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e70ea08d26ac-0 | Transvestic Disorder 703
Specifiers
The presence of fetishism decreases the likelih ood of gender dysphoria in men with trans-
vestic disorder. The presence of autogynephilia increases the likelihood of gender dyspho-
ria in men with transvestic disorder.
Diagnostic Features
The diagnosis of transvestic diso rder does not apply to all individuals who dress as the op-
posite sex, even those who do so habitually. It applies to individuals whose cross-dressing
or thoughts of cross-dressing are always or of ten accompanied by sexual excitement (Cri-
terion A) and who are emotionally distressed by this pattern or feel it impairs social or in-
terpersonal functioning (Crite rion B). The cross-dressing may involve only one or two
articles of clothing (e.g., for men, it may pertain only to women’s undergarments), or it
may involve dressing completely in the inner and outer garments of the other sex and (in
men) may include the use of women’s wigs and make-up. Transvestic disorder is nearly
exclusively reported in males. Sexual arousal, in its most obvious form of penile erection,
may co-occur with cross-dressing in various wa ys. In younger males, cross-dressing often
leads to masturbation, following which any fe male clothing is removed. Older males often
learn to avoid masturbating or doing anything to stimulate the penis so that the avoidance
of ejaculation allows them to prolong their cr oss-dressing session. Males with female part-
ners sometimes complete a cro ss-dressing session by having intercourse with their part-
ners, and some have difficult y maintaining a sufficient erec tion for intercourse without
cross-dressing (or private fantasies of cross-dressing).
Clinical assessment of distress or impairme nt, like clinical assessment of transvestic | dsm5.pdf |
e70ea08d26ac-1 | Clinical assessment of distress or impairme nt, like clinical assessment of transvestic
sexual arousal, is usually dependent on the in dividual’s self-report. The pattern of behav-
ior “purging and acquisition” often signifies the presence of distress in individuals with
transvestic disorder. During this behavioral pattern, an individual (usually a man) who
has spent a great deal of money on women’s clothes and other apparel (e.g., shoes, wigs)
discards the items (i.e., purges them) in an effort to overc ome urges to cross-dress, and
then begins acquiring a woman’s wardrobe all over again.
Associated Features Supporting Diagnosis
Transvestic disorder in men is often accompanied by autogynephilia (i.e., a male’s para-
philic tendency to be sexually aroused by th e thought or image of himself as a woman).
Autogynephilic fantasies and behaviors may focu s on the idea of exhibiting female phys-
iological functions (e.g., lactat ion, menstruation), engaging in stereotypically feminine be-
havior (e.g., knitting), or posses sing female anatomy (e.g., breasts).
Prevalence
The prevalence of transvestic di sorder is unknown. Transvesti c disorder is rare in males
and extremely rare in females. Fewer than 3% of males repo rt having ever been sexually
aroused by dressing in women’s attire. The percentage of individuals who have cross-
dressed with sexual arousal more than once or a few times in their lifetimes would be even
lower. The majority of males with transvesti c disorder identify as heterosexual, although
some individuals have occasional sexual in teraction with other males, especially when
they are cross-dressed.
Development and Course | dsm5.pdf |
e70ea08d26ac-2 | they are cross-dressed.
Development and Course
In males, the first signs of transvestic disorder may begin in childhood, in the form of
strong fascination with a particular item of women’s attire. Prior to puberty, cross-dress-
ing produces generalized feelings of pleasura ble excitement. With the arrival of puberty,
dressing in women’s clothes begins to elicit pe nile erection and, in some cases, leads di- | dsm5.pdf |
e764a1c52501-0 | 704 Paraphilic Disorders
rectly to first ejaculation. In many cases, cross-dressing elicits less and less sexual ex-
citement as the individual grows older; eventually it may produce no discernible penile
response at all. The desire to cross-dress, at the same time, remains the same or grows even
stronger. Individuals who report such a dimi nution of sexual response typically report
that the sexual excitement of cross-dressing has been replaced by feelings of comfort or
well-being.
In some cases, the course of transvestic disorder is contin uous, and in others it is epi-
sodic. It is not rare for men with transvestic d isorder to lose interest in cross-dressing when
they first fall in love with a woman and be gin a relationship, but such abatement usually
proves temporary. When the desire to cross-dr ess returns, so does the associated distress.
Some cases of transvestic disorder progress to gender dysphoria. The males in these
cases, who may be indistinguishable from othe rs with transvestic disorder in adolescence
or early childhood, gradually develop desires to remain in the female role for longer pe-
riods and to feminize their anatomy. The de velopment of gender dysphoria is usually ac-
companied by a (self-reported) reduction or e limination of sexual arousal in association
with cross-dressing.
The manifestation of transvestism in penile erection and stimulation, like the manifesta-
tion of other paraphilic as well as normophilic sexual interests, is most intense in adolescence
and early adulthood. The severity of transvestic disorder is highest in adulthood, when the
transvestic drives are most likely to conflict with performance in he terosexual intercourse | dsm5.pdf |
e764a1c52501-1 | transvestic drives are most likely to conflict with performance in he terosexual intercourse
and desires to marry and start a family. Middle -age and older men with a history of trans-
vestism are less likely to present with transvestic disorder than with gender dysphoria.
Functional Consequences of Transvestic Disorder
Engaging in transvestic behaviors can interfer e with, or detract from, heterosexual rela-
tionships. This can be a source of distress to men who wish to maintain conventional mar-
riages or romantic partnerships with women.
Differential Diagnosis
Fetishistic disorder. This disorder may resemble transv estic disorder, in particular, in
men with fetishism who put on women’s unde rgarments while masturbating with them.
Distinguishing transvestic disorder depends on the individual’s specific thoughts during
such activity (e.g., are there any ideas of be ing a woman, being like a woman, or being
dressed as a woman?) and on the presence of othe r fetishes (e.g., soft, silky fabrics, whether
these are used for garments or for something else).
Gender dysphoria. Individuals with transvestic disorder do not report an incongruence be-
tween their experienced gender and assigned gender nor a desire to be of the other gender; and
they typically do not have a history of chil dhood cross-gender behaviors, which would be
present in individuals with gender dysphoria. Individuals with a presentation that meets full
criteria for transvestic disorder as well as ge nder dysphoria should be given both diagnoses.
Comorbidity
Transvestism (and thus transvestic disorder) is often found in associ ation with other para-
philias. The most frequently co-occurring paraphilias are fetishism and masochism. One | dsm5.pdf |
e764a1c52501-2 | particularly dangerous form of masochism, autoerotic asphyxia, is associated with transves-
tism in a substantial proportion of fatal cases. | dsm5.pdf |
bc1873f284aa-0 | Other Specified Paraphilic Disorder 705
Other Specified Paraphilic Disorder
302.89 (F65.89)
This category applies to presentations in whic h symptoms characteristic of a paraphilic disor-
der that cause clinically significant distress or impairment in social, occupational, or other im-
portant areas of functioning predominate but do not meet the full criteria for any of the disorders
in the paraphilic disorders diagnostic class. The other specified paraphilic disorder category is
used in situations in which the clinician chooses to communicate the specific reason that the
presentation does not meet the cr iteria for any specific paraphilic disorder. This is done by re-
cording “other specified paraphilic disorder” followed by the spec ific reason (e.g., “zoophilia”).
Examples of presentations that can be specified using the “other specified” designation
include, but are not limited to, recurrent and intense sexual arousal involving telephone
scatologia (obscene phone calls), necrophilia (corpses), zoophilia (animals), coprophilia
(feces), klismaphilia (enemas), or urophilia (urine) that has been present for at least 6 months
and causes marked distress or impairment in social, occupational, or other important ar-
eas of functioning. Other specified paraphilic disorder can be specified as in remission
and/or as occurring in a controlled environment.
Unspecified Paraphilic Disorder
302.9 (F65.9)
This category applies to presentations in which symptoms characteristic of a paraphilic
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for any of | dsm5.pdf |
bc1873f284aa-1 | other important areas of functioning predominate but do not meet the full criteria for any of
the disorders in the paraphilic disorders diagnostic class. The unspecified paraphilic dis-
order category is used in situations in which the clinician chooses not to specify the reason
that the criteria are not met for a specific paraphilic disorder, and includes presentations
in which there is insufficient information to make a more specific diagnosis. | dsm5.pdf |
d9802890f8a6-0 | This page intentionally left blank | dsm5.pdf |
46f086507c3e-0 | 707Other Mental
Disorders
Four disorders are included in this chapter: ot her specified mental disorder due to
another medical condition; unsp ecified mental disorder due to another medical condition;
other specified mental disorder; and unspecified mental disorder. This residual category
applies to presentations in which symptoms char acteristic of a mental disorder that cause
clinically significant distress or impairment in social, occupational, or other important ar-
eas of functioning predominate but do not meet the full criteria for any other mental dis-
order in DSM-5. For other specified and un specified mental diso rders due to another
medical condition, it must be established that the disturbance is caused by the physiolog-
ical effects of another medica l condition. If other specified and unspecified mental disor-
ders are due to another medi cal condition, it is necessary to code and list the medical
condition first (e.g., 042 [B20] HIV disease), fo llowed by the other spec ified or unspecified
mental disorder (use appropriate code).
Other Specified Mental Disorder
Due to Another Medical Condition
294.8 (F06.8)
This category applies to presentations in whic h symptoms characteristic of a mental dis-
order due to another medical condition that cause clinically significant distress or impair-
ment in social, occupational, or other impor tant areas of functioning predominate but do
not meet the full criteria for any specific mental disorder attributable to another medical
condition. The other specified mental disor der due to another medical condition category
is used in situations in which the clinician chooses to communicate the specific reason that
the presentation does not meet the criteria for any specific mental disorder attributable to
another medical condition. This is done by recording the name of the disorder, with the
specific etiological medical condition inserted in place of “another medical condition,” fol- | dsm5.pdf |
46f086507c3e-1 | specific etiological medical condition inserted in place of “another medical condition,” fol-
lowed by the specific symptomatic manifestation that does not meet the criteria for any
specific mental disorder due to another medical condition. Furthermore, the diagnostic
code for the specific medical condition must be listed immediately before the code for the
other specified mental disorder due to anothe r medical condition. For example, dissocia-
tive symptoms due to complex partial seizures would be coded and recorded as 345.40
(G40.209), complex partial seizures 294.8 (F06. 8) other specified mental disorder due to
complex partial seizures, dissociative symptoms.
An example of a presentation that can be specified using the “other specified” desig-
nation is the following:
Dissociative symptoms: This includes symptoms occurring, for example, in the con-
text of complex partial seizures. | dsm5.pdf |
6775b6f959e9-0 | 708 Other Mental Disorders
Unspecified Mental Disorder
Due to Another Medical Condition
294.9 (F09)
This category applies to presentations in which symptoms characteristic of a mental dis-
order due to another medical condition that cause clinically significant distress or impair-
ment in social, occupational, or other impor tant areas of functioning predominate but do
not meet the full criteria for any specific mental disorder due to another medical condition.
The unspecified mental disorder due to another medical condition category is used in sit-
uations in which the clinician chooses not to specify the reason that the criteria are not met
for a specific mental disorder due to another medical condition, and includes presentations
for which there is insufficient information to make a more specific diagnosis (e.g., in emer-
gency room settings). This is done by recording the name of the disorder, with the specific
etiological medical condition inserted in plac e of “another medical condition.” Furthermore,
the diagnostic code for the specific medical condition must be listed immediately before
the code for the unspecified mental disorder due to another medical condition. For exam-
ple, dissociative symptoms due to complex partial seizures would be coded and recorded
as 345.40 (G40.209) complex partial seizures , 294.9 (F06.9) unspecified mental disorder
due to complex partial seizures.
Other Specified Mental Disorder
300.9 (F99)
This category applies to presentations in which symptoms characteristic of a mental dis-
order that cause clinically significant distre ss or impairment in social, occupational, or oth-
er important areas of functioning predominate but do not meet the full criteria for any
specific mental disorder. The other specified m ental disorder category is used in situations
in which the clinician chooses to communicate the specific reason that the presentation
does not meet the criteria for any specific mental disorder. This is done by recording “other | dsm5.pdf |
6775b6f959e9-1 | does not meet the criteria for any specific mental disorder. This is done by recording “other
specified mental disorder” followed by the specific reason.
Unspecified Mental Disorder
300.9 (F99)
This category applies to presentations in which symptoms characteristic of a mental dis-
order that cause clinically significant distre ss or impairment in social, occupational, or oth-
er important areas of functioning predominate but do not meet the full criteria for any
mental disorder. The unspecified mental disorder category is used in situations in which
the clinician chooses not to specify the reason that the criteria are not met for a specific
mental disorder, and includes presentations for which there is insufficient information to
make a more specific diagnosis (e.g., in emergency room settings). | dsm5.pdf |
aee65c948032-0 | 709Medication-Induced Movement
Disorders and Other Adverse
Effects of Medication
Medication-induced movement disorders are included in Section II because of
their frequent importance in 1) the management by medication of mental disorders or oth-
er medical conditions and 2) the differential diagnosis of mental disorders (e.g., anxiety
disorder versus neuroleptic-induced akathisi a; malignant catatonia versus neuroleptic
malignant syndrome). Although these moveme nt disorders are labeled “medication in-
duced,” it is often difficult to establish the causal relationship between medication expo-
sure and the development of the movement di sorder, especially because some of these
movement disorders also occu r in the absence of medicati on exposure. The conditions
and problems listed in this ch apter are not mental disorders.
The term neuroleptic is becoming outdated because it highlights the propensity of an-
tipsychotic medications to cause abnormal movements, and it is being replaced with the
term antipsychotic in many contexts. Nevertheless, the term neuroleptic remains appropri-
ate in this context. Although newer antipsychotic medications may be less likely to cause
some medication-induced move ment disorders, those disorders still occur. Neuroleptic
medications include so-called conventional, “t ypical,” or first-gene ration antipsychotic
agents (e.g., chlorpromazine, haloperidol, fl uphenazine); “atypical” or second-generation
antipsychotic agents (e.g., clozapine, risperidone, olanzapine, quetiapine); certain dopa-
mine receptor–blocking drugs used in the tr eatment of symptoms such as nausea and gas- | dsm5.pdf |
aee65c948032-1 | mine receptor–blocking drugs used in the tr eatment of symptoms such as nausea and gas-
troparesis (e.g., prochlorperazine, prometh azine, trimethobenzamide, thiethylperazine,
metoclopramide); and amoxapine, which is marketed as an antidepressant.
Neuroleptic-Induced Parkinsonism
Other Medication-Induced Parkinsonism
332.1 (G21.11) Neuroleptic-Induced Parkinsonism
332.1 (G21.19) Other Medication-Induced Parkinsonism
Parkinsonian tremor, muscular rigidity, akinesia (i.e., loss of movement or difficulty ini-
tiating movement), or bradykinesia (i.e., slowing movement) developing within a few
weeks of starting or raising the dosage of a me dication (e.g., a neuroleptic) or after reduc-
ing the dosage of a medication used to treat extrapyramidal symptoms.
Neuroleptic Malignant Syndrome
333.92 (G21.0) Neuroleptic Malignant Syndrome
Although neuroleptic malignant syndrome is easily recognized in its classic full-blown
form, it is often heterogeneous in onset, pres entation, progression, and outcome. The clin-
ical features described below are those consid ered most important in making the diagno-
sis of neuroleptic malignant syndrome based on consensus recommendations. | dsm5.pdf |
86b7b22ddf62-0 | 710 Medication-Induced Movement Disorders
Diagnostic Features
Patients have generally been exposed to a dopamine antagonist within 72 hours prior to
symptom development. Hyperthermia ( 100.4 F or 38.0C on at least two occasions,
measured orally), associated with profuse dia phoresis, is a distinguishing feature of neu-
roleptic malignant syndrome, sett ing it apart from other neurol ogical side effects of anti-
psychotic medications. Extreme elevations in temperature, reflecting a breakdown in
central thermoregulation, are more likely to support the diagnosis of neuroleptic malig-
nant syndrome. Generalized rigidity, described as “lead pipe” in its most severe form and
usually unresponsive to antiparkinsonian agen ts, is a cardinal feature of the disorder and
may be associated with other neurological symptoms (e.g., tremor, sialorrhea, akinesia,
dystonia, trismus, myoclonus, dysarthria, dysphagia, rhab domyolysis). Creatine kinase
elevation of at least four times the upper limit of normal is commonly seen. Changes in
mental status, characterized by delirium or altered consciousness ranging from stupor to
coma, are often an early sign. Affected indi viduals may appear alert but dazed and unre-
sponsive, consistent with catatonic stupor. Autonomic activation and instability—mani-
fested by tachycardia (rate 25% above baseline), diaphoresis, blood pressure elevation
(systolic or diastolic 25% above baseline) or fluctuation ( 20 mmHg diastolic change or | dsm5.pdf |
86b7b22ddf62-1 | 25 mmHg systolic change within 24 hours), urinary incontinence, and pallor—may be
seen at any time but provide an early clue to the diagnosis. Tachypnea (rate 50% above
baseline) is common, and respiratory distress —resulting from metabolic acidosis, hyper-
metabolism, chest wall restriction, aspiration pneumonia, or pulmonary emboli—can oc-
cur and lead to sudden respiratory arrest.
A workup, including laboratory investigation, to exclude other infectious, toxic, met-
abolic, and neuropsychiatric et iologies or complications is essential (see the section “Dif-
ferential Diagnosis” later in this discussion ). Although several laboratory abnormalities
are associated with neuroleptic malignant synd rome, no single abnormality is specific to
the diagnosis. Individuals with neuroleptic malignant syndrome may have leukocytosis,
metabolic acidosis, hypoxia, decreased serum iron concentrations, and elevations in se-
rum muscle enzymes and catecholamines. Findings from cerebrospinal fluid analysis and
neuroimaging studies are generally normal, whereas electroencephalography shows gen-
eralized slowing. Autopsy findings in fatal ca ses have been nonspecific and variable, de-
pending on complications.
Development and Course
Evidence from database studies suggests in cidence rates for neuroleptic malignant syn-
drome of 0.01%–0.02% among indi viduals treated with antips ychotics. The temporal pro-
gression of signs and symptoms provides important clues to the diagnosis and prognosis
of neuroleptic malignant syndrome. Alteration in mental status and other neurological
signs typically precede systemic signs. The on set of symptoms varies from hours to days
after drug initiation. Some cases develop with in 24 hours after drug initiation, most within | dsm5.pdf |
86b7b22ddf62-2 | after drug initiation. Some cases develop with in 24 hours after drug initiation, most within
the first week, and virtually all cases within 30 days. Once the syndrome is diagnosed and
oral antipsychotic drugs are d iscontinued, neuroleptic maligna nt syndrome is self-limited
in most cases. The mean reco very time after drug discontinuation is 7–10 days, with most
individuals recovering within 1 week and nearly all within 30 days. The duration may be
prolonged when long-acting antipsychotics are implicated. There have been reports of in-
dividuals in whom residual neurological signs persisted for weeks after the acute hyper-
metabolic symptoms re solved. Total resolution of symp toms can be obtained in most
cases of neuroleptic malignant syndrome; howe ver, fatality rates of 10%–20% have been | dsm5.pdf |
72b863fdf50b-0 | metabolic symptoms re solved. Total resolution of symp toms can be obtained in most
cases of neuroleptic malignant syndrome; howe ver, fatality rates of 10%–20% have been
reported when the disorder is not recogniz ed. Although many individuals do not experi-
ence a recurrence of neuroleptic malignant syndrome when rechallenged with antipsy-
chotic medication, some do, especially when antipsychotics are reinstituted soon after an
episode. | dsm5.pdf |
ec07b755c287-0 | Medication-Induced Movement Disorders 711
Risk and Prognostic Factors
Neuroleptic malignant sy ndrome is a potential risk in an y individual after antipsychotic
drug administration. It is not specific to an y neuropsychiatric diagnosis and may occur in
individuals without a diagnosable mental disorder who receive dopamine antagonists.
Clinical, systemic, and metabolic factors associ ated with a heightened risk of neuroleptic
malignant syndrome include agitation, exhaus tion, dehydration, and iron deficiency. A
prior episode associated with antipsychotics has been described in 15%–20% of index
cases, suggesting underlying vulnerability in some patients; however, genetic findings
based on neurotransmitter receptor polymorphi sms have not been replicated consistently.
Nearly all dopamine antagonists have been associated with neuroleptic malignant
syndrome, although high-potency antipsychotics pose a greater risk compared with low-
potency agents and newer atypical antipsychoti cs. Partial or milder forms may be associ-
ated with newer antipsychotics, but neurolep tic malignant syndrome varies in severity
even with older drugs. Dopami ne antagonists used in medical settings (e.g., metoclopra-
mide, prochlorperazine) have also been impl icated. Parenteral administration routes,
rapid titration rates, and higher total drug dosages have been associated with increased
risk; however, neuroleptic malignant syndrome usually occurs within the therapeutic dos-
age range of antipsychotics.
Differential Diagnosis
Neuroleptic malignant syndrome must be di stinguished from other serious neurological
or medical conditions, including central nerv ous system infections, inflammatory or au-
toimmune conditions, status ep ilepticus, subcortical structur al lesions, and systemic con- | dsm5.pdf |
ec07b755c287-1 | ditions (e.g., pheochromocytoma, thyrotoxicosis, tetanu s, heat stroke).
Neuroleptic malignant syndrome also must be distinguished from similar syndromes
resulting from the use of other substances or medications, such as serotonin syndrome;
parkinsonian hyperthermia syndrome following abrupt discontinuation of dopamine ag-
onists; alcohol or sedative withdrawal; malignant hyperthe rmia occurring during anes-
thesia; hyperthermia associated with abuse of stimulants and hallucinogens; and atropine
poisoning from anticholinergics.
In rare instances, individuals with schizophrenia or a mood diso rder may present with
malignant catatonia, which ma y be indistinguishable from neuroleptic malignant syn-
drome. Some investigators consider neurol eptic malignant syndrome to be a drug-
induced form of malignant catatonia.
Medication-Induced Acute Dystonia
333.72 (G24.02) Medication-Induced Acute Dystonia
Abnormal and prolonged contract ion of the muscles of the ey es (oculogyric crisis), head,
neck (torticollis or retrocollis), limbs, or trunk developing within a few days of starting or
raising the dosage of a medication (such as a neuroleptic) or after reducing the dosage of a
medication used to treat extrapyramidal symptoms.
Medication-Induced Acute Akathisia
333.99 (G25.71) Medication-Induced Acute Akathisia
Subjective complaints of restlessness, ofte n accompanied by observed excessive move-
ments (e.g., fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit | dsm5.pdf |
ec07b755c287-2 | or stand still), developing within a few weeks of starting or raising the dosage of a medi-
cation (such as a neuroleptic) or after reducing the dosage of a medication used to treat ex-
trapyramidal symptoms. | dsm5.pdf |
19387b90f7cf-0 | 712 Medication-Induced Movement Disorders
Tardive Dyskinesia
333.85 (G24.01) Tardive Dyskinesia
Involuntary athetoid or chorei form movements (lasting at le ast a few weeks) generally of
the tongue, lower face and jaw, and extremit ies (but sometimes involving the pharyngeal,
diaphragmatic, or trunk muscles) developing in association with the use of a neuroleptic
medication for at least a few months.
Symptoms may develop after a shorter period of medication use in older persons. In
some patients, movements of this type may ap pear after discontinuation, or after change
or reduction in dosage, of neuroleptic medica tions, in which case the condition is called
neuroleptic withdrawal -emergent dyskinesia. Because withdrawal-emergent dyskinesia is
usually time-limited, lasting less than 4–8 week s, dyskinesia that persists beyond this win-
dow is considered to be tardive dyskinesia.
Tardive Dystonia
Tardive Akathisia
333.72 (G24.09) Tardive Dystonia
333.99 (G25.71) Tardive Akathisia
Tardive syndrome involving other types of movement problems, such as dystonia or
akathisia, which are distinguished by their late emergence in the course of treatment and
their potential persistence for months to years, even in the face of neuroleptic discontinu-
ation or dosage reduction.
Medication-Induced Postural Tremor
333.1 (G25.1) Medication-Induced Postural Tremor
Fine tremor (usually in the range of 8–12 Hz) occurring during attempts to maintain a pos- | dsm5.pdf |
19387b90f7cf-1 | ture and developing in associ ation with the use of medicati on (e.g., lithium, antidepres-
sants, valproate). This tremor is very similar to the tremor seen with anxiety, caffeine, and
other stimulants.
Other Medication-Induced Movement Disorder
333.99 (G25.79) Other Medication-Induced Movement Disorder
This category is for medication-induced movement disorders not captured by any of the
specific disorders listed above. Examples include 1) presentations resembling neuroleptic
malignant syndrome that are associated with medications other than neuroleptics and
2) other medication-induc ed tardive conditions.
Antidepressant Discontinuation Syndrome
995.29 ( T43.205A )Initial encounter
995.29 ( T43.205D )Subsequent encounter
995.29 ( T43.205S )Sequelae
Antidepressant discontinuation syndrome is a set of symptoms that can occur after an
abrupt cessation (or marked re duction in dose) of an antide pressant medication that was
taken continuously for at least 1 month. Symp toms generally begin within 2–4 days and
typically include specific sensory, somatic, and cognitive-emotional manifestations. Fre- | dsm5.pdf |
4bac07806f0f-0 | Medication-Induced Movement Disorders 713
quently reported sensory and somatic symptoms include flashes of lights, “electric shock”
sensations, nausea, and hyperre sponsivity to nois es or lights. Nons pecific anxiety and
feelings of dread may also be reported. Symptoms are alleviated by restarting the same
medication or starting a different medication that has a similar mechanism of action—
for example, discontinuation symptoms afte r withdrawal from a serotonin-norepineph-
rine reuptake inhibitor may be alleviated by starting a tricyclic antidepressant. To qualify
as antidepressant discontinuation syndrome, the symptoms should not have been present
before the antidepressant dosa ge was reduced and are not be tter explained by another
mental disorder (e.g., manic or hypomanic episode, substance intoxication, substance
withdrawal, somatic symptom disorder).
Diagnostic Features
Discontinuation symptoms may occur following treatment with tricyclic antidepressants
(e.g., imipramine, amitriptyline, desipramine) , serotonin reuptake in hibitors (e.g., fluox-
etine, paroxetine, sertraline), and monoamine oxidase inhibitors (e.g., phenelzine, selegi-
line, pargyline). The incidence of this syndrome depends on the dosage and half-life of the
medication being taken, as well as the rate at which the medication is tapered. Short-acting
medications that are stopped ab ruptly rather than tapered gradually may pose the great-
est risk. The short-acting selective serotonin reuptake inhibitor (SSRI) paroxetine is the
agent most commonly associated with disconti nuation symptoms, but such symptoms oc-
cur for all types of antidepressants. | dsm5.pdf |
4bac07806f0f-1 | cur for all types of antidepressants.
Unlike withdrawal syndromes associated with opioids, alcohol, and other substances
of abuse, antidepressant discontinuation sy ndrome has no pathognomonic symptoms. In-
stead, the symptoms tend to be vague and variable and typically begin 2–4 days after the
last dose of the antidepressant. For SSRIs (e.g., paroxetine), symptoms such as dizziness,
ringing in the ears, “electric shocks in the head ,” an inability to sleep, and acute anxiety are
described. The antidepressant use prior to discontinuation must not have incurred hypo-
mania or euphoria (i.e., there should be confidence that the discontinuation syndrome is
not the result of fluctuations in mood stabi lity associated with the previous treatment).
The antidepressant discontinuation syndrome is based solely on pharmacological factors
and is not related to the reinforcing effects of an antidepressant. Also, in the case of stim-
ulant augmentation of an antidepressant, abru pt cessation may result in stimulant with-
drawal symptoms (see “Stimulant Withdraw al” in the chapter “Substance-Related and
Addictive Disorders”) rather than the antide pressant discontinuation syndrome described
here.
Prevalence
The prevalence of antidepressant discontinu ation syndrome is unknown but is thought to
vary according to the dosage prior to discon tinuation, the half-life and receptor-binding
affinity of the medication, and possibly the indi vidual’s genetically influenced rate of me-
tabolism for this medication.
Course and Development
Because longitudinal studies are lacking, little is known about the clinical course of anti-
depressant discontinuation syndrome. Sympto ms appear to abate over time with very
gradual dosage reductions. After an episode, some individuals may pr efer to resume med- | dsm5.pdf |
4bac07806f0f-2 | gradual dosage reductions. After an episode, some individuals may pr efer to resume med-
ication indefinitely if tolerated.
Differential Diagnosis
The differential diagnosis of antidepressant discontinuation syndrome includes anxiety
and depressive disorders, su bstance use disorders, and tolerance to medications. | dsm5.pdf |
7a15019526a8-0 | 714 Medication-Induced Movement Disorders
Anxiety and depressive disorders. Discontinuation symptoms often resemble symptoms
of a persistent anxiety disorder or a return of somatic symptoms of depression for which
the medication was initially given.
Substance use disorders. Antidepressant discontinuatio n syndrome differs from sub-
stance withdrawal in that antidepressants th emselves have no reinforcing or euphoric ef-
fects. The medication dosage has usually not been increased without the clinician’s
permission, and the individual generally does no t engage in drug-seeking behavior to ob-
tain additional medication. Criteria for a substance use disorder are not met.
Tolerance to medications. Tolerance and discontinuation symptoms can occur as a
normal physiological response to stopping medication after a substantial duration of
exposure. Most cases of medication tolerance can be managed through carefully con-
trolled tapering.
Comorbidity
Typically, the individual was initially started on the medication for a major depressive dis-
order; the original symptoms may return during the discontinuation syndrome.
Other Adverse Effect of Medication
995.20 ( T50.905A )Initial encounter
995.20 ( T50.905D )Subsequent encounter
995.20 ( T50.905S )Sequelae
This category is available for optional use by clinicians to code side effects of medication
(other than movement symptoms) when these ad verse effects become a main focus of clin-
ical attention. Examples include severe hypotension, cardia c arrhythmias, and priapism. | dsm5.pdf |
775d491fdef6-0 | 715Other Conditions That May Be
a Focus of Clinical Attention
This discussion covers other conditions and proble ms that may be a focus of clini-
cal attention or that may otherwise affect the diagnosis, course, prog nosis, or treatment of
a patient’s mental disorder. These conditio ns are presented with their corresponding
codes from ICD-9-CM (usually V codes) and ICD-10-CM (usu ally Z codes). A condition
or problem in this chapter may be coded if it is a reason for the current visit or helps to
explain the need for a test, procedure, or trea tment. Conditions and problems in this chap-
ter may also be included in the medical record as useful information on circumstances that
may affect the patient’s care, regardless of their relevance to the current visit.
The conditions and problems listed in this chapter are not mental disorders. Their in-
clusion in DSM-5 is meant to draw attention to the scope of additional issues that may be
encountered in routine clinical practice and to provide a systematic listing that may be
useful to clinicians in documenting these issues.
Relational Problems
Key relationships, especially intimate adult partner relationships and parent/caregiver-
child relationships, have a significant impact on the health of the individuals in these re-
lationships. These relationships can be health promoting and protective, neutral, or detri-
mental to health outcomes. In the extreme, th ese close relationships can be associated with
maltreatment or neglect, which has signif icant medical and psyc hological consequences
for the affected individual. A relational problem may come to clinical attention either as
the reason that the individual seeks health care or as a pr oblem that affects the course,
prognosis, or treatment of the individual’s mental or other medical disorder. | dsm5.pdf |
775d491fdef6-1 | prognosis, or treatment of the individual’s mental or other medical disorder.
Problems Related to Family Upbringing
V61.20 (Z62.820) Parent-Child Relational Problem
For this category, the term parent is used to refer to one of the child’s primary caregivers,
who may be a biological, adoptive, or foster pa rent or may be another relative (such as a
grandparent) who fulfills a parent al role for the child. This ca tegory should be used when
the main focus of clinical atte ntion is to address the quality of the parent-child relationship
or when the quality of the parent-child relati onship is affecting th e course, prognosis, or
treatment of a mental or other medical disorder. Typically, the parent-child relational
problem is associated with impaired functionin g in behavioral, cognitive, or affective do-
mains. Examples of behavioral problems include inadequate parental control, supervision,
and involvement with the child; parental over protection; excessive parental pressure; ar-
guments that escalate to threats of physical violence; and avoidance without resolution of
problems. Cognitive problems may include negati ve attributions of th e other’s intentions,
hostility toward or scapegoating of the other, and unwarranted feelings of estrangement.
Affective problems may include feelings of sadness, apathy, or anger about the other in-
dividual in the relationship. Clinicians should take into account the developmental needs
of the child and the cultural context. | dsm5.pdf |
9b813454c31e-0 | 716 Other Conditions That May Be a Focus of Clinical Attention
V61.8 (Z62.891) Sibling Relational Problem
This category should be used when the focus of clinical attention is a pattern of interaction
among siblings that is associated with significan t impairment in individual or family function-
ing or with development of symptoms in one or more of the siblings, or when a sibling relational
problem is affecting the course, prognosis, or treatment of a sibling’s mental or other medical
disorder. This category can be used for either children or adults if the focus is on the sibling re-
lationship. Siblings in this context include fu ll, half-, step-, foster , and adopted siblings.
V61.8 (Z62.29) Upbringing Away From Parents
This category should be used when the main focus of clinical attention pertains to issues
regarding a child being raised away from the parents or when this separate upbringing af-
fects the course, prognosis, or treatment of a mental or other medical disorder. The child
could be one who is under state custody and pl aced in kin care or foster care. The child
could also be one who is living in a nonparenta l relative’s home, or with friends, but whose
out-of-home placement is not mandated or sanctioned by the courts. Problems related to a
child living in a group home or orphanage are also included. This category excludes issues
related to V60.6 (Z59.3) ch ildren in boarding schools.
V61.29 (Z62.898) Child Affected by Parental Relationship Distress
This category should be used when the focus of clinical attention is the negative effects of
parental relationship discord (e.g., high levels of conflict, distress, or disparagement) on a
child in the family, including effects on the child’s mental or other medical disorders. | dsm5.pdf |
9b813454c31e-1 | child in the family, including effects on the child’s mental or other medical disorders.
Other Problems Related to Primary Support Group
V61.10 (Z63.0) Relationship Distress With Spouse or Intimate Partner
This category should be used when the major fo cus of the clinical contact is to address the
quality of the intimate (spouse or partner) relationship or when the quality of that rela-
tionship is affecting the course, prognosis, or treatment of a mental or other medical dis-
order. Partners can be of the same or differ ent genders. Typically, the relationship distress
is associated with impaired functioning in beha vioral, cognitive, or affective domains. Ex-
amples of behavioral proble ms include conflict resolution difficulty, withdrawal, and
overinvolvement. Cognit ive problems can manifest as chronic negative attributions of the
other’s intentions or dismissals of the part ner’s positive behaviors. Affective problems
would include chronic sadness, apathy, and/or anger about the other partner.
Note: This category excludes clinical encounte rs for V61.1x (Z69.1x) mental health ser-
vices for spousal or partner abuse prob lems and V65.49 (Z70.9) sex counseling.
V61.03 (Z63.5) Disruption of Family by Separation or Divorce
This category should be used when partners in an intimate adult couple are living apart
due to relationship problems or are in the process of divorce.
V61.8 (Z63.8) High Expressed Emotion Level Within Family
Expressed emotion is a construct used as a qualitat ive measure of the “amount” of emo-
tion—in particular, hostility, emotional overin volvement, and criticism directed toward a | dsm5.pdf |
9b813454c31e-2 | tion—in particular, hostility, emotional overin volvement, and criticism directed toward a
family member who is an identified patient—displayed in the family environment. This
category should be used when a family’s hi gh level of expressed emotion is the focus of
clinical attention or is affecting the course, prognosis, or treatment of a family member’s
mental or other medical disorder.
V62.82 (Z63.4) Uncomplicated Bereavement
This category can be used when the focus of cl inical attention is a normal reaction to the
death of a loved one. As part of their reaction to such a loss, some grieving individuals
present with symptoms characteristic of a major depressive episode—for example, feel- | dsm5.pdf |
1f9cc6497a2a-0 | Other Conditions That May Be a Focus of Clinical Attention 717
ings of sadness and associated symptoms su ch as insomnia, poor appetite, and weight
loss. The bereaved individual typically re gards the depressed mood as “normal,” al-
though the individual may seek professional help for relief of associated symptoms such
as insomnia or anorexia. The duration and expression of “normal” bereavement vary con-
siderably among different cultural groups. Fu rther guidance in distinguishing grief from
a major depressive episode is provided in the criteria for major depressive episode.
Abuse and Neglect
Maltreatment by a family member (e.g., caregiver, intimate adult partner) or by a nonrel-
ative can be the area of current clinical focu s, or such maltreatment can be an important
factor in the assessment and treatment of pati ents with mental or other medical disorders.
Because of the legal implications of abuse and neglect, care should be used in assessing
these conditions and assigning these codes. Ha ving a past history of abuse or neglect can
influence diagnosis and treatment response in a number of mental disorders, and may also
be noted along with the diagnosis.
For the following categories, in addition to listings of the confirmed or suspected event
of abuse or neglect, other code s are provided for use if the cu rrent clinical encounter is to
provide mental health services to either the victim or the perpetrator of the abuse or ne-
glect. A separate code is also provided for designating a past history of abuse or neglect.
Coding Note for ICD-10-CM Abuse and Neglect Conditions
For T codes only, the 7th character should be coded as follows:
A (initial encounter) —Use while the patient is receiving active treatment for
the condition (e.g., surgical treatment, emergency department encounter, eval- | dsm5.pdf |
1f9cc6497a2a-1 | the condition (e.g., surgical treatment, emergency department encounter, eval-
uation and treatment by a new clinician); or
D (subsequent encounter) —Use for encounters after the patient has received
active treatment for the condition and wh en he or she is receiving routine care
for the condition during the healing or re covery phase (e.g., cast change or re-
moval, removal of external or internal fixation device, medi cation adjustment,
other aftercare and follow-up visits).
Child Maltreatment and Neglect Problems
Child Physical Abuse
Child physical abuse is nonaccidental physical injury to a child—ranging from minor bruises
to severe fractures or death—occurring as a re sult of punching, beating, kicking, biting,
shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other object),
burning, or any other method that is inflicted by a parent, caregiver, or other individual who
has responsibility for the child. Such injury is considered abuse regardless of whether the
caregiver intended to hurt the ch ild. Physical discipline, such as spanking or paddling, is not
considered abuse as long as it is reasonable and causes no bodily injury to the child.
Child Physical Abuse, Confirmed
995.54 (T74.12XA) Initial encounter
995.54 (T74.12XD) Subsequent encounter
Child Physical Abuse, Suspected
995.54 (T76.12XA) Initial encounter
995.54 (T76.12XD) Subsequent encounter | dsm5.pdf |
979832185969-0 | 718 Other Conditions That May Be a Focus of Clinical Attention
Other Circumstances Related to Child Physical Abuse
V61.21 (Z69.010) Encounter for mental health services for victim of child abuse by parent
V61.21 (Z69.020) Encounter for mental health servic es for victim of nonparental child
abuse
V15.41 (Z62.810) Personal history (past history) of physical abuse in childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental child
abuse
V62.83 (Z69.021) Encounter for mental health servic es for perpetrator of nonparental
child abuse
Child Sexual Abuse
Child sexual abuse encompasses any sexual act involving a child that is intended to pro-
vide sexual gratification to a parent, caregi ver, or other individual who has responsibility
for the child. Sexual abuse includes activities such as fondling a child’s genitals, penetra-
tion, incest, rape, sodomy, and indecent exposure. Sexual abuse also includes noncontact
exploitation of a child by a parent or caregi ver—for example, forcing, tricking, enticing,
threatening, or pressuring a child to participate in acts for the sexual gratification of others,
without direct physical contact between child and abuser.
Child Sexual Abuse, Confirmed
995.53 (T74.22XA) Initial encounter
995.53 (T74.22XD) Subsequent encounter
Child Sexual Abuse, Suspected
995.53 (T76.22XA) Initial encounter
995.53 (T76.22XD) Subsequent encounter
Other Circumstances Related to Child Sexual Abuse
V61.21 (Z69.010) Encounter for mental health services for victim of child sexual abuse
by parent | dsm5.pdf |
979832185969-1 | by parent
V61.21 (Z69.020) Encounter for mental health servic es for victim of nonparental child
sexual abuse
V15.41 (Z62.810) Personal history (past history) of sexual abuse in childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental child
sexual abuse
V62.83 (Z69.021) Encounter for mental health servic es for perpetrator of nonparental
child sexual abuse
Child Neglect
Child neglect is defined as any confirmed or suspected egregious ac t or omission by a
child’s parent or other caregiver that deprives the child of basic age-appropriate needs and
thereby results, or has reasonab le potential to result, in physical or psychological harm to
the child. Child neglect encompasses abandonm ent; lack of appropriate supervision; fail-
ure to attend to necessary em otional or psychological needs; and failure to provide neces-
sary education, medical care, nouris hment, shelter, and/or clothing.
Child Neglect, Confirmed
995.52 (T74.02XA) Initial encounter
995.52 (T74.02XD) Subsequent encounter | dsm5.pdf |
e1dedfff919f-0 | Other Conditions That May Be a Focus of Clinical Attention 719
Child Neglect, Suspected
995.52 (T76.02XA) Initial encounter
995.52 (T76.02XD) Subsequent encounter
Other Circumstances Related to Child Neglect
V61.21 (Z69.010) Encounter for mental health servic es for victim of child neglect by
parent
V61.21 (Z69.020) Encounter for mental health servic es for victim of nonparental child
neglect
V15.42 (Z62.812) Personal history (past history) of neglect in childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental child
neglect
V62.83 (Z69.021) Encounter for mental health servic es for perpetrator of nonparental
child neglect
Child Psychological Abuse
Child psychological abuse is nonaccidental verb al or symbolic acts by a child’s parent or
caregiver that result, or have reasonable potential to result, in significant psychological
harm to the child. (Physical and sexual abusive acts are not included in this category.) Ex-
amples of psychological abuse of a child include berating, disparaging, or humiliating
the child; threatening the child; harming/abandoning—or indicating that the alleged
offender will harm/abandon—people or things that the child cares about; confining the
child (as by tying a child’s arms or legs togeth er or binding a child to furniture or another
object, or confining a child to a small enclosed area [e.g., a closet]); egregious scapegoating
of the child; coercing the child to inflict pain on himself or herself; and disciplining the
child excessively (i.e., at an extremely high fr equency or duration, even if not at a level of | dsm5.pdf |
e1dedfff919f-1 | physical abuse) through physical or nonphysical means.
Child Psychological Abuse, Confirmed
995.51 (T74.32XA) Initial encounter
995.51 (T74.32XD) Subsequent encounter
Child Psychological Abuse, Suspected
995.51 (T76.32XA) Initial encounter
995.51 (T76.32XD) Subsequent encounter
Other Circumstances Related to Child Psychological Abuse
V61.21 (Z69.010) Encounter for mental health services for victim of child psychological
abuse by parent
V61.21 (Z69.020) Encounter for mental health servic es for victim of nonparental child
psychological abuse
V15.42 (Z62.811) Personal history (past history) of psychological abuse in childhood
V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental child
psychological abuse
V62.83 (Z69.021) Encounter for mental health servic es for perpetrator of nonparental
child psychological abuse | dsm5.pdf |
0d16aa6fc876-0 | 720 Other Conditions That May Be a Focus of Clinical Attention
Adult Maltreatment and Neglect Problems
Spouse or Partner Violence, Physical
This category should be used when nonaccidental acts of physical force that result, or have
reasonable potential to result, in physical harm to an intimate partner or that evoke signif-
icant fear in the partner have occurred during the past year. Nonaccidental acts of physical
force include shoving, slapping, hair pulling, pinching, restraining, shaking, throwing,
biting, kicking, hitting with the fist or an ob ject, burning, poisoning, applying force to the
throat, cutting off the air supply, holding th e head under water, and using a weapon. Acts
for the purpose of physically protecting oneself or one’s partner are excluded.
Spouse or Partner Violen ce, Physical, Confirmed
995.81 (T74.11XA) Initial encounter
995.81 (T74.11XD) Subsequent encounter
Spouse or Partner Violence, Physical, Suspected
995.81 (T76.11XA) Initial encounter
995.81 (T76.11XD) Subsequent encounter
Other Circumstances Related to Spou se or Partner Violence, Physical
V61.11 (Z69.11) Encounter for mental health services for victim of spouse or partner
violence, physical
V15.41 (Z91.410) Personal history (past history) of spouse or partner violence, physical
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or
partner violence, physical
Spouse or Partner Violence, Sexual
This category should be used when forced or coerced sexual acts with an intimate partner
have occurred during the past year. Sexual violence may involve the use of physical force | dsm5.pdf |
0d16aa6fc876-1 | have occurred during the past year. Sexual violence may involve the use of physical force
or psychological coercion to compel the partner to engage in a sexual act against his or her
will, whether or not the act is completed. Also included in this category are sexual acts
with an intimate partner who is unable to consent.
Spouse or Partner Violence, Sexual, Confirmed
995.83 (T74.21XA) Initial encounter
995.83 (T74.21XD) Subsequent encounter
Spouse or Partner Violence, Sexual, Suspected
995.83 (T76.21XA) Initial encounter
995.83 (T76.21XD) Subsequent encounter
Other Circumstances Related to Sp ouse or Partner Violence, Sexual
V61.11 (Z69.81) Encounter for mental health services for victim of spouse or partner
violence, sexual
V15.41 (Z91.410) Personal history (past history) of spouse or partner violence, sexual
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or
partner violence, sexual | dsm5.pdf |
3cd01544cb5a-0 | Other Conditions That May Be a Focus of Clinical Attention 721
Spouse or Partner Neglect
Partner neglect is any egregious act or omission in the past year by one partner that de-
prives a dependent partner of basic needs and thereby results, or has reasonable potential
to result, in physical or psycho logical harm to the dependent pa rtner. This category is used
in the context of relationships in which one partner is extremely dependent on the other
partner for care or for assistance in navigating ordinary daily activities—for example, a
partner who is incapable of self-care owing to substantial physical, psychological/intel-
lectual, or cultural limitations (e.g., inability to communicat e with others and manage ev-
eryday activities due to living in a foreign culture).
Spouse or Partner Neglect, Confirmed
995.85 (T74.01XA) Initial encounter
995.85 (T74.01XD) Subsequent encounter
Spouse or Partner Neglect, Suspected
995.85 (T76.01XA) Initial encounter
995.85 (T76.01XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Neglect
V61.11 (Z69.11) Encounter for mental health services for victim of spouse or partner
neglect
V15.42 (Z91.412) Personal history (past history) of spouse or partner neglect
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or
partner neglect
Spouse or Partner Abuse, Psychological
Partner psychological abuse encompasses nonaccidental verbal or symbolic acts by one
partner that result, or have reasonable potentia l to result, in significant harm to the other
partner. This category should be used when such psycholo gical abuse has occurred during | dsm5.pdf |
3cd01544cb5a-1 | partner. This category should be used when such psycholo gical abuse has occurred during
the past year. Acts of psycholo gical abuse include berating or humiliating the victim; inter-
rogating the victim; restricting the victim’s ability to come and go freely; obstructing the vic-
tim’s access to assistance (e.g., law enforcemen t; legal, protective, or medical resources);
threatening the victim with physical harm or sexual assault; harming, or threatening to
harm, people or things that th e victim cares about; unwarranted restriction of the victim’s ac-
cess to or use of economic resources; isolating the victim from family, friends, or social sup-
port resources; stalking the victim; and trying to make the victim think that he or she is crazy.
Spouse or Partner Abuse, Psychological, Confirmed
995.82 (T74.31XA) Initial encounter
995.82 (T74.31XD) Subsequent encounter
Spouse or Partner Abuse, Psychological, Suspected
995.82 (T76.31XA) Initial encounter
995.82 (T76.31XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Abuse, Psychological
V61.11 (Z69.11) Encounter for mental health services for victim of spouse or partner
psychological abuse | dsm5.pdf |
4dd0e2781dd6-0 | 722 Other Conditions That May Be a Focus of Clinical Attention
V15.42 (Z91.411) Personal history (past history) of sp ouse or partner psychological abuse
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or part-
ner psychological abuse
Adult Abuse by Nons pouse or Nonpartner
These categories should be used when an ad ult has been abused by another adult who is
not an intimate partner. Such maltreatment may involve acts of physical, sexual, or emo-
tional abuse. Examples of adult abuse include nonaccidental acts of physical force (e.g.,
pushing/shoving, scratching, slapping, thro wing something that could hurt, punching,
biting) that have resulted—o r have reasonable potential to result—in physical harm or
have caused significant fear; forced or coer ced sexual acts; and ve rbal or symbolic acts
with the potential to cause psychological harm (e.g., berating or humiliating the person;
interrogating the person; restricting the person ’s ability to come and go freely; obstructing
the person’s access to assistance; threatening the person; harming or threatening to harm
people or things that the person cares about; restricting the person’s access to or use of eco-
nomic resources; isolating the person from fa mily, friends, or social support resources;
stalking the person; trying to make the person think that he or she is crazy). Acts for the
purpose of physically protecting oneself or the other person are excluded.
Adult Physical Abuse by Nonspouse or Nonpartner, Confirmed
995.81 (T74.11XA) Initial encounter
995.81 (T74.11XD) Subsequent encounter
Adult Physical Abuse by Nonspouse or Nonpartner, Suspected
995.81 (T76.11XA) Initial encounter | dsm5.pdf |
4dd0e2781dd6-1 | 995.81 (T76.11XA) Initial encounter
995.81 (T76.11XD) Subsequent encounter
Adult Sexual Abuse by Nonspo use or Nonpartner, Confirmed
995.83 (T74.21XA) Initial encounter
995.83 (T74.21XD) Subsequent encounter
Adult Sexual Abuse by Nonspo use or Nonpartn er, Suspected
995.83 (T76.21XA) Initial encounter
995.83 (T76.21XD) Subsequent encounter
Adult Psychological Abuse by Nonspouse or Nonpartner, Confirmed
995.82 (T74.31XA) Initial encounter
995.82 (T74.31XD) Subsequent encounter
Adult Psychological Abuse by Nonspouse or Nonpartner, Suspected
995.82 (T76.31XA) Initial encounter
995.82 (T76.31XD) Subsequent encounter
Other Circumstances Related to Adult Abuse by Nonspouse or Nonpartner
V65.49 (Z69.81) Encounter for mental health services for victim of nonspousal or non-
partner adult abuse
V62.83 (Z69.82) Encounter for mental health services for perpetrator of nonspousal or
nonpartner adult abuse | dsm5.pdf |
8e3f1279a0b1-0 | Other Conditions That May Be a Focus of Clinical Attention 723
Educational and Occu pational Problems
Educational Problems
V62.3 (Z55.9) Academic or Educational Problem
This category should be used when an academic or educational problem is the focus of
clinical attention or has an impact on the in dividual’s diagnosis, tr eatment, or prognosis.
Problems to be consider ed include illiteracy or low-level lit eracy; lack of access to school-
ing owing to unavailability or unattainability; problems with academ ic performance (e.g.,
failing school examinations, receiving failing marks or grades) or underachievement (be-
low what would be expected given the indivi dual’s intellectual capacity); discord with
teachers, school staff, or other students; an d any other problems related to education and/
or literacy.
Occupational Problems
V62.21 (Z56.82) Problem Related to Current Military Deployment Status
This category should be used when an occupa tional problem directly related to an indi-
vidual’s military deployment status is the focus of clinical attention or has an impact on the
individual’s diagnosis, treatment, or prognosi s. Psychological reactions to deployment are
not included in this category; such reactions would be better captured as an adjustment
disorder or another mental disorder.
V62.29 (Z56.9) Other Problem Related to Employment
This category should be used when an occupational problem is the focus of clinical atten-
tion or has an impact on the individual’s treatment or prog nosis. Areas to be considered
include problems with employment or in the work environment, including unemploy-
ment; recent change of job; threat of job loss; job dissatisfaction; stressful work schedule;
uncertainty about career choices; sexual ha rassment on the job; other discord with boss, | dsm5.pdf |
8e3f1279a0b1-1 | supervisor, co-workers, or others in the wo rk environment; uncongenial or hostile work
environments; other psychosocial stressors re lated to work; and any other problems re-
lated to employment and/or occupation.
Housing and Economic Problems
Housing Problems
V60.0 (Z59.0) Homelessness
This category should be used when lack of a regular dwelling or living quarters has an im-
pact on an individual’s treatment or prognosi s. An individual is considered to be homeless
if his or her primary nighttime residence is a homeless shelter, a warming shelter, a do-
mestic violence shelter, a public space (e.g., tunnel, transportation st ation, mall), a build-
ing not intended for residential use (e.g., abandoned structure, unused factory), a
cardboard box or cave, or some other ad hoc housing situation.
V60.1 (Z59.1) Inadequate Housing
This category should be used when lack of adequate housing has an impact on an individ-
ual’s treatment or prognosis. Examples of in adequate housing conditions include lack of
heat (in cold temperatures) or electricity, infestation by insects or rodents, inadequate
plumbing and toilet facilities , overcrowding, lack of adequa te sleeping space, and exces-
sive noise. It is important to consider cultural norms before assigning this category.
V60.89 (Z59.2) Discord With Neighbor, Lodger, or Landlord
This category should be used when discord with neighbors, lodgers, or a landlord is a fo-
cus of clinical attention or has an impact on the individual’s treatment or prognosis. | dsm5.pdf |
58fa9316a8a2-0 | 724 Other Conditions That May Be a Focus of Clinical Attention
V60.6 (Z59.3) Problem Related to Living in a Residential Institution
This category should be used when a problem (or problems) related to living in a residen-
tial institution is a focus of clinical attention or has an impact on the individual’s treatment
or prognosis. Psychological reactions to a chan ge in living situation are not included in this
category; such reactions would be better captured as an adjustment disorder.
Economic Problems
V60.2 (Z59.4) Lack of Adequate Food or Safe Drinking Water
V60.2 (Z59.5) Extreme Poverty
V60.2 (Z59.6) Low Income
V60.2 (Z59.7) Insufficient Social Insurance or Welfare Support
This category should be used for individuals wh o meet eligibility criter ia for social or wel-
fare support but ar e not receiving such support, who rece ive support that is insufficient to
address their needs, or who otherwise lack access to needed insurance or support pro-
grams. Examples include inability to qualify for welfare support owing to lack of proper
documentation or evidence of address, inability to obtain ad equate health insurance be-
cause of age or a preexisting condition, and denial of support owing to excessively strin-
gent income or other requirements.
V60.9 (Z59.9) Unspecified Housing or Economic Problem
This category should be used when there is a problem related to hou sing or economic cir-
cumstances other than as specified above.
Other Problems Related to the Social Environment
V62.89 (Z60.0) Phase of Life Problem
This category should be used when a problem adjusting to a life-cycle transition (a partic-
ular developmental phase) is the focus of clinic al attention or has an impact on the indi- | dsm5.pdf |
58fa9316a8a2-1 | vidual’s treatment or prognosis. Examples of such transitions include entering or
completing school, leaving parental control, getting married, starting a new career, be-
coming a parent, adjusting to an “empty ne st” after children leave home, and retiring.
V60.3 (Z60.2) Problem Related to Living Alone
This category should be used when a problem associated with living alone is the focus of
clinical attention or has an impact on the in dividual’s treatment or prognosis. Examples of
such problems include chronic feelings of lonelin ess, isolation, and lack of structure in car-
rying out activities of daily living (e.g., i rregular meal and sleep schedules, inconsistent
performance of home maintenance chores).
V62.4 (Z60.3) Acculturation Difficulty
This category should be used when difficulty in adjusting to a new culture (e.g., following
migration) is the focus of clinical attention or has an impact on the individual’s treatment
or prognosis.
V62.4 (Z60.4) Social Exclusion or Rejection
This category should be used when there is an imbalance of social power such that there is
recurrent social exclusion or rejection by others. Examples of social rejection include bul-
lying, teasing, and intimidation by others; be ing targeted by others for verbal abuse and
humiliation; and being purposefully excluded fr om the activities of peers, workmates, or
others in one’s social environment.
V62.4 (Z60.5) Target of (Perceived) Adverse Discrimination or Persecution
This category should be used when there is perceived or experienced discrimination
against or persecution of the individual based on his or her membership (or perceived | dsm5.pdf |
9d3154b63563-0 | Other Conditions That May Be a Focus of Clinical Attention 725
membership) in a specific category. Typically , such categories include gender or gender
identity, race, ethnicity, religion, sexual orientation, country of origin, political beliefs, dis-
ability status, caste, social status , weight, and physical appearance.
V62.9 (Z60.9) Unspecified Problem Related to Social Environment
This category should be used when there is a pr oblem related to the individual’s social en-
vironment other than as specified above.
Problems Related to Crime or Interaction
With the Legal System
V62.89 (Z65.4) Victim of Crime
V62.5 (Z65.0) Conviction in Civil or Criminal Proceedings Without Imprisonment
V62.5 (Z65.1) Imprisonment or Other Incarceration
V62.5 (Z65.2) Problems Related to Release From Prison
V62.5 (Z65.3) Problems Related to Other Legal Circumstances
Other Health Service Encounters for
Counseling and Medical Advice
V65.49 (Z70.9) Sex Counseling
This category should be used when the indi vidual seeks counseling related to sex educa-
tion, sexual behavior, sexual orientation, sexual attitudes (embarrassment, timidity), oth-
ers’ sexual behavior or orientation (e.g., spou se, partner, child), sexu al enjoyment, or any
other sex-related issue.
V65.40 (Z71.9) Other Counseling or Consultation
This category should be used when counseling is provided or advice/consultation is
sought for a problem that is not specified above or elsewhere in this chapter. Examples in-
clude spiritual or religious counseling, dietar y counseling, and counseling on nicotine use. | dsm5.pdf |
9d3154b63563-1 | clude spiritual or religious counseling, dietar y counseling, and counseling on nicotine use.
Problems Related to Other Psychosocial, Personal,
and Environmental Circumstances
V62.89 (Z65.8) Religious or Spiritual Problem
This category can be used when the focus of clinical attention is a religious or spiritual
problem. Examples include distressing experi ences that involve lo ss or questioning of
faith, problems associated with conversion to a new faith, or questioning of spiritual val-
ues that may not necessarily be related to an organized church or religious institution.
V61.7 (Z64.0) Problems Related to Unwanted Pregnancy
V61.5 (Z64.1) Problems Related to Multiparity
V62.89 (Z64.4) Discord With Social Service Provider, Including Probation Officer,
Case Manager, or Social Services Worker
V62.89 (Z65.4) Victim of Terrorism or Torture
V62.22 (Z65.5) Exposure to Disaster, War, or Other Hostilities
V62.89 (Z65.8) Other Problem Related to Psychosocial Circumstances
V62.9 (Z65.9) Unspecified Problem Related to Un specified Psychosocial Circum-
stances | dsm5.pdf |
e9f555acab16-0 | 726 Other Conditions That May Be a Focus of Clinical Attention
Other Circumstances of Personal History
V15.49 (Z91.49) Other Personal History of Psychological Trauma
V15.59 (Z91.5) Personal History of Self-Harm
V62.22 (Z91.82) Personal History of Military Deployment
V15.89 (Z91.89) Other Personal Risk Factors
V69.9 (Z72.9) Problem Related to Lifestyle
This category should be used when a lifestyle pr oblem is a specific focus of treatment or di-
rectly affects the course, prognosis, or treatmen t of a mental or other medical disorder. Ex-
amples of lifestyle problems include lack of physical exercise, inappropriate diet, high-risk
sexual behavior, and poor sleep hygiene. A prob lem that is attributable to a symptom of a
mental disorder should not be coded unless that problem is a specific focus of treatment or
directly affects the course, prognosis, or treatmen t of the individual. In such cases, both the
mental disorder and the lifesty le problem should be coded.
V71.01 (Z72.811) Adult Antisocial Behavior
This category can be used when the focus of c linical attention is adult antisocial behavior
that is not due to a mental disorder (e.g., conduct disorder , antisocial personality disor-
der). Examples include the behavior of some pr ofessional thieves, racketeers, or dealers in
illegal substances.
V71.02 (Z72.810) Child or Adolescent Antisocial Behavior
This category can be used when the focus of clinical attention is antisocial behavior in a
child or adolescent that is no t due to a mental disorder (e.g ., intermittent explosive disor-
der, conduct disorder). Examples include isol ated antisocial acts by children or adoles- | dsm5.pdf |
e9f555acab16-1 | der, conduct disorder). Examples include isol ated antisocial acts by children or adoles-
cents (not a pattern of antisocial behavior).
Problems Related to Access to Medical
and Other Health Care
V63.9 (Z75.3) Unavailability or Inaccessibility of Health Care Facilities
V63.8 (Z75.4) Unavailability or Inaccessibility of Other Helping Agencies
Nonadherence to Medical Treatment
V15.81 (Z91.19) Nonadherence to Medical Treatment
This category can be used when the focus of clinical attention is nonadherence to an im-
portant aspect of treatment for a mental diso rder or another medica l condition. Reasons
for such nonadherence may include discomfort resulting from treatment (e.g., medication
side effects), expense of treatment, personal value judgments or religious or cultural be-
liefs about the proposed treatment, age-related debility, and the presence of a mental dis-
order (e.g., schizophrenia, personality disorder ). This category should be used only when
the problem is sufficiently severe to warrant independent clinical attention and does not
meet diagnostic criteria fo r psychological factors affect ing other medical conditions.
278.00 (E66.9) Overweight or Obesity
This category may be used when overweight or obesity is a focus of clinical attention.
V65.2 (Z76.5) Malingering
The essential feature of malingering is the inte ntional production of false or grossly exag-
gerated physical or psychologi cal symptoms, motivated by external incentives such as
avoiding military duty, avoiding work, obta ining financial compensation, evading crimi-
nal prosecution, or obtaining drugs. Under some circumstances, malingering may repre- | dsm5.pdf |
322fea1998ba-0 | Other Conditions That May Be a Focus of Clinical Attention 727
sent adaptive behavior—for example, feigni ng illness while a captive of the enemy during
wartime. Malingering should be strongly suspected if any combination of the following is
noted:
1. Medicolegal context of presentation (e.g., th e individual is referred by an attorney to
the clinician for examination, or the indivi dual self-refers while litigation or criminal
charges are pending).
2. Marked discrepancy between the individual’s claimed stress or disability and the ob-
jective findings and observations.
3. Lack of cooperation during the diagnostic evaluation and in complying with the pre-
scribed treatment regimen.
4. The presence of antisocial personality disorder.
Malingering differs from factitious disorder in that the motiva tion for the symptom
production in malingering is an external ince ntive, whereas in factit ious disorder external
incentives are absent. Malingering is differen tiated from conversion disorder and somatic
symptom–related mental disorders by the inte ntional production of symptoms and by the
obvious external incentives assoc iated with it. Definite evidence of feigning (such as clear
evidence that loss of function is present du ring the examination but not at home) would
suggest a diagnosis of factitious disorder if the individual’s apparent aim is to assume the
sick role, or malingering if it is to obtain an incentive, such as money.
V40.31 (Z91.83) Wandering Associated With a Mental Disorder
This category is used for individuals with a mental disorder whose desire to walk about
leads to significant clinical management or safety concerns. For example, individuals with
major neurocognitive or neurodevelopmental disorders may experience a restless urge to | dsm5.pdf |
322fea1998ba-1 | major neurocognitive or neurodevelopmental disorders may experience a restless urge to
wander that places them at risk for falls and causes them to leave supervised settings with-
out needed accompaniment. This category excl udes individuals whose intent is to escape
an unwanted housing situation (e.g., childre n who are running away from home, patients
who no longer wish to remain in the hospital) or those who walk or pace as a result of med-
ication-induced akathisia.
Coding note: First code associated mental disorder (e.g., major neurocognitive disor-
der, autism spectrum disorder), then co de V40.31 (Z91.83) wandering associated with
[specific mental disorder].
V62.89 (R41.83) Borderline Intellectual Functioning
This category can be used when an individual’s borderline intellectual functioning is the fo-
cus of clinical attention or has an impact on the individual’s treatmen t or prognosis. Differ-
entiating borderline intellectual functioning and mild intellectual disability (intellectual
developmental disorder) requires careful asse ssment of intellectual and adaptive functions
and their discrepanc ies, particularly in the presence of co-occurring mental disorders that
may affect patient compliance with standardized testing procedures (e.g., schizophrenia or
attention-deficit/hyperactivity diso rder with severe impulsivity). | dsm5.pdf |
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4e4e08541458-0 | SECTION III
Emerging Measures and Models
Assessment Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .733
Cross-Cutting Symptom Measures . . . . . . . . . . . . . . . . . . . . . . . . . . .734
DSM-5 Self-Rated Level 1 Cross-Cutting
Symptom Measure—Adult. . . . . . . . . . . . . . . . . . . . . . . . . . . . .738
Parent/Guardian-Rated DSM-5 Level 1 Cross-Cutting
Symptom Measure—Child Age 6–17 . . . . . . . . . . . . . . . . . . . .740
Clinician-Rated Dimensions of Psycho sis Symptom Severity . . . . . .742
World Health Organization Disability Assessment Schedule 2.0
(WHODAS 2.0) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .745
Cultural Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .749
Cultural Formulation Interview (CFI). . . . . . . . . . . . . . . . . . . . . . . . . . .750
Cultural Formulation Interview (CFI)—Informant Version . . . . . . . . . .755 | dsm5.pdf |
4e4e08541458-1 | Alternative DSM-5 Model for Personality Disorders . . . . . . . . . . . . . . . .761
Conditions for Further Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .783
Attenuated Psychosis Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . .783
Depressive Episodes With Short-Duration Hypomania . . . . . . . . . . .786
Persistent Complex Bereavement Disorder . . . . . . . . . . . . . . . . . . . .789
Caffeine Use Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .792
Internet Gaming Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .795
Neurobehavioral Disorder Associated With
Prenatal Alcohol Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .798
Suicidal Behavior Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .801
Nonsuicidal Self-Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .803 | dsm5.pdf |
927e7dcc74de-0 | This page intentionally left blank | dsm5.pdf |
29429cf3701f-0 | This section contains tools and techniques to enhance the clinical deci-
sion-making process, understand the cultural context of mental disorders, and
recognize emerging diagnoses for further study. It provides strategies to en-
hance clinical practice and new criteria to stimulate future research, represent-
ing a dynamic DSM-5 that will evolve with advances in the field.
Among the tools in Section III is a Level 1 cross-cutting self/informant-rated
measure that serves as a review of systems across mental disorders. A clini-
cian-rated severity scale for schizophrenia and other psychotic disorders also
is provided, as well as the World He alth Organization Disability Assessment
Schedule, Version 2 (WHODAS 2.0). Level 2 severity measures are available
online (www.psychiatry.org/dsm5) and may be used to explore significant re-
sponses to the Level 1 screen. A comprehensive review of the cultural context
of mental disorders, and the Cultural Formulation Interview (CFI) for clinical use,
are provided.
Proposed disorders for future study are provided, which include a new
model for the diagnosis of personality disorders as an alternative to the estab-
lished diagnostic criteria; the proposed m odel incorporates impairments in per-
sonality functioning as well as pathological personality traits. Also included are
new conditions that are the focus of active research, such as attenuated psy-
chosis syndrome and nonsuicidal self-injury. | dsm5.pdf |
db831d07ca73-0 | This page intentionally left blank | dsm5.pdf |
44b9b5fa9ce7-0 | 733 Assessment
Measures
A growing body of scientific evidence favors dimensional concepts in the diagnosis
of mental disorders. The limitations of a cate gorical approach to diagnosis include the fail-
ure to find zones of rarity between diagnoses (i.e., delineation of mental disorders from one
another by natural boundaries), the need for in termediate categories like schizoaffective dis-
order, high rates of comorbidity, frequent not-otherwise-specified (NOS) diagnoses, relative
lack of utility in furthering the identification of unique antecedent validators for most men-
tal disorders, and lack of treatment specif icity for the various di agnostic categories.
From both clinical and research perspectiv es, there is a need for a more dimensional
approach that can be combined with DSM’s se t of categorical diagnoses. Such an approach
incorporates variations of features within an in dividual (e.g., differential severity of indi-
vidual symptoms both within and outside of a disorder’s diagnostic criteria as measured
by intensity, duration, or number of symptoms , along with other features such as type and
severity of disabilities) rather than relying on a simple yes-or-no approach. For diagnoses
for which all symptoms are needed for a diagnosis (a monothetic criteria set), different se-
verity levels of the constituent symptoms may be noted. If a threshold endorsement of
multiple symptoms is needed, su ch as at least five of nine symptoms for major depressive
disorder (a polythetic criteria set), both severity levels and different combinations of the
criteria may identify more ho mogeneous diagnostic groups.
A dimensional approach depending primarily on an individual’s subjective reports of
symptom experiences along with the clinician’s interpretation is consistent with current
diagnostic practice. It is expected that as our understanding of basic disease mechanisms | dsm5.pdf |
44b9b5fa9ce7-1 | diagnostic practice. It is expected that as our understanding of basic disease mechanisms
based on pathophysiology, neurocircuitry, ge ne-environment interactions, and laboratory
tests increases, approaches that integrate both objective and subjective patient data will be
developed to supplement and enhance the accuracy of the diagnostic process.
Cross-cutting symptom measures modeled on general medicine’s review of systems can
serve as an approach for reviewing critical psychopathological domains. The general med-
ical review of systems is crucial to detecting subtle changes in different organ systems that
can facilitate diagnosis and treatment. A simi lar review of various mental functions can
aid in a more comprehensive mental status assessment by drawing attention to symptoms
that may not fit neatly into the diagnostic cr iteria suggested by the individual’s presenting
symptoms, but may nonetheless be important to the individual’s care. The cross-cutting
measures have two levels: Level 1 questions ar e a brief survey of 13 symptom domains for
adult patients and 12 domains for child and ad olescent patients. Level 2 questions provide
a more in-depth assessment of certain domains. These measures were developed to be
administered both at initial interview and ov er time to track the patient’s symptom status
and response to treatment.
Severity measures are disorder-specific, corresponding closely to the criteria that consti-
tute the disorder definition. They may be ad ministered to individuals who have received
a diagnosis or who have a clinically signific ant syndrome that falls short of meeting full
criteria for a diagnosis. Some of the assess ments are self-completed by the individual,
while others require a clinician to complete . As with the cross-cutting symptom measures,
these measures were developed to be administered both at initial interview and over time
to track the severity of the individual’s disorder and response to treatment. | dsm5.pdf |
b3ae2d069704-0 | 734 Assessment Measures
The World Health Organization Disability Assessment Schedule , Version 2.0 (WHODAS 2.0)
was developed to assess a patient’s ability to perform activities in six areas: understanding
and communicating; getting around; self-care; getting along with people; life activities
(e.g., household, work/school); and participat ion in society. The scale is self-administered
and was developed to be used in patients with any medical disorder. It corresponds to
concepts contained in the WH O International Classification of Functioning, Disability
and Health. This assessment can also be used over time to track changes in a patient’s dis-
abilities.
This chapter focuses on the DSM-5 Leve l 1 Cross-Cutting Symptom Measure (adult
self-rated and parent/guardian versions); the Clinician-Rated Dimensions of Psychosis
Symptom Severity; and the WHODAS 2.0. Cl inician instructions, scoring information,
and interpretation guidelines are included for each. These measures and additional
dimensional assessments, including those for diagnostic severity, can be found online at
www.psychiatry.org/dsm5.
Cross-Cutting Symptom Measures
Level 1 Cross-Cuttin g Symptom Measure
The DSM-5 Level 1 Cross-Cuttin g Symptom Measure is a patien t- or informant-rated mea-
sure that assesses mental health domains th at are important across psychiatric diagnoses.
It is intended to help clinicians identify addi tional areas of inquiry that may have signifi-
cant impact on the individual’s treatment and prognosis. In addition, the measure may be
used to track changes in the individu al’s symptom presentation over time.
The adult version of the measure consists of 23 questions that assess 13 psychiatric do- | dsm5.pdf |
b3ae2d069704-1 | The adult version of the measure consists of 23 questions that assess 13 psychiatric do-
mains, including depression, an ger, mania, anxiety, somatic symptoms, suicidal ideation,
psychosis, sleep problems, memo ry, repetitive thoughts and behaviors, dissociation, per-
sonality functioning, and substance use (Table 1). Each domain consists of one to three
questions. Each item inquires about how mu ch (or how often) the individual has been
bothered by the specific symptom during the p ast 2 weeks. If the individual is of impaired
capacity and unable to complete the form (e .g., an individual with dementia), a knowl-
edgeable adult informant may complete this measure. The measure was found to be clin-
ically useful and to have good reliability in the DSM-5 field trials that were conducted in
adult clinical samples across the United States and in Canada.
The parent/guardian-rated ver sion of the measure (for childr en ages 6–17) consists of
25 questions that assess 12 psychiatric domain s, including depression, anger, irritability,
mania, anxiety, somatic symptoms, inattent ion, suicidal ideation/attempt, psychosis,
sleep disturbance, repetitive thoughts and behaviors, an d substance use (Table 2). Each
item asks the parent or guardian to rate ho w much (or how often) his or her child has been
bothered by the specific psychiatric symptom during the past 2 weeks. The measure was
also found to be clinically useful and to ha ve good reliability in the DSM-5 field trials that
were conducted in pediatric clinical samples across the United States. For children ages
11–17, along with the parent/guardian rating of the child’s sympto ms, the clinician may | dsm5.pdf |
b3ae2d069704-2 | consider having the child complete the child -rated version of the measure. The child-rated
version of the measure can be found online at www.psychiatry.org/dsm5.
Scoring and interpretation. On the adult self-rated version of the measure, each item is
rated on a 5-point scale (0=none or not at all; 1=slight or rare, less than a day or two; 2=mild
or several days; 3=moderate or more than half the days; and 4=severe or nearly every day).
The score on each item within a domain should be reviewed. However, a rating of mild (i.e.,
2) or greater on any item within a domain, ex cept for substance use, suicidal ideation, and | dsm5.pdf |
877033d68d74-0 | The score on each item within a domain should be reviewed. However, a rating of mild (i.e.,
2) or greater on any item within a domain, ex cept for substance use, suicidal ideation, and
psychosis, may serve as a guide for additional inquiry and follow-up to determine if a more
detailed assessment is necessary, which may include the Level 2 cross-cutting symptom as-
sessment for the domain (see Table 1). For substa nce use, suicidal idea tion, and psychosis, a | dsm5.pdf |
271afa4d1be9-0 | Assessment Measures 735
rating of slight (i.e., 1) or greater on any item within the domain may serve as a guide for ad-
ditional inquiry and follow-up to determine if a more detailed a ssessment is needed. As
such, indicate the highest score within a domain in the “Highest domain score” column.
Table 1 outlines threshold scores that may guide further inquiry for the remaining domains.
On the parent/guardian-rated version of the measure (for children ages 6–17), 19 of the 25
items are each rated on a 5-point scale (0=none or not at all; 1=slight or rare, less than a day or
two; 2=mild or several days; 3=moderate or mo re than half the days; and 4=severe or nearly
every day). The suicidal ideation, suicide atte mpt, and substance abuse items are each rated
on a “Yes, No, or Don’t Know” scale. The score on each item within a domain should be re-
viewed. However, with the exception of inattentio n and psychosis, a rating of mild (i.e., 2) or
greater on any item within a domain that is scored on the 5-point scale may serve as a guide
for additional inquiry and follow-up to determin e if a more detailed assessment is necessary,
which may include the Level 2 cross-cutting symptom assessment for the domain (see
Table 2). For inattention or psychosis, a rating of slight or greater (i.e., 1 or greater) may beTABLE 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure:
13 domains, thresholds for further inquiry, and associated DSM-5
Level 2 measures
Domain Domain nameThreshold to guide | dsm5.pdf |
271afa4d1be9-1 | Level 2 measures
Domain Domain nameThreshold to guide
further inquiryDSM-5 Level 2 Cross-Cutting Symptom
Measurea
I. Depression Mild or greater Lev el 2—Depression—Adult (PROMIS
Emotional Distress—Short Form)
II. Anger Mild or greater Level 2—Anger—Adult (PROMIS Emo-
tional Distress—Anger—Short Form)
III. Mania Mild or greater Level 2— Mania—Adult (Altman Self-Rating
Mania Scale [ASRM])
IV. Anxiety Mild or greater Level 2—Anxiety—Adult (PROMIS
Emotional Distress—Anxiety—Short
Form)
V. Somatic symptoms Mild or greater Le vel 2—Somatic Symptom—Adult (Patient
Health Questionnaire–15
[PHQ-15] Somatic Symptom Severity
Scale)
VI. Suicidal ideation Slight or greater None
VII. Psychosis Slight or greater None
VIII. Sleep problems Mild or greater Level 2—Sleep Disturbance—Adult
(PROMIS Sleep Disturbance—Short Form)
IX. Memory Mild or greater None
X. Repetitive thoughts
and behaviorsMild or greater Level 2—Repetitive Thoughts and
Behaviors—Adult (Florida Obsessive-
Compulsive Inventory [FOCI] Severity
Scale)
XI. Dissociation Mild or greater None
XII. Personality
functioningMild or greater None
XIII. Substance use Slight or greater L evel 2—Substance Us e—Adult (adapted
from the NIDA-Modified ASSIST)
Note. NIDA=National Institute on Drug Abuse. | dsm5.pdf |
271afa4d1be9-2 | Note. NIDA=National Institute on Drug Abuse.
aAvailable at www.ps ychiatry.org/dsm5. | dsm5.pdf |
01f44549660c-0 | 736 Assessment Measures
used as an indicator for additional inquiry. A parent or guardian’s ra ting of “Don’t Know” on
the suicidal ideation, suicide a ttempt, and any of the substance use items, especially for chil-
dren ages 11–17 years, may result in additional probing of the issues with the child, including
using the child-rated Level 2 Cross-Cutting Symptom Measure for the relevant domain. Be-
cause additional inquiry is made on the basis of the highest score on any item within a do-
main, clinicians should indicate that score in the “Highest Domain Score” column. Table 2
outlines threshold scores that may guide further inquiry for the remaining domains.TABLE 2 Parent/guardian-rated DSM-5 Level 1 Cross-Cutting Symptom Measure
for child age 6–17: 12 domains, thresholds for further inquiry, and
associated Level 2 measures
Domain Domain nameThreshold to guide
further inquiryDSM-5 Level 2 Cross-Cutting Symptom
Measurea
I. Somatic symptoms Mild or greater Le vel 2—Somatic Symptoms—Parent/Guard-
ian of Child Age 6–17 (Patient Health
Questionnaire–15 Somatic Symptom Sever-
ity Scale [PHQ-15])
II. Sleep problems Mild or greater Lev el 2—Sleep Disturbance—Parent/Guard-
ian of Child Age 6–17 (PROMIS Sleep
Disturbance—Short Form)
III. Inattention Slight or greater Level 2—Inattention—Parent/Guardian of
Child Age 6–17 (Swanson , Nolan, and Pel-
ham, Version IV [SNAP-IV])
IV. Depression Mild or greater Level 2—Depression—Parent/Guardian of | dsm5.pdf |
01f44549660c-1 | IV. Depression Mild or greater Level 2—Depression—Parent/Guardian of
Child Age 6–17 (PROMIS Emotional Dis-
tress—Depression—Parent Item Bank)
V. Anger Mild or greater Level 2—Anger—Parent/Guardian of Child
(PROMIS Calibrated Anger Measure—Parent)
VI. Irritability Mild or greater Level 2—Irritability—Parent/Guardian of
Child (Affective Reactivity Index [ARI])
VII. Mania Mild or greater Level 2— Mania—Parent/Guardian of Child
Age 6–17 (Altman Self-Rating Mania Scale
[ASRM])
VIII. Anxiety Mild or greater Level 2—Anxiety—Parent/Guardian of Child
Age 6–17 (PROMIS Emotional Distress—
Anxiety—Parent Item Bank)
IX. Psychosis Slight or greater None
X. Repetitive thoughts
and behaviorsMild or greater None
XI. Substance use Yes Level 2—Substance Use—Parent/Guardian of
Child Age 6–17 (adapted from the NIDA-
modified ASSIST)
Don’t Know NIDA-modified ASSIST (adapted)—
Child-Rated (age 11–17 years)
XII. Suicidal ideation/
suicide attemptsYes None
Don’t Know None
Note. NIDA=National Institute on Drug Abuse.
aAvailable at www.ps ychiatry.org/dsm5. | dsm5.pdf |
e5260cbe10d1-0 | Assessment Measures 737
Level 2 Cross-Cuttin g Symptom Measures
Any threshold scores on the Level 1 Cross- Cutting Symptom Measure (as noted in Tables
1 and 2 and described in “Scoring and Interpretation” indicate a possible need for detailed
clinical inquiry. Level 2 Cr oss-Cutting Symptom Measures provide one method of obtain-
ing more in-depth information on potentially significant symptoms to inform diagnosis,
treatment planning, and follow-up. They ar e available online at www.psychiatry.org/
dsm5. Tables 1 and 2 outline each Level 1 domain and identify the domains for which
DSM-5 Level 2 Cross-Cutting Symptom Measures are available for more detailed assess-
ments. Adult and pediatric (parent and child) versions are available online for most Level
1 symptom domains at www.psychiatry.org/dsm5.
Frequency of Use of the Cross-Cutting
Symptom Measures
To track change in the individual’s sympto m presentation over time , the Level 1 and rel-
evant Level 2 cross-cutting symptom measures may be completed at regular intervals as
clinically indicated, depending on the stab ility of the individual’s symptoms and treat-
ment status. For individuals with impaired capacity and for children ages 6–17 years, it is
preferable for the measures to be comple ted at follow-up appointments by the same
knowledgeable informant and by the same parent or guardian. Consistently high scores
on a particular domain may indicate signif icant and problematic sy mptoms for the indi-
vidual that might warrant further assessment, treatment, and follow-up. Clinical judg-
ment should guide decision making. | dsm5.pdf |
cfdb665af90d-0 | 738 Assessment MeasuresDSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult
Name:__________________________________________ ______________ Age: __________ Sex: [ ] Male [ ] Female Date:_____________
If the measure is being completed by an informant , what is your relationship with the individual?: __________________________ ____
In a typical week, approximately how much time do you spend with th e individual? _________________________ hours/week
Instructions: The questions below ask about things that might have bothered you. For each question, circle the nu mber that best describes ho w much (or how
often) you have been bothered by each problem during the past TWO (2) WEEKS.
During the past TWO (2) WEEKS, how much (or how often)
have you been bothered by the following problems?None
Not at
allSlight
Rare, less than
a day or twoMild
Several
daysModerate
More than
half the daysSevere
Nearly
every dayHighest
Domain Score
(clinician)
I. 1.Little interest or pleasure in doing things? 0 1 2 3 4
2.Feeling down, depressed, or hopeless? 0 1 2 3 4
II. 3. Feeling more irritated, gr ouchy, angry than usual? 0 1 2 3 4
III. 4.Sleeping less than usual, but still have a lot of energy? 0 1 2 3 4
5.Starting lots more projects than usual or doing more risky things
than usual?0 1 2 3 4
IV. 6.Feeling nervous, anxious, frig htened, worried, or on edge? 0 1 2 3 4 | dsm5.pdf |
cfdb665af90d-1 | 7.Feeling panic or being frightened? 0 1 2 3 4
8.Avoiding situations that make you anxious? 0 1 2 3 4
V. 9.Unexplained aches and pains (e.g., head, back, joints, abdomen,
legs)?0 1 2 3 4
10. Feeling that your illnesses are not being taken seriously enough? 0 1 2 3 4
VI. 11. Thoughts of actually hurting yourself? 0 1 2 3 4 | dsm5.pdf |
a8b0bad6dbaf-0 | Assessment Measures 739VII. 12. Hearing things other people couldn’t hear, such as voices even
when no one was around?0 1 2 3 4
13. Feeling that someone could hear your thoughts, or that you
could hear what another person was thinking?0 1 2 3 4
VIII. 14. Problems with sleep that affect ed your sleep quality over all? 0 1 2 3 4
IX. 15. Problems with memory (e.g., lear ning new information) or with
location (e.g., finding your way home)?0 1 2 3 4
X. 16. Unpleasant thoughts, urges, or images that repeatedly enter
your mind?0 1 2 3 4
17. Feeling driven to perform certai n behaviors or mental acts over
and over again?0 1 2 3 4
XI. 18. Feeling detached or distant from yourself, your body, your phys-
ical surroundings, or your memories?0 1 2 3 4
XII. 19. Not knowing who you really are or what you want out of life? 0 1 2 3 4
20. Not feeling close to other people or enjoying your relationships
with them?01 23 4
XIII. 21. Drink at least 4 drinks of any kind of alcohol in a single day? 0 1 2 3 4
22. Smoke any cigarettes, a cigar, or pipe, or use snuff or chewing
tobacco?0 1 2 3 4
23. Use any of the following medicines ON YOUR OWN, that is,
without a doctor’s prescription, in greater amounts or longer | dsm5.pdf |
a8b0bad6dbaf-1 | without a doctor’s prescription, in greater amounts or longer
than prescribed [e.g., painkillers (like Vicodin), stimulants (like
Ritalin or Adderall), sedatives or tranquilizers (like sleeping
pills or Valium), or drugs like marijuana, cocaine or crack, club
drugs (like ecstasy), hallucinogen s (like LSD), heroin, inhalants
or solvents (like glue), or methamphetamine (like speed)]?0 1 2 3 4 | dsm5.pdf |
df530d728ceb-0 | 740 Assessment MeasuresParent/Guardian-Rated DSM-5 Level 1 Cros s-Cutting Symptom Measure—Child Age 6–17
Child’s Name:__________________________________________ ___ Age: __________ Sex: [ ] Male [ ] Female Date:_____________
Relationship to the child: ___________________________________
Instructions (to parent or guardian of child): The questions below ask about things that might have bothered your child. For each question, circle the number that
best describes how much (or how often) your child has been bothered by each problem during t he past TWO (2) WEEKS.
During the past TWO (2) WEEKS, how much (or how often) has your
child…None
Not at
allSlight
Rare, less than
a day or twoMild
Several
daysModerate
More than
half the daysSevere
Nearly
every dayHighest
Domain Score
(clinician)
I. 1.Complained of stomachaches, headaches, or other aches and
pains?0 1 2 3 4
2.Said he/she was worried about hi s/her health or about getting
sick?0 1 2 3 4
II. 3. Had problems sleeping—that is, trouble falling asleep, staying
asleep, or waking up too early?01 23 4
III. 4.Had problems paying attention when he/she was in class or
doing his/her homework or read ing a book or playing a game?0 1 2 3 4
IV. 5. Had less fun doing things than he/she used to? 0 1 2 3 4
6. Seemed sad or depressed for several hours? 0 1 2 3 4
V.
and | dsm5.pdf |
df530d728ceb-1 | V.
and
VI.7.Seemed more irritated or easily annoyed than usual? 0 1 2 3 4
8.Seemed angry or lost his/her temper? 0 1 2 3 4
VII. 9. Starting lots more projects than usual or doing more risky things
than usual?01 23 4
10. Sleeping less than usual for him/her but still has lots of energy? 0 1 2 3 4
VIII. 11. Said he/she felt nervous, anxious, or scared? 0 1 2 3 4
12. Not been able to stop worrying? 0 1 2 3 4
13. Said he/she couldn’t do things he/she wanted to or should have
done because they made him/her feel nervous? 0 1 2 3 4 | dsm5.pdf |
885e86617a12-0 | Assessment Measures 741IX. 14. Said that he/she heard voices—when there was no one there—
speaking about him/her or tellin g him/her what to do or say-
ing bad things to him/her?01 23 4
15. Said that he/she had a vision when he/she was completely awake—
that is, saw something or someone that no one else could see?01 23 4
X.16. Said that he/she had thoughts that kept coming into his/her
mind that he/she would do so mething bad or that something
bad would happen to him/her or to someone else?0 1 2 3 4
17. Said he/she felt the need to chec k on certain things over and over
again, like whether a door was locked or whether the stove was
turned off?0 1 2 3 4
18. Seemed to worry a lot about things he/she touched being dirty or
having germs or being poisoned?0 1 2 3 4
19. Said that he/she had to do things in a certain way, like counting
or saying special things out lo ud, in order to keep something
bad from happening?0 1 2 3 4
In the past TWO (2) WEEKS, has your child…
XI. 20. Had an alcoholic beverage (beer, wine, liquor, etc.)? ❑ Yes ❑ No ❑ Don’t Know
21. Smoked a cigarette, a cigar, or pipe, or used snuff or chewing
tobacco?❑ Yes ❑ No ❑ Don’t Know
22. Used drugs like marijuana, cocaine or crack, club drugs (like
ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents | dsm5.pdf |
885e86617a12-1 | ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents
(like glue), or methamphetamine (like speed)?❑ Yes ❑ No ❑ Don’t Know
23. Used any medicine without a doctor ’s prescription (e.g., painkillers
[like Vicodin], stimulants [like Ritalin or Adderall], sedatives or
tranquilizers [like sleeping pills or Valium], or steroids)?❑ Yes ❑ No ❑ Don’t Know
XII. 24. In the past TWO (2) WEEKS, has he/she talked about wanting to
kill himself/herself or about wanting to commit suicide?❑ Yes ❑ No ❑ Don’t Know
25. Has he/she EVER tried to kill himself/herself? ❑ Yes ❑ No ❑ Don’t Know | dsm5.pdf |
34d83fe8abeb-0 | 742 Assessment Measures
Clinician-Rated Dimensions of
Psychosis Symptom Severity
As described in the chapter “Schizophrenia Spectrum and Other Psychotic Disorders,”
psychotic disorders are hetero geneous, and symptom severity can predict important as-
pects of the illness, such as the degree of cogn itive and/or neurobiological deficits. Dimen-
sional assessments capture meaningful variation in the severity of symptoms, which may
help with treatment planning, prognostic decision-making, and research on pathophysi-
ological mechanisms. The Clinician-Rated Dimensions of Psychosis Symptom Severity
provides scales for the dimensional assessment of the primary symptoms of psychosis, in-
cluding hallucinations, delusions, disorganiz ed speech, abnormal psychomotor behavior,
and negative symptoms. A scale for the dimensional assessment of cognitive impairment
is also included. Many individuals with psyc hotic disorders have im pairments in a range
of cognitive domains, which predict functional abilities. In addition, scales for dimensional
assessment of depression and mania are provided , which may alert clinicians to mood pa-
thology. The severity of mood symptoms in psychosis has prognostic value and guides
treatment.
The Clinician-Rated Dimensions of Psychosis Symptom Severity is an 8-item measure
that may be completed by the clinician at the time of the clinical assessment. Each item asks
the clinician to rate the severity of each sy mptom as experienced by the individual during
the past 7 days.
Scoring and Interpretation
Each item on the measure is rated on a 5-poin t scale (0=none; 1=equivocal; 2=present, but
mild; 3=present and moderate; and 4=present and severe) with a sy mptom-specific defi- | dsm5.pdf |
34d83fe8abeb-1 | nition of each rating level. The clinician may review all of the individual’s available infor-
mation and, based on clinical judgment, select (with checkmark) the level that most
accurately describes the severity of the indivi dual’s condition. The clinician then indicates
the score for each item in the “Score” column provided.
Frequency of Use
To track changes in the indi vidual’s symptom severity over time, the measure may be
completed at regular intervals as clinically in dicated, depending on the stability of the in-
dividual’s symptoms an d treatment status. Consistently high scores on a particular do-
main may indicate significant and problematic areas for the individual that might warrant
further assessment, treatment, and follow-up. Clinical judgment should guide decision
making. | dsm5.pdf |
da91e4712e4b-0 | Assessment Measures 743Clinician-Rated Dimensions of Psychosis Symptom Severity
Name:______________________________________ ______ Age: __________ Sex: [ ] Male [ ] Female Date:________________
Instructions: Based on all the information you have on the individual and usin g your clinical judgment, please rate (with checkmark) the pre sence and severity
of the following symptoms as experienced by the in dividual in the past seven (7) days.
Domain 0 1 2 3 4 Score
I. Hallucinations ❑ Not present ❑ Equivocal (severity or
duration not sufficient
to be considered psy-
chosis)❑ Present, but mild (lit-
tle pressure to act
upon voices, not very
bothered by voices)❑ Present and moderate
(some pressure to
respond to voices, or
is somewhat bothered
by voices)❑ Present and severe
(severe pressure to
respond to voices, or
is very bothered by
voices)
II. Delusions ❑ Not present ❑ Equivocal (severity or
duration not sufficient
to be considered psy-
chosis)❑ Present, but mild (lit-
tle pressure to act
upon delusional
beliefs, not very both-
ered by beliefs)❑ Present and moderate
(some pressure to act
upon beliefs, or is
somewhat bothered
by beliefs)❑ Present and severe
(severe pressure to act
upon beliefs, or is very
bothered by beliefs)
III. Disorganized speech ❑ Not present ❑ Equivocal (severity or
duration not sufficient
to be considered dis-
organization)❑ Present, but mild | dsm5.pdf |
da91e4712e4b-1 | to be considered dis-
organization)❑ Present, but mild
(some difficulty fol-
lowing speech)❑ Present and moderate
(speech often difficult
to follow)❑ Present and severe
(speech almost impos-
sible to follow)
IV. Abnormal psychomo-
tor behavior❑ Not present ❑ Equivocal (severity or
duration not sufficient
to be considered
abnormal psychomo-
tor behavior)❑ Present, but mild
(occasional abnormal
or bizarre motor
behavior or catatonia)❑ Present and moderate
(frequent abnormal or
bizarre motor behav-
ior or catatonia)❑ Present and severe
(abnormal or bizarre
motor behavior or
catatonia almost con-
stant)
V. Negative symptoms
(restricted emotional
expression or avolition)❑ Not present ❑ Equivocal decrease in
facial expressivity,
prosody, gestures, or
self-initiated behavior❑ Present, but mild
decrease in facial
expressivity, pros-
ody, gestures, or self-
initiated behavior❑ Present and moderate
decrease in facial
expressivity, pros-
ody, gestures, or self-
initiated behavior❑ Present and severe
decrease in facial
expressivity, pros-
ody, gestures, or self-
initiated behavior | dsm5.pdf |
9b9736ed12b6-0 | 744 Assessment Measures Domain 0 1 2 3 4 Score
VI. Impaired cognition ❑ Not present ❑ Equivocal (cognitive
function not clearly
outside the range
expected for age or
SES; i.e., within 0.5 SD
of mean)❑ Present, but mild
(some reduction in
cognitive function;
below expected for
age and SES, 0.5–1 SD
from mean)❑ Present and moderate
(clear reduction in
cognitive function;
below expected for
age and SES, 1–2 SD
from mean)❑ Present and severe
(severe reduction in
cognitive function;
below expected for
age and SES, >2 SD
from mean)
VII. Depression ❑ Not present ❑ Equivocal (occasion-
ally feels sad, down,
depressed, or hope-
less; concerned about
having failed some-
one or at something
but not preoccupied)❑ Present, but mild (fre-
quent periods of feel-
ing very sad, down,
moderately
depressed, or hope-
less; concerned about
having failed some-
one or at something,
with some preoccupa-
tion)❑ Present and moderate
(frequent periods of
deep depression or
hopelessness; preoc-
cupation with guilt,
having done wrong)❑ Present and severe
(deeply depressed or
hopeless daily; delu-
sional guilt or unrea-
sonable self-reproach
grossly out of propor-
tion to circumstances) | dsm5.pdf |
9b9736ed12b6-1 | sonable self-reproach
grossly out of propor-
tion to circumstances)
VIII. Mania ❑ Not present ❑ Equivocal (occasional
elevated, expansive,
or irritable mood or
some restlessness)❑ Present, but mild (fre-
quent periods of
somewhat elevated,
expansive, or irritable
mood or restlessness)❑ Present and moderate
(frequent periods of
extensively elevated,
expansive, or irritable
mood or restlessness)❑ Present and severe
(daily and extensively
elevated, expansive,
or irritable mood or
restlessness)
Note. SD=standard deviation; SES=socioeconomic status. | dsm5.pdf |
c5013352fbcf-0 | Assessment Measures 745
World Health Organization
Disability Assessment Schedule 2.0
The adult self-administered vers ion of the World Health Organization Disability Assessment
Schedule 2.0 (WHODAS 2.0) is a 36-item measur e that assesses disability in adults age 18
years and older. It assesses disability across six domains, including understanding and
communicating, getting around, self-care, gett ing along with people, life activities (i.e.,
household, work, and/or school activities), an d participation in society. If the adult indi-
vidual is of impaired capacity and unable to complete the form (e.g., a patient with demen-
tia), a knowledgeable informant may complete the proxy-administered version of the
measure, which is available at www.psychiatry. org/dsm5. Each item on the self-administered
version of the WHODAS 2.0 asks the individual to rate how much difficulty he or she has
had in specific areas of functioning during the past 30 days.
WHODAS 2.0 Scoring Instructions Provided by WHO
WHODAS 2.0 summary scores. There are two basic options for computing the summary
scores for the WHODAS 2.0 36-item full version.
Simple: The scores assigned to each of the items—“none” (1), “mild” (2), “moderate” (3),
“severe” (4), and “extreme” (5 )—are summed. This method is referred to as simple scoring
because the scores from each of the items are simply added up withou t recoding or collaps-
ing of response categories; thus, there is no we ighting of individual items. This approach is | dsm5.pdf |
c5013352fbcf-1 | practical to use as a hand-scoring approach, and may be the method of choice in busy clin-
ical settings or in paper-and-pencil interview situations. As a result, the simple sum of the
scores of the items across all domains constitutes a statistic that is suff icient to describe the
degree of functional limitations.
Complex: The more complex method of scoring is called “item-response-theory”
(IRT)–based scoring. It takes into account mu ltiple levels of diffic ulty for each WHODAS
2.0 item. It takes the coding for each item response as “none,” “mild,” “moderate,” “se-
vere,” and “extreme” separately, and then uses a computer to determine the summary
score by differentially weighting the items and the levels of severity. The computer pro-
gram is available from the WHO Web site. The scoring has three steps:
• Step 1—Summing of recoded item scores within each domain.
• Step 2—Summing of all six domain scores.
• Step 3—Converting the summary score in to a metric ranging from 0 to 100
(where 0=no disability; 100=full disability).
WHODAS 2.0 domain scores. WHODAS 2.0 produces domain-specific scores for six
different functioning domains: cognition, mobilit y, self-care, getting along, life activities
(household and work/school), and participation.
WHODAS 2.0 population norms. For the population norms fo r IRT-based scoring of the
WHODAS 2.0 and for the population distribution of IRT-based scores for WHODAS 2.0,
please see www.who.int/clas sifications/icf/Pop_norms_distrib_IRT_scores.pdf. | dsm5.pdf |
c5013352fbcf-2 | Additional Scoring and Inte rpretation Guidance for
DSM-5 Users
The clinician is asked to review the individu al’s response on each item on the measure
during the clinical interview and to indicate th e self-reported score for each item in the sec-
tion provided for “Clinician Use Only.” However, if the clinician determines that the score
on an item should be different based on the clinical interview and other information avail- | dsm5.pdf |
2c58b025ce88-0 | 746 Assessment Measures
able, he or she may indicate a corrected score in the raw item score box. Based on findings
from the DSM-5 Field Trials in adult patient samples across si x sites in the United States
and one in Canada, DSM-5 recommends calculation and use of average scores for each domain
and for general disability. The average scores are comparab le to the WHODAS 5-point scale,
which allows the clinician to think of the individual’s disability in terms of none (1), mild
(2), moderate (3), severe (4 ), or extreme (5). The averag e domain and general disability
scores were found to be reliable, easy to use, and clinically useful to the clinicians in the
DSM-5 Field Trials. The average domain score is calculated by dividing the raw domain score
by the number of items in the domain (e.g., if all the items within the “understanding and
communicating” domain are rated as being moderate then the average domain score
would be 18/6=3, indicating moderate disability). The average general disability score is cal-
culated by dividing the raw overall score by nu mber of items in the measure (i.e., 36). The
individual should be encouraged to complete a ll of the items on the WHODAS 2.0. If no re-
sponse is given on 10 or more items of the measure (i.e., more than 25% of the 36 total
items), calculation of the simple and average general disability scores may not be helpful.
If 10 or more of the total items on the measur e are missing but the items for some of the do-
mains are 75%–100% complete, the simple or aver age domain scores may be used for those
domains. | dsm5.pdf |
2c58b025ce88-1 | domains.
Frequency of use. To track change in the individual’s level of disability over time, the
measure may be completed at regular intervals as clinically indicated, depending on the
stability of the individual’s symptoms and trea tment status. Consistently high scores on a
particular domain may indicate significant and problematic areas for the individual that
might warrant further assessment and intervention. | dsm5.pdf |
35d3cd7355bb-0 | Assessment Measures 747
WHODAS 2.0
World Health Organization Disability Assessment Schedule 2.0
36-item version, self-administered
3DWLHQW1DPH BBBBBBBBBBBBBBBBBBBBBBB$JH BBBBBB 6H[ 0DOH)HPDOH ' D W H BBBBBBBBBBBBB
This questionnaire asks about difficulties due to health /mental health conditions. Health conditions include diseases or
illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems
with alcohol or drugs. Think back over the past 30 days and answer these questions thinking about how much difficulty you
had doing the following activities. For each question, please circle only one response.
ClinicianUse
Only
Numeric scores assigned to each of the items: 1 2 3 4 5
Raw Item
Score
Raw
Domain
Score
Average
Domain
Score In the last 30 days, how much difficulty did you have in:
Understanding and communicating
D1.1 Concentrating on doing so mething for ten minutes? None Mild Moderate Severe Extreme or
cannot do
____
30
____
5
D1.2 Remembering to do important things? None Mild Moderate Severe Extreme or
cannot do
D1.3 Analyzing and finding solutions to problems in day-
to-day life? None Mild Moderate Severe Extreme or
cannot do
D1.4 Learning a new task, for example, learning how to | dsm5.pdf |
35d3cd7355bb-1 | D1.4 Learning a new task, for example, learning how to
get to a new place? None Mild Moderate Severe Extreme or
cannot do
D1.5 Generally understanding what people say? None Mild Moderate Severe Extreme or
cannot do
D1.6 Starting and maintaining a conversation? None Mild Moderate Severe Extreme or
cannot do
Getting around
D2.1 Standing for long periods, such as 30 minutes? None Mild Moderate Severe Extreme or
cannot do
____
25
____
5
D2.2 Standing up from sitting down? None Mild Moderate Severe Extreme or
cannot do
D2.3 Moving around inside your home? None Mild Moderate Severe Extreme or
cannot do
D2.4 Getting out of your home? None Mild Moderate Severe Extreme or
cannot do
D2.5 Walking a long distance, such as a kilometer (or
equivalent)? None Mild Moderate Severe Extreme or
cannot do
Self-care
D3.1 Washing your whole body? None Mild Moderate Severe Extreme or
cannot do
____
20
____
5
D3.2 Getting dressed? None Mild Moderate Severe Extreme or
cannot do
D3.3 Eating? None Mild Moderate Severe Extreme or
cannot do
D3.4 Staying by yourself for a few days? None Mild Moderate Severe Extreme or
cannot do
Getting along with people
D4.1 Dealing with people you do not know? None Mild Moderate Severe Extreme or
cannot do
____
25
____ | dsm5.pdf |
35d3cd7355bb-2 | cannot do
____
25
____
5
D4.2 Maintaining a friendship? None Mild Moderate Severe Extreme or
cannot do
D4.3 Getting along with people who are close to you? None Mild Moderate Severe Extreme or
cannot do
D4.4 Making new friends? None Mild Moderate Severe Extreme or
cannot do
D4.5 Sexual activities? None Mild Moderate Severe Extreme or
cannot do | dsm5.pdf |
d2f2881a33f5-0 | 748 Assessment Measures
ClinicianUse
Only
Numeric scores assigned to each of the items: 1 2 3 4 5
Raw Item
Score
Raw
Domain
Score
Average
Domain
Score In the last 30 days, how much difficulty did you have in:
Life activities ͶHousehold
D5.1 Taking care of your household responsibilities? None Mild Moderate Severe Extreme or
cannot do
____
20
____
5
D5.2 Doing most important household tasks well? None Mild Moderate Severe Extreme or
cannot do
D5.3 Getting all of the household work done that you
needed to do? None Mild Moderate Severe Extreme or
cannot do
D5.4 Getting your household work done as quickly as
needed? None Mild Moderate Severe Extreme or
cannot do
Life activities ͶSchool/Work
If you work (paid, non-paid, self-employed) or go to school, complete questions D5.5 ʹD5.8, below.
Otherwise, skip to D6.1.
Because of your health condition, in the past 30 days, how much difficulty did you have in:
D5.5 Your day-to-day work/school? None Mild Moderate Severe Extreme or
cannot do
____
20
____
5
D5.6 Doing your most important work/school tasks well? None Mild Moderate Severe Extreme or
cannot do
D5.7 Getting all of the work done that you need to do? None Mild Moderate Severe Extreme or
cannot do | dsm5.pdf |
d2f2881a33f5-1 | cannot do
D5.8 Getting your work done as quickly as needed? None Mild Moderate Severe Extreme or
cannot do
Participation in society
In the past 30 days:
D6.1 How much of a problem did you have in joining in
community activities (for example, festivities,
religious, or other activities) in the same way as
anyone else can? None Mild Moderate Severe Extreme or
cannot do
____
40
____
5
D6.2 How much of a problem did you have because of
barriers or hindrances around you?
None
Mild
Moderate
Severe Extreme or
cannot do
D6.3 How much of a problem did you have living with
dignity because of the attitudes and actions of
others? None Mild Moderate Severe Extreme or
cannot do
D6.4 How much time did you spend on your health
condition or its consequences? None Some Moderate A Lot Extreme or
cannot do
D6.5 How much have you been emotionally affected by
your health condition? None Mild Moderate Severe Extreme or
cannot do
D6.6 How much has your health been a drain on the
financial resources of you or your family? None Mild Moderate Severe Extreme or
cannot do
D6.7 How much of a problem did your family have
because of your health problems? None Mild Moderate Severe Extreme or
cannot do
D6.8 How much of a problem did you have in doing
things by yourself for relaxation or pleasure? None Mild Moderate Severe Extreme or
cannot do
General Disability Score (Total): ____ | dsm5.pdf |
d2f2881a33f5-2 | cannot do
General Disability Score (Total): ____
180 ____
5
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7KH:RUOG+HDOWK2UJDQL]DWLRQKD VJUDQWHGWKH3XEOLVKHUSHUPLVV LRQIRUWKHUHSURGXFWLRQRIWKLV LQVWUXPHQW7KLVPDWHULDOFDQ
EHUHSURGXFHGZLWKRXWSHUPLVVLRQE\FOLQLFLDQVIRUXVHZLWKWKH LURZQSDWLHQWV$Q\RWKHUXVHLQFOXGLQJHOHFWURQLFXVH | dsm5.pdf |
d2f2881a33f5-3 | UHTXLUHVZULWWHQSHUPLVVLRQIURP:+2 © World Health Organization, 2012. All rights reserved. Measuring health and disability: manual for WHO Disability
Assessment Schedule (WHODAS 2.0), World Health Organization, 2010, Geneva.
The World Health Organization has granted the Publisher permission for the reproduction of this instrument. This material can
be reproduced without permission by clinicians for use with their own patients. Any other use, including electronic use,
requires written permission from WHO. | dsm5.pdf |
679f1b2555ce-0 | 749Cultural
Formulation
Understanding the cultural context of illness experience is essential for effec-
tive diagnostic assessment and clinical management. Culture refers to systems of knowl-
edge, concepts, rules, and practices that ar e learned and transmitted across generations.
Culture includes language, religion and spirit uality, family structur es, life-cycle stages,
ceremonial rituals, and customs, as well as moral and legal systems. Cultures are open,
dynamic systems that undergo continuous ch ange over time; in the contemporary world,
most individuals and groups are exposed to mu ltiple cultures, which they use to fashion
their own identities and make sense of experi ence. These features of culture make it cru-
cial not to overgeneralize cultur al information or stereotype groups in terms of fixed cul-
tural traits.
Race is a culturally constructed category of identity that divides humanity into groups
based on a variety of superficia l physical traits attributed to some hypothetical intrinsic,
biological characteristics. Racial categories an d constructs have varied widely over history
and across societies. The construct of race has no consistent biological definition, but it is
socially important because it supports racial ideologies, racism, discrimination, and social
exclusion, which can have strong negative effe cts on mental health. There is evidence that
racism can exacerbate many psychiatric disord ers, contributing to poor outcome, and that
racial biases can affect diagnostic assessment.
Ethnicity is a culturally constructed group identity used to define peoples and communi-
ties. It may be rooted in a common history, geography, language, religion, or other shared
characteristics of a group, which distinguish th at group from others. Ethnicity may be self-
assigned or attributed by out siders. Increasing mobility, inte rmarriage, and intermixing of | dsm5.pdf |