794 Conditions for Further Study
most commonly endorsed criteria being withdr awal (96%), persistent desire or unsuccess-
ful efforts to control use (89%), and use de spite knowledge of physical or psychological
problems caused by caffeine (87%). The most  common reasons for wanting to modify caf-
feine use were health-related (59%) and a desire to not be dependent on caffeine (35%).
The DSM-5 discussion of ca ffeine withdrawal in the Section II chapter “Substance-
Related and Addictive Disorders” provides info rmation on the features of the withdrawal
criterion. It is well documented  that habitual caffeine users can experience a well-defined
withdrawal syndrome upon ac ute abstinence from caffeine, and many caffeine-dependent
individuals report continued use of caffeine to avoid experiencing withdrawal symptoms.
Prevalence
The prevalence of caffeine use di sorder in the general population is unclear. Based on all
seven generic DSM-IV-TR criteria for dependence, 30% of current caffeine users may have
met DSM-IV criteria for a diagnosis of caffei ne dependence, with endorsement of three or
more dependence criteria, during the past year . When only four of the seven criteria (the
three primary criteria proposed above plus to lerance) are used, the prevalence appears to
drop to 9%. Thus, the expected prevalence of caffeine use disorder among regular caffeine
users is likely less than 9%. Given that approximately 75%–80% of the general population
uses caffeine regularly, the estimated preval ence would be less than 7%. Among regular
caffeine drinkers at higher risk for caffeine use problems (e.g., high school and college stu-
dents, individuals in drug treatment, and indi viduals at pain clinics who have recent his-
tories of alcohol or illicit drug misuse), ap proximately 20% may have a pattern of use that


meets all three of the proposed criteria in Criterion A.
Development and Course
Individuals whose patter n of use meets criteria for a ca ffeine use disorder have shown a
wide range of daily caffeine intake and have been consumer s of various types of caffein-
ated products (e.g., coffee, soft drinks, tea)  and medications. A diagnosis of caffeine use
disorder has been shown to prospectively pred ict a greater incidence of caffeine reinforce-
ment and more severe withdrawal.
There has been no longitudinal or cross-sect ional lifespan research on caffeine use dis-
order. Caffeine use disorder has been identi fied in both adolescents and adults. Rates of
caffeine consumption and overa ll level of caffeine consumption tend to increase with age
until the early to mid-30s and then level off.  Age-related factors for caffeine use disorder
are unknown, although concern is growing related to excessive caffeine consumption
among adolescents and young adults through use of caffeinated energy drinks.
Risk and Prognostic Factors
Genetic and physiological. Heritabilities of heavy caffeine use, caffeine tolerance, and
caffeine withdrawal range from  35% to 77%. For caffeine use, alcohol use, and cigarette
smoking, a common genetic factor (polysubst ance use) underlies the use of these three
substances, with 28%–41% of the heritable e ffects of caffeine use (or heavy use) shared
with alcohol and smoking. Caffeine and toba cco use disorders are associated and substan-
tially influenced by genetic factors unique to these licit drugs. The magnitude of heritabil-
ity for caffeine use disorder ma rkers appears to be similar to that for alcohol and tobacco
use disorder markers.
Functional Consequences of Caffeine Use Disorder


use disorder markers.
Functional Consequences of Caffeine Use Disorder
Caffeine use disorder may predict greater use of caffeine during pregnancy. Caffeine with-
drawal, a key feature of caffeine use disorder, has been shown to produce functional im-


Conditions for Further Study 795
pairment in normal daily activities. Caffeine intoxication may include symptoms of
nausea and vomiting, as well as impairment of normal activities. Significant disruptions in
normal daily activities may occur during caffeine abstinence.
Differential Diagnosis
Nonproblematic use of caffeine. The distinction between nonproblematic use of caf-
feine and caffeine use disorder can be difficul t to make because social, behavioral, or psy-
chological problems may be difficult to attribut e to the substance, espe cially in the context of
use of other substances. Regular,  heavy caffeine use that can result in tolerance and with-
drawal is relatively common, which by itself sh ould not be sufficient for making a diagnosis.
Other stimulant use disorder. Problems related to use of other stimulant medications
or substances may approximate the fe atures of caffeine use disorder.
Anxiety disorders. Chronic heavy caffeine use may mimi c generalized anxiety disorder,
and acute caffeine cons umption may produce and mimic panic attacks.
Comorbidity
There may be comorbidity between caffeine use disorder and daily cigarette smoking, a
family or personal history of alcohol use diso rder. Features of caffeine use disorder (e.g.,
tolerance, caffeine withdrawal) may be positive ly associated with several diagnoses: ma-
jor depression, generali zed anxiety disorder, panic disorder, adult antisocial personality
disorder, and alcohol, cannab is, and cocaine use disorders.
Internet Gaming Disorder
Proposed Criteria
Persistent and recurrent use of the Internet to engage in games, often with other players,
leading to clinically significant impairment or distress as indicated by five (or more) of the
following in a 12-month period:
1. Preoccupation with Internet games. (The individual thinks about previous gaming


1. Preoccupation with Internet games. (The individual thinks about previous gaming
activity or anticipates playing the next game; Internet gaming becomes the dominant
activity in daily life).
Note:  This disorder is distinct from Internet gambling, which is included under gam-
bling disorder.
2. Withdrawal symptoms when Internet gami ng is taken away. (These symptoms are typ-
ically described as irritability, anxiety, or sadness, but there are no physical signs of
pharmacological withdrawal.)
3. Tolerance—the need to spend increasing amounts of time engaged in Internet games.
4. Unsuccessful attempts to control the participation in Internet games.
5. Loss of interests in previous hobbies and entertainment as a result of, and with the ex-
ception of, Internet games.
6. Continued excessive use of Internet games despite knowledge of psychosocial problems.
7. Has deceived family members, therapists, or others regarding the amount of Internet
gaming.
8. Use of Internet games to escape or relieve a negative mood (e.g., feelings of helpless-
ness, guilt, anxiety).
9. Has jeopardized or lost a significant relationship, job, or educational or career oppor-
tunity because of participation in Internet games.


796 Conditions for Further Study
Note:  Only nongambling Internet games are included in this disorder. Use of the Internet
for required activities in a business or profe ssion is not included; nor is the disorder intend-
ed to include other recreational or social Internet use. Similarly, sexual Internet sites are
excluded.
Specify current severity:
Internet gaming disorder can be mild, moderate, or severe depending on the degree
of disruption of normal activities. Individuals with less severe Internet gaming disorder
may exhibit fewer symptoms and less disruption of their lives. Those with severe Inter-
net gaming disorder will have more hours spent on the computer and more severe loss
of relationships or career or school opportunities.
Subtypes
There are no well-researched subtypes for Inte rnet gaming disorder to date. Internet gam-
ing disorder most often involves specific Inte rnet games, but it co uld involve non-Internet
computerized games as well, although these have  been less researched. It is likely that pre-
ferred games will vary over time as new games are developed and popularized, and it is
unclear if behaviors and consequence associat ed with Internet gaming disorder vary by
game type.
Diagnostic Features
Gambling disorder is currently the only non-substance-related disorder proposed for in-
clusion with DSM-5 substance-related and addi ctive disorders. However, there are other
behavioral disorders that show some similari ties to substance use disorders and gambling
disorder for which the word addiction is commonly used in nonmedical settings, and the
one condition with a considerab le literature is the compulsive playing of Internet games.
Internet gaming has been reportedly define d as an “addiction” by the Chinese govern-
ment, and a treatment system has been set up. Reports of treatment of this condition have


ment, and a treatment system has been set up. Reports of treatment of this condition have
appeared in medical journals, mostly from A sian countries and some in the United States.
The DSM-5 work group reviewed more than 240 articles and found some behavioral
similarities of Internet gaming  to gambling disorder and to substance use disorders. The
literature suffers, howeve r, from lack of a standard defini tion from which to derive prev-
alence data. An understanding of the natural histories of cases, with or without treatment,
is also missing. The literature does describe many underlying similarities to substance ad-
dictions, including aspects of tolerance, withdr awal, repeated unsuccessful attempts to cut
back or quit, and impairment in normal func tioning. Further, the seemingly high preva-
lence rates, both in Asian countries and, to a lesser extent, in the West, justified inclusion of
this disorder in Section III of DSM-5.
Internet gaming disorder has significant public health importance, and additional re-
search may eventually lead to evidence that Internet gaming disorder (also commonly re-
ferred to as Internet use disorder,  Internet addiction,  or gaming addiction ) has merit as an
independent disorder. As with gambling disord er, there should be epidemiological stud-
ies to determine prevalence, c linical course, possible geneti c influence, and potential bio-
logical factors based on, for example, brain imaging data.
Internet gaming disorder is a pattern of exce ssive and prolonged Inte rnet gaming that re-
sults in a cluster of cognitive and behavioral symptoms, including progressive loss of control
over gaming, tolerance, and withdrawal sy mptoms, analogous to the symptoms of sub-
stance use disorders. As with substance-related disorders, individuals with Internet gaming


stance use disorders. As with substance-related disorders, individuals with Internet gaming
disorder continue to sit at a computer and en gage in gaming activi ties despite neglect of
other activities. They typically de vote 8–10 hours or more per day to this activity and at least
30 hours per week. If they are prevented from  using a computer and returning to the game,
they become agitated and angry. They often go  for long periods without food or sleep. Nor-


Conditions for Further Study 797
mal obligations, such as  school or work, or family obligati ons are neglected. This condition is
separate from gambling disorder involving the Internet because mo ney is not at risk.
The essential feature of Internet gaming di sorder is persistent an d recurrent participa-
tion in computer gaming, ty pically group games, for many hours. These games involve
competition between groups of players (often in  different global regions, so that duration
of play is encouraged by the time-zone inde pendence) participating in complex structured
activities that include a significant aspect of social interactions during play. Team aspects
appear to be a key motivation. Attempts to di rect the individual toward schoolwork or in-
terpersonal activities are strongly resisted. Thus personal, family, or vocational pursuits
are neglected. When individuals are asked, the major reasons given for using the com-
puter are more likely to be “avoiding boredo m” rather than communicating or searching
for information.
The description of criteria rela ted to this condition is adapt ed from a study in China. Un-
til the optimal criteria and threshold for di agnosis are determined empirically, conserva-
tive definitions ought to be used, such that diagnoses are considered for endorsement of
five or more of nine criteria.
Associated Features Supporting Diagnosis
No consistent personality types associated with  Internet gaming disorder have been iden-
tified. Some authors describe associated diagnoses, such as depressive disorders, atten-
tion-deficit/hyperactivity disorder (ADHD) , or obsessive-compulsive disorder (OCD).
Individuals with compulsive Internet gaming have demonstrated brain activation in spe-
cific regions triggered by exposure to the Internet game but not limited to reward system
structures
Prevalence
The prevalence of Internet gaming disorder is unclear because of the varying question-


Prevalence
The prevalence of Internet gaming disorder is unclear because of the varying question-
naires, criteria and thresholds employed, but it  seems to be highest in Asian countries and
in male adolescents 12–20 years of age. There is an abundance of reports from Asian coun-
tries, especially China and South Korea, bu t fewer from Europe and North America, from
which prevalence estimates are highly variable . The point prevalence in adolescents (ages
15–19 years) in one Asian study using a threshold of five criteria was 8.4% for males and
4.5% for females.
Risk and Prognostic Factors
Environmental. Computer availability with Internet connection allows access to the
types of games with which Internet gami ng disorder is most often associated.
Genetic and physiological. Adolescent males seem to be at greatest risk of developing
Internet gaming disorder, and it has been sp eculated that Asian environmental and/or ge-
netic background is another risk factor, but this remains unclear.
Functional Consequences of  Internet Gaming Disorder
Internet gaming disorder may lead to school failure, job loss, or marriage failure. The com-
pulsive gaming behavior tends to crowd out normal social, scholastic, and family activities.
Students may show declining grades and eventu ally failure in school. Family responsibil-
ities may be neglected.
Differential Diagnosis
Excessive use of the Internet not involving playing of online games (e.g., excessive use of
social media, such as Facebook; viewing porn ography online) is not considered analogous


798 Conditions for Further Study
to Internet gaming disorder, and future rese arch on other excessive uses of the Internet
would need to follow similar guidelines as suggested herein. Excessive gambling online
may qualify for a separate diagnosis of gambling disorder.
Comorbidity
Health may be neglected due to compulsive ga ming. Other diagnoses that may be associ-
ated with Internet gaming disorder incl ude major depressive disorder, ADHD, and OCD.
Neurobehavioral Disorder Associated
With Prenatal Alcohol Exposure
Proposed Criteria
A. More than minimal exposure to alcohol during gestation, including prior to pregnancy
recognition. Confirmation of gestational exposure to alcohol may be obtained from ma-
ternal self-report of alcohol use in pregnancy, medical or other records, or clinical ob-
servation.
B. Impaired neurocognitive functioning as manifested by one or more of the following:
1. Impairment in global intellectual performance (i.e., IQ of 70 or below, or a standard
score of 70 or below on a comprehensive developmental assessment).
2. Impairment in executive functioning (e.g., poor planning and organization; inflexi-
bility; difficulty with behavioral inhibition).
3. Impairment in learning (e.g., lower academic achievement than expected for intel-
lectual level; specific learning disability).
4. Memory impairment (e.g., problems remembering information learned recently;
repeatedly making the same mistakes; difficulty remembering lengthy verbal in-
structions).
5. Impairment in visual-spatial reasoning (e.g., disorganized or poorly planned draw-
ings or constructions; problems differentiating left from right).
C. Impaired self-regulation as manifested by one or more of the following:
1. Impairment in mood or behavioral regulation (e.g., mood lability; negative affect or
irritability; frequent behavioral outbursts).


irritability; frequent behavioral outbursts).
2. Attention deficit (e.g., difficulty shifting attention; difficulty sustaining mental effort).
3. Impairment in impulse control (e.g., difficulty waiting turn; difficulty complying with
rules).
D. Impairment in adaptive functioning as manifested by two or more of the following, one
of which must be (1) or (2):
1. Communication deficit (e.g., delayed acquisition of language; difficulty understand-
ing spoken language).
2. Impairment in social communication and interaction (e.g., overly friendly with strang-
ers; difficulty reading social cues; difficulty understanding social consequences).
3. Impairment in daily living skills (e.g., delayed toileting, feeding, or bathing; difficulty
managing daily schedule).
4. Impairment in motor skills (e.g., poor fine motor development; delayed attainment
of gross motor milestones or ongoing deficits in gross motor function; deficits in co-
ordination and balance).
E. Onset of the disorder (symptoms in Criteria B, C, and D) occurs in childhood.


Conditions for Further Study 799
F. The disturbance causes clinically significant distress or impairment in social, aca-
demic, occupational, or other im portant areas of functioning.
G. The disorder is not better explained by the direct physiological effects associated with
postnatal use of a substance (e.g., a medication, alcohol or other drugs), a general
medical condition (e.g., traumatic brain injury, delirium, dementia), another known te-
ratogen (e.g., fetal hydantoin syndrome), a genetic condition (e.g., Williams syndrome,
Down syndrome, Cornelia de Lange syndrome), or environmental neglect.
Alcohol is a neurobehavioral te ratogen, and prenatal alcoho l exposure has teratogenic
effects on central nervous system (CNS ) development and subsequent function. Neurobe-
havioral disorder associated with prenatal alcohol exposure  (ND-PAE) is a new clarifying term,
intended to encompass the full range of de velopmental disabilities associated with expo-
sure to alcohol in utero. The current diagnost ic guidelines allow ND-PAE to be diagnosed
both in the absence and in the presence of th e physical effects of prenatal alcohol exposure
(e.g., facial dysmorphology required for a diagnosis of fetal alcohol syndrome).
Diagnostic Features
The essential features of ND-PAE are the mani festation of impairment in neurocognitive,
behavioral, and adaptive functioning associated with prenatal alcohol exposure. Impair-
ment can be documented based on past diagnostic evaluation s (e.g., psychological or ed-
ucational assessments) or medical records, reports by the in dividual or informants, and/
or observation by a clinician.
A clinical diagnosis of fetal alcohol synd rome, including specific prenatal alcohol-
related facial dysmorphology and growth retardation, can be used as evidence of signifi-


related facial dysmorphology and growth retardation, can be used as evidence of signifi-
cant levels of prenatal alcohol exposure. Although both animal and human studies have
documented adverse effects of lower levels of drinking, identifying how much prenatal
exposure is needed to sign ificantly impact neurodevelop mental outcome remains chal-
lenging. Data suggest that a history of more than minimal gestationa l exposure (e.g., more
than light drinking) prior to pregnancy reco gnition and/or following pregnancy recogni-
tion may be required. Light drinking is defined as 1–13 drinks per month during preg-
nancy with no more than 2 of these drinks co nsumed on any 1 drinking occasion. Identifying
a minimal threshold of drinking during preg nancy will require consideration of a variety
of factors known to affect exposure and/or interact to influence developmental outcomes,
including stage of prenatal development, gestational smoking, maternal and fetal genet-
ics, and maternal physical status (i.e., ag e, health, and certain obstetric problems).
Symptoms of ND-PAE include marked impairment in global  intellectual performance
(IQ) or neurocognitive impair ments in any of the following areas: executive functioning,
learning, memory, and/or visual-spatial reasoning. Impairments in self-regulation are pres-
ent and may include impairment in mood or behavioral regulation, attention deficit, or
impairment in impulse control. Finally, impa irments in adaptive functioning include com-
munication deficits and impairment in soci al communication and interaction. Impairment
in daily living (self-help) skills and impairment in motor skills may be present.  As it may be
difficult to obtain an accurate assessment of the neurocogni tive abilities of very young chil-


dren, it is appropriate to defer a diagnosi s for children 3 years of age and younger.
Associated Features Supporting Diagnosis
Associated features vary depending on age,  degree of alcohol exposure, and the individ-
ual’s environment. An individual can be diag nosed with this disorder regardless of socio-
economic or cultural background. However, ongoing parental alcohol/substance misuse,
parental mental illness, exposure to domest ic or community violen ce, neglect or abuse,


economic or cultural background. However, ongoing parental alcohol/substance misuse,
parental mental illness, exposure to domest ic or community violen ce, neglect or abuse,
disrupted caregiving relationships, multiple out-of-home placements, and lack of conti-
nuity in medical or mental health care are often present.


800 Conditions for Further Study
Prevalence
The prevalence rates of ND-PAE are unknown. However, estimated prevalence rates of clini-
cal conditions associated with prenatal alco hol exposure are 2%–5% in the United States.
Development and Course
Among individuals with prenatal alcohol exposure, evidence of CNS dysfunction varies
according to developmental stage. Although about one-half of young children prenatally
exposed to alcohol show marked  developmental delay in the first 3 years of life, other chil-
dren affected by prenatal alcohol exposure may not exhibit signs of CNS dysfunction until
they are preschool- or school-age. Additionally, impairments in higher order cognitive
processes (i.e., executive functioning), which are often associated with  prenatal alcohol ex-
posure, may be more easily assessed in older children. When children reach school age,
learning difficulties, impairme nt in executive function, and problems with integrative lan-
guage functions usually emerge more clearly, and both social skills deficits and challeng-
ing behavior may become more evident. In particular, as school and other requirements
become more complex, greater deficits are no ted. Because of this, the school years repre-
sent the ages at which a diagnosis of ND-PAE would be most likely.
Suicide Risk
Suicide is a high-risk outcome, with rates incr easing significantly in late adolescence and
early adulthood.
Functional Consequences of Neurobehavioral Disorder
Associated With Prenatal Alcohol Exposure
The CNS dysfunction seen in individuals with ND-PAE often leads to decrements in adap-
tive behavior and to maladaptive behavior  with lifelong consequences. Individuals
affected by prenatal alcohol ex posure have a higher prevalence of disrupted school expe-
riences, poor employme nt records, trouble with the law,  confinement (legal or psychiat-


ric), and dependent living conditions.
Differential Diagnosis
Disorders that are attributable to the physiolo gical effects associated with postnatal use
of a substance, another medical condition, or environmental neglect. Other consid-
erations include the physiological effects of po stnatal substance use, such as a medication,
alcohol, or other substances; disorders due to another medical condition, such as traumatic
brain injury or other neurocognitive disorder s (e.g., delirium, majo r neurocognitive dis-
order [dementia]); or environmental neglect.
Genetic and teratogenic conditions. Genetic conditions such as Williams syndrome,
Down syndrome, or Cornelia de Lange syndro me and other teratogeni c conditions such as
fetal hydantoin syndrome and maternal phen ylketonuria may have similar physical and
behavioral characteristics. A careful review of prenatal exposure history is needed to clar-
ify the teratogenic agent, and an evaluation by  a clinical geneticist may be needed to dis-
tinguish physical characteristics associated with these and other genetic conditions.
Comorbidity
Mental health problems have been identified in more than 90% of individuals with histo-
ries of significant prenatal alcohol exposu re. The most common co-occurring diagnosis is
attention-deficit/hyperactivity disorder, bu t research has shown that individuals with
ND-PAE differ in neuropsychological charac teristics and in their responsiveness to phar-


Conditions for Further Study 801
macological interventions. Ot her high- probability co-occurring disorders include oppo-
sitional defiant disorder and co nduct disorder, but the appropriateness of these diagnoses
should be weighed in the context of the sign ificant impairments in general intellectual and
executive functioning that are often associa ted with prenatal al cohol exposure. Mood
symptoms, including symptoms of bipolar diso rder and depressive disorders, have been
described. History of prenatal alcohol exposure  is associated with an increased risk for
later tobacco, alcohol, and other substance use disorders.
Suicidal Behavior Disorder
Proposed Criteria
A. Within the last 24 months, the individual has made a suicide attempt.
Note:  A suicide attempt is a self-initiated sequence of behaviors by an individual who,
at the time of initiation, expected that the set of actions would lead to his or her own
death. The “time of initiation” is the time when a behavior took place that involved ap-
plying the method.)
B. The act does not meet criteria for nonsuicidal self-injury—that is, it does not involve
self-injury directed to the surface of the body undertaken to induce relief from a nega-
tive feeling/cognitive state or to achieve a positive mood state.
C. The diagnosis is not applied to suic idal ideation or to preparatory acts.
D. The act was not initiated during a state of delirium or confusion.
E. The act was not undertaken solely for a political or religious objective.
Specify if:
Current: Not more than 12 months since the last attempt.
In early remission:  12–24 months since the last attempt.
Specifiers
Suicidal behavior is often categorized in term s of violence of the method. Generally, over-


doses with legal or illegal substances are cons idered nonviolent in method, whereas jump-
ing, gunshot wounds, and other methods are considered violent. Another dimension for
classification is medical consequences of the behavior, with high-lethality attempts being
defined as those requiring medical hospitalizat ion beyond a visit to an emergency depart-
ment. An additional dimension considered incl udes the degree of planning versus impul-
siveness of the attempt, a characteristic th at might have consequences for the medical
outcome of a suicide attempt.
If the suicidal behavior occurred 12–24 mo nths prior to evaluation, the condition is
considered to be in early remission. Individua ls remain at higher risk  for further suicide at-
tempts and death in the 24 months after a suicide attempt, and the period 12–24 months af-
ter the behavior took place is specified as “early remission.”
Diagnostic Features
The essential manifestation of suicidal be havior disorder is a suicide attempt. A suicide at-
tempt  is a behavior that the individual has undertak en with at least some intent to die. The
behavior might or might not le ad to injury or serious medi cal consequences. Several fac-
tors can influence the medical consequences of the suicide a ttempt, including poor plan-
ning, lack of knowledge about the lethality of the method chosen, low intentionality or
ambivalence, or chance intervention by others  after the behavior has been initiated. These
should not be considered in assigning the diagnosis.


802 Conditions for Further Study
Determining the degree of intent can be challenging. Individuals might not acknowl-
edge intent, especially in situations where doin g so could result in hospitalization or cause
distress to loved ones. Markers of risk includ e degree of planning, including selection of a
time and place to minimize rescue or interrupt ion; the individual’s mental state at the time
of the behavior, with acute agitation being especially concerning; recent discharge from
inpatient care; or recent discon tinuation of a mood stabilizer such as lithium or an anti-
psychotic such as clozapine in the case of schizophrenia. Examples of environmental “trig-
gers” include recently learning of a potentia lly fatal medical diagnosis such as cancer,
experiencing the sudden and unexpected loss of a close relative or partner, loss of employ-
ment, or displacement from h ousing. Conversely, features su ch as talking to others about
future events or preparedness to sign a contract for safety are less reliable indicators.
In order for the criteria to be met, the indivi dual must have made at least one suicide at-
tempt. Suicide attempts can incl ude behaviors in which, after initiating the suicide attempt,
the individual changed his or her mind or so meone intervened. For example, an individual
might intend to ingest a given amount of medication or pois on, but either stop or be stopped
by another before ingesting the full amount. If the individual is dissuaded by another or
changes his or her mind before initiating th e behavior, the diagnosis should not be made.
The act must not meet criteria for nonsuicidal self-i njury—that is, it should not involve re-
peated (at least five times within the past 12 months) self-injurious episodes undertaken to


induce relief from a negative feeling/cognitive state or to achieve a positive mood state. The
act should not have been initiated during a st ate of delirium or confusion. If the individual
deliberately became intoxicated before initiating  the behavior, to reduce anticipatory anxi-
ety and to minimize interference with the inte nded behavior, the diagnosis should be made.
Development and Course
Suicidal behavior can occur at any time in the lifespan but is rarely seen in children under
the age of 5. In prepubertal children, the behavi or will often consist of a behavior (e.g., sit-
ting on a ledge) that a parent has forbidden because of the risk of accident. Approximately
25%–30% of persons who attempt suicide will go on to make more attempts.There is sig-
nificant variability in terms of frequency, me thod, and lethality of attempts. However, this
is not different from what is observed in other illnesses, such as major depressive disorder,
in which frequency of episode,  subtype of episode, and impa irment for a given episode can
vary significantly.
Culture-Related Diagnostic Issues
Suicidal behavior varies in frequency and form  across cultures. Cultural differences might
be due to method availability (e.g., poisonin g with pesticides in developing countries;
gunshot wounds in the southwestern United St ates) or the presence of culturally specific
syndromes (e.g., ataques de nervios,  which in some Latino group s might lead to behaviors
that closely resemble suic ide attempts or might facilitate suicide attempts).
Diagnostic Markers
Laboratory abnormalities consequent to the suicidal attempt are of ten evident. Suicidal
behavior that leads to blood loss can be a ccompanied by anemia, hypotension, or shock.


Overdoses might lead to coma or obtundatio n and associated laboratory abnormalities
such as electrolyte imbalances.
Functional Consequences of Suicidal Behavior Disorder
Medical conditions (e.g., lacerations or skel etal trauma, cardiopulm onary instability, in-
halation of vomit and suffocation, hepatic fa ilure consequent to use of paracetamol) can
occur as a consequence of suicidal behavior.


Conditions for Further Study 803
Comorbidity
Suicidal behavior is seen in th e context of a variety of mental disorders, most commonly bipo-
lar disorder, major depressive disorder, schizo phrenia, schizoaffective disorder, anxiety dis-
orders (in particular, panic disorders asso ciated with catastrophic content and PTSD
flashbacks), substance use disorders (especially  alcohol use disorders) , borderline personality
disorder, antisocial personality disorder, eating disorders, and adjustment disorders. It is
rarely manifested by individual s with no discernible pathology,  unless it is undertaken be-
cause of a painful medical condition with the in tention of drawing attention to martyrdom for
political or religious reasons, or in partners in  a suicide pact, both of which are excluded from
this diagnosis, or when third-party informants  wish to conceal the nature of the behavior.
Nonsuicidal Self-Injury
Proposed Criteria
A. In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted
damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain
(e.g., cutting, burning, stabbing, hitting, excessive rubbing), with the expectation that the
injury will lead to only minor or moderate physi cal harm (i.e., there is no suicidal intent).
Note:  The absence of suicidal intent has either been stated by the individual or can be
inferred by the individual’s repeated engagement in a behavior that the individual
knows, or has learned, is not likely to result in death.
B. The individual engages in the self-injurious behavior with one or more of the following
expectations:
1. To obtain relief from a negative feeling or cognitive state.
2. To resolve an interpersonal difficulty.


2. To resolve an interpersonal difficulty.
3. To induce a positive feeling state.
Note:  The desired relief or response is experienced during or shortly after the self-
injury, and the individual may display patterns of behavior suggesting a dependence
on repeatedly engaging in it.
C. The intentional self-injury is associated with at least one of the following:
1. Interpersonal difficulties or negative feelings or thoughts, such as depression, anx-
iety, tension, anger, generalized distress, or self-criticism, occurring in the period
immediately prior to the self-injurious act.
2. Prior to engaging in the act, a period of preoccupation with the intended behavior
that is difficult to control.
3. Thinking about self-injury that occurs frequently, even when it is not acted upon.
D. The behavior is not socially sanctioned (e.g., body piercing, tattooing, part of a religious
or cultural ritual) and is not restricted to picking a scab or nail biting.
E. The behavior or its consequences cause clinically significant distress or interference in
interpersonal, academic, or other important areas of functioning.
F. The behavior does not occur exclusively during psychotic episodes, delirium, sub-
stance intoxication, or substance withdrawal. In individuals with a neurodevelopmental
disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior
is not better explained by another mental disorder or medical condition (e.g., psychotic
disorder, autism spectrum disorder, intellectual disability, Lesch-Nyhan syndrome, ste-
reotypic movement disorder with self-injur y, trichotillomania [hair-pulling disorder], ex-
coriation [skin-picking] disorder).


804 Conditions for Further Study
Diagnostic Features
The essential feature of nonsuicidal self-injur y is that the individual repeatedly inflicts
shallow, yet painful injuries to the surface of  his or her body. Most commonly, the purpose
is to reduce negative emotions, such as tensio n, anxiety, and self-reproach, and/or to re-
solve an interpersonal difficulty. In some cases, the injury is conceived of as a deserved
self-punishment. The individual will often report  an immediate sensation of relief that oc-
curs during the process. When the behavior o ccurs frequently, it mi ght be associated with
a sense of urgency and craving, the resultant behavioral pattern resembling an addiction.
The inflicted wounds can become deeper and more numerous.
The injury is most often inflicted with a knif e, needle, razor, or other sharp object. Com-
mon areas for injury include the frontal area of the thighs and the dorsal side of the forearm.
A single session of injury might involve a se ries of superficial, parallel cuts—separated by
1 or 2 centimeters—on a visible or accessible location. The resulting cuts will often bleed and
will eventually leave a characteristic pattern of scars.
Other methods used include stabbing an area , most often the upper arm, with a needle
or sharp, pointed knife; inflicti ng a superficial burn with a lit cigarette end; or burning the
skin by repeated rubbing with an eraser. En gagement in nonsuicidal self-injury with mul-
tiple methods is associated with more severe  psychopathology, including engagement in
suicide attempts.
The great majority of individuals who engage in nonsuicidal self-injury do not seek
clinical attention. It is not known if this re flects frequency of engagement in the disorder,


because accurate reporting is seen as stigma tizing, or because the behaviors are experi-
enced positively by the individual who engages in them, who is unmotivated to receive
treatment. Young children might experiment wi th these behaviors but not experience re-
lief. In such cases, youths often report that  the procedure is painful or distressing and
might then discontinue the practice.
Development and Course
Nonsuicidal self-injury most often starts in the early teen years and can continue for many
years. Admission to hospital for nonsuicida l self-injury reaches a peak at 20–29 years of
age and then declines. However, research that  has examined age at hospitalization did not
provide information on age at onset of the behavior, and prospective research is needed to
outline the natural history of nonsuicidal self-injury and the factors that promote or in-
hibit its course. Individuals often learn of th e behavior on the recommendation or observa-
tion of another. Research has shown that wh en an individual who engages in nonsuicidal
self-injury is admitted to an inpatient unit, other individuals may begin to engage in the
behavior.
Risk and Prognostic Factors
Male and female prevalence rates of nonsuicida l self-injury are closer to each other than in
suicidal behavior disorder, in which the female-to-male ratio is about 3:1 or 4:1.
Two theories of psychopathology—based on functional behavioral analyses—have been
proposed: In the first, based on learning theo ry, either positive or negative reinforcement
sustains the behavior. Positive reinforcement might result fr om punishing oneself in a way
that the individual feels is de served, with the behavior induci ng a pleasant and relaxed state


that the individual feels is de served, with the behavior induci ng a pleasant and relaxed state
or generating attention and help from a signific ant other, or as an expression of anger. Neg-
ative reinforcement results from affect regula tion and the reduction of unpleasant emotions
or avoiding distressing thoughts, including th inking about suicide. In the second theory,
nonsuicidal self-injury is thought to be a form of self-punishment, in which self-punitive ac-
tions are engaged in to make up for acts that caused distress or harm to others.


Conditions for Further Study 805
Functional Consequences of  Nonsuicidal Self-Injury
The act of cutting might be performed with shared implements, raising the possibility of
blood-borne disease transmission.
Differential Diagnosis
Borderline personality disorder. As indicated, nonsuicidal se lf-injury has long been re-
garded as a “symptom” of borderline pers onality disorder, even though comprehensive
clinical evaluations have found that most individuals with nonsuicidal self-injury have
symptoms that also meet criteria for other di agnoses, with eating disorders and substance
use disorders being especially common. Histor ically, nonsuicidal self-injury was regarded
as pathognomonic of borderline personality d isorder. Both conditions are associated with
several other diagnoses. Although frequently  associated, borderline personality disorder
is not invariably found in individuals with no nsuicidal self-injury. The two conditions dif-
fer in several ways. Individuals with borderline personality disorder often manifest dis-
turbed aggressive and hostile behaviors, whereas nonsuicidal self-injury is more often
associated with phases of closeness, collaborati ve behaviors, and positive relationships. At
a more fundamental level, there are difference s in the involvement of different neurotrans-
mitter systems, but these will not be apparent on clinical examination.
Suicidal behavior disorder. The differentiation between nonsuicidal self-injury and sui-
cidal behavior disorder is base d either on the stated goal of  the behavior being a wish to
die (suicidal behavior disorder) or, in nonsuicidal self-injury, to experience relief as de-
scribed in the criteria. Depending on the ci rcumstances, individuals may provide reports
of convenience, and several studies report high  rates of false intent declaration. Individu-


of convenience, and several studies report high  rates of false intent declaration. Individu-
als with a history of frequent nonsuicidal se lf-injury episodes have learned that a session
of cutting, while painful, is, in the short-term, largely benign. Be cause individuals with
nonsuicidal self-injury can and do attempt and commit suicide,  it is important to check
past history of suicidal behavior and to ob tain information from a third party concerning
any recent change in stress exposure and mo od. Likelihood of suicide intent has been as-
sociated with the use of multiple  previous methods of self-harm.
In a follow-up study of cases of “self-harm” in males treated at one of several multiple
emergency centers in the United Kingdom, in dividuals with nonsuicidal self-injury were
significantly more likely to commit suicide th an other teenage individuals drawn from the
same cohort. Studies that have examined the relationship be tween nonsuicidal self-injury
and suicidal behavior disorder  are limited by being retrospe ctive and failing to obtain ver-
ified accounts of the method used during pr evious “attempts.” A significant proportion of
those who engage in nonsuicidal self-injury have responded positively when asked if they
have ever engaged in self-cutti ng (or their preferred means of self-injury) with an intention
to die. It is reasonable to co nclude that nonsuicidal self-injury, while not presenting a high
risk for suicide when first manifested, is an  especially dangerous form of self-injurious
behavior.
This conclusion is also supported by a mult isite study of depressed adolescents who had
previously failed to respond to  antidepressant medi cation, which noted th at those with pre-


vious nonsuicidal self-inj ury did not respond to cognitive-behavioral therapy,  and by a study
that found that nonsuicida l self-injury is a predicto r of substance use/misuse.
Trichotillomania (hair-pulling disorder). Trichotillomania is an injurious behavior con-
fined to pulling out one’s own hair, most commonly from the sc alp, eyebrows, or eyelashes.
The behavior occurs in “sessions” that can last fo r hours. It is most likely to occur during a
period of relaxation or distraction.


806 Conditions for Further Study
Stereotypic self-injury. Stereotypic self-injury, which can include head banging, self-
biting, or self-hitting, is usually associated with intense concentration or under conditions
of low external stimulation and might be associated with developmental delay.
Excoriation (skin-picking) disorder. Excoriation disorder occurs mainly in females and
is usually directed to picking at an area of th e skin that the individual feels is unsightly or
a blemish, usually on the face or the scalp. As in nonsuicidal self-injury, the picking is often
preceded by an urge and is experienced as pleasurable, even thoug h the individual real-
izes that he or she is harming himself or hersel f. It is not associated with the use of any im-
plement.


APPENDIX
Highlights of Changes From DSM-IV to DSM-5  . . . . . . . . . . . . . . . . . . .809
Glossary of Technical Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .817
Glossary of Cultural Concepts of Distress  . . . . . . . . . . . . . . . . . . . . . . .833
Alphabetical Listing of DSM-5 Diagnoses and Codes
(ICD-9-CM and ICD-10-CM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .839
Numerical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM) . . . . . .863
Numerical Listing of DSM-5 Diagnoses and Codes (ICD-10-CM) . . . . .877
DSM-5 Advisors and Other Contributors. . . . . . . . . . . . . . . . . . . . . . . . .897


809Highlights of Changes From
DSM-IV to DSM-5
Changes made to DSM-5  diagnostic criteria and text s are outlined in this chapter
in the same order in which they appear in the DSM-5 classification. This abbreviated descrip-
tion is intended to orient readers to only the most significant changes in each disorder cate-
gory. An expanded description of nearly all changes (e.g., except minor text or wording
changes needed for clarity) is available online (www.psychiatry.org/ds m5). It should also be
noted that Section I contains a description of changes pertaining to the chapter organization
in DSM-5, the multiaxial sy stem, and the introduction of dimensional assessments.
Neurodevelopmental Disorders
The term mental retardation  was used in DSM-IV. However, intellectual disability (intel-
lectual developmental disorder)  is the term that has come into common use over the past
two decades among medical, ed ucational, and other professi onals, and by the lay public
and advocacy groups. Diagnostic criteria em phasize the need for an assessment of both
cognitive capacity (IQ) and adaptive functionin g. Severity is determined by adaptive func-
tioning rather than IQ score.
The communication disorders,  which are newly named from DSM-IV phonological dis-
order and stuttering, respectively, include language disorder  (which combines the previous
expressive and mixed receptive-ex pressive language disorders), speech sound disorder  (pre-
viously phonological disorder), and childhood-onset fluency disorder  (previously stutter-
ing). Also included is social (pragmatic) communication disorder,  a new condition involving
persistent difficulties in the social us es of verbal and nonverbal communication.
Autism spectrum disorder  is a new DSM-5 disorder encompassing the previous DSM-


Autism spectrum disorder  is a new DSM-5 disorder encompassing the previous DSM-
IV autistic disorder (autism), Asperger’s disorder, childhood disi ntegrative disorder,
Rett’s disorder, and pervasive developmental di sorder not otherwise specified. It is char-
acterized by deficits in two core domains: 1) deficits in social communication and social in-
teraction and 2) restricted repetitive patterns of behavior, interests, and activities.
Several changes have been made to the diagnostic criteria for attention-deficit/hyperactiv-
ity disorder  (ADHD). Examples have been added to the criterion items to facilitate application
across the life span; the age at onset descri ption has been changed (from “some hyperactive-
impulsive or inattentive symptoms that caused impairment were present before age 7 years”
to “Several inattentive or hy peractive-impulsive symptoms we re present prior to age 12”);
subtypes have been replaced with presentation specifiers that map directly to the prior sub-
types; a comorbid diagnosis with autism spec trum disorder is now allowed; and a symptom
threshold change has been made for adults, to reflect the substantial evidence of clinically sig-
nificant ADHD impairment, with the cutoff for ADHD of five symptoms, instead of six re-
quired for younger persons, both for inatte ntion and for hyperactivity and impulsivity.
Specific learning disorder  combines the DSM-IV diagnose s of reading disorder, math-
ematics disorder, disorder of  written expression, and lear ning disorder not otherwise
specified. Learning deficits in the areas of  reading, written expr ession, and mathematics
are coded as separate specifiers. Acknowledgment  is made in the text that specific types of
reading deficits are described internationally in various ways as dyslexia  and specific types


reading deficits are described internationally in various ways as dyslexia  and specific types
of mathematics deficits as dyscalculia.


810 Highlights of Changes From DSM-IV to DSM-5
The following motor disorders  are included in DSM-5: deve lopmental coordination disor-
der, stereotypic movement disorder, Tourette’s disorder, persistent (chronic) motor or vocal
tic disorder, provisional tic disorder, other spec ified tic disorder, and un specified tic disorder.
The tic criteria have been standardized across all of these disorders in this chapter.
Schizophrenia Spectrum and Other Psychotic Disorders
Two changes were made to Criterion A for schizophrenia:  1) the elimination of the special at-
tribution of bizarre delusions and Schneiderian fi rst-rank auditory hallucinations (e.g., two or
more voices conversing), leadin g to the requirement of at least two Criterion A symptoms for
any diagnosis of schizophrenia, and 2) the addition  of the requirement that at least one of the
Criterion A symptoms must be delusions, hallu cinations, or disorganized speech. The DSM-IV
subtypes of schizophrenia were eliminated due to their limited diagnostic stability, low reli-
ability, and poor validity. Instead, a dimensional approach to rating severity for the core symp-
toms of schizophrenia is includ ed in DSM-5 Section III to capt ure the important heterogeneity
in symptom type and severity  expressed across individual s with psychotic disorders.
Schizoaffective disorder  is reconceptualized as a longitudin al instead of a cross-sectional di-
agnosis—more comparable to schizophrenia, bipolar disorder, and majo r depressive disorder,
which are bridged by this condition—and requires  that a major mood episode be present for a
majority of the total disorder ’s duration after Criterion A has been met. Criterion A for delu-
sional disorder no longer has the requirement that th e delusions must be nonbizarre; a spec-


ifier is now included for bizarre type delusions to provide continuity with DSM-IV. Criteria for
catatonia are described uniformly across DSM-5. Fu rthermore, catatonia may be diagnosed
with a specifier (for depressive, bipolar, and psychotic disorders, incl uding schizophrenia), in
the context of a known medical condition,  or as an other specified diagnosis.
Bipolar and Related Disorders
Diagnostic criteria for bipolar disorders  now include both changes in mood and changes in
activity or energy. The DSM-IV diagnosis of bipolar I disorder, mixed episodes—requiring
that the individual simultaneous ly meet full criteria for both mania and major depressive ep-
isode—is replaced with a new specifier “with mixed features.” Particular conditions can
now be diagnosed under other specified bipolar and related disorder, including categori-
zation for individuals with a past history of  a major depressive di sorder whose symptoms
meet all criteria for hypomania except the duration criterion is  not met (i.e., the episode lasts
only 2 or 3 days instead of the required 4 cons ecutive days or more). A second condition con-
stituting an other specified bipolar and related disorder variant is that too few symptoms of
hypomania are present to meet criteria for the full bipolar II syndrome, although the dura-
tion, at least 4 consecutive days, is sufficient. Finally, in both this chapter and in the chapter
“Depressive Disorders,” an anxious distress specifier is delineated.
Depressive Disorders
To address concerns about potential overdiagno sis and overtreatment of bipolar disorder in
children, a new diagnosis, disruptive mood dysregulation disorder,  is included for children
up to age 18 years who exhibit persistent irrita bility and frequent episodes of extreme behav-


ioral dyscontrol. Premenstrual dysphoric disorder  is now promoted from Appendix B, “Cri-
teria Sets and Axes Provided for Further Study, ” in DSM-IV to the main body of DSM-5. What
was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive
disorder,  which includes both chronic major depre ssive disorder and the previous dysthymic


was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive
disorder,  which includes both chronic major depre ssive disorder and the previous dysthymic
disorder. The coexistence within a major depressive episode  of at least three manic symp-
toms (insufficient to satisfy cr iteria for a manic episode) is no w acknowledged by the specifier


Highlights of Changes From DSM-IV to DSM-5 811
“with mixed features.” In DSM-IV, there was an exclusion criterion for a major depressive ep-
isode that was applied to depressive symptoms lasting less than 2 months following the death
of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several
reasons, including the recognitio n that bereavement is a severe psychosocial stressor that can
precipitate a major depressive episode in a vu lnerable individual, generally beginning soon
after the loss, and can add an additional risk for suffering, feelings of worthlessness, suicidal
ideation, poorer medical health, and worse interp ersonal and work functioning. It was critical
to remove the implication that bereavement ty pically lasts only 2 months, when both physi-
cians and grief counselors recognize that the duration is more commonly 1–2 years. A detailed
footnote has replaced the more simplistic DSM- IV exclusion to aid clinicians in making the
critical distinction between the symptoms characteristic of be reavement and those of a major
depressive disorder. Finally, a new specifier to  indicate the presence of mixed symptoms has
been added across both the bipo lar and the depressive disorders.
Anxiety Disorders
The chapter on anxiety disorders no longer includes obsessive-compulsive disorder (which
is in the new chapter “Obsessive-Compulsiv e and Related Disorders”) or posttraumatic
stress disorder (PTSD) and acut e stress disorder (which are in the new chapter “Trauma-
and Stressor-Related Disorders”). Changes in criteria for specific phobia  and social anxiety
disorder (social phobia)  include deletion of the requirement that individuals over age 18
years recognize that their anxiet y is excessive or unreasonable . Instead, the anxiety must be


years recognize that their anxiet y is excessive or unreasonable . Instead, the anxiety must be
out of proportion to the actual danger or threat  in the situation, after cultural contextual fac-
tors are taken into account. In addition, the 6-month duration is now extended to all ages.
Panic attacks  can now be listed as a specifier that is applicable to all DSM-5 disorders. Panic
disorder  and agoraphobia  are unlinked in DSM-5. Thus, the former DSM-IV diagnoses of
panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia
without history of panic disorder are now replaced by two diagnoses, panic disorder and ag-
oraphobia, each with separate crit eria. The “generalized” specifier for social anxiety disor-
der has been deleted and replaced with a “performance only” specifier. Separation anxiety
disorder  and selective mutism  are now classified as anxiety di sorders. The wording of the
criteria is modified to more adequately repres ent the expression of se paration anxiety symp-
toms in adulthood. Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that
onset must be before age 18 years, and a duration statement—“typically lasting for 6 months
or more”—has been added for adults to minimize overdia gnosis of transient fears.
Obsessive-Compulsive and Related Disorders
The chapter “Obsessive-Compulsive and Related Disorders” is new in DSM-5. New disor-
ders include hoarding disorder, excoriation (skin-pi cking) disorder, substance/medica-
tion-induced obsessive-compulsive and related disorder,  and obsessive-compulsive and
related disorder due to another medical condition.  The DSM-IV diagnosis of trichotillo-


mania is now termed trichotillomania (hair-pulling disorder) and has been moved from a
DSM-IV classification of impulse-control di sorders not elsewhere classified to obsessive-
compulsive and related disorders in DSM-5. The DSM-IV “with poor insight” specifier for
obsessive-compulsive disorder  has been refined to allow a distinction between individuals
with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compul-
sive disorder beliefs (i.e., comp lete conviction that obsessive-compulsive disorder beliefs


with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compul-
sive disorder beliefs (i.e., comp lete conviction that obsessive-compulsive disorder beliefs
are true). Analogous “insight” specifiers have  been included for body dysmorphic disorder
and hoarding disorder. A “tic-related” specifier for obsessive-compuls ive disorder has also
been added, because presence of a comorbid tic disorder may have important clinical im-
plications. A “muscle dy smorphia” specifier for body dysmorphic disorder  is added to re-
flect a growing literature on the diagnostic validity and clinical utility of making this


812 Highlights of Changes From DSM-IV to DSM-5
distinction in individuals with body dysmorphic disorder. The delusional variant of body
dysmorphic disorder (which identifies individu als who are completely convinced that their
perceived defects or flaws are truly abnormal ap pearing) is no longer coded as both delu-
sional disorder, somatic type, and body dysmorph ic disorder; in DSM-5, this presentation is
designated only as body dysmorphic disorder with the absent insight/delusional specifier.
Individuals can also be diagnosed with other specified obsessive-compulsive and related
disorder, which can include conditions such as body-focused repetitive behavior disorder
and obsessional jealousy, or unspecified obsessive-compulsive and related disorder.
Trauma- and Stressor-Related Disorders
For a diagnosis of acute stress disorder,  qualifying traumatic events are now explicit as to
whether they were experienced directly, witnessed, or experienced indirectly. Also, the
DSM-IV Criterion A2 regarding the subjective reaction to th e traumatic event (e.g., expe-
riencing “fear, helplessness, or  horror”) has been eliminated. Adjustment disorders  are
reconceptualized as a heterogeneous array of  stress-response syndromes that occur after
exposure to a distressing (traum atic or nontraumatic) event, rather than as a residual cat-
egory for individuals who exhibit clinically  significant distress but whose symptoms do
not meet criteria for a more d iscrete disorder (as in DSM-IV).
DSM-5 criteria for PTSD differ significantly from the DS M-IV criteria. The stressor cri-
terion (Criterion A) is more ex plicit with regard to events that qualify as “traumatic” ex-
periences. Also, DSM-IV Criterion A2 (subje ctive reaction) has been eliminated. Whereas


there were three major symptom clusters in DSM-IV—reexperiencing, avoidance/numb-
ing, and arousal—there are no w four symptom clusters in DSM-5, because the avoidance/
numbing cluster is divided into two distinct clusters: avoidance and persistent negative al-
terations in cognitions and mood. This latter  category, which retains most of the DSM-IV
numbing symptoms, also includes new or re conceptualized symptoms, such as persistent
negative emotional states. The final cluster— alterations in arousal and reactivity—retains
most of the DSM-IV arousal symptoms. It also includes irritable behavior or angry out-
bursts and reckless or self-destructive beha vior. PTSD is now develo pmentally sensitive in
that diagnostic thresholds have been lowe red for children and adolescents. Furthermore,
separate criteria have been added for childre n age 6 years or younger with this disorder.
The DSM-IV childhood diagno sis reactive attachment di sorder had two subtypes:
emotionally withdrawn/inhibited and indiscri minately social/disinhibited. In DSM-5,
these subtypes are defined as distinct disorders: reactive attachment disorder  and disin-
hibited social engagement disorder.
Dissociative Disorders
Major changes in dissociative disorders in DS M-5 include the following: 1) derealization is
included in the name and symptom structure of what previously was called depersonali-
zation disorder ( depersonalization/derealization disorder ); 2) dissociative fugue is now a
specifier of dissociative amnesia rather than a separate diagnosis, and 3) the criteria for
dissociative identity disorder  have been changed to indicate that symptoms of disruption
of identity may be reported as well as observed, and that gaps in the recall of events may


of identity may be reported as well as observed, and that gaps in the recall of events may
occur for everyday and not just traumatic ev ents. Also, experiences of pathological pos-
session in some cultures are included in the description of identity disruption.
Somatic Symptom and Related Disorders
In DSM-5, somatoform disorders are now referred to as somatic symptom and related dis-
orders.  The DSM-5 classification reduces the number of these disorders and subcategories to
avoid problematic overlap. Diagnoses of somatization disorder, hypochondriasis, pain dis-


orders.  The DSM-5 classification reduces the number of these disorders and subcategories to
avoid problematic overlap. Diagnoses of somatization disorder, hypochondriasis, pain dis-
order, and undifferentiated somatoform diso rder have been removed. Individuals previ-


Highlights of Changes From DSM-IV to DSM-5 813
ously diagnosed with somatization disorder wi ll usually have sympto ms that meet DSM-5
criteria for somatic symptom disorder,  but only if they have th e maladaptive thoughts, feel-
ings, and behaviors that define the disorder, in addition to their somatic symptoms. Because
the distinction between somati zation disorder and undifferen tiated somatoform disorder
was arbitrary, they are merged in DSM-5 un der somatic symptom diso rder. Individuals pre-
viously diagnosed with hypochondriasis who have high health anxiety but no somatic symp-
toms would receive a DSM-5 diagnosis of illness anxiety disorder (unless their health
anxiety was better explained by  a primary anxiety disorder, su ch as generalized anxiety dis-
order). Some individuals with chronic pain w ould be appropriately di agnosed as having so-
matic symptom disorder, with predominant pain . For others, psychological factors affecting
other medical conditions or an adjustment disorder would be more appropriate.
Psychological factors affect ing other medical conditions  is a new mental disorder in
DSM-5, having formerly been listed in the DSM-IV chapter “Other Conditions That May
Be a Focus of Clinical At tention.” This disorder and factitious disorder  are placed among
the somatic symptom and related disorders because somatic symptoms are predominant
in both disorders, and both are most often en countered in medical settings. The variants of
psychological factors affecting other medical conditions are removed in favor of the stem
diagnosis. Criteria for conversion disorder (functional neurological symptom disorder)
have been modified to emphasize the essent ial importance of the neurological examina-
tion, and in recognition that relevant psychological factors may not be demonstrable at the
time of diagnosis. Other spec ified somatic symptom disorder , other specified illness anx-


time of diagnosis. Other spec ified somatic symptom disorder , other specified illness anx-
iety disorder, and pseudocyesis ar e now the only exemplars of the other specified somatic
symptom and related disorder classification.
Feeding and Eating Disorders
Because of the elimination of the DSM-IV-TR chapter “Disorders Us ually First Diagnosed
During Infancy, Childhood, or Adolescence,” th is chapter describes several disorders found in
the DSM-IV section “Feeding and Eating Disord ers of Infancy or Early Childhood,” such as
pica  and rumination disorder.  The DSM-IV category feeding disorder of infancy or early
childhood has been renamed avoidant/restrictive f ood intake disorder,  and the criteria are
significantly expanded. The core diagnostic criteria for anorexia nervosa  are conceptually un-
changed from DSM-IV with one exception: the requirement for amenorrhea is eliminated. As
in DSM-IV, individuals with this disorder are requ ired by Criterion A to be at a significantly
low body weight for their developmental stage.  The wording of the criterion is changed for
clarification, and guidan ce regarding how to judge whether an individual is at or below a sig-
nificantly low weight is provided in the text. In  DSM-5, Criterion B is expanded to include not
only overtly expressed fear of weight gain but also persistent behavior that interferes with
weight gain. The only change in the DSM-IV criteria for bulimia nervosa  is a reduction in the
required minimum average frequency of binge eating and inappropri ate compensatory be-
havior frequency from twice to once weekly. The extensive research that followed the prom-
ulgation of preliminary criteria for binge-eating disorder  in Appendix B of DSM-IV


ulgation of preliminary criteria for binge-eating disorder  in Appendix B of DSM-IV
documented the clinical utility and validity of binge-eating disorder. The only significant dif-
ference from the prelimin ary criteria is that the minimum average frequency of binge eating re-
quired for diagnosis is once weekly over the la st 3 months, identical to the frequency criterion
for bulimia nervosa (rather than at least 2 days a week for 6 months in DSM-IV).
Elimination Disorders


for bulimia nervosa (rather than at least 2 days a week for 6 months in DSM-IV).
Elimination Disorders
There have been no significant changes in this diagnostic class from DSM-IV to DSM-5.
The disorders in this chapter were previously  classified under disorders usually first di-
agnosed in infancy, childhood, or adolescenc e in DSM-IV and exist now as an independent
classification in DSM-5.


814 Highlights of Changes From DSM-IV to DSM-5
Sleep-Wake Disorders
In DSM-5, the DSM-IV diagnose s named sleep disorder related to another mental disorder
and sleep disorder related to another medica l condition have been removed, and instead
greater specification of coexisting conditions is provided for each sleep-wake disorder. The
diagnosis of primary insomnia has been renamed insomnia disorder  to avoid the differen-
tiation between primary and secondary insomnia. DSM-5 also distinguishes narcolepsy —
now known to be associated with hypocretin deficiency—from other forms of hypersomno-
lence (hypersomnolence disorder ). Finally, throughout the DSM-5 classification of sleep-
wake disorders, pediatric and developmental cr iteria and text are integrated where existing
science and considerations of clinical utility support such integration. Breathing-related
sleep disorders are divided into three relatively distinct disorders: obstructive sleep apnea
hypopnea, central sleep apnea, and sleep-related hypoventilation. The subtypes of circadian
rhythm sleep disorders  are expanded to include advanced  sleep phase type and irregular
sleep-wake type, whereas the jet lag type has b een removed. The use of the former “not oth-
erwise specified” diagnoses in DSM- IV have been reduced by elevating rapid eye move-
ment sleep behavior disorder  and restless legs syndrome  to independent disorders.
Sexual Dysfunctions
In DSM-5, some gender-specifi c sexual dysfunctions have been added, and, for females,
sexual desire and arousal disorders have  been combined into one disorder: female sexual
interest/arousal disorder.  All of the sexual dysfunctions (except substance/medication-in-
duced sexual dysfunction ) now require a minimum duration of approximately 6 months and
more precise severity criteria. Genito-pelvic pain/p enetration disorder  has been added to


DSM-5 and represents a merging of vaginismus and dyspareunia, which were highly co-
morbid and difficult to distinguish. The diagno sis of sexual aversion disorder has been re-
moved due to rare use and la ck of supporting research.
There are now only two subtyp es for sexual dysfunctions: lifelong versus  acquired
and generalized  versus situational.  To indicate the presence and degree of medical and
other nonmedical correlates, the following associated features  have been added to the text:
partner factors, relationship factors, individu al vulnerability factors, cultural or religious
factors, and medical factors.
Gender Dysphoria
Gender dysphoria  is a new diagnostic class in DSM-5 and reflects a change in conceptual-
ization of the disorder’s defining features by emphasizing the phenomenon of “gender in-
congruence” rather than cross-gender identification per se, as was the case in DSM-IV gender
identity disorder. Gender dyspho ria includes separate sets of criteria: for children and for
adults and adolescents. For the adolescents an d adults criteria, the previous Criterion A
(cross-gender identification) and Criterion B (aversion toward one’s gender) are merged. In
the wording of the criteria, “the other sex” is replaced by “the other gender” (or “some alter-
native gender”).” Gender  instead of sex is used systematically because the concept “sex” is in-
adequate when referring to individuals with a disorder of sex development. In the child
criteria, “strong desire to be of the other gend er” replaces the previous “repeatedly stated de-
sire to be...the other sex” to capture the situat ion of some children who, in a coercive envi-


ronment, may not verbalize the desire to be of  another gender. For child ren, Criterion A1 (“a
strong desire to be of the other gender or an in sistence that he or she is the other gender.. .)”
is now necessary (but not sufficient), which makes the diagnosi s more restrictive and conser-
vative. The subtyping on the basis of sexual or ientation is removed because the distinction is


is now necessary (but not sufficient), which makes the diagnosi s more restrictive and conser-
vative. The subtyping on the basis of sexual or ientation is removed because the distinction is
no longer considered clinically useful. A posttransition specifier  has been added to identify


Highlights of Changes From DSM-IV to DSM-5 815
individuals who have undergone at least one medical procedure or treatment to support the
new gender assignment (e.g., cross-sex hormon e treatment). Although the concept of post-
transition is modeled on the concept of full or partial remission, the term remission  has impli-
cations in terms of symptom reduction that do not apply directly to gender dysphoria.
Disruptive, Impulse-Control, and Conduct Disorders
The chapter “Disruptive, Impulse-Control, and Conduct Disorders” is new to DSM-5 and
combines disorders that were pr eviously included in the chapte r “Disorders Usually First Di-
agnosed in Infancy, Childhood, or Adolescence” (i.e., oppositional defiant disorder; conduct
disorder; and disruptive behavior disorder not otherwise specified, now categorized as other
specified and unspecified disrup tive, impulse-control, and cond uct disorders) and the chap-
ter “Impulse-Control Disorders Not Elsewhere Cl assified” (i.e., intermittent explosive disor-
der, pyromania, and kleptomania). These diso rders are all characterized by problems in
emotional and behavioral self-control. Notably,  ADHD is frequently comorbid with the dis-
orders in this chapter but is listed with the neurodevelopmental disorders. Because of its
close association with co nduct disorder, antisocial  personality disorder is listed both in this
chapter and in the chapter “Personality Diso rders,” where it is described in detail.
The criteria for oppositional defiant disorder  are now grouped into three types: an-
gry/irritable mood, argumentative/defiant be havior, and vindictiveness. Additionally,
the exclusionary criterion for conduct diso rder has been removed. The criteria for conduct


the exclusionary criterion for conduct diso rder has been removed. The criteria for conduct
disorder include a descriptive features specifier for individuals who meet full criteria for
the disorder but al so present with limited prosocial emotions. The primary change in in-
termittent explosive disorder  is in the type of aggressive outbursts that should be consid-
ered: DSM-IV required physical aggression, whereas in DSM-5 verbal aggression and
nondestructive/noninjurious physical aggression  also meet criteria. DSM-5 also provides
more specific criteria defining  frequency needed to meet the criteria and specifies that the
aggressive outbursts ar e impulsive and/or anger based in nature, and must cause marked
distress, cause impairment in occupational or interpersonal functioning, or be associated
with negative financial or legal consequences. Furthermore, a minimum age of 6 years (or
equivalent developmental level) is now required.
Substance-Related and Addictive Disorders
An important departure from past diagnostic ma nuals is that the chapter on substance-related
disorders has been expanded to include gambling disorder. Another key change is that
DSM-5 does not separate the diagnoses of substance abuse  and dependence  as in DSM-IV. Rather
criteria are provided for substance use disorder,  accompanied by criteria for intoxication,
withdrawal, substance-induced disorders, and unspecified substance-related disorders,
where relevant. Within substance use disorders,  the DSM-IV recurrent substance-related legal
problems criterion has been dele ted from DSM-5, and a new criter ion—craving, or a strong de-
sire or urge to use a substance—has been adde d. In addition, the thre shold for substance use
disorder diagnosis in DSM-5 is set at two or more  criteria, in contrast to a threshold of one or


more criteria for a diagnosis of DSM-IV substance abuse and three or more for DSM-IV depen-
dence. Cannabis withdrawal and caffeine withdrawal  are new disorders (the latter was in
DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study”).
Severity  of the DSM-5 substance use disorders is  based on the number of criteria en-
dorsed. The DSM-IV specifier fo r a physiological subtype is eliminated in DSM-5, as is the
DSM-IV diagnosis of polysubstance dependence. Early remission from a DSM-5 substance


dorsed. The DSM-IV specifier fo r a physiological subtype is eliminated in DSM-5, as is the
DSM-IV diagnosis of polysubstance dependence. Early remission from a DSM-5 substance
use disorder is defined as at least 3 but less than 12 months without meeting substance use
disorder criteria (except crav ing), and sustained remission is defined as at least 12 months
without meeting criteria (except craving). Additional new DSM-5 specifiers include “in a
controlled environment”  and “on maintenance therapy”  as the situation warrants.


816 Highlights of Changes From DSM-IV to DSM-5
Neurocognitive Disorders
The DSM-IV diagnoses of dementia and amnestic disorder are subsumed under the newly
named entity major neurocognitive disorder  (NCD). The term dementia  is not precluded from
use in the etiological subtypes where that te rm is standard. Furthermore, DSM-5 now recog-
nizes a less severe level of cognitive impairment, mild NCD,  which is a new disorder that per-
mits the diagnosis of less disabling syndromes that may nonetheless be the focus of concern
and treatment. Diagnostic criteria  are provided for both of these disorders, foll owed by diag-
nostic criteria for different etiological subtypes.  In DSM-IV, individual diagnoses were desig-
nated for dementia of the Alzheimer’s type , vascular dementia, and substance-induced
dementia, whereas the other neurodegenerative disorders were classified as dementia due to
another medical condition, with HIV, head trauma, Parkinson’s disease, Huntington’s disease,
Pick’s disease, Creutzfeldt-Jako b disease, and other medical co nditions specified. In DSM-5,
major or mild NCD due to Alzheimer’s disease and major or mild vascular NCD have been re-
tained, while new separate criteria are now presented for major or mild frontotemporal NCD,
NCD with Lewy bodies, and NCDs due to trau matic brain injury, a substance/medication,
HIV infection, prion disease, Parkinson’s diseas e, Huntington’s disease, another medical con-
dition, and multiple etiologies, respectively. Un specified NCD is also included as a diagnosis.
Personality Disorders
The criteria for personality disorders in Sectio n II of DSM-5 have not changed from those in


DSM-IV. An alternative approach to the diag nosis of personality di sorders was developed
for DSM-5 for further study and can be found in Section III (see “Alternative DSM-5 Model
for Personality Disorders”). For the general criteria for personality disorder, presented  in
Section III, a revised personality functioning criterion (Criterion A) has been developed
based on a literature review of reliable clinical  measures of core impa irments central to per-
sonality pathology. A diagnosis of personality disorder—trait specified,  based on moderate
or greater impairment in person ality functioning and the presence of pathological personal-
ity traits, replaces personality disorder not ot herwise specified and prov ides a much more in-
formative diagnosis for individuals who are not optimally described as having a specific
personality disorder. A greater emphasis on pe rsonality functioning and trait-based criteria
increases the stability and empiri cal bases of the disorders. Personality functioning and per-
sonality traits  also can be assessed whether or not the individual has a personality disor-
der—a feature that provides clinically useful information about all individuals.
Paraphilic Disorders
An overarching change from DSM-IV is the addition of the course specifiers “in a controlled
environment”  and “in remission”  to the diagnostic criteria se ts for all the paraphilic disor-
ders. These specifiers are added to indicate important changes in an individual’s status. In
DSM-5, paraphilias are not ipso facto  mental disorders. There is a distinction between paraphil-
ias and paraphilic disorders. A paraphilic disorder is a paraphilia that is currently causing dis-
tress or impairment to the individual or a pa raphilia whose satisfaction has entailed personal


tress or impairment to the individual or a pa raphilia whose satisfaction has entailed personal
harm, or risk of harm, to others. A paraphilia is a necessary but not a sufficient condition for
having a paraphilic disorder, and a paraphilia by it self does not automatically justify or require
clinical intervention. The distinction between paraphilias and paraphilic disorders was im-
plemented without making any changes to the basi c structure of the diagnostic criteria as they
had existed since DSM-III-R. Th e change proposed for DSM-5 is that individuals who meet


plemented without making any changes to the basi c structure of the diagnostic criteria as they
had existed since DSM-III-R. Th e change proposed for DSM-5 is that individuals who meet
both Criterion A and Criterion B would now be diagnosed as having a paraphilic disorder. A
diagnosis would not be given to  individuals whose symptoms meet Criterion A but not Cri-
terion B—that is, to individuals who have  a paraphilia but not a paraphilic disorder.


817Glossary of
 Technical Terms
affect A pattern of observable behaviors that is the expression of a subjectively experi-
enced feeling state (emotion). Examples of af fect include sadness, elation, and anger. In
contrast to mood,  which refers to a pervasive and sustained emotional “climate,” affect
refers to more fluctuating changes in emot ional “weather.” What is considered the nor-
mal range of the expression of affect varies  considerably, both within and among dif-
ferent cultures. Disturba nces in affect include
blunted Significant reduction in the inte nsity of emotional expression.
flat Absence or near absence of an y sign of affective expression.
inappropriate Discordance between affective expression and the content of speech
or ideation.
labile Abnormal variability in affect with repeated, rapid, and abrupt shifts in af-
fective expression.
restricted or constricted Mild reduction in the range and intensity of emotional ex-
pression.
affective blunting See AFFECT .
agitation (psychomotor) See PSYCHOMOTOR  AGITATION .
agnosia Loss of ability to recognize objects, persons, sounds, shapes, or smells that occurs
in the absence of either impairment of the specific sense or significant memory loss.
alogia An impoverishment in thinking that is inferred from observing speech and lan-
guage behavior. There may be brief and concre te replies to questions and restriction in
the amount of spontaneous speech (termed poverty of speech ). Sometimes the speech is
adequate in amount but conveys little inform ation because it is overconcrete, overab-
stract, repetitive, or stereotyped (termed poverty of content ).
amnesia An inability to recall important autobiog raphical information that is inconsis-
tent with ordinary forgetting.


tent with ordinary forgetting.
anhedonia Lack of enjoyment from, engagement in , or energy for life’s experiences; def-
icits in the capacity to feel pleasure and take interest in things. Anhedonia is a facet of
the broad personality trait domain D ETACHMENT .
anosognosia A condition in which a person with an illness seems unaware of the exis-
tence of his or her illness.
antagonism Behaviors that put an individual at od ds with other people, such as an ex-
aggerated sense of self-importance with a concomitant expectation of special treat-
ment, as well as a callous antipathy toward others, encompassing both unawareness of
others’ needs and feelings, and a readiness to use others in the service of self-enhance-
ment. Antagonism is one of the five broad PERSONALITY  TRAIT  DOMAINS  defined in Sec-
tion III “Alternative DSM-5 Mo del for Personality Disorders.”
SMALL  CAPS  indicate term found elsewhere in this glossary. Glossary definitions were informed by
DSM-5 Work Groups, publicly available Internet so urces, and previously published glossaries for
mental disorders (World Heal th Organization and American  Psychiatric Association).


818 Glossary of Technical Terms
antidepressant discontinuation syndrome A set of symptoms that can occur after
abrupt cessation, or marked reduction in dose, of an antidepressant medication that
had been taken continuously for at least 1 month.
anxiety The apprehensive anticipation of future  danger or misfortune accompanied by
a feeling of worry, distress, an d/or somatic symptoms of tension. The focus of antici-
pated danger may be internal or external.
anxiousness Feelings of nervousness or tenseness in reaction to diverse situations; frequent
worry about the negative effect s of past unpleasant experiences and future negative possi-
bilities; feeling fearful and apprehensive about uncertainty; expecting the worst to happen.
Anxiousness is a facet of the broad personality trait domain N EGATIVE  AFFECTIVITY .
arousal The physiological and psychological state of  being awake or reactive to stimuli.
asociality A reduced initiative for interacting with other people.
attention The ability to focus in a sustained manner on a particular stimulus or activity.
A disturbance in attention ma y be manifested by easy DISTRACTIBILITY  or difficulty in
finishing tasks or in concentrating on work.
attention seeking Engaging in behavior designed to attract notice and to make oneself
the focus of others’ attention and admiration . Attention seeking is a facet of the broad
personality trait domain ANTAGONISM .
autogynephilia Sexual arousal of a natal male associated with the idea or image of being
a woman.
avoidance The act of keeping away from stress-rela ted circumstances; a tendency to cir-
cumvent cues, activities, and situations that remind the individual of a stressful event
experienced.
avolition An inability to initiate and persist in go al-directed activities . When severe enough
to be considered pathological, avolition is pervasive and prevents the person from com-


to be considered pathological, avolition is pervasive and prevents the person from com-
pleting many different types of activities (e.g., work, intellectual pursuits, self-care).
bereavement The state of having lost through death someone with whom one has had
a close relationship. This state includes a range of grief and mourning responses.
biological rhythms See CIRCADIAN  RHYTHMS .
callousness Lack of concern for the feelings or problems of others; lack of guilt or re-
morse about the negative or harmful effects of one’s actions on others. Callousness is a
facet of the broad personality trait domain ANTAGONISM .
catalepsy Passive induction of a posture held  against gravity. Compare with WAXY  FLEX -
IBILITY .
cataplexy Episodes of sudden bilateral loss of mu scle tone resulting in the individual
collapsing, often occurring in association wi th intense emotions such as laughter, an-
ger, fear, or surprise.
circadian rhythms Cyclical variations in physiological and biochemical function, level
of sleep-wake activity, and emotional state. Circadian rhythms have a cycle of about 24
hours, ultradian rhythms have a cycle that is shorter than 1 day, and infradian rhythms
have a cycle that may last weeks or months.
cognitive and perceptual dysregulation Odd or unusual thought processes and experi-
ences, including DEPERSONALIZATION , DEREALIZATION , and DISSOCIATION ; mixed sleep-
wake state experiences; and thought-cont rol experiences. Cognitive and perceptual
dysregulation is a facet of the broad personality trait domain P SYCHOTICISM .
coma State of complete loss of consciousness.


Glossary of Technical Terms 819
compulsion Repetitive behaviors (e.g., hand wash ing, ordering, checking) or mental
acts (e.g., praying, counting, repeating word s silently) that the individual feels driven
to perform in response to an obsession, or according to rules that must be applied rig-
idly. The behaviors or mental acts are aimed at preventing or redu cing anxiety or dis-
tress, or preventing some dreaded event or situation; however, these behaviors or
mental acts are not connected in a realistic way with what they are designed to neutral-
ize or prevent or are clearly excessive.
conversion symptom A loss of, or alteration in, voluntary motor or sensory functioning,
with or without apparent impairment of consciousness. The symptom is not fully ex-
plained by a neurological or another medical condition or the direct effects of a sub-
stance and is not intentiona lly produced or feigned.
deceitfulness Dishonesty and fraudulence; misrep resentation of self; embellishment or
fabrication when relating even ts. Deceitfulness is a facet of the broad personality trait
domain A NTAGONISM .
defense mechanism Mechanisms that mediate the indi vidual´s reaction to emotional
conflicts and to external stressors. Some defense mechanisms (e.g., projection, splitting,
acting out) are almost invariably maladapt ive. Others (e.g., suppression, denial) may
be either maladaptive or adaptive, dependin g on their severity, their inflexibility, and
the context in which they occur.
delusion A false belief based on incorrect inferenc e about external reality that is firmly
held despite what almost everyone else beli eves and despite what constitutes incontro-
vertible and obvious proof or evidence to th e contrary. The belief is not ordinarily ac-


vertible and obvious proof or evidence to th e contrary. The belief is not ordinarily ac-
cepted by other members of the person’s culture or subculture (i.e., it is not an article of
religious faith). When a false belief involves a value judgment, it is regarded as a delusion
only when the judgment is so extreme as to defy credibility. Delusional conviction can
sometimes be inferred from an overvalued idea (in which case the individual has an un-
reasonable belief or idea but does not hold it as firmly as is the case with a delusion). De-
lusions are subdivided according to thei r content. Common types are listed below:
bizarre A delusion that involves a phenomenon that the person’s culture would re-
gard as physically impossible.
delusional jealousy A delusion that one’s sexual partner is unfaithful.
erotomanic A delusion that another person, usually of higher status, is in love with
the individual.
grandiose A delusion of inflated worth, power, knowledge, identity, or special re-
lationship to a deity or famous person.
mixed type Delusions of more than one type (e.g., EROTOMANIC , GRANDIOSE , PERSE -
CUTORY , SOMATIC ) in which no one theme predominates.
mood-congruent See MOOD -CONGRUENT  PSYCHOTIC  FEATURES .
mood-incongruent See MOOD -INCONGRUENT  PSYCHOTIC  FEATURES .
of being controlled A delusion in which feelings, impulses, thoughts, or actions
are experienced as being under the control of some external force rather than be-
ing under one’s own control.
of reference A delusion in which events, objects, or other persons in one’s immedi-


of reference A delusion in which events, objects, or other persons in one’s immedi-
ate environment are seen as having a particular and unusual significance. These
delusions are usually of a negative or pejo rative nature but also may be grandiose
in content. A delusion of reference differs from an idea of reference,  in which the
false belief is not as firmly held nor as fully organized into a true belief.
persecutory A delusion in which the central theme is that one (or someone to whom
one is close) is being attacked, harassed, cheated, persecuted, or conspired against.


820 Glossary of Technical Terms
somatic A delusion whose main content pertains  to the appearance or functioning
of one’s body.
thought broadcasting A delusion that one’s thoughts are being broadcast out loud
so that they can be perceived by others.
thought insertion A delusion that certain of one’s thoughts are not one´s own, but
rather are inserted into one’s mind.
depersonalization The experience of feeling detached from, and as if one is an outside
observer of, one’s mental processes, body, or  actions (e.g., feeling like one is in a dream;
a sense of unreality of self, perceptual al terations; emotional and/or physical numbing;
temporal distortions; sense of unreality).
depressivity Feelings of being intensely sad, mise rable, and/or hopeless. Some patients
describe an absence of feelings and/or dy sphoria; difficulty recovering from such
moods; pessimism about the fu ture; pervasive shame and/or guilt; feelings of inferior
self-worth; and thoughts of suicide and suicid al behavior. Depressivity is a facet of the
broad personality trait domain D ETACHMENT .
derealization The experience of feeling detached from, and as if one is an outside ob-
server of, one’s surroundings  (e.g., individuals or obje cts are experienced as unreal,
dreamlike, foggy, lifeless, or visually distorted).
detachment Avoidance of socioemotional experience, including both WITHDRAWAL  from
interpersonal interactions (rangi ng from casual, daily interactions to friendships and inti-
mate relationships [i.e., INTIMACY  AVOIDANCE ]) and RESTRICTED  AFFECTIVITY , particularly
limited hedonic capacity. Detachment is one of the five pathological PERSONALITY  TRAIT


limited hedonic capacity. Detachment is one of the five pathological PERSONALITY  TRAIT
DOMAINS  defined in Section III “Alternative DSM-5 Model for Personality Disorders.”
disinhibition Orientation toward immediate gratification, leading to impulsive behav-
ior driven by current thoughts, feelings, an d external stimuli, without regard for past
learning or consideration of future consequences. R IGID PERFECTIONISM , the opposite
pole of this domain, reflects  excessive constraint of impu lses, risk avoidance, hyper-
responsibility, hyperperfectio nism, and rigid, rule-govern ed behavior. Disinhibition
is one of the five pathological PERSONALITY  TRAIT  DOMAINS  defined in Section III “Al-
ternative DSM-5 Model for Personality Disorders.”
disorder of sex development Condition of significant inborn somatic deviations of the
reproductive tract from the norm and/or of  discrepancies among the biological indica-
tors of male and female.
disorientation Confusion about the time of day, date, or season (time); where one is
(place); or who one is (person).
dissociation The splitting off of clusters of ment al contents from conscious awareness.
Dissociation is a mechanism central to dissocia tive disorders. The term is also used to
describe the separation of an idea from its emotional significance and affect, as seen in
the inappropriate affect in schizophrenia. Of ten a result of psychic trauma, dissociation
may allow the individual to maintain allegiance to two contradictory truths while re-
maining unconscious of the contradiction. An extreme manifestatio n of dissociation is
dissociative identity disorder, in which a person may exhibit several independent per-
sonalities, each unaware of the others.
distractibility Difficulty concentrating and focusing on  tasks; attention is easily divert-


distractibility Difficulty concentrating and focusing on  tasks; attention is easily divert-
ed by extraneous stimuli; difficulty main taining goal-focused behavior, including both
planning and completing tasks. Distractibilit y is a facet of the broad personality trait
domain D ISINHIBITION .
dysarthria A disorder of speech sound production due to structural or motor impair-
ment affecting the articulatory apparatus. Such disorders include cleft palate, muscle


Glossary of Technical Terms 821
disorders, cranial nerve disorders, and cerebr al palsy affecting bulbar structures (i.e.,
lower and upper motor neuron disorders).
dyskinesia Distortion of voluntary movements with involuntary muscle activity.
dysphoria (dysphoric mood) A condition in which a person experiences intense feelings
of depression, discontent, and in some case s indifference to th e world around them.
dyssomnias Primary disorders of sleep or wakefulness characterized by INSOMNIA  or
HYPERSOMNIA  as the major presenting symptom.  Dyssomnias are disorders of the
amount, quality, or timing of sleep. Compare with PARASOMNIAS .
dysthymia Presence, while depressed, of two or more of the following: 1) poor appetite
or overeating, 2) insomnia or hypersomnia, 3) low energy or fatigue, 4) low self-esteem,
5) poor concentration or difficulty making decisions, or 6) feelings of hopelessness.
dystonia Disordered tonicity of muscles.
eccentricity Odd, unusual, or bizarre behavior , appearance, and/or speech having
strange and unpredictable thoughts; saying un usual or inappropriate things. Eccentric-
ity is a facet of the broad personality trait domain P SYCHOTICISM .
echolalia The pathological, parrotlike, and apparently senseless repetition (echoing) of
a word or phrase just spoken by another person.
echopraxia Mimicking the movements of another.
emotional lability Instability of emotional experience s and mood; emotions that are
easily aroused, intense, and/or out of proportion to events and circumstances. Emo-
tional lability is a facet of the broad personality trait domain NEGATIVE  AFFECTIVITY .


empathy Comprehension and appreciation of othe rs’ experiences and motivations; tol-
erance of differing perspectives; understand ing the effects of own behavior on others.
episode (episodic) A specified duration of time during which the patient has developed or
experienced symptoms that meet the diagnostic  criteria for a given mental disorder. De-
pending on the type of mental disorder, episode  may denote a certain number of symptoms
or a specified severity or frequency of symptoms. Episodes may be further differentiated
as a single (first) episode or a recurrence or relapse of mult iple episodes if appropriate.
euphoria A mental and emotional condition in wh ich a person experiences intense feel-
ings of well-being, elation, happiness, excitement, and joy.
fatigability Tendency to become easily fatigued. See also  FATIGUE .
fatigue A state (also called exhaustion, tiredness, lethargy, languidness, languor, lassi-
tude, and listlessness) usually associated with a weakening or depletion of one’s phys-
ical and/or mental resources,  ranging from a general state of lethargy to a specific,
work-induced burning sensation within one’s muscles. Physical fatigue leads to an in-
ability to continue functioning at one’s norm al level of activity. Although widespread
in everyday life, this state usually becomes particularly noticeable during heavy exer-
cise. Mental fatigue, by contrast, most often manifests as SOMNOLENCE  (sleepiness).
fear An emotional response to perceived imminent threat or danger associated with
urges to flee or fight.
flashback A dissociative state during which aspe cts of a traumatic event are reexperi-
enced as though they were occurring at that moment.
flight of ideas A nearly continuous flow of accele rated speech with abrupt changes


flight of ideas A nearly continuous flow of accele rated speech with abrupt changes
from topic to topic that are usually based on understandable associations, distracting
stimuli, or plays on words. When the cond ition is severe, speech may be disorganized
and incoherent.