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The Criterion A clause, indicating that the signs or symptoms of pedophilia have per- sisted for 6 months or longer, is intended to ensure that the sexual attraction to children is not merely transient. However, the diagnosis may be made if there is clinical evidence of sustained persistence of the sexual attraction to children even if the 6-month duration can- not be precisely determined.
The extensive use of pornography depicting prepubescent children is a useful diagnostic indicator of pedophilic disorder. This is a specific instance of the general case that individ- uals are likely to choose the kind of pornography that corresponds to their sexual interests.
The population prevalence of pedophilic disorder is unknown. The highest possible prev- alence for pedophilic disorder in the male population is approximately 3%—5%. The pop- ulation prevalence of pedophilic disorder in females is even more uncertain, but it is likely a small fraction of the prevalence in males.
Adult males with pedophilic disorder may indicate that they become aware of strong or preferential sexual interest in children around the time of puberty—the same time frame in which males who later prefer physically mature partners became aware of their sexual interest in women or men. Attempting to diagnose pedophilic disorder at the age at which it first manifests is problematic because of the difficulty during adolescent development in differentiating it from age-appropriate sexual interest in peers or from sexual curiosity.
Hence, Criterion C requires for diagnosis a minimum age of 16 years and at least 5 years older than the child or children in Criterion A.
Pedophilia per se appears to be a lifelong condition. Pedophilic disorder, however, necessarily includes other elements that may change over time with or without treatment: subjective distress (e.g., guilt, shame, intense sexual frustration, or feelings of isolation) or psychosocial impairment, or the propensity to act out sexually with children, or both.
Therefore, the course of pedophilic disorder may fluctuate, increase, or decrease with age.
Adults with pedophilic disorder may report an awareness of sexual interest in children that preceded engaging in sexual behavior involving children or self-identification as a pedo- phile. Advanced age is as likely to similarly diminish the frequency of sexual behavior involv— ing children as it does other paraphilically motivated and normophilic sexual behavior.
Temperamental. There appears to be an interaction between pedophilia and antisocial- ity, such that males with both traits are more likely to act out sexually with children. Thus, males with pedophilia.
Environmental. Adult males with pedophilia often report that they were sexually abused as children. It is unclear, however, whether this correlation reflects a causal influence of childhood sexual abuse on adult pedophilia.
Genetic and physiological. Since pedophilia is a necessary condition for pedophilic dis- order, any factor that increases the probability of pedophilia also increases the risk of pe- dophilic disorder. There is some evidence that neurodevelopmental perturbation in utero increases the probability of development of a pedophilic orientation.
Psychophysiological laboratory measures of sexual interest, which are sometimes useful in di- agnosing pedophilic disorder in males, are not necessarily useful in diagnosing this disorder in females, even when an identical procedure (e.g., viewing time) or analogous procedures (e.g., penile plethysmography and vaginal photoplethysmography) are available. | DSM5 Psichiatry |
Psychophysiological measures of sexual interest may sometimes be useful when an indi- vidual’s history suggests the possible presence of pedophilic disorder but the individual denies strong or preferential attraction to children. The most thoroughly researched and longest used of such measures is penile plethysmography, although the sensitivity and spec- ificity of diagnosis may vary from one site to another. Viewing time, using photographs of nude or minimally clothed persons as visual stimuli, is also used to diagnose pedophilic disorder, especially in combination with self—report measures. Mental health professionals in the United States, however, should be aware that possession of such visual stimuli, even for diagnostic purposes, may violate American law regarding possession of child pornog- raphy and leave the mental health professional susceptible to criminal prosecution.
Many of the conditions that could be differential diagnoses for pedophilic disorder also sometimes occur as comorbid diagnoses. It is therefore generally necessary to evaluate the evidence for pedophilic disorder and other possible conditions as separate questions.
Antisocial personality disorder. This disorder increases the likelihood that a person who is primarily attracted to the mature physique will approach a child, on one or a few occa- sions, on the basis of relative availability. The individual often shows other signs of this personality disorder, such as recurrent law-breaking.
Alcohol and substance use disorders. The disinhibiting effects of intoxication may also increase the likelihood that a person who is primarily attracted to the mature physique will sexually approach a child.
Obsessive-compulsive disorder. There are occasional individuals who complain about ego-dystonic thoughts and worries about possible attraction to children. Clinical inter- viewing usually reveals an absence of sexual thoughts about children during high states of sexual arousal (e.g., approaching orgasm during masturbation) and sometimes additional ego-dystonic, intrusive sexual ideas (e.g., concerns about homosexuality).
Psychiatric comorbidity of pedophilic disorder includes substance use disorders; depres- sive, bipolar, and anxiety disorders; antisocial personality disorder; and other paraphilic disorders. However, findings on comorbid disorders are largely among individuals con- izable to other individuals with pedophilic disorder (e.g., individuals who have never approached a child sexually but who qualify for the diagnosis of pedophilic disorder on the basis of subjective distress).
Diagnostic Criteria 302.81 (F65.0)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body pad(s), as manifested by fantasies. urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impair- ment in social, occupational, or other important areas of functioning.
C. The fetish objects are not limited to articles of clothing used in cross-dressing (as in transvestic disorder) or devices specifically designed for the purpose of tactile genital stimulation (e.g.. vibrator).
Specify:
Specify if: in a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in fetishistic behaviors are restricted.
In full remIssIon: There has been no distress or impairment in social, occupational, or other areas of functioning for at least 5 years while in an uncontrolled environment.
Although individuals with fetishistic disorder may report intense and recurrent sexual arousal to inanimate objects or a specific body part, it is not unusual for non—mutually ex- clusive combinations of fetishes to occur. Thus, an individual may have fetishistic disorder associated with an inanimate object (e.g., female undergarments) or an exclusive focus on an intensely eroticized body part (e.g., feet, hair), or their fetishistic interest may meet cri- teria for various combinations of these specifiers (e.g., socks, shoes and feet). | DSM5 Psichiatry |
The paraphilic focus of fetishistic disorder involves the persistent and repetitive use of or de as primary elements associated with sexual arousal (Criterion A). A diagnosis of fetishistic dis- (Criterion B). Common fetish objects include female undergarments, male or female footwear, rubber articles, leather clothing, or other wearing apparel. Highly eroticized body parts asso- ciated with fetishistic disorder include feet, toes, and hair. It is not uncommon for sexualized fetishes to include both inanimate objects and body parts (e.g., dirty socks and feet), and for this reason the definition of fetishistic disorder now re-incorporates partiulism (i.e., an exclusive focus on a body part) into its boundaries. Partialism, previously considered a paraphilia not otherwise specified disorder, had historically been subsumed in fetishism prior to DSM-Il].
Many individuals who self—identify as fetishist practitioners do not necessarily report clinical impairment in association with their fetish-associated behaviors. Such individuals could be considered as having a fetish but not fetishistic disorder. A diagnosis of fetishistic disorder requires concurrent fulfillment of both the behaviors in Criterion A and the clin- ically significant distress or impairment in ftmctioning noted in Criterion B.
Fetishistic disorder can be a multisensory experience, including holding, tasting, rubbing, inserting, or smelling the fetish object while masturbating, or preferring that a sexual part- ner wear or utilize a fetish object during sexual encounters. Some individuals may acquire extensive collections of highly desired fetish objects.
Usually paraphilias have an onset during puberty, but fetishes can develop prior to ado- lescence. Once established, fetishistic disorder tends to have a continuous course that fluc- tuates in intensity and frequency of urges or behavior.
Knowledge of and appropriate consideration for normative aspects of sexual behavior are important factors to explore to establish a clinical diagnosis of fetishistic disorder and to distinguish a clinical diagnosis from a socially acceptable sexual behavior.
Fetishistic disorder has not been systematically reported to occur in females. In clinical samples, fetishistic disorder is nearly exclusively reported in males.
Functional Consequences of Fetishistic Disorder
Typical impairments associated with fetishistic disorder include sexual dysfunction during romantic reciprocal relationships when the preferred fetish object or body part is unavailable during foreplay or coitus. Some individuals with fetishistic disorder may pre- fer solitary sexual activity associated with their fetishistic preference(s) even while in- volved in a meaningful reciprocal and affectionate relationship.
Although fetishistic disorder is relatively uncommon among arrested sexual offenders with paraphilias, males with fetishistic disorder may steal and collect their particular fe- tishistic objects of desire. Such individuals have been arrested and charged for nonsexual antisocial behaviors (e.g., breaking and entering, theft, burglary) that are primarily moti- vated by the fetishistic disorder.
Transvestic disorder. The nearest diagnostic neighbor of fetishistic disorder is transves- tic disorder. As noted in the diagnostic criteria, fetishistic disorder is not diagnosed when fetish objects are limited to articles of clothing exclusively worn during cross-dressing (as in transvestic disorder), or when the object is genitally stimulating because it has been de~ signed for that purpose (e.g., a vibrator).
Sexual masochism disorder or other paraphilic disorders. Fetishes can co-occur with other paraphilic disorders, especially ”sadomasochism” and transvestic disorder. When an individual fantasizes about or engages in ”forced cross-dressing” and is primarily sex- ually aroused by the domination or humiliation associated with such fantasy or repetitive activity, the diagnosis of sexual masochism disorder should be made. | DSM5 Psichiatry |
Fetishistic behavior without fetishistic disorder. Use of a fetish object for sexual arousal quence would not meet criteria for fetishistic disorder, as the threshold required by Crite- rion B would not be met. For example, an individual whose sexual partner either shares or can successfully incorporate his interest in caressing, smelling, or licking feet or toes as an important element of foreplay would not be diagnosed with fetishistic disorder; nor would an individual who prefers, and is not distressed or impaired by, solitary sexual be- havior associated with wearing rubber garments or leather boots.
Fetishistic disorder may co-occur with other paraphilic disorders as well as hypersexual- ity. Rarely, fetishistic disorder may be associated with neurological conditions.
Diagnostic Criteria 302.3 (F65.1)
A. Over a period of at least 6 months. recurrent and intense sexual arousal from cross- dressing, as manifested by fantasies, urges, or behaviors.
B. The fantasies. sexual urges. or behaviors cause clinically significant distress or impair- ment in social. occupational, or other important areas of functioning.
Specify if:
Wlth fetishism: If sexually aroused by fabrics, materials, or garments.
With autogynephllia: If sexually aroused by thoughts or images of self as female.
Specify it:
In a controiled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to cross-dress are restricted.
In full remisslon: There has been no distress or impairment in social, occupational, or other areas of functioning for at least 5 years while in an uncontrolled environment.
The presence of fetishism decreases the likelihood of gender dysphoria in men with trans- vestic disorder. The presence of autogynephilia increases the likelihood of gender dyspho- ria in men with transvestic disorder.
The diagnosis of transvestic disorder does not apply to all individuals who dress as the op- posite sex, even those who do so habitually. It applies to individuals whose cross-dressing or thoughts of cross-dressing are always or often accompanied by sexual excitement (Cri- terion A) and who are emotionally distressed by this pattern or feel it impairs social or in- terpersonal functioning (Criterion B). The cross-dressing may involve only one or two articles of clothing (e.g., for men, it may pertain only to women’s undergarments), or it may involve dressing completely in the inner and outer garments of the other sex and (in men) may include the use of women’s wigs and make-up. Transvestic disorder is nearly exclusively reported in males. Sexual arousal, in its most obvious form of penile erection, may co-occur with cross-dressing in various ways. In younger males, cross-dressing often leads to masturbation, following which any female clothing is removed. Older males often learn to avoid masturbating or doing anything to stimulate the penis so that the avoidance of ejaculation allows them to prolong their cross-dressing session. Males with female part- ners sometimes complete a cross-dressing session by having intercourse with their part- ners, and some have difficulty maintaining a sufficient erection for intercourse without cross-dressing (or private fantasies of cross-dressing).
Clinical assessment of distress or impairment, like clinical assessment of transvestic sexual arousal, is usually dependent on the individual’s self—report. The pattern of behav- ior "purging and acquisition” often signifies the presence of distress in individuals with transvestic disorder. During this behavioral pattern, an individual (usually a man) who has spent a great deal of money on women’s clothes and other apparel (e.g., shoes, wigs) discards the items (i.e., purges them) in an effort to overcome urges to cross-dress, and then begins acquiring a woman’s wardrobe all over again. | DSM5 Psichiatry |
Transvestic disorder in men is often accompanied by autogynephilia (i.e., a male’s para- philic tendency to be sexually aroused by the thought or image of himself as a woman).
Autogynephilic fantasies and behaviors may focus on the idea of exhibiting female phys- iological functions (e.g., lactation, menstruation), engaging in stereotypically feminine be- havior (e.g., knitting), or possessing female anatomy (e.g., breasts).
The prevalence of transvestic disorder is unknown. Transvestic disorder is rare in males and extremely rare in females. Fewer than 3% of males report having ever been sexually aroused by dressing in women’s attire. The percentage of individuals who have cross- dressed with sexual arousal more than once or a few times in their lifetimes would be even lower. The majority of males with transvestic disorder identify as heterosexual, although some individuals have occasional sexual interaction with other males, especially when they are cross-dressed.
In males, the first signs of transvestic disorder may begin in childhood, in the form of strong fascination with a particular item of women’s attire. Prior to puberty, cross-dress- ing produces generalized feelings of pleasurable excitement. With the arrival of puberty, dressing in women’s clothes begins to elicit penile erection and, in some cases, leads di- rectly to first ejaculation. In many cases, cross-dressing elicits less and less sexual ex- citement as the individual grows older; eventually it may produce no discernible penile response at all. The desire to cross-dress, at the same time, remains the same or grows even stronger. Individuals who report such a diminution of sexual response typically report that the sexual excitement of cross-dressing has been replaced by feelings of comfort or well-being.
In some cases, the course of transvestic disorder is continuous, and in others it is epi- sodic. It is not rare for men with transvestic disorder to lose interest in cross-dressing when they first fall in love with a woman and begin a relationship, but such abatement usually proves temporary. When the desire to cross-dress returns, so does the associated distress.
Some cases of transvestic disorder progress to gender dysphoria. The males in these cases, who may be indistinguishable from others with transvestic disorder in adolescence or early childhood, gradually develop desires to remain in the female role for longer pe- riods and to feminize their anatomy. The development of gender dysphoria is usually ac- companied by a (self-reported) reduction or elimination of sexual arousal in association with cross-dressing.
The manifestation of transvestism in penile erection and stimulation, like the manifesta- tion of other paraphilic as well as normophilic sexual interests, is most intense in adolescence and early adulthood. The severity of transvestic disorder is highest in adulthood, when the transvestic drives are most likely to conflict with performance in heterosexual intercourse and desires to marry and start a family. Middle—age and older men with a history of trans- vestism are less likely to present with transvestic disorder than with gender dysphoria.
Functional Consequences of Transvestic Disorder
Engaging in transvestic behaviors can interfere with, or detract from, heterosexual rela- tionships. This can be a source of distress to men who wish to maintain conventional mar— riages or romantic partnerships with women.
Fetishistic disorder. This disorder may resemble transvestic disorder, in particular, in men with fetishism who put on women’s undergarments while masturbating with them.
Distinguishing transvestic disorder depends on the individual’s specific thoughts during such activity (e.g., are there any ideas of being a woman, being like a woman, or being dressed as a woman?) and on the presence of other fetishes (e.g., soft, silky fabrics, whether these are used for garments or for something else). | DSM5 Psichiatry |
Gender dysphoria. Individuals with transvestic disorder do not report an incongruence be- tween their experienced gender and assigned gender nor a desire to be of the other gender; and they typically do not have a history of childhood cross-gender behaviors, which would be present in individuals with gender dysphoria. Individuals with a presentation that meets full criteria for transvestic disorder as well as gender dysphoria should be given both diagnoses.
Transvestism (and thus transvestic disorder) is often found in association with other para- philias. The most frequently co-occurring paraphilias are fetishism and masochism. One particularly dangerous form of masochism, au toerotic asphyxia, is associated with transves- tism in a substantial proportion of fatal cases.
302.89 (F65.89)
This category applies to presentations in which symptoms characteristic of a paraphilic disor- der that cause clinically significant distress or impairment in social, occupational, or other im- portant areas of functioning predominate but do not meet the full criteria for any of the disorders in the paraphilic disorders diagnostic class. The other specified paraphilic disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific paraphilic disorder. This is done by re- cording “other specified paraphilic disorder’ followed by the specific reason (e.g., “zoophilia”).
Examples of presentations that can be specified using the "other specified" designation include, but are not limited to, recurrent and intense sexual arousal involving telephone scatologia (obscene phone calls), necrophilia (corpses), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), or urophilia (urine) that has been present for at least 6 months and causes marked distress or impairment in social, occupational, or other important ar- eas of functioning. Other specified paraphilic disorder can be specified as in remission and/or as occurring in a controlled environment.
302.9 (F65.9)
This category applies to presentations in which symptoms characteristic of a paraphilic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the paraphilic disorders diagnostic class. The unspecified paraphilic dis- order category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific paraphilic disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis.
FOUF disorders are included in this chapter: other specified mental disorder due to another medical condition; unspecified mental disorder due to another medical condition; other specified mental disorder; and unspecified mental disorder. This residual category applies to presentations in which symptoms characteristic of a mental disorder that cause clinically significant distress or impairment in social, occupational, or other important ar- eas of functioning predominate but do not meet the full criteria for any other mental dis- order in DSM—5. For other specified and unspecified mental disorders due to another medical condition, it must be established that the disturbance is caused by the physiolog- ical effects of another medical condition. If other specified and unspecified mental disor- ders are due to another medical condition, it is necessary to code and list the medical condition first (e.g., 042 [820] HIV disease), followed by the other specified or unspecified mental disorder (use appropriate code).
Due to Another Medical Condition 294.8 (F06.8) | DSM5 Psichiatry |
This category applies to presentations in which symptoms characteristic of a mental dis- order due to another medical condition that cause clinically significant distress or impair— ment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any specific mental disorder attributable to another medical condition. The other specified mental disorder due to another medical condition category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific mental disorder attributable to another medical condition. This is done by recording the name of the disorder, with the specific etiological medical condition inserted in place of “another medical condition," fol- lowed by the specific symptomatic manifestation that does not meet the criteria for any specific mental disorder due to another medical condition. Furthermore, the diagnostic code for the specific medical condition must be listed immediately before the code for the other specified mental disorder due to another medical condition. For example, dissocia- tive symptoms due to complex partial seizures would be coded and recorded as 345.40 (640.209), complex partial seizures 294.8 (F06.8) other specified mental disorder due to complex partial seizures, dissociative symptoms.
An example of a presentation that can be specified using the “other specified" desig- nation is the following:
Dissociative symptoms: This includes symptoms occurring, for example, in the con- text of complex partial seizures.
Due to Another Medical Condition 294.9 (F09)
This category applies to presentations in which symptoms characteristic of a mental dis- order due to another medical condition that cause clinically significant distress or impair- ment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any specific mental disorder due to another medical condition.
The unspecified mental disorder due to another medical condition category is used in sit- uations in which the clinician chooses not to specify the reason that the criteria are not met for a specific mental disorder due to another medical condition, and includes presentations for which there is insufficient information to make a more specific diagnosis (e.g., in emer- gency room settings). This is done by recording the name of the disorder, with the specific etiological medical condition inserted in place of “another medical condition." Furthermore, the diagnostic code for the specific medical condition must be listed immediately before the code for the unspecified mental disorder due to another medical condition. For exam- ple, dissociative symptoms due to complex partial seizures would be coded and recorded as 345.40 (640.209) complex partial seizures, 294.9 (F069) unspecified mental disorder due to complex partial seizures.
300.9 (F99)
This category applies to presentations in which symptoms characteristic of a mental dis- order that cause clinically significant distress or impairment in social, occupational. or oth- er important areas of functioning predominate but do not meet the full criteria for any specific mental disorder. The other specified mental disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific mental disorder. This is done by recording "other specified mental disorder” followed by the specific reason.
300.9 (F99)
This category applies to presentations in which symptoms characteristic of a mental dis- order that cause clinically significant distress or impairment in social, occupational, or oth- er important areas of functioning predominate but do not meet the full criteria for any mental disorder. The unspecified mental disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific mental disorder, and includes presentations for which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).
MedlCaftiOn-lnduced.MOvem‘e'
Disorders and ,Other‘ Advers | DSM5 Psichiatry |
Medication—induced movement disorders are included in Section II because of their frequent importance in 1) the management by medication of mental disorders or oth- er medical conditions and 2) the differential diagnosis of mental disorders (e.g., anxiety malignant syndrome). Although these movement disorders are labeled “medication in- duced,” it is often difficult to establish the causal relationship between medication expo- sure and the development of the movement disorder, especially because some of these movement disorders also occur in the absence of medication exposure. The conditions and problems listed in this chapter are not mental disorders.
The term neuroleptic is becoming outdated because it highlights the propensity of an- tipsychotic medications to cause abnormal movements, and it is being replaced with the term antipsychotic in many contexts. Nevertheless, the term neuroleptic remains appropri- ate in this context. Although newer antipsychotic medications may be less likely to cause some medication-induced movement disorders, those disorders still occur. Neuroleptic medications include so-called conventional, ”typical,” or first-generation antipsychotic agents (e.g., chlorpromazine, haloperidol, fluphenazine); ”atypical” or second-generation antipsychotic agents (e.g., clozapine, risperidone, olanzapine, quetiapine); certain dopa- mine receptor—blocking drugs used in the treatment of symptoms such as nausea and gas- troparesis (e.g., prochlorperazine, promethazine, trimethobenzamide, thiethylperazine, metoclopramide); and amoxapine, which is marketed as an antidepressant.
332.1 (G21.11) Neuroleptic-Induced Parkinsonism 332.1 (621.19) Other Medication-Induced Parkinsonism
Parkinsonian tremor, muscular rigidity, akinesia (i.e., loss of movement or difficulty ini- tiating movement), or bradykinesia (i.e., slowing movement) developing within a few weeks of starting or raising the dosage of a medication (e.g., a neuroleptic) or after reduc- ing the dosage of a medication used to treat extrapyramidal symptoms.
333.92 (G21.0) Neuroleptic Malignant Syndrome
Although neuroleptic malignant syndrome is easily recognized in its classic full-blown form, it is often heterogeneous in onset, presentation, progression, and outcome. The clin- ical features described below are those considered most important in making the diagno- sis of neuroleptic malignant syndrome based on consensus recommendations. | DSM5 Psichiatry |
Patients have generally been exposed to a dopamine antagonist within 72 hours prior to symptom development. Hyperthermia (>100.4°F or >38.0°C on at least two occasions, measured orally), associated with profuse diaphoresis, is a distinguishing feature of neu- roleptic malignant syndrome, setting it apart from other neurological side effects of anti- psychotic medications. Extreme elevations in temperature, reflecting a breakdown in central thermoregulation, are more likely to support the diagnosis of neuroleptic malig- nant syndrome. Generalized rigidity, described as ”lead pipe” in its most severe form and usually unresponsive to antiparkinsonian agents, is a cardinal feature of the disorder and may be associated with other neurological symptoms (e.g., tremor, sialorrhea, akinesia, dystonia, trismus, myoclonus, dysarthria, dysphagia, rhabdomyolysis). Creatine kinase elevation of at least four times the upper limit of normal is commonly seen. Changes in mental status, characterized by delirium or altered consciousness ranging from stupor to coma, are often an early sign. Affected individuals may appear alert but dazed and unre- sponsive, consistent with catatonic stupor. Autonomic activation and instability—mani- fested by tachycardia (rate>25% above baseline), diaphoresis, blood pressure elevation 225 mmHg systolic change within 24 hours), urinary incontinence, and pallor—may be seen at any time but provide an early clue to the diagnosis. Tachypnea (rate >50°/o above baseline) is common, and respiratory distress—resulting from metabolic acidosis, hyper- metabolism, chest wall restriction, aspiration pneumonia, or pulmonary emboli—can oc- cur and lead to sudden respiratory arrest.
A workup, including laboratory investigation, to exclude other infectious, toxic, met- abolic, and neuropsychiatric etiologies or complications is essential (see the section ”Dif- ferential Diagnosis” later in this discussion). Although several laboratory abnormalities are associated with neuroleptic malignant syndrome, no single abnormality is specific to the diagnosis. Individuals with neuroleptic malignant syndrome may have leukocytosis, metabolic acidosis, hypoxia, decreased serum iron concentrations, and elevations in se- rum muscle enzymes and catecholamines. Findings from cerebrospinal fluid analysis and neuroimaging studies are generally normal, whereas electroencephalography shows gen- eralized slowing. Autopsy findings in fatal cases have been nonspecific and variable, de- pending on complications. | DSM5 Psichiatry |
drome of 0.01%—0.02% among individuals treated with antipsychotics. The temporal pro- gression of signs and symptoms provides important clues to the diagnosis and prognosis of neuroleptic malignant syndrome. Alteration in mental status and other neurological signs typically precede systemic signs. The onset of symptoms varies from hours to days after drug initiation. Some cases develop within 24 hours after drug initiation, most within the first week, and virtually all cases within 30 days. Once the syndrome is diagnosed and oral antipsychotic drugs are discontinued, neuroleptic malignant syndrome is self—limited in most cases. The mean recovery time after drug discontinuation is 7—10 days, with most individuals recovering within 1 week and nearly all within 30 days. The duration may be prolonged when long-acting antipsychotics are implicated. There have been reports of in- dividuals in whom residual neurological signs persisted for weeks after the acute hyper- metabolic symptoms resolved. Total resolution of symptoms can be obtained in most cases of neuroleptic malignant syndrome; however, fatality rates of 10%—20% have been reported when the disorder is not recognized. Although many individuals do not experi- ence a recurrence of neuroleptic malignant syndrome when rechallenged with antipsy- chotic medication, some do, especially when antipsychotics are reinstituted soon after an episode.
Neuroleptic malignant syndrome is a potential risk in any individual after antipsychotic drug administration. It is not specific to any neuropsychiatric diagnosis and may occur in individuals without a diagnosable mental disorder who receive dopamine antagonists.
Clinical, systemic, and metabolic factors associated with a heightened risk of neuroleptic malignant syndrome include agitation, exhaustion, dehydration, and iron deficiency. A prior episode associated with antipsychotics has been described in 15%—20% of index cases, suggesting underlying vulnerability in some patients; however, genetic findings based on neurotransmitter receptor polymorphisms have not been replicated consistently.
Nearly all dopamine antagonists have been associated with neuroleptic malignant syndrome, although high-potency antipsychotics pose a greater risk compared with low- potency agents and newer atypical antipsychotics. Partial or milder forms may be associ- ated with newer antipsychotics, but neuroleptic malignant syndrome varies in severity even with older drugs. Dopamine antagonists used in medical settings (e.g., metoclopra- mide, prochlorperazine) have also been implicated. Parenteral administration routes, rapid titration rates, and higher total drug dosages have been associated with increased risk; however, neuroleptic malignant syndrome usually occurs within the therapeutic dos- age range of antipsychotics.
or medical conditions, including central nervous system infections, inflammatory or au- toimmune conditions, status epilepticus, subcortical structural lesions, and systemic con- ditions (e.g., pheochromocytoma, thyrotoxicosis, tetanus, heat stroke).
resulting from the use of other substances or medications, such as serotonin syndrome; parkinsonian hyperthermia syndrome following abrupt discontinuation of dopamine ag- thesia; hyperthermia associated with abuse of stimulants and hallucinogens; and atropine poisoning from anticholinergics.
In rare instances, individuals with schizophrenia or a mood disorder may present with malignant catatonia, which may be indistinguishable from neuroleptic malignant syn- drome. Some investigators consider neuroleptic malignant syndrome to be a drug- induced form of malignant catatonia.
333.72 (624.02) Medication-Induced Acute Dystonia | DSM5 Psichiatry |
Abnormal and prolonged contraction of the muscles of the eyes (oculogyric crisis), head, neck (torticollis or retrocollis), limbs, or trunk developing within a few days of starting or raising the dosage of a medication (such as a neuroleptic) or after reducing the dosage of a medication used to treat extrapyramidal symptoms.
333.99 (G25.71) Medication-Induced Acute Akathisia
Subjective complaints of restlessness, often accompanied by observed excessive move- ments (e.g., fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still), developing within a few weeks of starting or raising the dosage of a medi- cation (such as a neuroleptic) or after reducing the dosage of a medication used to treat ex- trapyramidal symptoms.
333.85 (624.01) Tardive Dyskinesia the tongue, lower face and jaw, and extremities (but sometimes involving the pharyngeal, diaphragmatic, or trunk muscles) developing in association with the use of a neuroleptic medication for at least a few months.
Symptoms may develop after a shorter period of medication use in older persons. In some patients, movements of this type may appear after discontinuation, or after change or reduction in dosage, of neuroleptic medications, in which case the condition is called neuroleptic withdrawal—emergent dyskinesia. Because withdrawal-emergent dyskinesia is usually time-limited, lasting less than 4—8 weeks, dyskinesia that persists beyond this win- dow is considered to be tardive dyskinesia.
333.72 (624.09) Tardive Dystonia 333.99 (G25.71) Tardive Akathisia
Tardive syndrome involving other types of movement problems, such as dystonia or akathisia, which are distinguished by their late emergence in the course of treatment and their potential persistence for months to years, even in the face of neuroleptic discontinu- ation or dosage reduction.
333.1 (625.1) Medication-Induced Postural Tremor
Fine tremor (usually in the range of 8—12 Hz) occurring during attempts to maintain a pos- ture and developing in association with the use of medication (e.g., lithium, antidepres- sants, valproate). This tremor is very similar to the tremor seen with anxiety, caffeine, and other stimulants.
333.99 (625.79) Other Medication-Induced Movement Disorder
This category is for medication-induced movement disorders not captured by any of the specific disorders listed above. Examples include 1) presentations resembling neuroleptic malignant syndrome that are associated with medications other than neuroleptics and 2) other medication-induced tardive conditions.
995.29 (T43.205A) Initial encounter 995.29 (T 43.205D) Subsequent encounter 995.29 (T 43.2053) Sequelae | DSM5 Psichiatry |
Antidepressant discontinuation syndrome is a set of symptoms that can occur after an abrupt cessation (or marked reduction in dose) of an antidepressant medication that was taken continuously for at least 1 month. Symptoms generally begin within 2—4 days and typically include specific sensory, somatic, and cognitive-emotional manifestations. Fre- quently reported sensory and somatic symptoms include flashes of lights, ”electric shock” sensations, nausea, and hyperresponsivity to noises or lights. Nonspecific anxiety and feelings of dread may also be reported. Symptoms are alleviated by restarting the same medication or starting a different medication that has a similar mechanism of action— for example, discontinuation symptoms after withdrawal from a serotonin-norepineph- rine reuptake inhibitor may be alleviated by starting a tricyclic antidepressant. To qualify as antidepressant discontinuation syndrome, the symptoms should not have been present before the antidepressant dosage was reduced and are not better explained by another mental disorder (e.g., manic or hypomanic episode, substance intoxication, substance withdrawal, somatic symptom disorder).
Discontinuation symptoms may occur following treatment with tricyclic antidepressants (e.g., imipramine, amitriptyline, desipramine), serotonin reuptake inhibitors (e.g., fluox- etine, paroxetine, sertraline), and monoamine oxidase inhibitors (e.g., phenelzine, selegi- line, pargyline). The incidence of this syndrome depends on the dosage and half-life of the medication being taken, as well as the rate at which the medication is tapered. Short-acting medications that are stopped abruptly rather than tapered gradually may pose the great- est risk. The short-acting selective serotonin reuptake inhibitor (SSRI) paroxetine is the agent most commonly associated with discontinuation symptoms, but such symptoms oc- cur for all types of antidepressants.
Unlike withdrawal syndromes associated with opioids, alcohol, and other substances of abuse, antidepressant discontinuation syndrome has no pathognomonic symptoms. In- stead, the symptoms tend to be vague and variable and typically begin 2—4 days after the last dose of the antidepressant. For SSRIs (e.g., paroxetine), symptoms such as dizziness, ringing in the ears, "electric shocks in the head," an inability to sleep, and acute anxiety are described. The antidepressant use prior to discontinuation must not have incurred hypo- mania or euphoria (i.e., there should be confidence that the discontinuation syndrome is not the result of fluctuations in mood stability associated with the previous treatment).
The antidepressant discontinuation syndrome is based solely on pharmacological factors and is not related to the reinforcing effects of an antidepressant. Also, in the case of stim- ulant augmentation of an antidepressant, abrupt cessation may result in stimulant with- drawal symptoms (see ”Stimulant Withdrawal" in the chapter ”Substance-Related and
Addictive Disorders”) rather than the antidepressant discontinuation syndrome described here.
The prevalence of antidepressant discontinuation syndrome is unknown but is thought to vary according to the dosage prior to discontinuation, the half-life and receptor-binding affinity of the medication, and possibly the individual’s genetically influenced rate of me- tabolism for this medication.
Because longitudinal studies are lacking, little is known about the clinical course of anti- depressant discontinuation syndrome. Symptoms appear to abate over time with very gradual dosage reductions. After an episode, some individuals may prefer to resume med- ication indefinitely if tolerated.
The differential diagnosis of antidepressant discontinuation syndrome includes anxiety and depressive disorders, substance use disorders, and tolerance to medications. | DSM5 Psichiatry |
Anxiety and depressive disorders. Discontinuation symptoms often resemble symptoms of a persistent anxiety disorder or a return of somatic symptoms of depression for which the medication was initially given.
Substance use disorders. Antidepressant discontinuation syndrome differs from sub- fects. The medication dosage has usually not been increased without the clinician’s permission, and the individual generally does not engage in drug-seeking behavior to ob- tain additional medication. Criteria for a substance use disorder are not met.
Tolerance to medications. Tolerance and discontinuation symptoms can occur as a normal physiological response to stopping medication after a substantial duration of exposure. Most cases of medication tolerance can be managed through carefully con- trolled tapering.
Typically, the individual was initially started on the medication for a major depressive dis- order; the original symptoms may return during the discontinuation syndrome.
Other Adverse Effect of Medication 995.20 (T 50.905A) Initial encounter 995.20 (T 50.905D) Subsequent encounter 995.20 (T 50.9058) Sequelae
This category is available for optional use by clinicians to code side effects of medication (other than movement symptoms) when these adverse effects become a main focus of clin- ical attention. Examples include severe hypotension, cardiac arrhythmias, and priapism.
a Focus of Cllnical Attention
This d iscussion covers other conditions and problems that may be a focus of clini- cal attention or that may otherwise affect the diagnosis, course, prognosis, or treatment of a patient’s mental disorder. These conditions are presented with their corresponding codes from ICD-9-CM (usually V codes) and ICD-10-CM (usually Z codes). A condition or problem in this chapter may be coded if it is a reason for the current visit or helps to explain the need for a test, procedure, or treatment. Conditions and problems in this chap- ter may also be included in the medical record as useful information on circumstances that may affect the patient’s care, regardless of their relevance to the current visit.
The conditions and problems listed in this chapter are not mental disorders. Their in- clusion in DSM-5 is meant to draw attention to the scope of additional issues that may be encountered in routine clinical practice and to provide a systematic listing that may be useful to clinicians in documenting these issues.
Key relationships, especially intimate adult partner relationships and parent/caregiver- child relationships, have a significant impact on the health of the individuals in these re- lationships. These relationships can be health promoting and protective, neutral, or detri- mental to health outcomes. In the extreme, these close relationships can be associated with maltreatment or neglect, which has significant medical and psychological consequences for the affected individual. A relational problem may come to clinical attention either as the reason that the individual seeks health care or as a problem that affects the course, prognosis, or treatment of the individual’s mental or other medical disorder.
Problems Related to Family Upbringing
V61.20 (Z62.820) Parent-Child Relational Problem
For this category, the term parent is used to refer to one of the child’s primary caregivers, who may be a biological, adoptive, or foster parent or may be another relative (such as a grandparent) who fulfills a parental role for the child. This category should be used when the main focus of clinical attention is to address the quality of the parent-child relationship or when the quality of the parent—child relationship is affecting the course, prognosis, or treatment of a mental or other medical disorder. Typically, the parent-child relational problem is associated with impaired functioning in behavioral, cognitive, 0r affective do- mains. Examples of behavioral problems include inadequate parental control, supervision, and involvement with the child; parental overprotection; excessive parental pressure; ar- guments that escalate to threats of physical violence; and avoidance without resolution of problems. Cognitive problems may include negative attributions of the other’s intentions, hostility toward or scapegoating of the other, and unwarranted feelings of estrangement. | DSM5 Psichiatry |
Affective problems may include feelings of sadness, apathy, or anger about the other in- dividual in the relationship. Clinicians should take into account the developmental needs of the child and the cultural context.
716 Other Conditions That May Be a Focus of Clinical Attention
V61.8 (262.891) Sibling Relational Problem
This category should be used when the focus of clinical attention is a pattern of interaction among siblings that is associated with significant impairment in individual or family function- ing or with development of symptoms in one or more of the siblings, or when a sibling relational problem is affecting the course, prognosis, or treatment of a sibling’s mental or other medical disorder. This category can be used for either children or adults if the focus is on the sibling re- lationship. Siblings in this context include full, half-, step-, foster, and adopted siblings.
V61.8 (262.29) Upbringing Away From Parents
This category should be used when the main focus of clinical attention pertains to issues regarding a child being raised away from the parents or when this separate upbringing af- fects the course, prognosis, or treatment of a mental or other medical disorder. The child could be one who is under state custody and placed in kin care or foster care. The child could also be one who is living in a nonparental relative’s home, or with friends, but whose out—of—home placement is not mandated or sanctioned by the courts. Problems related to a child living in a group home or orphanage are also included. This category excludes issues related to V60.6 (Z593) children in boarding schools.
V61.29 (262.898) Child Affected by Parental Relationship Distress
This category should be used when the focus of clinical attention is the negative effects of parental relationship discord (e.g., high levels of conflict, distress, or disparagement) on a child in the family, including effects on the child’s mental or other medical disorders.
Other Problems Related to Primary Support Group
V61.10 (263.0) Relationship Distress With Spouse or Intimate Partner
This category should be used when the major focus of the clinical contact is to address the quality of the intimate (spouse or partner) relationship or when the quality of that rela- tionship is affecting the course, prognosis, or treatment of a mental or other medical dis- order. Partners can be of the same or different genders. Typically, the relationship distress is associated with impaired functioning in behavioral, cognitive, or affective domains. Ex- amples of behavioral problems include conflict resolution difficulty, withdrawal, and overinvolvement. Cognitive problems can manifest as chronic negative attributions of the other’s intentions or dismissals of the partner’s positive behaviors. Affective problems would include chronic sadness, apathy, and / or anger about the other partner.
Note: This category excludes clinical encounters for V61.1x (Z69.1x) mental health ser- vices for spousal or partner abuse problems and V65.49 (270.9) sex counseling.
V61.03 (263.5) Disruption of Family by Separation or Divorce
This category should be used when partners in an intimate adult couple are living apart due to relationship problems or are in the process of divorce.
V61.8 (263.8) High Expressed Emotion Level Within Family
Expressed emotion is a construct used as a qualitative measure of the ”amount" of emo- tion—in particular, hostility, emotional overinvolvement, and criticism directed toward a family member who is an identified patient—displayed in the family environment. This category should be used when a family’s high level of expressed emotion is the focus of clinical attention or is affecting the course, prognosis, or treatment of a family member’s mental or other medical disorder.
V62.82 (263.4) Uncomplicated Bereavement | DSM5 Psichiatry |
This category can be used when the focus of clinical attention is a normal reaction to the death of a loved one. As part of their reaction to such a loss, some grieving individuals present with symptoms characteristic of a major depressive episodchfor example, feel-
Other Conditions That May Be a Focus of Clinical Attention 717 ings of sadness and associated symptoms such as insonmia, poor appetite, and weight loss. The bereaxed individual typically regards the depressed mood as ”normal,” al- though the individual may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of "normal” bereavement vary con- siderably among different cultural groups. Further guidance in distinguishing grief from a major depressive episode is provided in the criteria for major depressive episode.
Maltreatment by a family member (e.g., caregiver, intimate adult partner) or by a nonrel- ative can be the area of current clinical focus, or such maltreatment can be an important factor in the assessment and treatment of patients with mental or other medical disorders.
Because of the legal implications of abuse and neglect, care should be used in assessing these conditions and assigning these codes. Having a past history of abuse or neglect can influence diagnosis and treatment response in a number of mental disorders, and may also be noted along with the diagnosis.
For the following categories, in addition to listings of the confirmed or suspected event of abuse or neglect, other codes are provided for use if the current clirtical encounter is to provide mental health services to either the victim or the perpetrator of the abuse or ne- glect. A separate code is also provided for designating a past history of abuse or neglect.
For T codes only, the 7th character should be coded as follows:
A (initial encounter)—Use while the patient is receiving active treatment for the condition (e.g., surgical treatment, emergency department encounter, eval-
D (subsequent encounter)—Use for encounters after the patient has received active treatment for the condition and when he or she is receiving routine care for the condition during the healing or recovery phase (e.g., cast change or re- moval, removal of external or internal fixation device, medication adjustment, other aftercare and follow-up Visits).
Child physical abuse is nonaccidental physical injury to a child—ranging from minor bruises to severe fractures or death—occurring as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other object), burning, or any other method that is inflicted by a parent, caregiver, or other individual who has responsibility for the child. Such injury is considered abuse regardless of whether the caregiver intended to hurt the child. Physical discipline, such as spanking or paddling, is not considered abuse as long as it is reasonable and causes no bodily injury to the child.
Child Physical Abuse, Confirmed 995.54 (T74.12XA) Initial encounter 995.54 (T74.12XD) Subsequent encounter
Child Physical Abuse, Suspected 995.54 (T76.12XA) Initial encounter 995.54 (T76.12XD) Subsequent encounter 718 Other Conditions That May Be a Focus of Clinical Attention
Other Circumstances Related to Child Physical Abuse
V61 .21 (269.010) Encounter for mental health services for victim of child abuse by parent
V61.21 (269.020) Encounter for mental health services for victim of nonparental child
V15.41 (262.810) Personal history (past history) of physical abuse in childhood
V61 .22 (269.011) Encounter for mental health services for perpetrator of parental child
V62.83 (269.021) Encounter for mental health services for perpetrator of nonparental | DSM5 Psichiatry |
Child sexual abuse encompasses any sexual act involving a child that is intended to pro- vide sexual gratification to a parent, caregiver, or other individual who has responsibility for the child. Sexual abuse includes activities such as fondling a child’s genitals, penetra- tion, incest, rape, sodomy, and indecent exposure. Sexual abuse also includes noncontact exploitation of a child by a parent or caregiver—for example, forcing, tricking, enticing, threatening, or pressuring a child to participate in acts for the sexual gratification of others, without direct physical contact between child and abuser.
Child Sexual Abuse, Confirmed 995.53 (T 74.22XA) Initial encounter 995.53 (T 74.22XD) Subsequent encounter
Child Sexual Abuse, Suspected 995.53 (T76.22XA) Initial encounter 995.53 (T76.22XD) Subsequent encounter
Other Circumstances Related to Child Sexual Abuse
V61.21 (269.010) Encounter for mental health services for victim of child sexual abuse
V61.21 (269.020) Encounter for mental health services for victim of nonparental child
V15.41 (262.810) Personal history (past history) of sexual abuse in childhood
V61.22 (269.011) Encounter for mental health services for perpetrator of parental child
V62.83 (269.021) Encounter for mental health services for perpetrator of nonparental
Child neglect is defined as any confirmed or suspected egregious act or omission by a child’s parent or other caregiver that deprives the child of basic age-appropriate needs and thereby results, or has reasonable potential to result, in physical or psychological harm to the child. Child neglect encompasses abandonment; lack of appropriate supervision; fail- ure to attend to necessary emotional or psychological needs; and failure to provide neces- sary education, medical care, nourishment, shelter, and/ or clothing.
Child Neglect, Confirmed 995.52 (T74.02XA) Initial encounter 995.52 (T74.02XD) Subsequent encounter
Other Conditions That May Be a Focus of Clinical Attention 719
Child Neglect, Suspected 995.52 (T 76.02“) Initial encounter 995.52 (T76.02XD) Subsequent encounter
Other Circumstances Related to Child Neglect
V61.21 (269.010) Encounter for mental health services for victim of child neglect by
V61.21 (269.020) Encounter for mental health services for victim of nonparental child
V1 5.42 (262.81 2) Personal history (past history) of neglect in childhood
V61.22 (269.011) Encounter for mental health services for perpetrator of parental child
V62.83 (269.021) Encounter for mental health services for perpetrator of nonparental | DSM5 Psichiatry |
Child psychological abuse is nonaccidental verbal or symbolic acts by a child’s parent or caregiver that result, or have reasonable potential to result, in significant psychological harm to the child. (Physical and sexual abusive acts are not included in this category.) Ex- amples of psychological abuse of a child include berating, disparaging, or humiliating the child; threatening the child; harming/abandoning—or indicating that the alleged offender will harm/abandon—people or things that the child cares about; confining the child (as by tying a child’s arms or legs together or binding a child to furniture or another object, or confining a child to a small enclosed area [e.g., a closet]); egregious scapegoating of the child; coercing the child to inflict pain on himself or herself; and disciplining the child excessively (i.e., at an extremely high frequency or duration, even if not at a level of physical abuse) through physical or nonphysical means.
Child Psychological Abuse, Confirmed 995.51 (T74.32XA) Initial encounter 995.51 (T74.32XD) Subsequent encounter
Child Psychological Abuse, Suspected 995.51 (T76.32XA) Initial encounter 995.51 (T76.32XD) Subsequent encounter
Other Circumstances Related to Child Psychological Abuse
V61 .21 (269.010) Encounter for mental health services for victim of child psychological
V61.21 (269.020) Encounter for mental health services for victim of nonparental child
V15.42 (262.811) Personal history (past history) of psychological abuse in childhood
V61.22 (269.011) Encounter for mental health services for perpetrator of parental child
V62.83 (269.021) Encounter for mental health services for perpetrator of nonparental 720 Other Conditions That May Be a Focus of Clinical Attention
Spouse or Partner Violence, Physical
This category should be used when nonaccidental acts of physical force that result, or have reasonable potential to result, in physical harm to an intimate partner or that evoke signif- icant fear in the partner have occurred during the past year. Nonaccidental acts of physical force include shoving, slapping, hair pulling, pinching, restraining, shaking, throwing, biting, kicking, hitting with the fist or an object, burning, poisoning, applying force to the throat, cutting off the air supply, holding the head under water, and using a weapon. Acts for the purpose of physically protecting oneself or one’s partner are excluded.
Spouse or Partner Violence, Physical, Confirmed 995.81 (T74.11XA) Initial encounter 995.81 (T 74.1 1 XD) Subsequent encounter
Spouse or Partner Violence, Physical, Suspected 995.81 (T 76.1 1 XA) Initial encounter 995.81 (T 76.1 1 XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Violence, Physical
V61.11 (269.11) Encounter for mental health services for Victim of spouse or partner violence, physical
V15.41 (291 .410) Personal history (past history) of spouse or partner violence, physical
V61.12 (269.12) Encounter for mental health services for perpetrator of spouse or partner violence, physical
Spouse or Partner Violence, Sexual
This category should be used when forced or coerced sexual acts with an intimate partner have occurred during the past year. Sexual violence may involve the use of physical force or psychological coercion to compel the partner to engage in a sexual act against his or her will, whether or not the act is completed. Also included in this category are sexual acts with an intimate partner who is unable to consent. | DSM5 Psichiatry |
Spouse or Partner Violence, Sexual, Confirmed 995.83 (T7 4.21 XA) Initial encounter 995.83 (T7 4.21 XD) Subsequent encounter
Spouse or Partner Violence, Sexual, Suspected 995.83 (17 6.21 XA) Initial encounter 995.83 (T7 6.21 XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Violence, Sexual
V61.11 (269.81) Encounter for mental health services for victim of spouse or partner violence, sexual
V15.41 (291.410) Personal history (past history) of spouse or partner violence, sexual
V61.12 (269.12) Encounter for mental health services for perpetrator of spouse or partner violence, sexual
Other Conditions That May Be a Focus of Clinical Attention 721
Partner neglect is any egregious act or omission in the past year by one partner that de- prives a dependent partner of basic needs and thereby results, or has reasonable potential to result, in physical or psychological harm to the dependent partner. This category is used in the context of relationships in which one partner is extremely dependent on the other partner for care or for assistance in navigating ordinary daily activities—for example, a partner who is incapable of self—care owing to substantial physical, psychological/intel- lectual, or cultural limitations (e.g., inability to communicate with others and manage ev- eryday activities due to living in a foreign culture).
Spouse or Partner Neglect, Confirmed 995.85 (T 74.01 XA) Initial encounter 995.85 (T 74.01 XD) Subsequent encounter
Spouse or Partner Neglect, Suspected 995.85 (T7 6.01 XA) Initial encounter 995.85 (T 76.01 XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Neglect
V61.11 (269.11) Encounter for mental health services for victim of spouse or partner
V15.42 (291 .412) Personal history (past history) of spouse or partner neglect
V61.12 (269.12) Encounter for mental health services for perpetrator of spouse or
Spouse or Partner Abuse, Psychological partner that result, or have reasonable potential to result, in significant harm to the other partner. This category should be used when such psychological abuse has occurred during the past year. Acts of psychological abuse include berating or humiliating the victim; inter- rogating the victim; restricting the victim’s ability to come and go freely; obstructing the vic— tim’s access to assistance (e.g., law enforcement; legal, protective, or medical resources); threatening the victim with physical harm or sexual assault; harming, or threatening to harm, people or things that the victim cares about; unwarranted restriction of the victim’s ac— cess to or use of economic resources; isolating the victim from family, friends, or social sup- port resources; stalking the victim; and trying to make the victim think that he or she is crazy.
Spouse or Partner Abuse, Psychological, Confirmed 995.82 (T74.31XA) Initial encounter 995.82 (T74.31XD) Subsequent encounter
Spouse or Partner Abuse, Psychological, Suspected 995.82 (T7 6.31 XA) Initial encounter 995.82 (T7 6.31 XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Abuse, Psychological
V61.11 (269.11) Encounter for mental health services for victim of spouse or partner 722 Other Conditions That May Be a Focus of Clinical Attention
V15.42 (291 .41 1) Personal history (past history) of spouse or partner psychological abuse | DSM5 Psichiatry |
V61 .12 (269.12) Encounter for mental health services for perpetrator of spouse or part- not an intimate partner. Such maltreatment may involve acts of physical, sexual, or emo- tional abuse. Examples of adult abuse include nonaccidental acts of physical force (e.g., pushing/shoving, scratching, slapping, throwing something that could hurt, punching, biting) that have resulted—or have reasonable potential to result—in physical harm or with the potential to cause psychological harm (e.g., berating or humiliating the person; interrogating the person; restricting the person’s ability to come and go freely; obstructing the person’s access to assistance; threatening the person; harming or threatening to harm people or things that the person cares about; restricting the person’s access to or use of eco- nomic resources; isolating the person from family, friends, or social support resources; stalking the person; trying to make the person think that he or she is crazy). Acts for the purpose of physically protecting oneself or the other person are excluded.
Adult Physical Abuse by Nonspouse or N onpartner, Confirmed 995.81 (T 74.1 1 XA) Initial encounter 995.81 (T 74.1 1 XD) Subsequent encounter
Adult Physical Abuse by Nonspouse or Nonpartner, Suspected 995.81 (T 76.1 1XA) Initial encounter 995.81 (T 76.1 1 XD) Subsequent encounter
Adult Sexual Abuse by Nonspouse or Nonpartner, Confirmed 995.83 (T 74.21 XA) Initial encounter 995.83 (T74.21XD) Subsequent encounter
Adult Sexual Abuse by Nonspouse or Nonpartner, Suspected 995.83 (T76.21XA) Initial encounter 995.83 (T 76.21 XD) Subsequent encounter
Adult Psychological Abuse by Nonspouse or Nonpartner, Confirmed 995.82 (T 74.31 XA) Initial encounter 995.82 (T74.31XD) Subsequent encounter
Adult Psychological Abuse by Nonspouse or Nonpartner, Suspected 995.82 (T76.31XA) Initial encounter 995.82 (T 76.31 XD) Subsequent encounter
Other Circumstances Related to Adult Abuse by Nonspouse or Nonpartner
V65.49 (269.81) Encounter for mental health services for victim of nonspousal or non—
V62.83 (269.82) Encounter for mental health services for perpetrator of nonspousal or
Other Conditions That May Be a Focus of Clinical Attention 723
V62.3 (255.9) Academic or Educational Problem
This category should be used when an academic or educational problem is the focus of clinical attention or has an impact on the individual’s diagnosis, treatment, or prognosis.
Problems to be considered include illiteracy or low-level literacy; lack of access to school- ing owing to unavailability or unattainability; problems with academic performance (e.g., failing school examinations, receiving failing marks or grades) or underachievement (be- low what would be expected given the individual’s intellectual capacity); discord with teachers, school staff, or other students; and any other problems related to education and / or literacy.
V62.21 (256.82) Problem Related to Current Military Deployment Status
This category should be used when an occupational problem directly related to an indi- vidual’s military deployment status is the focus of clinical attention or has an impact on the individual’s diagnosis, treatment, or prognosis. Psychological reactions to deployment are not included in this category; such reactions would be better captured as an adjustment disorder or another mental disorder. | DSM5 Psichiatry |
V62.29 (256.9) Other Problem Related to Employment
This category should be used when an occupational problem is the focus of clinical atten- tion or has an impact on the individual’s treatment or prognosis. Areas to be considered include problems with employment or in the work environment, including unemploy- ment; recent change of job; threat of job loss; job dissatisfaction; stressful work schedule; uncertainty about career choices; sexual harassment on the job; other discord with boss, supervisor, co-workers, or others in the work environment; uncongenial or hostile work environments; other psychosocial stressors related to work; and any other problems re- lated to employment and / or occupation.
V60.0(259.0) Homelessness
This category should be used when lack of a regular dwelling or living quarters has an im- pact on an individual’s treatment or prognosis. An individual is considered to be homeless if his or her primary nighttime residence is a homeless shelter, a warming shelter, a do— mestic violence shelter, a public space (e.g., tunnel, transportation station, mall), a build- ing not intended for residential use (e.g., abandoned structure, unused factory), a cardboard box or cave, or some other ad hoc housing situation.
V60.1 (259.1) Inadequate Housing
This category should be used when lack of adequate housing has an impact on an individ- ual’s treatment or prognosis. Examples of inadequate housing conditions include lack of heat (in cold temperatures) or electricity, infestation by insects or rodents, inadequate plumbing and toilet facilities, overcrowding, lack of adequate sleeping space, and exces- sive noise. It is important to consider cultural norms before assigning this category.
V60.89 (259.2) Discord With Neighbor, Lodger, or Landlord
This category should be used when discord with neighbors, lodgers, or a landlord is a fo- cus of clinical attention or has an impact on the individual's treatment or prognosis.
724 Other Conditions That May Be a Focus of Clinical Attention
V60.6 (259.3) Problem Related to Living in a Residential Institution
This category should be used when a problem (or problems) related to living in a residen- tial institution is a focus of clinical attention or has an impact on the individual’s treatment or prognosis. Psychological reactions to a change in living situation are not included in this category; such reactions would be better captured as an adjustment disorder.
V60.2 (259.4) Lack of Adequate Food or Safe Drinking Water
V60.2 (259.5) Extreme Poverty
V60.2 (259.6) Low Income
V60.2 (259.7) Insufficient Social Insurance or Welfare Support fare support but are not receiving such support, who receive support that is insufficient to address their needs, or who otherwise lack access to needed insurance or support pro- grams. Examples include inability to qualify for welfare support owing to lack of proper documentation or evidence of address, inability to obtain adequate health insurance be- cause of age or a preexisting condition, and denial of support owing to excessively strin- gent income or other requirements.
V60.9 (259.9) Unspecified Housing or Economic Problem
This category should be used when there is a problem related to housing or economic cir- cumstances other than as specified above.
Other Problems Related to the Social Environment
V62.89 (260.0) Phase of Life Problem
This category should be used when a problem adjusting to a life-cycle transition (a partic- ular developmental phase) is the focus of clinical attention or has an impact on the indi- vidual’s treatment or prognosis. Examples of such transitions include entering or completing school, leaving parental control, getting married, starting a new career, be- coming a parent, adjusting to an ”empty nest” after children leave home, and retiring. | DSM5 Psichiatry |
V60.3 (260.2) Problem Related to Living Alone
This category should be used when a problem associated with living alone is the focus of clinical attention or has an impact on the individual’s treatment or prognosis. Examples of such problems include chronic feelings of loneliness, isolation, and lack of structure in car— rying out activities of daily living (e.g., irregular meal and sleep schedules, inconsistent performance of home maintenance chores).
V62.4 (260.3) Acculturation Difficulty
This category should be used when difficulty in adjusting to a new culture (e.g., following migration) is the focus of clinical attention or has an impact on the individual’s treatment or prognosis.
V62.4 (260.4) Social Exclusion or Rejection
This category should be used when there is an imbalance of social power such that there is recurrent social exclusion or rejection by others. Examples of social rejection include bul- lying, teasing, and intimidation by others; being targeted by others for verbal abuse and humiliation; and being purposefully excluded from the activities of peers, workmates, or others in one’s social environment.
V62.4 (260.5) Target of (Perceived) Adverse Discrimination or Persecution
This category should be used when there is perceived or experienced discrimination against or persecution of the individual based on his or her membership (or perceived
Other Conditions That May Be a Focus of Clinical Attention 725 membership) in a specific category. Typically, such categories include gender or gender identity, race, ethnicity, religion, sexual orientation, country of origin, political beliefs, dis- ability status, caste, social status, weight, and physical appearance.
V62.9 (260.9) Unspecified Problem Related to Social Environment
This category should be used when there is a problem related to the individual's social en- vironment other than as specified above.
Problems Related to Crime or Interaction
With the Legal System
V62.89 (265.4) Victim of Crime
V62.5 (265.0) Conviction in Civil or Criminal Proceedings Without Imprisonment
V62.5 (265.1) Imprisonment or Other Incarceration
V62.5 (265.2) Problems Related to Release From Prison
V62.5 (265.3) Problems Related to Other Legal Circumstances
V65.49 (270.9) Sex Counseling
This category should be used when the individual seeks counseling related to sex educa- tion, sexual behavior, sexual orientation, sexual attitudes (embarrassment, timidity), oth- ers’ sexual behavior or orientation (e.g., spouse, partner, child), sexual enjoyment, or any other sex-related issue.
V65.40 (271.9) Other Counseling or Consultation
This category should be used when counseling is provided or advice/consultation is sought for a problem that is not specified above or elsewhere in this chapter. Examples in- clude spiritual or religious counseling, dietary counseling, and counseling on nicotine use.
Problems Related to Other Psychosocial, Personal,
V62.89 (265.8) Religious or Spiritual Problem
This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of spiritual val- ues that may not necessarily be related to an organized church or religious institution.
V61.7 (264.0) Problems Related to Unwanted Pregnancy
V61.5 (264.1) Problems Related to Multiparity
V62.89 (264.4) Discord With Social Service Provider, Including Probation Officer,
Case Manager, or Social Services Worker
V62.89 (265.4) Victim of Terrorism or Torture
V62.22 (265.5) Exposure to Disaster, War, or Other Hostilities | DSM5 Psichiatry |
V62.89 (265.8) Other Problem Related to Psychosocial Circumstances
V62.9 (265.9) Unspecified Problem Related to Unspecified Psychosocial Circum- 726 Other Conditions That May Be a Focus of Clinical Attention
Other Circumstances of Personal History
V15.49 (291.49) Other Personal History of Psychological Trauma
V15.59 (291.5) Personal History of Self-Harm
V62.22 (291.82) Personal History of Military Deployment
V15.89 (291.89) Other Personal Risk Factors
V69.9 (272.9) Problem Related to Lifestyle
This category should be used when a lifestyle problem is a specific focus of treatment or di- rectly affects the course, prognosis, or treatment of a mental or other medical disorder. Ex- amples of lifestyle problems include lack of physical exercise, inappropriate diet, high-risk sexual behavior, and poor sleep hygiene. A problem that is attributable to a symptom of a mental disorder should not be coded unless that problem is a specific focus of treatment or directly affects the course, prognosis, or treatment of the individual. In such cases, both the mental disorder and the lifestyle problem should be coded.
V71.01 (272.811) Adult Antisocial Behavior
This category can be used when the focus of clinical attention is adult antisocial behavior that is not due to a mental disorder (e.g., conduct disorder, antisocial personality disor- der). Examples include the behavior of some professional thieves, racketeers, or dealers in illegal substances.
V71.02 (272.810) Child or Adolescent Antisocial Behavior
This category can be used when the focus of clinical attention is antisocial behavior in a child or adolescent that is not due to a mental disorder (e.g., intermittent explosive disor- der, conduct disorder). Examples include isolated antisocial acts by children or adoles- cents (not a pattern of antisocial behavior).
Problems Related to Access to Medical
V63.9 (275.3) Unavailability or Inaccessibility of Health Care Facilities
V63.8 (275.4) Unavailability or Inaccessibility of Other Helping Agencies
Nonadherence to Medical Treatment
V15.81 (291.19) Nonadherence to Medical Treatment
This category can be used when the focus of clinical attention is nonadherence to an im- portant aspect of treatment for a mental disorder or another medical condition. Reasons for such nonadherence may include discomfort resulting from treatment (e.g., medication side effects), expense of treatment, personal value judgments or religious or cultural be- liefs about the proposed treatment, age-related debility, and the presence of a mental dis- order (e.g., schizophrenia, personality disorder). This category should be used only when the problem is sufficiently severe to warrant independent clinical attention and does not meet diagnostic criteria for psychological factors affecting other medical conditions.
278.00 (E66.9) Overweight or Obesity
This category may be used when overweight or obesity is a focus of clinical attention.
V65.2 (276.5) Malingering
The essential feature of malingering is the intentional production of false or grossly exag- gerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading crimi- nal prosecution, or obtaining drugs. Under some circumstances, malingering may repre- | DSM5 Psichiatry |
Other Conditions That May Be a Focus of Clinical Attention 727 sent adaptive behavior—for example, feigning illness while a captive of the enemy during wartime. Malingering should be strongly suspected if any combination of the following is noted: 1. Medicolegal context of presentation (e.g., the individual is referred by an attorney to the clinician for examination, or the individual self—refers while litigation or criminal charges are pending).
2. Marked discrepancy between the individual’s claimed stress or disability and the ob- jective findings and observations.
3. Lack of cooperation during the diagnostic evaluation and in complying with the pre- scribed treatment regimen.
4. The presence of antisocial personality disorder.
Malingering differs from factitious disorder in that the motivation for the symptom production in malingering is an external incentive, whereas in factitious disorder external incentives are absent. Malingering is differentiated from conversion disorder and somatic symptom—related mental disorders by the intentional production of symptoms and by the obvious external incentives associated with it. Definite evidence of feigning (such as clear evidence that loss of function is present during the examination but not at home) would suggest a diagnosis of factitious disorder if the individual’s apparent aim is to assume the sick role, or malingering if it is to obtain an incentive, such as money.
V40.31 (291.83) Wandering Associated With a Mental Disorder
This category is used for individuals with a mental disorder whose desire to walk about leads to significant clinical management or safety concerns. For example, individuals with wander that places them at risk for falls and causes them to leave supervised settings with- out needed accompaniment. This category excludes individuals whose intent is to escape an unwanted housing situation (e.g., children who are running away from home, patients who no longer wish to remain in the hospital) or those who walk or pace as a result of med- ication-induced akathisia.
Coding note: First code associated mental disorder (e.g., major neurocognitive disor- der, autism spectrum disorder), then code V40.31 (291.83) wandering associated with [specific mental disorder].
V62.89 (R41.83) Borderline Intellectual Functioning
This category can be used when an individual’s borderline intellectual functioning is the fo- cus of clinical attention or has an impact on the individual’s treatment or prognosis. Differ- developmental disorder) requires careful assessment of intellectual and adaptive functions and their discrepancies, particularly in the presence of co-occurring mental disorders that may affect patient compliance with standardized testing procedures (e.g., schizophrenia or attention—deficit/hyperactivity disorder with severe impulsivity).
Assessment Measures ....................................... 733
Cross-Cutting Symptom Measures ........................... 734
Symptom Measure—Adult ............................. 738
Symptom Measure—Child Age 6—17 .................... 740
CIinician-Rated Dimensions of Psychosis Symptom Severity ...... 742
World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) .......................................... 745
Cultural Formulation ......................................... 749
Cultural Formulation Interview (CFI) ........................... 750
Cultural Formulation Interview (CFI)—|nformant Version .......... 755
Alternative DSM-5 Model for Personality Disorders ................ 761
Conditions for Further Study .................................. 783
Attenuated Psychosis Syndrome ............................. 783
Depressive Episodes With Short-Duration Hypomania ........... 786
Persistent Complex Bereavement Disorder .................... 789
Caffeine Use Disorder ...................................... 792
Internet Gaming Disorder ................................... 795
Prenatal Alcohol Exposure ................................ 798
Suicidal Behavior Disorder .................................. 801 | DSM5 Psichiatry |
Nonsuicidal SeIf-Injury ..................................... 803
This section contains tools and techniques to enhance the clinical deci- sion-making process, understand the cultural context of mental disorders, and recognize emerging diagnoses for further study. It provides strategies to en- hance clinical practice and new criteria to stimulate future research, represent- ing a dynamic DSM-5 that will evolve with advances in the field.
Among the tools in Section III is a Level 1 cross—cutting seIf/informant-rated measure that serves as a review of systems across mental disorders. A clini- is provided, as well as the World Health Organization Disability Assessment
Schedule, Version 2 (WHODAS 2.0). Level 2 severity measures are available online (www.psychiatry.org/dsm5) and may be used to explore significant re- sponses to the Level 1 screen. A comprehensive review of the cultural context of mental disorders, and the Cultural Formulation Interview (CFI) for clinical use, are provided.
Proposed disorders for future study are provided, which include a new model for the diagnosis of personality disorders as an alternative to the estab- lished diagnostic criteria; the proposed model incorporates impairments in per- sonality functioning as well as pathological personality traits. Also included are new conditions that are the focus of active research, such as attenuated psy- chosis syndrome and nonsuicidal seIf-injury.
A growing body of scientific evidence favors dimensional concepts in the diagnosis of mental disorders. The limitations of a categorical approach to diagnosis include the fail- ure to find zones of rarity between diagnoses (i.e., delineation of mental disorders from one another by natural boundaries), the need for intermediate categories like schizoaffective dis- order, high rates of comorbidity, frequent not—otherwise—specified (NOS) diagnoses, relative lack of utility in furthering the identification of unique antecedent validators for most men- tal disorders, and lack of treatment specificity for the various diagnostic categories.
From both clinical and research perspectives, there is a need for a more dimensional approach that can be combined with DSM’s set of categorical diagnoses. Such an approach incorporates variations of features within an individual (e.g., differential severity of indi— vidual symptoms both within and outside of a disorder’s diagnostic criteria as measured by intensity, duration, or number of symptoms, along with other features such as type and severity of disabilities) rather than relying on a simple yes-or-no approach. For diagnoses for which all symptoms are needed for a diagnosis (a monothetic criteria set), different se- verity levels of the constituent symptoms may be noted. If a threshold endorsement of multiple symptoms is needed, such as at least five of nine symptoms for major depressive disorder (a polythetic criteria set), both severity levels and different combinations of the criteria may identify more homogeneous diagnostic groups.
symptom experiences along with the clinician’s interpretation is consistent with current diagnostic practice. It is expected that as our understanding of basic disease mechanisms based on pathophysiology, neurocircuitry, gene-environment interactions, and laboratory tests increases, approaches that integrate both objective and subjective patient data will be developed to supplement and enhance the accuracy of the diagnostic process.
Cross—cutting symptom measures modeled on general medicine’s review of systems can serve as an approach for reviewing critical psychopathological domains. The general med- ical review of systems is crucial to detecting subtle changes in different organ systems that can facilitate diagnosis and treatment. A similar review of various mental functions can aid in a more comprehensive mental status assessment by drawing attention to symptoms that may not fit neatly into the diagnostic criteria suggested by the individual’s presenting symptoms, but may nonetheless be important to the individual’s care. The cross-cutting measures have two levels: Level 1 questions are a brief survey of 13 symptom domains for adult patients and 12 domains for child and adolescent patients. Level 2 questions provide a more in-depth assessment of certain domains. These measures were developed to be administered both at initial interview and over time to track the patient’s symptom status and response to treatment. | DSM5 Psichiatry |
Severity measures are disorder-specific, corresponding closely to the criteria that consti- tute the disorder definition. They may be administered to individuals who have received a diagnosis or who have a clinically significant syndrome that falls short of meeting full criteria for a diagnosis. Some of the assessments are self—completed by the individual, while others require a clinician to complete. As with the cross-cutting symptom measures, these measures were developed to be administered both at initial interview and over time to track the severity of the individual’s disorder and response to treatment.
The World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0) was developed to assess a patient's ability to perform activities in six areas: understanding and communicating; getting around; self—care; getting along with people; life activities (e.g., household, work/school); and participation in society. The scale is self—administered and was developed to be used in patients with any medical disorder. It corresponds to concepts contained in the WHO International Classification of Functioning, Disability and Health. This assessment can also be used over time to track changes in a patient’s dis- abilities.
This chapter focuses on the DSM-5 Level 1 Cross—Cutting Symptom Measure (adult self-rated and parent/guardian versions); the Clinician-Rated Dimensions of Psychosis
Symptom Severity; and the WHODAS 2.0. Clinician instructions, scoring information, and interpretation guidelines are included for each. These measures and additional dimensional assessments, including those for diagnostic severity, can be found online at www.psychiatryorg/dsmS.
The DSM-5 Level 1 Cross-Cutting Symptom Measure is a patient— or informant-rated mea- sure that assesses mental health domains that are important across psychiatric diagnoses.
It is intended to help clinicians identify additional areas of inquiry that may have signifi- cant impact on the individual’s treatment and prognosis. In addition, the measure may be used to track changes in the individual’s symptom presentation over time.
The adult version of the measure consists of 23 questions that assess 13 psychiatric do- mains, including depression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and behaviors, dissociation, per— sonality functioning, and substance use (Table 1). Each domain consists of one to three questions. Each item inquires about how much (or how often) the individual has been bothered by the specific symptom during the past 2 weeks. If the individual is of impaired capacity and unable to complete the form (e.g., an individual with dementia), a know]- edgeable adult informant may complete this measure. The measure was found to be clin- ically useful and to have good reliability in the DSM-5 field trials that were conducted in adult clinical samples across the United States and in Canada.
The parent/guardian-rated version of the measure (for children ages 6—17) consists of 25 questions that assess 12 psychiatric domains, including depression, anger, irritability, mania, anxiety, somatic symptoms, inattention, suicidal ideation/attempt, psychosis, sleep disturbance, repetitive thoughts and behaviors, and substance use (Table 2). Each item asks the parent or guardian to rate how much (or how often) his or her child has been bothered by the specific psychiatric symptom during the past 2 weeks. The measure was also found to be clinically useful and to have good reliability in the DSM-5 field trials that were conducted in pediatric clinical samples across the United States. For children ages 11—17, along with the parent/guardian rating of the child’s symptoms, the clinician may consider having the child complete the child-rated version of the measure. The child—rated version of the measure can be found online at www.psychiatry.org/dsm5. | DSM5 Psichiatry |
Scoring and interpretation. On the adult self—rated version of the measure, each item is rated on a 5-point scale (0=none or not at all; 1=slight or rare, less than a day or two; 2=mild or several days; 3=moderate or more than half the days; and 4=severe or nearly every day).
The score on each item within a domain should be reviewed. However, a rating of mild (i.e., 2) or greater on any item within a domain, except for substance use, suicidal ideation, and psychosis, may serve as a guide for additional inquiry and follow-up to determine if a more detailed assessment is necessary, which may include the Level 2 cross-cutting symptom as- sessment for the domain (see Table 2). For substance use, suicidal ideation, and psychosis, a
TABLE 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure: 13 domains, thresholds for further inquiry, and associated DSM-5
Threshold to guide DSM-5 Level 2 Cross-Cutting Symptom
I. Depression Mild or greater Level 2—Depression—Adult (PROMIS
II. Anger Mild or greater Level 2—Anger—Adult (PROMIS Emo— 111. Mania Mild or greater Level 2—Mania—Adult(A1tman Self-Rating
IV. Anxiety Mild or greater Level 2—Anxiety—Adult (PROMIS
V. Somatic symptoms Mild or greater Level 2—Somatic Symptom—Adult (Patient
VI. Suicidal ideation Slight or greater None
VII. Psychosis Slight or greater None
VIII. Sleep problems Mild or greater Level 2—Sleep Disturbance—Adult
IX. Memory Mild or greater None
X. Repetitive thoughts Mild or greater Level 2—Repetitive Thoughts and
XI. Dissociation Mild or greater None
XII. Personality Mild or greater None
XIII. Substance use Slight or greater Level 2—Substance Use—Adult (adapted from the NIDA-Modified ASSIST)
Note. NIDA=National Institute on Drug Abuse.
aAvailable at www.psychiatry.org/dsm5.
rating of slight (i.e., 1) or greater on any item within the domain may serve as a guide for ad- ditional inquiry and follow-up to determine if a more detailed assessment is needed. As such, indicate the highest score within a domain in the ”Highest domain score” column.
Table 1 outlines threshold scores that may guide further inquiry for the remaining domains.
On the parent/guardian—rated version of the measure (for children ages 6—17), 19 of the 25 items are each rated on a 5—point scale (0=none or not at all; 1=slight or rare, less than a day or two; =mild or several days; 3=moderate or more than half the days; and 4=severe or nearly every day). The suicide ideation, suicide attempt, and substance abuse items are each rated on a ”Yes, No, or Don’t Know” scale. The score on each item within a domain should be re- viewed. However, with the exception of inattention and psychosis, a rating of mild (i.e., 2) or greater on any item within a domain that is scored on the 5-point scale may serve as a guide for additional inquiry and follow-up to determine if a more detailed assessment is necessary, which may include the Level 2 cross-cutting symptom assessment for the domain (see
Table 2). For inattention or psychosis, a rating of slight or greater (i.e., 1 or greater) may be for child age 6—17: 12 domains, thresholds for further inquiry, and
Threshold to guide DSM-5 Level 2 Cross-Cutting Symptom | DSM5 Psichiatry |
I. Somatic symptoms Mild or greater Level 2—Somatic Symptoms—Parent/Guard- ian of Child Age 6—17 (Patient Health 11. Sleep problems Mild or greater Level 2—Sleep Disturbance—Parent/Guard- ian of Child Age 6—17 (PROMIS Sleep
III. Inattention Slight or greater Level 2—Inattention—Parent/Guardian of
Child Age 6—17(Swanson, Nolan, and Pel- ham, Version IV [SNAP-IV])
IV. Depression Mild or greater bevel 2—Depression—Parent/Guardian of
V. Anger Mild or greater Level 2—Anger—Parent/Guardian of Child
VI. Irritability Mild or greater Level 2—Irritability—Parent/Guardian of
VII. Mania Mild or greater Level 2—Mania—Parent/Guardic'1 of Child
VIII. Anxiety Mild or greater Level 2—Anxiety—Parent/Guardian of Child
IX. Psychosis Slight or greater None
X. Repetitive thoughts Mild or greater None
XI. Substance use Yes Level 2—Substance Use—Parent/Guardian of
Child (adapted from the NIDA-modified
XII. Suicidal ideation/ Yes None
Note. NIDA=National Institute on Drug Abuse.
aAvailable at www.psychiatry.org/dsm5.
used as an indicator for additional inquiry. A parent or guardian’s rating of "Don’t Know” on the suicidal ideation, suicide attempt, and any of the substance use items, especially for chil- dren ages 11—17 years, may result in additional probing of the issues with the child, including using the child-rated Level 2 Cross-Cutting Symptom Measure for the relevant domain. Be- cause additional inquiry is made on the basis of the highest score on any item within a do- main, clinicians should indicate that score in the ”Highest Domain Score” column. Table 2 outlines threshold scores that may guide further inquiry for the remaining domains.
Any threshold scores on the Level 1 Cross-Cutting Symptom Measure (as noted in Tables clinical inquiry. Level 2 Cross-Cutting Symptom Measures provide one method of obtain- ing more in-depth information on potentially significant symptoms to inform diagnosis, treatment planning, and follow-up. They are available online at www.psychiatry.org/ dsm5. Tables 1 and 2 outline each Level 1 domain and identify the domains for which
DSM-S Leve12 Cross-Cutting Symptom Measures are available for more detailed assess- ments. Adult and pediatric (parent and child) versions are available online for most Level 1 symptom domains at www.psychiatry.org/dsm5.
Frequency of Use of the Cross-CUuing
To track change in the individual’s symptom presentation over time, the Level 1 and rel- clinically indicated, depending on the stability of the individual’s symptoms and treat- ment status. For individuals with impaired capacity and for children ages 6—17 years, it is preferable for the measures to be completed at follow-up appointments by the same knowledgeable informant and by the same parent or guardian. Consistently high scores on a particular domain may indicate significant and problematic symptoms for the indi- vidual that might warrant further assessment, treatment, and follow-up. Clinical judg— ment should guide decision making.
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As described in the chapter "Schizophrenia Spectrum and Other Psychotic Disorders,” psychotic disorders are heterogeneous, and symptom severity can predict important as- pects of the illness, such as the degree of cognitive and / or neurobiological deficits. Dimen- sional assessments capture meaningful variation in the severity of symptoms, which may help with treatment planning, prognostic decision-making, and research on pathophysi- ological mechanisms. The Clinician-Rated Dimensions of Psychosis Symptom Severity provides scales for the dimensional assessment of the primary symptoms of psychosis, in- cluding hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, and negative symptoms. A scale for the dimensional assessment of cognitive impairment is also included. Many individuals with psychotic disorders have impairments in a range of cognitive domains, which predict functional abilities. In addition, scales for dimensional assessment of depression and mania are provided, which may alert clinicians to mood pa- thology. The severity of mood symptoms in psychosis has prognostic value and guides treatment.
The Clinician—Rated Dimensions of Psychosis Symptom Severity is an 8-item measure that may be completed by the clinician at the time of the clinical assessment. Each item asks the clinician to rate the severity of each symptom as experienced by the individual during the past 7 days.
Each item on the measure is rated on a 5-point scale (0=none; 1=equivoca1; 2=present, but mild; 3=present and moderate; and 4=present and severe) with a symptom-specific defi- nition of each rating level. The clinician may review all of the individual’s available infor- mation and, based on clinical judgment, select (by circling) the level that most accurately describes the severity of the individual’s condition. The clinician then indicates the score for each item in the ”Score” column provided.
Frequency of Use
To track changes in the individual’s symptom severity over time, the measure may be completed at regular intervals as clinically indicated, depending on the stability of the in- dividual’s symptoms and treatment status. Consistently high scores on a particular do- main may indicate significant and problematic areas for the individual that might warrant further assessment, treatment, and follow-up. Clinical judgment should guide decision making. | DSM5 Psichiatry |
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.5 ~53?» 9 95:8: 5 £35K, 2 ucommw: 55> 5: £85> :0:: .zmm «5.5358 2... 3 | DSM5 Psichiatry |
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The adult self-admim‘stered version of the World Health Organization Disability Assessment
Schedule 2.0 (WHODAS 2.0) is a 36-item measure that assesses disability in adults age 18 years and older. It assesses disability across six domains, including understanding and communicating, getting around, self—Care, getting along with people, life activities (i.e., household, work, and / or school activities), and participation in society. If the adult indi- vidual is of impaired capacity and unable to complete the form (e.g., a patient with demen- tia), a knowledgeable informant may complete the proxy—administered version of the measure, which is available at www.psychiatry.org/dsm5. Each item on the self-administered version of the WHODAS 2.0 asks the individual to rate how much difficulty he or she has had in specific areas of functioning during the past 30 days.
WHODAS 2.0 Scoring Instructions Provided by WHO
WHODAS 2.0 summary scores. There are two basic options for computing the summary scores for the WHODAS 2.0 316-item full version.
Simple: The scores assigned to each of the items—"none" (1), "mild” (2), ”moderate” (3), ”severe” (4), and ”extreme” (5)—are summed. This method is referred to as simple scoring because the scores from each of the items are simply added up without recoding or collaps- ing of response categories; thus, there is no weighting of individual items. This approach is practical to use as a hand-scoring approach, and may be the method of choice in busy clin- ical settings or in paper-and-pencil interview situations. As a result, the simple sum of the scores of the items across all domains constitutes a statistic that is sufficient to describe the degree of functional limitations. | DSM5 Psichiatry |
Complex: The more complex method of scoring is called ”item-response-theory” (IRT)—based scoring. It takes into account multiple levels of difficulty for each WHODAS 2.0 item. It takes the coding for each item response as "none,” ”mild,” ”moderate,” ”se- vere," and ”extreme” separately, and then uses a computer to determine the summary score by differentially weighting the items and the levels of severity. The computer pro- gram is available from the WHO Web site. The scoring has three steps: 0 Step l—Summing of recoded item scores within each domain.
0 Step 2—Summing of all six domain scores.
' Step 3—Converting the summary score into a metric ranging from 0 to 100 (where 0=no disability; 100=full disability).
WHODAS 2.0 domain scores. WHODAS 2.0 produces domain-specific scores for six different functioning domains: cognition, mobility, self—care, getting along, life activities (household and work/school), and participation.
WHODAS 2.0 population norms. For the population norms for IRT-based scoring of the
WHODAS 2.0 and for the population distribution of IRT-based scores for WHODAS 2.0, please see www.Who.int/classifications / icf/ P0p_norms_distrib_IRT_scores.pdf.
The clinician is asked to review the individual’s response on each item on the measure during the clinical interview and to indicate the self—reported score for each item in the sec- tion provided for "Clinician Use Only." However, if the clinician determines that the score on an item should be different based on the clinical interview and other information avail- able, he or she may indicate a corrected score in the raw item score box. Based on findings from the DSM-S Field Trials in adult patient samples across six sites in the United States and one in Canada, DSM-5 recommends calculation and use of average scores for each domain and for general disability. The average scores are comparable to the WHODAS 5-point scale, which allows the Clinician to think of the individual’s disability in terms of none (1), mild (2), moderate (3), severe (4), or extreme (5). The average domain and general disability scores were found to be reliable, easy to use, and clinically useful to the clinicians in the
DSM-S Field Trials. The average domain score is calculated by dividing the raw domain score by the number of items in the domain (e.g., if all the items within the "understanding and communicating” domain are rated as being moderate then the average domain score would be 18 / 6:3, indicating moderate disability). The average general disability score is cal- culated by dividing the raw overall score by number of items in the measure (i.e., 36). The individual should be encouraged to complete all of the items on the WHODAS 2.0. If no re- sponse is given on 10 or more items of the measure (i.e., more than 25% of the 36 total items), calculation of the simple and average general disability scores may not be helpful.
If 10 or more of the total items on the measure are missing but the items for some of the do- mains are 75%—100% complete, the simple or average domain scores may be used for those domains.
Frequency of use. To track change in the individual’s level of disability over time, the measure may be completed at regular intervals as clinically indicated, depending on the stability of the individual's symptoms and treatment status. Consistently high scores on a particular domain may indicate significant and problematic areas for the individual that might warrant further assessment and intervention.
\ WHODAS 2.0
World Health Organization Disability Assessment Schedule 2.0 36-item version, self—administered
Patient Name: Age: Sex: El Male CI Female Date: | DSM5 Psichiatry |
This questionnaire asks about difficulties due to healthimental health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and answer these questions thinking about how much difficulty you had doing the following activities, For each question, please circle only m response.
: Only
Numeric scores assigned to each of the items: 4' ; ' 1 I 1 l 3 i 4 l1. 5 g c m z . _ u, ._
In the last 30 days, how much difficulty did you have in: g E i E § g g E . . . ‘ . a . Extreme or 01.1 Concegtgtmg on doung something for ten minutes? None Mlld Moderate Severe cannot do — 01.2 Remembering to do imgortant things? None Mild Moderate Severe :33“;
D13 . m all“ 0 ‘ems j‘ av None Mild Moderate Severe Extreme or e ay life? a cannot do i
Learnin a new task for xam le, le ' how t 30 5 01.4 e p ammg 0 None Mild Moderate Severe Extreme or get to a new place? cannot do
D13 neral und n in what people say? None Mild Moderate Severe 2mm” °' 01.6 Starting and maintaining a conversation? None Mild Moderate Severe :33; . . . - . Extreme or 02.1 Standing for long periods, §UCh as 30 minutes?‘ None Mlld Moderate Severe mm do . t . _ Extreme or 02.2 Standing ug from Slttlng down? None Mlld Moderate Severe cannot do
D23 Moving around inside your home? None Mild Moderate Severe Emma °r _._. .— .. cannot do 25 5
D2.4 Getting out Of your home? None Mild Moderate Severe :3?er
W “ti 3 lo ce such as a kilom r r
D2.5 . ate (0 None Mild Moderate Severe Extreme or
Fquwalem)? cannot do s . 7‘ ‘ Extreme Of 03.1 nghlng your whole body? None Mild Moderate Severe cannot do 03.2 Getting dressed? None Mild Moderate Severe “'3'“ °' . Extreme or 20 5
D33 Eggs? None Mild Moderate Severe cannot do . . Extreme or 03.4 Staying by yourself for a few days? None Mlld Moderate Severe cannot do
Getting along with people . t Extreme or 04.1 9:31!th with people ou do not know? None Mild Moderate Seven cannot do . . . l . Extreme Of
D4.2 Maintaining a friendshlg. None Mlld Moderate Severe cannot do . . . Extreme or
D43 Gefimg along wuth people who are close to you? None Mlld Moderate Severe “mm do —-25 —5
D4i4 Making new friends. None Mlld Moderate Severe cannot do . . . Extreme or 04.5 Sexual actrvltles. None Mlld Moderate Severe cannot do
Only .
Numeric scores assigned to each of the items: I 1 I 2 l 3 l 4 l 5 E c w c
In the last 30 days how much difficulty did you have in: g g E fig g E g
DS.1 Taking care of your hgusghglg responsibilities? ., None M Mlld Moderate Severe mm“ °' ; . « cannot do .u ,
DSTZ Doing most important household tasks well? None Mild Moderate Severe 2:39er ” _ | DSM5 Psichiatry |
Getting all of the household work done that you " 5‘ i ‘ Extreme or I ‘ ~ J . , -—-- ~- - 20 5 053‘ NEW to do? None Mild" kModerate Severe cannot do _" 054 Getting your household work done as guuckly as None Mild Moderate Severe Extreme ar ' ’1 ; a needed? cannot do . .
Life activities—School/Work E 7 '- 7‘ .
If you work (paid, non»paid, self~employedl or go to school, complete questions 05.5—05.8, below. “‘ ‘ ’“
Otherwise, skip to D6.1. ‘ .,
Because of your health condition, in the past 30 days how much difficulg did you have in: , 7 ’ , 05.5 Your day-to«day wogfichool? 3 : None Mild Moderate“ same“ :32: ,
D5.6 Doing your most important work/school tasks well? None Mild Moderate Severe E25212: " I "~ ' ’: 55.7 us all of the work done that you rfeed to do? 5 None Mlld Moderate Severe :33: —‘ 2° 5
D5.8 Getting your work done as Quickly as needed? None Mild Moderate Severe :33?er
In the past 30 days: "
How much of a problem did you have in 'olning in : “.- V : _ (for example festivities 3‘ 7 f : Extreme or ' .1 , , . . ' ' " N M” ' Mod at St? ' 2 ,
D6 lous, or other actwntles) m the same way as s ; me ' ~ ' er 5 vere cannot do - .
nyone else can? - “ =.
D6 2 How much of a problem did you have because of Extreme or :, ' barriers or hindrances around you? None Mild Moderate Severe cannot do l much of a problem did you have Iivlng with E 96.3 ‘ ‘ because of the attitudes and actions of None Mfld Moderate Severe $32?
06.4 Howmuch tltne dId M spend on your health None Some Mademe A Lot Extreme or 40 5 condition or Its consequences? cannot do 06.5 health condition? , , None Mild Moderate Severe cannot do _
D6.6 l-tow much has your health been a drain on the None Mild Modems Severe Extreme or ‘ fmanual resources of you or your family? cannot do 05.7 How much of a problem dld your family have None Mud M Meme Severe Extreme or so of your health problems? cannot do
D6. 8 How much of a problem dld you have In domg None M" d Moderate Severe Extreme or thlngs by yourself for relaxation or pleasure? cannot do
General Dlsablllty Score (Total): E T © World Health Organiution, 2012. All rights reserved. Measuring health and disability: manual for WHO Disability
Assessment Schedule (WHODAS 2.0), World Health Organization, 2010, Geneva.
The World Health Organization has granted the Publisher permission for the reproduction of this instrument. This material can be reproduced without permission by clinicians for use with their own patients, Any other use, including electronic use, requires written permission from WHO.
_ Formul : tion
E ass: .—
U nd erstand in g the CU llU ral context of illness experience is essential for effec- tive diagnostic assessment and clinical management. Culture refers to systems of knowl- edge, concepts, rules, and practices that are learned and transmitted across generations. | DSM5 Psichiatry |
Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems. Cultures are open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultures, which they use to fashion their own identities and make sense of experience. These features of culture make it cru- cial not to overgeneralize cultural information or stereotype groups in terms of fixed cul- tural traits.
Race is a culturally constructed category of identity that divides humanity into groups based on a variety of superficial physical traits attributed to some hypothetical intrinsic, biological characteristics. Racial categories and constructs have varied widely over history and across societies. The construct of race has no consistent biological definition, but it is socially important because it supports racial ideologies, racism, discrimination, and social exclusion, which can have strong negative effects on mental health. There is evidence that racism can exacerbate many psychiatric disorders, contributing to poor outcome, and that racial biases can affect diagnostic assessment.
Ethnicity is a culturally constructed group identity used to define peoples and communi- ties. It may be rooted in a common history, geography, language, religion, or other shared characteristics of a group, which distinguish that group from others. Ethnicity may be self- assigned or attributed by outsiders. Increasing mobility, intermarriage, and intermixing of cultures has defined new mixed, multiple, or hybrid ethnic identities.
Culture, race, and ethnicity are related to economic inequities, racism, and discrimina- tion that result in health disparities. Cultural, ethnic, and racial identities can be sources of strength and group support that enhance resilience, but they may also lead to psycholog- ical, interpersonal, and intergenerational conflict or difficulties in adaptation that require diagnostic assessment.
The Outline for Cultural Formulation introduced in DSM-IV provided a framework for as— sessing information about cultural features of an individual’s mental health problem and how it relates to a social and cultural context and history. DSM-S not only includes an up- dated version of the Outline but also presents an approach to assessment, using the Cul- tural Formulation Interview (CFI), which has been field-tested for diagnostic usefulness among clinicians and for acceptability among patients.
The revised Outline for Cultural Formulation calls for systematic assessment of the fol- lowing categories:
I Cultural identity of the individual: Describe the individual’s racial, ethnic, or cultural reference groups that may influence his or her relationships with others, access to re- sources, and developmental and current challenges, conflicts, or predicaments. For im- migrants and racial or ethnic minorities, the degree and kinds of involvement with both the culture of origin and the host culture or majority culture should be noted separately.
Language abilities, preferences, and patterns of use are relevant for identifying difficul- ties with access to care, social integration, and the need for an interpreter. Other clini— cally relevant aspects of identity may include religious affiliation, socioeconomic background, personal and family places of birth and growing up, migrant status, and sexual orientation.
0 Cultural conceptualizations of distress: Describe the cultural constructs that influence how the individual experiences, understands, and communicates his or her symptoms or problems to others. These constructs may include cultural syndromes, idioms of dis- tress, and explanatory models or perceived causes. The level of severity and meaning of the distressing experiences should be assessed in relation to the norms of the individ- ual’s cultural reference groups. Assessment of coping and help-seeking patterns should consider the use of professional as well as traditional, alternative, or complementary sources of care. | DSM5 Psichiatry |
. Psychosocial stressors and cultural features of vulnerability and resilience: Identify key stressors and supports in the individual’s social environment (which may include both local and distant events) and the role of religion, family, and other social networks (e.g., friends, neighbors, coworkers) in providing emotional, instrumental, and infor- mational support. Social stressors and social supports vary with cultural interpreta- tions of events, family structure, developmental tasks, and social context. Levels of functioning, disability, and resilience should be assessed in light of the individual’s cul- tural reference groups.
0 Cultural features of the relationship between the individual and the clinician: Iden- tify differences in culture, language, and social status between an individual and clini- treatment. Experiences of racism and discrimination in the larger society may impede establishing trust and safety in the clinical diagnostic encounter. Effects may include problems eliciting symptoms, misunderstanding of the cultural and clinical signifi- cance of symptoms and behaviors, and difficulty establishing or maintaining the rap- port needed for an effective clinical alliance.
0 Overall cultural assessment: Summarize the implications of the components of the cul- tural formulation identified in earlier sections of the Outline for diagnosis and other clinically relevant issues or problems as well as appropriate management and treat- ment intervention.
The Cultural Formulation Interview (CFI) is a set of 16 questions that clinicians may use to obtain information during a mental health assessment about the impact of culture on key aspects of an individual’s clinical presentation and care. In the CPI, culture refers to 0 The values, orientations, knowledge, and practices that individuals derive from mem- bership in diverse social groups (e.g., ethnic groups, faith communities, occupational groups, veterans groups).
0 Aspects of an individual’s background, developmental experiences, and current social contexts that may affect his or her perspective, such as geographical origin, migration, language, religion, sexual orientation, or race/ethnicity.
0 The influence of family, friends, and other community members (the individual’s social network) on the individual’s illness experience.
The CFI is a brief semistructured interview for systematically assessing cultural factors in the clinical eneounter that may be used with any individual. The CFI focuses on the in- dividual’s experience and the social contexts of the clinical problem. The CFI follows a per- son-centered approach to cultural assessment by eliciting information from the individual about his or her own views and those of others in his or her social network. This approach is designed to avoid stereotyping, in that each individual’s cultural knowledge affects how he or she interprets illness experience and guides how he or she seeks help. Because the
CFI concerns the individual’s personal views, there are no right or wrong answers to these questions. The interview follows and is available online at www.psychiatry.org/dsm5.
The CFI is formatted as two text columns. The left-hand column contains the instruc- tions for administering the CFI and describes the goals for each interview domain. The questions in the right-hand column illustrate how to explore these domains, but they are not meant to be exhaustive. Follow-up questions may be needed to clarify individuals’ an- swers. Questions may be rephrased as needed. The CFI is intended as a guide to cultural as- sessment and should be used flexibly to maintain a natural flow of the interview and rapport with the individual.
The CFI is best used in conjunction with demographic information obtained prior to the interview in order to tailor the CPI questions to address the individual’s background and current situation. Specific demographic domains to be explored with the CFI will vary across individuals and settings. A comprehensive assessment may include place of birth, age, gender, racial/ethnic origin, marital status, family composition, education, language fluencies, sexual orientation, religious or spiritual affiliation, occupation, employment, in- come, and migration history. | DSM5 Psichiatry |
The CFI can be used in the initial assessment of individuals in all clinical settings, regard- less of the cultural background of the individual or of the clinician. Individuals and clini- cians who appear to share the same cultural background may nevertheless differ in ways that are relevant to care. The CFI may be used in its entirety, or components may be incor- porated into a clinical evaluation as needed. The CFI may be especially helpful when there is 0 Difficulty in diagnostic assessment owing to significant differences in the cultural, re- ligious, or socioeconomic backgrounds of clinician and the individual.
Uncertainty about the fit between culturally distinctive symptoms and diagnostic criteria.
Difficulty in judging illness severity or impairment.
Disagreement between the individual and clinician on the course of care.
Limited engagement in and adherence to treatment by the individual.
The CFI emphasizes four domains of assessment: Cultural Definition of the Problem (questions 1-3); Cultural Perceptions of Cause, Context, and Support (questions 4—10); Cul-
Factors Affecting Current Help Seeking (questions 14—16). Both the person-centered process of conducting the CFI and the information it elicits are intended to enhance the cultural va- lidity of diagnostic assessment, facilitate treatment planning, and promote the individual’s engagement and satisfaction. To achieve these goals, the information obtained from the CFI should be integrated with all other available clinical material into a comprehensive clinical and contextual evaluation. An Informant version of the CFI can be used to collect collateral information on the CFI domains from family members or caregivers.
Supplementary modules have been developed that expand on each domain of the CFI and guide clinicians who wish to explore these domains in greater depth. Supplementary modules have also been developed for specific populations, such as children and adoles- cents, elderly individuals, and immigrants and refugees. These supplementary modules are referenced in the CFI under the pertinent subheadings and are available online at www.psychiatry.org / dsm5.
Supplementary modules used to expand each CFI subtopic are noted in parentheses.
GUIDE TO INTERVIEWER ITALICIZED.
Thefollowing questions aim to clarify key aspects of INTRODUCTION FOR THE INDIVIDUAL: the presenting Clinical problem from the point of I would like to understand the problems that view of the individual and other members of the bring you here so that 1 can help you more individual's social network (i.e.,family,friends, or effectively. I want to know about your experi- athers involved in current problem). This includes ence and ideas. 1 will ask some questions the problem’s meaning, potential 50“"55 ofhelp, about what is going on and how you are deal- and expectations for services ing with it. Please remember there are no right or wrong answers.
(Explanatory Model, Level of Functioning)
Elicit the individual’s view of core problems and key 1. What brings you here today?
concerns. IF INDIVIDUAL GIVES FEW DETAILS OR
Focus on the individual’s own way ofunderstand- ONLY MENTIONS SYMPTOMS OR A ing the problem. MEDICAL DIAGNOSIS, PROBE:
Use the term, expression, or briefdescription elicited People often understand their problems in in question 1 to identify the problem in subsequent their own way, which may be similar to or questions (e.g., “your conflict with your son"). different from how doctors describe the problem. How would you describe your problem?
Ask how individualframes the problem for members 2. Sometimes people have different ways of of the social network. describing their problem to their family, friends, or others in their community. How would you describe your problem to them?
Focus on the aspects of the problem that matter most 3. What troubles you most about your prob- to the individual. lem?
CULTURAL PERCEPTIONS 0F CAUSE, CONTEXT, AND SUPPORT (Explanatory Model, Social Network, Older Adults)
This question indicates the meaning of the condition 4. Why do you think this is happening to for the individual, which may be relevant for clin— you? What do you think are the causes of ical care. your [PROBLEM]? | DSM5 Psichiatry |
Note that individuals may identify multiple causes, PROMPT FURTHER IF REQUIRED: depending 0" thefacet 0f the problem they are con- Some people may explain their problem as sidering. the result of bad things that happen in their life, problems with others, a physical ill- ness, a spiritual reason, or many other causes.
Focus on the views of members of the individual’s 5. What do others in your family, your social network. These may be diverse and vary from friends, or others in your community think the individual’s. is causing your [PROBLEM]?
Supplementary modules used to expand each CFI subtopic are noted in parentheses.
GUIDE TO INTERVIEWER ITALICIZED.
(Social Network, Caregivers, Psychosocial Stressors, Religion and Spirituality, Immigrants and
Refugees, Cultural Identity, Older Adults, Coping and Help Seeking)
Elicit information on the individual’s life context, 6. Are there any kinds of support that make focusing on resources, social supports, and resil— your [PROBLEM] better, such as support ience. May also probe other supports (e.g., from co- from family, friends, or others?
workers, from participation in religion or spiritu- ality).
Focus on stressful aspects of the individual’s envi- 7. Are there any kinds of stresses that make ronment. Can also probe, e.g., relationship prob» your [PROBLEM] worse, such as difficul- lems, difi‘iculties at work or school, or ties with money, or family problems?
discrimination.
(Cultural Identity, Psychosocial Stressors, Religion and Spirituality, Immigrants and Refugees,
Older Adults, Children and Adolescents)
Sometimes, aspects of people’s back-
LEM] better or worse. By background or identity, I mean, for example, the commu- nities you belong to, the languages you speak, where you or your family are from, your race or ethnic background, your gen- der or sexual orientation, or your faith or religion.
Ask the individual to reflect on the most salient ele— 8. For you, what are the most important ments of his or her cultural identity. Use this aspects of your background or identity?
information to tailor questions 9—10 as needed.
Elicit aspects of identity that make the problem bet- 9. Are there any aspects of your background ter or worse. or identity that make a difference to your
Probe as needed (e.g., clinical worsening as a result [PROBLEM]?
of discrimination due to migration status, race/ ethnicity, or sexual orientation).
Probe as needed (e.g., migration-related problems; 10. Are there any aspects of your background conflict across generations or due to gender roles). or identity that are causing other concerns or difficulties for you?
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers,
Clarify self-coping for the problem. 11. Sometimes people have various ways of dealing with problems like [PROBLEM].
What have you done on your own to cope with your [PROBLEM]?
Supplementary modules used to expand each CFI subtopic are noted in parentheses.
GUIDE TO INTERVIEWER ITALICIZED.
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers, Psychosocial
Stressors, Immigrants and Refugees, Social Network, ClinicianvPatient Relationship)
Elicit various sources ofhelp (e.g., medical care, 12. Often, people look for help from many dif- mental health treatment, support groups, work- ferent sources, including different kinds of based counseling,folk healing, religious or spiri- doctors, helpers, or healers. In the past, tual counseling, other forms of traditional or alter— what kinds of treatment, help, advice, or native healing). healing have you sought for your [PROB-
Probe as needed (e.g., "What other sources of help LEM]?
have you used?"). PROBE IF DOES NOT DESCRIBE USE— | DSM5 Psichiatry |
Clarify the individual’s experience and regard for FULNESS OF HELP RECEIVED: previous help. What types of help or treatment were most useful? Not useful?
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Psychosocial Stressors, Immi- grants and Refugees, Social Network, Clinician-Patient Relationship)
Clarify the role of social barriers to help seeking, 13. Has anything prevented you from getting access to care, and problems engaging in previous the help you need?
treatment. PROBE AS NEEDED:
Probe details as needed (e.g., ”What got in the 1:01- example, money, work or family com- way? ”)~ mitments, stigma or discrimination, or lack or background?
(Social Network, Caregivers, Religion and Spirituality, Older Adults, Coping and Help Seeking)
Clarify individual’s current perceived needs and Now let’s talk some more about the help expectations of help, broadly defined. you need.
Probe 1f individual lists only one source ofhelp (eg., 14‘ What kinds of help do you think would be “What other kinds of help would be useful to you most useful to you at this time for your at this time?”). [PROBLEM]?
Focus on the views of the social network regarding 15. Are there other kinds of help that your fam— help seeking. ily, friends, or other people have suggested would be helpful for you now?
(Clinician—Patient Relationship, Older Adults)
Elicit possible concerns about the clinic or the clini— Sometimes doctors and patients misunder- cian-patient relationship, including perceived rac- stand each other because they come from ism, language barriers, or cultural differences that different backgrounds or have different may undermine goodwill, communication, or care expectations.
delivery. 16. Have you been concerned about this and is
Probe details as needed (e.g., ”In what way?"). there anything that we can do to provide
Address possible barriers to care or concerns about You With the care You need?
the clinic and the clinician-patient relationship raised previously.
The CFI—Inforniant Version collects collateral information from an informant who is knowledgeable about the clinical problems and life circumstances of the identified indi- vidual. This version can be used to supplement information obtained from the core CFI or can be used instead of the core CFI when the individual is unable to provide information— as might occur, for example, with children or adolescents, floridly psychotic individuals, or persons with cognitive impairment.
GUIDE TO INTERVIEWER ITALICIZED.
The following questions aim to clarify key aspects of INTRODUCTION FOR THE INFORMANT: the presenting clinical problemfrom the infor- I would like to understand the problems that mant’s point ofview. This includes the problem’s bring your family member/friend here so meaning, potential sources ofhelp, “"d exaecta- that I can help you and him/her more effec- tions for services. tively. I want to know about your experience and ideas. I will ask some questions about what is going on and how you and your fam- ily member/friend are dealing with it. There are no right or wrong answers.
Clarify the informant’s relationship with the indi- 1. How would you describe your relationship vidual and/or the individual'sfamily. to [INDIVIDUAL OR TO FAMILY]?
PROBE IF NOT CLEAR:
How often do you see [INDIVIDUAL]?
Elicit the informant’s view of core problems and key 2. What brings your family member/friend concerns. here today?
Focus on the informant’s way of understanding the IF INFORMANT GIVES FEW DETAILS OR individual's problem. ONLY MENTIONS SYMPTOMS OR A | DSM5 Psichiatry |
Use the term, expression, or briefdescription elicited MEDICAL DIAGNOSIS, PROBE: in question 1 to identify the problem in subsequent People often understand problems in their questions (e.g., ”her conflict with her son”). own way, which may be similar or differ- ent from how doctors describe the prob- lem. How would you describe [INDIVIDUAL’S] problem?
Ask how informantframes the problem for members 3. Sometimes people have different ways of of the social network. describing the problem to family, friends, or others in their community. How would them?
Focus on the aspects of the problem that matter most 4. What troubles you most about [INDIVID- to the informant. UAL’S] problem?
GUIDE TO INTERVIEWER ITALICIZED.
CULTURAL PERCEPTIONS OF CAUSE, CONTEXT, AND SUPPORT
This question indicates the meaning of the condition 5. Why do you think this is happening to for the informant, which may be relevant for clini— [INDIVIDUAL]? What do you think are the cal care. causes of his / her [PROBLEM]?
Note that informants may identify multiple causes PROMPT FURTHER IF REQUIRED: depending on the facet of the problem they are con- Some people may explajn the problem as the sidering. result of bad things that happen in their life, problems with others, a physical illness, a spiritual reason, or many other causes.
Focus on the views of members of the individual's 6. What do others in [INDIVIDUAL’S] fam- social network. These may be diverse and vary ily, his/her friends, or others in the com- from the informant's. munity think is causing [INDIVIDUAL’S] [PROBLEM]?
Elicit information on the individual’s life context, 7. Are there any kinds of supports that make focusing on resources, social supports, and resil— his/her [PROBLEM] better, such as from ience. May also probe other supports ( e.g., from co- family, friends, or others?
workers, from participation in religion or spiritu- ality).
Focus on stressful aspects of the individual's environ— 8. Are there any kinds of stresses that make ment. Can also probe, e.g., relationship problems, dlf- his/her [PROBLEM] worse, such as diffi- ficulties at work or school, or discrimination. culties with money, or family problems?
Sometimes, aspects of people’s background or identity can make the [PROBLEM] better or worse. By background or identity, I mean, for example, the communities you belong to, the languages you speak, where you or your family are from, your race or ethnic back- ground, your gender or sexual orientation, and your faith or religion.
Ask the informant to reflect on the most salient ele— 9. For you, what are the most important ments of the individual’s cultural identity. Use this aspects of [INDIVIDUAL’S] background or information to tailor questions 10—11 as needed. identity?
Elicit aspects of identity that make the problem bet- 104 Are there any aspects of [INDIVIDUAL’S] ter or worse. background or identity that make a differ—
Probe as needed (e.g., clinical worsening as a result ence to his/her [PROBLEM]?
of discrimination due to migration status, race/ ethnicity, or sexual orientation).
Probe as needed (erg., migration-related problems; 11. Are there any aspects of [INDIVIDUAL’S] conflict across generations or due to gender roles). background or identity that are causing other concerns or difficulties for him/her?
GUIDE TO INTERVIEWER ITALICIZED.
Clarify individual's self-coping for the problem.
12. Sometimes people have various ways of dealing with problems like [PROBLEM].
own to cope with his/her [PROBLEM]?
Elicit various sources of help (e.g., medical care, mental health treatment, support groups, work— based counseling,folk healing, religious or spiri- tual counseling, other alternative healing). | DSM5 Psichiatry |
Probe as needed (e.g., ”What other sources of help has he/she used .7 ")t
Clarify the individual’s experience and regard for previous help.
13. Often, people also look for help from many different sources, including different kinds of doctors, helpers, or healers. In the past, what kinds of treatment, help, advice, or her [PROBLEM]?
FULNESS OF HELP RECEIVED:
What types of help or treatment were most useful? Not useful?
Clarify the role ofsocial barriers to help—seeking, access to care, and problems engaging in previous treatment.
Probe details as needed (e.g., ”What got in the way?").
14. Has anything prevented [INDIVIDUAL] from getting the help he/she needs?
PROBE AS NEEDED:
For example, money, work or family com— mitments, stigma or discrimination, or lack guage or background?
expectations ofhelp, broadly defined, from the point of view of the informant.
Probe if informant lists only one source of help (e.g., ”What other kinds of help would be useful to [INDIVIDUAL] at this time?").
Focus on the views of the social network regarding help seeking.
Now let’s talk about the help [INDIVID-
UAL] needs.
15. What kinds of help would be most useful to
LEM]?
16. Are there other kinds of help that [INDI-
VIDUAL’S] family, friends, or other people her now?
Elicit possible concerns about the clinic or the clini— cian—patient relationship, including perceived rac— ism, language barriers, or cultural differences that may undermine goodwill, communication, or care delivery.
Probe details as needed (e.g., "In what way?”).
Address possible barriers to care or concerns about the clinic and the clinician-patient relationship raised previously.
stand each other because they come from expectations.
17. Have you been concerned about this, and is there anything that we can do to provide [INDIVIDUAL] with the care he/she needs?
Cultural Concepts of Distress
Cultural concepts of distress refers to ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions. Three main types of cultural concepts may be distinguished. Cultural syndromes are clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts and that are recognized locally as coherent patterns of experience. Cultural idioms of distress are ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns. For example, everyday talk about ”nerves” or ”depression” may refer to widely varying forms of suffering without mapping onto a discrete set of symptoms, syndrome, or disorder. Cultural explanations or perceived causes are labels, attributions, or features of an explanatory model that indicate culturally recog- nized meaning or etiology for symptoms, illness, or distress.
These three concepts—syndromes, idioms, and explanations—are more relevant to clinical practice than the older formulation culture-bound syndrome. Specifically, the term culture-bound syndrome ignores the fact that clinically important cultural differences often involve explanations or experience of distress rather than culturally distinctive configura- tions of symptoms. Furthermore, the term culture-bound overemphasizes the local partic- ularity and limited distribution of cultural concepts of distress. The current formulation acknowledges that all forms of distress are locally shaped, including the DSM disorders.
From this perspective, many DSM diagnoses can be understood as operationalized proto- types that started out as cultural syndromes, and became widely accepted as a result of their clinical and research utility. Across groups there remain culturally patterned differ- ences in symptoms, ways of talking about distress, and locally perceived causes, which are in turn associated with coping strategies and patterns of help seeking.
and emotional distress, and they may also reflect the influence of biomedical concepts. | DSM5 Psichiatry |
Cultural concepts have four key features in relation to the DSM-S nosology: - There is seldom a one-to—one correspondence of any cultural concept with a DSM diag- nostic entity; the correspondence is more likely to be one-to-many in either direction, included in a single folk concept, and diverse presentations that might be classified by
DSM-5 as variants of a single disorder may be sorted into several distinct concepts by an indigenous diagnostic system.
0 Cultural concepts may apply to a wide range of severity, including presentations that do not meet DSM criteria for any mental disorder. For example, an individual with acute grief or a social predicament may use the same idiom of distress or display the same cultural syndrome as another individual with more severe psychopathology.
0 In common usage, the same cultural term frequently denotes more than one type of cultural concept. A familiar example may be the concept of ”depression,” which may be used to describe a syndrome (e.g., major depressive disorder), an idiom of distress (e.g., as in the common expression “I feel depressed"), or a perceived cause (similar to ”stress").
0 Like culture and DSM itself, cultural concepts may change over time in response to both local and global influences.
Cultural concepts are important to psychiatric diagnosis for several reasons: ' To avoid misdiagnosis: Cultural variation in symptoms and in explanatory models as- sociated with these cultural concepts may lead clinicians to misjudge the severity of a problem or assign the wrong diagnosis (e.g., unfamiliar spiritual explanations may be misunderstood as psychosis).
0 To obtain useful clinical information: Cultural variations in symptoms and attribu- tions may be associated with particular features of risk, resilience, and outcome.
I To improve clinical rapport and engagement: ”Speaking the language of the patient,” both linguistically and in terms of his or her dominant concepts and metaphors, can re- sult in greater communication and satisfaction, facilitate treatment negotiation, and lead to higher retention and adherence.
0 To improve therapeutic efficacy: Culture influences the psychological mechanisms of disorder, which need to be understood and addressed to improve clinical efficacy. For example, culturally specific catastrophic cognitions can contribute to smptom escala— tion into panic attacks.
0 To guide clinical research: Locally perceived connections between cultural concepts may help identify patterns of comorbidity and underlying biological substrates.
. To clarify the cultural epidemiology: Cultural concepts of distress are not endorsed uniformly by everyone in a given culture. Distinguishing syndromes, idioms, and ex- planations provides an approach for studying the distribution of cultural features of ill- ness across settings and regions, and over time. It also suggests questions about cultural determinants of risk, course, and outcome in clinical and community settings to en- hance the evidence base of cultural research.
DSM-S includes information on cultural concepts in order to improve the accuracy of diagnosis and the comprehensiveness of clinical assessment. Clinical assessment of indi- viduals presenting with these cultural concepts should determine whether they meet
DSM-5 criteria for a specified disorder or an other specified or unspecified diagnosis. Once the disorder is diagnosed, the cultural terms and explanations should be included in case for- wise be confusing. Individuals whose symptoms do not meet DSM criteria for a specific by—case basis. In addition to the CFI and its supplementary modules, DSM-S contains the in clinical practice: 0 Data in DSM-S criteria and text for specific disorders: The text includes information on cultural variations in prevalence, symptomatology, associated cultural concepts, and other clinical aspects. It is important to emphasize that there is no one-to-one cor- respondence at the categorical level between DSM disorders and cultural concepts. Dif- variation with information elicited by the CFI.
0 Other Conditions That May Be a Focus of Clinical Attention: Some of the clinical con- cerns identified by the CFI may correspond to V codes or Z codes—for example, accul- turation problems, parent—child relational problems, or religious or spiritual problems. | DSM5 Psichiatry |
. Glossary of Cultural Concepts of Distress: Located in the Appendix, this glossary pro- vides examples of well-studied cultural concepts of distress that illustrate the relevance of cultural information for clinical diagnosis and some of the interrelationships among cultural syndromes, idioms of distress, and causal explanations.
The current approach to personality disorders appears in Section II of DSM-S, and an alternative model developed for DSM-S is presented here in Section III. The inclu- sion of both models in DSM-S reflects the decision of the APA Board of Trustees to pre- serve continuity with current clinical practice, while also introducing a new approach that aims to address numerous shortcomings of the current approach to personality disorders.
For example, the typical patient meeting criteria for a specific personality disorder fre- quently also meets criteria for other personality disorders. Similarly, other specified or un- specified personality disorder is often the correct (but mostly uninformative) diagnosis, in the sense that patients do not tend to present with patterns of symptoms that correspond with one and only one personality disorder.
In the following alternative DSM~5 model, personality disorders are characterized by impairments in personalityfunctioning and pathological personality traits. The specific personality disorder diagnoses that may be derived from this model include antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality dis- orders. This approach also includes a diagnosis of personality disorder—trait specified (PD-TS) that can be made when a personality disorder is considered present but the crite- ria for a specific disorder are not met.
The essential features of a personality disorder are
A. Moderate or greater impairment in personality (self/interpersonal) functioning.
B. One or more pathological personality traits.
C. The impairments in personality functioning and the individual’s personality trait expres- sion are relatively inflexible and pervasive across a broad range of personal and social situations.
D. The impairments in personality functioning and the individual's personality trait expres- sion are relatively stable across _time, with onsets that can be traced back to at least adolescence or early adulthood.
E. The impairments in personality functioning and the individual’s personality trait expres- sion are not better explained by another mental disorder.
F. The impairments in personality functioning and the individual’s personality trait expres- sion are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma).
G. The impairments in personality functioning and the individual’s personality trait expres- sion are not better understood as normal for an individual’s developmental stage or so- ciocultural environment.
A diagnosis of a personality disorder requires two determinations: 1) an assessment of the level of impairment in personality functioning, which is needed for Criterion A, and 2) an evaluation of pathological personality traits, which is required for Criterion B. The im- pairments in personality functioning and personality trait expression are relatively inflex- ible and pervasive across a broad range of personal and social situations (Criterion C); relatively stable across time, with onsets that can be traced back to at least adolescence or
E); not attributable to the effects of a substance or another medical condition (Criterion F); and not better understood as normal for an individual’s developmental stage or sociocul- tural environment (Criterion G). All Section III personality disorders described by criteria sets, as well as PD-TS, meet these general criteria, by definition.
Crlterion A: Level of Personality Functioning
Disturbances in self and interpersonal functioning constitute the core of personality psy- chopathology and in this alternative diagnostic model they are evaluated on a continuum.
empathy and intimacy (see Table 1). The Level of Personality Functioning Scale (LPFS; see | DSM5 Psichiatry |
Table 2, pp. 775—778) uses each of these elements to differentiate five levels of impairment, ranging from little or no impairment (i.e., healthy, adaptive functioning; Level 0) to some (Level 1), moderate (Level 2), severe (Level 3), and extreme (Level 4) impairment.
TABLE 1 Elements of personality tunctioning
Self: 1. Identity: Experience of oneself as unique, with clear boundaries between self and others; sta— bility of self—esteem and accuracy of self—appraisal; capacity for, and ability to regulate, a range of emotional experience.
2. Self-direction:1’ursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively.
Interpersonal: 1. Empathy: Comprehension and appreciation of others’ experiences and motivations; tolerance of differing perspectives; understanding the effects of one’s own behavior on others.
2. Intimacy: Depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior.
Impairment in personality functioning predicts the presence of a personality disorder, and the severity of impairment predicts whether an individual has more than one person- ality disorder or one of the more typically severe personality disorders. A moderate level of impairment in personality functioning is required for the diagnosis of a personality dis- order; this threshold is based on empirical evidence that the moderate level of impairment maximizes the ability of clinicians to accurately and efficiently identify personality disor- der pathology.
Crlterion B: Pathological Personallty Traits
Pathological personality traits are organized into five broad domains: Negative Affectiv- ity, Detachment, Antagonism, Disinhibition, and Psychoticism. Within the five broad trait domains are 25 specific trait facets that were developed initially from a review of existing trait models and subsequently through iterative research with samples of persons who sought mental health services. The full trait taxonomy is presented in Table 3 (see pp. 779— 781). The B criteria for the specific personality disorders comprise subsets of the 25 trait facets, based on meta-analytic reviews and empirical data on the relationships of the traits to DSM-IV personality disorder diagnoses.
Criteria C and D: Pervasiveness and Stability
Impairments in personality functioning and pathological personality traits are relatively per- vasive across a range of personal and social contexts, as personality is defined as a pattern of perceiving, relating to, and thinking about the environment and oneself. The term relatively reflects the fact that all except the most extremely pathological personalities show some de- gree of adaptability. The pattern in personality disorders is maladaptive and relatively inflex- ible, which leads to disabilities in social, occupational, or other important pursuits, as individuals are unable to modify their thinking or behavior, even in the face of evidence that their approach is not working. The impairments in functioning and personality traits are also relatively stable. Personality traits—the dispositions to behave or feel in certain ways—are more stable than the symptomatic expressions of these dispositions, but personality traits can also change. Impairments in personality functioning are more stable than symptoms.
Criteria E, F, and G: Alternative Explanations for | DSM5 Psichiatry |
On some occasions, what appears to be a personality disorder may be better explained by another mental disorder, the effects of a substance or another medical condition, or a nor— mal developmental stage (e.g., adolescence, late life) or the individual’s sociocultural en- vironment. When another mental disorder is present, the diagnosis of a personality disorder is not made, if the manifestations of the personality disorder clearly are an ex- pression of the other mental disorder (e.g., it features of schizotypal personality disorder are present only in the context of schizophrenia). On the other hand, personality disorders can be accurately diagnosed in the presence of another mental disorder, such as major de- pressive disorder, and patients with other mental disorders should be assessed for comor- bid personality disorders because personality disorders often impact the course of other mental disorders. Therefore, it is always appropriate to assess personality functioning and pathological personality traits to provide a context for other psychopathology.
Section 111 includes diagnostic criteria for antisocial, avoidant, borderline, narcissistic, ob— sessive-compulsive, and schizotypal personality disorders. Each personality disorder is pathological personality traits (Criterion B): 0 Typical features of antisocial personality disorder are a failure to conform to lawful and ethical behavior, and an egocentric, callous lack of concern for others, accompanied by deceitfulness, irresponsibility, manipulativeness, and / or risk taking.
0 Typical features of avoidant personality disorder are avoidance of social situations and inhibition in interpersonal relationships related to feelings of ineptitude and inade- quacy, anxious preoccupation with negative evaluation and rejection, and fears of rid- icule or embarrassment.
0 Typical features of borderline personality disorder are instability of self—image, per- sonal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking, and / 0r hostility.
0 Typical features of narcissistic personality disorder are variable and vulnerable self- esteem, with attempts at regulation through attention and approval seeking, and either overt or covert grandiosity.
0 Typical features of obsessive-compulsive personality disorder are difficulties in estab- lishing and sustaining close relationships, associated with rigid perfectionism, inflexi- bility, and restricted emotional expression.
' Typical features of schizotypal personality disorder are impairments in the capacity for social and close relationships, and eccentricities in cognition, perception, and behav- ior that are associated with distorted self—image and incoherent personal goals and ac- companied by suspiciousness and restricted emotional expression.
The A and B criteria for the six specific personality disorders and for PD-TS follow. All personality disorders also meet criteria C through G of the General Criteria for Personality
Disorder.
Typical features of antisocial personality disorder are a failure to conform to lawful and ethical behavior, and an egocentric, callous lack of concern for others, accompanied by de- ceitfulness, irresponsibility, manipulativeness, and/ or risk taking. Characteristic difficul- ties are apparent in identity, self-direction, empathy, and / or intimacy, as described below, along with specific maladaptive traits in the domains of Antagonism and Disinhibition.
A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas: 1. Identity: Egocentrism; seIf-esteem derived trom personal gain, power, or pleasure.
2. SeIt-direction: Goal setting based on personal gratification; absence of prosocial internal standards, associated with failure to conform to lawful or culturally norma- tive ethical behavior.
3. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of re- morse after hurting or mistreating another.
4. Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others. | DSM5 Psichiatry |
B. Six or more of the following seven pathological personality traits: 1. Manipulativeness (an aspect of Antagonism): Frequent use of subterfuge to in- fluence or control others; use at seduction, charm, glibness, or ingratiation to achieve one’s ends.
2. Callousness (an aspect of Antagonism): Lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one's ac- tions on others; aggression; sadism.
3. Deceitfulness (an aspect of Antagonism): Dishonesty and fraudulence; misrepre- sentation of self; embellishment or fabrication when relating events.
4. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior.
5. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky. and poten- tially self-damaging activities, unnecessarily and without regard for consequences; boredom proneness and thoughtless initiation of activities to counter boredom; lack of concern for one’s limitations and denial of the reality of personal danger.
6. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in re- sponse to immediate stimuli; acting on a momentary basis without a plan or consid- eration of outcomes; difficulty establishing and following plans.
7. irresponsibility (an aspect of Disinhibition): Disregard for—and failure to honor— tinancial and other obligations or commitments; lack of respect for—and lack of toi-
Iow-through on—agreements and promises.
Note. The individual is at least 18 years of age.
Specify it:
With psychopathic features.
Specifiers. A distinct variant often termed psychopathy (or ”primary” psychopathy) is marked by a lack of anxiety or fear and by a bold interpersonal style that may mask mal- adaptive behaviors (e.g., fraudulence). This psychopathic variant is characterized by low levels of anxiousness (Negative Affectivity domain) and withdrawal (Detachment do- main) and high levels of attention seeking (Antagonism domain). High attention seeking and low withdrawal capture the social potency (assertive/dominant) component of psy- chopathy, whereas low anxiousness captures the stress immunity (emotional stability/re- silience) component.
In addition to psychopathic features, trait and personality functioning specifiers may be used to record other personality features that may be present in antisocial personality dis- order but are not required for the diagnosis. For example, traits of Negative Affectivity (e.g., anxiousness), are not diagnostic criteria for antisocial personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impair- ment in personality functioning is required for the diagnosis of antisocial personality disor- der (Criterion A), the level of personality functioning can also be specified.
Typical features of avoidant personality disorder are avoidance of social situations and in— hibition in interpersonal relationships related to feelings of ineptitude and inadequacy, anxious preoccupation with negative evaluation and rejection, and fears of ridicule or em- barrassment. Characteristic difficulties are apparent in identity, self—direction, empathy, and/ or intimacy, as described below, along with specific maladaptive traits in the do- mains of Negative Affectivity and Detachment.
A. Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following tour areas: 1. Identity: Low self—esteem associated with seIf-appraisal as socially inept. person- ally unappealing, or interior; excessive feelings of shame.
2. Selt-direction: Unrealistic standards for behavior associated with reluctance to pursue goals, take personal risks, or engage in new activities involving interper- sonal contact. | DSM5 Psichiatry |
3. Empathy: Preoccupation with, and sensitivity to, criticism or rejection, associated with distorted inference of others' perspectives as negative.
4. Intimacy: Reluctance to get involved with people unless being certain of being liked; diminished mutuality within intimate relationships because of fear of being shamed or ridiculed.
B. Three or more of the following four pathological personality traits. one of which must be (1) Anxiousness: 1. Anxiousness (an aspect of Negative Attectivlty): Intense feelings of nervous- ness, tenseness, or panic. often in reaction to social situations; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling tearful, apprehensive, or threatened by uncertainty; tears of embarrass- ment.
2. Withdrawal (an aspect of Detachment): Reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.
3. Anhedonia (an aspect of Detachment): Lack of enjoyment from, engagement in, or energy for life's experiences; deficits in the capacity to feel pleasure or take in- terest in things.
4. Intimacy avoidance (an aspect of Detachment): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.
Specifiers. Considerable heterogeneity in the form of additional personality traits is found among individuals diagnosed with avoidant personality disorder. Trait and level of personality functioning specifiers can be used to record additional personality features that may be present in avoidant personality disorder. For example, other Negative Affec- tivity traits (e.g., depressivity, separation insecurity, submissiveness, suspiciousness, hos- tility) are not diagnostic criteria for avoidant personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of avoidant personality disorder (Cri- terion A), the level of personality functioning also can be specified.
Typical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking, and/ or hostility. Characteristic difficulties are apparent in identity, self—direction, empa- thy, and / or intimacy, as described below, along with specific maladaptive traits in the do- main of Negative Affectivity, and also Antagonism and / or Disinhibition.
A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following tour areas: 1. Identity: Markedly impoverished, poorly developed, or unstable seIf-image, often associated with excessive self—criticism; chronic feelings of emptiness; dissociative states under stress.
2. SeIt-direction: Instability in goals, aspirations, values, or career plans.
3. Empathy: Compromised ability to recognize the feelings and needs of others asso- ciated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); per- ceptions of others selectively biased toward negative attributes or vulnerabilities.
4. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternat- ing between overinvolvement and withdrawal.
B. Four or more of the following seven pathological personality traits, at least one of which must be (5) Impulsivity, (6) Risk taking, or (7) Hostility: 1. Emotional lability (an aspect of Negative Affectivity): Unstable emotional expe- riences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances. | DSM5 Psichiatry |
2. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervous- ness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibili- ties; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.
3. Separation insecurity (an aspect of Negative Affectivity): Fears of rejection by— and/or separation from—significant others, associated with tears of excessive de- pendency and complete loss of autonomy.
4. Depressivity (an aspect of Negative Affectivity): Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior seIt-worth; thoughts of sui- cide and suicidal behavior.
5. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in re- sponse to immediate stimuli; acting on a momentary basis without a plan or consid- eration of outcomes; difficulty establishing or following plans; a sense of urgency and seIt-harming behavior under emotional distress.
6. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and po- tentially selt-damaging activities, unnecessarily and without regard to conse- quences; lack of concern for one's limitations and denial of the reality of personal danger.
7. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
Specifiers. Trait and level of personality functioning specifiers may be used to record ad- not required for the diagnosis. For example, traits of Psychoticism (e.g., cognitive and per- ceptual dysregulation) are not diagnostic criteria for borderline personality disorder (see
Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of borderline personality disorder (Criterion A), the level of personality functioning can also be specified.
Typical features of narcissistic personality disorder are variable and vulnerable self-esteem, with attempts at regulation through attention and approval seeking, and either overt 0r covert grandiosity. Characteristic difficulties are apparent in identity, self—direction, em- pathy, and/ or intimacy, as described below, along with specific maladaptive traits in the domain of Antagonism.
A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following tour areas: 1. Identity: Excessive reference to others for seIt-detinition and seif-esteem regula- tion; exaggerated seli—appraisal inflated or deflated, or vaciilating between extremes; emotional regulation mirrors fluctuations in self-esteem.
2. SeIt-direction: Goat setting based on gaining approval from others; personal stan- dards unreasonably high in order to see oneselt as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
3. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.
4. Intimacy: Relationships largely superficial and exist to serve seli-esteem regula- dominance of a need for personal gain.
B. Both of the following pathological personality traits: 1 . Grandiosity (an aspect of Antagonism): Feelings of entitlement, either overt or co- vert; selt-centeredness; firmly holding to the belief that one is better than others; condescension toward others. ' 2. Attention seeking (an aspect of Antagonism): Excessive attempts to attract and be the focus of the attention of others; admiration seeking. | DSM5 Psichiatry |
Specifiers. Trait and personality functioning specifiers may be used to record additional personality features that may be present in narcissistic personality disorder but are not re- quired for the diagnosis. For example, other traits of Antagonism (e.g., manipulativeness, de- ceitfulness, callousness) are not diagnostic criteria for narcissistic personality disorder (see
Criterion B) but can be specified when more pervasive antagonistic features (e.g., ”malignant narcissism”) are present. Other traits of Negative Affectivity (e.g., depressivity, anxiousness) can be specified to record more "vulnerable” presentations. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of narcissistic personality disorder (Criterion A), the level of personality functioning can also be specified.
Typical features of obsessive-compulsive personality disorder are difficulties in establish- ing and sustaining close relationships, associated with rigid perfectionism, inflexibility, and restricted emotional expression. Characteristic difficulties are apparent in identity, self—direction, empathy, and / or intimacy, as described below, along with specific mal- adaptive traits in the domains of Negative Affectivity and/ or Detachment.
A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas: 1. Identity: Sense of self derived predominantly from work or productivity; constricted experience and expression of strong emotions.
2. SeIf-direction: Difficulty completing tasks and realizing goals, associated with rigid and unreasonably high and inflexible internal standards of behavior; overly consci- entious and moralistic attitudes.
3. Empathy: Difficulty understanding and appreciating the ideas, feelings, or behav- iors of others.
4. Intimacy: Relationships seen as secondary to work and productivity; rigidity and stubbornness negatively affect relationships with others.
B. Three or more of the following four pathological personality traits, one of which must be (1) Rigid perfectionism: 1. Rigid perfectionism (an aspect of extreme Conscientiousness [the opposite pole of DetachmentD: Rigid insistence on everything being flawless, perfect, and without errors or faults, including one’s own and others’ performance; sacrificing of timeli- ness to ensure correctness in every detail; believing that there is only one right way to do things; difficulty changing ideas and/or viewpoint; preoccupation with details, organization, and order.
2. Perseveration (an aspect of Negative Affectivity): Persistence at tasks long after the behavior has ceased to be functional or effective; continuance of the same be- havior despite repeated failures.
3. Intimacy avoidance (an aspect of Detachment): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.
4. Restricted affectivity (an aspect of Detachment): Little reaction to emotionally or coldness.
Specifiers. Trait and personality functioning specifiers may be used to record additional not required for the diagnosis. For example, other traits of Negative Affectivity (e.g., anxious- ness) are not diagnostic criteria for obsessive-compulsive personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impair- ment in personality functioning is required for the diagnosis of obsessive-compulsive person- ality disorder (Criterion A), the level of personality functioning can also be specified.
Typical features of schizotypal personality disorder are impairments in the capacity for so- cial and close relationships and eccentricities in cognition, perception, and behavior that are associated with distorted self—image and incoherent personal goals and accompanied by suspiciousness and restricted emotional expression. Characteristic difficulties are ap- parent in identity, self—direction, empathy, and / or intimacy, along with specific maladap- tive traits in the domains of Psychoticism and Detachment. | DSM5 Psichiatry |
A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas: 1. Identity: Confused boundaries between self and others; distorted seIf-concept; emotional expression often not congruent with context or internal experience.
2. Self-direction: Unrealistic or incoherent goals; no clear set of internal standards.
3. Empathy: Pronounced difficulty understanding impact of own behaviors on others; frequent misinterpretations of others’ motivations and behaviors.
4. Intimacy: Marked impairments in developing close relationships, associated with mistrust and anxiety.
B. Four or more of the following six pathological personality traits: 1. Cognitive and perceptual dysregulation (an aspect of Psychoticism): Odd or unusual thought processes; vague, circumstantial, metaphorical, overelaborate, or stereotyped thought or speech; odd sensations in various sensory modalities.
2. Unusual beliefs and experiences (an aspect of Psychoticism): Thought content and views of reality that are viewed by others as bizarre or idiosyncratic; unusual experiences of reality.
3. Eccentricity (an aspect of Psychoticism): Odd, unusual, or bizarre behavior or appearance; saying unusual or inappropriate things.
4. Restricted affectivity (an aspect of Detachment): Little reaction to emotionally or coldness.
5. Withdrawal (an aspect of Detachment): Preference for being alone to being with others; reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.
6. Suspiciousness (an aspect of Detachment): Expectations ot—and heightened sensitivity to—signs of interpersonal iII-intent or harm; doubts about loyalty and fi- delity of others; feelings of persecution.
Specifiers. Trait and personality functioning specifiers may be used to record additional personality features that may be present in schizotypal personality disorder but are not re- quired for the diagnosis. For example, traits of Negative Affectivity (e.g., depressivity, anxiousness) are not diagnostic criteria for schizotypal personality disorder (see Criterion
B) but can be specified when appropriate. Furthermore, although moderate or greater im- pairment in personality functioning is required for the diagnosis of schizotypal personal- ity disorder (Criterion A), the level of personality functioning can also be specified.
A. Moderate or greater impairment in personality functioning, manifested by difficulties in two or more of the following four areas: 1. Identity 2. SeIf-direction 3. Empathy 4. Intimacy
B. One or more pathological personality trait domains OR specific trait facets within do- mains, considering ALL of the following domains: 1. Negative Affectivity (vs. Emotional Stability): Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/ shame, worry, anger), and their behavioral (e.g., self—harm) and interpersonal (e.g., dependency) manifestations.
2. Detachment'(vs. Extraversion): Avoidance of socioemotional experience, includ- ing both withdrawal from interpersonal interactions, ranging from casual, daily in- teractions to friendships to intimate relationships, as well as restricted affective experience and expression, particularly limited hedonic capacity.
3. Antagonism (vs. Agreeableness): Behaviors that put the individual at odds with other people, including an exaggerated sense of selt-importance and a concomi- tant expectation of special treatment, as well as a callous antipathy toward others, encompassing both unawareness of others' needs and feelings, and a readiness to use others in the service of selt-enhancement.
4. Disinhibition (vs. Conscientiousness): Orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences. | DSM5 Psichiatry |
5. Psychoticism (vs. Lucidity): Exhibiting a wide range of culturally incongruent odd, eccentric, or unusual behaviors and cognitions, including both process (e.g., per- ception, dissociation) and content (e.g., beliefs).
Subtypes. Because personality features vary continuously along multiple trait dimen- sions, a comprehensive set of potential expressions of PD-TS can be represented by DSM- 5’s dimensional model of maladaptive personality trait variants (see Table 3, pp. 779—781).
Thus, subtypes are unnecessary for PD-TS, and instead, the descriptive elements that con- stitute personality are provided, arranged in an empirically based model. This arrange- ment allows clinicians to tailor the description of each individual’s personality disorder profile, considering all five broad domains of personality trait variation and drawing on the descriptive features of these domains as needed to characterize the individual.
Specifiers. The specific personality features of individuals are always recorded in eval- uating Criterion'B, so the combination of personality features characterizing an individual directly constitutes the specifiers in each case. For example, two individuals who are both characterized by emotional lability, hostility, and depressivity may differ such that the first individual is characterized additionally by callousness, whereas the second is not.
The requirement for any two of the tour A criteria for each of the six personality disorders was based on maximizing the relationship of these criteria to their corresponding person- ality disorder. Diagnostic thresholds for the B criteria were also set empirically to minimize change in prevalence of the disorders from DSM-IV and overlap with other personality disorders, and to maximize relationships with functional impairment. The resulting diag- nostic criteria sets represent clinically useful personality disorders with high fidelity, in terms of core impairments in personality functioning of varying degrees of severity and constellations of pathological personality traits.
Individuals who have a pattern of impairment in personality functioning and maladaptive traits that matches one of the six defined personality disorders should be diagnosed with that personality disorder. If an individual also has one or even several prominent traits that may have clinical relevance in addition to those required for the diagnosis (e.g., see narcis- sistic personality disorder), the option exists for these to be noted as specifiers. Individuals whose personality functioning or trait pattern is substantially different from that of any of the six specific personality disorders should be diagnosed with PD—TS. The individual may not meet the required number of A or B criteria and, thus, have a subthreshold presentation of a personality disorder. The individual may have a mix of features of personality disorder types or some features that are less characteristic of a type and more accurately considered a mixed or atypical presentation. The specific level of impairment in personality function- ing and the pathological personality traits that characterize the individual’s personality can be specified for PD-TS, using the Level of Personality Functioning Scale (Table 2) and the pathological trait taxonomy (Table 3). The current diagnoses of paranoid, schizoid, histri- onic, and dependent personality disorders are represented also by the diagnosis of PD—TS; these are defined by moderate or greater impairment in personality functioning and can be specified by the relevant pathological personality trait combinations.
Level of Personality Functioning
Like most human tendencies, personality functioning is distributed on a continuum. Cen- tral to functioning and adaptation are individuals’ characteristic ways of thinking about and understanding themselves and their interactions with others. An optimally function- ing individual has a complex, fully elaborated, and well—integrated psychological world that includes a mostly positive, volitional, and adaptive self—concept; a rich, broad, and ap- propriately regulated emotional life; and the capacity to behave as a productive member of society with reciprocal and fulfilling interpersonal relationships. At the opposite end of the continuum, an individual with severe personality pathology has an impoverished, dis- organized, and/ or conflicted psychological world that includes a weak, unclear, and mal- adaptive self—concept; a propensity to negative, dysregulated emotions; and a deficient capacity for adaptive interpersonal functioning and social behavior. | DSM5 Psichiatry |
Generalized severity may be the most important single predictor of concurrent and pro- spective dysfunction in assessing personality psychopathology. Personality disorders are optimally characterized by a generalized personality severity continuum with additional specification of stylistic elements, derived from personality disorder symptom constella- tions and personality traits. At the same time, the core of personality psychopathology is tion is consistent with multiple theories of personality disorder and their research bases. The components of the Level of Personality Functioning Scale—identity, self—direction, empa- thy, and intimacy (see Table 1)—are particularly central in describing a personality func- tioning continuum.
Mental representations of the self and interpersonal relationships are reciprocally in- fluential and inextricably tied, affect the nature of interaction with mental health pro- fessionals, and can have a significant impact on both treatment efficacy and outcome, underscoring the importance of assessing an individual’s characteristic self—concept as well as views of other people and relationships. Although the degree of disturbance in the self and interpersonal functioning is continuously distributed, it is useful to consider the level of impairment in functioning for clinical characterization and for treatment planning and prognosis.
Rating Levei of Personaiity Functioning
To use the Level of Personality Functioning Scale (LPFS), the clinician selects the level that most closely captures the individual’s current overall level of impairment in personality func- tioning. The rating is necessary for the diagnosis of a personality disorder (moderate or greater impairment) and can be used to specify the severity of impairment present for an individual with any personality disorder at a given point in time. The LPFS may also be used as a global indicator of personality functioning without specification of a personality disorder diagnosis, or in the event that personality impairment is subthreshold for a disorder diagnosis.
Criterion B in the alternative model involves assessments of personality traits that are grouped into five domains. A personality trait is a tendency to feel, perceive, behave, and think in relatively consistent ways across time and across situations in which the trait may manifest. For example, individuals with a high level of the personality trait of anxiousness would tend to feel anxious readily, including in circumstances in which most people would be calm and relaxed. Individuals high in trait anxiousness also would perceive sit- uations to be anxiety-provoking more frequently than would individuals with lower lev- els of this trait, and those high in the trait would tend to behave so as to avoid situations that they think would make them anxious. They would thereby tend to think about the world as more anxiety provoking than other people.
Importantly, individuals high in trait anxiousness would not necessarily be anxious at all times and in all situations. Individuals' trait levels also can and do change throughout life. Some changes are very general and reflect maturation (e.g., teenagers generally are higher on trait impulsivity than are older adults), whereas other changes reflect individ- uals’ life experiences.
Dimensionality of personality traits. All individuals can be located on the spectrum of trait dimensions; that is, personality traits apply to everyone in different degrees rather than being present versus absent. Moreover, personality traits, including those identified specifically in the Section 111 model, exist on a spectrum with two opposing poles. For ex- ample, the opposite of the trait of callousness is the tendency to be empathic and kind- hearted, even in circumstances in which most persons would not feel that way. Hence, al- though in Section 111 this trait is labeled callousness, because that pole of the dimension is the primary focus, it could be described in full as callousness versus kind-heartedness. More- over, its opposite pole can be recognized and may not be adaptive in all circumstances (e.g., individuals who, due to extreme kind-heartedness, repeatedly allow themselves to be taken advantage of by unscrupulous others). | DSM5 Psichiatry |
Hierarchical structure of personality. Some trait terms are quite specific (e.g., ”talkative") and describe a narrow range of behaviors, whereas others are quite broad (e.g., Detach- ment) and Characterize a wide range of behavioral propensities. Broad trait dimensions are called domains, and specific trait dimensions are calledfacets. Personality trait domains comprise a spectrum of more specific personalityfacets that tend to occur together. For ex- ample, withdrawal and anhedonia are specific traitfacets in the trait domain of Detachment.
Despite some cross-cultural variation in personality trait facets, the broad domains they collectively comprise are relatively consistent across cultures.
The Personality Trait Model
The Section III personality trait system includes five broad domains of personality trait variation—Negative Affectivity (vs. Emotional Stability), Detachment (vs. Extraversion),
Antagonism (vs. Agreeableness), Disinhibition (vs. Conscientiousness), and Psychoticism (vs. Lucidity)—comprising 25 specific personality trait facets. Table 3 provides definitions of all personality domains and facets. These five broad domains are maladaptive variants of the five domains of the extensively validated and replicated personality model known as the ”Big Five", or Five Factor Model of personality (FFM), and are also similar to the do- mains of the Personality Psychopathology Five (PSY-5). The specific 25 facets represent a list of personality facets chosen for their clinical relevance.
Although the Trait Model focuses on personality traits associated with psychopathol- ogy, there are healthy, adaptive, and resilient personality traits identified as the polar opposites of these traits, as noted in the parentheses above (i.e., Emotional Stability, Ex- traversion, Agreeableness, Conscientiousness, and Lucidity). Their presence can greatly mitigate the effects of mental disorders and facilitate coping and recovery from traumatic injuries and other medical illness.
Distinguishing Traits, Symptoms, and Specific Behaviors
Although traits are by no means immutable and do change throughout the life span, they show relative consistency compared with symptoms and specific behaviors. For example, a person may behave impulsively at a specific time for a specific reason (e.g., a person who is rarely impulsive suddenly decides to spend a great deal of money on a particular item because of an unusual opportunity to purchase something of unique value), but it is only when behaviors aggregate across time and circumstance, such that a pattern of behavior distinguishes between individuals, that they reflect traits. Nevertheless, it is important to recognize, for example, that even people who are impulsive are not acting impulsively all of the time. A trait is a tendency or disposition toward specific behaviors; a specific behav- ior is an instance or manifestation of a trait.
Similarly, traits are distinguished from most symptoms because symptoms tend to wax and wane, whereas traits are relatively more stable. For example, individuals with higher levels of depressivity have a greater likelihood of experiencing discrete episodes of a depressive disorder and of showing the symptoms of these disorders, such difficulty con- centrating. However, even patients who have a trait propensity to depressivity typically cy— cle through distinguishable episodes of mood disturbance, and specific symptoms such as difficulty concentrating tend to wax and wane in concert with specific episodes, so they do not form part of the trait definition. Importantly, however, symptoms and traits are both amenable to intervention, and many interventions targeted at symptoms can affect the longer term patterns of personality functioning that are captured by personality traits.
Assessment of the DSM-5 Section III
The clinical utility of the Section IH multidimensional personality trait model lies in its ability to focus attention on multiple relevant areas of personality variation in each individual patient. | DSM5 Psichiatry |
Rather than focusing attention on the identification of one and only one optimal diagnostic label, clinical application of the Section III personality trait model involves reviewing all five broad personality domains portrayed in Table 3. The clinical approach to personality is similar to the well-known review of systems in clinical medicine. For example, an individual’s pre- senting complaint may focus on a specific neurological symptom, yet during an initial evaluation clinicians still systematically review functioning in all relevant systems (e.g., car- diovascular, respiratory, gastrointestinal), lest an important area of diminished functioning and corresponding opportunity for effective intervention be missed.
Clinical use of the Section III personality trait model proceeds similarly. An initial in- quiry reviews all five broad domains of personality. This systematic review is facilitated by the use of formal psychometric instruments designed to measure specific facets and do- mains of personality. For example, the personality trait model is operationalized in the
Personality Inventory for DSM-S (PID-S), which can be completed in its self—report form by patients and in its informant-report form by those who know the patient well (e.g., a spouse). A detailed clinical assessment would involve collection of both patient- and in- formant—report data on all 25 facets of the personality trait model. However, if this is not possible, due to time or other constraints, assessment focused at the five-domain level is an acceptable clinical option when only a general (vs. detailed) portrait of a patient’s person- ality is needed (see Criterion B of PD—TS). However, if personality-based problems are the focus of treatment, then it will be important to assess individuals’ trait facets as well as do- mains.
Because personality traits are continuously distributed in the population, an approach to making the judgment that a specific trait is elevated (and therefore is present for diag- nostic purposes) could involve comparing individuals’ personality trait levels with pop— ulation norms and / or clinical judgment. If a trait is elevated—that is, formal psychometric testing and/ or interview data support the clinical judgment of elevation—then it is con- sidered as contributing to meeting Criterion B of Section III personality disorders.
Clinical Utility of the Multidimensional Personality
Disorder and trait constructs each add value to the other in predicting important anteced- ent (e.g., family history, history of child abuse), concurrent (e.g., functional impairment, medication use), and predictive (e.g., hospitalization, suicide attempts) variables. DSM-S ute independently to clinical decisions about degree of disability; risks for self—harm, vio- lence, and criminality; recommended treatment type and intensity; and prognosis—all important aspects of the utility of psychiatric diagnoses. Notably, knowing the level of an the clinician with a rich base of information and is valuable in treatment planning and in predicting the course and outcome of many mental disorders in addition to personality disorders. Therefore, assessment of personality functioning and pathological personality traits may be relevant whether an individual has a personality disorder or not.
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TABLE 3 Definitions of DSM-5 personality disorder trait domains
NEGATIVEAFFECTIVITY Frequent and intense experiences of high levels of a wide range of (vs. Emotional Stability) (vs. Extraversion) negative emotions (e.g., anxiety, depression, guilt/ shame, worry, anger) and their behavioral (e.g., self-harm) and interpersonal (e.g.,
Instability of emotional experiences and mood; emotions that are easily aroused, intense, and/ or out of proportion to events and cir-
Feelings of nervousness, tenseness, or panic in reaction to diverse situa- tions; frequent worry about the negative effects of past unpleasant apprehensive about uncertainty; expecting the worst to happen.
Fears of being alone due to rejection by—and/ or separation from— significant others, based in a lack of confidence in one’s ability to care for oneself, both physically and emotionally.
Adaptation of one’s behavior to the actual or perceived interests and desires of others even when doing so is antithetical to one’s own interests, needs, or desires.
to minor slights and insults; mean, nasty, or vengeful behavior. See also Antagonism.
Persistence at tasks or in a particular way of doing things long after the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures or clear reasons for stopping.
See Detachment.
See Detachment.
The lack of this facet characterizes low levels of Negative Affectivity.
See Detachment for definition of this facet.
Avoidance of socioemotiona] experience, including both withdrawal from interpersonal interactions (ranging from casual, daily interac- tions to friendships to intimate relationships) and restricted affective experience and expression, particularly limited hedonic capacity. | DSM5 Psichiatry |
Preference for being alone to being with others; reticence in social sit- uations; avoidance of social contacts and activity; lack of initiation of social contact.
Avoidance of close or romantic relationships, interpersonal attach- ments, and intimate sexual relationships.
Lack of enjoyment from, engagement in, or energy for life’s experiences; deficits in the capacity to feel pleasure and take interest in things
Feelings of being down, miserable, and / or hopeless; difficulty recov- ering from such moods; pessimism about the future; pervasive shame and/ or guilt; feelings of inferior self—worth; thoughts of sui- cide and suicidal behavior.
Little reaction to emotionally arousing situations; constricted emo- matively engaging situations.
Expectations of—and sensitivity to—signs of interpersonal ill- intent or harm; doubts about loyalty and fidelity of others; feelings of being mistreated, used, and / or persecuted by others.
TABLE 3 Definitions of DSM-5 personality disorder trait domains
ANTAGONISM (vs.
(vs. Conscientiousness)
Behaviors that put the individual at odds with other people, includ- ing an exaggerated sense of self-importance and a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both an unawareness of others’ needs and feelings and a readiness to use others in the service of self—enhancement.
Use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one’s ends.
Dishonesty and fraudulence; misrepresentation of self; embellish- ment or fabrication when relating events.
Believing that one is superior to others and deserves special treat- ment; self—centeredness; feelings of entitlement; condescension toward others.
Engaging in behavior designed to attract notice and to make oneself the focus of others’ attention and admiration.
Lack of concern for the feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one’s actions on others.
See Negative Affectivity.
Orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stim- uli, without regard for past learning or consideration of future consequences.
Disregard for—and failure to honor—financial and other obliga- tions or commitments; lack of respect for—and lack of follow- through on—agreements and promises; carelessness with others’ property.
Acting on the spur of the moment in response to immediate stimuli; urgency and self—harming behavior under emotional distress.
Difficulty concentrating and focusing on tasks; attention is easily focused behavior, including both planning and completing tasks.
Engagement in dangerous, risky, and potentially self—damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of per- sonal danger; reckless pursuit of goals regardless of the level of risk involved.
Rigid insistence on everything being flawless, perfect, and without errors or faults, including one’s own and others’ performance; sac- rificing of timeliness to ensure correctness in every detail; believ- ing that there is only one right way to do things; difficulty changing ideas and / or viewpoint; preoccupation with details, organization, and order. The lack of this facet characterizes low levels of Disinhibition.
TABLE 3 Definitions of DSM-S personality disorder trait domains
PSYCHOTICISM Exhibiting a wide range of culturally incongruent odd, eccentric, 01' (VS. Lucidity) unusual behaviors and cognitions, including both process (e.g., perception, dissociation) and content (e.g., beliefs).
Unusual beliefs and Belief that one has unusual abilities, such as mind reading, telekine- experiences sis, thought-action fusion, unusual experiences of reality, includ- ing hallucination-like experiences.
Eccentricity Odd, unusual, or bizarre behavior, appearance, and/ or speech; inappropriate things. | DSM5 Psichiatry |
Cognitive and perceptual Odd or unusual thought processes and experiences, including depersonalization, derealization, and dissociative experiences; mixed sleep-wake state experiences; thought-control experiences.
Proposed criterla sets are presented for conditions on which future research is en- couraged. The specific items, thresholds, and durations contained in these research crite- ria sets were set by expert consensus—informed by literature review, data reanalysis, and field trial results, where available—and are intended to provide a common language for researchers and clinicians who are interested in studying these disorders. It is hoped that such research will allow the field to better understand these conditions and will inform decisions about possible placement in forthcoming editions of DSM. The DSM-S Task
Force and Work Groups subjected each of these proposed criteria sets to a careful empir- ical review and invited wide commentary from the field as well as from the general public.
The Task Force determined that there was insufficient evidence to warrant inclusion of these proposals as official mental disorder diagnoses in Section 11. These proposed criteria sets are not intended for clinical use; only the criteria sets and disorders in Section II of
DSM—5 are officially recognized and can be used for clinical purposes.
A. At least one of the following symptoms is present in attenuated form, with relatively in- tact reality testing, and is of sufficient severity or frequency to warrant clinical attention: 1. Delusions.
2. Hallucinations.
3. Disorganized speech.
B. Symptom(s) must have been present at least once per week for the past month.
C. Symptom(s) must have begun or worsened in the past year.
D. Symptom(s) is sufficiently distressing and disabling to the individual to warrant clinical attention.
E. Symptom(s) is not better explained by another mental disorder, including a depressive or bipolar disorder with psychotic features, and is not attributable to the physiological effects of a substance or another medical condition.
F. Criteria for any psychotic disorder have never been met.
Attenuated psychotic symptoms, as defined in Criterion A, are psychosis—like but below the threshold for a full psychotic disorder. Compared with psychotic disorders, the symptoms are less severe and more transient, and insight is relatively maintained. A diagnosis of atten- uated psychosis syndrome requires state psychopathology associated with functional impairment rather than long-standing trait pathology. The psychopathology has not pro- gressed to full psychotic severity. Attenuated psychosis syndrome is a disorder based on the manifest pathology and impaired function and distress. Changes in experiences and behav- iors are noted by the individual and / or others, suggesting a change in mental state (i.e., the symptoms are of sufficient severity or frequency to warrant clinical attention) (Criterion A).
tent, including persecutory ideas of reference. The individual may have a guarded, distrust- ful attitude. When the delusions are moderate in severity, the individual views others as untrustworthy and may be hypervigilant or sense ill will in others. When the delusions are severe but still within the attenuated range, the individual entertains loosely organized be- liefs about danger or hostile intention, but the delusions do not have the fixed nature that is necessary for the diagnosis of a psychotic disorder. Guarded behavior in the interview can interfere with the ability to gather information. Reality testing and perspective can be elic- ited with nonconfirming evidence, but the propensity for viewing the world as hostile and dangerous remains strong. Attenuated delusions may have grandiose content presenting as an unrealistic sense of superior capacity. When the delusions are moderate, the individual harbors notions of being gifted, influential, or special. When the delusions are severe, the in- dividual has beliefs of superiority that often alienate friends and worry relatives. Thoughts of being special may lead to unrealistic plans and investments, yet skepticism about these at- titudes can be elicited with persistent questioning and confrontation. | DSM5 Psichiatry |
Attenuated hallucinations (Criterion A2) include alterations in sensory perceptions, usually auditory and/ or visual. When the hallucinations are moderate, the sounds and images are often unformed (e.g., shadows, trails, halos, murmurs, rumbling), and they are experienced as unusual or puzzling. When the hallucinations are severe, these experiences become more vivid and frequent (i.e., recurring illusions or hallucinations that capture at- tention and affect thinking and concentration). These perceptual abnormalities may dis— rupt behavior, but skepticism about their reality can still be induced.
Disorganized communication (Criterion A3) may manifest as odd speech (vague, meta- phorical, overelaborate, stereotyped), unfocused speech (confused, muddled, too fast or too slow, wrong words, irrelevant context, off track), or meandering speech (circumstantial, tan- gential). When the disorganization is moderately severe, the individual frequently gets into irrelevant topics but responds easily to clarifying questions. Speech may be odd but under- standable. At the moderately severe level, speech becomes meandering and circumstantial, and when the disorganization is severe, the individual fails to get to the point without external guidance (tangential). At the severe level, some thought blocking and / or loose as- sociations may occur infrequently, especially when the individual is under pressure, but re- orienting questions quickly return structure and organization to the conversation.
The individual realizes that changes in mental state and / or in relationships are taking place. He or she maintains reasonable insight into the psychotic-like experiences and gen— erally appreciates that altered perceptions are not real and magical ideation is not compel- ling. The individual must experience distress and/ or impaired performance in social or role functioning (Criterion D), and the individual or responsible others must note the changes and express concern, such that clinical care is sought (Criterion A).
The individual may experience magical thinking, perceptual aberrations, difficulty in con- centration, some disorganization in thought or behavior, excessive suspiciousness, anxi- ety, social withdrawal, and disruption in sleep-wake cycle. Impaired cognitive function and negative symptoms are often observed. Neuroimaging variables distinguish cohorts with attenuated psychosis syndrome from normal control cohorts with patterns similar to, but less severe than, that observed in schizophrenia. However, neuroimaging data is not diagnostic at the individual level.
The prevalence of attenuated psychosis syndrome is unknown. Symptoms in Criterion A are not uncommon in the non-help-seeking population, ranging from 23%—13% for hallu- cinatory experiences and delusional thinking. There appears to be a slight male prepon- derance for attenuated psychosis syndrome.
Onset of attenuated psychosis syndrome is usually in mid-to-late adolescence or early adulthood. It may be preceded by normal development or evidence for impaired cogni- tion, negative symptoms, and/ or impaired social development. In help-seeking cohorts, criteria for a psychotic disorder. In some cases, the syndrome may transition to a depres- sive or bipolar disorder with psychotic features, but development to a schizophrenia spec- trum disorder is more frequent. It appears that the diagnosis is best applied to individuals ages 15—35 years. Long—term course is not yet described beyond 7—12 years.
Temperamental. Factors predicting prognosis of attenuated psychosis syndrome have not been definitively characterized, but the presence of negative symptoms, cognitive im- pairment, and poor functioning are associated with poor outcome and increase risk of transition to psychosis.
Genetic and physiological. A family history of psychosis places the individual with at- tenuated psychosis syndrome at increased risk for developing a full psychotic disorder.
Structural, functional, and neurochemical imaging data are associated with increased risk of transition to psychosis. | DSM5 Psichiatry |
Many individuals may experience functional impairments. Modest-to-moderate impair— ment in social and role functioning may persist even with abatement of symptoms. A sub- stantial portion of individuals with the diagnosis will improve over time; many continue to have mild symptoms and impairment, and many others will have a full recovery.
Brief psychotic disorder. When symptoms of attenuated psychosis syndrome initially manifest, they may resemble symptoms of brief psychotic disorder. However, in attenu- ated psychosis syndrome, the symptoms do not cross the psychosis threshold and reality testing/insight remains intact.
Schizotypal personality disorder. Schizotypal personality disorder, although having symptomatic features that are similar to those of attenuated psychosis syndrome, is a rel- atively stable trait disorder not meeting the state-dependent aspects (Criterion C) of atten- uated psychosis syndrome. In addition, a broader array of symptoms is required for schizotypal personality disorder, although in the early stages of presentation it may re- semble attenuated psychosis syndrome.
Depressive or bipolar disorders. Reality distortions that are temporally limited to an episode of a major depressive disorder or bipolar disorder and are descriptively more characteristic of those disorders do not meet Criterion E for attenuated psychosis syn- drome. For example, feelings of low self—esteem or attributions of low regard from others in the context of major depressive disorder would not qualify for comorbid attenuated psychosis syndrome.
Anxiety disorders. Reality distortions that are temporally limited to an episode of an anxiety disorder and are descriptively more characteristic of an anxiety disorder do not meet Criterion E for attenuated psychosis syndrome. For example, a feeling of being the focus of undesired attention in the context of social anXiety disorder would not qualify for comorbid attenuated psychosis syndrome.
Bipolar || disorder. Reality distortions that are temporally limited to an episode of ma- nia or hypomania and are descriptively more characteristic of bipolar disorder do not meet
Criterion E for attenuated psychosis syndrome. For example, inflated self—esteem in the context of pressured speech and reduced need for sleep would not qualify for comorbid at- tenuated psychosis syndrome.
Borderline personality disorder. Reality distortions that are concomitant with border- line personality disorder and are descriptively more characteristic of it do not meet Crite- rion E for attenuated psychosis syndrome. For example, a sense of being unable to experience feelings in the context of an intense fear of real or imagined abandonment and recurrent self—mutilation would not qualify for comorbid attenuated psychosis syndrome.
Adjustment reaction of adolescence. Mild, transient symptoms typical of normal de- velopment and consistent with the degree of stress experienced do not qualify for attenu- ated psychosis syndrome.
Extreme end of perceptual aberration and magical thinking in the non-ill population.
This diagnostic possibility should be strongly entertained when reality distortions are not associated with distress and functional impairment and need for care.
Substance/medication-induced psychotic disorder. Substance use is common among individuals whose symptoms meet attenuated psychosis syndrome criteria. When other- wise qualifying characteristic symptoms are strongly temporally related to substance use episodes, Criterion E for attenuated psychosis syndrome may not be met, and a diagnosis
Attention-deficit/hyperactivity disorder. A history of attentional impairment does not exclude a Current attenuated psychosis syndrome diagnosis. Earlier attentional impair- ment may be a prodromal condition or comorbid attention-deficit/hyperactivity disorder. | DSM5 Psichiatry |
Individuals with attenuated psychosis syndrome often experience anxiety and/ or depres— sion. Some individuals with an attenuated psychosis syndrome diagnosis will progress to another diagnosis, including anxiety, depressive, bipolar, and personality disorders. In such cases, the psychopathology associated with the attenuated psychosis syndrome diagnosis is reconceptualized as the prodromal phase of another disorder, not a comorbid condition.
Lifetime experience of at least one major depressive episode meetlng the following criteria:
A. Five (or more) of the following criteria have been present during the same 2-week pe- riod 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 a medical condition.) 1. Depressed mood most of the day, nearly every day. as indicated by either subjec- tive report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., 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 (e.g., a change of more than 5% 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.) 4. Insomnia or hypersomnia nearly every day.
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 delu- sional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei- ther by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with- out a specific plan, or a suicide attempt or a specific plan for committing suicide.
. The symptoms cause clinically significant distress or impairment in social, occupa- tional, or other important areas of functioning.
. The disturbance is not attributable to the physiological effects of a substance or an- other medical condition.
. The disturbance is not better explained by schizoaffective disorder and is not superim- posed on schizophrenia, schizophreniform disorder, delusional disorder, or other spec- ified or unspecified schizophrenia spectrum and other psychotic disorder.
At least two lifetime episodes of hypomanic periods that involve the required crite- rion symptoms below but are of insufficient duration (at least 2 days but less than 4 consecutive days) to meet criteria for a hypomanic episode. The criterion symp- toms are as follows:
A.
B.
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goaI-directed activity or energy.
During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a no- ticeable change from usual behavior, and have been present to a significant degree:
Inflated seIt-esteem or grandiosity.
Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
More talkative than usual or pressured to keep talking.
Flight of ideas or subjective experience that thoughts are racing.
Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. | DSM5 Psichiatry |
7. Excessive involvement in activities that have a high potential for painful conse- quences (e.g., the individual engages in unrestrained buying sprees, sexual indis- cretions, or foolish business investments).
. The episode is associated with an unequivocal change in functioning that is uncharac- teristic of the individual when not symptomatic.
. The disturbance in mood and the change in functioning are observable by others.
The episode is not severe enough to cause marked impairment in social or occupa- tional functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.
The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment).
Individuals with short-duration hypomania have experienced at least one major depres- sive episode as well as at least two episodes of 2—3 days’ duration in which criteria for a hy- pomanic episode were met (except for symptom duration). These episodes are of sufficient intensity to be categorized as a hypomanic episode but do not meet the 4-day duration re- quirement. Symptoms are present to a significant degree, such that they represent a no— ticeable change from the individual’s normal behavior.
An individual with a history of a syndromal hypomanic episode and a major depres- sive episode by definition has bipolar II disorder, regardless of current duration of hypo- manic symptoms.
sive episode, with their increased comorbidity with substance use disorders and a greater family history of bipolar disorder, more closely resemble individuals with bipolar disor- der than those with major depressive disorder.
Differences have also been found between individuals with short-duration hypomania and those with syndromal bipolar disorder. Work impairment was greater for individuals with syndromal bipolar disorder, as was the estimated average number of episodes. Indi- viduals with short-duration hypomania may exhibit less severity than individuals with syndromal hypomanic episodes, including less mood lability.
The prevalence of short-duration hypomania is unclear, since the criteria are new as of this edition of the manual. Using somewhat different criteria, however, it has been estimated that short-duration hypomania occurs in 2.8% of the population (compared with hypoma- nia or mania in 5.5% of the population). Short-duration hypomania may be more common in females, who may present with more features of atypical depression.
Genetic and physiological. A family history of mania is two to three times more common in individuals with short-duration hypomania compared with the general population, but less than half as common as in individuals with a history of syndromal mania'or hypomania.
Individuals with short-duration hypomania have higher rates of suicide attempts than healthy individuals, although not as high as the rates in individuals with syndromal bipo- lar disorder.
Functional Consequences of Short-Duration Hypomania
Functional impairments associated specifically with short-duration hypomania are as yet not fully determined. However, research suggests that individuals with this disorder have less work impairment than individuals with syndromal bipolar disorder but more comor- bid substance use disorders, particularly alcohol use disorder, than individuals with major depressive disorder.
Bipolar II disorder. Bipolar II disorder is characterized by a period of at least 4 days of hypomanic symptoms, whereas short—duration hypomania is characterized by periods of 2—3 days of hypomanic symptoms. Once an individual has experienced a hypomanic ep- isode (4 days or; more), the diagnosis becomes and remains bipolar II disorder regardless of future duration of hypomanic symptom periods.
Major depressive disorder. Major depressive disorder is also Characterized by at least one lifetime major depressive episode. However, the additional presence of at least two life— time periods of 2—3 days of hypomanic symptoms leads to a diagnosis of short-duration hy- pomania rather than to major depressive disorder. | DSM5 Psichiatry |
Major depressive disorder with mixed features. Both major depressive disorder with mixed features and short-duration hypomania are characterized by the presence of some hypomanic symptoms and a major depressive episode. However, major depressive disor- der with mixed features is characterized by hypomanic features present concurrently with a major depressive episode, while individuals with short—duration hwomania experience subsyndromal hypomania and fully syndromal major depression at different times.
Bipolar I disorder. Bipolar I disorder is differentiated from short-duration hypomania by at least one lifetime manic episode, which is longer (at least 1 week) and more severe (causes more impaired social functioning) than a hypomanic episode. An episode (of any duration) that involves psychotic symptoms or necessitates hospitalization is by definition a manic episode rather than a hypomanic one.
Cyclothymic disorder. While cyclothymic disorder is characterized by periods of de- pressive symptoms and periods of hypomanic symptoms, the lifetime presence of a major depressive episode precludes the diagnosis of cyclothymic disorder.
Short-duration hypomania, similar to full hypomanic episodes, has been associated with higher rates of comorbid anxiety disorders and substance use disorders than are found in the general population.
A. The individual experienced the death of someone with whom he or she had a close re- lationship.
B. Since the death, at least one of the following symptoms is experienced on more days than not and to a clinically significant degree and has persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children: 1. Persistent yearning/Ionging for the deceased. In young children, yearning may be expressed in play and behavior, including behaviors that reflect being separated from, and also reuniting with, a caregiver or other attachment figure.
2. Intense sorrow and emotional pain in response to the death.
Preoccupation with the deceased.
4. Preoccupation with the circumstances of the death. In children, this preoccupation with the deceased may be expressed through the themes of play and behavior and may extend to preoccupation with possible death of others close to them.
.03
C. Since the death, at least six of the following symptoms are experienced on more days than not and to a clinically significant degree, and have persisted for at least 12 months after the death in the case of bereaved adults and 6 months for bereaved children:
Reactive distress to the death 1. Marked difficulty accepting the death. In children, this is dependent on the child’s capacity to comprehend the meaning and permanence of death.
Experiencing disbelief or emotional numbness over the loss.
Difficulty with positive reminiscing about the deceased.
Bitterness or anger related to the loss.
Maladaptive appraisals about oneself in relation to the deceased or the death (e.g., self-blame).
Excessive avoidance of reminders of the loss (e.g., avoidance of individuals, places, or situations associated with the deceased; in children, this may include avoidance of thoughts and feelings regarding the deceased).
."":“S’--3!\J .07 7. A desire to die in order to be with the deceased.
8. Difficulty trusting other individuals since the death.
9. Feeling alone or detached from other individuals since the death.
10. Feeling that life is meaningless or empty without the deceased, or the belief that one cannot function without the deceased.
11. Confusion about one’s role in life, or a diminished sense of one’s identity (e.g., ieel- ing that a part of oneself died with the deceased).
12. Difficulty or reluctance to pursue interests since the loss or to plan for the future (e.g., friendships, activities).
D. The disturbance causes clinically significant distress or impairment in social, occupa- tional, or other important areas of functioning.
E. The bereavement reaction is out of proportion to or inconsistent with cultural, religious, or age-appropriate norms.
Specify it: | DSM5 Psichiatry |
With traumatic bereavement: Bereavement due to homicide or suicide with persis- tent distressing preoccupations regarding the traumatic nature of the death (often in re- sponse to loss reminders), including the deceased’s last moments, degree of suffering and mutilating injury, or the malicious or intentional nature of the death.
Persistent complex bereavement disorder is diagnosed only if at least 12 months (6 months in children) have elapsed since the death of someone with whom the bereaved had a close relationship (Criterion A). This time frame discriminates normal grief from persistent grief. The condition typically involves a persistent yearning/longing for the deceased (Criterion Bl), which may be associated with intense sorrow and frequent crying (Crite- rion 82) or preoccupation with the deceased (Criterion B3). The individual may also be preoccupied with the manner in which the person died (Criterion B4).
Six additional symptoms are required, including marked difficulty accepting that the in- dividual has died (Criterion C1) (e.g. preparing meals for them), disbelief that the individual is dead (Criterion C2), distressing memories of the deceased (Criterion C3), anger over the loss (Criterion C4), maladaptive appraisals about oneself in relation to the deceased or the death (Criterion C5), and excessive avoidance of reminders of the loss (Criterion C6). Individuals may also report a desire to die because they wish to be with the deceased (Criterion C7); be dis- trustful of others (Criterion C8); feel isolated (Criterion C9); believe that life has no meaning or purpose without the deceased (Criterion C10); experience a diminished sense of identity in which they feel a part of themselves has died or been lost (Criterion C11); or have difficulty en- gaging in activities, pursuing relationships, or planning for the future (Criterion C12).
pairment in psychosocial functioning (Criterion D). The nature and severity of grief must be beyond expected norms for the relevant cultural setting, religious group, or develop- mental stage (Criterion E). Although there are variations in how grief can manifest, the symptoms of persistent complex bereavement disorder occur in both genders and in di- verse social and cultural groups.
Some individuals with persistent complex bereavement disorder experience hallucina- tions of the deceased (auditory or visual) in which they temporarily perceive the deceased’s presence (e.g., seeing the deceased sitting in his or her favorite chair). They may also ex- perience diverse somatic complaints (e.g., digestive complaints, pain, fatigue), including symptoms experienced by the deceased.
The prevalence of persistent complex bereavement disorder is approximately 2.4%—4.8%.
The disorder is more prevalent in females than in males.
Persistent complex bereavement disorder can occur at any age, beginning after the age of 1 year. Symptoms usually begin within the initial months after the death, although there may be a delay of months, or even years, before the full syndrome appears. Although grief responses commonly appear immediately following bereavement, these reactions are not diagnosed as persistent complex bereavement disorder unless the symptoms persist be- yond 12 months (6 months for children).
Young children may experience the loss of a primary caregiver as traumatic, given the disorganizing effects the caregiver’s absence can have on a child’s coping response. In Chil- dren, the distress may be expressed in play and behavior, developmental regressions, and anxious or protest behavior at times of separation and reunion. Separation distress may be predominant in younger children, and social/identity distress and risk for comorbid de— pression can increasingly manifest in older children and adolescents.
Environmental. Risk for persistent complex bereavement disorder is heightened by in- creased dependency on the deceased person prior to the death and by the death of a child.
Disturbances in caregiver support increase the risk for bereaved children.
Genetic and physiological. Risk for the disorder is heightened by the bereaved individ- ual being female. | DSM5 Psichiatry |
The symptoms of persistent complex bereavement disorder are observed across cultural settings, but grief responses may manifest in culturally specific ways. Diagnosis of the dis- order requires that the persistent and severe responses go beyond cultural norms of grief responses and not be better explained by culturally specific mourning rituals.
Individuals with persistent complex bereavement disorder frequently report suicidal ideation.
Persistent complex bereavement disorder is associated with deficits in work and social func- tioning and with harmful health behaviors, such as increased tobacco and alcohol use. It is also associated with marked increases in risks for serious medical conditions, including cardiac dis- ease, hypertension, cancer, immunological deficiency, and reduced quality of life.
Normal grief. Persistent complex bereavement disorder is distinguished from normal grief by the presence of severe grief reactions that persist at least 12 months (or 6 months in children) after the death of the bereaved. It is only when severe levels of grief response per- sist at least 12 months following the death and interfere with the individual’s capacity to function that persistent complex bereavement disorder is diagnosed.
Depressive disorders. Persistent complex bereavement disorder, major depressive dis- order, and persistent depressive disorder (dysthymia) share sadness, crying, and suicidal thinking. Whereas major depressive disorder and persistent depressive disorder can share depressed mood with persistent complex bereavement disorder, the latter is characterized by a focus on the loss.
Posttraumatic stress disorder. Individuals who experience bereavement as a result of trau- bereavement disorder. Both conditions can involve intrusive thoughts and avoidance.
Whereas intrusions in PTSD revolve around the traumatic event, intrusive memories in per- sistent complex bereavement disorder focus on thoughts about many aspects of the relation- ship with the deceased, including positive aspects of the relationship and distress over the separation. In individuals with the traumatic bereavement specifier of persistent complex be- reavement disorder, the distressing thoughts or feelings may be more overtly related to the manner of death, with distressing fantasies of what happened. Both persistent complex be- reavement disorder and PTSD can involve avoidance of reminders of distressing events.
Whereas avoidance in PTSD is characterized by consistent avoidance of internal and external reminders of the traumatic experience, in persistent complex bereavement disorder, there is also a preoccupation with the loss and yeaming for the deceased, which is absent in PTSD.
Separation anxiety disorder. Separation anxiety disorder is characterized by anxiety about separation from current attachment figures, whereas persistent complex bereavement disorder involves distress about separation from a deceased individual.
The most common comorbid disorders with persistent complex bereavement disorder are major depressive disorder, PTSD, and substance use disorders. PTSD is more frequently comorbid with persistent complex bereavement disorder when the death occurred in trau- matic or violent circumstances.
A problematic pattern of caffeine use leading to clinically significant impairment or distress, as manifested by at least the first three of the following criteria occurring within a 12-month period: 1. A persistent desire or unsuccessful efforts to cut down or control caffeine use.
2. Continued caffeine use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by caffeine.
3. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome ior caffeine.
b. Caffeine (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.
4. Caffeine is often taken in larger amounts or over a longer period than was intended.
5. Recurrent caffeine use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated tardiness or absences from work or school related to caffeine use or withdrawal). | DSM5 Psichiatry |
6. Continued caffeine use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of caffeine (e.g., arguments with spouse about consequences of use, medical problems, cost).
7. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of caffeine to achieve desired effect.
b. Markedly diminished effect with continued use of the same amount of caffeine.
8. A great deal of time is spent in activities necessary to obtain caffeine, use caffeine, or recover from its effects.
9. Craving or a strong desire or urge to use caffeine.
A diagnosis of substance dependence due to caffeine is recognized by the World Health
Organization in ICD-10. Since the publication of DSM-IV in 1994, considerable research on caffeine dependence has been published, and several recent reviews provide a current analysis of this literature. There is now sufficient evidence to warrant inclusion of caffeine use disorder as a research diagnosis in DSM-S to encourage additional research. The work- ing diagnostic algorithm proposed for the study of caffeine use disorder differs from that of the other substance use disorders, reflecting the need to identify only cases that have sufficient clinical importance to warrant the labeling of a mental disorder. A key goal of in- cluding caffeine use disorder in this section of DSM-S is to stimulate research that will determine the reliability, validity, and prevalence of caffeine use disorder based on the proposed diagnostic schema, with particular attention to the association of the diagnosis with functional impairments as part of validity testing.
The proposed criteria for caffeine use disorder reflect the need for a diagnostic thresh- old higher than that used for the other substance use disorders. Such a threshold is in- tended to prevent overdiagnosis of caffeine use disorder due to the high rate of habitual nonproblematic daily caffeine use in the general population.
Caffeine use disorder is characterized by the continued use of caffeine and failure to con- trol use despite negative physical and / or psychological consequences. In a survey of the general population, 14% of caffeine users met the criterion of use despite harm, with most reporting that a physician or counselor had advised them to stop or reduce caffeine use within the last year. Medical and psychological problems attributed to caffeine included heart, stomach, and urinary problems, and complaints of anxiety, depression, insomnia, irritability, and difficulty thinking. In the same survey, 45% of caffeine users reported de- sire or unsuccessful efforts to control caffeine use, 18% reported withdrawal, 8% reported tolerance, 28% used more than intended, and 50% reported spending a great deal of time using caffeine. In addition, 19% reported a strong desire for caffeine that they could not re- sist, and less than 1% reported that caffeine had interfered with social activities.
Among those seeking treatment for quitting problematic caffeine use, 88% reported having made prior serious attempts to modify caffeine use, and 43% reported having been advised by a medical professional to reduce or eliminate caffeine. Ninety—three percent endorsed signs and symptoms meeting DSM-IV criteria for caffeine dependence, with the most commonly endorsed criteria being withdrawal (96%), persistent desire or unsuccess- ful efforts to control use (89%), and use despite knowledge of physical or psychological problems caused by caffeine (87%). The most common reasons for wanting to modify caf— feine use Were health-related (59%) and a desire to not be dependent on caffeine (35%).
The DSM-S discussion of caffeine withdrawal in the Section 11 chapter ”Substance- | DSM5 Psichiatry |
Related and Addictive Disorders” provides information on the features of the withdrawal criterion. It is well documented that habitual caffeine users can experience a well-defined withdrawal syndrome upon acute abstinence from caffeine, and many caffeine-dependent individuals report continued use of caffeine to avoid experiencing withdrawal symptoms.
The prevalence of caffeine use disorder in the general population is unclear. Based on all seven generic DSM-IV-TR criteria for dependence, 30% of current caffeine users may have met DSM-IV criteria for a diagnosis of caffeine dependence, with endorsement of three or more dependence criteria, during the past year. When only four of the seven criteria (the three primary criteria proposed above plus tolerance) are used, the prevalence appears to drop to 9%. Thus, the expected prevalence of caffeine use disorder among regular caffeine users is likely less than 9%. Given that approximately 75%—80% of the general population uses caffeine regularly, the estimated prevalence would be less than 7%. Among regular caffeine drinkers at higher risk for caffeine use problems (e.g., high school and college stu- dents, individuals in drug treatment, and individuals at pain clinics who have recent his- tories of alcohol or illicit drug misuse), approximately 20% may have a pattern of use that meets all three of the proposed criteria in Criterion A.
Individuals whose pattern of use meets criteria for a caffeine use disorder have shown a wide range of daily caffeine intake and have been consumers of various types of caffein- ated products (e.g., coffee, soft drinks, tea) and medications. A diagnosis of caffeine use disorder has been shown to prospectively predict a greater incidence of caffeine reinforce- ment and more severe withdrawal.
order. Caffeine use disorder has been identified in both adolescents and adults. Rates of caffeine consumption and overall level of caffeine consumption tend to increase with age until the early to mid—30s and then level off. Age—related factors for caffeine use disorder are unknown, although concern is growing related to excessive caffeine consumption among adolescents and young adults through use of caffeinated energy drinks.
Genetic and physiological. Heritabilities of heavy caffeine use, caffeine tolerance, and caffeine withdrawal range from 35% to 77%. For caffeine use, alcohol use, and cigarette smoking, a common genetic factor (polysubstance use) underlies the use of these three substances, with 28%—41% of the heritable effects of caffeine use (or heavy use) shared with alcohol and smoking. Caffeine and tobacco use disorders are associated and substan— tially influenced by genetic factors unique to these licit drugs. The magnitude of heritabil- ity for caffeine use disorder markers appears to be similar to that for alcohol and tobacco use disorder markers.
Functional Consequences of Caffeine Use Disorder
Caffeine use disorder may predict greater use of caffeine during pregnancy. Caffeine with- drawal, a key feature of caffeine use disorder, has been shown to produce functional im- pairment in normal daily activities. Caffeine intoxication may include symptoms of nausea and vomiting, as well as impairment of normal activities. Significant disruptions in normal daily activities may occur during caffeine abstinence.
Nonproblematic use of caffeine. The distinction between nonproblematic use of caf— feine and caffeine use disorder can be difficult to make because social, behavioral, or psy- chological problems may be difficult to attribute to the substance, especially in the context of use of other substances. Regular, heavy caffeine use that can result in tolerance and with- drawal is relatively common, which by itself should not be sufficient for making a diagnosis.
Other stimulant use disorder. Problems related to use of other stimulant medications or substances may approximate the features of caffeine use disorder. | DSM5 Psichiatry |
Anxiety disorders. Chronic heavy caffeine use may mimic generalized anxiety disorder, and acute caffeine consumption may produce and mimic panic attacks.
There may be comorbidity between caffeine use disorder and daily cigarette smoking, a family or personal history of alcohol use disorder. Features of caffeine use disorder (e.g., tolerance, caffeine withdrawal) may be positively associated with several diagnoses: ma— jor depression, generalized anxiety disorder, panic disorder, adult antisocial personality disorder, and alcohol, cannabis, and cocaine use disorders.
Persistent and recurrent use of the Internet to engage in games, often with other players, leading to clinically significant impairment or distress as indicated by five (or more) of the following in a 12-month period: 1. Preoccupation with Internet games. (The individual thinks about previous gaming activity or anticipates playing the next game; Internet gaming becomes the dominant activity in daily life).
Note: This disorder is distinct from Internet gambling, which is included under gam- bling disorder.
2. Withdrawal symptoms when Internet gaming is taken away. (These symptoms are typ- ically described as irritability, anxiety, or sadness, but there are no physical signs of pharmacological withdrawal.) 3. Tolerance—the need to spend increasing amounts of time engaged in Internet games.
Unsuccessful attempts to control the participation in Internet games.
5. Loss of interests in previous hobbies and entertainment as a result of, and with the ex- ception of. Internet games.
Continued excessive use of Internet games despite knowledge of psychosocial problems.
7. Has deceived family members, therapists, or others regarding the amount of Internet gaming.
8. Use of Internet games to escape or relieve a negative mood (e.g., feelings of helpless- ness, guilt, anxiety).
9. Has jeopardized or lost a significant relationship, job. or educational or career oppor- tunity because of participation in Internet games.
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Note: Only nongambling Internet games are included in this disorder. Use of the Internet for required activities in a business or profession is not included; nor is the disorder intend- ed to include other recreational or social Internet use. Similarly, sexual Internet sites are excluded.
Specify current severity:
Internet gaming disorder can be mild, moderate, or severe depending on the degree of disruption of normal activities. Individuals with less severe Internet gaming disorder may exhibit fewer symptoms and less disruption of their lives. Those with severe Inter- net gaming disorder will have more hours spent on the computer and more severe loss of relationships or career or school opportunities.
There are no well-researched subtypes for Internet gaming disorder to date. Internet gam- ing disorder most often involves specific Internet games, but it could involve non-Internet computerized games as well, although these have been less researched. It is likely that pre- ferred games will vary over time as new games are developed and popularized, and it is unclear if behaviors and consequence associated with Internet gaming disorder vary by game type.
Gambling disorder is currently the only non-substance-related disorder proposed for in- clusion with DSM-S substance—related and addictive disorders. However, there are other behavioral disorders that show some similarities to substance use disorders and gambling disorder for which the word addiction is commonly used in nonmedical settings, and the one condition with a considerable literature is the compulsive playing of Intemet games.
Internet gaming has been reportedly defined as an ”addiction” by the Chinese govern- ment, and a treatment system has been set up. Reports of treatment of this condition have appeared in medical journals, mostly from Asian countries and some in the United States. | DSM5 Psichiatry |
The DSM-5 work group reviewed more than 240 articles and found some behavioral similarities of Internet gaming to gambling disorder and to substance use disorders. The literature suffers, however, from lack of a standard definition from which to derive prev- alence data. An understanding of the natural histories of cases, with or without treatment, is also missing. The literature does describe many underlying similarities to substance ad- dictions, including aspects of tolerance, withdrawal, repeated unsuccessful attempts to cut back or quit, and impairment in normal functioning. Further, the seemingly high preva- lence rates, both in Asian countries and, to a lesser extent, in the West, justified inclusion of this disorder in Section III of DSM-S.
Internet gaming disorder has significant public health importance, and additional re- search may eventually lead to evidence that Internet gaming disorder (also commonly re- ferred to as Internet use disorder, Internet addiction, or gaming addiction) has merit as an independent disorder. As with gambling disorder, there should be epidemiological stud- ies to determine prevalence, clinical course, possible genetic influence, and potential bio- logical factors based on, for example, brain imaging data.
Internet gaming disorder is a pattern of excessive and prolonged Internet gaming that re- sults in a cluster of cognitive and behavioral symptoms, including progressive loss of control over gaming, tolerance, and withdrawal symptoms, analogous to the symptoms of sub- stance use disorders. As with substance-related disorders, individuals with Intemet gaming disorder continue to sit at a computer and engage in gaming activities despite neglect of other activities. They typically devote 8—10 hours or more per day to this activity and at least 30 hours per week. If they are prevented from using a computer and returning to the game, they become agitated and angry. They often go for long periods without food or sleep. Nor- mal obligations, such as school or work, or family obligations are neglected. This condition is separate from gambling disorder involving the Internet because money is not at risk.
The essential feature of Internet gaming disorder is persistent and recurrent participa- tion in computer gaming, typically group games, for many hours. These games involve competition between groups of players (often in different global regions, so that duration of play is encouraged by the time-zone independence) participating in complex structured activities that include a significant aspect of social interactions during play. Team aspects appear to be a key motivation. Attempts to direct the individual toward schoolwork or in- terpersonal activities are strongly resisted. Thus personal, family, or vocational pursuits are neglected. When individuals are asked, the major reasons given for using the com- puter are more likely to be ”avoiding boredom” rather than communicating or searching for information.
The description of criteria related to this condition is adapted from a study in China. Un- til the optimal criteria and threshold for diagnosis are determined empirically, conserva- tive definitions ought to be used, such that diagnoses are considered for endorsement of five or more of nine criteria.
No consistent personality types associated with Internet gaming disorder have been iden- tified. Some authors describe associated diagnoses, such as depressive disorders, atten- tion-deficit/hyperactivity disorder (ADHD), or obsessive-compulsive disorder (OCD).
Individuals with compulsive Internet gaming have demonstrated brain activation in spe- cific regions triggered by exposure to the Internet game but not limited to reward system
The prevalence of Internet gaming disorder is unclear because of the varying question- naires, criteria and thresholds employed, but it seems to be highest in Asian countries and in male adolescents 12—20 years of age. There is an abundance of reports from Asian coun- tries, especially China and South Korea, but fewer from Europe and North America, from which prevalence estimates are highly variable. The point prevalence in adolescents (ages 15—19 years) in one Asian study using a threshold of five criteria was 8.4% for males and 4.5% for females.
Environmental. Computer availability with Internet connection allows access to the types of games with which Internet gaming disorder is most often associated.
Genetic and physiological. Adolescent males seem to be at greatest risk of developing | DSM5 Psichiatry |
Internet gaming disorder, and it has been speculated that Asian environmental and / or ge— netic background is another risk factor, but this remains unclear.
Functional Consequences of Internet Gaming Disorder
Internet gaming disorder may lead to school failure, job loss, or marriage failure. The com- pulsive gaming behavior tends to crowd out normal social, scholastic, and family activities.
Students may show declining grades and eventually failure in school. Family responsibil- ities may be neglected.
Excessive use of the Internet not involving playing of online games (e.g., excessive use of social media, such as Facebook; viewing pornography online) is not considered analogous to Internet gaming disorder, and future research on other excessive uses of the Internet would need to follow similar guidelines as suggested herein. Excessive gambling online may qualify for a separate diagnosis of gambling disorder.
Health may be neglected due to compulsive gaming. Other diagnoses that may be associ- ated with Internet gaming disorder include major depressive disorder, ADHD, and OCD.
A. More than minimal exposure to alcohol during gestation. including prior to pregnancy recognition. Confirmation of gestational exposure to alcohol may be obtained from ma- ternal seIf-report of alcohol use in pregnancy, medical or other records, or clinical ob- servation.
B. Impaired neurocognitive functioning as manifested by one or more of the following: 1. Impairment in global intellectual performance (i.e., IQ of 70 or below, or a standard score of 70 or below on a comprehensive developmental assessment).
2. Impairment in executive functioning (e.g., poor planning and organization; inflexi- bility; difficulty with behavioral inhibition).
3. Impairment in learning (e.g., lower academic achievement than expected for intel- lectual level; specific learning disability).
4. Memory impairment (e.g., problems remembering information learned recently; repeatedly making the same mistakes; difficulty remembering lengthy verbal in- structions).
5. Impairment in visuaI-spatial reasoning (e.g., disorganized or poorly planned draw- ings or constructions; problems differentiating left from right).
C. Impaired seIf-regulation as manifested by one or more of the following: 1. Impairment in mood or behavioral regulation (e.g.. mood lability; negative affect or irritability; frequent behavioral outbursts).
2. Attention deficit (e.g., difficulty shifting attention; difficulty sustaining mental effort).
3. Impairment in impulse control (e.g., difficulty waiting turn; difficulty complying with rules).
D. Impairment in adaptive functioning as manifested by two or more of the following, one of which must be (1) or (2): 1. Communication deficit (e.g., delayed acquisition of language; difficulty understand- ing spoken language).
2. Impairment in social communication and interaction (e.g., overly friendly with strang- ers; difficulty reading social cues; difficulty understanding social consequences).
3. Impairment in daily living skills (e.g., delayed toileting, feeding, or bathing; difficulty managing daily schedule).
4. Impairment in motor skills (e.g., poor fine motor development; delayed attainment ordination and balance).
E. Onset of the disorder (symptoms in Criteria B, C, and D) occurs in childhood.
F. The disturbance causes clinically significant distress or impairment in social, aca- demic, occupational, or other important areas of functioning.
G. The disorder is not better explained by the direct physiological effects associated with postnatal use of a substance (e.g., a medication, alcohol or other drugs), a general medical condition (e.g., traumatic brain injury, delirium, dementia), another known te- ratogen (e.g., fetal hydantoin syndrome), a genetic condition (e.g., Williams syndrome,
Down syndrome, Cornelia de Lange syndrome), or environmental neglect. | DSM5 Psichiatry |
Alcohol is a neurobehavioral teratogen, and prenatal alcohol exposure has teratogenic effects on central nervous system (CNS) development and subsequent function. Neurobe- havioral disorder associated with prenatal alcohol exposure (ND—PAE) is a new clarifying term, intended to encompass the full range of developmental disabilities associated with expo- sure to alcohol in utero. The current diagnostic guidelines allow ND—PAE to be diagnosed both in the absence and in the presence of the physical effects of prenatal alcohol exposure (e.g., facial dysmorphology required for a diagnosis of fetal alcohol syndrome).
The essential features of ND-PAE are the manifestation of impairment in neurocognitive, behavioral, and adaptive functioning associated with prenatal alcohol exposure. Impair- ment can be documented based on past diagnostic evaluations (e.g., psychological or ed- ucational assessments) or medical records, reports by the individual or informants, and/ or observation by a clinician.
A clinical diagnosis of fetal alcohol syndrome, including specific prenatal alcohol- related facial dysmorphology and growth retardation, can be used as evidence of signifi- cant levels of prenatal alcohol exposure. Although both animal and human studies have documented adverse effects of lower levels of drinking, identifying how much prenatal exposure is needed to significantly impact neurodevelopmental outcome remains chal- lenging. Data suggest that a history of more than minimal gestational exposure (e.g., more than light drinking) prior to pregnancy recognition and / or following pregnancy recogni- tion may be required. Light drinking is defined as 1—13 drinks per month during preg- nancy with no more than 2 of these drinks consumed on any 1 drinking occasion. Identifying a minimal threshold of drinking during pregnancy will require consideration of a variety of factors known to affect exposure and / or interact to influence developmental outcomes, including stage of prenatal development, gestational smoking, maternal and fetal genet- ics, and maternal physical status (i.e., age, health, and certain obstetric problems).
Symptoms of ND-PAE include marked impairment in global intellectual performance (IQ) 0r neurocognitive impairments in any of the following areas: executive functioning, learning, memory, and / or visual-spatial reasoning. Impairments in self-regulation are pres- ent and may include impairment in mood or behavioral regulation, attention deficit, or impairment in impulse control. Finally, impairments in adaptive functioning include com- munication deficits and impairment in social communication and interaction. Impairment in daily living (self-help) skills and impairment in motor skills may be present. As it may be difficult to obtain an accurate assessment of the neurocognitive abilities of very young chil- dren, it is appropriate to defer a diagnosis for children 3 years of age and younger.
Associated features vary depending on age, degree of alcohol exposure, and the individ- ual’s environment. An individual can be diagnosed with this disorder regardless of socio- economic or cultural background. However, ongoing parental alcohol/substance misuse, parental mental illness, exposure to domestic or community violence, neglect or abuse, disrupted caregiving relationships, multiple out-of-home placements, and lack of conti- nuity in medical or mental health care are often present.
The prevalence rates of ND-PAE are unknown. However, estimated prevalence rates of clini- cal conditions associated with prenatal alcohol exposure are 2%—5% in the United States. | DSM5 Psichiatry |
Among individuals with prenatal alcohol exposure, evidence of CNS dysfunction varies according to developmental stage. Although about one-half of young children prenatally exposed to alcohol show marked developmental delay in the first 3 years of life, other chil- dren affected by prenatal alcohol exposure may not exhibit signs of CNS dysfunction until they are preschool- or school-age. Additionally, impairments in higher order cognitive processes (i.e., executive functioning), which are often associated with prenatal alcohol ex- posure, may be more easily assessed in older children. When children reach school age, learning difficulties, impairment in executive function, and problems with integrative lan- guage functions usually emerge more clearly, and both social skills deficits and challeng- ing behavior may become more evident. In particular, as school and other requirements become more complex, greater deficits are noted. Because of this, the school years repre- sent the ages at which a diagnosis of ND-PAE would be most likely.
Suicide is a high-risk outcome, with rates increasing significantly in late adolescence and early adulthood.
Functional Consequences of Neurobehavioral Disorder
The CNS dysfunction seen in individuals with ND—PAE often leads to decrements in adap- tive behavior and to maladaptive behavior with lifelong consequences. Individuals affected by prenatal alcohol exposure have a higher prevalence of disrupted school expe- riences, poor employment records, trouble with the law, confinement (legal or psychiat- ric), and dependent living conditions.
Disorders that are attributable to the physiological effects associated with postnatal use of a substance, another medical condition, or environmental neglect. Other consid- erations include the physiological effects of postnatal substance use, such as a medication, alcohol, or other substances; disorders due to another medical condition, such as traumatic brain injury or other neurocognitive disorders (e.g., delirium, major neurocognitive dis- order [dementia]); or environmental neglect.
Genetic and teratogenic conditions. Genetic conditions such as Williams syndrome,
Down syndrome, or Cornelia de Lange syndrome and other teratogenic conditions such as behavioral characteristics. A careful review of prenatal exposure history is needed to clar- ify the teratogenic agent, and an evaluation by a clinical geneticist may be needed to dis- tinguish physical characteristics associated with these and other genetic conditions.
Mental health problems have been identified in more than 90% of individuals with histo- ries of significant prenatal alcohol exposure. The most common co-occurring diagnosis is attention-deficit/hyperactivity disorder, but research has shown that individuals with
ND-PAE differ in neuropsychological characteristics and in their responsiveness to phar- macological interventions. Other high- probability co-occurring disorders include oppo- sitional defiant disorder and conduct disorder, but the appropriateness of these diagnoses should be weighed in the context of the significant impairments in general intellectual and executive functioning that are often associated with prenatal alcohol exposure. Mood symptoms, including symptoms of bipolar disorder and depressive disorders, have been described. History of prenatal alcohol exposure is associated with an increased risk for later tobacco, alcohol, and other substance use disorders.
A. Within the last 24 months, the individual has made a suicide attempt.
Note: A suicide attempt is a seIf-initiated sequence of behaviors by an individual who, at the time of initiation, expected that the set of actions would lead to his or her own death. The “time of initiation" is the time when a behavior took place that involved ap- plying the method.)
B. The act does not meet criteria for nonsuicidal seIf-injury—that is, it does not involve self-injury directed to the surface of the body undertaken to induce relief from a nega- tive feeling/cognitive state or to achieve a positive mood state.
C. The diagnosis is not applied to suicidal ideation or to preparatory acts.
D. The act was not initiated during a state of delirium or confusion.
E. The act was not undertaken solely for a political or religious objective. | DSM5 Psichiatry |
Specify if:
Current: Not more than 12 months since the last attempt.
In early remission: 12—24 months since the last attempt.
Suicidal behavior is often categorized in terms of violence of the method. Generally, over— doses with legal or illegal substances are considered nonviolent in method, whereas jump- ing, gunshot wounds, and other methods are considered violent. Another dimension for classification is medical consequences of the behavior, with high—lethality attempts being defined as those requiring medical hospitalization beyond a visit to an emergency depart- ment. An additional dimension considered includes the degree of planning versus impul— siveness of the attempt, a characteristic that might have consequences for the medical outcome of a suicide attempt.
If the suicidal behavior occurred 12—24 months prior to evaluation, the condition is considered to be in early remission. Individuals remain at higher risk for further suicide at- tempts and death in the 24 months after a suicide attempt, and the period 12—24 months af— ter the behavior took place is specified as "early remission."
The essential manifestation of suicidal behavior disorder is a suicide attempt. A suicide at— tempt is a behavior that the individual has undertaken with at least some intent to die. The behavior might or might not lead to injury or serious medical consequences. Several fac- tors can influence the medical consequences of the suicide attempt, including poor plan- ning, lack of knowledge about the lethality of the method chosen, low intentionality or ambivalence, or chance intervention by others after the behavior has been initiated. These should not be considered in assigning the diagnosis.
Determining the degree of intent can be challenging. Individuals might not acknowl— edge intent, especially in situations where doing so could result in hospitalization or cause distress to loved ones. Markers of risk include degree of planning, including selection of a time and place to minimize rescue or interruption; the individual’s mental state at the time of the behavior, with acute agitation being especially concerning; recent discharge from inpatient care; or recent discontinuation of a mood stabilizer such as lithium or an anti- psychotic such as clozapine in the case of schizophrenia. Examples of environmental “trig- gers” include recently learning of a potentially fatal medical diagnosis such as cancer, experiencing the sudden and unexpected loss of a close relative or partner, loss of employ— ment, or displacement from housing. Conversely, features such as talking to others about future events or preparedness to sign a contract for safety are less reliable indicators.
In order for the criteria to be met, the individual must have made at least one suicide at- tempt. Suicide attempts can include behaviors in which, after initiating the suicide attempt, the individual changed his or her mind or someone intervened. For example, an individual might intend to ingest a given amount of medication or poison, but either stop or be stopped by another before ingesting the full amount. If the individual is dissuaded by another or changes his or her mind before initiating the behavior, the diagnosis should not be made.
The act must not meet criteria for nonsuicidal self—injury—that is, it should not involve re- peated (at least five times within the past 12 months) self-injurious episodes undertaken to induce relief from a negative feeling/ cognitive state or to achieve a positive mood state. The act should not have been initiated during a state of delirium or confusion. If the individual deliberately became intoxicated before initiating the behavior, to reduce anticipatory anxi— ety and to minimize interference with the intended behavior, the diagnosis should be made.
Suicidal behavior can occur at any time in the lifespan but is rarely seen in children under the age of 5. In prepubertal children, the behavior will often consist of a behavior (e.g., sit- ting on a ledge) that a parent has forbidden because of the risk of accident. Approximately 25%—30% of persons who attempt suicide will go on to make more attempts.There is sig- nificant variability in terms of frequency, method, and lethality of attempts. However, this is not different from what is observed in other illnesses, such as major depressive disorder, in which frequency of episode, subtype of episode, and impairment for a given episode can vary significantly. | DSM5 Psichiatry |
Suicidal behavior varies in frequency and form across cultures. Cultural differences might be due to method availability (e.g., poisoning with pesticides in developing countries; gunshot wounds in the southwestern United States) or the presence of culturally specific syndromes (e.g., ataques de nervios, which in some Latino groups might lead to behaviors that closely resemble suicide attempts or might facilitate suicide attempts).
Laboratory abnormalities consequent to the suicidal attempt are often evident. Suicidal behavior that leads to blood loss can be accompanied by anemia, hypotension, or shock.
Overdoses might lead to coma or obtundation and associated laboratory abnormalities such as electrolyte imbalances.
Functional Consequences of Suicidal Behavior Disorder
Medical conditions (e.g., lacerations or skeletal trauma, cardiopulmonary instability, in- halation of vomit and suffocation, hepatic failure consequent to use of paracetamol) can occur as a consequence of suicidal behavior.
Suicidal behavior is seen in the context of a variety of mental disorders, most commonly bipo— lar disorder, major depressive disorder, schizophrenia, schizoaffective disorder, anxiety dis- orders (in particular, panic disorders associated with catastrophic content and PTSD flashbacks), substance use disorders (especially alcohol use disorders), borderline personality disorder, antisocial personality disorder, eating disorders, and adjustment disorders. It is rarely manifested by individuals with no discernible pathology, unless it is undertaken be- cause of a painful medical condition with the intention of drawing attention to martyrdom for political or religious reasons, or in partners in a suicide pact, both of which are excluded from this diagnosis, or when thiId-party informants wish to conceal the nature of the behavior.
A. In the last year, the individual has, on 5 or more days, engaged in intentional seIf-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), with the expectation that the injury will lead to only minor or moderate physical harm (i.e., there is no suicidal intent).
Note: The absence of suicidal intent has either been stated by the individual or can be inferred by the individual’s repeated engagement in a behavior that the individual knows, or has learned, is not likely to result in death.
B. The individual engages in the seIf-injurious behavior with one or more of the following expectations: 1. To obtain relief from a negative feeling or cognitive state.
2. To resolve an interpersonal difficulty.
3. To induce a positive feeling state.
Note: The desired relief or response is experienced during or shortly after the self- injury, and the individual may display patterns of behavior suggesting a dependence on repeatedly engaging in it.
C. The intentional self-injury is associated with at least one of the following: 1. Interpersonal difficulties or negative feelings or thoughts, such as depression, anx- iety, tension, anger, generalized distress, or seIf—criticism, occurring in the period immediately prior to the seIf-injurious act.
2. Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to control.
3. Thinking about seIf-injury that occurs frequently, even when it is not acted upon.
D. The behavior is not socially sanctioned (e.g., body piercing, tattooing, part of a religious or cultural ritual) and is not restricted to picking a scab or nail biting.
E. The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning. | DSM5 Psichiatry |
F. The behavior does not occur exclusively during psychotic episodes, delirium, sub- stance intoxication, or substance withdrawal. In individuals with a neurodevelopmental disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior is not better explained by another mental disorder or medical condition (e.g., psychotic disorder, autism spectrum disorder. intellectual disability, Lesch-Nyhan syndrome, ste- reotypic movement disorder with seIf-injury, trichotillomania [hair-pulling disorder]. ex- coriation [skin-picking] disorder).
The essential feature of nonsuicidal self-injury is that the individual repeatedly inflicts shallow, yet painful injuries to the surface of his or her body. Most commonly, the purpose is to reduce negative emotions, such as tension, anxiety, and self—reproach, and / or to re- solve an interpersonal difficulty. In some cases, the injury is conceived of as a deserved self—punishment. The individual will often report an immediate sensation of relief that oc- curs during the process. When the behavior occurs frequently, it might be associated with a sense of urgency and craving, the resultant behavioral pattern resembling an addiction.
The inflicted wounds can become deeper and more numerous.
The injury is most often inflicted with a knife, needle, razor, or other sharp object. Com- mon areas for injury include the frontal area of the thighs and the dorsal side of the forearm.
A single session of injury might involve a series of superficial, parallel cuts—separated by 1 or 2 centimeters—on a visible or accessible location. The resulting cuts will often bleed and will eventually leave a characteristic pattern of scars.
Other methods used include stabbing an area, most often the upper arm, with a needle or sharp, pointed knife; inflicting a superficial burn with a lit cigarette end; or burning the skin by repeated rubbing with an eraser. Engagement in nonsuicidal self—injury with mul- tiple methods is associated with more severe psychopathology, including engagement in suicide attempts.
The great majority of individuals Who engage in nonsuicidal self—injury do not seek clinical attention. It is not known if this reflects frequency of engagement in the disorder, because accurate reporting is seen as stigmatizing, or because the behaviors are experi- enced positively by the individual who engages in them, who is unmotivated to receive treatment. Young Children might experiment with these behaviors but not experience re- lief. In such cases, youths often report that the procedure is painful or distressing and might then discontinue the practice.
Nonsuicidal self—injury most often starts in the early teen years and can continue for many years. Admission to hospital for nonsuicidal self—injury reaches a peak at 20—29 years of age and then declines. However, research that has examined age at hospitalization did not provide information on age at onset of the behavior, and prospective research is needed to outline the natural history of nonsuicidal self—injury and the factors that promote or in- hibit its course. Individuals often learn of the behavior on the recommendation or observa- tion of another. Research has shown that when an individual who engages in nonsuicidal self—injury is admitted to an inpatient unit, other individuals may begin to engage in the behavior.
Male and female prevalence rates of nonsuicidal self—injury are closer to each other than in suicidal behavior disorder, in which the female-to-male ratio is about 3:1 or 4:1. | DSM5 Psichiatry |
Two theories of psychopathology—based on functional behavioral analyses—have been proposed: In the first, based on learning theory, either positive or negative reinforcement sustains the behavior. Positive reinforcement might result from punishing oneself in a way that the individual feels is deserved, with the behavior inducing a pleasant and relaxed state or generating attention and help from a significant other, or as an expression of anger. Neg- ative reinforcement results from affect regulation and the reduction of unpleasant emotions or avoiding distressing thoughts, including thinking about suicide. In the second theory, nonsuicidal self-injury is thought to be a form of self—punishment, in which self—punitive ac- tions are engaged in to make up for acts that caused distress or harm to others.
Functional Consequences of Nonsuicidal SeIf-lniury
The act of cuttingkmight be performed with shared implements, raising the possibility of blood—bome disease transmission.
Borderline personality disorder. As indicated, nonsuicidal self-injury has long been re- garded as a ”symptom" of borderline personality disorder, even though comprehensive clinical evaluations have found that most individuals with nonsuicidal self-injury have symptoms that also meet criteria for other diagnoses, with eating disorders and substance use disorders being especially common. Historically, nonsuicidal self-injury was regarded as pathognomonic of borderline personality disorder. Both conditions are associated with several other diagnoses. Although frequently associated, borderline personality disorder is not invariably found in individuals with nonsuicidal self—injury. The two conditions dif- fer in several ways. Individuals with borderline personality disorder often manifest dis- turbed aggressive and hostile behaviors, whereas nonsuicidal self—injury is more often associated with phases of closeness, collaborative behaviors, and positive relationships. At a more fundamental level, there are differences in the involvement of different neurotrans— mitter systems, but these will not be apparent on clinical examination.
Suicidal behavior disorder. The differentiation between nonsuicidal self-injury and sui- cidal behavior disorder is based either on the stated goal of the behavior being a wish to die (suicidal behavior disorder) or, in nonsuicidal self—injury, to experience relief as de- scribed in the criteria. Depending on the circumstances, individuals may provide reports of convenience, and several studies report high rates of false intent declaration. Individu- als with a history of frequent nonsuicidal self—injury episodes have learned that a session of cutting, while painful, is, in the short-term, largely benign. Because individuals with nonsuicidal self—injury can and do attempt and commit suicide, it is important to check past history of suicidal behavior and to obtain information from a third party concerning any recent change in stress exposure and mood. Likelihood of suicide intent has been as- sociated with the use of multiple previous methods of self—harm.
In a follow-up study of cases of ”self—harm" in males treated at one of several multiple emergency centers in the United Kingdom, individuals with nonsuicidal self-injury were significantly more likely to commit suicide than other teenage individuals drawn from the same cohort. Studies that have examined the relationship between nonsuicidal self-injury and suicidal behavior disorder are limited by being retrospective and failing to obtain ver- ified accounts of the method used during previous "attempts.” A significant proportion of have ever engaged in self-cutting (or their preferred means of self—injury) with an intention to die. It is reasonable to conclude that nonsuicidal self-injury, while not presenting a high risk for suicide when first manifested, is an especially dangerous form of self—injurious behavior.
This conclusion is also supported by a multisite study of depressed adolescents who had previously failed to respond to antidepressant medication, which noted that those with pre- vious nonsuicidal self—injury did not respond to cognitive-behavioral therapy, and by a study that found that nonsuicidal self-injury is a predictor of substance use/misuse. | DSM5 Psichiatry |
Trichotillomania (hair-pulling disorder). Trichotillomania is an injurious behavior con- fined to pulling out one’s own hair, most commonly from the scalp, eyebrows, or eyelashes.
The behavior occurs in ”sessions" that can last for hours. It is most likely to occur during a period of relaxation or distraction.
Stereotypic seIf-injury. Stereotypic self—injury, which can include head banging, self- biting, or self—hitting, is usually associated with intense concentration or under conditions of low external stimulation and might be associated with developmental delay.
Excoriation (skin-picking) disorder. Excoriation disorder occurs mainly in females and is usually directed to picking at an area of the skin that the individual feels is unsightly or a blemish, usually on the face or the scalp. As in nonsuicidal self-injury, the picking is often preceded by an urge and is experienced as pleasurable, even though the individual real- izes that he or she is harming himself or herself. It is not associated with the use of any im- plement.
Highlights of Changes From DSM-IV to DSM-5 ................... 809
Glossary of Technical Terms .................................. 817
Glossary of Cultural Concepts of Distress ....................... 833
Alphabetical Listing of DSM-5 Diagnoses and Codes (lCD-9-CM and lCD—10-CM) ................................. 839
Numerical Listing of DSM—5 Diagnoses and Codes (ICD-9-CM) ...... 863
Numerical Listing of DSM-5 Diagnoses and Codes (|CD-10-CM) ..... 877
DSM-5 Advisors and Other Contributors ......................... 897 ‘ Highlights °f Changes Fro .
DSM-IV to DSM
C ham 9% mad 9 IO DSM-5 diagnostic criteria and texts are outlined in this chapter in the same order in which they appear in the DSM-S classification. This abbreviated descrip- tion is intended to orient readers to only the most significant changes in each disorder cate- gory. An expanded description of nearly all changes (e.g., except minor text or wording changes needed for clarity) is available online (www.psychiatry.org/ dsmS). It should also be noted that Section I contains a description of changes pertaining to the chapter organization in DSM-S, the multiaxial system, and the introduction of dimensional assessments.
The term mental retardation was used in DSM-IV. However, intellectual disability (intel- lectual developmental disorder) 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. Diagnostic criteria emphasize the need for an assessment of both cognitive capacity (IQ) and adaptive functioning. Severity is determined by adaptive func- tioning rather than IQ score.
The communication disorders, which are newly named from DSM-IV phonological dis- order and stuttering, respectively, include language disorder (which combines the previous expressive and mixed receptive-expressive language disorders), speech sound disorder (pre- viously phonological disorder), and childhood-onset fluency disorder (previously stutter- ing). Also included is social (pragmatic) communication disorder, a new condition involving persistent difficulties in the social uses of verbal and nonverbal communication.
Autism spectrum disorder is a new DSM-S disorder encompassing the previous DSM-
IV autistic disorder (autism), Asperger’s disorder, Childhood disintegrative disorder,
Rett’s disorder, and pervasive developmental disorder not otherwise specified. It is char- acterized by deficits in two core domains: 1) deficits in social communication and social in- teraction and 2) restricted repetitive patterns of behavior, interests, and activities. | DSM5 Psichiatry |
Several changes have been made to the diagnostic criteria for attention-deficit/hyperactiv- ity disorder (ADHD). Examples have been added to the criterion items to facilitate application across the life span; the age at onset description has been changed (from “some hyperactive- to ”Several inattentive or hyperactive-impulsive symptoms were present prior to age 12”); subtypes have been replaced with presentation specifiers that map directly to the prior sub- types; a comorbid diagnosis with autism spectrum disorder is now allowed; and a symptom threshold change has been made for adults, to reflect the substantial evidence of Clinically sig- nificant ADHD impairment, with the cutoff for ADHD of five symptoms, instead of six re- quired for younger persons, both for inattention and for hyperactivity and impulsivity.
Specific learning disorder combines the DSM-IV diagnoses of reading disorder, math- ematics disorder, disorder of written expression, and learning disorder not otherwise specified. Learning deficits in the areas of reading, written expression, and mathematics are coded as separate specifiers. Acknowledgment is made in the text that specific types of reading deficits are described internationally in various ways as dyslexia and specific types of mathematics deficits as dyscalculia.
810 Highlights of Changes From DSM-IV to DSM-5
The following motor disorders are included in DSM-S: developmental coordination disor- der, stereotypic movement disorder, Tourette’s disorder, persistent (chronic) 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.
Two changes were made to Criterion A for schizophrenia: 1) the elimination of the special at- tribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing), leading to the requirement of at least two Criterion A symptoms for any diagnosis of schizophrenia, and 2) the addition of the requirement that at least one of the
Criterion A symptoms must be delusions, hallucinations, or disorganized speech. The DSM-IV subtypes of schizophrenia were eliminated due to their limited diagnostic stability, low reli- ability, and poor validity. Instead, a dimensional approach to rating severity for the core symp- toms of schizophrenia is included in DSM-S Section III to capture the important heterogeneity in symptom type and severity expressed across individuals with psychotic disorders.
Schizoaffective disorder is reconceptualized as a longitudinal instead of a cross-sectional di- agnosis—more comparable to schizophrenia, bipolar disorder, and major depressive disorder, which are bridged by this condition—and requires that a major mood episode be present for a majority of the total disorder’s duration after Criterion A has been met. Criterion A for delu- sional disorder no longer has the requirement that the delusions must be nonbizarre; a spec- ifier is now included for bizarre type delusions to provide continuity with DSM-IV. Criteria for catatonia are described uniformly across DSM-5. Furthermore, catatonia may be diagnosed with a specifier (for depressive, bipolar, and psychotic disorders, including schizophrenia), in the context of a known medical condition, or as an other specified diagnosis. | DSM5 Psichiatry |
activity or energy. The DSM-IV diagnosis of bipolar I disorder, mixed episodes—requiring that the individual simultaneously meet full criteria for both mania and major depressive ep- isode—is replaced with a new specifier "with mixed features.“ Particular conditions can now be diagnosed under other specified bipolar and related disorder, including categori- zation for individuals with a past history of a major depressive disorder whose symptoms meet all criteria for hypomania except the duration criterion is not met (i.e., the episode lasts only 2 or 3 days instead of the required 4 consecutive days or more). A second condition con- stituting an other specified bipolar and related disorder variant is that too few symptoms of hypomania are present to meet criteria for the full bipolar II syndrome, although the dura- tion, at least 4 consecutive days, is sufficient. Finally, in both this chapter and in the chapter ”Depressive Disorders,” an anxious distress specifier is delineated.
To address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is included for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behav- ioral dyscontrol. Premenstrual dysphoric disorder is now promoted from Appendix B, ”Cri- teria Sets and Axes Provided for Further Study,” in DSM-IV to the main body of DSM-S. What was referred to as dysthyrnia in DSM-IV now falls under the category of persistent depressive disorder, which includes both chronic major depressive disorder and the previous dysthymic disorder. The coexistence within a major depressive episode of at least three manic symp- toms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier
Highlights of Changes From DSM-IV to DSM-5 811 ”with mixed features." In DSM-IV, there was an exclusion criterion for a major depressive ep- isode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM—S for several reasons, including the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss, and can add an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer medical health, and worse interpersonal and work functioning. It was critical to remove the implication that bereavement typically lasts only 2 months, when both physi- cians and grief counselors recognize that the duration is more commonly 1—2 years. A detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive disorder. Finally, a new specifier to indicate the presence of mixed symptoms has been added across both the bipolar and the depressive disorders.
The chapter on anxiety disorders no longer includes obsessive-compulsive disorder (which is in the new chapter ”Obsessive-Compulsive and Related Disorders”) or posttraumatic stress disorder (PTSD) and acute stress disorder (which are in the new chapter ”Trauma- and Stressor-Related Disorders"). Changes in criteria for specific phobia and social anxiety disorder (social phobia) include deletion of the requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable. Instead, the anxiety must be out of proportion to the actual danger or threat in the situation, after cultural contextual fac- tors are taken into account. In addition, the 6-month duration is now extended to all ages. | DSM5 Psichiatry |
Panic attacks can now be listed as a specifier that is applicable to all DSM-5 disorders. Panic disorder and agoraphobia are unlinked in DSM-S. Thus, the former DSM-IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses, panic disorder and ag- oraphobia, each with separate criteria. The ”generalized" specifier for social anxiety disor- der has been deleted and replaced with a ”performance only” specifier. Separation anxiety disorder and selective mutism are now classified as anxiety disorders. The wording of the criteria is modified to more adequately represent the expression of separation anxiety symp- toms in adulthood. Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that onset must be before age 18 years, and a duration statement—"typically lasting for 6 months or more”—has been added for adults to minimize overdiagnosis of transient fears.
The chapter ”Obsessive-Compulsive and Related Disorders" is new in DSM-S. New disor- ders include hoarding disorder, excoriation (skin-picking) disorder, substance/medica- tion-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. The DSM-IV diagnosis of trichotillo- mania is now termed trichotillomania (hair-pulling disorder) and has been moved from a
DSM—IV classification of impulse—control disorders not elsewhere classified to obsessive- compulsive and related disorders in DSM-5. The DSM-IV ”with poor insight” specifier for obsessive-compulsive disorder has been refined to allow a distinction between individuals with good or fair insight, poor insight, and "absent insight/delusional” obsessive-compul- sive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). Analogous "insight” specifiers have been included for body dysmorphic disorder and hoarding disorder. A "tic-related" specifier for obsessive-compulsive disorder has also been added, because presence of a comorbid tic disorder may have important clinical im- plications. A ”muscle dysmorphia” specifier for body dysmorphic disorder is added to re- flect a growing literature on the diagnostic validity and clinical utility of making this 812 Highlights of Changes From DSM-IV to DSM-5 distinction in individuals with body dysmorphic disorder. The delusional variant of body dysmorphic disorder (which identifies individuals who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delu- sional disorder, somatic type, and body dysmorphic disorder; in DSM-S, this presentation is designated only as body dysmorphic disorder with the absent insight/ delusional specifier.
Individuals can also be diagnosed with other specified obsessive-compulsive and related disorder, which can include conditions such as body-focused repetitive behavior disorder and obsessional jealousy, or unspecified obsessive-compulsive and related disorder.
For a diagnosis of acute stress disorder, qualifying traumatic events are now explicit as to whether they were experienced directly, witnessed, or experienced indirectly. Also, the
DSM-IV Criterion A2 regarding the subjective reaction to the traumatic event (e.g., expe- riencing ”fear, helplessness, or horror”) has been eliminated. 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 cat- not meet criteria for a more discrete disorder (as in DSM-IV). | DSM5 Psichiatry |
DSM-S criteria for PTSD differ significantly from the DSM-IV criteria. The stressor cri- terion (Criterion A) is more explicit with regard to events that qualify as ”traumatic” ex- periences. Also, DSM-IV Criterion A2 (subjective reaction) has been eliminated. Whereas there were three major symptom clusters in DSM-IV—reexperiencing, avoidance/numb- ing, and arousal—there are now four symptom clusters in DSM-5, because the avoidance/ numbing cluster is divided into two distinct clusters: avoidance and persistent negative al- terations in cognitions and mood. This latter category, which retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as persistent negative emotional states. The final cluster—alterations in arousal and reactivity—retains most of the DSM-IV arousal symptoms. It also includes irritable behavior or angry out- bursts and reckless or self—destructive behavior. PTSD is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder.
The DSM-IV childhood diagnosis reactive attachment disorder had two subtypes: emotionally withdrawn/ inhibited and indiscriminately social/disinhibited. In DSM-S, these subtypes are defined as distinct disorders: reactive attachment disorder and disin- hibited social engagement disorder.
Major changes in dissociative disorders in DSM-S include the following: 1) derealization is included in the name and symptom structure of what previously was called depersonali- zation disorder (depersonalization/derealization disorder); 2) dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis, and 3) the criteria for dissociative identity disorder have been changed to indicate that symptoms of disruption of identity may be reported as well as observed, and that gaps in the recall of events may occur for everyday and not just traumatic events. Also, experiences of pathological pos- session in some cultures are included in the description of identity disruption.
In DSM-5, somatoform disorders are now referred to as somatic symptom and related dis- orders. The DSM-S classification reduces the number of these disorders and subcategories to avoid problematic overlap. Diagnoses of somatization disorder, hypochondriasis, pain dis- order, and undifferentiated somatoform disorder have been removed. Individuals previ-
Highlights of Changes From DSM-IV to DSM—5 813 ously diagnosed with somatization disorder will usually have symptoms that meet DSM-5 criteria for somatic symptom disorder, but only if they have the maladaptive thoughts, feel- ings, and behaviors that define the disorder, in addition to their somatic symptoms. Because the distinction between somatization disorder and undifferentiated somatoform disorder was arbitrary, they are merged in DSM—S under somatic symptom disorder. Individuals pre- viously diagnosed with hypochondriasis who have high health anxiety but no somatic symp- toms would receive a DSM-S diagnosis of illness anxiety disorder (unless their health anxiety was better explained by a primary anxiety disorder, such as generalized anxiety dis- order). Some individuals with chronic pain would be appropriately diagnosed as having so- matic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an adjustment disorder would be more appropriate.
Psychological factors affecting other medical conditions is a new mental disorder in
DSM-5, having formerly been listed in the DSM-IV chapter ”Other Conditions That May | DSM5 Psichiatry |
Be a Focus of Clinical Attention.” This disorder and factitious disorder are placed among the somatic symptom and related disorders because somatic symptoms are predominant in both disorders, and both are most often encountered in medical settings. The variants of psychological factors affecting other medical conditions are removed in favor of the stern diagnosis. Criteria for conversion disorder (functional neurological symptom disorder) have been modified to emphasize the essential importance of the neurological examina- tion, and in recognition that relevant psychological factors may not be demonstrable at the time of diagnosis. Other specified somatic symptom disorder, other specified illness anx- iety disorder, and pseudocyesis are now the only exemplars of the other specified somatic symptom and related disorder classification.
Because of the elimination of the DSM-IV-TR chapter ”Disorders Usually First Diagnosed
During Infancy, Childhood, or Adolescence,” this chapter describes several disorders found in the DSM-IV section ”Feeding and Eating Disorders of Infancy or Early Childhood,” such as pica and rumination disorder. The DSM-IV category feeding disorder of infancy or early childhood has been renamed avoidant/restrictive food intake disorder, and the criteria are significantly expanded. The core diagnostic criteria for anorexia nervosa are conceptually un- changed from DSM-IV with one exception: the requirement for amenorrhea is eliminated. 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 is changed for clarification, and guidance regarding how to judge whether an individual is at or below a sig- nificantly low weight is provided in the text. In DSM-S, Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behavior that interferes with weight gain. The only change in the DSM-IV criteria for bulimia nervosa is a reduction in the required minimum average frequency of binge eating and inappropriate compensatory be- havior frequency from twice to once weekly. The extensive research that followed the prom- ulgation of preliminary criteria for binge-eating disorder in Appendix B of DSM-IV documented the clinical utility and validity of binge—eating disorder. The only significant dif- ference from the preliminary criteria is that the minimum average frequency of binge eating re- quired for diagnosis is once weekly over the last 3 months, identical to the frequency criterion for bulimia nervosa (rather than at least 2 days a week for 6 months in DSM-IV).
There have been no significant changes in this diagnostic class from DSM-IV to DSM-S.
The disorders in this chapter were previously classified under disorders usually first di- agnosed in infancy, childhood, or adolescence in DSM-IV and exist now as an independent classification in DSM-S.
814 Highlights of Changes From DSM-IV to DSM-5
In DSM-5, the DSM-IV diagnoses named sleep disorder related to another mental disorder and sleep disorder related to another medical condition have been removed, and instead greater specification of coexisting conditions is provided for each sleep-wake disorder. The diagnosis of primary insomnia has been renamed insomnia disorder to avoid the differen- tiation between primary and secondary insomnia. DSM-S also distinguishes narcolepsy— now known to be associated with hypocretin deficiency—from other forms of hypersomno- lence (hypersomnolence disorder). Finally, throughout the DSM-S classification of sleep- wake disorders, pediatric and developmental criteria and text are integrated where existing science and considerations of clinical utility support such integration. Breathing-related sleep disorders are divided into three relatively distinct disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. The subtypes of circadian rhythm sleep disorders are expanded to include advanced sleep phase type and irregular sleep-wake type, whereas the jet lag type has been removed. The use of the former “not oth- ment sleep behavior disorder and restless legs syndrome to independent disorders. | DSM5 Psichiatry |
In DSM-5, some gender-specific sexual dysfunctions have been added, and, for females, sexual desire and arousal disorders have been combined into one disorder: female sexual interestlarousal disorder. All of the sexual dysfunctions (except substance/medication-in- duced sexual dysfunction) now require a minimum duration of approximately 6 months and more precise severity criteria. Genito-pelvic pain/penetration disorder has been added to
DSM-S and represents a merging of vaginismus and dyspareunia, which were highly co- morbid and difficult to distinguish. The diagnosis of sexual aversion disorder has been re- moved due to rare use and lack of supporting research.
There are now only two subtypes for sexual dysfunctions: lifelong versus acquired and generalized versus situational. T0 indicate the presence and degree of medical and other nonmedical correlates, the following associated features have been added to the text: partner factors, relationship factors, individual vulnerability factors, cultural or religious factors, and medical factors.
Gender dysphoria is a new diagnostic class in DSM-S and reflects a change in conceptual- ization of the disorder’s defining features by emphasizing the phenomenon of ”gender in- congruence” rather than cross-gender identification per se, as was the case in DSM-IV gender identity disorder. Gender dysphoria includes separate sets of criteria: for children and for adults and adolescents. For the adolescents and adults criteria, the previous Criterion A (cross-gender identification) and Criterion B (aversion toward one’s gender) are merged. In the wording of the criteria, ”the other sex” is replaced by ”the other gender" (or ”some alter- native gender").” Gender instead of sex is used systematically because the concept ”sex” is in- adequate 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 de- sire to be...the other sex” to capture the situation of some children who, in a coercive envi- ronment, may not verbalize the desire to be of another gender. For children, Criterion A1 (”a strong desire to be of the other gender or an insistence that he or she is the other gender.. .)” is now necessary (but not sufficient), which makes the diagnosis more restrictive and conser- vative. The subtyping on the basis of sexual orientation is removed because the distinction is no longer considered clinically useful. A posttransition specifier has been added to identify
Highlights of Changes From DSM-IV to DSM-S 815 individuals who have undergone at least one medical procedure or treatment to support the new gender assignment (e.g., cross-sex hormone treatment). Although the concept of post- transition is modeled on the concept of full or partial remission, the term remission has impli- cations in terms of symptom reduction that do not apply directly to gender dysphoria.
Disruptive, Impulse-Control, and Conduct Disorders
The chapter “Disruptive, Impulse—Control, and Conduct Disorders” is new to DSM-S and combines disorders that were previously included in the chapter “Disorders Usually First Di- agnosed in Infancy, Childhood, or Adolescence” (i.e., oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified, now categorized as other specified and unspecified disruptive, impulse—control, and conduct disorders) and the chap- ter ”Impulse—Control Disorders Not Elsewhere Classified” (i.ei, intermittent explosive disor- der, pyromania, and kleptomania). These disorders are all characterized by problems in emotional and behavioral self—control. Notably, ADHD is frequently comorbid with the dis- orders in this chapter but is listed with the neurodevelopmental disorders. Because of its close association with conduct disorder, antisocial personality disorder is listed both in this chapter and in the chapter ”Personality Disorders,” where it is described in detail. | DSM5 Psichiatry |
The criteria for oppositional defiant disorder are now grouped into three types: an- gry/irritable mood, argumentative/defiant behavior, and vindictiveness. Additionally, the exclusionary criterion for conduct disorder has been removed. The criteria for conduct the disorder but also present with limited prosocial emotions. The primary change in in- termittent explosive disorder is in the type of aggressive outbursts that should be consid- ered: DSM-IV required physical aggression, whereas in DSM-5 verbal aggression and nondestructive/noninjurious physical aggression also meet criteria. DSM-S also provides more specific criteria defining frequency needed to meet the criteria and specifies that the aggressive outbursts are impulsive and / or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences. Furthermore, a minimum age of 6 years (or equivalent developmental level) is now required.
An important departure from past diagnostic manuals is that the chapter on substance—related disorders has been expanded to include gambling disorder. Another key change is that
DSM-S does not separate the diagnoses of substance abuse and dependence as in DSM-IV. Rather criteria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, substance-induced disorders, and unspecified substance-related disorders, where relevant. Within substance use disorders, the DSM-IV recurrent substance-related legal problems criterion has been deleted from DSM-S, and a new criterion—craving, or a strong de- sire or urge to use a substance—has been added. In addition, the threshold for substance use disorder diagnosis in DSM—S is set at two or more criteria, in contrast to a threshold of one or more criteria for a diagnosis of DSM—IV substance abuse and three or more for DSM-IV depen- dence. Cannabis withdrawal and caffeine withdrawal are new disorders (the latter was in
DSM-IV Appendix B, ”Criteria Sets and Axes Provided for Further Study").
Severity of the DSM-S substance use disorders is based on the number of criteria en- dorsed. The DSM-IV specifier for a physiological subtype is eliminated in DSM-S, as is the
DSM-IV diagnosis of polysubstance dependence. Early remission from a DSM-S substance use disorder is defined as at least 3 but less than 12 months without meeting substance use disorder criteria (except craving), and sustained remission is defined as at least 12 months without meeting criteria (except craving). Additional new DSM-S specifiers include ”in a controlled environment” and ”on maintenance therapy” as the situation warrants.
816 Highlights of Changes From DSM-IV to DSM-5
The DSM-IV diagnoses of dementia and amnestic disorder are subsumed under the newly named entity maj or neurocognitive disorder (NCD). The term dementia is not precluded from use in the etiological subtypes where that term is standard. Furthermore, DSM-S now recog- nizes a less severe level of cognitive impairment, mild NCD, which is a new disorder that per- mits the diagnosis of less disabling syndromes that may nonetheless be the focus of concern and treatment. Diagnostic criteria are provided for both of these disorders, followed by diag- nostic criteria for different etiological subtypes. In DSM-IV, individual diagnoses were desig- nated 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-S, major or mild NCD due to Alzheimer's disease and major or mild vascular NCD have been re— tained, while new separate criteria are now presented for major or mild frontotemporal NCD, | DSM5 Psichiatry |
NCD with Lewy bodies, and NCDs due to traumatic brain injury, a substance/ medication,
HIV infection, prion disease, Parkinson’s disease, Huntington’s disease, another medical con- dition, and multiple etiologies, respectively. Unspecified NCD is also included as a diagnosis.
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 Personality Disorders”). For the general criteria for personality disorder, presented in
Section III, a revised personality functioning criterion (Criterion A) has been developed based on a literature review of reliable clinical measures of core impairments central to per- sonality pathology. A diagnosis of personality disorder—trait specified, based on moderate or greater impairment in personality functioning and the presence of pathological personal- ity traits, replaces personality disorder not otherwise specified and provides a much more in- formative diagnosis for individuals who are not optimally described as having a specific personality disorder. A greater emphasis on personality functioning and trait—based criteria increases the stability and empirical bases of the disorders. Personality functioning and per- sonality traits also can be assessed whether or not the individual has a personality disor- der—a feature that provides clinically useful information about all individuals.
An overarching change from DSM-IV is the addition of the course specifiers ”in a controlled environment” and ”in remission” to the diagnostic criteria sets for all the paraphilic disor- ders. These specifiers are added to indicate important changes in an individual’s status. In
DSM-S, paraphilias are not ipsofucto mental disorders. There is a distinction between paraphil- ias and paraphilic disorders. A paraphilic disorder is a paraphilia that is currently causing dis- tress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. A paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not automatically justify or require clinical intervention. The distinction between paraphilias and paraphilic disorders was im- plemented without making any changes to the basic structure of the diagnostic criteria as they had existed since DSM-III-R. The change proposed for DSM-S 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 symptoms meet Criterion A but not Cri- terion B—that is, to individuals who have a paraphilia but not a paraphilic disorder.
*:._ , Glossary of affect A pattern of observable behaviors that is the expression of a subjectively experi- enced feeling state (emotion). Examples of affect include sadness, elation, and anger. In contrast to mood, which refers to a pervasive and sustained emotional ”climate,” affect refers to more fluctuating changes in emotional "weather." What is considered the nor- mal range of the expression of affect varies considerably, both within and among dif- ferent cultures. Disturbances in affect include blunted Significant reduction in the intensity of emotional expression.
flat Absence or near absence of any sign of affective expression.
inappropriate Discordance between affective expression and the content of speech or ideation.
labile Abnormal variability in affect with repeated, rapid, and abrupt shifts in af- fective expression.
restricted or constricted Mild reduction in the range and intensity of emotional ex- pression.
affective blunting See AFFECT.
agitation (psychomotor) See PSYCHOMOTOR AGITATION.
agnosia Loss of ability to recognize objects, persons, sounds, shapes, or smells that occurs in the absence of either impairment of the specific sense or significant memory loss. | DSM5 Psichiatry |
alogia An impoverishment in thinking that is inferred from observing speech and lan- guage behavior. There may be brief and concrete replies to questions and restriction in the amount of spontaneous speech (termed poverty of speech). Sometimes the speech is adequate in amount but conveys little information because it is overconcrete, overab— stract, repetitive, or stereotyped (termed poverty of content).
amnesia An inability to recall important autobiographical information that is inconsis- tent with ordinary forgetting.
anhedonia Lack of enjoyment from, engagement in, or energy for life’s experiences; def- icits in the capacity to feel pleasure and take interest in things. Anhedonia is a facet of the broad personality trait domain DETACHMENT.
anosognosia A condition in which a person with an illness seems unaware of the exis- tence of his or her illness.
antagonism Behaviors that put an individual at odds with other people, such as an ex- aggerated sense of self—importance with a concomitant expectation of Special treat— ment, as well as a callous antipathy toward others, encompassing both unawareness of others’ needs and feelings, and a readiness to use others in the service of self-enhance- ment. Antagonism is one of the five broad PERSONALITY TRAIT DOMAINS defined in Sec- tion 111 ”Alternative DSM-S Model for Personality Disorders.”
SMALL CAPS indicate term found elsewhere in this glossary. Glossary definitions were informed by
DSM-5 Work Groups, publicly available Internet sources, and previously published glossaries for mental disorders (World Health Organization and American Psychiatric Association).
818 Glossary of Technical Terms antidepressant discontinuation syndrome A set of symptoms that can occur after abrupt cessation, or marked reduction in dose, of an antidepressant medication that had been taken continuously for at least 1 month.
anxiety The apprehensive anticipation of future danger or misfortune accompanied by a feeling of worry, distress, and / or somatic symptoms of tension. The focus of antici- pated danger may be internal or external.
anxiousness Feelings of nervousness or tenseness in reaction to diverse situations; frequent worry about the negative effects of past unpleasant experiences and future negative possi- bilities; feeling fearful and apprehensive about uncertainty; expecting the worst to happen.
Anxiousness is a facet of the broad personality trait domain N EGATIVE AFFECI'IVITY.
arousal The physiological and psychological state of being awake or reactive to stimuli.
asociality A reduced initiative for interacting with other people.
attention The ability to focus in a sustained manner on a particular stimulus or activity.
finishing tasks or in concentrating on work.
attention seeking Engaging in behavior designed to attract notice and to make oneself the focus of others’ attention and admiration. Attention seeking is a facet of the broad personality trait domain ANTAGONISM.
autogynephilia Sexual arousal of a natal male associated with the idea or image of being a woman.
avoidance The act of keeping away from stress-related circumstances; a tendency to cir- cumvent cues, activities, and situations that remind the individual of a stressful event experienced.
avolition An inability to initiate and persist in goal-directed activities. When severe enough to be considered pathological, avolition is pervasive and prevents the person from com- pleting many different types of activities (e.g., work, intellectual pursuits, self-care).
bereavement The state of having lost through death someone with whom one has had a close relationship. This state includes a range of grief and mourning responses.
biological rhythms See CIRCADIAN RHYTHMS.
callousness Lack of concern for the feelings or problems of others; lack of guilt or re- morse about the negative or harmful effects of one’s actions on others. Callousness is a facet of the broad personality trait domain ANTAGONISM.
catalepsy Passive induction of a posture held against gravity. Compare with WAXY FLEX-
IBILITY. | DSM5 Psichiatry |
cataplexy Episodes of sudden bilateral loss of muscle tone resulting in the individual collapsing, often occurring in association with intense emotions such as laughter, an— ger, fear, or surprise.
circadian rhythms Cyclical variations in physiological and biochemical function, level of sleep-wake activity, and emotional state. Circadian rhythms have a cycle of about 24 hours, ultradian rhythms have a cycle that is shorter than 1 day, and infmdian rhythms have a cycle that may last weeks or months.
ences, including DEPERSONALIZATION, DEREALIZATION, and DISSOCIATION; mixed sleep- wake state experiences; and thought-control experiences. Cognitive and perceptual dysregulation is a facet of the broad personality trait domain PSYCHOTICISM.
coma State of complete loss of consciousness.
Glossary of Technical Terms 819 compulsion Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession, or according to rules that must be applied rig- idly. The behaviors or mental acts are aimed at preventing or reducing anxiety or dis- tress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutral- ize or prevent or are clearly excessive.
conversion symptom A loss of, or alteration in, voluntary motor or sensory functioning, with or without apparent impairment of consciousness. The symptom is not fully ex- plained by a neurological or another medical condition or the direct effects of a sub- stance and is not intentionally produced or feigned.
deceitfulness Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events. Deceitfulness is a facet of the broad personality trait domain ANTAGONISM.
defense mechanism Mechanisms that mediate the individual’s reaction to emotional conflicts and to external stressors. Some defense mechanisms (e.g., projection, splitting, acting out) are almost invariably maladaptive. Others (e.g., suppression, denial) may be either maladaptive or adaptive, depending on their severity, their inflexibility, and the context in which they occur.
delusion A false belief based on incorrect inference about external reality that is firmly vertible and obvious proof or evidence to the contrary. The belief is not ordinarily ac- cepted by other members of the person’s culture or subculture (i.e., it is not an article of religious faith). When a false belief involves a value judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility. Delusional conviction can sometimes be inferred from an overvalued idea (in which case the individual has an un- reasonable belief or idea but does not hold it as firmly as is the case with a delusion). De- lusions are subdivided according to their content. Common types are listed below: bizarre A delusion that involves a phenomenon that the person’s culture would re- gard as physically impossible.
delusional jealousy A delusion that one's sexual partner is unfaithful.
erotomanic A delusion that another person, usually of higher status, is in love with the individual.
grandiose A delusion of inflated worth, power, knowledge, identity, or special re- lationship to a deity or famous person.
mixed type Delusions of more than one type (e.g., EROTOMANIC, GRANDIOSE, PERSE-
CUTORY, SOMATIC) in which no one theme predominates.
mood-congruent See MOOD-CONGRUENT PSYCHOTIC FEATURES.
mood-incongruent See MOOD—INCONGRUENT PSYCHOTIC FEATURES.
of being controlled A delusion in which feelings, impulses, thoughts, or actions are experienced as being under the control of some external force rather than be- ing under one’s own control. | DSM5 Psichiatry |
of reference A delusion in which events, objects, or other persons in one’s immedi- ate environment are seen as having a particular and unusual significance. These delusions are usually of a negative or pejorative nature but also may be grandiose in content. A delusion of reference differs from an idea of reference, in which the false belief is not as firmly held nor as fully organized into a true belief.
persecutory A delusion in which the central theme is that one (or someone to whom one is close) is being attacked, harassed, cheated, persecuted, or conspired against.
820 Glossary of Technical Terms somatic A delusion whose main content pertains to the appearance or functioning of one’s body.
thought broadcasting A delusion that one’s thoughts are being broadcast out loud so that they can be perceived by others.
thought insertion A delusion that certain of one’s thoughts are not one’s own, but rather are inserted into one’s mind.
depersonalization The experience of feeling detached from, and as if one is an outside observer of, one’s mental processes, body, or actions (e.g., feeling like one is in a dream; a sense of unreality of self, perceptual alterations; emotional and / or physical numbing; temporal distortions; sense of unreality).
depressivity Feelings of being intensely sad, miserable, and / or hopeless. Some patients describe an absence of feelings and/ or dysphoria; difficulty recovering from such moods; pessimism about the future; pervasive shame and/ or guilt; feelings of inferior self—worth; and thoughts of suicide and suicidal behavior. Depressivity is a facet of the broad personality trait domain DETACHMENT.
derealization The experience of feeling detached from, and as if one is an outside ob- server of, one’s surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
detachment Avoidance of socioemotional experience, including both WTTHDRAWAL from interpersonal interactions (ranging from casual, daily interactions to friendships and inti- mate relationships [i.e., H\1TIMACY AVOIDANCED and RESTRICTED AFFECTIVITY, particularly limited hedonic capacity. Detachment is one of the five pathological PERSONALITY TRAIT
DOMAINS defined in Section III "Altemative DSM-5 Model for Personality Disorders.” disinhibition Orientation toward immediate gratification, leading to impulsive behav- ior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences. RIGID PERFECTIONISM, the opposite pole of this domain, reflects excessive constraint of impulses, risk avoidance, hyper- responsibility, hyperperfectionism, and rigid, rule—governed behavior. Disinhibition is one of the five pathological PERSONALITY TRAIT DOMAINS defined in Section 111 ”Al- ternative DSM-S Model for Personality Disorders." disorder of sex development Condition of significant inborn somatic deviations of the reproductive tract from the norm and / or of discrepancies among the biological indica- tors of male and female.
disorientation Confusion about the time of day, date, or season (time); where one is (place); or who one is (person).
dissociation The splitting off of clusters of mental contents from conscious awareness.
Dissociation is a mechanism central to dissociative disorders. The term is also used to describe the separation of an idea from its emotional significance and affect, as seen in the inappropriate affect in schizophrenia. Often a result of psychic trauma, dissociation may allow the individual to maintain allegiance to two contradictory truths while re- maining unconscious of the contradiction. An extreme manifestation of dissociation is dissociative identity disorder, in which a person may exhibit several independent per- sonalities, each unaware of the others. | DSM5 Psichiatry |
distractibility Difficulty concentrating and focusing on tasks; attention is easily divert- ed by extraneous stimuli; difficulty maintaining goal-focused behavior, including both planning and completing tasks. Distractibility is a facet of the broad personality trait domain DISINHIBITION.
dysarthria A disorder of speech sound production due to structural or motor impair- ment affecting the articulatory apparatus. Such disorders include cleft palate, muscle
Glossary of Technical Terms 821 disorders, cranial nerve disorders, and cerebral palsy affecting bulbar structures (i.e., lower and upper motor neuron disorders).
dyskinesia Distortion of voluntary movements with involuntary muscle activity.
of depression, discontent, and in some cases indifference to the world around them.
dyssomnias Primary disorders of sleep or wakefulness characterized by INSOMNIA or
HYPERSOMNIA as the major presenting symptom. Dyssomnias are disorders of the amount, quality, or timing of sleep. Compare with PARASOMNIAS.
dysthymia Presence, while depressed, of two or more of the following: 1) poor appetite or overeating, 2) insomnia or hypersomnia, 3) low energy or fatigue, 4) low self—esteem, 5) poor concentration or difficulty making decisions, or 6) feelings of hopelessness.
dystonia Disordered tonicity of muscles.
eccentricity Odd, unusual, or bizarre behavior, appearance, and / or speech having strange and unpredictable thoughts; saying unusual or inappropriate things. Eccentric- ity is a facet of the broad personality trait domain PSYCHOTICISM.
echolalia The pathological, parrotlike, and apparently senseless repetition (echoing) of a word or phrase just spoken by another person.
echopraxia Mimicking the movements of another.
emotional lability Instability of emotional experiences and mood; emotions that are easily aroused, intense, and/ or out of proportion to events and circumstances. Emo- tional lability is a facet of the broad personality trait domain NEGATIVE AFFECTIVITY.
empathy Comprehension and appreciation of others’ experiences and motivations; tol- erance of differing perspectives; understanding the effects of own behavior on others.
episode (episodic) A specified duration of time during which the patient has developed or experienced symptoms that meet the diagnostic criteria for a given mental disorder. De- pending on the type of mental disorder, episode may denote a certain number of symptoms or a specified severity or frequency of symptoms. Episodes may be further differentiated as a single (first) episode or a recurrence or relapse of multiple episodes if appropriate.
ings of well-being, elation, happiness, excitement, and joy.
fatigability Tendency to become easily fatigued. See also FATIGUE.
fatigue A state (also called exhaustion, tiredness, lethargy, languidness, languor, lassi- tude, and listlessness) usually associated with a weakening or depletion of one’s phys- ical and / or mental resources, ranging from a general state of lethargy to a specific, work-induced burning sensation within one’s muscles. Physical fatigue leads to an in- ability to continue functioning at one’s normal level of activity. Although widespread in everyday life, this state usually becomes particularly noticeable during heavy exer- cise. Mental fatigue, by contrast, most often manifests as SOMNOLENCE (sleepiness).
fear An emotional response to perceived imminent threat or danger associated with urges to flee or fight.
flashback A dissociative state during which aspects of a traumatic event are reexperi- enced as though they were occurring at that moment.
flight of ideas A nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations, distracting stimuli, or plays on words. When the condition is severe, speech may be disorganized and incoherent. | DSM5 Psichiatry |
822 Glossary of Technical Terms gender The public (and usually legally recognized) lived role as boy or girl, man or woman. Biological factors are seen as contributing in interaction with social and psy- chological factors to gender development.
gender assignment The initial assignment as male or female, which usually occurs at birth and is subsequently referred to as the ”natal gender.” gender dysphoria Distress that accompanies the incongruence between one’s experi- enced and expressed gender and one’s assigned or natal gender.
gender experience The unique and personal ways in which individuals experience their gender in the context of the gender roles provided by their societies.
gender expression The specific ways in which individuals enact gender roles provided in their societies.
gender identity A category of social identity that refers to an individual’s identification as male, female or, occasionally, some category other than male or female.
gender reassignment A change of gender that can be either medical (hormones, sur- gery) or legal (government recognition), or both. In case of medical interventions, often referred to as sex reassignment.
geometric hallucination See HALLUCINATION.
grandiosity Believing that one is superior to others and deserves special treatment; self- centeredness; feelings of entitlement; condescension toward others. Grandiosity is a facet of the broad personality trait domain ANTAGONISM.
grimace (grimacing) Odd and inappropriate facial expressions unrelated to situation (as seen in individuals with CATATONIA).
hallucination A perception-like experience with the clarity and impact of a true percep- tion but without the external stimulation of the relevant sensory organ. Hallucinations should be distinguished from ILLUSIONS, in which an actual external stimulus is misperceived or misinterpreted. The person may or may not have insight into the non— veridical nature of the hallucination. One hallucinating person may recognize the false sensory experience, whereas another may be convinced that the experience is grounded in reality. The term hallucination is not ordinarily applied to the false perceptions that occur during dreaming, while falling asleep (hypnagogic), or upon awakening (hypno— pompic). Transient hallucinatory experiences may occur without a mental disorder.
auditory A hallucination involving the perception of sound, most commonly of voice.
geometric Visual hallucinations involving geometric shapes such as tunnels and funnels, spirals, lattices, or cobwebs.
gustatory A hallucination involving the perception of taste (usually unpleasant).
mood-congruent See MOOD-CONGRUENT PSYCHOTIC FEATURES.
mood-incongruent See MOOD-INCONGRUENT PSYCHOTIC FEATURES.
olfactory A hallucination involving the perception of odor, such as of burning rub- ber or decaying fish.
somatic A hallucination involving the perception of physical experience localized within the body (e.g., a feeling of electricity). A somatic hallucination is to be dis- medical condition, from hypochondriacal preoccupation with normal physical sensations, or from a tactile hallucination.
tactile A hallucination involving the perception of being touched or of something being under one’s skin. The most common tactile hallucinations are the sensation
Glossary of Technical Terms 823 of electric shocks and formication (the sensation of something creeping or crawl- ing on or under the skin).
visual A hallucination involving sight, which may consist of formed images, such as of people, or of unformed images, such as flashes of light. Visual hallucinations should be distinguished from ILLUSIONS, which are misperceptions of real external stimuli.
hostility Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior. Hostility is a facet of the broad personality trait domain ANTAGONISM.
hyperacusis Increased auditory perception.
hyperorality A condition in which inappropriate objects are placed in the mouth.
hypersexuality A stronger than usual urge to have sexual activity. | DSM5 Psichiatry |
hypersomnia Excessive sleepiness, as evidenced by prolonged nocturnal sleep, difficul- ty maintaining an alert awake state during the day, or undesired daytime sleep epi- sodes. See also SOMNOLENCE.
hypervigilance An enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompa- nied by a state of increased anxiety which can cause exhaustion. Other symptoms include abnormally increased arousal, a high responsiveness to stimuli, and a continual scanning of the environment for threats. In hypervigilance, there is a perpetual scanning of the envi- ronment to search for sights, sounds, people, behaviors, smells, or anything else that is rem- iniscent of threat or trauma. The individual is placed on high alert in order to be certain danger is not near. Hypervigilance can lead to a variety of obsessive behavior patterns, as well as producing difficulties with social interaction and relationships.
hypomania An abnormality of mood resembling mania but of lesser intensity. See also
MANIA.
hypopnea Episodes of overly shallow breathing or an abnormally low respiratory rate.
ideas of reference The feeling that causal incidents and external events have a particu- lar and unusual meaning that is specific to the person. An idea of reference is to be dis- tinguished from a DELUSION OF REFERENCE, in which there is a belief that is held with delusional conviction.
identity Experience of oneself as unique, with clear boundaries between self and others; stability of self—esteem and accuracy of self—appraisal; capacity for, and ability to regu- late, a range of emotional experience.
illusion A misperception or misinterpretation of a real external stimulus, such as hear- ing the rustling of leaves as the sound of voices. See also HALLUCINATION.
impulsivity Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establish- ing and following plans; a sense of urgency and self—harming behavior under emotion- al distress. Impulsivity is a facet of the broad personality trait domain DISINHIBITION.
incoherence Speech or thinking that is essentially incomprehensible to others because word or phrases are joined together without a logical or meaningful connection. This disturbance occurs within clauses, in contrast to derailment, in which the disturbance is between clauses. This has sometimes been referred to a ”word salad” to convey the degree of linguistic disorganization. Mildly ungrammatical constructions or idiomatic usages characteristic of a particular regional or cultural backgrounds, lack of educa- tion, or low intelligence should not be considered incoherence. The term is generally not applied when there is evidence that the disturbance in speech is due to an aphasia.
insomnia A subjective complaint of difficulty falling or staying asleep or poor sleep quality.
824 Glossary of Technical Terms ological indicators of sex.
intimacy Depth and duration of connection with others; desire and capacity for close- ness; mutuality of regard reflected in interpersonal behavior.
intimacy avoidance Avoidance of close or romantic relationships, interpersonal attach- ments, and intimate sexual relationships. Intimacy avoidance is a facet of the broad personality trait domain DETACHMENT.
irresponsibility Disregard for—and failure to honor—financial and other obligations or commitments; lack of respect for—and lack of follow-through on—agreements and promises; carelessness with others’ property. Irresponsibility is a facet of the broad per- sonality trait domain DISINHIBITION.
language pragmatics The understanding and use of language in a given context. For example, the warning ”Watch your hands” when issued to a child who is dirty is in- tended not only to prompt the child to look at his or her hands but also to communicate the admonition ”Don’t get anything dirty." lethargy A state of decreased mental activity, characterized by sluggishness, drowsi- ness, inactivity, and reduced alertness. | DSM5 Psichiatry |
macropsia The visual perception that objects are larger than they actually are. Compare with MICROPSIA.
magical thinking The erroneous belief that one’s thoughts, words, or actions will cause cause and effect. Magical thinking may be a part of normal child development.
mania A mental state of elevated, expansive, or irritable mood and persistently in- creased level of activity or energy. See also HYPOMANLA.
manipulativeness Use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one’s ends. Manipulativeness is a facet of the broad personality trait domain ANTAGONISM.
mannerism A peculiar and characteristic individual style of movement, action, thought, or speech.
melancholia (melancholic) A mental state characterized by very severe depression.
micropsia The Visual perception that objects are smaller than they actually are. Com- pare with MACROPSIA.
mixed symptoms The specifier ”with mixed features” is applied to mood episodes during which subthreshold symptoms from the opposing pole are present. Whereas these con- current ”mixed” symptoms are relatively simultaneous, they may also occur closely juxtaposed in time as a waxing and waning of individual symptoms of the opposite pole (i.e., depressive symptoms during hypomanic or manic episodes, and vice versa).
mood A pervasive and sustained emotion that colors the perception of the world. Com- mon examples of mood include depression, elation, anger, and anxiety. In contrast to aflect, which refers to more fluctuating changes in emotional ”weather," mood refers to a pervasive and sustained emotional ”climate." Types of mood include dysphoric An unpleasant mood, such as sadness, anxiety, or irritability.
elevated An exaggerated feeling of well—being, or euphoria or elation. A person with elevated mood may describe feeling ”high,” ”ecstatic,” ”on top of the world," or "up in the clouds.” euthymic Mood in the ”normal” range, which implies the absence of depressed or elevated mood.
Glossary of Technical Terms 825 expansive Lack of restraint in expressing one’s feelings, frequently with an over- valuation of one’s significance or importance.
irritable Easily annoyed and provoked to anger.
mood-congruent psychotic features Delusions or hallucinations whose content is en- tirely consistent with the typical themes of a depressed or manic mood. If the mood is depressed, the content of the delusions or hallucinations would involve themes of per- sonal inadequacy, guilt, disease, death, nihilism, or deserved punishment. The content of the delusion may include themes of persecution if these are based on self—derogatory concepts such as deserved punishment. If the mood is manic, the content of the delusions or hallucinations would involve themes of inflated worth, power, knowledge, or iden- tity, or a special relationship to a deity or a famous person. The content of the delusion may include themes of persecution if these are based on concepts such as inflated worth or deserved punishment.
mood-incongruent psychotic features Delusions or hallucinations whose content is not consistent with the typical themes of a depressed or manic mood. In the case of depres- sion, the delusions or hallucinations would not involve themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. In the case of mania, the delu- sions or hallucinations would not involve themes of inflated worth, power, knowledge, or identity, or a special relationship to a deity or a famous person.
multiple sleep latency test Polysomnographic assessment of the sleep-onset period, with several short sleep-wake cycles assessed during a single session. The test repeat- edly measures the time to daytime sleep onset (”sleep latency”) and occurrence of and time to onset of the rapid eye movement sleep phase. | DSM5 Psichiatry |
mutism No, or very little, verbal response (in the absence of known aphasia).
narcolepsy Sleep disorder characterized by periods of extreme drowsiness and frequent daytime lapses into sleep (sleep attacks). These must have been occurring at least three times per week over the last 3 months (in the absence of treatment).
negative affectivity Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/shame, worry, anger), and their be- havioral (e.g., self—harm) and interpersonal (e.g., dependency) manifestations. Nega- tive Affectivity is one of the five pathological PERSONALITY TRAIT DOMAINS defined in
Section III ”Altemative DSM-5 Model for Personality Disorders.” negativism Opposition to suggestion or advice; behavior opposite to that appropriate to a specific situation or against the wishes of others, including direct resistance to efforts to be moved.
night eating syndrome Recurrent episodes of night eating, as manifested by eating after awakening from sleep or excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better accounted for by ex- ternal influences such as changes in the individual’s sleep-wake cycle or by local social norms.
nightmare disorder Repeated occurrences of extended, extremely dysphoric, and well- remembered dreams that usually involve efforts to avoid threats to survival, security or physical integrity and that generally occur during the second half of the major sleep episode. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.
lated to any substance of abuse that shares some features with substance-induced addiction.
826 Glossary of Technical Terms obsession Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted and that in most individ- uals cause marked anxiety or distress. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or ac- tion (i.e., by performing a compulsion).
overeating Eating too much food too quickly.
overvalued idea An unreasonable and sustained belief that is maintained with less than delusional intensity (i.e., the person is able to acknowledge the possibility that the be- lief may not be true). The belief is not one that is ordinarily accepted by other members of the person’s culture or subculture.
panic attacks Discrete periods of sudden onset of intense fear or terror, often associated with feelings of impending doom. During these attacks there are symptoms such as shortness of breath or smothering sensations; palpitations, pounding heart, or acceler- ated heart rate; chest pain or discomfort; choking; and fear of going crazy or losing con- trol. Panic attacks may be unexpected, in which the onset of the attack is not associated with an obvious trigger and instead occurs ”out of the blue,” or expected, in which the panic attack is associated with an obvious trigger, either internal or external.
paranoid ideation Ideation, of less than delusional proportions, involving suspicious- ness or the belief that one is being harassed, persecuted, or unfairly treated.
parasomnias Disorders of sleep involving abnormal behaviors or physiological events occurring during sleep or sleep-wake transitions. Compare with DYSSOMNIAS.
perseveration Persistence at tasks or in particular way of doing things long after the be- havior has ceased to be functional or effective; continuance of the same behavior de- spite repeated failures or clear reasons for stopping. Perseveration is a facet of the broad personality trait domain NEGATIVE AFFECTIVITY.
personality Enduring patterns of perceiving, relating to, and thinking about the envi- ronment and oneself. PERSONALITY TRAITS are prominent aspects of personality that are exhibited in relatively consistent ways across time and across situations. Personality traits influence self and interpersonal functioning. Depending on their severity, im- presence of a personality disorder. | DSM5 Psichiatry |