Changes made to DSM-5 diagnostic criteria and texts are outlined in this chapter in the same order in which they appear in the DSM-5 classification. This abbreviated description is intended to orient readers to only the most significant changes in each disorder category. An expanded description of nearly all changes (e.g., except minor text or wording changes needed for clarity) is available online (www.psychiatry.org/dsm5). It should also be noted that Section I contains a description of changes pertaining to the chapter organization in DSM-5, the multiaxial system, and the introduction of dimensional assessments.
Neurodevelopmental Disorders
The term mental retardation was used in DSM-IV. However, intellectual disability (intellectual developmental disorder) is the term that has come into common use over the past two decades among medical, educational, and other professionals, and by the lay public and advocacy groups. Diagnostic criteria emphasize the need for an assessment of both cognitive capacity (IQ) and adaptive functioning. Severity is determined by adaptive functioning rather than IQ score.
The communication disorders, which are newly named from DSM-IV phonological disorder and stuttering, respectively, include language disorder (which combines the previous expressive and mixed receptive-expressive language disorders), speech sound disorder (previously phonological disorder), and childhood-onset fluency disorder (previously stuttering). Also included is social (pragmatic) communication disorder, a new condition involving persistent difficulties in the social uses of verbal and nonverbal communication.
Autism spectrum disorder is a new DSM-5 disorder encompassing the previous DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, Rett’s disorder, and pervasive developmental disorder not otherwise specified. It is characterized by deficits in two core domains: 1) deficits in social communication and social interaction and 2) restricted repetitive patterns of behavior, interests, and activities.
Several changes have been made to the diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD). Examples have been added to the criterion items to facilitate application across the life span; the age at onset description has been changed (from “some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years” to “Several inattentive or hyperactive-impulsive symptoms were present prior to age 12”); subtypes have been replaced with presentation specifiers that map directly to the prior subtypes; a comorbid diagnosis with autism spectrum disorder is now allowed; and a symptom threshold change has been made for adults, to reflect the substantial evidence of clinically significant ADHD impairment, with the cutoff for ADHD of five symptoms, instead of six required for younger persons, both for inattention and for hyperactivity and impulsivity.
Specific learning disorder combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Learning deficits in the areas of reading, written expression, and mathematics are coded as separate specifiers. Acknowledgment is made in the text that specific types of reading deficits are described internationally in various ways as dyslexia and specific types of mathematics deficits as dyscalculia.
The following motor disorders are included in DSM-5: developmental coordination disorder, stereotypic movement disorder, Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder. The tic criteria have been standardized across all of these disorders in this chapter.
Schizophrenia Spectrum and Other Psychotic Disorders
Two changes were made to Criterion A for schizophrenia: 1) the elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing), leading to the requirement of at least two Criterion A symptoms for any diagnosis of schizophrenia, and 2) the addition of the requirement that at least one of the Criterion A symptoms must be delusions, hallucinations, or disorganized speech. The DSM-IV subtypes of schizophrenia were eliminated due to their limited diagnostic stability, low reliability, and poor validity. Instead, a dimensional approach to rating severity for the core symptoms of schizophrenia is included in DSM-5 Section III to capture the important heterogeneity in symptom type and severity expressed across individuals with psychotic disorders. Schizoaffective disorder is reconceptualized as a longitudinal instead of a cross-sectional diagnosis—more comparable to schizophrenia, bipolar disorder, and major depressive disorder, which are bridged by this condition—and requires that a major mood episode be present for a majority of the total disorder’s duration after Criterion A has been met. Criterion A for delusional disorder no longer has the requirement that the delusions must be nonbizarre; a specifier is now included for bizarre type delusions to provide continuity with DSM-IV. Criteria for catatonia are described uniformly across DSM-5. Furthermore, catatonia may be diagnosed with a specifier (for depressive, bipolar, and psychotic disorders, including schizophrenia), in the context of a known medical condition, or as an other specified diagnosis.
Bipolar and Related Disorders
Diagnostic criteria for bipolar disorders now include both changes in mood and changes in activity or energy. The DSM-IV diagnosis of bipolar I disorder, mixed episodes—requiring that the individual simultaneously meet full criteria for both mania and major depressive episode—is replaced with a new specifier “with mixed features.” Particular conditions can now be diagnosed under other specified bipolar and related disorder, including categorization for individuals with a past history of a major depressive disorder whose symptoms meet all criteria for hypomania except the duration criterion is not met (i.e., the episode lasts only 2 or 3 days instead of the required 4 consecutive days or more). A second condition constituting an other specified bipolar and related disorder variant is that too few symptoms of hypomania are present to meet criteria for the full bipolar II syndrome, although the duration, at least 4 consecutive days, is sufficient. Finally, in both this chapter and in the chapter “Depressive Disorders,” an anxious distress specifier is delineated.
Depressive Disorders
To address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is included for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol. Premenstrual dysphoric disorder is now promoted from Appendix B, “Criteria Sets and Axes Provided for Further Study,” in DSM-IV to the main body of DSM-5. What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive disorder, which includes both chronic major depressive disorder and the previous dysthymic disorder. The coexistence within a major depressive episode of at least three manic symptoms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier “with mixed features.” In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons, including the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss, and can add an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer medical health, and worse interpersonal and work functioning. It was critical to remove the implication that bereavement typically lasts only 2 months, when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. A detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive disorder. Finally, a new specifier to indicate the presence of mixed symptoms has been added across both the bipolar and the depressive disorders.
Anxiety Disorders
The chapter on anxiety disorders no longer includes obsessive-compulsive disorder (which is in the new chapter “Obsessive-Compulsive and Related Disorders”) or posttraumatic stress disorder (PTSD) and acute stress disorder (which are in the new chapter “Trauma- and Stressor-Related Disorders”). Changes in criteria for specific phobia and social anxiety disorder (social phobia) include deletion of the requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable. Instead, the anxiety must be out of proportion to the actual danger or threat in the situation, after cultural contextual factors are taken into account. In addition, the 6-month duration is now extended to all ages. Panic attacks can now be listed as a specifier that is applicable to all DSM-5 disorders. Panic disorder and agoraphobia are unlinked in DSM-5. Thus, the former DSM-IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses, panic disorder and agoraphobia, each with separate criteria. The “generalized” specifier for social anxiety disorder has been deleted and replaced with a “performance only” specifier. Separation anxiety disorder and selective mutism are now classified as anxiety disorders. The wording of the criteria is modified to more adequately represent the expression of separation anxiety symptoms in adulthood. Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that onset must be before age 18 years, and a duration statement—“typically lasting for 6 months or more”—has been added for adults to minimize overdiagnosis of transient fears.
Obsessive-Compulsive and Related Disorders
The chapter “Obsessive-Compulsive and Related Disorders” is new in DSM-5. New disorders include hoarding disorder, excoriation (skin-picking) disorder, substance/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. The DSM-IV diagnosis of trichotillomania is now termed trichotillomania (hair-pulling disorder) and has been moved from a DSM-IV classification of impulse-control disorders not elsewhere classified to obsessive-compulsive and related disorders in DSM-5. The DSM-IV “with poor insight” specifier for obsessive-compulsive disorder has been refined to allow a distinction between individuals with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compulsive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). Analogous “insight” specifiers have been included for body dysmorphic disorder and hoarding disorder. A “tic-related” specifier for obsessive-compulsive disorder has also been added, because presence of a comorbid tic disorder may have important clinical implications. A “muscle dysmorphia” specifier for body dysmorphic disorder is added to reflect a growing literature on the diagnostic validity and clinical utility of making this distinction in individuals with body dysmorphic disorder. The delusional variant of body dysmorphic disorder (which identifies individuals who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delusional disorder, somatic type, and body dysmorphic disorder; in DSM-5, this presentation is designated only as body dysmorphic disorder with the absent insight/delusional specifier. Individuals can also be diagnosed with other specified obsessive-compulsive and related disorder, which can include conditions such as body-focused repetitive behavior disorder and obsessional jealousy, or unspecified obsessive-compulsive and related disorder.
Trauma- and Stressor-Related Disorders
For a diagnosis of acute stress disorder, qualifying traumatic events are now explicit as to whether they were experienced directly, witnessed, or experienced indirectly. Also, the DSM-IV Criterion A2 regarding the subjective reaction to the traumatic event (e.g., experiencing “fear, helplessness, or horror”) has been eliminated. Adjustment disorders are reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event, rather than as a residual category for individuals who exhibit clinically significant distress but whose symptoms do not meet criteria for a more discrete disorder (as in DSM-IV).
DSM-5 criteria for PTSD differ significantly from the DSM-IV criteria. The stressor criterion (Criterion A) is more explicit with regard to events that qualify as “traumatic” experiences. Also, DSM-IV Criterion A2 (subjective reaction) has been eliminated. Whereas there were three major symptom clusters in DSM-IV—reexperiencing, avoidance/numbing, and arousal—there are now four symptom clusters in DSM-5, because the avoidance/numbing cluster is divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood. This latter category, which retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as persistent negative emotional states. The final cluster—alterations in arousal and reactivity—retains most of the DSM-IV arousal symptoms. It also includes irritable behavior or angry outbursts and reckless or self-destructive behavior. PTSD is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder.
The DSM-IV childhood diagnosis reactive attachment disorder had two subtypes: emotionally withdrawn/inhibited and indiscriminately social/disinhibited. In DSM-5, these subtypes are defined as distinct disorders: reactive attachment disorder and disinhibited social engagement disorder.
Dissociative Disorders
Major changes in dissociative disorders in DSM-5 include the following: 1) derealization is included in the name and symptom structure of what previously was called depersonalization disorder (depersonalization/derealization disorder); 2) dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis, and 3) the criteria for dissociative identity disorder have been changed to indicate that symptoms of disruption of identity may be reported as well as observed, and that gaps in the recall of events may occur for everyday and not just traumatic events. Also, experiences of pathological possession in some cultures are included in the description of identity disruption.
Somatic Symptom and Related Disorders
In DSM-5, somatoform disorders are now referred to as somatic symptom and related disorders. The DSM-5 classification reduces the number of these disorders and subcategories to avoid problematic overlap. Diagnoses of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed. Individuals previously diagnosed with somatization disorder will usually have symptoms that meet DSM-5 criteria for somatic symptom disorder, but only if they have the maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to their somatic symptoms. Because the distinction between somatization disorder and undifferentiated somatoform disorder was arbitrary, they are merged in DSM-5 under somatic symptom disorder. Individuals previously diagnosed with hypochondriasis who have high health anxiety but no somatic symptoms would receive a DSM-5 diagnosis of illness anxiety disorder (unless their health anxiety was better explained by a primary anxiety disorder, such as generalized anxiety disorder). Some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an adjustment disorder would be more appropriate.
Psychological factors affecting other medical conditions is a new mental disorder in DSM-5, having formerly been listed in the DSM-IV chapter “Other Conditions That May Be a Focus of Clinical Attention.” This disorder and factitious disorder are placed among the somatic symptom and related disorders because somatic symptoms are predominant in both disorders, and both are most often encountered in medical settings. The variants of psychological factors affecting other medical conditions are removed in favor of the stem diagnosis. Criteria for conversion disorder (functional neurological symptom disorder) have been modified to emphasize the essential importance of the neurological examination, and in recognition that relevant psychological factors may not be demonstrable at the time of diagnosis. Other specified somatic symptom disorder, other specified illness anxiety disorder, and pseudocyesis are now the only exemplars of the other specified somatic symptom and related disorder classification.
Feeding and Eating Disorders
Because of the elimination of the DSM-IV-TR chapter “Disorders Usually First Diagnosed During Infancy, Childhood, or Adolescence,” this chapter describes several disorders found in the DSM-IV section “Feeding and Eating Disorders of Infancy or Early Childhood,” such as pica and rumination disorder. The DSM-IV category feeding disorder of infancy or early childhood has been renamed avoidant/restrictive food intake disorder, and the criteria are significantly expanded. The core diagnostic criteria for anorexia nervosa are conceptually unchanged from DSM-IV with one exception: the requirement for amenorrhea is eliminated. As in DSM-IV, individuals with this disorder are required by Criterion A to be at a significantly low body weight for their developmental stage. The wording of the criterion is changed for clarification, and guidance regarding how to judge whether an individual is at or below a significantly low weight is provided in the text. In DSM-5, Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behavior that interferes with weight gain. The only change in the DSM-IV criteria for bulimia nervosa is a reduction in the required minimum average frequency of binge eating and inappropriate compensatory behavior frequency from twice to once weekly. The extensive research that followed the promulgation of preliminary criteria for binge-eating disorder in Appendix B of DSM-IV documented the clinical utility and validity of binge-eating disorder. The only significant difference from the preliminary criteria is that the minimum average frequency of binge eating required for diagnosis is once weekly over the last 3 months, identical to the frequency criterion for bulimia nervosa (rather than at least 2 days a week for 6 months in DSM-IV).
Elimination Disorders
There have been no significant changes in this diagnostic class from DSM-IV to DSM-5. The disorders in this chapter were previously classified under disorders usually first diagnosed in infancy, childhood, or adolescence in DSM-IV and exist now as an independent classification in DSM-5.
Sleep-Wake Disorders
In DSM-5, the DSM-IV diagnoses named sleep disorder related to another mental disorder and sleep disorder related to another medical condition have been removed, and instead greater specification of coexisting conditions is provided for each sleep-wake disorder. The diagnosis of primary insomnia has been renamed insomnia disorder to avoid the differentiation between primary and secondary insomnia. DSM-5 also distinguishes narcolepsy—now known to be associated with hypocretin deficiency—from other forms of hypersomnolence (hypersomnolence disorder). Finally, throughout the DSM-5 classification of sleep-wake disorders, pediatric and developmental criteria and text are integrated where existing science and considerations of clinical utility support such integration. Breathing-related sleep disorders are divided into three relatively distinct disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. The subtypes of circadian rhythm sleep disorders are expanded to include advanced sleep phase type and irregular sleep-wake type, whereas the jet lag type has been removed. The use of the former “not otherwise specified” diagnoses in DSM-IV have been reduced by elevating rapid eye movement sleep behavior disorder and restless legs syndrome to independent disorders.
Sexual Dysfunctions
In DSM-5, some gender-specific sexual dysfunctions have been added, and, for females, sexual desire and arousal disorders have been combined into one disorder: female sexual interest/arousal disorder. All of the sexual dysfunctions (except substance/medication-induced sexual dysfunction) now require a minimum duration of approximately 6 months and more precise severity criteria. Genito-pelvic pain/penetration disorder has been added to DSM-5 and represents a merging of vaginismus and dyspareunia, which were highly comorbid and difficult to distinguish. The diagnosis of sexual aversion disorder has been removed due to rare use and lack of supporting research.
There are now only two subtypes for sexual dysfunctions: lifelong versus acquired and generalized versus situational. To indicate the presence and degree of medical and other nonmedical correlates, the following associated features have been added to the text: partner factors, relationship factors, individual vulnerability factors, cultural or religious factors, and medical factors.
Gender Dysphoria
Gender dysphoria is a new diagnostic class in DSM-5 and reflects a change in conceptualization of the disorder’s defining features by emphasizing the phenomenon of “gender incongruence” rather than cross-gender identification per se, as was the case in DSM-IV gender identity disorder. Gender dysphoria includes separate sets of criteria: for children and for adults and adolescents. For the adolescents and adults criteria, the previous Criterion A (cross-gender identification) and Criterion B (aversion toward one’s gender) are merged. In the wording of the criteria, “the other sex” is replaced by “the other gender” (or “some alternative gender”).” Gender instead of sex is used systematically because the concept “sex” is inadequate when referring to individuals with a disorder of sex development. In the child criteria, “strong desire to be of the other gender” replaces the previous “repeatedly stated desire to be...the other sex” to capture the situation of some children who, in a coercive environment, may not verbalize the desire to be of another gender. For children, Criterion A1 (“a strong desire to be of the other gender or an insistence that one is the other gender…)” is now necessary (but not sufficient), which makes the diagnosis more restrictive and conservative. The subtyping on the basis of sexual orientation is removed because the distinction is no longer considered clinically useful. A posttransition specifier has been added to identify individuals who have undergone at least one medical procedure or treatment to support the new gender assignment (e.g., cross-sex hormone treatment). Although the concept of posttransition is modeled on the concept of full or partial remission, the term remission has implications in terms of symptom reduction that do not apply directly to gender dysphoria.
Disruptive, Impulse-Control, and Conduct Disorders
The chapter “Disruptive, Impulse-Control, and Conduct Disorders” is new to DSM-5 and combines disorders that were previously included in the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” (i.e., oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified, now categorized as other specified and unspecified disruptive, impulse-control, and conduct disorders) and the chapter “Impulse-Control Disorders Not Elsewhere Classified” (i.e., intermittent explosive disorder, pyromania, and kleptomania). These disorders are all characterized by problems in emotional and behavioral self-control. Notably, ADHD is frequently comorbid with the disorders in this chapter but is listed with the neurodevelopmental disorders. Because of its close association with conduct disorder, antisocial personality disorder is listed both in this chapter and in the chapter “Personality Disorders,” where it is described in detail.
The criteria for oppositional defiant disorder are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. Additionally, the exclusionary criterion for conduct disorder has been removed. The criteria for conduct disorder include a descriptive features specifier for individuals who meet full criteria for the disorder but also present with limited prosocial emotions. The primary change in intermittent explosive disorder is in the type of aggressive outbursts that should be considered: DSM-IV required physical aggression, whereas in DSM-5 verbal aggression and nondestructive/noninjurious physical aggression also meet criteria. DSM-5 also provides more specific criteria defining frequency needed to meet the criteria and specifies that the aggressive outbursts are impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences. Furthermore, a minimum age of 6 years (or equivalent developmental level) is now required.
Substance-Related and Addictive Disorders
An important departure from past diagnostic manuals is that the chapter on substance-related disorders has been expanded to include gambling disorder. Another key change is that DSM-5 does not separate the diagnoses of substance abuse and dependence as in DSM-IV. Rather criteria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, substance-induced disorders, and unspecified substance-related disorders, where relevant. Within substance use disorders, the DSM-IV recurrent substance-related legal problems criterion has been deleted from DSM-5, and a new criterion—craving, or a strong desire or urge to use a substance—has been added. In addition, the threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria, in contrast to a threshold of one or more criteria for a diagnosis of DSM-IV substance abuse and three or more for DSM-IV dependence. Cannabis withdrawal and caffeine withdrawal are new disorders (the latter was in DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study”).
Severity of the DSM-5 substance use disorders is based on the number of criteria endorsed. The DSM-IV specifier for a physiological subtype is eliminated in DSM-5, as is the DSM-IV diagnosis of polysubstance dependence. Early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without meeting substance use disorder criteria (except craving), and sustained remission is defined as at least 12 months without meeting criteria (except craving). Additional new DSM-5 specifiers include “in a controlled environment” and “on maintenance therapy” as the situation warrants.
Neurocognitive Disorders
The DSM-IV diagnoses of dementia and amnestic disorder are subsumed under the newly named entity major neurocognitive disorder (NCD). The term dementia is not precluded from use in the etiological subtypes where that term is standard. Furthermore, DSM-5 now recognizes a less severe level of cognitive impairment, mild NCD, which is a new disorder that permits the diagnosis of less disabling syndromes that may nonetheless be the focus of concern and treatment. Diagnostic criteria are provided for both of these disorders, followed by diagnostic criteria for different etiological subtypes. In DSM-IV, individual diagnoses were designated for dementia of the Alzheimer’s type, vascular dementia, and substance-induced dementia, whereas the other neurodegenerative disorders were classified as dementia due to another medical condition, with HIV, head trauma, Parkinson’s disease, Huntington’s disease, Pick’s disease, Creutzfeldt-Jakob disease, and other medical conditions specified. In DSM-5, major or mild NCD due to Alzheimer’s disease and major or mild vascular NCD have been retained, while new separate criteria are now presented for major or mild frontotemporal NCD, NCD with Lewy bodies, and NCDs due to traumatic brain injury, a substance/medication, HIV infection, prion disease, Parkinson’s disease, Huntington’s disease, another medical condition, and multiple etiologies, respectively. Unspecified NCD is also included as a diagnosis.
Personality Disorders
The criteria for personality disorders in Section II of DSM-5 have not changed from those in DSM-IV. An alternative approach to the diagnosis of personality disorders was developed for DSM-5 for further study and can be found in Section III (see “Alternative DSM-5 Model for Personality Disorders”). For the general criteria for personality disorder, presented in Section III, a revised personality functioning criterion (Criterion A) has been developed based on a literature review of reliable clinical measures of core impairments central to personality pathology. A diagnosis of personality disorder—trait specified, based on moderate or greater impairment in personality functioning and the presence of pathological personality traits, replaces personality disorder not otherwise specified and provides a much more informative diagnosis for individuals who are not optimally described as having a specific personality disorder. A greater emphasis on personality functioning and trait-based criteria increases the stability and empirical bases of the disorders. Personality functioning and personality traits also can be assessed whether or not the individual has a personality disorder—a feature that provides clinically useful information about all individuals.
Paraphilic Disorders
An overarching change from DSM-IV is the addition of the course specifiers “in a controlled environment” and “in remission” to the diagnostic criteria sets for all the paraphilic disorders. These specifiers are added to indicate important changes in an individual’s status. In DSM-5, paraphilias are not ipso facto mental disorders. There is a distinction between paraphilias and paraphilic disorders. A paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. A paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not automatically justify or require clinical intervention. The distinction between paraphilias and paraphilic disorders was implemented without making any changes to the basic structure of the diagnostic criteria as they had existed since DSM-III-R. The change proposed for DSM-5 is that individuals who meet both Criterion A and Criterion B would now be diagnosed as having a paraphilic disorder. A diagnosis would not be given to individuals whose symptoms meet Criterion A but not Criterion B—that is, to individuals who have a paraphilia but not a paraphilic disorder.