maladaptive

American Psychiatric Association

Officers 2012-2013 President D ilip V. Jeste, M.D.

President-Elect Jeffrey A. Lieberman, M.D. Treasurer David Fassler, M.D.

Secretary Rcxser Peele, M.D.

Assembly Speaker R. Scott Benson, M.D.

Speaker-Elect M elinda L. Young, M.D.

Board of Trustees Jeffrey Akaka, M.D.

Carol A. Bernstein, M.D. BrL·̂ ̂Crowley, M.D.

Anita S. Everett, M.D. Jeffrey Geller, M.D., M.P.H.

M ^ c David Graff, M.D. ‘ J ^ e&A. G i^ eneVM.D. Judith F. Kashtan, M.D. Molly K. McVoy, M.D. James E. N ininger, M.D. John M. Oldham , M.D.

Alan F. Schatzberg, M.D. Alik s . W idge, M.D., Ph .D.

Erik R. Vanderlip, M.D., Member-in-Training Trustee-Elect

DIAGNOSTIC AND STATISTICAL MANUAL OF

MENTAL DISORDERS7 FI FTH E D I T I O N

DSM-5TM

New School Library

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Osvchiatric

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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 ^ n A CIP record is available from the British Library. ^

Text Design—Tammy J. Cordova

Manufacturing—Edwards Brothers Malloy ^

cH

Contents

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

Section I DSM-5 Basics

Introduction……………………………………………………………………….. 5

Use of the Manual………………………………………………………………19

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

Section II Diagnostic Criteria and Codes

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

Disruptive, Impulse-Control, and Conduct Disorders…………..461 Substance-Related and Addictive Disorders……………………… 481 Neurocognitive Disorders…………………………………………………. 591 Personality Disorders……………………………………………………….645 Paraphilic Disorders…………………………………………………………685 Other Mental Disorders…………………………………………………… 707

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

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

Section III Emerging Measures and Models

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

Cultural Formulation…………………………………………………………749

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

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

Appendix Highlights of Changes From DSM-IV to DSM-5………………….. 809 Glossary of Technical Terms……………………………………………. 817 Glossary of Cultural Concepts of Distress…………………………. 833 Alphabetical Listing of DSM-5 Diagnoses and Codes

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

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

(ICD-10-CM)………………………………………………………………….877 DSM-5 Advisors and Other Contributors…………………………… 897

Index………………………………………………………………………………. 917

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

Task Force Chair Darrel A. Regier, M.D., M.P.H.

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

Research Director

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)

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

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

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

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

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

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

Jennifer J. Shupinka, Assistant Director, DSM Operations

Seung-Hee Hong, DSM Senior Research Associate

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

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

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

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

Christopher M. Reynolds, Executive Assistant

APA Office of the IVIedlcal Director James 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

David Shaffer, M.D. Chair

F. Xavier Castellanos, M.D. Co-Chair

Paul J. Frick, Ph.D., Text Coordinator Luis Augusto Rohde, M.D., Sc.D. Glorisa Canino, Ph.D. Rosemary Tannock, Ph.D. Terrie E. Moffitt, Ph.D. Eric A. Taylor, M.B. Joel T. Nigg, Ph.D. Richard Todd, Ph.D., M.D. (d. 2008)

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

Katharine A. Phillips, M.D. Chair

Michelle G. Craske, Ph.D., Text Scott L. Rauch, M.D. Coordinator H. Blair Simpson, M.D., Ph.D.

J. Gavin Andrews, M.D. David Spiegel, M.D. Susan M. Bögels, Ph.D. Dan J. Stein, M.D., Ph.D. Matthew J. Friedman, M.D., Ph.D. Murray B. Stein, M.D. Eric Hollander, M.D. (2007-2009) Robert J. Ursano, M.D. Roberto Lewis-Fernandez, M.D., M.T.S. Hans-Ulrich Wittchen, Ph.D. Robert S. Pynoos, M.D., M.P.H.

Childhood and Adolescent Disorders Daniel S. Pine, M.D.

Chair Ronald E. Dahl, M.D. James F. Leckman, M.D. E. Jane Costello, Ph.D. (2007-2009) Ellen Leibenluft, M.D. Regina Smith James, M.D. Judith H. L. Rapoport, M.D. Rachel G. Klein, Ph.D. Charles H. Zeanah, M.D.

Eating Disorders B. T imothy W alsh, M.D.

Chair Stephen A. Wonderlich, Ph.D., Richard E. Kreipe, M.D.

Text Coordinator Marsha D. Marcus, Ph.D. Evelyn Attia, M.D. James E. Mitchell, M.D. Anne E. Becker, M.D., Ph.D., Sc.M. Ruth H. Striegel-Moore, Ph.D. Rachel Bryant-Waugh, M.D. G. Terence Wilson, Ph.D. Hans W. Hoek, M.D., Ph.D. Barbara E. Wolfe, Ph.D. A.P.R.N.

Mood Disorders Ja n a . F a w ce 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 Dan G. Blazer, M.D., Ph .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 Susan E. Swedo, M.D.

Chair Gillian Baird, M.A., M.B., B.Chir.,

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

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

Personality and Personality Disorders^ Andrew E. Skodol, M.D.

Chair John M. Oldham , M.D.

Co-Chair Robert F. Krueger, Ph.D., Text

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

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

̂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. Carpenter Jr ., M.D.

Chair Deanna M. Barch, Ph.D., Text Dolores Malaspina, M.D., M.S.P.H.

Coordinator Michael J. Owen, M.D., Ph.D. Juan R. Bustillo, M.D. Susan K. Schultz, M.D. Wolfgang Gaebel, M.D. Rajiv Tandon, M.D. Raquel E. Gur, M.D., Ph.D. Ming T. Tsuang, M.D., Ph.D. Stephan H. Heckers, M.D. Jim van Os, M.D.

Sexual and Gender Identity Disorders Kenneth J. Zucker, Ph .D.

Chair Lori Brotto, Ph.D., Text Coordinator Martin P. Kafka, M.D. Irving M. Binik, Ph.D. Richard B. Krueger, M.D. Ray M. Blanchard, Ph.D. Niklas Langström, M.D., Ph.D. Peggy T. Cohen-Kettenis, Ph.D. Heino F.L. Meyer-Bahlburg, Dr. rer. nat. Jack Drescher, M.D. Friedemann Pfäfflin, M.D. Cynthia A. Graham, Ph.D. Robert Taylor Segraves, M.D., Ph.D.

Sleep-Wake Disorders Charles F. Reynolds III, M.D.

Chair Ruth M. O’Hara, Ph.D., Text Coordinator Kathy P. Parker, Ph.D., R.N. Charles M. Morin, Ph.D. Susan Redline, M.D., M.P.H. Allan I. Pack, Ph.D. Dieter Riemann, Ph.D.

Somatic Symptom Disorders Joel E. D imsdale, M.D.

Chair James L. Levenson, M.D., Text Michael R. Irwin, M.D.

Coordinator Francis J. Keefe, Ph.D. (2007-2011) Arthur J. Barsky III, M.D. Sing Lee, M.D. Francis Creed, M.D. Michael Sharpe, M.D. Nancy Frasure-Smith, Ph.D. (2007-2011) Lawson R. Wulsin, M.D.

Substance-Related Disorders Charles P. O ‘Brien, M.D., Ph .D.

Chair Thomas J. Crowley, M.D.

Co-Chair Wilson M. Compton, M.D., M.P.E., Thomas R. Kosten, M.D. (2007-2008)

Text Coordinator Walter Ling, M.D. Marc Auriacombe, M.D. Spero M. Manson, Ph.D. (2007-2008) Guilherme L. G. Borges, M.D., Dr .Sc. A. Thomas McLellan, Ph.D. (2007-2008) Kathleen K. Bucholz, Ph.D. Nancy M. Petry, Ph.D. Alan J. Budney, Ph.D. Marc A. Schuckit, M.D. Bridget F. Grant, Ph.D., Ph.D. Wim van den Brink, M.D., Ph.D. Deborah S. Hasin, Ph.D. (2007-2008)

DSM-5 Study Groups Diagnostic Spectra and DSM/ICD Harmonization

Steven E. Hyman, M.D. Chair (2007-2012)

William T. Carpenter Jr., M.D. William E. Narrow, M.D., M.P.H. Wilson M. Compton, M.D., M.P.E. Charles P. O’Brien, M.D., Ph.D. Jan A. Fawcett, M.D. John M. Oldham, M.D. Helena C. Kraemer, Ph.D. Katharine A. Phillips, M.D. David J. Kupfer, M.D. Darrel A. Regier, M.D., M.P.H.

Lifespan Developmental Approaches Eric J. Lenze, M.D.

Chair Susan K. Schultz, M.D.

Chair Emeritus Daniel S. Pine, M.D.

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

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

Gender and Cross-Cultural Issues Kimberly A. Yonkers, M.D.

Chair Roberto Lewis-Fernândez, 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 Lawson 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 Jan e S. P au lsen , Ph.D.

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

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

Diagnostic Assessment Instruments Jack D. Burke Jr ., M.D., M.P.H.

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

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

DSM-5 Research Group W illiam E. Narrow , M.D., M.P.H.

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

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

Course Specifiers and Glossary Wolfgang Gaebel, M.D.

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

Consultant Susan K. Schultz, M.D.

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

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 (___.__) Intellectual Disability (Intellectual Developmental Disorder) (33)

Specify current severity; (F70) Mild (F71) Moderate (F72) Severe (F73) Profound

315.8 (F88) Global Developmental Delay (41)

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

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

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

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

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

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

Specific Learning Disorder (66) ___.__ (___.__) Specific Learning Disorder (66)

Specify if: 315.00 (F81.0) With impairment in reading {specify if with word reading

accuracy, reading rate or fluency, reading comprehension) 315.2 (F81.81 ) With impairment in written expression {specify if with spelling

accuracy, grammar and punctuation accuracy, clarity or organization of written expression)

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

Specify current severity: Mild, Moderate, Severe

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

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

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

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

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

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)

297.1 (F22)

298.8 (F23)

295.40 (F20.81)

295.90 (F20.9)

295.70 (F25.0) 295.70 (F25.1)

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

Schizotypal (Personality) Disorder (90)

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

postpartum onset Schizophreniform Disorder^’ ̂ (96) Specify if: With good prognostic features. Without good prognostic fea­

tures Schizophrenia^’ ̂(99)

Schizoaffective Disorder^’ ̂(105) Specify whether:

Bipolar type 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

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:

Ŝpecify: 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

296.41 296.42 296.43 296.44 296.45 296.46 296.40 296.40 296.45 296.46 296.40

296.51 296.52 296.53 296.54 296.55 296.56 296.50 296.7

(F31.11) (F31.12) (F31.13) (F31.2) (F31.73) (F31.74) (F31.9) (F31.0) (F31.73) (F31.74) (F31.9)

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

296.89 (F31.81)

Bipolar I Disorder® (123) Current or most recent episode manic

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

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

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

Current or most recent episode unspecified

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

293.83 (__ ._ )

(F06.33) (F06.33) (F06.34)

296.89 (F31.89)

296.80 (F31.9)

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

Bipolar and Related Disorder Due to Another Medical Condition (145)

Specify if: With manic features With manic- or hypomanic-like episode With mixed features

Other Specified Bipolar and Related Disorder (148)

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 mood- congruent 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)

. ( _ . ) Single episode 296.21 (F32.0) Mild 296.22 (F32.1) Moderate 296.23 (F32.2) Severe 296.24 (F32.3) With psychotic features 296.25 (F32.4) In partial remission 296.26 (F32.5) In full remission 296.20 (F32.9) Unspecified

. ( _ · ) Recurrent episode 296.31 (F33.0) Mild 296.32 (F33.1) Moderate 296.33 (F33.2) Severe 296.34 (F33.3) With psychotic features 296.35 (F33.41) In partial remission 296.36 (F33.42) In full remission 296.30 (F33.9) Unspecified 300.4 (F34.1) Persistent Depressive Disorder (Dysthymia)® (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

625.4 (N94.3)

(__■_)

293.83 (__ ._ )

(F06.31) (F06.32) (F06.34)

311 (F32.8)

311 (F32.9)

episode; With intermittent major depressive episodes, without current episode

Specify current severity: Mild, Moderate, Severe 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

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

With depressive features With major depressive-like episode With mixed features

Other Specified Depressive Disorder (183)

Unspecified Depressive Disorder (184)

Anxiety Disorders (189) 309.21 (F93.0)

312.23 (F94.0)

300.29 (__ ._ )

(F40.218) (F40.228) ( _ · _ ) (F40.230) (F40.231) (F40.232) (F40.233) (F40.248) (F40.298)

300.23 (F40.10)

300.01 (F41.0)

300.22 (F40.00)

300.02 (F41.1)

Separation Anxiety Disorder (190)

Selective Mutism (195)

Specific Phobia (197) Specify if:

Animal Natural environment Blood-injection-injury

Fear of blood Fear of injections and transfusions Fear of other medical care Fear of injury

Situational Other

Social Anxiety Disorder (Social Phobia) (202) Specify if: Performance only Panic Disorder (208)

Panic Attack Specifier (214)

Agoraphobia (217)

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)

300.7 (F45.22)

300.3 (F42)

312.39 (F63.2)

698.4 (L98.1)

(_._J

294.8 (F06.8)

300.3 (F42)

300.3 (F42)

Obsessive-Compulsive Disorder^ (237) Specify if: Tic-related Body Dysmorphic Disorder^ (242) Specify if: With muscle dysmorphia Hoarding Disorder^ (247) Specify if: With excessive acquisition Trichotillomania (Hair-Pulling Disorder) (251)

Excoriation (Skin-Picking) Disorder (254)

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

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

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

Obsessive-Compulsive and Related Disorder Due to Another Medical Condition (260)

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

Other Specified Obsessive-Compulsive and Related Disorder (263)

Unspecified Obsessive-Compulsive and Related Disorder (264)

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

313.89 (F94.2)

309.81 (F43.10)

308.3 (F43.0)

Reactive Attachment Disorder (265) Specify if: Persistent Specify current severity: Severe Disinhibited Social Engagement Disorder (268) Specify if: Persistent Specify current severity: Severe Posttraumatic Stress Disorder (includes Posttraumatic Stress

Disorder for Children 6 Years and Younger) (271) Specify whether: With dissociative symptoms Specify if: With delayed expression Acute Stress Disorder (280)

XX DSM-5 Classification

( ■_) Adjustment Disorders (286) Specify whether:

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

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

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

Dissociative Disorders (291) 300.14 (F44.81) Dissociative Identity Disorder (292)

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

300.13 (F44.1) With dissociative fugue

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

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

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

Somatic Symptom and Related Disorders (309) 300.82 (F45.1) Somatic Symptom Disorder (311)

Specify if: With predominant pain Specify if: Persistent Specify current severity: Mild, Moderate, Severe

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

300.11 ( ._ ) Conversion Disorder (Functional Neurological Symptom Disorder) (318)

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

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

logical stressor

316 (F54)

300.19 (F68.10)

300.89 (F45.8)

300.82 (F45.9)

Psychological Factors Affecting Other Medical Conditions (322) Specify current severity: Mild, Moderate, Severe, Extreme Factitious Disorder (includes Factitious Disorder Imposed on Self,

Factitious Disorder Imposed on Another) (324) Specify Single episode. Recurrent episodes Other Specified Somatic Symptom and Related Disorder (327)

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

Ŝpecify 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 ( . ) Anorexia Nervosa^’ ̂(338) Specify whether:

(F50.01) Restricting type (F50.02) 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) With fecal symptoms

. ( . ) Unspecified Elimination Disorder (360) 788.30 (R32) With urinary symptoms 787.60 (R15.9) 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 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 Narcolepsy with cataplexy but without hypocretin deficiency Autosomal dominant cerebellar ataxia, deafness, and

narcolepsy Autosomal dominant narcolepsy, obesity, and type 2 diabetes Narcolepsy secondary to another medical condition

780.54 (G47.10)

347.00 (G47.419) 347.01 (G47.411) 347.00 (G47.419)

347.00 (G47.419) 347.10 (G47.429)

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

327.21 (G47.31) 786.04 (R06.3) 780.57 (G47.37)

327.24 (G47.34) 327.25 (G47.35) 327.26 (G47.36)

307.45 (G47.21)

307.45 (G47.22)

307.45 (G47.23) 307.45 (G47.24)

Central Sleep Apnea (383) Specify whether:

Idiopathic central sleep apnea Cheyne-Stokes breathing Central sleep apnea comorbid with opioid use Note: First code opioid use disorder, if present. Specify current severity

Sleep-Related Hypoventilation (387) Specify whether:

Idiopathic hypoventilation Congenital central alveolar hypoventilation Comorbid sleep-related hypoventilation Specify current severity

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) 307.45 (G47.20)

Parasomnias (399)

Shift work type (397) Unspecified type

307.46 (F51.3)

307.46 (F51.4)

307.47 (F51.5)

327.42 (G47.52)

333.94 (025.81)

( _ . _ )

780.52 (G47.09)

780.52 (G47.00)

780.54 (G47.19)

780.54 (G47.10)

780.59 (G47.8)

780.59 (G47.9)

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

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

Rapid Eye Movement Sleep Behavior Disorder (407)

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 Other Specified Insomnia Disorder (420)

Unspecified Insonmia Disorder (420)

Other Specified Hypersomnolence Disorder (421)

Unspecified Hypersomnolence Disorder (421)

Other Specified Sleep-Wake Disorder (421)

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)

Erectile Disorder®’ (426)

Female Orgasmic Disorder®’ *̂ ‘ (429) Specify if: Never experienced an orgasm under any situation Female Sexual Interest/Arousal Disorder®’ (433)

Genito-Pelvic Pain/Penetration Disorder®’ ̂(437)

302.72 (F52.21)

302.73 (F52.31)

302.72 (F52.22)

302.76 (F52.6)

302.71 (F52.0)

302.75 (F52.4)

302.79 (F52.8)

302.70 (F52.9)

Male Hypoactive Sexual Desire Disorder^’ ̂ (440)

Premature (Early) Ejaculation^’ ̂(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 Other Specified Sexual Dysfunction (450)

Unspecified Sexual Dysfunction (450)

Gender Dysplioria (451)

. { · ) Gender Dysphoria (452) 302.6 (F64.2) Gender Dysphoria in Children

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

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

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

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

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

Disruptive, 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)

■ ‘ Conduct Disorder (469) Specify whether: 312.81 (F91.1) 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 (F60.2) Antisocial Personality Disorder (476)

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

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)

. ( . ) Alcohol Use Disorder®’ (490) Specify current severity:

305.00 (F10.10) Mild 303.90 (FI 0.20) Moderate 303.90 (F10.20) Severe

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

291.81 ( ._ ) Alcohol Withdrawal^’ ̂ (499) (FI0.239) Without perceptual disturbances (FI 0.232) With perceptual disturbances

. ( ._ ) Other Alcohol-Induced Disorders (502)

291.9 (FI 0.99) Unspecified Alcohol-Related Disorder (503)

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

292.0 (F15.93) Caffeine Withdrawal (506)

. ( _ · ) Other Caffeine-Induced Disorders (508)

292.9 (FI 5.99) Unspecified Caffeine-Related Disorder (509)

Cannabis-Related Disorders (509)

. ( ■ ) Cannabis Use Disorder^’ ̂ (509) Specify current severity:

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

292.89 (__

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

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

(F12.288)

( _ . _ )

292.0

292.9 (F12.99) Hallucinogen-Related Disorders (520)

Cannabis Intoxication‘s (516) Without perceptual disturbances

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

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

Cannabis Withdrawal*^ (517)

Other Cannabis-Induced Disorders (519)

Unspecified Cannabis-Related Disorder (519)

305.90 (F16.10) 304.60 (F16.20) 304.60 (F16.20)

( _ ■ _ )

305.30 (F16.10) 304.50 (F16.20) 304.50 (F16.20)

292.89 (__ ._ ) (F16.129) (F16.229) (F16.929)

292.89 (__ ._ )

Phencyclidine Use Disorder®’ (520) Specify current severity:

Mild Moderate Severe

Other Hallucinogen Use Disorder®’ (523) Specify the particular hallucinogen Specify current severity;

Mild Moderate Severe

Phencyclidine Intoxication (527) With use disorder, mild With use disorder, moderate or severe Without use disorder

Other Hallucinogen Intoxication (529) With use disorder, mild With use disorder, moderate or severe Without use disorder

Hallucinogen Persisting Perception Disorder (531)

Other Phencyclidine-Induced Disorders (532)

Other Hallucinogen-Induced Disorders (532)

Unspecified Phencyclidine-Related Disorder (533)

Unspecified Hallucinogen-Related Disorder (533)

Inhalant-Related Disorders (533)

___. _ (__ ._ ) Inhalant Use Disorder®’ (533) Specify the particular inhalant Specify current severity:

305.90 (F18.10) Mild

(F16.129) (F16.229) (F16.929)

292.89 (F16.983)

( _ . _ )

292.9

292.9

(F16.99)

(F16.99)

304.60 (F18.20) 304.60 (F18.20)

292.89 (__ ._ ) (F18.129) (F18.229) (F18.929)

( _ ■ _ ) 292.9 (F18.99)

Moderate Severe

Inhalant Intoxication (538) With use disorder, mild With use disorder, moderate or severe Without use disorder

Other Inhalant-Induced Disorders (540)

Unspecified Inhalant-Related Disorder (540)

Opioid-Related Disorders (540)

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

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

292.89 ( . ) Opioid Intoxication‘s (546) Without perceptual disturbances

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

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

292.0 (F11.23) Opioid Withdrawal‘s (547)

. ( ■ ) Other Opioid-Induced Disorders (549)

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

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

■ ( – ) Sedative, Hypnotic, or Anxiolytic Use Disorder^’ ̂ (550) Specify current severity:

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

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

292.0 ( . ) Sedative, Hypnotic, or Anxiolytic Withdrawal^’ ̂ (557) (FI 3.239) Without perceptual disturbances (F13.232) With perceptual disturbances

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

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

305.70 305.60 305.70

Stimulant-Related

( _ ■ _ ) (F15.10) (F14.10) (F15.10) ( _ ■ _ ) (F15.20) (F14.20) (F15.20) ( _ . _ ) (F15.20) (F14.20) (F15.20)

304.40 304.20 304.40

304.40 304.20 304.40

292.89 (__ ._ )

292.89 (__ ._ )

(F15.129) (F15.229) (F15.929)

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

292.89 (__ ._ )

(F15.122) (F15.222) (F15.922)

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

292.0 (__ ._ )

(F15.23) (FI 4.23)

( _ . _ )

Disorders (561)

Stimulant Use Disorder®’* ̂ (561) Specify current severity:

Mild Amphetamine-t)φe substance Cocaine Other or unspecified stimulant

Moderate Amphetamine-type substance Cocaine Other or unspecified stimulant

Severe Amphetamine-type substance Cocaine Other or unspecified stimulant

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

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

Amphetamine or other stimulant. With perceptual disturbances

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

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 5.9̂ 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:

305.1 (Z72.0) Mild 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)

— ■- (_ _ . ) Other (or Unknown) Substance Use Disorder®’ (577) Specify current severity:

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

292.89 ( _ . ) Other (or Unknown) Substance Intoxication (581) (FI 9.129) With use disorder, mild (F19.229) With use disorder, moderate or severe (F19.929) Without use disorder

292.0 (F19.239) Other (or Unknown) Substance Withdrawal*^ (583)

■ ( ._ ) Other (or Unknown) Substance-Induced Disorders (584)

292.9 (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)

292.81 (__ ._J 293.0 (F05)

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^ Medication-induced delirium^ Delirium due to another medical condition

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)

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

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

331.9 (G31.9) Possible Major Neurocognitive Disorder Due to Alzheimer’s Disease^’ ^

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

Major or Mild Frontotemporal Neurocognitive Disorder (614)

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

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

331.9 (G31.9) Possible Major Neurocognitive Disorder Due to Frontotemporal Lobar Degeneration^’ ^

331.83 (G31,84) Mild Neurocognitive Disorder Due to Frontotemporal Lobar Degeneration^

Major or Mild Neurocognitive Disorder With Lewy Bodies (618)

___.__ (__ .__) Probable Major Neurocognitive Disorder With Leŵ y Bodies^ Note: Code first 331.82 (G31.83) Lewy body disease.

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

— ■— ( ·_)

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

331.9 (G31.9)

331.83 (G31.84)

331.9 (G31.9) Possible Major Neurocognitive Disorder With Lewy Bodies^’ ̂

331 -83 (G31.84) Mild Neurocognitive Disorder With Lewy Bodies^

Major or Mild Vascular Neurocognitive Disorder (621)

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)

___.__ (__ .__) 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.

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

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

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)

___.__ (___.__) Major Neurocognitive Disorder Due to Prion Disease^ Note: Code first 046.79 (A81.9) prion disease.

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

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

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

__ .__ (__ .__) Major Neurocognitive Disorder Probably Due to Parkinson’s Disease^

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

—- ■— ( ._ )

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

331.83 (G31.84)

331.9 (G31.9) Major Neurocognitive Disorder Possibly Due to Parkir\son’s Disease®’ ^

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

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

___.__ (__ .__) Major Neurocognitive Disorder Due to Huntington’s Disease*’ Note: Code first 333.4 (GIO) Huntington’s disease.

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

331 -83 (G31.84) Mild Neurocognitive Disorder Due to Huntington’s Disease^

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

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

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

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

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

___.__ (__ .__) Major Neurocognitive Disorder Due to Multiple Etiologies^ Note: Code first all the etiological medical conditions (with the exception

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

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

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

Personality Disorders (645)

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

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

301.22 (F21) Schizotypal Personality Disorder (655)

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

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

301.50 (F60.4) Histrionic Personality Disorder (667) 301.81 (F60.81) Narcissistic Personality Disorder (669)

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 (F60.9) Unspecified Personality Disorder (684)

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)

302.4 (F65.2)

302.89 (F65.81)

302.83 (F65.51)

302.84 (F65.52) 302.2 (F65.4)

302.81 (F65.0)

302.3 (F65.1)

302.89 (F65.89) 302.9 (F65.9)

Voyeuristic Disorder® (686)

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

Frotteuristic Disorder® (691)

Sexual Masochism Disorder® (694) Specify if: With asphyxiophilia Sexual Sadism Disorder® (695) 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 Fetishistic Disorder® (700) Specify: Body part(s). Nonliving object(s). Other Transvestic Disorder® (702) Specify if: With fetishism. With autogynephilia Other Specified Paraphilic Disorder (705) 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 (G25.1) Medication-Induced Postural Tremor (712)

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

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

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

Other Conditions That 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 (Z63.8) High Expressed Emotion Level Within Family (716)

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 (Z59.1) Inadequate Housing (723)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

V65.40 (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 (Z65.9) Unspecified Problem Related to Unspecified Psychosocial Circumstances (725)

V15.49 (Z91.49)

V15.59 (Z91.5)

V62.22 (Z91.82)

V15.89 (Z91.89)

V69.9 (Z72.9)

V71.01 (Z72.811)

V71.02 (Z72.810)

Other Circumstances of Personal History (726) Other Personal History of Psychological Trauma (726)

Personal History of Self-Harm (726)

Personal History of Military Deployment (726)

Other Personal Risk Factors (726)

Problem Related to Lifestyle (726)

Adult Antisocial Behavior (726)

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 Sn P s y c h iâ t r ic 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 âtion 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 A A A) 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 îx) 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-def icit/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 gender- related specifier, such as perinatal onset of a mood episode, provides additional informa­ tion on gender and diagnosis. Finally, other issues that are pertinent to diagnosis and gen­ der considerations can be found in the section “Gender-Related Diagnostic Issues.”

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

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 tr o d u c tio 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 sleep- wake disorders. Although a fifth digit is sometimes assigned to code a subtype or specifier (e.g., 294.11 [F02.81] major neurocognitive disorder due to Alzheimer’s disease, with be­ havioral disturbance) or severity (296.21 [F32.0] major depressive disorder, single episode, mild), the majority of subtypes and specifiers included in DSM-5 cannot be coded within the ICD-9-CM and ICD-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 substance- related diagnosis such as alcohol use disorder is accompanied by a non-substance-related diagnosis such as schizophrenia. For example, it may be unclear which diagnosis should

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/medication- induced disorders), the appropriate code depends on further specification and is listed within the criteria set for the disorder, as coding notes, and, in some cases, further clarified in a section on recording procedures. The names of some disorders are followed by alter­ native terms enclosed in parentheses, which, in most cases, were the DSM-IV names for the disorders.

Looking to the Future: Assessment and Monitoring Tools

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

ment tools, a cultural formulation interview, and conditions for further study included in Section III are those for which we determined that the scientific evidence is not yet avail­ able to support widespread clinical use. These diagnostic aids and criteria are included to highlight the evolution and direction of scientific advances in these areas and to stimulate further research.

Each of the measures in Section III is provided to aid in a comprehensive assessment of individuals that will contribute to a diagnosis and treatment plan tailored to the individ­ ual presentation and clinical context. Where cultural dynamics are particularly important for diagnostic assessment, the cultural formulation interview should be considered as a useful aid to communication with the individual. Cross-cutting symptom and diagnosis- specific severity measures provide quantitative ratings of important clinical areas that are designed to be used at the initial evaluation to establish a baseline for comparison with rat­ ings on subsequent encounters to monitor changes and inform treatment planning.

The use of such measures will undoubtedly be facilitated by digital 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 lth o u g h th 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.

.«=̂-iî -~-™eî3?Æar!!!*„„̂,….. : .:iâê.,̂.̂».ŵîssâîS!̂ œ̂âsæ»?i?g®®=̂ÂS3sBsæsç̂ss6iS»ŝ8®®®̂Eæsæsias»saŝ^̂m»!i»a5srâ^ “3ôfê riDiagnostic ‘ 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— t̂he 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 ΐάΙ disorders are a group of conditions with onset in the developmental period. The disorders typically manifest early in development, often be­ fore the child enters grade school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning. The range of developmental deficits varies from very specific limitations of learning or control of executive functions to global impairments of social skills or intelligence. The neurode- velopmental disorders frequently co-occur; for example, individuals with autism spec­ trum disorder often have intellectual disability (intellectual developmental disorder), and many children with attention-deficit/hyperactivity disorder (ADHD) also have a specific learning disorder. For some disorders, the clinical presentation includes symptoms of ex­ cess as well as deficits and delays in achieving expected milestones. For example, autism spectrum disorder is diagnosed only when the characteristic deficits of social communi­ cation are accompanied by excessively repetitive behaviors, restricted interests, and insis­ tence on sameness.

Intellectual disability (intellectual developmental disorder) is characterized by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience. The deficits result in impair­ ments of adaptive functioning, such that the individual fails to meet standards of personal independence and social responsibility in one or more aspects of daily life, including com- mimication, 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, self- biting, or hitting. The movements interfere with social, academic, or other activities. If the behaviors cause self-injury, this should be specified as part of the diagnostic description. Tic disorders are characterized by the presence of motor or vocal tics, which are sudden, rapid, recurrent, nonrhythmic, sterotyped motor movements or vocalizations. The dura­ tion, presumed etiology, and clinical presentation define the specific tic disorder that is di­ agnosed: Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder. Tourette’s disorder is diagnosed when the individual has multiple motor and vocal tics that have been present for at least 1 year and that have a waxing-waning symptom course.

Specific learning disorder, as the name implies, is diagnosed when there are specific defi­ cits in an individual’s ability to perceive or process information efficiently and accurately. This neurodevelopmental disorder first manifests during the years of formal schooling and is characterized by persistent and impairing difficulties with learning 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 v̂ l̂l 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 adaptiv

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