Frotteuristic Disorder 693
10%–14% of adult males seen in outpatient se ttings for paraphilic disorders and hypersex-
uality have a presentation that meets diagnost ic criteria for frotteuristic disorder. Hence,
whereas the population prev alence of frotteuristic disorder  is unknown, it is not likely that
it exceeds the rate found in selected clinical settings.
Development and Course
Adult males with frotteuristic disorder often re port first becoming aware of their sexual in-
terest in surreptitiously touching unsuspecting persons during late adolescence or emerging
adulthood. However, children and adolescents may also touch or rub against unwilling oth-
ers in the absence of a diagnosis of frotteuris tic disorder. Although th ere is no minimum age
for the diagnosis, frotteuristic disorder can be difficult to di fferentiate from conduct-disor-
dered behavior without sexual motivation in individuals at younger ages. The persistence of
frotteurism over time is unclear. Frotteuristic disorder, however, by de finition requires one
or more contributing factors that may change over time with or without treatment: subjec-
tive distress (e.g., guilt, shame,  intense sexual frustration, loneliness); psychiatric morbidity;
hypersexuality and sexual impulsivity; psycho social impairment; and/ or the propensity to
act out sexually by touching or  rubbing against unconsenting persons. Therefore, the course
of frotteuristic disorder is like ly to vary with age. As with other sexual preferences, advanc-
ing age may be associated with decreasing fr otteuristic sexual preferences and behavior.
Risk and Prognostic Factors
Temperamental. Nonsexual antisocial behavior and sexual preoccupation/hypersexuality


Temperamental. Nonsexual antisocial behavior and sexual preoccupation/hypersexuality
might be nonspecific risk factors, although the causal relationship to frotteurism is uncertain
and the specificity unclear. However, frotteurism is a necessary precondition for frotteuristic
disorder, so risk factors for frot teurism should also increase the rate of frotteuristic disorder.
Gender-Related Diagnostic Issues
There appear to be substantially fewer female s with frotteuristic sexual preferences than
males.
Differential Diagnosis
Conduct disorder and antiso cial personality disorder. Conduct disorder in adolescents
and antisocial personality disorder would be  characterized by additional norm-breaking
and antisocial behaviors, and the specific sexual interest in touching or rubbing against a
nonconsenting individual should be lacking.
Substance use disorders. Substance use disorders, particularly those involving stimu-
lants such as cocaine and amphetamines, might involve single frotteuristic episodes by in-
toxicated individuals but should not involve the typical sustained sexual interest in
touching or rubbing against unsuspecting persons. Hence, recurrent frotteuristic sexual
fantasies, urges, or be haviors that occur also when the individual is not intoxicated sug-
gest that frotteuristic d isorder might be present.
Comorbidity
Known comorbidities in frotteuristic disorder  are largely based on research with males
suspected of or convicted for criminal acts involving sexually motivated touching of or
rubbing against a nonconsentin g individual. Hence, these co morbidities might not apply
to other individuals with a diagnosis of frotte uristic disorder based on subjective distress
over their sexual interest. Conditions that o ccur comorbidly with frot teuristic disorder in-


clude hypersexuality and other paraphilic disord ers, particularly exhibitionistic disorder
and voyeuristic disorder. Conduct disorder, antisocial personality disorder, depressive


694 Paraphilic Disorders
disorders, bipolar disorders, anxiety disorders, and substanc e use disorders also co-occur.
Potential differential diagnoses for frotteuristic disorder so metimes occur also as comor-
bid disorders. Therefore, it is generally necessary to evaluate  the evidence for frotteuristic
disorder and possible comorbid co nditions as separate questions.
Sexual Masochism Disorder
Diagnostic Criteria 302.83 (F65.51)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from the act
of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fan-
tasies, urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impair-
ment in social, occupational, or other important areas of functioning.
Specify if:
With asphyxiophilia:  If the individual engages in the practice of achieving sexual
arousal related to restriction of breathing.
Specify if:
In a controlled environment:  This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to engage in masochistic sexual
behaviors are restricted.
In full remission:  There has been no distress or impairment in social, occupational,
or other areas of functioning for at last 5 years while in an uncontrolled environment.
Diagnostic Features
The diagnostic criteria for sexual masochism disorder are intended to apply to individuals
who freely admit to having such paraphilic interests. Such individuals openly acknowl-
edge intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise
made to suffer, as manifested by  fantasies, urges, or behaviors. If these individuals also re-
port psychosocial difficulties because of thei r sexual attractions or preferences for being


port psychosocial difficulties because of thei r sexual attractions or preferences for being
humiliated, beaten, bound, or otherwise made to suffer, they may be diagnosed with sex-
ual masochism disorder. In contrast, if they de clare no distress, exemplified by anxiety, ob-
sessions, guilt, or shame, about these paraphi lic impulses, and are not hampered by them
in pursuing other personal goals, they coul d be ascertained as having masochistic sexual
interest but should not be diagnosed with sexual masochism disorder.
The Criterion A time frame, indicating that the signs or symptoms  of sexual masoch-
ism must have persisted for at least 6 months, should be understood as a general guideline,
not a strict threshold, to ensure that the sexual interest in being humiliated, beaten, bound,
or otherwise made to suffer is not merely transient. However, the disorder can be diag-
nosed in the context of a clearly sustained but shorter time period.
Associated Features Supporting Diagnosis
The extensive use of pornography involving the ac t of being humiliated, beaten, bound, or oth-
erwise made to suffer is sometimes an asso ciated feature of sexual masochism disorder.
Prevalence
The population prevalence of sexual masochis m disorder is unknown. In Australia, it has
been estimated that 2.2% of males and 1.3% of females had been involved in bondage and
discipline, sadomasochism, or dominance and submissio n in the past 12 months.


Sexual Sadism Disorder 695
Development and Course
Community individuals with paraphilias have reported a mean age at onset for masoch-
ism of 19.3 years, although earlier ages, in cluding puberty and childhood, have also been
reported for the onset of masochistic fantasi es. Very little is known about persistence over
time. Sexual masochism disorder per definition  requires one or more contributing factors,
which may change over time with or without treatment. These include subjective distress
(e.g., guilt, shame, intense sexual frustration,  loneliness), psychiatri c morbidity, hypersex-
uality and sexual impulsivity, and psychosocial  impairment. Therefore, the course of sex-
ual masochism disorder is likely to vary with age. Advancing age is likely to have the same
reducing effect on sexual preference involvin g sexual masochism as it has on other para-
philic or normophilic sexual behavior.
Functional Consequences of Sexual Masochism Disorder
The functional consequences of sexual maso chism disorder are unknown. However, mas-
ochists are at risk of accidental death while practicing asphyxiophilia or other autoerotic
procedures.
Differential Diagnosis
Many of the conditions that could be differ ential diagnoses for sexual masochism disorder
(e.g., transvestic fetishism, sexual sadism di sorder, hypersexuality, alcohol and substance
use disorders) sometimes occur also as comorbid diagnoses. Therefore, it is necessary to
carefully evaluate the evidence for sexual masochism disorder, keep ing the possibility of
other paraphilias or other mental  disorders as part of the di fferential diagnosis. Sexual
masochism in the absence of distress (i.e., no disorder) is also includ ed in the differential,


as individuals who conduct the behaviors may be satisfied with thei r masochistic interest.
Comorbidity
Known comorbidities with sexu al masochism disorder are largely based on individuals in
treatment. Disorders that occur comorbidly wi th sexual masochism disorder typically in-
clude other paraphilic disorders,  such as transvestic fetishism.
Sexual Sadism Disorder
Diagnostic Criteria 302.84 (F65.52)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from the phys-
ical or psychological suffering of another person, as manifested by fantasies, urges, or
behaviors.
B. The individual has acted on these sexual  urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify if:
In a controlle d environment:  This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to engage in sadistic sexual behav-
iors are restricted.
In full remission:  The individual has not acted on the urges with a nonconsenting per-
son, and there has been no distress or impairment in social, occupational, or other ar-
eas of functioning, for at least 5 years while in an uncontrolled environment.


696 Paraphilic Disorders
Diagnostic Features
The diagnostic criteria for sexual sadism disord er are intended to apply both to individuals
who freely admit to having such paraphilic interests and to those who deny any sexual interest
in the physical or psychological suffering of another individual despite substantial objective
evidence to the contrary. Indivi duals who openly acknowledge in tense sexual interest in the
physical or psychological suffering of others are referred to as “admitting individuals.” If these
individuals also report psychosocial difficulties because of their sexual  attractions or prefer-
ences for the physical or psychological suffering of another individual, they may be diagnosed
with sexual sadism disorder. In contrast, if admitting individuals declare no distress, exempli-
fied by anxiety, obsessions, gu ilt, or shame, about these para philic impulses, and are not ham-
pered by them in pursuing other goals, and thei r self-reported, psychiat ric, or legal histories
indicate that they do not act on them, then they  could be ascertained as having sadistic sexual
interest but they would not meet criteria for sexual sadism disorder.
Examples of individuals who deny any interest in the physical or psychological suffering
of another individual include in dividuals known to have inflicted pain or suffering on mul-
tiple victims on separate occasions but who de ny any urges or fantasies about such sexual
behavior and who may further claim that known episodes of sexual assault were either un-
intentional or nonsexual. Others may admit past  episodes of sexual behavior involving the
infliction of pain or suffering on a nonconsenting individual but do not report any significant
or sustained sexual interest in the physical or  psychological suffering of another individual.
Since these individuals deny having urges or fantasies involving sexual arousal to pain and
suffering, it follows that they would also deny feeling subjectively distressed or socially im-


suffering, it follows that they would also deny feeling subjectively distressed or socially im-
paired by such impulses. Such individuals may be diagnosed with sexual sadism disorder
despite their negative self-report. Their recurrent behavior constitutes clinical support for
the presence of the paraphilia of sexual sadi sm (by satisfying Criterion A) and simultane-
ously demonstrates that their paraphilically motivated behavior is causing clinically signif-
icant distress, harm, or risk of harm  to others (satisfying Criterion B).
“Recurrent” sexual sadism invo lving nonconsenting others (i .e., multiple victims, each
on a separate occasion) may, as general rule , be interpreted as three or more victims on
separate occasions. Fewer victims can be interpre ted as satisfying this criterion, if there are
multiple instances of infliction of pain and su ffering to the same victim, or if there is cor-
roborating evidence of a strong  or preferential interest in  pain and suffering involving
multiple victims. Note that multiple victims, as suggested earlier, are a sufficient but not
a necessary condition for diagnosis, as the crit eria may be met if the individual acknowl-
edges intense sadistic sexual interest.
The Criterion A time frame, indicating that  the signs or symptoms of sexual sadism
must have persisted for at least 6 months, should also be understood as a general guide-
line, not a strict threshold, to ensure that the sexual interest in inflicting pain and suffering
on nonconsenting victims is not merely tran sient. However, the diagnosis may be met if
there is a clearly sustaine d but shorter period of sadistic behaviors.
Associated Features Supporting Diagnosis
The extensive use of pornography involving the inflic tion of pain and suffering is some-
times an associated  feature of sexual  sadism disorder.


times an associated  feature of sexual  sadism disorder.
Prevalence
The population prevalence of sexual sadism  disorder is unknown and is largely based on
individuals in forensic settings. Depending on the criteria for sexual sadism, prevalence


Prevalence
The population prevalence of sexual sadism  disorder is unknown and is largely based on
individuals in forensic settings. Depending on the criteria for sexual sadism, prevalence
varies widely, from 2% to 30%. Among civi lly committed sexual offenders in the United
States, less than 10% have sexual sadism. Among individuals who have committed sexu-
ally motivated homicides, rates of sexual  sadism disorder range from 37% to 75%.


Pedophilic Disorder 697
Development and Course
Individuals with sexual sadism in forensic samples are almost exclusively male, but a rep-
resentative sample of the population in Aust ralia reported that 2.2% of men and 1.3% of
women said they had been involved in bondage and discipline, “sadomasochism,” or dom-
inance and submission in the previous year . Information on the development and course
of sexual sadism disorder is extremely lim ited. One study reported that females became
aware of their sadomasochistic interest as young adults, and another reported that the
mean age at onset of sadism in a group of males was 19.4 years. Whereas sexual sadism per
se is probably a lifelong characteristic, sexu al sadism disorder may fluctuate according to
the individual’s subjective distress or his or her propensity to harm nonconsenting others.
Advancing age is likely to have the same reducing effect on this disorder as it has on other
paraphilic or normophilic sexual behavior.
Differential Diagnosis
Many of the conditions that could be diffe rential diagnoses for sexual sadism disorder
(e.g., antisocial pers onality disorder, sexual masochism disorder, hypersexuality, sub-
stance use disorders) sometime s occur also as comorb id diagnoses. Therefore, it is neces-
sary to carefully evaluate the evidence for sexual sadism disorder, keeping the possibility
of other paraphilias or mental disorders as pa rt of the differential diagnosis. The majority
of individuals who are active in community networks that pr actice sadistic and masoch-
istic behaviors do not express any dissatisfaction  with their sexual interests, and their be-
havior would not meet DSM-5 criteria for sexual  sadism disorder. Sadi stic interest, but not
the disorder, may be considered in the differential diagnosis.


the disorder, may be considered in the differential diagnosis.
Comorbidity
Known comorbidities with sexual sadism diso rder are largely based on individuals (al-
most all males) convicted for criminal acts involving sadistic acts against nonconsenting
victims. Hence, these comorbidities might not apply to all individuals who never engaged
in sadistic activity with a nonconsenting vi ctim but who qualify for a diagnosis of sexual
sadism disorder based on subjec tive distress over their sexual  interest. Diso rders that are
commonly comorbid with sexual sadism diso rder include other paraphilic disorders.
Pedophilic Disorder
Diagnostic Criteria 302.2 (F65.4)
A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sex-
ual urges, or behaviors involving sexual activity with a prepubescent child or children
(generally age 13 years or younger).
B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause
marked distress or interpersonal difficulty.
C. The individual is at least age 16 years and at  least 5 years older than the child or chil-
dren in Criterion A.
Note:  Do not include an individual in late adolescence involved in an ongoing sexual
relationship with a 12- or 13-year-old.
Specify whether:
Exclusive type  (attracted only to children)
Nonexclusive type


698 Paraphilic Disorders
Specify if:
Sexually attracted to males
Sexually attracted to females
Sexually attracted to both
Specify if:
Limited to incest
Diagnostic Features
The diagnostic criteria for pedophilic disorder are intended to apply both to individuals who
freely disclose this paraphilia and to individuals who deny any sexual attraction to prepuber-
tal children (generally age 13 years or younger) , despite substantial objective evidence to the
contrary. Examples of disclosing this paraphilia include candidly acknowledging an intense
sexual interest in children and indicating that sexual interest in children is greater than or equal
to sexual interest in physically mature individuals. If individuals also complain that their sex-
ual attractions or preferences for children are caus ing psychosocial difficulties, they may be di-
agnosed with pedophilic disorder. However, if they report an absence of feelings of guilt,
shame, or anxiety about these impulses and are not functionally limited by their paraphilic im-
pulses (according to self-repor t, objective assessment, or both), and their self-reported and le-
gally recorded histories indicate that they ha ve never acted on their impulses, then these
individuals have a pedophilic sexual interest but not pedophilic disorder.
Examples of individuals who deny attraction to children include individuals who are
known to have sexually approached multiple children on separate occasions but who deny
any urges or fantasies about sexual behavior involving children, and who may further claim
that the known episodes of physical contact were  all unintentional and nonsexual. Other indi-
viduals may acknowledge past episodes of sexual behavior involving children but deny any
significant or sustained sexual interest in children. Since these individuals may deny experi-
ences impulses or fantasies involving children, they may also deny feeling subjectively dis-
tressed. Such individuals may still be diagnosed with pedophilic disorder despite the absence


tressed. Such individuals may still be diagnosed with pedophilic disorder despite the absence
of self-reported distress, provided that there is  evidence of recurrent behaviors persisting for
6 months (Criterion A) and evidence that the individual has acted on sexual urges or experi-
enced interpersonal difficulties as a cons equence of the disorder (Criterion B).
Presence of multiple victims, as discussed above, is su fficient but not necessary for di-
agnosis; that is, the individual can still meet  Criterion A by merely acknowledging intense
or preferential sexual interest in children.
The Criterion A clause, indicating that the signs or symptoms of pedophilia have per-
sisted for 6 months or longer, is  intended to ensure that the sexual attraction to children is
not merely transient. However, the diagnosis ma y be made if there is  clinical evidence of
sustained persistence of the sexual attraction to children even if the 6-month duration can-
not be precisely determined.
Associated Features Supporting Diagnosis
The extensive use of pornography depicting prepubescent children is a useful diagnostic
indicator of pedophilic disorder. This is a specific instance of the general case that individ-
uals are likely to choose the kind of pornography  that corresponds to their sexual interests.
Prevalence
The population prevalence of pedophilic disorder is unknown.  The highest possible prev-
alence for pedophilic disorder in the male population is approximately 3%–5%. The pop-
ulation prevalence of pedophilic disorder in females is even more  uncertain, but it is likely
a small fraction of the prevalence in males.


Pedophilic Disorder 699
Development and Course
Adult males with pedophilic disorder may indi cate that they become aware of strong or
preferential sexual interest in children arou nd the time of puberty—the same time frame
in which males who later prefer physically ma ture partners became aware of their sexual
interest in women or men. Attempting to diag nose pedophilic disorder at the age at which
it first manifests is problematic because of th e difficulty during adolescent development in
differentiating it from age-appropriate sexual interest in peers or from sexual curiosity.
Hence, Criterion C requires for diagnosis a minimum age of 16 years and at least 5 years
older than the child or children in Criterion A.
Pedophilia per se appears to be a lifelong condition. Pedophilic disorder, however,
necessarily includes other elements that may change over time with or without treatment:
subjective distress (e.g., guilt, shame, intense se xual frustration, or feelings of isolation) or
psychosocial impairment, or the propensity to  act out sexually with children, or both.
Therefore, the course of pedophilic disorder may fluctuate, in crease, or decr ease with age.
Adults with pedophilic disorder may report an awareness of sexual interest in children
that preceded engaging in sexual behavior invo lving children or self-identification as a pedo-
phile. Advanced age is as likely to similarly di minish the frequency of sexual behavior involv-
ing children as it does other paraphilically  motivated and normophilic sexual behavior.
Risk and Prognostic Factors
Temperamental. There appears to be an interaction between pedophilia and antisocial-
ity, such that males with both traits are more  likely to act out sexually with children. Thus,
antisocial personality disorder may be consid ered a risk factor for pedophilic disorder in


antisocial personality disorder may be consid ered a risk factor for pedophilic disorder in
males with pedophilia.
Environmental. Adult males with pedophilia often repo rt that they were sexually abused
as children. It is unclear, however, whether this correlation reflects a causal influence of
childhood sexual abuse on adult pedophilia.
Genetic and physiological. Since pedophilia is a necessary condition for pedophilic dis-
order, any factor that increase s the probability of pedophilia al so increases the risk of pe-
dophilic disorder. There is some  evidence that neurodevelopme ntal perturbation in utero
increases the probability of develo pment of a pedoph ilic interest.
Gender-Related Diagnostic Issues
Psychophysiological laboratory measures of sexu al interest, which are sometimes useful in di-
agnosing pedophilic disorder in males, are not necessarily useful in diagnosing this disorder in
females, even when an identical procedure (e.g., viewing time) or anal ogous procedures (e.g.,
penile plethysmography and vaginal photoplethysmography) are available.
Diagnostic Markers
Psychophysiological measures of sexual interest  may sometimes be useful when an indi-
vidual’s history suggests the possible presence  of pedophilic disorder but the individual
denies strong or preferential  attraction to children. The most thoroughly researched and
longest used of such measures is penile plethysmography, although the sensitivity and spec-
ificity of diagnosis may vary from one site to another. Viewing time,  using photographs of
nude or minimally clothed person s as visual stimuli, is also used to diagnose pedophilic
disorder, especially in combination with self-report measures. Mental health professionals
in the United States, however, should be aware that possession of such visual stimuli, even


in the United States, however, should be aware that possession of such visual stimuli, even
for diagnostic purposes, may violate American  law regarding possession of child pornog-
raphy and leave the mental health professio nal susceptible to criminal prosecution.


700 Paraphilic Disorders
Differential Diagnosis
Many of the conditions that could be differ ential diagnoses for pedophilic disorder also
sometimes occur as comorbid diagnoses. It is th erefore generally necessary to evaluate the
evidence for pedophilic disord er and other possible condit ions as separate questions.
Antisocial personality disorder. This disorder increases the li kelihood that a person who
is primarily attracted to the mature physique will approach a child, on one or a few occa-
sions, on the basis of relative availability. The individual often shows other signs of this
personality disorder, such as recurrent law-breaking.
Alcohol and substance use disorders. The disinhibiting effects of intoxication may also
increase the likelihood that a person who is primarily attracted to th e mature physique will
sexually approach a child.
Obsessive-compulsive disorder. There are occasional individuals who complain about
ego-dystonic thoughts and worries about possi ble attraction to children. Clinical inter-
viewing usually reveals an absence of sexual thoughts about children during high states of
sexual arousal (e.g., approaching orgasm during masturbation) and sometimes additional
ego-dystonic, intrusive se xual ideas (e.g., concerns about homosexuality).
Comorbidity
Psychiatric comorbidity of pedophilic disorder includes substance use disorders; depres-
sive, bipolar, and anxiety disorders; antisocial personality disorder; and other paraphilic
disorders. However, findings on comorbid disorders are largely among individuals con-
victed for sexual offenses involving childre n (almost all males) and may not be general-
izable to other individuals wi th pedophilic disorder (e.g., individuals who have never
approached a child sexually but who qualify for the diagnosis of pedophilic disorder on
the basis of subjective distress).
Fetishistic Disorder


the basis of subjective distress).
Fetishistic Disorder
Diagnostic Criteria 302.81 (F65.0)
A. Over a period of at least 6 months, recu rrent and intense sexual arousal from either
the use of nonliving objects or a highly specific focus on nongenital body part(s), as
manifested by fantasies, urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impair-
ment in social, occupational, or other important areas of functioning.
C. The fetish objects are not limited to articles of clothing used in cross-dressing (as in
transvestic disorder) or devices specifical ly designed for the purpose of tactile genital
stimulation (e.g., vibrator).
Specify:
Body part(s)
Nonliving object(s)
Other
Specify if:
In a controlled environment:  This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to engage in fetishistic behaviors
are restricted.
In full remission:  There has been no distress or impairment in social, occupational,
or other areas of functioning for at least 5 years while in an uncontrolled environment.


Fetishistic Disorder 701
Specifiers
Although individuals with fetishistic disord er may report intens e and recurrent sexual
arousal to inanimate objects or a specific body part, it is not unusual for non–mutually ex-
clusive combinations of fetishes  to occur. Thus, an individual may have fetishistic disorder
associated with an inanimate object (e.g., fe male undergarments) or an exclusive focus on
an intensely eroticized body part (e.g., feet, ha ir), or their fetishisti c interest may meet cri-
teria for various combinations of these specifiers (e.g., socks, shoes and feet).
Diagnostic Features
The paraphilic focus of fetishistic disorder involves the persistent and repetitive use of or de-
pendence on nonliving objects or a highly specif ic focus on a (typically nongenital) body part
as primary elements associated with sexual arous al (Criterion A). A diagnosis of fetishistic dis-
order must include clinically significant pers onal distress or psycho social role impairment
(Criterion B). Common fetish objects include female undergarments, male or female footwear,
rubber articles, leather cl othing, or other wearing apparel. Hi ghly eroticized body parts asso-
ciated with fetishistic disorder include feet, toes, and hair. It is not uncommon for sexualized
fetishes to include both inanimate objects and bo dy parts (e.g., dirty socks and feet), and for
this reason the definition of feti shistic disorder now re-incorporates partialism (i.e., an exclusive
focus on a body part) into its boundaries. Part ialism, previously considered a paraphilia not
otherwise specified disorder, ha d historically been subsumed in fetishism prior to DSM-III.
Many individuals who self-identify as fetish ist practitioners do not necessarily report


Many individuals who self-identify as fetish ist practitioners do not necessarily report
clinical impairment in association with their fetish-associated behavi ors. Such individuals
could be considered as having a fetish but not fetishistic diso rder. A diagnosis of fetishistic
disorder requires concurrent fulfillment of both the behaviors in Criterion A and the clin-
ically significant distress or impairment in functioning noted in Criterion B.
Associated Features Supporting Diagnosis
Fetishistic disorder can be a multisensory ex perience, including holding, tasting, rubbing,
inserting, or smelling the fetish object while ma sturbating, or preferring that a sexual part-
ner wear or utilize a fetish object during sexual encounters. Some individuals may acquire
extensive collections of high ly desired fetish objects.
Development and Course
Usually paraphilias have an onset during pube rty, but fetishes can develop prior to ado-
lescence. Once established, fetish istic disorder tends to have a continuous course that fluc-
tuates in intensity and freq uency of urges or behavior.
Culture-Related Diagnostic Issues
Knowledge of and appropriate consideration fo r normative aspects of sexual behavior are
important factors to explore to establish a clinical diagnosis of fetishistic disorder and to
distinguish a clinical diagnosis from a socially acceptable sexual behavior.
Gender-Related Diagnostic Issues
Fetishistic disorder has not been systematically reported to occur in females. In clinical
samples, fetishistic disorder is ne arly exclusively re ported in males.
Functional Consequences of Fetishistic Disorder
Typical impairments associated with fetishistic disorder include sexual dysfunction
during romantic reciprocal rela tionships when the preferred fe tish object or body part is


702 Paraphilic Disorders
unavailable during foreplay or  coitus. Some individuals with  fetishistic disorder may pre-
fer solitary sexual activity as sociated with their fetishistic preference (s) even while in-
volved in a meaningful reciprocal and affectionate relationship.
Although fetishistic disorder is relatively  uncommon among arrested sexual offenders
with paraphilias, males with fe tishistic disorder may steal an d collect their particular fe-
tishistic objects of desire. Such individuals have been arrested and charged for nonsexual
antisocial behaviors (e.g., breaking and enteri ng, theft, burglary) that are primarily moti-
vated by the fetishistic disorder.
Differential Diagnosis
Transvestic disorder. The nearest diagnostic neighbor of  fetishistic diso rder is transves-
tic disorder. As noted in the diagnostic criter ia, fetishistic disorder is not diagnosed when
fetish objects are limited to ar ticles of clothing exclusively worn during cross-dressing (as
in transvestic disorder), or when the object is genitally stimulating because it has been de-
signed for that purpose (e.g., a vibrator).
Sexual masochism disorder or  other paraphilic disorders. Fetishes can co-occur with
other paraphilic disorders, especially “sad omasochism” and transvestic disorder. When
an individual fantasizes about or engages in “forced cross-dressing” and is primarily sex-
ually aroused by the domination or humiliation  associated with such fantasy or repetitive
activity, the diagnosis of sexual ma sochism disorder should be made.
Fetishistic behavior with out fetishistic disorder. Use of a fetish object for sexual arousal
without any associated distress or psychosoci al role impairment or  other adverse conse-
quence would not meet criteria for fetishisti c disorder, as the threshold required by Crite-


quence would not meet criteria for fetishisti c disorder, as the threshold required by Crite-
rion B would not be met. For example, an indi vidual whose sexual partner either shares or
can successfully incorporate his interest in caressing, smelling, or licking feet or toes as an
important element of foreplay would not be  diagnosed with fetishistic disorder; nor
would an individual who prefers, and is not di stressed or impaired by, solitary sexual be-
havior associated with wearing rubber garments or leather boots.
Comorbidity
Fetishistic disorder may co-occur with othe r paraphilic disorders as well as hypersexual-
ity. Rarely, fetishistic disorder may be associated with neurological conditions.
Transvestic Disorder
Diagnostic Criteria 302.3 (F65.1)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from cross-
dressing, as manifested by fantasies, urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impair-
ment in social, occupational, or other important areas of functioning.
Specify if:
With fetishism: If sexually aroused by fabrics, materials, or garments.
With autogynephilia:  If sexually aroused by thoughts or images of self as female.
Specify if:
In a controlled environment:  This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to cross-dress are restricted.
In full remission:  There has been no distress or impairment in social, occupational,
or other areas of functioning for at least 5 years while in an uncontrolled environment.


Transvestic Disorder 703
Specifiers
The presence of fetishism decreases the likelih ood of gender dysphoria in men with trans-
vestic disorder. The presence of autogynephilia increases the likelihood of gender dyspho-
ria in men with transvestic disorder.
Diagnostic Features
The diagnosis of transvestic diso rder does not apply to all individuals who dress as the op-
posite sex, even those who do so habitually. It applies to individuals whose cross-dressing
or thoughts of cross-dressing are always or of ten accompanied by sexual excitement (Cri-
terion A) and who are emotionally distressed by this pattern or feel it impairs social or in-
terpersonal functioning (Crite rion B). The cross-dressing may involve only one or two
articles of clothing (e.g., for men, it may pertain only to women’s undergarments), or it
may involve dressing completely in the inner and outer garments of the other sex and (in
men) may include the use of women’s wigs and make-up. Transvestic disorder is nearly
exclusively reported in males. Sexual arousal, in its most obvious form of penile erection,
may co-occur with cross-dressing in various wa ys. In younger males, cross-dressing often
leads to masturbation, following which any fe male clothing is removed. Older males often
learn to avoid masturbating or doing anything to stimulate the penis so that the avoidance
of ejaculation allows them to prolong their cr oss-dressing session. Males with female part-
ners sometimes complete a cro ss-dressing session by having intercourse with their part-
ners, and some have difficult y maintaining a sufficient erec tion for intercourse without
cross-dressing (or private fantasies of cross-dressing).
Clinical assessment of distress or impairme nt, like clinical assessment of transvestic


Clinical assessment of distress or impairme nt, like clinical assessment of transvestic
sexual arousal, is usually dependent on the in dividual’s self-report. The pattern of behav-
ior “purging and acquisition” often signifies the presence of  distress in individuals with
transvestic disorder. During this behavioral pattern, an individual (usually a man) who
has spent a great deal of money on women’s clothes and other apparel (e.g., shoes, wigs)
discards the items (i.e., purges  them) in an effort to overc ome urges to cross-dress, and
then begins acquiring a woman’s wardrobe all over again.
Associated Features Supporting Diagnosis
Transvestic disorder in men is often accompanied by autogynephilia  (i.e., a male’s para-
philic tendency to be sexually aroused by th e thought or image of himself as a woman).
Autogynephilic fantasies and behaviors may focu s on the idea of exhibiting female phys-
iological functions (e.g., lactat ion, menstruation), engaging in stereotypically feminine be-
havior (e.g., knitting), or posses sing female anatomy (e.g., breasts).
Prevalence
The prevalence of transvestic di sorder is unknown. Transvesti c disorder is rare in males
and extremely rare in females.  Fewer than 3% of males repo rt having ever been sexually
aroused by dressing in women’s attire. The percentage of individuals who have cross-
dressed with sexual arousal more than once or  a few times in their lifetimes would be even
lower. The majority of males with transvesti c disorder identify as heterosexual, although
some individuals have occasional sexual in teraction with other males, especially when
they are cross-dressed.
Development and Course


they are cross-dressed.
Development and Course
In males, the first signs of transvestic disorder may begin in childhood, in the form of
strong fascination with a particular item of women’s attire. Prior to  puberty, cross-dress-
ing produces generalized feelings of pleasura ble excitement. With the arrival of puberty,
dressing in women’s clothes begins to elicit pe nile erection and, in some cases, leads di-


704 Paraphilic Disorders
rectly to first ejaculation. In many cases, cross-dressing elicits less and less sexual ex-
citement as the individual grows older; eventually it may produce no discernible penile
response at all. The desire to cross-dress, at  the same time, remains the same or grows even
stronger. Individuals who report such a dimi nution of sexual response typically report
that the sexual excitement of cross-dressing has been replaced by feelings of comfort or
well-being.
In some cases, the course of transvestic disorder is contin uous, and in others it is epi-
sodic. It is not rare for men with transvestic d isorder to lose interest  in cross-dressing when
they first fall in love with a woman and be gin a relationship, but such abatement usually
proves temporary. When the desire to cross-dr ess returns, so does the associated distress.
Some cases of transvestic disorder progress  to gender dysphoria. The males in these
cases, who may be indistinguishable from othe rs with transvestic disorder in adolescence
or early childhood, gradually develop desires to remain in the female role for longer pe-
riods and to feminize their anatomy. The de velopment of gender dysphoria is usually ac-
companied by a (self-reported) reduction or e limination of sexual arousal in association
with cross-dressing.
The manifestation of transvestism in penile erection and stimulation, like the manifesta-
tion of other paraphilic as well as normophilic sexual interests, is most intense in adolescence
and early adulthood. The severity of transvestic disorder is highest in adulthood, when the
transvestic drives are most likely to conflict  with performance in he terosexual intercourse


transvestic drives are most likely to conflict  with performance in he terosexual intercourse
and desires to marry and start a family. Middle -age and older men with a history of trans-
vestism are less likely to present with transvestic disorder  than with gender dysphoria.
Functional Consequences of Transvestic Disorder
Engaging in transvestic behaviors can interfer e with, or detract from, heterosexual rela-
tionships. This can be a source of distress to  men who wish to maintain conventional mar-
riages or romantic partnerships with women.
Differential Diagnosis
Fetishistic disorder. This disorder may resemble transv estic disorder, in particular, in
men with fetishism who put on women’s unde rgarments while masturbating with them.
Distinguishing transvestic disorder depends on  the individual’s specific thoughts during
such activity (e.g., are there any ideas of be ing a woman, being like a woman, or being
dressed as a woman?) and on the presence of othe r fetishes (e.g., soft, silky fabrics, whether
these are used for garments or for something else).
Gender dysphoria. Individuals with transvestic disorder do not report an incongruence be-
tween their experienced gender and assigned gender nor a desire to be of the other gender; and
they typically do not have a history of chil dhood cross-gender behaviors, which would be
present in individuals with gender dysphoria. Individuals with a presentation that meets full
criteria for transvestic disorder as well as ge nder dysphoria should be given both diagnoses.
Comorbidity
Transvestism (and thus transvestic disorder) is often found in associ ation with other para-
philias. The most frequently co-occurring paraphilias are fetishism and masochism. One


particularly dangerous form of masochism, autoerotic asphyxia,  is associated with transves-
tism in a substantial proportion of fatal cases.


Other Specified Paraphilic Disorder 705
Other Specified Paraphilic Disorder
302.89 (F65.89)
This category applies to presentations in whic h symptoms characteristic of a paraphilic disor-
der that cause clinically significant distress or impairment in social, occupational, or other im-
portant areas of functioning predominate but do not meet the full criteria for any of the disorders
in the paraphilic disorders diagnostic class. The other specified paraphilic disorder category is
used in situations in which the clinician chooses to communicate the specific reason that the
presentation does not meet the cr iteria for any specific paraphilic  disorder. This is done by re-
cording “other specified paraphilic  disorder” followed by the spec ific reason (e.g., “zoophilia”).
Examples of presentations that can be specified using the “other specified” designation
include, but are not limited to, recurrent and intense sexual arousal involving telephone
scatologia  (obscene phone calls), necrophilia  (corpses), zoophilia  (animals), coprophilia
(feces), klismaphilia  (enemas), or urophilia  (urine) that has been present for at least 6 months
and causes marked distress or impairment in social, occupational, or other important ar-
eas of functioning. Other specified paraphilic disorder can be specified as in remission
and/or as occurring in a controlled environment.
Unspecified Paraphilic Disorder
302.9 (F65.9)
This category applies to presentations in which symptoms characteristic of a paraphilic
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for any of


other important areas of functioning predominate but do not meet the full criteria for any of
the disorders in the paraphilic disorders diagnostic class. The unspecified paraphilic dis-
order category is used in situations in which the clinician chooses not  to specify the reason
that the criteria are not met for a specific  paraphilic disorder, and includes presentations
in which there is insufficient information to make a more specific diagnosis.


707Other Mental
Disorders
Four disorders  are included in this chapter: ot her specified mental disorder due to
another medical condition; unsp ecified mental disorder due to another medical condition;
other specified mental disorder; and unspecified mental disorder. This residual category
applies to presentations in which symptoms char acteristic of a mental disorder that cause
clinically significant distress or impairment in social, occupational, or other important ar-
eas of functioning predominate but do not meet  the full criteria for any other mental dis-
order in DSM-5. For other specified and un specified mental diso rders due to another
medical condition, it must be established that  the disturbance is caused by the physiolog-
ical effects of another medica l condition. If other specified and unspecified mental disor-
ders are due to another medi cal condition, it is necessary to code and list the medical
condition first (e.g., 042 [B20] HIV disease), fo llowed by the other spec ified or unspecified
mental disorder (use  appropriate code).
Other Specified Mental Disorder
Due to Another Medical Condition
294.8 (F06.8)
This category applies to presentations in whic h symptoms characteristic of a mental dis-
order due to another medical condition that cause clinically significant distress or impair-
ment in social, occupational, or other impor tant areas of functioning predominate but do
not meet the full criteria for any specific mental disorder attributable to another medical
condition. The other specified mental disor der due to another medical condition category
is used in situations in which the clinician chooses to communicate the specific reason that
the presentation does not meet the criteria for any specific mental disorder attributable to
another medical condition. This is done by recording the name of the disorder, with the
specific etiological medical condition inserted in place of “another medical condition,” fol-


specific etiological medical condition inserted in place of “another medical condition,” fol-
lowed by the specific symptomatic manifestation that does not meet the criteria for any
specific mental disorder due to another medical condition. Furthermore, the diagnostic
code for the specific medical condition must be listed immediately before the code for the
other specified mental disorder due to anothe r medical condition. For example, dissocia-
tive symptoms due to complex partial seizures would be coded and recorded as 345.40
(G40.209), complex partial seizures 294.8 (F06. 8) other specified mental disorder due to
complex partial seizures, dissociative symptoms.
An example of a presentation that can be specified using the “other specified” desig-
nation is the following:
Dissociative symptoms:  This includes symptoms occurring, for example, in the con-
text of complex partial seizures.


708 Other Mental Disorders
Unspecified Mental Disorder
Due to Another Medical Condition
294.9 (F09)
This category applies to presentations in which symptoms characteristic of a mental dis-
order due to another medical condition that cause clinically significant distress or impair-
ment in social, occupational, or other impor tant areas of functioning predominate but do
not meet the full criteria for any specific mental disorder due to another medical condition.
The unspecified mental disorder due to another  medical condition category is used in sit-
uations in which the clinician chooses not to specify the reason that the criteria are not met
for a specific mental disorder due to another medical condition, and includes presentations
for which there is insufficient information to make a more specific diagnosis (e.g., in emer-
gency room settings). This is done by recording the name of the disorder, with the specific
etiological medical condition inserted in plac e of “another medical condition.” Furthermore,
the diagnostic code for the specific medical condition must be listed immediately before
the code for the unspecified mental disorder due to another medical condition. For exam-
ple, dissociative symptoms due to complex partial seizures would be coded and recorded
as 345.40 (G40.209) complex partial seizures , 294.9 (F06.9) unspecified mental disorder
due to complex partial seizures.
Other Specified Mental Disorder
300.9 (F99)
This category applies to presentations in which symptoms characteristic of a mental dis-
order that cause clinically significant distre ss or impairment in social, occupational, or oth-
er important areas of functioning predominate but do not meet the full criteria for any
specific mental disorder. The other specified m ental disorder category is used in situations
in which the clinician chooses to communicate the specific reason that the presentation
does not meet the criteria for any specific mental disorder. This is done by recording “other


does not meet the criteria for any specific mental disorder. This is done by recording “other
specified mental disorder” followed by the specific reason.
Unspecified Mental Disorder
300.9 (F99)
This category applies to presentations in which symptoms characteristic of a mental dis-
order that cause clinically significant distre ss or impairment in social, occupational, or oth-
er important areas of functioning predominate but do not meet the full criteria for any
mental disorder. The unspecified mental disorder category is used in situations in which
the clinician chooses not to specify the reason that the criteria are not met for a specific
mental disorder, and includes presentations for which there is insufficient information to
make a more specific diagnosis (e.g., in emergency room settings).


709Medication-Induced Movement
Disorders and Other Adverse
Effects of Medication
Medication-induced  movement disorders are included in Section II because of
their frequent importance in 1)  the management by medication of mental disorders or oth-
er medical conditions and 2) the differential diagnosis of mental disorders (e.g., anxiety
disorder versus neuroleptic-induced akathisi a; malignant catatonia versus neuroleptic
malignant syndrome). Although these moveme nt disorders are labeled “medication in-
duced,” it is often difficult to establish the causal relationship between medication expo-
sure and the development of the movement di sorder, especially because some of these
movement disorders also occu r in the absence of medicati on exposure. The conditions
and problems listed in this ch apter are not mental disorders.
The term neuroleptic  is becoming outdated because it highlights the propensity of an-
tipsychotic medications to cause abnormal movements, and it is being replaced with the
term antipsychotic  in many contexts. Nevertheless, the term neuroleptic remains appropri-
ate in this context. Although newer antipsychotic medications may be less likely to cause
some medication-induced move ment disorders, those disorders still occur. Neuroleptic
medications include so-called conventional, “t ypical,” or first-gene ration antipsychotic
agents (e.g., chlorpromazine, haloperidol, fl uphenazine); “atypical” or second-generation
antipsychotic agents (e.g., clozapine, risperidone, olanzapine, quetiapine); certain dopa-
mine receptor–blocking drugs used in the tr eatment of symptoms such as nausea and gas-


mine receptor–blocking drugs used in the tr eatment of symptoms such as nausea and gas-
troparesis (e.g., prochlorperazine, prometh azine, trimethobenzamide, thiethylperazine,
metoclopramide); and amoxapine, which is marketed as an antidepressant.
Neuroleptic-Induced Parkinsonism
Other Medication-Induced Parkinsonism
332.1 (G21.11) Neuroleptic-Induced Parkinsonism
332.1 (G21.19) Other Medication-Induced Parkinsonism
Parkinsonian tremor, muscular rigidity, akinesia (i.e., loss of movement or difficulty ini-
tiating movement), or bradykinesia (i.e., slowing movement) developing within a few
weeks of starting or raising the dosage of a me dication (e.g., a neuroleptic) or after reduc-
ing the dosage of a medication used  to treat extrapyramidal symptoms.
Neuroleptic Malignant Syndrome
333.92 (G21.0) Neuroleptic Malignant Syndrome
Although neuroleptic malignant syndrome is easily recognized in its classic full-blown
form, it is often heterogeneous in onset, pres entation, progression, and outcome. The clin-
ical features described below are those consid ered most important in making the diagno-
sis of neuroleptic malignant syndrome  based on consensus recommendations.


710 Medication-Induced Movement Disorders
Diagnostic Features
Patients have generally been exposed to a dopamine antagonist within 72 hours prior to
symptom development. Hyperthermia ( 100.4 F or 38.0C on at least two occasions,
measured orally), associated with profuse dia phoresis, is a distinguishing feature of neu-
roleptic malignant syndrome, sett ing it apart from other neurol ogical side effects of anti-
psychotic medications. Extreme elevations in temperature, reflecting a breakdown in
central thermoregulation, are more likely to support the diagnosis of neuroleptic malig-
nant syndrome. Generalized rigidity, described as “lead pipe” in its most severe form and
usually unresponsive to antiparkinsonian agen ts, is a cardinal feature of the disorder and
may be associated with other neurological symptoms (e.g., tremor, sialorrhea, akinesia,
dystonia, trismus, myoclonus,  dysarthria, dysphagia, rhab domyolysis). Creatine kinase
elevation of at least four times the upper limit of normal is commonly seen. Changes in
mental status, characterized by  delirium or altered consciousness ranging from stupor to
coma, are often an early sign. Affected indi viduals may appear alert but dazed and unre-
sponsive, consistent with catatonic stupor. Autonomic activation and instability—mani-
fested by tachycardia (rate 25% above baseline), diaphoresis, blood pressure elevation
(systolic or diastolic 25% above baseline) or fluctuation ( 20 mmHg diastolic change or


25 mmHg systolic change within 24 hours), urinary incontinence, and pallor—may be
seen at any time but provide an early clue to the diagnosis. Tachypnea (rate 50% above
baseline) is common, and respiratory distress —resulting from metabolic acidosis, hyper-
metabolism, chest wall restriction, aspiration pneumonia, or pulmonary emboli—can oc-
cur and lead to sudden respiratory arrest.
A workup, including laboratory investigation,  to exclude other infectious, toxic, met-
abolic, and neuropsychiatric et iologies or complications is essential (see the section “Dif-
ferential Diagnosis” later in this discussion ). Although several laboratory abnormalities
are associated with neuroleptic malignant synd rome, no single abnormality is specific to
the diagnosis. Individuals with neuroleptic malignant syndrome may have leukocytosis,
metabolic acidosis, hypoxia, decreased serum iron concentrations, and elevations in se-
rum muscle enzymes and catecholamines. Findings from cerebrospinal fluid analysis and
neuroimaging studies are generally normal, whereas electroencephalography shows gen-
eralized slowing. Autopsy findings in fatal ca ses have been nonspecific and variable, de-
pending on complications.
Development and Course
Evidence from database studies suggests in cidence rates for neuroleptic malignant syn-
drome of 0.01%–0.02% among indi viduals treated with antips ychotics. The temporal pro-
gression of signs and symptoms provides important clues to the diagnosis and prognosis
of neuroleptic malignant syndrome. Alteration  in mental status and other neurological
signs typically precede systemic signs. The on set of symptoms varies from hours to days
after drug initiation. Some cases develop with in 24 hours after drug initiation, most within


after drug initiation. Some cases develop with in 24 hours after drug initiation, most within
the first week, and virtually all cases within 30 days. Once the syndrome is diagnosed and
oral antipsychotic drugs are d iscontinued, neuroleptic maligna nt syndrome is self-limited
in most cases. The mean reco very time after drug discontinuation is 7–10 days, with most
individuals recovering within 1 week and nearly all within 30 days. The duration may be
prolonged when long-acting antipsychotics are implicated. There have been reports of in-
dividuals in whom residual neurological signs persisted for weeks after the acute hyper-
metabolic symptoms re solved. Total resolution of symp toms can be obtained in most
cases of neuroleptic malignant syndrome; howe ver, fatality rates of 10%–20% have been


metabolic symptoms re solved. Total resolution of symp toms can be obtained in most
cases of neuroleptic malignant syndrome; howe ver, fatality rates of 10%–20% have been
reported when the disorder is not recogniz ed. Although many individuals do not experi-
ence a recurrence of neuroleptic malignant syndrome when rechallenged with antipsy-
chotic medication, some do, especially when antipsychotics are reinstituted soon after an
episode.


Medication-Induced Movement Disorders 711
Risk and Prognostic Factors
Neuroleptic malignant sy ndrome is a potential risk in an y individual after antipsychotic
drug administration. It is not specific to an y neuropsychiatric diagnosis and may occur in
individuals without a diagnosable mental disorder who receive dopamine antagonists.
Clinical, systemic, and metabolic factors associ ated with a heightened risk of neuroleptic
malignant syndrome include agitation, exhaus tion, dehydration, and iron deficiency. A
prior episode associated with antipsychotics has been described in 15%–20% of index
cases, suggesting underlying vulnerability in  some patients; however, genetic findings
based on neurotransmitter receptor polymorphi sms have not been replicated consistently.
Nearly all dopamine antagonists have been associated with neuroleptic malignant
syndrome, although high-potency antipsychotics  pose a greater risk compared with low-
potency agents and newer atypical antipsychoti cs. Partial or milder forms may be associ-
ated with newer antipsychotics, but neurolep tic malignant syndrome  varies in severity
even with older drugs. Dopami ne antagonists used in medical settings (e.g., metoclopra-
mide, prochlorperazine) have also been impl icated. Parenteral administration routes,
rapid titration rates, and higher total drug dosages have been associated with increased
risk; however, neuroleptic malignant syndrome  usually occurs within the therapeutic dos-
age range of antipsychotics.
Differential Diagnosis
Neuroleptic malignant syndrome must be di stinguished from other serious neurological
or medical conditions, including central nerv ous system infections, inflammatory or au-
toimmune conditions, status ep ilepticus, subcortical structur al lesions, and systemic con-


ditions (e.g., pheochromocytoma, thyrotoxicosis, tetanu s, heat stroke).
Neuroleptic malignant syndrome also must  be distinguished from similar syndromes
resulting from the use of other substances or medications, such as serotonin syndrome;
parkinsonian hyperthermia syndrome following abrupt discontinuation of dopamine ag-
onists; alcohol or sedative withdrawal; malignant hyperthe rmia occurring during anes-
thesia; hyperthermia associated with abuse of stimulants and hallucinogens; and atropine
poisoning from anticholinergics.
In rare instances, individuals with schizophrenia or a mood diso rder may present with
malignant catatonia, which ma y be indistinguishable from neuroleptic malignant syn-
drome. Some investigators consider neurol eptic malignant syndrome to be a drug-
induced form of malignant catatonia.
Medication-Induced Acute Dystonia
333.72 (G24.02) Medication-Induced Acute Dystonia
Abnormal and prolonged contract ion of the muscles of the ey es (oculogyric crisis), head,
neck (torticollis or retrocollis), limbs, or trunk developing within a few days of starting or
raising the dosage of a medication (such as a neuroleptic) or after reducing the dosage of a
medication used to treat extrapyramidal symptoms.
Medication-Induced Acute Akathisia
333.99 (G25.71) Medication-Induced Acute Akathisia
Subjective complaints of restlessness, ofte n accompanied by observed excessive move-
ments (e.g., fidgety movements of  the legs, rocking from foot to  foot, pacing, inability to sit


or stand still), developing within a few weeks of starting or raising the dosage of a medi-
cation (such as a neuroleptic) or after reducing the dosage of a medication used to treat ex-
trapyramidal symptoms.


712 Medication-Induced Movement Disorders
Tardive Dyskinesia
333.85 (G24.01) Tardive Dyskinesia
Involuntary athetoid or chorei form movements (lasting at le ast a few weeks) generally of
the tongue, lower face and jaw, and extremit ies (but sometimes involving the pharyngeal,
diaphragmatic, or trunk muscles) developing in association with the use of a neuroleptic
medication for at least a few months.
Symptoms may develop after a shorter period  of medication use in older persons. In
some patients, movements of this type may ap pear after discontinuation, or after change
or reduction in dosage, of neuroleptic medica tions, in which case the condition is called
neuroleptic withdrawal -emergent dyskinesia.  Because withdrawal-emergent dyskinesia is
usually time-limited, lasting less than 4–8 week s, dyskinesia that persists beyond this win-
dow is considered to be tardive dyskinesia.
Tardive Dystonia
Tardive Akathisia
333.72 (G24.09) Tardive Dystonia
333.99 (G25.71) Tardive Akathisia
Tardive syndrome involving other types of movement problems, such as dystonia or
akathisia, which are distinguished by their late  emergence in the course of treatment and
their potential persistence for months to years,  even in the face of neuroleptic discontinu-
ation or dosage reduction.
Medication-Induced Postural Tremor
333.1 (G25.1) Medication-Induced Postural Tremor
Fine tremor (usually in the range of 8–12 Hz) occurring during attempts to maintain a pos-


ture and developing in associ ation with the use of medicati on (e.g., lithium, antidepres-
sants, valproate). This tremor is very similar to the tremor seen with anxiety, caffeine, and
other stimulants.
Other Medication-Induced Movement Disorder
333.99 (G25.79) Other Medication-Induced Movement Disorder
This category is for medication-induced movement disorders not captured by any of the
specific disorders listed above.  Examples include 1) presentations resembling neuroleptic
malignant syndrome that are associated with  medications other than neuroleptics and
2) other medication-induc ed tardive conditions.
Antidepressant Discontinuation Syndrome
995.29 ( T43.205A )Initial encounter
995.29 ( T43.205D )Subsequent encounter
995.29 ( T43.205S )Sequelae
Antidepressant discontinuation syndrome is a set of symptoms that can occur after an
abrupt cessation (or marked re duction in dose) of an antide pressant medication that was
taken continuously for at least 1 month. Symp toms generally begin within 2–4 days and
typically include specific sensory, somatic,  and cognitive-emotional manifestations. Fre-


Medication-Induced Movement Disorders 713
quently reported sensory and somatic symptoms  include flashes of lights, “electric shock”
sensations, nausea, and hyperre sponsivity to nois es or lights. Nons pecific anxiety and
feelings of dread may also be reported. Symptoms are alleviated by restarting the same
medication or starting a different medication that has a similar mechanism of action—
for example, discontinuation symptoms afte r withdrawal from a serotonin-norepineph-
rine reuptake inhibitor may be alleviated by starting a tricyclic antidepressant. To qualify
as antidepressant discontinuation syndrome, the symptoms should not have been present
before the antidepressant dosa ge was reduced and are not be tter explained by another
mental disorder (e.g., manic or hypomanic episode, substance intoxication, substance
withdrawal, somatic symptom disorder).
Diagnostic Features
Discontinuation symptoms may occur following treatment with tricyclic antidepressants
(e.g., imipramine, amitriptyline, desipramine) , serotonin reuptake in hibitors (e.g., fluox-
etine, paroxetine, sertraline), and monoamine oxidase inhibitors (e.g., phenelzine, selegi-
line, pargyline). The incidence of this syndrome  depends on the dosage and half-life of the
medication being taken, as well as the rate at  which the medication is tapered. Short-acting
medications that are stopped ab ruptly rather than tapered gradually may pose the great-
est risk. The short-acting selective serotonin reuptake inhibitor (SSRI) paroxetine is the
agent most commonly associated with disconti nuation symptoms, but such symptoms oc-
cur for all types of antidepressants.


cur for all types of antidepressants.
Unlike withdrawal syndromes associated with  opioids, alcohol, and other substances
of abuse, antidepressant discontinuation sy ndrome has no pathognomonic symptoms. In-
stead, the symptoms tend to be vague and variable and typically begin 2–4 days after the
last dose of the antidepressant. For SSRIs (e.g., paroxetine), symptoms such as dizziness,
ringing in the ears, “electric shocks in the head ,” an inability to sleep, and acute anxiety are
described. The antidepressant use prior to discontinuation must not have incurred hypo-
mania or euphoria (i.e., there should be confidence that the discontinuation syndrome is
not the result of fluctuations in mood stabi lity associated with the previous treatment).
The antidepressant discontinuation syndrome is based solely on pharmacological factors
and is not related to the reinforcing effects of an antidepressant. Also, in the case of stim-
ulant augmentation of an antidepressant, abru pt cessation may result in stimulant with-
drawal symptoms (see “Stimulant Withdraw al” in the chapter “Substance-Related and
Addictive Disorders”) rather than the antide pressant discontinuation syndrome described
here.
Prevalence
The prevalence of antidepressant discontinu ation syndrome is unknown but is thought to
vary according to the dosage prior to discon tinuation, the half-life and receptor-binding
affinity of the medication, and possibly the indi vidual’s genetically influenced rate of me-
tabolism for this medication.
Course and Development
Because longitudinal studies are lacking, little is known about the clinical course of anti-
depressant discontinuation syndrome. Sympto ms appear to abate over time with very
gradual dosage reductions. After an episode, some individuals may pr efer to resume med-


gradual dosage reductions. After an episode, some individuals may pr efer to resume med-
ication indefinitely if tolerated.
Differential Diagnosis
The differential diagnosis of antidepressant discontinuation syndrome includes anxiety
and depressive disorders, su bstance use disorders, and tolerance to medications.


714 Medication-Induced Movement Disorders
Anxiety and depressive disorders. Discontinuation symptoms often resemble symptoms
of a persistent anxiety disorder  or a return of somatic symptoms of depression for which
the medication was initially given.
Substance use disorders. Antidepressant discontinuatio n syndrome differs from sub-
stance withdrawal in that antidepressants th emselves have no reinforcing or euphoric ef-
fects. The medication dosage has usually not been increased without the clinician’s
permission, and the individual generally does no t engage in drug-seeking behavior to ob-
tain additional medication. Criteria for a substance use disorder are not met.
Tolerance to medications. Tolerance and discontinuation symptoms can occur as a
normal physiological response to stopping medication after a substantial duration of
exposure. Most cases of medication tolerance can be managed through carefully con-
trolled tapering.
Comorbidity
Typically, the individual was initially started on the medication for a major depressive dis-
order; the original symptoms may return  during the discontinuation syndrome.
Other Adverse Effect of Medication
995.20 ( T50.905A )Initial encounter
995.20 ( T50.905D )Subsequent encounter
995.20 ( T50.905S )Sequelae
This category is available for optional use by clinicians to code side effects of medication
(other than movement symptoms) when these ad verse effects become a main focus of clin-
ical attention. Examples include severe hypotension, cardia c arrhythmias, and priapism.


715Other Conditions That May Be
a Focus of Clinical Attention
This discussion  covers other conditions and proble ms that may be a focus of clini-
cal attention or that may otherwise affect the diagnosis, course, prog nosis, or treatment of
a patient’s mental disorder. These conditio ns are presented with their corresponding
codes from ICD-9-CM (usually  V codes) and ICD-10-CM (usu ally Z codes). A condition
or problem in this chapter may be coded if it  is a reason for the current visit or helps to
explain the need for a test, procedure, or trea tment. Conditions and problems in this chap-
ter may also be included in the medical record  as useful information on circumstances that
may affect the patient’s care, regardless of their relevance to the current visit.
The conditions and problems listed in this chapter are not mental disorders. Their in-
clusion in DSM-5 is meant to draw attention to  the scope of additional issues that may be
encountered in routine clinical practice and to provide a systematic listing that may be
useful to clinicians in documenting these issues.
Relational Problems
Key relationships, especially intimate adult partner relationships and parent/caregiver-
child relationships, have a significant impact on the health of the individuals in these re-
lationships. These relationships can be health  promoting and protective, neutral, or detri-
mental to health outcomes. In the extreme, th ese close relationships can be associated with
maltreatment or neglect, which has signif icant medical and psyc hological consequences
for the affected individual. A relational problem may come to clinical attention either as
the reason that the individual  seeks health care or as a pr oblem that affects the course,
prognosis, or treatment of the individual’s mental or other medical disorder.


prognosis, or treatment of the individual’s mental or other medical disorder.
Problems Related to Family Upbringing
V61.20 (Z62.820) Parent-Child Relational Problem
For this category, the term parent  is used to refer to one of the child’s primary caregivers,
who may be a biological, adoptive, or foster pa rent or may be another relative (such as a
grandparent) who fulfills a parent al role for the child. This ca tegory should be used when
the main focus of clinical atte ntion is to address the quality of the parent-child relationship
or when the quality of the parent-child relati onship is affecting th e course, prognosis, or
treatment of a mental or other medical disorder. Typically, the parent-child relational
problem is associated with impaired functionin g in behavioral, cognitive, or affective do-
mains. Examples of behavioral problems include inadequate parental control, supervision,
and involvement with the child; parental over protection; excessive parental pressure; ar-
guments that escalate to threats of physical violence; and avoidance without resolution of
problems. Cognitive problems may include negati ve attributions of th e other’s intentions,
hostility toward or scapegoating of the other,  and unwarranted feelings of estrangement.
Affective problems may include feelings of sadness, apathy, or anger about the other in-
dividual in the relationship. Clinicians should take into account the developmental needs
of the child and the cultural context.


716 Other Conditions That May Be a Focus of Clinical Attention
V61.8 (Z62.891) Sibling Relational Problem
This category should be used when the focus of  clinical attention is a pattern of interaction
among siblings that is associated with significan t impairment in individual or family function-
ing or with development of symptoms in one or more of the siblings, or when a sibling relational
problem is affecting the course, prognosis, or treatment of a sibling’s mental or other medical
disorder. This category can be used for either children or adults if the focus is on the sibling re-
lationship. Siblings in this context include fu ll, half-, step-, foster , and adopted siblings.
V61.8 (Z62.29) Upbringing Away From Parents
This category should be used when the main focus of clinical attention pertains to issues
regarding a child being raised away from the parents or when this separate upbringing af-
fects the course, prognosis, or treatment of a mental or other medical disorder. The child
could be one who is under state custody and pl aced in kin care or foster care. The child
could also be one who is living in a nonparenta l relative’s home, or with friends, but whose
out-of-home placement is not mandated or sanctioned by the courts. Problems related to a
child living in a group home or orphanage are also included. This category excludes issues
related to V60.6 (Z59.3) ch ildren in boarding schools.
V61.29 (Z62.898) Child Affected by Parental Relationship Distress
This category should be used when the focus of clinical attention is the negative effects of
parental relationship discord (e.g., high levels of conflict, distress, or disparagement) on a
child in the family, including effects on the child’s mental or other medical disorders.


child in the family, including effects on the child’s mental or other medical disorders.
Other Problems Related to  Primary Support Group
V61.10 (Z63.0) Relationship Distress With Spouse or Intimate Partner
This category should be used when the major fo cus of the clinical contact is to address the
quality of the intimate (spouse or partner) relationship or when the quality of that rela-
tionship is affecting the course, prognosis, or  treatment of a mental or other medical dis-
order. Partners can be of the same or differ ent genders. Typically, the relationship distress
is associated with impaired functioning in beha vioral, cognitive, or affective domains. Ex-
amples of behavioral proble ms include conflict resolution difficulty, withdrawal, and
overinvolvement. Cognit ive problems can manifest as chronic negative attributions of the
other’s intentions or dismissals of the part ner’s positive behaviors. Affective problems
would include chronic sadness, apathy, and/or anger about the other partner.
Note:  This category excludes clinical encounte rs for V61.1x (Z69.1x) mental health ser-
vices for spousal or partner abuse prob lems and V65.49 (Z70.9) sex counseling.
V61.03 (Z63.5) Disruption of Family by  Separation or Divorce
This category should be used when partners in  an intimate adult couple are living apart
due to relationship problems or are in the process of divorce.
V61.8 (Z63.8) High Expressed Emotion Level Within Family
Expressed emotion  is a construct used as a qualitat ive measure of the “amount” of emo-
tion—in particular, hostility, emotional overin volvement, and criticism directed toward a


tion—in particular, hostility, emotional overin volvement, and criticism directed toward a
family member who is an identified patient—displayed in the family environment. This
category should be used when a family’s hi gh level of expressed emotion is the focus of
clinical attention or is affecting the course, prognosis, or treatment of a family member’s
mental or other medical disorder.
V62.82 (Z63.4) Uncomplicated Bereavement
This category can be used when the focus of cl inical attention is a normal reaction to the
death of a loved one. As part of their reaction to such a loss, some grieving individuals
present with symptoms characteristic of a major depressive episode—for example, feel-


Other Conditions That May Be a Focus of Clinical Attention 717
ings of sadness and associated symptoms su ch as insomnia, poor appetite, and weight
loss. The bereaved individual typically re gards the depressed mood as “normal,” al-
though the individual may seek professional  help for relief of associated symptoms such
as insomnia or anorexia. The duration and expression of “normal” bereavement vary con-
siderably among different cultural groups. Fu rther guidance in distinguishing grief from
a major depressive episode is provided in the criteria for major depressive episode.
Abuse and Neglect
Maltreatment by a family member (e.g., caregiver, intimate adult partner) or by a nonrel-
ative can be the area of current clinical focu s, or such maltreatment  can be an important
factor in the assessment and treatment of pati ents with mental or other medical disorders.
Because of the legal implications of abuse and neglect, care should be used in assessing
these conditions and assigning these codes. Ha ving a past history of abuse or neglect can
influence diagnosis and treatment response in a number of mental disorders, and may also
be noted along with the diagnosis.
For the following categories, in addition to listings of the confirmed or suspected event
of abuse or neglect, other code s are provided for use if the cu rrent clinical encounter is to
provide mental health services to either the victim or the perpetrator of the abuse or ne-
glect. A separate code is also provided for designating a past history of abuse or neglect.
Coding Note for ICD-10-CM Abuse and Neglect Conditions
For T codes only, the 7th character should be coded as follows:
A (initial encounter) —Use while the patient is receiving active treatment for
the condition (e.g., surgical treatment, emergency department encounter, eval-


the condition (e.g., surgical treatment, emergency department encounter, eval-
uation and treatment by a new clinician); or
D (subsequent encounter) —Use for encounters after the patient has received
active treatment for the condition and wh en he or she is receiving routine care
for the condition during the healing or re covery phase (e.g., cast change or re-
moval, removal of external or internal fixation device, medi cation adjustment,
other aftercare and follow-up visits).
Child Maltreatment and Neglect Problems
Child Physical Abuse
Child physical abuse is nonaccidental physical injury to a child—ranging from minor bruises
to severe fractures or death—occurring as a re sult of punching, beating, kicking, biting,
shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other object),
burning, or any other method that is inflicted by a parent, caregiver, or other individual who
has responsibility for the child. Such injury is  considered abuse regardless of whether the
caregiver intended to hurt the ch ild. Physical discipline, such as  spanking or paddling, is not
considered abuse as long as it is reasonable  and causes no bodily  injury to the child.
Child Physical Abuse, Confirmed
995.54 (T74.12XA) Initial encounter
995.54 (T74.12XD) Subsequent encounter
Child Physical Abuse, Suspected
995.54 (T76.12XA) Initial encounter
995.54 (T76.12XD) Subsequent encounter


718 Other Conditions That May Be a Focus of Clinical Attention
Other Circumstances Related to Child Physical Abuse
V61.21 (Z69.010) Encounter for mental health services for victim of child abuse by parent
V61.21 (Z69.020) Encounter for mental health servic es for victim of nonparental child
abuse
V15.41 (Z62.810) Personal history (past history) of physical abuse in childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental child
abuse
V62.83 (Z69.021) Encounter for mental health servic es for perpetrator of nonparental
child abuse
Child Sexual Abuse
Child sexual abuse encompasses any sexual act involving a child that is intended to pro-
vide sexual gratification to a parent, caregi ver, or other individual who has responsibility
for the child. Sexual abuse includes activities such as fondling a child’s genitals, penetra-
tion, incest, rape, sodomy, and indecent exposure. Sexual abuse also includes noncontact
exploitation of a child by a parent or caregi ver—for example, forcing, tricking, enticing,
threatening, or pressuring a child to participate in acts for the sexual gratification of others,
without direct physical contact between child and abuser.
Child Sexual Abuse, Confirmed
995.53 (T74.22XA) Initial encounter
995.53 (T74.22XD) Subsequent encounter
Child Sexual Abuse, Suspected
995.53 (T76.22XA) Initial encounter
995.53 (T76.22XD) Subsequent encounter
Other Circumstances Related to Child Sexual Abuse
V61.21 (Z69.010) Encounter for mental health services  for victim of child sexual abuse
by parent


by parent
V61.21 (Z69.020) Encounter for mental health servic es for victim of nonparental child
sexual abuse
V15.41 (Z62.810) Personal history (past history)  of sexual abuse in childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental child
sexual abuse
V62.83 (Z69.021) Encounter for mental health servic es for perpetrator of nonparental
child sexual abuse
Child Neglect
Child neglect is defined as any confirmed or suspected egregious ac t or omission by a
child’s parent or other caregiver that deprives  the child of basic age-appropriate needs and
thereby results, or has reasonab le potential to result, in physical or psychological harm to
the child. Child neglect encompasses abandonm ent; lack of appropriate supervision; fail-
ure to attend to necessary em otional or psychological needs;  and failure to provide neces-
sary education, medical care, nouris hment, shelter, and/or clothing.
Child Neglect, Confirmed
995.52 (T74.02XA) Initial encounter
995.52 (T74.02XD) Subsequent encounter


Other Conditions That May Be a Focus of Clinical Attention 719
Child Neglect, Suspected
995.52 (T76.02XA) Initial encounter
995.52 (T76.02XD) Subsequent encounter
Other Circumstances Related to Child Neglect
V61.21 (Z69.010) Encounter for mental health servic es for victim of child neglect by
parent
V61.21 (Z69.020) Encounter for mental health servic es for victim of nonparental child
neglect
V15.42 (Z62.812) Personal history (past history) of neglect in childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental child
neglect
V62.83 (Z69.021) Encounter for mental health servic es for perpetrator of nonparental
child neglect
Child Psychological Abuse
Child psychological abuse is nonaccidental verb al or symbolic acts by a child’s parent or
caregiver that result, or have reasonable potential to result, in significant psychological
harm to the child. (Physical and sexual abusive acts are not included in this category.) Ex-
amples of psychological abuse of a child include berating, disparaging, or humiliating
the child; threatening the child; harming/abandoning—or indicating that the alleged
offender will harm/abandon—people or things  that the child cares about; confining the
child (as by tying a child’s arms or legs togeth er or binding a child to furniture or another
object, or confining a child to a small enclosed  area [e.g., a closet]); egregious scapegoating
of the child; coercing the child to inflict pain  on himself or herself; and disciplining the
child excessively (i.e., at an extremely high fr equency or duration, even if not at a level of


physical abuse) through physical or nonphysical means.
Child Psychological Abuse, Confirmed
995.51 (T74.32XA) Initial encounter
995.51 (T74.32XD) Subsequent encounter
Child Psychological Abuse, Suspected
995.51 (T76.32XA) Initial encounter
995.51 (T76.32XD) Subsequent encounter
Other Circumstances Related to Child Psychological Abuse
V61.21 (Z69.010) Encounter for mental health services  for victim of child psychological
abuse by parent
V61.21 (Z69.020) Encounter for mental health servic es for victim of nonparental child
psychological abuse
V15.42 (Z62.811) Personal history (past history) of psychological abuse in childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental child
psychological abuse
V62.83 (Z69.021) Encounter for mental health servic es for perpetrator of nonparental
child psychological abuse


720 Other Conditions That May Be a Focus of Clinical Attention
Adult Maltreatment and Neglect Problems
Spouse or Partner Violence, Physical
This category should be used when nonaccidental acts of physical force that result, or have
reasonable potential to result, in physical harm  to an intimate partner or that evoke signif-
icant fear in the partner have occurred during  the past year. Nonaccidental acts of physical
force include shoving, slapping, hair pulling, pinching, restraining, shaking, throwing,
biting, kicking, hitting with the fist or an ob ject, burning, poisoning,  applying force to the
throat, cutting off the air supply, holding th e head under water, and using a weapon. Acts
for the purpose of physically protecting oneself or one’s partner are excluded.
Spouse or Partner Violen ce, Physical, Confirmed
995.81 (T74.11XA) Initial encounter
995.81 (T74.11XD) Subsequent encounter
Spouse or Partner Violence, Physical, Suspected
995.81 (T76.11XA) Initial encounter
995.81 (T76.11XD) Subsequent encounter
Other Circumstances Related to Spou se or Partner Violence, Physical
V61.11 (Z69.11) Encounter for mental health services  for victim of spouse or partner
violence, physical
V15.41 (Z91.410) Personal history (past history) of spouse or partner violence, physical
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or
partner violence, physical
Spouse or Partner Violence, Sexual
This category should be used when forced or coerced sexual acts with an intimate partner
have occurred during the past year. Sexual violence may involve the use of physical force


have occurred during the past year. Sexual violence may involve the use of physical force
or psychological coercion to compel the partner to engage in a sexual act against his or her
will, whether or not the act is completed. Also  included in this category are sexual acts
with an intimate partner who is unable to consent.
Spouse or Partner Violence, Sexual, Confirmed
995.83 (T74.21XA) Initial encounter
995.83 (T74.21XD) Subsequent encounter
Spouse or Partner Violence, Sexual, Suspected
995.83 (T76.21XA) Initial encounter
995.83 (T76.21XD) Subsequent encounter
Other Circumstances Related to Sp ouse or Partner Violence, Sexual
V61.11 (Z69.81) Encounter for mental health services  for victim of spouse or partner
violence, sexual
V15.41 (Z91.410) Personal history (past history) of spouse or partner violence, sexual
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or
partner violence, sexual


Other Conditions That May Be a Focus of Clinical Attention 721
Spouse or Partner Neglect
Partner neglect is any egregious act or omission  in the past year by one partner that de-
prives a dependent partner of basic needs and thereby results, or has reasonable potential
to result, in physical or psycho logical harm to the dependent pa rtner. This category is used
in the context of relationships in which one partner is extremely dependent on the other
partner for care or for assistance in navigating ordinary daily activities—for example, a
partner who is incapable of self-care owing to substantial physical, psychological/intel-
lectual, or cultural limitations  (e.g., inability to communicat e with others and manage ev-
eryday activities due to living in a foreign culture).
Spouse or Partner Neglect, Confirmed
995.85 (T74.01XA) Initial encounter
995.85 (T74.01XD) Subsequent encounter
Spouse or Partner Neglect, Suspected
995.85 (T76.01XA) Initial encounter
995.85 (T76.01XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Neglect
V61.11 (Z69.11) Encounter for mental health services  for victim of spouse or partner
neglect
V15.42 (Z91.412) Personal history (past history) of spouse or partner neglect
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or
partner neglect
Spouse or Partner Abuse, Psychological
Partner psychological abuse encompasses nonaccidental verbal or symbolic acts by one
partner that result, or have reasonable potentia l to result, in significant harm to the other
partner. This category should  be used when such psycholo gical abuse has occurred during


partner. This category should  be used when such psycholo gical abuse has occurred during
the past year. Acts of psycholo gical abuse include berating or  humiliating the victim; inter-
rogating the victim; restricting the victim’s ability to come and go freely; obstructing the vic-
tim’s access to assistance (e.g., law enforcemen t; legal, protective, or medical resources);
threatening the victim with physical harm or sexual assault; harming, or threatening to
harm, people or things that th e victim cares about; unwarranted restriction of the victim’s ac-
cess to or use of economic resources; isolating the victim from family, friends, or social sup-
port resources; stalking the victim; and trying to make the victim think that he or she is crazy.
Spouse or Partner Abuse, Psychological, Confirmed
995.82 (T74.31XA) Initial encounter
995.82 (T74.31XD) Subsequent encounter
Spouse or Partner Abuse, Psychological, Suspected
995.82 (T76.31XA) Initial encounter
995.82 (T76.31XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Abuse, Psychological
V61.11 (Z69.11) Encounter for mental health services  for victim of spouse or partner
psychological abuse


722 Other Conditions That May Be a Focus of Clinical Attention
V15.42 (Z91.411) Personal history (past history) of sp ouse or partner psychological abuse
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or part-
ner psychological abuse
Adult Abuse by Nons pouse or Nonpartner
These categories should be used when an ad ult has been abused by another adult who is
not an intimate partner. Such maltreatment may involve acts of physical, sexual, or emo-
tional abuse. Examples of adult abuse include nonaccidental acts of physical force (e.g.,
pushing/shoving, scratching, slapping, thro wing something that could hurt, punching,
biting) that have resulted—o r have reasonable potential to  result—in physical harm or
have caused significant fear; forced or coer ced sexual acts; and ve rbal or symbolic acts
with the potential to cause psychological harm  (e.g., berating or humiliating the person;
interrogating the person; restricting the person ’s ability to come and go freely; obstructing
the person’s access to assistance; threatening the person; harming or threatening to harm
people or things that the person cares about; restricting the person’s access to or use of eco-
nomic resources; isolating the person from fa mily, friends, or social support resources;
stalking the person; trying to make the person think that he or she is crazy). Acts for the
purpose of physically protecting oneself or the other person are excluded.
Adult Physical Abuse by Nonspouse or Nonpartner, Confirmed
995.81 (T74.11XA) Initial encounter
995.81 (T74.11XD) Subsequent encounter
Adult Physical Abuse by Nonspouse or Nonpartner, Suspected
995.81 (T76.11XA) Initial encounter


995.81 (T76.11XA) Initial encounter
995.81 (T76.11XD) Subsequent encounter
Adult Sexual Abuse by Nonspo use or Nonpartner, Confirmed
995.83 (T74.21XA) Initial encounter
995.83 (T74.21XD) Subsequent encounter
Adult Sexual Abuse by Nonspo use or Nonpartn er, Suspected
995.83 (T76.21XA) Initial encounter
995.83 (T76.21XD) Subsequent encounter
Adult Psychological Abuse by Nonspouse or Nonpartner, Confirmed
995.82 (T74.31XA) Initial encounter
995.82 (T74.31XD) Subsequent encounter
Adult Psychological Abuse by Nonspouse or Nonpartner, Suspected
995.82 (T76.31XA) Initial encounter
995.82 (T76.31XD) Subsequent encounter
Other Circumstances Related to Adult Abuse by Nonspouse or Nonpartner
V65.49 (Z69.81) Encounter for mental health services  for victim of nonspousal or non-
partner adult abuse
V62.83 (Z69.82) Encounter for mental health services  for perpetrator of nonspousal or
nonpartner adult abuse


Other Conditions That May Be a Focus of Clinical Attention 723
Educational and Occu pational Problems
Educational Problems
V62.3 (Z55.9) Academic or Educational Problem
This category should be used when an academic or educational problem is the focus of
clinical attention or has an impact on the in dividual’s diagnosis, tr eatment, or prognosis.
Problems to be consider ed include illiteracy or low-level lit eracy; lack of access to school-
ing owing to unavailability or unattainability;  problems with academ ic performance (e.g.,
failing school examinations, receiving failing marks or grades) or underachievement (be-
low what would be expected given the indivi dual’s intellectual capacity); discord with
teachers, school staff, or other students; an d any other problems related to education and/
or literacy.
Occupational Problems
V62.21 (Z56.82) Problem Related to Current Military Deployment Status
This category should be used when an occupa tional problem directly related to an indi-
vidual’s military deployment status is the focus of  clinical attention or has an impact on the
individual’s diagnosis, treatment, or prognosi s. Psychological reactions to deployment are
not included in this category; such reactions would be better captured as an adjustment
disorder or another mental disorder.
V62.29 (Z56.9) Other Problem Related to Employment
This category should be used when an occupational problem is the focus of clinical atten-
tion or has an impact on the individual’s treatment or prog nosis. Areas to be considered
include problems with employment or in the work environment, including unemploy-
ment; recent change of job; threat of job loss; job dissatisfaction; stressful work schedule;
uncertainty about career choices; sexual ha rassment on the job; other discord with boss,


supervisor, co-workers, or others in the wo rk environment; uncongenial or hostile work
environments; other psychosocial stressors re lated to work; and any other problems re-
lated to employment and/or occupation.
Housing and Economic Problems
Housing Problems
V60.0 (Z59.0) Homelessness
This category should be used when lack of a regular dwelling or living quarters has an im-
pact on an individual’s treatment or prognosi s. An individual is considered to be homeless
if his or her primary nighttime residence is a homeless shelter, a warming shelter, a do-
mestic violence shelter, a public space (e.g., tunnel, transportation st ation, mall), a build-
ing not intended for residential use (e.g., abandoned structure, unused factory), a
cardboard box or cave, or some other ad hoc housing situation.
V60.1 (Z59.1) Inadequate Housing
This category should be used when lack of adequate housing has an impact on an individ-
ual’s treatment or prognosis. Examples of in adequate housing conditions include lack of
heat (in cold temperatures) or electricity, infestation by insects or rodents, inadequate
plumbing and toilet facilities , overcrowding, lack of adequa te sleeping space, and exces-
sive noise. It is important to consider cultural norms before assigning this category.
V60.89 (Z59.2) Discord With Neighbor, Lodger, or Landlord
This category should be used when discord with  neighbors, lodgers, or a landlord is a fo-
cus of clinical attention or has an impact on the individual’s treatment or prognosis.


724 Other Conditions That May Be a Focus of Clinical Attention
V60.6 (Z59.3) Problem Related to Living in a Residential Institution
This category should be used when a problem (or problems) related to living in a residen-
tial institution is a focus of clinical attention or has an impact on the individual’s treatment
or prognosis. Psychological reactions to a chan ge in living situation are not included in this
category; such reactions would be better  captured as an adjustment disorder.
Economic Problems
V60.2 (Z59.4) Lack of Adequate Food or Safe Drinking Water
V60.2 (Z59.5) Extreme Poverty
V60.2 (Z59.6) Low Income
V60.2 (Z59.7) Insufficient Social Insurance or Welfare Support
This category should be used for individuals wh o meet eligibility criter ia for social or wel-
fare support but ar e not receiving such support, who rece ive support that is insufficient to
address their needs, or who otherwise lack access to needed insurance or support pro-
grams. Examples include inability to qualify for welfare support owing to lack of proper
documentation or evidence of address, inability to obtain ad equate health insurance be-
cause of age or a preexisting condition, and denial of support owing to excessively strin-
gent income or other requirements.
V60.9  (Z59.9) Unspecified Housing or  Economic Problem
This category should be used when there is a problem related to hou sing or economic cir-
cumstances other than as specified above.
Other Problems Related to the Social Environment
V62.89 (Z60.0) Phase of Life Problem
This category should be used when a problem adjusting to a life-cycle transition (a partic-
ular developmental phase) is the focus of clinic al attention or has an impact on the indi-


vidual’s treatment or prognosis. Examples of such transitions include entering or
completing school, leaving parental control, getting married, starting a new career, be-
coming a parent, adjusting to an “empty ne st” after children leave home, and retiring.
V60.3 (Z60.2) Problem Related to Living Alone
This category should be used when a problem associated with living alone is the focus of
clinical attention or has an impact on the in dividual’s treatment or prognosis. Examples of
such problems include chronic feelings of lonelin ess, isolation, and lack of structure in car-
rying out activities of daily living (e.g., i rregular meal and sleep schedules, inconsistent
performance of home maintenance chores).
V62.4 (Z60.3) Acculturation Difficulty
This category should be used when difficulty in adjusting to a new culture (e.g., following
migration) is the focus of clinical attention or  has an impact on the individual’s treatment
or prognosis.
V62.4 (Z60.4) Social Exclusion or Rejection
This category should be used when there is an  imbalance of social power such that there is
recurrent social exclusion or rejection by others. Examples of social rejection include bul-
lying, teasing, and intimidation by others; be ing targeted by others for verbal abuse and
humiliation; and being purposefully excluded fr om the activities of peers, workmates, or
others in one’s social environment.
V62.4 (Z60.5) Target of (Perceived) Adverse Discrimination or Persecution
This category should be used when there is perceived or experienced discrimination
against or persecution of the individual based on his or her membership (or perceived