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Adjustment Disorders
Section I: DSM-5 Basics Bipolar and Related Disorders
Bipolar I Disorder Dissociative Disorders
Section II: Diagnostic Criteria & Codes Bipolar II Disorder Dissociative Identity Disorder
Cyclothymic Disorder Dissociative Amnesia
Neurodevelopmental Disorders Substance/Medication-Induced Bipolar and Depersonalization/Derealization Disorder
Intellectual disabilities Related
Intellectual disability Bipolar and Related Disorder Due to Another Somatic Symptom and Related Disorders
Global Developmental Delay Medical Somatic Symptom Disorder
Communication Disorders Illness Anxiety Disorder
Language Disorder Conversion Disorder
Speech Sound Disorder (previously Depressive Disorders Psychological Factors Affecting Other Medical
Phonological) Disruptive Mood Dysregulation Disorder Conditions
Social (Pragmatic) Communication Major Depressive Disorder, Single & Recurrent Factitious Disorder
Disorder Episodes Feeding and Eating Disorders
Autism Spectrum Disorder Persistent Depressive Disorder (Dysthymia) Pica
Attention-Deficit/Hyperactivity Disorder Premenstrual Dysphoric Disorder Rumination Disorder
ADHD Substance/Medication Induced Depressive Avoidant/Restrictive Food Intake Disorder
Specific Learning Disorder Disorder Anorexia Nervosa
Motor disorders Depressive Disorder Due to Another Medical Bulimia Nervosa
Developmental Coordination Disorder Cond. Binge-Eating Disorder
Stereotypic Movement Disorder
Tic Disorders Anxiety Disorders Elimination Disorders
Tourette’s Disorder Separation Anxiety Disorder Enuresis
Persistent (Chronic) Motor or Vocal Tic Selective Mutism Encopresis
Disorder Specific Phobia
Provisional Tic Disorder Social Anxiety Disorder (Social Phobia) Sleep-Wake Disorders
Other Neurodevelopmental Disorders Panic Disorder Insomnia Disorder
Other specified Neurodevelopmental Panic Attack (Specifier) Hypersomnolence Disorder
Disorder Agoraphobia Narcolepsy
Unspecified Neurodevelopmental Generalized Anxiety Disorder
Disorder Substance/Medication Induced Anxiety Breathing-Related Sleep Disorders
Disorder Obstructive Sleep Apnea Hypopnea
Schizophrenia Spectrum and Other Anxiety Disorder Due to Another Medical Cond. Central Sleep Apnea
Psychotic Disorders Sleep-Related Hypoventilation
Schizotypal (Personality) Disorder Obsessive-Compulsive and Related Circadian Rhythm Sleep- Wake Disorder
Delusional Disorder Disorders
Brief Psychotic Disorder Obsessive-Compulsive Disorder Parasomnias
Schizophreniform Disorder Body Dysmorphic Disorder Non-REM Sleep Arousal Disorder
Schizophrenia Hoarding Disorder Sleepwalking
Schizoaffective Disorder Trichotillomania (Hair-Pulling Disorder) Sleep Terrors
Substance/Medication-Induced Psychotic Excoriation (Skin-Picking) Disorder Nightmare Disorder
Disorder Substance/Medication Induced O-C and Related REM Sleep Behavior Disorder
Psychotic Disorder Due to Another Disorder Restless Legs Syndrome
Medical Condition O-C Disorder Due to Another Medical Cond. Substance/Mediation-Induced Sleep Disorder
Catatonia
Catatonia Associated with Another Trauma-and Stresssor-Related Disorders Sexual Dysfunctions
Mental Disorder Reactive Attachment Disorder Delayed Ejaculation
Catatonia Disorder Due to Another Disinhibited Social Engagement Disorder Erectile Disorder
Medical Cond. Posttraumatic Stress Disorder Female Orgasmic Disorder
Female Sexual Interest/Arousal Disorder Major and Mild Neurocognitive (NC) Voyeuristic Disorder
Genito-Pelvic Pain Disorder Disorders Exhibitionistic Disorder
Male Hypoactive Sexual Desire Disorder Major/Mild Neurocognitive Disorders Frotteuristic Disorder
Premature (Early) Ejaculation Major/Mild NC Disorder Due to Alzheimer’s Sexual Masochism Disorder
Substance/Medication-Induced Sexual Disease Sexual Sadism Disorder
Dysfunction Major/Mild Frontotemporal NC Disorder Pedophilic Disorder
Major/Mild NC Disorder With Lewy Bodies Fetishistic Disorder
Gender Dysphoria Major/Mild Vascular NC Disorder Transvestic Disorder
Gender Dysphoria Major/Mild NC Disorder Due to Traumatic Brain
Injury Other Mental Disorders
Substance/Medication-Induced Major/Mild NC Other Specified Mental Disorder Due to Another
Disorder Medical Condition
Major/Mild NC Disorder Due to HIV Infection Unspecified Mental Disorder Due to Another
Major/Mild NC Disorder Due to Prion Disease Medical Condition
Disruptive, Impulse-Control, and Conduct Major/Mild NC Disorder Due to Parkinson’s
Disorders Disease Medication-Induced Movement Disorders
Oppositional Defiant Disorder Major/Mild NC Disorder Due to Huntington’s and Other Adverse Effects of Medication
Intermittent Explosive Disorder Disease
Conduct Disorder Major/Mild NC Disorder Due to Another Medical Other Conditions That May Be a Focus of
Antisocial Personality Disorder Condition Clinical Attention
Pyromania Major/Mild NC Disorder Due to Multiple
Kleptomania Etiologies Section III: Emerging Measures and
Unspecified NC Disorder Models
Substance-Related and Addictive
Disorders Assessment Measures
Substance-Related Disorders
Substance Use Disorders Cultural Formulation
Substance-Induced Disorders
Substance Intoxication and Withdrawal Personality Disorders Alternative DSM-5 Model for Personality
Substance/Medication-Induced Mental General Personality Disorders Disorders
Disorders Cluster A Personality Disorders
Alcohol-Related Disorders Paranoid
Caffeine-Related Disorders Schizoid Conditions for Further Study
Cannabis-Related Disorders Schizotypal Attenuated Psychosis Syndrome
Hallucinogen-Related Disorders Cluster B Personality Disorders Depressive Episodes with Short-Duration
Inhalant-Related Disorders Antisocial Hypomania
Opioid-Related Disorders Borderline Persistent Complex Bereavement Disorder
Sedative-, Hypnotic-, or Anxiolytic-Related Histrionic Caffeine Use Disorder
Disorders Narcissistic Internet Gaming Disorder
Stimulant-Related Disorders Cluster C Personality Disorders Neurobehavioral Disorder Associated with
Tobacco-Related Disorders Avoidant Prenatal
Other (or Unknown) Substance-Related Dependent Alcohol Exposure
Disorder Obsessive-Compulsive Suicidal Behavior Disorder
Non-Substance-Related Disorders Other Personality Disorders Nonsuicidal Self-Injury
Gambling Disorder Personality Change Due to Another Medical
Condition Appendix
Neurocognitive Disorders
Delirium Paraphilic Disorders
DSM-5 STUDY GUIDE
ANXIETY DISORDERS
Excessive fear and anxiety and related behavioral disturbances
Fear – emotional response to real or perceived imminent threat (e.g. arousal for
fight or flight, thoughts of immediate danger, escape behaviors)
Anxiety – anticipation of future threat (e.g. muscle tension, vigilance, cautious or
avoidant behaviors)
Panic attack – particular type of fear response prominent within anxiety
disorders
Anxiety disorders are best differentiated by the types of situations feared or
avoided and content of associated thoughts or beliefs
Transient fear or anxiety (often stress-induced and temporary) vs. Anxiety
disorder (persistent, usually 6 months or more)
Fear or anxiety is excessive or out of proportion
Sex Ratio: Female-Male: 2:1
Panic attacks (may be expected – response to typically feared object or
situation; unexpected – occurs for no apparent reason)
Generalized Anxiety Disorder – persistent and excessive anxiety and worry
about various domains which are difficult to control in addition to physical
symptoms such as restlessness, easily fatigued, difficulty concentrating,
irritability, muscle tension and sleep disturbance
Panic Disorder – recurrent unexpected panic attacks and persistently worried
of having more panic attacks which may cause maladaptive behaviors
Agoraphobia – fear and anxiety of “unsafe” situations (e.g. public
transportation, open spaces, enclosed places, standing in line or being in a
crowd, being outside home alone) where panic-like symptoms may occur and
help or escape is unlikely
Specific Phobia – fear, anxiety or avoidance of circumscribed objects or
situations that is out of proportion to actual risk (subtypes: animal, natural
environment, blood-injection-injury, situational, other)
Social Anxiety Disorder (Social Phobia) – fear, anxiety or avoidance of
social interactions and situations where scrutiny is possible in addition to
cognitive ideation of being negatively evaluated or offending others
Separation Anxiety Disorder – fear or anxiety about developmentally
inappropriate separation from attachment figures; nightmares and physical
symptoms may be present
Selective Mutism – consistent failure to speak in social situations even though
individual speaks in other situations which leads to significant consequences on
achievement or interferes social communication (usually diagnosed in addition
to social anxiety disorder)
Substance/Medication-Induced Anxiety Disorder – anxiety due to
substance intoxication or withdrawal or exposure to a medication treatment
Anxiety Disorder Due to Another Medical Condition – anxiety symptoms
are direct pathophysiological consequence of another medical condition
Other Specified Anxiety Disorder – anxiety-like symptoms that cause
clinically significant distress or impairment but does not meet full criteria and
clinician specifies the reason (e.g. limited symptom attacks, generalized anxiety
not occurring more days than not)
Unspecified Anxiety Disorder - anxiety-like symptoms that cause clinically
significant distress or impairment but does not meet full criteria and clinician
does not choose to communicate the reason and there is insufficient information
to make more specific diagnosis (e.g. emergency room settings)
TRAUMA- AND STRESSOR-RELATED DISORDERS
Psychological distress following exposure to a traumatic or stressful event is a
required criteria
Most prominent characteristics are anhedonic and dysphoric symptoms,
aggressive symptoms or dissociative symptoms
Generally more common in females
Conditions associated with social neglect (inadequate care during childhood):
cognitive delays, language delays, developmental delays, stereotypies, reactive
attachment, disinhibited social engagement, malnutrition or poor care
Reactive Attachment Disorder – expressed with depressive symptoms and
withdrawn behavior and compromised emotional regulation capacity which are
caused by serious social neglect
Disinhibited Social Engagement Disorder – marked by culturally
inappropriate, overly familiar behavior with relative strangers which is caused
by serious social neglect
Posttraumatic Stress Disorder – development of varying characteristics
symptoms (e.g. fear-based emotional and behavioral, anhedonic or dysphoric
mood and negative cognitions, arousal and reactive-externalizing) following
exposure to one or more traumatic events
Acute Stress Disorder – PTSD symptoms lasting from 3 days to 1 month
following exposure to the traumatic event/s
Adjustment Disorders – presence of emotional or behavioral symptoms in
response to an identifiable stressor; may be single/multiple,
recurrent/continuous
Other Specified Trauma- and Stressor Related Disorder – trauma- and
stressor-like symptoms that cause clinically significant distress or impairment
but do not meet full criteria and clinician specifies the reason (ex. Persistent
complex bereavement disorder, adjustment-like disorders with delayed onset of
symptoms that occur more than 3 months after the stressor, ataque de nervios)
Unspecified Trauma- and Stressor Related Disorder – trauma- and
stressor-like symptoms that cause clinically significant distress or impairment
but do not meet full criteria and clinician chooses not to specify the reason and
there is insufficient information to make more specific diagnosis (e.g.
emergency room settings)
DISSOCIATIVE DISORDERS
Disruption and/or discontinuity in normal integration of consciousness, memory,
identity, emotion, perception, body representation, motor control and behavior
Positive dissociated symptoms: fragmentation of identity, depersonalization and
derealization; Negative dissociated symptoms: amnesia
Depersonalization/Derealization Disorder – persistent depersonalization
(unreality or detachment from oneself) and/or derealization (unreality or
detachment from one’s surroundings) accompanied by intact reality testing
Dissociative Amnesia – inability to recall autobiographical information which
may be generalized (identity and life history), localized (event or period of time)
or selective (specific aspect of event) and may or may not involve dissociative
fugue (purposeful travel or wandering)
Dissociative Identity Disorder – presence of two or more distinct personality
states (or experience of possession) and recurrent episodes of amnesia
Other Specified Dissociative Disorder - dissociative-like symptoms that
cause clinically significant distress or impairment but does not meet full criteria
and clinician specifies the reason (e.g. dissociative trance, acute dissociative
reactions to stressful events)
Unspecified Dissociative Disorder - dissociative-like symptoms that cause
clinically significant distress or impairment but does not meet full criteria and
clinician does not choose to communicate the reason and there is insufficient
information to make more specific diagnosis (e.g. emergency room settings)
DEPRESSIVE DISORDERS
Presence of sad, empty or irritable mood accompanied by somatic and cognitive
changes significantly affecting one’s capacity to function
In grief, the predominant affect is feelings of emptiness and loss, in major
depressive episode it is persistent depressed mood and inability to anticipate
happiness or pleasure
Disruptive Mood Dysregulation Disorder – chronic, severe persistent (non-
episodic) irritability through frequent verbal and/or behavioral temper outbursts
in response to frustration and persistent irritable or angry mood between the
outbursts
Major Depressive Disorder – persistent depressed mood and/or loss of
interest or pleasure nearly most of the day every day for at least two weeks
(plus 4 more symptoms)
Persistent Depressive Disorder (Dysthymia) – depressed mood most of the
day, for more days than not, for at least 2 years (plus 2 more symptoms)
Premenstrual Dysphoric Disorder – mood lability, irritability, dysphoria and
anxiety symptoms accompanied by behavioral and physical symptoms that
occur repeatedly during premenstrual phase and remit around onset of menses
or shortly thereafter
Substance/Medication-Induced Depressive Disorder – prominent and
persistent depressed mood and/or anhedonia that developed during or soon
after intoxication, withdrawal or exposure to substance/medication which is
capable of producing said symptoms
Depressive Disorder Due to Another Medical Condition – prominent and
persistent depressed and/or anhedonia that is the direct pathophysiological
consequence of another medical condition
Other Specified Depressive Disorder – presentations of depressed mood
with clinically significant impairment that do not meet criteria for duration or
severity (e.g. recurrent brief depression, short-duration depressive episode (4-
13 days), depressive episode with insufficient symptoms)
Unspecified Depressive Disorder – presentations of depressed mood with
clinically significant impairment that do not meet full criteria and clinician does
not wish to specify the reason, possibly due to insufficient information
Specifiers: With anxious distress, With mixed features, With melancholic
features, With atypical features, With psychotic features, With catatonia, With
peripartum onset, With seasonal pattern; In partial remission, In full remission;
Severity: Mild, Moderate, Severe
PERSONALITY DISORDERS
Shared criteria: Pervasive pattern of emotions, cognitions and behaviors +
begins by early adulthood (or adolescence) + present in a variety of contexts +
does not occur exclusively during the course of another mental disorder + not
attributable to another medical condition
General Personality Disorder – enduring pattern of inner experience and
behavior that deviates markedly from expectations of one’s culture in at least 2
ways (cognitive, affectivity, interpersonal functioning, impulse control)
Paranoid Personality Disorder – distrust and suspiciousness of others
without any justification (indicated by 4 symptoms)
Schizoid Personality Disorder – detachment from social relationships and
restricted range of emotional expression in interpersonal settings (indicated by
4 symptoms)
Schizotypal Personality Disorder – social and interpersonal deficits and
cognitive or perceptual distortions and eccentricities of behavior (indicated by 4
symptoms)
Antisocial Personality Disorder – disregard for and violation of the rights of
others (indicated by 3 symptoms)
Borderline Personality Disorder – instability of interpersonal relationships,
self-image and affects and marked impulsivity (indicated by 5 symptoms)
Histrionic Personality Disorder – excessive emotionality and attention
seeking (indicated by 5 symptoms)
Narcissistic Personality Disorder – grandiosity, need for admiration and lack
of empathy (indicated by 5 symptoms)
Avoidant Personality Disorder – social inhibition, feelings of inadequacy and
hypersensitivity to negative evaluation (indicated by 4 symptoms)
Dependent Personality Disorder – excessive need to be taken care of that
leads to submissive and clinging behavior and fears of separation (indicated by
5 symptoms)
Obsessive-Compulsive Personality Disorder – preoccupation with
orderliness, perfectionism and mental and interpersonal control, at the expense
of flexibility, openness and efficiency (indicated by 4 symptoms)
Personality Change Due to Another Medical Condition – persistent
personality disturbance due to the direct physiological effects of a medical
condition (e.g. frontal lobe lesion)
Other Specified Personality Disorder / Unspecified Personality Disorder
– (1) personality pattern meets the general criteria for personality disorder, and
traits of several different personality disorders are present, but criteria for any
specific personality disorder are not met; or (2) personality pattern meets
general criteria but considered to have a personality disorder not included in
DSM-5 classification (e.g. passive-aggressive personality disorder)
Elimination Disorders
Nocturnal: Nighttime sleep; Diurnal: Waking hours
Enuresis – repeated voiding of urine into bed or clothes, whether involuntary or
intentional (2x a week for 3 months, at least 5 years of age)
Encopresis – repeated passage of feces into inappropriate places, whether
involuntary or intentional (once a month for 3 months, at least 4 years of age)
Other Specified Elimination Disorder – related symptoms that cause
clinically significant distress or impairment but does not meet full criteria and
clinician specifies the reason (e.g. low-frequency enuresis)
Unspecified Elimination Disorder – related symptoms that cause clinically
significant distress or impairment but does not meet full criteria and clinician
does not choose to communicate the reason, possibly due to insufficient
information
Sexual Dysfunctions
Clinically significant disturbance in a person’s ability to respond sexually or to
experience sexual pleasure for a duration of at least 6 months
Lifelong: sexual problem that has been present from first sexual experiences /
Acquired: sexual disorders that develop after a period of relatively normal
sexual function
Generalized: sexual difficulties that are not limited to certain types of
stimulation, situations or partners / Situational: sexual difficulties that only occur
with certain types of stimulation, situations or partners
Delayed Ejaculation – marked delay in or inability to achieve ejaculation
despite adequate sexual stimulation and desire to ejaculate during partnered
sexual activities
Erectile Disorder – repeated failure to obtain or maintain erections during
partnered sexual activities
Female Orgasmic Disorder – difficulty experiencing orgasm and/or markedly
reduced intensity of orgasmic sensations
Female Sexual Interest/Arousal Disorder – lack of or significantly reduced
sexual interest/arousal
Genito-Pelvic Pain/Penetration Disorder – difficulty having intercourse,
genitor-pelvic pain, fear of pain or vaginal penetration, or tension of the pelvic
floor muscles
Male Hypoactive Sexual Desire Disorder – persistent deficient or absent
sexual/erotic thoughts or fantasies and desire for sexual activity
Premature (Early) Ejaculation – persistent ejaculation during partnered
sexual activity within approximately 1 minute following vaginal penetration and
before individual wishes it
Substance/Medication-Induced Sexual Dysfunction – clinically significant
sexual disturbance during or soon after substance intoxication/withdrawal or
exposure to medication capable of producing said symptoms
Other Specified Sexual Dysfunction – related sexual disturbance that cause
clinically significant distress or impairment but does not meet full criteria and
clinician specifies the reason (e.g. sexual aversion)
Unspecified Sexual Dysfunction – related sexual disturbance that cause
clinically significant distress or impairment but does not meet full criteria and
clinician does not choose to communicate the reason, possibly due to
insufficient information
Gender Dysphoria
Sex: biological indicators of male and female, such as in sex chromosomes,
gonads, sex hormones and nonambiguous internal and external genitalia
Gender: lived role in society and/or the identification as male or female could
not be uniformly associated with or predicted from the biological indicators
Gender assignment: initial assignment as male or female, occurs usually at birth
(natal gender)
Gender-atypical / Gender-nonconforming: somatic features or behaviors that are
not typical of individuals with the same assigned gender in a given society and
historical era
Gender reassignment: official and legal change of gender
Gender identity: category of social identity and refers to an individual’s
identification as male, female or some category other than male or female
Gender dysphoria: general term for individual’s affective/cognitive discontent
with the assigned gender
Transgender: broad spectrum of individuals who transiently or persistently
identify with a gender different from their natal gender
Transsexual: individual who seeks, or has undergone, a social transition from
male to female (or vice-versa) which usually involves cross-sex hormone
treatment and genital surgery
Gender Dysphoria – clinically significant distress that may accompany the
incongruence between one’s experienced or expressed gender and one’s
assigned gender (at least 6 symptoms in children, 2 symptoms in adolescents
and adults for at least 6 months)
Other Specified Gender Dysphoria – related symptoms that cause clinically
significant distress or impairment but does not meet full criteria and clinician
specifies the reason (e.g. brief gender dysphoria
Unspecified Gender Dysphoria – related symptoms that cause clinically
significant distress or impairment but does not meet full criteria and clinician
does not choose to communicate the reason, possibly due to insufficient
information
Paraphilic Disorders
Selected for specific listing and assignment of diagnostic criteria because they
are relatively common and some are classed as criminal offenses due to their
noxiousness and potential harm to others
Paraphilia: any intense and persistent sexual interest other than in genital
stimulation
Anomalous Activity Preferences: sexual interest in activities that equals or
exceeds one’s interest in copulation or equivalent interaction with another
person
Courtship disorders: resemble distorted components of human courtship
behavior / Algolagnic disorders: involve pain and suffering
Anomalous Target Preferences: sexual interest in children, corpses or amputees
or in nonhuman animals, such as horses or dogs or in inanimate objects
Paraphilic disorder: paraphilia that causes distress or impairment to individual or
paraphilia whose satisfaction entails personal harm, or risk of harm, to others
Shared criteria: Recurrent and intense sexual arousal + as manifested by
fantasies, urges or behaviors + acting on these sexual urges with a
nonconsenting person or related clinically significant distress or impairment +
over the period of at least 6 months
Voyeuristic Disorder – recurrent and intense sexual arousal from observing an
unsuspecting person who is naked, disrobing or engaging in sexual activity
Exhibitionistic Disorder – recurrent and intense sexual arousal from exposure
of one’s genitals to an unsuspecting person
Frotteuristic Disorder – recurrent and intense sexual arousal from touching or
rubbing against a nonconsenting person
Sexual Masochism Disorder – recurrent and intense sexual arousal from the
act of being humiliated, beaten, bound or otherwise made to suffer (specifier:
with asphyxiophilia)
Sexual Sadism Disorder – recurrent and intense sexual arousal from the
physical or psychological suffering of another person
Pedophilic Disorder – recurrent and intense sexual arousal involving sexual
activity with a prepubescent child or children (generally 13 years or younger)
(must be at least age 16 years and at least 5 years older than the child)
Fetishistic Disorder – recurrent and intense sexual arousal from either use of
nonliving objects or highly specific focus on nongenital body part/s
Tranvestic Disorder – recurrent and intense sexual arousal from crossdressing
Other Specified Paraphilic Disorder – paraphilic symptoms that cause
clinically significant distress or impairment but does not meet full criteria and
clinician specifies the reason (e.g. telephone scatologia, necrophilia, zoophilia,
coprophilia, urophilia)
Unspecified Paraphilic Disorder – paraphilic symptoms that cause clinically
significant distress or impairment but does not meet full criteria and clinician
does not choose to communicate the reason, possibly due to insufficient
information
Neurocognitive Disorders
Group of disorders in which the primary clinical deficit is in cognitive function
and that are acquired rather than developmental
Neurocognitive domains: Complex attention, Executive function, Learning and
memory, Language, Perceptual-motor, Social cognition
Sustained attention: maintenance of attention over time
Selective attention: maintenance of attention despite competing stimuli and/or
distracters
Divided attention: attending to two tasks within the same time period
Planning: ability to find the exit to a maze
Decision making: performance of tasks that assess process of deciding in the
face of competing alternatives
Working memory: ability to hold information for a brief period and to manipulate
it
Feedback/error utilization: ability to benefit from feedback to infer the rules for
solving a problem
Overriding habits/inhibition: ability to choose a more complex and effortful
solution to be correct
Mental/cognitive flexibility: ability to shift between two concepts, tasks or
response rules
Immediate memory span: ability to repeat a list of words or digits
Recent memory: assesses the process of encoding new information through free
recall, cued recall and recognition memory
Expressive language: confrontational naming, fluency or phonemic
Grammar and syntax: omission or incorrect use of articles, prepositions,
auxiliary verbs
Receptive language: comprehension; performance of actions/activities
according to verbal command
Visual perception: line bisection tasks can be used to detect basic visual defect
or attentional neglect
Visuoconstructional: assembly of items required hand-eye coordination, such as
drawing, copying and block assembly
Perceptual-motor: integrating perception with purposeful movement
Praxis: integrity of learned movements, such as ability to imitate gestures or
pantomime use of objects to command
Gnosis: perceptual integrity of awareness and recognition, such as recognition
of faces and colors
Recognition of emotions: identification of emotion in images of faces
representing a variety of both positive and negative emotions
Theory of mind: ability to consider another person’s mental state (thoughts,
desires, intentions) or experience
Delirium – disturbance of attention or awareness accompanied by a change in
baseline cognition, that is a direct physiological consequence of another medical
condition, substance intoxication or withdrawal, or toxin exposure, or
combination of these factors
Other Specified Delirium – delirium-like symptoms that cause clinically
significant distress or impairment but does not meet full criteria and clinician
specifies the reason (e.g. attenuated delirium syndrome)
Unspecified Delirium – delirium-like symptoms that cause clinically significant
distress or impairment but does not meet full criteria and clinician does not
choose to communicate the reason, possibly due to insufficient information
Major Neurocognitive Disorder – significant cognitive decline from a
previous level of performance in at least one neurocognitive domain which
interferes with independence in everyday activities
Mild Neurocognitive Disorder – modest cognitive decline from a previous
level of performance in at least one neurocognitive domain which does not
interfere with independence in everyday activities but greater effort,
compensatory strategies or accommodating may be required
Specifiers – Alzheimer’s disease, frontotemporal lobar degeneration, Lewy
body disease, vascular disease, traumatic brain injury, substance/medication
use, HIV infection, Prion disease, Parkinson’s disease, Huntington’s disease,
another medical condition, multiple etiologies, unspecified
Due to Alzheimer’s Disease – insidious onset and gradual progression of
cognitive and behavioral symptoms typically with impairment in memory and
learning
Frontotemporal (Lobar Degeneration) – progressive development of
behavioral and personality change and/or language impairment (behavioral
disinhibition, apathy or inertia, loss of sympathy or empathy,
perseverative/stereotyped/compulsive/ritualistic behavior, hyperorality and
dietary changes)
With Lewy Bodies (Disease) – core features are pronounced variations in
attention and alertness, recurrent detailed visual hallucinations and
spontaneous features of Parkinsonism; suggestive features are REM sleep
behavior disorder and severe neuroleptic sensitivity
Vascular (Disease) – clinical features consistent with vascular etiology as
suggested by relation of onset to at least one cerebrovascular event and
prominent decline in complex attention and frontal-executive function domains
Due to Traumatic Brain Injury – clinical features presented immediately after
occurrence of traumatic brain injury or immediately after recovery of
consciousness as evidenced by loss of consciousness, posttraumatic amnesia,
disorientation and confusion, neurological symptoms
Substance/Medication Induced – clinically significant neurocognitive
impairment during or soon after substance intoxication/withdrawal or exposure
to medication capable of producing said symptoms
Due to HIV Infection – neurocognitive impairment attributable to a
documented infection with human immunodeficiency virus (HIV)
Due to Prion Disease – neurocognitive impairment attributable to prion
disease (most common type is Creutzfeldt-Jakob disease), with insidious onset
and rapid progression of motor features such as myoclonus or ataxia
Due to Parkinson’s Disease – neurocognitive impairment attributable to
established Parkinson’s disease
Due to Huntington’s Disease – neurocognitive impairment attributable to
clinically established Huntington’s disease or risk based on family history or
genetic testing
Due to Another Medical Condition – neurocognitive impairment that is the
pathophysiological consequence of another medical condition based on history,
physical examination or laboratory findings (e.g. primary or secondary brain
tumors, subdural hematoma, hypothyroidism, epilepsy, multiple sclerosis,
deficiencies of thiamine or niacin)
Due to Multiple Etiologies – neurocognitive impairment that is the
pathophysiological consequence of more than one etiological process, excluding
substances
Unspecified Neurocognitive Disorder – neurocognitive impairment that does
not meet the full criteria and in which the precise etiology cannot be determined
with sufficient certainty
Neurodevelopmental Disorders
Group of conditions with onset in the developmental period, typically
manifesting before the child enters grade school, and are characterized by
developmental deficits from learning or control of executive functions to global
impairments of social skills or intelligence
Speech: expressive production of sounds and includes articulation, fluency,
voice and resonance quality
Language: form, function and use of a conventional system of symbols in a rule-
governed manner for communication
Communication: any verbal or nonverbal behavior (whether intentional or
unintentional) that influences behavior, ideas or attitudes of another individual
Expressive ability: production of vocal, gestural or verbal signals
Receptive ability: process of receiving and comprehending language messages
Pragmatics: social use of language and communication
Intellectual Disability (Intellectual Developmental Disorder) – deficits in
general mental abilities (reasoning, problem solving, planning, abstract thinking,
judgment, academic learning and learning from experience) and impairment in
everyday adaptive functioning in comparison to one’s age, gender and peers
(Mild, Moderate, Severe, Profound)
Global Developmental Delay – failure to meet expected developmental
milestones in several areas of intellectual functioning and inability to undergo
systematic assessment of intellectual functioning (under age of 5 years,
requires reassessment after a period of time)
Unspecified Intellectual Disability (Intellectual Developmental
Disorder) – assessment of degree of intellectual disability is difficult or
impossible because of associated sensory or physical impairments (over age of
5 years, requires reassessment)
Language Disorder – persistent difficulties in acquisition and use of language
across modalities due to deficits in comprehension or production of vocabulary,
sentence structure and discourse
Speech Sound Disorder – persistent difficulty with speech sound production
that interferes with speech intelligibility or prevents verbal communication of
messages
Childhood-Onset Fluency Disorder (Stuttering) – disturbance in the normal
fluency and motor production of speech (repetitive sounds or syllables,
prolongation of consonants or vowel sounds, broken words, blocking or words
produced with an excess of physical tension)
Social (Pragmatic) Communication Disorder – persistent difficulties in the
social use of verbal and nonverbal communication
Unspecified Communication Disorder – clinically significant symptoms
characteristic of communication disorder but do not meet full criteria and reason
not specified
Autism Spectrum Disorder – persistent deficits in social communication and
social interaction accompanied by excessively repetitive behaviors, restricted
interests and insistence on sameness
Attention-Deficit/Hyperactivity Disorder – persistent pattern of inattention
and/or hyperactivity-impulsivity that interferes with functioning or development
Other Specified Attention-Deficit/Hyperactivity Disorder – clinically
significant symptoms characteristic of communication disorder but do not meet
full criteria (e.g. with insufficient inattention symptoms)
Unspecified Attention-Deficit/Hyperactivity Disorder – clinically significant
symptoms characteristic of communication disorder but do not meet full criteria
Specific Learning Disorder – specific deficits in ability to perceive or process
information efficiently and accurately; persistent and impairing difficulties with
learning foundational academic skills in reading, writing and/or math
Developmental Coordination Disorder – deficits in the acquisition and
execution of coordinated motor skills and manifested by clumsiness and
slowness or inaccuracy of motor performance
Stereotypic Movement Disorder – repetitive, seemingly driven, and
apparently purposeless motor behaviors (hand flapping, body rocking, head
banging, self-biting, hitting)
Tic Disorders: presence of motor or vocal tics which are sudden, rapid,
recurrent, nonrhythmic, stereotyped motor movements or vocalizations
Tourette’s Disorder – waxing-waning multiple motor and vocal tics present for
at least 1 year
Persistent (Chronic) Motor or Vocal Tic Disorder – waxing-waning single or
multiple motor or vocal tics (not both at the same time) present for at least 1
year
Other Specified Tic Disorder – clinically significant symptoms characteristic
of tic disorder but do not meet full criteria (e.g. with onset after age 18 years)
Unspecified Tic Disorder – clinically significant symptoms characteristic of tic
disorder but do not meet full criteria and reason not specified
Other Specified Neurodevelopmental Disorder – clinically significant
symptoms characteristic of neurodevelopmental disorder but do not meet full
criteria (e.g. neurodevelopmental disorder associated with prenatal alcohol
exposure)
Unspecified Neurodevelopmental Disorder – clinically significant symptoms
characteristic of neurodevelopmental disorder but do not meet full criteria and
reason not specified
Residual Categories
Disturbance caused by physiological effects of another medical condition
Other Specified Mental Disorder Due to Another Medical Condition – e.g.
Dissociative symptoms
Unspecified Mental Disorder Due to Another Medical Condition
Symptoms characteristic of a mental disorder that cause clinically significant
distress or impairment of functioning but do not meet full criteria for any other
mental disorder in DSM-5
Other Specified Mental Disorder
Unspecified Mental Disorder
Highlights
of Changes from
DSM-IV-TR to DSM-5
Changes made to the DSM-5 diagnostic criteria and texts are outlined in this chapter in the same order
in which they appear in the DSM-5 classification. This is not an exhaustive guide; minor changes in text
or wording made for clarity are not described here. It should also be noted that Section I of DSM-5 con-
tains a description of changes pertaining to the chapter organization in DSM-5, the multiaxial system,
and the introduction of dimensional assessments (in Section III).
Terminology
The phrase “general medical condition” is replaced in DSM-5 with “another medical condition” where
relevant across all disorders.
Neurodevelopmental Disorders
Intellectual Disability (Intellectual Developmental Disorder)
Diagnostic criteria for intellectual disability (intellectual developmental disorder) emphasize the need
for an assessment of both cognitive capacity (IQ) and adaptive functioning. Severity is determined by
adaptive functioning rather than IQ score. The term mental retardation was used in DSM-IV. However,
intellectual disability is the term that has come into common use over the past two decades among
medical, educational, and other professionals, and by the lay public and advocacy groups. Moreover, a
federal statue in the United States (Public Law 111-256, Rosa’s Law) replaces the term “mental retarda-
tion with intellectual disability. Despite the name change, the deficits in cognitive capacity beginning
in the developmental period, with the accompanying diagnostic criteria, are considered to constitute a
mental disorder. The term intellectual developmental disorder was placed in parentheses to reflect the
World Health Organization’s classification system, which lists “disorders” in the International Classifica-
tion of Diseases (ICD; ICD-11 to be released in 2015) and bases all “disabilities” on the International
Classification of Functioning, Disability, and Health (ICF). Because the ICD-11 will not be adopted for
several years, intellectual disability was chosen as the current preferred term with the bridge term for
the future in parentheses.
Communication Disorders
The DSM-5 communication disorders include language disorder (which combines DSM-IV expressive
and mixed receptive-expressive language disorders), speech sound disorder (a new name for phono-
logical disorder), and childhood-onset fluency disorder (a new name for stuttering). Also included is
social (pragmatic) communication disorder, a new condition for persistent difficulties in the social uses
of verbal and nonverbal communication. Because social communication deficits are one component of
autism spectrum disorder (ASD), it is important to note that social (pragmatic) communication disorder
cannot be diagnosed in the presence of restricted repetitive behaviors, interests, and activities (the oth-
er component of ASD). The symptoms of some patients diagnosed with DSM-IV pervasive developmen-
tal disorder not otherwise specified may meet the DSM-5 criteria for social communication disorder.
Attention-Deficit/Hyperactivity Disorder
The diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) in DSM-5 are similar to those
in DSM-IV. The same 18 symptoms are used as in DSM-IV, and continue to be divided into two symp-
tom domains (inattention and hyperactivity/impulsivity), of which at least six symptoms in one domain
are required for diagnosis. However, several changes have been made in DSM-5: 1) examples have
been added to the criterion items to facilitate application across the life span; 2) the cross-situational
requirement has been strengthened to “several” symptoms in each setting; 3) the onset criterion has
been changed from “symptoms that caused impairment were present before age 7 years” to “several
inattentive or hyperactive-impulsive symptoms were present prior to age 12”; 4) subtypes have been
replaced with presentation specifiers that map directly to the prior subtypes; 5) a comorbid diagnosis
with autism spectrum disorder is now allowed; and 6) a symptom threshold change has been made for
adults, to reflect their substantial evidence of clinically significant ADHD impairment, with the cutoff
for ADHD of five symptoms, instead of six required for younger persons, both for inattention and for
hyperactivity and impulsivity. Finally, ADHD was placed in the neurodevelopmental disorders chapter
to reflect brain developmental correlates with ADHD and the DSM-5 decision to eliminate the DSM-IV
chapter that includes all diagnoses usually first made in infancy, childhood, or adolescence.
Motor Disorders
The following motor disorders are included in the DSM-5 neurodevelopmental disorders chapter: devel-
opmental coordination disorder, stereotypic movement disorder, Tourette’s disorder, persistent (chron-
ic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic
disorder. The tic criteria have been standardized across all of these disorders in this chapter. Stereotypic
movement disorder has been more clearly differentiated from body-focused repetitive behavior disor-
ders that are in the DSM-5 obsessive-compulsive disorder chapter.
Schizophrenia subtypes
The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and
residual types) are eliminated due to their limited diagnostic stability, low reliability, and poor validity.
These subtypes also have not been shown to exhibit distinctive patterns of treatment response or lon-
gitudinal course. Instead, a dimensional approach to rating severity for the core symptoms of schizo-
phrenia is included in Section III to capture the important heterogeneity in symptom type and severity
expressed across individuals with psychotic disorders.
Schizoaffective Disorder
The primary change to schizoaffective disorder is the requirement that a major mood episode be pres-
ent for a majority of the disorder’s total duration after Criterion A has been met. This change was made
on both conceptual and psychometric grounds. It makes schizoaffective disorder a longitudinal instead
of a cross-sectional diagnosis—more comparable to schizophrenia, bipolar disorder, and major depres-
sive disorder, which are bridged by this condition. The change was also made to improve the reliability,
diagnostic stability, and validity of this disorder, while recognizing that the characterization of patients
with both psychotic and mood symptoms, either concurrently or at different points in their illness, has
been a clinical challenge.
Delusional Disorder
Criterion A for delusional disorder no longer has the requirement that the delusions must be non-
bizarre. A specifier for bizarre type delusions provides continuity with DSM-IV. The demarcation of
delusional disorder from psychotic variants of obsessive-compulsive disorder and body dysmorphic
disorder is explicitly noted with a new exclusion criterion, which states that the symptoms must not be
better explained by conditions such as obsessive-compulsive or body dysmorphic disorder with absent
insight/delusional beliefs. DSM-5 no longer separates delusional disorder from shared delusional dis-
order. If criteria are met for delusional disorder then that diagnosis is made. If the diagnosis cannot be
made but shared beliefs are present, then the diagnosis “other specified schizophrenia spectrum and
other psychotic disorder” is used.
Catatonia
The same criteria are used to diagnose catatonia whether the context is a psychotic, bipolar, depres-
sive, or other medical disorder, or an unidentified medical condition. In DSM-IV, two out of five symp-
tom clusters were required if the context was a psychotic or mood disorder, whereas only one symp-
tom cluster was needed if the context was a general medical condition. In DSM-5, all contexts require
three catatonic symptoms (from a total of 12 characteristic symptoms). In DSM-5, catatonia may be
diagnosed as a specifier for depressive, bipolar, and psychotic disorders; as a separate diagnosis in the
context of another medical condition; or as an other specified diagnosis.
Depressive Disorders
DSM-5 contains several new depressive disorders, including disruptive mood dysregulation disorder
and premenstrual dysphoric disorder. To address concerns about potential overdiagnosis and overtreat-
ment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is includ-
ed for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme
behavioral dyscontrol. Based on strong scientific evidence, premenstrual dysphoric disorder has been
moved from DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study,” to the main body
of DSM-5. Finally, DSM-5 conceptualizes chronic forms of depression in a somewhat modified way.
What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive dis-
order, which includes both chronic major depressive disorder and the previous dysthymic disorder. An
inability to find scientifically meaningful differences between these two conditions led to their combi-
nation with specifiers included to identify different pathways to the diagnosis and to provide continuity
with DSM-IV.
Bereavement Exclusion
In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depres-
sive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement
exclusion). This exclusion is omitted in DSM-5 for several reasons. The first is to remove the implication
that bereavement typically lasts only 2 months when both physicians and grief counselors recognize
that the duration is more commonly 1–2 years. Second, bereavement is recognized as a severe psy-
chosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally
beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it
adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health,
worse interpersonal and work functioning, and an increased risk for persistent complex bereavement
disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section
III. Third, bereavement-related major depression is most likely to occur in individuals with past personal
and family histories of major depressive episodes. It is genetically influenced and is associated with
similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence
as non–bereavement-related major depressive episodes. Finally, the depressive symptoms associated
with bereavement-related depression respond to the same psychosocial and medication treatments as
non–bereavement-related depression. In the criteria for major depressive disorder, a detailed footnote
has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction be-
tween the symptoms characteristic of bereavement and those of a major depressive episode. Thus, al-
though most people experiencing the loss of a loved one experience bereavement without developing
a major depressive episode, evidence does not support the separation of loss of a loved one from other
stressors in terms of its likelihood of precipitating a major depressive episode or the relative likelihood
that the symptoms will remit spontaneously.
Anxiety Disorders
The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (which is
included with the obsessive-compulsive and related disorders) or posttraumatic stress disorder and
acute stress disorder (which is included with the trauma- and stressor-related disorders). However, the
sequential order of these chapters in DSM-5 reflects the close relationships among them.
Panic Attack
The essential features of panic attacks remain unchanged, although the complicated DSM-IV terminol-
ogy for describing different types of panic attacks (i.e., situationally bound/cued, situationally predis-
posed, and unexpected/uncued) is replaced with the terms unexpected and expected panic attacks.
Panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comor-
bidity across an array of disorders, including but not limited to anxiety disorders. Hence, panic attack
can be listed as a specifier that is applicable to all DSM-5 disorders.
Specific Phobia
The core features of specific phobia remain the same, but there is no longer a requirement that indi-
viduals over age 18 years must recognize that their fear and anxiety are excessive or unreasonable, and
the duration requirement (“typically lasting for 6 months or more”) now applies to all ages. Although
they are now referred to as specifiers, the different types of specific phobia have essentially remained
unchanged.
Selective Mutism
In DSM-IV, selective mutism was classified in the section “Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence.” It is now classified as an anxiety disorder, given that a large majority of
children with selective mutism are anxious. The diagnostic criteria are largely unchanged from DSM-IV.
Hoarding Disorder
Hoarding disorder is a new diagnosis in DSM-5. DSM-IV lists hoarding as one of the possible symptoms
of obsessive-compulsive personality disorder and notes that extreme hoarding may occur in obsessive-
compulsive disorder. However, available data do not indicate that hoarding is a variant of obsessive-
compulsive disorder or another mental disorder. Instead, there is evidence for the diagnostic validity
and clinical utility of a separate diagnosis of hoarding disorder, which reflects persistent difficulty dis-
carding or parting with possessions due to a perceived need to save the items and distress associated
with discarding them. Hoarding disorder may have unique neurobiological correlates, is associated with
significant impairment, and may respond to clinical intervention.
Adjustment Disorders
In DSM-5, adjustment disorders are reconceptualized as a heterogeneous array of stress-response
syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event, rather than as
a residual category for individuals who exhibit clinically significant distress without meeting criteria for
a more discrete disorder (as in DSM-IV ). DSM-IV subtypes marked by depressed mood, anxious symp-
toms, or disturbances in conduct have been retained, unchanged.
In DSM-IV, the diagnosis undifferentiated somatoform disorder had been created in recognition that
somatization disorder would only describe a small minority of “somatizing” individuals, but this disor-
der did not prove to be a useful clinical diagnosis. Because the distinction between somatization disor-
der and undifferentiated somatoform disorder was arbitrary, they are merged in DSM-5 under somatic
symptom disorder, and no specific number of somatic symptoms is required.
Pain Disorder
DSM-5 takes a different approach to the important clinical realm of individuals with pain. In DSM-IV, the
pain disorder diagnoses assume that some pains are associated solely with psychological factors, some
with medical diseases or injuries, and some with both. There is a lack of evidence that such distinctions
can be made with reliability and validity, and a large body of research has demonstrated that psycho-
logical factors influence all forms of pain. Most individuals with chronic pain attribute their pain to a
combination of factors, including somatic, psychological, and environmental influences. In DSM-5, some
individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder,
with predominant pain. For others, psychological factors affecting other medical conditions or an ad-
justment disorder would be more appropriate.
Anorexia Nervosa
The core diagnostic criteria for anorexia nervosa are conceptually unchanged from DSM-IV with one ex-
ception: the requirement for amenorrhea has been eliminated. In DSM-IV, this requirement was waived
in a number of situations (e.g., for males, for females taking contraceptives). In addition, the clinical
characteristics and course of females meeting all DSM-IV criteria for anorexia nervosa except amenor-
rhea closely resemble those of females meeting all DSM-IV criteria. As in DSM-IV, individuals with this
disorder are required by Criterion A to be at a significantly low body weight for their developmental
stage. The wording of the criterion has been changed for clarity, and guidance regarding how to judge
whether an individual is at or below a significantly low weight is now provided in the text. In DSM-5,
Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent
behavior that interferes with weight gain.
Bulimia Nervosa
The only change to the DSM-IV criteria for bulimia nervosa is a reduction in the required minimum
average frequency of binge eating and inappropriate compensatory behavior frequency from twice to
once weekly. The clinical characteristics and outcome of individuals meeting this slightly lower thresh-
old are similar to those meeting the DSM-IV criterion.
Binge-Eating Disorder
Extensive research followed the promulgation of preliminary criteria for binge eating disorder in Ap-
pendix B of DSM-IV, and findings supported the clinical utility and validity of binge-eating disorder. The
only significant difference from the preliminary DSM-IV criteria is that the minimum average frequency
of binge eating required for diagnosis has been changed from at least twice weekly for 6 months to at
least once weekly over the last 3 months, which is identical to the DSM-5 frequency criterion for buli-
mia nervosa.
Elimination Disorders
No significant changes have been made to the elimination disorders diagnostic class from DSM-IV to
DSM-5. The disorders in this chapter were previously classified under disorders usually first diagnosed
in infancy, childhood, or adolescence in DSM-IV and exist now as an independent classification in DSM-5.
12 • Highlights of Changes from DSM-IV-TR to DSM-5
Sleep-Wake Disorders
Because of the DSM-5 mandate for concurrent specification of coexisting conditions (medical and
mental), sleep disorders related to another mental disorder and sleep disorder related to a general
medical condition have been removed from DSM-5, and greater specification of coexisting conditions is
provided for each sleep-wake disorder. This change underscores that the individual has a sleep disorder
warranting independent clinical attention, in addition to any medical and mental disorders that are also
present, and acknowledges the bidirectional and interactive effects between sleep disorders and coex-
isting medical and mental disorders. This reconceptualization reflects a paradigm shift that is widely ac-
cepted in the field of sleep disorders medicine. It moves away from making causal attributions between
coexisting disorders. Any additional relevant information from the prior diagnostic categories of sleep
disorder related to another mental disorder and sleep disorder related to another medical condition
has been integrated into the other sleep-wake disorders where appropriate.
Consequently, in DSM-5, the diagnosis of primary insomnia has been renamed insomnia disorder to
avoid the differentiation of primary and secondary insomnia. DSM-5 also distinguishes narcolepsy,
which is now known to be associated with hypocretin deficiency, from other forms of hypersomno-
lence. These changes are warranted by neurobiological and genetic evidence validating this reorganiza-
tion. Finally, throughout the DSM-5 classification of sleep-wake disorders, pediatric and developmental
criteria and text are integrated where existing science and considerations of clinical utility support such
integration. This developmental perspective encompasses age-dependent variations in clinical presentation.
Rapid Eye Movement Sleep Behavior Disorder and Restless Legs Syndrome
The use of DSM-IV “not otherwise specified” diagnoses has been reduced by designating rapid eye
movement sleep behavior disorder and restless legs syndrome as independent disorders. In DSM-IV,
both were included under dyssomnia not otherwise specified. Their full diagnostic status is supported
by research evidence.
Sexual Dysfunctions
In DSM-IV, sexual dysfunctions referred to sexual pain or to a disturbance in one or more phases of the
sexual response cycle. Research suggests that sexual response is not always a linear, uniform process
and that the distinction between certain phases (e.g., desire and arousal) may be artificial. In DSM-5,
gender-specific sexual dysfunctions have been added, and, for females, sexual desire and arousal disor-
ders have been combined into one disorder: female sexual interest/arousal disorder.
To improve precision regarding duration and severity criteria and to reduce the likelihood of overdiag-
Highlights of Changes from DSM-IV-TR to DSM-5 • 13
nosis, all of the DSM-5 sexual dysfunctions (except substance-/medication-induced sexual dysfunction)
now require a minimum duration of approximately 6 months and more precise severity criteria. These
changes provide useful thresholds for making a diagnosis and distinguish transient sexual difficulties
from more persistent sexual dysfunction.
Subtypes
DSM-IV included the following subtypes for all sexual disorders: lifelong versus acquired, generalized
versus situational, and due to psychological factors versus due to combined factors. DSM-5 includes
only lifelong versus acquired and generalized versus situational subtypes. Sexual dysfunction due to a
general medical condition and the subtype due to psychological versus combined factors have been
deleted due to findings that the most frequent clinical presentation is one in which both psychological
and biological factors contribute. To indicate the presence and degree of medical and other nonmedical
correlates, the following associated features are described in the accompanying text: partner factors,
relationship factors, individual vulnerability factors, cultural or religious factors, and medical factors.
Gender Dysphoria
Gender dysphoria is a new diagnostic class in DSM-5 and reflects a change in conceptualization of the
disorder’s defining features by emphasizing the phenomenon of “gender incongruence” rather than
cross-gender identification per se, as was the case in DSM-IV gender identity disorder. In DSM-IV, the
chapter “Sexual and Gender Identity Disorders” included three relatively disparate diagnostic classes:
gender identity disorders, sexual dysfunctions, and paraphilias. Gender identity disorder, however, is
neither a sexual dysfunction nor a paraphilia. Gender dysphoria is a unique condition in that it is a di-
agnosis made by mental health care providers, although a large proportion of the treatment is endocri-
nological and surgical (at least for some adolescents and most adults). In contrast to the dichotomized
DSM-IV gender identity disorder diagnosis, the type and severity of gender dysphoria can be inferred
from the number and type of indicators and from the severity measures.
The experienced gender incongruence and resulting gender dysphoria may take many forms. Gender
dysphoria thus is considered to be a multicategory concept rather than a dichotomy, and DSM-5 ac-
knowledges the wide variation of gender -incongruent conditions. Separate criteria sets are provided
for gender dysphoria in children and in adolescents and adults. The adolescent and adult criteria
include a more detailed and specific set of polythetic symptoms. The previous Criterion A (cross-gender
identification) and Criterion B (aversion toward one’s gender) have been merged, because no support-
ing evidence from factor analytic studies supported keeping the two separate. In the wording of the
criteria, “the other sex” is replaced by “some alternative gender.” Gender instead of sex is used system-
atically because the concept “sex” is inadequate when referring to individuals with a disorder of sex
development.
In the child criteria, “strong desire to be of the other gender” replaces the previous “repeatedly stated
desire” to capture the situation of some children who, in a coercive environment, may not verbalize the
desire to be of another gender. For children, Criterion A1 (“a strong desire to be of the other gender or
14 • Highlights of Changes from DSM-IV-TR to DSM-5
an insistence that he or she is the other gender . . .)” is now necessary (but not sufficient), which makes
the diagnosis more restrictive and conservative.
Conduct Disorder
The criteria for conduct disorder are largely unchanged from DSM-IV. A descriptive features specifier
has been added for individuals who meet full criteria for the disorder but also present with limited pro-
social emotions. This specifier applies to those with conduct disorder who show a callous and unemo-
tional interpersonal style across multiple settings and relationships. The specifier is based on research
showing that individuals with conduct disorder who meet criteria for the specifier tend to have a rela-
tively more severe form of the disorder and a different treatment response.
Neurocognitive Disorders
Delirium
The criteria for delirium have been updated and clarified on the basis of currently available evidence.
Although the threshold between mild NCD and major NCD is inherently arbitrary, there are important
reasons to consider these two levels of impairment separately. The major NCD syndrome provides
consistency with the rest of medicine and with prior DSM editions and necessarily remains distinct to
capture the care needs for this group. Although the mild NCD syndrome is new to DSM-5, its presence
is consistent with its use in other fields of medicine, where it is a significant focus of care and research,
notably in individuals with Alzheimer’s disease, cerebrovascular disorders, HIV, and traumatic brain
injury.
Etiological Subtypes
In DSM-IV, individual criteria sets were designated for dementia of the Alzheimer’s type, vascular
dementia, and substance-induced dementia, whereas the other neurodegenerative disorders were
classified as dementia due to another medical condition, with HIV, head trauma, Parkinson’s disease,
Huntington’s disease, Pick’s disease, Creutzfeldt-Jakob disease, and other medical conditions specified.
In DSM-5, major or mild vascular NCD and major or mild NCD due to Alzheimer’s disease have been re-
tained, whereas new separate criteria are now presented for major or mild NCD due to frontotemporal
NCD, Lewy bodies, traumatic brain injury, Parkinson’s disease, HIV infection, Huntington’s disease, prion
disease, another medical condition, and multiple etiologies. Substance/medication-induced NCD and
unspecified NCD are also included as diagnoses.
Personality Disorders
The criteria for personality disorders in Section II of DSM-5 have not changed from those in DSM-IV.
An alternative approach to the diagnosis of personality disorders was developed for DSM-5 for further
study and can be found in Section III. For the general criteria for personality disorder presented in Sec-
tion III, a revised personality functioning criterion (Criterion A) has been developed based on a litera-
ture review of reliable clinical measures of core impairments central to personality pathology. Further-
more, the moderate level of impairment in personality functioning required for a personality disorder
diagnosis in DSM-5 Section III was set empirically to maximize the ability of clinicians to identify per-
sonality disorder pathology accurately and efficiently. With a single assessment of level of personality
functioning, a clinician can determine whether a full assessment for personality disorder is necessary.
The diagnostic criteria for specific DSM-5 personality disorders in the alternative model are consis-
tently defined across disorders by typical impairments in personality functioning and by characteristic
pathological personality traits that have been empirically determined to be related to the personality
disorders they represent. Diagnostic thresholds for both Criterion A and Criterion B have been set em-
pirically to minimize change in disorder prevalence and overlap with other personality disorders and to
maximize relations with psychosocial impairment. A diagnosis of personality disorder—trait specified,
based on moderate or greater impairment in personality functioning and the presence of pathologi-
cal personality traits, replaces personality disorder not otherwise specified and provides a much more
Highlights of Changes from DSM-IV-TR to DSM-5 • 17
informative diagnosis for patients who are not optimally described as having a specific personality dis-
order. A greater emphasis on personality functioning and trait-based criteria increases the stability and
empirical bases of the disorders.
Personality functioning and personality traits also can be assessed whether or not an individual has a
personality disorder, providing clinically useful information about all patients. The DSM-5 Section III ap-
proach provides a clear conceptual basis for all personality disorder pathology and an efficient assess-
ment approach with considerable clinical utility.
Paraphilic Disorders
Specifiers
An overarching change from DSM-IV is the addition of the course specifiers “in a controlled environ-
ment” and “in remission” to the diagnostic criteria sets for all the paraphilic disorders. These specifiers
are added to indicate important changes in an individual’s status. There is no expert consensus about
whether a long-standing paraphilia can entirely remit, but there is less argument that consequent psy-
chological distress, psychosocial impairment, or the propensity to do harm to others can be reduced to
acceptable levels. Therefore, the “in remission” specifier has been added to indicate remission from a
paraphilic disorder. The specifier is silent with regard to changes in the presence of the paraphilic inter-
est per se. The other course specifier, “in a controlled environment,” is included because the propensity
of an individual to act on paraphilic urges may be more difficult to assess objectively when the individu-
al has no opportunity to act on such urges.
The distinction between paraphilias and paraphilic disorders was implemented without making any
changes to the basic structure of the diagnostic criteria as they had existed since DSM-III-R. In the diag-
nostic criteria set for each of the listed paraphilic disorders, Criterion A specifies the qualitative nature
of the paraphilia (e.g., an erotic focus on children or on exposing the genitals to strangers), and Crite-
rion B specifies the negative consequences of the paraphilia (distress, impairment, or harm—or risk of
harm—to others).
The change for DSM-5 is that individuals who meet both Criterion A and Criterion B would now be
diagnosed as having a paraphilic disorder. A diagnosis would not be given to individuals whose symp-
toms meet Criterion A but not Criterion B—that is, to those individuals who have a paraphilia but not a
paraphilic disorder.
The distinction between paraphilias and paraphilic disorders is one of the changes from DSM-IV that
applies to all atypical erotic interests. This approach leaves intact the distinction between normative
and nonnormative sexual behavior, which could be important to researchers or to persons who have
nonnormative sexual preferences, but without automatically labeling nonnormative sexual behavior as
DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders. The American Psychiatric
Association (APA) will publish DSM-5 in 2013, culminating a 14-year revision process. For more information, go to www.
DSM5.org.
APA is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treat-
ment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psychiatry.org.
For more information, please contact Eve Herold at 703-907-8640 or press@psych.org.
Occurs on its own, rather than as part of the course of another mental
health problem, such as a substance use disorder, depression or bipolar
disorder
Has shown spiteful or vindictive behavior at least twice in the past six
months
These behaviors must be displayed more often than is typical for your child's
peers. For children younger than 5 years, the behavior must occur on most days
for a period of at least six months. For individuals 5 years or older, the behavior
must occur at least once a week for at least six months.
DSM-5 diagnostic criteria for a major depressive episode
A. Five (or more) of the following symptoms have been present during the same two-week period and represent a
change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest
or pleasure.
NOTE: Do not include symptoms that are clearly attributable to another medical condition.
1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad,
empty, hopeless) or observations made by others (eg, appears tearful). (NOTE: In children and adolescents, can
be irritable mood.)
2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as
indicated by either subjective account or observation)
3) Significant weight loss when not dieting or weight gain (eg, a change of more than 5 percent of body weight
in a month), or decrease or increase in appetite nearly every day. (NOTE: In children, consider failure to make
expected weight gain.)
5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings
of restlessness or being slowed down)
6) Fatigue or loss of energy nearly every day
7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day
(not merely self-reproach or guilt about being sick)
8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by their subjective
account or as observed by others)
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing suicide
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas
of functioning.
C. The episode is not attributable to the direct physiological effects of a substance or to another medical condition.
NOTE: Responses to a significant loss (eg, bereavement, financial ruin, losses from a natural disaster, a serious
medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor
appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms
may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition
to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the
exercise of clinical judgement based on the individual's history and the cultural norms for the expression of distress
in the context of loss.
D. The occurence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other
psychotic disorders.
NOTE: This exclusion does not apply if all of the manic-like or hypomanic-like epsidoes are substance-
induced or are attributable to the physiological effects of another medical condition.
Specify:
With catatonia
:The criteria for adjustment disorder with depressed mood are as follows [6]
Significant distress that exceeds what would be expected given the nature of the •
stressor
The syndrome does not meet criteria for another psychiatric disorder (eg, unipolar major ●
depression)
After the stressor and its consequences have ended, the syndrome resolves within six ●
months
Major depression and other depressive disorders often occur in the context of psychosocial
stressors; thus, the diagnosis of adjustment disorder with depressed mood is superseded by a
depressive disorder. Clinicians distinguish a depressive disorder from adjustment disorder not by
noting whether a stressor is present, but by determining whether the patient’s symptoms are
sufficient in number, severity, and duration to meet diagnostic criteria for major depression or
.another depressive disorder
DIAGNOSIS — The diagnostic criteria for acute stress disorder (ASD) from DSM-5 are described
:below [61]
A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of
:the following ways
Learning that the event(s) occurred to a close family member or close friend .3
Note: In cases of actual or threatened death of a family member or friend, the event(s)
.must have been violent or accidental
Note: This does not apply to exposure through electronic media, television, movies, or
.pictures, unless this exposure is work-related
B. Presence of nine (or more) of the following symptoms from any of the five categories of
intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after
:the traumatic event(s) occurred
Intrusion symptoms
Recurrent distressing dreams in which the content and/or affect of the dream .2
.are related to the event(s)
.Note: In children, there may be frightening dreams without recognizable content
Dissociative symptoms
An altered sense of the reality of one's surroundings or oneself (eg, seeing oneself .6
.from another's perspective, being in a daze, time slowing)
Avoidance symptoms
Arousal symptoms
Sleep disturbance (eg, difficulty falling or staying asleep, restless sleep) .10
Irritable behavior and angry outbursts (with little or no provocation), typically .11
expressed as verbal or physical aggression toward people or objects
Hypervigilance .12
C. Duration of the disturbance (symptoms in Criterion B) is three days to one month after trauma
.exposure
Note: Symptoms typically begin immediately after the trauma, but persistence for at least three
.days and up to a month is needed to meet disorder criteria
E. The disturbance is not attributable to the physiological effects of a substance (eg, medication or
alcohol) or another medical condition (eg, mild traumatic brain injury) and is not better explained
.by brief psychotic disorder
A. Two (or more) of the following, each present for a significant portion of time during a one-month period (or less
if successfully treated). At least one of these must be (1), (2), or (3):
1) Delusions.
2) Hallucinations.
3) Disorganized speech (eg, frequent derailment or incoherence).
4) Grossly disorganized or catatonic behavior.
5) Negative symptoms (ie, diminished emotional expression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major
areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or
when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic,
or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This six-month period must include at least 1
month of symptoms (or less if successfully treated) that meet Criterion A (ie, active-phase symptoms) and may
include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the
disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A
present in an attenuated form (eg, odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because
either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2)
if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total
duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the direct physiological effects of a substance (eg, a drug of abuse, a
medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional
diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required
symptoms of schizophrenia, are also present for at least one month (or less if successfully treated).
Of the 6 criteria: 4 are like MDD criteria ► Fatigue (lack of energy), Lack of
concentration // Irritability (Psychomotor agitation) // Sleep disturbance
+++ Restlessness, (↔ Irritability), muscle tension.