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Nicole O. 1318 “ ABOUT QUIZ “ and performing excessive health-related behaviors - Illness...

Nicole O. 1318 “ ABOUT QUIZ “ and performing excessive health-related behaviors - Illness Anxiety Disorder 1. How many in the population have had the disorder (Existing Case) - Prevalence 15. ______ are repetitive behaviors or mental acts that an individual feels driven to perform in response to an 2. The essential feature of Trichotillomania? - Hair Pulling obsession or according to rules that must be applied rigidly - Compulsion 3. People with this disorder often worry about everyday, routine life circumstances, such as possible job responsibilities, health, and finances, the health of family members, misfortune to their children, or minor matters - Generalized Anxiety Disorder “ ANXIETY DISORDERS “ - disorders that share features of excessive fear and anxiety 4. The essential feature of Agoraphobia? - Marked fear or and related behavioral disturbances. Fear is the emotional anxiety in public places response to real or perceived imminent threat, whereas anxiety is anticipation of future threat. 5. What is the term used for the beginning of the disorder? - Onset Diagnostic Criteria of Separation Anxiety Disorder (SAD) A. Developmentally inappropriate and excessive fear or 6. The essential feature of Body Dysmorphic Disorder? anxiety concerning separation from those to whom the - Preoccupation with perceive defects or flaws in physical individual is attached, as evidenced by at least three of the appearance following: 7. Neurotransmitters that regulate the emotion? 1. Recurrent excessive distress when anticipating or - Serotonin experiencing separation from home or from major attachment figures. 8. This is a type of neurotransmitters that affect our 2. Persistent and excessive worry about losing major reward system when we feel something good or attachment figures or pleasurable experience - Dopamine about possible harm to them, such as illness, injury, disasters, or death. 9. Miko has persistent difficulty in discarding and parting 3. Persistent and excessive worry about experiencing with his possessions like keeping used tissue, bottles of an untoward event (e.g., drinks, and other things that can contaminate his house getting lost, being kidnapped, having an accident, - Hoarding Disorder becoming ill) that causes separation from a major attachment figure. 10. What is the term used for the individual pattern of 4. Persistent reluctance or refusal to go out, away symptoms? - Course from home, to school, to work, or elsewhere because of fear of separation. 11. _______ intrusive and nonsensical thoughts, images or, 5. Persistent and excessive fear of or reluctance or urges an individual tries to eliminate or suppress about being alone or without - Obsession major attachment figures at home or in other settings. 12. the most essential characteristics of Social Anxiety 6. Persistent reluctance or refusal to sleep away Disorder? - Fear of evaluation by other people from home or to go to sleep without being near a major attachment figure. 13. Refers to a historical approach in mental care that 7. Repeated nightmares involving the theme of focuses on early intervention, environmental modifications, separation. humane treatment to prevent chronicity among the 8. Repeated complaints of physical symptoms (e.g., mental illness - Moral Therapy headaches, stomachaches, nausea, vomiting) when separation from major 14. Preoccupation with having or acquiring a serious, attachment figures occurs or undiagnosed medical illness with a high level of Anxiety is anticipated.  Nicole O. 1318 Note: In children, the fear or anxiety may be B. The fear, anxiety, or avoidance is persistent, lasting expressed by crying, tantrums, freezing, or clinging. at least 4 weeks in children and adolescents and typically 6 months or more in adults. B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The disturbance causes clinically significant distress or impairment in social, academic, C. The phobic object or situation is actively avoided or occupational, or other important areas of endured with intense fear or anxiety. functioning. D. The fear or anxiety is out of proportion to the actual D. The disturbance is not better explained by another danger posed by the specific object or situation and to mental disorder, such as refusing to leave home the sociocultural context. because of excessive resistance to change in autism spectrum disorder; delusions or E. The fear, anxiety, or avoidance is persistent, typically hallucinations concerning separation in psychotic lasting for 6 months or more. disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill F. The fear, anxiety, or avoidance causes clinically health or other harm befalling significant others in significant distress or impairment in social, occupational, generalized anxiety disorder; or concerns about or other important areas of functioning. having an illness in illness anxiety disorder. G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with Diagnostic Criteria of Selective Mutism panic-like symptoms or other incapacitating symptoms A. Consistent failure to speak in specific social (as in agoraphobia); objects or situations related to situations in which there is an expectation for obsessions (as in obsessive-compulsive disorder); speaking (e.g., at school) despite speaking in other reminders of traumatic events (as in posttraumatic situations. stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social B. The disturbance interferes with educational or situations (as in social anxiety disorder). occupational achievement or with social communication. Code based on the phobic stimulus: F40.218 Animal (e.g., spiders, insects, dogs). C. The duration of the disturbance is at least 1 month F40.228 Natural environment (e.g., heights, storms, (not limited to the first month of school). water). F40.23x Blood-injection-injury (e.g., needles, invasive D. The failure to speak is not attributable to a lack of medical procedures). knowledge of, or comfort with, the spoken language required in the social situation. Coding note: Select specific ICD-10-CM code as follows: E. The disturbance is not better explained by a F40.230 fear of blood communication disorder (e.g., childhood-onset F40.231 fear of injections and transfusions fluency disorder) and does not occur exclusively F40.232 fear of other medical care during the course of autism spectrum disorder, F40.233 fear of injury schizophrenia, or another psychotic disorder. F40.248 Situational (e.g., airplanes, elevators, enclosed places). F40.298 Other (e.g., situations that may lead to choking or vomiting; in children, e.g., loud sounds or Diagnostic Criteria of Specific Phobia costumed characters). A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an Coding note: When more than one phobic stimulus injection, seeing blood). is present, code all ICD-10-CM codes that apply (e.g.,  Nicole O. 1318 for fear of snakes and flying, F40.218 specific disorder, such as panic disorder, body dysmorphic phobia, animal, and F40.248 specific phobia, disorder, or autism spectrum disorder. situational). J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is Diagnostic Criteria of Social Anxiety Disorder (SAD) excessive. A. Marked fear or anxiety about one or more social situations in which the individual is exposed to Specify if: possible scrutiny by others. Examples include Performance only: If the fear is restricted to speaking or social interactions (e.g., having a conversation, performing in public. meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). Note: In children, the anxiety must occur in Diagnostic Criteria of Panic Disorder peer settings and not just during interactions A. Recurrent unexpected panic attacks. A panic attack is an with adults. abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time B. The individual fears that he or she will act in a way four (or more) of the following symptoms occur: or show anxiety symptoms that will be negatively Note: The abrupt surge can occur from a calm state evaluated (i.e., will be humiliating or embarrassing; or an anxious state. will lead to rejection or offend others). 1. Palpitations, pounding heart, or accelerated heart rate. C. The social situations almost always provoke fear or 2. Sweating. anxiety. 3. Trembling or shaking. Note: In children, the fear or anxiety may be 4. Sensations of shortness of breath or expressed by crying, tantrums, freezing, smothering. clinging, shrinking, or failing to speak in social 5. Feelings of choking. situations. 6. Chest pain or discomfort. 7. Nausea or abdominal distress. D. The social situations are avoided or endured with 8. Feeling dizzy, unsteady, light-headed, or faint. intense fear or anxiety. 9. Chills or heat sensations. 10. Paresthesias (numbness or tingling E. The fear or anxiety is out of proportion to the sensations). actual threat posed by the social situation and to 11. Derealization (feelings of unreality) or the sociocultural context. depersonalization (being detached from oneself). F. The fear, anxiety, or avoidance is persistent, 12. Fear of losing control or “going crazy.” typically lasting for 6 months or more. 13. Fear of dying. Note: Culture-specific symptoms (e.g., G. The fear, anxiety, or avoidance causes clinically tinnitus, neck soreness, headache, significant distress or impairment in social, uncontrollable screaming or crying) may be occupational, or other important areas of seen. Such symptoms should not count as functioning. one of the four required symptoms. H. The fear, anxiety, or avoidance is not attributable B. At least one of the attacks has been followed by 1 to the physiological effects of a substance (e.g., a month (or more) of one or both of the following: drug of abuse, a medication) or another medical 1. Persistent concern or worry about additional condition. panic attacks or their consequences (e.g., losing control, having a heart attack, “going I. The fear, anxiety, or avoidance is not better crazy”). explained by the symptoms of another mental  Nicole O. 1318 2. A significant maladaptive change in E. The fear or anxiety is out of proportion to the actual behavior related to the attacks (e.g., danger posed by the agoraphobic situations and to the behaviors designed to avoid having sociocultural context. panic attacks, such as avoidance of exercise or unfamiliar situations). F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of G. The fear, anxiety, or avoidance causes clinically abuse, a medication) or another medical condition significant distress or impairment in social, occupational, (e.g., hyperthyroidism, cardiopulmonary disorders). or other important areas of functioning. D. The disturbance is not better explained by another H. If another medical condition (e.g., inflammatory bowel mental disorder (e.g., the panic attacks do not disease, Parkinson’s disease) is present, the fear, anxiety, occur only in response to feared social situations, or avoidance is clearly excessive. as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in I. The fear, anxiety, or avoidance is not better explained specific phobia; in response to obsessions, as in by the symptoms of another mental disorder—for obsessive-compulsive disorder; in response to example, the symptoms are not confined to specific reminders of traumatic events, as in posttraumatic phobia, situational type; do not involve only social stress disorder; or in response to separation from situations (as in social anxiety disorder); and are not attachment figures, as in separation anxiety related exclusively to obsessions (as in obsessive- disorder). compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation Diagnostic Criteria of Agoraphobia anxiety disorder). A. Marked fear or anxiety about two (or more) of the following five situations: Note: Agoraphobia is diagnosed irrespective of the presence 1. Using public transportation (e.g., automobiles, of panic disorder. If an individual’s presentation meets buses, trains, ships, planes). criteria for panic disorder and agoraphobia, both diagnoses 2. Being in open spaces (e.g., parking lots, should be assigned. marketplaces, bridges). 3. Being in enclosed places (e.g., shops, theaters, cinemas). 4. Standing in line or being in a crowd. Diagnostic Criteria of Generalized Anxiety Disorder (GAD) 5. Being outside of the home alone. A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, B. The individual fears or avoids these situations about a number of events or activities (such as work or because of thoughts that escape might be difficult school performance). or help might not be available in the event of developing panic-like symptoms or other B. The individual finds it difficult to control the worry. incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence). C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some C. The agoraphobic situations almost always provoke symptoms having been present for more days than not fear or anxiety. for the past 6 months): D. The agoraphobic situations are actively avoided, Note: Only one item is required in children. require the presence of a companion, or are 1. Restlessness or feeling keyed up or on edge. endured with intense fear or anxiety. 2. Being easily fatigued. 3. Difficulty concentrating or mind going blank. 4. Irritability.  Nicole O. 1318 5. Muscle tension. 2. The individual attempts to ignore or suppress 6. Sleep disturbance (difficulty falling or staying such thoughts, urges, or images, or to asleep, or restless, unsatisfying sleep). neutralize them with some other thought or action (i.e., by performing a compulsion). D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, Compulsions are defined by (1) and (2): occupational, or other important areas of 1. Repetitive behaviors (e.g., hand washing, functioning. ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) E. The disturbance is not attributable to the that the individual feels driven to perform in physiological effects of a substance (e.g., a drug of response to an obsession or according to abuse, a medication) or another medical condition rules that must be applied rigidly. (e.g., hyperthyroidism). 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or F. The disturbance is not better explained by another preventing some dreaded event or situation; mental disorder (e.g., anxiety or worry about however, these behaviors or mental acts are having panic attacks in panic disorder, negative not connected in a realistic way with what evaluation in social anxiety disorder, they are designed to neutralize or prevent, or contamination or other obsessions in obsessive- are clearly excessive. compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders Note: Young children may not be able to articulate of traumatic events in posttraumatic stress the aims of these behaviors or mental acts. disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, B. The obsessions or compulsions are time-consuming perceived appearance flaws in body dysmorphic (e.g., take more than 1 hour per day) or cause clinically disorder, having a serious illness in illness anxiety significant distress or impairment in social, occupational, disorder, or the content of delusional beliefs in or other important areas of functioning. schizophrenia or delusional disorder). C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. “ OBSESSIVE COMPULSIVE & RELATED DISORDERS “ D. The disturbance is not better explained by the - OCD is characterized by the presence of obsessions symptoms of another mental disorder (e.g., excessive and/or compulsions. Obsessions are recurrent and worries, as in generalized anxiety disorder; persistent thoughts, urges, or images that are preoccupation with appearance, as in body dysmorphic experienced as intrusive and unwanted, whereas disorder; difficulty discarding or parting with compulsions are repetitive behaviors or mental acts possessions, as in hoarding disorder; hair pulling, as in that an individual feels driven to perform in response to trichotillomania [hair-pulling disorder]; skin picking, as an obsession or according to rules that must be applied in excoriation [skin-picking] disorder; stereotypies, as in rigidly. stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and Diagnostic Criteria for Obsessive-Compulsive Disorder addictive disorders; preoccupation with having an illness, A. Presence of obsessions, compulsions, or both: as in illness anxiety disorder; sexual urges or fantasies, Obsessions are defined by (1) and (2): as in paraphilic disorders; impulses, as in disruptive, 1. Recurrent and persistent thoughts, impulse-control, and conduct disorders; guilty urges, or images that are experienced, at ruminations, as in major depressive disorder; thought some time during the disturbance, as insertion or delusional preoccupations, as in intrusive and unwanted, and that in schizophrenia spectrum and other psychotic disorders; most individuals cause marked anxiety or distress.  Nicole O. 1318 or repetitive patterns of behavior, as in autism beliefs are definitely or probably not true or that spectrum disorder). they may or may not be true. With poor insight: The individual thinks that the body Specify if: dysmorphic disorder beliefs are probably true. With good or fair insight: The individual recognizes that With absent insight/delusional beliefs: The individual obsessive-compulsive disorder beliefs are definitely or is completely convinced that the body dysmorphic probably not true or that they may or may not be true. disorder beliefs are true. With poor insight: The individual thinks obsessive- compulsive disorder beliefs are probably true. With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive Diagnostic Criteria for Hoarding Disorder disorder beliefs are true. A. Persistent difficulty discarding or parting with possessions, regardless of their actual value. Specify if: Tic-related: The individual has a current or past history B. This difficulty is due to a perceived need to save the of a tic disorder. items and to distress associated with discarding them. C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter Diagnostic Criteria for Body Dysmorphic Disorder active living areas and substantially compromises their A. Preoccupation with one or more perceived defects intended use. If living areas are uncluttered, it is only or flaws in physical appearance that are not because of the interventions of third parties (e.g., family observable or appear slight to others. members, cleaners, authorities). B. At some point during the course of the disorder, D. The hoarding causes clinically significant distress or the individual has performed repetitive behaviors impairment in social, occupational, or other important (e.g., mirror checking, excessive grooming, skin areas of functioning (including maintaining a safe picking, reassurance seeking) or mental acts (e.g., environment for self and others). comparing his or her appearance with that of others) in response to the appearance concerns. E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, C. The preoccupation causes clinically significant Prader-Willi syndrome). distress or impairment in social, occupational, or other important areas of functioning. F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in D. The appearance preoccupation is not better obsessive-compulsive disorder, decreased energy in explained by concerns with body fat or weight in major depressive disorder, delusions in schizophrenia an individual whose symptoms meet diagnostic or another psychotic disorder, cognitive deficits in major criteria for an eating disorder. neurocognitive disorder, restricted interests in autism spectrum disorder). Specify if: With muscle dysmorphia: The individual is preoccupied Specify if: with the idea that his or her body build is too small or With excessive acquisition: If difficulty discarding possessions insufficiently muscular. This specifier is used even if the is accompanied by excessive acquisition of items that are not individual is preoccupied with other body areas, which needed or for which there is no available space. is often the case. Specify if: Specify if: With good or fair insight: The individual recognizes that Indicate degree of insight regarding body dysmorphic hoarding-related beliefs and behaviors (pertaining to disorder beliefs (e.g., “I look ugly” or “I look deformed”). difficulty discarding items, clutter, or excessive acquisition) With good or fair insight: The individual are problematic. recognizes that the body dysmorphic disorder  Nicole O. 1318 With poor insight: The individual is mostly convinced disorder, attempts to improve a perceived defect or flaw that hoarding-related beliefs and behaviors (pertaining in appearance in body dysmorphic disorder, to difficulty discarding items, clutter, or excessive stereotypies in stereotypic movement disorder, or acquisition) are not problematic despite evidence to the intention to harm oneself in nonsuicidal self-injury). contrary. With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. “ TRAUMA & STRESSOR RELATED DISORDERS “ Diagnostic Criteria for Reactive Attachment Disorder Diagnostic Criteria for Trichotillomania (Hair-Pulling A. A consistent pattern of inhibited, emotionally withdrawn Disorder) behavior toward adult caregivers, manifested by both of A. Recurrent pulling out of one’s hair, resulting in hair the following: loss. 1. The child rarely or minimally seeks comfort when distressed. B. Repeated attempts to decrease or stop hair pulling. 2. The child rarely or minimally responds to comfort when distressed. C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other B. A persistent social and emotional disturbance important areas of functioning. characterized by at least two of the following: 1. Minimal social and emotional responsiveness D. The hair pulling or hair loss is not attributable to to others. another medical condition (e.g., a dermatological 2. Limited positive affect. condition). 3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during E. The hair pulling is not better explained by the nonthreatening interactions with adult symptoms of another mental disorder (e.g., caregivers. attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder). C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: 1. Social neglect or deprivation in the form of Diagnostic Criteria for Excoriation (Skin-Pulling Disorder) persistent lack of having basic emotional A. Recurrent skin picking resulting in skin lesions. needs for comfort, stimulation, and affection met by caregiving adults. B. Repeated attempts to decrease or stop skin 2. Repeated changes of primary caregivers that picking. limit opportunities to form stable attachments (e.g., frequent changes in foster care). C. The skin picking causes clinically significant 3. Rearing in unusual settings that severely limit distress or impairment in social, occupational, or opportunities to form selective attachments other important areas of functioning. (e.g., institutions with high child-to-caregiver ratios). D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) D. The care in Criterion C is presumed to be responsible for or another medical condition (e.g., scabies). the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of E. The skin picking is not better explained by adequate care in Criterion C). symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic E. The criteria are not met for autism spectrum disorder.  Nicole O. 1318 D. The care in Criterion C is presumed to be responsible for F. The disturbance is evident before age 5 years. the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the G. The child has a developmental age of at least 9 pathogenic care in Criterion C). months. E. The child has a developmental age of at least 9 months. Specify if: Persistent: The disorder has been present for more Specify if: than 12 months. Persistent: The disorder has been present for more than 12 months. Specify current severity: Reactive attachment disorder is specified as severe Specify current severity: when a child exhibits all symptoms of the disorder, with Disinhibited social engagement disorder is specified as each symptom manifesting at relatively high levels. severe when the child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels. Diagnostic Criteria for Disinhibited Social Engagement Disorder A. A pattern of behavior in which a child actively Diagnostic Criteria for Post Traumatic Stress Disorder approaches and interacts with unfamiliar adults Posttraumatic Stress Disorder in Individuals Older Than 6 and exhibits at least two of the following: Years. 1. Reduced or absent reticence in Note: The following criteria apply to adults, adolescents, and approaching and interacting with children older than 6 years. unfamiliar adults. A. Exposure to actual or threatened death, serious injury, 2. Overly familiar verbal or physical or sexual violence in one (or more) of the following ways: behavior (that is not consistent with 1. Directly experiencing the traumatic event(s). culturally sanctioned and with age- 2. Witnessing, in person, the event(s) as it appropriate social boundaries). occurred to others. 3. Learning that the traumatic event(s) occurred B. The behaviors in Criterion A are not limited to to a close family member or close friend. In impulsivity (as in attention-deficit/hyperactivity cases of actual or threatened death of a family disorder) but include socially disinhibited behavior. member or friend, the event(s) must have been violent or accidental. C. The child has experienced a pattern of extremes of 4. Experiencing repeated or extreme exposure insufficient care as evidenced by at least one of the to aversive details of the traumatic event(s) following: (e.g., first responders collecting human 1. Social neglect or deprivation in the form remains; police officers repeatedly exposed to of persistent lack of having basic details of child abuse). emotional needs for comfort, Note: Criterion A4 does not apply to exposure stimulation, and affection met by through electronic media, television, movies, or caregiving adults. pictures, unless this exposure is work related. 2. Repeated changes of primary caregivers that limit opportunities to form stable B. Presence of one (or more) of the following intrusion attachments (e.g., frequent changes in symptoms associated with the traumatic event(s), foster care). beginning after the traumatic event(s) occurred: 3. Rearing in unusual settings that severely 1. Recurrent, involuntary, and intrusive limit opportunities to form selective distressing memories of the traumatic attachments (e.g., institutions with high event(s). Note: In children older than 6 years, child-to-caregiver ratios). repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.  Nicole O. 1318 2. Recurrent distressing dreams in which completely dangerous,” “My whole nervous the content and/or affect of the dream system is permanently ruined”). are related to the traumatic event(s). 3. Persistent, distorted cognitions about the Note: In children, there may be cause or consequences of the traumatic frightening dreams without recognizable event(s) that lead the individual to blame content. himself/herself or others. 3. Dissociative reactions (e.g., flashbacks) in 4. Persistent negative emotional state (e.g., fear, which the individual feels or acts as if the horror, anger, guilt, or shame). traumatic event(s) were recurring. (Such 5. Markedly diminished interest or participation reactions may occur on a continuum, in significant activities. with the most extreme expression being 6. Feelings of detachment or estrangement from a complete loss of awareness of present others. surroundings.) Note: In children, trauma- 7. Persistent inability to experience positive specific reenactment may occur in play. emotions (e.g., inability to experience 4. Intense or prolonged psychological happiness, satisfaction, or loving feelings). distress at exposure to internal or external cues that symbolize or E. Marked alterations in arousal and reactivity associated resemble an aspect of the traumatic with the traumatic event(s), beginning or worsening event(s). after the traumatic event(s) occurred, as evidenced by 5. Marked physiological reactions to two (or more) of the following: internal or external cues that symbolize 1. Irritable behavior and angry outbursts (with or resemble an aspect of the traumatic little or no provocation) typically expressed as event(s). verbal or physical aggression toward people or objects. C. Persistent avoidance of stimuli associated with the 2. Reckless or self-destructive behavior. traumatic event(s), beginning after the traumatic 3. Hypervigilance. event(s) occurred, as evidenced by one or both of 4. Exaggerated startle response. the following: 5. Problems with concentration. 1. Avoidance of or efforts to avoid 6. Sleep disturbance (e.g., difficulty falling or distressing memories, thoughts, or staying asleep or restless sleep). feelings about or closely associated with the traumatic event(s). F. Duration of the disturbance (Criteria B, C, D, and E) is 2. Avoidance of or efforts to avoid external more than 1 month. reminders (people, places, conversations, activities, objects, situations) that arouse G. The disturbance causes clinically significant distress or distressing memories, thoughts, or impairment in social, occupational, or other important feelings about or closely associated with areas of functioning. the traumatic event(s). H. The disturbance is not attributable to the physiological D. Negative alterations in cognitions and mood effects of a substance (e.g., medication, alcohol) or associated with the traumatic event(s), beginning another medical condition. or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: Specify whether: 1. Inability to remember an important With dissociative symptoms: The individual’s symptoms meet aspect of the traumatic event(s) (typically the criteria for posttraumatic stress disorder, and in addition, due to dissociative amnesia and not to in response to the stressor, the individual experiences other factors such as head injury, persistent or recurrent symptoms of either of the following: alcohol, or drugs). 1. Depersonalization: Persistent or recurrent 2. Persistent and exaggerated negative experiences of feeling detached from, and as if one beliefs or expectations about oneself, were an outside observer of, one’s mental others, or the world (e.g., “I am bad,” “No processes or body (e.g., feeling as though one were one can be trusted,” “The world is  Nicole O. 1318 in a dream; feeling a sense of unreality of self traumatic event(s) were recurring. (Such or body or of time moving slowly). reactions may occur on a continuum, with the 2. Derealization: Persistent or recurrent most extreme expression being a complete experiences of unreality of surroundings (e.g., loss of awareness of present surroundings.) the world around the individual is Such trauma-specific reenactment may occur experienced as unreal, dreamlike, distant, or in play. distorted). 4. Intense or prolonged psychological distress at Note: To use this subtype, the dissociative symptoms exposure to internal or external cues that must not be attributable to the physiological effects of a symbolize or resemble an aspect of the substance (e.g., blackouts, behavior during alcohol traumatic event(s). intoxication) or another medical condition (e.g., 5. Marked physiological reactions to reminders complex partial seizures). of the traumatic event(s). C. One (or more) of the following symptoms, representing Specify if: either persistent avoidance of stimuli associated with With delayed expression: If the full diagnostic criteria the traumatic event(s) or negative alterations in are not met until at least 6 months after the event cognitions and mood associated with the traumatic (although the onset and expression of some symptoms event(s), must be present, beginning after the event(s) may be immediate). or worsening after the event(s): Persistent Avoidance of Stimuli 1. Avoidance of or efforts to avoid activities, Posttraumatic Stress Disorder in Children 6 Years and places, or physical reminders that arouse Younger recollections of the traumatic event(s). A. In children 6 years and younger, exposure to 2. Avoidance of or efforts to avoid people, actual or threatened death, serious injury, or conversations, or interpersonal situations that sexual violence in one (or more) of the following arouse recollections of the traumatic event(s). ways: Negative Alterations in Cognitions 1. Directly experiencing the traumatic 3. Substantially increased frequency of negative event(s). emotional states (e.g., fear, guilt, sadness, 2. Witnessing, in person, the event(s) as it shame, confusion). occurred to others, especially primary 4. Markedly diminished interest or participation caregivers. in significant activities, including constriction 3. Learning that the traumatic event(s) of play. occurred to a parent or caregiving figure. 5. Socially withdrawn behavior. 6. Persistent reduction in expression of positive B. Presence of one (or more) of the following emotions. intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) D. Alterations in arousal and reactivity associated with the occurred: traumatic event(s), beginning or worsening after the 1. Recurrent, involuntary, and intrusive traumatic event(s) occurred, as evidenced by two (or distressing memories of the traumatic more) of the following: event(s). Note: Spontaneous and 1. Irritable behavior and angry outbursts intrusive memories may not necessarily (with little or no provocation) typically appear distressing and may be expressed as verbal or physical expressed as play reenactment. aggression toward people or objects 2. Recurrent distressing dreams in which (including extreme temper tantrums). the content and/or affect of the dream 2. Hypervigilance. are related to the traumatic event(s). 3. Exaggerated startle response. Note: It may not be possible to ascertain 4. Problems with concentration. that the frightening content is related to 5. Sleep disturbance (e.g., difficulty falling the traumatic event. or staying asleep or restless sleep). 3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the E. The duration of the disturbance is more than 1 month.  Nicole O. 1318 death of a family member or friend, the F. The disturbance causes clinically significant event(s) must have been violent or accidental. distress or impairment in relationships with 4. Experiencing repeated or extreme exposure parents, siblings, peers, or other caregivers or with to aversive details of the traumatic event(s) school behavior. (e.g., first responders collecting human remains, police officers repeatedly exposed to G. The disturbance is not attributable to the details of child abuse). Note: This does not physiological effects of a substance (e.g., apply to exposure through electronic media, medication or alcohol) or another medical television, movies, or pictures, unless this condition. exposure is work related. Specify whether: B. Presence of nine (or more) of the following symptoms With dissociative symptoms: The individual’s symptoms from any of the five categories of intrusion, negative meet the criteria for posttraumatic stress disorder, and mood, dissociation, avoidance, and arousal, beginning the individual experiences persistent or recurrent or worsening after the traumatic event(s) occurred: symptoms of either of the following: Intrusion Symptoms 1. Depersonalization: Persistent or recurrent 1. Recurrent, involuntary, and intrusive experiences of feeling detached from, and as distressing memories of the traumatic if one were an outside observer of, one’s event(s). Note: In children, repetitive play may mental processes or body (e.g., feeling as occur in which themes or aspects of the though one were in a dream; feeling a sense traumatic event(s) are expressed. of unreality of self or body or of time moving 2. Recurrent distressing dreams in which the slowly). content and/or affect of the dream are related 2. Derealization: Persistent or recurrent to the event(s). Note: In children, there may be experiences of unreality of surroundings (e.g., frightening dreams without recognizable the world around the individual is content. experienced as unreal, dreamlike, distant, or 3. Dissociative reactions (e.g., flashbacks) in distorted). which the individual feels or acts as if the Note: To use this subtype, the dissociative symptoms traumatic event(s) were recurring. (Such must not be attributable to the physiological effects of a reactions may occur on a continuum, with the substance (e.g., blackouts) or another medical condition most extreme expression being a complete (e.g., complex partial seizures). loss of awareness of present surroundings.) Note: In children, trauma-specific Specify if: reenactment may occur in play. With delayed expression: If the full diagnostic criteria 4. Intense or prolonged psychological distress or are not met until at least 6 months after the event marked physiological reactions in response to (although the onset and expression of some symptoms internal or external cues that symbolize or may be immediate). resemble an aspect of the traumatic event(s). Negative Mood 5. Persistent inability to experience positive emotions (e.g., inability to experience Diagnostic Criteria for Acute Stress Disorder happiness, satisfaction, or loving feelings). A. Exposure to actual or threatened death, serious Dissociative Symptoms injury, or sexual violence in one (or more) of the 6. An altered sense of the reality of one’s following ways: surroundings or oneself (e.g., seeing oneself 1. Directly experiencing the traumatic from another’s perspective, being in a daze, event(s). time slowing). 2. Witnessing, in person, the event(s) as it 7. Inability to remember an important aspect of occurred to others. the traumatic event(s) (typically due to 3. Learning that the event(s) occurred to a dissociative amnesia and not to other factors close family member or close friend. such as head injury, alcohol, or drugs). Note: In cases of actual or threatened Avoidance Symptoms  Nicole O. 1318 8. Efforts to avoid distressing memories, might influence symptom severity and thoughts, or feelings about or closely presentation. associated with the traumatic event(s). 2. Significant impairment in social, occupational, 9. Efforts to avoid external reminders or other important areas of functioning. (people, places, conversations, activities, objects, situations) that arouse C. The stress-related disturbance does not meet the distressing memories, thoughts, or criteria for another mental disorder and is not merely feelings about or closely associated with an exacerbation of a preexisting mental disorder. the traumatic event(s). D. The symptoms do not represent normal bereavement Arousal Symptoms and are not better explained by prolonged grief disorder. 10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep). E. Once the stressor or its consequences have terminated, 11. Irritable behavior and angry outbursts the symptoms do not persist for more than an (with little or no provocation), typically additional 6 months. expressed as verbal or physical aggression toward people or objects. Specify whether: 12. Hypervigilance. F43.21 With depressed mood: Low mood, tearfulness, or 13. Problems with concentration. feelings of hopelessness are predominant. 14. Exaggerated startle response. F43.22 With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant. C. Duration of the disturbance (symptoms in F43.23 With mixed anxiety and depressed mood: A Criterion B) is 3 days to 1 month after trauma combination of depression and anxiety is predominant. exposure. Note: Symptoms typically begin F43.24 With disturbance of conduct: Disturbance of conduct immediately after the trauma, but persistence for is predominant. at least 3 days and up to a month is needed to F43.25 With mixed disturbance of emotions and conduct: meet disorder criteria. Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant. D. The disturbance causes clinically significant F43.20 Unspecified: For maladaptive reactions that are not distress or impairment in social, occupational, or classifiable as one of the specific subtypes of adjustment other important areas of functioning. disorder. E. The disturbance is not attributable to the Specify if: physiological effects of a substance (e.g., Acute: This specifier can be used to indicate persistence of medication or alcohol) or another medical symptoms for less than 6 months. condition (e.g., mild traumatic brain injury) and is Persistent (chronic): This specifier can be used to indicate not better explained by brief psychotic disorder. persistence of symptoms for 6 months or longer. By definition, symptoms cannot persist for more than 6 months after the termination of the stressor or its consequences. The persistent specifier therefore applies when the duration of Diagnostic Criteria for Adjustment Disorder the disturbance is longer than 6 months in response to a A. The development of emotional or behavioral chronic stressor or to a stressor that has enduring symptoms in response to an identifiable stressor(s) consequences. occurring within 3 months of the onset of the stressor(s). B. These symptoms or behaviors are clinically Diagnostic Criteria for Prolonged Grief Disorder significant, as evidenced by one or both of the A. The death, at least 12 months ago, of a person who was following: close to the bereaved individual (for children and 1. Marked distress that is out of proportion adolescents, at least 6 months ago). to the severity or intensity of the stressor, taking into account the external B. Since the death, the development of a persistent grief context and the cultural factors that response characterized by one or both of the following  Nicole O. 1318 symptoms, which have been present most days to disorder or posttraumatic stress disorder, and are not a clinically significant degree. In addition, the attributable to the physiological effects of a substance symptom(s) has occurred nearly every day for at (e.g., medication, alcohol) or another medical condition. least the last month: 1. Intense yearning/longing for the deceased person. 2. Preoccupation with thoughts or memories of the deceased person (in “ DISSOCIATIVE DISODERS ” children and adolescents, preoccupation - are characterized by a disruption of and/or discontinuity in may focus on the circumstances of the the normal integration of consciousness, memory, identity, death). emotion, perception, body representation, motor control, and behavior. C. Since the death, at least three of the following symptoms have been present most days to a Diagnostic Criteria for Dissociative Identity Disorder clinically significant degree. In addition, the A. Disruption of identity characterized by two or more symptoms have occurred nearly every day for at distinct personality states, which may be described in least the last month: some cultures as an experience of possession. The 1. Identity disruption (e.g., feeling as disruption in identity involves marked discontinuity in though part of oneself has died) since sense of self and sense of agency, accompanied by the death. related alterations in affect, behavior, consciousness, 2. Marked sense of disbelief about the memory, perception, cognition, and/or sensory-motor death. functioning. These signs and symptoms may be 3. Avoidance of reminders that the person observed by others or reported by the individual. is dead (in children and adolescents, may be characterized by efforts to avoid B. Recurrent gaps in the recall of everyday events, reminders). important personal information, and/or traumatic 4. Intense emotional pain (e.g., anger, events that are inconsistent with ordinary forgetting. bitterness, sorrow) related to the death. 5. Difficulty reintegrating into one’s C. The symptoms cause clinically significant distress or relationships and activities after the impairment in social, occupational, or other important death (e.g., problems engaging with areas of functioning. friends, pursuing interests, or planning for the future). D. The disturbance is not a normal part of a broadly 6. Emotional numbness (absence or accepted cultural or religious practice. Note: In children, marked reduction of emotional the symptoms are not better explained by imaginary experience) as a result of the death. playmates or other fantasy play. 7. Feeling that life is meaningless as a result of the death. E. The symptoms are not attributable to the physiological 8. Intense loneliness as a result of the effects of a substance (e.g., blackouts or chaotic death. behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Diagnostic Criteria for Dissociative Amnesia E. The duration and severity of the bereavement A. An inability to recall important autobiographical reaction clearly exceed expected social, cultural, or information, usually of a traumatic or stressful nature, religious norms for the individual’s culture and that is inconsistent with ordinary forgetting. Note: context. Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or F. The symptoms are not better explained by another generalized amnesia for identity and life history. mental disorder, such as major depressive  Nicole O. 1318 B. The symptoms cause clinically significant distress symptomatic is persistent (typically more than 6 or impairment in social, occupational, or other months). important areas of functioning. Specify if: C. The disturbance is not attributable to the With predominant pain (previously pain disorder): This physiological effects of a substance (e.g., alcohol or specifier is for individuals whose somatic symptoms other drug of abuse, a medication) or a predominantly involve pain. neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, Specify if: sequelae of a closed head injury/traumatic brain Persistent: A persistent course is characterized by severe injury, other neurological condition). symptoms, marked impairment, and long duration (more than 6 months). D. The disturbance is not better explained by Specify current severity: dissociative identity disorder, posttraumatic stress Mild: Only one of the symptoms specified in Criterion B is disorder, acute stress disorder, somatic symptom fulfilled. disorder, or major or mild neurocognitive disorder. Moderate: Two or more of the symptoms specified in Criterion B are fulfilled. Coding note: The code for dissociative amnesia without Severe: Two or more of the symptoms specified in Criterion B dissociative fugue is F44.0. The code for dissociative are fulfilled, plus there are multiple somatic complaints (or amnesia with dissociative fugue is F44.1. one very severe somatic symptom). Specify if: F44.1 With dissociative fugue: Apparently purposeful travel or bewildered wandering that is associated with Diagnostic Criteria for Illness Anxiety Disorder amnesia for identity or for other important A. Preoccupation with having or acquiring a serious illness. autobiographical information. B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the “ SOMATIC SYMPTOMS & RELATED DISORDERS “ preoccupation is clearly excessive or disproportionate. Diagnostic Criteria for Somatic Symptom Disorder C. There is a high level of anxiety about health, and the A. One or more somatic symptoms that are individual is easily alarmed about personal health status. distressing or result in significant disruption of daily life. D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for B. Excessive thoughts, feelings, or behaviors related signs of illness) or exhibits maladaptive avoidance (e.g., to the somatic symptoms or associated health avoids doctor appointments and hospitals). concerns as manifested by at least one of the following: E. Illness preoccupation has been present for at least 6 1. Disproportionate and persistent months, but the specific illness that is feared may thoughts about the seriousness of one’s change over that period of time. symptoms. 2. Persistently high level of anxiety about F. The illness-related preoccupation is not better explained health or symptoms. by another mental disorder, such as somatic symptom 3. Excessive time and energy devoted to disorder, panic disorder, generalized anxiety disorder, these symptoms or health concerns. body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type. C. Although any one somatic symptom may not be continuously present, the state of being Specify whether:  Nicole O. 1318 Care-seeking type: Medical care, including physician Specify if: visits or undergoing tests and procedures, is frequently With mental disorder, including substance use disorders used. With medical condition Care-avoidant type: Medical care is rarely used. With another sleep disorder Coding note: The code F51.01 applies to all three specifiers. Code also the relevant associated mental disorder, medical “ SLEEP-WAKE DISORDERS” condition, or other sleep disorder immediately after the code for insomnia disorder in order to indicate the association. Diagnostic Criteria for Insomnia Disorder A. A predominant complaint of dissatisfaction with Specify if: sleep quantity or quality, associated with one (or Episodic: Symptoms last at least 1 month but less than 3 more) of the following symptoms: months. 1. Difficulty initiating sleep. (In children, this Persistent: Symptoms last 3 months or longer. may manifest as difficulty initiating sleep Recurrent: Two (or more) episodes within the space of 1 year. without caregiver intervention.) 2. Difficulty maintaining sleep, Note: Acute and short-term insomnia (i.e., symptoms lasting characterized by frequent awakenings or less than 3 months but otherwise meeting all criteria with problems returning to sleep after regard to frequency, intensity, distress, and/or impairment) awakenings. (In children, this may should be coded as an other specified insomnia disorder. manifest as difficulty returning to sleep without caregiver intervention.) 3. Early-morning awakening with inability to return to sleep. B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning. C. The sleep difficulty occurs at least 3 nights per week. D. The sleep difficulty is present for at least 3 months. E. The sleep difficulty occurs despite adequate opportunity for sleep. F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing- related sleep disorder, a circadian rhythm sleep- wake disorder, a parasomnia). G. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication). H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.