Diagnostic_and_Statistical 03

 

6. Increased or excessive involvement in activities that have a high potential for

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

7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be

contrasted with insomnia).

B. Mixed symptoms are observable by others and represent a change from the person’s usual behavior.

C. For individuals whose symptoms meet full criteria for either mania or hypomania,

the diagnosis should be bipolar I or bipolar II disorder.

D. The mixed symptoms are not attributable to the physiological effects of a substance

(e.g., a drug of abuse, a medication or other treatment).

Note: Mixed features associated with a major depressive episode have been found

to be a significant risk factor for the development of bipolar I or bipolar II disorder.

As a result, it is clinically useful to note the presence of this specifier for treatment

planning and monitoring of response to treatment.

With melancholic features:

A. One of the following is present during the most severe period of the current episode:

1. Loss of pleasure in all, or almost all, activities.

2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even

temporarily, when something good happens).

B. Three (or more) of the following;

1. A distinct quality of depressed mood characterized by profound despondency,

despair, and/or moroseness or by so-called empty mood.

2. Depression that is regularly worse in the morning.

3. Early-morning awakening (i.e., at least 2 hours before usual awakening).

4. Marked psychomotor agitation or retardation.

5. Significant anorexia or weight loss.

6. Excessive or inappropriate guilt.

Note: The specifier “with melancholic features” is applied if these features are present

at the most severe stage of the episode. There is a near-complete absence of the capacity for pleasure, not merely a diminution. A guideline for evaluating the lack of reactivity of mood is that even highly desired events are not associated with marked

brightening of mood. Either mood does not brighten at all, or it brightens only partially

(e.g., up to 20%-^0% of normal for only minutes at a time). The “distinct quality” of mood

that is characteristic of the “with melancholic features” specifier is experienced as qualitatively different from that during a nonmelancholic depressive episode. A depressed

mood that is described as merely more severe, longer lasting, or present without a reason is not considered distinct in quality. Psychomotor changes are nearly always present and are observable by others.

Melancholic features exhibit only a modest tendency to repeat across episodes in the

same individual. They are more frequent in inpatients, as opposed to outpatients; are

less likely to occur in milder than in more severe major depressive episodes; and are

more likely to occur in those with psychotic features.

With atypical features: This specifier can be applied when these features predominate during the majority of days of the current or most recent major depressive episode

or persistent depressive disorder.

A. Mood reactivity (i.e., mood brightens in response to actual or potential positive

events).

B. Two (or more) of the following:

1. Significant weight gain or increase in appetite.

2. Hypersomnia.

3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).

4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.

C. Criteria are not met for “with melancholic features” or “with catatonia” during the

same episode.

Note: “Atypical depression” has historical significance (i.e., atypical in contradistinction

to the more classical agitated, “endogenous” presentations of depression that were the

norm when depression was rarely diagnosed in outpatients and almost never in adolescents or younger adults) and today does not connote an uncommon or unusual clinical presentation as the term might imply.

Mood reactivity is the capacity to be cheered up when presented with positive events

(e.g., a visit from children, compliments from others). Mood may become euthymie (not

sad) even for extended periods of time if the external circumstances remain favorable.

Increased appetite may be manifested by an obvious increase in food intake or by

weight gain. Hypersomnia may include either an extended period of nighttime sleep or

daytime napping that totals at least 10 hours of sleep per day (or at least 2 hours more

than when not depressed). Leaden paralysis is defined as feeling heavy, leaden, or

weighted down, usually in the arms or legs. This sensation is generally present for at

least an hour a day but often lasts for many hours at a time. Unlike the other atypical

features, pathological sensitivity to perceived interpersonal rejection is a trait that has

an early onset and persists throughout most of adult life. Rejection sensitivity occurs

both when the person is and is not depressed, though it may be exacerbated during

depressive periods.

With psychotic features: Delusions and/or hallucinations are present.

With mood-congruent psychotic features: The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.

With mood-incongruent psychotic features: The content of the delusions or hallucinations does not involve typical depressive themes of personal inadequacy,

guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture

of mood-incongruent and mood-congruent themes.

With catatonia: The catatonia specifier can apply to an episode of depression if catatonic features are present during most of the episode. See criteria for catatonia associated with a mental disorder (for a description of catatonia, see the chapter

“Schizophrenia Spectrum and Other Psychotic Disorders”).

With péripartum onset: This specifier can be applied to the current or, if full criteria

are not currently met for a major depressive episode, most recent episode of major depression if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.

Note: Mood episodes can have their onset either during pregnancy or postpartum.

Although the estimates differ according to the period of follow-up after delivery, between 3% and 6% of women will experience the onset of a major depressive episode during pregnancy or in the weeks or months following delivery. Fifty percent

of “postpartum” major depressive episodes actually begin prior to delivery. Thus,

these episodes are referred to collectively as péripartum episodes. Women with

péripartum major depressive episodes often have severe anxiety and even panic

attacl<s. Prospective studies have demonstrated that mood and anxiety symptoms

during pregnancy, as well as the “baby blues,” increase the risk for a postpartum

major depVessive episode.

Peripartum-onset mood episodes can present either with or without psychotic

features. Infanticide is most often associated with postpartum psychotic episodes

that are characterized by command hallucinations to kill the infant or delusions that

the infant is possessed, but psychotic symptoms can also occur in severe postpartum mood episodes without such specific delusions or hallucinations.

Postpartum mood (major depressive or manic) episodes with psychotic features

appear to occur in from 1 in 500 to 1 in 1,000 deliveries and may be more common

in primiparous women. The risk of postpartum episodes with psychotic features is

particularly increased for women with prior postpartum mood episodes but is also

elevated for those with a prior history of a depressive or bipolar disorder (especially

bipolar I disorder) and those with a family history of bipolar disorders.

Once a woman has had a postpartum episode with psychotic features, the risk

of recurrence with each subsequent delivery is between 30% and 50%. Postpartum

episodes must be differentiated from delirium occurring in the postpartum period,

which is distinguished by a fluctuating level of awareness or attention. The postpartum period is unique with respect to the degree of neuroendocrine alterations and

psychosocial adjustments, the potential impact of breast-feeding on treatment

planning, and the long-term implications of a history of postpartum mood disorder

on subsequent family planning.

With seasonal pattern: This specifier applies to recurrent major depressive disorder.

A. There has been a regular temporal relationship between the onset of major depressive episodes in major depressive disorder and a particular time of the year (e.g.,

in the fall or winter).

Note: Do not include cases in which there is an obvious effect of seasonally related

psychosocial stressors (e.g., regularly being unemployed every winter).

B. Full remissions (or a change from major depression to mania or hypomania) also

occur at a characteristic time of the year (e.g., depression disappears in the spring).

C. In the last 2 years, two major depressive episodes have occurred that demonstrate

the temporal seasonal relationships defined above and no nonseasonal major depressive episodes have occurred during that same period.

D. Seasonal major depressive episodes (as described above) substantially outnumber the nonseasonal major depressive episodes that may have occurred over the

individual’s lifetime.

Note: The specifier “with seasonal pattern” can be applied to the pattern of major depressive episodes in major depressive disorder, recurrent. The essential feature is the

onset and remission of major depressive episodes at characteristic times of the year.

In most cases, the episodes begin in fall or winter and remit in spring. Less commonly,

there may be recurrent summer depressive episodes. This pattern of onset and remission of episodes must have occurred during at least a 2-year period, without any nonseasonal episodes occurring during this period. In addition, the seasonal depressive

episodes must substantially outnumber any nonseasonal depressive episodes over

the individual’s lifetime.

This specifier does not apply to those situations in which the pattern is better explained by seasonally linked psychosocial stressors (e.g., seasonal unemployment or

school schedule). Major depressive episodes that occur in a seasonal pattern are often

characterized by prominent energy, hypersomnia, overeating, weight gain, and a craving for carbohydrates. It is unclear whether a seasonal pattern is more likely in recurrent major depressive disorder or in bipolar disorders. However, within the bipolar

disorders group, a seasonal pattern appears to be more likely in bipolar II disorder than

in bipolar I disorder. In some individuals, the onset of manic or hypomanie episodes

may also be linked to a particular season.

The prevalence of winter-type seasonal pattern appears to vary with latitude, age,

and sex. Prevalence increases with higher latitudes. Age is also a strong predictor of

seasonality, with younger persons at higher risk for winter depressive episodes.

Specify if:

In partial remission: Symptoms of the immediately previous major depressive episode

are present, but full criteria are not met, or there is a period lasting less than 2 months

without any significant symptoms of a major depressive episode following the end of

such an episode.

In full remission: During the past 2 months, no significant signs or symptoms of the

disturbance were present.

Specify current severity:

Severity is based on the number of criterion symptoms, the severity of those symptoms,

and the degree of functional disability.

Mild: Few, if any, symptoms in excess of those required to make the diagnosis are

present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning.

Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.”

Severe: The number of symptoms is substantially in excess of that required to make

the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.

A n x ie ty diSOrdGrS include disorders that share features of excessive fear and anxiety and related behavioral disturbances. Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat. Obviously, these

two states overlap, but they also differ, with fear more often associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape

behaviors, and anxiety more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviors. Sometimes the level of fear

or anxiety is reduced by pervasive avoidance behaviors. Panic attacks feature prominently

within the anxiety disorders as a particular type of fear response. Panic attacks are not limited to anxiety disorders but rather can be seen in other mental disorders as well.

The anxiety disorders differ from one another in the types of objects or situations that

induce fear, anxiety, or avoidance behavior, and the associated cognitive ideation. Thus,

while the anxiety disorders tend to be highly comorbid with each other, they can be differentiated by close examination of the types of situations that are feared or avoided and

the content of the associated thoughts or beliefs.

Anxiety disorders differ from developmentally normative fear or anxiety by being excessive or persisting beyond developmentally appropriate periods. They differ from transient fear or anxiety, often stress-induced, by being persistent (e.g., typically lasting 6 months

or more), although the criterion for duration is intended as a general guide with allowance

for some degree of flexibility and is sometimes of shorter duration in children (as in separation anxiety disorder and selective mutism). Since individuals with anxiety disorders

typically overestimate the danger in situations they fear or avoid, the primary determination of whether the fear or anxiety is excessive or out of proportion is made by the clinician,

taking cultural contextual factors into account. Many of the anxiety disorders develop in

childhood and tend to persist if not treated. Most occur more frequently in females than in

males (approximately 2:1 ratio). Each anxiety disorder is diagnosed only when the symptoms are not attributable to the physiological effects of a substance/medication or to another

medical condition or are not better explained by another mental disorder.

The chapter is arranged developmentally, with disorders sequenced according to the

typical age at onset. The individual with separation anxiety disorder is fearful or anxious

about separation from attachment figures to a degree that is developmentally inappropriate. There is persistent fear or anxiety about harm coming to attachment figures and

events that could lead to loss of or separation from attachment figures and reluctance to go

away from attachment figures, as well as nightmares and physical symptoms of distress. Although the symptoms often develop in childhood, they can be expressed throughout adulthood as well.

Selective mutism is characterized by a consistent failure to speak in social situations in

which there is an expectation to speak (e.g., school) even though the individual speaks in

other situations. The failure to speak has significant consequences on achievement in academic or occupational settings or otherwise interferes with normal social communication.

Individuals with specific phobia are fearful or anxious about or avoidant of circumscribed objects or situations. A specific cognitive ideation is not featured in this disorder,

as it is in other anxiety disorders. The fear, anxiety, or avoidance is almost always imme-

diately induced by the phobic situation, to a degree that is persistent and out of proportion

to the actual risk posed. There are various types of specific phobias: animal; natural environment; blood-injection-injury; situational; and other situations.

In social anxiety disorder (social phobia), the individual is fearful or anxious about or

avoidant of social interactions and situations that involve the possibility of being scrutinized. These include social interactions such as meeting unfamiliar people, situations in

which the individual may be observed eating or drinking, and situations in which the individual performs in front of others. The cognitive ideation is of being negatively evaluated by others, by being embarrassed, humiliated, or rejected, or offending others.

In panic disorder, the individual experiences recurrent unexpected panic attacks and is

persistently concerned or worried about having more panic attacks or changes his or her

behavior in maladaptive ways because of the panic attacks (e.g., avoidance of exercise or of

unfamiliar locations). Panic attacks are abrupt surges of intense fear or intense discomfort

that reach a peak within minutes, accompanied by physical and/or cognitive symptoms.

Limited-symptom panic attacks include fewer than four symptoms. Panic attacks may be

expected, such as in response to a typically feared object or situation, or unexpected, meaning

that the panic attack occurs for no apparent reason. Panic attacks function as a marker and

prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders, including, but not limited to, the anxiety disorders (e.g., substance use, depressive

and psychotic disorders). Panic attack may therefore be used as a descriptive specifier for

any anxiety disorder as well as other mental disorders.

Individuals with agoraphobia are fearful and anxious about two or more of the following situations: using public transportation; being in open spaces; being in enclosed places;

standing in line or being in a crowd; or being outside of the home alone in other situations.

The individual fears these situations because of thoughts that escape might be difficult or

help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms. These situations almost always induce fear or anxiety and are often avoided and require the presence of a companion.

The key features of generalized anxiety disorder are persistent and excessive anxiety

and worry about various domains, including work and school performance, that the individual finds difficult to control. In addition, the individual experiences physical symptoms,

including restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; and sleep disturbance.

Substance/medication-induced anxiety disorder involves anxiety due to substance intoxication or withdrawal or to a medication treatment. In anxiety disorder due to another

medical condition, anxiety symptoms are the physiological consequence of another medical condition.

Disorder-specific scales are available to better characterize the severity of each anxiety

disorder and to capture change in severity over time. For ease of use, particularly for individuals with more than one anxiety disorder, these scales have been developed to have

the same format (but different focus) across the anxiety disorders, with ratings of behavioral symptoms, cognitive ideation symptoms, and physical symptoms relevant to each

disorder.

Separation Anxiety Disorder

Diagnostic Criteria 309.21 (F93.0)

A. Developmentally inappropriate and excessive fear or anxiety concerning separation from

those to whom the individual is attached, as evidenced by at least three of the following:

1. Recurrent excessive distress when anticipating or experiencing separation from

home or from major attachment figures.

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

3. Persistent and excessive worry about experiencing an untoward event (e.g., getting

lost, being kidnapped, having an accident, becoming ill) that causes separation

from a major attachment figure.

4. Persistent reluctance or refusal to go out, away from home, to school, to work, or

elsewhere because of fear of separation.

5. Persistent and excessive fear of or reluctance about being alone or without major

attachment figures at home or in other settings.

6. Persistent reluctance or refusal to sleep away from home or to go to sleep without

being near a major attachment figure.

7. Repeated nightmares involving the theme of separation.

8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.

B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and

adolescents and typically 6 months or more in adults.

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

D. The disturbance is not better explained by another mental disorder, such as refusing

to leave home because of excessive resistance to change in autism spectrum disorder;

delusions or hallucinations concerning separation in psychotic disorders; refusal to go

outside without a trusted companion in agoraphobia; worries about ill health or other

harm befalling significant others in generalized anxiety disorder; or concerns about

having an illness in illness anxiety disorder.

Diagnostic Features

The essential feature of separation anxiety disorder is excessive fear or anxiety concerning

separation from home or attachment figures. The anxiety exceeds what may be expected

given the person's developmental level (Criterion A). Individuals with separation anxiety

disorder have symptoms that meet at least three of the following criteria: They experience

recurrent excessive distress when separation from home or major attachment figures is anticipated or occurs (Criterion Al). They worry about the well-being or death of attachment

figures, particularly when separated from them, and they need to know the whereabouts

of their attachment figures and want to stay in touch with them (Criterion A2). They also

worry about untoward events to themselves, such as getting lost, being kidnapped, or

having an accident, that would keep them from ever being reunited with their major attachment figure (Criterion A3). Individuals with separation anxiety disorder are reluctant

or refuse to go out by themselves because of separation fears (Criterion A4). They have

persistent and excessive fear or reluctance about being alone or without major attachment

figures at home or in other settings. Children with separation anxiety disorder may be unable to stay or go in a room by themselves and may display "clinging" behavior, staying

close to or "shadowing" the parent around the house, or requiring someone to be with

them when going to another room in the house (Criterion A5). They have persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep

away from home (Criterion A6). Children with this disorder often have difficulty at bedtime and may insist that someone stay with them until they fall asleep. During the night,

they may make their way to their parents' bed (or that of a significant other, such as a sibling). Children may be reluctant or refuse to attend camp, to sleep at friends' homes, or to

go on errands. Adults may be uncomfortable when traveling independently (e.g., sleeping

in a hotel room). There may be repeated nightmares in which the content expresses the in­

dividual's separation anxiety (e.g., destruction of the family through fire, murder, or other

catastrophe) (Criterion A7). Physical symptoms (e.g., headaches, abdominal complaints,

nausea, vomiting) are common in children when separation from major attachment figures occurs or is anticipated (Criterion A8). Cardiovascular symptoms such as palpitations,

dizziness, and feeling faint are rare in younger children but may occur in adolescents and

adults.

The disturbance must last for a period of at least 4 weeks in children and adolescents

younger than 18 years and is typically 6 months or longer in adults (Criterion B). However,

the duration criterion for adults should be used as a general guide, with allowance for

some degree of flexibility. The disturbance must cause clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning (Criterion C).

Associated Features Supporting Diagnosis

When separated from major attachment figures, children with separation anxiety disorder

may exhibit social withdrawal, apathy, sadness, or difficulty concentrating on work or

play. Depending on their age, individuals may have fears of animals, monsters, the dark,

muggers, burglars, kidnappers, car accidents, plane travel, and other situations that are

perceived as presenting danger to the family or themselves. Some individuals become

homesick and uncomfortable to the point of misery when away from home. Separation

anxiety disorder in children may lead to school refusal, which in turn may lead to academic

difficulties and social isolation. When extremely upset at the prospect of separation, children may show anger or occasionally aggression toward someone who is forcing separation. When alone, especially in the evening or the dark, young children may report unusual

perceptual experiences (e.g., seeing people peering into their room, frightening creatures

reaching for them, feeling eyes staring at them). Children with this disorder may be described as demanding, intrusive, and in need of constant attention, and, as adults, may appear dependent and overprotective. The individual's excessive demands often become a

source of frustration for family members, leading to resentment and conflict in the family.

Prevalence

The 12-month prevalence of separation anxiety disorder among adults in the United States

is 0.9%-1.9%. In children, 6- to 12-month prevalence is estimated to be approximately 4%.

In adolescents in the United States, the 12-month prevalence is 1.6%. Separation anxiety

disorder decreases in prevalence from childhood through adolescence and adulthood and

is the most prevalent anxiety disorder in children younger than 12 years. In clinical samples of children, the disorder is equally common in males and females. In the community,

the disorder is more frequent in females.

Development and Course

Periods of heightened separation anxiety from attachment figures are part of normal early

development and may indicate the development of secure attachment relationships (e.g.,

around 1 year of age, when infants may suffer from stranger anxiety). Onset of separation

anxiety disorder may be as early as preschool age and may occur at any time during childhood and more rarely in adolescence. Typically there are periods of exacerbation and remission. In some cases, both the anxiety about possible separation and the avoidance of

situations involving separation from the home or nuclear family (e.g., going away to college, moving away from attachment figures) may persist through adulthood. However,

the majority of children with separation anxiety disorder are free of impairing anxiety disorders over their lifetimes. Many adults with separation anxiety disorder do not recall a

childhood onset of separation anxiety disorder, although they may recall symptoms.

The manifestations of separation anxiety disorder vary with age. Younger children are

more reluctant to go to school or may avoid school altogether. Younger children may not

express worries 6r specific fears of definite threats to parents, home, or themselves, and the

anxiety is manifested only when separation is experienced. As children age, worries

emerge; these are often worries about specific dangers (e.g., accidents, kidnapping, mugging, death) or vague concerns about not being reunited with attachment figures. In adults,

separation anxiety disorder may limit their ability to cope with changes in circumstances

(e.g., moving, getting married). Adults with the disorder are typically overconcemed about

their offspring and spouses and experience marked discomfort when separated from them.

They may also experience significant disruption in work or social experiences because of

needing to continuously check on the whereabouts of a significant other.

Risk and Prognostic Factors

Environmental. Separation anxiety disorder often develops after life stress, especially a

loss (e.g., the death of a relative or pet; an illness of the individual or a relative; a change of

schools; parental divorce; a move to a new neighborhood; immigration; a disaster that involved periods of separation from attachment figures). In young adults, other examples of

life stress include leaving the parental home, entering into a romantic relationship, and becoming a parent. Parental overprotection and intrusiveness may be associated with separation anxiety disorder.

Genetic and physiological. Separation anxiety disorder in children may be heritable.

Heritability was estimated at 73% in a community sample of 6-year-old twins, with higher

rates in girls. Children with separation anxiety disorder display particularly enhanced

sensitivity to respiratory stimulation using C02-enriched air.

Cuiture-Related Diagnostic issues

There are cultural variations in the degree to which it is considered desirable to tolerate

separation, so that demands and opportunities for separation between parents and children are avoided in some cultures. For example, there is wide variation across countries

and cultures with respect to the age at which it is expected that offspring should leave the

parental home. It is important to differentiate separation anxiety disorder from the high

value some cultures place on strong interdependence among family members.

Gender-Reiated Diagnostic issues

Girls manifest greater reluctance to attend or avoidance of school than boys. Indirect expression of fear of separation may be more common in males than in females, for example,

by limited independent activity, reluctance to be away from home alone, or distress when

spouse or offspring do things independently or when contact with spouse or offspring is

not possible.

Suicide Risic

Separation anxiety disorder in children may be associated with an increased risk for suicide. In a community sample, the presence of mood disorders, anxiety disorders, or substance use has been associated with suicidal ideation and attempts. However, this

association is not specific to separation anxiety disorder and is found in several anxiety

disorders.

Functionai Consequences of Separation Anxiety Disorder

Individuals with separation anxiety disorder often limit independent activities away from

home or attachment figures (e.g., in children, avoiding school, not going to camp, having

difficulty sleeping alone; in adolescents, not going away to college; in adults, not leaving the

parental home, not traveling, not working outside the home).

Differential Diagnosis

Generalized anxiety disorder. Separation anxiety disorder is distinguished from generalized anxiety disorder in that the anxiety predominantly concerns separation from attachment figures, and if other worries occur, they do not predominate the clinical picture.

Panic disorder. Threats of separation may lead to extreme anxiety and even a panic attack. In separation anxiety disorder, in contrast to panic disorder, the anxiety concerns the

possibility of being away from attachment figures and worry about untoward events befalling them, rather than being incapacitated by an unexpected panic attack.

Agoraphobia. Unlike individuals with agoraphobia, those with separation anxiety disorder are not anxious about being trapped or incapacitated in situations from which escape is perceived as difficult in the event of panic-like symptoms or other incapacitating

symptoms.

Conduct disorder. School avoidance (truancy) is common in conduct disorder, but anxiety about separation is not responsible for school absences, and the child or adolescent

usually stays away from, rather than returns to, the home.

Social anxiety disorder. School refusal may be due to social anxiety disorder (social phobia). In such instances, the school avoidance is due to fear of being judged negatively by others rather than to worries about being separated from the attachment figures.

Posttraumatic stress disorder. Fear of separation from loved ones is common after traumatic events such as a disasters, particularly when periods of separation from loved ones

were experienced during the traumatic event. In posttraumatic stress disorder (PTSD), the

central symptoms concern intrusions about, and avoidance of, memories associated with

the traumatic event itself, whereas in separation anxiety disorder, the worries and avoidance concern the well-being of attachment figures and separation from them.

Illness anxiety disorder. Individuals with illness anxiety disorder worry about specific

illnesses they may have, but the main concern is about the medical diagnosis itself, not

about being separated from attachment figures.

Bereavement. Intense yearning or longing for the deceased, intense sorrow and emotional pain, and preoccupation with the deceased or the circumstances of the death are expected responses occurring in bereavement, whereas fear of separation from other

attachment figures is central in separation anxiety disorder.

Depressive and bipolar disorders. These disorders may be associated with reluctance

to leave home, but the main concern is not worry or fear of untoward events befalling attachment figures, but rather low motivation for engaging with the outside world. However, individuals with separation anxiety disorder may become depressed while being

separated or in anticipation of separation.

Oppositional defiant disorder. Children and adolescents with separation anxiety disorder may be oppositional in the context of being forced to separate from attachment figures.

Oppositional defiant disorder should be considered only when there is persistent oppositional behavior unrelated to the anticipation or occurrence of separation from attachment

figures.

Psychotic disorders. Unlike the hallucinations in psychotic disorders, the unusual perceptual experiences that may occur in separation anxiety disorder are usually based on a

misperception of an actual stimulus, occur only in certain situations (e.g., nighttime), and

are reversed by the presence of an attachment figure.

Personality disorders. Dependent personality disorder is characterized by an indiscriminate tendency to rely on others, whereas separation anxiety disorder involves concern about the proximity and safety of main attachment figures. Borderline personality

disorder is characterized by fear of abandonment by loved ones, but problems in identity,

self-direction, interpersonal functioning, and impulsivity are additionally central to that

disorder, whereas they are not central to separation anxiety disorder.

Comorbidity

In children, separation anxiety disorder is highly comorbid with generahzed anxiety disorder and specific phobia. In adults, common comorbidities include specific phobia,

PTSD, panic disorder, generalized anxiety disorder, social anxiety disorder, agoraphobia,

obsessive-compulsive disorder, and personality disorders. Depressive and bipolar disorders are also comorbid with separation anxiety disorder in adults.

Selective Mutism

Diagnostic Criteria 312.23 (F94.0)

A. Consistent failure to speak in specific social situations in which there is an expectation

for speaking (e.g., at school) despite speaking in other situations.

B. The disturbance interferes with educational or occupational achievement or with social

communication.

C. The duration of the disturbance is at least 1 month (not limited to the first month of

school).

D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the

spoken language required in the social situation.

E. The disturbance is not better explained by a communication disorder (e.g., childhoodonset fluency disorder) and does not occur exclusively during the course of autism

spectrum disorder, schizophrenia, or another psychotic disorder.

Diagnostic Features

When encountering other individuals in social interactions, children with selective mutism do not initiate speech or reciprocally respond when spoken to by others. Lack of

speech occurs in social interactions with children or adults. Children with selective mutism will speak in their home in the presence of immediate family members but often not

even in front of close friends or second-degree relatives, such as grandparents or cousins.

The disturbance is often marked by high social anxiety. Children with selective mutism often refuse to speak at school, leading to academic or educational impairment, as teachers

often find it difficult to assess skills such as reading. The lack of speech may interfere with

social communication, although children with this disorder sometimes use nonspoken or

nonverbal means (e.g., grunting, pointing, writing) to communicate and may be willing or

eager to perform or engage in social encounters when speech is not required (e.g., nonverbal parts in school plays).

Associated Features Supporting Diagnosis

Associated features of selective mutism may include excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism,

temper tantrums, or mild oppositional behavior. Although children with this disorder

generally have normal language skills, there may occasionally be an associated commu-

nication disorder, although no particular association with a specific communication disorder has been identified. Even when these disorders are present, anxiety is present as

well. In clinical settings, children with selective mutism are almost always given an additional diagnosis of another anxiety disorder—most commonly, social anxiety disorder (social phobia).

Prevalence

Selective mutism is a relatively rare disorder and has not been included as a diagnostic category in epidemiological studies of prevalence of childhood disorders. Point prevalence

using various clinic or school samples ranges between 0.03% and 1% depending on the setting (e.g., clinic vs. school vs. general population) and ages of the individuals in the sample.

The prevalence of the disorder does not seem to vary by sex or race/ethnicity. The disorder is more likely to manifest in young children than in adolescents and adults.

Development and Course

The onset of selective mutism is usually before age 5 years, but the disturbance may not

come to clinical attention until entry into school, where there is an increase in social interaction and performance tasks, such as reading aloud. The persistence of the disorder is

variable. Although clinical reports suggest that many individuals "'outgrow" selective

mutism, the longitudinal course of the disorder is unknown. In some cases, particularly in

individuals with social anxiety disorder, selective mutism may disappear, but symptoms

of social anxiety disorder remain.

Risk and Prognostic Factors

Temperamental. Temperamental risk factors for selective mutism are not well identified. Negative affectivity (neuroticism) or behavioral inhibition may play a role, as may

parental history of shyness, social isolation, and social anxiety. Children with selective

mutism may have subtle receptive language difficulties compared with their peers, although receptive language is still within the normal range.

Environmental. Social inhibition on the part of parents may serve as a model for social

reticence and selective mutism in children. Furthermore, parents of children with selective

mutism have been described as overprotective or more controlling than parents of children with other anxiety disorders or no disorder.

Genetic and physiological factors. Because of the significant overlap between selective

mutism and social anxiety disorder, there may be shared genetic factors between these

conditions.

Culture-Related Diagnostic Issues

Children in families who have immigrated to a country where a different language is spoken may refuse to speak the new language because of lack of knowledge of the language.

If comprehension of the new language is adequate but refusal to speak persists, a diagnosis of selective mutism may be warranted.

Functional Consequences of Selective Mutism

Selective mutism may result in social impairment, as children may be too anxious to engage in reciprocal social interaction with other children. As children with selective mutism

mature, they may face increasing social isolation. In school settings, these children may

suffer academic impairment, because often they do not communicate with teachers regarding their academic or personal needs (e.g., not understanding a class assignment, not

asking to use the restroom). Severe impairment in school and social functioning, including

that resulting from teasing by peers, is common. In certain instances, selective mutism

may serve as a compensatory strategy to decrease anxious arousal in social encounters.

Differential Diagnosis

Communication disorders. Selective mutism should be distinguished from speech disturbances that are better explained by a communication disorder, such as language

disorder, speech sound disorder (previously phonological disorder), childhood-onset

fluency disorder (stuttering), or pragmatic (social) communication disorder. Unlike selective mutism, the speech disturbance in these conditions is not restricted to a specific social

situation.

Neurodevelopmental disorders and schizophrenia and other psychotic disorders.

Individuals with an autism spectrum disorder, schizophrenia or another psychotic disorder, or severe intellectual disability may have problems in social communication and be

unable to speak appropriately in social situations. In contrast, selective mutism should be

diagnosed only when a child has an established capacity to speak in some social situations

(e.g., typically at home).

Social anxiety disorder (social phobia). The social anxiety and social avoidance in social anxiety disorder may be associated with selective mutism. In such cases, both diagnoses may be given.

Comorbidity

The most common comorbid conditions are other anxiety disorders, most commonly social anxiety disorder, followed by separation anxiety disorder and specific phobia. Oppositional behaviors have been noted to occur in children with selective mutism, although

oppositional behavior may be limited to situations requiring speech. Communication delays or disorders also may appear in some children with selective mutism.

Specific Phobia

Diagnostic Criteria

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals,

receiving an injection, seeing blood).

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing,

or clinging.

B. The phobic object or situation almost always provokes immediate fear or anxiety.

C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.

D. The fear or anxiety is out of proportion to the actual danger posed by the specific object

or situation and to the sociocultural context.

E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

G. The disturbance is not better explained by the symptoms of another mental disorder,

including fear, anxiety, and avoidance of situations associated with panic-like symptoms

or other incapacitating symptoms (as in agoraphobia): objects or situations related to

obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in

posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

Specify if:

Code based on the phobic stimulus:

300.29 (F40.218) Animal (e.g., spiders, insects, dogs).

300.29 (F40.228) Natural environment (e.g., heights, storms, water).

300.29 (F40.23X) Blood-injection-injury (e.g., needles, invasive medical procedures).

Coding note: Select specific ICD-10-CM code as follows: F40.230 fear of blood;

F40.231 fear of injections and transfusions; F40.232 fear of other medical care; or

F40.233 fear of injury.

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

300.29 (F40.298) Other (e.g., situations that may lead to choking or vomiting: in children, e.g., loud sounds or costumed characters).

Coding note: When more than one phobic stimulus is present, code all ICD-10-CM codes

that apply (e.g., for fear of snakes and flying, F40.218 specific phobia, animal, and

F40.248 specific phobia, situational).

Specifiers

It is common for individuals to have multiple specific phobias. The average individual with

specific phobia fears three objects or situations, and approximately 75% of individuals with

specific phobia fear more than one situation or object. In such cases, multiple specific phobia

diagnoses, each with its own diagnostic code reflecting the phobic stimulus, would need to be

given. For example, if an individual fears thunderstorms and flying, then two diagnoses

would be given: specific phobia, natural environment, and specific phobia, situational.

Diagnostic Features

A key feature of this disorder is that the fear or anxiety is circumscribed to the presence of a

particular situation or object (Criterion A), which may be termed the phobic stimulus. The categories of feared situations or objects are provided as specifiers. Many individuals fear objects

or situations from more than one category, or phobic stimulus. For the diagnosis of specific

phobia, the response must differ from normal, transient fears that commonly occur in the population. To meet the criteria for a diagnosis, the fear or anxiety must be intense or severe (i.e.,

"marked") (Criterion A). The amount of fear experienced may vary with proximity to the

feared object or situation and may occur in anticipation of or in the actual presence of the object

or situation. Also, the fear or anxiety may take the form of a full or limited symptom panic attack (i.e., expected panic attack). Another characteristic of specific phobias is that fear or anxiety is evoked nearly every time the individual comes into contact with the phobic stimulus

(Criterion B). Thus, an individual who becomes anxious only occasionally upon being confronted with the situation or object (e.g., becomes anxious when flying only on one out of every

five airplane flights) would not be diagnosed with specific phobia. However, the degree of fear

or anxiety expressed may vary (from anticipatory anxiety to a full panic attack) across different

occasions of encountering the phobic object or situation because of various contextual factors

such as the presence of others, duration of exposure, and other threatening elements such as

turbulence on a flight for individuals who fear flying. Fear and anxiety are often expressed differently between children and adults. Also, the fear or anxiety occurs as soon as the phobic object or situation is encountered (i.e., immediately rather than being delayed).

The individual actively avoids the situation, or if he or she either is unable or decides

not to avoid it, the situation or object evokes intense fear or anxiety (Criterion C). Active

avoidance means the individual intentionally behaves in ways that are designed to prevent

or minimize contact with phobic objects or situations (e.g., takes tunnels instead of bridges

on daily commute to work for fear of heights; avoids entering a dark room for fear of spiders; avoids accepting a job in a locale where a phobic stimulus is more common). Avoid-

ance behaviors are often obvious (e.g., an individual who fears blood refusing to go to the

doctor) but are sometimes less obvious (e.g., an individual who fears snakes refusing to

look at pictures ihat resemble the form or shape of snakes). Many individuals with specific

phobias have suffered over many years and have changed their living circumstances in

ways designed to avoid the phobic object or situation as much as possible (e.g., an individual diagnosed with specific phobia, animal, who moves to reside in an area devoid of

the particular feared animal). Therefore, they no longer experience fear or anxiety in their

daily life. In such instances, avoidance behaviors or ongoing refusal to engage in activities

that would involve exposure to the phobic object or situation (e.g., repeated refusal to accept offers for work-related travel because of fear of flying) may be helpful in confirming

the diagnosis in the absence of overt anxiety or panic.

The fear or anxiety is out of proportion to the actual danger that the object or situation

poses, or more intense than is deemed necessary (Criterion D). Although individuals with

specific phobia often recognize their reactions as disproportionate, they tend to overestimate the danger in their feared situations, and thus the judgment of being out of proportion is made by the clinician. The individual's sociocultural context should also be taken

into account. For example, fears of the dark may be reasonable in a context of ongoing

violence, and fear of insects may be more disproportionate in settings where insects are

consumed in the diet. The fear, anxiety, or avoidance is persistent, typically lasting for

6 months or more (Criterion E), which helps distinguish the disorder from transient fears

that are common in the population, particularly among children. However, the duration

criterion should be used as a general guide, with allowance for some degree of flexibility.

The specific phobia must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning in order for the disorder to be diagnosed (Criterion F).

Associated Features Supporting Diagnosis

Individuals with specific phobia typically experience an increase in physiological arousal

in anticipation of or during exposure to a phobic object or situation. However, the physiological response to the feared situation or object varies. Whereas individuals with situational, natural environment, and animal specific phobias are likely to show sympathetic

nervous system arousal, individuals with blood-injection-injury specific phobia often

demonstrate a vasovagal fainting or near-fainting response that is marked by initial brief

acceleration of heart rate and elevation of blood pressure followed by a deceleration of

heart rate and a drop in blood pressure. Current neural systems models for specific phobia

emphasize the amygdala and related structures, much as in other anxiety disorders.

Prevaience

In the United States, the 12-month community prevalence estimate for specific phobia is

approximately 7%-9%. Prevalence rates in European countries are largely similar to those

in the United States (e.g., about 6%), but rates are generally lower in Asian, African, and

Latin American countries (2%-4%). Prevalence rates are approximately 5% in children and

are approximately 16% in 13- to 17-year-olds. Prevalence rates are lower in older individuals (about 3%-5%), possibly reflecting diminishing severity to subclinical levels. Females

are more frequently affected than males, at a rate of approximately 2:1, although rates vary

across different phobic stimuli. That is, animal, natural environment, and situational specific phobias are predominantly experienced by females, whereas blood-injection-injury

phobia is experienced nearly equally by both genders.

Development and Course

Specific phobia sometimes develops following a traumatic event (e.g., being attacked by

an animal or stuck in an elevator), observation of others going through a traumatic event (e.g.,

watching someone drown), an unexpected panic attack in the to be feared situation (e.g.,

an unexpected panic attack while on the subway), or informational transmission (e.g., extensive media coverage of a plane crash). However, many individuals with specific phobia

are unable to recall the specific reason for the onset of their phobias. Specific phobia usually develops in early childhood, with the majority of cases developing prior to age 10

years. The median age at onset is between 7 and 11 years, with the mean at about 10 years.

Situational specific phobias tend to have a later age at onset than natural environment, animal, or blood-injection-injury specific phobias. Specific phobias that develop in childhood and adolescence are likely to wax and wane during that period. However, phobias

that do persist into adulthood are unlikely to remit for the majority of individuals.

When specific phobia is being diagnosed in children, two issues should be considered.

First, young children may express their fear and anxiety by crying, tantrums, freezing,

or clinging. Second, young children typically are not able to understand the concept of

avoidance. Therefore, the clinician should assemble additional information from parents,

teachers, or others who know the child well. Excessive fears are quite common in young

children but are usually transitory and only mildly impairing and thus considered developmentally appropriate. In such cases a diagnosis of specific phobia would not be made.

When the diagnosis of specific phobia is being considered in a child, it is important to

assess the degree of impairment and the duration of the fear, anxiety, or avoidance, and

whether it is typical for the child's particular developmental stage.

Although the prevalence of specific phobia is lower in older populations, it remains

one of the more commonly experienced disorders in late life. Several issues should be considered when diagnosing specific phobia in older populations. First, older individuals

may be more likely to endorse natural environment specific phobias, as well as phobias of

falling. Second, specific phobia (like all anxiety disorders) tends to co-occur with medical

concerns in older individuals, including coronary heart disease and chronic obstructive

pulmonary disease. Third, older individuals may be more likely to attribute the symptoms

of anxiety to medical conditions. Fourth, older individuals may be more likely to manifest

anxiety in an atypical manner (e.g., involving symptoms of both anxiety and depression)

and thus be more likely to warrant a diagnosis of unspecified anxiety disorder. Additionally, the presence of specific phobia in older adults is associated with decreased quality of

life and may serve as a risk factor for major neurocognitive disorder.

Although most specific phobias develop in childhood and adolescence, it is possible for a

specific phobia to develop at any age, often as the result of experiences that are traumatic. For

example, phobias of choking almost always follow a near-choking event at any age.

Risk and Prognostic Factors

Temperamental. Temperamental risk factors for specific phobia, such as negative affectivity (neuroticism) or behavioral inhibition, are risk factors for other anxiety disorders as

well.

Environmental. Environmental risk factors for specific phobias, such as parental overprotectiveness, parental loss and separation, and physical and sexual abuse, tend to predict other anxiety disorders as well. As noted earlier, negative or traumatic encounters

with the feared object or situation sometimes (but not always) precede the development of

specific phobia.

Genetic and physiological. There may be a genetic susceptibility to a certain category of

specific phobia (e.g., an individual with a first-degree relative with a specific phobia of animals is significantly more likely to have the same specific phobia than any other category

of phobia). Individuals with blood-injection-injury phobia show a unique propensity to

vasovagal syncope (fainting) in the presence of the phobic stimulus.

Culture-Related Diagnostic Issues

In the United States, Asians and Latinos report significantly lower rates of specific phobia

than non-Latino whites, African Americans, and Native Americans. In addition to having

lower prevalence rates of specific phobia, some countries outside of the United States, particularly Asian and African countries, show differing phobia content, age at onset, and

gender ratios.

Suicide Risk

Individuals with specific phobia are up to 60% more likely to make a suicide attempt than

are individuals without the diagnosis. However, it is likely that these elevated rates are

primarily due to comorbidity with personality disorders and other anxiety disorders.

Functional Consequences of Specific Phobia

Individuals with specific phobia show similar patterns of impairment in psychosocial

functioning and decreased quality of life as individuals with other anxiety disorders and

alcohol and substance use disorders, including impairments in occupational and interpersonal functioning. In older adults, impairment may be seen in caregiving duties and

volunteer activities. Also, fear of falling in older adults can lead to reduced mobility and

reduced physical and social functioning, and may lead to receiving formal or informal

home support. The distress and impairment caused by specific phobias tend to increase

with the number of feared objects and situations. Thus, an individual who fears four objects or situations is likely to have more impairment in his or her occupational and social

roles and a lower quality of life than an individual who fears only one object or situation.

Individuals with blood-injection-injury specific phobia are often reluctant to obtain medical care even when a medical concern is present. Additionally, fear of vomiting and choking may substantially reduce dietary intake.

Differential Diagnosis

Agoraphobia. Situational specific phobia may resemble agoraphobia in its clinical presentation, given the overlap in feared situations (e.g., flying, enclosed places, elevators). If

an individual fears only one of the agoraphobia situations, then specific phobia, situational, may be diagnosed. If two or more agoraphobic situations are feared, a diagnosis of

agoraphobia is likely warranted. For example, an individual who fears airplanes and elevators (which overlap with the '"public transportation" agoraphobic situation) but does

not fear other agoraphobic situations would be diagnosed with specific phobia, situational, whereas an individual who fears airplanes, elevators, and crowds (which overlap

with two agoraphobic situations, "using public transportation" and "standing in line and

or being in a crowd") would be diagnosed with agoraphobia. Criterion B of agoraphobia

(the situations are feared or avoided "because of thoughts that escape might be difficult or

help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms") can also be useful in differentiating agoraphobia

from specific phobia. If the situations are feared for other reasons, such as fear of being

harmed directly by the object or situations (e.g., fear of the plane crashing, fear of the animal biting), a specific phobia diagnosis may be more appropriate.

Social anxiety disorder. If the situations are feared because of negative evaluation, social anxiety disorder should be diagnosed instead of specific phobia.

Separation anxiety disorder. If the situations are feared because of separation from a

primary caregiver or attachment figure, separation anxiety disorder should be diagnosed

instead of specific phobia.

Panic disorder. Individuals with specific phobia may experience panic attacks when confronted with their feared situation or object. A diagnosis of specific phobia would be given if

the panic attacks only occurred in response to the specific object or situation, whereas a diagnosis of panic disorder would be given if the individual also experienced panic attacks

that were unexpected (i.e., not in response to the specific phobia object or situation).

Obsessive-compulsive disorder. If an individual's primary fear or anxiety is of an object or situation as a result of obsessions (e.g., fear of blood due to obsessive thoughts about

contamination from blood-borne pathogens [i.e., HIV]; fear of driving due to obsessive images of harming others), and if other diagnostic criteria for obsessive-compulsive disorder

are met, then obsessive-compulsive disorder should be diagnosed.

Trauma- and stressor-related disorders. If the phobia develops following a traumatic

event, posttraumatic stress disorder (PTSD) should be considered as a diagnosis. However, traumatic events can precede the onset of PTSD and specific phobia. In this case, a diagnosis of specific phobia would be assigned only if all of the criteria for PTSD are not met.

Eating disorders. A diagnosis of specific phobia is not given if the avoidance behavior is

exclusively limited to avoidance of food and food-related cues, in which case a diagnosis

of anorexia nervosa or bulimia nervosa should be considered.

Schizophrenia spectrum and other psychotic disorders. When the fear and avoidance

are due to delusional thinking (as in schizophrenia or other schizophrenia spectrum and

other psychotic disorders), a diagnosis of specific phobia is not warranted.

Comorbidity

Specific phobia is rarely seen in medical-clinical settings in the absence of other psychopathology and is more frequently seen in nonmedical mental health settings. Specific phobia is frequently associated with a range of other disorders, especially depression in older

adults. Because of early onset, specific phobia is typically the temporally primary disorder.

Individuals with specific phobia are at increased risk for the development of other disorders, including other anxiety disorders, depressive and bipolar disorders, substancerelated disorders, somatic symptom and related disorders, and personality disorders (particularly dependent personality disorder).

Social Anxiety Disorder (Social Phobia)

Diagnostic Criteria 300.23 (F40.10)

A. Marked fear or anxiety about one or more social situations in which the individual is

exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).

Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

B. The individual fears that he or she will act in a way or show anxiety symptoms that will

be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection

or offend others).

C. The social situations almost always provoke fear or anxiety.

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing,

clinging, shrinking, or failing to speak in social situations.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation

and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

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

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another

mental disorder, such as panic disorder, body dysmoφhic disorder, or autism spectrum

disorder.

J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from bums

or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specify if:

Performance only: If the fear is restricted to speaking or performing in public.

Specifiers

Individuals with the performance only type of social anxiety disorder have performance

fears that are typically most impairing in their professional lives (e.g., musicians, dancers,

performers, athletes) or in roles that require regular public speaking. Performance fears

may also manifest in work, school, or academic settings in which regular public presentations are required. Individuals with performance only social anxiety disorder do not fear

or avoid nonperformance social situations.

Diagnostic Features

The essential feature of social anxiety disorder is a marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others. In children the fear or

anxiety must occur in peer settings and not just during interactions with adults (Criterion

A). When exposed to such social situations, the individual fears that he or she will be negatively evaluated. The individual is concerned that he or she will be judged as anxious,

weak, crazy, stupid, boring, intimidating, dirty, or unlikable. The individual fears that

he or she will act or appear in a certain way or show anxiety symptoms, such as blushing,

trembling, sweating, stumbling over one's words, or staring, that will be negatively evaluated by others (Criterion B). Some individuals fear offending others or being rejected as

a result. Fear of offending others—for example, by a gaze or by showing anxiety symptoms—may be the predominant fear in individuals from cultures with strong collectivistic

orientations. An individual with fear of trembling of the hands may avoid drinking, eating, writing, or pointing in public; an individual with fear of sweating may avoid shaking

hands or eating spicy foods; and an individual with fear of blushing may avoid public performance, bright lights, or discussion about intimate topics. Some individuals fear and

avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or

"shy bladder syndrome").

The social situations almost always provoke fear or anxiety (Criterion C). Thus, an individual who becomes anxious only occasionally in the social situation(s) would not be diagnosed with social anxiety disorder. However, the degree and type of fear and anxiety

may vary (e.g., anticipatory anxiety, a panic attack) across different occasions. The anticipatory anxiety may occur sometimes far in advance of upcoming situations (e.g., worrying

every day for weeks before attending a social event, repeating a speech for days in advance).

In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, or

shrinking in social situations. The individual will often avoid the feared social situations.

Alternatively, the situations are endured with intense fear or anxiety (Criterion D). Avoid-

ance can be extensive (e.g., not going to parties, refusing school) or subtle (e.g., overpreparing the text of a speech, diverting attention to others, limiting eye contact).

The fear or anxiety is judged to be out of proportion to the actual risk of being negatively evaluated or to the consequences of such negative evaluation (Criterion E). Sometimes, the anxiety may not be judged to be excessive, because it is related to an actual

danger (e.g., being bullied or tormented by others). However, individuals with social anxiety disorder often overestimate the negative consequences of social situations, and thus

the judgment of being out of proportion is made by the clinician. The individual's sociocultural context needs to be taken into account when this judgment is being made. For example, in certain cultures, behavior that might otherwise appear socially anxious may be

considered appropriate in social situations (e.g., might be seen as a sign of respect).

The duration of the disturbance is typically at least 6 months (Criterion F). This duration threshold helps distinguish the disorder from transient social fears that are common, particularly among children and in the community. However, the duration criterion

should be used as a general guide, with allowance for some degree of flexibility. The fear,

anxiety, and avoidance must interfere significantly with the individual's normal routine,

occupational or academic functioning, or social activities or relationships, or must cause

clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion G). For example, an individual who is afraid to speak in public would not receive a diagnosis of social anxiety disorder if this activity is not routinely

encountered on the job or in classroom work, and if the individual is not significantly distressed about it. However, if the individual avoids, or is passed over for, the job or education he or she really wants because of social anxiety symptoms. Criterion G is met.

Associated Features Supporting Diagnosis

Individuals with social anxiety disorder may be inadequately assertive or excessively submissive or, less commonly, highly controlling of the conversation. They may show overly

rigid body posture or inadequate eye contact, or speak with an overly soft voice. These individuals may be shy or withdrawn, and they may be less open in conversations and disclose little about themselves. They may seek employment in jobs that do not require social

contact, although this is not the case for individuals with social anxiety disorder, performance only. They may live at home longer. Men may be delayed in marrying and having

a family, whereas women who would want to work outside the home may live a life as

homemaker and mother. Self-medication with substances is common (e.g., drinking before going to a party). Social anxiety among older adults may also include exacerbation of

symptoms of medical illnesses, such as increased tremor or tachycardia. Blushing is a hallmark physical response of social anxiety disorder.

Prevaience

The 12-month prevalence estimate of social anxiety disorder for the United States is approximately 7%. Lower 12-month prevalence estimates are seen in much of the world using the same diagnostic instrument, clustering around 0.5%-2.0%; median prevalence in

Europe is 2.3%. The 12-month prevalence rates in children and adolescents are comparable

to those in adults. Prevalence rates decrease with age. The 12-month prevalence for older

adults ranges from 2% to 5%. In general, higher rates of social anxiety disorder are found

in females than in males in the general population (with odds ratios ranging from 1.5 to

2.2), and the gender difference in prevalence is more pronounced in adolescents and

young adults. Gender rates are equivalent or slightly higher for males in clinical samples,

and it is assumed that gender roles and social expectations play a significant role in explaining the heightened help-seeking behavior in male patients. Prevalence in the United

States is higher in American Indians and lower in persons of Asian, Latino, African American, and Afro-Caribbean descent compared with non-Hispanic whites.

Development and Course

Median age at onset of social anxiety disorder in the United States is 13 years, and 75% of

individuals have an age at onset between 8 and 15 years. The disorder sometimes emerges

out of a childhood history of social inhibition or shyness in U.S. and European studies. Onset can also occur in early childhood. Onset of social anxiety disorder may follow a stressful or humiliating experience (e.g., being bullied, vomiting during a public speech), or it

may be insidious, developing slowly. First onset in adulthood is relatively rare and is more

likely to occur after a stressful or humiliating event or after life changes that require new

social roles (e.g., marrying someone from a different social class, receiving a job promotion). Social anxiety disorder may diminish after an individual with fear of dating marries

and may reemerge after divorce. Among individuals presenting to clinical care, the disorder tends to be particularly persistent.

Adolescents endorse a broader pattern of fear and avoidance, including of dating,

compared with younger children. Older adults express social anxiety at lower levels but

across a broader range of situations, whereas younger adults express higher levels of social anxiety for specific situations. In older adults, social anxiety may concern disability

due to declining sensory functioning (hearing, vision) or embarrassment about one's appearance (e.g., tremor as a symptom of Parkinson's disease) or functioning due to medical

conditions, incontinence, or cognitive impairment (e.g., forgetting people's names). In the

community approximately 30% of individuals with social anxiety disorder experience remission of symptoms within 1 year, and about 50% experience remission within a few

years. For approximately 60% of individuals without a specific treatment for social anxiety

disorder, the course takes several years or longer.

Detection of social anxiety disorder in older adults may be challenging because of several factors, including a focus on somatic symptoms, comorbid medical illness, limited

insight, changes to social environment or roles that may obscure impairment in social

functioning, or reticence about describing psychological distress.

Risk and Prognostic Factors

Temperamental. Underlying traits that predispose individuals to social anxiety disorder include behavioral inhibition and fear of negative evaluation.

Environmental. There is no causative role of increased rates of childhood maltreatment or

other early-onset psychosocial adversity in the development of social anxiety disorder. However, childhood maltreatment and adversity are risk factors for social anxiety disorder.

Genetic and physiological. Traits predisposing individuals to social anxiety disorder,

such as behavioral inhibition, are strongly genetically influenced. The genetic influence is

subject to gene-environment interaction; that is, children with high behavioral inhibition

are more susceptible to environmental influences, such as socially anxious modeling by

parents. Also, social anxiety disorder is heritable (but performance-only anxiety less so).

First-degree relatives have a two to six times greater chance of having social anxiety disorder, and liability to the disorder involves the interplay of disorder-specific (e.g., fear of

negative evaluation) and nonspecific (e.g., neuroticism) genetic factors.

Cuiture-Related Diagnostic issues

The syndrome of taijin kyofusho (e.g., in Japan and Korea) is often characterized by socialevaluative concerns, fulfilling criteria for social anxiety disorder, that are associated with

the fear that the individual makes other people uncomfortable (e.g., "My gaze upsets people so they look away and avoid me"), a fear that is at times experienced with delusional

intensity. This symptom may also be found in non-Asian settings. Other presentations

of taijin kyofusho may fulfill criteria for body dysmorphic disorder or delusional disorder.

Immigrant status is associated with significantly lower rates of social anxiety disorder in

both Latino and non-Latino white groups. Prevalence rates of social anxiety disorder may

not be in line with self-reported social anxiety levels in the same culture—that is, societies

with strong collectivistic orientations may report high levels of social anxiety but low prevalence of social anxiety disorder.

Gender-Related Diagnostic Issues

Females with social anxiety disorder report a greater number of social fears and comorbid

depressive, bipolar, and anxiety disorders, whereas males are more likely to fear dating,

have oppositional defiant disorder or conduct disorder, and use alcohol and illicit drugs to

relieve symptoms of the disorder. Paruresis is more common in males.

Functional Consequences of Social Anxiety Disorder

Social anxiety disorder is associated with elevated rates of school dropout and with decreased well-being, employment, workplace productivity, socioeconomic status, and quality

of life. Social anxiety disorder is also associated with being single, unmarried, or divorced

and with not having children, particularly among men. In older adults, there may be impairment in caregiving duties and volunteer activities. Social anxiety disorder also impedes leisure activities. Despite the extent of distress and social impairment associated with social

anxiety disorder, only about half of individuals with the disorder in Western societies ever

seek treatment, and they tend to do so only after 15-20 years of experiencing symptoms. Not

being employed is a strong predictor for ihe persistence of social aimety disorder.

Differential Diagnosis

Normative shyness. Shyness (i.e., social reticence) is a common personality trait and is

not by itself pathological. In some societies, shyness is even evaluated positively. However, when there is a significant adverse impact on social, occupational, and other important areas of functioning, a diagnosis of social anxiety disorder should be considered, and

when full diagnostic criteria for social anxiety disorder are met, the disorder should be diagnosed. Only a minority (12%) of self-identified shy individuals in the United States have

symptoms that meet diagnostic criteria for social anxiety disorder.

Agoraphobia. Individuals with agoraphobia may fear and avoid social situations (e.g., going to a movie) because escape might be difficult or help might not be available in the event of

incapacitation or panic-like symptoms, whereas individuals with social anxiety disorder are

most fearful of scrutiny by others. Moreover, individuals with social anxiety disorder are likely

to be calm when left entirely alone, which is often not the case in agoraphobia.

Panic disorder. Individuals with social anxiety disorder may have panic attacks, but the

concern is about fear of negative evaluation, whereas in panic disorder the concern is

about the panic attacks themselves.

Generalized anxiety disorder. Social worries are common in generalized anxiety disorder,

but the focus is more on the nature of ongoing relationships rather than on fear of negative

evaluation. Individuals with generalized anxiety disorder, particularly children, may have excessive worries about the quality of their social performance, but these worries also pertain to

nonsocial performance and when the individual is not being evaluated by others. In social anxiety disorder, the worries focus on social performance and others' evaluation.

Separation anxiety disorder. Individuals with separation anxiety disorder may avoid

social settings (including school refusal) because of concerns about being separated from

attachment figures or, in children, about requiring the presence of a parent when it is not

developmentally appropriate. Individuals with separation anxiety disorder are usually

comfortable in social settings when their attachment figure is present or when they are at

home, whereas those with social anxiety disorder may be uncomfortable when social situations occur at home or in the presence of attachment figures.

Specific phobias. Individuals with specific phobias may fear embarrassment or humiliation (e.g., embarrassment about fainting when they have their blood drawn), but they do

not generally fear negative evaluation in other social situations.

Selective mutism. Individuals with selective mutism may fail to speak because of fear of

negative evaluation, but they do not fear negative evaluation in social situations where no

speaking is required (e.g., nonverbal play).

Major depressive disorder. Individuals with major depressive disorder may be concerned about being negatively evaluated by others because they feel they are bad or not

worthy of being liked. In contrast, individuals with social anxiety disorder are worried

about being negatively evaluated because of certain social behaviors or physical symptoms.

Body dysmorphic disorder. Individuals with body dysmorphic disorder are preoccupied with one or more perceived defects or flaws in their physical appearance that are not

observable or appear slight to others; this preoccupation often causes social anxiety and

avoidance. If their social fears and avoidance are caused only by their beliefs about their

appearance, a separate diagnosis of social anxiety disorder is not warranted.

Delusional disorder. Individuals with delusional disorder may have nonbizarre delusions and/or hallucinations related to the delusional theme that focus on being rejected by

or offending others. Although extent of insight into beliefs about social situations may

vary, many individuals with social anxiety disorder have good insight that their beliefs are

out of proportion to the actual threat posed by the social situation.

Autism spectrum disorder. Social anxiety and social communication deficits are hallmarks of autism spectrum disorder. Individuals with social anxiety disorder typically

have adequate age-appropriate social relationships and social communication capacity,

although they may appear to have impairment in these areas when first interacting with

unfamiliar peers or adults.

Personality disorders. Given its frequent onset in childhood and its persistence into and

through adulthood, social anxiety disorder may resemble a personality disorder. The most

apparent overlap is with avoidant personality disorder. Individuals with avoidant personality disorder have a broader avoidance pattern than those with social anxiety disorder.

Nonetheless, social anxiety disorder is typically more comorbid with avoidant personality

disorder than with other personality disorders, and avoidant personality disorder is more

comorbid with social anxiety disorder than with other anxiety disorders.

Other mental disorders. Social fears and discomfort can occur as part of schizophrenia,

but other evidence for psychotic symptoms is usually present. In individuals with an eating disorder, it is important to determine that fear of negative evaluation about eating

disorder symptoms or behaviors (e.g., purging and vomiting) is not the sole source of social anxiety before applying a diagnosis of social anxiety disorder. Similarly, obsessivecompulsive disorder may be associated with social anxiety, but the additional diagnosis of

social anxiety disorder is used only when social fears and avoidance are independent of

the foci of the obsessions and compulsions.

Other medical conditions. Medical conditions may produce symptoms that may be embarrassing (e.g. trembling in Parkinson's disease). When the fear of negative evaluation

due to other medical conditions is excessive, a diagnosis of social anxiety disorder should

be considered.

Oppositional defiant disorder. Refusal to speak due to opposition to authority figures

should be differentiated from failure to speak due to fear of negative evaluation.

Comorbidity

Social anxiety disorder is often comorbid with other anxiety disorders, major depressive

disorder, and substance use disorders, and the onset of social anxiety disorder generally

precedes that of the other disorders, except for specific phobia and separation anxiety disorder. Chronic social isolation in the course of a social anxiety disorder may result in major

depressive disorder. Comorbidity with depression is high also in older adults. Substances

may be used as self-medication for social fears, but the symptoms of substance intoxication or withdrawal, such as trembling, may also be a source of (further) social fear. Social

anxiety disorder is frequently comorbid with bipolar disorder or body dysmorphic disorder; for example, an individual has body dysmorphic disorder concerning a preoccupation with a slight irregularity of her nose, as well as social anxiety disorder because of a

severe fear of sounding unintelligent. The more generalized form of social anxiety disorder, but not social anxiety disorder, performance only, is often comorbid with avoidant

personality disorder. In children, comorbidities with high-functioning autism and selective mutism are common.

Panic Disorder

Diagnostic Criteria 300.01 (F41.0)

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear

or intense discomfort that reaches a peak within minutes, and during which time four

(or more) of the following symptoms occur;

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

1. Palpitations, pounding heart, or accelerated heart rate.

2. Sweating.

3. Trembling or shaking.

4. Sensations of shortness of breath or smothering.

5. Feelings of choking.

6. Chest pain or discomfort.

7. Nausea or abdominal distress.

8. Feeling dizzy, unsteady, light-headed, or faint.

9. Chills or heat sensations.

10. Paresthesias (numbness or tingling sensations).

11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).

12. Fear of losing control or “going crazy.”

13. Fear of dying.

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of

the four required symptoms.

B. At least one of the attacks has been followed by 1 month (or more) of one or both of

the following:

1. Persistent concern or worry about additional panic attacks or their consequences

(e.g., losing control, having a heart attack, “going crazy”).

2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors

designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar

situations).

C. The disturbance is not attributable to the physiological effects of a substance (e.g., a

drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).

D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder: in response to circumscribed phobic objects or situations, as in specific phobia:

in response to obsessions, as in obsessive-compulsive disorder: in response to reminders of traumatic events, as in posttraumatic stress disorder: or in response to separation from attachment figures, as in separation anxiety disorder).

Diagnostic Features

Panic disorder refers to recurrent unexpected panic attacks (Criterion A). A panic attack is

an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes,

and during which time four or more of a list of 13 physical and cognitive symptoms occur.

The term recurrent literally means more than one unexpected panic attack. The term unexpected refers to a panic attack for which there is no obvious cue or trigger at the time of occurrence—that is, the attack appears to occur from out of the blue, such as when the

individual is relaxing or emerging from sleep (nocturnal panic attack). In contrast, expected

panic attacks are attacks for which there is an obvious cue or trigger, such as a situation in

which panic attacks typically occur. The determination of whether panic attacks are expected or unexpected is made by the clinician, who makes this judgment based on a combination of careful questioning as to the sequence of events preceding or leading up to the

attack and the individual's own judgment of whether or not the attack seemed to occur for

no apparent reason. Cultural interpretations may influence the assignment of panic attacks as expected or unexpected (see section "Culture-Related Diagnostic Issues" for this

disorder). In the United States and Europe, approximately one-half of individuals with

panic disorder have expected panic attacks as well as unexpected panic attacks. Thus, the

presence of expected panic attacks does not rule out the diagnosis of panic disorder. For

more details regarding expected versus unexpected panic attacks, see the text accompanying panic attacks (pp. 214-217).

The frequency and severity of panic attacks vary widely. In terms of frequency, there

may be moderately frequent attacks (e.g., one per week) for months at a time, or short

bursts of more frequent attacks (e.g., daily) separated by weeks or months without any attacks or with less frequent attacks (e.g., two per month) over many years. Persons who

have infrequent panic attacks resemble persons with more frequent panic attacks in terms

of panic attack symptoms, demographic characteristics, comorbidity with other disorders,

family history, and biological data. In terms of severity, individuals with panic disorder

may have both full-symptom (four or more symptoms) and limited-symptom (fewer than

four symptoms) attacks, and the number and type of panic attack symptoms frequently

differ from one panic attack to the next. However, more than one unexpected full-symptom panic attack is required for the diagnosis of panic disorder.

The worries about panic attacks or their consequences usually pertain to physical concerns, such as worry that panic attacks reflect the presence of life-threatening illnesses

(e.g., cardiac disease, seizure disorder); social concerns, such as embarrassment or fear of

being judged negatively by others because of visible panic symptoms; and concerns about

mental functioning, such as ''going crazy" or losing control (Criterion B). The maladaptive

changes in behavior represent attempts to minimize or avoid panic attacks or their consequences. Examples include avoiding physical exertion, reorganizing daily life to ensure

that help is available in the event of a panic attack, restricting usual daily activities, and

avoiding agoraphobia-type situations, such as leaving home, using public transportation,

or shopping. If agoraphobia is present, a separate diagnosis of agoraphobia is given.

Associated Features Supporting Diagnosis

One type of unexpected panic attack is a nocturnal panic attack (i.e., waking from sleep in

a state of panic, which differs from panicking after fully waking from sleep). In the United

States, this type of panic attack has been estimated to occur at least one time in roughly

one-quarter to one-third of individuals with panic disorder, of whom the majority also

have daytime panic attacks. In addition to worry about panic attacks and their consequences, many individuals with panic disorder report constant or intermittent feelings of

anxiety that are more broadly related to health and mental health concerns. For example,

individuals with panic disorder often anticipate a catastrophic outcome from a mild physical symptom or medication side effect (e.g., thinking that they may have heart disease or

that a headache means presence of a brain tumor). Such individuals often are relatively intolerant of medication side effects. In addition, there may be pervasive concerns about

abilities to complete daily tasks or withstand daily stressors, excessive use of drugs (e.g.,

alcohol, prescribed medications or illicit drugs) to control panic attacks, or extreme behaviors aimed at controlling panic attacks (e.g., severe restrictions on food intake or avoidance

of specific foods or medications because of concerns about physical symptoms that provoke panic attacks).

Prevalence

In the general population, the 12-month prevalence estimate for panic disorder across the

United States and several European countries is about 2%-3% in adults and adolescents. In

the United States, significantly lower rates of panic disorder are reported among Latinos,

African Americans, Caribbean blacks, and Asian Americans, compared with non-Latino

whites; American Indians, by contrast, have significantly higher rates. Lower estimates

have been reported for Asian, African, and Latin American countries, ranging from 0.1%

to 0.8%. Females are more frequently affected than males, at a rate of approximately 2:1. The

gender differentiation occurs in adolescence and is already observable before age 14 years.

Although panic attacks occur in children, the overall prevalence of panic disorder is low

before age 14 years (<0.4%). The rates of panic disorder show a gradual increase during adolescence, particularly in females, and possibly following the onset of puberty, and peak during adulthood. The prevalence rates decline in older individuals (i.e., 0.7% in adults over

the age of 64), possibly reflecting diminishing severity to subclinical levels.

Development and Course

The median age at onset for panic disorder in the United States is 20-24 years. A small

number of cases begin in childhood, and onset after age 45 years is unusual but can occur.

The usual course, if the disorder is untreated, is chronic but waxing and waning. Some individuals may have episodic outbreaks with years of remission in between, and others

may have continuous severe symptomatology. Only a minority of individuals have full

remission without subsequent relapse within a few years. The course of panic disorder

typically is complicated by a range of other disorders, in particular other anxiety disorders, depressive disorders, and substance use disorders (see section "Comorbidity" for

this disorder).

Although panic disorder is very rare in childhood, first occurrence of "fearful spells" is

often dated retrospectively back to childhood. As in adults, panic disorder in adolescents

tends to have a chronic course and is frequently comorbid with other anxiety, depressive,

and bipolar disorders. To date, no differences in the clinical presentation between adolescents and adults have been found. However, adolescents may be less worried about additional panic attacks than are young adults. Lower prevalence of panic disorder in older

adults appears to be attributable to age-related "dampening" of the autonomic nervous

system response. Many older individuals with "panicky feelings" are observed to have a

"hybrid" of limited-symptom panic attacks and generalized anxiety. Also, older adults

tend to attribute their panic attacks to certain stressful situations, such as a medical procedure or social setting. Older individuals may retrospectively endorse explanations for

the panic attack^which would preclude the diagnosis of panic disorder), even if an attack

might actually have been unexpected in the moment (and thus qualify as the basis for a

panic disorder diagnosis). This may result in under-endorsement of unexpected panic attacks in older individuals. Thus, careful questioning of older adults is required to assess

whether panic attacks were expected before entering the situation, so that unexpected

panic attacks and the diagnosis of panic disorder are not overlooked.

While the low rate of panic disorder in children could relate to difficulties in symptom

reporting, this seems unlikely given that children are capable of reporting intense fear or

panic in relation to separation and to phobic objects or phobic situations. Adolescents

might be less willing than adults to openly discuss panic attacks. Therefore, clinicians

should be aware that unexpected panic attacks do occur in adolescents, much as they do in

adults, and be attuned to this possibility when encountering adolescents presenting with

episodes of intense fear or distress.

Risk and Prognostic Factors

Temperamental. Negative affectivity (neuroticism) (i.e., proneness to experiencing negative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of

anxiety are harmful) are risk factors for the onset of panic attacks and, separately, for

worry about panic, although their risk status for the diagnosis of panic disorder is unknown. History of "fearful spells" (i.e., limited-symptom attacks that do not meet full criteria for a panic attack) may be a risk factor for later panic attacks and panic disorder.

Although separation anxiety in childhood, especially when severe, may precede the later

development of panic disorder, it is not a consistent risk factor.

Environmental. Reports of childhood experiences of sexual and physical abuse are more

common in panic disorder than in certain other anxiety disorders. Smoking is a risk factor

for panic attacks and panic disorder. Most individuals report identifiable stressors in the

months before their first panic attack (e.g., interpersonal stressors and stressors related to

physical well-being, such as negative experiences with illicit or prescription drugs, disease, or death in the family).

Genetic and physiological. It is believed that multiple genes confer vulnerability to panic

disorder. However, the exact genes, gene products, or functions related to the genetic regions implicated remain unknown. Current neural systems models for panic disorder emphasize the amygdala and related structures, much as in other anxiety disorders. There is

an increased risk for panic disorder among offspring of parents with anxiety, depressive,

and bipolar disorders. Respiratory disturbance, such as asthma, is associated with panic

disorder, in terms of past history, comorbidity, and family history.

Culture-Related Diagnostic issues

The rate of fears about mental and somatic symptoms of anxiety appears to vary across

cultures and may influence the rate of panic attacks and panic disorder. Also, cultural expectations may influence the classification of panic attacks as expected or unexpected. For

example, a Vietnamese individual who has a panic attack after walking out into a windy

environment (trilng gio; "hit by the wind") may attribute the panic attack to exposure to

wind as a result of the cultural syndrome that links these two experiences, resulting in classification of the panic attack as expected. Various other cultural syndromes are associated

with panic disorder, including ataque de nervios ("attack of nerves") among Latin Americans and khyal attacks and "soul loss" among Cambodians. Ataque de nervios may involve

trembling, uncontrollable screaming or crying, aggressive or suicidal behavior, and depersonalization or derealization, which may be experienced longer than the few minutes typical

of panic attacks. Some clinical presentations of ataque de nervios fulfill criteria for conditions other than panic attack (e.g., other specified dissociative disorder). These syndromes

impact the symptoms and frequency of panic disorder, including the individual's attribution of unexpectedness, as cultural syndromes may create fear of certain situations, ranging from interpersonal arguments (associated with ataque de nervios), to types of exertion

(associated with khyâl attacks), to atmospheric wind (associated with trùng gio attacks).

Clarification of the details of cultural attributions may aid in distinguishing expected and

unexpected panic attacks. For more information regarding cultural syndromes, refer to the

"Glossary of Cultural Concepts of Distress" in the Appendix.

The specific worries about panic attacks or their consequences are likely to vary from

one culture to another (and across different age groups and gender). For panic disorder,

U.S. community samples of non-Latino whites have significantly less functional impairment than African Americans. There are also higher rates of objectively defined severity in

non-Latino Caribbean blacks with panic disorder, and lower rates of panic disorder overall in both African American and Afro-Caribbean groups, suggesting that among individuals of African descent, the criteria for panic disorder may be met only when there is

substantial severity and impairment.

Gender-Related Diagnostic Issues

The clinical features of panic disorder do not appear to differ between males and females.

There is some evidence for sexual dimorphism, with an association between panic disorder and the catechol-O-methyltransferase (COMT) gene in females only.

Diagnostic IVIarkers

Agents with disparate mechanisms of action, such as sodium lactate, caffeine, isoproterenol, yohimbine, carbon dioxide, and cholecystokinin, provoke panic attacks in individuals

with panic disorder to a much greater extent than in healthy control subjects (and in some

cases, than in individuals with other anxiety, depressive, or bipolar disorders without

panic attacks). Also, for a proportion of individuals with panic disorder, panic attacks are

related to hypersensitive medullary carbon dioxide detectors, resulting in hypocapnia and

other respiratory irregularities. However, none of these laboratory findings are considered diagnostic of panic disorder.

Suicide Risk

Panic attacks and a diagnosis of panic disorder in the past 12 months are related to a higher

rate of suicide attempts and suicidal ideation in the past 12 months even when comorbidity and a history of childhood abuse and other suicide risk factors are taken into account.

Functional Consequences of Panic Disorder

Panic disorder is associated with high levels of social, occupational, and physical disability; considerable economic costs; and the highest number of medical visits among the anxiety disorders, although the effects are strongest with the presence of agoraphobia.

Individuals with panic disorder may be frequently absent from work or school for doctor

and emergency room visits, which can lead to unemployment or dropping out of school.

In older adults, impairment may be seen in caregiving duties or volunteer activities. Fullsymptom panic attacks typically are associated with greater morbidity (e.g., greater health

care utilization, more disability, poorer quality of life) than limited-symptom attacks.

Differential Diagnosis

other specified anxiety disorder or unspecified anxiety disorder. Panic disorder should

not be diagnosed if full-symptom (unexpected) panic attacks have never been experienced. In

the case of only limited-symptom unexpected panic attacks, an other specified anxiety disorder or unspecified anxiety disorder diagnosis should be considered.

Anxiety disorder due to another medical condition. Panic disorder is not diagnosed if

the panic attacks are judged to be a direct physiological consequence of another medical

condition. Examples of medical conditions that can cause panic attacks include hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure disorders, and cardiopulmonary conditions (e.g., arrhythmias, supraventricular tachycardia,

asthma, chronic obstructive pulmonary disease [COPD]). Appropriate laboratory tests

(e.g., serum calcium levels for hyperparathyroidism; Holter monitor for arrhythmias) or

physical examinations (e.g., for cardiac conditions) may be helpful in determining the etiological role of another medical condition.

Substance/medication-induced anxiety disorder. Panic disorder is not diagnosed if

the panic attacks are judged to be a direct physiological consequence of a substance. Intoxication with central nervous system stimulants (e.g., cocaine, amphetamines, caffeine)

or cannabis and withdrawal from central nervous system depressants (e.g., alcohol, barbiturates) can precipitate a panic attack. However, if panic attacks continue to occur outside of the context of substance use (e.g., long after the effects of intoxication or withdrawal

have ended), a diagnosis of panic disorder should be considered. In addition, because

panic disorder may precede substance use in some individuals and may be associated

with increased substance use, especially for purposes of self-medication, a detailed history

should be taken to determine if the individual had panic attacks prior to excessive substance use. If this is the case, a diagnosis of panic disorder should be considered in addition

to a diagnosis of substance use disorder. Features such as onset after age 45 years or the

presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness,

loss of bladder or bowel control, slurred speech, armiesia) suggest the possibility that another medical condition or a substance may be causing the panic attack symptoms.

Other mental disorders with panic attacks as an associated feature (e.g., other anxiety

disorders and psychotic disorders). Panic attacks that occur as a symptom of other anxiety disorders are expected (e.g., triggered by social situations in social anxiety disorder, by

phobic objects or situations in specific phobia or agoraphobia, by worry in generalized anxiety disorder, by separation from home or attachment figures in separation anxiety disorder)

and thus would not meet criteria for panic disorder. (Note: Sometimes an unexpected panic

attack is associated with the onset of another anxiety disorder, but then the attacks become

expected, whereas panic disorder is characterized by recurrent unexpected panic attacks.) If

the panic attacks occur only in response to specific triggers, then only the relevant anxiety

disorder is assigned. However, if the individual experiences unexpected panic attacks as

well and shows persistent concern and worry or behavioral change because of the attacks,

then an additional diagnosis of panic disorder should be considered.

Comorbidity

Panic disorder infrequently occurs in clinical settings in the absence of other psychopathology. The prevalence of panic disorder is elevated in individuals with other disorders,

particularly other anxiety disorders (and especially agoraphobia), major depression, bipolar disorder, and possibly mild alcohol use disorder. While panic disorder often has an earlier age at onset than the comorbid disorder(s), onset sometimes occurs after the comorbid

disorder and may be seen as a severity marker of the comorbid illness.

Reported lifetime rates of comorbidity between major depressive disorder and panic

disorder vary widely, ranging from 10% to 65% in individuals with panic disorder. In approximately one-third of individuals with both disorders, the depression precedes the onset of panic disorder. In the remaining two-thirds, depression occurs coincident with or

following the onset of panic disorder. A subset of individuals with panic disorder develop

a substance-related disorder, which for some represents an attempt to treat their anxiety

with alcohol or medications. Comorbidity with other anxiety disorders and illness anxiety

disorder is also common.

Panic disorder is significantly comorbid with numerous general medical symptoms

and conditions, including, but not limited to, dizziness, cardiac arrhythmias, hyperthyroidism, asthma, COPD, and irritable bowel syndrome. However, the nature of the association (e.g., cause and effect) between panic disorder and these conditions remains

unclear. Although mitral valve prolapse and thyroid disease are more common among individuals with panic disorder than in the general population, the differences in prevalence

are not consistent.

Panic Attack Specifier

Note: Symptoms are presented for the purpose of identifying a panic attacl<; however,

panic attack is not a mental disorder and cannot be coded. Panic attacl<s can occur in the

context of any anxiety disorder as well as other mental disorders (e.g., depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic

attack is identified, it should be noted as a specifier (e.g., “posttraumatic stress disorder

with panic attacks”). For panic disorder, the presence of panic attack is contained within

the criteria for the disorder and panic attack is not used as a specifier.

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes,

and during which time four (or more) of the following symptoms occur:

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

1. Palpitations, pounding heart, or accelerated heart rate.

2. Sweating.

3. Trembling or shaking.

4. Sensations of shortness of breath or smothering.

5. Feelings of choking.

6. Chest pain or discomfort.

7. Nausea or abdominal distress.

8. Feeling dizzy, unsteady, light-headed, or faint.

9. Chilis or heat sensations.

10. Paresthesias (numbness or tingling sensations).

11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).

12. Fear of losing control or “going crazy.”

13. Fear of dying.

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable

screaming or crying) may be seen. Such symptoms should not count as one of the four

required symptoms.

Features

The essential feature of a panic attack is an abrupt surge of intense fear or intense discomfort

that reaches a peak within minutes and during which time four or more of 13 physical and cognitive symptoms occur. Eleven of these 13 symptoms are physical (e.g., palpitations, sweating), while two are cognitive (i.e., fear of losing control or going crazy, fear of dying). 'Tear of

going crazy" is a colloquialism often used by individuals with panic attacks and is not intended as a pejorative or diagnostic term. The term within minutes means that the time to peak

intensity is literally only a few minutes. A panic attack can arise from either a calm state or an

anxious state, and time to peak intensity should be assessed independently of any preceding

anxiety. That is, the start of the panic attack is the point at which there is an abrupt increase in

discomfort rather than the point at which armety first developed. Likewise, a panic attack can

return to either an anxious state or a calm state and possibly peak again. A panic attack is distinguished from ongoing anxiety by its time to peak intensity, which occurs within minutes; its

discrete nature; and its typically greater severity. Attacks that meet all other criteria but have

fewer than four physical and/or cognitive symptoms are referred to as limited-symptom attacks.

There are two characteristic types of panic attacks: expected and unexpected. Expected

panic attacks are attacks for which there is an obvious cue or trigger, such as situations in

which panic attacks have typically occurred. Unexpected panic attacks are those for which

there is no obvious cue or trigger at the time of occurrence (e.g., when relaxing or out of

sleep [nocturnal panic attack]). The determination of whether panic attacks are expected

or unexpected is made by the clinician, who makes this judgment based on a combination

of careful questioning as to the sequence of events preceding or leading up to the attack

and the individual's own judgment of whether or not the attack seemed to occur for no apparent reason. Cultural interpretations may influence their determination as expected or

unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen; however, such symptoms should not count as

one of the four required symptoms. Panic attacks can occur in the context of any mental

disorder (e.g., anxiety disorders, depressive disorders, bipolar disorders, eating disorders,

obsessive-compulsive and related disorders, personality disorders, psychotic disorders,

substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal), with the majority never meeting criteria for panic disorder. Recurrent unexpected panic attacks are required for a diagnosis of panic disorder.

Associated Features

One type of unexpected panic attack is a nocturnal panic attack (i.e., waking from sleep in a

state of panic), which differs from panicking after fully waking from sleep. Panic attacks

are related to a higher rate of suicide attempts and suicidal ideation even when comorbidity and other suicide risk factors are taken into account.

Prevalence

In the general population, 12-month prevalence estimates for panic attacks in the United

States is 11.2% in adults. Twelve-month prevalence estimates do not appear to differ significantly among African Americans, Asian Americans, and Latinos. Lower 12-month

prevalence estimates for European countries appear to range from 2.7% to 3.3%. Females

are more frequently affected than males, although this gender difference is more pronounced for panic disorder. Panic attacks can occur in children but are relatively rare until

the age of puberty, when the prevalence rates increase. The prevalence rates decline in

older individuals, possibly reflecting diminishing severity to subclinical levels.

Development and Course

The mean age at onset for panic attacks in the United States is approximately 22-23 years

among adults. However, the course of panic attacks is likely influenced by the course of

any co-occurring mental disorder(s) and stressful life events. Panic attacks are uncommon,

and unexpected panic attacks are rare, in preadolescent children. Adolescents might be

less willing than adults to openly discuss panic attacks, even though they present with episodes of intense fear or discomfort. Lower prevalence of panic attacks in older individuals

may be related to a weaker autonomic response to emotional states relative to younger individuals. Older individuals may be less inclined to use the word "fear" and more inclined

to use the word "discomfort" to describe panic attacks. Older individuals with "panicky

feelings" may have a hybrid of limited-symptom attacks and generalized anxiety. In

addition, older individuals tend to attribute panic attacks to certain situations that are

stressful (e.g., medical procedures, social settings) and may retrospectively endorse explanations for the panic attack even if it was unexpected in the moment. This may result in under-endorsement of unexpected panic attacks in older individuals.

Risk and Prognostic Factors

Temperamental. Negative affectivity (neuroticism) (i.e., proneness to experiencing negative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of

anxiety are harmful) are risk factors for the onset of panic attacks. History of "fearful

spells" (i.e., limited-symptom attacks that do not meet full criteria for a panic attack) may

be a risk factor for later panic attacks.

Environmental. Smoking is a risk factor for panic attacks. Most individuals report identifiable stressors in the months before their first panic attack (e.g., interpersonal stressors

and stressors related to physical well-being, such as negative experiences with illicit or

prescription drugs, disease, or death in the family).

Culture-Related Diagnostic issues

Cultural interpretations may influence the determination of panic attacks as expected or

unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) may be seen; however, such symptoms should not count

as one of the four required symptoms. Frequency of each of the 13 symptoms varies crossculturally (e.g., higher rates of paresthesias in African Americans and of dizziness in several Asian groups). Cultural syndromes also influence the cross-cultural presentation of

panic attacks, resulting in different symptom profiles across different cultural groups. Examples include khyal (wind) attacks, a Cambodian cultural syndrome involving dizziness,

tinnitus, and neck soreness; and trùnggiô (wind-related) attacks, a Vietnamese cultural

syndrome associated with headaches. Ataque de nervios (attack of nerves) is a cultural syndrome among Latin Americans that may involve trembling, uncontrollable screaming or

crying, aggressive or suicidal behavior, and depersonalization or derealization, and which

may be experienced for longer than only a few minutes. Some clinical presentations of

ataque de nervios fulfill criteria for conditions other than panic attack (e.g., other specified

dissociative disorder). Also, cultural expectations may influence the classification of panic

attacks as expected or unexpected, as cultural syndromes may create fear of certain situations, ranging from interpersonal arguments (associated with ataque de nervios), to types of

exertion (associated with khyâl attacks), to atmospheric wind (associated with trùnggiô attacks). Clarification of the details of cultural attributions may aid in distinguishing expected and unexpected panic attacks. For more information about cultural syndromes, see

"Glossary of Cultural Concepts of Distress" in the Appendix to this manual.

Gender-Related Diagnostic Issues

Panic attacks are more common in females than in males, but clinical features or symptoms of panic attacks do not differ between males and females.

Diagnostic Markers

Physiological recordings of naturally occurring panic attacks in individuals with panic

disorder indicate abrupt surges of arousal, usually of heart rate, that reach a peak within

minutes and subside within minutes, and for a proportion of these individuals the panic

attack may be preceded by cardiorespiratory instabilities.

Functional Consequences of Panic Attaclcs

In the context of^co-occurring mental disorders, including anxiety disorders, depressive

disorders, bipolar disorder, substance use disorders, psychotic disorders, and personality

disorders, panic attacks are associated with increased symptom severity, higher rates of

comorbidity and suicidality, and poorer treatment response. Also, full-symptom panic attacks typically are associated with greater morbidity (e.g., greater health care utilization,

more disability, poorer quality of life) than limited-symptom attacks.

Differential Diagnosis

Other paroxysmal episodes (e.g., “anger attacks”). Panic attacks should not be diagnosed if the episodes do not involve the essential feature of an abrupt surge of intense fear

or intense discomfort, but rather other emotional states (e.g., anger, grief).

Anxiety disorder due to another medical condition. Medical conditions that can cause

or be misdiagnosed as panic attacks include hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure disorders, and cardiopulmonary conditions (e.g., arrhythmias, supraventricular tachycardia, asthma, chronic obstructive

pulmonary disease). Appropriate laboratory tests (e.g., serum calcium levels for hyperparathyroidism; Holter monitor for arrhythmias) or physical examinations (e.g., for cardiac conditions) may be helpful in determining the etiological role of another medical condition.

Substance/medication-induced anxiety disorder. Intoxication with central nervous

system stimulants (e.g., cocaine, amphetamines, caffeine) or cannabis and withdrawal

from central nervous system depressants (e.g., alcohol, barbiturates) can precipitate a

panic attack. A detailed history should be taken to determine if the individual had panic

attacks prior to excessive substance use. Features such as onset after age 45 years or the

presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness,

loss of bladder or bowel control, slurred speech, or amnesia) suggest the possibility that a

medical condition or a substance may be causing the panic attack symptoms.

Panic disorder. Repeated unexpected panic attacks are required but are not sufficient for

the diagnosis of panic disorder (i.e., full diagnostic criteria for panic disorder must be met).

Comorbidity

Panic attacks are associated with increased likelihood of various comorbid mental disorders, including anxiety disorders, depressive disorders, bipolar disorders, impulsecontrol disorders, and substance use disorders. Panic attacks are associated with increased

likelihood of later developing anxiety disorders, depressive disorders, bipolar disorders,

and possibly other disorders.

Agoraphobia

Diagnostic Criteria 300.22 (F40.00)

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

1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).

2. Being in open spaces (e.g., parking lots, marketplaces, bridges).

3. Being in enclosed places (e.g., shops, theaters, cinemas).

4. Standing in line or being in a crowd.

5. Being outside of the home alone.

B. The individual fears or avoids these situations because of thoughts that escape might

be difficult or help might not be available in the event of developing panic-like symp­

toms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).

C. The agoraphobic situations almost always provoke fear or anxiety.

D. The agoraphobic situations are actively avoided, require the presence of a companion,

or are endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic

situations and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease)

is present, the fear, anxiety, or avoidance is clearly excessive.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational

type; do not involve only social situations (as in social anxiety disorder): and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects

or flaws in physical appearance (as in body dysmoφhic disorder), reminders of traumatic

events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).

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

should be assigned.

Diagnostic Features

The essential feature of agoraphobia is marked, or intense, fear or anxiety triggered by the

real or anticipated exposure to a wide range of situations (Criterion A). The diagnosis requires endorsement of symptoms occurring in at least two of the following five situations:

1) using public transporation, such as automobiles, buses, trains, ships, or planes; 2) being

in open spaces, such as parking lots, marketplaces, or bridges; 3) being in enclosed spaces,

such as shops, theaters, or cinemas; 4) standing in line or being in a crowd; or 5) being outside of the home alone. The examples for each situation are not exhaustive; other situations

may be feared. When experiencing fear and anxiety cued by such situations, individuals

typically experience thoughts that something terrible might happen (Criterion B). Individuals frequently believe that escape from such situations might be difficult (e.g., "can't get

out of here") or that help might be unavailable (e.g., "there is nobody to help me") when

panic-like symptoms or other incapacitating or embarrassing symptoms occur. "Panic-like

symptoms" refer to any of the 13 symptoms included in the criteria for panic attack, such as

dizziness, faintness, and fear of dying. "Other incapacitating or embarrassing symptoms"

include symptoms such as vomiting and inflammatory bowel symptoms, as well as, in

older adults, a fear of falling or, in children, a sense of disorientation and getting lost.

The amount of fear experienced may vary with proximity to the feared situation and

may occur in anticipation of or in the actual presence of the agoraphobic situation. Also,

the fear or anxiety may take the form of a full- or limited-symptom panic attack (i.e., an expected panic attack). Fear or anxiety is evoked nearly every time the individual comes into

contact with the feared situation (Criterion C). Thus, an individual who becomes anxious

only occasionally in an agoraphobic situation (e.g., becomes anxious when standing in line

on only one out of every five occasions) would not be diagnosed with agoraphobia. The individual actively avoids the situation or, if he or she either is unable or decides not to avoid

it, the situation evokes intense fear or anxiety (Criterion D). Active avoidance means the individual is currently behaving in ways that are intentionally designed to prevent or minimize contact with agoraphobic situations. Avoidance can be behavioral (e.g., changing

daily routines, choosing a job nearby to avoid using public transportation, arranging for

food delivery to avoid entering shops and supermarkets) as well as cognitive (e.g., using

distraction to get through agoraphobic situations) in nature. The avoidance can become so

severe that the person is completely homebound. Often, an individual is better able to confront a feared situation when accompanied by a companion, such as a partner, friend, or

health professional.

The fear, anxiety, or avoidance must be out of proportion to the actual danger posed by

the agoraphobic situations and to the sociocultural context (Criterion E). Differentiating

clinically significant agoraphobic fears from reasonable fears (e.g., leaving the house during a bad storm) or from situations that are deemed dangerous (e.g., walking in a parking

lot or using public transportation in a high-crime area) is important for a number of reasons.

First, what constitutes avoidance may be difficult to judge across cultures and sociocultural

contexts (e.g., it is socioculturally appropriate for orthodox Muslim women in certain parts

of the world to avoid leaving the house alone, and thus such avoidance would not be considered indicative of agoraphobia). Second, older adults are likely to overattribute their

fears to age-related constraints and are less likely to judge their fears as being out of proportion to the actual risk. Third, individuals with agoraphobia are likely to overestimate

danger in relation to panic-like or other bodily symptoms. Agoraphobia should be diagnosed only if the fear, anxiety, or avoidance persists (Criterion F) and if it causes clinically

significant distress or impairment in social, occupational, or other important areas of functioning (Criterion G). The duration of "typically lasting for 6 months or more" is meant to

exclude individuals with short-lived, transient problems. However, the duration criterion

should be used as a general guide, with allowance for some degree of flexibility.

Associated Features Supporting Diagnosis

In its most severe forms, agoraphobia can cause individuals to become completely homebound, unable to leave their home and dependent on others for services or assistance to provide even for basic needs. Demoralization and depressive symptoms, as well as abuse of

alcohol and sedative medication as inappropriate self-medication strategies, are common.

Prevaience

Every year approximately 1.7% of adolescents and adults have a diagnosis of agoraphobia.

Females are twice as likely as males to experience agoraphobia. Agoraphobia may occur in

childhood, but incidence peaks in late adolescence and early adulthood. Twelve-month

prevalence in individuals older than 65 years is 0.4%. Prevalence rates do not appear to

vary systematically across cultural/racial groups.

Deveiopment and Course

The percentage of individuals with agoraphobia reporting panic attacks or panic disorder

preceding the onset of agoraphobia ranges from 30% in community samples to more than

50% in clinic samples. The majority of individuals with panic disorder show signs of anxiety and agoraphobia before the onset of panic disorder.

In two-thirds of all cases of agoraphobia, initial onset is before age 35 years. There is a

substantial incidence risk in late adolescence and early adulthood, with indications for

a second high incidence risk phase after age 40 years. First onset in childhood is rare. The

overall mean age at onset for agoraphobia is 17 years, although the age at onset without

preceding panic attacks or panic disorder is 25-29 years.

The course of agoraphobia is typically persistent and chronic. Complete remission is

rare (10%), unless the agoraphobia is treated. With more severe agoraphobia, rates of full

remission decrease, whereas rates of relapse and chronicity increase. A range of other disorders, in particular other anxiety disorders, depressive disorders, substance use disorders, and personality disorders, may complicate the course of agoraphobia. The long-term

course and outcome of agoraphobia are associated with substantially elevated risk of secondary major depressive disorder, persistent depressive disorder (dysthymia), and substance use disorders.

The clinical features of agoraphobia are relatively consistent across the lifespan, although

the type of agoraphobic situations triggering fear, anxiety, or avoidance, as well as the type of

cognitions, may vary. For example, in children, being outside of the home alone is the most frequent situation feared, whereas in older adults, being in shops, standing in line, and being in

open spaces are most often feared. Also, cognitions often pertain to becoming lost (in children),

to experiencing panic-like symptoms (in adults), to falling (in older adults).

TTie low prevalence of agoraphobia in children could reflect difficulties in symptom reporting, and thus assessments in young children may require solicitation of information

from multiple sources, including parents or teachers. Adolescents, particularly males,

may be less willing than adults to openly discuss agoraphobic fears and avoidance; however, agoraphobia can occur prior to adulthood and should be assessed in children and

adolescents. In older adults, comorbid somatic symptom disorders, as well as motor disturbances (e.g., sense of falling or having medical complications), are frequently mentioned by individuals as the reason for their fear and avoidance. In these instances, care is

to be taken in evaluating whether the fear and avoidance are out of proportion to the real

danger involved.

Risk and Prognostic Factors

Temperamental. Behavioral inhibition and neurotic disposition (i.e., negative affectivity

[neuroticism] and anxiety sensitivity) are closely associated with agoraphobia but are relevant to most anxiety disorders (phobic disorders, panic disorder, generalized anxiety disorder). Anxiety sensitivity (the disposition to believe that symptoms of anxiety are

harmful) is also characteristic of individuals with agoraphobia.

Environmental. Negative events in childhood (e.g., separation, death of parent) and other

stressful events, such as being attacked or mugged, are associated with the onset of agoraphobia. Furthermore, individuals with agoraphobia describe the fannily climate and child-rearing

behavior as being characterized by reduced warmth and increased overprotection.

Genetic and physiological. Heritability for agoraphobia is 61%. Of the various phobias,

agoraphobia has the strongest and most specific association with the genetic factor that

represents proneness to phobias.

Gender-Reiated Diagnostic Issues

Females have different patterns of comorbid disorders than males. Consistent with gender

differences in the prevalence of mental disorders, males have higher rates of comorbid

substance use disorders.

Functional Consequences of Agoraphobia

Agoraphobia is associated with considerable impairment and disability in terms of role

functioning, work productivity, and disability days. Agoraphobia severity is a strong determinant of the degree of disability, irrespective of the presence of comorbid panic disorder, panic attacks, and other comorbid conditions. More than one-third of individuals

with agoraphobia are completely homebound and unable to work.

Differential Diagnosis

When diagnostic criteria for agoraphobia and another disorder are fully met, both diagnoses

should be assigned, unless the fear, anxiety, or avoidance of agoraphobia is attributable to the

other disorder. Weighting of criteria and clinical judgment may be helpful in some cases.

Specific phobia, situational type. Differentiating agoraphobia from situational specific

phobia can be challenging in some cases, because these conditions share several symptom

characteristics and criteria. Specific phobia, situational type, should be diagnosed versus agoraphobia if the fear, anxiety, or avoidance is limited to one of the agoraphobic situations.

Requiring fears from two or more of the agoraphobic situations is a robust means for differentiating agoraphobia from specific phobias, particularly the situational subtype. Additional differentiating features include the cognitive ideation. Thus, if the situation is feared for reasons

other than panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fears

of being directly harmed by the situation itself, such as fear of the plane crashing for individuals who fear flying), then a diagnosis of specific phobia may be more appropriate.

Separation anxiety disorder. Separation anxiety disorder can be best differentiated

from agoraphobia by examining cognitive ideation. In separation anxiety disorder, the

thoughts are about detachment from significant others and the home environment (i.e.,

parents or other attachment figures), whereas in agoraphobia the focus is on panic-like

symptoms or other incapacitating or embarrassing symptoms in the feared situations.

Social anxiety disorder (social phobia). Agoraphobia should be differentiated from social anxiety disorder based primarily on the situational clusters that trigger fear, anxiety,

or avoidance and the cognitive ideation. In social anxiety disorder, the focus is on fear of

being negatively evaluated.

Panic disorder. When criteria for panic disorder are met, agoraphobia should not be diagnosed if the avoidance behaviors associated with the panic attacks do not extend to avoidance of two or more agoraphobic situations.

Acute stress disorder and posttraumatic stress disorder. Acute stress disorder and

posttraumatic stress disorder (PTSD) can be differentiated from agoraphobia by examining whether the fear, anxiety, or avoidance is related only to situations that remind the

individual of a traumatic event. If the fear, anxiety, or avoidance is restricted to trauma reminders, and if the avoidance behavior does not extend to two or more agoraphobic situations, then a diagnosis of agoraphobia is not warranted.

Major depressive disorder. In major depressive disorder, the individual may avoid leaving home because of apathy, loss of energy, low self-esteem, and anhedonia. If the avoidance is unrelated to fears of panic-like or other incapacitating or embarrassing symptoms,

then agoraphobia should not be diagnosed.

Other medical conditions. Agoraphobia is not diagnosed if the avoidance of situations

is judged to be a physiological consequence of a medical condition. This determination is

based on history, laboratory findings, and a physical examination. Other relevant medical

conditions may include neurodegenerative disorders with associated motor disturbances

(e.g., Parkinson's disease, multiple sclerosis), as well as cardiovascular disorders. Individuals with certain medical conditions may avoid situations because of realistic concerns

about being incapacitated (e.g., fainting in an individual with transient ischemic attacks)

or being embarrassed (e.g., diarrhea in an individual with Crohn's disease). The diagnosis

of agoraphobia should be given only when the fear or avoidance is clearly in excess of that

usually associated with these medical conditions.

Comorbidity

The majority of individuals with agoraphobia also have other mental disorders. The most

frequent additional diagnoses are other anxiety disorders (e.g., specific phobias, panic disorder, social anxiety disorder), depressive disorders (major depressive disorder), PTSD,

and alcohol use disorder. Whereas other anxiety disorders (e.g., separation anxiety disorder, specific phobias, panic disorder) frequently precede onset of agoraphobia, depressive

disorders and substance use disorders typically occur secondary to agoraphobia.

Generalized Anxiety Disorder

Diagnostic Criteria 300.02 (F41.1)

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than

not for at least 6 months, about a number of events or activities (such as work or school

performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the

past 6 months);

Note: Only one item is required in children.

1. Restlessness or feeling keyed up or on edge.

2. Being easily fatigued.

3. Difficulty concentrating or mind going blank.

4. Irritability.

5. Muscle tension.

6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying

sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a

drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another mental disorder (e.g., anxiety or

worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder,

reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety

disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Diagnostic Features

The essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive expectation) about a number of events or activities. The intensity, duration, or

frequency of the anxiety and worry is out of proportion to the actual likelihood or impact

of the anticipated event. The individual finds it difficult to control the worry and to keep

worrisome thoughts from interfering with attention to tasks at hand. Adults with generalized anxiety disorder often worry about everyday, routine life circumstances, such as

possible job responsibilities, health and finances, the health of family members, misfortune to their children, or minor matters (e.g., doing household chores or being late for appointments). Children with generalized anxiety disorder tend to worry excessively about

their competence or the quality of their performance. During the course of the disorder,

the focus of worry may shift from one concern to another.

Several features distinguish generalized anxiety disorder from nonpathological anxiety.

First, the worries associated with generalized anxiety disorder are excessive and typically interfere significantly with psychosocial functioning, whereas the worries of everyday life

are not excessive and are perceived as more manageable and may be put off when more

pressing matters arise. Second, the worries associated with generalized anxiety disorder are

more pervasive, pronounced, and distressing; have longer duration; and frequently occur

without précipitants. The greater the range of life circumstances about which a person

worries (e.g., finances, children's safety, job performance), the more likely his or her symptoms are to meet criteria for generalized anxiety disorder. Third, everyday worries are much

less likely to be accompanied by physical symptoms (e.g., restlessness or feeling keyed up

or on edge). Individuals with generalized anxiety disorder report subjective distress due

to constant worry and related impairment in social, occupational, or other important areas

of functioning.

The anxiety and worry are accompanied by at least three of the following additional

symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty

concentrating or mind going blank, irritability, muscle tension, and disturbed sleep, although only one additional symptom is required in children.

Associated Features Supporting Diagnosis

Associated with muscle tension, there may be trembling, twitching, feeling shaky, and

muscle aches or soreness. Many individuals with generalized anxiety disorder also experience somatic symptoms (e.g., sweating, nausea, diarrhea) and an exaggerated startle response. Symptoms of autonomic hyperarousal (e.g., accelerated heart rate, shortness of

breath, dizziness) are less prominent in generalized anxiety disorder than in other anxiety

disorders, such as panic disorder. Other conditions that may be associated with stress (e.g.,

irritable bowel syndrome, headaches) frequently accompany generalized anxiety disorder.

Prevaience

The 12-month prevalence of generalized anxiety disorder is 0.9% among adolescents and

2.9% among adults in the general community of the United States. The 12-month prevalence for the disorder in other countries ranges from 0.4% to 3.6%. The lifetime morbid risk

is 9.0%. Females are twice as likely as males to experience generalized anxiety disorder. The

prevalence of the diagnosis peaks in middle age and declines across the later years of life.

Individuals of European descent tend to experience generalized anxiety disorder more

frequently than do individuals of non-European descent (i.e., Asian, African, Native

American and Pacific Islander). Furthermore, individuals from developed countries are

more likely than individuals from nondeveloped countries to report that they have experienced symptoms that meet criteria for generalized anxiety disorder in their lifetime.

Deveiopment and Course

Many individuals with generalized anxiety disorder report that they have felt anxious and

nervous all of their lives. The median age at onset for generalized anxiety disorder is 30

years; however, age at onset is spread over a very broad range. The median age at onset is

later than that for the other anxiety disorders. The symptoms of excessive worry and anxiety may occur early in life but are then manifested as an anxious temperament. Onset of

the disorder rarely occurs prior to adolescence. The symptoms of generalized anxiety disorder tend to be chronic and wax and wane across the lifespan, fluctuating between syndromal and subsyndromal forms of the disorder. Rates of full remission are very low.

The clinical expression of generalized anxiety disorder is relatively consistent across

the lifespan. The primary difference across age groups is in the content of the individual's

worry. Children and adolescents tend to worry more about school and sporting performance, whereas older adults report greater concern about the well-being of family or their

own physical heath. Thus, the content of an individual's worry tends to be age appropriate. Younger adults experience greater severity of symptoms than do older adults.

The earlier in life individuals have symptoms that meet criteria for generalized anxiety

disorder, the more comorbidity they tend to have and the more impaired they are likely to

be. The advent of chronic physical disease can be a potent issue for excessive worry in the

elderly. In the frail elderly, worries about safety—and especially about falling—may limit

activities. In those with early cognitive impairment, what appears to be excessive worry

about, for example, the whereabouts of things is probably better regarded as realistic

given the cognitive impairment.

In children and adolescents with generalized anxiety disorder, the anxieties and worries often concern the quality of their performance or competence at school or in sporting

events, even when their performance is not being evaluated by others. There may be excessive concerns about punctuality. They may also worry about catastrophic events, such

as earthquakes or nuclear war. Children with the disorder may be overly conforming, perfectionist, and unsure of themselves and tend to redo tasks because of excessive dissatisfaction with less-than-perfect performance. They are typically overzealous in seeking

reassurance and approval and require excessive reassurance about their performance and

other things they are worried about.

Generalized anxiety disorder may be overdiagnosed in children. When this diagnosis

is being considered in children, a thorough evaluation for the presence of other childhood

anxiety disorders and other mental disorders should be done to determine whether the

worries may be better explained by one of these disorders. Separation anxiety disorder, social anxiety disorder (social phobia), and obsessive-compulsive disorder are often accompanied by worries that may mimic those described in generalized anxiety disorder. For

example, a child with social anxiety disorder may be concerned about school performance

because of fear of humiliation. Worries about illness may also be better explained by separation anxiety disorder or obsessive-compulsive disorder.

Risk and Prognostic Factors

Temperamental. Behavioral inhibition, negative affectivity (neuroticism), and harm

avoidance have been associated with generalized anxiety disorder.

Environmental. Although childhood adversities and parental overprotection have been

associated with generalized anxiety disorder, no environmental factors have been identified as specific to generalized anxiety disorder or necessary or sufficient for making the diagnosis.

Genetic and physiological. One-third of the risk of experiencing generalized anxiety

disorder is genetic, and these genetic factors overlap with the risk of neuroticism and are

shared with other anxiety and mood disorders, particularly major depressive disorder.

Culture-Related Diagnostic Issues

There is considerable cultural variation in the expression of generalized anxiety disorder.

For example, in some cultures, somatic symptoms predominate in the expression of the

disorder, whereas in other cultures cognitive symptoms tend to predominate. This difference may be more evident on initial presentation than subsequently, as more symptoms

are reported over time. There is no information as to whether the propensity for excessive

worrying is related to culture, although the topic being worried about can be culture specific. It is important to consider the social and cultural context when evaluating whether

worries about certain situations are excessive.

Gender-Related Diagnostic Issues

In clinical settings, generalized anxiety disorder is diagnosed somewhat more frequently

in females than in males (about 55%-60% of those presenting with the disorder are

female). In epidemiological studies, approximately two-thirds are female. Females and

males who experience generalized anxiety disorder appear to have similar symptoms but

demonstrate different patterns of comorbidity consistent with gender differences in the

prevalence of disorders. In females, comorbidity is largely confined to the anxiety disorders and unipolar depression, whereas in males, comorbidity is more likely to extend to

the substance use disorders as well.

Functional Consequences of

Generalized Anxiety Disorder

Excessive worrying impairs the individual's capacity to do things quickly and efficiently,

whether at home or at work. The worrying takes time and energy; the associated symptoms of muscle tension and feeling keyed up or on edge, tiredness, difficulty concentrating, and disturbed sleep contribute to the impairment. Importantly the excessive worrying

may impair the ability of individuals with generalized anxiety disorder to encourage confidence in their children.

Generalized anxiety disorder is associated with significant disability and distress that is

independent of comorbid disorders, and most non-institutionalized adults with the disorder

are moderately to seriously disabled. Generalized anxiety disorder accounts for 110 million disability days per annum in the U.S. population.

Differential Diagnosis

Anxiety disorder due to another medical condition. The diagnosis of anxiety disorder

associated with another medical condition should be assigned if the individual's anxiety

and worry are judged, based on history, laboratory findings, or physical examination, to

be a physiological effect of another specific medical condition (e.g., pheochromocytoma,

hyperthyroidism).

Substance/medication-induced anxiety disorder. A substance/medication-induced

anxiety disorder is distinguished from generalized anxiety disorder by the fact that a substance or medication (e.g., a drug of abuse, exposure to a toxin) is judged to be etiologically

related to the anxiety. For example, severe anxiety that occurs only in the context of heavy

coffee consumption would be diagnosed as caffeine-induced anxiety disorder.

Social anxiety disorder. Individuals with social anxiety disorder often have anticipatory anxiety that is focused on upcoming social situations in which they must perform or

be evaluated by others, whereas individuals with generalized anxiety disorder worry,

whether or not they are being evaluated.

Obsessive-compulsive disorder. Several features distinguish the excessive worry of

generalized anxiety disorder from the obsessional thoughts of obsessive-compulsive disorder. In generalized anxiety disorder the focus of the worry is about forthcoming problems, and it is the excessiveness of the worry about future events that is abnormal. In

obsessive-compulsive disorder, the obsessions are inappropriate ideas that take the form of

intrusive and unwanted thoughts, urges, or images.

Posttraumatic stress disorder and adjustment disorders. Anxiety is invariably present in posttraumatic stress disorder. Generalized anxiety disorder is not diagnosed if the

anxiety and worry are better explained by symptoms of posttraumatic stress disorder.

Anxiety may also be present in adjustment disorder, but this residual category should be

used only when the criteria are not met for any other disorder (including generalized anxiety disorder). Moreover, in adjustment disorders, the anxiety occurs in response to an

identifiable stressor within 3 months of the onset of the stressor and does not persist for

more than 6 months after the termination of the stressor or its consequences.

Depressive, bipolar, and psychotic disorders. Generalized anxiety/worry is a common

associated feature of depressive, bipolar, and psychotic disorders and should not be di-

agnosed separately if the excessive worry has occurred only during the course of these

conditions.

Comorbidity

Individuals whose presentation meets criteria for generalized anxiety disorder are likely

to have met, or currently meet, criteria for other anxiety and unipolar depressive disorders. The neuroticism or emotional liability that underpins this pattern of comorbidity is

associated with temperamental antecedents and genetic and environmental risk factors

shared between these disorders, although independent pathways are also possible. Comorbidity with substance use, conduct, psychotic, neurodevelopmental, and neurocognitive disorders is less common.

Substance/Medication-Induced

Anxiety Disorder

Diagnostic Criteria

A. Panic attacks or anxiety is predominant in the clinical picture.

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

(1)and (2):

1. The symptoms in Criterion A developed during or soon after substance intoxication

or withdrawal or atter exposure to a medication.

2. The involved substance/medication is capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by an anxiety disorder that is not substance/

medication-induced. Such evidence of an independent anxiety disorder could include

the following:

The symptoms precede the onset of the substance/medication use; the symptoms

persist for a substantial period of time (e.g., about 1 month) atter the cessation of

acute withdrawal or severe intoxication: or there is other evidence suggesting the

existence of an independent non-substance/medication-induced anxiety disorder

(e.g., a history of recurrent non-substance/medication-related episodes).

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

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

Note: This diagnosis should be made instead of a diagnosis of substance intoxication or

substance withdrawal only when the symptoms in Criterion A predominate in the clinical

picture and they are sufficiently severe to warrant clinical attention.

Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific substance/medication]-induced anxiety disorders are indicated in the table below. Note that the ICD-10-CM

code depends on whether or not there is a comorbid substance use disorder present for

the same class of substance. If a mild substance use disorder is comorbid with the substance-induced anxiety disorder, the 4th position character is “1,” and the clinician should

record “mild [substance] use disorder” before the substance-induced anxiety disorder

(e.g., “mild cocaine use disorder with cocaine-induced anxiety disorder”). If a moderate or

severe substance use disorder is comorbid with the substance-induced anxiety disorder,

the 4th position character is “2,” and the clinician should record “moderate [substance] use

disorder or “severe [substance] use disorder,” depending on the severity of the comorbid

substance use disorder. If there is no comorbid substance use disorder (e.g., after a one­

time heavy use of the substance), then the 4th position character is “9,” and the clinician

should record only the substance-induced anxiety disorder.

_______________ s -. , - ,

ICD-10-CM

ICD-9-CM

With use

disorder,

mild

With use

disorder,

moderate

or severe

Without

use

disorder

Alcohol 291.89 F10.180 FI 0.280 FI 0.980

Caffeine 292.89 F15.180 FI 5.280 FI 5.980

Cannabis 292.89 F12.180 FI 2.280 FI 2.980

Phencyclidine 292.89 F16.180 FI 6.280 FI 6.980

Other hallucinogen 292.89 F16.180 F16.280 F16.980

Inhalant 292.89 FI 8.180 FI 8.280 F18.980

Opioid 292.89 F11.188 F11.288 F11.988

Sedative, hypnotic, or anxiolytic 292.89 FI 3.180 FI 3.280 FI 3.980

Amphetamine (or other

stimulant)

292.89 FI 5.180 FI 5.280 FI 5.980

Cocaine 292.89 FI 4.180 FI 4.280 FI 4.980

Other (or unl<nown) substance 292.89 FI 9.180 FI 9.280 FI 9.980

Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for diagnoses associated with substance class):

With onset during intoxication: This specifier applies if criteria are met for intoxication with the substance and the symptoms develop during intoxication.

Witli onset during withdrawai: This specifier applies if criteria are met for withdrawal

from the substance and the symptoms develop during, or shortly after, withdrawal.

Witli onset after medication use: Symptoms may appear either at initiation of medication or after a modification or change in use.

Recording Procedures

ICD-9-CM. The name of the substance/medication-induced anxiety disorder begins

with the specific substance (e.g., cocaine, salbutamol) that is presumed to be causing the

anxiety symptoms. The diagnostic code is selected from the table included in the criteria

set, which is based on the drug class. For substances that do not fit into any of the classes

(e.g., salbutamol), the code for "other substance" should be used; and in cases in which

a substance is judged to be an etiological factor but the specific class of substance is unknown, the category "unknown substance" should be used.

The name of the disorder is followed by the specification of onset (i.e., onset during intoxication, onset during withdrawal, with onset during medication use). Unlike the recording procedures for ICD-IO-CM, which combine the substance-induced disorder and

substance use disorder into a single code, for ICD-9-CM a separate diagnostic code is given

for the substance use disorder. For example, in the case of anxiety symptoms occurring during withdrawal in a man with a severe lorazepam use disorder, the diagnosis is 292.89 lorazepam-induced anxiety disorder, with onset during withdrawal. An additional diagnosis of

304.10 severe lorazepam use disorder is also given. When more than one substance is judged

to play a significant role in the development of anxiety symptoms, each should be listed sep-

arately (e.g., 292.89 methylphenidate-induced anxiety disorder, with onset during intoxication; 292.89 salbutamol-induced anxiety disorder, with onset after medication use).

ICD-10-CM. The name of the substance/medication-induced anxiety disorder begins

with the specific substance (e.g., cocaine, salbutamol) that is presumed to be causing the

anxiety symptoms. The diagnostic code is selected from the table included in the criteria

set, which is based on the drug class and presence or absence of a comorbid substance use

disorder. For substances that do not fit into any of the classes (e.g., salbutamol), the code

for "other substance" should be used; and in cases in which a substance is judged to be an

etiological factor but the specific class of substance is unknown, the category "unknown

substance" should be used.

When recording the name of the disorder, the comorbid substance use disorder (if any)

is listed first, followed by the word "with," followed by the name of the substance-induced

anxiety disorder, followed by the specification of onset (i.e., onset during intoxication,

onset during withdrawal, with onset during medication use). For example, in the case of

anxiety symptoms occurring during withdrawal in a man with a severe lorazepam use disorder, the diagnosis is F13.280 severe lorazepam use disorder with lorazepam-induced

anxiety disorder, with onset during withdrawal. A separate diagnosis of the comorbid severe lorazepam use disorder is not given. If the substance-induced anxiety disorder occurs

without a comorbid substance use disorder (e.g., after a one-time heavy use of the substance),

no accompanying substance use disorder is noted (e.g., F16.980 psilocybin-induced anxiety disorder, with onset during intoxication). When more than one substance is judged to

play a significant role in the development of anxiety symptoms, each should be listed separately (e.g., F15.280 severe methylphenidate use disorder with methylphenidate-induced

anxiety disorder, with onset during intoxication; F19.980 salbutamol-induced anxiety disorder, with onset after medication use).

Diagnostic Features

The essential features of substance/medication-induced anxiety disorder are prominent

symptoms of panic or anxiety (Criterion A) that are judged to be due to the effects of a substance (e.g., a drug of abuse, a medication, or a toxin exposure). The panic or anxiety symptoms must have developed during or soon after substance intoxication or withdrawal or

after exposure to a medication, and the substances or medications must be capable of producing the symptoms (Criterion B2). Substance/medication-induced anxiety disorder

due to a prescribed treatment for a mental disorder or another medical condition must

have its onset while the individual is receiving the medication (or during withdrawal, if a

withdrawal is associated with the medication). Once the treatment is discontinued, the

panic or anxiety symptoms will usually improve or remit within days to several weeks to

a month (depending on the half-life of the substance/medication and the presence of withdrawal). The diagnosis of substance/medication-induced anxiety disorder should not be

given if the onset of the panic or anxiety symptoms precedes the substance/medication intoxication or withdrawal, or if the symptoms persist for a substantial period of time (i.e.,

usually longer than 1 month) from the time of severe intoxication or withdrawal. If the

panic or anxiety symptoms persist for substantial periods of time, other causes for the

symptoms should be considered.

The substance/medication-induced anxiety disorder diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the

symptoms in Criterion A are predominant in the clinical picture and are sufficiently severe

to warrant independent clinical attention.

Associated Features Supporting Diagnosis

Panic or anxiety can occur in association with intoxication with the following classes of substances: alcohol, caffeine, cannabis, phencyclidine, other hallucinogens, inhalants, stimu­

lants (including cocaine), and other (or unknown) substances. Panic or anxiety can occur in

association with withdrawal from the following classes of substances: alcohol; opioids; sedatives, hypnotics, and anxiolytics; stimulants (including cocaine); and other (or unknown)

substances. Some medications that evoke anxiety symptoms include anesthetics and analgesics, sympathomimetics or other bronchodilators, anticholinergics, insulin, thyroid preparations, oral contraceptives, antihistamines, antiparkinsonian medications, corticosteroids,

antihypertensive and cardiovascular medications, anticonvulsants, lithium carbonate, antipsychotic medications, and antidepressant medications. Heavy metals and toxins (e.g.,

organophosphate insecticide, nerve gases, carbon monoxide, carbon dioxide, volatile substances such as gasoline and paint) may also cause panic or anxiety symptoms.

Prevalence

The prevalence of substance/medication-induced anxiety disorder is not clear. General

population data suggest that it may be rare, with a 12-month prevalence of approximately

0.002%. However, in clinical populations, the prevalence is likely to be higher.

Diagnostic iViarlcers

Laboratory assessments (e.g., urine toxicology) may be useful to measure substance intoxication as part of an assessment for substance/medication-induced anxiety disorder.

Differential Diagnosis

Substance intoxication and substance withdrawal. Anxiety symptoms commonly occur in substance intoxication and substance withdrawal. The diagnosis of the substancespecific intoxication or substance-specific withdrawal will usually suffice to categorize the

symptom presentation. A diagnosis of substance/medication-induced anxiety disorder

should be made in addition to substance intoxication or substance withdrawal when the

panic or anxiety symptoms are predominant in the clinical picture and are sufficiently severe to warrant independent clinical attention. For example, panic or anxiety symptoms

are characteristic of alcohol withdrawal.

Anxiety disorder (i.e., not induced by a substance/medication). Substance/medicationinduced anxiety disorder is judged to be etiologically related to the substance/medication.

Substance/medication-induced anxiety disorder is distinguished from a primary anxiety

disorder based on the onset, course, and other factors with respect to substances/medications. For drugs of abuse, there must be evidence from the history, physical examination, or

laboratory findings for use, intoxication, or withdrawal. Substance/medication-induced

anxiety disorders arise only in association with intoxication or withdrawal states, whereas

primary anxiety disorders may precede the onset of substance/medication use. The presence of features that are atypical of a primary anxiety disorder, such as atypical age at onset

(e.g., onset of panic disorder after age 45 years) or symptoms (e.g., atypical panic attack

symptoms such as true vertigo, loss of balance, loss of consciousness, loss of bladder control, headaches, slurred speech) may suggest a substance/medication-induced etiology. A

primary anxiety disorder diagnosis is warranted if the panic or anxiety symptoms persist

for a substantial period of time (about 1 month or longer) after the end of the substance intoxication or acute withdrawal or there is a history of an anxiety disorder.

Delirium. If panic or anxiety symptoms occur exclusively during the course of delirium,

they are considered to be an associated feature of the delirium and are not diagnosed separately.

Anxiety disorder due to another medical condition. If the panic or anxiety symptoms

are attributed to the physiological consequences of another medical condition (i.e., rather

than to the medication taken for the medical condition), anxiety disorder due to another

medical condition should be diagnosed. The history often provides the basis for such a

judgment. At times, a change in the treatment for the other medical condition (e.g., medication substitution or discontinuation) may be needed to determine whether the medication is the causative agent (in which case the symptoms may be better explained by

substance/medication-induced anxiety disorder). If the disturbance is attributable to both

another medical condition and substance use, both diagnoses (i.e., anxiety disorder due to

another medical condition and substance/medication-induced anxiety disorder) may be

given. When there is insufficient evidence to determine whether the panic or anxiety symptoms are attributable to a substance/medication or to another medical condition or are primary (i.e., not attributable to either a substance or another medical condition), a diagnosis

of other specified or unspecified anxiety disorder would be indicated.

Anxiety Disorder Due to

Another Medical Condition

Diagnostic Criteria 293.84 (F06.4)

A. Panic attacks or anxiety is predominant in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.

C. The disturbance is not better explained by another mental disorder.

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

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

Coding note: Include the name of the other medical condition within the name of the mental disorder (e.g., 293.84 [F06.4] anxiety disorder due to pheochromocytoma). The other

medical condition should be coded and listed separately immediately before the anxiety

disorder due to the medical condition (e.g., 227.0 [D35.00] pheochromocytoma; 293.84

[F06.4] anxiety disorder due to pheochromocytoma._____________________________

Diagnostic Features

The essential feature of anxiety disorder due to another medical condition is clinically significant anxiety that is judged to be best explained as a physiological effect of another medical condition. Symptoms can include prominent anxiety symptoms or panic attacks (Criterion A).

The judgment that the symptoms are best explained by the associated physical condition must

be based on evidence from the history, physical examination, or laboratory findings (Criterion

B). Additionally, it must be judged that the symptoms are not better accounted for by another

mental disorder, in particular, adjustment disorder, with anxiety, in which the stressor is the

medical condition (Criterion C). In this case, an individual with adjustment disorder is especially distressed about the meaning or the consequences of the associated medical condition.

By contrast, there is often a prominent physical component to the anxiety (e.g., shortness of

breath) when the anxiety is due to another medical condition. The diagnosis is not made if the

anxiety symptoms occur only during the course of a delirium (Criterion D). The anxiety symptoms must cause clinically significant distress or impairment in social, occupational, or other

important areas of functioning (Criterion E).

In determining whether the anxiety symptoms are attributable to another medical condition, the clinician must first establish the presence of the medical condition. Furthermore, it must be established that anxiety symptoms can be etiologically related to the

medical condition through a physiological mechanism before making a judgment that this

is the best explanation for the symptoms in a specific individual. A careful and compre­

hensive assessment of multiple factors is necessary to make this judgment. Several aspects

of the clinical presentation should be considered: 1) the presence of a clear temporal association between the onset, exacerbation, or remission of the medical condition and the anxiety symptoms; 2) the presence of features that are atypical of a primary anxiety disorder

(e.g., atypical age at onset or course); and 3) evidence in the literature that a known physiological mechanism (e.g., hyperthyroidism) causes anxiety. In addition, the disturbance

must not be better explained by a primary anxiety disorder, a substance/medicationinduced anxiety disorder, or another primary mental disorder (e.g., adjustment disorder).

Associated Features Supporting Diagnosis

A number of medical conditions are known to include anxiety as a symptomatic manifestation. Examples include endocrine disease (e.g., hyperthyroidism, pheochromocytoma,

hypoglycemia, hyperadrenocortisolism), cardiovascular disorders (e.g., congestive heart

failure, pulmonary embolism, arrhythmia such as atrial fibrillation), respiratory illness

(e.g., chronic obstructive pulmonary disease, asthma, pneumonia), metabolic disturbances (e.g., vitamin B^2 deficiency, porphyria), and neurological illness (e.g., neoplasms,

vestibular dysfunction, encephalitis, seizure disorders). Anxiety due to another medical

condition is diagnosed when the medical condition is known to induce anxiety and when

the medical condition preceded the onset of the anxiety.

Prevalence

The prevalence of anxiety disorder due to another medical condition is unclear. There appears to be an elevated prevalence of anxiety disorders among individuals with a variety

of medical conditions, including asthma, hypertension, ulcers, and arthritis. However, this

increased prevalence may be due to reasons other than the anxiety disorder directly causing the medical condition.

Development and Course

The development and course of anxiety disorder due to another medical condition generally follows the course of the underlying illness. This diagnosis is not meant to include

primary anxiety disorders that arise in the context of chronic medical illness. This is important to consider with older adults, who may experience chronic medical illness and

then develop independent anxiety disorders secondary to the chronic medical illness.

Diagnostic Markers

Laboratory assessments and/or medical examinations are necessary to confirm the diagnosis of the associated medical condition.

Differential Diagnosis

Delirium. A separate diagnosis of anxiety disorder due to another medical condition is

not given if the anxiety disturbance occurs exclusively during the course of a delirium.

However, a diagnosis of anxiety disorder due to another medical condition may be given

in addition to a diagnosis of major neurocognitive disorder (dementia) if the etiology of

anxiety is judged to be a physiological consequence of the pathological process causing the

neurocognitive disorder and if anxiety is a prominent part of the clinical presentation.

Mixed presentation of symptoms (e.g., mood and anxiety). If the presentation includes

a mix of different types of symptoms, the specific mental disorder due to another medical

condition depends on which symptoms predominate in the clinical picture.

Substance/medication-induced anxiety disorder. If there is evidence of recent or prolonged substance use (including medications with psychoactive effects), withdrawal from

a substance, or exposure to a toxin, a substance/medication-induced anxiety disorder

should be considered. Certain medications are known to increase anxiety (e.g., corticosteroids, estrogens, metoclopramide), and when this is the case, the medication may be the

most likely etiology, although it may be difficult to distinguish whether the anxiety is attributable to the medications or to the medical illness itself. When a diagnosis of substanceinduced anxiety is being made in relation to recreational or nonprescribed drugs, it may be

useful to obtain a urine or blood drug screen or other appropriate laboratory evaluation.

Symptoms that occur during or shortly after (i.e., within 4 weeks of) substance intoxication

or withdrawal or after medication use may be especially indicative of a substance/medication-induced anxiety disorder, depending on the type, duration, or amount of the substance used. If the disturbance is associated with both another medical condition and

substance use, both diagnoses (i.e., anxiety disorder due to another medical condition and

substance/medication-induced anxiety disorder) can be given. Features such as onset after age 45 years or the presence of atypical symptoms during a panic attack (e.g., vertigo,

loss of consciousness, loss of bladder or bowel control, slurred speech, amnesia) suggest

the possibility that another medical condition or a substance may be causing the panic attack symptoms.

Anxiety disorder (not due to a known medical condition). Anxiety disorder due to another medical condition should be distinguished from other anxiety disorders (especially

panic disorder and generalized anxiety disorder). In other anxiety disorders, no specific

and direct causative physiological mechanisms associated with another medical condition

can be demonstrated. Late age at onset, atypical symptoms, and the absence of a personal

or family history of anxiety disorders suggest the need for a thorough assessment to rule

out the diagnosis of anxiety disorder due to another medical condition. Anxiety disorders

can exacerbate or pose increased risk for medical conditions such as cardiovascular events

and myocardial infarction and should not be diagnosed as anxiety disorder due to another

medical condition in these cases.

Illness anxiety disorder. Anxiety disorder due to another medical condition should be

distinguished from illness anxiety disorder. Illness anxiety disorder is characterized by

worry about illness, concern about pain, and bodily preoccupations. In the case of illness

anxiety disorder, individuals may or may not have diagnosed medical conditions. Although an individual with illness anxiety disorder and a diagnosed medical condition is

likely to experience anxiety about the medical condition, the medical condition is not

physiologically related to the anxiety symptoms.

Adjustment disorders. Anxiety disorder due to another medical condition should be

distinguished from adjustment disorders, with anxiety, or with anxiety and depressed

mood. Adjustment disorder is warranted when individuals experience a maladaptive response to the stress of having another medical condition. The reaction to stress usually

concerns the meaning or consequences of the stress, as compared with the experience of

anxiety or mood symptoms that occur as a physiological consequence of the other medical

condition. In adjustment disorder, the anxiety symptoms are typically related to coping

with the stress of having a general medical condition, whereas in anxiety disorder due to

another medical condition, individuals are more likely to have prominent physical symptoms and to be focused on issues other than the stress of the illness itself.

Associated feature of another mental disorder. Anxiety symptoms may be an associated feature of another mental disorder (e.g., schizophrenia, anorexia nervosa).

Other specified or unspecified anxiety disorder. This diagnosis is given if it cannot be

determined whether the anxiety symptoms are primary, substance-induced, or associated

with another medical condition.

Other Specified Anxiety Disorder

^ 300.09 (F41.8)

This category applies to presentations in which symptoms characteristic of an anxiety disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the

disorders in the anxiety disorders diagnostic class. The other specified anxiety disorder

category is used in situations in which the clinician chooses to communicate the specific

reason that the presentation does not meet the criteria for any specific anxiety disorder.

This is done by recording “other specified anxiety disorder” followed by the specific reason

(e.g., “generalized anxiety not occurring more days than not”).

Examples of presentations that can be specified using the “other specified” designation

include the following;

1. Limited-symptom attacks.

2. Generalized anxiety not occurring more days than not.

3. Khyâl cap (wind attacks): See “Glossary of Cultural Concepts of Distress” in the Appendix.

4. Ataque de nervios (attack of nerves): See “Glossary of Cultural Concepts of Distress”

in the Appendix.

Unspecified Anxiety Disorder

300.00 (F41.9)

This category applies to presentations in which symptoms characteristic of an anxiety disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the

disorders in the anxiety disorders diagnostic class. The unspecified anxiety 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 anxiety disorder, and includes presentations in which

there is insufficient information to make a more specific diagnosis (e.g., in emergency room

settings).

Obsessive-Coinpiilsive and

Related Disorders

O bSG SSiV G -C O m p u lsiV G and related disorders include obsessive-compulsive

disorder (OCD), body dysmorphic disorder, hoarding disorder, trichotillomania (hairpulling disorder), excoriation (skin-picking) disorder, substance/medication-induced obsessive-compulsive and related disorder, obsessive-compulsive and related disorder due

to another medical condition, and other specified obsessive-compulsive and related disorder and unspecified obsessive-compulsive and related disorder (e.g., body-focused repetitive behavior disorder, obsessional jealousy).

OCD is characterized by the presence of obsessions and/or compulsions. Obsessions

are recurrent and persistent thoughts, urges, or images that are experienced as intrusive

and unwanted, whereas compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must

be applied rigidly. Some other obsessive-compulsive and related disorders are also characterized by preoccupations and by repetitive behaviors or mental acts in response to the

preoccupations. Other obsessive-compulsive and related disorders are characterized primarily by recurrent body-focused repetitive behaviors (e.g., hair pulling, skin picking) and

repeated attempts to decrease or stop the behaviors.

The inclusion of a chapter on obsessive-compulsive and related disorders in DSM-5 reflects the increasing evidence of these disorders' relatedness to one another in terms of a

range of diagnostic validators as well as the clinical utility of grouping these disorders in

the same chapter. Clinicians are encouraged to screen for these conditions in individuals

who present with one of them and be aware of overlaps between these conditions. At the

same time, there are important differences in diagnostic validators and treatment approaches across these disorders. Moreover, there are close relationships between the anxiety disorders and some of the obsessive-compulsive and related disorders (e.g., OCD),

which is reflected in the sequence of DSM-5 chapters, with obsessive-compulsive and related disorders following anxiety disorders.

The obsessive-compulsive and related disorders differ from developmentally normative preoccupations and rituals by being excessive or persisting beyond developmentally

appropriate periods. The distinction between the presence of subclinical symptoms and a

clinical disorder requires assessment of a number of factors, including the individual's

level of distress and impairment in functioning.

The chapter begins with OCD. It then covers body dysmorphic disorder and hoarding

disorder, which are characterized by cognitive symptoms such as perceived defects or

flaws in physical appearance or the perceived need to save possessions, respectively. The

chapter then covers trichotillomania (hair-pulling disorder) and excoriation (skin-picking)

disorder, which are characterized by recurrent body-focused repetitive behaviors. Finally,

it covers substance/medication-induced obsessive-compulsive and related disorder,

obsessive-compulsive and related disorder due to another medical condition, and other

specified obsessive-compulsive and related disorder and unspecified obsessive-compulsive and related disorder.

While the specific content of obsessions and compulsions varies among individuals,

certain symptom dimensions are common in OCD, including those of cleaning (contamination obsessions and cleaning compulsions); symmetry (symmetry obsessions and repeat-

ing, ordering, and counting compulsions); forbidden or taboo thoughts (e.g., aggressive,

sexual, and religious obsessions and related compulsions); and harm (e.g., fears of harm to

oneself or others and related checking compulsions). The tic-related specifier of OCD is

used v^hen an individual has a current or past history of a tic disorder.

Body dysmorphic disorder is characterized by preoccupation with one or more perceived defects or flav^s in physical appearance that are not observable or appear only slight

to others, and by repetitive behaviors (e.g., mirror checking, excessive grooming, skin

picking, or reassurance seeking) or mental acts (e.g., comparing one's appearance v^ith that

of other people) in response to the appearance concerns. The appearance preoccupations

are not better explained by concerns with body fat or weight in an individual with an eating disorder. Muscle dysmoφhia is a form of body dysmorphic disorder that is characterized by the belief that one's body build is too small or is insufficiently muscular.

Hoarding disorder is characterized by persistent difficulty discarding or parting with

possessions, regardless of their actual value, as a result of a strong perceived need to save

the items and to distress associated with discarding them. Hoarding disorder differs from

normal collecting. For example, symptoms of hoarding disorder result in the accumulation of a large number of possessions that congest and clutter active living areas to the extent that their intended use is substantially compromised. The excessive acquisition form

of hoarding disorder, which characterizes most but not all individuals with hoarding disorder, consists of excessive collecting, buying, or stealing of items that are not needed or

for which there is no available space.

Trichotillomania (hair-pulling disorder) is characterized by recurrent pulling out of

one's hair resulting in hair loss, and repeated attempts to decrease or stop hair pulling.

Excoriation (skin-picking) disorder is characterized by recurrent picking of one's skin resulting in skin lesions and repeated attempts to decrease or stop skin picking. The bodyfocused repetitive behaviors that characterize these two disorders are not triggered by obsessions or preoccupations; however, they may be preceded or accompanied by various

emotional states, such as feelings of anxiety or boredom. They may also be preceded by an

increasing sense of tension or may lead to gratification, pleasure, or a sense of relief when

the hair is pulled out or the skin is picked. Individuals with these disorders may have varying degrees of conscious awareness of the behavior while engaging in it, with some individuals displaying more focused attention on the behavior (with preceding tension and

subsequent relief) and other individuals displaying more automatic behavior (with the behaviors seeming to occur without full awareness).

Substance/medication-induced obsessive-compulsive and related disorder consists of

symptoms that are due to substance intoxication or withdrawal or to a medication. Obsessive-compulsive and related disorder due to another medical condition involves symptoms

characteristic of obsessive-compulsive and related disorders that are the direct pathophysiological consequence of a medical disorder. Other specified obsessive-compulsive and related

disorder and unspecified obsessive-compulsive and related disorder consist of symptoms

that do not meet criteria for a specific obsessive-compulsive and related disorder because of

atypical presentation or uncertain etiology; these categories are also used for other specific

syndromes that are not listed in Section Π and when insufficient information is available to diagnose the presentation as another obsessive-compulsive and related disorder. Examples of

specific syndromes not listed in Section Π, and therefore diagnosed as other specified obsessive-compulsive and related disorder or as unspecified obsessive-compulsive and related

disorder include body-focused repetitive behavior disorder and obsessional jealousy.

Obsessive-compulsive and related disorders that have a cognitive component have insight as the basis for specifiers; in each of these disorders, insight ranges from "good or fair

insight" to "poor insight" to "absent insight/delusional beliefs" with respect to disorderrelated beliefs. For individuals whose obsessive-compulsive and related disorder symptoms warrant the "with absent insight/delusional beliefs" specifier, these symptoms

should not be diagnosed as a psychotic disorder.

Obsessive-Compulsive Disorder

-------------------- i-------------------------------------------------------------------------------------------

Diagnostic Criteria 300.3 (F42)

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some

time during the disturbance, as intrusive and unwanted, and that in most individuals

cause marked anxiety or distress.

2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to

neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,

praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or

mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Note: Young children may not be able to articulate the aims of these behaviors or

mental acts.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per

day) or cause clinically significant distress or impairment in social, occupational, or

other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects

of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder

(e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder];

skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic

movement disorder; ritualized eating behavior, as in eating disorders; preoccupation

with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies,

as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or

repetitive patterns of behavior, as in autism spectrum disorder).

Specify if:

With good or fair insiglit: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.

With poor insight: The individual thinks obsessive-compulsive disorder beliefs are

probably true.

With absent insight/deiusionai beiiefs: The individual is completely convinced that

obsessive-compulsive disorder beliefs are true.

Specify if:

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

Specifiers

Many individuals with obsessive-compulsive disorder (OCD) have dysfunctional beliefs.

These beliefs can include an inflated sense of responsibility and the tendency to overestimate threat; perfectionism and intolerance of uncertainty; and over-importance of thoughts

(e.g., believing that having a forbidden thought is as bad as acting on it) and the need to

control thoughts.

Individuals with OCD vary in the degree of insight they have about the accuracy of the

beliefs that underlie their obsessive-compulsive symptoms. Many individuals have good or

fair insight (e.g., the individual believes that the house definitely will not, probably will not,

or may or may not bum down if the stove is not checked 30 times). Some have poor insight

(e.g., the individual believes that the house will probably burn down if the stove is not

checked 30 times), and a few (4% or less) have absent insight/delusional beliefs (e.g., the individual is convinced that the house will bum down if the stove is not checked 30 times).

Insight can vary within an individual over the course of the illness. Poorer insight has been

linked to worse long-term outcome.

Up to 30% of individuals with OCD have a lifetime tic disorder. This is most common

in males with onset of OCD in childhood. These individuals tend to differ from those without a history of tic disorders in the themes of their OCD symptoms, comorbidity, course,

and pattem of familial transmission.

Diagnostic Features

The characteristic symptoms of OCD are the presence of obsessions and compulsions (Criterion A). Obsessions are repetitive and persistent thoughts (e.g., of contamination), images

(e.g., of violent or horrific scenes), or urges (e.g., to stab someone). Importantly, obsessions

are not pleasurable or experienced as voluntary: they are intrusive and unwanted and

cause marked distress or anxiety in most individuals. The individual attempts to ignore or

suppress these obsessions (e.g., avoiding triggers or using thought suppression) or to neutralize them with another thought or action (e.g., performing a compulsion). Compulsions

(or rituals) are repetitive behaviors (e.g., washing, checking) or mental acts (e.g., counting,

repeating words silently) that the individual feels driven to perform in response to an

obsession or according to rules that must be applied rigidly. Most individuals with OCD

have both obsessions and compulsions. Compulsions are typically performed in response

to an obsession (e.g., thoughts of contamination leading to washing rituals or that something is incorrect leading to repeating rituals until it feels "just right")· The aim is to reduce

the distress triggered by obsessions or to prevent a feared event (e.g., becoming ill). However, these compulsions either are not connected in a realistic way to the feared event (e.g.,

arranging items symmetrically to prevent harm to a loved one) or are clearly excessive

(e.g., showering for hours each day). Compulsions are not done for pleasure, although some

individuals experience relief from anxiety or distress.

Criterion B emphasizes that obsessions and compulsions must be time-consuming (e.g.,

more than 1 hour per day) or cause clinically significant distress or impairment to warrant

a diagnosis of OCD. This criterion helps to distinguish the disorder from the occasional intmsive thoughts or repetitive behaviors that are common in the general population (e.g.,

double-checking that a door is locked). The frequency and severity of obsessions and compulsions vary across individuals with OCD (e.g., some have mild to moderate symptoms,

spending 1-3 hours per day obsessing or doing compulsions, whereas others have nearly

constant intmsive thoughts or compulsions that can be incapacitating).

Associated Features Supporting Diagnosis

The specific content of obsessions and compulsions varies between individuals. However,

certain themes, or dimensions, are common, including those of cleaning (contamination

obsessions and cleaning compulsions); symmetry (symmetry obsessions and repeating.

ordering, and counting compulsions); forbidden or taboo thoughts (e.g., aggressive, sexual,

or religious obsessions and related compulsions); and harm (e.g., fears of harm to oneself

or others and checking compulsions). Some individuals also have difficulties discarding

and accumulate (hoard) objects as a consequence of typical obsessions and compulsions,

such as fears of harming others. These themes occur across different cultures, are relatively consistent over time in adults w^ith the disorder, and may be associated v^ith different neural substrates. Importantly, individuals often have symptoms in more than one

dimension.

Individuals with OCD experience a range of affective responses when confronted with

situations that trigger obsessions and compulsions. For example, many individuals experience marked anxiety that can include recurrent panic attacks. Others report strong feelings of disgust. While performing compulsions, some individuals report a distressing

sense of "incompleteness" or uneasiness until things look, feel, or sound "just right."

It is common for individuals with the disorder to avoid people, places, and things that

trigger obsessions and compulsions. For example, individuals with contamination concerns might avoid public situations (e.g., restaurants, public restrooms) to reduce exposure to feared contaminants; individuals with intrusive thoughts about causing harm

might avoid social interactions.

Prevalence

The 12-month prevalence of OCD in the United States is 1.2%, with a similar prevalence internationally (1.1%-1.8%). Females are affected at a shghtly higher rate than males in

adulthood, although males are more commonly affected in childhood.

Development and Course

In the United States, the mean age at onset of OCD is 19.5 years, and 25% of cases start by

age 14 years. Onset after age 35 years is unusual but does occur. Males have an earlier age

at onset than females: nearly 25% of males have onset before age 10 years. The onset of

symptoms is typically gradual; however, acute onset has also been reported.

If OCD is untreated, the course is usually chronic, often with waxing and waning symptoms. Some individuals have an episodic course, and a minority have a deteriorating

course. Without treatment, remission rates in adults are low (e.g., 20% for those reevaluated 40 years later). Onset in childhood or adolescence can lead to a lifetime of OCD. However, 40% of individuals with onset of OCD in childhood or adolescence may experience

remission by early adulthood. The course of OCD is often complicated by the co-occurrence

of other disorders (see section "Comorbidity" for this disorder).

Compulsions are more easily diagnosed in children than obsessions are because compulsions are observable. However, most children have both obsessions and compulsions

(as do most adults). The pattern of symptoms in adults can be stable over time, but it is

more variable in children. Some differences in the content of obsessions and compulsions

have been reported when children and adolescent samples have been compared with

adult samples. These differences likely reflect content appropriate to different developmental stages (e.g., higher rates of sexual and religious obsessions in adolescents than in

children; higher rates of harm obsessions [e.g., fears of catastrophic events, such as death

or illness to self or loved ones] in children and adolescents than in adults).

Risk and Prognostic Factors

Temperamental. Greater internalizing symptoms, higher negative emotionality, and

behavioral inhibition in childhood are possible temperamental risk factors.

Environmental. Physical and sexual abuse in childhood and other stressful or traumatic

events have been associated with an increased risk for developing OCD. Some children

may develop the sudden onset of obsessive-compulsive symptoms, v^hich has been associated with different environmental factors, including various infectious agents and a

post-infectious autoimmune syndrome.

Genetic and physiological. The rate of OCD among first-degree relatives of adults with

OCD is approximately two times that among first-degree relatives of those without the

disorder; however, among first-degree relatives of individuals with onset of OCD in childhood or adolescence, the rate is increased 10-fold. Familial transmission is due in part to

genetic factors (e.g., a concordance rate of 0.57 for monozygotic vs. 0.22 for dizygotic twins).

Dysfunction in the orbitofrontal cortex, anterior cingulate cortex, and striatum have been

most strongly implicated.

Culture-Related Diagnostic issues

OCD occurs across the world. There is substantial similarity across cultures in the gender

distribution, age at onset, and comorbidity of OCD. Moreover, around the globe, there is a

similar symptom structure involving cleaning, symmetry, hoarding, taboo thoughts, or

fear of harm. However, regional variation in symptom expression exists, and cultural

factors may shape the content of obsessions and compulsions.

Gender-Related Diagnostic issues

Males have an earlier age at onset of OCD than females and are more likely to have comorbid tic disorders. Gender differences in the pattern of symptom dimensions have been

reported, with, for example, females more likely to have symptoms in the cleaning dimension and males more likely to have symptoms in the forbidden thoughts and symmetry dimensions. Onset or exacerbation of OCD, as well as symptoms that can interfere with the

mother-infant relationship (e.g., aggressive obsessions leading to avoidance of the infant),

have been reported in the péripartum period.

Suicide Risk

Suicidal thoughts occur at some point in as many as about half of individuals with OCD.

Suicide attempts are also reported in up to one-quarter of individuals with OCD; the presence of comorbid major depressive disorder increases the risk.

Functional Consequences of

Obsessive-Compulsive Disorder

OCD is associated with reduced quality of life as well as high levels of social and occupational impairment. Impairment occurs across many different domains of life and is associated with symptom severity. Impairment can be caused by the time spent obsessing and

doing compulsions. Avoidance of situations that can trigger obsessions or compulsions

can also severely restrict functioning. In addition, specific symptoms can create specific

obstacles. For example, obsessions about harm can make relationships with family and

friends feel hazardous; the result can be avoidance of these relationships. Obsessions

about symmetry can derail the timely completion of school or work projects because the

project never feels "just right," potentially resulting in school failure or job loss. Health

consequences can also occur. For example, individuals with contamination concerns may

avoid doctors' offices and hospitals (e.g., because of fears of exposure to germs) or develop

dermatological problems (e.g., skin lesions due to excessive washing). Sometimes the

symptoms of the disorder interfere with its own treatment (e.g., when medications are considered contaminated). When the disorder starts in childhood or adolescence, individuals

may experience developmental difficulties. For example, adolescents may avoid socializing with peers; young adults may struggle when they leave home to live independently.

The result can be few significant relationships outside the family and a lack of autonomy

and financial independence from their family of origin. In addition, some individuals with

OCD try to impose rules and prohibitions on family members because of their disorder

(e.g., no one in the family can have visitors to the house for fear of contamination), and this

can lead to family dysfunction.

Differential Diagnosis

Anxiety disorders. Recurrent thoughts, avoidant behaviors, and repetitive requests for

reassurance can also occur in anxiety disorders. However, the recurrent thoughts that are

present in generalized anxiety disorder (i.e., worries) are usually about real-life concerns,

whereas the obsessions of OCD usually do not involve real-life concerns and can include

content that is odd, irrational, or of a seemingly magical nature; moreover, compulsions

are often present and usually linked to the obsessions. Like individuals with OCD, individuals with specific phobia can have a fear reaction to specific objects or situations; however, in specific phobia the feared object is usually much more circumscribed, and rituals

are not present. In social anxiety disorder (social phobia), the feared objects or situations

are limited to social interactions, and avoidance or reassurance seeking is focused on reducing this social fear.

Major depressive disorder. OCD can be distinguished from the rumination of major

depressive disorder, in which thoughts are usually mood-congruent and not necessarily

experienced as intrusive or distressing; moreover, ruminations are not linked to compulsions, as is typical in OCD.

Other obsessive-compulsive and related disorders. In body dysmorphic disorder, the

obsessions and compulsions are limited to concerns about physical appearance; and in

trichotillomania (hair-pulling disorder), the compulsive behavior is limited to hair pulling

in the absence of obsessions. Hoarding disorder symptoms focus exclusively on the persistent difficulty discarding or parting with possessions, marked distress associated with

discarding items, and excessive accumulation of objects. However, if an individual has obsessions that are typical of OCD (e.g., concerns about incompleteness or harm), and these

obsessions lead to compulsive hoarding behaviors (e.g., acquiring all objects in a set to attain a sense of completeness or not discarding old newspapers because they may contain

information that could prevent harm), a diagnosis of OCD should be given instead.

Eating disorders. OCD can be distinguished from anorexia nervosa in that in OCD the

obsessions and compulsions are not limited to concerns about weight and food.

Tics (in tic disorder) and stereotyped movements. A tic is a sudden, rapid, recurrent,

nonrhythmic motor movement or vocalization (e.g., eye blinking, throat clearing). A stereotyped movement is a repetitive, seemingly driven, nonfunctional motor behavior (e.g.,

head banging, body rocking, self-biting). Tics and stereotyped movements are typically

less complex than compulsions and are not aimed at neutralizing obsessions. However,

distinguishing between complex tics and compulsions can be difficult. Whereas compulsions are usually preceded by obsessions, tics are often preceded by premonitory sensory

urges. Some individuals have symptoms of both OCD and a tic disorder, in which case

both diagnoses may be warranted.

Psychotic disorders. Some individuals with OCD have poor insight or even delusional

OCD beliefs. However, they have obsessions and compulsions (distinguishing their

condition from delusional disorder) and do not have other features of schizophrenia or

schizoaffective disorder (e.g., hallucinations or formal thought disorder).

Other compulsive-like behaviors. Certain behaviors are sometimes described as ''compulsive," including sexual behavior (in the case of paraphilias), gambling (i.e., gambling

disorder), and substance use (e.g., alcohol use disorder). However, these behaviors differ

from the compulsions of OCD in that the person usually derives pleasure from the activity

and may wish to resist it only because of its deleterious consequences.

Obsessive-compulsive personality disorder. Although obsessive-compulsive personality disorder and OCD have similar names, the clinical manifestations of these disorders

are quite different. Obsessive-compulsive personality disorder is not characterized by intrusive thoughts, images, or urges or by repetitive behaviors that are performed in response to these intrusions; instead, it involves an enduring and pervasive maladaptive

pattern of excessive perfectionism and rigid control. If an individual manifests symptoms

of both OCD and obsessive-compulsive personality disorder, both diagnoses can be given.

Comorbidity

Individuals with OCD often have other psychopathology. Many adults with the disorder

have a lifetime diagnosis of an anxiety disorder (76%; e.g., panic disorder, social anxiety

disorder, generalized anxiety disorder, specific phobia) or a depressive or bipolar disorder

(63% for any depressive or bipolar disorder, with the most common being major depressive disorder [41%]). Onset of OCD is usually later than for most comorbid anxiety disorders (with the exception of separation anxiety disorder) and PTSD but often precedes that

of depressive disorders. Comorbid obsessive-compulsive personality disorder is also

common in individuals with OCD (e.g., ranging from 23% to 32%).

Up to 30% of individuals with OCD also have a lifetime tic disorder. A comorbid tic

disorder is most common in males with onset of OCD in childhood. These individuals

tend to differ from those without a history of tic disorders in the themes of their OCD

symptoms, comorbidity, course, and pattern of familial transmission. A triad of OCD, tic

disorder, and attention-deficit/hyperactivity disorder can also be seen in children.

Disorders that occur more frequently in individuals with OCD than in those without

the disorder include several obsessive-compulsive and related disorders such as body

dysmorphic disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-picking) disorder. Finally, an association between OCD and some disorders characterized by

impulsivity, such as oppositional defiant disorder, has been reported.

OCD is also much more common in individuals with certain other disorders than

would be expected based on its prevalence in the general population; when one of those

other disorders is diagnosed, the individual should be assessed for OCD as well. For example, in individuals with schizophrenia or schizoaffective disorder, the prevalence of

OCD is approximately 12%. Rates of OCD are also elevated in bipolar disorder; eating disorders, such as anorexia nervosa and bulimia nervosa; and Tourette's disorder.

Body Dysmorphic Disorder

Diagnostic Criteria 300.7 (F45.22)

A. Preoccupation with one or more perceived defects or flaws in physical appearance that

are not observable or appear slight to others.

B. At some point during the course of the disorder, the individual has performed repetitive

behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.

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

D. The appearance preoccupation is not better explained by concerns with body fat or

weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Specify if:

With muscle dysmorphia: The individual is preoccupied with the idea that his or her

body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case.

Specify if:

Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., “I look ugly” or

“I lool< deformed”).

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

With poor insight: The individual thinks that the body dysmorphic disorder beliefs are

probably true.

With absent insight/delusionai beliefs: The individual is completely convinced that

the body dysmorphic disorder beliefs are true.

Diagnostic Features

Individuals with body dysmorphic disorder (formerly known as dysmorphophobia) are preoccupied with one or more perceived defects or flaws in their physical appearance, which

they believe look ugly, unattractive, abnormal, or deformed (Criterion A). The perceived

flaws are not observable or appear only slight to other individuals. Concerns range from

looking "unattractive" or "not right" to looking "hideous" or "like a monster." Preoccupations can focus on one or many body areas, most commonly the skin (e.g., perceived

acne, scars, lines, wrinkles, paleness), hair (e.g., "thinning" hair or "excessive" body or facial hair), or nose (e.g., size or shape). However, any body area can be the focus of concern

(e.g., eyes, teeth, weight, stomach, breasts, legs, face size or shape, lips, chin, eyebrows,

genitals). Some individuals are concerned about perceived asymmetry of body areas. The

preoccupations are intrusive, unwanted, time-consuming (occurring, on average, 3-8

hours per day), and usually difficult to resist or control.

Excessive repetitive behaviors or mental acts (e.g., comparing) are performed in response to the preoccupation (Criterion B). The individual feels driven to perform these behaviors, which are not pleasurable and may increase anxiety and dysphoria. They are

typically time-consuming and difficult to resist or control. Common behaviors are comparing one's appearance with that of other individuals; repeatedly checking perceived

defects in mirrors or other reflecting surfaces or examining them directly; excessively

grooming (e.g., combing, styling, shaving, plucking, or pulling hair); camouflaging (e.g.,

repeatedly applying makeup or covering disliked areas with such things as a hat, clothing,

makeup, or hair); seeking reassurance about how the perceived flaws look; touching disliked areas to check them; excessively exercising or weight lifting; and seeking cosmetic

procedures. Some individuals excessively tan (e.g., to darken "pale" skin or diminish perceived acne), repeatedly change their clothes (e.g., to camouflage perceived defects), or

compulsively shop (e.g., for beauty products). Compulsive skin picking intended to

improve perceived skin defects is common and can cause skin damage, infections, or

ruptured blood vessels. The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C);

usually both are present. Body dysmoφhic disorder must be differentiated from an eating

disorder.

Muscle dysmorphia, a form of body dysmoφhic disorder occurring almost exclusively

in males, consists of preoccupation with the idea that one's body is too small or insufficiently lean or muscular. Individuals with this form of the disorder actually have a normal-looking body or are even very muscular. They may also be preoccupied with other

body areas, such as skin or hair. A majority (but not all) diet, exercise, and/or lift weights

excessively, sometimes causing bodily damage. Some use potentially dangerous anabolic-

androgenic steroids and other substances to try to make their body bigger and more muscular. Body dysmorphic disorder by proxy is a form of body dysmorphic disorder in

which individuals are preoccupied with defects they perceive in another person's appearance.

Insight regarding body dysmorphic disorder beliefs can range from good to absent/

delusional (i.e., delusional beliefs consisting of complete conviction that the individual's

view of their appearance is accurate and undistorted). On average, insight is poor; onethird or more of individuals currently have delusional body dysmorphic disorder beliefs.

Individuals with delusional body dysmorphic disorder tend to have greater morbidity in

some areas (e.g., suicidality), but this appears accounted for by their tendency to have

more severe body dysmorphic disorder symptoms.

Associated Features Supporting Diagnosis

Many individuals with body dysmorphic disorder have ideas or delusions of reference,

believing that other people take special notice of them or mock them because of how they

look. Body dysmorphic disorder is associated with high levels of anxiety, social anxiety,

social avoidance, depressed mood, neuroticism, and perfectionism as well as low extroversion and low self-esteem. Many individuals are ashamed of their appearance and their

excessive focus on how they look, and are reluctant to reveal their concerns to others. A

majority of individuals receive cosmetic treatment to try to improve their perceived defects. Dermatological treatment and surgery are most common, but any type (e.g., dental,

electrolysis) may be received. Occasionally, individuals may perform surgery on themselves. Body dysmorphic disorder appears to respond poorly to such treatments and

sometimes becomes worse. Some individuals take legal action or are violent toward the

clinician because they are dissatisfied with the cosmetic outcome.

Body dysmorphic disorder has been associated with executive dysfunction and visual

processing abnormalities, with a bias for analyzing and encoding details rather than holistic or configurai aspects of visual stimuli. Individuals with this disorder tend to have a

bias for negative and threatening interpretations of facial expressions and ambiguous scenarios.

Prevalence

The point prevalence among U.S. adults is 2.4% (2.5% in females and 2.2% in males). Outside the United States (i.e., Germany), current prevalence is approximately 1.7%-1,8%,

with a gender distribution similar to that in the United States. The current prevalence is

9%-15% among dermatology patients, 7%-8% among U.S. cosmetic surgery patients, 3%-

16% among international cosmetic surgery patients (most studies), 8% among adult orthodontia patients, and 10% among patients presenting for oral or maxillofacial surgery.

Deveiopment and Course

The mean age at disorder onset is 16-17 years, the median age at onset is 15 years, and the

most common age at onset is 12-13 years. Two-thirds of individuals have disorder onset

before age 18. Subclinical body dysmorphic disorder symptoms begin, on average, at age

12 or 13 years. Subclinical concerns usually evolve gradually to the full disorder, although

some individuals experience abrupt onset of body dysmorphic disorder. The disorder

appears to usually be chronic, although improvement is likely when evidence-based

treatment is received. The disorder's clinical features appear largely similar in children/

adolescents and adults. Body dysmoφhic disorder occurs in the elderly, but little is known

about the disorder in this age group. Individuals with disorder onset before age 18 years

are more likely to attempt suicide, have more comorbidity, and have gradual (rather than

acute) disorder onset than those with adult-onset body dysmorphic disorder.

Risk and Prognostic Factors

Environmental. " Body dysmorphic disorder has been associated with high rates of childhood neglect and abuse.

Genetic and physiological. The prevalence of body dysmorphic disorder is elevated in

first-degree relatives of individuals with obsessive-compulsive disorder (OCD).

Culture-Reiated Diagnostic issues

Body dysmorphic disorder has been reported internationally. It appears that the disorder

may have more similarities than differences across races and cultures but that cultural

values and preferences may influence symptom content to some degree. Taijin kyofusho,

included in the traditional Japanese diagnostic system, has a subtype similar to body dysmorphic disorder: shubo-kyofu ("the phobia of a deformed body").

Gender-Reiated Diagnostic issues

Females and males appear to have more similarities than differences in terms of most clinical features— for example, disliked body areas, types of repehtive behaviors, symptom

severity, suicidality, comorbidity, illness course, and receipt of cosmetic procedures for

body dysmorphic disorder. However, males are more likely to have genital preoccupations, and females are more likely to have a comorbid eating disorder. Muscle dysmorphia

occurs almost exclusively in males.

Suicide Risic

Rates of suicidal ideation and suicide attempts are high in both adults and children/adolescents with body dysmorphic disorder. Furthermore, risk for suicide appears high in adolescents. A substantial proportion of individuals attribute suicidal ideation or suicide

attempts primarily to their appearance concerns. Individuals with body dysmorphic disorder have many risk factors for completed suicide, such as high rates of suicidal ideation

and suicide attempts, demographic characteristics associated with suicide, and high rates

of comorbid major depressive disorder.

Functionai Consequences of

Body Dysmorphic Disorder

Nearly all individuals with body dysmorphic disorder experience impaired psychosocial

functioning because of their appearance concerns. Impairment can range from moderate

(e.g., avoidance of some social situations) to extreme and incapacitating (e.g., being completely housebound). On average, psychosocial functioning and quality of life are markedly poor. More severe body dysmorphic disorder symptoms are associated with poorer

functioning and quality of life. Most individuals experience impairment in their job, academic, or role functioning (e.g., as a parent or caregiver), which is often severe (e.g., performing poorly, missing school or work, not working). About 20% of youths with body

dysmorphic disorder report dropping out of school primarily because of their body dysmorphic disorder symptoms. Impairment in social functioning (e.g., social activities, relationships, intimacy), including avoidance, is common. Individuals may be housebound

because of their body dysmorphic disorder symptoms, sometimes for years. A high proportion of adults and adolescents have been psychiatrically hospitalized.

Differential Diagnosis

Normal appearance concerns and clearly noticeable physical defects. Body dysmorphic disorder differs from normal appearance concerns in being characterized by exces­

sive appearance-related preoccupations and repetitive behaviors that are time-consuming,

are usually difficult to resist or control, and cause clinically significant distress or impairment in functioning. Physical defects that are clearly noticeable (i.e., not slight) are not

diagnosed as body dysmorphic disorder. However, skin picking as a symptom of body

dysmoφhic disorder can cause noticeable skin lesions and scarring; in such cases, body dysmorphic disorder should be diagnosed.

Eating disorders. In an individual with an eating disorder, concerns about being fat are

considered a symptom of the eating disorder rather than body dysmorphic disorder.

However, weight concerns may occur in body dysmorphic disorder. Eating disorders and

body dysmorphic disorder can be comorbid, in which case both should be diagnosed.

Other obsessive-compulsive and related disorders. The preoccupations and repetitive

behaviors of body dysmorphic disorder differ from obsessions and compulsions in OCD

in that the former focus only on appearance. These disorders have other differences, such

as poorer insight in body dysmoφhic disorder. When skin picking is intended to improve

the appearance of perceived skin defects, body dysmorphic disorder, rather than excoriation (skin-picking) disorder, is diagnosed. When hair removal (plucking, pulling, or other

types of removal) is intended to improve perceived defects in the appearance of facial

or body hair, body dysmoφhic disorder is diagnosed rather than trichotillomania (hairpulling disorder).

Illness anxiety disorder. Individuals with body dysmorphic disorder are not preoccupied with having or acquiring a serious illness and do not have particularly elevated levels

of somatization.

Major depressive disorder. The prominent preoccupation with appearance and excessive repetitive behaviors in body dysmorphic disorder differentiate it from major depressive disorder. However, major depressive disorder and depressive symptoms are

common in individuals with body dysmoφhic disorder, often appearing to be secondary

to the distress and impairment that body dysmorphic disorder causes. Body dysmoφhic

disorder should be diagnosed in depressed individuals if diagnostic criteria for body dysmoφhic disorder are met.

Anxiety disorders. Social anxiety and avoidance are common in body dysmorphic disorder. However, unlike social anxiety disorder (social phobia), agoraphobia, and avoidant

personality disorder, body dysmorphic disorder includes prominent appearance-related

preoccupation, which may be delusional, and repetitive behaviors, and the social anxiety

and avoidance are due to concerns about perceived appearance defects and the belief or

fear that other people will consider these individuals ugly, ridicule them, or reject them because of their physical features. Unlike generalized anxiety disorder, anxiety and worry in

body dysmoφhic disorder focus on perceived appearance flaws.

Psychotic disorders. Many individuals with body dysmorphic disorder have delusional appearance beliefs (i.e., complete conviction that their view of their perceived defects is accurate), which is diagnosed as body dysmoφhic disorder, with absent insight/

delusional beliefs, not as delusional disorder. Appearance-related ideas or delusions of

reference are common in body dysmorphic disorder; however, unlike schizophrenia or

schizoaffective disorder, body dysmoφhic disorder involves prominent appearance preoccupations and related repetitive behaviors, and disorganized behavior and other psychotic symptoms are absent (except for appearance beliefs, which may be delusional).

Other disorders and symptoms. Body dysmorphic disorder should not be diagnosed if

the preoccupation is limited to discomfort with or a desire to be rid of one's primary and/

or secondary sex characteristics in an individual with gender dysphoria or if the preoccupation focuses on the belief that one emits a foul or offensive body odor as in olfactory

reference syndrome (which is not a DSM-5 disorder). Body identity integrity disorder

(apotemnophilia) (which is not a DSM-5 disorder) involves a desire to have a limb amputated to correct ^n experience of mismatch between a person's sense of body identity and

his or her actual anatomy. However, the concern does not focus on the limb's appearance,

as it would in body dysmorphic disorder. Koro, a culturally related disorder that usually

occurs in epidemics in Southeastern Asia, consists of a fear that the penis (labia, nipples, or

breasts in females) is shrinking or retracting and will disappear into the abdomen, often

accompanied by a belief that death will result. Koro differs from body dysmorphic disorder in several ways, including a focus on death rather than preoccupation with perceived

ugliness. Dysmorphic concern (which is not a DSM-5 disorder) is a much broader construct

than, and is not equivalent to, body dysmorphic disorder. It involves symptoms reflecting

an overconcern with slight or imagined flaws in appearance.

Comorbidity

Major depressive disorder is the most common comorbid disorder, with onset usually after that of body dysmorphic disorder. Comorbid social anxiety disorder (social phobia),

OCD, and substance-related disorders are also common.

Hoarding Disorder

Diagnostic Criteria 300.3 (F42)

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

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

with discarding them.

C. The difficulty discarding possessions results in the accumulation of possessions that

congest and clutter active living areas and substantially compromises their intended

use. If living areas are uncluttered, it is only because of the interventions of third parties

(e.g., family members, cleaners, authorities).

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

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

F. The hoarding is not better explained by the symptoms of another mental disorder (e.g.,

obsessions in obsessive-compulsive disorder, decreased energy in major depressive

disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in

major neurocognitive disorder, restricted interests in autism spectrum disorder).

Specify if:

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

Specify if:

With good or fair insight: The individual recognizes that hoarding-related beliefs and

behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are

problematic.

With poor insight: The individual is mostly convinced that hoarding-related beliefs

and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

With absent insight/deiusionai beliefs: The individual is completely convinced that

hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter,

or excessive acquisition) are not problematic despite evidence to the contrary.

Specifiers

With excessive acquisition. Approximately 80%-90% of individuals with hoarding

disorder display excessive acquisition. The most frequent form of acquisition is excessive

buying, followed by acquisition of free items (e.g., leaflets, items discarded by others).

Stealing is less common. Some individuals may deny excessive acquisition when first assessed, yet it may appear later during the course of treatment. Individuals with hoarding

disorder typically experience distress if they are unable to or are prevented from acquiring

items.

Diagnostic Features

The essential feature of hoarding disorder is persistent difficulties discarding or parting

with possessions, regardless of their actual value (Criterion A). The term persistent indicates a long-standing difficulty rather than more transient life circumstances that may lead

to excessive clutter, such as inheriting property. The difficulty in discarding possessions

noted in Criterion A refers to any form of discarding, including throwing away, selling,

giving away, or recycling. The main reasons given for these difficulties are the perceived

utility or aesthetic value of the items or strong sentimental attachment to the possessions.

Some individuals feel responsible for the fate of their possessions and often go to great

lengths to avoid being wasteful. Fears of losing important information are also common.

The most commonly saved items are newspapers, magazines, old clothing, bags, books,

mail, and paperwork, but virtually any item can be saved. The nature of items is not limited to possessions that most other people would define as useless or of limited value.

Many individuals collect and save large numbers of valuable things as well, which are often found in piles mixed with other less valuable items.

Individuals with hoarding disorder purposefully save possessions and experience distress when facing the prospect of discarding them (Criterion B). This criterion emphasizes

that the saving of possessions is intentional, which discriminates hoarding disorder from

other forms of psychopathology that are characterized by the passive accumulation of

items or the absence of distress when possessions are removed.

Individuals accumulate large numbers of items that fill up and clutter active living areas to the extent that their intended use is no longer possible (Criterion C). For example,

the individual may not be able to cook in the kitchen, sleep in his or her bed, or sit in a

chair. If the space can be used, it is only with great difficulty. Clutter is defined as a large

group of usually unrelated or marginally related objects piled together in a disorganized

fashion in spaces designed for other purposes (e.g., tabletops, floor, hallway). Criterion C

emphasizes the ''active" living areas of the home, rather than more peripheral areas, such

as garages, attics, or basements, that are sometimes cluttered in homes of individuals without hoarding disorder. However, individuals with hoarding disorder often have possessions that spill beyond the active living areas and can occupy and impair the use of other

spaces, such as vehicles, yards, the workplace, and friends' and relatives' houses. In some

cases, living areas may be uncluttered because of the intervention of third parties (e.g.,

family members, cleaners, local authorities). Individuals who have been forced to clear

their homes still have a symptom picture that meets criteria for hoarding disorder because

the lack of clutter is due to a third-party intervention. Hoarding disorder contrasts with

normative collecting behavior, which is organized and systematic, even if in some cases

the actual amount of possessions may be similar to the amount accumulated by an individual with hoarding disorder. Normative collecting does not produce the clutter, distress, or impairment typical of hoarding disorder.

Symptoms (i.e., difficulties discarding and/or clutter) must cause clinically significant

distress or impairment in social, occupational, or other important areas of functioning, including maintaining a safe environment for self and others (Criterion D). In some cases.

particularly when there is poor insight, the individual may not report distress, and the impairment may apparent only to those around the individual. Hov^ever, any attempts to

discard or clear the possessions by third parties result in high levels of distress.

Associated Features Supporting Diagnosis

Other common features of hoarding disorder include indecisiveness, perfectionism,

avoidance, procrastination, difficulty planning and organizing tasks, and distractibility.

Some individuals with hoarding disorder live in unsanitary conditions that may be a logical consequence of severely cluttered spaces and/or that are related to planning and organizing difficulties. Animal hoarding can be defined as the accumulation of a large number

of animals and a failure to provide minimal standards of nutrition, sanitation, and veterinary care and to act on the deteriorating condition of the animals (including disease, starvation, or death) and the environment (e.g., severe overcrowding, extremely unsanitary

conditions). Animal hoarding may be a special manifestation of hoarding disorder. Most

individuals who hoard animals also hoard inanimate objects. The most prominent differences between animal and object hoarding are the extent of unsanitary conditions and the

poorer insight in animal hoarding.

Prevalence

Nationally representative prevalence studies of hoarding disorder are not available. Community surveys estimate the point prevalence of clinically significant hoarding in the

United States and Europe to be approximately 2%-6%. Hoarding disorder affects both

males and females, but some epidemiological studies have reported a significantly greater

prevalence among males. This contrasts with clinical samples, which are predominantly

female. Hoarding symptoms appear to be almost three times more prevalent in older

adults (ages 55-94 years) compared with younger adults (ages 34-44 years).

Development and Course

Hoarding appears to begin early in life and spans well into the late stages. Hoarding symptoms may first emerge around ages 11-15 years, start interfering with the individual's everyday functioning by the mid-20s, and cause clinically significant impairment by the

mid-30s. Participants in clinical research studies are usually in their 50s. Thus, the severity

of hoarding increases with each decade of life. Once symptoms begin, the course of hoarding is often chronic, with few individuals reporting a waxing and waning course.

Pathological hoarding in children appears to be easily distinguished from developmentally adaptive saving and collecting behaviors. Because children and adolescents

typically do not control their living environment and discarding behaviors, the possible

intervention of third parties (e.g., parents keeping the spaces usable and thus reducing interference) should be considered when making the diagnosis.

Risk and Prognostic Factors

Temperamental. Indecisiveness is a prominent feature of individuals with hoarding disorder and their first-degree relatives.

Environmental. Individuals with hoarding disorder often retrospectively report stressful

and traumatic life events preceding the onset of the disorder or causing an exacerbation.

Genetic and physiological. Hoarding behavior is familial, with about 50% of individuals who hoard reporting having a relative who also hoards. Twin studies indicate that approximately 50% of the variability in hoarding behavior is attributable to additive genetic

factors.

Culture-Related Diagnostic issues

While most of the research has been done in Western, industrialized countries and urban

communities, the available data from non-Western and developing countries suggest that

hoarding is a universal phenomenon with consistent clinical features.

Gender-Related Diagnostic issues

The key features of hoarding disorder (i.e., difficulties discarding, excessive amount of

clutter) are generally comparable in males and females, but females tend to display more

excessive acquisition, particularly excessive buying, than do males.

Functional Consequences of Hoarding Disorder

Clutter impairs basic activities, such as moving through the house, cooking, cleaning, personal hygiene, and even sleeping. Appliances may be broken, and utilities such as water

and electricity may be disconnected, as access for repair work may be difficult. Quality of

life is often considerably impaired. In severe cases, hoarding can put individuals at risk for

fire, falling (especially elderly individuals), poor sanitation, and other health risks. Hoarding disorder is associated with occupational impairment, poor physical health, and high

social service utilization. Family relationships are frequently under great strain. Conflict

with neighbors and local authorities is common, and a substantial proportion of individuals with severe hoarding disorder have been involved in legal eviction proceedings, and

some have a history of eviction.

Differential Diagnosis

Other medical conditions. Hoarding disorder is not diagnosed if the symptoms are

judged to be a direct consequence of another medical condition (Criterion E), such as traumatic brain injury, surgical resection for treatment of a tumor or seizure control, cerebrovascular disease, infections of the central nervous system (e.g., herpes simplex encephalitis),

or neurogenetic conditions such as Prader-Willi syndrome. Damage to the anterior ventromedial prefrontal and cingulate cortices has been particularly associated with the excessive accumulation of objects. In these individuals, the hoarding behavior is not present

prior to the onset of the brain damage and appears shortly after the brain damage occurs.

Some of these individuals appear to have little interest in the accumulated items and are

able to discard them easily or do not care if others discard them, whereas others appear to

be very reluctant to discard anything.

Neurodevelopmental disorders. Hoarding disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of a neurodevelopmental disorder, such

as autism spectrum disorder or intellectual disability (intellectual developmental disorder).

Schizophrenia spectrum and other psychotic disorders. Hoarding disorder is not diagnosed if the accumulation of objects is judged to be a direct consequence of delusions or

negative symptoms in schizophrenia spectrum and other psychotic disorders.

Major depressive episode. Hoarding disorder is not diagnosed if the accumulation of

objects is judged to be a direct consequence of psychomotor retardation, fatigue, or loss of

energy during a major depressive episode.

Obsessive-compulsive disorder. Hoarding disorder is not diagnosed if the symptoms

are judged to be a direct consequence of typical obsessions or compulsions, such as fears

of contamination, harm, or feelings of incompleteness in obsessive-compulsive disorder

(OCD). Feelings of incompleteness (e.g., losing one's identity, or having to document and

preserve all life experiences) are the most frequent OCD symptoms associated with this

form of hoarding. The accumulation of objects can also be the result of persistently avoid­

ing onerous rituals (e.g., not discarding objects in order to avoid endless washing or checking rituals). \

In OCD, the behavior is generally unwanted and highly distressing, and the individual experiences no pleasure or reward from it. Excessive acquisition is usually not present; if excessive acquisition is present, items are acquired because of a specific obsession (e.g., the need to

buy items that have been accidentally touched in order to avoid contaminating other people),

not because of a genuine desire to possess the items. Individuals who hoard in the context of

OCD are also more likely to accumulate bizarre items, such as trash, feces, urine, nails, hair,

used diapers, or rotten food. Accumulation of such items is very unusual in hoarding disorder.

When severe hoarding appears concurrently with other typical symptoms of OCD but

is judged to be independent from these symptoms, both hoarding disorder and OCD may

be diagnosed.

Neurocognitive disorders. Hoarding disorder is not diagnosed if the accumulation of

objects is judged to be a direct consequence of a degenerative disorder, such as neurocognitive disorder associated with frontotemporal lobar degeneration or Alzheimer's disease.

Typically, onset of the accumulating behavior is gradual and follows onset of the neurocognitive disorder. The accumulating behavior may be accompanied by self-neglect and

severe domestic squalor, alongside other neuropsychiatric symptoms, such as disinhibition, gambling, rituals/stereotypies, tics, and self-injurious behaviors.

Comorbidity

Approximately 75% of individuals with hoarding disorder have a comorbid mood or anxiety disorder. The most common comorbid conditions are major depressive disorder (up

to 50% of cases), social anxiety disorder (social phobia), and generalized anxiety disorder.

Approximately 20% of individuals with hoarding disorder also have symptoms that meet

diagnostic criteria for OCD. These comorbidities may often be the main reason for consultation, because individuals are unlikely to spontaneously report hoarding symptoms, and

these symptoms are often not asked about in routine clinical interviews.

Trichotillomania (Hair-Pulling Disorder)

Diagnostic Criteria 312.39 (F63.2)

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

B. Repeated attempts to decrease or stop hair pulling.

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

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

E. The hair pulling is not better explained by the symptoms of another mental disorder

(e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic

disorder).

Diagnostic Features

The essential feature of trichotillomania (hair-pulling disorder) is the recurrent pulling out

of one's own hair (Criterion A). Hair pulling may occur from any region of the body in

which hair grows; the most common sites are the scalp, eyebrows, and eyelids, while less

common sites are axillary, facial, pubic, and peri-rectal regions. Hair-pulling sites may

vary over time. Hair pulling may occur in brief episodes scattered throughout the day or

during less frequent but more sustained periods that can continue for hours, and such hair

pulling may endure for months or years. Criterion A requires that hair pulling lead to hair

loss, although individuals with this disorder may pull hair in a widely distributed pattern

(i.e., pulling single hairs from all over a site) such that hair loss may not be clearly visible.

Alternatively, individuals may attempt to conceal or camouflage hair loss (e.g., by using

makeup, scarves, or wigs). Individuals with trichotillomania have made repeated attempts to decrease or stop hair pulling (Criterion B). Criterion C indicates that hair pulling

causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The term distress includes negative affects that may be experienced by individuals with hair pulling, such as feeling a loss of control, embarrassment,

and shame. Significant impairment may occur in several different areas of functioning

(e.g., social, occupational, academic, and leisure), in part because of avoidance of work,

school, or other public situations.

Associated Features Supporting Diagnosis

Hair pulling may be accompanied by a range of behaviors or rituals involving hair. Thus,

individuals may search for a particular kind of hair to pull (e.g., hairs with a specific texture or color), may try to pull out hair in a specific way (e.g., so that the root comes out intact), or may visually examine or tactilely or orally manipulate the hair after it has been

pulled (e.g., rolling the hair between the fingers, pulling the strand between the teeth, biting the hair into pieces, or swallowing the hair).

Hair pulling may also be preceded or accompanied by various emotional states; it may

be triggered by feelings of anxiety or boredom, may be preceded by an increasing sense of

tension (either immediately before pulling out the hair or when attempting to resist the

urge to pull), or may lead to gratification, pleasure, or a sense of relief when the hair is

pulled out. Hair-pulling behavior may involve varying degrees of conscious awareness,

with some individuals displaying more focused attention on the hair pulling (with preceding tension and subsequent relief), and other individuals displaying more automatic

behavior (in which the hair pulling seems to occur without full awareness). Many individuals report a mix of both behavioral styles. Some individuals experience an "itch-like" or

tingling sensation in the scalp that is alleviated by the act of pulling hair. Pain does not

usually accompany hair pulling.

Patterns of hair loss are highly variable. Areas of complete alopecia, as well as areas of

thinned hair density, are common. When the scalp is involved, there may be a predilection

for pulling out hair in the crown or parietal regions. There may be a pattern of nearly complete baldness except for a narrow perimeter around the outer margins of the scalp, particularly at the nape of the neck ("tonsure trichotillomania"). Eyebrows and eyelashes may

be completely absent.

Hair pulling does not usually occur in the presence of other individuals, except immediate family members. Some individuals have urges to pull hair from other individuals

and may sometimes try to find opportunities to do so surreptitiously. Some individuals

may pull hairs from pets, dolls, and other fibrous materials (e.g., sweaters or carpets).

Some individuals may deny their hair pulling to others. The majority of individuals with

trichotillomania also have one or more other body-focused repetitive behaviors, including

skin picking, nail biting, and lip chewing.

Prevaience

In the general population, the 12-month prevalence estimate for trichotillomania in adults

and adolescents is l%-2%. Females are more frequently affected than males, at a ratio of

approximately 10:1. This estimate likely reflects the true gender ratio of the condition, although it may also reflect differential treatment seeking based on gender or cultural attitudes regarding appearance (e.g., acceptance of normative hair loss among males).

Among children with trichotillomania, males and females are more equally represented.

Development and Course

Hair pulling maÿ be seen in infants, and this behavior typically resolves during early development. Onset of hair pulling in trichotillomania most commonly coincides with, or follows

the onset of, puberty. Sites of hair pulling may vary over time. The usual course of trichotillomania is chronic, with some waxing and waning if the disorder is untreated. Symptoms may

possibly worsen in females accompanying hormonal changes (e.g., menstruation, perimenopause). For some individuals, the disorder may come and go for weeks, months, or years at a

time. A minority of individuals remit without subsequent relapse within a few years of onset.

Risk and Prognostic Factors

Genetic and physiological. There is evidence for a genetic vulnerability to trichotillomania. The disorder is more common in individuals with obsessive-compulsive disorder

(OCD) and their first-degree relatives than in the general population.

Cuiture-Related Diagnostic issues

Trichotillomania appears to manifest similarly across cultures, although there is a paucity

of data from non-Westem regions.

Diagnostic iVlarlcers

Most individuals with trichotillomania admit to hair pulling; thus, dermatopathological

diagnosis is rarely required. Skin biopsy and dermoscopy (or trichoscopy) of trichotillomania are able to differentiate the disorder from other causes of alopecia. In trichotillomania, dermoscopy shows a range of characteristic features, including decreased hair

density, short vellus hair, and broken hairs with different shaft lengths.

Functional Consequences of

Triciiotiiiomania (Hair-Puliing Disorder)

Trichotillomania is associated with distress as well as with social and occupational impairment. There may be irreversible damage to hair growth and hair quality. Infrequent medical consequences of trichotillomania include digit purpura, musculoskeletal injury (e.g.,

carpal tunnel syndrome; back, shoulder and neck pain), blepharitis, and dental damage

(e.g., worn or broken teeth due to hair biting). Swallowing of hair (trichophagia) may lead

to trichobezoars, with subsequent anemia, abdominal pain, hematemesis, nausea and

vomiting, bowel obstruction, and even perforation.

Differential Diagnosis

Normative hair removal/manipulation. Trichotillomania should not be diagnosed when

hair removal is performed solely for cosmetic reasons (i.e., to improve one's physical appearance). Many individuals twist and play with their hair, but this behavior does not usually qualify for a diagnosis of trichotillomania. Some individuals may bite rather than pull

hair; again, this does not qualify for a diagnosis of trichotillomania.

Other obsessive-compulsive and related disorders. Individuals with OCD and symmetry concerns may pull out hairs as part of their symmetry rituals, and individuals with

body dysmorphic disorder may remove body hair that they perceive as ugly, asymmetrical, or abnormal; in such cases a diagnosis of trichotillomania is not given. The description

of body-focused repetitive behavior disorder in other specified obsessive-compulsive and

related disorder excludes individuals who meet diagnostic criteria for trichotillomania.

Neurodevelopmental disorders. In neurodevelopmental disorders, hair pulling may

meet the definition of stereotypies (e.g., in stereotypic movement disorder). Tics (in tic disorders) rarely lead to hair pulling.

Psychotic disorder. Individuals with a psychotic disorder may remove hair in response

to a delusion or hallucination. Trichotillomania is not diagnosed in such cases.

Another medical condition. Trichotillomania is not diagnosed if the hair pulling or hair

loss is attributable to another medical condition (e.g., inflammation of the skin or other dermatological conditions). Other causes of scarring alopecia (e.g., alopecia areata, androgenic

alopecia, telogen effluvium) or nonscarring alopecia (e.g., chronic discoid lupus erythematosus, lichen planopilaris, central centrifugal cicatricial alopecia, pseudopelade, folliculitis

decalvans, dissecting foUiculitis, acne keloidalis nuchae) should be considered in individuals with hair loss who deny hair pulling. Skin biopsy or dermoscopy can be used to differentiate individuals with trichotillomania from those with dermatological disorders.

Substance-related disorders. Hair-pulling symptoms may be exacerbated by certain

substances—for example, stimulants—^but it is less likely that substances are the primary

cause of persistent hair pulling.

Comorbidity

Trichotillomania is often accompanied by other mental disorders, most commonly major

depressive disorder and excoriation (skin-picking) disorder. Repetitive body-focused

symptoms other than hair pulling or skin picking (e.g. nail biting) occur in the majority of

individuals with trichotillomania and may deserve an additional diagnosis of other specified obsessive-compulsive and related disorder (i.e., body-focused repetitive behavior

disorder).

Excoriation (Skin-Picking) Disorder

Diagnostic Criteria 698.4 (L98.1)

A. Recurrent skin picking resulting in skin lesions.

B. Repeated attempts to decrease or stop skin picking.

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

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

E. The skin picking is not better explained by symptoms of another mental disorder (e.g.,

delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury).

Diagnostic Features

The essential feature of excoriation (skin-picking) disorder is recurrent picking at one's

own skin (Criterion A). The most commonly picked sites are the face, arms, and hands, but

many individuals pick from multiple body sites. Individuals may pick at healthy skin, at

minor skin irregularities, at lesions such as pimples or calluses, or at scabs from previous

picking. Most individuals pick with their fingernails, although many use tweezers, pins,

or other objects. In addition to skin picking, there may be skin rubbing, squeezing, lancing,

and biting. Individuals with excoriation disorder often spend significant amounts of time

on their picking behavior, sometimes several hours per day, and such skin picking may

endure for months or years. Criterion A requires that skin picking lead to skin lesions, although individu^als with this disorder often attempt to conceal or camouflage such lesions

(e.g., with makeup or clothing). Individuals with excoriation disorder have made repeated

attempts to decrease or stop skin picking (Criterion B).

Criterion C indicates that skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The term distress includes negative affects that may be experienced by individuals with skin picking, such as

feeling a loss of control, embarrassment, and shame. Significant impairment may occur in

several different areas of functioning (e.g., social, occupational, academic, and leisure), in

part because of avoidance of social situations.

Associated Features Supporting Diagnosis

Skin picking may be accompanied by a range of behaviors or rihials involving skin or scabs.

Thus, individuals may search for a particular kind of scab to pull, and they may examine,

play with, or mouth or swallow the skin after it has been pulled. Skin picking may also be preceded or accompanied by various emotional states. Skin picking may be triggered by feelings

of anxiety or boredom, may be preceded by an increasing sense of tension (either immediately before picking the skin or when attempting to resist the urge to pick), and may lead to

gratification, pleasure, or a sense of relief when the skin or scab has been picked. Some individuals report picking in response to a minor skin irregularity or to relieve an uncomfortable

bodily sensation. Pain is not routinely reported to accompany skin picking. Some individuals

engage in skin picking that is more focused (i.e., with preceding tension and subsequent relief), whereas others engage in more automatic picking (i.e., when skin picking occurs without preceding tension and without full awareness), and many have a mix of both behavioral

styles. Skin picking does not usually occur in the presence of other individuals, except immediate faniily members. Some individuals report picking the skin of others.

Prevaience

In the general population, the lifetime prevalence for excoriation disorder in adults is 1.4%

or somewhat higher. Three-quarters or more of individuals with the disorder are female.

This likely reflects the true gender ratio of the condition, although it may also reflect differential treatment seeking based on gender or cultural attitudes regarding appearance.

Development and Course

Although individuals with excoriation disorder may present at various ages, the skin picking most often has onset during adolescence, commonly coinciding with or following the

onset of puberty. The disorder frequently begins with a dermatological condition, such

as acne. Sites of skin picking may vary over time. The usual course is chronic, with some

waxing and waning if untreated. For some individuals, the disorder may come and go for

weeks, months, or years at a time.

R isk and Prognostic Factors

Genetic and physiological. Excoriation disorder is more common in individuals with

obsessive-compulsive disorder (OCD) and their first-degree family members than in the

general population.

Diagnostic iVlaricers

Most individuals with excoriation disorder admit to skin picking; therefore, dermatopathological diagnosis is rarely required. However, the disorder may have characteristic

features on histopathology.

Functional Consequences of

Excoriation (Sl(in-Picicing) Disorder

Excoriation disorder is associated with distress as well as with social and occupational impairment. The majority of individuals with this condition spend at least 1 hour per day

picking, thinking about picking, and resisting urges to pick. Many individuals report

avoiding social or entertainment events as well as going out in public. A majority of individuals with the disorder also report experiencing work interference from skin picking on

at least a daily or weekly basis. A significant proportion of students with excoriation disorder report having missed school, having experienced difficulties managing responsibilities

at school, or having had difficulties studying because of skin picking. Medical complications of skin picking include tissue damage, scarring, and infection and can be life-threatening. Rarely, synovitis of the wrists due to chronic picking has been reported. Skin picking

often results in significant tissue damage and scarring. It frequently requires antibiotic treatment for infection, and on occasion it may require surgery.

Differential Diagnosis

Psychotic disorder. Skin picking may occur in response to a delusion (i.e., parasitosis)

or tactile hallucination (i.e., formication) in a psychotic disorder. In such cases, excoriation

disorder should not be diagnosed.

Other obsessive-compulsive and related disorders. Excessive washing compulsions

in response to contamination obsessions in individuals with OCD may lead to skin lesions,

and skin picking may occur in individuals with body dysmorphic disorder who pick their

skin solely because of appearance concerns; in such cases, excoriation disorder should not

be diagnosed. The description of body-focused repetitive behavior disorder in other specified obsessive-compulsive and related disorder excludes individuals whose symptoms

meet diagnostic criteria for excoriation disorder.

Neurodevelopmental disorders. While stereotypic movement disorder may be characterized by repetitive self-injurious behavior, onset is in the early developmental period.

For example, individuals with the neurogenetic condition Prader-Willi syndrome may

have early onset of skin picking, and their symptoms may meet criteria for stereotypic

movement disorder. While tics in individuals with Tourette's disorder may lead to selfinjury, the behavior is not tic-like in excoriation disorder.

Somatic symptom and related disorders. Excoriation disorder is not diagnosed if the

skin lesion is primarily attributable to deceptive behaviors in factitious disorder.

Other disorders. Excoriation disorder is not diagnosed if the skin picking is primarily

attributable to the intention to harm oneself that is characteristic of nonsuicidal self-injury.

Other medical conditions. Excoriation disorder is not diagnosed if the skin picking is

primarily attributable to another medical condition. For example, scabies is a dermatological condition invariably associated with severe itching and scratching. However, excoriation disorder may be precipitated or exacerbated by an underlying dermatological

condition. For example, acne may lead to some scratching and picking, which may also be

associated with comorbid excoriation disorder. The differentiation between these two

clirücal situations (acne with some scratching and picking vs. acne with comorbid excoriation disorder) requires an assessment of the extent to which the individual's skin picking

has become independent of the underlying dermatological condition.

Substance/medication-induced disorders. Skin-picking symptoms may also be induced

by certain substances (e.g., cocaine), in which case excoriation disorder should not be diagnosed. If such skin picking is clinically significant, then a diagnosis of substance/medication-induced obsessive-compulsive and related disorder should be considered.

Comorbidity

Excoriation disorder is often accompanied by other mental disorders. Such disorders include OCD and trichotillomania (hair-pulling disorder), as well as major depressive disorder. Repetitive body-focused symptoms other than skin picking and hair pulling (e.g.,

nail biting) occur in many individuals with excoriation disorder and may deserve an additional diagnosis of other specified obsessive-compulsive and related disorder (i.e.,

body-focused repetitive behavior disorder).

Substance/Medication-Induced

Obsessive-Compulsive and Related Disorder

Diagnostic Criteria

A. Obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of the obsessive-compulsive and related disorders predominate in the clinical picture.

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

(1)and (2):

1. The symptoms in Criterion A developed during or soon after substance intoxication

or withdrawal or after exposure to a medication.

2. The involved substance/medication is capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by an obsessive-compulsive and related disorder that is not substance/medication-induced. Such evidence of an independent obsessive-compulsive and related disorder could include the following:

The symptoms precede the onset of the substance/medication use; the symptoms

persist for a substantial period of time (e.g., about 1 month) after the cessation of acute

withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non-substance/medication-induced obsessive-compulsive and related disorder (e.g., a history of recurrent non-substance/medicationrelated episodes).

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

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

Note: This diagnosis should be made in addition to a diagnosis of substance intoxication

or substance withdrawal only when the symptoms in Criterion A predominate in the clinical

picture and are sufficiently severe to warrant clinical attention.

Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific substance/medication]-induced obsessive-compulsive and related disorders are indicated in the table below.

Note that the ICD-10-CM code depends on whether or not there is a comorbid substance

use disorder present for the same class of substance. If a mild substance use disorder is

comorbid with the substance-induced obsessive-compulsive and related disorder, the 4th

position character is “1 and the clinician should record “mild [substance] use disorder”

before the substance-induced obsessive-compulsive and related disorder (e.g., “mild cocaine use disorder with cocaine-induced obsessive-compulsive and related disorder"). If

a moderate or severe substance use disorder is comorbid with the substance-induced obsessive-compulsive and related disorder, the 4th position character is “2,” and the clinician

should record “moderate [substance] use disorder” or “severe [substance] use disorder,”

depending on the severity of the comorbid substance use disorder. If there Is no comorbid

substance use disorder (e.g., after a one-time heavy use of the substance), then the 4th

position character is “9,” and the clinician should record only the substance-induced obsessive-compulsive and related disorder.

ICD-10-CM

ICD-9-CIVI

With use

disorder,

mild

With use

disorder,

moderate

or severe

Without

use

disorder

Amphetamine (or other

stimulant)

292.89 F15.188 F15.288 F15.988

Cocaine 292.89 F14.188 FI 4.288 F14.988

Other (or unknown) substance 292.89 F19.188 F19.288 F19.988

Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for diagnoses associated with substance class):

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

Witii onset during withdrawai: If criteria are met for withdrawal from the substance

and the symptoms develop during, or shortly after, withdrawal.

Witli onset after medication use: Symptoms may appear either at initiation of medication or after a modification or change in use.

Recording Procedures

ICD-9-CM. The name of the substance/medication-induced obsessive-compulsive and

related disorder begins with the specific substance (e.g., cocaine) that is presumed to be

causing the obsessive-compulsive and related symptoms. The diagnostic code is selected

from the table included in the criteria set, which is based on the drug class. For substances

that do not fit into any of the classes, the code for "other substance" should be used; and in

cases in which a substance is judged to be an etiological factor but the specific class of substance is unknown, the category "unknown substance" should be used.

The name of the disorder is followed by the specification of onset (i.e., onset during intoxication, onset during withdrawal, with onset after medication use). Unlike the recording procedures for ICD-IO-CM, which combine the substance-induced disorder and

substance use disorder into a single code, for ICD-9-CM a separate diagnostic code is

given for the substance use disorder. For example, in the case of repetitive behaviors occurring during intoxication in a man with a severe cocaine use disorder, the diagnosis is

292.89 cocaine-induced obsessive-compulsive and related disorder, with onset during intoxication. An additional diagnosis of 304.20 severe cocaine use disorder is also given.

When more than one substance is judged to play a significant role in the development of

the obsessive-compulsive and related disorder, each should be listed separately.

ICD-10-CM. The name of the substance/medication-induced obsessive-compulsive and related disorder begins with the specific substance (e.g., cocaine) that is presumed to be causing

the obsessive-compulsive and related symptoms. The diagnostic code is selected from the table included in the criteria set, which is based on the drug class and presence or absence of a

comorbid substance use disorder. For substances that do not fit into any of the classes,

the code for "other substance" with no comorbid substance use should be used; and in cases in

which a substance is judged to be an etiological factor but the specific class of substance is unknown, the category "unknown substance" with no comorbid substance use should be used.

When recording the name of the disorder, the comorbid substance use disorder (if any) is

listed first, followed by the word "with," followed by the name of the substance-induced obsessive-compulsive and related disorder, followed by the specification of onset (i.e., onset during intoxication, onset during withdrawal, with onset after medication use). For example, in

the case of repetitive behaviors occurring during intoxication in a man with a severe cocaine

use disorder, the diagnosis is F14.288 severe cocaine use disorder with cocaine-induced obsessive-compulsive and related disorder, with onset during intoxication. A separate diagnosis of

the comorbid severe cocaine use disorder is not given. If the substance-induced obsessivecompulsive and related disorder occurs without a comorbid substance use disorder (e.g., after

a one-time heavy use of the substance), no accompanying substance use disorder is noted (e.g.,

F15.988 amphetamine-induced obsessive-compulsive and related disorder, with onset during

intoxication). When more than one substance is judged to play a significant role in the development of the obsessive-compulsive and related disorder, each should be listed separately.

Diagnostic Features

The essential features of substance/medication-induced obsessive-compulsive and related

disorder are prominent symptoms of an obsessive-compulsive and related disorder (Criterion

A) that are judged to be attributable to the effects of a substance (e.g., drug of abuse, medication). The obsessive-compulsive and related disorder symptoms must have developed during

or soon after substance intoxication or withdrawal or after exposure to a medication or toxin,

and the substance/medication must be capable of producing the symptoms (Criterion B). Substance/medication-induced obsessive-compulsive and related disorder due to a prescribed

treatment for a mental disorder or general medical condition must have its onset while the individual is receiving the medication. Once the treatment is discontinued, the obsessive-compulsive and related disorder symptoms will usually improve or remit within days to several

weeks to 1 month (depending on the half-life of the substance/medication). The diagnosis of

substance/medication-induced obsessive-compulsive and related disorder should not be

given if onset of the obsessive-compulsive and related disorder symptoms precedes the substance intoxication or medication use, or if the symptoms persist for a substantial period of

time, usually longer than 1 month, from the time of severe intoxication or withdrawal. If the

obsessive-compulsive and related disorder symptoms persist for a substantial period of time,

other causes for the symptoms should be considered. The substance/medication-induced obsessive-compulsive and related disorder diagnosis should be made in addition to a diagnosis

of substance intoxication only when the symptoms in Criterion A predominate in the clinical

picture and are sufficiently severe to warrant independent clinical attention

Associated Features Supporting Diagnosis

Obsessions, compulsions, hair pulling, skin picking, or other body-focused repetitive behaviors can occur in association with intoxication with the following classes of substances:

stimulants (including cocaine) and other (or unknown) substances. Heavy metals and toxins may also cause obsessive-compulsive and related disorder symptoms. Laboratory assessments (e.g., urine toxicology) may be useful to measure substance intoxication as part

of an assessment for obsessive-compulsive and related disorders.

Prevaience

In the general population, the very limited data that are available indicate that substanceinduced obsessive-compulsive and related disorder is very rare.

Differentiai Diagnosis

Substance intoxication. Obsessive-compulsive and related disorder symptoms may occur in substance intoxication. The diagnosis of the substance-specific intoxication will usu­

ally suffice to categorize the symptom presentation. A diagnosis of an obsessive-compulsive

and related disorder should be made in addition to substance intoxication when the symptoms are judged to be in excess of those usually associated with intoxication and are sufficiently severe to warrant independent clinical attention.

Obsessive-compulsive and related disorder (i.e., not induced by a substance). Substance/medication-induced obsessive-compulsive and related disorder is judged to be

etiologically related to the substance/medication. Substance/medication-induced obsessive-compulsive and related disorder is distinguished from a primary obsessive-compulsive and related disorder by considering the onset, course, and other factors with respect

to substances/medications. For drugs of abuse, there must be evidence from the history,

physical examination, or laboratory findings for use or intoxication. Substance/medication-induced obsessive-compulsive and related disorder arises only in association with intoxication, whereas a primary obsessive-compulsive and related disorder may precede the

onset of substance/medication use. The presence of features that are atypical of a primary

obsessive-compulsive and related disorder, such as atypical age at onset of symptoms,

may suggest a substance-induced etiology. A primary obsessive-compulsive and related

disorder diagnosis is warranted if the symptoms persist for a substantial period of time

(about 1 month or longer) after the end of the substance intoxication or the individual has

a history of an obsessive-compulsive and related disorder.

Obsessive-compulsive and related disorder due to another medical condition. If the

obsessive-compulsive and related disorder symptoms are attributable to another medical

condition (i.e., rather than to the medication taken for the other medical condition), obsessive-compulsive and related disorder due to another medical condition should be diagnosed. The history often provides the basis for judgment. At times, a change in the

treatment for the other medical condition (e.g., medication substitution or discontinuation) may be needed to determine whether or not the medication is the causative agent (in

which case the symptoms may be better explained by substance/medication-induced obsessive-compulsive and related disorder). If the disturbance is attributable to both another

medical condition and substance use, both diagnoses (i.e., obsessive-compulsive and related

disorder due to another medical condition and substance/medication-induced obsessivecompulsive and related disorder) may be given. When there is insufficient evidence to determine whether the symptoms are attributable to either a substance/medication or another medical condition or are primary (i.e., attributable to neither a substance/medication

nor another medical condition), a diagnosis of other specified or unspecified obsessivecompulsive and related disorder would be indicated.

Delirium. If obsessive-compulsive and related disorder symptoms occur exclusively

during the course of delirium, they are considered to be an associated feature of the delirium and are not diagnosed separately.

Obsessive-Compulsive and Related Disorder

Due to Another Medical Condition

Diagnostic Criteria 294.8 (F06.8)

A. Obsessions, compulsions, preoccupations with appearance, hoarding, sl<in picking,

hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic

of obsessive-compulsive and related disorder predominate in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings that the

disturbance is the direct pathophysiological consequence of another medical condition.

C. The disturbance is not better explained by another mental disorder.

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

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

Specify if:

With obsessive-compulsive disorder-lil<e symptoms: If obsessive-compulsive disorder-like symptoms predominate in the clinical presentation.

Witli appearance preoccupations: If preoccupation with perceived appearance defects or flaws predominates in the clinical presentation.

Witli hoarding symptoms: If hoarding predominates in the clinical presentation.

With hair-pulling symptoms: If hair pulling predominates in the clinical presentation.

With sl(in-picl(ing symptoms: If skin picking predominates in the clinical presentation.

Coding note: Include the name of the other medical condition in the name of the mental

disorder (e.g., 294.8 [F06.8] obsessive-compulsive and related disorder due to cerebral

infarction). The other medical condition should be coded and listed separately immediately

before the obsessive-compulsive and related disorder due to the medical condition (e.g.,

438.89 [169.398] cerebral infarction; 294.8 [F06.8] obsessive-compulsive and related disorder due to cerebral infarction)._____________________________________________

Diagnostic Features

The essential feature of obsessive-compulsive and related disorder due to another medical

condition is clinically significant obsessive-compulsive and related symptoms that are

judged to be best explained as the direct pathophysiological consequence of another medical condition. Symptoms can include prominent obsessions, compulsions, preoccupations with appearance, hoarding, hair pulling, skin picking, or other body-focused

repetitive behaviors (Criterion A). The judgment that the symptoms are best explained by

the associated medical condition must be based on evidence from the history, physical examination, or laboratory findings (Criterion B). Additionally, it must be judged that the

symptoms are not better explained by another mental disorder (Criterion C). The diagnosis is not made if the obsessive-compulsive and related symptoms occur only during the

course of a delirium (Criterion D). The obsessive-compulsive and related symptoms must

cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E).

In determining whether the obsessive-compulsive and related symptoms are attributable to another medical condition, a relevant medical condition must be present. Furthermore, it must be established that obsessive-compulsive and related symptoms can be

etiologically related to the medical condition through a pathophysiological mechanism

and that this best explains the symptoms in the individual. Although there are no infallible

guidelines for determining whether the relationship between the obsessive-compulsive

and related symptoms and the medical condition is etiological, considerations that may

provide some guidance in making this diagnosis include the presence of a clear temporal

association between the onset, exacerbation, or remission of the medical condition and the

obsessive-compulsive and related symptoms; the presence of features that are atypical of

a primary obsessive-compulsive and related disorder (e.g., atypical age at onset or course);

and evidence in the literature that a known physiological mechanism (e.g., striatal damage) causes obsessive-compulsive and related symptoms. In addition, the disturbance

cannot be better explained by a primary obsessive-compulsive and related disorder, a substance/medication-induced obsessive-compulsive and related disorder, or another mental disorder.

There is some controversy about whether obsessive-compulsive and related disorders

can be attributed to Group A streptococcal infection. Sydenham's chorea is the neurolog­

ical manifestation of rheumatic fever, which is in turn due to Group A streptococcal infection. Sydenham's chorea is characterized by a combination of motor and nonmotor

features. Nonmotor features include obsessions, compulsions, attention deficit, and emotional lability. Although individuals w^ith Sydenham's chorea may present with nonneuropsychiatric features of acute rheumatic fever, such as carditis and arthritis, they may

present with obsessive-compulsive disorder-like symptoms; such individuals should

be diagnosed with obsessive-compulsive and related disorder due to another medical

condition.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) has been identified as another post-infectious autoimmune disorder

characterized by the sudden onset of obsessions, compulsions, and/or tics accompanied

by a variety of acute neuropsychiatric symptoms in the absence of chorea, carditis, or arthritis, after Group A streptococcal infection. Although there is a body of evidence that

supports the existence of PANDAS, it remains a controversial diagnosis. Given this ongoing controversy, the description of PANDAS has been modified to eliminate etiological

factors and to designate an expanded clinical entity: pediatric acute-onset neuropsychiatric syndrome (PANS) or idiopathic childhood acute neuropsychiatric symptoms (CANS),

which deserves further study.

Associated Features Supporting Diagnosis

A number of other medical disorders are known to include obsessive-compulsive and related symptoms as a manifestation. Examples include disorders leading to striatal damage, such as cerebral infarction.

Deveiopment and Course

The development and course of obsessive-compulsive and related disorder due to another

medical condition generally follows the course of the underlying illness.

Diagnostic iViaricers

Laboratory assessments and/or medical examinations are necessary to confirm the diagnosis of another medical condition.

Differential Diagnosis

Delirium. A separate diagnosis of obsessive-compulsive and related disorder due to another medical condition is not given if the disturbance occurs exclusively during the

course of a delirium. However, a diagnosis of obsessive-compulsive and related disorder

due to another medical condition may be given in addition to a diagnosis of major neurocognitive disorder (dementia) if the etiology of the obsessive-compulsive symptoms is

judged to be a physiological consequence of the pathological process causing the dementia

and if obsessive-compulsive symptoms are a prominent part of the clinical presentation.

Mixed presentation of symptoms (e.g., mood and obsessive-compulsive and related

disorder symptoms). If the presentation includes a mix of different types of symptoms,

the specific mental disorder due to another medical condition depends on which symptoms predominate in the clinical picture.

Substance/medication-induced obsessive-compulsive and related disorders. If there

is evidence of recent or prolonged substance use (including medications with psychoactive effects), withdrawal from a substance, or exposure to a toxin, a substance/medicationinduced obsessive-compulsive and related disorder should be considered. When a substance/medication-induced obsessive-compulsive and related disorder is being diagnosed in relation to drugs of abuse, it may be useful to obtain a urine or blood drug screen

or other appropriate laboratory evaluation. Symptoms that occur during or shortly after

(i.e., within 4 v^eeks of) substance intoxication or withdrawal or after medication use may

be especially indicative of a substance/medication-induced obsessive-compulsive and related disorder, depending on the type, duration, or amount of the substance used.

Obsessive-compulsive and related disorders (primary). Obsessive-compulsive and related disorder due to another medical condition should be distinguished from a primary

obsessive-compulsive and related disorder. In primary mental disorders, no specific and

direct causative physiological mechanisms associated with a medical condition can be

demonstrated. Late age at onset or atypical symptoms suggest the need for a thorough assessment to rule out the diagnosis of obsessive-compulsive and related disorder due to another medical condition.

Illness anxiety disorder. Illness anxiety disorder is characterized by a preoccupation with

having or acquiring a serious illness. In the case of illness anxiety disorder, individuals

may or may not have diagnosed medical conditions.

Associated feature of another mental disorder. Obsessive-compulsive and related symptoms may be an associated feature of another mental disorder (e.g., schizophrenia, anorexia nervosa).

Other specified obsessive-compulsive and related disorder or unspecified obsessivecompulsive and related disorder. These diagnoses are given if it is unclear whether the

obsessive-compulsive and related symptoms are primary, substance-induced, or due to

another medical condition.

Other Specified Obsessive-Compulsive

and Related Disorder

300.3 (F42)

This category applies to presentations in which symptoms characteristic of an obsessivecompulsive and related disorder that cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning predominate but do not meet

the full criteria for any of the disorders in the obsessive-compulsive and related disorders

diagnostic class. The other specified obsessive-compulsive and related disorder category

is used in situations in which the clinician chooses to communicate the specific reason that

the presentation does not meet the criteria for any specific obsessive-compulsive and related disorder. This is done by recording “other specified obsessive-compulsive and related disorder” followed by the specific reason (e.g., “body-focused repetitive behavior

disorder”).

Examples of presentations that can be specified using the “other specified” designation

include the following:

1. Body dysmorphic-like disorder witli actual flaws: This is similar to body dysmorphic disorder except that the defects or flaws in physical appearance are clearly observable by others (i.e., they are more noticeable than “slight”). In such cases, the

preoccupation with these flaws is clearly excessive and causes significant impairment

or distress.

2. Body dysmorphic-like disorder without repetitive behaviors: Presentations that

meet body dysmorphic disorder except that the individual has not performed repetitive

behaviors or mental acts in response to the appearance concerns.

3. Body-focused repetitive behavior disorder: This is characterized by recurrent bodyfocused repetitive behaviors (e.g., nail biting, lip biting, cheek chewing) and repeated

attempts to decrease or stop the behaviors. These symptoms cause clinically significant

distress or impairment in social, occupational, or other important areas of functioning

and are not better explained by trichotillomania (hair-pulling disorder), excoriation (skinpicking) disorder, stereotypic movement disorder, or nonsuicidal self-injury.

4. Obsessional jealousy: This is characterized by nondelusional preoccupation with a

partner’s perceived infidelity. The preoccupations may lead to repetitive behaviors or

mental acts in response to the infidelity concerns; they cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; and

they are not better explained by another mental disorder such as delusional disorder,

jealous type, or paranoid personality disorder.

5. Shubo-kyofu: A variant of taijin kyofusho (see “Glossary of Cultural Concepts of Distress” in the Appendix) that is similar to body dysmorphic disorder and is characterized

by excessive fear of having a bodily deformity.

6. Koro: Related to dhat syndrome (see “Glossary of Cultural Concepts of Distress” in

the Appendix), an episode of sudden and intense anxiety that the penis (or the vulva

and nipples in females) will recede into the body, possibly leading to death.

7. Jikoshu-kyofu: A variant of taijin l<yofusho (see “Glossary of Cultural Concepts of Distress” in the Appendix) characterized by fear of having an offensive body odor (also

termed olfactory reference syndrome).

Unspecified Obsessive-Compulsive

and Related Disorder

300.3 (F42)

This category applies to presentations in which symptoms characteristic of an obsessivecompulsive and related disorder that cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning predominate but do not meet

the full criteria for any of the disorders in the obsessive-compulsive and related disorders

diagnostic class. The unspecified obsessive-compulsive and related 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 obsessive-compulsive and related disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in

emergency room settings).

Trauma- and

Stressor-Related Disorders

T r3 U m 3 - â n d StrG SSO r-rG lâÎG d disorders include disorders in which exposure to

a traumatic or stressful event is listed explicitly as a diagnostic criterion. These include reactive

attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), acute stress disorder, and adjustment disorders. Placement of this chapter reflects

the close relationship between these diagnoses and disorders in the surrounding chapters on

anxiety disorders, obsessive-compulsive and related disorders, and dissociative disorders.

Psychological distress following exposure to a traumatic or stressful event is quite variable. In some cases, symptoms can be well understood within an anxiety- or fear-based

context. It is clear, however, that many individuals who have been exposed to a traumatic

or stressful event exhibit a phenotype in which, rather than anxiety- or fear-based symptoms, the most prominent clinical characteristics are anhedonic and dysphoric symptoms,

externalizing angry and aggressive symptoms, or dissociative symptoms. Because of these

variable expressions of clinical distress following exposure to catastrophic or aversive

events, the aforementioned disorders have been grouped under a separate category:

trauma- and stressor-related disorders. Furthermore, it is not uncommon for the clinical picture to include some combination of the above symptoms (with or without anxiety- or

fear-based symptoms). Such a heterogeneous picture has long been recognized in adjustment disorders, as well. Social neglect—that is, the absence of adequate caregiving during

childhood—is a diagnostic requirement of both reactive attachment disorder and disinhibited social engagement disorder. Although the two disorders share a common etiology,

the former is expressed as an internalizing disorder with depressive symptoms and withdrawn behavior, while the latter is marked by disinhibition and externalizing behavior.

Reactive Attachment Disorder

Diagnostic Criteria 313.89 (F94.1)

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

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

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

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

1. Minimal social and emotional responsiveness to others.

2. Limited positive affect.

3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even

during nonthreatening interactions with adult caregivers.

C. The child has experienced a pattern of extremes of insufficient care as evidenced by

at least one of the following:

1. Social neglect or deprivation in the form of persistent laci< of having basic emotional

needs for comfort, stimulation, and affection met by caregiving adults.

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

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

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

in Criterion C).

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

F. The disturbance is evident before age 5 years.

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

Specify if:

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

Specify current severity:

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

Diagnostic Features

Reactive attachment disorder of infancy or early childhood is characterized by a pattern of

markedly disturbed and developmentally inappropriate attachment behaviors, in which a

child rarely or minimally turns preferentially to an attachment figure for comfort, support,

protection, and nurturance. The essential feature is absent or grossly underdeveloped attachment between the child and putative caregiving adults. Children with reactive attachment disorder are believed to have the capacity to form selective attachments. However,

because of limited opportunities during early development, they fail to show the behavioral

manifestations of selective attachments. That is, when distressed, they show no consistent

effort to obtain comfort, support, nurturance, or protection from caregivers. Furthermore,

when distressed, children with this disorder do not respond more than minimally to comforting efforts of caregivers. Thus, the disorder is associated with the absence of expected

comfort seeking and response to comforting behaviors. As such, children with reactive

attachment disorder show diminished or absent expression of positive emotions during

routine interactions with caregivers. In addition, their emotion regulation capacity is compromised, and they display episodes of negative emotions of fear, sadness, or irritability

that are not readily explained. A diagnosis of reactive attachment disorder should not be

made in children who are developmentally unable to form selective attachments. For this

reason, the child must have a developmental age of at least 9 months.

Associated Features Supporting Diagnosis

Because of the shared etiological association with social neglect, reactive attachment disorder often co-occurs with developmental delays, especially in delays in cognition and

language. Other associated features include stereotypies and other signs of severe neglect

(e.g., malnutrition or signs of poor care).

Prevaience

The prevalence of reactive attachment disorder is unknown, but the disorder is seen relatively rarely in clinical settings. The disorder has been found in young children exposed to

severe neglect before being placed in foster care or raised in institutions. However, even in

populations of severely neglected children, the disorder is uncommon, occurring in less

than 10% of such children.

Development and Course

Conditions of sotial neglect are often present in the first months of life in children diagnosed with reactive attachment disorder, even before the disorder is diagnosed. The clinical features of the disorder manifest in a similar fashion between the ages of 9 months and

5 years. That is, signs of absent-to-minimal attachment behaviors and associated emotionally aberrant behaviors are evident in children throughout this age range, although differing cognitive and motor abilities may affect how these behaviors are expressed. Without

remediation and recovery through normative caregiving environments, it appears that signs

of the disorder may persist, at least for several years.

It is unclear whether reactive attachment disorder occurs in older children and, if so, how

it differs from its presentation in young children. Because of this, the diagnosis should be

made with caution in children older than 5 years.

Risk and Prognostic Factors

Environmental. Serious social neglect is a diagnostic requirement for reactive attachment disorder and is also the only known risk factor for the disorder. However, the majority of severely neglected children do not develop the disorder. Prognosis appears to

depend on the quality of the caregiving environment following serious neglect.

Cuiture-Related Diagnostic Issues

Similar attachment behaviors have been described in young children in many different

cultures around the world. However, caution should be exercised in making the diagnosis

of reactive attachment disorder in cultures in which attachment has not been studied.

Functional Consequences of

Reactive Attachment Disorder

Reactive attachment disorder significantly impairs young children's abilities to relate inteφersonally to adults or peers and is associated with functional impairment across many

domains of early childhood.

Differential Diagnosis

Autism spectrum disorder. Aberrant social behaviors manifest in young children with

reactive attachment disorder, but they also are key features of autism spectrum disorder.

Specifically, young children with either condition can manifest dampened expression of

positive emotions, cognitive and language delays, and impairments in social reciprocity.

As a result, reactive attachment disorder must be differentiated from autism spectrum disorder. These two disorders can be distinguished based on differential histories of neglect

and on the presence of restricted interests or ritualized behaviors, specific deficit in social

communication, and selective attachment behaviors. Children with reactive attachment

disorder have experienced a history of severe social neglect, although it is not always possible to obtain detailed histories about the precise nature of their experiences, especially in

initial evaluations. Children with autistic spectrum disorder will only rarely have a history

of social neglect. The restricted interests and repetitive behaviors characteristic of autism

spectrum disorder are not a feature of reactive attachment disorder. These clinical features

manifest as excessive adherence to rituals and routines; restricted, fixated interests; and

unusual sensory reactions. However, it is important to note that children with either condition can exhibit stereotypic behaviors such as rocking or flapping. Children with either

disorder also may exhibit a range of intellectual functioning, but only children with autis-

tic spectrum disorder exhibit selective impairments in social communicative behaviors,

such as intentional communication (i.e., impairment in communication that is deliberate,

goal-directed, and aimed at influencing the behavior of the recipient). Children with reactive attachment disorder show social communicative functioning comparable to their

overall level of intellectual functioning. Finally, children with autistic spectrum disorder

regularly show attachment behavior typical for their developmental level. In contrast,

children with reactive attachment disorder do so only rarely or inconsistently, if at all.

Intellectual disability (intellectual developmental disorder). Developmental delays often accompany reactive attachment disorder, but they should not be confused with the

disorder. Children with intellectual disability should exhibit social and emotional skills

comparable to their cognitive skills and do not demonstrate the profound reduction in

positive affect and emotion regulation difficulties evident in children with reactive attachment disorder. In addition, developmentally delayed children who have reached a cognitive age of 7-9 months should demonstrate selective attachments regardless of their

chronological age. In contrast, children with reactive attachment disorder show lack of

preferred attachment despite having attained a developmental age of at least 9 months.

Depressive disorders. Depression in young children is also associated with reductions

in positive affect. There is limited evidence, however, to suggest that children with depressive disorders have impairments in attachment. That is, young children who have been diagnosed with depressive disorders still should seek and respond to comforting efforts by

caregivers.

Comorbidity

Conditions associated with neglect, including cognitive delays, language delays, and stereotypies, often co-occur with reactive attachment disorder. Medical conditions, such as

severe malnutrition, may accompany signs of the disorder. Depressive symptoms also

may co-occur with reactive attachment disorder.

Disinhiblted Social Engagement Disorder

Diagnostic Criteria 313.89 (F94.2)

A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar

adults and exhibits at least two of the following:

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

2. Overly familiar verbal or physical behavior (that is not consistent with culturally

sanctioned and with age-appropriate social boundaries).

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

in unfamiliar settings.

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

B. The behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhiblted behavior.

C. The child has experienced a pattern of extremes of insufficient care as evidenced by

at least one of the following:

1. Social neglect or deprivation in the form of persistent lack of having basic emotional

needs for comfort, stimulation, and affection met by caregiving adults.

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

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

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

Criterion C).

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

Specify if:

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

Specify current severity:

Disinhibited social engagement disorder is specified as severe when the child exhibits

all symptoms of the disorder, with each symptom manifesting at relatively high levels.

Diagnostic Features

The essential feature of disinhibited social engagement disorder is a pattern of behavior

that involves culturally inappropriate, overly familiar behavior with relative strangers

(Criterion A). This overly familiar behavior violates the social boundaries of the culture. A

diagnosis of disinhibited social engagement disorder should not be made before children

are developmentally able to form selective attachments. For this reason, the child must

have a developmental age of at least 9 months.

Associated Features Supporting Diagnosis

Because of the shared etiological association with social neglect, disinhibited social engagement disorder may co-occur with developmental delays, especially cognitive and language delays, stereotypies, and other signs of severe neglect, such as malnutrition or poor

care. However, signs of the disorder often persist even after these other signs of neglect are

no longer present. Therefore, it is not uncommon for children with the disorder to present

with no current signs of neglect. Moreover, the condition can present in children who

show no signs of disordered attachment. Thus, disinhibited social engagement disorder

may be seen in children with a history of neglect who lack attachments or whose attachments to their caregivers range from disturbed to secure.

Prevaience

The prevalence of disinhibited social attachment disorder is unknown. Nevertheless, the

disorder appears to be rare, occurring in a minority of children, even those who have been

severely neglected and subsequently placed in foster care or raised in institutions. In such

high-risk populations, the condition occurs in only about 20% of children. The condition is

seen rarely in other clinical settings.

Deveiopment and Course

Conditions of social neglect are often present in the first months of life in children diagnosed with disinhibited social engagement disorder, even before the disorder is diagnosed. However, there is no evidence that neglect beginning after age 2 years is associated

with manifestations of the disorder. If neglect occurs early and signs of the disorder

appear, clinical features of the disorder are moderately stable over time, particularly if

conditions of neglect persist. Indiscriminate social behavior and lack of reticence with unfamiliar adults in toddlerhood are accompanied by attention-seeking behaviors in preschoolers. When the disorder persists into middle childhood, clinical features manifest as

verbal and physical overfamiliarity as well as inauthentic expression of emotions. These

signs appear particularly apparent when the child interacts with adults. Peer relationships

are most affected in adolescence, with both indiscriminate behavior and conflicts apparent. The disorder has not been described in adults.

Disinhibited social engagement disorder has been described from the second year of

life through adolescence. There are some differences in manifestations of the disorder

from early childhood through adolescence. At the youngest ages, across many cultures,

children show reticence when interacting with strangers. Young children with the disorder

fail to show reticence to approach, engage with, and even accompany adults. In preschool

children, verbal and social intrusiveness appear most prominent, often accompanied by

attention-seeking behavior. Verbal and physical overfamiliarity continue through middle

childhood, accompanied by inauthentic expressions of emotion. In adolescence, indiscriminate behavior extends to peers. Relative to healthy adolescents, adolescents with the

disorder have more "superficial" peer relationships and more peer conflicts. Adult manifestations of the disorder are unknown.

Risk and Prognostic Factors

Environmental. Serious social neglect is a diagnostic requirement for disinhibited social

engagement disorder and is also the only known risk factor for the disorder. However, the

majority of severely neglected children do not develop the disorder. Neurobiological vulnerability may differentiate neglected children who do and do not develop the disorder.

However, no clear link with any specific neurobiological factors has been established. The

disorder has not been identified in children who experience social neglect only after age

2 years. Prognosis is only modestly associated with quality of the caregiving environment

following serious neglect. In many cases, the disorder persists, even in children whose

caregiving environment becomes markedly improved.

Course modifiers. Caregiving quality seems to moderate the course of disinhibited social engagement disorder. Nevertheless, even after placement in normative caregiving

environments, some children show persistent signs of the disorder, at least through adolescence.

Functional Consequences of

Disinhibited Sociai Engagement Disorder

Disinhibited social engagement disorder significantly impairs young children's abilities to

relate interpersonally to adults and peers.

Differential Diagnosis

Attention-deficit/hyperactivity disorder. Because of social impulsivity that sometimes

accompanies attention-deficit/hyperactivity disorder (ADHD), it is necessary to differentiate the two disorders. Children with disinhibited social engagement disorder may be

distinguished from those with ADHD because the former do not show difficulties with attention or hyperactivity.

Comorbidity

Limited research has examined the issue of disorders comorbid with disinhibited social

engagement disorder. Conditions associated with neglect, including cognitive delays,

language delays, and stereotypies, may co-occur with disinhibited social engagement disorder. In addition, children may be diagnosed with ADHD and disinhibited social engagement disorder concurrently.

Posttraumatic Stress Disorder

Diagnostic Criteria 309.81 (F43.10)

Posttraumatic Stress Disorder

Note: The following criteria apply to adults, adolescents, and children older than 6 years.

For children 6 years and younger, see corresponding criteria below.

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or

more) of the following ways:

1. Directly experiencing the traumatic event(s).

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

3. Learning that the traumatic event(s) occurred to a close family member or close

friend. In cases of actual or threatened death of a family member or friend, the

event(s) must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic

event(s) (e.g., first responders collecting human remains: police officers repeatedly

exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television,

movies, or pictures, unless this exposure is work related.

B. Presence of one (or more) of the following intrusion symptoms associated with the

traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: In children older than 6 years, repetitive play may occur in which themes or

aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect of the dream are

related to the traumatic event(s).

Note: In children, there may be frightening dreams without recognizable content.

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if

the traumatic event(s) were recurring. (Such reactions may occur on a continuum,

with the most extreme expression being a complete loss of awareness of present

surroundings.)

Note: In children, trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues

that symbolize or resemble an aspect of the traumatic event(s).

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

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after

the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about

or closely associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external reminders (people, places, conversations,

activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s),

beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or

more) of the following:

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

2. Persistent and exaggerated negative beliefs or expectations about oneself, others,

or the world (e.g., “I am bad,” “No one can be trusted,” ‘The world is completely

dangerous,” “My whole nervous system is permanently ruined”).

3. Persistent, distorted cognitions about the cause or consequences of the traumatic

event(s) that lead the individual to blame himself/herself or others.

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

5. Markedly diminished interest or participation in significant activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to experience

happiness, satisfaction, or loving feelings).

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

more) of the following:

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

2. Reckless or self-destructive behavior.

3. Hypervigilance.

4. Exaggerated startle response.

5. Problems with concentration.

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

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

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

H. The disturbance is not attributable to the physiological effects of a substance (e.g.,

medication, alcohol) or another medical condition.

Specify whether:

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

1. Depersonalization: Persistent or recurrent experiences of feeling detached from,

and as if one were an outside observer of, one’s mental processes or body (e.g.,

feeling as though one were in a dream; feeling a sense of unreality of self or body

or of time moving slowly).

2. Dereaiization: Persistent or recurrent experiences of unreality of surroundings

(e.g., the world around the individual is experienced as unreal, dreamlike, distant,

or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the

physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months

after the event (although the onset and expression of some symptoms may be immediate).

Posttraumatic Stress Disorder for Children 6 Years and Younger

A. In children 6 years and younger, exposure to actual or threatened death, serious injury,

or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

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

Note: Witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures.

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

B. Presence of one (or more) of the following intrusion symptoms associated with the

traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic

event(s).

Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play reenactment.

2. Recurrent distressing dreams in which the content and/or affect of the dream are

related to the traumatic event(s).

Note: It may not be possible to ascertain that the frightening content is related to

the traumatic event.

3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the

traumatic event(s) were recurring. (Such reactions may occur on a continuum, with

the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues

that symbolize or resemble an aspect of the traumatic event(s).

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

C. One (or more) of the following symptoms, representing either persistent avoidance of

stimuli associated with the traumatic event(s) or negative alterations in cognitions and

mood associated with the traumatic event(s), must be present, beginning after the

event(s) or worsening after the event(s):

Persistent Avoidance of Stimuli

1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse

recollections of the traumatic event(s).

2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations

that arouse recollections of the traumatic event(s).

Negative Alterations in Cognitions

3. Substantially increased frequency of negative emotional states (e.g., fear, guilt,

sadness, shame, confusion).

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

5. Socially withdrawn behavior.

6. Persistent reduction in expression of positive emotions.

D. Alterations in arousal and reactivity associated with the traumatic event(s), beginning

or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of

the following:

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

2. Hypervigilance.

3. Exaggerated startle response.

4. Problems with concentration.

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

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

F. The disturbance causes clinically significant distress or impairment in relationships

with parents, siblings, peers, or other caregivers or with school behavior.

G. The disturbance is not attributable to the physiological effects of a substance (e.g.,

medication or alcohol) or another medical condition.

Specify whether:

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

1. Depersonalization: Persistent or recurrent experiences of feeling detached from,

and as if one were an outside observer of, one’s mental processes or body (e.g.,

feeling as though one were in a dream; feeling a sense of unreality of self or body

or of time moving slowly).

2. Derealization: Persistent or recurrent experiences of unreality of surroundings

(e.g., the world around the individual is experienced as unreal, dreamlike, distant,

or distorted).

Note: To use this subtype, the dissociative symptoms must not be attributable to the

physiological effects of a substance (e.g., blackouts) or another medical condition

(e.g., complex partial seizures).

Specify if:

With delayed expression: If the full diagnostic criteria are not met until at least

6 months after the event (although the onset and expression of some symptoms may

be immediate).

Diagnostic Features

The essential feature of posttraumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. Emotional reactions to the traumatic event (e.g., fear, helplessness, horror) are no longer a part of

Criterion A. The clinical presentation of PTSD varies. In some individuals, fear-based reexperiencing, emotional, and behavioral symptoms may predominate. In others, anhedonic or dysphoric mood states and negative cognitions may be most distressing. In some

other individuals, arousal and reactive-externalizing symptoms are prominent, while in

others, dissociative symptoms predominate. Finally, some individuals exhibit combinations of these symptom patterns.

The directly experienced traumatic events in Criterion A include, but are not limited

to, exposure to war as a combatant or civilian, threatened or actual physical assault (e.g.,

physical attack, robbery, mugging, childhood physical abuse), threatened or actual sexual

violence (e.g., forced sexual penetration, alcohol/drug-facilitated sexual penetration, abusive sexual contact, noncontact sexual abuse, sexual trafficking), being kidnapped, being

taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or human-made disasters, and severe motor vehicle accidents. For children, sexually violent

events may include developmentally inappropriate sexual experiences without physical

violence or injury. A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event. Medical incidents that qualify as traumatic events involve sudden, catastrophic events (e.g., waking during surgery, anaphylactic shock).

Witnessed events include, but are not limited to, observing threatened or serious injury,

unnatural death, physical or sexual abuse of another person due to violent assault, domestic violence, accident, war or disaster, or a medical catastrophe in one's child (e.g., a lifethreatening hemorrhage). Indirect exposure through learning about an event is limited to

experiences affecting close relatives or friends and experiences that are violent or accidental (e.g., death due to natural causes does not qualify). Such events include violent per­

sonal assault, suicide, serious accident, and serious injury. The disorder may be especially

severe or long-lasting when the stressor is interpersonal and intentional (e.g., torture, sexual violence). ^

The traumatic event can be reexperienced in various ways. Commonly, the individual

has recurrent, involuntary, and intrusive recollections of the event (Criterion Bl). Intrusive

recollections in PTSD are distinguished from depressive rumination in that they apply

only to involuntary and intrusive distressing memories. The emphasis is on recurrent

memories of the event that usually include sensory, emotional, or physiological behavioral

components. A common reexperiencing symptom is distressing dreams that replay the

event itself or that are representative or thematically related to the major threats involved

in the traumatic event (Criterion B2). The individual may experience dissociative states

that last from a few seconds to several hours or even days, during which components of

the event are relived and the individual behaves as if the event were occurring at that moment (Criterion B3). Such events occur on a continuum from brief visual or other sensory

intrusions about part of the traumatic event without loss of reality orientation, to complete

loss of awareness of present surroundings. These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened

arousal. For young children, reenactment of events related to trauma may appear in play

or in dissociative states. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the individual is exposed to triggering events that

resemble or symbolize an aspect of the traumatic event (e.g., windy days after a hurricane;

seeing someone who resembles one's perpetrator). The triggering cue could be a physical

sensation (e.g., dizziness for survivors of head trauma; rapid heartbeat for a previously

traumatized child), particularly for individuals with highly somatic presentations.

Stimuli associated with the trauma are persistently (e.g., always or almost always)

avoided. The individual commonly makes deliberate efforts to avoid thoughts, memories,

feelings, or talking about the traumatic event (e.g., utilizing distraction techniques to avoid

internal reminders) (Criterion Cl) and to avoid activities, objects, situations, or people

who arouse recollections of it (Criterion C2).

Negative alterations in cognitions or mood associated with the event begin or worsen

after exposure to the event. These negative alterations can take various forms, including an

inability to remember an important aspect of the traumatic event; such amnesia is typically

due to dissociative amnesia and is not due to head injury, alcohol, or drugs (Criterion Dl).

Another form is persistent (i.e., always or almost always) and exaggerated negative expectations regarding important aspects of life applied to oneself, others, or the future (e.g.,

"I have always had bad judgment"; "People in authority can't be trusted") that may manifest as a negative change in perceived identity since the trauma (e.g., "I can't trust anyone

ever again"; Criterion D2). Individuals with PTSD may have persistent erroneous cognitions about the causes of the traumatic event that lead them to blame themselves or others

(e.g., "It's all my fault that my uncle abused me") (Criterion D3). A persistent negative

mood state (e.g., fear, horror, anger, guilt, shame) either began or worsened after exposure

to the event (Criterion D4). The individual may experience markedly diminished interest

or participation in previously enjoyed activities (Criterion D5), feeling detached or estranged from other people (Criterion D6), or a persistent inability to feel positive emotions

(especially happiness, joy, satisfaction, or emotions associated with intimacy, tenderness,

and sexuality) (Criterion D7).

Individuals with PTSD may be quick tempered and may even engage in aggressive

verbal and/or physical behavior with little or no provocation (e.g., yelling at people, getting into fights, destroying objects) (Criterion El). They may also engage in reckless or selfdestructive behavior such as dangerous driving, excessive alcohol or drug use, or selfinjurious or suicidal behavior (Criterion E2). PTSD is often characterized by a heightened

sensitivity to potential threats, including those that are related to the traumatic experience

(e.g., following a motor vehicle accident, being especially sensitive to the threat potentially

caused by cars or trucks) and those not related to the traumatic event (e.g., being fearful of

suffering a heart attack) (Criterion E3). Individuals with PTSD may be very reactive to unexpected stimuli, displaying a heightened startle response, or jumpiness, to loud noises or

unexpected movements (e.g., jumping markedly in response to a telephone ringing) (Criterion E4). Concentration difficulties, including difficulty remembering daily events (e.g.,

forgetting one's telephone number) or attending to focused tasks (e.g., following a conversation for a sustained period of time), are commonly reported (Criterion E5). Problems

with sleep onset and maintenance are common and may be associated with nightmares

and safety concerns or with generalized elevated arousal that interferes with adequate sleep

(Criterion E6). Some individuals also experience persistent dissociative symptoms of detachment from their bodies (depersonalization) or the world around them (derealization);

this is reflected in the ''with dissociative symptoms" specifier.

Associated Features Supporting Diagnosis

Developmental regression, such as loss of language in young children, may occur. Auditory pseudo-hallucinations, such as having the sensory experience of hearing one's

thoughts spoken in one or more different voices, as well as paranoid ideation, can be present. Following prolonged, repeated, and severe traumatic events (e.g., childhood abuse,

torture), the individual may additionally experience difficulties in regulating emotions or

maintaining stable interpersonal relationships, or dissociative symptoms. When the traumatic event produces violent death, symptoms of both problematic bereavement and PTSD

may be present.

Prevalence

In the United States, projected lifetime risk for PTSD using DSM-IV criteria at age 75 years

is 8.7%. Twelve-month prevalence among U.S. adults is about 3.5%. Lower estimates are

seen in Europe and most Asian, African, and Latin American countries, clustering around

0.5%-L0%. Although different groups have different levels of exposure to traumatic

events, the conditional probability of developing PTSD following a similar level of exposure may also vary across cultural groups. Rates of PTSD are higher among veterans and

others whose vocation increases the risk of traumatic exposure (e.g., police, firefighters,

emergency medical personnel). Highest rates (ranging from one-third to more than onehalf of those exposed) are found among survivors of rape, military combat and captivity,

and ethnically or politically motivated internment and genocide. The prevalence of PTSD

may vary across development; children and adolescents, including preschool children,

generally have displayed lower prevalence following exposure to serious traumatic

events; however, this may be because previous criteria were insufficiently developmentally informed. The prevalence of full-threshold PTSD also appears to be lower among

older adults compared with the general population; there is evidence that subthreshold

presentations are more common than full PTSD in later life and that these symptoms are

associated with substantial clinical impairment. Compared with U.S. non-Latino whites,

higher rates of PTSD have been reported among U.S. Latinos, African Americans, and

American Indians, and lower rates have been reported among Asian Americans, after adjustment for traumatic exposure and demographic variables.

Development and Course

PTSD can occur at any age, beginning after the first year of life. Symptoms usually begin

within the first 3 months after the trauma, although there may be a delay of months, or

even years, before criteria for the diagnosis are met. There is abundant evidence for what

DSM-IV called "delayed onset" but is now called "delayed expression," with the recognition that some symptoms typically appear immediately and that the delay is in meeting

full criteria.

Frequently, an individual's reaction to a trauma initially meets criteria for acute stress

disorder in the immediate aftermath of the trauma. The symptoms of PTSD and the relative predominance of different symptoms may vary over time. Duration of the symptoms

also varies, with complete recovery within 3 months occurring in approximately one-half

of adults, while some individuals remain symptomatic for longer than 12 months and

sometimes for more than 50 years. Symptom recurrence and intensification may occur in

response to reminders of the original trauma, ongoing life stressors, or newly experienced

traumatic events. For older individuals, declining health, worsening cognitive functioning, and social isolation may exacerbate PTSD symptoms.

The clinical expression of reexperiencing can vary across development. Young children

may report new onset of frightening dreams without content specific to the traumatic event.

Before age 6 years (see criteria for preschool subtype), young children are more likely to express reexperiencing symptoms through play that refers directly or symbolically to the

trauma. They may not manifest fearful reactions at the time of the exposure or during reexperiencing. Parents may report a wide range of emotional or behavioral changes in young

children. Children may focus on imagined interventions in their play or storytelling. In addition to avoidance, children may become preoccupied with reminders. Because of young

children's limitations in expressing thoughts or labeling emotions, negative alterations in

mood or cognition tend to involve primarily mood changes. Children may experience cooccurring traumas (e.g., physical abuse, witnessing domestic violence) and in chronic circumstances may not be able to identify onset of symptomatology. Avoidant behavior may

be associated with restricted play or exploratory behavior in young children; reduced participation in new activities in school-age children; or reluctance to pursue developmental opportunities in adolescents (e.g., dating, driving). Older children and adolescents may judge

themselves as cowardly. Adolescents may harbor beliefs of being changed in ways that

make them socially undesirable and estrange them from peers (e.g., '"Now I'll never fit in")

and lose aspirations for the future. Irritable or aggressive behavior in children and adolescents can interfere with peer relationships and school behavior. Reckless behavior may lead

to accidental injury to self or others, thrill-seeking, or high-risk behaviors. Individuals who

continue to experience PTSD into older adulthood may express fewer symptoms of hyperarousal, avoidance, and negative cognitions and mood compared with younger adults

with PTSD, although adults exposed to traumatic events during later life may display more

avoidance, hyperarousal, sleep problems, and crying spells than do younger adults exposed

to the same traumatic events. In older individuals, the disorder is associated with negative

health perceptions, primary care utilization, and suicidal ideation.

Risk and Prognostic Factors

Risk (and protective) factors are generally divided into pretraumatic, peritraumatic, and

posttraumatic factors.

Pretraumatic factors

Temperamental. These include childhood emotional problems by age 6 years (e.g., prior

traumatic exposure, externalizing or anxiety problems) and prior mental disorders (e.g.,

panic disorder, depressive disorder, PTSD, or obsessive-compulsive disorder [OCD]).

Environmental. These include lower socioeconomic status; lower education; exposure to

prior trauma (especially during childhood); childhood adversity (e.g., economic deprivation, family dysRinction, parental separation or death); cultural characteristics (e.g., fatalistic or self-blaming coping strategies); lower intelligence; minority racial/ethnic status;

and a family psychiatric history. Social support prior to event exposure is protective.

Genetic and physiological. These include female gender and younger age at the time of

trauma exposure (for adults). Certain genotypes may either be protective or increase risk

of PTSD after exposure to traumatic events.

Peritraumatic factors

Environmental. These include severity (dose) of the trauma (the greater the magnitude

of trauma, the greater the likelihood of PTSD), perceived life threat, personal injury, interpersonal violence (particularly trauma peφetrated by a caregiver or involving a witnessed threat to a caregiver in children), and, for military personnel, being a perpetrator,

witnessing atrocities, or killing the enemy. Finally, dissociation that occurs during the trauma

and persists afterward is a risk factor.

Posttraumatic factors

Temperamental. These include negative appraisals, inappropriate coping strategies,

and development of acute stress disorder.

Environmental. These include subsequent exposure to repeated upsetting reminders, subsequent adverse life events, and financial or other trauma-related losses. Social support (including family stability, for children) is a protective factor that moderates outcome after trauma.

Culture-Related Diagnostic issues

The risk of onset and severity of PTSD may differ across cultural groups as a result of variation in the type of traumatic exposure (e.g., genocide), the impact on disorder severity of

the meaning attributed to the traumatic event (e.g., inability to perform funerary rites after

a mass killing), the ongoing sociocultural context (e.g., residing among unpunished perpetrators in postconflict settings), and other cultural factors (e.g., acculturative stress in

immigrants). The relative risk for PTSD of particular exposures (e.g., religious persecution) may vary across cultural groups. The clinical expression of the symptoms or symptom clusters of PTSD may vary culturally, particularly with respect to avoidance and

numbing symptoms, distressing dreams, and somatic symptoms (e.g., dizziness, shortness of breath, heat sensations).

Cultural syndromes and idioms of distress influence the expression of PTSD and the

range of comorbid disorders in different cultures by providing behavioral and cognitive

templates that link traumatic exposures to specific symptoms. For example, panic attack

symptoms may be salient in PTSD among Cambodians and Latin Americans because of

the association of traumatic exposure with panic-like khyâl attacks and ataque de nervios.

Comprehensive evaluation of local expressions of PTSD should include assessment of cultural concepts of distress (see the chapter "Cultural Formulation" in Section III).

Gender-Related Diagnostic issues

PTSD is more prevalent among females than among males across the lifespan. Females in

the general population experience PTSD for a longer duration than do males. At least some

of the increased risk for PTSD in females appears to be attributable to a greater likelihood

of exposure to traumatic events, such as rape, and other forms of interpersonal violence.

Within populations exposed specifically to such stressors, gender differences in risk for

PTSD are attenuated or nonsignificant.

Suicide Risk

Traumatic events such as childhood abuse increase a person's suicide risk. PTSD is associated

with suicidal ideation and suicide attempts, and presence of the disorder may indicate which

individuals with ideation eventually make a suicide plan or actually attempt suicide.

Functional Consequences of

Posttraumatic Stress Disorder

PTSD is associated with high levels of social, occupational, and physical disability, as well

as considerable economic costs and high levels of medical utilization. Impaired function­

ing is exhibited across social, inteq:)ersonal, developmental, educational, physical health,

and occupational domains. In community and veteran samples, PTSD is associated with

poor social and family relationships, absenteeism from work, lower income, and lower educational and occupational success.

Differential Diagnosis

Adjustment disorders. In adjustment disorders, the stressor can be of any severity or

type rather than that required by PTSD Criterion A. The diagnosis of an adjustment disorder is used when the response to a stressor that meets PTSD Criterion A does not meet

all other PTSD criteria (or criteria for another mental disorder). An adjustment disorder is

also diagnosed when the symptom pattern of PTSD occurs in response to a stressor that

does not meet PTSD Criterion A (e.g., spouse leaving, being fired).

Other posttraumatic disorders and conditions. Not all psychopathology that occurs in

individuals exposed to an extreme stressor should necessarily be attributed to PTSD. The

diagnosis requires that trauma exposure precede the onset or exacerbation of pertinent

symptoms. Moreover, if the symptom response pattern to the extreme stressor meets criteria for another mental disorder, these diagnoses should be given instead of, or in addition to, PTSD. Other diagnoses and conditions are excluded if they are better explained by

PTSD (e.g., symptoms of panic disorder that occur only after exposure to traumatic reminders). If severe, symptom response patterns to the extreme stressor may warrant a separate diagnosis (e.g., dissociative amnesia).

Acute stress disorder. Acute stress disorder is distinguished from PTSD because the

symptom pattern in acute stress disorder is restricted to a duration of 3 days to 1 month

following exposure to the traumatic event.

Anxiety disorders and obsessive-compulsive disorder. In OCD, there are recurrent

intrusive thoughts, but these meet the definition of an obsession. In addition, the intrusive

thoughts are not related to an experienced traumatic event, compulsions are usually present, and other symptoms of PTSD or acute stress disorder are typically absent. Neither the

arousal and dissociative symptoms of panic disorder nor the avoidance, irritability, and

anxiety of generalized anxiety disorder are associated with a specific traumatic event. The

symptoms of separation anxiety disorder are clearly related to separation from home or

family, rather than to a traumatic event.

Major depressive disorder. Major depression may or may not be preceded by a traumatic event and should be diagnosed if other PTSD symptoms are absent. Specifically, major depressive disorder does not include any PTSD Criterion B or C symptoms. Nor does it

include a number of symptoms from PTSD Criterion D or E.

Personality disorders. Interpersonal difficulties that had their onset, or were greatly exacerbated, after exposure to a traumatic event may be an indication of PTSD, rather than a

personality disorder, in which such difficulties would be expected independently of any

traumatic exposure.

Dissociative disorders. Dissociative amnesia, dissociative identity disorder, and depersonalization-derealization disorder may or may not be preceded by exposure to a traumatic event or may or may not have co-occurring PTSD symptoms. When full PTSD criteria

are also met, however, the PTSD ''with dissociative symptoms" subtype should be considered.

Conversion disorder (functional neurological symptom disorder). New onset of somatic

symptoms within the context of posttraumatic distress might be an indication of PTSD

rather than conversion disorder (functional neurological symptom disorder).

Psychotic disorders. Flashbacks in PTSD must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in schizophrenia, brief psychotic disorder, and other psychotic disorders; depressive and bipolar disorders with

psychotic features; delirium; substance/medication-induced disorders; and psychotic disorders due to another medical condition.

Traumatic brain injury. When a brain injury occurs in the context of a traumatic event (e.g.,

traumatic accident, bomb blast, acceleration/deceleration trauma), sjmnptoms of PTSD may

appear. An event causing head trauma may also constitute a psychological traumatic event,

and tramautic brain injury (TBI)-related neurocognitive symptoms are not mutually exclusive

and may occur concurrently. Symptoms previously termed postconcussive (e.g., headaches,

dizziness, sensitivity to light or sound, irritability, concentration deficits) can occur in braininjured and non-brain-injured populations, including individuals with PTSD. Because symptoms of PTSD and TBI-related neurocognitive symptoms can overlap, a differential diagnosis

between PTSD and neurocognitive disorder symptoms attributable to TBI may be possible

based on the presence of symptoms that are distinctive to each presentation. Whereas reexperiencing and avoidance are characteristic of PTSD and not the effects of TBI, persistent disorientation and confusion are more specific to TBI (neurocognitive effects) than to PTSD.

Comorbidity

Individuals with PTSD are 80% more likely than those without PTSD to have symptoms

that meet diagnostic criteria for at least one other mental disorder (e.g., depressive, bipolar, anxiety, or substance use disorders). Comorbid substance use disorder and conduct

disorder are more common among males than among females. Among U.S. military personnel and combat veterans who have been deployed to recent wars in Afghanistan and

Iraq, co-occurrence of PTSD and mild TBI is 48%. Although most young children with

PTSD also have at least one other diagnosis, the patterns of comorbidity are different than

in adults, with oppositional defiant disorder and separation anxiety disorder predominating. Finally, there is considerable comorbidity between PTSD and major neurocognitive

disorder and some overlapping symptoms between these disorders.

Acute Stress Disorder

Diagnostic Criteria 308.3 (F43.0)

A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or

more) of the following ways:

1. Directly experiencing the traumatic event(s).

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

3. Learning that the event(s) occurred to a close family member or close friend. Note:

In cases of actual or threatened death of a family member or friend, the event(s)

must have been violent or accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic

event(s) (e.g., first responders collecting human remains, police officers repeatedly

exposed to details of child abuse).

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

B. Presence of nine (or more) of the following symptoms from any of the five categories

of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred:

Intrusion Symptoms

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic

event(s). Note: In children, repetitive play may occur in which themes or aspects of

the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect of the dream are

related to the event(s). Note: In children, there may be frightening dreams without

recognizable content.

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if

the traumatic event(s) were recurring. (Such reactions may occur on a continuum,

with the most extreme expression being a complete loss of awareness of present

surroundings.) Note: In children, trauma-specific reenactment may occur in play.

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

traumatic event(s).

Negative Mood

5. Persistent inability to experience positive emotions (e.g., inability to experience

happiness, satisfaction, or loving feelings).

Dissociative Symptoms

6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself

from another’s perspective, being in a daze, time slowing).

7. Inability to remember an important aspect of the traumatic event(s) (typically due to

dissociative amnesia and not to other factors such as head injury, alcohol, or

drugs).

Avoidance Symptoms

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

9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or

closely associated with the traumatic event(s).

Arousal Symptoms

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

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

12. Hypervigilance.

13. Problems with concentration.

14. Exaggerated startle response.

C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma

exposure.

Note: Symptoms typically begin immediately after the trauma, but persistence for at

least 3 days and up to a month is needed to meet disorder criteria.

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

E. The disturbance is not attributable to the physiological effects of a substance (e.g.,

medication or alcohol) or another medical condition (e.g., mild traumatic brain injury)

and is not better explained by brief psychotic disorder._________________________

Diagnostic Features

The essential feature of acute stress disorder is the development of characteristic symptoms lasting from 3 days to 1 month following exposure to one or more traumatic events.

Traumatic events that are experienced directly include, but are not limited to, exposure

to war as a combatant or civilian, threatened or actual violent personal assault (e.g., sexual

violence, physical attack, active combat, mugging, childhood physical and/or sexual violence, being kidnapped, being taken hostage, terrorist attack, torture), natural or humanmade disasters (e.g., earthquake, hurricane, airplane crash), and severe accident (e.g.,

severe motor vehicle, industrial accident). For children, sexually traumatic events may

include inappropriate sexual experiences without violence or injury. A life-threatening

illness or debilitating medical condition is not necessarily considered a traumatic event.

Medical incidents that qualify as traumatic events involve sudden, catastrophic events (e.g.,

waking during surgery, anaphylactic shock). Stressful events that do not possess the severe

and traumatic components of events encompassed by Criterion A may lead to an adjustment disorder but not to acute stress disorder.

The clinical presentation of acute stress disorder may vary by individual but typically

involves an anxiety response that includes some form of reexperiencing of or reactivity to

the traumatic event. In some individuals, a dissociative or detached presentation can predominate, although these individuals typically will also display strong emotional or physiological reactivity in response to trauma reminders. In other individuals, there can be a

strong anger response in which reactivity is characterized by irritable or possibly aggressive responses. The full symptom picture must be present for at least 3 days after the traumatic event and can be diagnosed only up to 1 month after the event. Symptoms that occur

immediately after the event but resolve in less than 3 days would not meet criteria for

acute stress disorder.

Witnessed events include, but are not limited to, observing threatened or serious injury, unnatural death, physical or sexual violence inflicted on another individual as a result of violent assault, severe domestic violence, severe accident, war, and disaster; it may

also include witnessing a medical catastrophe (e.g., a life-threatening hemorrhage) involving one's child. Events experienced indirectly through learning about the event are limited

to close relatives or close friends. Such events must have been violent or accidental—death

due to natural causes does not qualify—and include violent personal assault, suicide, serious accident, or serious injury. The disorder may be especially severe when the stressor

is interpersonal and intentional (e.g., torture, rape). The likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase.

The traumatic event can be reexperienced in various ways. Commonly, the individual

has recurrent and intrusive recollections of the event (Criterion Bl). The recollections are

spontaneous or triggered recurrent memories of the event that usually occur in response

to a stimulus that is reminiscent of the traumatic experience (e.g., the sound of a backfiring

car triggering memories of gunshots). These intrusive memories often include sensory

(e.g., sensing the intense heat that was perceived in a house fire), emotional (e.g., experiencing the fear of believing that one was about to be stabbed), or physiological (e.g., experiencing the shortness of breath that one suffered during a near-drowning) components.

Distressing dreams may contain themes that are representative of or thematically related to the major threats involved in the traumatic event. (For example, in the case of a

motor vehicle accident survivor, the distressing dreams may involve crashing cars generally; in the case of a combat soldier, the distressing dreams may involve being harmed in

ways other than combat.)

Dissociative states may last from a few seconds to several hours, or even days, during

which components of the event are relived and the individual behaves as though experiencing the event at that moment. While dissociative responses are common during a traumatic event, only dissociative responses that persist beyond 3 days after trauma exposure

are considered for the diagnosis of acute stress disorder. For young children, reenactment

of events related to trauma may appear in play and may include dissociative moments

(e.g., a child who survives a motor vehicle accident may repeatedly crash toy cars during

play in a focused and distressing manner). These episodes, often referred to as flashbacks,

are typically brief but involve a sense that the traumatic event is occurring in the present

rather than being remembered in the past and are associated with significant distress.

Some individuals with the disorder do not have intrusive memories of the event itself,

but instead experience intense psychological distress or physiological reactivity when

they are exposed to triggering events that resemble or symbolize an aspect of the traumatic

event (e.g., windy days for children after a hurricane, entering an elevator for a male or female who was raped in an elevator, seeing someone who resembles one's perpetrator).

The triggering cue could be a physical sensation (e.g., a sense of heat for a bum victim, dizziness for survivors of head trauma), particularly for individuals with highly somatic presentations. The individual may have a persistent inability to feel positive emotions (e.g.,

happiness, joy, satisfaction, or emotions associated with intimacy, tenderness, or sexuality) but can experience negative emotions such as fear, sadness, anger, guilt, or shame.

Alterations in awareness can include depersonalization, a detached sense of oneself (e.g.,

seeing oneself from the other side of the room), or derealization, having a distorted view of

one's surroundings (e.g., perceiving that things are moving in slow motion, seeing things

in a daze, not being aware of events that one would normally encode). Some individuals

also report an inability to remember an important aspect of the traumatic event that was

presumably encoded. This symptom is attributable to dissociative amnesia and is not attributable to head injury, alcohol, or drugs.

Stimuli associated with the trauma are persistently avoided. The individual may refuse

to discuss the traumatic experience or may engage in avoidance strategies to minimize

awareness of emotional reactions (e.g., excessive alcohol use when reminded of the experience). This behavioral avoidance may include avoiding watching news coverage of

the traumatic experience, refusing to return to a workplace where the trauma occurred, or

avoiding interacting with others who shared the same traumatic experience.

It is very common for individuals with acute stress disorder to experience problems

with sleep onset and maintenance, which may be associated with nightmares or with generalized elevated arousal that prevents adequate sleep. Individuals with acute stress disorder may be quick tempered and may even engage in aggressive verbal and/or physical

behavior with little provocation. Acute stress disorder is often characterized by a heightened sensitivity to potential threats, including those that are related to the traumatic experience (e.g., a motor vehicle accident victim may be especially sensitive to the threat

potentially caused by any cars or trucks) or those not related to the traumatic event (e.g.,

fear of having a heart attack). Concentration difficulties, including difficulty remembering

daily events (e.g., forgetting one's telephone number) or attending to focused tasks (e.g.,

following a conversation for a sustained period of time), are commonly reported. Individuals with acute stress disorder may be very reactive to unexpected stimuli, displaying a

heightened startle response or jumpiness to loud noises or unexpected movements (e.g.,

the individual may jump markedly in the response to a telephone ringing).

Associated Features Supporting Diagnosis

Individuals with acute stress disorder commonly engage in catastrophic or extremely negative thoughts about their role in the traumatic event, their response to the traumatic experience, or the likelihood of future harm. For example, an individual with acute stress

disorder may feel excessively guilty about not having prevented the traumatic event or

about not adapting to the experience more successfully. Individuals with acute stress disorder may also interpret their symptoms in a catastrophic manner, such that flashback

memories or emotional numbing may be interpreted as a sign of diminished mental capacity. It is common for individuals with acute stress disorder to experience panic attacks

in the initial month after trauma exposure that may be triggered by trauma reminders or

may apparently occur spontaneously. Additionally, individuals with acute stress disorder

may display chaotic or impulsive behavior. For example, individuals may drive recklessly, make irrational decisions, or gamble excessively. In children, there may be significant separation anxiety, possibly manifested by excessive needs for attention from

caregivers. In the case of bereavement following a death that occurred in traumatic circumstances, the symptoms of acute stress disorder can involve acute grief reactions. In

such cases, reexperiencing, dissociative, and arousal symptoms may involve reactions to

the loss, such as intrusive memories of the circumstances of the individual's death, disbelief that the individual has died, and anger about the death. Postconcussive symptoms

(e.g., headaches, dizziness, sensitivity to light or sound, irritability, concentration deficits),

which occur frequently following mild traumatic brain injury, are also frequently seen in

individuals with acute stress disorder. Postconcussive symptoms are equally common in

brain-injured and non-brain-injured populations, and the frequent occurrence of postconcussive symptoms could be attributable to acute stress disorder symptoms.

Prevalence

The prevalence of acute stress disorder in recently trauma-exposed populations (i.e.,

within 1 month of trauma exposure) varies according to the nature of the event and the

context in which it is assessed. In both U.S. and non-U.S. populations, acute stress disorder

tends to be identified in less than 20% of cases following traumatic events that do not involve interpersonal assault; 13%-21% of motor vehicle accidents, 14% of mild traumatic

brain injury, 19% of assault, 10% of severe burns, and 6%-12% of industrial accidents.

Higher rates (i.e., 20%-50%) are reported following interpersonal traumatic events, including assault, rape, and witnessing a mass shooting.

Development and Course

Acute stress disorder cannot be diagnosed until 3 days after a traumatic event. Although

acute stress disorder may progress to posttraumatic stress disorder (PTSD) after 1 month,

it may also be a transient stress response that remits within 1 month of trauma exposure

and does not result in PTSD. Approximately half of individuals who eventually develop

PTSD initially present with acute stress disorder. Symptom worsening during the initial

month can occur, often as a result of ongoing life stressors or further traumatic events.

The forms of reexperiencing can vary across development. Unlike adults or adolescents, young children may report frightening dreams without content that clearly reflects

aspects of the trauma (e.g., waking in fright in the aftermath of the trauma but being unable

to relate the content of the dream to the traumatic event). Children age 6 years and younger

are more likely than older children to express reexperiencing symptoms through play that

refers directly or symbolically to the trauma. For example, a very young child who survived a fire may draw pictures of flames. Young children also do not necessarily manifest

fearful reactions at the time of the exposure or even during reexperiencing. Parents typically report a range of emotional expressions, such as anger, shame, or withdrawal, and

even excessively bright positive affect, in young children who are traumatized. Although

children may avoid reminders of the trauma, they sometimes become preoccupied with

reminders (e.g., a young child bitten by a dog may talk about dogs constantly yet avoid going outside because of fear of coming into contact with a dog).

Risk and Prognostic Factors

Temperamental. Risk factors include prior mental disorder, high levels of negative affectivity (neuroticism), greater perceived severity of the traumatic event, and an avoidant

coping style. Catastrophic appraisals of the traumatic experience, often characterized by

exaggerated appraisals of future harm, guilt, or hopelessness, are strongly predictive of

acute stress disorder.

Environmental. First and foremost, an individual must be exposed to a traumatic event to

be at risk for acute stress disorder. Risk factors for the disorder include a history of prior

trauma.

Genetic and physiological. Females are at greater risk for developing acute stress disorder.

\

Elevated reactivity, as reflected by acoustic startle response, prior to trauma exposure

increases the risk for developing acute stress disorder.

Culture-Related Diagnostic Issues

The profile of symptoms of acute stress disorder may vary cross-culturally, particularly

with respect to dissociative symptoms, nightmares, avoidance, and somatic symptoms

(e.g., dizziness, shortness of breath, heat sensations). Cultural syndromes and idioms of

distress shape the local symptom profiles of acute stress disorder. Some cultural groups

may display variants of dissociative responses, such as possession or trancelike behaviors

in the initial month after trauma exposure. Panic symptoms may be salient in acute stress

disorder among Cambodians because of the association of traumatic exposure with paniclike khyâl attacks, and ataque de nervios among Latin Americans may also follow a traumatic

exposure.

Gender-Related Diagnostic Issues

Acute stress disorder is more prevalent among females than among males. Sex-linked neurobiological differences in stress response may contribute to females' increased risk for

acute stress disorder. The increased risk for the disorder in females may be attributable in

part to a greater likelihood of exposure to the types of traumatic events with a high conditional risk for acute stress disorder, such as rape and other interpersonal violence.

Functional Consequences of Acute Stress Disorder

Impaired functioning in social, interpersonal, or occupational domains has been shown

across survivors of accidents, assault, and rape who develop acute stress disorder. The extreme levels of anxiety that may be associated with acute stress disorder may interfere

with sleep, energy levels, and capacity to attend to tasks. Avoidance in acute stress disorder can result in generalized withdrawal from many situations that are perceived as

potentially threatening, which can lead to nonattendance of medical appointments, avoidance of driving to important appointments, and absenteeism from work.

Differential Diagnosis

Adjustment disorders. In acute stress disorder, the stressor can be of any severity rather

than of the severity and type required by Criterion A of acute stress disorder. The diagnosis of

an adjustment disorder is used when the response to a Criterion A event does not meet the criteria for acute stress disorder (or another specific mental disorder) and when the symptom pattern of acute stress disorder occurs in response to a stressor that does not meet Criterion A for

exposure to actual or threatened death, serious injury, or sexual violence (e.g., spouse leaving,

being fired). For example, severe stress reactions to life-threatening illnesses that may include

some acute stress disorder symptoms may be more appropriately described as an adjustment

disorder. Some forms of acute stress response do not include acute stress disorder symptoms

and may be characterized by anger, depression, or guilt. These responses are more appropriately described as primarily an adjustment disorder. Depressive or anger responses in an

adjustment disorder may involve rumination about the traumatic event, as opposed to involuntary and intrusive distressing memories in acute stress disorder.

Panic disorder. Spontaneous panic attacks are very common in acute stress disorder.

However, panic disorder is diagnosed only if panic attacks are unexpected and there is

anxiety about future attacks or maladaptive changes in behavior associated with fear of

dire consequences of the attacks.

Dissociative disorders. Severe dissociative responses (in the absence of characteristic

acute stress disorder symptoms) may be diagnosed as derealization/depersonalization

disorder. If severe amnesia of the trauma persists in the absence of characteristic acute

stress disorder symptoms, the diagnosis of dissociative amnesia may be indicated.

Posttraumatic stress disorder. Acute stress disorder is distinguished from PTSD because

the symptom pattern in acute stress disorder must occur within 1 month of the traumatic event

and resolve within that 1-month period. If the symptoms persist for more than 1 month and

meet criteria for PTSD, the diagnosis is changed from acute stress disorder to PTSD.

Obsessive-compulsive disorder. In obsessive-compulsive disorder, there are recurrent

intrusive thoughts, but these meet the definition of an obsession. In addition, the intrusive

thoughts are not related to an experienced traumatic event, compulsions are usually present, and other symptoms of acute stress disorder are typically absent.

Psychotic disorders. Flashbacks in acute stress disorder must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in schizophrenia, other psychotic disorders, depressive or bipolar disorder with psychotic features, a

delirium, substance/medication-induced disorders, and psychotic disorders due to another medical condition. Acute stress disorder flashbacks are distinguished from these

other perceptual disturbances by being directly related to the traumatic experience and by

occurring in the absence of other psychotic or substance-induced features.

Traumatic brain injury. When a brain injury occurs in the context of a traumatic event

(e.g., traumatic accident, bomb blast, acceleration/deceleration trauma), symptoms of

acute stress disorder may appear. An event causing head trauma may also constitute a

psychological traumatic event, and tramautic brain injury (TBI)-related neurocognitive

symptoms are not mutually exclusive and may occur concurrently. Symptoms previously

termed postconcussive (e.g., headaches, dizziness, sensitivity to light or sound, irritability,

concentration deficits) can occur in brain-injured and non-brain injured populations, including individuals with acute stress disorder. Because symptoms of acute stress disorder

and TBI-related neurocognitive symptoms can overlap, a differential diagnosis between

acute stress disorder and neurocognitive disorder symptoms attributable to TBI may be

possible based on the presence of symptoms that are distinctive to each presentation. Whereas reexperiencing and avoidance are characteristic of acute stress disorder and

not the effects of TBI, persistent disorientation and confusion are more specific to TBI (neurocognitive effects) than to acute stress disorder. Furthermore, differential is aided by the

fact that symptoms of acute stress disorder persist for up to only 1 month following trauma

exposure.

Adjustment Disorders

Diagnostic Criteria

A. The development of emotional or behavioral symptoms in response to an identifiable

stressor(s) occurring within 3 months of the onset of the stressor(s).

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

the following:

1. Marked distress that is out of proportion to the severity or intensity of the stressor,

taking into account the external context and the cultural factors that might influence

symptom severity and presentation.

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

C. The stress-related disturbance does not meet the criteria for another mental disorder

and is not merely an exacerbation of a preexisting mental disorder.

D. The symptoms do not represent normal bereavement.

E. Once the stressor or its consequences have terminated, the symptoms do not persist

for more than an additional 6 months.

Specify whether:

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

309.24 (F43.22) With anxiety: Nervousness, worry, jitteriness, or separation anxiety

is predominant.

309.28 (F43.23) With mixed anxiety and depressed mood: A combination of depression and anxiety is predominant.

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

309.4 (F43.25) With mixed disturbance of emotions and conduct: Both emotional

symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant.

309.9 (F43.20) Unspecified: For maladaptive reactions that are not classifiable as one

of the specific subtypes of adjustment disorder.______________________________

Diagnostic Features

The presence of emotional or behavioral symptoms in response to an identifiable stressor

is the essential feature of adjustment disorders (Criterion A). The stressor may be a single

event (e.g., a termination of a romantic relationship), or there may be multiple stressors

(e.g., marked business difficulties and marital problems). Stressors may be recurrent (e.g.,

associated with seasonal business crises, unfulfilling sexual relationships) or continuous

(e.g., a persistent painful illness with increasing disability, living in a crime-ridden neighborhood). Stressors may affect a single individual, an entire family, or a larger group or

community (e.g., a natural disaster). Some stressors may accompany specific developmental events (e.g., going to school, leaving a parental home, reentering a parental home, getting married, becoming a parent, failing to attain occupational goals, retirement).

Adjustment disorders may be diagnosed following the death of a loved one when the

intensity, quality, or persistence of grief reactions exceeds what normally might be expected, when cultural, religious, or age-appropriate norms are taken into account. A more

specific set of bereavement-related symptoms has been designated persistent complex bereavement disorder.

Adjustment disorders are associated with an increased risk of suicide attempts and

completed suicide.

Prevalence

Adjustment disorders are common, although prevalence may vary widely as a function of

the population studied and the assessment methods used. The percentage of individuals

in outpatient mental health treatment with a principal diagnosis of an adjustment disorder

ranges from approximately 5% to 20%. In a hospital psychiatric consultation setting, it is

often the most common diagnosis, frequently reaching 50%.

Development and Course

By definition, the disturbance in adjustment disorders begins within 3 months of onset of

a stressor and lasts no longer than 6 months after the stressor or its consequences have

ceased. If the stressor is an acute event (e.g., being fired from a job), the onset of the disturbance is usually immediate (i.e., within a few days) and the duration is relatively brief

(i.e., no more than a few months). If the stressor or its consequences persist, the adjustment

disorder may also continue to be present and become the persistent form.

Risk and Prognostic Factors

Environmental. Individuals from disadvantaged life circumstances experience a high

rate of stressors and may be at increased risk for adjustment disorders.

Culture-Reiated Diagnostic issues

The context of the individual's cultural setting should be taken into account in making the

clinical judgment of whether the individual's response to the stressor is maladaptive or

whether the associated distress is in excess of what would be expected. The nature, meaning, and experience of the stressors and the evaluation of the response to the stressors may

vary across cultures.

Functional Consequences of Adjustment Disorders

The subjective distress or impairment in functioning associated with adjustment disorders

is frequently manifested as decreased performance at work or school and temporary

changes in social relationships. An adjustment disorder may complicate the course of illness in individuals who have a general medical condition (e.g., decreased compliance with

the recommended medical regimen; increased length of hospital stay).

Differential Diagnosis

Major depressive disorder. If an individual has symptoms that meet criteria for a major

depressive disorder in response to a stressor, the diagnosis of an adjustment disorder is

not applicable. The symptom profile of major depressive disorder differentiates it from adjustment disorders.

Posttraumatic stress disorder and acute stress disorder. In adjustment disorders, the

stressor can be of any severity rather than of the severity and type required by Criterion A

of acute stress disorder and posttraumatic stress disorder (PTSD). In distinguishing adjustment disorders from these two posttraumatic diagnoses, there are both timing and

symptom profile considerations. Adjustment disorders can be diagnosed immediately

and persist up to 6 months after exposure to the traumatic event, whereas acute stress disorder can only occur between 3 days and 1 month of exposure to the stressor, and PTSD

cannot be diagnosed until at least 1 month has passed since the occurrence of the traumatic

stressor. The required symptom profile for PTSD and acute stress disorder differentiates

them from the adjustment disorders. With regard to symptom profiles, an adjustment disorder may be diagnosed following a traumatic event when an individual exhibits symptoms

of either acute stress disorder or PTSD that do not meet or exceed the diagnostic threshold

for either disorder. An adjustment disorder should also be diagnosed for individuals who

have not been exposed to a traumatic event but who otherwise exhibit the full symptom profile of either acute stress disorder or PTSD.

Personality disorders. With regard to personality disorders, some personality features

may be associated with a vulnerability to situational distress that may resemble an adjustment disorder. The lifetime history of personality functioning will help inform the interpretation of distressed behaviors to aid in distinguishing a long-standing personality

disorder from an adjustment disorder. In addition to some personality disorders incurring

vulnerability to distress, stressors may also exacerbate personality disorder symptoms. In

the presence of a personality disorder, if the symptom criteria for an adjustment disorder

are met, and the stress-related disturbance exceeds what may be attributable to maladaptive personality disorder symptoms (i.e.. Criterion C is met), then the diagnosis of an adjustment disorder should be made.

Psychological factors affecting other medical conditions. In psychological factors affecting other medical conditions, specific psychological entities (e.g., psychological symptoms, behaviors, other factors) exacerbate a medical condition. These psychological

factors can precipitate, exacerbate, or put an individual at risk for medical illness, or they

can worsen an existing condition. In contrast, an adjustment disorder is a reaction to the

stressor (e.g., having a medical illness).

Normative stress reactions. When bad things happen, most people get upset. This is

not an adjustment disorder. The diagnosis should only be made when the magnitude of

the distress (e.g., alterations in mood, anxiety, or conduct) exceeds what would normally

be expected (which may vary in different cultures) or when the adverse event precipitates

functional impairment.

Comorbidity

Adjustment disorders can accompany most mental disorders and any medical disorder.

Adjustment disorders can be diagnosed in addition to another mental disorder only if the

latter does not explain the particular symptoms that occur in reaction to the stressor. For

example, an individual may develop an adjustment disorder, with depressed mood, after

losing a job and at the same time have a diagnosis of obsessive-compulsive disorder. Or,

an individual may have a depressive or bipolar disorder and an adjustment disorder as

long as the criteria for both are met. Adjustment disorders are common accompaniments

of medical illness and may be the major psychological response to a medical disorder.

Other Specified Trauma- and

Stressor-Related Disorder

309.89 (F43.8)

This category applies to presentations in which symptoms characteristic of a trauma- and

stressor-related disorder that cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning predominate but do not meet the full

criteria for any of the disorders in the trauma- and stressor-related disorders diagnostic

class. The other specified trauma- and stressor-related 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 trauma- and stressor-related disorder. This

is done by recording “other specified trauma- and stressor-related disorder” followed by

the specific reason (e.g., “persistent complex bereavement disorder”).

Examples of presentations that can be specified using the “other specified” designation

include the following:

1. Adjustment-like disorders with delayed onset of symptoms that occur more than

3 months after the stressor.

2. Adjustment-like disorders with prolonged duration of more than 6 months without prolonged duration of stressor.

3. Ataque de nervios: See “Glossary of Cultural Concepts of Distress” in the Appendix.

4. Other cultural syndromes: See “Glossary of Cultural Concepts of Distress” in the Appendix.

5. Persistent complex bereavement disorder: This disorder is characterized by severe

and persistent grief and mourning reactions (see the chapter “Conditions for Further

Study”)

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