vidual with hoarding disord er. Normative collecting does not produce the clutter, dis-
tress, or impairment typi cal of hoarding disorder.
Symptoms (i.e., difficulties discarding and/or  clutter) must cause clinically significant
distress or impairment in social, occupational , or other important area s of functioning, in-
cluding maintaining a safe environment for self  and others (Criterion D). In some cases,


Hoarding Disorder 249
particularly when there is poor insight, the individual may not report distress, and the im-
pairment may be apparent only to those arou nd the individual. However, any attempts to
discard or clear the possessions by third pa rties result in high levels of distress.
Associated Features Supporting Diagnosis
Other common features of hoarding disorder include indecisiveness, perfectionism,
avoidance, procrastination, di fficulty planning and organizing tasks, and distractibility.
Some individuals with hoarding disorder live in unsanitary conditions that may be a log-
ical consequence of severely cluttered spaces and/or that are related to planning and or-
ganizing difficulties. Animal hoarding  can be defined as the accumulation of a large number
of animals and a failure to provide minimal st andards of nutrition, sanitation, and veter-
inary care and to act on the de teriorating condition of the an imals (including disease, star-
vation, or death) and the en vironment (e.g., severe overcrowding, extremely unsanitary
conditions). Animal hoarding may be a spec ial manifestation of ho arding disorder. Most
individuals who hoard animals also hoard inan imate objects. The mo st prominent differ-
ences between animal and object hoarding are the extent of unsanitary conditions and the
poorer insight in animal hoarding.
Prevalence
Nationally representative prevalence studies of hoarding disorder are not available. Com-
munity surveys estimate the point prevalence of clinically significant hoarding in the
United States and Europe to be approximately 2%–6%. Hoarding disorder affects both
males and females, but some epidemiological studies have reported a significantly greater
prevalence among males. This contrasts with clinical samples, which are predominantly
female. Hoarding symptoms appear to be almost three times more prevalent in older


female. Hoarding symptoms appear to be almost three times more prevalent in older
adults (ages 55–94 years) compared with younger adults (ages 34–44 years).
Development and Course
Hoarding appears to begin early in life and spans well into the late stages. Hoarding symp-
toms may first emerge around ages 11–15 years, start interfering with the individual’s ev-
eryday functioning by the mid-20s, and cause clinically significant impairment by the
mid-30s. Participants in clinical research stud ies are usually in their 50s. Thus, the severity
of hoarding increases with each decade of lif e. Once symptoms begin, the course of hoard-
ing is often chronic, with few individuals reporting a waxing and waning course.
Pathological hoarding in children appears to be easily distin guished from develop-
mentally adaptive saving and collecting behaviors. Because children and adolescents
typically do not control their living environm ent and discarding behaviors, the possible
intervention of third parties (e.g., parents ke eping the spaces usable and thus reducing in-
terference) should be considered when making the diagnosis.
Risk and Prognostic Factors
Temperamental. Indecisiveness is a prominent featur e of individuals wi th hoarding dis-
order and their first-degree relatives.
Environmental. Individuals with hoarding disorder often retrospectively report stressful
and traumatic life events preceding the onset of the disorder or causing an exacerbation.
Genetic and physiological. Hoarding behavior is familial,  with about 50% of individu-
als who hoard reporting having a relative who also hoards. Twin studies indicate that ap-
proximately 50% of the variability in hoarding behavior is attr ibutable to additive genetic
factors.


250 Obsessive-Compulsive and Related Disorders
Culture-Related Diagnostic Issues
While most of the research has been done in  Western, industrialized countries and urban
communities, the available data from non-Western and developing countries suggest that
hoarding is a universal phenomenon wi th consistent clinical features.
Gender-Related Diagnostic Issues
The key features of hoarding disorder (i.e., difficulties discarding, excessive amount of
clutter) are generally comparable in males an d females, but females tend to display more
excessive acquisition, particularly excessive buying, than do males.
Functional Consequences  of Hoarding Disorder
Clutter impairs basic activities, such as moving through the house, cooking, cleaning, per-
sonal hygiene, and even sleepin g. Appliances may be broken, and utilities such as water
and electricity may be disconnected, as access for repair work may be difficult. Quality of
life is often considerably impaired. In severe cases, hoarding can put in dividuals at risk for
fire, falling (especially elderly individuals), po or sanitation, and other health risks. Hoard-
ing disorder is associated with occupational impairment, poor physical health, and high
social service utilization. Family relationsh ips are frequently under great strain. Conflict
with neighbors and local author ities is common, and a substa ntial proportion of individ-
uals with severe hoarding disorder have been  involved in legal eviction proceedings, and
some have a history of eviction.
Differential Diagnosis
Other medical conditions. Hoarding disorder is not di agnosed if the symptoms are
judged to be a direct conseque nce of another medical condition (Criterion E), such as trau-
matic brain injury, surgical resection for trea tment of a tumor or seizure control, cerebro-


vascular disease, infections of the central ne rvous system (e.g., herpes simplex encephalitis),
or neurogenetic conditions such as Prader -Willi syndrome. Damage to the anterior ven-
tromedial prefrontal and cingulate cortices ha s been particularly associated with the ex-
cessive accumulation of objects. In these individuals, the hoarding behavior is not present
prior to the onset of the brain damage and a ppears shortly after the brain damage occurs.
Some of these individuals appear to have li ttle interest in the accumulated items and are
able to discard them easily or do not care if  others discard them, whereas others appear to
be very reluctant to discard anything.
Neurodevelopmental disorders. Hoarding disorder is not diagnosed if the accumula-
tion of objects is judged to be a direct co nsequence of a neurodevel opmental disorder, such
as autism spectrum disorder or  intellectual disability (intellectual developmental disorder).
Schizophrenia spectrum and other psychotic disorders. Hoarding disorder is not di-
agnosed if the accumulation of objects is judged  to be a direct consequence of delusions or
negative symptoms in schizophrenia sp ectrum and other psychotic disorders.
Major depressive episode. Hoarding disorder is not diagnosed if the accumulation of
objects is judged to be a dire ct consequence of ps ychomotor retardation, fatigue, or loss of
energy during a major depressive episode.
Obsessive-compulsive disorder. Hoarding disorder is not diagnosed if the symptoms
are judged to be a direct consequence of typical obsessions or compulsions, such as fears
of contamination, harm, or feelings of inco mpleteness in obsessive-compulsive disorder
(OCD). Feelings of incomplete ness (e.g., losing one’s identity , or having to document and
preserve all life experiences) are the most frequent OCD symptoms associated with this


preserve all life experiences) are the most frequent OCD symptoms associated with this
form of hoarding. The accumulation of objects can also be the result of persistently avoid-


Trichotillomania (Hair-Pulling Disorder) 251
ing onerous rituals (e.g., not discarding object s in order to avoid endless washing or check-
ing rituals).
In OCD, the behavior is gene rally unwanted and highly distressing, and the individual ex-
periences no pleasure or reward from it. Excessive acquisition is  usually not present; if exces-
sive acquisition is present, items are acquired because of a specific obsession (e.g., the need to
buy items that have been accidentally touched in order to avoid cont aminating other people),
not because of a genuine desire to possess the items. Individuals who hoard in the context of
OCD are also more likely to accumulate bizarre it ems, such as trash, feces, urine, nails, hair,
used diapers, or rotten food. Accumulation of su ch items is very unusual in hoarding disorder.
When severe hoarding appears concurrently  with other typical symptoms of OCD but
is judged to be independent from these symptoms, both hoarding disorder and OCD may
be diagnosed.
Neurocognitive disorders. Hoarding disorder is not diagnosed if the accumulation of
objects is judged to be a direct consequence of a degenerati ve disorder, such as neurocog-
nitive disorder associated wi th frontotemporal lobar degeneration or Alzheimer’s disease.
Typically, onset of the accumu lating behavior is gradual and follows onset of the neuro-
cognitive disorder. The accumulating behavior  may be accompanied by self-neglect and
severe domestic squalor, alongside other neuropsychiatric symptoms, such as disinhibi-
tion, gambling, rituals/stereotypies, tics, and self-injurious behaviors.
Comorbidity
Approximately 75% of individuals with hoardi ng disorder have a comorbid mood or anx-


iety disorder. The most common comorbid conditions are major depressive disorder (up
to 50% of cases), social anxi ety disorder (social phobia), an d generalized anxiety disorder.
Approximately 20% of individuals with hoardi ng disorder also have symptoms that meet
diagnostic criteria for OCD. These comorbidit ies may often be the main reason for consul-
tation, because individuals are unlikely to spontaneously report hoarding symptoms, and
these symptoms are often not asked ab out in routine clinical interviews.
Trichotillomania (Hair-Pulling Disorder)
Diagnostic Criteria 312.39 (F63.3)
A. Recurrent pulling out of one’s hair, resulting in hair loss.
B. Repeated attempts to decrease or stop hair pulling.
C. The hair pulling causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
D. The hair pulling or hair loss is not attri butable to another medical condition (e.g., a der-
matological condition).
E. The hair pulling is not better explained by the symptoms of another mental disorder
(e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic
disorder).
Diagnostic Features
The essential feature of trichotillomania (hai r-pulling disorder) is the recurrent pulling out
of one’s own hair (Criterion A). Hair pullin g may occur from any region of the body in
which hair grows; the most co mmon sites are the scalp, eyebrows, and eyelids, while less
common sites are axillary, facial, pubic, and peri-rectal regions. Hair-pulling sites may
vary over time. Hair pulling may occur in brief episodes sc attered throughout the day or


vary over time. Hair pulling may occur in brief episodes sc attered throughout the day or
during less frequent bu t more sustained periods that can continue for hours, and such hair


252 Obsessive-Compulsive and Related Disorders
pulling may endure for months or years. Criterion A requires th at hair pulling lead to hair
loss, although individuals with this disorder may pull hair in a widely distributed pattern
(i.e., pulling single hairs from all over a site) such that hair loss may not be clearly visible.
Alternatively, individuals may attempt to conceal or camouflage hair loss (e.g., by using
makeup, scarves, or wigs). Individuals with  trichotillomania have made repeated at-
tempts to decrease or stop hair pulling (Crite rion B). Criterion C indicates that hair pulling
causes clinically significant distress or impa irment in social, occupational, or other impor-
tant areas of functioning. The term distress  includes negative affects that may be experi-
enced by individuals with hair  pulling, such as feeling a lo ss of control, embarrassment,
and shame. Significant impairment may occur in several different areas of functioning
(e.g., social, occupational, academic, and leisure), in part because of avoidance of work,
school, or other public situations.
Associated Features Supporting Diagnosis
Hair pulling may be accompanied by a range of behaviors or rituals involving hair. Thus,
individuals may search for a particular kind of hair to pull (e.g., hairs with a specific tex-
ture or color), may try to pull out hair in a spec ific way (e.g., so that the root comes out in-
tact), or may visually examine or tactilely or  orally manipulate the hair after it has been
pulled (e.g., rolling the hair between the fingers,  pulling the strand between the teeth, bit-
ing the hair into pieces, or swallowing the hair).
Hair pulling may also be preceded or acco mpanied by various emot ional states; it may


be triggered by feelings of anxiety or boredo m, may be preceded by an increasing sense of
tension (either immediately before pulling out the hair or when attempting to resist the
urge to pull), or may lead to gratification, pleasure, or a sense of relief when the hair is
pulled out. Hair-pulling behavior may involv e varying degrees of conscious awareness,
with some individuals displaying more focused attention on the hair pulling (with pre-
ceding tension and subsequent relief), and other individuals displaying more automatic
behavior (in which the hair pulling seems to occur without full awareness). Many individ-
uals report a mix of both behavioral styles. Some individuals experience an “itch-like” or
tingling sensation in the scalp that is alleviated by the act of pulling hair. Pain does not
usually accompany hair pulling.
Patterns of hair loss are highly variable. Ar eas of complete alopecia, as well as areas of
thinned hair density, are common. When the sc alp is involved, there may be a predilection
for pulling out hair in the crown or parietal regions. There may be a pattern of nearly com-
plete baldness except for a narrow perimeter around the outer margins of the scalp, par-
ticularly at the nape of the neck (“tonsure trichotillomania”). Eyebrows and eyelashes may
be completely absent.
Hair pulling does not usually occur in the pr esence of other individuals, except imme-
diate family members. Some in dividuals have urges to pull hair from other individuals
and may sometimes try to find opportunities to  do so surreptitiously. Some individuals
may pull hairs from pets, dolls, and other fi brous materials (e.g., sw eaters or carpets).
Some individuals may deny their hair pulling to others. The majority of individuals with


Some individuals may deny their hair pulling to others. The majority of individuals with
trichotillomania also have one or more other body-focused repetitive behaviors, including
skin picking, nail biting, and lip chewing.
Prevalence
In the general population, the 12-month preval ence estimate for trichotillomania in adults
and adolescents is 1%–2%. Females are more frequently affected than males, at a ratio of
approximately 10:1. This estimate  likely reflects the true gender  ratio of the condition, al-


and adolescents is 1%–2%. Females are more frequently affected than males, at a ratio of
approximately 10:1. This estimate  likely reflects the true gender  ratio of the condition, al-
though it may also reflect differential treatment seeking based on ge nder or cultural at-
titudes regarding appearance (e.g., acceptan ce of normative hair loss among males).
Among children with trichotillo mania, males and females are more equally represented.


Trichotillomania (Hair-Pulling Disorder) 253
Development and Course
Hair pulling may be seen in infants, and this behavior typically resolves during early devel-
opment. Onset of hair pulling in trichotilloman ia most commonly coincides with, or follows
the onset of, puberty. Sites of hair pulling may vary over time. The usual course of trichotillo-
mania is chronic, with some waxing and waning if the disorder is untreated. Symptoms may
possibly worsen in females accompanying horm onal changes (e.g., menstruation, perimeno-
pause). For some individuals, the disorder may come and go for weeks, months, or years at a
time. A minority of individuals remit without su bsequent relapse within a few years of onset.
Risk and Prognostic Factors
Genetic and physiological. There is evidence for a genetic vulnerability to trichotillo-
mania. The disorder is more common in in dividuals with obsessi ve-compulsive disorder
(OCD) and their first-degree relative s than in the general population.
Culture-Related Diagnostic Issues
Trichotillomania appears to manifest similarly across cultures, although there is a paucity
of data from non-Western regions.
Diagnostic Markers
Most individuals with trichotillomania admit to hair pulling; thus, dermatopathological
diagnosis is rarely required. Skin biopsy an d dermoscopy (or trichoscopy) of trichotillo-
mania are able to differentiat e the disorder from other causes of alopecia. In trichotil-
lomania, dermoscopy shows a range of charac teristic features, in cluding decreased hair
density, short vellus hair, and broken hairs with different shaft lengths.
Functional Consequences of


Functional Consequences of
Trichotillomania (Hair-Pulling Disorder)
Trichotillomania is associated with distress as well as with social and occupational impair-
ment. There may be irreversible  damage to hair growth and hair quality. Infrequent med-
ical consequences of trichotillomania includ e digit purpura, muscul oskeletal injury (e.g.,
carpal tunnel syndrome; back, shoulder and neck pain), blepharitis, and dental damage
(e.g., worn or broken teeth due to hair biting). Swallowing of hair (trichophagia) may lead
to trichobezoars, with subs equent anemia, abdominal pain , hematemesis, nausea and
vomiting, bowel obstruction,  and even perforation.
Differential Diagnosis
Normative hair re moval/manipulation. Trichotillomania should not be diagnosed when
hair removal is performed solely for cosmetic reasons (i.e., to improve one’s physical ap-
pearance). Many individuals twist and play with  their hair, but this behavior does not usu-
ally qualify for a diagnosis of trichotillomania . Some individuals may bite rather than pull
hair; again, this does not qualify for a diagnosis of trichotillomania.
Other obsessive-compulsive and related disorders. Individuals with OCD and sym-
metry concerns may pull out hairs as part of their symmetry rituals, and individuals with
body dysmorphic disorder may remove body ha ir that they perceive as ugly, asymmetri-
cal, or abnormal; in such cases a diagnosis of  trichotillomania is not given. The description
of body-focused repetitive behavior disorder  in other specified ob sessive-compulsive and
related disorder excludes individuals who meet  diagnostic criteria for trichotillomania.


254 Obsessive-Compulsive and Related Disorders
Neurodevelopmental disorders. In neurodevelopmental di sorders, hair pulling may
meet the definition of stereotypies (e.g., in stereotypic movement disorder). Tics (in tic dis-
orders) rarely lead to hair pulling.
Psychotic disorder. Individuals with a psychotic disord er may remove hair in response
to a delusion or hallucinati on. Trichotillomania is not diagnosed in such cases.
Another medical condition. Trichotillomania is not diagnosed if the hair pulling or hair
loss is attributable to another medical conditio n (e.g., inflammation of the skin or other der-
matological conditions). Other causes of scarri ng alopecia (e.g., alop ecia areata, androgenic
alopecia, telogen effluvium) or nonscarring al opecia (e.g., chronic discoid lupus erythema-
tosus, lichen planopilaris, central centrifugal cicatricial alopecia, pseudopelade, folliculitis
decalvans, dissecting folliculitis, acne keloidalis nuchae) should be considered in individu-
als with hair loss who deny hair pulling. Skin biopsy or dermoscopy ca n be used to differ-
entiate individuals with tric hotillomania from those with  dermatological disorders.
Substance-related disorders. Hair-pulling symptoms may be exacerbated by certain
substances—for example, stimulants—but it is less likely that substances are the primary
cause of persistent hair pulling.
Comorbidity
Trichotillomania is often accompanied by ot her mental disorders, most commonly major
depressive disorder and excoriation (skin- picking) disorder. Repetitive body-focused


depressive disorder and excoriation (skin- picking) disorder. Repetitive body-focused
symptoms other than hair pulling or skin picking (e.g. nail biting) occur in the majority of
individuals with trichotillomania and may dese rve an additional diagnosis of other spec-
ified obsessive-compulsive and related disorder (i.e., body-focused repetitive behavior
disorder).
Excoriation (Skin-Picking) Disorder
Diagnostic Criteria 698.4 (L98.1)
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
D. The skin picking is not attributable to the physiological effects of a substance (e.g., co-
caine) or another medical condition (e.g., scabies).
E. The skin picking is not better explained by symptoms of another mental disorder (e.g.,
delusions or tactile hallucinations in a psychotic disorder, attempts to improve a per-
ceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in ste-
reotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury).
Diagnostic Features
The essential feature of excori ation (skin-picking) disorder is recurrent picking at one’s
own skin (Criterion A). The mo st commonly picked sites are the face, arms, and hands, but
many individuals pick from multiple body sit es. Individuals may pick at healthy skin, at
minor skin irregularities, at le sions such as pimples or calluse s, or at scabs from previous
picking. Most individuals pick with their fi ngernails, although many use tweezers, pins,


or other objects. In addition to skin picking,  there may be skin rubbing, squeezing, lancing,
and biting. Individuals with excoriation diso rder often spend signif icant amounts of time
on their picking behavior, sometimes several hours per day, and such skin picking may


Excoriation (Skin-Picking) Disorder 255
endure for months or years. Cr iterion A requires that skin picking lead to skin lesions, al-
though individuals with this disorder often at tempt to conceal or camouflage such lesions
(e.g., with makeup or clothing). Individuals with excoriation disorder have made repeated
attempts to decrease or stop skin picking (Criterion B).
Criterion C indicates that skin picking causes clinically significant distress or impair-
ment in social, occupational, or other im portant areas of func tioning. The term distress  in-
cludes negative affects that may be experience d by individuals with skin picking, such as
feeling a loss of control, em barrassment, and shame. Significant impairment may occur in
several different areas of functioning (e.g., so cial, occupational, academic, and leisure), in
part because of avoidance of social situations.
Associated Features Supporting Diagnosis
Skin picking may be accompanied by a range of behaviors or rituals involving skin or scabs.
Thus, individuals may search for a particular kind of scab to pull, and they may examine,
play with, or mouth or swallow th e skin after it has be en pulled. Skin picking may also be pre-
ceded or accompanied by various emotional stat es. Skin picking may be triggered by feelings
of anxiety or boredom, may be preceded by an  increasing sense of tension (either immedi-
ately before picking the skin or when attempting to resist the urge to pick), and may lead to
gratification, pleasure, or a sense of relief when the skin or scab has been picked. Some indi-
viduals report picking in response to a minor skin irregularity or to relieve an uncomfortable
bodily sensation. Pain is not routinely reported to accompany skin picking. Some individuals


bodily sensation. Pain is not routinely reported to accompany skin picking. Some individuals
engage in skin picking that is more focused (i .e., with preceding tens ion and subsequent re-
lief), whereas others engage in more automatic picking (i.e., when skin picking occurs with-
out preceding tension and without full awarene ss), and many have a mix of both behavioral
styles. Skin picking does not usually occur in the presence of other individuals, except im-
mediate family members. Some individual s report picking the skin of others.
Prevalence
In the general population, the lifetime prevalence  for excoriation disorder in adults is 1.4%
or somewhat higher. Three-quarters or more of individuals with the disorder are female.
This likely reflects the true gender ratio of the condition, although it may also reflect dif-
ferential treatment seeking based on gender or cultural attitudes regarding appearance.
Development and Course
Although individuals with excoriation disorder may present at various ages, the skin pick-
ing most often has onset during adolescence, commonly coinciding wi th or following the
onset of puberty. The disorder frequently begins with a dermatological condition, such
as acne. Sites of skin picking may vary over time. The usual course is chronic, with some
waxing and waning if untreated. For some in dividuals, the disorder may come and go for
weeks, months, or years at a time.
Risk and Prognostic Factors
Genetic and physiological. Excoriation disorder is more  common in individuals with
obsessive-compulsive disorder (OCD) and thei r first-degree family members than in the
general population.
Diagnostic Markers
Most individuals with excoriation disorder admit to skin picking; therefore, dermato-
pathological diagnosis is rarely required. Ho wever, the disorder ma y have characteristic


pathological diagnosis is rarely required. Ho wever, the disorder ma y have characteristic
features on histopathology.


256 Obsessive-Compulsive and Related Disorders
Functional Consequences of
Excoriation (Skin-Picking) Disorder
Excoriation disorder is associated  with distress as well as with social and occupational im-
pairment. The majority of indi viduals with this condition spend at least 1 hour per day
picking, thinking about picking, and resist ing urges to pick. Many individuals report
avoiding social or entertainment events as well as going out in public. A majority of indi-
viduals with the disorder also report experien cing work interference from skin picking on
at least a daily or weekly basi s. A significant proportion of students with excoriation disor-
der report having missed school, having expe rienced difficulties managing responsibilities
at school, or having had diffi culties studying because of skin picking. Medical complica-
tions of skin picking include ti ssue damage, scarring, and infe ction and can be life-threaten-
ing. Rarely, synovitis of the wrists due to ch ronic picking has been reported. Skin picking
often results in significant tissue damage and sc arring. It frequently requires antibiotic treat-
ment for infection, and on o ccasion it may require surgery.
Differential Diagnosis
Psychotic disorder. Skin picking may occur in response to a delusion (i.e., parasitosis)
or tactile hallucination (i.e., fo rmication) in a psychotic disorder. In such cases, excoriation
disorder should not be diagnosed.
Other obsessive-compulsive and related disorders. Excessive washing compulsions
in response to contamination obsessions in in dividuals with OCD may lead to skin lesions,
and skin picking may occur in individuals with body dysmorphic disorder who pick their


and skin picking may occur in individuals with body dysmorphic disorder who pick their
skin solely because of appearance concerns; in  such cases, excoriatio n disorder should not
be diagnosed. The description of body-focused repetitive behavior disorder in other spec-
ified obsessive-compulsive and related diso rder excludes individuals whose symptoms
meet diagnostic criteria for excoriation disorder.
Neurodevelopmental disorders. While stereotypic movement disorder may be charac-
terized by repetitive self-injurious behavior , onset is in the early developmental period.
For example, individuals with  the neurogenetic condition Prader-Willi syndrome may
have early onset of skin picking, and their symptoms may meet criteria for stereotypic
movement disorder. While tics in individuals with Tourette’s disorder may lead to self-
injury, the behavior is not ti c-like in excoriation disorder.
Somatic symptom and related disorders. Excoriation disorder is not diagnosed if the
skin lesion is primarily attributable to de ceptive behaviors in factitious disorder.
Other disorders. Excoriation disorder is not diagnosed if the skin picking is primarily
attributable to the intention to harm oneself th at is characteristic of nonsuicidal self-injury.
Other medical conditions. Excoriation disorder is not di agnosed if the skin picking is
primarily attributable to another medical condition. For example, scabies is a dermatolog-
ical condition invariably associated with seve re itching and scratching. However, excori-
ation disorder may be precipitated or ex acerbated by an unde rlying dermatological
condition. For example, acne may lead to so me scratching and picking, which may also be
associated with comorbid excoriation diso rder. The differentiation between these two
clinical situations (acne with some scratching  and picking vs. acne with comorbid excori-


ation disorder) requires an assessment of the extent to which the individual’s skin picking
has become independent of the unde rlying dermatological condition.
Substance/medication-induced disorders. Skin-picking symptoms may also be induced
by certain substances (e.g., cocaine), in whic h case excoriation disorder should not be di-
agnosed. If such skin picking is clinically significant, then a diagnosis of substance/med-
ication-induced obsessive-compulsive and re lated disorder should be considered.


Substance/Medication-Induced Obsessive-Compulsive and Related Disorder 257
Comorbidity
Excoriation disorder is often accompanied by other mental disorders. Such disorders in-
clude OCD and trichotillomania (hair-pulling disorder), as well as major depressive dis-
order. Repetitive body-focused symptoms othe r than skin picking an d hair pulling (e.g.,
nail biting) occur in many individuals with excoriation disorder and may deserve an ad-
ditional diagnosis of other specified obsessive-compulsive and related disorder (i.e.,
body-focused repetitive behavior disorder).
Substance/Medication-Induced
 Obsessive-Compulsive and Related Disorder
Diagnostic Criteria
A. Obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive be-
haviors, or other symptoms characteristic of the obsessive-compulsive and related dis-
orders predominate in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings of both
(1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication
or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms in Crite-
rion A.
C. The disturbance is not better explained by an obsessive-compulsive and related disor-
der that is not substance/medication-induced. Such evidence of an independent ob-
sessive-compulsive and related disorder could include the following:
The symptoms precede the onset of the substance/medication use; the symptoms
persist for a substantial period of time (e.g., about 1 month) after the cessation of acute
withdrawal or severe intoxication; or there is other evidence suggesting the exis-


withdrawal or severe intoxication; or there is other evidence suggesting the exis-
tence of an independent non-substance/medication-induced obsessive-compul-
sive and related disorder (e.g., a history of recurrent non-substance/medication-
related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
Note:  This diagnosis should be made in addition to a diagnosis of substance intoxication
or substance withdrawal only when the symptom s in Criterion A predominate in the clinical
picture and are sufficiently severe to warrant clinical attention.
Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific substance/medica-
tion]-induced obsessive-compulsive and related disorders are indicated in the table below.
Note that the ICD-10-CM code depends on whether or not there is a comorbid substance
use disorder present for the same class of substance. If a mild substance use disorder is
comorbid with the substance-induced obsessive-compulsive and related disorder, the 4th
position character is “1,” and the clinician should record “mild [substance] use disorder”
before the substance-induced obsessive-compulsive and related disorder (e.g., “mild co-
caine use disorder with cocaine-induced obs essive-compulsive and related disorder”). If
a moderate or severe substance use disorder is comorbid with the substance-induced ob-
sessive-compulsive and related disorder, the 4th position character is “2,” and the clinician
should record “moderate [substance] use disorder” or “severe [substance] use disorder,”


depending on the severity of the comorbid substance use disorder. If there is no comorbid


258 Obsessive-Compulsive and Related Disorders
substance use disorder (e.g., after a one-time heavy use of the substance), then the 4th
position character is “9,” and the clinician should record only the substance-induced ob-
sessive-compulsive and related disorder.
Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for di-
agnoses associated with substance class):
With onset during intoxication:  If the criteria are met for intoxication with the sub-
stance and the symptoms develop during intoxication.
With onset during withdrawal:  If criteria are met for withdrawal from the substance
and the symptoms develop during, or shortly after, withdrawal.
With onset after medication use:  Symptoms may appear either at initiation of medi-
cation or after a modification or change in use.
Recording Procedures
ICD-9-CM. The name of the substanc e/medication-induced ob sessive-compulsive and
related disorder begins with the specific subs tance (e.g., cocaine) that is presumed to be
causing the obsessive-compulsive and related symptoms. The diagnostic code is selected
from the table included in the criteria set, wh ich is based on the drug class. For substances
that do not fit into any of the classes, the co de for “other substance” should be used; and in
cases in which a substance is judged to be an etiological factor but the specific class of sub-
stance is unknown, the category “u nknown substance” should be used.
The name of the disorder is followed by the sp ecification of onset (i.e., onset during in-
toxication, onset during withdrawal, with onse t after medication use). Unlike the record-
ing procedures for ICD-10-CM, which combine the substance-induced disorder and


ing procedures for ICD-10-CM, which combine the substance-induced disorder and
substance use disorder into a single code, for ICD-9-CM a separate diagnostic code is
given for the substance use disorder. For exampl e, in the case of re petitive behaviors oc-
curring during intoxica tion in a man with a severe coca ine use disorder, the diagnosis is
292.89 cocaine-induced obsessive-compulsive and related disorder, with onset during in-
toxication. An additional diagnosis of 304.20 severe cocaine use disorder is also given.
When more than one substance is judged to play a significant role in the development of
the obsessive-compulsive and related disord er, each should be listed separately.
ICD-10-CM. The name of the substance/medication-induced obsessive-compulsive and re-
lated disorder begins with the specific substance (e.g., cocaine) that is presumed to be causing
the obsessive-compulsive and related symptoms. Th e diagnostic code is selected from the ta-
ble included in the criteria set,  which is based on the drug clas s and presence or absence of a
comorbid substance use disorder . For substances that do no t fit into any of the classes,
the code for “other substance” with no comorb id substance use should be used; and in cases in
which a substance is judged to be an etiological fa ctor but the specific class of substance is un-
known, the category “unknown substance” with  no comorbid substance use should be used.ICD-10-CM
ICD-9-CMWith use
disorder,
mildWith use
disorder,
moderate
or severeWithout
use
disorder
Amphetamine (or other


or severeWithout
use
disorder
Amphetamine (or other
stimulant)292.89 F15.188 F15.288 F15.988
Cocaine 292.89 F14.188 F14.288 F14.988
Other (or unknown) substance 292.89 F19.188 F19.288 F19.988


Substance/Medication-Induced Obsessive-Compulsive and Related Disorder 259
When recording the name of the disorder, the comorbid substance use disorder (if any) is
listed first, followed by the wo rd “with,” followed by the name  of the substance-induced ob-
sessive-compulsive and related diso rder, followed by the specification of onset (i.e., onset dur-
ing intoxication, onset during withdrawal, with  onset after medication use). For example, in
the case of repetitive behaviors occurring during  intoxication in a man with a severe cocaine
use disorder, the diagnosis is F14.288 severe co caine use disorder with cocaine-induced obses-
sive-compulsive and related disorder, with onse t during intoxication. A separate diagnosis of
the comorbid severe cocaine use disorder is not given. If the substance-induced obsessive-
compulsive and related disorder occurs without a comorbid substance use disorder (e.g., after
a one-time heavy use of the substance), no accompanying substance use disorder is noted (e.g.,
F15.988 amphetamine-induced obsessive-compulsive  and related disorder, with onset during
intoxication). When more than on e substance is judged to play a significant role in the devel-
opment of the obsessive-compulsive and relate d disorder, each should be listed separately.
Diagnostic Features
The essential features of substance/medicati on-induced obsessive-co mpulsive and related
disorder are prominent symptoms of an obsessive-compulsive  and related disorder (Criterion
A) that are judged to be attributable to the e ffects of a substance (e.g., drug of abuse, medica-
tion). The obsessive-compulsive and related disorder symptoms must have developed during
or soon after substance intoxication or withdraw al or after exposure to a medication or toxin,


or soon after substance intoxication or withdraw al or after exposure to a medication or toxin,
and the substance/medication must be capable of producing the symptoms (Criterion B). Sub-
stance/medication-induced obsessive-compulsive and related disorder due to a prescribed
treatment for a mental disorder or general medi cal condition must have its onset while the in-
dividual is receiving the medi cation. Once the treatment is discontinued, the obsessive-com-
pulsive and related disorder symp toms will usually improve or remit within days to several
weeks to 1 month (depending on the half-life of the substance/medica tion). The diagnosis of
substance/medication-induced obsessive-comp ulsive and related disorder should not be
given if onset of the obsessive-compulsive an d related disorder symp toms precedes the sub-
stance intoxicati on or medication use, or if the symp toms persist for a substantial period of
time, usually longer than 1 month,  from the time of severe into xication or with drawal. If the
obsessive-compulsive and related disorder symptoms persist for a substantial period of time,
other causes for the symptoms should be cons idered. The substance/medication-induced ob-
sessive-compulsive and related disorder diagnosis should be made in addition to a diagnosis
of substance intoxication only when the sympto ms in Criterion A pred ominate in the clinical
picture and are sufficiently severe to warrant independent clinical attention
Associated Features Supporting Diagnosis
Obsessions, compulsions, hair pulling, skin pick ing, or other body-focused repetitive be-
haviors can occur in association with intoxication with the following classes of substances:
stimulants (including cocaine) and other (o r unknown) substances. Heavy metals and tox-
ins may also cause obsessive-compulsive and related disorder symptoms. Laboratory as-


ins may also cause obsessive-compulsive and related disorder symptoms. Laboratory as-
sessments (e.g., urine toxicology) may be usef ul to measure substance intoxication as part
of an assessment for obsessive-co mpulsive and related disorders.
Prevalence
In the general population, the very limited data  that are available indicate that substance-
induced obsessive-compulsive and related disorder is very rare.
Differential Diagnosis
Substance intoxication. Obsessive-compulsive and relate d disorder symptoms may oc-


induced obsessive-compulsive and related disorder is very rare.
Differential Diagnosis
Substance intoxication. Obsessive-compulsive and relate d disorder symptoms may oc-
cur in substance intoxication. The diagnosis of  the substance-specific  intoxication will usu-


260 Obsessive-Compulsive and Related Disorders
ally suffice to categorize the symptom presentation. A diagnosis of an obsessive-compulsive
and related disorder should be made in additi on to substance intoxication when the symp-
toms are judged to be in exce ss of those usually associated with intoxication and are suf-
ficiently severe to warrant independent clinical attention.
Obsessive-compulsive and related disorder (i.e., not induced by a substance). Sub-
stance/medication-induced obsessive-compulsive and related disorder is judged to be
etiologically related to the substance/medi cation. Substance/medi cation-induced obses-
sive-compulsive and related disorder is dist inguished from a prim ary obsessive-compul-
sive and related disorder by considering the onset, course, and other factors with respect
to substances/medications. For drugs of abuse, there must be  evidence from the history,
physical examination, or laboratory findings  for use or intoxication. Substance/medica-
tion-induced obsessive-compulsiv e and related disorder arises only in association with in-
toxication, whereas a primary obsessive-compulsive and relate d disorder may precede the
onset of substance/medication use. The presence  of features that are atypical of a primary
obsessive-compulsive and relate d disorder, such as atypical age at onset of symptoms,
may suggest a substance-induced etiology. A primary obsessive-compulsive and related
disorder diagnosis is warranted if the sympto ms persist for a substa ntial period of time
(about 1 month or longer) after the end of the substance intoxication or the individual has
a history of an obsessive-co mpulsive and related disorder.
Obsessive-compulsive and related disorder due to another medical condition. If the


Obsessive-compulsive and related disorder due to another medical condition. If the
obsessive-compulsive and relate d disorder symptoms are attr ibutable to another medical
condition (i.e., rather than to the medication taken for the other me dical condition), obses-
sive-compulsive and related di sorder due to another medical condition should be diag-
nosed. The history often provides the basis for judgment. At times, a change in the
treatment for the other medical condition (e.g ., medication substitu tion or discontinua-
tion) may be needed to determine whether or not the medication is the causative agent (in
which case the symptoms may be better expl ained by substance/medication-induced ob-
sessive-compulsive and related diso rder). If the disturbance is attributable to both another
medical condition and substance use, both diagnoses (i.e., obsessive-compulsive and related
disorder due to another medical condition and substance/medicati on-induced obsessive-
compulsive and related disorder) may be given. When there is insufficie nt evidence to de-
termine whether the symptoms are attributable  to either a substanc e/medication or an-
other medical condition or are primary (i.e., a ttributable to neither a substance/medication
nor another medical condition), a diagnosis of other specified or unspecified obsessive-
compulsive and related disorder would be indicated.
Delirium. If obsessive-compulsive and related disorder symptoms occur exclusively
during the course of delirium, they are consid ered to be an associated  feature of the delir-
ium and are not diagnosed separately.
Obsessive-Compulsive and Related Disorder
Due to Another Medical Condition
Diagnostic Criteria 294.8 (F06.8)


Due to Another Medical Condition
Diagnostic Criteria 294.8 (F06.8)
A. Obsessions, compulsions, preoccupations with appearance, hoarding, skin picking,
hair pulling, other body-focused repetitive beha viors, or other symptoms characteristic
of obsessive-compulsive and related disorder predominate in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder.


Obsessive-Compulsive and Related Disorder Due to Another Medical Condition 261
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
Specify if:
With obsessive-compulsive disorder–like symptoms:  If obsessive-compulsive dis-
order–like symptoms predominate in the clinical presentation.
With appearance preoccupations:  If preoccupation with perceived appearance de-
fects or flaws predominates in the clinical presentation.
With hoarding symptoms: If hoarding predominates in the clinical presentation.
With hair-pulling symptoms:  If hair pulling predominates in the clinical presentation.
With skin-picking symptoms:  If skin picking predominates in the clinical presenta-
tion.
Coding note: Include the name of the other medical condition in the name of the mental
disorder (e.g., 294.8 [F06.8] obsessive-compulsive and related disorder due to cerebral
infarction). The other medical condition should be coded and listed separately immediately
before the obsessive-compulsive and related disorder due to the medical condition (e.g.,
438.89 [I69.398] cerebral infarction; 294.8 [F06.8] obsessive-compulsive and related dis-
order due to cerebral infarction).
Diagnostic Features
The essential feature of obsessive-compulsive an d related disorder due to another medical
condition is clinically significant obsessiv e-compulsive and related symptoms that are
judged to be best explained as the direct pathophysiological consequence of another med-
ical condition. Symptoms can include pr ominent obsessions, compulsions, preoccu-
pations with appearance, hoarding, hair pull ing, skin picking, or other body-focused


pations with appearance, hoarding, hair pull ing, skin picking, or other body-focused
repetitive behaviors (Criterion A). The judgme nt that the symptoms are best explained by
the associated medical condition must be based on evidence from the history, physical ex-
amination, or laboratory findings (Criterion B). Additionally, it must be judged that the
symptoms are not better explained by another mental disorder (Criterion C). The diagno-
sis is not made if the obsessive-compulsive and related symptoms o ccur only during the
course of a delirium (Criterion D). The obsessive-compulsive and related symptoms must
cause clinically significant distress or impairment in social, occupa tional, or other impor-
tant areas of functioning (Criterion E).
In determining whether the ob sessive-compulsive and rela ted symptoms are attribut-
able to another medical condit ion, a relevant medical condition must be present. Further-
more, it must be established that obsessive-compulsive and related symptoms can be
etiologically related to the medical condit ion through a pathophysiological mechanism
and that this best explains the symptoms in the individual. Although there are no infallible
guidelines for determining whether the relationship between the obsessive-compulsive
and related symptoms and the medical conditio n is etiological, considerations that may
provide some guidance in making this diagno sis include the presence of a clear temporal
association between the onset, exacerbation, or remission of the medical condition and the
obsessive-compulsive and related symptoms; the presence of features that are atypical of
a primary obsessive-compulsive and related disord er (e.g., atypical age at onset or course);
and evidence in the literature that a known physiological mechanism (e.g., striatal dam-
age) causes obsessive-compulsive and rela ted symptoms. In addi tion, the disturbance


age) causes obsessive-compulsive and rela ted symptoms. In addi tion, the disturbance
cannot be better explained by a primary obse ssive-compulsive and related disorder, a sub-
stance/medication-induced obsessive-compul sive and related disorder, or another men-
tal disorder.
There is some controversy about whether ob sessive-compulsive and related disorders
can be attributed to Group A streptococcal infection. Sydenham’s chorea is the neurolog-


262 Obsessive-Compulsive and Related Disorders
ical manifestation of rheumatic fever, which is in turn due to Group A streptococcal in-
fection. Sydenham’s chorea is characterized by a combination of motor and nonmotor
features. Nonmotor feat ures include obsessions, compulsi ons, attention deficit, and emo-
tional lability. Although indi viduals with Sydenh am’s chorea may present with non-
neuropsychiatric features of acute rheumatic fe ver, such as carditis and arthritis, they may
present with obsessive-compu lsive disorder–like symptoms; such individuals should
be diagnosed with obsessive-compulsive and related disorder due to another medical
condition.
Pediatric autoimmune neuropsychiatric diso rders associated with  streptococcal infec-
tions (PANDAS) has been identified as an other post-infectious autoimmune disorder
characterized by the sudden onset of obsessions, compulsions, and/or tics accompanied
by a variety of acute neuropsychiatric symptoms  in the absence of chorea, carditis, or ar-
thritis, after Group A streptoc occal infection. Although there is a body of evidence that
supports the existence of PANDAS, it remains a controversial diagnosis. Given this ongo-
ing controversy, the description of PANDAS ha s been modified to eliminate etiological
factors and to designate an expanded clinical  entity: pediatric acute-onset neuropsychiat-
ric syndrome (PANS) or idiopathic childhood  acute neuropsychiatric symptoms (CANS),
which deserves further study.
Associated Features Supporting Diagnosis
A number of other medical disorders are know n to include obsessive-compulsive and re-
lated symptoms as a manifestation. Examples  include disorders leading to striatal dam-
age, such as cerebral infarction.


age, such as cerebral infarction.
Development and Course
The development and course of  obsessive-compulsive and rela ted disorder due to another
medical condition generally follows the course of the underlying illness.
Diagnostic Markers
Laboratory assessments and/or medical examinations are necessary to confirm the diag-
nosis of another medical condition.
Differential Diagnosis
Delirium. A separate diagnosis of obsessive-compul sive and related disorder due to an-
other medical condition is not given if the disturbance occurs exclusively during the
course of a delirium. Howeve r, a diagnosis of obsessive-compulsive and related disorder
due to another medical condition may be given in addition to a diagnosis of major neuro-
cognitive disorder (dementia) if the etiolo gy of the obsessive-compulsive symptoms is
judged to be a physiological consequence of the pathological process causing the dementia
and if obsessive-compulsive symptoms are a pr ominent part of the clinical presentation.
Mixed presentation of symptoms (e.g., mood and obsessive-compulsive and related
disorder symptoms). If the presentation includes a mix of different types of symptoms,
the specific mental disorder due to another medical condition depends on which symp-
toms predominate in the clinical picture.
Substance/medication-induced obsessive-compulsive and related disorders. If there
is evidence of recent or pr olonged substance use (including medications with psychoac-
tive effects), withdrawal from a substance, or exposure to a toxin, a substance/medication-
induced obsessive-compulsive and related diso rder should be considered. When a sub-
stance/medication-induced ob sessive-compulsive and related disorder is being diag-
nosed in relation to drugs of abuse, it may be  useful to obtain a urine or blood drug screen


Other Specified Obsessive-Compulsive and Related Disorder 263
or other appropriate laboratory evaluation. Symptoms that o ccur during or shortly after
(i.e., within 4 weeks of) substance intoxication  or withdrawal or after medication use may
be especially indicative of a substance/medi cation-induced obsessive-compulsive and re-
lated disorder, depending on the type, duration, or amount of the substance used.
Obsessive-compulsive and re lated disorders (primary). Obsessive-compulsive and re-
lated disorder due to another medical condition should be distinguished fr om a primary
obsessive-compulsive and related disorder. In primary mental disorders, no specific and
direct causative physiological mechanisms associated with a medical condition can be
demonstrated. Late age at onse t or atypical symptoms suggest the need for a thorough as-
sessment to rule out the diagnosis of obsessive-compulsive and related disorder due to an-
other medical condition.
Illness anxiety disorder. Illness anxiety disorder is charac terized by a preoccupation with
having or acquiring a serious illness. In the case of illness anxiety disorder, individuals
may or may not have diagnosed medical conditions.
Associated feature of another mental disorder. Obsessive-compulsive and related symp-
toms may be an associated feature of another mental disorder (e.g., schizophrenia, an-
orexia nervosa).
Other specified obsessive-compulsive and related disorder or unspecified obsessive-
compulsive and related disorder. These diagnoses are given if it is unclear whether the
obsessive-compulsive and rela ted symptoms are primary, substance-induced, or due to
another medical condition.
Other Specified Obsessive-Compulsive
and Related Disorder
300.3 (F42)
This category applies to presentations in which symptoms characteristic of an obsessive-


This category applies to presentations in which symptoms characteristic of an obsessive-
compulsive and related disorder that cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning predominate but do not meet
the full criteria for any of the disorders in the obsessive-compulsive and related disorders
diagnostic class. The other specified obsessive -compulsive and related 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 obsessive-compulsive and re-
lated disorder. This is done by recording “other specified obsessive-compulsive and relat-
ed disorder” followed by the specific reason (e.g., “body-focused repetitive behavior
disorder”).
Examples of presentations that can be specified using the “other specified” designation
include the following:
1.Body dysmorphic–like disorder with actual flaws:  This is similar to body dysmor-
phic disorder except that the defects or flaws in physical appearance are clearly ob-
servable by others (i.e., they are more noticeable than “slight”). In such cases, the
preoccupation with these flaws is clearly excessive and causes significant impairment
or distress.
2.Body dysmorphic–like disorder  without repetitive behaviors: Presentations that
meet body dysmorphic disorder except that the individual has not performed repetitive
behaviors or mental acts in response to the appearance concerns.
3.Body-focused repetitive behavior disorder:  This is characterized by recurrent body-
focused repetitive behaviors (e.g., nail biting, lip biting, cheek chewing) and repeated
attempts to decrease or stop the behaviors. These symptoms cause clinically significant


264 Obsessive-Compulsive and Related Disorders
distress or impairment in social, occupational , or other important areas of functioning
and are not better explained by trichotillomania (hair-pulling disorder), excoriation (skin-
picking) disorder, stereotypic movement disorder, or nonsuicidal self-injury.
4.Obsessional jealousy:  This is characterized by nondelusional preoccupation with a
partner’s perceived infidelity. The preoccupations may lead to repetitive behaviors or
mental acts in response to the infidelity concerns; they cause clinically significant dis-
tress or impairment in social, occupational, or other important areas of functioning; and
they are not better explained by another mental  disorder such as delusional disorder,
jealous type, or paranoid personality disorder.
5.Shubo-kyofu: A variant of taijin kyofusho  (see “Glossary of Cultural Concepts of Dis-
tress” in the Appendix) that is similar to body dysmorphic disorder and is characterized
by excessive fear of having a bodily deformity.
6.Koro:  Related to dhat syndrome (see “Glossary of Cultural Concepts of Distress” in
the Appendix), an episode of sudden and intense anxiety that the penis (or the vulva
and nipples in females) will recede into the body, possibly leading to death.
7.Jikoshu-kyofu:  A variant of taijin kyofusho  (see “Glossary of Cultural Concepts of Dis-
tress” in the Appendix) characterized by fear of having an offensive body odor (also
termed olfactory reference syndrome).
Unspecified Obsessive-Compulsive
and Related Disorder
300.3 (F42)
This category applies to presentations in which symptoms characteristic of an obsessive-


This category applies to presentations in which symptoms characteristic of an obsessive-
compulsive and related 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 of the disorders in the obsessive-compulsive and related disorders
diagnostic class. The unspecified obsessive-co mpulsive and related 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 obsessive-compul sive and related disorder, and includes presen-
tations in which there is insufficient information to make a more specific diagnosis (e.g., in
emergency room settings).


265Trauma- and
 Stressor-Related Disorders
Trauma- and stressor-related  disorders include disorders in which exposure to
a traumatic or stressful event is listed explicitly  as a diagnostic criterion. These include reactive
attachment disorder, disinhibit ed social engagement disorder , posttraumatic stress disor-
der (PTSD), acute stress disorder, and adjustment disorders. Placement of this chapter reflects
the close relationship between these diagnoses and disorders in the surrounding chapters on
anxiety disorders, obsessive-c ompulsive and related disorder s, and dissociative disorders.
Psychological distress following exposure to a traumatic or stressful event is quite vari-
able. In some cases, symptoms  can be well understood with in an anxiety- or fear-based
context. It is clear, however, that many in dividuals who have been exposed to a traumatic
or stressful event exhibit a phenotype in which,  rather than anxiety- or fear-based symp-
toms, the most prominent clin ical characteristics are anhedonic and dysphoric symptoms,
externalizing angry and aggressive symptoms, or  dissociative symptoms. Because of these
variable expressions of clinic al distress following exposure  to catastrophic or aversive
events, the aforementioned di sorders have been grouped under a separate category:
trauma- and stressor-related disorders. Furthermore, it is not uncommon for the clinical pic-
ture to include some combination of the ab ove symptoms (with or without anxiety- or
fear-based symptoms). Such a heterogeneous picture has long been recognized in adjust-
ment disorders, as well. Social  neglect—that is, the absence of adequate caregiving during
childhood—is a diagnostic requirement of both reactive attachment disorder and disin-
hibited social engagement diso rder. Although the two disord ers share a common etiology,
the former is expressed as an internalizing di sorder with depressive symptoms and with-


the former is expressed as an internalizing di sorder with depressive symptoms and with-
drawn behavior, while the latter is marked by  disinhibition and externalizing behavior.
Reactive Attachment Disorder
Diagnostic Criteria 313.89 (F94.1)
A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregiv-
ers, manifested by both of the following:
1. The child rarely or minimally seeks comfort when distressed.
2. The child rarely or minimally responds to comfort when distressed.
B. A persistent social and emotional disturbance c haracterized by at least two of the following:
1. Minimal social and emotional responsiveness to others.
2. Limited positive affect.
3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even
during nonthreatening interactions with adult caregivers.
C. The child has experienced a pattern of extremes of insufficient care as evidenced by
at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having basic emotional
needs for comfort, stimulation, and affection met by caregiving adults.


266 Trauma- and Stressor-Related Disorders
2. Repeated changes of primary caregivers that limit opportunities to form stable at-
tachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form selective at-
tachments (e.g., institutions with high child-to-caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Cri-
terion A (e.g., the disturbances in Criterion A began following the lack of adequate care
in Criterion C).
E. The criteria are not met for autism spectrum disorder.
F. The disturbance is evident before age 5 years.
G. The child has a developmental age of at least 9 months.
Specify if:
Persistent:  The disorder has been present for more than 12 months.
Specify current severity:
Reactive attachment disorder is specified as severe  when a child exhibits all symp-
toms of the disorder, with each symptom manifesting at relatively high levels.
Diagnostic Features
Reactive attachment disorder of infancy or early childhood is characterized by a pattern of
markedly disturbed and develo pmentally inappropriate attachment behaviors, in which a
child rarely or minimally turns preferentially to an attachment figure  for comfort, support,
protection, and nurturance. The essential featur e is absent or grossly underdeveloped at-
tachment between the child and putative caregiving adults. Children with reactive attach-
ment disorder are believed to have the capa city to form selective attachments. However,
because of limited opportunitie s during early development, they  fail to show the behavioral
manifestations of select ive attachments. That is, when di stressed, they show no consistent
effort to obtain comfort, support, nurturance, or protection from caregivers. Furthermore,


effort to obtain comfort, support, nurturance, or protection from caregivers. Furthermore,
when distressed, children with this disorder do not respond more than minimally to com-
forting efforts of caregivers. Thus, the disord er is associated with th e absence of expected
comfort seeking and response to comforting behaviors. As such, children with reactive
attachment disorder show dimi nished or absent expression of positive emotions during
routine interactions with caregivers. In addi tion, their emotion regulation capacity is com-
promised, and they displa y episodes of negative emotions of fear, sadness, or irritability
that are not readily explained. A diagnosis of reactive attachment disorder should not be
made in children who are developmentally unab le to form se lective attachments. For this
reason, the child must have a develo pmental age of at least 9 months.
Associated Features Supporting Diagnosis
Because of the shared etiologica l association with social negl ect, reactive attachment dis-
order often co-occurs with developmental dela ys, especially in delays in cognition and
language. Other associated features include stereotypies and other signs of severe neglect
(e.g., malnutrition or signs of poor care).
Prevalence
The prevalence of reactive atta chment disorder is unknown, bu t the disorder is seen rela-
tively rarely in clinical settings. The disorder has been found in young children exposed to
severe neglect before being placed in foster care or raised in  institutions. However, even in
populations of seve rely neglected children, the disord er is uncommon, occurring in less
than 10% of such children.


Reactive Attachment Disorder 267
Development and Course
Conditions of social neglect are often present in the first months of life in children diag-
nosed with reactive attachment disorder, even before the disorder is diagnosed. The clin-
ical features of the disorder manifest in a similar fashion between the ages of 9 months and
5 years. That is, signs of absent-to-minima l attachment behaviors and associated emotion-
ally aberrant behaviors are evident in childre n throughout this age range, although differ-
ing cognitive and motor abilities may affect how these behaviors ar e expressed. Without
remediation and recovery through normative care giving environments, it appears that signs
of the disorder may persist, at least for several years.
It is unclear whether reactive attachment disorder occurs in older children and, if so, how
it differs from its presentation in young ch ildren. Because of this, the diagnosis should be
made with caution in children older than 5 years.
Risk and Prognostic Factors
Environmental. Serious social neglect is a diagnost ic requirement for reactive attach-
ment disorder and is also the only known risk factor for the disorder. However, the ma-
jority of severely neglecte d children do not develop the disorder. Prognosis appears to
depend on the quality of the caregiving  environment following serious neglect.
Culture-Related Diagnostic Issues
Similar attachment behaviors have been described in young children in many different
cultures around the world. Ho wever, caution should be exercised in making the diagnosis
of reactive attachment disorder in cultures  in which attachment has not been studied.
Functional Consequences of
Reactive Attachment Disorder
Reactive attachment disorder significantly impairs young children’s abilities to relate in-
terpersonally to adults or peer s and is associated with functional impairment across many
domains of early childhood.
Differential Diagnosis


domains of early childhood.
Differential Diagnosis
Autism spectrum disorder. Aberrant social behaviors mani fest in young children with
reactive attachment disorder, but they also ar e key features of auti sm spectrum disorder.
Specifically, young children with either co ndition can manifest dampened expression of
positive emotions, cognitive and language delays, and impairments in social reciprocity.
As a result, reactive attachment disorder must  be differentiated from  autism spectrum dis-
order. These two disorders can be distinguished based on differential histories of neglect
and on the presence of restricted interests or ritualized behaviors, specific deficit in social
communication, and selective attachment beha viors. Children with reactive attachment
disorder have experienced a history of severe so cial neglect, although it is not always pos-
sible to obtain detailed historie s about the precise nature of th eir experiences, especially in
initial evaluations. Children with autistic spec trum disorder will only rarely have a history
of social neglect. The restricted interests an d repetitive behaviors ch aracteristic of autism
spectrum disorder are not a feature of reactive attachment disorder. These clinical features
manifest as excessive adherenc e to rituals and routines; restricted, fixated interests; and
unusual sensory reactions. However, it is important to note that children with either con-
dition can exhibit stereotypic behaviors such as rocking or flapping. Children with either
disorder also may exhibit a range of intellectual functioning, but only children with autis-


268 Trauma- and Stressor-Related Disorders
tic spectrum disorder exhibit selective impa irments in social communicative behaviors,
such as intentional communication (i.e., im pairment in communication that is deliberate,
goal-directed, and aimed at influencing the be havior of the recipient). Children with reac-
tive attachment disorder show social commu nicative functioning comparable to their
overall level of intellectual functioning. Fina lly, children with autistic spectrum disorder
regularly show attachment behavior typical for their develo pmental level. In contrast,
children with reactive attachment disorder do so only rarely or inconsistently, if at all.
Intellectual disability (intell ectual developmental disorder). Developmental delays of-
ten accompany reactive attachment disorder, but they should not be confused with the
disorder. Children with intellectual disability should exhibit social and emotional skills
comparable to their cognitive skills and do  not demonstrate the profound reduction in
positive affect and emotion regula tion difficulties evident in children with reactive attach-
ment disorder. In addition, developmentall y delayed children who have reached a cogni-
tive age of 7–9 months should demonstrate selective attachments regardless of their
chronological age. In contrast , children with reactive attach ment disorder show lack of
preferred attachment despite ha ving attained a developmental age of at least 9 months.
Depressive disorders. Depression in young children is also associated with reductions
in positive affect. There is limited evidence, ho wever, to suggest that  children with depres-
sive disorders have impairments in attachment . That is, young children who have been di-
agnosed with depressive disord ers still should seek and resp ond to comforting efforts by
caregivers.
Comorbidity
Conditions associated with neglect, includin g cognitive delays, language delays, and ste-


Conditions associated with neglect, includin g cognitive delays, language delays, and ste-
reotypies, often co-occur with reactive atta chment disorder. Medical conditions, such as
severe malnutrition, may accompany signs of the disorder. Depressive symptoms also
may co-occur with reactive attachment disorder.
Disinhibited Social Engagement Disorder
Diagnostic Criteria 313.89 (F94.2)
A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar
adults and exhibits at least two of the following:
1. Reduced or absent reticence in approaching and interacting with unfamiliar adults.
2. Overly familiar verbal or physical behavior (that is not consistent with culturally
sanctioned and with age-appropriate social boundaries).
3. Diminished or absent checking back with adult caregiver after venturing away, even
in unfamiliar settings.
4. Willingness to go off with an unfamiliar adult with minimal or no hesitation.
B. The behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyper-
activity disorder) but include socially disinhibited behavior.
C. The child has experienced a pattern of extremes of insufficient care as evidenced by
at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having basic emotional
needs for comfort, stimulation, and affection met by caregiving adults.
2. Repeated changes of primary caregivers that limit opportunities to form stable at-
tachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form selective at-
tachments (e.g., institutions with high child-to-caregiver ratios).


Disinhibited Social Engagement Disorder 269
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Cri-
terion A (e.g., the disturbances in Criterion A began following the pathogenic care in
Criterion C).
E. The child has a developmental age of at least 9 months.
Specify if:
Persistent:  The disorder has been present for more than 12 months.
Specify current severity:
Disinhibited social engagement disorder is specified as severe  when the child exhibits
all symptoms of the disorder, with each symptom manifesting at relatively high levels.
Diagnostic Features
The essential feature of disinhibited social en gagement disorder is a pattern of behavior
that involves culturally inappropriate, overl y familiar behavior with relative strangers
(Criterion A). This overly familiar behavior violat es the social boundaries of the culture. A
diagnosis of disinhibited social engagement d isorder should not be made before children
are developmentally able to form selective attachments. For this reason, the child must
have a developmental age of at least 9 months.
Associated Features Supporting Diagnosis
Because of the shared etiological association with social neglect, disinhibited social en-
gagement disorder may co-occu r with developmental delays, especially cognitive and lan-
guage delays, stereotypies, and other signs of severe neglect, such as malnutrition or poor
care. However, signs of the disorder often per sist even after these other signs of neglect are
no longer present. Therefore, it is not uncomm on for children with the disorder to present
with no current signs of neglect. Moreover , the condition can present in children who
show no signs of disordered attachment. Th us, disinhibited social engagement disorder
may be seen in children with a history of neglect who lack attach ments or whose attach-
ments to their caregivers range from disturbed to secure.
Prevalence


ments to their caregivers range from disturbed to secure.
Prevalence
The prevalence of disinhibited social attachment disorder is unknown. Nevertheless, the
disorder appears to be rare, occurring in a mi nority of children, even those who have been
severely neglected and subsequently placed in fo ster care or raised in institutions. In such
high-risk populations, the condition occurs in only about 20% of ch ildren. The condition is
seen rarely in other clinical settings.
Development and Course
Conditions of social neglect are often present in the first months of life in children diag-
nosed with disinhibited social engagement di sorder, even before the disorder is diag-
nosed. However, there is no evidence that ne glect beginning after age 2 years is associated
with manifestations of the disorder. If ne glect occurs early and signs of the disorder
appear, clinical features of the disorder are moderately stable over time, particularly if
conditions of neglect pe rsist. Indiscriminate social behavior and lack of reticence with un-
familiar adults in toddlerhood are accompan ied by attention-seeking behaviors in pre-
schoolers. When the disorder persists into middle childhood, clinical features manifest as
verbal and physical overfamiliarity as well as  inauthentic expression of emotions. These
signs appear particularly apparent when the child interacts with adults. Peer relationships
are most affected in adolescence, with both  indiscriminate behavior and conflicts appar-
ent. The disorder has not been described in adults.


270 Trauma- and Stressor-Related Disorders
Disinhibited social engagement disorder ha s been described from  the second year of
life through adolescence. There are some differences in manifestations of the disorder
from early childhood through adolescence. At  the youngest ages, across many cultures,
children show reticenc e when interacting with strangers. Young children with the disorder
fail to show reticence to approach, engage with, and even accompany adults. In preschool
children, verbal and social intrusiveness appear most prominent, often accompanied by
attention-seeking behavior. Ve rbal and physical overfamiliarity continue through middle
childhood, accomp anied by inauthentic expressions of  emotion. In adolescence, indis-
criminate behavior extends to peers. Relative to healthy adolescents, adolescents with the
disorder have more “superficial” peer relationships and more peer conflicts. Adult man-
ifestations of the disorder are unknown.
Risk and Prognostic Factors
Environmental. Serious social neglect is a diagnost ic requirement for disinhibited social
engagement disorder and is also the only know n risk factor for the disorder. However, the
majority of severely neglected children do not develop the disorder . Neurobiological vul-
nerability may differentiate neglected childr en who do and do not develop the disorder.
However, no clear link with any specific neur obiological factors has been established. The
disorder has not been identified in children who experience social neglect only after age
2 years. Prognosis is only mode stly associated with quality of the caregiving environment
following serious neglect. In many cases, th e disorder persists, even in children whose
caregiving environment be comes markedly improved.
Course modifiers. Caregiving quality seems to moderate the course of disinhibited so-
cial engagement disorder. Nevertheless, ev en after placement in normative caregiving


cial engagement disorder. Nevertheless, ev en after placement in normative caregiving
environments, some children show persistent signs of the disorder, at least through ado-
lescence.
Functional Consequences of
Disinhibited Social Engagement Disorder
Disinhibited social engagement disorder significantly impairs young children’s abilities to
relate interpersonally to adults and peers.
Differential Diagnosis
Attention-deficit/hyperactivity disorder. Because of social impulsivity that sometimes
accompanies attention-deficit/hyperactivity di sorder (ADHD), it is necessary to differ-
entiate the two disorders. Children with disi nhibited social engagement disorder may be
distinguished from those with ADHD because th e former do not show difficulties with at-
tention or hyperactivity.
Comorbidity
Limited research has examined the issue of disorders comorbid with disinhibited social
engagement disorder. Conditions associated with neglect, including cognitive delays,
language delays, and stereotypies, may co-occu r with disinhibited social engagement dis-
order. In addition, children may be diagnosed with ADHD and disinhibited social engage-
ment disorder concurrently.


Posttraumatic Stress Disorder 271
Posttraumatic Stress Disorder
Diagnostic Criteria 309.81 (F43.10)
Posttraumatic Stress Disorder
Note:  The following criteria apply to adults, adolescents, and children older than 6 years.
For children 6 years and younger, see corresponding criteria below.
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or
more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurre d to a close family member or close
friend. In cases of actual or threatened death of a family member or friend, the
event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic
event(s) (e.g., first responders collecting human remains; police officers repeatedly
exposed to details of child abuse).
Note:  Criterion A4 does not apply to exposur e through electronic media, television,
movies, or pictures, unless this exposure is work related.
B. Presence of one (or more) of the following intrusion symptoms associated with the
traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive dist ressing memories of the traumatic event(s).
Note:  In children older than 6 years, repetitive play may occur in which themes or
aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are
related to the traumatic event(s).
Note:  In children, there may be frightening dreams without recognizable content.


Note:  In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if
the traumatic event(s) were recurring. (Such reactions may occur on a continuum,
with the most extreme expression being a complete loss of awareness of present
surroundings.)
Note:  In children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or re-
semble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after
the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about
or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations,
activities, objects, situations) that arouse distressing memories, thoughts, or feel-
ings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Inability to remember an important aspect of the trauma tic event(s) (typically due to dis-
sociative amnesia and not to other factors such as head injury, alcohol, or drugs).


272 Trauma- and Stressor-Related Disorders
2. Persistent and exaggerated negative beliefs or expectations about oneself, others,
or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely
dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic
event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), be-
ginning or worsening after the traumatic event(s) occurred, as evidenced by two (or
more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically ex-
pressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.
G. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g.,
medication, alcohol) or another medical condition.
Specify whether:


medication, alcohol) or another medical condition.
Specify whether:
With dissociative symptoms:  The individual’s symptoms meet the criteria for post-
traumatic stress disorder, and in addition, in response to the stressor, the individual ex-
periences persistent or recurrent symptoms of either of the following:
1.Depersonalization:  Persistent or recurrent experiences of feeling detached from,
and as if one were an outside observer of, one’s mental processes or body (e.g.,
feeling as though one were in a dream; feeling a sense of unreality of self or body
or of time moving slowly).
2.Derealization:  Persistent or recurrent experiences of unreality of surroundings
(e.g., the world around the individual is experienced as unreal, dreamlike, distant,
or distorted).
Note:  To use this subtype, the dissociative symptoms must not be attributable to the
physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxica-
tion) or another medical condition (e.g., complex partial seizures).
Specify if:
With delayed expression:  If the full diagnostic criteria are not met until at least 6 months
after the event (although the onset and expression of some symptoms may be immediate).
Posttraumatic Stress Disorder for Children 6 Years and Younger
A. In children 6 years and younger, exposure to actual or threatened death, serious injury,
or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others, especially primary care-
givers.


Posttraumatic Stress Disorder 273
Note:  Witnessing does not include events that are witnessed only in electronic me-
dia, television, movies, or pictures.
3. Learning that the traumatic event(s) o ccurred to a parent or caregiving figure.
B. Presence of one (or more) of the following intrusion symptoms associated with the
traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic
event(s).
Note:  Spontaneous and intrusive memories may not necessarily appear distress-
ing and may be expressed as play reenactment.
2. Recurrent distressing dreams in which the content and/or affect of the dream are
related to the traumatic event(s).
Note:  It may not be possible to ascertain that the frightening content is related to
the traumatic event.
3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the
traumatic event(s) were recurring. (Such reactions may occur on a continuum, with
the most extreme expression being a complete loss of awareness of present sur-
roundings.) Such trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to reminders of the traumatic event(s).
C. One (or more) of the following symptoms, representing either persistent avoidance of
stimuli associated with the traumatic event(s) or negative alterations in cognitions and
mood associated with the traumatic event(s), must be present, beginning after the
event(s) or worsening after the event(s):
Persistent Avoidance of Stimuli
1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse


1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse
recollections of the traumatic event(s).
2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations
that arouse recollections of the traumatic event(s).
Negative Alterations in Cognitions
3. Substantially increased frequency of negative emotional states (e.g., fear, guilt,
sadness, shame, confusion).
4. Markedly diminished interest or participation in significant activities, including con-
striction of play.
5. Socially withdrawn behavior.
6. Persistent reduction in expression of positive emotions.
D. Alterations in arousal and reactivity associated with the traumatic event(s), beginning
or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of
the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically ex-
pressed as verbal or physical aggression toward people or objects (including ex-
treme temper tantrums).
2. Hypervigilance.
3. Exaggerated startle response.
4. Problems with concentration.
5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
E. The duration of the disturbance is more than 1 month.


274 Trauma- and Stressor-Related Disorders
F. The disturbance causes clinically significant distress or impairment in relationships
with parents, siblings, peers, or other caregivers or with school behavior.
G. The disturbance is not attributable to the physiological effects of a substance (e.g.,
medication or alcohol) or another medical condition.
Specify whether:
With dissociative symptoms:  The individual’s symptoms meet the criteria for post-
traumatic stress disorder, and the individual experiences persistent or recurrent symp-
toms of either of the following:
1.Depersonalization:  Persistent or recurrent experiences of feeling detached from,
and as if one were an outside observer of, one’s mental processes or body (e.g.,
feeling as though one were in a dream; feeling a sense of unreality of self or body
or of time moving slowly).
2.Derealization:  Persistent or recurrent experiences of unreality of surroundings
(e.g., the world around the individual is experienced as unreal, dreamlike, distant,
or distorted).
Note:  To use this subtype, the dissociative symptoms must not be attributable to the
physiological effects of a substance (e.g., blackouts) or another medical condition
(e.g., complex partial seizures).
Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least
6 months after the event (although the onset and expression of some symptoms may
be immediate).
Diagnostic Features
The essential feature of posttraumatic stress disorder (PTSD) is the development of char-
acteristic symptoms following exposure to one or more tr aumatic events. Emotional re-
actions to the traumatic event (e.g., fear, he lplessness, horror) are no longer a part of
Criterion A. The clinical presentation of PTSD  varies. In some individuals, fear-based re-


Criterion A. The clinical presentation of PTSD  varies. In some individuals, fear-based re-
experiencing, emotional, and behavioral sy mptoms may predominate. In others, anhe-
donic or dysphoric mood states and negative cognitions may be most distressing. In some
other individuals, arousal an d reactive-externalizing symptoms are prominent, while in
others, dissociative symptoms predominate. Finally, some individuals exhibit combina-
tions of these symptom patterns.
The directly experienced traumatic events in  Criterion A include, but are not limited
to, exposure to war as a combatant or civilian,  threatened or actual physical assault (e.g.,
physical attack, robbery, mugging, childhood phy sical abuse), threatened or actual sexual
violence (e.g., forced sexual penetration, al cohol/drug-facilitated se xual penetration, abu-
sive sexual contact, noncontact sexual abuse,  sexual trafficking), being kidnapped, being
taken hostage, terrorist attack, torture, incarc eration as a prisoner of war, natural or hu-
man-made disasters, and severe motor vehicle accidents. For children, sexually violent
events may include developmentally inapprop riate sexual experiences without physical
violence or injury. A life-threatening illness or debilitating medical condition is not neces-
sarily considered a traumatic event. Medical in cidents that qualify as traumatic events in-
volve sudden, catastrophic ev ents (e.g., waking during su rgery, anaphylactic shock).
Witnessed events include, but are not limited to, observing threatened  or serious injury,
unnatural death, physical or sexual abuse of another person due to violent assault, domes-
tic violence, accident, war or di saster, or a medical catastrophe  in one’s child (e.g., a life-


threatening hemorrhage). Indirect exposure th rough learning about an event is limited to
experiences affecting close relatives or friend s and experiences that are violent or acciden-
tal (e.g., death due to natural causes does no t qualify). Such events include violent per-


Posttraumatic Stress Disorder 275
sonal assault, suicide, serious accident, and se rious injury. The disorder may be especially
severe or long-lasting when the stressor is interpersonal and intentiona l (e.g., torture, sex-
ual violence).
The traumatic event can be reexperienced in various ways. Commonly, the individual
has recurrent, involuntary, and intrusive recollect ions of the event (Criterion B1). Intrusive
recollections in PTSD are distinguished from depressive rumination in that they apply
only to involuntary and intrusive distressing memories. The emphasis is on recurrent
memories of the event that us ually include sensory, emotiona l, or physiological behavioral
components. A common reexperiencing symptom is distressing dreams that replay the
event itself or that are representative or th ematically related to th e major threats involved
in the traumatic event (Criterion B2). The in dividual may experience dissociative states
that last from a few seconds to several hours or even days , during which components of
the event are relived and the individual behaves as if the event were occurring at that mo-
ment (Criterion B3). Such events occur on a continuum from brief vi sual or other sensory
intrusions about part of the traumatic event wi thout loss of reality or ientation, to complete
loss of awareness of present surroundings. These episodes, often re ferred to as “flash-
backs,” are typically brief but can be associ ated with prolonged distress and heightened
arousal. For young children, reenactment of events related to trauma may appear in play
or in dissociative states. Intense psychological distress (Criterion B4) or physiological re-
activity (Criterion B5) often occurs when the individual is exposed to triggering events that


activity (Criterion B5) often occurs when the individual is exposed to triggering events that
resemble or symbolize an aspect of the trauma tic event (e.g., windy days after a hurricane;
seeing someone who resembles one’s perpetrator). The trigge ring cue could be a physical
sensation (e.g., dizziness for survivors of head trauma; rapid heartbeat for a previously
traumatized child), particularly for indivi duals with highly somatic presentations.
Stimuli associated with the trauma are pers istently (e.g., always or almost always)
avoided. The individual commonly makes delib erate efforts to avoid thoughts, memories,
feelings, or talking about the traumatic event (e .g., utilizing distraction techniques to avoid
internal reminders) (Criterion C1) and to av oid activities, objects, situations, or people
who arouse recollections of it (Criterion C2).
Negative alterations in cognitions or mood associated with the event begin or worsen
after exposure to the event. These negative al terations can take various forms, including an
inability to remember an important aspect of the traumatic event; such amnesia is typically
due to dissociative amnesia and is not due to he ad injury, alcohol, or drugs (Criterion D1).
Another form is persistent (i.e., always or almost always) and exaggerated negative ex-
pectations regarding important aspects of life a pplied to oneself, others, or the future (e.g.,
“I have always had bad judgment”; “People in  authority can’t be trusted”) that may man-
ifest as a negative change in perceived identi ty since the trauma (e.g., “I can’t trust anyone
ever again”; Criterion D2). Individuals with PTSD may have persistent erroneous cogni-
tions about the causes of the traumatic event that lead them to blame themselves or others


tions about the causes of the traumatic event that lead them to blame themselves or others
(e.g., “It’s all my fault that my uncle abused me”) (Criterion D3). A persistent negative
mood state (e.g., fear, horror, anger, guilt, shame) either began or worsened after exposure
to the event (Criterion D4). The individual may experience markedly diminished interest
or participation in previously enjoyed activities (C riterion D5), feeling detached or es-
tranged from other people (Criterion D6), or a persiste nt inability to feel positive emotions
(especially happiness, joy, satisfaction, or em otions associated with intimacy, tenderness,


tranged from other people (Criterion D6), or a persiste nt inability to feel positive emotions
(especially happiness, joy, satisfaction, or em otions associated with intimacy, tenderness,
and sexuality) (Criterion D7).
Individuals with PTSD may be quick temp ered and may even engage in aggressive
verbal and/or physical behavior with little or  no provocation (e.g., yelling at people, get-
ting into fights, destroying objects) (Criterion E1). They may also engage in reckless or self-
destructive behavior such as dangerous drivin g, excessive alcohol or drug use, or self-
injurious or suicidal behavior (Criterion E2).   PTSD is often characterized by a heightened
sensitivity to potential threats,  including t hose that are related to the traumatic experience
(e.g., following a motor vehicle accident, being especially sensitive to the threat potentially