ure of recall is absent. Other catatonic symptoms  (e.g., rigidity, post uring, negativism) are
usually present.
Factitious disorder and malingering. There is no test, battery of tests, or set of procedures
that invariably distinguishes dissociative am nesia from feigned amnesia. Individuals with
factitious disorder or malingering have been noted to continue their deception even during


that invariably distinguishes dissociative am nesia from feigned amnesia. Individuals with
factitious disorder or malingering have been noted to continue their deception even during
hypnotic or barbiturate-facilitated interviews. Feigned amnesia is more common in individ-
uals with 1) acute, florid dissociative amnesia; 2) financial, sexual, or legal problems; or 3) a
wish to escape stressful circumstances. True amnesia can be associated with those same cir-
cumstances. Many individuals who malinger confess spontane ously or when confronted.


302 Dissociative Disorders
Normal and age-related changes in memory. Memory decrements in major and mild
neurocognitive disorders differ from those of  dissociative amnesia, which are usually as-
sociated with stressful events and are more specific, extensive, and/or complex.
Comorbidity
As dissociative amnesia begins  to remit, a wide variety of  affective phenomena may sur-
face: dysphoria, grief, rage, shame, guilt, psychological conf lict and turmoil, and suicidal
and homicidal ideation, impulses, and acts. These individuals may have symptoms that
then meet diagnostic criteria  for persistent depressive disorder (dysthymia); major de-
pressive disorder; other specified or unspec ified depressive disord er; adjustment disor-
der, with depressed mood; or adjustment disorder, with mixed disturbance of emotions
and conduct. Many individuals with dissociative amnesia develop PTSD at some point
during their life, especially when the traumatic antecedent s of their amnesia are brought
into conscious awareness.
Many individuals with dissociative amnesia have symptoms that meet diagnostic cri-
teria for a comorbid somatic symptom or related disorder (and vice versa), including so-
matic symptom disorder and conversion di sorder (functional neurological symptom
disorder). Many individuals with dissociative  amnesia have symptoms  that meet diagnos-
tic criteria for a personality disorder, especially dependent, avoidant, and borderline.
Depersonalization/Derealization Disorder
Diagnostic Criteria 300.6 (F48.1)
A. The presence of persistent or recurrent experiences of depersonalization, derealiza-
tion, or both:
1.Depersonalization:  Experiences of unreality, detachment, or being an outside ob-


server with respect to one’s thoughts, feelings, sensations, body, or actions (e.g.,
perceptual alterations, distorted sense of time, unreal or absent self, emotional and/
or physical numbing).
2.Derealization:  Experiences of unreality or detachment with respect to surround-
ings (e.g., individuals or objects are ex perienced as unreal, dreamlike, foggy, life-
less, or visually distorted).
B. During the depersonalization or derealization experiences, reality testing remains intact.
C. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, medication) or another medical condition (e.g., seizures).
E. The disturbance is not better explained by another mental disorder, such as schizo-
phrenia, panic disorder, major depressive di sorder, acute stress disorder, posttrau-
matic stress disorder, or another dissociative disorder.
Diagnostic Features
The essential features of depe rsonalization/derealization diso rder are persistent or recur-
rent episodes of depersonalization, derealization, or both. Episodes of depersonalization
are characterized by a feeling of unreality or detachment from, or unfamiliarity with, one’s
whole self or from aspects of the self (Cri terion A1). The indivi dual may feel detached
from his or her entire being (e.g., “I am no on e,” “I have no self”). He or she may also feel
subjectively detached from aspects of the self , including feelings (e.g., hypoemotionality:


Depersonalization/Derealization Disorder 303
“I know I have feelings but I don’t feel them”), thoughts (e.g., “My thoughts don’t feel like
my own,” “head filled with cotton ”), whole body or body parts, or sensations (e.g., touch,
proprioception, hunger, thirst, libido). There may also be a diminished sense of agency
(e.g., feeling robotic, like an automaton; lacking control of one’s speech or movements).
The depersonalization experience can sometimes be one of a split self, with one part ob-
serving and one participating, known as an “o ut-of-body experience” in its most extreme
form. The unitary symptom of “depersonalization” consists of several symptom factors:
anomalous body experiences (i.e., unreality of  the self and perceptual alterations); emo-
tional or physical numbing; an d temporal distortions with anomalous subjective recall.
Episodes of derealization are characterize d by a feeling of unreality or detachment
from, or unfamiliarity with, the world, be it individuals, inanimate objects, or all surround-
ings (Criterion A2). The individual may feel as if he or she were in a fog, dream, or bubble, or
as if there were a veil or a glass wall between the individual and world around. Surround-
ings may be experienced as artificial, colorles s, or lifeless. Derealization is commonly ac-
companied by subjective visual distortions, su ch as blurriness, heig htened acuity, widened
or narrowed visual field, two-dimensionalit y or flatness, exaggerated three-dimensional-
ity, or altered distance or size of objects (i.e ., macropsia or micropsia). Auditory distortions


can also occur, whereby voices or sounds ar e muted or heightened. In addition, Criterion
C requires the presence of clinically signific ant distress or impairment in social, occupa-
tional, or other important areas of functionin g, and Criteria D and E describe exclusionary
diagnoses.
Associated Features Supporting Diagnosis
Individuals with depersonalization/derealizat ion disorder may have difficulty describ-
ing their symptoms and may think they are “crazy” or “going crazy”. Another common
experience is the fear of irreversible brai n damage. A commonly associated symptom is a
subjectively altered sense of time (i.e., too fast  or too slow), as well as a subjective difficulty
in vividly recalling past memories and owning  them as personal and emotional. Vague so-
matic symptoms, such as head fullness, ting ling, or lightheadedne ss, are not uncommon.
Individuals may suffer extreme rumination or  obsessional preoccupation (e.g., constantly
obsessing about whether they really exist, or checking their perc eptions to determine
whether they appear real). Varying degrees of  anxiety and depression are also common as-
sociated features. Individuals with the disord er have been found to have physiological
hyporeactivity to emotional stimuli. Neural substrates of interest include the hypotha-
lamic-pituitary-adrenocortical ax is, inferior parietal lobule, and prefrontal cortical-limbic
circuits.
Prevalence
Transient depersonalization/derealization sy mptoms lasting hours to days are common
in the general population. The 12-month prev alence of depersonalization/derealization
disorder is thought to be markedly less than  for transient symptoms, although precise es-


disorder is thought to be markedly less than  for transient symptoms, although precise es-
timates for the disorder are unavailable. In general, approximately one-half of all adults
have experienced at least one lifetime episode of depersonalization/derealization. How-
ever, symptomatology that meets full criter ia for depersonalization/derealization disor-
der is markedly less common than transient sy mptoms. Lifetime prevalence in U.S. and
non-U.S. countries is approximat ely 2% (range of 0.8% to 2. 8%). The gender ratio for the
disorder is 1:1.
Development and Course
The mean age at onset of depersonalization/derealization disorder is 16 years, although the
disorder can start in early or middle childhood; a minority cannot recall ever not having had


304 Dissociative Disorders
the symptoms. Less than 20% of individuals experience onset after age 20 years and only
5% after age 25 years. Onset in the fourth decade of life or later is highly unusual. Onset can
range from extremely sudden to gradual. Du ration of depersonalization/derealization
disorder episodes can vary greatly, from brief (hours or days) to prolonged (weeks,
months, or years). Given the rari ty of disorder onset after age 40 years, in such cases the in-
dividual should be examined more closely fo r underlying medical conditions (e.g., brain
lesions, seizure disorders, sl eep apnea). The course of the disorder is often persistent.
About one-third of cases involve discrete episodes; another third, continuous symptoms
from the start; and still another third, an initially episodic co urse that even tually becomes
continuous.
While in some individuals the intensity of symptoms can wax and wane considerably,
others report an unwavering level of intensity that in extreme cases can be constantly pres-
ent for years or decades. Internal and extern al factors that affect  symptom intensity vary
between individuals, yet some typical pattern s are reported. Exacerbations can be trig-
gered by stress, worsening mood or anxiety symptoms, novel or over stimulating settings,
and physical factors such as lighting or lack of sleep.
Risk and Prognostic Factors
Temperamental. Individuals with depersonalization/ derealization disorder are charac-
terized by harm-avoidant temperament, imma ture defenses, and both disconnection and
overconnection schemata. Imma ture defenses such as idea lization/devaluation, projec-
tion and acting out result in deni al of reality and poor adaptation. Cognitive disconnection


tion and acting out result in deni al of reality and poor adaptation. Cognitive disconnection
schemata  reflect defectiveness and emotional inhibi tion and subsume themes of abuse, ne-
glect, and deprivation. Overconnection schemata  involve impaired autonomy with themes
of dependency, vulnerability, and incompetence.
Environmental. There is a clear association between the disorder and childhood interper-
sonal traumas in a substantial portion of individu als, although this association is not as prev-
alent or as extreme in the nature of the trau mas as in other dissociative disorders, such as
dissociative identity disorder. In particular, emotional abuse and emotional neglect have been
most strongly and consistently associated with  the disorder. Other st ressors can include phys-
ical abuse; witnessing domestic  violence; growing up with a se riously impaired, mentally ill
parent; or unexpected de ath or suicide of a family member or close friend. Sexual abuse is a
much less common antecedent but can be encountered. The most common proximal precipi-
tants of the disorder are severe stress (interpersonal, financ ial, occupational), depression, anx-
iety (particularly panic attacks), and illicit drug  use. Symptoms may be specifically induced by
substances such as tetrahydrocannabinol, ha llucinogens, ketamine, MDMA (3,4-methylene-
dioxymethamphetamine; “ecstasy ”) and salvia. Marijuana use may precipitate new-onset
panic attacks and depersonalization/derealization symptoms simultaneously.
Culture-Related Diagnostic Issues
Volitionally induced experiences of depersonalization/dereali zation can be a part of med-
itative practices that are prevalent in many religions and cult ures and should not be diag-


itative practices that are prevalent in many religions and cult ures and should not be diag-
nosed as a disorder. However, there are in dividuals who initially induce these states
intentionally but over time lose control over  them and may develop a fear and aversion for
related practices.
Functional Consequences of
Depersonalization/De realization Disorder
Symptoms of depersonalization/derealization disorder are highly distressing and are as-
sociated with major morbidity. The affectivel y flattened and robotic demeanor that these


Depersonalization/Derealization Disorder 305
individuals often demonstrate may appear incongruent with the extreme emotional pain
reported by those with the disorder. Impairment is often experienced in both interpersonal
and occupational spheres, largel y due to the hypoemotionality with others, subjective diffi-
culty in focusing and retaining information, and a general sense of disconnectedness from
life.
Differential Diagnosis
Illness anxiety disorder. Although individuals with depersonalization/derealization dis-
order can present with vague somatic complaints as well as fears of permanent brain dam-
age, the diagnosis of depersonalization/derealization disorder is characterized by the
presence of a constellation of typical depersonalization/derealization symptoms and the ab-
sence of other manifestations  of illness anxiety disorder.
Major depressive disorder. Feelings of numbness, deadne ss, apathy, and being in a
dream are not uncommon in major depressive  episodes. However, in depersonalization/
derealization disorder, such symptoms are a ssociated with further symptoms of the dis-
order. If the depersonalization/derealization clearly precedes the onset of a major depres-
sive episode or clearly continues after its resolution, the diagnosis of depersonalization/
derealization disorder applies.
Obsessive-compulsive disorder. Some individuals with depersonalization/dereal-
ization disorder can become obsessively preo ccupied with their subjective experience or
develop rituals checking on the status of their symptoms. However, other symptoms of
obsessive-compulsive disorder  unrelated to depersonali zation/derealization are not
present.
Other dissociative disorders. In order to diagnose depersonalization/derealization
disorder, the symptoms should not occur in th e context of another dissociative disorder,


disorder, the symptoms should not occur in th e context of another dissociative disorder,
such as dissociative identity disorder. Differentiation from dissociative amnesia and con-
version disorder (functional neurological sy mptom disorder) is simpler, as the symptoms
of these disorders do not overlap with those of depersonalization/derealization disorder.
Anxiety disorders. Depersonalization/derealization is one of the symptoms of panic at-
tacks, increasingly common as panic attack severity increases. Therefore, depersonal-
ization/derealization disorder should not be diagnosed when the symptoms occur only
during panic attacks that are part of panic disorder, social anxiety disorder, or specific
phobia. In addition, it is not uncommon for depersonalization/derealization symptoms
to first begin in the context of new-onset pani c attacks or as panic disorder progresses and
worsens. In such presentations, the diagno sis of depersonalization/ derealization disorder
can be made if 1) the depersonalization/de realization component of  the presentation is
very prominent from the start, clearly exceed ing in duration and intensity the occurrence
of actual panic attacks; or 2) the depersona lization/derealization continues after panic dis-
order has remitted or has be en successfully treated.
Psychotic disorders. The presence of intact reality testing specifically regarding the
depersonalization/derealization symptoms is essential to differentiating depersonal-
ization/derealization disord er from psychotic disorder s. Rarely, positive-symptom
schizophrenia can pose a diagnostic challenge when nihilistic delusions are present. For
example, an individual may complain that he or she is dead or the world is not real; this
could be either a subjective experience that the individual knows is not true or a delusional
conviction.


conviction.
Substance/medication-induced disorders. Depersonalization/dere alization associated
with the physiological effects of substances duri ng acute intoxication or withdrawal is not
diagnosed as depersonalization/derealizatio n disorder. The most common precipitating
substances are the illicit drugs marijuana, hallucinogens, ketamine, ecstasy, and salvia. In


306 Dissociative Disorders
about 15% of all cases of depersonalization/derealization disorder, the symptoms are pre-
cipitated by ingestion of such substances. If the symptoms persist for some time in the ab-
sence of any further substance or medication  use, the diagnosis of depersonalization/
derealization disorder applies. This diagnosis is usually easy to establish since the vast ma-
jority of individuals with this presentation become highly phobic and aversive to the trig-
gering substance and do not use it again.
Mental disorders due to another medical condition. Features such as onset after age
40 years or the presence of atypical symptoms  and course in any individual suggest the
possibility of an underlying medical condition. In such cases, it is essential to conduct a
thorough medical and neurological evaluation, which may include standard laboratory
studies, viral titers, an electroencephalogram, ve stibular testing, visual testing, sleep stud-
ies, and/or brain imaging. When the suspicion of an underlying seizure disorder proves
difficult to confirm, an ambulatory electr oencephalogram may be indicated; although
temporal lobe epilepsy is most commonly implicated, pariet al and frontal lobe epilepsy
may also be associated.
Comorbidity
In a convenience sample of adults recruite d for a number of depersonalization research
studies, lifetime comorbidities were high for unipolar depressive disorder and for any
anxiety disorder, with a signific ant proportion of the sample having both disorders. Comor-
bidity with posttraumatic stress disorder was low. The three most commonly co-occurring
personality disorders were avoidant, borderline, and ob sessive-compulsive.
Other Specified Dissociative Disorder
300.15 (F44.89)


Other Specified Dissociative Disorder
300.15 (F44.89)
This category applies to presentations in which symptoms characteristic of a dissociative
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 dissociative disorders diagnostic class. The other specified dissocia-
tive 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 disso-
ciative disorder. This is done by recording “other specified dissociative disorder” followed
by the specific reason (e.g., “dissociative trance”).
Examples of presentations that can be specified using the “other specified” designation
include the following:
1.Chronic and recurrent syndromes of  mixed dissociative symptoms:  This cate-
gory includes identity disturbance associated with less-than-marked discontinuities in
sense of self and agency, or alterations of identity or episodes of possession in an in-
dividual who reports no dissociative amnesia.
2.Identity disturbance due to prolong ed and intense coercive persuasion:  Individ-
uals who have been subjected to intense coercive persuasion (e.g., brainwashing,
thought reform, indoctrination while captive, torture, long-term political imprisonment,
recruitment by sects/cults or by terror organizations) may present with prolonged
changes in, or conscious questioning of, their identity.
3.Acute dissociative reactions to stressful events:  This category is for acute, tran-
sient conditions that typically last less than 1 month, and sometimes only a few hours
or days. These conditions are characterized by constriction of consciousness; deper-


or days. These conditions are characterized by constriction of consciousness; deper-
sonalization; derealization; perceptual disturbances (e.g., time slowing, macropsia);


Unspecified Dissociative Disorder 307
micro-amnesias; transient stupor; and/or altera tions in sensory-motor functioning (e.g.,
analgesia, paralysis).
4.Dissociative trance:  This condition is characterized by an acute narrowing or com-
plete loss of awareness of immediate surroundings that manifests as profound unre-
sponsiveness or insensitivity to environmental stimuli. The unresponsiveness may be
accompanied by minor stereotyped behaviors (e.g., finger movements) of which the in-
dividual is unaware and/or that he or she cannot control, as well as transient paralysis
or loss of consciousness. The dissociative trance is not a normal part of a broadly ac-
cepted collective cultural or religious practice.
Unspecified Dissociative Disorder
300.15 (F44.9)
This category applies to presentations in which symptoms characteristic of a dissociative
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 dissociative disorders diagnostic class. The unspecified dissociative
disorder category is used in situations in which the clinician chooses not to specify the rea-
son that the criteria are not met for a specific dissociative disorder, and includes presen-
tations for which there is insufficient information to make a more specific diagnosis (e.g.,
in emergency room settings).


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309Somatic Symptom and
Related Disorders
Somatic symptom disorder  and other disorders with  prominent somatic symp-
toms constitute a new ca tegory in DSM-5 called somatic symptom an d related disorders.  This
chapter includes the diagnoses of somatic sy mptom disorder, illness anxiety disorder, con-
version disorder (functional neurological symptom disorder), psychological factors affect-
ing other medical conditions, factitious disorder, other specified somatic symptom and
related disorder, and unspecified somatic symp tom and related disorder. All of the disor-
ders in this chapter share a common feature: the prominence of soma tic symptoms associ-
ated with significant distress and impairment . Individuals with diso rders with prominent
somatic symptoms are commonly encountered in primary care and other medical settings
but are less commonly encountered in psychiatric and other mental health settings. These
reconceptualized diagnoses, based on a reorga nization of DSM-IV somatoform disorder di-
agnoses, are more useful for primary care and other medical (nonpsychiatric) clinicians.
The major diagnosis in this diagnostic cl ass, somatic symptom disorder, emphasizes
diagnosis made on the basis of positive sy mptoms and signs (distressing somatic symp-
toms plus abnormal thoughts,  feelings, and behaviors in response to these symptoms)
rather than the absence of a medical explanat ion for somatic symptoms. A distinctive char-
acteristic of many individuals with somati c symptom disorder is not the somatic symp-
toms per se, but instead the way they present and interpret them. Incorporating affective,
cognitive, and behavioral components into th e criteria for somatic symptom disorder pro-
vides a more comprehensive and accurate reflecti on of the true clinical picture than can be
achieved by assessing the somatic complaints alone.


achieved by assessing the somatic complaints alone.
The principles behind the changes in the somatic symptom and related diagnoses from
DSM-IV are crucial in understanding th e DSM-5 diagnoses. The DSM-IV term somatoform
disorders  was confusing and is replaced by somatic symptom and related disorders . In DSM-IV
there was a great deal of over lap across the somatoform disorders and a lack of clarity
about the boundaries of diag noses. Although individuals wi th these disorders primarily
present in medical rather than mental health  settings, nonpsychiatric physicians found the
DSM-IV somatoform diagnoses difficult to understand and use. The current DSM-5 clas-
sification recognizes this overlap by reducing the total number of disorders as well as their
subcategories.
The previous criteria overemphasized the cent rality of medically unexplained symptoms.
Such symptoms are present to various degrees, particularly in conver sion disorder, but so-
matic symptom disorders can also accompany diagnosed medical disorders. The reli-
ability of determining that a somatic sympto m is medically unexplai ned is limited, and
grounding a diagnosis on the absence of an  explanation is problematic and reinforces
mind-body dualism. It is not appropriate to give  an individual a mental disorder diagnosis
solely because a medical cause cannot be demo nstrated. Furthermore, the presence of a
medical diagnosis does not exclude the possibility of a comorbid ment al disorder, includ-
ing a somatic symptom and related disorder. Perhaps because of the predominant focus
on lack of medical explanation, individuals re garded these diagnoses as pejorative and de-
meaning, implying that their physical symp toms were not “real.” The new classification
defines the major diagnosis, somatic symptom d isorder, on the basis of positive symptoms


defines the major diagnosis, somatic symptom d isorder, on the basis of positive symptoms
(distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response


310 Somatic Symptom and Related Disorders
to these symptoms). However, medically unexplained symptoms remain a key feature in
conversion disorder and pseu docyesis (other specified somatic symptom and related dis-
order) because it is possible to demonstrate de finitively in such disorders that the symp-
toms are not consistent with medical pathophysiology.
It is important to note that some other ment al disorders may initially manifest with pri-
marily somatic symptoms (e.g., major depressi ve disorder, panic disorder). Such diagno-
ses may account for the somatic symptoms, or they may occur alongside one of the somatic
symptom and related diso rders in this chapter. There is also considerable medical comor-
bidity among somatizing individuals. Althou gh somatic symptoms are frequently associ-
ated with psychological distress and psyc hopathology, some somatic symptom and
related disorders can arise spontaneously, and their causes can remain obscure. Anxiety
disorders and depressive disorders may acco mpany somatic symptom and related disor-
ders. The somatic component adds severity an d complexity to depressive and anxiety dis-
orders and results in higher severity, functi onal impairment, and ev en refractoriness to
traditional treatments. In rare instances, the degree of preoccupation may be so severe as
to warrant consideration of a delusional disorder diagnosis.
A number of factors may contribute to so matic symptom and related disorders. These
include genetic and biological vulnerability (e.g., increased sensitivity to pain), early trau-
matic experiences (e.g., violence, abuse, deprivation), and learning (e.g., attention ob-
tained from illness, lack of reinforcement of nonsomatic expressions of distress), as well as
cultural/social norms that devalue and stig matize psychological suffering as compared


cultural/social norms that devalue and stig matize psychological suffering as compared
with physical suffering. Differences in medical care across cultures affect the presentation,
recognition, and management of these somatic presentations. Variations in symptom pre-
sentation are likely the result of the interact ion of multiple factors within cultural con-
texts that affect how individuals identify and classify bodily sensations, perceive illness,
and seek medical attention for them. Thus, somatic presentations can be viewed as expres-
sions of personal suffering inserted  in a cultural and social context.
All of these disorders are characterized by  the prominent focus on somatic concerns
and their initial presentation mainly in medical rather than mental health care settings. So-
matic symptom disorder offers a more clinica lly useful method of characterizing individ-
uals who may have been considered in the pa st for a diagnosis of somatization disorder.
Furthermore, approximately 75% of individuals previously  diagnosed with hypochon-
driasis are subsumed under the diagnosis of  somatic symptom diso rder. Howe ver, about
25% of individuals with hypoch ondriasis have high health anxiety in the absence of so-
matic symptoms, and many such individuals’ symptoms would not qualify for an anxiety
disorder diagnosis. The DSM-5 diagnosis of illness anxiety disorder is for this latter group
of individuals. Illness anxiety disorder can be considered eith er in this diagnostic section
or as an anxiety disorder. Because of the st rong focus on somatic concerns, and because ill-
ness anxiety disorder is most often encountere d in medical settings, for utility it is listed
with the somatic symptom and re lated disorders. In conversion  disorder, the essential fea-
ture is neurological symptoms that are foun d, after appropriate neurological assessment,
to be incompatible with neurological pathophysiology. Psychological factors affecting


to be incompatible with neurological pathophysiology. Psychological factors affecting
other medical conditions is also included in th is chapter. Its essential feature is the pres-
ence of one or more clinically significant psyc hological or behavioral factors that adversely


other medical conditions is also included in th is chapter. Its essential feature is the pres-
ence of one or more clinically significant psyc hological or behavioral factors that adversely
affect a medical condition by increasing the risk  for suffering, death, or disability. Like the
other somatic symptom and related disorders,  factitious disorder embodies persistent
problems related to illness percep tion and identity. In the great majority of reported cases
of factitious disorder, both imposed on self and imposed on another, individuals present
with somatic symptoms and medical disease convi ction. C onsequently, DSM-5 factitious
disorder is included among the somatic symp tom and related disorders. Other specified
somatic symptom and related disorder and un specified somatic symptom and related dis-
order include conditions for which some, but no t all, of the criteria for somatic symptom
disorder or illness anxiety disord er are met, as well as pseudocyesis.


Somatic Symptom Disorder 311
Somatic Symptom Disorder
Diagnostic Criteria 300.82 (F45.1)
A. One or more somatic symptoms that are distressing or result in significant disruption
of daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associ-
ated health concerns as manifested by at least one of the following:
1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of be-
ing symptomatic is persistent (typically more than 6 months).
Specify if:
With predominant pain  (previously pain disorder): This specifier is for individuals
whose somatic symptoms predominantly involve pain.
Specify if:
Persistent:  A persistent course is characterized by severe symptoms, marked impair-
ment, and long duration (more than 6 months).
Specify current severity:
Mild:  Only one of the symptoms specified in Criterion B is fulfilled.
Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.
Severe:  Two or more of the symptoms specified in Criterion B are fulfilled, plus there
are multiple somatic complaints (or one very severe somatic symptom).
Diagnostic Features
Individuals with somatic symptom disorder ty pically have multiple, current, somatic symp-
toms that are distressing or result in signific ant disruption of daily life (Criterion A), al-
though sometimes only one severe symptom,  most commonly pain, is present. Symptoms
may be specific (e.g., localized pain) or rela tively nonspecific (e.g., fatigue). The symptoms


sometimes represent normal bodi ly sensations or discomfort that does not generally sig-
nify serious disease. Somatic symptoms with out an evident medical explanation are not
sufficient to make this diagnosis. The individu al’s suffering is authen tic, whether or not it
is medically explained.
The symptoms may or may not be associated  with another medical condition. The di-
agnoses of somatic symptom disorder and a concurrent medical illness are not mutually
exclusive, and these frequently occur together . For example, an indi vidual may become se-
riously disabled by symptoms of somatic sy mptom disorder after an uncomplicated myo-
cardial infarction even if the myocardial infarc tion itself did not result in any disability. If
another medical condition or high risk for de veloping one is present (e.g., strong family
history), the thoughts, feelings, and behavior s associated with this condition are excessive
(Criterion B).
Individuals with somatic symptom disorder tend to have very high levels of worry
about illness (Criterion B). They appraise th eir bodily symptoms as unduly threatening,
harmful, or troublesome and often think the worst about their health. Even when there is
evidence to the contrary, some patients sti ll fear the medical seriousness of their symp-
toms. In severe somatic symptom disorder, he alth concerns may assume a central role in
the individual’s life, becoming a feature of his or her identity and dominating interper-
sonal relationships.


312 Somatic Symptom and Related Disorders
Individuals typically experience distress that  is principally focused on somatic symp-
toms and their significance. When asked direct ly about their distress, some individuals de-
scribe it in relation to other aspects of thei r lives, while others deny any source of distress
other than the somatic symptoms. Health-relat ed quality of life is often impaired, both
physically and mentally. In severe somatic symptom disorder, the impairment is marked,
and when persistent, the diso rder can lead to invalidism.
There is often a high level of medical care utilization, which rarely alleviates the individ-
ual’s concerns. Consequently, the patient may se ek care from multiple doctors for the same
symptoms. These individuals often seem unre sponsive to medical interventions, and new
interventions may only exacerbate the presenting symptoms . Some individuals with the dis-
order seem unusually sensitive to medication si de effects. Some feel that their medical as-
sessment and treatment have been inadequate.
Associated Features Supporting Diagnosis
Cognitive features include at tention focused on somatic symptoms, attribution of normal
bodily sensations to physical illness (possibly with catastrophic interpretations), worry
about illness, and fear that any physical activity may damage the body. The relevant as-
sociated behavioral features may include repe ated bodily checking for abnormalities, re-
peated seeking of medical help and reassurance, and avoidance of physical activity. These
behavioral features are most pronounced in severe, persistent somatic symptom disorder.
These features are usually associated with freq uent requests for medical help for different
somatic symptoms. This may lead to medical consultations in which individuals are so fo-
cused on their concerns about somatic symptom( s) that they cannot be redirected to other
matters. Any reassurance by the doctor that the symptoms are not indicative of serious


matters. Any reassurance by the doctor that the symptoms are not indicative of serious
physical illness tends to be short-lived and/ or is experienced by the individuals as the
doctor not taking their sympto ms with due seriousness. As  the focus on somatic symp-
toms is a primary feature of the disorder, in dividuals with somatic symptom disorder typ-
ically present to general medical health servic es rather than mental health services. The
suggestion of referral to a mental health spec ialist may be met with surprise or even frank
refusal by individuals with somatic symptom disorder.
Since somatic symptom disorder is associated with depressive disorders, there is an in-
creased suicide risk. It is not known whethe r somatic symptom disorder is associated with
suicide risk independent of its asso ciation with depressive disorders.
Prevalence
The prevalence of somatic symptom disorder is not known. However, the prevalence of
somatic symptom disorder is expected to be higher than that of the more restrictive DSM-
IV somatization disorder (<1%) but lower than  that of undifferentiated somatoform dis-
order (approximately 19%). The prevalence of  somatic symptom disorder in the general
adult population may be around 5%–7%. Fema les tend to report more somatic symptoms
than do males, and the preval ence of somatic symptom diso rder is consequently likely to
be higher in females.
Development and Course
In older individuals, somatic symptoms and concurrent medical illnesses are common,
and a focus on Criterion B is crucial for making the diagnosis. Somatic symptom disorder
may be underdiagnosed in older adults either because certain somatic symptoms (e.g.,
pain, fatigue) are considered part of normal aging or because illness worry is considered


pain, fatigue) are considered part of normal aging or because illness worry is considered
“understandable” in older adults who have  more general medical illnesses and medica-
tions than do younger people. Concurrent de pressive disorder is common in older people
who present with numerous somatic symptoms.


Somatic Symptom Disorder 313
In children, the most common  symptoms are recurrent abdominal pain, headache, fa-
tigue, and nausea. A single  prominent symptom is more common in children than in
adults. While young children may have somatic complaints, they rarely worry about “ill-
ness” per se prior to adolescence. The parents’ response to the sy mptom is important, as
this may determine the level of associated dist ress. It is the parent who may determine the
interpretation of symptoms and the associated time off school and medical help seeking.
Risk and Prognostic Factors
Temperamental. The personality trait of negative affe ctivity (neuroticism ) has been identi-
fied as an independent correlate/risk factor of a high number of somatic symptoms. Comorbid
anxiety or depression is common and ma y exacerbate symptoms and impairment.
Environmental. Somatic symptom disorder is more freq uent in individuals with few years
of education and low socioeconomic status, an d in those who have recently experienced
stressful life events.
Course modifiers. Persistent somatic symptoms are associated with demographic fea-
tures (female sex, older age, fewer years of education, lo wer socioeconomic status, un-
employment), a reported history of sexual ab use or other childhood adversity, concurrent
chronic physical illness or psychiatric disorder (depression, anxiety, persistent depressive
disorder [dysthymia], panic), social stress, and reinforcing social factors such as illness
benefits. Cognitive factors that affect clinical course include sensitization to pain, height-
ened attention to bodily sen sations, and attribution of bod ily symptoms to a possible med-
ical illness rather than recognizing them as a normal phenomenon or psychological stress.
Culture-Related Diagnostic Issues


Culture-Related Diagnostic Issues
Somatic symptoms are prominent in various “culture-bound syndromes.” High numbers
of somatic symptoms are found in population -based and primary care studies around the
world, with a similar pattern of the most commonly reported soma tic symptoms, impair-
ment, and treatment seeking. The relationship  between number of somatic symptoms and
illness worry is similar in different cultures, and marked illness worry is associated with
impairment and greater treatment seeking across cultures. The relationship between nu-
merous somatic symptoms and depression a ppears to be very similar around the world
and between different cult ures within one country.
Despite these similarities, th ere are differences in somatic symptoms among cultures
and ethnic groups. The description of somatic symptoms varies with linguistic and other
local cultural factors. These somatic presenta tions have been described as “idioms of dis-
tress” because somatic symptoms may have special meanings and shape patient-clinician
interactions in the particular cultural cont exts. “Burnout,” the sensation of heaviness or
the complaints of “gas”; too much heat in the body; or burning in the head are examples of
symptoms that are common in some cultures or ethnic groups but rare in others. Explan-
atory models also vary, and somatic symptoms may be attributed variously to particular
family, work, or environmental stresses; general medical illness; the suppression of feel-
ings of anger and resentment; or certain culture-specific ph enomena, such as semen loss.
There may also be differences in medical trea tment seeking among cultural groups, in ad-
dition to differences due to variable access to medical care services. Seeking treatment for
multiple somatic symptoms in general medical clinics is a worldwide phenomenon and
occurs at similar rates among ethnic groups in the same country.


occurs at similar rates among ethnic groups in the same country.
Functional Consequences of  Somatic Symptom Disorder
The disorder is associated with marked impa irment of health status. Many individuals
with severe somatic symptom disorder are lik ely to have impaired health status scores
more than 2 standard deviatio ns below population norms.


314 Somatic Symptom and Related Disorders
Differential Diagnosis
If the somatic symptoms are consistent with an other mental disorder (e.g., panic disorder),
and the diagnostic criteria for that disorder are fulfilled, then that mental disorder should
be considered as an alternative or additional diagnosis. A separate diagnosis of somatic
symptom disorder is not made if the somatic symptoms and related thoughts, feelings, or
behaviors occur only during major depressive episodes. If, as commonly occurs, the crite-
ria for both somatic symptom disorder and another mental disorder diagnosis are ful-
filled, then both should be coded, as both may require treatment.
Other medical conditions. The presence of somatic symptoms of unclear etiology is not
in itself sufficient to make the diagnosis of somatic symptom disorder. The symptoms of
many individuals with disorders like irritabl e bowel syndrome or fibromyalgia would not
satisfy the criterion necessary to diagnose somatic symptom disorder (Criterion B). Con-
versely, the presence of somatic symptoms of an established medical disorder (e.g., diabe-
tes or heart disease) does not exclude the di agnosis of somatic symptom disorder if the
criteria are otherwise met.
Panic disorder. In panic disorder, somatic symptoms  and anxiety about health tend to
occur in acute episodes, wher eas in somatic symptom disorder, anxiety and somatic symp-
toms are more persistent.
Generalized anxiety disorder. Individuals with generalized anxiety disorder worry about
multiple events, situations, or  activities, only one of whic h may involve their health. The
main focus is not usually somatic symptoms or fear of illness as it is in somatic symptom
disorder.
Depressive disorders. Depressive disorders are comm only accompanied by somatic
symptoms. However, depressive disorders ar e differentiated from somatic symptom dis-


symptoms. However, depressive disorders ar e differentiated from somatic symptom dis-
order by the core depressive symptoms of  low (dysphoric) mo od and anhedonia.
Illness anxiety disorder. If the individual has extensive worries about health but no or
minimal somatic symptoms, it ma y be more appropriate to consider illness anxiety disorder.
Conversion disorder (functional neurological symptom disorder). In conversion disor-
der, the presenting symptom is loss of function  (e.g., of a limb), whereas in somatic symp-
tom disorder, the focus is on the distress th at particular symptoms  cause. The features
listed under Criterion B of somatic symptom diso rder may be helpful in differentiating the
two disorders.
Delusional disorder. In somatic symptom disorder, the in dividual’s beliefs that somatic
symptoms might reflect serious underlying phy sical illness are not held with delusional
intensity. Nonetheless, the in dividual’s beliefs concerning the somatic symptoms can be
firmly held. In contrast, in delusional disorder, somatic subtype, the somatic symptom be-
liefs and behavior are stronger than th ose found in somatic symptom disorder.
Body dysmorphic disorder. In body dysmorphic disorder, the individual is excessively
concerned about, and preoccupied by, a perceived defect in his or her physical features. In
contrast, in somatic symptom disorder, the co ncern about somatic symptoms reflects fear
of underlying illness, not of  a defect in appearance.
Obsessive-compulsive disorder. In somatic symptom disorder , the recurrent ideas about
somatic symptoms or illness are less intrusive, and individuals with this disorder do not
exhibit the associated repetiti ve behaviors aimed at reducing  anxiety that occur in obses-
sive-compulsive disorder.
Comorbidity


sive-compulsive disorder.
Comorbidity
Somatic symptom disorder is associated with hi gh rates of comorbidity with medical dis-
orders as well as anxiety and depressive di sorders. When a concurrent medical illness is


Illness Anxiety Disorder 315
present, the degree of impairment is more ma rked than would be expected from the phys-
ical illness alone. When an individual’s sy mptoms meet diagnostic  criteria for somatic
symptom disorder, the disorder sh ould be diagnosed; however, in view of the frequent co-
morbidity, especially with anxiety and depre ssive disorders, evidence for these concur-
rent diagnoses should be sought.
Illness Anxiety Disorder
Diagnostic Criteria 300.7 (F45.21)
A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if pr esent, are only mild in intensity. If another
medical condition is present or there is a high risk for developing a medical condition
(e.g., strong family history is present), the preoccupation is clearly excessive or dispro-
portionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed about
personal health status.
D. The individual performs excessive health-related behaviors (e.g., repeatedly checks
his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doc-
tor appointments and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the specific illness
that is feared may change over that period of time.
F. The illness-related preoccupation is not better explained by another mental disorder, such
as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmor-
phic disorder, obsessive-compulsive disor der, or delusional disorder, somatic type.
Specify whether:
Care-seeking type:  Medical care, including physician visits or undergoing tests and
procedures, is frequently used.
Care-avoidant type:  Medical care is rarely used.
Diagnostic Features


Care-avoidant type:  Medical care is rarely used.
Diagnostic Features
Most individuals with hypochondriasis are now classified as having somatic symptom
disorder; however, in a minority of cases, th e diagnosis of illness anxiety disorder applies
instead. Illness anxiety disorder entails a pr eoccupation with having or acquiring a seri-
ous, undiagnosed medical illness (Criterion A) . Somatic symptoms are not present or, if
present, are only mild in intensity (Criterion B). A thorough evaluation fails to identify a
serious medical condition that accounts for the individual’s concer ns. While the concern
may be derived from a nonpathological physica l sign or sensation, the individual’s dis-
tress emanates not primar ily from the physical complaint it self but rather from his or her
anxiety about the meaning, significance, or ca use of the complaint (i.e., the suspected med-
ical diagnosis). If a physical sign or symptom is present, it is often a normal physiological
sensation (e.g., orthostatic dizziness), a benign  and self-limited dysf unction (e.g., transient
tinnitus), or a bodily discomfo rt not generally considered indicative of disease (e.g., belch-
ing). If a diagnosable medical condition is present, the individual’s anxiety and preoccu-
pation are clearly excessive and disproportionate  to the severity of the condition (Criterion
B). Empirical evidence and existing literatur e pertain to previously defined DSM hypo-
chondriasis, and it is unclear to what extent and how precisely they apply to the descrip-
tion of this new diagnosis.
The preoccupation with the idea that one is  sick is accompanied by substantial anxiety
about health and disease (Criterion C). Indivi duals with illness anxiety disorder are easily


316 Somatic Symptom and Related Disorders
alarmed about illness, such as by hearing abou t someone else falling ill or reading a health-
related news story. Their concerns about undiagnosed disease do not respond to appro-
priate medical reassurance, negative diagnostic  tests, or benign course. The physician’s at-
tempts at reassurance and symptom palliation generally do not alleviate the individual’s
concerns and may heighten them . Illness concerns assume a prominent place in the indi-
vidual’s life, affecting daily activities, and may even result in inva lidism. Illness becomes
a central feature of the individual’s identity and self-image, a frequent topic of social dis-
course, and a characteristic response to stressful life events. Individuals with the disorder
often examine themselves repeatedly (e.g., ex amining one’s throat in the mirror) (Crite-
rion D). They research their suspected disease excessively (e.g., on the Internet) and re-
peatedly seek reassurance from family, friends, or physicians. This incessant worrying often
becomes frustrating for others and may result in considerable strain within the family. In
some cases, the anxiety leads to maladaptive avoidance of situations (e.g., visiting sick
family members) or activities (e.g., exercise ) that these individuals fear might jeopardize
their health.
Associated Features Supporting Diagnosis
Because they believe they are medically ill, individuals with illness anxiety disorder are
encountered far more frequently in medical than  in mental health settings. The majority of
individuals with illness anxiety disorder have  extensive yet unsatisfactory medical care,
though some may be too anxious to seek medi cal attention. They generally have elevated
rates of medical utilization but do not utilize me ntal health services more than the general


rates of medical utilization but do not utilize me ntal health services more than the general
population. They often consult multiple physi cians for the same problem and obtain re-
peatedly negative diagnostic te st results. At times, medical attention leads to a paradoxical
exacerbation of anxiety or to iatrogenic complications from diagnostic tests and proce-
dures. Individuals with the disorder are genera lly dissatisfied with their medical care and
find it unhelpful, often feelin g they are not being taken seriously by physicians. At times,
these concerns may be justif ied, since physicians sometimes are dismissive or respond
with frustration or hostility. Th is response can occasionally result in a failure to diagnose
a medical condition that is present.
Prevalence
Prevalence estimates of illness anxiety disorder  are based on estimates of the DSM-III and
DSM-IV diagnosis hypochondriasis.  The 1- to 2-year prevalen ce of health anxiety and/or
disease conviction in community surveys and population-based samp les ranges from 1.3%
to 10%. In ambulatory medica l populations, the 6-month/1-ye ar prevalence rates are be-
tween 3% and 8%. The prevalence of the disorder is similar in  males and females.
Development and Course
The development and course of illness anxiety disorder are unclear. Illness anxiety disor-
der is generally thought to be a chronic and relapsing condition with an age at onset in
early and middle adulthood. In population-b ased samples, health -related anxiety in-
creases with age, but the ages of individuals with high health anxi ety in medical settings
do not appear to differ from those of other patients in those settings. In older individuals,


do not appear to differ from those of other patients in those settings. In older individuals,
health-related anxiety often focuses on memory loss; the disorder is thought to be rare in
children.
Risk and Prognostic Factors
Environmental. Illness anxiety disorder may sometimes be precipitated by a major life
stress or a serious but ultimately  benign threat to the individu al’s health. A history of child-


Illness Anxiety Disorder 317
hood abuse or of a serious childhood illness may predispose to deve lopment of the disor-
der in adulthood.
Course modifiers. Approximately one-third to one-half of individuals with illness anx-
iety disorder have a transient form, which is associated with less psychiatric comorbidity,
more medical comorbidity, and less severe illness anxiety disorder.
Culture-Related Diagnostic Issues
The diagnosis should be made with caution in  individuals whose ideas about disease are
congruent with widely held, culturally sanctioned beliefs. Little is known about the phe-
nomenology of the disorder acro ss cultures, although the prevalence appears to be similar
across different countries with diverse cultures.
Functional Consequences of  Illness Anxiety Disorder
Illness anxiety disorder causes substantial role impairment and decrements in physical
function and health-related quality of life. He alth concerns often interfere with interper-
sonal relationships, disrupt family life,  and damage occupational performance.
Differential Diagnosis
Other medical conditions. The first differential diagnostic  consideration is an underly-
ing medical condition, includin g neurological or endocrine conditions, occult malignan-
cies, and other diseases that affect multiple  body systems. The presence of a medical
condition does not rule out the possibility of coexisting illness anxiety disorder. If a med-
ical condition is present, the health-related  anxiety and disease concerns are clearly dis-
proportionate to its seriousnes s. Transient preoccupations related to a medical condition
do not constitute illn ess anxiety disorder.
Adjustment disorders. Health-related anxiety is a norm al response to serious illness
and is not a mental disorder. Such nonpathologic al health anxiety is clearly related to the
medical condition and is typica lly time-limited. If the health anxiety is severe enough, an


adjustment disorder may be diagnosed. Howeve r, only when the health anxiety is of suf-
ficient duration, severity, and distress can illnes s anxiety disorder be diagnosed. Thus, the
diagnosis requires the continuous  persistence of disproportio nate health-related anxiety
for at least 6 months.
Somatic symptom disorder. Somatic symptom disorder is diagnosed when significant
somatic symptoms are present. In contrast, individuals with illness anxiety disorder have
minimal somatic symptoms and are primarily concerned with the idea they are ill.
Anxiety disorders. In generalized anxiety disorder, individuals worry about multiple
events, situations, or activiti es, only one of which may invol ve health. In panic disorder,
the individual may be concerned that the pani c attacks reflect the presence of a medical ill-
ness; however, although these individuals may have health an xiety, their anxiety is typi-
cally very acute and episodic. In illness anxi ety disorder, the health anxiety and fears are
more persistent and enduring. Individuals wi th illness anxiety disorder may experience
panic attacks that are triggere d by their illness concerns.
Obsessive-compulsive and related disorders. Individuals with illness anxiety disor-
der may have intrusive though ts about having a disease and also may have associated
compulsive behaviors (e.g., seeking reassurance) . However, in illness anxiety disorder, the
preoccupations are usually focused on having  a disease, whereas in  obsessive-compulsive
disorder (OCD), the thoughts are intrusive an d are usually focused on fears of getting a
disease in the future. Most individuals with OCD have obsessions or compulsions involv-
ing other concerns in addition  to fears about contracting disease. In body dysmorphic dis-


318 Somatic Symptom and Related Disorders
order, concerns are limited to the individual’s physical appearance, which is viewed as
defective or flawed.
Major depressive disorder. Some individuals with a major depressive episode rumi-
nate about their health and worry excessively about illness. A separate diagnosis of illness
anxiety disorder is not made if these concer ns occur only during major depressive epi-
sodes. However, if excessive illness worry persists after remi ssion of an episode of major
depressive disorder, the diagnosis of illness anxiety disorder should be considered.
Psychotic disorders. Individuals with illness anxiety disorder are not delusional and
can acknowledge the possibility that the feared disease is no t present. Their ideas do not
attain the rigidity and intens ity seen in the somatic delusions occurring in psychotic dis-
orders (e.g., schizophrenia; delusional disord er, somatic type; major depressive disorder,
with psychotic features). True  somatic delusions are generall y more bizarre (e.g., that an
organ is rotting or dead) than  the concerns seen in illness  anxiety disorder. The concerns
seen in illness anxiety disorder, though not founded in reality, are plausible.
Comorbidity
Because illness anxiety disorder is a new di sorder, exact co morbidities are unknown. Hy-
pochondriasis co-occurs with anxiety disorders (in particular, generalized anxiety disor-
der, panic disorder, and OCD)  and depressive disorders. Approximately two-thirds of
individuals with illness anxiety disorder are lik ely to have at least one other comorbid ma-
jor mental disorder. Individuals with illness anxiety disorder may have an elevated risk
for somatic symptom disorder  and personality disorders.
Conversion Disorder
(Functional Neurological Symptom Disorder)
Diagnostic Criteria


Conversion Disorder
(Functional Neurological Symptom Disorder)
Diagnostic Criteria
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recog-
nized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social, oc-
cupational, or other important areas of functioning or warrants medical evaluation.
Coding note: The ICD-9-CM code for conversion disorder is 300.11, which is assigned
regardless of the symptom type. The ICD-10-CM code depends on the symptom type (see
below).
Specify symptom type:
(F44.4) With weakness or paralysis
(F44.4) With abnormal movement  (e.g., tremor, dystonic movement, myoclonus, gait
disorder)
(F44.4) With swallowing symptoms
(F44.4) With speech symptom  (e.g., dysphonia, slurred speech)
(F44.5) With attacks or seizures
(F44.6) With anesthesia or sensory loss
(F44.6) With special sensory symptom  (e.g., visual, olfactory, or hearing distur-
bance)
(F44.7) With mixed symptoms


Conversion Disorder (Functional Neurological Symptom Disorder) 319
Specify if:
Acute episode:  Symptoms present for less than 6 months.
Persistent:  Symptoms occurring for 6 months or more.
Specify if:
With psychological stressor  (specify stressor)
Without psychological stressor
Diagnostic Features
Many clinicians use the alternative names of “functional” (referring to abnormal central
nervous system functioning) or “psychogenic” (referring to an assumed etiology) to de-
scribe the symptoms of conversion disord er (functional neurol ogical symptom disor-
der). In conversion disorder, there may be on e or more symptoms of various types. Motor
symptoms include weakness or paralysis; abno rmal movements, such as tremor or dys-
tonic movements; gait abnormalities; and abnormal limb posturing. Sensory symptoms
include altered, reduced, or absent skin sens ation, vision, or hearing. Episodes of abnor-
mal generalized limb shaking with apparent im paired or loss of consciousness may resem-
ble epileptic seizures (also called psychogenic or non-epileptic seizures ). There may be
episodes of unresponsiveness  resembling syncope or coma. Other symptoms include re-
duced or absent speech volume (dysphonia/apho nia), altered articulation (dysarthria), a
sensation of a lump in the th roat (globus), and diplopia.
Although the diagnosis requires that the symptom is not explained by neurological
disease, it should not be ma de simply because results from investigations are normal or
because the symptom is “bizarre.” There must be clinical findings that show clear evidence
of incompatibility with neurological disease. Internal inconsistency at examination is one
way to demonstrate incompatibility (i.e., demonstrating that physical signs elicited


way to demonstrate incompatibility (i.e., demonstrating that physical signs elicited
through one examination method are no longer  positive when tested a different way). Ex-
amples of such examination findings include
• Hoover’s sign, in which weakness of hip exte nsion returns to normal strength with con-
tralateral hip flexio n against resistance.
• Marked weakness of ankle plantar-flexion when  tested on the bed in an individual who
is able to walk on tiptoes;
• Positive findings on the tremor entrainmen t test. On this test, a unilateral tremor may
be identified as functional if the tremor ch anges when the individual is distracted away
from it. This may be observed if the individual is asked to copy the examiner in making
a rhythmical movement with their unaffected hand and this causes the functional
tremor to change such that it copies or “entrains” to the rhythm of the unaffected hand
or the functional tremor is suppressed, or no longer makes a simple rhythmical move-
ment.
• In attacks resembling epilepsy or syncope (“ psychogenic” non-epileptic attacks), the
occurrence of closed eyes with resistance to  opening or a normal simultaneous electro-
encephalogram (although this alone does not exclude all forms of epilepsy or syncope).
• For visual symptoms, a tubular visual field (i.e., tunnel vision).
It is important to note that the diagnosis of conversion disorder should be based on the
overall clinical picture and not on a single clinical finding.
Associated Features Supporting Diagnosis
A number of associated featur es can support the diagnosis of  conversion disorder. There
may be a history of multiple similar somatic symptoms. Onset may be associated with
stress or trauma, either psychological or physi cal in nature. The potential etiological rele-


320 Somatic Symptom and Related Disorders
vance of this stress or trauma may be sugges ted by a close temporal  relationship. However,
while assessment for stress and trauma is im portant, the diagnosis should not be withheld
if none is found.
Conversion disorder is often associated wi th dissociative symptoms, such as deperson-
alization, derealization, and dissociative amne sia, particularly at symptom onset or during
attacks.
The diagnosis of conversion disorder does not require the judgment that the symptoms
are not intentionally produced (i.e., not feigne d), as the definite ab sence of feigning may
not be reliably discerned. The phenomenon of la belle indifférence  (i.e., lack of concern about
the nature or implications of the symptom)  has been associated wi th conversion disorder
but it is not specific for conver sion disorder and should not be  used to make the diagnosis.
Similarly the concept of secondary gain  (i.e., when individuals derive external benefits such
as money or release from respon sibilities) is also not specific to conversion disorder and
particularly in the context of definite evid ence for feigning, the diagnoses that should be
considered instead would include factitious disorder or malingering (see the section “Dif-
ferential Diagnosis” for this disorder).
Prevalence
Transient conversion symptoms are common, but the precise prevalence of the disorder is
unknown. This is partly because the diagnosis usually requires assessment in secondary
care, where it is found in approximately 5% of referrals to neurology clinics. The incidence
of individual persistent conversion sympto ms is estimated to be 2–5/100,000 per year.
Development and Course
Onset has been reported throughout the life course. The on set of non-epileptic attacks


peaks in the third decade, and motor symptoms have their peak onset in the fourth decade.
The symptoms can be transient or persistent. The prognosis may be better in younger chil-
dren than in adolescents and adults.
Risk and Prognostic Factors
Temperamental. Maladaptive personality traits ar e commonly associated with conver-
sion disorder.
Environmental. There may be a history of childhood  abuse and neglect. Stressful life
events are often, but not always, present.
Genetic and physiological. The presence of neurological disease that causes similar symp-
toms is a risk factor (e.g., non-epileptic se izures are more common in patients who also
have epilepsy).
Course modifiers. Short duration of symptoms and acceptance of the diagnosis are pos-
itive prognostic factors. Mala daptive personality traits, the presence of comorbid physical
disease, and the receipt of disability bene fits may be negative prognostic factors.
Culture-Related Diagnostic Issues
Changes resembling conversion (and dissoci ative) symptoms are common in certain
culturally sanctioned rituals. If the sympto ms are fully explained within the particular
cultural context and do not result in clinically significant  distress or disability, then the di-
agnosis of conversion di sorder is not made.
Gender-Related Diagnostic Issues
Conversion disorder is two to thre e times more common in females.


Conversion Disorder (Functional Neurological Symptom Disorder) 321
Functional Consequences of Conversion Disorder
Individuals with conversion symptoms may have substantial disability. The severity of dis-
ability can be similar to that experienced by individuals with comparable medical diseases.
Differential Diagnosis
If another mental disorder be tter explains the symptoms, th at diagnosis should be made.
However the diagnosis of conversion disorder may be made in the presence of another
mental disorder.
Neurological disease. The main differential diagnosis is neurological disease that might
better explain the symptoms. After a thorough  neurological assessment, an unexpected
neurological disease cause for the symptoms is rarely found at follow up. However, reas-
sessment may be required if the symptoms appe ar to be progressive. Conversion disorder
may coexist with neurological disease.
Somatic symptom disorder. Conversion disorder may be diagnosed in addition to so-
matic symptom disorder. Most of the somati c symptoms encountered in somatic symptom
disorder cannot be demonstrated to be clea rly incompatible with pathophysiology (e.g.,
pain, fatigue), whereas in conversion disorder , such incompatibility is required for the di-
agnosis. The excessive thoughts, feelings, and behaviors characterizing somatic symptom
disorder are often absent  in conversion disorder.
Factitious disorder and malingering. The diagnosis of conversion  disorder does not re-
quire the judgment that the symptoms are not intentionally produced  (i.e., not feigned),
because assessment of conscious intention is  unreliable. However definite evidence of
feigning (e.g., clear evidence that loss of fu nction is present during the examination but not
at home) would suggest a diagno sis of factitious disorder if the individual’s apparent aim
is to assume the sick role or malingering if the aim is to obtain an incentive such as money.


Dissociative disorders. Dissociative symptoms are co mmon in individuals with con-
version disorder. If both conversion disorder and a dissociati ve disorder are present, both
diagnoses should be made.
Body dysmorphic disorder. Individuals with body dysmorphic disorder are exces-
sively concerned about a perceived defect in th eir physical features bu t do not complain of
symptoms of sensory or motor functi oning in the affected body part.
Depressive disorders. In depressive disorders, individuals may report general heavi-
ness of their limbs, whereas the weakness of co nversion disorder is more focal and prom-
inent. Depressive disorders ar e also differentiated by the presence of core depressive
symptoms.
Panic disorder. Episodic neurological symptoms (e.g., tremors and paresthesias) can
occur in both conversion disorder and panic attacks. In panic attacks, the neurological
symptoms are typically transient and acutely episodic with characteristic cardiorespira-
tory symptoms. Loss of awareness with amne sia for the attack and violent limb move-
ments occur in non-epileptic atta cks, but not in panic attacks.
Comorbidity
Anxiety disorders, especially  panic disorder, and depressive disorders commonly co-occur
with conversion disorder. Somatic symptom diso rder may co-occur as well. Psychosis, sub-
stance use disorder, and alcohol misuse ar e uncommon. Personalit y disorders are more
common in individuals with conversion disorder than in the general population. Neuro-
logical or other medical cond itions commonly coexist with conversion disorder as well.


322 Somatic Symptom and Related Disorders
Psychological Factors Affecting
 Other Medical Conditions
Diagnostic Criteria 316 (F54)
A. A medical symptom or condition (other than a mental disorder) is present.
B. Psychological or behavioral factors adversely affect the medical condition in one of the
following ways:
1. The factors have influenced the course of the medical condition as shown by a
close temporal association between the psychological factors and the development
or exacerbation of, or delayed recovery from, the medical condition.
2. The factors interfere with the treatment of the medical condition (e.g., poor adher-
ence).
3. The factors constitute additional well-established health risks for the individual.
4. The factors influence the underlying pathophysiology, precipitating or exacerbating
symptoms or necessitating medical attention.
C. The psychological and behavioral factors in Criterion B are not better explained by an-
other mental disorder (e.g., panic disorder , major depressive disorder, posttraumatic
stress disorder).
Specify current severity:
Mild:  Increases medical risk (e.g., inconsistent adherence with antihypertension treat-
ment).
Moderate: Aggravates underlying medical condition (e.g., anxiety aggravating
asthma).
Severe:  Results in medical hospitalization or emergency room visit.
Extreme: Results in severe, life-threatening risk (e.g., ignoring heart attack symp-
toms).
Diagnostic Features
The essential feature of  psychological factors affecting other medical conditions is the
presence of one or more clinically significant  psychological or behavi oral factors that ad-
versely affect a medical condition by increasi ng the risk for suffering, death, or disability
(Criterion B). These factors can adversely affe ct the medical condition by influencing its


(Criterion B). These factors can adversely affe ct the medical condition by influencing its
course or treatment, by constituting an additi onal well-established health risk factor, or by
influencing the underlying pathophysiology to  precipitate or exac erbate symptoms or to
necessitate medical attention.
Psychological or behavioral factors include ps ychological distress, patterns of interper-
sonal interaction, coping styles, and maladaptiv e health behaviors, such as denial of symp-
toms or poor adherence to medical reco mmendations. Common clin ical examples are
anxiety-exacerbating asthma, denial of need for treatment for acute chest pain, and manip-
ulation of insulin by an individual with diab etes wishing to lose weight. Many different
psychological factors have been demonstrated  to adversely influence medical conditions—
for example, symptoms of depression or anxi ety, stressful life events, relationship style,
personality traits, and coping styles. The adverse effects can range from acute, with imme-
diate medical consequences (e.g., Takotsubo cardiomyopathy) to chronic, occurring over a
long period of time (e.g., chronic occupational  stress increasing risk for hypertension). Af-
fected medical conditions can be those with clear pathophysiology (e.g., diabetes, cancer,
coronary disease), functional syndromes (e.g ., migraine, irritable bowel syndrome, fibro-
myalgia), or idiopathic medical sympto ms (e.g., pain, fatigue, dizziness).


Psychological Factors Affecting Other Medical Conditions 323
This diagnosis should be reserved for situations in which the effect of the psychological
factor on the medical condition is evident and the psychological factor has clinically sig-
nificant effects on the course or outcome of  the medical condition. Abnormal psychologi-
cal or behavioral symptoms that develop in  response to a medical condition are more
properly coded as an adjustme nt disorder (a clinically significant psychological response
to an identifiable stressor). Th ere must be reasonable eviden ce to suggest an association
between the psychological factors and the medical condition, although it may often not be
possible to demonstrate direct causality or  the mechanisms underlying the relationship.
Prevalence
The prevalence of psychological factors affect ing other medical conditions is unclear. In
U.S. private insurance billing data, it is a more common diagnosis than somatic symptom
disorders.
Development and Course
Psychological factors affecting other medical conditions can occur across the lifespan. Par-
ticularly with young children, corroborative history from parents or school can assist the di-
agnostic evaluation. Some conditions are characteri stic of particular life stages (e.g., in older
individuals, the stress associated with acting as a caregiver for an ill spouse or partner).
Culture-Related Diagnostic Issues
Many differences between cult ures may influence psychologi cal factors and their effects
on medical conditions, such as those in la nguage and communication style, explanatory
models of illness, patterns of seeking health care, service availability and organization,
doctor-patient relationships and other healing practices, family and gender roles, and at-
titudes toward pain and death. Psychologica l factors affecting other medical conditions
must be differentiated from culturally specific  behaviors such as using faith or spiritual
healers or other variations in illness manageme nt that are acceptable within a culture and


healers or other variations in illness manageme nt that are acceptable within a culture and
represent an attempt to help the medical condition rather than interfere with it. These local
practices may complement rather than obstruct  evidence-based interventions. If they do
not adversely affect out comes, they should not be pathol ogized as psychological factors
affecting other medical conditions.
Functional Consequences of Psychological Factors
Affecting Other Medical Conditions
Psychological and behavioral factors have been demonstrated to affect the course of many
medical diseases.
Differential Diagnosis
Mental disorder due to another medical condition. A temporal association between
symptoms of a mental disorder and those of a medical condition is also  characteristic of a
mental disorder due to another medical condition, but the presumed causality is in the op-
posite direction. In a mental disorder du e to another medical condition, the medical
condition is judged to be caus ing the mental disorder through a direct physiological mech-
anism. In psychological factors affecting other medical conditions, the psychological or be-
havioral factors are judged to affect the course of the medical condition.
Adjustment disorders. Abnormal psychological or behavioral symptoms that develop in
response to a medical condition are more proper ly coded as an adjustment disorder (a clin-
ically significant psychological response to an identifiable stressor). For example, an indi-


324 Somatic Symptom and Related Disorders
vidual with angina that is precipitated when ever he becomes enraged would be diagnosed
as having psychological factors affecting ot her medical conditions, whereas an individual
with angina who developed maladaptive anticipatory anxiety would be diagnosed as hav-
ing an adjustment disorder with anxiety. In clinical practice, however, psychological fac-
tors and a medical condition are often mutua lly exacerbating (e.g., anxiety as both a
precipitant and a consequence of angina), in which case the distinction is arbitrary. Other
mental disorders frequently result in medica l complications, most notably substance use
disorders (e.g., alcohol use disorder, tobacco use disorder). If an indi vidual has a coexisting
major mental disorder that adversely affects or causes another medical condition, diagno-
ses of the mental disorder and the medical co ndition are usually sufficient. Psychological
factors affecting other medical conditions is diagnosed when the psychological traits or
behaviors do not meet criteria for a mental diagnosis.
Somatic symptom disorder. Somatic symptom disorder is characterized by a combina-
tion of distressing somatic symptoms and ex cessive or maladaptive thoughts, feelings,
and behavior in response to these symptoms or associated health co ncerns. The individual
may or may not have a diagnosable medical cond ition. In contrast, in psychological factors
affecting other medical conditions, the psycho logical factors advers ely affect a medical
condition; the individual’s th oughts, feelings, and behavior  are not necessarily excessive.
The difference is one of emphasis, rather than a clear-cut distinction. In psychological fac-
tors affecting other medical conditions, the emphasis is on the exacerbation of the medical
condition (e.g., an individual with angina th at is precipitated whenever he becomes anx-


ious). In somatic symptom disorder, the empha sis is on maladaptive thoughts, feelings,
and behavior (e.g., an individual with angina  who worries constantly that she will have a
heart attack, takes her blood pressure multiple  times per day, and restricts her activities).
Illness anxiety disorder. Illness anxiety disorder is charac terized by high illness anxiety
that is distressing and/or disruptive to daily life with minimal somatic symptoms. The fo-
cus of clinical concern is the individual’s wo rry about having a disease; in most cases, no
serious disease is present. In psychological factors affecting other medical conditions, anx-
iety may be a relevant psychological factor affecting a medical condition, but the clinical
concern is the adverse effects on the medical condition.
Comorbidity
By definition, the diagnosis of psychological fa ctors affecting other medi cal conditions entails
a relevant psychological or behavioral syndro me or trait and a comorbid medical condition.
Factitious Disorder
Diagnostic Criteria 300.19 (F68.10)
Factitious Disorder Imposed on Self
A. Falsification of physical or psychological signs or symptoms, or induction of injury or
disease, associated with identified deception.
B. The individual presents himself or herself to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional
disorder or another psychotic disorder.
Specify:
Single episode
Recurrent episodes  (two or more events of falsification of illness and/or induction of
injury)


Factitious Disorder 325
Factitious Disorder Imposed on Another
(Previously Factitious Disorder by Proxy)
A. Falsification of physical or psychological signs or symptoms, or induction of injury or
disease, in another, associated with identified deception.
B. The individual presents another individual (vic tim) to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional
disorder or another psychotic disorder.
Note: The perpetrator, not the victim, receives this diagnosis.
Specify:
Single episode
Recurrent episodes  (two or more events of falsification of illness and/or induction of
injury)
Recording Procedures
When an individual falsifies illness in another (e .g., children, adults, pets), the diagnosis is
factitious disorder imposed on another. The pe rpetrator, not the victim, is given the diag-
nosis. The victim may be given an abuse di agnosis (e.g., 995.54 [T74.12X]; see the chapter
“Other Conditions That May Be a Focus of Clinical Attention”).
Diagnostic Features
The essential feature of factitious disorder is th e falsification of medical or psychological signs
and symptoms in oneself or others that are as sociated with the identified deception. Indi-
viduals with factitious disorder can also seek  treatment for themselves  or another following
induction of injury or disease. The diagnosis requires demonstrating that the individual is
taking surreptitious actions to misrepresent, simulate, or ca use signs or symptoms of ill-
ness or injury in the absence of obvious exte rnal rewards. Methods of illness falsification
can include exaggeration, fabrication, simula tion, and induction. While a preexisting med-


ical condition may be present,  the deceptive behavior or induction of injury associated
with deception causes others to view such in dividuals (or another) as more ill or impaired,
and this can lead to excessive clinical intervention. Individuals with factitious disorder
might, for example, report feelings of depres sion and suicidality following the death of a
spouse despite the death not being true or the individual’s not ha ving a spouse; decep-
tively report episodes of neurological symptoms  (e.g., seizures, dizzine ss, or blacking out);
manipulate a laboratory test (e .g., by adding blood to urine) to falsely indicate an abnor-
mality; falsify medical records to indicate an  illness; ingest a substance (e.g., insulin or
warfarin) to induce an abnormal laboratory result or illness; or physically injure them-
selves or induce illness in themselves or anot her (e.g., by injecting fecal material to produce
an abscess or to induce sepsis).
Associated Features Supporting Diagnosis
Individuals with factitious disorder imposed on  self or factitious disorder imposed on an-
other are at risk for experiencing great psyc hological distress or functional impairment by
causing harm to themselves and others. Family , friends, and health care professionals are
also often adversely affected by their behavi or. Factitious disorders have similarities to
substance use disorders, eating disorders, im pulse-control disorders,  pedophilic disorder,
and some other established disorders related to  both the persistence of the behavior and
the intentional efforts to conceal the disord ered behavior through deception. Whereas
some aspects of factitious disorders might represent criminal behavior (e.g., factitious dis-


326 Somatic Symptom and Related Disorders
order imposed on another, in  which the parent’s actions represent abuse and maltreat-
ment of a child), such criminal  behavior and mental illness are not mutually exclusive. The
diagnosis of factitious disorder emphasizes the objective identification of falsification of
signs and symptoms of illness, rather than an inference abou t intent or possible underly-
ing motivation. Moreover, such behaviors, incl uding the induction of injury or disease, are
associated with deception.
Prevalence
The prevalence of factitious disorder is unknow n, likely because of the role of deception in
this population. Among patients in hospital sett ings, it is estimated that about 1% of indi-
viduals have presentations that meet the criteria for factitious disorder.
Development and Course
The course of factitious disorder is usually one of intermittent episodes. Single episodes
and episodes that are characterized as pers istent and unremitting are both less common.
Onset is usually in early adulthood, often after hospitalization for a medical condition or a
mental disorder. When imposed on another, the disorder may begin after hospitalization
of the individual’s child or other dependent. In individuals with recu rrent episodes of fal-
sification of signs and symptoms of illness and/ or induction of injury, this pattern of suc-
cessive deceptive contact with medical personnel, including hospitalizations, may become
lifelong.
Differential Diagnosis
Caregivers who lie about abuse injuries in depe ndents solely to protect themselves from lia-
bility are not diagnosed with factitious disord er imposed on another because protection from
liability is an external reward (Criterion C, th e deceptive behavior is evident even in the ab-
sence of obvious external rewards). Such caregi vers who, upon observation, analysis of med-


ical records, and/or interviews with others, are found to lie more extensively than needed for
immediate self-protect ion are diagnosed with factitious disorder imposed on another.
Somatic symptom disorder. In somatic symptom disorder, there may be excessive at-
tention and treatment seeking for perceived medical concerns, but there is no evidence that
the individual is providing false info rmation or behaving deceptively.
Malingering. Malingering is differentiated from fact itious disorder by the intentional re-
porting of symptoms for personal gain (e.g., money, time off work). In contrast, the diag-
nosis of factitious disorder requires  the absence of obvious rewards.
Conversion disorder (functional neurological symptom disorder). Conversion disorder
is characterized by neurological symptoms that  are inconsistent with neurological patho-
physiology. Factitious disorder with neurological symptoms is distinguished from con-
version disorder by evidence of de ceptive falsification of symptoms.
Borderline personality disorder. Deliberate physical self-harm in the absence of suicidal
intent can also occur in association with other mental disorders su ch as borderline person-
ality disorder. Factitious disord er requires that the induction of injury occur in association
with deception.
Medical condition or mental disorder not associated with intentional symptom falsifi-
cation. Presentation of signs and sy mptoms of illness that do not conform to an identi-
fiable medical condition or mental disorder increases the likelihood of the presence of a
factitious disorder. However, the diagnosis of factitious disorder does not exclude the
presence of true medical cond ition or mental disorder, as comorbid illness often occurs in
the individual along with factitious disord er. For example, individuals who might manip-
ulate blood sugar levels to produce symptoms may also have diabetes.


Other Specified Somatic Symptom and Related Disorder 327
Other Specified Somatic Symptom and
Related Disorder
300.89 (F45.8)
This category applies to presentations in which symptoms characteristic of a somatic
symptom and related disorder that cause clinically significant distress or impairment in so-
cial, occupational, or other important areas of functioning predominate but do not meet the
full criteria for any of the disorders in the somatic symptom and related disorders diagnos-
tic class.
Examples of presentations that can be specified using the “other specified” designation
include the following:
1.Brief somatic symptom disorder:  Duration of symptoms is less than 6 months.
2.Brief illness anxiety disorder:  Duration of symptoms is less than 6 months.
3.Illness anxiety disorder without excessive health-related behaviors:  Criterion D
for illness anxiety disorder is not met.
4.Pseudocyesis:  A false belief of being pregnant that is associated with objective signs
and reported symptoms of pregnancy.
Unspecified Somatic Symptom and
Related Disorder
300.82 (F45.9)
This category applies to presentations in which symptoms characteristic of a somatic
symptom and related disorder that cause clinically significant distress or impairment in so-
cial, occupational, or other important areas of functioning predominate but do not meet the
full criteria for any of the disorders in the somatic symptom and related disorders diagnos-
tic class. The unspecified somatic symptom and related disorder category should not be
used unless there are decidedly unusual situations where there is insufficient information
to make a more specific diagnosis.


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329Feeding and
Eating Disorders
Feeding and eating  disorders are characterized by a persistent disturbance of eat-
ing or eating-related behavior that results in the altered consumption or absorption of
food and that significantly impairs physical he alth or psychosocial functioning. Diagnos-
tic criteria are provid ed for pica, rumination disorder, avoidant/restrictive food intake
disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder.
The diagnostic criteria for rumination diso rder, avoidant/restrictive food intake dis-
order, anorexia nervosa,  bulimia nervosa, and binge-eating  disorder result in a classifica-
tion scheme that is mutually ex clusive, so that during a sing le episode, only one of these
diagnoses can be assigned. The rationale for this approach is that, despite a number of
common psychological and behavioral features , the disorders differ substantially in clin-
ical course, outcome, and treatment needs. A diagnosis of pica, however, may be assigned
in the presence of any other feeding and eating disorder.
Some individuals with disorders described in  this chapter report eating-related symp-
toms resembling those typically endorsed by individuals with substance use disorders,
such as craving and patterns of compulsive use. This resemblance may reflect the involve-
ment of the same neural systems, including th ose implicated in regulatory self-control and
reward, in both groups of disorders. Howeve r, the relative contributions of shared and
distinct factors in the development and perp etuation of eating an d substance use disor-
ders remain insuffic iently understood.
Finally, obesity is not included in DSM-5 as  a mental disorder. Obesity (excess body fat)
results from the long-term excess of energy in take relative to energy expenditure. A range


results from the long-term excess of energy in take relative to energy expenditure. A range
of genetic, physiological, behavioral, and en vironmental factors that vary across individ-
uals contributes to the development of obesit y; thus, obesity is not considered a mental
disorder. However, there are ro bust associations between ob esity and a number of mental
disorders (e.g., binge-eating disorder, depre ssive and bipolar disorders, schizophrenia).
The side effects of some psychotropic medica tions contribute importantly to the develop-
ment of obesity, and obesity may be a risk fa ctor for the development of some mental dis-
orders (e.g., depr essive disorders).
Pica
Diagnostic Criteria
A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.
B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental
level of the individual.
C. The eating behavior is not part of a culturally  supported or socially normative practice.
D. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual
disability [intellectual developmental disorder], autism spectrum disorder, schizophre-
nia) or medical condition (including pregnancy), it is sufficiently severe to warrant ad-
ditional clinical attention.


330 Feeding and Eating Disorders
Coding note:  The ICD-9-CM code for pica is 307.52 and is used for children or adults.
The ICD-10-CM codes for pica are (F98.3)  in children and (F50.8)  in adults.
Specify if:
In remission:  After full criteria for pica were previously met, the criteria have not been
met for a sustained period of time.
Diagnostic Features
The essential feature of pica is the eating of on e or more nonnutritive, nonfood substances on a
persistent basis over a period of at least 1 month (Criterion A) that is severe enough to warrant
clinical attention. Typical substances ingested te nd to vary with age and availability and might
include paper, soap, cloth, hair , string, wool, soil, chalk, talc um powder, paint, gum, metal,
pebbles, charcoal or coal, ash, clay, starch, or ice. The term nonfood  is included because the di-
agnosis of pica does not apply to ingestion of diet products that have minimal nutritional con-
tent. There is typically no aversion to food in general. The eating of nonnutritive, nonfood
substances must be developmentally inappropriate (Criterion B)  and not part of a culturally
supported or socially normativ e practice (Criterion C). A minimum age of 2 years is suggested
for a pica diagnosis to exclude developmentally normal mouthing of objects by infants that re-
sults in ingestion. The eating of nonnutritive, nonfood substances can be an associated feature
of other mental disorders (e.g., intellectual disability [intellectual developmental disorder],
autism spectrum disorder, schizo phrenia). If the eating behavior occurs exclusively in the con-


text of another mental disorder, a separate diagnosis of pica should be made only if the eating
behavior is sufficiently severe to warrant additional clinical attention (Criterion D).
Associated Features Supporting Diagnosis
Although deficiencies in vitamins or minerals (e .g., zinc, iron) have been reported in some
instances, often no specific biological abnorm alities are found. In some cases, pica comes
to clinical attention only following general medical complications (e.g., mechanical bowel
problems; intestinal obstruction,  such as that resulting from  a bezoar; intestinal perfora-
tion; infections such as toxoplasmosis and toxoca riasis as a result of ingesting feces or dirt;
poisoning, such as by ingestion of lead-based paint).
Prevalence
The prevalence of pica is unclear. Among in dividuals with intellectual disability, the prev-
alence of pica appears to increase with the severity of the condition.
Development and Course
Onset of pica can occur in childhood, adolesce nce, or adulthood, although childhood onset
is most commonly reported. Pi ca can occur in otherwise normally developing children,
whereas in adults, it appears more likely to o ccur in the context of intellectual disability or
other mental disorders. The ea ting of nonnutritive, nonfood substances may also manifest
in pregnancy, when specific cravings (e.g., chalk or ice) might occur. The diagnosis of pica
during pregnancy is only appropriate if such  cravings lead to the ingestion of nonnutri-
tive, nonfood substances to the extent that th e eating of these substances poses potential
medical risks. The course of th e disorder can be protracted an d can result in medical emer-
gencies (e.g., intestinal obstruction, acute weight loss, poisoning). The disorder can poten-


tially be fatal depending on substances ingested.
Risk and Prognostic Factors
Environmental. Neglect, lack of supervision, and de velopmental delay can increase the
risk for this condition.


Pica 331
Culture-Related Diagnostic Issues
In some populations, the eating of earth or other seemingly nonn utritive substances is believed
to be of spiritual, medicinal, or  other social value, or may be a culturally supported or socially
normative practice. Such  behavior does not warrant a di agnosis of pica (Criterion C).
Gender-Related Diagnostic Issues
Pica occurs in both males and females. It ca n occur in females during pregnancy; however,
little is known about the course of pica in the postpartum period.
Diagnostic Markers
Abdominal flat plate radiography, ultrasound, and other scanning methods may reveal
obstructions related to pica. Blood tests and other laboratory tests can be used to ascertain
levels of poisoning or the nature of infection.
Functional Consequences of Pica
Pica can significantly impair physical functioning,  but it is rarely the sole cause of impair-
ment in social functioning. Pica often occu rs with other disorders associated with im-
paired social functioning.
Differential Diagnosis
Eating of nonnutritive, nonfood substances may occur during the course of other mental
disorders (e.g., autism spectr um disorder, schizophrenia) an d in Kleine-Levin syndrome.
In any such instance, an additional diagnosis of pica should be given only if the eating be-
havior is sufficiently persistent and severe to warrant additional clinical attention.
Anorexia nervosa. Pica can usually be distinguished from the other feeding and eating
disorders by the consumption of  nonnutritive, nonfoo d substances. It is important to note,
however, that some presentations of anorexia nervosa include ingestion of nonnutritive,
nonfood substances, such as paper tissues, as a means of attempting to control appetite. In


nonfood substances, such as paper tissues, as a means of attempting to control appetite. In
such cases, when the eating of nonnutritive,  nonfood substances is primarily used as a
means of weight control, anorexia ne rvosa should be the primary diagnosis.
Factitious disorder. Some individuals with factitious disorder may intentionally ingest
foreign objects as part of the pattern of fals ification of physical symptoms. In such in-
stances, there is an element of deception that is consistent with deliberate induction of in-
jury or disease.
Nonsuicidal self-injury and nonsuicidal self -injury behaviors in personality disorders.
Some individuals may swallow potentially harm ful items (e.g., pins, needles, knives) in
the context of maladaptive be havior patterns associated with personality disorders or
nonsuicidal self-injury.
Comorbidity
Disorders most commonly comorb id with pica are autism spectrum disorder and intellec-
tual disability (intellectual deve lopmental disorder), and, to a lesser degree, schizophrenia
and obsessive-compulsive disorder. Pica can be associated with trichotillomania (hair-
pulling disorder) and exco riation (skin-picking) disorder. In comorbid presentations, the
hair or skin is typically ingested. Pica can al so be associated with av oidant/restrictive food
intake disorder, particularly in individuals with a strong sensory component to their pre-
sentation. When an individual is known to  have pica, assessment should include con-
sideration of the possibility of gastrointestinal complications, poisoning, infection, and
nutritional deficiency.