DSM-5-TR Diagnostic Manual PDF

 i DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FIFTH EDITION TEXT REVISION DSM-5-TR™  ii American Psychiatric Association DSM-5-TR Officers 2021–2022 PRESIDENT...

 i DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FIFTH EDITION TEXT REVISION DSM-5-TR™  ii American Psychiatric Association DSM-5-TR Officers 2021–2022 PRESIDENT VIVIAN B. PENDER, M.D. PRESIDENT-ELECT REBECCA W. BRENDEL, M.D., J.D. TREASURER RICHARD F. SUMMERS, M.D. SECRETARY SANDRA DEJONG, M.D., M.SC. Assembly SPEAKER MARY JO FITZ-GERALD, M.D., M.B.A. SPEAKER-ELECT ADAM P. NELSON, M.D. Board of Trustees ELIE G. AOUN, M.D., M.R.O. JENNY L. BOYER, M.D., PH.D., J.D. KENNETH CERTA, M.D. C. FREEMAN, M.D., M.B.A. MARY HASBAH ROESSEL, M.D. GLENN A. MARTIN, M.D. ERIC M. PLAKUN, M.D. MICHELE REID, M.D. FELIX TORRES, M.D., M.B.A. SANYA VIRANI, M.D., M.P.H. CHERYL D. WILLS, M.D. MELINDA YOUNG, M.D. UROOJ YAZDANI, M.D., RESIDENT-FELLOW MEMBER TRUSTEE-ELECT  DSM-5 Officers 2012–2013 PRESIDENT DILIP V. JESTE, M.D. PRESIDENT-ELECT JEFFREY A. LIEBERMAN, M.D. TREASURER DAVID FASSLER, M.D. SECRETARY ROGER PEELE, M.D. Assembly SPEAKER R. SCOTT BENSON, M.D. SPEAKER-ELECT MELINDA L. YOUNG, M.D. Board of Trustees JEFFREY AKAKA, M.D. CAROL A. BERNSTEIN, M.D. BRIAN CROWLEY, M.D. ANITA S. EVERETT, M.D. JEFFREY GELLER, M.D., M.P.H. MARC DAVID GRAFF, M.D. JAMES A. GREENE, M.D. JUDITH F. KASHTAN, M.D. MOLLY K. MCVOY, M.D. JAMES E. NININGER, M.D. JOHN M. OLDHAM, M.D. ALAN F. SCHATZBERG, M.D. ALIK S. WIDGE, M.D., PH.D. ERIK R. VANDERLIP, M.D., MEMBER-IN-TRAINING TRUSTEE-ELECT  iii DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FIFTH EDITION TEXT REVISION DSM-5-TR™  iv Copyright © 2022 American Psychiatric Association DSM, DSM-5, and DSM-5-TR are registered trademarks of the American Psychiatric Association. Use of these terms is prohibited without permission of the American Psychiatric Association. ALL RIGHTS RESERVED. Unless authorized in writing by the APA, no part of this book may be reproduced or used in a manner inconsistent with the APA’s copyright. This prohibition applies to unauthorized uses or reproductions in any form, including electronic applications. Correspondence regarding copyright permissions should be directed to DSM Permissions, American Psychiatric Association Publishing, 800 Maine Avenue SW, Suite 900, Washington, DC 20024-2812. Manufactured in the United States of America on acid-free paper. ISBN 978-0-89042-575-6 (Hardcover) 1st printing February 2022 ISBN 978-0-89042-576-3 (Paperback) 1st printing February 2022 American Psychiatric Association 800 Maine Avenue SW Suite 900 Washington, DC 20024-2812 www.psychiatry.org The correct citation for this book is American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2022. Library of Congress Cataloging-in-Publication Data Names: American Psychiatric Association, issuing body. Title: Diagnostic and statistical manual of mental disorders : DSM-5-TR / American Psychiatric Association. Other titles: DSM-5-TR Description: Fifth edition, text revision. | Washington, DC : American Psychiatric Association Publishing, | Includes index. Identifiers: LCCN 2021051781 (print) | LCCN 2021051782 (ebook) | ISBN 9780890425756 (hardcover ; alk. paper) | ISBN 9780890425763 (paperback ; alk. paper) | ISBN 9780890425770 (ebook) Subjects: MESH: Diagnostic and statistical manual of mental disorders. 5th ed | Mental Disorders—classification | Mental Disorders—diagnosis Classification: LCC RC455.2.C4 (print) | LCC RC455.2.C4 (ebook) | NLM WM 15 | DDC 616.89/ 075—dc23/eng/20211209 LC record available at https://lccn.loc.gov/2021051781 LC ebook record available at https://lccn.loc.gov/2021051782. British Library Cataloguing in Publication Data A CIP record is available from the British Library. Text Design—Tammy J. Cordova Manufacturing—Sheridan Books, Inc.  v Contents DSM-5-TR Chairs and Review Groups DSM-5 Task Force and Work Groups Preface to DSM-5-TR Preface to DSM-5 DSM-5-TR Classification Section I DSM-5 Basics Introduction Use of the Manual Cautionary Statement for Forensic Use of DSM-5 Section II Diagnostic Criteria and Codes Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders vi Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse-Control, and Conduct Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Mental Disorders and Additional Codes Medication-Induced Movement Disorders and Other Adverse Effects of Medication Other Conditions That May Be a Focus of Clinical Attention Section III Emerging Measures and Models Assessment Measures Culture and Psychiatric Diagnosis Alternative DSM-5 Model for Personality Disorders Conditions for Further Study Appendix Alphabetical Listing of DSM-5-TR Diagnoses and ICD-10-CM Codes Numerical Listing of DSM-5-TR Diagnoses and ICD-10-CM Codes DSM-5 Advisors and Other Contributors Index  vii DSM-5-TR Chairs MICHAEL B. FIRST, M.D. Revision Subcommittee Co-Chair and DSM-5-TR Editor PHILIP WANG, M.D., DR.P.H. Revision Subcommittee Co-Chair WILSON M. COMPTON, M.D., M.P.E. Revision Subcommittee Vice Chair DANIEL S. PINE, M.D. Revision Subcommittee Vice Chair SUSAN K. SCHULTZ, M.D. Text Consultant PHILIP R. MUSKIN, M.D., M.A. Conflict of Interest Review Editor ANN M. ENG DSM Managing Editor APA Division of Research Staff on DSM-5-TR NITIN GOGTAY, M.D. Chief, Division of Research, and Deputy Medical Director PHILIP WANG, M.D., DR.P.H. former Deputy Medical Director and Director of Research Diana E. Clarke, Ph.D., Managing Director of Research and Senior Research Statistician/Epidemiologist Lamyaa H. Yousif, M.D., Ph.D., M.Sc., Senior DSM Operations Manager and Research Associate Sejal Patel, M.P.H., Senior Research Associate Laura Thompson, M.S., Research Associate and Program Manager Stephanie Smith, Ph.D., former Senior DSM Operations Manager and Science Writer APA Office of the Medical Director SAUL LEVIN, M.D., M.P.A. CEO and Medical Director COLLEEN M. COYLE, J.D. General Counsel  DSM Steering Committee PAUL S. APPELBAUM, M.D. Chairperson ELLEN LEIBENLUFT, M.D. Vice Chairperson KENNETH S. KENDLER, M.D. Vice Chairperson Members Renato D. Alarcón, M.D., M.P.H Pamela Y. Collins, M.D., M.P.H. Michelle G. Craske, Ph.D. Michael B. First, M.D. Dolores Malaspina, M.D., M.S., M.S.P.H. Glenn Martin, M.D. Susan K. Schultz, M.D. Andrew E. Skodol, M.D. Kimberly A. Yonkers, M.D. viii Liaisons Wilson M. Compton, M.D., M.P.E., National Institute on Drug Abuse George F. Koob, Ph.D. (2019–2020), National Institute on Alcohol Abuse and Alcoholism Lorenzo Leggio, M.D., Ph.D. (2020– ), National Institute on Alcohol Abuse and Alcoholism Sarah Morris, Ph.D., National Institute of Mental Health Cross-Cutting Review Groups Cross-Cutting Culture Review Group ROBERTO LEWIS-FERNÁNDEZ, M.D. Chair Renato D. Alarcón, M.D., M.P.H. Anne E. Becker, M.D., Ph.D. Kamaldeep Bhui, C.B.E., M.D. Guilherme Borges, Ph.D. Suparna Choudhury, Ph.D. Jack Drescher, M.D. Ana Gómez-Carrillo, M.D. Brian J. Hall, Ph.D. Felicia Heidenreich-Dutray, M.D. Eva Heim, Ph.D. Stefan G. Hofmann, Ph.D. G. Eric Jarvis, M.D. Christian Kieling, M.D., Ph.D. Laurence J. Kirmayer, M.D. Brandon Kohrt, M.D., Ph.D. Rishav Koirala, M.D., Ph.D. candidate Andrian Liem, Ph.D. Francis G. Lu, M.D. Kwame McKenzie, M.D. Fahimeh Mianji, Ph.D. Byamah Brian Mutamba, M.B.Ch.B., M.Med. (Psych), M.P.H., Ph.D. Claudia Rafful, Ph.D. Cécile Rousseau, M.D. Andrew G. Ryder, Ph.D. Vedat Şar, M.D. Soraya Seedat, M.D., Ph.D. Gwen Yeo, Ph.D. Ricardo Orozco Zavala, Ph.D. Cross-Cutting Forensic Review Group DEBRA A. PINALS, M.D. Chair Carl E. Fisher, M.D. Steven K. Hoge, M.D. Reena Kapoor, M.D. Jeffrey L. Metzner, M.D. Howard Zonana, M.D. Cross-Cutting Sex and Gender Review Group KIMBERLY A. YONKERS, M.D. Chair Margaret Altemus, M.D. Lucy C. Barker, M.D. Ariadna Forray, M.D. Constance Guille, M.D. Susan G. Kornstein, M.D. Melissa A. Nishawala, M.D. Jennifer L. Payne, M.D. Walter A. Rocca M.D., M.P.H. Manpreet K. Singh, M.D., M.S. Simone Vigod, M.D., M.Sc. Kristine Yaffe, M.D. Anahita Bassir Nia, M.D., Consultant ix Cross-Cutting Suicide Review Group MICHAEL F. GRUNEBAUM, M.D. Lead Reviser David A. Brent, M.D., Reviewer Katalin Szanto, M.D., Reviewer Ethnoracial Equity and Inclusion Work Group ROBERTO LEWIS-FERNÁNDEZ, M.D. Co-Chair DANIELLE HAIRSTON, M.D. Co-Chair Renato D. Alarcón, M.D., M.P.H. Paul S. Appelbaum, M.D., ex officio Diana E. Clarke, Ph.D., M.Sc. Constance E. Dunlap, M.D. Nitin Gogtay, M.D. Joseph P. Gone, Ph.D. Jessica E. Isom, M.D., M.P.H. Laurence J. Kirmayer, M.D. Francis G. Lu, M.D. Dolores Malaspina, M.D., M.S., M.S.P.H. Altha J. Stewart, M.D. Lamyaa H. Yousif, M.D., Ph.D., M.Sc. Review Groups by Section II Chapter Neurodevelopmental Disorders GILLIAN BAIRD, M.B., B.CHIR. Section Editor Michael H. Bloch, M.D., M.S. Jane E. Clark, Ph.D. James C. Harris, M.D.† Bryan H. King, M.D., M.B.A. James F. Leckman, M.D., Ph.D. Amy E. Margolis, Ph.D. Diane Paul, Ph.D. Steven R. Pliszka, M.D. Mabel L. Rice, Ph.D. Amy M. Wetherby, Ph.D. Juliann Woods, Ph.D. Schizophrenia Spectrum and Other Psychotic Disorders STEPHAN HECKERS, M.D. Section Editor Somya Abubucker, M.D. Oliver Freudenreich, M.D. Paolo Fusar-Poli, M.D., Ph.D. Dr. med. Stefan Gutwinski Andreas Heinz, M.D., Ph.D. Frank Pillmann, M.D., Ph.D. James B. Potash, M.D., M.P.H. Marc A. Schuckit, M.D. Paul Summergrad, M.D. Rajiv Tandon, M.D. Sebastian Walther, M.D. Bipolar and Related Disorders MICHAEL J. OSTACHER, M.D., M.P.H., M.M.SC. Section Editor Benjamin I. Goldstein, M.D., Ph.D. Greg Murray, Ph.D. Martha Sajatovic, M.D. Marc A. Schuckit, M.D. Paul Summergrad, M.D. Trisha Suppes, M.D., Ph.D. Holly A. Swartz, M.D. Bryan K. Tolliver, M.D., Ph.D. x Depressive Disorders WILLIAM H. CORYELL, M.D.  Section Editor Scott R. Beach, M.D. Ellen Leibenluft, M.D. Robert M. McCarron, D.O. Marc A. Schuckit, M.D. Kimberly A. Yonkers, M.D. Sidney Zisook, M.D. Anxiety Disorders MICHELLE G. CRASKE, PH.D. Section Editor Katja Beesdo-Baum, Ph.D. Susan Bogels, Ph.D. Lily A. Brown, Ph.D. Richard LeBeau, Ph.D. Vijaya Manicavasagar, Ph.D. Bita Mesri, Ph.D. Peter Muris, Ph.D. Thomas H. Ollendick, Ph.D. Kate Wolitzky-Taylor, Ph.D. Tomislav D. Zbozinek, Ph.D. Susan K. Schultz, M.D., Text Consultant Obsessive-Compulsive and Related Disorders KATHARINE A. PHILLIPS, M.D. Section Editor Randy O. Frost, Ph.D. Jon E. Grant, M.D., M.P.H., J.D. Christopher Pittenger, M.D., Ph.D. Helen Blair Simpson, M.D., Ph.D. Dan J. Stein, M.D., Ph.D. Gail Steketee, Ph.D. Susan K. Schultz, M.D., Text Consultant Trauma- and Stressor-Related Disorders MATTHEW J. FRIEDMAN, M.D., PH.D. Section Editor David A. Brent, M.D. Richard Bryant, Ph.D. Julianna M. Finelli, M.D. Dean G. Kilpatrick, Ph.D. Roberto Lewis-Fernández, M.D. Holly G. Prigerson, Ph.D. Robert S. Pynoos, M.D., M.P.H. Paula P. Schnurr, Ph.D. James J. Strain, M.D. Robert J. Ursano, M.D. Frank W. Weathers, Ph.D. Charles H. Zeanah Jr., M.D. Susan K. Schultz, M.D., Text Consultant Dissociative Disorders RICHARD J. LOEWENSTEIN, M.D. Section Editor Frank W. Putnam Jr., M.D. Daphne Simeon, M.D. Susan K. Schultz, M.D., Text Consultant Somatic Symptom and Related Disorders JAMES L. LEVENSON, M.D. Section Editor Marc D. Feldman, M.D. Bernd Löwe, Prof. Dr. med. Dipl.-Psych. Jill M. Newby, Ph.D. Jon Stone, M.B.Ch.B., Ph.D. Gregory Yates, M.A. xi Feeding and Eating Disorders B. TIMOTHY WALSH, M.D. Section Editor MICHAEL J. DEVLIN, M.D. Reviewer Elimination Disorders DANIEL S. PINE, M.D.  Section Editor Israel Franco, M.D. Patricio C. Gargollo, M.D. Peter L. Lu, M.D., M.S. Stephen A. Zderic, M.D. Sleep-Wake Disorders MICHAEL J. SATEIA, M.D. Section Editor R. Robert Auger, M.D. Jack D. Edinger, Ph.D. Kiran Maski, M.D., M.P.H. Stuart F. Quan, M.D. Thomas E. Scammell, M.D. Marc A. Schuckit, M.D. Erik K. St. Louis, M.D., M.S. John W. Winkelman, M.D., Ph.D. Sexual Dysfunctions LORI A. BROTTO, PH.D. Section Editor Stanley E. Althof, Ph.D. Cynthia A. Graham, Ph.D. Dennis Kalogeropoulos, Ph.D. Julie Larouche, M.Ps. Pedro Nobre, Ph.D. Michael A. Perelman, Ph.D. Natalie O. Rosen, Ph.D. Marc A. Schuckit, M.D. Sharon J. Parish, M.D., Medical Reviewer Susan K. Schultz, M.D., Text Consultant Gender Dysphoria JACK DRESCHER, M.D. Section Editor Stewart L. Adelson, M.D. Walter O. Bockting, Ph.D. William Byne, M.D., Ph.D. Annelou L.C. de Vries, M.D., Ph.D. Cecilia Dhejne, M.D., Ph.D. Thomas D. Steensma, Ph.D. Disruptive, Impulse-Control, and Conduct Disorders PAUL J. FRICK, PH.D. Section Editor Jeffrey D. Burke, Ph.D. S. Alexandra Burt, Ph.D. Emil F. Coccaro, M.D. Jon E. Grant, M.D., M.P.H., J.D. xii Substance-Related and Addictive Disorders DEBORAH S. HASIN, PH.D. Section Editor Carlos Blanco, M.D., Ph.D. David Bochner, Ph.D. Alan J. Budney, Ph.D. Wilson M. Compton, M.D., M.P.E. John R. Hughes, M.D. Laura M. Juliano, Ph.D. Bradley T. Kerridge, Ph.D. Marc N. Potenza, M.D., Ph.D. Marc A. Schuckit, M.D. Neurocognitive Disorders SUSAN K. SCHULTZ, M.D. Section Editor Brian S. Appleby, M.D. David B. Arciniegas, M.D. Karl Goodkin, M.D., Ph.D. Sharon K. Inouye, M.D., M.P.H. Constantine Lyketsos, M.D., M.H.S. Ian G. McKeith, M.D. Bruce L. Miller, M.D. David J. Moser, Ph.D. Peggy C. Nopoulos, M.D. Howard J. Rosen, M.D. Perminder S. Sachdev, M.D., Ph.D. Marc A. Schuckit, M.D. Paul Summergrad, M.D. Daniel Weintraub, M.D. Personality Disorders MARK ZIMMERMAN, M.D. Section Editor Donald W. Black, M.D. Robert F. Bornstein, Ph.D. Erin A. Hazlett, Ph.D. Lisa Lampe, M.B.,B.S., Ph.D. Royce Lee, M.D. Joshua D. Miller, Ph.D. Anthony Pinto, Ph.D. Elsa F. Ronningstam, Ph.D. Douglas B. Samuel, Ph.D. Susan K. Schultz, M.D. Glen L. Xiong, M.D. Mary C. Zanarini, Ed.D. Paraphilic Disorders RICHARD B. KRUEGER, M.D. Section Editor Peer Briken, M.D. Luk Gijs, Ph.D. Andreas Mokros, Ph.D. Pekka Santtila, Ph.D. Michael C. Seto, Ph.D. Medication-Induced Movement Disorders and Other Adverse Effects of Medication ALAN F. SCHATZBERG, M.D. Section Editor Jacob S. Ballon, M.D., M.P.H. Kevin J. Black, M.D. Peter F. Buckley, M.D. Leslie Citrome, M.D., M.P.H. Ira D. Glick, M.D. Rona Hu, M.D. Paul E. Keck Jr., M.D. Stephen R. Marder, M.D. Laura Marsh, M.D. Richard C. Shelton, M.D. Nolan Williams, M.D. xiii Other Conditions That May Be a Focus of Clinical Attention Michael B. First, M.D. Nitin Gogtay, M.D. Diana E. Clarke, Ph.D. Lamyaa H. Yousif, M.D., Ph.D., M.Sc. Reviewers for Section III Texts Assessment Measures Nitin Gogtay, M.D. Philip Wang, M.D., Dr.P.H. Diana E. Clarke, Ph.D. Lamyaa H. Yousif, M.D., Ph.D., M.Sc. Stephanie Smith, Ph.D. Culture and Psychiatric Diagnosis ROBERTO LEWIS-FERNÁNDEZ, M.D. Section Editor Neil Krishan Aggarwal, M.D., M.B.A., M.A. Ana Gómez-Carrillo, M.D. G. Eric Jarvis, M.D. Bonnie N. Kaiser, Ph.D., M.P.H. Laurence J. Kirmayer, M.D. Brandon Kohrt, M.D., Ph.D. Conditions for Further Study Attenuated Psychosis Syndrome Paolo Fusar-Poli, M.D., Ph.D. Stephan Heckers, M.D. Depressive Episodes With Short-Duration Hypomania Benjamin I. Goldstein, M.D., Ph.D. Greg Murray, Ph.D. Michael J. Ostacher, M.D., M.P.H., M.M.Sc. Caffeine Use Disorder Laura M. Juliano, Ph.D. Alan J. Budney, Ph.D. Deborah S. Hasin, Ph.D. Wilson M. Compton, M.D., M.P.E. Internet Gaming Disorder Charles O’Brien, M.D., Ph.D. Jon E. Grant, M.D., M.P.H., J.D. Wilson M. Compton, M.D., M.P.E. Deborah S. Hasin, Ph.D. Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure Bridget F. Grant, Ph.D., Ph.D. Deborah S. Hasin, Ph.D. Suicidal Behavior Disorder Michael F. Grunebaum, M.D. David A. Brent, M.D. Katalin Szanto, M.D. Nonsuicidal Self-Injury E. David Klonsky, Ph.D. Jennifer J. Muehlenkamp, Ph.D. Jason J. Washburn, Ph.D. Review Committees of the DSM Steering Committee Note: These groups reviewed formal proposals for changes vetted by the DSM Steering Committee since the publication of DSM-5. Neurodevelopmental Disorders DANIEL S. PINE, M.D. Chairperson Catherine E. Lord, Ph.D. Sally Ozonoff, Ph.D. Joseph Piven, M.D. Moira A. Rynn, M.D. Anita Thapar, M.D. xiv Serious Mental Disorders CARRIE E. BEARDEN, PH.D. Chairperson William T. Carpenter, M.D. Benoit H. Mulsant, M.D., M.S. Peter V. Rabins, M.D., M.P.H. Mark Zimmerman, M.D. Internalizing Disorders ROBERTO LEWIS-FERNÁNDEZ, M.D. Chairperson William H. Coryell, M.D. Constance Hammen, Ph.D. James L. Levenson, M.D. Katharine A. Phillips, M.D. Dan J. Stein, M.D., Ph.D. Additional Reviewers for Prolonged Grief Disorder David A. Brent, M.D. Michael B. First, M.D. Matthew J. Friedman, M.D., Ph.D. Christopher M. Layne, Ph.D. Roberto Lewis-Fernández, M.D. Paul K. Maciejewski, Ph.D. Katharine A. Phillips, M.D. Holly G. Prigerson, Ph.D. Robert S. Pynoos, M.D. Charles F. Reynolds III, M.D. M. Katherine Shear, M.D. Thomas A. Widiger, Ph.D. Kimberly A. Yonkers, M.D. Helena Chmura Kraemer, Ph.D., Consultant Externalizing Disorders and Personality Disorders CARLOS BLANCO, M.D., PH.D. Chairperson Lee Anna Clark, Ph.D. Richard B. Krueger, M.D. Christopher J. Patrick, Ph.D. Marc A. Schuckit, M.D. Body Systems Disorders PETER DANIOLOS, M.D. Chairperson Cynthia A. Graham, Ph.D. Debra K. Katzman, M.D. B. Timothy Walsh, M.D. Joel Yager, M.D. †Died April 5, 2021.  xv DSM-5 Task Force and Work Groups DAVID J. KUPFER, M.D. Task Force Chair DARREL A. REGIER, M.D., M.P.H. Task Force Vice-Chair William E. Narrow, M.D., M.P.H., Research Director Susan K. Schultz, M.D., Text Editor Emily A. Kuhl, Ph.D., APA Text Editor Dan G. Blazer, M.D., Ph.D., M.P.H. Jack D. Burke Jr., M.D., M.P.H. William T. Carpenter Jr., M.D. F. Xavier Castellanos, M.D. Wilson M. Compton, M.D., M.P.E. Joel E. Dimsdale, M.D. Javier I. Escobar, M.D., M.Sc. Jan A. Fawcett, M.D. Bridget F. Grant, Ph.D., Ph.D. (2009–) Steven E. Hyman, M.D. (2007–2012) Dilip V. Jeste, M.D. (2007–2011) Helena C. Kraemer, Ph.D. Daniel T. Mamah, M.D., M.P.E. James P. McNulty, A.B., Sc.B. Howard B. Moss, M.D. (2007–2009) Charles P. O’Brien, M.D., Ph.D. Roger Peele, M.D. Katharine A. Phillips, M.D. Daniel S. Pine, M.D. Charles F. Reynolds III, M.D. Maritza Rubio-Stipec, Sc.D. David Shaffer, M.D. Andrew E. Skodol II, M.D. Susan E. Swedo, M.D. B. Timothy Walsh, M.D. Philip Wang, M.D., Dr.P.H. (2007–2012) William M. Womack, M.D. Kimberly A. Yonkers, M.D. Kenneth J. Zucker, Ph.D. Norman Sartorius, M.D., Ph.D., Consultant APA Division of Research Staff on DSM-5 Darrel A. Regier, M.D., M.P.H., Director, Division of Research William E. Narrow, M.D., M.P.H., Associate Director Emily A. Kuhl, Ph.D., Senior Science Writer; Staff Text Editor Diana E. Clarke, Ph.D., M.Sc., Research Statistician Lisa H. Greiner, M.S.S.A., DSM-5 Field Trials Project Manager Eve K. Moscicki, Sc.D., M.P.H., Director, Practice Research Network S. Janet Kuramoto, Ph.D., M.H.S., Senior Scientific Research Associate, Practice Research Network Amy Porfiri, M.B.A. Director of Finance and Administration Jennifer J. Shupinka, Assistant Director, DSM Operations Seung-Hee Hong, DSM Senior Research Associate Anne R. Hiller, DSM Research Associate Alison S. Beale, DSM Research Associate Spencer R. Case, DSM Research Associate Joyce C. West, Ph.D., M.P.P., Health Policy Research Director, Practice Research Network Farifteh F. Duffy, Ph.D., Quality Care Research Director, Practice Research Network Lisa M. Countis, Field Operations Manager, Practice Research Network Christopher M. Reynolds, Executive Assistant APA Office of the Medical Director JAMES H. SCULLY JR., M.D. Medical Director and CEO xvi Editorial and Coding Consultants Michael B. First, M.D. Maria N. Ward, M.Ed., RHIT, CCS-P DSM-5 Work Groups  ADHD and Disruptive Behavior Disorders DAVID SHAFFER, M.D. Chair F. XAVIER CASTELLANOS, M.D. Co-Chair Paul J. Frick, Ph.D., Text Coordinator Glorisa Canino, Ph.D. Terrie E. Moffitt, Ph.D. Joel T. Nigg, Ph.D. Luis Augusto Rohde, M.D., Sc.D. Rosemary Tannock, Ph.D. Eric A. Taylor, M.B. Richard Todd, Ph.D., M.D. (d. 2008) Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders KATHARINE A. PHILLIPS, M.D. Chair Michelle G. Craske, Ph.D., Text Coordinator J. Gavin Andrews, M.D. Susan M. Bögels, Ph.D. Matthew J. Friedman, M.D., Ph.D. Eric Hollander, M.D. (2007–2009) Roberto Lewis-Fernández, M.D., M.T.S. Robert S. Pynoos, M.D., M.P.H. Scott L. Rauch, M.D. H. Blair Simpson, M.D., Ph.D. David Spiegel, M.D. Dan J. Stein, M.D., Ph.D. Murray B. Stein, M.D. Robert J. Ursano, M.D. Hans-Ulrich Wittchen, Ph.D. Childhood and Adolescent Disorders DANIEL S. PINE, M.D. Chair Ronald E. Dahl, M.D. E. Jane Costello, Ph.D. (2007–2009) Regina Smith James, M.D. Rachel G. Klein, Ph.D. James F. Leckman, M.D. Ellen Leibenluft, M.D. Judith H. L. Rapoport, M.D. Charles H. Zeanah, M.D. Eating Disorders B. TIMOTHY WALSH, M.D. Chair Stephen A. Wonderlich, Ph.D., Text Coordinator Evelyn Attia, M.D. Anne E. Becker, M.D., Ph.D., Sc.M. Rachel Bryant-Waugh, M.D. Hans W. Hoek, M.D., Ph.D. Richard E. Kreipe, M.D. Marsha D. Marcus, Ph.D. James E. Mitchell, M.D. Ruth H. Striegel-Moore, Ph.D. G. Terence Wilson, Ph.D. Barbara E. Wolfe, Ph.D., A.P.R.N. xvii Mood Disorders JAN A. FAWCETT, M.D. Chair Ellen Frank, Ph.D., Text Coordinator Jules Angst, M.D. (2007–2008) William H. Coryell, M.D. Lori L. Davis, M.D. Raymond J. DePaulo, M.D. Sir David Goldberg, M.D. James S. Jackson, Ph.D. Kenneth S. Kendler, M.D. (2007–2010) Mario Maj, M.D., Ph.D. Husseini K. Manji, M.D. (2007–2008) Michael R. Phillips, M.D. Trisha Suppes, M.D., Ph.D. Carlos A. Zarate, M.D. Neurocognitive Disorders  DILIP V. JESTE, M.D. (2007–2011) Chair Emeritus DAN G. BLAZER, M.D., PH.D., M.P.H. Chair RONALD C. PETERSEN, M.D., PH.D. Co-Chair Mary Ganguli, M.D., M.P.H., Text Coordinator Deborah Blacker, M.D., Sc.D. Warachal Faison, M.D. (2007–2008) Igor Grant, M.D. Eric J. Lenze, M.D. Jane S. Paulsen, Ph.D. Perminder S. Sachdev, M.D., Ph.D. Neurodevelopmental Disorders SUSAN E. SWEDO, M.D. Chair Gillian Baird, M.A., M.B., B.Chir., Text Coordinator Edwin H. Cook Jr., M.D. Francesca G. Happé, Ph.D. James C. Harris, M.D. Walter E. Kaufmann, M.D. Bryan H. King, M.D. Catherine E. Lord, Ph.D. Joseph Piven, M.D. Sally J. Rogers, Ph.D. Sarah J. Spence, M.D., Ph.D. Rosemary Tannock, Ph.D. Fred Volkmar, M.D. (2007–2009) Amy M. Wetherby, Ph.D. Harry H. Wright, M.D. Personality and Personality Disorders1 ANDREW E. SKODOL, M.D. Chair JOHN M. OLDHAM, M.D. Co-Chair Robert F. Krueger, Ph.D., Text Coordinator Renato D. Alarcón, M.D., M.P.H. Carl C. Bell, M.D. Donna S. Bender, Ph.D. Lee Anna Clark, Ph.D. W. John Livesley, M.D., Ph.D. (2007–2012) Leslie C. Morey, Ph.D. Larry J. Siever, M.D. Roel Verheul, Ph.D. (2008–2012) xviii Psychotic Disorders WILLIAM T. CARPENTER JR., M.D. Chair Deanna M. Barch, Ph.D., Text Coordinator Juan R. Bustillo, M.D. Wolfgang Gaebel, M.D. Raquel E. Gur, M.D., Ph.D. Stephan H. Heckers, M.D. Dolores Malaspina, M.D., M.S.P.H. Michael J. Owen, M.D., Ph.D. Susan K. Schultz, M.D. Rajiv Tandon, M.D. Ming T. Tsuang, M.D., Ph.D. Jim van Os, M.D. Sexual and Gender Identity Disorders KENNETH J. ZUCKER, PH.D. Chair Lori Brotto, Ph.D., Text Coordinator Irving M. Binik, Ph.D. Ray M. Blanchard, Ph.D. Peggy T. Cohen-Kettenis, Ph.D. Jack Drescher, M.D. Cynthia A. Graham, Ph.D. Martin P. Kafka, M.D. Richard B. Krueger, M.D. Niklas Långström, M.D., Ph.D. Heino F.L. Meyer-Bahlburg, Dr. rer. nat. Friedemann Pfäfflin, M.D. Robert Taylor Segraves, M.D., Ph.D.  Sleep-Wake Disorders CHARLES F. REYNOLDS III, M.D. Chair Ruth M. O’Hara, Ph.D., Text Coordinator Charles M. Morin, Ph.D. Allan I. Pack, Ph.D. Kathy P. Parker, Ph.D., R.N. Susan Redline, M.D., M.P.H. Dieter Riemann, Ph.D. Somatic Symptom Disorders JOEL E. DIMSDALE, M.D. Chair James L. Levenson, M.D., Text Coordinator Arthur J. Barsky III, M.D. Francis Creed, M.D. Nancy Frasure-Smith, Ph.D. (2007–2011) Michael R. Irwin, M.D. Francis J. Keefe, Ph.D. (2007–2011) Sing Lee, M.D. Michael Sharpe, M.D. Lawson R. Wulsin, M.D. Substance-Related Disorders CHARLES P. O’BRIEN, M.D., PH.D. Chair THOMAS J. CROWLEY, M.D. Co-Chair Wilson M. Compton, M.D., M.P.E., Text Coordinator Marc Auriacombe, M.D. Guilherme L. G. Borges, M.D., Dr.Sc. Kathleen K. Bucholz, Ph.D. Alan J. Budney, Ph.D. Bridget F. Grant, Ph.D., Ph.D. Deborah S. Hasin, Ph.D. Thomas R. Kosten, M.D. (2007–2008) Walter Ling, M.D. Spero M. Manson, Ph.D. (2007-2008) A. Thomas McLellan, Ph.D. (2007–2008) Nancy M. Petry, Ph.D. Marc A. Schuckit, M.D. Wim van den Brink, M.D., Ph.D. (2007–2008) xix DSM-5 Study Groups Diagnostic Spectra and DSM/ICD Harmonization STEVEN E. HYMAN, M.D. Chair (2007–2012) William T. Carpenter Jr., M.D. Wilson M. Compton, M.D., M.P.E. Jan A. Fawcett, M.D. Helena C. Kraemer, Ph.D. David J. Kupfer, M.D. William E. Narrow, M.D., M.P.H. Charles P. O’Brien, M.D., Ph.D. John M. Oldham, M.D. Katharine A. Phillips, M.D. Darrel A. Regier, M.D., M.P.H. Lifespan Developmental Approaches ERIC J. LENZE, M.D. Chair SUSAN K. SCHULTZ, M.D. Chair Emeritus DANIEL S. PINE, M.D. Chair Emeritus Dan G. Blazer, M.D., Ph.D., M.P.H. F. Xavier Castellanos, M.D. Wilson M. Compton, M.D., M.P.E. Daniel T. Mamah, M.D., M.P.E. Andrew E. Skodol II, M.D. Susan E. Swedo, M.D. Gender and Cross-Cultural Issues KIMBERLY A. YONKERS, M.D. Chair  ROBERTO LEWIS-FERNÁNDEZ, M.D., M.T.S. Co-Chair, Cross-Cultural Issues Renato D. Alarcón, M.D., M.P.H. Diana E. Clarke, Ph.D., M.Sc. Javier I. Escobar, M.D., M.Sc. Ellen Frank, Ph.D. James S. Jackson, Ph.D. Spero M. Manson, Ph.D. (2007–2008) James P. McNulty, A.B., Sc.B. Leslie C. Morey, Ph.D. William E. Narrow, M.D., M.P.H. Roger Peele, M.D. Philip Wang, M.D., Dr.P.H. (2007–2012) William M. Womack, M.D. Kenneth J. Zucker, Ph.D. Psychiatric/General Medical Interface LAWSON R. WULSIN, M.D. Chair Ronald E. Dahl, M.D. Joel E. Dimsdale, M.D. Javier I. Escobar, M.D., M.Sc. Dilip V. Jeste, M.D. (2007–2011) Walter E. Kaufmann, M.D. Richard E. Kreipe, M.D. Ronald C. Petersen, M.D., Ph.D. Charles F. Reynolds III, M.D. Robert Taylor Segraves, M.D., Ph.D. B. Timothy Walsh, M.D. xx Impairment and Disability JANE S. PAULSEN, PH.D. Chair J. Gavin Andrews, M.D. Glorisa Canino, Ph.D. Lee Anna Clark, Ph.D. Diana E. Clarke, Ph.D., M.Sc. Michelle G. Craske, Ph.D. Hans W. Hoek, M.D., Ph.D. Helena C. Kraemer, Ph.D. William E. Narrow, M.D., M.P.H. David Shaffer, M.D. Diagnostic Assessment Instruments JACK D. BURKE JR., M.D., M.P.H. Chair Lee Anna Clark, Ph.D. Diana E. Clarke, Ph.D., M.Sc. Bridget F. Grant, Ph.D., Ph.D. Helena C. Kraemer, Ph.D. William E. Narrow, M.D., M.P.H. David Shaffer, M.D. DSM-5 Research Group WILLIAM E. NARROW, M.D., M.P.H. Chair Jack D. Burke Jr., M.D., M.P.H. Diana E. Clarke, Ph.D., M.Sc. Helena C. Kraemer, Ph.D. David J. Kupfer, M.D. Darrel A. Regier, M.D., M.P.H. David Shaffer, M.D. Course Specifiers and Glossary WOLFGANG GAEBEL, M.D. Chair Ellen Frank, Ph.D. Charles P. O’Brien, M.D., Ph.D. Norman Sartorius, M.D., Ph.D., Consultant Susan K. Schultz, M.D. Dan J. Stein, M.D., Ph.D. Eric A. Taylor, M.B. David J. Kupfer, M.D. Darrel A. Regier, M.D., M.P.H. 1 The members of the Personality and Personality Disorders Work Group are responsible for the alternative DSM-5 model for personality disorders that is included in Section III. The Section II personality disorders criteria and text (with updating of the text) are retained from DSM-IV-TR.  xxi Preface to DSM-5-TR The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), is the first published revision to DSM-5. This revised manual integrates the original published DSM-5 diagnostic criteria with modifications (mostly for clarity) for over 70 disorders, comprehensively updated descriptive text accompanying each of the DSM disorders based on reviews of the literature since the publication of DSM-5, and the addition of a new diagnosis, prolonged grief disorder, and symptom codes for reporting suicidal and nonsuicidal self-injurious behavior. These changes differ from the scope of the prior text revision, DSM-IV-TR, in which the updates were confined almost exclusively to the text, leaving the diagnostic criteria virtually unchanged. This edition also integrates all prior online updates made to DSM-5 after its publication in 2013, in response to usage, specific scientific advances, and ICD-10-CM coding adjustments through an iterative revision process. Consequently, DSM-5-TR is the product of three separate revision processes, each one overseen by separate (but overlapping) groups of experts: the development of the original DSM-5 diagnostic criteria and text by the DSM-5 Task Force, published in 2013; updates to the DSM-5 diagnostic criteria and text by the DSM Steering Committee, which has overseen the iterative revision process; and fully updated text overseen by the Revision Subcommittee. The clinical and research understanding of mental disorders continues to advance. As a result, most of the DSM-5-TR disorder texts have had at least some revision since the 9 years from original publication in DSM-5, with the overwhelming majority having had significant revisions. Sections of the text that were most extensively updated were Prevalence, Risk and Prognostic Factors, Culture-Related Diagnostic Issues, Sex- and Gender-Related Diagnostic Issues, Association With Suicidal Thoughts or Behavior, and Comorbidity. Also, for the first time ever, the entire DSM text has been reviewed and revised by a Work Group on Ethnoracial Equity and Inclusion to ensure appropriate attention to risk factors such as the experience of racism and discrimination, as well as to the use of non-stigmatizing language. For future periodic DSM-5-TR coding and other updates, see www.dsm5.org. For benefit of reference in this manual, “DSM” refers generally to DSM as an entity, not specifying a particular edition (e.g., “Clinical training and experience are needed to use DSM for determining a clinical diagnosis.”). “DSM-5” refers to the entire set of currently approved criteria sets, disorders, other conditions, and content officially published in May 2013. “DSM-5- TR” refers to approved text in this current volume. Although the scope of the text revision did not include conceptual changes to the criteria sets or to other DSM-5 constructs, the need to make changes in certain diagnostic criteria sets for the purpose of clarification became apparent in conjunction with the text updates made across the book. Because the conceptual construct of criteria is unchanged, the criteria sets in DSM-5-TR that had their origins in DSM-5 are still referred to as “DSM-5-criteria.” The new diagnostic entity prolonged grief disorder is referred to as a DSM-5-TR disorder, because of its addition in this volume. The development of DSM-5-TR was a tremendous team effort. We are especially indebted to the tireless efforts of Wilson M. Compton, M.D., M.P.E., and Daniel S. Pine, M.D., as DSM-5 Text Revision Subcommittee Vice Chairs, as well as the more than 200 experts from across our field who did the lion’s share of the work in the preparation of the text revision. We would also like to thank Paul Appelbaum, M.D., Chair of the DSM Steering xxii Committee, along with the entire DSM Steering Committee, for their careful review of the text and criteria clarifications, and for making other helpful suggestions. Special gratitude goes to Ann M. Eng, DSM Managing Editor, for her timely shepherding of the DSM-5-TR development process from planning to completion and for her meticulous attention to detail, all critical to the success of this revision. We are grateful for the valuable contributions and help of Nitin Gogtay, M.D., Chief of the American Psychiatric Association Division of Research and Deputy Medical Director; Diana E. Clarke, Ph.D., Managing Director of Research and Senior Research Statistician/Epidemiologist; and Lamyaa H. Yousif, M.D., Ph.D., M.Sc., Senior DSM Operations Manager and Research Associate. We are thankful for the leadership of John McDuffie, Publisher, American Psychiatric Association Publishing, and the work of the following editorial and production staff at American Psychiatric Association Publishing in bringing this important work to fruition: Greg Kuny, Managing Editor, Books; Tammy Cordova, Graphic Design Manager; Andrew Wilson, Director of Production; Judy Castagna, Assistant Director of Production Services; Erika Parker, Acquisitions Editor; Alisa Riccardi, Senior Editor, Books; and Carrie Y. Farnham, Senior Editor, Books. Finally, we also recognize with appreciation Saul Levin, M.D., M.P.A., CEO and Medical Director of the American Psychiatric Association, for his advocacy and support of this comprehensive text revision. Michael B. First, M.D. Revision Subcommittee Co-Chair and DSM-5-TR Editor Philip Wang, M.D., Dr.P.H. Revision Subcommittee Co-Chair November 5, 2021  xxiii Preface to DSM-5 The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification of mental disorders with associated criteria designed to facilitate more reliable diagnoses of these disorders. With successive editions over the past 60 years, it has become a standard reference for clinical practice in the mental health field. Since a complete description of the underlying pathological processes is not possible for most mental disorders, it is important to emphasize that the current diagnostic criteria are the best available description of how mental disorders are expressed and can be recognized by trained clinicians. DSM is intended to serve as a practical, functional, and flexible guide for organizing information that can aid in the accurate diagnosis and treatment of mental disorders. It is a tool for clinicians, an essential educational resource for students and practitioners, and a reference for researchers in the field. Although this edition of DSM was designed first and foremost to be a useful guide to clinical practice, as an official nomenclature it must be applicable in a wide diversity of contexts. DSM has been used by clinicians and researchers from different orientations (biological, psychodynamic, cognitive, behavioral, interpersonal, family/systems), all of whom strive for a common language to communicate the essential characteristics of mental disorders presented by their patients. The information is of value to all professionals associated with various aspects of mental health care, including psychiatrists, other physicians, psychologists, social workers, nurses, counselors, forensic and legal specialists, occupational and rehabilitation therapists, and other health professionals. The criteria are concise and explicit and intended to facilitate an objective assessment of symptom presentations in a variety of clinical settings—inpatient, outpatient, partial hospital, consultation-liaison, clinical, private practice, and primary care—as well in general community epidemiological studies of mental disorders. DSM-5 is also a tool for collecting and communicating accurate public health statistics on mental disorder morbidity and mortality rates. Finally, the criteria and corresponding text serve as a textbook for students early in their profession who need a structured way to understand and diagnose mental disorders as well as for seasoned professionals encountering rare disorders for the first time. Fortunately, all of these uses are mutually compatible. These diverse needs and interests were taken into consideration in planning DSM-5. The classification of disorders is harmonized with the World Health Organization’s International Classification of Diseases (ICD), the official coding system used in the United States, so that the DSM criteria define disorders identified by ICD diagnostic names and code numbers. In DSM-5, both ICD-9-CM and ICD-10-CM codes (the latter scheduled for adoption in October 2015) are attached to the relevant disorders in the classification. Although DSM-5 remains a categorical classification of separate disorders, we recognize that mental disorders do not always fit completely within the boundaries of a single disorder. Some symptom domains, such as depression and anxiety, involve multiple diagnostic categories and may reflect common underlying vulnerabilities for a larger group of disorders. In recognition of this reality, the disorders included in DSM-5 were reordered into a revised organizational structure meant to stimulate new clinical perspectives. This new structure corresponds with the organizational arrangement of disorders planned for ICD-11 scheduled for release in 2015. Other enhancements have been introduced to promote ease of use across all settings: xxiv Representation of developmental issues related to diagnosis. The change in chapter organization better reflects a lifespan approach, with disorders more frequently diagnosed in childhood (e.g., neurodevelopmental disorders) at the beginning of the manual and disorders more applicable to older adulthood (e.g., neurocognitive disorders) at the end of the manual. Also, within the text, subheadings on development and course provide descriptions of how disorder presentations may change across the lifespan. Age-related factors specific to diagnosis (e.g., symptom presentation and prevalence differences in certain age groups) are also included in the text. For added emphasis, these age-related factors have been added to the criteria themselves where applicable (e.g., in the criteria sets for insomnia disorder and posttraumatic stress disorder, specific criteria describe how symptoms might be expressed in children). Likewise, gender and cultural issues have been integrated into the disorders where applicable. Integration of scientific findings from the latest research in genetics and neuroimaging. The revised chapter structure was informed by recent research in neuroscience and by emerging genetic linkages between diagnostic groups. Genetic and physiological risk factors, prognostic indicators, and some putative diagnostic markers are highlighted in the text. This new structure should improve clinicians’ ability to identify diagnoses in a disorder spectrum based on common neurocircuitry, genetic vulnerability, and environmental exposures. Consolidation of autistic disorder, Asperger’s disorder, and pervasive developmental disorder into autism spectrum disorder. Symptoms of these disorders represent a single continuum of mild to severe impairments in the two domains of social communication and restrictive repetitive behaviors/interests rather than being distinct disorders. This change is designed to improve the sensitivity and specificity of the criteria for the diagnosis of autism spectrum disorder and to identify more focused treatment targets for the specific impairments identified. Streamlined classification of bipolar and depressive disorders. Bipolar and depressive disorders are the most commonly diagnosed conditions in psychiatry. It was therefore important to streamline the presentation of these disorders to enhance both clinical and educational use. Rather than separating the definition of manic, hypomanic, and major depressive episodes from the definition of bipolar I disorder, bipolar II disorder, and major depressive disorder as in the previous edition, we included all of the component criteria within the respective criteria for each disorder. This approach will facilitate bedside diagnosis and treatment of these important disorders. Likewise, the explanatory notes for differentiating bereavement and major depressive disorder will provide far greater clinical guidance than was previously provided in the simple bereavement exclusion criterion. The new specifiers of anxious distress and mixed features are now fully described in the narrative on specifier variations that accompanies the criteria for these disorders. Restructuring of substance use disorders for consistency and clarity. The categories of substance abuse and substance dependence have been eliminated and replaced with an overarching new category of substance use disorders—with the specific substance used defining the specific disorders. “Dependence” has been easily confused with the term “addiction” when, in fact, the tolerance and withdrawal that previously defined dependence are actually very normal responses to prescribed medications that affect the central nervous system and do not necessarily indicate the presence of an addiction. By revising and clarifying these criteria in DSM-5, we hope to alleviate some of the widespread misunderstanding about these issues.  Enhanced specificity for major and mild neurocognitive disorders. Given the explosion in neuroscience, neuropsychology, and brain imaging over the past 20 years, it was critical to convey the current state-of-the-art in the diagnosis of specific types of disorders that were previously referred to as the “dementias” or organic brain diseases. Biological markers identified by imaging for vascular and traumatic brain disorders and xxv specific molecular genetic findings for rare variants of Alzheimer’s disease and Huntington’s disease have greatly advanced clinical diagnoses, and these disorders and others have now been separated into specific subtypes. Transition in conceptualizing personality disorders. Although the benefits of a more dimensional approach to personality disorders have been identified in previous editions, the transition from a categorical diagnostic system of individual disorders to one based on the relative distribution of personality traits has not been widely accepted. In DSM-5, the categorical personality disorders are virtually unchanged from the previous edition. However, an alternative “hybrid” model has been proposed in Section III to guide future research that separates interpersonal functioning assessments and the expression of pathological personality traits for six specific disorders. A more dimensional profile of personality trait expression is also proposed for a trait-specified approach. Section III: new disorders and features. A new section (Section III) has been added to highlight disorders that require further study but are not sufficiently well established to be a part of the official classification of mental disorders for routine clinical use. Dimensional measures of symptom severity in 13 symptom domains have also been incorporated to allow for the measurement of symptom levels of varying severity across all diagnostic groups. Likewise, the WHO Disability Assessment Schedule (WHODAS), a standard method for assessing global disability levels for mental disorders that is based on the International Classification of Functioning, Disability and Health (ICF) and is applicable in all of medicine, has been provided to replace the more limited Global Assessment of Functioning scale. It is our hope that as these measures are implemented over time, they will provide greater accuracy and flexibility in the clinical description of individual symptomatic presentations and associated disability during diagnostic assessments. Online enhancements. DSM-5 features online supplemental information. Additional cross-cutting and diagnostic severity measures are available online (www.psychiatry.org/dsm5), linked to the relevant disorders. In addition, the Cultural Formulation Interview, Cultural Formulation Interview—Informant Version, and supplementary modules to the core Cultural Formulation Interview are also included online at www.psychiatry.org/dsm5. These innovations were designed by the leading authorities on mental disorders in the world and were implemented on the basis of their expert review, public commentary, and independent peer review. The 13 work groups, under the direction of the DSM-5 Task Force, in conjunction with other review bodies and, eventually, the APA Board of Trustees, collectively represent the global expertise of the specialty. This effort was supported by an extensive base of advisors and by the professional staff of the APA Division of Research; the names of everyone involved are too numerous to mention here but are listed in the Appendix. We owe tremendous thanks to those who devoted countless hours and invaluable expertise to this effort to improve the diagnosis of mental disorders. We would especially like to acknowledge the chairs, text coordinators, and members of the 13 work groups, listed in the front of the manual, who spent many hours in this volunteer effort to improve the scientific basis of clinical practice over a sustained 6-year period. Susan K. Schultz, M.D., who served as text editor, worked tirelessly with Emily A. Kuhl, Ph.D., senior science writer and DSM-5 staff text editor, to coordinate the efforts of the work groups into a cohesive whole. William E. Narrow, M.D., M.P.H., led the research group that developed the overall research strategy for DSM-5, including the field trials, that greatly enhanced the evidence base for this revision. In addition, we are grateful to those who contributed so much time to the independent review of the revision proposals, including Kenneth S. Kendler, M.D., and Robert Freedman, M.D., co-chairs of the Scientific Review Committee; John S. McIntyre, M.D., and Joel Yager, M.D., co-chairs of the Clinical and Public Health Committee; and Glenn Martin, M.D., chair of the APA Assembly xxvi review process. Special thanks go to Helena C. Kraemer, Ph.D., for her expert statistical consultation; Michael B. First, M.D., for his valuable input on the coding and review of criteria; and Paul S. Appelbaum, M.D., for feedback on forensic issues. Maria N. Ward, M.Ed., RHIT, CCS-P, also helped in verifying all ICD coding. The Summit Group, which included these consultants, the chairs of all review groups, the task force chairs, and the APA executive officers, chaired by Dilip V. Jeste, M.D., provided leadership and vision in helping to achieve compromise and consensus. This level of commitment has contributed to the balance and objectivity that we feel are hallmarks of DSM-5. We especially wish to recognize the outstanding APA Division of Research staff—identified in the Task Force and Work Group listing at the front of this manual—who worked tirelessly to interact with the task force, work groups, advisors, and reviewers to resolve issues, serve as liaisons between the groups, direct and manage the academic and routine clinical practice field trials, and record decisions in this important process. In particular, we appreciate the support and guidance provided by James H. Scully Jr., M.D., Medical Director and CEO of the APA, through the years and travails of the development process. Finally, we thank the editorial and production staff of American Psychiatric Publishing—specifically, Rebecca Rinehart, Publisher; John McDuffie, Editorial Director; Ann Eng, Senior Editor; Greg Kuny, Managing Editor; and Tammy Cordova, Graphics Design Manager—for their guidance in bringing this all together and creating the final product. It is the culmination of efforts of many talented individuals who dedicated their time, expertise, and passion that made DSM-5 possible. David J. Kupfer, M.D. DSM-5 Task Force Chair Darrel A. Regier, M.D., M.P.H. DSM-5 Task Force Vice-Chair December 19, 2012  xxvii DSM-5-TR Classification Before each disorder name, ICD-10-CM codes are provided. Blank lines indicate that the ICD- 10-CM code depends on the applicable subtype, specifier, or class of substance. For periodic DSM-5-TR coding and other updates, see www.dsm5.org. Following chapter titles and disorder names, page numbers for the corresponding text or criteria are included in parentheses. Note for all mental disorders due to another medical condition: Insert the name of the etiological medical condition within the name of the mental disorder due to [the medical condition]. The code and name for the etiological medical condition should be listed first immediately before the mental disorder due to the medical condition. Neurodevelopmental Disorders (35) Intellectual Developmental Disorders (37) ___.__ Intellectual Developmental Disorder (Intellectual Disability) (37) Specify current severity: F70 Mild F71 Moderate F72 Severe F73 Profound F88 Global Developmental Delay (46) F79 Unspecified Intellectual Developmental Disorder (Intellectual Disability) (46) Communication Disorders (46) F80.2 Language Disorder (47) F80.0 Speech Sound Disorder (50) F80.81 Childhood-Onset Fluency Disorder (Stuttering) (51) Note: Later-onset cases are diagnosed as F98.5 adult-onset fluency disorder. F80.82 Social (Pragmatic) Communication Disorder (54) F80.9 Unspecified Communication Disorder (56) xxviii Autism Spectrum Disorder (56) F84.0 Autism Spectrum Disorder (56) Specify current severity: Requiring very substantial support, Requiring substantial support, Requiring support Specify if: With or without accompanying intellectual impairment, With or without accompanying language impairment Specify if: Associated with a known genetic or other medical condition or environmental factor (Coding note: Use additional code to identify the associated genetic or other medical condition); Associated with a neurodevelopmental, mental, or behavioral problem Specify if: With catatonia (use additional code F06.1) Attention-Deficit/Hyperactivity Disorder (68) ___.__ Attention-Deficit/Hyperactivity Disorder (68) Specify if: In partial remission Specify current severity: Mild, Moderate, Severe Specify whether: F90.2 Combined presentation F90.0 Predominantly inattentive presentation F90.1 Predominantly hyperactive/impulsive presentation F90.8 Other Specified Attention-Deficit/Hyperactivity Disorder (76) F90.9 Unspecified Attention-Deficit/Hyperactivity Disorder (76) Specific Learning Disorder (76) ___.__ Specific Learning Disorder (76) Specify current severity: Mild, Moderate, Severe Specify if: F81.0 With impairment in reading (specify if with word reading accuracy, reading rate or fluency, reading comprehension) F81.81 With impairment in written expression (specify if with spelling accuracy, grammar and punctuation accuracy, clarity or organization of written expression) F81.2 With impairment in mathematics (specify if with number sense, memorization of arithmetic facts, accurate or fluent calculation, accurate math reasoning) Motor Disorders (85) F82 Developmental Coordination Disorder (85) F98.4 Stereotypic Movement Disorder (89) Specify if: With self-injurious behavior, Without self-injurious behavior Specify if: Associated with a known genetic or other medical condition, neurodevelopmental disorder, or environmental factor Specify current severity: Mild, Moderate, Severe Tic Disorders F95.2 Tourette's Disorder (93) F95.1 Persistent (Chronic) Motor or Vocal Tic Disorder (93) Specify if: With motor tics only, With vocal tics only  xxix F95.0 Provisional Tic Disorder (93) F95.8 Other Specified Tic Disorder (98) F95.9 Unspecified Tic Disorder (98) Other Neurodevelopmental Disorders (99) F88 Other Specified Neurodevelopmental Disorder (99) F89 Unspecified Neurodevelopmental Disorder (99) Schizophrenia Spectrum and Other Psychotic Disorders (101) The following specifiers apply to Schizophrenia Spectrum and Other Psychotic Disorders where indicated: aSpecify if: The following course specifiers are only to be used after a 1-year duration of the disorder: 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 bSpecify if: With catatonia (use additional code F06.1) cSpecifycurrent severity of delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression, and mania symptoms F21 Schizotypal (Personality) Disorder (104) F22 Delusional Disordera,c (104) Specify whether: Erotomanic type, Grandiose type, Jealous type, Persecutory type, Somatic type, Mixed type, Unspecified type Specify if: With bizarre content F23 Brief Psychotic Disorderb,c (108) Specify if: With marked stressor(s), Without marked stressor(s), With peripartum onset F20.81 Schizophreniform Disorderb,c (111) Specify if: With good prognostic features, Without good prognostic features F20.9 Schizophreniaa,b,c (113) ___.__ Schizoaffective Disordera,b,c (121) Specify whether: F25.0 Bipolar type F25.1 Depressive type ___.__ Substance/Medication-Induced Psychotic Disorderc (126) Note: For applicable ICD-10-CM codes, refer to the substance classes under Substance-Related and Addictive Disorders for the specific substance/medication-induced psychotic disorder. See also the criteria set and corresponding recording procedures in the manual for more information. Coding note: The ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given. Specify if: With onset during intoxication, With onset during withdrawal, With onset after medication use xxx ___.__ Psychotic Disorder Due to Another Medical Conditionc (131) Specify whether: F06.2 With delusions F06.0 With hallucinations F06.1 Catatonia Associated With Another Mental Disorder (Catatonia Specifier) (135) F06.1 Catatonic Disorder Due to Another Medical Condition (136) F06.1 Unspecified Catatonia (137) Note: Code first R29.818 other symptoms involving nervous and musculoskeletal systems. F28 Other Specified Schizophrenia Spectrum and Other Psychotic Disorder (138) F29 Unspecified Schizophrenia Spectrum and Other Psychotic Disorder (138) Bipolar and Related Disorders (139) The following specifiers apply to Bipolar and Related Disorders where indicated: aSpecify: With anxious distress (specify current severity: mild, moderate, moderate-severe, severe); With mixed features; With rapid cycling; With melancholic features; With atypical features; With mood-congruent psychotic features; With mood- incongruent psychotic features; With catatonia (use additional code F06.1); With peripartum onset; With seasonal pattern bSpecify: With anxious distress (specify current severity: mild, moderate, moderate-severe, severe); With mixed features; With rapid cycling; With peripartum onset; With seasonal pattern ___.__ Bipolar I Disordera (139) ___.__ Current or most recent episode manic F31.11 Mild F31.12 Moderate F31.13 Severe F31.2 With psychotic features F31.73 In partial remission F31.74 In full remission F31.9 Unspecified F31.0 Current or most recent episode hypomanic F31.71 In partial remission F31.72 In full remission F31.9 Unspecified ___.__ Current or most recent episode depressed F31.31 Mild F31.32 Moderate F31.4 Severe F31.5 With psychotic features F31.75 In partial remission F31.76 In full remission F31.9 Unspecified F31.9 Current or most recent episode unspecified xxxi F31.81 Bipolar II Disorder (150) Specify current or most recent episode: Hypomanicb, Depresseda Specify course if full criteria for a mood episode are not currently met: In partial remission, In full remission Specify severity if full criteria for a major depressive episode are currently met: Mild, Moderate, Severe F34.0 Cyclothymic Disorder (159) Specify if: With anxious distress (specify current severity: mild, moderate, moderate-severe, severe) ___.__ Substance/Medication-Induced Bipolar and Related Disorder (162) Note: For applicable ICD-10-CM codes, refer to the substance classes under Substance-Related and Addictive Disorders for the specific substance/medication-induced bipolar and related disorder. See also the criteria set and corresponding recording procedures in the manual for more information. Coding note: The ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given. Specify if: With onset during intoxication, With onset during withdrawal, With onset after medication use ___.__ Bipolar and Related Disorder Due to Another Medical Condition (166) Specify if: F06.33 With manic features F06.33 With manic- or hypomanic-like episode F06.34 With mixed features F31.89 Other Specified Bipolar and Related Disorder (168) F31.9 Unspecified Bipolar and Related Disorder (169) F39 Unspecified Mood Disorder (169) Depressive Disorders (177) F34.81 Disruptive Mood Dysregulation Disorder (178) ___.__ Major Depressive Disorder (183) Specify: With anxious distress (specify current severity: mild, moderate, moderate-severe, severe); With mixed features; With melancholic features; With atypical features; With mood-congruent psychotic features; With mood-incongruent psychotic features; With catatonia (use additional code F06.1); With peripartum onset; With seasonal pattern ___.__ Single episode F32.0 Mild F32.1 Moderate F32.2 Severe F32.3 With psychotic features F32.4 In partial remission F32.5 In full remission F32.9 Unspecified xxxii ___.__ Recurrent episode F33.0 Mild F33.1 Moderate F33.2 Severe F33.3 With psychotic features F33.41 In partial remission F33.42 In full remission F33.9 Unspecified F34.1 Persistent Depressive Disorder (193) Specify: With anxious distress (specify current severity: mild, moderate, moderate-severe, severe); With atypical features Specify if: In partial remission, In full remission Specify if: Early onset, Late onset Specify if: With pure dysthymic syndrome; With persistent major depressive episode; With intermittent major depressive episodes, with current episode; With intermittent major depressive episodes, without current episode Specify current severity: Mild, Moderate, Severe F32.81 Premenstrual Dysphoric Disorder (197) ___.__ Substance/Medication-Induced Depressive Disorder (201) Note: For applicable ICD-10-CM codes, refer to the substance classes under Substance-Related and Addictive Disorders for the specific substance/medication-induced depressive disorder. See also the criteria set and corresponding recording procedures in the manual for more information. Coding note: The ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given. Specify if: With onset during intoxication, With onset during withdrawal, With onset after medication use ___.__ Depressive Disorder Due to Another Medical Condition (206) Specify if: F06.31 With depressive features F06.32 With major depressive–like episode F06.34 With mixed features F32.89 Other Specified Depressive Disorder (209) F32.A Unspecified Depressive Disorder (210) F39 Unspecified Mood Disorder (210) Anxiety Disorders (215) F93.0 Separation Anxiety Disorder (217) F94.0 Selective Mutism (222) ___.__ Specific Phobia (224) Specify if: F40.218 Animal F40.228 Natural environment ___.__ Blood-injection-injury xxxiii F40.230 Fear of blood F40.231 Fear of injections and transfusions F40.232 Fear of other medical care F40.233 Fear of injury F40.248 Situational F40.298 Other F40.10 Social Anxiety Disorder (229) Specify if: Performance only F41.0 Panic Disorder (235) ___.__ Panic Attack Specifier (242) F40.00 Agoraphobia (246) F41.1 Generalized Anxiety Disorder (250) ___.__ Substance/Medication-Induced Anxiety Disorder (255) Note: For applicable ICD-10-CM codes, refer to the substance classes under Substance-Related and Addictive Disorders for the specific substance/medication-induced anxiety disorder. See also the criteria set and corresponding recording procedures in the manual for more information. Coding note: The ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given. Specify if: With onset during intoxication, With onset during withdrawal, With onset after medication use F06.4 Anxiety Disorder Due to Another Medical Condition (258) F41.8 Other Specified Anxiety Disorder (261) F41.9 Unspecified Anxiety Disorder (261) Obsessive-Compulsive and Related Disorders (263) The following specifier applies to Obsessive-Compulsive and Related Disorders where indicated: aSpecify if: With good or fair insight, With poor insight, With absent insight/delusional beliefs F42.2 Obsessive-Compulsive Disordera (265) Specify if: Tic-related F45.22 Body Dysmorphic Disordera (271) Specify if: With muscle dysmorphia F42.3 Hoarding Disordera (277) Specify if: With excessive acquisition F63.3 Trichotillomania (Hair-Pulling Disorder) (281) F42.4 Excoriation (Skin-Picking) Disorder (284) ___.__ Substance/Medication-Induced Obsessive-Compulsive and Related Disorder (287) Note: For applicable ICD-10-CM codes, refer to the substance classes under Substance-Related and Addictive Disorders for the specific substance/medication-induced obsessive-compulsive and related disorder. See also the criteria set and corresponding recording procedures in the manual for more information. xxxiv Coding note: The ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given. Specify if: With onset during intoxication, With onset during withdrawal, With onset after medication use F06.8 Obsessive-Compulsive and Related Disorder Due to Another Medical Condition (291) Specify if: With obsessive-compulsive disorder–like symptoms, With appearance preoccupations, With hoarding symptoms, With hair-pulling symptoms, With skin-picking symptoms F42.8 Other Specified Obsessive-Compulsive and Related Disorder (293) F42.9 Unspecified Obsessive-Compulsive and Related Disorder (294) Trauma- and Stressor-Related Disorders (295) F94.1 Reactive Attachment Disorder (295) Specify if: Persistent Specify current severity: Severe F94.2 Disinhibited Social Engagement Disorder (298) Specify if: Persistent Specify current severity: Severe F43.10 Posttraumatic Stress Disorder (301) Specify whether: With dissociative symptoms Specify if: With delayed expression ___.__ Posttraumatic Stress Disorder in Individuals Older Than 6 Years (301) ___.__ Posttraumatic Stress Disorder in Children 6 Years and Younger (303) F43.0 Acute Stress Disorder (313) ___.__ Adjustment Disorders (319) Specify if: Acute, Persistent (chronic) Specify whether: F43.21 With depressed mood F43.22 With anxiety F43.23 With mixed anxiety and depressed mood F43.24 With disturbance of conduct F43.25 With mixed disturbance of emotions and conduct F43.20 Unspecified F43.8 Prolonged Grief Disorder (322) F43.8 Other Specified Trauma- and Stressor-Related Disorder (327) F43.9 Unspecified Trauma- and Stressor-Related Disorder (328) Dissociative Disorders (329) F44.81 Dissociative Identity Disorder (330) F44.0 Dissociative Amnesia (337) xxxv Specify if: F44.1 With dissociative fugue F48.1 Depersonalization/Derealization Disorder (343) F44.89 Other Specified Dissociative Disorder (347) F44.9 Unspecified Dissociative Disorder (348) Somatic Symptom and Related Disorders (349) F45.1 Somatic Symptom Disorder (351) Specify if: With predominant pain Specify if: Persistent Specify current severity: Mild, Moderate, Severe F45.21 Illness Anxiety Disorder (357) Specify whether: Care-seeking type, Care-avoidant type ___.__ Functional Neurological Symptom Disorder (Conversion Disorder) (360) Specify if: Acute episode, Persistent Specify if: With psychological stressor (specify stressor), Without psychological stressor Specify symptom type: F44.4 With weakness or paralysis F44.4 With abnormal movement F44.4 With swallowing symptoms F44.4 With speech symptom F44.5 With attacks or seizures F44.6 With anesthesia or sensory loss F44.6 With special sensory symptom F44.7 With mixed symptoms F54 Psychological Factors Affecting Other Medical Conditions (364) Specify current severity: Mild, Moderate, Severe, Extreme ___.__ Factitious Disorder (367) Specify: Single episode, Recurrent episodes F68.10 Factitious Disorder Imposed on Self F68.A Factitious Disorder Imposed on Another F45.8 Other Specified Somatic Symptom and Related Disorder (370) F45.9 Unspecified Somatic Symptom and Related Disorder (370) Feeding and Eating Disorders (371) The following specifiers apply to Feeding and Eating Disorders where indicated: aSpecify if: In remission bSpecify if: In partial remission, In full remission cSpecify current severity: Mild, Moderate, Severe, Extreme ___.__ Picaa (371) F98.3 In children F50.89 In adults xxxvi F98.21 Rumination Disordera (374) F50.82 Avoidant/Restrictive Food Intake Disordera (376) ___.__ Anorexia Nervosab,c (381) Specify whether: F50.01 Restricting type F50.02 Binge-eating/purging type F50.2 Bulimia Nervosab,c (387) F50.81 Binge-Eating Disorderb,c (392) F50.89 Other Specified Feeding or Eating Disorder (396) F50.9 Unspecified Feeding or Eating Disorder (397) Elimination Disorders (399) F98.0 Enuresis (399) Specify whether: Nocturnal only, Diurnal only, Nocturnal and diurnal F98.1 Encopresis (402) Specify whether: With constipation and overflow incontinence, Without constipation and overflow incontinence ___.__ Other Specified Elimination Disorder (405) N39.498 With urinary symptoms R15.9 With fecal symptoms ___.__ Unspecified Elimination Disorder (405) R32 With urinary symptoms R15.9 With fecal symptoms Sleep-Wake Disorders (407) The following specifiers apply to Sleep-Wake Disorders where indicated: aSpecify if: Episodic, Persistent, Recurrent bSpecify if: Acute, Subacute, Persistent cSpecify current severity: Mild, Moderate, Severe F51.01 Insomnia Disordera (409) Specify if: With mental disorder, With medical condition, With another sleep disorder F51.11 Hypersomnolence Disorderb,c (417) Specify if: With mental disorder, With medical condition, With another sleep disorder ___.__ Narcolepsyc (422) Specify whether: G47.411 Narcolepsy with cataplexy or hypocretin deficiency (type 1) G47.419 Narcolepsy without cataplexy and either without hypocretin deficiency or hypocretin unmeasured (type 2) xxxvii G47.421 Narcolepsy with cataplexy or hypocretin deficiency due to a medical  condition G47.429 Narcolepsy without cataplexy and without hypocretin deficiency due to a medical condition Breathing-Related Sleep Disorders (429) G47.33 Obstructive Sleep Apnea Hypopneac (429) ___.__ Central Sleep Apnea (435) Specify current severity Specify whether: G47.31 Idiopathic central sleep apnea R06.3 Cheyne-Stokes breathing G47.37 Central sleep apnea comorbid with opioid use Note: First code opioid use disorder, if present. ___.__ Sleep-Related Hypoventilation (439) Specify current severity Specify whether: G47.34 Idiopathic hypoventilation G47.35 Congenital central alveolar hypoventilation G47.36 Comorbid sleep-related hypoventilation ___.__ Circadian Rhythm Sleep-Wake Disordersa (443) Specify whether: G47.21 Delayed sleep phase type (444) Specify if: Familial, Overlapping with non-24-hour sleep-wake type G47.22 Advanced sleep phase type (446) Specify if: Familial G47.23 Irregular sleep-wake type (447) G47.24 Non-24-hour sleep-wake type (448) G47.26 Shift work type (450) G47.20 Unspecified type Parasomnias (451) __.__ Non–Rapid Eye Movement Sleep Arousal Disorders (452) Specify whether: F51.3 Sleepwalking type Specify if: With sleep-related eating, With sleep-related sexual behavior (sexsomnia) F51.4 Sleep terror type F51.5 Nightmare Disorderb,c (457) Specify if: During sleep onset Specify if: With mental disorder, With medical condition, With another sleep disorder G47.52 Rapid Eye Movement Sleep Behavior Disorder (461) G25.81 Restless Legs Syndrome (464) xxxviii ___.__ Substance/Medication-Induced Sleep Disorder (468) Note: For applicable ICD-10-CM codes, refer to the substance classes under Substance-Related and Addictive Disorders for the specific substance/medication-induced sleep disorder. See also the criteria set and corresponding recording procedures in the manual for more information. Coding note: The ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given. Specify whether: Insomnia type, Daytime sleepiness type, Parasomnia type, Mixed type Specify if: With onset during intoxication, With onset during withdrawal, With onset after medication use G47.09 Other Specified Insomnia Disorder (475) G47.00 Unspecified Insomnia Disorder (475) G47.19 Other Specified Hypersomnolence Disorder (475) G47.10 Unspecified Hypersomnolence Disorder (476) G47.8 Other Specified Sleep-Wake Disorder (476) G47.9 Unspecified Sleep-Wake Disorder (476) Sexual Dysfunctions (477) The following specifiers apply to Sexual Dysfunctions where indicated: aSpecify whether: Lifelong, Acquired bSpecify whether: Generalized, Situational cSpecify current severity: Mild, Moderate, Severe F52.32 Delayed Ejaculationa,b,c (478) F52.21 Erectile Disordera,b,c (481) F52.31 Female Orgasmic Disordera,b,c (485) Specify if: Never experienced an orgasm under any situation F52.22 Female Sexual Interest/Arousal Disordera,b,c (489) F52.6 Genito-Pelvic Pain/Penetration Disordera,c (493) F52.0 Male Hypoactive Sexual Desire Disordera,b,c (498) F52.4 Premature (Early) Ejaculationa,b,c (501) ___.__ Substance/Medication-Induced Sexual Dysfunctionc (504)  Note: For applicable ICD-10-CM codes, refer to the substance classes under Substance-Related and Addictive Disorders for the specific substance/medication-induced sexual dysfunction. See also the criteria set and corresponding recording procedures in the manual for more information. Coding note: The ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given. Specify if: With onset during intoxication, With onset during withdrawal, With onset after medication use F52.8 Other Specified Sexual Dysfunction (509) F52.9 Unspecified Sexual Dysfunction (509) xxxix Gender Dysphoria (511) The following specifier and note apply to Gender Dysphoria where indicated: aSpecify if: With a disorder/difference of sex development bNote: Code the disorder/difference of sex development if present, in addition to gender dysphoria. __.__ Gender Dysphoria (512) F64.2 Gender Dysphoria in Childrena,b F64.0 Gender Dysphoria in Adolescents and Adultsa,b Specify if: Posttransition F64.8 Other Specified Gender Dysphoria (520) F64.9 Unspecified Gender Dysphoria (520) Disruptive, Impulse-Control, and Conduct Disorders (521) F91.3 Oppositional Defiant Disorder (522) Specify current severity: Mild, Moderate, Severe F63.81 Intermittent Explosive Disorder (527) __.__ Conduct Disorder (530) Specify if: With limited prosocial emotions Specify current severity: Mild, Moderate, Severe Specify whether: F91.1 Childhood-onset type F91.2 Adolescent-onset type F91.9 Unspecified onset F60.2 Antisocial Personality Disorder (537) F63.1 Pyromania (537) F63.2 Kleptomania (539) F91.8 Other Specified Disruptive, Impulse-Control, and Conduct Disorder (541) F91.9 Unspecified Disruptive, Impulse-Control, and Conduct Disorder (541) Substance-Related and Addictive Disorders (543) Substance-Related Disorders (544) Alcohol-Related Disorders (553) ___.__ Alcohol Use Disorder (553) Specify if: In a controlled environment Specify current severity/remission: F10.10 Mild F10.11 In early remission F10.11 In sustained remission xl F10.20 Moderate F10.21 In early remission F10.21 In sustained remission F10.20 Severe F10.21 In early remission F10.21 In sustained remission ___.__ Alcohol Intoxication (561) F10.120 With mild use disorder F10.220 With moderate or severe use disorder F10.920 Without use disorder ___.__ Alcohol Withdrawal (564) Without perceptual disturbances F10.130 With mild use disorder F10.230 With moderate or severe use disorder F10.930 Without use disorder With perceptual disturbances F10.132 With mild use disorder F10.232 With moderate or severe use disorder F10.932 Without use disorder ___.__ Alcohol-Induced Mental Disorders (567) Note: Disorders are listed in their order of appearance in the manual.  aSpecify With onset during intoxication, With onset during withdrawal bSpecify if: Acute, Persistent c Specify if: Hyperactive, Hypoactive, Mixed level of activity ___.__ Alcohol-Induced Psychotic Disordera (126) F10.159 With mild use disorder F10.259 With moderate or severe use disorder F10.959 Without use disorder ___.__ Alcohol-Induced Bipolar and Related Disordera (162) F10.14 With mild use disorder F10.24 With moderate or severe use disorder F10.94 Without use disorder ___.__ Alcohol-Induced Depressive Disordera (201) F10.14 With mild use disorder F10.24 With moderate or severe use disorder F10.94 Without use disorder ___.__ Alcohol-Induced Anxiety Disordera (255) F10.180 With mild use disorder F10.280 With moderate or severe use disorder F10.980 Without use disorder ___.__ Alcohol-Induced Sleep Disordera (468) Specify whether Insomnia type F10.182 With mild use disorder xli F10.282 With moderate or severe use disorder F10.982 Without use disorder ___.__ Alcohol-Induced Sexual Dysfunctiona (504) Specify if: Mild, Moderate, Severe F10.181 With mild use disorder F10.281 With moderate or severe use disorder F10.981 Without use disorder ___.__ Alcohol Intoxication Deliriumb,c (672) F10.121 With mild use disorder F10.221 With moderate or severe use disorder F10.921 Without use disorder ___.__ Alcohol Withdrawal Deliriumb,c (673) F10.131 With mild use disorder F10.231 With moderate or severe use disorder F10.931 Without use disorder ___.__ Alcohol-Induced Major Neurocognitive Disorder (712) Specify if: Persistent ___.__ Amnestic-confabulatory type F10.26 With moderate or severe use disorder F10.96 Without use disorder ___.__ Nonamnestic-confabulatory type F10.27 With moderate or severe use disorder F10.97 Without use disorder ___.__ Alcohol-Induced Mild Neurocognitive Disorder (712) Specify if: Persistent F10.188 With mild use disorder F10.288 With moderate or severe use disorder F10.988 Without use disorder F10.99 Unspecified Alcohol-Related Disorder (568) Caffeine-Related Disorders (569) F15.920 Caffeine Intoxication (569) F15.93 Caffeine Withdrawal (571) ___.__ Caffeine-Induced Mental Disorders (574) Note: Disorders are listed in their order of appearance in the manual. Specify With onset during intoxication, With onset during withdrawal, With onset after medication use. Note: When taken over the counter, substances in this class can also induce the relevant substance- induced mental disorder. F15.980 Caffeine-Induced Anxiety Disorder (255) F15.982 Caffeine-Induced Sleep Disorder (468) Specify whether Insomnia type, Daytime sleepiness type, Mixed type F15.99 Unspecified Caffeine-Related Disorder (574) xlii Cannabis-Related Disorders (575) ___.__ Cannabis Use Disorder (575) Specify if: In a controlled environment  Specify current severity/remission: F12.10 Mild F12.11 In early remission F12.11 In sustained remission F12.20 Moderate F12.21 In early remission F12.21 In sustained remission F12.20 Severe F12.21 In early remission F12.21 In sustained remission ___.__ Cannabis Intoxication (582) Without perceptual disturbances F12.120 With mild use disorder F12.220 With moderate or severe use disorder F12.920 Without use disorder With perceptual disturbances F12.122 With mild use disorder F12.222 With moderate or severe use disorder F12.922 Without use disorder ___.__ Cannabis Withdrawal (584) F12.13 With mild use disorder F12.23 With moderate or severe use disorder F12.93 Without use disorder ___.__ Cannabis-Induced Mental Disorders (586) Note: Disorders are listed in their order of appearance in the manual. aSpecify With onset during intoxication, With onset during withdrawal, With onset after medication use. Note: When prescribed as medication, substances in this class can also induce the relevant substance-induced mental disorder. bSpecify if: Acute, Persistent cSpecify if: Hyperactive, Hypoactive, Mixed level of activity ___.__ Cannabis-Induced Psychotic Disordera (126) F12.159 With mild use disorder F12.259 With moderate or severe use disorder F12.959 Without use disorder ___.__ Cannabis-Induced Anxiety Disordera (255) F12.180 With mild use disorder F12.280 With moderate or severe use disorder F12.980 Without use disorder ___.__ Cannabis-Induced Sleep Disordera (468) Specify whether Insomnia type, Daytime sleepiness type, Mixed type F12.188 With mild use disorder F12.288 With moderate or severe use disorder xliii F12.988 Without use disorder ___.__ Cannabis Intoxication Deliriumb,c (672) F12.121 With mild use disorder F12.221 With moderate or severe use disorder F12.921 Without use disorder F12.921 Pharmaceutical Cannabis Receptor Agonist–Induced Deliriumb,c (674) Note: When pharmaceutical cannabis receptor agonist medication taken as prescribed. The designation “taken as prescribed” is used to differentiate medication-induced delirium from substance intoxication delirium. F12.99 Unspecified Cannabis-Related Disorder (586) Hallucinogen-Related Disorders (587) ___.__ Phencyclidine Use Disorder (587) Specify if: In a controlled environment Specify current severity/remission: F16.10 Mild F16.11 In early remission F16.11 In sustained remission F16.20 Moderate F16.21 In early remission F16.21 In sustained remission F16.20 Severe F16.21 In early remission F16.21 In sustained remission ___.__ Other Hallucinogen Use Disorder (590) Specify the particular hallucinogen Specify if: In a controlled environment Specify current severity/remission: F16.10 Mild F16.11 In early remission F16.11 In sustained rem