In Chapter 5, “The 30-Minute Pediatric Diagnostic Interview,” we outlined a diagnostic interview that included a screening question for each of the DSM-5 (American Psychiatric Association 2013) categories of mental disorders commonly experienced by children and adolescents. If you are speaking with a young person who answers affirmatively to one of those questions, we show how the screening questions are the avenues of the psychiatric diagnostic interview. A good interviewer skillfully travels these avenues with a young person and, when possible, reaches a specific and accurate diagnosis along the way.
This chapter follows the order of DSM-5 disorder categories, beginning with neurodevelopmental disorders. For each category of DSM-5 diagnoses presented, whether bipolar disorders or elimination disorders, the section begins with one or more screening questions from the model interview presented in Chapter 5. After the screening questions, follow-up questions are provided. If the follow-up questions include a measure of impairment or a measure of time, these measures are a required part of the subsequent diagnostic criteria. By asking follow-up questions before the additional symptom questions in the diagnostic criteria, we make the interview more efficient and precise while reserving the full diagnosis of a mental disorder for a person impaired by his experiences.
The screening and follow-up questions are followed by the diagnostic criteria. When the diagnostic criteria are to be elicited by the interviewer, we offer italicized prompts for the relevant symptom. We structured these questions so that an affirmative answer meets the criteria for that symptom. When the diagnostic criteria are observed rather than elicited, as in the case of disorganized speech, psychomotor retardation, or autonomic hyperactivity, they are listed as instructions to the interviewer, set in roman type. The minimum number of 84symptoms necessary to reach a particular diagnosis is underlined. We do not list all the possible questions that can be used to elicit a relevant symptom, but the included questions are specifically designed to follow DSM-5. To make the diagnostic process as clear as possible, we have included negative criteria for a DSM-5 diagnosis under the heading “Exclusion(s).” For example, DSM-5 observes that a young person’s recurrent, aggressive outbursts do not meet criteria for intermittent explosive disorder if they occur only during an adjustment disorder. These exclusion criteria usually do not require you to ask a specific question but instead depend on the history you elicit. The most common subtypes, specifiers, and severity measures are listed under the heading “Modifiers,” but the complete array of modifiers is found only in DSM-5.
In the interest of brevity, this guide includes diagnostic questions for the most common DSM-5 disorders. The idea is to focus on learning the diagnostic criteria for the paradigmatic disorders in each section before exploring the related diagnoses—that is, to know the main streets of DSM-5 before learning its side streets.
In this book, the side streets are labeled as alternatives, a term that is not used in DSM-5. These alternatives include only related diagnoses from the same DSM-5 chapter. For example, schizophreniform disorder is listed as an alternative to schizophrenia because both are grouped together in DSM-5. In contrast, bipolar I disorder and other diagnoses listed in the differential diagnosis for schizophrenia are not in the alternatives section for schizophrenia because the disorders are found in different sections of DSM-5. For each diagnosis listed as alternatives, the essential diagnostic criteria are included, and the interviewer is referred to the corresponding pages in DSM-5 to read the diagnostic criteria and associated material in detail.
We eliminated repetitive DSM-5 criteria, especially for the various mental disorders associated with another medical condition or substance-induced mental disorders, in which, broadly, the symptoms of a disorder are present as a direct effect of another medical condition or the use of a substance.
As this overview suggests, this book is not a substitute for DSM-5 but serves as a practical diagnostic tool with specific phrasing you can use, an operationalized version of DSM-5— the equivalent of the sketched version of a city street that a GPS device displays rather than the detailed portrait of each side street. If you desire those details, after each diagnosis we 85list a series of numbers and a letter that direct you to additional information. For example, after autism spectrum disorder, you will see this notation: [F84.0, 50–59].
The first entry is the ICD-10 (World Health Organization 1992) code, and the second entry is the page numbers of the main DSM-5 text for the disorder. These codes and references are provided to assist practitioners with coding and with quickly finding additional information.
Unfortunately, at times, the notations are more cryptic, as in this notation: [F90.x, 59–65].
As before, the first entry is the ICD-10 code corresponding to attention-deficit/hyperactivity disorder, and the second entry is the page numbers of the main DSM-5 text for the disorder. However, the use of an “x” indicates that you need additional information to find the specific ICD-10 code. In this case, that additional information is whether a young person’s deficits are predominantly inattentive, predominantly hyperactive/impulsive, or a combined presentation, which can be found in the specifiers section following the main diagnostic criteria. We organized the diagnoses this way to reduce the repetitive listing of diagnoses and to keep your focus on efficient, accurate diagnoses. ICD-10 codes are complex. (The ICD is, after all, a diagnostic list that includes codes for being struck by an orca, an exceedingly uncommon event.) Listing every code would double the length of this book, which would reduce its clinical utility. Listing every code would also shift the focus of the book to accurate coding, whereas our goal is to help you make an accurate diagnosis.
As this strategy suggests, we tried to balance brevity and detail. For each diagnosis, the notation always provides the general form of the ICD-10 codes, along with the page numbers of DSM-5 so that you can quickly find the additional information you need. This book lacks the rich detail of DSM-5 but will deliver you to your diagnostic destination in a timely fashion.
DSM-5 pp. 31–86
This section contains questions phrased for interviewing an older child with an ability to self-reflect. For younger children, rephrase these questions to interview the child’s caregiver instead.
86Screening questions: Did you have any learning problems, or did you get into trouble a lot for your behavior when you were younger? When you started school, did you have trouble getting along with your classmates or difficulty keeping up academically?
If yes, ask: Do you have trouble concentrating or struggle with being impulsive or overactive? Do you have difficulty communicating with other people? Are there specific things that you do frequently and find hard to control? Do you struggle to learn, more than your classmates do?
• If deficits in intellectual functioning or specific academic skills predominate, proceed to intellectual disability (intellectual developmental disorder) criteria.
• If deficits in social interactions or impairing motor behaviors predominate, proceed to autism spectrum disorder criteria.
• If inattention, hyperactivity, or impulsivity predominate, proceed to attention-deficit/hyperactivity disorder criteria.
1. Intellectual Disability (Intellectual Developmental Disorder) [F7x, 33–41]
a. Inclusion: Requires intellectual deficits, beginning during early development, that impair adaptive function as manifested by both of the following symptoms.
i. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and experiential learning. Must be confirmed by both clinical assessment and individualized, standardized intelligence testing.
ii. Impaired adaptive functioning, normalized for age and culture, which restricts participation and performance in one or more aspects of daily life activities. The limitations result in the need for ongoing support at school, at work, or for independent life.
b. Modifiers
i. Severity (DSM-5, pp. 34–36, Table 1)
• Mild (F70, 34)
• Moderate (F71, 35)
• Severe (F72, 36)
• Profound (F73, 36)
87c. Alternatives
i. If a person younger than 5 years fails to meet expected developmental milestones in several areas of intellectual functioning and is unable to undergo systematic assessment of intellectual functioning, consider global developmental delay [F88, 41], a diagnosis that requires reassessment after a period of time.
ii. If a person older than 5 years has intellectual disability that cannot be well characterized because of associated sensory or physical impairments, consider unspecified intellectual disability (intellectual developmental disorder) [F79, 41], a diagnosis that requires eventual reassessment and should be reserved for exceptional circumstances.
iii. If a person has persistent difficulties in the acquisition of language (spoken, written, sign, or other modalities) that begin in the early developmental period and result in substantial functional limitations, consider the diagnosis of language disorder [F80.2, 42–44]. Language disorders occur as a primary impairment or coexist with other disorders. This diagnosis should not be used if the language difficulties are better explained by hearing or sensory impairment, intellectual disability, or global developmental delay or are caused by another medical or neurological condition.
iv. If a person has persistent difficulties in speech sound production that interfere with speech intelligibility or prevent verbal communication of messages, consider speech sound disorder [F80.0, 44–45]. The symptoms must be present in the early developmental period and result in limitations in effective communication, social participation, academic achievement, and occupational performance, individually or in any combination. Speech sound disorder occurs as a primary impairment or coexists with other disorders or congenital or acquired conditions. This diagnosis should not be used if the speech sound difficulties are due to congenital or acquired medical or neurological conditions.
v. If a person has marked and frequent disturbances in the fluency and time patterning of speech that 88are inappropriate for the person’s age and language skills, consider childhood-onset fluency disorder (stuttering) [F80.81, 45–47]. Symptoms must begin in the early developmental period. The disturbance must cause anxiety about speaking or the ability to communicate effectively. This disorder co-occurs with other disorders. The diagnosis should not be used if the disorder is attributable to a speech-motor or sensory deficit, is due to another medical or neurological condition, or is better explained by another mental disorder.
vi. If a person has persistent difficulties in the social use of verbal and nonverbal communication that functionally limit effective communication, social participation, social relationships, academic achievement, or occupational performance, consider social (pragmatic) communication disorder [F80.89, 47–49]. Symptoms begin during the early developmental period. This disorder co-occurs with other disorders. The diagnosis should not be used if the symptoms are better explained by intellectual disability, global developmental delay, or another mental disorder or are attributable to another medical or neurological condition.
vii. If a person has symptoms of a communication disorder that cause clinically significant distress or impairment but do not meet the full criteria for a communication disorder or another neurodevelopmental disorder, consider unspecified communication disorder [F80.9, 49].
viii. If a person has persistent difficulties in learning and using academic skills that begin during school-age years and eventually result in significant interference with academic or occupational performance, consider specific learning disorder [F81.x, 66–74]. To meet criteria, the current skills must be well below the average range for the person’s age, gender, cultural group, and level of education. The symptoms must not be better accounted for by another intellectual, medical, mental, neurological, or sensory disorder.
2. Autism Spectrum Disorder [F84.0, 50–59]
This section contains questions phrased for interviewing an older child with an ability to self-reflect. For younger children 89 or those with limited cognitive functioning, rephrase these questions to interview the child’s caregiver instead.
a. Inclusion: Requires persistent deficits in social communication and social interaction, across multiple contexts, that are present in early childhood but that may not be manifest until social demands exceed limited capacities and that cause clinically significant impairment in functioning. The disorder is marked by all of the following persistent deficits in social communication and interaction.
i. Deficits in social-emotional reciprocity: How do you introduce yourself to other people? Do you find it hard to greet another person? Do you find it hard to share your interests, thoughts, and feelings with other people? Do you dislike hearing about what other people are interested in or how they feel?
ii. Deficits in nonverbal communicative behaviors used for social interaction; these are usually observed by a practitioner and range from poorly integrated verbal and nonverbal communication, to abnormalities in eye contact and body language or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.
iii. Deficits in developing and maintaining relationships: Are you disinterested in other people? Are you unable to engage in imaginative play with other people? Do you find it difficult to make new friends? When a situation changes, do you find it hard to adjust what you do in response?
b. Inclusion: In addition, the diagnosis requires at least two of the following signs of restricted, repetitive patterns of behavior, interests, or activities.
i. Stereotyped or repetitive speech, motor movements, or use of objects, such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases.
ii. Insistence on sameness and excessive adherence to routines or avoidance of change: Do you have any special routines or patterns of behavior? What happens when you cannot follow these routines or engage in these behaviors? Do you struggle to change?
90iii. Restricted interests of abnormal intensity or focus: Do you intensely focus on, or find yourself very interested in, just a few things?
iv. Hyper- or hyporeactivity to sensory input: Do you have intense responses to something that is painful? Something hot? Something cold? Are there particular sounds, textures, or smells to which you respond strongly? Do you find yourself fascinated with lights or spinning objects?
c. Modifiers
i. Specifiers
• With (or without) accompanying intellectual impairment
• With (or without) accompanying language impairment
• Associated with a known medical or genetic condition or environmental factor
• Associated with another neurodevelopmental, mental, or behavioral disorder
• With catatonia
ii. Severity is coded separately for the social communication impairments and for the restricted, repetitive patterns of behavior.
• Level 1: Requiring support
• Level 2: Requiring substantial support
• Level 3: Requiring very substantial support
d. Alternatives
i. If a person shows motor performance substantially below expected levels, which significantly interferes with activities of daily living or academic achievement, consider developmental coordination disorder [F82, 74–77]. Examples include clumsiness, as well as slow and inaccurate performance of motor skills. The disturbance cannot be due to another medical or neurological condition or be better explained by another mental disorder.
ii. If a person has repetitive, seemingly driven, yet apparently purposeless motor behavior, such as hand shaking or waving, body rocking, head banging, or self-biting, consider stereotypic movement disorder [F98.4, 77–80]. The motor disturbance causes clinically significant distress or 91impairment. The motor behavior is not due to the direct physiological effects of a substance or a general medical condition and is not better explained by the symptoms of another mental disorder.
iii. A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization. If a person experiences both motor and vocal tics beginning before age 18 years, consider Tourette’s disorder [F95.2, 81–85]. The tics may wax and wane in frequency but must persist for at least 1 year after onset. The tics cannot be due to the direct physiological effects of another medical condition or a substance.
iv. If a person experiences either motor or vocal tics, but not both, during his illness, and has never met criteria for Tourette’s disorder, consider persistent (chronic) motor or vocal tic disorder [F95.1, 81–85]. The onset is before age 18 years, and the tics may wax and wane in frequency but must have persisted for more than 1 year since their onset.
v. If a person experiences motor and/or vocal tics for less than 1 year, beginning before age 18 years, and the tics are not due to the direct physiological consequences of a substance or another medical condition, and he has never met criteria for Tourette’s disorder or persistent (chronic) motor or vocal tic disorder, consider provisional tic disorder [F95.0, 81–85].
vi. If a person experiences tics that do not meet criteria for a specific tic disorder because the movements or vocalizations are atypical in relation to age at onset or clinical presentation, consider other specified tic disorder [F95.8, 85] or unspecified tic disorder [F95.9, 85].
3. Attention-Deficit/Hyperactivity Disorder [F90.x, 59–65]
a. Inclusion: Requires a pattern of behavior, with onset before age 12 years, that is present in multiple settings and gives rise to social, educational, or work performance difficulties. The symptoms must be persistently present for at least 6 months to a degree inconsistent with developmental level. The disorder is manifested by at least six of the following symptoms of inattention.
i. Overlooks details: Over at least the last 6 months, have other people told you that you often overlook or miss details or that you made careless mistakes in your work?
92ii. Task inattention: Do you often have difficulty staying focused on a task or an activity, such as reading a lengthy text or listening to a lecture or conversation?
iii. Appears not to listen: Do other people tell you that when they speak to you, your mind often seems to be elsewhere or that it seems like you are not listening?
iv. Fails to finish tasks: Do you often struggle to finish schoolwork, chores, or work assignments because you lose focus or are easily sidetracked?
v. Difficulty organizing tasks: Do you often find it difficult to organize tasks or activities? Do you struggle with time management or fail to meet deadlines?
vi. Avoids tasks requiring sustained mental activity: Do you often avoid tasks that require sustained focus?
vii. Often loses things necessary for tasks: Do you often lose things that are essential for tasks or activities, such as school materials, books, tools, wallets, keys, paperwork, eyeglasses, or your phone?
viii. Easily distracted: Do you find that you are often easily distracted by things or thoughts unrelated to the activity or task you are supposed to be doing?
ix. Often forgetful: Do you find, or do other people find, that you are often forgetful in
your daily activities?
b. Inclusion: Alternatively, requires the presence of at least six of the following manifestations of hyperactivity and impulsivity over the same course.
i. Fidgets: Over the last 6 months, have you often found yourself fidgeting with your hands or feet? Do you find it hard to sit without squirming?
ii. Leaves seat: When you are in a situation where you are expected to sit, do you often leave your seat?
iii. Runs or climbs: Do you often find yourself running around or climbing in a situation where doing so is inappropriate?
iv. Unable to maintain quiet: Do you often find yourself unable to work or play quietly?
v. Hyperactivity: Do you often feel as if you are, or do other people describe you as always being, “on the go” or as acting as if you were “driven by a motor?” Is it hard to sit still for an extended time?
vi. Talks excessively: Do you often talk excessively?
vii. Blurts answers: Do you often struggle to wait your turn in a conversation? Do you often complete other 93people’s sentences or blurt out an answer before a question has been completed?
viii. Struggles to take turns: Do you often have difficulty waiting your turn or waiting in line?
ix. Interrupts or intrudes: Do you often butt into other people’s activities, conversations, or games? Do you often start using other people’s things without permission?
c. Exclusion: If the criteria are not met in two or more settings or there is no evidence that the symptoms interfere with functioning, the symptoms occur only in the context of a psychotic disorder, or the symptoms are better explained by another mental disorder, do not use this diagnosis.
d. Modifiers
i. Specifiers
• Combined presentation [F90.2, 60]: If both inattention and hyperactivity-impulsivity criteria are met for the past 6 months.
• Predominantly inattentive presentation [F90.0, 60]: If inattention criteria are met but hyperactivity-impulsivity criteria have not been met for the past 6 months.
• Predominantly hyperactive/impulsive presentation [F90.1, 60]: If hyperactivity-impulsivity criteria are met and inattention criteria have not been met for the past 6 months.
• In partial remission if full criteria no longer met but still symptomatic.
ii. Severity
• Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.
• Moderate: Symptoms or functional impairment between “mild” and “severe” is present.
• Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.
94e. Alternatives: If a young person is experiencing subthreshold symptoms or you have not yet had sufficient opportunity to verify all criteria, consider other specified attention-deficit/hyperactivity disorder [F90.8, 65–66] or unspecified attention-deficit/hyperactivity disorder [F90.9, 66]. The symptoms must be associated with impairment and do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder.
DSM-5 pp. 87–122
Screening questions: Have you seen visions or other things that other people did not see? Have you heard noises, sounds, or voices that other people did not hear? Do you ever feel as if people are following you or trying to hurt you in some way? Have you ever felt that you had special powers or found special messages from the radio or TV seemingly meant just for you?
If yes, ask: Do these experiences change what you do or tell you to do things? Did these experiences ever cause you significant trouble with your friends or family, at school, or in another setting?
• If yes, proceed to schizophrenia criteria.
1. Schizophrenia [F20.9, 99–105]
a. Inclusion: Requires at least 6 months of continuous signs of disturbance, which may include prodromal or residual symptoms. During at least 1 month of that period, at least two of the following symptoms are present, and at least one of the symptoms must be delusions, hallucinations, or disorganized speech.
i. Delusions: Is anyone working to harm or hurt you? When you read a book, watch television, or work at a computer, do you ever find that there are messages intended just for you? Do you have special powers or abilities?
ii. Hallucinations: When you are awake, do you ever hear a voice different from your own thoughts that other people cannot hear? When you are awake, do you ever see things that other people cannot see?
95iii. Disorganized speech such as frequent derailment or incoherence
iv. Grossly disorganized or catatonic behavior
v. Negative symptoms such as diminished emotional expression or avolition
b. Exclusions
i. If the disturbance is attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition, do not use this diagnosis.
ii. If a young person has been diagnosed with an autism spectrum disorder, schizophrenia may be diagnosed only if prominent delusions or hallucinations are also present for at least 1 month.
c. Modifiers
i. Specifiers
• First episode, currently in acute episode
• First episode, currently in partial remission
• First episode, currently in full remission
• Multiple episodes, currently in acute episode
• Multiple episodes, currently in partial remission
• Multiple episodes, currently in full remission
• Continuous
• Unspecified
ii. Additional specifiers
• With catatonia [F06.1, 119–120]: Use when at least three of the following are present: catalepsy, waxy flexibility, stupor, agitation, mutism, negativism, posturing, mannerisms, stereotypies, grimacing, echolalia, echopraxia.
iii. Severity
• Severity is rated by a quantitative assessment of the primary symptoms of psychosis, each of which may be rated for its current severity on a five-point scale (see Clinician-Rated Dimensions of Psychosis Symptom Severity in DSM-5, pp. 743–744).
d. Alternatives
i. If a person experiences only delusions, whether bizarre or nonbizarre; has never met full criteria 96for schizophrenia; and has functioning that is not markedly impaired beyond the ramifications of his delusion, consider delusional disorder [F22, 90–93]. The criteria include multiple specifiers. The diagnosis should not be used if the delusions are due to the physiological effects of a substance or another medical condition. The diagnosis also should not be used if the delusions are better explained by another mental disorder.
ii. If a person has experienced at least 1 day but less than 1 month of schizophrenia symptoms, consider brief psychotic disorder [F23, 94–96]. The person usually has an acute onset, fewer negative symptoms, and less functional impairment and always experiences an eventual return to the previous level of functioning.
iii. If a person has experienced at least 1 month but less than 6 months of schizophrenia symptoms, consider schizophreniform disorder [F20.81, 96–99]. The criteria include specifiers for catatonia, as well as with and without good prognostic features.
iv. If a person who meets criteria for schizophrenia also experiences major mood disturbances—either major depressive episodes or manic episodes—for at least half the time he has met criteria for schizophrenia, consider schizoaffective disorder [F25.x, 105–110]. Over a person’s lifetime, he also must have experienced at least 2 weeks of delusions or hallucinations in the absence of a major mood episode.
v. If a substance or medication directly causes a psychotic episode, consider substance/medication-induced psychotic disorder [F1x.x, 110–115].
vi. If another medical condition directly causes the psychotic episode, consider psychotic disorder due to another medical condition [F06.x, 115–118].
vii. If a person experiences psychotic symptoms that cause clinically significant distress or functional impairment without meeting full criteria for another psychotic disorder, consider unspecified schizophrenia spectrum and other psychotic disorder [F29, 122]. To communicate the specific reason a person’s symptoms do not meet the criteria, consider other specified schizophrenia spectrum 97and other psychotic disorder [F28, 122]. Examples include persistent auditory hallucinations in the absence of any other psychotic symptom and delusional symptoms in the partner of an individual with delusional disorder.
DSM-5 pp. 123–154
Screening question: Has there been a time when for many days straight your mood was super happy, you were more self-confident, and you had much more energy than usual?
If yes, ask: During those times, did you feel this way all day or most of the day? Did something happen that started those feelings? Did those times ever last at least a week or result in your being hospitalized? Did these periods ever cause you significant trouble with your friends or family, at school, or in another setting?
• If symptoms lasted a week or caused hospitalization, proceed to bipolar I disorder criteria.
• If not, proceed to bipolar II disorder criteria.
1. Bipolar I Disorder [F31.x, 123–132]
For a diagnosis of bipolar I disorder, it is necessary to meet criteria for at least one manic episode. The manic episode may have been preceded by and may be followed by hypomanic episodes or major depressive episodes.
a. Inclusion: A manic episode—defined as a distinct period of abnormally and persistently elevated or irritable mood and increased goal-directed activity or energy, lasting at least 1 week and present most of the day—requires at least three of the following symptoms.
i. Inflated self-esteem or grandiosity: During that period, did you feel especially confident, as though you could accomplish something extraordinary that you could not have done otherwise?
ii. Decreased need for sleep: During that period, did you notice any change in how much sleep you needed to feel rested? Did you feel rested after less than 3 hours of sleep?
iii. More talkative than usual: During that period, did anyone tell you that you talked more than usual or that it was hard to interrupt you?
98iv. Flight of ideas: During that period, were your thoughts racing? Did you have so many ideas that you could not keep up with them?
v. Distractibility: During that period, were you having more trouble than usual focusing? Did you find yourself easily distracted?
vi. Increased goal-directed activity: During that period, how did you spend your time? Did you find yourself much more active than usual?
vii. Excessive involvement in activities that have a high potential for painful consequences: During that period, did you engage in activities that were unusual for you? Did you spend money, use substances, or engage in sexual activities in a way that is unusual for you? Did any of these activities cause trouble for anyone?
b. Exclusions
i. The occurrence of manic or major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
ii. The episode is not due to the physiological effects of a substance or another medical condition. However, a manic episode that both emerges during antidepressant treatment and persists beyond the physiological effect of the treatment meets criteria for bipolar I disorder.
c. Modifiers
i. Current (or most recent) episode
• Manic [F31.x, 126–127]
• Hypomanic
• Depressed [F31.x, 126–127]
• Unspecified (use when the symptoms, but not the duration, of an episode meet criteria)
ii. Specifiers
• With anxious distress
• With mixed features: Use if at least three of the symptoms of a major depressive episode are present simultaneously.
• With rapid cycling
99• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern
iii. Course and severity
• Current or most recent episode manic, hypomanic, depressed, unspecified
• Mild, moderate, severe
• With psychotic features
• In partial remission, in full remission
• Unspecified
d. Alternatives
i. If a substance directly causes the episode, including a substance prescribed to treat depression, consider substance/medication-induced bipolar and related disorder [F1x.xx, 142–145].
ii. If another medical condition causes the episode, consider bipolar and related disorder due to another medical condition [F06.3x, 145–147].
2. Bipolar II Disorder [F31.81, 132–139]
For a diagnosis of bipolar II disorder, it is necessary to meet criteria for at least one hypomanic episode. The hypomanic episode may have been preceded by and may be followed by major depressive episodes.
a. Inclusion: A hypomanic episode—defined as a distinct period of abnormally and persistently elevated or irritable mood and increased goal-directed activity or energy, lasting at least 4 days and present most of the day—requires the presence of at least three of the following symptoms.
i. Inflated self-esteem or grandiosity: During that period, did you feel especially confident, as though you could accomplish something extraordinary that you could not have done otherwise?
ii. Decreased need for sleep: During that period, did you notice any change in how much sleep you needed to feel rested? Did you feel rested after less than 3 hours of sleep?
100iii. More talkative than usual: During that period, did anyone tell you that you talked more than usual or that it was hard to interrupt you?
iv. Flight of ideas: During that period, were your thoughts racing? Did you have so many ideas that you could not keep up with them?
v. Distractibility: During that period, were you having more trouble than usual focusing? Did you find yourself easily distracted?
vi. Increased goal-directed activity: During that period, how did you spend your time? Did you find yourself much more active than usual?
vii. Excessive involvement in activities that have a high potential for painful consequences: During that period, did you engage in activities that were unusual for you? Did you spend money, use substances, or engage in sexual activities in a way that is unusual for you? Did any of these activities cause trouble for anyone?
b. Exclusions
i. If there has ever been a manic episode or if the episode is attributable to the physiological effects of a substance/medication, do not use this diagnosis.
ii. If the hypomanic episode is better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders, do not use this diagnosis.
iii. If the hypomanic episode is severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization, do not use this diagnosis.
c. Modifiers
i. Specify current or most recent episode
• Hypomanic
• Depressed
ii. Specifiers
• With anxious distress
• With mixed features: Use if at least three of the symptoms of a major depressive episode are present simultaneously.
• With rapid cycling
• With mood-congruent psychotic features
101• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern
iii. Course
• In partial remission
• In full remission
iv. Severity
• Mild
• Moderate
• Severe
d. Alternatives
i. If a person reports 1 or more years of multiple hypomanic and depressive symptoms that never rose to the level of a hypomanic or major depressive episode, consider cyclothymic disorder [F34.0, 139–141]. During the same 1-year period, the hypomanic and depressive periods have been present for at least half the time, and the individual has not been without the symptoms for more than 2 months at a time. If the symptoms are due to the physiological effects of a substance or another medical condition, do not use this diagnosis.
ii. If a person experiences symptoms characteristic of bipolar disorder that cause clinically significant distress or functional impairment without meeting full criteria for a bipolar disorder, consider unspecified bipolar and related disorder [F31.9, 149–154]. To communicate the specific reason a person’s symptoms do not meet the criteria, as in short-duration hypomania, short-duration cyclothymia, and hypomania without prior major depressive episode, consider other specified bipolar and related disorder [F31.89, 148].
DSM-5 pp. 155–188
Screening question: Have you been feeling sad, blue, down, depressed, or irritable? If so, does feeling this way make it hard to do things, to concentrate, or to sleep? Are you angry most of the time?
102If yes, ask: Did those times ever last at least 2 weeks? Did these periods ever cause you significant trouble with your friends or family, at school, or in another setting?
• If yes, proceed to major depressive disorder criteria.
• If a child age 6 years or older says no, ask the irritability screening question, which appears after the specifiers for major depressive disorder later in this section.
1. Major Depressive Disorder [F3x.xx, 160–168]
a. Inclusion: Requires the presence of at least five of the following symptoms, which must include either depressed mood or loss of interest or pleasure (anhedonia), during the same 2-week episode.
i. Depressed mood most of the day (already assessed)
ii. Markedly diminished interest or pleasure in activities (already assessed)
iii. Significant weight loss or gain: During that period, did you notice any change in your appetite? Did you notice any change in your weight?
iv. Insomnia or hypersomnia: During that period, how much and how well were you sleeping?
v. Psychomotor agitation or retardation: During that period, did anyone tell you that you seemed to move faster or slower than usual?
vi. Fatigue or loss of energy: During that period, what was your energy level like? Did anyone tell you that you seemed worn down or less energetic than usual?
vii. Feelings of worthlessness or excessive guilt: During that period, did you feel tremendous regret or guilt about current or past events or relationships?
viii. Diminished concentration: During that period, were you able to make decisions or concentrate like you usually do?
ix. Recurrent thoughts of death or suicide: During that period, did you think about death more than you usually do? Have you thought about hurting yourself or taking your own life?
b. Exclusions
i. If there has ever been a manic episode or a hypomanic episode, or the major depressive episode is attributable to the physiological effects of a substance 103or to another medical condition, do not use this diagnosis.
ii. If the major depressive episode is better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders, do not use this diagnosis.
c. Modifiers
i. Specifiers
• With anxious distress
• With mixed features: Use if at least three of the symptoms of a major depressive episode are present simultaneously.
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern
ii. Course and severity
• Single episode
• Recurrent episode
• Mild [F3x.0, 162]
• Moderate [F3x.1, 162]
• Severe [F3x.2, 162]
• With psychotic features [F3x.3, 162]
• In partial remission [F3x.4, 162]
• In full remission [F3x.xx, 162]
• Unspecified [F3x.9, 162]
d. Alternatives
i. If a person reports experiencing depression or anhedonia for at least 1 year resulting in clinically significant distress or impairment, along with at least two of the symptoms of a major depressive episode, consider persistent depressive disorder (dysthymia) [F34.1, 168–171]. If a person experiences 2 continuous months without depressive symptoms, do not use this diagnosis. If the person has ever had symptoms that met the criteria for a 104bipolar disorder or a cyclothymic disorder, do not use this diagnosis. If the disturbance is better explained by a psychotic disorder or is due to the physiological effects of a substance or another medical condition, do not use this diagnosis.
ii. If a young woman describes pronounced mood changes that begin in the week before her menses, decrease in the week after menses, and abate in the week postmenses, consider premenstrual dysphoric disorder [N94.3, 171–175]. The diagnostic criteria include at least one of the following: marked affective lability, marked irritability or interpersonal conflicts, marked depressed mood, or marked anxiety. At least one of the following symptoms must additionally be present (to reach a total of five symptoms when combined with the symptoms above): decreased interest in usual activities; subjective difficulty in concentration; lethargy, easy fatigability, or marked lack of energy; change in appetite; hypersomnia or insomnia; sense of being overwhelmed; or physical symptoms such as breast tenderness or swelling, joint or muscle pain, bloating, and weight gain.
iii. If a substance directly causes the episode, including a substance prescribed to treat depression, consider a substance/medication-induced depressive disorder [F1x.x4, 175–180].
iv. If another medical condition causes the episode, consider a depressive disorder due to another medical condition [F06.3x, 180–183].
v. If a person experiences a depressive episode that causes clinically significant distress or functional impairment without meeting full criteria for a depressive disorder, consider unspecified depressive disorder [F32.9, 184]. To communicate the specific reason a young person’s symptoms do not meet the criteria, consider other specified depressive disorder [F32.8, 183–184]. Examples includes recurrent brief depression and depressive episode with insufficient symptoms.
Irritability screening question for children older than 6 years: Do you lose your temper, get mad, and yell or hit things?
105If yes, ask: Do you lose your temper and feel really mad every day or every other day? Does your angry mood or yelling cause trouble at home or school?
• If yes, proceed to disruptive mood dysregulation disorder criteria.
• If no, seek collateral information from caregivers or proceed to another diagnostic category.
2. Disruptive Mood Dysregulation Disorder [F34.8, 156–160]
a. Inclusion: Requires severe recurrent temper outbursts in response to common stressors, averaging at least three per week, for at least 1 year. The outbursts must occur in at least two distinct settings such as school or home, be severe in at least one setting, begin before age 10 years but not before age 6 years, and be characterized by the following three symptoms.
i. Temper or behavioral outbursts: When you get upset or lose your temper, what happens? Do you yell? Do you slap, punch, bite, or hit another person? Do you break or destroy things?
ii. Disproportionate reaction: When you get upset or lose your temper, do you know what sets you off? What kinds of things bother you so much that you feel like yelling or hitting?
iii. Persistently irritable of angry mood between temper outbursts: When you are not yelling or upset, how do you feel inside? Do you usually feel grouchy, angry, irritable, or sad?
b. Exclusions
i. These responses must be inconsistent with a child’s developmental level.
ii. If the behaviors occur exclusively during an episode of major depressive disorder and are better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]), do not use this diagnosis.
iii. If the symptoms are attributable to the physiological effects of a substance or to another medical or neurological condition, do not use this diagnosis.
iv. If a child is currently diagnosed with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, do not use this diagnosis.
106c. Alternatives: If, during the last year, there was a period lasting at least 1 day during which the child had abnormally elevated mood and three criteria of a manic episode, consider the possibility of a bipolar disorder (see DSM-5, pp. 123–154).
DSM-5 pp. 189–233
Screening question: Would you say that you worry a lot or more than other kids your age? Do people say that you worry too much or are too shy? Do you feel afraid when you’re alone or away from your family? Do you get scared about going to school? Is it hard for you to control or stop your worrying? Are there specific things, places, or situations that make you feel very anxious or afraid? Have you ever felt suddenly frightened, nervous, or anxious for no reason at all? If so, can you tell me about that?
If yes, ask: Do these experiences ever cause you significant trouble with your friends or family, at school, or in another setting?
• If a specific phobia is elicited, proceed to specific phobia disorder criteria.
• If no, first proceed to panic disorder criteria. Then proceed to generalized anxiety disorder criteria.
1. Specific Phobia [F40.2xx, 197–202]
a. Inclusion: Requires that for at least 6 months, a person has experienced marked fear or anxiety as characterized by the following three symptoms.
i. Specific fear: Do you fear a specific object or situation such as flying, heights, animals, or something else so much that being exposed to it makes you feel immediately afraid or anxious? What is it?
ii. Fear or anxiety provoked by exposure: When you encounter this, do you experience an immediate sense of fear or anxiety, cry, throw tantrums, or hold on to a parent?
iii. Avoidance: Do you find yourself taking steps to avoid this? What are they? When you have to encounter this, do you experience intense fear or anxiety, cry, throw tantrums, or hold on to a parent?
107b. Exclusion: The fear, anxiety, and avoidance are not restricted to objects or situations related to obsessions, reminders of traumatic events, separation from home or attachment figures, or social situations.
c. Modifiers
i. Specifiers
• Animal
• Natural environment
• Blood-injection-injury
• Situational
• Other
d. Alternatives
i. If a young person reports developmentally inappropriate and excessive distress when separated from home or a major attachment figure or expresses persistent worry that his major attachment figure will be harmed or will die, which results in reluctance or refusal to be separated from home or a major attachment figure, consider separation anxiety disorder [F93.0, 190–195]. The onset of this disorder is before age 18. The minimum duration of symptoms necessary to meet the diagnostic criteria is 4 weeks for children and adolescents.
ii. If a young person consistently fails to speak in specific social situations for at least 1 month, interfering with educational or occupational achievement, consider selective mutism [F94.0, 195–197]. If the disturbance is due to a lack of knowledge of, or comfort with, the spoken language, do not use this diagnosis. If the disturbance is better explained by a communication disorder, autism spectrum disorder, or psychotic disorder, do not use this diagnosis.
iii. If a young person reports at least 6 months of marked and disproportionate fear or anxiety about situations such as public transportation, open spaces, being in shops or theaters, standing in line or being in a crowd, or being outside of the home alone, and if these fears cause him or her to actively avoid these situations, consider agoraphobia [F40.00, 217–221].
108iv. If a young person reports at least 6 months of marked fear or anxiety about, or avoidance of, social situations in which he fears that other people will observe or scrutinize him or her out of proportion to the actual threat posed by these social situations, these social situations provoke fear or anxiety, and these situations are either avoided or endured, consider social anxiety disorder (social phobia) [F40.10, 202–208]. In children, the anxiety must occur with peers, not just with adults. Children may express fear or anxiety by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
2. Panic Disorder [F41.0, 208–214]
a. Inclusion: Requires recurrent panic attacks, as characterized by at least four of the following symptoms:
i. Palpitations, pounding heart, or accelerated heart rate: When you experience these sudden surges of intense fear or discomfort, does your heart race or pound?
ii. Sweating: During these events, do you find yourself sweating more than usual?
iii. Trembling or shaking: During these events, do you shake or develop a tremor?
iv. Sensations of shortness of breath or smothering: During these events, do you feel like you are being smothered or cannot catch your breath?
v. Feelings of choking: During these events, do you feel as though you are choking, as if something is blocking your throat?
vi. Chest pain or discomfort: During these events, do you feel intense pain or discomfort in your chest?
vii. Nausea or abdominal distress: During these events, do you feel sick to your stomach or like you need to vomit?
viii. Feeling dizzy, unsteady, light-headed, or faint: During these events, do you feel dizzy, light-headed, or like you may faint?
ix. Chills or heat sensations: During these events, do you feel very cold and shiver, or do you feel intensely hot?
x. Paresthesias: During these events, do you feel numbness or tingling?
xi. Derealization or depersonalization: During these events, do you feel as if people or places that are familiar to you are unreal or that you are so detached from your 109body that it is like you are standing outside your body or watching yourself?
xii. Fear of losing control: During these events, do you fear you may be losing control or even “going crazy?”
xiii. Fear of dying: During these events, do you fear you may be dying?
b. Inclusion: At least one panic attack is followed by at least 1 month of at least one of the following symptoms:
i. Persistent worry about consequences: Are you persistently concerned or worried about additional panic attacks? Are you persistently concerned or worried that these attacks mean you are having a heart attack, losing control, or “going crazy”?
ii. Maladaptive changes to avoid attacks: Have you made significant changes in your behavior, such as avoiding unfamiliar situations or exercise, in order to avoid attacks?
c. Exclusion: If the disturbance is better explained by another mental disorder or is attributable to the physiological effects of a substance/medication or another medical condition, do not use this diagnosis.
d. Alternatives
i. If a young person reports panic attacks as described above but neither experiences persistent worry about consequences nor makes maladaptive changes to avoid attacks, consider using the panic attack specifier (DSM-5, pp. 214–217). The panic attack specifier can be used with other anxiety disorders, as well as with depressive, traumatic, and substance use disorders.
3. Generalized Anxiety Disorder [F41.1, 222–226]
a. Inclusion: Requires excessive anxiety and worry that is difficult to control, occurring more days than not for at least 6 months, about a number of events or activities (such as school performance), associated with at least three of the following symptoms.
i. Restlessness: When you think about events or activities that make you anxious or worried, do you feel restless, on edge, or “keyed up?”
ii. Easily fatigued: Do you find that you often tire or fatigue easily?
110iii. Difficulty concentrating: When you are anxious or worried, do you often find it hard to concentrate or find that your mind goes blank?
iv. Irritability: When you are anxious or worried, do you often feel irritable or easily annoyed?
v. Muscle tension: When you get anxious or worried, do you often experience muscle tightness or tension?
vi. Sleep disturbance: Do you find it difficult to fall asleep or stay asleep or experience restless and unsatisfying sleep?
b. Exclusion: If the anxiety and worry are better explained by another mental disorder or are attributable to the physiological effects of a substance/medication or another medical condition, do not use this diagnosis.
c. Alternatives
i. If a substance directly causes the episode, including a medication prescribed to treat a mental disorder, consider a substance/medication-induced anxiety disorder [F1x.x8x, 226–230].
ii. If another medical condition directly causes the anxiety and worry, consider an anxiety disorder due to another medical condition [F06.4, 230–232].
iii. If a young person experiences symptoms characteristic of an anxiety disorder that cause clinically significant distress or functional impairment without meeting full criteria for another anxiety disorder, consider unspecified anxiety disorder [F41.9, 233]. If you wish to communicate the specific reason a young person’s symptoms do not meet the criteria for a specific anxiety disorder, consider other specified anxiety disorder [F41.8, 233]. Examples include generalized anxiety not occurring more days than not and ataque de nervios (attack of nerves).
DSM-5 pp. 235–264
Screening question: Do you ever get unwanted thoughts, urges, or pictures stuck in your mind and repeating that you cannot get rid of? Is there anything you feel you have to check, clean, or organize over and over again in order to feel OK?
111If yes, ask: Do these experiences or behaviors ever cause you significant trouble with your friends or family, at school, or in another setting?
• If yes, proceed to obsessive-compulsive disorder criteria.
• If no, proceed to the body-focused repetitive behavior screening question, which follows the obsessive-compulsive disorder section.
1. Obsessive-Compulsive Disorder [F42, 237–242]
a. Inclusion: Requires the presence of obsessive thoughts, compulsive behaviors, or both, as manifested by the following symptoms.
i. Obsessive thoughts: When you experience these unwanted images, thoughts, or urges, do they make you anxious or distressed? Do you have to work hard to ignore or suppress these kinds of thoughts?
ii. Compulsive behaviors: Some people try to reverse intrusive ideas by repeatedly performing some kind of action such as hand washing or lock checking or by a mental act such as counting, praying, or silently repeating words. Do you do something like that? Do you think that doing so will reduce your distress or prevent something from occurring?
b. Inclusion: The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment.
c. Exclusions
i. If the obsessions or compulsions are better explained by another mental disorder, do not use this diagnosis.
ii. If the obsessive-compulsive symptoms are attributable to the physiological effects of a substance, do not use this diagnosis.
iii. If a young person reports that his intrusive images, thoughts, or urges are pleasurable, he does not meet the criteria for an obsessive-compulsive disorder.
d. Modifiers
i. Specifiers
• Insight
• With good or fair insight: Use if a person recognizes that his beliefs are definitely or probably untrue.
112• With poor insight: Use if a person thinks his beliefs are probably true.
• With absent insight/delusional beliefs: Use if a person is completely convinced his beliefs are true.
ii. Tic-related: Use if a young person meets criteria for a current or lifetime chronic tic disorder.
e. Alternatives
i. If a person reports intrusive images, thoughts, or urges centered on his body image, consider body dysmorphic disorder [F45.22, 242–247]. The criteria include preoccupation with perceived defects in physical appearance beyond concern about weight or body fat in a person with an eating disorder, repetitive behaviors or mental acts in response to concern about appearance, and clinically significant distress or impairments because of the preoccupation.
ii. If a person reports persistent difficulty in parting with possessions regardless of their value, consider hoarding disorder [F42, 247–251]. The criteria include strong urges to save items, distress associated with discarding items, and the accumulation of a large number of possessions that clutter the home or workplace to the extent that it can no longer be used for its intended function.
iii. If a substance directly causes the condition, including a substance prescribed to treat depression, consider substance/medication-induced obsessive-compulsive and related disorder [F1x.x88, 257–260].
iv. If another medical condition directly causes the episode, consider obsessive-compulsive and related disorder due to another medical condition [F06.8, 260–263].
v. If a young person reports intrusive images, thoughts, or urges centered on more real-world concerns, consider an anxiety disorder.
vi. If a person experiences symptoms characteristic of an obsessive-compulsive and related disorder that cause clinically significant distress or functional impairment without meeting full criteria for another obsessive-compulsive and related disorder, consider 113unspecified obsessive-compulsive and related disorder [F42, 264]. If you wish to communicate the specific reason a person’s symptoms do not meet the criteria for a specific obsessive-compulsive and related disorder, consider other specified obsessive-compulsive and related disorder [F42, 263–264]. Examples include body-focused repetitive behavior disorder, obsessional jealousy, and koro.
2. Body-Focused Repetitive Behaviors
a. Inclusion: DSM-5 includes two conditions, trichotillomania (hair-pulling disorder) [F63.3, 251–254] and excoriation (skin-picking) disorder [L98.1, 254–257], with identically structured criteria. Either diagnosis requires the presence of all three of the following symptoms, plus distress or impairment caused by the symptoms.
i. Behavior: Do you frequently pull your hair or pick at your skin so much that it has caused hair loss or skin lesions?
ii. Repeated attempts to change: Have you repeatedly tried to decrease or stop this behavior?
iii. Impairment: Does this behavior cause you to feel ashamed or out of control? Do you avoid school or social settings because of these behaviors?
b. Exclusion
i. If the behavior is associated with another medical condition or mental disorder or is the result of substance use, the behavior should be diagnostically accounted for with those conditions, and you should not diagnose either trichotillomania or excoriation disorder.
DSM-5 pp. 265–290
Screening question: What is the worst thing that has ever happened to you? Has anyone ever touched you in a way did not want? Have you ever experienced or witnessed an event in which you were seriously injured or your life was in danger or you thought you were going to be seriously injured or endangered?
114If yes, ask: Do you think about or reexperience these events? Does thinking about these experiences ever cause significant trouble with your friends or family, at school, or in another setting?
• If yes, proceed to posttraumatic stress disorder criteria.
• If a child says no but his family or caregivers report disturbances in his primary attachments, proceed to reactive attachment disorder criteria.
1. Posttraumatic Stress Disorder [F43.10, 271–280]
a. Inclusion: Requires exposure to actual or threatened death, serious injury, or sexual violation. The exposure can be firsthand or witnessed. In a child 6 years or younger, the traumatic exposure can be learning of the trauma experienced by a parent or caregiver. In a person older than 6 years, the traumatic exposure also can be learning of the trauma experienced by a parent or caregiver, but the experienced trauma must be violent or accidental. In addition, a person must experience at least one of the following intrusion symptoms for at least 1 month after the traumatic experience.
i. Memories: After that experience, did you ever experience intrusive memories of the experience when you did not want to think about it? For young children, repetitive reenactment through play qualifies: Do you repeatedly reenact that experience with your toys or dolls when playing?
ii. Dreams: Did you have recurrent, distressing dreams related to the experience? For young children, frightening dreams without recognizable content qualifies: Do you frequently have very frightening dreams that you cannot recall or describe?
iii. Flashbacks: After that experience, did you ever feel as if it were happening to you again, like in a flashback? For young children, this may be observed in their play.
iv. Exposure distress: When you are around people, places, and objects that remind you of that experience, do you feel intense or prolonged distress?
v. Physiological reactions: When you are around people, places, or objects that remind you of that experience, do you have distressing physical responses?
115b. Inclusion: In addition, a young person older than 6 years must experience at least one of the following avoidance symptoms after the traumatic experience. For a child 6 years or younger, no negative mood symptoms need be experienced if at least one negative mood symptom (see item c below) is present.
i. Internal reminders: Do you work hard to avoid thoughts, feelings, or physical sensations that bring up memories of this experience?
ii. External reminders: Do you work hard to avoid people, places, and objects that bring up memories of this experience?
c. Inclusion: In addition, a young person older than 6 years must experience at least two of the following negative symptoms. For a child 6 years or younger, no negative mood symptoms need be experienced if at least one avoidance symptom (see item b above) is present.
i. Impaired memory: Do you have trouble remembering important parts of the experience?
ii. Negative self-image: Do you frequently think negative thoughts about yourself, other people, or the world?
iii. Blame: Do you frequently blame yourself or others for your experience, even when you know that you or they were not responsible?
iv. Negative emotional state: Do you stay down, angry, ashamed, or fearful most of the time?
v. Decreased participation: Are you much less interested in activities in which you used to participate?
vi. Detachment: Do you feel detached or estranged from the people in your life because of this experience?
vii. Inability to experience positive emotion: Do you find that you cannot feel happy, loved, or satisfied? Do you feel numb or as if you cannot love?
d. Inclusion: In addition, a young person must experience at least two of the following arousal behaviors.
i. Irritable or aggressive: Do you often act very grumpy or get aggressive?
ii. Reckless: Do you often act reckless or self-destructive?
iii. Hypervigilance: Are you always on edge or keyed up?
iv. Exaggerated startle: Do you startle easily?
116v. Impaired concentration: Do you often have trouble concentrating on a task or problem?
vi. Sleep disturbance: Do you often have difficulty falling asleep or staying asleep, or do you often wake up without feeling rested?
e. Exclusions
i. If the witnessing of traumatic events includes events witnessed only in electronic media, television, movies, or pictures, do not use this diagnosis.
ii. If the episode is directly caused by the use of a substance or by another medical condition, do not use this diagnosis.
f. Modifiers
i. Subtypes
• With dissociative symptoms: depersonalization
• With dissociative symptoms: derealization
ii. Specifiers
• With delayed expression: Use if a person does not meet all the diagnostic criteria until at least 6 months after the traumatic experience.
g. Alternatives
i. If the episode lasts less than 1 month and the experience occurred within the past month and the young person experiences at least nine of the posttraumatic symptoms described earlier, consider acute stress disorder [F43.0, 280–286].
ii. If the episode began within 3 months of the experience and a young person does not meet the symptomatic and behavioral criteria for posttraumatic stress disorder, consider an adjustment disorder [F43.2x, 286–289]. The criteria include marked distress disproportionate to an acute stressor, either traumatic or nontraumatic, and significant impairment in function.
iii. If a young person experiences symptoms characteristic of a trauma- and stressor-related disorder that cause clinically significant distress or functional impairment without meeting full criteria for one of the named disorders, consider unspecified trauma- and stressor-related disorder [F43.9, 290]. If you wish to communicate the specific reason 117a young person’s symptoms do not meet the criteria for a specific disorder, consider other specified trauma- and stressor-related disorder [F43.8, 289]. Examples include adjustment-like disorders with delayed onset of symptoms that occur more than 3 months after the stressor.
2. Reactive Attachment Disorder [F94.1, 265–268]
This section contains questions phrased for interviewing an older child with an ability to self-reflect. For younger children or those with limited cognitive functioning, rephrase these questions to interview the child’s caregiver instead.
a. Inclusion: Requires that a child experience pathogenic care, before age 5 years, that results in both of the following behaviors.
i. Rare or minimal comfort seeking: When you are feeling really angry, upset, or sad, do you avoid comfort or consolation from other people?
ii. Rare or minimal response to comfort: When you are feeling really angry, upset, or sad, and somebody says or does something nice for you, does it make you feel a little better?
b. Inclusion: Requires the persistent experience of at least two of the following states.
i. Relative lack of social and emotional responsiveness to others: When you interact with other people, do you usually have very little feeling or emotion?
ii. Limited positive affect: Do you usually find it hard to be excited or to feel good or cheerful?
iii. Episodes of unexplained irritability, sadness, or fearfulness, which are evident during nonthreatening interactions with caregivers: Do you often have episodes where you become irritable, sad, or afraid with an adult caregiver who does not pose a threat to you?
c. Inclusion: Requires the persistent experience of at least one of the following states that should be assessed in the social history.
i. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met.
ii. Repeated changes of primary caregivers that limit opportunities to form stable attachments.
118iii. Rearing in unusual settings that severely limit opportunities to form selective attachments.
d. Exclusions
i. If a child does not have a developmental age of at least 9 months, do not use this diagnosis.
ii. If a child meets criteria for autism spectrum disorder, do not use this diagnosis.
e. Modifier
i. Specifier
• Persistent: Use when the disorder is present for more than 12 months.
ii. Severity: Specified severe when a child meets all symptoms of the disorder, with each symptom manifesting in relatively high levels.
f. Alternative: If a young child who has experienced extremes of insufficient care shows profoundly disturbed externalizing behavior, consider disinhibited social engagement disorder [F94.2, 268–270]. The criteria include at least two of the following symptoms: reduced reticence with unfamiliar adults, overly familiar verbal or physical behavior, diminished checking back with adult caregiver after venturing away, and a willingness to go off with an unfamiliar adult with reduced hesitation.
DSM-5 pp. 291–307
Screening question: Everyone has trouble remembering things sometimes, but do you ever lose time, forget important details about yourself, or find evidence that you took part in events that you cannot recall? Do you ever feel as if people or places that are familiar to you are unreal or that you are so detached from your body that it is like you are standing outside your body or watching yourself?
If yes, ask: Did these experiences ever cause you significant trouble with your friends or family, at school, or in another setting?
• If amnesia predominates, proceed to dissociative amnesia criteria.
• If depersonalization or derealization predominates, proceed to depersonalization/derealization disorder criteria.
1191. Dissociative Amnesia [F44.0, 298–302]
a. Inclusion: Requires the presence of inability to recall important autobiographical information beyond ordinary forgetting, most often manifested by at least one of the following symptoms.
i. Localized or selective amnesia: Do you find yourself unable to recall a really important event, especially events that were especially stressful or even traumatic?
ii. Generalized amnesia: Do you find yourself unable to recall really important moments in your life history or details of your very identity?
b. Exclusions
i. If the disturbance is better accounted for by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, or somatic symptom disorder, do not use this diagnosis.
ii. If the disturbance is due to the physiological effects of a substance or a neurological or other medical condition, do not use this diagnosis.
c. Modifiers
i. Specifier
• With dissociative fugue [F44.1, 298]: Use when a person engages in purposeful travel or bewildered wandering for which he has amnesia.
d. Alternative: If a young person reports a disruption of identity, characterized by two or more distinct personality states or an experience of possession, that causes clinically significant distress and functional impairment, consider dissociative identity disorder [F44.81, 292–298]. The criteria include recurrent gaps in recall that are inconsistent with ordinary forgetting and dissociative experiences that are not a normal part of a broadly accepted cultural or religious practice and that are not attributable to the physiological effects of a substance or another medical condition.
2. Depersonalization/Derealization Disorder [F48.1, 302–306]
a. Inclusion: Requires at least one of the following manifestations.
i. Depersonalization: Do you frequently have experiences of unreality or detachment—as if you are an outside observer 120of your mind, thoughts, feelings, sensations, body, or your whole self?
ii. Derealization: Do you frequently have experiences of unreality or detachment for your surroundings—that you often experience people or places as unreal, dreamlike, foggy, lifeless, or visually distorted?
b. Inclusion: Requires intact reality testing. During these experiences, can you distinguish the experiences from actual events—what is occurring outside of you?
c. Exclusions
i. If the disturbance is due to the physiological effects of a substance or a neurological or other medical condition, do not use this diagnosis.
ii. If depersonalization or derealization occurs exclusively as symptoms of or during the course of another mental disorder, do not use this diagnosis.
d. Alternative: If a young person is experiencing a disorder whose most prominent symptoms are amnestic but does not meet the criteria for a specific disorder, consider unspecified dissociative disorder [F44.9, 307]. If you wish to communicate the specific reason a young person’s symptoms do not meet criteria for a specific disorder, consider other specified dissociative disorder [F44.89, 306–307]. Examples include subthreshold dissociative disturbances in identity and memory, chronic and recurrent syndromes of mixed dissociative symptoms, identity disturbances in individuals subjected to prolonged periods of intense coercive persuasion, acute reactions to stressful situations, acute psychotic states intermixed with dissociative symptoms in a person who does not meet criteria for delirium or a psychotic disorder, and dissociative trance.
DSM-5 pp. 309–327
Screening question: Do you worry about your physical health more than most young people? Do you get sick more often than most young people?
If yes, ask: Do these experiences significantly affect your daily life at home or in school?
121If yes, ask: Which is worse for you, worrying about the symptoms you experience or worrying about your health and the possibility that you are sick?
• If worry about symptoms predominates, proceed to somatic symptom disorder criteria.
• If worry about being ill or sick predominates, proceed to illness anxiety disorder criteria.
1. Somatic Symptom Disorder [F45.1, 311–315]
a. Inclusion: Requires at least one somatic symptom that is distressing. Do you experience symptoms that cause you to feel anxious or distressed? Do these symptoms significantly disrupt your daily life?
b. Inclusion: Requires at least one of the following thoughts, feelings, or behaviors, for at least 6 months.
i. Disproportionate thoughts: How serious are your health concerns, and do you think about them often?
ii. Persistently high level of anxiety: Do you persistently feel a high level of anxiety or worry about your health concerns?
iii. Excessive investment: Do you find yourself investing a lot more time and energy into your health concerns than you would like to?
c. Modifiers
i. Specifiers
• With predominant pain
• Persistent
ii. Severity
• Mild: One of the additional symptoms specified in (b) above.
• Moderate: Two or more of the additional symptoms specified in (b) above.
• Severe: Two or more of the additional symptoms specified in (b) above plus multiple somatic complaints (or one very severe somatic symptom)
d. Alternatives
i. If a young person is focused on the loss of bodily function rather than on the distress a particular symptom causes, consider conversion disorder 122(functional neurological symptom disorder) [F44.x, 318–321]. The criteria for this disorder include symptoms or deficits affecting voluntary motor or sensory function, clinical evidence that these symptoms or deficits are inconsistent with a recognized medical or neurological disease, and significant impairment in social or occupational functioning.
ii. If a young person has a documented medical condition, but behavioral or psychological factors adversely affect the course of his medical condition by delaying recovery, decreasing adherence, significantly increasing health risks, or influencing the underlying pathophysiology, consider psychological factors affecting other medical conditions [F54, 322–324].
iii. If a young person falsifies physical or psychological signs or symptoms or induces injury or disease to deceptively present himself or herself to others as ill, impaired, or injured, consider factitious disorder imposed on self [F68.10, 324–326]. If a young person exhibits these behaviors in pursuit of obvious external rewards, as in malingering, do not use this diagnosis. If a young person’s symptoms are better accounted for by another mental disorder, such as a psychotic disorder, do not use this diagnosis.
iv. If a person falsifies physical or psychological signs or symptoms or induces injury or disease to deceptively present someone else to others as ill, impaired, or injured, consider factitious disorder imposed on another [F68.10, 325–326]. The diagnosis is assigned to the perpetrator rather than the victim. If the perpetrator exhibits these behaviors in pursuit of obvious external rewards, as in malingering, do not use this diagnosis. If the perpetrator’s behavior is better accounted for by another mental disorder, such as a psychotic disorder, do not use this diagnosis.
2. Illness Anxiety Disorder [F45.21, 315–318]
a. Inclusion: Requires all of the following symptoms for at least 6 months and the absence of somatic symptoms.
123i. Preoccupation: Do you find yourself unable to stop thinking about having or acquiring a serious illness?
ii. Anxiety: Do you feel a high level of anxiety or worry about having or acquiring a serious illness?
iii. Associated behaviors: Have these worries affected your behavior? Some people find themselves frequently checking their body for signs of illness; reading about illness all the time; or avoiding persons, places, or objects to ward off illness. Do you find yourself doing any of those things or things like that?
b. Exclusion: If a person’s symptoms are better explained by another mental disorder, do not use this diagnosis.
c. Modifiers
i. Subtypes
• Care-seeking type
• Care-avoidant type
ii. Course
• Transient
d. Alternatives: If a young person endorses symptoms characteristic of a somatic symptom and related disorder that cause clinically significant distress or impairment without meeting the full criteria for a specific disorder, consider unspecified somatic symptom and related disorder [F45.9, 327]. If you wish to communicate the specific reason a young person’s symptoms do not meet criteria for a specific disorder, consider other specified somatic symptom and related disorder [F45.8, 327]. Examples include brief somatic symptom disorder, brief illness anxiety disorder, illness anxiety disorder without excessive health-related behaviors, and pseudocyesis.
DSM-5 pp. 329–354
Screening question: What do you think of your appearance? Do you ever restrict or avoid particular foods so much that it negatively affects your health or weight?
124If yes, ask: When you consider yourself, is the shape or weight of your body one of the most important things about you?
• If yes, proceed to anorexia nervosa criteria.
• If no, proceed to avoidant/restrictive food intake disorder criteria.
1. Anorexia Nervosa [F50.0x, 338–345]
a. Inclusion: Requires the presence of all three of the following features.
i. Energy restriction leading to significantly low body weight adjusted for age, developmental trajectory, physical health, and sex: Have you limited the food you eat to achieve a low body weight? What was the least you ever weighed? What do you weigh now?
ii. Fear of weight gain or behavior interfering with weight gain: Do you have an intense fear of gaining weight or becoming fat? Has there ever been a time when you were already at a low weight and still did things to interfere with gaining weight?
iii. Disturbance in self-perceived weight or shape: How do you experience the weight and shape of your body? How do you think having a significantly low body weight will affect your physical health?
b. Modifiers
i. Subtypes
• Restricting type [F50.01, 339]: Use when a young person reports no recurrent episodes of binge eating or purging in the last 3 months.
• Binge-eating/purging type [F50.02, 339]: Use when a young person reports recurrent episodes of binge eating or purging in the last 3 months.
ii. Specifiers
• In partial remission
• In full remission
iii. Severity
• Mild: Age- and gender-matched percentiles equivalent to adult body mass index (BMI) ≥ 17 kg/m2
• Moderate: Age- and gender-matched percentiles equivalent to adult BMI 16–16.99 kg/m2
• Severe: Age- and gender-matched percentiles equivalent to adult BMI 15–15.99 kg/m2
125• Extreme: Age- and gender-matched percentiles equivalent to adult BMI < 15 kg/m2
c. Alternatives
i. If a young person reports recurrent binge eating, recurrent inappropriate compensatory behaviors to prevent weight gain (e.g., misuse of laxatives or other medications, self-induced vomiting, excessive exercise), and self-image unduly influenced by the shape or weight of his body, consider bulimia nervosa [F50.2, 345–350]. The diagnosis requires that binge eating and compensatory behaviors both occur, on average, at least once a week for 3 months. If binge eating and compensating behaviors occur only during episodes of anorexia nervosa, the diagnosis should not be given.
2. Avoidant/Restrictive Food Intake Disorder [F50.8, 334–338]
a. Inclusion: Requires significant disturbance in eating or feeding manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with at least one of the following sequelae.
i. Faltering growth or significant weight loss: Do you avoid certain foods or restrict what you eat to the extent that you have not grown at the expected rate or have experienced a significant weight loss?
ii. Significant nutritional deficiency: Do you avoid or restrict food to the extent that it has negatively affected your health, as in experiencing a significant nutritional deficiency?
iii. Dependence on enteral feeding or oral supplements: Have you avoided or restricted food to the extent that you depend on tube feedings or oral supplements to maintain nutrition?
iv. Marked interference with psychosocial functioning: Can you eat with other people or participate in social activities when food is present? Has avoiding or restricting food impaired your ability to participate in your usual social activities or made it hard to form or sustain relationships?
b. Exclusions
i. If the eating disturbance is better explained by lack of available food, by an associated culturally sanctioned practice, or by eating practices related 126to a disturbance in body image, do not use this diagnosis.
ii. If the eating disturbance is due to another medical condition or is better explained by another mental disorder, do not use this diagnosis.
c. Alternatives
i. If a young person persistently eats nonfood substances over a period of at least 1 month, consider pica [F98.3, 329–331]. The eating of nonnutritive, nonfood substances must be inappropriate to his developmental stage and must not be part of a culturally supported or socially normative practice.
ii. If a young person repeatedly regurgitates food over a period of at least 1 month, consider rumination disorder [F98.21, 332–333]. If the regurgitation occurs as the result of an associated gastrointestinal or other medical condition or occurs exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder, do not use this diagnosis.
iii. If a young person has an atypical, mixed, or subthreshold disturbance in his eating and feeding, or if you lack sufficient information to make a more specific diagnosis, consider unspecified feeding or eating disorder [F50.9, 354]. DSM-5 also allows the use of this category for specific syndromes that are not formally included, such as purging disorder. If you wish to communicate the specific reason a young person’s symptoms do not meet criteria for a specific disorder, consider other specified feeding or eating disorder [F50.8, 353–354]. Examples include atypical anorexia nervosa, binge-eating disorder, and purging disorder.
DSM-5 pp. 355–360
Screening question: Have you repeatedly passed urine or feces onto your clothing, your bed, the floor, or another inappropriate place?
• If passing urine, proceed to enuresis criteria.
• If passing feces, proceed to encopresis criteria.
1271. Enuresis [F98.0, 355–357]
a. Inclusion
i. Intentional or involuntary voiding of urine: On average, have you been urinating like this at least two times a week?
ii. Duration: Has this urinating occurred for at least 3 months in a row?
b. Exclusions
i. If a child is younger than 5 years, or the equivalent developmental age, do not use this diagnosis.
ii. If the behavior is due to the physiological effects of a substance or another medical condition through a mechanism other than constipation, do not use this diagnosis.
c. Modifiers
i. Nocturnal only
ii. Diurnal only
iii. Nocturnal and diurnal
d. Alternatives
i. If a young person experiences symptoms characteristic of an elimination disorder that cause clinically significant distress or impairment without meeting the full criteria for an elimination disorder, consider unspecified elimination disorder with urinary symptoms [R32, 360]. If you wish to communicate the specific reason that full criteria are not met, consider other specified elimination disorder with urinary symptoms [N39.498, 359].
2. Encopresis [F98.1, 357–359]
a. Inclusion
i. Intentional or involuntary voiding of feces: On average, have you been defecating like this at least once a month?
ii. Duration: Has this defecating occurred for at least 3 months in a row?
b. Exclusions
i. If a child is younger than 4 years, or the equivalent developmental age, do not use this diagnosis.
ii. If the behavior is due to the physiological effects of a substance or another medical condition through a 128mechanism other than constipation, do not use this diagnosis.
c. Modifiers
i. With constipation and overflow incontinence
ii. Without constipation and overflow incontinence
d. Alternatives
i. If a young person experiences symptoms characteristic of an elimination disorder that cause clinically significant distress or impairment without meeting the full criteria for an elimination disorder, consider unspecified elimination disorder with fecal symptoms [R15.9, 360]. If you wish to communicate the specific reason that full criteria are not met, consider other specified elimination disorder with fecal symptoms [R15.9, 359].
DSM-5 pp. 361–422
Screening question: Is your sleep often inadequate or of poor quality? Alternatively, do you often experience excessive sleepiness? Have you, or someone else, noticed any unusual behaviors while you sleep? Have you, or someone else, noticed that you stop breathing or gasp for air while sleeping?
• If dissatisfaction with sleep quantity or quality predominates, proceed to insomnia disorder criteria.
• If excessive sleep predominates, proceed to hypersomnolence disorder criteria.
• If an irrepressible need to sleep or sudden lapses into sleep predominate, proceed to narcolepsy criteria.
• If unusual sleep behaviors (parasomnias) predominate, proceed to restless legs syndrome criteria.
• If sleep-breathing problems predominate, proceed to obstructive sleep apnea hypopnea criteria.
1. Insomnia Disorder [F51.01, 362–368]
a. Inclusion: Requires dissatisfaction with sleep quantity or quality, at least 3 nights per week, for at least 3 months, as manifested by at least one of the following symptoms.
129i. Difficulty initiating sleep: Do you often have trouble getting to sleep without the help of a parent or someone else?
ii. Difficulty maintaining sleep: If you wake up when you wanted to be asleep, do you need the help of a parent or someone else to get back to sleep?
iii. Early-morning awakening: Do you often wake up earlier than you intended and find yourself unable to return to sleep?
b. Exclusions
i. If a young person does not have adequate opportunity for sleep, do not use this diagnosis.
ii. If a young person’s insomnia is better explained by another sleep-wake disorder, another mental disorder, or another medical condition, do not use this diagnosis.
iii. If the physiological effects of a substance cause a young person’s insomnia, do not use this diagnosis.
c. Modifiers
i. Specifiers
• With non–sleep disorder mental comorbidity, including substance use disorders
• With other medical comorbidity
• With other sleep disorder
ii. Course
• Episodic: symptoms last between 1 and 3 months
• Persistent: symptoms last 3 months or longer
• Recurrent: At least two episodes within 1 year
d. Alternatives
i. If a young person experiences a persistent or recurrent pattern of sleep disruption leading to excessive sleepiness, insomnia, or both, and this disruption is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by a person’s physical environment or social or professional schedule, consider a circadian rhythm sleep-wake disorder [G47.2x, 390–398]. The sleep disturbance must cause clinically significant distress or functional impairment. 130Subtypes include delayed sleep phase type, advanced sleep phase type, and irregular sleep-wake type.
ii. If substance use, intoxication, or withdrawal is etiologically related to insomnia that causes significant distress or impairment, consider substance/medication-induced sleep disorder, insomnia type [F1x.x92, 413–420]. If the insomnia is better accounted for by delirium, a non-substance-induced sleep disorder, or the sleep symptoms usually associated with an intoxication or withdrawal syndrome, this diagnosis should not be used.
iii. If a young person experiences symptoms characteristic of an insomnia disorder that cause clinically significant distress or impairment without meeting criteria for a disorder, consider unspecified insomnia disorder [G47.00, 420]. If you wish to communicate the specific reason that full criteria are not met, consider other specified insomnia disorder [G47.09, 420]. Examples include brief insomnia disorder and insomnia restricted to nonrestorative sleep.
2. Hypersomnolence Disorder [F51.11, 368–372]
a. Inclusion: Requires excessive sleepiness at least three times per week for at least 3 months, despite a main sleep period lasting at least 7 hours, that causes significant distress or functional impairment. The hypersomnolence is manifested by at least one of the following symptoms.
i. Recurrent periods of sleep: Do you often have several periods of sleep within the same day?
ii. Prolonged nonrestorative sleep episode: When you sleep for at least 9 hours, do you still wake up without feeling refreshed or restored?
iii. Sleep inertia: Do you often have difficulty being fully awake? After an awakening, do you often feel groggy or notice that you have trouble engaging in tasks or activities that would otherwise be simple for you?
b. Exclusion: If the hypersomnia occurs exclusively during the course of another sleep disorder, is better accounted for by another sleep disorder, or is attributable to the physiological effects of a substance, do not use this diagnosis.
131c. Modifiers
i. Specifiers
• With mental disorder, including substance use disorders
• With medical condition
• With another sleep disorder
ii. Course
• Acute: duration of less than 1 month
• Subacute: duration of 1–3 months
• Persistent: duration of more than 3 months
iii. Severity
• Mild: difficulty maintaining daytime alertness 1–2 days/week
• Moderate: difficulty maintaining daytime alertness 3–4 days/week
• Severe: difficulty maintaining daytime alertness 5–7 days/week
d. Alternative: If substance use, intoxication, or withdrawal is etiologically related to daytime sleepiness, consider substance/medication-induced sleep disorder, daytime sleepiness type [F1x.x92, 413–420]. If the disturbance is better accounted for by delirium, a non–substance-induced sleep disorder, or the sleep symptoms usually associated with an intoxication or withdrawal syndrome, this diagnosis should not be used.
3. Narcolepsy [G47.4xx, 372–378]
a. Inclusion: Requires periods of an irrepressible need to sleep or lapsing into sleep, at least three times per week over the past 3 months, along with at least one of the following.
i. Episodes of cataplexy: At least a few times a month, do you find that all of a sudden you grimace, open your mouth wide and thrust out your tongue, or lose muscle tone throughout your body?
ii. Hypocretin deficiency: Measured using cerebrospinal fluid hypocretin-1 (CSF-1) immunoreactivity values.
iii. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep latency of 15 minutes or less or a multiple sleep latency test showing mean sleep latency of 8 minutes or less and two or more sleep-onset REM periods.
132b. Modifiers
i. Specifiers
• Narcolepsy without cataplexy but with hypocretin deficiency: low CSF-1 levels and positive polysomnograpy/multiple sleep latency test but no cataplexy
• Narcolepsy with cataplexy but without hypocretin deficiency: cataplexy and positive polysomnograpy/multiple sleep latency test but normal CSF-1 levels
• Autosomal dominant cerebellar ataxia, deafness, and narcolepsy: subtype caused by exon 21 DNA (cytosine-5)-methyltransferase-1 mutations and characterized by late-onset (age 30–40 years) narcolepsy (with low or intermediate CSF hypocretin-1 levels), deafness, cerebellar ataxia, and eventually dementia
• Autosomal dominant narcolepsy, obesity, and type 2 diabetes: Narcolepsy, obesity, and type 2 diabetes and low CSF-1 levels associated with a mutation in the myelin oligodendrocyte glycoprotein gene
• Narcolepsy secondary to another medical condition: Narcolepsy developing secondary to medical conditions that cause infectious (e.g., Whipple’s disease, sarcoidosis), traumatic, or tumoral destruction of hypocretin neurons
ii. Severity
• Mild: Infrequent cataplexy (less than once per week), need for naps only once or twice per day, and less disturbed nocturnal sleep
• Moderate: Cataplexy once daily or every few days, disturbed nocturnal sleep, and need for multiple naps daily
• Severe: Drug-resistant cataplexy with multiple attacks daily, nearly constant sleepiness, and disturbed nocturnal sleep (i.e., movements, insomnia, and vivid dreaming)
4. Obstructive Sleep Apnea Hypopnea [G47.33, 378–383]
a. Inclusion: Requires repeated episodes of upper airway obstruction during sleep. There must be polysomnographic evidence of at least five obstructive 133apneas or hypopneas per hour of sleep and either of the following symptoms.
i. Nocturnal breathing disturbances: Do you often disturb your parents, siblings, or anyone else with snoring, snorting, gasping for air, or breathing pauses during sleep?
ii. Daytime sleepiness, fatigue, or nonrestorative sleep that is not attributable to another medical condition or is not explained by psychiatric morbidity: When you have an opportunity to get sleep, do you still wake up the next day feeling exhausted, sleepy, or fatigued?
b. Inclusion: Alternatively, the diagnosis can be made by polysomnographic evidence of 15 or more obstructive apneas or hypopneas per hour of sleep regardless of accompanying symptoms.
c. Modifiers
i. Severity
• Mild: apnea hypopnea index less than 15
• Moderate: apnea hypopnea index between 15 and 30
• Severe: apnea hypopnea index greater than 30
d. Alternatives
i. If a young person has five or more central apneas per hour of sleep during polysomnographic examination and this disturbance is not better accounted for by another current sleep disorder, consider central sleep apnea [G47.31, 383–386].
ii. If a young person has episodes of shallow breathing associated with arterial oxygen desaturation and/or elevated carbon dioxide levels during polysomnographic examination and this disturbance is not better accounted for by another current sleep disorder, consider sleep-related hypoventilation [G47.3x, 387–390]. This disorder is most commonly associated with medical or neurological disorders, obesity, medication use, or substance use disorders.
5. Restless Legs Syndrome [G25.81, 410–413]
a. Inclusion: Requires an urge to move the legs, usually accompanied by or in response to uncomfortable and 134unpleasant sensations in the legs, at least three times per week for at least 3 months, as manifested by all of the following symptoms.
i. Urge to move legs: While you are asleep, do you often experience uncomfortable or unpleasant sensations in the legs? Do you often experience an urge to move your legs when you are otherwise inactive?
ii. Relieved with movement: Are these symptoms partially or completely relieved by moving your legs?
iii. Nocturnal worsening: What times of day do you most experience the urge to move your legs? Is it worse in the evening or at night, no matter what you have done during the day?
b. Exclusions
i. If a young person’s restless legs are better explained by another mental disorder, another medical condition, or a behavioral condition, do not use this diagnosis.
ii. If the physiological effects of a substance cause a young person’s restless legs, do not use this diagnosis.
c. Alternatives
i. If a young person experiences recurrent episodes of incomplete awakening from sleep in which he experiences an abrupt and terrifying awakening (sleep terror) or he rises from bed and walks about (sleepwalking), usually during the first third of the major sleep episode, consider non–rapid eye movement sleep arousal disorders [F51.x, 399– 404]. When experiencing an episode, a person experiences little to no dream imagery. The young person experiences amnesia for the episode and is relatively unresponsive to efforts of other people.
ii. If a young person repeatedly experiences extremely dysphoric and well-remembered dreams and rapidly becomes alert and oriented on awakening from these dysphoric dreams, consider nightmare disorder [F51.5, 404–407]. The dream disturbance, or the sleep disturbance produced by awakening from the nightmare, causes clinically significant distress or functional impairment. If the dysphoric dreams occur exclusively during another mental disorder or 135as the physiological effect of a substance or another medical condition, do not use this diagnosis.
iii. If a young person repeatedly experiences episodes of arousal from sleep associated with vocalization and/or complex motor behaviors sufficient to result in injury to himself or herself or his bed partner, consider rapid eye movement sleep behavior disorder [G47.52, 407–410]. These behaviors arise during REM sleep and typically occur more than 90 minutes after sleep onset. On awakening, the person is fully awake, alert, and oriented. The diagnosis requires either polysomnographic evidence of REM sleep disturbance or evidence that the behaviors are injurious, potentially injurious, or disruptive.
iv. If substance use, intoxication, or withdrawal is etiologically related to daytime sleepiness, consider substance/medication-induced sleep disorder, parasomnia type [F1x.x92, 413–420]. If the disturbance is better accounted for by delirium, a non-substance-induced sleep disorder, or the sleep symptoms usually associated with an intoxication or withdrawal syndrome, the diagnosis should not be given.
v. If a young person experiences symptoms characteristic of restless legs or another sleep disturbance that cause clinically significant distress or impairment without meeting criteria for a disorder, consider unspecified insomnia disorder [G47.00, 420]. If you wish to communicate the specific reason that full criteria are not met, consider other specified insomnia disorder G47.09, 420].
DSM-5 pp. 451–459
Screening question: Are you really uncomfortable with your assigned gender?
If yes, ask: Has this discomfort lasted at least 6 months and gotten to the point where you really feel that your assigned gender is incongruent with your gender identity? Does this discomfort cause significant trouble with your friends or family, at school, or in another setting?
136• If a child says yes, proceed to gender dysphoria in children.
• If an adolescent says yes, proceed to gender dysphoria in adolescents.
1. Gender Dysphoria in Children [F64.2, 452–459]
a. Inclusion: Requires at least six of the following manifestations (one of which must be a strong desire to be of the other gender) for at least 6 months’ duration.
i. Desire to be of other gender: Have you experienced a strong desire to be of a gender other than your assigned gender? Do you insist that people treat you as a member of a gender other than your assigned gender?
ii. Cross-dressing: Do you have a strong preference for clothes usually associated with a gender other than your assigned gender?
iii. Cross-gender fantasy: When you play fantasy games, do you have a strong preference for cross-gender roles?
iv. Cross-gender play: When you play, do you have a strong preference for toys or activities that most people associate with the other gender?
v. Cross-gender playmates: Do you have a strong preference for friends of the other gender?
vi. Rejection of toys, games, and activities: Do you strongly reject the toys, games, and activities typically associated with your assigned gender?
vii. Dislike of anatomy: Do you have a strong dislike of your sexual anatomy?
viii. Desire to have other sex characteristics: Have you experienced a strong desire for the primary or secondary sex characteristics that match your experience of gender?
b. Specifiers
i. With a disorder of sex development
2. Gender Dysphoria in Adolescents [F64.1, 452–459]
a. Inclusion: Requires at least two of the following manifestations for at least 6 months’ duration.
i. Incongruence: Have you experienced a profound sense that your primary or secondary sex characteristics do not match your gender identity?
ii. Desire to change: Have you experienced a profound desire to change your primary or secondary sex characteristics because they do not match your gender identity?
137iii. Desire to have sexual characteristics of other gender: Have you experienced a strong desire for the primary or secondary sex characteristics that match your experience of gender?
iv. Desire to be another gender: Have you experienced a strong desire to be of a gender other than your assigned gender?
v. Desire to be treated as another gender: Have you experienced a strong desire to be treated as a gender other than your assigned gender?
vi. Conviction that one has feelings of another gender: Have you experienced a strong conviction that your typical feelings and reactions are those of the gender other than your assigned gender?
b. Modifiers
i. Specifiers
• With a disorder of sex development
• Posttransition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen.
c. Alternatives
i. If a person experiences symptoms characteristic of gender dysphoria that cause clinically significant distress or impairment without meeting the full criteria for gender dysphoria, consider unspecified gender dysphoria [F64.9, 459]. If you wish to communicate the specific reason that a person’s symptoms do not meet full criteria, consider other specified gender dysphoria [F64.8, 459].
DSM-5 pp. 461–480
Screening question: Do you often have times when you become so upset that you make or even act on verbal or physical threats to hurt other people, animals, or property? Have you ever been aggressive 138to people and animals, destroyed property, deceived other people, or stolen things?
If yes, ask: Have these behaviors ever caused you significant trouble with your friends or family, at school or work, with the authorities, or in another setting?
• If persistent anger or argumentativeness predominates, proceed to oppositional defiant disorder criteria.
• If recurrent behavioral outbursts predominate, proceed to intermittent explosive disorder criteria.
• If recurrent rule breaking predominates, proceed to conduct disorder criteria.
1. Oppositional Defiant Disorder [313.81, 462–466]
This section contains questions phrased for interviewing an older child with an ability to self-reflect. For younger children or those with limited cognitive functioning, rephrase these questions to interview the child’s caregiver instead.
a. Inclusion: Requires a pattern of at least four of the following angry, argumentative, or vindictive behaviors with nonsiblings over the course of more than 6 months:
Angry/irritable mood
i. Often loses temper: Do you often get explosively mad at people? Does your getting really mad cause you more problems?
ii. Often touchy or easily annoyed: Do you get annoyed really easily by other people?
iii. Often angry and resentful: Do you feel angry much of the time? Do you often feel people are making your life difficult?
Argumentative/defiant behavior
i. Often argues with adults: Do you often get in arguments with your parents or teachers?
ii. Often actively defies rules or requests from authorities: Do you often push back against rules or expectations?
iii. Often deliberately annoys others: Do you often push other people’s buttons just to get them to react?
iv. Often blames others for own mistakes or misbehaviors: When you get caught doing something you 139aren’t supposed to, are you likely to say it was someone else’s fault?
Vindictiveness
i. Has been spiteful or vindictive twice or more in past 6 months: Have you planned to get back at people you think have wronged you and then acted on that plan?
b. Inclusion: Behavior disturbance causes distress in individual or others in their immediate social context or impacts functioning.
c. Exclusion: Problem does not exclusively occur from psychosis, substance abuse, depression, bipolar disorder, or disruptive mood dysregulation disorder.
2. Intermittent Explosive Disorder [F63.81, 466–469]
a. Inclusion: Requires recurrent behavioral outbursts in which a young person does not control aggressive impulses as manifested by either of the following.
i. Verbal or physical aggression: Over the past 3 months, have you had impulsive outbursts in which you were verbally or physically aggressive toward other people, animals, or property? Have these outbursts occurred, on average, at least twice weekly?
ii. Three behavioral outbursts involving damage to or destruction of property and/or physical assault: Over the last 12 months, have you assaulted other people or destroyed property three or more times? Over the last 3 months, have you also had at least one impulsive outburst when you lost control of your behavior?
b. Inclusion: Also requires all three of the following.
i. Magnitude of aggressiveness is disproportionate to any provocation or psychosocial stressor: If you look back at these outbursts, can you identify any events or stressors that you associate with them? Was your response much more aggressive or extreme than these events or stressors?
ii. Recurrent outbursts are neither premeditated nor in pursuit of a tangible objective: When you had these outbursts, did they happen when you were feeling angry or impulsive? Did the outburst occur without a clear goal such as obtaining money or intimidating someone?
140iii. Outbursts cause marked personal distress, impair function, or are associated with financial or legal consequences: How do these outbursts affect how you feel about yourself and how you get along with friends, family, and other people in your life? Have you ever suffered financial or legal consequences because of your outbursts?
c. Exclusions
i. If a young person’s chronological age, or equivalent developmental age, is younger than 6 years, do not use this diagnosis.
ii. If the recurrent aggressive outbursts are fully explained by another mental disorder or are attributable to another medical condition or to the physiological effects of a substance/medication, do not use this diagnosis.
iii. If aggressive behavior occurs only in the context of an adjustment disorder, do not use this diagnosis.
3. Conduct Disorder [F91.x, 469–475]
a. Inclusion: Requires a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following in the past 12 months and at least one of the following in the past 6 months.
i. Often bullies, threatens, or intimidates others: Do you often bully, threaten, or intimidate other people?
ii. Often initiates physical fights: Do you often start physical fights?
iii. Has used a weapon that can cause serious physical harm to others: Have you used a weapon that could cause serious harm to someone else, such as a bat, brick, broken bottle, knife, or gun?
iv. Has been physically cruel to people: Have you caused physical pain or suffering to other people?
v. Has been physically cruel to animals: Have you caused physical pain or suffering to animals?
vi. Has stolen while confronting a victim: Have you forcibly taken or stolen something from someone while the person was present?
vii. Has forced someone into sexual activity: Have you forced someone into sexual activity?
141viii. Has deliberately engaged in fire setting with the intention of causing serious damage: Have you set fires in order to cause serious damage to a person, animal, or property?
ix. Has deliberated destroyed others’ property: Have you deliberately destroyed someone else’s belongings?
x. Has broken into someone else’s house, building, or car: Have you broken into someone else’s house, building, or car?
xi. Often lies to obtain goods or favors or to avoid obligations: Do you often lie to get out of school or work or to get things you want?
xii. Has stolen items of nontrivial value without confronting a victim: Have you taken or stolen something valuable from someone when the person was not present?
xiii. Often stays out at night despite parental prohibitions, beginning before age 13: Before age 13, did you have a curfew, a time after which you had to be at home, that you often violated by staying out later than you were supposed to?
xiv. Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period): Have you ever run away from home? How many times? Did you ever run away from home without returning for a long time?
xv. Is often truant from school, beginning before age 13: Before age 13, did you often cut class or skip school?
b. Modifiers
i. Specifiers
• Childhood-onset type [F91.1, 470]: Use when at least one criterion symptom begins before age 10 years.
• Adolescent-onset type [F91.2, 470]: Use when no criteria symptoms are present before age 10 years.
• Unspecified onset [F91.9, 470]: Use when the age at onset is unknown.
• With limited prosocial emotions: Use for a young person who persistently has at least two of the following characteristics: lack of remorse or guilt, callous lack of empathy, lack of concern about performance, and shallow or deficient affect. 142To meet criteria, these characteristics must be seen in multiple relationships and settings over at least 12 months. That is, these characteristics reflect a person’s typical pattern of interpersonal and emotional functioning and not just occasional occurrences in some situations.
ii. Severity
• Mild: Few, if any, conduct problems beyond those required for diagnosis and relatively minor harm to others
• Moderate
• Severe: Many conduct problems beyond those required for diagnosis, or considerable harm to others
c. Alternatives
i. If a young person shows at least 6 months of a persistent pattern of angry and irritable mood along with defiant and vindictive behavior, consider oppositional defiant disorder [F91.3, 462–466]. The pattern is manifested by at least four of the following: often losing temper, being touchy or easily annoyed by others, being angry and resentful, arguing with adults, actively defying or refusing to comply with adults’ requests or rules, deliberately annoying people, blaming others for one’s mistakes or misbehaviors, or being spiteful or vindictive at least twice within the past 6 months. In addition, it is important to consider the persistence and frequency of these behaviors in relation to a person’s developmental stage. For children younger than age 5, the behavior must occur on most days for at least 6 months. For children age 5 years or older, the behavior must occur at least once a week for at least 6 months. The behaviors must also cause clinically significant impairment and cannot occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder, and the criteria for disruptive mood dysregulation disorder cannot be met.
ii. If a young person reports deliberate and purposeful fire setting on at least two occasions, consider pyromania [F63.1, 476–477]. The diagnosis requires 143tension or affective arousal before the fire setting, fascination with fire, and pleasure or relief when setting or witnessing fires. If the fire setting is done for monetary gain, to conceal criminal activity, out of anger, or in response to a hallucination, do not use this diagnosis. If the fire setting is better explained by intellectual disability, conduct disorder, mania, or antisocial personality disorder, do not use this diagnosis.
iii. If a young person repeatedly fails to resist impulses to steal objects that are not needed for his personal use or their monetary value, consider kleptomania [F63.2, 478–479]. The diagnosis requires tension or affective arousal before the theft and pleasure or relief at the time of the theft. If the stealing is done out of anger or vengeance or in response to a hallucination, do not use this diagnosis. If the stealing is better explained by conduct disorder, mania, or antisocial personality disorder, do not use this diagnosis.
iv. If a young person has symptoms characteristic of a disruptive, impulse-control, and conduct disorder that cause clinically significant distress or impairment without meeting the full criteria for a diagnosis named earlier, consider unspecified disruptive, impulse-control, and conduct disorder [F91.9, 480]. If you wish to communicate the specific reason that a young person does not meet the full criteria, consider other specified disruptive, impulse-control, and conduct disorder [F91.8, 479].
DSM-5 pp. 481–589
Screening question: In the past year, have you drunk alcohol, smoked marijuana, or used anything else to get high? Have you ever ridden in a car with someone who was high or drinking alcohol? Do you ever use alcohol or drugs when you are alone? Do you ever use alcohol or drugs to relax? (Knight et al. 2002)
If yes, ask: Did these experiences ever cause you significant trouble with your friends or family, at school, or in another setting?
144• If a young person reports problems with substance use, proceed to the substance use disorder criteria for each particular substance.
• If a young person presents with substance intoxication, proceed to the substance intoxication criteria for each particular substance.
• If a young person reports problems with substance withdrawal, proceed to the substance withdrawal criteria for each particular substance.
1. Alcohol Use Disorder [F10.x0, 490–497]
a. Inclusion: Requires a problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the following symptoms in a 12-month period.
i. Drinking more alcohol over a longer period than intended: When you drink, do you find that you drink more, and for a longer time, than you planned to?
ii. Persistent desire or unsuccessful effort to reduce alcohol use: Do you want to cut back or stop drinking? Have you ever tried and failed to cut back or stop drinking?
iii. Great deal of time spent: Do you spend a great deal of your time obtaining alcohol, drinking alcohol, or recovering from your alcohol use?
iv. Cravings: Do you experience strong desires or cravings to drink alcohol?
v. Failure to fulfill major role obligations: Have you repeatedly failed to fulfill major obligations at home, school, or work because of your alcohol use?
vi. Continued use despite awareness of interpersonal or social problems: Do you drink alcohol even though you suspect, or even know, that it creates or worsens interpersonal or social problems?
vii. Giving up activities for alcohol: Are there important social, occupational, or recreational activities that you have given up or reduced because of your alcohol use?
viii. Use in hazardous situations: Have you repeatedly used alcohol in situations in which it was physically hazardous, such as driving a car or operating a machine while intoxicated?
ix. Continued use despite awareness of physical or psychological problems: Do you drink alcohol even 145though you suspect, or even know, that it creates or worsens problems with your mind and body?
x. Tolerance as manifested by either of the following.
• Markedly increased amounts: Do you find that in order to get intoxicated or achieve the desired effect of drinking, you need to consume much more alcohol than you used to?
• Markedly diminished effects: If you drink the same amount of alcohol as you used to, do you find that it has a lot less effect on you than it used to?
xi. Withdrawal as manifested by either of the following.
• Characteristic alcohol withdrawal syndrome: When you stop drinking, do you undergo withdrawal?
• The same or closely related substance is taken to relieve or avoid withdrawal symptoms: Have you ever drunk alcohol or taken another substance to prevent alcohol withdrawal?
b. Modifiers
i. Specifiers
• In early remission
• In sustained remission
• In a controlled environment
ii. Severity
• Mild [F10.10, 491]: use when two to three symptoms are present
• Moderate [F10.20, 491]: use when four to five symptoms are present
• Severe [F10.20, 491]: use when six or more symptoms are present
c. Alternatives
i. If a young person received more than minimal exposure to alcohol at any time during gestation and subsequently experiences neurocognitive impairment, impaired self-regulation, and deficits in adaptive functioning, consider neurobehavioral disorder associated with prenatal alcohol exposure and other specified neurodevelopmental disorder [F88, 86]. The prenatal exposure results in symptoms beginning before age 18 years that result 146in clinically significant distress or functional impairment.
ii. If a young person experiences problems associated with the use of alcohol that are not classifiable as alcohol use disorder, alcohol intoxication, alcohol withdrawal, alcohol intoxication delirium, alcohol withdrawal delirium, alcohol-induced neurocognitive disorder, alcohol-induced psychotic disorder, alcohol-induced bipolar disorder, alcohol-induced depressive disorder, alcohol-induced anxiety disorder, alcohol-induced sexual dysfunction, or alcohol-induced sleep disorder, consider unspecified alcohol-related disorder [F10.99, 503].
2. Alcohol Intoxication [F10.x29, 497–499]
a. Inclusion: Requires at least one of the following signs or symptoms developing during, or shortly after, alcohol use.
i. Slurred speech
ii. Incoordination
iii. Unsteady gait
iv. Nystagmus
v. Impairment in attention or memory
vi. Stupor or coma
b. Inclusion: Requires clinically significant problematic behavioral or psychological changes. Since you began this episode of drinking, have you observed any significant changes in your behavior, mood, or judgment? Have you engaged in problematic activities or thought problematic thoughts that you would not have if you were sober?
c. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with another substance, do not use this diagnosis.
3. Alcohol Withdrawal [F10.23x, 499–501]
a. Inclusion: Requires at least two of the following symptoms developing within several hours to a few days of ceasing (or reducing) alcohol use that has been heavy and prolonged.
i. Autonomic hyperactivity
ii. Increased hand tremor
147iii. Insomnia: Over the last couple of days, have you found it more difficult than usual to get to sleep and to stay asleep?
iv. Nausea or vomiting: Over the last couple of days, have you felt sick to your stomach, felt nauseated, or even vomited?
v. Transient visual, tactile, or auditory hallucinations or illusions: Over the last couple of days, have you had any experiences where you worried that your mind was playing tricks on you, such as seeing, hearing, or feeling things that other people could not?
vi. Psychomotor agitation
vii. Anxiety: Over the last couple of days, have you felt more worried or anxious than usual?
viii. Generalized tonic-clonic seizures
b. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with or withdrawal from another substance, do not use this diagnosis.
c. Modifiers
i. Specifier
• With perceptual disturbances [F10.232, 500]
4. Caffeine Intoxication [F15.929, 503–506]
a. Inclusion: Requires clinically significant problematic behavioral or psychological changes shortly after caffeine ingestion, usually in excess of 250 mg (e.g., 2–3 cups of brewed coffee), as manifested by at least five of the following signs or symptoms.
i. Restlessness: Over the last several hours, have you felt less able to remain at rest than usual?
ii. Nervousness: Over the last several hours, have you felt more jittery or nervous than usual?
iii. Excitement: Over the last several hours, have you felt more excited than usual?
iv. Insomnia: Over the last several hours, if you tried to sleep, did you find it more difficult to get to sleep or stay asleep than usual?
v. Flushed face
vi. Diuresis: Over the last several hours, have you urinated more often or a greater amount than usual?
148vii. Gastrointestinal disturbance: Over the last several hours, have you experienced an upset stomach, nausea, vomiting, or diarrhea?
viii. Muscle twitching: Over the last several hours, have you noticed your muscles twitching more than usual?
ix. Rambling flow of thought and speech: Over the last several hours, have you or anyone else noticed that your thoughts or speech have been long winded or even confused?
x. Tachycardia or cardiac arrhythmia
xi. Periods of inexhaustibility: Over the last several hours, have you felt as if you had so much energy it could not be used up?
xii. Psychomotor agitation
b. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with another substance, do not use this diagnosis.
c. Alternative: If a person experiences problems associated with the use of caffeine that are not classifiable as caffeine intoxication, caffeine withdrawal, caffeine-induced anxiety disorder, or caffeine-induced sleep disorder, consider unspecified caffeine-related disorder [F15.99, 509].
5. Caffeine Withdrawal [F15.93, 506–508]
a. Inclusion: Requires at least three of the following symptoms developing within 24 hours of ceasing (or reducing) caffeine use that has been prolonged.
i. Headache: Over the last day, have you had any headaches?
ii. Marked fatigue or drowsiness: Over the last day, have you felt extremely tired or sleepy?
iii. Dysphoric or depressed mood or irritability: Over the last day, have you felt more down, more depressed, or even more irritable than usual?
iv. Difficulty concentrating: Over the last day, have you had difficulty staying focused on a task or an activity?
v. Flulike symptoms: Over the last day, have you experienced flulike symptoms, nausea, vomiting, or muscle pain or stiffness?
b. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with or withdrawal 149from another substance, do not use this diagnosis.
6. Cannabis Use Disorder [F12.x0, 509–516]
a. Inclusion: Requires a problematic pattern of cannabis use leading to clinically significant impairment or distress as manifested by at least two of the following in a 12-month period.
i. Consuming more cannabis over a longer period than intended: When you use cannabis, do you find that you use more, and for a longer time, than you planned to?
ii. Persistent desire or unsuccessful effort to reduce cannabis use: Do you want to cut back or stop using cannabis? Have you ever tried and failed to cut back or stop?
iii. Great deal of time spent: Do you spend a great deal of your time obtaining cannabis, using cannabis, or recovering from your cannabis use?
iv. Cravings: Do you experience strong desires or cravings to use cannabis?
v. Failure to fulfill major role obligations: Have you repeatedly failed to fulfill major obligations at home, school, or work because of your cannabis use?
vi. Continued use despite awareness of interpersonal or social problems: Do you use cannabis even though you suspect, or even know, that it creates or worsens interpersonal or social problems?
vii. Giving up activities for cannabis: Are there important social, occupational, or recreational activities that you have given up or reduced because of your cannabis use?
viii. Use in hazardous situations: Have you repeatedly used cannabis in situations in which it was physically hazardous, such as driving a car or operating a machine while intoxicated?
ix. Continued use despite awareness of physical or psychological problems: Do you use cannabis even though you suspect, or even know, that it creates or worsens problems with your mind and body?
x. Tolerance as manifested by either of the following.
• Markedly increased amounts: Do you find that in order to get high or achieve the desired effect of using cannabis, you need to smoke or ingest much more cannabis than you used to?
150• Markedly diminished effects: If you use the same amount of cannabis as you used to, do you find that it has a lot less effect on you than it used to?
xi. Withdrawal as manifested by either of the following.
• Characteristic cannabis withdrawal syndrome: When you stop using cannabis, do you undergo withdrawal?
• The same or related substance is taken to relieve or avoid withdrawal symptoms: Have you used cannabis or another substance to prevent yourself from withdrawing from cannabis?
b. Modifiers
i. Specifiers
• In early remission
• In sustained remission
• In a controlled environment
ii. Severity
• Mild [F12.10, 510]: use when two or three symptoms are present
• Moderate [F12.20, 510]: use when four or five symptoms are present
• Severe [F12.20, 510]: use when six or more symptoms are present
c. Alternative: If a young person experiences problems associated with the use of cannabis that are not classifiable as cannabis use disorder, cannabis intoxication, cannabis withdrawal, cannabis intoxication delirium, cannabis withdrawal delirium, cannabis-induced neurocognitive disorder, cannabis-induced psychotic disorder, cannabis-induced bipolar disorder, cannabis-induced depressive disorder, cannabis-induced anxiety disorder, cannabis-induced sexual dysfunction, or cannabis-induced sleep disorder, consider unspecified cannabis-related disorder [F12.99, 519].
7. Cannabis Intoxication [F12.x2x, 516–517]
a. Inclusion: Requires at least two of the following signs or symptoms shortly after cannabis use.
i. Conjunctival injection
ii. Increased appetite: Over the last several hours, have you been much hungrier than usual?
151iii. Dry mouth: Over the last several hours, have you noticed that your mouth has been dry?
iv. Tachycardia
b. Inclusion: Requires clinically significant problematic behavioral or psychological changes. Since you began this episode of cannabis use, have you observed any significant changes in your mood, judgment, ability to interact with others, or sense of time? Have you engaged in problematic activities, or thought problematic thoughts, that you would not have without cannabis?
c. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with another substance, do not use this diagnosis.
d. Modifiers
i. Specifier
• With perceptual disturbance [F12.x22, 516]
8. Cannabis Withdrawal [F12.288, 517–519]
a. Inclusion: Requires at least three of the following symptoms developing within 1 week of ceasing (or reducing) cannabis use that has been heavy and prolonged.
i. Irritability, anger, or aggression: Over the last week or so, have you felt more irritable or angry or that you were ready to confront or attack someone?
ii. Nervousness or anxiety: Over the last week or so, have you felt more worried or anxious than usual?
iii. Sleep difficulty: Over the last week or so, have you had any disturbing dreams or found it more difficult to get to sleep and to stay asleep than usual?
iv. Decreased appetite or weight loss: Over the last week or so, have you been less hungry or even lost weight?
v. Restlessness: Over the last week or so, have you felt less able to remain at rest than usual?
vi. Depressed mood: Over the last week or so, have you felt more down or depressed than usual?
vii. Somatic symptoms: Over the last week or so, have you felt any unusual physical discomfort, such as stomach pain, tremors, sweating, fever, chills, or headaches?
b. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another 152mental disorder, including intoxication with or withdrawal from another substance, do not use this diagnosis.
9. Phencyclidine or Other Hallucinogen Use Disorder [F16.x0, 520–527]
a. Inclusion: Requires a problematic pattern of phencyclidine or other hallucinogen use leading to clinically significant impairment or distress as manifested by at least two of the following in a 12-month period.
i. Using more phencyclidine or other hallucinogens over a longer period than intended: When you use hallucinogens, do you find that you use more, and for a longer time, than you planned to?
ii. Persistent desire or unsuccessful effort to reduce hallucinogen use: Do you want to cut back or stop using hallucinogens? Have you ever tried and failed to cut back or stop using hallucinogens?
iii. Great deal of time spent: Do you spend a great deal of your time obtaining hallucinogens, using hallucinogens, or recovering from your hallucinogen use?
iv. Cravings: Do you experience strong desires or cravings to use hallucinogens?
v. Failure to fulfill major role obligations: Have you repeatedly failed to fulfill major obligations at home, school, or work because of your hallucinogen use?
vi. Continued use despite awareness of interpersonal or social problems: Do you use hallucinogens even though you suspect, or even know, that your use creates or worsens interpersonal or social problems?
vii. Giving up activities for hallucinogens: Are there important social, occupational, or recreational activities that you have given up or reduced because of your hallucinogen use?
viii. Use in hazardous situations: Have you repeatedly used hallucinogens in situations in which it was physically hazardous, such as driving a car or operating a machine while intoxicated?
ix. Continued use despite awareness of physical or psychological problems: Do you use hallucinogens even though you suspect, or even know, that they create or worsen problems with your mind and body?
x. Tolerance as manifested by either of the following.
153• Markedly increased amounts: Do you find that in order to achieve the desired effect of hallucinogens, you need to consume much more than you used to?
• Markedly diminished effects: If you use the same amount of a hallucinogen as you used to, do you find that it has a lot less effect on you than it used to?
b. Modifiers
i. Specifiers
• In early remission
• In sustained remission
• In a controlled environment
ii. Severity
• Mild [F16.10, 521/524]: use when two or three symptoms are present
• Moderate [F16.20, 521/524]: use when four or five symptoms are present
• Severe [F16.20, 521/524]: use when six or more symptoms are present
c. Alternative: If a young person experiences problems associated with the use of phencyclidine or other hallucinogens that are not classifiable as phencyclidine or other hallucinogen use disorder, phencyclidine or other hallucinogen intoxication, phencyclidine or other hallucinogen withdrawal, phencyclidine or other hallucinogen intoxication delirium, phencyclidine or other hallucinogen withdrawal delirium, phencyclidine- or other hallucinogen-induced neurocognitive disorder, phencyclidine- or other hallucinogen-induced psychotic disorder, phencyclidine- or other hallucinogen-induced bipolar disorder, phencyclidine- or other hallucinogen-induced depressive disorder, phencyclidine- or other hallucinogen-induced anxiety disorder, phencyclidine- or other hallucinogen-induced sexual dysfunction, or phencyclidine- or other hallucinogen-induced sleep disorder, consider unspecified phencyclidine-related disorder or unspecified hallucinogen-related disorder [F16.99, 533].
10. Phencyclidine or Other Hallucinogen Intoxication [F16.x29, 527–530]
a. Inclusion: Requires at least two of the following signs during or shortly after hallucinogen use.
154Phencyclidine
i. Vertical or horizontal nystagmus
ii. Hypertension or tachycardia
iii. Numbness or diminished responsiveness to pain
iv. Ataxia
v. Dysarthria
vi. Muscle rigidity
vii. Seizures or coma
viii. Hyperacusis
Other Hallucinogens
i. Pupillary dilation
ii. Tachycardia
iii. Sweating: Since taking the hallucinogen, have you noticed any change in how much you sweat?
iv. Palpitations: Since taking the hallucinogen, has your heartbeat been more rapid, strong, or irregular than usual?
v. Blurring of vision: Since taking the hallucinogen, has your vision been blurred?
vi. Tremors
vii. Incoordination: Since taking the hallucinogen, have you found it hard to coordinate your movements as you walk or otherwise move?
b. Inclusion: Requires clinically significant problematic behavioral or psychological changes. Since you began this episode of hallucinogen use, have you observed any significant changes in your mood, judgment, ability to interact with others, or sense of time? Have you engaged in problematic activities, or thought problematic thoughts, that you would not have without hallucinogens?
c. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with another substance, do not use this diagnosis.
11. Inhalant Use Disorder [F18.x0, 533–538]
a. Inclusion: Requires a problematic pattern of inhalant use leading to clinically significant impairment or distress as manifested by at least two of the following in a 12-month period.
i. Using more inhalants over a longer period than intended: When you inhale, do you find that you use more inhalant, and for a longer time, than you planned to?
155ii. Persistent desire or unsuccessful effort to reduce inhalant use: Do you want to cut back or stop inhaling? Have you ever tried and failed to cut back or stop inhaling?
iii. Great deal of time spent: Do you spend a great deal of your time obtaining inhalants, using inhalants, or recovering from your inhalant use?
iv. Cravings: Do you experience strong desires or cravings to use inhalants?
v. Failure to fulfill major role obligations: Have you repeatedly failed to fulfill major obligations at home, school, or work because of your inhalant use?
vi. Continued use despite awareness of interpersonal or social problems: Do you use inhalants even though you suspect, or even know, that your use creates or worsens interpersonal or social problems?
vii. Giving up activities for inhalants: Are there important social, occupational, or recreational activities that you have given up or reduced because of your inhalant use?
viii. Use in hazardous situations: Have you repeatedly used inhalants in situations in which it was physically hazardous, such as driving a car or operating a machine while high?
ix. Continued use despite awareness of physical or psychological problems: Do you use inhalants even though you suspect, or even know, that it creates or worsens problems with your mind and body?
x. Tolerance as manifested by either of the following.
• Markedly increased amounts: Do you find that in order to get high or achieve the desired effect of using inhalants, you need to use much more than you used to?
• Markedly diminished effects: If you inhale the same amount of an inhalant as you used to, do you find that it has a lot less effect on you than it used to?
b. Modifiers
i. Specifiers
• In early remission
• In sustained remission
• In a controlled environment
ii. Severity
• Mild [F18.10, 534]: use when two or three symptoms are present
156• Moderate [F18.20, 534]: use when four or five symptoms are present
• Severe [F18.20, 534]: use when six or more symptoms are present
c. Alternative: If a young person experiences problems associated with the use of an inhalant that are not classifiable as inhalant use disorder, inhalant intoxication, inhalant withdrawal, inhalant intoxication delirium, inhalant withdrawal delirium, inhalant-induced neurocognitive disorder, inhalant-induced psychotic disorder, inhalant-induced bipolar disorder, inhalant-induced depressive disorder, inhalant-induced anxiety disorder, inhalant-induced sexual dysfunction, or inhalant-induced sleep disorder, consider unspecified inhalant-related disorder [F18.99, 540].
12. Inhalant Intoxication [F18.x29, 538–540]
a. Inclusion: Requires at least two of the following signs or symptoms after intended or unintended short-term, high-dose inhalant exposure.
i. Dizziness: Since using the inhalant, have you felt like you were reeling or about to fall?
ii. Nystagmus
iii. Incoordination: Since using the inhalant, have you found it hard to coordinate your movements as you walk or otherwise move?
iv. Slurred speech
v. Unsteady gait
vi. Lethargy: Since using the inhalant, have you felt very sleepy or a marked lack of energy?
vii. Depressed reflexes
viii. Psychomotor retardation
ix. Tremor
x. Generalized muscle weakness
xi. Blurred vision or diplopia: Since using the inhalant, has your vision been blurred, or have you been seeing double?
xii. Stupor or coma
xiii. Euphoria: Since using the inhalant, have you felt mentally or physically elated or intensely excited or happy?
b. Inclusion: Requires clinically significant problematic behavioral or psychological changes. Since you began this episode of inhalant use, have you observed any significant 157changes in your mood, judgment, ability to interact with others, or sense of time? Have you engaged in problematic activities, or thought problematic thoughts, that you would not have without inhalants?
c. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with another substance, do not use this diagnosis.
13. Opioid Use Disorder [F11.x0, 541–546]
a. Inclusion: Requires a maladaptive pattern of opioid use leading to clinically significant impairment or distress as manifested by at least two of the following in a 12-month period.
i. Using more opioids over a longer period than intended: When you use opioids, do you find that you use more, and for a longer time, than you planned to?
ii. Persistent desire or unsuccessful effort to reduce opioid use: Do you want to cut back or stop using opioids? Have you ever tried and failed to cut back or stop your opioid use?
iii. Great deal of time spent: Do you spend a great deal of your time obtaining opioids, using opioids, or recovering from your opioid use?
iv. Cravings: Do you experience strong desires or cravings to use opioids?
v. Failure to fulfill major role obligations: Have you repeatedly failed to fulfill major obligations at home, school, or work because of your opioid use?
vi. Continued use despite awareness of interpersonal or social problems: Do you continue to use opioids even though you suspect, or even know, that your use creates or worsens interpersonal or social problems?
vii. Giving up activities for opioids: Are there important social, occupational, or recreational activities that you have given up or reduced because of your opioid use?
viii. Use in hazardous situations: Have you repeatedly used opioids in situations in which it was physically hazardous, such as driving a car or operating a machine while intoxicated?
ix. Continued use despite awareness of physical or psychological problems: Do you use opioids even though you suspect, or even know, that it creates or worsens problems with your mind and body?
158x. Tolerance as manifested by either of the following.
• Markedly increased amounts: Do you find that in order to get high or achieve the desired effect of using opioids, you need to consume much more than you used to?
• Markedly diminished effects (excluding opioid medications taken under medical supervision): If you use the same amount of an opioid as you used to, do you find that it has a lot less effect on you than it used to?
xi. Withdrawal as manifested by either of the following.
• Characteristic opioid withdrawal syndrome: When you stop using opioids, do you undergo withdrawal?
• The same or closely related substance is taken to relieve or avoid withdrawal symptoms: Have you ever taken opioids or another substance to prevent opioid withdrawal?
b. Modifiers
i. Specifiers
• In early remission
• In sustained remission
• On maintenance therapy
• In a controlled environment
ii. Severity
• Mild [F11.10, 542]: use when two or three symptoms are present
• Moderate [F11.20, 542]: use when four or five symptoms are present
• Severe [F11.20, 542]: use when six or more symptoms are present
c. Alternative: If a young person experiences problems associated with the use of opioids that are not classifiable as opioid use disorder, opioid intoxication, opioid withdrawal, opioid intoxication delirium, opioid withdrawal delirium, opioid-induced neurocognitive disorder, opioid-induced psychotic disorder, opioid-induced bipolar disorder, opioid-induced depressive disorder, opioid-induced anxiety disorder, 159opioid-induced sexual dysfunction, or opioid-induced sleep disorder, consider unspecified opioid-related disorder [F11.99, 550].
14. Opioid Intoxication [F11.x2x, 546–547]
a. Inclusion: Requires pupillary constriction shortly after opioid use and at least one of the following signs.
i. Drowsiness or coma
ii. Slurred speech
iii. Impairment in attention or memory
b. Inclusion: Requires clinically significant problematic behavioral or psychological changes. Since you began this episode of opioid use, have you observed any significant changes in your mood, judgment, ability to interact with others, or sense of time? Have you engaged in problematic activities, or thought problematic thoughts, that you would not have without opioids?
c. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with another substance, do not use this diagnosis.
d. Modifiers
i. Specifier
• With perceptual disturbance [F11.x22, 546–547]
15. Opioid Withdrawal [F11.23, 547–549]
a. Inclusion: Requires at least three of the following symptoms developing within minutes to several days of ceasing (or reducing) opioid use that has been heavy and prolonged OR following the administration of an opioid antagonist after a period of opioid use.
i. Dysphoric mood: Over the last couple of days, have you been feeling more down or depressed than usual?
ii. Nausea or vomiting: Over the last couple of days, have you felt sick to your stomach, felt nauseated, or even vomited?
iii. Muscle aches: Over the last couple of days, have you experienced muscle aches or pains?
iv. Lacrimation or rhinorrhea: Over the last couple of days, have you noticed that you have been shedding tears when you did not feel like crying? Have you noticed 160that your nose has been running, or discharging clear fluid, more than usual?
v. Pupillary dilation, piloerection, or sweating
vi. Diarrhea: Over the last couple of days, have you experienced more frequent or more liquid stools than usual?
vii. Yawning: Over the last couple of days, have you been yawning much more than usual?
viii. Fever
ix. Insomnia: Over the last couple of days, have you found it more difficult than usual to get to sleep and to stay asleep?
b. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with or withdrawal from another substance, do not use this diagnosis.
16. Sedative, Hypnotic, or Anxiolytic Use Disorder [F13.x0, 550–556]
a. Inclusion: Requires a problematic pattern of sedative, hypnotic, or anxiolytic use leading to clinically significant impairment or distress as manifested by at least two of the following in a 12-month period.
i. Using more sedatives, hypnotics, or anxiolytics over a longer period than intended: When you use sedatives, hypnotics, or anxiolytics, do you find that you use more, and for a longer time, than you planned to?
ii. Persistent desire or unsuccessful effort to reduce sedative, hypnotic, or anxiolytic use: Do you want to cut back or stop using sedatives, hypnotics, or anxiolytics? Have you ever tried and failed to cut back or stop using sedatives, hypnotics, or anxiolytics?
iii. Great deal of time spent: Do you spend a great deal of your time obtaining and using sedatives, hypnotics, or anxiolytics or recovering from your sedative, hypnotic, or anxiolytic use?
iv. Cravings: Do you experience strong desires or cravings to use sedatives, hypnotics, or anxiolytics?
v. Failure to fulfill major role obligations: Have you repeatedly failed to fulfill major obligations at home, school, or work because of your sedative, hypnotic, or anxiolytic use?
vi. Continued use despite awareness of interpersonal or social problems: Do you use a sedative, hypnotic, or 161anxiolytic even though you suspect, or even know, that it creates or worsens interpersonal or social problems?
vii. Giving up activities for sedatives, hypnotics, or anxiolytics: Are there important social, occupational, or recreational activities that you have given up or reduced because of your sedative, hypnotic, or anxiolytic use?
viii. Use in hazardous situations: Have you repeatedly used a sedative, hypnotic, or anxiolytic in situations in which it was physically hazardous, such as driving a car or operating a machine while intoxicated?
ix. Continued use despite awareness of physical or psychological problems: Do you use sedatives, hypnotics, or anxiolytics even though you suspect, or even know, that your use creates or worsens problems with your mind and body?
x. Tolerance as manifested by either of the following.
• Markedly increased amounts: Do you find that in order to get intoxicated or achieve the desired effect of using sedatives, hypnotics, or anxiolytics, you need to consume much more than you used to?
• Markedly diminished effects: If you use the same amount of a sedative, hypnotic, or anxiolytic as you used to, do you find that it has a lot less effect on you than it used to?
xi. Withdrawal as manifested by either of the following.
• Characteristic sedative, hypnotic, or anxiolytic withdrawal syndrome: When you stop using sedatives, hypnotics, or anxiolytics, do you undergo withdrawal?
• The same or closely related substance is taken to relieve or avoid withdrawal symptoms: Have you ever taken sedatives, hypnotics, anxiolytics, or another substance to prevent withdrawal?
b. Modifiers
i. Specifiers
• In early remission
• In sustained remission
• In a controlled environment
ii. Severity
• Mild [F13.10, 552]: use when two or three symptoms are present
162• Moderate [F13.20, 552]: use when four or five symptoms are present
• Severe [F13.20, 552]: use when six or more symptoms are present
c. Alternative: If a young person experiences problems associated with the use of a sedative, hypnotic, or anxiolytic that are not classifiable as sedative, hypnotic, or anxiolytic use disorder; sedative, hypnotic, or anxiolytic intoxication; sedative, hypnotic, or anxiolytic withdrawal; sedative, hypnotic, or anxiolytic intoxication delirium; sedative, hypnotic, or anxiolytic withdrawal delirium; sedative-, hypnotic-, or anxiolytic-induced neurocognitive disorder; sedative-, hypnotic-, or anxiolytic-induced psychotic disorder; sedative-, hypnotic-, or anxiolytic-induced bipolar disorder; sedative-, hypnotic-, or anxiolytic-induced depressive disorder; sedative-, hypnotic-, or anxiolytic-induced anxiety disorder; sedative-, hypnotic-, or anxiolytic-induced sexual dysfunction; or sedative-, hypnotic-, or anxiolytic-induced sleep disorder, consider unspecified sedative-, hypnotic-, or anxiolytic-related disorder [F13.99, 560].
17. Sedative, Hypnotic, or Anxiolytic Intoxication [F13.x29, 556–557]
a. Inclusion: Requires one of the following signs shortly after sedative, hypnotic, or anxiolytic use.
i. Slurred speech
ii. Incoordination
iii. Unsteady gait
iv. Nystagmus
v. Impairment in cognition (i.e., attention or memory)
vi. Stupor or coma
b. Inclusion: Requires clinically significant problematic behavioral or psychological changes. Since you began this episode of sedative, hypnotic, or anxiolytic use, have you observed any significant changes in your mood, judgment, ability to interact with others, or sense of time? Have you engaged in problematic activities, or thought problematic thoughts, that you would not have without the sedative, hypnotic, or anxiolytic?
c. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another 163mental disorder, including intoxication with another substance, do not use this diagnosis.
18. Sedative, Hypnotic, or Anxiolytic Withdrawal [F13.23x, 557–560]
a. Inclusion: Requires at least two of the following symptoms developing within several hours to a few days after ceasing (or reducing) sedative, hypnotic, or anxiolytic use that has been heavy and prolonged.
i. Autonomic hyperactivity
ii. Hand tremor
iii. Insomnia: Over the last couple of days, have you found it more difficult than usual to get to sleep and to stay asleep?
iv. Nausea or vomiting: Over the last couple of days, have you felt sick to your stomach, felt nauseated, or even vomited?
v. Transient visual, tactile, or auditory hallucinations or illusions: Over the last couple of days, have you had any experiences where you worried that your mind was playing tricks on you, like seeing, hearing, or feeling things that other people could not?
vi. Psychomotor agitation
vii. Anxiety: Over the last couple of days, have you felt more worried or anxious than usual?
viii. Grand mal seizures
b. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with or withdrawal from another substance, do not use this diagnosis.
c. Modifiers
i. Specifier
• With perceptual disturbances [F13.232, 558]
19. Stimulant Use Disorder [F1x.x0, 561–567]
a. Inclusion: Requires a problematic pattern of stimulant use leading to clinically significant impairment or distress as manifested by at least two of the following in a 12-month period.
i. Using more stimulants over a longer period than intended: When you use stimulants, do you find that you use more, and for a longer time, than you planned to?
164ii. Persistent desire or unsuccessful effort to reduce stimulant use: Do you want to cut back or stop using stimulants? Have you ever tried and failed to cut back or stop using stimulants?
iii. Great deal of time spent: Do you spend a great deal of your time obtaining stimulants, using stimulants, or recovering from your stimulant use?
iv. Cravings: Do you experience strong desires or cravings to use stimulants?
v. Failure to fulfill major role obligations: Have you repeatedly failed to fulfill major obligations at home, school, or work because of your stimulant use?
vi. Continued use despite awareness of interpersonal or social problems: Do you use stimulants even though you suspect, or even know, that your use creates or worsens interpersonal or social problems?
vii. Giving up activities for stimulants: Are there important social, occupational, or recreational activities that you have given up or reduced because of your stimulant use?
viii. Use in hazardous situations: Have you repeatedly used stimulants in situations in which it was physically hazardous, such as driving a car or operating a machine while intoxicated?
ix. Continued use despite awareness of physical or psychological problems: Do you use stimulants even though you suspect, or even know, that it creates or worsens problems with your mind and body?
x. Tolerance as manifested by either of the following. Note: This criterion is not met if taking stimulants as prescribed under medical supervision.
• Markedly increased amounts: Do you find that in order to get intoxicated or achieve the desired effect of using stimulants, you need to consume much more than you used to?
• Markedly diminished effects (excluding stimulant medications taken under medical supervision to treat attention-deficit/hyperactivity disorder or narcolepsy): If you use the same amount of a stimulant as you used to, do you find that it has a lot less effect on you than it used to?
xi. Withdrawal as manifested by either of the following. Note: This criterion is not met if taking stimulants as prescribed under medical supervision.
165• Characteristic stimulant withdrawal syndrome: When you stop using stimulants, do you undergo withdrawal?
• The same or a closely related substance is taken to relieve or avoid withdrawal symptoms (excluding stimulant medications taken under medical supervision to treat attention-deficit/hyperactivity disorder or narcolepsy): Have you ever taken stimulants or another substance to prevent withdrawal?
b. Modifiers
i. Specify stimulant
• Amphetamine-type substance
• Cocaine
• Other or unspecified stimulant
ii. Specifiers
• In early remission
• In sustained remission
• In a controlled environment
iii. Severity
• Mild [F1x.10, 562]: use when two or three symptoms are present
• Moderate [F1x.20, 562]: use when four or five symptoms are present
• Severe [F1x.20, 562]: use when six or more symptoms are present
c. Alternative: If a young person experiences problems associated with the use of stimulants that are not classifiable as stimulant use disorder, stimulant intoxication, stimulant withdrawal, stimulant intoxication delirium, stimulant withdrawal delirium, stimulant-induced neurocognitive disorder, stimulant-induced psychotic disorder, stimulant-induced bipolar disorder, stimulant-induced depressive disorder, stimulant-induced anxiety disorder, stimulant-induced sexual dysfunction, or stimulant-induced sleep disorder, consider unspecified stimulant-related disorder [F1x.99, 570].
20. Stimulant Intoxication [F1x.x2x, 567–569]
a. Inclusion: Requires at least two of the following signs shortly after stimulant use.
166i. Tachycardia or bradycardia
ii. Pupillary dilation
iii. Elevated or lowered blood pressure
iv. Perspiration or chills: Over the last couple of hours, have you experienced chills or been sweating more than usual?
v. Nausea or vomiting: Over the last couple of hours, have you felt sick to your stomach, felt nauseated, or even vomited?
vi. Evidence of weight loss
vii. Psychomotor agitation or retardation
viii. Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias
ix. Confusion, seizures, dyskinesias, dystonias, or coma
b. Inclusion: Requires clinically significant problematic behavioral or psychological changes. Since you began this episode of stimulant use, have you observed any significant changes in your mood, judgment, ability to interact with others, or sense of time? Have you engaged in problematic activities, or thought problematic thoughts, that you would not have without stimulants?
c. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with another substance, do not use this diagnosis.
d. Modifiers
i. Specifiers
• Specify the intoxicant: amphetamine, cocaine, or other stimulant
• With perceptual disturbances [F1x.x29, 567]
21. Stimulant Withdrawal [F1x.23, 569–570]
a. Inclusion: Requires the following symptom, developing within hours to days of ceasing (or reducing) stimulant use that has been heavy or prolonged.
i. Dysphoric mood: Over the last few hours or days, have you felt much more down or depressed than usual?
b. Inclusion: Also requires at least two of the following symptoms developing simultaneously.
167i. Fatigue: Over the last few hours or days, have you felt extremely sleepy or tired?
ii. Vivid, unpleasant dreams: Over the last few hours or days, have you experienced unusually vivid, unpleasant dreams?
iii. Insomnia or hypersomnia: Over the last few hours or days, have you found it more difficult than usual to get to sleep and to stay asleep? Alternatively, have you found that you have been sleeping much more than usual?
iv. Increased appetite: Over the last few hours or days, have you desired food much more than usual?
v. Psychomotor retardation or agitation
c. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with or withdrawal from another substance, do not use this diagnosis.
d. Modifiers
i. Specifiers
• Specify the intoxicant: amphetamine, cocaine, or other stimulant
22. Tobacco Use Disorder [xxx.x, 571–574]
a. Inclusion: Requires a problematic pattern of tobacco use leading to clinically significant impairment or distress as manifested by at least two of the following in a 12-month period.
i. Using more tobacco over a longer period than intended: When you use tobacco, do you find that you use more, and for a longer time, than you planned to?
ii. Persistent desire or unsuccessful effort to reduce tobacco use: Do you want to cut back or stop using tobacco? Have you ever tried and failed to cut back or stop using tobacco?
iii. Great deal of time spent: Do you spend a great deal of your time obtaining tobacco, using tobacco, or recovering from your tobacco use?
iv. Cravings: Do you experience strong desires or cravings to use tobacco?
v. Failure to fulfill major role obligations: Have you repeatedly failed to fulfill major obligations at home, school, or work because of your tobacco use?
168vi. Continued use despite awareness of interpersonal or social problems: Do you use tobacco even though you suspect, or even know, that your use creates or worsens interpersonal or social problems?
vii. Giving up activities for tobacco: Are there important social, occupational, or recreational activities that you have given up or reduced because of your tobacco use?
viii. Use in hazardous situations: Have you repeatedly used tobacco in situations in which it was physically hazardous, such as smoking in bed?
ix. Continued use despite awareness of physical or psychological problems: Do you use tobacco even though you suspect, or even know, that it creates or worsens problems with your mind and body?
x. Tolerance as manifested by either of the following.
• Markedly increased amounts: Do you find that in order to get the desired effect of tobacco, you need to consume much more than you used to?
• Markedly diminished effects: If you use the same amount of tobacco as you used to, do you find that it has a lot less effect on you than it used to?
xi. Withdrawal as manifested by either of the following.
• Characteristic tobacco withdrawal syndrome: When you stop using tobacco, do you undergo withdrawal?
• The same substance is taken to relieve or avoid withdrawal symptoms: Have you ever used tobacco to avoid or relieve symptoms of tobacco withdrawal?
b. Modifiers
i. Specifiers
• In early remission
• In sustained remission
• On maintenance therapy
• In a controlled environment
ii. Severity
• Mild [Z72.0, 572]: use when two or three symptoms are present
• Moderate [F17.200, 572]: use when four or five symptoms are present
• Severe [F17.200, 572]: use when six or more symptoms are present
169c. Alternatives: If a young person experiences clinically significant problems associated with the use of tobacco that do not meet criteria for a specific diagnosis, consider unspecified tobacco-related disorder [F17.209, 577].
23. Tobacco Withdrawal [F17.203, 575–576]
a. Inclusion: Requires at least four of the following symptoms developing within 24 hours of ceasing (or reducing) tobacco use that has been daily for at least several weeks.
i. Irritability, frustration, or anger: Over the last 24 hours, have you felt more irritable, frustrated, or angry than usual?
ii. Anxiety: Over the last 24 hours, have you felt more worried or anxious than usual?
iii. Difficulty concentrating: Over the last 24 hours, have you had difficulty staying focused on a task or an activity?
iv. Increased appetite: Over the last 24 hours, have you desired food more than usual?
v. Restlessness: Over the last 24 hours, have you felt less able to remain at rest than usual?
vi. Depressed mood: Over the last 24 hours, have you been feeling more down or depressed than usual?
vii. Insomnia: Over the last 24 hours, have you found it more difficult than usual to get to sleep and to stay asleep?
b. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with or withdrawal from another substance, do not use this diagnosis.
24. Other (or Unknown) Substance Use Disorder [F19.x0, 577–580]
a. Inclusion: Requires a problematic pattern of use of an intoxicating substance not able to be classified within the other substance categories listed earlier, leading to clinically significant impairment or distress as manifested by at least two of the following in a 12-month period.
i. Taking more of the substance over a longer period than intended: When you use the substance, do you 170find that you use it more often, or for a longer time, than you planned to?
ii. Persistent desire or unsuccessful effort to reduce substance use: Do you want to cut back or stop using the substance? Have you ever tried and failed to cut back or stop using the substance?
iii. Great deal of time spent: Do you spend a great deal of your time obtaining or using the substance or recovering from your substance use?
iv. Cravings: Do you experience strong desires or cravings to use the substance?
v. Failure to fulfill major role obligations: Have you repeatedly failed to fulfill major obligations at home, school, or work because of your substance use?
vi. Continued use despite awareness of interpersonal or social problems: Do you use the substance even though you suspect, or even know, that it creates or worsens interpersonal or social problems?
vii. Giving up activities for the substance: Are there important social, occupational, or recreational activities that you have given up or reduced because of your substance use?
viii. Use in hazardous situations: Have you repeatedly used the substance in situations in which it was physically hazardous, such as driving a car or operating a machine while intoxicated?
ix. Continued use despite awareness of physical or psychological problems: Do you use the substance even though you suspect, or even know, that it creates or worsens problems with your mind and body?
x. Tolerance as manifested by either of the following.
• Markedly increased amounts: Do you find that in order to get intoxicated or achieve the desired effect of substance use, you need to consume much more of the substance than you used to?
• Markedly diminished effects: If you use the same amount of the substance as you used to, do you find that it has a lot less effect on you than it used to?
xi. Withdrawal as manifested by either of the following.
• Characteristic withdrawal syndrome for the substance: When you stop using the substance, do you undergo withdrawal?
• The same or a closely related substance is taken to relieve or avoid withdrawal symptoms: Have 171you ever taken the substance or another substance to prevent withdrawal?
b. Modifiers
i. Specifiers
• In early remission
• In sustained remission
• In a controlled environment
ii. Severity
• Mild [F19.10, 578]: use when two or three symptoms are present
• Moderate [F19.20, 578]: use when four or five symptoms are present
• Severe [F19.20, 578]: use when six or more symptoms are present
25. Other (or Unknown) Substance Intoxication [F19.x29, 581–582]
a. Inclusion: Development of a reversible substance-specific syndrome attributable to recent ingestion of (or exposure to) a substance that is not listed elsewhere or is unknown.
b. Inclusion: Requires clinically significant problematic behavioral or psychological changes. Since you began using this substance, have you observed any significant changes in your mood, judgment, ability to interact with others, or sense of time? Have you engaged in problematic activities, or thought problematic thoughts, that you would not have without using this substance?
c. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another mental disorder, including intoxication with another substance, do not use this diagnosis.
26. Other (or Unknown) Substance Withdrawal [F19.239, 583–584]
a. Inclusion: Development of a substance-specific syndrome shortly after the cessation of (or reduction in) use of the substance that has been heavy and prolonged.
b. Inclusion: Requires clinically significant distress or impairment in social, occupational, or other important areas of functioning.
c. Exclusion: If the symptoms are attributable to another medical condition or are better explained by another 172mental disorder, including withdrawal from another substance, do not use this diagnosis.
27. Gambling Disorder [F63.0, 585–589]
a. Inclusion: Requires persistent, recurrent problematic gambling that leads to clinically significant impairment or distress, lasting at least 12 months, as indicated by at least four of the following symptoms.
i. Escalates spending on gambling: Do you find that it takes increasing amounts of money to get the excitement you want from gambling?
ii. Is irritable when quitting: When you try to reduce or quit gambling, are you irritable or restless?
iii. Is unable to quit: Have you unsuccessfully tried to reduce or quit gambling on several occasions?
iv. Is preoccupied: Are you preoccupied with gambling?
v. Gambles when distressed: When you are feeling anxious, down, or helpless, do you gamble?
vi. Chases losses: After you lose money, do you return another day to try to get even?
vii. Lies: Do you lie to conceal how much you gamble?
viii. Loses relationships: Have you lost a relationship, job, or opportunity because of your gambling?
ix. Borrows money: Do you have to rely on other people for money to cover desperate financial situations caused by gambling?
b. Exclusion: If the gambling behavior is better accounted for by a manic episode, do not use this diagnosis.
c. Modifiers
i. Course
• Episodic: Meeting diagnostic criteria at more than one time point, with symptoms subsiding between periods of gambling disorder for at least several months
• Persistent: Experiencing continuous symptoms to meet diagnostic criteria for multiple years
• In early remission
• In sustained remission
ii. Severity
• Mild: use when four or five symptoms are present
173• Moderate: use when six or seven symptoms are present
• Severe: use when eight or nine symptoms are present
DSM-5 pp. 715–727
DSM-5 includes other conditions and problems that may be a focus of clinical attention or that may otherwise affect the diagnosis, course, prognosis, or treatment of a patient’s mental disorder. These conditions and problems include, but are not limited to, the psychosocial and environmental problems that were coded on Axis IV in DSM-IV-TR (American Psychiatric Association 2000). The authors of DSM-5 provide a selected list of conditions and problems drawn from ICD-10-CM (usually Z codes). A condition or problem listed in the ICD-10 Z codes listed in Chapter 11, “Rating Scales and Alternative Diagnostic Systems,” Table 11–3, may be coded if it is a reason for the current visit or helps to explain the need for a test, procedure, or treatment.
Conditions and problems from this list also may 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 section are not mental disorders. Their inclusion in DSM-5 is meant to draw attention to the scope of additional issues that are encountered in routine clinical practice and to provide a systematic listing that may be useful to clinicians in documenting these issues.
We include some commonly used codes in Chapter 11, “Rating Scales and Alternative Diagnostic Systems.” 174