Genetic and physiological. There are no clear differences in  illness development, course,
or family history between DSM-IV dysthymi c disorder and chronic major depressive dis-
order. Earlier findings pertaining to either disorder are therefore likely to apply to per-
sistent depressive disorder. It is thus likel y that individuals with persistent depressive
disorder will have a higher pr oportion of first-degree relatives with persistent depressive
disorder than do individuals with major de pressive disorder, and more depressive disor-
ders in general.
A number of brain regions (e.g., prefrontal  cortex, anterior cing ulate, amygdala, hip-
pocampus) have been implicated in persiste nt depressive disorder. Possible polysomno-
graphic abnormalities exist as well.
Functional Consequences of
Persistent Depressive Disorder
The degree to which persistent depressive diso rder impacts social and occupational func-
tioning is likely to vary widely, but effects can be as great as or greater than those of major
depressive disorder.
Differential Diagnosis
Major depressive disorder. If there is a depressed mood plus two or more symptoms
meeting criteria for a persistent depressive ep isode for 2 years or more, then the diagnosis of
persistent depressive disorder is made. Th e diagnosis depends on the 2-year duration,
which distinguishes it from episodes of depressi on that do not last 2 years. If the symptom


Premenstrual Dysphoric Disorder 171
criteria are sufficient for a diagnosis of a major depressive episode at any time during this pe-
riod, then the diagnosis of major depression shou ld be noted, but it is coded not as a separate
diagnosis but rather as a specifie r with the diagnosis of  persistent depressive disorder. If the
individual’s symptoms currently meet full crit eria for a major depressive episode, then the
specifier of “with intermittent major depressi ve episodes, with current episode” would be
made. If the major depressive episode has pers isted for at least a 2-year duration and re-
mains present, then the specifie r “with persistent major depressive episode” is used. When
full major depressive episode cr iteria are not currently met but there has been at least one
previous episode of major depression in the cont ext of at least 2 years of persistent depres-
sive symptoms, then the specifier of “with in termittent major depres sive episodes, without
current episode” is used. If the individual ha s not experienced an episode of major depres-
sion in the last 2 years, then the specifier “with pure dysthymic syndrome” is used.
Psychotic disorders. Depressive symptoms are a common  associated feature of chronic
psychotic disorders (e.g., schi zoaffective disorder, schizophrenia, delusional disorder). A
separate diagnosis of persistent depressive disorder is not made if the symptoms occur
only during the course of the psychoti c disorder (including residual phases).
Depressive or bipolar and related diso rder due to another medical condition. Persistent
depressive disorder must be distinguished from a depressive or bipolar and related dis-
order due to another medical co ndition. The diagnosis is depressive or bipolar and related


order due to another medical co ndition. The diagnosis is depressive or bipolar and related
disorder due to another medical condition if the mood disturbance is judged, based on his-
tory, physical examination, or laboratory findin gs, to be attributable to the direct patho-
physiological effects of a specific, usually  chronic, medical condition (e.g., multiple
sclerosis). If it is judged that the depressive  symptoms are not attrib utable to the physiolog-
ical effects of another medical condition, then the primary ment al disorder (e.g., persistent
depressive disorder) is recorded, and the medi cal condition is noted as a concomitant med-
ical condition (e.g., diabetes mellitus).
Substance/medication-induced depressive or bipolar disorder. A substance/medi-
cation-induced depressive or bipolar and rela ted disorder is distin guished from persis-
tent depressive disorder when a substance (e.g ., a drug of abuse, a medication, a toxin) is
judged to be etiologically re lated to the mood disturbance.
Personality disorders. Often, there is evidence of a co existing personality disturbance.
When an individual’s presentation meets the cr iteria for both persis tent depressive disor-
der and a personality disorder , both diagnoses are given.
Comorbidity
In comparison to individuals with major depressive disorder, those with persistent de-
pressive disorder are at higher risk for psychiatric comorbidit y in general, and for anxiety
disorders and substance use disorders in partic ular. Early-onset persistent depressive dis-
order is strongly associated with DSM-IV  Cluster B and C personality disorders.
Premenstrual Dysphoric Disorder
Diagnostic Criteria 625.4 (N94.3)
A. In the majority of menstrual cycles, at least five symptoms must be present in the final


A. In the majority of menstrual cycles, at least five symptoms must be present in the final
week before the onset of menses, start to improve  within a few days after the onset of
menses, and become minimal  or absent in the week postmenses.
B. One (or more) of the following symptoms must be present:
1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or in-
creased sensitivity to rejection).


172 Depressive Disorders
2. Marked irritability or anger or increased interpersonal conflicts.
3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.
C. One (or more) of the following symptoms must additionally be present, to reach a total
of five  symptoms when combined with sym ptoms from Criterion B above.
1. Decreased interest in usual activities (e.g., work, school, friends, hobbies).
2. Subjective difficulty in concentration.
3. Lethargy, easy fatigability, or marked lack of energy.
4. Marked change in appetite; overeating; or specific food cravings.
5. Hypersomnia or insomnia.
6. A sense of being overwhelmed or out of control.
7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a
sensation of “bloating,” or weight gain.
Note:  The symptoms in Criteria A–C must have been met for most menstrual cycles that
occurred in the preceding year.
D. The symptoms are associated with clinically significant distress or interference with
work, school, usual social activities, or relationships with others (e.g., avoidance of so-
cial activities; decreased productivity and efficiency at work, school, or home).
E. The disturbance is not merely an exacerbation of the symptoms of another disorder,
such as major depressive disorder, panic disorder, persistent depressive disorder
(dysthymia), or a personality disorder (a lthough it may co-occur with any of these dis-
orders).
F. Criterion A should be confirmed by prospect ive daily ratings during at least two symptom-
atic cycles. ( Note:  The diagnosis may be made provisionally prior to this confirmation.)


atic cycles. ( Note:  The diagnosis may be made provisionally prior to this confirmation.)
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication, other treatment ) or another medical condition (e.g., hy-
perthyroidism).
Recording Procedures
If symptoms have not been confirmed by prospective daily ratings of at least two symp-
tomatic cycles, “provisional” should be noted after the name of the diagnosis (i.e., “pre-
menstrual dysphoric disorder, provisional”).
Diagnostic Features
The essential features of premenstrual dyspho ric disorder are the expression of mood la-
bility, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the pre-
menstrual phase of the cycle and remit around the onset of me nses or shortl y thereafter.
These symptoms may be accompanied by behavioral and physical symptoms. Symptoms
must have occurred in most of the menstrual cycles during the past year and must have an
adverse effect on work or social functioning.  The intensity and/or expressivity of the ac-
companying symptoms may be closely related to social and cultural background charac-
teristics of the affected female, family pers pectives, and more specific factors such as
religious beliefs, social tolerance,  and female gender role issues.
Typically, symptoms peak around the time of  the onset of menses. Although it is not
uncommon for symptoms to linger into the first few days of menses, the individual must
have a symptom-free period in the follicular  phase after the menstrual period begins.
While the core symptoms include mood and anxiety symptoms, behavioral and somatic
symptoms commonly also occur. However, the presence of physic al and/or behavioral


symptoms commonly also occur. However, the presence of physic al and/or behavioral
symptoms in the absence of mood and/or anxious symptoms is not sufficient for a diag-


Premenstrual Dysphoric Disorder 173
nosis. Symptoms are of comparab le severity (but not duration) to those of another mental
disorder, such as a major depressive episode or generalized anxiety disorder. In order to
confirm a provisional diagnosis, daily pros pective symptom ratings are required for at
least two symptomatic cycles.
Associated Features Supporting Diagnosis
Delusions and hallucinations have been described in the late luteal phase of the menstrual
cycle but are rare. The premenstrual phase has b een considered by some to be a risk period
for suicide.
Prevalence
Twelve-month prevalence of premenstrual dy sphoric disorder is between 1.8% and 5.8%
of menstruating women. Estimates are substant ially inflated if they are based on retro-
spective reports rather than prospective da ily ratings. However,  estimated prevalence
based on a daily record of symptoms for 1–2 months may be less representative, as indi-
viduals with the most severe symptoms may be  unable to sustain the rating process. The
most rigorous estimate of premenstrual dy sphoric disorder is 1.8% for women whose
symptoms meet the full criteria without fu nctional impairment and 1.3% for women
whose symptoms meet the current criteria wi th functional impairment and without co-oc-
curring symptoms from another mental disorder.
Development and Course
Onset of premenstrual dysphoric disorder ca n occur at any point after menarche. Inci-
dence of new cases over a 40-month follow-up period is 2.5% (95% confidence interval =
1.7–3.7). Anecdotally, many individuals, as th ey approach menopause, report that symp-


toms worsen. Symptoms cease after menopaus e, although cyclical hormone replacement
can trigger the re-expression of symptoms.
Risk and Prognostic Factors
Environmental. Environmental factors associated with the expression of premenstrual
dysphoric disorder include stress, history of  interpersonal trauma, seasonal changes, and
sociocultural aspects of female sexual behavior  in general, and female gender role in par-
ticular.
Genetic and physiological. Heritability of prem enstrual dysphoric disorder is unknown.
However, for premenstrual sy mptoms, estimates for heritability range between 30% and
80%, with the most stable component of premenstrual symptoms es timated to be about
50% heritable.
Course modifiers. Women who use oral contraceptiv es may have fewer premenstrual
complaints than do women who do not use oral contraceptives.
Culture-Related Diagnostic Issues
Premenstrual dysphoric disord er is not a culture-bound syndrome and has been observed
in individuals in the United States, Europe, India, and Asia. It is unclear as to whether rates
differ by race. Nevertheless, fr equency, intensity, and expres sivity of symptoms and help-
seeking patterns may be significantl y influenced by cultural factors.
Diagnostic Markers
As indicated earlier, the diagnosis of premenstrual dysphoric disorder is appropriately
confirmed by 2 months of pros pective symptom ratings. A number of scales, including the


174 Depressive Disorders
Daily Rating of Severity of Problems and the Visual Analogue Sc ales for Premenstrual
Mood Symptoms, have undergone validation and are commonly used in clinical trials for
premenstrual dysphoric disorder. The Premenst rual Tension Syndrome Rating Scale has a
self-report and an observer vers ion, both of which have been validated and used widely to
measure illness severity in women who ha ve premenstrual dysphoric disorder.
Functional Consequences of
Premenstrual Dysphoric Disorder
Symptoms must be associated with clinically  meaningful distress and/or an obvious and
marked impairment in the ability to function so cially or occupationally in the week prior
to menses. Impairment in social functionin g may be manifested by marital discord and
problems with children, other family members,  or friends. Chronic marital or job prob-
lems should not be confused with dysfunction that occurs only in association with pre-
menstrual dysphoric disorder.
Differential Diagnosis
Premenstrual syndrome. Premenstrual syndrome differs from premenstrual dysphoric
disorder in that a minimum of five symptoms is not required, and there is no stipulation of
affective symptoms for individuals who have premenstrual syndrome. This condition
may be more common than premenstrual dy sphoric disorder, although the estimated
prevalence of premenstrual syndrome varies. While premen strual syndrome shares the
feature of symptom expression during the premenstrual phase of the menstrual cycle, it is
generally considered to be less severe than  premenstrual dysphoric disorder. The pres-
ence of physical or  behavioral symptoms in the pr emenstruum, without the required
affective symptoms, likely meet s criteria for prem enstrual syndrome and not for premen-


strual dysphoric disorder.
Dysmenorrhea. Dysmenorrhea is a syndrome of painful menses, but this is distinct from a
syndrome characterized by affective changes.  Moreover, symptoms of dysmenorrhea begin
with the onset of menses, whereas symptoms of  premenstrual dysphoric disorder, by defini-
tion, begin before the onset of menses, even if they linger into the first few days of menses.
Bipolar disorder, major depressive disord er, and persistent depressive disorder
(dysthymia). Many women with (either naturally occurring or substance/medication-
induced) bipolar or major depressive disorder  or persistent depressive disorder believe
that they have premenstrual dysphoric disorder. However, when they chart symptoms,
they realize that the symptoms do not follo w a premenstrual pattern. Women with an-
other mental disorder may experience chronic symptoms or interm ittent symptoms that
are unrelated to menstrual cycle phase. Howeve r, because the onset of menses constitutes
a memorable event, they may report that symptoms occur only during the premenstruum
or that symptoms worsen premenstrually. This  is one of the rationales for the requirement
that symptoms be confirmed by daily prospect ive ratings. The process of differential di-
agnosis, particularly if the clinician relies on retrospective symptoms only, is made more
difficult because of the overlap between sy mptoms of premenstrual dysphoric disorder
and some other diagnoses. The overlap of symp toms is particularly salient for differenti-
ating premenstrual dysphoric disorder from major depressive episodes, persistent de-
pressive disorder, bipolar disorders, and bo rderline personality di sorder. However, the


pressive disorder, bipolar disorders, and bo rderline personality di sorder. However, the
rate of personality disorders is no higher in individuals with premenstrual dysphoric dis-
order than in those without the disorder.
Use of hormonal treatments. Some women who present with moderate to severe pre-
menstrual symptoms may be using hormonal treatments, including hormonal contracep-
tives. If such symptoms occur after initia tion of exogenous hormone use, the symptoms


Substance/Medication-Induced Depressive Disorder 175
may be due to the use of hormones rather th an to the underlying condition of premen-
strual dysphoric disorder. If the woman stops hormones and the symptoms disappear,
this is consistent with substance/medi cation-induced depressive disorder.
Comorbidity
A major depressive episode is the most frequent ly reported previous disorder in individuals
presenting with premenstrual dysphoric disorder. A wide range of medical (e.g., migraine,
asthma, allergies, seizure disorders) or other mental disorders (e.g., depressive and bipolar
disorders, anxiety disorders, bulimia nervosa, substance use disorders) may worsen in the
premenstrual phase; however, the absence of  a symptom-free period during the postmen-
strual interval obviates a diagnosis of premenstrual dysphoric disorder. These conditions
are better considered premenstrual  exacerbation of a current mental or medical disorder. Al-
though the diagnosis of premenstrual dysphoric disorder should not be assigned in situa-
tions in which an individual only experien ces a premenstrual exacerbation of another
mental or physical disorder, it can be considered in addition to the diagnosis of another men-
tal or physical disorder if the individual experiences symptoms and changes in level of func-
tioning that are characteristic of premenstrual dysphoric disorder and markedly different
from the symptoms experienced as part of the ongoing disorder.
Substance/Medication-Induced
Depressive Disorder
Diagnostic Criteria
A. A prominent and persistent disturbance in mood that predominates in the clinical pic-
ture and is characterized by depressed mood or markedly diminished interest or plea-
sure in all, or almost all, activities.


sure in all, or almost all, activities.
B. There is evidence from the history, physical examination, or laboratory findings of both
(1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication
or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms in Crite-
rion A.
C. The disturbance is not better explained by a depressive disorder that is not substance/
medication-induced. Such evidence of an independent depressive disorder could in-
clude the following:
The symptoms preceded the onset of the substance/medication use; the symptoms
persist for a substantial period of time (e.g., about 1 month) after the cessation of acute
withdrawal or severe intoxication; or there is other evidence suggesting the existence
of an independent non-substance/medication-i nduced depressive disorder (e.g., a his-
tory of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
Note:  This diagnosis should be made instead of a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical
picture and when they are sufficiently severe to warrant clinical attention.
Coding note:  The ICD-9-CM and ICD-10-CM codes for the [specific substance/medica-
tion]-induced depressive disorders are indicate d in the table below. Note that the ICD-10-


176 Depressive Disorders
CM code depends on whether or not there is a comorbid substance use disorder present for
the same class of substance. If a mild substance use disorder is comorbid with the substance-
induced depressive disorder, the 4th position character is “1,” and the clinician should record
“mild [substance] use disorder” before the substance-induced depressive disorder (e.g.,
“mild cocaine use di sorder with cocain e-induced depressive disorder”). If a moderate or se-
vere substance use disorder is comorbid with the substance-induced depressive disorder,
the 4th position character is “2,” and the clinician should record “moderate [substance] use
disorder” or “severe [substance] use disorder,” depending on the severity of the comorbid
substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-
time heavy use of the substance), then the 4th position character is “9,” and the clinician should
record only the substance-induced depressive disorder.
Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for di-
agnoses associated with substance class):
With onset during intoxication:  If criteria are met for intoxication with the substance
and the symptoms develop during intoxication.
With onset during withdrawal:  If criteria are met for withdrawal from the substance
and the symptoms develop during, or shortly after, withdrawal.
Recording Procedures
ICD-9-CM. The name of the substance/medication -induced depressive disorder begins
with the specific substance (e.g., cocaine, de xamethasone) that is presumed to be causing
the depressive symptoms. The diagnostic code is selected from the table included in the


the depressive symptoms. The diagnostic code is selected from the table included in the
criteria set, which is based on the drug class. For substances that do not fit into any of the
classes (e.g., dexamethasone), th e code for “other substance” should be used; and in cases
in which a substance is judged to be an etiologi cal factor but the specific class of substance
is unknown, the category “unknown substance” should be used.
The name of the disorder is followed by the sp ecification of onset (i.e., onset during in-
toxication, onset during with drawal). Unlike the recording procedures for ICD-10-CM,
which combine the substance-induced disorder and substance use disorder into a singleICD-10-CM
ICD-9-CMWith use
disorder,
mildWith use
disorder,
moderate
or severeWithout
use
disorder
Alcohol 291.89 F10.14 F10.24 F10.94
Phencyclidine 292.84 F16.14 F16.24 F16.94
Other hallucinogen 292.84 F16.14 F16.24 F16.94
Inhalant 292.84 F18.14 F18.24 F18.94
Opioid 292.84 F11.14 F11.24 F11.94
Sedative, hypnotic, or anxiolytic 292.84 F13.14 F13.24 F13.94
Amphetamine (or other
stimulant)292.84 F15.14 F15.24 F15.94
Cocaine 292.84 F14.14 F14.24 F14.94


Cocaine 292.84 F14.14 F14.24 F14.94
Other (or unknown) substance 292.84 F19.14 F19.24 F19.94


Substance/Medication-Induced Depressive Disorder 177
code, for ICD-9-CM a separate diagnostic code  is given for the substance use disorder. For
example, in the case of depressive symptoms  occurring during withdrawal in a man with
a severe cocaine use disorder, the diagnosis is 292.84 cocaine-induced depressive disorder,
with onset during with drawal. An additional diagnosis of 304.20 severe cocaine use dis-
order is also given. When more than one substance is judged to play a significant role in
the development of depressive mood symptoms , each should be listed separately (e.g.,
292.84 methylphenidate-induced depressive disorder, with onset during withdrawal;
292.84 dexamethasone-induced depressive diso rder, with onset during intoxication).
ICD-10-CM. The name of the substance/medication -induced depressive disorder begins
with the specific substance (e.g., cocaine, de xamethasone) that is presumed to be causing
the depressive symptoms. The diagnostic code is selected from the table included in the
criteria set, which is based on the drug class and presence or absence of a comorbid sub-
stance use disorder. For substances that do no t fit into any of the cl asses (e.g., dexameth-
asone), the code for “other substance” should be used; and in cases in which a substance is
judged to be an etiological factor but the spec ific class of substance is unknown, the category
“unknown substance” should be used.
When recording the name of the disorder, the comorbid substance use disorder (if any) is
listed first, followed by the word “with,” follo wed by the name of the substance-induced de-
pressive disorder, followed by the specification of onset (i.e., onset during intoxication, onset


pressive disorder, followed by the specification of onset (i.e., onset during intoxication, onset
during withdrawal). For example,  in the case of depressive sy mptoms occurring during with-
drawal in a man with a severe cocaine use disorder, the diagnosis is F14.24 severe cocaine use
disorder with cocaine-induced depressive disorder, with onset during withdrawal. A separate
diagnosis of the comorbid severe cocaine use disorder is not given. If the substance-induced
depressive disorder occurs without a comorbid  substance use disorder  (e.g., after a one-time
heavy use of the substance), no accompanying substance use disorder is noted (e.g., F16.94
phencyclidine-induced depr essive disorder, with onset during intoxication). When more than
one substance is judged to play a significant role in the development of depressive mood
symptoms, each should be listed separately (e .g., F15.24 severe methylphenidate use disorder
with methylphenidate-induced depressive diso rder, with onset during withdrawal; F19.94
dexamethasone-induced depressive disord er, with onset during intoxication).
Diagnostic Features
The diagnostic features of substance/medication-induced depressive disorder include the
symptoms of a depressive disorder, such as major depressive disorder; however, the de-
pressive symptoms are associated with the ingestion, injection, or inhalation of a sub-
stance (e.g., drug of abuse,  toxin, psychotropic medicati on, other medication), and the
depressive symptoms persist be yond the expected length of physiological effects, intoxi-
cation, or withdrawal period. As evidenced by  clinical history, phy sical examination, or
laboratory findings, th e relevant depressive disorder should have developed during or
within 1 month after use of a substance that is capable of producing the depressive disor-


within 1 month after use of a substance that is capable of producing the depressive disor-
der (Criterion B1). In additi on, the diagnosis is not better  explained by an independent
depressive disorder. Evidence of an indepe ndent depressive disorder includes the de-
pressive disorder preceded the onset of inge stion or withdrawal from the substance; the
depressive disorder persists beyo nd a substantial period of ti me after the cessation of sub-
stance use; or other evidence suggests th e existence of an independent non-substance/
medication-induced depressive disorder (Criterion C). This diagnosis should not be made


stance use; or other evidence suggests th e existence of an independent non-substance/
medication-induced depressive disorder (Criterion C). This diagnosis should not be made
when symptoms occur exclusivel y during the course of a delirium (Criterion D). The de-
pressive disorder associated with the substance use, intoxication, or withdrawal must
cause clinically significant distress or impairment in social, occupa tional, or other impor-
tant areas of functioning to qualify for this diagnosis (Criterion E).
Some medications (e.g., stimulants, steroids, L-dopa, antibiotics, central nervous
system drugs, dermatological agents, chem otherapeutic drugs, immunological agents)


178 Depressive Disorders
can induce depressive mood di sturbances. Clinical judgment is essential to determine
whether the medication is truly associated with inducing the depressive disorder or
whether a primary depressive disorder happen ed to have its onset while the person was
receiving the treatment. For example, a depres sive episode that developed within the first
several weeks of beginning alpha-methyldopa (an antihypertensive agent) in an individ-
ual with no history of major depressive diso rder would qualify for the diagnosis of med-
ication-induced depressive diso rder. In some cases, a prev iously established condition
(e.g., major depressive disorder , recurrent) can recur while th e individual is coincidentally
taking a medication that has the capacity  to cause depressive symptoms (e.g., L-dopa, oral
contraceptives). In such cases, the clinicia n must make a judgment  as to whether the med-
ication is causative in this particular situation.
A substance/medication-induced depressive disorder is distinguished from a primary
depressive disorder by considering the onset, course, and other factors associated with the
substance use. There must be evidence from the history, phy sical examination, or labora-
tory findings of substance use, abuse, intoxication, or withdrawal prior to the onset of the
depressive disorder. The withdrawal state for some substances can be relatively pro-
tracted, and thus intense depressive symptoms can last for a long period after the cessation
of substance use.
Prevalence
In a nationally representative U.S. adult po pulation, the lifetime pr evalence of substance/
medication-induced depressive disorder is 0.26%.
Development and Course
A depressive disorder associated with the use of substance (i.e., alcoho l, illicit drugs, or a


prescribed treatment for a mental disorder or another medical condition) must have its on-
set while the individual is using the substanc e or during withdrawal, if there is a with-
drawal syndrome associated with the substanc e. Most often, the de pressive disorder has
its onset within the first few weeks or 1 month of use of the substance. Once the substance
is discontinued, the depressive symptoms usually  remit within days to several weeks, de-
pending on the half-life of the substance/medication and the presence of a withdrawal
syndrome. If symptoms persist 4 weeks beyond the expected time course of withdrawal of
a particular substance/medi cation, other causes for th e depressive mood symptoms
should be considered.
Although there are a few prospective controlle d trials examining the association of de-
pressive symptoms with use of a medication, most report s are from postmarketing sur-
veillance studies, retrospective observational studies, or case  reports, making evidence of
causality difficult to determine. Substances implicated in medication-induced depressive
disorder, with varying degrees of evidence, in clude antiviral agents (efavirenz), cardio-
vascular agents (clonidine, guanethidine, me thyldopa, reserpine), re tinoic acid deriva-
tives (isotretinoin), antidepressants, antico nvulsants, anti-migraine agents (triptans),
antipsychotics, hormonal agents (corticost eroids, oral contrace ptives, gonadotropin-
releasing hormone agonists, tamoxifen), smoking cessation agents (varenicline), and im-
munological agents (interferon) . However, other potential su bstances continue to emerge
as new compounds are synthesized. A history of  such substance use may help increase di-
agnostic certainty.


agnostic certainty.
Risk and Prognostic Factors
Temperamental. Factors that appear to increase the risk of substance/medication-
induced depressive disorder can be conceptualized as pertaining to the specific type of
drug or to a group of individuals with underlying alcohol or drug use disorders. Risk fac-


Substance/Medication-Induced Depressive Disorder 179
tors common to all drugs incl ude history of major depressive disorder, history of drug-
induced depression, and psychosocial stressors.
Environmental.  There are also risks factors pertaini ng to a specific type of medication
(e.g., increased immune activation prior to treatment for hepatitis C associated with inter-
feron-alfa-induced depression); high doses (greater than 80 mg/day prednisone-equiva-
lents) of corticosteroids or high plasma conc entrations of efavirenz; and high estrogen/
progesterone content in  oral contraceptives.
Course modifiers. In a representative U.S. adult popu lation, compared with individuals
with major depressive disorder who did not have a substance use disorder, individuals
with substance-induced depressive disorder were more likely to be male, to be black, to
have at most a high school diploma, to lack  insurance, and to have  lower family income.
They were also more likely to report higher  family history of substance use disorders and
antisocial behavior, higher 12-month history of stressful life events, and a greater number
of DSM-IV major depressive diso rder criteria. They were more  likely to report feelings of
worthlessness, insomnia/hypersomnia, and thoughts of deat h and suicide attempts, but
less likely to report depressed mood and parental loss by death before age 18 years.
Diagnostic Markers
Determination of the substance of use can so metimes be made through laboratory assays
of the suspected substance in the blood or urine to corroborate the diagnosis.
Suicide Risk
Drug-induced or treatment-emergent suicidality represents a marked change in thoughts
and behavior from the person’s baseline, is us ually temporally associated with initiation of


and behavior from the person’s baseline, is us ually temporally associated with initiation of
a substance, and must be distinguished from  the underlying prim ary mental disorders.
In regard to the treatment-emergent suicida lity associated with antidepressants, a U.S.
Food and Drug Administration (FDA) adviso ry committee considered meta-analyses of
99,839 participants enrolled in 372 randomized clin ical trials of antidepressants in trials for
mental disorders. The analyses  showed that when the data were pooled across all adult
age groups, there was no perceptible increased risk of suicidal behavior or ideation. How-
ever, in age-stratified analyses , the risk for patients ages 18–24 years was elevated, albeit
not significantly (odds ratio [OR] = 1.55; 95%  confidence interval [CI] = 0.91–2.70). The
FDA meta-analyses reveal an absolute risk of suicide in patients taking investigational an-
tidepressants of 0.01%. In conc lusion, suicide is clearly an extremely rare treatment-emer-
gent phenomenon, but the outcome of suicid e was serious enough to prompt the FDA to
issue an expanded black-box warning in 2007 regarding the importance of careful moni-
toring of treatment-emergent suicidal ideati on in patients receiving antidepressants.
Differential Diagnosis
Substance intoxication and withdrawal. Depressive symptoms occur commonly in sub-
stance intoxication and substance withdrawal, and the diagnosis of the substance-specific
intoxication or withdrawal will usually suffice to categorize the symptom presentation. A
diagnosis of substance-induced depressive di sorder should be made  instead of a diag-
nosis of substance intoxicati on or substance withdrawal when the mood symptoms are
sufficiently severe to warrant independent clinical attention. For example, dysphoric


sufficiently severe to warrant independent clinical attention. For example, dysphoric
mood is a characteristic feature of coca ine withdrawal. Substance/medication-induced
depressive disorder should be diagnosed inst ead of cocaine withdrawal only if the mood
disturbance is substantially more intense or longer lasting than what is usually encountered
with cocaine withdrawal and is sufficiently seve re to be a separate focus of attention and
treatment.


180 Depressive Disorders
Primary depressive disorder. A substance/medication-induc ed depressive disorder is
distinguished from a primary de pressive disorder by the fact that a substance is judged to
be etiologically related to the symptoms, as  described earlier (see section “Development
and Course” for this disorder).
Depressive disorder due to another medical condition. Because individuals with other
medical conditions often take medications for th ose conditions, the clinician must consider the
possibility that the mood symptoms are caused by the physiological consequences of the med-
ical condition rather than the medication, in which case depres sive disorder due to another
medical condition is diagnosed. The history often provides the primary basis for such a judg-
ment. At times, a change in the treatment for the other medical condition (e.g., medication sub-
stitution or discontinuation) may be needed to determine empirically whether the medication
is the causative agent. If the clinician has ascertained that the disturbance is a function of both
another medical condition and su bstance use or withdrawal, both  diagnoses (i.e., depressive
disorder due to another medical condition and substance/medication-induced depressive
disorder) may be given. When there is insuffic ient evidence to determine whether the depres-
sive symptoms are associated with substance (including a medication) ingestion or with-
drawal or with another medical condition or are primary (i.e., not a function of either a
substance or another medical condition), a diagno sis of other specified depressive disorder or
unspecified depressive diso rder would be indicated.
Comorbidity
Compared with individuals with major depre ssive disorder and no comorbid substance
use disorder, those with substance/medicati on-induced depressive disorder have higher


use disorder, those with substance/medicati on-induced depressive disorder have higher
rates of comorbidity with any DSM-IV mental disorder; are more likely to have specific
DSM-IV disorders of pathological gambling and paranoid, histrionic, and antisocial per-
sonality disorders; and are less likely to have  persistent depressive  disorder (dysthymia).
Compared with individuals with major depressive disorder and a comorbid substance use
disorder, individuals with substance/medication-induced depressive disorder are more
likely to have alcohol use disorder, any othe r substance use disorder, and histrionic per-
sonality disorder; however, they are less likely to have persistent depressive disorder.
Depressive Disorder
 Due to Another Medical Condition
Diagnostic Criteria
A. A prominent and persistent period of depressed mood or markedly diminished interest
or pleasure in all, or almost all, activiti es that predominates in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condi-
tion.
C. The disturbance is not better explained by another mental disorder (e.g., adjustment
disorder, with depressed mood, in which the stressor is a serious medical condition).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
Coding note: The ICD-9-CM code for depressive di sorder due to another medical condi-
tion is 293.83,  which is assigned regardless of the specifier. The ICD-10-CM code de-
pends on the specifier (see below).


Depressive Disorder Due to Another Medical Condition 181
Specify if:
(F06.31) With depressive features: Full criteria are not met for a major depressive
episode.
(F06.32) With major depressive–like episode:  Full criteria are met (except Criterion
C) for a major depressive episode.
(F06.34) With mixed features: Symptoms of mania or hypomania are also present but
do not predominate in the clinical picture.
Coding note:  Include the name of the other medical condition in the name of the mental dis-
order (e.g., 293.83 [F06.31] depressive disorder due to hypothyroidism, with depressive fea-
tures). The other medical condition should al so be coded and listed separately immediately
before the depressive disorder due to the medical condition (e.g., 244.9 [E03.9] hypothyroid-
ism; 293.83 [F06.31] depressive disorder due to hypothyroidism, with depressive features).
Diagnostic Features
The essential feature of depressive disorder  due to another medical condition is a promi-
nent and persistent period of depressed mood or markedly diminished interest or plea-
sure in all, or almost all, ac tivities that predominates in th e clinical picture (Criterion A)
and that is thought to be related to the direct  physiological effects of another medical con-
dition (Criterion B). In determining whethe r the mood disturbance is due to a general
medical condition, the clinician must first establish the presence of a general medical con-
dition. Further, the clinician mu st establish that the mood di sturbance is etiologically re-
lated to the general medical condition through a physiological mechanism. A careful and
comprehensive assessment of multiple factor s is necessary to make this judgment. Al-


comprehensive assessment of multiple factor s is necessary to make this judgment. Al-
though there are no infallible guidelines  for determining whether the relationship
between the mood disturbance and the general medical condition is etiological, several
considerations provide some guidance in this area. One consideration is the presence of a
temporal association between th e onset, exacerbation, or remission of the general medical
condition and that of the mood disturbance. A second consideration is the presence of fea-
tures that are atypical of prim ary Mood Disorders (e.g., atypic al age at onset or course or
absence of family history). Evidence from the literature that suggests th at there can be a di-
rect association between the general medical condition in question and the development
of mood symptoms can provide a useful contex t in the assessment of a particular situation.
Associated Features Supporting Diagnosis
Etiology (i.e., a causal relationship to anothe r medical condition based on best clinical ev-
idence) is the key variable in depressive di sorder due to another medical condition. The
listing of the medical conditions that are said to be able to in duce major depression is never
complete, and the clinician’s best judg ment is the essence of this diagnosis.
There are clear associations, as well as some neuroanatomical correlates, of depression
with stroke, Huntington’s dise ase, Parkinson’s disease, and traumatic brain injury. Among
the neuroendocrine conditions most closely associated with  depression are Cushing’s dis-
ease and hypothyroidism. There are numerous other conditions thought to be associated
with depression, such as multiple sclerosis.  However, the literature’s support for a causal
association is greater with some conditions , such as Parkinson’s disease and Huntington’s
disease, than with others, for which the differ ential diagnosis may be  adjustment disorder,
with depressed mood.


with depressed mood.
Development and Course
Following stroke, the onset of depression appear s to be very acute, occurring within 1 day
or a few days of the cerebrovascular accident (CVA) in the largest case series. However, in


182 Depressive Disorders
some cases, onset of the depression is weeks to months following the CVA. In the largest
series, the duration of the major depressive episode follo wing stroke was 9–11 months on
average. Similarly, in Huntington’s disease the depressive state comes quite early in the
course of the illness. With Parkinson’s disease and Huntington’s disease, it often precedes
the major motor impairments and cognitive impairments associ ated with each condition.
This is more prominently the case for Huntin gton’s disease, in which depression is con-
sidered to be the first neuropsychiatric symptom. There is some observational evidence
that depression is less common as the dementia of Huntington’s disease progresses.
Risk and Prognostic Factors
The risk of acute onset of a major depressive disorder following a CVA (within 1 day to a
week of the event) appears to be strongly correlated with lesion location, with greatest risk
associated with left frontal strokes and least risk apparently associated with right frontal
lesions in those individuals who present within days of the stroke. The association with
frontal regions and laterality is not observed in depressive states that occur in the 2–6 months
following stroke.
Gender-Related Diagnostic Issues
Gender differences pertain to those associat ed with the medical condition (e.g., systemic
lupus erythematosus is more common in fema les; stroke is somewhat more common in
middle-age males compared with females).
Diagnostic Markers
Diagnostic markers pertain to those associated with the medical condition (e.g., steroid
levels in blood or urine to help corroborate the diagnosis of Cushing’s disease, which can
be associated with manic or depressive syndromes).
Suicide Risk
There are no epidemiological stud ies that provide evidence to differentiate the risk of sui-


There are no epidemiological stud ies that provide evidence to differentiate the risk of sui-
cide from a major depressive episode due to another medical conditio n compared with the
risk from a major depressive episode in general. There are case reports of suicides in
association with major depressive episodes  associated with another medical condition.
There is a clear association between serious medical illnesses and suicide, particularly
shortly after onset or diagnosis of the illness. Thus, it would be prudent to assume that the
risk of suicide for major depressive episodes associated with medical conditions is not less
than that for other forms of major depres sive episode, and might even be greater.
Functional Consequences of Depressive Disorder
Due to Another Medical Condition
Functional consequences pertain to those asso ciated with the medical condition. In gen-
eral, it is believed, but not es tablished, that a major depres sive episode induced by Cush-
ing’s disease will not recur if the Cushing’s dise ase is cured or arrested. However, it is also
suggested, but not established, that mood syndromes, including depressive and manic/
hypomanic ones, may be episodic (i.e., recurring ) in some individuals with static brain in-
juries and other central nervous system diseases.
Differential Diagnosis
Depressive disorders not due to another medical condition. Determination of whether
a medical condition accompanying a depressive disorder is causing the disorder depends
on a) the absence of an episode(s) of depressive episodes prior to the onset of the medical


Other Specified Depressive Disorder 183
condition, b) the probability that the associ ated medical condition has a potential to pro-
mote or cause a depressive disorder, and c) a course of the depressive symptoms shortly
after the onset or worsening of  the medical condition, especially if the depressive symp-
toms remit near the time that the medical disorder is effectively treated or remits.
Medication-induced depressive disorder. An important caveat is that some medical con-
ditions are treated with medications (e.g., steroi ds or alpha-interferon) that can induce depres-
sive or manic symptoms. In these cases, clinical  judgment, based on all the evidence in hand, is
the best way to try to separate the most likely and/or the most important of two etiological fac-
tors (i.e., association with the medical condition vs. a substance-induced syndrome).
Adjustment disorders. It is important to differentiate a depressive episode from an ad-
justment disorder, as the onset of the medical co ndition is in itself a life stressor that could
bring on either an adjustment disorder or an episode of major depression. The major dif-
ferentiating elements are the pervasiveness the depressive picture and the number and
quality of the depressive symptoms that the pa tient reports or demonstrates on the mental
status examination. The differential diagnosis of the associated medical conditions is rel-
evant but largely beyond the scope of the present manual.
Comorbidity
Conditions comorbid with depressive disorder  due to another medical condition are those
associated with the medical conditions of etio logical relevance. It has been noted that de-
lirium can occur before or along with depres sive symptoms in individuals with a variety
of medical conditions, such as Cushing’s di sease. The association of anxiety symptoms,


of medical conditions, such as Cushing’s di sease. The association of anxiety symptoms,
usually generalized symptoms, is common in depressive disorders, regardless of cause.
Other Specified Depressive Disorder
311 (F32.8)
This category applies to presentations in which symptoms characteristic of a depressive
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 depressive disorders di agnostic class. The other specified depressive
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 depressive
disorder. This is done by recording “other specified depressive disorder” followed by the
specific reason (e.g., “short-duration depressive episode”).
Examples of presentations that can be specified using the “other specified” designation
include the following:
1.Recurrent brief depression:  Concurrent presence of depressed mood and at least
four other symptoms of depression for 2–13 days at least once per month (not associ-
ated with the menstrual cycle) for at least 12 consecutive months in an individual
whose presentation has never met criteria for any other depressive or bipolar disorder
and does not currently meet active or residual criteria for any psychotic disorder.
2.Short-duration depressi ve episode (4–13 days): Depressed affect and at least four
of the other eight symptoms of a major depressive episode associated with clinically
significant distress or impairment that persists for more than 4 days, but less than 14 days,
in an individual whose presentation has never  met criteria for any other depressive or
bipolar disorder, does not currently meet active  or residual criteria for any psychotic dis-
order, and does not meet criteria for recurrent brief depression.


order, and does not meet criteria for recurrent brief depression.
3.Depressive episode with insufficient symptoms:  Depressed affect and at least one
of the other eight symptoms of a major depressive episode associated with clinically


184 Depressive Disorders
significant distress or impairment that persist for at least 2 weeks in an individual
whose presentation has never met criteria for any other depressive or bipolar disorder,
does not currently meet active or residual criteria for any psychotic disorder, and does
not meet criteria for mixed anxiety and depressive disorder symptoms.
Unspecified Depressive Disorder
311 (F32.9)
This category applies to presentations in whic h symptoms characteristic of a depressive dis-
order that cause clinically significant distress or impairment in social, occupational, or other im-
portant areas of functioning predominate but do not meet the full criteria for any of the disorders
in the depressive disorders diagnostic class. Th e unspecified depressive disorder category is
used in situations in which the clinician chooses not to specify the reason that the criteria are
not met for a specific depressive disorder, and includes presentations for which there is insuf-
ficient information to make a more specific diagnosis (e.g., in emergency room settings).
Specifiers for Depressive Disorders
Specify if:
With anxious distress:  Anxious distress is defined as the presence of at least two of
the following symptoms during the majority of days of a major depressive episode or
persistent depressive disorder (dysthymia):
1. Feeling keyed up or tense.
2. Feeling unusually restless.
3. Difficulty concentrating because of worry.
4. Fear that something awful may happen.
5. Feeling that the individual might lose control of himself or herself.
Specify current severity:
Mild:  Two symptoms.
Moderate: Three symptoms.
Moderate-severe:  Four or five symptoms.
Severe:  Four or five symptoms and with motor agitation.
Note:  Anxious distress has been noted as a prominent feature of both bipolar and ma-
jor depressive disorder in both primary care  and specialty mental health settings. High


jor depressive disorder in both primary care  and specialty mental health settings. High
levels of anxiety have been associated with higher suicide risk, longer duration of ill-
ness, and greater likelihood of treatment nonresponse. As a result, it is clinically useful
to specify accurately the presence and severity levels of anxious distress for treatment
planning and monitoring of response to treatment.
With mixed features:
A. At least three of the following manic/hypomanic symptoms are present nearly every
day during the majority of days of a major depressive episode:
1. Elevated, expansive mood.
2. Inflated self-esteem or grandiosity.
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Increase in energy or goal-directed activity (either socially, at work or school, or
sexually).


Specifiers for Depressive Disorders 185
6. Increased or excessive involvement in activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees, sexual in-
discretions, foolish business investments).
7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be
contrasted with insomnia).
B. Mixed symptoms are observable by others and represent a change from the per-
son’s usual behavior.
C. For individuals whose symptoms meet full criteria for either mania or hypomania,
the diagnosis should be bipolar I or bipolar II disorder.
D. The mixed symptoms are not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication or other treatment).
Note:  Mixed features associated with a major depressive episode have been found
to be a significant risk factor for the development of bipolar I or bipolar II disorder.
As a result, it is clinically useful to note the presence of this specifier for treatment
planning and monitoring of response to treatment.
With melancholic features:
A. One of the following is present during the most severe period of the current epi-
sode:
1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even
temporarily, when something good happens).
B. Three (or more) of the following:
1. A distinct quality of depressed mood characterized by profound despondency,
despair, and/or moroseness or by so-called empty mood.
2. Depression that is regularly worse in the morning.
3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
4. Marked psychomotor agitation or retardation.
5. Significant anorexia or weight loss.


5. Significant anorexia or weight loss.
6. Excessive or inappropriate guilt.
Note:  The specifier “with melancholic features” is applied if these features are present
at the most severe stage of the episode. There is a near-complete absence of the ca-
pacity for pleasure, not merely a diminution. A guideline for evaluating the lack of reac-
tivity of mood is that even highly desired events are not associated with marked
brightening of mood. Either mood does not bri ghten at all, or it brightens only partially
(e.g., up to 20%–40% of normal for only minutes at a time). The “distinct quality” of mood
that is characteristic of the “with melancholic features” specifier is experienced as qual-
itatively different from that during a nonm elancholic depressive episode. A depressed
mood that is described as merely more severe, longer lasting, or present without a rea-
son is not considered distinct in quality. Psychomotor changes are nearly always pres-
ent and are observable by others.
Melancholic features exhibit only a modest tendency to repeat across episodes in the
same individual. They are more frequent in inpatients, as opposed to outpatients; are
less likely to occur in milder than in more severe major depressive episodes; and are
more likely to occur in those with psychotic features.
With atypical features:  This specifier can be applied when these features predomi-
nate during the majority of days of the current or most recent major depressive episode
or persistent depressive disorder.
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive
events).


186 Depressive Disorders
B. Two (or more) of the following:
1. Significant weight gain or increase in appetite.
2. Hypersomnia.
3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
4. A long-standing pattern of interpersonal rejection sensitivity (not limited to epi-
sodes of mood disturbance) that results in significant social or occupational im-
pairment.
C. Criteria are not met for “with melancholic  features” or “with catatonia” during the
same episode.
Note:  “Atypical depression” has historical significance (i.e., atypical in contradistinction
to the more classical agitated, “endogenous” presentations of depression that were the
norm when depression was rarely diagnosed in outpatients and almost never in ado-
lescents or younger adults) and today does not connote an uncommon or unusual clin-
ical presentation as the term might imply.
Mood reactivity is the capacity to be cheered up when presented with positive events
(e.g., a visit from children, compliments from others). Mood may become euthymic (not
sad) even for extended periods of time if the external circumstances remain favorable.
Increased appetite may be manifested by an obvious increase in food intake or by
weight gain. Hypersomnia may include either an extended period of nighttime sleep or
daytime napping that totals at least 10 hours of sleep per day (or at least 2 hours more
than when not depressed). Leaden paralysis is defined as feeling heavy, leaden, or
weighted down, usually in the arms or legs. This sensation is generally present for at
least an hour a day but often lasts for many  hours at a time. Unlike the other atypical
features, pathological sensitivity to perceived interpersonal rejection is a trait that has


features, pathological sensitivity to perceived interpersonal rejection is a trait that has
an early onset and persists throughout most of adult life. Rejection sensitivity occurs
both when the person is and is not depressed, though it may be exacerbated during
depressive periods.
With psychotic features:  Delusions and/or hallucinations are present.
With mood-congruent psychotic features: The content of all delusions and hal-
lucinations is consistent with the typical depressive themes of personal inade-
quacy, guilt, disease, death, nihilism, or deserved punishment.
With mood-incongruent psychotic features:  The content of the delusions or hal-
lucinations does not involve typical depressive themes of personal inadequacy,
guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture
of mood-incongruent and mood-congruent themes.
With catatonia:  The catatonia specifier can apply to an episode of depression if cata-
tonic features are present during most of the episode. See criteria for catatonia asso-
ciated with a mental disorder (for a description of catatonia, see the chapter
“Schizophrenia Spectrum and Other Psychotic Disorders”).
With peripartum onset:  This specifier can be applied to the current or, if full criteria
are not currently met for a major depressive episode, most recent episode of major de-
pression if onset of mood symptoms occurs during pregnancy or in the 4 weeks follow-
ing delivery.
Note:  Mood episodes can have their onset either during pregnancy or postpartum.
Although the estimates differ according to the period of follow-up after delivery, be-
tween 3% and 6% of women will experience the onset of a major depressive epi-
sode during pregnancy or in the weeks or months following delivery. Fifty percent


sode during pregnancy or in the weeks or months following delivery. Fifty percent
of “postpartum” major depressive episodes actually begin prior to delivery. Thus,
these episodes are referred to collectively as peripartum episodes. Women with
peripartum major depressive episodes often have severe anxiety and even panic


Specifiers for Depressive Disorders 187
attacks. Prospective studies have demonstrated that mood and anxiety symptoms
during pregnancy, as well as the “baby blues,” increase the risk for a postpartum
major depressive episode.
Peripartum-onset mood episodes can pres ent either with or without psychotic
features. Infanticide is most often associated with postpartum psychotic episodes
that are characterized by command hallucinations to kill the infant or delusions that
the infant is possessed, but psychotic symptoms can also occur in severe postpar-
tum mood episodes without such specific delusions or hallucinations.
Postpartum mood (major depressive or manic) episodes with psychotic features
appear to occur in from 1 in 500 to 1 in 1,000 deliveries and may be more common
in primiparous women. The risk of postpartum episodes with psychotic features is
particularly increased for women with prior postpartum mood episodes but is also
elevated for those with a prior history of a depressive or bipolar disorder (especially
bipolar I disorder) and those with a family history of bipolar disorders.
Once a woman has had a postpartum episode with psychotic features, the risk
of recurrence with each subsequent delivery is between 30% and 50%. Postpartum
episodes must be differentiated from delirium occurring in the postpartum period,
which is distinguished by a fluctuating level of awareness or attention. The postpar-
tum period is unique with respect to the degree of neuroendocrine alterations and
psychosocial adjustments, the potential impact of breast-feeding on treatment
planning, and the long-term implications of a history of postpartum mood disorder
on subsequent family planning.
With seasonal pattern: This specifier applies to recurrent major depressive disorder.
A. There has been a regular temporal relationship between the onset of major depres-


A. There has been a regular temporal relationship between the onset of major depres-
sive episodes in major depressive disorder and a particular time of the year (e.g.,
in the fall or winter).
Note:  Do not include cases in which there is an obvious effect of seasonally related
psychosocial stressors (e.g., regularly being unemployed every winter).
B. Full remissions (or a change from major depression to mania or hypomania) also
occur at a characteristic time of the year (e.g., depression disappears in the spring).
C. In the last 2 years, two major depressive episodes have occurred that demonstrate
the temporal seasonal relationships defined above and no nonseasonal major de-
pressive episodes have occurred during that same period.
D. Seasonal major depressive episodes (as described above) substantially outnum-
ber the nonseasonal major depressive episodes that may have occurred over the
individual’s lifetime.
Note:  The specifier “with seasonal pattern” can be applied to the pattern of major de-
pressive episodes in major depressive disor der, recurrent. The essential feature is the
onset and remission of major depressive episodes at characteristic times of the year.
In most cases, the episodes begin in fall or winter and remit in spring. Less commonly,
there may be recurrent summer depressive episodes. This pattern of onset and remis-
sion of episodes must have occurred during at least a 2-year period, without any non-
seasonal episodes occurring during this period. In addition, the seasonal depressive
episodes must substantially outnumber any nonseasonal depressive episodes over
the individual’s lifetime.
This specifier does not apply to those situations in which the pattern is better ex-
plained by seasonally linked psychosocial stressors (e.g., seasonal unemployment or
school schedule). Major depressive episodes that occur in a seasonal pattern are often


school schedule). Major depressive episodes that occur in a seasonal pattern are often
characterized by prominent energy, hypersomn ia, overeating, weight gain, and a crav-
ing for carbohydrates. It is unclear whether a seasonal pattern is more likely in recur-
rent major depressive disorder or in bipol ar disorders. However, within the bipolar


ing for carbohydrates. It is unclear whether a seasonal pattern is more likely in recur-
rent major depressive disorder or in bipol ar disorders. However, within the bipolar
disorders group, a seasonal pattern appears to be more likely in bipolar II disorder than


188 Depressive Disorders
in bipolar I disorder. In some individuals, the onset of manic or hypomanic episodes
may also be linked to a particular season.
The prevalence of winter-type seasonal pattern appears to vary with latitude, age,
and sex. Prevalence increases with higher latitudes. Age is also a strong predictor of
seasonality, with younger persons at higher risk for winter depressive episodes.
Specify if:
In partial remission:  Symptoms of the immediately previous major depressive episode
are present, but full criteria are not met, or there is a period lasting less than 2 months
without any significant symptoms of a major depressive episode following the end of
such an episode.
In full remission:  During the past 2 months, no significant signs or symptoms of the
disturbance were present.
Specify current severity:
Severity is based on the number of criterion symptoms, the severity of those symptoms,
and the degree of functional disability.
Mild:  Few, if any, symptoms in excess of those required to make the diagnosis are
present, the intensity of the symptoms is distressing but manageable, and the symp-
toms result in minor impairment in social or occupational functioning.
Moderate: The number of symptoms, intensity of symptoms, and/or functional impair-
ment are between those specified for “mild” and “severe.”
Severe:  The number of symptoms is substantially in excess of that required to make
the diagnosis, the intensity of the symptoms is seriously distressing and unmanage-
able, and the symptoms markedly interfere with social and occupational functioning.


189Anxiety
 Disorders
Anxiety disorders  include disorders that share feat ures of excessive fear and anxi-
ety and related behavioral disturbances. Fear  is the emotional response to real or per-
ceived imminent threat, whereas anxiety is anticipation of future threat. Obviously, these
two states overlap, but they a lso differ, with fear more ofte n associated with surges of au-
tonomic arousal necessary for fight or flight , thoughts of immediate danger, and escape
behaviors, and anxiety more often associated with muscle tension and vigilance in prep-
aration for future danger and cautious or avoidant behavior s. Sometimes the level of fear
or anxiety is reduced by pervasive avoidance behaviors. Panic attacks  feature prominently
within the anxiety disorders as a particular ty pe of fear response. Panic attacks are not lim-
ited to anxiety disorders but rather can be  seen in other mental disorders as well.
The anxiety disorders differ from one anothe r in the types of objects or situations that
induce fear, anxiety, or avoidance behavior, and the associated cognitive ideation. Thus,
while the anxiety disorders tend to be highly comorbid with each other, they can be dif-
ferentiated by close examination of the types of  situations that are feared or avoided and
the content of the associated thoughts or beliefs.
Anxiety disorders differ from developmentally  normative fear or anxiety by being ex-
cessive or persisting beyond developmentally appropriate periods. They differ from tran-
sient fear or anxiety, often st ress-induced, by being persistent (e.g., typically lasting 6 months
or more), although the criterion for duration is intended as a general guide with allowance
for some degree of flexibility and is sometimes of shorter duration in children (as in sepa-
ration anxiety disorder  and selective mutism). Since in dividuals with anxiety disorders


ration anxiety disorder  and selective mutism). Since in dividuals with anxiety disorders
typically overestimate the danger in situations  they fear or avoid, the primary determina-
tion of whether the fear or anxiety is excessive or out of proportion is made by the clinician,
taking cultural contextual fa ctors into account. Many of the anxiety disorders develop in
childhood and tend to persist if not treated. Most occur more frequent ly in females than in
males (approximately 2:1 ratio). Each anxiety disorder is diagnosed only when the symp-
toms are not attributable to th e physiological effects of a substance/medication or to another
medical condition or are not better explained by another mental disorder.
The chapter is arranged developmentally, with disord ers sequenced according to the
typical age at onset. The individual with sepa ration anxiety disorder is fearful or anxious
about separation from attachment figures to a degree that is developmentally inappro-
priate. There is persistent fear or anxiety about harm coming to attachment figures and
events that could lead to loss of or separati on from attachment figures and reluctance to go
away from attachment figures, as well as nightmares and physical symptoms of distress. Al-
though the symptoms often deve lop in childhood, they can be  expressed throughout adult-
hood as well.
Selective mutism is characterized by a consiste nt failure to speak in  social situations in
which there is an expectation to speak (e.g.,  school) even though the individual speaks in
other situations. The failure to  speak has significant consequences on achievement in aca-
demic or occupational settings or otherwise interferes with normal social communication.
Individuals with specific phobia are fearful or anxious about or avoidant of circum-
scribed objects or situations. A specific cognitive ideation is not featured in this disorder,


scribed objects or situations. A specific cognitive ideation is not featured in this disorder,
as it is in other anxiety diso rders. The fear, anxiety, or av oidance is almost always imme-


190 Anxiety Disorders
diately induced by the phobic situation, to a de gree that is persistent and out of proportion
to the actual risk posed. There are various ty pes of specific phobias: animal; natural envi-
ronment; blood-injectio n-injury; situational; and other situations.
In social anxiety disorder (social phobia), the individual is fearful or anxious about or
avoidant of social interactions and situations  that involve the possi bility of being scruti-
nized. These include social interactions such as meeting unfamiliar people, situations in
which the individual may be observed eating or drinking, and situations in which the in-
dividual performs in front of others. The cogn itive ideation is of being negatively evalu-
ated by others, by being em barrassed, humiliated, or re jected, or offending others.
In panic disorder, the individual experiences recurrent unexpected panic attacks and is
persistently concerned or worr ied about having more panic attacks or changes his or her
behavior in maladaptive ways because of the pa nic attacks (e.g., avoidance of exercise or of
unfamiliar locations). Panic attacks are abrupt surges of intense fear or intense discomfort
that reach a peak within minutes, accompan ied by physical and/or cognitive symptoms.
Limited-symptom panic attacks include fewer than four symptoms. Panic attacks may be
expected,  such as in response to a typically  feared object or situation, or unexpected,  meaning
that the panic attack occurs for no apparent reason. Panic attacks function as a marker and
prognostic factor for severity of diagnosis, co urse, and comorbidity ac ross an array of dis-
orders, including, but not limit ed to, the anxiety disorders (e.g., substance use, depressive
and psychotic disorders). Panic attack may therefore be used as a descriptive specifier for


and psychotic disorders). Panic attack may therefore be used as a descriptive specifier for
any anxiety disorder as well as  other mental disorders.
Individuals with agoraphobia are fearful and anxious about two or more of the follow-
ing situations: using public transportation; being in open spaces; being in enclosed places;
standing in line or being in a crowd; or bein g outside of the home alone in other situations.
The individual fears these situations because of  thoughts that escape might be difficult or
help might not be available in the event of developing panic-like symptoms or other inca-
pacitating or embarrassing symptoms. These situ ations almost always induce fear or anx-
iety and are often avoided and requ ire the presence of a companion.
The key features of generalized anxiety diso rder are persistent and excessive anxiety
and worry about various domains,  including work and school performance, that the indi-
vidual finds difficult to contro l. In addition, the individual experiences physical symptoms,
including restlessness or feeling keyed up or on edge; being easily fatigued; difficulty con-
centrating or mind going blank; irritabilit y; muscle tension; and sleep disturbance.
Substance/medication-induced anxiety disord er involves anxiety due to substance in-
toxication or withdrawal or to a medication treatment. In anxiety di sorder due to another
medical condition, anxiety symptoms are th e physiological consequence of another med-
ical condition.
Disorder-specific scales are available to bette r characterize the seve rity of each anxiety
disorder and to capture change in severity over time. For ease of use, particularly for in-
dividuals with more than one anxiety disorder, these scales have been developed to have
the same format (but different focus) across the anxiety disorders, with ratings of behav-


the same format (but different focus) across the anxiety disorders, with ratings of behav-
ioral symptoms, cognitive idea tion symptoms, and physical symptoms relevant to each
disorder.
Separation Anxiety Disorder
Diagnostic Criteria 309.21 (F93.0)
A. Developmentally inappropriate and excessive fear or anxiety concerning separation from
those to whom the individual is attached, as evidenced by at least three of the following:


A. Developmentally inappropriate and excessive fear or anxiety concerning separation from
those to whom the individual is attached, as evidenced by at least three of the following:
1. Recurrent excessive distress when antic ipating or experiencing separation from
home or from major attachment figures.


Separation Anxiety Disorder 191
2. Persistent and excessive worry about losing major attachment figures or about pos-
sible harm to them, such as illness, injury, disasters, or death.
3. Persistent and excessive worry about experiencing an untoward event (e.g., getting
lost, being kidnapped, having an accident, becoming ill) that causes separation
from a major attachment figure.
4. Persistent reluctance or refusal to go out, away from home, to school, to work, or
elsewhere because of fear of separation.
5. Persistent and excessive fear of or reluctance about being alone or without major
attachment figures at home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to sleep without
being near a major attachment figure.
7. Repeated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nau-
sea, vomiting) when separation from major attachment figures occurs or is antici-
pated.
B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and
adolescents and typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in social, aca-
demic, occupational, or other im portant areas of functioning.
D. The disturbance is not better explained by another mental disorder, such as refusing
to leave home because of excessive resistance to change in autism spectrum disorder;
delusions or hallucinations concerning separation in psychotic disorders; refusal to go
outside without a trusted companion in agoraphobia; worries about ill health or other
harm befalling significant others in generalized anxiety disorder; or concerns about
having an illness in illness anxiety disorder.
Diagnostic Features
The essential feature of separation anxiety disorder is excessive fear or anxiety concerning


Diagnostic Features
The essential feature of separation anxiety disorder is excessive fear or anxiety concerning
separation from home or attachment figures. The anxiety exceeds what may be expected
given the person’s developmental level (Criteri on A). Individuals with separation anxiety
disorder have symptoms that meet at least th ree of the following criteria: They experience
recurrent excessive distress when separation fr om home or major atta chment figures is an-
ticipated or occurs (Criterion A1). They wo rry about the well-being or death of attachment
figures, particularly when separated from them, and they need to know the whereabouts
of their attachment figures and want to stay in touch with them (Criterion A2). They also
worry about untoward events to themselves, such as getting los t, being kidnapped, or
having an accident, that would keep them fr om ever being reunited with their major at-
tachment figure (Criterion A3). Individuals with separation anxiety disorder are reluctant
or refuse to go out by themselves because of  separation fears (Criterion A4). They have
persistent and excessive fear or reluctance about being alone or without major attachment
figures at home or in other settings. Children with separa tion anxiety disorder may be un-
able to stay or go in a room by themselv es and may display “clinging” behavior, staying
close to or “shadowing” the parent around the house, or requiring someone to be with
them when going to another room in the house (Criterion A5). They have persistent reluc-
tance or refusal to go to sleep without bein g near a major attachme nt figure or to sleep
away from home (Criterion A6). Children with  this disorder often have difficulty at bed-
time and may insist that someone stay with them until they fall asleep. During the night,


time and may insist that someone stay with them until they fall asleep. During the night,
they may make their way to their parents’ bed (or that of a significant other, such as a sib-
ling). Children may be reluctant or refuse to at tend camp, to sleep at friends’ homes, or to
go on errands. Adults may be uncomfortable when traveling independently (e.g., sleeping
in a hotel room). There may be repeated nightmares in which the content expresses the in-


192 Anxiety Disorders
dividual’s separation anxiety (e.g., destructio n of the family through fire, murder, or other
catastrophe) (Criterion A7). Physical sympto ms (e.g., headaches, abdominal complaints,
nausea, vomiting) are common in children when separation from major attachment fig-
ures occurs or is anticipated (Criterion A8). Cardiovascular symptoms such as palpitations,
dizziness, and feeling faint are rare in youn ger children but may occur in adolescents and
adults.
The disturbance must last for a period of at least 4 weeks in children and adolescents
younger than 18 years and is typically 6 months or longer in adults (Criterion B). However,
the duration criterion for adults should be used as a general guide, with allowance for
some degree of flexibilit y. The disturbance must cause clinically significant distress or im-
pairment in social, academic, occupational, or  other important areas of functioning (Cri-
terion C).
Associated Features Supporting Diagnosis
When separated from major attachment figure s, children with separation anxiety disorder
may exhibit social withdrawal, apathy, sadne ss, or difficulty concentrating on work or
play. Depending on their age, individuals may have fears of animals, monsters, the dark,
muggers, burglars, kidnappers, car accidents, plane travel, and other situations that are
perceived as presenting danger to the family or themselves. So me individuals become
homesick and uncomfortable to the point of misery when away from home. Separation
anxiety disorder in children may lead to school refusal, which in turn may lead to academic
difficulties and social isolation. When extrem ely upset at the prospect of separation, chil-
dren may show anger or occasionally aggres sion toward someone who is forcing separa-


dren may show anger or occasionally aggres sion toward someone who is forcing separa-
tion. When alone, especially in  the evening or the dark, youn g children may report unusual
perceptual experiences (e.g., seeing people p eering into their room, frightening creatures
reaching for them, feeling eyes staring at them ). Children with this disorder may be de-
scribed as demanding, intrusive, and in need of constant attention, and, as adults, may ap-
pear dependent and overprotective. The indi vidual’s excessive de mands often become a
source of frustration fo r family members, leading to resent ment and conflict in the family.
Prevalence
The 12-month prevalence of separation anxiety disorder among adults in the United States
is 0.9%–1.9%. In children, 6- to  12-month prevalence is estima ted to be approximately 4%.
In adolescents in the United States, the 12-mo nth prevalence is 1.6%. Separation anxiety
disorder decreases in prevalence from child hood through adolescence and adulthood and
is the most prevalent anxiety diso rder in children younger than 12 years. In clinical sam-
ples of children, the disorder is equally common in males and females. In the community,
the disorder is more frequent in females.
Development and Course
Periods of heightened separation anxiety from attachment figures are part of normal early
development and may indicate the development of secure attachment relationships (e.g.,
around 1 year of age, when infants may suffe r from stranger anxiety). Onset of separation
anxiety disorder may be as early as preschoo l age and may occur at any time during child-
hood and more rarely in adolescence. Typica lly there are periods of  exacerbation and re-


mission. In some cases, both the anxiety ab out possible separation and the avoidance of
situations involving separation from the home or nuclear family (e.g., going away to col-
lege, moving away from attachment figure s) may persist through adulthood. However,
the majority of children with separation anxiety disorder are free of impairing anxiety dis-
orders over their lifetimes. Many  adults with separation anxi ety disorder do not recall a
childhood onset of separation anxiety disorder, although they may recall symptoms.


Separation Anxiety Disorder 193
The manifestations of separation anxiety di sorder vary with age. Younger children are
more reluctant to go to school or may avoi d school altogether. Younger children may not
express worries or specific fears of definite th reats to parents, home, or themselves, and the
anxiety is manifested only when separation  is experienced. As children age, worries
emerge; these are often worries about specific  dangers (e.g., accidents, kidnapping, mug-
ging, death) or vague concerns about not being reunited with attachment figures. In adults,
separation anxiety disorder may limit their ability to cope with changes in circumstances
(e.g., moving, getting married). Adults with the disorder are typically overconcerned about
their offspring and spouses and experience ma rked discomfort when separated from them.
They may also experience significant disruption in work or social experiences because of
needing to continuously check on the whereabouts of a significant other.
Risk and Prognostic Factors
Environmental. Separation anxiety disorder often deve lops after life stress, especially a
loss (e.g., the death of a relative  or pet; an illness of the individual or a relative; a change of
schools; parental divorce; a move to a new neighborhood; immigratio n; a disaster that in-
volved periods of separation from attachment  figures). In young adults, other examples of
life stress include leaving the parental home, en tering into a romantic relationship, and be-
coming a parent. Parental overprotection and intrusiveness may be associated with sepa-
ration anxiety disorder.
Genetic and physiological. Separation anxiety disorder in  children may be heritable.
Heritability was estimated at 73% in a communi ty sample of 6-year-old twins, with higher
rates in girls. Children with separation an xiety disorder display particularly enhanced


rates in girls. Children with separation an xiety disorder display particularly enhanced
sensitivity to respirat ory stimulation using CO2-enriched air.
Culture-Related Diagnostic Issues
There are cultural variations in  the degree to which it is co nsidered desirable to tolerate
separation, so that demands and opportunit ies for separation between parents and chil-
dren are avoided in some cultures. For exampl e, there is wide variation across countries
and cultures with respect to the age at which it  is expected that offspring should leave the
parental home. It is important to differenti ate separation anxiety disorder from the high
value some cultures place on strong interdependence among family members.
Gender-Related Diagnostic Issues
Girls manifest greater reluctance to attend or  avoidance of school th an boys. Indirect ex-
pression of fear of separation may be more common in males than in females, for example,
by limited independent activity , reluctance to be away from  home alone, or distress when
spouse or offspring do things independently or when contact with spouse or offspring is
not possible.
Suicide Risk
Separation anxiety disorder in children may be associated with an increased risk for sui-
cide. In a community sample, the presence of mood disorders,  anxiety disorders, or sub-
stance use has been associated with suicidal ideation and attempts. However, this
association is not specific to separation anxi ety disorder and is found in several anxiety
disorders.
Functional Consequences of Separation Anxiety Disorder
Individuals with separation anxiety disorder often limit independent activities away from
home or attachment figures (e.g., in children, avoiding school, not going to camp, having


194 Anxiety Disorders
difficulty sleeping alone; in adol escents, not going away to coll ege; in adults, not leaving the
parental home, not tr aveling, not working outside the home).
Differential Diagnosis
Generalized anxiety disorder. Separation anxiety disorder is distinguished from gener-
alized anxiety disorder in that  the anxiety predominantly concerns separation from attach-
ment figures, and if other wo rries occur, they do not pred ominate the clinical picture.
Panic disorder. Threats of separation may lead to extreme anxiety and even a panic at-
tack. In separation anxiety disorder, in contr ast to panic disorder, the anxiety concerns the
possibility of being away from attachment figures and worry about untoward events be-
falling them, rather than being incapacitated by an unexpected panic attack.
Agoraphobia. Unlike individuals with agoraphobia, those with separation anxiety dis-
order are not anxious about being trapped or incapacitated in situations from which es-
cape is perceived as difficult in the event of panic-like sy mptoms or other incapacitating
symptoms.
Conduct disorder. School avoidance (truancy) is common in conduct disorder, but anx-
iety about separation is not responsible for school absences, and the child or adolescent
usually stays away from, rather  than returns to, the home.
Social anxiety disorder. School refusal may be due to soci al anxiety disorder (social pho-
bia). In such instances, the school avoidance is due to fear of being judged negatively by oth-
ers rather than to worries about being separated from the attachment figures.
Posttraumatic stress disorder. Fear of separation from loved ones is common after trau-
matic events such as a disasters, particularly when periods of separation from loved ones


matic events such as a disasters, particularly when periods of separation from loved ones
were experienced during the traumatic event. In posttraumatic stress  disorder (PTSD), the
central symptoms concern intr usions about, and avoidance of, memories associated with
the traumatic event itself, whereas in separa tion anxiety disorder, the worries and avoid-
ance concern the well-being of attachme nt figures and separation from them.
Illness anxiety disorder. Individuals with illness anxiety disorder worry about specific
illnesses they may have, but the main concer n is about the medical diagnosis itself, not
about being separated fr om attachment figures.
Bereavement. Intense yearning or longing for th e deceased, intense sorrow and emo-
tional pain, and preoccupation with the deceased or the circumstances of the death are ex-
pected responses occurring in  bereavement, whereas fear of separation from other
attachment figures is central in  separation anxiety disorder.
Depressive and bipolar disorders. These disorders may be associated with reluctance
to leave home, but the main concern is not wo rry or fear of untoward events befalling at-
tachment figures, but rather low motivation for engaging with the outside world. How-
ever, individuals with separation anxiety disorder may become depressed while being
separated or in anticipation of separation.
Oppositional defiant disorder. Children and adolescents with separation anxiety disor-
der may be oppositional in the context of being forced to separate from attachment figures.
Oppositional defiant disorder should be considered only wh en there is persistent opposi-
tional behavior unrelated to the anticipation or occurrence of separation from attachment
figures.
Psychotic disorders. Unlike the hallucinations in psychotic disorders, the unusual per-
ceptual experiences that may occur in separati on anxiety disorder are usually based on a


ceptual experiences that may occur in separati on anxiety disorder are usually based on a
misperception of an actual stimulus, occur only in certain situations (e.g., nighttime), and
are reversed by the presence of an attachment figure.


Selective Mutism 195
Personality disorders. Dependent personality disorder is characterized by an indis-
criminate tendency to rely on others, wherea s separation anxiety disorder involves con-
cern about the proximity and safety of main attachment figures. Bo rderline personality
disorder is characterized by fear of abandonm ent by loved ones, but problems in identity,
self-direction, interpersonal fu nctioning, and impulsivity are additionally central to that
disorder, whereas they are not centra l to separation anxiety disorder.
Comorbidity
In children, separation anxiety disorder is hi ghly comorbid with ge neralized anxiety dis-
order and specific phobia. In adults, comm on comorbidities include specific phobia,
PTSD, panic disorder, generalized anxiety diso rder, social anxiety disorder, agoraphobia,
obsessive-compulsive disorder, and personality disorders. Depressive and bipolar disor-
ders are also comorbid with separation anxiety disorder in adults.
Selective Mutism
Diagnostic Criteria 313.23 (F94.0)
A. Consistent failure to speak in specific social situations in which there is an expectation
for speaking (e.g., at school) despite speaking in other situations.
B. The disturbance interferes with educational or  occupational achievement or with social
communication.
C. The duration of the disturbance is at least 1 month (not limited to the first month of
school).
D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the
spoken language required in the social situation.
E. The disturbance is not better explained by a communication disorder (e.g., childhood-
onset fluency disorder) and does not occur exclusively during the course of autism
spectrum disorder, schizophrenia, or another psychotic disorder.
Diagnostic Features


spectrum disorder, schizophrenia, or another psychotic disorder.
Diagnostic Features
When encountering other individuals in social interactions, children with selective mut-
ism do not initiate speech or reciprocally respond when spoken to by others. Lack of
speech occurs in social interactions with chil dren or adults. Children with selective mut-
ism will speak in their home in the presence  of immediate family members but often not
even in front of close friends or second-degr ee relatives, such as grandparents or cousins.
The disturbance is often marked by high social  anxiety. Children with selective mutism of-
ten refuse to speak at school, leading to ac ademic or educational impairment, as teachers
often find it difficult to assess skills such as reading. The lack of speech may interfere with
social communication, although children wi th this disorder sometimes use nonspoken or
nonverbal means (e.g., grunting, pointing, wr iting) to communicate and may be willing or
eager to perform or engage in social encounters when speech is not required (e.g., nonver-
bal parts in school plays).
Associated Features Supporting Diagnosis
Associated features of selectiv e mutism may include excessive shyness, fear of social em-
barrassment, social isolation and withdrawal , clinging, compulsive traits, negativism,
temper tantrums, or mild oppositional beha vior. Although children  with this disorder
generally have normal language skills, ther e may occasionally be an associated commu-


196 Anxiety Disorders
nication disorder, although no particular association with a specific communication dis-
order has been identified. Even when these disorders are present, anxiety is present as
well. In clinical settings, children with select ive mutism are almost always given an addi-
tional diagnosis of another anxiety disorder—most commonly, social anxiety disorder (so-
cial phobia).
Prevalence
Selective mutism is a relatively  rare disorder and has not been  included as a diagnostic cat-
egory in epidemiological studies of prevalen ce of childhood disorders. Point prevalence
using various clinic or school samples ranges between 0.03% and 1% depending on the set-
ting (e.g., clinic vs. school vs. general population) and ages  of the individual s in the sample.
The prevalence of the disorder does not seem to vary by sex or race/ethnicity. The disor-
der is more likely to manifest in young children than in adolescents and adults.
Development and Course
The onset of selective mutism is usually befo re age 5 years, but the disturbance may not
come to clinical attention until entry into scho ol, where there is an increase in social inter-
action and performance tasks, such as readin g aloud. The persistence of the disorder is
variable. Although clinical reports suggest that many individuals “outgrow” selective
mutism, the longitudinal course of the disorder  is unknown. In some cases, particularly in
individuals with social anxiety disorder, selective mutism may disappear, but symptoms
of social anxiety disorder remain.
Risk and Prognostic Factors
Temperamental. Temperamental risk factors for sele ctive mutism are not well identi-
fied. Negative affectivity (neuroticism) or be havioral inhibition may play a role, as may


parental history of shyness, social isolation,  and social anxiety. Children with selective
mutism may have subtle receptive language difficulties compared wi th their peers, al-
though receptive language is still within the normal range.
Environmental. Social inhibition on the part of parents may serve as a model for social
reticence and selective mutism in children. Furthermore, parents of children with selective
mutism have been described as  overprotective or more cont rolling than parents of chil-
dren with other anxiety d isorders or no disorder.
Genetic and physiological factors. Because of the significant overlap between selective
mutism and social anxiety disorder, there may be shared genetic factors between these
conditions.
Culture-Related Diagnostic Issues
Children in families who have immigrated to a country where a different language is spo-
ken may refuse to speak the new language beca use of lack of knowledge of the language.
If comprehension of the new language is adequa te but refusal to speak persists, a diagno-
sis of selective mutism may be warranted.
Functional Consequences  of Selective Mutism
Selective mutism may result in  social impairment, as childr en may be too anxious to en-
gage in reciprocal social interaction with other children. As children with selective mutism
mature, they may face increasing  social isolation. In school settings, these children may
suffer academic impairment, because often th ey do not communicate with teachers re-
garding their academic or personal needs (e.g ., not understanding a class assignment, not


Specific Phobia 197
asking to use the restroom). Severe impairment  in school and social functioning, including
that resulting from teasing by peers, is co mmon. In certain instances, selective mutism
may serve as a compensatory strategy to decr ease anxious arousal in social encounters.
Differential Diagnosis
Communication disorders. Selective mutism should be di stinguished from speech dis-
turbances that are better explained by a communication disorder, such as language
disorder, speech sound disorder (previously phonological disorder), childhood-onset
fluency disorder (stuttering), or pragmatic (social) communication disorder. Unlike selec-
tive mutism, the speech disturbance in these cond itions is not restricted to a specific social
situation.
Neurodevelopmental disorders and schizo phrenia and other psychotic disorders.
Individuals with an autism spectrum disord er, schizophrenia or another psychotic disor-
der, or severe intellectual disability may ha ve problems in social communication and be
unable to speak appropriately in  social situations. In contrast, selective mutism should be
diagnosed only when a child has an established capacity to speak in some social situations
(e.g., typically at home).
Social anxiety disorder (social phobia). The social anxiety and social avoidance in so-
cial anxiety disorder may be associated with selective mutism. In such cases, both diagno-
ses may be given.
Comorbidity
The most common comorbid conditions are other anxiety disorders, most commonly so-
cial anxiety disorder, followed by separation anxiety diso rder and specific phobia. Oppo-
sitional behaviors have been noted to occur in children with selective mutism, although
oppositional behavior may be limited to sit uations requiring speech. Communication de-
lays or disorders also may appear in  some children with  selective mutism.
Specific Phobia