8 Introduction
variety of patient populations; the latter su pplied valuable information about how proposed
revisions performed in everyday clinical settings among a diverse sample of DSM users. It is
anticipated that future clinical and basic research  studies will focus on the validity of the re-
vised categorical diagnostic criteria and the underlying dimensional features of these disor-
ders (including those now being explored by th e NIMH Research Domain  Criteria initiative).
The medical-academic field trials were cond ucted at 11 North American medical-academic
sites and assessed the reliability, feasibility, and clinical utility of select revisions, with priority
given to those that represented the greatest degree of change from DSM-IV or those potentially
having the greatest public health impact. The fu ll clinical patient populations coming to each
site were screened for DSM-IV diagnoses or qu alifying symptoms likely to predict several spe-
cific DSM-5 disorders of interest. Stratified sample s of four to seven specific disorders, plus a
stratum containing a representative sample of all other diagnoses, were id entified for each site.
Patients consented to the study and were randomly assigned for a clinical interview by a cli-
nician blind to the diagnosis, followed by a se cond interview with a clinician blind to previous
diagnoses. Patients first filled out a computer-assisted inventory of cross-cutting symptoms in
more than a dozen psychological domains. These inventories were scored  by a central server,
and results were provided to clinicians before they conducted a typical clinical interview (with
no structured protocol). Clinicians were required to score the presence of qualifying criteria on
a computer-assisted DSM-5 diagnostic checklist, de termine diagnoses, score the severity of the
diagnosis, and submit all data to the central Web-based server. This study design allowed the
calculation of the degree to wh ich two independent clinicians could agree on a diagnosis (us-


calculation of the degree to wh ich two independent clinicians could agree on a diagnosis (us-
ing the intraclass kappa statistic) and the agreement of a single  patient or two different clini-
cians on two separate ratings of cross-cutting symptoms, pers onality traits, disability, and
diagnostic severity meas ures (using intraclass correlation coefficients) along with information
on the precision of these estimates of reliabilit y. It was also possible to assess the prevalence
rates of both DSM-IV and DSM-5 conditions  in the respective clinical populations.
The routine clinical practice field trials in volved recruitment of individual psychiatrists
and other mental health clinicians. A volunteer  sample was recruited that included gener-
alist and specialty psychiatrists, psychologists, licensed clinical social workers, counselors,
marriage and family therapists , and advanced practice psychiatric mental health nurses.
The field trials provided exposure of the proposed DSM-5 diagnoses and dimensional mea-
sures to a wide range of clinicians to assess their feasibility and clinical utility.
Public and Professional Review
In 2010, the APA launched a unique Web site to  facilitate public and professional input into
DSM-5. All draft diagnostic criteria and prop osed changes in organization were posted on
www.dsm5.org for a 2-month co mment period. Feedback totaled more than 8,000 submis-
sions, which were systematically reviewed by each of the 13 work  groups, whose members,
where appropriate, integrated questions and comments into discussions of draft revisions
and plans for field trial testing. After revisions to the initial draft criteria and proposed
chapter organization, a second posting occurred in 2011. Wo rk groups considered feedback
from both Web postings and the results of th e DSM-5 Field Trials when drafting proposed


from both Web postings and the results of th e DSM-5 Field Trials when drafting proposed
final criteria, which were posted on the Web si te for a third and final time in 2012. These
three iterations of external review produced more than 13 ,000 individually signed com-


final criteria, which were posted on the Web si te for a third and final time in 2012. These
three iterations of external review produced more than 13 ,000 individually signed com-
ments on the Web site that were received and reviewed by the work groups, plus thousands
of organized petition signers for and against so me proposed revisions, all of which allowed
the task force to actively address concerns of DSM users, as well as patients and advocacy
groups, and ensure that clinical utility remained a high priority.
Expert Review
The members of the 13 work groups, representi ng expertise in their respective areas, col-
laborated with advisors and reviewers unde r the overall direction of the DSM-5 Task


Introduction 9
Force to draft the diagnostic criteria and ac companying text. This effort was supported by
a team of APA Division of Research staff an d developed through a network of text coor-
dinators from each work group. The preparation of the text was coordinated by the text
editor, working in close collaboration with th e work groups and under the direction of the
task force chairs. The Scientific Review Comm ittee (SRC) was established to provide a sci-
entific peer review process that was external to that of the work groups. The SRC chair,
vice-chair, and six committee members were charged with reviewing the degree to which
the proposed changes from DSM-IV could be  supported with scientific evidence. Each
proposal for diagnostic revi sion required a memorandum of evidence for change pre-
pared by the work group and accompanied by a summary of supportive data organized
around validators for the proposed diagnostic criteria (i.e., antecedent validators such as
familial aggregation, concurrent validators such as biological markers, and prospective
validators such as response to  treatment or course of illness). The submissions were re-
viewed by the SRC and scored according to the strength of the supportive scientific data.
Other justifications for change, such as those arising from clinical experience or need or
from a conceptual reframing of diagnostic ca tegories, were generall y seen as outside the
purview of the SRC. The reviewers’ scores, wh ich varied substantially across the different
proposals, and an accompanying brief commen tary were then returned to the APA Board
of Trustees and the work groups  for consideration and response.
The Clinical and Public Health Committee (CPH C), composed of a chair, vice-chair, and
six members, was appointed to consider additi onal clinical utility, public health, and log-


ical clarification issues for criteria that ha d not yet accumulated the type or level of evi-
dence deemed sufficient for change by the SRC. This review process was particularly
important for DSM-IV disorders with known deficiencies for whic h proposed remedies
had neither been previously considered in the DSM revision process nor been subjected to
replicated research studies. These selected d isorders were evaluated by four to five exter-
nal reviewers, and the blinded results were  reviewed by CPHC members, who in turn
made recommendations to the APA Boar d of Trustees and the work groups.
Forensic reviews by the members of the APA Council on Psychiatry and Law were con-
ducted for disorders frequently appearing in forensic environments and ones with high
potential for influencing civil and criminal judgments in courtroom settings. Work groups
also added forensic experts as advisors in pertinent areas to complement expertise pro-
vided by the Council on Psychiatry and Law.
The work groups themselves were charged with the responsib ility to review the entire re-
search literature surrounding a diagnostic area, including old, revised, and new diagnostic cri-
teria, in an intensive 6-year re view process to assess the pros and cons of making either small
iterative changes or major conceptual changes to  address the inevitable reification that occurs
with diagnostic conceptual approaches that pe rsist over several decades. Such changes in-
cluded the merger of previously separate diagno stic areas into more dimensional spectra, such
as that which occurred with autism spectrum disorder, substance use disorders, sexual dys-
functions, and somatic symptom and related di sorders. Other changes included correcting
flaws that had become apparent over time in th e choice of operational criteria for some disor-
ders. These types of changes po sed particular challenges to the SRC and CPHC review pro-


cesses, which were not constructed to evaluate the validity of DSM-IV diagnostic criteria.
However, the DSM-5 Task Force, which had re viewed proposed changes and had responsi-


cesses, which were not constructed to evaluate the validity of DSM-IV diagnostic criteria.
However, the DSM-5 Task Force, which had re viewed proposed changes and had responsi-
bility for reviewing the text describing each  disorder contemporaneously with the work
groups during this period, was in a unique positio n to render an informed judgment on the sci-
entific merits of such revisions. Furthermore, ma ny of these major changes were subject to field
trial testing, although comprehensive testing of all proposed changes could not be accommo-
dated by such testing because of time limitations and availa bility of resources.
A final recommendation from the task forc e was then provided  to the APA Board of
Trustees and the APA Assembly’s Committee on DSM-5 to consider some of the clinical
utility and feasibility features of the propos ed revisions. The assembly is a deliberative


10 Introduction
body of the APA representing the district branches and wider membership that is com-
posed of psychiatrists from throughout the United States who provide geographic, prac-
tice size, and interest-based diversity. The Committee on DSM-5 is a committee made up
of a diverse group of assembly leaders.
Following all of the preceding review steps,  an executive “summit committee” session
was held to consolidate input from review and assembly committee chairs, task force
chairs, a forensic advisor, and a statistical ad visor, for a preliminary review of each disor-
der by the assembly and APA Board of Trus tees executive committees. This preceded a
preliminary review by the full APA Board of  Trustees. The assembly voted, in November
2012, to recommend that the bo ard approve the publication of DSM-5, and the APA Board
of Trustees approved its publication in December 2012. The ma ny experts, re viewers, and
advisors who contributed to this pr ocess are listed in the Appendix.
Organizational Structure
The individual disorder definitions that cons titute the operationali zed sets of diagnostic
criteria provide the core of DSM-5 for clinic al and research purpos es. These criteria have
been subjected to scientific re view, albeit to varying degrees , and many disorders have un-
dergone field testing for interrater reliability. In  contrast, the classification of disorders (the
way in which disorders are grou ped, which provides a high-level organization for the man-
ual) has not generally been thought of as scientif ically significant, despite the fact that judg-
ments had to be made when disorders were initially divided into chapters for DSM-III.
DSM is a medical classification of disorders and as such serves as a historically deter-
mined cognitive schema imposed on clinical an d scientific informatio n to increase its com-


mined cognitive schema imposed on clinical an d scientific informatio n to increase its com-
prehensibility and utility. Not surprisingly, as th e foundational science that ultimately led
to DSM-III has approached a half-century in ag e, challenges have begun to emerge for cli-
nicians and scientists alike that are inherent in the DSM structure rather than in the de-
scription of any single disorder. These challenges include high rates of comorbidity within
and across DSM chapters, an exce ssive use of and need to rely on “not otherwise specified”
(NOS) criteria, and a growing inability to integrate DSM disorders with the results of ge-
netic studies and other scientific findings.
As the APA and the WHO began to plan their respective revisions of the DSM and the
International Classification of Disorders  (ICD), both cons idered the possibility of improving
clinical utility (e.g., by helping to explain a pparent comorbidity) and facilitating scientific
investigation by rethinking the organizational structures of both publications in a linear
system designated by alphanume ric codes that sequence chap ters according to some ra-
tional and relational structure.  It was critical to both th e DSM-5 Task Force and the WHO
International Advisory Group on the revision  of the ICD-10 Section on Mental and Behav-
ioral Disorders that the revisions to the or ganization enhance clinical utility and remain
within the bounds of well-replicated scientific information. Although the need for reform
seemed apparent, it was import ant to respect the state of the science as well as the chal-
lenge that overly rapid change would pose for the clinical and research communities. In
that spirit, revision of the organization was approached as a conservative, evolutionary di-
agnostic reform that would be guided by emer ging scientific evidence on the relationships


agnostic reform that would be guided by emer ging scientific evidence on the relationships
between disorder groups. By reordering and regrouping the existing disorders, the re-
vised structure is meant to stim ulate new clinical perspectives  and to encourage research-
ers to identify the psychological and physiologi cal cross-cutting factors that are not bound
by strict categorical designations.


ers to identify the psychological and physiologi cal cross-cutting factors that are not bound
by strict categorical designations.
The use of DSM criteria has the clear virtue of creating a common language for com-
munication between clinicians about the diagno sis of disorders. The official criteria and
disorders that were determined to have accepted clinical applicability are located in Sec-
tion II of the manual. However, it should be noted that these diagnostic criteria and their


Introduction 11
relationships within the classification are ba sed on current research and may need to be
modified as new evidence is gathered by fu ture research both within and across the do-
mains of proposed disorders. “Conditions for Further Study,” described in Section III, are
those for which we determined that the scient ific evidence is not yet available to support
widespread clinical use. These diagnostic crit eria are included to highlight the evolution
and direction of scientific advances in these areas to stimulate further research.
With any ongoing review proces s, especially one of this co mplexity, different viewpoints
emerge, and an effort was made to consider various viewpoints and, when warranted, ac-
commodate them. For example, personality diso rders are included in both Sections II and
III. Section II represents an update of the te xt associated with the same criteria found in
DSM-IV-TR, whereas Section III includes the proposed research model for personality dis-
order diagnosis and conceptualization developed by the DSM-5 Personality and Personality
Disorders Work Group. As this field evolves, it is hoped that both versions will serve clin-
ical practice and research initiatives.
Harmonization With ICD-11
The groups tasked with revising the DSM and ICD systems shared the overarching goal of
harmonizing the two classifications as much as possible, for the following reasons:
• The existence of two major classifications of mental disorders hinders the collection and
use of national health statistics, the design of clinical trials aimed at developing new
treatments, and the consideration of global ap plicability of the results by international
regulatory agencies.
• More broadly, the existence of two classificat ions complicates attempts to replicate sci-
entific results across national boundaries.
• Even when the intention was to identify identical patient populations, DSM-IV and


• Even when the intention was to identify identical patient populations, DSM-IV and
ICD-10 diagnoses did not always agree.
Early in the course of the revisions, it be came apparent that a shared organizational
structure would help harmonize the classificatio ns. In fact, the use of a shared framework
helped to integrate the work of DSM and ICD work groups and to focus on scientific is-
sues. The DSM-5 organization and the proposed linear structure of the ICD-11 have been
endorsed by the leadership of the NIMH Resear ch Domain Criteria (RDoC) project as con-
sistent with the initial overa ll structure of that project.
Of course, principled disagreements on th e classification of psychopathology and on
specific criteria for certain disorders were expected given the current state of scientific
knowledge. However, most of  the salient differences betw een the DSM and the ICD classi-
fications do not reflect real sc ientific differences, but rather represent historical by-products
of independent committee processes.
To the surprise of participants in both revi sion processes, large sections of the content
fell relatively easily into place, reflecting real strengths in some areas of th e scientific lit-
erature, such as epidem iology, analyses of comorbidity, twin studies, and certain other ge-
netically informed designs. When disparities emerged, they almost always reflected the
need to make a judgment about where to plac e a disorder in the face of incomplete—or,
more often, conflicting—d ata. Thus, for example, on the ba sis of patterns of symptoms, co-
morbidity, and shared risk factors, attentio n-deficit/hyperactivity disorder (ADHD) was
placed with neurodevelopmental  disorders, but the same data also supported strong ar-


placed with neurodevelopmental  disorders, but the same data also supported strong ar-
guments to place ADHD within disruptive , impulse-control, and conduct disorders.
These issues were settled with the preponderance of evidence (most notably validators ap-
proved by the DSM-5 Task Force). The work gr oups recognize, however, that future dis-
coveries might change the placement as well as the contours of individual disorders and,


proved by the DSM-5 Task Force). The work gr oups recognize, however, that future dis-
coveries might change the placement as well as the contours of individual disorders and,
furthermore, that the simple and linear organi zation that best supports clinical practice


12 Introduction
may not fully capture the complexity and hete rogeneity of mental di sorders. The revised
organization is coordinated with the mental and behavioral disorders chapter (Chapter V)
of ICD-11, which will utilize an expanded numeric–alphanumeric coding system. How-
ever, the official coding system in use in the Un ited States at the time  of publication of this
manual is that of the International Classificatio n of Diseases, Ninth Revi sion, Clinical Modifica-
tion (ICD-9-CM)—the U.S. adaptation of ICD-9. International Classificat ion of Diseases, Tenth
Revision, Clinical Modification  (ICD-10-CM), adapted from IC D-10, is scheduled for imple-
mentation in the United States in October 2014. Given the impending release of ICD-11, it
was decided that this iteration, and not ICD-10, would be the most relevant on which to focus
harmonization. However, given that adoption of the ICD-9-CM coding system will remain
at the time of the DSM-5 releas e, it will be necessary to use the ICD-9-CM codes. Further-
more, given that DSM-5’s organizational stru cture reflects the an ticipated structure of
ICD-11, the eventual ICD-11 co des will follow the sequential  order of diagnoses in the
DSM-5 chapter structure more closely. At present, both the ICD-9-CM and the ICD-10-CM
codes have been indicated for each disorder. These codes will not be in sequential order
throughout the manual because they were assigned to complement earlier organizational
structures.
Dimensional Approach to Diagnosis
Structural problems rooted in the basic de sign of the previous DSM classification, con-


Structural problems rooted in the basic de sign of the previous DSM classification, con-
structed of a large number of narrow diagnostic categories, have emerged in both clinical
practice and research. Relevant evidence come s from diverse sources, including studies of
comorbidity and the substantia l need for not otherwise specified diagnoses, which repre-
sent the majority of diagnoses in areas such as eating disorders, personality disorders, and
autism spectrum disorder. Stud ies of both genetic and environmental risk factors, whether
based on twin designs, familial transmission , or molecular analyses, also raise concerns
about the categorical structure of the DSM system. Because the previous DSM approach
considered each diagnosis as categorically sepa rate from health and from other diagnoses,
it did not capture the widespread sharing of symptoms and risk factors across many dis-
orders that is apparent in studies of comorb idity. Earlier editions of DSM focused on ex-
cluding false-positive results fr om diagnoses; thus, its categories were overly narrow, as is
apparent from the widespread need to use NO S diagnoses. Indeed, the once plausible goal
of identifying homogeneous populations for trea tment and research resu lted in narrow di-
agnostic categories that did not capture clinical reality, symptom heterogeneity within dis-
orders, and significant sharing of symptoms across multiple disorders. The historical
aspiration of achieving diagnostic homogene ity by progressive subt yping within disorder
categories no longer is sensible; like most  common human ills, mental disorders are het-
erogeneous at many levels, ranging fr om genetic risk factors to symptoms.
Related to recommendations about alteration s in the chapter structure of DSM-5, mem-
bers of the diagnostic spectra study group examined whether scientific validators could
inform possible new groupings of related diso rders within the existing categorical frame-
work. Eleven such indicators were recommended for this purpose: shared neural sub-


work. Eleven such indicators were recommended for this purpose: shared neural sub-
strates, family traits, genetic risk factors, sp ecific environmen tal risk factors, biomarkers,
temperamental antecedents, abnormalities of emotional or cognitive processing, symptom
similarity, course of illness, high comorbidit y, and shared treatmen t response. These indi-
cators served as empirical guidelines to info rm decision making by the work groups and


similarity, course of illness, high comorbidit y, and shared treatmen t response. These indi-
cators served as empirical guidelines to info rm decision making by the work groups and
the task force about how to cluster disorders to maximize their validity and clinical utility.
A series of papers was developed and published in a prominent international journal
(Psychological Medicine,  Vol. 39, 2009) as part of both the DSM-5 and the ICD-11 develop-
mental processes to document that such valid ators were most useful for suggesting large
groupings of disorders rather th an for “validating” individual disorder diagnostic criteria.
The regrouping of mental disorders in DSM-5 is intended to enable future research to en-


Introduction 13
hance understanding of disease origins and pathophysiological commonalities between
disorders and provide a base for future replication wherein data can be reanalyzed over
time to continually assess validity. Ongoing revisions of DSM-5 will make it a “living doc-
ument,” adaptable to future discoveries in  neurobiology, genetics, and epidemiology.
On the basis of the published findings of this common DSM-5 and ICD-11 analysis, it
was demonstrated that clustering of diso rders according to what has been termed internal-
izing and externalizing  factors represents an empirically  supported framework. Within both
the internalizing group (representing disorder s with prominent anxiety, depressive, and
somatic symptoms) and the externalizing group (representing disorders with prominent
impulsive, disruptive conduct, and substance use symptoms), the sh aring of genetic and
environmental risk factor s, as shown by twin studies, like ly explains much of the system-
atic comorbidities seen in both clinical an d community samples. The adjacent placement of
“internalizing disorders,” characterized by de pressed mood, anxiety, and related physio-
logical and cognitive symptoms, should aid in developing new diagnostic approaches, in-
cluding dimensional approaches, while facilitati ng the identification of biological markers.
Similarly, adjacencies of the “externalizing group,” including disord ers exhibiting antiso-
cial behaviors, conduct disturbances, addictio ns, and impulse-control disorders, should en-
courage advances in identifying diagnoses, markers, and underlying mechanisms.
Despite the problem posed by categorical diagnoses, the DSM-5 Task Force recognized
that it is premature scientifically to propose alternative definitions fo r most disorders. The
organizational structure is meant to serve as a bridge to new diagnostic approaches with-
out disrupting current clinical practice or  research. With support from DSM-associated


out disrupting current clinical practice or  research. With support from DSM-associated
training materials, the National Institutes of  Health other funding agencies, and scientific
publications, the more dimensional DSM-5 approach and organizational structure can fa-
cilitate research across current diagnostic ca tegories by encouraging broad investigations
within the proposed chapters and across adja cent chapters. Such a reformulation of re-
search goals should also keep DSM-5 central to the development of dimensional approaches
to diagnosis that will likely supplement or supersede current categorical approaches in
coming years.
Developmental and Life span Considerations
To improve clinical utility, DSM-5 is organi zed on developmental and lifespan consider-
ations. It begins with diagnoses thought to reflect developmental processes that manifest
early in life (e.g., neurodevelopmental and schizophrenia spectrum  and other psychotic
disorders), followed by diagnoses that more  commonly manifest in adolescence and
young adulthood (e.g., bipolar, depressive, and anxiety disorders), an d ends with diagno-
ses relevant to adulthood and later life (e.g.,  neurocognitive disord ers). A similar approach
has been taken, where possible, within each chapter. This organizational structure facili-
tates the comprehensive use of lifespan informat ion as a way to assist in diagnostic deci-
sion making.
The proposed organization of chapters of DSM-5, after the neurodevelopmental disor-
ders, is based on groups of internalizing (emoti onal and somatic) disorders, externalizing
disorders, neurocognitive disorders, and other disorders. It is hoped that this organization
will encourage furthe r study of underlying pathophysiological processes that give rise to
diagnostic comorbidity and sy mptom heterogeneity. Furthermore, by arranging disorder
clusters to mirror clinical reality, DSM-5 shou ld facilitate identifica tion of potential diag-


noses by non–mental health specialist s, such as primary care physicians.


clusters to mirror clinical reality, DSM-5 shou ld facilitate identifica tion of potential diag-
noses by non–mental health specialist s, such as primary care physicians.
The organizational structure of DSM-5, alon g with ICD harmonization, is designed to
provide better and more flexible  diagnostic concepts for the next epoch of research and to
serve as a useful guide to clinicians in explai ning to patients why they might have received
multiple diagnoses or why they might have re ceived additional or altered diagnoses over
their lifespan.


14 Introduction
Cultural Issues
Mental disorders are defined in relation to cultural, social, and familial norms and values.
Culture provides interpretive frameworks that  shape the experience and expression of the
symptoms, signs, and behaviors that are criter ia for diagnosis. Culture is transmitted, re-
vised, and recreated within the family and other social systems and institutions. Diagnostic
assessment must therefore consider whether an individual’s experiences, symptoms, and
behaviors differ from sociocultural norms and lead to difficult ies in adaptation in the cul-
tures of origin and in specific social or familial  contexts. Key aspects of culture relevant to di-
agnostic classification and assessment have been considered in the development of DSM-5.
In Section III, the “Cultural Formulation” contains a detailed discussion of culture and
diagnosis in DSM-5, including tools for in-dep th cultural assessment. In the Appendix, the
“Glossary of Cultural Concepts of Distress ” provides a description of some common cul-
tural syndromes, idioms of distress, and causal explanations  relevant to clinical practice.
The boundaries between normalit y and pathology vary across cultures for specific types
of behaviors. Thresholds of tolerance for spec ific symptoms or behaviors differ across cul-
tures, social settings, and fami lies. Hence, the level at which an experience becomes prob-
lematic or pathological  will differ. The judgment that a given behavior is abnormal and
requires clinical attention depends on cultural norms that are internalized by the individual
and applied by others around them, including family members and clinicians. Awareness of
the significance of culture may correct mistaken  interpretations of ps ychopathology, but cul-
ture may also contribute to vulnerability and suffering (e.g., by amplif ying fears that main-
tain panic disorder or health anxiety). Cultural meanings, habits, and traditions can also


tain panic disorder or health anxiety). Cultural meanings, habits, and traditions can also
contribute to either stigma or support in the social and familial response to mental illness.
Culture may provide coping strategies that enhance resilience in response to illness, or sug-
gest help seeking and options for accessing heal th care of various types, including alterna-
tive and complementary health systems. Culture may influence acceptance or rejection of a
diagnosis and adherence to treatments, affecting the course of illness and recovery. Culture
also affects the conduct of the cl inical encounter; as a result, cultural differences between the
clinician and the patient have implications fo r the accuracy and acceptance of diagnosis as
well as for treatment decisions, prognost ic considerations, and clinical outcomes.
Historically, the construct of the culture- bound syndrome has been a key interest of
cultural psychiatry. In DSM-5, this construct h as been replaced by three concepts that offer
greater clinical utility:
1.Cultural syndrome  is a cluster or group of co-occurr ing, relatively invariant symptoms
found in a specific cultural gr oup, community, or context (e.g., ataque de nervios ). The
syndrome may or may not be recognized as an  illness within the culture (e.g., it might
be labeled in various ways), but such cultural patterns of distress and features of illness
may nevertheless be recognizab le by an outside observer.
2.Cultural idiom of distress  is a linguistic term, phrase, or  way of talking about suffering
among individuals of a cultural group (e.g.,  similar ethnicity and religion) referring to
shared concepts of pathology and ways of  expressing, communicating, or naming es-
sential features of distress (e.g., kufungisisa ). An idiom of distress need not be associated


with specific symptoms, syndromes, or perceived causes. It may be used to convey a
wide range of discomfort, including everyd ay experiences, subclinical conditions, or
suffering due to social circumstances rather than mental disorders. For example, most


wide range of discomfort, including everyd ay experiences, subclinical conditions, or
suffering due to social circumstances rather than mental disorders. For example, most
cultures have common bodily idioms of dist ress used to express a wide range of suf-
fering and concerns.
3.Cultura l explanation or perceived cause  is a label , attribution, or  feature of an explanatory
model that provides a culturally conceived etiology or cause for symptoms, illness, or
distress (e.g., maladi moun ). Causal explanations may be salient features of folk classi-
fications of disease used by  laypersons or healers.


Introduction 15
These three concepts (for whic h discussion and examples are provided in Section III
and the Appendix) suggest cultural ways of understanding and describing illness experi-
ences that can be elicited in the clinical encounter. They influence symptomatology, help
seeking, clinical presentations, expectations  of treatment, illness adaptation, and treat-
ment response. The same cultur al term often serves more than one of these functions.
Gender Differences
Sex and gender differences as they relate to th e causes and expression of medical conditions
are established for a number of diseases, including selected mental disorders. Revisions to
DSM-5 included review of potential differenc es between men and women in the expression
of mental illness. In terms of nomenclature, sex differences  are variations attributable to an
individual’s reproductive organs an d XX or XY chromosomal complement. Gender differ-
ences are variations that result from biological sex as well as an individual’s self-represen-
tation that includes the psychological, be havioral, and social consequences of one’s
perceived gender. The term gender differences  is used in DSM-5 because, more commonly,
the differences between men and women are a re sult of both biological sex and individual
self-representation. However, some of the di fferences are based on only biological sex.
Gender can influence illness in a variety of ways. First, it may exclusively determine
whether an individual is at risk for a disord er (e.g., as in premenstrual dysphoric disor-
der). Second, gender may moderate the overa ll risk for development of a disorder as
shown by marked gender differences in the prevalence and incidence rates for selected
mental disorders. Third, gender may influence the likelihood that particular symptoms of
a disorder are experienced by an individual . Attention-deficit/hype ractivity disorder is


a disorder are experienced by an individual . Attention-deficit/hype ractivity disorder is
an example of a disorder with differences in  presentation that are most commonly expe-
rienced by boys or girls. Gender likely has other effects on the experience of a disorder that
are indirectly relevant to psychiatric diagnosis. It may be that certain symptoms are more
readily endorsed by men or women, and that this contributes to differences in service pro-
vision (e.g., women may be more likely to recognize a depr essive, bipolar, or anxiety dis-
order and endorse a more comprehen sive list of symptoms than men).
Reproductive life cycle events, including estr ogen variations, also contribute to gender
differences in risk and expression of illness. Thus, a specifier for postpartum onset of mania
or major depressive episode denotes a time frame wherein women may be at increased risk
for the onset of an illness episode. In the case  of sleep and energy, alterations are often nor-
mative postpartum and thus may have lower diagnostic reliability in postpartum women.
The manual is configured to include information on gender at  multiple levels. If there
are gender-specific symptoms, th ey have been added to the di agnostic criteria. A gender-
related specifier, such as perinatal onset of a mood episode, provides additional informa-
tion on gender and diagnosis. Finally, other issues that are pertinent to diagnosis and gen-
der considerations can be found in the se ction “Gender-Related Diagnostic Issues.”
Use of Other Specified and Unspecified Disorders
To enhance diagnostic specificity, DSM-5 repl aces the previous NOS designation with two
options for clinical use: other specified disorder  and unspecified disorder.  The other specified
disorder category is provided to allow the clinician to communicate the specific reason


disorder category is provided to allow the clinician to communicate the specific reason
that the presentation does not meet the criteria for any specific category within a diagnos-
tic class. This is done by recording the name of the category, followed by the specific rea-
son. For example, for an in dividual with clin ically significant depressive symptoms


tic class. This is done by recording the name of the category, followed by the specific rea-
son. For example, for an in dividual with clin ically significant depressive symptoms
lasting 4 weeks but whose symptomatology falls short of the diagnostic threshold for a
major depressive episode, the clinician would re cord “other specified depressive disorder,
depressive episode with insufficient symptoms.” If the clinician chooses not to specify the


16 Introduction
reason that the criteria are not met for a sp ecific disorder, then “unspecified depressive
disorder” would be diagnosed. Note that th e differentiation between other specified and
unspecified disorders is based on the clinic ian’s decision, providing maximum flexibility
for diagnosis. Clinicians do not have to diff erentiate between other specified and unspec-
ified disorders based on some feature of the presentation itself. When the clinician deter-
mines that there is evidence to specify the na ture of the clinical presentation, the other
specified diagnosis can be given. When the clinician is not able to further specify and de-
scribe the clinical presentation, the unspecifie d diagnosis can be given. This is left entirely
up to clinical judgment.
For a more detailed discussion of how to us e other specified and unspecified designa-
tions, see “Use of the Manual” in Section I.
The Multiaxial System
Despite widespread use and its adoption by certain insurance and governmental agencies,
the multiaxial system in DSM-IV was not requ ired to make a mental disorder diagnosis. A
nonaxial assessment system was also included that simply listed the appropriate Axis I, II,
and III disorders and conditio ns without axial designations. DSM-5 has moved to a nonax-
ial documentation of diagnosis (formerly Axes I, II, and III), with separate notations for
important psychosocial and contextual factors (formerly Ax is IV) and disability (formerly
Axis V). This revision is consistent with the DSM-IV text that states, “The multiaxial dis-
tinction among Axis I, Axis II, and Axis III disorders does not imply that there are funda-
mental differences in their conceptualizatio n, that mental disorders are unrelated to
physical or biological factors or processes, or  that general medical conditions are unrelated


physical or biological factors or processes, or  that general medical conditions are unrelated
to behavioral or psychosocial factors or processes.” The approa ch of separately noting di-
agnosis from psychosocial and contextual fact ors is also consistent with established WHO
and ICD guidance to consider the individual’s functional status separately from his or her
diagnoses or symptom status. In DSM-5, Axis  III has been combined with Axes I and II.
Clinicians should continue to list medical cond itions that are import ant to the understand-
ing or management of an individual’s mental disorder(s).
DSM-IV Axis IV covered psychosocial and en vironmental problems that may affect the
diagnosis, treatment, and prognosis of ment al disorders. Although this axis provided
helpful information, even if it was not us ed as frequently as intended, the DSM-5 Task
Force recommended that DSM-5 should not deve lop its own classification of psychosocial
and environmental problems, bu t rather use a selected set of the ICD-9-CM V codes and
the new Z codes contained in ICD-10-CM. Th e ICD-10 Z codes were examined to deter-
mine which are most relevant to mental  disorders and also to identify gaps.
DSM-IV Axis V consisted of the Global Assessment of Functionin g (GAF) scale, repre-
senting the clinician's judgment of the individu al’s overall level of “functioning on a hy-
pothetical continuum of ment al health–illness.” It was recommended that the GAF be
dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., in-
cluding symptoms, suicide risk, and disabilities in its descriptors) and questionable psy-


cluding symptoms, suicide risk, and disabilities in its descriptors) and questionable psy-
chometrics in routine practice. In order to provide a global measur e of disability, the WHO
Disability Assessment Schedule (WHODAS) is included, for further stud y, in Section III of
DSM-5 (see the chapter “Assessment Measure s”). The WHODAS is based on the Interna-
tional Classification of  Functioning, Disability and Health (ICF) for use across all of medicine
and health care. The WHODAS (version 2.0), and a modification developed for children/
adolescents and their parents by the Impairment and Disability Study Group were in-
cluded in the DSM-5 field trial.


Introduction 17
Online Enhancements
It was challenging to determine what to incl ude in the print version of DSM-5 to be most
clinically relevant and useful and at the same time maintain a manageable size. For this
reason, the inclusion of clinical rating scales  and measures in the pr int edition is limited to
those considered most relevant. Additional as sessment measures used  in the field trials
are available online (www.psychiatry.org/dsm5 ), linked to the relevant disorders. The
Cultural Formulation Interview, Cultural Fo rmulation Interview—Informant Version, and
supplementary modules to the core Cultural Formulation Interview are also available on-
line at www.psychiatry.org/dsm5.
DSM-5 is available as an online subscription  at PsychiatryOnline.org as well as an e-
book. The online component contains modules and assessment tools to enhance the diag-
nostic criteria and text. Also available online is a complete set of supportive references as
well as additional helpful information. The organizational structure of DSM-5, its use of
dimensional measures, and compatibility with ICD codes will allow it to be readily adapt-
able to future scientific discoveries and refinements in its c linical utility. DSM-5 will be an-
alyzed over time to continually assess its validity and enhance its value to clinicians.


19Use of the Manual
The introduction  contains much of the history and developmental process of the
DSM-5 revision. This section is designed to prov ide a practical guide to using DSM-5, par-
ticularly in clinical practice. The primary purp ose of DSM-5 is to assist trained clinicians
in the diagnosis of their patients’ mental diso rders as part of a case formulation assess-
ment that leads to a fully informed treatmen t plan for each individual. The symptoms con-
tained in the respective diagnostic criter ia sets do not constitute comprehensive
definitions of underlying disorders, which encompass cognitive, emotional, behavioral,
and physiological processes that are far more co mplex than can be described in these brief
summaries. Rather, they are intended to summa rize characteristic syndromes of signs and
symptoms that point to an underlying disord er with a characteristic developmental his-
tory, biological and environmental risk factors, neuropsychological and physiological cor-
relates, and typical clinical course.
Approach to Clinical Case Formulation
The case formulation for any given patient must  involve a careful clinical history and con-
cise summary of the social, psychological, and biological factors that may have contrib-
uted to developing a given mental disorder. Hence, it is not sufficient to simply check off
the symptoms in the diag nostic criteria to make a mental  disorder diagnosis. Although a
systematic check for the presence of these crit eria as they apply to each patient will assure
a more reliable assessment, the relative severity and valence of in dividual criteria and
their contribution to a diagnosis require clin ical judgment. The symptoms in our diagnos-
tic criteria are part of the relatively limited repertoire of human emotional responses to in-
ternal and external stresses that are genera lly maintained in a homeostatic balance without


ternal and external stresses that are genera lly maintained in a homeostatic balance without
a disruption in normal functioning. It requires  clinical training to recognize when the com-
bination of predisposing, precipitating, perpetuating, and protective factors has resulted
in a psychopathological condition in which physical signs and symptoms exceed normal
ranges. The ultimate goal of a clinical case formulation is to use the available contextual
and diagnostic information in developing a comprehensive treatment plan that is in-
formed by the individual’s cultural and social context. However, recommendations for the
selection and use of the most appropriate ev idence-based treatment options for each dis-
order are beyond the scope of this manual.
Although decades of scientific effort have go ne into developing the diagnostic criteria
sets for the disorders included in  Section II, it is well recognized  that this set of categorical
diagnoses does not fully describe the full rang e of mental disorders that individuals ex-
perience and present to clinicians on a daily  basis throughout the world. As noted previ-
ously in the introduction, the range of genetic/environmental interactions over the course
of human development affecting cognitive, em otional and behavioral function is virtually
limitless. As a result, it is impossible to capt ure the full range of psychopathology in the
categorical diagnostic categories  that we are now using. Hence,  it is also necessary to in-
clude “other specified/unspecified” disorder  options for presentations that do not fit
exactly into the diagnostic boundaries of disorders in each chapter. In an emergency de-
partment setting, it may be possible to id entify only the most prominent symptom ex-
pressions associated with a particular chap ter—for example, delusions, hallucinations,


20 Use of the Manual
mania, depression, anxiety, substance intoxi cation, or neurocognitive symptoms—so that
an “unspecified” disorder in that category is identified until a fuller differential diagnosis
is possible.
Definition of a Mental Disorder
Each disorder identified in Section II of the manual (excluding those in the chapters enti-
tled “Medication-Induced Movement Disord ers and Other Adverse Effects of Medica-
tion” and “Other Conditions That May Be a Fo cus of Clinical Attention”) must meet the
definition of a mental disorder. Although no definition can capture all aspects of all dis-
orders in the range contained in DSM-5,  the following elements are required:
A mental disorder is a syndrome characte rized by clinically significant distur-
bance in an individual’s cognition, emotion regulation, or behavior that reflects
a dysfunction in the psychological, biological, or developmental processes un-
derlying mental functioning. Mental disorders are usually associated with signif-
icant distress or disability in social, occupational, or other important activities.
An expectable or culturally approved response to a common stressor or loss,
such as the death of a loved one, is not a mental disorder. Socially deviant be-
havior (e.g., political, religious, or sex ual) and conflicts that are primarily be-
tween the individual and society are not mental disorders unless the deviance
or conflict results from a dysfuncti on in the individual, as described above.
The diagnosis of a mental disorder should have  clinical utility: it should help clinicians
to determine prognosis, treatment plans, and potential treatment outcomes for their pa-
tients. However, the diagnosis of a mental disorder is not equivalent to a need for treat-
ment. Need for treatment is a complex clinic al decision that takes into consideration


ment. Need for treatment is a complex clinic al decision that takes into consideration
symptom severity, symptom salience (e.g., the pr esence of suicidal ideation), the patient’s
distress (mental pain) associated with the sy mptom(s), disability related to the patient’s
symptoms, risks and benefits of available trea tments, and other factors (e.g., psychiatric
symptoms complicating other illness). Clinicians may thus encounter individuals whose
symptoms do not meet full crit eria for a mental disorder bu t who demonstrate a clear need
for treatment or care. The fact that some in dividuals do not show all symptoms indicative
of a diagnosis should not be used to justify limiting their access to appropriate care.
Approaches to validating diagnostic criteria  for discrete categorical mental disorders
have included the following types of evidence: antecedent validators (similar genetic mark-
ers, family traits, temperament, and environmen tal exposure), concurrent validators (simi-
lar neural substrates, biomarkers, emotional and cognitive processing, and symptom
similarity), and predictive validators (simila r clinical course and treatment response). In
DSM-5, we recognize that the current diagnostic criteria for any single disorder will not nec-
essarily identify a homogeneous group of patients who can be characterized reliably with all
of these validators. Available evidence shows that these va lidators cross existing diagnostic
boundaries but tend to congregate more frequently within  and across adjacent DSM-5 chap-
ter groups. Until incontrovertible etiological or pathophysiological mechanisms are identi-
fied to fully validate specific disorders or disorder spectra, the most important standard for
the DSM-5 disorder criteria will be their clin ical utility for the assessment of clinical course
and treatment response of individuals groupe d by a given set of diagnostic criteria.


and treatment response of individuals groupe d by a given set of diagnostic criteria.
This definition of mental disorder was developed for clinical, public health, and re-
search purposes. Additional information is usua lly required beyond that contained in the
DSM-5 diagnostic criteria in or der to make legal judgments on  such issues as criminal re-


search purposes. Additional information is usua lly required beyond that contained in the
DSM-5 diagnostic criteria in or der to make legal judgments on  such issues as criminal re-
sponsibility, eligibility for disability compen sation, and competency (see “Cautionary
Statement for Forensic Use of DSM-5” elsewhere in this manual).


Use of the Manual 21
Criterion for Clinical Significance
There have been substantial e fforts by the DSM-5 Task Force and the World Health Orga-
nization (WHO) to separate the concepts of mental disorder  and disability (impairment in
social, occupational, or other important areas of functioning). In the WHO system, the In-
ternational Classification of Diseases (ICD) c overs all diseases and disorders, while the In-
ternational Classification of Functioning, Disability and Health (ICF) provides a separate
classification of global disability. The WHO Disability Assessment Schedule (WHODAS)
is based on the ICF and has proven useful as a standardized measure of disability for men-
tal disorders. However, in the absence of clea r biological markers or clinically useful mea-
surements of severity for many mental disord ers, it has not been possible to completely
separate normal and pathological symptom expressions contained in diagnostic criteria.
This gap in information is particularly problematic in clinical situations in which the pa-
tient’s symptom presentation by itself (particu larly in mild forms) is not inherently path-
ological and may be encountered in individuals for whom a diagnosis of “mental
disorder” would be inappropriat e. Therefore, a generic diagno stic criterion requiring dis-
tress or disability has been used to establish disorder thresholds, usually worded “the dis-
turbance causes clinically significant distre ss or impairment in social, occupational, or
other important areas of functioning.” The text  following the revised definition of a mental
disorder acknowledges that this criterion may be especially helpful in determining a pa-
tient’s need for treatment. Use of informatio n from family members and other third parties
(in addition to the individual) regarding the individual’s perf ormance is recommended
when necessary.
Elements of a Diagnosis


when necessary.
Elements of a Diagnosis
Diagnostic Criteria  and Descriptors
Diagnostic criteria are offered as guidelines for making diagnoses, and their use should be
informed by clinical judgment. Text descript ions, including introductory sections of each
diagnostic chapter, can help support diagnosis (e.g., providing differential diagnoses; de-
scribing the criteria more fully  under “Diagnostic Features”).
Following the assessment of diagnostic criter ia, clinicians should consider the applica-
tion of disorder subtypes and/ or specifiers as appropriate. Severity and course specifiers
should be applied to denote the individual’s current presentation, but only when the full
criteria are met. When full criteria are no t met, clinicians should consider whether the
symptom presentation meets crit eria for an “other specified” or “unspecified” designa-
tion. Where applicable, specific criteria for defining disorder severity (e.g., mild, moder-
ate, severe, extreme), descriptive features (e.g.,  with good to fair insight; in a controlled
environment), and course (e.g., in partial remi ssion, in full remission, recurrent) are pro-
vided with each diagnosis. On the basis of the clinical interview, text descriptions, criteria,
and clinician judgment, a final diagnosis is made.
The general convention in DSM-5 is to allo w multiple diagnoses to be assigned for
those presentations that meet criteria  for more than one DSM-5 disorder.
Subtypes and Specifiers
Subtypes and specifiers (some of which are code d in the fourth, fifth, or sixth digit) are
provided for increased specificity. Subtypes  define mutually exclusive and jointly exhaus-
tive phenomenological subgroupings within a diagnosis and are indicated by the instruc-
tion “ Specify  whether” in the criteria set. In contrast, specifiers  are not intended to be


mutually exclusive or jointly exhaustive, and as a consequence, more than one specifier
may be given. Specifiers are indicated by the instruction “ Specify ” or “Specify if” in the cri-
teria set. Specifiers provide an opportunity to define a more homogeneous subgrouping of


22 Use of the Manual
individuals with the disorder who share certai n features (e.g., major depressive disorder,
with mixed features) and to conv ey information that is relevant to the management of the
individual’s disorder, such as the “with other medical comorbidity” specifier in sleep-
wake disorders. Although a fifth digit is sometimes assigned to code a subtype or specifier
(e.g., 294.11 [F02.81] major neurocognitive disorder due to Alzheimer’s disease, with be-
havioral disturbance) or severity (296.21 [F32. 0] major depressive disorder, single episode,
mild), the majority of subtypes and specifie rs included in DSM-5 cannot be coded within
the ICD-9-CM and ICD-10-CM systems and are indicated only by including the subtype or
specifier after the name of the disorder (e.g.,  social anxiety disorder [social phobia], per-
formance type). Note that in some cases, a specifier or subtype is codable in ICD-10-CM
but not in ICD-9-CM. Accordingly, in some c ases the 4th or 5th character codes for the sub-
types or specifiers are provided only for the ICD-10-CM coding designations.
A DSM-5 diagnosis is usually applied to the individual’s current presentation; previ-
ous diagnoses from which the individual has recovered shoul d be clearly noted as such.
Specifiers indicating course  (e.g., in partial remission, in full remission) may be listed after
the diagnosis and are indicated in a numb er of criteria sets. Where available, severity spec-
ifiers  are provided to guide clinicians in rating  the intensity, frequency, duration, symptom
count, or other severity indicator of a disorder . Severity specifiers are indicated by the in-


count, or other severity indicator of a disorder . Severity specifiers are indicated by the in-
struction “ Specify  current severity” in the criteria se t and include disorder-specific defini-
tions. Descriptive features specifiers  have also been provided in the criteria set and convey
additional information that can inform trea tment planning (e.g., obsessive-compulsive
disorder, with poor insight). Not all disorders include course , severity, and/or descriptive
features specifiers.
Medication-Induced Movement Disorders and Other
Conditions That May Be a Fo cus of Clinical Attention
In addition to important psychosocial and en vironmental factors (see “The Multiaxial Sys-
tem” in the “Introduction” elsewhere in this ma nual), these chapters in Section II also con-
tain other conditions that are not mental disorders but may be encountered by mental
health clinicians. These conditions may be listed as a reason for clinical visit in addition to,
or in place of, the mental disorders listed in  Section II. A separate chapter is devoted to
medication-induced disorders and other adverse effects of medication that may be as-
sessed and treated by clinicians in mental health practice such as akathisia, tardive dyski-
nesia, and dystonia. The description of neurol eptic malignant syndrome is expanded from
that provided in DSM-IV-TR to highlight the em ergent and potentially life-threatening na-
ture of this condition, and a new entry on an tidepressant discontinuation syndrome is pro-
vided. An additional chapter discusses other conditions that may be a focus of clinical
attention. These include relational problems, problems related to abuse and neglect, prob-
lems with adherence to treatment regimens, obesity, antisocial behavior, and malingering.
Principal Diagnosis


Principal Diagnosis
When more than one diagnosis for an individual is given in an inpatient setting, the prin-
cipal diagnosis is the condition established after study to be chiefly responsible for occa-
sioning the admission of the individual. When more than one diagnosis is given for an
individual in an outpatient setting, the reason  for visit is the condition that is chiefly re-
sponsible for the ambulatory care medical servic es received during the visit. In most cases,
the principal diagnosis or the reason for visit is also the main focus of attention or treat-
ment. It is often difficult (and somewhat ar bitrary) to determine which diagnosis is the


the principal diagnosis or the reason for visit is also the main focus of attention or treat-
ment. It is often difficult (and somewhat ar bitrary) to determine which diagnosis is the
principal diagnosis or the reason for visit, especially when, for example, a substance-
related diagnosis such as alcohol use disorder  is accompanied by a non-substance-related
diagnosis such as schizophrenia. For example, it may be unclear which diagnosis should


Use of the Manual 23
be considered “principal” for an individual hospitalized with both schizophrenia and al-
cohol use disorder, because each condition ma y have contributed equally to the need for
admission and treatment. The principal diagnosis is indicated by listing it first, and the re-
maining disorders are listed in order of focu s of attention and treatment. When the prin-
cipal diagnosis or reason for visit is a ment al disorder due to another medical condition
(e.g., major neurocognitive disorder due to Alzheimer’s disease, psychotic disorder due to
malignant lung neoplasm), ICD coding rules re quire that the etiological medical condition
be listed first. In that case, the principal diagnosis or reason for visit would be the mental
disorder due to the medical condition, the seco nd listed diagnosis. In  most cases, the dis-
order listed as the principal diagnosis or the reason for visit is followed by the qualifying
phrase “(principal diagnosis)” or “(reason for visit).”
Provisional Diagnosis
The specifier “provisional” can be used when there is a strong presumption that the full
criteria will ultimately be met for a disord er but not enough information is available to
make a firm diagnosis. The clinician can indi cate the diagnostic uncertainty by recording
“(provisional)” following the diagnosis. For example, this diagnosis might be used when
an individual who appears to ha ve a major depressive disorder  is unable to give an ade-
quate history, and thus it canno t be established that the full cr iteria are met. Another use of
the term provisional is for those situations in which differential diagnosis depends exclu-
sively on the duration of illness. For example,  a diagnosis of schizophreniform disorder re-
quires a duration of less than 6 months bu t of at least 1 month and can only be given


provisionally if assigned before remission has occurred.
Coding and Reporting Procedures
Each disorder is accompanied by an identify ing diagnostic and statistical code, which is
typically used by institutions and agencies for data collection and billing purposes. There
are specific recording protocol s for these diagnostic codes (i dentified as coding notes in
the text) that were established  by WHO, the U.S. Centers fo r Medicare and Medicaid Ser-
vices (CMS), and the Centers for Disease Cont rol and Prevention’s National Center for
Health Statistics to ensure co nsistent international recordin g of prevalence and mortality
rates for identified health conditions. For most clinicians, the codes are used to identify the
diagnosis or reason for visit for CMS and private insurance servic e claims. The official
coding system in use in the United States as of publication of this ma nual is ICD-9-CM. Of-
ficial adoption of ICD-10-CM is scheduled to take place on October 1, 2014, and these
codes, which are shown parenthetically in this manual, should not be used until the offi-
cial implementation occurs. Both ICD-9-CM and ICD-10-CM codes have  been listed 1) pre-
ceding the name of the disorder in the classification and 2) accompanying the criteria set
for each disorder. For some diagnoses (e.g ., neurocognitive and substance/medication-
induced disorders), the appropriate code depe nds on further specification and is listed
within the criteria set for the disorder, as coding  notes, and, in some cases, further clarified
in a section on recording proc edures. The names of some di sorders are followed by alter-
native terms enclosed in parentheses, which,  in most cases, were the DSM-IV names for
the disorders.
Looking to the Future:


the disorders.
Looking to the Future:
Assessment and Monitoring Tools
The various components of DSM-5 are provided to facilitate patient assessment and to aid
in developing a comprehensive case formulation. Whereas the diagnostic criteria in Sec-
tion II are well-established measures that have undergone extensive review, the assess-


24 Use of the Manual
ment tools, a cultural formul ation interview, and conditions  for further study included in
Section III are those for which we determined that the scientific evidence is not yet avail-
able to support widespread clinical use. These diagnostic aids and criteria are included to
highlight the evolution and direction of scientif ic advances in these areas and to stimulate
further research.
Each of the measures in Section III is provi ded to aid in a compre hensive assessment of
individuals that will contribute to a diagnosi s and treatment plan tailored to the individ-
ual presentation and clinical context. Where cultural dynamics are particularly important
for diagnostic assessment, the cultural formulation interview should be considered as a
useful aid to communication with the individual. Cross-cutting symptom and diagnosis-
specific severity measures provide quantitative  ratings of important clinical areas that are
designed to be used at the initial evaluation to establish a baseline for comparison with rat-
ings on subsequent encounters to monito r changes and inform treatment planning.
The use of such measures will undoubtedly be facilitated by digital applications, and
the measures are included in Section III to provide for further evaluation and develop-
ment. As with each DSM edition, the diagnostic criteria and the DSM-5 classification of
mental disorders reflect the current consensu s on the evolving knowledge in our field.


25Cautionary Statement for
Forensic Use of DSM-5
Although the DSM-5  diagnostic criteria and text are primarily designed to assist
clinicians in conducting clinical assessment,  case formulation, an d treatment planning,
DSM-5 is also used as a reference for the cour ts and attorneys in assessing the forensic con-
sequences of mental disorders. As a result, it  is important to note that the definition of
mental disorder included in DSM-5 was developed to meet the needs of clinicians, public
health professionals, and research investigators rather than all of the technical needs of the
courts and legal professionals. It is also im portant to note that DSM-5 does not provide
treatment guidelines for any given disorder.
When used appropriately, diagnoses and di agnostic information can assist legal deci-
sion makers in their determinations. For exampl e, when the presence of a mental disorder
is the predicate for a su bsequent legal determination (e.g ., involuntary civil commitment),
the use of an established system of diagnosi s enhances the value and reliability of the de-
termination. By providing a co mpendium based on a review of the pertinent clinical and
research literature, DSM-5 may facilitate legal decision makers’ understanding of the rel-
evant characteristics of mental disorders. The literature related to di agnoses also serves as
a check on ungrounded speculation about ment al disorders and about the functioning of a
particular individual. Finally, diagnostic in formation about longitud inal course may im-
prove decision making when the legal issue co ncerns an individual’s mental functioning
at a past or future point in time.
However, the use of DSM-5 should be inform ed by an awareness of the risks and lim-
itations of its use in forensic settings. When  DSM-5 categories, criteria, and textual descrip-


tions are employed for forensic purposes, ther e is a risk that diagnostic information will be
misused or misunderstood. These dangers aris e because of the imperfect fit between the
questions of ultimate concern to  the law and the information contained in a clinical diagno-
sis. In most situations, the clinical diagnosis of a DSM-5 mental disorder such as intellec-
tual disability (intellectual developmental di sorder), schizophrenia , major neurocognitive
disorder, gambling disorder, or pedophilic di sorder does not imply that an individual
with such a condition meets legal criteria for the presence of a mental disorder or a speci-
fied legal standard (e.g., for co mpetence, criminal responsibility , or disability). For the latter,
additional information is usually required beyond that contained in the DSM-5 diagnosis,
which might include information about the individual’s functional impairments and how
these impairments affect the particular abilities in question. It is precisely because impair-
ments, abilities, and disabilities vary widely wi thin each diagnostic category that assign-
ment of a particular diagnosis does not imply a specific level of im pairment or disability.
Use of DSM-5 to assess for th e presence of a mental diso rder by nonclinical, nonmed-
ical, or otherwise insufficiently trained indi viduals is not advised. Nonclinical decision
makers should also be cautioned that a di agnosis does not carry any necessary implica-
tions regarding the etiology or causes of the individual’s mental di sorder or the individ-
ual’s degree of control over behaviors that may be associat ed with the disorder. Even
when diminished control over one’s behavior is a feature of the disorder, having the diag-
nosis in itself does not demons trate that a particular individu al is (or was) unable to con-


trol his or her behavior at a particular time.


Other Mental Disorders  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .707
Medication-Induced Movement Disorders and
Other Adverse Effects of Medication. . . . . . . . . . . . . . . . . . . . . . . . . .709
Other Conditions That May Be a Focus of Clinical Attention. . . . . . . . .715


This section  contains the diagnostic criteria approved for routine clinical
use along with the ICD-9-CM codes (ICD-10 codes are shown parenthetically).
For each mental disorder, the diagnostic criteria are followed by descriptive
text to assist in diagnostic decision making. Where needed, specific recording
procedures are presented with the diagnostic criteria to provide guidance in
selecting the most appropriate code. In some cases, separate recording pro-
cedures for ICD-9-CM and ICD-10-CM are provided. Although not considered
as official DSM-5 disorders, medication -induced movement disorders and other
adverse effects of medication, as well as other conditions that may be a focus
of clinical attention (including additi onal ICD-9-CM V codes and forthcoming
ICD-10-CM Z codes), are provided to indicate other reasons for a clinical visit
such as environmental factors and relational problems. These codes are adapted
from ICD-9-CM and ICD-10-CM and we re neither reviewed nor approved as
official DSM-5 diagnoses, but can provide additional context for a clinical for-
mulation and treatment plan. These three components—the criteria and their
descriptive text, the medication-i nduced movement disorders and other ad-
verse effects of medication, and the descriptions of other conditions that may
be a focus of clinical attention—represent the key elements of the clinical di-
agnostic process and thus are presented together.


31Neurodevelopmental
Disorders
The neurodevelopmental  disorders are a group of co nditions with onset in the
developmental period. The diso rders typically manifest early in development, often be-
fore the child enters grade school, and are characterized by developmental deficits that
produce impairments of person al, social, academic, or occupational functioning. The
range of developmental deficits varies from very  specific limitations of  learning or control
of executive functions to glob al impairments of social skills  or intelligence. The neurode-
velopmental disorders frequent ly co-occur; for example, in dividuals with autism spec-
trum disorder often have intellectual disability (intellectual developmental disorder), and
many children with attention-deficit/hyperactivity disorder (ADHD) also have a specific
learning disorder. For some diso rders, the clinical presentation includes symptoms of ex-
cess as well as deficits and delays in achiev ing expected milestones. For example, autism
spectrum disorder is diagnose d only when the characteristic deficits of social communi-
cation are accompanied by excessively repetitive  behaviors, restricted interests, and insis-
tence on sameness.
Intellectual disability (intel lectual developmental disorder) is characterized by deficits
in general mental abilities, such as reasoning, problem solving, planning, abstract thinking,
judgment, academic learning, and learning from experience. The deficits result in impair-
ments of adaptive functioning, such that the individual fails to meet standards of personal
independence and social responsibility in one or more aspects of daily life, including com-
munication, social participation, academic or occupational functionin g, and personal inde-
pendence at home or in community settings . Global developmental delay, as its name
implies, is diagnosed when an individual fa ils to meet expected developmental milestones


implies, is diagnosed when an individual fa ils to meet expected developmental milestones
in several areas of intellectual functioning. The diagnosis is used for individuals who are
unable to undergo systematic assessments of intellectual functioning, including children
who are too young to participate in standardiz ed testing. Intellectual disability may result
from an acquired insult during the developm ental period from, for example, a severe head
injury, in which case a neurocognitive disorder also may be diagnosed.
The communication disorders include language disorder, speech sound disorder, so-
cial (pragmatic) communication  disorder, and childhood-onset fluency disorder (stutter-
ing). The first three disorders are characterize d by deficits in the development and use of
language, speech, and social communication, respectively. Childhood -onset fluency dis-
order is characterized by disturbances of the normal fluency an d motor production of
speech, including repetitive sounds or syllables, prolongation of consonants or vowel
sounds, broken words, blocking, or words pr oduced with an exce ss of physical tension.
Like other neurodevelopmental  disorders, communication di sorders begin early in life
and may produce lifelong functional impairments.
Autism spectrum disorder is characterized by  persistent deficits in social communica-
tion and social interaction across multiple cont exts, including deficits in social reciprocity,
nonverbal communicative behavior s used for social interaction, and skills in developing,
maintaining, and understandin g relationships. In addition  to the social communication
deficits, the diagnosis of autism spectrum disorder requires th e presence of restricted, re-
petitive patterns of behavior, interests, or activities. Because symptoms change with de-
velopment and may be masked by compensator y mechanisms, the diagnostic criteria may


32 Neurodevelopmental Disorders
be met based on historical information, although the current presentation must cause sig-
nificant impairment.
Within the diagnosis of autism spectrum disorder, individual clinical characteristics
are noted through the use of specifiers (with or without accompanying intellectual impair-
ment; with or without accompan ying structural language im pairment; associated with a
known medical/genetic or environmental/acquired condition; associated with another
neurodevelopmental, mental, or behavioral disorder), as well as specifiers that describe
the autistic symptoms (age at first concern; wi th or without loss of established skills; sever-
ity). These specifiers provide clinicians with an opportunity to individualize the diagnosis
and communicate a richer clinical description of  the affected individuals. For example, many
individuals previously diagnosed with Asperg er’s disorder would now receive a diagnosis
of autism spectrum disorder without language or intellectual impairment.
ADHD is a neurodevelopmental disorder defined by impairing levels of inattention, dis-
organization, and/or hyperactivity-impulsivity. Inattention and disorganization entail inabil-
ity to stay on task, seeming not to listen, and lo sing materials, at leve ls that are inconsistent
with age or developmental level.  Hyperactivity-impulsivity entails  overactivity, fidgeting, in-
ability to stay seated, intruding into other people’s activities , and inability to wait—symptoms
that are excessive for age or developmental level. In childhood, ADHD frequently overlaps
with disorders that are often considered to be “externalizing disorders,” such as oppositional
defiant disorder and conduct di sorder. ADHD often persists in to adulthood, with resultant
impairments of social, academic and occupational functioning.
The neurodevelopmental motor disorders in clude developmental coordination disor-
der, stereotypic movement disorder, and tic disorders. Developmen tal coordination dis-


der, stereotypic movement disorder, and tic disorders. Developmen tal coordination dis-
order is characterized by deficits in the acquisition and execution of coordinated motor
skills and is manifested by clumsiness and slow ness or inaccuracy of performance of mo-
tor skills that cause interference with activiti es of daily living. St ereotypic movement dis-
order is diagnosed when an individual has repetitive, seemingly driven, and apparently
purposeless motor behaviors, such as hand fl apping, body rocking, head banging, self-
biting, or hitting. The movements interfere with  social, academic, or other activities. If the
behaviors cause self-injury, this  should be specified as part of the diagnostic description.
Tic disorders are characterized by the presen ce of motor or vocal tics, which are sudden,
rapid, recurrent, nonrhythmic, sterotyped motor movements or vocalizations. The dura-
tion, presumed etiology, and clinical presentation  define the specific tic disorder that is di-
agnosed: Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, provisional
tic disorder, other specified tic disorder, and unspecified tic disorder . Tourette’s disorder
is diagnosed when the individual has multiple motor and vocal tics that have been present
for at least 1 year and that have  a waxing-waning symptom course.
Specific learning disorder, as the name implie s, is diagnosed when there are specific defi-
cits in an individual’s ability to perceive or process information efficiently and accurately. This
neurodevelopmental disorder first manifests during the years of formal schooling and is
characterized by persistent and impairing diffi culties with learning foundational academic
skills in reading, writing, and/ or math. The individual’s perfor mance of the affected academic


skills is well below average for age, or acceptable performance levels are achieved only with
extraordinary effort. Specific learning disorder may occur in individuals identified as intellec-


skills is well below average for age, or acceptable performance levels are achieved only with
extraordinary effort. Specific learning disorder may occur in individuals identified as intellec-
tually gifted and manifest only when the le arning demands or assessment procedures (e.g.,
timed tests) pose barriers that cannot be overcome by their innate intelligence and c ompensa-
tory strategies. For all individuals, specific le arning disorder can produce lifelong impairments
in activities dependent on the skills , including occupational performance.
The use of specifiers for the neurodevelopme ntal disorder diagnoses enriches the clin-
ical description of the individual’s clinical  course and current symptomatology. In addi-
tion to specifiers that describe the clinical presentation, such as age at onset or severity
ratings, the neurodevelopmental disorders ma y include the specifier “associated with a
known medical or genetic condition or environmental factor.” This specifier gives clini-


Intellectual Disability (Intellectual Developmental Disorder) 33
cians an opportunity to document factors that may have played a role in the etiology of the
disorder, as well as those that might affect the clinical course. Examples include genetic
disorders, such as fragile X syndrome, tuberous sclerosis, and Rett syndrome; medical con-
ditions such as epilepsy; and environmental fa ctors, including very low birth weight and
fetal alcohol exposure (even in the absence of stigmata of fetal alcohol syndrome).
Intellectual Disabilities
Intellectual Disability
 (Intellectual Developmental Disorder)
Diagnostic Criteria
Intellectual disability (intellectual development al disorder) is a disorder with onset during
the developmental period that includes both intellectual and adaptive functioning deficits
in conceptual, social, and practical domains. The following three criteria must be met:
A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract
thinking, judgment, academic learning, and learning from experience, confirmed by
both clinical assessment and individualized, standardized intelligence testing.
B. Deficits in adaptive functioning that result in failure to meet developmental and socio-
cultural standards for personal independence and social responsibility. Without ongo-
ing support, the adaptive deficits limit functioning in one or more activities of daily life,
such as communication, social participation, and independent living, across multiple
environments, such as home, school, work, and community.
C. Onset of intellectual and adaptive deficits during the developmental period.
Note:  The diagnostic term intellectual disability  is the equivalent term for the ICD-11 diag-
nosis of intellectual developmental disorders.  Although the term intellectual disability  is
used throughout this manual, both terms are used in the title to clarify relationships with
other classification systems. Moreover, a federal statute in the United States (Public Law


other classification systems. Moreover, a federal statute in the United States (Public Law
111-256, Rosa’s Law) replaces the term mental retardation with intellectual disability,  and
research journals use the term intellectual disability. Thus, intellectual disability  is the
term in common use by medical, educational, and other professions and by the lay public
and advocacy groups.
Specify current severity (see Table 1):
317 (F70)    Mild
318.0 (F71) Moderate
318.1 (F72) Severe
318.2 (F73) Profound
Specifiers
The various levels of severity are defined on the basis of adaptive functioning, and not IQ
scores, because it is adaptive  functioning that determines the level of supports required.
Moreover, IQ measures ar e less valid in the lower end of the IQ range.


34 Neurodevelopmental DisordersTABLE 1 Severity levels for intellectual disability (intellectual developmental disorder)
Severity
level Conceptual domain Social domain Practical domain
Mild For preschool children, there
may be no obvious conceptual
differences. Fo r school-age
children and adults, there are
difficulties in learning aca-
demic skills involving reading,
writing, arithmetic, time, or
money, with support needed
in one or more areas to meet
age-related expectations. In
adults, abstract thinking, exec-
utive function (i.e., planning,
strategizing, priority setting,
and cognitive flexibility), and
short-term memory, as well as
functional use of academic
skills (e.g., reading, money
management), are impaired.
There is a somewhat concrete
approach to problems and
solutions compared with
age-mates. Compared with typically developing age-
mates, the individual is immature in social
interactions. For example, there may be diffi-
culty in accurately perceiving peers’ social
cues. Communication, conversation, and lan-
guage are more concrete or immature than
expected for age. There may be difficulties reg-
ulating emotion and behavior in age-appropri-
ate fashion; these difficulties are noticed by
peers in social situations. There is limited
understanding of risk in social situations;
social judgment is immature for age, and
the person is at risk of being manipulated
by others (gullibility).The individual may functi on age-appropriately in
personal care. Individuals need some support with
complex daily living tasks in comparison to peers. In
adulthood, supports typicall y involve grocery shop-


adulthood, supports typicall y involve grocery shop-
ping, transportation, home  and child-care organiz-
ing, nutritious food preparation, and banking and
money management. Recreati onal skills resemble
those of age-mates, although judgment related to
well-being and organization around recreation
requires support. In adulthood, competitive
employment is often seen in  jobs that do not empha-
size conceptual skills. Individuals generally need
support to make health care decisions and legal
decisions, and to learn to perform a skilled vocation
competently. Support is typically needed to raise a
family.


Intellectual Disability (Intellectual Developmental Disorder) 35Moderate All through development, the
individual’s conceptual skills
lag markedly behind those of
peers. For preschoolers, lan-
guage and pre-academic skills
develop slowly. For school-age
children, progress in reading,
writing, mathematics, and
understanding of time and
money occurs slowly across
the school years and is mark-
edly limited compared with
that of peers. For adults, aca-
demic skill development is
typically at an elementary
level, and support is required
for all use of academic skills in
work and personal life. Ongo-
ing assistance on a daily basis
is needed to complete concep-
tual tasks of day-to-day life,
and others may take over these
responsibilities fully for the
individual.The individual shows marked differences from
peers in social and communicative behavior
across development. Spoken language is typi-
cally a primary tool for social communication
but is much less complex than that of peers.
Capacity for relationships is evident in ties to
family and friends, and the individual may
have successful friendships across life and
sometimes romantic relations in adulthood.
However, individuals may not perceive or
interpret social cues ac curately. Social judg-
ment and decision-making abilities are lim-
ited, and caretakers must assist the person
with life decisions. Friendships with typically
developing peers are often affected by com-
munication or social limitations. Significant
social and communicative support is needed
in work settings for success. The individual can care for personal needs involving
eating, dressing, elimination, and hygiene as an


eating, dressing, elimination, and hygiene as an
adult, although an  extended period of teaching and
time is needed for the individual to become indepen-
dent in these areas, and reminders may be needed.
Similarly, participation in all household tasks can be
achieved by adulthood, although an extended
period of teaching is ne eded, and ongoing supports
will typically occur for adult-level performance.
Independent employment in jobs that require lim-
ited conceptual and communication skills can be
achieved, but considerable support from co-work-
ers, supervisors, and others is needed to manage
social expectations, job co mplexities, and ancillary
responsibilities such as scheduling, transportation,
health benefits, and mone y management. A variety
of recreational skills can be developed. These typi-
cally require additional  supports and learning
opportunities over an ex tended period of time.
Maladaptive behavior is present in a significant
minority and causes  social problems.TABLE 1 Severity levels for intellectual disability (intellectual developmental disorder) (continued)
Severity
level Conceptual domain Social domain Practical domain


36 Neurodevelopmental DisordersSevere Attainment of conceptual skills
is limited. The individual gen-
erally has little understanding
of written language or of con-
cepts involving numbers,
quantity, time, and money.
Caretakers provide extensive
supports for problem solving
throughout life. Spoken language is quit e limited in terms of
vocabulary and grammar. Speech may be sin-
gle words or phrases and may be supple-
mented through augmentative means. Speech
and communication are focused on the here
and now within everyday  events. Language is
used for social communication more than for
explication. Individuals understand simple
speech and gestural communication. Relation-
ships with family members and familiar others
are a source of pleasure and help. The individual requires suppo rt for all activities of
daily living, including meals, dressing, bathing, and
elimination. The individual requires supervision at
all times. The individual cannot make responsible
decisions regarding well-being of self or others. In
adulthood, participation in tasks at home, recre-
ation, and work requires ongoing support and assis-
tance. Skill acquisition in all domains involves long-
term teaching and ongoing support. Maladaptive
behavior, including self-injury, is present in a signif-
icant minority.
Profound Conceptual skills generally
involve the physical world
rather than symbolic pro-
cesses. The individual may use
objects in goal-directed fashion
for self-care, work, and recre-
ation. Certain visuospatial
skills, such as matching and
sorting based on physical char-
acteristics, may be acquired.
However, co-occ urring motor
and sensory impairments may


However, co-occ urring motor
and sensory impairments may
prevent functional use of
objects. The individual has very limited understanding
of symbolic communication in speech or ges-
ture. He or she may understand some simple
instructions or gestures. The individual
expresses his or her own desires and emotions
largely through nonverbal, nonsymbolic com-
munication. The individu al enjoys relation-
ships with well-known family members,
caretakers, and familiar others, and initiates
and responds to social interactions through
gestural and emotional  cues. Co-occurring
sensory and physical impairments may pre-
vent many social activities. The individual is dependent on others for all aspects of
daily physical care, health, and safety, although he or
she may be able to participat e in some of these activi-
ties as well. Individuals without severe physical
impairments may assist with some daily work tasks at
home, like carrying dishes to the table. Simple actions
with objects may be the basi s of participation in some
vocational activities with high levels of ongoing sup-
port. Recreational activities  may involve, for example,
enjoyment in listening to music, watching movies,
going out for walks, or part icipating in water activi-
ties, all with the support of others. Co-occurring
physical and sensory impairments are frequent
barriers to participation (beyond watching) in home,
recreational, and vocational activities. Maladaptive
behavior is present in a significant minority.TABLE 1 Severity levels for intellectual disability (intellectual developmental disorder) (continued)
Severity
level Conceptual domain Social domain Practical domain


Intellectual Disability (Intellectual Developmental Disorder) 37
Diagnostic Features
The essential features of intellectual disab ility (intellectual developmental disorder) are
deficits in general mental abilities (Criteri on A) and impairment in everyday adaptive
functioning, in comparison to an individual ’s age-, gender-, and socioculturally matched
peers (Criterion B). Onset is during the developmental period  (Criterion C). The diagnosis
of intellectual disability is based on both clinical assessment and standardized testing of
intellectual and adaptive functions.
Criterion A refers to intellectual function s that involve reasoning, problem solving,
planning, abstract thinking, judgment, lear ning from instruction and experience, and
practical understanding. Critical componen ts include verbal comprehension, working
memory, perceptual reasoning, quantitative reasoning, abstract thought, and cognitive ef-
ficacy. Intellectual functioning is typically me asured with individually administered and
psychometrically valid, comprehensive, cultur ally appropriate, psychometrically sound
tests of intelligence. Individuals with intellec tual disability have scores of approximately
two standard deviations or more below the population mean, including a margin for mea-
surement error (generally +5 points). On te sts with a standard deviation of 15 and a mean
of 100, this involves a score of 65–75 (70 ± 5). Clinical training and judgment are required
to interpret test results and assess intellectual performance.
Factors that may affect test scores include practice effects and the “Flynn effect’ (i.e.,
overly high scores due to out- of-date test norms). Invalid scores may result from the use of
brief intelligence screening tests or group tests;  highly discrepant individual subtest scores
may make an overall IQ score invalid. Instrume nts must be normed for the individual’s so-


ciocultural background and native language. Co-occurring disorders that affect communi-
cation, language, and/or motor or sensory fu nction may affect test scores. Individual
cognitive profiles based on ne uropsychological testing are mo re useful for understanding
intellectual abilities than a single IQ score.  Such testing may identify areas of relative
strengths and weaknesses, an assessment import ant for academic and vocational planning.
IQ test scores are approximat ions of conceptual function ing but may be insufficient to
assess reasoning in real-life situations and ma stery of practical task s. For example, a per-
son with an IQ score above 70 may have such severe adaptive behavi or problems in social
judgment, social understanding, and other area s of adaptive functioning that the person’s
actual functioning is comparable to that of in dividuals with a lower IQ score. Thus, clinical
judgment is needed in interpre ting the results of IQ tests.
Deficits in adaptive functioning (Criterion B) refer to how well a person meets community
standards of personal independen ce and social responsibility, in comparison to others of sim-
ilar age and sociocultural background. Adaptive  functioning involves adaptive reasoning in
three domains: conceptual, social, and practical. The conceptual (academic) domain  involves
competence in memory, language, reading, writing, math reasoning, acquisition of practical
knowledge, problem solving, and judgment  in novel situations , among others. The social do-
main  involves awareness of others’ thoughts, feelings, and experiences; empathy; interper-
sonal communication skills; friendship abilit ies; and social judgment, among others. The
practical domain involves learning and self-management across life settings, including personal
care, job responsibilities, money management, recreation, self-management of behavior, and


care, job responsibilities, money management, recreation, self-management of behavior, and
school and work task organization, among others . Intellectual capacity, education, motivation,
socialization, personality features, vocational opportunity, cultural experience, and coexisting


school and work task organization, among others . Intellectual capacity, education, motivation,
socialization, personality features, vocational opportunity, cultural experience, and coexisting
general medical conditions or mental di sorders influence adaptive functioning.
Adaptive functioning is assessed using both clinical evaluation and individualized,
culturally appropriate, psychometrically sound measures. Standardized measures are
used with knowledgeable informants (e.g., pa rent or other f amily member; teacher; coun-
selor; care provider) and the individual to th e extent possible. Additional sources of infor-
mation include educational, developmental, medical, and mental health evaluations.
Scores from standardized measures and interv iew sources must be interpreted using clin-
ical judgment. When standardized testing is di fficult or impossible, because of a variety of


38 Neurodevelopmental Disorders
factors (e.g., sensory impairme nt, severe problem behavior), the individual may be diag-
nosed with unspecified intellectual disability.  Adaptive functioning may be difficult to
assess in a controlled setting (e.g., prisons, dete ntion centers); if poss ible, corrob orative in-
formation reflecting functioning outsid e those settings should be obtained.
Criterion B is met when at least one domain  of adaptive functioning—conceptual, so-
cial, or practical—is sufficiently impaired th at ongoing support is needed in order for the
person to perform adequately in one or more life settings at school, at work, at home, or in
the community. To meet diagnostic criteria for intellectual disability, the deficits in adap-
tive functioning must be directly related to  the intellectual impairments described in Cri-
terion A. Criterion C, onset during the deve lopmental period, refers to recognition that
intellectual and adaptive deficits are pr esent during childhood or adolescence.
Associated Features Supporting Diagnosis
Intellectual disability is a heterogeneous condition with multiple causes. There may be
associated difficulties with social judgment; assessment of risk; self-management of behav-
ior, emotions, or interpersonal relationships; or  motivation in school or work environments.
Lack of communication skills may predispose to disruptive and aggressive behaviors. Gull-
ibility is often a feature, involving naiveté in social situations and a tendency for being easily
led by others. Gullibility and lack of awareness of  risk may result in exploitation by others
and possible victimization, fraud, unintentional criminal involvement, false confessions,
and risk for physical and sexual abuse. These associated features can be important in crim-
inal cases, including Atkins-type hearings involving the death penalty.
Individuals with a diagnosis of intellectual disability with co-occurring mental disor-


Individuals with a diagnosis of intellectual disability with co-occurring mental disor-
ders are at risk for suicide. They think about suicide, make  suicide attempts, and may die
from them. Thus, screening for su icidal thoughts is essential in the assessment process. Be-
cause of a lack of awareness of risk and dang er, accidental injury rates may be increased.
Prevalence
Intellectual disability has an overall general population prevalence of approximately 1%,
and prevalence rates vary by age. Prevalence for severe intellectual disability is approxi-
mately 6 per 1,000.
Development and Course
Onset of intellectual disability is in the de velopmental period. The age and characteristic
features at onset depend on the etiology and severity of brain dysfunction. Delayed motor,
language, and social milestones may be identifi able within the first 2 years of life among
those with more severe intellectual disability, while mild levels may not be identifiable un-
til school age when difficulty with academic learning becomes appare nt. All criteria (in-
cluding Criterion C) must be fulfilled by hi story or current presentation. Some children
under age 5 years whose presentation will even tually meet criteria for intellectual disabil-
ity have deficits that meet criter ia for global developmental delay.
When intellectual disability is associated with  a genetic syndrome, there may be a char-
acteristic physical appearance (as in, e.g., Down syndrome). Some syndromes have a
behavioral phenotype,  which refers to specific behaviors that are characteristic of particular
genetic disorder (e.g., Lesch-Nyhan syndro me). In acquired forms, the onset may be
abrupt following an illness such as meningitis  or encephalitis or head trauma occurring
during the developmental period. When intellectual disability results from a loss of pre-


during the developmental period. When intellectual disability results from a loss of pre-
viously acquired cognitive skills, as in severe  traumatic brain injury , the diagnoses of in-
tellectual disability and of  a neurocognitive disorder may both be assigned.
Although intellectual disability is generally nonprogressive, in certain genetic disor-