Diagnostic and Statistical Manual of Mental Disorders

Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
DSM 5
Roy Q. Sanders, MD

2 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.
Bernard "Hap" Kliban

Why Change?
Coordination with ICD nomenclature
–Special consideration for ICD-11
–In October 2014 the US will adopt
ICD-10
Integration of latest research and
clinical experience
Enhanced specificity

Definition of a Mental
Disorder
“A mental disorder is a syndrome characterized by
clinically significant disturbance in an individual’s
cognition, emotion regulation, or behavior that reflects a
dysfunction in the psychological, biological, or
developmental processes underlying mental functioning.
Mental disorders are usually associated with significant
distress of disability in social, occupational, or other
important activities. An expectable or culturally approved
response to a common stressor or loss, such as the
death of a loved one, is not a mental disorder. Socially
deviant behavior (e.g. political, religious, or sexual) and
conflicts that are primarily between the individual and
society are not mental disorders unless the deviance or
conflict results from a dysfunction in the individual, as
described above.”

Assessment System
 Non axial
 Listing of diagnoses starting with the most pertinent
 Separate notations
• Psychosocial & contextual factors
 ICD-9 V codes & ICD-10 Z codes
• Disability
 No GAF
 WHO Disability Assessment Scale (WHODAS)

Diagnostic Specifiers
 If meet full criteria
• Severity = mild, moderate, severe, extreme
 Many disorders – number of symptoms
• Descriptive = insight, environment
• Course = partial remission, full remission,
recurrent
 If do not meet full criteria
• Other Specified Disorder
 Reason not meet criteria
• Unspecified disorder
 No reason given for not meeting criteria

Diagnostic Considerations
 Number of diagnoses can not be made if patient
has certain other diagnosis
 All diagnoses require distress/ impairment
 Most disorder categories have medical condition/
substance related version of disorder
• Substance/ Medication-Induced Disorder
• Disorder Due to Another Medical Condition

Intellectual Disabilities
Intellectual Disability
(Intellectual Developmental Disorder = ICD)
 Deficits in
• Intellectual functions
• Adaptive functioning
 Onset during developmental period
 Severity = adaptive functioning, not IQ
• Mild, moderate, severe, profound
• Conceptual, social, practical domains

Intellectual Disabilities
Global Developmental Delay
 < 5 years
 Several areas of delay
 Unable to undergo systematic assessment
Unspecified Intellectual Disability
 > 5 years
 Unable to assess due to sensory/ physical
impairments, behavior

Changes
 Name
 Developmental period not age
 Increased emphasis on adaptive function
 Severity by adaptive functioning not IQ

Communication Disorders
Language Disorder
 Persistent difficulties in acquisition & use of
language across modalities
• Deficits in comprehension or production
 Reduced vocabulary
 Limited sentence structure
 Impairments in discourse
 Below age/ impaired function
 Onset, early developmental period

Speech Sound Disorder
 Persistent difficulty with speech sound production
• Speech intelligibility
• Prevents verbal communication of messages
 Limitations in effective communication

Childhood-Onset Fluency Disorder
(Stuttering)
 Speech fluency/ time patterning disturbances
• Inappropriate for age & language skills
• Persist over time
• Frequent/ marked occurrences
 Various specific sound/ speech abnormalities
 Impairment

Social (Pragmatic) Communication
Disorder
 Persistent difficulties – social use of verbal &
nonverbal communication
• Social
• Change with context/ listener
• Rules of conversation/ story-telling
• Non explicit
 Functional limitations

Changes
 Name changes
 Consolidation of several disorders
 New disorder
• Target those with social uses of communication

Autism Spectrum Disorders
 Persistent deficits
• Social communication/ interaction
• Restricted, repetitive pattern of behavior, interests, activities
 Present, early developmental period; may manifest later
 Impairment, assess each deficit separately
 Severity (each deficit)
• Requiring support, requiring substantial support, requiring very
substantial support
 Specifiers
• With/ without accompanying intellectual impairment
• With/ without accompanying language impairment
• Associated with known medical or genetic condition or
environmental factor
• Associated with another neurodevelopmental, mental, or
behavioral disorder
• With catatonia

Changes
 Consolidation of all variants into 1 disorder
 Specifiers to indicate specific characteristics

Attention-Deficit/Hyperactivity
Disorder
 Persistent pattern
• inattention and/or hyperactivity-impulsivity
• 6 or more symptoms (5 for > 17 years), either category
• > 6 months
 Several symptoms
• < 12 year; > 2 settings
 Interferes with functioning or development
 Specify
• Combined, primarily inattentive, primarily hyperactive/
impulsive
• Severity
• Partial remission

Changes
 Examples in criterion items to describe symptoms
for broader range of ages
 Onset prior to age 12 years
 Specifiers rather than subtypes
 Fewer symptoms required for adults
 Can diagnose with autism spectrum disorder

Specific Learning Disorder
Specific Learning Disorder
 Difficulties learning & using academic skills
• > 1 symptom
 Reading, comprehension, spelling, written,
numbers, math reasoning
• > 6 months despite targeted interventions
 Impairment, below developmental level
 Begin in school age
 Specify
• reading, written expression, mathematics
• severity

Changes
 Combine several diagnoses
 Specifiers

Motor Disorders
Developmental Coordination Disorder
 Acquisition/ execution of coordinated motor skills
• Below expected developmental level
 Impairment
 Onset, early developmental level

Motor Disorders
Stereotypic Movement Disorders
 Repetitive, seemingly driven, apparently purposeful
motor behavior
 Interference/ impairment
 Specify
• With/ without self-injurious behavior
• Associated with medical, genetic,
neurodevelopmental disorder, environmental
factor
• Severity

Tic Disorders
Tourette’s Disorder
 Multiple motor & vocal tics, present at some time
(don’t have to be concurrent)
 > 1 year
 onset < 18 years

Tic Disorders
Persistent (Chronic) Motor or Vocal Tic Disorder
 Single or multiple motor or vocal tics
 > 1 year
 onset < 18 years
 specify
• Motor or vocal

Changes
 Specifiers to Stereotypic Movement Disorder
 Tic criteria standardized across manual

Schizophrenia Spectrum & Other
Psychotic Disorders
Key Features
 Delusions
 Hallucinations
 Disorganized Thinking (Speech)
 Grossly Disorganized or Abnormal Motor Behavior
(including Catatonia)
 Negative Symptoms

Psychotic Disorders
Delusional Disorder
 > 1 delusions
 > 1 month
 Specify
• Erotomanic, Grandiose, Jealous
 Adequate functioning/ not bizarre, Persecutory, Somatic,
Mixed, Unspecified
• With bizarre content
• First/ multiple episodes
• Acute/ partial remission/ full remission
• Continuous
• Severity
 Each symptom, 0-4; last 7 days

Psychotic Disorders
Brief Psychotic Disorder
 > 1 symptoms
 > 1 = delusions, hallucinations, disorganized
speech, disorganized/ catatonic behavior
 > 1 day < 1 month, full return to pre-morbid
functioning
 Specify
• With/ without marked stressors
• With postpartum onset
• With catatonia
• Severity (don’t have to use)
 Each symptom, 0-4; last 7 days

Psychotic Disorders
Schizophreniform Disorder
 > 2 symptoms, significant period of time during 1 month
(less if treated)
• > 1 = delusions, hallucinations, disorganized speech,
disorganized/ catatonic behavior, negative symptoms
• > 1 month < 6 months
 Specify
• With/ without good prognostic features
• With catatonia
• Severity
 Each symptoms, 0-4; last 7 days

Psychotic Disorders
Schizophrenia
 > 2 symptoms, significant period of time during 1 month
(less if treated)
• > 1 = delusions, hallucinations, disorganized speech,
disorganized/ catatonic behavior, negative symptoms
 Impaired functioning
 Continuous signs > 6 months
 Specify
• First/ multiple episodes; continuous
• Acute/partial or full remission
• With catatonia
• Severity
 Primary symptoms, 0-4; last 7 days

Psychotic Disorders
Schizoaffective Disorder
 Uninterrupted period of illness
• Major mood episode
• Concurrent criterion A, schizophrenia
 Lifetime, delusions/ hallucinations > 2 wks without mood
symptoms
 Major mood symptoms present, majority of time
 Specify
• Bipolar/ depressive
• With catatonia
• First/ multiple episodes; continuous
• Acute/partial or full remission
• With catatonia
• Severity
 Each symptoms, 0-4; last 7 days

Psychotic Disorders
Catatonia Associated with Another Mental
Disorder (Catatonia Specifier)
 Clinical picture dominated by > 3 of
• Stupor, catalepsy, waxy flexibility, mutism,
negativism, posturing, mannerism, stereotypy,
agitation, grimacing, echolalia, echopraxia
 Code with mental disorder

Psychotic Disorders
Catatonic Disorder Due to Another Medical
Condition
 Clinical picture dominated by > 3 of
• Stupor, catalepsy, waxy flexibility, mutism,
negativism, posturing, mannerism, stereotypy,
agitation, grimacing, echolalia, echopraxia
 Evidence (hx, PE, lab)
• Direct pathophysiological consequence of
another medical condition
 Code – include medical condition

Changes
Delusion Disorder
 Delusions no longer have to be non bizarre
Schizophrenia
 No subtypes
 2 criterion A for diagnosis
 > 1 criterion A
• Delusions, hallucinations, disorganized speech
 Dimensional rating scale in section III

Changes
Schizoaffective Disorder
 Longitudinal not cross sectional
 Major mood episode present most of disorder
duration after criterion A met
Catatonia
 Can be a specifier
 Criteria been standardized across manual
 Diagnosis with specifiers
• Medical condition
• Mental disorder

Bipolar and
Related
Disorders

Manic Episode
 Distinct period of abnormally & persistently
elevated, expansive or irritable mood
 Abnormally & persistently increased goal directed
activity
 > 1 week, most of day, nearly every day (any
duration if hospitalized)
 > 3 symptoms (4 if irritable)
• Grandiosity, less sleep, talkative, racing
thoughts, distractibility, goal directed activity,
high risk behavior
 Impairment

Hypomanic Episode
 Distinct period of abnormally & persistently
elevated, expansive or irritable mood
 Abnormally & persistently increased goal directed
activity
 > 4 days, most of day, nearly every day (any
duration if hospitalized)
 > 3 symptoms (4 if irritable)
• Grandiosity, less sleep, talkative, racing
thoughts, distractibility, goal directed activity,
high risk behavior
 Change in function, observable by others

Major Depressive Episode
 > 5 symptoms, same 2 week period, change in
functioning
• > 1 = depressed mood, loss of interest/ pleasure
• Depressed mood (kids = irritability), loss of
interest/ pleasure, weight loss (kids = failure to
gain), sleep changes, agitation/ retardation,
fatigue, worthlessness/ guilt, poor concentration,
death/ suicide
 Distress/ impairment
 Can diagnose in presence of major stressors:
bereavement, disaster, illness, disability, etc)

 Must meet criteria for manic episode
 May be preceded by and followed by hypomanic or major
depressive episodes
 Specify
• Type of most recent/ current episode
• Severity
 Mild, moderate, severe
• Presence of psychotic features
• Remission status
• With anxiety, mixed features, rapid cycling, melancholic
features, atypical features, mood congruent/ mood
incongruent psychotic features, catatonia, peripartum
onset, seasonal pattern
Bipolar I Disorder

 Meet criteria for current/ past hypomanic episode and
 Criteria for current/ past major depressive episode
 No manic episodes
 Specifiers
• With anxious distress, mixed features, rapid cycling,
mood-congruent psychotic features, with mood
incongruent psychotic features, catatonia, peripartum
onset, seasonal pattern
• In partial/ full remission
• Severity
 Mild, moderate, severe
Bipolar II Disorders

 > 2 years (> 1 year in kids), numerous periods with
hypomanic symptoms and periods of depressive
symptoms, not meet criteria
 Symptoms present at least 50% time, not been
without symptoms for > 2 months at a time
 Not met criteria for major depressive, manic,
hypomanic episodes
 Specify
• With anxious distress
Cyclothymic Disorder

Changes
 Manic/ Hypomanic Episodes
• Increased energy/ activity as criterion A symptom
 Specifiers
• With mixed features (Mixed Episode eliminated)
• With anxious distress

Depressive Disorders

Disruptive Mood Dysregulation Disorder
 Severe recurrent temper outbursts, verbal or
behavior, out of proportion in intensity/ duration
 Inconsistent with developmental level
 On average, > 3 times a week
 Intervening mood, consistently irritable/ angry most
of day
 > 12 months, < 3 months without all symptoms
 Present in 2 of 3 settings, at least 1 severe
 Onset before 10 years, not make diagnosis before
6 years/ after 18 years
 Not with ODD, IED, Bipolar

Major Depressive Disorder
 Major depressive episode
 Specify
• Severity
• Presence of psychotic features
• With anxiety, mixed features, rapid cycling,
melancholic features, atypical features, mood
congruent/ mood incongruent psychotic features,
catatonia, peripartum onset, seasonal pattern

Persistent Depressive Disorder (Dysthymia)
 Depressed mood, most of day, most days, > 2 years (kids =
irritability, 1 year)
 While depressed, > 2 symptoms
• Appetite change, sleep change, fatigue, low self-esteem, poor
concentration, hopelessness
 Never been without symptoms, > 2 months
 Criteria for major depressive disorder may > 2 years
 Specify
• Severity
• With anxiety, mixed features, melancholic features, atypical
features, mood congruent/ mood incongruent psychotic features,
catatonia, peripartum onset
• Early/ late onset
• With pure dysthymic syndrome, persistent depressive episode,
intermittent major depressive episodes, with/ without current
episodes

Premenstrual Dysphoric Disorder
 Majority of menstrual cycles, preceding year
• > 5 symptoms in final week before onset of menses
• Improve within few days after onset of menses
• Minimal or absent in week post menses
• > 1 symptoms
 Marked affective lability, irritability/ anger/conflicts,
depression, anxiety
• > 1 symptoms
 Decreased interest/ concentration, fatigue, appetite
change, sleep change, overwhelmed, physical
symptoms
 Impairment

Changes
 Added Mood Dysregulation Disorder
• Children with extreme behavioral dyscontrol
• Persistent, not episodic irritability
• Decrease diagnosis of pediatric bipolar
 Major Depressive Episode
• Can be diagnosed in presence of major stressors
including bereavement
• More detailed explanation to help with diagnosis
during bereavement
• Additional specifiers

Changes
 Moved Premenstrual Dysphoric Disorder into
diagnostic section from study section
 Persistent Depressive Disorder
• Integration of Chronic Major Depressive Disorder
and Dysthymic Disorder

Anxiety Disorders

Anxiety Disorders
Separation Anxiety Disorder
 Developmentally inappropriate/ excessive fear or
anxiety re separation from individuals attached to
 > 3 symptoms
• separation, loss, harm, go out, being alone,
sleep, nightmares, physical symptoms
 Persistent, > 4 weeks in kids, > 6 months in adults
 Impairment

Anxiety Disorders
Selective Mutism
 Consistent failure to speak in social situations
where expected to despite speaking in other
situations
 Impairment
 > 1 month (not 1st
month of school)
 Not language/ speech problem

Anxiety Disorders
Specific Phobia
 Marked fear/ anxiety about specific object/ situation
(kids = crying, tantrums, freezing)
 Phobic object - immediate fear, avoided
 Out of proportion
 Persistent, > 6 months
 Impairment
 Specifiers
• Animal, natural environment, blood-injection-
injury, situation, other

Anxiety Disorders
Social Anxiety Disorder (Social Phobia)
 Marked fear/ anxiety, > 1 social situations, exposed to
possible scrutiny by others (kids must be with peers)
 Fear act in way/ show anxiety that negatively evaluated
by others
 Social situations almost always provoke fear, avoided/
endured (kids – crying, tantrums, freezing, clinging,
shrinking, not talking)
 Persistent, > 6 months
 Impairment
 Specifier
• Performance only

Anxiety Disorders
Panic Disorder
 Recurrent unexpected panic attacks
• From calm or anxious state; abrupt surge of
intense fear/ discomfort; peak within minutes; > 4
symptoms
 At least 1 attack followed by > 1 mo of > 1
• Persistent concern/ worry about attacks
• Significant maladaptive behavior change

Anxiety Disorders
Agoraphobia
 Marked fear/ anxiety about > 2 of
• Public transportation
• Open spaces
• Enclosed places
• In line/ crowd
• Outside of home alone
 Fear, no help/ escape not possible, panic
 Situations cause anxiety/ avoided
 > 6 months
 Impairment

Anxiety Disorders
Generalized Anxiety Disorder
 Excessive anxiety/ work, more days than not, > 6
months, about number of events
 Difficult to control anxiety
 Associated with > 3 (only 1 in kids) or more
• Restlessness, fatigue, difficulty concentration,
irritability, muscle tension, sleep disturbance
 Impairment

Changes
 OCD and PTSD in different categories
 Selective Mutism and Separation Anxiety moved
into this category
 Separation Anxiety Disorder
• Criterion descriptions broadened to cover
lifespan
• Eliminated requirement for onset before 18
• Adult duration = 6 months or more

Changes
 Specific Phobia and Social Anxiety Disorders
• Eliminate recognition that
excessive/unreasonable
• Duration = 6 months for all ages
 Social Anxiety
• Specifier
 Generalized deleted
 Added performance only

Changes
 Panic Attacks
• Standard criteria
• Specifier for multiple disorders
 Panic Disorder/ Agoraphobia
• Unlinked, separate disorders with own criteria

Obsessive-Compulsive
and Related Disorders

Obsessive-Compulsive and Related
Disorders
Obsessive-Compulsive Disorder
 Presence of obsessions, compulsions or both
• Obsessions = recurrent & persistent thoughts, urges,
images; intrusive & unwanted; marked anxiety &
distress; attempts to ignore, suppress, neutralize
• Compulsions = repetitive behaviors in response to
obsession or rigid rules; aim to prevent/ reduce
anxiety/ distress/ dreaded event; no realistic
connection (kids may not be able articulate these
aims)
 Time consuming or distress/ impairment
 Specify
• With good/ fair/ poor insight
• With absent insight/ delusional beliefs
• Tic-related

Disorders
Body Dysmorphic Disorder
 Preoccupation, > 1 defects/ flaws in appearance/
not observable by others
 Repetitive behaviors in response to concerns
 Specify
• With muscle dysmorphia

Disorders
Hoarding Disorder
 Persistent difficulty discarding/ parting with
possessions regardless of value
 Perceived need to save item & distress with
discarding
 Accumulation of possessions congest/ clutter active
living areas
 Specify
• With excessive acquisition

Disorders
Trichotillomania (Hair-Pulling Disorder)
 Recurrent pulling out of hair/ hair loss
 Repeated attempts to stop/ decrease

Disorders
Excoriation (Skin-Picking) Disorder
 Recurrent skin picking, cause skin lesions
 Repeated attempts to decrease/ stop

Changes
 New category
 New disorders
 OCD
• Insight specifier refined
 Body Dysmorphic Disorder
• moved into this category from somatoform
• Insight specifier expanded
• Muscle dysmorphia specifier
• Delusional variant no longer coded as delusional
disorder
 Trichotillomania moved from impulse control
disorder into this category

Trauma and Stressor-
Related Disorders

Trauma- and Stressor-Related
Disorders
Reactive Attachment Disorder
 Consistent pattern of inhibited, emotionally withdrawn behavior toward
adult caregivers
 Rarely/ minimally seeks/ responds to comfort when distressed
 Persistent social & emotional disturbance, > 2
• Minimal social & emotional responsiveness to others
• Limited positive affect
• Episodes – unexplained irritability, sadness, fearfulness, even during
non threatening interactions with caretakers
 Experienced pattern, insufficient care, > 1
• Social neglect/ deprivation, basic needs
• Repeated changes in caretakers, limit stable attachments
• Rearing, unusual situations, limit selective attachments
 Care presumed to be responsible for attachment issues
 Specifiers
• persistent, > 12 months
• severity

Disorders
Disinhibited Social Engagement Disorder
 Behavior pattern – actively approaches and interacts with unfamiliar
adults and exhibits > 2 symptoms
• Reduced/ absent reticence with unfamiliar adults; overly familiar
verbal & physical behavior; diminished or absent checking back
with adult caregiver after venturing away; willingness to go off with
unfamiliar adult with minimal or no hesitation
 Symptoms not limited to impulsivity but include socially disinhibited
behavior
 Experienced pattern, insufficient care, > 1
• Social neglect/ deprivation, basic needs
• Repeated changes in caretakers, limit stable attachments
• Rearing, unusual situations, limit selective attachments
 Care presumed to be responsible for attachment issues
 Specifiers
• persistent, > 12 months
• severity

Disorders
Posttraumatic Stress Disorder, Criteria, > 6 years
 Exposure to actual/ threatened death, injury, serious violence, > 1
• Experiencing, witnessing, learning about close others, repeated/
extreme exposure to aversive details
 Presence > 1, intrusion symptoms
 Persistent avoidance of associated stimuli, > 1
 Negative alterations in cognitions & mood, > 2
 Marked alterations in arousal/ reactivity, > 2
 Duration > 1 month; distress/ impairment
 Specify
• With dissociative symptoms (depersonalization, derealization)
• With delayed expression

Disorders
Posttraumatic Stress Disorder, Criteria, < 6 years
 Exposure to actual/ threatened death, injury, serious
violence, > 1
• Experiencing, witnessing
 Presence > 1, intrusion symptoms
 Persistent avoidance of associated stimuli, > 1
 Negative alterations in cognitions & mood, > 2
 Marked alterations in arousal/ reactivity, > 2
 Duration > 1 month
 Specify
• With dissociative symptoms (depersonalization,
derealization)
• With delayed expression

Disorders
Acute Stress Disorder
 Exposure to actual/ threatened death, injury,
serious violence, > 1
• Experiencing, witnessing, learning about close
others, repeated/ extreme exposure to aversive
details
 > 9 symptoms from categories of intrusion,
negative mood, dissociation, avoidance, arousal
 Duration, immediately after, 3 days to 1 mo

Disorders
Adjustment Disorder
 Emotional/ behavioral symptoms in response to
identifiable stressor, within 3 months
 Distress out of proportion
 Impairment
 Not normal bereavement
 Specify
• With depressed mood, anxiety, mixed anxiety &
depressed mood, disturbance of conduct, mixed
disturbance of emotions & conduct, unspecified

Changes
Reactive Attachment Disorder
 split into 2 diagnoses
• Reactive Attachment Disorder
 Poorly formed/ absent attachments
 Similar to ADHD and Disruptive Behavior
Disorders
• Disinhibited Social Engagement Disorder
 Insecure/ more secure attachments
 Similar to depression and other internalizing
disorders

Changes
PTSD
 Stressor criterion more explicit about what qualifies as
traumatic
 Elimination of subjective reaction
 Expansion to 4 symptom clusters from 3
• Intrusion
• Avoidance
• Negative alterations in mood and cognition
 Includes persistent negative emotion states
• Alterations in arousal and reactivity
 Adds irritable behavior, angry outbursts, reckless/
self-destructive behavior
 Separate criteria for children under 6

Changes
Acute Stress Disorder
 Explicit qualification of traumatic events
• Direct, witnessed, indirect
 Eliminate subjective reaction
Adjustment Disorder
 Re-conceptualization as heterogeneous group of
stress response syndromes
 Occur after exposure to traumatic or distressing
event

Dissociative
Disorders

Dissociative Disorders
Dissociative Identity Disorder
 Disruption of identity, > 2 distinct personality states
 Recurrent gaps in everyday events, personal
information, traumatic events
 Not accepted culture/ religion
 Kids – not imaginary friends/ fantasy play

Dissociative Amnesia
 Inability to recall important autobiographical
information, usually traumatic/ stressful
• Most often localized/ selective for specific events;
generalized for identity, life history
 Code
• With/ without dissociative fugue

Depersonalization/ Derealization Disorder
 Presence of persistent/ recurrent experiences of
depersonalization, derealization or both
 Reality testing during episodes intact

Changes
 New names
• Derealization added to depersonalization disorder
 Dissociative Fugue
• No longer separate diagnosis
• Specifier for dissociative amnesia
 Dissociative Identity Disorder
• Symptoms of identity disruption can be reported as
well as observed
• Recall gaps can be for everyday events not just
trauma
• Additional descriptions of cultural phenomena in
exclusion criteria

Somatic Symptom
and Related
Disorders

Somatic Symptom and Related
Disorders
Somatic Symptom Disorder
 > 1 somatic symptoms, distressing/ impair
 Excessive thoughts, feelings, behaviors related to symptoms,
health concerns, > 1
• Disproportionate, persistent thoughts about seriousness
• Persistently high level of anxiety
• Excessive time & energy devoted
 Symptoms persistent, > 6 months
 Specify
• With predominant pain
• Persistent
• Severity
• Mild = 1
• Moderate = > 2
• Severe = > 2 and multiple somatic symptoms (or one very
severe)

Disorders
Illness Anxiety Disorder
 Preoccupation, having/ acquiring serious illness
 No/ mild somatic symptoms
 High level anxiety about health
 Excessive health related behaviors
 Present > 6 months
 Specify
• Care seeking type/ care avoidant type

Disorders
Conversion Disorder (Functional Neurological
Symptom Disorder)
 > 1 symptoms of altered voluntary motor or sensory
function
 Clinical findings, evidence of no compatibility between
symptom & recognized medical/ neurological conditions
 Specifiers
 With weakness or paralysis; with abnormal
movement; with swallowing symptoms; with
speech symptom; with attacks or seizures; with
anesthesia or sensory loss, with special sensory
symptom; with mixed symptoms
 Acute/ persistent
 With/ without psychological stressor

Disorders
Psychological Factors Affecting Other Medical Conditions
 Medical symptoms/ disorder present
 Psychological/ behavioral factors adversely affect medical
condition, 1 of following ways
• Temporal association between factors & disease
exacerbation
• Factors interfere with treatment of medical condition
• Factors constitute health risks
• Factors influence underlying pathophysiology
 Specify
• Severity
 Mild, moderate, severe, extreme

Disorders
Factitious Disorders
 Factitious Disorder Imposed on Self
 Falsification of physical/ psychological signs,
symptoms; induction of injury, disease associated
with deception in self
 Presents as ill, impaired, injured
 Deceptive behavior evident even in absence of
obvious external rewards
 Specify
• Single/ recurrent episodes

Disorders
Factitious Disorders
 Factitious Disorder Imposed on Another
 Falsification of physical/ psychological signs, symptoms;
induction of injury, disease associated with deception in
another
 Presents other as ill, impaired, injured
 Deceptive behavior evident even in absence of obvious
external rewards
 Perpetrator receives diagnosis
 Specify
• Single/ recurrent episodes

Changes
 Renaming of category
 Renaming/ reorganization of disorders
 De-emphasis on unexplained medical symptoms
 Emphasis on maladaptive thoughts/ feelings/ behavior
 Consolidation of disorders
• Somatic Symptom Disorder
• Illness Anxiety Disorder
Conversion Disorder
• Criteria modified to emphasize importance of neurological
exam and that psychological factors may not be evident at
diagnosis
Psychological Factors Affecting a Medical Condition
• Moved to disorder section from other conditions
 No longer describe variants in disorder name
Factitious Disorder
• Renamed, of self and of other

Feeding and
Eating Disorders

Feeding and Eating Disorders
Pica
 Persistent eating of nonnutritive, nonfood
substances, > 1 month
 Inappropriate for developmental level
 Not cultural or socially normative

Rumination Disorder
 Repeated regurgitation of food, > 1 month
 Not GI or other medical condition
 Not another eating disorder
 Specify
• In remission

Avoidant/ Restrictive Food Intake Disorder
 Eating/ feeding disturbance, persistent failure to meet
nutritional/ energy assoc with > 1
• Weight loss/ failure to gain
• Significant nutritional deficiency
• Dependent on supplementary feedings
• Interference with psychosocial functioning
 Not no available food/ assoc cultural practice
 Not another eating disorder
 Specify if in remission

Anorexia Nervosa
 Restriction of energy intake, low body weight
 Intense fear of gaining weight/ becoming fat;
persistent behavior interferes with weight gain
 Disturbance in way body weight/ shape
experienced, undue influence on self-esteem. Lack
of recognition of seriousness of low weight
 Specify
• Restricting type / binge-eating/ purging type
• Partial/ full remission
• Severity
 BMI

Bulimia Nervosa
 Recurrent episodes of binge eating
• Eating in discrete period of time, larger amount of food than most
eat
• Sense of lack of control
 Recurrent inappropriate compensatory behaviors, prevent weight
gain
 Eating & compensation, on avg, once a week for 3 months
 Self evaluation unduly influenced by body shape & weight
 Specify
• Severity
 Average frequency of episodes of inappropriate compensatory
behaviors per week

Binge Eating Disorder
 Recurrent episodes of binge eating
 Episodes associated with > 3
 Eating more rapidly than normal, until uncomfortably full, not
physically hungry, alone because embarrassed, disgusted with self
 Distress
 On avg, once a week, 3 months
 Specify
• Severity
 Number of binge eating episodes per week

Changes
 Name changes
 Avoidant/ Restrictive Food Intake Disorder
• Was Feeding Disorder of Infancy
 Expanded criteria

Changes
Anorexia Nervosa
• Amenorrhea requirement eliminated
• Wording changed to help with identification of
low body weight; additional guidance provided
 Bulimia Nervosa
• Reduction in frequency for binge eating &
inappropriate compensatory behavior
 Binge Eating Disorder
• Moved to disorder section from study section
• Frequency criteria changed, matches BN

Elimination
Disorders

Elimination Disorders
Enuresis
 Repeated voiding of urine, bed/ clothes, involuntary,
intentional
 > 2 week/ 3 months or distress
 > 5 years
 Specify
• Nocturnal only
• Diurnal only
• Nocturnal and diurnal

Elimination Disorders
Encopresis
 Repeated passage of feces into inappropriate
places, involuntary or intentional
 At least 1 event each month for > 3 months
 > 4 years
 Specifier
• With constipation and overflow incontinence
• Without constipation and overflow incontinence

Changes
 Own category

Sleep-Wake
Disorders

Sleep-Wake Disorders
Insomnia Disorder
 Predominant complaint of dissatisfaction with sleep quantity
or quality, assoc with > 1
• Difficulty initiating sleep
• Difficulty maintaining sleep
• Early morning awakening, inability to return to sleep
 > 3 nights/ week; > 3 months
 Occurs despite adequate opportunity
 Specify
• With non sleep disorder mental comorbidity
• With other medical comorbidity
• With other sleep disorder

Hypersomnolence Disorder
 Self reported excessive sleepiness despite sleep > 7 hours
 At least 1 of the following
• Recurrent periods of sleep/ lapses, same day
• Non-restorative main sleep > 9 hours
• Difficulty being awake after abrupt awakening
 > 3 times/ week; > 3 months
 Specify
• With mental disorder, medical condition, another sleep disorder
• Acute/ subacute/ persistent
• Severity
 Difficulty maintaining daytime alertness

Narcolepsy
 Recurrent episodes of irrepressible need to sleep, lapsing into sleep,
napping; > 3 times/ week for 3 months
 Presence > 1
• Cataplexy, few times a month
• Hypocretin deficiency
• Nocturnal sleep polysomnography, REM sleep latency < 15 min,
multiple sleep latency < 8 min
 Specify
• Narcolepsy without cataplexy but with hypocretin deficiency
• Narcolepsy with cataplexy but without hypocretin deficiency
• Autosomal dominant cerebellar ataxia, deafness and narcolepsy
• Autosomal dominant natcolepsy, obesity and type 2 diabetes
• Narcolepsy secondary to another medical condition
• Severity
 Frequency of cataplexy

Breathing-Related Sleep Disorders
Obstructive Sleep Apnea Hypopnea
 Evidence by polysomnography of > 5 obstructive
apneas/ hypopneas per hour of sleep and either
• Nocturnal breathing disturbances
• Daytime sleepiness, fatigue, unrefreshing sleep
 Evidence of polysomnography >15 per hour
regardless of symptoms
 Specify
• Severity
 Apnea hyponea index

Central Sleep Apnea
 Evidence by polysomnography of > 5 central
apneas per hour of sleep
 Not another sleep disorder
 Specify
• Idiopathic central sleep apnea
• Cheyne-Stokes breathing
• Central sleep apnea comorbid with opiod use
• Severity
 Frequency of breathing disturbances, extent of
associated oxygen desaturation and sleep
fragmentation

Sleep-Related Hypoventilation
 Polysomnography – episodes of decreased
respiration associated with elevated CO2
 Not another sleep disorder
 Specify
• Idiopathic hypoventilation
• Congenital central alveolar hypoventilation
• Comorbid sleep-related hypoventilation
• Severity
 Degree of hypoxemia & hypercarbia present
during sleep, evidence of end organ
impairment due abn

Circadian Rhythm Sleep-Wake Disorders
 Persistent pattern of sleep disruption due to alteration of
circadian system or misalignment between system and
individual schedule
 Excessive sleepiness or insomnia or both
 Specify
• Delayed sleep phase type; familial; overlapping with
non 24 hour sleep-wake type
• Advanced sleep phase type; familial
• Irregular sleep phase type
• Non 24 hour sleep wake type
• Shift work type
• Episodic/ persistent/ recurrent

Parasomnias
Non Rapid Eye Movement Sleep Arousal Disorders
 Recurrent episodes of incomplete awakening from
sleep, usually 1st
third of sleep, with 1 of
• Sleepwalking
• Sleep terrors
 Little/ no dream recall
 Amnesia for events
 Specify
• Sleepwalking type
 with sleep-related eating/ sexual behavior
• Sleep terror type

Parasomnias
Nightmare Disorder
 Repeated, dysphoric, scary, remembered dreams,
second half of sleep
 Awakening, rapidly alert
 Specify
• During sleep onset
• With associated non sleep/ other medical/ other
sleep disorder
• Acute/ subacute/persistent
• Severity
 Frequency of episodes per week

Parasomnias
Rapid Eye Movement Sleep Behavior Disorder
 Repeated episodes of arousal during sleep associated
with vocalization/ complex motor behaviors
 Arise during REM, > 90 minutes after onset
 Awakening, completely alert
 Either
• REM sleep without atonia or polysomnography
• History suggestive of REM sleep behavior and
synucleinopathy diagnosis

Restless Legs Syndrome
 Urge to move legs, accompanied by/ response to
uncomfortable leg sensation
 Begins/ worsens during rest/ inactivity
 Relieved by movement
 Worse in evening
 > 3 times/ week, > 3 months

Changes
 Eliminated sleep disorders due to mental disorder &
medical condition, replaced with expanded
specifiers
 Science and development information integrated
 Insomnia renamed
 Narcolepsy
• Separated from hypersomnolence disorder
• Multiple specifiers
 Moved from study to disorder section
• REM Sleep Disorder
• Restless Leg Syndrome

Changes
Breathing-related sleep disorders
 3 distinct groups
• Obstructive Sleep Apnea Hypopnea
• Central Sleep Apnea
• Sleep-Related Hypoventilation
 Specific diagnostic criteria
 Circadian Rhythm Sleep Disorders
• Expanded subtypes
• Jet lag removed

Sexual
Dysfunctions

Sexual Dysfunctions
Delayed Ejaculation
 Either symptom, almost all or all occasions, partnered
sexual activity, without individual desiring delay
• Marked delay in ejaculation
• Marked infrequency/ absence of ejaculation
 > 6 months
 Distress
 Specify
• Lifelong/ acquired
• Generalized/ situational
• Severity
 Distress over symptoms

Sexual Dysfunctions
Erectile Disorder
 Experienced almost all/ all occasions of sexual activity
• Marked difficulty in obtaining erection
• Marked difficulty in maintaining erection until completion
• Marked decrease in erectile rigidity
 > 6 months
 Distress
 Specify
• Severity

Sexual Dysfunctions
Female Orgasmic Disorder
 Experienced almost all/ all occasions of sexual
activity
• Marked delay/ infrequency/absence orgasm
• Marked reduced intensity of orgasmic sensations
 > 6 months
 Distress
 Specify
• Severity

Sexual Dysfunctions
Female Sexual Interest/ Arousal Disorder
 Lack of/decreased sexual interest/ arousal, > 3
• Absent/ decreased interest, sexual/ erotic thoughts/
fantasies, no/ decreased initiation, unreceptive,
absent/ reduced sexual excitement, less interest/
arousal in response, decreased response during
sexual activity
 > 6 months
 Distress
 Specify
• Severity

Sexual Dysfunctions
Male Hypoactive Sexual Desire Disorder
 Persistent/ recurrent deficient sexual, erotic thoughts,
fantasies, desire for sexual activity
 > 6 months
 Distress
 Specify
• Severity

Sexual Dysfunctions
Genito-Pelvic Pain/ Penetration Disorder
 Persistent/ recurrent difficulties, > 1
• Vaginal penetration during intercourse
• Vulvovaginal/ pelvic pain during intercourse/
penetration
• Fear/ anxiety about pain re penetration
• Tensing/ tightening, pelvic floor muscles during
attempted penetration
 Duration > 6 months
 Distress
 Specify
• Severity

Sexual Dysfunctions
Premature (Early) Ejaculation
 Persistent/ recurrent pattern of ejaculation during
partnered sexual activity, within 1 minute
 > 6 months, almost all/ all occasions
 Specify
• Severity
 Timing of ejaculation related to vaginal
penetration/ start of sexual activity

Changes
 Added disorders, gender specific
 Disorders consolidated, renamed
 All disorders
• Minimal duration of 6 months
• More precise criteria for severity
• Additional information in text on factors
• Partner, relationship, individual vulnerability,
cultural/ religious, medical
• 2 subtypes
 Lifelong/ acquired
 Generalized/ situational

Gender
Dysphoria

Gender Dysphoria
Gender Dysphoria in Children
 Marked incongruence between experienced/
expressed gender and assigned gender, > 6
months, > 6 symptoms
 Distress
 Specify
• With disorder of sex development

Gender Dysphoria
Gender Dysphoria in Adults
 Marked incongruence between experienced/
expressed gender and assigned gender, > 2
months, > 6 symptoms
 Distress
 Specify
• With disorder of sex development
• Posttransition

Changes
 New category
 New name
 Emphasis on gender incongruence rather than cross gender
identification
 Emphasis on emotional component
 Gender used rather than sex
 No subtyping for sexual orientation
 Separate criteria for children and adults
 Children
• Strong desire instead of expression of desire
• Desire necessary but not sufficient, more restrictive
 Adolescents/ Adults
• Cross gender identification and aversion to own gender
merged
• Posttransition (after > 1 treatment/ procedure) specifier

Disruptive, Impulse-Control and
Conduct Disorders
Oppositional Defiant Disorder
 Pattern of
• angry/ irritable mood
• defiant/ oppositional behavior
• vindictiveness
 > 6 months; > 4 symptoms
 Distress
 Specify
• Severity
 Number of settings symptoms expressed in

Disruptive, Impulse-Control and Conduct
Disorders
Intermittent Explosive Disorder
 Recurrent behavioral outbursts, failure to control
aggressive impulses, manifested by
• Verbal aggressiveness, on avg, 2x/ week over 3
months
• Behavioral outbursts, property damage, injury, >
3 over 12 months
 Not premeditated
 Distress
 > 6 years

Disorders
Conduct Disorder
 Repetitive, persistent behavior pattern, > 3 symptoms, past 12 months, 1
criterion in last 6 months
• Aggression to people & animals
• Destruction of property
• Deceitfulness or Theft
• Serious violations of rules
 Impairment
 If > 18 years, not meet antisocial PD
 Specify
• Childhood (< 10 years)/ adolescent onset
• Limited prosocial emotions
 > 2 symptoms, persistent, > 12 months, multiple relationships/
settings
 Lack of remorse/ guilt; callous- lack of empathy; unconcerned about
performance; shallow or deficient affect
 Severity

Disorders
Pyromania
 Deliberate, purposeful fire setting, >1
 Tension or affective arousal
 Fascination/ interest in fire
 Pleasure, gratification when witnessing
 Not monetary gain, expression of sociopolitical
ideology, conceal criminal activity, express anger/
vengeance, improve one’s living circumstances, in
response to delusion/ hallucination, impaired
judgment

Disorders
Kleptomania
 Recurrent failure to resist impulses to steal object,
not needed for personal object
 Increasing sense of tension immediately before
 Pleasure, gratification at time of theft
 Not anger, vengeance, not response to
hallucination/ delusion

Changes
 New category
 Include disruptive and impulse control disorders
 Disorders with emotional and behavioral self control
 ODD
• 3 types: angry/ irritable; argumentative/ defiant;
vindictiveness
• Conduct disorder exclusion removed

Changes
Conduct Disorder
 Additional specifier re prosocial emotions
Intermittent Explosive Disorder
 Expanded criteria for outbursts
• Added verbal, nondestructive/ non-injurious physical
aggression
• More specific criteria for frequency
• Outbursts = impulsive, anger based
 Marked distress/ impairment
• Marked distress
• Occupational/ interpersonal functioning impairment
• Negative financial or legal consequences
 Minimal age of 6 years/equivalent development level

Substance
Related and
Addictive
Disorders

Substance Related and Addictive
Disorders
Substance Induced Disorders
 Intoxication
 Withdrawal
 Use Disorder
 Specify
• Early/ sustained remission
• Controlled environment/ maintenance therapy
• Severity
 Number of symptoms

Disorders
Substances
 Alcohol
 Caffeine (Use Disorder in Study section)
 Cannabis
 Phencyclidine
 Other Hallucinogen
 Inhalant
 Opioid
 Sedative, Hypnotic, Anxiolytic
 Stimulant
 Tobacco

Disorders
 Some substances
• Specifiers based on primary symptoms,
substances
 Severity = Number of symptoms/ 11 criteria
• Mild = 2-3
• Moderate = 4-5
• Severe = > 6
 Remission
• Early = > 3 but < 12 months not meet criteria
(except craving)
• Sustained = > 12 months not meet criteria
(except Craving)

Disorders
Non Substance Related Disorders
Gambling Disorder
 Persistent, problematic gambling behavior
 Impairment/ distress
 > 4 symptoms, 12 months
 Specify
• Episodic/ persistent
• Early/ sustained remission
• Severity
 Number of criteria met

Changes
 Gambling disorder added
 Abuse and dependence no longer separated
 Criteria
• Intoxication
• Withdrawal
• Substance Induced Disorders
 Added cannabis and caffeine withdrawal

Changes
Substance Use Disorders
 Legal problems deleted
 Craving/ strong desire to use added
 Threshold changed to > 2 symptoms
 Physiological subtype eliminated
 Polysubstance dependence eliminated
 Severity based on symptoms
 Additional specifiers
• Remission, environment, maintenance

Neurocognitive
Disorders

Neurocognitive Disorders
Delirium
 Disturbance in attention
 Develops over short period of time
 Additional disturbance in cognition
 Specifier
• Substance intoxication/ withdrawal
• Medication induced
• Another medical condition
• Multiple etiologies
• Acute/ persistent
• Hyperactive/ hypoactive/ mixed level of activity

 Mild
 Major
 Defined cognitive domains
• Complex attention
• Executive function
• Learning and memory
• Language
• Perceptual-motor
• Social cognition

Major Neurocognitive Disorder
 Significant cognitive decline from previous
performance level in > 1 domains
• Concern of individual, informant, clinician that
been significant decline
• Substantial impairment in cognitive performance
on testing/ clinical performance
 Interfere with independence in everyday activities
 Not delirium

Mild Neurocognitive Disorder
 Modest cognitive decline from previous level of
performance in > 1 cognitive domains
• Concern of individual, informant, clinician that
been significant decline
• Modest impairment in cognitive performance on
testing/ clinical performance
 Not interfere with capacity of independence in
everyday activities
 Not delirium

Subtypes
 Alzheimer’s disease
 Vascular disease
 Frontotemporal
 Lewy bodies
 Traumatic brain injury
 Substance/ medication
 HIV infection
 Prion disease
 Parkinson’s disease
 Huntington’s disease
 Another medical condition
 Multiple etiologies

 Specifiers
 With/ without behavioral disturbances
 Severity (major)
• Difficulties with basic activities of daily living

Changes
 New term – Neurocognitive disorder
 Category includes dementia and amnesia
 New disorders
• Broader range of etiologies
• Expanded to cover wider range of function and
ages
• Includes less severe dysfunction
• Previous dementia subtypes now organized as
separate, independent disorders

Personality
Disorders

Personality Disorders
 Paranoid
 Schizoid
 Schizotypal
 Antisocial
 Borderline
 Histrionic
 Narcissistic
 Avoidant
 Dependent
 Obsessive-Compulsive

General Criteria
 Enduring pattern of inner experience that deviates
markedly from cultural experiences, > 2 manifestations
• Cognition
• Affectivity
• Interpersonal functioning
• Impulse control
 Pattern, inflexible & pervasive across broad range of
personal and social situations
 Pattern stable & enduring; from adolescence/ early
adulthood

Paranoid
 Distrust and suspiciousness of others, motives
interpreted as malevolent
 > 4 symptoms
• Suspicious without basis of being exploited/
harm/deception; preoccupied with unjustified
doubts about loyalty; reluctant to confide, fear
information used against; reads hidden
demeaning/ threatening meaning in remarks;
bears grudges; attacks on character; suspicious
of fidelity

Schizoid
 Detachment from social relationships and restricted
range of expression of emotions in interpersonal
settings
 > 4
• not desire/ enjoy close relationships; chooses
solitary activities; no interest in sexual
relationship; pleasure in few activities; lacks
close friends; indifferent to feedback from others;
emotional coldness/ detachment

Schizotypal Disorder
 Social and interpersonal deficits, acute discomfort
with/ reduced capacity for close relationships;
cognitive/ perceptual distortions/ behavior
eccentricities
 > 5
• Ideas of reference, odd beliefs/ magical thinking,
influences behavior; unusual perceptual
experiences; odd thinking and speech;
suspiciousness/ paranoid delusion

Personality Disorder
Antisocial
 Disregard for and violation of rights of others
 Since 15 years
 > 3
 Failure to conform to social norms related to lawful
behaviors; deceitfulness; impulsivity; irritability/
aggressiveness; reckless disregard for safety of
self/ others; consistent irresponsibility; lack of
remorse
 > 18 years
 Evidence of conduct disorder < 15 years

Borderline
 Instability of interpersonal relationships, self-image,
affects; marked impulsivity
 > 5
 Frantic efforts to avoid real or imagined abandonment;
unstable and intense interpersonal relationships, alternat
between extremes of idealization and devaluation; identit
disturbance; impulsivity in 2 areas; recurrent suicidal/ self
mutilating behavior; affective instability due to marked
reactivity of mood; chronic feelings of emptiness;
inappropriate, intense anger; transient, stress related
paranoid ideation, severe dissociative symptoms

Histrionic
 Excessive emotionality and attention seeking
 > 5
• Uncomfortable when not center of attention;
interaction with others characterized by
inappropriate sexual behavior; rapidly shifting and
shallow expression of emotions; uses physical
appearance to draw attention to self; speech
style, excessively impressionistic and lacking in
detail; self-dramatization, theatricality;
suggestible; considers relationships more
intimate than are

Narcissistic
 Grandiosity (fantasy or behavior), need for
admiration, lack of empathy
 > 5
• grandiose sense of self-importance,
preoccupied with fantasies of unlimited
success, etc; believes is special/ unique;
requires excessive admiration; sense of
entitlement; interpersonally exploitative; lacks
empathy; envious of others; arrogant

Avoidant
 Social inhibition, feelings of inadequacy,
hypersensitivity to negative evaluation
 > 4
• Avoids occupational activities that require
interpersonal contact, fear of criticism, disapproval,
rejection; unwilling to get involved with others unless
certain liked; restraint in intimate relationships, fear
of being shamed/ ridiculed; preoccupied with being
criticized or rejected in social situations; inhibited in
new interpersonal situations due to feelings of
inadequacy; views self as socially inept/ personally
unappealing/ inferior to others; unusually reluctant to
take risks/ engage in new activities

Dependent
 Excessive need to be taken care of, submissive and clinging
behavior and fears of separation
 > 5
• Difficulty making everyday decisions, needs excessive
advice and reassurance from others; needs others to
assume responsibility in most areas of life; difficulty
expressing disagreement with others due to fear of loss of
support; difficulty initiating projects or doing things on own,
lack of self confidence; excessive lengths to obtain
nurturance and support from others; uncomfortable/
helpless when alone, fears of being unable to care for self;
urgently seeks another relationships as soon as one ends;
unrealistically preoccupied with fears of being left to care
for self

Obsessive Compulsive
 Preoccupation with orderliness, perfectionism, mental/
interpersonal control; at expense of flexibility,
openness, efficiency
 > 4
• Preoccupied with details, rules, lists, order,
organization, schedules that major point of activity
lost; perfectionism that interferes with task
completion; excessively devoted to work and
productivity to exclusion of leisure activities and
friendships; overconscientious, scrupulous, inflexible
about matters of morality, ethics, values

Changes
 None
 Alternative approach in Section III

Paraphilic
Disorders

Paraphilic Disorders
 Exhibitionistic disorder
 Fetishistic disorder
 Frotteuristic disorder
 Pedophilic disorder
 Sexual masochism disorder
 Sexual sadism disorder
 Transvestic disorder
 Voyeuristic disorder

 Not exhaustive list
• Disorders emphasized common, involve actions that
considered criminal because others involved
 Paraphilia
• Any intense and persistent sexual interest
 other than sexual interest, genital stimulation or
preparatory fondling with phenotypically normal
physically mature, consenting human partners
• Necessary but not sufficient for disorder
 Paraphilic disorder
• Distress or impairment to individual
• Satisfaction entails harm or risk of harm to others

Voyeuristic Disorder
 Recurrent and intense sexual arousal from
observing unsuspecting person, naked, disrobing,
sex, as manifested by fantasies, urges, behaviors,
> 6 months
 Acted on urges with non-consenting person or
urges cause distress
 > 18 years
 Specifiers
• In controlled environment
• In full remission

Exhibitionistic Disorder
 Recurrent and intense sexual arousal, exposure of
genitals to unsuspected persons as manifested by
fantasies, urges, behaviors, > 6 months
 Acted on urges with non consenting person or in
distress
 Specifiers
• Sexually aroused by exposing genitals
 Prepubertal children; physically mature
individuals; prepubertal children and physically
mature individuals
• In controlled environment/ in full remission

Frotteuristic Disorder
 Recurrent and intense sexual arousal from touching
or rubbing against non consenting person as
manifested by fantasies, urges, behaviors, > 6
months
distress
 Specifiers

Paraphilic Disorder
Sexual Masochism Disorder
 Recurrent and intense sexual arousal from act of
being humiliated, beaten, bound or otherwise made
to suffer as manifested by fantasies, urges,
behaviors, > 6 months
 Cause distress
 Specifiers
• With asphyxiophilia

Sexual Sadism Disorder
 Recurrent and intense sexual arousal from physical
or psychological suffering of another person as
manifested by fantasies, urges, behaviors, > 6
months
distress
 Specifiers

Pedophilic Disorder
 Recurrent and intense sexual arousing fantasies, sexual
urges or behaviors involving sexual activity with a
prepubescent child or children (< 13 years), > 6 months
 Acted on urges or in distress
 > 16 years old and > 5 years old than child
• Not include late adolescent in sexual relationship with
12 or 13 year old
 Specifiers
• Exclusive/ non exclusive
• Sexually attracted to
 Males, females, both
• Limited to incest

Fetishistic Disorder
 Recurrent and intense sexual arousal from either
uses of non living objects or highly specific focus on
non genital body parts as manifested by fantasies,
urges, behaviors, > 6 months
 Cause distress
 Objects not limited to clothing used for cross
dressing or devices specifically designed for
purpose of tactile genital stimulation
 Specifiers
• Body parts, nonliving objects, other

Transvestic Disorder
 Recurrent and intense sexual arousal from cross
dressing as manifested by fantasies, urges,
behaviors, > 6 months
 Cause distress
 Specifiers
• With fetishism/ autogynephilia

Changes
 Emphasize paraphilias vs paraphilic disorders
• Paraphilia necessary but not sufficient
• Paraphilias - consenting adults not necessarily disorders
 No change in basic structure of diagnostic criteria
 Transvestic Disorder
• no longer just restricted to heterosexual males
 Specifiers – controlled environment/ in remission
 Disorder
• Individual in distress/impaired
• Satisfaction causes personal harm or risk of harm to others
• Have to meet criteria for A and B

Assessment Measures
WHODAS Domains
 Understanding and communicating
 Getting around
 Self Cares
 Getting along with people
 Life Activities
• Household
• Work or school
 Participation in Society

Conditions for Further Study
 Attenuated Psychosis Syndrome
 Depressive Episodes with Short Duration
Hypomania
 Persistent Complex Bereavement Disorder
 Caffeine Use Disorder
 Internet Gaming Disorder
 Neurobehavioral Disorder Associated with Prenatal
Alcohol Exposure
 Suicidal Behavior Disorder
 Nonsuicidal Self-Injury

Conditions for Further Study
Attenuated Psychosis Syndrome
 > 1, attenuated form, relatively intact reality testing;
sufficient severity/ frequency to warrant clinical
attention
• Delusions, hallucinations, disorganized speech
 > 1 symptom/ week for past month
 Began or worsened in past year
 Distressing/ impairing

Diagnostic and Statistical Manual of Mental Disorders

Diagnostic and Statistical Manual of Mental Disorders

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