disorder, 802 in trauma- and stressor-related disorders acute stress disorder, 285 adjustment disorders, 288 posttraumatic stress disorder, 278 reactive attachment disorder, 267 Cultural syndromes, 14, 758 Culture-bound syndromes, 14, 758 Cyclothymic disorder, 123,139-141 comorbidity with, 141 development and course of, 140-141 diagnostic criteria for, 139-140 diagnostic features of, 140 differential diagnosis of, 141 prevalence of, 140 risk and prognostic factors for, 141 Definition of a mental disorder, 20 Delayed ejaculation, 423,424-426 associated features supporting diagnosis of, 424-425

comorbidity with, 426 culture-related diagnostic issues in, 425 development and course of, 425 diagnostic criteria for, 424 diagnostic features of, 424 differential diagnosis of, 425-426 functional consequences of, 425 prevalence of, 425 risk and prognostic factors for, 425 Delirium, 591, 596-602 due to another medical condition, 597 associated features supporting diagnosis of, 600 development and course of, 600-601 diagnostic criteria for, 596-598 diagnostic features of, 599-600 diagnostic markers for, 601 differential diagnosis of, 601 functional consequences of, 601 medication-induced, 597, 599 due to multiple etiologies, 597 other specified, 602 prevalence of, 600 recording procedures for, 598-599 risk and prognostic factors for, 601 specifiers for, 599 substance intoxication, 596-597,598 substance withdrawal, 597, 598-599 unspecified, 602 Delusional disorder, 89, 90-93 associated features supporting diagnosis of, 92 culture-related diagnostic issues in, 93 delusional symptoms in partner of individual with, 122 development and course of, 92-93 diagnostic criteria for, 90-91 diagnostic features of, 92 functional consequences of, 93 prevalence of, 92 subtypes of, 91-92 Delusions, 87, 89, 90-93 bizarre, 87, 91 of control, 87 érotomanie, 87, 90 grandiose, 87, 90 jealous, 90, 91 mixed type, 91 nihilistic, 87 nonbizarre, 87 persecutory, 87, 90-91 referential, 87 with significant overlapping mood episodes, 122

somatic, 87,90, 92 unspecified type, 91 Dementia, 591. See also Neurocognitive disorders

Dependent personality disorder, 645,646, 675-678 associated features supporting diagnosis of, 677 culture-related dia^iostic issues in, 677 development and course of, 677 diagnostic criteria for, 675 diagnostic features of, 675-677 differential diagnosis of, 677-678 gender-related diagnostic issues in, 677 prevalence of, 677 Depersonalization/derealization disorder, 291, 302-306 associated features supporting diagnosis of, 303 comorbidity with, 306 culture-related diagnostic issues in, 304 development and course of, 303-304 diagnostic criteria for, 302 diagnostic features of, 302-303 differential diagnosis of, 305-306 functional consequences of, 304-305 prevalence of, 303 risk and prognostic factors for, 304 Depressive disorder due to another medical condition, 155,180-183 associated features supporting diagnosis of, 181 comorbidity with, 183 development and course of, 181-182 diagnostic criteria for, 180-181 diagnostic features of, 181 diagnostic markers for, 182 differential diagnosis of, 182-183 functional consequences of, 182 gender-related diagnostic issues in, 182 risk and prognostic factors for, 182 suicide risk in, 182 Depressive disorders, 155-188 depressive disorder due to another medical condition, 155,180-183 disruptive mood dysregulation disorder, 155, 156-160 highlights of changes from DSM-IV to DSM-5, 810-eil major depressive disorder, 155,160-168 other specified depressive disorder, 155, 183-184 persistent depressive disorder (dysthymia), 155,168-171 premenstrual dysphoric disorder, 155,171-175 specifiers for, 184-188 substance /medication-induced depressive disorder, 155,175-180 unspecified depressive disorder, 155,184 Depressive episode or symptoms in bipolar and related disorders bipolar I disorder, 125-126,129 bipolar II disorder, 133-134,135-136

Depressive episodes with short-duration hypomania, 786-789 associated features supporting diagnosis of, 788 comorbidity with, 789 diagnostic features of, 788 differential diagnosis of, 788-789 functional consequences of, 788 prevalence of, 788 proposed criteria for, 786-787 risk and prognostic factors for, 788 suicide risk in, 788 Developmental coordination disorder, 32, 74-77 associated features supporting diagnosis of, 75 comorbidity with, 76 culture-related diagnostic issues in, 76 development and course of, 75-76 diagnostic criteria for, 74 diagnostic features of, 74-75 differential diagnosis of, 76-77 functional consequences of, 76 prevalence of, 75 risk and prognostic factors for, 76 Dhat syndrome, 833-834 Diagnosis, 5-6 assessment and monitoring measures for, 23^24, 733-748 categorical, 5,8,12,13,19,20 clinical utility of, 20 coding and reporting procedures for, 12,16, 22, 23, 29 criterion for clinical significance, 21 culture and, 14-15,749-759 definition of a mental disorder, 20 diagnostic criteria and descriptors, 21 dimensional approach to, 5, 8,9,12-13,17 elements of, 21-24 in forensic settings, 25 of medication-induced movement disorders, 20, 22, 29, 709-714 of other conditions that may be a focus of clinical attention, 20, 22, 29, 715-727 principal, 22-23 provisional, 23 Diagnostic criteria, 21, 29 case formulation and, 19 proposed criteria for conditions for further study, 11, 783 revisions of, 6-10 subtypes and specifiers for, 21-22 validators for, 5, 9,11,12, 20 Diagnostic spectra, 6,9,12

Disinhibited social engagement disorder, 265, 268-270 associated features supporting diagnosis of, 269 development and course of, 269-270 diagnostic criteria for, 268-269 diagnostic features of, 269 differential diagnosis of, 270 functional consequences of, 270 prevalence of, 269 risk and prognostic factors for, 270 Disorganized thinking (speech), 88 Disruptive, impulse-control, and conduct disorders, 461^80 antisocial personality disorder, 461,476, 645, 646,659-663 conduct disorder, 461,469-475 highlights of changes from DSM-IV to DSM-5, 815 intermittent explosive disorder, 461,466-469 kleptomania, 461,478-479 oppositional defiant disorder, 461, 462^66 other specified disruptive, impulse-control, and conduct disorder, 461,479 pyromania, 461,476-477 unspecified disruptive, impulse-control, and conduct disorder, 480 Disruptive mood dysregulation disorder, 155, 156-160 comorbidity with, 160 development and course of, 157 diagnostic criteria for, 156 diagnostic features of, 156-157 differential diagnosis of, 158-160 functional consequences of, 158 gender-related diagnostic issues in, 158 prevalence of, 157 risk and prognostic factors for, 157-158 suicide risk in, 158 Dissociative amnesia, 291, 298-302 associated features supporting diagnosis of, 299 comorbidity with, 302 culture-related diagnostic issues in, 300 development and course of, 299 diagnostic criteria for, 298 diagnostic features of, 298-299 differential diagnosis of, 300-302 functional consequences of, 300 prevalence of, 299 risk and prognostic factors for, 299-300 suicide risk in, 300 Dissociative disorders, 291-307 depersonalization/derealization disorder, 291, 302-306 dissociative amnesia, 291, 298-302

dissociative identity disorder, 291-298 highlights of changes from DSM-IV to DSM-5, 812 other specified dissociative disorder, 292, 306-307 unspecified dissociative disorder, 307 Dissociative identity disorder, 291-298 associated features supporting diagnosis of, 294 comorbidity with, 297-298 culture-related diagnostic issues in, 295 development and course of, 294 diagnostic criteria for, 292 diagnostic features of, 292-294 differential diagnosis of, 296-297 functional consequences of, 295-296 gender-related diagnostic issues in, 295 prevalence of, 294 risk and prognostic factors for, 294r-295 suicide risk in, 295 Dissociative reactions to stressful events, acute, 306-307 Dissociative stupor or coma, 292 Dissociative trance, 292,307 Down syndrome, 38,40,44,53 DSM, history of, 5, 6 DSM-5 cultural issues in, 14-15, 749-759 developmental and lifespan considerations in, 13 forensic use of, 25 gender differences in, 15 glossary of technical terms in, 817-831 harmonization with ICD-11,11-12 highlights of changes from DSM-IV to, 809-817 anxiety disorders, 811 bipolar and related disorders, 810 depressive disorders, 810-811 disruptive, impulse-control, and conduct disorders, 815 dissociative disorders, 812 elimination disorders, 813 feeding and eating disorders, 813 gender dysphoria, 814-815 neurodevelopmental disorders, 809-810 obsessive-compulsive and related disorders, 811-812 paraphilic disorders, 816 personality disorders, 816 schizophrenia spectrum and other psychotic disorders, 810 sexual dysfunctions, 814 sleep-wake disorders, 814 somatic symptom and related disorders, 812-813

substance-related and addictive disorders, 815-816 X trauma- and stressor-related disorders, 812 multiaxial system and, 16 online enhancements of, 17 organizational structure of, 10-11,13 other specified and unspecified mental disorders in, 15-16,19-20, 707-708 revision process for, 5, 6-10 expert review, 8-10 field trials, 7-8 proposals for revisions, 7 public and professional review, 8 use of, 19-24 assessment and monitoring tools, 23-24, 733-748 case formulation, 19-20 coding and reporting procedures, 12,16, 22,23,29 definition of a mental disorder, 20-21 elements of a diagnosis, 21-24 DSM-5 Level 1 Cross-Cutting Symptom Measure, 734-736 adult self-rated version, 734, 735, 738-739 parent/guardian-rated version, 734, 736, 740-741 scoring and interpretation of, 734-736 DSM-5 Level 2 Cross-Cutting Symptom Measures, 734,735, 736, 737 Dysthymia. See Persistent depressive disorder (dysthymia) Dystonia, medication-induced, 22 acute, 711 tardive, 712 Eating disorders. See Feeding and eating disorders Economic problems, 724 Educational problems, 723 Ejaculation delayed, 423,424-426 premature (early), 423,443-446 Elements of diagnosis, 21-24 Elimination disorders, 355-360 encopresis, 355,357-359 enuresis, 355-357 highlights of changes from DSM-IV to DSM-5, 813 other specified elimination disorder, 359 unspecified elimination disorder, 360 Encopresis, 355,357-359 associated features supporting diagnosis of, 358 comorbidity with, 359 development and course of, 359 diagnostic criteria for, 357-358 diagnostic features of, 358

diagnostic markers for, 359 differential diagnosis of, 359 prevalence of, 359 risk and prognostic factors for, 359 subtypes of, 358 Enuresis, 355-357 associated features supporting diagnosis of, 356 comorbidity with, 356 culture-related diagnostic issues in, 356 development and course of, 356 diagnostic criteria for, 355 diagnostic features of, 355-356 differential diagnosis of, 356 functional consequences of, 356 gender-related diagnostic issues in, 356 prevalence of, 356 risk and prognostic factors for, 356 subtypes of, 355 Erectile disorder, 423,426-429 associated features supporting diagnosis of, 427 comorbidity with, 429 culture-related diagnostic issues in, 428 development and course of, 427-428 diagnostic criteria for, 426-427 diagnostic features of, 427 diagnostic markers for, 428 differential diagnosis of, 428-429 functional consequences of, 428 prevalence of, 427 risk and prognostic factors for, 428 Excoriation (skin-picking) disorder, 235,236, 254-257 associated features supporting diagnosis of, 255 comorbidity with, 257 development and course of, 255 diagnostic criteria for, 254 diagnostic features of, 254-255 diagnostic markers for, 255 differential diagnosis of, 256 functional consequences of, 256 prevalence of, 255 risk and prognostic factors for, 255 Exhibitionistic disorder, 685,689-691 comorbidity with, 691 development and course of, 690 diagnostic criteria for, 689 diagnostic features of, 689-690 differential diagnosis of, 691 functional consequences of, 691 gender-related diagnostic issues in, 691 prevalence of, 690 risk and prognostic factors for, 690-691 specifiers for, 689 subtypes of, 689 Externalizing disorders, 13

Factitious disorder, 309, 310, 324-326 associated features supporting diagnosis of, 325-326 development and course of, 326 diagnostic criteria for, 324-325 diagnostic features of, 325 differential diagnosis of, 326 imposed on another, 310, 325-325, 338 prevalence of, 326 recording procedures for, 325 Family upbringing, problems related to, 715-716 Feeding and eating disorders, 329-354 anorexia nervosa, 329,338-345 avoidant/restrictive food intake disorder, 329, 334-338 binge-eating disorder, 329, 350-353 bulimia nervosa, 329, 345-350 highlights of changes from DSM-IV to DSM-5, 813 other specified feeding or eating disorder, 353-354 pica, 329-331 rumination disorder, 329,332-333 unspecified feeding or eating disorder, 354 Female orgasmic disorder, 423, 429-432 associated features supporting diagnosis of, 430-431 comorbidity with, 432 culture-related diagnostic issues in, 432 development and course of, 431 diagnostic criteria for, 429-430 diagnostic features of, 430 diagnostic markers for, 432 differential diagnosis of, 432 functional consequences of, 432 prevalence of, 431 risk and prognostic factors for, 431-432 Female sexual interest/arousal disorder, 423, 433-137 associated features supporting diagnosis of, 434-435 comorbidity with, 436-437 culture-related diagnostic issues in, 435^36 development and course of, 435 diagnostic criteria for, 433 diagnostic features of, 433-434 differential diagnosis of, 436 functional consequences of, 436 gender-related diagnostic issues in, 436 prevalence of, 435 risk and prognostic factors for, 435 Fetishistic disorder, 685, 700-702 associated features supporting diagnosis of, 701 comorbidity with, 702 culture-related diagnostic issues in, 701

development and course of, 701 diagnostic criteria for, 700 diagnostic features of, 701 differential diagnosis of, 702 functional consequences of, 701-702 gender-related diagnostic issues in, 701 specifiers for, 701 Forensic settings, 25 Formal thought disorder, 88 Frontotemporal neurocognitive disorder, major or mild, 591, 603, 614-618 associated features supporting diagnosis of, 616 development and course of, 616 diagnostic criteria for, 614-615 diagnostic features of, 615-616 diagnostic markers for, 616-617 differential diagnosis of, 617-618 functional consequences of, 617 prevalence of, 616 risk and prognostic factors for, 616 Frotteuristic disorder, 685, 691-694 comorbidity with, 693-694 development and course of, 693 diagnostic criteria for, 691-692 diagnostic features of, 692 differential diagnosis of, 693 gender-related diagnostic issues in, 693 prevalence of, 692-693 risk and prognostic factors for, 693 specifiers for, 692 Functional neurological symptom disorder. See Conversion disorder GAF (Global Assessment of Functioning) scale, 16 Gambling disorder, 481, 585-589 associated features supporting diagnosis of, 587 comorbidity with, 589 culture-related diagnostic issues in, 588 development and course of, 587-588 diagnostic criteria for, 585-586 diagnostic features of, 586-587 differential diagnosis of, 589 functional consequences of, 589 gender-related diagnostic issues in, 588 prevalence of, 587 risk and prognostic factors for, 588 specifiers for, 586 Gender differences, 15 Gender dysphoria, 451-459 associated features supporting diagnosis of, 454 comorbidity with, 458-459 culture-related diagnostic issues in, 457

development and course of, 454-456 in association with a disorder of sex development, 456 without a disorder of sex development, 455-456 diagnostic criteria for, 452-453 diagnostic features of, 453-454 diagnostic markers for, 457 differential diagnosis of, 458 functional consequences of, 457-458 highlights of changes from DSM-IV to DSM-5, 814-815 other specified, 459 prevalence of, 454 risk and prognostic factors for, 456-457 specifiers for, 453 unspecified, 459 Generalized anxiety disorder, 190,222-226 associated features supporting diagnosis of, 223 comorbidity with, 226 culture-related diagnostic issues in, 224 development and course of, 223-224 diagnostic criteria for, 222 diagnostic features of, 222-223 differential diagnosis of, 225-226 functional consequences of, 225 gender-related diagnostic issues in, 224-225 prevalence of, 223 risk and prognostic factors for, 224 Genito-pelvic pain/penetration disorder, 423, 437-440 associated features supporting diagnosis of, 438 comorbidity with, 440 culture-related diagnostic issues in, 439 development and course of, 439 diagnostic criteria for, 437 diagnostic features of, 437-438 differential diagnosis of, 440 functional consequences of, 439 gender-related diagnostic issues in, 439 prevalence of, 438 risk and prognostic factors for, 439 Global Assessment of Functioning (GAF) scale, 16 Global developmental delay, 31,41 Glossary of technical terms, 817-831 Hair pulling. See Trichotillomania (hair-pulling disorder) Hallucinations, 87-88 auditory, 87,103,116,122 gustatory, 116 hypnagogic, 87 hypnopompic, 88 olfactory, 116,118

tactile, 116 visual, 102,103,104,116,118 Hallucinogen persisting perception disorder, 531-532 associated features supporting diagnosis of, 531 comorbidity with, 532 development and course of, 532 diagnostic criteria for, 531 diagnostic features of, 531 differential diagnosis of, 532 functional consequences of, 532 prevalence of, 531 risk and prognostic factors for, 532 Hallucinogen-related disorders, 481, 520-533 diagnoses associated with, 482 hallucinogen persisting perception disorder, 531-532 other hallucinogen-induced disorders, 532-533 other hallucinogen intoxication, 529-530 other hallucinogen use disorder, 523-527 other phencyclidine-induced disorders, 532 phencyclidine intoxication, 527-529 phencyclidine use disorder, 520-523 unspecified hallucinogen-related disorder, 533 unspecified phencyclidine-related disorder, 533 Histrionic personality disorder, 645,646,667-669 associated features supporting diagnosis of, 668 culture-related diagnostic issues in, 668 diagnostic criteria for, 667 diagnostic features of, 667-668 differential diagnosis of, 669 gender-related diagnostic issues in, 668 prevalence of, 668 HIV infection, major or mild neurocognitive disorder due to, 591, 604, 632-634 associated features supporting diagnosis of, 633 comorbidity with, 634 development and course of, 633 diagnostic criteria for, 632 diagnostic features of, 632 diagnostic markers for, 634 differential diagnosis of, 634 functional consequences of, 634 prevalence of, 633 risk and prognostic factors for, 633 Hoarding disorder, 235,236, 247-251 associated features supporting diagnosis of, 249 comorbidity with, 251 culture-related diagnostic issues in, 250 development and course of, 249 diagnostic criteria for, 247 diagnostic features of, 248-249 differential diagnosis of, 250-251

Hoarding disorder (continued) functional consequences of, 250 gender-related diagnostic issues in, 250 prevalence of, 249 risk and prognostic factors for, 249 specifiers for, 248 Housing problems, 723-724 Huntington's disease, 81,117,181,182 major or mild neurocognitive disorder due to, 591, 604, 638-641 associated features supporting diagnosis of, 639 development and course of, 639-640 diagnostic criteria for, 638-639 diagnostic features of, 639 diagnostic markers for, 640 differential diagnosis of, 640-641 functional consequences of, 640 prevalence of, 639 risk and prognostic factors for, 640 Hypersomnolence disorder, 361,368-372 associated features supporting diagnosis of, 370 comorbidity with, 372 development and course of, 370 diagnostic criteria for, 368-369 diagnostic features of, 369-370 diagnostic markers for, 371 differential diagnosis of, 371-372 functional consequences of, 371 other specified, 421 prevalence of, 370 relationship to International Classification of Sleep Disorders, 372 risk and prognostic factors for, 370-371 unspecified, 421 Hypochondriasis, 310,315-316,318. See also Illness anxiety disorder Hypomanie episode or symptoms in bipolar and related disorders bipolar I disorder, 124-125,129 bipolar II disorder, 132-133,135-136 bipolar and related disorder due to another medical condition, 146 cyclothymic disorder, 139,140 depressive episodes with short-duration hypomania, 786-789 other specified bipolar and related disorder, 148 ICD. See International Classification of Diseases ICF (International Classification of Functioning, Disability and Health), 21, 734 ICSD-2. See International Classification of Sleep Disorders, 2nd Edition

Identity disturbance due to prolonged and intense coercive persuasion, 306 Illness anxiety disorder, 309,310,315-318 associated features supporting diagnosis of, 316 brief, 327 comorbidity with, 318 culture-related diagnostic issues in, 317 diagnostic criteria for, 315 diagnostic features of, 315-316 differential diagnosis of, 317-318 functional consequences of, 317 prevalence of, 316 risk and prognostic factors for, 316-317 without excessive health-related behaviors, 327 Inhalant intoxication, 538-540 associated features supporting diagnosis of, 539 diagnostic criteria for, 538 diagnostic features of, 538 differential diagnosis of, 539-540 functional consequences of, 539 gender-related diagnostic issues in, 539 prevalence of, 539 Inhalant-related disorders, 481,533-540 diagnoses associated with, 482 inhalant intoxication, 538-540 inhalant use disorder, 533-538 other inhalant-induced disorders, 540 unspecified inhalant-related disorder, 540 Inhalant use disorder, 533-538 associated features supporting diagnosis of, 535 comorbidity with, 538 culture-related diagnostic issues in, 536 development and course of, 536 diagnostic criteria for, 533-534 diagnostic features of, 535 diagnostic markers for, 536-537 differential diagnosis of, 537 functional consequences of, 537 gender-related diagnostic issues in, 536 prevalence of, 535-536 risk and prognostic factors for, 536 specifiers for, 535 Insomnia disorder, 361,362-368 associated features supporting diagnosis of, 364 brief, 420 comorbidity with, 368 development and course of, 365 diagnostic criteria for, 362-363 diagnostic features of, 363-364 diagnostic markers for, 366-367 differential diagnosis of, 367-368

functional consequences of, 367 gender-related c^iagnostic issues in, 366 other specified, 420 prevalence of, 364^365 relationship to International Classification of Sleep Disorders, 368 restricted to nonrestorative sleep, 420 risk and protective factors for, 366 unspecified, 420-421 Intellectual disability (intellectual developmental disorder), 31,33-41 associated features supporting diagnosis of, 38 coding and reporting for, 33 comorbidity with, 40 culture-related diagnostic issues in, 39 development and course of, 38-39 diagnostic criteria for, 33 diagnostic features of, 37-38 diagnostic markers for, 39 differential diagnosis of, 39-40 gender-related diagnostic issues in, 39 global developmental delay, 31,41 prevalence of, 38 relationship to other classifications, 40-41 risk and prognostic factors for, 39 specifiers for levels of severity of, 33,34-36 unspecified intellectual disability, 41 Intermittent explosive disorder, 461,466-469 associated features supporting diagnosis of, 467 comorbidity with, 469 culture-related diagnostic issues in, 468 development and course of, 467 diagnostic criteria for, 466 diagnostic features of, 466-467 differential diagnosis of, 468-469 functional consequences of, 468 gender-related diagnostic issues in, 468 prevalence of, 467 risk and prognostic factors for, 467-468 Internalizing disorders, 13 International Classification of Diseases (ICD), 21 revision process for ICD-11, 6,10,11-12 use of ICD-9-CM and ICD-10 codes, 12,16,22, 23,29 International Classification of Functioning, Disability and Health (ICF), 21, 734 International Classification of Sleep Disorders, 2nd Edition (ICSD-2), relationship of DSM-5 to, 361-362 circadian rhythm sleep-wake disorders, 398 hypersomnolence disorder, 372 insomnia disorder, 368 narcolepsy, 378 nightmare disorder, 407

obstructive sleep apnea hypopnea, 383 rapid eye movement sleep behavior disorder, 410 restless legs syndrome, 413 sleep-related hypoventilation, 390 substance/medication-induced sleep disorder, 420 Internet gaming disorder, 795-798 associated features supporting diagnosis of, 797 comorbidity with, 798 diagnostic features of, 796-797 differential diagnosis of, 797-798 functional consequences of, 797 prevalence of, 797 proposed criteria for, 795-796 risk and prognostic factors for, 797 subtypes of, 796 Intoxication, 481,485-487 alcohol, 497-499 associated with use of multiple substances, 486 caffeine, 503-506 cannabis, 516-517 delirium due to, 598 development and course of, 487 duration of effects and, 486 inhalant, 538-540 laboratory findings associated with, 486-487 opioid, 546-547 other hallucinogen, 529-530 other (or unknown) substance, 581-582 phencyclidine, 527-529 recording procedures for, 487 related to route of administration and speed of substance effects, 486 sedative, hypnotic, or anxiolytic, 556-557 stimulant, 567-569 Jealousy, obsessional, 264 Jikoshu-kyofu, 264 Khyâl cap, 211,212,233, 834 Kleptomania, 461,478-479 associated features supporting diagnosis of, 478 comorbidity with, 478 development and course of, 478 diagnostic criteria for, 478 diagnostic features of, 478 differential diagnosis of, 478 functional consequences of, 478 prevalence of, 478 risk and prognostic factors for, 478 Koro, 264 Kufungisisa, 14, 834-835

Language disorder, 31,42-44 associated features supporting diagnosis of, 43 comorbidity with, 44 development and course of, 43 diagnostic criteria for, 42 diagnostic features of, 42 differential diagnosis of, 43 risk and prognostic factors for, 43 Learning disorder. See Specific learning disorder Level of Personality Functioning Scale (LPFS), 772, 775-778 Lewy bodies, major or mild neurocognitive disorder with, 591, 603, 618-621 associated features supporting diagnosis of, 619 comorbidity with, 621 development and course of, 619-620 diagnostic criteria for, 618-619 diagnostic features of, 619 diagnostic markers for, 620 differential diagnosis of, 620 functional consequences of, 620 prevalence of, 619 risk and prognostic factors for, 620 LPFS (Level of Personality Functioning Scale), 772, 775-778 Major depressive disorder, 155,160-168 associated features supporting diagnosis of, 164-165 comorbidity with, 168 culture-related diagnostic issues in, 166 development and course of, 165-166 diagnostic criteria for, 160-162 diagnostic features of, 162-164 differential diagnosis of, 167-168 functional consequences of, 167 gender-related diagnostic issues in, 167 prevalence of, 165 risk and prognostic factors for, 166 suicide risk in, 164,167 Major depressive episode in bipolar and related disorders bipolar I disorder, 125-126,129 bipolar II disorder, 133-134,135-136 other specified bipolar and related disorder, 148 Maladi moun, 14,835 Male hypoactive sexual desire disorder, 423, 440-443 associated features supporting diagnosis of, 441-^ 2

comorbidity with, 443 culture-related diagnostic issues in, 442 development and course of, 442 diagnostic criteria for, 440-441

diagnostic features of, 441 differential diagnosis of, 443 gender-related diagnostic issues in, 4 4 2 ^ 3 prevalence of, 442 risk and prognostic factors for, 442 Manic episode in bipolar I disorder, 124,127-129 in bipolar and related disorder due to another medical condition, 146 Medication-induced delirium, 597, 599 Medication-induced movement disorders and other adverse effects of medication, 20, 22, 29, 709-714 antidepressant discontinuation syndrome, 22, 712-714 medication-induced acute akathisia, 22, 711 medication-induced acute dystonia, 711 medication-induced postural tremor, 712 neuroleptic-induced parkinsonism, 709 neuroleptic malignant syndrome, 22, 709-711 other adverse effect of medication, 712-714 other medication-induced movement disorder, 712 other medication-induced parkinsonism, 709 tardive akathisia, 712 tardive dyskinesia, 22, 712 tardive dystonia, 712 Mental disorder(s) culture and, 14-15, 749-759 definition of, 20 criterion for clinical significance, 21 in forensic settings, 25 gender and, 15 Motor disorders, neurodevelopmental, 32, 74-85 developmental coordination disorder, 74-77 stereotypic movement disorder, 77-80 tic disorders, 81-85 Movement disorders, medication-induced. See Medication-induced movement disorders and other adverse effects of medication Muscle dysmorphia, 236, 243, 245 Narcissistic personality disorder, 645, 646, 669-672 associated features supporting diagnosis of, 671 development and course of, 671 diagnostic criteria for, 669-670 diagnostic features of, 670-671 differential diagnosis of, 671-672 features and criteria in alternative DSM-5 model for personality disorders, 763, 767-768 gender-related diagnostic issues in, 671 prevalence of, 671

Narcolepsy, 361, 372-378 associated features supporting diagnosis of, 374-375 comorbidity with, 377-378 culture-related diagnostic issues in, 376 development and course of, 375 diagnostic criteria for, 372-373 diagnostic features of, 374 diagnostic markers for, 376 differential diagnosis of, 376-377 functional consequences of, 376 prevalence of, 375 relationship to International Classification of Sleep Disorders, 378 risk and prognostic factors for, 375-376 subtypes of, 373-374 NCDs. See Neurocognitive disorders Neglect child, 718-719 spouse or partner, 721 Nervios, 835 Neurobehavioral disorder associated with prenatal alcohol exposure, 798-801 associated features supporting diagnosis of, 799 comorbidity with, 800-801 development and course of, 800 diagnostic features of, 799 differential diagnosis of, 800 functional consequences of, 800 prevalence of, 800 proposed criteria for, 798-799 suicide risk in, 800 Neurocognitive disorders (NCDs), 591-643 delirium, 591, 596-602 other specified delirium, 602 unspecified delirium, 602 highlights of changes from DSM-IV to DSM-5, 816 major and mild neurocognitive disorders, 591, 602-611, 611-643 associated features supporting diagnosis of, 608 comorbidity with, 610-611 culture-related diagnostic issues in, 609 development and course of, 608-609 diagnostic criteria for, 602-606 diagnostic features of, 607-608 diagnostic markers for, 609-610 differential diagnosis of, 610 functional consequences of, 610 gender-related diagnostic issues in, 609 prevalence of, 608 risk and prognostic factors for, 609 specifiers for, 606-607 subtypes of, 591, 603 604 606, 611-643

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major or mild frontotemporal neuro­ cognitive disorder, 591, 603 614-618 major or mild neurocognitive disorder due to Alzheimer's disease, 591,603 611-614 major or mild neurocognitive disorder due to another medical condition, 591, 604 641-642 major or mild neurocognitive disorder due to HIV infection, 591, 604 632­ 634 major or mild neurocognitive disorder due to Huntington's disease, 591, 604 638-641 major or mild neurocognitive disorder with Lewy bodies, 591, 603 618-621 major or mild neurocognitive disorder due to multiple etiologies, 591, 604 642-643 major or mild neurocognitive disorder due to Parkinson's disease, 591,604 636-638 major or mild neurocognitive disorder due to prion disease, 591, 604 634­ 636 major or mild neurocognitive disorder due to traumatic brain injury, 591, 603 624-627, 626 major or mild substance/medicationinduced neurocognitive disorder, 591, 603 627-632 unspecified neurocognitive disorder, 591, 604 643 vascular neurocognitive disorder, 591, 603 621-624 neurocognitive domains, 592, 593-595 Neurodevelopmental disorders, 11,13, 31-86 attention-deficit/hyperactivity disorder, 11, 32, 59-66 autism spectrum disorders, 31-32, 50-59 communication disorders, 31, 41^ 9 highlights of changes from DSM-IV to DSM-5, 809-810 intellectual disabilities, 31, 33-41 motor disorders, 32, 74-85 other specified neurodevelopmental disorder, 86 specific learning disorder, 32, 66-74 specifiers for, 32-33 tic disorders, 32, 81-85 unspecified neurodevelopmental disorder, 86 Neurodevelopmental motor disorders, 32, 74-85 developmental coordination disorder, 74-77 stereotypic movement disorder, 77-80 tic disorders, 81-85

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Neuroleptic-induced parkinsonism, 709 Neuroleptic malignant syndrome, 22, 709-711 development and course of, 710 diagnostic features of, 710 differential diagnosis of, 711 risk and prognostic factors for, 711 Night eating syndrome, 354 Nightmare disorder, 361,404-407 associated features supporting diagnosis of, 405 comorbidity with, 407 culture-related diagnostic issues in, 406 development and course of, 405 diagnostic criteria for, 404 diagnostic features of, 404-405 diagnostic markers for, 406 differential diagnosis of, 406-407 functional consequences of, 406 gender-related diagnostic issues in, 406 prevalence of, 405 relationship to International Classification of Sleep Disorders, 407 risk and prognostic factors for, 405 Nonadherence to medical treatment, 22, 726-727 Non-rapid eye movement sleep arousal disorders, 361,399-404 associated features supporting diagnosis of, 400-401 comorbidity with, 403 development and course of, 401 diagnostic criteria for, 399 diagnostic features of, 400 diagnostic markers for, 402 differential diagnosis of, 402^03 functional consequences of, 402 gender-related diagnostic issues in, 401 prevalence of, 401 relationship to International Classification of Sleep Disorders, 404 risk and prognostic factors for, 401 Nonsuicidal self-injury, 803-805 development and course of, 804 diagnostic features of, 804 differential diagnosis of, 805-806 functional consequences of, 805 proposed criteria for, 803 risk and prognostic factors for, 804 Obesity, 22 feeding and eating disorders and, 329, 344, 348,351-353 sleep-wake disorders and, 413 hypersomnia, 372, 373, 375,376, 377 obstructive sleep apnea hypopnea, 379-380, 382 sleep-related hypoventilation, 387-388,389

Obsessional jealousy, 264 Obsessive-compulsive disorder (OCD), 235-236, 237-242 associated features supporting diagnosis of, 238-239 comorbidity with, 243 culture-related diagnostic issues in, 240 development and course of, 239 diagnostic criteria for, 237 diagnostic features of, 238 differential diagnosis of, 242-243 functional consequences of, 241-242 gender-related diagnostic issues in, 239,240 prevalence of, 239 risk and prognostic factors for, 239-240 specifiers for, 236,238 suicide risk in, 240 Obsessive-compulsive personality disorder, 645, 646,678-682 associated features supporting diagnosis of, 680^81 culture-related diagnostic issues in, 681 diagnostic criteria for, 678-679 diagnostic features of, 679-680 differential diagnosis of, 681-682 features and criteria in alternative DSM-5 model for personality disorders, 764, 768-769 gender-related diagnostic issues in, 681 prevalence of, 681 Obsessive-compulsive and related disorder due to another medical condition, 235, 236,260-263 associated features supporting diagnosis of, 262 development and course of, 262 diagnostic criteria for, 260-261 diagnostic features of, 261-262 diagnostic markers for, 262 differential diagnosis of, 262-263 Obsessive-compulsive and related disorders, 235-264 body dysmorphic disorder, 235,236, 242-247 excoriation (skin-picking) disorder, 235,236, 254-257 highlights of changes from DSM-FV to DSM-5, 811-812 hoarding disorder, 235, 236,247-251 obsessions and compulsions in, 235-236,239 obsessive-compulsive disorder, 235-236, 237-242 obsessive-compulsive and related disorder due to another medical condition, 235.236, 260-263 other specified obsessive-compulsive and related disorder, 235,236, 263-264

substance /medication-induced obsessivecompulsive and related disorder, 235, 236,257-260 ' trichotillomania (hair-pulling disorder), 235, 236, 251-254 unspecified obsessive-compulsive and related disorder, 235,236 Obstructive sleep apnea hypopnea, 378-383 associated features supporting diagnosis of, 379 comorbidity with, 383 culture-related diagnostic issues in, 381 development and course of, 379-380 diagnostic criteria for, 378 diagnostic features of, 379 diagnostic markers for, 381 differential diagnosis of, 381-383 functional consequences of, 381 gender-related diagnostic issues in, 381 prevalence of, 379 relationship to International Classification of Sleep Disorders, 383 risk and prognostic factors for, 380-381 specifiers for, 378-379 Occupational problems, 723 OCD. See Obsessive-compulsive disorder Olfactory reference syndrome, 246,264,837 Online enhancements, 17 Opioid intoxication, 546-547 diagnostic criteria for, 546-547 diagnostic features of, 547 differential diagnosis of, 547 specifiers for, 547 Opioid-related disorders, 481,540-550 diagnoses associated with, 482 opioid intoxication, 546-547 opioid use disorder, 541-546 opioid withdrawal, 484, 547-549 other opioid-induced disorders, 549 unspecified opioid-related disorder, 550 Opioid use disorder, 541-546 associated features supporting diagnosis of, 543 comorbidity with, 546 culture-related diagnostic issues in, 544 development and course of, 543 diagnostic criteria for, 541-542 diagnostic features of, 542 diagnostic markers for, 544 differential diagnosis of, 545-546 functional consequences of, 544-545 gender-related diagnostic issues in, 544 prevalence of, 543 risk and prognostic factors for, 543-544 specifiers for, 542 suicide risk in, 544

Opioid withdrawal, 484, 547-549 associated features supporting diagnosis of, 549 development and course of, 549 diagnostic criteria for, 547-548 diagnostic features of, 548 differential diagnosis of, 549 prevalence of, 549 Oppositional defiant disorder, 32,461,462-466 associated features supporting diagnosis of, 464 comorbidity with, 466 culture-related diagnostic issues in, 465 development and course of, 464 diagnostic criteria for, 462-463 diagnostic features of, 463 differential diagnosis of, 465 functional consequences of, 465 prevalence of, 464 risk and prognostic factors for, 464 specifiers for, 463 Other circumstances of personal history, 726 Other conditions that may be a focus of clinical attention, 20, 22, 29, 715-727 abuse and neglect, 717-722 adult maltreatment and neglect problems, 720-722 child maltreatment and neglect problems, 717-719 educational and occupational problems, 723 housing and economic problems, 723-724 nonadherence to medical treatment, 726-727 other circumstances of personal history, 726 other health service encounters for counseling and medical advice, 725 other problems related to the social environment, 724-725 problems related to access to medical and other health care, 726 problems related to crime or interaction with the legal system, 725 problems related to other psychosocial, personal, and environmental circumstances, 725 relational problems, 715-717 other problems related to primary support group, 716-717 problems related to family upbringing, 715-716 Other hallucinogen intoxication, 529-530 diagnostic criteria for, 529 diagnostic features of, 529 differential diagnosis of, 530 functional consequences of, 530 prevalence of, 530 suicide risk in, 530

Other hallucinogen use disorder, 523-527 associated features supporting diagnosis of, 525 comorbidity with, 527 culture-related diagnostic issues in, 526 development and course of, 525-526 diagnostic criteria for, 523-524 diagnostic features of, 524-525 diagnostic markers for, 526 differential diagnosis of, 527 functional consequences of, 527 gender-related diagnostic issues in, 526 prevalence of, 525 risk and prognostic factors for, 526 specifiers for, 524 Other health service encounters for counseling and medical advice, 725 Other mental disorders, 707-708 other specified mental disorder, 15-16,19, 708 other specified mental disorder due to another medical condition, 707 unspecified mental disorder, 15-16,19-20, 708 unspecified mental disorder due to another medical condition, 708 Other problems related to primary support group, 716-717 Other problems related to social environment, 724-725 Other psychosocial, personal, and environmental circumstances, problems related to, 725 Other specified mental disorder, 15-16,19, 708 due to another medical condition, 707 Other (or unknown) substance intoxication, 581-582 comorbidity with, 582 development and course of, 581-582 diagnostic criteria for, 581 diagnostic features of, 581 differential diagnosis of, 582 functional consequences of, 582 prevalence of, 581 Other (or unknown) substance-related disorders, 577-585 diagnoses associated with, 482 other (or unknown) substance-induced disorders, 584-585 other (or unknown) substance intoxication, 581-582 other (or unknown) substance use disorder, 577-580 other (or unknown) substance withdrawal, 583-584 unspecified other (or unknown) substancerelated disorder, 585

Other (or unknown) substance use disorder, 577-580 associated features supporting diagnosis of, 579 comorbidity with, 580 culture-related diagnostic issues in, 580 development and course of, 580 diagnostic criteria for, 577-578 diagnostic features of, 579 diagnostic markers for, 580 differential diagnosis of, 580 prevalence of, 579 risk and prognostic factors for, 580 specifiers for, 578 Other (or unknown) substance withdrawal, 583-584 comorbidity with, 584 culture-related diagnostic issues in, 583 development and course of, 583 diagnostic criteria for, 583 diagnostic features of, 583 differential diagnosis of, 584 functional consequences of, 584 prevalence of, 583 Panic attacks, 189,190,208-209, 214-217 associated features with, 215 comorbidity with, 217 culture-related diagnostic issues in, 216 development and course of, 215-216 diagnostic markers for, 216 differential diagnosis of, 217 expected vs. unexpected, 215 features of, 214-215 functional consequences of, 217 gender-related diagnostic issues in, 216 nocturnal, 209, 215 in older adults, 210-211, 215-216 prevalence of, 215 risk and prognostic factors for, 216 specifier for, 214-217 suicide risk and, 215 symptoms of, 214 Panic disorder, 190, 208-214 associated features supporting diagnosis of, 210 culture-related diagnostic issues in, 211-212 development and course of, 210-211 diagnostic criteria for, 208-209 diagnostic features of, 209 diagnostic markers for, 212 differential diagnosis of, 212-213 functional consequences of, 212 gender-related diagnostic issues in, 210.212 prevalence of, 210 risk and prognostic factors for, 211 suicide risk in, 212

Paranoid personality disorder, 645,646,649-652 associated features supporting diagnosis of, 650-651 ^ culture-related diagnostic issues in, 651 development and course of, 651 diagnostic criteria for, 649 diagnostic features of, 649-650 differential diagnosis of, 652 prevalence of, 651 risk and prognostic factors for, 651 Paraphilic disorders, 685-705 exhibitionistic disorder, 685, 689-691 fetishistic disorder, 685, 700-702 frotteuristic disorder, 685,691-694 highlights of changes from DSM-IV to DSM-5, 816 other specified paraphilic disorder, 705 pedophilic disorder, 685,697-700 sexual masochism disorder, 685,694-695 sexual sadism disorder, 685,695-697 tansvestic disorder, 685, 702-704 unspecified paraphilic disorder, 705 voyeuristic disorder, 685,686-688 Parasomnias, 361,399^10 nightmare disorder, 361,404^07 non-rapid eye movement sleep arousal disorders, 361,399-404 rapid eye movement sleep behavior disorder, 361,407-410 Parkinsonism neuroleptic-induced, 709 other medication-induced, 709 Parkinson's disease anxiety disorders and, 203,205,207,218,221 depressive disorders and, 181,182 major or mild neurocognitive disorder due to, 591,604,636-638 associated features supporting diagnosis of, 637 comorbidity with, 638 development and course of, 637 diagnostic criteria for, 636-637 diagnostic features of, 637 diagnostic markers for, 637-638 differential diagnosis of, 638 prevalence of, 637 risk and prognostic factors for, 637 sleep-wake disorders and, 372,383,395,413, 421 REM sleep behavior disorder, 361, 408,410 Pedophilic disorder, 685, 697-700 associated features supporting diagnosis of, 698 comorbidity with, 700 development and course of, 699 diagnostic criteria for, 697-698

diagnostic features of, 698 diagnostic markers for, 699 differential diagnosis of, 700 gender-related diagnostic issues in, 699 prevalence of, 698 risk and prognostic factors for, 699 Persistent complex bereavement disorder, 289, 789-792 associated features supporting diagnosis of, 791 comorbidity with, 792 culture-related diagnostic issues in, 791 development and course of, 791 diagnostic features of, 790-791 differential diagnosis of, 792 functional consequences of, 792 prevalence of, 791 proposed criteria for, 789-790 risk and prognostic factors for, 791 suicide risk in, 791 Persistent depressive disorder (dysthymia), 155, 168-171 comorbidity with, 171 development and course of, 170 diagnostic criteria for, 168-169 diagnostic features of, 169-170 differential diagnosis of, 170-171 functional consequences of, 170 prevalence of, 170 risk and prognostic factors for, 170 Personality change due to another medical condition, 645,682-684 associated features supporting diagnosis of, 683 diagnostic criteria for, 682 diagnostic features of, 683 differential diagnosis of, 683-684 subtypes of, 683 Personality disorders, 645-684 Cluster A, 646,649-659 paranoid personality disorder, 645,646, 649-652 schizoid personality disorder, 645,646, 652-655 schizotypal personality disorder, 87,89,90, 645,646, 655-659 Cluster B, 646, 659-672 antisocial personality disorder, 461,476, 645, 646, 659-663 borderline personality disorder, 645, 646, 663-666 histrionic personality disorder, 645,646, 667-669 narcissistic personality disorder, 645,646, 669-672

Personality disorders (continued) Cluster C, 646, 672-682 avoidant personality disorder, 645, 646, 672-675 dependent personality disorder, 645, 646, 675-678 obsessive-compulsive personality disorder, 645, 646, 678-682 general personality disorder, 646-649 criteria for, 646-647 culture-related diagnostic issues in, 648 development and course of, 647-648 diagnostic features of, 647 differential diagnosis of, 648-649 gender-related diagnostic issues in, 648 highlights of changes from DSM-IV to DSM-5, 816 other specified personality disorder, 645-646, 684 personality change due to another medical condition, 645, 682-684 unspecified personality disorder, 645-646, 684 Personality disorders: alternative DSM-5 model, 761-781 diagnosis of, 771 general criteria for personality disorder, 761-763 Criterion A: level of personality functioning, 762, 762 Criterion B: pathological personality traits, 762-763 Criteria C and D: pervasiveness and stability, 763 Criteria E, F, and G: alternative explanations for personality pathology, 763 level of personality functioning, 762, 762, 771-772 Level of Personality Functioning Scale for rating of, 772, 775-778 self- and interpersonal functioning dimensional definition, 772 personality traits, 772-774 assessment of Personality Trait Model, 774 clinical utility of multidimensional personality functioning and trait model, 774 definition and description of, 772-773 definitions of personality disorder trait domains and facets, 779-781 dimensionality of, 772-773 distinguishing traits, symptoms, and specific behaviors, 773-774 hierarchical structure of personality, 773 Personality Trait Model, 773

scoring algorithms for, 771 specific personality disorders, 763-771 antisocial personality disorder, 763, 764-765 avoidant personality disorder, 763, 765-766 borderline personality disorder, 763, 766­ 767 narcissistic personality disorder, 763, 767-768 obsessive-compulsive personality disorder, 764, 768-769 personality disorder—trait specified, 761, 770-771 schizotypal personality disorder, 764, 769-770 Phencyclidine intoxication, 527-529 diagnostic criteria for, 527-528 diagnostic features of, 528 diagnostic markers for, 528 differential diagnosis of, 528-529 functional consequences of, 528 prevalence of, 528 Phencyclidine-related disorders, 481 diagnoses associated v^ith, 482 other phencyclidine-induced disorders, 532 phencyclidine intoxication, 527-529 phencyclidine use disorder, 520-523 unspecified phencyclidine-related disorder, 533 Phencyclidine use disorder, 520-523 associated features supporting diagnosis of, 522 culture-related diagnostic issues in, 522 diagnostic criteria for, 520-521 diagnostic features of, 521-522 diagnostic markers for, 522 differential diagnosis of, 523 functional consequences of, 522 gender-related diagnostic issues in, 522 prevalence of, 522 risk and prognostic factors for, 522 specifiers for, 521 Phobic disorders agoraphobia, 190, 217-221 social anxiety disorder (social phobia), 190, 202-208 specific phobia, 189-190,197-202 Physical abuse child, 717-718 nonspouse or nonpartner, 722 spouse or partner, 720 Pica, 329-331 associated features supporting diagnosis of, 330 comorbidity with, 331 culture-related diagnostic issues in, 331 development and course of, 330 diagnostic criteria for, 329-330

diagnostic features of, 330 diagnostic markers for, 331 differential diagnosis' of, 331 functional consequences of, 331 gender-related diagnostic issues in, 331 prevalence of, 330 risk and prognostic factors for, 330 Posttraumatic stress disorder (PTSD), 265,271-280 associated features supporting diagnosis of, 276 comorbidity with, 280 culture-related diagnostic issues in, 278 development and course of, 276-277 diagnostic criteria for, 271-274 diagnostic features of, 274-276 differential diagnosis of, 279-280 functional consequences of, 278-279 gender-related diagnostic issues in, 278 prevalence of, 276 risk and prognostic factors for, 277-278 suicide risk in, 278 Postural tremor, medication-induced, 712 Premature (early) ejaculation, 423,443-446 associated features supporting diagnosis of, 444 comorbidity with, 446 culture-related diagnostic issues in, 445 development and course of, 444-445 diagnostic criteria for, 443-444 diagnostic features of, 444 diagnostic markers for, 445 differential diagnosis of, 445-446 functional consequences of, 445 gender-related diagnostic issues in, 445 prevalence of, 444 risk and prognostic factors for, 445 Premenstrual dysphoric disorder, 155,171-175 associated features supporting diagnosis of, 173 comorbidity with, 175 culture-related diagnostic issues in, 173 development and course of, 173 diagnostic criteria for, 171-172 diagnostic features of, 172-173 diagnostic markers for, 173-174 differential diagnosis of, 174-175 functional consequences of, 174 prevalence of, 173 recording procedures for, 172 risk and prognostic factors for, 173 Principal diagnosis, 22-23 Prion disease, major or mild neurocognitive disorder due to, 591, 604 634-636 development and course of, 635 diagnostic criteria for, 634-635 diagnostic features of, 635

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diagnostic markers for, 636 differential diagnosis of, 636 prevalence of, 635 risk and prognostic factors for, 636 Problems related to access to medical and other health care, 726 Problems related to crime or interaction with the legal system, 725 Problems related to family upbringing, 715-716 Problems related to other psychosocial, personal, and environmental circumstances, 725 Provisional diagnosis, 23 Pseudocyesis, 310,327 Psychological abuse child, 719 nonspouse or nonpartner, 722 spouse or partner abuse, 721-722 Psychological factors affecting other medical conditions, 309,310,322-324 comorbidity with, 324 culture-related diagnostic issues in, 323 development and course of, 323 diagnostic criteria for, 322 diagnostic features of, 322-323 differential diagnosis of, 323-324 functional consequences of, 323 prevalence of, 323 Psychotic disorder due to another medical condition, 89,115-118 associated features supporting diagnosis of, 116 comorbidity with, 118 development and course of, 117 diagnostic criteria for, 115-116 diagnostic features of, 116 diagnostic markers for, 117 differential diagnosis of, 118 functional consequences of, 118 prevalence of, 116-117 risk and prognostic factors for, 117 specifiers for, 116 suicide risk in, 118 Psychotic disorders. See Schizophrenia spectrum and other psychotic disorders PTSD. See Posttraumatic stress disorder Purging disorder, 353 Pyromania, 461,476-A77 associated features supporting diagnosis of, 476^77 comorbidity with, 477 development and course of, 477 diagnostic criteria for, 476 diagnostic features of, 476 differential diagnosis of, 477 gender-related diagnostic issues in, 477 prevalence of, 477

Rapid eye movement (REM) sleep behavior disorder, 361,407-410 associated features supporting diagnosis of, 408 comorbidity with, 410 development and course of, 408-409 diagnostic criteria for, 407-408 diagnostic features of, 408 diagnostic markers for, 409 differential diagnosis of, 409-410 functional consequences of, 409 prevalence of, 408 relationship to International Classification of Sleep Disorders, 410 risk and prognostic factors for, 409 Reactive attachment disorder, 265-268 associated features supporting diagnosis of, 266 comorbidity with, 268 culture-related diagnostic issues in, 267 development and course of, 266 diagnostic criteria for, 265-266 diagnostic features of, 266 differential diagnosis of, 267-268 functional consequences of, 267 prevalence of, 266 risk and prognostic factors for, 267 Recurrent brief depression, 183 Relational problems, 22, 715-717 other problems related to primary support group, 716-717 problems related to family upbringing, 715-716 REM sleep behavior disorder. See Rapid eye movement sleep behavior disorder Restless legs syndrome (RLS), 361,410-413 associated features supporting diagnosis of, 411 comorbidity with, 413 development and course of, 411-412 diagnostic criteria for, 410 diagnostic features of, 411 diagnostic markers for, 412 differential diagnosis of, 413 functional consequences of, 412-413 gender-related diagnostic issues in, 412 prevalence of, 411 relationship to International Classification of Sleep Disorders, 413 risk and prognostic factors for, 412 Rett syndrome, 33, 38, 51, 53, 56, 57, 79, 80 RLS. See Restless legs syndrome Rumination disorder, 329, 332-333 associated features supporting diagnosis of, 332-333 comorbidity with, 333 development and course of, 333 diagnostic criteria for, 332

diagnostic features of, 332 differential diagnosis of, 333 functional consequences of, 333 prevalence of, 333 risk and prognostic factors for, 333 Schizoaffective disorder, 89-90,105-110 associated features supporting diagnosis of, 107 comorbidity with, 110 culture-related diagnostic issues in, 108-109 development and course of, 108 diagnostic criteria for, 105-106 diagnostic features of, 106-107 differential diagnosis of, 109-110 functional consequences of, 109 prevalence of, 107-108 risk and prognostic factors for, 108 suicide risk in, 109 Schizoid personality disorder, 645, 646, 652-655 associated features supporting diagnosis of, 653-654 culture-related diagnostic issues in, 654 development and course of, 654 diagnostic criteria for, 652-653 diagnostic features of, 653 differential diagnosis of, 654-655 gender-related diagnostic issues in, 654 prevalence of, 654 risk and prognostic factors for, 654 Schizophrenia, 87, 99-105 associated features supporting diagnosis of, 101-102 with catatonia, 88,100 comorbidity with, 105 culture-related diagnostic issues in, 103 development and course of, 102-103 diagnostic features of, 87-88,100-101 differential diagnosis of, 104-105 functional consequences of, 104 gender-related diagnostic issues in, 103-104 prevalence of, 102 risk and prognostic factors for, 103 suicide risk in, 104 Schizophrenia spectrum and other psychotic disorders, 87-122 brief psychotic disorder, 89,94-96 catatonia, 88, 89,119-121 clinician-rated assessment of symptoms and related clinical phenomena in, 89-90 delusional disorder, 89,90-93 highlights of changes from DSM-IV to DSM-5, 810 key features of, 87-88 delusions, 87 disorganized thinking (speech), 88

grossly disorganized or abnormal motor behavior (including catatonia), 88 hallucinations, 87-88 negative symptoms, 88 other specified schizophrenia spectrum and other psychotic disorder, 122 psychotic disorder due to another medical condition, 89,115-118 schizoaffective disorder, 89-90,105-110 schizophrenia, 87,99-105 schizophreniform disorder, 89, 96-99 schizotypal (personality) disorder, 87, 89, 90 substance /medication-induced psychotic disorder, 89,110-115 unspecified schizophrenia spectrum and other psychotic disorder, 122 Schizophreniform disorder, 89, 96-99 associated features supporting diagnosis of, 98 development and course of, 98 diagnostic criteria for, 96-97 diagnostic features of, 97-98 differential diagnosis of, 98-99 functional consequences of, 98 prevalence of, 98 provisional diagnosis of, 97 risk and prognostic factors for, 98 Schizotypal personality disorder, 87,89,90, 645, 646,655-659 associated features supporting diagnosis of, 657 culture-related diagnostic issues in, 657 development and course of, 657 diagnostic criteria for, 655-656 diagnostic features of, 656-657 differential diagnosis of, 658-659 features and criteria in alternative DSM-5 model for personality disorders, 764, 769-770 gender-related diagnostic issues in, 658 prevalence of, 657 risk and prognostic factors for, 657 Sedative, hypnotic, or anxiolytic intoxication, 556-557 associated features supporting diagnosis of, 557 diagnostic criteria for, 556 diagnostic features of, 556-557 differential diagnosis of, 557 prevalence of, 557 Sedative-, hypnotic-, or anxiolytic-related disorders, 481, 550-560 diagnoses associated with, 482 other sedative-, hypnotic-, or anxiolyticinduced disorders, 560 sedative, hypnotic, or anxiolytic intoxication, 556-557

sedative, hypnotic, or anxiolytic use disorder, 550-556 sedative, hypnotic, or anxiolytic withdrawal, 484, 557-560 unspecified sedative-, hypnotic-, or anxiolyticrelated disorder, 560 Sedative, hypnotic, or anxiolytic use disorder, 550-556 associated features supporting diagnosis of, 553 comorbidity with, 555-556 culture-related diagnostic issues in, 554 development and course of, 553-554 diagnostic criteria for, 550-552 diagnostic features of, 552-553 diagnostic markers for, 554-555 differential diagnosis of, 555 functional consequences of, 555 gender-related diagnostic issues in, 554 prevalence of, 553 risk and prognostic factors for, 554 specifiers for, 552 Sedative, hypnotic, or anxiolytic withdrawal, 484, 557-560 associated features supporting diagnosis of, 559 diagnostic criteria for, 557-558 diagnostic features of, 558 diagnostic markers for, 559 differential diagnosis of, 559-560 prevalence of, 559 Selective mutism, 189,195-197 associated features supporting diagnosis of, 195-196 comorbidity with, 197 culture-related diagnostic issues in, 196 development and course of, 196 diagnostic criteria for, 195 diagnostic features of, 195 differential diagnosis of, 197 functional consequences of, 196-197 prevalence of, 196 risk and prognostic factors for, 196 Separation anxiety disorder, 189,190-195 associated features supporting diagnosis of, 192 comorbidity with, 195 culture-related diagnostic issues in, 193 development and course of, 192-193 diagnostic criteria for, 190-191 diagnostic features of, 191-192 differential diagnosis of, 194-195 functional consequences of, 193-194 gender-related diagnostic issues in, 193 prevalence of, 192 risk and prognostic factors for, 193 suicide risk in, 193

Severity measures, 733,742 Clinician-Rated Dimensions of Psychosis Symptom Severity, 742-744 frequency of use of, 742 scoring and inteφretation of, 742 Sexual abuse child, 718 nonspouse or nonpartner, 722 spouse or partner, 720 Sexual dysfunctions, 423-450 delayed ejaculation, 423,424-426 erectile disorder, 423,426-429 female orgasmic disorder, 423,429-432 female sexual interest/arousal disorder, 423, 433-437 genito-pelvic pain/penetration disorder, 423, 437-440 highlights of changes from DSM-IV to DSM-5, 814 male hypoactive sexual desire disorder, 423, 440-443 other specified sexual dysfunction, 423,450 premature (early) ejaculation, 423,443-446 substance/medication-induced sexual dysfunction, 423,446-450 subtypes of, 423 unspecified sexual dysfunction, 423,450 Sexual masochism disorder, 685, 694-695 associated features supporting diagnosis of, 694 comorbidity with, 695 development and course of, 695 diagnostic criteria for, 694 diagnostic features of, 694 differential diagnosis of, 695 functional consequences of, 695 prevalence of, 694 Sexual sadism disorder, 685,695-697 associated features supporting diagnosis of, 696 comorbidity with, 697 development and course of, 697 diagnostic criteria for, 695 diagnostic features of, 696 differential diagnosis of, 697 prevalence of, 696 Shenjing shuairuo, 835-836 Shubo-kyofu, 264 Skin picking. See Excoriation (skin-picking) disorder Sleep-related hypoventilation, 387-390 associated features supporting diagnosis of, 387-388 comorbidity with, 389-390 development and course of, 388 diagnostic criteria for, 387 diagnostic features, 387

diagnostic markers for, 389 differential diagnosis of, 389 functional consequences of, 389 gender-related diagnostic issues in, 389 prevalence of, 388 relationship to International Classification of Sleep Disorders, 390 risk and prognostic factors for, 388 subtypes of, 387 Sleep terrors, 399-403. See also Non-rapid eye movement sleep arousal disorders Sleep-wake disorders, 361^22 breathing-related sleep disorders, 361,378-390 central sleep apnea, 383-386 obstructive sleep apnea hypopnea, 378-383 sleep-related hypoventilation, 387-390 circadian rhythm sleep-wake disorders, 361, 390-398 advanced sleep phase type, 393-394 delayed sleep phase type, 391-392 irregular sleep-wake type, 394-396 non-24-hour sleep-wake type, 396-397 shift work type, 397-398 highlights of changes from DSM-IV to DSM-5, 814 hypersomnolence disorder, 361,368-372 other specified, 421 unspecified, 421 insomnia disorder, 361,362-368 other specified, 420 unspecified, 420-421 narcolepsy, 361,372-378 other specified sleep-wake disorder, 421 parasomnias, 399-410 nightmare disorder, 361,404-407 non-rapid eye movement sleep arousal disorders, 361,399-404 rapid eye movement sleep behavior disorder, 361,407-410 relationship to International Classification of Sleep Disorders, 361-362 (See also specific sleep-wake disorders) restless legs syndrome, 361,410-413 substance/medication-induced sleep disorder, 413-420 unspecified sleep-wake disorder, 422 Sleepwalking, 399-403. See also Non-rapid eye movement sleep arousal disorders Smoking. See Tobacco-related disorders Social anxiety disorder (social phobia), 190, 202-208 associated features supporting diagnosis of, 204 comorbidity with, 208 culture-related diagnostic issues in, 205-206

development and course of, 205 diagnostic criteria for, 202-203 diagnostic features oi, 203-204 differential diagnosis of, 206-207 functional consequences of, 206 gender-related diagnostic issues in, 204, 206 prevalence of, 204 risk and prognostic factors for, 205 specifiers for, 203 Social (pragmatic) communication disorder, 31, 47-49 associated features supporting diagnosis of, 48 development and course of, 48 diagnostic criteria for, 47-48 diagnostic features of, 48 differential diagnosis of, 49 risk and prognostic factors for, 48 Somatic symptom disorder, 309,310,311-315 associated features supporting diagnosis of, 312 comorbidity with, 314-315 culture-related diagnostic issues in, 313 development and course of, 312-313 diagnostic criteria for, 311 diagnostic features of, 311-312 differential diagnosis of, 314 prevalence of, 312 risk and prognostic factors for, 313 Somatic symptoms and related disorders, 309-327 conversion disorder (functional neurological symptom disorder), 309,310,318-321 factitious disorder, 309, 310, 324-326 highlights of changes from DSM-IV to DSM-5, 812-813 illness anxiety disorder, 309,310,315-318 other specified somatic symptom and related disorder, 309,310,327 psychological factors affecting other medical conditions, 309, 310, 322-324 somatic symptom disorder, 309, 310, 311-315 unspecified somatic symptom and related disorder, 309,310,327 Specific learning disorder, 32, 66-74 associated features supporting diagnosis of, 70 comorbidity with, 72, 74 culture-related diagnostic issues in, 72-73 development and course of, 70-72 diagnostic criteria for, 66-68 diagnostic features of, 68-70 differential diagnosis of, 73-74 functional consequences of, 73 gender-related diagnostic issues in, 73 prevalence of, 70 recording procedures for, 68 risk and prognostic factors for, 72

Specific phobia, 189-190,197-202 associated features supporting diagnosis of, 199 comorbidity with, 202 culture-related diagnostic issues in, 201 development and course of, 199-200 diagnostic criteria for, 197-198 diagnostic features of, 198-199 differential diagnosis of, 201-202 functional consequences of, 201 prevalence of, 199 risk and prognostic factors for, 200 specifiers for, 198 suicide risk in, 201 Specifiers, 21-22 Specifiers for bipolar and related disorders, 149-154 Specifiers for depressive disorders, 184^188 Speech sound disorder, 3 1 ,44r-45 associated features supporting diagnosis of, 44 development and course of, 44-45 diagnostic criteria for, 44 diagnostic features of, 44 differential diagnosis of, 45 Spouse or partner abuse, psychological, 721-722 Spouse or partner neglect, 721 Spouse or partner violence physical, 720 sexual, 720 Stereotypic movement disorder, 32, 77-80 comorbidity with, 80 culture-related diagnostic issues in, 79 development and course of, 79 diagnostic criteria for, 77-78 diagnostic features of, 78-79 differential diagnosis of, 79-80 prevalence of, 79 recording procedures for, 78 risk and prognostic factors for, 79 specifiers for, 78 Stimulant intoxication, 567-569 associated features supporting diagnosis of, 568 diagnostic criteria for, 567-568 diagnostic features of, 568 differential diagnosis of, 568-569 Stimulant-related disorders, 481, 561-570 diagnoses associated with, 482 other stimulant-induced disorders, 570 stimulant intoxication, 567-569 stimulant use disorder, 561-567 stimulant withdrawal, 484, 569-570 unspecified stimulant-related disorder, 570 Stimulant use disorder, 561-567 associated features supporting diagnosis of, 563-564 comorbidity with, 566-567

Stimulant use disorder (continued) culture-related diagnostic issues in, 565 development and course of, 564-565 diagnostic criteria for, 561-562 diagnostic features of, 563 diagnostic markers for, 565-566 differential diagnosis of, 566 functional consequences of, 566 prevalence of, 564 risk and prognostic factors for, 565 specifiers for, 563 Stimulant withdrawal, 484, 569-570 associated features supporting diagnosis of, 570 diagnostic criteria for, 569 differential diagnosis of, 570 Stroke, 46, 73,117 bipolar disorder and, 146,147 depressive disorders and, 164,167,181-182 Stuttering. See Childhood-onset fluency disorder (stuttering) Substance-induced disorders, 481,485^90. See also specific substances of abuse alcohol-related, 497-503 caffeine-related, 503-508 cannabis-related, 516-519 hallucinogen-related, 527-533 inhalant-related, 538-540 opioid-related, 546-549 other (or unknown) substance-related, 581-585 sedative-, hypnotic-, or anxiolytic-related, 556-560 substance intoxication and withdrawal, 481, 485-487 {See also Intoxication; Withdrawal from substance) associated with use of multiple substances, 486 development and course of, 487 duration of effects and, 486 laboratory findings associated with, 486-487 recording procedures for, 487 related to route of administration and speed of substance effects, 486 substance/medication-induced mental disorders, 481,487-490 development and course of, 489 features of, 488-489 functional consequences of, 490 recording procedures for, 490 tobacco-related, 575-576 Substance intoxication delirium, 596-597, 598 Substance/medication-induced anxiety disorder, 190,226-230 associated features supporting diagnosis of, 228-229

diagnostic criteria for, 226-227 diagnostic features of, 228 diagnostic markers for, 229 differential diagnosis of, 229-230 prevalence of, 229 recording procedures for, 227-228 Substance/medication-induced bipolar and related disorder, 123,142-145 associated features supporting diagnosis of, 144 comorbidity with, 146 development and course of, 144-145 diagnostic criteria for, 142-143 diagnostic features of, 144 diagnostic markers for, 145 differential diagnosis of, 145 prevalence of, 144 recording procedures for, 143-144 Substance/medication-induced depressive disorder, 155,175-180 comorbidity with, 180 development and course of, 178 diagnostic criteria for, 175-176 diagnostic features of, 177-178 diagnostic markers for, 179 differential diagnosis of, 179-180 prevalence of, 178 recording procedures for, 176-177 risk and prognostic factors for, 178-179 suicide risk in, 179 Substance /medication-induced neurocognitive disorder, 591, 603, 627-632 associated features supporting diagnosis of, 630 comorbidity with, 632 development and course of, 631 diagnostic criteria for, 627-629 diagnostic features of, 629-630 diagnostic markers for, 631 differential diagnosis of, 631 functional consequences of, 631 prevalence of, 630 recording procedures for, 629 risk and prognostic factors for, 631 Substance /medication-induced obsessivecompulsive and related disorder, 235, 236, 257-260 associated features supporting diagnosis of, 259 diagnostic criteria for, 257-258 diagnostic features of, 259 differential diagnosis of, 259-260 prevalence of, 259 recording procedures for, 258-259 Substance /medication-induced psychotic disorder, 89,110-115 associated features supporting diagnosis of, 113 development and course of, 114

diagnostic criteria for, 110-111 diagnostic features o(, 112-113 diagnostic markers for, 114 differential diagnosis of, 114-115 functional consequences of, 114 prevalence of, 113 recording procedures for, 112 Substance /medication-induced sexual dysfunction, 423,446-450 associated features supporting diagnosis of, 448-449 culture-related diagnostic issues in, 449 development and course of, 449 diagnostic criteria for, 446-447 diagnostic features of, 448 differential diagnosis of, 450 functional consequences of, 450 gender-related diagnostic issues in, 449 prevalence of, 449 recording procedures for, 447-448 Substance/medication-induced sleep disorder, 413-420 associated features supporting diagnosis of, 416-418 comorbidity with, 420 culture-related diagnostic issues in, 418 development and course of, 418 diagnostic criteria for, 413-415 diagnostic features of, 416 diagnostic markers for, 419 differential diagnosis of, 419^20 functional consequences of, 419 gender-related diagnostic issues in, 418 recording procedures for, 415^16 relationship to International Classification of Sleep Disorders, 420 risk and prognostic factors for, 418 Substance-related and addictive disorders, 481-589 gambling disorder, 481, 585-589 highlights of changes from DSM-IV to DSM-5, 815 substance-related disorders, 481-585 {See also specific substances of abuse) alcohol-related disorders, 490-503 caffeine-related disorders, 503-509 cannabis-related disorders, 509-519 diagnoses associated with substance class, 482 drug classes in, 481 hallucinogen-related disorders, 520-533 inhalant-related disorders, 533-540 opioid-related disorders, 540-550 other (or unknown) substance-related disorders, 577-585

sedative-, hypnotic- or anxiolytic-related disorders, 550-560 stimulant-related disorders, 561-570 substance-induced disorders, 481,485-490 substance use disorders, 481, 483-485, 490-585 tobacco-related disorders, 571-577 Substance use disorders, 481,483-485 alcohol use disorder, 490-497 caffeine use disorder, 792-795 cannabis use disorder, 509-516 features of, 483^84 inhalant use disorder, 533-538 opioid use disorder, 541-546 other hallucinogen use disorder, 523-527 other (or unknown) substance use disorder, 577-580 phencyclidine use disorder, 520-523 recording procedures for, 485 sedative, hypnotic, or anxiolytic use disorder, 550-556 severity and specifiers for, 484 stimulant use disorder, 561-567 tobacco use disorder, 571-574 tolerance and withdrawal in, 484 Substance withdrawal delirium, 597, 598-599 Suicidal behavior disorder, 801-803 comorbidity with, 803 culture-related diagnostic issues in, 802 development and course of, 802 diagnostic features of, 801-802 diagnostic markers for, 802 functional consequences of, 802 proposed criteria for, 801 specifiers for, 801 Suicide risk anorexia nervosa and, 343 bipolar I disorder and, 131 bipolar II disorder and, 138 body dysmorphic disorder and, 245 bulimia nervosa and, 349 depressive disorder due to another medical condition and, 182 depressive episodes with short-duration hypomania and, 788 disruptive mood dysregulation disorder and, 158 dissociative amnesia and, 300 dissociative identity disorder and, 295 major depressive disorder and, 164,167 neurobehavioral disorder associated with prenatal alcohol exposure and, 800 obsessive-compulsive disorder and, 240 opioid use disorder and, 544 other hallucinogen intoxication and, 530

Suicide risk (continued) panic attacks and, 215 panic disorder and, 212 persistent complex bereavement disorder and, 791 posttraumatic stress disorder and, 278 psychotic disorder due to another medical condition and, 118 schizoaffective disorder and, 109 schizophrenia and, 104 separation anxiety disorder and, 193 specific phobia and, 201 substance /medication-induced depressive disorder and, 180 Susto, 836-837 Taijin kyofiisho, 205, 837 Tardive akathisia, 712 Tardive dyskinesia, 22, 712 Tardive dystonia, 712 Technical terms, glossary of, 817-831 Tic disorders, 32, 81-85 comorbidity with, 83, 85 culture-related diagnostic issues in, 83 development and course of, 83 diagnostic criteria for, 81 diagnostic features of, 81-82 differential diagnosis of, 84 functional consequences of, 84 gender-related diagnostic issues in, 83, 84 other specified tic disorder, 85 prevalence of, 83 risk and prognostic factors for, 83 specifiers for, 81 unspecified tic disorder, 85 Tobacco-related disorders, 481, 571-577 diagnoses associated with, 482 other tobacco-induced disorders, 576 tobacco use disorder, 571-574 tobacco withdrawal, 484, 575-576 unspecified tobacco-related disorder, 577 Tobacco use disorder, 571-574 associated features supporting diagnosis of, 573 comorbidity with, 574 culture-related diagnostic issues in, 574 development and course of, 573 diagnostic criteria for, 571-572 diagnostic features of, 572-573 diagnostic markers for, 574 functional consequences of, 574 prevalence of, 573 risk and prognostic factors for, 573-574 specifiers for, 572 Tobacco withdrawal, 484,575-576 associated features supporting diagnosis of, 575

development and course of, 576 diagnostic criteria for, 575 diagnostic features of, 575 diagnostic markers for, 576 differential diagnosis of, 576 functional consequences of, 576 prevalence of, 576 risk and prognostic factors for, 576 Tolerance to substance effects, 484 Tourette's disorder, 32. See also Tic disorders diagnostic criteria for, 81 diagnostic features of, 81-82 functional consequences of, 84 prevalence of, 83 risk and prognostic factors for, 83 Transvestic disorder, 685, 702-704 associated features supporting diagnosis of, 703 comorbidity with, 704 development and course bf, 703-704 diagnostic criteria for, 702 diagnostic features of, 703 differential diagnosis of, 704 functional consequences of, 704 prevalence of, 703 specifiers for, 703 Trauma- and stressor-related disorders, 265-290 acute stress disorder, 265, 280-286 adjustment disorders, 265, 286-289 disinhibited social engagement disorder, 265, 268-270 highlights of changes from DSM-IV to DSM-5, 812 other specified trauma- and stressor-related disorder, 289 posttraumatic stress disorder, 265, 271-280 reactive attachment disorder, 265-268 unspecified trauma- and stressor-related disorder, 290 Traumatic brain injury bipolar disorder and, 146 depressive disorders and, 181 dissociative amnesia and, 298,299, 301 hoarding disorder and, 247, 250 major or mild neurocognitive disorder due to, 591, 603, 624-627, 626 associated features supporting diagnosis of, 625 comorbidity with, 627 development and course of, 625-626 diagnostic criteria for, 624 diagnostic features of, 625 diagnostic markers for, 627 differential diagnosis of, 627 functional consequences of, 627

prevalence of, 625 risk and prognostic factors for, 626-627 specifiers for, 62^ neurodevelopmental disorders and, 38,39,44, 73 psychotic disorders and, 99,117 severity ratings for, 625, 626 trauma- and stressor-related disorders and, 280, 281, 284, 286 Tremor, medication-induced, 712 Trichotillomania (hair-pulling disorder), 235, 236, 251-254 associated features supporting diagnosis of, 252 comorbidity with, 254 culture-related diagnostic issues in, 253 development and course of, 253 diagnostic criteria for, 251 diagnostic features of, 251-252 diagnostic markers for, 253 differential diagnosis of, 253-254 functional consequences of, 253 prevalence of, 252 risk and prognostic factors for, 253 Trùnggiô, 211,212 Unspecified mental disorder, 15-16,19-20, 708 due to another medical condition, 708 Vascular neurocognitive disorder, major or mild, 591, 603, 621-624 associated features supporting diagnosis of, 622 comorbidity with, 624 development and course of, 623 diagnostic criteria for, 621 diagnostic features of, 621-622 diagnostic markers for, 623 differential diagnosis of, 623-624 functional consequences of, 623 prevalence of, 622-623 risk and prognostic factors for, 623

Voyeuristic disorder, 685,686-688 comorbidity with, 688 development and course of, 688 diagnostic criteria for, 686-687 diagnostic features of, 687 differential diagnosis of, 688 gender-related diagnostic issues in, 688 prevalence of, 687-688 risk and prognostic factors for, 688 specifiers for, 687 Withdrawal from substance, 481,485-487 alcohol, 499-501 caffeine, 506-508 cannabis, 517-519 delirium due to, 598 development and course of, 487 duration of effects and, 486 laboratory findings associated with, 486-487 multiple substances, 486 opioids, 484,547-549 other (or unknown) substance, 583-584 recording procedures for, 487 related to route of administration and speed of substance effects, 486 sedative, hypnotic, or anxiolytic, 484, 557-560 stimulant, 484,569-570 tobacco, 484,575-576 World Health Organization (WHO), 6,23 International Classification of Diseases (ICD), 21 revision process for ICD-11,6,10,11-12 use of ICD-9-CM and ICD-10 codes, 12,16, 22, 23,29 International Classification of Functioning, Disability and Health (ICF), 21, 734 World Health Organization Disability Assessment Schedule 2.0 (WHODAS), 16,21, 734, 745-748 additional scoring and inteφretation guidance for DSM-5 users, 745-746 frequency of use of, 746 scoring instructions provided by WHO for, 745