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Copyright@2000 American Psychiatric Association
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Correspondence regilrding copyright permissions should be directed to the DS~'I
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The correct citation for this book is American Psychiatric Association: Diagnost
ic and Statistical
,Walll/al 01Mmtal Disor,lm, Fourth Edition, Text Revision. Washington, IX, Ameri
can Psychiatric
Association, 2000.
libraI'}' of Congress Cataloging-in-Publieation Data
Diagnostic and statistical manual of mental disorders; DS~'I-IV.-Ithed.,te;<t re
vision.
p. ; em.
Prepared by the Task Force on DS~IlV
and othercommHtecs and workgroups of the American
Psychiatric Association.
Includes index.
ISBN 0-89042-02+-6 (casebound; alk. paper}-ISBN 0-89CJ.l2-oE-4 (pbk.; alk. paper
)
J. Mental illness-Classification-Handbooks, manuals, ele. 2. ~'lentaJ
illness-DiagnosisHandbooks,
manuals, etc. L Title; DS~
l-rv. II. American Psychiatric Association. UI. American
Psychiabic Association. Task Force on DS~IIV.
IDNL~..I: 1. Mental Disorders-classification. 2. ~lental
Disorders--diagnosis.
WM IS 0.536 20001
RC45S.2.G 0.536 2000
616.89'075----dc21
00-024852
British Library Cataloguing in Publication Data
A CW record is available from the British Library.
Text Design-Anne Barnes
~Ianufactu.ring-R.R. Donnelley & Sons Company
Contents
Task Force on DSM-IV.................................. xi
Work Groups for the DSM-IV-TR Text Revision
Acknowledgments for DSM-IV-TR...................... xix
Acknowledgments for
DSM-IV Text Revision .......................... xxi
Introduction . ....................................... xxiii
Cautionary Statement _ xxxvii
Use of the Manual .................................1
DSM-IV-TR Classification .............................13
Multiaxial Assessment ..................................27
Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence ................ .39
Delirium, Dementia, and Amnestic and
Other Cognitive Disorders
Mental Disorders Due to a General Medical Condition
135
181
Substance-Related Disorders 191
Schizophrenia and
Other Psychotic Disorders .............................297
Mood Disorders ................................34S
Anxiety Disorders .................................... .429
Somatoform Disorders ............................ .485
Factitious Disorders ............................513
Dissociative Disorders
Sexual and Gender Identity Disorders...................535
Eating Disorders .............................583
Sleep Disorders 597
Impulse-Control Disorders Not Elsewhere Classified 663
Adjustment Disorders .................................679
Personality Disorders ..........................685
Other Conditions That May Be a
Focus of Clinical Attention ........................731
Additional Codes ....................................743
Appendix A
Decision Trees for Differential Diagnosis . ................ .745
Appendix B
Criteria Sets and Axes Provided for Further Study...........759
Appendix C
Glossary of Technical Terms...........................819
Appendix 0
Highlights of Changes in
DSM-IV Text Revision ............................829
Appendix E
Alphabetical Listing of
DSM-IV-TR Diagnoses and Codes ......................845
Appendix F
Numerical Listing of
D5M-IV-TR Diagnoses and Codes .....................857
Appendix G
ICD-9-CM Codes for Selected General Medical
-Conditions and Medication-Induced Disorders 867
Appendix H
DSM-IV Classification
(With ICD-lO Codes) ..................................883
Appendix I
Outline for Cultural Formulation and
Glossary of Culture-Bound Syndromes ................897
Appendix J
DSM-IV Contributors ..................................90S
Appendix K
DSM-IV Text Revision Advisers......................929
Index 933
TASK FORCE ON DSM-IV
ALLEN FRANCES, M.D.
Clzairpersoll
HAROLD ALAN PlNCUS, M.D.
\'ice-Clwirpersoll
MiCHAEL B. FIRST, lvLD.
Editor, Text alld Criteria
Nancy Coover Andreasen, M.D., Ph.D. Chester W. Schmidt M.D.
David H. Barlow, Ph.D. Marc Alan Schuckit, M.D.
Magda Campbell, M.D. David Shaffer, M.D.
Dennis P. Cantwell, M.D. Robert L Spitzer, M.D.
Special Adviser
Ellen Frank, Ph.D.
Gary]. Tucker, M.D.
Judith H. Gold, M.D.
B. Timothy Walsh, M.D.
John Gunderson, M.D.
Thomas A. Widiger, Ph.D.
Robert E. Hales, M.D.
Researcll Coordillator
Kenneth S. Kendler, M.D.
Janel B. W. Williams, OSW.
David J. Kupfer, M.D.
Jolm C. Urbaitis, M.D.
i'vtichael R. Liebowitz, M.D.
Assembly Linison
Juan Enrique Mezzich, M.D., Ph.D.
James J. Hudziak, M.D.
Peter E. Nathan, Ph.D.
Residellt Fellow (1990-.-1993)
Roger Peele, M.D.
Jwuus Gonzales, M.D.
Darrel A. Regier, M.D., M.P.H. Resident Fellow (1988-1990)
A. John Rush, M.D.
Ruth Ross, M.A.
Sciellce Editor
aney E. Vettorello, M.V.P.
Admillistrative Coordinator
~
Wendy Wakefield Davis, Ed.M.
Editorial Coordilwtor
Cindy D. Jones
Admillislrative Assistnllt
Nancy Sydnor-Greenberg, M.A.
Admillistratiue COllSllltallt
Myriam Kline, M.s.
FOCI/sed Field-Trial Coordillator
James W. Thompson, MD., M.P.H.
Videotape Field-Trial Coordinator
The DSM~rv
Text Revision Work Groups are listed on pp. xv-),:vii.
XI
DSM-IV Work Groups
Anxiety Disorders Work Group
Michael R. Liebowitz, M.D. James c. Ballenger, M.D.
Chairperson
Jonathan Davidson, M.D.
David H. Barlow, Ph.D.
Edna Faa, Ph.D.
Vice-Clwirpersol/
Abby Fyer, M.D.
Delirium, Dementia, and Amnestic and
Other Cognitive Disorders Work Group
Gary J. Tucker, M.D. MarshaJl Folstein, M.D.
Chairpersoll
Gary Lloyd Gottlieb, M.D.
Michael Popkin, M.D.
Igor Grant, M.D.
Vice-Clmirpersoll
Benjamin Liptzin, M.D.
Eric Douglas Caine, ~'1.D.
Disorders Usually First Diagnosed During Infancy,
Childhood, or Adolescence Work Group
David Shaffer, M.D. Rachel Klein, Ph.D.
Co-Chairpcrsoll
Benjamin Lahey, Ph.D.
r-,'lagda Campbell, M.D.
Rolf Loeber, Ph.D.
Co-CJwirpersoll
Jeffrey Newcom, M.D.
Susan J. Bradley, M.D.
Rhea Paul. Ph.D.
Dennis P. Cantwell, M.D.
Judith H. L. Rapoport, M.D.
Gabrielle A. Carlson, M.D.
Sir Michael Rutter, M.D.
Donald Jay Cohen, M.D.
Fred Volkmar, M.D.
Barry Garfinkel, M.D.
John S. Werry, M.D.
Eating Disorders Work Group
B. Timothy Walsh, M.D. Katherine A. Halmi. M.D.
Chairpersoll
James Mitchell, M.D.
Paul Garfinkel, M.D.
G. Terence ''''ilson, Ph.D.
Mood Disorders Work Group
A. John Rush, M.D. David Dunner, M.D.
Owirpersoll
Ellen Frank, Ph.D.
Martin B. Keller, M.D.
Donald F. Klein, M.D.
Vice-Owirpersoll
Mark S. Bauer, M.D.
/
DSM-IV Work Groups xiii I
Multiaxial Issues Work Group
janet B. W. vVilliams, D.5.W.
Clmirpersoll
Howard H. Goldman, M.D., Ph.D.
Vice-Clmirpersoll
Alan M. Gruenberg, M.D.
juan Enrique Mezzich, M.D.,\Ph.D.
Roger Peele, M.D.
Stephen Setterberg, M.D.
Andrew Edward Skodol II, M.D.
Personality Disorders Work Group
jolm Gunderson, M.D.
Chairpersoll
Robert M. A. Hirschfeld, M.D.
Vice-Clmirpersoll
Roger Blashfield, Ph.D.
Susan jean Fiester, M.D.
Theodore Millon, Ph.D.
Bruce Pfohl-M.D.
Tracie Shea, Ph.D.
Larry Siever, M.D.
Thomas A. Widiger, Ph.D.
Premenstrual Dysphoric Disorder Work Group
Judith H. Gold, M.D.
Clmirpersoll
Jean Endicott, Ph.D.
Barbara Parry, M.D.
Sally Severino, M.D.
Nada Logan Stotland, M.D.
Ellen Frank, Ph.D.
COIISII/tUllt
Psychiatric Systems Interface Disorders
(Adjustment, Dissociative, Factitious, Impulse-Control, and
Somatoform Disorders and Psychological Factors Affecting
Medical Conditions) Work Group
Robert E. Hales, M.D.
Clmirpersoll
C. Robert Cloninger, M.D.
Vice-Clmirpersoll
jonathan F. Borus, M.D.
jack Denning Burke, Jr., M.D., M.P.H.
joe P. Fagan, M.D.
Steven A. King, M.D.
Ronald L. Martin, M.D.
Katharine Anne Phillips, M.D.
David A. Spiegel, M.D.
Alan Stoudemire, M.D.
james j. Strain, M.D.
Michael G. Wise, M.D.
Schizophrenia and Other Psychotic Disorders Work Group
Nancy Coover Andreasen, M.D., Ph.D.
Clluirpersoll
john M. Kane, M.D.
Vice-CIJairpersoll
Samuel Keith, M.D.
Kenneth S. Kendler, M.D.
1l1OIllas McGlashan, M.D.
DSM-IV Work Groups
Sexual Disorders Work Group
Chester W. Schmidt, M.D.
Chairpersoll
Raul Schiavi, M.D.
Leslie Schaver, Ph.D.
Taylor Seagraves, lvl.D.
Thomas Nathan Wise, M.D.
Sleep Disorders Work Group
David J. Kupfer, M.D.
Chairperson
Charles F. Reynolds III, M.D.
Vice-Clmirpersoll
Daniel Buysse, M.D.
Roger Peele, M.D.
Quentin Regestein, M.D.
Michael Sateia, 1\'1.0.
MichaellllOrpy, M.D.
Substance-Related Disorders Work Group
Marc Alan Schuckit M.D. Linda B. Cottier, Ph.D.
Chairperson
Thomas Crowley, M.D.
John E. Helzer, M.D.
Peter E. Nathan, Ph.D.
Vice-Clmi'persoJl
George E. Woody, M.D.
Committee on Psychiatric Diagnosis and Assessment
Layton McCurdy, M.D.
C/mirpersoll (1987~1994)
Kenneth Z. Altshuler, M.D. (1987-1992)
Thomas F. Anders, M.D. (1988-1994)
Susan Jane Blumenthal, M.D. (1990
1993)
Leah Joan Dickstein, M.D. (1988-1991)
Lewis J. Judd, M.D. (1988-1994)
Gerald L. KIerman, M.D. (deceased)
(1988-1991)
Stuart C. Yudofsky, M.D. (1992-1994)
Jack D. Blaine, M.D.
Consultant (1987-1992)
Jerry M. Lewis, M.D.
COllsultant (1988-1994)
Daniel J. Luchins, M.D.
Consultant 0987-1991)
Katharine Anne Phillips, M.D.
COl/slt/tant (1992-1994)
Cynthia Pearl Rose, M.D.
COl/sultant (1990-1994)
Louis Alan Moench, M.D.
Assembly LiaiSOIl (1991-1994)
Steven K. Dobscha, M.D.
Resident Fellow (1990-1992)
Mark Zimmerman, M.D.
Resident Fel/ow (1992~1994)
Joint Committee of the Board of Trustees and
Assembly of District Branches on
Issues Related to DSM-IV
Ronald A. Shellow, M.D.
ClUlirperson ......
Harvey Bluestone, M.D.
Leah Joan Dickstein, M.D.
Arthur John Farley, M.D.
Carol Ann Bernstein, M.D.
,
WORK GROUPS FOR THE DSMIV TEXT REVISION
MICHAEL B. FIRST, M.D.
Co-CJlllirpersolllllld Editor
HAROLD ALAN PINCUS, M.D.
Co-Clmirpersoll
Laurie E. McQueen, M.s.s.\Al. Yoshie Satake, B.A.
D5M Project Mallager DSM Program Coordilwtor
Anxiety Disorders Text Revision Work Group
Murray B. Stein, M.D. Michelle Craske, Ph.D.
CI/lIirpersoJl
Edna Foa, Ph.D.
Jonathan Abramowitz, Ph.D.
Thomas Mellman, M.D.
Gordon Asmtmdson, Ph.D.
Ron Norton, Ph.D.
Jean c. Beckham, Ph.D.
Fr,mklin Schneier, M.D.
Timothy Brown, Ph.D., Psy.D.
Richard Zinbarg. Ph.D.
Delirium, Dementia, and Amnestic and
Other Cognitive Disorders and Mental Disorders
Due to a General Medical Condition Text Revision Work Group
Eric Douglas Caine, M.D. Jesse Fann, M.D., M.P.H.
Disorders Usually First Diagnosed During Infancy,
Childhood, or Adolescence Text Revision Work Group
David Shaffer, MD. Ami Klint Ph.D.
Chairpersoll
Daniel: Pine, M.D.
Donald J. Cohen, M.D.
Mark A. Riddle, M.D.
Stephen Hinshaw, Ph.D.
Fred R. Volkmar, M.D.
Rachel G. Klein, Ph.D.
Charles Zeanah, M.D.
,
Eating Disorders Text Revision Work Group
Katharine L. Locb, Ph.D. B. Timothy Walsh, MD.
Medication-Induced Movement Disorders
Text Revision Work Group
Gerard Addonizio, M.D. Alan Cdenberg, M.D.
Lenard Adler, .M.D. James Jefferson, MD.
Burton Angrist, M.D. Dilip ]estet M.D.
Daniel Casey, M.D. Peler Weiden, M.D.
xv
,
,
Ixvi DSM-IV-TR Work Groups
Mood Disorders Text Revision Work Group
Mark S. Bauer, M.D. J\1ichael E. Thase, M.D.
Patricia Suppes, M.D., Ph.D.
Multiaxial Text Revision Work Group
Alan M. Gruenberg, M.D.
Personality Disorders Text Revision Work Group
Bruce Pfohl, M.D. Thomas A. Widiger, Ph.D.
Premenstrual Dysphoric Disorder Text Revision Work Group
Sally Severino, rvl.D.
-
Psychiatric System Interface Disorders (Adjustment, Dissociative,
Factitious, Impulse-Control, and Somatoform Disorders and
Psychological Factors Affecting Medical Conditions)
Text Revision Work Group
Mitchell Cohen, M.D. Russell 'O)'e5, Jr., M.D.
Marc Feldman, M.D. Katharine Anne Phillips. M.D.
Eric Hollander, M.D. Eyal Shemesh, M.D.
Steven A. King, M.D. David A. Spiegel, l\.'I.D.
James Levenson, M.D. James J. Strain, M.D.
Ronald L. l\<lartin, M.D. (deceased) Sean H. Yutzy, M.D.
Jeffrey Newcom, M.D.
Schizophrenia and Other Psychotic Disorders
Text Revision Work Group
Michael Flaum, M.D. Xavier Amador, Ph.D.
Clmirpersoll
Sexual and Gender Identity Disorders Text Revision Work Group
Chester W. Schmidt, M.D. Thomas Nathan Wise, M.D.
R. Taylor Segraves, M.D. Kenneth]. Zucker, Ph.D.
Sleep Disorders Text Revision Work Group
Daniel Buysse, lI.I.D. Peter Nowell, M.D.
Substance-Related Disorders Text Revision Work Group
Marc Alan 5chuckit, M.D.
L_
DSM-IV-TR Work Groups
American Psychiatric Association
Committee on Psychiatric Diagnosis and Assessment
David J. Kupfer, M.D.
ellair
James Leckman, M.D.
Member
Katharine Anne Phillips, M.D.
Member
A. John Rush, M.D.
Member
Daniel Winstead, MD.
Member
Bonnie Zima, M.D., Ph.D.
Member
Barbara Kennedy, M.D., Ph.D.
COl/sultant
Janet B. W. Williams, DS.W.
COl/saltllllt
Louis Alan Moench, M.D.
Assembly Liaisoll
Jack Barchas, M.D.
Corresponding Member
Herbert ''','. Harris, M.D., Ph.D.
Correspolldillg Member
Charles Kaelber, M.D.
CorrespoJldillg Member
Jorge A. Costa e SiJva, M.D.
Correspol/dillg Member
T. Bedirhan Ustun, M.D.
Corresponding Member
Yeshuschandra Dhaibar, M.D.
APA/Glaxo-We//come Fe/low
Acknowledgments for DSM-IV
DSM-lV was a team effort. More than 1,000 people (and numerous professional
organizations) have helped us in the preparation of this document. Members of th
e
Task Force on DSM-IV and DSM-IV Staff are listed on p. xi, members of the DSM-IV
Work Groups are listed on pp. xii-xiv, and a list of olher participants is inclu
ded in
Appendix J.
The major responsibility for the content of DSM-IV rests with the Task Force on
DSM-IV and members of the DSM-lV Work Groups. They have worked (often much
harder than they bargained for) with a dedication and good cheer that has been i
nspirational
to us. Bob Spitzer has ourspecial thanks for his untiring efforts and unique per
spective.
Norman Sartorius, Darrel Regier, Lewis Judd, Fred Goodwin, and Chuck
Kaelber were instrumental in facilitating a mutually productive interchange betw
een
the American Psychiatric Association and the World Health Organization that has
improved both DsM-IV and ICD-lO, and increased their compatibility. We are grate
ful
to Robert Israel, Sue Meads, and Amy Blum at the National Center for Health
Statistics and Andrea Albawn-Feinstein at the American Health Information Manage
ment
Association for suggestions on the DSM-IV coding system. Denis Prager,
Peter Nathan, and David Kupfer helped us to develop a novel data reanalysis stra
tegy
that has been supported with funding from the John D. and Catherine T. MacArthur
Fowldation.
Many individuals within the American Psychiatric Association deserve recognition
.
Mel Sabshin's special wisdom and grace made even the most tedious tasks seem
worth doing. The American Psychiatric Association Committee on Psychiatric Diagn
osis
and Assessment (chaired by Layton McCurdy) provided valuable direction and
counsel. We would also like to thank the American Psychiatric Association Presid
ents
(Drs. Fink, Pardes, Benedek, HartmatUl, English, and Mcintyre) and Assembly Spea
kers
(Drs. Cohen, FlatIUTI, Hanin, Pfachler, and shellow).\\'ho helped with the plann
ing
of our work. Carolyn Robinowitz and Jack White, and their respective staffs in t
he
American Psychiatric Association Medical Director's Office and the Business Admi
.nistration
Office, have provided valuable assistatlCe in the organization of the project.
Several other individuals have our special gratitude. Wendy Davis, Nancy Vettore
llo,
and Nancy Sydnor-Greenberg developed and implemented an organizational
structure that has kept this complex project from spinning out of control. We ha
ve
also been blessed with an wlUsually able administrative staff, which has include
d
Elisabeth Fitzhugh, Willa I-fall, Kelly McKinney, Gloria ~{iele,
Helen stayna, Sarah
Tilly, lina Rosenthal, Susan Mann, Joanne Mas, and, especially, Cindy Jones. Rut
h
Ross, our tireless Science Editor, has been responsible for improving the clarit
y of expression
and organization of DsM-IV. Myriam Kline (Research Coordinator for the
NIH-funded DSM-IV Focused Field Trials), Jim Thompson (Research Coordinator for
XIX
Acknowledgments for DSMIV
the MacArthur Foundation-funded Videotape Field Trial), and Sandy Ferris (Assist
ant
Director for the Office of Research) have made many valuable contributions. We
would also like to acknowledge all the other staff persons at the American Psych
iatric
Association who have helped with this project. Ron Mc\1iUen, Claire Reinburg.. P
am
Harley. and Jane Davenport of American Psychiatric Press have provided expert pr
o-cluction
assistance.
Allen Frances, M.D.
Chairpersoll, Task Force OIl DSM-IV
Harold Alan Pincus, M.D.
Vice-ClJairpersoll, Task Force all DSM-IV
Michael B. First, M.D.......
Editor, DSM~lV
Text (/lid Criteria
Thomas A. Widiger, Ph.D.
Resenrcll Coordillator
Acknowledgments for
DSM-IV Text Revision
,
The effort to revise the DSM-IV text was also a team effor!. We are especially i
ndebted
to the tireless efforts of the DSM-IY Text Revision Work Groups (listed on
pp. xv-xvii), who did the lion's share of the work in the preparation of this re
vision.
''''e would also llke to acknowledge the contribution of the various .1dvisers t
o the
Work Groups (see Appendix K, p. 929), who provided their perspccti\!C on whether
the proposed dlanges were justified. Finally, we would like to thank the America
n
Psychiatric Association's Committee on Psychiatric Diagnosis and Assessment (lis
ted
on p. xvii), who provided helpful guidance and oversight during the process as w
ell
as approv,,] of the final document. Special gratitude goes to committee members
Katharine A. Phillips and Janet B. W. \,\'iHiams, for their meticulously careful
review
of the text revision. Of course, none of this could have happened without the in
valuable
organizational and administrative assistance provided by the DSM-IV staff,
Laurie tvlcQueen and Yoshie Satake, and production assistance provided by Anne
Barnes, Pam Harley, Greg Kuny, Claire Rcinburg, and Ron McMillen at American
Psychiatric Press.
~'lichaell3.
First, MD.
Co-CiUlirpersOIl and Editor
Harold AJan Pincus, M.D.
Co-Chairperson
XXI
Introduction
ThiS is the fourth edition of the American Psychiatric Association's Diagnostic
alld
Statistical Mmllla/ ofMel/tal Disorders, or DSM-IV. The utility and credibility
of DSM-IV
require that it focus on its clinical, research, and educational purposes and be
support
ed b)' an extensive empirical foundation. Our highest priority has been to provi
de a
helpful guide to clinical practice. We hoped to make DSM-IV practical and useful
for
clinicians by striving for brevity of criteria sets, clarity of language, and ex
plicit statements
of the constructs embodied in the diagnostic criteria. An additional goal was to
facilitate research and improve communication among clinicians and researchers.
We
were also mindful of the use of DSM-IV for improving the coUeenan of clinical in
formation
and as an educational tool for teaching psychopathology.
An official nomenclature must be applicable in a wide diversity of contexts. DSM
-IV
is used by clinicians and researchers of many different orientations (e.g., biol
ogical,
psychodynamic, cognitive, behavioral, interpersonal, family/systems). It is used
. by
psychiatrists, other physicians. psychologists, social workers, nurses, occupati
onal and
rehabilitation therapists, counselors, and other health and mental health profes
sionals.
DSl"f-IV must be usable across settings--inpatient, outpatient, partial hospital
,
consultation-liaison, clinic, private practice, and primary care, and with commu
nity
populations. It is also a necessary tool for collecting and commwtlcating accura
te
public health statistics. Fortunately, all these many uses are compatible with o
ne
another.
DSM-IV was the product of 13 Work Groups (see Appendix J), each of which had
primary responsibility for a section of the manual. This organization was design
ed to
increase participation by experts in each of the respective fields. We took a nu
mber of
precautions to ensure that the Work Group recommendations would reflect the
breadth of available evidence and opinion and not just the views of the specific
members.
After extensive consultations with experts and clinicians in each field, we sele
cted
\-\'ork Group members who represented a wide range of perspectives and
experiences. Work Group members were instructed that they were to participate as
consensus scholars and not as advocates of previously held views. Furthermore, w
e
established a formal e\'idence-based process for the \Nork Groups to follow.
The Work Groups reported to the Task Force on DSM-TV (see p. xi). which consiste
d
of 27 members, many of whom also chaired a Work Group. Each of the 13 Work
Groups was composed of 5 (or more) members whose reviews were critiqued by
beh\'een SO and 100 advisers, who were also chosen to represent diverse clinical
and
research expertise, disciplines, backgrounds, and settings. The involvement of m
any
international experts ensured that DSM-IV had available the widest pool of infor
mation
and would be applicable across cultures. Conferences and workshops were held
to prOVide conceptual and methodological guidance for the DSlI.<I-IV effort. The
se
xxiii
XXIV Introduction
included a number of consultations between the developers of DSM-IV and the deve
lopers
of lCD-lO conducted for the purpose of increasing compatibility between
the two systems. Also held were methods conferences thai focused on cultural fac
tors
in the diagnosis of menial disorder, on geriatric diagnosis, and on psychiatric
diagnosis
in primary care settings.
To maintain open and extensive lines of communication, the Task Force on DSM-IV
established a liaison with many other components within the American Psychiatric
Association and with more than 60 organizations and associations interested in t
he
development of DSM-IV (e.g., American Health information Management Association,
American Nurses' Association, American Occupational Therapy Association,
American Psychoanalytic Association, American Psychological Association, America
n
Psychological Society. Coalition for the Family, Group for the Advancement of
Psychiatry, National Association of Social Workers, alional Center for Health St
atistics,
''''arid Health Organization). We attempted 10 air issues and empirical evidence
early in the process in order to identify potential problems and differences in
interpretation. Exchanges of infomlation were also made possible through the dis
tribution
of a semiannual newsletter (the DSM-lV Updflte), the publication of a regular
column on DSM-IV in Hospitfll fllld COllllllunity Psyc1liatry, frequent presenta
tions at
national and international conferences, and numerous journal articles.
Two years before the publication of DSt>.'I-IV, the Task Force published. and wi
dely
distributed. the DSM-lV Options Book. This volume presented a comprehensive sum
mary of the alternative proposals that were being considered for inclusion in DS
M-IV
in order to solicit opinion and additional data for our deliberations. We receiv
ed ex
tensh'e correspondence from interested individuals who shared with us additional
data and recommendations on the potential impact of the possible changes in DSM-
TV
on their clinical practice, teaching, research, and administrative work. This br
eadth of
discussion helped us to anticipate problems and to attempt to find the best solu
tion
among the various options. One year before the publication of DSM-IV, a nearfinal
draft of the proposed criteria sets was dishibuted to allow for one last critiqu
e.
In arriving at final DSM-IV decisions, the Work Groups and the Task Force review
ed
all of the extensive empirical evidence and correspondence that had been
gathered. It is our belief that the major innovation of DSM-IV lies not in any o
f its specific
content changes but rather in the systematic and explicit process by which it wa
s
constructed and documented. More than any other nomenclature of mental disorders
,
D51\-1-1V is grounded in empirical evidence.
Historical Background
The need for a classification of mental disorders has been clear throughout the
history
of medicine, but there has been little agreement on which disorders should be in
clud
ed and the optimal method for their organization. The many nomenclatures that ha
ve
been developed. during the past h,o millennia have differed in their relative emp
hasis
on phenomenology. etiology, and course as defining features. Some systems have
included only a handful of diagnostic categories; others have included thousands
.
Moreover, the various systems for categorizing mental disorders have differed wi
th
respect to whether their principle objective was for use in clinical, research,
or statistical
settings. Because the history of classification is too extensive to be summarize
d
l_
Introduction XXIX I
fourth volume contains reports of the data reanalyses, reports of the field tria
ls, and
a final executive summary of the rationale for the decisions made by each Work
Group. In addition, many papers were stimulated by the efforts toward empirical
documentation in DSM.-IV, and these have been published in peer-reviewed journal
s.
Relation to ICD-10
The tenth re\'jsion of the Illtematiolltll Statistical Cfassificatioll of Diseas
es alld Related
Heaftl, Problems (ICD-lO), developed by WHO, was published in 1992. A clinical m
odification
of lCD-to (lCD-ID-eM) is expected to be implemented in the United States
in 2004. TIlOse preparing ICDlO and DSM-JV have worked closely to coordinate thei
r
efforts, resulting in much mutual influence. lCD-IO consists of an official codi
ng system
and other related clinical and research documents and instruments. The codes
and terms provided in DSM-IV are fully compatible with both ICD-9-CM and ICD-lO
(see Appendix H). The clinical and research drafts of lCD-10 were thoroughly re
viewed b}' the DSM-TV Work Groups and suggested important topics for DSM-IV lite
rature
reviews and data reanalyses. Draft versions of the ICD-lO Diagnostic Criteria
for Research were included as alternatives to be compared with DSM-rrT, OSM-ID-R
,
and suggested DSM-JV criteria sets in the DSM-JV field trials. The many consulta
tions
between the developers of DSM-JV and ICD10 (which were facilitated by
l'\.TJMH, i\.TJDA, and NlAAA) were enormously useful in increasing the congruenc
e
and reducing meaningless differences in wording behveen the two systems.
The DSM-IV Text Revision
One of the most important uses of DSM-JV has been as an educational tool. This i
s
especially true of the descriptive text that accompanies the criteria sets for O
Sr-.I-JV
disorders. Given that the interval beh,reen DSM-IV and DSMV is being extended
relative to the intervals beh"een earlier editions (from 7 years behveen DSM-ID
and
DSM-IH-R and behveen DSM-nt-R and DSM-lV, to at least 12 years), the information
in the text (which was prepared on the basis of literature dating up to 1992) ru
ns the
risk of becoming increasingly out-of-pace with the large volume of research pub
lished each year. In order to bridge the span between DSM-fV and DSM-V, a revisi
on
of the DSM-JV text was lll1dertaken. The goals of this text revision were severa
lfold:
1) to correct any factual errors that were identified in the DSM-IV text; 2) to
re\'iew
the DSMJV text to ensure that all of the information is still up-tn-date; 3) to m
ake
changes to the DSM-IV text to reneet new information available since the DSM-IV
literature
reviews were completed in 1992; 4) to make improvements that will enhance
the educational value of OSMlV; and 5) to update those lCD9CM codes that were
changed since the DSM-lV 1996 Coding Update. As with the original DSM-IV, all
changes proposed for the text had to be supported by empirical data. Furthermore
,
all proposed changes were limited to the text sections (e.g., Associated Feature
s and
Disorders, Prevalence). No substantive changes in the criteria sets were conside
red,
nor were any proposals entertained for new disorders, new subtypes, or changes i
n
the status of the DSM-IV appendix categories.
The text revision process began in 1997 with the appointment of DSM-TV Text Revi
sion
Work Groups, corresponding to the original DSM-IV Work Group structure.
Introduction xxv
here, we focus briefly only on those aspects that have led directly to the devel
opment
of the Diagnosfic alld Statistical Mallual of Mel/tal Disorders (DSM) and to the
"Menial
Disorders" sections in the various editions of the Illternatiollal Classificatio
ll of Diseases
(!CD).
In the United States, the initial impetus for developing a classification of men
tal
disorders was the need to collect statistical information. What might be conside
red
the first official attempt to gather information about mental illness in the Uni
ted
States was the recording of the frequency of one category-"idiocy/insanity" in t
he
1840 census. By the IBBO census, seven categories of mental illness were disting
uished-
mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy.
In 1917, the Committee on Statistics of the American Psychiatric Association
(atlhat time called the American Medico-Psychological Association [Ihe name was
changed in 1921)), together with the National Commission on Mental Hygiene, form
ulated
a plan that was adopted by the Bureau of the Census for gathering uniform
statistics across mental hospitals. Although this system devoted more attention
to
clinical utility than did previous systems, it was still primarily a statistical
classification.
TIle American Psychiatric Association subsequently collaborated with the New
York Academy of Medicine to develop a nationally acceptable psychiatric nomencla
ture
that would be incorporated within the first edition of the American Medic,ll
Association's Standard Classified Nomenclaltue of Disease. This nomenclature was
designed primarily for diagnosing inpatients with severe psychiatric and neurolo
gical
disorders.
A much broader nomenclature was later developed by the U.s. Army (and modified
by the Veterans Administration) in order to better incorporate the outpatient pr
esentations
of World War II servicemen and veterans (e.g., psychophysiological,
personality, and acute disorders). Contemporaneously, the World Health Organizat
ion
(WHO) published the sixth edition of lCD, whidl, for the first time, included
a section for mental disorders. rCD-6 was heavily influenced by the Veterans Adm
inistration
nomenclature and included 10 categories for psychoses, 9 for psychoneuroses,
and 7 for disorders of character, behavior, and intelligence.
The American Psychiatric Association Committee on omenclature and Statistics
developed a variant of the ICD-6that was published in 1952 as the first edition
of the
Diagnostic alld Statistical Mallllal: MCIltal Disorders (DSM-I). DSM-I contained
a glossary
of descriptions of the diagnostic categories and ,,:-as'the first official manua
l of
mental disorders to focus on clinical utility. TIle lise of the term reactioll t
hroughout
DSM-I reflected the influence of Adolf Meyer's psychobiological view that mental
disorders represented reactions of the personality to psychological, social, and
biological
factors.
In part because of the lack of widespread acceptance of the mental disorder taxo
nomy
contained in ICD-6 and ICD-7, WHO sponsored a comprehensive review of
diagnostic issues that was conducted by the British psychiatrist Stengel. His re
port
can be credited with having inspired many of the recent advances in diagnostic m
ethodology-
most especially the need for explicit definitions as a means of promoting
reliable clinical diagnoses. However, the next round of diagnostic revision, whi
ch led
to DSM-Il and ICD-B, did not follow Stengel's recommendations to any great degre
e.
DSM-ll was similar to DSM-I but eliminated the term reactioll.
As had been the case for DSM-I and DSM-II, the development of DSM-lII was co
XXVI Introduction
ordinated with the development of the next (ninth) version of lCD, which was pub
~
Iished in 1975 and implemented in 1978. Work began on DSM-m in 1974, with
publication in 1980. DSM-ill introduced a number of important methodological inn
ovations,
including explicit diagnostic criteria, a multiaxial system, and a descriptive
approach that attempted to be neutral with respect to theories of etiology. This
effort
was facilitated by the extensive empirical work then under wayan the constructio
n
and validation of explicit diagnostic criteria and the development of semistruct
ured
interviews. ICD-9 did not include diagnostic criteria or a multiaxial system lar
gely
because the primary function of this intemational system was to delineate catego
ries
to facilitate the collection of basic health statistics. In contrast, DS~'l-n]
was developed
with the additional goal of prOViding a medical nomenclature for clinicians and
researchers.
Because of dissatisfaction across aU of medicine with the lack of specificity
in lCD-9, a decision was made to modify it for use in the United States, resulti
ng in
ICD-9-CM (for Clinical Modification).
Experience with DSM-lli revealed a number of inconsistencies in the system and a
number of instances in which the criteria were not entirely clear. Therefore, th
e American
Psychiatric Assodation appointed a Work Group to Revise DSM-II1, which developed
the revisions and corrections that led to the publication of DSM-m-R in 1987.
The DSMIV Revision Process
The third edition of the Diag1l0stic and Statistical Malllmf ofMental Disorders
(DSM-Ill)
represented a major advance in the diagnosis of mental disorders and greatly fac
ilitated
empirical research. The development of DS~'I-IV
has benefited from the substantial
increase in the research on diagnosis that was generated in part by DSM-m
and DS}'<I-m-R. Most diagnoses now have an empirical literature or available dat
a
sets that are relevant to decisions regarding the revision of the diagnostic man
ual.
The Task Force on OSM-IV and its Work Groups conducted a three-stage empirical
process that included 1) comprehensive and systematic reviews of the published l
iterature,
2) reanalyses of already-collected data sets, and 3) extensive issue-focused
field trials.
Literature Reviews
Two methods conferences were sponsored to articulate for all the Work Groups a s
ystematic
procedure for finding, extracting, aggregating, and interpreting data in a
comprehensive and objective fashion. The initial tasks of each of the DSM-IV Wor
k
Groups were to identify the most pertinent issues regarding each diagnosis and t
o determine
the kinds of empirical data relevant to their resolution. A Work Group member
or adviser was then assigned the responsibility of conducting a systematic and
comprehensive review of the relevant literature that would inform the resolution
of
the issue and also document the text of DS~<I-IV.
The domains considered in making
decisions included clinical utility, reliability, descriptive validity, psychome
tric performance
characteristics of individual criteria, and a number of validating variables.
Each literature review specified 1) the issues or aspects of the text and criter
ia un
der consideration and the Significance of the issues with respect to DSM-fV; 2)
the re
"iew method (including the sources for identifying relevant studies, the number
of
Introduction xxvii I
studies considered, the criteria for inclusion and exclusion from the review, an
d the
variables catalogued in each study); 3) the results of the review (including a d
escriptive
summary of the studies with respect 10 methodology, design, and substantive
correlates of the findings, the relevant findings, and the analyses conducted on
these
findings); and 4) the various options for resoh'ing the issue, the advantages an
d disadvanlages
of each option, recommendations, and suggestions for additional research
that would be needed 10 provide a more conclusive resolution.
The goal of the DSM-IV literature reviews was to provide comprehensive and unbia
sed
information and to ensure thai DSMIV reflects the best available clinical and
research literature. For this reason, we used systematic computer searches and c
ritical
reviews done by large groups of advisers 10 ensure that the literature coverage
was
adequate and that the interprelation of the results was justified. Input was sol
icited
especiaUy from those persons likely 10 be critical of the conclusions of the rev
iew. The
literahIre reviews were revised many times to produce as comprehensi\'e and bala
nced
a resull as possible. It must be noted that for some issues addressed by the
DSM-IV Work Groups, particularly those thai were more concephIal in nahIre or fo
r
which there were insufficient data, a review of the empirical literature had lim
ited
utility. Despite these limitations, the reviews were helpful in documenting the
rationale
and empirical support for decisions made by the DSM-IV Work Groups.
Data Reanalyses
When a review of the literature revealed a lack of evidence (or conflicting evid
ence)
for the resolution of an issue, we often made use of h,o additional resources--d.
ata
reanalyses and field trials-to help in making final decisions. Analyses of relev
anl
unpublished data sets were supported by a grant to the American Psychiatric Asso
ciation
from Ihe John D. and Catherine T. MacArthur Foundation. Most of the 40 data
reanalyses perfomled for DSM-IV involved the collaboration of several investigat
ors
at different sites. These researchers jointly subjected their data to questions
posed by
the Work Groups concerning the criteria included in DSM-Ill-R or criteria that m
ight
be included in DSM-IV. Data reanalyses also made it possible for Work Groups
to generate several criteria sets that were then lested in the DSM-IV field tria
ls. Although,
for the most part, the data sets used in the reanalj'ses had been collected as
part of epidemiological studies or treatment or other clinical studies, they wer
e also
highly relevant to the nosological questions facing the DSM-TV Work Groups.
Field Trials
Twelve DSM-IV field trials were sponsored by the National Institute of Mental
Health (NIMH) in collaboration with the I ational Institute on Drug Abuse (NIDA)
and the National Institute on Alcohol Abuse and Alcoholism (1\'1AAA). The field
lrials
allowed the DSrvf-IV Work Groups to compare alternative options and to study
the possible impact of suggested changes. Field trials compared DSM-III, DSM-III
-R,
lCDlO, and proposed DSMIV criteria sets in 5-10 different sites per field trial, w
ith
approximately 100 subjects at each site. Diverse sites, with represenlative grou
ps of
subjects hom a range of sociocultural and ethnic backgrounds, were selected to e
n
sure generalizability of fieldtriaJ results and to test some of the most difficul
t ques
XXVIII Introduction
tions in differential diagnosis. The 12 field trials included more than 70 sites
and
evaluated more than 6,000 subjects. The field trials collected information on th
e reliability
and performance characteristics of each criteria set as a whole, as weU as of th
e
specific items within each criteria set. The field trials also helped to bridge
the boundary
beh,'een clinical research and clinical practice by determining how well suggest
ions
for change that are derived from clinical research findings apply in clinical
practice.
Criteria for Change
Although it was impossible to develop absolute and infallible criteria for when
changes
should be made, there were some principles that guided our efforts. The threshol
d for
making revisions in DSM-IV was set higher than that for DSM-lll and DSM-m-R. Dec
isions
had to be substantiated by explicit statements of rationale and by the systemati
c review
of relevant empirical data. To increase the practicality and clinical utility of
DSM-TV,
the criteria sets were simplified and clarified when this could be justified by
empirical
data. An attempt was made to sbike an optimal balance in DSM-TV with respect to
historical
tradition (as embodied in DSM-ITl and DSNI-ID-R), compatibility with ICD-IO,
evidence from reviews of the literature, analyses of lUlpublished data sets, res
ults of field
rnals, and consensus of the field. Although the amount of evidence required to s
upport
changes was set at iI high threshold, it necessarily varied across disorders bec
ause the
empirical support for the decisions made in DSM-ID and DSM-m-R also varied acros
s
disorders. Of course, common sense was necessary, and major changes to solve min
or
problems required more evidence than minor changes to solve major problems.
We received suggestions to include numerous new diagnoses in DSM-TV. TIle propon
ents
argued that the new diagnoses were necessary to improve the coverage of the
system by including a group of individuals that were undiagnosable in DSM-m~Ror
diagnosable only under the Not Otherwise Specified rubric. We decided that, in
general, new diagnoses should be included in the system only after research has
established
that they should be included rather than being included to stimulate that
research. However, diagnoses already included in ICD-I0 were given somewhat
more consideriltion than those that were being proposed fresh for DSM-IV. The in
creased
marginal utility, clarity, and coverage provided by each newly proposed di~
agnosis had to be balanced against the cumulative cumbersomeness imposed on the
whole system, the paucity of empirical documentation, and the possible misdiagno
sis
or misuse that might result. No classification of mental disorders can have a su
fficient
number of specific categories to encompass every conceivable clinical presentati
on.
The Not Otherwise Specified categories are provided to cover the not infrequent
presentations
that are at the bOlmdary of specific categorical definitions.
The DSM-IV Sourcebook
Documentation has been the essential foundation of the DSM-TV process. The DSM-I
V
Sourcebook, published in four volumes, is intended to provide a comprehensive an
d
convenient reference record of the clinkal and researdl support for the various
decisions
reached by the Work Groups and the Task Force. The first three volumes of the
Sourcebook contain condensed versions of the 150 DSM-IV literature reviews. The
xxx Introduction
The chairs of the original DSM4J\' Work Groups were consulted first regarding th
e
composition of these Text Revision '''lark Groups. Each Text Revision Work Group
was given primary responsibility for updating a section of the OSM-IV text. This
entailed
reviewing the lext carefully to identify errors or omissions and then conducting
a systematic. comprehensive literature review that focused on relevant material
that
has been published since 1992. Text Revision Work Group members then drafted pro
posed
changes, which were accompanied by written justifications for the changes
along with relevant references. During a series of conference calls, the propose
d
changes, justifications, and references were presented by a Text Revision Work
Group member to other members of the Text Revision Work Group, who provided
input regarding whether the changes were justified on the basis of the supportin
g
~
documentation. Once drafts of the proposed changes were finalized by the Text Re
vision
Work Groups, the changes were more widely disseminated to a group of section-
specific advisers (consisting of the original DSM-rv Work Group members
supplemented by additional consultants) for further comment and review. These ad
visers
were also given the opportunity to suggest additional changes if they could
provide sufficient convincing evidence justifying inclusion in the text. After c
onsideration
of the adviser comments, final drafts of proposed changes were produced and
submitted for final review and approval by the American Psychiatric Association'
s
Committee on Psychiatric Diagnosis and Assessment.
Most of the proposed literature-based changes were in the Associated Features
and Disorders (which includes Associated Laboratory Findings); Specific Culture,
Age, and Gender Features; Prevalence; Course; and Familial Pattern sections of t
he
text. For a number of disorders, the Differential Diagnosis section also was exp
anded
to provide more comprehensive differentials. Appendix D (see p. 829) provides an
overview of the changes included in this te-xt revision.
Definition of Mental Disorder
Although this volume is titled the Diagl/ostic al/d Statistical Mal/l/al ofMel/t
al Disorders,
the term //lental disorder unfortunately implies a distinction between "mental"
disorders
and "physical" disorders that is a reductionistic anachronism of mind/body
dualism. A compelling literature documents that there is much "physical" in "men
tal"
disorders and much "mental" in "physical" disorders. The problem raised by the
term "mental" disorders has been much clearer than its solution, and, unfortunat
ely,
the term persists in the title of DSMIV because we have not found an appropriate
substitute.
~'loreover,
although this manual provides a classification of mental disorders, it
must be admitted that no definition adequately specifies precise boundaries for
the
concept of "mental disorder." The concept of mental disorder, like many other co
ncepts
in medicine and science, lacks a consistent operational definition that covers a
ll
situations. All medical conditions are defined on various levels of abstraction-
fo<
example, structural patholog}' (e.g., ulcerative colitis), symptom presentation
(e.g.,
migraine), deviance from a physiological norm (e.g., hypertension), and etiology
(e.g., pneumococcal pneumonia). Mental disorders have also been defined by a var
iety
of concepts (e.g., distress, dysfunction, dyscontrol, disadvantage, disability,
inflexibility,
irrationality, syndromal pattern, etiology, and statistical deviation). Each
Introduction
is a useful indicator for a mental disorder, but none is equivalent to the conce
pt, and
different situations call for different definitions.
Despite these caveats, the definition of melltal disorder that was included in D
S~'I-m
and DSM-W-R is presented here because it is as useful as any other available def
inition
and has helped to guide decisions regarding which conditions on the boundary
between normality and pathology should be included in DSM-IV. In DSM-IV, each of
the mental disorders is conceptualized as a clinically significant behavioral or
psychological
syndrome or pattern that occurs in an individual and that is associated
with present distress (e.g., a painful symptom) or disability (i.e., impairment
in one
or more important areas of functioning) or with a significantly increased risk o
f suffering
death, pain, disability, or an important loss of freedom. In addition, this synd
rome
or pattern must not be merely an expectable and culturally sanctioned
response to a particular event, for example, the death of a loved one. \hatever i
ts
Original cause, it must currently be considered a manifestation of a behavioral,
psychological,
or biological dysfunction in the individual. 'either deviant behavior (e.g., p0l
itical,
religious, or sexual) nor connicts that are primarily behveen the individual and
society are mental disorders unless the deviance or connict is a symptom of a dy
sfunction
in the individual, as described above.
A common misconception is that a classification of mental disorders classifies p
e0ple,
when actually what are being classified are disorders that people have. For this
reason, the text of DSM-TV (as did the text of DSM-W-R) avoids the use of such e
xpressions
as "a schizophrenic" or "an alcoholic" and instead uses the more accurate,
but admittedly more cumbersome, "an individual with Schizophrenia" or "an indivi
dual
with Alcohol Dependence."
Issues in the Use of DSM-IV
Limitations of the Categorical Approach
OSM-rv is a categorical classification that divides mental disorders into types
based
on criteria sets with defining features. This naming of categories is the tradit
ional
method of organizing and transmitting information in e~er)'da)'
life and has been the
fundamental approacll used in all systems of medical diagnosis. A categorical ap
proach
to classification works best when all members of a diagnostic class are homogene
ous,
when there are clear boundaries behvccn classes, and when the different
classes are mutually exclusive. Nonetheless, the limitations of the categorical
classification
system must be recognized.
In DSM-IV, there is no assumption that each category of mental disorder is a com
pletely
discrete entity with absolute boundaries dividing it from other mental disorders
or from no mental disorder. There is also no assumption that all individuals
described as haVing the same mental disorder are alike in all important ways. Th
e clinician
using DSM-IV should therefore consider that individuals sharing a diagnosis
are likely to be heterogeneous even in regard to the defining features of the di
agnosis
and that boundary cases will be difficult to diagnose in any but a probabilistic
fash
ion. This outlook allows gTeater flexibility in the use of the system, encourage
s more
specific attention to boundary cases, and emphasizes the need to capture additio
nal
IXXXII Introduction
clinical information that goes beyond diagnosis. In recognition of the heterogen
eity
of clinical presentations, DSM-IV often includes polythetic criteria sets, in wh
ich the
individual need only present with a subset of items from a longer list (e.g., th
e diagnosis
of Borderline Personality Disorder requires only five out of nine items).
It was suggested that the DSM-IV Classification be organized fonowing a dimensio
nal
model rather than the categorical model used. in DSM-m-R. A dimensional system
classifies clinical presentations based on quantification of attributes rather t
han
the assignment to categories and works best in describing phenomena that are dis
tributed
continuously and that do not have clear boundaries. Although dimensional
systems increase reliability and communicate more clinical information (because
they
report clinical attribptes that might be subthreshold in a categorical system),
they also
have serious limitatio'ns and thus far have been less useful than categorical sy
stems
in clinical practice and in stimulating research. Numerical dimensional descript
ions
are much less familiar and vivid than are the categorical names for mental disor
ders.
Moreover, there is as yet no agreement on the dlOice of the optimal dimensions t
o be
used for classification purposes. 'onetheless, it is possible that the increasin
g research
on, and familiarity with, dimensional systems may eventually result in their
greater acceptance both as a method of conveying clinical information and as a r
esearch
tool.
Use of Clinical Judgment
DSM-IV is a classification of menta] disorders that was developed for use in cli
nical,
educational, and research settings. The diagnostic categories, criteria, and tex
tual de.scriptions
are meant to be employed by individuals with appropriate clinical training
and experience in diagnosis. It is important that OSM-IV not be applied. mechani
cally
by untrained individuals. The specific diagnostic criteria included in DSM-IV ar
e
meant to serve as guidelines to be informed by clinical judgment and are not mea
nt
to be used in a cookbook fashion. For example, the exercise of clinical judgment
may
justify giving a certain diagnosis to an individual even though the clinical pre
sentation
falls just short of meeting the full criteria for the diagnosis as long as the s
ymptoms
that are present are persistent and severe. On the other hand, lack of familiari
ty
with DSM-IV or excessively nexible and idiosyncratic application of DSM-IV crite
ria
or conventions substantially reduces its utility as a common language for commun
ication.
In addition to the need for clinical training and judgment, the method of data c
ollection
is also important. The valid application of the diagnostic criteria included in
this manual necessitates an evaluation that directly accesses the information co
ntained
in the criteria sets (e.g., whether a syndrome has persisted for a minimum perio
d
of time). Assessments that rely solely on psychological testing not covering the
criteria content (e.g., projective testing) cannot be validly used as the primar
y source
of diagnostic information.
Use of DSM-IV in Forensic Settings
When the DSM-IV categories, criteria, and textual descriptions are employed for
forensic purposes, there are significant risks that diagnostic information will
be mis
,
Introduction XXXIII
used or misunderstood. These dangers arise because of the imperfect fit between
the
questions of ultimate concern to the law and the information contained in a clin
ical
diagnosis. In most situations, the clinical diagnosis of a DSM-IV mental disorde
r is
not sufficient 10 establish the existence for legal purposes of a "mental disord
er,"
"mental disability," "mental disease," or "mental defect." In determining whethe
r an
individual meets .1 specified legal standard (e.g., for competence, criminal res
ponsibility,
or disability), additional information is usually required beyond that contained
in the DSMIV diagnosis. This might include information aboullhe individual's func
tional
impairments and how these impairments affect the particular abilities in questio
n.
It is precisely because impairments, abilities, and disabilities vary widely wit
hin
each diagnostic category that assignment of a particular diagnosis does not impl
y a
specific level of impairment or disability.
onclinical decision makers should also be cautioned that a diagnosis does not
Ci'lrry any necessary implications regarding the causes of the individual's ment
al dis
order or its associated impairments. Inclusion of a disorder in the Classificati
on (as in
medicine generally) does not require that there be knowledge about its etiology.
Moreover, the fact that an individual's presentation meets the criteria for a DS
M-IV
diagnosis does not carry any necessary implication regarding the individual's de
gree
of control over the behaviors that may be associated with the disorder. Even whe
n diminished
control over one's behavior is a feature of the disorder, having the diagnosis
in itself does not demonstrate that a particular individual is (or was) unable t
o control
his or her behavior at a particular time.
It must be noted that DSM-IV reflects a consensus about the classification and d
i
agnosis of mental disorders derived at the time of its initial publication. New
knowledge
generated by research or clinical experience will undoubtedly lead to an
increased Wlderstanding of the disorders included in DSM-JV, to the identificati
on of
new disorders, and to the removal of some disorders in future classifications. T
he text
and criteria sets induded in DSM-IV will require reconsideration in Light of evo
lVing
new information.
The use of DSM-JV in forensic settings should be informed by an awareness of the
risks and limitations discussed above. When used appropriately, diagnoses and di
ag
nostic information can assist decision makers in their determinations. For examp
le,
when the presence of a mental disorder is the predicate for a subsequent legal d
etermination
(e.g., invollUltary civil commitment), the use ohm. established system of
diagnosis enhances the value and reliability of the determination. By prOViding
a compendium
based on a review of the pertinent clinical and research literature, DSM-IV
may facilitate the legal decision makers' understanding of the relevant characte
ristics
of mental disorders. The literature related to diagnoses also sen'es as a check
on ungroWlded
speculation about mental disorders and about the functioning of a particular
individual. Finally, diagnostic information regarding longitudinal course may
improve decision making when the legal issue concerns an individual's mental fun
ctioning
at a past or fuhue point in time.
Ethnic and Cultural Considerations
Special efforts have been made in the preparation ofDSM-JV to incorporate an awa
reness
that the manual is used in culturally dh'erse populations in the United States a
nd
XXXIV Introduction
internationally. Clinicians are called on to evaluate individuals from numerous
dif
ferent ethnic groups and cultural backgrounds (including many who are recent im
migrants). Diagnostic assessment can be especially challenging when a clinician
from
one ethnic or cultural group uses the OSM-IV Classification to evaluate an indiv
idual
from a different ethnic or cultural group. A clinician who is unfamiliar with th
e nu
ances of an individual's cultural frame of reference may incorrectly judge as ps
ychopathology
those normal variations in behavior, belief, or experience that are
particular to the individual's culture. For example, certain religious practices
or beliefs
(e.g., hearing or seeing a deceased relative during bereavement) may be misdiagn
osed
as manifestations of a Psychotic Disorder. Applying Personality Disorder
criteria across cull1.Jlal settings may be especially difficult because of the w
ide cultural
variation in concePts of self, styles of communication, and coping mechanisms.
DSM-IV includes three types of information specifically related to cultural cons
iderations:
1) a discussion in the text of cultural variations in the clinical presentations
of those disorders that have been included in the OSMIV Classification; 2) a desc
rip
tion of culture-bound syndromes that have not been included in the OSM-IV C1assi
fication (these are included in Appendix I); and 3) an outline for cultural form
ulation
designed to assist the clinician in systematically evaluating and reporting the
impact
of the individual's cultural context (also in Appendix 1).
The wide international acceptance of OSM suggests that this classification is us
eful
in describing mental disorders as they are experienced by individuals throughout
the
world. Nonetheless, evidence also suggests that the symptoms and course of a num
ber
of DSMrv disorders are influenced by cultural and ethnic factors. To facilitate i
ts
application to individuals from diverse cultural and ethnic settings, DSM!V inclu
des
a new section in the text to cover culture-related features. This section descri
bes the
ways in which varied cultural backgrounds affect the content and form of the sym
ptom
presentation (e.g., depressive disorders characterized by a preponderance of som
atic
symptoms rather than sadness in certain cultures), preferred idioms for
describing distress, and information on prevalence when it is available.
The second type of cultural infonnation provided pertains to "culture-bound synd
romes"
that have been described in just one, or a few, of the world's societies. OSMrv
provides h\'o ways of increasing the recognition of culture-bound syndromes: 1)
some
(e.g., nmok, ntnqlle de Ileroios) are induded as separate examples in Not Otherw
ise
Specified categories; and 2) an appendix of culture-bound syndromes (Appendix I)
has been introduced in DSM-JV that includes the name for the condition, the cult
ures
in which it was first described, and a brief description of the psychopathology.
The provision of a cuJture-specific section in the OSM-IV text, the indusion of
a
glossary of culture-bound syndromes. and the provision of an outline for cultura
l formulation
are designed to enhance the cross-eultural applicability of OSMIV. It is
hoped that these new features will increase sensitivity to variations in how men
tal
disorders may be expressed in different cultures and will reduce the possible ef
fect of
unintended bias stemming from the clinician's own cultural background.
Use of DSM-IV in Treatment Planning
Making a DSM-IV diagnosis is only the first step in a comprehensive evaluation.
To
formulate an adequate treatment plan, the clinician will invariably require cons
ider
Introduction xxxv
able additional information about the person being evaluated beyond that require
d
to make a DSM~IV
diagnosis.
Distinction Between Mental Disorder and
General Medical Condition
The terms mellt"l disorder and gelleralmedicnl condition are used throughout thi
s manual.
The term nUN/tal disorder is explained above. The term gelleral medical conditiO
Il is
used merely as a convenient shorthand to refer to conditions and disorders that
are
listed outside the "Mental and Behavioural Disorders" chapter of ICD. It should
be
recognized thai these are merely terms of convenience and should not be taken to
imply
that there is any fundamental distinction between mental disorders and general
medical conditions, thai mental disorders are unrelated to physical or biologica
l factors
or processes, or that general medical conditions are unrelated to behavioral or
psychosocial factors or processes.
Organization of the Manual
The manual begins with instructions concerning the use of the manual (p. 1), foU
owed
by the DSM~IVTR
Classification (pp. 13-26), which proVides a systematic listing of
the official codes and categories. I ext is a description of the DSMrv Multiaxial
Sys
tern for assessment (pp. 27-37). This is followed by the diagnostic criteria for
each of
the DS~HV
disorders accompanied by descriptive text (pp. 39-743). Finally, DSi\'I-rv
includes 11 appendixes.
Cautionary Statement
Thespecified diagnostic criteria for each mental disorder are offered as guideli
nes
for making diagnoses, because it has been demonstrated that the use of such crit
eria
enhances agreement among clinicians and investigators. The proper use of these c
rileria
requires specialized clinical training that provides both a body of knowledge
and clinical skills.
These diagnostic criteria and the DSM-JV Classification of mental disorders refl
ect
a consensus of current formuJations of evolving knowledge in our field. They do
not
encompass, however, all the conditions for which people may be treated or that m
ay
be appropriate topics for research efforts.
The purpose of DSMIV is to provide clear descriptions of diagnostic categories in
order to enable clinicians and investigators to diagnose, communicate about, stu
dy,
and treat people with various mental disorders. It is to be Wlderstood that indu
sion
here, for clinical and research purposes, of a diagnostic category such as Patho
logical
Gambling or Pedophilia does not imply that the condition meets legal or other no
nmedical
criteria for what constitutes mental disease, mental disorder, or mental disabil
ity.
The clinical and scientific considerations involved in categorization of these
conditions as mental disorders may not be wholly relevant to legal judgments, fo
r
example, that take into accoWlt such issues as individual responsibility, disabi
lity
detennination, and competency.
XXXVII
Use of the Manual
,
Coding and Reporting Procedures
Diagnostic Codes
The official coding system in use in the United States as of publication of this
manual
is the Illtematiollal Classificatioll of Diseases, Ninth Revision, Clinical Modi
fication
(lCD-9-er-.l). Most OSM-IV disorders have a numerical ICD9-eM code that appears
several times: 1) preceding the name of the disorder in the Classification (pp.
13-26),
2) at the beginning of the text section (or each disorder, and 3) accompanying t
he criteria
set for each disorder. For some diagnoses (e.g., Mental Retardation, Substancein
duced
Mood Disorder), the appropriate code depends on hlrther specification and
is listed after the text and criteria set for the disorder. The names of some di
sorders
are followed by alternative tenns enclosed in parentheses, which, in most cases,
were
the DSM-lll-R names for the disorders.
The use of diagnostic codes is fundamental 10 medical record keeping. Diagnostic
coding facilitates dala collection and retrieval and compilation of statistical
information.
Codes also are often required to report diagnostic data to interested third part
ies,
including govenunental agencies, private insurers, and the World Health Organiza
tion.
For example, in the United States, Ihe use of these codes has been mandated by
the Health Care Financing Administration for purposes of reimbursement under the
Medicare system.
Subtypes (some of which are coded in the fifth digit) and specifiers are provide
d
for increased specificity. Subtypes define mutually exclusive and jointly exhaus
tive
phenomenological subgroupings within a diagnosis and are indicated by the instru
ction
"specify type" in the criteria set. For example, Del1,!sional Disorder is subtyp
ed
-
based on the content of the delusions, with seven subtypes provided: Erotomanic
Type, Grandiose Type, Jealous Type, Persecutory Type, Somatic Type, Mixed Type,
and Unspecified Type. In contrast, specifiers are not intended to be mutually ex
clusive
or jointly exhaustive and are indicaled by the instruction "specify" or "specify
if" in
the criteria sel (e.g., for Social Phobia, the instruction notes "Specify if: Ge
neralized'1.
Specifiers provide an opportunity 10 define a more homogeneous subgrouping of
individuals with the disorder who share certain features (e.g., Major Depressin
Disorder,
With Melancholic Features). Although a fifth digit is sometimes assigned 10
code a subtype or specifier (e.g., 294.11 Dementia of the Alzheimer's Type, With
Late
Onset, With Behavioral Disturbance) or severity (296.21 Major Depressive Disorde
r,
Single Episode, MUd), the majority of subtypes and specifiers included in DSM-TV
cannot be coded within the ICD-9-CM system and are indicated only by including t
he
subtype or specifier after the name of the disorder (e.g., Social Phobia, Genera
lized).
1
Use of the Manual
Severity and Course Specifiers
A DSM-IV diagnosis is usually applied to the individual's current presentation a
nd is
not typically used to denote previous diagnoses from which the individual has re
covered.
The following specifiers indicating severity and course may be listed after the
diagnosis: Mild, Moderate, Severe, In Partial Remission, In Full Remission, and
Prior
History.
The specifiers Mild, Moderate, and Severe should be used only when the full crit
eria
for the disorder are currently met. In deciding whether the presentation should
be described as mild, moderate, or severe, the clinician should take into accoun
t the
number and intensity of the signs and symptoms of the disorder and any resulting
impairment in occupatioQal or social functioning. For the majority of disorders,
the
following guidelines may be used:
Mild. Few, if any, symptoms in excess of those required to make the diagnosis
are present, and symptoms result in no more than minor impairment in social
or occupational functioning.
Moderate. Symptoms or functional impairment between "mild" and "severe"
are present.
Severe. Many symptoms in excess of those required to make the diagnosis,
or several symptoms that are particularly severe, are present, or the symptoms
result in marked impairment in social or occupational functioning.
In Partial Remission. The full criteria for the disorder were previously met,
but currently only some of the symptoms or signs of the disorder remain.
In Full Remission. There are no longer any symptoms or signs of the disorder,
but it is still clinically relevant to note the disorder-for example, in an
individual with previous episodes of Bipolar Disorder who has been symptom
free on lithitun for the past 3 years. After a period of time in full remission,
the
clinician may judge the individual to be recovered and, therefore, would no
longer code the disorder as a current diagnosis. The differentiation of In Full
Remission from recovered requires consideration of many factors, including
the characteristic course of the disorder, the length of time since the last per
iod
of disturbance, the total duration of the disturbance, and the need for continue
d
evaluation or prophylactic treatment.
Prior History. For some purposes, it may be useful to note a history of the
criteria having been met for a disorder even when the individual is considered
to be recovered from it. Such past diagnoses of mental disorder would be indicat
ed
by using the specifier Prior H.istory (e.g., Separation Anxiety Disorder,
Prior History, for an individual with a history of Separation Anxiety Disorder
who has no current disorder or who currently meets criteria for Panic Disorder).
Specific criteria for defining Mild, Moderate, and Severe have been provided for
the following: Mental Retardation, Conduct Disorder, Manic Episode, and Major
Depressive Episode. Specific criteria for defining In Partial Remission and In F
ull
Remission have been provided for the following: Manic Episode, Major Depressive
Episode, and Substance Dependence.
Use of the Manual
Recurrence
Not infrequently in clinical practice, individuals after a period of time in whi
ch the
full criteria for the disorder are no longer met (i.e., in partial or full remis
sion or recovery)
may develop symptoms that suggest a recurrence of their original disorder
but that do not yet meet the full threshold for that disorder as specified in th
e criteria
set. lt is a matter of clinical judgment as to how best to indicate the presence
of these
symptoms. The following options are available:
If the symptoms are judged to be a new episode of a recurrent condition, the dis
order
may be diagnosed as current (or provisional) even before the full criteria
have been met (e.g., after meeting criteria for a Major Depressive Episode for o
nly
10 days instead of the 14 days usually required).
If the symptoms are judged to be clinically significant but it is not clear whet
her
they constitute a recurrence of the original disorder, the appropriate Not Other
wise
Specified category may be given.
If it is judged that the symptoms are not clinically significant, no additional
current
or provisional diagnosis is given, but "Prior History" may be noted (see p. 2).
Principal Diagnosis/Reason for Visit
When more than one diagnosis for an individual is given in an inpatient setting,
the
principal diag1losis is the condition established after study to be chiefly resp
onsible for
occasioning the admission of the individual. When more than one diagnosis is giv
en
for an individual in an outpatient setting, the reason for visit is the conditio
n that is
chiefly responsible for the ambulatory care medical services received during the
visit.
In most cases, the principal diagnosis or the reason for visit is also the main
focus of
attention or treatment. lt is often difficult (and somewhat arbitrary) to determ
ine
which diagnosis is the principal diagnosis or the reason for visit, especially i
n situations
of "dual diagnosis" (a substance-related diagnosis like Amphetamine Dependence
accompanied by a non-substance-related diagnosis like Schizophrenia). For
example, it may be unclear which diagnosis should be considered "principal" for
an
individual hospitalized with both Schizophrenia and Amphetamine Intoxication, be
cause
each condition may have contributed equally tQ tJ1e need for admission and
treatment.
Multiple diagnoses can be reported in a multiaxial fashion (see p. 35) or in a n
on
axial fashion (see p. 37). When the principal diagnosis is an Axis I disorder, t
his is in
dicated by listing it first. The remaining disorders are listed in order of focu
s of
attention and treatment. When a person has both an Axis I and an Axis II diagnos
is,
the principal diagnosis or the reason for visit will be assumed to be on Axis I
unless
the Axis II diagnosis is followed by the qualifying phrase "(Principal Diagnosis
)" or
"(Reason for Visit)."
Provisional Diagnosis
The specifier provisional can be used when there is a strong presumption that th
e full
criteria will ultimately be met for a disorder, but not enough information is av
ailable
Use of the Manual
to make a fum diagnosis. The clinician can indicate the diagnostic uncertainty b
y recording
"(provisional)" following the diagnosis. For example, the individual appears
to have a Major Depressive Disorder, but is unable to give an adequate history t
o establish
that the full criteria are met. Another use of the term provisiolllli is for tho
se situations
in which differential diagnosis depends exclusively on the duration of Ulness.
For example, a diagnosis of 5chizophrenifonn Disorder requires a duration of les
s
than 6 months and can only be given provisionally if assigned before remission h
as
occurred.
Use of Not Otherwise Specified Categories
Because of the diversity ofclinical presentations, it is impossible for the diag
nostic nomenclature
to cover every possible situation. For this reason, each diagnostic class has
at least one Not Otherwise Specified (NOS) category and some classes have severa
l
NOS categories. There are four situations in which an NOS diagnosis may be appro
priate:
The presentation conforms to the general guidelines for a mental disorder in the
diagnostic class, but the symptomatic picture does not meet the criteria for any
of
the specific disorders. This would occur either when the symptoms are below the
diagnostic threshold for one of the specific disorders or when there is an atypi
cal
or mixed presentation.
The presentation conforms to a symptom pattem that has not been included in the
DSM-IV Classification but that causes clinically significant distress or impairm
ent.
Research criteria for some of these symptom patterns have been included in Appen
dix
B ("Criteria Sets and Axes Provided for Further Study"), in which case a page
reference to the suggested research criteria set in Appendix B is provided.
There is uncertainty about etiology (Le., whether the disorder is due to a gener
al
medical condition, is substance induced, or is primary).
There is insufficient opportunity for complete data collection (e.g., in emergen
cy
situations) or inconsistent or contradictory information, but there is enough in
formation
to place it within a particular diagnostic class (e.g., the clinician determines
that the individual has psychotic symptoms but does not have enough information
to diagnose a specific Psychotic Disorder).
Ways of Indicating Diagnostic Uncertainty
The following table indicates the various ways in which a clinidan may indicate
diagnostic
uncertainty:
Use of
the Manual
Term
Examples of clinical situations
V Codes (for Other Conditions That May
Be a Focus of Clinical Attention)
799.9
Diagnosis or Condition Deferred on
Axis I
799.9
Diagnosis Deferred on Axis II
300.9
Unspecified Mental Disorder
(nonpsychotic)
298.9
Psychotic Disorder Not Otherwise
Specified
[Class of disorder) Not Otherwise Specified
e.g., Depressive Disorder Not Otherwise
Specified
[Specific diagnosis) (Provisional)
e.g., Schizophreniform Disorder
(Provisional)
Insufficient information to know whether or
not a presenting problem is attributable to a
mental disorder, e.g., Academic Problem;
Adult Antisocial Behavior
Information inadequate to make any diagnostic
judgment about an Axis Idiagnosis or
condition
Information inadequate to make any diagnostic
judgment about an Axis II diagnosis
Enough information available to rule out a
Psychotic Disorder, but further specification
is not possible
Enough information available to determine
the presence of a Psychotic Disorder, but further
specification is not possible
Enough information available to indicate
the class of disorder that is present, but further
specification is not possible, either because
there is not sufficient information to
make a more specific diagnosis or because
the clinical features of the disorder do not
meet the criteria for any of the specific categories
in that class
Enough information available to make a
"working" diagnosis, but the clinician wishes
to indicate a significant degree of diagnostic
uncertainty
Frequently Used Criteria
'
Criteria Used to Exclude Other Diagnoses and
to Suggest Differential Diagnoses
Most of the criteria sets presented in this manual include exclusion criteria th
at are
necessary to establish boundaries between disorders and to clarify differential
diagnoses.
The several different wordings of exclusion criteria in the criteria sets throug
hout
DSM-IV reflect the different types of possible relationships among disorders:
"Criteria have never been mel for ..." This exclusion criterion is used to defin
e
a lifetime hierarchy between disorders. For example, a diagnosis of Major Depres
sive
Disorder can no longer be given once a Manic Episode has occurred and must
be changed to a diagnosis of Bipolar I Disorder.
Use of the Manual
"Criteria are not met for ..." This exclusion criterion is used to establish a h
ierarchy
behveen disorders (or subtypes) defined cross-sectionally. For example, the
specifier With Melancholic Features takes precedence over With Atypical Features
for describing the current Major Depressive Episode.
"does not occur exclusively during the course of ..." lltis exclusion criterion
prevents a disorder from being diagnosed when its symptom presentation occurs
only during the course of another disorder. For example, dementia is not diagnos
ed
separately if it occurs only during delirium; Conversion Disorder is not
diagnosed separately if it occurs only during Somatization Disorder; Bulimia Ner
vasa
is not diagnosed separately if it occurs only during episodes of Anorexia ervasa
.
This exclusion criterion is typically used in situations in which the symptoms
of one disorder are'associated features or a subset of the symptoms of the preem
pting
disorder. The clinician should consider periods of partial remission as part of
the "course of another disorder." It should be noted that the excluded diagnosis
can be given at times when it occurs independently (e.g., when the excluding dis
order
is in full remission).
"not due to the direct physiological effects of a substance (e.g., a drug of abu
se,
a medication) or a general medical condition." lltis exclusion criterion is used
to indicate that a substance-induced and general medical etiology must be consid
ered
and ruJed out before the disorder can be diagnosed (e.g., Major Depressive
Disorder can be diagnosed only after etiologies based on substance use and a gen
eral
medical condition have been ruJed out).
"not better accounted for by ..." This exclusion criterion is used to indicate t
hat
the disorders mentioned in the criterion must be considered in the differential
diagnosis
of the presenting psychopathology and that, in boundary cases, clinical
judgment will be necessary to determine which disorder provides the most appropr
iate
diagnosis. In such cases, the "Differential Diagnosis" section of the text for
the disorders should be consulted for guidance.
The general convention in DSM-IV is to allow multiple diagnoses to be assigned
for those presentations that meet criteria for more than one DSM-IV disorder. Th
ere
are three situations in which the above-mentioned exclusion criteria help to est
ablish
a diagnostic hierarchy (and thus prevent multiple diagnoses) or to highlight dif
ferential
diagnostic considerations (and thus discourage multiple diagnoses):
When a Mental Disorder Due to a General Medical Condition or a SubstanceInduced
Disorder is responsible for the symptoms, it preempts the diagnosis of the
corresponding primary disorder with the same symptoms (e.g., Cocaine-Induced
Mood Disorder preempts Major Depressive Disorder). In such cases, an exclusion
criterion containing the phrase "not due to the direct physiological effects of
..."
is included in the criteria set for the primary disorder.
When a more pervasive disorder (e.g., Schizophrenia) has among its defining
symptoms (or associated symptoms) what are the defining symptoms of a less perva
sive
disorder (e.g., Dysthymic Disorder), one of the following three exclusion
criteria appear5 in the criteria set for the less pervasive disorder, indicating
that
only the more pervasive disorder is diagnosed.: "Criteria have never been met
for ...," "Criteria are not met for ...," "does not occur exclusively during the
..
course 0 f ...
Use
of the Manual
\o\lhen there are particularly difficult differential diagnostic boundaries, the
phrase
"not better accounted for by ..." is included to indicate that clinical judgment
is
necessary to determine which diagnosis is most appropriate. For example, Panic
Disorder With Agoraphobia includes the criterion "not better accounted for by
Social Phobia" and Social Phobia includes the criterion "not better accounted fo
r
by Panic Disorder With Agoraphobia" in recognition of the fact that this is a pa
r
ticularly difficult boundary to draw. In some cases, both diagnoses might be
appropriate.
Criteria for Substance-Induced Disorders
It is often difficult to determine whether presenting symptomatology is substanc
e in
duced., that is, the direct physiological consequence of Substance Intoxication
or
Withdrawal, medication use, or toxin exposure. In an effort to provide some assi
s
tance in making this determination, the two criteria listed. below have been add
ed to
each of the Substance-Induced. Disorders. These criteria are intended to provide
gen
era} guidelines, but at the same lime allow for clinical judgment in determining
whether or not the presenting symptoms are best accounted for by the direct phys
iological
effects of the substance. For further discussion of this issue, see p. 209.
B.
There is evidence from the history, phYSical examination, or laboratory
findings of either (l) or (2):
(l)
the symptoms developed during, or within a month of, Substance
Intoxication or Withdrawal
(2)
medication use is etiologically related to the disturbance
C.
The disturbance is not better accounted for by a disorder that is not sub
stance induced. Evidence that the symptoms are better accounted for by a
disorder that is not substance induced might include the following: the
symptoms precede the onset of the substance use (or medication use); the
symptoms persist for a substantial period of time (e.g., about a month) after
the cessation of acute withdrawal or severe intoxication, or are substantial
Iy in excess of what would be expected given the type, duration, or amount
of the substance used; or there is other evidence that suggests the existence
of an independent non-substance-induced disorder (e.g., a history of recurrent
non-substance-related. episodes).
Criteria for a Mental Disorder Due to a
General Medical Condition
The criterion listed below is necessary to establish the etiological requirement
for
each of the Mental Disorders Due to a General Medical Condition (e.g., Mood Diso
rder
Due to Hypothyroidism). For further discussion of this issue, see p. 18I.
There is evidence from the history, physical examination, or laboratory findings
that the disturbance is the direct physiological consequence of a general
medical condition.
Use of the Manual
Criteria for Clinical Significance
The definition of mel/tal disorder in the introduction to DSM-IV requires that t
here be
clinically significant impainnent or distress. To highlight the importance of co
nsidering
this issue, the criteria sets for most disorders include a clinical significance
criterion
(usually worded "... causes clinically significant distress or impairment in soc
ial,
occupational, or other important areas of functioning"). This criterion help!" (
'stablish
the threshold for the diagnosis of a disorder in those situations in which the s
ymptomatic
presentation by itself (particularly in its milder forms) is not inherently
pathological and may be encountered in individuals for whom a diagnosis of "ment
al
disorder" would be inappropriate. Assessing whether Ihis criterion is met, espec
iaUy
in terms of role funqion, is an inherently difficult clinical judgment. Reliance
on information
from family members and other third parties (in addition to the individual)
regarding the individual's performance is often necessary.
Types of Information in the DSM-IV Text
The text of DS?>.'I-IV systematically describes each disorder under the followin
g headings:
"Diagnostic Features"; "Subtypes and/or Specifiers"; "Recording Procedures";
"Associated Features and Disorders"; "Specific Culture, Age, and Gender Features
";
"Pre\!alence"; "Course"; "Familial Pattern"; and "Differential Diagnosis." When
no
information is available for a section, that section is not included. In some in
stances,
when many of the specific disorders in a group of disorders share common feature
s,
this information is included in the general introduction to the group.
Diagnostic Features. This section clarifies the diagnostic criteria and often pr
ovides
illustrative examples.
Subtypes and/or Specifiers. This section provides definitions and brief discussi
ons
concerning applicable subtypes and/or specifiers.
Recording Procedures. This section provides guidelines for reporting the name of
the disorder and for selecting and recording the appropriate ICD-9-CM diagnostic
code. It also includes instructions for applying any appropriate subtypes and/or
specifiers.
Associated Features and Disorders. This section is usuaUy subdivided into three
parts:
Associated descriptive features and IIImtal disorders. This section includes cli
nical
features that are frequently associated with the disorder but that are not consi
dered
essential to making the diagnosis. In some cases, these features were considered
for inclusion as possible diagnostic criteria but were insufficiently sensitive
or
specific to be included in the fmal criteria set. Also noted in this section are
other
mental disorders associated with the disorder being discussed. It is specified
(when known) if these disorders precede, co-occur with, or are consequences of t
he
djsorder in question (e.g., Alcohol-Induced Persisting Dementia is a consequence
Use of the Manual
of chronic Alcohol Dependence). Ifavailable, information on predisposing factors
and complications is also included in this section.
Associated laboratoryjif/dif/gs. This section provides information on three type
s of
laboratory findings that may be associated with the disorder: 1) those associate
d
laboratory findings that are considered to be "diagnostic" of the disorder-for e
xample,
polysonmographic findings in certain sleep disorders; 2) those associated
laboratory findings that are not considered to be diagnostic of the disorder but
that
have been noted to be abnormal in groups of individuals with the disorder relati
ve
to control subjects-for example, ventricle size on computed tomography as a vali
dator
of the construct of Schizophrenia; and 3) those laboratory findings that are
associated with the complications of a disorder-for example, electrolyte imbalan
ces
in individuals with Anorexia Nervosa.
Associated physical examil/atio1l jil/dings aud general medical conditiolls. Thi
s section
includes information about symptoms elicited by history, or findings noted durin
g
physical examination, that may be of diagnostic significance but that are not es
sential
to the diagnosis-for example, dental erosion in Bulimia Nervosa. Also included
are those disorders that are coded outside the "Mental and Behavioural
Disorders" chapter of rCD that are associated with the disorder being djscussed.
As is done for associated mental disorders, the type of association (i.e., prece
des,
co-occurs with, is a consequence of) is specified if known-for example, that cir
rhosis
is a consequence of Alcohol Dependence.
Specific Culture, Age, and Gender Features. This section provides guidance for
the clinician concerning variations in the presentation of the disorder that may
be attributable
to the individual's cultural setting, developmental stage (e.g., infancy,
childhood, adolescence, adulthood, late We), or gender. This section also includ
es information
on differential prevalence rates related to culture, age, and gender (e.g., sex
ratio).
Prevalence. This section provides available data on point and lifetime prevalenc
e,
incidence, and lifetime risk. These data are provided for different settings (e.
g., community,
primary care, outpatient mental health clinics, and inpatient psychiatric settin
gs)
when this information is known.
'.
Course. This section describes the typical lifetime patterns of presentation and
evolution
of the disorder. It contains information on typical age at OJ/set and mode ofoll
set
(e.g., abrupt or insidious) of the disorder; episodic versus COJlfill/lOlIS cour
se; single episode
versus reClirrellt; duratioll, characterizing the typical length of the illness
and its
episodes; and progression, describing the general trend of the disorder over tim
e (e.g.,
stable, worsening, improving).
Familial Pattern. This section describes data on the frequency of the disorder
among first-degree biological relatives of those with the disorder compared with
the
frequency in the general population. It also indicates other disorders that tend
to
occur more frequently in family members of those with the disorder. Information
regarding the heritable nature of the disorder (e.g., data from hvin studies, kn
own
genetic t.ransmission patterns) is also included in this section.
Use of the Manual
Differential Diagnosis. This section discusses how to differentiate this disorde
r
hom other disorders that have some similar presenting characteristics.
DSM-IV Organizational Plan
The DSM-IV disorders are grouped into 16 major diagnostic classes (e.g., Subslan
ceRelated
Disorders, Mood Disorders, Anxiety Disorders) and one additional section,
"Other Conditions That May Be a Focus of Clinical Attention."
The first section is devoted to "Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence." This division of the Classification according to age
at
presentation is for convenience only and is not absolute. Although disorders in
this
section are usually fi~t
evident in childhood and adolescence, some individuals di
agnosed with disorders located in this section (e.g., Attention-Deficit/Hyperact
ivity
Disorder) may not present for clinical attention until adulthood. In addition, i
t is not
uncommon for the age at onset for many disorders placed in other sections to be
du.ring
childhood or adoles<ence (e.g., Major Depressive Disorder, Schizophrenia, Genera
lized
Anxiety Disorder). Clinicians who work primarily with children and
adolescents should therefore be familiar with the entire manual, and those who w
ork
primarily with aduJts should also be familiar with this section.
The next three sections-"Delirium, Dementia, and Amnestic and Other Cognitive
Disorders"; ''t-.olental Disorders Due to a General Medical Condition"; and "Sul
J.
stance-Related Disorders"-were grouped together in DSM-illR under the single
heading of "Organic Mental Syndromes and Disorders." The term "organic mental
disorder" is no longer used in DSM~IV
because it incorrectly implies that the other
mental disorders in the manual do not have a biological basis. As in DSM-m-R, th
ese
sections are placed before the remaining disorders in the manual because of thei
r pri~
ority in differential diagnosis (e.g., substance-related causes of depressed moo
d must
be ruled out before making a diagnosis of Major Depressi\'e Disorder). To facili
tate
differential diagnosis, complete lists of Mental Disorders Due to a General r.,fc
dical
Condition and Substance-Related Disorders appear in these sections, whereas the
text and criteria for these disorders are placed in the diagnostic sections with
disorders
with which they share phenomenology. For example, the text and criteria for
Substance-lnduced Mood Disorder and Mood Disorder Due to a General Medical
Condition are included in the Mood Disorders section.
The organizing principle for all the remaining sections (except for Adjustment D
isorders)
is to group disorders based on their shared phenomenological features in
order to facilitate differential diagnosis. The"Adjustment Disorders" section is
organized
differently in that these disorders are grouped based on their common etiology
(e.g., maladaptive reaction to a stressor). Therefore, the Adjustment Disorders
include
a variety of heterogeneous clinical presentations (e.g., Adjustment Disorder
With Depressed Mood, Adjustment Disorder ''''ith Anxiety, Adjustment Disorder
With Disturbance of Conduct).
Finally, DSM~IV
includes a section for "Other Conditions That May Be a Focus of
Clinical Attention."
DSM-lV includes 11 appendixes:
Appendix A: Decision Trees for Differential Diagnosis. This appendix contains
six decision trees (for Mental Disorders Due to a General Medical Condition, Sul
J.
Use of the Manual
stance-Induced Disorders, Psychotic Disorders, Mood Disorders, Anxiety Disorders
,
and Somatoform Disorders). Their purpose is to aid the clinician in differential
diagnosis
and in understanding the hierarchical structure of the DSM-IV Classification.
Appendix B: Criteria Sets and Axes Provided for Further Study. This appendix
contains a nwnber of proposals that were suggested. for possible inclusion in DS
M-IV.
Brief texts and research criteria sets are provided for the following: postconcu
ssional
disorder, mild neurocognitive disorder, caffeine withdrawal, postpsychotic depre
ssive
disorder of Schizophrenia, simple deteriorative disorder, premenstrual dysphoric
disorder, minor depressive disorder, recurrent brief depressive disorder, mixed
anxiety-depressive disorder, factitious disorder by proxy, dissociative trance d
isorder,
binge-eating disorder, depressive personality disorder, passive-aggressive
personality disorder, Neuroleptic-Induced Parkinsonism, Neuroleptic Malignant
Syndrome, Neuroleptic-Induced Acute Dystonia, Neuroleptic-Induced Acute Akathisi
a,
Neuroleptic-Induced Tardive Dyskinesia, and Medication-Induced Postural
Tremor. In addition, alternative dimensional descriptors for Schizophrenia and a
n alternative
Criterion B for Dysthymic Disorder are included. Finally, three proposed
axes (Defensive Functioning Scale, Global Assessment of Relational Functioning
[GARF] Scale, and Social and Occupational Flmctioning Assessment Scale (SOFAS])
are provided.
Appendix C: Glossary of Technical Terms. This appendix contains glossary definit
ions
of selected terms to assist users of the manual in the application of the criter
ia
""Is.
Appendix D: Highlights of Changes in DSM-IV Text Revision. This appendix
provides an overview of changes as a result of the DSM-fV text revision process.
Appendix E: Alphabetical listing of DSM-IV-TR Diagnoses and Codes. This appendix
lists the DSM-fV disorders and conditions (with their ICD-9-0vl codes) in alphab
etical
order. It has been included to facilitate the selection of diagnostic codes.
Appendix F: Numerical Listing of DSM-IV-TR Diagnoses and Codes. This appendix
lists the DSM-fV disorders and conditions (wit..l::l..their ICD-9-CM codes) in n
umerical
order by code. It has been included to facilitate recording of diagnostic terms.
Appendix G: ICD-9-CM Codes for Selected General Medical Conditions and Medicatio
n-
Induced Disorders. This appendix contains a list of ICD-9-CM codes for
selected general medical conditions and has been provided to facilitate coding o
n
Axis m. This appendix also provides ICD-9-CM E-codes for selected medications,
prescribed at therapeutic dose levels, that cause Substance-Induced Disorders. T
he
E-codes may optionally be coded on Axis I immediately following the related diso
rder
(e.g., 292.39 Oral Contraceptive-Induced Mood Disorder, With Depressive Features
;
932.2 oral contraceptives).
Appendix H: DSM-IV Classification (With ICD-lO Codes). As of the publication
of the text revision (in the late spring of 2000), the official coding system in
use in the
Use of the Manual
United States is the ll/temf/tiollaf Clf/ssification of Disenses, Ninth Revision
, Clinical
Modification (ICD-9CM). Throughout much of the world, the official coding system
is the IlltemntiOllal Sflltistical Clf/ssificatioll of Diseases aJld Related Hea
lt1/ Problems, Tenth
Revision (ICD-lO). To facilitate the use of DSM-IV internationally, this appendi
x contains
the complete OSMJV classification with ICD-lO diagnostic codes.
Appendix I: Outline for Cultural Fonnulation and Glossary of CultureBound
Syndromes. This appendix is divided into hvo sections. The first provides an out
line
for cultural formulation designed to assist the clinician in systematically eval
uating
and reporting the impact of the individual's cultural context The second is
a glossary of culture-bound syndromes.
~
Appendix J: DSM-IV Contributors. This appendix lists the names of the advisers
and field-trial participants and other individuals and organizations that contri
buted
to the development of DSM-IV.
Appendix K: DSM-rv Text Revision Advisers. This appendix lists the names of
the advisers who contributed to the DSM-IV Text Revision.
DSM-IV-TR Classification
NOS = Not Othen\'ise Specified.
An x appearing in a diagnostic code indicates
that a specific code number is required.
An ellipsis (...) is used in the names of
certain disorders to indicate that the
nalne of a specific mental disorder or
general medical condition should be
inserted when recording the name
(e.g.,293.0 Delirium Due to Hypothyroidism).
Numbers in parentheses are page numbers.
U criteria are currently met. one of the
following severity specifiers may be
noted after the diagnosis:
Wd
Moderate
$evere
If criteria are no longer met, one of the
following specifiers may be noted:
In Partial Remission
In Full Remission
Prior History
13
Disorders Usually First
Diagnosed in Infancy,
Childhood, or Adolescence (39)
MENTAL RETARDATION (41)
Note:
These nre coded 011 Axis 11.
317
Mild Mental Retardation (43)
318.0
Moderate Mental Retardation
(~3)
318.1
Severe Mental Retardation (43)
318.2
Profound Mental Retardation
(-14)
319
Mental Retardation, Severity
Unspecified (44)
LEARNING DISORDERS (49)
315.00
Reading Disorder (51)
315.1
Mathematics Disorder (53)
315.2
Disorder of Written Expression
(54)
315.9
Learning Disorder NOS (56)
MOTOR SKILLS DISORDER (56)
,.
315.4
Developmental Coordination
Disorder (56)
COMMUNICATION DISORDERS (58)
315.31
Ex-pressive Language Disorder
(58)
315.32
Mixed Receptive-Expressive
Language Disorder (62)
315.39
Phonological Disorder (65)
307.0
StuHering (67)
307.9
Communication Disorder NOS
(69)
D$M-IV-TR Classification
PERVASIVE DEVELOPMENTAL
DISORDERS (69)
299.00
Autistic Disorder (70)
299.80
Rett's Disorder (76)
299.10
Childhood Disintegrative
Disorder (77)
299.80
Asperger's Disorder (80)
299.80
Pervasive Developmental
Disorder NOS (S-t)
AITENTlONDEFICIT AND
DISRUPTIVE BEHAVIOR DISORDERS
(85)
314.xx Attention-Deficit/
Hyperactivity Disorder (85)
.01 Combined Type
.00 Predominantly Inattentive
Type
.01 Predominantly
Hyperactive-Impulsive Type
314.9 Attention-Deficit/
Hyperactivity Disorder NOS
(93)
312.xx Conduct Disorder (93)
.81 ChHdhood-Onset Type
.82 Adolescent-Onset Type
.89 Unspecified Onset
313.81 Oppositional Defiant Disorder
(100)
312.9 Disruptive Behavior Disorder
NOS (103)
FEEDING AND EATING DISORDERS
OF INFANCY OR EARLY
CHILDHOOD (103)
307.52
Pica (103)
307.53
Rumination Disorder (105)
307.59
Feeding Disorder of InfanC)' or
Early Childhood (107)
TIC DISORDERS (108)
307.23
Tourette's Disorder (111)
307.22
Chronic Motor or Vocal Tic
Disorder (114)
307.21
Transient Tic Disorder (115)
Spmfy if: Single Episode/Recurrent
307.20
Tic Disorder NOS (116)
ELIMINATION DISORDERS (116)
-.787.6
Encopresis (116)
With Constipation and
Overflow Incontinence
307.7 Without Constipation and
Overflow Incontinence
307.6 Enuresis (Not Due to a General
Medical Condition) (118)
Spify type.. Nocturnal Only/Diurnal
Only/Nocturnal and Diurnal
OTHER DISORDERS OF INFANCY,
CHILDHOOD, OR ADOLESCENCE
(121 )
309.21
Separation Anxiety Disorder
(121)
S/H'cify if:
Earl)' Onset
313.23
Selective Mutism (125)
313.89
Reactive Attachment Disorder
of Infancy or Early Childhood
(127)
Spffify typr.lnhibiled Type/
Disinhibiled Type
307.3
Stereotypic Movement Disorder
(131)
Specify if: With Self-Injurious Behavior
313.9
Disorder of Infancy,Childhood,
or Adolescence NOS (134)
Delirium, Dementia, and
Amnestic and Other Cognitive
Disorders (135)
DELIRIUM (136)
293.0
-.Delirium
Due to ... [Illdicate the
General Medical COllditioll/ (I'll)
Substance Intoxication Delirium
-(
refer to Substance-Related
Disorders for subs/alice-specific
codes) (143)
Substance Withdrawal
Delirium (refer fo SubsfallceRelated
Disorders for substallcespecific
codes) (143)
DSM-IV-TR Classification
-.-Delirium Due to Multiple
Etiologies (code each ofIIIe specific
etiologies) (146)
780.09
Delirium NOS (147)
DEMENTIA (147)
294.xx
Dementia of the Alzheimer's
Type, With Early Onset (also
code 331.0 Alzheimer's disease 011
Axis Ill) (154)
.10 Without Behavioral
Disturbance
.11 With Behavioral Disturbance
294.xx Dementja of the Alzheimer's
Type, With Late Onset (also code
331.0 Alz.heimer's disease 011
Axis Ill) (154)
.10 Without Behavioral
Disturbance
.11 With Behavioral Disturbance
290.xx
Vascular Dementia (158)
.40 Uncomplicated
.41 With Delirium
.42 With Delusions
.3 With Depressed Mood
Sptcify if.
With Beh,n;oral Disturbance
Code presence orabsence ofa beluwiornl
disturbQllce ill tilefifth digitfor Dementia
Due 10 a General Medical Condition:
0" Without Behavioral Disturbance
1 .. With Behavioral Disturbance
294.1x Dementia Due to rnv Disease
(also code 042 HlV all Axis Ill)
(163)
294.lx
Dementia Due to Head Trauma
(also code 854.00 head illjury all
Axis Ill) (164)
291.1x
Dementia Due to Parkinson's
Disease (also code 332.0
Parkinson's disease all Axis 111)
(1~)
I
29Ux Dementia Due to HWltington's
I
Disease (also code 333.4 HutltillgtOil'S
disease all Axis 111) (165)
'1CD-9-CM code \'alid after OcIOber 1, 2000.
294.lx""
Dementia Due to Pick's Disease
(also code 331.1 Pick's disease 011
Axis Ill) (165)
29"\'.h:
Dementia Due to CreutzfeldtJakob
Disease (also code 046.1
Crelllzfeldt-}akob disease 011 Axis
Ill) (166)
29-l.1~
Dementia Due to ... filldicate tile
Gellf!ral Medical COllditiollllOt
listed aooi./e1 (also code tile general
medical condition 011 Axis /II)
(167)
--Substance-lnduced Persisting
Dementia (refer to SubstallceRelated
Disorders for substancespecific
codes) (168)
--Dementia Due to Multiple
Etiologies (code each ofthe specific
etiologies) (170)
294.8 Dementia 'OS (171)
AMNESTIC DISOROERS (172)
294.0
Amnestic Disorder Due to ...
fIlldicate
tile General Medical
Condition] (175)
Specify if Transient/Chronic
--Substance-Induced Persisting
Amnestic Disorder (refer to
Substance-Related Disorders for
sllbstance-specijic codes) (177)
294.8
Amnestic Disorder NOS (179)
OTHER
COGNITIVE DISORDERS
(179)
294.9
Cognitive Disorder OS (179)
Mental Disorders Due to a
General Medical Condition
Not Elsewhere Classified (181)
293.89
Catatonic Disorder Due to ...
[Indicate IIle Gel/eral Medical
Condition] (185)
310.1
Personality Change Due to ...
[Indicate tlle General Medical
Conditiolll (187)
,,
DSMIVTR Classificatior,
Spteify t~
labile Type/Disinlubited
Type/Aggressi"e Type/Apathetic
Type/Paranoid Type/Other Type/
Combined Type/Unspecified Type
293.9
Mental Disorder NOS
Due 10 .. . lJlldicate tile Gelleral
Medical COllditioll] (190)
Substance-Related Disorders
(191)
TIle jol/orvillg specifiers apply to Substallce
Dependellce as noted:
~With
Physiological Dependence/Without
Ph}siological Dependence
"Enl}" FuU Remission/Early Partial RenUssion/
Sustained Full Remission/Sustained Partial
R~ion
"In a ControUed En,rjronmenl
don Agonist Therapy
The following specifiers apply to SubstalleeIllduced
Disorders as IIoted:
[WithOnset During Intoxication/\\'WithOnset
During Withdrawal
ALCOHOL-RELATED DISORDERS
(212)
Alcohol Use Disorders (213)
303.90
Alcohol Dependenceap,c (213)
305.00
Alcohol Abuse (214)
Alcohollnduced Disorders (214)
303.00
291.81
291.0
Alcohol Intoxication (214)
Alcohol Withdrawal (215)
Spmfy if. With Perceptual Disturbances
Alcohollntoxication Delirium
291.0
(143)
Alcohol Withdrawal Delirium
291.2
(143)
Alcohol-Induced Persisting
Dementia (168)
291.1 Alcohol-Induced Persisling
Amnestic Disorder (177)
291.x
.s
.3
291.89
291.89
291.89
291.89
291.9
Alcohol-Induced Psychotic
Disorder (338)
With Delusions!.w
With Hallucinationsl,\V
Alcohol-Induced Mood
Disorde,lw (405)
Alcohol-Induced Anxiety
Disorde,lw (479)
Alcohol-Induced Sexual
Dysfunctionl (562)
Alcohol-Induced Sleep
Disorde,l,w (655)
Alcohol-Related Disorder NOS
(223)
AMPHETAMINE (OR
AMPHETAMINE-lIKE)-RELATED
DISORDERS (223)
Amphetamine Use Disorders (224)
3O-t.-l0 Amphetamine Dependenccap,c
(224)
305.70
Amphetamine Abuse (225)
Amphetamine-Induced Disorders
(226)
292.89
292.0
292.81
292.xx
.11
.12
292.84
292.89
292.89
292.89
292.9
Amphetamine Intoxication
(226)
SJNdfy if: With Perceptual Disturbances
Amphetamine Withdrawal
(227)
Amphetamine Intoxication
Delirium (143)
Amphetamine-Induced
Psychotic Disorder (338)
With Delusionsl
With Hallucinationsl
Amphetamine-Induced 100d
Disorde,l,w (-IDS)
Amphetamine-InducedAnxiety
I);so,de,J (479)
Amphetatlline-Induced Sexual
Dysfunctionl (562)
Amphetamine-Induced Sleep
Disorderl,\\! (655)
Amphetamine-Related
Disorder NOS (231)
, ,
DSM-IV-TR Classification
CAFFEINE-RELATED DISORDERS
(231)
Caffeine-Induced Disorders (232)
305.90
Caffeine intoxication (232)
292.89
Caffeine-induced Anxiety
Disorde~
(-179)
292.89
Caffeine-Induced Sleep
Disorde~
(655)
292.9
Caffeine-Related Disorder NOS
(23-1)
CANNABIS-RELATED DISORDERS
(234)
Cannabis Use Disorders (236)
30-1.30 Cannabis Dependencea.b.c (236)
305.20 Cannabis Abuse (236)
Cannabis-Induced Disorders (237)
292.89
Cannabis Intoxication (237)
Sped!'l if: With Perceptual Disturbann's
292.81
Cannabis Intoxication Delirium
(143)
292.xx
Canmlbis-Induced Psychotic
Disorder (338)
.11 With Delusionsl
.12 With Hallucinations1
292.89
Cannabis-Induced Anxiety
Disorder! (479)
292.9
Cannabis-Related Disorder
NOS (241)
COCAINERELATED DISORDERS
(24I)
Cocaine Use Disorders (242)
304.20
Cocaine Dependencea,b,c (242)
305.60
Cocaine Abuse (243)
Cocaine-Induced Disorders (244)
292.89
Cocaine Intoxication (244)
s~~ify
if: With Perceptual Disturbances
292.0
Cocaine Withdrawal (245)
292.81
Cocaine Intoxication Delirium
(143)
292.xx
Cocaine-Induced Psychotic
Disorder (338)
.11 With Delusionst
.12 With Hallucinationsl
292.84
Cocaine-induced Mood
Disorder!.w (405)
292.89
Cocaine-Induced Anxiety
Disorde~'\V(479)
292.89
Cocaine-Induced Sexual
Dysfunctionl (562)
292.89
Cocaine-Induced Sleep
Disorde~'w
(655)
292.9
Cocame-Related Disorder 'OS
(250)
HALLUCINOGEN-RELATED
DISORDERS (250)
Hallucinogen Use Disorders (251)
3Q.l.30 Hallucinogen Dependenceb.c
(251)
305.30
Hallucinogen Abuse (252)
Hallucinogen-Induced Disorders
(252)
292.89
Hallucinogen Intoxication (252)
292.89
Hallucinogen Persisting
Perception Disorder
(Flashbacks) (253)
292.81
Hallucinogen Intoxication
Delirium (143)
292.xx
Hallucinogen-Induced
Psychotic Disorder (338)
.11 With Delusions'
.12 With Hallucinationsl
292.84
Hallucinogen-Induced Mood
Disorderl (405)
292.89
Hallucinogen-Induced Anxiety
Di~p~derl
(479)
292.9
Hallucinogen-Related Disorder
NOS (256)
INHALANT-RELATED DISORDERS
(257)
Inhalant Use Disorders (258)
304.60
Inhalant Dependenceb.c (258)
305.90
Inhalant Abuse (259)
Inhalant-Induced Disorders (259)
292.89
Inhalant Intoxication (259)
292.81
Inhalant Intoxication Delirium
(143)
DSM-IV-TR Classification
292.82
lnhalantlnduced Persisting
Dementia (168)
292.xx
lnhalantInduced Psychotic
Disorder (338)
.11 With Delusions'
.12 With Hallucinations!
292.84
Inhalant-Induced Mood
Disorder! (405)
292.89
Inhalant-Induced Anxiety
Disorder! (479)
292.9
Inhalant.Rel,!!ed Disorder NOS
(263)
NICOTINE-RELATED DISORDERS
(264)
Nicotine Use Disorder (264)
305.1 'icotine Dependencea.b (264)
Nicotine-Induced Disorder (265)
292.0 Nicotine Withdrawal (265)
292.9 Nicotine-Related Disorder OS
(269)
OPIOID-RELATED DISORDERS (269)
Opioid
Use Disorders (270)
304.00
Opioid Dependence",b.c,d (270)
305.50
Opioid Abuse (271)
Opioid-lnduced Disorders (271)
292.89
Opioid lntoxication (271)
Spify if With Perceptu'" Di!;turbances
292.0
Opioid Withdrawal (272)
292.81
Opioid lntoxication Delirium
(143)
292.xx
Opioidlnduced Psychotic
Disorder (338)
.11 With Delusions!
.12 With Hallucinationsl
292.84
Opioid.lnduced Mood
Disorde~
(405)
292.89
Opioid.lnduced Sexual
Dysfunctionl (562)
292.89
OpioidInduced Sleep
Disorde~'w
(655)
292.9
Opioid-ReIated Disorder OS
(277)
PHENCYCLIDINE (OR
PHENCYCLIDINE-L1KE)-RELATED
DiSORDERS (278)
Phencyclidine Use Disorders (279)
304.60
Phencyclidine Dependenceb.c
(279)
305.90
Phencyclidine Abuse (279)
Phencyclidine.lnduced Disorders
(280)
292.89
Phencyclidine Intoxication (280)
Sptdfy if: With Perceptual Disturbances
292.81
Phencyclidine Intoxication
Deliriwn (143)
292.xx
Phencyclidine-Induced
Psychotic Disorder (338)
.11 With Delusions'
.12 With Hallucinations'
292.84
Phencyclidine-Induced Mood
Disorde~
(405)
292.89
Phencyclidine-Induced Anxiety
Disorder! (479)
292.9
Phencyclidine-Related Disorder
NOS (283)
SEDATIVE, HYPNOTIC-, OR
ANXIOLYTlCRELATED DISORDERS
(284)
Sedative, Hypnotic. or Anxiolytic
Use Disorders (285)
304.10
Sedative, Hypnotic. or
Anxiolytic Dependencea.b.c
(285)
305.40
Sedative. Hypnotic, or
Anxiolytic Abuse (286)
Sedative-, Hypnotic-, or
Anxiolytic-Induced Disorders (286)
292.89
Sedative, Hypnotic, or
Anxiolytic Intoxication (286)
292.0
Sedative. Hypnotic, or
AnxioIytic Withdrawal (287)
spmfy ifWith Perceptual Disturbances
292.81
Sedative. Hypnotic, or
Anxiolytic Intoxication
Delirium (143)
292.81
Sedative. Hypnotic, or
Anxiolytic Wilhdrawal
Delirium (143)
DSM-IV-TR Classification
292.82
Sedative-, Hypnotic-, or
Anxiolytic-Induced Persisting
Dementia (168)
292.83
Sedative-, Hypnotic-, or
Anxiolytic-Induced Persisting
Amnestic Disorder (177)
292.xx
Sedative-, Hypnotic-, or
Anxiolytic-Induced Psychotic
Disorder (338)
.11 With Delusionsl.\\'
.12 With Hallucinations!,\\'
292.84
Sedative-, Hypnotic-, or
Anxiolytic-lnduced Mood
Disorder!'\\' (405)
292.89
Sedative-, Hypnotic-, or
Anxiolytic-Induced Anxiety
Disorder\\' (479)
292.89
Sedative-, Hypnotic-, or
Anxiolytic-lnduced Sexual
Dysfunctionl (562)
292.89
Sedative-, Hypnotic-, or
Anxiolytic-Induced Sleep
Disorderl.\V (655)
292.9
Sedative-, Hypnotic-. or
Anxiolytic-Related Disorder
NOS (293)
POLYSUBSTANCE-RELATED
DISORDER (293)
304.80
Polysubstance
Dependencea,b,c,d (293)
OTHER (OR UNKNOWN)
SUBSTANCE-RELATED DISORDERS
(294)
Other (or Unknown) Substance
Use Disorders (295)
304.90
Other (or Unknown) Substance
Dependencea,b,c,d (192)
305.90
Other (or Unknown) Substance
Abuse (198)
Other (or Unknown) SubstanceInduced
Disorders (295)
292.89
Other (or Unknown) Substance
Intoxication (199)
Sptrify if. With Pen:eptual Disturbances
292.0
Other (or Unknown) Substance
Withdrawal (201)
5prrify if \\'ith Perceptual DisturbanCl5
292.81
Other (or Unknown)
Substance-Induced Delirium
(143)
292.82
Other (or Unknown)
Substance-Induced Persisting
Dementia (168)
292.83
Other (or Unknown)
Substance-Induced Persisting
Amnestic Disorder (177)
292.xx
Other (or Unknown)
Substance-Induced Psychotic
Disorder (338)
.11 With DelusionslW
.12 With Hallucinationsl,\\'
292.84
Other (or Unknown)
Substance-Induced Mood.
Disorde~'\\'
(405)
292.89
Other (or Unknown)
Substance-Induced Anxiety
Disorde~'w(479)
292.89
Other (or Unknown)
Substance-Induced Sexual
Dysfunctionl (562)
292.89
Other (or Unknown)
Substance-Induced Sleep
Disorde~'1V
(655)
292.9
Other (or Unknown)
Substance-Related Disorder
N05 (295)
...
Schizophrenia and Other
Psychotic Disorders (297)
295.xx
Schizophrenia (298)
Thefollowing Classijicntiotr ofLongitudillal
Course applies to all subtypes of
ScJrizop/lrt11ia:
Episodic With Intenopisode Residual
Symptoms (spify if: With Prominent
Negati\'e S)'lTIptoms}/Episodic With No
Inlerepisode Residual S)mptoffiS
Continuou (spmfy if: With Prominent
Negative Symptoms)
Single Episode In Partial Remission ($pmfy if
With Prominent Negath'e Symptoms)/
Single Episode In Full Remission
Other or Unspecified P<lltem
.30 Paranoid Type (313)
.10 Disorganized Type (314)
.20 CatalonicType (315)
.90 Undifferentiated Type (316)
.60 Residual Type (316)
295.40
Schizophre.'tiform Disorder
(317)
spmfy if. Without Good Prognostic
Fe<l!un'S/With Good Prognostic
FNtures
Schizoaffective Disorder (319)
295.70
S,>ify typ;!; Bipol<lr Type/Depressive
Type
297.1
Delusional Disorder (323)
specify Iy~;
Erotom<lnic Type/
Grandiose Type/Je<llous Type/
Persecutory Type/Somatic Type/
Mixed Type/Unspecified Tn>e
298.8
Brief Psychotic Disorder (329)
Spt'rify if: Wilh Marked Slressor(s)/
Without ~tilrked
Stressor(s)/With
postp<lrtum Onset
297.3 Shared Psychotic Disorder (332)
293.:0: Psychotic Disorder Due to ...
(Indicate ti,e General Medical
Conditionl (334)
.81 With Delusions
.82 With Hallucinations
-.-Substance-Induced Psychotic
Disorder (refer to Subs/mICeRe1l1ted
Disorders for Sl/bsta/lcespecific
codes) (338)
spify if: With Onset During
lntoxication/With Onset During
Withdrawal
298.9 Psychotic Disorder NOS (:>-13)
DSM-IV-TR Classification
Mood Disorders (345)
Code current stllte of Major DepressiiJl!
Disorder or Bipolar I Disorder ill riftll digit
l" Mild
2" 1\lodcrale
3 "Se\"cre Withoutl'sychotic Features
.,\ "Severe With Psychotic Features
Sprdfy: Mood-Congruent Psychotic
Fealures/~
lo()(Hncongruent Psychotic
Features
5" In Partial Remis..sion
6" In FuU Remission
0" Unspecified
Thefollowing speCifiers apply (jorcllrrmt 01
1Il0st recellt episode) to Mood Disorders tiS
/loted:
"Sc\"erity/Psychotic/Remission Specifiers/
bChron(cl"With Catatonic FC<ltures/dWith
Melancholic Features/tWith Atypic<ll
Fe<llures/fWith Postpartum Onset
TIle follo<uillg speCifiers apply 10 Mood
Disorders liS /loted:
'With or Without Fulllntercpisode Rem\-e!)"/
hWith Seasonal P<llIem/;With R.tpid
Cycling
DEPRESSIVE DISORDERS (369)
296.xx
Major Depressive Disorder
(369)
Single Episode",b,c,d.e,f
.2x
Recurrenta,b,c,d,e,f,g..h
.3x
300.4
Dysthymic Disorder (376)
Specify if: Early Onset/Late Onset
Sprr-ify: With Atypical Features
311 Depressive Disorder NOS (381
BIPOLAR DISORDERS (382)
296.:0: Bipolar I Disorder (382)
.Ox Single Manic Episode<l,cJ
spify if.
Mb.ed
.40 Most Recent Episode
Hypomanic&-h.i
.4x Most Recent Episode
Manic<l,d,g.h,i
DSM-IV-TR Classification
.6>.:
Most Recent Episode
NUxeda,e,f,g,h,i
.OX
Most Recent Episode
Depresseda,b,c,d,e,f,g,h,i
Most Recent Episode
Unspecifiedg,h,i
296.89
Bipolar II Disordera,b,c,d,e,f,g..h,i
(392)
Specify (cIITrell! or /IIosl Tecml ryisode):
H}'P0manic/ Depressed
301.13
Cyclothymic Disorder (398)
296.80
Bipolar Disorder NOS (400)
293.83
Mood Disorder Due to ...
[Indimte tile Gelleral Medical
Condition] (401)
Specify tYI'e: With Depressive Features/
With foolajor Dl'pressi\'e-Like Episode/
With ~lanlc
Features/With MiXl'd
Features
--Substance-Induced Mood
Disorder (refer to Substallce-
Related Disorders for substance-
specific codes) (405)
Spify Iyl"': With Depressive Features/
With Manic Features/With Mi.xed
Features
Specify if: With Onset During
Intoxication/With Onset During
Withdrawal
296.90
Mood Disorder NOS (410)
Anxiety Disorders (429)
300.D1
Panic Disorder Without
Agoraphobia (433)
300.21
Panic Disorder With
Agoraphobia (433)
300.22
Agoraphobia Without History
of Panic Disorder (441)
300.29
Specific Phobia (443)
Sl"'cify fype: Animal Type/Natural
Environment T}'Pe/Biood-[njection~
Injury Type/Situational Type/Other
T}'Pe
300.23
Social Phobia (450)
Spt"cify if: Generalized
300.3
Obsessive-.-Compulsive
Disorder (456)
Spt"cify if: With Poor Insight
309.81
Posttraumatic Stress Disorder
(463)
Spt"cify if" Acute/Chronic
specify if With Delayed Onset
308.3
Acute Stress Disorder (469)
300.02
Generalized Anxiety Disorder
(472)
293.84
Anxiety Disorder Due to ...
[II/dicafe the General Medical
Condition] (476)
sprcify if With Generalized Anxiety/
With Panic Attacks/With Obsessive-
Compulsive Symptoms
--Substance-Induced Anxiety
Disorder (refer to Substance-
Related Disorders for sllbstal/cespecific
codes) (479)
Specify if: With Generalized Anxiety/
With Panic Attacks/With Obsessive-
Compulsive Symptoms/\\'ith Phobic
Symptoms
Specify if" With Onset During
Intoxication/With Onset During
\\'ithdrawal
300.00
Anxiety Disorder NOS (484)
Somatoform Disorders (485)
300.81
Somatization Disorder (486)
300.82
Undifferentiated Somatofonn
Disorder (490)
300.11
Conversion Disorder (492)
Specify fype: With :-'lotor Symptom or
Deficit/With Sensory S}'mptom or
Deficit/With Seizures or COn\'ulsions/
With i\Iixed Presentation
307.xx Pain Disorder (498)
.80 Associated With
Psychological Factors
.89 Associated With Both
Psychological Factors and a
Gener,11 Medical Condition
Specify if:
Acute/Chronic
300.7
Hypochondriasis (504)
Spteify if: With Poor Insight
300.7
Body Dysmorphic Disorder
(507)
300.82
Somatoform Disorder NOS
(511)
Factitious Disorders (513)
300.>0< Factitious Disorder (513)
.16 With Predominantly
Psychological Signs and
Symptoms
.19 With Predominantly
Physical Signs and
Symptoms
.19
,,,lith Combined
Psychological and Physical
Signs and Symptoms
300.19
Factitious Disorder NOS (517)
Dissociative Disorders (519)
300.12
Dissociative Amnesia (520)
300.13
Dissociative Fugue (523)
300.14
Dissociative Identity Disorder
(526)
300.6 Depersonalization Disorder
(530)
300.15
Dissociative Disorder NOS
(532)
Sexual and Gender Identity
Disorders (535)
SEXUAL DYSFUNCTIONS (535)
Tilefollowing specifiers apply to all primary
Sexual Dysfunctions:
DSMIVTR Classification
Lifelong Type!Acquired Trpe
Generalized Type/Situational Trpe
Due to PsrcllOlogical Factors/Due to
Combined Factors
Sexual Desire Disorders (539)
302.71
Hypoactive Sexual Desire
Disorder (539)
302.79
Sexual Aversion Disorder (541)
Sexual Arousal Disorders (543)
302.72
Female Sexual Arousal
Disorder (543)
302.72
Male Erectile Disorder (545)
Orgasmic Disorders (547)
302.73
Female Orgasmic Disorder
(547)
302.74
Male Orgasmic Disorder (550)
302.75
Premature Ejaculation (552)
Sexual Pain Disorders (554)
302.76
Dyspareunia (Nol Due to a
General Medical Condition)
(554)
306.51
Vaginismus (Not Due to a
General Medical Condition)
(556)
Sexual Dysfunction Due to a
General Medical Condition (558)
625.8
Female Hypoactive Sexual
Desire Disorder Due to ...
[Indicate tile General Medicnl
COllditioll! (558)
608.89
Male Hypoactive Sexual Desire
Disorder Due to ... (fndicate tile
Gelleral Medical COlldifioll/ (558)
607.84
Male Erectile Disorder Due to ...
[Illdicnle the General Medical
COllditiou! (558)
625.0
Female Dyspareunia Due 10 ...
(fndicnte the General Medical
COllditioll} (558)
608.89 Male Dyspareunia Due to ...
[fndicnte the General Medical
Conditioll} (558)
DSM-IV-TR Classification
625.8
Other Female Sexual
Dysfunction Due to ... {llldicate
tile General Medical Conditiol/]
(558)
608.89
Other Male Sexual Dysfunction
Due to ... {llldicate the Gel/eral
Medical COllditioll} (558)
Substance-Induced Sexual
Dysfunction <refer to SlIbstallceRelated
Disorders for 5l1bstallcespecific
codes) (562)
S~cify
if: With Impaired Desire/With
Impaired Arousal/With Impaired
Orgasm/With Sexual Pain
Specify if: With Onset During
Intoxication
302.70
Sexual Dysfunction NOS (565)
PARAPHILIAS (566)
302.4
Exhibitionism (569)
302.81
Fetishism (569)
302.89
Frotteurism (570)
302.2
Pedophilia (571)
Spt'cify if Sexually Attracted to ""lales/
Sexually Attracted to Females/Sexually
Attracted to Both
Spt'cify if: limited to Incest
Sl1t'Cify type: Exclusive Type/
NonexclusivE' Type
302.83
Sexual Masochism (572)
302.84
Sexual Sadism (573)
302.3
Transvestic Fetishism (574)
Spt'cify if: With Gt'nder Dysphoria
302.82
Voyeurism (575)
302.9
Paraphilia NOS (576)
GENDER IDENTITY DISORDERS
(576)
302.:0; Gender Identity Disorder (576)
.6 in Children
.85 in Adolescents or Adults
Spt'cify if: Sexually Attracted to Males/
Sexually Attracted to Females/Sexually
Attracted to Both/Sexuall)' Attracted to
Neither
302.6
Gender Identity Disorder NOS
(582)
302.9
Sexual Disorder NOS (582)
Eating Disorders (583)
307.1
Anorexia Nervosa (583)
spify typt'; Restricting Type; BingeEating/
Purging Type
307.51
Bulimia Nervosa (589)
spt'cify type; Purging Type/Nonpurging
Type
307.50
Eating Disorder NOS (594)
Sleep Disorders (597)
PRIMARY SLEEP DISORDERS (598)
Dyssomnias (598)
307.42
Primary InsoIImja (599)
307.44
Primary Hypersomnia (604)
Specify if: Recurrent
347 Narcolepsy (609)
780.59
Breathing-Related Sleep
Disorder (615)
307.45
Circadian Rhythm Sleep
Disorder (622)
Specify typt': Delayed Sleep Phase Type/
Jet Lag Type/Shift Work Type/
Unspecified Type
307.47
Dyssomnia NOS (629)
Parasomnias (630)
307.47
Nigh}ffiare Disorder (631)
307.46
Sleep Terror Disorder (634)
307.46
Sleepwalking Disorder (639)
307.47
Parasomnia NOS (644)
SLEEP DISORDERS RELATED TO
ANOTHER MENTAL DISORDER (645)
307.42
Insomnia Related to .. . 111ldicate
Ole Axis lor Axis II Disorder}
(645)
307.44
Hypersomnia Related 10 ...
/llldicate tile Axis lor Axis 11
Disorder} (645)
OTHER SLEEP DISORDERS (651)
780.xx Sleep Disorder Due to ...
/II/dicate the General Medical
COl/ditio,,] (651)
.52 Insomnia Type
.54 Hypersomnia Type
.59 Parasomrna Type
.59 Mixed Type
-.-
Substance-Induced Sleep
Disorder (refrr to 5l1bstallce~
Related Disorflers far Slibstallce
specific codes) (l;SS)
Sptrify type. Insomnia Type!
Hrpersomnia Trpe/P.HilSOmnia Type/
~-lixed
Type
Spify if. With Onset During
Intoxication/With On5e1 During
Withdrawal
Impulse-Control Disorders Not
Elsewhere Classified (663)
312.34 Intermittent Explosive Disorder
(663)
312.32
Kleptomania (667)
312.33
Pyromania (669)
312.31
Pathological Gambling (671)
312.39
Trichotillomania (674)
312.30
Impulse-Control Disorder I as
(677)
Adjustment Disorders (679)
DSM-IV-TR Classification
Personality Disorders (685)
Note:
301.0
301.20
301.22
301.7
301.83
301.50
301.81
301.82
301.6
301.4
301.9
Tl,ese are coded all Axis II.
Paranoid Personality Disorder
(690)
Schizoid Personality Disorder
(694)
Schizotypal Personality
Disorder (697)
Antisocial Personality Disorder
(701)
Borderline Personality Disorder
(706)
Histrionic Personality Disorder
(711)
Narcissistic Personality
Disorder (714)
Avoidant Personality Disorder
(71 B)
Dependent Personality
Disorder (721)
Obsessive-Compulsive
Personality Disorder (725)
Personality Disorder NOS (729)
309.xx
.0
.24
.28
.3
.4
.9
Adjustment Disorder (679)
With Depressed Mood
With Anxiety
With ~tixed
Anxiety and
Depressed Mood
With Disturbance of Conduct
'''lith Mixed Disturbance of
Emotions and Conduct
Unspecified
Spi'Cify if:
Acute/Chronic
Other Conditions That May Be a
Focus of Clinical Attention (731)
PSYCHOLOGICAL FACTORS
AFFECTING MEDICAL CONDITION
(731)
316
... {Specified Psyc11010gical Factor]
Affecting . .. {II/dimte ti,e General
Medical Conditiou} (731)
Choose lUll/It' based 011 natllre
offnctors:
Mental Disorder Affecting
Medical Condition
PsychologicalSymploms
Affecting Medical Condition
DSMIV-TR Classification
Personality Traits or Coping
Style Affecting Medical
PROBLEMS RELATEO TO ABUSE OR
NEGLECT (738)
Condition
Maladaptive Health Behaviors
Affecting Medical Condition
Stress-Related Physiological
Response Affecting Medical
Condition
Other or Unspecified
Psychological Factors
Affecting Medical Condition
MEDICATIONINDUCED
MOVEMENT DISORDERS (734)
332.1
Neuroleptic-Induced
Parkinsonism (735)
333.92
Teuroleptic Malignant
Syndrome (735)
333.7
Neuroleptic-Induced Acute
Dystonia (735)
333.99
Neuroleptic-Induced Acute
Akathisia (735)
333.82
Neuroleptic-Induced Tardive
Dyskinesia (736)
333.1
Medication-Induced Postural
Tremor (736)
333.90
Medicationlnduced Movement
Disorder NOS (736)
OTHER
MEDICATION-INDUCED
DISORDER (736)
995.2
Adverse Effects of Medication
NOS (736)
RELATIONAL PROBLEMS (736)
V61.9
Relational Problem Related to a
Mental Disorder or General
Medical Condition (737)
V61.20 Parent-ehild Relational
Problem (737)
V61.10 Partner Relational Problem
(737)
V61.8 Sibling Relational Problem (737)
V62.81 Relational Problem NOS (737)
V61.21
Physical Abuse of Child (738)
(rode 995.54 iffoms ofalleutioll is
all victim)
V61.21
Sexual Abuse of Child (738)
(code 995.53 iffows ofafte"tioll is
all victim)
V61.21
Neglect of Child (738)
(code 995.52 iffoclls ofattelltioll is
011 victim)
--Physical Abuse of Adult (738)
V61.12 (if by partner)
V62.83 (ifby person other than partner)
(code 995.81 iffoclls ofallentioll is
all victim)
--Sexual Abuse of Adult (738)
V61.12 (if by partner)
V62.83 (iiby person other than partner)
(code 995.83 iffoclls ofatfelltioll is
011 victim)
ADDITIONAL CONDITIONS THAT
MAY BE A FOCUS OF CLINICAL
ATIENTION (739)
V15.81 Toncompliance With
Treatment (739)
V65.2 Malingering (739)
V71.01 Adult Antisocial Behavior (7-10)
V71.02 Child or Adolescent Antisocial
Behavior (740)
Y62.89
Borderline Intellechlal
Functioning (740)
Note: This is coded on Axis [I.
~
780.9
AgeRelated Cognitive Decline
(740)
V62.82 Berea\'ement (740)
V62.3 Academic Problem (741)
V62.2 Occupational Problem (741)
313.82 Identity Problem (741)
V62.89 Religious or Spiritual Problem
(741)
Y62.4 Acculturation Problem (7-11)
V62.89 Phase of Life Problem (742)
DSM-IV-TR Classification
Additional Codes (743)
Multiaxial System
300.9
V71.09
799.9
V71.09
799.9
Unspecified Mental Disorder
(nonpsychotic) (743)
No Diagnosis or Condition on
Axis I (743)
Diagnosis or Condition
Deferred on Axis I (743)
'0 Diagnosis on.Axis II (743)
Diagnosis Deferred on Axis U
(743)
Axis I
Clinical Disorders
Other Conditions That May Bea
Focus of Clinical Attention
Axis n
Personality Disorders
Mental Retardation
Axis mGeneral Medical Conditions
Axis rv Psychosocial and
Envi.ronmental Problems
Axis V Global Assessment of
Flmctioning
Multiaxial Assessment
A multiaxial system involves an assessment on several axes, each of which refers
to a different domain of infomlation that may help the clinician plan treatment
and
predict outcome. There are five axes included in the DSM!V multiaxial classificat
ion:
Axis I Clinical Disorders
Other Conditions That May Be it Focus of Clinical Attention
Axis J1 Personality Disorders
Mental Retardation
AxislTl General Medical Conditions
Axis IV Psychosocial and Environmental Problems
Axis V Global Assessment of Functioning
The use of the multiaxial system facilitates comprehensive and systematic evalua
tion
with attention to the various mental disorders and general medical conditions.
psychosocial and environmental problems, and lenl of functioning that might be
overlooked if the focus were on assessing a single presenting problem. A multiax
ial
system provides a convenient format for organizing and communicating clinical
information, for capturing the complexity of clinical situations, and for descri
bing the
heterogeneity of individuals presenting with the same diagnosis. In addition, th
e
multiaxial system promotes the application of the biopsychosocial model in clini
cal,
educational, and research settings.
The rest of this section provides a description of each of the OSt-.I-IV axes. In
some
settings or situations, clinicians may prefer not to use the multiaxial system.
For this
reason, guidelines for reporting the results of a DSM-rv assessment without appl
ying
the formal multiaxial system are provided at the end of this section.
Axis I: Clinical Disorders
Other Conditions That May Be a Focus of Clinical Attention
Axis I is for reporting all the various disorders or conditions in the Classific
ation except
for the Personality Disorders and Mental Retardation (which are reported on
Axis IT). The major groups of disorders to be reported on Axis I are listed in t
he box
below. Also reported on Axis I are Other Conditions That ;Vlay Be a Focus of Cli
nical
Attention.
\Vhen an individual has more than one Axis I disorder, all of these should be re
ported
(for examples, see p. 35). U more than one Axis I disorder is present, the princ
ipal
diagnosis or the reason for visit (see p. 3) should be indicated by listing it f
irst. When
an individual has both an Axis I and an Axis II disorder, the principal diagnosi
s or the
27
Multiaxial Assessment
reason for visit will be assumed to be on Axis Iunless the Axis II diagnosis is
followed
by the qualifying phrase "(Principal Diagnosis)" or "(Reason for Visit)." U no A
xis I
disorderis present,this should becodedasV71.09. U anAxis1diagnosis isdeferred,
pending the gathering of additional information, this should be coded as 799.9.
Axis I
Clinical Disorders
Other Conditions That May Be a Focus of Clinical Attention
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
(excluding Mental Retardation, which is diagnosed on Axis fJ)
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Mental Disorders Due to a General Medical Condition
Substance-Related Disorders
Schizophrenia and Other Psychotic Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual and Gender Identity Disorders
Eating Disorders
Sleep Disorders
Impulse-Control Disorders Not Elsewhere Classified
Adjustment Disorders
Other Conditions That May Be a Focus of Clinical Attention
Axis II: Personality Disorders
Mental Retardation
Axis n is for reporting Personality Disorders and Mental Retardation. It may als
o be
used for noting prominent maladaptive personality features and defense mechanism
s.
The listing of Personality Disorders and Mental Retardation on a separate axis
ensures that consideration will be given to the possible presence of Personality
Disorders
and Mental Retardation that might othem'ise be overlooked when attention is
directed. to the usually more florid Axis I disorders. The coding of Personality
Disorders
on Axis II should not be taken to imply that their pathogenesis or range of
appropriate treatment is fundamentally different from that for the disorders cod
ed
on Axis 1. The disorders to be reported on Axis U are listed in the box below.
In the common situation in which an individual has more than one Axis II diagnos
is,
all should be reported. (for examples, see p. 35). When an individual has both a
n
Axis I and an Axis II diagnosis and the Axis II diagnosis is the principal diagn
osis or
the reason for visit, this should be indicated by adding the qualifying phrase "
(principal
Diagnosis)" or "(Reason for Visit)" after the Axis II diagnosis. If no Axis ndis
Multiaxial Assessment
order is present, this should be coded as V71.09. If an Axis II diagnosis is def
erred.,
pending the gathering of additional information, this should be coded as 799.9.
Axis II may also be used to indicate prominent maladaptive personality features
that do not meet the threshold for a Personality Disorder (in such instances. no
code
number should be used-see Example 3 on p. 37). The hahirual use of maladaptive
defense mechanisms may also be indicated on Axis II (see Appendix B, p. 811, for
definitions
and Example 1 on p. 37).
Axis II
Personality Disorders
Mental Retardation
Paranoid Personality Disorder Narcissistic Personality Disorder
Schizoid Personality Disorder Avoidant Personality Disorder
Schizotypal Personality Disorder Dependent Personality Disorder
Antisocial Personality Disorder Obsessive-Compulsive Personality Disorder
Borderline Personality Disorder Personality Disorder Not Otherwise Specified
Histrionic Personality Disorder Mental Retardation
Axis III: General Medical Conditions
Axis III is for reporting current general medical conditions that are potentiall
y relevant
to the understanding or management of the individual's mentaJ disorder. These
conditions are classified outside the "Mental Disorders" chapter of ICD-9-eM (an
d
outside Chapter V of lCD-tO). A listing of the broad categories of general medic
al
conditions is given in the box below. (For a more detailed listing including the
specific
1(0-9-0"'1 codes, refer to Appendix G.)
As discussed in the "Introduction;' the multiaxial distinction among Axis I, Axi
s n,
and Axis ill disorders does not imply that there are fundamental differences in
their
conceprualization, that mental disorders are unrelated to physical or biological
factors
or processes, or that general medical conditions are unrelated to behavioral or
psychosocial factors orprocesses. The purposeofdistingtIishinggeneraImedical con
ditions
is to encourage thoroughness in evaluation and to enhance communication
among health care providers.
General medical conditions can be related to mental disorders in a variety of wa
ys.
In some cases it is clear that the general medical condition is directly etiolog
ical to the
development or worsening of mental symptoms and that the mechanism for this effe
ct
is physiological. \o\'hen a mental disorder is judged to be a direct physiologic
al
consequence of the general medical condition, a Mental Disorder Due to a General
~'ledical
Condition should be diagnosed on Axis 1and the general medical condition
should be recorded on both Axis I and Axis m. For example, when hypothyroidism
is a direct cause of depressive symptoms, the designation on Axis I is 293.83 Mo
od
Disorder Due to Hypothyroidism, With Depressive Fearures, and the hypothyroidism
is listed again and coded on Axis ill as 244.9 (see Example 3, p. 37). For a fur
ther
discussion, see p. 181.
Multiaxial Assessment
In those instances in which the etiological relationship behveen the general med
ical
condition and the mental symptoms is insufficiently clear to warrant an Axis I d
iagnosis
of Mental Disorder Due to a General Medical Condition, the appropriate
mental disorder (e.g., Major Depressive Disorder) should be listed and coded on
Axis I;
the general medical condition should ani}' be coded on Axis Ill.
There are other situations in which general medical conditions are recorded on
Axis III because of their importance to the overall understanding or treatment o
f the
individual with the mental disorder. An Axis I disorder may be a psychological r
eaction
to an Axis III general medical condition (e.g., the development of 309.0 Adjustm
ent
Disorder '''lith Depressed Mood as a reaction to the diagnosis of carcinoma of
the breast). Some general medical conditions may not be directly related to the
mental
disorder but nonethcless have important prognostic or treatment implications (e.
g.,
when the diagnosis on Axis I is 296.30 Major Depressi\le Disorder, Recurrent, an
d on
Axis HI is 427.9 arrhythmia, the choice of pharmacotherapy is influenced by the
general
medical condition; or when a person with diabetes mellitus is admitted to the
hospital for an exacerbation of Schizophrenia and insulin management must be mon
4
itored).
When an individual has more than one clinically relevant Axis III diagnosis, all
should be reported. For examples, see p. 35. If no Axis III disorder is present,
this
should be indicated by the notation "Axis Ill: Tone." If an Axis In diagnosis is
deferred,
pending the gathering of additional information, this should be indicated by
the notation "Axis Ill: Deferred."
Axis III
General Medical Conditions (with ICD-9-CM codes)
Infectious and Parasitic Diseases (001-139)
Neoplasms (140-239)
Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders
(240-279)
Diseases of the Blood and Blood-Forming Organs (280-289)
Diseases of the Nervous System and Sense Organs (320-389)
Diseases of the Circulatory System (390-459)
Diseases of the Respiratory System (460-519)
Diseases of the Digestive System (520-579)
Diseases of the Genitourinary System (580-629)
Complications of Pregnancy, Childbirth, and the Puerperium (630-676)
Diseases of the Skin and Subcutaneous Tissue (680-709)
Diseases of the Musculoskeletal System and Connective Tissue (710-739)
Congenital Anomalies (740-759)
Certain Conditions Originating in the Perinatal Period (760-779)
Symptoms, Signs, and III-Defined Conditions (780-799)
Injury and Poisoning (800-999)
Multiaxial Assessment
Axis IV: Psychosocial and Environmental Problems
Axis IV is for reporting psychosocial and environmental problems that may affect
the
diagnosis, treatment, and prognosis of mental disorders (Axes I and 11). A psych
osocial
or em'ironmental problem may be a negative We event, an environmental difficulty
or deficiency, a familial or other interpersonal stress, an inadequacy of social
support or personal resources, or other problem relating to the context in which
a person's
difficulties have developed. So-called positive stressors, such as job promotion
,
should be listed only if they constitute or lead to a problem, as when a person
has difficulty
adapting to the new situation. In addition to playing a role in the initiation o
r
exacerbation of a mental disorder, psychosocial problems may also develop as a c
onsequence
of a person's psychopathology or may constitute problems that should be
considered in the overall management plan.
When an individual has multiple psychosocial or environmental problems, the cli~
nidan may note as many as are judged to be relevant. In general, the clinician s
hould
note only those psychosocial and environmental problems that have been present
during the year preceding the current evaluation. However, the clinician may cho
ose
to note psychosocial and environmental problems occurring prior to the previous
year if these clearly contribute to the mental disorder or have become a focus o
f treatment-
for example, previous combat experiences leading to Posttraumatic Stress
Disorder.
In practice, most psychosocial and environmental problems will be indicated on
Axis IV. However, when a psychosocial or environmental problem is the primary fo
cusofclinicalattention,
it should alsobe recordedonAxis I,witha codederivedfrom
the section "Other Conditions That May Be a Focus of Clinical Attention" (see p.
731).
For convenience, the problems are grouped together in the following categories:
Problems with primary support group--e.g., death of a family member; health
problems in family; disruption of family by separation, divorce, or estrangement
;
removal from the home; remarriage of parent; sexual or physical abuse; parental
overprotection; neglect of child; inadequate discipline; discord with siblings;
birth
of a sibling
Problems related to the social environment---e.g., death or loss of friend; inad
equate
social support; living alone; difficulty with acculturation; discrimination; adj
ustment
to life-cycle transition (such as retirement)
~
Educational problems---e.g., illiteracy; academic problems; discord with teacher
s
or classmates; inadequate school environment
Occupational problems---e.g., unemployment; threat of job loss; stressful work
schedule; difficult work conditions; job dissatisfaction; job change; discord wi
th
boss or co-workers
Housing problems---e.g., homelessness; inadequate housing; WlSafe neighborhood;
discord with neighbors or landlord
Economic problems---e.g., extreme po\'erty; inadequate finances; insufficient we
lfare
support
Problems with access to health care services---e.g., inadequate health care serv
ices;
transportation to health care facilities unavailable; inadequate health insuranc
e
Multiaxial Assessment
Problems related to interaction with the legal systemlcrime-e.g., arrest; incarc
eration;
litigation; victim of crime
Other psychosocial and environmental problems---e.g., exposure to disasters,
war, other hostilities; discord with nonfamily caregivers such as counselor, soc
ial
worker, or physician; unavailability of social service agencies
When using the Multiaxial Evaluation Report Form (see p. 36), the clinician shou
ld
identify the relevant categories of psychosocial and environmental problems and
indicate
the specific factors involved. If a recording form with a checklist of problem
categories is nol used, the clinician may simply list the specific problems on A
xis IV.
(See examples on p. 35.)
Axis IV
Psychosocial and Environmental Problems
Problems with primary support group
Problems related to the social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to health care services
Problems related to interaction with the legal system/crime
Other psychosocial and environmental problems
Axis V: Global Assessment of Functioning
Axis V is for reporting the clinician's judgment of the individual's overall lev
el of
functioning. This information is useful in planning treatment and measuring its
impact,
and in predicting outcome.
The reporting of overall functioning on Axis V can be done using the Global Asse
ssment
of Functioning (GAF) Scale. The GAF Scale may be particularly useful in
tracking the clinical progress of individuals in global terms, using a single me
asure.
The GAF Scale is to be rated with respect only to psychological, social. and occ
upational
functioning. The instructions specify, "Do not include impairment in function+
ing due to physical (or environmental) limitations."
The GAF scale is divided into 10 ranges of functioning. Making a GAF rating invo
lves
picking a single value that best reflects the individual's overall level of func
tioning.
The description of each la-point range in the GAF scale has h\'ocomponents:
the first part covers symptom severity, and the second part covers functioning.
The
GAF rating is within a particular decile if either the symptom severity or the l
evel of
functioning faUs within the range. For example, the first part of the range 41-5
0 describes
"serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent
shoplifting)" and the second part includes "any serious impairment in social, oc
eupa+
tional, or school functioning (e.g., no friends, unable to keep a job)." It shou
ld be noted
Multiaxial Assessment
that in situations where the individual's symptom severity and level of function
ing are
discordant, the final GAF rating always reflects the worse of the two. For examp
le, the
GAF rating for an individual who is a significant danger to self but is olhem'is
e functioning
well would be below 20. Similarly, the GAF rating for an individual with minimal
psychological symptomatology but significant impainnent in functioning (e.g.,
an individual whose excessive preoccupation with substance use has resulted in l
oss
of job and friends but no other psychopathology) would be 40 or lower.
In most instances, ratings on the GAF Scale should be for the current period (i.
e.,
the level of functioning at the time of the evaluation) because ratings of curre
nt functioning
will generally reflect the need for treatment or care. In order to account for d
ayto-
day variability in functioning, the GAF rating for the "current period" is somet
imes
operationalized as the lowest level of functioning for the past week. In some
settings, it may be useful to note the GAF Scale rating both at time of admissio
n and
at time of discharge. The GAf Scale may also be rated for other time periods (e.
g., the
highest level of functioning for at least a few months during the past year). Th
e GAF
Scale is reported on Axis V as follows: "GAF = ," followed by the GAf rating iTo
m 0
to 100, followed by the time period reflected by the rating in parentheses-for e
xample,
"(current)," "{highest level in past year)," "(at discharge)." (See examples on
p. 35.)
In order to ensure that no elements of the GAF scale are overlooked when a GAF
rating is being made, the following method for detennining a GAF rating may be
applied:
STEP 1: Starting at the top level, evaluate each range by asking "is either the
individual's
symptom severity OR level of functioning worse than what is indicated in
the range description?"
STEP 2: Keep moving down the scale until the range that best matches the individ
ual's
symptom severity OR the level of functioning is reached, whichever is worse.
STEP 3: Look at the next lower range as a double-check against having stopped pr
ematurely.
This range should be too severe on both symptom severity and level of
functioning. U it is, the appropriate range has been reached (continue with step
4). If
not, go back to step 2 and continue moving down the scale.
STEP 4: To determine the specific GAF rating within the selected 10-point range,
consider whether the individual is functioningat the higher or lower end of the
topoint
range. For example, consider an individual who hears voices that do not influenc
e
his behavior (e.g., someone with long-standing Schizophrenia who accepts his hal
lucinations
as part ofrus illness). If the voices occur relatively infrequently (once a week
or less), a rating of 39 or 40 might be most appropriate. In contrast, if the in
dividual
hears voices almost continuously, a rating of 31 or 32 would be more appropriate
.
In some settings, it may be useful to assess social and occupational disability
and
to track progress in rehabilitation independent of the severity of the psycholog
ical
symptoms. For this purpose, a proposed Social and Occupational Functioning
As.sessmentScale (SOFAS) (see p. 817) is induded in Appendix B. Two additional p
roposed
scales that may be useful in some settings-the Global Assessment of Rela
tional Functioning (GARF) Scale (see p. 814) and the Defensive Functioning Scale
(see
p. B07)-are also included in Appendix B.
Multiaxial Assessment
Global Assessment of Functioning (GAF) Scale
Consider psychological, social, and occupational functioning on a hypothetical c
ontinuum
of mental health-illness. Do not include impainnent in functioning due to
physical (or environmental) limitations.
Code (Note: Use Intermediate codes when appropriate, e.g., 45. 68, 72.)
, 00 Superior functionIng in a wide r"nge of activities, life's problems never s
eem to
I get out of hand, is sought out by others because of his or her many positive q
ual
91 ities. No symptoms.
90
Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning
I in all areas. int.!rested and involved in a wide range of activiti85, socially
eHe,81
tive, generally satisfied with life, no more than everyday problems or concerns
(e.g. an occasional argument with family members).
80 If symptoms are present,. they are transient and expectable reactions to psyc
hoI
50dal str.ssors (e.g., difficulty concentrating after family argument); no more
than
71 slight impairment in sodal, occupational, or school functioning (e.g., tempor
arily
falling behind in schoolwork).
70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficult
y in
I sodal, occupational, or school functioning (e.g. occasional truancy, or theft w
ithin the
61 household), but generally functioning pretty well. has some meaningfullnterpe
r
sonal relationships_
60 Moderate symptoms (e.g. flat affect and circumstantial speech, occasional pani
c attaoo)
I OR moderate difficulty in social, occupational. or school functioning (e.g., f
ew
51 friends, conflicts with peers or coworkers).
50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals. freque
nt shoplifting)
I OR any serious impairment in social. occupational. or school functioning (e.g.
, no
41 friends, unable to keep a job).
40 Some impairment in reality testing or communication (e.g. speech is at times i
IIagiI
cal. obscure. or irrelevant) OR major impairment in several areas, such as work
or
31
school, family relations, judgment, thinking, or mood (e.g., depressed man avoid
s
friends. neglects family, and is unable to work; child frequently beat5 up young
er children.
is defiant at home, and is failing at school).
30 Behavior is considerably influenced by delusions or hallucinations OR serious
I impairment in communication or judgment (e.g. sometimes incoherent, acts gro5ly
21 inappropriately, suicidal preoccupation) OR Inabllity to function in almost a
ll areas
(e.g., stays in bed all day; no job. home. or friends).
20 Some danger of hurting self or others (e.g., suicide attempt5 without dear ex
pectation
I of death; frequently violent; manic excitement) OR occo1lslonally faits to mai
ntain min
11 imal personal hygiene (e.g., smears IKes) OR gross impairment In communicatio
n
(e.g., largely incoherent or mute).
10 Persistent danger of severely hurting self or others (e.g. recurrent violence)
OR per
I sistent Inability to maintain minimal personal hygiene OR serious suicidal act
1 with clear expectation of death.
o Inadequate information.
The rating of overall psychological functioning on a scale of 0-100 was operatio
nalized by Lubarsky
in the HealthSickness Rating Scale (Lubarsky l: "Clinicians' Judgments of Mental
Health." Archives
of General Psychiatry 7:407-417, 1962). Spitzer and colleagues developed a revis
ion of the Health
Sickness Rating SCale called the Global Assessment SCale (GAS) (Endicott '. Spit
zer RL.. Fleiss JL.. Cohen
J: -The Global Assessment Scale: A Procedure for Measuring Overall Severity of P
sychiatric Disturbance.-
Archives of General Psychiatry 33:76&-711, 1976). A modified version 01 the GAS
was included
in DSM-IIl-R as the Global Assessment of Functioning (GAF) Scale.
Multiaxial Assessment
Examples of How to Record
Results of a DSM-IV Multiaxial Evaluation
Example 1:
Axis I
Axis II
Axis III
Axis IV
Axis V
Example 2:
Axis I
Axis II
Axis III
Axis IV
Axis V
Example 3:
Axis I
Axis II
Axis III
Axis IV
Axis V
Example 4:
Axis I
Axis 11
Axis III
Axis IV
Axis V
296.23
305.00
301.6
Major Depressive Disorder, Single Episode, Severe Without
Psychotic Features
Alcohol Abuse
Dependent Personality Disorder
Frequent use of denial
None
Threat of job loss
GAF = 35 (current)
300.4
315.00
V71.09
382.9
Dysthymic Disorder
Reading Disorder
No diagnosis
Otitis media, recurrent
Victim of child neglect
GAF = 53 (current)
293.83
V71.09
244.9
365.23
Mood Disorder Due to Hypothyroidism, With Depressive
Features
No diagnosis, histrionic personality features
Hypothyroidism
Chronic angle-closure glaucoma
None
GAF = 45 (on admission)
GAF = 65 (at discharge)
V61.10
V71.09
Partner Relational Problem
No diagnosis
None
Unemployment
GAF = 83 (highest level past year)
Multiaxial Assessment
Multiaxial Evaluation Report Form
The (ollowing form is oflered as one possibility for reporting multiaxial evalua
tions.
In some settings, this form may be used exactly as is; in other settings, the fo
rm may
be adapted to satisfy special needs.
AXIS I: Clinical Disorders
Other Conditions That May Be a Focus of Clinical Attention
Diagnostic code DSM-IV name
---"-
---"-
---"-
AXIS II: Personality Disorders
Mental Retardation
Diagnostic code DSM-IV name
---"-
---"-
AXIS III: General Medical Conditions
I(DgeM code ICD9CM name
---"-
---"-
---"-
AXIS IV: Psychosocial and Environmental Problems
Check:
Q Problems with primary support group Specify: _
Q Problems related to the social environment Specify: _
Q Educational problems Specify: _
Q Occupational problems Specify: _
a Housing problems Specify: _
a Economic problems Specify: _
a Problems with access to health care services Specify: _
Q Problems related to interadion with the legal system/crime Specify: _
Other psychosocial and environmental problems Specify: _
AXIS V: Global Assessment of Functioning Scale
Score: _
Time frame: _
Multiaxial Assessment
Nonaxial Format
Clinicians who do not wish to use the multiaxial format may simply list theappro
pri
ale diagnoses. Those choosing this option should follow the general rule of reco
rding
as many coexisting mental disorders, general medical conditions, and other facto
rs as
are relevant to the care and treatment of the individual. The Principal Diagnosi
s or
the Reason for Visit should be listed first.
The examples below illustrate the reporting of diagnoses in a format that does n
ot
use the multiaxial system.
Example 7:
296.23
Major Depressive Disorder, Single Episode, Severe Without Psychotic
Features
305.00
Alcohol Abuse
301.6
Dependent Personality Disorder; Frequent use of denial
Example 2:
300.4
Dysthymic Disorder
315.00
Reading Disorder
382.9
Otitis media, recurrent
Example 3:
293.83
Mood Disorder Due to Hypothyroidism, With Depressive Features
244.9
Hypothyroidism
365.23
Chronic angle-closure glaucoma
Histrionic personality features
Example 4:
V61.10
Partner Relational Problem
Disorders Usually First
Diagnosed in Infancy,
Childhood, or Adolescence
The provision of a separate section for disorders that are usually first diagnos
ed
in infancy, childhood, oradolescence is for convenience only and is not meant to
suggest
that there is any clear distinction behveen "childhood" and "adult" disorders.
Although most indh,jduals with. these disorders present for clinical attention d
uring
childhood or adolescence, the disorders sometimes are not diagnosed until adulth
ood.
Moreover. many disorders included in other sections of the manual often have
an onset during childhood or adolescence. In evaluating an infant, child, or ado
lescent,
the clinician should consider the diagnoses included in this section but also
should refer to the disorders described elsewhere in this manual. Adults may als
o be
diagnosed with disorders included in this section for Disorders Usually First Di
agnosed
in Infancy. Childhood, or Adolescence if their clinical presentation meets relev
ant
diagnostic criteria (e.g. Stuttering. Pica). Moreover, if an adult had symptoms a
s
a child that met full criteria for a disorder. but now presents with an attenuat
ed or
residual fonn, the In Partial Remission specifier may be indicated (e.g., Atlent
ionDeficit/
Hyperactivity Disorder. Combined Type, In Partial Remission). For most (but
not all) DSM-IV disorders, a single criteria set is provided that applies to chi
ldren, adolescents,
and adults (e.g., ifa child or adolescent has symptoms that meet the criteria
for Major Depressive Disorder, this diagnosis should be given, regardless of the
individual's
age). The variations in the presentation of a disorder that are attributable to
an individual's developmental stage are described in a section in the text title
d "Specific
Culture, Age, and Gender Features." Specific issues related to the diagnosis of
Personality Disorders in children or adolescenls arc disG;lssed on p. 687.
The foUowing disorders are included in lhis section:
Menial Retardation. This disorder is characterized by significantly subaverage i
ntellectual
functioning (an IQ of approximately 70 or below) with onset before age 18
years and concurrent deficits or impainnents in adaptive functioning. 5eparateco
des
are provided for Mild, Moderale, Severe, and Profound Mental Retardation and for
Menial Retardation, Severity Unspecified.
Learning Disorders. These disorders are characterized b)' academic functioning
thai is substantially below that expecled given the person's chronological age,
measured
intelligence, and age-appropriate education. The specific disorders included in
Ihis section are Reading Disorder, Mathematics Disorder, Disorder of Written Ex
pression, and Learning Disorder Not Otherwise Specified.
39
11
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Motor Skills Disorder. ntis includes Developmental Coordination Disorder,
which is characterized by motor coordination that is substantially below that ex
pected
given the person's chronological age and measured intelligence.
Communication Disorders. These disorders are characterized by difficulties in
speech or language and include Expressive language Disorder, Mixed ReceptiveExpr
essive
language Disorder, Phonological Disorder, Stuttering, and Communication
Disorder Not Othenvise Specified.
Pervasive Developmental Disorders. These disorders are characterized by severe
deficits and pen'asive impairment in multiple areas of development. These includ
e
impairment in reciprocal social interaction, impairment in communication, and th
e
presence of stereotyped behavior, interests, and activities. The specific disord
ers included
in this section are Autistic Disorder, Rett's Disorder, Childhood Disintegrative
Disorder, Asperger's Disorder, and Pervasive Developmental Disorder Not
Othenvise Specified.
AttentionDeficit and Disruptive Behavior Disorders. This section includes
AttentionDeficitlHyperactivity Disorder, which is characterized by prominent
symptoms of inattention and/or hyperactivity-impulsivity. Subtypes are prOVided
for specifying the predominant symptom presentation: Predominantly Inattentive
Type, Predominantly Hyperactive-lmpulsive Type, and Combined Type. Also included
in this section are the Disruptive Behavi.or Disorders: Conduct Disorder is
characterized by a pattern of behavior that violates the basic rights of others
or major
age-appropriate societal norms or rules; Oppositional Defiant Disorder is charac
terized
by a pattern of negativistic, hostile, and defiant behavior. This section also i
ncludes
two Not Othenvise Specified categories: Attention-DeficitlHyperactivity
Disorder Not Othenvise Specified and Disruptive Behavior Disorder Not Otherwise
Specified.
Feeding and Eating Disorders of Infancy or Early Childhood. These disorders are
characterized by persistent disturbances in feeding and eating. The specific dis
orders
included are Pica, Rumination Disorder, and Feeding Disorder of Infancy or Early
Childhood. Note that Anorexia Nervosa and Bulimia Nervosa are included in the
"Eating Disorders" section presented later in the manual (see p. 583).
Tic Disorders. These disorders are characterized by vocal and/or motor tics. The
specific disorders included are Tourette's Disorder, Chronic Motoror Vocal Tic D
is
order, Transient Tic Disorder, and Tic Disorder Not Othenvise Specified.
Elimination Disorders. This grouping includes Encopresis, the repeated passage
of feces into inappropriate places, and Enuresis, the repeated voiding of urine
into
inappropriate places.
Other Disorders of Infancy, Childhood, or Adolescence. This grouping is for diso
rders
that are not covered in the sections listed abO\'e. Separation Anxiety Disorder
is characterized by developmentally inappropriate and excessive anxiety concerni
ng
Mental Retardation
separation from home or from those to whom the child is attached. Selective Muti
sm
is characterized by a consistent failure to speak in specific social situations
despite
speaking inother situations. Reactive Attachment Disorder of lnfancy or Early Ch
ildhood
is characterized by markedly disturbed and developmentally inappropriate
social relatedness that occurs in most contexts and is associated with grossl)'
pathogenic
care. Stereotypic Movement Disorder is characterized by repetitive, seemingly
driven, and nonfunctional motor behavior that markedly interferes with normal ac
tivities
and at times may result in bodily injury. Disorder of Infancy, Childhood, or
Adolescence Not Othenvise Specified is a residual category for coding disorders
with onset in infancy, childhood, or adolescence that do not meet criteria for a
ny spe
rific disorder in the Classification.
Children or adolescents may present with problems requiring clinical attention
that are not defined as mental disorders (e.g., Relational Problems, Problems Re
lated
to Abuse or Neglect, Bereavement, Borderline Intellectual Functioning, Academic
Problem, Child or Adolescent Antisocial Behavior, Identity Problem). These are l
isted
at the end of the manual in the section "Other Conditions That May Be a Focus of
Clinical Attention" (see p. 731).
DSM-ID-R included two anxiety disorders specific 10 children and adolescents,
Overanxious Disorder of Childhood and Avoidant Disorder of Childhood, that have
been subsumed under Generalized Anxiety Disorder and Social Phobia, respectively
,
because of similarities in essential features.
Mental Retardation
Diagnostic Features
The essential feature of Mental Retardation is significantly subaverage general
intellectual
functioning (Criterion A) that is accompanied by significant limitations in adap
tive
functioning in at least ""'0 of the following skill areas: communication, self-c
are,
home liVing, social/interpersonal skills, use of community resources, self-direc
tion,
,
functional academic skills, work, leisure, health, and sa"fety (Criterion B). Th
e onset
must occur before age 18 years (Criterion C). Mental Retardation has many differ
ent
etiologies and may be seen as a final common pathway of various pathological pro
cesses
that affect the functioning of the central nervous system.
Gelleral intellectual fUllctiolling is defined by the intelligence quotient (IQ
or IQequivalent)
obtained by assessment with one or more of the standardized, individually
administered intelligence tests (e.g., Wechsler Intelligence Scales for Children
,
3rd Edition; Stanford-Binet, 4th Edition; Kaufman Assessment Battery for Childre
n).
Significantly subaverage intellectual functioning is defined as an IQ of about 7
0 or be-low
(approximately 2 standard deviations below the mean). It should be noted that
there is a measurement error of approximately 5 points in assessing IQ although
this
may vary from instrument to instrument (e.g., a Wechsler IQ of 70 is considered
to
represent a range of 65-75). Thus, it is possible to diagnose Mental Retardation
in
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
individuals with IQs between 70 and 75 who exhibit significant deficits in adapt
ive
behavior. Conversely, Mental Retardation would not be diagnosed in an individual
with an IQ lower than 70 if there are no significant deficits or impairments in
adaptive
functioning. The choice of testing instruments and interpretation of results sho
uld
take into account factors that may limit test performance (e.g., the individual'
s sociocultural
backgrmmd, native language, and associated communicative, motor, and
sensory handicaps). When there is significant scatler in the subtest scores, the
profile
of strengths and weaknesses, rather than the mathematically derived full-scale I
Q
will more accurately reflect the person's learning abilities. ''''hen there is a
marked
discrepancy across verbal and performance scores, averaging to obtain a hill-sca
le IQ
score can be misleading.
Impairments in adaptive functioning, rather than a low IQ, are usually the prese
nting
symptoms in individuals with Mental Retardation. AdaptivejUllctiolling refers to
how effectively individuals cope with corrunon life demands and how well they me
et
the standards of personal independence expected of someone in their particular a
ge
group, sociocultural background, and corrununity setting. Adaptive functioning m
ay
be influenced by various factors, including education, motivation, personality c
haracteristics,
social and vocational opportunities, and the mental disorders and general
medical conditions that may coexist with Mental Retardation. Problems in adaptat
ion
are more likely to improve with remedial efforts than is the cognitive 10, which
tends
to remain a more stable attribute.
It is useful to gather evidence for deficits in adaptive ftmctioning from one or
morc
reliable independent sources (e.g., teacher evaluation and educational, developm
ental,
and medical history). Several scales have also been designed to measure adaptive
functioning or behavior (e.g., the Vineland Adaptive Behavior Scales and the Ame
rican
Association on Mental Retardation Adaptive Behavior Scale). These scales general
ly
provide a clinical cutoff score that is a composite of performance in a number o
f
adaptive skill domains. It should be noted that scores for certain individual do
mains
are not included in some of these instruments and that individual domain scores
may
vary considerably in reliability. As in the assessment of intellectual hmctionin
g, consideration
should be given to the suitability of the instrument to the person's sociocultur
al
background, education, associated handicaps, motivation, and cooperation.
For instance, the presence of significant handicaps invalidates many adaptive sc
ale
norms. In addition, beha\'iors that would normally be considered maladaptive (e.
g., dependency,
passivity) may be evidence of good adaptation in the context of a particular
individual's life (e.g., in some institutional scttings).
Degrees of Severity of Mental Retardation
Four degrees of severity can be specified, reflecting the level of intellectual
impairment:
Mild, Moderate, Severe, and Profound.
317 Mild Mental Retardation: IQ level So-SS to approximately 70
318.0 Moderate Retardation: IQ level 35-40 to 50-S5
318.1 Severe Mental Retardation: IQ level 20--25 to 35-40
318.2 Profound Mental Retardation: IQ level below 20 or 25
317 Mild Mental Retardation
319 Mental Retardation, Severity Unspecified, can be used when there is a
strong presumption of Mental Retardation but the person's intelligence is untest
able
by standard tests (e.g., with individuals too impaired or uncooperative, or with
infants).
317 Mild Mental Retardation
~\'Iild
Mental Retardation is roughly equivalent to what used to be referred to as the
educational category of "educable." This group constitutes the largest segment
(about 85%) of those with the disorder. As a group, people with this level of Me
ntal
Retardation typicaUy develop social and communication skills during the preschoo
l
years (ages O-S years), have minimal impairment in sensorimotor areas, and often
are
not distinguishable from children without Mental Retardation until a later age.
By
their late teens, they can acquire academic skills up to approximately the sixth
-grade
level. During their adult years, they usually achieve social and vocational skil
ls adequate
for minimum self-support, but may need supervision, guidance, and assist,
1Oce, especially when under unusual social or economic stress. '''lith appropria
te
supports, individuals with Mild Ment,1l Retardation can usually live successfull
y in
the conuntmity, either independently or in supervised settings.
318.0 Moderate Mental Retardation
Moderate Mental Retardation is roughly equivalent to what used to be referred to
as
the educational category of "trainable." This outdated teon should not be used b
ecause
it wrongly implies that people with Moderate Mental Retardation cannot benefit
from educational programs. This group constitutes about 10% of the entire
population of people with Mental Retardation. Most of the individuals with this
level
of Mental Retardation acquire communication skills during early childhood years.
They profit from vocational training and, with moderate supervision, can attend
to
their personal care. They can also benefit from training in social and occupatio
nal
skills but are unlikely to progress beyond the second-grade level in academic su
bjects.
They may learn to travel independently in familiar places. During adolescence, t
heir difficulties
in recognizing social conventions may interfere with peer relationships. In thei
r
adult years, the majority are able to perforn1 unskilled or
~
semiskilled work lmder supervision
in sheltered workshops or in the general workforce. They adapt well to life in t
he
community, usually in supervised settings.
318.1 Severe Mental Retardation
The group with Severe Mental Retardation constihttes 3%--4% of individuals with
Mental Retardation. During the early childhood years, they acquire little or no
communicative
speech. During the school-age period, they may learn to talk and can be
trained in elementary self-care skills. They profit to only a limited extent fro
m instruction
in pre-academic subjects, such as familiarity with the alphabet and simple count
ing,
but can master skills sud, as learning sight reading of some "survival" words. I
n
their adult years, they may be able to perform simple tasks in closely supervise
d set
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
tings. Most adapt weU to We in the community, in group homes or with their famil
ies,
unless they have an associated handicap that requires specialized nursing or oth
er
care.
318.2 Profound Mental Retardation
The group with ProfOlmd Mental Retardation constitutes approximately 1%....2% of
people with Mental Retardation. Most individuals with this diagnosis have an ide
ntified
neurological condition that accounts for their Mental Retardation. During the
early childhood years, they display considerable impainnents in sensorimotor fun
ctioning.
Optimal development may occur in a highly structured environment with
constant aid and supervision and an individualized relationship with a caregiver
.
Motor development and self-care and communication skills may improve if appropri
ate
training is prOVided. Some can perform simple tasks in closely supervised and
sheltered settings.
319 Mental Retardation, Severity Unspecified
The diagnosis of Mental Retardation, Severity Unspecified, should be used when
there isa strong presumption of Mental Retardation but the person cannot be succ
essfully
tested by standardized intelligence tests. This may be the case when children.
adolescents, or adults are too impaired or uncooperative to be tested or, with i
nfants,
when there is a clinical judgment of significantly subaverage intellectual funct
ioning.
but the available tests (e.g., the Bayley Scales of Infant Development, Cattell
Infant
Intelligence ScaJes, and others) do not yield lQ values. In general, the younger
the
age, the more difficult it is to assess for the presence of Mental Retardation e
xcept in
those with profound impairment.
Recording Procedures
The specific diagnostic code for Mental Retardation is selected based on the lev
el of
severity as indicated above and is coded on Axis U. If Mental Retardation is ass
ociated
with another mental disorder (e.g., Autistic Disorder), the additional mental di
sorder
is coded on Axis r. If Mental Retardation is associated with a general medical
condition (e.g., Down syndrome), the general medical condition is coded on Axis
D1.
Associated Features and Disorders
Associated descriptive features and mental disordel'"$, No specific personality
and behavioral features are uniquely associated with Mental Retardation. Some in
dividuals
with Mental Retardation are passive, plaCid, and dependent, whereas others
can be aggressive and impulsive. Lack of communication skills may predispose to
disruptive and aggressive behaviors that substitute for communicative language.
Some general medical conditions associated with Mental Retardation are character
ized
by certain behavioral symptoms (e.g., the intractable selfinjurious behavior asso
ciated
with Lesch-Nyhan syndrome). Individuals with Mental Retardation may be
Mental Retardation
vulnerable to exploitation by others (e.g., being physically and sexually abused
) or
being denied rights and opportunities.
Individuals with Mental Retardation have a prevalence of comorbid mental disorde
rs
that is estimated to be three to four times greater than in the general populati
on. In some
cases, this may result from a shared etiology that is common to Mental Retardati
on and
the associated mental disorder (e.g., head trauma may result in Mental Retardati
on and
in Personality Change Due to Head Trauma). All types of mental disorders may be
seen,
and there is no evidence that the nature of a given mental disorder is different
in individ
uals who have Mental Retardation. The diagnosis of comorbid mental disorders is,
how
ever, often complicated by the fact that the clinical presentation may be modifi
ed by the
severity of the Mental Retardation and associated handicaps. Deficits in communi
cation
skills may result in an inability to provide an adequate history (e.g., the diag
nosis of Ma
jor Depressive Disorder in a nonverbal adult with Mental Retardation is often ba
sed pri
marily on manifestations such as depressed mood, irritability, anorexia, or inso
mnia that
are observed by others). More often than is the case in individuals without Ment
al Retar
dation, it may be difficult to choose a specific diagnosis and in such cases the
appropriate
'ot Othem'ise Specified category can be used (e.g., Depressive Disorder Not Othe
rwise
Specified). The most common assodated mental disorders are Attention-Deficit/Hyp
eractivity
Disorder, Mood. Disorders, Pervasive Developmental Disorders, Stereotypic
Movement Disorder, and Mental Disorders Due to a General Medical Condition (e.g.
, Dementia
Due to Head Trauma). Individuals who have Mental Retardation due to Down
syndrome may be at higher risk for developing Dementia of the Alzheimer's Type.
Pathological changes in the brain associated \\'ith this disorder usually develo
p by the
time these individuals are in their early 405, although the clinical symptoms of
dementia
are not evident until later.
Associations have been reported between specific etiological factors and certain
comorbid symptoms and mental disorders. For example, fragile Xsyndrome appears
to increase the risk for Attention-Deficit/Hyperactivity Disorder and Social Pho
bia;
individuals with Prader-Willi syndrome may exhibit hyperphagia and compulsivity,
and those with William's syndrome may have an increased risk of Anxiety Disorder
s
and Attention-Deficit/Hyperactivity Disorder.
Predisposing factors. Etiological factors may be primarily biological or primari
ly
psychOSOcial, or some combination of both. In approximately 30%.....40% of indiv
iduals
seen in clinical settings, no clear etiology for the Mental Retardation can be d
etermined
despite extensive evaluation efforts. Specific etiologies are more likely to be
identified in individuals with Severe or Profound Mental Retardation. The major
predisposing
factors include:
Heredity: These factors include inborn errors of metabolism inherited mostly
through autosomal recessive mechanisms (e.g., Tay-Sachs disease), other single-g
ene
abnormalities with Mendelian inheritance and variable expression (e.g., tuberous
sclerosis), and chromosomal aberrations (e.g., translocation Down syndrome, frag
ile
X syndrome). Advances in genetics will likely increase the identification of her
itable
fonns of Mental Retardation.
Early alterations of embryollic deuelopmenf: These factors include chromosomal
changes (e.g., Down syndrome due to trisomy) or prenatal damage due to toxins
(e.g., maternal alcohol consumption, infections).
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Environmental influences; These factors include deprivation of nurturance and of
social, linguistic, and other stimulation.
Melltal disorders: These factors include Autistic Disorder and other Pervasi\'e
[)e..
ve)opmental Disorders.
Pregnancy Qlld perinatal problems: These factors include fetal malnutrition, pre
maturity,
hypoxia, viral and other infections, and trauma.
General medical conditions acqllired ill illfolley or childhood: These factors i
nclude infections,
traumas, and poisoning (e.g., due to lead).
Associated laboratory findings. Other than the results of psychOlogical and adap
tive
behavior tests that are necessary for the diagnosis of Mental Retardation, there
are no laboratory findings that are uniquely associated. with Mental Retardation
. Di
agnostic laboratory findings may be associated with a specific accompanying gene
ral
medical condition (e.g., chromosomal findings in various genetic conditions, hig
h
blood phenylalanine in phenylketonuria, or abnormalities on central nervous syst
em
imaging).
Associated physical examination findings and general medical conditions.
There are no specific physical features associated with Mental Retardation. "''h
en
Mental Retardation is part of a specific syndrome, the clinical features of that
S}'O'
drome will be present (e.g., the physical features of Down s}'ndrome). The more
severe
the Mental Retardation (especially if it is severe or profound), the greater the
likelihood. of neurological (e.g., seizures), neuromuscular, visual. auditory, c
ardiovascular,
and other conditions.
Specific Culture, Age, and Gender Features
Care should be taken to ensure that intellectual testing procedures reflect adeq
uate
attention to the individual's ethnic, cultural, or linguistic background. This i
s usually
accomplished by using tests in which the individual's relevant characteristics a
re represented
in the standardization sample of the test or by employing an examiner who
is familiar with aspects of the individual's ethnic or cultural background.Indiv
idualized
testing is always required to make the diagnosis of Mental Retardation. The
prevalence of Mental Retardation due to known biological factors is similar amon
g
children of upper and lower socioeconomic classes, except that certain etiologic
al fac
lors are linked to lower socioeconomic status (e.g., lead poisoning and prematur
e
births). In cases in which no specific biological causation can be identified, t
he Mental
Retardation is usuall}' milder (although all degrees of severity are represented
) and
individuals from lower socioeconomic classes are overrepresented. Developmental
considerations should be taken into account in evaluating impairment in adaptive
skills because certain of the skill areas are less relevant at different ages (e
.g., use of
community resources or employment in school-age children). Mental Retardation is
more common among males, with a male-ta-female ratio of approximately 1.5:1.
Prevalence
The prevalence rate of Mental Retardation has been estimated at approximately l~
o.
However, different studies have reported different rates depending on definition
s
used, methods of ascertainment, and population studied.
Mental Retardation
Course
The diagnosis of Mental Retardation requires that the onset of the disorder be b
efore
age 18 years. The age and mode of onset depend on the etiology and severity of t
he
Mental Retardation. More severe retardation, especially when associated with a s
yndrome
with a dlaracteristic phenotype, tends to be recognized early (e.g., Down syndro
me
is usually diagnosed at birth). In contrast, Mild Retardation of unknown origin
is generally noticed later. In more severe retardation resulting from an acquire
d
cause, the intellectual impairment will develop more abruptly (e.g., retardation
following
an encephalitis). The course of Mental Retardation is influenced by the course
of underlying general medical conditions and by environmental factors (e.g., edu
cational
and other opportunities, environmental stimulation, and appropriateness of
management).lf an illIderlying general medical condition is static, the course i
s more
likely to be variable and to depend on environmental factors. Mental Retardation
is
not necessarily a lifelong disorder.lndividuals who had Mild Mental Retardation
earlier
in their lives manifested by failure in academic learning tasks may, with approp
riate
training and opportunities, develop good adaptive skills in other domains and
may no longer have the level of impairment required for a diagnosis of Mental Re
tardation.
Familial Pattern
Because of its heterogeneous etiology, no familial pattern is applicable to Ment
al Retardation
as a general category. The heritability of Mental Retardation is discussed
under "Predisposing Factors" (see p. 45).
Differential Diagnosis
The diagnostic criteria for Mental Retardation do not include an exclusion crite
rion;
therefore, the diagnosis should be made whenever the diagnostic criteria are met
, regardless
of and in addition to the presence of another disorder. In learning Disorders
or Communication Disorders (unassociated with Mental Retardation), the
development in a specific area (e.g., reading, expressive language) is impaired
but
there is no generalized impainnent in intellectual development and adaptive func
tioning.
A Learning Disorder or Communication Disorder can be diagnosed in an individual
with Mental Retardation if the specific deficit is out of proportion to the
severity of the Mental Retardation. In Pervasive Developmental Disorders, there
is
qualitative impairment in the development of reciprocal social interaction and i
n the
development of verbal and nonverbal social communication skills. Mental Retardat
ion
often accompanies Pervasive Developmental Disorders.
Some cases of Mental Retardation have their onset after a period of normal funct
ioning
and may qualify for the additional diagnosis of dementia. A diagnosis of dementi
a
requires that the memory impairment and other cognitive deficits represent
a significant decline from a previously higher level of functioning. Because it
may be
difficult to determine the previous level of fWlCtioning in very yOilllg childre
n, the
diagnosis of dementia may not be appropriate lUltil the child is between ages 4
and
6 years. In general, for individuals lmder age 18 years, the diagnosis of dement
ia is
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
made only when the condition is not characterized satisfactorily by the diagnosi
s of
Mental Retardation alone.
Borderline Intellectual Functioning (see p. 740) describes an IQ range that is h
igher
than that for Mental Retardation (generally 71--84). As discussed earlier, an IQ
score may involve a measurement error of approximately 5 points, depending on th
e
testing instrument. Thus, it is possible to diagnose Mental Retardation in indiv
iduals
with IQ scores between 71 and 75 if they have significant deficits in adaptive b
ehavior
that meet the criteria for Mental Retardation. Differentiating Mild Mental Retar
dation
from Borderline Intellectual Flmctioning requires careful consideration of all a
vailable
information.
Relationship to Other Classifications of Mental Retardation
The classification system of the American Association on Mental Retardation
(AAMR) includes the same three criteria (i.e., significantly subaverage intellec
tual
functioning, limitations in adaptive skills, and onset prior to age 18 years). I
n the
AAMR classification, the criterion ofsignificantly subaverage intellectual funct
ioning
refers to a standard score of approximately 70-75 or below (which takes into acc
ount
the potential meaSLUement error of plus or minus 5 points in IQ testing). Furtll
ermore,
DSM-IV specifies levels of severity, whereas the AAlvlR 1992 classification syst
em
specifies "Patterns and Intensity of Supports Needed" (i.e., "lntennittent,
Limited, Extensive, and Pervasive"), which are not directly comparable with the
degrees
of severity in DSM-IV. The definition of developmental disabilities in Public
Law 95-602 (1978) is not limited to Mental Retardation and is based on functiona
l criteria.
This law defines developmental disability as a disability attributable to a ment
al
or physical impairment, manifested before age 22 years, likely to continue indef
initely,
resulting in substantial limitation in three or more specified areas of function
ing,
and requiring specific and lifelong or extended care.
learning Disorders (formerly Academic Skills Disorders)
Diagnostic criteria for Mental Retardation
A.
Significantly subaverage intellectual functioning: an 10 of approximately 70 or
below
on an individually administered 10 test (for infants, a clinical judgment of sig
nificantly
subaverage intellectual functioning).
B.
Concurrent deficits or impairments in present adaptive functioning (i.e., the pe
rson's
effectiveness in meeting the standards expected for his or her age by his or her
cultural
group) in at least two of the following areas: communication, self-eare, home
living, socialfinterpersonal skills, use of community resources, self-direction,
functional
academic skills, work, leisure, health, and safety.
C.
The onset is before age 18 years.
Code based on degree of severity reflecting level of intellectual impairment:
317 Mild Mental Retardation: 10 level 50-55 to approximately 70
318.0
Moderate Mental Retardation: 10 level 35-40 to 50-55
318.1
Severe Mental Retardation: 10 level 20-25 to 35-40
318.2
Profound Mental Retardation: 10 level below 20 or 25
319
Mental Retardation, Severity Unspecified: when there is strong
presumption of Mental Retardation but the person's intelligence is
untestable by standard tests
Learning Disorders
(formerly Academic Skills Disorders)
The section on Learning Disorders includes Reading Disorder, Mathematics Disorde
r,
Disorder of Written Expression, and Learning Disorder Not Otherwise Specified.
Diagnostic Features
learning Disorders are diagnosed when the individual's achievement on individual
ly
administered, standardized tests in reading, mathematics, or written expression
is
substantially below that expected for age, schooling, and level of intelligence.
The
learning problems significantly interfere with academic achievement or activitie
s of
daily living that require reading, mathematical, or writing skills. A variety of
statistical
approaches can be used to establish that a discrepancy is significant. Substanti
ally
below is usually defined as a discrepancy of more than 2 standard deviations bet
ween
achievement and IQ. A smaller discrepancy between achievement and IQ (i.e., betw
een
1 and 2 standard deviations) is sometimes used, especially in cases where an
individual's perfonnance on an IQ test may have been compromised by an associate
d
disorder in cognitive processing, a comorbid mental disorder or general medical
condition,
or the individual's ethnic or cultural background. If a sensory deficit is
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
present. the learning difficulties must be in excess of those usually associated
with the
deficit. Learning Disorders may persist into adulthood.
Associated Features and Disorders
Demoralization, low self-esteem, and deficits in social skills may be associated
with
Leaming Disorders. The school drop-out rate (or children or adolescents with Lea
rning
Disorders is reported at nearly 40% (or approximately 1.5 times the average).
Adults with Leaming Disorders may have significant difficulties in employment or
social adjustment. Many individuals (10%-25%) with Conduct Disorder, Oppositiona
l
Defiant Disorder, Attention-Deficit/Hyperactivity Disorder, Major Depressive
,
Disorder, or Dysthymic Disorder also have Learning Disorders. There is evidence
that developmental delays in language may occur in association with Leaming Diso
rders
(particularly Reading Disorder), although these delays may not be sufficientl)'
severe to warrant the separate diagnosis of a Communication Disorder. Learning D
iY
orders may also be associated with a higher rate of Developmental Coordination
Disorder.
There may be underlying abnormalities in cognitive processing (e.g., deficits in
visual
perception, linguistic processes, attention, or memory, or a combination of thes
e)
that often precede or are associated with Learning Disorders. Standardized tests
to
measure these processes are generally less reliable and valid than other psychoe
ducational
tests. Although genetic predisposition, perinatal injury, and various neurologic
al
or other general medical conditions rna}' be associated with the development
of Learning Disorders, the presence of such conctitions does not invariably pred
ict an
eventual Learning Disorder, and there are many individuals with Learning Disorde
rs
who have no such history. Learning Disorders are, however, frequently found in a
ssociation
with a variety of general medical conditions (e.g., lead poisoning, fetal alcoho
l
syndrome, or fragile Xsyndrome).
Specific Culture Features
Care should be taken to ensure that intelligence testing procedures reflect adeq
uate
attention to the individual's ethnic or cultural background. This is usually acc
omplished
by using tests in which the individual's relevant characteristics are represente
d
in the standardization sample of the test or by employing an examiner who is
familiar with aspects of the individual's ethnic or cultural background. Individ
ualized
testing is always required to make the diagnosis of a Leaming Disorder.
Prevalence
Estimates of the prevalence of Learning Disorders range from 2% to 10% depending
on the nature of ascertainment and the definitions applied. Approximately 5% of
students in public schools in the United States are identified as having a Learn
ing
Disorder.
r
315.00 Reading Disorder
Differential Diagnosis
Learning Disorders must be differentiated from normal variations in academic att
ainment
and from scholastic difficulties due to lack of opportunity. poor teaching,
or cultural factors. Inadequate schooling can result in poor performance on stan
dardized
ac.rue\"ement tests. Children from ethnic or cultural backgroWlds different from
the prevailing school culture or in which English is not the primary language an
d
children who have attended class in schools where teaching has been inadequate m
ay
score poorly on achievement tests. Children from these same backgrounds may also
be at greater risk for absenteeism due 10 more frequent illnesses or impoverishe
d or
chaotic living environments.
Impaired vision or hearing may affect learning ability and should be investigate
d
through audiometric or visual screening tests. A Learning Disorder may be diagno
sed
in the presence of such sensory deficits only if the leaming difficulties are in
excess of those usually associated with these deficits. Accompanying neurologica
l or
other general medical conditions should be coded on Axis lU.
In Mental Retardation, leaming difficulties are commensurate with general impair
ment
in intellectual functioning. However, in some cases of Mild Mental Retardation,
the level of achievement in reading, mathematics, or written expression is
significantly below expected levels given the person's schooling and severity of
Mental
Retardation. In such cases, the additional diagnosis of the appropriate Learning
Disorder should be made.
An additional Learning Disorder diagnosis should be made in the context of a Per
vasive
Developmental Disorder only when academic impainnent is significantly below
expected levels given the indi\'idual's intellectual functioning and schooling.
In
individuals with Communication Disorders, intellectual functioning may have to b
e
assessed using standardized measures of nonverbal intellectual capacity. In case
s in
which academic achievement is significantly below this measured capacity, the ap
propriate
Learning Disorder should be diagnosed.
Mathematics Disorder and Disorder of Written Expression most commonly occur
in combination with Reading Disorder. When criteria are met for more than one
learning Disorder, all should be d.iagnosed.
315.00 Reading Disorder
Diagnostic Features
The essential feature of Reading Disorder is reading achievement (i.e., reading
accuracy,
speed, or comprehension as measured by individually administered standardized
tests) that falls substantially below that expected given the individual's
chronological age, measured intelligence, and age-appropriate education (Criteri
on
A). The disturbance in reading significantly interferes with academic acrue\'eme
nt or
with activities of daily living that require reading skills (Criterion B). Ifa s
ensory defiot
is present, the reading difficulties are in excess of those usually associated w
ith it
(Criterion C). If a neurological or other general medical condition or sensory d
eficit is
present, it should be coded on Axis Ill. In individuals with Reading Disorder (w
hich
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
has also been called "dyslexia"), oral reading is characterized by distortions,
substitutions,
or omissions; both oral and silent reading are characterized by slowness and
eTTors in comprehension.
Associated Features and Disorders
See the"Associated Features and Disorders" section for Leaming Disorders (p. 50)
.
Mathematics Disorder and Disorder of Written Expression are commonly associated
with Reading Disorder, and it is relatively rare for either of these disorders t
o be
found in the absence of Reading Disorder.
Specific Gender Features
From 60% to 80% of individuals diagnosed with Reading Disorder are males. Referr
al
procedures may often be biased toward identifying males, because they more frequ
ently
display disruptive behaviors in association with Learning Disorders. The disorde
r
has been found to occur at more equal rates in males and females when careful di
agnostic
ascertainment and stringent criteria are used rather than traditional schoolbase
d
referral and diagnostic procedures.
Prevalence
The prevalence of Reading Disorder is difficult to establish because many studie
s focus
on the prevalence of Learning Disorders without careful separation into specific
djsorders of Reading, Mathematics, or Written Expression. Reading Disorder, alon
e
or in combination with Mathematics Disorder or Disorder of Written Expression, a
ccounts
for approximately four of every five cases of Learning Disorder. The prevalence
of Reailing Disorder in the United States is estimated at 4% of schoolage
children. Lower incidence and prevalence figures for Reading Disorder may be fou
nd
in other countries in which stricter criteria are used.
Course
Although symptoms of reading difficulty (e.g., inability to distinguish among co
mmon
letters or to associate common phonemes with letter symbols) may occur a;;
early as kindergarten, Reading Disorder is seldom diagnosed before the end of ki
ndergarten
or the beginning of first grade because formal reailing instruction usually
does not begin until this point in most school settings. Particularly when Readi
ng Disorder
is associated with high IQ the child may function at or near grade level in the
early grades, and the Reailing Disorder may not be fully apparent until the four
th
grade or later. With early identification and inten'ention, the prognosis is goo
d. in
a significant percentage of cases. Reading Disorder may persist into adult life.
Familial Pattern
Reading Disorder aggregates familially and is more prevalent among first-degree
biological
relatives of individuals with Learning Disorders.
315.1 Mathematics Disorder
Differential Diagnosis
See the "Differential Diagnosis" section for Learning Disorders (p. 51).
Diagnostic criteria for 315.00 Reading Disorder
A.
Reading achievement, as measured by individually administered standardized tests
of reading accuracy or comprehension, is substantially below that expected given
the
person's chronological age, measured intelligence, and age-appropriate education
.
B.
The disturbance in Criterion A significantly interferes with academic achievemen
t or
activities of daily living that require reading skills.
C.
If a sensory deficit is present, the reading difficulties are in excess of those
usually associated
with it.
Coding note: If a general medical (e.g., neurological) condition or sensory defi
cit is
present, code the condition on Axis III.
315.1 Mathematics Disorder
Diagnostic Features
The essential feature of Mathematics Disorder is mathematical ability (as measur
ed
by individually administered standardized tests of mathematical calculation or r
ea~
soning) that falls substantially below that expected for the individual's c1uono
logical
age, measured intelligence, and age-appropriate education (Criterion A). The dis
turbance
in mathematics Significantly interferes with academic achievement or with activi
ties
of daily living that require mathematical skills (Criterion B). If a sensory
deficit is present, the difficulties in mathematical ability are in excess of th
ose usually
associated with it (Criterion C). If a neurological or other general medical con
dition
or sensory deficit is present, it should be coded on Axis Ill. A number of diffe
rent
skills may be impaired in Mathematics Disorder, inclu..ding "linguistic" skills
(e.g.,
understanding or naming mathematical terms, operations, or concepts, and decodin
g
written problems into mathematical symbols), "perceptual" skills (e.g., recogniz
ing
or reading numerical symbols or arithmetic signs, and clustering objects into gr
oups),
"attention" skills (e.g., copying numbers or figures correctly, remembering to a
dd
in "carried" numbers, and observing operational signs), and "mathematical" skill
s
(e.g., following sequences of mathematical steps, counting objects, and learning
multiplication
tables).
Associated Features and Disorders
See the "Associated Features and Disorders" section for Learning Disorders (p. 5
0).
Mathematics Disorder is commonly found in combination with Reading Disorder or
Disorder of Written Expression.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Prevalence
The prevalence of Mathematics Disorder is difficult to establish because many st
udies
focus on the prevalence of learning Disorders without careful separation into sp
ecific
disorders of Reading.. Mathematics, or Written Expression. The prevalence of Mat
hematics
Disorder alone (Le., when not found in association with other Leaming Disorders)
has been estimated at approximatel}' one in every five cases of Learning
Disorder. It is estimated. that 1% of school-age children have ~'IathematicsDiso
rder.
Course
Although symptoms of difficulty in mathematics (e.g., confusion in number concep
ts
or inability to count accurately) may appear as early as kindergarten or first g
rade,
Mathematics Disorder is seldom diagnosed before the end of first grade because s
uf
ficient formal mathematics instruction has usually not occurred until this point
in
most school settings. It usually becomes apparent during second or third grade.
Par
ticularly when Mathematics Disorder is associated with high IQ the child may be
able to function at or near grade level in the early grades, and Mathematics Dis
order
may not be apparent until the fifth grade or later.
Differential Diagnosis
See the "Differential Diagnosis" section for Learning Disorders (p. 51).
Diagnostic criteria for 315.1 Mathematics Disorder
A.
Mathematical ability, as measured by individually administered standardized test
s, is
substantially below that expected given the person's chronological age, measured
intelligence. and age-appropriate education.
B.
The disturbance in Criterion Asignificantly interferes with academic achievement
or
activities of daily living that require mathematical ability.
C.
If a sensory deficit is present, the difficulties in mathematical ability are in
excess of
those usually associated with it.
Coding note: If a general medical (e.g., neurological) condition or sensory defi
cit is
present, code the condition on Axis III.
315.2 Disorder of Written Expression
Diagnostic Features
The essential feature of Disorder of Written Expression is writing skills (as me
asured
by an individually administered standardized test or functional assessment of wr
iting
skills) thai fall substantially below those expected given the individual's chro
no
315.2 Disorder of Written Expression 55
logical age, measured intelligence, and age-appropriate education (Criterion A).
The
disturbance in written expression significantly interferes with academic achieve
ment
or with activities of daily living that require writing skills (Criterion B). If
a sensory
deficit is present, the difficulties in writing skills are in excess of those us
ually associated
with it (Criterion C). Ifa neurological or other general medical condition or se
nsory
deficit is present, it should be coded on Axis ill. There is generally a combina
tion
of difficulties in the individual's ability to compose written texts evidenced b
y grammatical
or punctuation errors within sentences, poor paragraph organization, multiple
spelling errors, and excessively poor handwriting. This diagnosis is generally n
ot
given if there are only spelling errors or poor handwriting in the absence of ot
her impairment
in written expression. Compared with other Learning Disorders, relatively
less is known about Disorders of Written Expression and their remediation, parti
cularly
when they occur in the absence of Reading Disorder. Except for spelling,
standardized tests in this area are less well developed than tests of reading or
mathematical
ability, and the evaluation of impairment in wrillen skills may require a
comparison beh\'een extensive samples of the individual's written schoolwork and
expected perfonnance for age and lQ. This is especially the case for young child
ren
in the early elementary grades. Tasks in which the child is asked to copy, write
to dictation,
and write spontaneously may all be necessary to establish the presence and exten
t
of this djsorder.
Associated Features and Disorders
See the"Associated Features and Disorders" section for Learning Disorders (p. 50
).
Disorder of Written Expression is commonly found in combination with Reading Dis
order
or Mathematics Disorder. There is some evidence that language and perceptualmoto
r
deficits may accompany this disorder.
Prevalence
The prevalence of Disorder of Written Expression is difficult to establish becau
se
many studies focus on the prevalence of Learning Disorders in general without ca
reful
separation into specific Disorders of Reading, Mathematics, or Written Expressio
n.
Disorder of Written Expression is rare when not associated with other Learning
Disorders.
Course
Although difficulty in writing (e.g., particularly poor handwriting or copying a
bility
or inability to remember letter sequences in common words) may appear as early a
s
the first grade, Disorder of Written Expression is seldom diagnosed before the e
nd of
first grade because sufficient fonnal writing instruction has usually not occurr
ed until
this point in most school settings. The disorder is usually apparent by second
grade. Disorder of Written Expression may occasionally be seen in older children
or
adults, and little is known about its long-term prognosis.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Differential Diagnosis
See the "Differential Diagnosis" section for Learning Disorders (p. 51). A disor
der in
spelling or handwriting alone, in the absence of other difficulties of written e
xpression.
generally does not qualify for a diagnosis of Disorder of Written Expression. U
poor handwriting is due to impairment in molor coordination, a diagnosis of Deve
lopmental
Coordination Disorder should be considered.
Diagnostic criteria for
315.2 Disorder of Written Expression
A.
Writing skills. as measured by individually administered standardized tests (or
functional
assessments of writing skills), are substantially below those expected given the
person's chronological age, measured intelligence. and age-appropriate education
.
B.
The disturbance in Criterion A significantly interferes with academic achievemen
t or
activities of daily living that require the composition of written texts (e.g.,
writing
grammatically correct sentences and organized paragraphs).
C.
If a sensory deficit is present, the difficulties in writing skills are in exces
s of those usu
ally associated with it.
Coding note: If a general medical (e.g. neurological) condition or sensory defici
t is
present, code the condition on Axis III.
315.9 Learning Disorder Not Otherwise Specified
This category is for disorders in learning that do not meet criteria (or any spe
cific
Learning Disorder. This category might include problems in all three areas (read
ing.
mathematics, written expression) that together Significantly interfere with acad
emic
achievement even though performance on tests measuring each indi\'idual skill is
not
substantially below that expected given the person's chronological age, measured
intelligence,
and age-appropriate education.
Motor Skills Disorder
315.4 Developmental Coordination Disorder
Diagnostic Features
The essential feature of Developmental Coordination Disorder is a marked impairm
ent
in the development of motor coordination (Criterion A). The diagnosis is made
only if this impairment significantly interferes with academic achievement or ac
tivi.
315.4 Developmental Coordination Disorder
ties of daily living (Criterion B). The diagnosis is made if the coordination di
fficulties
are not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or
muscular
dystrophy) and the criteria are not met for Pen'asive Developmental Disorder
(Criterion C). If Mental Retardation is present, the motor difficulties are in e
xcess of
those usually associated with it (Criterion D). The manifestations of this disor
der vary
with age and development. For example, younger children may display clumsiness
and delays in achieving developmental motor milestones (e.g., walking, crawling,
sitting,
tying shoelaces, buttoning shirts, zipping pants). Older children may display
difficulties with the motor aspects of assembling puzzles, building models, play
ing
ball, and printing or handwriting.
Associated Features and Disorders
Problems commonly associated with Developmental Coordination Disorder include
delays in other nonmotor milestones. Associated disorders may include Phonologic
al
Disorder, Expressive Language Disorder, and Mixed Receptive-Expressive Language
Disorder.
Prevalence
Prevalence of Developmental Coordination Disorder has been estimated to be as hi
gh
as 6% for children in the age range of 5-11 years.
Course
Recognition of Developmental Coordination Disorder usually occurs when the child
first attempts such tasks as running, holding a knife and fork, buttoning clothe
s, or
playing ball games. The course is variable. In some cases, lack of coordinationc
ontinues
through adolescence and adulthood.
Differential Diagnosis
Developmental Coordination Disorder must be distinguished from motor impairments
that are due to a general medical condition. Problems in coordination may be
associated with specific neurological disorders (e.g., cerebral palsy, progressi
ve
lesions of the cerebellum), but in these cases there is definite neural damage a
nd abnormal
findings on neurological examination. If Mental Retardation is present. Developm
ental
Coordination Disorder can be diagnosed only if the motor difficulties
are in excess of those usually associated with the Mental Retardation. A diagnos
is of
Developmental Coordination Disorder is not given if the criteria are met for a P
ervasive
Developmental Disorder. Individuals with Attenlion-DeficitlHyperactivity
Disorder may fall, bump into things, or knock things over, but this is usually d
ue to
distractibility and impulsiveness, rather than to a motor impairment. U criteria
for
both disorders are met, both diagnoses can be given.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Diagnostic criteria for
315.4 Developmental Coordination Disorder
A.
Performance in daily activities that require motor coordination is substantially
below
that expected given the person's chronological age and measured intelligence. Th
is
may be manifested by marked delays in achieving motor milestones (e.g., walking,
crawling, sitting), dropping things, "clumsiness," poor performance in sports, o
r poor
handwriting.
B.
The disturbance in Criterion A significantly interferes with academic achievemen
t or
activities of daily living.
C.
The disturbance is not due to a general medical condition (e.g., cerebral palsy.
hemiplegia,
or muscular dystrophy) and does not meet criteria for a Pervasive Developmental
Disorder.
D.
If Mental Retardation is present, the motor difficulties are in excess of those
usual~
associated with it.
Coding note: If a general medical (e.g., neurological) condition or sensory defi
cit is
present, code the condition on Axis III.
Communication Disorders
The following Communication Disorders are included in this section: Expressive
Language Disorder, Mixed Receptive-Expressive Language Disorder, Phonological
Disorder, Stuttering, and Communication Disorder Not Othenvise Specified. The)'
are included in this classification to familiarize clinicians with the ways in w
hich
Communication Disorders present and to facilitate their differential diagnosis.
315.31 Expressive Language Disorder
Diagnostic Features
The essential feahueof Expressive Language Disorder is an impaimlent in expressh
'e
language development as demonstrated by scores on standardjzed individually ad
ministered measures of expressive language development substantially below those
obtained from standardized measures of both nonverbal intellectual capacity and
receptive
language development (Criterion A). When standardized instruments are not
availableor appropriate, the diagnosis may be based on a thorough nmctjonal asse
ss
ment of the individual's language ability. The difficulties may occur in conunun
ica
tion involving both verbal language and sign language. The language difficulties
interfere with academic or occupational achievement or with social communication
(Criterion B). The symptoms do not meet criteria for Mixed Receptive-Exprcssire
315.31 Expressive Language Disorder
language Disorder or a Pervasive Developmental Disorder (Criterion C). if rvtent
al
Retardation, a speech-motor or sensory deficit, or environmental deprivation is
present, the language difficulties are in excess of those usually associated wit
h these
problems (Criterion D). If a speech-motor or sensory deficit or neurological con
dition
is present, it should be coded on Axis III.
The linguistic features of the disorder vary depending on its severity and the a
ge
of the child. These features include a limited amount of speech, limited range o
f vocabulary,
difficulty acquiring new words, word-finding or vocabulary errors, shortened
sentences, simplified grammatical structmes, limited varieties of grammatical
structures (e.g., verb forms), limited varieties of sentence types (e.g., impera
tives,
questions), omissions of critical parts of sentences, use of unusual word order,
and
slow rate of language development. Nonlinguistic functioning (as measured by per
fOffilance
intelligence tests) and language comprehension skills are usually within
normal limits. Expressive Language Disorder may be either acquired or developmen
tal.
In the acquired type, an impairment in expressive language occurs after a period
of normal development as a result of a nemological or other general medical cond
ition
(e.g., encephalitis, head trauma, irradiation). In the developmental type, there
is
an impairment in expressive language that is not associated with a postnatal neu
rological
insult of known origin. Children with this type often begin speaking late and
progress more slowly than usual through the various stages of expressive languag
e
development.
Associated Features and Disorders
The most common associated feature of Expressive Language Disorder in ymmger
children is Phonological Disorder. There may also be a disnubance in fluency and
language
formulation involving an abnormally rapid rate and erratic rhythm of speech
and disturbances in language structure ("cluttering"). When Expressive L.,nguage
Disorder is acquired, additional speech difficulties are also common and may inc
lude
motor articulation problems, phonological errors, slow speech, syllable repetiti
ons,
and monotonous intonation and stress patterns. Among school-age children, school
and learning problems (e.g., writing to dictation, copying sentences, and spelli
ng)
that sometimes meet criteria for Learning Disorders are often associated with
Expressive Language Disorder. There may also be some mild impairment in receptiv
e
language skills, but when this is significant, a diagnosis of Mixed ReceptiveExp
ressive
Language Disorder should be made. A history of delay in reaching some
motor milestones, Developmental Coordination Disorder, and Enuresis are not unco
mmon.
Social withdrawal and some mental disorders such as Attention-Deficit/
Hyperactivity Disorder are also commonly associated. Expressive Language Disorde
r
may be accompanied by EEG abnormalities, abnormal findings on neuroimaging,
dysarthric or apraxic behaviors, or other neurological signs.
Specific Culture and Gender Features
Assessments of the development of communication abilities must take into account
the individual's cultmal and language context, particularly for individuals grow
ing
up in bilingual environments. The standardized measures of language development
,
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
and of nonverbal intellectual capacity must be relevant for the cultural and lin
guistic
group (i.e., tests developed and standardized for one group may not provide appr
opriate
norms for a different group). The developmental type of Expressive Language
Disorder is more common in males than in females.
Prevalence
Prevalence estimates vary with age. In children under 3, language delays are qui
te
CODUnan, occurring in 100/..-15% of children. By school age, prevalence estimate
s.
range from 3% to 7%. The developmental type of Expressive Language Disorder is
more common than the acquired type.
Course
The developmental type of Expressive Language Disorder is usually recognized by
age 3 years, although milder forms of the disorder may not become apparent until
early adolescence, when language ordinarily becomes more complex. The acquired
type of Expressive language Disorder due to brain lesions, head trauma, or strok
e
may occur at any age, and the onset is sudden. The outcome of the developmental
type of Expressive Language Disorder is variable. A majority of children with th
is
disorder improve substantially; in a smaller proportion, difficulties persist in
to adult
hood.
Most children ultimately acquire more or less normal language abilities by late
adolescence,
although subtle deficits may persist. In the acquired type of Expressi\'e
Language Disorder, the course and prognosis are related to the severity and loca
tion
of brain pathology, as well as to the age of the child and the extent of languag
e development
at the time the disorder is acquired. Clinical improvement in language abilities
is sometimes rapid and complete, although deficits in communication and related
cognitive abilities may persist. In other instances there may be progressive def
icit.
Familial Pattern
It appears that the developmental type of Expressive Language Disorder is more l
ikely
to occur in individuals who have a family history of Commlmication or Learning
Disorders. There is no evidence of familial aggregation in the acqUired type.
Differential Diagnosis
Expressive Language Disorder is distinguished &om Mixed Receptive-Expressive
Language Disorder by the presence in the latter of significant impairment in rec
eptive
language; many individuals with ExpreSSive Language Disorder have subtledif
ficulties in receptive skills as well.
Expressive Language Disorder is not diagnosed if the criteria are met for Autist
ic
Disorder or another Pervasive Developmental Disorder. Autistic Disorder also inv
oh"
es expressive language impairment but may be distinguished Cram Expressin
and Mixed Receptive-expressive Language Disorders by the characteristics of the
communication impairment (e.g., stereotyped use of language) and by the presence
315.31 Expressive Language Disorder
of a qualitative impainnent in social interaction and restricted, repetitive, an
d stereotyped
patterns of behavior. Expressive and receptive language development may be
impaired due to Mental Retardation, a hearing impairment or othersensory deficit
,
a speechmotor deficit, or severe environmental deprivation. The presence of these
problems may be established by intelligence testing, audiometric testing, neurol
ogical
testing, and history_ U the language difficulties are in excess of those usually
associated
with these problems, a concurrent diagnosis of Expressive Language or Mixed
Recepth'eExpressive Language Disorder may be made. Children with expressive
language delays due to environmental deprivation may show rapid gains once the
environmental problems are ameliorated.
In Disorder of Written Expression, there is a disturbance in writing skills. If
deficits
in oral expression are also present, an additional diagnosis of Expressive Langu
age
Disorder may be appropriate. Selective Mutism involves limited expressive
output that may mimic Expressive or Mixed Receptive-Expressive Language Disorder
;
careful history and observation are necessary to determine the presence of norma
llangllage
in some settings. Acquired aphasia associated with a general medical
condition in childhood is often transient. A diagnosis of Expressive Language Di
sorder
is appropriate only if the language disturbance persists beyond the acute recove
ry
period for the etiological general medical condition (e.g., head trauma, viral
infection).
Diagnostic criteria for
315.31 Expressive Language Disorder
A.
The scores obtained from standardized individually administered measures of expr
essive
language development are substantially below those obtained from standardized
measures of both nonverbal intellectual capacity and receptive language
development. The disturbance may be manifest clinically by symptoms that include
having a markedly limited vocabulary, making errors in tense, or having difficul
ty recalling
words or producing sentences with developmentally appropriate length or
complexity.
B.
The difficulties with expressive language interfere with academic or occupationa
l
achievement or with social communication. ......
C.
Criteria are not met for Mixed Receptive-Expressive Language Disorder or a Perva
sive
Developmental Disorder.
D.
If Mental Retardation, a speech-motor or sensory deficit, or environmental depri
vation
is present, the language difficulties are in excess of those usually associated
with
these problems.
Coding note: If a speech-motor or sensory deficit or a neurological condition is
present,
code the condition on Axis III.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
315.32 Mixed Receptive-Expressive
Language Disorder
Diagnostic Features
The essential feature of Mixed Receptive-Expressive Language Disorder is an impa
irment
in both receptive and expressive language development as demonstrated by
scores on standardized individually administered measures of both receptive and
expressive
language development that are substantially below those obtained from
standardized measures of nonverbal intellectual capacity (Criterion A). When sta
ndardized
instruments are not available or appropriate, the diagnosis may be based on
a thorough ftmctional assessment of the individual's language ability. The diffi
culties
may occur in communication involving both verbal language and sign language. The
language difficulties interfere with academic or occupational achievement or wit
h
social communication (Criterion B), and the symptoms do not meet criteria for a
Pervasive
Developmental Disorder (Criterion C). If Ment.l1 Retardation, a speech-motor
or sensory deficit, or envirorunental deprivation is present, the language diffi
culties
are in excess of those usually associated with these problems (Criterion D). If
a
speech-motor or sensory deficit or a neurological condition is present, it shoul
d be
coded on Axis Ill.
An individual with this disorder has the difficulties associated with Expressive
Language Disorder (e.g., a markedly limited vocabulary, errors in tense, difficu
lty recalling
words or producing sentences with developmentally appropriate length or
complexity, and general difficulty expressing ideas) and also has impaimlent in
receptive
language development (e.g., difficulty lmderstanding words, sentences, or
specific types of words). In mild cases, there may be difficulties only in under
standing
particular types of words (e.g., spatial terms) or statements (e.g., complex "if
then"
sentences). In more severe cases, there may be multiple disabilities, including
an inability to understand basic vocabulary or simple sentences, and deficits in
various
areas of auditory processing (e.g., discrimination of sounds, association of sou
nds
and symbols, storage, recall, and sequencing). Because the development of expres
sive
language in childhood relies on the acquisition of receptive skills, a pure rece
ptive
language disorder (analogous to a Wernicke's aphasi.l in adults) is virtually ne
l'er
seen (although in some cases the receptive deficit may be more severe than the e
xpressive
one).
Mixed Receptive-Expressive Language Disorder may be either acquired or devel
opmental. In the acquired type, an impainnent in receptive and expressive langua
ge
occurs after a period of normal development as a result of a neurological or oth
er gen
eral medical condition (e.g., encephalitis, head trauma, irr.ldiation). In the d
evelop
mental type, there is an impai.rment in receptive and expressive language that i
s nol
associated with a neurological insult of known origin. This type is char.lcteriz
ed by a
slow rate of language development in which speech may begin late and advance
slowly through the stages of language development.
315.32 Mixed Receptive-Expressive language Disorder
Associated Features and Disorders
The linguistic features of the production impairment in Mixed Receptive-Expressi
ve
language Disorder are similar to those that accompany Expressive Language Disord
er.
The comprehension deficit is the primary feature that differentiates this disord
er
from Expressive Language Disorder, and this can vary depending on the severity o
f
the disorder and the age of the child. impairments in language comprehension can
be
less obvious than those in language production because they are not as readily a
pparent
to the observer and may appear only on formal assessment. The child may intermit
tently
appear not to hear or to be confused or not paying attention when spoken
to. The child may follow commands incorrectly, or not at all, and give tangentia
l or
inappropriilte responses to questions. The child may be exceptionally quiet or,
con\'
ersely, very talkative. Conversational skills (e.g., taking turns, maintilining
iI topic)
are often quite poor or inappropriate. Deficits in various areas of sensory info
rmation
processing are common, especially in temporal auditory processing (e.g., process
ing
rate, association of smmds and symbols, sequence of sounds and memory, attention
to and discrimination of sounds); these kinds of difficulties are sometimes refe
rred to
as "central auditory processing" disorders.
Difficulty in producing motor sequences smoothly and quickly is also characteris
tic.
Phonological Disorder, Learning Disorders, and deficits in speech perception are
often present and accompanied by memory impairments. Other associated disorders
are Attention-Deficit/Hyperactivity Disorder, Developmental Coordination Disorde
r,
and Emuesis. Mixed Receptive-Expressive Language Disorder may be accompanied
by EEG abnormalities, abnormal findings on neuroimaging, and other neurological
signs. A form of acquired J\1.ixed Receptive-Expressive Language Disorder that h
as its
onset at about ages 3-9 yeaTS and is accompanied by seizures is referred to as L
andauKleffner
syndrome.
Specific Culture and Gender Features
Assessments of the development of communication abilities must take into account
the individual's cultural and language context, particularly for individuals gro
wing
up in bilingual environments. The standardized measures of language development
and of nonverbal intellectual cilpacity must be relevant tor the cultural and li
nguistic
group. The developmental type is probably more prevalent in males than in female
s.
Prevalence
Prevalence estimates vary with age. It is estimated that the developmental type
of
Mixed Receptive-Expressive Language Disorder may occur in up to 5% of preschool
children and 3% of school-age dlildren but is probably less common than Expressi
ve
language Disorder. Landau-Kleffner syndrome and other forms of the acquired type
of the disorder are relatively uncommon.
Course
The developmental type of Mixed Receptive-Expressive Language Disorder is usuall
y
detectable before age 4 years. Severe forms of the disorder may be apparent by a
ge
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
2 years. Milder forms may not be recognized until the child reaches elementary
school, where deficits in comprehension become more apparent. The acquired type
of Mixed Receptive-Expressive Language Disorder due to brain lesions, head traum
a,
or stroke may occur at any age. The acquired type due to Landau-Kleffner syndrom
e
(acquired epileptic aphasia) usually occurs beh\'een ages 3 and 9 years. Many ch
ildren
with Mixed Receptive-Expressive Language Disorder eventually acquire normal
language abilities, but the prognosis is worse than for those with Expressive
Language Disorder. In the acquired type of Mixed Receptive-Expressive Language
Disorder, the course and prognosis are related to the severity and location of b
rain
pathology, as well as to the age of the child and the extent of language develop
ment
at the time the disorder is acquired. Clinical improvement in language abilities
is
sometimes complete or nearly so. In other instances, there may be incomplete rec
overy
or progressive deficit. Children with more severe forms are likely to develop
Learning Disorders.
Familial Pattern
The developmental type of MLxed Receptive-Expressive Language Disorder is more
common among first-degree biological relatives of those with the disorder than i
n the
general population. There is no evidence of familial aggregation in the acquired
type
of the disorder.
Differential Diagnosis
See the "Differential Diagnosis" section for Expressive Language Disorder (p. 60
).
Diagnostic criteria for
315.32 Mixed ReceptiveExpressive Language Disorder
A
The scores obtained from a battery of standardized individually administered mea
sures
of both receptive and expressive language development are substantially below
those obtained from standardized measures of nonverbal intellectual capacity.
Symptoms include those for Expressive Language Disorder as well as difficulty un
derstanding
words, sentences, or specific types of words, such as spatial terms.
B.
The difficulties with receptive and expressive language significantly interfere
with
academic or occupational achievement or with social communication.
C.
Criteria are not met for a Pervasive Developmental Disorder.
D.
If Mental Retardation, a speech-motor or sensory deficit, or environmental depri
vation
is present, the language difficulties are in excess of those usually associated
with
these problems.
Coding note: If a speech-motor or sensory deficit or a neurological condition is
present,
code the condition on Axis III.
315.39 Phonological Disorder
(formerly Developmental Articulation Disorder)
315.39 Phonological Disorder
(formerly Developmental Articulation Disorder)
Diagnostic Features
The essential feature of Phonological Disorder is a failure to use developmental
ly
expected speech sounds that are appropriate for the individual's age and dialect
(Criterion
A). nus may involve errors in sound production, use, representation, or organiza
tion
such as, but not limited 10, substitutions of one sound for another (use of
ItI for target Ikl sound) or omissions of sounds (e.g., final consonants). The d
ifficulties
in speech sound production interfere with academic or occupational achievement
or with social communication (Criterion B). U Mental Retardation, a speech-molar
or
sensory deficit, or environmental deprivation is present, the speech difficultie
s are in
excess of those usually associated with these problems (Criterion C). If a speec
hmotor
or sensory deficit or neurological condition is present, it should be coded. on
Axis m.
Phonological Disorder includes phonological production (Le., articulation) error
s
that involve the failure to fOml speech sounds correctly and cognitively based f
orms
of phonological problems that involve a deficit in linguistic categorization of
speech
sounds (e.g., a difficulty in sorting out which sounds in the language make a di
fference
in meaning). Severity ranges from little or no effect on speech intelligibility
to
completely unintelligible speech. Sound omissions are typically viewed as more s
evere
than are sound substitutions, which in tum are more severe than sound distortion
s.
The most frequently misarticulated sounds are those acquired later in the
de\elopmental sequence (I, ',5, I, fll. ell), but in younger or more severely aff
ected. individuals,
consonants and vowels that develop earlier may also be affected.. Lisping
(i.e., misarticulation of sibilants) is particularly common. Phonological Disord
er may
also involve errors of selection and ordering of sounds within syllables and wor
ds
(e.g., aks for ask).
Associated Features and Disorders
Although there may be an association with clear causal factors such as hearing i
mpairment
(e.g., due to chronic otitis media) or structuraLdeficits of the oral peripheral
speech mechanism (e.g., cleft palate), neurological conditions (e.g., cerebral p
alsy).
cognitive limitations (e.g., Mental Retardation), or psychosocial problems, at l
east 3%
of preschool children present with Phonological Disorders of unknown or suspect
origin,
which are often referred to asjl/Ilctional or developmelltal. There may be a del
ayed
onset of speech. Some forms of Phonological Disorder, involving inconsistent err
ors,
difficulty sequencing sounds in connected. speech, and vowel distortions, are so
metimes
referred. to as "developmental dyspraxia of speech."
Specific Culture and Gender Features
Assessments of the development of communication abilities must take into account
the individual's cultural and language context, particularly for individuals gro
wing
up in bilingual environments. Phonological Disorder is more prevalent in males.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Prevalence
Approximately 2% of 6-and 7-year-"{)!ds present with moderate to severe Phonolog
ical
Disorder, although the prevalence of milder forms of this disorder is higher. Th
e
prevalence falls to 0.5% by age 17 years.
Course
In severe Phonological Disorder, the child's speech may be relatively unintellig
ible
even to family members. Less severe forms of the disorder may not be recognized
until
the child enters a preschool or SdlOOI environment and has difficulty being unde
rstood
by those outside the immediate family. The course of the disorder is variable
depending on associated causes and severity. In children with mild to moderate p
honological
problems not due to a general medical condition, about three-fourths show
spontaneous nom1alization by age 6.
Familial Pattern
A familial pattern has been demonstrated for some forms of Phonological Disorder
.
Differential Diagnosis
Speech difficulties may be associated. with Mental Retardation, a hearing impair
ment
or other sensory deficit, a speech-motor deficit, or severe environmental depriv
ation.
The presence of these problems may be established by intelligence testing, audio
metric
testing, neurologicallesting, and history. If the speech difficulties are in exc
ess of those
usually associated with these problems or if they interfere with the child's abi
lity 10 be
understood by significant others, a concurrent diagnosis of Phonological Disorde
r may
be made. Problems limited to speech rhythm or voice are not included as part of
Phonological
Disorder and instead are diagnosed as Stuttering or Communication Disorder
Not OthenYise Specified. Children with speech difficulties due to envirorullenta
l
deprivation may show rapid gains once the environmental problems are ameliorated
.
Diagnostic criteria for 315.39 Phonological Disorder
A.
Failure to use deyelopmentally expected speech sounds that are appropriate for a
ge
and dialect (e.g., errors in sound production, use, representation, or organizat
ion
such as, but not limited to, substitutions of one sound for another luse of ItJ
for target
IkJ sound] or omissions of sounds such as final consonants).
B.
The difficulties in speech sound production interfere with academic or occupatio
nal
achievement or with social communication.
C.
If Mental Retardation, a speech-motor or sensory deficit, or environmental depri
vation
is present, the speech difficulties are in excess of those usually associated wi
th
these problems.
Coding note: If a speech-motor or sensory deficit or a neurological condition is
present.
code the condition on Axis III.
307.0 Stuttering
307.0 Stuttering
Diagnostic Features
The essential featureofStultering is a disturbance in the nonnal fluency and tim
e patterning
ofspeech that is inappropriate for the individual's age (Criterion A). This dist
urbance
is characterized by frequent repetitions or prolongations of sounds or
syllables (Criteria Aland A2). Various other types of speech dysfluencics Illay
also
be involved, including interjections (Criterion A3), broken words (e.g., pauses
within
a word) (Criterion A4). audible or silent blocking (fiUed or unfilled pauses in
speech)
(Criterion AS), circumlocutions (i.e., word substitutions to a\oid problematic wo
rds)
(Criterion A6), words produced with an excess of physical tension (Criterion A7)
, and
monosyllabic wholeword repetitions (e.g., "111-1 see him") (Criterion A8). The dist
urbance
in fluency interferes with academic or occupational achievement or with
social communication (Criterion B). Ifa speech-motor orsensory deficit is presen
t, the
speech difficulties are in excess of those usually associated with these problem
s (Criterion
C). U a speech-motor or sensory deficit or a neurological disorder is present,
this condition should also be coded on Axis Ill. The extent of the disturbance v
aries
from situation to situation and often is more severe when there is special press
ure to
communicate (e.g., giving a report at school, interviewing for a job). Stutterin
g is often
absent during oral reading, singing, or talking to inanimate objects or to pets.
Associated Features and Disorders
At the onset of Stuttering, the speaker may not be aware of the problem, althoug
h
awareness and even fearful anticipation of the problem may develop later. The sp
eaker
may attempt to avoid stuttering by linguistic mechanisms (e.g., altering the rat
e of
speech, avoiding certain speech situations such as telephoning or public speakin
g, or
a\"Oiding certain words or sounds). Shlttering may be accompanied by motor movem
ents
(e.g., eye blinks, tics, tremors of the lips or face, jerking of the head, breat
hing
movements, or fist clenching). Stress or anxiety have been shown to exacerbate S
tuttering.
Impairment of social functioning may result from associated anxiety, frustration
,
or low self-esteem. In adults, Stuttering may limit occupational choice or
advancement. Phonological Disorder and Expressivelanguage Disorder occur at a
higher frequency in individuals with Stuttering than in the general population.
Prevalence
The prevalence of Stuttering in prepubertal children is 1% and drops to 0.8% in
adolescence.
The rnale-to-female ratio is approximately 3:1.
Course
Retrospective studies of individuals with Shlttering report onset typically betw
een
ages 2 and 7 years (with peak onset at a.round age 5 years). Onset occurs before
age
10 years in 98% of cases. The onset is usually insidious, covering many months d
uring
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
which episodic, unnoticed speech dysfluencies become a chronic problem. Typicall
y,
the disturbance starts gradually, with repetition of initial consonants, words t
hat are
usually the first words of a phrase, or long words. The child is generally not a
ware of
Stuttering. As the disorder progresses, there is a waxing and waning course. The
dys
fluencies become more frequent, and the Stuttering occurs on the most meaningful
words or phrases in the utterance. As the child becomes aware of the speech diff
i
culty, mechanisms for avoiding the dysfluencies and emotional responses may occu
r.
Research suggests that some proportion recover; estimates range from 20% to 80%.
Some individuals with Stuttering recover spontaneously, typically before age 16
years.
Familial Pattern
Family and twin studies provide strong evidence of a genetic factor in the etiol
ogy of
Stuttering. The presence of a Phonological Disorder or the developmental type of
Expressive Language Disorder, or a family history of these, increases the likeli
hood
of Stuttering. The risk of Stuttering among first-degree biological relatives is
more
than three times the risk in the general population. For men with a history of S
tutter
ing, about 10% of their daughters and 20% of their sons will stutter.
Differential Diagnosis
Speech difficulties may be associated with a hearing impainnent or other sensory
def
icit or a speech-motor deficit. In instances where the speech difficulties are i
n excess of
those usually associated with these problems, a concurrent diagnosis of Stutteri
ng may
be made. Stuttering must be distinguished from nonnal dysfluencies that occur fr
equently
in young children, which include whole--word or phrase repetitions (e.g., "I
want, I want ice cream"), incomplete phrases, interjections, unfilled pauses, an
d parenthetical
remarks. If these difficulties increase in frequency or complexity as the child
grows older, a diagnosis of Stuttering becomes more likely.
307.9 Communication Disorder Not Otherwise Specified
69
Diagnostic criteria for 307.0 Stuttering
A.
Disturbance in the normal fluency and time panerning of speech (inappropriate fo
r
the individual's age), characterized by frequent occurrences of one or more of t
he
following:
(1)
sound and syllable repetitions
(2)
sound prolongations
(3)
interjections
(4) broken words (e.g., pauses within a word)
(5)
audible or silent blocking (filled or unfilled pauses in speech)
(6)
circumlocutions (word substitutions to avoid problematic words)
(7)
words produced with an excess of physical tension
(8)
monosyllabic whole-word repetitions (e.g., "1_1_1_1 see him")
B.
The disturbance in fluency interferes with academic or occupational achievement
or
with social communication.
C.
If a speech-motor or sensory deficit is present, the speech difficulties are in
excess of
those usually associated with these problems.
Coding note: If a speechmotor or sensory deficit or a neurological condition is p
resent,
code the condition on Axis Ill.
307.9 Communication Disorder
Not Otherwise Specified
This category is for disorders in communication that do not meet criteria for an
y specific
Communication Disorder; for example. a voice disorder (i.e., an abnormality of
\'ocal pitch, loudness, quality, tone, or resonance).
Pervasive Developmental Disorders
Pervasive De\'elopmental Disorders are characterized by severe and pervasive imp
airment
in several areas of de\'elopment reciprocal social interaction skills, communica
tion
skills, or the presence of stereotyped behavior, interests, and activities. The
qualitative impairments that define these conditions are distinctly deviant rela
tive to
the indi\'idual's developmental level or mental age. This section contains Autis
tic
Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorde
r,
and Pervasive Developmental Disorder ot OtherwiseSpecified. These disorders are
usuaUy evident in the first years of life and are often associated with some deg
ree of
Mental Retardation, which, if present, should be coded on Axis II. The Pervasive
De\'
elopmental Disorders are sometimes observed with a diverse group of other genera
l
medical conditions (e.g., chromosomal abnormalities, congenital infections, srru
ctur
Disorders Usually First Diagnosed in Infancy,
Childhood, or AdolescencE
al abnormalities of the central nervous system). If such conditions are present,
the}'
should be noted on Axis Ill. Although terms like "psychosis" and "childhood schi
zophrenia"
were once used to refer to individuals with these conditions, there is considera
ble
evidence to suggest that the Pervasive Developmental Disorders are distinct
from Schizophrenia (however, an individual with Pervasive Developmental Disorder
may occasionally later develop Schizophrenia).
299.00 Autistic Disorder
Diagnostic Features
The essential feahtre5 oL(\utistic Disorder are the presence of markedly abnorma
l or
impaired development in social interaction and communication and a markedly rest
ricted
repertoire of activity and interests. Manifestations of the disorder vary greatl
y
depending on the developmental level and chronological age of the individual.
Autistic Disorder is sometimes referred to as early infantile autism, c1/i/dhood
autism, or
KnII IIer's a/Ifi5111.
The impairment in reciprocal social interaction is gross and sustained. There ma
y
be marked impairment in the use of multiple nonverbal behaviors (e.g., eye-to-ye
gaze, facial expression, body postures and gestures) to regulate social interact
ion and
communication (Criterion Ala). There may be failure to develop peer relationship
s
appropriate to developmental level (Criterion Alb) that may take different forms
at
different ages. Younger individuals may have lillIe or no interest in establishi
ng
friendships. Older individuals may have an interest in friendship but lack under
standing
of the conventions of social interaction. There rna}' be a lack of spontaneous
seeking to share enjoyment, interests, or achievements with other people (e.g.,
not
showing, bringing, or pointing out objects they find interesting) (Criterion Ale
). Lack
of social or emotional reciprocity may be present (e.g., not actively participat
ing in
simple social play or games, preferring solitary activities, or involving others
in activitiesonly
as tools or "mechanical" aids) (Criterion Ald). Often an individual's awareness
of others is markedly impaired. Individuals with this disorder may be oblivious
to other children (including siblings), may have no concept of the needs of othe
rs, or
may not notice another person's distress.
The impairment in communication is also marked and sustained and affects both
verbal and nonverbal skills. There may be delay in, or total lack of. the develo
pment
of spoken language (Criterion A2a). In individuals who do speak, there may be
marked impairment in the ability to initiate or sustain a conversation with othe
rs
(Criterion A2b), or a stereotyped and repetitive use of language or idiosyncrati
c language
(Criterion Alc). There may also be a lack of varied, spontaneous makebelieve
play or social imitative play appropriate to developmental level (Criterion A2d)
.
When speech does develop, the pitch, intonation, rate, rhythm, or stress may be
abnormal
(e.g., tone of voice may be monotonous or inappropriate to context or may
contain questionlike rises at ends of statements). Grammatical structures are of
ten
immature and include stereotyped and repetitive use of language (e.g., repetitio
n of
words or phrases regardless of meaning; repeating jingles or commercials) or idi
osyncratic
language (i.e., language that has meaning only to those familiar with the
individual's communication style). Language comprehension is often very delayed,
299.00 Autistic Disorder
and the individual may be unable to understand simple questions or directions. A
disturbance in the pragmatic (social use) of language is often evidenced by an i
nability
to integrate words with gestures or understand humor or nonliteral aspects of
speech such as irony or implied meaning. Imaginative play is often absent or mar
kedly
impaired. These individuals also tend not to engage in the simple imitation
games or routines of infancy or early childhood or do so ani)' out of context or
in a
mechanical way.
individuals with Autistic Disorder have restricted, repetitive, and stereotyped
patterns
of behavior, interests, and activities. There may be an encompassing preoccupati
on
with one or more stereotyped and restricted patterns of interest that is abnorma
l
either in intensity or focus (Criterion A3a); an apparently inflexible adherence
to specific,
nonfunctional routines or rituals (Criterion A3b); stereotyped and repetitive
motor mannerisms (Criterion A3c); or a persistent preoccupation with parts of ob
jects
(Criterion A3d). Individuals with Autistic Disorder display a markedly restricte
d
range of interests and are often preoccupied with one narrow interest (e.g., dat
es,
phone numbers, radio station call letters). They may line up an exact number of
play
things in the same manner over and over again or repetitively mimic the actions
of
a television actor. They may insist on sameness and show resistance to or distre
ss
over trivial dlanges (e.g., a younger child may have a catastrophic reaction to
a minor
change in the environment such as rearrangement of the furniture or use of a new
set
of utensils at the dinner table). There is often an interest in nonfunctional ro
utines or
rituals or an unreasonable insistence on follOWing routines (e.g., taking exactl
y the
same route to school every day). Stereotyped body movements include the hands
(clapping, finger flicking) or whole body (rocking, dipping, and swaying). Abnor
malities
of posture (e.g., walking on tiptoe, odd hand movements and body postures)
may be present. These individuals show a persistent preoccupation with parts of
objects
(buttons, parts of the body). There may also be a fascination with movement
(e.g., the spinning wheels of toys, the opening and closing of doors, an electri
c fan or
other rapidly revolving object). The person rna)' be highly attached to some ina
nimate
object (e.g., a piece of string or a rubber band).
The disturbance must be manifest by delays or abnormal functioning in at least
one (and often several) of the following areas prior to age 3 years: social inte
raction,
language as used in social communication, or symbolic or imaginative play (Crite
rion
B). in most cases, there is no period of wlequivocaUy normal development, althou
gh
in perhaps 20% of cases parents report relatively normal development for lor2 ye
ars.
In such cases, parents may report that the child acquired a few words and lost t
hese
or seemed to stagnate developmentally.
By defmition, if there is a period of nonnal den'lopment, it cannot extend past
age
3 years. The disturbance must not be better accounted for by Rett's Disorder or
Childhood
Disintegrative Disorder (Criterion C).
Associated Features and Disorders
Associated descriptive features and mental disorders. In most cases, there is an
associated diagnosis of Mental Retardation, which can range from mild to profoun
d.
There may be abnormalities in the development of cognitive skills. The profile o
f cog
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
nitive skills is usually uneven, regardJess of the general level of intelligence
, with verbal
skills typically weaker than nonverbal skills. Sometimes special skills are pres
ent
(e.g., a 4Jh-year-old girl with Autistic Disorder may be able to "decode" writte
n
materials with minimallUlderstanding of the meaning of what is read [hyperlexia]
or
a IO-year-old boy may have prodigious abilities to calculate dates [calendar cal
culation]).
Estimates of single-word (receptive or expressive) vocabulary are not always
good estimates of language level (i.e., actual language skills may be at much lo
wer
levels).
Individuals with Autistic Disorder may have a range of behavioral symptoms, incl
uding
hyperacti\'ity, short attention span, impulsivity, aggressiveness, self-injuriou
s
behaviors, and, particularly in young children, temper tantrums. There may be od
d
responses to sensory..s.timuli (e.g., a high threshold for pain, oversensitivity
to smmds
or being touched, exaggerated reactions to light or odors, fascination with ccrt
ain
stimuli). There may be abnormalities in eating (e.g., limiting diet to a few foo
ds, Pica)
or sleeping (e.g., recurrent awakening at night with rocking). Abnormalities of
mood
or affect (e.g., giggling or weeping for no apparent reason, an apparent absence
of
emotional reaction) may be present. There may be a lack of fear in response to r
eal
dangers, and excessivc fearfulness in response to harmless objects. A variety of
selfinjurious
behaviors may be present (e.g., head banging or finger, hand, or wrist biting).
In adolescence or early adult life, individuals with Autistic Disorder who have
the intellectual capacity for insight may become depressed in response to the re
alization
of their serious impairment.
Associated laboratory findings. When Autistic Disorder is associated with a gene
ral
medical condition, laboratory findings consistent with the general medical condi
tion
will be observed. There are group differences in some measures of serotonergic
activity, but these are not diagnostic for Autistic Disorder. Imaging studies ma
y be
abnormal in some cases, but no specific pattern has been clearly identified. EEG
abnormalities
are common even in the absence of seizure disorders.
Associated physical examination findings and general medical conditions.
Various nonspecific neurological symptoms or signs may be noted (e.g., primitive
reflexes,
delayed development of hand dominance) in Autistic Disorder. The condition
is sometimes observed in association with a neurological or other general medica
l
condition (e.g., fragile X syndrome and tuberous sclerosis).
Seizures may develop (particularly in adolescence) in as many as 25% of cases.
Both microcephaly and macrocephaly are observed. When other general medical cond
itions
are present, they should be noted on Axis m.
Specific Age and Gender Features
TIle nature of the impairment in social interaction may change over time in Auti
stic
Disorder and may vary depending on the developmental level of the individual. In
infants, there may be a failure to cuddle; an indifference or aversion to affect
ion or
physical contact; a lack of eye contact, facial responsiveness, or socially dire
cted
smiles; and a failure to respond to their parents' voices. As a result, parents
may be
concerned initially that the child is deaf. Young children with this disorder ma
y treat
299.00 Autistic Disorder
adults as interchangeable, may ding mechanically to a specific person, or may us
e the
parent's hand to obtain desired objects without e\'er making eye contact (as if
it were
the hand rather than the person that is relevant). Over the course of developmen
t, the
child may become more willing to be passively engaged in social interaction and
may
e"en become more interested in social interaction. However, even in such instanc
es, the
child tends to treat other people in unusual ways (e.g., expecting other people
to answer
ritualized questions in specific ways, haVing little sense of other people's bou
ndaries,
and being inappropriately intrusive in social interaction). In older individuals
,
tasks involving long-term memory (e.g., train timetables, historical dates, chem
ical formulas,
or ret:all of the exact words of songs heard years before) may be excellent, but
the information tends to be repeated over and o\'er again, regardless of the app
ropriateness
of the information to the social context. Rates of the disorder are four to five
times higher in males than in females. Females with the disorder are more likely
, howc\'
er, to exhibit more severe Mental Retardation.
Prevalence
The median rate of Autistic Disorder in epidemiological studies is 5 cases per 1
0,000
indh'iduals, with reported rates ranging from 2 to 20 cases per 10,000 individua
ls. It
remains unclear whether the higher reported rates reflect differences in methodo
logy
or an increased frequency of the condition.
Course
By definition, the onset of Autistic Disorder is prior to age 3 years. In some i
nstances.
parents will report that they have been worried about the child since birth or s
hortly
afterward because of the child's lack of interest in social interaction. Manifes
tations
of the disorder in infancy are more subtle and difficult to define than those se
en after
age 2 years. In a minority of cases, the child may be reported to ha\'e develope
d normally
for the first )'ear (or even 2 years) of life. Autistic Disorder follows a conti
nuous
course. In school-age children and adolescents, developmental gains in some area
s
are common (e.g., increased interest in social functioning as the child reaches
school
age). Some individuals deteriorate behaviorally during adolescence, whereas othe
rs
improve. Language skills (e.g., presence of communicative speech) and overall in
telleduililevel
are the strongest factors related to ultimate prognosis. Available followup
studies suggest that only a small percentage of individuals with the disorder go
on as adults to live and work independently. In about one-third of cases, some d
egree
of partial independence is possible. The highest functioning adults with Autisti
c Disorder
typically continue to exhibit problems in social interaction and communication
along with markedl)' restricted interests and activities.
Familial Pattern
There is an increased risk of Autistic Disorder among siblings of individuals wi
th the
disorder, with approximately 5% of siblings also exhibiting the condition. There
also
appears to be risk for various developmental difficulties in affected siblings.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Differential Diagnosis
Periods of developmental regression may be observed in normal development, but
these are neilher as severe or as prolonged as in Autistic Disorder. Autistic Di
sorder
must be differentiated from other Pervasive Developmental Disorders. ReU's Dis
order differs from Autistic Disorder in its characleristic sex ratio and pattern
of deficits.
Rett's Disorder has been diagnosed only in females, whereas Autistic Disorder
occurs much more frequently in males. In ReU's Disorder, there is a characterist
ic pattern
of head growth deceleration, loss of previollsly acquired purposeful hand skills
,
and the appearance of poorly coordinated gait or trunk movements. Particularly d
uring
the preschool years, individuals with Reu's Disorder may exhibit djfficulties in
social interaction siml~r
to those observed in Autistic Disorder, but Ihese lend to be
transient. Autistic Disorder differs from Childhood Disintegrative Disorder, whi
ch
has a distinctive paUern of severe developmental regression in multiple areas of
functioning following at least 2 years of normal development. In Autistic Disord
er,
developmental abnomlalities are usually noted witllin the first year of life. Wh
en information
on early development is unavailable or when it is not possible to document
the required period of nonnal development, the diagnosis of Autistic Disorder
should be made. Asperger's Disorder can be distinguished from Autistic Disorder
by
the lack of delay or deviance in early language development. Asperger's Disorder
is
not diagnosed if criteria are met for Autistic Disorder.
Schizophrenia with childhood onset usually develops after years of normal, or
near normal, development. An additional diagnosis of Schizophrenia can be made i
f
an individual with Autistic Disorder develops the characteristic features of Sch
izophrenia
(see p. 298) with active-phase symptoms of prominent delusions or hallucinations
that lasl for at least 1 month. In Selective Mutism, the child usually exhibits
appropriate communication skills in certain contexts and does not have the sever
e
impairment in social interaction and the restricted patterns of behavior associa
ted
with Autistic Disorder. In Expressive Language Disorder and Mixed ReceptiveExpre
ssive
language Disorder, there is a language impairment, but it is nol associated
with the presence of a qualitative impairment in social interaction and restrict
ed,
repetitive, and stereotyped pallerns of behavior. It is sometimes difficull to d
etermine
whether an additional diagnosis of Autistic Disorder is warranted in an individu
al
with Mental Retardation, especially if the Mental Retardation is Severe or Profo
und.
An additional diagnosis of Autistic Disorder is reserved for those situations in
which
there are qualitative deficits in social and communicative skills and the specif
ic behaviors
characteristic of Autistic Disorder are present. Motor stereotypies are characte
ristic
of Autistic Disorder; an additional diagnosis of Stereotypic Movement
Disorder is not given when these are better accounted for as pari of the present
ation
of Autistic Disorder. Symptoms of overactivity and inattention are frequent in A
utistic
Disorder, but a diagnosis of Attention-Deficit/Hyperactivity Disorder is not
made if Autistic Disorder is present.
299.00 Autistic Disorder
Diagnostic criteria for 299.00 Autistic Disorder
A.
A total of six (or more) items from (1). (2), and (3). with at least t\vo from (
1). and one
each from (2) and (3):
(1)
qualitative impairment in social interaction. as manifested by at least two of t
he
following:
(a)
marked impairment in the use of multiple nonverbal behaviors such as eyeto-
eye gaze, facial expression, body postures, and gestures to regulate social
interaction
(b)
failure to develop peer relationships appropriate to developmental level
(c)
a lack of spontaneous seeking to share enjoyment, interests, or achievements
with other people (e.g., by a lack of showing, bringing, or pointing
out objects of interest)
(d)
lack of social or emotional reciprocity
(2)
qualitative impairments in communication as manifested by at least one of the
following:
(a)
delay in, or total lack of, the development of spoken language (not accompanied
by an attempt to compensate through alternative modes of communication
such as gesture or mime)
(b)
in individuals with adequate speech, marked impairment in the ability to
initiate or sustain a conversation with others
(c)
stereotyped and repetitive use of language or idiosyncratic language
(d)
lack of varied, spontaneous make-believe play or social imitative play appropria
te
to developmental level
(3)
restricted repetitive and stereotyped patterns of behavior. interests, and activ
ities,
as manifested by at least one of the following:
(a)
encompassing preoccupation with one or more stereotyped and restricted
patterns of interest that is abnormal either in intensity or focus
(b)
apparently inflexible adherence to specific, nonfunctional routines or ritu,,,
(c)
stereotyped and repetitive motor mannerisms (e.g.. hand or finger flapping
or twisting. or complex whole-body movements)
(d)
persistent preoccupation with parts of objects
B.
Delays or abnormal functioning in at least one of the following areas, with onse
t
prior to age 3 years: (l) social interaction, (2) language as used in social com
munication,
or (3) symbolic or imaginative play.
C.
The disturbance is not better accounted for by Rett's Disorder or Childhood Disi
ntegrative
Disorder.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
299.80 Rett's Disorder
Diagnostic Features
The essential feature of Rett's Disorder is the development of multiple specific
deficits
following a period of normal functioning after birth. Individuals have an appare
ntly
normal prenatal and perinatal period. (Criterion AI) with normal psychomotor
dcvelopment through the first 5 months of We (Criterion A2). Head circumference
at
birth is also within normal limits (Criterion A3). Beh\'een ages 5 and 48 months
, head
growth decelerates (Criterion 81). There is a loss of previously acquired purpos
eful
hand skills beh\'een ages 5 and 30 months, with the subsequent development ofcha
r
acteristic stereotyped Rand movements resembling hand-wringing or hand washing
(Criterion 82). Interest in the social environment diminishes in the first fcw y
ears after
the onset of the disorder (Criterion 83), although social interaction may often
develop
later in the course. Problems develop in the coordination of gait or trunk movem
ents
(Criterion 84). There is also severe impairment in expressive and receptive lang
uage
development, with severe psychomotor retardation (Criterion 85).
Associated Features and Disorders
Rett's Disorder is typically associated with Severe or Profound Mental Retardati
on.
which, if present, should be coded on Axis n. There are no specific laboratory f
indings
associated with the disorder. There may be an increased frequency of EEG abnorma
lities
and seizure disorder in individuals with Rett's Disorder. TonspecifiC
abnormalities on brain imaging have been reported. Preliminary data suggest that
a genetic mutation is the cause of some cases of Rett's Disorder.
Prevalence
Data are limited to mostly case series, and it appears that ReU's Disorder is mu
ch less
common than Autistic Disorder. This disorder has been reported only in females.
(ourse
The pattern of developmental regression is highly distinctive. Rett's Disorder h
as its
onset prior to age 4 years, usuall)' in the first or second year of life. The du
ration of
the disorder is lifelong, and the loss of skills is generally persistent and pro
gressi\'e.
In most instances, recovery is quite limited, although some very modest developm
ental
gains rna)' be made and interest in social interaction may be obsen'ed as indivi
duals
enter later childhood or adolescence. The communicative and beha\'ioral
difficulties usually remain relatively constant throughout life.
Differential Diagnosis
Periods of developmental regression may be obsen'ed in normal development, but
these are neither as severe or as prolonged as in Rett's Disorder. For the diffe
rential
299.10 Childhood Disintegrative Disorder
diagnosis between Rett's Disorder and Autistic Disorder, see p. 7.t. Rett's Diso
rder
differs from Childhood Disintegrative Disorder and Aspergers Disorder in its
characteristic sex ratio, onset, and pattern of deficits. Rett's Disorder has be
en diagnosed
only in females, whereas Childhood Disintegrative Disorder and Asperger's
Disorder appear to be more common in males. The onset of symptoms in Rett's Diso
rder
can begin as early as age 5 months, whereas in Childhood Disintegrative Disorder
the period of nonnal development is typically more prolonged (i.e., at least
until age 2 years). In Rett's Disorder, there is a characteristic pattern of hea
d growth
deceleration, loss of previously acquired purposeful hand skills, and the appear
ance
of poorly coordinated gait or trunk movements. In contrast to Asperger's Disorde
r,
Rett's Disorder is characterized by a severe impainnent in expressive and recept
ive
language development.
Diagnostic criteria for 299.80 Rett's Disorder
A.
All of the following:
(1)
apparently normal prenatal and perinatal development
(2)
apparently normal psychomotor development through the first 5 months after
birth
(3)
normal head circumference at birth
8. Onset of all of the following after the period of normal development:
(1)
deceleration of head growth between ages 5 and 48 months
(2)
loss of previously acquired purposeful hand skills between ages 5 and 30
months with the subsequent development of stereotyped hand movements
(e.g., hand-wringing or hand washing)
(3)
loss of social engagement early in the course (although often social interaction
develops later)
(4)
appearance of poorly coordinated gait or trunk movements
(S)
severely impaired expressive and receptive language development with severe
psychomotor retardation
299.10 Childhood Disintegrative Disorder
Diagnostic Features
The essential feature of Childhood Disintegrative Disorder is a marked regressio
n in
multiple areas of functioning following a period of at least 2 years of apparent
ly normal
development (Criterion A). Apparentl}' normal development is reflected in ageapp
ropriate
verbal and nonverbal communication, social relationships, play, and
adaptive behavior. After the first 2 years of life (but before age 10 years), th
e child has
a clinically significant loss of previously acquired skills in at least two of t
he follOWing
areas: expressive or receptive language, social skills or adaptive behavior, bow
el or
bladder control, play, or motor skills (Criterion B). Most typically, acquired s
kills arc
lost in almost all areas.
Disorders Usually first Diagnosed in Infancy,
Childhood, or Adolescence
lndh,jduals with this disorder exhibit the social and communicative deficits and
behavioral features generally observed in Autistic Disorder (see p. 70). There i
s qualitative
impairment in social interaction (Criterion el) and in communication (Criterion
e2), and restricted, repetitive, and stereotyped patterns of behavior, interests
,
and activities (Criterion C3). The disturbance is not better accounted for by an
other
specific Pervasive Developmental Disorder or by Schjzophrenia (Criterion D). Thi
s
condition has also been termed Heller's syndrome, demelltia ill/nlltiUs, or disi
lltegrative
Jlsychosis.
Associated Features and Disorders
Childhood Disintegrative Disorder is usually associated with Severe Mental Retar
dation,
which, if present, should be coded on Axis n. Various nonspecific neurological
symptoms or signs may be noted. There seems to be an increased frequency of EEG
abnormalities and seizure disorder. Although it appears likely that the conditio
n is
the result of some insult to the developing central nervous system, no precise m
echanjsm
has been identified. The condition is occasionally observed in association with
a general medical condition (e.g., metachromatic leukodystrophy, Schilder's dise
ase)
that might account for the developmental regression. In most instances, howe\"er
,
extensive im'estigation does not reveal such a condition. If a neurological or o
ther
general medical condition is associated with the disorder, it should be recorded
on
Axis m. The laboratory findings will reflect any associated general medical cond
itions.
Prevalence
Epidemiological data are limited, but Childhood Disintegrative Disorder appears
to
be very rare and much less common than Autistic Disorder, although the condition
is
likely underdiagnosed. Although initial studies suggested an equal sex ratio. th
e
most recent data suggest that the condition is more common among males.
Course
By definition, Childhood Disintegrative Disorder can only be diagnosed if the sy
mptoms
are preceded by at least 2 years of nonnal development and the onset is prior to
age 10 years. When the period of normal development has been quite prolonged (5
or
more years), it is particularly important to conduct a thorough physical and neu
rological
examination to assess for the presence of a general medical condition. In most
cases, the onset is behveen ages 3 and -I rears and may be insidious or abrupt.
Premonitory
signs can include increased activity levels, irritability, and anxiety followed
by a loss of speech and other skills. During this time, the child may also lose
intefl:'S1
in the environment. Usually the loss of skills reaches a plateau, after which so
me lim
iled improvement may occur, although improvement is rarely marked. In other inst
ances,
especially when the disorder is associated with a progressive neurological
condition, the loss of skills is progressive. This disorder foHows a continuous
course,
and in the majority of cases, the duration is lifelong. The social, communicativ
e, and
behavioral difficulties remain relatively constant throughout life.
299.10 Childhood Disintegrative Disorder
Differential Diagnosis
Periods of regression may be observed in normal development, but these are neith
er
as senre or as prolonged as in Childhood Disintegrative Disorder. Childhood Disi
ntegrative
Disorder must be differentiated from other Pervasive Developmental
Disorders. For the differential diagnosis with Autistic Disorder, seep. 74. For
the differential
diagnosis with Rett's Disorder, see p. 76. In contrast to Asperger's Disorder,
Childhood Disintegrative Disorder is characterized by a clinically significant l
oss in
previously acquired skills and a greater likelihood of Mental Retardation. In As
perger's
Disorder, there is no delay in language development and no marked loss of develo
pmental
skills.
Childhood Disintegrative Disorder must be differentiated from a dementia with
onset during infancy or childhood. Dementia occurs as a consequence of the direc
t
physiological effects of a general medical condition (e.g., head trauma), wherea
s
Childhood Disintegrative Disorder typically occurs in the absence of an associat
ed
general medical condition.
Diagnostic criteria for
299.10 Childhood Disintegrative Disorder
A.
Apparently normal development for at least the fir~
2 years after birth as manifested
by the presence of age-appropriate verbal and nonverbal communication, social re
lationships,
play. and adaptive behavior.
B.
Clinically significant loss of previously acquired skills (before age 10 years)
in at least
" ....0 of the following areas:
(1)
expressive or receptive language
(2)
social skills or adaptive behavior
(3)
bowel or bladder control
(4)
play
(5)
motor skills
C.
Abnormalities of functioning in at least two of the following areas:
(1)
qualitative impairment in social interaction (e.g., impairment in nonverbal beha
viors,
failure to develop peer relationships, lack of social or emotional reciprocity)
(2)
qualitative impairments in communication (e.g., delay or lack of spoken Ian
guage, inability to initiate or sustain a conversation, stereotyped and repetiti
ve
use of language. lack of varied make-believe play)
(3)
restricted, repetitive. and stereotyped patterns of behavior, interests, and act
ivities.
including motor stereotypies and mannerisms
D.
The di~urbance
is not better accounted for by another specific Pervasive Developmental
Disorder or by Schizophrenia.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Iso
299.80 Asperger's Disorder
Diagnostic Features
The essential features of Asperger's Disorder are severe and sustained impairmen
t in
social interaction (Criterion A) and the development of restricted, repetitive p
aNems
of behavior, interests, and activities (Criterion B). The disturbance must cause
clinically
significant impairment in social. occupational, or other important areas of func
tioning
(Criterion C). In contrast to Autistic Disorder. there are no clinically
significant delays or deviance in language acquisition (e.g., single non-echoed
words
are used communicatively by age 2 years, and spontaneous communicative phrases
are used by age 3 years) (Criterion 0), allhough more subtle aspects of social c
ommunication
(e.g., typical give-and-take in conversation) may be affected. In addition,
during the first 3 years of life, there are no clinically significant delays in
cognitive development
as manifested by expressing nonnal curiosity about the environment or in
the acquisition of age-appropriate learning skills and adaptive behaviors (other
than
in social interaction) (Criterion E). Finally, the criteria are not met for anot
her specific
Pervasive Developmental Disorder or for Schizophrenia (Criterion F). This condit
ion
is also termed Asperger's syndrome.
The impairment in reciprocal social interaction is gross and sustained. There ma
y
be marked impairment in the use of multiple nonverbal behaviors (e.g., eye-ta-ey
e
gaze, facial expression, body postures and gestures) to regulate social interact
ion and
communication (Criterion A1). There may be failure to de\'elop peer relationship
s
appropriate to developmental level (Criterion A2) that may take different forms
at
different ages. Younger individuals may have little or no interest in establishi
ng
friendships. Older individuals may have an interest in friendship but lack under
standing
of the conventions of social interaction. There may be a lack of spontaneous
seeking to share enjoyment, interests, or achievements with other people (e.g.,
not
showing, bringing, or pointing out objects they find interesting) (Criterion A3)
. Lack
of social or emotional reciprocity may be present (e.g., not actively participat
ing in
simple social play or games, preferring solitary activities, or involving others
in activities
only as tools or "mechanical" aids) (Criterion A4). Although the social deficit
in
Asperger's Disorder is severe and is defined in the same way as in Autistic Diso
rder,
the lack of social reciprocity is more typically manifest by an eccentric and on
e-sided
social approach to others (e.g., pursuing a conversational topic regardless of o
thers'
reactions) rather than social and emotional indifference.
As in Autistic Disorder, restricted, repetitive patterns of behavior, interests,
and
activities are present (Criterion B). Often these are primarily manifest in the
development
of encompassing preoccupations about a circumscribed topic or interest, about
which the individual can amass a great deal of facts and information (Criterion
Bl).
These interests and activities are pursued with great intensity often to the exd
usion
of other activities.
The disturbance must cause clinically significant impairment in social adaptatio
n,
which in tum may have a Significant impact on sell-suftiency or on occupational
or
other important areas of functioning (Criterion C). The social deficits and rest
ricted
patterns of interests, activities, and behavior are the source of considerable d
isability.
299.80 Asperger's Disorder
In contrast to Autistic Disorder, there are no clinically significant delays in
early
language (e.g., single words are used by age 2, communicath'e phrases are used b
y
age 3) (Criterion D). Subsequent language may be unusual in terms of the individ
ual's
preoccupation with certain topics and his or her verbosity. Difficulties in comm
unication
may result from social dysfunction and the failure to appreciate and utilize
com'entional rules of conversation, failure to appreciate nonverbal cues, and li
mited
capacities for self-monitoring.
Individuals with Asperger's Disorder do not have clinically significant delays i
n
cognitive development or in age-appropriate self-help skills, adaptive behavior
(oth~
er than in social interaction), and curiosity about the environment in childhood
. (Criterion
E). Because early language and cognitive skills are within nonnallimits in the
first 3 years of life, parents or caregivers are not usually concerned about the
child's
development during that time, although upon detailed interviewing they may recal
l
unusual behaviors. The child may be described as talking before walking, and ind
eed
parents may believe the child to be precocious (e.g., with a rich or "adult" voc
abulary).
Although subtle social problems may exist, parents or caregivers often are not
concerned until the child begins to attend a preschool or is exposed to same-age
children;
at this point the child's social difficulties with same-age peers may become app
arent.
By definition the diagnosis is not given if the criteria are met for any other s
pecific
Pervasive Developmental Disorder or for Schizophrenia (although the diagnoses of
Asperger's Disorder and Schizophrenia may coexist if the onset of the Asperger's
Disorder
dearly preceded the onset of Schizophrenia) (Criterion F).
Associated Features and Disorders
In contrast to Autistic Disorder, Mental Retardation is not usually obseryed in
Asperger's
Disorder, although occasional cases in which Mild Mental Retardation is
present have been noted (e.g., when the Mental Retardation becomes apparent only
in the school years, with no apparent cognitive or language delay in the first y
ears of
life). Variability of cognitive functioning may be observed, often with strength
s in areas
of verbal ability (e.g., vocabulary, rate auditory memory) and weaknesses in non
verbal
areas (e.g., visual-motor and visual-spatial skills). Motor c1Ull15iness and
awkwardness may be present but usually are relatively mild, although motor diffi
culties
may contribute to peer rejection and social isolation (e.g., inability to partic
ipate
in group sports). Symptoms of overactivity and inattention are frequent in
Asperger's Disorder, and indeed many individuals with this condition receive a d
iagnosis
of Attention-Deficit/Hyperactivity Disorder prior to the diagnosis of Asperger's
Disorder. Asperger's Disorder has been reported to be associated with a
number of other mental disorders, including Depressive Disorders.
Specific Age and Gender Features
The clinical picture may present differently at different ages. Often the social
disability
of individuals with the disorder becomes more striking over time. By adolescence
some individuals with the disorder may learn to use areas of strength (e.g., rot
e verbal
abilities) to compensate for areas of weakness. Individuals with Asperger's Dis
Disorders Usually First Diagnosed in Infancy,
Childhood. or Adolescence
order may experience victimizationby others; this, and feelings ofsocial isolati
onand
an increasing capacity for self-awareness, may contribute 10 the development of
depression
and anxiety in adolescence and young adulthood. The disorder is diagnosed
much more frequently (at least five times) in males than in females
Prevalence
Definitive data regarding the prevalence of Asperger's Disorder are lacking.
Course
Asperger"s Disorder is a continuous and Welong disorder. In Sdlool-age children.
good \'erbal abilities may, to some extent, mask the severity of the child's soc
ial dyshmction
and may also mislead caregivers and teachers-that is, caregivers and teachers
may focus on the child's good verbal skills but be insuffidently aware of proble
ms
in other areas (particularly social adjustment). The child's relatively good \'e
rbal
skills may also lead teachers and caregivers to erroneously attribute behavioral
difficulties
to willfulness or stubbornness in the child. Interest in forming social relation
ships
may increase in adolescence as the individuals learn some ways of responding
more adaptively to their difficulties-for example, the individual may learn to a
pply
explicit verbal rules or routines in certain stressful situations. Older individ
uals rna}'
have an interest in friendship but lack understanding of the conventions of soci
al
interaction and may more likely make relationships with individuals much older o
r
younger than themselves. The prognosis appears significantly better than in Auti
stic
Disorder, as followup studies suggest that, as adults, many indi\'iduals are capa
ble
of gainful employment and personal self-sufficiency.
Familial Pattern
Although the available data are limited, there appears to be an increased freque
ncy
of Asperger's Disorder among famil}' members of individuals who have the disorde
r.
There may also be an increased risk for Autjstic Disorder as well as more genera
l S(}cial
difficulties.
Differential Diagnosis
Asperger's Disorder must be distinguished from the other Pervasive Developmental
Disorders, all of which are characterized by problems in social interaction. It
differs
from Autistic Disorder in several ways. In Autistic Disorder there are, by defin
ition,
significant abnormalities in the areas ofsocial interaction, language, and play,
whereas
in Asperger's Disorder early cognitive and language skills are not delayed signi
ficantly.
Furthermore, in Autistic Disorder, restricted, repetitive, and stereotyped
interests and activities are often characterized by the presence of motor manner
isms,
preoccupation with parts of objects, rituals, and marked distress in change, whe
reas
in Asperger's Disorder these are primarily observed in the all-encompassing purs
uit
of a circumscribed interest involVing a topic to which the individual devotes in
ordi
nate amounts of time amassing information and facts. Differentiation of the t\\'
o (on
299.80 Asperger's Disorder
ditions can be problematic in some cases. In Autistic Disorder, typical social
interaction patterns arc marked by self-isolation or markedly rigid social appro
aches,
whereas in Asperger's Disorder there may appear to be motivation for approaching
others even though this is then done in a highly eccentric, one-sided, verbose,
and insensitive
manner.
Asperger's Disorder must also be differentiated from Pervasive Developmental Dis
orders
other than Autistic Disorder. Rett's Disorder differs from Asperger's Disorder
in its characteristic sex ratio and pattern of deficits. Rett's Disorder has bee
n diagnosed
only in females, whereas Asperger's Disorder occurs much more frequently in male
s.
In Rett's Disorder, there is a dlaracteristic pattern of head growth deceleratio
n, loss of
previously acquired purposeful hand skills, and the appearance of poorly coordin
ated
gait or trunk movements. Rett's Disorder is also associated with marked degrees
of
Mental Retardation and gross impairments in language and communication.
Asperger's Disorder differs from Childhood Disintegrative Disorder, which has
a distinctive pattern of developmental regression following at least 2 years of
normal
development. Children with Childhood Disintegrative Disorder also display marked
degrees of Mental Retardation and language impairment. In contrast, in Asperger'
s
Disorder there is no pattern of developmental regression and, by definition, no
significant
cognitive or language delays.
Schizophrenia of childhood onset usually develops after years of normal. or near
normal, development, and characteristic features of the disorder, including hall
ucinations,
delusions, and disorganized speech, are present. In Selective Mutism, the
child usually exhibits appropriate comnumication skills in certain contexts and
does
not have the severe impairnlent in social interaction and the restricted pattern
s of behavior
associated with Asperger's Disorder. Conversely, individuals with Asperger's
Disorder are typically verbose. In Expressive Language Disorder and Mixed Recept
ive-
Expressive Language Disorder, there is language impairment but no associated
qualitative impairment in social interaction and restricted, repetitive, and ste
reotyped
patterns of behavior. Some individuals with Asperger's Disorder may exhibit
behavioral patterns suggesting Obsessive-Compulsive Disorder, although special
clinical attention should be given to the differentiation between preoccupations
and
activities in Asperger's Disorder and obsessions and compulsions in ObsessiveCom
pulsive
Disorder. In Asperger's Disorder these interests are the source of some
apparent pleasure or comfort, whereas in Obsessive-Compulsive Disorder they are
the source of anxiety. Furthermore, Obsessive-Compulsive Disorder is typically n
ot
associated with the level of impairment in social interaction and social communi
ca
tion seen in Asperger's Disorder.
The relationship between Asperger's Disorder and Schizoid Personality Disor
der is unclear. In general, the social difficulties in Asperger's Disorder are m
ore se
vere and of earlier onset. Although some i.ndividuals with Asperger's Disorder m
ay
experience heightened and debilitating anxiety in social settings as in Social P
hobia
or other Anxiety Disorders, the latter conditions are not characterized by perva
sive
impairments in social development or by the circumscribed interests typical of A
s
perger's Disorder. Asperger's Disorder must be distinguished from normal social
awkwardness and normal age-appropriate interests and hobbies. In Asperger's
Disorder, the social deficits are quite severe and the preoccupations arc all-en
com
passing and interfere with the acquisition of basic skills.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Diagnostic criteria for 299.80 Asperger's Disorder
A.
Qualitative impairment in social interaction, as manifested by at least two of t
he fol
lowing:
(1)
marked impairment in the use of multiple nonverbal behaviors such as eye-toeye
gaze, facial expression, body postures, and gestures to regulate social inter
action
(2)
failure to develop peer relationships appropriate to developmental level
(3)
a lack of spontaneous seeking to share enjoyment, interests, or achievemenu
with other people (e.g., by a lack of showing, bringing, or pointing out objem
of interest to other people)
(4)
lack of social or emotional reciprocity
B.
Restricted repetitive and stereotyped patterns of behavior, interests, and activ
ities,
as manifested by at least one of the following:
(1)
encompassing preoccupation with one or more stereotyped and restricted pat
terns of interest that is abnormal either in intensity or focus
(2)
apparently inflexible adherence to specific, nonfunctional routines or ritual~
(3)
stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or
twisting, or complex whole-body movements)
(4)
persistent preoccupation with parts of objects
C.
The disturbance causes clinically significant impairment in social, occupational
, or
other important areas of functioning.
D.
There is no clinically significant general delay in language (e.g., single words
used by
age 2 years, communicative phrases used by age 3 years).
E.
There is no clinically significant delay in cognitive development or in the deve
lopment
of age-appropriate self-help skills, adaptive behavior (other than in social int
eraction),
and curiosity about the environment in childhood.
F.
Criteria are not met for another specific Pervasive Developmental Disorder or Sc
hizophrenia.
299.80 Pervasive Developmental Disorder Not
Otherwise Specified (Including Atypical Autism)
This category should be used when there is a severe and pervasive impairment in
tbe
development of reciprocal social interaction associated with impairment in eithe
r
verbal or nonverbal communication skills or with the presence of stereotyped beh
a\"
ior, interests, and activities, but the criteria are not met for a specific Perv
asive Den>!opmental
Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant
Personality Disorder. For example, this category includes "atypical autism"-p"",
,"
tations that do not meet the criteria for Autistic Disorder because of late age
,1t onset,
atypical symptomatology, or subthreshold symptomatology, or all of these.
Attention-Deficit and Disruptive Behavior Disorders
Attention-Deficit and
Disruptive Behavior Disorders
Attention-Deficit/Hyperactivity Disorder
Diagnostic Features
The essential feature of Attention-Deficit/Hyperactivity Disorder is a persisten
t pattern
of inattention and/or hyperactivity-impulsivity that is more frequently displaye
d
and more severe than is typically observed in individuals at a comparable
level of development (Criterion A). Some hyperactive-impulsive or inattentive sy
mptoms
that cause impairment must have been present before age 7 years, although
many individuals are diagnosed after the symptoms have been present for a number
of years, especially in the case of individuals with the Predominantly Inattenti
ve
Type (Criterion B). Some impairment from the symptoms must be present in at leas
t
two settings (e.g., at home and at school or work) (Criterion C). There must be
dear
evidence of interference with developmentally appropriate social, academic, or o
ccupational
functioning (Criterion D). The disturbance does not occurexdusively during
the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psycho
tic
Disorder and is not better accounted for by another mental disorder (e.g., a Moo
d Disorder,
Anxiety Disorder, Dissociative Disorder, or Personality Disorder) (Criterion E).
Inattention may be manifest in academic, occupational, or social situations. Ind
ividuals
with this disorder may fail to give close attention to details or may make carel
ess
mistakes in schoolwork or other tasks (Criterion Ala). Work is often messy and
performed carelessly and without considered thought. Individuals often have diff
iculty
sustaining attention in tasks or play acth'ities and often find it hard to persi
st
with tasks until completion (Criterion Alb). They often appear as if their mind
is elsewhere
or as ifthey are not listening or did not hear what has just been said (Criterio
n
Ale). There may be frequent shifts from one uncompleted activity to another. ind
ividuals
diagnosed with this disorder may begin a task, move on to another, then tum
to yet something else, prior to completing anyone task.....They often do not fol
low
through on requests or instructions and fail to complete schoolwork, chores, or
other
duties (Criterion AId). Failure to complete tasks should be considered in making
this
diagnosis only if it is due to inattention as opposed to other possible reasons
(e.g.,
failure to understand instructions, defiance). These individuals often ha\'e dif
ficulties
organizing tasks and activities (Criterion Ale). Tasks that require sustained me
ntal
effort are experienced as unpleasant and markedly aversive. As a result, these i
ndividuals
typically avoid or have a strong dislike for activities that demand sustained
self-application and mental effort or that require organizational demands or dos
e
concentration (e.g., homework or paperwork) (Criterion ~
1f). This avoidance must
be due to the person's difficulties with attention and not due to a primary oppo
sitional
attitude, although secondary oppositionalism may also occur. Work habits are oft
en
disorganized and the materials necessary for doing the task are often scattered,
lost, or carelessly handled and damaged (Criterion Alg). Individuals with this d
isor
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
dec are easily distracted by irrelevant stimuli and frequently interrupt ongoing
tasks
to attend to trivial noises or events that are usually and easily ignored by oth
ers (e.g.,
a car honking, a background conversation) (Criterion Alh). They are often forget
ful
in daily activities (e.g., missing appoinhnents, forgetting to bring hmch) (Crit
erion
AIi). In social situations, inattention may be expressed as frequent shifts in c
onversation,
not listening to others, not keeping one's mind on conversations, and not follow
ing
details or rules of games or acti\,jties.
Hyperactivity may be manifested by fidgetiness or squirming in one's seat (Crite
rion
Ala), by not remaining scated when expected to do so (Criterion Alb), by excessi
ve
numing or climbing in situations where it is inappropriate (Criterion A2c), by h
aving
difficulty playing or engaging quietly in leisure activities (Criterion A2d), by
appear~
ing to be often "on the go" or as if "driven by a motor" (Criterion A2e), or by
talking
excessively (Criterion A2f). Hyperactivity may vary with the individual's age an
d developmental
level, and the diagnosis should be made cautiously in yOlmg children.
Toddlers and preschoolers with this disorder differ from normally active young c
hildren
by being constantly on the go and into everything; they dart back and forth, are
"out of the door before their coat is on," jump or climb on furniture, run throu
gh the
house, and have difficulty participating in sedentary group activities in presdl
ool
classes (e.g., listening to a story). School-age children display similar behavi
ors but
usually with less frequency or intensity than toddlers and preschoolers. TIley h
ave
difficulty remaining seated, get up frequently, and squirm in, or hang on to the
edge
of, their seat. They fidget with objects, tap their hands, and shake their feet
or legs excessively.
They often get up from the table during meals, while watching television,
or while doing homework; they talk excessively; and they make excessive noise du
ring
quiet activities. in adolescents and adults, symptoms of hyperactivity take the
form of feelings of restlessness and difficulty engaging in quiet sedentary acti
vities.
Impulsivity manifests itself as impatience, difficulty in delaying responses, bl
urting
out answers before questions have been completed (Criterion A2g), difficulty
awaiting one's tum (Criterion A2h), and frequently interrupting or intruding on
others
to the point of causing difficulties in social, academic, or occupational settin
gs
(Criterion A2i). Others may complain that they cannot get a word in edgewise. in
dividuals
with this disorder typically make comments out of tum, fail to listen to directi
ons,
initiate conversations at inappropriate times, interrupt others excessively,
intrude on others, grab objects from others, touch things they are not supposed
to
touch, and clown around. Impulsivity may lead to accidents (e.g., knocking over
objects,
banging into people, grabbing a hot pan) and to engagement in potentially danger
ous
activities without consideration of possible consequences (e.g., repeatedly
climbing to precarious positions or riding a skateboard over extremely rough ter
rain).
Attenlional and behavioral manifestations usually appear in multiple contexts, i
ncluding
home, school, work, and social situations. To make the diagnosis, some impairmen
t
must be present in at least hvo settings (Criterion C). It is very unusual for
an individual to display the same level of dysfunction in all settings or within
the
same setting at all times. Symptoms typically worsen in situations that require
sustained
attention or mental effort or that lack intrinsic appeal or novelty (e.g., liste
ning
to classroom teachers, doing class assigrunents, listening to or reading lengthy
matE'rials,
or working on monotonous, repetitive tasks). Signs of the disorder may be
minimal or absent when the person is receiving frequent rewards for appropriate
Attention-Deficit/Hyperactivity Disorder
behavior, is under close supervision, is in a no\'el setting, is engaged in espe
cially interesting
activities, or is in a one-to-one situation (e.g., the clinician's office). The
symptoms are more likely to occur in group situations (e.g., in playgroups, clas
srooms,
or work environments). The clinician should therefore gather information from mu
ltiple
sources (e.g., parents, teachers) and inquire about the individual's behavior in
a variety
of situations within each setting (e.g., doing homework, having meals).
Subtypes
Although many individuals present with symptoms of both inattention and h)'perac
tivity-
impulsivity, there are individuals in whom one or Ule other pattem is predominan
t.
The appropriate subtype (for a current diagnosis) should be indicated
based on the predominant symptom pattern for the past 6 months.
314.01 Attention-DeficitlHyperactivity Disorder, Combined Type. Thissubtype
should be used ifsix (or more) symptoms of inattention and six (or more)
symptoms of hyperactivity-impulsivity have persisted for at least 6 months.
Most children and adolescents with the disorder have the Combined Type. It
is not known whether the same is true of adults with the disorder.
314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly lnatlentive
Type. This subtype should be used if six (or more) symptoms of inattention
(but fewer than six symptoms of hyperactivity-impulsivity) have persisted for
at least 6 months. Hyperactivity may still be a significant clinical feature in
many
such cases, whereas other cases are more purely inattentive.
314.01 Atlention-DefidtfHyperactivity Disorder, Predominantly Hyperactive-
Impulsive Type. This subtype should be used if six (or more) symptoms
of hyperactivity-impulsivity (but fewer than six symptoms of inattention)
have persisted for at least 6 months. Inattention may often still be a Significa
nt
clinical feature in such cases.
Recording Procedures
Individuals who at an earlier stage of the disorder had the Predominantly Inatte
ntive
Type or the Predominantly Hyperactive-Impulsive Type may go on to develop the Co
mbined
Type and vice versa. The appropriate subtype (for a current diagnosis) should be
indicated on the basis of the predominant symptom pattern for the past 6 months.
U
clinically Significant symptoms remain but criteria are no longer met for any of
the
subtypes, the appropriate diagnosis is Attention-Deficit/Hyperactivity Disorder,
In
Partial Remission. When an individual's symptoms do not currently meet full crit
eria
for the disorder and it is unclear whether criteria for the disorder have previo
usly
been met, Attention-Deficit/Hyperactivity Disorder Tot Otherwise Specified shoul
d
be diagnosed.
Associated Features and Disorders
Associated descriptive features and mental disorders. Associated features vary
depending on age and developmental stage and may include low frustration toleran
ce,
temper outbursts, bossiness, stubbornness, excessive and frequent insistence
Disorders Usually First Diagnosed in Infancy,
Childhood. or Adolescence
that requests be met, mood lability, demoralization, dysphoria, rejection by pee
rs,
and poor self-esteem. Academic achievement is often markedly impaired and devalu
ed,
typically leading to conflict with the family and with school authorities. Inade
quate
self-application to tasks that require sustained effort is often interpreted by
others as indicating laziness. a poor sense of responsibility. and oppositional
beha\'
ior. Family relationships are often characterized by resentment and antagonism,
especially
because variability in the individual's symptomatic status often leads others
to believe that all the troublesome behavior is willful. Family discord and nega
tive
parent-child inter,lctions are often present. Such negative interactions often d
iminish
with successful treatment. On average, indh'iduals with Attention-Deficit/Hypera
ctivity
Disorder obtain less schooling than their peers and have poorer vocational
achievement. Also, on average, inteUectuallevel. as assessed by indh'iduallQ tes
ts,
is several points lower in children with this disorder compared with peers. At t
he
same time, great variability in IQ is evidenced: individuals with Attention-Defi
cit!
Hyperactivity Disorder may show intellectual development in the above-average or
gifted range. In its severe form, the disorder is markedly impairing, affecting
social,
familial, and scholastic adjustment. All three subtypes are associated with sign
ificant
impairment. Academic deficits and school-related problems tend to be most pronou
nced
in the types marked by inattention (Predominantly Inattentive and Combined
Types), whereas peer rejection and, to a lesser extent, accidental injury are mo
st
salient in the types marked by hyperactivity and impulsivity (Predominantly Hype
ractive-
lmpulsive and Combined Types). Individuals with the Predominantly lnallentive
Type tend to be socially passive and appear to be neglected, rather than rejecte
d,
by peers.
A substantial proportion (approximately half) of clinic-referred children with A
.ttention-
Deficit/H)'Peractivity Disorder also have Oppositional Defiant Disorder or
Conduct Disorder. The rates of Co-DCcurrence of Attention-Deficit/Hyperactivity
Disorder with these other Disruptive Behavior Disorders are higher than with oth
er
mental disorders, and this co-occurrence is most likely in the hvo subtypes mark
ed
by hyperacti\'ity-impulsivity (Hyperactive-lmpulsh'e and Combined Types). Other
associated disorders include Mood Disorders, Anxiety Disorders, Learning Disorde
rs,
and Communication Disorders in children with Attention-Deficit/Hyperacti\ity
Disorder. Although Attention-Deficit/Hyperactivity Disorder appears in at least
50% of clinic-referred individuals with Touretle's Disorder, most individuals wi
th
Attention-Deficit/Hyperactivity Disorder do not have accompanying Tourette's Dis
order. When the h\'O disorders coexist, the onset of the Attention-Deficit/Hyper
acti\
ity Disorder often precedes the onset of the Tourelte's Disorder.
There may be a history of child abuse or neglect, multiple foster placements, ne
u
rotoxin exposure (e.g., lead poisoning), infections (e.g., encephalitis), drug e
"posure
in utero, or Mental Retardation. Although low birth weight may sometimes be asso
ciated
with Atlention-Defidt/H)rperactivit)' Disorder, most children with low birth
weight do not develop Attention-Deficit/Hyperactivity Disorder, and most childre
n
with Attention-Deficit/Hyperactivity Disorder do not have a history of low birth
weight.
Associated laboratory findings. There are no laboratory tests, neurological asse
ssments,
or attentional assessments that have been established as diagnostic in the clin
Attenti0n-DeficitlHyperactivity Disorder
ieal assessment of Attention-Deficit/Hyperactivity Disorder. Tests that require
effortful mental processing have been noted to be abnormal in groups of individu
als
with Attention-Deficit/Hyperactivity Disorder compared with peers, but these tes
ts
are not of demonstrated utility when one is trying to determine whether a partic
ular
individual has the disorder. It is not yet known what ftmdamental cognitive defi
cits
are responsible for such group differences.
Associated physical examination findings and general medical conditions.
There are no specific physical features associated with Attention-Deficit/Hypera
ctivity
Disorder, although minor physical anomalies (e.g., hypertelorism, highly arched
palate, low-set ears) may occur at a higher r..ate than in the general populatio
n. There
may also be a higher rate of accidental physical injury.
Specific Culture, Age, and Gender Features
Attention-Deficit/Hyperactivity Disorder is known to occur in various cultures,
with
variations in reported prevalence among '"'''estern countries probably arising m
ore
from different diagnostic practices than from differences in clinical presentati
on.
It is difficult to establish this diagnosis in children younger than age 4 or 5
years,
bC(:ause their characteristic behavior is much more variable than that of older
children
and may include features that are similar to symptoms of Attention-Deficit/
Hyperactivity Disorder. Furthermore, symptoms of inattention in toddlers or pres
chool
children arc oftcn not readily observed because young children typically
experience few demands for sustained attention. However, cvcn the attention of
toddlers can be held in a variety of situations (e.g., the avcrage 2-or 3-year-o
ld child
can typically sit with an adult looking through picture books). Young childrcn w
ith
Attention-Deficit/Hyperactivity Disorder move excessively and typically are diff
icult
to contain. Inquiring about a wide variety of behaviors in a young child may be
helpful in ensuring that a full clinical picture has been obtained. Substantial
impairment
has been demonstrated in preschool-age children with Attention-Deficit/
Hyperactivity Disorder. In school-age children, symptoms of inattention affect c
lassroom
work and academic performance. Impulsive symptoms may also lead to the
breaking of familial, interpersonal, and educational rules. Symptoms of Attentio
nDeficit/
Hyperactivity Disorder are typically at their most prominent during the elementa
ry
grades. As children mature, symptoms usually become less conspicuous. By
late childhood and early adolescence, signs of excessive gross motor activity (e
.g., excessive
running and climbing, not remaining seated) are less common, and hyperactivity
symptoms may be confined to fidgetiness or an inner feeling of jitteriness or
restlessness. In adulthood, restlessness may lead to difficulty in participating
in sedentary
activities and 10 avoiding pastimes or occupations that provide limited opportun
ity
for spontaneous movement (e.g., desk jobs). Social dysfunction in adults
appears to be especially likely in those who had additional concurrent diagnoses
in
dilldhood. Caution should be exercised in making the diagnosis of Attention-Defi
cit/
Hyperactivity Disorder in adults solely on the basis of the adult's recall of be
ing inattentive
or hyperactive as a child, because the validity of such retrospective data is
often problematic. Although supporting infomlat"ion may not always be available,
corroborating information from other informants (including prior school records)
is
helpful for improving the accuracy of Ihe diagnosis.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
The disorder is more frequent in males than in females, with male-la-female rati
os
ranging from 2:1 to 9:1, depending on the type (i.e., the Predominantly Inattent
ive Type
may have a gender ratio that is less pronounced) and setting (Le., clinic-referr
ed dilldren
are morc likely to be male).
Prevalence
The prevalence of Attention-Deficit/Hyperactivity Disorder has been estimated al
3%-7% in school-age children. These reported rail'S vary depending on the nature
of
the population sampled and the method of ascertainment. Data on prevalence in .1
dolescence
and adulthood are limited. Evidence suggests that the prevalence of Attention-
Deficit/Hyperactivity Disorder as defined in DSM-IV may be somewhat greater
than the prevalence of the disorder based on DSM-III-R criteria because of the i
nclusion
of the Predominantly Hyperactive-Impulsive and Predominantly Inattentive
Types (which would have been diagnosed as Attention-Deficit Hyperactivity Disord
er
Not Otherwise Specified in DSM-III-R).
Course
Most parents first observe excessive motor activity when the children are toddle
rs,
frequently coinciding with the development of independent locomotion. However,
because many overactive toddlers will not go on to develop Attention-Deficit/
Hyperactivity Disorder, special attention should be paid to differentiating nonn
al
overactivity from the hyperactivity characteristic of Attention-Deficit/Hyperact
ivity
Disorder before making this diagnosis in early years. Usually, the disorder is f
irst diagnosed
during elementary school years, when school adjustment is compromised.
Some children with the Predominantly Inattentive Type may not come to clinical a
t
tention lmtillate childhood. In the majority of cases seen in clinical settings,
the disorder
is relatively stable through early adolescence. In most individuals, symptoms
(particularly motor hyperactivity) attenuate during late adolescence and adultho
od,
although a minority experience the full complement of symptoms of Attention-Defi
cit/
Hyperactivity Disorder into mid-adulthood. Other adults may retain only some
of the symptoms, in which case the diagnosis of Attention-Deficit/Hyperactivity
Disorder,
In Partial Remission, should be used. The latter diagnosis applies to individual
s
who no longer have the full disorder but still retain some symptoms that cauSl.'
functional impairment.
Familial Pattern
Attention-Deficit/Hyperactivity Disorder has been fOWld to be more common in the
first-degree biological relatives of children with Atlenlion-Deficil/ Hyperactiv
ity Disorder
than in the general population. Considerable evidence attests to the strong infl
uence
of genetic factors on levels of hyperactivity, impulsivity, and inattention as
measured dimensionally. However, family, school, and peer influences are also cr
ucial
in determining the extent of impairments and comorbidity. Studies also suggest
that there is a higher prevalence of Mood and Anxiety Disorders, Learning Disord
ers,
Substance-Related Disorders, and Antisocial Personality Disorder in family membe
rs
of individuals with Attention-Deficit/Hyperactivity Disorder.
Attentian-DeficitiHyperactivity Disorder
Differential Diagnosis
In early childhood, it may be difficult to distinguish symptoms of Attention-Def
icit/
Hyperactivity Disorder from age-appropriate behaviors in active children (e.g.,
running
arOlmd or being noisy).
Symptoms of inattention are common among children with low IQ who are placed in
academic settings that are inappropriate to their intellectual ability. These be
haviors must
be distinguished from similar signs in clilldren with Attention-Deficit/Hyperact
ivity
Disorder. In children with Mental Retardation, an additional diagnosis ofAttenti
on-Defidt/
Hyperactivity Disorder should be made only if the symptoms of inattention or hyp
eractivity
are excessive for the child's mental age. Inattention in the classroom may also
occur when children with high inteUigenceare placed in academically understimula
ting
environments. Attention-Deficit/Hyperactivity Disorder must also be distinguishe
d
from difficulty in goal-dire<:ted behavior in children from inadequate, disorgan
ized, or
chaotic environments. Thorough hislories of symptom pattern obtained from multip
le
informants (e.g., baby-sitters, grandparents, or parents of playmates) are helpf
ul in providing
a confluence of observations concerning the child's inattention, hyperactivity,
and
capacity for developmentally appropriate self-regulation in various settings.
Individuals with oppositional behavior may resist work or school tasks that requ
ire
self-application because of an unwillingness to conform to others' demands. Thes
e
s}'mptoms must be differentiated from the avoidance of school tasks seen in indi
viduals
with Attention-Deficit/Hyperactivity Disorder. Complicating the differential
diagnosis is the fact Ihat some individuals with Attention-Deficit/Hyperactivity
Disorder
develop secondary oppositional attitudes toward such tasks and devalue their
importance, often as a rationalization for their failure.
The increased motor activity that may occur in Attention-Defidt/Hyperacti\'ity
Disorder must be distinguished from the repetitive motor behavior that character
izes
Stereotypic Movement Disorder. In Stereotypic Movement Disorder, the motor be
havior is generally focused and fixed (e.g., body rocking, self-bitingt whereas
the
fidgetiness and restlessness in Attention-Deficit/Hyperactivity Disorder are mor
e
t>'Pically generalized. Furthermore, individuals with Stereotypic Movement Disor
der are not generally overactive; aside from the stereotypy, they may be lUldera
clive.
Attention-Deficit/Hyperactivity Disorder is not diagnosed if the symptoms are be
tter
accounted for by another mental disorder (e.g., Mood Disorder [especially Bipola
r Dis
orderj, Anxiety Disorder, Dissociative Disorder, Personality Disorder, Personali
ty
Change Due to a General Medical Condition, or a Substance-Related Disorder). In
all
these disorders, the symptoms of inattention typically have an onset after age 7
years, and
the childhood history of school adjustment generally is not characterized by dis
rupti\'e
behavior or teacher complaints conceming inattentive, hyperactive, or impulsive
behav
ior. When a Mood Disorder or Anxiety Disorder CO-OCCUr5 with Attention-Deficit/
Hypefilctivity Disorder, each should be diagnosed. Attention-Deficit/Hyperactivi
ty Dis
order is not diagnosed if the symptoms of inattention and hyperactivity occur ex
clusively
during the course of a Pervasive Developmental Disorder or a Psychotic Disorder.
Symptoms of inattention, hyperactivity, or impulsivity related to the use of med
ication
(e.g., broncllOdilators, isoniazid, akathisia from neuroleptics) in children bef
ore age 7
years are not diagnosed as Attention-Deficit/Hyperactivity Disorder but instead
are di
agnosed as Other Substance-Related Disorder Not Othenvise Specified.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Diagnostic criteria for
Attention-Deficit/Hyperactivity Disorder
A.
Either (1) or (2):
(1)
six (or more) of the following symptoms of inattention have persisted for at
least 6 months to a degree that is maladaptive and inconsistent with development
al
level:
.
Inattention
(a)
often fails to give close attention to details or makes careless mistakes in
schoolwork. work. or other activities
(b)
often has difficulty sustaining attention in tasks or play activities
(c)
often does not seem to listen when spoken to directly
(d)
often does not follow through on instructions and fails to finish school
work. chores, or duties in the workplace (not due to oppositional behavior
or failure to understand instructions)
(e)
often has difficulty organizing tasks and activities
(f)
often avoids, dislikes, or is reluctant to engage in tasks that require sustaine
d
mental effort (such as schoolwork or homework)
(g)
often loses things necessary for tasks or activities (e.g., toys, school assignm
ents,
pencils. books. or tools)
(h)
is often easily distracted by extraneous stimuli
(i)
is often forgetful in daily activities
(2)
six (or more) of the following symptoms of hyperactivity-impulsivity have
persisted for at least 6 months to a degree that is maladaptive and inconsistent
with developmental level:
Hyperactivity
(a)
often fidgets with hands or feet or squirms in seat
(b)
often leaves seat in classroom or in other situations in which remaining
seated is expected
(c)
often runs about or climbs excessively in situations in which it is inappropriat
e
(in adolescents or adults. may be limited to subjective feelings of
restlessness)
(d)
often has difficulty playing or engaging in leisure activities quietly
(e)
is often "on the go" or often acts as if "driven by a motor"
(f)
often talks excessively
Impulsivity
(g)
often blurts out answers before questions have been completed
(h)
often has difficulty awaiting turn
(i)
often interrupts or intrudes on others (e.g., butts into conversations or
games)
B.
Some hyperactive-impulsive or inattentive symptoms that caused impairment were
present before age 7 years.
C.
Some impairment from the symptoms is present in t\vo or more settings (e.g. at
school (or work] and at home).
314.9 Attention-Deficit/Hyperactivity Disorder
Not Otherwise Specified
Diagnostic criteria for
Attention-Deficit/Hyperactivity Disorder (continued)
D.
There must be clear evidence of clinically significant impairment in social, aca
demic,.
or occupational functioning.
E.
The symptoms do not occur exclusively during the course of a Pervasive Developme
ntal
Disorder. Schizophrenia. or other Psychotic Disorder and are not better accounte
d
for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociat
ive
Disorder, or a Personality Disorder).
Code based on type:
314.01 Attention-DeficitlHyperactivity Disorder, Combined Type:
if both Criteria Aland A2 are met for the past 6 months
314.00 Attention.DeficitIHyperactivity Disorder, Predominantly
Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for
the past 6 months
314.01 Attention.DeficitIHyperactivity Disorder. Predominantly
Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met
for the past 6 months
Coding note: For individuals (especially adolescents and adults) who currently h
ave
symptoms that no longer meet full criteria, "In Partial Remission" should be spe
cified.
314.9 Attention-Deficit/Hyperactivity Disorder
Not Otherwise Specified
Thiscategory is for disorders with prominent symptoms of inattention or hyperact
ivityimpulsi\
rity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder.
Examples include
1.
lndividuaJs whose symptoms and impairment meet the criteria for AttentionDeficit
/
Hyperactivity Disorder. Predominantly Inattentive Type but whose age
at onset is 7 years or after ~
2.
Individuals with clinically significant impairment who present with inattention
and whose symptom pattern does not meet the full criteria for the disorder but
have a behavioral pattern marked by sluggishness, daydreaming, and hypoactivHy
Conduct Disorder
Diagnostic Features
The essential feature of Conduct Disorder is a repetitive and persistent pattern
of
behavior in which the basic rights of others or major age-appropriate societal n
orms
or rules are violated (Criterion A). These behaviors fall into four main groupin
gs:
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
aggressive conduct that causes or threatens physical harm to other people or ani
mals
(Criteria AI-A7), nonaggressive conduct that causes property loss or damage (Cri
teria
A8-A9), deceitfulness or theft (Criteria AIG-A12), and serious violations of rul
es
(Criteria Al3-A15). Truee (or more) characteristic behaviors must have been pres
ent
during the past 12 months, with at least one behavior present in the past 6 mont
hs.
The disturbance in behavior causes clinically significant impairment in social,
academic,
or occupational functioning (Criterion B). Conduct Disorder may be diagnosed
in individuals who are older than age 18 years, but only if the criteria for
Antisocial Personality Disorder are not met (Criterion C). The behavior pattern
is
usually present in a variety of settings such as home, school, or the community.
Because individuals with Conduct Disorder are likely to minimize their conduct
problems, the clinician often must rely on additional infonnants. However, the i
nformant's
knowledge of the child's conduct problems may be limited by inadequate
supervision or by the child's not having revealed them.
Children or adolescents with this disorder often initiate aggressive behavior an
d
react aggressively to others. They may display bullying, threatening, or intimid
ating
behavior (Criterion AI); initiate frequent physical fights (Criterion Al); use a
weapon
that can cause serious physical harm (e.g., a bat, brick, broken bottle, knife,
or gun)
(Criterion A3); be physically cruel to people (Criterion A4) or animals (Criteri
on AS);
steal while confronting a victim (e.g., mugging, purse snatching, extortion, or
armed
robbery) (Criterion A6); or force someone into sexual activity (Criterion A7). P
hysical
violence may take the fonn of rape, assault, or, in rare cases, homicide.
Deliberate destruction of others' property may include deliberate fire setting w
ith
the intention of causing serious damage (Criterion AS) or deliberately destroyin
g other
people's property in other ways (e.g., smashing car windows, school vandalism)
(Criterion A9).
Acts of deceitfulness or theft may include breaking into someone else's house,
building, or car (Criterion AIO); frequently lying or breaking promises to obtai
n
goods or favors or to avoid debts or obligations (e.g., "conning" other people)
(Criterion
All); or .stealing items of nontrivial value without confronting the victim (e.g
.,
shoplifting, forgery) (Criterion AI2).
There may also be serious violations of rules (e.g., school. parental) by indivi
duals
with this disorder. Children with this disorder often have a pattern, beginning
before
age 13 years, of staying out late at night despite parental prohibitions (Criter
ion An).
There may be a pattern of running away from home overnight (Criterion AI4). To b
e
considered a symptom of Conduct Disorder, the numing away must have occurred
at least twice (or only once if the individual did not return for a lengthy peri
od). Runaway
episodes that occur as a direct consequence of physical or sexual abuse do not
typicany qualify for this criterion. Children with this disorder may often be tr
uant
from school, beginning prior to age 13 years (Criterion AI5). In older individua
ls, this
behavior is manifested by often being absent from work without good reason.
Subtypes
Two subtypes of Conduct Disorder are provided based on the age at onset of the d
isorder
(i.e., Childhood-Onset Type and Adolescent-Onset Type). The subtypes differ
in regard to the characteristic nature of the presenting conduct problems, devel
op
Conduct Disorder
mental course and prognosis, and gender ratio. Both subtypes can occur in a mild
,
moderate, or severe form. In assessing the age at onset, information should pref
erably
be obtained from the youth and from caregiver(s). Because many of the behaviors
may be concealed, caregivers may underreport symptoms and overestimate the age
at onset.
312.81 ChildhoodOnset Type. This subtype is defmed by the onset of at
least one criterion characteristic ofConduct Disorder prior to age 10 years. Ind
ividuals
with Childhood-Onset Type are usually male, frequently display
physical aggression toward others, have disturbed peer relationships, may
have had Oppositional Defiant Disorder during early childhood, and usually
have symptoms that meet full criteria for Conduct Disorder prior to puberty.
Many children with this subtype also have concurrent Attention-Deficit/
Hyperactivity Disorder. Individuals with Childhood-0nsel Type are more
likely to have persistent Conduct Disorder and to develop adult Antisocial
Personality Disorder than are those with Adolescent-Onset Type.
312.82 Adolescent-Onset Type. This subtype is defined by the absence of
any criteria characteristic of Conduct Disorder prior to age 10 years. Compared
with those with the Childhood-0nset Type, these indi\'iduals are less
likel)' to display aggressive behaviors and tend to have more normative peer
relationships (although they often display conduct problems in the company
of others). These individuals are less likely to have persistent Conduct Dis
order or to develop adult Antisocial Personality Disorder. The ratio of males
10 females with Conduct Disorder is lower for the Adolescent...Qnsel Type than
for the Childhood-0nset Type.
312.89 Unspecified Onset. This subtype is used if the age at onset of Conduct
Disorder is unknown.
Severity Specifiers
Mild. Few if any conduct problems in excess of those required to make the
diagnosis are present, and conduct problems cause relatively minor harm to
others (e.g., lying, truancy, staying out after dark without permission).
Moderate. The number of conduct problems and the effect on others are intermedia
te
between "mild" and "severe" (e.g., stealing \\~ithout
confronting a
victim, vandalism).
Severe. Many conduct problems in excess of those required to make the di
agnosis are present, or conduct problems cause considerable harm to others
(e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting
a victim, breaking and entering).
Associated Features and Disorders
Associated descriptive features and mental disorders. Individuals with Conduct
Disorder may have little empathy and little concern for the feelings, wishes, an
d wellbeing
of others. Especially in ambiguous situations, aggressive individuals with this
disorder frequently misperceive the intentions of others as more hostile and thr
eatening
than is the case and respond with aggression that they then feel is reasonable a
nd
--.
Disorders Usually First Diagnosed in Infancy,
96
Childhood, or Adolescence
justified. They may be callous and lack appropriate feelings of guilt or remorse
. It can
be difficult to evaluate whether displayed remorse is genuine because some of th
ese
individuals leam that expressing guilt may reduce or prevent punishment. Individ
uals
with this disorder may readily inform on their companions and try to blame other
s
for their own misdeeds. Self-esteem may be low, despite a projected image of
"tougluless." For other individuals, measured self'esteem may be overly inflated
.
Poor frustration tolerance, irritability, temper outbursts, and recklessness are
frequent
associated features. Accident rates appear to be higher in individuals with Cond
uct
Disorder than in those without it.
Conduct Disorder is often associated with an early onset of sexual behavior,drin
king,
smoking. use of illegal substances, and reckless and risktaking acts. lllcgal dru
g
use may increase the risk that Conduct Disorder will persist. Conduct Disorder b
ehaviors
may lead to school suspension or expulsion, problems in work adjuslmen~
legal difficulties, sexually transmilled diseases, unplanned pregnancy, and phys
ical
injury from accidents or fights. These problems may preclude attendance in ordin
ary
schools or living in a parental or foster home. Suicidal ideation, suidde attemp
ts, and
completed suicide occur at a higherthan~expected
rale. Conduct Disorder may beassodated
with lower~than~averageintelligence, particularly with regard to verballQ.
Academic achievement, particularly in reading and other verbal skills, is often
belO\l'
the level expected on the basis of age and intelligence and may justify the addi
tional
diagnosis of a Learning or Communication Disorder. Attention-Defidt/Hyperacth-
ity Disorder is common in children with Conduct Disorder. Conduct Disorder ma),
also be associated with one or more of the follOWing mental disorders: Learning
Viiorders,
Anxiety Disorders, Mood Disorders, and Substance-Related Disorders. The
foUowing factors may predispose the individual to the development of Conduct Vii
order:
parental rejection and neglect, difficult infant temperament, inconsistent child
rearing practices with harsh discipline, physical or sexual abuse, lack of super
vision.
early institutional living, frequent changes of caregivers, large family size, h
istory of
maternal smoking during pregnancy, peer rejection, association with a delinquent
peer group, neighborhood exposure to violence, and certain kinds of familial ps}
"chopatholog}'
(e.g., Antisocial Personality Disorder, Substance Dependence or Abuse).
Associated laboratory findings. In some studies, lower heart rate and lower skin
conductance have been noted in individuals with Conduct Disorder compared with
those without the disorder. However, levels of physiological arousal are not dia
gnostic
of the disorder.
Specific Culture, Age, and Gender Features
Concerns have been raised that the Conduct Disorder diagnosis may at times be mi
sapplied
to individuals in settings where patterns of undesirable behavior are sometimes
viewed as protective (e.g., threatening. impoverished, high-crime). Consislmi
with the DS~l-lV
definition of mental disorder, the Conduct Disorder diagnosis
should be applied only when the behavior in question is symptomatic of an underl
ying
dysfunction within the individual and not simply a reaction to the immediatt
social context. Moreover, immigrant youth from war-ravaged countries who hawa
history of aggressive behaviors that may have been necessary for their survival
in tNt
Conduct Disorder
context would not necessarily warrant a diagnosis of Conduct Disorder. It may be
helpful for the clinician to consider the social and economic context in which t
he undesirable
behaviors have occurred.
Symptoms of the disorder vary with age as the individual develops increased
physical strength, cognitive abilities, and sexual maturity. Less severe behavio
rs (e.g.,
lying, shoplifting, physical fighting) tend to emerge first, whereas others (e.g
., burglary)
tend to emerge later. Typically, the most severe conduct problems (e.g., rape,
theft while confronting a victim) tend to emerge last. However, there are wide d
ifferences
among individuals, with some engaging in the more damaging behaviors at an
early age (which is predictive of a worse prognosis).
Conduct Disorder, especially the Childhood-Onset Type, is more common in
males. Gender differences are also found in specific types of conduct problems.
Males
with a diagnosis of Conduct Disorder frequently exhibit fighting, stealing, vand
alism,
and school discipline problems. Females with a diagnosis of Conduct Disorder
are more likely to exhibit lying, truancy, running away, substance use, and pros
titution.
Whereas confrontational aggression is more often displayed by males, females
tend to use more nonconfrontational behaviors.
Prevalence
The prevalence of Conduct Disorder appears to have increased over the last decad
es
and may be higher in urban than in Nral settings. Rates vary widely depending on
the nature of the population sampled and methods of ascertairunent. General popu
lation
studies report fates ranging from less than 1% to more than 10%. Prevalence
rates are higher among males than females. Conduct Disorder is one of the most f
requently
diagnosed conditions in outpatient and inpatient mental health facilities for
children.
Course
The onset of Conduct Disorder may occur as early as the preschool years, but the
first
Significant s}'mptoms usually emerge during the period from middle childhood
through middle adolescence. Oppositional Defiant Disorder is a common precursor
to the Childhood-Onset Type of Conduct Disorder. Onset is rare after age 16 year
s.
The course of Conduct Disorder is variable. In a majority of individuals, the di
sorder
remits by adulthood. However, a substantial proportion continue to show behavior
s
in adulthood that meet criteria for Antisocial Personality Disorder. Many indivi
duals
with Conduct Disorder, particularly those with Adolescent-Onset Type and those
with few and milder symptoms, achieve adequate social and occupational adjustmen
t
as adults. Early onset predicts a worse prognosis and an increased risk in adult
life for Antisocial Personality Disorder and Substance-Related Disorders. Indivi
duals
with Conduct Disorder are at risk for later Mood Disorders, Anxiety Disorders, S
omatofonn
Disorders, and Substance-Related Disorders.
Familial Pattern
Estimates from twin and adoption studies show that Conduct Disorde.r is influenc
ed
by both genetic and environmental factors. The risk for Conduct Disorder is incr
eased
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
in children with a biological or adoptive parent with Antisocial Personality Dis
order
or a sibling with Conduct Disorder. The disorder also appears to be more common
in
children of biological parents wilh Alcohol Dependence, Mood Disorders, or Schiz
ophrenia
or biological parents who have a history of Attention-Deficit/Hyperactivity
Disorder or Conduct Disorder.
Differential Diagnosis
Although Oppositional Defiant Disorder includes some of the features observed in
Conduct Disorder (e.g., disobedience and opposition to authority figures), it do
es not
include the persistent pattern of the more serious forms of behavior in which ei
ther
the basic rights of others or age-appropriate societal norms or rules are violat
ed.
When the individual's pattern of behavior meets the criteria for both Conduct Di
sorder
and Oppositional Defiant Disorder, the diagnosis of Conduct Disorder takes prece
dence
and Oppositional Defiant Disorder is not diagnosed.
Although children with Attention-DeficitIHyperactivity Disorder often exhibit
h)-peractive and impulsive behavior that may be disruptive, this behavior does n
ot
by itself violate age-appropriate societal norms and therefore does not usually
meet
criteria for Conduct Disorder. When criteria are met for both Attention-Defidt/H
yperactivity
Disorder and Conduct Disorder, both diagnoses should be given.
Irritability and conduct problems often occur in children or adolescents with a
Mood Disorder. These can usually be distinguished from the pattern of conduct
problems seen in Conduct Disorder based on the episodic course and accompanying
symptoms characteristic of the Mood Disorder. If criteria for both are met, diag
noses
of both Conduct Disorder and the Mood Disorder can be given.
The diagnosis of Adjustment Disorder (With Disturbance of Conduct or With
Mixed Disturbance of Emotions and Conduct) should be considered if clinically si
gnificant
conduct problems that do not meet the criteria for another specific disorder
develop in clear association with the onset of a ps)'chosocial stressor. Isolate
d conduct
problems that do not meet criteria for Conduct Disorder or Adjustment Disorder m
ay
be coded as Child or Adolescent Antisocial Behavior (see "Additional Conditions
That May Be a Focus of Clinical Attention," p. 740). Conduct Disorder is diagnos
ed
only if the conduct problems represent a repetitive and persistent pattern that
is associated
with impairment in social, academic, or occupational functioning.
Diagnostic criteria for Conduct Disorder
A.
A repetitive and persistent pattern of behavior in which the basic rights of oth
ers or
major age-appropriate societal norms or rules are violated, as manifested by the
presence of three (or more) of the following criteria in the past 12 months. wit
h at
least one criterion present in the past 6 months:
Aggression to people and animals
(1)
often bullies. threatens, or intimidates others
(2)
often initiates physical fights
(3)
has used a weapon that can cause serious physical harm to others (e.g., a bat,
brick, broken bottle, knife. gun)
Conduct Disorder
Diagnostic criteria for Conduct Disorder (continued)
(4)
has been physically cruel to people
(5)
has been physically cruel to animals
(6)
has stolen while confronting a victim (e.g., mugging, purse snatching, extortion
,
armed robbery)
(7) has forced someone into sexual activity
Destruction of property
(8)
has deliberately engaged in fire setting with the intention of causing serious
damage
(9)
has deliberately destroyed others' property (other than by fire setting)
Deceitfulness or theft
(10) has broken into someone else's house, building, or car
(11)
often lies to obtain goods or favors or to avoid obligations (i.e., "cons" other
s)
(12) has stolen items of nontrivial value without confronting a victim (e.g., sh
oplifting,
but without breaking and entering; forgery)
Serious violations of rules
(13)
often stays out at night despite parental prohibitions, beginning before age 13
yea~
(14) has run away from home overnight at least t...tfice while living in parenta
l or parental
surrogate home (or once without returning for a lengthy period)
(15)
is often truant from school, beginning before age 13 years
8.
The disturbance in behavior causes clinically significant impairment in social,
academic,
or occupational functioning.
C.
If the individual is age 18 years or older, criteria are not met for Antisocial
Personality
Disorder.
Code based on age at onset:
312.81 Conduct Disorder, ChildhoodOnset Type: onset of at least one
criterion characteristic of Conduct Disorder prior to age 10 years
312.82 Conduct Disorder, AdolescentOnset Type: absence of any criteria
characteristic of Conduct Disorder prior to age 10 years
312.89 Conduct Disorder, Unspecified Onset: age at onset is not known
Specify severity:
Mild: few if any conduct problems in excess of those required to make the diagno
sis
and conduct problems cause only minor harm to others
Moderate: number of conduct problems and effect on others intermediate between
"mild-and "'severe-
Severe: many conduct problems in excess of those required to make the diagnosis
or conduct problems cause considerable harm to othe~
For ifldividuals over age 18 years, a diagnosis of Conduct Disorder can be given
only ifthe criteria are not also met for Antisocial Personality Disorder. The di
agnosis
of Antisocial Personality Disorder cannot be given to individuals under age 18 y
ears.
Disorders Usually First Diagnosed in Infancy,
1,00
Childhood. or Adolescence
313.81 Oppositional Defiant Disorder
Diagnostic Features
The essential feature of Oppositional Defiant Disorder is a recurrent pattern of
negativistic,
defiant, disobedient. and hostile behavior toward authority figures that persist
s
for at least 6 months (Criterion A) and is characterized by the frequent
occurrence of at least four of the following behaviors: losing temper (Criterion
Al).
arguing with adults (Criterion A2), actively defying or refusing to comply with
the
requests or rules of adults (Criterion A3), deliberately doing things thai will
annoy
other people (Criterion A4), blaming others for his or her own mistakes or misbe
havior
(Criterion AS), being touchy or easily annoyed. by others (Criterion A6), being
angry
and resentful (Criterion A7), or being spiteful or vindictive (Criterion AS). To
qualify for Oppositional Defiant Disorder, the behaviors must occur more frequen
tly
than is typically observed in individuals of comparable age and developmental le
vel
and must lead to significant impairment in social, academic, or occupational fun
ctioning
(Criterion B). The diagnosis is not made if the disturbance in behavior occurs
exclusively during the course of a Psychotic or 1l.lood Disorder (Criterion C) or
if criteria
are met for Conduct Disorder or Antisocial Personality Disorder (in an individ
ual over age 1S years).
Tegativistic and defiant behaviors are expressed by persistent ShJbbornness, res
is
tance to directions, and unwillingness to compromise, give in, or negotiate with
adults or peers. Defiance may also include deliberate or persistent testing of l
imits,
usually by ignoring orders, arguing, and failing to accept blame for misdeeds. H
ostility
can be directed at adults or peers and is shown by deliberately annoying others
or by verbal aggression (usually without the more serious physical aggression se
en
in Conduct Disorder). Manifestations of the disorder are almost invariably prese
nt in
the home setting, but may not be evident at school or in the communit)'. Symptom
s
of the disorder are typically more evident in interactions with adults or peers
whom
the individual knows weU, and thus may not be apparent during clinical examinati
on.
Usually individuals with this disorder do not regard themselves as oppositional
or defiant, but justify their behavior as a response to unreasonable demands or
circumstances.
Associated Features and Disorders
Associated features and disorders vary as a function of the individual's age and
the
severity of the Oppositional Defiant Disorder. In males, the disorder has been s
hown
to be more prevalent among those who, in the preschool years, have problematic t
emperaments
(e.g., high reactivity, difficulty being soothed) or high motor activity_ During
the school years, there may be low selfesteem (or overly inflated self-esteem),
mood lability, low frustration tolerance, swearing, and the precocious use of al
cohol,
tobacco, or illicit drugs. There are often conflicts with parents, teachers, and
peers.
There may be a vicious cyde in which the parent and chi.ld bring out the worst i
n each
other. Oppositional Defiant Disorder is more prevalent in families in which chil
d care
is disrupted by a succession of different caregivers or in families in which har
sh,
313.81 Oppositional Defiant Disorder
inconsistent, or neglectful child~rearing
practices are common. Attention-Deficit/
Hyperactivity Disorder is common in children with Oppositional Defiant Disorder.
learning Disorders and Communication Disorders also tend to be associated with
Oppositional Defiant Disorder.
Specific Age and Gender Features
Because transient oppositional behavior is very common in preschool children and
in
adolescents, caution should be exercised in making the diagnosis of Oppositional
Defiant
Disorder especially during these developmental periods. The number of opposition
al
symptoms tends to increase with age. The disorder is more prevalent in males
than in females before puberty, but the rates appear to be equal after puberty.
Symptoms
are generally similar in each gender, except that males may have more confrontat
ional
behavior and more persistent symptoms.
Prevalence
Rates of Oppositional Defiant Disorder from 2% to 16% have been reported, depend
ing
on the nature of the population sample and methods of ascertainment.
Course
Oppositional Defiant Disorder usually becomes evident before age 8 years and usu
ally
not later than earl)' adolescence. The oppositional symptoms often emerge in the
home setting but over time may appear in other settings as welL Onset is typical
ly
gradual, usually occurring over the course of months or years. In a significant
proportion
of cases, Oppositional Defiant Disorder is a developmental antecedent to Conduct
Disorder. Although Conduct Disorder, Childhood-Onset Type is often preceded
by Oppositional Defiant Disorder, many children with Oppositional Defiant Disord
er
do not subsequently develop Conduct Disorder.
Familial Pattern
Oppositional Defiant Disorder appears to be more common in families in which at
least one parent has a history of a Mood Disorder, Oppositional Defiant Disorder
,
Conduct Disorder, Attention-Deficit/Hyperactivity Disorder, Antisocial Personali
ty
Disorder, or a Substance-Related Disorder. in addition, some studies suggest tha
t
mothers with a Depressive Disorder are more likely to have children with opposit
ional
behavior, but it is unclear to what extent maternal depression results from or c
auses
oppositional beha\'ior in children. Oppositional Defiant Disorder is more common
in
families in which there is serious marital discord.
Differential Diagnosis
The disruptive behaviors of individuals with Oppositional Defiant Disorder are o
f
a less senre nature than those of individuals with Conduct Disorder and typicall
y do
not include aggression toward people or animals, destruction of property, or a p
at
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
tern of theft or deceit. Because aU of the features of Oppositional Defiant Diso
rder are
usually present in Conduct Disorder, Oppositional Defiant Disorder is not diagno
sed
if the criteria are met for Conduct Disorder. Oppositional behavior is a common
associated feature of Mood Disorders and Psychotic Disorders presenting in
children and adolescents and should not be diagnosed separately if the symptoms
occur
exclusively during the course of a Mood or Psychotic Disorder. Oppositional
behaviors must also be distinguished from the disruptive behavior resulting from
inattention
and impulsivity in AttentionOeficitiHyperactivity Disorder. When the
two disorders co-occur, both diagnoses should be made. In individuals with Menta
l
Retardation, a diagnosis of Oppositional Defiant Disorder is given only if the o
ppositional
behavior is markedly greater than is commonly observed among individuals
of comparable age, gender, and severity of Mental Retardation. Oppositional Defi
ant
Disorder must also be distinguished from a failure to follow directions that is
the result
of impaired language comprehension (e.g., hearing loss, Mixed ReceptiveExpressiv
e
Language Disorder). Oppositional behavior is a typical feature of certain
developmental stages (e.g., early childhood and adolescence). A diagnosis of Opp
ositional
Defiant Disorder should be considered only if the behaviors occur more frequentl
y
and have more serious consequences lhan is typically observed in other
individuals of comparable developmental stage and lead to significant impairment
in
social, academic, or occupational functioning. New onset of oppositional behavio
rs
in adolescence may be due to the process of normal individuation.
Diagnostic criteria for
313.81 Oppositional Defiant Disorder
A.
A pattern of negativistic, hostile, and defiant behavior lasting at least 6 mont
hs, during
which four (or more) of the following are present:
(1)
often loses temper
(2)
often argues with adults
(3)
often actively defies or refuses to comply with adults' requests or rules
(4)
often deliberately annoys people
(5)
often blames others for his or her mistakes or misbehavior
(6)
is often touchy or easily annoyed by others
(7)
is often angry and resentful
(8)
is often spiteful or vindictive
Note: Consider a criterion met only if the behavior occurs more frequently than
is
typically observed in individuals of comparable age and developmental level.
B.
The disturbance in behavior causes clinically significant impairment in social,
academic,
or occupational functioning.
C.
The behaviors do not occur exclusively during the course of a Psychotic or Mood
Dis
order.
D.
Criteria are not met for Conduct Disorder, and, if the individual is age 18 year
s or old
er, criteria are not met for Antisocial Personality Disorder.
312.9 Disruptive Behavior Disorder Not Otherwise Specified
312.9 Disruptive Behavior Disorder
Not Otherwise Specified
This category is for disorders characterized by conduct or oppositional defiant
behaviors
that do not meet the criteria for Conduct Disorder or Oppositional Defiant Disor
der.
For example, include clinical presentations that do not meet full criteria eithe
r
for Oppositional Defiant Disorder orConduct Disorder, but in which there is clin
ically
Significant impairment.
Feeding and Eating Disorders of
Infancy or Early Childhood
The Feeding and Eating Disorders of Infancy or Early Childhood are characterized
by
persistent feeding and eating disturbances. The specific disorders included are
Pica,
Rumination Disorder, and Feeding Disorder of Infancy or Early Childhood. late th
at
Anorexia 'ervosa and Bulimia 'ervosa are included in the "Eating Disorders" sect
ion
(see p. 583).
307.52 Pica
Diagnostic Features
The essential feature of Pica is the eating of one or more nonnutritive substanc
es on a
persistent basis for a period. of at least 1 month (Criterion A). The typical su
bstances
ingested tend to vary' with age. Infants and younger children typically eat pain
t. pIaster,
string, hair, or doth. Older children may eat animal droppings, sand, insects,
lea\'es, or pebbles. Adolescents and adults may consume clay orsoil. There is no
aversion
to food. This behavior must be developmentally inappropriate (Criterion B) and
not part of a culturally sanctioned practice (Criterion C). The eating of nonnut
ritive
substances is an associated feature of other mental disorders (e.g., Pervasive D
evelopmental
Disorder, Mental Retardation). Ii the eating behavior occurs exclusively
during the course of another mental disorder, a separate diagnosis of Pica shoul
d be
made only if the eating behavior is sufficiently severe to warrant independent c
linical
attention (Criterion D).
Associated Features and Disorders
Pica is frequently associated with Mental Retardation and Pen'ash'e Developmenta
l
Disorders. Although vitamin or mineral deficiencies (e.g., zinc) have been repor
ted in
some instances, usually no specific biological abnormalities are found. In some
cases,
Pica comes to clinical attention only following general medical complications (e
.g.,
lead poisoning as a result of ingesting paint or paint-soaked plaster. mechanica
l bowel
problems, intestinal obstruction as a result of hair ball hlmors, intestinal per
foration,
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
or infections such as toxoplasmosis and toxocariasis as a result of ingesting fe
ces or
dirt). Poverty, neglect, lack of parental supervision, and developmental delay i
ncrease
the risk for the condition.
Specific Culture, Age, and Gender Features
In some cultures, the eating of dirt or other seemingly nonnutritive substances
is believed
to be of value. Pica is more commonly seen in young children and occasionally
in pregnant females.
Prevalence
Epidemiological data on Pica are limited. Among individuals with Mental Retardat
ion,
the prevalence of the disorder appears to increase with the severity of the reta
rdation
(e.g., it has been reported to be as high as 15% in adults with Severe Mental
Retardation).
Course
Pica may have its onset in infancy. In most instances, the disorder appears to l
ast for
several months and then remits. It may occasionally continue into adolescence or
, less
frequently, into adulthood. In individuals with Mental Retardation, the behavior
may
diminish during adulthood.
Differential Diagnosis
Before approximately ages 18-24 months, mouthing and sometimes eating of nonnutr
itive
substances are relatively common and do not imply the presence of Pica. Pica
is diagnosed only when the behavior is judged to be persistent (i.e., present fo
r at least
1 month) and inappropriate given the individual's developmental level. Eating of
nonnutritive substances may occur during the course of other mental disorders (e
.g.,
in a Pervasive Developmental Disorder, in Schizophrenia as a result of delusiona
l
beliefs, and in Kleine-levin syndrome). In such instances, an additional diagnos
is of
Pica should be given only if the eating behavior is sufficiently severe to warra
nt independent
clinical attention. Pica can be distinguished from other eating disorders
(e.g., Rumination Disorder, Feeding Disorder of Infancy or Early Childhood, Anor
exia
I ervosa, and Bulimia Nen'osa) by the consumption of nonnutrith'e substances.
307.53 Rumination Disorder
Diagnostic criteria for 307.52 Pica
A.
Persistent eating of nonnutritive subrtances for a period of at least 1 month.
B.
The eating of nonnutritive subrtances is inappropriate to the developmental leve
l.
C.
The eating behavior is not part of a culturally sanctioned practice.
D.
If the eating behavior occurs exclusively during the course of another mental di
sorder
(e.g., Mental Retardation, Pervasive Developmental Disorder, Schizophrenia), it
is sufficiently severe to warrant independent clinical attention.
307.53 Rumination Disorder
Diagnostic Features
The essential feature of Rumination Disorder is the repeated regurgitation and r
echewing
of food occurring after feeding that develops in an infant or child after a peri
od
of normal functioning and lasts for at least 1 month (Criterion A). Partially
digested food is brought up into the mouth without apparent nausea, retching, di
sgust,
or associated gastrointestinal disorder. The food is then either ejected from th
e
mouth or, more frequently, chewed and reswallowed. The symptoms are not due to
an associated gastrointestinal or other general medical condition (e.g., Sandife
r'ssyndrome,
esophageal renux) (Criterion B) and do not occur exclusively during the
course of Anorexia Nervosa or Bulimia Nervosa. If the symptoms occur exclusively
during the course of Mental Retardation or a Pen'asive Developmental Disorder,
they must be sufficiently severe to warrant independent clinical attention (Crit
erion
C). The disorder is most commonJ}' obsen'ed in infants but may be seen in older
individuals,
particularly those who also have Mental Retardation. lnfants with the disorder
display a characteristic position of straining and arching the back with the hea
d
held back, make sucking movements with their tongues, and give the impression of
gaining satisfaction from the activity.
Associated Features and Disorders
Infants with Rumination Disorder are generally irritable and hungry between epis
odes
of regurgitation. Although the infant is apparently hungry and ingests large
amounts of food, malnutrition may occur because regurgitation immediately follow
s
the feedings. Weight loss, failure to make expected weight gains, and even death
can
result (with mortality rates as high as 25% reported). Malnutrition appears to b
e less
likely in older children and adults in whom the disorder may be either continuou
s or
episodic. Psychosocial problems such as lack of stimulation, neglect, stressful
life situations,
and problems in the parent-child relationship may be predisposing factors.
Understimulation of the infant may result if the caregiver becomes discouraged a
nd
alienated because of the unsuccessful feeding experiences or the noxious odor of
the
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
regurgitated material. In some instances, Feeding Disorder of Infancy or Early C
hildhood
may also develop. in older children and adults, Mental Retardation is a predispo
sing
factoT.
Prevalence
Rumination Disorder appears 10 be uncommon. It may occur more often in males
than in females.
Course
The onset of Rumination Disorder may occur in the context of developmental delay
s.
The age at onset is between ages 3 and 12 months, except in individuals with Men
tal
Retardation in \\'hom the disorder may occur at a somewhat later developmental
stage. In infants, the disorder frequently remits spontaneously. In some severe
cases,
however, the course is continuous.
Differential Diagnosis
In infants. congenital anomalies (e.g., pyloric stenosis or gastroesophageal ref
lux) or
other general medical conditions (e.g., infections of the gastrointestinal syste
m) can
cause regurgitation of food and should be ruled out by appropriate physical exam
inations
and laboratory tests. Rumination can be distingujshed from normal vomiting
of early infancy by the apparently voluntary nature of the rumination (e.g., obs
ervation
of characteristic preparatory movements followed by regurgitation and sucking
or chewing movements that appear to be pleasurable). Rumination Disorder is not
diagnosed if the symptoms occur exclusively during the course of Anorexia Tervos
a
or Bulimia Nervosa.
Diagnostic criteria for 307.53 Rumination Disorder
A.
Repeated regurgitation and rechewing of food for a period of at least 1 month fo
l
lowing a period of normal functioning.
B.
The behavior is not due to an associated gastrointestinal or other general medic
al
condition (e.g. esophageal reflux).
C.
The behavior does not occur exclusively during the course of Anorexia Nervosa or
Bu
limia Nervosa. If the symptoms occur exclusively during the course of Mental Ret
ardation
or a Pervasive Developmental Disorder, they are sufficiently severe to warrant
independent clinical attention.
307.59 Feeding Disorder of Infancy or Early Childhood
307.59 Feeding Disorder of Infancy or
Early Childhood
Diagnostic Features
The essential feature of Feeding Disorder of Infancy or Early Childhood is the p
ersistent
failure to eat adequately, as renected in significant failure to gain weight or
significant
weight loss over at least 1 month (Criterion A). There is no gastrointestinal or
other general medical condition (e.g., esophageal reflux) severe enough to accou
nt for
the feeding disturbance (Criterion B). The feeding disturbance is also not bette
r accounted
for by another Mental Disorder (e.g., Rumination Disorder) or by lack of
available food (Criterion C). The onset of the disorder must be before age 6 yea
rs (Criterion
D).
Associated Features and Disorders
Associated descriptive features and mental disorders. Infants with feeding disor
ders
may be more irritable and difficult to console during feeding than infants
without feeding disorders. They may appear apathetic and withdra\\'n and may als
o
exhibit developmental delays. In some instances, parenH::hild interaction proble
ms
may contribute to or exacerbate the infant's feeding problem (e.g., presenting f
ood inappropriately
or responding to the infant's food refusal as if it were an act of aggression
or rejection). Inadequate caloric intake may exacerbate the associated features
(e.g., irritability, developmental lags) and further contribute to feeding diffi
culties.
Factors in the infant that may be associated with the condition include temperam
ental
characteristics or intrauterine growth retardation and preexisting developmental
impairments that make the infant less responsive. Other factors that may be asso
ciated
with the condition include parental ps}'chopathoiogy and child abuse or neglect
Associated laboratory findings. There may be nonspecific findings associated wit
h
the malnutrition that is sometimes seen with Feeding Disorder of infancy or Earl
y
Childhood (e.g., anemia and low serum albumin and total protein).
Associated physical examination findings and general medical conditions.
There may be malnutrition that, in severe cases, can be life threatening in Feed
ing
Disorder of Infancy or Early Childhood.
Specific Age and Gender Features
A later onset (e.g., age 2 or 3 years rather than infancy) is associated with le
sser degrees
of developmental delay and malnutrition, although growth retardation may be
observed. Feeding Disorder of Infancy or Early Childhood is equalJy common in
males and females.
Prevalence
Of all pediatric hospital admissions, 10/0-5% are for failure to thrive, and up
to onehalf
of these may reflect feeding disturbances without any apparent predisposing
Disorders Usually First Diagnosed in Infancy,
Childhood. or Adolescence
general medical condition. Data from community samples suggest a point prevalenc
e
of around 3% for failure to thrive.
Course
Feeding Disorder of Infancy or Early Childhood commonly has its onset in the fir
st
year of life, but may have an onset in children ages 2-3 years. The majority of
children
have improved growth after variable lengths of time, although they remain shorte
r
and lighter up through adolescence compared with children who did not experience
growth failure.
Differential Diagnosis
Minor problems in feeding are common in infancy. The diagnosis of Feeding Disord
er
of Infancy or Early Childhood should be made only if the eating problem results
in significant failure to gain weight or loss of weight.
This disorder is not diagnosed if the feeding disturbances are fully explained b
y a
gastrointestinal, endocrinological, or neurological condition. Children with an
underlying
general medical condition may be more difficult to feed, and the diagnosis
of Feeding Disorder of Infancy or Early Childhood should not be made in such cas
es
unless the degree of disturbance is of greater severity than would be expected o
n the
basis of the general medical condition alone. The diagnosis is suggested if ther
e is impro\'
ement in feeding and weight gain in response to changing caregivers.
Diagnostic criteria for
307.59 Feeding Disorder of Infancy or Early Childhood
A.
Feeding disturbance as manifested by persistent failure to eat adequately with s
ignificant
failure to gain weight or significant loss of weight over at least 1 month.
8.
The disturbance is not due to an associated gastrointestinal or other general me
dical
condition (e.g., esophageal reflux).
C.
The disturbance is not better accounted for by another mental disorder (e.g., Ru
mination
Disorder) or by lack of available food.
D.
The onset is before age 6 years.
Tic Disorders
Four disorders are included in this section: Tourette's Disorder, Chronic Motor
or Vocal
Tic Disorder, Transient Tic Disorder, and Tic Disorder I ot Othem'ise Specified.
A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or
vocalization. Motor and vocal tics may be simple (involVing only a few muscles o
r
Tic Disorders 1091
simple soWlds) or complex (involving multiple groups of muscles recruited. in or
chestrated
bouts or words and sentences). Examples of simple motor tics are eye blinking,
nose wrinkling, neck jerking, shoulder shrugging, facial grimacing, and abdomina
l
tensing. These tics usually last less than several hundred milliseconds. Complex
motor
tits include hand gestures, jumping, touching, pressing, stomping, fadal contort
ions,
repeatedly smelling an object, squatting, deep knee bends, retracing steps, twir
ling
when walking, and assuming and holding unusual postures (including "dystonic
ticsn such as holding the neck in a particular tensed position). These tics are
longer in
duration, lasting seconds or longer. Copropraxia (a sudden, lie-like vulgar, sex
ual, or
obscene gesture) and mirror phenomena such as echopraxia (involWltary, spontaneo
us
imitation of someone else's movements) are complex motor Iics.
Simple vocal tics are meaningless sounds such as tluoat clearing, grunting, snif
fing,
snorting, and chirping. Complex vocal/ics more clearly involve speech and langua
ge
md include the sudden, spontaneous expression of single words or phrases; speech
blocking; sudden and meaningless changes in the pitch, emphasis, or volume of
speech; palilalia (repeating one's own sounds or words); and echolalia (repeatin
g the
last-heard sound, word, or phrase). Coprolalia is the sudden, inappropriate expr
essionof
a socially unacceptable word or phrase and may include obscenities as well as
specific etlmic, racial, or religious slurs. Coprolalia is found in fewer than 1
0% of individuals
with a tic disorder.
Tics generally are experienced as irresistible but can be suppressed for varying
lengths of time. Some children (and an occasional adult) are not aware of their
tics.
Howe\er, with development, many (but not all) persons with ties experience a prem
onitory
urge-a rising tension or somatic sensation in a part of the body that precedes
the motor or vocal tic, and a feeling of relief or tension reduction following t
he
expression of the tic. lndividuals with tics may feel that the tic is between "v
oluntary"
and "involuntary" in that it is often experienced as a giving in to a mounting t
ension
or bodily need, similar to the tension that precedes a sneeze or the almost irre
sistible
need to scratch an itch. An individual may feel the need to perform a complex ti
c in
a specific way or repeatedly until he or she achieves the feeling that the tic h
as been
done "just right." Only then will the individual experience a reduction in the a
nxiety
or tension.
Tics are often emitted in bouts of one or several tics; the bouts are separated
by periods
of nontic behavior lasting from seconds to hours. Tics generally change in se\
erily (frequency of tics, forcefulness, and the degree tics disrupt ongoing behav
ior)
during the course of hours and over the course of a day. Tics may vary in freque
ncy
and disruptiveness in different contexts. For example, children and adults may b
e
better able to suppress tics when in school, at work, or in the physician's offi
ce than
at home. Tics generally decrease or stop during sleep, although some individuals
ha\'e occasional tics while asleep or awaken suddenl}' with a tic. Tics are ofte
n more
frequent when a person relaxes in private (e.g., when watching television) and a
re decreased
when the individual engages in directed, effortful activity (e.g., reading or
sewing). Tics may be exacerbated during periods of stress, such as when there ar
e
heightened work pressures or during examinations.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adofescence
Differential Diagnosis
Tic Disorders must be distinguished from other types of abnormal movements that
may accompany general medical conditions (e.g., Huntington's disease, stroke,
Lesch-Nyhan syndrome, Wilson's disease, Sydenham's chorea, multiple sclerosis,
postviral encephalitis, head injury) and from abnormal movements that are due to
the direct effects of a substance (e.g., a neuroleptic medication). Taking accou
nt of
the medical and family history, movement morphology, rhythm, and modifying in
fluences can assist in making a correct diagnosis. Chorea typically is a simple,
ran
dom, irregular, and nonstereotyped. movement that has no premonitory component
and increases when the person is distracted. Dystonic movements are slow, protra
cted
twisting movements interspersed with prolonged states of muscular tension.
Athetoid movements are slow, irregular, writhing movements, most frequently in
the fingers and toes but often involving the neck. Myoclonic movements are brief
,
simple, shocklike muscle contractions that may affect parts of muscles or muscle
gTOUpS. Unlike tics, myoclonic movements may continue during sleep. Hemiballismi
c
movements are intermittent, coarse, largeamplitude, unilateral movements of
the limbs. Spasms are stereotypic, prolonged movements involving the same groups
of muscles that are usually slower but are sometimes more rapid than tics. Hemi
facial spasm consists of irregular, repetitive, unilateral jerks of facial muscl
es. Syn.
kinesis is an involuntary movement that is concurrent exclusively with a speciJi
(
vohUltary act (e.g., movement of the comer of the mouth when the person intends
to
close the eye).
When the tics are a direct physiological consequence of medication use, a Medica
tion
lnduced Movement Disorder lot Othenvise Specified would be diagnosed m.
stead of a Tic Disorder (e.g., in the clearest case, when the tics occur with th
e use of a
medication and stop when the medication is discontinued). In some cases, certain
medications (e.g., stimulants) may exacerbate a preexisting Tic Disorder, in whi
ch
case no additional diagnosis of a medication-induced disorder is necessary.
Tics must also be distinguished from Stereotypic Movement Disorder and stereotyp
ies
in Pervasive Developmental Disorders. Differentiating simple tics (e.g., eye
blinking) from the complex movements characteristic of stereotyped movements is
relatively straightforward. The djstinction between complex motor tics and stere
otyped
movements is less clearcut. In general, stereotyped movements appear to be
more driven, rhythmic, self-stimulating or soothing, and intentional, whereas ti
cs
have a more involuntary quality (although some individuals describe tics as havi
ng
a voluntary component) and generally occur in temporal bouts or clusters. Comple
x
tics may be difficult to distinguish from compulsions (as in Obsessive-Compulsi\
'e
Disorder); making this distinction is all the more challenging because ObsessiwC
ompulsive
Disorder is common in individuals with Tic Disorders. Compulsions are
performed in response to an obsession (e.g., hand washing to allay a concern abo
ut
germs) or according to rules that must be applied rigidly (e.g., the need to lin
e things
up in a specific order). Compulsions typically are more elaborate than tics and
are
more likely to resemble "normal" behavior. \oVhereas compulsions are often, thou
gh
not always, preceded by a persistent worry or concern, tics are more likely to b
e preceded
by a transient "physical" tension in a part of the body (e.g., in the nose or sh
oulder
muscles or in the throat) that is reduced by the tic. When individuals manifest
307.23 lourette's Disorder 111 I
symptoms of both Obsessive-Compulsive Disorder and a Tic Disorder (especially
Tourctte's Disorder). both diagnoses may be warranted. Certain vocal or motor ti
cs
(e.g., barking, echolalia, palilalia) must be distinguished from disorganized or
catatonic
behavior in Schizophrenia.
The Tic Disorders can be distinguished from one another based on duration and
variety of tics and age at onset. Transient Tic Disorder includes motor andlor v
ocal
tics lasting for at least -l weeks but for no longer than 12 consecutive months.
Touretle's Disorder and Chronic Motor or Vocal Tic Disorder each have a duration
of more than 12 months, but Touretle's Disorder requires multiple motor tics and
at
least one vocal tic during part of this time. Often, the diagnosis may change ov
er time
during the natural history of a Tic Disorder. For example, during the first mont
hs, a
child may be diagnosed as having a Transient Tic Disorder. After a year, with fu
rther
lies and longer duration, the diagnosis may become Tourette's Disorder. Tic Diso
rder
Not Othenvise Specified would be appropriate for clinically significant presenta
tions
lasting less than 4 weeks, for presentations with an age at onset above age 18
years, and for the unusual case of an individual with only one motor tic and onl
y one
vocal tic.
307.23 laurette's Disorder
Diagnostic Features
Theessential features ofTDurette's Disorderare multiple motor ticsand oneor more
,ocal tics (Criterion A). These may appear simullaneously or at different periods
during the illness. The tics occur many times a day, recurrently throughout a pe
riod
of more than 1 year. During this period, there is never a tic-free period of mor
e than
3 consecutive months (Criterion B). The onset of the disorder is before age 18 y
ears
(Criterion C). The ties are not due to the direct physiological effects of a sub
stance
(e.g., stimulants) or a general medical condition (e.g., Huntington's disease or
postviral
encephalitis) (Criterion D).
The anatomical location, number, frequency, complexity, and severity of the tics
change over time. Simple and complex motor tics may affect any part of the body,
including
the face, head, lorso, and upper and lower limbs. Simple motor tics are rapid,
meaningless contractions of one or a few muscles, such as eye blinking. Complex
motor
ties involving touching, squatting, deep knee bends, retracing steps, and twirli
ng
when walking may be present. The vocal tics include various words or sounds such
as dicks, grunts, yelps, barks, sniffs, snorts, and coughs. Coprolalia, a comple
x vocal
lie involving the uttering of obscenities, is present in only a small minority o
f individuals
(less than 10%) and is not required for a diagnosis of Tourette's Disorder.
In approximately one-half of the individuals with this disorder, the first sympt
oms
to appear are bouts of a single tic, most frequently eye blinking. Less frequent
ly, initial
tics involve another part of the face or the body, such as facial grimacing, hea
d
jerking, tongue protrusion, sniffing, hopping, skipping, throat dearing, stutter
inglike
block in speech fluency. or uttering sounds ocwords. Sometimes this disorder beg
ins
with multiple symptoms starting at the same time.
Disorders Usually First Diagnosed in Infancy,
1112 Childhood, or Adolescence
Associated Features and Disorders
The most common associated symptoms of Tourette's Disorder are obsessions and
compulsions. Hyperactivity, distractibility, and impulsivity are also relatively
common.
Social discomfort, shame, self-consciousness, and demoralization and sadness
frequently occur. Persistent motor and vocal tics may cause a broad range of dis
tress
and impairment, ranging from none to severe. Younger children, in particular, ma
y
be unaware of their tics, suffer no distress, and show no impairment in any area
of
functioning. A high percentage of children, adolescents, and adults with Tourett
e's
Disorder do not seek medical attention for their tics. At the otherend of the sp
ectrum,
there are indi\'iduals with Tourette's Disorder who are burdened by intrusive, r
ecurrent,
forceful, and social1y stigmatizing motor and vocal tics.
Social, academic, and occupational functioning may be impaired because of reject
ion
by others or anxiety about haVing tics in social situations. Chronic tic symptom
s
can cause considerable distress and can lead to social isolation and personality
changes.
In severe cases of Tourette's Disorder, the tics rna}' directly interfere with d
aily activities
(e.g., conversing, reading, or writing). Rare complications of Tourette's Disord
er
include physical injury, such as blindness due to self-inflicted eye injury (fro
m head
banging or eye gouging), orthopedic problems (from knee bending, neck jerking, o
r
head turning), skin problems (from picking or lip licking), and neurological seq
uelae
(e.g., from disc disease related to many years of forceful neck movements). The
severity
of the tics may be exacerbated by administration of central nervous system stimu
lants,
such as those used in the treatment of Attention-Deficit/Hyperactivity
Disorder, although some individuals can tolerate these medications without an ex
acerbation
of their tics or may even have a reduction in tics. Obsessive-Compulsive Disorde
r
and Attention-Deficit/Hyperactivity Disorder often co-occur in individuals
with Tourette's Disorder. Attentional problems or obsessive symptomatology may
precede or follow the onset of tics. Obsessive-compulsive symptoms found in indi
viduals
with Tourette's Disorder may constitute a specific subtype of ObsessiveCompulsi\
"
e Disorder. This subtype appears to be characterized by an earlier age at
onset, male preponderance, higher frequency of certain obsessive-compulsive S}'I
l1ptoms
(more aggressive symptoms and less concern about contamination and hoarding),
and poorer response to pharmacotherapy with selective serotonin reuptake
inhibitors. Disruptive behavior, impulsiveness, and social immaturity are promin
ent
features in those children and adolescents who also have Attention-Deficit/Hyper
activity
Disorder. These clinical features may interfere with academic progress and
interpersonal relationships and lead to greater impairment than that caused by t
he
Tourette's Disorder.
Specific Culture and Gender Features
Tourette's Disorder has been widely reported in diverse racial and ethnic groups
. Although
in clinical settings the disorder is diagnosed approximately three to five times
more often in males than in females, the gender ratio is perhaps as low as 2:1 i
n community
samples.
307.23 Taurette's Disorder
Prevalence
The prevalence of Tourette's Disorder is related to age. Many more children (5-3
0 per
10,(00) are affected than adults (1-2 per 10,000).
Course
The age at onset of Tourette's Disorder may be as early as age 2 years, is usual
ly during
childhood or early adolescence, and is by definition before age 18 years. The me
dian
age at onset for motor tics is about 6-7 years. The duration of the disorder may
be lifelong, though periods of remission lasting from weeks to years may occur.
In
most cases, the severity, frequency, disruptiveness, and variability of the symp
toms
diminish during adolescence and adulthood. In other cases, the symptoms aCluaU}'
disappear entirely, usually by early adulthood. In a few cases, the symptoms may
worsen in adulthood. The predictors of this course are not known.
Familial Pattern
The vulnerability to Tourette's Disorder and related disorders is transmitted wi
thin
families and appears to be genetic. The mode of genetic transmission, however, i
s not
known. Pedigree studies suggest that there are genes of major effect. Although s
ome
early studies suggested a pattern of transmission that is consistent wHh an auto
somal
dominant pattern, other studies suggest a more complex mode of transmission. "Vu
lnerability"
implies that the child receives the genetic or constitutional basis for developi
ng
a Tic Disorder; the precise type or severity of disorder may be different from
one generation to another and is modified by nongenetic factors. Not e\'eryone w
ho
inherits the genetic vulnerability will express symptoms of a Tic Disorder. The
range
of forms in which the vulnerability may be expressed includes Tourette's Disorde
r,
Chronic Motor or Vocal Tic Disorder, and some forms of Obsessive-Compulsive Diso
rder.
It also appears that individuals with Tourette's Disorder are at greater risk fo
r
Attention-Deficit/Hyperactivity Disorder. In some individuals with Tourette's Di
sorder,
there is no evidence of a familial pattern.
Differential Diagnosis
Refer to the "Differential Diagnosis" section for Tic Disorders (p. 110).
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
1114
Diagnostic criteria for 307.23 lourette's Disorder
A.
Both multiple motor and one or more vocal tics have been present at some time du
ring
the illness, although not necessarily concurrently. (A tic is a sudden, rapid, r
ecurrent,
nonrhythmic. stereotyped motor movement or vocalization.)
B.
The tics occur many times a day (usually in bouts) nearly every day or intermitt
ently
throughout a period of more than 1 year, and during this period there was never
a
tic-free period of more than 3 consecutive months.
C.
The onset is before age 18 years.
D.
The disturbance is not due to the direct physiological effects of a substance (e
.g.,
stimulants) or a general medical condition (e.g., Huntington's disease or portvi
ral
encephalitis).
307.22 Chronic Motor or Vocal Tic Disorder
Diagnostic Features
The essential feature of Chronic Malar or Vocal Tic Disorder is the presence of
either
motor tics or vocal tics, but lIot both (Criterion A). This differs from Tourett
e's Disor~
der in which there must be both multiple motor and one or more vocal tics. The o
ther
essential features (Criteria B, C, and D) are the same as for Tourette's Disorde
r. A diagnosis
of Chronic Motor or Vocal Tic Disorder cannot be made if the criteria for
Tourette's Disorder have ever been met (Criterion E). The other characteristics
of
Chronic Motor or Vocal Tic Disorder are generally the same as for Tourette's Dis
order
(see p. 111), except that the severity of the symptoms and the functional impair
ment
are usually much less. It appears that Chronic Motor or Vocal Tic Disorder and
Tourette's Disorder may be genetically related because they often occur in the s
ame
families.
Differential Diagnosis
Refer to the "Differential Diagnosis" section for Tic Disorders (p. 110).
307.21 Transient Tic Disorder
Diagnostic criteria for 307.22 Chronic Motor or
Vocal Tic Disorder
A.
Single or multiple motor or vocal tics (i.e., sudden, rapid, recurrent, nonrhyth
mic,
stereotyped motor movements or vocalizations), but not both, have been present a
t
some time during the illness.
B.
The tics occur many times a day nearly every day or intermittently throughout a
period
of more than 1 year, and during this period there was never a tic-free period of
more than 3 consecutive months.
C.
The onset is before age 18 years.
D.
The disturbance is not due to the direct physiological effects of a substance (e
.g.,
stimulants) or a general medical condition (e.g., Huntington's disease or postvi
ral
encephalitis).
E.
Criteria have never been met for Tourette's Disorder.
307.21 Transient Tic Disorder
Diagnostic Features
The essential feature of Transient Tic Disorder is the presence of single or mul
tiple
motor tics and/or vocall'ics (Criterion A). The tics occw many times a day, near
ly every
day for alleast 4 weeks, but for no longer than 12 consecutive months (Criterion
B). The other essential features (Criteria C and D) are the same as for Towette'
s Dis~
order. Transient Tic Disorder is not diagnosed if the criteria for Tourette's Di
sorder
or Chronic Motor or Vocal Tic Disorder (both of which require a duration of at l
east
1 year) have ever been met (Criterion E). The other characteristics of the disor
der are
generally the same as for Touretle's Disorder (see p. 111), except that the seve
rity of
the symptoms and the functional impairment are usuaUy much less.
Specifiers
The course of Transient Tic Disorder may be indicated by specifying Single Episo
de
or Recurrent.
Differential Diagnosis
Refer 10 the "Differential Diagnosis" section for Tic Disorders (p. 110).
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Diagnostic criteria for 307.21 Transient Tic Disorder
A.
Single or multiple motor andlor vocal tics (i.e. sudden, rapid. recurrent. nonrhy
thmic.
stereotyped motor movements or vocalizations)
B.
The tics occur many times a day, nearly everyday for at least 4 weeks. but for n
o longer
than 12 consecutive months.
C.
The onset is before age 18 years.
D.
The disturbance is not due to the direct physiological effects of a substance (e
.g.
stimulants) or a general medical condition (e.g., Huntington's disease or portvi
ral
encephalitis).
E.
Criteria have never been met for lourette's Disorder or Chronic Motor or Vocal T
ic
Disorder.
Specify if:
Single Episode or Recurrent
307.20 Tic Disorder Not Otherwise Specified
This category is for disorders characterized by tics that do nol meet criteria f
or a spedfic
Tic Disorder. Examples include tics lasting less than 4 weeks or tics with an on
set
after age 18 years.
Elimination Disorders
Encopresis
Diagnostic Features
The essential feature of Encopresis is repeated passage of feces into inappropri
ate
places (e.g.; clothing or floor) (Criterion A). Most often this is involuntary b
ut occasionally
may be intentional. The event must Deem at least once a month for at least
3 months (Criterion B), and the chronological age of the child must be at least
4 years
(orfor children with developmentaldelays,a mentalageofat least4years)(Criterion
q.
The fecal incontinence must not be due exclusively to the direct physiological e
ffects
of a substance (e.g., laxatives) or a general medical condition except through a
mechanism
involving constipation (Criterion D).
''''hen the passage of feces is involuntary rather than intentional, it is often
related
to constipation, impaction, and retention with subsequent overno\\,. The constip
ation
may develop for psychological reasons (e.g., anxiety about defecating in a parti
cular
place or a more general patlem of anxious or oppositional behavior) leading to a
void
Encopresis
ance of defecation. Physiological predispositions to constipation include ineffe
ctual
straining or paradoxical defecation dynamics, with contraction rather than relax
ation
of the external sphincter or pelvic floor during straining for defecation. Dehyd
ration
associated with a febrile illness, hypothyroidism, or a medication side effect c
an also
induce constipation. Once constipation has developed, it may be complicated by a
n
anal fissure, painful defecation, and further fecal retention. The consistency o
f the
stool may vary. In some individuals it may be of nannal or near-normal consisten
cy.
It may be liquid in other individuals who ha\-e overflow incontinence secondary
to
fecal retention.
Subtypes
Encopresis is coded according to the subtype that characterizes the presentation
:
787.6 With Constipation and Overflow Incontinence. There is evidence of
constipation on physical examination (i.e., the presence of tl large stool mass
on abdominal or rectal examination) or a history of a stool frequency of less
than three per week. Feces in overflow incontinence are characteristically (but
not invariably) poorly formed, and leakage can be infrequent to continuous,
occurring mostly during the day and rarely during sleep. Only part of the feces
is passed during toiletting, and the incontinence resolves after treatment of th
e
constipation.
307.7 Without Constipation and Overflow Incontinence. There is no evidence
of constipation on physical examination or by history. Feces are likely to
be of normal form and consistency, and soiling is intermiUent. Feces may be
deposited in a prominent location. This is usually associated with the presence
of Oppositional Defiant Disorder or Conduct Disorder or may be the consequence
of anal masturbation. Soiling without constipation appears to be less
common than soiling with constipation.
Associated Features and Disorders
The child with Encopresis often feels ashamed and may wish to avoid situations (
e.g.,
camp or school) that might lead to embarrassment. The amount of impairment is a
function of the effect on the child's self-esteem, the degree of social ostracis
m by
peers, and the anger, punishment, and rejection on the part of caregivers. Smear
ing
feces may be deliberate or accidental resulting from the child's attempt to dean
or
hide feces that were passed involuntarily. When the incontinence is dearly delib
erate,
features of Oppositional Defiant Disorder or Conduct Disorder may also be presen
t.
Many children with Encopresis and chronic constipation are enuretic and may have
associated \'esico--ureteric reflux and chronic urinary tract infections that ma
y remit
with treatment.
Prevalence
It is estimated that approximately 1% of 5-year-olds have Encopresis, and the di
sorder
is more common in males than in females.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Course
Encopresis is not diagnosed until a child has reached a chronological age of at
least
-1 years (or for children with developmental delays. a mental age of alleasl-l y
ears).
Inadequate, inconsistent toilet training and psychosocial stress (e.g., entering
school
or the birth of a sibling) may be predisposing factors. Two types of course have
been
described: a "primary" type in which the individual has never established fecal
continence,
and a "secondary" type in which the disturbance develops after a period of
established fecal continence. Encopresis can persist with intermittent exacerbat
ions
for years.
Differential Diagnosis
A diagnosis of Encopresis in the presence of a general medical condition is appr
opriateonly
if the mechanism involves functional constipation. Fecal incontinence related
to other general medical conditions (e.g., chronic diarrhea, spina bifida, anal
stenosis)
would not warrant a DSM-IV diagnosis of Encopresis.
Diagnostic criteria for Encopresis
A.
Repeated passage of feces into inappropriate places (e.g.. clothing or floor) wh
ether
involuntary or intentional.
B.
At least one such event a month for at least 3 months.
C.
Chronological age is at least 4 years (or equivalent developmental level).
D.
The behavior is not due exclusively to the direct physiological effects of a sub
stance
(e.g., laxatives) or a general medical condition except through a mechanism invo
lving
constipation.
Code as follows:
787.6 With Constipation and Overflow Incontinence
307.7 Without Constipation and Overflow Incontinence
307.6 Enuresis
(Not Due to a General Medical Condition)
Diagnostic Features
The essential feature of Enuresis is repeated voiding of urine during the day or
at
night into bed or clothes (Criterion A). ~'Iost
often this is involuntary but occasionally
may be intentional. To qualify for a diagnosis of Enuresis, the voiding of urine
must
occur at least hvice per week for at least 3 months or else must cause clinicall
y significant
distress or impairment in social, academic (occupational), or other important
areas of functioning (Criterion B). The individual must have reached an age at w
hich
307.6 Enuresis (Not Due to a General Medical Condition) 119
continence is expected (i.e., the chronological age of the child must be at leas
t 5 years,
or, for children with developmental delays, a mental age of at least 5 years) (C
riterion
C). The urinary incontinence is not due exclusively to the direct physiological
effects
of a substance (e.g., diuretics) or a general medical condition (e.g., diabetes,
spina
bifida, a seizure disorder) (Criterion D).
Subtypes
The situation in which the Enuresis occurs may be noted by one of the following
subtypes:
Nocturnal Only. This is the most common subtype and is defined as passage
of urine only during nighttime sleep. The enuretic event typically occurs during
the first one~third
of the night. Occasionally the voiding takes place during
the rapid eye movement (REM) stage of sleep, and the child may recall a
dream that involved the act of urinating.
Diurnal Only. This subtype is defined as the passage of urine only during
waking hours. Diurnal Enuresis is more common in females than in males and
is W1COnlll10n after age9 years. Individuals with dilunal Enuresis can be divide
d
into two groups. One group with "luge incontinence" has Enuresis characterized
by sudden urge symptoms and detrusor instability on cystometry.
Another group with "voiding postponement" consciously defer micturition
urges lmtil incontinence results, with the deferral sometimes due to a reluctanc
e
to use the toilet because of social anxiety or a preoccupation with school
or play activity. This hitler group has a high rate of symptoms of disruptive be
havior.
The enuretic event most commonly occurs in the early afternoon on
school days.
Nocturnal and Diurnal. This subtype is defined as a combination of the two
subtypes above.
Associated Features and Disorders
The amount of impainnent associated with Enuresis is a function of the Hmitation
on
the child's social activities (e.g., ineligibility for sleep-away camp) or its e
ffect on the
child's self-esteem, the degree of social ostracism by peers, and the anger, pun
ishment,
and rejection on the part of caregivers. Although most children with Enuresis
do not have a coexisting mental disorder, the prevalence of coexisting behaviora
l
symptoms is higher in children with Enuresis than in children without Enuresis.
Developmental
delays, including speech, language, learning, and motor skills delays,
are also present in a portion of children with Enuresis. Encopresis, Sleepwalkin
g Disorder,
and Sleep Terror Disorder may be present. Urinary tract infections are more
common in children with Enuresis, especially the Diurnal Type, than in those who
are
continent. The Enuresis commonly persists after appropriate treatment of an asso
ciated
infection. A number of predisposing factors have been suggested, including delay
ed
or lax toilet training, psychosocial stress, delays in the development of nonnal
circadian rhythms of urine production with resulting nocturnal polyuria or abnor
malities
of central vasopressin receptor sensitivity, and reduced functional bladder
capacities with bladder hyperreactivity (unstable bladder syndrome).
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
\120
Prevalence
The prevalence of Enuresis is around 5%---10% among S'year--olds, 30/0-5% among
10year-
olds, and around 1% among individuals age 15 years or older.
Course
Two types of course of Enuresis have been described: a "primary" type in which t
he
individual has never established urinary continence. and a "secondary" type in
which the disturbance develops after a period of established urinary continence.
By
definition, primary Enuresis begins at age 5 years. The most common time for the
onset
of secondary Enuresis is between the ages of 5and 8 years, but it may occur at a
ny
time. After age 5 years, the rale of spontaneous remission is behveen 5% and 10%
per
year. Most children with the disorder become continent by adolescence, but in ap
proximately
1% of cases the disorder continues into adulthood.
Familial Pattern
Approximately 75% of all children with Enuresis have a first-degree biological r
elative
who has had the disorder. The risk of Enuresis is five-to sevenfold greater in t
he
offspring of a parent who had a history of Enuresis. The concordance for the dis
order
is greater in monozygotic twins than in dizygotic twins. Although molecular gene
tic
anal)'ses have detected links to several chromosomes, no significant association
s between
linkage to a chromosome interval and type of enuresis have been identified.
Differential Diagnosis
The diagnosis of Enuresis is not made in the presence of a neurogenic bladder or
the
presence of a general medical condition that causes polyuria or urgency (e.g'l u
ntreated
diabetes mellitus or diabetes insipidus) orduring an acute urinary tract infecti
on.
However, a diagnosis of Enuresis is compatible with such conditions if urinary
incontinence was reglliarl)' present prior to the development of the general med
ical
condition or if it persists after the institution of appropriate treatment.
Other Disorders of Infancy, Childhood, or Adolescence
Diagnostic criteria for 307.6 Enuresis
A.
Repeated voiding of urine into bed or clothes (whether involuntary or intentiona
l).
8.
The behavior is clinically significant as manifested by either a frequency of tw
ice a
week for at least 3 consecutive months or the presence of clinically significant
distress
or impairment in social, academic (occupational), or other important areas of fu
nctioning.
C.
Chronological age is at least 5 years (or equivalent developmental level).
D.
The behavior is not due exclusively to the direct physiological effect of a subs
tance
(e.g., a diuretic) or a general medical condition (e.g., diabetes, spina bifida,
a seizure
disorder).
Specify type;
Nocturnal Only
Diurnal Only
Nocturnal and Diurnal
Other Disorders of Infancy,
Childhood, or Adolescence
309.21 Separation Anxiety Disorder
Diagnostic Features
The essential feature of Separation Anxiety Disorder is excessive anxiety concer
ning
separation from the home or from those to whom the person is attached (Criterion
A).
TIlis anxiety is beyond that which is expected for the individual's developmenta
l level.
The disturbance must last for a period of at least 4 weeks (Criterion B), begin
before
age 18 years (Criterion C), and cause clinically significant distress or impairm
ent in
social, academic (occupational), or other important areas of functioning (Criter
ion D).
The diagnosis is not made if the anxiety occurs exclusively during the course of
a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic Disorder or, in adoles
cents
or adults, if it is beUer accounted for by Panic Disorder With Agoraphobia
(Criterion E).
Individuals with this disorder may experience recurrent excessive distress on se
paration
from home or major attachment figures (Criterion Al). When separated from
attachment figures. they often need to know their whereabouts and need to stay i
n
touch with them (e.g., by telephone calls). Some individuals become extremely ho
mesick
and uncomfortable to the point of misery when away from home. They may
yearn to return home and be preoccupied with reunion fantasies. \Nhen separated
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
1122
from major attachment figures, these individuals are oflen preoccupied with fear
s
that accidents or illness will befall the attachment figures or themselves (Crit
erion
A2). Children with this disorder often express fear of being lost and never bein
g reunited
with their parents (Criterion A3). They are often uncomfortable when tra\'eling
independently away from the house or from other familiar areas and may avoid
going placesby themselves. They may be reluctant or refuse to attend school or c
amp.
to visit or sleep at friends' homes, or to go on errands (Criterion At). These c
hildren
may be unable to stay or go in a room by themselves and may display "clinging" b
ehavior,
staying close to and "shadowing" the parent around the house or requiring
someone to be with them when going to another room in the house (Criterion AS).
Children with this disorder often have difficulty at bedtime and may insist that
someone stay with them until they fall asleep (Criterion A6). During the night,
the)'
may make their way to their parents' bed (or that of another significant person,
such
as a sibling); if entTy to the parental bedroom is barred, they may sleep outsid
e the
parents' door. There may be nighhnares whose content expresses the individual's
fears (e.g., destruction of the family through fire, murder, or other catastroph
e) (Criterion
A7). Physical complaints, such as stomachaches, headaches, nausea, and vomiting
are common when separation occurs or is anticipated (Criterion AS). Cardiovascul
ar
symptoms such as palpitations, dizziness, and feeling faint are rare in younger
chilo
dren but may occur in older individuals.
Specifier
Early Onset. This specifier may be used to indicate onset of the disorder before
age 6 years.
Associated Features and Mental Disorders
Children with Separation Anxiety Disorder tend to come from families that are cl
oseknit.
When separated from home or major attadunent figures, they may recurrentl}'
exhibit social withdrawal, apathy, sadness, or difficulty concentrating on work
or
play. Depending on their age, individuals may have fears of animals, monsters, t
he
dark, muggers, burglars, kidnappers, car accidents, plane travel, and other situ
ations
that are perceived as presenting danger to the integrity of the family or themse
lves.
Concerns about death and dying are common. School refusal may lead to academic
difficulties and social avoidance. Children may complain that no one loves them
or
cares about them and that they wish they were dead. "'hen extremely upset at the
prospect of separation, they may show anger or occasionally hit out at someone w
ho
is forcing separation. When alone, especially in the evening or the dark, young
chilo
dren may report unusual perceprual experiences (e.g., seeing people peering into
their room, scary creatures reaching for them, feeling eyes staring at them). Ch
ildren
with this disorder are often described as demanding, intrusive, and in need of c
onstant
attention. Thechild's excessive demands often become a source of parental frustr
ation,
leading to resenhnent and conflict in the family. Sometimes, children with the
disorder are described as unusually conscientious, compliant, and eager to pleas
e.
The children may have somatic complaints that result in physical examinations an
d
medical procedures. Depressed mood is frequently present and may become more per
309.21 Separation Anxiety Disorder
sistent over time, justifying an additional diagnosis of Dysthymic Disorder or M
ajor
Depressive Disorder in some cases. The disorder may precede the development of P
anic
Disorder With Agoraphobia. Comorbidity with other Anxiety Disorders may be
common, especially in clinical settings.
Specific Culture, Age, and Gender Features
TIlere are cultural variations in the degree to which it is considered desirable
to tolerate
separation. It is important to differentiate Separation Anxiety Disorder from th
e
high value some cultures place on strong interdependence among family members.
The manifestations of the disorder may vary with age. Younger children may not
express specific fears of definite threats to parents, home, or themselves. As c
hildren
gel older, worries or fears are often of specific dangers (e.g., kidnapping, mug
ging).
Anxiety and anticipation of separation become manifest in mid-childhood. Althoug
h
adolescents with this disorder, especially males, may deny anxiety about separat
ion,
it may be reflected in their limited independent activity and reluctance to leav
e home.
In older individuals, the disorder may limit the person's ability to handle chan
ges in
circumstances (e.g., moving, getting married). Adults with the disorder are typi
cally
overconcemed about their offspring and spouses and experience marked discomfort
when separated from them. In clinical samples, the disorder is apparently equall
y
common in males and females. In epidemiological samples, the disorder is more fr
equent
in females.
Prevalence
Separation Anxiety Disorder is not uncommon; prevalence estimates average about
4% in children and ymmg adolescents. Separation Anxiety Disorder decreases in
prevalence from childhood through adolescence.
Course
Separation Anxiety Disorder may develop after some life stress (e.g., the death
of
a relative or pet, an illness of the child or a relative, a change of schools, a
move to a
new neighborhood, or immigration). Onset may be as early as preschool age and ma
y
occur at any time before age 18 years, but onset as late as adolescence is uncom
mon.
Typically there are periods of exacerbation and remission. In some cases, both t
he
an;ciety about possible separation and the avoidance of situations involving sep
aration
(e.g., going away to college) may persist for many years. However, the majority
of children with Separation Anxiety Disorder are free of impairing Anxiety Disor
ders
at extended follow-up.
Familial Pattern
Separation Anxiety Disorder is more common in first-degree biological relatives
than
in the general population and is relatively more frequent in children of mothers
with
Panic Disorder.
Disorders Usually First Diagnosed in Infancy,
Chifdhood. or Adolescence
Differential Diagnosis
Separation anxiety can be an associated feature of Pervasive Developmental Disor
ders.
Schizophrenia, or other Psychotic Disorders. If the symptoms of Separation
Anxiety Disorder occurexdusively during the course of one of these disorders. a
separate
diagnosis of Separation Anxiety Disorder is not given. Separation Anxiety Disord
er
is distinguished from Generalized Anxiety Disorder in that the anxiety
predominantly concems separation from home and attachment figures. In children o
r
adolescents with Separation Anxiety Disorder, threats of separation may lead to
extreme an.xiety and even a Panic Attack. In contrast to Panic Disorder, the anx
iet}'
concems separation from attachment figures or from home rather than being incapa
c
Hated by an unexpected Panic Attack. In adults. Separation Anxiety Disorder is r
are
and should not be given as an additional diagnosis if the separation fears are b
etter
accounted for by Agoraphobia in Panic Disorder With Agoraphobia or Agoraphobia
Without History of Panic Disorder. Truancy is common in Conduct Disorder,
but an;~iety
about separation is not responsible for school absences and the child usually
stays away from, rather than returns to, the home. Some cases of school refusal,
especially in adolescence, are due to Social Phobia or Mood Disorders rather tha
n
separation anxiety. Children with Separation Anxiety Disorder may be oppositiona
l
in the context of being forced to separate from attachment figures. Oppositional
Defiant
Disorder should be diagnosed only if there is oppositional behavior at times
other than at times of separation or when separation is anticipated. Similarly.
children
with Separation Anxiety Disorder may become depressed while being separated
or in anticipation of separation. A Depressive Disorder should be diagnosed only
if the depression occurs at other limes.
Unlike the hallucinations in Psychotic Disorders, the unusual perceptual experie
nces
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 b
y
the presence of an attachment figure. Clinical judgment must be used in distingu
ishing
developmentally appropriate levels of separation anxiety from the clinically sig
nificant
concerns about separation seen in Separation Anxiety Disorder.
313.23 Selective Mutism (formerly Elective Mutism)
Diagnostic criteria for 309.21 Separation Anxiety Disorder
A.
Developmentally inappropriate and excessive anxiety concerning separation from
home or from those to whom the individual is attached, as evidenced by three (or
more) of the following:
(1)
recurrent excessive distress when separation from home or major attachment
figures occurs or is anticipated
(2)
persistent and excessive worry about losing, or about possible harm befalling,
major attachment figures
(3)
persistent and excessive worry that an untoward event will lead to separation
from a major attachment figure (e.g., getting lost or being kidnapped)
(4)
persistent reluctance or refusal to go to school or elsewhere because of fear of
separation
(5)
persistently and excessively fearful or reluctant to be alone or without major
attachment figures at home or without significant adults in other settings
(6)
persistent reluctance or refusal to go to sleep without being near a major attac
hment
figure or to sleep away from home
(7)
repeated nightmares involving the theme of separation
(8)
repeated complaints of physical symptoms (such as headaches, stomachaches,
nausea, or vomiting) when separation from major attachment figures occurs or
is anticipated
B.
The duration of the disturbance is at least 4 weeks.
C.
The onset is before age 18 years.
D.
The disturbance causes clinically significant distress or impairment in social,
academic
(occupational), or other important areas of functioning.
E.
The disturbance does not occur exclusively during the course of a Pervasive Deve
lopmental
Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and
adults, is not better accounted for by Panic Disorder With Agoraphobia.
Specify if:
Early Onset: if onset occurs before age 6 years
313.23 Selective Mutism
(formerly Elective Mutism)
Diagnostic Features
The essential feature of Selective Mutism is the persistent failure to speak in
specific
social situations (e.g., school, with playmates) where speaking is expected, des
pite
speaking in other situations (Criterion A). The disturbance interferes with educ
ational
or occupational achievement or with social communication (Criterion B). The dist
urbance
must last for at least 1 month and is not limited to the first month of school
(during which many children may be shy and reluct,1nt to speak) (Criterion C). S
elec
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
tive ivlutism should not be diagnosed if the individual's failure to speak is du
e solely
to a lack of knowledge of, or comfort with, the spoken language required in the
social
situation (Criterion D). It is also not diagnosed if the disturbance is better a
ccounted
for by embarrassment related to having a Communication Disorder (e.g., Stutterin
g)
or if it occurs exclusively during a Pervasive Developmental Disorder, Schizophr
enia,
or other Psychotic Disorder (Criterion E). Instead of communicating by standard
verbalization, children with this disorder may communicate by gesttues, nodding
or
shaking the head, or pulling or pushing. or, in some cases, by monosyllabic. sho
rt. or
monotone utterances, or in an altered. voice.
Associated Features and Disorders
Associated features of Selective Mutism may include excessive shyness, fear of s
ocial
embarrassment, social isolation and withdrawal, clinging, compulsive traits, neg
ativism,
temper tantrums, or controlling or oppositional behavior, particularly at home.
There may be severe impairment in social and school functioning. Teasing or scap
egoating
by peers is common. Although children with this disorder generally have
normal language skills, there may occasionally be an associated Communication
Disorder (e.g., Phonological Disorder, Expressi\'e Language Disorder, or Mixed
Receptive-Expressive Language Disorder) or a general medical condition thai caus
es
abnormalities ofarticulation. Mental Retardation, hospitalization, orextreme psy
chosocial
stressors may be associated with the disorder. In addition, in clinical settings
,
children with Selective Mutism are almost always given an additional diagnosis o
f an
Anxiety Disorder (especially Social Phobia).
Specific Culture and Gender Features
Immigrant children who are unfamiliar with or uncomfortable in the official lang
uage
of their new host country may refuse to speak to strangers in their new environm
ent.
This behavior should not be diagnosed as Selective Mutism. Selective
Mutism is slightly more common in females than in males.
Prevalence
Selective Mutism is apparently rare and is found in fewer than 10/0 of individua
ls seen
in mental health settings.
Course
Onset of Selective Mutism is usually before age 5 years, but the disturbance may
not
come to clinical attention until entry into school. The degree of persistence of
the disorder
is variable. It may persist for only a few months or may continue for several
years. In some cases, particularly in those with severe Social Phobia, anxiety s
ymptoms
rna}' become chronic.
313.89 Reactive Attachment Disorder of Infancy or Early Childhood 127
Differential Diagnosis
Selective Mutism should be distinguished from speech disturbances that are beHer
accounted for by a Communication Disorder, such as Phonological Disorder, Ex
pressive language Disorder, Mixed Receptive-Expressive Language Disorder, or
Stuttering. Unlike Selective Mutism, the speech disturbance in these conditions
is not
restricted to a specific sociaJ situation. Children in families who have immigra
ted to
a country where a different language is spoken may rehlse to speak the new langu
age
because of lack of knowledge of the language. U comprehension of the new languag
e
is adequate, but refusal to speak persists, a diagnosis of Selective Mutism may
be warranted. Individuals with a Pervasive Developmental Disorder, Schizophre
nia or other Psychotic Disorder, or severe Mental Retardation may have problems
in social communication and be unable to speak appropriately in social situation
s. In
contrast, Selective Mutism should only be diagnosed in a child who has an establ
ished
capacity to speak in some social situations (e.g., typically at home). The socia
l
anxiety and social avoidance in Social Phobia may be associated with Selective M
utism.
In such cases, both diagnoses may be given.
Diagnostic criteria for 313.23 Selective Mutism
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 mo
nth of
school).
D.
The failure to speak is not due to a lack of knowledge of, or comfort with, the
spoken
language required in the social situation.
E.
The disturbance is not berter accounted for by a Communication Disorder (e.g., S
tuttering)
and does not occur exclusively during the course of a Pervasive Developmental
Disorder, Schizophrenia, or other Psychotic Disorder.
313.89 Reactive Attachment Disorder of
Infancy or Early Childhood
Diagnostic Features
The essential feature of Reactive Attachment Disorder is markedly disturbed and
developmentally
inappropriate social relatedness in most contexts that begins before
age 5 years and is associated with grossly pathological care (Criterion A). Ther
e are
two types of presentations. In the Inhibited Type, the child persistently fails
to initiate
and to respond to most social interactions in a developmentally appropriate way.
The
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
child shows a pattern of excessively inhibited, hypervigilant, or highly ambival
ent reo
sponses (e.g., frozen watchfulness. resistance 10 comfort, or a mixture of appro
ach
and avoidance) (Criterion Al). In the Disinhibited Type, there is a pattern of d
iffuse
attachments. The child exhibits indiscriminate sociability or a lack of selectiv
ity in the
choiceofattachment figures (Criterion Al). The disturbance is not accounted for
soleI)'
by developmental delay (e.g., as in Mental Retardation) and does not meet criter
ia
for Pervash'e Developmental Disorder (Criterion B). By definition, the condition
is associated
with grossly pathological care that may take the form of persistent disregard
of the child's basic emotional needs for comfort, stimulation, and affection (Cr
iterion
Cl); persistent disregard of the child's basic physical needs (Criterion C2); or
repeated
changes of primary caregh'er that prevent formation of stable attachments (e.g.,
frequent changes in foster care) (Criterion C3). The pathological care is presum
ed to
be responsible for the disturbed social relatedness (Criterion D).
Subtypes
The predominant type of disturbance in social relatedness may be indicated by sp
ec
ifying one of the follOWing subtypes for Reacti\'e Attachment Disorder:
Inhibited Type. In this subtype, the predominant disturbance in social relat
edness is the persistent failure to initiate and to respond to most social inter
actions
in a developmentally appropriate way.
Disinhibited Type. This subtype is used if the predominant disturbance in
social relatedness is indiscriminate sociability or a lack of selectivity in the
choice of attachment figures.
Associated Features and Disorders
Associated descriptive features and mental disorders. Certain situations (e.g.,
prolonged hospitalization of the child, extreme poverty, or parental inexperienc
e)
may predispose to the development of pathological care. However, grossly patholo
g
icat care does not always result in the development of Reactive Attachment Disor
der;
some children may form stable attachments and social relationships even in the f
ace
of marked neglect or abuse. Extreme neglect-and especially institutional care wi
th
limited opportunities to form selective attachments-increases risk of developing
the
disorder. Reactive Attachment Disorder may be associated with developmental dela
ys,
Feeding Disorder of Infancy or Early Childhood, Pica, or Rumination Disorder.
Associated laboratory findings. Laboratory findings consistent with malnutrition
may be present.
Associated physical examination findings and general medical conditions.
Physical examination may document associated general medical conditions that are
associated with extreme neglect (e.g., growth delay, evidence of physical abuse,
malnutrition,
vitamin deficiencies, or infectious diseases).
313.89 Reactive Attachment Disorder of Infancy or Early Childhood 129
Prevalence
Epidemiological data are limited, but Reactive Attachment Disorder appears to be
\'ery uncommon.
Course
The onset of Reactive Attachment Disorder is usually in the first several years
of life
and, by definition, begins before age 5 years. The course appears to vary depend
ing
on individual factors in child and caregivers, the severity and duration of asso
ciated
psychosocial deprivation, and the nature of intervention. Considerable improveme
nt
or remission may occur if an appropriately supportive environment is provided. O
therwise,
the disorder follows a continuous course. Indiscriminate sociability may persist
even after the child has de\'eloped selective attachments.
Differential Diagnosis
In Mental Retardation, appropriate attachments to caregivers usually develop con
sistent
with the child's general developmentallevet and these attachments are clearly
present by the time a child has a mental age of 10 months. However, some infants
and
young children with Severe Mental Retardation may present particula.r problems f
or
caregivers and exhibit symptoms characteristic of Reactive Attachment Disorder.
Reactive
Attachment Disorder should be diagnosed only if it is clear that the characteris
tic
problems in formation of selective attachments are not a function of the
retardation.
Reactive Attachment Disorder must be differentiated from Autistic Disorder and
other Pervasive Developmental Disorders. In the Pervasive Developmental Disorder
s,
selective attachments either fail to develop or are highly deviant, but this usu
ally
occurs in the face of a reasonably supportive psychosocial envi.ronment. Autisti
c
Disorder and other Pervasive Developmental Disorders are also characterized by t
he
presence of a qualitative impai.rment in communication and restricted, repetitiv
e, and
stereot)'ped patterns of behavior. Reactive Attachment Disorder is not diagnosed
if
the criteria are met for a Pervasive Developmental Disorder.
The Inhibited Type of Reactive Attachment Disorder must be distinguished from
Social Phobia. In Social Phobia, the social inhibition is apparent in social set
tings or
in anticipation of social encounters but does not occur with familiar caregivers
in familiar
settings. Socially deviant behavior in Reactive Attachment Disorder, including
inhibition, is apparent across social contexts.
The Disinhibited. Type must be distingUished from the impulsive or hyperactive
behavior characteristic of Attention-Deficit/Hyperactivity Disorder. In contrast
to
Attention-Deficit/Hyperactivity Disorder, the disinhibited behavior in Reactive
Attadunent
Disorder is characteristically associated. with being overly familiar with or
seeking comfort from an unfamiliar adult caregiver rather than with generally im
pulsive
behavior.
Reactive Attachment Disorder should also be differentiated from Disruptive Beha\
!
ior Disorders such as Conduct Disorder and Oppositional Defiant Disorder.
The term "affectionless psychopath" has been used to describe children who were
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
raised in settings that limited opportunities for the child to develop selective
attach
ments (e.g., institutions) and who exhibited a pattern of antisocial and aggress
ive behavior,
inability to form lasting relationships with adulls, and miscellaneous
symptoms such as enuresis and stereotypies. Nevertheless, no direct link beh,'ee
n
Reactl\'e Attachment Disorder and "affectionless psychopathy" has been establish
ed.
Disturbances of attachment in the early years may increase the risk for antisoci
al behaviors
in later childhood and adolescence, but antisocial behaviors are not necessarily
signs of Reactive Attachment Disorder. Grossly pathogenic care is a defining
feature of Reactive Attachment Disorder. An additional notation of Child Abuse,
Child Neglect, or Parent-Child Relational Problem may be warranted. When grossly
pathogenic care docs not result in marked disturbances in social relatedness, Ch
ild
'eglect or Parent-Child Relational Problem may be noted rather than Reactive Att
achment
Disorder.
Diagnostic criteria for 313.89 Reactive Attachment
Disorder of Infancy or Early Childhood
A.
Markedly disturbed and developmentally inappropriate social relatedness in most
contexts, beginning before age 5 years, as evidenced by either (1) or (2):
(1)
persistent failure to initiate or respond in a developmentally appropriate fashi
on
to most social interactions. as manifest by excessively inhibited, hypervigilant
,
or highly ambivalent and contradictol)l responses (e.g., the child may
respond to caregivers with a mixture of approach, avoidance, and resistance to
comforting, or may exhibit frozen watchfulness)
(2)
diffuse attachments as manifest by indiscriminate sociability with marked in
ability to exhibit appropriate selective attachments (e.g., excessive familiarit
y
with relative strangers or lack of selectivity in choice of attachment figures)
B.
The disturbance in Criterion A is not accounted for solely by developmental dela
y (as
in Mental Retardation) and does not meet criteria for a Pervasive Developmental
Disorder.
C.
Pathogenic care as evidenced by at least one of the following:
(1)
persistent disregard of the child's basic emotional needs for comfort, stimulati
on,
and affection
(2)
persistent disregard of the child's basic physical needs
(3)
repeated changes of primary caregiver that prevent formation of stable attachmen
ts
(e.g., frequent changes in foster care)
D.
There is a presumption that the care in Criterion C is responsible for the distu
rbed
behavior in Criterion A (e.g., the disturbances in Criterion A began following t
he
pathogenic care in Criterion O.
Specify type:
Inhibited Type: if Criterion A1 predominates in the clinical presentation
Disinhibited Type: if Criterion A2 predominates in the clinical presentation
307.3 Stereotypic Movement Disorder (formerly Stereotypy!
Habit Disorder)
131\
307.3 Stereotypic Movement Disorder
(formerly Stereotypy/Habit Disorder)
Diagnostic Features
The essential feature of Stereotypic Movement Disorder is motor beha\'ior that i
s repetitive,
often seemingly driven, and nonfunctional (Criterion A). This motor behavior
markedly interferes with normal activities or results in self-inflicted bodily i
njury
that is significant enough to require medical treatment (or would result in such
injury
if protective measures were not used) (Criterion B). If Mental Retardation is pr
esent,
the stereotypic or self-injurious behavior is sufficiently severe to become a fo
cus of
treatment (Criterion C). The behavior is not better accounted for by a compulsio
n (as
in Obsessive-Compulsive Disorder), a tic (as in the Tic Disorders), a stereotypy
that
ispartofa PervasiveDevelopmentaIDisorder, orhairpu11ing (as inTrichotillomarua)
(Criterion D). The behavior is also not due to the direct physiological effects
of a substance
or a general medical condition (Criterion E). The motor behaviors must persist
for at least 4 weeks (Criterion F).
The stereotypic movements may include hand waving, rocking, playing with
hands, fiddling with fingers, h\lirling objects, head banging, self-biting, or h
itting various
parts of one's own body. Sometimes the individual uses an object in performing
these behaviors. The behaviors may cause permanent and disabling tissue damage
and may sometimes be We-threatening. For instance, severe head banging or hittin
g
may lead to cuts, bleeding, infection, retinal detachment, and blindness.
Specifiers
The clinician may specify With Self-Injurious Behavior if the behavior results i
n
bodily damage that requires specific treatment (or that would result in bodily d
amage
if protective measures were not used).
Associated Features and Disorders
Associated descriptive features and mental disorders. TI,e individual (especiall
y
an individual with Lesch-Nyhan syndrome) may develop methods of self-restTaint
(e.g., holding hands inside shirts, trousers, or in pockets) to allempt to contr
ol the selfinjurious
behaviors. ,""hen I:h.e self-restraint is interfered with, the behaviors return.
Ifthe behaviors are extreme or repulsive to others, there may be psychosocial co
mplications
due to the individual's exclusion from social and community activities. 5tereol)
'
Pic Movement Disorder occurs most commonly in association with ~'lental
Retardation. The more severe the retardation, the higher the risk for self-injur
ious beha\'
iors. The disorder can also occur in non-developmentally delayed populations
(e.g., individuals with body rocking associated with Generalized Anxiel)' Disord
er).
This disorder may also occur in association wil:h. se\'ere sensory deficits (bli
ndness
and deafness) and may be more common in institutional environments in which the
individual receives insufficient stimulation. Self-injurious behaviors occur in
certain
general medical conditions associated with Mental Retardation (e.g., fragile X s
yn
Disorders Usually First Diagnosed in Infancy,
Childhood. or Adolescence
drcme, Down syndrome. de Lange syndrome. and especially lesc.h-I yhan syndrome.
which is characterized by severe self-biting).
Associated laboratory findings. If there is self-injury. the laboratory findings
will
reflect its nature and sevcrit}' (e.g., anemia may be present if there is a chro
nic blood
loss from self-inflicted rectal bleeding).
Associated physical examination findings and general medical conditions.
Signs of chronic tissue damage may be present (e.g., bruises. bite marks, cuts,
scratches,
skin infections. rectal fissures. foreign bodies in bodily orifices. visual impa
irment
due 10 eye gouging or traumatic cataract, and fractures or deformed bones). In l
ess
se\'ere cases, there may be a dlronic skin irritation or calluses from biting, p
inching,
scratching, or saliva smearing.
Specific Age and Gender Features
Self-injurious behaviors occur in individuals of all ages. There are indications
that
head banging is more prevalent in males (with about a 3:1 ratio), and self-bitin
g may
be more prevalent in females.
Prevalence
There is limited information on the prevalence of Stereotypic Movement Disorder.
Theestimates ofprevalenceofself-injuriousbehaviors in individuals with Mental Re
tardation
vary from 2% and 3% in children and adolescents li\ring in the community
to approximately 25''10 in adults with severe or profound Menta1Retardation livi
ng in
institutions.
(ourse
There is no typical age at onset or pattern of onset for Stereotypic Movement Di
sorder.
The onset may foUow a stressful environmental event. In nonverbal individuaJs
with Severe Mental Retardation, stereotypic movements may be triggered by a pain
hl1
general medical condition (e.g., a middle ear infection leading to head banging)
.
The stereotypic movements often peak in adolescence and then may gradually decli
ne.
However, especially in individuals with Severe or Profound i\'[ental Retardation
,
the movements may persist for years. The focus of these behaviors often changes
(e.g., a person may engage in hand biting that may then subside and head hitting
may
emerge).
Differential Diagnosis
Stereotypic movements may be associated with Mental Retardation, especially for
individuals in nonstimulating environments. Stereotypic Movement Disorder should
be diagnosed only in individuals in whom the stereotypic or self-injurious behav
ior
is ofsufficient severity to become a focus of treatment. Repetitive stereotyped
movements
are a characteristic feature of Pervasive Developmental Disorders_ Stereol}tp
307.3 Stereotypic Movement Disorder (formerly Stereotypy!
Habit Disorder)
1331
ic Movement Disorder is not diagnosed if the stereotypies are better accounted f
or
by a Pervasi\'e Developmental Disorder. Compulsions in ObsessiveCompulsive
Disorder are generally more complex and ritualistic and are perfonned in respons
e
to an obsession Or according to rules that must be applied rigidly. Differentiat
ing the
complex movements characteristic of Stcreotypic Movement Disorder from simple
tics (e.g., eye blinking) is relatively straightforward. However, differentiatin
g SterCOtypic
Movement Disorder from complex motor tics can be quite difficult, given the
similarities beh\'een the h\'o in terms of intentionality, rhythmicity, and driv
enness.
In Trichotillomania, by definition, the repetiti\'e behavior is limited to hair
pulling.
The self-induced injuries in Stereotypic Movement Disorder should be distinguish
ed
from Factitious Disorder With Predominantly Physical Signs and Symptoms, in
which the motivation of the seU-injury is to assume the sick role. Selfmutilation
associated with certain Psychotic Disorders and Personality Disorders is premedi
tated,
complex, and sporadic and has a meaning for the individual within the context
of the underlying, severe mental disorder (e.g., is the result of delusional thi
nking).
Involuntary movements associated with neurological conditions (such as Huntingto
n's
disease) usually follow a typical pattern, and the signs and symptoms of the
neurological condition are present. Tardive Dyskinesia usually results from chro
nic
neuroleptic use and consists of characteristic orofadal dyskinesias or, less com
monly,
irregular truncal or limb movements. In addition, these types of movements do no
t
result in direct self-injury.
Developmentally appropriate self-stimulatory behaviors in young children
(e.g., thumb sucking, rocking, and head banging) are usually self-limited and ra
rely
result in tissue damage requiring treatment. Self-directed behaviors in individu
als
with sensory deficits (e.g., blindness) are repetitive and stereotyped but usual
ly do
not result in dysfunction or in seU-injury.
Many people engage in repetitive behaviors for various reasons (practicing to im
prove
a motor skill, culturally sanctioned practices). In contrast to Siereol)'pic Mov
ement
Disorder, these behaviors do not interfere with nonnal activities nor do they
result in self-injury.
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence
Diagnostic criteria for 307.3 Stereotypic Movement Disorder
A.
Repetitive, seemingly driven, and nonfunctional motor behavior (e.g., hand shaki
ng
or waving, body rocking, head banging, mouthing of objects, self-biting, picking
at
skin or bodily orifices, hitting own body).
B.
The behavior markedly interferes with normal activities or results in self-infli
cted
bodily injury that requires medical treatment (or would result in an injury if p
reventive
measures were not used).
C.
If Mental Retardation is present, the stereotypic or self-injurious behavior is
of sufficient
severity to become a focus of treatment.
D.
The behavior is not better accounted for by a compulsion (as in Obsessive-Compul
sive
Disorder), a tic (as in Tic Disorder), a stereotypy that is part of a Pervasive
Developmental
Disorder, or hair pulling (as in Trichotillomania).
E.
The behavior is not due to the direct physiological effects of a substance or a
general
medical condition.
F.
The behavior persists for 4 weeks or longer.
Specify if:
With Self-Injurious Behavior: if the behavior results in bodily damage that
requires specific treatment (or that would result in bodily damage if protective
measures were not used)
313.9 Disorder of Infancy, Childhood, or
Adolescence Not Otherwise Specified
TItis category is a residual category for disorders with onset in infancy, child
hood, or
adolescence that do not meet criteria for any specific disorder in the Classific
ation.
Delirium, Dementia, and
Amnestic and Other
Cognitive Disorders
ThiS section includes Delirium, Dementia, Amnestic Disorders, and Cognitive
Disorder Not Otherwise Specified. The predominant disturbance is a clinically si
gnificant
deficit in cognition that represents a significant change from a previous level
of
functioning. For each disorder in this section, the etiology is either a general
medical
condition (although the specific general medical condition may not be identifiab
le) or
a substance (i.e., a drug of abuse, medication, or toxin), or a combination of t
hese
factors.
in DSM-m-R, these disorders were placed in a section titled "Organic Mental Synd
romes
and Disorders." The term organic mel/lal disorder is no longer used in DSM-IV
because it incorrectly implies that "nanorganic" mental disorders do not have a
biological
basis. In DSM-IV, disorders formerly called "organic mental disorders" have
been grouped into three sections: 1) Delirium, Dementia, and Amnestic and Other
Cognitive Disorders; 2) Mental Disorders Due to a General Medical Condition; and
3) Substance-Related Disorders.
A delirium is characterized by a disturbance of consciousness and a change in co
g
rution that develop onr a short period of time. The disorders included in the "D
elirium"
section are Listed according to presumed etiology: Delirium Due to a General
Medical Condition, Substance-Induced Delirium (i.e., due to a drug of abuse, a m
edication,
or toxin exposure), Delirium Due to Multiple Etiologies, or Delirium NotOtherwis
e
Specified (if the etiology is indeterminate).
A dementia is characterized by multiple cognitive deficits thai include impairme
nt
in memory. The dementias are also listed according to presumed etiology: Dementi
a
of the Alzheimer's Type, Vascular Dementia, Dementia Due to Other General Medica
l
Conditions (e.g., human immunodeficiency virus (HIV] disease, head trauma,
Parkinson's disease, Huntington's disease), Substance-Induced Persisting Dementi
a
(i.e., due to a drug of abuse, a medication, or toxin exposure), Dementia Due to
Multiple Etiologies, or Dementia Not Otherwise Specified (if the etiology is ind
eterminate).
An amnestic disorder is characterized by memory impairment in the absence of
othersignificant accompanyingcognitiveimpairments.Thedisorders in the"Anmestic
Disorders" section also are lisled according 10 presumed etiology: Amnestic Diso
rder
Due to a General Medical Condition, Substancelnduced Persisting Amnestic
Disorder, or Amnestic Disorder Not Othenvise Specified.
135
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Cognitive Disorder Not Otherwise Specified is for presentations that are charact
erized
by cognitive dyshmction presumed to be due to either a general medical condition
or substance use that do not meet criteria for any of the disorders lisled
elsewhere in this scction.
Introductory text is provided that discusses the genera] features for each group
of
disorders, regardless of etiology. This is followed by text and criteria for eac
h disorder
with specific etiology.
Delirium
The disorders in the "Delirium" section share a common symptom presentation of a
disturbance in consciousness and cognition, but are differentiated based on etio
logy:
Delirium Due to a General Medical Condition, Substance-Induced Delirium (indudin
g
medication side effects), and Delirium Due to Multiple Etiologies. In addition,
Delirium Not Othenvise Specified is included in this section for presentations
in which the clinician is unable to determine a specific etiology for the deliri
um.
Diagnostic Features
The essential feature of a delirium is a disturbance of consciousness that is ac
companied
by a change in cognition that cannot be better accounted for by a preexisting or
evolving dementia. The disturbance develops over a short period of time, usually
hours to days, and tends to fluctuate during the course of the day. There is evi
dence
from the history, physical examination, or laboratory tests that the delirium is
a direct
physiological consequence of a general medical condition, Substance Intoxication
or
Withdrawal, use of a medication, or toxin exposure, or a combination of these fa
ctors.
The disturbance in consciousness is manifested by a reduced clarity of awareness
of the environment. The ability to focus, sustain, or shift attention is impaire
d (Criterion
A). Questions must be repeated because the individual's attention wanders, or
the individual may perseverate with an answer to a previous question rather than
appropriately shift attention. The person is easily distracted by irrelevant sti
muli.
Because of these problems, it may be difficult (or impossible) to engage the per
son in
conversation.
There is an accompanying change in cognition (which may include memory impaimlen
t,
disorientation, or language disturbance) or development of a perceptual
disturbance (Criterion B). Memory impairment is most commonly evident in rffent
memory and can be tested by asking the person to remember several unrelated obje
cts
or a brief sentence, and then to repeat them after a few minutes of distraction.
Disorientation
is usually manifested by the individual's being disoriented to time
(e.g., thinking it is morning in the middle of the night) or being disoriented t
o place
(e.g., thinking he or she is home rather than in a hospital). In mild delirium,
disorientation
to time may be the first symptom to appear. Disorientation to self is less commo
n.
Speedl or language distu.rbances may be evident as dysarthria (i.e., the
impaired ability to articulate), dysnomia (i.e., the impaired ability to name ob
jffts),
Delirium 137
dysgraphia (i.e., the impaired ability to write), or even aphasia.ln some cases,
speech
is rambling and irrelevant, in others pressured and incoherent, with unpredictab
le
switching from subject to subject. It may be difficult for the clinician to asse
ss for
changes in cognitive function because the individual may be inattentive and inco
herent.
Under these circumstances, it is helpful to review carefully the individual's hi
story
and to obtain information from other informants, particularly family members.
Perceptual disturbances may include misinterpretations, illusions, or hallucina
lions. For example, the banging of a door may be mistaken for a gunshot (misinte
r
pretation); the folds of the bedclothes may appear to be animate objects (illusi
on); or
the person may "see" a group of people hO\'ering o\'er the bed when no onc is ac
tually
there (hallucination). Although sensory misperceptions are most commonly visual,
they may occur in other sensory modalities as \\'eU, such as auditory, tactile,
gustatory, and olfactory. lvtisperceptions range from simple and uniform to high
l)'
complex. The individual may have a delusional conviction of the reality of the h
allucinations
and exhibit emotional and behavioral responses consistent with their
content.
The disturbance develops over a short period of time and tends to fluctuate duri
ng
the course of the day (Criterion C). For example, during morning hospital rounds
, the
person may be coherent and cooperative, but at night might insist on pulling out
intravenous
lines and going home to parents who died years ago.
Associated Features and Disorders
Delirium is often associated with a disturbance in the sleep+wake cycle. This di
stur
bance can include daytime sleepiness or nighttime agitation and difficulty falli
ng
asleep or excessive sleepiness throughout the day or wakefulness throughout the
night. In some cases, complete reversal of the night-day sleepwake cycle can occu
r.
Delirium is frequently accompanied by disturbed psychomotor behavior. Many indi
viduals with delirium are restless or hyperactive. Manifestations of increased p
sychomotor
activity may include groping or picking at the bedclothes, attempting to get
out of bed when it is unsafe or untimely, and sudden movements. On the other han
d.
the individual may show decreased psychomotor activity, with sluggishness and
lethargy that approach stupor. Psychomotor activity often shifts from one extrem
e to
the other over the course of a day. 'While hyperactive, the individual is more l
ikely to
show evidence of hallucinations, delusions, and agitation, whereas in hypoactive
slates, the individual is less likely to show evidence of hallucinations, delusi
ons, or
other perceptual disturbances. Comparable levels of cognitive impairment have be
en
observed with both the hyperactive and the hypoactive states.
The individual may exhibit emotional disturbances such as anxiety, fear, depres+
sion, irritability, anger, euphoria, and apathy. There may be rapid and unpredic
table
shifts from one emotional state to another, although some individuals with delir
ium
have a constant emotional tone. Fear often accompanies threatening hallucination
s or
transient delusions. Iffear is marked, the person may attack those who are false
ly perceived
as threatening. Injuries may be sustained from falling out of bed or trying to
escape while attached to intravenous lines, respiratory tubes, urinary catheters
, or
other medical equipment. The disturbed emotional state may also be evident in ca
lling
out, screaming, cursing, muttering, moaning, or other sounds. These behaviors
Delirium. Dementia. and Amnestic and Other Cognitive Disorders
are especially prevalent at night and under conditions in which stimulation and
environmental
cues are lacking. Impaired judgment may interfere with proper medical
treatment. Depending on the etiology, delirium can be associated with a number o
f
nonspecific neurological abnonnalities, such as tremor, myoclonus, asterixis, an
d reflex
or muscle tone changes.
In addition to laboratory findings that are characteristic of associated or etio
logical
general medical conditions (or intoxication or withdrawal states), the EEG is ty
pically
abnonnal, showing generalized slowing. Fast activity is occasionall)' found, for
example,
in some cases of Alcohol Withdrawal Delirium.
Specific Culture, Age, and Gender Features
Cultural and educational background should be taken into consideration in the ev
aluation
of an individual's mental capacity. Individuals from certain backgrounds rna)'
not be familiar with the information used in certain tests of general knowledge
(e.g.,
names of presidents, geographical knowledge). memory (e.g., date of birth in cul
tures
that do not routinely celebrate birthdays), and orientation (e.g., sense of plac
ement
and location may be conceptualized differently in some cultures).
Children may be particularly susceptible to delirium compared with adults (other
than the elderly), especially when it is related to febrile illnesses and certai
n medications
(e.g., anticholinergics). This is perhaps due to their immature brain developmen
t
and physiological differences. In children, delirium may be mistaken for uncoope
rative
behavi.or, and eliciting the distinctive cognitive signs may be difficult. If fa
miliar
figures cannot soothe the child, this may be suggestive of delirium. The elderl}
' are
also especially susceptible to delirium compared with younger adults, perhaps be
cause
of physiological differences. Increasing age in adults is associated wi.th highe
r
rates of delirium even after controlling for other risk factors. Male gender app
ears to
be an independent risk factor for delirium i.n elderly individuals.
Prevalence
The point prevalence of delirium in the general population is 0.4% in adults age
18
years and older and 1.1 % in those age 55 and older. The point prevalence of del
irium
in the hospitalized medically ill ranges from 10% to 30%. In the hospitalized el
derly,
about 100/0-15% are reported to exhibit delirium on admission, and 10/0-40% may b
e
diagnosed with delirium while in the hospital. Up to 60% of nursing home residen
ts
age 75 years and older may be delirious at any given time. As many as 25% of hos
pitalized
cancer patients and 30%--40% of hospitalized AIDS patients develop delirium
during their hospitalization. Up to 80% of those with terminal illness develop d
elirium
near death. The rate of delirium in these populations depends greatly on the nat
ure
of their associated general medical conditions and surgical procedures.
Course
The symptoms of delirium usually develop over hours to days, although in some
individuals they may begin abruptly (e.g., after a head injury). More typically,
prodromal
symptoms, such as restlessness, anxiety, irritability, disorientation, distracti
Delirium
139\
bility, or sleep disturbance, progress to fuJI-blown delirium within a 1-to 3-da
y
period. The delirium may resolve in a few hours to days, or symptoms may persist
for weeks to months, particularly in elderly individuals and individuals with co
existing
dementia. If the underlying etiological factor is promptly corrected or is selfl
imited,
recovery is more likely to be complete and more rapid. Individuals with
better premorbid cOgnitive and physical functioning have better recovery from de
lirium.
Those with previous episodes of delirium may be at increased risk for recurrent
symptoms.
While the majority of individuals have a full recovery, delirium may progress to
stupor,coma, seizures, or death, partieu..larly if the underlying cause is untre
ated. Full
recovery is less likely in the elderly, with estimated rates of full recovery by
the time
of hospital discharge varying from 4% to 40%. Many symptoms will not have resolv
ed
by 3-6 months after discharge. Persistent cognitive deficits are also common
in elderly individuals recovering from delirium, although such deficits may be d
ue
to preexisting dementia that was nDt fully appreciated. Being admitted tD a hDsp
ital
from home (as opposed tD from an institutional setting) is related tD a higher r
ate Df
improvement in mental state.
Delirium in the medically ill is associated with significant mDrbidity. ~..ledjc
ally ill
individuals with delirium, particularly the elderly, have significantly increase
d risk
of medical complications, such as pneumonia and decubitus ulcers, resulting in l
ongerduration
ofhospitaJ stays. Delirium is also associated with increased functional decline
and risk of institutional placement. Hospitalized patients 65 years or older wit
h
delirium have three times the risk of nursing hDme placement and abDut three tim
es
the functionaIdecline as hDspitalized patients without deli rium atboth discharg
e and
3 months pDstdisdlarge. In pDstoperative patients, delirium is a harbinger of li
mited
recovery and poor IDng-term Dutcome and is Dften associated with increased risk
for
postoperative complications, IDnger postDperative recuperation periods, longer h
ospital
stays, and increased !ong-tenn disability.
Delirium in the medically ill is also associated with increased mortality. Elder
ly individuals
who develop delirium during a hospitalization may have up to a 20"/..-75%
chance of dying during that hospitalization. Patients who develop delirium durin
g
a hospitalization also have a very high death rate during the months following d
ischarge.
Up to 15% of elderly patients with delirium die within a l-month periDd and
up to 25% die within a 6-mDnth period after discharge. Other risk factDrs, such
as type
of iJ1ness, illness severity, preexisting cognitive impairment, and age, CDntrib
ute significantly
tD this associatiDn. Patients with malignancies and delirium have a particularly
high mortality rate both in-hospital and after discharge compared with
patients with malignancies who dD not also have delirium.
Differential Diagnosis
The most common differential diagnDstic issue is whether the person has a dement
ia
rather than a delirium, has a delirium alDne, or has a delirium superimposed Dn
a preexisting
dementia. Memory impairment is common tD both a delirium and a dementia,
but the person with a dementia alDne is alert and does nDt have the disturbance
in consciDusness that is characteristic Df a delirium. The tempDral Dnset and co
urse of
cognitive impainnents are helpful in distinguishing between delirium and dementi
a.
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
In delirium the onset of symptoms is much more rapid (i.e., usually over hours t
o
days), whereas in dementia the onset is typically more gradual or insidious. Del
irium
symptom severity characteristically fluctuates during a 24-hour period, whereas
dementia
symptom severity generally does not. When symptoms of a delirium are
present, infonnation from family members, other caretakers, or medical records m
ay
be helpful in determining whether the symptoms of a dementia were preexisting.
Coding of a delirium superimposed on the different types of dementias is discuss
ed
under "Recording Procedures" for each type of delirium.
The presumed etiology determines the specific delirium diagnosis (text and crite
ria
for each delirium diagnosis are provided separately later in this section). U it
is
judged that the delirium is a consequence of the direct physiological effects of
a general
medical condition, then Delirium Due to a General Medical Condition is diagnosed
.
Ifthe delirium results from the direct physiological effects of a drug of abuse,
then Substance Intoxication Delirium or Substance Withdrawal Delirium is diagnos
ed,
depending on whether the delirium occurred in association with Substance
Intoxication or Substance Withdrawal. U the delirium results from medication use
or
toxin exposure, then Substance-Induced Delirium is diagnosed. It is not unconuno
n
for the delirium to be due to both a general medical condition and substance (in
cluding
medication) use. This may be seen, for example, in an elderly individual with a
serious general medical condition that is being treated with multiple medication
s.
When there is more than one etiology (e.g., both a substance and a general medic
al
condition), Delirium Due to Multiple Etiologies is diagnosed. If it is not possi
ble to
establish a specific etiology (i.e., substance induced or due to a general medic
al condition),
Delirium Not Othenvise Specified is diagnosed.
The diagnosis of Substance Intoxication Delirium or Substance Withdrawal Deliriu
m
is made instead of Substance Intoxication or Substance Withdrawal only if the
symptoms of the delirium are in excess of those usually associated with the into
xication
or withdrawal syndrome and are sufficiently severe to warrant independentclinica
l
attention. Even in individuals with obvious signs of intoxication or withdrawal,
other possible causes of the delirium (i.e., Delirium Due to a General Medical C
ondition)
must not be overlooked. For example, a head injury that occurs as a result of fa
lls
or fighting during intoxication may be responsible for the delirium.
Delirium that is characterized by vivid hallucinations, delusions, language dist
urbances,
and agitation must be distinguished from Brief Psychotic Disorder, Schizo
phrenia, Schizophreniform Disorder, and other Psychotic Disorders, as well as
from Mood Disorders With Psychotic Features. In delirium, the psychotic symptoms
are fragmented and unsystematized. Delirium that is characterized by mood change
s
and anxiety must also be distinguished from Mood Disorders and Anxiety Disorders
.
Finally, delirium associated with fear, anxiety, and dissociative symptoms such
as depersonalization must be distinguished from Acute Stress Disorder, which is
precipitated by exposure to a severely traumatic event. Psychotic, mood, anxiety
, and
dissociative symptoms associated with delirium typically fluctuate, occur in the
context
of a reduced ability to appropriately maintain and shift attention, and are usua
lly
associated with EEG abnormalities. There is often memory impairment and disorien
tation
in delirium, but generally not in these other disorders. Finally, in delirium, t
he
person generally shows evidence of an underlying general medical condition, Subs
tance
Intoxication or Withdrawal, or medication use.
293.0 Delirium Due to a General Medical Condition 141
Delirium must be distinguished from Malingering and from Factitious Disorder.
This distinction is made based on the often atypical presentation in Malingering
and
Factitious Disorder and the absence of a general medical condition or substance
that
is etiologically related to the apparent cognitive disturbance.
Individuals may present with some but not all symptoms of delirium. Subsyndromal
presentations need to be carefully assessed because they may be harbingers of a
full-blown delirium or may signal an as yet undiagnosed underlying general medic
al
condition. Such presentations should be coded as Cognitive Disorder Not Othenvis
e
Specified.
293.0 Delirium Due to a
General Medical Condition
Diagnostic and Associated Features
The descriptive features of Delirium Due to a General Medical Condition (Criteri
a AC)
are discussed on pp. 136-137. In addition, to diagnose Delirium Due to a General
~'Iedical
Condition, there must be evidence from the history, physical examination, or
laboratory findings that the cognitive disturbance is the direct physiological c
onsequence
of a general medical condition (Criterion D).
In determining whether the delirium is due to a general medical condition, the c
li
nician must first establish the presence of a general medical condition. Further
, the
clinician must establish that the delirium is etiologically related 10 the gener
al medi
cal condition. A careful and comprehensive assessment of multiple factors is nec
es
sary to make this judgment. Although there are no infallible guidelines, several
considerations provide some guidance in this area. One consideration is the pres
ence
of a temporal association between the onset, exacerbation, or remission of the g
eneral
medical condition and that of the delirium. Evidence from the literature that su
ggests
that there can be a direcl association behveen the general medical condition in
ques
tionand the development of a delirium can provide a useful context in the assess
ment
ofa particular situation. In addition, the clinician must also judge thai the di
sturbance
is not better accounted for by a Substance-Induced Delirium or a primary mental
dis
order (e.g., a Manic Episode). This determination is explained in greater detail
in the
"Menial Disorders Due to a General Medical Condition" section (p. 181).
Delirium can be associated with many different general medical conditions, each
ofwhich has characteristic physical examination and laboratory findings. In syst
emic
illnesses, focal neurological signs are not usually found. Various forms of trem
or may
be present. Asterixis, a flapping movement of the hyperextended hands, was origi
naUy described in hepatic encephalopathy but may also be found in association wi
th
other causes of delirium. Signs of autonomic hyperactivity (e.g., tachycardia, s
weat
ing, flushed face, dilated pupils, and elevated blood pressure) conunonly occur.
In
addition to laboratory findings thai are characteristic of etiological general m
edical
conditions (or intoxication or withdrawal stales), the EEG is generaUy abnormal,
showing either generalized slowing or fast activity.
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Recording Procedures
In recording the diagnosis of Delirium Due to a General Medical Condition, the c
linician
should note both the delirium and the identified general medical condition
judged 10 be causing the disturbance on Axis I (e.g., 293.0 Delirium Due to Hypo
glycemia).
The ICD-9-eM code for the general medical condition should also be noted on
Axis ill (e.g., 251.2 hypoglycemia.) (See Appendix G for a list of selected ICD-
9--CM
diagnostic codes for general medical conditions.) When the delirium is superimpo
sed
on a preexisting dementia, both diagnoses should be made (e.g., 294.11 Dementia
of
the Alzheimer's Type, With Behavioral Disturbance, and 293.0 Delirium Due to
Hyponatremia). Since Alzheimer's disease is not an established etiology for deli
rium
but onl)' a risk factor, the etiology of an}' delirium superimposed on Alzheimer
's disease
must be determined. Because of ICD-9-eM coding requirements, delirium superimpos
ed
on Vascular Dementia is noted by coding the appropriate subtype of the
dementia (e.g., 290.41 Vascular Dementia, With Delirium). In situations in which
it is
unclear whether the cognitive deficilS are due to delirium or to dementia, it ma
y be
useful to make a provisional diagnosis of delirium and observe the person carefu
lly
while continuing efforts to identify the nature of the disturbance.
Associated General Medical Conditions
General medical conditions associated with delirium include central nervous syst
em
disorders (e.g., head trauma, ictal and postictal states, vascular diseases such
as
stroke and hypertensive encephalopathy, degenerative diseases such as Pick's dis
-ease,
infection, brain tumor), metabolic disorders (e.g., renal or hepatic disease, fl
uid
or electrolyte imbalance such as dehydration, sodium or potassium imbalance, ane
mia,
hypoxia, hypercarbia, hypoglycemia, thiamine deficiency, hypoalbuminemia,
endocrinopathy, acid-base imbalance), cardiopulmonary disorders (myocardial infa
rction,
congestive heart failure, cardiac arrhythmia, shock, respiratory failure), and
systemic illness or effects (e.g., infection such as septicemia, pneumonia, and
urinary
tract infection; neoplasm; severe trauma; sensory deprivation such as visual and
hearing impairment; temperature dysregulation; postoperative state). Certain foc
al
lesions of the right parietal lobe and inferomedial surface of the occipital lob
e also
may lead to a delirium.
Differential Diagnosis
See p. 139 for a general discussion of the differential diagnosis of delirium.
Substance-Induced Delirium
Diagnostic criteria for 293.0 Delirium Due to ...
[Indicate the General Medical Condition]
A.
Di!iturbance of consciousness (i.e., reduced clarity of awareness of the environ
ment)
with reduced ability to focus, SU!itain, or shift attention.
B.
A change in cognition (such as memory deficit, disorientation, language di!iturb
ance)
or the development of a perceptual di!iturbance that is not better accounted for
by
a preexi!iting, e!itablished. or evolving dementia.
e.
The disturbance develops over a short period of time (usually hours to days) and
tends to fluctuate during the course of the day.
D.
There is evidence from the history. physical examination, or laboratory findings
that
the disturbance is caused by the direct physiological consequences of a general
medical
condition.
Coding note: If delirium is superimposed on a preexisting Vascular Dementia, ind
icate
the delirium by coding 290.41 Vascular Dementia, With Delirium.
Coding note: Include the name of the general medical condition on Axis I, e.g.,
293.0
Delirium Due to Hepatic Encephalopathy; also code the general medical condition
on Axis
III (see Appendix G for codes).
Substance-Induced Delirium
Diagnostic and Associated Features
The descriptive features of Substance-Induced Delirium (Criteria A-e) are discus
sed
on pp. 136-137. In addition, to diagnose Substance-Induced Delirium, there must
be
evidence from the history, physical examination, or laboratory findings of Subst
ance
Intoxication or Withdrawal. medication side effects, or toxin exposure judged to
be
etiologically related to the delirium (Criterion D). A delirium that occurs duri
ng Substance
Intoxication is diagnosed as Substance Intoxication Delirium, and a delirium
that occurs during Substance Withdrawal is diagnosed as Substance Withdrawal Del
irium.
A delirium that is associated with medication side effects or toxin exposure is
diagnosed as Substance-Induced Delirium (see criteria set for Substance lntoxica
tion
Delirium, p. 1-1-5).
Delirium that occurs during Substance Intoxication usually arises within minutes
to hours after taking relatively high doses of certain drugs such as cannabis, c
ocaine,
and hallucinogens. However, onset can also be delayed for some substances that c
an
accumulate O\'er time because they have long half-lives (e.g., diazepam). Usuall
y the
delirium resolves as the intoxication ends or within a few hours to days. Howeve
r,
the duration may be longer after intoxication with phencyclidine and might persi
st
for longer periods for individuals with brain damage, in the elderly, and in ind
ividuals
taking combinations of substances. The time between taking a substance and
onset of Intoxication Delirium may be shorter in individuals having poor clearan
ce
(e.g., due to renal or hepatic disease).
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Delirium that is associated with Substance Withdrawal de\'elops as tissue and
fluid concentrations of the substance decrease after reduction or termination of
sustained,
usually high-dose use of alcohol or sedative, hypnotic, or anxioiytic drugs. In
individuals having poor clearance, experiencing drug interactions, or taking com
binations
of substances, Substance Withdrawal Delirium can occur after the reduction
or termination of lower doses. The duration of the delirium tends to vary with t
he
half-life of the substance im'olved: longer-acting substances usually are associ
ated
with more protracted withdrawal. Substance \\'ithdrawal Delirium may continue fo
r
only a few hours or may persist for as long as 2--4 weeks.
This diagnosis should be made instead of a diagnosis of Substance Intoxication o
r
Substance Withdrawal only when the cognitive symptoms are in excess of those usu
ally
associated with the intoxication or withdrawal syndrome and when the symptoms
are sufficiently se\'ere to warrant independent clinical attention. For a more
detailed discussion of the features associated with Substance-Related Disorders,
see
p. ]91.
Recording Procedures
A diagnosis of Substance-Induced Delirium begins with the name of the specific
substance (rather than the class of substances) that is presumed to be causing t
he delirium
(e.g., "Diazepam" rather than "Sedative, Hypnotic, or Anxiolytic"). The diagnost
ic
code is selected from the listing of classes of substances provided in the crite
ria
set. For substances that do not fit into any of the classes (e.g., digitalis), t
he code for
"Other Substance" should be used. In addition, for medications prescribed at the
rapeutic
doses, the Specific medication can be indicated by listing the appropriate E-cod
e
(see Appendix G). For substances that produce intoxication or withdrawal, the na
me
of the substance is followed by the context in which the symptoms developed (e.g
.,
292.81 Dextroamphetamine Intoxication Delirium; 291.0 Alcohol Withdrawal Deliriu
m).
For medication side effects and toxin exposure, the term "-Induced" is used
(e.g., 292.81 Digitalis-Induced Delirium). When more than one substance is judge
d to
playa significant role in the development of the delirium, each should be listed
separately.
Ifa substance is judged to be the etiological factor but the specific substance
or class of substances is unknown, the diagnosis is 292.81 Unknown SubstanceIndu
ced
Delirium.
Specific Substances
Substance Intoxication Delirium can occur with the follOWing classes of substanc
es:
alcohol; amphetamines and related substances; cannabis; cocaine; hallucinogens;
inhalants;
opioids; phencyclidine and related substances; sedatives, hypnotics, and
anxiolytics; and other or unknown substances. Substance Withdrawal Delirium can
occur with the following classes of substances: alcohol (often called "delirium
tremens");
sedatives, hypnotics, and anxiolytics; and other or unknown substances.
Medications reported to cause delirium include anesthetics, analgesics, antiasth
matic
agents, anticonvulsants, antihistamines, antihypertensive and cardiovascular
medications, antimicrobials, antiparkinsonian drugs, corticosteroids, gastrointe
stinal
medications, histamine Hrreceptor antagonists (e.g., cimetidine), immunosuppres
Substance-Induced Delirium
sive agents, lithium, muscle relaxants, and psychotropic medications with antich
olinergic
side effects. Toxins reported to cause delirium include organophosphate
(anticholinesterase), insecticides, carbon monoxide, and volatile substances suc
h as
fuel or organic solvents.
Differential Diagnosis
See p. 139 for a general discussion of the differential diagnosis of delirium an
d p. 207 for
a discussion of the differential diagnosis of Substance Intoxication and Withdra
wal.
Diagnostic criteria for Substance Intoxication Delirium
A.
Disturbance of consciousness (i.e. reduced clarity of awareness of the environmen
t)
with reduced ability to focus, sustain. or shift attention.
B.
A change in cognition (such as memory deficit, disorientation, language disturba
nce)
or the development of a perceptual disturbance that is not better accounted for
by
a preexisting, established, or evolving dementia.
e.
The disturbance develops over a short period of time (usually hours to days) and
tends to fluctuate during the course of the day.
D.
There is evidence from the history, physical examination, or laboratory findings
of
either (1) or (2):
(1)
the symptoms in Criteria A and 8 developed during Substance Intoxication
(2)
medication use is etiologically related to the disturbance"
Note: This diagnosis should be made instead of a diagnosis of Substance Intoxica
tion
only when the cognitive symptoms are in excess of those usually associated with
the intoxication syndrome and when the symptoms are sufficiently severe to warra
nt
independent clinical attention.
"Note: The diagnosis should be recorded as Substance-Induced Delirium if related
to medication use. Refer to Appendix G for E-eodes indicating specific medicatio
ns.
Code [Specific Substance) Intoxication Delirium:
(291.0 Alcohol; 292.81 Amphetamine [or Amphetamine-Like Substance];
292.81 Cannabis; 292.81 Cocaine; 292.81 Hallucinogen; 292.81 Inhalant;
292.81 Opioid; 292.81 Phencyclidine lor Phencyclidine-Like Substance);
292.81 Sedative, Hypnotic, or Anxiolytic; 292.81 Other lor Unknown] Substance
le.g., cimetidine, digitalis. benztropine))
Delirium. Dementia, and Amnestic and Other Cognitive Disorders
Diagnostic criteria for Substance Withdrawal Delirium
A.
Disturbance of consciousness (i.e. reduced clarity of awareness of the environmen
t)
with reduced ability to focus, sustain, or shift attention.
B.
A change in cognition (such as memory deficit, disorientation, language disturba
nce)
or the development of a perceptual disturbance that is not better accounted for
by
a preexisting, established. or evolving dementia.
e.
The disturbance develops over a short period of time (usually hours to days) and
tends to fluctuate during the course of the day.
D.
There is evidence from the history, physical examination, or laboratory findings
that
the symptoms in Criteria A and Bdeveloped during, or shortly after, a withdrawal
syndrome.
Note: This diagnosis should be made instead of a diagnosis of Substance Withdraw
al
only when the cognitive symptoms are in excess of those usually associated with
the withdrawal
syndrome and when the symptoms are sufficiently severe to warrant independent
clinical attention.
Code (Specific Substancel Withdrawal Delirium:
(291.0 Alcohol; 292.B1 Sedative, Hypnotic. or Anxiolytic; 292.B1 Other lor Unkno
wn]
Substance)
Delirium Due to Multiple Etiologies
The Delirium Due to Multiple Etiologies category is included to alert clinicians
to the
common situation, particularly in critically ill and elderly hospitalized patien
ts, in
which the delirium has more than one etiology. For example, there may be more th
an
one general medical condjtion etiologically related to the delirium (e.g., Delir
ium
Due to Hepatic Encephalopathy, Delirium Due to Head Trauma), or the delirium
may be due to the combined effects of a general medical condition (e.g., viral e
ncephalitis)
and substance use (e.g., Alcohol Withdrawal). A higher number of general
medical conditions and substances is associated with a higher rate of delirium.
Recording Procedures
Delirium Due to Multiple Etiologies does not have ils own separate code and shou
ld
not be recorded as a diagnosis. For example, to code a delirium due to both hepa
tic
encephalopathy and withdrawal from alcohol, the clinician would list both 293.0
Delirium
Due to Hepatic Encephalopathy and 291.0 Alcohol Withdrawal Delirium on
Axis I and 572.2 hepatic encephalopathy on Axis m.
780.09 Delirium Not Otherwise Specified
Diagnostic criteria for Delirium Due to Multiple Etiologies
A.
Disturbance of consciousness (i.e., reduced clarity of awareness of the environm
ent)
with reduced ability to focus, sustain, or shift attention.
B.
Achange in cognition (such as memory deficit, disorientation, language disturban
ce)
or the development of a perceptual disturbance that is not better accounted for
by
a preexisting, established, or evolving dementia.
C.
The disturbance develops over a short period of time (usually hours to days) and
tends to fluctuate during the course of the day.
D.
There is evidence from the history, physical examination, or laboratory findings
that
the delirium has more than one etiology (e.g., more than one etiological general
medical condition, a general medical condition plus Substance Intoxication or me
dication
side effect).
Coding note: Use multiple codes reflecting specific delirium and specific etiolo
gies,
e.g., 293.0 Delirium Due to Viral Encephalitis; 291.0 Alcohol Withdrawal Deliriu
m.
780.09 Delirium Not Otherwise Specified
This category should be used to diagnose a delirium that does not meet criteria
for
any of the specific types of delirium described in this section.
Examples include
1.
A clinical presentation of delirium that is sllspected to be due to a general me
dical
condition or substance use but for which there is insufficient evidence to estab
lish
a specific etiology
2.
Delirium due to causes not listed in this section (e.g., sensory deprivation)
Dementia
The disorders in the "Dementia" section are characterized by the development of
multiple cognitive deficits (including memory impairment) that are due to the di
red
physiological effects of a general medical condition, to the persisting effects
of a substance,
or to multiple etiologies (e.g., the combined effects of cerebrovascular disease
and Alzheimer's disease). The disorders in this section share a corrunon symptom
presentation but are differentiated based on etiology. The diagnostic features l
isted
in the next section pertain to Dementia of the Alzheimer's Type, Vascular Dement
ia,
Dementia Due to HIV Disease, Dementia Due to Head Trauma, Dementia Due
to Parkinson's Disease, Dementia Due to Huntington's Disease, Dementia Due to
Pick's Disease, Dementia Due to Creutzfeldt-Jakob Disease, Dementia Due to Oth
er General Medical Conditions, Substancelnduced Persisting Dementia, and De
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
mentia Due to Multiple Etiologies. In addition, Dementia Not Otherwise Specified
is included in this section for presentations in which the clinician is unable t
o deter
mine a specific etiology for the multiple cognitive deficits.
Diagnostic Features
The essential feature of a dementia is the development of multiple cognitive def
icits
that include memory impairment and at least one of the following cognitive distu
rbances:
aphasia, apraxia, agnosia, or a disturbance in executive functioning. The cognit
ive
deficits must be sufficiently severe to cause impairment in occupational or
social functioning and must represent a decline from a previously higher level o
f
functioning. A diagnosis of a dementia should not be made if the cognitive defic
its
occur exclusively during the course of a delirium. However, a dementia and a del
irium
may both be diagnosed if the dementia is present at times when the delirium is
not present. Dementia may be ctiologically related to a general medical conditio
n, to
the persisting effects of substance use (including toxin exposure), or to a comb
ination
of these factors.
Memory impairment is required to make the diagnosis of a dementia and is a
prominent early symptom (Criterion AI). Individuals with dementia become impaire
d
in their ability to learn new material. or they forget previously learned materi
al.
Most individuals with dementia have both forms of memory impairment,
although it is sometimes difficult to demonstrate the loss of previously learned
material
early in the course of the disorder. They may lose valuables like wallets and ke
ys,
forget food cooking on the stove, and become lost in unfamiliar neighborhoods. I
n
advanced stages ofdementia, mcmory impairment is SO severe that the person forge
ts
his or her occupation, schooling, birthday, family members, and sometimes cven
name.
Memory may be formally tested by asking the pcrson to register, retain, recall,
and
recognize information. The ability to learn new information may be assessed by a
sking
the individual to learn a list of words. The individual is requested to repeat t
he
words (registration), to recall the information after a dela}' of several minute
s (retention,
recall), and to recognize the words from a multiple list (recognition). Individu
als
with difficulty learning new information are not helped by clues or prompts (e.g
.,
multiple-choice questions) because they did not learn the material initially. In
contrast,
individuals with primarily retrieval deficits can bc helped by clues and prompts
because their impairmcnt is in the ability to acccss their memories. Remote memo
ry
may be tested by asking the individual to recall personal information or past ma
terial
that the individual found of interest (e.g., politics, sports, entertainment). I
t is also
useful to determine (from the individual and informants) the impact of the memor
y
disturbances on the individual's functioning (e.g., ability to work, shop, cook,
pay
bills, return home without getting lost).
Deterioration of language function (aphasia) may be manifested by difficulty pr~
dueing the names of individuals and objects (Criterion Ala). The speech of indiv
iduals
with aphasia rna)' become vague orempt)', with long circumlocutory phrases and
excessive use of terms of indefinite reference such as "thing" and "il." Compreh
ension
of spoken and written language and repetition of language rna)' also be compromi
sed.
In the advanced stages of dementia, individuals may be mute or have a deteriorat
ed
Dementia 149
speech pattern characterized by echolalia (i.e., echoing what is heard) or palil
alia (i.e.,
repeating sounds or words over and over). Language is tested by asking the indiv
idual
to name objects in the room (e.g., tie, dress, desk, lamp) or body parts (e.g.,
nose,
chin, shoulder), follow commands ("Point at the door and then at the table"), or
repeat
phrases ("no ifs, ands, or buts").
Individuals with dementia may exhibit apraxia (i.e., impaired ability to execute
motor activities despite intact motor abilities, sensory ftmction, and comprehen
sion
of the required task) (Criterion Alb). They will be impaired in their ability to
pantomime
the useof objects (e.g., combing hair) or to execute known motor acts (e.g., wav
ing
goodbye). Apraxia may contribute to deficits in cooking, dressing, and drawing.
Motor skill disturbances may be tested by asking the individual to execute motor
flUlctions (e.g., to show how to brush teeth, to copy intersecting pentagons, to
assemble
blocks, or to arrange sticks in specific designs).
Individuals with dementia may exhibit agnosia (i.e., failure to recognize or ide
ntify
objects despite intact sensory function) (Criterion Alc). For example, the indiv
idual
may have normal visual acuity but lose the ability to recognize objects such as
chairs or pencils. Eventually they may be unable to recognize family members or
e\'en their own reflection in the mirror. Similarly, they may have normal tactil
e sensation,
but be unable to identify objects placed in their hands by touch alone (e.g., a
coin or keys).
Disturbances in executive functioning are a common manifestation of dementia
(Criterion A2d) and may be related especially to disorders of the frontal lobe o
r associated
subcortical pathways. Executive flUlctioning involves the ability to think
abstractly and to plan, initiate, sequence, monitor, and stop complex behavior.
Impairment
in abstract thinking may be manifested by the individual having difficulty
coping with novel tasks and avoiding situations that require the processing of n
ew
and complex information. The ability to abstract can be formally assessed by ask
ing
the person to find similarities or differences between related words. Executive
dysfunction
is also evident in a reduced ability to shift mental sets, to generate novel ver
bal
or nonverbal information, and to execute serial motor activities. Tests for exec
utive
function include asking the individual to count to 10, recite the alphabet, subt
ract serial
7s, state as many animals as possible in 1 minute, or draw a continuous line con
sisting
of alternating m's and n's. It is also useful to determine (from the individual
and informants) the impact of the disturbances in executive functioning on the i
ndividual's
daily We (e.g., ability to work, plan activities, budget).
The items in both Criterion Al (memory impairment) and Criterion A2 (aphasia,
apraxia, agnosia, or disturbance in executive ftmctioning) must be severe enough
to
cause significant impairment in social or occupational functioning (e.g., going
to
school, working, shopping, dressing, bathing, handling finances, and other activ
ities
of daily living) and must represent a decline from a previous (evel of functioni
ng (Criterion
B). The nature and degree of impairment are variable and often depend on the
particular social setting of the individual. The same level of cognitive impairm
ent
may significantly impair an individual's ability to perform a complex job, but n
ot a
job that is less demanding. Standardized published rating scales that measure ph
ysical
maintenance (e.g., personal hygiene), intellectual flUlctioning, and the ability
to
use implements or tools (e.g., telephone, washing machine) can be used to measur
e
the severity of impairment.
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Dementia is not diagnosed if these symptoms occur exclusively during the course
of a delirium. However, a delirium may be superimposed on a preexisting dementia
,
in which case both diagnoses should be given.
Associated Features and Disorders
Associated descriptive features and mental disorders. Individuals with dementia
may become spatially disoriented and ha,"e difficuJty with spatial tasks. Visuos
patial
functioning can be assessed by asking the individual to copy drawings, such as
a circle, overlapping pentagons, and a cube. Poor judgment and poor insight arec
omman
in dementia. Individuals may exhibit little or no awareness of memory loss or
other cognitive abnormaUties. TIley may make unrealistic assessments of their ab
ilities
and make plans that are not congruent with their deficits and prognosis (e.g.,
planning to start a new busi.ness). They may underestimate the risks involved in
activities
(e.g., driving). Occasionally, they may harm others by becoming violent. Suicida
l
behavior may occur, particularly in early stages when the indi\'iduaJ is more
capable of carrying out a plan of action. Dementia is sometimes accompanied by m
otor
disturbances of gait leading to falls. Some individuals with dementia show disin
hibited
behavior, including making inappropriatejokes, neglecting personal hygiene,
exhibiting undue familiarity with strangers, or disregarding conventional rules
of social
conduct. Slurred speech may occur in dementia thai is associated with subcortica
l
pathology such as Parkinson's disease, Huntington's disease, and some cases of V
ascular
Dementia. The multiple cognitive impainnents of dementia are often associated
with anxiety, mood, and sleep disturbances. Delusions are common, especiaUy thos
e
involving themes of pe.rsecution (e.g., that misplaced possessions have been sto
len).
Hallucinations can occur in all sensory modalities, but visual hallucinations ar
e most
common. Delirium is frequently superimposed on dementia because the underlying
brain disease may increase susceptibility to confusional states that may be prod
uced
by medications or other concurrent general medi.cal conditions. Individuals wilh
dementia
may be especially vulnerable to physical slTessors (e.g., illness or minor surge
ry)
and psychosocial stressors (e.g., going to the hospital, bereavement), which
may exacerbate their intellectual deficits and other associated problems.
Associated laboratory findings. A discussion of associated laboratory findings t
hat
are specific to types of dementia is included in the texi for each dementia. Inv
ariably
there are abnormalities in cognitive and memory functioning, which can be assess
ed
using mental status examinations and neuropsychological testing. Neuroimaging
may aid in the differe.ntial diagnosis of dementia. Computed tomography (Cf) or
magnetic resonance imaging (MRI) may reveal cerebral alTophy, focal brain lesion
s
(cortical strokes, tumors, subdural hematomas), hydrocephalus, or periventricula
r ischemic
brain injury. Functional imaging such as positroncmission tomography
(PEl) or single photon emission computed. tomography (SPECf) are not routinely
used. in the e\aluation of dementia, but may pcovide useful differential diagnost
ic information
(e.g., parietal lobe changes in Alzheimer's disease or frontal lobe alterations
in frontal lobe degenerations) in individuals without e\'idence of structural
changes on cror r-.oo scans.
Dementia 151
Associated physical examination findings and general medical conditions. The
associated physical examination findings of dementia depend on the nature, locat
ion,
and stage of progression of the wlderlying pathology. The most common cause of d
ementia
is Alzheimer's disease. Other frequent forms include Vascular Dementia and
dementia due to other nemodegenerative processes, such as Lewy body disease
(including dementia due to Parkinson's disease) and frontotemporal degeneration
(including Pick's disease). Other causes are less common and include normal-pres
sme
hydrocephalus, Huntington's disease, traumatic brain injury, brain tumors, anoxi
a,
infectious disorders (e.g., human immunodeficiency virus [HIVj, syphilis), prion
diseases
(e.g., Creutzfeldt-Jakob disease), endocrine conditions (e.g., hypothyroidism,
hypercalcemia, hypoglycemia), vitamin deficiencies (e.g., deficiencies of thiami
ne or
niacin), immune disorders (e.g., temporal arteritis, systemic lupus eryUlematosu
s),
hepatic conditions, metabolic conditions (e.g., Kufs' disease, adrenoleukodystro
phy,
metachromatic leukodystrophy, and other storage diseases of adulthood and childh
ood),
and other neurological conditions (e.g., multiple sclerosis).
Specific Culture and Age Features
Cultural and educational background should be taken into consideration in the ev
aluation
of an individual's mental capacity. Individuals from certain backgrounds may
not be familiar with the information used in certain tests of general knowledge
(e.g.,
names of presidents, geographical knowledge), memory (e.g., date ofbirth in cult
ures
that do not routinely celebrate birthdays), and orientation (e.g., sense of plac
e and
location may be conceptualized differently in some cultures). The prevalence of
different
causes of dementia (e.g., infections, nutritional deficiencies, traumatic brain
injury,
endocrine conditions, cerebrovascular diseases, seizure disorders, brain tumors,
substance abuse) varies substantially across cultural groups.
The age at onset of dementia depends on the etiology, but is usually late in lif
e,
with highest prevalence above age 85 years. A significant deterioration in memor
y
and in multiple cognitive skills, which is necessary for the diagnosis of dement
ia, may
be difficult to document in very young children. Thus, the diagnosis of dementia
may
not be practical until the child is older (usually behveen ages 4 and 6 years).
In individuals
under age 18 years with Mental Retardation, an additional diagnOSis of a dementi
a
should be made only if the condition is not characterized satisfactorily by the
diagnosis of Mental Retardation alone. Dementia is uncommon in children and adol
escents,
but can occm as a result of general medical conditions (e.g., head injury,
brain tumors, HIV infection, strokes, adrenoleukodystrophies). Dementia in child
ren
may present as a deterioration in functioning (as in adults) or as a significant
delay or
deviation in normal development. Deteriorating school performance may be an earl
y
Sign.
Prevalence
Reported prevalence of dementia varies among epidemiological studies, depending
on the ages of the subjects sampled; methods of determining the presence, severi
ty,
and type of cognitive impairment; and the regions or countries studied. Communit
y
studies estimated a I-year prospective prevalence of almost 3.0% with severe cog
ni
Delirium. Dementia. and Amnestic and Other Cognitive Disorders
tive impainnent in the adult population. The study assessed individuals with a b
rief
instrument that assessed current cognitive status (the Mini-Mental State Exam),
which does nol identify specific diagnoses. A variety of epidemiological studies
have
shown thallhe prevalence of dementia. especially Dementia of the Alzheimer's Typ
e,
increases with age. The prevalence figures range from l.4'}o to 1.6% for individ
uals
ages 65-69 years, rising 10 16% to 25% for those over age 85 years.
Course
Historically, the term demelltin implied a progressive or irreversible course. T
he DSMIV
definition of demel/tin, howe\'er, is based on the pattern of cognitive deficits
and
carries no connotation concerning prognosis. Dementia may be progressive, static
, or
remitting. The reversibility of a dementia is a function of the underlying patho
logy
and of the availability and timely application of effective treatment. The mode
of onset
and subsequent course of dementia also depend on the underlying etiology. The
level of disability depends not only on the severity of the individual's cogniti
ve impairments
but also on the available social supports. In advanced dementia, the individual
may become totall)' oblivious to his or her surroundings and require constant
care. Individuals with scvere dementia are susceptible to accidents and infectio
us diseases,
which often prove fatal.
Differential Diagnosis
Memory impairment occurs in both delirium and dementia. Delirium is also charact
erized
by a reduced ability to maintain and shift attention appropriately. The clinical
course can help to differentiate between delirium and dementia. Typically, symp-
toms
in delirium fluctuate and symptoms in dementia are relativelv stahl~cognitive
imp-airments that..persist-irwm_unchanged form for more than a few months
suggest dementia rather tb.<Ul_drlirium.J2elirium may be superimposed on a deUle
ll:-ria,
in which case both disorders are diagnosed. In situations in which it is unclear
whether the cognitive deficits are due to a delirium or a dementia, it may be us
eful to
make a provisional diagnosis of delirium and observe the person carefully while
con
tinuing efforts to identify the natu.re of the disturbance.
An amnestic disorder is characterized by severe memory impairment without other
significant impairments of cognitive functioning (I.e., aphasia, apraxia, agnosi
a, or
disturbances in executive functioning).
The presumed etiology determines the specific dementia diagnosis. If the clinici
an
has determined that the dementia is due to multiple etiologies, multiple codes b
ased
on the specific dementias and their etiologies should be used (see Dementia Due
to
Multiple Etiologies, p. 170). In Vascular Dementia, focal neurological signs (e.
g., exaggeration
of deep tendon reflexes, extensor plantar response) and laboratory evidence
of vascular disease judged to be related to the dementia are present. The
clinical course of Vascular Dementia is variable and typically progresses in ste
pwise
fashion. The presence of Dementia Due to Other General Medical Conditions (e.g.,
Pick's disease, HI\') requires evidence from the history, physical examination,
and
appropriate laboratory tests that a general medical condition is etiologically r
elated
to the dementia. The onset of the deterioration (gradual or sudden) and its cour
se
Dementia
1531
(acute, subacute, or chronic) may be useful in suggesting the etiology. For exam
ple,
the severity of the impairment in cognitive functioning often remains static aft
er head
injury, encephalitis, or stroke.
~'Iultiple
cognitive deficits that occur only in the context of substance use are diagnosed
as Substance Intoxication or Substance Withdrawal. If the dementia results
from the persisting effects of a substance (i.e., a drug of abuse, a medication,
or toxin
exposure), then Substance-Induced Persisting Dementia is diagnosed. Other causes
of dementia (e.g., Dementia Due to a General Medical Condition) should always be
considered, even in a person with Substance Dependence. For example, head injury
is not infrequent during substance use and may underlie the dementia. Although r
esearchers
are seeking to develop sensitive and specific tests to confirm the diagnosis
of Dementia of the Alzheimer's Type, it currently remains a diagnosis of exclusi
on,
and other causes for the cognitive deficits (see above) must first be ruled out.
In addition,
the course is dlaracterized by gradual onset and continuing cognitive decline.
In those cases in which there is insufficient evidence to determine whether the
dementia
is due to a general medical condition or is substance induced, Dementia Not
Othenvise Specified should be coded.lndividuals may present with some but not al
l
of the symptoms of dementia. Such presentations should be coded as Cognitive Dis
order
Not Othenvise Specified.
Mental Retardation is characterized by significantly subaverage current general
intellectual functioning, with concurrent impairments in adaptive functioning an
d
with an onset before age ]8 years. Mental Retardation is not necessarily associa
ted
with memory impairment. In contrast, the age at onset of dementia is usually lat
e in
life. If the onset of the dementia is before age 18 years, both dementia and Men
tal Retardation
may be diagnosed. if the criteria for both disorders are met. Documenting
a significant deterioration in memory and in other cognitive skills, which is ne
cessary
for the diagnosis of dementia, may be difficult in persons under age .. years. I
n individuals
under age 18 years, the diagnosis of dementia should be made only if the conditi
on
is not characterized satisfactorily by the diagnosis of Mental Retardation alone
.
Schizophrenia can also be associated with multiple cognitive impairments and a
decline in functioning, but Schizophrenia is unlike dementia in its generally ea
rlier
age at onset, its characteristic symptom pattern, and the absence of a specific
etiological
general medical condition or substance. Typically, the cognitive impairment asso
ciated
with Schizophrenia is less severe than that seen in Dementia.
Major Depressive Disorder may be associated with complaints of memory impainnent
,
difficulty thinking and concentrating, and an overall reduction in intellectual
abilities. Individuals sometimes perfonn poorly on mental status examinations
and neuropsychological testing. Particularly in elderly persons, it is often dif
ficult to
determine whether cognitive symptoms are better accounted for by a dementia or b
y
a Major DepreSSive Episode. This differential diagnosis may be informed by a tho
rough
medical evaluation and an evaluation of the onset of the disturbance, the tempor
al
sequencing of depressive and cognitive symptoms, the course of illness, family
history, and treatment response. The premorbid state of the individual may help
to
differentiate "pseudodementia" (i,e., cognitive impairments due to the ~'fajor
Depressh"
e Episode) from dementia. In dementia, there is usually a premorbid history of d
eclining
cognitive function, whereas the individual with a Major Depressive Episode
is much more likely to have a relatively nonnal premorbid state and abrupt cogni
tive
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
decline associated with the depression.lf the clinician determines that both a d
ementia
and Major Depressive Disorder are present with independent etiologies, both
should be diagnosed.
Dementia must be distinguished from Malingering and Factitious Disorder. The
patterns of cognitive deficits presented in Malingering and Factitious Disorder
are
usually not consistent over time and arc not characteristic of those typically s
een in
dementia. For example, individuals with Factitious Disorder or Malingering manif
esting
as dementia may perform calculations while keeping score during a card
game, but then claim to be unable to perform similar calculations during a menta
l status
examination.
Dementia must be distinguished from the normal decline in cognitive functioning
that occurs with aging (as in Age-Related Cognitive Decline). The diagnosis of d
ementia
is warranted only if there is demDnstrable evidence of greater memDry and
other cognitive impairment than would be expected due to normal aging processes
and the symptoms cause impairment in social or Dccupational flUlctiDning.
294.1x* Dementia of the Alzheimer's Type
Diagnostic Features
The cognitive deficits (Criterion A) and the required impairment (Criterion B) a
re discussed
on pp. 147-150. The onset of Dementia of the Alzheimer's Type is gradual and
involves continuing cognitive decline (CriteriDn C). Because of the difficulty D
f obtaining
direct pathological evidence of the presence of Alzheimer's disease, the diagnDs
is
can be made only when other etiologies for the dementia have been ruled out.
Specifically, the cognitive deficits are nDt due to other central nervous system
conditions
that cause progressive deficits in memory or cognition (e.g., cerebrovascular
disease, Parkinson's disease, Hlmtington's disease), systemic conditions that ar
e
known to cause dementia (e.g., hypothyroidism, vitamin B12 deficiency, HIV infec
tion),
or the persisting effects of a substance (e.g., alcohol) (Criterion D). If there
is an
additional etiDlogy (e.g., head trauma worsening a Dementia of the Alzheimer's
Type), both types of dementia should be coded (see Dementia Due to Multiple Etio
logies,
p. 170). Dementia of the Alzheimer's Type should not be diagnosed if the
symptDms occur exclusively during delirium (Criterion E). However, delirium may
be superimposed on a preexisting Dementia of the Alzheimer's Type, in which case
the With Delirium subtype should be indicated. Finally, the cognitive deficits a
re not
better accounted for by another Axis I disorder (e.g., Major Depressive Disorder
or
Schizophrenia) (Criterion F).
Subtypes
The age at Dnset of Dementia of the Alzheimer's Type is indicated by the use of
one
of the follOWing subtypes:
ICD-9-CM code v.11id after October 1,2000.
294.1x* Dementia of the Alzheimer's Type
With Early Onset. This subtype is used if the onset of the dementia is age
65 years or under.
With Late Onset. This subtype is used if the onset of the dementia is after age
65 years.
The presence or absence of a clinically significant behavioral disturbance is in
dicated
by using one of the following coded subtypes:
.10 Without Behavioral Disturbance. This subtype is used if the cognitive
disturbance is not accompanied by any clinically significant behavioral disturba
nce.
.11 With Behavioral Disturbance. This subtype is used if the cognitive disturban
ce
is accompanied by a clinically significant behavioral disturbance
(e.g., wandering, agitation).
Recording Procedures
The diagnostic code depends entirely on the presence or absence of a clinically
Signif
icant behavioral disturbance and not whether the dementia is of early versus lat
e on
set. Thus, the diagnostic code is 294.10 for Dementia of the Alzheimer's Type, W
ith
Early Onset, Without Behavioral Disturbance; 294.10 for Dementia of the Alzheime
r's
Type, With Late Onset, Without Behavioral Disturbance;}94.11 for Dementia of the
Alzheimer's Type, With Early Onset. With...Jl#1avioral Disturbance; and 294.11 f
or
-Dementia of the Alzheimer's Type, With Late Onset, With Behavioral Disturbance.
In
addition, 331.0 Alzheimer's disease should be coded on Axis m.
Other prominent clinical features related to the Alzheimer's disease can be indi
cat
ed by coding the specific additional mental disorders due to Alzheimer's disease
on
Axis I. For example, to indicate the presence of prominent delusions, clinically
siglill
kant depressed mood, and the development of persistent aggressive behavior, 293.
81
Psychotic Disorder Due to Alzheimer's Disease, With Delusions; 293.83 Mood Dis
order Due to Alzheimer's Disease, With Depressive Features; and 310.1 Personalit
y
Change Due to Alzheimer's Disease, Aggressive Type, would also be coded on Axis
1.
Associated Features and Disorders
Associated descriptive features and mental disorders. See p. 150 for a general
discussion of features and disorders associated with dementia. The prevalence of
Dementia
of the Alzheimer's Type is increased in individuals with Down syndrome and
in individuals with a history of head trauma. Pathological changes that are char
acteristic
of Alzheimer's disease are present in the brains of individuals with Down syndro
me
by the time they are in their early 40s, although the clinical symptoms of
dementia are not usually evident until later.
Associated laboratory findings. widely accepted, sensitive, and specific
biological marker is currently available that is universally accepted as diagnos
tic of
Dementia of the Alzheimer's Type in a living individuaL In the majority of cases
,
br,1in atrophy is present in Dementia of the Alzheimer's Type, with wider cortic
al
-
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
sulci and larger cerebral ventricles than would be ex ected ven the normal agio
process. may e emonstrated by computed tomography (CT) or magnetic res
onance imaging (~1RI).
Microscopic examination usually reveals histopathological
changes, including senile plaques, neurofibrillary tangles, granulovascular dege
neration.
neuronal loss, astrocytic gliosis, and amyloid angiopathy. Lewy bodies are
sometimes seen in the cortical neurons.
Associated physical examination findings and general medical conditions. In the
first years of illness, few moior and sensory signs are associated with Dementia
of the
Alzheimer's Type. Later in the course, myoclonus and gait disorder may appear. S
eizures
occur in approximately 10% of individuals with the disorder.
Specific Culture, Age, and Gender Features
See p. 151 for a general discussion of culture and age features associated with
dementia.
Late onset (after age 65 years) of Dementia of the Alzheimer's Type is much morc
common than early onsel. Few cases develop before age 50 years. The disorder is
slightly mOTC common in females than in males.
Prevalence
The prevalence of Dementia of the Alzheimer's Type increases dramatically with i
ncreasing
age. rising from 0.6% in males and 0.8% in females at age 65 (all levels of seve
rity)
to 11% in males and 14% in females at age 85. At age 90 the prevalence rises to
21% in males and 25% in females, and by age 95 the prevalence is 36% in males an
d
-11% in females. Moderate to severe cases make up about 40%...60% of these estim
ated
prevalence rates.
Course
See p. 152 for a general discussion of the course of dementia. The course of Dem
entia
of the Alzheimer's Type tends to be slowly progressive, with a loss of 3-4 point
s per
year on a standard assessment instrument such as the MiniMental State Exam. Vario
us
patterns of deficits are seen. A common pattern is an insidious onset, with earl
)'
deficits in recent memory followed by the development of aphasia, apraxia, and a
gnosia
after several years. Many individuals show personality changes, increased irrita
bility,
and other behavioral signs and symptoms, starting in the early stages and
becoming most pronounced in the middle stages of the disease. In the later stage
s of
the disease, individuals may develop gait and motor disturbances and eventually
become
mute and bedridden. The average duration of the illness from onset of sym?,"
toms to death is 8-10 years.
Familial Pattern
Compared with the general population, first-degree biological relatives of indh'
iduals
with Dementia of the Alzheimer's Type, With Early Onset, are more likely to deve
lop
the disorder. Late-onset cases may also have a genetic component. Dementia of
294.1x* Dementia of the Alzheimer's Type
the Alzheimer's Type in some families has been shown to be inherited as an autos
omal
dominant trait with linkage to several chromosomes, including chromosomes 1,
14, and 21. However, the proportion of cases that are related to specific inheri
ted
abnonnalities is not known. Individuals carrying one or both alleles coding for
apolipoprotein
E-4 (APOE4) on chromosome 19 bear an elevated risk for later-onset
Alzheimer's disease, although this gene is not itself a cause of the disorder.
Differential Diagnosis
See
p. 152 for a general discussion of the differential diagnosis of dementia.
Diagnostic criteria for 294.1x Dementia of
the
Alzheimer's Type
A.
The development of multiple cognitive deficits manifested by both
v(1)
memory impairment (impaired ability to learn new information or to recall previo
usly
learned information)
(2)
one (or more) of the following cognitive disturbances:
via)
aphasia (language disturbance)
(b)
apraxia (impaired ability to carry out motor activities despite intact motor
function)
(c)
agnosia (failure to recognize or identify objects despite intact sensory
function)
(d)
disturbance in executive functioning (i.e., planning, organizing, sequencing,
abstracting)
B,/The cognitive deficits in Criteria Al and A2 each cause significant impairmen
t in soJ
ciaI or occupational functioning and represent a significant decline from a prev
ious
level of functioning.
/
..-c.
The course is characterized by gradual onset and continuing cognitive decline.
D.
The cognitive deficits in Criteria Aland A2 are not due to any of the following:
,7
~other central nervous system conditions that cause progressive deficits in memo
ry
and cognition (e.g., cerebrovascular disease, Parkinson's disease, Huntington's
disease, subdural hematoma, normal-pressure hydrocephalus, brain
tumor)
(2)
systemic conditions that are known to cause dementia (e.g., hypothyroidism,
J
vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyp
hilis,
HIV infection)
(3)
substance-induced conditions
1,./The deficits do not occur exclusively during the course of a delirium.
/"The disturbance is not better accounted for by another Axis I disorder (e.g.,
Major Depressive
Disorder, Schizophrenia).
Code based on presence or absence of a clinically significant behavioral disturb
ance:
294.10
Without Behavioral Disturbance: if the cognitive disturbance is not
accompanied by any clinically significant behavioral disturbance.
Delirium. Dementia, and Amnestic and Other Cognitive Disorders
Diagnostic criteria for 294.1 x Dementia of
the Alzheimer's Type (continued)
294.11 With Behavioral Disturbance: if the cognitive disturbance is accompanied
by a clinically significant behavioral disturbance (e.g.. wandering, agitation).
Specify subtype:
With Early Onset: if onset is at age 65 years or below
With Late Onset: if onset is after age 65 years
Coding note: Also code 331.0 Alzheimer's disease on Axis III. Indicate other pro
minent
clinical features related to the Alzheimer's disease on Axis I (e.g., 293.83 Moo
d Disorder
Due to Alzheimer's Disease, With Depressive Features, and 310.1 Personality Chan
ge Due
to Alzheimer's Disease, Aggressive Type).
290.4x Vascular Dementia
(formerly Multi-Infarct Dementia)
Diagnostic Features
The cognitive deficits (Criterion A) and the required impairment (Criterion B) i
n Vascular
Dementia are discussed on pp. 147-150. There must be evidence of cerebrovascular
disease (i.e., focal neurological signs and symptoms or laboratory evidence) tha
t
is judged to be etiologically related to the dementia (Criterion C). The focal n
eurological
signs and symptoms include extensor plantar response, pseudobulbar palsy, gait
abnormalities, exaggeration of deep tendon reflexes, or weakness of an extremity
.
Computed tomography (cr) of the head and magnetic resonance imaging (MRl) usuall
y
demonstrate multiple vascular lesions of the cerebral cortex and subcortical
structures. Vascular Dementia is not diagnosed if the symptoms occur exclusively
during delirium (Criterion D). However, delirium may be superimposed on a preexi
sting
Vascular Dementia, in which case the subtype With Delirium should be indicated.
Subtypes
By ICD-9-0vl convention, Vascular Dementia is the only type of dementia that emp
loys
subtypes to indicate the presence of significant associated symptoms. The follow
ing
subtypes (each of which has its own separate code) must be used to indicate
the predominant feature of the current clinical presentation:
With Delirium. This subtype is used if delirium is superimposed on the dementia.
With Delusions. This subtype is used if delusions are the predominant feature.
290Ax Vascular Dementia (formerly Multi-Infarct Dementia)
With Depressed Mood. This subtype is used if depressed mood (including
presentations that meet symptom criteria for a Major Depressive Episode) is
the predominant feahue. A separate diagnosis of Mood Disorder Due to a
General Medical Condition is not given.
Uncomplicated. This subtype is used if none of the above predominates in
the Clurent clinical presentation.
The specifier With Behavioral Disturbance (wh.icll camlOt be coded) C.1I1 also b
e
used to indicate clinically significant behavioral disturbances (e.g., wandering
).
Recording Procedures
By ICD-9-CM convention, only Vascular Dementia has codable subtypes. The diagnos
tic
codes for Vascular Dementia depend on the subtype for predominant features:
290.41 for "'Vith Delirium, 290.42 for With Delusions, 290.43 for With Depressed
~'lood,
290.40 for Uncomplicated. The specifier \o\'ith Behavioral. Disturbance is uncod
ed
and can be applied to each of the above subtypes (e.g., 290.43 Vascular Dementia
,
With Depressed Mood, With Behavioral Disturbance). In addition, the cerebrovascu
lar
condition (e.g., 436 stTOke) should be coded on Axis lil.
Associated Features and Disorders
Associated descriptive features and mental disorders. See p. 150 for a general d
iscussion
of features and disorders associated with dementia.
Associated laboratory findings. The extent of central nervous system lesions de~
lected by CT and MRI in Vascular Dementia typically exceeds the extent of change
s
detected in the brains of healthy elderly persons (e.g., periventricular and whi
te matter
hyperintensities noted on MRl scans). Lesions often appear in both white matter
and gray matter structures, including subcortical regions and nuclei. Evidence o
f old
infarctions (e.g., focal atrophy) may be detected, as well as findings of more r
ecent
disease. EEG findings may reflect focal lesions in the brain. In addition, there
may be
laboratory evidence of associated cardiac and systemic vascular conditions (e.g.
, ICG
abnormalities, laboratory evidence of renal failure).
Associated physical examination findings and general medical conditions.
Common neurological signs (e.g., abnormal reflexes, weakness of an extremity, ga
it
disturbance) are discussed in the "Diagnostic Features" section. There is often
evidence
of long~sta.ndingarlerial hypertension (e.g., funduscopic abnormalities, enlarge
d
heart), valvular heart disease (e.g., abnormal heart sounds), or extracranial. v
ascular
disease that may be sources of cerebral emboli. A single stroke may cause a rela
tively
circumscribed change in mental state (e.g., an aphasia. following damage to the
left
hemisphere, or an amnestic disorder from infarction in the distribution of the p
osterior
cerebral arteries), but generally does not cause Vascular Dementia, whicll Iypic
ally
results from the occurrence of multiple strokes, usually at different times.
Delirium, Dementia. and Amnestic and Other Cognitive Disorders
Specific Culture, Age, and Gender Features
See p. 151 for a general discussion of culture and age features of dementia.
The onset of Vascular Dementia is typically earlier than thai of Dementia of the
Alzheimer's Type. The disorder is apparently more common in males than in female
s.
Prevalence
Vascular Dementia is reportedly much less common than Dementia of the Alzheimer'
s
Type.
Course
See p. 152 for a general discussion of the course of dementia.
The onset of Vascular Dementia is typicaUy abrupt, followed by a stepwise and
fluctuating course that is characterized by rapid changes in functioning rather
than
slow progression. The course, however, may be highly variable, and an insidious
onset with gradual decline is also encountered. Usually the pattern of deficits
is
"patchy," depending on which regions of the brain have been destroyed. Certain c
ogniti\'
e functions may be affected early, whereas others remain relatively unimpaired.
Early treatment of hypertension and vascular disease may prevent further progres
sion.
Differential Diagnosis
See p. 152 for a general discussion of the differential diagnosis of dementia.
290.4x Vascular Dementia (formerly Multi-Infarct Dementia)
Diagnostic criteria for 290.4x Vascular Dementia
A.
The development of multiple cognitive deficits manifested by both
(1)
memory impairment (impaired ability to learn new information or to recall previo
usly
learned information)
(2)
one (or more) of the following cognitive disturbances:
(a)
aphasia (language disturbance)
(b)
apraxia (impaired ability to carry out motor activities despite intact motor
function)
(c)
agnosia (failure to recognize or identify objects despite intact sensory
function)
(d)
disturbance in executive functioning (i.e., planning, organizing, sequencing,
abstracting)
B.
The cognitive deficits in Criteria Aland A2 each cause significant impairment in
social
or occupational functioning and represent a significant decline from a previous
level of functioning.
C.
Focal neurological signs and symptoms (e.g., exaggeration of deep tendon reflexe
s,
extensor plantar response, pseudobulbar palsy, gait abnormalities, weakness of a
n
extremity) or laboratory evidence indicative of cerebrovascular disease (e.g., m
ultiple
infarctions involving cortex and underlying white matter) that are judged to be
etiologically
related to the disturbance.
D.
The deficits do not occur exclusively during the course of a delirium.
Code based on predominant features:
290.41 With Delirium: if delirium is superimposed on the dementia
290.42 With Delusions: if delusions are the predominant feature
290.43 With Depressed Mood: if depressed mood (including presentations
that meet full symptom criteria for a Major Depressive Episode) is the predomina
nt
feature. A separate diagnosis of Mood Disorder Due to a General Medical Conditio
n
is not given.
290.40 Uncomplicated: if none of the above predominates in the current
clinical presentation
Specify if:
With Behavioral Disturbance
Coding note: Also code cerebrovascular condition on Axis III.
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Dementias Due to
Other General Medical Conditions
Diagnostic Features
The cognitive deficits (Criterion A) and the required impairment (Criterion B) o
f Dementia
Due to Other GeneraJ Medical Conditions are discussed on pp. 147-150. There
must be evidence from the history. physical examination. or laboratory findings
that
a general medical condition (other than Alzheimer's disease or cerebrovascular d
isease)
is etiologically related to the dementia (e.g., HN infection, traumatic brain in
jury.
Parkinson's disease, Huntington's disease. Pick's disease, Creutzfeldt-Jakob
disease, normal-pressure hydrocephalus. hypothyroidism, brain tumor, or vitamin
812 deficiency) (Criterion C). Dementia Due to a General Medical Condition is no
t di
agnosed if the symptoms occur exclusively during delirium (Criterion D). However
,
delirium may be superimposed on a preexisting Dementia Due to a General Medical
Condition, in which case both diagnoses should be given.
In determining whether the dementia is due to a general medical condition, thecl
i
nician must first establish the presence of a general medical condition. Further
, the
clinician must establish that the dementia is etiologically related to the gener
al medical
condition through a physiological mechanism. A careful and comprehensive assessm
ent
of multiple factors is necessary to make this judgment. Although there are
no infallible guidelines for determining whether the relationship between the de
mentia
and the general medical condition is etiological, several considerations proVide
some guidance in this area. One consideration is the presence of a temporal asso
ciation
between the onset or exacerbation of the general medical condition and that of
the cognitive deficits. Evidence from the literature that suggests that there ca
n be a
direct association behveen the general medical condition in question and the dev
el
opment of a dementia can prO\'ide a useful context in the assessment of a partic
ular
situation. In addition, the clinician must also judge that the disturbance is no
t better
accounted for by Dementia of the Alzheimer's Type, Vascular Dementia, a Substanc
eLnduced
Persisting Dementia, or another mental disorder (e.g., Major Depressive Dis
order). These determinations are explained in greater detail in the "Mental Diso
rders
Due to a General Medical Condition" section (p. 181).
See p. 150 for a general discussion of the features and disorders associated wit
h dementia.
Subtypes
The presence or absence of a clinically Significant behavioral disturbance can b
e indio
cated by using one of the following coded subtypes:
.10 Without Behavioral Disturbance. nussubtype is used if thecogruti\'e
disturbance is not accompanied by any clinically Significant behavioral disturba
nce.
.11 With Behavioral Disturbance. nusSUbtype is used if the cognitive disturbance
is accompanied by a clinically significant behavioral disturbance
(e.g., wandering, agitation).
294.1x* Dementia Due to H1V Disease
Recording Procedures
The diagnostic codes are selected depending on whelher there is a clinically sig
nifi
cant behavioral disturbance (i.e., Ihe diagnostic code 294.10 applies when Ihere
is no
clinically Significant behavioral disturbance, and 294.11 applies when Ihere is
a clinically
Significant behavioral disturbance accompanying Ihe cognitive defidts). The
ICo.9-CM code for the etiological condition should also be noted on Axis III (e.
g.,
332.0 Parkinson's disease, 331.1 Pick's disease, 244.9 hypothyroidism). (See App
endix
G for a list of selected ICD-9-CM diagnostic codes for general medical condition
s.)
In an individual with an established history of a dementia, a superimposed Delir
ium
Due to a General Medical Condition should be noted by coding both the dementia
and the delirium on Axis I (e.g., 294.1 Dementia Due to Parkinson's Disease and
293.0 Delirium Due to Hepatic Encephalopathy). This is in contrast to Vascular D
ementia,
in which the "Vith Delirium subtype is spedfied.
Other prominent clinical features related to the etiological general medical con
dition
can be indicated by coding the specific additional Mental Disorder Due to Genera
l
Medical Condition on Axis 1. For example, to indicate the presence of prominent
delusions, clinically significant depressed mood, and a change to a labile perso
nality
in an individual with Dementia Due to Parkinson's Disease, 293.81 Psychotic Diso
rder
Due to Parkinson's Disease, With Delusions; 293.83 Mood Disorder Due to Par
kinson's Disease, With Depressive Features; and 310.1 Personality Change Due to
Parkinson's Disease, labile Type would also be coded on Axis I.
294.1x Dementia Due to HIV Disease
The essential feature of Dementia Due to HIV Disease is the presence of a dement
ia
that is judged to be the direct pathophysiological consequence of human immunode
ficiency
virus (HIV) disease. Neuropathological findings most commonly involve
diffuse, multifocal destruction of the white matter and subcortical structures.
The spinal
nuid may show normal or slightly elevated protein and a mild lymphocytosis,
and HIV can usually be isolated directly from cerebrospinal nuid. Dementia that
is
associated with direct HIV infection of the central nervous system is typically
characterized
by forgetfulness, slowness, poor concentration, and difficulties with problem
solVing. Behavioral manifestations most commonly jncludfLapjtili and social with
~
an
occasionally these may' be accompanied by-delirium, delusions, or hal!
cinatioQ? Tremor, impaired rapid repetitive movements, imbalance, ataxia,
hypertonia, generalized hyperrenexia, positive frontal release signs, and impair
ed
pursuit and saccadic eye movements may be present on physical examination. Child
ren
may also develop Dementia Due to HIV Disease, typically manifested by developmen
tal
delay, hypertonia, microcephaly, and basal ganglia calcification. Dementia
in association with HIV infection may also result from accompanying central nen'
ous
system tumors (e.g., primary central nervous system lymphoma) and from opportuni
stic
infections (e.g., toxoplasmosis, cytomegalovirus infection, cryptococcosis, tube
rculosis,
and syphilis), in which case the appropriate type of dementia should be
diagnosed (e.g., 294.1 Dementia Due to Toxoplasmosis). Unusual systemic infectio
ns
ICD-9-e1'.1 code \'alid after October 1, 2000.
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
(e.g., Plleufllocystis cnrillii pneumonia) or neoplasms (e.g., Kaposi's sarcoma)
may also
be present.
294.1x* Dementia Due to Head Trauma
The essential feature of Dementia Due to Head Trauma is the presence of a dement
ia
that is judged to be the direct pathophysiological consequence of head trauma. T
he
degree and type of cognitive impainnents or behavioral disturbances depend on th
e
location and extent of the brain injury. Posttraumatic amnesia is frequently pre
sent,
along with persisting memory impairment. A variety of other behavioral symptoms
may be evident. with or without the presence of motor or sensory deficits. These
symptoms include aphasia, attentional problems, irritability, anxiety, depressio
n or
affective lability, apathy, increased aggression, or other changes in personalit
y. Alcohol
or other Substance Intoxication is often present in individuals with acute head
injuries,
and concurrent Substance Abuse or Dependence may be present. Head injury
occurs most often in young males and has been associated with risk-taking behavi
ors.
When it occurs in the context of a single injury, Dementia Due to Head Trauma is
usually
nonprogressive, but repeated head injury (e.g., from boxing) may lead to a progr
essive
dementia (so-caUed dementia pugilistica). A single head trauma that is
followed by a progressive decline in cognitive function should raise the possibi
lity
of another superimposed process such as hydrocephalus or a Major Depressive
Episode.
294.1x* Dementia Due to Parkinson's Disease
The essential feature of Dementia Due to Parkinson's Disease is the presence of
a dementia
that is judged to be the direct pathophysiological consequence of Parkinson's
disease. Parkinson's disease is a slowly progressive neurological condition, cha
racterized
by tremor, rigidity, bradykinesia, and postural instability. Dementia has been
reported to occur in approximately 20"/0-60"/0 of individuals with Parkinson's d
isease
and is more likely to be present in older individuals or those with more severe
or advanced
disease. The dementia associated with Parkinson's disease is characterized b}'
cognitive and motoric slowing, executive dysfunction, and impaimlent in memory
retricval Declining cognitive performance in individuals with Parkinson's diseas
e is
frequently exacerbated by depression. Findings on physical examination include t
he
characteristic abnonnal motor signs of resting tremor, evidence of slowness and
po\'erty
of movement (such as micrographia), or muscular rigidity and loss of associated
movements. At autopsy, neuronal loss and Lewy bodies are evident in the substant
ia
nigra. There are a number of syndromes that may manifest with dementia, parkinso
nian
movement disorders, and additional neurological features (e.g., progressive
supranuclear palsy, olivopontocerebeUar degeneration, and Vascular Dementia).
Some individuals with Parkinson's disease and dementia are found at autopsy to
have coexisting neuropathology indicative of Alzheimer's disease or of diffuse L
ew)'
body disease. Dementia due to Lew)' &dy Disease in the absence of evidence of Pa
rkinson's
(such as tremor and cogwheel rigidity) should be diagnosed as Dementia
ICD-9-CM code valid after October 1, 2000.
J
294.1x Dementia Due to Huntington's Disease
Due to Lewy body disease, one of the dementias due to other general medical cond
itions
(see p. 167).
294.1x* Dementia Due to Huntington's Disease
The essential feature of Dementia Due to Huntington's Disease is the presence of
a
dementia that is judged to be the direct pathophysiological consequence of Hunti
ngton's
disease. Huntington's disease is an inherited progressive degenerative disease
of cognition, emotion, and movement. The disease affects men and women equally
and is transmitted by a single autosomal dominant gene on the short arm of chrom
osome
4. The disease is usually diagnosed in the late 30s to early 40s but may begin a
s
early as age 4 years in the juvenile form or as late as age 85 years in the late
-onset
fonn. The onset of Huntington's disease is often heralded by insidious changes i
n beha\'
ior and personality, including depression, irritability, and anxiety. Some indiv
iduals
present with abnormalities of movement that resemble increased fidgeting and
that later progress to characteristic generalized choreoathetosis. Difficulties
with
memory retrieval, executive functioning, and judgment are common early in the
course, with more severe memory deficits occurring as the disease progresses. Di
sorganized
speech and psychotic features are sometimes present. Late in the disease,
characteristic "boxcar ventricles" may be seen on structural brain imaging due t
o the
atrophy of the striatum. Positron-emission tomography (PET) may show striatal hy
pometabolism
early in the disease. Offspring of individuals with Huntington's disease
have a 50% chance of developing the disease. A genetic test is available to
determine with relative certainty whether a given at-risk individual is likely t
o develop
the disease; however, such testing may be best administered by centers with expe
rience
in counseling and foUow-up of individuals at risk for Huntington's disease.
294.1x* Dementia Due to Pick's Disease
The essential feature of Dementia Due to Pick's Disease is the presence of a dem
entia
that is judged to be the direct pathophysiological consequence of Pick's disease
.
Pick's disease is a degenerative disease of the brain that particularly affects
the frontal
and temporal lobes. As in other frontal lobe dementias, Pick's disease is charac
terized
clinically by changes in personality early in the course, deterioration of socia
l skills,
emotional blunting, behavioral disinhibition, and prominent language abnormaliti
es.
Difficulties with memory, apraxia, and olher features of dementia usually foUow
later
in the course. Prominent primitive reflexes (snout, suck, grasp) may be present.
As
the dementia progresses, it may be accompanied by either apathy or extreme agita
tion.
Individuals may develop such severe problems in language, attention, or behavior
that it may be difficult to assess their degree of cognitive impairment. Structu
ral
brain imaging typically reveals prominent frontal and/or temporal atrophy, and
functional brain imaging may localize frontotemporal hypometabolism, even in the
absence of clear structural atrophy. The disorder most commonly manifests itself
in
individuals between ages 50 and 60 years, although it can occur among older indi
viduals.
Pick's disease is one of the pathologically distinct etiologies among lhe hetero
geneous
group of dementing processes that are associated wilh frontotemporal brain
'ICD9-eM code valid after October I, 2000.
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
atrophy. The specific diagnosis of a frontal lobe dementia such as Pick's diseas
e is
usually established at autopsy with the pathologicaI finding of characteristic i
ntranewonal
argentophilic Pick inclusion bodies. Clinically, Pick's disease often cannot
be distinguished with certainty from atypical cases of Alzheimer's disease or fr
om
other dementias that affect the frontal lobes. Dementia due to frontotemporal de
generation
other than Pick's disease should be diagnosed as Dementia Due 10 Frontotemporal
Degeneration, one of the dementias due to other general medical conditions
(see p. 167).
294.1x* Dementia Due to
Creutzfeldt-Jakob Disease
The essential feature of Dementia Due to CreutzfeldHakob Disease is the presence
of a dementia that is judged to be the direct pathophysiological consequence of
Creutzfeldt-Jakob disease. Creutzfeldt-Jakob disease is one of the subacute spon
giform
encephalopathies, a group of central nervous system diseases caused by trammissi
ble
agents known as "slow viruses" or prions. Typically, individuals with
CreutzfeldHakob disease manifest the clinical triad of dementia, involuntary mO\
'ements
(particularly myoclonus), and periodic EEG activity. However, up to 25%ofindivid
uals
with the disorder may have atypical presentations, and the disease can be
confirmed only by biopsy or at autopsy with the demonstration of spongiform neu
ropathological changes. CreutzfeldHakob disease may develop at any age in adults
,
but most typically when they are behveen ages 40 and 60 years. From 5% to 15% of
cases may have a familial component. Prodromal symptoms ofCreutzfeldt-Jakobdisea
se
may include fatigue, anxiety, or problems with appetite, sleeping, or concentrat
ion
and may be followed after several weeks by incoordination, altered vision, or
abnormal gait or other movements that may be myoclonic, choreoathetoid, or baJli
s.
tic, along with a rapidly progressive dementia. The disease typicall}' progresse
s \.ery
rapidly over several months, although more rarely it can progress over years and
appear
similar in its course to other dementias. Although there are no distinctive fmd
ings on cerebrospinal fluid analysis, reliable biomarkers are being developed.
Nonspecific atrophy may be apparent on neuroimaging.ln most individuals, the HG
typically reveals periodic sharp, often triphasic and synchronous discharges at
a rate
of 0.5-2 Hz at some point during the course of the disorder. The transmissible a
gent
thought to be responsible for Creutzfeldt-Jakob disease is resistant to boiling,
formalin,
alcohol, and ultraviolet radiation, but it can be inactivated by pressured autoc
la\'ing
or by bleach. Transmission by corneal transplantation and human growth factor
injection has been documented, and anecdotal cases of transmission to health car
e
workers ha\'e been reported. Therefore, when neurosurgery, brain biopsy, or brai
n
autopsy is undertaken, universal precautions should be taken with both tissue an
d
equipment that comes in contact with tissue. Cross-species transmission of prion
infections, with agents that are closely related to the human form, has now bet>
n
demonstrated (e.g., the outbreak of bovine spongiform encephalopathy (mad cow
disease) human variant Creutzfeldt-Jakob disease in the United Kingdom during th
e
mid-1990s).
"ICD-9-CM code valid after October I, 2000.
294.lx* Dementia Due to Other General Medical Conditions
294.1x* Dementia Due to Other
General Medical Conditions
In addition to the specific categories described above, a number of other genera
l medical
conditions can cause dementia. Two of the most common are due to Lewy bodrrelate
d.
neurodegeneration ("Lew)' body dementia") and to focal degeneration in the
frontal and temporal lobes ("frontotemporal dementia"). Dementia Due to Parkinso
n's
Disease is an example of the former (see p. 164), and Dementia Due to Pick's
Disease is an example of the latter (see p. 165). The descriptive features, cour
se, and
etiology of dementia due to diffuse Lewy body disease without Parkinson's diseas
e
and dementia due to frontotemporal degeneration other than Pick's disease requir
e
further research. Other conditions associated with dementia include structural l
esions
(primary or secondary brain tumors, subdural hematoma, slowly progressive
or normal-pressure hydrocephalus), endocrine conditions (hypothyroidism, hyperca
lcemia,
hypoglycemia), nutritional conditions (deficiencies of thiamine or niacin),
other infectious conditions (neurosyphilis, cryptococcosis), immune disorders (e
.g.,
temporal arteritis, systemic lupus erythematosus), derangements of renal and hep
atic
function, metabolic conditions (e.g., Kufs' disease, adrenoleukodyslTophy, metac
hromatic
leukodystrophy, and other storage diseases of adulthood and childhood), and
other neurological conditions such as multiple sclerosis. Unusual causes of cent
ral
nervous system injury, such as electrical shock or intTacranial radiation, are g
eneraUy
evident from the history. Rare disorders such as the childhood and adult storage
diseases
have a distinctive family history or clinical presentation. Associated physical
examination and laboratory findings and other clinical features depend on the na
ture
and severity of the general medical condition.
Differential Diagnosis
See p. 152 for a general discussion of the differential diagnosis of dementia.
ICD--9-0.' code valid after October 1, 2000.
1168
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Diagnostic criteria for 294.1x Dementia Due to
Other General Medical Conditions
A.
The development of multiple cognitive deficits manifested by both
(1)
memory impairment (impaired ability to learn new information or to recall previo
usly
learned information)
(2)
one (or more) of the following cognitive disturbances:
(a)
aphasia (language disturbance)
(b)
apraxia (impaired ability to carry out motor activities despite intact motor
function)
(c)
agnosia (failure to recognize or identify objem despite intact sensory
function)
(d)
disturbance in executive functioning (i.e., planning, organizing, sequencing,
abstracting)
B.
The cognitive deficits in Criteria Aland A2 each cause significant impairment in
social
or occupational functioning and represent a significant decline from a previous
level of functioning.
c.
There is evidence from the history, physical examination, or laboratory findings
that
the disturbance is the direct physiological consequence of a general medical con
dition
other than Alzheimer's disease or cerebrovascular disease (e.g., HIV infection,
traumatic brain injury, Parkinson's disease, Huntington's disease, Pick's diseas
e,
Creutzfeldt-Jakob disease, normal-pressure hydrocephalus, hypothyroidism, brain
tumor, or vitamin 812 deficiency).
D.
The deficits do not occur exclusively during the course of a delirium.
Code based on presence or absence of a clinically significant behavioral disturb
ance:
294.10 Without Behavioral Disturbance: if the cognitive disturbance is not
accompanied by any clinically significant behavioral disturbance.
294,11 With Behavioral Disturbance: if the cognitive disturbance is accompanied
by a clinically significant behavioral disturbance (e.g., wandering, agitation).
Coding note: Also code the general medical condition on Axis 111 (e.g., 042 HIV
infection,
8S4.OO head injury, 332.0 Parkinson's disease, 333.4 Huntington's disease, 331.1
Pick's
disease, 046.1 Creutzfeldt-Jakob disease; see Appendix G for additional codes).
Substance-Induced Persisting Dementia
Diagnostic and Associated Features
The cognitive deficits (Criterion A) and the required impairment (Criterion B) a
re discussed
on pp. 1-17-150. Substance-Induced Persisting Dementia is diagnosed if the
symptoms persist beyond the usual duration of Substance Intoxication or Withdraw
al
and is not diagnosed if they occur exclusively during the course of a delirium (
Criterion
C). However, delirium may be superimposed on a preexisting SubstanceInduced
Persisting Dementia, in which case both diagnoses should be given. There
Substance-Induced Persisting Dementia
must be evidence from the history, physical examination, or laboratory findings
that
the deficits are etiologically related to the persisting effects of substance us
e (e.g., a
drug of abuse, a medication, toxin exposure) (Criterion D). This disorder is ter
med
"persisting" because the dementia persists long after the individual has experie
nced
the effects of Substance Intoxication or Substance Withdrawal.
Features that are associated with Substance-Induced Persisting Dementia are thos
e
associated with dementias generally (see p. 147). Even if currently abstinent fr
om
substance use, most individuals with this disorder have previollsly had a patter
n of
prolonged and heavy substance use that met criteria for Substance Dependence. Be
cause
these disorders persist long after use of the substance has stopped, blood or
urine screens may be negative for the etiological substance. The age at onset of
Substance-Induced Persisting Dementia is rarely before age 20 years. This disord
er
usually has an insidious onset and slow progression, typically during a period w
hen
the person qualifies for a Substance Dependence diagnosis. The deficits are usua
lly
permanent and may worsen even if the substance use stops, although some cases do
show improvement.
For a more detailed discussion of the features associated with Substance-Related
Disorders, see p. 191.
Recording Procedures
The name of the diagnosis begins with the specific substance (e.g., alcohol) tha
t is presumed
to have caused the dementia. The diagnostic code is selected from the listing
of classes of substances provided in the criteria set. For substances that do no
t fit into
any of the classes, the code for "Other Substance" should be used. In addition,
for
medications prescribed at therapeutic doses, the specific medication can be indi
cated
by listing the appropriate E-code (see Appendix G). When more than one substance
is judged to playa significant role in the development of the persisting dementi
a,
each should be listed separately (e.g., 291.2 Alcohol-Induced Persisting Dementi
a;
292.82lnhalant-lnduced Persisting Dementia). Ua substance is judged. to be the e
tiological
factor, but the specific substance or class of substances is unknown, the diagno
sis
is 292.82 Unknown Substance-Induced Persisting Dementia.
Specific Substances
Substance-Induced Persisting Dementia can occur in association with the foUowing
classes of substances: alcohol; inhalants; sedatives, hypnotics, and anxiolytics
; or other
or unknown substances. Medications reported to cause dementia include anticonvuI
sants
and intrathecal methotrexate. Toxins reported to evoke symptoms of
dementia include lead, mercury, carbon monoxide, organophosphate insecticides,
and industTial solvents.
Differential Diagnosis
See p. 152 for a general discussion of the differential diagnosis of dementia.
Delirium, Dementia. and Amnestic and Other Cognitive Disorders
Diagnostic criteria for
Substance-Induced Persisting Dementia
A.
The development of multiple cognitive deficits manifested by both
(1)
memory impairment (impaired ability to learn new information or to recall previo
usly
learned information)
(2)
one (or more) of the following cognitive disturbances:
(a)
aphasia (language disturbance)
(b)
apraxia (impaired ability to carry out motor activities despite intact motor
function)
(c)
agnosia (failure to recognize or identify objects despite intact sensory
function)
(d)
disturbance in executive functioning (i.e., planning, organizing, sequencing,
abstracting)
B.
The cognitive deficits in Criteria Aland A2 each cause significant impairment in
social
or occupational functioning and represent a significant decline from a previous
level of functioning.
C.
The deficits do not occur exclusively during the course of a delirium and persis
t be
yond the usual duration of Substance Intoxication or Withdrawal.
D.
There is evidence from the history, physical examination, or laboratory findings
that
the deficits are etiologically related to the persisting effects of substance us
e (e.g., a
drug of abuse, a medication).
Code (Specific Substancel-Induced Persisting Dementia:
(291.2 Alcohol; 292.82 Inhalant; 292.82 Sedative, Hypnotic. or Anxiolytic;
292.82 Other [or Unknown) Substance)
Dementia Due to Multiple Etiologies
The Dementia Due to Multiple Etiologies category is included to alert clinicians
to the
common situation in which the dementia has more than one etiology. More than one
general medical condition may be etiologically related to the dementia (e.g., De
mentia
of the Alzheimer's Type and Dementia Due to Head Trauma). or the dementia
may be due to the combined effects of a general medical condition (e.g., Parkins
on's
disease) and the long-term use of a substance (e.g., Alcohol-Induced Persisting
Dementia).
Recording Procedures
Dementia Due to Multiple Etiologies does not have its own separate code and shou
ld
not be recorded as a diagnosis. For example, both Dementia of the Alzheimer's Ty
pe
and Vascular Dementia should be diagnosed for an individual with Dementia of the
Alzheimer's Type, With Late Onset, Without Behavioral Disturbance, who, over the
294.8 Dementia Not Otherwise Specified
171
course of several strokes, develops a significant further decline in cognitive f
unctioning.
In this example, the clinician wouJd list both 294.10 Dementia of the AJzheimers
Type, With Late Onset, Without Behavioral Disturbance, and 290.40, Vascular Deme
ntia,
Uncomplicated, on Axis I, and 331.0 Alzheimer's Disease and 436 Stroke on
Axis
m.
Diagnostic criteria for Dementia Due to Multiple Etiologies
A.
The development of multiple cognitive deficits manifested by both
(1)
memory impairment (impaired ability to learn new information or to recall previo
usly
learned information)
(2)
one (or more) of the following cognitive disturbances:
(a)
aphasia (language disturbance)
(b)
apraxia (impaired ability to carry out motor activities despite intact motor
function)
(cl
agnosia (failure to recognize or identify objects despite intact sensory
function)
(d)
disturbance in executive functioning (i.e., planning, organizing. sequencing,
abstracting)
B.
The cognitive deficits in Criteria Aland A2 each cause significant impairment in
social
or occupational functioning and represent a significant decline from a previous
level of functioning.
C.
There is evidence from the history, physical examination, or laboratory findings
that
the disturbance has more than one etiology (e.g., head trauma plus chronic alcoh
ol
use, Dementia of the Alzheimer's Type with the subsequent development of Vascula
r
Dementia).
D.
The deficits do not occur exclusively during the course of a delirium.
Coding note: Use multiple codes based on specific dementias and specific etiolog
ies,
e.g., 294.10 Dementia of the Alzheimer's Type, With late Onset, Without Behavior
al Disturbance;
290.40 Vascular Dementia, Uncomplicated.
294.8 Dementia Not Otherwise Specified
This category shouJd be used to diagnose a dementia that does not meet criteria
for
an}' of the specific types described in this section.
An example is a clinical presentation of dementia foe which there is insufficien
t evidence
to establish a specific etiology.
1172 Delirium, Dementia, and Amnestic and Other Cognitive Disorders
Amnestic Disorders
The disorders in the"Amnestic Disorders" section are characterized by a disturba
nce
in memory that is either due 10 the direct physiological effects of a general me
dical
condition or due to the persisting effects of a substance (i.e., a drug of abuse
, a medication.
or toxin exposure). The disorders in this section share the common symptom
presentation of memory impairment. but are differentiated based on etiology. The
diagnostic features listed below pertain to Amnestic Disorder Due to a General M
ed
ical Condition (e.g., physical trauma and vitamin deficiency) and Substancelnduce
d
Persisting Amnestic Disorder (including medication side effects). In addition. A
mnestic
Disorder Not Othenvise Specified is included in this section for presentations
in which the clinician is unable to determine a specific etiology for the memory
disturbance.
Text and criteria for Dissociative Disorders involving memory loss are not
included here and instead are contained in the Dissociative Disorders section (s
ee
p.519).
Diagnostic Features
Individuals with an amnestic disorder are impaired in their abilit), to learn ne
w information
or are unable to recall previously learned information or past events (Criterion
A). The memory disturbance must be sufficiently severe to cause marked
impairment in social or occupational functioning and must represent a significan
t
decline from a pccvious level of functioning (Criterion B). The memory disturban
re
must not occur exclusively during the course of a delirium or a dementia (Criter
ion q.
The ability to learn and recall new information is always affected in an amnesti
c disorder,
whereas problems remembering previously learned information occur more
variably, depending on the location and severity of brain damage. The memory def
icit
is most apparent on tasks that require spontaneous recall and may also be eviden
t
when the examiner provides stimuli for the person to recall at a later time. Dep
ending
on the specific area of the brain affected, deficits may be predominantly relate
d to
verbal or visual stimuli. In some forms of an amnestic disorder, the individual
rna)'
remember things from the very remote past better than more recent events (e.g.,
a
person ma)' remember in vivid detail a hospital stay that took place a decade be
fore
the examination, but may have no idea that he or she is currently in the hospita
l).
The diagnosis is not made if the memory impairment occurs exclusively during the
course of a delirium (Le., occurs only in the context of reduced ability to main
tain and
shift attention). The ability to immediately repeat a sequential string of infor
mation
(e.g., digit span) is typically not impaired in an amnestic disorder. "''hen suc
h impairment
is evident, it suggests the presence of an attentional disturbance that may be i
ndicative
of a delirium. The diagnosis is also not made in the presence of other
cognitive deficits (e.g., aphasia, apraxia, agnosia, disturbance in executive fu
nctioning)
that are characteristic of a dementia. Individuals with an amnestic disorder rna
)'
experience major impairment in their social and "ocational functioning as a resu
lt of
their memory deficits, which, at its extreme, may necessitate supervised liVing
situations
to ensure appropriale feeding and care.
Amnestic Disorders
Associated Features and Disorders
An amnestic disorder is often preceded by an evolving clinical picture that incl
udes
confusion and disorientation, occasionally with attentional problems that sugges
t a
delirium (e.g., Anmestic Disorder Due to Thiamine Deficiency). Confabulation, of
ten
evidenced by the recitation of imaginary events to fill gaps in memory, may be n
oted
during the early stages of an amnestic disorder but tends to disappear with time
. It
may therefore be important to obtain corroborating information from family membe
rs
or other informants. Profound amnesia may result in disorientation to place and
time, but rarely to sell. Disorientation to sell may be encountered in individua
ls with
a dementia but is unusual in an amnestic disorder. Most individuals with a sever
e
Amnestic Disorder lack insight into their memory deficits and may explicitly den
y
the presence of severe memory impairment despite evidence to the contrary. This
lack of insight may lead to accusations against others or, in rare instances, to
agitation.
Some individuals may acknowledge that they have a problem but appear
unconcerned. Apathy, lack of initiative, emotional blandness, or other changes s
uggestive
of altered personality nmction may be encountered. Individuals may be superficia
lly
friendly or agreeable, but they may have a shallow or diminished range of
affective expression. Individuals with transient global amnesia often appear bew
ildered
or befuddled. Subtle deficits in other cognitive functions may be noted, but, by
definition, they are not severe enough to cause clinically Significant impairmen
t.
Quantitative neuropsychological testing often demonstrates specific memory defic
its
in the absence of other cognitive disturbances. Performance on standardized test
s
that assess recall of well-known historical events or public figures may be vari
able
among individuals with an Amnestic Disorder, depending on the nature and extent
of the deficit.
Specific Culture Features
Cultural and educational background should be taken into consideration in the ev
aluation
of memory. Individuals from certain backgrounds may not be familiar with
the information used in certain tests of memory (e.g., date of birth in cultures
that do
not routinely celebrate birthdays).
Course
Age at onset and subsequent course of amnestic disorders may be quite variable,
depending
on the primary pathological process causing the amnestic disorder. Traumatic
brain injury, stroke or other cerebrovascular events, or specific types of
neurotoxic exposure (e.g., carbon monoxide poisoning) may lead to an acute onset
of
an amnestic disorder. Other conditions such as prolonged substance abuse, chroni
c
neurotoxic exposure, or sustained nutritional deficiency may lead to an insidiou
s onset.
Transient amnesia due to a cerebrovascular etiology may be recurrent, with episo
des
lasting from several hours to several days. Amnestic Disorders Due to Head
Trauma may last for variable amounts of time, with a characteristic pattern of g
reatest
deficit immediately after injury and improvement during the ensuing 2 years (fur
ther
improvement beyond 24 months has been noted, but less commonly). Disorders due
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
to destruction of middle-temporal lobe structures (e.g., from infarction, surgic
al ablation,
or malnutrition occurring in the context of Alcohol Dependence) may cause persis
ting
impairments.
Differential Diagnosis
Memory impairment is also a feature of delirium and dementia. In delirium, memor
y
dyshmction occurs in association with impaired consciousness, with reduced abil
ity to focus, sustain, or shift attention. In dementia, memory impairment must b
e
accompanied by multiple cognitive deficits (i.e., aphasia, apraxia, agnosia, or
a disturbance
in executive functioning) that lead to clinically significant impairment.
An amnestic disorder must be distinguished from Dissociative Amnesia and amnesia
occurring in the context of other Dissociative Disorders (e.g., Dissociative
Identity Disorder). By definition, an amnestic disorder is due to the direct phy
siological
effects of a general medical condition or substance use. Furthermore, amnesia in
Dissociative Disorders typically does not involve deficits in learning and recal
ling
new information; rather, individuals present with a circumscribed inability to r
ecall
previous memories, usually of a traumatic or stressful nature.
For memory disturbances (e.g., blackouts) that occur only during intoxication wi
th
or withdrawal from a drug of abuse, the appropriate Substance Intoxication or Su
bstance
Withdrawal should be diagnosed and a separate amnestic disorder diagnosis
is not made. For memory disturbances that are associated with the use of medic.1
tion,
Adverse Effects of Medication Not Othem'ise Specified (p. 736) may be noted, wit
h
the medication indicated by the use of an E-code (see Appendix G).
The presumed etiology of the amnestic disorder determines the diagnosis (text an
d
criteria for each amnestic disorder diagnosis are provided separately later in t
his sec
tion). If it is judged that the memory disturbance is a consequence of the direc
t phys
iological effects of a general medical condition (including head trauma), then
Amnestic Disorder Due to a General Medical Condition is diagnosed. If the memory
disturbance results from the persisting effects of a substance (i.e., a drug of
abuse,
a medication, or toxin exposure), then SubstanceInduced Persisting Amnestic Dis
order is diagnosed. ""hen both a substance (e.g., alcohol) and a general medical
condition
(e.g., head trauma) have had an etiological role in the development of the
memory dishubance, both diagnoses are given. If it is not possible to establish
asp....
cific etiology (i.e., dissociative, substance induced, or due to a general medic
al condition),
Amnestic Disorder Not Othenvise Specified is diagnosed.
Amnestic disorder must be distinguished from Malingering and from Factitious
Disorder. This difficult distinction can be assisted by systematic memory testin
g
(whid1 often yields inconsistent results in Factitious Disorder or Malingering)
and b)'
the absence of a general medical condition or substance use that is etiologicall
y relat
ed to the memory impairment.
Amnestic disorder should be distinguished from the less efficient memory charact
eristic
of Age-Related Cognitive Decline, which is within the expected age-adjusted
normative range for the individual.
294.0 Amnestic Disorder Due to a General Medical Condition
294.0 Amnestic Disorder Due to a
General Medical Condition
Diagnostic and Associated Features
The descriptive features of Amnestic Disorder Due to a General Medical Condition
(Criteria A-e) are discussed on p. 172. In addition, the diagnosis requires that
there
must be evidence from the history, physicaJ examination, or laboratory findings
that
the memory disturbance is the direct physiologicaJ consequence of a general medi
cal
condition (including physical trauma) (Criterion D).
In determining whether the amnestic disturbance is due to a general medical cond
ition,
the clinician must first establish the presence of a general medical condition.
Further, the clinician must establish that the amnestic disturbance is etiologic
ally related
to the general medical condition through a physiological mechanism. A careful
and comprehensive assessment of multiple factors is necessary 10 make this judgm
ent.
Although there are no infallible guidelines for determining whether the relation
ship
between the amnestic disturbance and the general medical condition is
etiological, several considerations provide some guidance in this area. One cons
ideration
is the presence of a temporal association beh\'een the onset, exacerbation, or r
emission
of the general medical condition and that of the amnestic disturbance.
A second consideration is the presence of features that are atypical of memory i
m~
paiement in the context of a dissociative or other mentaJ disorder (e.g., atypic
al age at
onset or course). Evidence from the literature that suggests that there can be a
direct
association behveen the general medical condition in question and the de"elopmcn
t
of memory impairment can provide a useful context in the assessment of a particu
lar
situation. In addition, the clinician must also judge that the disturbance is no
t better
accounted for by a Dissociative Disorder, Substance-Induced Persisting Amnestic
Disorder, or another primary mental disorder (e.g., Major Depressive Disorder).
These determinations are explained in greater detail in the "Mental Disorders Du
e to
a General Medical Condition" section (p. 181).
Individuals with Amnestic Disorder Due to a General Medical Condition often
show other features of the primary systemic or cerebral disease that caused the
memory
impairment. However, disordered mental status may be the sole presenting feature
.
There are no specific or diagnostic features detectable with procedures SUcll as
magnetic resonance imaging (MRl) or computed tomography (CT). However, damage
to mediotemporallobe structures is common and may be renected byenlargement
of third ventricle or temporal homs or by structural atrophy detected on MRJ.
Specifiers
The following specifiers may be noted to indicate the duration of the disturbanc
e.
Transient. 1lUs specifier is used to indicate durations usually from several
hours to a few days and for no more than 1 month. \hen the diagnosis is made
within the first month without wailing for recovery, the term "provisional"
may be added. "Transient global amnesia" is a specific form of transient amnesti
c
disorder, characterized by a dense, transitory inability to learn new in
Delirium, Dementia, and Amnestic and Other Cognitive Disorders
formation and a variable impaired ability to recall events that occurred jU51
before, or in the midst of, the etiological cerebrovascular problem.
Chrome. This specifier is used for disturbances that last for more than
1 month.
Recording Procedures
In recording the diagnosis of Amnestic Disorder Due to a General Medical Conditi
on,
the clinician should note the identified general medical condition judged to be
causing
the disturbance on Axis I (e.g., 29tQ Amnestic Disorder Due to Stroke). The ICD-9
-Q.1
code for the general medical condition should also be noted on Axis ill (e.g., 4
36
stroke). (See Appendix G for a list of selected ICD-9-CM diagnostic codes for ge
neral
medical conditions.)
Associated General Medical Conditions
An amnestic disorder often occurs as the result of pathological processes (e.g.,
closed
head trauma, penetrating missile wounds, surgical intervention, hypoxia, infarct
ion
of the distribution of the posterior cerebral artery, and herpes simplex encepha
litis)
that cause damage to specific diencephalic and mediotemporallobe structures (e.g
..
mammillary bodies, hippocampus, fomi.''(). Pathology is most often bilateral, bu
t def
icits may arise from unilateral lesions. Transient Amnestic Disorder, when encou
ntered
as "transient global amnesia," is typically associated with cerebrovascular
disease and pathology in the vertehrohasilar system. Transient Amnestic Disorder
may also arise from episodic general medical conditions (e.g., metabolic conditi
ons
or seizures).
Differential Diagnosis
See p. 174 for a discussion of the differential diagnosis of amnestic disorders.
Substance-Induced Persisting Amnestic Disorder
Diagnostic criteria for 294.0 Amnestic Disorder Due to ...
[Indicate the General Medical Condition]
A.
The development of memory impairment as manifested by impairment in the ability
to learn new information or the inability to recall previously learned informati
on.
B.
The memory disturbance causes significant impairment in social or occupational
functioning and represents a significant decline from a previous level of functi
oning.
C.
The memory disturbance does not occur exclusively during the course of a deliriu
m
or a dementia.
D.
There is evidence from the history, physical examination. or laboratory findings
that
the disturbance is the direct physiological consequence of a general medical con
dition
(including physical trauma).
Specify if:
Transient: if memory impairment lasts for 1 month or less
Chronic: if memory impairment lasts for more than 1 month
Coding note: Include the name of the general medical condition on Axis I, e.g.,
294.0
Amnestic Disorder Due to Head Trauma; also code the general medical condition on
Axis
III (see Appendix G for codes).
Substance-Induced Persisting Amnestic Disorder
Diagnostic and Associated Features
ThedescriptivefeaturesofSubstance-Induced Persisting Amnestic Disorder(Criteria
A and B) are discussed on p. 172. The memory disturbance does not occur exclusiv
ely
during the course of a delirium or a dementia and persists beyond the usual dura
tion
of Substance Intoxication or Withdrawal (Criterion C). In addition, to diagnose
Substance-Induced Persisting Amnestic Disorder, there must be evidence from the
history, physical examination, or laboratory findings that the memory dishlrbanc
e is
etiologically related to the persisting effects of substance use (e.g., a drug o
f abuse, a
medication, toxin exposure) (Criterion D). This disorder is termed "persisting"
because
the memory disturbance persists long after the inctividual is no longer experien
dng
the effects of Substance Intoxication or Substance Withdrawal.
Features that are associated with Substance-induced Persisting Amnestic Disorder
are those associated with amnestic disorders generally (see p. ]73). Even if cur
rently
abstinent from substance use, most individuals with this disorder have previousl
y
had a pattern of prolonged and heavy substance use that met criteria for Substan
ce
Dependence. Because these disorders persist long after use of the substance has
stopped, blood or urine screens may be negative for the etiological substance. T
he age
at onset is rarely before age 20 years. The resulting impairment may remain stab
le or
worsen, even if substance use stops.
Delirium, Dementia. and Amnestic and Other Cognitive Disorders
For a more detailed discussion of the features associated with Substance-Related
Disorders, see p. 191.
Recording Procedures
The name of the diagnosis begins with the specific substance (e.g., alcohol. sec
obarbital)
that is presumed to be causing the memory diShlrbance. The diagnostic code is
selected from the listing of classes of substances provided in the criteria set.
For substances
that do not fit into any of the classes, the code for "Other Substance" shouJd
be used. In addition, for medications prescribed at therapeutic doses, the speci
fic
medication can be indicated by listing the appropriate E-code (see Appendix G).
When more than onesubstance is judged to playa significant Tole in the developme
nt
of the memory disturbance. each should be listed separatel}' (e.g., 291.1 Alcoho
lInduced
Persisting Amnestic Disorder; 292.83 Secobarbital-Induced Persisting Amnestic
Disorder). U a substance is judged to be the etiological factor but the specific
substance or class of substances is unknown, the diagnosis is 292.83 Unknown Sub
stance-
Induced Persisting Amnestic Disorder.
Specific Substances
Substance-Induced Persisting Amnestic Disorder can occur in association with the
following classes of substances: alcohol; sedatives, hypnotics, and anxiolytics;
and
other or unknown substances.
Alcohol-Induced Persisting Amnestic Disorder is apparently due to the vitamin
deficiency that is associated with prolonged, heavy ingestion of alcohol. Neurol
ogical
disturbances such as peripheral neuropathy, cerebellar ataxia, and myopathy are
among the associated features. Alcohol-Induced Persisting Amnestic Disorder due
10
thiamine deficiency (Korsakoff's syndrome) often follows an acute episode of Wer
nicke's
encephalopathy, a neurological condition manifested by confusion, ataxia,
eye-movement abnormalities (gaze palsies, nystagmus), and other neurological
signs. Gradually. these manifeslations subside, but a major impairment of memory
remains. U Wernicke's encephalopath}' is treated early with large doses of thiam
ine,
Alcohol-Induced Persisting Amnestic Disorder may not develop. Although age is no
t
a specific etiological factor in the condition, individuals who develop Alcohol
Induced Persisting Amnestic Disorder generally have histories of many years of
heavy alcohol use and are mosl often over age 40 years. Although the mode of ons
et
is typically abrupt, some individuals may develop deficits insidiously over many
years, due to repeated toxic and nutritional insults, prior to the emergence of
a final,
more dramatically impairing episode apparently related to thiamine deficiency. O
nce
established, Alcohol-Induced Persisting Amnestic Disorder usually persists indef
initely,
although there may be slight improvement over time and in a minority of the
cases the condition can remit. Impairment is usually quite severe, and lifelong
custodial
care may be necessary. Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting
Amnestic Disorder can follow prolonged and heavy use of drugs from this class. T
he
course is variable, and, unlike Alcohol-Induced Persisting Amnestic Disorder, fu
ll
recovery can occur. Medications reported to cause amnestic disorders include ant
icOJl\'
ulsants and intrathecal methotrexate. Toxins reported to evoke symptoms of
294.8 Amnestic Disorder Not Otherwise Specified
sufficiently 5e\'ere to
warranl independent
clinical attenlion
No
PSYCHOTIC
DISORDER DUE TO
A GENERAL
MEDICAL
CONDIlION
MOOD DISORDER
OUETOA
GENERAL MEDICAL
CONDITION
=0=-
'"'
ANXIETY
DISORDER DUE TO
A GENERAL
MEDICAL
CONDITION
SEXUAL
DYSFUNCTION
OUETO A
GENERAL MEDICAL
(ONOmON
SLEEP DISORDER
DUE TOA
GENERAL MEDICAL
CONDITION
I Yes
Caliltonia
,
No
CATATONICDISORDER DUE TO
A GENERAL
MEDICAL
CONDITION
'(Ch,,];;~".,;'~in~p~re~'.:;i~;;;;:--~V~e~''--------------------.
PERSONAUTY
personality paltem
~
No
Clinically sibonific.:mt IYes
symptoms
t'tiologicilly IYlated
10 a general medical
condition that do
not meet criteria for
a specific Mental
Disorder Due to a
General Medical
I Condition I
~
No
No mental disorder
(s}mptoms trot are
not clinically significant)
CHANGE DUE TO
A GENERAL
MEDICAL
CONDITION
MENTAL DISORDER
NOS DUETO A
GENERAL MEDICAL
CONDmON
1748 Appendix A
Differential Diagnosis of Substancelnduced Disorders
(Not Including Dependence and Abuse)
Symptoms thai an!
due to the direct
physiological effects
of a substance (ie.,
a drug of abuse, a
medication, or a
to"in)
~-I---!
IYes 1r------,rNor------y.,
A disturbance of ~
hidence that the ---+ Onset of delirium ,..--+
,-----,
SUBSTANCE
INDUCED
WITHDRAWAL
DELIRIUM
SUBSTANCE
INDUCED
INTOXICATION
DELIRIUM
DELIRIUM DUE
TO MULTIPLE
ETIOLOGIES
consciousnl$S and a
change in cognition
that are in ex(l':5S of
that usually seen in
intoxication or
"'ithdrawiil and that
warrant indl'Jl'l'ndent
I clinical attention
No
,
disturbance has
during withdraw.ll
more than one
from a substance
etiology (e.g.,
substance and
general medical
condition)
II I
y"
I
No
0
Per.;islenl memory
impairment
No
Y",I-'-,-'-,,-,-,-o-,-.---'I Yes r'-'-"-d-"-'-'-'-h-.-"-h.--No
;---+ ---+
additional , disturbance has
cognith-e deficit more than one
etiology (e.g.
substan>:e MId
general medkal
condition)
No Y
SUBSTANCE
INDUCED
PERSISTING
DEMENTIA
DEMENTIA DUE
TO MULTIPLE
ETIOLOGIES
SUBSTANCEINDUCED
PERSISTING
AMNESTIC
DISORDER
Decision Trees for Differential Diagnosis
+
'O;;;;;;;;~;;;~l.;;;;;;;;;;;;;;;;;;;;;;;;;;~~;;;~'.:'V~o~.,--
DelusioT15 OT hallucinatioT15 predominate, Me in
excess of that usuall)' ~n
in into'dcalion or
withdrilwal, and warrant independent clinical
attention
~
to SUBSTANCEINDUCED
PSYCHOTIC
DISOROER
Specify if omet
during intoxic3tion
or withdrawal
A mood disturbance predominates, is in excess
of that usuall), seen in intoxication or
v.ithdrawal, and warrants independent cliniul
attention
I
v.. to SUBSTANCEINDUCED
MOOD
DISORDER
Specify if omet
during intoxication
or withdrawal
~NO
Anxiet)', panic attacks, or obsessions or I Yes
compulsions predominate; are in excess of Ihal
usually set'n in intoxication or "ithdra""al; and
warranl independenl clinical attention
~NO
(C;'~i";;k~'"U~'-!'~igru~'fifi~"~"~'~~~";;';;'~d~l~";;f~~<:;ti;;O~"-::-=--'...:'
V~O~'--
e.>.dusivel)' due to a substance is in excess of
that usually set'n in intoxication, and warrants
independiml clinical attention
,
1No
I Disturbance in sleep that is sufficientl)' sen~re
10
\'".l.rrant independent clinical alli"ntion and is in
excess of that usually seen in intoxication or
withdrawal
! lJe\"elopment of il re\'ersibh-' syndrome due 10
I recent usc of a substance
V..
V..
~
SUBSTANCEINDUCED
ANXIETY
DISORDER
Specify if on\et
during intoxication
or withdrawal
+t
SUBSTANCE
INDUCED SEXUAL
DYSFUNCTION
SUBSTANCE
INDUCED SLEEP
DISORDER
Specify if onset
during intoxication
or withdrawal
--'--=--------+t SUBSTANCE
INTOXICATION
No
IOcn'lopment of a syndrome due to reduction OT
~tion
of usc of a substance
V.,
SUBSTANCE
WITHDRAWAL
No
'C=-,---,,---,,---,:::----'-'=--,---,---, Yo.
linically significant symptoms due to a _--="----+~
substance that do not meel criteria for one of
Ithe Substmce-Induced Oiso-C"''''''''m''---_____
~NO
No Substance-Induced Disorder
(subst~nce-inducedsymptoms that an! not
clinically signifk,mt)
SUBSTANCE
RELATED
DISORDER NOS
750 Appendix A
Differential Diagnosis of Psychotic Disorders
Delusions, hallucinations, disorganized
speedl. or grossl), disorganized
beha\';or
Ve,
Dul.' to the direct ph}'siologicaJ effects PSYCHOTIC
of a general medical condition DISORDER
DUETOA
GENERAL
MEDICAL
CONDITION
No
Due 10 the direct I Ve. SUBSTANCE
physiologiC31 effects INDUCED
of a substanre (e.g., PSYCHOTIC
a drug of abuse, a DISORDER
med.iation,. or a
tom) I
Symptoms of LYe,.
actiYe phase of
Schizophrenia.
lasting at least
I month
No
No
M.ajor
IJrepressive or
Manic Episode
ooncurrenl with
acti\"e-phase
symptoms
Ve.
TOI.11 dut.1tion lYe~1
Duration at
Ve. SCHIZO
of mood least 6 months
PHRENIA
episode;; has
I
been brief
relat;\'" 10
duration of
No
act;" .. and
residual pEriods
,
No
SCHIZO
PH RENIFORM
DISORDER
Ve.
SCHIZO-
At least:2 weeks
AFFECTIVE
of delusions or
DISORDER
hallucinations
No
in the ab5enre
of prominent
Imood symptolTl'51
MOOD
DISORDER
WlTH
--..
PSYCHOTIC
FEATURES
(see Mood
Disorders tree)
Decision Trees for Differential Diagnosis
--'----'1Ves~~------'
I Ves I
1Nonbiune -----. -Tola! duration
delusions of mood
lasting at least episodes has
1 month been brief
nolam-e to
duration (Jf
delusional
periodsI
delusions,
functioning not
IIW:kedJy
impaired
No
No
--=cc--'+NO
Delusioru;
occur only
during mood
episodes
__---------------
~~
0.::--::-''-----,1 Yes
Duration mono
than I day but
I
I
less than I~;;;----
1 month IN
'-~
0
Apart from
V.. DELUSIONAL
.. PSYCHOTICINo
DISORDER
DISORDER NOS
MOOD
DISORDER
WITH
PSYCHOTIC
FEATURES
(see Mood
Disorders tree)
PSYCHOTIC
BRIEf
~D_'_SD_RD_E_R__~
--------....
..
PSYCHOTIC
DISORDER NOS
752 Appendix A
Differential Diagnosis of Mood Disorders
Depll$5t'd. elevated,
expansh'e, or irritable mood
Due to the direct
physiological effects of a
general medical condition
No
Due to the direct
physiological effects of a
substance (i.e., a drug of
abuse, a medication, or a
toxin)
iNo
Dt-Iermine type of prescnt
and past mood episodes
Ele\'atrd, e.>:paru;i\-e, or
Ye,
Yeo
irritable mood. at least I-.....eek
duration; marked impairment
or hospitaliz.ation
No+
Elevated. expansive. or
il'Tilable mood. at least +day
duration; changes observable
by others hut less 5e\"ere
than a ~Ianic
Episode
No
At least 2 weeks of
depressed mood or loss of
interest plus ass0ci4tl!'d
symptoms, and not better
accounted for by Bereavement
NO+'4
Criteria met foc Manic
Episode and Major
Depressive Episode nearly
e\'er}' day for at least I week
!:s
~s
..!:s
Yes'
..c;"
No
Has e\"er had a MAJ\.'lC
EPISODE or a MIXED
EPISODE
No
lVes
-
,
MANIC EPISODE
HYPOMANIC EPISODE
MAJOR DEPRESSIVE
EPISODE
MIXED EPISODE
Psychotic symptoms occur at
times other than dUring "'"anic
or Mixed Episodes
..Yes
0ccu.rTed exdusi\"ely dUring
Schizoaffecti\"e Disorder
(review Ps)'chotic Disorde~
tree)
J~
MOOD DISORDER DUE TO
A GENERAL MEDICAL
CONDITION
SUBSTANCE-INDUCED
MOOD DISORDER
-
I
n
I
0
N.
,...
LY:
s
BIPOlAR I DISORDER
SCH1ZOAffECTlVE
DISORDER,. BIPOLAR
TYPE
BIPaLAR DISORDER
NOS (superimposed on
a Psychotic Di~order)
Decision Trees for Differential Diagnosis
Has e\er had a HYPOMA1\'lC
EPISODE and all...asl one
MAJOR DEPRESSIVE EPISODE
--:-------:-:--'*"'-No:;;;--c:v!!'e'"-
2+ yea" of hrpom.utic
srmptoms and periods of
depll'Ssed mood
, .-=N-O---'
I Yes
ClinicaUy significant
manic/hrpomanic srmptoms
thilt do not meet crileria for a
I spific Bipolar Disorder
v"
+No
BIPOLAR II DISORDER
--+ r::-==-:-==,
CYCLOTHYMIC DISORDER
BIPOLAR DISORDER NOS
Has ever had a MAJOR LYe.!
Psychotic symptoms occur at ~o
DEPRESSIVE EPISODE
times other than during Major
Depressive Episodes
No .1 Yes
Occurred exdush-ely during LYes
5<::hi:l;oaffectin' Disorder .......
(r-e'iew Psychotic DisordeTS
,~)
No
MAJOR DEPRESSIVE
DISORDER
SCHIZOAFfECTIVE
DISORDER.. DEPRESSIVE
TYPE
DEPRESSIVE DISORDER
NOS (superimpo~ed
on
Psychotic Disorder)
Ve,
Depressed mood, more days DYSTHYMIC DISORDER
than not. for at least 2 rears
,,;th assoriated spnptoms
No
I""~p~"""'~~~m~ood~~n~o'~m;;;;~~tin;;
~g-'...lv~.~,-----------..
ADJUSTMENT DISORDER
criteria (or one of abo'-e WITH DEPRESSED MOOD
~Iood
Disorders that develops
in response 10 a stressor
No
DEPRESSIVE
Clinicillly signific.rnt v"
DISORDER NOS
not meet criteria for a specific
Mood Disorder --'
depressive symptoms that do
.NO
No ~tood
Disorder (mood
symptoms that are not
clinically signific.ml)
754 Appendix A
Differential Diagnosis of Anxiety Disorders
Symptoms of il.I1Xiet}', fear,
a\oida~.
or increased
arousal
+
Due to the direct
phr~iological
effects of a
general medical condition
~NO
!No
Rl'CU!Tl."Ilt une:>.:pected Panic ~5Attad<5 plus a month of
worry, roneem about attacks.
or change in behavior
No
Agoraphobia, ie., anxiety
V
about being in places from
which escape might be
diffu:ulf orembarrassing in
the event of ha\ing panic-like
spnptoms
!No
Anxiety concerning
separation from attachment
figures ....ith onset in
I childhood
~NO
Fear of humiliation or
embarrassment in social or
perform.:lnce silu.lDons
~No
Fear wed by object or
siluillion
~NO
Obsessions or rompulsiorui
V.. ANXIETY DISORDER DUE
TO A GENERAL MEDICAL
I CONDITION
VDue to the direct
physiological effects of a
substance (e.g., a drog of
abuse, a medication, a toxin)
SUBSTANCE-INDUCED
ANXIETY DISORDER
Agoraphobia. i.e., anxiety
about being in places from
which escape might be
difficult or embarrassing in
the event of hit\ing a Panic
,..."
'Yes
,...
No
PANIC DISORDER
WITHOUT AGORAPHOBIA
AGORAPHOBIA WITHOUT
HISTORY OF PANIC
DISORDER
V
V
Veo
I
V
I
OBSESSIVE-eOMPULSIVE
DISORDER
ISPECIFIC PHOBIA
PANIC DISORDER WITH
AGORAPHOBIA
SEPARATION ANXIETY
DISORDER
SOCIAL PHOBIA (SOCIAL
ANXIETY DISORDER)
I
J
~
"C&Cm-oo--'-"-I"'-riodC.-';-C07,m'---~CCCi,C.,:--'::S-(ko;-,C~--'-CmCd~~--:;"C.,
CICyCdC~=.
CgC,-1 NtO
GENERALIZED ANXIETY
anxiety and .....orry plU5 ~
lood OT Psychotic Disorder
DISORDER
anxiety spnploms
No Ye.
See Mood Disorder.; or
Psychotic DUorders tree
lYes
ReexpenendTIg of ~'l"l\t,
Anxiety in response 10 a
;-+
increased ilroUsal, and
avoidance of stimuli
associated with traumatic
el'enl
5l'\"ere lraumatic e\"enl
rDecision Trees for Differential Diagnosis
No
,
,
No .Yes
IYes
Our<ltion of more than
POSTIRAUMATIC STRESS
1 month r
DISORDER
No
,
ACUTE STRESS DISORDER
]Yes
Anxiety that does not meet
ADJUSTMENT DISORDER
criteria for one of the abon'
WITH ANXIETY
Anxiety Disorder.; and
de\"elops in response 10
ill stressor
INO
ANXIETY DISORDER NOS
Qinjc.J.lI)' Significant lvI'S
300.82
Somatoform Disorder 'OS
300.29
Specific Phobia
307.3
Stereot}pic Movement Disorder
307.0
Stuttering
Appendix E
Appendix E Alphabetical listing of DSM-IV-TR Diagnoses and Codes
8551
307.20
307.23
307.21
302.3
312.39
300.82
300.9
306.51
290.40
290.41
290.42
290.43
302.82
!r)
I
Condition]
Tic Disorder NOS
Tourette's Disorder
Transient Tic Disorder
Transvestic Fetishism
Trichotillomania
Undifferentiated Somatoform Disorder
Unspecified Mental Disorder (nonpsychotic)
Vaginismus (Not Due to a General Medical Condition)
Vascular Dementia
Uncomplicated
With Delirium
With Delusions
With Depressed Mood
Voyeurism
Appendix F
Numerical Listing of
DSM-IV-TR Diagnoses and Codes
To maintain compatibility with ICDg-eM, some DSM-IV diagnoses share the
same code numbers. These are indicated in this list by brackets.
NOS = Not Otherwise Specified.
290.40
290.41
290.42
290.43
[ 291.0
291.0
291.1
291.2
291.3
291.5
291.81
291.89
291.89
291.89
[
291.89
291.9
292.0
292.0
292.0
292.0
292.0
-292.0
-292.11
292.11
292.11
292.11
292.11
, 292.11
Vascular Dementia, Uncomplicated
Vascular Dementia, With Delirium
Vascular Dementia, With Delusions
Vascular Dementia, With Depressed Mood
Akohollntoxication Delirium
Alcohol Withdrawal Delirium
Alcohol-Induced Persisting Amnestic Disorder
Alcohol-Induced Persisting Dementia
Alcohol-Induced Psychotic Disorder, With Hallucinations
Alcohol-Induced Psychotic Disorder, With Delusions
Alcohol Withdrawal
Alcohol-Induced Anxiety Disorder
Alcohol-Induced Mood Disorder
Alcohol-Induced Sexual Dysfunction
Alcohol-Induced Sleep Disorder
Alcohol-Related Disorder NOS
Amphetamine Withdrawal
Cocaine Withdrawal
icotine Withdrawal
Opioid Withdrawal
Other (or Unknown) Substance Withdrawal
Sedative, Hypnotic, or Anxiol}'tic Withdrawal
Amphetamine-Induced Psychotic Disorder, With Delusions
Cannabis-Induced Psychotic Disorder, With Delusions
Cocaine-Induced Psychotic Disorder, With Delusions
Halludnogen-Induced Psychotic Disorder, With Delusions
Inhalant-Induced Psychotic Disorder, With Delusions
Opioid-Induced Psychotic Disorder, With Delusions
857
858 Appendix F
292.11
292.11
292.11
292.12
292.12
292.12
292.12
292.12
292.12
292.12
292.12
292.12
292.81
292.81
292.81
292.81
292.81
292.81
292.81
292.81
292.81
292.81
[
[
292.82
292.82
292.82
292.83
[
292.83
292.84
292.84
292.84
292.84
292.84
292.84
292.84
292.84
292.89
292.89
292.89
292.89
292.89
292.89
292.89
292.89
292.89
Other (or Unknown) Substance-Induced Psychotic Disorder, With Delusions
Phencyclidine-Induced Psychotic Disorder, With Delusions
Sedative-. Hypnotic-, or Anxiolytic-lnduced Psychotic Disorder, With
Delusions
Amphetamine-Induced Psychotic Disorder, With Hallucinations
Cannabis-Induced Ps)'chotic Disorder, With Hallucinations
Cocaine-Induced Psychotic Disorder, With Hallucinations
HaUucinogen-induced Psychotic Disorder, With Hallucinations
Inhalant-Induced Psychotic Disorder, With Hallucinations
Opioid-Induced Psychotic Disorder, With Hallucinations
Other (or Unknown) Substance-Induced Psychotic Disorder, With
Hallucinations
Phencyclidine~InducedPsychotic Disorder, With Hallucinations
Sedative-, Hypnotic-, or Anxioiytic-lnduced Psychotic Disorder, With
Hallucinations
Amphetamine Intoxication Delirium
Cannabis Intoxication Delirium
Cocaine Intoxication Delirium
Hallucinogen Intoxication Delirium
Inhalant Intoxication Delirium
Opioid Intoxication Delirium
Other (or Unknown) Substance-Induced Delirium
Phencyclidine Intoxication Delirium
Sedative, Hypnotic, or Anxiolytic Intoxication Delirium
Sedative, Hypnotic, or Anxiolytic Withdrawal Delirium
Inhalant-Induced Persisting Dementia
Other (or Unknown) Substance-Induced Persisting Dementia
Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Dementia
Other (or Unknown) Substance-Induced Persisting Amnestic Disorder
Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Amnestic Disorder
Amphetamine-Induced Mood Disorder
Cocaine-Induced Mood Disorder
Hallucinogen-Induced Mood Disorder
Inhalant-Induced Mood Disorder
Opioid-Induced Mood Disorder
Other (or Unknown) Substance-Induced Mood Disorder
Phencyclidine-Induced Mood Disorder
Sedative-, Hypnotic-, or Anxiolytic-Induced Mood Disorder
Amphetamine-Induced Anxiety Disorder
Amphetamine-Induced Sexual Dysfunction
Amphetamine-Induced Sleep Disorder
Amphetamine Intoxication
Caffeine-Induced Anxiety Disorder
Caffeine-Induced Sleep Disorder
Cannabis-Induced Anxiety Disorder
Cannabis Intoxication
Cocaine-Induced Anxiety Disorder
Numerical listing of DSM-IV-TR Diagnoses and Codes
I 292.89 Cocaine-Induced Sexual Dysfunction
292.89
Cocaine-Induced Sleep DisOrder
292.89
Cocaine Intoxication
292.89
Hallucinogen-Induced Anxiety Disorder
292.89
Hallucinogen Intoxication
292.89
Hallucinogen Persisting Perception Disorder
292.89
lnhaJant-lnduced Anxiety Disorder
292.89
lnhaJant Intoxication
292.89
Opioid-Induced Sexual Dysfunction
292.89
Opioid-Induced Sleep Disorder
292.89
Opioid Intoxication
292.89
Other (or Unknown) Substance-Induced Anxiety Disorder
292.89
Other (or Unknown) Substance-Induced Sexual Dysfunction
292.89
Other (or Unknown) Substance-Induced Sleep Disorder
1:92.89
Other (or Unknown) Substance Intoxication
292.89
Phencyclidine-Induced Anxiety Disorder
292.89
Phencyclidine Intoxication
292.89
Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety Disorder
292.89
Sedative-, Hypnotic-, or Anxiolytic-Induced Sexual Dysfunction
292.89 Sedative-, Hypnotic, or Anxiolytic-Induced Sleep Disorder
-292.89 Sedative, Hypnotic, or Anxiolytic Intoxication
-292.9 Amphetamine-Related Disorder NOS
292.9
Caffeine-Related Disorder NOS
292.9
Cannabis-Related Disorder NOS
292.9
Cocaine-Related Disorder NOS
292.9
Hallucinogen-Related Disorder NOS
292.9
lnhalant-Related Disorder NOS
292.9
Nicotine-Related Disorder NOS
292.9
Opioid-Related Disorder lOS
292.9
Other (or Unknown) Substance-Related Disorder 'OS
292.9 Phencyclidine-Related Disorder NOS
-292.9 Sedative-, Hypnotic-, or Anxiolytic-Related Disorder NOS
293.0
Delirium Due to .. . lTlldicafe tIJe General Medical COlldition)
293.81
Psychotic Disorder Due to ... fl/ldicate tile General Medical COllditiOIl], ''''
ith
Delusions
293.82
Psychotic Disorder Due to ... {Iudicate tile Gel/eraf Medical Conditioll], With
Hallucinations
293.83
Mood Disorder Due to lTlldicate tile General Medical Condition]
293.84
Anxiety Disorder Due to {I/ldicate the General Medical COlldiliol/]
293.89
Catatonic Disorder Due to lTndicate tile General Medical COl/dition]
293.9
i\'lental Disorder NOS Due to ... {Indicate the GeJleral Medical Conditio,,]
294.0
Amnestic Disorder Due to ... [Judicafe the General Medical Condition]
294.10" Dementia Due to ... /llldicafe ti,e General Medical Condition], Without
Behavioral Disturbance
ICD9G.,,1 code valid after October I, 2000.
1860
Appendix F
294.10""
Dementia of the Alzheimer's Type, With Early Onset, Without Behavioral
Disturbance
294.10"
Dementia of the Alzheimer's Type, With Late Onset, \,\'ithout Behavioral
Disturbance
294.11" Dementia Due to ... /1lldicnte IIle General Medical Condition], With Beh
avioral
Disturbance
294.11
Dementia of the Alzheimer's Type, With Early Onset, With Behavioral
Disturbance
294.11 Dementia of the Alzheimer's Type, With Late Onset, With Behavioral
Disturbance
c
c
294.8 Amnestic Disorder NOS
294.8
Dementia NOS
294.9
Cognitive Disorder ros
295.10
Schizophrenia, Disorganized Type
295.20
Schizophrenia, Catatonic Type
295.30
Schizophrenia, Paranoid Type
295.40
Schizophrenifonn Disorder
295.60
Schizophrenia, Residual Type
295.70
Schizoaffective Disorder
295.90
Schizophrenia, Undifferentiated Type
296.00
Bipolar I Disorder, Single Manic Episode, Unspecified
296.01
Bipolar I Disorder, Single Manic Episode, MUd
296.02
Bipolar I Disorder, Single Manic Episode, Moderate
296.03 Bipolar I Disorder, Single Manic Episode, Severe Without Psychotic Featur
es
296.1 Bipolar I Disorder, Single Manic Episode, Severe With Psychotic Features
296.05
Bipolar I Disorder, Single Manic Episode, In Partial Remission
296.06
Bipolar I Disorder, Single Manic Episode, In Full Remission
296.20
Major Depressive Disorder, Single Episode, Unspecified
296.21
Major Depressive Disorder, Single Episode, Mild
296.22
Major Depressive Disorder, Single Episode, Moderate
296.23
Major Depressive Disorder, Single Episode, Severe Without Psychotic
Features
296.24
Major Depressive Disorder, Single Episode, Severe With Psychotic Features
296.25
Major Depressive Disorder, Single Episode, In Partial Remission
296.26
Major Depressive Disorder, Single Episode, In Full Remission
296.30
Major Depressive Disorder, Recurrent, Unspecified
296.31
Major Depressive Disorder, Recurrent, tvWd
296.32
Major Depressive Disorder, Recurrent, Moderate
296.33
Major Depressive Disorder, Recurrent, Severe \\'ithout Psychotic Features
296.34
Major Depressive Disorder, Recurrent, Severe With Psychotic Features
296.35
Major Depressive Disorder, Recurrent, In Partial Remission
296.36
Major Depressive Disorder, Recurrent, In Full Remission
296.40
Bipolar I Disorder, Most Recent Episode Hypomanic
296.40
Bipolar I Disorder, Most Recent Episode Manic, Unspecified
296.41
Bipolar I Disorder, Most Recent Episode Manic, Mild
ICD-9-eM code valid after October 1, 2000.
r
Numerical listing of DSM-IV-TR Diagnoses and Codes
296.42
296.43
296.45
296.46
296.50
29651
296.52
29653
296.54
296.55
296.56
296.60
296.61
296.62
296.63
296.64
296.65
296.66
296.7
296.80
296.89
296.90
297.1
297.3
298.8
298.9
299.00
299.10
299.80
L299.80
299.80
300.00
300.01
300.02
300.11
300.12
300.13
300.14
300.15
300.16
Bipolar I Disorder, Most Recent Episode Manic. Moderate
Bipolar I Disorder, Most Recent Episode Manic, Severe Without Psychotic
FeahJres
Bipolar 1 Disorder, Most Recent Episode Manic. Severe With Psychotic
Features
Bipolar I Disorder, Most Recent Episode Manic, In Partial Remission
Bipolar I Disorder, Most Recent Episode 1'lanic, In Full Remission
Bipolar I Disorder. Most Recent Episode Depressed, Unspecified
Bipolar J Disorder, Most Recent Episode Depressed. Mild
Bipolar I Disorder, Most Recent Episode Depressed. Moderate
Bipolar I Disorder, Mosl Recent Episode Depressed, Severe Without
Psychotic Features
Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic
Features
Bipolar I Disorder, Most Recent Episode Depressed, In Partial Remission
Bipolar I Disorder, Most Recent Episode Depressed, In Full Remission
Bipolar I Disorder, Most Recent Episode t\fu:ed, Unspecified
Bipolar I Disorder, Most Recent Episode Mixed, Mild
Bipolar I Disorder, Most Recent Episode ivlixed, Moderate
Bipolar I Disorder, Most Recent Episode Mixed, Severe Without Psychotic
Features
Bipolar I Disorder, Most Recent Episode !l.fu:ed, Severe With Psychotic
Features
Bipolar I Disorder, Most Recent Episode Mixed, In Partial Remission
Bipolar I Disorder, Most Recent Episode Mixed, In Full Remission
Bipolar I Disorder, Most Recent Episode Unspecified
Bipolar Disorder NOS
Bipolar II Disorder
Mood Disorder NOS
Delusional Disorder
Shared Psychotic Disorder
Brief Psychotic Disorder
Psychotic Disorder NOS
Autistic Disorder
Childhood Disintegrative Disorder
Asperger's Disorder
Pervasive Developmental Disorder NOS
Rett's Disorder
Anxiety Disorder NOS
Panic Disorder Without Agoraphobia
Generalized Anxiety Disorder
Conversion Disorder
Dissociative Amnesia
Dissociative Fugue
Dissociative Identity Disorder
Dissociative Disorder TOS
Factitious Disorder With Predominantly Psychological Signs and Symptoms
Appendix F
300.19
[
[
300.19
300.19
300.21
300.22
300.23
300.29
300.3
300.4
300.6
c::
c::
300.7
300.7
300.81
300.82
[
300.82
300.9
301.0
301.13
301.20
301.22
301.4
301.50
301.6
301.7
301.81
301.82
301.83
301.9
302.2
302.3
302.4
302.6
[
302.6
302.70
302.71
c::
c::
302.72
302.72
302.73
302.74
302.75
302.76
302.79
302.81
302.82
302.83
302.84
Factitious Disorder NOS
Factitious Disorder With Combined Psychological and Physical Signs and
Symptoms
Factitious Disorder With Predominantly Physical Signs and Symptoms
Panic Disorder With Agoraphobia
Agoraphobia \'\'ithout History of Panic Disorder
Social Phobia
Specific Phobia
Obsessive-Compulsive Disorder
Dysthymic Disorder
Depersonalization Disorder
Body Dysmorphic Disorder
Hypochondriasis
Somatization Disorder
Somatoform Disorder NOS
Undifferentiated Somatoform Disorder
Unspecified Mental Disorder (nonpsychotic)
Paranoid Personality Disorder
Cyclothymic Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Obsessive-Compulsive Personality Disorder
Histrionic Personality Disorder
Dependent Personality Disorder
Antisocial Personality Disorder
Nardssistic Personality Disorder
Avoidant Personality Disorder
Borderline Personality Disorder
Personality Disorder NOS
Pedophilia
TrafiSvestic Fetishism
Exhibitionism
Gender Identity Disorder in Children
Gender Identity Disorder NOS
Sexual Dysfunction NOS
Hypoactive Sexual Desire Disorder
Female Sexual Arousal Disorder
Male Erectile Disorder
Female Orgasmic Disorder
Male Orgasmic Disorder
Premature Ejaculation
Dyspareunia (Not Due to a General r",Iedical Condition)
Sexual Aversion Disorder
Fetishism
Voyeurism
Sexual Masochism
Sexual Sadism
Numerical listing of DSM-IV-TR Diagnoses and Codes
8631
302.85
302.89
[ 302.9
302.9
303.00
303.90
304.00
304.10
304.20
304.30
304AO
30450
1-304.60
-304.60
304.80
304.90
305.00
305.1
305.20
305.30
305.40
305.50
305.60
305.70
305.90
305.90
1305.90
-305.90
306.51
307.0
307.\
307.20
307.21
307.22
307.23
307.3
-307A2L 307A2
307.44
307.-14
307.-15
L
307.46
'-307.46
307.47
307.47
[
307.47
307.50
Gender Identity Disorder in Adolescents or Adults
Frotteurism
Paraphilia NOS
Sexual Disorder NOS
Alcohol Intoxication
Alcohol Dependence
Opioid Dependence
Sedative, Hypnotic, or Anxiolytic Dependence
Cocaine Dependence
Cannabis Dependence
Amphetamine Dependence
Hallucinogen Dependence
Inhalant Dependence
Phencyclidine Dependence
Polysubstance Dependence
Other (or Unknown) Substance Dependence
AJcohol Abuse
Nicotine Dependence
Cannabis Abuse
Hallucinogen Abuse
Sedative, Hypnotic, or Anxiolytic Abuse
Opioid Abuse
Cocaine Abuse
Amphetamine Abuse
Caffeine Intoxication
Inhalant Abuse
Other (or Unknown) Substance Abuse
Phencyclidine Abuse
Vaginismus (Not Due to a General Medical Condition)
Stuttering
Anorexia Nervosa
Tic Disorder NOS
Transient Tic Disorder
Chronic Motor or Vocal Tic Disorder
Tourette's Disorder
Stereotypic Movement Disorder
Insomnia Related to .. . 1lJldicate llle Axis lor Axis II DisorderJ
Primary Insomnia
Hypersomnia Related to .. . 1l1ldicate the Axis lor Aris 11 DisorderJ
Primary Hypersomnia
Circadian Rhythm Sleep Disorder
Sleep Terror Disorder
Sleepwalking Disorder
Dyssomnia NOS
ightmare Disorder
Parasomnia NOS
Eating Disorder NOS
864
307.51
307.52
307.53
307.59
307.6
307.7
307.80
307.89
307.9
308.3
309.0
309.21
309.24
309.28
309.3
309.4
309.81
309.9
310.1
311
312.30
312.31
312.32
312.33
312.34
312.39
312.81
312.82
312.89
312.9
313.23
313.81
313.82
313.89
313.9
314.00
314.01
314.01
314.9
315.00
315.1
315.2
315.31
315.32
315.39
Appendix F
Bulimia Nen'osa
Pica
Rumination Disorder
Feeding Disorder of Infancy or Earl}' Childhood
Enuresis (Not Due to a General Medical Condition)
Encopresis, Without Constipation and Overflow Incontinence
Pain Disorder Associated. With Psychological Factors
Pain Disorder Associated With Both Psychological Factors and a General
Medical Condition
Communication Disorder 'OS
Acute Stress Disorder
Adjustment Disorder With Depressed Mood
Separation Anxiety Disorder
Adjustment Disorder With Anxiety
Adjustment Disorder With Mixed Anxiety and Depressed Mood
Adjustment Disorder With Disturbance of Conduct
Adjustment Disorder With Mixed Disturbance of Emotions and Conduct
Posllraumatic Stress Disorder
Adjustment Disorder Unspecified
Personality Change Due to ... [Jlldicafe tile Gelleral Medialf Condition]
Depressive Disorder NOS
Impulse-Control Disorder NOS
Pathological Gambling
Kleptomania
Pyromania
Intermittent Explosive Disorder
Trichotillomania
Conduct Disorder, Childhood-Onset Type
Conduct Disorder, Adolescent-Qnset Type
Conduct Disorder, Unspecified Onset
Disruptive Behavior Disorder NOS
Selective Mutism
Oppositional Defiant Disorder
Identity Problem
Reactive Attachment Disorder of Infancy or Early Childhood
Disorder of Infancy, Childhood, or Adolescence NOS
Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Typ
Attention-Deficit/Hyperactivity Disorder, Combined Type
Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive.
Impulsive Type
Attention-Deficit/Hyperactivity Disorder NOS
Reading Disorder
Mathematics Disorder
Disorder of Written Expression
Expressive Language Disorder
l\1ixed Receptive-Expressive Language Disorder
Phonological Disorder
Numerical Listing of D$M-IV-TR Diagnoses and Codes
8651
315.4
Developmental Coordina~onDisorder
315.9
Learning Disorder OS
316
... [Specified Psychological Factor] Affecting ... [Indicate tlie Get/eral Medic
al
<::Ollriilioll}
317
Mild Mental Retardation
318.0
Moderate Mental Retardation
318.1
Severe Mental Retardation
318.2 Profound Mental Retardation
319 Mental Relardation, Severity Unspecified
332.1
Neuroleptic-Induced Parkinsonism
333.1
Medication-Induced Postural Tremor
333.7
Neuroleptic-Induced Acute Dystonia
333.82
Neuroleptic-Induced Tardive Dyskinesia
333.90
Medication-Induced Movement Disorder NOS
333.92
Neuroleptic Malignant Syndrome
333.99 Neuroleptic-Induced Acute Akathisia
347 Narcolepsy
607.84
Male Erectile Disorder Due to ... [Jndicate the Gel/eral Medial! <::ollditioll}
608.89
Male Dyspareunia Due 10 ... [Judicate the General Medical <::ondifion}
608.89
Male Hypoactive Sexual Desire Disorder Due to .. . 11/lriicate the Medical
<::ondition}
608.89
Other ?o.'lale Sexual D}'sfunction Due 10 .. . 1111dicate tile Gel/eral Medical
<::ollditiollj
625.0
Female Dyspareunia Due to .. . 1111dimte tile Gmeral Meriical <::ondition}
625.8
Female Hypoactive Sexual Desire Disorder Due to .. . 11ndicate tile Gelleral
Medical <::onriifionj
625.8
Other Female Sexual Dysfunction Due to ... [l/ldicate the Gf!Jleral Medical
<::O/lriitiOll}
780.09
Delirium NOS
780.52
Sleep Disorder Due to ... [Jndicate the General Meriical <::ollditiOllJ. Insomni
a
Type
780.54
Sleep Disorder Due 10 ... [JI/dicate tile Gmeral Medical <::ollditiOllj,
Hypersoomia Type
[
[
780.59 Breathing-Related Sleep Disorder
780.59
Sleep Disorder Due to 11l1riicate tile General Medical <::olldi!iOll], Mixed Typ
e
780.59
Sleep Disorder Due to fIndicate tile General Medical <::ollditioll/, Parasomnia
Type
780.9
Age-Related Cognitive Decline
787.6
Encopresis, ''''ith Constipation and Overflow Incontinence
799.9
Diagnosis Deferred on Axis [j
799.9
Diagnosis or Condition Deferred on Axis I
995.2
Adverse Effects of Medication 'OS
995.52 'eglect of Child (iffows ofattelltioll is 011 victim)
995.53
Sexual Abuse of Child (ifJoeus ofatte1l1iOll is all victim)
995.54
Physical Abuse of Child (iffoclls ofattelltioll is on victim)
995.81
Physical Abuse of Adult (iffoclls ofattelltion is 011 victim)
995.83
Sexual Abuse of Adult (iffocus of atteutiOlI is 011 victim)
[
[
[
[
[
1866
V15.81
V61.10
V61.12
V61.12
V61.20
V61.21
V61.21
V61.21
V61.8
V61.9
\162.2
V62.3
\/62.4
V62.81
\/62.82
V62.83
\/62.83
V62.89
V62.89
V62.89
V65.2
V71.01
V71.02
V71.09
V71.09
Appendix F
ToncompLiance \'\lith Treatment
Partner Relational Problem
Physical Abuse of Adult (if by partner)
Sexual Abuse of Adull (if by partner)
Parent-Child Relational Problem
Neglect of Child
Ph}'sical Abuse of Child
Sexual Abuse of Child
Sibling Relational Problem
Relational Problem Related to a Mental Disorder or General Medical
Condition
Occupational Problem
Academic Problem
Acculturation Problem
Relational Problem OS
Bereavement
Physical Abuse of Adult (if by person other than partner)
Sexual Abuse of Adult (ifby person other than partner)
Borderline Intellectual Functioning
Phase of Life Problem
Religious or Spiritual Problem
Malingering
Adult Antisocial Behavior
Child or Adolescent Antisocial Behavior
10 Diagnosis on Axis II
No Diagnosis or Condition on Axis I
Appendix G
ICD-9-CM Codes for Selected
General Medical Conditions and
Medication-Induced Disorders
Updated to include ICD-9-Cr.'1 codes effective October 1,2000
Theofficial coding system in use as of the publication of DSM-IV is the Illtemat
ionni
Classification ofDiseases, 9th Revision, Clinical Modification (lCD-9-eM). TIlis
appendix
contains two sections that are provided to fadlitate ICD-9-CM coding: 1) codes f
or
selected general medical conditions, and 2) codes for medication-induced disorde
rs.
ICD-9-CM Codes for
Selected General Medical Conditions
The codes specified for use on Axis I and Axis n of DSM-IV represent only a smal
l
fraction of the codes provided in ICD-9-CM. The conditions classified outside th
e
"Mental Disorders" chapter of ICD-9-eM are also important for clinical diagnosis
and management in mental health settings. Axis ill is provided 10 fadlitate the
reporting
of these conditions (see p. 29). To assist c1inidans in finding the ICD-9-eM cod
es,
this appendix provides a selective index of those ICD-9-eM codes for general med
ical
conditions that are most relevant to diagnosis and care in mental health setting
s.
ICD-9-CM offers diagnostic specificity beyond that reflected in many of the code
s
that appear in this appendix (e.g., to denote a specific anatomical site or tile
presence
of a specific complication). In cases in which increased specificity is noted in
the fifth
digit of the code, the least specific code (usually "0") has been selected. For
example,
the code for l}.mphosarcoma is given as 200.10 (for unspecified site), although
more
specificity with regard to anatomical site can be noted in the other fifth-digit
codes,
for example, 200.12 lymphosarcoma, intrathoracic lymph nodes. In cases in which
increased
specificity is reflected in the fourth digit of the code, this appendix often pr
ovides
the "unspecified" category (e.g., 555.9 is listed for regional enteritis; ICD-9-
CM
also includes 555.0 for enteritis involving the small intestine, 555.1 for invol
vement of
the large intestine, and 555.2 for involvement of both). Diagnostic codes for wh
ich
more specificity is available are indicated in this appendix by an asterisk (").
Clinicians
interested in recordinggreaterspecificityshould referto thecompletelistingofcode
s
published in the lCD-9-eM Diseases: Tabular List (Volume 1) and the ICD-9-CM Dis
867
1868 Appendix G
eases: Alphabetic Index (Volume 2). These documents are updated every October an
d
arc published by the U.S. Department of Health and Human Services. They are avai
l
able from the Superintendent of Documents, U.S. Government Printing Office, as
well as from a number of private publishers.
Note: An asterisk e> following the ICD-9-eM code indicates that greater specific
ity
(e.g., a specific complication or anatomical site) is available. Refer to the IC
D-9-e~'1
Diseases: Tabular List (Volume 1) entry for thai code for additional information
.
Diseases of the Nervous System
324.0 Abscess, intracranial
331.0 Alzheimer's disease
437.0 Atherosclerosis, cerebral
354.0 Carpal tunnel syndrome
35c1..l Causalgia
334.3 Cerebellar ataxia
850.9 Concussion
851.SO Contusion, cerebral
359.1 Dystrophy, Duchenne's muscular
348.5 Edema, cerebral
049.9" Encephalitis, viral
572.2 Encephalopathy, hepatic
437.2 Encephalopathy, hypertensive
3-18.3 Encephalopathy, unspecified
345.10" Epilepsy, grand mal
345.40" Epilepsy, partial, with impairment of consciousness (temporal lobe)
345.50 Epilepsy, partial, without impairment of consciousness Oacksonian)
345.00 Epilepsy, petit mal (absences)
3-16.20 Headache, duster
432.0 Hemorrhage, extradwaJ. nontraumatic
852.40 Hemorrhage, extradural. traumatic
431 Hemorrhage, intracerebral, nontraumatic
430 Hemorrhage, subarachnoid, nontraumatic
852.00" Hemorrhage, subarachnoid, traumatic
432.1 Hemorrhage, subdural, nontraumatic
852.20 Hemorrhage, subdural, traumatic
333.4 Huntington's chorea
331.3 Hydrocephalus, communicating
331.4 Hydrocephalus, obstructive
435.9" Ischemic attack, transient
046.1 Jakob-Creutzfeldt disease
046.0 Kuru
lJ.l6.3 Leukoencephalopathy, progressive multifocal
330.1 Upidosis, cerebral
320.9 Meningitis, bacterial (due to W\Specified bacterium)
321.0 IVleningitis, cryptococcal
05-1.72 Meningitis, herpes simplex virus
ICD-9-CM Codes for Selected General Medical Conditions and
Medication-Induced Disorders
053.0 Meningitis, herpes zoster
321.1~
Meningitis, other fungal
094.2 Meningitis, syphilitic
(l.I7.9 Meningitis, viral (due to unspecified virus)
346.00" Migraine, classical (with aura)
346.10 Migraine, common
346.90" Migraine, unspecified
358.0 Myasthenia gravis
350.1 Neuralgia, trigeminal
337.1 Neuropathy, peripheral autonomic
434.9" Occlusion, cerebral artery
350.2 Pain, face, atypical
351.0 Palsy, Bell's
343.9 Palsy, cerebral
335.23 Palsy, pseudobulbar
(l.I6.2 Panencephalitis, subacute sclerosing
094.1 Paresis, general
332.0 Parkinson's disease, primary
331.1 Pick's disease
357.9+ POlyneuropathy
348.2 Pseudotumor cerebri (benign intracranial hypertension)
335.20 Sclerosis, amyotrophic lateral
340 Sclerosis, multiple (MS)
345.3 Status, grand mal
345.2 Status, petit mal
345.70 Status, temporal lobe
433.1 Stenosis, carotid artery, without cerebral infarction
436 Stroke (CVA)
330.1 Tay-Sachs disease
333.1 Tremor, benign essential
Diseases of the Circulatory System
413.9 Angina pectoris
424.1 Aortic valve disorder
440.9+ Atherosclerosis
426.10" Block, atrio\'enmcular
426.3 Block, left bundle branch
426.4 Block, right bundle branch
427.5 Cardiac arrest
425.5 Cardiomyopathy. alcoholic
425.4" Cardiomyopathy, idiopathic
416.9" Chronic pulmonary heart disease
414.00" Coronary atherosclerosis
427.9 Dysrhythmia, cardiac, unspecified
415.19+ Embolism, pulmonary
421.9 Endocarditis, bacterial
1870 Appendix G
428.0~
Failure, congestive heart
427.31 Fibrillation, atrial
427.41 Fibrillation, ventricular
427.32 Flutter, atrial
427A2 Flutter, ventricular
455.6* Hemorrhoids
-Wl.9* Hypertension, essential
402.914 Hypertensive heart disease with congestive heart failure
402.90 Hypertensive heart disease without congestive heart failure
403.910-Hypertensive renal disease with failure
403.900-Hypertensive renal disease without failure
458.0 Hypotension, orthostatic
nO.90"" infarction, myocardial, acute
424.0 Mitral valve insufficiency (nonrheumatic)
424.0 Mitral valve prolapse
394.0" Mitral valve stenosis (rheumatic)
423.'r Pericarditis
443.9* Peripheral vascular disease
451.9"" Phlebitis/thrombophlebitis
446.0 Polyarteritis nodosa
427.60" Premature beats
424.3 Pulmonary valve disease (nonrheumatic)
397.1 Pulmonary valve disease, rheumatic
427.0 Tachycardia, paroxysmal supraventricular
427.2 Tachycardia, paroxysmal. WlSpeci.fied.
427.1 Tachycardia, ventricular (paroxysmal)
424.2 Tricuspid valve disease (nonrheumatic)
397.0 Tricuspid valve disease, rheumatic
456.0 Varices, esophageal, with bleeding
456.1 Varices, esophageal, without bleeding
-t54.9" Varicose veins, lower extremities
Diseases of the Respiratory System
513.0 Abscess of lung
518.0 Atelectasis
-t93.20" Asthma, chronic obstructive
-t93.90" Asthma, unspecified.
494.1 Bronchiectasis, acute
466.0 Bronchitis, acute
491.21 Bronchitis, obstructive chronic (COPD), wi.th acute exacerbation
491.20 Bronchitis, obstructive chronic (COPD), without acute exacerbation
2n.OO" Cystic fibrosis
511.9" Effusion, pleural
492.8'" Emphysema
518.81'" Failure, respiratory
505 Pneumoconiosis
ICD-9-CM Codes for Selected General Medical Conditions and
r Medication-Induced Disorders 871 I
860A~
Pneumohemothorax, traumatic
483.0 Pneumonia, mycoplasma
4S2.9~
Pneumonia, unspecified bacterial
481 Pneumonia, pneumococcal
136.3 Pneumonia, pneumocystis
482.30" Pneumonia, streptococcus
486" Pneumonia, unspecified organism
480.9 Pneumonia, viral
512.S Pneumothorax, spontaneous
860.0" Pneumothorax, traumatic
011.9 Tuberculosis, pulmonary
Neoplasms
ICD-9-eM diagnostic codes for neoplasms are classified in the table of neoplasms
in
the ICD-9-OvI Alphabetic Index (Volume 2) according to site and degree of malign
anc)'
(primary, secondary, in situ, benign, uncertain, unspecified). Note: For patient
s
with a personal history of malignant neoplasms that have been surgically removed
or
eradicated by chemotherapy or radiation therapy, codes V10.o-V10.9 should be use
d;
for specific sites, refer to the Alphabetic Index (Volume 2) of ICD-9-CM under "
History
(personal) of, malignant neoplasm."
Listed below are some of the most common codes assigned. for neoplasms.
228.02 Hemangioma of brain
201.90" Hodgkin's disease
176.9 Kaposi's sarcoma
208.01 Leukemia, acute, in remission
208.00 Leukemia, acute
208.11" Leukemia, chronic, in remission
208.10" Leukemia, chronic
200.10 Lymphosarcoma
225.2 Meningioma (cerebral)
203.Q1 Multiple myeloma, in remission
203.00 Multiple myeloma
225.0 Neoplasm, benign, of brain
211.4 Neoplasm, benign, of colon
195.2 Neoplasm, malignant, abdominal cavity, primary
194.0 Neoplasm, malignant, adrenal gland, primary
188.9 Neoplasm, malignant, bladder, primary
170.9" Neoplasm, malignant, bone, primary
198.5 Neoplasm, malignant, bone, secondary
191.9" Neoplasm, malignant, brain, primary
198.3 Neoplasm, malignant, brain, secondary
174.9 Neoplasm, malignant, breast, female, primary
175.9 eoplasm, malignant, breast, male, primary
162.9 Neoplasm, malignant, bronchus, primary
180.9 Neoplasm, malignant, cervix, primary
872
153.9+ Teoplasm, malignant, colon, primary
197.5 Teoplasm, malignant, colon, secondary
171.9+ eoplasm, malignant, connective tissue, primary
150.9+ Neoplasm, malignant, esophagus, primary
152.9+ Teoplasm, malignant, intestine, small. primary
189.0" Neoplasm, malignant, kidney, primary
155.0 Neoplasm. malignant, liver, primary
197.7 Neoplasm, malignant, liver, secondary
162.9+ eoplasm, malignant, lung, primary
197.0 leoplasm, malignant, lung, secondary
196.9" eoplasm, malignant, lymph nodes, secondary
172.9" Neoplasm, malignant, melanoma, primary
183.0 Neoplasm, malignant ovary, primary
157.9* Neoplasm, malignant. pancreas, primary
185 Neoplasm, malignant, prostate, primary
154.1 Neoplasm, malignant, rectum, primary
173.9" Neoplasm, malignant, skin, primary
151.9+ 'ooplasm, malignant, stomach, site unspecified, primary
186.9* Neoplasm, malignant, testis, primary
193 Neoplasm, malignant, thyroid, primary
179* Neoplasm, malignant uterus, primary
237.70* Neurofibromatosis
227.0 Pheochromocytoma, benign
194.0 Pheochromocytoma, malignant
238..1 Polycythemia vera
Endocrine Diseases
253.0 Acromegaly
255.2 Adrenogenital disorder
259.2 Carcinoid syndrome
255.4 Corticoadrenal insufficiency
255.0 Cushing's syndrome
253.5 Diabetes insipidus
250.00* Diabetes mellitus, type D/non-insulin-dependent
250m* Diabetes mellitus, type I/insulin-dependent
253.2 Dwarfism, pituitary
241.9* Goiter. nontoxic nodular
240.9 Goiter, simple
255.1 Hyperaldosteronism
252.0 Hyperparathyroidism
252.1 Hypoparathyroidism
244.9* Hypothyroidism, acquired
243 Hypothyroidism, congenital
256.9* Ovarian dysfunction
253.2 Panhypopituitarism
259.0 Sexual development and puberty, delayed
Appendix G
ICD-9-CM Codes for Selected General Medical Conditions and
Medication-Induced Disorders
259.1 Sexual development and puberty, precocious
257.9t Testicular dysfunction
245.9t Thyroiditis
242.9t Thyrotoxicosis
Nutritional Diseases
265.0 Beriberi
269.3 Calcium deficiency
266.2 Folic acid deficiency
269.3 Iodine deficiency
260 Kwashiorkor
262 Malnulrition, protein-ealoric, severe
261 Nutritional marasmus
278.00~
Obesity
265.2 Pellagra (niacin deficiency)
266.0 Riboflavin deficiency
264.9t Vitamin A deficiency
266.1 Vitamin 86 deficiency
266.2 Vitamin B12 deficiency
267 Vitamin C deficiency
268.9~
Vitamin 0 deficiency
269.1 Vitamin E deficiency
269.0 Vitamin K deficiency
Metabolic Diseases
276.2 Acidosis
276.3 Alkalosis
277.3 Amyloidosis
276.5 Depletion, volwne (dehydration)
271.3 Disaccharide malabsorption (lactose intolerance)
276.9t Electrolyte imbalance
276.6 Fluid overload/retention
274.9t Gout
275.0 Hemochromatosis
275.42 Hypercalcemia
276.7 Hyperkalemia
276.0 Hypematremia
275.41 Hypocalcemia
276.8 Hypokalemia
276.1 Hyponatremia
270.1 Phenylketonuria (pKU)
277.1 Porphyria
277.2 Lesch-Nyhan syndrome
275.1 Wilson's disease
Appendix G
Diseases of the Digestive System
540.9'" Appendicitis, acute
578.9'" Bleeding, gastrointestinal
575.0 Cholecystitis, acute
575.11 Cholecystitis, chronic
571.2 Cirrhosis, alcoholic
556.9'" Colitis, ulcerative
564.0 Constipation
555.9'" Crohn's disease
009.2 Diarrhea, infectious
558.9'" Diarrhea, unspecified
562.10 Diverticulitis of colon, unspecified
562.12 Diverticulitis of colon, with hemorrhage
562.11 Diverticulosis of colon, unspecified
562.13 Diverticulosis of colon, with hemorrhage
535.50'" Duodenitis and gastritis
535.9'" Enteritis, regional
335.50'" Gastritis and duodenitis
558.9'" Gastroenteritis
530.1 Esophagitis
571.1 Hepatitis, alcoholic, acute
571.40'" Hepatitis, chronic
573.3'" Hepatitis, toxic (indudes drug induced)
070.1'" Hepatitis, viral A
070.30'" Hepatitis, viral B
070.51'" Hepatitis, viral C
560.39'" Impaction, fecal
550.90'" Inguinal hernia
56-U Irritable bowel syndrome
576.2 Obstruction, bile duct
560.9'" Obstruction, intestinal
577.0 Pancreatitis, acute
577.1 Pancreatitis, chronic
567.9'" Peritonitis
530.1 Reflux, esophageal
530.-1 Rupture, esophageal
530.3 Stricture, esophageal
532.30'" Ulcer, duodenal, acute
532.70'" Ulcer, duodenal, chronic
531.30'" Ulcer, gastric, acute
531.70'" Ulcer, gastric, chronic
Genitourinary System Diseases
596.4 Atonic bladder
592.0 Calculus, renal
lCD-9-CM Codes for Selected General Medical Conditions and
Medication-Induced Disorders
592.1 Calculus, ureter
592.9 Calculus, urinary, unspecified
595.9 Cystitis
625.3 Dysmenorrhea
617.9 Endometriosis
584.9 Failure, renal, acute
585 Failure, renal, chronic
403.9P Failure, renal, hypertensive
586 Failure, renal, unspecified
218.9* Fibroid of uterus
580.9 Glomerulonephritis, acute
600.0 Hypertrophy, prostatic, benign (BPH)
628.9 Infertility, female
606.9 Infertility, male
627.9"" Menopausal or postmenopausal disorder
626.9* Menstruation, disorder of, and abnormal bleeding
625.2 NUttelschmerz
620.2 Ovarian cyst
61 ..1.9 Pelvic inflammatory disease (PID)
607..3 Priapism
618.9 Prolapse, genital
601.9"" Prostatitis
593.3 Stricture, ureteral
598.9 Stricture, urethral
599.0 Urinary tract infection (UTI)
Hematological Diseases
288.0 Agranulocytosis
287.0 Allergic purpura
284.9 Anemia, aplastic
281.2 Anemia, folate-deficiency
283.9 Anemia, hemolytic, acquired
283.11 Anemia, hemolytic-uremic syndrome
280.9"" Anemia, iron-deficiency
283.10 Anemia, nonautoimmune hemolytic, WlSpecified
283.19 Anemia, other autoimmune hemolytic
281.0 Anemia, pernicious
282.60 Anemia, sickle-cell
286.9 Coagulation defects
288.3 Eosinophilia
282.4 Thalassemia
287.5* Thrombocytopenia
Diseases of the Eye
366.9 Cataract
3n.9 Conjunctiva disorder
8751
Appendix G
361.9 Detachment, retinal
365.9"" Glaucoma
377.30"" Neuritis, optic
379.50"" ),stagmus
377.oo~
Papilledema
369.9"" Visual loss
Diseases of the Ear, Nose, and Throat
460 Common cold
389.9" Hearing loss
464.0 Laryngitis, acute
386.00" Meniere's disease
382.9" Otitis media
462 Pharyngitis, acute
477.9" Rhinitis, allergic
461.9"" Sinusitis, acute
473.9"" Sinusitis, chronic
388.30" Tinnitus, unspecified
463 Tonsillitis, acute
Musculoskeletal System and Connective Tissue Diseases
716.20" Arthritis, allergic
711.90"" Arthritis. infective
714.0 Arthritis, rheumatoid
733.40~
Aseptic necrosis of bone
710.3 Dermatomyositis
n2.91 Disc disorder, intervertebral, cervical
722.93 Disc disorder, intervertebral, lumbar
722.92 Disc disorder, intervertebral, thoracic
733.10 Fracture, pathological
715.90"" Osteoarthrosis (osteoarthritis)
730.20"" Osteomyelitis
733.00"" Osteoporosis
710.1 Scleroderma (systemic sclerosis)
737.30 Scoliosis
710.2 Sjogren's disease
no.o Spondylitis, ankylosing
710.0 Systemic lupus erythematosus
Diseases of the Skin
704.00" Alopecia
692.9" Dermatitis, contact
693.0" Dermatitis, due to substance (taken internally)
682.9" Cellulitis, unspecified site
ICD-9-CM Codes for Selected General Medical Conditions and
Medication-Induced Disorders
8771
695.1 Erythema multiforme
703.0 Ingrowing nail
701.4 Keloid scar
696.1'" Psoriasis
707.0 Ulcer, decubitus
708.0 Urticaria, allergic
Congenital Malformations, Deformations, and
Chromosomal Abnormalities
749.10' Clefllip
7-19'(x)" Cleft palate
758.3 Cri-du-ehat syndrome (antimongolism)
758.0 Down's syndrome
760.71 Fetal alcohol syndrome
751.3 Hirschsprung's disease (congenital colon dysfunction)
7-12.3 Hydrocephalus, congenital
752.7 Indeterminate sex and pseudohermaphroditism
758.7 Klinefelter's syndrome
759.82 Marfan's syndrome
7-12.1 Microcephalus
741.90'" Spina bifida
750.5 Stenosis, congenital hypertrophic pyloric
760.71 Toxic effects of alcohol
760.75 Toxic effects of cocaine
760.73 Toxic effects of hallucinogens
760.72 Toxic effects of narcotics
760.70 Toxic effects of other substances (including medications)
759.5 Tuberous sclerosis
758.6 Turner's syndrome
752.51 Undescended testicle
Diseases of Pregnancy, Childbirth, and the Puerperium
Diagnoses associated with pregnancies can be located in the Alphabetic Index (Vo
lume
2) of ICD-9-CM indented under "Pregnancy, complicated (by)," or "Pregnancy,
management affected by." Listed below are some of the most common conditions.
6-12.00" Eclampsia
6-13.0'" Hyperemesis gravidarum, mild
643.0" Hyperemesis gravidarllm, with metabolic disturbance
6-1.2.0" Pre-eclampsia, mild
6-12.0" Pre-eclampsia, severe
Infectious Diseases
The foUowing codes represent ICD-9-CM diagnostic codes for infections from speci
fic
organisms. Traditionally, codes for organisms from the 041 category are used as
Appendix G
secondary codes (e.g., urinary tract infection due to Escheric/lin coli would be
coded as
599.0 (primary diagnosis) and 041.4 {secondary diagnosis)).
006.9 Amebiasis
112.5 Candidiasis, disseminated
112A Candidiasis, lung
112.0 Candidiasis, mouth
112.2 Candidiasis, other urogenital sites
112.3 Candidiasis, skin and nails
112.9 Candidiasis, unspecified site
112.1 Candidiasis, vulva and vagina
099.41 C1l1nmydin tmchomntis
001.9-' Cholera
Q.t.l.83 Clostridill/ll peifrigens
11.,l.9 Coccidioidomycosis
078.1 Condyloma oCll11li1l011111l (viral warts)
079.2 Coxsackie virus
117.5 Cryptococcosis
OI1A Esc1leric1lin coli (E. colI)
007.1 Giardiasis
098.2'" Gonorrhea
Q.t.1.5 Hemophilus i'ifllIellZllc (H. influellZJle)
070.1 Hepatitis, viral A
070.3 Hepatitis, viral B
070.51 Hepatitis, viral C
05-1.9-' Herpes simplex
053.9-' Herpes zoster
115.9-' Histoplasmosis
042 HIV infection (symptomatic)
036.9-' Infection, meningococcal
079.99-' Infection, viral, unspecified
-187.1 Influenza, unspecified
487.0 Influenza, with pneumonia
041.3-' Klebsie//n pllel/lllonine
088.81 Lyme disease
084.6 Malaria
075 Mononucleosis
072.9Mumps
Q.t.1.81 Mycoplnsmn
Q.t.1.2 PllelimococcllS
Q.t.1.6 Protells
Q.t.1.7 Pseudomonas
071 Rabies
056.9 Rubella
003.9-' SalmoneUa
135 Sarcoidosis
001.9 Shigellosis
ICD9CM Codes for Selected General Medical Conditions and
Medication-Induced Disorders 879
Q.Jl.10+ StapliylococClls
Q.Jl.00+ Str~tococClls
097.9+ Syphilis
082.9+ Tick-bome rikettsiosis
130.9+ Toxoplasmosis
124 Trichinosis
131.9+ Trichomoniasis
002.0 Typhoid fever
081.9+ Typhus
Overdose
Additional diagnostic codes for overdose/poisoning can be located in the Alphabe
tic
Index (Volume 2) of ICD-9-efl.r in the table of drugs and chemicals, listed alpha
betically
by drug in the "Poisoning" column.
965.-l Acetaminophen
962.0 Adrenal cortical steroids
972.4 Amyl/butyl/nitrite
962.1 Androgens and anabolic steroids
971.1 Anticholinergics
969.0 Antidepressants
967.0 Barbiturates
969.4 Benzodiazepine-based tranquilizers
%9.2 Butyrophenone-bascd tranquilizers
%7.1 Chloral hydrate
968.5 Cocaine
967.5 Glutethimide
969.6 HaUucinogens/ cannabis
962.3 Insulin and antidiabetic agents
967.4 Methaqualone
968.2 Nitrous oxide
970.1 Opioid antagonists
965.00 Opioids
967.2 Paraldehyde
968.3 Phencyclidine
969.1 Phenothiazine-based tranquilizers
965.1 Salicylatcs
970.9 Stimulants
%2.7 Thyroid and thyroid derh'ativcs
Additional Codes for Medication-Induced Disorders
The following are the ICD-9-0vl codes for selected medications that may cause
Substance-Induced Disorders. They are made available for optional use by clinici
ans
in situations in which these medications, prescribed at therapeutic dose levels,
have
resulted in one of the foUowing: Substance-induced Delirium, Substance-Induced
~
/880 Appendix G
Persisting Dementia, Substance-Induced Persisting Amnestic Disorder, SubstanceIn
duced
Psychotic Disorder, Substance-Induced Mood Disorder, Substance-Induced
Anxiety Disorder, Substance-Induced Sexual Dysfunction, Substance-Induced Sleep
Disorder, and Medication-Induced Movement Disorders. When used in multiaxial
evaluation, the E-codes should be coded on Axis I immediately following the rela
ted
disorder. It should be noted that these I-codes do not apply to poisonings or 10
a
medication taken as an overdose.
Example:
292.39 Substance-Induced Mood Disorder, With Depressive Features
932.2 Oral contraceptives
Analgesics and Antipyretics
935.4 Acetaminophen/phenacetin
935.1 Methadone
935.6 onsteroidal anti-inflammatory agents
935.2 Other narcotics (e.g., codeine, meperidine)
E935.3 Salicylates (e.g., aspirin)
Anticonvulsants
936.3 Carbamazepine
E936.2 Ethosuximide
E937.0 Phenobarbital
936.1 Phenytoin
936.3 Valproic acid
Antiparkinsonian Medications
936.4 Amantadine
941.1 Benztropine
933.0 Diphenhydramine
936.4 l-Dopa
Neuroleptic Medications
939.2 Butyrophenone-based neuroleptics (e.g., haloperidol)
939.3 Other neuroleptics (e.g., thiothixene)
939.1 Phenothiazine-based neuroleptics (e.g., chlorpromazine)
Sedatives, Hypnotics, and Anxiolytics
937.0 Barbiturates
939.4 Benzodiazepine-based medications
937.1 Chloral hydrate
939.5 Hydroxyzine
937.2 Paraldehyde
ICD-9-CM Codes for Selected General Medical Conditions and
Medication-Induced Disorders
Other Psychotropic Medications
E939.0 Antidepressants
E939.6 Cannabis
E940.1 Opioid antagonists
E939.7 Stimulants (excluding central appetite depressants)
Cardiovascular Medications
E942.0 Antiarrhythmic medication (includes propranolol)
E9c12.2 Antilipemic and cholesterol-lowering medication
E942.1 Cardiac glycosides (e.g., digitalis)
E942.4 Coronary vasodilato"rs (e.g., nitrates)
E9-12.3 Ganglion-blocking agents (pentamethonium)
E942.6 Other antihypertensive agents (e.g., c1onidine, guanethidine, reserpine)
E9c12.s Other vasodilators (e.g., hydralazine)
Primarily Systemic Agents
E933.0 Antiallergic and antiemetic agents (excluding phenothiazines, hydroxyzine
)
E941.1 Anticholinergics (e.g., atropine) and spasmolytics
E93-1.2 Anticoagulants
E933.1 Antineoplastic and immunosuppressi\'e drugs
E941.0 Cholinergics (parasympathomimetics)
E941.2 Sympathomimetics (adrenergics)
E933.5 Vitamins (excluding vitamin K)
Medications Acting on Muscles and the Respiratory System
E945.7 Antiasthmatics (aminophylline)
E945.4 Antitussives (e.g., dextromethorphan)
E945.8 Other respiratory drugs
E945.0 Oxytocic agents (ergot alkaloids. prostaglandins)
E945.2 Skeletal muscle relaxants
E945.1 Smooth muscle relaxants (metaproterenol)
Hormones and Synthetic Substitutes
E932.0 Adrenal cortical steroids
E932.1 Anabolic steroids and androgens
E932.8 Antithyroid agents
E932.2 Ovarian hormones (includes oral contraceptives)
E932.7 Thyroid replacements
Diuretics and Mineral and Uric Acid Metabolism Drugs
E944.2 Carbonic acid anhydrase inhibitors
E944.3 Chlorthiazides
E944.0 Mercurial diuretics
1882 Appendix G
E9+lA Other diuretics (furosemide, ethacrynic acid)
E9+.l.1 Purine derivative diuretics
E9+1.7 Uric acid metabolism drugs (probenecid)
Appendix H
DSM-IV Classification
(With ICD-10 Codes)
As of the publication of this text revision (in the late spring of 2000), the of
ficial
coding system in use in the United States is the lutemalionot Classification of
Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM). Throughout much of the world,
the official coding system is the IlileTllotiol/fll Statistical Cfassijicatioll
of Diseases and Related
Healtfl Problems, Tenth Revision (ICD-10). The preparation of DSM-IV has been
closely coordinated with the preparation of Chapter V, "Mental and Behavioural D
is
orders," of ICD-IO (developed by the World Health Organization in anticipation o
f
ils evennlal implementation in the United States). Consultations between the Ame
rican
Psychiatric Association and the World Health Organization have resulted in
DSM-IV codes and terms that are fully compatible with the codes and tem,s in the
tabular index of lCD-to. To facilitate the use of DSM-IV intemationaUy, presente
d be.
low is the DSM-IV Classification with the lCD-tO codes.
NOS = ot Otherwise Specified.
An x appearing in a diagnostic code
indicates that a specific code number is
requjred.
An ellipsis ( ... ) is used in the names
of certain disorders to indicate that the
name of a specific mental disorder or
general medical condition should be inserted
when recording the name (e.g.,
F05.0 Delirium Due to Hypothyroidism).
umbers in parentheses are page num~
bers.
U criteria are currently met, one of the
following severity specifiers may be noted
after the diagnosis:
Mild
Moderate
Severe
If criteria are no longer met, one of the
following specifiers may be noted:
In Partial Remission
In Full Remission
Prior History
883
884
Appendix I
ATIENTION-DEFICIT AND DISRUPTIVE
BEHAVIOR DISORDERS (85)
Disorders Usually First Diagnosed
in Infancy, Childhood, or
Adolescence (39)
MENTAL RETARDATION (41)
Note: T/ltSe are coded 0'1 Atis ll.
F70.9 Mild Mental Retardation (43)
F71.9 Moderate Mental Retardation
(43)
F72.9 Severe Menial Retardation (43)
F73.9 Profound Mental Retardation
(44)
F79.9
Mental Retardation, Severity
Unspecified (44)
LEARNING
DISORDERS (49)
F81.0 Reading Disorder (51)
F8l.2 Mathematics Disorder (53)
FB1.8 Disorder of Written Expression
(~)
F81.9
Leaming Disorder NOS (56)
MDTOR
SKILLS DISORDER (56)
F82
DevelopmentaJ Coordination
Disorder (56)
COMMUNICATION DISORDERS (58)
FSO.l
Expressive Language Disorder
(58)
FSO.2
Mixed Receptive-Expressive
Language Disorder (62)
F80.0 Phonological Disorder (65)
F98.5 Stuttering (67)
F80.9 Communication Disorder NOS
(69)
PERVASIVE DEVELOPMENTAL
DISORDERS (69)
F84.0 Autistic Disorder (70)
FB-l.2 Rett's Disorder (76)
F84.3 Childhood Disintegrative
Disorder (77)
F84.s Asperger's Disorder (80)
F84.9 Pervasive Developmental
Disorder NOS (~)
_._ Attention-Deficit/
Hyperadi\ity Disorder (85)
F90.0 Combined T}'Pe
F98.8 Predominantly Inattentive
Type
F90.0 Predominantly HyperactiveImpulsive
Type
F90.9 Attention-Deficit/Hyperactivity
Disorder TOS (93)
F91.8 Conduct Disorder (93)
Specify type; Childhood-Dnsel Type/
Adolescent-Onsel Type
F91,3 Oppositional Defiant Disorder
(100)
F91.9 Disruptive Behavior Disorder
NOS (103)
FEEDING AND EATING DISORDERS OF
INFANCY OR EARLY CHILDHOOD (103)
F98.3 Pica (103)
F98.2 Rumination Disorder (105)
F98.2 Feeding Disorder of lnfancy or
Eady Childhood (107)
TIC DiSORDERS (108)
F95.2 Tourette's Disorder (111)
F95.1 Chronic Motor or Vocal Tic
Disorder (114)
F95.0 Transient Tic Disorder (115)
SPf'fify if Single Episode/Rerurrent
F95.9 Tic Disorder NOS (116)
ELIMINATION DISORDERS (116)
_'_ Entopresis (116)
R15
With Constipation and
Overflow Incontinence (also
code KS9.0 c01lstipatioll Oil
Axis 11I)
F98.1
Without Constipation and
(hterflow Incontinence
F98.0
Enuresis (Not Due to a General
Medical Condition) (118)
spmfy~:
Noctum.al Only/Diurnal
OnI}'/Noctumal and Diurnal
DSM-IV
Classification (With ICD-l0 Codes)
OTHER DISORDERS OF INFANCY,
DEMENTIA (147)
CHILDHOOD, OR ADOLESCENCE (121)
F93.0
Separation Anxiety Disorder
(121)
Spify if.
Early Onset
F9.,1.0
Selective Mutism (l25)
F94.x
Reactive Attachment Disorder
of Infancy or Early Childhood
(127)
.1 inhibited Type
.2 Disinhibited Type
F98.4
Stereotypic Movement
Disorder (131)
Sptrify if With Self-Injurious Behavior
F98.9
Disorder of Infancy, Childhood,
or Adolescence NOS (134)
Delirium, Dementia, and Amnestic
and Other Cognitive Disorders
(135)
DELIRIUM (136)
F05.0 Delirium Due to ... {Indicate tile
Celleral Medical Conditioll] (code
FOS.l ifsllperimposed all
Demelltia) (141)
_._ Substance Intoxication
Delirium (refer to SllbstallceRelated
Disorders for silbstallcespecific
codes) (143)
_._ Substance Withdrawal
Delirium (refer to SubstallceRelated
Disorders for Sllbstalfcespecific
codes) (143)
__._ Delirium Due to Multiple
Etiologies (code eadl ofthe specific
etiologies) (146)
F05.9 Delirium NOS (147)
FOO.xx
.00
.01
.03
FOO.xx
.10
.11
.13
F01.xx
.80
.81
.83
F02A
F02.8
F02.3
F02.2
F02.0
F02.1
Dementia of the Alzheimer's
Type, With Early Onset (also
code GJO.O Alzheimer's Disease,
Witll Early Ollset, Oil Axis III)
(154)
Uncomplicated
With Delusions
With Depressed Mood
Sptdfy if With Beha\o1oral DiJ;turbance
Dementia of the Alzheimer's
Type, With Late Onset (also code
G30.1 Alzheimer's Disease, WitlE
LAte Onset, 011 Axis JIl) (154)
Uncomplicated
With Delusions
With Depressed Mood
speofy if
With Beha\'ioral Disturbance
Vascular Dementia (l58)
Uncomplicated
With Delusions
With Depressed Mood
Spify if. With Beh.wioral DiJ;tumance
Dementia Due to HlV Disease
(also code 822.0 HI'V disease
resultillg ill encephalopathy all
Axis IIl) (163)
Dementia Due to Head Trauma
(also code S06.9lntracranial illjllry
011 Axis 111) (164)
Dementia Due to Parkinson's
Disease (also code G20
Parkinson's disease all Axis 111)
(164)
Dementia Due to Huntington's
Disease (also code C10
HI/ntillgtoll's disease on Axis Ill)
(165)
Dementia Due to Pick's Disease
(also code G31.0 Pick's disease all
Axis ITl) (165)
Dementia Due to Creutzfeldt
Jakob Disease (also code A81.0
Crelltzfeldt-fakob disease all Axis
IIl) (166)
886
Appendix'
F02.S Dementia Due to .. . LIlldicate the
General Medical COlldition lIot
listed oboue} (also code tile general
medicnl condition all Axis 111)
(167)
f02.8
-'Substance-
Induced Persisting
Dementia (refer to SubstallURe/
ated Disorders for Sllbstallcespecific
codes) (168)
Dementia Due to Multiple
Etiologies (illstead code FOO.21ar
mixed Alzheimer's alld VnSCl/lar
Demelltia) (170)
f03 Dementia NOS (171)
AMNESTIC DISORDERS (172)
F04
Amnestic Disorder Due 10 ...
[Indicate
tlJe Gel/eral Medical
COllditioll/ (175)
5pifiJ if Transient/Chronic
_"_
Substance-Induced Persisting
Amnestic Disorder (refer to
Substallce-Related Disorders for
substance-specific codes) (177)
R-Il.3
Amnestic Disorder 'OS (179)
OTHER COGNITIVE DISORDERS (179)
f06.9
Cognitive Disorder NOS (179)
Mental Disorders Due to a General
Medical Condition Not Elsewhere
Classified (181)
f06.1 Catatonic Disorder Due to ...
(Il/dicate the Gel/eml Medical
f07.0
COllditiollJ (185)
Personality Change Due 10 ...
11lldicnte file General Medical
f09
Condition) (187)
Spmfy ~
LabileType/Disinhibiled
Type!Aggressi\"e Typel Apathetic
Type/Paranoid TYfHL'/Other Typel
Combined Type/Unspecified Type
Mental Disorder NOS Due
to .. . Ill/dimte tile General
Medical Condition} (190)
Substance-Related Disorders (191)
ilTllefollowillg specifiers may be applied to
Substance Depf'lldellce:
sp<'cify if. With Physiological Dependencrl
Withoul Physiological Dependence
Code course of Dependence ill fiftl!
diameter:
0", Early Full Remission/Early Partial
Remission
0", Sustained Full Remission/Sustained
I'artial Remission
I = in a Controlled Environment
2", On Agonist Therapy
-I = Mild/Moderate/Se\"ere
TIle followillg specifiers apply to SlIhstancrIudl/
ud Disorders as 1loted:
IWith Onset During Intoxication/ \\'With
Onset During Withdrawal
ALCOHOLRELATED DISORDERS (21;
Alcohol Use Disorders (213)
FlO.2x Alcohol Dependence'" (213)
FlO.IAlcohol Abuse (214)
Alcohol-Induced Disorders (214)
FlO.DO Alcohollnloxication (214)
FlO.3 Alcohol Withdrawal (215)
Sprdfy if With Perceptual DisturbanCt'S
FIO.03 A!cohollntoxication Delirium
(143)
fJO.4
Alcohol Withdrawal Delirium
(143)
fl0.73 Alcohol-Induced Persist.ing
Dementia (168)
FlO.6 Akohollnduced Persisting
Amnestic Disorder (177)
FlO.xx Alcohol-lnduced Psychotic
Disorder (338)
.51 With DelusionsI.W
.52 ''''ith Hallucinations!.w
flO.8
Alcohol-Induced ~Ifood
Disorder',w (.lOS)
DSM-IV
Classification (With ICD-1 0 Codes)
FlO.8 Alcohol-Induced. Anxiety
Disorde~'w(479)
FlO.8 Alcohol-Induced Sexual
Dysfunctionl (562)
FlO.8 Alcohol-Induced Sleep
Disorder I.W (655)
FlO.9
Alcohol-Related Disorder OS
(223)
AMPHETAMINE (OR AMPHETAMINElIKE)-
RELATED DISORDERS (223)
Amphetamine Use Disorders (224)
F15.2x Amphetamine Dependencea
(224)
F15.1 Amphetamine Abuse (225)
Amphetamine-Induced Disorders
(226)
FI5.00
Amphetamine Intoxication
(226)
F15.D-l Amphetamine Intoxication,
With Perceptual Disturbances
(226)
F15.3 Amphetamine Withdrawal
(227)
F15.03 Amphetamine Intoxication
Delirium (143)
F15.xx Amphetamine-Induced
Psychotic Disorder (338)
.51 With Delusionsl
.52 With Hallucinations!
Fl5.8 Amphetamine-Induced Mood
Disorderl,w (405)
F15.8 Amphetamine-lnduced Anxiety
Disorderl (479)
F15.8 Amphetamine-Induced Sexual
Dysfunctionl (562)
F15.8 Amphetamine-Induced Sleep
Disorder!'W (655)
F15.9
Amphetamine-Related
Disorder NOS (231)
F15.8
Caffeine-Induced Sleep
Disorderl (655)
F15.9
Caffeine-Related Disorder NOS
(234)
CANNABIS-RELATED DISORDERS (234)
Cannabis Use Disorders (236)
F12.2x Cannabis Dependencea (236)
F12.1 Cannabis Abuse (236)
Cannabis-Induced Disorders (237)
F12.00 Cannabis Intoxication (237)
F12.04 CaIUlabis Intoxication, With
Perceptual Disturbances (237)
F12.03 Cannabis Intoxication Delirium
(143)
F12.xx Cannabis-Induced Psychotic
Disorder (338)
.51 With Delusionsl
.52 With Hallucinations!
Fl2.8 Cannabis-Induced Anxiety
Di,."de~
(479)
F12.9
Cannabis-Related Disorder
NOS (241)
COCAINE-RELATED DISORDERS (241)
Cocaine Use Disorders (242)
F14.2x Cocaine Dependenceil (U2)
F14.1 Cocaine Abuse (243)
Cocaine-Induced Disorders (244)
F14.00 Cocaine Intoxication (244)
F14.04 Cocaine Intoxication, With
Perceptual DiShlrbances (244)
F14.3 Cocaine \<\'ithdrawal (245)
F14.03 Cocaine Intoxication Delirium
(143)
F14.xx Cocaine-Induced Psychotic
Disorder (338)
.51 With Delusions!
.52 With Hallucinations!
F14.8 Cocaine-Induced Mood
CAFFEINE-RELATED DISORDERS (231) Disorde~'w
(-105)
Fl-l.8 Cocainelnduced Anxiety
Caffeine-Induced Disorders (232)
Disorde~'w
(-179)
F15.00
Caffeine Intoxication (232)
F14.8
Cocaine-Induced Sexual
F15.8
Caffeine-Induced Anxiety
Dysfunctionl (562)
Disorder! (479)
1888
F14.8
Cocaine-Induced Sleep
Disordeclw (655)
F14.9
Cocaine-Related Disorder NOS
(250)
HALLUCINOGEN-RELATED DISORDERS
(250)
Hallucinogen Use Disorders (251)
FIG.2x
Hallucinogen Dependence3
(251)
fIG.) Hallucinogen Abuse (252)
Hallucinogen-Induced Disorders (252)
fI6.DO
Hallucinogen Intoxication (252)
f16.70
Hallucinogen Persisting
Perception Disorder
(FI"hbacks) (253)
FI6.03 Hallucinogen Intoxication
Delirium (143)
FIG.xx Hallucmogenlnduced
Psychotic Disorder (338)
.51 With Delusionsl
.52 With HaUudnationsI
F16.8 HalluOnogenInduced Mood
Disorde~
(405)
FI6.S Hallucinogen-Induced Anxiety
Disorde~
(479)
f16.9
Hallucinogen-Related Disorder
NOS (256)
INHALANT-RELATED DISORDERS (257)
Inhalant Use Disorders (258)
FIB.2x Inhalant Dependencea (258)
FIB.1 Inhalant Abuse (259)
Inhalant-Induced Disorders (259)
FI8.00
Inhalant Intoxication (259)
F18.03
Inhalant Intoxication Delirium
(143)
F18.73 Inhalant-Induced Persisting
Appendix H
F18.8
Inhalant-Induced Anxiety
Diso,de~
(479)
F18.9
Inhalant-Related Disorder lOS
(263)
NICOTINE-RELATED DISORDERS (264)
Nicotine Use Disorder (264)
F17.2x icotine DependenceOl (264)
Nicotine-Induced Disorder (265)
FI7.3 1 icotine Withdrawal (265)
Fl7.9
Nicotine-Related Disorder NOS
(269)
OPIOID-RELATED DISORDERS (269)
Opioid Use Disorders (270)
Fll.2x Opioid DependenceOl (270)
FI1.1 Opioid Abuse (271)
Opioid-lnduced Disorders (271)
Fl1.00 Opioid Intoxication
(271)
Fl1.O-:l Opioid Intoxication, With
Perceprual Disturbances (2n)
FlI.3 Opioid Withdrawal (272)
F11.03 Opioid Intoxication Delirium
(143)
FII.xx Opioid-Induced Psychotic
Disorder (338)
.51 With Delusions'
.52 With Hallucinations'
Fll.S
Opioid-Induced Mood
Disorderl (405)
FII.S Opioid-Lnduced
Sexual Dysfunction' (562)
Fl1.S Opioid-Induced
Sleep Disorder',w (655)
FII.9
Opioid-Related Disorder NOS
(277)
Dementia (168)
FI8.xx Inhalant-Induced Psychotic
Disorder (338)
.51 With Delusions!
.52 With Hallucinationsl
F18.8 Inhalant-Induced
Mood. Disorde~
(405)
PHENCYCLIDINE
(OR PHENCYCLIDINE-L1KE)-RELATED
DISORDERS (278)
.
Phencyclidine Use Disorders (279)
F19.2x Phencyclidine Dependence3
(279)
F19.I Phencyclidine Abuse (279)
DSM-IV Classification (With ICD-lO Codes)
Phencyclidine-Induced Disorders (280) F13.xx Sedative-, Hypnotic-, or
Fl9.00 Phencyclidine Intoxication (280)
F19.04 Phencyclidine Intoxication,
With Perceptual Disturbances
(280)
FI9.OJ Phencyclidine Intoxication
Delirium (143)
F19.xx Phencyclidine-Induced.
Psychotic Disorder (338)
.51 With Delusionsl
52 With Hallucinations'
F19.8
Phencyclidine-Induced Mood
Disorderl (405)
Fi9.S Phencyclidine-Induced Anxiety
Disorde~
(479)
F19.9
Phencyclidine-Related Disorder
NOS (283)
SEDATIVE-, HYPNOTIC-, OR
ANXIOLYTIC-RELATED DISORDERS
(284)
Sedative, Hypnotic, or Anxiolytic Use
Disorders (285)
F13.2x Sedative, Hypnotic, or
Anxiolytic Dependencea (285)
F13.1 Sedative, Hypnotic, or
Anxiolytic Abuse (286)
Sedative-, Hypnotic-, or AnxiolyticInduced
Disorders (286)
F13.00 Sedative, Hypnotic, or
An.xiolytic Intoxication (286)
F13.3
Sedative, Hypnotic, or
Anxiolytic Withdrawal (287)
Specify if: With Perceptual Disturbances
FI3.03
Sedative, Hypnotic, or
Anxioiytic Intoxication
Delirium (143)
F13.-l
Sedative, Hypnotic, or
Anxioiytic Withdrawal
Delirium (143)
F13.73
Sedative-, Hypnotic-, or
Anxiolytic-Induced Persisting
Dementia (168)
F13.6
Sedative-, Hypnotic-, or
Anxiolytic-lnduced. Persisting
Amnestic Disorder (In)
Anxioiytic-Induced Psychotic
Disorder (338)
.51 With DelusionslW
.,
.,.
With Hallucinations!.'\'
F13.8
Sedative-, Hypnotic-, or
Anxiolytic-lnduced Mood
Disorderlw(405)
F13.8
Sedative-, Hypnotic-, or
Anxiolytic-Induced Anxiety
Disorderw (479)
F13.8
Sedative-, Hypnotic-, or
Anxioi},tic-Induced Sexual
Dysnmction' (562)
F13.8
Sedative-, Hypnotic-, or
Anxiolytic-Induced Sleep
Disorderlw(655)
F13.9
Sed.ative-, Hypnotic-, or
Anxiolytic-Relaled Disorder
NOS (293)
POLYSUBSTANCE-RElATED DISORDER
(293)
FI9.2\: Polysubstance Dependencea
(293)
OTHER (OR UNKNOWN) SUBSTANCE
RELATED DISORDERS (294)
Other (or Unknown) Substance Use
Disorders (294)
F19.2x Other (or Unknown) Substance
Dependencea (192)
F19.1 Other (or Unknown) Substance
Abuse (198)
Other (or Unknown) SubstanceInduced
Disorders (295)
F19.00 Other (or Unknown) Substance
Intoxication (199)
F19.Q.l Other (or Unknown) Substance
Intoxication, \>\Iith Perceptual
rhsturbances(l99)
F19.3 Other (or Unknown) Substance
Withdrawal (201)
5pmfy if: With Perceptual Disturbances
/890
Appendix H
F19.03
F19.73
F19.6
F19.xx
.51
-,
.,
F19.8
F19.8
F19.8
F19.8
F19.9
Other (or Unknown)
Substance-Induced Delirium
(code F19.4 ifonset durillg
witIJdrawnl) (143)
Other (or Unl'llown)
Substance-Induced Persisting
Dementia (168)
Other (or Unknown)
Substance-Induced Persisting
AflUlestiC Disorder (177)
Other (or Unknown)
Substance-induced Psychotic
Disorder (338)
With Delusions!.\\'
With HaUucinationsI.W
Other (or Unknown)
Substance-Induced Mood
Disorde~'\\'
(405)
Other (or Unknown)
Substance-Induced Anxiety
Disorder!'\\' (479)
Other (or Unknown)
Substance-Induced Sexual
Dysfunctionl (562)
Other (or Unknown)
Substance-Induced Sleep
Disorderl,\\' (655)
Other (or Unknown)
Substance-Related Disorder
NOS (295)
Schizophrenia and
Other Psychotic Disorders (297)
F20.xx Schizophrenia (298)
.Ox Paranoid Type (313)
.lx Disorganized Type (314)
.2x Catatonic Type (315)
.3x Undifferentiated Type (316)
.5x Residual Type (316)
Code course ofSc1li:oplmmia ill fifth
clmrncter;
Z",
Episodic With lnterepisode Residual
Symptoms (specify if. With Prominent
N!.'gatiw Symptoms)
3'" Episodic With No Interepisode Residual
S)'IJlpiOms
0", Continuous (Spif!I if: With Prominent
Negati,,!.' Symptoms)
-t =-Singl!.' Episod!.' In Partial Remission
(specify if. With Prominent Negathe
Spnptoms)
5", Single Episode In Full Remission
8 '"
Other or Unspecified Pattern
9 '"
Less than 1 year since onset of initial
acti\'e-phase symptoms
F20.S
F25.x
.0
.1
Fll.O
F23.xx
.81
.80
F24
F06.x
.2
.0
-'
F29
Schizophreniform Disorder
(317)
Specify if. Without Good Prognostic
Featwes/With Good Prognostic
Features
Schizoaffective Disorder (319)
Bipolar Type
Depressive Type
Delusional Disorder (323)
5pmfy type: Erotomanic Trpe/
Grandiose T)'pe/Jealous Trpe/
Persecutol")' Type/Somatic Trpe/
Mixed Type/Unspecified Type
Brief Psychotic Disorder (329)
With Marked Stressor(s)
Without Marked Stressor(s)
SPffif!l if With Postpartum Onset
Shared Psychotic Disorder (332)
Psychotic Disorder Due to ...
{llIdicate Ille Gel/ernl Medical
COlldilioll} (334)
With Delusions
With Hallucinations
Substance-Induced Psychotic
Disorder (refer to SubstallceRelated
Disorders for substancespecific
codes) (338)
Sj>f'rify if With Onset During
Intoxication/With Onset During
Withdrawal
Psychotic Disorder NOS (343)
DSMIV Classification (With ICDl0 Codes)
Mood Disorders (345)
ThefolIOivillg specifiersapply(for CIIrrmt or
/IIost recellt episode) to Mood Disorders as
/loted:
"Se,"erity/Psychotic/Rernission Spl'cifiers/
toChronic/cWith Cataton'c Features/dWith
~Ielancholic
Features/~\'ith
Atypical
FeaturestfWith Postpartum Onset
The following specifiers apply fa Mood
Disorders as /loted:
SWith or Without FuU Interepisode Recovery/
hWith Seasonal Palleml'With Rapid Cycling
DEPRESSIVE DISORDERS (369)
F32.x Major Depressive Disorder,
Single Episodea,b,.c,d.e.f (369)
F33.x Major Depressive Disorder,
Recurren~b,.c,d.e.f,g.h(369)
Code currelll state ofMajor Depressive
Episode in fourth character:
O,."liId
1= Moderate
2,. Severe Without Psychotic Features
3,. Se\"ere With Psychotic Features
Sp.ify: Mood-Congruent Psychotic
Features/t-.loodlncongruent Psychotic
Features
4 = In Partial Remission
4 = In Full Remission
9 = Unspecified
F34"l
Dysthymic Disorder (376)
Spify if: Earl)' Onset/Late Onset
Spify: With Atypical Features
F32.9
Depressive Disorder NOS (381)
BIPOLAR DISORDERS (3B2)
F30.x
Bipolar I Disorder, Single Manic
d
Episodeol(382)
Spmfy if Mi>oed
Code CIIrre"t state ofMallic Episode ill
follrt11 clmracfer:
1 = Mild, Moderate, or 5e\"ere Without
Psychotic Featur'es
2 = Severe With Psychotic Features
8 = In Partial or FuU Remission
F31.0 Bipolar I Disorder, Most Recent
Episode Hypomanicg,h.i (382)
F3Lx Bipolar I Disorder, Most Recent
Episode ManicJ.c.fg.h.i (382)
Code CIIrrellt state ofMallie Episode ill
follrth clUlracler:
1 "" Mild.
Moduate, or Se\"ere Without
Psychotic Features
2,. Se'"ere With Psychotic Features
7,. In Partial or Full Remission
F31.6
Bipolar I Disorder, Most Recent
Episode Mixeda.c,f,g.h,i (382)
F31.x
Bipolar I Disorder, Most Recent
Episode Depresseda,b,c,d,e,f,g.h,i
(382)
Code CIIrrCllt state of Major Depressive
Episode ill/ollrt1l cllflracter:
3 = Mild or Moderate
4 = Severe Without Psychotic Features
5", Severe With Psychotic Features
7 "" In Partial or FuU Remission
F31.9 Bipolar I Disorder, Most Recent
Episode Unspecifiedg.hi (382)
F3L8 Bipolar II Disorde~,b.c,d.ef.g.h,i
(392)
Spify (eu,"nl or mOil rt'CE/II qJL-u):
Hypomanic/Depressed
F34.0 Cyclothymic Disorder (398)
F3L9 Bipolar Disorder NOS (400)
F06.xx Mood Disorder Due to "" "
[Illdicate tile General Medical
COl/ditioll] (401)
.32 With Depressive Features
.32 With Major Depressive-Like
Episode
.30 With Manic Features
.33 With Mixed Features
_.-Substance-Induced Mood.
Disorder (refer to Subsfal/ceRelated
Disorders for sllbstallce~
specific codes) (405)
Spify~;
With Depressh-e Features/
With Manic Features/With Mb::l."d
Features
Spt?cify if With Onset During
Intoxication/With Onset During
\\'ithdrawal
F39
Mood Disorder NOS (410)
Appendix H
Anxiety Disorders (429) Somatoform Disorders (485)
HI.O Panic Disorder Without F45.0 Somatization Disorder (486)
Agoraphobia (433) F-l5.1 Undifferentiated Somatofonn
HO.O! Panic Disorder With Disorder (490)
Agoraphobia (433) F-H.x Conversion Disorder (.192)
HO.OO Agoraphobia Without History A With Motor Symptom or
of Panic Disorder (441) Deficit
F40.2 Specific Phobia (443) .5 With Seizures or
Specify type: Animal Type/Natural Convulsions
Em'ironment Type/Blood-Injection
.6 With Sensory Symptom or
Injury Type/Situational Type/Other
Deficit
Type
.7 With Mixed Presentation
F40.1 Social Phobia (450)
F45.4 Pain Disorder (498)
Specify if: Generalized
Spify typt; Associated With
F42.8 Obsessive-Compulsive
PS)'(hological Factors/Associated W
Disorder (456)
Both Psychological Factors and
Spify if With Poor Insight
a General Medical Condition
FH.! Posttraumatic Stress Disorder
Spmfy if A(Ute/Chronic
(463) F45.2 Hypochondriasis (504)
Sprofy if A(Ute/Chronic Sprofy if With Poor Insight
Spmfy if With Delayed Onset
H5.2 Body Dysmorphic Disorder
F43.0 Acute Stress Disorder (469)
(507)
F-l1.1 Generalized Anxiety Disorder
F-15.9 Somatofonn Disorder NOS (511
(472)
F06A Anxiety Disorder Due to ...
[llldicate tile Ge/leral Medical
Conditioll] (476) Factitious Disorders (513)
S,"'cify if; With Generalized Anxiety/
With Panic Attacks/With Obsessive-
Compulsive Symptoms
F68.1 Factitious Disorder (513)
_.-Substance-Induced Anxiety
Specify Iype: With Predominantl)'
Disorder (refer 10 Subsfallce-
PsrchologicalSigns and Symptoms/
Related Disorders for Sllbstallce-With Predominantly Physical Signs and
specific codes) (479) Symptoms/With Combined
Spijy if With Generalized Anxiety/ Psychological and Physical Signs and
With Panic Attacks/With ObsesSive-Symptoms
Compulsi\'e Symptoms/With Phobic F68.! Factitious Disorder NOS (517)
Symploms
S~cify
if With Onset During
Intoxication/With Onset During
Withdrawal
Dissociative Disorders (519)
F41.9 Anxiety Disorder 'OS (484)
F+t.O Dissociative Amnesia (520)
F44.! Dissociative Fugue (523)
DSM-IV Classification (With lCD-10 Codes)
f.l4.81
Dissociative Identity Disorder
(526)
F48.1 DepersonaHzation Disorder
(530)
F44.9
Dissociati\'e Disorder NOS (532)
Sexual and Gender Identity
Disorders (535)
SEXUAL DYSFUNCTIONS (S35)
TilefOllowing specifiers apply to all primary
Sexual Dysfllllctions:
lifelong Type!Acquired Type/Generalized
Ty~
/Siluational Type/ Due to Psychological
Factors/Due to Combined Factors
Sexual Desire Disorders (539)
F52.0
N50.8
Male Hypoactive Sexual Desire
Disorder Due 10 .. . I/I/dicatc tlie
Gelleral Medical COllditiOIl} (558)
N-l8.4
Male &ectile Disorder Due
to ... [Illdicate the General
Medical Condition} (558)
N9-l.1
Female Dyspareunia Due to ...
fllldicate ti,e General Medical
Condition] (558)
NSO.8
Male Dyspareunia Due to ...
fl"dicate the General Medical
Condition] (558)
N94.8
Other Female Sexual
Dysfunction Due to ... {Indicate
tile General Medical Condition!
(558)
N50.8
Other Male Sexual Dysfunction
Due to ... [Indicate l1,e General
Medical COlldition} (558)
Substance-Induced Sexual
Hypoactive Sexual Desire
Disorder (539)
F52.10 Sexual Aversion Disorder (541)
Sexual Arousal Disorders (543)
F52.2 Female Sexual Arousal
Disorder (543)
F52.Z Male Erectile Disorder (5tS)
Orgasmic Disorders (547)
F52.3
Female Orgasmic Disorder
(517)
F52.3 Male Orgasmic Disorder (550)
F52.4 Premature Ejaculation (552)
Sexual Pain Disorders (554)
F52.6
Dyspareunia (Not Due to a
General Medical Condition)
(551)
F52.5
Vaginismus (Not Due to a
General Medical Condition)
(556)
Sexual Dysfunction Due to a General
Medical Condition (558)
N94.8
Female Hypoactive Sexual
Desire Disorder Due to ...
Ill/dicatc tire GCl/cral Medical
Conditioll} (558)
Dysfunction (refer to SrlbsttlllCeRelated
Disorders for substallcespecific
codes) (562)
Spify if With Impaired Desire/With
Impaired Arousal/With Impaired
Orgasm/With Sexual Pain
Specify if With Onset During
Intoxication
F52.9
Sexual Dysfunction NOS (565)
PARAPHILIAS (566)
F65.2 Exhibitionism (569)
F65.0 Fetishism (569)
F65.8 Frotteunsm (570)
F65.4 Pedophilia (571)
Specify if Sexually Attracled 10 Males/
Sexually Attractt'd 10 Fl'males/Se:..-ually
Attracted 10 Both
Specify if Limited to Incest
5rttcify t!fPi: Exclusi'e Type/
Nonl'xclusi\'1' Type
F65.5 Sexual Masochism (572)
F65.5 Sexual Sadism (573)
F65.1 Transvestic Fetishism (574)
S~ify
if With Gender Dysphoria
F65.3 Voyeurism (575)
F65.9 Paraphilia NOS (576)
1894
Appendix H
GENDER IDENTITY DISORDERS (S76) F51.3 Sleepwalking Disorder (639)
F64.x Gender Identity Disorder (576)
.2 in Children
.0 in Adolescents or Adults
SIltcify if; Sexually Attracted to Males!
Sexually Attracted to Females/Sexually
Attracted to Both/Sexually Attracted to
Neither
F64.9 Gender Identity Disorder 'OS
(582)
F52.9 Sexual Disorder 'OS (582)
Eating Disorders (583)
F50.0
Anorexia Nervosa (583)
5pmfy type Restricting Type; BingeEating/
Purging Trpe
F50.2
Bulimia Nervosa (589)
5pmfy ty;x; Purging Type/Nonpurging
Typ.
F50.9
Eating Disorder NOS (594)
Sleep Disorders (S97)
PRIMARY SLEEP DISORDERS (S9B)
Dyssomnias (598)
F51.0 Primary Insomnia (599)
F51.1 Primary Hypersomnia (604)
SptCify if: Recurrent
G47.4 Narcolepsy (609)
G47.3 Breathing-Related Sleep
Disorder (615)
F51.2
Circadian Rhythm Sleep
Disorder (622)
s"mfy hJ1x: Delayed Sleep Phase Typel
let Lag Type/Shifl Work Typel
Unspecified Type
F51.9 Dyssomnia NOS (629)
Parasomnias (630)
F51.5 Nightmare Disorder (631)
F51.4 Sleep Terror Disorder (634)
F51.8
Parasomnia NOS (644)
SLEEP DISORDERS RELATED TO
ANOTHER MENTAL DISORDER (64S)
F51.0 Insomnia Related to ... [lndiCllte
tlU! Axis 1or Axis II Disorderl
F51.l
(645)
Hypersomnia Related to ...
[llldicare tIJe Axis I or Aris 11
Disorder} (645)
OTHER
SLEEP DISORDERS (6S1)
G47.x
Sleep Disorder Due to ...
[llldicnte the Genernl Medical
Condition} (651)
.0 Insomnia Type
.1 Hypersomnia Type
.8 Parasomnia Type
.8 Mixed Type
_._
Substance-Induced Sleep
Disorder (refer to SubstallceRelated
Disorders for substallce
specific codes) (655)
S/>er:lfy IY1K: Insomnia Typel
Hypersomnia Type/Parasomnia Typel
Mixed Type
S~rify
if: With Onset During
Intoxication/With Onset During
Withdrawal
ImpulseControl Disorders Not
Elsewhere Classified (663)
F63.8
Intermittent Explosive Disorder
(663)
F63.2 Kleptomania (667)
F63.1 Pyromania (669)
F63.0 Pathological Gambling (671)
F63.3 Trichotillomania (674)
F63.9 Impulse-Control Disorder 'OS
(677)
DSM-IV Classification (With ICD-10 Codes)
Adjustment Disorders (679)
F43.xx
.20
.28
.22
.24
.25
Adjustment Disorder (679)
With Depressed Mood
With Anxiety
With Mixed Anxiety and
Depressed Mood
With Disturbance of Conduct
With Mixed Disturbance of
Emotions and Conduct
Unspecified
Specify if: Acute/Chronic
Personality Disorders (685)
Note: TI1ese {Ire coded 011 Axis II.
F60.0 Paranoid Personality Disorder
(690)
F60.1 Schizoid Personality Disorder
(694)
F21 Schizotypal Personality
Disorder (697)
F60.2 Antisocial Personality Disorder
(701)
F60.31 Borderline Personality Disorder
(706)
F60.4 Histrionic Personality Disorder
(711)
F60.8 Narcissistic Personality
Disorder (714)
F60.6 Avoidant Personality Disorder
(718)
F60.7 Dependent Personality
Disorder (721)
F60.5 Obsessive-Compulsive
Personality Disorder (725)
F60.9 Personality Disorder NOS (729)
Other Conditions That May Be a
Focus of Clinical Attention (731)
PSYCHOLOGICAL FACTORS
AFFECTING MEDICAL CONDITION
(731 )
F54 ... {Specified PsycJlological Factor]
Affecting ... (Indicate Ole General
Medical COlldifioll]
CllOose /lame based OIl I/{Itllre of
factors: (731)
Mental Disorder Affecting
Medical Condition
Psychological Symptoms
Affecting Medical Condition
Personality Traits or Coping
Style Affecting Medical
Condition
Maladaptive Health Behaviors
Affecting Medical Condition
Stress-Related Physiological
Response Affecting Medical
Condition
Other or Unspecified
Psychological Factors
Affecting Medical Condition
MEDICATION-INDUCED MOVEMENT
DISORDERS (734)
G21.0 Neuroleptic-Induced
Parkinsonism (735)
G21.0 Neuroleptic Malignant
Syndrome (735)
G24.0 Neuroleptic-Induced Acute
Dystonia (735)
G21.] Neuroleptic-Induced Acute
Akathisia (735)
G24.0 Neuroleptic-Induced Tardive
Dyskinesia (736)
G25.1 Medication-Induced Postural
Tremor (736)
G25.9 Medication-Induced Movement
Disorder NOS (736)
1896
OTHER
MEDICATION-INDUCED
DISORDER (736)
T88.7 Adverse Effects of Medication
'OS (736)
RELATIONAL PROBLEMS (736)
263.7
Relational Problem Related to a
Mental Disorder or General
Medical Condition (737)
263.8
Parent-Child Relational
Problem (code 263.1 iffocus of
attelltiOIl is 011 child) (737)
263.0
Partner Relational Problem
(737)
F93.3
Sibling Relational Problem (737)
263.9
Relational Problem NOS (737)
PROBLEMS RELATED TO ABUSE OR
NEGLECT (738)
174.1 Physical Abuse of Child (738)
174.2 Sexual Abuse of Child (738)
174.0 Neglect of Child (738)
T7U Physical Abuse of Adult (738)
174.2 Sexual Abuse of Adult (738)
ADDITIONAL CONDITIONS THAT MAY
BE A FOCUS OF CLINICAL ATIENTION
(739)
291.1
Noncompliance With
Treatment (739)
276.5
Malingering (739)
272.8
Adult Antisocial Behavior (740)
Appendix H
272.8
R41.8
R41.8
263.4
255.8
7..56.7
F93.8
271.8
260.3
260.0
Child or Adolescent Antisocial
Behavior (740)
Borderline Intellectual
Functioning (740)
Age-Related Cognitive Decline
(7~0)
Bereavement (740)
Academic Problem (741)
Occupational Problem (741)
Identity Problem (741)
Religious or Spiritual Problem
(741)
Acculturation Problem (741)
Phase of Life Problem (742)
Additional Codes (743)
F99 Unspecified Mental Disorder
(nonpsychotic) (743)
ZQ3.2 No Diagnosis or Condition on
Axis 1(743)
R69 Diagnosis or Condition
Deferred on Axis I (7B)
ZQ3.2 No Diagnosis on Axis II (in)
R4:6.8 Diagnosis Deferred on Axis II
(743)
Appendix I
Outline for Cultural
Formulation and Glossary of
Culture-Bound Syndromes
r his appendix is divided into hvo sections. The first section provides an outli
ne
for cultural fonnulation designed to assist the clinician in systematically eval
uating
and reporting the impact of the individual's cultural context. The second is a g
lossary
of culture-bolUld syndromes.
Outline for Cultural Formulation
The following outline for cultural formulation is meant to supplement the multia
xial
diagnostic assessment and to address difficulties that may be encountered in app
lying
DSM-TV criteria in a multicultural environment. The cultural formulation pro~
vides a systematic re\iew of the individual's cultural background, the role of th
e
cultural context in the expression and evaluation of symptoms and dysfunction, a
nd
the effect that cultural differences may have on the relationship between the in
dividual
and the clinician.
As indicated in the introduction to the manual (see p. xxxiii), it is important
that
the clinician take into account the individual's ethnic and cultural context in
the evaluation
of each of the DSM-lV axes. In addition, the cultural formulation suggested belo
w
provides an opportunity to describe systematically the individual's cultural and
social reference group and ways in which the cultural context is relevant to cli
nical
care. The clinician may provide a narrative summary for each of the following ca
tegones:
Cultural identity of the individual. Note the individual's ethnic or cultural re
ference
groups. For immigrants and ethnic minorities, note separately the degree of invo
lvement
with both the culhue of origin and the host culture (where applicable).
Also note language abilities, use, and preference (including multilingualism).
Cultural explanations of the individual's illness. The following may be identifi
ed:
the predominant idioms of distress through which symptoms or the need for social
support are communicated (e.g., "nerves," possessing spirits, somatic complaints
, inexplicable
misfortune), the meaning and perceived severity of the individual's symp~
897
1898 Appendix I
toms in relation to norms of the cultural reference group, any local illness cat
egory
used. by the individual's family and community to identify the condition (see "G
lossary
of Culture-Bound Syndromes" below), the perceived causes or explanatory
models that the individual and the reference group use to explain the illness, a
nd eurrent
preferences for and past experiences with professional and popular sources of
care.
Cultural fadors related to psychosocial environment and levels of functioning.
Note culturally relevant interpretations of social stressors, available social s
upports,
and levels of functioning and disability. nus would include stresses in the loca
l social
environment and the role of religion and kin neh"orks in providing emotional, in
strumental,
and informational support.
Cultural elements of the relationship behveen the individual and the clinician.
Indicate differences in culture and social status between the individual and the
clinician
and problems that these differences may cause in diagnosis and treatment (e.g.,
difficulty in communicating in the individual's first language, in eliciting sym
ptoms
or understanding their cultural significance, in negotiating an appropriate rela
tionship
or level of intimacy, in detennining whether a behavior is normative or patholog
ical).
Overall cultural assessment for diagnosis and care. The formulation concludes
with a discussion of how cultural considerations specifically innuence comprehen
sive
diagnosis and care.
Glossary of Culture-Bound Syndromes
The term CIllture-boulld syndrome denotes recurrent, locality--specific patterns
of aberrant
behavior and troubling experience that mayor may not be linked to a particular
DSM-IV diagnostic category. Many of these patterns are indigenously considered t
o
be "illnesses," or at least afflictions, and most have local names. Although pre
sentations
conforming to the major DSMrv categories can be found throughout the world,
the particular symptoms, course, and social response are very often innuenced by
local cull'ural factors. In contrast, cultu.re-bound syndr0':les are generally l
imited to
specific societies or culture areas and are localized, folk, diagnostic categori
es that
frame coherent meanings for certain repetitive, patterned, and troubling sets of
experiences
and observations.
There is seldom a one-to-one equh'alence of any culture-bound syndrome with a
DSM diagnostic entity. Aberrant behavior that might besorted by a diagnostician
using
DSMIV into several categories may be included in a single folk category, and pres
entations
that might be considered by a diagnostician using DSM-IV as belonging to
a single category may be sorted into several by an indigenous clinician. Moreove
r,
some conditions and disorders have been conceptualized as culture-bound syndrome
s
specific to industrialized cu.lture (e.g., Anorexia Nervosa, Dissociative Identi
ty
Disorder), given their apparent rarity or absence in other cultures. Itshould al
so
be noted that all industrialized societies include distinctive subcultures and W
idely
diverse immigrant groups who may present with culture-bound syndromes.
Outline for Cultural Formulation and Glossary of
Culture-Bound Syndromes
This glossary lists some of the best-studied culture-bound syndromes and idioms
of distress that may be encountered in clinical practice in orth America and inc
ludes
relevant DSM-rv categories when data suggest that they should be considered in a
diagnostic formulation.
amok A dissociative episode characterized by a period of brooding followed by an
outburst of violent, aggressive, or homicidal behavior directed at people and ob
jects.
The episode tends to be precipitated by a perceived slight or insult and seems t
o be
prevalent only among males. The episode is often accompanied by persecutory idea
s,
automatism, amnesia, exhaustion, and a return to premorbid state following the e
pisoc:
le. Some instances of amok may occur during a brief psychotic episode or constit
ute
the onset or an exacerbation of a chronic psychotic process. The original report
s
that used this term were from Malaysia. A similar behavior pattern is found in L
aos,
Philippines, Polynesia (cafard orcafllllrd), Papua New Guinea, and Puerto Rico (
mal de
pelea), and among the Tavajo (iich'aa).
ataque de nervios An idiom of distress principally reported among Latinos from
the Caribbean but recognized among many Latin American and Latin Mediterranean
groups. Commonly reported symptoms include uncontrollable shouting, attacks of
crying, trembling, heat in the chest rising into the head, and verbal or physica
l aggression.
Dissociative experiences, seizurelike or fainting episodes, and suicidal gesture
s
are prominent in some attacks but absent in others. A general feature of an ataq
ue de
nervios is a sense of being out of control. Ataques de nervios frequently occur
as a direct
result of a stressful event relating to the family (e.g., news of the death of a
close
relative, a separation or divorce from a spouse, conflicts with a spouse or chil
dren, or
witnessing an accident involving a family member). People may experience amnesia
for what occurred during the ataque de nervios, but they otherwise retum rapidly
to
their usual level of functioning. Although descriptions of some ataques de nervi
os
most closel}' fit with the DSM-rv description of Panic Attacks, the association
of most
ataques with a precipitating event and the frequent absence of the hallmark symp
toms
of acute (ear or apprehension distinguish them from Panic Disorder. Ataques
span the range from normal expressions of distress not associated with having a
mental
disorder to symptom presentations associated with the diagnoses of Anxiety,
Mood, Dissociative, or Somatoform Disorders.
bilis and calera (also referred to as l/Iuilla) The underlying cause of these sy
ndromes
is thought to be strongly experienced anger or rage. Anger is viewed among
many Latino groups as a particularly powerful emotion that can have direct effec
ts
on the body and can exacerbate existing symptoms. The major effect of anger is t
o disturb
core body balances (which are understood as a balance between hot and cold valen
ces
in the body and between the material and spiritual aspects of the body).
Symptoms can include acute nervous tension, headache, trembling, screaming, stom
ach
disturbances, and, in more severe cases, loss of consciousness. Chronic fatigue
may result from the acute episode.
bouIee delirante A syndrome observed in West Africa and Haiti. This French term
refers to a sudden outburst of agitated and aggressive behavior, marked confusio
n,
Appendix I
and psychomotor excitement. It may sometimes be accompanied by visual and audito
ry
hallucinations or paranoid ideation. These episodes may resemble an episode of
Brief Psychotic Disorder.
brain fag A term initially used in '"Vest Africa to refer to a condition experie
nced by
high school or university students in response to the challenges of schooling. S
ymptoms
include difficulties in concentrating, remembering, and thinking. Students often
state that their brains are "fatigued." Additional somatic symptoms are usually
centered
around the head and neck and include pain, pressure or tightness, blurring of
vision, heat, or burning. "Brain tiredness" or fatigue from "too much thinking"
is an
idiom of distress in many cultures, and resulting syndromes can resemble certain
Anxiety, Depressive, and Somatoform Disorders.
dhat A folk diagnostic term used in India to refer to severe anxiety and hypocho
ndriacal
concerns associated with the discharge of semen, whitish discoloration of the
urine, and feelings of weakness and exhaustion. Similar to jirynll (India), SlIh
n prnme1m
(Sri Lanka), and sIJen-k'llei (China).
falling-out or blacking out These episodes occur primarily in southern United
States and Caribbean groups. They are characterized by a sudden coUapse, which
sometimes occurs without warning but sometimes is preceded by feelings of dizzin
ess
or "swimming" in the head. The individual's eyes are usually open but the person
claims an inability to see. The person usually hears and understands what is
occurring around him or her but feels powerless to move. This may correspond to
a
diagnosis of Conversion Disorder or a Dissociative Disorder.
ghost sickness A preoccupation with death and the deceased (sometimes associated
with witchcraft) frequently observed among members of many American Indian
tribes. Various symptoms can be attributed to ghost sickness, including bad drea
ms,
weakness, feelings of danger, loss of appetite, fainting, dizziness, fear, anxie
ty, haJludnations,
loss of consciousness, confusion, feelings of futility, and a sense of suffocati
on.
hwa-byung (also known as wool-hwa-byung) A Korean folk syndrome literally
translated into English as "anger syndrome" and attributed to the suppression of
anger.
The symptoms include insomnia, fatigue, panic, fear of impending death, dysphori
c
affect, indigestion, anorexia, dyspnea, palpitations, generalized aches and
pains, and a feeling of a mass in the epigastrium.
koro A term, probably of Malaysian origin, that refers to an episode of sudden a
nd
intense anxiety that the penis (or, in females, the vulva and nipples) will rece
de into
the body and possibly cause death. The syndrome is reported in south and east As
ia,
where it is known by a variety of local lerms, such as sllflk yang, shook yong,
and S/IO
yang (Chinese); jinjinia bemar (Assam); or rok-joo (Thailand). It is occasionall
y found in
the West. Koro at times occurs in localized epidemic form in east Asian areas. T
his
diagnosis is included in the Chillese Classification of Melltal Disorders, Secon
d Edition
(CCMD-2).
Outline for Cultural Formulation and Glossary of
Culture-Bound Syndromes
latah Hypersensitivity to sudden fright, often with echopraxia, echolalia, comma
nd
obedience, and dissociative or trancelike behavior. The term latah is of Malaysi
an or
Indonesian origin, but the syndrome has been found in many parts of the world. O
ther
terms for this condition are allillrakh, irkimii, ikota, o/all, lIlyriachit, and
menkeiti (Siberian
groups); bah tschi, bah-lsi, and baah-ji (fhailand); illll/ (Ainu, Sakhalin, Jap
an);
and lIlali-mali and silok (philippines). In Malaysia it is more frequent in midd
le-aged
women.
lacuta A term used by Latinos in the United States and Latin America to refer to
a
severe form of chronic psychosis. The condition is attributed to an inherited vu
lnerability,
to the effect of multiple life difficulties, or to a combination of both factors
.
Symptoms exhibited b}' persons with lacura include incoherence, agitation, audit
ory
and visual hallucinations, inability to foUow rules of social interaction, unpre
dictability,
and possible violence.
mal de ajo A concept widely found in Mediterranean cultures and elsewhere in the
world. Mal de ojo is a Spanish phrase translated into English as "evil eye." Chi
ldren
are especially at risk. Symptoms include fitful sleep, crying without apparent c
ause,
diarrhea, vomiting, and fever in a child or infant. Sometimes adults (especially
females)
have the condition.
nervias A common idiom of distress among Latinos in the United States and L-atin
America. A number of other ethnic groups have related, though often somewhat dis
tinctive,
ideas of "nerves" (such as llevra among Greeks in North America). Nervios
refers both to a general state of vulnerability to stressful life experiences an
d to a syndrome
brought on by difficult life circumstances. The term neroios includes a wide
range of symptoms of emotional distress, somatic disturbance, and inability to f
unction.
Common symptoms include headaches and "brain aches," irritability, stomach
disturbances, sleep difficulties, nervousness, easy tearfulness, inability to co
ncentrate,
trembling, tingling sensations, and mnreos (dizziness with occasional vertigolik
e
exacerbations). fervios tends to be an ongoing problem, although variable in the
degree of disability manifested. Nervios is a very broad syndrome that spans the
range from cases free of a mental disorder to presentations resembling Adjustmen
t,
Anxiety, Depressive, Dissociative, Somatoform, or Psychotic Disorders. Different
ial
diagnosis will depend on the constellation of symptoms experienced, the kind of
social
events that are associated with the onset and progress of nen'ios, and the level
of
disability experienced.
pibloktoq An abrupt dissociative episode accompanied by extreme excitement of
up to 30 minutes' duration and frequently followed by convulsive seizures and co
ma
lasting up to 12 hours. This is observed primarily in arctic and subarctic Eskim
o communities,
although regional variations in name exist. The individual may be withdrawn
or mildly irritable for a period of hours or days before the attack and will
typically report complete amnesia for the attack. During the attack, the individ
ual
may tear off his or her clothing, break furniture, shout obscenities, eat feces,
flee from
protective shelters, or perform other irrational or dangerous acts.
Appendix I
qi-gong psychotic reaction A term describing an acute, time-limited episode char
acterized by dissociative, paranoid, or other psychotic or nonpsychotic symptoms
that may occur after participation in the Chinese folk heaHhenhancing practice of
qigong
("exercise of vital energy"). Especially vulnerable are individuals who become
overly involved in the practice. This diagnosis is included in the Chillese C1as
siftcatiOll
of Mental Disorders, Second Edition (CCMD-2).
roohvork A set of cultural interpretations that ascribe illness to hexing, witch
craft,
sorcery, or the evil influence of another person. Symptoms may include generaliz
ed
anxiety and gastrointestinal complaints (e.g., nausea, vomiting, diarrhea), weak
ness,
dizziness, the fear of being poisoned, and sometimes fear of being killed ("vood
oo
death"). "Roots," "spells," or "hexes" can be "put" or placed on other persons,
caus
ingavariety ofemotional and psychologicalproblems.The "hexed" person mayeven
fear death until the "root" has been "taken off" (eliminated), usually through t
he
work of a "root doctor" (a healer in this tradition), who can also be called on
to bewitch
an enemy. "Rootwork" is found in the southern United States among both African
American and European American populations and in Caribbean societies. It is
also known as mal pllestO or bmjeria in latino societies.
sangue dormido ("sleeping blood") This syndrome is found among Portuguese
Cape Verde Islanders (and immigrants from there to the United States) and includ
es
pain, numbness, tremor, paralysis, convulsions, stroke, blindness, heart attack,
infection,
and miscarriage.
shenjing shuairuo ("neurasthenia") In China, a condition characterized by physic
al
and mental fatigue, dizziness, headaches. other pains, concentration difficultie
s,
sleep disturbance, and memory loss. Other symptoms include gastrointestinal prob
lems,
sexual dysfunction, irritability, excitability, and various signs suggesting dis
turbance
of the autonomic nervous system. In many cases, the symptoms would meet
the criteria for a DSM-JV Mood or Anxiety Disorder. This diagnosis is included i
n the
Glinese C1assificatioll ofMelltal Disorders, Second Edition (CCMD-2).
shen-k'uei (Taiwan); shenkui (China) A Chinese folk label describing marked anxi
ety
or panic symptoms with accompanying somatic complaints for which no physical
cause can be demonstrated. Symptoms include dizziness, backache, fatigability,
general weakness, insomnia, frequent dreams, and complaints of sexual dysfunctio
n
(such as premature ejaculation and impotence). Symptoms are attributed. to exces
sive
semen loss hom frequent intercourse, masturbation, nocturnal emission, or passin
g
of "white turbid urine" believed to contain semen. Excessive semen loss is feare
d because
of the belief that it represents the loss of one's vital essence and can thereby
be
life threatening.
shin-byung A Korean folk label for a syndrome in which initial phases are charac
terized
by anxiety and somatic complaints (general weakness, dizziness, fear, anorexia,
insomnia, gastrointestinal problems), with subsequent dissociation and
possession by ancestral spirits.
Outline for Cultural Formulation and Glossary of
Culture-Bound Syndromes
9031
spell A trance state in which individuals "communicate" with deceased relatives
or
with spirits. At times this state is associated with brief periods of personalit
y change.
This culture-specific syndrome is seen among African Americans and European
Americans from the southern United States. Spells are not considered to be medic
al
events in the folk tradition but may be misconstrued as psychotic episodes in cl
inical
settings.
susto ("fright," or "soul loss") A folk illness prevalent among some Latinos in
the
United States and among people in Mexico, Central America, and South America.
Susto is also referred to as espnllto, paSIllD, tripa ida, perdida del alllla, o
r c1/ibi1l. Susto is
an illness attributed to a frightening event that causes the soul to leave the b
ody and
results in unhappiness and sickness. Individuals with susto also experience sign
ificant
strains in key social roles. Symptoms may appear any time from days to years
after the fright is experienced. It is believed that in extreme cases, susto may
result in
death. Typical symptoms include appetite disturbances, inadequate or excessive
sleep, troubled sleep or dreams, feeling of sadness, lack of motivation to do an
}'thing,
and feelings of low selfworth or dirtiness. Somatic symptoms accompanying susto
include muscle aches and pains, headache, stomachache, and diarrhea. Ritual heal
ings
are focused on calling the soul back to the body and cleansing the person to res
tore
bodily and spiritual balance. Different experiences of susto may be related to
Major Depressive Disorder, Posttraumatic Stress Disorder, and Somatoform Disorde
rs.
Similar etiological beliefs and symptom configurations are found in may parts
of the world.
taijin kyofusho A culturally distinctive phobia in Japan, in some ways resemblin
g
Social Phobia in DSMIV. This syndrome refers to an individual's intense fear that
his
or her body, its parts or its functions, displease, embarrass, or are offensive
to other
people in appearance, odor, facial expressions, or movements. This syndrome is i
ncluded
in the official Japanese diagnostic system for mental disorders.
zar A general term applied in Ethiopia, Somalia, Egypt, Sudan, lran, and other
North African and Middle Eastern societies to the experience of spirits possessi
ng an
individual. Persons possessed by a spirit may experience dissociative episodes t
hat
may include shouting, laughing, hitting the head against a waU, singing. or weep
ing.
Individuals may show apathy and withdrawal, refusing to eat or carry out daily
tasks, or may develop a long-term relationship with the possessing spirit. Such
behavior
is not considered pathological locally.
j
Appendix J
DSM-IV Contributors
Because DSM-IV is meant to be used by a diverse group of mental health professio
nals
in a variety of settings, the Task Force on DSM-IV and the Work Groups solicited
and encouraged the participation of a wide range of professionals to serve as
advisers to the Task Force and individual Work Groups. Advisers included individ
uals
from other health associations; clinical practitioners; researchers; forensic sp
ecialists;
experts on gender, age, and cultural issues; and international experts.
Advisory groups identified pertinent questions regarding each diagnosis; develop
ed
and critiqued literature reviews, text, and criteria; and participated in field-
trial and
data-reanalysis projects. The Task Force on DSM-IV and the Work Group members
extend their appreciation and heartfelt thanks to the individuals and organizati
ons
who contributed so generously of their time and expertise.
Work Group Advisers
Anxiety Disorders Advisers Raymond R. Crowe, M.D.
W. Stewart Agras, M.D. George C. Curtis, M.D.
Hagop Akiskal, M.D. Yael Danieli, Ph.D.
Lauren Bersh Alloy, M.D. Joseph A. Deltito, t"f.D.
James Barbie, M.D. Peter A. DiNardo, Ph.D.
Aaron T. Beck, M.D. Keith Stephen Dobson. Ph.D.
Jean Beckham, Ph.D. Spencer Eth. M.D.
Deborah C. Beidel, Ph.D. John Fairbank. Ph.D.
Istvan Biller, M.D. Brian Fallon, lvt.D.
Arthur S. Blank, Jr., M.D. Charles Figley, Ph.D.
Thomas D. Borkovec, Ph.D. Stephen M. Ford, M.D.
loretta E. Braxton, Ph.D. Ellen Frank, Ph.D.
taomi Breslau, Ph.D. Mathew Friedman, M.D.
Elizabeth Brett, Ph.D. Kishore Gaddc, M.D.
Evelyn Bromet, Ph.D. Ronald Ganellen, Ph.D.
Timothy A. Brown, Psy.D. Michael Gelder, M.D.
Allan Burstein, M.D. Earl Giller, M.D.
David M. Clark, Ph.D. Wayne Goodman, M.D.
Lee Anna Clark, Ph.D. Tana Grady, M.D.
Deborah S. Cowley, M.D. Bonnie Green, Ph.D.
1ichelle G. Craske, Ph.D. Peter J. Guamacda. Ph.D.
905
Richard Heimberg, Ph.D.
John E. Helzer, M.D.
Judith Herman, M.D.
Rudolf Hoehn-Saric, M.D.
Steven Ken Hoge, M.D.
Eric Hollander, M.D.
Mardi Horowitz, M.D.
Tom Inse], M.D.
~4.ichael
Jenike, M.D.
Wayne Katon, M.D.
Heinz Katschnig, M.D.
Terrance Keane, Ph.D.
Dean Kilpatrick, Ph.D.
laurence Kirmayer, M.D.
Donald F. Klein, M.D.
Stuart Kleinman, M.D.
Gerald L. Klerman, M.D. (deceased)
Lawrence Kolb, M.D.
Michael J. Kozak, Ph.D.
Cynthia Last, Ph.D.
Bernard Lerer, M.D.
Andrew Levin, M.D.
R. Bruce Lydiard, M.D., Ph.D.
Salvatore Mannuzza, Ph.D.
John S. March, M.D.
Andrew Mathews, Ph.D.
Matig Mavissakalian, M.D.
Alexander McFarlane, M.B., B.5. (Hans),
M.D.
Richard M ally, M.D.
Charles A. Meyer, Jr., M.D.
Karla Moras, Ph.D.
Dennis Munjack, M.D.
Lars Goran Ost, Ph.D.
Howard Parad, O.5.W.
Kok Lee Peng, M.D.
Roger Pitman, M.D.
Robert Pynoos, M.D.
Ronald M. Rapee, Ph.D.
Beverley Raphael, M.D.
Steven Rasmussen, M.D.
James Reich, M.D., M.P.H.
Patricia A. Resick, Ph.D.
Jeffrey c. Richards, Ph.D.
Karl Rickels, M.D.
John H. Riskind, Ph.D.
Sir Martin Roth, M.D.
Appendix J
Barbara Rothbaum, Ph.D.
Peter Roy-Byrne, M.D.
Philip Saigh, Ph.D.
Paul Salko\'skis, Ph.D.
William C. Sanderson, PhD.
Franklin Schneier, M.D.
Javaid Sheikh, M.D.
Zahava Soloman, A-J.D.
Susan Solomon, Ph.D.
L,rry H. Strasburger, M.D., Ph.D.
Suzanne Sutherland, M.D.
Richard Swinson, M.D.
Lenore Terr, M.D.
Peter Trower, Ph.D.
Samuel M. Turner, Ph.D.
Thomas Uhde, M.D.
David Watson, Ph.D.
Hans Ulrich Wittchen, Ph.D.
Patti Zetlin, MS.W.
Richard Zinbarg, Ph.D.
Joseph Zohar, M.D.
Delirium, Dementia, and Amnestic
and Other Cognitive Disorders
Advisers
Frank Benson, M.D.
John Breimer, M.D.
Steve Buckingham, M.S.S.\"I.
Nelson Butters, Ph.D.
Sleven Cohen-Cole, M.D.
Jeffrey Lee Cummings, M.D.
Horacio Fabrega, Jr., M.D.
Barry Fogel, M.D.
Robert P. Granacher, M.D., Ph.D.
Robert C. Green, M.D.
Robert Heaton, M.D.
Steven Ken Hoge, M.D.
I( Ranga Rama Krishnan, M.D.
Keh-Ming Lin, M.D.
Zbigniew Upowski, M.D.
Alwyn Lishman, M.D.
Richard Mayeux, M.D.
Marsel Mesulam, M.D.
Vernon. Neppe, M.D.
Barry Reisberg, M.D.
Sir Martin Roth, M.D.
David Rubinm\', M.D.
DSM-IV Contributors
Randy Schiffer, M.D.
Michael Taylor, M.D.
Linda Teri, Ph.D.
Allan YozawHz, M.D.
Stuart C Yudofsky, M.D.
Michael Zaudig, M.D.
Disorders Usually First Diagnosed
During Infancy, Childhood, or
Adolescence Advisers
Marc Amaya, M.D.
Usa Amaya-Jackson, M.D.
Adrian Angold, M.B., B.s., M.R.CPsydl.
William Arroyo, M.D.
Robert F. Asarnow, Ph.D.
George Bailey, M.D.
Joseph Biederman, M.D.
Ray Blanchard, Ph.D.
Lewis M. Bloomingdale, M.D.
John Bradford, M.D.
Joel Bregman, M.D.
Glorissa Canino, Ph.D.
Ian Alberto Canino, M.D.
Iris Chagwedera, Ph.D.
Dante Cicchetti, Ph.D.
Susan Coates, Ph.D.
Patricia Cohen, Ph.D.
C Keith Conners, Ph.D.
Jane Costello, M.D.
Charles Davenport, M.D.
Robert Delong, M.D.
Martha Denckla, M.D.
Park Elliott Dietz, M.D., Ph.D.
Craig Donnelly, M.D.
Felton Earls, M.D.
L. Erlenmeyer-Kimling, Ph.D.
Jack Fletcher, Ph.D.
Steven Forness, Ed.D.
Richard Green, M.D., J.D.
Laurence Greenhill, M.D.
Stanley Greenspan, M.D.
Richard L Gross, M.D.
Robert Harmon, M.D.
Lily Hechtman, M.D.
Margaret Herlzig, M.D.
James J. Hudziak, M.D.
Peter Jensen, M.D.
Gloria Johnson-Powell, M.D.
Robert King, M.D.
Mindy Krotick, M.A.
Cynthia Last, Ph.D.
James Leckman, M.D.
James Lee, M.D.
Stephen Levine, M.D.
John Lachman, M.D.
Catherine Lord, Ph.D.
John S. March, M.D.
James McKinney, Ph.D.
Jon Meyer, M.D.
Heino F. L. Meyer-Bahlburg, Dr., rer.,
nat.
Juan Enrique Mezzich, M.D., Ph.D.
Klaus Minde, M.D.
David Mrazek, M.D.
joy Osofsky, Ph.D.
Ira Pauly, M.D.
Gary Peterson, M.D.
Sally Provence, M.D.
Joaquim PUig-Antich, M.D. (deceased)
Kathleen May Quinn, M.D.
Steven Rasmussen, M.D.
Robert J. Reichler, M.D.
Mark A. Riddle, M.D.
Edward Ritvo, M.D.
Richard Rosner, M.D.
Byron Rourke, Ph.D.
Diane H. Schetky, M.D.
Eric Schopler, Ph.D.
Rourke Schopler, Ph.D.
Arthur Shapiro, M.D.
Theodore Shapiro, M.D.
Bennet Shaywitz, M.D.
Larry Silver, M.D.
Robert Stoller, M.D. (deceased)
Alan Stone, M.D.
Peter Szatmari, M.D.
Ludwig Szymanski, M.D.
Paula TallaL Ph.D.
Kenneth Towbin, M.D.
Luke Tsai, M.D.
Kenneth Jay Weiss, M.D.
Myrna M. Weissman, Ph.D.
Elizabeth Weller, M.D.
Karen Wells, Ph.D.
Appendix J
Agnes \\'hittaker, M.D.
Janet B. W. Williams, DS.W.
Ronald Winchel, M.D.
Allan Yozawitz, M.D.
Kenneth J. Zucker, Ph.D.
Barry Zuckerman, M.D.
Bernard Zuger, M.D.
Eating Disorders Advisers
W. Stewart Agras, M.D.
Arnold Anderson, M.D.
William Berman, Ph.D.
Peter Beumont, M.D.
Barton J. Blinder, M.D.
Susan Jane Blumenthal, M.D.
LCDR James M. Blunt
Harry A. Brandt, M.D.
Timothy D. Brewerton, M.D.
Kelly Brownell, Ph.D.
Gabrielle A. Carlson, M.D.
Eva Carr, M.A.
Regina Casper, M.D.
Leslie Citrome, M.D.
Peter J. Cooper, M.D.
Arthur H. Crisp, M.D.
Maria DaCosta, M.D.
Bonnie Dansky, Ph.D.
Michael Devlin, 1.0.
Adam Drewnowski, Ph.D.
Elke Eckert, M.D.
Robert Edelman, M.D.
Christopher Fairburn, M.D.
Madeline Fernstrom, PhD.
Manfred Fichter, M.D.
Martine Aament, M.D.
Henri Aikier, AC.S.W.
Victor Fornari, M.D.
Chris Freeman, M.D.
David r..-1. Gamer, Ph.D.
Philip W. Gold, M.D.
Harry E. Gwirtsman, M.D.
Deborah Hasin, Ph.D.
C. Peter Herman, Ph.D.
David Herzog, M.D.
Jules Hirsch, M.D.
Hans W. Hoek, M.D., Ph.D.
Steven Ken Hoge, M.D.
L. K. George fuu, M.D.
James I. Hudson, MD.
Laurie Humphries, M.D.
Philippe Jeammet, M.D.
David C. Jimerson, M.D.
Craig Johnson, Ph.D.
Ross S. Kalucy, M.D.
Jack L. Katz, M.D.
Walter Kaye, M.D.
Justin Kenardy, Ph.D.
Kenneth S. Kendler, M.D.
Sid Kennedy, M.D.
Dean Kilpatrick, PhD.
Dean D. Krahn, MD.
Sing Lee, M.R.C.Psych.
Pierre Leichner, M.D.
Harold Leitenberg, Ph.D.
Jill Leolbonne, M.D.
Gloria Leon, Ph.D.
Katharine Loeb, B.A.
Alexander R. Lucas, M.D.
Marsha Marcus, Ph.D.
Valerie Rae McClain, B.A.
Juan Enrique Mezzich, ~-I.D.,
Ph.D.
Julian Morrow, Ph.D.
Claes Norring, Dr.Med.Sc.
Patrick O'Conner, Ph.D.
Marion P. Olmstead, Ph.D.
Carol B. Peterson, ph.D.
Karl Pirke, M.D.
Janet Polivy, Ph.D.
Harrison Pope, M.D.
Charles Portney, 1\-1.0.
Albert M. Powell, M.D.
Raymond Prince, M.D.
Richard Pyle, M.D.
Ellen Raynes, Psy.D.
Rory Richardson, M.A.
Cheryl Ritenbaugh, Ph.D., M.P.H.
Paul Robinson, M.D.
Judith Rodin, Ph.D.
Barbara J. Rolls, Ph.D.
James Rosen, Ph.D.
Gerald.Russell, M.D.
Ronna Saunders, LC.S.W.
Joseph Silverman, M.D.
Michael Strober, Ph.D.
-
~
DSM-IV Contributors
Albert J. Stunkard, lI.I.D.
Allan Sugarman, M.D.
George Szmukler, M.D.
Sten Theander, M.D.
Suellen Thomsen, B.A.
David Tobin, Ph.D.
V,'alter Vandereycken, rvl.D.
David Veale, M.R.C.Psych.
Kelly Bemis Vitousek, Ph.D.
Thomas Wadden, Ph.D.
David Waller, M.D.
\'''inny \"'eed.a-~'Iannak,Ph.D.
Herbert Weiner, M.D.
~'litchel
Weiss, M.D., Ph.D.
David Wheadon, M.D.
Rena Wing, M.D.
Steve Wonderlich, Ph.D.
Susan Wooley, Ph.D.
Wayne ""ooley, Ph.D.
Judith Wurtman, Ph.D.
Joel Yager, M.D.
Susan Yanovski, M.D.
Preston Zucker, M.D.
Mood Disorders Advisers
Hagop Akiskal, M.D.
Jay Amsterdam, 1\'1.0.
Jules Angst, M.D.
Paul S. Appelbaum, M.D.
Marie sberg, M.D.
David Avery, M.D.
Aaron T. Beck, M.D.
James c. Beck, M.D.
Dan Blazer, M.D.
Charles Bowden, 1.D.
Ian Brockington, M.D.
Susan B. Campbell, Ph.D.
DeIU'lis P. Cantwell, M.D.
Bernard J. Carroll, M.D. Ph.D.
Giovanni Cassano, M.D.
Paul Chodoff, M.D.
William Coryell, M.D.
JaM L. Cox, D.M.
Jonathan Davidson, l.D.
JaM Davis, M.D.
Christine Dean, M.D.
Robert Delong, M.D.
J. Raymond DePaulo, 1.D.
Jean Endicott, Ph.D.
Cecile Ernst, M.D.
Max Fink, M.D.
Leslie M. Fonnan, l\.l.D.
Linda George, Ph.D.
Robert Gerner, M.D.
Elliot Gershon, M.D.
William Goldstein, M.D.
Byron Good, Ph.D.
Frederick K. Goodwin, M.D.
Thomas Gordon Gutheil. M.D.
Wilma M. Harrison, M.D.
Jonathon M. Himmelhoch, M.D.
Robert M. A. Hirschfeld, M.D.
Sleven Ken Hoge, M.D.
Charles Holzer Ill, M.D.
Robert Howland, M.D.
Emily Hoyer, B.A.
James Jefferson, M.D.
Ira Katz, M.D.
Gabor Keitner, M.D.
Robert Kendell, M.D.
Kenneth S. Kendler, M.D.
Daniel Klein, Ph.D.
Gerald L. Klennan, M.D. (deceased)
James Kocsis, M.D.
Harold Koenig, M.D.
Ernest Kovacs, M.D.
Helena Kraemer, Ph.D.
K. Ranga Rama KrisMan, M.D.
Andrew Krystal, M.D.
David J. Kupfer, M.D.
Jacqueline LaUve, M.D.
Peter Lewinshon, Ph.D.
Wolfgang Maier, M.D.
JaM Mann, M.D.
Spero Manson, Ph.D.
James P. McCullough, Ph.D.
Patrick McGralh, M.D.
Julien Mendelewicz, M.D.
Kathleen Merikangas, Ph.D.
Robert Michels, M.D.
Ivan Miller, Ph.D.
Phyllis Nash, DSW.
Michael O'Hara, Ph.D.
David aSSeT, M.D.
Gordon Parker, M.D.
Barbara Parry, M.D.
Eugene Payke!. M.D.
Kok Lee Peng, M.D.
Fredrick Petty, M.D., Ph.D.
Robert M. Post, M.D.
Daniel Purdy, A.B.
Frederic Quitkin, M.D.
Judith G. Rabkin, Ph.D.
Ted Reich, M.D.
Richard Ries, M.D.
Donald Robinson, M.D.
Holly Rogers, M.D.
Jerrold F. Rosenbaum, M.D.
Torman Rosenthal, M.D.
Anthony Rothschild, M.D.
Alec Roy, M.D.
Cordelia Russell, B.A.
Alan Schatzberg, rvl.D.
Jan Scott, Ph.D.
Trade Shea, Ph.D.
Anne Simmons, Ph.D.
Stuart Sotsky, M.D.
David Steffens, M.D.
Jonathan Stewart, M.D.
Larry H. Strasburger, M.D., Ph.D.
Trisha Suppes, M.D., Ph.D.
Michael Thase, M.D.
Richard Weiner, M.D.
Jan Weissenburger, r-,'I.A.
~Ilyma
M. Weissman, Ph.D.
Kenneth Wells, M.D.
Peter C. Whybrow, M.D.
George Winokur, M.D.
Anna Wirz-Justice, Ph.D.
Hans Ulrich Wittchen, Ph.D.
Multiaxial Issues Advisers
Jonathan F. Borus, M.D.
Kathleen Buckwalter, Ph.D.
Fredric Busch, M.D.
Eric Douglas Caine, M.D.
Thomas Carli, M.D.
Arnold Cooper, M.D.
Paul Crits-Christoph, M.D.
Susan Fine, M.A.
Paul J. Fink, M.D.
AppendixJ
Jack Froom, M.D.
Milia Fujinawa, M.D.
Daniel W. Gillette, M.D.
Robert Glick, M.D.
Byron Good, Ph.D.
Richard E. Gordon, M.D., Ph.D.
Barry Gurland, M.D.
Herta A. Guttman, M.D.
Richard Hall, M.D.
Mardi Horowitz, ~'l.D.
Charles Hughes, Ph.D.
T. Byram Karasu, M.D.
James Karls, D.S.W.
Florence Kaslow, Ph.D.
Otto Kemberg, M.D.
Gerald L. KJerman, M.D. (deceased)
Thomas Kuhlman, Ph.D.
Powell Lawton, Ph.D.
Joshua D. Lipsitz, Ph.D.
Christine Lloyd, M.D.
Lester Lubarsky, M.D.
Roger Mackinnon, M.D.
Carolyn Mazure, Ph.D.
Theodore Millon, Ph.D.
Glen Pearson, M.D.
J. Christopher Perry, M.D.
George H. Pollock, M.D.
Joseph M. Rey, Ph.D.
Lawrence Rockland, M.D.
Geoffre}' Shrader, M.D.
Ronald C. Simons, M.D., M..A.
Alan Stoudemire, M.D.
James J. Strain, M.D.
John S. Strauss, M.D.
Christopher Tennant, M.D.
Mary Durand Thomas, R.N., Ph.D.
Virginia Tilden, R.N., D.N.Sc.
George Vaillant, MD.
Holly Skodol Wilson, R.N., Ph.D.
Ronald M. Wintrob, M.D.
Lyman C. Wynne, M.D., Ph.D.
Personality Disorders Advisers
Gerald Adler, M.D.
Salman Akhtar, M.D.
Hagop AkiskaI. M.D.
Norimassa Alcuta, M.D.
I I
DSM-IV Contributors
Renata Daniel Alarcon. M.D. M.P.H.
Arthur Alterman. Ph.D.
Antonio Andreoli, M.D.
Paul S. Appelbaum, M.D.
Beng-Ake Armelius, Ph.D.
Lorna Smith Benjamin, Ph.D.
Mark Berelowitz, M.D.
Jack Brandes, M.D.
Remi Cadoret. M.D.
Paul Chadof. M.D.
Lee Anna Clark, Ph.D.
John Clarkin, Ph.D.
C. Robert Cloninger; M.D.
Jerome Cohen. D.5.W.
Karyl Cole. M.D.
Arnold Cooper, M.D.
Paul Costa, Ph.D.
Alv A. Dahl, M.D.
Carl Eisdorfer, M.D., Ph.D., MS.W
Edward F. Foulks, M.D., Ph.D.
John Frosch, M.D.
William Goldstein, M.D.
Seymour L. Halleck, M.D.
Robert Hare. Ph.D.
Judith Hennan, M.D.
Steven Ken Hoge, M.D.
Mardi Horowitz, M.D.
Stephen W. Hurt, Ph.D.
Steven Hyler, M.D.
Karen John, M.D.
Patricia Judd, M.5.W.
Charles Kaelber, M.D.
Oren Kalus, M.D.
Kenneth S. Kendler, M.D.
Otto Kernberg, M.D.
Donald Kiesler, Ph.D.
Daniel Klein, Ph.D.
Donald F. Klein, M.D.
Arthur Kleinman, M.D., Ph.D.
Harold Koenigsberg, M.D.
Jerome Kroll, M.D.
Marsha Linehan, Ph.D.
Paul Links, M.D.
John Lion, M.D.
W. John Uvesley, M.D.
Armand Loranger, Ph.D.
Spencer Lyerly, Ph.D.
Michael Lyons, Ph.D.
K. Roy MacKenzie, M.D.
Roger Mackinnon, M.D.
Nikolas Manos. M.D.
James Masterson, M.D.
Robert McCrae. Ph.D.
Thomas McGlashan, M.D.
Robert David Miller, M.D., Ph.D.
Leslie Morey, Ph.D.
Ole Mors, M.D.
Kazuhisa Nakao, M.D.
H. George Numberg, M.D.
John Oldham, M.D.
Yutaka Ono, M.D.
Stephen L. Oxley. Ph.D.
Joel Paris, M.D.
Gordon Parker, M.D.
Glen Pearson, M.D.
Kok Lee Peng, M.D. rChristopher Perry, M.D.
Ethel Person, M.D.
Katharine Anne PruUips, M.D.
Paul Pilkonis, Ph.D.
Harrison Pope, M.D.
Charles Pull, M.D.
James Reich, M.D., M.P.H.
William H. Reid, M.D.
Lee Robins, Ph.D.
Elsa Ronningstam, Ph.D.
Loren Henry Roth, M.D.
Robert Ruegg. M.D.
Pedro Ruiz, M.D.
A. John Rush, M.D.
Marvin Schwartz, 1.0.
Richard Selman, M.D.
Kenneth Silk, M_D.
Bennett Simon, M.D.
Richard C. Simons, M.D.
Erik Simonsen, M.D.
Andrew Edward Skodolll, M.D.
Paul Harris Soloff, M.D.
Stephen Sternbach, M.D.
Alan Stone, M.D.
Michael Stone, M.D.
Lawrence Tancredi, M.D.
Alex Tamopolsky, M.D.
Auke Tellegen, Ph.D.
1912
Pekka Tienari, M.D.
Svenn Torgensen, M.D.
Joseph Triehwasser, M.D.
Robert Tringone, Ph.D.
Timothy Trull, Ph.D.
Peler Tyrer, M.D.
Lindsey Tweed, M.D.
T. Bedirhan Ustun, M.D.
Pcr Vaglum, M.D.
Sonya Vaglum, M.D.
George Vaillant, M.D.
lenore B. Walker, Ed.D.
Dennot Walsh, M.B.
Jack Wiggins, Ph.D.
Jerry Wiggins, PhD.
Mary C. Zanarini, Ed.D.
Premenstrual Dysphoric Disorder
Advisers
Elissa P. Benedek, M.D.
Sarah BeTga, 1'"'-0.
Susan Jane Blumenthal, M.D.
Leah Joan Dickstein, M.D.
Ellen W. Freeman, Ph.D.
Sheryl Gallant, Ph.D.
Leslie Gise, M.D.
Uricl Halbreich, M.D.
Jean Hamilton, M.D.
Michelle Harrison, M.D.
Roger F. Haskett, M.D.
Steven Ken Hoge. M.D.
Stephen W. Hurt, Ph.D.
Renee Johns, B.A.
W. Keye, Jr., M.D.
Martha Kirkpatrick, M.D.
Martha McClintock, Ph.D.
Margaret l. r...loline, Ph.D.
Carol C. Nadelson, M.D.
Howard Osofsky. M.D.
Mary Brown Parlee, PhD.
Jeff Rausch, M.D.
Robert Reid, M.D.
R. Rhodes, M.D.
Ana Rivera-Tovar, PhD.
Gail Robinson, M.D.
Miriam Rosenthal, M.D.
Peter Roy-Byrne, M.D.
Appendix J
David Rubinow, M.D.
Paula Schnurr, Ph.D.
John Steege, M.D.
~'leir
Stemer, M.D., Ph.D.
Donna Stewart, M.D.
Anna Stout, M.D.
Lenore B. Walker, Ed.D.
David Youngs, M.D.
Psychiatric Systems Interface
Disorders (Adjustment, Dissociative,
Factitious, Impulse-Control, and
Somatoform Disorders and
Psychological Factors Affecting
Medical Condition) Advisers
Paul S. Appelbaum, M.D.
Allyson Ashley, D.S.W.
Arthur J. Barsky, M.D.
David H. Barlow, Ph.D.
Johnathon O. Beahrs, MD.
David Bear, M.D.
Gale Beardsley, M.D.
Sidney Benjamin, M.D., M.Phii.
Kenneth Bowers, Ph.D.
John Bradford, ~'I.D.
Bennett Braun, M.D.
Etzel Cardena, Ph.D.
James Chu, M.D.
Catherine Classen, Ph.D.
Philip Coons, M.D.
Douglas Detrick, Ph.D.
Robert H. Dworkin, Ph.D.
David Folks, MD.
Fred Frankel, M.D.
Edward Frischholz, Ph.D.
George Fulup, MD.
Rollin Gallagher, M.D.
Jeffrey Geller, M.D.
Daniel W. Gillette, M.D.
Michael G. Goldstein, M.D.
Veerainder Goli, M.B.
Carlos A. Gonzalez, M.D.
Junius Gonzales, M.D.
Michael I. Goocl, M.D.
Ezra E. H. Griffith, M.D.
Samuel B. Guze, M.D.
Seymour L. Halleck, M.D.
DSMIV Contributors
Abraham L. Halpern, ~".D.,
Ph.D.
Nelson Hendler, M.s., M.D.
Ernest Hilgard, Ph.D.
Steven Ken Hoge, M.D.
Jimmie C. Holland, M.D.
Eric Hollander, M.D.
James J. Hudziak, M.D.
Janis H. Jenkins, Ph.D.
Roger Kathol, M.D.
J. David Kinzie, M.D.
Laurence Kirmayer, M.D.
Arthur Kleinman, M.D., Ph.D.
Richard Kluft, M.D.
Cheryl Koopman, Ph.D.
Donald S. Kornfeld, M.D.
K. Ranga Raffia Krishnan, M.D.
John Kurtz, M.D.
Henry R. Lesieur, Ph.D.
James Levenson, M.D.
Roberto Lewis-Fernilndez, M.D.
John Lion, M.D.
Zbigniew J. Lipowski, M.D.
Don R. Lipsitt, M.D.
Richard Loewenstein, M.D.
Jeffrey Mattes, M.D.
M. Eileen ~k!"amara,
M.D.
Harold Metskey, D.M.
Michael Moran, M.D.
George B. Murray, M.D.
John Nemiah, M.D.
Jeffrey Newcom, M.D.
Raymond Niaura, Ph.D.
Perry M. Nicassio, Ph.D.
Martin Orne, M.D., Ph.D.
Kalpana Pakianathan, M.D.
Robert O. Pasnau, M.D.
Kok Lee Peng, M.D.
Samuel W. Perry m, M.D.
Gary Peterson, M.D.
John Plewes, M.D.
Stanley L. Portnow, M.D., Ph.D.
Frank Putnam, M.D.
Phillip Jacob Resnick, M.D.
Richard J. Rosenthal, M.D.
Colin A. Ross, M.D.
Jolul Z. Sadler, M.D.
Shirley Sanders, Ph.D.
9131
Stephen M. Saravay, M.D.
Jonathon F. Silver, M.D.
Herbert Spiegel, M.D.
Marlene Steinberg, M.D.
Robert Stewart, O.5.W.
Marvin Swartz, M.D.
Troy L. Thompson IT, M.D.
Moshe Torem, M.D.
Eldon Tunks, 1\'1.0.
William L. ''''ebb, Jr., M.D. (deceased)
Kenneth Jay Weiss, M.D.
Mitchel Weiss, M.D., Ph.D.
Lewis Jolly West, M.D.
Ronald Winchel, M.D.
Thomas Nathan Wise, M.D.
Dennis Wolf" M.D.
Derson Young, to.
Smart C. Yudofsky, M.D.
Sean Yutzy, M.D.
Schizophrenia and Other Psychotic
Disorders Advisers
Xavier Amador, PhD.
Stephan Arndt, Ph.D.
Peter Berner, M.D.
Istvan Bitter, M.D.
Donald W. Black, M.D.
Randy Borum, M.D.
Malcolm B. Bowers, Jr., M.D.
H. Stefan Bracha, M.D.
Ian Brockington, M.D.
'William Carpenter, M.D.
Richard J. Castillo, Ph.D.
David Copolov, MD.
Lawrence A. Dunn, M.D.
William Edell, PhD.
Akira Fujinawa, M.D.
Carlos A. Gonzalez, M.D.
Jack Gorman, M.D.
Igor Grant, M.D.
Ezra E. H. Griffith, MD.
Gretchen Haas, Ph.D.
Martin Harrow, Ph.D.
Steven Ken Hoge, M.D.
Janis H. Jenkins, Ph.D.
Dilip V. Jeste, MD.
Marvin Kama, M.D.
914 Appendix J
Robert Kendell, M.D.
Anthony F. Lehman, M.D., M.5.P.H.
Roberto Lewis-Fernandez, M.D.
Robert Liberman, M.D.
Jeffrey Ueberman, M.D.
Mario Maj, M.D.
Joseph P. McEvoy. M.D.
Max McGee. M.D.
Patrick McGorry, M.B.B.5.
Herbert Meltzer, M.D.
AJan Metz, M.D.
Jeffrey l. Metzner, M.D.
Mark Richard Munetz, M.D.
Alistair Munroe, M.D.
Keith leuchterlein. Ph.D.
Yuji Okazaki, M.D.
AUonso Ontiveros, M.D., M.Sc.
Stein Opjordsmoen, Ph.D.
Ananda K. Pandurangi, M.D.
Godfrey Pearlson, M.D.
Delbert Robinson, M.D.
Nina Schooler, Ph.D.
Larry Siever, M.D.
Samuel Siris, M.D.
John Sweeney. Ph.D.
Sally Szymanski, D.o.
Mauricio Tohen, M.D.
Ming Tso Tsuang, M.D., Ph.D.
Michael Zaudig, M.D.
Sexual Disorders Advisers
John Bradford, M.D.
Robert P. Cabaj, M.D.
Dona L. Davis, Ph.D.
Park Elliott Dietz, M.D., Ph.D.
Leslie Gise, M.D.
Abraham L. Halpern, M.D., Ph.D.
Gilbert Herdt, Ph.D.
Steven Ken Hoge, M.D.
Helen Kaplan, M.D.
Kok Lee Peng, M.D.
Anna Stout, M.D.
Sleep Disorders Advisers
Edward Bixler, M.D.
Jack Edinger, M.D.
Charles W. Erwin, M.D.
Eugene C. Fletcher, M.D.
Abraham L. Halpern, M.D., Ph.D.
Peter Hauri, Ph.D.
Anthony Kales, M.D.
Milton Kramer, M.D.
Rocco Manfredi, M.D.
Cail Marsh, M.D.
Jeffrey L. Metzner, M.D.
Harvey Moldofsky, M.D.
Timothy H. Monk, Ph.D.
Ralph Pascualy, M.D., R.N.
Howard Roffwarg.. M.D.
Thomas Roth, Ph.D.
A. John Rush, M.D.
Constantin R. Soldatos, M.D.
Edward Stepanski, Ph.D.
Michael Thorpy, M.D.
SubstanceRelated Disorders Advisers
Henry Abraham, M.D.
Christer Allgulander, M.D.
Arthur Alterman, Ph.D.
Roland Atkinson, M.D.
Tom Babor, Ph.D.
George Bailey, M.D.
James Barbie, M.D.
Jeffrey Bedrick, M.D.
Fred K. Berger, M.D.
Jack D. Blaine, M.D.
Sheila Blume, M.D.
Richard Bonnie, J.D.
Kathleen Bucholz, Ph.D.
John Cacciola, Ph.D.
Clarissa Canino, Ph.D.
William D. Clark, M.D.
Stephen Dinwiddie, M.D.
Criffith Edwards, M.D.
Marian Fischman, Ph.D.
Richard Frances, M.D.
William Frosch, M.D.
Marc Galanter, M.D.
Frank Gawin, M.D.
Edith S. Linansky Gomberg.. Ph.D.
Enoch Cordis, M.D.
David Gorelick, M.D.
Bridget Grant, Ph.D.
Marcus Grant, Ph.D.
DSM-IV Contributors
Lester Grinspoon, MD.
Alfred Harkley, M.D.
James Hartford, M.D.
Deborah Hasin, Ph.D.
Steven Ken Hoge, M.D.
Arthur M. Horton, Ph.D.
John R. Hughes, M.D.
Michael Invin, M.D.
Jerome Jaffe, M.D.
Denise Kandel, Ph.D.
Edward Kaufman, M.D.
Herbert Kleber, M.D.
Thomas Kosten, M.D.
Mary Jeanne Kreek, M.D.
James Langenbucher, Ph.D.
Edward D. Levin, Ph.D.
Benjamin Liptzin, M.D.
James Maddox, M.D.
Enrique Madrigal, M.D.
Peter Martin, MD.
Roy Mathew, M.D.
Wayne McFadden, M.D.
Thomas McLellan, Ph.D.
Jack H. Mendelsohn, M.D.
Roger Meyer, M.D.
Norman Miller, MD.
Robert Millman, M.D.
Maristela Monteiro, M.D.
Advisers on Coding Issues
Andrea Albaum-Feinstein
Margaret Arnatayakul, M.B.A., KKA.
Amy Blum, M.P.H., RRA.
Delray Green, RRA.
Deborah K. Hansen, ART., c.C.S.
Robert A. Israel, M.P.H.
L Ann Kirner, c.C.S.
Perrianne Lurie, M.D., M.P.H.
Sue Meads, RRA.
James W. Thompson, M.D., M.P.H.
Advisers on Cross-Cultural Issues
Juan Enrique Mezzich, M.D., PhD.
Arthur Kleinman, M.D., Ph.D.
Robert M. Morse, M.D.
David F. Naftolowilz, M.D.
Paul Nagy
Charles O'Brien, M.D.
Glen Pearson, M.D.
Stanton Peele, Ph.D.
Helen Pettinatti, Ph.D.
Roy Pickens, Ph.D.
Andrzej Piotrowski, M.D.
Rumi Price, Ph.D.
Anthony Radcliffe, M.D.
Charles Riordan, M.D.
Jed Rose, PhD.
Bruce Rounsaville, M.D.
John Saunders, M.D.
Sidney H. Schnall, M.D.
Charles K Schuster, Ph.D.
Boris Segal, M.D.
Roy Stein, M.D.
Lee L Towle, Ph.D.
John Tsuang, M.D.
Harold Urschel! ill, M.D.
Dermot Walsh, M.B.
Robert Weinrieb, M.D.
Joseph Westermeyer, M.D., Ph.D.,
M.P.H.
Kenneth WinteTS, Ph.D.
Sheldon Zimberg, M.D.
Task Force Advisers
Horacia Fabrega, Jr., M.D.
Delores Parron, Ph.D.
Byron Good, Ph.D.
Keh-Ming Lin, M.D.
Spero Manson, Ph.D.
Gloria Johnson-Powell, M.D.
Victor R. Adebimpe, M.D.
Renata Daniel Alarcon, M.D., M.P.H.
William Arroyo, M.D.
Morton Beiser, M.D.
James Boster, Ph.D.
Glorissa Canino, Ph.D.
Tan Alberto Canino, M.D.
Richard J. Castillo, Ph.D.
916
Freda Cheung, Ph.D.
Ellen Corin, Ph.D.
Dona L. Davis, Ph.D.
Armando Favazza, M.D.
Candace Fleming, Ph.D.
Edward F. Foulks, MD., Ph.D.
Atwood Gaines, Ph.D.
Alber! Gaw, M.D.
James Gibbs, Ph.D.
Carlos A. Gonzalez, M.D.
Ezra E. H. Griffith, MD.
Peler J. Guamaccia, Ph.D.
Gilbert HerdI, Ph.D.
Kim Hopper, PhD.
David Hufford, PhD.
Charles Hughes, Ph.D.
janis H. Jenkins, Ph.D.
Marvin Kama, M.D.
Marianne Kastrup, M.D., Ph.D.
J. David Kinzie, M.D.
Laurence Kirmayer, M.D.
Paul Koegel, Ph.D.
Robert F. Kraus, M.D.
Tina K. Leonard-Green, MS, R.D.
Roberto Lewis-Fernandez, rvl.D.
T-Y Lin, MD.
Roland Littlewood, M.B., D.Phil.
Francis Lu, M.D.
Enrique Madrigal, M.D.
Theresa O'Neil, Ph.D.
Raymond Prince, MD.
Juan Ramos, Ph.D.
Cheryl Ritenbaugh, Ph.D., M.P.H.
Lloyd Rogier, Ph.D.
William H. Sack, MD.
Ihsan Salloum, M.D., M.P.H.
Norman Sartorius, M.D., Ph.D.
Catherine L. Shisslak, PhD.
Ronald C. Simons, M.D., M.A.
Jeanne M. Spurlock, M.D.
Nicolette Teufel, Ph.D.
James W. TIlOmpson, M.D., M.P.H.
Wen-Shing Tseng, M.D.
Mitchel \'Veiss, M.D., Ph.D.
Joseph Westermeyer, M.D., Ph.D.,
M.P.H.
Charles "Vilkinson, M.D.
Appendix J
Ronald M. ''''introb, M.D.
Joseph Yamamoto, M.D.
Advisers on Family/Relational Issues
James Alexander, Ph.D.
Arthur M. Bodin, Ph.D.
Robert Butler, M.D.
Patricia Chamberlain, Ph.D.
Dante Cichetti, Ph.D.
John Clarkin, Ph.D.
Daniel Corwin, M.D.
Mark R. Ginsberg, Ph.D.
Michael J. Goldstein, Ph.D.
Herta A. Guttman, M.D.
Michael D. Kahn, Ph.D.
Sandra Kaplan, M.D.
Florence Kaslow, PhD.
John F. Knutson, PhD.
Judy Magil, M.$.W.
David Milkowitz, Ph.D.
K Daniel O'Leary, Ph.D.
David Olson, PhD.
David Pelcovitz, Ph.D.
Angus M. Strachan, Ph.D.
Terry S. Trepper, Ph.D.
Lyman C. W)'lme, M.D., Ph.D.
Ramsy Yassa, M.D.
Advisers on Forensic Issues
Paul S. Appelbaum, M.D.
James c. Beck, M.D.
Lewis M. l3loomingdale, M.D.
Richard Bonnie, J.D.
Jeffrey Lee Cummings, MD.
Jeffrey Geller, M.D.
Robert P. Granacher, M.D., Ph.D.
TIlOmas Gordon Gutheil, M.D.
Abraham L. Halpern, M.D., Ph.D.
Steven Ken Hoge, M.D.
Stuart Kleinman, M.D.
Jeffrey L. Metzner, M.D.
Charles A. Meyer, Jr., M.D.
Robert David Miller, M.D., Ph.D.
Mark.Richard Munetz, M.D.
Stanley L. Pormow, M.D., Ph.D.
Phillip Jacob Resnick, M.D.
Richard Rosner, 1\'[,0.
DSM-IV Contributors 9171
Daniel W. Shuman
Larry H. Strasburger, M.D., Ph.D.
Kenneth Jay Weiss, }..tD.
Howard Zonana, M.D.
Advisers on Medication-Induced
Movement Disorders
Gerard Addonizio, M.D.
Lenard Adler, M.D.
Burt Angrist, M.D.
Ross J. Baldessarini, MD.
Stanley N. CaroC!, MD.
Daniel Casey, MD.
Jeffrey Lee Cummings, M.D.
George Gardos, M.D.
Allen Gelenberg, M.D.
James Jefferson, M.D.
Dilip V. Jeste, M.D.
John M. Kane, M.D.
Paul E. Keck, M.D.
James Levenson, M.D.
Stephan C. Mann, M.D.
Ananda K. Pandurangi, M.D.
Patricia Rosebush, M.D.
Virginia Susman, M.D.
Peter Weiden, M.D.
Ramsy Yassa, M.D.
Advisers to the Task Force on DSM-IV
Boris M. Astrachan, M.D.
Robert Avant, M.D.
Jeanette Bair, B.s., M.B.A.
W. Robert Beavers, M.D.
Jeffrey Bedrick, M.D.
Carl Bell, M.D.
Ellen Berman, M.D.
Eugene Broadhead, M.D., Ph.D.
Laura Brown, Ph.D.
Robert P. Cabaj, M.D.
Robert Cahan, M.D.
Robert Chiarello, M.D.
'Nilliam D. Clark, MD.
Steven Cohen-Cole, M.D.
Lee Combrinck-Graham, M.D.
Vicky Conn, R.N.
Harris Cooper, Ph.D.
Michael Crouch, M.D.
Alan Daniels
Frank deGruy, M.D.
Susan Dime-Meenan
Stacy Donovan, B.A.
Richard Dudley, M.D.
Suzanne Dworak-Peck
Bruce Emery, A.C.S.W.
Spencer Falcon, M.D.
Louis Fine, M.D.
Susan Fine, M.A.
Rita Finnegan, R.R.A.
Gerald H. Flamm, M.D.
Laurie Flynn, B.A.
Raymond D. Fowler, Ph.D.
Richard Frances, MD.
Jack Froom, M.D.
Robert W. Gibson, M.D.
Junius Gonzales, M.D.
Raphael S. Good, M.D.
Robert C. Green, M.D.
Larry P. Griffin, M.D.
Claire Griffin-Francell, R.N.
Alfred Hackley, M.D.
Nonnan B. Hartstein, M.D.
Ann Hohmann, Ph.D.
Theodore Hutchison, M.D.
Dale Johnson, Ph.D.
John E. Joyner, M.D.
Harold Kaminetzky, M.D.
Ira Katz, M.D.
Jerald Kay, M.D.
Kelly Kelleher, M.D.
Helena Kraemer, Ph.D.
John J. LaFerla, M.D.
Marion Langer, Ph.D.
Martha Lasseter, R.R.A.
Philip Lavori, Ph.D.
Lawrence N. Lazarus, M.D.
Harriet Lefley, Ph.D.
James Levenson, M.D.
Frank Ling, M.D.
Mack Lipkin, M.D.
Don-David Lusterman, Ph.D.
Richard M. Magraw, M.D.
Kathryn Magruder, Ph.D., M.P.H.
Dale Matthews, M.D.
Chuck Miles, M.D.
Appendix J
Sheldon I. Miller, M.D.
Paul D. Mozley, M.D.
Kathi Pajer, M.D.
Joseph Palombi, M.D.
Robert C. Park, M.D.
Elaine Purpel, M.5.W.
Peter Rabins, M.D.
Anthony Radcliffe, M.D.
Richard Rahe, M.D.
Peter Rappa, M.D.
Marilyn Rosenson, M.S.\"'.
Marshall Rosman, Ph.D.
Donald J. Scherl, M.D.
Sidney H. Schnall, M.D.
Diana Seebold, R.R.A.
Charles A. Shamoian, M.D., Ph.D.
Steven Sharfstein, M.D.
J. Gregory Shea
Alfred Skinner, M.D.
William W. Snavely
Janet T. Spence
Leon Speroff, M.D.
Emanuel Steindler
Melvin Stem, M.D.
James E. Strain, M.D.
Rev. Paul C. Tomlinson
Michael B. Unhjem
Jerome Vaccaro, M.D.
Jeanne Van Riper, A.R.T.
Alan J. Wabrek, M.D.
Lenore B. Walker, Ed.D.
Steven Wartman, M.D.
Robert Weinrieb, M.D.
Robert Weinstock, Ph.D.
Bryant Welch, Ph.D.
Eleanor White, Ph.D.
Robert L. Williams, M.D.
Mark Wolraich, M.D.
David Youngs, M.D.
International Advisers
The Task Force on DSM-rv sought the expertise of a wide range of international e
xpeds.
The contributions of international experts helped to ensure cultural sensitivity
,
applicability for international mental health professionals, and greater compati
bility
with ICDI0. International experts advised both the Task Force and individual Work
Groups.
Christer Allgulander, M.D. (Sweden)
Paulo Alterwain, M.D. (Uruguay)
Antonio Andreoli, M.D. (Switzerland)
Jules Angst, M.D. (Switzerland)
BengAke Armelius, Ph.D.
(Switzerland)
Marie Asberg, M.D. (Sweden)
Tolani Asuni, ~'I.D.
(Nigeria)
Sidney Benjamin, M.D., M.Phil.
(England)
Mark Berelowitz, M.D. (England)
Peter Berner, M.D. (Austria)
Aksel Bertelsen, M.D. (Denmark)
Peter Beumon!, M.D. (Australia)
Ish'an Bitler, M.D. (HWlgary)
Ray Blanchard, Ph.D. (Canada)
Daniel Bobon (Belgium)
Jacek Bomba, M.D. (poland)
Kenneth Bowers, Ph.D. (Canada)
John Bradford, M.D. (Canada)
Susan Bradley, M.D. (Canada)
Jack Brandes, M.D. (Canada)
Ian Brockington, M.D. (England)
Graham Burrows, M.D. (Australia)
Patricia Casey, M.D. (Ireland)
Giovanni Cassano, M.D. (Italy)
Doc YOWlg Cho, M.D. (Korea)
David M. Clark, Ph.D. (England)
John E. Cooper, M.D. (England)
Peter J. Cooper, M.D. (England)
Daviq Copolov, M.D. (Australia)
Jorge Costa e Silva, M.D. (Brazil)
Arthur H. Crisp, M.D. (England)
Stanislaw Dabrowski, M.D. (poland)
DSM-IV Contributors
Adrian Dafunchio, M.D. (Argentina)
Alv A. Dahl, M.D. (Nom'ay)
Christine Dean, M.D. (England)
Horst Dilling,. M.D. (Germany)
Keith Stephen Dobson, Ph.D. (Canada)
Griffith Edwards, M.D. (England)
Christopher Fairburn, M.D. (England)
Francois Ferrero, M.D. (Switzerland)
Manfred Fichter, M.D. (Germany)
Martine Flament, M.D. (France)
Chris Freeman, M.D. (Scotland)
Harold Freyberger, M.D. (Germany)
Akira Fujinawa, M.D. Oapan)
Paul Garfinkel, M.D. (Canada)
Michael Gelder, M.D. (England)
Semyon Gluzman, M.D. (former USSR)
Judith H. Gold, M.D. (Canada)
Marcus Grant, Ph.D. (Switzerland)
Herta A. Guttman, M.D. (Canada)
Heinz Hafner, M.D. (Germany)
Robert Hare, Ph.D. (Canada)
Lily Hechtman, M.D. (Canada)
Michiel W. Hengeveld, M.D., Ph.D.
(Netherlands)
C. Peter Herman, Ph.D. (Canada)
Hans Hippius, M.D. (Germany)
WWem M. Hies, M.D. ( 'etherlands)
Teo Seng Hock, M.D. (Singapore)
Hans W. Hoek, M.D., Ph.D.
( Tetherlands)
Yoshiko Ikeda, M.D. Oapan)
Assen Jablensky, M.D. (Bulgaria)
Aleksander Janca, M.D. (Switzerland)
Philippe Jeammet. M.D. (France)
Karen John, M.D. (England)
Miguel Jorge, M.D., Ph.D. (Brazil)
Ross S. Kalucy, M.D. (Australia)
Marianne Kastrup, M.D., Ph.D.
(DenmMk)
Heinz Katschnig, M.D. (Austria)
Justin Kenardy, Ph.D. (Australia)
Robert Kendell, M.D. (Scotland)
Sid Kennedy, M.D. (Canada)
Renard Knabbe, M.D. (Switzerland)
Vladimir Kovalev, M.D. (former USSR)
Evsey Krasik, M.D. (former USSR)
Yves LeCrubier, M.D. (France)
Pierre Leic1uler. M.D. (Canada)
Jill Leolbonne, M.D. (England)
Bernard Lerer, M.D. (Israel)
Aubrey Levin, M.D. (South Africa)
Paul Links, M.D. (Canada)
Zbigniew Lipowski, M.D. (Canada)
Alwyn Lishman, M.D. (England)
W. John Livesley, M.D. (Canada)
J. L6pezlbor, Jr., M.D. (Spain)
Mario Maj, M.D. (Italy)
Felice Ueh Mak (China)
Nikolas Manos, M.D. (Greece)
Isaac Marks, M.D. (England)
Alexander C. Mcfarlane, M.B.B.s.
(Hans), M.D. (Australia)
Patrick McGarry, M.B.B.s. (Australia)
Julien Mendelewicz, M.D. (Belgium)
Klaus r>.1inde, M.D. (Canada)
Harvey Moldofsky, M.D. (Canada)
Maristela Monteiro, M.D. (Brazil)
Stuart Montgomery, M.D. (England)
Ole Mars, M.D. (Denmark)
Alistair Munroe, M.D. (Canada)
GuJam Mustafa, M.D. (Kenya)
Yoshiburni Takane, M.D. Oapan)
W.A. Tolen (Netherlands)
C1aes NorOng. Dr.Med.Sc. (Sweden)
Yuri Nuller (former USSR)
Aluned Okasha, M.D. (Egypt)
Yuji Okazaki, M.D. Oapan)
Yutaka Ono, M.D. Oapan)
Alfonso Ontiveros. M.D., M.Sc. (Mexico)
Stein Opjordsmoen, Ph.D. ( orwa)')
John Orley, M.D. (Switzerland)
Lars Goran Ost, Ph.D. (Sweden)
Stefano Pallanti, M.D. (Italy)
Joel Paris, M.D. (Canada)
Gordon Parker, M.D. (Australia)
Eugene Paykel, 1\-1.0. (England)
Kok Lee Peng. M.D. (Singapore)
Uwe Henrick Peters, M.D. (Germany)
Carlo Perris, M.D. (Sweden)
Pierre Pichot, M.D. (France)
Andrzej Piotrowski, M.D. (Poland)
Karl Pirke, M.D. (Germany)
Janet Polh'y, Ph.D. (Canada)
Charles Pull, M.D. (Luxembourg)
j
Kari Pylkkanen, M.D. (Finland)
Juan Ramon de la Fuente, M.D. (Mexico)
Beverley Raphael. M.D. (Australia)
Robert Reid, M.D. (Canada)
Helmut Remschmidt (Gennany)
Nils Rettersol, r.,I.D. (Non"ay)
Joseph M. Rey, Ph.D. (Australia)
Jeffrey c. Richards, Ph.D. (Australia)
Antonio A. Rizzoli, M.D. (Italy)
Paul Robinson, M.D. (England)
Sir Martin Roth, M.D. (England)
Byron Rourke, Ph.D. (Canada)
Gerald Russell, M.D. (England)
Sir Michael Rutter, M.D. (England)
Javier Saavedra, M.D. (peru)
Paul Salkovskis, Ph.D. (England)
'orman Sartorius, M.D., Ph.D.
(Switzerland)
John Saunders, M.D. (Australia)
Aart H. Schene. M.D. (Netherlands)
Marcus Fini Schulsinger, M.D.
(Denmark)
Jan Scott, Ph.D. (England)
Ruben Hernandez Serrano, M.D.
(Venezuela)
Michael Shephard, M.D. (England)
Erik Simonsen, M.D. (Denmark)
Cees J. Siooff, M.D. (Netherlands)
Constantin R. Soldatos, M.D. (Greece)
Zahava Soloman, M.D. (Israel)
Marin Stancu, M.D. (Romania)
Meir Steiner, M.D., Ph.D. (Canada)
Donna Stewart, M.D. (Canada)
Appendix J
Eric Stromgren, M.D. (Denmark)
Peter Szatmari, M.D. (Canada)
George Szmukler, ro.,+I.D. (England)
Alex Tamopolsky, M.D. (Canada)
Christopher Tennant, M.D. (Australia)
Sten Theander, M.D. (Sweden)
Pekka Tienari, M.D. (Finland)
Svenn Torgensen, M.D. (Norway)
Peter Trower, Ph.D. (England)
Eldon Tlmks, M.D. (Canada)
Peter Tyrer, M.D. (England)
T. Bedirhan Ustun, M.D. (Switzerland)
Per Vaglum, M.D. (Nom'ay)
Walter Vandereycken, M.D. (Belgium)
Jenny Van Drimmelen-Krabbe, M.D.
(Switzerland)
J. T. van t\'fens, M.D. (Netherlands)
David Veale, M.R.C.Psych. (England)
F. C. Verhulst (Netherlands)
Marcia Versiani, M.D. (Brazil)
Marten ''''. de Vries, M.D. (Netherlands)
Dermot Walsh, M.B. (Ireland)
Winny Weeda-Mannak, Ph.D.
( 'etherlands)
John S. Werry, M.D. (New Zealand)
Hans Ulrich Wittchen, Ph.D. (Germany)
Ramsy Yassa, M.D. (Canada)
Derson Young, M.D. (China)
Michael Zaudig, M.D. (Gennany)
Joseph Zohar, M.D. (Israel)
Kenneth J. Zucker, Ph.D. (Canada)
Roberto Llanos Zuloaga, M.D. (peru)
DSMIV Focused Field-Trial Projects
The field-trial project:s funded by the National Institute of Mental Health in c
ollaboration
with the National Institute on Drug Abuse and the Nationallnstitute on Alcohol
Abuse and Alcoholism were an invaluable source of data and contributed greatly
to the quality of DSM-IV. Our thanks to Darrel Regier, M.D., M.P.H., Director of
the
Division of Epidemiology and Sen'ices Research, and Charles Kaelber. M.D., the
Project Officer, for their support and expertise. Our thanks, too, to the follow
ing fieldtrial
participant:s:
Principal Investigator Co-Principal Investigator
Allen Frances, M.D. Harold Alan Pincus, M.D.
DSMIV Contributors
Focused Field-Trial Coordinator
Myriam Kline, M.s.
Statistical Consultant
Helena Kraemer, Ph.D.
Antisocial Personality Disorder
Field Trial
Project Director
Thomas A. Widiger, Ph.D.
Site Coordinators
Arthur Alterman, Ph.D.
Remi J. Cadoret, MD.
Robert Hare, Ph.D.
Lee Robins, Ph.D.
Gl'Orge E. Woody, M.D.
Mary C. Zanarini, Ed.D.
Autism and Pervasive Developmental
Disorders Field Trial
Project Director
Fred Volkmar, M.D. (also Site
Coordinator)
Site Coordilmtors
Magda Campbell, M.D.
B.J. Freeman, Ph.D.
Ami Klin, Ph.D.
Catherine Lord, Ph.D.
E. Rih'o, M.D.
Sir Michael Rutter, MD.
Eric 5chopler, Ph.D.
Sife CoordilUlfors, VO/III/teer Sites
Joel Bregman, M.D.
Jan BUilelaar, M.D.
Soc Churl Cho, M.D.
Eric Fombonne, M.D.
Joaquin Fuentes, M.D.
Yossie Hattab, M.D.
Yoshihiko Hoshino, M.D.
j. Kerbeshian, M.D.
William Kline, Ph.D.
Katherine Loveland, PhD.
Bryna Siegel, Ph.D.
Wendy Stone, M.D.
Peter Szahnari, M.D.
LudWig Szymanski, M.D.
921 I
Kenneth Towbin, M.D.
john S. Werry, M.D.
Disruptive Behavior Disorder
Field Trial
Project Director
Benjamin Lahey, Ph.D. (also Site
Coordinator)
Site Coordillators
Russell Barkley, Ph.D.
joseph Biederman, M.D.
Barry Garfinkel, M.D.
Laurence Greenhill, M.D.
George Hynd, Ed.D.
Keith McBurnett, Ph.D.
Jeffrey Newcorn, M.D.
Thomas Ollendick, Ph.D.
Site Coordinators, Volunteer Sites
Paul Frick, Ph.D.
Peter jensen, M.D.
Lynn Kerdyk, Ph.D.
John Richters, Ph.D.
Data Coordinator
Dorcas Perez, B.A.
Major Depression, Dysthymia, and
Minor Depressive Disorder Field Trial
Project Director
Martin B. Keller, M.D. (also Site
Coordinator)
Project Co-Directors
i\1..ichael B. First, M.D.
James Kocsis, M.D. (also Site
Coordinator)
Site Coordillators
Robert M. A. Hirschfeld, M.D.
Charles Holzer, Ph.D.
Gabor Keitner, M.D.
Daniel Klein, Ph.D.
Deborah Marin, M.D.
James P. McCullough, Ph.D.
l\'an Miller, PhD.
Tracie Shea, Ph.D.
Data Coordillators
Diane Hanks, M.A.
Cordelia Russell, B.A.
Mixed Anxiety-Depressive Disorder
Field Trial
Project Directors
David H. Barlow, Ph.D. (also Site
Coordinator)
Michael R. Liebowitz, M.D. (also Site
Coordinator)
Richard Zinbarg, Ph.D. (also Site
Coordinator)
Site Coordil/ators
Phil Brantley, Ph.D.
Eugene Broadhead, M.D., Ph.D.
Wayne Katon, M.D.
Jean-Pierre Lepine, M.D.
Jeffrey c. Richards, Ph.D.
Peter Roy-Byrne, M.D.
Linda Street, Ph.D.
Mardjan Teherani, Ph.D.
Obsessive-Compulsive Disorder
Field Trial
Project Director
Edna Foa, Ph.D. (also Site Coordinator)
Site Coordillators
Jane Eisen, M.D.
Wayne Goodman, M.D.
Hella Hiss, Ph.D.
Eric Hollander, M.D.
Michael Jemke, M.D.
Michael J. Kozak, Ph.D.
Steven Rasmussen, M.D.
Joseph Ricciardi, Ph.D.
Peggy Richter, M.D.
Barbara Rothbaum, Ph.D.
Panic Disorder Field Trial
Project Director
Abby Fyer, M.D. (also Site Coordinator)
Project Co-Director
James C. Ballenger, M.D. (also Site
Coordinator)
AppendixJ
Site Coordillators
David H. Barlow, Ph.D.
Michael Hollifield, M.D.
Wayne Katon, M.D.
Richard Swinson, M.D.
Data Analysts
Tim Chapman, M.Phil.
Salvatore Mannuzza, Ph.D.
Dntn Coordinator
Hilary Rassnick, M.A.
Posttraumatic Stress Disorder
Field Trial
Project Director
Dean Kilpatrick, Ph.D. (also Site
Coordinator)
Bessel van der Kolk, M.D. (also Site
Coordinator)
Site Coordinators
John Freedy, Ph.D.
Sandra Kaplan, M.D.
David Pelcovitz, Ph.D.
Patricia A. Resick, Ph.D.
Heidi Resnick, Ph.D.
Susan Roth, Ph.D.
Schizophrenia and Related Psychotic
Disorders Field Trial
Project Directors
Nancy Coover Andreasen, ~f.D.,
Ph.D.
(also Site Coordinator)
I'vlichael A. Flaum, M.D. (also Site
Coordinator)
Site Coordinators
Xavier Amador, Ph.D.
H. Stefan Bracha, M.D.
William Edell, Ph.D.
Jack Gorman, M.D.
Kenneth S. Kendler, M.D.
Jeffrey Lieberman, M.D.
Thomas McGlashan, M.D.
Anani;la K Pandurangi, M.D.
Delbert Robinson, M.D.
Sire Coordilmtors, Volullteer Sites
Patrick McGorry, M.B.B.5.
J
DSMIV Contributors 9231
Alfonso Ontiveros, M.D., M.Sc.
Maurido Tohen, M.D.
Sleep Disorders Field Trial
Project Directors
Daniel Buysse, M.D. (also Site
Coordinator)
David J. Kupfer, M.D.
Charles F. Reynolds Ill, M.D.
Site Coordinators
Edward Bixler, M.D.
Peter Hauri, Ph.D.
Anthony Kales, M.D.
Rocco r\'lanfredj, M.D.
Thomas Roth, Ph.D.
Edward Stepanski, Ph.D.
Michael Thorpy, M.D.
Data Coordillator
Debbie Mesiano, B.S.
Somatization Disorder Field Trial
Project Director
C. Robert Cloninger, 1.0.
Site Coordinators
Samuel B. Cuze, M.D.
Roger Kathol, M.D.
Ronald L. Martin, M.D.
Richard Smith, M.D.
James J. Strain, M.D.
Sean Yutzy, M.D.
Substance Use Field Trial
Project Directors
Linda Cottier, Ph.D. (also Site
Coordinator)
John E. Helzer. M.D.
Marc Alan Sc.huckit. M.D. (also Site
Coordinator)
Site Coordinators
Thomas Crowley, M.D.
John R. Hughes, M.D.
George E. \Nood)', M.D.
Site CoordiJlators, Vollillteer Sites
Jean-Pierre Lepine, M.D.
MacArthur Data-Reanalysis Project
The data-reanalysis projects funded by a generous grant from the John D. and Cat
herine
T. MacArthur Foundation provided an extensive research database. ~'lany
thanks to Dennis Prager at the Foundation for his tremendous support. Our sincer
e
appreciation to the follOWing individuals who conducted data-reanalysis projects
:
Principal Investigator
Allen Frances, M.D.
CoPrindpal Investigators
Harold Alan Pincus, M.D.
Thomas A. Widiger, Ph.D.
Anxiety Disorders
David H. Barlow, Ph.D.
Deborah C. Beidel, Ph.D.
Thomas Burton, B.A.
Michelle G. Craske, Ph.D.
George C. Curtis, M.D.
Peter A. DiNardo. Ph.D.
Abby Frer, M.D.
Robin Garfinkel, Ph.D.
Richard Heimberg, Ph.D.
Elizabeth M. Hill, Ph.D.
Christopher D. Hornig, B.A.
Ewald Horwath, M.D., ~'I.Sc.
James Johnson, Ph.D. (deceased)
Harlan Juster, Ph.D.
Wayne Katon, M.D.
Gerald L. Klerman, M.D. (deceased)
Karen Law, B.A.
Andrew Leon, Ph.D.
Michael R. Liebowitz, M.D.
Salvatore Mannuzza, Ph.D.
Appendix J
Jill Mattia, M.A.
Eryn Oberlander, M.D.
Susan Orsillo, M.A.
Peter RoyByme, M.D.
Paul Salkovskis, Ph.D.
Franklin Schneier, M.D.
Samuel M. Turner, Ph.D.
Myrna M. Weissman, Ph.D.
Susan I. Walk, M.D.
Roberto Zarate, M.A.
Delirium, Dementia, and Amnestic
and Other Cognitive Disorders
Michael O. Colvin, M.D.
Marshall Foistein, M.D.
Gary Lloyd Gottlieb, M.D.
DiHp V. Jeste, M.D.
Sue Levkoff, D.Se.
Benjamin Liptzin, M.D.
George W. Rebok, Ph.D.
David Salmon, Ph.D.
Leon ThaI, M.D.
Disorders Usually First Diagnosed
During Infancy, Childhood, or
Adolescence
Brooks Applegate, Ph.D.
Gerald August, Ph.D.
Susan J. Bradley, M.D.
Joel Bregman, M.D.
Patricia Cohen, Ph.D.
Michael Flory, Ph.D.
Susan Folstein, M.D.
Eric Fombonne, M.D.
Barry Garfinkel, M.D.
Richard Green, M.D., lD.
Stephanie M. Green, M.s.
Jane E. Hood, M.A.
Kate Keenan, r..l.5.
Benjamin Lahey, Ph.D.
Marion Leboyer, M.D.
Rolf Loeber, Ph.D.
Catherine Lord, Ph.D.
John Mclennan, M.D.
'ancy Minshew, M.D.
Rhea Paul, Ph.D.
Andrew Pickles, Ph.D.
Howard M. Rebach, Ph.D.
Mary F. Russo, Ph.D.
Sir Michael Rutter, M.D.
Eric Schopler, Ph.D.
Christopher Thomas, ~I.D.
Fred Volkmar, M.D.
Katherine Williams, Ph.D.
Kenneth J. Zucker, Ph.D.
Eating Disorders
Arnold Anderson, M.D.
Christopher Fairburn, M.D.
Martine Flament, M.D.
Paul Garfinkel, M.D.
Dean Kilpatrick, Ph.D.
James Mitchell, M.D.
G. Terence Wilson, Ph.D.
Steven Wanderlich, M.D.
Mood Disorders
Gregory Asnis, M.D.
Mark S. Bauer, M.D.
Diane Bynum
Joseph Calabrese, M.D.
William CoryeU, M.D.
David Dunner, M.D.
Ellen Frank, Ph.D.
Laszlo Gyulai, M.D.
Martin B. Keller, M.D.
James Kocsis, M.D.
Philip L.wori, Ph.D.
Yves LeCrubier, M.D.
Robert M. Post, M.D.
Samuel J. Simmens, Ph.D.
Stuart Sotsky, M.D.
Dan L. Tweed, Ph.D.
Lindsey Tweed, M.D.
Peter C. Whybrow, M.D.
Sharon Younkin
Personality Disorders
Emil F. Coccaro, M.D.
Mark Davies, M.D.
Michael B. First, M.D.
Robert Hare, Ph.D.
Theodore Millon, Ph.D.
Vivian Mitropoulou, M.A.
Leslie Morey, Ph.D.
D$M-IV Contributors 9251
Bruce pfohl, M.D.
Lee Robins, Ph.D.
Larry J. Siever, M.D.
Jeremy M. Silverman, Ph.D.
Andrew Edward Skodol II, M.D.
Timothy Trull, Ph.D.
TIlomas A. Widiger, Ph.D.
Mary C. Zanarini, Ed.D.
Premenstrual Dysphoric Disorder
Ellen Frank, Ph.D.
Ellen W. Freeman, Ph.D.
Lesl.ie Gise, M.D.
Judith H. Gold, M.D.
Barbara Parry, M.D.
Pallia Schnurr, Ph.D.
Sally Severino, M.D.
John Steege, M.D.
Meir Steiner, M.D., Ph.D.
Psychiatric Systems Interface
Disorders (Adjustment, Dissociative,
Factitious, Impulse-Control, and
Somatoform Disorders and
Psychological Factors Affecting
Medical Condition)
Henry R. Lesiern, M.D.
Juan Enrique Mezzidl, M.D., Ph.D.
Jeffrey Newcom, M.D.
David Spiegel, M.D.
James J. Strain, M.D.
Schizophrenia and Other Psychotic
Disorders
Nancy Coover Andreasen, M.D., Ph.D.
Gretchen Haas, Ph.D.
Jeffrey Lieberman, M.D.
Patrick McGorry, M.B.B.5.
Keith leuchterlein, Ph.D.
Mauricio Tohen, M.D.
Sleep Disorders
Daniel Buysse, M.D.
Charles F. Reynolds Ill, M.D.
Substance-Related Disorders
Jolm Cacciola, Ph.D.
Linda B. Cottler, Ph.D.
John E. Helzer, M.D.
Rumi Price, Ph.D.
Lee Robins, Ph.D.
Marc Alan Schuckit, M.D.
George E. Woody, M.D.
MacArthur General Reliability Field Trial
As D$M-IV is being published, an additional project sponsored by the John D. and
Catherine T. MacArthur Foundation will provide further information regarding the
val.idity of DSM-IV criteria. TIle ongoing videotape field-trial project is expe
cted to be
completed in 1995. Om thanks to the foDowing individuals who participated in the
project:
Principal Investigator Pilot Participants
ADen Frances, M.D. Xavier Amador, Ph.D.
James W. Thompson, M.D., lvI.P.H. Nancy Coover Andreasen, M.D., Ph.D.
F. M. Baker, M.D.
Co-Principal Investigators Donald W. Black, M.D.
Harold Alan Pincus, M.D. Carlos S. Castillo, M.D.
Michael B. First, M.D. Scott C. Clark, M.D.
Michael A. Flaum, M.D. William Coryell, M.D.
Anthony F. Lehman, M.D., M.5.P.H. Lisa B. Dixon, M.D.
Jack E. Downhill, Jr., M.D.
Katherine P. Duffy, t\'!.D.
Jean Endicott, Ph.D.
Michael A. Fauman, M.D., Ph.D.
Miriam Gibbon, M.5.W.
Jack Gorman, M.D.
Paul E. Hogsten, M.D.
Michael L. Jeffries, M.D.
Douglas Langbelm, M.D.
Joseph Liberlo, M.D.
David B. Mallot, M.D.
Del D. ~'Iiller,
Pharm.D., M.D.
Lewis A. Opler, M.D., Ph.D.
Expert-Phase Participants
AppendixJ
Jill A. RachBeisel, .M.D.
Robert P. Schwartz, M.D.
Andrew Edward SkodollI, M.D.
David H. Strauss, M.D.
Scott Stuart, M.D.
Janet B. VV. Williams, DS.W.
Catherine Woodman, M.D.
Project Coordinator
Jennifer Norbeck, M.5.W.
Video Consultant
Vincent C1aylon, M.A.
The following represents the project participants at the time that DSM-IV went t
o
press. It is anticipated that other sites and individuals will join the project.
Jonathan Alpert, M.D.
Katherine Attala, M.D.
David Avery, M.D.
Monica Ramirez Basco, Ph.D.
Mark S. Bauer, M.D. (also Site
Coordinator)
Thomas F. Betzler, r.,'I.D.
Melanie M. Biggs, Ph.D. (also Site
Coordinator)
Robert J. Bishop, M.D.
Danielle Bordeau, M.D.
Malcolm B. Bowers, Jr., M.D.
Gary Bruss, Ph.D.
Peler Buckley, M.D.
Deborah S. Cowley, M.D.
Brian Cox, Ph.D.
James David, M.D.
Collette De Mameffe, Ph.D.
Judith Dogin, M.D.
Seda Ebrahimi, Ph.D.
Jane Eisen, M.D.
Maurizio Fava, M.D.
Paul Federoff, M.D.
Mark K. Fulton, M.D.
Diego Garcia-Borreguero, M.D.
Roya Ghadimi, M.D.
David S. Goldbloom, M.D.
Reed D. Goldstein, Ph.D. (also Site
Coordinator)
l\'1icael Golinkoff, Ph.D.
Peter Goyer, M.D.
.Alan M. Gruenberg, M.D.
Michael E. Henry, M.D.
Selby C. Jacobs, M.D.
J. Joel Jeffries, M.B. (also Site
Coordinator)
Sheri Johnson, Ph.D.
Kathleen Kim, M.D., M.P.H.
Carolyn r.,.1. Mazure, Ph.D. (also Site
Coordinator)
Joseph P. McE\'oy, M.D.
Arnold Merrimam, M.D.
Timothy J. Mueller, M.D.
Andrew I ierenberg, M.D.
Michael Otto, Ph.D.
Michelle Pato, M.D.
Joel Pa"a, Ph.D.
Katharine Anne Phillips, M.D. (also Site
Coordinator)
Mark Pollack M.D.
Horatio Preval, M.D.
David W. Preven, M.D. (also Site
Coordinator)
Richard Ries, M.D.
Roberl C. Risinger, M.D.
Robert Ronis, M.D.
Jerrold F. Rosenbaum, M.D. (also Site
Coordinator)
OSM-IV Contributors
Peter Roy-Byrne, M.D. (also Site Michael J. Semyak, M.D.
Coordinator) Richard Swinson, ~'I.D.
~llark
Schmidt, M.D. (also Site Madhukar H. Trivedi, M.D.
Coordinator) Andrea Weiss, M.D.
S. Charles Schulz, M.D. Kerrin \,\'hite, M.D.
Bnlce Schwartz, M.D. Lawrence Wilson, M.D.
tvlichael Schwartz, M.D. (also Site John Worthington, M.D.
Coordinator) Joan Youchah, M.D.
Other Health Organizations
At the inception of the project, the Task Force on DSM-TV invited over 60 health
associations
to designate liaisons to the Task Force to ensure the openness of the revision
process and to ensure that a variety of views would be represented. The
associations listed below designated representatives who reeeh'ed regular commun
ications
from the Work Groups and the Task Force.
American Academy of Child and
Adolescent Psychiatry
American Academy of Family
Physicians
American Academy of Pediatrics
American Academ}' of Psychiatrists in
Alcoholism and Addictions
American Academy of Psychiatry and
the law
American Association for Geriatric
Psychiatry
American Association for Marriage and
Family Therapy
American Association of Chairmen of
Departments of Psychiatry
American Association of Directors of
Psychiatric Residency Training
American Association of Psychiatric
Administrators
American Board of Family Practice
American College of Obstetricians and
Gynecologists
American CoUege of Physicians
American Group Psychotherapy
Association
American Health Information
Management Association
American Medical Society on Alcohol
and Other Drug Dependencies
American Nurses' Association
American Occupational Therapy
Association
American Psychoanalytic Association
American Psychological Association
American Psychological Society
American Psychosomatic Society, Inc.
American Society for Adolescent
Psychiatry
Association of Departments of Family
Medicine
Association of Gay and Lesbian
Psychiatrists
Association of Mental Health Clergy
Coalition for the Family
Group for the Advancement of
Psychiatry
National Alliance for the MentaUy III
I ational Association of Social Workers
ational Association of Veterans Affairs
Chiefs of Psychiatry
National Center for Health Statistics
National Council of Community Mental
Health Centers
National Depressive and r-.Ianic
Depressh'e Association
National Medical Association
National Mental Health Association
Society of General Internal Medicine
Society of Teachers of Family r"ledicine
World Health Organization
Appendix K
DSM-IV Text Revision Advisers
Advisers to Anxiety Disorders Text Revision Work Group
Lisa Amaya-jackson, MD.
Martin M. Antony, Ph.D.
David Barlow, Ph.D.
J. Gayle Beck, Ph.D.
Deborah C. Beidel, Ph.D.
Thomas Borkovec, Ph.D.
Brian Cox, Ph.D.
Jonathan R. T. Davidson, M.D.
Matthew]. Friedman, M.D., Ph.D.
Wayne Katon, M.D.
Michael R. Liebowitz, M.D.
R. Bruce Lydiard, Ph.D., M.D.
Richard]. McNally, Ph.D.
Peter P. RoyByrne, M.D.
Paula P. Schnurr, Ph.D.
Manuel Tancer, M.D.
Steven Taylor, PhD.
Advisers to Delirium, Dementia, Amnestic and
Other Cognitive Disorders, and Mental Disorders Due to a
General Medical Condition Text Revision Work Group
''''illiam Breitbart, rvl.D.
Martin Cole, M.D.
Sanford Finkel, M.D.
Marshall Folstein, M.D.
Igor Grant, M.D.
James Levenson, M.D.
Susan Levkoff, SeD.
Benjamin Liptzin, M.D.
Jacobo E. Mintzer, M.D.
Michael K. Popkin, M.D.
Peter V. Rabins, M.D.
Gary W. Small, l\.f.D.
Friedrich Stiefel, M.D.
Gary J. Tucker, M.D.
Advisers to Disorders Usually First Diagnosed
During Infancy, Childhood, or
Adolescence Text Revision Work Group
Howard Abikoff, Ph.D.
Deborah C. Beidel, Ph.D.
Diane Benoit, M.D.
Boris Birmaher, M.D.
Caryn L. Carlson, Ph.D.
Gabrielle A Carlson, M.D.
Paul Frick, Ph.D.
Christopher Gillberg, M.D., Ph.D.
Laraine Masters Glidden, Ph.D.
Philip C. Kendall, Ph.D., AB.P.P.
Benjamin Lahey, Ph.D.
Alan Lincoln, M.D.
Vera LoeningBauck, M.D.
Catherine Lord, Ph.D.
Don Lynam, Ph.D.
Keith McBurnett, Ph.D.
929
Gary Mesibov, Ph.D.
Nancy Minshew, M.D.
Sally Ozonoff, Ph.D.
Rhea Paul, Ph.D.
John Piacentini, Ph.D.
John Pomeroy. M.D.
Byron Rourke, F.R.S.c.
Sir Michael Rutter, M.D.
Appendix K
John E. Schowalter, M.D.
Larry Silver, M.D.
Ludwik Szymanski, M.D.
Digby Tantam, F.R.C.Psych.
Lorna ''''ing, M.D.
SuJa Wolff, F.R.C.P.
Joseph Woolston, M.D.
Advisers to Eating Disorders
Text Revision Work Group
'\'. Stewart Agras. M.D.
Barton J. Blinder, M.D., Ph.D.
Cynthia M. Bulik, Ph.D.
Scott Crow, M.D.
Michael Devlin, MD.
Christopher Fairburn, M.D.
Paul Garfinkel. M.D.
Katherine Halmi, M.D.
Da\,jd Herzog.. M.D.
Hans W. Hoek, M.D., Ph.D.
James 1. Hudson, M.D.
David C. Jimerson, 1\'l.0.
Kenneth Kendler. M.D.
Sing lee, F.R.c.rsych.
Marsha D. Marcus, Ph.D.
Marion P. Olmsted, Ph.D.
Albert Shmkard, M.D.
David Tobin, Ph.D.
Janel Treasure, M.D.
''''aller Vandereycken, M.D., Ph.D.
Joel Yager. M.D.
Advisers to Mood Disorders
Text Revision Work Group
Hagop Akiskal, M.D.
Lori L Altshuler, r.,I.D.
Ross J. Baldessarini, M.D.
Joseph Calabrese, M.D.
David L. Dunner, M.D.
Joseph Goldberg, M.D.
Paul E. Keck, M.D.
Daniel N. Klein, Ph.D.
James H. Kocsis, M.D.
Ellen Leibenluft, M.D.
Lawrence H. Price, M.D.
Gregory Simon, M.D.
Andrew Stoll, M.D.
Kimberly Yonkers, ~'l.D.
Advisers to Personality Disorders
Text Revision Work Group
Hagop Akiskal, M.D.
Arthur Alterman, Ph.D.
Lee Baer, Ph.D.
Roger Blashfield, Ph.D.
Robert Bornstein, Ph.D.
Paul Costa, Ph.D.
,--------
AUen Frances, M.D.
John Gunderson, M.D.
Robert Hare, Ph.D.
Daniel N. Klein, Ph.D.
Majorie Klein, Ph.D.
Theodore Millon, Ph.D., D.Se.
-
DSM-IV Text Revision Advisers 931 I
Gerald Nestadt, ~II.D.
Elsa Ronningstarn, Ph.D.
John Oldham, M.D. Megan Rutherford, Ph.D.
joel Paris, M.D. Larry J. Siever, M.D.
Katharine A. Phillips, M.D. Robert L. Spitzer, M.D.
Paul Pilkonis, Ph.D. Timothy Trull, Ph.D.
James Reich, M.D., M.P.H. Peter Tyrer, M.D.
Lee Robins, Ph.D.
Advisers to Premenstrual Dysphoric
Disorder Text Revision Work Group
Jean Endicott, Ph.D. Barbara Parry, M.D.
Ellen Freeman, Ph.D. David Rubinow, M.D.
Judith Gold, M.D. Nada L Stotland, t"I.D., M.P.H.
Uriel Halbreich, M.D. Kimberly Yonkers. M.D.
Advisers to Psychiatric Systems Interface
Disorders (Adjustment, Dissociative, Factitious,
Impulse-Control, and Somatoform Disorders and
Psychological Factors Affecting Medical Condition)
Text Revision Work Group
Donald W. Black, M.D. Henry Lesieur, Ph.D.
Michael Bond, KB., M.B. Roy Meadow, M.D., F.R.CP.
Elizabeth S. Bowman, M.D. Harold Merskey, D.M., F.R.CP.(C)
James D. Bremner, M.D. Juan Mezzich, M.D., Ph.D.
Thomas Markham Brown, M.D. Fugen leziroglu, Ph.D.
Etzel Cardelia, Ph.D. Philip Ninan, M.D.
Gary Christenson, M.D. Russell Porlenoy, M.D.
C Robert Cloninger, M.D. Hasant K. Puri, M.A., M.B., B.Chir.,
Philip M. Coons, M.D. M.R.CPsych.
J. A. Cotterill, M.D. Frank Putnam, M.D.
Alan J. Cunnien, M.D. Richard Rogers, Ph.D.
Stuart Eisendrath, M.D. James Rosen, Ph.D.
David A. Fishbain, M.D. Richard J. Rosenthal, M.D.
David Folks, M.D. Colin A. Ross, M.D.
Victor Fornari, r.,I.D. Loreen Rugle, Ph.D.
Gregory Fritz, M.D. Elina Sarasola, M.D.
Mahlon S. Hale, M.D. Daniel J. Stein, M.B.
Michael JeUinek, M.D. Marlene Steinberg, M.D.
Roger Kathol, M.D. Maurice Steinberg, M.D.
Nathaniel Katz, M.D. Alan Stoudemire, M.D.
Richard Kluft, M.D. Margaret Stuber, M.D.
Robert Ladouceur, Ph.D. Susan Sweda, to.
Michel Lejoyeux, r.,l.D., Ph.D. Eldon Tunks, M.D.
J
1932 Appendix I<
David Veale, M.D. Thomas N. Wise, M.D.
Matti Virkkunen, M.D., Ph.D.
Advisers to Schizophrenia and
Other Psychotic Disorders Text Revision Work Group
Nancy Andreasen, M.D., Ph.D.
David Braff, M.D.
Michaeline Bresnahan, Ph.D.
Jill M. Goldstein, Ph.D.
~'Iichael
Green, Ph.D.
John Hsiao, M.D.
Richard Keefe, Ph.D.
Dolores Malaspina, M.D., M.5.P.H.
Thomas McGlashan, M.D.
Henry asraJlah, to.
Judith Rapoport, ~I.D.
r.,+farc-Andre Roy, M.D., M.Sc.
Ezra Susser, M.D.
Advisers to Sexual Disorders
Text Revision Work Group
Ray Blanchard, Ph.D.
Susan J. Bradley, M.D.
Peter Fagan, Ph.D.
Richard Green, MD., J.D.
Stephen Levine, M.D.
Heino F. L Meyer-Bahlburg, Dr.rer.nat.
Raul Schiavi, M.D.
Leslie Schover, Ph.D.
Advisers to Sleep Disorders
Text Revision Work Group
Ronald D. Chel'\'in, M.D., M.s.
Jack Edinger, Ph.D.
David J. Kupfer, M.D.
Clete Kushida, M.D., Ph.D.
Kenneth Lichstein, Ph.D.
Emmanuel ~lignot,
M.D., Ph.D.
Timothy H. Monk, Ph.D., D.Se.
Charles Morin, Ph.D.
Quentin Regestein, M.D.
~'Iartin
Reite, M.D.
Charles Reynolds, M.D.
Leon Rosenthal, M.D.
Michael Sateia, M.D.
Edward Stepanski, Ph.D.
Michael Thorpy, M.D.
Alexandros Vgontzas, M.D.
James Walsh, Ph.D.
John Winkelman, M.D., Ph.D.
Phyllis Zee, M.D., Ph.D.
Advisers to Substance-Related Disorders
Text Revision Work Group
Enoch Gordis, M.D.
David Gorelick, M.D., Ph.D.
Bridget F. Grant, Ph.D.
Deborah Hasin, Ph.D.
Alan l. Leshner, Ph.D.
A. Thomas McLellan, Ph.D.
Peler lathan, Ph.D.
Bruce RounsaviUe, ~'I.D.
George Woody, M.D.
Index
Pagt llrlfllb~'T5
for diagnostic crit.'ria or resenrcll criteria an! el/closed ill parmtlu..ses.
A
Abuse of substances, 198 (199)
Set a/so sIIl'ciftc subs/auct's by /lmllt'
Abuse or neglect problems. 738
Neglect of child, 738
Physical abuse of adult, 738
Phrsical abuse of child, 738
Sexual abuse of adult, 738
Sexual abuse of child, 738
Academic problem. iU
Set' also learning disorders
Academic skills disorders. Sec Learning
disorders
Acculturation problem, 741
Acute stress disorder, -469 (-471)
Additional codes, 7.0
Diagnosis deferred on Axis ti, {n
Diagnosis oecondition deferred on Axis I,
743
No diagnosis on Axis II, 743
No diagnosis or condition on Axis I, 743
Unspecified mental disorder
(nonpsychotic),743
Adjustment disorders, 679
With anxiety. 6SO (6S3)
With depressed mood. 679 (683)
With disturbance of conduct, 680 (683)
With mixed anxiety and depressed mood,
680 (683)
With mixed disturbance of emotions and
conduct, 680 (68,3)
u"'j><cified, 680 (683)
Adolescent antisocial behavior, 7-W
Adult antisocial behavior, 7-W
Adverse effects of medication not otherwise
specified, 736
Age-related cognitive decline, 740
Agoraphobia, 432 (433)
Panic disorder with, -l33 (4-U)
Without history of panic disorder,-1-41
(...n)
Akathisia, acute
Neuroleptic-induced, 735, 800 (802)
Alcohol-induced disorders
Intoxication, 2H. (215)
Other disorders, 217
Withdrawal, 215 (216)
Alcohol-related disorders, 212
Not otherwise specified, 223
Alcohol use disorders
Abuse, 214
Dependence, 213
Alzheimer's type dementia, 15-l (157)
Amnesia. See Amnestic disorders;
Dissociative amnesia
Amnestic disorders
Due to a general medical condition, 175
(177)
Not other"'jsc specified, 179
Substance-induced persisting amnestic
disorder, 177(179)
Amphetamine-induced disorders
Intoxication, 226 (227)
Other disorders, 228
Withdrawal, 127 (228)
Amphetamine (or amphetamine-like}related
disorders, 223
Not othendse specified, 231
Amphetamine use disorders
Abuse, 225
Dependence, 224
Anorexia nen'osa, 583 (SS9)
Antisocial behavior
Adult, 740
Child or adolescent, 740
Antisocial personality disorder, 701 (706)
Anxiety disorders,-l29
Acute stTess disorder, 469 (-171)
Agoraphobia, 432 (433)
Panic disorder with, -133 (<HI)
Without history of panic disorder.-l-U
(...-13)
933
1934
.>\nxiety disorders (cotltil/lled)
Due to a general medical condition, -176
(m)
Generalized anxiety disorder (includes
o\'eranxious disorder of childhood),
472 (476)
tOI otherwise specified, 48-1
Obsessi\'c-compulsi\'e disorder,-I56
(-162)
Panic attack, ..no (-132)
Panic disorder, ill(-l-W--l4I)
With agoraphobia, -133 (4-11)
Without agoraphobia, -133 (-l-IO)
Posttraumatic stress disorder, 463
(-167)
Separation anxiety disorder, 121 (125)
Social phobia (social anxiety disorder),
450 (456)
Specific phobia 4,0 (4-19)
Substance-induced anxiety disorder,-I79
(483)
Anxiolylic-related disorders. See Sedath'e-,
hypnotic-, or anxiolytic-related
disorders
Arousal disorders. See Sexual arousal
disorders
Asperger's disorder, 80 (84)
Attention-dcficit and disruptive behavior
disorders. 85
Attention-deficil/hyperacth-it)' disorder,
85 (92)
Combined type, 87 (93)
Predominantly hyperacth"e-impulsh-e
type, 87 (93)
Predominantly inattenti\'e type, 87
(93)
Attention-deficit/hyperacti\'ity disorder
not othenvise specified, 93
Conduct disorder, 93 (98)
Disrupti\'e beha\"ior disorder not
othen\"ise specified, 103
Oppositional defiant disorder, 100 (102)
Attention-deficit/hyperacti\,itr disorder, 85
(92)
Not othem'ise specified, 93
Atypical autism, 8-1
Atypical featufl$ specifier for mood episode,
420 (422)
Autistic disorder, 70 (75)
I\\-oidanl personality disorder, 718
(721)
Index
8
Bereavement. 7-W
Binge-eating disorder, 785 (787)
Bipolar disorders
Bipolar I disorder
Most recent episode depressed, 382
(391)
Most recent episode hypomanic, 382
(388)
Most recent episode manic, 382 (389)
MOSI recent episode mixed, 382 (390)
Most recent episode unspecified, 382
(392)
Single manic episode, 382 (388)
Bipolar II disorder (recurrent major
depressh"e episodes with hypomanic
episodes), 392 (397)
Cyclothymic disorder, 398 (400)
Not othem"ise specified. .wo
Body drsmorphic disorder, 507 (510)
Borderline intellectual functioning. 740
Borderline per.>onalily disorder, 706 (710)
Breathing-related sleep disorder, 615 (622)
Brief psychotic disorder, 329 (332)
Bulimia nervoS<!, 589 (594)
c
Caffeine-induced disorders
Intoxication, 232 (232)
Other disorders, 233
Caffeine-relaled disorders, 231
Not othem"ise specified, ill
Caffeine withdrawal, 76-1 (765)
C.1IUlabis-induced disorders
Intoxication, 237 (238)
Other disorders, 238
Cannabis-related disorders, ill
Not othem'Lse specified, 2.,11
Cannabis use disorders
Abuse,236
Dependence, 236
Catatonic disorder
Due to a general medical condition, 185
(187)
Catatonic features specifier for mood
episode, 417 (418)
Catatonic type of schizophrenia, 315 (316)
Child antisocial behavior, 7.,10
Childhood disintegrati\"C disorder, 77 (79)
Child or adolescent antisocial beha\'ior, 7-ID
Index 935
Chronic motor or \"ocal tic disorder, 114
(115)
Chronic specifier for major depressh"e
episode, 417 (-117)
Circadian rhythm sleep disorder, 622
(629)
Cocaine-induced disorders
Intoxication,2..J..J (2..J5)
Other disorders, 2-16
Withdrawal, 2-15 (2-16)
Cocaine-related disorders, 2-B
Not othemise specified, 250
Cocaine use disorders
Abuse, 243
Dependence, 242
Cognitive disorders
See a/so Amnestic disorders; Delirium;
Dementia
Agl"-rclated cognith"e decline, 740
Not otherwise specified, 179
Conunurtication disorders, 58
Exprcssh:e language disorder, 58
(61)
Mixed receptive-expressh"e language
disorder, 62 (6-1)
Not otherwise specified. 69
Phonological disorder, 65 (66)
Stuttering, 67 (69)
Conduct disorder, 93 (98)
Com"ersion disorder, 492 (498)
Cceut2feldt-Jakob disease
Dementia due to, 166 (168)
Culture-bound syndromes, 897-903
Cyclothymic disorder, 398 (400)
o
Defensive Functioning Scille, 807-813
Delirium, 136
Due 10 a general medical condition, 141
(1-13)
Due 10 multiple etiologies, 1-16 (147)
Not othem'ise specified, 147
Substance-induced, 143 (145-1-16)
Delirium, dementia, and amnestic and other
cognitiw disorders, 135
Amnestic disorders, 172
Cognitive disorder not otherwise
specified, 179
Delirium, 136
Dementia, 1-17
Delusional disorder, 323 (329)
Dementia, l..J7
of the Alzheimer's type, 15..J (157)
Due to multiple etiologies, 170 (171)
Due to other general medical conditions,
162,167 (168)
CreutzfeldtJakob disease, 166 (168)
Head tr.1Oma, 164 (168)
HJV disease, 163 (168)
Huntington's disease, 165 (168)
Parkinson's disease, 16..J (168)
Pick's disease, 165 (168)
lot otherwise specified, 171
Substance-induced persistingdementia, 168
(170)
Vascular, 158 (161)
Dependence on subst.mces, 192 (197)
SrI.' also SptCifiC subs/anus by 110mI.'
Dependent personality disorder, nl (725)
Depersonalization disorder, 530 (532)
Depres..si\"(! disorders
Dysthymic disorder, 376 (380)
Major depressh-e disorder, 369
Recurrent,369 (376)
Single episode, 369 (375)
Nol othem'ise specified, 381
Depressive episode, major, 3-19 (356)
Depressive personality disorder, 788 (789)
Developmental articulation disorder.
Sei' Phonological disorder
Developmental coordination disorder, 56 (58)
De\'elopmental disorders" yt Learning
disorders;l\lenlal retardation; Pervasive
d('\'elopmental disorders
Diagnosis deferred on Axis 0, 7-13
Diagnosis or condition deferred on Axis I,
m
Disorder of infancy, childhood, or
adolescence nol otherwise specified, 1>1
Disorder of written expression, 5..J (56)
Disorders usually first diagnosed in infancy,
childhood, or adolescence, 39
Attention-deficit and disruptin~behavior
disorders, 85
Communication disorders, Disorder
of infancy, childhood, or
i1dolescence not otherwise specified,
134
Elimination disorders, 116
Feeding and eatingdisordersofinfancy or
cilrly childhood, 103
Learning disorders, 49
936 Index
Disorders usually first diagnosed in infanc)'.
childhood, or adolescence (COlltiflllf'd)
Mental retardation, 41
Molor skills disorder, 56
Pervasi\"e dc\"elopmental disorders. 69
Reaeti\"e attachment disorder of infancy
or early childhood, 127 (130)
5electil"c mutism, 125 (l27)
Separation anxiety disorder, 121 (125)
Stereotypic mo\"emenl disorder,I31 (134)
Tic disorders, 108
Disorganized tJ'pe of schizophrenia, 314 (315)
Disruptive beha\;or disorders. See
Attention-defidt and disruptive
behavior disorders
Dissociative amnesia, 520 (523)
Dissociative disorders, 519
Depersonalization disorder, 530 (532)
Dissociative amnesia, 520 (523)
Dissociative fugue, 523 (526)
Dissociative identity disorder, 526 (529)
Not otherwise specified, 532
Dissociative fugue, 523 (526)
Dissociative identity disorder, 526 (529)
Dissocialh"e !noce disorder, 783 (785)
Dream anxiety disorder. See Nightmare
disorder
Dyspareunia
Due to a general medical condition, 558
(561)
Not due to a general medical condition,
5iH (556)
Dyssomnias,598
Breathing-relaled sleep disorder, 615
(622)
Circadian rhythm sll"Cp disorder, 622
(629)
Narcolepsy, 609 (615)
Not otherwise specified, 629
Primary h)-persomnia, 6O-l (609)
Primary insomnia, 599 (604)
Dysthymic disorder, 376 (380)
Alternative research crilerion B, 774 (775)
Dystonia, acute
Neuroleptic-induced, 735, 798 (800)
E
Eating disorders, 583
See al5() Feeding and eating disorders of
inf.1ncy or early childhood
Anorexia nen'osa, 583 (589)
Bulimia nerv05a, 589 (594)
Not othem'ise specified, 594
Elective mutism. See Selective mutism
Elimination disorders. See Encopresis;
Enuresis
Encopresis
With constipation and o\'erflow
incontinence, 116 (l18)
Without constipation and overflow
incontinence, 116 (lIB)
Enuresis (not due to a general medical
condition), 118 (121)
Erectile disorder, male. 545 (547)
Due to a general medical condition. 558
(561)
Exhibitionism, 569 (569)
Expressive language disorder, 58 (61)
F
Factitious disorder by proxy. 781 (783)
Factitious disorders, 513
Not othem'ise specified, 517
Wilh combined psychological ilnd
physical signs and symptoms, 515
(517)
With predominantly physical signs and
symploms, 514 (517)
With predominantly psychological signs
and symptoms, 51-1 (517)
Feeding and eating disorders of infancy or
early childhood, 103
Feeding disorder of infanc)' or early
childhood, 107 (l08)
Pica, 103 (lOS)
Rumination disorder, 105 (106)
Feeding disorder of inf,1nC}' or early
childhood. 107 (108)
Female orgasmic disorder, 5-1-7 (549)
Female sexual arousal disorder, 5-1-3,
(5+l)
Fetishism, 569 (570)
Transwstic. 57-1 (575)
Flashbacks. See HallUCinogen persisting
perception disorder (flashbacks)
Folie adeux. Sei Shared psychotic disorder
Frotteurism, 570 (570)
Fugue. See Dissociath'e fugue
G
GAF Scale. See Global Assessment of
Functioning Scale
Index
Gambling. See Pathological gambling
GARF Scale_ SuGlobal Assessment of
Relational Functioning Scale
Gender identity disorder, 576 (581)
in adolescenlS or adults (581)
in children (581)
Not otherwise specified, 582
General medical condition
Amnestic disorder due 10, 175 (I")
Anxiely disorder due 10, 476 (479)
Catatonic disorder due to, 185 (187)
Delirium due to, 141 (143)
Dementia due to, 15+--168
Mental disorder due to, 181
Mental disorder not otherwise specified
due to, 190
Mood disorder due to, 401 (40-1)
Pain disorder associated with, 498 (503)
Personality change due to, 187 (190)
Psychotic disorder due to, 334 (338)
Relational problem related to,737
Sexual dysfwlCtion due to, 558 (561)
Sleep disorder due to, 651 (65-1)
Generalized anxiety disorder (includes
overanxious disorder of childhood), 472
(476)
Global Assessment of Functioning (GAF)
Scale, 34
Global AsscssmentofRelational Functioning
(GARF) Scale, 814-816
H
Hallucinogen-induced disorders
Hallucinogen persisting perception
disorder (flashbacks), 253 (23,1)
Intoxic.ltion, 252 (253)
Other disorders, 254
Hallucinogen-related disorders, 250
Not otherwise specified, 256
Hallucinogen use disorders
Abuse,lS2
Dependence, 251
Head trauma
Dementia due to, 164 (168)
Histrionic personality disorder, 711 (714)
HIV disease
Dementia due to, 163 (168)
Huntington's disease
Dementia due 10, 165 (168)
Hyperactivity. See Attention-deficitl
hyperactivity disorder
937
Hypersomnia
Primary. 604 (609)
Related to another mental disorder, 64-5
(650)
Substance-induced, 655 (660)
Hypnotic-related disorders. See Sedative-,
hypnotic-, or anxiolytic-related disorders
Hypoacti\-e sexual desire disorder, 539 (541)
Due to a general medical condition. 558
(;(;1)
Hypochondriasis, 5().1 (507)
Hypomanic episode, 365 (368)
I
Identity disorders. See Dissociative disorder;
Gender identity disorder
Identity problem, 741
Impulse-control disorders not elsewhere
classified, 663
Intermittent explosi\-e disorder, 663
(667)
Kleptomania, 667 (669)
Not otherwise specified, 677
Pathological gambling, 671 (674)
Pyromania, 669 (671)
Trichotillomania, 674 (677)
Inhal.lnt-induced disorders
Intoxication, 259 (260)
Other disorders, 260
Inhalant-related disorders, 257
Not otherwise specified, 263
lnhaJant use disorders
Abuse, 259
Dependence, 238
Inhibited female orgasm. See Female
org.lsmic disorder
Inhibited male orgasm_ Se.. r.,'I.lle orgasmic
disorder
Insomnia
Primary. 599 (604)
Related to another mental disorder, fH5
(650)
Substance-induced, 655 (660)
InleUectual functioning_ Set' Borderline
intellectual functioning
Intermittent explosive disorder, 663 (667)
Intoxication, 199 (201)
See also specific subS/fillets by /lam..
K
Kleptomania. 667 (669)
j
Learning disorders
Disorder of written expression, 5-1,
(56)
Mathematics disorder, 53 (54)
Not otherwise specified, 56
Reading disorder, 51 (53)
Longitudinal course specifiers (with and
without full inlerepisode recovery) for
mood disorders. .,12-1 (-125)
M
tvlajor depressive disorder
Recurrent, 369 (376)
Single episode, 369 (375)
Major depressh'c episode. J.l9 (356)
Chronic specifier, 417 (417)
Severity/ ps}'chotic/ remission specifiers,
411 (413)
}.Iale erectile disorder, 545 (>17)
Due to a general medical condition, 538
(561)
t\'lale orgasmic disorder, 550 (552)
Malingering, 739
~'Ianic
episode, 357 (362)
Severity/psychotic/remission specifiers
U3 (4lS)
l\'1athematics disorder, 53 (54)
Medication-induced disorder
Adverse effects of medication not
otherwise specified, 736
~'Iedicationinduced
mo\"ementdisorders.
73-l,791
Neuroleptic-induced acute akathisia, 735,
800(802)
Neuroleptic-induced acute dystonia, 735,
798 (BOO)
Neuroleptic-induced parkinsonism, 735,
792 (795)
Neuroleptic-induced tardive dyskinesia,
736, 803 (805)
Neuroleptic malignant syndrome, 735,
795 (798)
Not otherwise specified, 736, 807
Postural tremor, 736, 805 (807)
Melancholic features specifier for mood
episode, 419 (420)
Mental disorder not othen\'ise specified
due to a general medical condition.
190
Index
Mental retardation, 41 (49)
Mild, 43 (49)
Moderate, 43 (49)
Profound, +4 (49)
Se\'ere,43 (49)
Sc\<erit)' unspecified, +l (49)
r-,'Iental retardation, severity unspecified, 44
(49)
r-.'lild mental retardation, 43 (49)
Mild neurocognitive disorder. 762 (764)
Minor depressive disorder, 775 (777)
Mixed anxiety-depressive disorder, 780
(781)
Mi,<ed episode, 362 (365)
Severit)'/ psychotic/remission specifiers,
415 (416)
Mixed recepti\'e-expresske language
disorder, 62 (64)
Moderate mental retardation, 43 (49)
Mood disorders, 345
See also r.lood episodes
Bipolar disorders, 382
Depressive disorders. 369
Due to a general medic.ll condition, 401
(404)
Not othem'ise specified, 410
Substance-induced mood disorder. 405
(409)
j\lood disorders, specifiers for, 410
Atypical features specifier, 420 (422)
Catatonic features specifier, 417 (418)
Chronic specifier, 417 (417)
Longitudinal course specifiers (with and
without full interepisode reco\'el'}'),
-l24 (425)
Melancholic features specifier, 419
(420)
Postpartum onset specifier. 422 (423)
Rapid-g.'c1ing specifier. -l27 (-l28)
Seasonal pattern Specifier, -125 (U7)
Se\'erity/ psychotic/remission specifiers
Major depressive episode, 411 (413)
Manic episode, 413 (415)
t\'lixed episode. 415 (4.16)
Mood episodes
Hypomanic episode. 365 (368)
Major depressive episode, 3-l9 (356)
Manic episode, 357 (362)
Mixed episode, 362 (365)
Motor or \'ocal tic disorder, chronic. Ste
Chronic motor or \"ocal tic disorder
Index
Motor skills disorder, 56
De\'elopmental coordination disorder, 56
C)
Multi-infarct dementia. See Vascular dementia
Multiple etiologies
Delirium due to, 1,16 (1,17)
Dementia due to, 170 (171)
Multiple personality disorder. Sri.'
Dissociatiw identity disorder
N
Narcissistic personality disorder, 714 (717)
Narcolepsy. 609 (615)
Neglect of child, 738
Neuroleptic-induced disorders
Acute akalhisia. 735, BOO (802)
Acute dystonia, 735, 798 (BOO)
Neuroleptic malignant s}'Jldrome, 735,
795 (798)
Parkinsonism, 735, 792 (795)
Tardive dyskinesia, 736, 803 (805)
Neuroleptic malignant syndrome, 735, 795
(798)
Nicotine-induced disorder
Withdrawal, 265 (266)
Nicotine-related disorders, 26-1
lot otherwise specified, 269
Nicotine use disorder
Dependence, 2&1
Nightmare disorder, 631 (63-4)
fO diagnosis on Axis 11, 7,13
No diagnOSiS or condition on Axis I, 7,13
Noncompliance with treahnent, 739
Not othenvise specified
Adverse effects of medication, 736
Alcohol-related disorder, 223
Amnestic disorder, 179
Amphetamine-related disorder, 231
An.xiety disorder,-I8-I
Attention-defidt/hyperacthity disorder, 93
Bipolar disorder,-IOO
Caffeine-related disorder, 23-1
Cannabis-related disorder, 2-11
Cocaine-related disorder, 2.50
COb'l1.itin~
disorder, 179
Communication disorder, 69
Delirium, 1-17
Dementia, 171
Depressh'e disorder, 381
Disorder of infancy, childhood, or
ildolescence,l3-1
Disrupth'e behavior disorder. 103
Dis.sodati\'e disorder. 532
Dyssomnia,629
Eating disorder, 59-1
Factitious disorder. 517
Gender identity disorder, 582
Hallucinogen-related disorder, 256
Impulse-<:ontrol disorder, 677
Inhalant-related disorder, 263
Learning disorder, 56
t-,Iedication-induced movement disorder,
736,807
t-,'Iental disorder due to a general medical
condition, 190
Mood disorder.-IIO
Nicotine-related disorder, 269
Opioid-related disorder, m
Other (or unkno\\'Jl) substance-related
disorder, 295
Paraphilia, 576
P.1Tasomnia,64-I
Personality disorder, 729
Pervasive developmental disorder
(including ilt}'Pical autism), ~
Phencyclidine (or phencyclidine-like)
related disorders, 283
Psychotic disorder, 3-13
Relational problem. 737
Sedati\e-. h)'Pnotic.or anxiolyticreiated
disorder. 293
Sexual disorder, 582
Sexual dysfWlction, 565
Somatoform disorder, 511
Tic disorder, 116
o
Obsessive-compulsive disorder, 456 (462)
Obsessivc-compulsive personality disorder,
723 (729)
Occupational problem, 7-11
Opioid-induced disorders
Intoxication, 271 (272)
Other disorders, 27-1
Withdrawal, 272 (273)
Opioid-relatM disorders, 269
Not othem'ise specified, 2//
Opioid use disorders
Abuse. 271
Dependence, 270
Oppositional defiant disorder, 100
(102)
Orgasmic disorders
Female orgasmic disorder, 547 (5-19)
/I.'lale orgasmic disorder, 550 (552)
Premature ejaculation, 552 (55-1)
O ..eranxious disorder of childhood, See
Generalized anxiety disorder
p
Pain disorder
See IIlso Sexual pain disorders
Associated with a general medical
condition, 498 (503)
Associated with both psychological
factors and a general medical
condition, 498
Associated with psychological factors,
.98
Panic attack, 430 (432)
Panic disorder, 433 (440--441)
With agoraphobia, 433 (+I()-441)
Without agoraphobia, 433 (440-441)
Paranoid personality disorder, 690 (694)
Paranoid type of schizophrenia, 313 (314)
Paraphilias,566
Exhibitionism, 569 (569)
Fetishism, 569 (570)
Frolleurism, 570 (570)
Not othem'ise specified, 576
Pedophilia, 571 (572)
Sexual masochism, 572 (573)
Sexual sadism, 573 (574)
Trans\'estic fetishism, 574 (575)
Voyeurism, 575 (575)
Parasomnias,63O
Nightmare disorder, 631 (634)
Not otherwise specified, 6H
Sleep terror disorder, 634 (639)
Sleepwalking disorder, 639 (64-1)
Parent<hild relational problem, 737
Parkinsonism
euroleptic-induced, 735, 792 (795)
Parkinson's disease
Dementia due to, 11).1 (168)
Partner relational problem, 737
Passh"e-aggressive personality disorder
(negativistic personality disorder), 789
(791)
P,lthological gambling, 671 (674)
Pedophilia, 571 (572)
Personality change due to a general medical
condition, 187 (190)
Index
Personality disorders, 685 (689)
Antisocial personality disorder, 701 (706)
Avoidant personality disorder, 718 (721)
Borderline personality disorder, 706 (710)
Dependent personality disorder, 721 (ns)
Histrionic personality disorder, 711 (714)
Narcissistic personality disorder, 714
(717)
Tot otherwise specified, 729
Obsessive-<ompulsive personality
disorder, 725 (729)
Paranoid personality disorder, 690 (694)
Schizoid personality disorder, 694 (697)
Schizotypal personality disorder, 697
(701)
Pervasive de\elopmental disorder nol
othem'ise specified, 84Pervasive
developmental disorders, 69
Asperger's disorder, 80 (84)
Autistic disorder, 70 (75)
Childhood disintegrative disorder, 77 (79)
Not othem'ise specified (including
atypical autism), 84
Rett's disorder, 76 (77)
Phase of life problem, 742
Phencyclidine-induced disorders
intoxication, 280 (281)
Other disorders, 281
Phencyclidine (or phencydidine-Iike)related
disorders, 278
Not othen\'ise specified, 283
Phencyclidine use disorders
Abuse, 279
Dependence, 279
Phonological disorder, 65 (66)
Ph}'sical abuse
of adult, 738
ofchild,738
Pica, 103 (105)
Pick's disease
Dementia due to, 165 (168)
Polysubstance-related disorder
Polysubstance dependence, 293
Postconcussional disorder, 760 (761)
Postpartum onset specifier for mood
episode, 422 (423)
Postpsychotic depressive disorder of
schizophrenia, 767 (768)
Posttraumatic stress disorder, 463 (467)
Postural tremor, medication-induced, 736,
805 (807)
Index
Premature ejaculation, 552 (55-1)
Premenstrual dysphoric disorder, nl (774)
Primary hypersomnia, 604 (609)
Primary insomnia, 599 (604)
Primary sleep disorders
Oyssomnias,598
Parasomnias,630
Profound menIal retardation, +1 (~9)
Psychogenic amnesia. See Dissociati\"C
amnesia
Psychogenic fugue. St't' Dissodati\'e fugue
Psychological factor affecting medical
condition. 731 (73-1)
Psychotic disorders
Brief psychotic disorder, 329 (332)
Delusionill disorder, 323 (329)
Due to a general medical condition, 334
(338)
Not otherwise specified, 3-l3
Schizoaffedh'c disorder, 319 (323)
Schizophrenia, 298 (312)
Schizophreniform disorder, 317 (319)
Shared psychotic disorder. 332 (334)
Substance-induced psychotic disorder,
338 (3-I2)
Psychotic features specifier
Major depressive episode, ~
11 (413)
~\Ilanic
episode, ~13
(.t15)
~'[ixed
episode, 415 (416)
Pyromania, 669 (671)
R
Rapid...(:ycling specifier for mood disorder,
il7 (428)
Reactive attachment disorder of infancy or
early childhood, 127 (130)
l~eading
disorder, 51 (53)
Recurrent brief depressive disorder. 778
(119)
Reiationill problems, 736
Not otherwise specified. 737
Parent-child relational problem, 737
Partner relational problem, 737
Related to a menial disorder or general
medical condition, 737
Sibling relational problem, 737
Religious or spiritual problem. 7~1
Residuallype of schizophrenia. 316 (317)
Rett's disorder, 76 (77)
Rumination disorder, 105 (106)
5
5chizoaffe<:tive disorder, 319 (323)
Schizoid personality disorder, 694 (697)
Schizophrenia. 298 (312)
Alternative dimensional descriptors, 765
(766)
Catatonic type. 315 (316)
Disorganized type. 314 (315)
Paranoid Iype, 313 (314)
Residual type, 316 (317)
Undifferentiated type, 316 (316)
Schizophrenia and other psychotic
disorders. Su Psychotic disorders;
Schizophrenia
Schizophrenifonn disorder, 317 (319)
Schizot}'Pal personality disorder, 697 (70l)
Seasonal pattern spe<:ifier for mood disorder,
-125 (427)
Sedative-, h}'Pnotic-, or anxiolytic-induced
disorders
Intoxication, 286 (287)
Other disorders. 289
Withdrawal, 287 (289)
Sedathe-. hypnotic-, or anxiolytic-rclaled
disorders,28-!
Not otherwise specified, 293
Sedati\"t~,
hypnotic. or anxiolytic use
disorders
Abuse, 286
Dependence, 285
Sedative-related disorders. See Sedative-
hypnotic.... or anxiolytic...rdaled disorders
Seledin mutism, US (127)
Separation anxiety disorder, 121 (125)
Se\'ere menial retardation, -l3 (49)
Severit}'/ psychotic/ remission specifiers
~'laior
depressive episode, 411 (413)
r-.'Ianic episode, 413 (415)
Mi."ed episode, U5 (~16)
Severit}' W\Specified mental retardation,-I-I
(49) ...
Sexual abuse
of adult, 738
of child, 738
Sexual arousal disorders
Female sexual arousal disorder, 51.3 (5-1-1)
~'Iale
erectile disorder, ili(5-17)
Due to a general medical condition,
558 (561)
Sexual a\'ersion disorder. 541 (542)
942 Index
Sexual desire disorders
H)'POOctke sexual desire disorder, 539
(5Ul
Due to a general medical condition,
558 (561)
Sexual a\"ecsion disorder, 5-11 (542)
Sexual disorders
Sel' also Paraphilias; Sexual dysfunctions
Not otherwise specified, 582
Sexual dysfunctions, 535
Due 10 a general medical condition, 558
(;<;1)
Not othemjse specified, 565
Orgasmic disorders
Female orgasmic disorder, 547
(549)
~'Iale
orgasmic disorder, 550 (552)
Premature ejaculation, 552 (55-1)
Sexual arousal disorders
Female sexual arousal disorder, 5-13
(5+1)
~'Iale
erectile disorder, 5-15 (5-17)
Due 10 a general medical condition,
558(361)
Sexual desire disorders
HypoactiH!sexual desiredisorder, 539
(541)
Due 10ageneral mediealcondition,
558 (561)
Sexual aH~rsion
disorder, 5-41 (5-12)
Sexual pain disorders
Dyspareunia
Due 10 a general medical condition,
558 (561)
Not due 10 a general medical
condition, 554 (556)
Vaginismus (not due 10 a gcncr.1l
medical condition), 556 (558)
Substance-induced sexual dysfunction,
562 (565)
Sexual masochism, 572 (573)
Sexual pain disorders
Dyspareunia
Due to a general medical condition,
558 (;<;1)
'01 due to a general medical
condition,554 (556)
Vaginismus (not due to a general medical
condilion). 556 (5-)
Sexual sadism, 573 (57,1)
Shared psychotic disorder. 332 (33-1)
Sibling relational problem, 737
Simple deteriorative disorder (simple
schizophrenia), 769 (771)
Simple phobia. 5 Specific phobia
Sleep disorders. 597
Due to a general medical condition, 651
(654)
Hypersomnia type, 652 (6,5.l)
Insomnia Iype, 652 (654)
Mixed type. 652 (6s.l)
Parasomnia type. 652 (654)
Primary sleep disorders
Dyssomnias. 598
Parasomnias, 630
Related to another mental disorder
Hypersomnia related to another
mcntal disorder, 645 (650)
Insomnia related to another menial
disorder, 6-15 (650)
Substance-induced sleep disorder, 655
(660)
Sleep terror disorder, 63-l (639)
Sleep-wake schedule disordcr. 5ee Circadian
rhyUun sleep disorder
Sleepwalking disorder, 639 (6H)
Social and Occupational Functioning
Assessment Scale (SOFAS), 817-818
Sodal anxiety disorder. Sec Sodal phobia
(social anxiety disorder)
Sodal phobia (social anxiety disorder), 450
(';<;)
SOFAS. 5eeSociai and Occupationa!
Functioning Assessment Scale
Somatization disorder, 486 (490)
Somaloform disorders, 485
Bod)' dysmorphic disorder, 507 (510)
Conversion disorder, 492 (498)
Hypochondriasis, 504 (507)
Not otherwise specified, 511
Pain disorder
Associated with a gener<l! medical
condition, 498 (503)
Associated with both psychologica!
factors and a general medical
condition, -198 (503)
Associated with psychological factors,
-198 (503)
Somatization disorder, 486 (490)
Undifferentiated somatoform disorder,
490 (-192)
Specific phobia, +13 (+19)
Index 943
Spiritual problem. See Religious or spiritual
problem
Stereotypic mo'ement disorder, 131 (134)
Stereotypy/habit disorder. See Stereotypic
movement disorder
Stress disorder. SrI' Acute stress disorder
Stuttering, 67 (69)
Substance-induced disorders, 199
See also SpiCifiC substllllces by /lame
Anxiety disorder, -179 (483)
Delirium, 1-l3 (1-15-1-16)
Hallucinogen persisting perception
disorder (nashbacks), 253 (25-1)
Intoxication, 199 (201)
r-,'Iood disorder, 403 (409)
Persisting amnestic disorder, 177 (179)
Persisting dementia, 168 (170)
Psychotic disorder, 338 (3-12)
Sexual dysfunction, 362 (565)
Sleep disorder, 653 (660)
Withdrawal, 201 (202)
Substance-related disorders, 191
See also "/Mcific !>lIbstancs by /lame
Other (or unknown) disorders, 293
Substance usc disorders, 192
Su also sprcific substances by 1/I111/e
Abuse, 198 (199)
Dependence, 192 (197)
T
Tardh-e dyskinesia
Neuroleptic-induced, 736, 803 (803)
Tic disorders, 108
Chronic motor or nxal tic disorder, 114
(115)
Not othem'lse specified, 116
Tourette's disorder, 111 (UI)
Transient tic disorder, 115 (116)
Tourette's disorder, 111 (114)
Transient tic disorder, 113 (116)
Transvestic fetishism, 574 (575)
Tremor. See Postural !remor, medication
induced
Trichotillomania, 674 (677)
U
Undifferentiated somatoform disorder, 490
(4.92)
Undifferentiated type of schizophrenia, 316
(316)
Unspecified mental disorder (nonpsychotic),
743
v
Vaginismus (not due to a general medie.tl
condition), 336 (5-)
Vascular dementia, 1-(161)
Vocal tic disorders. See Chronic motor or
\"lxal tic disorder
Voyeurism, 575 (575)
w
Withdrawal from substances, 201 (202)
See also specific substances by nllme
Written expression, disorder of, 54.
(56)