Diagnostic_and_Statistical 01
American Psychiatric Association
Officers 2012-2013
President Dilip V. Jeste, M.D.
President-Elect Jeffrey A. Lieberman, M.D.
Treasurer David Fassler, M.D.
Secretary Rcxser Peele, M.D.
Assembly
Speaker R. Scott Benson, M.D.
Speaker-Elect Melinda L. Young, M.D.
Board of Trustees
Jeffrey Akaka, M.D.
Carol A. Bernstein, M.D.
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. Gi^ eneVM.D.
Judith F. Kashtan, M.D.
Molly K. McVoy, M.D.
James E. Nininger, M.D.
John M. Oldham, M.D.
Alan F. Schatzberg, M.D.
Alik s . Widge, M.D., Ph .D.
Erik R. Vanderlip, M.D.,
Member-in-Training Trustee-Elect
DIAGNOSTIC AND STATISTICAL
MANUAL OF
MENTAL DISORDERS7
FIFTH EDITION
DSM-5TM
New School Library
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Amcriccin
Osvchiatric
ADivi«ono(AmCT»MlVhijtiKAMod<tk>n
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
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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
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Arlington, VA 22209-3901
www.psych.org
The correct citation for this book is American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 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 of Research
William E. Narrow, M.D., M.P.H.,
Associate Director
Emily A. Kuhl, Ph.D., Senior Science
Writer; Staff Text Editor
Diana E. Clarke, Ph.D., M.Sc., Research
Statistician
Lisa H. Greiner, M.S.S.A., DSM-5 Field
Trials Project Manager
Eve K. Moscicki, Sc.D., M.P.H.,
Director, Practice Research Network
S. Janet Kuramoto, Ph.D. M.H.S.,
Senior Scientific Research Associate,
Practice Research Network
Amy Porfiri, M.B.A.
Director of Finance and Administration
Jennifer J. Shupinka, Assistant Director,
DSM Operations
Seung-Hee Hong, DSM Senior Research
Associate
Anne R. Hiller, DSM Research Associate
Alison S. Beale, DSM Research Associate
Spencer R. Case, DSM Research Associate
Joyce C. West, Ph.D., M.P.P.,
Health Policy Research Director, Practice
Research Network
Farifteh F. Duffy, Ph.D.,
Quality Care Research Director, Practice
Research Network
Lisa M. Countis, Field Operations
Manager, Practice Research Network
Christopher M. Reynolds,
Executive Assistant
APA Office of the 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. Timothy Walsh, 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
William 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
C harles 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. Dimsdale, 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. Wulsin, M.D.
Chair
Ronald E. Dahl, M.D.
Joel E. Dimsdale, M.D.
Javier I. Escobar, M.D., M.Sc.
Dilip V. Jeste, M.D. (2007-2011)
Walter E. Kaufmann, M.D.
Richard E. Kreipe, M.D.
Ronald C. Petersen, Ph.D., M.D.
Charles F. Reynolds III, M.D.
Robert Taylor Segraves, M.D., Ph.D.
B. Timothy Walsh, M.D.
Impairment and Disability
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
William E. Narrow, M.D., M.P.H.
Chair
Jack D. Burke Jr., M.D., M.P.H.
Diana E. Clarke, Ph.D., M.Sc.
Helena C. Kraemer, Ph.D.
David J. Kupfer, M.D.
Darrel A. Regier, M.D., M.P.H.
David Shaffer, M.D.
Course Specifiers and Glossary
Wolfgang Gaebel, M.D.
Chair
Ellen Frank, Ph.D.
Charles P. O'Brien, M.D., Ph.D.
Norman Sartorius, M.D., Ph.D.,
Consultant
Susan K. Schultz, M.D.
Dan J. Stein, M.D., Ph.D.
Eric A. Taylor, M.B.
David J. Kupfer, M.D.
Darrel A. Regier, M.D., M.P.H.
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 September 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 condition]. The code and name for the other medical condition should be listed first immediately 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 environmental factor; Associated with another neurodevelopmental, mental, 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, neurodevelopmental 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 disorder: First episode, currently in acute episode; First episode, currently in partial remission;
First episode, currently in full remission; Multiple episodes, currently in acute episode; Multiple 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 psychomotor 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. Persecutory 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 features
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:
^Specify: With anxious distress (specify current severity: mild, moderate, moderate-severe, severe);
With mixed features; With rapid cycling; With melancholic features; With atypical features;
With mood-congruent psychotic features; With mood-incongruent psychotic features; With
catatonia (use additional code 293.89 [F06.1]); With péripartum onset; With seasonal pattem
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 moodcongruent psychotic features; With mood-incongruent psychotic features; With catatonia
(use additional code 293.89 [F06.1]); With péripartum onset; With seasonal pattern
296.99 (F34.8) Disruptive Mood Dysregulation Disorder (156)
. (_ ■ ) Major Depressive Disorder® (160)
. ( _ . ) 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 depressive 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 hairpulling 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 psychological 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
^Specify current severity: Mild, Moderate, Severe, Extreme
307.52 ( . ) Pica® (329)
(F98.3) In children
(F50.8) In adults
307.53 (F98.21) Rumination Disorder^ (332)
307.59 {F50.8) Avoidant/Restrictive Food Intake Disorder^ (334)
307.1 ( . ) 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 discontinuation/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 5.9^9) Amphetamine or other stimulant
(FI 4.99) Cocaine
Tobacco-Related Disorders (571)
( ._ ) Tobacco Use Disorder® (571)
Specify if: On maintenance therapy. In a controlled environment
Specify current severity:
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. Multiple etiologies. Unspecified
^Specify Without behavioral disturbance. With behavioral disturbance. For possible major neurocognitive 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 neurocognitive 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 Lew^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 children 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. Sexually 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 designed 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 diagnostic 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 (biological, psychodynamic, cognitive, behavioral, interpersonal, family/systems), all of
whom strive for a common language to communicate the essential characteristics of mental 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 specialists, occupational and rehabilitation therapists, and other health professionals. The criteria
are concise and explicit and intended to facilitate an objective assessment of symptom presentations in a variety of clinical settings—inpatient, outpatient, partial hospital, consultation-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 communicating 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. Fortunately, 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 International 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 adoption in October 2014) are attached to the relevant disorders in the classification.
Although DSM-5 remains a categorical classification of separate disorders, we recognize 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 diagnostic 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 promote 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 diagnosed in childhood (e.g., neurodevelopmental disorders) at the beginning of the manual 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, specific 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 neuroimaging. 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 highlighted in the text. This new structure should improve clinicians' ability to identify diagnoses in a disorder spectrum based on common neurocircuitry, genetic vulnerability,
and environmental exposures.
• Consolidation of autistic disorder, Asperger's disorder, and pervasive developmental disorder into autism spectrum disorder. Symptoms of these disorders represent a
single continuum of mild to severe impairments in the two domains of social communication and restrictive repetitive behaviors/interests rather than being distinct disorders. 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 targets for the specific impairments identified.
• Streamlined classification of bipolar and depressive disorders. Bipolar and depressive disorders are the most commonly diagnosed conditions in psychiatry. It was therefore 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 component criteria within the respective criteria for each disorder. This approach will facilitate 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 bereavement exclusion criterion. The new specifiers of anxious distress and mixed features 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 explosion 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 disorders that were previously referred to as the "dementias" or organic brain diseases. Biological markers identified by imaging for vascular and traumatic brain disorders and
specific molecular genetic findings for rare variants of Alzheimer's disease and Huntington'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 editions, 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 expression 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. Dimensional measures of symptom severity in 13 symptom domains have also been incorporated 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 applicable in all of medicine, has been provided to replace the more limited Global Assessment 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 assessments.
• 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 Cultural 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 Trustees, 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 Research; 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 invaluable 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 volunteer effort to improve the scientific basis of clinical practice over a sustained 6-year period. 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 Scientific 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 criteria; 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 particular, 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 Publishing—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, expertise, 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 evolution of DSM-5, but rather to give readers a succinct overview of its key elements. 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 assessing disability is also presented. “Use of the Manual” includes “Definition of
a Mental Disorder,” forensic considerations, and a brief overview of the diagnostic 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 manual, 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 morbidity and mortality rates. As the understanding of mental disorders and their treatments
has evolved, medical, scientific, and clinical professionals have focused on the characteristics 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 community 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, iterative changes if DSM is to maintain its place as the touchstone classification of mental disorders. 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 initiatives 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 families, including twin studies and molecular genetic studies, make strong arguments for what
many astute clinicians have long observed: the boundaries between many disorder "categories" are more fluid over the life course than DSM-IV recognized, and many symptoms assigned 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 accommodate 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 diagnostic criteria reflect the comprehensive manifestation of an underlying psychopathological
disorder). DSM-5 is designed to better fill the need of clinicians, patients, families, and researchers for a clear and concise description of each mental disorder organized by explicit diagnostic criteria, supplemented, when appropriate, by dimensional measures that cross
diagnostic boundaries, and a brief digest of information about the diagnosis, risk factors, associated 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, physical signs, syndrome combinations, and durations that require clinical expertise to differentiate 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, scientific evidence now places many, if not most, disorders on a spectrum with closely related disorders 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, families, 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 monitoring 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 institutionalized 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 diagnoses 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 disorders. 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 National Institute on Drug Abuse (NIDA), and the National Institute on Alcoholism and Alcohol 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 diagnostic areas to prepare for revisions in developing both DSM-5 and the International Classification 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 multidisciplinary range of expertise who would oversee the development of DSM-5. An additional 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 pharmaceutical industry, in the previous 3 years, the imposition of an income cap from all commercial 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 process. 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 process 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 professional 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 management 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 nosology 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 refined 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 subject 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). Disorders 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 validity, 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 introduced in DSM-III. The design and implementation strategy of the DSM-5 Field Trials represent 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 revised categorical diagnostic criteria and the underlying dimensional features of these disorders (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 specific 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 clinician 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 (using the intraclass kappa statistic) and the agreement of a single patient or two different clinicians 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 generalist 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 measures 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 submissions, 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 comments 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, collaborated 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 coordinators 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 scientific 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 prepared 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 reviewed 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 logical clarification issues for criteria that had not yet accumulated the type or level of evidence 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 external 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 conducted 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 provided by the Council on Psychiatry and Law.
The work groups themselves were charged with the responsibility to review the entire research literature surrounding a diagnostic area, including old, revised, and new diagnostic criteria, 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 included the merger of previously separate diagnostic areas into more dimensional spectra, such
as that which occurred with autism spectrum disorder, substance use disorders, sexual dysfunctions, 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 disorders. These types of changes posed particular challenges to the SRC and CPHC review processes, 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 responsibility 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 scientific 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 accommodated 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 composed of psychiatrists from throughout the United States who provide geographic, practice 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 disorder 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 undergone 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 manual) has not generally been thought of as scientifically significant, despite the fact that judgments 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 determined cognitive schema imposed on clinical and scientific information to increase its comprehensibility 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 clinicians and scientists alike that are inherent in the DSM structure rather than in the description 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 genetic 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 rational 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 Behavioral 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 challenge 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 diagnostic reform that would be guided by emerging scientific evidence on the relationships
between disorder groups. By reordering and regrouping the existing disorders, the revised structure is meant to stimulate new clinical perspectives and to encourage researchers 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 communication between clinicians about the diagnosis of disorders. The official criteria and
disorders that were determined to have accepted clinical applicability are located in Section 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 domains 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, accommodate 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 disorder 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 clinical 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 scientific 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 issues. 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 consistent 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 classifications 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 literature, such as epidemiology, analyses of comorbidity, twin studies, and certain other genetically 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, comorbidity, and shared risk factors, attention-deficit/hyperactivity disorder (ADHD) was
placed with neurodevelopmental disorders, but the same data also supported strong arguments to place ADHD within disruptive, impulse-control, and conduct disorders.
These issues were settled with the preponderance of evidence (most notably validators approved by the DSM-5 Task Force). The work groups recognize, however, that future discoveries 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. However, 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 Modification (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 implementation 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. Furthermore, 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, constructed 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 represent 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 disorders that is apparent in studies of comorbidity. Earlier editions of DSM focused on excluding 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 diagnostic categories that did not capture clinical reality, symptom heterogeneity within disorders, 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 heterogeneous at many levels, ranging from genetic risk factors to symptoms.
Related to recommendations about alterations in the chapter structure of DSM-5, members of the diagnostic spectra study group examined whether scientific validators could
inform possible new groupings of related disorders within the existing categorical framework. Eleven such indicators were recommended for this purpose: shared neural substrates, 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 indicators 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 developmental 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 document," 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 internalizing 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 systematic comorbidities seen in both clinical and community samples. The adjacent placement of
"internalizing disorders," characterized by depressed mood, anxiety, and related physiological and cognitive symptoms, should aid in developing new diagnostic approaches, including dimensional approaches, while facilitating the identification of biological markers.
Similarly, adjacencies of the "externalizing group," including disorders exhibiting antisocial behaviors, conduct disturbances, addictions, and impulse-control disorders, should encourage 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 without 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 facilitate research across current diagnostic categories by encouraging broad investigations
within the proposed chapters and across adjacent chapters. Such a reformulation of research 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 considerations. 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 diagnoses relevant to adulthood and later life (e.g., neurocognitive disorders). A similar approach
has been taken, where possible, within each chapter. This organizational structure facilitates the comprehensive use of lifespan information as a way to assist in diagnostic decision making.
The proposed organization of chapters of DSM-5, after the neurodevelopmental disorders, 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 diagnoses 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, revised, 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 cultures of origin and in specific social or familial contexts. Key aspects of culture relevant to diagnostic 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 cultural 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 cultures, social settings, and families. Hence, the level at which an experience becomes problematic 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 culture may also contribute to vulnerability and suffering (e.g., by amplifying fears that maintain 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 suggest help seeking and options for accessing health care of various types, including alternative 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 essential 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 suffering 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 classifications of disease used by laypersons or healers.
These three concepts (for which discussion and examples are provided in Section III
and the Appenc^ix) suggest cultural ways of understanding and describing illness experiences that can be elicited in the clinical encounter. They influence symptomatology, help
seeking, clinical presentations, expectations of treatment, illness adaptation, and treatment 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 differences are variations that result from biological sex as well as an individual's self-representation 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 disorder). 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 experienced 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 provision (e.g., women may be more likely to recognize a depressive, bipolar, or anxiety disorder 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 normative postpartum and thus may have lower diagnostic reliability in postpartum women.
The manual is configured to include information on gender at multiple levels. If there
are gender-specific symptoms, they have been added to the diagnostic criteria. A genderrelated specifier, such as perinatal onset of a mood episode, provides additional information on gender and diagnosis. Finally, other issues that are pertinent to diagnosis and gender 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 diagnostic class. This is done by recording the name of the category, followed by the specific reason. 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 unspecified disorders based on some feature of the presentation itself. When the clinician determines 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 describe 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 designations, 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 nonaxial 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 distinction among Axis I, Axis II, and Axis III disorders does not imply that there are fundamental 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 diagnosis 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 understanding 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 determine 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, representing the clinician's judgment of the individual's overall level of "functioning on a hypothetical 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., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics 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 International 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 included 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 online at www.psychiatry.org/dsm5.
DSM-5 is available as an online subscription at PsychiatryOnline.org as well as an ebook. The online component contains modules and assessment tools to enhance the diagnostic 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 adaptable to future scientific discoveries and refinements in its clinical utility. DSM-5 will be analyzed 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, particularly 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 assessment that leads to a fully informed treatment plan for each individual. The symptoms contained 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 history, biological and environmental risk factors, neuropsychological and physiological correlates, and typical clinical course.
Approach to Clinical Case Formulation
The case formulation for any given patient must involve a careful clinical history and concise summary of the social, psychological, and biological factors that may have contributed 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 diagnostic criteria are part of the relatively limited repertoire of human emotional responses to internal 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 combination 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 informed 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 disorder 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 experience and present to clinicians on a daily basis throughout the world. As noted previously 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 include "other specified/unspecified" disorder options for presentations that do not fit
exactly into the diagnostic boundaries of disorders in each chapter. In an emergency department setting, it may be possible to identify only the most prominent symptom expressions 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 entitled "Medication-Induced Movement Disorders and Other Adverse Effects of Medication" 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 disorders in the range contained in DSM-5, the following elements are required:
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects
a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant 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 behavior (e.g., political, religious, or sexual) and conflicts that are primarily between 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 patients. However, the diagnosis of a mental disorder is not equivalent to a need for treatment. 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 markers, family traits, temperament, and environmental exposure), concurrent validators (similar 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 necessarily 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 chapter groups. Until incontrovertible etiological or pathophysiological mechanisms are identified 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 research 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 responsibility, 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 Organization (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 International Classification of Diseases (ICD) covers all diseases and disorders, while the International 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 mental disorders. However, in the absence of clear biological markers or clinically useful measurements 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 patient's symptom presentation by itself (particularly in mild forms) is not inherently pathological and may be encountered in individuals for whom a diagnosis of "mental
disorder" would be inappropriate. Therefore, a generic diagnostic criterion requiring distress or disability has been used to establish disorder thresholds, usually worded "the disturbance 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 patient'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; describing the criteria more fully under "Diagnostic Features").
Following the assessment of diagnostic criteria, clinicians should consider the application 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" designation. Where applicable, specific criteria for defining disorder severity (e.g., mild, moderate, 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 provided 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 exhaustive phenomenological subgroupings within a diagnosis and are indicated by the instruction "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 criteria set. Specifiers provide an opportunity to define a more homogeneous subgrouping of
individuals with the disorder who share certain features (e.g., major depressive disorder,
with mixed features) and to convey information that is relevant to the management of the
individual's disorder, such as the "with other medical comorbidity" specifier in sleepwake disorders. Although a fifth digit is sometimes assigned to code a subtype or specifier
(e.g., 294.11 [F02.81] major neurocognitive disorder due to Alzheimer's disease, with behavioral 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], performance 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 subtypes 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; previous 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 specifiers 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 instruction "Specify current severity" in the criteria set and include disorder-specific definitions. 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 System" in the "Introduction" elsewhere in this manual), these chapters in Section II also contain 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 assessed and treated by clinicians in mental health practice such as akathisia, tardive dyskinesia, 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 nature of this condition, and a new entry on antidepressant discontinuation syndrome is provided. An additional chapter discusses other conditions that may be a focus of clinical
attention. These include relational problems, problems related to abuse and neglect, problems 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 principal diagnosis is the condition established after study to be chiefly responsible for occasioning 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 responsible 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 treatment. It is often difficult (and somewhat arbitrary) to determine which diagnosis is the
principal diagnosis or the reason for visit, especially when, for example, a substancerelated diagnosis such as alcohol use disorder is accompanied by a non-substance-related
diagnosis such as schizophrenia. For example, it may be unclear which diagnosis should
be considered "principal" for an individual hospitalized with both schizophrenia and alcohol 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 remaining disorders are listed in order of focus of attention and treatment. When the principal 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 disorder 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 adequate 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 exclusively on the duration of illness. For example, a diagnosis of schizophreniform disorder requires 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 Services (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. Official 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 official implementation occurs. Both ICD-9-CM and ICD-IO-CM codes have been listed 1) preceding the name of the disorder in the classification and 2) accompanying the criteria set
for each disorder. For some diagnoses (e.g., neurocognitive and substance/medicationinduced disorders), the appropriate code depends on further specification and is listed
within the criteria set for the disorder, as coding notes, and, in some cases, further clarified
in a section on recording procedures. The names of some disorders are followed by alternative 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 Section 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 available 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 individual presentation and clinical context. Where cultural dynamics are particularly important
for diagnostic assessment, the cultural formulation interview should be considered as a
useful aid to communication with the individual. Cross-cutting symptom and diagnosisspecific severity measures provide quantitative ratings of important clinical areas that are
designed to be used at the initial evaluation to establish a baseline for comparison with ratings 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 development. 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 consequences 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 decision 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 determination. 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 relevant 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 improve 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 limitations of its use in forensic settings. When DSM-5 categories, criteria, and textual descriptions 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 diagnosis. In most situations, the clinical diagnosis of a DSM-5 mental disorder such as intellectual 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 specified 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 impairments, abilities, and disabilities vary widely within each diagnostic category that assignment 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, nonmedical, or otherwise insufficiently trained individuals is not advised. Nonclinical decision
makers should also be cautioned that a diagnosis does not carry any necessary implications regarding the etiology or causes of the individual's mental disorder or the individual'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 diagnosis in itself does not demonstrate that a particular individual is (or was) unable to control his or her behavior at a particular time.
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"3ôfe^ 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 procedures 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 formulation and treatment plan. These three components—^the criteria and their
descriptive text, the medication-induced movement disorders and other adverse effects of medication, and the descriptions of other conditions that may
be a focus of clinical attention—represent the key elements of the clinical diagnostic process and thus are presented together.
ΤΙ 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 before the child enters grade school, and are characterized by developmental deficits that
produce impairments of personal, social, academic, or occupational functioning. The
range of developmental deficits varies from very specific limitations of learning or control
of executive functions to global impairments of social skills or intelligence. The neurodevelopmental disorders frequently co-occur; for example, individuals with autism spectrum 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 excess as well as deficits and delays in achieving expected milestones. For example, autism
spectrum disorder is diagnosed only when the characteristic deficits of social communication are accompanied by excessively repetitive behaviors, restricted interests, and insistence 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 impairments of adaptive functioning, such that the individual fails to meet standards of personal
independence and social responsibility in one or more aspects of daily life, including commimication, social participation, academic or occupational functioning, and personal independence 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, social (pragmatic) communication disorder, and childhood-onset fluency disorder (stuttering). The first three disorders are characterized by deficits in the development and use of
language, speech, and social communication, respectively. Childhood-onset fluency disorder 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 communication 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, repetitive patterns of behavior, interests, or activities. Because symptoms change with development and may be masked by compensatory mechanisms, the diagnostic criteria may
be met based on historical information, although the current presentation must cause significant impairment.
Within the diagnosis of autism spectrum disorder, individual clinical characteristics
are noted through the use of specifiers (with or without accompanying intellectual impairment; 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; severity). 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, disorganization, and/or hyperactivity-impulsivity. Inattention and disorganization entail inability 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, inability 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 disorder, stereotypic movement disorder, and tic disorders. Developmental coordination disorder 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 motor skills that cause interference with activities of daily living. Stereotypic movement disorder is diagnosed when an individual has repetitive, seemingly driven, and apparently
purposeless motor behaviors, such as hand flapping, body rocking, head banging, selfbiting, or hitting. The movements interfere with social, academic, or other activities. If the
behaviors cause self-injury, this should be specified as part of the diagnostic description.
Tic disorders are characterized by the presence of motor or vocal tics, which are sudden,
rapid, recurrent, nonrhythmic, sterotyped motor movements or vocalizations. The duration, presumed etiology, and clinical presentation define the specific tic disorder that is diagnosed: 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 deficits 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 intellectually 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 compensatory 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 clinical description of the individual's clinical course and current symptomatology. In addition to specifiers that describe the clinical presentation, such as age at onset or severity
ratings, the neurodevelopmental disorders may include the specifier "associated with a
known medical or genetic condition or environmental factor." This specifier gives clini
cians an opportunity to document factors that may have played a role in the etiology of the
disorder, as v^^ll as those that might affect the clinical course. Examples include genetic
disorders, such as fragile X syndrome, tuberous sclerosis, and Rett syndrome; medical conditions 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 sociocultural standards for personal independence and social responsibility. Without ongoing 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 diagnosis of intellectual developmental disorders. Although the term intellectual disability is
used throughout this manual, both terms are used in the title to clarify relationships with
other classification systems. Moreover, a federal statute in the United States (Public Law
111 -256, Rosa’s Law) replaces the term mental retardation with intellectual disability, and
research journals use the term intellectual disability. Thus, intellectual disability is the
term in common use by medical, educational, and other professions and by the lay public
and advocacy groups.
Coding note: The ICD-9-CM code for intellectual disability (intellectual developmental
disorder) is 319, which is assigned regardless of the severity specifier. The ICD-10-CM code
depends on the severity specifier (see below).
Specify current severity (see Table 1 ):
(F70) Mild
(F71) lUloderate
(F72) Severe
(F73) Profound
Specifiers
The various levels of severity are defined on the basis of adaptive functioning, and not IQ
scores, because it is adaptive functioning that determines the level of supports required.
Moreover, IQ measures are less valid in the lower end of the IQ range.
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Diagnostic Features
The essential fèatures of intellectual disability (intellectual developmental disorder) are
deficits in general mental abilities (Criterion A) and impairment in everyday adaptive
functioning, in comparison to an individual's age-, gender-, and socioculturally matched
peers (Criterion B). Onset is during the developmental period (Criterion C). The diagnosis
of intellectual disability is based on both clinical assessment and standardized testing of
intellectual and adaptive functions.
Criterion A refers to intellectual functions that involve reasoning, problem solving,
planning, abstract thinking, judgment, learning from instruction and experience, and
practical understanding. Critical components include verbal comprehension, working
memory, perceptual reasoning, quantitative reasoning, abstract thought, and cognitive efficacy. Intellectual functioning is typically measured with individually administered and
psychometrically valid, comprehensive, culturally appropriate, psychometrically sound
tests of intelligence. Individuals with intellectual disability have scores of approximately
two standard deviations or more below the population mean, including a margin for measurement error (generally +5 points). On tests with a standard deviation of 15 and a mean
of 100, this involves a score of 65-75 (70 ± 5). Clinical training and judgment are required
to interpret test results and assess intellectual performance.
Factors that may affect test scores include practice effects and the "Flynn effect' (i.e.,
overly high scores due to out-of-date test norms). Invalid scores may result from the use of
brief intelligence screening tests or group tests; highly discrepant individual subtest scores
may make an overall IQ score invalid. Instruments must be normed for the individual's sociocultural background and native language. Co-occurring disorders that affect communication, language, and/or motor or sensory function may affect test scores. Individual
cognitive profiles based on neuropsychological testing are more useful for understanding
intellectual abilities than a single IQ score. Such testing may identify areas of relative
strengths and weaknesses, an assessment important for academic and vocational planning.
IQ test scores are approximations of conceptual functioning but may be insufficient to
assess reasoning in real-life situations and mastery of practical tasks. For example, a person with an IQ score above 70 may have such severe adaptive behavior problems in social
judgment, social understanding, and other areas of adaptive functioning that the person's
actual functioning is comparable to that of individuals with a lower IQ score. Thus, clinical
judgment is needed in interpreting the results of IQ tests.
Deficits in adaptive functioning (Criterion B) refer to how well a person meets community
standards of personal independence and social responsibility, in comparison to others of similar age and sociocultural background. Adaptive functioning involves adaptive reasoning in
three domains: conceptual, social, and practical. The conceptual (academic) domain involves
competence in memory, language, reading, writing, math reasoning, acquisition of practical
knowledge, problem solving, and judgment in novel situations, among others. The social domain involves awareness of others' thoughts, feelings, and experiences; empathy; interpersonal communication skills; friendship abilities; and social judgment, among others. The
practical domain involves learning and self-management across life settings, including personal
care, job responsibilities, money management, recreation, self-management of behavior, and
school and work task organization, among others. Intellectual capacity, education, motivation,
socialization, personality features, vocational opportunity, cultural experience, and coexisting
general medical conditions or mental disorders influence adaptive functioning.
Adaptive functioning is assessed using both clinical evaluation and individualized,
culturally appropriate, psychometrically sound measures. Standardized measures are
used with knowledgeable informants (e.g., parent or other family member; teacher; counselor; care provider) and the individual to the extent possible. Additional sources of information include educational, developmental, medical, and mental health evaluations.
Scores from standardized measures and interview sources must be interpreted using clinical judgment. When standardized testing is difficult or impossible, because of a variety of
factors (e.g., sensory impairment, severe problem behavior), the individual may be diagnosed with unspecified intellectual disability. Adaptive functioning may be difficult to
assess in a controlled setting (e.g., prisons, detention centers); if possible, corroborative information reflecting functioning outside those settings should be obtained.
Criterion B is met when at least one domain of adaptive functioning—conceptual, social, or practical—is sufficiently impaired that ongoing support is needed in order for the
person to perform adequately in one or more life settings at school, at work, at home, or in
the community. To meet diagnostic criteria for intellectual disability, the deficits in adaptive functioning must be directly related to the intellectual impairments described in Criterion A. Criterion C, onset during the developmental period, refers to recognition that
intellectual and adaptive deficits are present during childhood or adolescence.
Associated Features Supporting Diagnosis
Intellectual disability is a heterogeneous condition with multiple causes. There may be
associated difficulties with social judgment; assessment of risk; self-management of behavior, emotions, or interpersonal relationships; or motivation in school or work environments.
Lack of communication skills may predispose to disruptive and aggressive behaviors. Gullibility is often a feature, involving naiveté in social situations and a tendency for being easily
led by others. Gullibility and lack of awareness of risk may result in exploitation by others
and possible victimization, fraud, unintentional criminal involvement, false confessions,
and risk for physical and sexual abuse. These associated features can be important in criminal cases, including Atkins-type hearings involving the death penalty.
Individuals with a diagnosis of intellectual disability with co-occurring mental disorders are at risk for suicide. They think about suicide, make suicide attempts, and may die
from them. Thus, screening for suicidal thoughts is essential in the assessment process. Because of a lack of awareness of risk and danger, accidental injury rates may be increased.
Prevalence
Intellectual disability has an overall general population prevalence of approximately 1%,
and prevalence rates vary by age. Prevalence for severe intellectual disability is approximately 6 per 1,000.
Deveiopment and Course
Onset of intellectual disability is in the developmental period. The age and characteristic
features at onset depend on the etiology and severity of brain dysfunction. Delayed motor,
language, and social milestones may be identifiable within the first 2 years of life among
those with more severe intellectual disability, while mild levels may not be identifiable until school age when difficulty with academic learning becomes apparent. All criteria (including Criterion C) must be fulfilled by history or current presentation. Some children
under age 5 years whose presentation will eventually meet criteria for intellectual disability have deficits that meet criteria for global developmental delay.
When intellectual disability is associated with a genetic syndrome, there may be a characteristic physical appearance (as in, e.g.. Down syndrome). Some syndromes have a
behavioral phenotype, which refers to specific behaviors that are characteristic of particular
genetic disorder (e.g., Lesch-Nyhan syndrome). In acquired forms, the onset may be
abrupt following an illness such as meningitis or encephalitis or head trauma occurring
during the developmental period. When intellectual disability results from a loss of previously acquired cognitive skills, as in severe traumatic brain injury, the diagnoses of intellectual disability and of a neurocognitive disorder may both be assigned.
Although intellectual disability is generally nonprogressive, in certain genetic disorders (e.g., Rett syndrome) there are periods of worsening, followed by stabilization, and in
others (e.g., San Phillippo syndrome) progressive worsening of intellectual function. After
early childhood^ the disorder is generally lifelong, although severity levels may change
over time. The course may be influenced by underlying medical or genetic conditions and
co-occurring conditions (e.g., hearing or visual impairments, epilepsy). Early and ongoing interventions may improve adaptive functioning throughout childhood and adulthood. In
some cases, these result in significant improvement of intellectual functioning, such that
the diagnosis of intellectual disability is no longer appropriate. Thus, it is common practice
when assessing infants and young children to delay diagnosis of intellectual disability until after an appropriate course of intervention is provided. For older children and adults,
the extent of support provided may allow for full participation in all activities of daily living and improved adaptive function. Diagnostic assessments must determine whether improved adaptive skills are the result of a stable, generalized new skill acquisition (in which
case the diagnosis of intellectual disability may no longer be appropriate) or whether the
improvement is contingent on the presence of supports and ongoing interventions (in
which case the diagnosis of intellectual disability may still be appropriate).
Risk and Prognostic Factors
Genetic and physiological. Prenatal etiologies include genetic syndromes (e.g., sequence variations or copy number variants involving one or more genes; chromosomal
disorders), inborn errors of metabolism, brain malformations, maternal disease (including
placental disease), and environmental influences (e.g., alcohol, other drugs, toxins, teratogens). Perinatal causes include a variety of labor and delivery-related events leading to
neonatal encephalopathy. Postnatal causes include hypoxic ischemic injury, traumatic
brain injury, infections, demyelinating disorders, seizure disorders (e.g., infantile spasms),
severe and chronic social deprivation, and toxic metabolic syndromes and intoxications
(e.g., lead, mercury).
Culture-Reiated Diagnostic issues
Intellectual disability occurs in all races and cultures. Cultural sensitivity and knowledge
are needed during assessment, and the individual's ethnic, cultural, and linguistic background, available experiences, and adaptive functioning within his or her community and
cultural setting must be taken into account.
Gender-Reiated Diagnostic issues
Overall, males are more likely than females to be diagnosed with both mild (average
maleifemale ratio 1.6:1) and severe (average male:female ratio 1.2:1) forms of intellectual
disability. However, gender ratios vary widely in reported studies. Sex-linked genetic factors and male vulnerability to brain insult may accoimt for some of the gender differences.
Diagnostic iVlaricers
A comprehensive evaluation includes an assessment of intellectual capacity and adaptive
functioning; identification of genetic and nongenetic etiologies; evaluation for associated
medical conditions (e.g., cerebral palsy, seizure disorder); and evaluation for co-occurring
mental, emotional, and behavioral disorders. Components of the evaluation may include
basic pre- and perinatal medical history, three-generational family pedigree, physical examination, genetic evaluation (e.g., karyotype or chromosomal microarray analysis and testing
for specific genetic syndromes), and metabolic screening and neuroimaging assessment.
Differential Diagnosis
The diagnosis of intellectual disability should be made whenever Criteria A, B, and C are
met. A diagnosis of intellectual disability should not be assumed because of a particular
genetic or medical condition. A genetic syndrome linked to intellectual disability should
be noted as a concurrent diagnosis with the intellectual disability.
Major and mild neurocognitive disorders. Intellectual disability is categorized as a neurodevelopmental disorder and is distinct from the neurocognitive disorders, which are
characterized by a loss of cognitive functioning. Major neurocognitive disorder may cooccur with intellectual disability (e.g., an individual with Down syndrome who develops
Alzheimer's disease, or an individual with intellectual disability who loses further cognitive capacity following a head injury). In such cases, the diagnoses of intellectual disability
and neurocognitive disorder may both be given.
Communication disorders and specific learning disorder. These neurodevelopmental
disorders are specific to the communication and learning domains and do not show deficits in intellectual and adaptive behavior. They may co-occur with intellectual disability.
Both diagnoses are made if full criteria are met for intellectual disability and a communication disorder or specific learning disorder.
Autism spectrum disorder. Intellectual disability is common among individuals with
autism spectrum disorder. Assessment of intellectual ability may be complicated by social-communication and behavior deficits inherent to autism spectrum disorder, which
may interfere with understanding and complying with test procedures. Appropriate assessment of intellectual functioning in autism spectrum disorder is essential, with reassessment across the developmental period, because IQ scores in autism spectrum disorder
may be unstable, particularly in early childhood.
Comorbidity
Co-occurring mental, neurodevelopmental, medical, and physical conditions are frequent
in intellectual disability, with rates of some conditions (e.g., mental disorders, cerebral
palsy, and epilepsy) three to four times higher than in the general population. The prognosis
and outcome of co-occurring diagnoses may be influenced by the presence of intellectual
disability. Assessment procedures may require modifications because of associated disorders, including communication disorders, autism spectrum disorder, and motor, sensory,
or other disorders. Knowledgeable informants are essential for identifying symptoms
such as irritability, mood dysregulation, aggression, eating problems, and sleep problems,
and for assessing adaptive functioning in various community settings.
The most common co-occurring mental and neurodevelopmental disorders are attention-deficit/hyperactivity disorder; depressive and bipolar disorders; anxiety disorders;
autism spectrum disorder; stereotypic movement disorder (with or without self-injurious
behavior); impulse-control disorders; and major neurocognitive disorder. Major depressive disorder may occur throughout the range of severity of intellectual disability. Selfinjurious behavior requires prompt diagnostic attention and may warrant a separate diagnosis of stereotypic movement disorder. Individuals with intellectual disability, particularly those with more severe intellectual disability, may also exhibit aggression and
disruptive behaviors, including harm of others or property destruction.
Reiationship to Other Classifications
ICD-11 (in development at the time of this publication) uses the term intellectual developmental disorders to indicate that these are disorders that involve impaired brain functioning
early in life. These disorders are described in ICD-11 as a metasyndrome occurring in the
developmental period analogous to dementia or neurocognitive disorder in later life.
There are four subtypes in ICD-11: mild, moderate, severe, and profound.
The American Association on Intellectual and Developmental Disabilities (AAIDD)
also uses the term intellectual disability with a similar meaning to the term as used in this
manual. The AAIDD's classification is multidimensional rather than categorical and is
based on the disability construct. Rather than listing specifiers as is done in DSM-5, the
AAIDD emphasizes a profile of supports based on severity.
Global Developmental Delay
315.8 (F88)
This diagnosis is reserved for individuals under the age of 5 years when the clinical severity
level cannot be reliably assessed during early childhood. This category is diagnosed when
an individual fails to meet expected developmental milestones in several areas of intellectual functioning, and applies to individuals who are unable to undergo systematic assessments of intellectual functioning, including children who are too young to participate in
standardized testing. This category requires reassessment after a period of time.
Unspecified Intellectual Disability
(Intellectual Developmental Disorder)
319 (F79)
This category is reserved for individuals over the age of 5 years when assessment of the
degree of intellectual disability (intellectual developmental disorder) by means of locally
available procedures is rendered difficult or impossible because of associated sensory or
physical impairments, as in blindness or prelingual deafness; locomotor disability; or presence of severe problem behaviors or co-occurring mental disorder. This category should
only be used in exceptional circumstances and requires reassessment after a period of time.
Communication Disorders
Disorders of communication include deficits in language, speech, and communication.
Speech is the expressive production of sounds and includes an individual's articulation,
fluency, voice, and resonance quality. Language includes the form, function, and use of a
conventional system of symbols (i.e., spoken words, sign language, written words, pictures) in a rule-governed manner for communication. Communication includes any verbal
or nonverbal behavior (whether intentional or unintentional) that influences the behavior,
ideas, or attitudes of another individual. Assessments of speech, language and communication abilities must take into account the individual’s cultural and language context,
particularly for individuals growing up in bilingual environments. The standardized measures of language development and of nonverbal intellectual capacity must be relevant for
the cultural and linguistic group (i.e., tests developed and standardized for one group may
not provide appropriate norms for a different group). The diagnostic category of communication disorders includes the following: language disorder, speech sound disorder,
childhood-onset fluency disorder (stuttering), social (pragmatic) communication disorder, and other specified and unspecified communication disorders.
Language Disorder
Diagnostic Criteria 315.39 (F80.9)
A. Persistent difficulties in the acquisition and use of language across modalities (i.e.,
spoken, written, sign language, or other) due to deficits in comprehension or production that include the following:
1. Reduced vocabulary (word knowledge and use).
2. Limited sentence structure (ability to put words and word endings together to form
sentences based on the rules of grammar and morphology).
3. Impairments in discourse (ability to use vocabulary and connect sentences to explain or describe a topic or series of events or have a conversation).
B. Language abilities are substantially and quantifiably below those expected for age, resulting in functional limitations in effective communication, social participation, academic achievement, or occupational performance, individually or in any combination.
C. Onset of symptoms is in the early developmental period.
D. The difficulties are not attributable to hearing or other sensory impairment, motor dysfunction, or another medical or neurological condition and are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.
Diagnostic Features
The core diagnostic features of language disorder are difficulties in the acquisition and use
of language due to deficits in the comprehension or production of vocabulary, sentence
structure, and discourse. The language deficits are evident in spoken communication,
written communication, or sign language. Language learning and use is dependent on
both receptive and expressive skills. Expressive ability refers to the production of vocal, gestural, or verbal signals, while receptive ability refers to the process of receiving and comprehending language messages. Language skills need to be assessed in both expressive
and receptive modalities as these may differ in severity. For example, an individual's expressive language may be severely impaired, while his receptive language is hardly impaired at all.
Language disorder usually affects vocabulary and grammar, and these effects then
limit the capacity for discourse. The child's first words and phrases are likely to be delayed
in onset; vocabulary size is smaller and less varied than expected; and sentences are
shorter and less complex with grammatical errors, especially in past tense. Deficits in comprehension of language are frequently underestimated, as children may be good at using
context to infer meaning. There may be word-finding problems, impoverished verbal definitions, or poor understanding of synonyms, multiple meanings, or word play appropriate for age and culture. Problems with remembering new words and sentences are
manifested by difficulties following instructions of increasing length, difficulties rehearsing strings of verbal information (e.g., remembering a phone number or a shopping list),
and difficulties remembering novel sound sequences, a skill that may be important for
learning new words. Difficulties with discourse are shown by a reduced ability to provide
adequate information about the key events and to narrate a coherent story.
The language difficulty is manifest by abilities substantially and quantifiably below
that expected for age and significantly interfering with academic achievement, occupational performance, effective communication, or socialization (Criterion B). A diagnosis of
language disorder is made based on the synthesis of the individual's history, direct clinical
observation in different contexts (i.e., home, school, or work), and scores from standardized tests of language ability that can be used to guide estimates of severity.
Associated Features Supporting Diagnosis
A positive family history of language disorders is often present. Individuals, even children, can be adept at accommodating to their limited language. They may appear to be shy
or reticent to talk. Affected individuals may prefer to communicate only with family members or other familiar individuals. Although these social indicators are not diagnostic of a
language disorder, if they are notable and persistent, they warrant referral for a full language assessment. Language disorder, particularly expressive deficits, may co-occur with
speech sound disorder.
Deveiopment and Course
Language acquisition is marked by changes from onset in toddlerhood to the adult level of
competency that appears during adolescence. Changes appear across the dimensions of
language (sounds, words, grammar, narratives/expository texts, and conversational
skills) in age-graded increments and synchronies. Language disorder emerges during the
early developmental period; however, there is considerable variation in early vocabulary
acquisition and early word combinations, and individual differences are not, as single
indicators, highly predictive of later outcomes. By age 4 years, individual differences in
language ability are more stable, with better measurement accuracy, and are highly predictive of later outcomes. Language disorder diagnosed from 4 years of age is likely to be
stable over time and typically persists into adulthood, although the particular profile of
language strengths and deficits is likely to change over the course of development.
Risic and Prognostic Factors
Children with receptive language impairments have a poorer prognosis than those with
predominantly expressive impairments. They are more resistant to treatment, and difficulties with reading comprehension are frequently seen.
Genetic and physiological. Language disorders are highly heritable, and family members are more likely to have a history of language impairment.
Differentiai Diagnosis
Normal variations in language. Language disorder needs to be distinguished from normal developmental variations, and this distinction may be difficult to make before 4 years
of age. Regional, social, or cultural/ethnic variations of language (e.g., dialects) must be
considered when an individual is being assessed for language impairment.
Hearing or other sensory impairment. Hearing impairment needs to be excluded as the
primary cause of language difficulties. Language deficits may be associated with a hearing
impairment, other sensory deficit, or a speech-motor deficit. When language deficits are in
excess of those usually associated with these problems, a diagnosis of language disorder
may be made.
Intellectual disability (intellectual developmental disorder). Language delay is often the
presenting feature of intellectual disability, and the definitive diagnosis may not be made
until the child is able to complete standardized assessments. A separate diagnosis is not
given unless the language deficits are clearly in excess of the intellectual limitations.
Neurological disorders. Language disorder can be acquired in association with neurological disorders, including epilepsy (e.g., acquired aphasia or Landau-Kleffner syndrome).
Language regression. Loss of speech and language in a child younger than 3 years may
be a sign of autism spectrum disorder (with developmental regression) or a specific neurological condition, such as Landau-Kleffner syndrome. Among children older than 3 years,
language loss may be a symptom of seizures, and a diagnostic assessment is necessary to
exclude the presence of epilepsy (e.g., routine and sleep electroencephalogram).
Comorbidity
Language disorder is strongly associated with other neurodevelopmental disorders in
terms of specific learning disorder (literacy and numeracy), attention-deficit/hyperactivity disorder, autism spectrum disorder, and developmental coordination disorder. It is
also associated with social (pragmatic) communication disorder. A positive family history
of speech or language disorders is often present.
Speech Sound Disorder
Diagnostic Criteria 315.39 (F80.0)
A. Persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication of messages.
B. The disturbance causes limitations in effective communication that interfere with social
participation, academic achievement, or occupational performance, individually or in
any combination.
C. Onset of symptoms is in the early developmental period.
D. The difficulties are not attributable to congenital or acquired conditions, such as cerebral palsy, cleft palate, deafness or hearing loss, traumatic brain injury, or other medical or neurological conditions.
Diagnostic Features
Speech sound production describes the clear articulation of the phonemes (i.e., individual
sounds) that in combination make up spoken words. Speech sound production requires both
the phonological knowledge of speech sounds and the ability to coordinate the movements of
the articulators (i.e., the jaw, tongue, and lips,) with breathing and vocalizing for speech. Children with speech production difficulties may experience difficulty with phonological knowledge of speech sounds or the ability to coordinate movements for speech in varying degrees.
Speech sound disorder is thus heterogeneous in its underlying mechanisms and includes phonological disorder and articulation disorder. A speech sound disorder is diagnosed when
speech sound production is not what would be expected based on the child's age and developmental stage and when the deficits are not the result of a physical, structural, neurological,
or hearing impairment. Among typically developing children at age 4 years, overall speech
should be intelligible, whereas at age 2 years, only 50% may be understandable.
Associated Features Supporting Diagnosis
Language disorder, particularly expressive deficits, may be found to co-occur with speech
sound disorder. A positive family history of speech or language disorders is often present.
If the ability to rapidly coordinate the articulators is a particular aspect of difficulty,
there may be a history of delay or incoordination in acquiring skills that also utilize the
articulators and related facial musculature; among others, these skills include chewing,
maintaining mouth closure, and blowing the nose. Other areas of motor coordination may
be impaired as in developmental coordination disorder. Verbal dyspraxia is a term also
used for speech production problems.
Speech may be differentially impaired in certain genetic conditions (e.g.. Down syndrome, 22q deletion, FoxPZ gene mutation). If present, these should also be coded.
Deveiopment and Course
Learning to produce speech sounds clearly and accurately and learning to produce connected speech fluently are developmental skills. Articulation of speech sounds follows a
developmental pattern, which is reflected in the age norms of standardized tests. It is not
unusual for typically developing children to use developmental processes for shortening
words and syllables as they are learning to talk, but their progression in mastering speech
sound production should result in mostly inteUigible speech by age 3 years. Children with
speech sound disorder continue to use immature phonological simplification processes
past the age when most children can produce words clearly.
Most speech sounds should be produced clearly and most words should be pronounced
accurately according to age and community norms by age 7 years. The most frequently misarticulated sounds also tend to be learned later, leading them to be called the ''late eight" (/, r,
s, z, th, ch, dzh, and zh). Misarticulation of any of these sounds by itself could be considered
within normal limits up to age 8 years. When multiple sounds are involved, it may be appropriate to target some of those sounds as part of a plan to improve intelligibility prior to the age
at which almost all children can produce them accurately. Lisping (i.e., misarticulating sibilants) is particularly common and may involve frontal or lateral patterns of airstream direction. It may be associated with an abnormal tongue-thrust swallowing pattern.
Most children with speech sound disorder respond well to treatment, and speech difficulties improve over time, and thus the disorder may not be lifelong. However, when a
language disorder is also present, the speech disorder has a poorer prognosis and may be
associated with specific learning disorders.
Differential Diagnosis
Normal variations in speech. Regional, social, or cultural/ethnic variations of speech
should be considered before making the diagnosis.
Hearing or other sensory impairment. Hearing impairment or deafness may result in
abnormalities of speech. Deficits of speech sound production may be associated with a
hearing impairment, other sensory deficit, or a speech-motor deficit. When speech deficits
are in excess of those usually associated with these problems, a diagnosis of speech sound
disorder may be made.
Structural deficits. Speech impairment may be due to structural deficits (e.g., cleft palate).
Dysarthria. Speech impairment may be attributable to a motor disorder, such as cerebral
palsy. Neurological signs, as well as distinctive features of voice, differentiate dysarthria
from speech sound disorder, although in young children (under 3 years) differentiation
may be difficult, particularly when there is no or minimal general body motor involvement (as in, e.g., Worster-Drought syndrome).
Selective mutism. Limited use of speech may be a sign of selective mutism, an anxiety
disorder that is characterized by a lack of speech in one or more contexts or settings. Selective mutism may develop in children with a speech disorder because of embarassment
about their impairments, but many children with selective mutism exhibit normal speech
in "safe" settings, such as at home or with close friends.
Childhood-Onset Fluency Disorder (Stuttering)
Diagnostic Criteria 315.35 (F80.81)
A. Disturbances in the normal fluency and time patterning of speech that are inappropriate for the individual’s age and language skills, persist over time, and are characterized
by frequent and marked occurrences of one (or more) of the following:
1. Sound and syllable repetitions.
2. Sound prolongations of consonants as well as vowels.
3. Broken words (e.g., pauses within a word).
4. Audible or silent blocking (filled or unfilled pauses in speech).
5. Circumlocutions (word substitutions to avoid problematic words).
6. Words produced with an excess of physical tension.
7. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”).
B. The disturbance causes anxiety about speaking or limitations in effective communication, social participation, or academic or occupational performance, individually or in
any combination.
C. The onset of symptoms is in the early developmental period. (Note: Later-onset cases
are diagnosed as 307.0 [F98.5] adult-onset fluency disorder.)
D. The disturbance is not attributable to a speech-motor or sensory deficit, dysfluency associated with neurological insult (e.g., stroke, tumor, trauma), or another medical condition and is not better explained by another mental disorder.
Diagnostic Features
The essential feature of childhood-onset fluency disorder (stuttering) is a disturbance in
the normal fluency and time patterning of speech that is inappropriate for the individual's
age. This disturbance is characterized by frequent repetitions or prolongations of sounds
or syllables and by other types of speech dysfluencies, including broken words (e.g.,
pauses within a word), audible or silent blocl^g (i.e., filled or unfilled pauses in speech),
circumlocutions (i.e., word substitutions to avoid problematic words), words produced
with an excess of physical tension, and monosyllabic whole-word repetitions (e.g., 'T-I-I-I
see him"). The disturbance in fluency interferes with academic or occupational achievement or with social communication. The extent of the disturbance varies from situation to
situation and often is more severe when there is special pressure to communicate (e.g., giving a report at school, interviewing for a job). Dysfluency is often absent during oral reading, singing, or talking to inanimate objects or to pets.
Associated Features Supporting Diagnosis
Fearful anticipation of the problem may develop. The speaker may attempt to avoid dysfluencies by linguistic mechanisms (e.g., altering the rate of speech, avoiding certain
words or sounds) or by avoiding certain speech situations, such as telephoning or public
speaking. In addition to being features of the condition, stress and anxiety have been
shown to exacerbate dysfluency.
Childhood-onset fluency disorder may also be accompanied by motor movements
(e.g., eye blinks, tics, tremors of the lips or face, jerking of the head, breathing movements,
fist clenching). Children with fluency disorder show a range of language abilities, and the
relationship between fluency disorder and language abilities is unclear.
Deveiopment and Course
Childhood-onset fluency disorder, or developmental stuttering, occurs by age 6 for 80%-
90% of affected individuals, with age at onset ranging from 2 to 7 years. The onset can be
insidious or more sudden. Typically, dysfluencies start gradually, with repetition of initial
consonants, first words of a phrase, or long words. The child may not be aware of dysfluencies. As the disorder progresses, the dysfluencies become more frequent and interfering,
occurring on the most meaningful words or phrases in the utterance. As the child becomes
aware of the speech difficulty, he or she may develop mechanisms for avoiding the dysfluencies and emotional responses, including avoidance of public speaking and use of
short and simple utterances. Longitudinal research shows that 65%-85% of children re
cover from the dysfluency, with severity of fluency disorder at age 8 years predicting recovery or persisjence into adolescence and beyond.
Risk and Prognostic Factors
Genetic and physiological. The risk of stuttering among first-degree biological relatives of individuals with childhood-onset fluency disorder is more than three times the
risk in the general population.
Functional Consequences of
Childhood-Onset Fiuency Disorder (Stuttering)
In addition to being features of the condition, stress and anxiety can exacerbate dysfluency. Impairment of social functioning may result from this anxiety.
Differential Diagnosis
Sensory deficits. Dysfluencies of speech may be associated with a hearing impairment
or other sensory deficit or a speech-motor deficit. When the speech dysfluencies are in excess of those usually associated with these problems, a diagnosis of childhood-onset fluency disorder may be made.
Normal speech dysfluencies. The disorder must be distinguished from normal dysfluencies that occur frequently in young children, which include whole-word or phrase repetitions (e.g., 'T want, I want ice cream"), incomplete phrases, interjections, unfilled
pauses, and parenthetical remarks. If these difficulties increase in frequency or complexity
as the child grows older, a diagnosis of childhood-onset fluency disorder is appropriate.
Medication side effects. Stuttering may occur as a side effect of medication and may be
detected by a temporal relationship with exposure to the medication.
Adult-onset dysfluencies. If onset of dysfluencies is during or after adolescence, it is an
"adult-onset dysfluency" rather than a neurodevelopmental disorder. Adult-onset dysfluencies are associated with specific neurological insults and a variety of medical conditions
and mental disorders and may be specified with them, but they are not a DSM-5 diagnosis.
Tourette’s disorder. Vocal tics and repetitive vocalizations of Tourette's disorder
should be distinguishable from the repetitive sounds of childhood-onset fluency disorder
by their nature and timing.
Social (Pragmatic) Communication Disorder
Diagnostic Criteria 315.39 (F80.89)
A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:
1. Deficits in using communication for social purposes, such as greeting and sharing
information, in a manner that is appropriate for the social context.
2. Impairment of the ability to change communication to match context or the needs of
the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language.
3. Difficulties following rules for conversation and storytelling, such as taking turns in
conversation, rephrasing when misunderstood, and knowing how to use verbal and
nonverbal signals to regulate interaction.
4. Difficulties understanding wliat is not explicitly stated (e.g., making inferences) and
nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors,
multiple meanings that depend on the context for interpretation).
B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination.
C. The onset of the symptoms is in the early developmental period (but deficits may not
become fully manifest until social communication demands exceed limited capacities).
D. The symptoms are not attributable to another medical or neurological condition or to low
abilities in the domains of word structure and grammar, and are not better explained by
autism spectrum disorder, intellectual disability (intellectual developmental disorder),
global developmental delay, or another mental disorder.
Diagnostic Features
Social (pragmatic) communication disorder is characterized by a primary difficulty with
pragmatics, or the social use of language and communication, as manifested by deficits in
understanding and following social rules of verbal and nonverbal communication in naturalistic contexts, changing language according to the needs of the listener or situation,
and following rules for conversations and storytelling. The deficits in social communication result in functional limitations in effective communication, social participation, development of social relationships, academic achievement, or occupational performance. The
deficits are not better explained by low abilities in the domains of structural language or
cognitive abihty.
Associated Features Supporting Diagnosis
The most common associated feature of social (pragmatic) communication disorder is language impairment, which is characterized by a history of delay in reaching language milestones, and historical, if not current, structural language problems (see ''Language Disorder"
earlier in this chapter). Individuals with social communication deficits may avoid social interactions. Attention-deficit/hyperactivity disorder (ADHD), behavioral problems, and specific
learning disorders are also more common among affected individuals.
Development and Course
Because social (pragmatic) communication depends on adequate developmental progress
in speech and language, diagnosis of social (pragmatic) communication disorder is rare
among children younger than 4 years. By age 4 or 5 years, most children should possess
adequate speech and language abilities to permit identification of specific deficits in social
communication. Milder forms of the disorder may not become apparent until early adolescence, when language and social interactions become more complex.
The outcome of social (pragmatic) communication disorder is variable, with some children improving substantially over time and others continuing to have difficulties persisting into adulthood. Even among those who have significant improvements, the early
deficits in pragmatics may cause lasting impairments in social relationships and behavior
and also in acquisition of other related skills, such as written expression.
Risic and Prognostic Factors
Genetic and physiological. A family history of autism spectrum disorder, communication disorders, or specific learning disorder appears to increase the risk for social (pragmatic) communication disorder.
Differential Diagnosis
Autism spectrum disorder. Autism spectrum disorder is the primary diagnostic consideration for individuals presenting with social communication deficits. The two disorders can be differentiated by the presence in autism spectrum disorder of restricted/
repetitive patterns of behavior, interests, or activities and their absence in social (pragmatic) communication disorder. Individuals with autism spectrum disorder may only display the restricted/repetitive patterns of behavior, interests, and activities during the early
developmental period, so a comprehensive history should be obtained. Current absence of
symptoms would not preclude a diagnosis of autism spectrum disorder, if the restricted
interests and repetitive behaviors were present in the past. A diagnosis of social (pragmatic) communication disorder should be considered only if the developmental history
fails to reveal any evidence of restricted/repetitive patterns of behavior, interests, or activities.
Attention-deficit/hyperactivity disorder. Primary deficits of ADHD may cause impairments in social communication and functional limitations of effective communication, social participation, or academic achievement.
Social anxiety disorder (social phobia). The symptoms of social communication disorder overlap with those of social anxiety disorder. The differentiating feature is the timing
of the onset of symptoms. In social (pragmatic) communication disorder, the individual
has never had effective social communication; in social anxiety disorder, the social communication skills developed appropriately but are not utilized because of anxiety, fear, or
distress about social interactions.
Intellectual disability (intellectual developmental disorder) and global developmental
delay. Social communication skills may be deficient among individuals with global developmental delay or intellectual disability, but a separate diagnosis is not given unless
the social communication deficits are clearly in excess of the intellectual limitations.
Unspecified Communication Disorder
307.9 (F80.9)
This category applies to presentations in which symptoms characteristic of communication
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for communication disorder or for any of the disorders in the neurodevelopmental disorders diagnostic class. The unspecified communication disorder category is used in situations in
which the clinician chooses not to specify the reason that the criteria are not met for communication disorder or for a specific neurodevelopmental disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis.
Autism Spectrum Disorder
Autism Spectrum Disorder
Diagnostic Criteria 299.00 (F84.0)
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative,
not exhaustive; see text):
1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social
approach and failure of normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging,
for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of
gestures: to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties
in sharing imaginative play or in making friends; to absence of interest in peers.
Specify current severity:
Severity is based on social communication impairments and restricted, repetitive patterns of behavior (seeTable 2).
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at
least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple
motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic
phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of
verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties
with transitions, rigid thinking patterns, greeting rituals, need to take same route or
eat same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g.,
strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of
the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects,
visual fascination with lights or movement).
Specify current severity:
Severity is based on social communication impairments and restricted, repetitive patterns of behavior (see Table 2).
C. Symptoms must be present in the early developmental period (but may not become
fully manifest until social demands exceed limited capacities, or may be masked by
learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism
spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.
Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s
disorder, or pervasive developmental disorder not otherwise specified should be given the
diagnosis of autism spectrum disorder. Individuals who have marked deficits in social
communication, but whose symptoms do not othenwise meet criteria for autism spectrum
disorder, should be evaluated for social (pragmatic) communication disorder.
Specify if;
With or without accompanying inteliectual impairment
With or without accompanying language impairment
Associated with a icnown medicai or genetic condition or environmental factor
(Coding note: Use additional code to identify the associated medical or genetic condition.)
Associated with another neurodevelopmental, mental, or behavioral disorder
(Coding note: Use additional code[s] to identify the associated neurodevelopmental,
mental, or behavioral disorder[s].)
With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119-120, for definition) (Coding note: Use additional code 293.89 [F06.1]
catatonia associated with autism spectrum disorder to indicate the presence of the comorbid catatonia.)
Recording Procedures
For autism spectrum disorder that is associated with a known medical or genetic condition
or environmental factor, or with another neurodevelopmental, mental, or behavioral disorder, record autism spectrum disorder associated with (name of condition, disorder, or
factor) (e.g., autism spectrum disorder associated with Rett syndrome). Severity should be
recorded as level of support needed for each of the two psychopathological domains in
Table 2 (e.g., "requiring very substantial support for deficits in social communication and
requiring substantial support for restricted, repetitive behaviors"). Specification of "with
accompanying intellectual impairment" or "without accompanying intellectual impairment" should be recorded next. Language impairment specification should be recorded
thereafter. If there is accompanying language impairment, the current level of verbal functioning should be recorded (e.g., "with accompanying language impairment—no intelligible speech" or "with accompanying language impairment—phrase speech"). If catatonia is
present, record separately "catatonia associated with autism spectrum disorder."
Specifiers
The severity specifiers (see Table 2) may be used to describe succinctly the current symptomatology (which might fall below level 1), with the recognition that severity may vary by
context and fluctuate over time. Severity of social communication difficulties and restricted, repetitive behaviors should be separately rated. The descriptive severity categories
should not be used to determine eligibility for and provision of services; these can only be
developed at an individual level and through discussion of personal priorities and targets.
Regarding the specifier "with or without accompanying intellectual impairment," understanding the (often uneven) intellectual profile of a child or adult with autism spectrum
disorder is necessary for interpreting diagnostic features. Separate estimates of verbal and
nonverbal skill are necessary (e.g., using untimed nonverbal tests to assess potential
strengths in individuals with limited language).
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To use the specifier "with or without accompanying language impairment," the current level of verbal functioning should be assessed and described. Examples of the specific
descriptions for "with accompanying language impairment" might include no intelligible
speech (nonverbal), single words only, or phrase speech. Language level in individuals
"without accompanying language impairment" might be further described by speaks in
full sentences or has fluent speech. Since receptive language may lag behind expressive
language development in autism spectrum disorder, receptive and expressive language
skills should be considered separately.
The specifier "associated with a known medical or genetic condition or environmental factor" should be used when the individual has a known genetic disorder (e.g., Rett syndrome.
Fragile X syndrome. Down syndrome), a medical disorder (e.g. epilepsy), or a history of environmental exposure (e.g., valproate, fetal alcohol syndrome, very low birth weight).
Additional neurodevelopmental, mental or behavioral conditions should also be noted
(e.g., attention-deficit/hyperactivity disorder; developmental coordination disorder; disruptive behavior, impulse-control, or conduct disorders; anxiety, depressive, or bipolar
disorders; tics or Tourette's disorder; self-injury; feeding, elimination, or sleep disorders).
Diagnostic Features
The essential features of autism spectrum disorder are persistent impairment in reciprocal
social communication and social interaction (Criterion A), and restricted, repetitive patterns of behavior, interests, or activities (Criterion B). These symptoms are present from
early childhood and limit or impair everyday functioning (Criteria C and D). The stage at
which functional impairment becomes obvious will vary according to characteristics of
the individual and his or her environment. Core diagnostic features are evident in the
developmental period, but intervention, compensation, and current supports may mask
difficulties in at least some contexts. Manifestations of the disorder also vary greatly depending on the severity of the autistic condition, developmental level, and chronological age;
hence, the term spectrum. Autism spectrum disorder encompasses disorders previously referred to as early infantile autism, childhood autism, Kanner's autism, high-functioning
autism, atypical autism, pervasive developmental disorder not otherwise specified, childhood disintegrative disorder, and Asperger's disorder.
The impairments in communication and social interaction specified in Criterion A are
pervasive and sustained. Diagnoses are most valid and reliable when based on multiple
sources of information, including clinician's observations, caregiver history, and, when
possible, self-report. Verbal and nonverbal deficits in social communication have varying
manifestations, depending on the individual's age, intellectual level, and language ability,
as well as other factors such as treatment history and current support. Many individuals
have language deficits, ranging from complete lack of speech through language delays,
poor comprehension of speech, echoed speech, or stilted and overly literal language. Even
when formal language skills (e.g., vocabulary, grammar) are intact, the use of language for
reciprocal social communication is impaired in autism spectrum disorder.
Deficits in social-emotional reciprocity (i.e., the ability to engage with others and share
thoughts and feelings) are clearly evident in young children with the disorder, who may
show little or no initiation of social interaction and no sharing of emotions, along with reduced or absent imitation of others' behavior. What language exists is often one-sided,
lacking in social reciprocity, and used to request or label rather than to comment, share
feelings, or converse. In adults without intellectual disabilities or language delays, deficits
in social-emotional reciprocity may be most apparent in difficulties processing and responding to complex social cues (e.g., when and how to join a conversation, what not to
say). Adults who have developed compensation strategies for some social challenges still
struggle in novel or unsupported situations and suffer from the effort and anxiety of consciously calculating what is socially intuitive for most individuals.
Deficits in nonverbal communicative behaviors used for social interaction are manifested by absent, reduced, or atypical use of eye contact (relative to cultural norms), gestures, facial expressions, body orientation, or speech intonation. An early feature of autism
spectrum disorder is impaired joint attention as manifested by a lack of pointing, showing,
or bringing objects to share interest with others, or failure to follow someone's pointing or
eye gaze. Individuals may learn a few functional gestures, but their repertoire is smaller
than that of others, and they often fail to use expressive gestures spontaneously in communication. Among adults with fluent language, the difficulty in coordinating nonverbal
communication with speech may give the impression of odd, wooden, or exaggerated
"body language" during interactions. Impairment may be relatively subtle within individual modes (e.g., someone may have relatively good eye contact when speaking) but
noticeable in poor integration of eye contact, gesture, body posture, prosody, and facial expression for social communication.
Deficits in developing, maintaining, and understanding relationships should be
judged against norms for age, gender, and culture. There may be absent, reduced, or atypical social interest, manifested by rejection of others, passivity, or inappropriate approaches that seem aggressive or disruptive. These difficulties are particularly evident in
young children, in whom there is often a lack of shared social play and imagination (e.g.,
age-appropriate flexible pretend play) and, later, insistence on playing by very fixed rules.
Older individuals may struggle to understand what behavior is considered appropriate in
one situation but not another (e.g., casual behavior during a job interview), or the different
ways that language may be used to communicate (e.g., irony, white lies). There may be an
apparent preference for solitary activities or for interacting with much younger or older
people. Frequently, there is a desire to establish friendships without a complete or realistic
idea of what friendship entails (e.g., one-sided friendships or friendships based solely on
shared special interests). Relationships with siblings, co-workers, and caregivers are also
important to consider (in terms of reciprocity).
Autism spectrum disorder is also defined by restricted, repetitive patterns of behavior,
interests, or activities (as specified in Criterion B), which show a range of manifestations
according to age and ability, intervention, and current supports. Stereotyped or repetitive
behaviors include simple motor stereotypies (e.g., hand flapping, finger flicking), repetitive use of objects (e.g., spinning coins, lining up toys), and repetitive speech (e.g., echolalia, the delayed or immediate parroting of heard words; use of "you" when referring to
self; stereotyped use of words, phrases, or prosodic patterns). Excessive adherence to routines and restricted patterns of behavior may be manifest in resistance to change (e.g., distress at apparently small changes, such as in packaging of a favorite food; insistence on
adherence to rules; rigidity of thinking) or ritualized patterns of verbal or nonverbal behavior (e.g., repetitive questioning, pacing a perimeter). Highly restricted, fixated interests
in autism spectrum disorder tend to be abnormal in intensity or focus (e.g., a toddler
strongly attached to a pan; a child preoccupied with vacuum cleaners; an adult spending
hours writing out timetables). Some fascinations and routines may relate to apparent hyper- or hyporeactivity to sensory input, manifested through extreme responses to specific
sounds or textures, excessive smelling or touching of objects, fascination with lights or
spinning objects, and sometimes apparent indifference to pain, heat, or cold. Extreme reaction to or rituals involving taste, smell, texture, or appearance of food or excessive food
restrictions are common and may be a presenting feature of autism spectrum disorder.
Many adults with autism spectrum disorder without intellectual or language disabilities learn to suppress repetitive behavior in public. Special interests may be a source of
pleasure and motivation and provide avenues for education and employment later in life.
Diagnostic criteria may be met when restricted, repetitive patterns of behavior, interests,
or activities were clearly present during childhood or at some time in the past, even if
symptoms are no longer present.
Criterion D requires that the features must cause clinically significant impairment in social, occupational, or other important areas of current functioning. Criterion E specifies that
the social communication deficits, although sometimes accompanied by intellectual disability (intellectual developmental disorder), are not in line with the individual's developmental
level; impairments exceed difficulties expected on the basis of developmental level.
Standardized behavioral diagnostic instruments with good psychometric properties,
including caregiver interviews, questionnaires and clinician observation measures, are
available and can improve reliability of diagnosis over time and across clinicians.
Associated Features Supporting Diagnosis
Many individuals with autism spectrum disorder also have intellectual impairment and/or
language impairment (e.g., slow to talk, language comprehension behind production). Even
those with average or high intelligence have an uneven profile of abilities. The gap between
intellectual and adaptive functional skills is often large. Motor deficits are often present, including odd gait, clumsiness, and other abnormal motor signs (e.g., walking on tiptoes). Selfinjury (e.g., head banging, biting the wrist) may occur, and disruptive/challenging behaviors are more common in children and adolescents with autism spectrum disorder than
other disorders, including intellectual disability. Adolescents and adults with autism spectrum disorder are prone to anxiety and depression. Some individuals develop catatonic-like
motor behavior (slowing and "freezing" mid-action), but these are typically not of the magnitude of a catatonic episode. However, it is possible for individuals with autism spectrum
disorder to experience a marked deterioration in motor symptoms and display a full catatonic episode with symptoms such as mutism, posturing, grimacing and waxy flexibility.
The risk period for comorbid catatonia appears to be greatest in the adolescent years.
Prevalence
In recent years, reported frequencies for autism spectrum disorder across U.S. and nonU.S. countries have approached 1% of the population, with similar estimates in child and
adult samples. It remains unclear whether higher rates reflect an expansion of the diagnostic criteria of DSM-IV to include subthreshold cases, increased awareness, differences
in study methodology, or a true increase in the frequency of autism spectrum disorder.
Development and Course
The age and pattern of onset also should be noted for autism spectrum disorder. Symptoms
are typically recognized during the second year of life (12-24 months of age) but may be seen
earlier than 12 months if developmental delays are severe, or noted later than 24 months if
symptoms are more subtle. The pattern of onset description might include information
about early developmental delays or any losses of social or language skills. In cases where
skills have been lost, parents or caregivers may give a history of a gradual or relatively
rapid deterioration in social behaviors or language skills. Typically, this would occur between 12 and 24 months of age and is distinguished from the rare instances of developmental regression occurring after at least 2 years of normal development (previously described
as childhood disintegrative disorder).
The behavioral features of autism spectrum disorder first become evident in early
childhood, with some cases presenting a lack of interest in social interaction in the first
year of life. Some children with autism spectrum disorder experience developmental plateaus or regression, with a gradual or relatively rapid deterioration in social behaviors or
use of language, often during the first 2 years of life. Such losses are rare in other disorders and may be a useful "red flag" for autism spectrum disorder. Much more unusual
and warranting more extensive medical investigation are losses of skills beyond social
communication (e.g., loss of self-care, toileting, motor skills) or those occurring after the
second birthday (see also Rett syndrome in the section "Differential Diagnosis" for this
disorder).
First symptoms of autism spectrum disorder frequently involve delayed language development, often accompanied by lack of social interest or unusual social interactions (e.g.,
pulling individuals by the hand without any attempt to look at them), odd play patterns
(e.g., carrying toys around but never playing with them), and unusual communication
patterns (e.g., knowing the alphabet but not responding to own name). Deafness may be
suspected but is typically ruled out. During the second year, odd and repetitive behaviors
and the absence of typical play become more apparent. Since many typically developing
young children have strong preferences and enjoy repetition (e.g., eating the same foods,
watching the same video multiple times), distinguishing restricted and repetitive behaviors that are diagnostic of autism spectrum disorder can be difficult in preschoolers. The
clinical distinction is based on the type, frequency, and intensity of the behavior (e.g., a
child who daily lines up objects for hours and is very distressed if any item is moved).
Autism spectrum disorder is not a degenerative disorder, and it is typical for learning
and compensation to continue throughout life. Symptoms are often most marked in early
childhood and early school years, with developmental gains typical in later childhood in
at least some areas (e.g., increased interest in social interaction). A small proportion of individuals deteriorate behaviorally during adolescence, whereas most others improve.
Only a minority of individuals with autism spectrum disorder live and work independently in adulthood; those who do tend to have superior language and intellectual abilities
and are able to find a niche that matches their special interests and skills. In general, individuals with lower levels of impairment may be better able to function independently.
However, even these individuals may remain socially naive and vulnerable, have difficulties organizing practical demands without aid, and are prone to anxiety and depression.
Many adults report using compensation strategies and coping mechanisms to mask their
difficulties in public but suffer from the stress and effort of maintaining a socially acceptable facade. Scarcely anything is known about old age in autism spectrum disorder.
Some individuals come for first diagnosis in adulthood, perhaps prompted by the diagnosis of autism in a child in the family or a breakdown of relations at work or home. Obtaining detailed developmental history in such cases may be difficult, and it is important to consider selfreported difficulties. Where clinical observation suggests criteria are currently met, autism
spectrum disorder may be diagnosed, provided there is no evidence of good social and communication skills in childhood. For example, the report (by parents or another relative) that the
individual had ordinary and sustained reciprocal friendships and good nonverbal communication skills throughout childhood would rule out a diagnosis of autism spectrum disorder;
however, the absence of developmental information in itself should not do so.
Manifestations of the social and communication impairments and restricted/repetitive behaviors that define autism spectrum disorder are clear in the developmental period.
In later life, intervention or compensation, as well as current supports, may mask these difficulties in at least some contexts. However, symptoms remain sufficient to cause current
impairment in social, occupational, or other important areas of functioning.
Risk and Prognostic Factors
The best established prognostic factors for individual outcome within autism spectrum
disorder are presence or absence of associated intellectual disability and language impairment (e.g., functional language by age 5 years is a good prognostic sign) and additional
mental health problems. Epilepsy, as a comorbid diagnosis, is associated with greater intellectual disability and lower verbal ability.
Environmental. A variety of nonspecific risk factors, such as advanced parental age, low
birth weight, or fetal exposure to valproate, may contribute to risk of aufism spectrum disorder.
Genetic and physiological. Heritability estimates for autism spectrum disorder have
ranged from 37°/^ to higher than 90%, based on twin concordance rates. Currently, as many
as 15% of cases of autism spectrum disorder appear to be associated with a known genetic
mutation, with different de novo copy number variants or de novo mutations in specific
genes associated with the disorder in different families. However, even when an autism
spectrum disorder is associated with a known genetic mutation, it does not appear to be
fully penetrant. Risk for the remainder of cases appears to be polygenic, with perhaps hundreds of genetic loci making relatively small contributions.
Culture-Related Diagnostic Issues
Cultural differences will exist in norms for social interaction, nonverbal communication,
and relationships, but individuals with autism spectrum disorder are markedly impaired
against the norms for their cultural context. Cultural and socioeconomic factors may affect
age at recognition or diagnosis; for example, in the United States, late or underdiagnosis of
autism spectrum disorder among African American children may occur.
Gender-Related Diagnostic Issues
Autism spectrum disorder is diagnosed four times more often in males than in females. In
clinic samples, females tend to be more likely to show accompanying intellectual disability, suggesting that girls without accompanying intellectual impairments or language
delays may go unrecognized, perhaps because of subtler manifestation of social and communication difficulties.
Functional Consequences of Autism Spectrum Disorder
In young children with autism spectrum disorder, lack of social and communication abilities may hamper learning, especially learning through social interaction or in settings
with peers. In the home, insistence on routines and aversion to change, as well as sensory
sensitivities, may interfere with eating and sleeping and make routine care (e.g., haircuts,
dental work) extremely difficult. Adaptive skills are typically below measured IQ. Extreme difficulties in planning, organization, and coping with change negatively impact
academic achievement, even for students with above-average intelligence. During adulthood, these individuals may have difficulties establishing independence because of continued rigidity and difficulty with novelty.
Many individuals with autism spectrum disorder, even without intellectual disability,
have poor adult psychosocial functioning as indexed by measures such as independent
living and gainful employment. Functional consequences in old age are unknown, but social isolation and communication problems (e.g., reduced help-seeking) are likely to have
consequences for health in older adulthood.
Differential Diagnosis
Rett syndrome. Disruption of social interaction may be observed during the regressive
phase of Rett syndrome (typically between 1-4 years of age); thus, a substantial proportion
of affected young girls may have a presentation that meets diagnostic criteria for autism
spectrum disorder. However, after this period, most individuals with Rett syndrome improve their social communication skills, and autistic features are no longer a major area of
concern. Consequently, autism spectrum disorder should be considered only when all diagnostic criteria are met.
Selective mutism. In selective mutism, early development is not typically disturbed.
The affected child usually exhibits appropriate communication skills in certain contexts
and settings. Even in settings where the child is mute, social reciprocity is not impaired,
nor are restricted or repetitive patterns of behavior present.
Language disorders and social (pragmatic) communication disorder. In some forms
of language disorder, there may be problems of communication and some secondary social difficulties. However, specific language disorder is not usually associated with abnormal nonverbal communication, nor with the presence of restricted, repetitive patterns of
behavior, interests, or activities.
When an individual shows impairment in social communication and social interactions
but does not show restricted and repetitive behavior or interests, criteria for social (pragmatic) communication disorder, instead of autism spectrum disorder, may be met. The diagnosis of autism spectrum disorder supersedes that of social (pragmatic) communication
disorder whenever the criteria for autism spectrum disorder are met, and care should be
taken to enquire carefully regarding past or current restricted/repetitive behavior.
Intellectual disability (intellectual developmental disorder) without autism spectrum
disorder. Intellectual disability without autism spectrum disorder may be difficult to
differentiate from autism spectrum disorder in very young children. Individuals with intellectual disability who have not developed language or symbolic skills also present a
challenge for differential diagnosis, since repetitive behavior often occurs in such individuals as well. A diagnosis of autism spectrum disorder in an individual with intellectual
disability is appropriate when social communication and interaction are significantly impaired relative to the developmental level of the individual's nonverbal skills (e.g., fine
motor skills, nonverbal problem solving). In contrast, intellectual disability is the appropriate diagnosis when there is no apparent discrepancy between the level of social-communicative skills and other intellectual skills.
Stereotypic movement disorder. Motor stereotypies are among the diagnostic characteristics of autism spectrum disorder, so an additional diagnosis of stereotypic movement
disorder is not given when such repetitive behaviors are better explained by the presence
of autism spectrum disorder. However, when stereotypies cause self-injury and become a
focus of treatment, both diagnoses may be appropriate.
Attention-deficit/hyperactivity disorder. Abnormalities of attention (overly focused or
easily distracted) are common in individuals with autism spectrum disorder, as is hyperactivity. A diagnosis of attention-deficit/hyperactivity disorder (ADHD) should be
considered when attentional difficulties or hyperactivity exceeds that typically seen in individuals of comparable mental age.
Schizophrenia. Schizophrenia with childhood onset usually develops after a period of
normal, or near normal, development. A prodromal state has been described in which social impairment and atypical interests and beliefs occur, which could be confused with the
social deficits seen in autism spectrum disorder. Hallucinations and delusions, which are
defining features of schizophrenia, are not features of autism spectrum disorder. However, clinicians must take into account the potential for individuals with autism spectrum
disorder to be concrete in their interpretation of questions regarding the key features of
schizophrenia (e.g., "Do you hear voices when no one is there?" "Yes [on the radio]").
Comorbidity
Autism spectrum disorder is frequently associated with intellectual impairment and structural language disorder (i.e., an inability to comprehend and construct sentences with proper
grammar), which should be noted under the relevant specifiers when applicable. Many individuals with autism spectrum disorder have psychiatric symptoms that do not form part of
the diagnostic criteria for the disorder (about 70% of individuals with autism spectrum disorder may have one comorbid mental disorder, and 40% may have two or more comorbid
mental disorders). When criteria for both ADHD and autism spectrum disorder are met, both
diagnoses should be given. This same principle applies to concurrent diagnoses of autism
spectrum disorder and developmental coordination disorder, anxiety disorders, depressive
disorders, and other comorbid diagnoses. Among individuals who are nonverbal or have
language deficits, observable signs such as changes in sleep or eating and increases in challenging behavior should trigger an evaluation for anxiety or depression. Specific learning difficulties (literacy and numeracy) are common, as is developmental coordination disorder.
Medical conditions commonly associated with autism spectrum disorder should be noted
under the "associated with a known medical/genetic or environmental/acquired condition"
specifier. Such medical conditions include epilepsy, sleep problems, and constipation.
Avoidant-restrictive food intake disorder is a fairly frequent presenting feature of autism
spectrum disorder, and extreme and narrow food preferences may persist.
Attention-Deficit/Hyperactivity
Disorder
Attention-Deficit/Hyperactivity Disorder
Diagnostic Criteria
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with
functioning or development, as characterized by (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted for at least
6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents
and adults (age 17 and older), at least five symptoms are required.
a. Often fails to give close attention to details or makes careless mistakes in
schoolwork, at work, or during other activities (e.g., overlooks or misses details,
work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and
is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained
mental effort (e.g., schoolwork or homework; for older adolescents and adults,
preparing reports, completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, papenwork, eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and
adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older
adolescents and adults, returning calls, paying bills, keeping appointments).
2. Hyperactivity and impuisivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level
and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents
and adults (age 17 and older), at least five symptoms are required.
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves
his or her place in the classroom, in the office or other workplace, or in other
situations that require remaining in place).
c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be
experienced by others as being restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or
activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others
are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age
12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).
Specify whether:
314.01 (F90.2) Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months.
314.00 (F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention)
is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.
314.01 (F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months.
Specify if:
in partial remission: When full criteria were previously met, fewer than the full criteria
have been met for the past 6 months, and the symptoms still result in impairment in
social, academic, or occupational functioning.
Specify current severity:
lUlild: Few, if any, symptoms in excess of those required to make the diagnosis are
present, and symptoms result in no more than minor impairments in social or occupational functioning.
Moderate: Symptoms or functional impairment between “mild” and “severe” are present.
Severe: Many symptoms in excess of tliose required to mal<e tlie diagnosis, or several
symptoms that are particularly severe, are present, or the symptoms result in marked
impairment in social or occupational functioning.
Diagnostic Features
The essential feature of attention-deficit/hyperactivity disorder (ADHD) is a persistent
pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or
development. Inattention manifests behaviorally in ADHD as wandering off task, lacking
persistence, having difficulty sustaining focus, and being disorganized and is not due to
defiance or lack of comprehension. Hyperactivity refers to excessive motor activity (such as
a child running about) when it is not appropriate, or excessive fidgeting, tapping, or talkativeness. In adults, hyperactivity may manifest as extreme restlessness or wearing others
out with their activity. Impulsivity refers to hasty actions that occur in the moment without
forethought and that have high potential for harm to the individual (e.g., darting into the
street without looking). Impulsivity may reflect a desire for immediate rewards or an inability to delay gratification. Impulsive behaviors may manifest as social intrusiveness
(e.g., interrupting others excessively) and/or as making important decisions without consideration of long-term consequences (e.g., taking a job without adequate information).
ADHD begins in childhood. The requirement that several symptoms be present before
age 12 years conveys the importance of a substantial clinical presentation during childhood. At the same time, an earlier age at onset is not specified because of difficulties in establishing precise childhood onset retrospectively. Adult recall of childhood symptoms
tends to be unreliable, and it is beneficial to obtain ancillary information.
Manifestations of the disorder must be present in more than one setting (e.g., home and
school, work). Confirmation of substantial symptoms across settings typically cannot be
done accurately without consulting informants who have seen the individual in those settings. Typically, symptoms vary depending on context within a given setting. Signs of the
disorder may be minimal or absent when the individual is receiving frequent rewards for
appropriate behavior, is under close supervision, is in a novel setting, is engaged in especially interesting activities, has consistent external stimulation (e.g., via electronic screens),
or is interacting in one-on-one situations (e.g., the clinician's office).
Associated Features Supporting Diagnosis
Mild delays in language, motor, or social development are not specific to ADHD but often cooccur. Associated features may include low frustration tolerance, irritability, or mood lability.
Even in the absence of a specific learning disorder, academic or work performance is often impaired. Inattentive behavior is associated with various underlying cognitive processes, and individuals with ADHD may exhibit cognitive problems on tests of attention, executive
function, or memory, although these tests are not sufficiently sensitive or specific to serve as diagnostic indices. By early adulthood, ADHD is associated with an increased risk of suicide attempt, primarily when comorbid with mood, conduct, or substance use disorders.
No biological marker is diagnostic for ADHD. As a group, compared with peers, children with ADHD display increased slow wave electroencephalograms, reduced total
brain volume on magnetic resonance imaging, and possibly a delay in posterior to anterior
cortical maturation, but these findings are not diagnostic. In the uncommon cases where
there is a known genetic cause (e.g.. Fragile X syndrome, 22qll deletion syndrome), the
ADHD presentation should still be diagnosed.
Prevalence
Population surveys suggest that ADHD occurs in most cultures in about 5% of children
and about 2.5% of adults.
Development and Course
Many parents first observe excessive motor activity when the child is a toddler, but symptoms are difficult to distinguish from highly variable normative behaviors before age 4
years. ADHD is most often identified during elementary school years, and inattention becomes more prominent and impairing. The disorder is relatively stable through early adolescence, but some individuals have a worsened course with development of antisocial
behaviors. In most individuals with ADHD, symptoms of motoric hyperactivity become
less obvious in adolescence and adulthood, but difficulties with restlessness, inattention,
poor planning, and impulsivity persist. A substantial proportion of children with ADHD
remain relatively impaired into adulthood.
In preschool, the main manifestation is hyperactivity. Inattention becomes more prominent during elementary school. During adolescence, signs of hyperactivity (e.g., running
and climbing) are less common and may be confined to fidgetiness or an inner feeling of
jitteriness, restlessness, or impatience. In adulthood, along with inattention and restlessness, impulsivity may remain problematic even when hyperactivity has diminished.
Risk and Prognostic Factors
Temperamental. ADHD is associated with reduced behavioral inhibition, effortful control, or constraint; negative emotionality; and/or elevated novelty seeking. These traits
may predispose some children to ADHD but are not specific to the disorder.
Environmental. Very low birth weight (less than 1,500 grams) conveys a two- to threefold risk for ADHD, but most children with low birth weight do not develop ADHD. Although ADHD is correlated with smoking during pregnancy, some of this association
reflects common genetic risk. A minority of cases may be related to reactions to aspects of
diet. There may be a history of child abuse, neglect, multiple foster placements, neurotoxin
exposure (e.g., lead), infections (e.g., encephalitis), or alcohol exposure in utero. Exposure
to environmental toxicants has been correlated with subsequent ADHD, but it is not
known whether these associations are causal.
Genetic and physiological. ADHD is elevated in the first-degree biological relatives of
individuals with ADHD. The heritability of ADHD is substantial. While specific genes
have been correlated with ADHD, they are neither necessary nor sufficient causal factors.
Visual and hearing impairments, metabolic abnormalities, sleep disorders, nutritional deficiencies, and epilepsy should be considered as possible influences on ADHD symptoms.
ADHD is not associated with specific physical features, although rates of minor physical anomalies (e.g., hypertelorism, highly arched palate, low-set ears) may be relatively
elevated. Subtle motor delays and other neurological soft signs may occur. (Note that
marked co-occurring clumsiness and motor delays should be coded separately [e.g., developmental coordination disorder].)
Course modifiers. Family interaction patterns in early childhood are unlikely to cause
ADHD but may influence its course or contribute to secondary development of conduct
problems.
Cuiture-Reiated Diagnostic Issues
Differences in ADHD prevalence rates across regions appear attributable mainly to different diagnostic and methodological practices. However, there also may be cultural variation in attitudes toward or interpretations of children's behaviors. Clinical identification
rates in the United States for African American and Latino populations tend to be lower
than for Caucasian populations. Informant symptom ratings may be influenced by cultural group of the child and the informant, suggeshng that culturally appropriate practices
are relevant in assessing ADHD.
Gender-Related Diagnostic Issues
ADHD is more frequent in males than in females in the general population, with a ratio of
approximately 2:1 in children and 1.6:1 in adults. Females are more likely than males to
present primarily with inattentive features.
Functional Consequences of
Attention-Deficit/Hyperactivity Disorder
ADHD is associated with reduced school performance and academic attainment, social rejection, and, in adults, poorer occupational performance, attainment, attendance, and
higher probability of unemployment as well as elevated interpersonal conflict. Children
with ADHD are significantly more likely than their peers without ADHD to develop conduct disorder in adolescence and antisocial personality disorder in adulthood, consequently increasing the likelihood for substance use disorders and incarceration. The risk of
subsequent substance use disorders is elevated, especially when conduct disorder or antisocial personality disorder develops. Individuals with ADHD are more likely than peers
to be injured. Traffic accidents and violations are more frequent in drivers with ADHD.
There may be an elevated likelihood of obesity among individuals with ADHD.
Inadequate or variable self-application to tasks that require sustained effort is often interpreted by others as laziness, irresponsibility, or failure to cooperate. Family relationships may be characterized by discord and negative interactions. Peer relationships afe
often disrupted by peer rejection, neglect, or teasing of the individual with ADHD. On average, individuals with ADHD obtain less schooling, have poorer vocational achievement,
and have reduced intellectual scores than their peers, although there is great variability. In
its severe form, the disorder is markedly impairing, affecting social, familial, and scholastic/occupational adjustment.
Academic deficits, school-related problems, and peer neglect tend to be most associated with elevated symptoms of inattention, whereas peer rejection and, to a lesser extent,
accidental injury are most salient with marked symptoms of hyperactivity or impulsivity.
Differential Diagnosis
Oppositional defiant disorder. Individuals with oppositional defiant disorder may resist work or school tasks that require self-application because they resist conforming to
others' demands. Their behavior is characterized by negativity, hostility, and defiance.
These symptoms must be differentiated from aversion to school or mentally demanding
tasks due to difficulty in sustaining mental effort, forgetting instructions, and impulsivity
in individuals with ADHD. Complicating the differential diagnosis is the fact that some
individuals with ADHD may develop secondary oppositional attitudes toward such tasks
and devalue their importance.
Intermittent explosive disorder. ADHD and intermittent explosive disorder share high
levels of impulsive behavior. However, individuals with intermittent explosive disorder
show serious aggression toward others, which is not characteristic of ADHD, and they do
not experience problems with sustaining attention as seen in ADHD. In addition, intermittent explosive disorder is rare in childhood. Intermittent explosive disorder may be diagnosed in the presence of ADHD.
Other neurodevelopmental disorders. The increased motoric activity that may occur in
ADHD must be distinguished from the repetitive motor behavior that characterizes stereotypic movement disorder and some cases of autism spectrum disorder. In stereotypic
movement disorder, the motoric behavior is generally fixed and repetitive (e.g., body rocking, self-biting), whereas the fidgetiness and restlessness in ADHD are typically generalized and not characterized by repetitive stereotypic movements. In Tourette's disorder,
frequent multiple tics can be mistaken for the generalized fidgetiness of ADHD. Prolonged
observation may be needed to differentiate fidgetiness from bouts of multiple tics.
Specific learning disorder. Children with specific learning disorder may appear inattentive because of frustration, lack of interest, or limited ability. However, inattention in
individuals with a specific learning disorder who do not have ADHD is not impairing outside of academic work.
Intellectual disability (intellectual developmental disorder). Symptoms of ADHD are
common among children placed in academic settings that are inappropriate to their intellectual ability. In such cases, the symptoms are not evident during non-academic tasks. A
diagnosis of ADHD in intellectual disability requires that inattention or hyperactivity be
excessive for mental age.
Autism spectrum disorder. Individuals with ADHD and those with autism spectrum
disorder exhibit inattention, social dysfunction, and difficult-to-manage behavior. The social dysfunction and peer rejection seen in individuals with ADHD must be distinguished
from the social disengagement, isolation, and indifference to facial and tonal communication cues seen in individuals with autism spectrum disorder. Children with autism spectrum disorder may display tantrums because of an inability to tolerate a change from their
expected course of events. In contrast, children with ADHD may misbehave or have a tantrum during a major transition because of impulsivity or poor self-control.
Reactive attachment disorder. Children with reactive attachment disorder may show
social disinhibition, but not the full ADHD symptom cluster, and display other features
such as a lack of enduring relationships that are not characteristic of ADHD.
Anxiety disorders. ADHD shares symptoms of inattention with anxiety disorders. Individuals with ADHD are inattentive because of their attraction to external stimuli, new
activities, or preoccupation with enjoyable activities. This is distinguished from the inattention due to worry and rumination seen in anxiety disorders. Restlessness might be seen
in anxiety disorders. However, in ADHD, the symptom is not associated with worry and
rumination.
Depressive disorders. Individuals with depressive disorders may present with inability to concentrate. However, poor concentration in mood disorders becomes prominent
only during a depressive episode.
Bipolar disorder. Individuals with bipolar disorder may have increased activity, poor
concentration, and increased impulsivity, but these features are episodic, occurring several days at a time. In bipolar disorder, increased impulsivity or inattention is accompanied by elevated mood, grandiosity, and other specific bipolar features. Children with
ADHD may show significant changes in mood within the same day; such lability is distinct from a manic episode, which must last 4 or more days to be a clinical indicator of bipolar disorder, even in children. Bipolar disorder is rare in preadolescents, even when
severe irritability and anger are prominent, whereas ADHD is common among children
and adolescents who display excessive anger and irritability.
Disruptive mood dysregulation disorder. Disruptive mood dysregulation disorder is
characterized by pervasive irritability, and intolerance of frustration, but impulsiveness
and disorganized attenhon are not essential features. However, most children and adolescents with the disorder have symptoms that also meet criteria for ADHD, which is diagnosed separately.
Substance use disorders. Differentiating ADHD from substance use disorders may be
problematic if the first presentation of ADHD symptoms follows the onset of abuse or frequent use. Clear evidence of ADHD before substance misuse from informants or previous
records may be essential for differential diagnosis.
Personality disorders. In adolescents and adults, it may be difficult to distinguish ADHD
from borderline, narcissistic, and other personality disorders. All these disorders tend to
share the features of disorganization, social intrusiveness, emotional dysregulation, and
cognitive dysregulation. However, ADHD is not characterized by fear of abandonment,
self-injury, extreme ambivalence, or other features of personality disorder. It may take
extended clinical observation, informant interview, or detailed history to distinguish impulsive, socially intrusive, or inappropriate behavior from narcissistic, aggressive, or domineering behavior to make this differential diagnosis.
Psychotic disorders. ADHD is not diagnosed if the symptoms of inattention and hyperactivity occur exclusively during the course of a psychotic disorder.
Medication-induced symptoms of ADHD. Symptoms of inattention, hyperactivity, or
impulsivity attributable to the use of medication (e.g., bronchodilators, isoniazid, neuroleptics [resulting in akathisia], thyroid replacement medication) are diagnosed as other
specified or unspecified other (or unknown) substance-related disorders.
Neurocognitive disorders. Early major neurocognitive disorder (dementia) and/or
mild neurocognitive disorder are not known to be associated with ADHD but may present
with similar clinical features. These conditions are distinguished from ADHD by their late
onset.
Comorbidity
In clinical settings, comorbid disorders are frequent in individuals whose symptoms meet
criteria for ADHD. In the general population, oppositional defiant disorder co-occurs with
ADHD in approximately half of children with the combined presentation and about a
quarter with the predominantly inattentive presentation. Conduct disorder co-occurs in
about a quarter of children or adolescents with the combined presentation, depending on
age and setting. Most children and adolescents with disruptive mood dysregulation disorder have symptoms that also meet criteria for ADHD; a lesser percentage of children
with ADHD have symptoms that meet criteria for disruptive mood dysregulation disorder. Specific learning disorder commonly co-occurs with ADHD. Anxiety disorders and
major depressive disorder occur in a minority of individuals with ADHD but more often
than in the general population. Intermittent explosive disorder occurs in a minority of
adults with ADHD, but at rates above population levels. Although substance use disorders are relatively more frequent among adults with ADHD in the general population, the
disorders are present in only a minority of adults with ADHD. In adults, antisocial and
other personality disorders may co-occur with ADHD. Other disorders that may co-occur
with ADHD include obsessive-compulsive disorder, tic disorders, and autism spectrum
disorder.
Other Specified Attention-Deficit/
Hyperactivity Disorder
314.01 (F90.8)
This category applies to presentations in which symptoms characteristic of attentiondeficit/hyperactivity disorder that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet the
full criteria for attention-deficit/hyperactivity disorder or any of the disorders in the neurodevelopmental disorders diagnostic class. The other specified attention-deficit/hyperactivity disorder category is used in situations in which the clinician chooses to communicate
the specific reason that the presentation does not meet the criteria for attention-deficit/
hyperactivity disorder or any specific neurodevelopmental disorder. This is done by recording “other specified attention-deficit/hyperactivity disorder” followed by the specific
reason (e.g., “with insufficient inattention symptoms”).
Unspecified Attention-Deficit/
Hyperactivity Disorder
314.01 (F90.9)
This category applies to presentations in which symptoms characteristic of attentiondeficit/hyperactivity disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the
full criteria for attention-deficit/hyperactivity disorder or any of the disorders in the neurodevelopmental disorders diagnostic class. The unspecified attention-deficit/hyperactivity
disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for attention-deficit/hyperactivity disorder or for a specific
neurodevelopmental disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis.
Specific Learning Disorder
Specific Learning Disorder
Diagnostic Criteria
A. Difficulties learning and using academic skills, as indicated by the presence of at least
one of the following symptoms that have persisted for at least 6 months, despite the
provision of interventions that target those difficulties:
1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or slowly and hesitantly, frequently guesses words, has difficulty sounding
out words).
2. Difficulty understanding the meaning of what is read (e.g., may read text accurately
but not understand the sequence, relationships, inferences, or deeper meanings of
what is read).
3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).
4. Difficulties with written expression (e.g., makes multiple grammatical or punctuation errors within sentences; employs poor paragraph organization; written expression of ideas lacks clarity).
5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor
understanding of numbers, their magnitude, and relationships; counts on fingers to
add single-digit numbers instead of recalling the math fact as peers do; gets lost in
the midst of arithmetic computation and may switch procedures).
6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical concepts, facts, or procedures to solve quantitative problems).
B. The affected academic skills are substantially and quantifiably below those expected
for the individual’s chronological age, and cause significant interference with academic
or occupational performance, or with activities of daily living, as confirmed by individually administered standardized achievement measures and comprehensive clinical
assessment. For individuals age 17 years and older, a documented history of impairing
learning difficulties may be substituted for the standardized assessment.
C. The learning difficulties begin during school-age years but may not become fully manifest until the demands for those affected academic sl<ills exceed the individual’s limited capacities (e.g., as in timed tests, reading or writing lengthy complex reports for a
tight deadline, excessively heavy academic loads).
D. The learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, other mental or neurological disorders, psychosocial
adversity, lack of proficiency in the language of academic instruction, or inadequate
educational instruction.
Note; The four diagnostic criteria are to be met based on a clinical synthesis of the individual’s history (developmental, medical, family, educational), school reports, and psychoeducational assessment.
Coding note: Specify all academic domains and subskills that are impaired. When more
than one domain is impaired, each one should be coded individually according to the following specifiers.
Specify if:
315.00 (F81.0) With impairment in reading:
Word reading accuracy
Reading rate or fluency
Reading comprehension
Note: Dyslexia is an alternative term used to refer to a pattern of learning difficulties
characterized by problems with accurate or fluent word recognition, poor decoding,
and poor spelling abilities. If dyslexia is used to specify this particular pattern of difficulties, it is important also to specify any additional difficulties that are present,
such as difficulties with reading comprehension or math reasoning.
315.2 (F81.81) Witli impairment in written expression:
Spelling accuracy
Grammar and punctuation accuracy
Clarity or organization of written expression
315.1 (FBI .2) With impairment in mathematics:
Number sense
Memorization of arithmetic facts
Accurate or fluent calculation
Accurate math reasoning
Note: Dyscalculia is an altemative term used to refer to a pattern of difficulties characterized by problems processing numerical information, learning arithmetic facts,
and performing accurate or fluent calculations. If dyscalculia is used to specify this
particular pattern of mathematic difficulties, it is important also to specify any additional difficulties that are present, such as difficulties with math reasoning or word reasoning accuracy.
Specify current severity:
lUliid: Some difficulties learning skills in one or two academic domains, but of mild enough
severity that the individual may be able to compensate or function well when provided with
appropriate accommodations or support services, especially during the school years.
Moderate: Marked difficulties learning skills in one or more academic domains, so that
the individual is unlikely to become proficient without some intervals of intensive and
specialized teaching during the school years. Some accommodations or supportive
services at least part of the day at school, in the workplace, or at home may be needed
to complete activities accurately and efficiently.
Severe: Severe difficulties learning skills, affecting several academic domains, so that
the individual is unlikely to learn those skills without ongoing intensive individualized
and specialized teaching for most of the school years. Even with an array of appropriate accommodations or services at home, at school, or in the workplace, the individual
may not be able to complete all activities efficiently.
Recording Procedures
Each impaired academic domain and subskill of specific learning disorder should be recorded. Because of ICD coding requirements, impairments in reading, impairments in written expression, and impairments in mathematics, with their corresponding impairments in
subskills, must be coded separately. For example, impairments in reading and mathematics
and impairments in the subskills of reading rate or fluency, reading comprehension, accurate or fluent calculation, and accurate math reasoning would be coded and recorded as
315.00 (F81.0) specific learning disorder with impairment in reading, with impairment in
reading rate or fluency and impairment in reading comprehension; 315.1 (F81.2) specific
learning disorder with impairment in mathematics, with impairment in accurate or fluent
calculation and impairment in accurate math reasoning.
Diagnostic Features
Specific learning disorder is a neurodevelopmental disorder with a biological origin that is
the basis for abnormalities at a cognitive level that are associated with the behavioral signs
of the disorder. The biological origin includes an interaction of genetic, epigenetic, and environmental factors, which affect the brain's ability to perceive or process verbal or nonverbal information efficiently and accurately.
One essential feature of specific learning disorder is persistent difficulties learning keystone academic skills (Criterion A), with onset during the years of formal schooling (i.e., the developmental period). Key academic skills include reading of single words accurately and
fluently, reading comprehension, written expression and spelling, arithmetic calculation, and
mathematical reasoning (solving mathematical problems). In contrast to talking or walking,
which are acquired developmental milestones that emerge with brain maturation, academic
skills (e.g., reading, spelling, writing, mathematics) have to be taught and learned explicitly.
Specific learning disorder disrupts the normal pattern of learning academic skills; it is not simply a consequence of lack of opportunity of learning or inadequate instruction. Difficulties
mastering these key academic skills may also impede learning in other academic subjects (e.g.,
history, science, social studies), but those problems are attributable to difficulties learning the
underlying academic skills. Difficulties learning to map letters with the sounds of one's language—^to read printed words (often called dyslexia)—is one of the most common manifestations of specific learning disorder. The learning difficulties manifest as a range of observable,
descriptive behaviors or symptoms (as listed in Criteria A1-A6). These clinical symptoms may
be observed, probed by means of the clinical interview, or ascertained from school reports, rating scales, or descriptions in previous educational or psychological assessments. The learning
difficulties are persistent, not transitory. In children and adolescents, persistence is defined as
restricted progress in learning (i.e., no evidence that the individual is catching up with classmates) for at least 6 months despite the provision of extra help at home or school. For example,
difficulties learning to read single words that do not fully or rapidly remit with the provision of
instruction in phonological skills or word identification strategies may indicate a specific
learning disorder. Evidence of persistent learning difficulties may be derived from cumulative
school reports, portfolios of the child's evaluated work, curriculum-based measures, or clinical
interview. In adults, persistent difficulty refers to ongoing difficulties in literacy or numeracy
skills that manifest during childhood or adolescence, as indicated by cumulative evidence
from school reports, evaluated portfolios of work, or previous assessments.
A second key feature is that the individual's performance of the affected academic skills is
well below average for age (Criterion B). One robust clinical indicator of difficulties learning
academic skills is low academic achievement for age or average achievement that is sustainable only by extraordinarily high levels of effort or support. In children, the low academic skills
cause significant interference in school performance (as indicated by school reports and
teacher's grades or ratings). Another clinical indicator, particularly in adults, is avoidance of
activities that require the academic skills. Also in adulthood, low academic skills interfere with
occupational performance or everyday activities requiring those skills (as indicated by self-report or report by others). However, this criterion also requires psychometric evidence from an
individually administered, psychometrically sound and culturally appropriate test of academic achievement that is norm-referenced or criterion-referenced. Academic skills are distributed along a continuum, so there is no natural cutpoint that can be used to differentiate
individuals with and without specific learning disorder. Thus, any threshold used to specify
what constitutes significantly low academic achievement (e.g., academic skills weU below age
expectation) is to a large extent arbitrary. Low achievement scores on one or more standardized tests or subtests within an academic domain (i.e., at least 1.5 standard deviations [SD] below the population mean for age, which translates to a standard score of 78 or less, which is
below the 7th percentile) are needed for the greatest diagnostic certainty. However, precise
scores will vary according to the particular standardized tests that are used. On the basis of
clinical judgment, a more lenient threshold may be used (e.g., 1.0-2.5 SD below the population mean for age), when learning difficulties are supported by converging evidence
from clinical assessment, academic history, school reports, or test scores. Moreover, since
standardized tests are not available in all languages, the diagnosis may then be based in
part on clinical judgment of scores on available test measures.
A third core feature is that the learning difficulties are readily apparent in the early
school years in most individuals (Criterion C). However, in others, the learning difficulties
may not manifest fully until later school years, by which time learning demands have increased and exceed the individual's limited capacities.
Another key diagnostic feature is that the learning difficulties are considered "specific," for four reasons. First, they are not attributable to intellectual disabilities (intellectual disability [intellectual developmental disorder]); global developmental delay;
hearing or vision disorders, or neurological or motor disorders) (Criterion D). Specific
learning disorder affects learning in individuals who otherwise demonstrate normal levels of intellectual functioning (generally estimated by an IQ score of greater than about 70
[±5 points allowing for measurement error]). The phrase "unexpected academic underachievement" is often cited as the defining characteristic of specific learning disorder in
that the specific learning disabilities are not part of a more general learning difficulty as
manifested in intellectual disability or global developmental delay. Specific learning disorder may also occur in individuals identified as intellectually "gifted." These individuals
may be able to sustain apparentiy adequate academic functioning by using compensatory
strategies, extraordinarily high effort, or support, until the learning demands or assessment procedures (e.g., timed tests) pose barriers to their demonstrating their learning or
accomplishing required tasks. Second, the learning difficulty cannot be attributed to more
general external factors, such as economic or environmental disadvantage, chronic absenteeism, or lack of education as typically provided in the individual's community context.
Third, the learning difficulty cannot be attributed to a neurological (e.g., pediatric stroke)
or motor disorders or to vision or hearing disorders, which are often associated with problems learning academic skills but are distinguishable by presence of neurological signs.
Finally, the learning difficulty may be restricted to one academic skill or domain (e.g., reading single words, retrieving or calculating number facts).
Comprehensive assessment is required. Specific learning disorder can only be diagnosed
after formal education starts but can be diagnosed at any point afterward in children, adolescents, or adults, providing there is evidence of onset during the years of formal schooling (i.e.,
the developmental period). No single data source is sufficient for a diagnosis of specific learning disorder. Rather, specific learning disorder is a clinical diagnosis based on a synthesis of
the individual's medical, developmental, educational, and family history; the history of the
learning difficulty, including its previous and current manifestation; the impact of the difficulty on academic, occupational, or social functioning; previous or current school reports;
portfolios of work requiring academic skills; curriculum-based assessments; and previous or
current scores from individual standardized tests of academic achievement. If an intellectual,
sensory, neurological, or motor disorder is suspected, then the clinical assessment for specific
learning disorder should also include methods appropriate for these disorders. Thus, comprehensive assessment will involve professionals with expertise in specific learning disorder and
psychological/cognitive assessment. Since specific learning disorder typically persists into
adulthood, reassessment is rarely necessary, unless indicated by marked changes in the learning difficulties (amelioration or worsening) or requested for specific purposes.
Associated Features Supporting Diagnosis
Specific learning disorder is frequently but not invariably preceded, in preschool years, by
delays in attention, language, or motor skills that may persist and co-occur with specific
learning disorder. An uneven profile of abilities is common, such as above-average abilities in drawing, design, and other visuospatial abilities, but slow, effortful, and inaccurate
reading and poor reading comprehension and written expression. Individuals with specific learning disorder typically (but not invariably) exhibit poor performance on psychological tests of cognitive processing. However, it remains unclear whether these cognitive
abnormalities are the cause, correlate, or consequence of the learning difficulties. Also, although cognitive deficits associated with difficulties learning to read words are well documented, those associated with other manifestations of specific learning disorder (e.g.,
reading comprehension, arithmetic computation, written expression) are underspecified
or unknown. Moreover, individuals with similar behavioral symptoms or test scores are
found to have a variety of cognitive deficits, and many of these processing deficits are also
found in other neurodevelopmental disorders (e.g., attention-deficit/hyperactivity disorder [ADHD], autistic spectrum disorder, communication disorders, developmental coordination disorder). Thus, assessment of cognitive processing deficits is not required for
diagnostic assessment. Specific learning disorder is associated with increased risk for suicidal ideation and suicide attempts in children, adolescents, and adults.
There are no known biological markers of specific learning disorder. As a group, individuals with the disorder show circumscribed alterations in cognitive processing and
brain structure and function. Genetic differences are also evident at the group level. But
cognitive testing, neuroimaging, or genetic testing are not useful for diagnosis at this time.
Prevalence
The prevalence of specific learning disorder across the academic domains of reading, writing, and mathematics is 5%-15% among school-age children across different languages
and cultures. Prevalence in adults is unknown but appears to be approximately 4%.
Development and Course
Onset, recognition, and diagnosis of specific learning disorder usually occurs during the
elementary school years when children are required to learn to read, spell, write, and learn
mathematics. However, precursors such as language delays or deficits, difficulties in
rhyming or counting, or difficulties with fine motor skills required for writing commonly
occur in early childhood before the start of formal schooling. Manifestations may be behavioral (e.g., a reluctance to engage in learning; oppositional behavior). Specific learning
disorder is lifelong, but the course and clinical expression are variable, in part depending
on the interactions among the task demands of the environment, the range and severity of
the individual's learning difficulties, the individual's learning abilities, comorbidity, and
the available support systems and intervention. Nonetheless, problems with reading fluency and comprehension, spelling, written expression, and numeracy skills in everyday life
typically persist into adulthood.
Changes in manifestation of symptoms occur with age, so that an individual may have
a persistent or shifting array of learning difficulties across the lifespan.
Examples of symptoms that may be observed among preschool-age children include a lack
of interest in playing games with language sounds (e.g., repetition, rhyming), and they may
have trouble learning nursery rhymes. Preschool children with specific learning disorder may
frequently use baby talk, mispronounce words, and have trouble remembering names of letters, numbers, or days of the week. They may fail to recognize letters in their own names and
have trouble learning to count. Kindergarten-age children with specific learning disorder may
be unable to recognize and write letters, may be unable to write their own names, or may use
invented spelling. They may have trouble breaking down spoken words into syllables (e.g.,
"cowboy" into "cow" and "boy") and trouble recognizing words that rhyme (e.g., cat, bat, hat).
Kindergarten-age children also may have trouble cormecting letters with their sounds (e.g., letter b makes the sound /b/) and may be unable to recognize phonemes (e.g., do not know
which in a set of words [e.g., dog, man, car] starts with the same sound as "cat").
Specific learning disorder in elementary school-age children typically manifests as
marked difficulty learning letter-sound correspondence (particularly in English-speaking
children), fluent word decoding, spelling, or math facts; reading aloud is slow, inaccurate,
and effortful, and some children struggle to understand the magnitude that a spoken or
written number represents. Children in primary grades (grades 1-3) may continue to have
problems recognizing and manipulating phonemes, be unable to read common one-syllable words (such as mat or top), and be unable recognize common irregularly spelled
words (e.g., said, two). They may commit reading errors that indicate problems in connecting sounds and letters (e.g., "big" for "got") and have difficulty sequencing numbers
and letters. Children in grades 1-3 also may have difficulty remembering number facts or
arithmetic procedures for adding, subtracting, and so forth, and may complain that reading or arithmetic is hard and avoid doing it. Children with specific learning disorder in the
middle grades (grades 4-6) may mispronounce or skip parts of long, multisyllable words
(e.g., say "conible" for "convertible," "aminal" for "animal") and confuse words that
sound alike (e.g., "tornado" for "volcano"). They may have trouble remembering dates,
names, and telephone numbers and may have trouble completing homework or tests on
time. Children in the middle grades also may have poor comprehension with or without
slow, effortful, and inaccurate reading, and they may have trouble reading small function
words (e.g., that, the, an, in). They may have very poor spelling and poor written work.
They may get the first part of a word correctly, then guess wildly (e.g., read "clover" as
"clock"), and may express fear of reading aloud or refuse to read aloud.
By contrast, adolescents may have mastered word decoding, but reading remains slow
and effortful, and they are likely to show marked problems in reading comprehension and
written expression (including poor spelling) and poor mastery of math facts or mathematical problem solving. During adolescence and into adulthood, individuals with specific
learning disorder may continue to make numerous spelling mistakes and read single
words and connected text slowly and with much effort, with trouble pronouncing multisyllable words. They may frequently need to reread material to understand or get the main
point and have trouble making inferences from written text. Adolescents and adults may
avoid activities that demand reading or arithmetic (reading for pleasure, reading instructions). Adults with specific learning disorder have ongoing spelling problems, slow and
effortful reading, or problems making important inferences from numerical information
in work-related written documents. They may avoid both leisure and work-related activities that demand reading or writing or use alternative approaches to access print (e.g.,
text-to-speech/speech-to-text software, audiobooks, audiovisual media).
An alternative clinical expression is that of circumscribed learning difficulties that persist across the lifespan, such as an inability to master the basic sense of number (e.g., to
know which of a pair of numbers or dots represents the larger magnitude), or lack of proficiency in word identification or spelling. Avoidance of or reluctance to engage in activities requiring academic skills is common in children, adolescents, and adults. Episodes of
severe anxiety or anxiety disorders, including somatic complaints or panic attacks, are
common across the lifespan and accompany both the circumscribed and the broader expression of learning difficulties.
Risk and Prognostic Factors
Environmental. Prematurity or very low birth weight increases the risk for specific
learning disorder, as does prenatal exposure to nicotine.
Genetic and physiological. Specific learning disorder appears to aggregate in families,
particularly when affecting reading, mathematics, and spelling. The relative risk of specific learning disorder in reading or mathematics is substantially higher (e.g., 4-8 times
and 5-10 times higher, respectively) in first-degree relatives of individuals with these
learning difficulties compared with those without them. Family history of reading difficulties (dyslexia) and parental literacy skills predict literacy problems or specific learning
disorder in offspring, indicating the combined role of genetic and environmental factors.
There is high heritability for both reading ability and reading disability in alphabetic and
nonalphabetic languages, including high heritability for most manifestations of learning abilities and disabilities (e.g., heritability estimate values greater than 0.6). Covariation between
various manifestations of learning difficulties is high, suggesting that genes related to one
presentation are highly correlated with genes related to another manifestation.
Course modifiers. Marked problems with inattentive behavior in preschool years is predictive of later difficulties in reading and mathematics (but not necessarily specific learning disorder) and nonresponse to effective academic interventions. Delay or disorders in
speech or language, or impaired cognitive processing (e.g., phonological awareness,
working memory, rapid serial naming) in preschool years, predicts later specific learning
disorder in reading and written expression. Comorbidity with ADHD is predictive of
worse mental health outcome than that associated with specific learning disorder without
ADHD. Systematic, intensive, individualized instruction, using evidence-based interventions, may improve or ameliorate the learning difficulties in some individuals or promote
the use of compensatory strategies in others, thereby mitigating the otherwise poor outcomes.
Culture-Related Diagnostic issues
Specific learning disorder occurs across languages, cultures, races, and socioeconomic
conditions but may vary in its manifestation according to the nature of the spoken and
written symbol systems and cultural and educational practices. For example, the cognitive
processing requirements of reading and of working with numbers vary greatly across orthographies. In the English language, the observable hallmark clinical symptom of difficulties learning to read is inaccurate and slow reading of single words; in other alphabetic
languages that have more direct mapping between sounds and letters (e.g., Spanish, German) and in non-alphabetic languages (e.g., Chinese, Japanese), the hallmark feature is
slow but accurate reading. In English-language learners, assessment should include consideration of whether the source of reading difficulties is a limited proficiency with English or a specific learning disorder. Risk factors for specific learning disorder in Englishlanguage learners include a family history of specific learning disorder or language delay
in the native language, as well as learning difficulties in English and failure to catch up
with peers. If there is suspicion of cultural or language differences (e.g., as in an Englishlanguage learner), the assessment needs to take into account the individual's language
proficiency in his or her first or native language as well as in the second language (in this
example, English). Also, assessment should consider the linguistic and cultural context in
which the individual is living, as well as his or her educational and learning history in the
original culture and language.
Gender-Related Diagnostic issues
Specific learning disorder is more common in males than in females (ratios range from
about 2:1 to 3:1) and cannot be attributed to factors such as ascertainment bias, definitional
or measurement variation, language, race, or socioeconomic status.
Functionai Consequences of
Specific Learning Disorder
Specific learning disorder can have negative functional consequences across the lifespan,
including lower academic attainment, higher rates of high school dropout, lower rates of
postsecondary education, high levels of psychological distress and poorer overall mental
health, higher rates of unemployment and under-employment, and lower incomes. School
dropout and co-occurring depressive symptoms increase the risk for poor mental health
outcomes, including suicidality, whereas high levels of social or emotional support predict
better mental health outcomes.
Differential Diagnosis
Normal variations in academic attainment. Specific learning disorder is distinguished
from normal variations in academic attainment due to external factors (e.g., lack of educational opportunity, consistently poor instruction, learning in a second language), because the learning difficulties persist in the presence of adequate educational opportunity
and exposure to the same instruction as the peer group, and competency in the language of
instruction, even when it is different from one's primary spoken language.
Intellectual disability (intellectual developmental disorder). Specific learning disorder
differs from general learning difficulties associated with intellectual disability, because the
learning difficulties occur in the presence of normal levels of intellectual functioning (i.e.,
IQ score of at least 70 ± 5). If intellectual disability is present, specific learning disorder can
be diagnosed only when the learning difficulties are in excess of those usually associated
with the intellectual disability.
Learning difficulties due to neurological or sensory disorders. Specific learning disorder is distinguished from learning difficulties due to neurological or sensory disorders
(e.g., pediatric stroke, traumatic brain injury, hearing impairment, vision impairment), because in these cases there are abnormal findings on neurological examination.
Neurocognitive disorders. Specific learning disorder is distinguished from learning
problems associated with neurodegenerative cognitive disorders, because in specific
learning disorder the clinical expression of specific learning difficulties occurs during the
developmental period, and the difficulties do not manifest as a marked decline from a former state.
Attention-deficit/hyperactivity disorder. Specific learning disorder is distinguished from
the poor academic performance associated with ADHD, because in the latter condition the
problems may not necessarily reflect specific difficulties in learning academic skills but
rather may reflect difficulties in performing those skills. However, the co-occurrence of
specific learning disorder and ADHD is more frequent than expected by chance. If criteria
for both disorders are met, both diagnoses can be given.
Psychotic disorders. Specific learning disorder is distinguished from the academic and
cognitive-processing difficulties associated with schizophrenia or psychosis, because with
these disorders there is a decline (often rapid) in these functional domains.
Comorbidity
Specific learning disorder commonly co-occurs with neurodevelopmental (e.g., ADHD,
communication disorders, developmental coordination disorder, autistic spectrum disorder) or other mental disorders (e.g., anxiety disorders, depressive and bipolar disorders).
These comorbidities do not necessarily exclude the diagnosis specific learning disorder
but may make testing and differential diagnosis more difficult, because each of the cooccurring disorders independently interferes with the execution of activities of daily living, including learning. Thus, clinical judgment is required to attribute such impairment to
learning difficulties. If there is an indication that another diagnosis could account for the
difficulties learning keystone academic skills described in Criterion A, specific learning
disorder should not be diagnosed.
Motor Disorders
Developmental Coordination Disorder
Diagnostic Criteria 315.4 (F82)
A. The acquisition and execution of coordinated motor skills is substantially below that expected given the individual’s chronological age and opportunity for skill learning and
use. Difficulties are manifested as clumsiness (e.g., dropping or bumping into objects)
as well as slowness and inaccuracy of performance of motor skills (e.g., catching an
object, using scissors or cutlery, handwriting, riding a bike, or participating in sports).
B. The motor skills deficit in Criterion A significantly and persistently interferes with activities of daily living appropriate to chronological age (e.g., self-care and self-maintenance) and impacts academic/school productivity, prevocational and vocational
activities, leisure, and play.
C. Onset of symptoms is in the early developmental period.
D. The motor skills deficits are not better explained by intellectual disability (Intellectual developmental disorder) or visual impairment and are not attributable to a neurological condition affecting movement (e.g., cerebral palsy, muscular dystrophy, degenerative disorder).
Diagnostic Features
The diagnosis of developmental coordinahon disorder is made by a clinical synthesis of the
history (developmental and medical), physical examination, school or workplace report, and
individual assessment using psychometrically sound and culturally appropriate standardized
tests. The manifestation of impaired skills requiring motor coordination (Criterion A) varies
with age. Young children may be delayed in achieving motor milestones (i.e., sitting, crawling,
walking), although many achieve typical motor milestones. They also may be delayed in developing skills such as negotiating stairs, pedaling, buttoning shirts, completing puzzles, and
using zippers. Even when the skill is achieved, movement execution may appear awkward,
slow, or less precise than that of peers. Older children and adults may display slow speed or inaccuracy with motor aspects of activities such as assembling puzzles, building models, playing
ball games (especially in teams), handwriting, typing, driving, or carrying out self-care sldlls.
Developmental coordination disorder is diagnosed only if the impairment in motor
skills significantly interferes with the performance of, or participation in, daily activities in
family, social, school, or community life (Criterion B). Examples of such activities include
getting dressed, eating meals with age-appropriate utensils and without mess, engaging
in physical games with others, using specific tools in class such as rulers and scissors, and
participating in team exercise activities at school. Not only is ability to perform these actions impaired, but also marked slowness in execution is common. Handwriting competence is frequently affected, consequently affecting legibility and/or speed of written output
and affecting academic achievement (the impact is distinguished from specific learning
difficulty by the emphasis on the motoric component of written output skills). In adults,
everyday skills in education and work, especially those in which speed and accuracy are
required, are affected by coordination problems.
Criterion C states that the onset of symptoms of developmental coordination disorder
must be in the early developmental period. However, developmental coordination disorder is
typically not diagnosed before age 5 years because there is considerable variation in the age at
acquisition of many motor skills or a lack of stability of measurement in early childhood (e.g.,
some children catch up) or because other causes of motor delay may not have fully manifested.
Criterion D specifies that the diagnosis of developmental coordination disorder is
made if the coordination difficulties are not better explained by visual impairment or attributable to a neurological condition. Thus, visual function examination and neurological
examination must be included in the diagnostic evaluation. If intellectual disability (intellectual developmental disorder) is present, the motor difficulties are in excess of those expected for the mental age; however, no IQ cut-off or discrepancy criterion is specified.
Developmental coordination disorder does not have discrete subtypes; however, individuals may be impaired predominantly in gross motor skills or in fine motor skills, including handwriting skills.
Other terms used to describe developmental coordination disorder include childhood
dyspraxia, specific developmental disorder of motor function, and clumsy child syndrome.
Associated Features Supporting Diagnosis
Some children with developmental coordination disorder show additional (usually suppressed) motor activity, such as choreiform movements of unsupported limbs or mirror
movements. These "overflow" movements are referred to as neurodevelopmental immaturities or
neurological soft signs rather than neurological abnormalities. In both current literature and
clinical practice, their role in diagnosis is still unclear, requiring further evaluation.
Prevaience
The prevalence of developmental coordination disorder in children ages 5-11 years is 5%-
6% (in children age 7 years, 1.8% are diagnosed with severe developmental coordination
disorder and 3% with probable developmental coordination disorder). Males are more often affected than females, with a maleifemale ratio between 2:1 and 7:1.
Development and Course
The course of developmental coordination disorder is variable but stable at least to 1 year
follow-up. Although there may be improvement in the longer term, problems with coor
dinated movements continue through adolescence in an estimated 50%-70% of children.
Onset is in early childhood. Delayed motor milestones may be the first signs, or the disorder is first recognized when the child attempts tasks such as holding a knife and fork, buttoning clothes, or playing ball games. In middle childhood, there are difficulties with
motor aspects of assembling puzzles, building models, playing ball, and handwriting, as
well as with organizing belongings, when motor sequencing and coordination are required. In early adulthood, there is continuing difficulty in learning new tasks involving
complex/automatic motor skills, including driving and using tools. Inability to take notes
and handwrite quickly may affect performance in the workplace. Co-occurrence with
other disorders (see the section "Comorbidity" for this disorder) has an additional impact
on presentation, course, and outcome.
Risk and Prognostic Factors
Environmental. Developmental coordination disorder is more common following prenatal exposure to alcohol and in preterm and low-birth-weight children.
Genetic and physiological. Impairments in underlying neurodevelopmental processes—
particularly in visual-motor skills, both in visual-motor perception and spatial mentalizing—
have been found and affect the ability to make rapid motoric adjustments as the complexity of
the required movements increases. Cerebellar dysfunction has been proposed, but the neural
basis of developmental coordination disorder remains unclear. Because of the co-occurrence of
developmental coordination disorder with attention-deficit/hyperactivity disorder (ADHD),
specific learning disabilities, and autism spectrum disorder, shared genetic effect has been proposed. However, consistent co-occurrence in twins appears only in severe cases.
Course modifiers. Individuals with ADHD and with developmental coordination disorder demonstrate more impairment than individuals with ADHD without developmental coordination disorder.
Culture-Related Diagnostic issues
Developmental coordination disorder occurs across cultures, races, and socioeconomic
conditions. By definition, "activities of daily living" implies cultural differences necessitating consideration of the context in which the individual child is living as well as
whether he or she has had appropriate opportunities to learn and practice such activities.
Functional Consequences of
Developmental Coordination Disorder
Developmental coordination disorder leads to impaired functional performance in activities of daily living (Criterion B), and the impairment is increased with co-occurring conditions. Consequences of developmental coordination disorder include reduced
participation in team play and sports; poor self-esteem and sense of self-worth; emotional
or behavior problems; impaired academic achievement; poor physical fitness; and reduced physical activity and obesity.
Differential Diagnosis
Motor impairments due to another medical condition. Problems in coordination may
be associated with visual function impairment and specific neurological disorders (e.g.,
cerebral palsy, progressive lesions of the cerebellum, neuromuscular disorders). In such
cases, there are additional findings on neurological examination.
Intellectual disability (intellectual developmental disorder). If intellectual disability is
present, motor competences may be impaired in accordance with the intellectual disabil-
ity. However, if the motor difficulties are in excess of what could be accounted for by the
intellectual disability, and criteria for developmental coordination disorder are met, developmental coordination disorder can be diagnosed as well.
Attention-deficit/hyperactivity disorder. Individuals with ADHD may fall, bump into
objects, or knock things over. Careful observation across different contexts is required to
ascertain if lack of motor competence is attributable to distractibility and impulsiveness
rather than to developmental coordination disorder. If criteria for both ADHD and developmental coordination disorder are met, both diagnoses can be given.
Autism spectrum disorder. Individuals with autism spectrum disorder may be uninterested in participating in tasks requiring complex coordination skills, such as ball sports,
which will affect test performance and function but not reflect core motor competence. Cooccurrence of developmental coordination disorder and autism spectrum disorder is common. If criteria for both disorders are met, both diagnoses can be given.
Joint hypermobility syndrome. Individuals with syndromes causing hyperextensible
joints (found on physical examination; often with a complaint of pain) may present with
symptoms similar to those of developmental coordination disorder.
Comorbidity
Disorders that commonly co-occur with developmental coordination disorder include
speech and language disorder; specific learning disorder (especially reading and writing);
problems of inattention, including ADHD (the most frequent coexisting condition, with
about 50% co-occurrence); autism spectrum disorder; disruptive and emotional behavior
problems; and joint hypermobility syndrome. Different clusters of co-occurrence may be
present (e.g., a cluster with severe reading disorders, fine motor problems, and handwriting
problems; another cluster with impaired movement control and motor planning). Presence
of other disorders does not exclude developmental coordination disorder but may make
testing more difficult and may independently interfere with the execution of activities of
daily living, thus requiring examiner judgment in ascribing impairment to motor skills.
Stereotypic Movement Disorder
Diagnostic Criteria 307.3 (F98.4)
A. Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand
shaking or waving, body rocking, head banging, self-biting, hitting own body).
B. The repetitive motor behavior interferes with social, academic, or other activities and
may result in self-injury.
C. Onset is in the early developmental period.
D. The repetitive motor behavior is not attributable to the physiological effects of a substance or neurological condition and is not better explained by another neurodevelopmental or mental disorder (e.g., trichotillomania [hair-pulling disorder], obsessivecompulsive disorder).
Specify if:
With self-injurious behavior (or behavior that would result in an injury if preventive
measures were not used)
Without self-injurious behavior
Specify if:
Associated with a known medical or genetic condition, neurodevelopmental disorder, or environmental factor (e.g., Lesch-Nyhan syndrome, intellectual disability
[intellectual developmental disorder], intrauterine alcohol exposure)
Coding note: Use additional code to identify the associated medical or genetic
condition, or neurodevelopmental disorder.
Specify current severity:
Mild: Symptoms are easily suppressed by sensory stimulus or distraction.
Moderate: Symptoms require explicit protective measures and behavioral modification.
Severe: Continuous monitoring and protective measures are required to prevent serious injury.
Recording Procedures
For stereotypic movement disorder that is associated with a known medical or genetic
condition, neurodevelopmental disorder, or environmental factor, record stereotypic
movement disorder associated with (name of condition, disorder, or factor) (e.g., stereotypic movement disorder associated with Lesch-Nyhan syndrome).
Specifiers
The severity of non-self-injurious stereotypic movements ranges from mild presentations
that are easily suppressed by a sensory stimulus or distraction to continuous movements
that markedly interfere with all activities of daily living. Self-injurious behaviors range in severity along various dimensions, including the frequency, impact on adaptive functioning,
and severity of bodily injury (from mild bruising or erythema from hitting hand against
body, to lacerations or amputation of digits, to retinal detachment from head banging).
Diagnostic Features
The essential feature of stereotypic movement disorder is repetitive, seemingly driven,
and apparently purposeless motor behavior (Criterion A). These behaviors are often
rhythmical movements of the head, hands, or body without obvious adaptive function.
The movements may or may not respond to efforts to stop them. Among typically developing children, the repetitive movements may be stopped when attention is directed to
them or when the child is distracted from performing them. Among children with neurodevelopmental disorders, the behaviors are typically less responsive to such efforts. In
other cases, the individual demonstrates self-restraining behaviors (e.g., sitting on hands,
wrapping arms in clothing, finding a protective device).
The repertoire of behaviors is variable; each individual presents with his or her own individually patterned, "signature" behavior. Examples of non-self-injurious stereotypic
movements include, but are not limited to, body rocking, bilateral flapping or rotating
hand movements, flicking or fluttering fingers in front of the face, arm waving or flapping,
and head nodding. Stereotyped self-injurious behaviors include, but are not limited to, repetitive head banging, face slapping, eye poking, and biting of hands, lips, or other body
parts. Eye poking is particularly concerning; it occurs more frequently among children
with visual impairment. Multiple movements may be combined (e.g., cocking the head,
rocking the torso, waving a small string repetitively in front of the face).
Stereotypic movements may occur many times during a day, lasting a few seconds to
several minutes or longer. Frequency can vary from many occurrences in a single day to
several weeks elapsing between episodes. The behaviors vary in context, occurring when
the individual is engrossed in other activities, when excited, stressed, fatigued, or bored.
Criterion A requires that the movements be "apparently" purposeless. However, some
functions may be served by the movements. For example, stereotypic movements might
reduce anxiety in response to external stressors.
Criterion B states that the stereotypic movements interfere with social, academic, or
other activities and, in some children, may result in self-injury (or would if protective measures were not used). If self-injury is present, it should be coded using the specifier. Onset
of stereotypic movements is in the early developmental period (Criterion C). Criterion D
states that the repetitive, stereotyped behavior in stereotypic movement disorder is not attributable to the^physiological effects of a substance or neurological condition and is not
better explained by another neurodevelopmental or mental disorder. The presence of
stereotypic movements may indicate an undetected neurodevelopmental problem, especially in children ages 1-3 years.
Prevalence
Simple stereotypic movements (e.g., rocking) are common in young typically developing children. Complex stereotypic movements are much less common (occurring in approximately
3%-4%). Between 4% and 16°/« of individuals v^ith intellectual disability (intellectual developmental disorder) engage in stereotypy and self-injury. The risk is greater in individuals with
severe intellectual disability. Among individuals with intellectual disability living in residential facilities, 10%-15% may have stereotypic movement disorder with self-injury.
Development and Course
Stereotypic movements typically begin within the first 3 years of life. Simple stereotypic movements are common in infancy and may be involved in acquisition of motor mastery. In children who develop complex motor stereotypies, approximately 80% exhibit symptoms before
24 months of age, 12% between 24 and 35 months, and 8% at 36 months or older. In most typically developing children, these movements resolve over time or can be suppressed. Onset of
complex motor stereotypies may be in infancy or later in the developmental period. Among
individuals with intellectual disability, the stereotyped, self-injurious behaviors may persist
for years, even though the typography or pattern of self-injury may change.
Risk and Prognostic Factors
Environmental. Social isolation is a risk factor for self-stimulation that may progress to
stereotypic movements with repetitive self-injury. Environmental stress may also trigger
stereotypic behavior. Fear may alter physiological state, resulting in increased frequency
of stereotypic behaviors.
Genetic and physiological. Lower cognitive functioning is linked to greater risk for stereotypic behaviors and poorer response to interventions. Stereotypic movements are more frequent among individuals with moderate-to-severe/profound intellectual disability, who by
virtue of a particular syndrome (e.g., Rett syndrome) or environmental factor (e.g., an environment with relatively insufficient stimulation) seem to be at higher risk for stereotypies. Repetitive self-injurious behavior may be a behavioral phenotype in neurogenetic syndromes. For
example, in Lesch-Nyhan syndrome, there are both stereotypic dystonie movements and selfmutilation of fingers, lip biting, and other forms of self-injury unless the individual is restrained, and in Rett syndrome and Cornelia de Lange syndrome, self-injury may result from
the hand-to-mouth stereotypies. Stereotypic behaviors may result from a painful medical condition (e.g., middle ear infection, dental problems, gastroesophageal reflux).
Culture-Related Diagnostic Issues
Stereotypic movement disorder, with or without self-injury, occurs in all races and cultures.
Cultural attitudes toward unusual behaviors may result in delayed diagnosis. Overall cultural
tolerance and attitudes toward stereotypic movement vary and must be considered.
Differential Diagnosis
Normal development. Simple stereotypic movements are common in infancy and early
childhood. Rocking may occur in the transition from sleep to awake, a behavior that usu
ally resolves with age. Complex stereotypies are less common in typically developing
children and can usually be suppressed by distraction or sensory stimulation. The individual's daily routine is rarely affected, and the movements generally do not cause the
child distress. The diagnosis would not be appropriate in these circumstances.
Autism spectrum disorder. Stereotypic movements may be a presenting symptom of
autism spectrum disorder and should be considered when repetitive movements and behaviors are being evaluated. Deficits of social communication and reciprocity manifesting
in autism spectrum disorder are generally absent in stereotypic movement disorder, and
thus social interaction, social communication, and rigid repetitive behaviors and interests
are distinguishing features. When autism spectrum disorder is present, stereotypic movement disorder is diagnosed only when there is self-injury or when the stereotypic behaviors are sufficiently severe to become a focus of treatment.
Tic disorders. Typically, stereotypies have an earlier age at onset (before 3 years) than
do tics, which have a mean age at onset of 5-7 years. They are consistent and fixed in their
pattern or topography compared with tics, which are variable in their presentation. Stereotypies may involve arms, hands, or the entire body, while tics commonly involve eyes,
face, head, and shoulders. Stereotypies are more fixed, rhythmic, and prolonged in duration than tics, which, generally, are brief, rapid, random, and fluctuating. Tics and stereotypic movements are both reduced by distraction.
Obsessive-compulsive and related disorders. Stereotypic movement disorder is distinguished from obsessive-compulsive disorder (OCD) by the absence of obsessions, as
well as by the nature of the repetitive behaviors. In OCD the individual feels driven to perform repetitive behaviors in response to an obsession or according to rules that must be applied rigidly, whereas in stereotypic movement disorder the behaviors are seemingly
driven but apparently purposeless. Trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder are characterized by body-focused repetitive behaviors (i.e.,
hair pulling and skin picking) that may be seemingly driven but that are not apparently
purposeless, and that may not be patterned or rhythmical. Furthermore, onset in trichotillomania and excoriation disorder is not typically in the early developmental period, but
rather around puberty or later.
Other neurological and medical conditions. The diagnosis of stereotypic movements
requires the exclusion of habits, mannerisms, paroxysmal dyskinesias, and benign hereditary chorea. A neurological history and examination are required to assess features
suggestive of other disorders, such as myoclonus, dystonia, tics, and chorea. Involuntary
movements associated with a neurological condition may be distinguished by their signs
and symptoms. For example, repetitive, stereotypic movements in tardive dyskinesia can
be distinguished by a history of chronic neuroleptic use and characteristic oral or facial
dyskinesia or irregular trunk or limb movements. These types of movements do not result
in self-injury. A diagnosis of stereotypic movement disorder is not appropriate for repetitive skin picking or scratching associated with amphetamine intoxication or abuse (e.g.,
patients are diagnosed with substance/medication-induced obsessive-compulsive and related disorder) and repetitive choreoathetoid movements associated with other neurological disorders.
Comorbidity
Stereotypic movement disorder may occur as a primary diagnosis or secondary to another
disorder. For example, stereotypies are a common manifestation of a variety of neurogenetic disorders, such as Lesch-Nyhan syndrome, Rett syndrome, fragile X syndrome,
Cornelia de Lange syndrome, and Smith-Magenis syndrome. When stereotypic movement disorder co-occurs with another medical condition, both should be coded.
Tic Disorders
------------------------ ----------------------------------------------------------------------------------------------------------------
Diagnostic Criteria
Note: A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.
Tourette’s Disorder 307.23 (F95.2)
A. Both multiple motor and one or more vocal tics have been present at some time during
the illness, although not necessarily concurrently.
B. The tics may wax and wane in frequency but have persisted for more than 1 year since
first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
Persistent (Chronic) Motor or Vocal Tic Disorder 307.22 (F95.1 )
A. Single or multiple motor or vocal tics have been present during the illness, but not both
motor and vocal.
B. The tics may wax and wane in frequency but have persisted for more than 1 year since
first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder.
Specify if:
With motor tics only
With vocal tics only
Provisional Tic Disorder 307.21 (F95.0)
A. Single or multiple motor and/or vocal tics.
B. The tics have been present for less than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or
vocal tic disorder.______________________________________________________
Specifiers
The "motor tics only" or "vocal tics only" specifier is only required for persistent (chronic)
motor or vocal tic disorder.
Diagnostic Features
Tic disorders comprise four diagnostic categories: Tourette's disorder, persistent (chronic)
motor or vocal tic disorder, provisional tic disorder, and the other specified and unspecified
tic disorders. Diagnosis for any tic disorder is based on the presence of motor and/or vocal
tics (Criterion A), duration of tic symptoms (Criterion B), age at onset (Criterion C), and absence of any known cause such as another medical condition or substance use (Criterion D).
The tic disorders are hierarchical in order (i.e., Tourette's disorder, followed by persistent
[chronic] motor or vocal tic disorder, followed by provisional tic disorder, followed by the
other specified and unspecified tic disorders), such that once a tic disorder at one level of the
hierarchy is diagnosed, a lower hierarchy diagnosis cannot be made (Criterion E).
Tics are sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations. An
individual may have various tic symptoms over time, but at any point in time, the tic repertoire recurs in a characteristic fashion. Although tics can include almost any muscle group
or vocalization, certain tic symptoms, such as eye blinking or throat clearing, are common
across patient populations. Tics are generally experienced as involuntary but can be voluntarily suppressed for varying lengths of time.
Tics can be either simple or complex. Simple motor tics are of short duration (i.e., milliseconds) and can include eye blinking, shoulder shrugging, and extension of the extremities. Simple vocal tics include throat clearing, sniffing, and grunting often caused by
contraction of the diaphragm or muscles of the oropharynx. Complex motor tics are of longer duration (i.e., seconds) and often include a combination of simple tics such as simultaneous head turning and shoulder shrugging. Complex tics can appear purposeful, such
as a tic-like sexual or obscene gesture (copropraxia) or a tic-like imitation of someone else's
movements (echopraxia). Similarly, complex vocal tics include repeating one's own sounds
or words {palilalia), repeating the last-heard word or phrase (echolalia), or uttering socially
unacceptable words, including obscenities, or ethnic, racial, or religious slurs (coprolalia).
Importantly, coprolalia is an abrupt, sharp bark or grunt utterance and lacks the prosody
of similar inappropriate speech observed in human interactions.
The presence of motor and/or vocal tics varies across the four tic disorders (Criterion
A). For Tourette's disorder, both motor and vocal tics must be present, whereas for persistent (chronic) motor or vocal tic disorder, only motor or only vocal tics are present. For
provisional tic disorder, motor and/or vocal tics may be present. For other specified or unspecified tic disorders, the movement disorder symptoms are best characterized as tics but
are atypical in presentation or age at onset, or have a known etiology.
The 1-year minimum duration criterion (Criterion B) assures that individuals diagnosed with either Tourette's disorder or persistent (chronic) motor or vocal tic disorder
have had persistent symptoms. Tics wax and wane in severity, and some individuals may
have tic-free periods of weeks to months; however, an individual who has had tic symptoms of greater than 1 year's duration since first tic onset would be considered to have persistent symptoms regardless of duration of tic-free periods. For an individual with motor
and/or vocal tics of less than 1 year since first tic onset, a provisional tic disorder diagnosis
can be considered. There is no duration specification for other specified and unspecified tic
disorders. The onset of tics must occur prior to age 18 years (Criterion C). Tic disorders
typically begin in the prepubertal period, with an average age at onset between 4 and 6
years, and with the incidence of new-onset tic disorders decreasing in the teen years. New
onset of tic symptoms in adulthood is exceedingly rare and is often associated with exposures to drugs (e.g., excessive cocaine use) or is a result of a central nervous system insult
(e.g., postviral encephalitis). Although tic onset is uncommon in teenagers and adults, it is
not uncommon for adolescents and adults to present for an initial diagnostic assessment
and, when carefully evaluated, provide a history of milder symptoms dating back to childhood. New-onset abnormal movements suggestive of tics outside of the usual age range
should result in evaluation for other movement disorders or for specific etiologies.
Tic symptoms cannot be attributable to the physiological effects of a substance or another medical condition (Criterion D). When there is strong evidence from the history,
physical examination, and/or laboratory results to suggest a plausible, proximal, and
probable cause for a tic disorder, a diagnosis of other specified tic disorder should be used.
Having previously met diagnostic criteria for Tourette's disorder negates a possible diagnosis of persistent (chronic) motor or vocal tic disorder (Criterion E). Similarly, a previous diagnosis of persistent (chronic) motor or vocal tic disorder negates a diagnosis of
provisional tic disorder or other specified or unspecified tic disorder (Criterion E).
Prevalence
Tics are common in childhood but transient in most cases. The estimated prevalence of
Tourette's disorder ranges from 3 to 8 per 1,000 in school-age children. Males are more
commonly affected than females, with the ratio varying from 2:1 to 4:1. A national survey
in the United States estimated 3 per 1,000 for the prevalence of clinically identified cases.
The frequency of identified cases was lower among African Americans and Hispanic
Americans, which may be related to differences in access to care.
Development and Course
Onset of tics is typically between ages 4 and 6 years. Peak severity occurs between ages 10
and 12 years, with a decline in severity during adolescence. Many adults with tic disorders
experience diminished symptoms. A small percentage of individuals will have persistently severe or worsening symptoms in adulthood.
Tic symptoms manifest similarly in all age groups and across the lifespan. Tics wax and
wane in severity and change in affected muscle groups and vocalizations over time. As
children get older, they begin to report their tics being associated with a premonitory
urge—a somatic sensation that precedes the tic—and a feeling of tension reduction following the expression of the tic. Tics associated with a premonitory urge may be experienced
as not completely ''involuntary" in that the urge and the tic can be resisted. An individual
may also feel the need to perform a tic in a specific way or repeat it until he or she achieves
the feeling that the tic has been done "'just right."
The vulnerability toward developing co-occurring conditions changes as individuals
pass through the age of risk for various co-occurring conditions. For example, prepubertal
children with tic disorders are more likely to experience attention-deficit/hyperactivity
disorder (ADHD), obsessive-compulsive disorder (OCD), and separation anxiety disorder
than are teenagers and adults, who are more likely to experience the new onset of major
depressive disorder, substance use disorder, or bipolar disorder.
Risk and Prognostic Factors
Temperamental. Tics are worsened by anxiety, excitement, and exhaustion and are better
during calm, focused activities. Individuals may have fewer tics when engaged in schoolwork
or tasks at work than when relaxing at home after school or in the evening. Stressful/exciting
events (e.g., taking a test, participating in exciting activities) often make tics worse.
Environmental. Observing a gesture or sound in another person may result in an individual with a tic disorder making a similar gesture or sound, which may be incorrectly
perceived by others as purposeful. This can be a particular problem when the individual is
interacting with authority figures (e.g., teachers, supervisors, police).
Genetic and physiological. Genetic and environmental factors influence tic symptom
expression and severity. Important risk alleles for Tourette's disorder and rare genetic
variants in families with tic disorders have been identified. Obstetrical complications,
older paternal age, lower birth weight, and maternal smoking during pregnancy are associated with worse tic severity.
Culture-Related Diagnostic Issues
Tic disorders do not appear to vary in clinical characteristics, course, or etiology by race,
ethnicity, and culture. However, race, ethnicity, and culture may impact how tic disorders
are perceived and managed in the family and community, as well as influencing patterns
of help seeking, and choices of treatment.
Gender-Related Diagnostic Issues
Males are more commonly affected than females, but there are no gender differences in the
kinds of tics, age at onset, or course. Women with persistent tic disorders may be more
likely to experience anxiety and depression.
Functional Consequences of Tic Disorders
Many individuals with mild to moderate tic severity experience no distress or impairment
in functioning and may even be unaware of their tics. Individuals with more severe symptoms generally have more impairment in daily living, but even individuals with moderate
or even severe tic disorders may function well. The presence of a co-occurring condition,
such as ADHD or OCD, can have greater impact on functioning. Less commonly, tics disrupt functioning in daily activities and result in social isolation, interpersonal conflict,
peer victimization, inability to work or to go to school, and lower quality of life. The individual also may experience substantial psychological distress. Rare complications of Tourette's disorder include physical injury, such as eye injury (from hitting oneself in the face),
and orthopedic and neurological injury (e.g., disc disease related to forceful head and neck
movements).
Differential Diagnosis
Abnormal movements that may accompany other medical conditions and stereotypic
movement disorder. Motor stereotypies are defined as involuntary rhythmic, repetitive,
predictable movements that appear purposeful but serve no obvious adaptive function or
purpose and stop with distraction. Examples include repetitive hand waving/rotating,
arm flapping, and finger wiggling. Motor stereotypies can be differentiated from tics based
on the former's earlier age at onset (younger than 3 years), prolonged duration (seconds to
minutes), constant repetitive fixed form and location, exacerbation when engrossed in activities, lack of a premonitory urge, and cessation with distraction (e.g., name called or
touched). Chorea represents rapid, random, continual, abrupt, irregular, unpredictable,
nonstereotyped actions that are usually bilateral and affect all parts of the body (i.e., face,
trunk, and limbs). The timing, direction, and distribution of movements vary from moment to moment, and movements usually worsen during attempted voluntary action. Dystonia is the simultaneous sustained contracture of both agonist and antagonist muscles,
resulting in a distorted posture or movement of parts of the body. Dystonie postures are often triggered by attempts at voluntary movements and are not seen during sleep.
Substance-induced and paroxysmal dyskinesias. Paroxysmal dyskinesias usually occur as dystonie or choreoathetoid movements that are precipitated by voluntary movement or exertion and less commonly arise from normal background activity.
Myoclonus. Myoclonus is characterized by a sudden unidirectional movement that is
often nonrhythmic. It may be worsened by movement and occur during sleep. Myoclonus
is differentiated from tics by its rapidity, lack of suppressibility, and absence of a premonitory urge.
Obsessive-compulsive and related disorders. Differentiating obsessive-compulsive
behaviors from tics may be difficult. Clues favoring an obsessive-compulsive behavior include a cognitive-based drive (e.g., fear of contamination) and the need to perform the action in a particular fashion a certain number of times, equally on both sides of the body, or
until a "just right" feeling is achieved. Impulse-control problems and other repetitive behaviors, including persistent hair pulling, skin picking, and nail biting, appear more goal
directed and complex than tics.
Comorbidity
Many medical and psychiatric conditions have been described as co-occurring with tic disorders, with ADHD and obsessive-compulsive and related disorders being particularly common. The obsessive-compulsive symptoms observed in tic disorder tend to be characterized
by more aggressive symmetry and order symptoms and poorer response to pharmacotherapy
with selective serotonin reuptake inhibitors. Children with ADHD may demonstrate disruptive behavior, social immaturity, and learning difficulties that may interfere with academic
progress and interpersonal relationships and lead to greater impairment than that caused by a
tic disorder. Individuals with tic disorders can also have other movement disorders and other
mental disorders, such as depressive, bipolar, or substance use disorders.
Other Specified Tic Disorder
307.20 (F95.8)
This category applies to presentations in which symptoms characteristic of a tic disorder
that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for a tic disorder
or any of the disorders in the neurodevelopmental disorders diagnostic class. The other
specified tic disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for a tic disorder or any specific neurodevelopmental disorder. This is done by recording “other specified
tic disorder” followed by the specific reason (e.g., “with onset after age 18 years”).
Unspecified Tic Disorder
307.20 (F95.9)
This category applies to presentations in which symptoms characteristic of a tic disorder
that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for a tic disorder
or for any of the disorders in the neurodevelopmental disorders diagnostic class. The unspecified tic disorder category is used in situations in which the clinician chooses not to
specify the reason that the criteria are not met for a tic disorder or for a specific neurodevelopmental disorder, and includes presentations in which there is insufficient information
to make a more specific diagnosis.
Other Neurodevelopmental Disorders
Other Specified Neurodevelopmental Disorder
315.8 (F88)
This category applies to presentations in which symptoms characteristic of a neurodevelopmental disorder that cause impairment in social, occupational, or other important areas
of functioning predominate but do not meet the full criteria for any of the disorders in the
neurodevelopmental disorders diagnostic class. The other specified neurodevelopmental
disorder category is used in situations in which the clinician chooses to communicate the
specific reason that the presentation does not meet the criteria for any specific neurodevelopmental disorder. This is done by recording “other specified neurodevelopmental disorder” followed by the specific reason (e.g., “neurodevelopmental disorder associated with
prenatal alcohol exposure”).
An example of a presentation that can be specified using the “other specified” designation is the following:
Neurodevelopmental disorder associated with prenatal alcohol exposure: Neurodevelopmental disorder associated with prenatal alcohol exposure is characterized
by a range of developmental disabilities following exposure to alcohol in utero.
Unspecified Neurodevelopmental Disorder
315.9 (F89)
This category applies to presentations in which symptoms characteristic of a neurodevelopmental disorder that cause impairment in social, occupational, or other important areas
of functioning predominate but do not meet the full criteria for any of the disorders in the
neurodevelopmental disorders diagnostic class. The unspecified neurodevelopmental disorder category is used in situations in which the clinician chooses not to specify the reason
that the criteria are not met for a specific neurodevelopmental disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis
(e.g., in emergency room settings).
S^izophrenïa Spectrum and
Other Psychotic Disorder·
SchiZOphreniâ spectrum and other psychotic disorders include schizophrenia,
other psychotic disorders, and schizotypal (personality) disorder. They are defined by abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including
catatonia), and negative symptoms.
Key Features That Define the Psychotic Disorders
Delusions
Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence.
Their content may include a variety of themes (e.g., persecutory, referential, somatic, religious, grandiose). Persecutory delusions (i.e., belief that one is going to be harmed, harassed,
and so forth by an individual, organization, or other group) are most common. Referential
delusions (i.e., belief that certain gestures, comments, environmental cues, and so forth are
directed at oneself) are also common. Grandiose delusions (i.e., when an individual believes
that he or she has exceptional abilities, wealth, or fame) and érotomanie delusions (i.e., when
an individual believes falsely that another person is in love with him or her) are also seen.
Nihilistic delusions involve the conviction that a major catastrophe will occur, and somatic
delusions focus on preoccupations regarding health and organ function.
Delusions are deemed bizarre if they are clearly implausible and not understandable to
same-culture peers and do not derive from ordinary life experiences. An example of a bizarre delusion is the belief that an outside force has removed his or her internal organs and
replaced them with someone else's organs without leaving any wounds or scars. An example of a nonbizarre delusion is the belief that one is under surveillance by the police, despite a lack of convincing evidence. Delusions that express a loss of control over mind or
body are generally considered to be bizarre; these include the belief that one's thoughts
have been "removed" by some outside force {thought withdrawal), that alien thoughts have
been put into one's mind (thought insertion), or that one's body or actions are being acted on
or manipulated by some outside force (delusions of control). The distinction between a delusion and a strongly held idea is sometimes difficult to make and depends in part on the
degree of conviction with which the belief is held despite clear or reasonable contradictory
evidence regarding its veracity.
Hallucinations
Hallucinations are perception-like experiences that occur without an external stimulus.
They are vivid and clear, with the full force and impact of normal perceptions, and not
under voluntary control. They may occur in any sensory modality, but auditory hallucinations are the most common in schizophrenia and related disorders. Auditory hallucinations are usually experienced as voices, whether familiar or unfamiliar, that are perceived
as distinct from the individual's own thoughts. The hallucinations must occur in the context of a clear sensorium; those that occur while falling asleep (hypnagogic) or waking up
(hypnopompic) are considered to be within the range of normal experience. Hallucinations
may be a normal part of religious experience in certain cultural contexts.
Disorganized Thinking (Speech)
Disorganized thinking (formal thought disorder) is typically inferred from the individual's
speech. The individual may switch from one topic to another {derailment or loose associations). Answers to questions may be obliquely related or completely unrelated (tangentiality). Rarely, speech may be so severely disorganized that it is nearly incomprehensible and
resembles receptive aphasia in its linguistic disorganization {incoherence or "word salad").
Because mildly disorganized speech is common and nonspecific, the symptom must be severe enough to substantially impair effective communication. The severity of the impairment may be difficult to evaluate if the person making the diagnosis comes from a
different linguistic background than that of the person being examined. Less severe disorganized thinking or speech may occur during the prodromal and residual periods of
schizophrenia.
Grossly Disorganized or Abnormai iViotor Behavior
(inciuding Catatonia)
Grossly disorganized or abnormal motor behavior may manifest itself in a variety of ways,
ranging from childlike "silliness" to unpredictable agitation. Problems may be noted in
any form of goal-directed behavior, leading to difficulties in performing activities of daily
living.
Catatonic behavior is a marked decrease in reactivity to the environment. This ranges
from resistance to instructions {negativism); to maintaining a rigid, inappropriate or bizarre posture; to a complete lack of verbal and motor responses {mutism and stupor). It can
also include purposeless and excessive motor activity without obvious cause {catatonic
excitement). Other features are repeated stereotyped movements, staring, grimacing,
mutism, and the echoing of speech. Although catatonia has historically been associated
with schizophrenia, catatonic symptoms are nonspecific and may occur in other mental
disorders (e.g., bipolar or depressive disorders with catatonia) and in medical conditions
(catatonic disorder due to another medical condition).
Negative Symptoms
Negative symptoms account for a substantial portion of the morbidity associated with
schizophrenia but are less prominent in other psychotic disorders. Two negative symptoms are particularly prominent in schizophrenia: diminished emotional expression and
avolition. Diminished emotional expression includes reductions in the expression of emotions in the face, eye contact, intonation of speech (prosody), and movements of the hand,
head, and face that normally give an emotional emphasis to speech. Avolition is a decrease
in motivated self-initiated purposeful activities. The individual may sit for long periods of
time and show little interest in participating in work or social activities. Other negative
symptoms include alogia, anhedonia, and asociality. Alogia is manifested by diminished
speech output. Anhedonia is the decreased ability to experience pleasure from positive
stimuli or a degradation in the recollection of pleasure previously experienced. Asociality
refers to the apparent lack of interest in social interactions and may be associated with avolition, but it can also be a manifestation of limited opportunities for social interactions.
Disorders in Tliis CInapter
This chapter is organized along a gradient of psychopathology. Clinicians should first consider conditions that do not reach full criteria for a psychotic disorder or are limited to one
domain of psychopathology. Then they should consider time-limited conditions. Finally,
the diagnosis of a schizophrenia spectrum disorder requires the exclusion of another condition that may give rise to psychosis.
Schizotypal personality disorder is noted within this chapter as it is considered within
the schizophrenia spectrum, although its full description is found in the chapter "Personality Disorders." The diagnosis schizotypal personality disorder captures a pervasive pattern of social and interpersonal deficits, including reduced capacity for close relationships;
cognitive or perceptual distortions; and eccentricities of behavior, usually beginning by
early adulthood but in some cases first becoming apparent in childhood and adolescence.
Abnormalities of beliefs, thinking, and perception are below the threshold for the diagnosis of a psychotic disorder.
Two conditions are defined by abnormalities limited to one domain of psychosis: delusions or catatonia. Delusional disorder is characterized by at least 1 month of delusions but
no other psychotic symptoms. Catatonia is described later in the chapter and further in this
discussion.
Brief psychotic disorder lasts more than 1 day and remits by 1 month. Schizophreniform disorder is characterized by a symptomatic presentation equivalent to that of schizophrenia except for its duration (less than 6 months) and the absence of a requirement for a
decline in functioning.
Schizophrenia lasts for at least 6 months and includes at least 1 month of active-phase
symptoms. In schizoaffective disorder, a mood episode and the active-phase symptoms of
schizophrenia occur together and were preceded or are followed by at least 2 weeks of delusions or hallucinations without prominent mood symptoms.
Psychotic disorders may be induced by another condition. In substance/medicationinduced psychotic disorder, the psychotic symptoms are judged to be a physiological consequence of a drug of abuse, a medication, or toxin exposure and cease after removal of the
agent. In psychotic disorder due to another medical condition, the psychotic symptoms
are judged to be a direct physiological consequence of another medical condition.
Catatonia can occur in several disorders, including neurodevelopmental, psychotic, bipolar, depressive, and other mental disorders. This chapter also includes the diagnoses
catatonia associated with another mental disorder (catatonia specifier), catatonic disorder
due to another medical condition, and unspecified catatonia, and the diagnostic criteria for
all three conditions are described together.
Other specified and unspecified schizophrenia spectrum and other psychotic disorders are included for classifying psychotic presentations that do not meet the criteria for
any of the specific psychotic disorders, or psychotic symptomatology about which there is
inadequate or contradictory information.
Clinician-Rated Assessment of Symptoms and
Related Clinical Phenomena in Psychosis
Psychotic disorders are heterogeneous, and the severity of symptoms can predict important aspects of the illness, such as the degree of cognitive or neurobiological deficits. To
move the field forward, a detailed framework for the assessment of severity is included in
Section III "Assessment Measures," which may help with treatment planning, prognostic
decision making, and research on pathophysiological mechanisms. Section III "Assessment Measures" also contains dimensional assessments of the primary symptoms of psychosis, including hallucinations, delusions, disorganized speech (except for substance/
medication-induced psychotic disorder and psychotic disorder due to another medical
condition), abnormal psychomotor behavior, and negative symptoms, as well as dimensional assessments of depression and mania. The severity of mood symptoms in psychosis
has prognostic value and guides treatment. There is growing evidence that schizoaffect
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