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DSM-5TM

Handbook

of Differential

Diagnosis

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DSM-5TM

Handbook

of Differential

Diagnosis

Michael B. First, M.D. Professor of Clinical Psychiatry, Columbia University; and

Research Psychiatrist, Division of Clinical Phenomenology, New York State Psychiatric Institute, New York, New York

Washington, DC London, England

Note: The author has worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this book. For these reasons and because human and mechanical errors sometimes occur, we rec- ommend that readers follow the advice of physicians directly involved in their care or the care of a member of their family.

Books published by American Psychiatric Publishing (APP) represent the findings, con- clusions, and views of the individual authors and do not necessarily represent the poli- cies and opinions of APP or the American Psychiatric Association.

If you would like to buy between 25 and 99 copies of this or any other APP title, you are eligible for a 20% discount; please contact Customer Service at [email protected] or 800– 368–5777. If you wish to buy 100 or more copies of the same title, please e-mail us at [email protected] for a price quote.

The author, Michael B. First, M.D., has no competing interests to disclose.

Manufactured in the United States of America on acid-free paper 17 16 15 14 13 5 4 3 2 1 First Edition

Typeset in Palatino LT Std and HelveticaNeue LT Std.

American Psychiatric Publishing A Division of American Psychiatric Association 1000 Wilson Boulevard Arlington, VA 22209-3901 www.appi.org

Library of Congress Cataloging-in-Publication Data First, Michael B., 1956– author.

DSM-5 handbook of differential diagnosis / Michael B. First. — First edition. p. ; cm.

Handbook of differential diagnosis Includes index. ISBN 978-1-58562-462-1 (pbk. : alk. paper) I. American Psychiatric Association, issuing body. II. Title. III. Title: Handbook of

differential diagnosis. [DNLM: 1. Diagnostic and statistical manual of mental disorders. 5th ed. 2. Mental

Disorders—diagnosis—Handbooks. 3. Diagnosis, Differential—Handbooks. WM 34] RC473.D54 616.89'075—dc23

2013036943

British Library Cataloguing in Publication Data A CIP record is available from the British Library.

To Leslee, my bashert, for all the love and support

that made this book possible.

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Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii

1 Differential Diagnosis Step by Step . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Differential Diagnosis by the Trees. . . . . . . . . . . . . . . . . . . . . . . . 17

2.1 Decision Tree for Poor School Performance . . . . . . . . . . . . . . . . . 22

2.2 Decision Tree for Behavioral Problems in a Child or Adolescent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

2.3 Decision Tree for Speech Disturbance . . . . . . . . . . . . . . . . . . . . . 30

2.4 Decision Tree for Distractibility . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

2.5 Decision Tree for Delusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

2.6 Decision Tree for Hallucinations . . . . . . . . . . . . . . . . . . . . . . . . . . 44

2.7 Decision Tree for Catatonic Symptoms . . . . . . . . . . . . . . . . . . . . 49

2.8 Decision Tree for Elevated or Expansive Mood . . . . . . . . . . . . . . 52

2.9 Decision Tree for Irritable Mood . . . . . . . . . . . . . . . . . . . . . . . . . . 56

2.10 Decision Tree for Depressed Mood . . . . . . . . . . . . . . . . . . . . . . 61

2.11 Decision Tree for Suicidal Ideation or Behavior . . . . . . . . . . . . . 67

2.12 Decision Tree for Psychomotor Retardation . . . . . . . . . . . . . . . . 72

2.13 Decision Tree for Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

2.14 Decision Tree for Panic Attacks . . . . . . . . . . . . . . . . . . . . . . . . . 80

2.15 Decision Tree for Avoidance Behavior . . . . . . . . . . . . . . . . . . . . 83

2.16 Decision Tree for Trauma or Psychosocial Stressors Involved in the Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

2.17 Decision Tree for Somatic Complaints or Illness/Appearance Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

2.18 Decision Tree for Appetite Changes or Unusual Eating Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

2.19 Decision Tree for Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

2.20 Decision Tree for Hypersomnolence . . . . . . . . . . . . . . . . . . . . . 104

2.21 Decision Tree for Sexual Dysfunction in a Female . . . . . . . . . . 109

2.22 Decision Tree for Sexual Dysfunction in a Male . . . . . . . . . . . . 113

2.23 Decision Tree for Aggressive Behavior . . . . . . . . . . . . . . . . . . 116

2.24 Decision Tree for Impulsivity or Impulse-Control Problems. . . . 122

2.25 Decision Tree for Self-Injury or Self-Mutilation . . . . . . . . . . . . . 126

2.26 Decision Tree for Excessive Substance Use. . . . . . . . . . . . . . . 129

2.27 Decision Tree for Memory Loss. . . . . . . . . . . . . . . . . . . . . . . . . 135

2.28 Decision Tree for Cognitive Impairment . . . . . . . . . . . . . . . . . . 139

2.29 Decision Tree for Etiological Medical Conditions . . . . . . . . . . . 149

3 Differential Diagnosis by the Tables. . . . . . . . . . . . . . . . . . . . . . 157

Neurodevelopmental Disorders

3.1.1 Differential Diagnosis for Intellectual Disability (Intellectual Developmental Disorder) . . . . . . . . . . . . . . . . . . . 162

3.1.2 Differential Diagnosis for Communication Disorders . . . . . . . . 164

3.1.3 Differential Diagnosis for Autism Spectrum Disorder . . . . . . . . 166

3.1.4 Differential Diagnosis for Attention-Deficit/Hyperactivity Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

3.1.5 Differential Diagnosis for Specific Learning Disorder . . . . . . . 172

3.1.6 Differential Diagnosis for Tic Disorders . . . . . . . . . . . . . . . . . 174

Schizophrenia Spectrum and Other Psychotic Disorders

3.2.1 Differential Diagnosis for Schizophrenia or Schizophreniform Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

3.2.2 Differential Diagnosis for Schizoaffective Disorder. . . . . . . . . . 177

3.2.3 Differential Diagnosis for Delusional Disorder . . . . . . . . . . . . . 178

3.2.4 Differential Diagnosis for Brief Psychotic Disorder . . . . . . . . . . 180

3.2.5 Differential Diagnosis for Unspecified Catatonia . . . . . . . . . . . 181

Bipolar and Related Disorders

3.3.1 Differential Diagnosis for Bipolar I Disorder . . . . . . . . . . . . . . . 182

3.3.2 Differential Diagnosis for Bipolar II Disorder. . . . . . . . . . . . . . . 185

3.3.3 Differential Diagnosis for Cyclothymic Disorder . . . . . . . . . . . . 188

Depressive Disorders

3.4.1 Differential Diagnosis for Major Depressive Disorder . . . . . . . 189

3.4.2 Differential Diagnosis for Persistent Depressive Disorder (Dysthymia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

3.4.3 Differential Diagnosis for Premenstrual Dysphoric Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

3.4.4 Differential Diagnosis for Disruptive Mood Dysregulation Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196

Anxiety Disorders

3.5.1 Differential Diagnosis for Separation Anxiety Disorder . . . . . . 198

3.5.2 Differential Diagnosis for Selective Mutism . . . . . . . . . . . . . . . 201

3.5.3 Differential Diagnosis for Specific Phobia . . . . . . . . . . . . . . . . 202

3.5.4 Differential Diagnosis for Social Anxiety Disorder (Social Phobia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204

3.5.5 Differential Diagnosis for Panic Disorder . . . . . . . . . . . . . . . . 208

3.5.6 Differential Diagnosis for Agoraphobia . . . . . . . . . . . . . . . . . . 210

3.5.7 Differential Diagnosis for Generalized Anxiety Disorder . . . . . 212

Obsessive-Compulsive and Related Disorders

3.6.1 Differential Diagnosis for Obsessive-Compulsive Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

3.6.2 Differential Diagnosis for Body Dysmorphic Disorder . . . . . . . 218

3.6.3 Differential Diagnosis for Hoarding Disorder . . . . . . . . . . . . . . 220

3.6.4 Differential Diagnosis for Trichotillomania (Hair-Pulling Disorder) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

3.6.5 Differential Diagnosis for Excoriation (Skin-Picking) Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224

Trauma- and Stressor-Related Disorders

3.7.1 Differential Diagnosis for Posttraumatic Stress Disorder or Acute Stress Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

3.7.2 Differential Diagnosis for Adjustment Disorder. . . . . . . . . . . . . 227

Dissociative Disorders

3.8.1 Differential Diagnosis for Dissociative Amnesia . . . . . . . . . . . . 229

3.8.2 Differential Diagnosis for Depersonalization/Derealization Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Somatic Symptom and Related Disorders

3.9.1 Differential Diagnosis for Somatic Symptom Disorder . . . . . . . 234

3.9.2 Differential Diagnosis for Illness Anxiety Disorder . . . . . . . . . . 236

3.9.3 Differential Diagnosis for Conversion Disorder (Functional Neurological Symptom Disorder) . . . . . . . . . . . . . . 239

3.9.4 Differential Diagnosis for Psychological Factors Affecting Other Medical Conditions . . . . . . . . . . . . . . . . . . . . . 241

3.9.5 Differential Diagnosis for Factitious Disorder . . . . . . . . . . . . . . 243

Feeding and Eating Disorders

3.10.1 Differential Diagnosis for Avoidant/Restrictive Food Intake Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

3.10.2 Differential Diagnosis for Anorexia Nervosa . . . . . . . . . . . . . . 246

3.10.3 Differential Diagnosis for Bulimia Nervosa . . . . . . . . . . . . . . . 249

3.10.4 Differential Diagnosis for Binge-Eating Disorder . . . . . . . . . . 251

Sleep-Wake Disorders

3.11.1 Differential Diagnosis for Insomnia Disorder . . . . . . . . . . . . . 252

3.11.2 Differential Diagnosis for Hypersomnolence Disorder . . . . . . 255

Sexual Dysfunctions

3.12.1 Differential Diagnosis for Sexual Dysfunctions . . . . . . . . . . . . 258

Gender Dysphoria

3.13.1 Differential Diagnosis for Gender Dysphoria . . . . . . . . . . . . . 260

Disruptive, Impulse-Control, and Conduct Disorders

3.14.1 Differential Diagnosis for Oppositional Defiant Disorder. . . . . 262

3.14.2 Differential Diagnosis for Intermittent Explosive Disorder. . . . 264

3.14.3 Differential Diagnosis for Conduct Disorder . . . . . . . . . . . . . . 266

Substance-Related and Addictive Disorders

3.15.1 Differential Diagnosis for Substance Use Disorders . . . . . . . 268

3.15.2 Differential Diagnosis for Gambling Disorder . . . . . . . . . . . . . 270

Neurocognitive Disorders

3.16.1 Differential Diagnosis for Delirium . . . . . . . . . . . . . . . . . . . . . 271

3.16.2 Differential Diagnosis for Major or Mild Neurocognitive Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273

Personality Disorders

3.17.1 Differential Diagnosis for Paranoid Personality Disorder . . . . 276

3.17.2 Differential Diagnosis for Schizoid Personality Disorder. . . . . 277

3.17.3 Differential Diagnosis for Schizotypal Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

3.17.4 Differential Diagnosis for Antisocial Personality Disorder. . . . 279

3.17.5 Differential Diagnosis for Borderline Personality Disorder . . . 281

3.17.6 Differential Diagnosis for Histrionic Personality Disorder . . . . 282

3.17.7 Differential Diagnosis for Narcissistic Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

3.17.8 Differential Diagnosis for Avoidant Personality Disorder . . . . 284

3.17.9 Differential Diagnosis for Dependent Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

3.17.10 Differential Diagnosis for Obsessive-Compulsive Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

3.17.11 Differential Diagnosis for Personality Change Due to Another Medical Condition . . . . . . . . . . . . . . . . . . . . . . . . . . 287

Paraphilic Disorders

3.18.1 Differential Diagnosis for Paraphilic Disorders . . . . . . . . . . . . 288

Appendix: DSM-5 Classification . . . . . . . . . . . . . . . . . . . . . . . . . 291

Alphabetical Index of Decision Trees. . . . . . . . . . . . . . . . . . . . . 319

Alphabetical Index of Differential Diagnosis Tables . . . . . . . . . 321

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Preface

xiii

Differential diagnosis is the bread and butter of our task as clinicians. Most patients do

not come to the office saying, “I have major depressive disorder...give me an antidepres-

sant” (although some do!). More typically, the patient consults us seeking some relief from

particular symptoms such as depressed mood and fatigue (the “chief complaints” in the

parlance of medicine) that are the source of clinically significant distress or impairment.

When we are confronted with these presenting symptoms, our job is to cull from all of

the myriad conditions included in DSM-5 those that could possibly account for them

(e.g., for depressed mood and fatigue, the possibilities include Major Depressive Disor-

der, Persistent Depressive Disorder [Dysthymia], Bipolar I Disorder, Bipolar II Disorder,

Schizoaffective Disorder, Depressive Disorder Due to Another Medical Condition, Sub-

stance/Medication-Induced Depressive Disorder, Adjustment Disorder, etc.). Once we

have determined a list of candidates, our next job is to collect additional information—

from personal history, other informants, treatment records, mental status examination,

and laboratory investigations—that will allow a winnowing down of this differential di-

agnosis list to a single most likely contender, which becomes the initial diagnosis leading

to an initial treatment plan. We must still keep an open mind, however, for the possibility

that additional information that becomes available after the initial assessment is com-

pleted might justify a change in the diagnosis and possibly the treatment plan. For ex-

ample, an initial diagnosis of recurrent Major Depressive Disorder might be changed to

Bipolar I Disorder after a requested copy of the medical record for a past hospitalization

reveals that what was reported by a patient as a past Major Depressive Episode was in

fact a Manic Episode With Mixed Features.

This handbook should improve your skill in formulating a comprehensive differen-

tial diagnosis by presenting the problem from a number of different perspectives. Chap-

ter 1, “Differential Diagnosis Step by Step,” explores the differential diagnostic issues

that must be considered in each and every patient being evaluated by providing a six-

step diagnostic framework. In Chapter 2, “Differential Diagnosis by the Trees,” the dif-

ferential diagnosis is approached from the bottom up—that is, from a point of origin that

begins with the patient’s presenting symptom(s) such as depressed mood, delusions,

and insomnia. Each of the 29 decision trees indicates which DSM-5 diagnoses must be

considered in the differential diagnosis of that particular symptom, and offers decision

points reflecting the thinking process involved in choosing from among the possible

xiv DSM-5 Handbook of Differential Diagnosis

contenders. In Chapter 3, “Differential Diagnosis by the Tables,” the differential diagno-

sis is approached from a later point in the diagnostic assessment process—that is, after

you have reached a tentative diagnosis and want to ensure that all reasonable alterna-

tives have received adequate consideration. This section contains 66 differential diagno-

sis tables, one for each of the most important DSM-5 disorders. To facilitate the linkage

between the decision trees in Chapter 2 and the differential diagnosis tables in Chapter

3, each of the disorders included in the terminal branches of the decision trees indicates

the corresponding differential diagnosis table. Additionally, appendixes to this hand-

book include the DSM-5 classification, which has been included to facilitate coding and

to provide an overview of all the DSM-5 diagnoses that must be considered in formulat-

ing a differential diagnosis, as well as alphabetical indexes of the decision trees and dif-

ferential diagnosis tables, which provide an alternate way to locate a particular decision

tree or differential diagnostic table that may be of interest.

The information provided in the decision trees and the differential diagnosis tables is

somewhat overlapping, but each format has its own strengths and may be more or less

useful depending on the situation. The decision trees highlight the overall algorithmic

rules that govern the classification of a particular symptom. Differential diagnosis tables

are provided for most of the disorders in DSM-5 and indicate those disorders that share

important features and thus should be considered and ruled out. They have the advantage

of providing a head-to-head comparison of each disorder, highlighting both the points of

similarity as well as the points of differentiation. Various readers will have different pur-

poses for and different methods of using this handbook. Some individuals will be inter-

ested in a comprehensive overview of the process of making DSM-5 diagnoses and will

find it rewarding to review the handbook cover to cover. Others will use the handbook

more as a reference guide to assist in the differential diagnosis of a particular patient.

The art and science of psychiatric diagnosis is cursed and blessed by the fact that indi-

viduals are so much more complex than the diagnostic rules laid out in any set of decision

trees or tables. Clinicians must always temper the temptation to apply the DSM-5 criteria

or the decision trees and differential diagnosis tables in this handbook in a rote or cook-

book fashion. The approaches outlined here are meant to enhance and not to replace the

central role of clinical judgment and the wisdom of accumulated experience. On the other

hand, clinicians who are not aware of the guidelines for differential diagnosis included in

DSM-5 may become idiosyncratic in their diagnostic habits, undermining one of the cen-

tral functions of the DSM-5, which is to facilitate communication of diagnostic information

among clinicians and between clinicians and their patients and family members. It is use-

ful to know and take advantage of the precision afforded by following the DSM-5 rules but

not to be enslaved by them.

Acknowledgments I would like to thank Allen Frances, M.D., and Harold Alan Pincus, M.D., my coauthors

on the DSM-IV and DSM-IV-TR editions of the Handbook of Differential Diagnosis, for

helping to provide a solid foundation for this book. I would also like to thank my wife,

Leslee Snyder, for her careful proofreading of the manuscript. Finally, I would like to

Preface xv

thank those at American Psychiatric Publishing who assisted in the production of this

book: Rick Prather, Production Manager, who was responsible for redrawing the deci-

sion trees; Debra J. Berman, who did the initial copyediting; and especially Ann M. Eng,

Senior Developmental Editor, whose meticulous editing of the decision trees and differ-

ential diagnosis tables has helped to ensure that I got all of the details right.

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Differential Diagnosis Step by Step

The process of DSM-5 differential diagnosis can be broken down into six basic steps: 1)

ruling out Malingering and Factitious Disorder, 2) ruling out a substance etiology, 3) rul-

ing out an etiological medical condition, 4) determining the specific primary disorder(s),

5) differentiating Adjustment Disorder from the residual Other Specified and Unspeci-

fied conditions, and 6) establishing the boundary with no mental disorder. A thorough

review of this chapter provides a useful framework for understanding and applying the

decision trees presented in the next chapter.

Step 1: Rule Out Malingering and Factitious Disorder The first step is to rule out Malingering and Factitious Disorder because if the patient is

not being honest regarding the nature or severity of his or her symptoms, all bets are off

regarding the clinician’s ability to arrive at an accurate psychiatric diagnosis. Most psy-

chiatric work depends on a good-faith collaborative effort between the clinician and the

patient to uncover the nature and cause of the presenting symptoms. There are times,

however, when everything may not be as it seems. Some patients may elect to deceive

the clinician by producing or feigning the presenting symptoms. Two conditions in

DSM-5 are characterized by feigning: Malingering and Factitious Disorder. These two

conditions are differentiated based on the motivation for the deception. When the moti-

vation is the achievement of a clearly recognizable goal (e.g., insurance compensation,

2 DSM-5 Handbook of Differential Diagnosis

avoiding legal or military responsibilities, obtaining drugs), the patient is considered to

be Malingering. When the deceptive behavior is present even in the absence of obvious

external rewards, the diagnosis is Factitious Disorder. Although the motivation for

many individuals with Factitious Disorder is to assume the sick role, this criterion was

dropped in DSM-5 because of the inherent difficulty in determining an individual’s un-

derlying motivation for his or her observed behavior.

The intent is certainly not to advocate that every patient should be treated as a hostile

witness and that every clinician should become a cynical district attorney. However, the

clinician’s index of suspicion should be raised 1) when there are clear external incentives

to the patient’s being diagnosed with a psychiatric condition (e.g., disability determina-

tions, forensic evaluations in criminal or civil cases, prison settings), 2) when the patient

presents with a cluster of psychiatric symptoms that conforms more to a lay perception

of mental illness rather than to a recognized clinical entity, 3) when the nature of the

symptoms shifts radically from one clinical encounter to another, 4) when the patient

has a presentation that mimics that of a role model (e.g., another patient on the unit, a

mentally ill close family member), and 5) when the patient is characteristically manipu-

lative or suggestible. Finally, it is useful for clinicians to become mindful of tendencies

they might have toward being either excessively skeptical or excessively gullible.

Step 2: Rule Out Substance Etiology (Including Drugs of Abuse, Medications) The first question that should always be considered in the differential diagnosis is

whether the presenting symptoms arise from a substance that is exerting a direct effect

on the central nervous system (CNS). Virtually any presentation encountered in a men-

tal health setting can be caused by substance use. Missing a substance etiology is prob-

ably the single most common diagnostic error made in clinical practice. This error is

particularly unfortunate because making a correct diagnosis has immediate treatment

implications. For example, if the clinician determines that psychotic symptoms are due

to Cocaine Intoxication, it usually does not make sense for the patient to immediately

start taking an antipsychotic medication unless the psychotic symptoms are putting the

patient (or others) in immediate danger. The determination of whether psychopathol-

ogy is due to substance use often can be difficult because although substance use is fairly

ubiquitous and a wide variety of different symptoms can be caused by substances, the

fact that substance use and psychopathology occur together does not necessarily imply

a cause-and-effect relationship between them.

Obviously, the first task is to determine whether the person has been using a sub- stance. This entails careful history taking and physical examination for signs of Substance

Intoxication or Substance Withdrawal. Because substance-abusing individuals are noto-

rious for underestimating their intake, it is usually wise to consult with family members

and obtain laboratory analysis of body fluids to ascertain recent usage of particular sub-

stances. It should be remembered that patients who use or are exposed to any of a variety

of substances (not only drugs of abuse) can and often do present with psychiatric symp-

toms. Medication-induced psychopathology is more and more common, and very often

missed, especially as the population ages and many individuals are taking multiple med-

Step 2: Rule Out Substance Etiology (Including Drugs of Abuse, Medications) 3

ications. Although it is less common, toxin exposure should be considered, especially for

people whose occupations bring them into contact with potential toxins.

Once substance use has been established, the next task is to determine whether there is an etiological relationship between it and the psychiatric symptomatology. This requires distinguishing among three possible relationships between the substance

use and the psychopathology: 1) the psychiatric symptoms result from the direct effects

of the substance on the CNS (resulting in diagnosis of Substance-Induced Disorders in

DSM-5; e.g., Cocaine-Induced Psychotic Disorder, Reserpine-Induced Depressive Disor-

der); 2) the substance use is a consequence (or associated feature) of having a primary

psychiatric disorder (e.g., self-medication); and 3) the psychiatric symptoms and the

substance use are independent. Each of these relationships is discussed in turn.

1. In diagnosing a Substance-Induced Disorder, there are three considerations in de- termining whether there is a causal relationship between the substance use and the psychiatric symptomatology. First, you must determine whether there is a close

temporal relationship between the substance or medication use and the psychiatric

symptoms. Then, you must consider the likelihood that the particular pattern of sub-

stance/medication use can result in the observed psychiatric symptoms. Finally, you

should consider whether there are better alternative explanations (i.e., a non-sub-

stance/medication-induced cause) for the clinical picture.

• You should consider whether a temporal relationship exists between the substance/medica- tion use and the onset or maintenance of the psychopathology. The determination of

whether there was a period of time when the psychiatric symptoms were present

outside the context of substance/medication use is probably the best (although

still fallible) method for evaluating the etiological relationship between sub-

stance/medication use and psychiatric symptoms. At the extremes, this is rela-

tively straightforward. If the onset of the psychopathology clearly precedes the

onset of the substance/medication use, then it is likely that a non-substance/med-

ication-induced psychiatric condition is primary and the substance/medication

use is secondary (e.g., as a form of self-medication) or is unrelated. Conversely, if

the onset of the substance/medication use clearly and closely precedes the psy-

chopathology, it lends greater credence to the likelihood of a Substance-Induced

Disorder. Unfortunately, in practice this seemingly simple determination can be

quite difficult because the onsets of the substance/medication use and the psycho-

pathology may be more or less simultaneous or impossible to reconstruct retro-

spectively. In such situations, you will have to rely more on what happens to the

psychiatric symptoms when the person is no longer taking the substance or med-

ication. Psychiatric symptoms that occur in the context of Substance Intoxication,

Substance Withdrawal, and medication use result from the effects of the substance

or medication on neurotransmitter systems. Once these effects have been removed

(by a period of abstinence after the withdrawal phase), the symptoms should

spontaneously resolve. Persistence of the psychiatric symptomatology for a signif-

icant period of time beyond periods of intoxication or withdrawal or medication

use suggests that the psychopathology is primary and not due to substance/med-

ication use. The exceptions to this are Substance/Medication-Induced Major or

4 DSM-5 Handbook of Differential Diagnosis

Mild Neurocognitive Disorder, in which by definition the cognitive symptoms

must persist after the cessation of acute intoxication or withdrawal or medication

use, and Hallucinogen Persisting Perception Disorder, in which following cessa-

tion of use of a hallucinogen, one or more of the perceptual symptoms that the in-

dividual experienced while intoxicated with the hallucinogen (e.g., geometric

hallucinations, flashes of color, trails of images of moving objects, halos around

objects) are reexperienced. The DSM-5 criteria for substance/medication-induced

presentations suggest that psychiatric symptoms be attributed to substance use if

they remit within 1 month of the cessation of acute intoxication, withdrawal, or

medication use. It should be noted, however, that the need to wait 1 full month be-

fore making a diagnosis of a primary psychiatric disorder is only a guideline that

must be applied with clinical judgment; depending on the setting, it might make

sense to use a more extended duration or a shorter duration depending on your

concern for avoiding false positives versus false negatives with respect to detect-

ing a substance/medication-induced presentation. Some clinicians, particularly

those who work in substance use treatment settings, are most concerned about the

possibility of misdiagnosing a substance/medication-induced presentation as a

primary mental disorder that is not caused by substance use and might prefer al-

lowing 6–8 weeks of abstinence before considering the diagnosis to be a primary

mental disorder. On the other hand, clinicians who work primarily in psychiatric

settings may be more concerned that given the wide use of substances among pa-

tients seen in clinical settings, such a long waiting period is impractical and might

result in an overdiagnosis of Substance-Induced Disorders and an underdiagnosis

of primary mental disorders. Moreover, it must be recognized that the one-size-

fits-all 1-month time frame applies to a wide variety of substances and medica-

tions with very different pharmacokinetic properties and a wide variety of possible

consequent psychopathologies. Therefore, the time frame must be applied flexibly,

considering the extent, duration, and nature of the substance/medication use.

Sometimes, it is simply not possible to determine whether there was a period of

time when the psychiatric symptoms occurred outside of periods of substance/

medication use. This may occur in the often-encountered situation in which the pa-

tient is too poor a historian to allow a careful determination of past temporal rela-

tionships. In addition, substance use and psychiatric symptoms can have their onset

around the same time (often in adolescence), and both can be more or less chronic

and continuous. In these situations, it may be necessary to assess the patient during

a current period of abstinence from substance use or to stop the medication sus-

pected of causing the psychiatric symptoms. If the psychiatric symptoms persist in

the absence of substance/medication use, then the psychiatric disorder can be con-

sidered to be primary. If the symptoms remit during periods of abstinence, then the

substance use is probably primary. It is important to realize that this judgment can

only be made after waiting for enough time to elapse so as to be confident that the

psychiatric symptoms are not a consequence of withdrawal. Ideally, the best setting

for making this determination is in a facility where the patient’s access to substances

can be controlled and the patient’s psychiatric symptomatology can be serially as-

sessed. Of course, it is often impossible to observe a patient for as long as 4 weeks in

Step 2: Rule Out Substance Etiology (Including Drugs of Abuse, Medications) 5

a tightly controlled setting. Consequently, these judgments must be based on less

controlled observation, and the clinician’s confidence in the accuracy of the diagno-

sis should be more guarded.

• In determining the likelihood that the pattern of substance/medication use can account for the symptoms, you must also consider whether the nature, amount, and duration of sub- stance/medication use are consistent with the development of the observed psychiatric symptoms. Only certain substances and medications are known to be causally re-

lated to particular psychiatric symptoms. Moreover, the amount of substance or

medication taken and the duration of its use must be above a certain threshold for

it to reasonably be considered the cause of the psychiatric symptomatology. For

example, a severe and persisting depressed mood following the isolated use of a

small amount of cocaine should probably not be considered to be attributed to the

cocaine use, even though depressed mood is sometimes associated with Cocaine

Withdrawal. Similarly, cannabis smoked in typical moderate doses rarely causes

prominent psychotic symptoms. For individuals who are regular substance users,

a significant change in the amount used (either a large increase or a decrease in

amount sufficient to trigger withdrawal symptoms) may in some cases cause the

development of psychiatric symptoms.

• You should also consider other factors in the presentation that suggest that the presenta- tion is not caused by a substance or medication. These include a history of many sim-

ilar episodes not related to substance/medication use, a strong family history of

the particular primary disorder, or the presence of physical examination or labo-

ratory findings suggesting that a medical condition might be involved. Consider-

ing factors other than substance/medication use as a cause for the presentation of

psychiatric symptoms requires fine clinical judgment (and often waiting and see-

ing) to weigh the relative probabilities in these situations. For example, an individ-

ual may have heavy family loading for Anxiety Disorders and still have a cocaine-

induced panic attack that does not necessarily presage the development of pri-

mary Panic Disorder.

2. In some cases, the substance use can be the consequence or an associated feature (rather than the cause) of psychiatric symptomatology. Not uncommonly, the sub-

stance-taking behavior can be considered a form of self-medication for the psychiat-

ric condition. For example, an individual with a primary Anxiety Disorder might use

alcohol excessively for its sedative and antianxiety effects. One interesting implica-

tion of using a substance to self-medicate is that individuals with particular psychi-

atric disorders often preferentially choose certain classes of substances. For example,

patients with negative symptoms of Schizophrenia often prefer stimulants, whereas

patients with Anxiety Disorders often prefer CNS depressants. The hallmark of a pri-

mary psychiatric disorder with secondary substance use is that the primary psychi-

atric disorder occurs first and/or exists at times during the person’s lifetime when he

or she is not using any substance. In the most classic situation, the period of comor-

bid psychiatric symptomatology and substance use is immediately preceded by a pe-

riod of time when the person had the psychiatric symptomatology but was abstinent

from the substance. For example, an individual currently with 5 months of heavy al-

cohol use and depressive symptomatology might report that the alcohol use started

6 DSM-5 Handbook of Differential Diagnosis

in the midst of a Major Depressive Episode, perhaps as a way of counteracting in-

somnia. Clearly the validity of this judgment depends on the accuracy of the pa-

tient’s retrospective reporting. Because such information is sometimes suspect, it

may be useful to confer with other informants (e.g., family members) or review past

records to document the presence of psychiatric symptoms occurring in the absence

of substance use.

3. In other cases, both the psychiatric disorder and the substance use can be initially unrelated and relatively independent of each other. The high prevalence rates of

both psychiatric disorders and Substance Use Disorders mean that by chance alone,

some patients would be expected to have two apparently independent illnesses (al-

though there may be some common underlying factor predisposing to the develop-

ment of both the Substance Use Disorder and the psychiatric disorder). Of course,

even if initially independent, the two disorders may interact to exacerbate each other

and complicate the overall treatment. This independent relationship is essentially a

diagnosis made by exclusion. When confronted with a patient having both psychiat-

ric symptomatology and substance use, you should first rule out that one is causing

the other. A lack of a causal relationship in either direction is more likely if there are

periods when the psychiatric symptoms occur in the absence of substance use and if

the substance use occurs at times unrelated to the psychiatric symptomatology.

After deciding that a presentation is due to the direct effects of a substance or med- ication, you must then determine which DSM-5 Substance-Induced Disorder best de- scribes the presentation. DSM-5 includes a number of specific Substance/Medication-

Induced Mental Disorders, along with Substance Intoxication and Substance With-

drawal. Please refer to 2.26 Decision Tree for Excessive Substance Use in Chapter 2, “Dif-

ferential Diagnosis by the Trees,” for a presentation of the steps involved in making this

determination.

Step 3: Rule Out a Disorder Due to a General Medical Condition After ruling out a substance/medication-induced etiology, the next step is to determine

whether the psychiatric symptoms are due to the direct effects of a general medical con-

dition. This and the previous step of the differential diagnosis make up what was tradi-

tionally considered the “organic rule-outs” in psychiatry, in which the clinician is asked

to first consider and rule out “physical” causes of the psychiatric symptomatology. Al-

though DSM no longer uses words such as organic, physical, and functional, to avoid the

anachronistic mind-body dualism implicit in such terms, the need to first rule out sub-

stances and general medical conditions as specific causes of the psychiatric symptom-

atology remains crucial. For similar reasons, the phrase “due to a medical condition” is

avoided in DSM because of the potential implication that psychiatric symptomatology

and mental disorders are separate and distinct from the concept of “medical condi-

tions.” In fact, from a disease classification perspective, psychiatric disorders are but one

chapter of the International Classification of Diseases (ICD), as are infectious diseases,

neurological conditions, and so forth. When the phrase “due to a medical condition” is

Step 3: Rule Out a Disorder Due to a General Medical Condition 7

used, what is really meant is that the symptoms are due to a medical condition that is

classified outside the ICD mental disorders chapter—that is, a nonpsychiatric medical

condition. In DSM-5 and this handbook, therefore, the phrase “medical condition” is

modified with adjectives such as another, other, or general to clarify that the etiological

condition, like a mental disorder, is a medical condition but that it is differentiated from

psychiatric medical conditions by virtue of being nonpsychiatric.

From a differential diagnostic perspective, ruling out a general medical etiology is

one of the most important and difficult distinctions in psychiatric diagnosis. It is impor-

tant because many individuals with general medical conditions have resulting psychi-

atric symptoms as a complication of the general medical condition and because many

individuals with psychiatric symptoms have an underlying general medical condition.

The treatment implications of this differential diagnostic step are also profound. Appro-

priate identification and treatment of the underlying general medical condition can be

crucial in both avoiding medical complications and reducing the psychiatric symptom-

atology.

This differential diagnosis can be difficult for four reasons: 1) symptoms of some

psychiatric disorders and of many general medical conditions can be identical (e.g.,

symptoms of weight loss and fatigue can be attributable to a Depressive or Anxiety Dis-

order or to a general medical condition); 2) sometimes the first presenting symptoms of

a general medical condition are psychiatric (e.g., depression preceding other symptoms

in pancreatic cancer or a brain tumor); 3) the relationship between the general medical

condition and the psychiatric symptoms may be complicated (e.g., depression or anxiety

as a psychological reaction to having the general medical condition vs. the medical con-

dition being a cause of the depression or anxiety via its direct physiological effect on the

CNS); and 4) patients are often seen in settings primarily geared for the identification

and treatment of mental disorders in which there may be a lower expectation for, and

familiarity with, the diagnosis of medical conditions.

Virtually any psychiatric presentation can be caused by the direct physiological effects of a general medical condition, and these are diagnosed in DSM-5 as one of the Mental Disorders Due to Another Medical Condition (e.g., Depressive Disorder Due to Hypothyroidism). It is no great trick to suspect the possible etiological role of a gen-

eral medical condition if the patient is encountered in a general hospital or primary care

outpatient setting. The real diagnostic challenge occurs in mental health settings in

which the base rate of general medical conditions is much lower but nonetheless conse-

quential. It is not feasible (nor cost-effective) to order every conceivable screening test

on every patient. You should direct the history, physical examination, and laboratory

tests toward the diagnosis of those general medical conditions that are most commonly

encountered and most likely to account for the presenting psychiatric symptoms (e.g.,

thyroid function tests for depression, brain imaging for late-onset psychotic symptoms).

Once a general medical condition is established, the next task is to determine its etiological relationship, if any, to the psychiatric symptoms. There are five possible re-

lationships: 1) the general medical condition causes the psychiatric symptoms through

a direct physiological effect on the brain; 2) the general medical condition causes the

psychiatric symptoms through a psychological mechanism (e.g., depressive symptoms

in response to being diagnosed with cancer—diagnosed as Major Depressive Disorder

8 DSM-5 Handbook of Differential Diagnosis

or Adjustment Disorder); 3) medication taken for the general medical condition causes

the psychiatric symptoms, in which case the diagnosis is a Medication-Induced Mental

Disorder (see “Step 2: Rule Out Substance Etiology” in this chapter); 4) the psychiatric

symptoms cause or adversely affect the general medical condition (e.g., in which case

Psychological Factors Affecting Other Medical Condition may be indicated); and 5) the

psychiatric symptoms and the general medical condition are coincidental (e.g., hyper-

tension and Schizophrenia). In the real clinical world, however, several of these relation-

ships may occur simultaneously with a multifactorial etiology (e.g., a patient treated

with an antihypertensive medication who has a stroke may develop depression due to

a combination of the direct effects of the stroke on the brain, the psychological reaction

to the resultant paralysis, and a side effect of the antihypertensive medication).

There are two clues suggesting that psychopathology is caused by the direct phys- iological effect of a general medical condition. Unfortunately, neither of these is infal-

lible, and clinical judgment is always necessary.

• The first clue involves the nature of the temporal relationship and requires consideration of whether the psychiatric symptoms begin following the onset of the general medical condition, vary in severity with the severity of the general medical condition, and disappear when the general medical condition resolves. When all of these relationships can be demonstrated,

a fairly compelling case can be made that the general medical condition has caused

the psychiatric symptoms; however, such a clue does not establish that the relation-

ship is physiological (the temporal covariation could also be due to a psychological

reaction to the general medical condition). Also, sometimes the temporal relationship

is not a good indicator of underlying etiology. For instance, psychiatric symptoms

may be the first harbinger of the general medical condition and may precede by

months or years any other manifestations. Conversely, psychiatric symptoms may be

a relatively late manifestation occurring months or years after the general medical

condition has been well established (e.g., depression in Parkinson’s disease).

• The second clue that a general medical condition should be considered in the differential diag- nosis is if the psychiatric presentation is atypical in symptom pattern, age at onset, or course. For example, the presentation cries out for a medical workup when severe memory

or weight loss accompanies a relatively mild depression or when severe disorienta-

tion accompanies psychotic symptoms. Similarly, the first onset of a manic episode in

an elderly patient may suggest that a general medical condition is involved in the eti-

ology. However, atypicality does not in and of itself indicate a general medical etiol-

ogy because the heterogeneity of primary psychiatric disorders leads to many

“atypical” presentations.

Nonetheless, the most important bottom line with regard to this task in the differen-

tial diagnosis is not to miss possibly important underlying general medical conditions.

Establishing the nature of the causal relationship often requires careful evaluation, lon-

gitudinal follow-up, and trials of treatment.

Finally, if you have determined that a general medical condition is responsible for the psychiatric symptoms, you must determine which of the DSM-5 Mental Disorders Due to Another Medical Condition best describes the presentation. DSM-5 includes a

Step 4: Determine the Specific Primary Disorder(s) 9

number of such disorders, each differentiated by the predominant symptom presenta-

tion. Please refer to 2.29 Decision Tree for Etiological Medical Conditions in Chapter 2,

“Differential Diagnosis by the Trees,” for a presentation of the steps involved in making

this determination.

Step 4: Determine the Specific Primary Disorder(s) Once substance use and general medical conditions have been ruled out as etiologies,

the next step is to determine which among the primary DSM-5 mental disorders best ac-

counts for the presenting symptomatology. Many of the diagnostic groupings in DSM-5

(e.g., Schizophrenia Spectrum and Other Psychotic Disorders, Anxiety Disorders, Disso-

ciative Disorders) are organized around common presenting symptoms precisely to fa-

cilitate this differential diagnosis. The decision trees in Chapter 2 provide the decision

points needed for choosing among the primary mental disorders that might account for

each presenting symptom. Once you have selected what appears to be the most likely

disorder, you may wish to review the pertinent differential diagnosis table in Chapter 3,

“Differential Diagnosis by the Tables,” to ensure that all other likely contenders in the

differential diagnosis have been considered and ruled out.

Step 5: Differentiate Adjustment Disorders From the Residual Other Specified or Unspecified Disorders Many clinical presentations (particularly in outpatient and primary care settings) do not

conform to the particular symptom patterns, or they fall below the established severity

or duration thresholds to qualify for one of the specific DSM-5 diagnoses. In such situa-

tions, if the symptomatic presentation is severe enough to cause clinically significant im-

pairment or distress and represents a biological or psychological dysfunction in the

individual, a diagnosis of a mental disorder is still warranted and the differential comes

down to either an Adjustment Disorder or one of the residual Other Specified or Un-

specified categories. If the clinical judgment is made that the symptoms have developed

as a maladaptive response to a psychosocial stressor, the diagnosis would be an Adjust-

ment Disorder. If it is judged that a stressor is not responsible for the development of the

clinically significant symptoms, then the relevant Other Specified or Unspecified cate-

gory may be diagnosed, with the choice of the appropriate residual category depending

on which DSM-5 diagnostic grouping best covers the symptomatic presentation. For ex-

ample, if the patient’s presentation is characterized by depressive symptoms that do not

meet the criteria for any of the disorders included in the DSM-5 chapter “Depressive

Disorders,” then Other Specified Depressive Disorder or Unspecified Depressive Disor-

der is diagnosed (rules regarding which of these two categories to use are provided in

the next paragraph). Because stressful situations are a daily feature of most people’s

lives, the judgment in this step is centered more on whether a stressor is etiological

rather than on whether a stressor is present.

10 DSM-5 Handbook of Differential Diagnosis

DSM-5 offers two versions of residual categories: Other Specified Disorder and Un-

specified Disorder. As the names suggest, the differentiation between the two depends on

whether the clinician chooses to specify the reason that the symptomatic presentation does

not meet the criteria for any specific category in that diagnostic grouping. If the clinician

wants to indicate the specific reason, the name of the disorder (“Other Specified Disor-

der”) is followed by the reason why the presentation does not conform to any of the spe-

cific disorder definitions. For example, if a patient has a clinically significant symptomatic

presentation characterized by 4 weeks of depressed mood, most of the day nearly every

day, which is accompanied by only two additional depressive symptoms (e.g., insomnia

and fatigue), the clinician would record Other Specified Depressive Disorder, Depressive

Episode With Insufficient Symptoms. If the clinician chooses not to indicate the specific

reason why the presentation does not conform to any of the specific disorder definitions,

the Unspecified Disorder designation is used. For example, if the clinician declines to in-

dicate the reason why the depressive presentation does not fit any of the specified catego-

ries, the diagnosis Unspecified Depressive Disorder is made instead. The clinician might

choose the unspecified option if there is insufficient information to make a more specific

diagnosis and the clinician expects that additional information may be forthcoming, or if

the clinician decides it is in the patient’s best interest not to be specific about the reason

(e.g., to avoid offering potentially stigmatizing information about the patient).

Step 6: Establish the Boundary With No Mental Disorder Generally, the last step in each of the decision trees is to establish the boundary between a

disorder and no mental disorder. This decision is by no means the least important or eas-

iest to make. Taken individually, many of the symptoms included in DSM-5 are fairly

ubiquitous and are not by themselves indicative of the presence of a mental disorder.

During the course of their lives, most people may experience periods of anxiety, depres-

sion, sleeplessness, or sexual dysfunction that may be considered as no more than an ex-

pected part of the human condition. To be explicit that not every such individual qualifies

for a diagnosis of a mental disorder, DSM-5 includes with most criteria sets a criterion

that is usually worded more or less as follows: “The disturbance causes clinically signif-

icant distress or impairment in social, occupational, or other important areas of function-

ing.” This criterion requires that any psychopathology must lead to clinically significant

problems in order to warrant a mental disorder diagnosis. For example, a diagnosis of

Male Hypoactive Sexual Desire Disorder, which includes the requirement that the low

sexual desire causes clinically significant distress in the individual, would not be made

in a man with low sexual desire who is not currently in a relationship and who is not

particularly bothered by the low desire.

Unfortunately, but necessarily, DSM-5 makes no attempt to define the term clinically significant. The boundary between disorder and normality can be set only by clinical

judgment and not by any hard-and-fast rules. What may seem clinically significant is

undoubtedly influenced by the cultural context, the setting in which the individual is

seen, clinician bias, patient bias, and the availability of resources. “Minor” depression

may seem much more clinically significant in a primary care setting than in a psychiatric

Differential Diagnosis and Comorbidity 11

emergency room or state hospital where the emphasis is on the identification and treat-

ment of far more impairing conditions.

In clinical mental health settings, the judgment regarding whether a presentation is

clinically significant is often a nonissue; the fact that the individual has sought help au-

tomatically makes it “clinically significant.” More challenging are situations in which

the symptomatic picture is discovered in the course of treating another mental disorder

or a medical condition, which, given the high comorbidity among mental disorders and

between mental disorders and medical conditions, is not an uncommon occurrence.

Generally, as a rule of thumb, if the comorbid psychiatric presentation warrants clinical

attention and treatment, it is considered to be clinically significant.

Finally, some conditions that can impair functioning, such as Uncomplicated Be-

reavement, may still not qualify for the use of an Other Specified or Unspecified Disor-

der category because they do not represent an internal psychological or biological

dysfunction in the individual, as is required in the DSM-5 definition of a mental disor-

der. Such “normal” but impairing symptomatic presentations may be worthy of clinical

attention, but they do not qualify as a mental disorder and should be diagnosed with a

category (usually a V or Z code, corresponding to ICD-9-CM or ICD-10-CM, respec-

tively) from the DSM-5 Section II chapter “Other Conditions That May Be a Focus of

Clinical Attention,” which is included after the mental disorders chapters.

Differential Diagnosis and Comorbidity Differential diagnosis is generally based on the notion that the clinician is choosing a single

diagnosis from among a group of competing, mutually exclusive diagnoses to best explain

a given symptom presentation. For example, in a patient who presents with delusions, hal-

lucinations, and manic symptoms, the question is whether the best diagnosis is Schizo-

phrenia, Schizoaffective Disorder, or Bipolar Disorder With Psychotic Features; only one

of these can be given to describe the current presentation. Very often, however, DSM-5 di-

agnoses are not mutually exclusive, and the assignment of more than one DSM-5 diagno-

sis to a given patient is both allowed and necessary to adequately describe the presenting

symptoms. Thus, multiple decision trees may need to be consulted to adequately cover all

of the important clinically significant aspects of the patient’s presentation. For example, a

patient who presents with multiple unexpected panic attacks, significant depression,

binge eating, and excessive substance use would require a consideration of the following

decision trees: panic attacks (2.14), depressed mood (2.10), appetite changes or unusual

eating behavior (2.18), and excessive substance use (2.26). Moreover, because of comorbid-

ity within diagnostic groupings, multiple passes through a particular decision tree may be

required to cover all possible diagnoses. For example, it is well recognized that if a patient

has one Anxiety Disorder (e.g., Social Anxiety Disorder [Social Phobia]), he or she is more

likely to have other comorbid Anxiety Disorders (e.g., Separation Anxiety Disorder, Panic

Disorder). The anxiety decision tree (2.13), however, helps to differentiate among the var-

ious Anxiety Disorders, and therefore a pass through the tree will result in the diagnosis

of only one of the Anxiety Disorders. Multiple passes through the anxiety tree, answering

the key questions differently each time depending on which anxiety symptom is the cur-

rent focus, are needed to capture the comorbidity.

12 DSM-5 Handbook of Differential Diagnosis

The use of multiple diagnoses is in itself neither good nor bad as long as the impli-

cations are understood. A naïve and mistaken view of comorbidity might assume that a

patient assigned more than one descriptive diagnosis actually has multiple independent

conditions. This is certainly not the only possible relationship. In fact, there are six dif-

ferent ways in which two so-called comorbid conditions may be related to one another:

1) condition A may cause or predispose to condition B; 2) condition B may cause or pre-

dispose to condition A; 3) an underlying condition C may cause or predispose to both

conditions A and B; 4) conditions A and B may, in fact, be part of a more complex unified

syndrome that has been artificially split in the diagnostic system; 5) the relationship be-

tween conditions A and B may be artifactually enhanced by definitional overlap; and 6)

the comorbidity is the result of a chance co-occurrence that may be particularly likely for

those conditions that have high base rates. The particular nature of the relationships is

often very difficult to determine. The major point to keep in mind is that “having” more

than one DSM-5 diagnosis does not mean that there is more than one underlying patho-

physiological process. Instead, DSM-5 diagnoses should be considered descriptive

building blocks that are useful for communicating diagnostic information.

How to Use the Handbook: Case Example To demonstrate how to use the diagnostic tools provided in this handbook to determine

a differential diagnosis, consider the following case, adapted from DSM-5 Clinical Cases, edited by John W. Barnhill, M.D. (pp. 32–34).1

John is a 25-year-old single, unemployed white man who has been seeing a psychiatrist for several years for management of psychosis, depression, anxiety, and abuse of marijuana and alcohol.

After an apparently normal childhood, John began to show dysphoric mood, anhedo- nia, low energy, and social isolation by age 15. At about the same time, John began to drink alcohol and smoke marijuana every day. In addition, he developed recurrent panic attacks, marked by a sudden onset of palpitations, diaphoresis, and thoughts that he was going to die. When he was at his most depressed and panicky, he twice received a combination of sertraline 100 mg/day and psychotherapy. In both cases, his most intense depressive symptoms lifted within a few weeks, and he discontinued the sertraline after a few months. Between episodes of severe depression, he was generally seen as sad, irritable, and amotivated. His school performance declined around tenth grade and remained mar- ginal through the rest of high school. He did not attend college, which had been his par- ents’ expectation, but instead lived at home and did odd jobs in the neighborhood.

Around age 20, John developed a psychotic episode in which he had the conviction that he had murdered people when he was 6 years old. Although he could not remember who these people were or the circumstances, he was absolutely convinced that it had hap- pened, something that was confirmed by continuous voices accusing him of being a mur- derer. He also became convinced that other people would punish him for what happened when he was 6 years old and thus he also feared for his life. Over the next 2 or 3 weeks, he became guilt ridden and preoccupied with the idea that he should kill himself by slashing

1Adapted with permission from Heckers S: “Sad and Psychotic,” in DSM-5 Clinical Cases. Edited by Barnhill JW. Washington, DC, American Psychiatric Publishing, 2014, pp. 32–34. Copyright © 2014 American Psychiatric Association.

How to Use the Handbook: Case Example 13

his wrists, culminating in his being psychiatrically hospitalized because of his parents’ concerns that he would act on these delusions. Although his affect on admission was anx- ious, within a couple of days he also became very depressed with accompanying symp- toms of dysphoria, prominent anhedonia, poor sleep, and decreased appetite and concentration. With the combined use of antipsychotic and antidepressant medications, both the depression and psychotic symptoms remitted after an additional 4 weeks. Thus, the total duration of the psychotic episode was approximately 7 weeks, 4 of which were also characterized by the depressive episode. He was hospitalized with the same pattern of symptoms two additional times before age 22, starting out with a couple of weeks of de- lusions and hallucinations related to his conviction that he had murdered someone when he was a child, followed by severe depression lasting an additional month. Both of those relapses occurred while he was apparently adhering to reasonable dosages of antipsy- chotic medication. For the past 3 years, John has been adherent to clozapine and has been without any further episodes of hallucinations, delusions, or depression.

John began to abuse marijuana and alcohol at age 15. Before the onset of psychosis at age 20, he smoked several joints of marijuana almost daily and binge drank on weekends with occasional blackouts. After the onset of psychosis, his marijuana use decreased signif- icantly, yet he continued to have two more psychotic episodes through age 22 (as described above). He started attending Alcoholics Anonymous and Narcotics Anonymous groups, achieved sobriety from marijuana and alcohol at age 23, and has since remained sober.

This case presents with both prominent psychotic symptoms (delusions and halluci-

nations) and mood symptoms (depression). Thus, the clinician can start the differential

diagnosis process with any of the following decision trees: delusions (2.5), hallucina-

tions (2.6), or depressed mood (2.10). Given the especially prominent nature of the delu-

sions, we first start with the delusions decision tree (2.5). The first question, whether the

beliefs are a manifestation of a culturally or religiously sanctioned belief system, can be

answered “no” because John’s fixed belief that he murdered people when he was age 6

is not a manifestation of any sanctioned belief system and is thus appropriately consid-

ered to be a delusion. The next question, regarding whether his delusions are due to the

physiological effects of a substance, must be seriously considered given the fact that his

delusions first emerged at age 20 during a time when he was smoking several joints of

marijuana almost daily. To answer this question, we need to consider Step 2 of the six

differential diagnosis steps presented earlier in this chapter, which provides guidance

on how to rule out a substance etiology. In determining whether there is a causal rela-

tionship between the marijuana use and the delusions, we need to determine whether

all three of the following conditions are true: 1) that there is a close temporal relationship

between marijuana use and the onset and maintenance of the delusions, 2) that the pat-

tern of marijuana use is consistent (in terms of dosage and duration) with the develop-

ment of delusions, and 3) that there is no alternative (i.e., non-substance/medication-

induced) explanation for the delusions. Although it is not common for marijuana to

cause florid delusions, heavy marijuana use in some vulnerable individuals can result

in delusions during Marijuana Intoxication, so the second condition (i.e., substance use

is heavy and/or prolonged enough to induce the symptom) is met. In evaluating the

first condition, however, although the delusions emerged during heavy marijuana use,

the fact that the delusions persisted in the hospital when John was abstinent from mar-

ijuana and then subsequently reoccurred when his marijuana use was minimal indicates

that the delusions cannot be explained as a manifestation of his marijuana use. Thus, the

14 DSM-5 Handbook of Differential Diagnosis

answer to the second question in the delusions decision tree, regarding whether there is

a cannabis etiology for the delusions, is “no.” The absence of any reported general med-

ical conditions in John also rules out a medical etiology, and therefore the answer to the

following question is also “no.”

After ruling out cultural and religious, substance/medication-induced, and general

medical etiologies for John’s delusions, we then must differentiate among the primary

psychotic and mood disorders as possible explanations for the delusions. The next ques-

tion, which asks whether the delusions have occurred only in the context of an episode

of elevated, expansive, or irritable mood, is answered “no” because of the absence of a

history of manic or hypomanic symptoms. The subsequent question, about whether the

delusions have occurred only in the context of an episode of depressed mood, is also an-

swered “no” because the delusions also occurred at times when John was not experienc-

ing a depressive episode (i.e., each psychotic episode is characterized by a several-week

period of delusions before the development of the severe depressive symptoms).

The next block of questions in the delusions tree provides the differential diagnosis

of non-mood-restricted delusions. The question inquiring whether the delusions last for

1 month or more is answered “yes” (i.e., each time the delusions have occurred, they

lasted for several weeks), moving us for the first time to the right in the decision tree to

consider the differential between Schizophrenia, Schizophreniform Disorder, Schizoaf-

fective Disorder, Delusional Disorder, and Bipolar or Major Depressive Disorder With

Psychotic Features. The subsequent question about whether the delusions are accompa-

nied by other psychotic symptoms characteristic of Schizophrenia (i.e., hallucinations,

disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms)

is also answered “yes” given that in John’s case the delusions of having murdered a per-

son when he was a child are accompanied by accusatory auditory hallucinations. The

next question (i.e., whether there is a history of Major Depressive or Manic Episodes) is

answered “yes” given the history of recurrent Major Depressive Episodes, as is the fol-

lowing question (i.e., whether during an uninterrupted period of illness the psychotic

symptoms occur concurrently with the mood episodes) because the delusions and hal-

lucinations continued to persist after the Major Depressive Episodes emerged, thus in-

dicating a period of overlap.

The next question, which provides the crucial differential diagnostic distinction be-

tween Schizoaffective Disorder and Schizophrenia, asks whether, during an uninter-

rupted period of illness, the mood episodes have been present for a minority of the total

duration of the active and residual phases of the illness. In John’s case, each of the psy-

chotic episodes was present for approximately 7–8 weeks, with about 4 of those weeks

characterized by the simultaneous occurrence of a severe Major Depressive Episode.

Therefore, it is not the case that the mood episodes were present for only a minority of

the time during an uninterrupted episode of illness (they were in fact present for a ma-

jority of the time), so the question is answered “no,” ruling out the diagnoses of both

Schizophrenia and Schizophreniform Disorder. The next question, regarding whether

delusions and hallucinations have occurred for at least 2 weeks in the absence of a Major

Depressive Episode or Manic Episode, is answered “yes” (i.e., for the first 3 or 4 weeks of

the psychotic episode, John was anxious but not suffering from significant depressed

mood), bringing us to the terminal branch of the delusions decision tree (2.5) and the di-

How to Use the Handbook: Case Example 15

agnosis of Schizoaffective Disorder. It should be noted that given the complete co-occur-

rence of the delusions and hallucinations during the psychotic episodes, had we started

with the hallucinations tree (2.6) instead of the delusions tree, we would have gone

through almost the exact same sequence of steps to arrive at the diagnosis of Schizoaf-

fective Disorder, given the similarity of the branching structure of the delusions and hal-

lucinations trees.

Alternatively, we could have approached this case from the perspective of John’s se-

vere depressive symptoms and instead started with the depressed mood decision tree

(2.10). The first question in this tree inquires about a substance etiology for the depres-

sive symptoms. Applying the same principles discussed above with regard to the rela-

tionship between John’s marijuana use and his delusions, this question can also be

answered in the negative because although the marijuana use is sufficient to cause de-

pressed mood, the fact that John continued to experience episodes of severe depression

after he stopped his heavy use of marijuana indicates that, like the delusions, his depres-

sion cannot be considered to have been induced by the marijuana use. The next question

asks whether the depression is due to the physiological effects of a general medical con-

dition, and that question can also be answered “no” because of the absence of any his-

tory of medical problems. The next question asks whether the depressed mood was part

of a Major Depressive Episode. The answer to that question is “yes” given that the de-

pressive periods that developed after the onset of delusions and hallucinations were

characterized by approximately 4 weeks of dysphoric mood, prominent anhedonia,

poor sleep, decreased appetite, and reduced concentration, thus meeting syndromal cri-

teria for a Major Depressive Episode. Note that the decision tree does not end at this

point but that the diagnostic flow continues onward because Major Depressive Episode

is not a codable diagnostic entity in DSM-5 but instead comprises one of the building

blocks for the diagnoses of Bipolar I or Bipolar II Disorder, Major Depressive Disorder,

and Schizoaffective Disorder. The next question, about the presence of clinically signifi-

cant manic or hypomanic symptoms, is answered “no,” bringing us to a consideration

of the relationship between the Major Depressive Episodes and the psychotic symp-

toms. The question about whether there is a history of delusions or hallucinations is an-

swered “yes,” bringing us to the critical question as to whether the psychotic symptoms

occur exclusively during Manic or Major Depressive Episodes. In John’s case, the psy-

chotic symptoms have not occurred exclusively during the Major Depressive Episodes

(i.e., the delusions and hallucinations occurred on their own for 3–4 weeks prior to the

onset of the depressive episode), so the answer to this question is “no.” At this point in

the depressed mood decision tree (2.10), rather than being offered additional questions,

we are told that a Schizophrenia Spectrum or Other Psychotic Disorder is present and

are instructed to go to the delusions tree (2.5) or hallucinations tree (2.6) for the differen-

tial diagnosis, resulting in the diagnosis of Schizoaffective Disorder.

After arriving at the diagnosis of Schizoaffective Disorder through the use of the de-

cision trees, we can refer to the DSM-5 classification in the Appendix to get the diagnos-

tic code for Schizoaffective Disorder and/or we can review the differential diagnosis

table for Schizoaffective Disorder in Chapter 3 (Table 3.2.2) to confirm that the key con-

tenders to a diagnosis of Schizoaffective Disorder have been appropriately ruled out.

The two main diagnostic contenders in this case are Schizophrenia and Major Depres-

16 DSM-5 Handbook of Differential Diagnosis

sive Disorder With Psychotic Features. Accordingly, the differential diagnosis table for

Schizoaffective Disorder notes that Schizophrenia is differentiated from Schizoaffective

Disorder by virtue of the fact that Schizophrenia is characterized by mood episodes that

“have been present for a minority of the total duration of the active and residual periods

of the illness.” In John’s case, each episode of the illness was characterized by a Major

Depressive Episode being present for more than half of the time (i.e., about 4 weeks) of

the total duration (i.e., 7–8 weeks), thus ruling out the diagnosis of Schizophrenia. More-

over, the table also notes that Schizoaffective Disorder is differentiated from Major De-

pressive Disorder With Psychotic Features by virtue of the fact that Major Depressive

Disorder With Psychotic Features is characterized by psychotic symptoms that occur ex-

clusively during Major Depressive Episodes. In John’s case, the psychotic symptoms

were not confined exclusively to the depressive episodes, ruling out the diagnosis of Ma-

jor Depressive Disorder With Psychotic Features.

Differential Diagnosis by the Trees

Differential diagnosis is at the heart of every initial clinical encounter and is the begin-

ning of every treatment plan. The clinician must determine which disorders are possible

candidates for consideration and then choose from among them the disorder (or disor-

ders) that best accounts for the presenting symptoms. The biggest problem encountered

in differential diagnosis is the tendency for premature closure in coming to a final diag-

nosis. Studies in cognitive science have indicated that clinicians typically decide on the

diagnosis within the first 5 minutes of meeting the patient and then spend the rest of the

time during their evaluation interpreting (and often misinterpreting) elicited informa-

tion through this diagnostic bias. Forming initial impressions can be valuable in helping

to suggest which questions need to be asked and which hypotheses need to be tested.

Unfortunately, however, first impressions are sometimes wrong—particularly because

the patient’s current state may not be a true reflection of the longitudinal course. Accu-

rate diagnosis requires a methodical consideration of all possible contenders in the dif-

ferential diagnosis.

Perhaps the best way to avoid prematurely jumping to a diagnostic conclusion is to

approach the problem from the bottom up: by generating the differential diagnosis based

on the presenting symptoms. This section of the handbook, which includes 29 symptom-

oriented decision trees, facilitates this process. Each decision tree starts with a particular

presenting symptom and then provides decision points for determining which diagnosis

may best account for it. For any given patient, several trees may (and often do) apply. In

many instances, following the branches within the different pertinent decision trees will

lead to the same diagnosis, suggesting that the presenting symptoms constitute a single

syndrome. In other instances, more than one diagnosis may be indicated.

18 DSM-5 Handbook of Differential Diagnosis

The first step in using these decision trees is to determine which ones apply to the

clinical presentation. The listings of the decision trees included in this handbook are or-

ganized in three different ways to facilitate finding the relevant decision trees. Two lists

are provided at the end of this introduction to Chapter 2. The first itemizes the decision

trees in order of the DSM-5 diagnostic groupings (trees related to neurodevelopmental

presentations are listed first, trees related to psychotic presentations second, and so

forth). The second list is organized by mental status examination domain (trees related

to mood/affect, trees related to behavior, and so forth). Finally, at the end of this hand-

book, an alphabetical index of the decision trees is included, as well as an alphabetical

index of the differential diagnosis tables covered in Chapter 3.

Each decision tree is laid out in a standardized fashion. The presenting symptom for

each tree is shown in bold text in a box at the upper left. The boxes on the far right, the

diagnostic end points, are indicated by shading and a thick border; these show all of the

disorders that need to be considered in the differential diagnosis of the presenting symp-

tom. The numerical codes in parentheses refer to the corresponding differential diagnos-

tic table in Chapter 3. Intermediate boxes are decision points that indicate how different

disorders are ruled in or ruled out. You should consider the statement in the decision box

and then follow the “Y” branch if the answer is “yes” and the “N” branch if the answer

is “no.” Occasional intermediate boxes are not decision points per se but represent inter-

mediate diagnostic conclusions, and thus lack the “Y” and “N” choices. For example, the

Decision Tree for Elevated or Expansive Mood (2.8) includes intermediate boxes in

which the presence of a Manic Episode or Hypomanic Episode is asserted, reflecting the

fact that Manic Episode and Hypomanic Episode are building blocks for the diagnoses

of Bipolar I and Bipolar II Disorders.

You should always keep in mind that the decision trees are no more than an over-

view of the DSM-5 diagnostic system and a guide to differential diagnosis. Clinical judg-

ment is always required in the evaluation of each decision point. Moreover, when you

have arrived at a diagnostic end point in a tree (i.e., a “final diagnosis”), it is important

to review the actual DSM-5 criteria set for the disorder in question to ensure that the full

criteria for that disorder have in fact been met. This confirmation is necessary for two

reasons. First, the decision trees contain only summarized versions of the DSM-5 diag-

nostic criteria rather than the complete text of the criteria. Second, the decision trees only

include selected criteria from the criteria sets—that is, those diagnostic criteria that dif-

ferentiate between the various DSM-5 disorders. A review of the complete DSM-5 diag-

nostic criteria sets is needed to ensure that the case meets the full set of required

diagnostic features and course requirements (e.g., persistence, minimum duration); for

the most part, these are not included in the decision trees.

Many of the decision trees follow a standard format that mirrors the stepwise

thought process used in making a differential diagnosis presented in Chapter 1 of this

handbook. The first consideration is whether the particular symptom is the result of the

direct effects of substance use (including medication) or a general medical condition

(Steps 2 and 3 in Chapter 1). The next steps in the decision tree typically cover the pri-

mary mental disorders that may account for the symptom (Step 4). The final decision

points in most of the decision trees provide the differential diagnosis for those presenta-

tions that do not conform to or that fall below the threshold for a specific DSM-5 diag-

Differential Diagnosis by the Trees 19

nosis. These decision points thus differentiate among Adjustment Disorder, a residual

Other Specified or Unspecified Disorder category, and no mental disorder at all (Steps 5

and 6). The important step of determining whether the presenting symptom has been

feigned (as in Malingering or Factitious Disorder) has not been included in most of the

decision trees because, as discussed in Step 1 in Chapter 1, that task potentially applies

to the evaluation of all presenting symptoms but only in certain contexts and settings

(e.g., forensic).

As noted above, the order of the 29 decision trees in this handbook corresponds

roughly to the organization of the DSM-5 disorders. The following lists show the deci-

sion trees organized by 1) DSM-5 diagnostic grouping and 2) mental status examination

domain.

Decision trees organized by DSM-5 diagnostic grouping

Neurodevelopmental presentations 2.1 Poor school performance 2.2 Behavioral problems in a child or adolescent 2.3 Speech disturbance 2.4 Distractibility

Schizophrenia and other psychotic presentations 2.5 Delusions 2.6 Hallucinations 2.7 Catatonic symptoms

Bipolar presentations 2.8 Elevated or expansive mood 2.9 Irritable mood

Depressive presentations 2.10 Depressed mood 2.11 Suicidal ideation or behavior 2.12 Psychomotor retardation

Anxiety presentations 2.13 Anxiety 2.14 Panic attacks 2.15 Avoidance behavior

Trauma- and stressor-related presentations 2.16 Trauma or psychosocial stressors involved in the etiology

Somatic symptom presentations 2.17 Somatic complaints or illness/appearance anxiety

Feeding and eating presentations 2.18 Appetite changes or unusual eating behavior

Sleep-wake presentations 2.19 Insomnia 2.20 Hypersomnolence

20 DSM-5 Handbook of Differential Diagnosis

Sexual dysfunction presentations 2.21 Sexual dysfunction in a female 2.22 Sexual dysfunction in a male

Disruptive, impulse-control, and conduct presentations 2.23 Aggressive behavior 2.24 Impulsivity or impulse-control problems 2.25 Self-injury or self-mutilation

Substance-related presentations 2.26 Excessive substance use

Neurocognitive presentations 2.27 Memory loss 2.28 Cognitive impairment

Etiological medical presentations 2.29 Etiological medical conditions

Decision trees organized by mental status examination domain

Mood/affect 2.8 Elevated or expansive mood 2.9 Irritable mood 2.10 Depressed mood 2.13 Anxiety 2.14 Panic attacks

Behavior 2.2 Behavioral problems in a child or adolescent 2.7 Catatonic symptoms 2.11 Suicidal ideation or behavior 2.12 Psychomotor retardation 2.15 Avoidance behavior 2.23 Aggressive behavior 2.24 Impulsivity or impulse-control problems 2.25 Self-injury or self-mutilation 2.26 Excessive substance use

Cognition 2.4 Distractibility 2.27 Memory loss 2.28 Cognitive impairment

Thought form/speech 2.3 Speech disturbance

Decision trees organized by DSM-5 diagnostic grouping (continued)

Differential Diagnosis by the Trees 21

Thought content 2.5 Delusions 2.11 Suicidal ideation or behavior

Perceptual disturbance 2.6 Hallucinations

Somatic symptoms 2.14 Panic attacks 2.17 Somatic complaints or illness/appearance anxiety

Personality features 2.24 Impulsivity or impulse-control problems 2.25 Self-injury or self-mutilation

Sleep/eating/sex 2.18 Appetite changes or unusual eating behavior 2.19 Insomnia 2.20 Hypersomnolence 2.21 Sexual dysfunction in a female 2.22 Sexual dysfunction in a male

Functioning 2.1 Poor school performance

Etiological factors 2.16 Trauma or psychosocial stressors involved in the etiology 2.26 Excessive substance use 2.29 Etiological medical conditions

Decision trees organized by mental status examination domain (continued)

22 DSM-5 Handbook of Differential Diagnosis

2.1 Decision Tree for Poor School Performance Poor school performance is an all-too-common and very nonspecific aspect of childhood

and adolescence. On the one hand, clinicians should certainly not assume that every

poor student has a mental disorder underlying his or her poor academic performance.

On the other hand, most (if not all) mental disorders occurring in children are likely to

have a negative impact on school performance, and, not infrequently, difficulty in school

is the chief complaint.

The evaluation for the causes of poor school performance will usually include testing

for overall IQ and for deficits in specific academic skills (e.g., reading, mathematics,

writing, expressive and receptive language). A definitive diagnosis of a DSM-5 neuro-

developmental disorder requires that the learning or communication difficulties be sub-

stantially and quantifiably below what would be expected given the individual’s age

and that they substantially interfere with school, work, or social functioning. The next

step is a careful assessment for the presence of the various psychiatric disorders that

have impaired school performance as a consequence. This entails a careful history (sup-

plemented by reports from parents, teachers, and pediatricians), clinical observation,

and an evaluation of the role of substance use. For example, are there significant deficits

in the social use of verbal and nonverbal communication (as in Autism Spectrum Disor-

der and Social [Pragmatic] Communication Disorder)? Are there clinically significant

symptoms of inattention and/or hyperactive-impulsive behavior occurring in two or

more different settings (as in Attention-Deficit/Hyperactivity Disorder)? Are there fre-

quent uncontrollable temper tantrums on top of a baseline of persistent anger and irri-

tability (as in Disruptive Mood Dysregulation Disorder)? Is there a pattern of antisocial

behaviors such as truancy (as in Conduct Disorder)? Is there school refusal based on an

inability to separate from attachment figures (as in Separation Anxiety Disorder)? Is

there clinically significant depressed mood (as in Major Depressive Disorder)? Because

neurodevelopmental disorders and other mental disorders frequently co-occur, it is im-

portant to evaluate for all possibilities in the tree (which may require going through the

tree several times) and to make whichever diagnoses are appropriate.

The presence of a psychiatric disorder does not guarantee that it is the cause of prob-

lematic school performance. Other factors (e.g., poor work habits, excessive TV watching

or video game playing, lack of motivation, poor schooling, disruptive home or commu-

nity environment) may also play a significant role. Occasionally, the psychiatric disorder

(e.g., Adjustment Disorder, Oppositional Defiant Disorder, Major Depressive Disorder)

may be more the result of poor school performance than its cause.

2.1 Decision Tree for Poor School Performance 23

Poor school performance

Associated with deficits in intellectual function (confirmed by clinical assessment and intelligence testing) and deficits in adaptive functioning, with onset during developmental period

Occurring in association with deficits in social use of verbal and nonverbal communication

INTELLECTUAL DISABILITY (INTELLECTUAL DEVELOPMENTAL DISORDER) (3.1.1)

Accompanied by deficits in developing and understanding AUTISM SPECTRUMrelationships; deficits in DISORDER (3.1.3)social-emotional reciprocity; and restricted, repetitive patterns of behavior, interests, or activities

SOCIAL (PRAGMATIC) COMMUNICATION DISORDER (3.1.2)

Occurring in the context of SPECIFIC LEARNING difficulties in learning and DISORDER (3.1.5) using academic skills

Occurring in the context of persistent difficulties in the LANGUAGE DISORDER acquisition and use of (3.1.2) language

Related to failing to speak in SELECTIVE MUTISM school (despite speaking (3.5.2) at home)

Associated with symptoms of inattention and hyperactivity ATTENTION-DEFICIT/ with onset before age 12 and HYPERACTIVITY clear evidence of interference DISORDER (3.1.4) with functioning

Associated with a pattern of severe temper outbursts that

DISRUPTIVE MOODare grossly out of proportion DYSREGULATIONto the situation, accompanied DISORDER (3.4.4)by persistent anger and

irritability between outbursts

Y Y

24 DSM-5 Handbook of Differential Diagnosis

Associated with a pattern of CONDUCT DISORDER antisocial behavior (3.14.3)

Associated with a pattern of OPPOSITIONAL DEFIANTnegativistic, hostile, and DISORDER (3.14.1)defiant behavior

Related to excessive substance SUBSTANCE USE use DISORDER (3.15.1)

Refusal to attend school SEPARATION ANXIETY related to fears of separation DISORDER (3.5.1)

Indicate specific disorderOther anxiety, mood, (e.g., SCHIZOPHRENIApsychotic, or other disorders [3.2.1], MAJORthat interfere with school DEPRESSIVE DISORDERperformance [3.4.1])

Maladaptive response to a ADJUSTMENT psychosocial stressor DISORDER (3.7.2)

Not related to a mental disorder (e.g., poor work habits, disruptive environment)

2.2 Decision Tree for Behavioral Problems in a Child or Adolescent 25

2.2 Decision Tree for Behavioral Problems in a Child or Adolescent A common reason for referring a child or adolescent to a mental health professional is

to request an evaluation and possible treatment for a reported behavioral problem. It

goes without saying, however, that many behavioral problems occurring in children or

adolescents are not due to a mental disorder. In some instances, the behavioral problems

are not of sufficient severity or duration to warrant such a diagnosis. In others, the prob-

lem is more of a disturbance in the family relationship than a problem emanating pri-

marily from the child. Finally, there are some very serious behavioral problems (e.g.,

shooting, mugging, rape) that occur for reasons outside the domain of the mental disor-

ders covered in DSM-5 (e.g., financial gain, status, revenge).

Behavioral problems with an onset in early childhood are most often associated with

Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Disruptive

Mood Dysregulation Disorder, Autism Spectrum Disorder, Stereotypic Movement Dis-

order, and Intellectual Disability (Intellectual Developmental Disorder). The differential

among these is usually straightforward and is determined by a consideration of the ac-

companying symptoms.

A first onset of behavioral problems during adolescence strongly suggests that sub-

stances may play an important role. The behavioral problems may result from the direct

effect of the substance on the brain (as in Substance Intoxication), may be a by-product of

a Substance Use Disorder (e.g., illegal activities associated with procurement), or may be

motivated by gain (e.g., a plan to get rich quick as a drug dealer). Other disorders that

often have an onset in later childhood or early adolescence include the Adolescent-Onset

Type of Conduct Disorder (which has a better prognosis than Childhood-Onset Type oc-

curring before age 10), Major Depressive Disorder, Bipolar Disorder, Schizophrenia,

Kleptomania, and Pyromania. Conduct Disorder that has an onset in childhood (i.e., be-

fore age 10) is particularly worrisome and is associated with a higher incidence of vio-

lence, poorer peer relationships, and an increased likelihood for the child to develop into

an adult with Antisocial Personality Disorder.

Behavioral problems occurring in response to a psychosocial stressor suggest either

1) a diagnosis of Posttraumatic Stress Disorder or Acute Stress Disorder, if the stressor is

of a particularly traumatic nature and the behavioral problems are accompanied by in-

trusion symptoms associated with the traumatic events, avoidance of reminders of the

event, and a change in cognition, mood, and arousal; or 2) a diagnosis of Adjustment

Disorder.

If the behavioral problems are not covered by any of the decision points so far and

the problems are clinically significant and represent a psychological or biological dys-

function in the individual, a residual category—Other Specified Disruptive, Impulse-

Control, and Conduct Disorder or Unspecified Disruptive, Impulse-Control, and Con-

duct Disorder—would apply, the choice depending on whether the clinician wishes to

record the symptomatic presentation on the chart (in which case Other Specified Disrup-

tive, Impulse-Control, and Conduct Disorder would be used, followed by the specific

reason) or not (in which case Unspecified Disruptive, Impulse-Control, and Conduct

Disorder would be used). Otherwise, the behavioral problems would be considered

26 DSM-5 Handbook of Differential Diagnosis

problematic but not indicative of a mental disorder, possibly justifying the V code or Z

code (dependent on whether ICD-9-CM or ICD-10-CM is applicable, respectively) for

Child or Adolescent Antisocial Behavior, which is listed in “Other Conditions That May

Be a Focus of Clinical Attention” in DSM-5.

Behavioral problems in a child or adolescent

SUBSTANCE/MEDICATION- INDUCED DISORDER;Associated with substance use SUBSTANCE INTOXICATION;(including medication) SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Related to a problematic pattern of substance use SUBSTANCE USE DISORDER (e.g., illegal behavior to (3.15.1) obtain drugs)

Y Y

Due to the direct physiological effects of a substance (or medication) on the central nervous system

DELIRIUM DUE TO ANOTHERDue to the physiological Y Y MEDICAL CONDITIONeffects of a general medical (3.16.1)condition

Associated with a disturbance in attention and awareness characterized by a fluctuating course

MAJOR or MILD NEUROCOGNITIVEY DISORDER DUE TO ANOTHER MEDICAL CONDITION (3.16.2), WITH BEHAVIORAL DISTURBANCE

Associated with evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

Occurring in a pattern PERSONALITY CHANGEYrepresenting a change DUE TO ANOTHER from a previous MEDICAL CONDITION personality pattern (3.17.11)

OTHER SPECIFIED MENTAL DISORDER DUE TO ANOTHER MEDICAL CONDITION; UNSPECIFIED MENTAL DISORDER DUE TO ANOTHER MEDICAL CONDITION

2.2 Decision Tree for Behavioral Problems in a Child or Adolescent 27

Occurring in the context of severe temper outbursts that DISRUPTIVE MOOD are grossly out of proportion DYSREGULATION DISORDER to the situation accompanied (3.4.4) by persistent anger and irritability between outbursts

Part of a pattern of persistent ATTENTION-DEFICIT/ Y Ysymptoms of hyperactivity, HYPERACTIVITY DISORDER

impulsivity, and inattention (3.1.4)

Occurring in at least two different situations and causing clinically significant impairment, with several symptoms present before age 12

Occurring in association with a pattern of Y Y OPPOSITIONAL DEFIANT argumentativeness, defiance, DISORDER (3.14.1) and vindictiveness

Persistence and frequency of the behaviors are outside normal limits given the child’s developmental age

Occurring in association with INTELLECTUAL DISABILITYdeficits in intellectual function

Y (INTELLECTUALand accompanying deficits in DEVELOPMENTALadaptive functioning with DISORDER) (3.1.1)onset during the

developmental period

“Normal” oppositional behavior

Occurring as a consequence Y Y AUTISM SPECTRUM of stereotyped movements DISORDER (3.1.3)

Occurring in association with persistent deficits in social communication and social interaction, accompanied by restricted repetitive patterns of behaviors, interests, or activities

28 DSM-5 Handbook of Differential Diagnosis

Occurring as part of a pattern Y CONDUCT DISORDER of antisocial behavior (3.14.3)

Characterized by deliberate, purposeful fire setting Y PYROMANIA associated with arousal before the act

Characterized by recurrent failure to resist impulses to Y KLEPTOMANIAsteal objects that are not needed or for their monetary value

MANIC EPISODE or HYPOMANIC EPISODE inAssociated with periods of BIPOLAR I (3.3.1) orelevated, euphoric, or irritable Y BIPOLAR II (3.3.2) DISORDER,mood accompanied by SCHIZOAFFECTIVEincreased energy DISORDER (3.2.2), or CYCLOTHYMIC DISORDER (3.3.3)

MAJOR DEPRESSIVE Associated with episodes of EPISODE in MAJOR depressed or irritable mood DEPRESSIVE DISORDER accompanied by other Y (3.4.1) or SCHIZOAFFECTIVE characteristic symptoms of DISORDER (3.2.2); depression (e.g., feelings of PERSISTENT DEPRESSIVE worthlessness) DISORDER (3.4.2)

STEREOTYPIC MOVEMENT DISORDER

Psychotic Disorder (e.g., Associated with psychotic SCHIZOPHRENIA [3.2.1]). symptoms See Delusions Tree (2.5) or

Hallucinations Tree (2.6) for differential diagnosis

2.2 Decision Tree for Behavioral Problems in a Child or Adolescent 29

Occurring in the context of a POSTTRAUMATIC STRESSYsymptomatic response to a DISORDER or ACUTE STRESS psychosocial stressor DISORDER (3.7.1)

OTHER SPECIFIED Clinically significant DISRUPTIVE, behavioral problems not Y IMPULSE-CONTROL, AND covered above that represent CONDUCT DISORDER; a psychological or biological UNSPECIFIED DISRUPTIVE, dysfunction in the individual IMPULSE-CONTROL, AND

CONDUCT DISORDER

CHILD or ADOLESCENT ANTISOCIAL BEHAVIOR (V or Z code)

Age-appropriate rambunctious behavior

Stressor is of an extremely traumatic nature (e.g., life-threatening situation) and there is recurrent reexperiencing of the stressor

ADJUSTMENT DISORDER (3.7.2)

Illegal behavior for gain or revenge

30 DSM-5 Handbook of Differential Diagnosis

2.3 Decision Tree for Speech Disturbance The decision tree for speech disturbance covers three types of disturbed speech: disor-

ganized speech, impairment in speech production, and unusual speech. Disorganized speech is characterized by the individual’s switching from one topic to another without

a discernible connection or providing answers to questions that are only obliquely re-

lated or unrelated to the question. Impaired speech production may be related to problems

with the acquisition and use of language, with the ability to articulate words intelligibly,

or with speech fluency. Unusual speech includes deficits in understanding and following

the social rules of verbal communication, slowed or pressured speech, or repetitive or

stereotyped speech.

Disorganized speech is one of the most challenging symptoms to diagnose because

there is no standard by which to judge when speech is “disorganized.” This judgment

depends in part on your ability to comprehend and on the patient’s pattern of speech

production. Furthermore, no one speaks in logically coherent and syntactically correct

sentences all the time. Many clinicians and trainees have a tendency to overcall mildly

illogical speech as clinically significant “loosening of associations.” The kinds of “disor-

ganized speech” covered in this decision tree should be obvious even to the most casual

observer. If you have difficulty deciding whether or not a patient’s speech is disorga-

nized, then it should probably not be considered pathological.

Once it is established that the individual has disorganized, impaired, or unusual

speech, the next challenge is to determine which of the many possible mental disorders

best accounts for it. This usually requires an evaluation of the context and the accompa-

nying symptoms. Speech disturbance that is due to a general medical condition may be

diagnosed as aphasia, Delirium, or a Major or Mild Neurocognitive Disorder, depending

on which other symptoms are present. The speech disturbance in Delirium is accompa-

nied by a disturbance of attention and awareness, whereas the speech disturbance in

Major or Mild Neurocognitive Disorder is accompanied by other cognitive deficits.

Aphasia (impairment in the understanding or transmission of ideas by language due to

injury or disease of the brain centers involved in language) that occurs in the absence of

other cognitive symptoms can be diagnosed using the ICD-9-CM symptom code 784.3

(or ICD-10-CM symptom code R47.01).

Disorganized speech is a common manifestation of substance use. Usually a diagno-

sis of Substance Intoxication or Substance Withdrawal will suffice, but severely disorga-

nized speech suggests a diagnosis of Substance Intoxication Delirium or Substance

Withdrawal Delirium or an underlying Substance/Medication-Induced Major Neuro-

cognitive Disorder. The differential diagnosis of disorganized speech in a Manic Episode

versus Schizophrenia has been the subject of considerable discussion. The disorganized

speech in an episode of Schizophrenia (e.g., so-called loosening of associations) presum-

ably is distinguished from the “flight of ideas” in mania based on the observer’s ability

to follow the train of thought. Theoretically at least, one can discern how the patient got

from one topic to the next in a flight of ideas, whereas the derailments in the speech of

patients with Schizophrenia are much less understandable. Although this distinction

may be helpful in the most classic cases, at the boundary there are many instances in

which it is difficult or impossible to distinguish between loosening of associations and

2.3 Decision Tree for Speech Disturbance 31

flight of ideas. Similarly, whereas rapid or pressured speech is often characteristic of ma-

nia, the speech of an excited or agitated patient with Schizophrenia may also be over-

whelming. Therefore, it is best to base the differential diagnosis between Schizophrenia

and Manic Episodes on the accompanying symptoms and overall course rather than on

an isolated evaluation of the speech pattern.

The decision tree also includes the differential diagnosis for several disorders that are

characterized by impaired speech first presenting during development. A diagnosis of

a Language Disorder may be warranted if an individual has symptoms such as difficulty

understanding words, sentences, or specific types of words; a markedly limited vocab-

ulary; and/or difficulty producing sentences. Difficulties with speech sound production

that interfere with intelligibility may warrant a diagnosis of Speech Sound Disorder.

Problems in the fluency and time patterning of speech that are inappropriate for age and

language skills suggest a diagnosis of Childhood-Onset Fluency Disorder (Stuttering).

In Autism Spectrum Disorder and Social (Pragmatic) Communication Disorder, there

are deficits in the social use of verbal and nonverbal communication. These problems

may be manifested by the person having difficulties with understanding and following

social rules of verbal and nonverbal communication in naturalistic contexts, struggles

with changing language according to the needs of the listener or situation, and problems

following rules for conversations and storytelling. Inappropriate vocal outbursts that

occur in the context of otherwise normal speech suggest a Tic Disorder.

32 DSM-5 Handbook of Differential Diagnosis

Speech disturbance (including disorganized, impaired, or unusual speech)

SUBSTANCE INTOXICATION Due to the physiological DELIRIUM; SUBSTANCE effects of a substance WITHDRAWAL DELIRIUM; (including medications) MEDICATION-INDUCED

DELIRIUM (3.16.1)

Associated with evidence of decline in one or more of the following cognitive SUBSTANCE/MEDICATION- domains: complex INDUCED attention, executive NEUROCOGNITIVE function, learning and DISORDER (3.16.2) memory, language, perceptual-motor, or social cognition

Y Y

Associated with a disturbance in attention and awareness characterized by a fluctuating course

Due to the physiological DELIRIUM DUE TO ANOTHER Y Yeffects of a general medical MEDICAL CONDITION

condition (3.16.1)

Associated with a disturbance in attention and awareness characterized by a fluctuating course

MAJOR or MILD NEUROCOGNITIVEY DISORDER DUE TO ANOTHER MEDICAL CONDITION (3.16.2)

Associated with evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

N Aphasia (not a mental disorder)

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Rapid pressured speech with subjective sense of racing MANIC EPISODE in BIPOLAR thoughts, associated with Y I DISORDER (3.3.1) or euphoric, expansive, or SCHIZOAFFECTIVE irritable mood and increased DISORDER (3.2.2) energy

2.3 Decision Tree for Speech Disturbance 33

MAJOR DEPRESSIVESlowed speech occurring in EPISODE in MAJORthe context of an episode of DEPRESSIVE DISORDERdepressed mood, diminished (3.4.1), BIPOLAR I (3.3.1) orinterest or pleasure, and other BIPOLAR II (3.3.2) DISORDER,characteristic symptoms of or SCHIZOAFFECTIVEdepression DISORDER (3.2.2)

Duration at least 6 months SCHIZOPHRENIA (3.2.1)

Disorganized speech in association with delusions, hallucinations, grossly Y disorganized or catatonic behavior, or negative symptoms (e.g., diminished emotional expression or avolition)

BRIEF PSYCHOTIC DISORDER (3.2.4)

Speech difficulties associated with problems in the

Y LANGUAGE DISORDERacquisition and use of (3.1.2)language due to deficits in comprehension and production

Mimicking another’s speech (echolalia)

Y Catatonic symptom (see Catatonic Symptoms Tree [2.7] for differential diagnosis)

Y SCHIZOPHRENIFORM DISORDER (3.2.1)

Duration between 1 month and 6 months

Difficulties with speech sound Y SPEECH SOUND DISORDER production that interferes with (3.1.2) intelligibility

Disturbances in the normal CHILDHOOD-ONSET fluency a Ynd time patterning of FLUENCY DISORDER speech that are inappropriate (STUTTERING) (3.1.2) for age and language skills

Accompanied by deficits in developing and understanding relationships, deficits in AUTISM SPECTRUM social-emotional DISORDER (3.1.3) reciprocity, and restricted, repetitive patterns of behavior, interests, or activities

Y YDeficit in social use of verbal and nonverbal communication

N SOCIAL (PRAGMATIC) COMMUNICATION DISORDER (3.1.2)

34 DSM-5 Handbook of Differential Diagnosis

Repetitive, rhythmic vocal Y TIC DISORDER (3.1.6) outbursts

Clinically significant speech disturbance not covered UNSPECIFIEDY above that represents a COMMUNICATION psychological or biological DISORDER dysfunction in the individual

"Normal" variations in speech

2.4 Decision Tree for Distractibility 35

2.4 Decision Tree for Distractibility Distractibility refers to an inability to filter out extraneous stimuli when attempting to con-

centrate on a particular task or activity. This is a very nonspecific symptom that occurs in

a wide variety of mental disorders, as well as in individuals without any mental disorder.

The differential diagnosis rests on the age at onset, severity, the symptoms with which the

distractibility is associated, and whether it results from a reaction to an external stressor.

Clinically significant inattention with an onset in early childhood suggests a diagnosis of

Attention-Deficit/Hyperactivity Disorder. Inattention with onset in adolescence sug-

gests a variety of possible disorders, including recurrent Substance Intoxication or Sub-

stance Withdrawal, Major Depressive or Bipolar Disorder, and Schizophrenia. When

inattention has a first onset later in life, it is especially important to consider the possible

etiological role of a medication, drug of abuse, or general medical condition.

You should consider a diagnosis of Delirium when inattention is severe and is asso-

ciated with other cognitive or perceptual symptoms (e.g., disorientation, hallucina-

tions). The hallmark of Delirium is a disturbance of attention and awareness—the

patient is unable to appreciate or respond appropriately to the external environment, to

filter out irrelevant stimuli, and to follow instructions or reply to questions. Because De-

lirium is often a medical emergency, it is crucial to identify (and then correct) the under-

lying etiological factors that may be related to a general medical condition, substance

use (including medication side effects), or some combination of these.

Distractibility is rarely the presenting symptom in disorders other than Attention-

Deficit/Hyperactivity Disorder and Delirium. The evaluation of the differential diagno-

sis depends on what the accompanying features are (e.g., elevated mood in Manic Epi-

sode, excessive worry and anxiety in Generalized Anxiety Disorder, persistent psychotic

symptoms in Schizophrenia). It is also always useful to determine whether the patient

has experienced psychosocial stressors that may be causing or increasing distractibility.

Finally, everybody has differing abilities to filter out extraneous stimuli from the en-

vironment. Moreover, the nature and level of stimulation characteristic of the environ-

ment can increase or reduce any individual’s ability to maintain attention. Whether a

particular manifestation of distractibility constitutes an aspect of a mental disorder or

should be considered within the normal range depends on its severity and persistence,

and on whether it causes clinically significant distress or impairment.

36 DSM-5 Handbook of Differential Diagnosis

Distractibility

Due to the direct effects of a substance (including medications)

Due to the direct effects of a general medical condition

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL

Associated with a disturbance in attention DELIRIUM DUE TO and awareness ANOTHER MEDICAL characterized by a CONDITION (3.16.1) fluctuating course

OTHER SPECIFIED MENTAL DISORDER DUE TO ANOTHER MEDICAL CONDITION; UNSPECIFIED MENTAL DISORDER DUE TO ANOTHER MEDICAL CONDITION

MANIC EPISODE inRelated to an inability to filter BIPOLAR I DISORDERout unimportant external (3.3.1) orstimuli accompanied by other SCHIZOAFFECTIVEsymptoms of mania DISORDER (3.2.2)

MAJOR DEPRESSIVE EPISODE in MAJOR DEPRESSIVE DISORDER

Related to an inability to (3.4.1), BIPOLAR I concentrate accompanied by (3.3.1) or BIPOLAR II other symptoms of depression (3.3.2) DISORDER, or

SCHIZOAFFECTIVE DISORDER (3.2.2); PERSISTENT DEPRESSIVE DISORDER (3.4.2)

Y Y

Associated with evidence of decline in one or more MAJOR or MILDof the following cognitive NEUROCOGNITIVEdomains: complex DISORDER DUE TOattention, executive ANOTHER MEDICALfunction, learning and CONDITION (3.16.2)memory, language, perceptual-motor, or social cognition

2.4 Decision Tree for Distractibility 37

Accompanied by other symptoms of inattention and/ or hyperactivity/impulsivity

Associated with problems in concentration arising as a response to exposure to a traumatic stressor

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (3.1.4)

POSTTRAUMATIC STRESSPersists for at least 1 month DISORDER (3.7.1)

ACUTE STRESS DISORDER (3.7.1)

Associated with difficulty concentrating, accompanied GENERALIZED ANXIETY by at least 6 months of DISORDER (3.5.7) excessive anxiety and worry

Y Y

N N

Clinically significant distractibility not covered above that represents a psychological or biological dysfunction in the individual

Occurring in response to ADJUSTMENT DISORDER a psychosocial stressor (3.7.2)

OTHER SPECIFIED ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER; UNSPECIFIED ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER

Y Y

N N

"Normal" distractibility

Associated with delusions or hallucinations

N Psychotic Disorder (e.g., SCHIZOPHRENIA [3.2.1]).Y See Delusions Tree (2.5) or Hallucinations Tree (2.6) for differential

N diagnosis

38 DSM-5 Handbook of Differential Diagnosis

2.5 Decision Tree for Delusions A common error regarding the differential diagnosis for delusions is to assume that a be-

lief that is unusual (at least from the clinician’s perspective) is necessarily a delusion.

Such misattributions can be avoided through a careful application of the DSM-5 glos-

sary definition of delusion:

A false belief based on incorrect inference about external reality that is firmly held despite what almost everyone else believes and despite what constitutes incontrovertible and ob- vious proof or evidence to the contrary. The belief is not ordinarily accepted by other mem- bers of the person’s culture or subculture (e.g., it is not an article of religious faith). When a false belief involves a value judgment, it is regarded as a delusion only when the judg- ment is so extreme as to defy credibility. Delusional conviction can sometimes be inferred from an overvalued idea (in which case the individual has an unreasonable belief or idea but does not hold it as firmly as is the case with a delusion). (p. 819)

Several aspects of this definition are helpful to keep in mind when attempting to de-

termine whether a patient is delusional. Delusional convictions are impervious to com-

pelling evidence of their implausibility, and the person remains totally convinced of

their veracity, rejecting alternative explanations out of hand. In deciding whether a be-

lief is fixed and false enough to be considered a delusion, you must first determine that

a serious error in inference and reality testing has occurred and then determine the

strength of the conviction. It may be helpful to ask the patient to talk at length about his

or her conviction because it is often only in the specific details of the belief that the errors

of inference become apparent. In evaluating the strength of the delusional conviction,

you should present alternative explanations (e.g., the possibility that the phone hang-

ups are due to people dialing a wrong number). The patient who cannot even acknowl-

edge the possibility of these explanations is most likely to be delusional. It should be

noted that the evaluation of whether a religious belief is delusional is especially chal-

lenging because religious beliefs cannot be subject to the typical test of whether the belief

is “true” or “false” and thus cannot be challenged with incontrovertible evidence or

proof to the contrary. In such situations the clinician must consider the parameters of the

belief system that is characteristic of the person’s religion and determine if the person’s

beliefs deviate markedly from what would be considered “normal” within the context

of his or her religion. If you are unfamiliar with the beliefs characteristic of the individ-

ual’s cultural or religious background, consultation with other individuals who are fa-

miliar with the patient’s culture or religion is often necessary to avoid misdiagnosing a

religious belief as a delusion. As noted in the first step of this decision tree, fixed beliefs

that are sanctioned by that person’s culture or religion should not be considered to be

delusions.

Once it is determined that a delusion is present, your next task is to determine which

from among the many possible DSM-5 disorders best accounts for it. The particular con-

tent and form of a delusion are much less important in making the diagnosis than is the

context in which it occurs. The most common diagnostic error here is to overlook the

critically important role of substances (including medications) and general medical con-

ditions in the etiology of delusions. In younger individuals presenting with delusions, it

is important to do a careful history and drug screening to rule out the role of drugs of

2.5 Decision Tree for Delusions 39

abuse. First onset of delusional thinking at a late age should always raise a red flag for

a possible underlying general medical condition or a medication side effect.

Once substance and general medical etiologies have been ruled out, the next task is

to determine whether clinically significant mood symptoms are also present. The pres-

ence of a Manic or Major Depressive Episode raises the possibility that the delusions are

part of a Bipolar I Disorder With Psychotic Features, Bipolar II Disorder With Psychotic

Features, Major Depressive Disorder With Psychotic Features, or Schizoaffective Disor-

der. The differential diagnosis in this case depends on the temporal relationship between

the delusions and the mood episodes. If the delusions are confined exclusively to the

mood episodes, then the diagnosis is Bipolar I Disorder With Psychotic Features, Bipolar

II Disorder With Psychotic Features, or Major Depressive Disorder With Psychotic Fea-

tures. On the other hand, if delusions and other psychotic symptoms also occur before

or after the mood episodes, the diagnosis might be Schizophrenia, Schizophreniform

Disorder, Delusional Disorder, or Schizoaffective Disorder, depending on the overlap

between the mood episodes and delusions, and the relative duration of the mood epi-

sodes versus the delusions. The diagnosis is Schizophrenia, Schizophreniform Disorder,

or Delusional Disorder if either there is no period of overlap between mood episodes

and delusions or, if there is a period of overlap, the mood episodes have been present for

only a minority of the total duration of the psychotic illness (e.g., several months of

mood episodes during a chronic psychotic disturbance lasing years). In contrast, the di-

agnosis is Schizoaffective Disorder if the mood episodes overlap with the delusions and

the mood episodes are present for the majority of the total duration of the psychotic dis-

turbance (e.g., a 2-year psychotic disturbance with 1½ years of mood symptoms). Note

that in those cases of Schizophrenia, Schizophreniform Disorder, or Delusional Disorder

in which there are mood episodes that either 1) do not overlap with the psychotic symp-

toms or 2) are present for only a minority of the time relative to the total duration of a

psychotic disturbance, a comorbid diagnosis of Bipolar I, Bipolar II, or Major Depressive

Disorder may also be given. This is a change from DSM-IV-TR, in that the hierarchy be-

tween Schizophrenia–Schizophreniform Disorder–Delusional Disorder and Bipolar Dis-

order–Major Depressive Disorder has been eliminated in DSM-5, making it permissible

for an individual to be diagnosed with comorbid 1) Schizophrenia, Schizophreniform

Disorder, or Delusional Disorder and 2) Bipolar or Major Depressive Disorder.

Once you have ruled out significant mood episodes, the differential diagnosis de-

pends on symptom pattern and duration. The distinction between Schizophrenia and

Delusional Disorder is usually based on the presence in Schizophrenia of one or more

additional characteristic symptoms (e.g., hallucinations, disorganized speech, grossly

disorganized or catatonic behavior, negative symptoms). The duration of the episode is

what distinguishes Schizophrenia (over 6 months’ duration), Schizophreniform Disor-

der (1–6 months’ duration), and Brief Psychotic Disorder (less than 1 month).

40 DSM-5 Handbook of Differential Diagnosis

Delusions

SUBSTANCE INTOXICATION Due to the physiological DELIRIUM; SUBSTANCE effects of a substance WITHDRAWAL DELIRIUM; (including medication) MEDICATION-INDUCED

DELIRIUM (3.16.1)

Delusions predominate in SUBSTANCE/MEDICATION-the clinical picture and INDUCED PSYCHOTICare sufficiently severe to DISORDERwarrant clinical attention

Y Y

Associated with a disturbance in attention and awareness characterized by a fluctuating course

Due to the physiological Y Y DELIRIUM DUE TO ANOTHER effects of a general medical MEDICAL CONDITION condition (3.16.1)

Associated with a disturbance in attention and awareness characterized by a fluctuating course

MAJOR or MILD NEUROCOGNITIVE

Y DISORDER DUE TO ANOTHER MEDICAL CONDITION (3.16.2), WITH BEHAVIORAL DISTURBANCE

Associated with evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

N PSYCHOTIC DISORDER DUE TO ANOTHER MEDICAL CONDITION

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Manifestation of a culturally or religiously sanctioned belief system

Y Nonpathological strongly held beliefs; no mental disorder

2.5 Decision Tree for Delusions 41

Occurring only in the context MAJOR DEPRESSIVE of an episode of depressed EPISODE WITH PSYCHOTIC mood or diminished interest or FEATURES in MAJOR pleasure accompanied by DEPRESSIVE DISORDER characteristic depressive (3.4.1) or BIPOLAR I (3.3.1) or symptoms BIPOLAR II (3.3.2) DISORDER

Accompanied by hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms

SCHIZOPHRENIA (3.2.1) (plus comorbid BIPOLAR I [3.3.1], BIPOLAR II [3.3.2], or MAJOR DEPRESSIVE [3.4.1] DISORDER if history of Major Depressive or Manic Episodes)

Occurring only in the context of an episode of elevated, expansive, or irritable mood accompanied by increased energy

MANIC EPISODE WITH PSYCHOTIC FEATURES in BIPOLAR I DISORDER (3.3.1)

Duration of delusions 1 month or more

During an uninterrupted period of illness, psychotic symptoms concurrent with mood episodes

History of Major Depressive or Manic Episodes

Y Duration at least 6 months

During an uninterrupted period of illness, the mood episodes have been present for a minority of the total duration of the active and residual periods of the illness

42 DSM-5 Handbook of Differential Diagnosis

Delusions or hallucinations for at least 2 weeks in the absence of a Major Depressive Episode or Manic Episode during the lifetime duration of the illness

DELUSIONAL DISORDER (3.2.3) (plus comorbid BIPOLAR I [3.3.1], BIPOLAR II [3.3.2], or MAJOR DEPRESSIVE [3.4.1] DISORDER if history of Major Depressive or Manic Episodes)

History of Major Depressive or Manic Episodes

Apart from Y delusions,

functioning is not markedly impaired

Total duration of mood episodes has been brief relative to duration of delusional periods

N N

OTHER SPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER; UNSPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER

BIPOLAR I (3.3.1), BIPOLAR II (3.3.2), or MAJOR DEPRESSIVE (3.4.1) DISORDER, WITH PSYCHOTIC FEATURES

SCHIZOPHRENIFORM DISORDER (3.2.1) (plus comorbid BIPOLAR I [3.3.1], BIPOLAR II [3.3.2], or MAJOR DEPRESSIVE [3.4.1] DISORDER if history of Major Depressive or Manic Episodes)

SCHIZOAFFECTIVE DISORDER (3.2.2)

Psychotic symptoms are confined to the mood episodes

N N N

2.5 Decision Tree for Delusions 43

Delusions occur only during mood episodes

OTHER SPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER; UNSPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER

Duration of delusions more Y than 1 day but less than 1 month

Delusions not covered above that cause clinically significant impairment or distress

OTHER SPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER; UNSPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER

BIPOLAR I (3.3.1), BIPOLAR II (3.3.2), or MAJOR DEPRESSIVE (3.4.1) DISORDER, WITH PSYCHOTIC FEATURES

OTHER SPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER; UNSPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER

BRIEF PSYCHOTIC DISORDER (3.2.4)

N N N

Nonpathological delusion

44 DSM-5 Handbook of Differential Diagnosis

2.6 Decision Tree for Hallucinations Hallucinations are sensory perceptions without external stimulation. When trying to de-

termine the etiology of a hallucination, you need to consider the sensory modality in-

volved (i.e., whether the hallucination is auditory, visual, gustatory, olfactory, or tactile).

As a rule of thumb, visual, gustatory, and olfactory hallucinations are especially sugges-

tive of an etiological substance or general medical condition and demand a careful med-

ical workup. Similarly, a late age at first onset of hallucinations in any modality suggests

the need for an especially careful medical workup. Hallucinations can occur in the con-

text of a Delirium (either substance- or medication-induced or due to a general medical

condition), in the context of a Major or Mild Neurocognitive Disorder Due to Another

Medical Condition (in which case the specifier “With Behavioral Disturbance” should be

used), in the absence of accompanying cognitive impairment as a direct physiological

consequence of a substance or general medical condition (diagnosed respectively as a

Substance/Medication-Induced Psychotic Disorder or a Psychotic Disorder Due to An-

other Medical Condition), or as a typical feature of an intoxication or withdrawal syn-

drome.

After ruling out a general medical condition or substance as an etiological factor, you

must then consider whether the hallucination is indicative of a psychotic disorder. There

are four circumstances in which “hallucinations” should not count toward the diagnosis

of a psychotic disorder: 1) those that occur in the context of conversion (so-called pseu-

dohallucinations), which tend to affect multiple sensory modalities at the same time and

to have psychologically meaningful content presented to the clinician in the form of an

interesting story; 2) hallucinatory experiences that are part of a religious ritual or are a

culturally sanctioned experience (e.g., hearing the voice of a dead relative giving ad-

vice); 3) those substance-induced hallucinations that occur with intact reality testing

(e.g., an individual who is aware that the perceptual disturbances are due to recent hal-

lucinogen use); and 4) hypnopompic or hypnagogic hallucinations that occur at the be-

ginning or end of sleep episodes.

The next task is to determine whether clinically significant mood symptoms are pres-

ent and, if so, the relationship between the hallucinations and the mood symptoms. The

presence of a Manic or Major Depressive Episode raises the possibility that the hallucina-

tions are part of a Bipolar I Disorder With Psychotic Features, Bipolar II Disorder With

Psychotic Features, Major Depressive Disorder With Psychotic Features, or Schizoaffec-

tive Disorder. The differential diagnosis here depends on the temporal relationship be-

tween the hallucinations and the mood episodes. If the hallucinations are confined

exclusively to the mood episodes, then the diagnosis is Bipolar I Disorder With Psychotic

Features, Bipolar II Disorder With Psychotic Features, or Major Depressive Disorder

With Psychotic Features. Such hallucinations can be mood congruent (e.g., castigating ac-

cusatory voices in an individual with depression) or mood incongruent (i.e., hallucina-

tions that have nothing to do with the prevailing mood).

On the other hand, if hallucinations and other psychotic symptoms also occur before

or after the mood episodes, the diagnosis might be Schizophrenia, Schizophreniform

Disorder, or Schizoaffective Disorder, depending on the overlap between the mood epi-

sodes and hallucinations, and the relative duration of the mood episodes versus the total

2.6 Decision Tree for Hallucinations 45

duration of the psychotic disturbance. The diagnosis is Schizophrenia or Schizophreni-

form Disorder if there is no period of overlap between mood episodes and the halluci-

nations or, if there is a period of overlap, the mood episodes have been present for only

a minority of the total duration of the psychotic illness (e.g., several months of mood ep-

isodes during a chronic psychotic disturbance lasting years). By contrast, the diagnosis

is Schizoaffective Disorder if the mood episodes overlap with the hallucinations and

the mood episodes are present for a majority of the total time of the disturbance (e.g., a

2-year psychotic disturbance with 1½ years of mood symptoms). Note that in those cases

of Schizophrenia or Schizophreniform Disorder in which either 1) there are mood epi-

sodes that do not overlap with the psychotic symptoms or 2) all mood episodes are pres-

ent for a minority of the time relative to the total duration of the psychotic disturbance,

a comorbid diagnosis of Bipolar Disorder or Major Depressive Disorder may also be

given. This is a change from DSM-IV-TR, in that the hierarchy between Schizophrenia

and Bipolar Disorder/Major Depressive Disorder has been eliminated in DSM-5, mak-

ing it permissible to have comorbidity between Schizophrenia and Bipolar or Major De-

pressive Disorder.

Illusions differ from hallucinations; an illusion involves a misperception of an actual

stimulus. When illusions occur in the absence of hallucinations, they do not count toward

a diagnosis of a psychotic disorder and instead suggest Delirium, Substance Intoxication

or Substance Withdrawal, Schizotypal Personality Disorder, or no mental disorder.

46 DSM-5 Handbook of Differential Diagnosis

Hallucinations

SUBSTANCE INTOXICATION Due to the physiological DELIRIUM; SUBSTANCE effects of a substance WITHDRAWAL DELIRIUM; (including medication) MEDICATION-INDUCED

DELIRIUM (3.16.1)

Hallucinations predominate in the SUBSTANCE/MEDICATION- clinical picture and are INDUCED PSYCHOTIC sufficiently severe to DISORDER warrant clinical attention

Y Y

Associated with a disturbance in attention and awareness characterized by a fluctuating course

Due to the direct Y Y DELIRIUM DUE TO ANOTHER physiological effects of a MEDICAL CONDITION general medical condition (3.16.1)

Associated with a disturbance in attention and awareness characterized by a fluctuating course

MAJOR or MILD NEUROCOGNITIVE

Y DISORDER DUE TO ANOTHER MEDICAL CONDITION (3.16.2), WITH BEHAVIORAL DISTURBANCE

Associated with evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

N PSYCHOTIC DISORDER DUE TO ANOTHER MEDICAL CONDITION

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Hallucinatory experiences with intact insight, not accompanied by other Y CONVERSION DISORDER psychotic symptoms, usually (3.9.3) occurring in several sensory modalities, and having a fantastic or childish content (“pseudohallucinations”)

YHallucinatory experiences are culturally sanctioned

No mental disorder

2.6 Decision Tree for Hallucinations 47

Occurs only in the context of MAJOR DEPRESSIVE an episode of depressed EPISODE WITH PSYCHOTIC mood or diminished interest or FEATURES in MAJOR pleasure accompanied by DEPRESSIVE DISORDER characteristic depressive (3.4.1) or BIPOLAR I (3.3.1) symptoms or BIPOLAR II (3.3.2)

DISORDER

SCHIZOPHRENIA (3.2.1) (plus comorbid BIPOLAR I [3.3.1], BIPOLAR II [3.3.2], or MAJOR DEPRESSIVE [3.4.1] DISORDER if history of Major Depressive or Manic Episodes)

MANIC EPISODE WITH PSYCHOTIC FEATURES in BIPOLAR I DISORDER (3.3.1)

Hallucinations last for 1 month or more

YY Duration at least 6 months

Occurs only in the context of an episode of elevated, expansive, or irritable mood accompanied by increased energy

Accompanied by delusions, disorganized

Y History of Major speech, grossly Depressive or disorganized or Manic Episodes catatonic behavior, or negative symptoms

During an uninterrupted period of illness, psychotic symptoms concurrent with mood episodes

During an uninterrupted period of illness, mood episodes have been present for a minority of the total duration of the active and residual periods of the illness

48 DSM-5 Handbook of Differential Diagnosis

OTHER SPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER; UNSPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER

Delusions or hallucinations for at least 2 weeks in the absence of a Major Depressive Episode or Manic Episode during the lifetime course of the illness

Psychotic symptoms are confined to the mood episodes

BIPOLAR I (3.3.1) or BIPOLAR II (3.3.2) DISORDER, WITH PSYCHOTIC FEATURES; MAJOR DEPRESSIVE DISORDER (3.4.1), SINGLE or RECURRENT EPISODE, WITH PSYCHOTIC FEATURES

BRIEF PSYCHOTIC DISORDER (3.2.4)

SCHIZOAFFECTIVE DISORDER (3.2.2)

SCHIZO- PHRENIFORM DISORDER (3.2.1) (plus comorbid BIPOLAR I [3.3.1], BIPOLAR II [3.3.2], or MAJOR DEPRESSIVE [3.4.1] DISORDER if history of Major Depressive or Manic Episodes)

N N N N

Duration of hallucinations more than 1 day but less than 1 month

OTHER SPECIFIED SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDER

Hallucinations not covered above that cause clinically significant impairment or distress

Nonpathological hallucinations

2.7 Decision Tree for Catatonic Symptoms 49

2.7 Decision Tree for Catatonic Symptoms The catatonic symptoms covered here include stupor (i.e., no psychomotor activity, no ac-

tive relating to environment), catalepsy (i.e., passive induction of a posture held against

gravity), waxy flexibility (i.e., slight, even resistance to positioning by examiner), mutism

(i.e., no, or very little, verbal response), negativism (i.e., opposing or not responding to in-

structions or external stimuli), posturing (i.e., spontaneous and active maintenance of a

posture against gravity), mannerisms (i.e., odd, circumstantial caricatures of normal ac-

tions), stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements),

agitation (not influenced by external stimuli), grimacing, echolalia (i.e., mimicking an-

other’s speech), and echopraxia (i.e., mimicking another’s movements).

The initial task is to determine whether the “syndrome” of catatonia is present. This

can be difficult because a number of the individual items resemble other types of symp-

toms characteristic of DSM-5 disorders (e.g., catatonic excitement may resemble psycho-

motor agitation in a Manic or Major Depressive Episode, catatonic stupor may resemble

extreme psychomotor retardation in a Major Depressive Episode or Delirium, catatonic

mutism may resemble alogia and avolition in Schizophrenia). The judgment about these

distinctions is based in part on the context in which the symptom occurs (i.e., the pres-

ence of multiple catatonic symptoms vs. the presence of symptoms characteristic of the

other disorder) and on its presentation (i.e., individuals with catatonic symptoms ap-

pear to be oblivious to external environmental stimuli, although they may later report

accurately about what was happening around them).

If catatonic symptoms are present but do not constitute the syndrome of catatonia, a

substance- or medication-induced etiology for such symptoms should first be consid-

ered. If the symptoms are due to the direct physiological effect of substance use, such as

from Phencyclidine Intoxication, a diagnosis of Substance Intoxication or Substance

Withdrawal would apply. If the catatonic-like symptoms are judged to be due to the use

of a neuroleptic medication, then one of the neuroleptic-induced movement disorders

(i.e., Neuroleptic Malignant Syndrome, Neuroleptic-Induced Dystonia, or Neuroleptic-

Induced Parkinsonism) would apply.

Once the syndrome of catatonia has been established, the next step is to determine

the etiology. A catatonic syndrome can be due to the direct physiological effects of a neu-

rological or other medical condition (in which case Catatonic Disorder Due to Another

Medical Condition is diagnosed), can be a manifestation of a Manic Episode or Major

Depressive Episode (in which case catatonia associated with Bipolar I Disorder, Bipolar

II Disorder, or Major Depressive Disorder would be diagnosed), or can occur in the con-

text of other psychotic symptoms such as delusions, hallucinations, or disorganized

speech (in which case Catatonia Associated With [the appropriate psychotic disorder]

would be diagnosed).

If the clinically significant catatonic symptoms are present, are not covered by one of

the decision points so far, and represent a psychological or biological dysfunction in the

individual (thus meeting the definitional requirements of a mental disorder), the resid-

ual category Unspecified Catatonia would apply. Otherwise, the motoric symptoms

would be considered part of the normal repertoire of changes in psychomotor activity

or behavior and not indicative of a mental disorder.

50 DSM-5 Handbook of Differential Diagnosis

Catatonic symptoms (i.e., marked psychomotor disturbance that may involve decreased motor activity, decreased engagement during interview or physical exam, or excessive and peculiar motor activity)

Catatonic syndrome is present (i.e., clinical picture is dominated by three or more of SUBSTANCE the following catatonic INTOXICATION; symptoms: stupor, catalepsy, SUBSTANCE WITHDRAWAL waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, echopraxia) Judged to be due to the

use of a neuroleptic medication

N Y

Due to Substance Intoxication (e.g., Phencyclidine Intoxication) or Substance Withdrawal

Y NEUROLEPTIC MALIGNANT SYNDROME

Judged to be due to a Y neurological or other medical condition

Accompanied by muscular rigidity and elevated temperature

Y DELIRIUM DUE TO ANOTHER MEDICAL CONDITION (3.16.1)

Associated with a disturbance in attention and awareness characterized by a fluctuating course

N CATATONIC DISORDER DUE TO ANOTHER MEDICAL CONDITION (3.2.5)

OTHER MEDICATION- INDUCED MOVEMENT DISORDER

Occurs in the context of an episode of elevated, Y CATATONIA ASSOCIATED expansive, or irritable mood WITH A MANIC EPISODE in accompanied by increased BIPOLAR I DISORDER (3.3.1) energy

UNSPECIFIED CATATONIA. If restricted to decreased motor activity, see Psychomotor Retardation Tree (2.12) for differential

Y diagnosis

Y MEDICATION-INDUCED ACUTE DYSTONIA

Abnormal posturing or muscle spasm

Y NEUROLEPTIC-INDUCED PARKINSONISM

Muscular rigidity, usually with tremor and/or akinesia

2.7 Decision Tree for Catatonic Symptoms 51

CATATONIA ASSOCIATEDOccurs in the context of an WITH A MAJOR DEPRESSIVEepisode of depressed mood Y EPISODE in MAJORor diminished interest or DEPRESSIVE DISORDERpleasure accompanied by (3.4.1) or BIPOLAR I (3.3.1)characteristic depressive or BIPOLAR II (3.3.2)symptoms DISORDER

“Normal” change in psychomotor behavior or activity

CATATONIA ASSOCIATED WITH SCHIZOPHRENIA

Occurs in the context of other (3.2.1), SCHIZOAFFECTIVE psychotic symptoms (e.g., Y DISORDER (3.2.2), delusions, hallucinations, SCHIZOPHRENIFORM disorganized speech) DISORDER (3.2.1), or BRIEF

PSYCHOTIC DISORDER (3.2.4)N

Clinically significant catatonic symptoms not covered above Y UNSPECIFIED CATATONIAthat represent a psychological (3.2.5)or biological dysfunction in the individual

52 DSM-5 Handbook of Differential Diagnosis

2.8 Decision Tree for Elevated or Expansive Mood Most people have experienced at least some periods of elevated or expansive mood in

their lives, usually in response to a particularly wonderful event or experience such as

falling in love, having a child, graduating from school, landing a coveted job, being vic-

torious at a sporting event, or winning money at a game of chance. These mood states

become a concern only when they are abnormally elevated or expansive and are discon-

nected from contextual factors, in which the individual feels persistently euphoric for no

particular reason.

The first step in the differential diagnosis is to ensure that the mood disturbance is

not caused by substance/medication use or a general medical condition. The clinician’s

first reflex, particularly for any late onset of these symptoms, should be to conduct a

thorough medical workup and to evaluate whether the individual is using any medica-

tion (or drugs of abuse) that may produce mood changes as a side effect. In younger in-

dividuals, there is always a strong possibility that the changes in mood are caused by the

effects of Substance Intoxication or Substance Withdrawal.

The next step is to determine whether the elevated mood is part of a Manic or Hypo-

manic Episode. Such episodes are not coded separately in DSM-5 but instead form the

building blocks for the bipolar disorders. It should be noted that the symptomatic defi-

nitions of Manic and Hypomanic Episodes are essentially the same. The boundary be-

tween them depends on a clinical judgment as to the severity and impairment caused by

the mood disturbance. By definition, a Hypomanic Episode does not cause marked im-

pairment or distress and may even be compatible with improved social and job perfor-

mance. The bipolar disorders are made up of combinations of Manic, Hypomanic, and

Major Depressive Episodes. Bipolar I Disorder consists of one or more Manic Episodes

and (optionally) one or more Major Depressive Episodes. The term bipolar is used even

for individuals who have had only unipolar Manic Episodes (with no depressive epi-

sodes) because the vast majority of such individuals will eventually go on to have Major

Depressive Episodes, and their course, family loading, and treatment issues are equiva-

lent to those who have had both Manic and Major Depressive Episodes. Bipolar II Dis-

order consists of one or more Major Depressive Episodes with intercurrent Hypomanic

Episodes.

If the individual has a lifetime history of delusions or hallucinations, you must also

be sure to differentiate Bipolar I or Bipolar II Disorder With Psychotic Features from

other psychotic disorders such as Schizophrenia, Delusional Disorder, or Schizoaffective

Disorder. If psychotic symptoms are confined to Manic or Major Depressive Episodes,

then the diagnosis is Bipolar I or Bipolar II Disorder With Psychotic Features. If, how-

ever, there have been clinically significant delusions or hallucinations that extend be-

yond the mood episodes, then a non-mood-related psychotic disorder will have to be

diagnosed to account for the psychotic symptoms. In these cases, you should refer to the

delusions tree (2.5) or hallucinations tree (2.6) for the differential diagnosis.

Cyclothymic Disorder is a relatively uncommon bipolar spectrum disorder charac-

terized by the alternation between periods of hypomania and depression that are less se-

vere than a Manic, Hypomanic, or Major Depressive Episode. Finally, because for most

2.8 Decision Tree for Elevated or Expansive Mood 53

people, periods of elevated and expansive mood are intermittently common during

gambling (i.e., at least when a person is winning), it is important not to diagnose such

symptoms as evidence of mania if they are confined to sessions of gambling. However,

given that some individuals might engage in (often reckless) gambling behavior during

Manic Episodes, the combination of gambling and euphoric mood does not necessarily

rule out a diagnosis of Bipolar Disorder.

54 DSM-5 Handbook of Differential Diagnosis

Elevated or expansive mood

Due to the physiological Y Y SUBSTANCE/MEDICATION- effects of a substance INDUCED BIPOLAR (including medication) DISORDER

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Symptoms of elevated or expansive mood predominate in the clinical picture and are sufficiently severe to warrant clinical attention

Criteria met for a Manic Episode (i.e., at least 1 week of elevated or expansive mood accompanied by Y increased activity or energy and at least three other characteristic symptoms sufficiently severe to cause marked impairment)

Manic Episode

BIPOLAR I DISORDER (3.3.1)

MAJOR or MILD NEUROCOGNITIVE

Due to the physiological Y Y DISORDER DUE TO effects of a general medical ANOTHER MEDICAL condition CONDITION (3.16.2),

WITH BEHAVIORAL DISTURBANCE

BIPOLAR AND RELATED DISORDER DUE TO ANOTHER MEDICAL CONDITION

Associated with evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

Criteria met for a Hypomanic Episode (i.e., at least 4 days of elevated or expansive mood accompanied by Y increased activity or energy and at least three other characteristic symptoms that are not severe enough to cause marked impairment)

Hypomanic Episode

Y History of delusions or N Present or past Manic Episode hallucinations

N Y

2.8 Decision Tree for Elevated or Expansive Mood 55

Y BIPOLAR I DISORDER (3.3.1), WITH PSYCHOTIC FEATURES

Psychotic symptoms occur exclusively during Manic or Major Depressive Episodes

Schizophrenia Spectrum or Other Psychotic Disorder (see Delusions Tree [2.5] or Hallucinations Tree [2.6] for differential diagnosis)

NY BIPOLAR II DISORDER (3.3.2)History of delusions or

hallucinations

Y BIPOLAR II DISORDER (3.3.2), WITH PSYCHOTIC FEATURES

Psychotic symptoms occur exclusively during Major Depressive Episodes

2+ years of hypomanic Y CYCLOTHYMIC DISORDERsymptoms and periods of (3.3.3)depressed mood

NElevated or euphoric mood Y GAMBLING DISORDERconfined to periods of (3.15.2)gambling

Persistent and problematic gambling behavior leading to clinically significant impairment or distress

Normal gambling behavior N

Clinically significant manic or OTHER SPECIFIED BIPOLARhypomanic symptoms not Y AND RELATED DISORDER;covered above that represent UNSPECIFIED BIPOLAR ANDa psychological or biological RELATED DISORDERdysfunction in the individual

"Normal" elevated or euphoric mood

N Y

Present or past Hypomanic Episode and at least one Major Depressive Episode

Schizophrenia Spectrum or Other Psychotic Disorder (see Delusions Tree [2.5] or Hallucinations Tree [2.6] for differential diagnosis)

56 DSM-5 Handbook of Differential Diagnosis

2.9 Decision Tree for Irritable Mood All people can become more or less irritable under the right set of circumstances (e.g.,

not enough sleep, caught in traffic, under deadline pressure). The decision tree for irri-

table mood is not meant to apply to everyday experiences of irritable mood but instead

to periods of irritability that are either so persistent or so severe as to cause clinically sig-

nificant distress or impairment.

The first step in the differential diagnosis is to ensure that the irritability is not caused

by substance/medication use or a general medical condition. The clinician’s first reflex,

particularly for any late onset of these symptoms, should be to conduct a thorough med-

ical workup and to evaluate whether the individual is using any medication (or drugs

of abuse) that may produce irritability as a side effect. In younger individuals, there is

always a strong possibility that the irritability is caused by the effects of Substance In-

toxication or Substance Withdrawal.

The next step is to determine whether the irritable mood is part of a Manic or Hypo-

manic Episode. Distinct episodes of abnormally and persistently irritable mood accom-

panied by increased activity or energy and at least four other characteristic symptoms

define a Manic Episode or Hypomanic Episode. Note that four associated manic or hy-

pomanic symptoms (rather than the typical three) are required to make a diagnosis of a

Manic or Hypomanic Episode in the absence of elevated or expansive mood so that the

episode can more easily be differentiated from a Major Depressive Episode with associ-

ated irritability. These episodes are not coded separately in DSM-5 but instead form the

building blocks for the bipolar disorders. Bipolar I Disorder consists of one or more

Manic Episodes and (optionally) one or more Major Depressive Episodes. Bipolar II Dis-

order consists of one or more Major Depressive Episodes with intercurrent Hypomanic

Episodes. In Cyclothymic Disorder, which is characterized by a persistent pattern of al-

ternation between periods of hypomania and depression, irritable mood may occur dur-

ing the periods of hypomania.

Irritability is also a very common associated feature of depressed mood. In fact, ac-

cording to the original DSM-III definition, major depressive episode was defined in terms

of a “dysphoric mood,” which was characterized by symptoms such as feeling de-

pressed, sad, blue, hopeless, low, down in the dumps, or irritable. Therefore, the next

steps in the decision tree involve considering whether the irritable mood occurs in the

context of a Major Depressive Episode, Persistent Depressive Disorder (Dysthymia), or

Premenstrual Dysphoric Disorder.

Next in the differential are two disorders with prominent irritability that have their

onset in childhood: Disruptive Mood Dysregulation Disorder, which is characterized by

frequent severe temper outbursts that are grossly out of proportion to the situation with

persistently angry or irritable mood between the outbursts, and Oppositional Defiant

Disorder, which is also characterized by a pattern of persistent angry and irritable mood

that is accompanied by argumentativeness, defiance, and vindictiveness. If the irritabil-

ity is a fundamental part of the person’s characteristic repertoire of mood states, then a

diagnosis of a Personality Disorder may be most appropriate. Also, two of the DSM-5

personality disorders, Borderline Personality Disorder and Antisocial Personality Disor-

der, include chronic irritability among their characteristic features.

2.9 Decision Tree for Irritable Mood 57

Finally, clinically significant irritability that is not covered so far could qualify for a

diagnosis of Adjustment Disorder if it has occurred as a maladaptive response to a psy-

chosocial stressor. Otherwise, clinically significant irritability that does not meet the cri-

teria for any other mental disorder yet is judged to represent a psychological or

biological dysfunction in the individual could qualify for a diagnosis of Other Specified

Bipolar and Related Disorder or Unspecified Bipolar and Related Disorder.

58 DSM-5 Handbook of Differential Diagnosis

Irritable mood

Due to the physiological SUBSTANCE/MEDICATION-Y Yeffects of a substance INDUCED BIPOLAR (including medication) DISORDER

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFEECT OF MEDICATION

Symptoms of irritable mood predominate in the clinical picture and are sufficiently severe to warrant clinical attention

Criteria met for a Manic Episode (i.e., at least 1 week of irritable mood Yaccompanied by increased activity or energy and at least four other characteristic symptoms sufficiently severe to cause marked impairment)

Manic Episode

BIPOLAR I DISORDER (3.3.1)

N N

MAJOR or MILD NEUROCOGNITIVE

Due to the physiological Y Y DISORDER DUE TO effects of a general medical ANOTHER MEDICAL condition CONDITION (3.16.2),

WITH BEHAVIORAL DISTURBANCE

BIPOLAR AND RELATED DISORDER DUE TO ANOTHER MEDICAL CONDITION

Associated with evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

Criteria met for a Hypomanic Episode (i.e., at least 4 days of irritable mood Yaccompanied by increased activity or energy and at least four other characteristic symptoms not severe enough to cause marked impairment)

Hypomanic Episode

Y History of delusions or N Present or past Manic Episode hallucinations

N Y

2.9 Decision Tree for Irritable Mood 59

Y BIPOLAR I DISORDER (3.3.1), WITH PSYCHOTIC FEATURES

Psychotic symptoms occur exclusively during Manic or Major Depressive Episodes

NPresent or past Hypomanic Y Episode and at least one BIPOLAR II DISORDER (3.3.2) Major Depressive Episode

History of delusions or hallucinations

Y BIPOLAR II DISORDER (3.3.2), WITH PSYCHOTIC FEATURES

Psychotic symptoms occur exclusively during Major Depressive Episodes

2+ years of hypomanic Y CYCLOTHYMIC DISORDERsymptoms and periods of (3.3.3)depressed mood

YOccurring only in association Y MAJOR DEPRESSIVEwith periods of depressed DISORDER (3.4.1)mood

At least 2 weeks of depressed mood or diminished interest plus associated characteristic symptoms (e.g., changes in weight and appetite, changes in sleep, fatigue, suicidal thoughts)

Y PERSISTENT DEPRESSIVE DISORDER (3.4.2)

Depressed mood, more days than not, for at least 2 years with associated symptoms

Y PREMENSTRUAL DYSPHORIC DISORDER (3.4.3)

Depressed mood that is regularly present in the final week before the onset of menses and that becomes absent in the week postmenses

N Y

Schizophrenia Spectrum or Other Psychotic Disorder (see Delusions Tree [2.5] or Hallucinations Tree [2.6] for differential diagnosis)

60 DSM-5 Handbook of Differential Diagnosis

Occurring in the context of severe temper outbursts that

Y DISRUPTIVE MOODare grossly out of proportion DYSREGULATIONto the situation with persistent DISORDER (3.4.4)anger and irritability between outbursts

Occurring in association with a pattern of Y OPPOSITIONAL DEFIANT argumentativeness, defiance, DISORDER (3.14.1) and vindictiveness

Occurring as part of a persistent and pervasive pattern of instability of Y BORDERLINE PERSONALITYinterpersonal relationships, DISORDER (3.17.5)self-image, and affects, and marked impulsivity, beginning by early adulthood

Occurring as part of a persistent and pervasive Y ANTISOCIAL PERSONALITY pattern of disregard for, and DISORDER (3.17.4) violation of, the rights of others, occurring since age 15

Y Clinically significant irritability not covered above that Y ADJUSTMENT DISORDER represents a psychological or (3.7.2) biological dysfunction in the individual

Maladaptive response to a stressor

N OTHER SPECIFIED BIPOLAR AND RELATED DISORDER; UNSPECIFIED BIPOLAR AND

"Normal" irritability RELATED DISORDER

2.10 Decision Tree for Depressed Mood 61

2.10 Decision Tree for Depressed Mood Depressed or dysphoric mood is one of the most common presenting symptoms in men-

tal health settings and is a component of many psychiatric conditions. The differential

diagnosis of depressed mood requires a consideration of both the context in which the

depression occurs and the clustering and duration of symptoms.

Substances (including both drugs of abuse and medication side effects) must first be

ruled out. Depression can arise during intoxication with certain substances (e.g., canna-

bis), result from taking a medication, or be part of the withdrawal syndrome for a sub-

stance (e.g., cocaine). Because depressed mood is a frequent concomitant of intoxication

and withdrawal, it usually does not require a separate diagnosis. However, if the depres-

sive symptoms predominate in the clinical presentation and are sufficiently severe to

warrant clinical attention, then a diagnosis of Substance/Medication-Induced Depres-

sive Disorder may be more appropriate. The differential between Substance/Medica-

tion-Induced Depressive Disorder and a non-substance-induced depressive disorder

can be made historically by documenting that the depressed mood occurs only in rela-

tion to substance/medication use. When such a history is not forthcoming, a period of

abstinence is usually required to determine whether the depressed mood resolves once

the effects of the substance wear off. DSM-5 suggests waiting for “about 1 month” after

cessation of substance use to see whether the mood symptoms spontaneously resolve,

although the actual time frame varies depending on the drug and the clinical situation.

Other factors that should be considered include previous history of Major Depressive

Episodes, family history, and the likelihood that this type of substance in the amount

used could have caused the depressive symptoms. If the mood symptoms continue to

persist after a reasonable waiting period, then a Substance/Medication-Induced De-

pressive Disorder is unlikely and the diagnosis should be a non-substance-induced de-

pressive disorder.

One of the most difficult differential diagnostic determinations in psychiatry is to

distinguish between primary depressive disorders and those that are the direct physio-

logical consequences of a general medical condition. A very large number of general

medical conditions are known to cause depression through their direct effect on the

brain. If severe cognitive impairment is also present, Major Neurocognitive Disorder

Due to Another Medical Condition, With Behavioral Disturbance, must be considered.

However, it is important not to assume that the severity of the cognitive impairment

necessarily indicates a diagnosis of Neurocognitive Disorder Due to Another Medical

Condition. The cognitive impairment that can occur as part of a Major Depressive Epi-

sode can be so severe as to mimic a Major Neurocognitive Disorder. Often, only time,

serial evaluations, and sequential antidepressant treatment trials will confirm whether

a particular presentation is better explained by a Major Neurocognitive Disorder or a

Major Depressive Episode with severe cognitive symptoms.

The next step of the differential diagnosis is to determine whether the depressed mood

is part of a mood episode (e.g., Major Depressive Episode or a Manic Episode With Mixed

Features). These episodes are not coded separately in DSM-5 but instead form the building

blocks for the mood disorders (e.g., Major Depressive Disorder, Bipolar I Disorder, Bipolar

II Disorder). A Major Depressive Episode requires a minimum duration of at least 2 weeks

of depressed mood for most of the day, nearly every day. Furthermore, the depressed

62 DSM-5 Handbook of Differential Diagnosis

mood must be accompanied by at least four additional symptoms over the same time

period (e.g., changes in appetite or weight, sleep, level of motor activity, and suicidal

ideation). If the criteria are simultaneously met for a Manic Episode, then the combina-

tion of depressive and manic symptoms is considered in DSM-5 to be a Manic Episode,

and the specifier “With Mixed Features” is used to indicate the concomitant depressive

symptomatology.

The next three steps in the decision tree serve to identify those individuals whose

current presentation is depressed but whose overall course is characteristic of one of the

disorders in the Bipolar and Related Disorders diagnostic class in DSM-5. Depressive

symptoms accompanied by a history of Manic Episodes indicate Bipolar I Disorder, Hy-

pomanic Episodes with Major Depressive Episodes indicate Bipolar II Disorder, and

persistent depressive symptoms alternating with periods of hypomanic symptoms war-

rant a diagnosis of Cyclothymic Disorder.

Once the presence of lifetime manic or hypomanic symptoms has been ruled out, the

remaining decision points in the tree determine which depressive disorder best accounts

for the symptomatic presentation. The specific diagnosis depends on the presence of

Major Depressive Episodes, in which case the diagnosis is either Major Depressive Dis-

order or a Schizophrenia Spectrum or Other Psychotic Disorder (e.g., when psychotic

symptoms persist in the absence of prominent depression). The persistence of the cur-

rent Major Depressive Episode for at least 2 years warrants an additional diagnosis of

Persistent Depressive Disorder (Dysthymia). A diagnosis of Persistent Depressive Dis-

order by itself is warranted for presentations characterized by chronic depression per-

sisting for at least 2 years that is consistently below the symptom threshold for a Major

Depressive Episode. Periods of depressed mood that are regularly present in the final

week before the onset of menses and that become absent in the week postmenses are di-

agnosed as Premenstrual Dysphoric Disorder.

Finally, if the depression is not adequately explained by any of the decision points so

far in the tree, it may still justify a DSM-5 diagnosis. If the depression is a symptomatic

manifestation of a maladaptive response to a psychosocial stressor, a diagnosis of Ad-

justment Disorder With Depressed Mood might apply. If not, and the depression is clin-

ically significant and represents a psychological or biological dysfunction in the

individual (thus qualifying as a mental disorder), a residual category would apply, the

choice depending on whether the clinician wishes to record the symptomatic presenta-

tion on the chart (in which case Other Specified Depressive Disorder would be used, fol-

lowed by the specific reason) or not (in which case Unspecified Depressive Disorder

would be used). Otherwise, the depression would be considered part of “normal” every-

day blues and not indicative of a mental disorder.

2.10 Decision Tree for Depressed Mood 63

Depressed mood

Due to the SUBSTANCE/ physiological effects Y Y MEDICATION- of a substance INDUCED (including DEPRESSIVE medications) DISORDER

Depressive symptoms predominate in the clinical picture and are sufficiently severe to warrant clinical attention

N N

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

MAJOR or MILD NEUROCOGNITIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION (3.16.2), WITH BEHAVIORAL DISTURBANCE

Due to the physiological effects of a general medical condition

DEPRESSIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION

Associated with evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

Y Y

At least 2 weeks of depressed mood or diminished interest plus associated characteristic symptoms (e.g., changes in weight and appetite, changes in sleep, fatigue, suicidal thoughts)

Criteria also met at the same time for a Manic Episode (i.e., at least 1 week of elevated, expansive, Nor irritable mood Major Depressive Episode accompanied by increased energy and other characteristic symptoms sufficiently severe to cause marked impairment)

Manic Episode, With Mixed Features

64 DSM-5 Handbook of Differential Diagnosis

Clinically significant Y Y BIPOLAR I DISORDERmanic or hypomanic (3.3.1)symptoms

Criteria met for a Manic Episode (i.e., at least 1 week of elevated, expansive, or irritable mood accompanied by increased activity or energy and other characteristic symptoms sufficiently severe to cause marked impairment)

BIPOLAR I DISORDER (3.3.1), WITH PSYCHOTIC FEATURES

BIPOLAR II DISORDER (3.3.2)

Criteria met for a Hypomanic Episode (i.e., at least 4 days of elevated, expansive, or irritable mood accompanied by increased activity or energy and other characteristic symptoms not severe enough to cause marked impairment) and has at other times met criteria for a Major Depressive Episode

BIPOLAR II DISORDER (3.3.2), WITH PSYCHOTIC FEATURES

History of delusions or hallucinations

Psychotic symptoms occur exclusively during Manic or Major Depressive Episodes

History of delusions or hallucinations

Psychotic symptoms occur exclusively during Major Depressive Episodes

Schizophrenia Spectrum or Other Psychotic Disorder (see Delusions Tree [2.5] or Hallucinations Tree [2.6] for differential diagnosis)

2.10 Decision Tree for Depressed Mood 65

MAJOR DEPRESSIVEOne or more Major DISORDER (3.4.1)Depressive Episodes Y N plus PERSISTENTwithout any Manic or DEPRESSIVEHypomanic Episodes DISORDER (3.4.2)

History of delusions or hallucinations

CYCLOTHYMIC DISORDER (3.3.3)

MAJOR DEPRESSIVE DISORDER (3.4.1),Psychotic symptoms WITH PSYCHOTICoccur exclusively FEATURES, plusduring Major PERSISTENTDepressive Episodes DEPRESSIVE DISORDER (3.4.2)

Duration of episode 2 years or longer

2+ years of Yhypomanic symptoms

and periods of depressed mood

OTHER SPECIFIED BIPOLAR AND RELATED DISORDER; UNSPECIFIED BIPOLAR AND RELATED DISORDER

MAJOR DEPRESSIVE DISORDER (3.4.1)

MAJOR DEPRESSIVE DISORDER (3.4.1), WITH PSYCHOTIC FEATURES

N N N Schizophrenia Spectrum or Other Psychotic Disorder (see Delusions Tree [2.5] or Hallucinations Tree [2.6] for differential diagnosis)

Schizophrenia Spectrum or Other Psychotic Disorder (see Delusions Tree [2.5] or Hallucinations Tree [2.6] for differential diagnosis)

66 DSM-5 Handbook of Differential Diagnosis

Depressed mood that is regularly present in

Y PREMENSTRUALthe final week before DYSPHORICthe onset of menses DISORDER (3.4.3)and that becomes absent in the week postmenses and is associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others

OTHER SPECIFIED DEPRESSIVE DISORDER; UNSPECIFIED DEPRESSIVE DISORDER

Depressed or dysphoric mood as an associated feature of another mental disorder (e.g., “demoralization” about having Obsessive-Compulsive Disorder)

OTHER SPECIFIED DEPRESSIVE DISORDER; UNSPECIFIED DEPRESSIVE DISORDER

Mood disturbance clinically significant

No mood disorder diagnosis needed

Y ADJUSTMENT DISORDER WITH DEPRESSED MOOD (3.7.2)

Clinically significant depressive symptoms not covered above Y that represent a psychological or biological dysfunction in the individual

Maladaptive response to a psychosocial stressor

"Normal" everyday blues

Y PERSISTENT DEPRESSIVE DISORDER (3.4.2)

Depressed mood, more days than not, for at least 2 years with associated symptoms

2.11 Decision Tree for Suicidal Ideation or Behavior 67

2.11 Decision Tree for Suicidal Ideation or Behavior When you are evaluating suicidality, it is important to determine the urgency of current

suicidal thoughts, the degree to which definite plans have been formulated and acted

on, the availability of a means of suicide, the lethality of the method, the urgency of the

impulse, the presence of psychotic symptoms, the history of previous suicidal thoughts

and attempts, family history of suicidal behavior, and current and past substance use.

The degree of suicidality is on a continuum ranging from recurrent wishes to be dead,

to feelings that others would be better off if one were dead (“passive suicidal thoughts”),

to formulating suicidal plans, to overt suicidal behaviors.

Perhaps because suicidal behavior is a defining feature of a Major Depressive Epi-

sode, most people associate suicide most closely with mood disorders. For this reason,

the third branch of the tree offers a “mini-differential diagnosis” of those DSM-5 condi-

tions associated with depressed mood, and the fourth branch covers conditions with a

concurrent mixture of depressive and manic symptoms (so-called mixed states). As this

decision tree illustrates, although suicidal ideation is a characteristic feature of mood

disorders, it must be considered in the management of a wide array of DSM-5 disorders.

Moreover, the risk of suicide increases dramatically when the individual has more than

one disorder because each disorder may independently contribute to the risk (e.g., a par-

ticularly common and dangerous combination includes Major Depressive Disorder, Al-

cohol Use Disorder, and Borderline Personality Disorder).

Suicidal behavior may result from symptoms other than depressed mood. For exam-

ple, suicidal behavior may occur under the direction of delusions or command halluci-

nations (e.g., in Schizophrenia, Bipolar Disorder With Psychotic Features, or Major

Depressive Disorder With Psychotic Features), may be related to confusion or other cog-

nitive impairment (e.g., in Delirium, Major Neurocognitive Disorder, Substance Intoxi-

cation or Substance Withdrawal), or may result from disinhibition (e.g., in a Manic

Episode or Substance Intoxication). Borderline Personality Disorder and Antisocial Per-

sonality Disorder have a 5%–10% risk of successful suicide, perhaps resulting from the

impulsivity, labile moods, low frustration tolerance, and high rates of substance use

characteristic of individuals with such disorders. Similarly, Conduct Disorder is an im-

portant predictor of suicide in adolescents, particularly when it is accompanied by sub-

stance use and mood symptoms.

The evaluation of suicidal ideation or behavior must take into account the fact that

such symptoms are sometimes feigned as a way of gaining admission to the hospital or

of “solving” other life problems. Patients quickly learn the power of saying the phrase,

“I want to kill myself,” as a way of influencing clinicians, family members, and other im-

portant individuals in their lives. In Malingering, the patient’s motivation is some obvi-

ous external reward (e.g., getting transferred from prison to hospital, getting a place to

spend the night). In contrast, in Factitious Disorder, the presumed motivation is a psy-

chological need to assume the sick role, especially for individuals who are attempting to

make the hospital their more or less permanent home. Adjustment Disorder applies to

68 DSM-5 Handbook of Differential Diagnosis

those individuals who develop suicidal ideation or behavior in response to psychosocial

stressors and in the absence of other symptoms that would meet the criteria for a specific

DSM-5 disorder. This diagnosis is most commonly used to describe suicidal behavior in

adolescents.

Another possibility is that in certain extreme circumstances (e.g., an intractable ter-

minal illness), the desire to kill oneself may not necessarily represent a mental disorder.

However, before a clinician can arrive at this conclusion, a thorough evaluation is nec-

essary to rule out all other more treatable causes of suicidal ideation (e.g., depression,

pain, insomnia, psychosis, Delirium).

2.11 Decision Tree for Suicidal Ideation or Behavior 69

Suicidal ideation or behavior

Self-injurious behavior without a desire to die

Related to a delusion (e.g., delusional conviction of being possessed by the devil) or in response to a command hallucination

Occurring in the context of clinically significant depressive symptomatology without any accompanying manic symptomatology

Depressive symptoms are DEPRESSIVE DISORDERdue to the physiological DUE TO ANOTHEReffects of a general MEDICAL CONDITIONmedical condition

Not suicidal behavior (see Self-Injury or Self- Multilation Tree [2.25] for differential diagnosis)

Depressive symptoms are SUBSTANCE/due to the physiological MEDICATION-INDUCEDeffects of a substance DEPRESSIVE DISORDER(including medication)

Occurs in the context of an episode of depressed mood or diminished interest or pleasure accompanied by characteristic depressive symptoms

Occurring in the context of depressed mood that

PERSISTENT DEPRESSIVEhas been present for more DISORDER (3.4.2)days than not for at least

2 years

Occurring in the context of depressed mood that is regularly present in the PREMENSTRUAL final week before the DYSPHORIC DISORDER onset of menses and that (3.4.3) becomes absent in the week postmenses

Psychotic Disorder (e.g., SCHIZOPHRENIA [3.2.1]). See Delusions Tree (2.5) or Hallucinations Tree (2.6) for differential diagnosis

MAJOR DEPRESSIVE EPISODE in MAJOR DEPRESSIVE DISORDER (3.4.1), BIPOLAR I (3.3.1) or BIPOLAR II (3.3.2) DISORDER, or SCHIZOAFFECTIVE DISORDER (3.2.2)

70 DSM-5 Handbook of Differential Diagnosis

Associated with the disinhibition, dysphoria, or confusion related to Substance Intoxication or Substance Withdrawal or a medication side effect

Occurring in the context of a mixture of manic and depressive symptomatology

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Manic and depressive BIPOLAR DISORDER DUEsymptoms are due to the TO ANOTHER MEDICALphysiological effects of a CONDITIONgeneral medical condition

Manic and depressive symptoms are due to the SUBSTANCE/ physiological effects of a MEDICATION-INDUCED substance (including BIPOLAR DISORDER medication)

Occurring in the context of an episode of depressed MANIC EPISODE WITH mood or diminished MIXED FEATURES in interest or pleasure BIPOLAR I DISORDER accompanied by (3.3.1) characteristic depressive symptoms

Associated with confusion or lack of judgment in the context of a Neurocognitive Disorder

DELIRIUM DUE TO ANOTHER MEDICAL

Associated with a CONDITION; disturbance in attention SUBSTANCE and awareness INTOXICATION characterized by a DELIRIUM; SUBSTANCE fluctuating course WITHDRAWAL DELIRIUM;

MEDICATION-INDUCED DELIRIUM (3.16.1)

MAJORAssociated with evidence NEUROCOGNITIVEof decline in one or more DISORDER DUE TOof the following cognitive ANOTHER MEDICALdomains: complex CONDITION;attention, executive SUBSTANCE/function, learning and MEDICATION-INDUCEDmemory, language, MAJORperceptual-motor, or social NEUROCOGNITIVEcognition DISORDER (3.16.2)

2.11 Decision Tree for Suicidal Ideation or Behavior 71

Related to irritability, aggressiveness, impulsivity, and/or legal problems

No mental disorder diagnosis necessarily present (e.g., motivation to terminate intractable physical symptoms or their consequences)

CONDUCT DISORDER (3.14.3); ANTISOCIAL PERSONALITY DISORDER (3.17.4)

Associated with severe recurrent temper outbursts grossly out of proportion to provocation; with persistent angry, irritable mood in between outbursts; and with onset before age 10

DISRUPTIVE MOOD DYSREGULATION DISORDER (3.4.4)

Related to a chronic pattern of fears of abandonment, intense anger, and poor impulse control

BORDERLINE PERSONALITY DISORDER (3.17.5)

Suicidal ideation or behavior is feigned

FACTITIOUS DISORDER (3.9.5); MALINGERING

Occurring in the context of severe demoralization associated with a mental disorder or general medical condition

MENTAL DISORDER plus Section III: Suicidal Behavior Disorder

Occurring in response to a psychosocial stressor and behavior is not accounted for by another specific mental disorder

ADJUSTMENT DISORDER (3.7.2)

72 DSM-5 Handbook of Differential Diagnosis

2.12 Decision Tree for Psychomotor Retardation Psychomotor retardation is defined as visible generalized slowing of movements and

speech. In its extreme form, psychomotor retardation may be characterized by unrespon-

siveness and mutism that is indistinguishable from catatonic stupor. The symptom of

psychomotor retardation should be distinguished from other similar symptoms. Fatigue

is a subjective sense of having decreased energy or being tired all the time but is not char-

acterized by visible evidence of slowed movements. Leaden paralysis is the subjective

sense that one’s arms and legs are as “heavy as lead” and is a part of the “atypical” pat-

tern of symptoms in a Major Depressive Episode With Atypical Features. Avolition (one

of the negative symptoms of Schizophrenia) is characterized by a lack of motivation to

carry out behaviors rather than being physically slowed down.

General medical conditions may cause psychomotor retardation that usually does

not warrant a separate mental disorder diagnosis. It is important to remember that psy-

chomotor changes associated with Delirium go in both directions. Very few clinicians

miss the dramatic presentations of Delirium associated with psychomotor agitation

(e.g., the patient pulling out an intravenous line). The “quiet” cases of Delirium associ-

ated with psychomotor retardation are much more likely to go unrecognized. Such sce-

narios are noted by specifying the psychomotor level of activity as being “hypoactive.”

Another common “missed” cause of slowed movements is Neuroleptic-Induced Parkin-

sonism. This differentiation is complicated by the fact that a number of disorders for

which neuroleptics are given can themselves present with psychomotor retardation

(e.g., Schizophrenia, Bipolar Disorder or Major Depressive Disorder With Psychotic Fea-

tures, Delirium). A change in medication (e.g., reducing the neuroleptic dosage or ad-

ministering anticholinergic medication) can often be helpful in making the distinction.

2.12 Decision Tree for Psychomotor Retardation 73

NEUROLEPTIC-INDUCEDDue to the direct effects of a PARKINSONISM;substance (including NEUROLEPTIC MALIGNANTmedication) SYNDROME

SUBSTANCE INTOXICATION DELIRIUM, HYPOACTIVE

Associated with a TYPE; SUBSTANCE disturbance in attention WITHDRAWAL DELIRIUM, and awareness HYPOACTIVE TYPE; characterized by a MEDICATION-INDUCED fluctuating course DELIRIUM, HYPOACTIVE

TYPE (3.16.1)

Y Y

Related to the use of neuroleptic medication

SUBSTANCE/MEDICATION- Y INDUCED MAJOR

NEUROCOGNITIVE DISORDER (3.16.2)

Associated with evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

Occurring in the context Y SUBSTANCE/MEDICATION- of severe depressive INDUCED DEPRESSIVE symptoms DISORDER

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Due to the physiological Y Y DELIRIUM DUE TO ANOTHER effects of a general medical MEDICAL CONDITION, condition HYPOACTIVE TYPE (3.16.1)

Associated with a disturbance in attention and awareness characterized by a fluctuating course

Psychomotor retardation

74 DSM-5 Handbook of Differential Diagnosis

MAJOR NEUROCOGNITIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION (3.16.2)

Catatonic mutism plus at CATATONIC DISORDER DUE least two other catatonic TO ANOTHER MEDICAL symptoms CONDITION (3.2.5)

Associated with evidence of decline in one of more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

Occurring in the context Y DEPRESSIVE DISORDER DUE of severe depressive TO ANOTHER MEDICAL symptoms CONDITION

Associated with at least two characteristic symptoms of Y Catatonia (See Catatonic Catatonia (e.g., catalepsy, Symptoms Tree [2.7] for waxy flexibility, negativism, differential diagnosis) posturing, stereotypy, echolalia)

Symptom of a general medical condition (e.g., hypothyroidism)

Occurring in the context of an episode of depressed mood or Y diminished interest or pleasure accompanied by characteristic depressive symptoms

Schizophrenia Spectrum or Other Psychotic Disorder (seeAssociated with delusions, Y Delusions Tree [2.5],hallucinations, or Hallucinations Tree [2.6], ordisorganized speech Speech Disturbance Tree [2.3] for differential diagnosis)

"Normal" variation in psychomotor activity

MAJOR DEPRESSIVE EPISODE in MAJOR DEPRESSIVE DISORDER (3.4.1), BIPOLAR I (3.3.1) or BIPOLAR II (3.3.2) DISORDER, or SCHIZOAFFECTIVE DISORDER (3.2.2)

2.13 Decision Tree for Anxiety 75

2.13 Decision Tree for Anxiety As is always the case, the first step in the differential diagnosis is to rule out substance/

medication use or a general medical condition as the direct physiological cause of a pa-

tient’s anxiety. Because anxiety can be an associated feature of Delirium and Major or

Mild Neurocognitive Disorder, these more specific conditions are also considered within

this section of the decision tree.

When the anxiety occurs in discrete episodes with a sudden onset and is accompa-

nied by a number of somatic symptoms (e.g., palpitations, shortness of breath, dizzi-

ness) and cognitive symptoms (e.g., fear of going crazy or having a heart attack), it is

considered to be a Panic Attack (or, if the number of characteristic symptoms falls short

of the minimum threshold of four, a “limited-symptom attack”). Because of the specific

treatment implications of panic attacks, a separate decision tree (2.14) is provided for

them.

The remaining decision points in the anxiety tree differentiate among the Anxiety

Disorders by determining what the individual is afraid of, what situations are avoided,

and whether the anxiety is in response to a stressor. In Panic Disorder, the anxiety is re-

lated to the fear of having additional panic attacks and the possible consequences of

these attacks. Agoraphobia is similar in that the person is afraid of places or situations

that would be difficult or embarrassing to get out of in the event of a Panic Attack or

panic-like symptoms, but the focus is on the fear and avoidance of the places and situa-

tions rather than on the Panic Attack itself. Reflecting the more generalized nature of the

avoidance in Agoraphobia (compared with the more limited nature of avoided situa-

tions in conditions such as Specific Phobia), a diagnosis of Agoraphobia requires that the

individual must be fearful of situations from at least two “agoraphobic clusters”: public

transportation, open spaces, enclosed spaces, standing in a line or being in a crowd, and

being outside the home alone. Separation Anxiety Disorder, Social Anxiety Disorder

(Social Phobia), Specific Phobia, and Illness Anxiety Disorder each has a specific focus

of fear and avoidance (i.e., about separation from major attachment figures, situations in

which the person may be exposed to scrutiny of others, exposure to a feared object [e.g.,

spider] or situation [e.g., flying in an airplane], and having or acquiring a serious illness,

respectively). Disorders from the Obsessive-Compulsive and Related Disorders group-

ing may also be associated with anxiety (e.g., anxiety associated with the preoccupation

with an imagined bodily defect in Body Dysmorphic Disorder, being contaminated in

Obsessive-Compulsive Disorder, being forced to discard personal items by an individ-

ual with Hoarding Disorder). Although not included in the Obsessive-Compulsive and

Related Disorders diagnostic class, Generalized Anxiety Disorder is phenomenologi-

cally similar in that it is characterized by excessive ruminations and worries about un-

toward events that go along with the chronic anxiety.

Anxiety that develops in response to exposure to a traumatic stressor may be indica-

tive of Posttraumatic Stress Disorder or Acute Stress Disorder if the other characteristic

features are also present (i.e., intrusion and avoidance symptoms related to the traumatic

stressor or its circumstances, negative alterations in cognitions and mood, and alterations

in arousal and activity); the differentiation is based on duration (i.e., 1 month or less for

Acute Stress Disorder, greater than 1 month for Posttraumatic Stress Disorder).

76 DSM-5 Handbook of Differential Diagnosis

Anxiety occurs so commonly with Major Depressive Episodes, Manic Episodes, and

Hypomanic Episodes that its co-occurrence is more the rule than the exception. To indi-

cate the comorbid presence of anxiety, DSM-5 has introduced the specifier With Anxious

Distress that allows the clinician to indicate the severity of comorbid anxiety (ranging

from mild to severe). Finally, if the anxiety is not adequately explained by any of the de-

cision points so far in the tree, a DSM-5 diagnosis may still be justified. If the anxiety is

a symptomatic manifestation of a maladaptive response to a psychosocial stressor, the

diagnosis is Adjustment Disorder With Anxiety. If not, and it is clinically significant and

represents a psychological or biological dysfunction in the individual (thus qualifying

as a mental disorder), a residual category would apply, the choice depending on

whether the clinician wishes to record the symptomatic presentation on the chart (in

which case Other Specified Anxiety Disorder would be used, followed by the specific

reason) or not (in which case Unspecified Anxiety Disorder would be used). Otherwise,

the anxiety would be considered part of the normal repertoire of emotional expression

and not indicative of a mental disorder.

2.13 Decision Tree for Anxiety 77

Anxiety

Due to the physiological Y effects of a substance (including medications)

Y SUBSTANCE/MEDICATION- INDUCED ANXIETY DISORDER

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Anxiety symptoms predominate in the clinical picture and are sufficiently severe to warrant clinical attention

PANIC DISORDER (3.5.5)

Due to the physiological DELIRIUM DUE TO ANOTHER Y Y

effects of a general medical MEDICAL CONDITION condition (3.16.1)

ANXIETY DISORDER DUE TO ANOTHER MEDICAL CONDITION

Associated with a disturbance in attention and awareness characterized by a fluctuating course

Occurring in the context of an abrupt surge of intense fear Y and discomfort that reaches a peak within minutes

Panic Attack or limited- symptom attack (see Panic Attacks Tree [2.14] for differential diagnosis)

YRecurrent unexpected clinically significant Panic Attacks

MAJOR or MILD NEUROCOGNITIVE

Y DISORDER DUE TO ANOTHER MEDICAL CONDITION (3.16.2), WITH BEHAVIORAL DISTURBANCE

Associated with evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

SUBSTANCE INTOXICATION Y DELIRIUM; SUBSTANCE

WITHDRAWAL DELIRIUM; MEDICATION-INDUCED DELIRIUM (3.16.1)

Associated with a disturbance in attention and awareness characterized by a fluctuating course

78 DSM-5 Handbook of Differential Diagnosis

Anxiety or worry concerning separation from major Y SEPARATION ANXIETY attachment figures, without DISORDER (3.5.1) more generalized worries

HOARDING DISORDER (3.6.3)

Y Anxiety about discarding or parting with personal items, resulting in accumulation of possessions cluttering living areas

Anxiety about heath and Yabout having or acquiring a

serious illness, without more generalized worries

N ILLNESS ANXIETY DISORDER (3.9.2)

Psychotic Disorder (see Delusions Tree [2.5] for differential diagnosis)

Belief about serious physical illness is of delusional intensity

Anxiety or worry about social situations in which the person Y SOCIAL ANXIETY is exposed to scrutiny of DISORDER (3.5.4) others, without more generalized worries

Anxiety about exposure to a feared object (e.g., spiders) or Y SPECIFIC PHOBIA (3.5.3)situation (e.g., getting an injection, flying)

BODY DYSMORPHIC DISORDER (3.6.2)

YAnxiety or worry about an imagined defect in appearance

AGORAPHOBIA (3.5.6) Y

Anxiety about being in places from which escape might be difficult or embarrassing in the event of having a Panic Attack or panic-like symptoms, without more generalized worries

Y SOMATIC SYMPTOM DISORDER (3.9.1)

Somatic symptoms that are distressing

2.13 Decision Tree for Anxiety 79

MAJOR DEPRESSIVE EPISODE WITH ANXIOUS FEATURES in MAJOR DEPRESSIVE (3.4.1), BIPOLAR I (3.3.1), or BIPOLAR II (3.3.2) DISORDER; MANIC EPISODE WITH ANXIOUS FEATURES in BIPOLAR I DISORDER (3.3.1); HYPOMANIC EPISODE WITH ANXIOUS FEATURES in BIPOLAR I (3.3.1) or BIPOLAR II (3.3.2) DISORDER

Clinically significant anxiety not covered above that Y Y ADJUSTMENT DISORDER represents a psychological or WITH ANXIETY (3.7.2) biological dysfunction in the individual

Occurring in response to a psychosocial stressor

Y Anxiety associated with a Manic Episode, a Hypomanic Episode, or a Major Depressive Episode

Y POSTTRAUMATIC STRESS DISORDER (3.7.1)

ACUTE STRESS DISORDER (3.7.1)

Duration of more than 1 month

N OTHER SPECIFIED ANXIETY DISORDER; UNSPECIFIED ANXIETY DISORDER

"Normal" anxiety

Anxiety associated with Y Yrecurrent worries, thoughts, or OBSESSIVE-COMPULSIVE

ruminations DISORDER (3.6.1)

Recurrent thoughts are experienced as intrusive, unwanted, and ego-dystonic

Y GENERALIZED ANXIETY DISORDER (3.5.7)

Excessive worry and anxiety about several events or situations, persisting for at least 6 months

Anxiety associated with Y exposure to a severe traumatic stressor

Occurring with intrusion symptoms, avoidance of stimuli associated with the traumatic stressor, negative alterations in cognitions and mood, and alterations in arousal and activity

80 DSM-5 Handbook of Differential Diagnosis

2.14 Decision Tree for Panic Attacks Panic attacks are discrete episodes of intense fear or discomfort accompanied by symp-

toms such as palpitations, shortness of breath, sweating, trembling, derealization, and a

fear of losing control or dying. Although panic attacks are required for a diagnosis of

Panic Disorder, they also occur in association with a number of other DSM-5 disorders

listed in the tree. For example, if a patient with a snake phobia goes on a hike and steps

on a snake, that experience could easily result in a Panic Attack that would be indicative

of a Specific Phobia rather than Panic Disorder.

The first step in the differential for a Panic Attack is to rule out the presence of etio-

logical substance/medication use. When taken in high enough doses or during Sub-

stance Withdrawal, a number of substances and medications can lead to a Panic Attack.

Because caffeine is a common but covert culprit in this regard, taking a careful history of

the consumption of caffeine-containing substances is important. If substance-related

Panic Attacks warrant clinical attention, Substance/Medication-Induced Anxiety Disor-

der should be diagnosed; otherwise, a diagnosis of Substance Intoxication or Substance

Withdrawal will suffice. Sometimes, individuals have their first Panic Attack while tak-

ing a substance and then go on to have additional attacks even when they are not taking

any substances. Such subsequent attacks should not be considered substance-induced

Panic Attacks but instead might warrant a diagnosis of Panic Disorder.

Next, possible etiological general medical conditions, such as hyperthyroidism or a

pheochromocytoma, should be considered. If evidence indicates that such a general

medical condition is the direct cause of the Panic Attack (e.g., the onset of the Panic At-

tacks paralleled the onset of the general medical condition, and the Panic Attacks remit-

ted after initiation of successful treatment for the general medical condition), that would

suggest the diagnosis of Anxiety Disorder Due to Another Medical Condition. Although

mitral valve prolapse appears to be more frequent in individuals with Panic Attacks, a

direct etiological connection has not been established; therefore, an individual with mi-

tral valve prolapse and Panic Attacks is considered to have a primary Panic Disorder.

Once it is clear that the Panic Attacks are not the direct physiological consequence of

a substance or general medical condition, the next step is to determine the relationship

between the Panic Attacks and a possible situational trigger. By definition, at least two

of the panic attacks in Panic Disorder must be unexpected—that is, there is no relation-

ship between the attacks and a situational cue (i.e., they arise “out of the blue”). In con-

trast, the panic attacks that occur in patients with Social Anxiety Disorder (Social

Phobia), Specific Phobia, Separation Anxiety Disorder, Posttraumatic Stress Disorder or

Acute Stress Disorder, Illness Anxiety Disorder, Obsessive-Compulsive Disorder, and

Generalized Anxiety Disorder are closely related to the pertinent situational trigger

(e.g., social situations such as public speaking, a specific situation such as closed places,

being separated from major attachment figures, being exposed to reminders of the

trauma, the possibility of having a serious illness, obsessive concerns such as contami-

nation fears, and worry about a number of events or situations, respectively). If the Panic

Attacks are not an associated feature of a specific DSM-5 disorder but nonetheless are

judged to be clinically significant, either a diagnosis of Adjustment Disorder (if the Panic

Attacks are a response to a psychosocial stressor) or a diagnosis of a residual category

2.14 Decision Tree for Panic Attacks 81

(Other Specified Anxiety Disorder or Unspecified Anxiety Disorder) may be appropri-

ate. Finally, Panic Attacks triggered by a realistic threat (e.g., being held up at gunpoint)

or the experience of a single isolated Panic Attack (or very occasional Panic Attacks)

does not warrant a diagnosis of a mental disorder.

Panic Attacks

Due to the physiological Y Y SUBSTANCE/MEDICATION- effects of a substance INDUCED ANXIETY (including medication) DISORDER

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Panic Attacks predominate in the clinical picture and are sufficiently severe to warrant clinical attention

N N

ANXIETY DISORDER DUE TODue to the physiological Y ANOTHER MEDICALeffects of a general medical CONDITION, WITH PANICcondition ATTACKS N

Recurrent unexpected Panic Attacks accompanied by at Y PANIC DISORDER (3.5.5)least 1 month of concern or maladaptive changes in behavior

Trigger for Panic Attack is fear Y SOCIAL ANXIETY DISORDER of embarrassment in social (3.5.4) WITH PANIC situations ATTACKS

Trigger for Panic Attack is fear Yof specific object (e.g., SPECIFIC PHOBIA (3.5.3)

spiders) or situation (e.g., WITH PANIC ATTACKS heights, seeing blood)

Trigger for Panic Attack is fear Y SEPARATION ANXIETY of separation from major DISORDER (3.5.1) WITH attachment figures PANIC ATTACKS

82 DSM-5 Handbook of Differential Diagnosis

Trigger for Panic Attack is exposure to situation resembling prior traumatic experience occurring in the POSTTRAUMATIC STRESScontext of intrusion symptoms, Y Y

DISORDER (3.7.1) WITHavoidance of stimuli PANIC ATTACKSassociated with the traumatic stressor, negative alterations in cognitions and mood, and alterations in arousal and ACUTE STRESS DISORDER activity (3.7.1) WITH PANIC ATTACKS

Duration of more than 1 month

Trigger for Panic Attack is the Y ILLNESS ANXIETY DISORDER threat of having a serious (3.9.2) WITH PANIC illness ATTACKS

Trigger for Panic Attack is exposure to a focus of an Y OBSESSIVE-COMPULSIVE obsessional concern (e.g., to DISORDER (3.6.1) WITH dirt for an individual with a PANIC ATTACKS contamination obsession)

Trigger for Panic Attack is excessive anxiety and worry Y GENERALIZED ANXIETY about a number of events or DISORDER (3.5.7) WITH activities such as work or PANIC ATTACKS school performance

“Normal” context-justified Panic Attacks (e.g., an immediate response to a severe threat)

Clinically significant discrete periods of anxiety not covered Y Y ADJUSTMENT DISORDER above that represent a (3.7.2) WITH ANXIETY psychological or biological dysfunction in the individual

OTHER SPECIFIED ANXIETY DISORDER; UNSPECIFIED ANXIETY DISORDER

Occurring in response to a stressor

2.15 Decision Tree for Avoidance Behavior 83

2.15 Decision Tree for Avoidance Behavior Avoidance behavior (particularly of realistically harmful situations) is often adaptive. This

decision tree applies only when the avoidance is based on unrealistic or excessive fears

and leads to clinically significant distress or impairment. Avoidance is a fairly ubiquitous

and nonspecific symptom and is an associated feature of many disorders. The evaluation

of this symptom requires determining the specific circumstances triggering the avoidance.

This is one of the few decision trees included in this handbook that does not include a de-

cision point for ruling out substance/medication use or a general medical condition as an

etiological factor. This is because avoidance behavior is almost invariably a psychological

reaction to an underlying anxiety or fear. Although substance/medication use or a general

medical condition can cause anxiety, the lack of contextual associations makes the devel-

opment of avoidance behavior related to Substance/Medication-Induced Anxiety Disor-

der or Anxiety Disorder Due to Another Medical Condition unlikely.

The first order of business is determining whether the avoidance behavior involves

multiple situations and places. If so, and if the situations are avoided due to thoughts

that escape might be difficult or help might not be available in the event of developing

panic-like symptoms, the diagnosis of Agoraphobia might apply. Individuals associate

the risk of having a Panic Attack or panic-like symptoms with particular locations or sit-

uations that then become conditioned stimuli particularly likely to trigger additional at-

tacks. The individuals then avoid what appear to be “triggering” situations in an effort

to minimize the chance of having panic attacks or panic-like symptoms.

The avoidance in Social Anxiety Disorder (Social Phobia) is related to the fear of social

embarrassment. This avoidance comes in two forms: the performance anxiety form of So-

cial Anxiety Disorder concerns the avoidance of public activities (e.g., speaking, playing

music, acting, eating, urinating, writing) that can easily be performed by the individual

in the privacy of his or her own home, and can be indicated by the “Performance Only”

specifier; the generalized form includes virtually any situation that involves social inter-

action and in many cases may be virtually identical to Avoidant Personality Disorder. The

Specific Phobias probably involve some interaction between evolutionarily predeter-

mined inborn fears and the occurrence of aversive early-life experiences that reinforce

them. In Separation Anxiety Disorder, which can occur in both childhood and in adult-

hood, situations in which the person is apart from major attachment figures are avoided.

In Posttraumatic Stress Disorder and Acute Stress Disorder, the individual avoids situa-

tions that are reminiscent of the traumatic stressor (e.g., someone who resembles the as-

sailant, loud sounds that recall wartime, tremors that recall a major earthquake). Some

individuals with Obsessive-Compulsive Disorder learn that avoiding certain triggering

situations will prevent the onset of obsessions (e.g., avoidance of handshakes will help

reduce contamination obsessions). Similarly, some individuals with Illness Anxiety Dis-

order will avoid situations that they feel might jeopardize their health (e.g., visiting sick

family members) lest they trigger ruminations about having contracted a serious illness.

Many other psychiatric disorders can have avoidance as an associated feature. For ex-

ample, in psychotic disorders avoidance behavior can occur in the context of a particular

delusional system, such as when a delusional patient avoids going outside for fear that

the FBI is after him or her. Low motivation, which may be due to the anhedonia in a Major

84 DSM-5 Handbook of Differential Diagnosis

Depressive Episode or as part of the negative symptoms in Schizophrenia, may lead to

a generalized avoidance of going out of the house. Because of a sexual dysfunction, sex-

ual situations may be avoided because of anxiety about poor sexual performance. Indi-

viduals with Anorexia Nervosa and Avoidant/Restrictive Food Intake Disorder avoid

certain foods (e.g., high-calorie foods in Anorexia Nervosa, aversive foods in Avoidant/

Restrictive Food Intake Disorder), leading to clinically significant weight loss and poten-

tial malnutrition. A generalized pattern of avoidance characterizes Avoidant Personality

Disorder, which by definition has its onset by early adulthood and tends to be relatively

persistent and stable over the course of the person’s lifetime.

Finally, if the avoidance behavior is not adequately explained by any of the decision

points so far in the tree, it may still justify a DSM-5 diagnosis. If the avoidance behavior

is a symptomatic manifestation of a maladaptive response to a psychosocial stressor, a

diagnosis of Adjustment Disorder might apply. If not, and it is clinically significant and

represents a psychological or biological dysfunction in the individual (thus qualifying

as a mental disorder), a residual category would apply. DSM-5 does not include a resid-

ual category for avoidance behavior per se. The closest residual category would be

Other Specified Anxiety Disorder or Unspecified Anxiety Disorder because most likely

the avoidance is serving to prevent some sort of anxiety. The choice of category depends

on whether the clinician wishes to record the symptomatic presentation on the chart (in

which case Other Specified Anxiety Disorder would be used, followed by the specific

reason) or not (in which case Unspecified Anxiety Disorder would be used). Otherwise,

the avoidance would be considered part of the normal repertoire of human behavior and

not indicative of a mental disorder.

2.15 Decision Tree for Avoidance Behavior 85

Avoidance behavior

Avoidance of two or more types of situations (i.e., public transportation, open Y Y AGORAPHOBIA (3.5.6)spaces, enclosed spaces, standing in a line or being in a crowd, being outside of the home alone)

Avoidance of situations due to thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms

SPECIFIC PHOBIA (3.5.3)

SOCIAL ANXIETY DISORDERAvoidance of social situations Y N (3.5.4) (also considerbecause of fear of AVOIDANT PERSONALITYembarrassment DISORDER [3.17.8])

No mental disorder (contextual anxiety)

Related to embarrassment about another medical condition (e.g., Parkinson’s disease)

N Y

Y Avoidance of specific feared objects (e.g., spiders) or situations (e.g., heights, seeing blood)

SEPARATION ANXIETY DISORDER (3.5.1)

Y Avoidance of situations in which the individual is separated from major attachment figures

Avoidance of stimuli Y Y POSTTRAUMATIC STRESSassociated with a traumatic DISORDER (3.7.1)event

ACUTE STRESS DISORDER (3.7.1)

Duration of more than 1 month

N N

OBSESSIVE-COMPULSIVE DISORDER (3.6.1)

Y Avoidance of stimuli that might trigger an obsession or compulsion (e.g., contamination, knives)

SOCIAL ANXIETY DISORDER (3.5.4) (also consider AVOIDANT PERSONALITY DISORDER [3.17.8])

The fear, anxiety, or avoidance is excessive

86 DSM-5 Handbook of Differential Diagnosis

MAJOR DEPRESSIVE DISORDER (3.4.1); SCHIZOPHRENIA (3.2.1)

YAvoidance of situations related to lack of energy, anhedonia, or avolition

SEXUAL DYSFUNCTION (3.12.1)

YAvoidance of sexual situations because of concerns about sexual performance

Avoidance of foods, leading Y Y ANOREXIA NERVOSA to significant weight loss (3.10.2)

AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER (3.10.1)

Accompanied by an intense fear of gaining weight or being fat

N N

AVOIDANT PERSONALITY DISORDER (3.17.8)

Y Pattern of avoidance related to fears of negative evaluation with onset by early adulthood

Psychotic Disorder (e.g., SCHIZOPHRENIA [3.2.1]). See Delusions Tree (2.5) for differential diagnosis

Avoidance of situations related to delusional fears (e.g., not leaving home because the individual is convinced that he or she is the target of a murder plot)

ILLNESS ANXIETY DISORDER (3.9.2)

Avoidance of situations that might jeopardize health (e.g., visiting sick family members) because they will lead to preoccupation with a serious illness

Clinically significant avoidance not covered above Y Y ADJUSTMENT DISORDER that represents a (3.7.2) psychological or biological dysfunction in the individual

OTHER SPECIFIED ANXIETY DISORDER; UNSPECIFIED ANXIETY DISORDER

Occurring in response to a stressor

“Normal” avoidance behavior

2.16 Decision Tree for Trauma or Psychosocial Stressors Involved in the Etiology 87

2.16 Decision Tree for Trauma or Psychosocial Stressors Involved in the Etiology Psychosocial stressors are important in the pathogenesis of all of the DSM-5 disorders,

but their specific etiological role serves as a defining feature for only a few. Four disorders

in DSM-5 can be diagnosed only when the individual has been exposed to an extreme

stressor: Posttraumatic Stress Disorder, Acute Stress Disorder, Reactive Attachment Dis-

order, and Disinhibited Social Engagement Disorder. Posttraumatic Stress Disorder re-

quires exposure to an event that involved actual or threatened death, serious injury, or

sexual violation, and is characterized by persistent intrusion symptoms associated with

the traumatic event (e.g., intrusive memories of the event, distressing dreams, flash-

backs, distress upon exposure to cues reminiscent of the event), avoidance of stimuli as-

sociated with the event, negative alterations in cognitions and moods associated with

the event (e.g., negative beliefs about oneself and the world, distorted blame of self or

others, feelings of detachment, persistent negative state, inability to experience positive

emotions), and marked alterations in reactivity and arousal. The symptom profile of

Acute Stress Disorder closely resembles that of Posttraumatic Stress Disorder except that

the symptoms have lasted for less than 1 month. Reactive Attachment Disorder and Dis-

inhibited Social Engagement Disorder both require extended exposure to extremes of in-

sufficient care as a young child, such as frequent changes in primary caregivers or being

raised in poorly staffed institutional settings.

Although not required as part of the disorder definition, Brief Psychotic Disorder,

Dissociative Amnesia, and Conversion Disorder (Functional Neurological Symptom

Disorder) often develop in response to a severe psychosocial stressor. A diagnosis of

Brief Psychotic Disorder applies if the reaction to an extreme stressor involves the devel-

opment of psychotic symptoms lasting for less than 1 month. If the individual is unable

to recall important autobiographical information related to a traumatic experience, then

the diagnosis of Dissociative Amnesia might apply. If the person develops symptoms of

altered voluntary motor or sensory function that are incompatible with any recognized

neurological condition in response to a psychosocial stressor, then a diagnosis of Con-

version Disorder would apply. Although the development of each of these disorders is

often related to exposure to a traumatic stressor, any of these conditions can develop

without exposure to a stressor.

Many clinicians are confused about the relationship between the Adjustment Disor-

ders and the other conditions in DSM-5 that are often precipitated by the presence of a psy-

chosocial stressor. Adjustment Disorder is diagnosed for those presentations in which the

maladaptive response to the stressor causes clinically significant distress or impairment

but does not meet the threshold requirements for any specific DSM-5 disorder. In contrast,

when the criteria are met for a specific DSM-5 disorder, that disorder is diagnosed regard-

less of the presence or absence of associated stressors. For example, if a depressive reaction

occurs in response to a job loss or learning that one has a serious illness, the diagnosis is

Major Depressive Disorder if the reaction meets the full criteria for a Major Depressive Ep-

isode. A less severe, but nonetheless clinically significant, depressive reaction might in-

stead be diagnosed as Adjustment Disorder With Depressed Mood.

88 DSM-5 Handbook of Differential Diagnosis

Finally, some individuals, in response to the loss of a loved one, develop a persistent,

prolonged, and abnormal grief response that has been given the name Persistent Com-

plex Bereavement Disorder (see “Conditions for Further Study” in DSM-5 Section III). It

involves the persistence for at least 12 months of symptoms such as longing or yearning

for the deceased, intense sorrow and pain, and preoccupation with the deceased and the

circumstances of the death. Although there are undoubtedly individuals suffering from

this syndrome who would benefit from treatment, the developers of DSM-5 felt that in-

sufficient data exist regarding the specifics of the definition to warrant its inclusion in

the main body of DSM-5. Clinicians wishing to make this diagnosis must use Other

Specified Trauma- and Stressor-Related Disorder, and specify Persistent Complex Be-

reavement Disorder.

2.16 Decision Tree for Trauma or Psychosocial Stressors Involved in the Etiology 89

Trauma or psychosocial stressors involved in the

etiology

Exposure to a traumatic Ystressor (e.g., life-threatening

situation)

Response characterized by intrusion symptoms, avoidance of stimuli associated with the event, negative alterations in cognitions and mood, and alterations in arousal and activity

BRIEF PSYCHOTIC DISORDER (3.2.4) WITH MARKED STRESSOR

Y POSTTRAUMATIC STRESS DISORDER (3.7.1)

ACUTE STRESS DISORDER (3.7.1)

Duration of at least 1 month

YPsychotic symptoms lasted less than 1 month in response to marked stressor

DISSOCIATIVE AMNESIA (3.8.1)

YInability to recall important autobiographical information after exposure to a stressor

History of extremes of insufficient care, such as persistent social neglect or deprivation, repeated Y Y REACTIVE ATTACHMENT changes of primary caregiver, DISORDER or being reared in settings that severely limited opportunities to form selective attachments

Pattern of inhibited emotionally withdrawn behavior toward adult caregivers and persistent social and emotional disturbance (e.g., minimal emotional responsiveness; unexplained irritability, sadness, or fearfulness)

Y DISINHIBITED SOCIAL ENGAGEMENT DISORDER

Pattern of reduced reticence in approaching unfamiliar adults, overly familiar verbal or physical behavior, and a willingness to go off with unfamiliar adults

90 DSM-5 Handbook of Differential Diagnosis

Specified mental disorder (e.g., Major Depressive Disorder)

Y Symptoms in response to a stressor that meet criteria for a specific mental disorder (other than Adjustment Disorder)

ADJUSTMENT DISORDER (3.7.2)

YReaction is maladaptive and in excess of what would be expected

Development of symptoms of Y CONVERSION DISORDERaltered voluntary motor or

(3.9.3) WITHsensory function after PSYCHOLOGICAL STRESSORexposure to a stressor

Y Section III: Persistent Complex Bereavement Disorder

Persistent yearning/ longing for the deceased, intense sorrow and emotional pain, preoccupation with the deceased or the circumstances of the death, lasting at least 12 months

Stressor is the death of a loved one

“Normal” reaction to stressor

2.17 Decision Tree for Somatic Complaints or Illness/Appearance Anxiety 91

2.17 Decision Tree for Somatic Complaints or Illness/Appearance Anxiety When a patient presents with distressing somatic complaints, the focus of the differen-

tial diagnosis is usually on which general medical condition best explains the somatic

complaints. However, when the somatic complaints are accompanied by abnormal

thoughts, feelings, and behaviors, the presence of a Somatic Symptom Disorder or other

mental disorder should be considered.

Physical complaints that are feigned by the patient warrant either the mental disor-

der diagnosis Factitious Disorder or the nondisordered condition known as Malinger-

ing. The differentiation between these two conditions depends on a consideration of the

context in which the somatic symptoms developed. If the feigning of the symptoms oc-

curs in the absence of obvious external rewards, the diagnosis is Factitious Disorder,

whereas feigning in settings in which the presence of the somatic symptoms provides an

obvious financial or other benefit to the patient suggests Malingering.

Somatic complaints can occur as a manifestation of a wide variety of psychiatric con-

ditions. Substance Intoxication or Substance Withdrawal is typically manifested as a

characteristic syndrome of somatic and behavioral symptoms. States of high anxiety are

typically associated with a variety of somatic complaints. Consequently, somatic com-

plaints are commonly associated with many of the Anxiety Disorders. For some Anxiety

Disorders, such as Panic Disorder and Generalized Anxiety Disorder, the distressing so-

matic complaints characteristic of these disorders may be the reason for the patient to

seek treatment. In other cases, the somatic complaints are related to the manifestations

of a psychotic disorder (e.g., somatic delusions) or an Obsessive-Compulsive and Re-

lated Disorder, such as the preoccupation with an imagined physical defect in Body Dys-

morphic Disorder.

When the somatic complaints themselves are the patient’s central focus, a diagnosis

of one of the DSM-5 Somatic Symptom and Related Disorders might be most appropri-

ate. Patients presenting with neurological symptoms such as paralysis or seizures

which, upon examination and laboratory investigation, do not conform to a pattern

characteristic of a known neurological or other medical condition, can be diagnosed

with Conversion Disorder (Functional Neurological Symptom Disorder). Other types of

somatic complaints, when accompanied by disproportionate thoughts about the seri-

ousness of the illness, persistently high levels of anxiety about health or about symp-

toms, or the devotion of excessive time and energy to symptoms or health concerns, may

warrant a diagnosis of Somatic Symptom Disorder. In contrast to the DSM-IV Somato-

form Disorder diagnoses in which the somatic complaints were by definition medically

unexplained, a diagnosis of Somatic Symptom Disorder in DSM-5 can be given to pa-

tients with a bona fide medical illness. The DSM-5 diagnosis depends on the presence of

cognitions, feelings, and behaviors that are, in the clinician’s judgment, “excessive”

given the nature of the general medical condition. To avoid pathologizing appropriate

reactions to serious or disabling general medical conditions, this diagnosis should be

used very cautiously in medically ill individuals, being reserved only for cases in which

the person’s reactions to having the medical illness are clearly extreme and maladaptive.

92 DSM-5 Handbook of Differential Diagnosis

Somatic complaints or illness\

appearance anxiety

Physical symptoms Y Y FACTITIOUSare intentionally DISORDER (3.9.5)produced or feigned

The deceptive behavior is evident even in the absence of obvious external rewards

N N

MALINGERING

SUBSTANCE Due to the direct INTOXICATION; physiological effects SUBSTANCE of a substance WITHDRAWAL; (including medication) OTHER ADVERSE

EFFECT OF MEDICATION

Associated with Psychotic Disorder delusions involving (see Delusions Tree bodily functions or [2.5] for differential sensations diagnosis)

Development of a symptom or deficit affecting voluntary motor or sensory CONVERSION function that is not DISORDER (3.9.3) better explained by a neurological or other medical condition or mental disorder

Preoccupation with imagined defects or

BODY DYSMORPHICflaws in physical DISORDER (3.6.2)appearance that are

not observable to others

Occurring as part of PANIC ATTACK (seean abrupt surge of Panic Attacks Treeintense fear or [2.14] for differentialdiscomfort that diagnosis)reaches a peak within minutes

2.17 Decision Tree for Somatic Complaints or Illness/Appearance Anxiety 93

SOMATICHigh level of anxiety Y Y SYMPTOMabout health DISORDER (3.9.1)

Accompanied by one or more somatic symptoms that are distressing or that disrupt everyday lifeN

Somatic symptoms (e.g., dry mouth, palpitations) accompanying anxiety that is part of an Anxiety Disorder

Y Anxiety Disorders (see Anxiety Tree [2.13] for differential diagnosis)

Psychotic DisorderPreoccupation with Y (see Delusions Treehaving or acquiring a [2.5] for differentialserious illness diagnosis)

The belief that one has a serious illness is held with delusional intensity

ILLNESS ANXIETY DISORDER (3.9.2)

One or more somatic Y Y SOMATICsymptoms that are SYMPTOMdistressing or disrupt DISORDER (3.9.1)everyday life

Accompanied by disproportionate thoughts about seriousness of illness or excessive time and energy devoted to symptoms

N N

Clinically significant somatic complaints that interfere with

Y Yfunctioning and ADJUSTMENT represent a DISORDER (3.7.2) psychological dysfunction in the individual

Occurring in response to a psychosocial stressor

PSYCHOLOGICAL A general medical condition is

Y FACTORS present, and psychological AFFECTING OTHER factors adversely affect the MEDICAL medical condition CONDITION (3.9.4)

General medical condition (no mental disorder diagnosis)

OTHER SPECIFIED SOMATIC SYMPTOM AND RELATED DISORDER; UNSPECIFIED SOMATIC SYMPTOM AND RELATED DISORDER

“Normal” everyday aches and pains

94 DSM-5 Handbook of Differential Diagnosis

2.18 Decision Tree for Appetite Changes or Unusual Eating Behavior This decision tree covers several disparate symptoms associated with eating: weight and

appetite changes, binge eating, rumination, and pica. Because changes in appetite and

weight are commonly caused by general medical conditions, your first thought should

always be to rule out cancer, endocrine disturbances, chronic infections, and other ill-

nesses before assuming that the symptoms are psychiatric. This is especially the case

when weight loss or gain is of major proportion and occurs in conjunction with other

physical symptoms. Note that in the assessment of an etiological general medical condi-

tion in the branch of the decision tree covering the differential diagnosis of weight gain,

obesity is listed as one of the possible etiological general medical conditions. This re-

flects the fact that obesity (defined as a body mass index [BMI] 30) by itself is consid-

ered not a mental disorder but instead a general medical condition. A BMI of 30 would

be considered a component of a psychiatric disorder only when it is a consequence of a

disturbed eating pattern (such as in Binge-Eating Disorder).

Changes in appetite and weight (in both directions) are also frequently caused by the

use of certain drugs of abuse (especially stimulants and cannabis) and certain prescribed

medications. In fact, one of the major reasons for noncompliance with many of the psy-

chotropic medications (e.g., selective serotonin reuptake inhibitors, serotonin-norepi-

nephrine reuptake inhibitors, tricyclic antidepressants, lithium, divalproex, monoamine

oxidase inhibitors, atypical antipsychotics) is the fear of weight gain that commonly ac-

companies their use. Attributing changes in weight can be difficult precisely because

many of the conditions treated by these psychotropic medications are themselves asso-

ciated with changes in weight independent of the use of medication. For example, if a

depressed patient gains weight while being treated with an antidepressant, this could

be a side effect of the antidepressant, a characteristic symptom of the depression, or a

desirable treatment effect (e.g., improved appetite in someone previously experiencing

loss of appetite).

Because changes in appetite and gains or losses in weight are common in many dif-

ferent psychiatric disorders, they are relatively nonspecific on their own in providing

clues to the differential diagnosis. Therefore, you must rely on the temporal relationship

with the other presenting symptoms in deciding which is the most appropriate explana-

tion for the change in appetite or weight. For example, is the individual not eating be-

cause of a delusion that the food is poisoned (as in Delusional Disorder), because of a

feeling of being unworthy or a loss of pleasure in eating (as in Major Depressive Epi-

sode), or because of a diminished appetite or being “too busy” (as in Manic Episode)?

In some individuals, weight loss or weight gain is most often associated with a spe-

cific presentation of severe body image distortions and/or binge eating. In Anorexia

Nervosa, the pathological fear of being (or becoming) fat results in an often dangerously

low weight. Some individuals with Anorexia Nervosa engage in binge eating and purg-

ing behavior, whereas others achieve low weight exclusively through fasting and exces-

sive exercise. In contrast to those with Anorexia Nervosa, individuals with Bulimia

Nervosa have normal or above normal weight. They engage in cycles of binge eating

compensated for by the use of inappropriate methods of counteracting the effects of

2.18 Decision Tree for Appetite Changes or Unusual Eating Behavior 95

their excessive caloric intake (e.g., self-induced vomiting, misuse of laxatives, fasting,

excessive exercise). Individuals with Binge-Eating Disorder, however, engage in regular

binge eating (i.e., at least once per week for at least 3 months) without employing any

inappropriate compensatory mechanisms to keep from gaining weight. Thus, these in-

dividuals are typically overweight. Some individuals have a significant weight loss (or

a failure to make expected weight gain) in the absence of a fear of gaining weight or be-

ing fat. Instead, their weight loss occurs as a result of lack of interest in eating, avoidance

of food based on extreme sensitivity to its sensory characteristics (e.g., appearance, color,

texture, temperature, taste), or anticipation of aversive consequences to eating such as

choking. Such individuals may be diagnosed with Avoidant/Restrictive Food Intake

Disorder.

The decision tree also contains several eating disturbances that occur primarily in in-

fants, young children, or individuals with Intellectual Disability (Intellectual Develop-

mental Disorder). Pica is the developmentally inappropriate and persistent eating of

nonnutritive substances (e.g., paint chips, string, dirt, animal droppings). Rumination

Disorder is the repeated regurgitation and rechewing of food. The previously discussed

category Avoidant/Restrictive Food Intake Disorder is also applicable to infants or chil-

dren with severe weight loss (or failure of weight gain) that usually results from a com-

bination of a difficult-to-feed child and an inexperienced caretaker.

Clinically significant changes in weight and pathological eating behavior that are not

covered so far in the decision tree could occur as a response to a psychosocial stressor,

in which case a diagnosis of Adjustment Disorder may be appropriate. Other clinically

significant Eating Disorders that do not meet criteria for one of the specific DSM-5 Eat-

ing Disorder categories (e.g., recurrent purging without binge eating) would be diag-

nosed using a residual category, the choice depending on whether the clinician wishes

to record the symptomatic presentation on the chart (in which case Other Specified

Feeding or Eating Disorder would be used, followed by the specific reason) or not (in

which case Unspecified Feeding or Eating Disorder would be used). Finally, it is impor-

tant to remember that concerns about body appearance, gaining and losing weight, and

fad dieting are fairly ubiquitous aspects of life. A diagnosis of Other Specified or Un-

specified Feeding or Eating Disorder should be given only if the eating disturbance rep-

resents a psychological or biological dysfunction in the individual.

96 DSM-5 Handbook of Differential Diagnosis

(e.g., binge eating, eating nonnutritive substances)

Decreased appetite, weight Yloss, or failure to make expected weight gains

Fully accounted for by the physiological effects of a general medical condition (e.g., cancer)

Y SUBSTANCE-RELATED DISORDER; OTHER ADVERSE EFFECT OF MEDICATION

Fully accounted for by substance use (e.g., cocaine) or medication side effect

Y Etiological general medical condition

Psychotic Disorder (e.g., Y SCHIZOPHRENIA [3.2.1]).

See Delusions Tree (2.5) or Hallucinations Tree (2.6) for differential diagnosis

Not eating in response to a delusion (e.g., fear that food is poisoned) or hallucination (e.g., command hallucination not to eat)

YOccurring in the context of depressive symptoms

Y Occurring in the context of a Manic Episode, secondary to increase in activity and neglect of regular mealtimes

Y ANOREXIA NERVOSA (3.10.2)

Accompanied by an intense fear of gaining weight or being fat

Y RUMINATION DISORDER

Associated with repeated regurgitation of food, which may be rechewed, reswallowed, or spit out

Appetite changes or unusual eating behavior

MAJOR DEPRESSIVE EPISODE in MAJOR DEPRESSIVE DISORDER (3.4.1), BIPOLAR I (3.3.1) or BIPOLAR II (3.3.2) DISORDER, or SCHIZOAFFECTIVE DISORDER (3.2.2); PERSISTENT DEPRESSIVE DISORDER (3.4.2)

MANIC EPISODE in BIPOLAR I DISORDER (3.3.1) or SCHIZOAFFECTIVE DISORDER (3.2.2)

2.18 Decision Tree for Appetite Changes or Unusual Eating Behavior 97

Increased appetite or weight Y gain (not due to binge eating)

Fully accounted for by the physiological effects of a general medical condition (e.g., hypothyroidism) or obesityN

Y SUBSTANCE-RELATED DISORDER; OTHER ADVERSE EFFECT OF MEDICATION

Fully accounted for by substance use (e.g., Cannabis Intoxication, Cocaine Withdrawal) or medication side effects

Y Etiological general medical condition

MAJOR DEPRESSIVE EPISODE in MAJOR DEPRESSIVE DISORDER (3.4.1), BIPOLAR IY (3.3.1) or BIPOLAR II (3.3.2) DISORDER, or SCHIZOAFFECTIVE DISORDER (3.2.2); PERSISTENT DEPRESSIVE DISORDER (3.4.2)

Occurring in the context of depressive symptoms

Y ANOREXIA NERVOSA (3.10.2)

Accompanied by an abnormally low body weight

BULIMIAY NERVOSA (3.10.3)

Accompanied by regular, inappropriate, compensatory behaviors (e.g., purging)

Occurring in association with a lack of interest in eating, the avoidance of food based on its sensory characteristics, or concern about aversive consequences of eating (e.g., choking)

Y AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER (3.10.1)

Binge eating

Recurrent and frequent binge eating

98 DSM-5 Handbook of Differential Diagnosis

Repeated regurgitation of food, which may be Y rechewed, reswallowed, or spit out

Occurring as part of a pattern of impulsivity, mood dysregulation, and identity disturbance with onset by early adulthood

RUMINATION DISORDER

Y BORDERLINE PERSONALITY DISORDER (3.17.5)

Y ADJUSTMENT DISORDER (3.7.2)

Occurring as a maladaptive response to a stressor

BINGE-EATINGY DISORDER (3.10.4)

Binge eating accompanied by symptoms such as eating until uncomfortably full or when not hungry, eating alone because of embarrassment, and feeling disgusted, depressed, or guilty

Clinically significant changes in weight or pathological eating behavior not covered above (e.g., purging without binge eating) that represent a psychological or biological dysfunction in the individual

Persistent eating of nonnutritive, nonfood Y substances

PICA

“Normal” variations in eating or weight (e.g., fad dieting)

OTHER SPECIFIED FEEDING OR EATING DISORDER; UNSPECIFIED FEEDING OR EATING DISORDER

2.19 Decision Tree for Insomnia 99

2.19 Decision Tree for Insomnia Insomnia is defined in DSM-5 as dissatisfaction with sleep quantity or quality with com-

plaints of difficulty initiating or maintaining sleep. Drugs of abuse and many prescribed

and over-the-counter medications have insomnia as a significant side effect. For drugs of

abuse, typically a diagnosis of Substance Intoxication or Substance Withdrawal will suf-

fice to cover the symptoms of insomnia. A diagnosis of Substance/Medication-Induced

Sleep Disorder, Insomnia Type, should be considered only if the insomnia predominates

in the clinical picture and is sufficiently severe to warrant clinical attention. A diagnosis

of Substance/Medication-Induced Sleep Disorder can also be given for clinically notable

insomnia related to medications.

You must then rule out other more specific sleep disorders as the cause of the insom-

nia because the manifestations of the other sleep disorders can interrupt nighttime sleep.

Narcolepsy is characterized by recurrent periods of an irrepressible need for sleep ac-

companied by cataplexy (i.e., brief periods of sudden bilateral loss of muscle tone pre-

cipitated by laughter), hypocretin deficiency (as measured in cerebrospinal fluid), or

characteristic polysomnographic findings (i.e., rapid eye movement [REM] sleep latency

of 15 minutes or less, or multiple sleep latency test with mean sleep latency of 8 minutes

or less and two or more sleep-onset REM periods). DSM-5 includes three distinct disor-

ders under the general rubric of Breathing-Related Sleep Disorders, each of which can

cause insomnia because of middle-of-the-night awakenings. Obstructive Sleep Apnea

Hypopnea, which is the most common form of Breathing-Related Sleep Disorder, is

characterized by repeated episodes of upper airway obstruction during sleep. Central

Sleep Apnea is characterized by repeated episodes of apneas and hypopneas during

sleep caused by variability in respiratory effort. Sleep-Related Hypoventilation is char-

acterized by episodes of decreased ventilation during sleep associated with elevated

CO2 levels. Non–Rapid Eye Movement Sleep Arousal Disorder is characterized by re-

current episodes of incomplete awakening from sleep, usually during the first third of

the night, which can take the form of Sleep Terrors or Sleepwalking. Nightmare Disorder

and REM Sleep Behavior Disorder describe problematic phenomena occurring during

REM sleep: extended, extremely dysphoric, and well-remembered dreams in the case of

Nightmare Disorder, and repeated arousals during REM sleep with vocalizations or

complex motor behavior in the case of REM Sleep Behavior Disorder. Restless Legs Syn-

drome is characterized by recurrent or persistent urges to move the legs in response to

unpleasant sensations. Circadian Rhythm Sleep-Wake Disorder is characterized by a

mismatch between the individual’s schedule and natural sleep-wake patterns. Insomnia

that occurs exclusively during, and is better explained by, any of these sleep disorders

does not warrant a separate diagnosis of Insomnia Disorder. If the severity of the insom-

nia exceeds what would be expected from another sleep disorder or occurs at times

other than when that sleep disorder is present, a comorbid diagnosis of Insomnia Disor-

der may be appropriate.

The next step in the assessment is to consider whether the insomnia is actually a

symptom of another mental disorder. A number of mental disorders, such as Major De-

pressive Disorder, may include prominent symptoms of insomnia. If the insomnia is ad-

equately explained by the mental disorder, only the mental disorder is diagnosed and

100 DSM-5 Handbook of Differential Diagnosis

an additional diagnosis of Insomnia Disorder is not made. If, however, the insomnia pre-

dominates in the clinical picture and warrants clinical attention, then a comorbid diag-

nosis of Insomnia Disorder may be appropriate. Similarly, a number of general medical

conditions, such as back pain, may significantly disrupt sleep. An additional diagnosis

of Insomnia Disorder may also be appropriate in such cases if the insomnia is not ade-

quately explained by the general medical condition.

Some difficulty falling asleep (or maintaining sleep) is to be expected in everyone’s

life, especially in association with psychosocial stressors and as part of advancing age.

Insomnia should be considered as evidence of a mental disorder only if the insomnia is

severe, is prolonged, and results in clinically significant distress or impairment.

2.19 Decision Tree for Insomnia 101

Insomnia

Due to the physiological SUBSTANCE/MEDICATION-Y Y effects of a substance INDUCED SLEEP DISORDER, (including medication) INSOMNIA TYPE

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Insomnia predominates in the clinical picture and is sufficiently severe to warrant clinical attention

Recurrent periods of an irrepressible need to sleep accompanied by cataplexy,

Y Yhypocretin deficiency, NARCOLEPSYcharacteristic nocturnal polysomnography findings, or characteristic multiple sleep latency findings

Insomnia occurs exclusively during, and is better explained by the diagnosis of, Narcolepsy

N N

BREATHING-RELATED SLEEP DISORDER (i.e.,

Y Y OBSTRUCTIVE SLEEP APNEA HYPOPNEA, CENTRAL SLEEP APNEA, SLEEP-RELATED HYPOVENTILATION)

Insomnia occurs exclusively during, and is better explained by the diagnosis of, a Breathing- Related Sleep Disorder

Occurring as a result of Y Y NON–RAPID EYE Sleepwalking or Sleep Terrors MOVEMENT SLEEP AROUSAL

DISORDER

Insomnia occurs exclusively during, and is better explained by the diagnosis of, Non–Rapid Eye Movement Sleep Arousal Disorder

Occurring as a result of repeated awakenings Y Y because of extended, NIGHTMARE DISORDER extremely dysphoric, and well-remembered dreams

Insomnia occurs exclusively during, and is better explained by the diagnosis of, Nightmare Disorder

Accompanied by evidence on polysomnography of five or more obstructive apneas or hypopneas per hour of sleep, five or more central sleep apneas per hour of sleep, or decreased respiration associated with elevated CO2 levels

102 DSM-5 Handbook of Differential Diagnosis

Repeated episodes of arousals during sleep that arise during rapid eye Y Y RAPID EYE MOVEMENT movement sleep with SLEEP BEHAVIOR DISORDER vocalizations or complex motor behaviors

Insomnia occurs exclusively during, and is better explained by the diagnosis of, Rapid Eye Movement Sleep Behavior Disorder

Occurring as a result of urges Y Yto move the legs in response RESTLESS LEGS SYNDROME to unpleasant sensations

Insomnia occurs exclusively during, and is better explained by the diagnosis of, Restless Legs Syndrome

N N

CIRCADIAN RHYTHM SLEEP- WAKE DISORDER (i.e., DELAYED SLEEP PHASE TYPE,Occurring as a result of a

Y Y ADVANCED SLEEP PHASEmismatch between the TYPE, IRREGULAR SLEEP-individual’s schedule and WAKE TYPE, NON-24-HOURnatural sleep-wake pattern SLEEP-WAKE TYPE, SHIFT WORK TYPE, UNSPECIFIED TYPE)

Insomnia occurs exclusively during, and is better explained by the diagnosis of, Circadian Rhythm Sleep Disorder

Presence of a comorbid mental disorder Y Y Mental Disorder associatedcharacterized by insomnia

with insomnia(e.g., Major Depressive Disorder)

Insomnia is adequately explained by the mental disorder

N N

Presence of a comorbid general medical condition Y Y General medical condition associated with insomnia associated with insomnia (e.g., back pain)

Insomnia is adequately explained by the general medical condition

N N

Lack of adequate opportunity Y for sleep

No sleep disorder

2.19 Decision Tree for Insomnia 103

Causes clinically significant distress or impairment and Y Y ADJUSTMENT DISORDERrepresents a psychological or (3.7.2)biological dysfunction in the individual

OTHER SPECIFIED INSOMNIA DISORDER; UNSPECIFIFIED INSOMNIA DISORDER

Insomnia occurs as a maladaptive response to a psychosocial stressor

Occurring at least 3 nights Y INSOMNIA DISORDERper week for at least 3 (3.11.1)months

N N

“Normal” need for sleep (e.g., “short sleeper”)

104 DSM-5 Handbook of Differential Diagnosis

2.20 Decision Tree for Hypersomnolence Hypersomnolence is a broad diagnostic term and includes symptoms of excessive quan-

tity of sleep (e.g., extended nighttime sleep or involuntary daytime naps), deteriorated

quality of wakefulness (e.g., difficulty awakening or inability to remain awake when re-

quired), and sleep inertia (i.e., a period of impaired performance and reduced vigilance

upon awakening). A diagnosis of Hypersomnolence Disorder should be considered

only if the person has been regularly getting adequate amounts of sleep—individuals

would not qualify for this diagnosis if they are sleep deprived either because of insom-

nia or to accommodate their overscheduled lives.

Drugs of abuse and many prescribed and over-the-counter medications have day-

time drowsiness as a significant side effect. For drugs of abuse, typically a diagnosis of

Substance Intoxication or Substance Withdrawal will suffice to cover the hypersomno-

lence. A diagnosis of Substance-Induced Sleep Disorder, Daytime Sleepiness Type, should

be considered only if the hypersomnolence predominates in the clinical picture and is

sufficiently severe to warrant clinical attention. A diagnosis of Medication-Induced Sleep

Disorder can also be given for clinically notable hypersomnolence related to medications.

You must then rule out other specific sleep disorders as the cause of the hypersomno-

lence, given that daytime sleepiness is a characteristic feature of some specific sleep disor-

ders (e.g., Narcolepsy) or might be a consequence of the disturbance in nighttime sleep

caused by the other sleep disorder (e.g., Nightmare Disorder). Narcolepsy is characterized

by recurrent periods of an irrepressible need for sleep accompanied by cataplexy (i.e., brief

periods of sudden bilateral loss of muscle tone precipitated by laughter), hypocretin defi-

ciency (as measured in cerebrospinal fluid), or characteristic polysomnographic findings

(i.e., rapid eye movement [REM] sleep latency of 15 minutes or less, or multiple sleep la-

tency test with mean sleep latency of 8 minutes or less and two or more sleep-onset REM

periods). DSM-5 includes three distinct disorders under the general rubric of Breathing-

Related Sleep Disorders, each of which can cause daytime fatigue. Obstructive Sleep Ap-

nea Hypopnea, which is the most common form of Breathing-Related Sleep Disorder, is

characterized by repeated episodes of upper airway obstruction during sleep. Central

Sleep Apnea is characterized by repeated episodes of apneas and hypopneas during sleep

caused by variability in respiratory effort. Sleep-Related Hypoventilation is characterized

by episodes of decreased ventilation during sleep associated with elevated CO2 levels.

Non–Rapid Eye Movement Sleep Arousal Disorder is characterized by recurrent epi-

sodes of incomplete awakening from sleep, usually during the first third of the night,

which can take the form of Sleep Terrors or Sleepwalking. Nightmare Disorder and REM

Sleep Behavior Disorder describe problematic phenomena occurring during REM sleep:

extended extremely dysphoric and well-remembered dreams in the case of Nightmare

Disorder, and repeated arousals during REM sleep with vocalizations or complex motor

behavior in the case of REM Sleep Behavior Disorder. Restless Legs Syndrome is charac-

terized by recurrent or persistent urges to move the legs in response to unpleasant sensa-

tions. Circadian Rhythm Sleep-Wake Disorder is characterized by a mismatch between the

individual’s schedule and natural sleep-wake patterns. Finally, Insomnia Disorder is char-

acterized by a predominant complaint of dissatisfaction with sleep quality or quantity, as-

sociated with difficulty falling asleep, maintaining sleep, or early-morning awakening.

2.20 Decision Tree for Hypersomnolence 105

Hypersomnolence that occurs exclusively during, and is better explained by, any of these

sleep disorders does not warrant a separate diagnosis of Hypersomnolence Disorder. If

the severity of the hypersomnolence exceeds what would be expected from another sleep

disorder or occurs at times other than when that sleep disorder is present, a comorbid di-

agnosis of Hypersomnolence Disorder may be appropriate.

The next step in the assessment is to consider whether the hypersomnolence is actu-

ally a symptom of another mental disorder. A number of mental disorders may include

prominent symptoms of hypersomnolence, especially in Major Depressive Episodes

With Atypical Features, as seen in Major Depressive Disorder, Bipolar I Disorder, and Bi-

polar II Disorder. If the daytime fatigue is adequately explained by the mental disorder,

only the mental disorder is diagnosed and an additional diagnosis of Hypersomnolence

Disorder is not made. If, however, the hypersomnolence predominates in the clinical

picture and warrants clinical attention, then a comorbid diagnosis of Hypersomnolence

Disorder may be appropriate. Similarly, a number of general medical conditions, such

as mononucleosis, may be characterized by daytime fatigue. An additional diagnosis of

Hypersomnolence Disorder may also be appropriate in such cases if the degree of hy-

persomnolence is not adequately explained by the general medical condition.

106 DSM-5 Handbook of Differential Diagnosis

Hypersomnolence

Due to the physiological SUBSTANCE/MEDICATION-Y Y effects of a substance INDUCED SLEEP DISORDER, (including medication) DAYTIME SLEEPINESS TYPE

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL

Hypersomnolence predominates in the clinical picture and is sufficiently severe to warrant clinical attention

Recurrent periods of an irrepressible need to sleep accompanied by cataplexy, hypocretin deficiency, Y Y

NARCOLEPSYcharacteristic nocturnal polysomnography findings, or characteristic multiple sleep latency findings

Hypersomnolence occurs exclusively during, and is better explained by the diagnosis of, Narcolepsy

N N

Accompanied by evidence on polysomnography of five or BREATHING-RELATED SLEEPmore obstructive apneas or DISORDER (i.e.,hypopneas per hour of sleep, Y Y OBSTRUCTIVE SLEEP APNEAfive or more central sleep HYPOPNEA, CENTRAL SLEEPapneas per hour of sleep, or APNEA, SLEEP-RELATEDdecreased respiration HYPOVENTILATION)associated with elevated CO2 levels

Hypersomnolence occurs exclusively during, and is better explained by the diagnosis of, a Breathing- Related Sleep Disorder

Daytime fatigue as a result of Y Y NON–RAPID EYE Sleepwalking or Sleep Terrors MOVEMENT SLEEP AROUSAL

DISORDER

Hypersomnolence occurs exclusively during, and is better explained by the diagnosis of, Non–Rapid Eye Movement Sleep Arousal Disorder

Daytime fatigue as a result of repeated occurrences of Y Y extended, extremely NIGHTMARE DISORDER dysphoric, and well- remembered dreams

Hypersomnolence occurs exclusively during, and is better explained by the diagnosis of, Nightmare Disorder

N N

2.20 Decision Tree for Hypersomnolence 107

Daytime fatigue as a result of repeated episodes of arousals during sleep that arise during Y Y RAPID EYE MOVEMENT rapid eye movement sleep SLEEP BEHAVIOR DISORDER with vocalizations or complex motor behaviors

Hypersomnolence occurs exclusively during, and is better explained by the diagnosis of, Rapid Eye Movement Sleep Behavior Disorder

Daytime fatigue as a result of urges to move the legs in Y Y RESTLESS LEGS SYNDROME response to unpleasant sensations

Hypersomnolence occurs exclusively during, and is better explained by the diagnosis of, Restless Legs Syndrome

N N

CIRCADIAN RHYTHM SLEEP- WAKE DISORDER (i.e., DELAYED SLEEP PHASE TYPE,Daytime fatigue related to a

Y Y ADVANCED SLEEP PHASEmismatch between the TYPE, IRREGULAR SLEEP-individual’s schedule and WAKE TYPE, NON-24-HOURnatural sleep-wake pattern SLEEP-WAKE TYPE, SHIFT WORK TYPE, UNSPECIFIED TYPE)

Hypersomnolence occurs exclusively during, and is better explained by the diagnosis of, Circadian Rhythm Sleep-Wake Disorder

Predominant complaint is dissatisfaction with quantity or quality of sleep associated Y Y INSOMNIA DISORDER with difficulty initiating or (3.11.1) maintaining sleep or early- morning awakening

Hypersomnolence occurs exclusively during, and is better explained by the diagnosis of, Insomnia Disorder

N N

Presence of a comorbid mental disorder characterized Y Y Mental Disorder associated by daytime fatigue (e.g., with hypersomnolence Major Depressive Disorder)

Hypersomnolence is adequately explained by the mental disorder

N N

108 DSM-5 Handbook of Differential Diagnosis

Presence of a comorbid Y Y General medical conditiongeneral medical condition

associated withcharacterized by daytime hypersomnolencefatigue (e.g., mononucleosis)

Hypersomnolence is adequately explained by the general medical condition

N N

Due to “voluntary” sleep Y deprivation

No sleep disorder

Occurring at least three times Y HYPERSOMNOLENCEper week for at least DISORDER (3.11.2)3 months

Causes clinically significant OTHER SPECIFIED distress or impairment and Y HYPERSOMNOLENCE represents a psychological or biological dysfunction in the individual

DISORDER; UNSPECIFIED HYPERSOMNOLENCE DISORDER

“Normal” need for sleep (e.g., “long sleeper”)

2.21 Decision Tree for Sexual Dysfunction in a Female 109

2.21 Decision Tree for Sexual Dysfunction in a Female The major difficulty in evaluating sexual dysfunctions in both women and men is that

there are no accepted guidelines for determining what is “normal” sexual functioning.

The threshold for normal sexual functioning varies with the woman’s age and prior sex-

ual experience, the availability and novelty of partners, and the expectations and stan-

dards characteristic of the woman’s cultural, ethnic, or religious group. Successful

arousal and orgasm require a level of sexual stimulation that is adequate in focus, inten-

sity, and duration. A diagnosis of Female Sexual Interest/Arousal Disorder or Female Or-

gasmic Disorder therefore requires a clinical judgment that the woman has experienced

adequate stimulation. Moreover, occasional sexual dysfunction is an inherent part of hu-

man sexuality and is not indicative of a disorder unless it is persistent (i.e., lasting for at

least 6 months) or recurrent and results in marked distress or interpersonal difficulty.

Once the clinical judgment has been made that the sexual dysfunction is clinically

significant, the next task is to determine its underlying etiology. The possible etiologies

include psychological factors, general medical conditions, the side effects of many pre-

scribed medications, and the consequence of drug abuse. This evaluation can be difficult

because very often more than one etiology contributes to the sexual dysfunction. Before

deciding that a sexual dysfunction is mediated entirely by psychological factors, you

need to consider the possible contribution of a general medical condition or substance

(including medication side effects), especially because these etiologies often have spe-

cific treatment implications (e.g., discontinuation of the offending medication). Also,

you need to remember that the identification of a specific etiological general medical

condition, medication, or drug of abuse does not negate the important contribution of

psychological factors to the etiology of the sexual dysfunction.

Sexual problems are also commonly associated with a number of mental disorders

(e.g., Depressive Disorders, Anxiety Disorders, Schizophrenia Spectrum and Other Psy-

chotic Disorders). An additional diagnosis of a sexual dysfunction is not given if the sex-

ual problems are better explained by the mental disorder. For example, low sexual desire

occurring only during a Major Depressive Episode would not justify a separate diagno-

sis of Female Sexual Interest/Arousal Disorder. Both diagnoses can be given only if the

low sexual desire is judged to be independent of the depressive disorder (i.e., it precedes

the onset of the Major Depressive Episode or persists long after the depression has re-

mitted). Similarly, sexual dysfunction that is better explained as a consequence of severe

relationship distress would be diagnosed as a relational problem rather than a sexual

dysfunction unless evidence demonstrated that the sexual dysfunction occurred inde-

pendently of the relational problem.

After substances, general medical conditions, and relationship distress have been

considered and ruled out, the focus then goes to the primary sexual dysfunctions them-

selves. In DSM-5, the female version of the DSM-IV-TR category Hypoactive Sexual De-

sire Disorder and the DSM-IV-TR category Female Sexual Arousal Disorder have been

combined into a single diagnostic category called Female Sexual Interest/Arousal Dis-

order, reflecting evidence that sexual desire and sexual arousal are often not separable

concepts in woman. Thus, Female Sexual Interest/Arousal Disorder covers a wide vari-

110 DSM-5 Handbook of Differential Diagnosis

ety of problems, including reduced interest in sexual activity, reduced frequency of

erotic thoughts or fantasies, reduced frequency of initiation of sexual activity, reduced

sexual excitement or pleasure during sexual activity, reduced interest or arousal in re-

sponse to erotic cues, and reduced genital and nongenital sensations during sexual ac-

tivity. Female Orgasmic Disorder includes marked delay in achieving orgasm, marked

infrequency or absence of orgasm, or markedly reduced intensity of orgasmic sensa-

tions. The DSM-5 category Genito-Pelvic Pain/Penetration Disorder combines two

DSM-IV-TR categories (i.e., Vaginismus and Dyspareunia) and includes difficulties with

having vaginal intercourse or penetration; marked vulvovaginal or pelvic pain during

intercourse or penetration attempts; marked fear or anxiety about vulvovaginal or pel-

vic pain in anticipation of, during, or as a result of vaginal penetration; or marked tens-

ing or tightening of the pelvic floor muscles during attempted vaginal penetration.

If a sexual dysfunction does not meet criteria for one of the sexual dysfunctions de-

scribed above (perhaps because of inadequate frequency or duration) or occurs as part

of a maladaptive response to a psychosocial stressor, a diagnosis of an Adjustment Dis-

order may be appropriate.

2.21 Decision Tree for Sexual Dysfunction in a Female 111

Sexual dysfunction in a female

Due to the physiological Y Y SUBSTANCE/MEDICATION- effects of a substance INDUCED SEXUAL (including medication) DYSFUNCTION

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Sexual dysfunction symptoms predominate in the clinical picture and are sufficiently severe to warrant clinical attention

N N

Better explained by another Mental Disorder diagnosis (noY mental disorder (e.g., Major additional sexual dysfunction Depressive Disorder) diagnosis necessary)

Significantly reduced sexual interest or arousal (i.e., reduced interest, erotic thoughts, initiation of sexual Y N activity, excitement or FEMALE SEXUAL INTEREST/ pleasure during sexual AROUSAL DISORDER activity, genital sensations during sexual activity), lasting at least 6 months and causing clinically significant distress

Occurring in the context of a “desire discrepancy” in which the woman has lower desire for sexual activity than her partner

Entirely explained by lack of Y adequate stimulation

Not a sexual dysfunction

Due to the physiological Y Sexual dysfunction causedeffects of a general medical

by a general medicalcondition (e.g., pelvic nerve conditiondamage)

Better explained as a Y consequence of severe RELATIONAL PROBLEM relationship distress

112 DSM-5 Handbook of Differential Diagnosis

Clinically significant sexual dysfunction not covered above Y Y ADJUSTMENT DISORDER that represents a biological or (3.7.2) psychological dysfunction in the individual

OTHER SPECIFIED SEXUAL DYSFUNCTION; UNSPECIFIED SEXUAL DYSFUNCTION

Occurring in response to a psychosocial stressor

Marked delay in, infrequency of, or absence of orgasm or reduced intensity of orgasmic Y sensation lasting at least 6 months and causing clinically significant distress

N N

Difficulties with having vaginal intercourse or penetration, vulvovaginal or pelvic pain during intercourse, Y GENITO-PELVIC PAIN/ fear or anxiety about PENETRATION DISORDER vulvovaginal pain, or tensing or tightening of pelvic floor during attempted penetration, lasting at least 6 months and causing clinically significant distress

FEMALE ORGASMIC DISORDER

“Normal” variability in sexual functioning

2.22 Decision Tree for Sexual Dysfunction in a Male 113

2.22 Decision Tree for Sexual Dysfunction in a Male The major difficulty in evaluating sexual dysfunctions in both men and women is that

there are no accepted guidelines for determining what is “normal” sexual functioning.

The threshold for normal sexual functioning varies with the man’s age and prior sexual

experience, the availability and novelty of partners, and the expectations and standards

characteristic of the man’s cultural, ethnic, or religious group. Successful arousal and or-

gasm require a level of sexual stimulation that is adequate in focus, intensity, and dura-

tion. A diagnosis of Erectile Disorder or Delayed Ejaculation therefore requires a clinical

judgment that the man has experienced adequate stimulation. Moreover, occasional sex-

ual dysfunction is an inherent part of human sexuality and is not indicative of a disorder

unless it is persistent (i.e., lasting for at least 6 months) or recurrent and results in

marked distress or interpersonal difficulty.

Once the clinical judgment has been made that the sexual dysfunction is clinically sig-

nificant, the next task is to determine its underlying etiology. The possible etiologies in-

clude psychological factors, general medical conditions, the side effects of many

prescribed medications, and the consequence of drug abuse. This evaluation can be diffi-

cult because very often more than one etiology contributes to the sexual dysfunction. For

example, it is not uncommon for someone who develops mild erectile dysfunction as a

result of a general medical condition (e.g., vascular problems) to develop other sexual

dysfunctions (e.g., low desire) as a psychological consequence. Before deciding that any

sexual dysfunction is mediated strictly by psychological factors, you need to consider the

possible contribution of a general medical condition or substance (including medication

side effects), especially because these etiologies often have specific treatment implications

(e.g., discontinuation of the offending medication). Also, you need to remember that the

identification of a specific etiological general medical condition, medication, or drug of

abuse does not negate the important contribution of psychological factors to the etiology

of the dysfunction.

Sexual problems are also commonly associated with a number of mental disorders

(e.g., Depressive Disorders, Anxiety Disorders, Schizophrenia Spectrum and Other Psy-

chotic Disorders). An additional diagnosis of a sexual dysfunction is not given if the sex-

ual problems are better explained by the mental disorder. For example, low sexual desire

occurring only during a Major Depressive Episode would not warrant a separate diag-

nosis of Male Hypoactive Sexual Desire Disorder. Both diagnoses can be given only if

the low sexual desire is judged to be independent of the depressive disorder (i.e., it pre-

cedes the onset of the Major Depressive Episode or persists long after the depression has

remitted). Similarly, sexual dysfunction that is better explained as a consequence of se-

vere relationship distress would be diagnosed as a relational problem rather than a sex-

ual dysfunction unless evidence demonstrated that the sexual dysfunction occurred

independently of the relational problem.

The primary sexual dysfunctions of males are organized based on when during the

sexual response cycle the problem occurs. Male Hypoactive Sexual Desire Disorder is re-

lated to the initial phase, sexual desire. Erectile Disorder is related to the second phase,

sexual arousal. Delayed Ejaculation and Premature (Early) Ejaculation are for problems

114 DSM-5 Handbook of Differential Diagnosis

that occur in the third phase, orgasm. Not infrequently, problems occur in more than one

phase of the sexual response cycle. Because the phases of the sexual response cycle occur

in sequence, successful functioning in one phase generally requires successful function-

ing in the previous phases (e.g., orgasm requires some level of arousal, which requires

some level of desire). However, anticipation of the recurrence of problems in a later

phase (e.g., difficulty ejaculating) often leads to problems in an earlier phase (e.g., con-

sequent erectile dysfunction or low sexual desire).

Sexual dysfunction in a male

Due to the physiological Y Y SUBSTANCE/MEDICATION- effects of a substance INDUCED SEXUAL (including medication) DYSFUNCTION

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Sexual dysfunction symptoms predominate in the clinical picture and are sufficiently severe to warrant clinical attention

N N

Mental Disorder diagnosis Better explained by another Y (no additional sexual mental disorder (e.g., Major dysfunction diagnosis Depressive Disorder) necessary)

Deficient sexual or erotic thoughts or fantasies and

Ndesire for sexual activity, Y MALE HYPOACTIVE SEXUAL lasting at least 6 months and DESIRE DISORDER causing clinically significant distress

Occurring in the context of a “desire discrepancy” in which the man has lower desire for sexual activity than his partner

Entirely explained by lack of Y adequate stimulation

Not a sexual dysfunction

Due to the physiological Sexual dysfunction caused effects of a general medical Y

by a general medical condition (e.g., vascular condition disease)

Better explained as a Y consequence of severe RELATIONAL PROBLEM relationship distress

2.22 Decision Tree for Sexual Dysfunction in a Male 115

Clinically significant sexual dysfunction not covered above Y Y ADJUSTMENT DISORDER that represents a biological or (3.7.2) psychological dysfunction in the individual

OTHER SPECIFIED SEXUAL DYSFUNCTION; UNSPECIFIED SEXUAL DYSFUNCTION

Occurring in response to a psychosocial stressor

Ejaculation during partnered sexual activity within 1 minute Y following penetration and before the individual wishes it, lasting at least 6 months and causing clinically significant distress

N N

Marked delay in ejaculation or marked infrequency or Y absence of ejaculation lasting DELAYED EJACULATION at least 6 months and causing clinically significant distress

PREMATURE (EARLY) EJACULATION

“Normal” variability in sexual functioning

Marked difficulty obtaining or maintaining an erection Y during sexual activity, lasting at least 6 months and causing clinically significant distress

ERECTILE DISORDER

116 DSM-5 Handbook of Differential Diagnosis

2.23 Decision Tree for Aggressive Behavior Although aggressive behavior is a defining feature of only a handful of DSM-5 disorders

(i.e., Intermittent Explosive Disorder, Conduct Disorder, Antisocial Personality Disor-

der, and Disruptive Mood Dysregulation Disorder), it is a complication of a number of

mental disorders. It is important to note that most violent behavior occurs for reasons

very far afield from the domain of mental illness (e.g., material gain, status, sadistic plea-

sure, revenge, furthering a political or religious cause). This is reflected in the last deci-

sion in the tree, in which aggressive behavior that does not represent a psychological or

biological dysfunction in the individual is considered to be nonpsychiatric antisocial be-

havior. Moreover, even when the aggressive behavior is associated with a mental disor-

der, this fact does not by itself absolve the individual of criminal responsibility.

Among the DSM-5 disorders, the Substance-Related Disorders are by far the most fre-

quent cause of aggressive behavior. Aggression can also result from the cognitive impair-

ment and reduction in impulse control that is characteristic of Delirium and Major or

Mild Neurocognitive Disorder Due to Another Medical Condition. When the aggressive

behavior is a direct physiological consequence of a general medical condition but occurs

in the absence of cognitive impairment, Personality Change Due to Another Medical

Condition should be diagnosed. One issue that sometimes arises in the diagnosis of Per-

sonality Change Due to Another Medical Condition is whether to consider nonspecific

medical findings (e.g., neurological soft signs, diffuse slowing on electroencephalogram)

as evidence of a causative general medical condition. The DSM-5 convention is to diag-

nose Personality Change Due to Another Medical Condition only if the findings consti-

tute a diagnosable general medical condition. However, when clinical judgment strongly

suggests that a central nervous system dysfunction is present and responsible for the per-

sonality change but no specific diagnosis can be made, the general medical condition

called Unspecified Condition of Brain can be indicated as the causative disorder and

coded as an additional disorder (ICD-9-CM: 348.9, ICD-10-CM: G93.9).

Although the association is much less prominent, episodes of aggressive behavior

may occur at somewhat elevated rates in individuals with Schizophrenia, other Psy-

chotic Disorder, and Bipolar Disorder. A long-standing pattern of aggressive behavior

suggests that the behavior is part of a Personality Disorder (e.g., Antisocial Personality

Disorder, Borderline Personality Disorder). Aggressive behavior in children can occur in

the context of a number of disorders. When it occurs as part of a pattern of antisocial be-

havior in a child, the diagnosis of Conduct Disorder applies. If the aggressive behavior

occurs in the context of severe temper outbursts that are grossly out of proportion in in-

tensity or duration to the situation or provocation, with persistent anger and irritability

between the outbursts, the new DSM-5 diagnosis Disruptive Mood Dysregulation Dis-

order should be considered. Much less commonly, aggressive behavior can be associated

with other childhood disorders, including Oppositional Defiant Disorder, Attention-

Deficit/Hyperactivity Disorder, Separation Anxiety Disorder, Autism Spectrum Disor-

der, and Intellectual Disability (Intellectual Developmental Disorder).

Recurrent episodes of aggressive behavior (i.e., verbal aggression or physical aggres-

sion against people, animals, or property) that is not accounted for by any other mental

disorder (including a Personality Disorder) may qualify the individual for a diagnosis

2.23 Decision Tree for Aggressive Behavior 117

of Intermittent Explosive Disorder if the minimum requirements are met for the fre-

quency of outbursts (twice weekly for 3 months for verbal or physical aggression that

does not result in injury or destruction of property, or alternatively three outbursts in a

12-month period resulting in injury or damage to property).

Aggressive behavior can also occur in response to a stressor. If the stressor is of a

traumatic nature, the aggressive behavior might be part of the syndrome of Posttrau-

matic Stress Disorder (or Acute Stress Disorder if the duration is less than 1 month). Oth-

erwise, aggressive behavior can be a manifestation of an Adjustment Disorder.

118 DSM-5 Handbook of Differential Diagnosi

Aggressive behavior

SUBSTANCE/MEDICATION- Y INDUCED MAJOR or MILD

NEUROCOGNITIVE DISORDER (3.16.2), WITH BEHAVIORAL DISTURBANCE

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Associated with evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

Due to the physiological DELIRIUM DUE TO ANOTHERY effects of a general medical MEDICAL CONDITION condition (3.16.1)

PERSONALITY CHANGEY DUE TO ANOTHER MEDICAL CONDITION (3.17.11), AGGRESSIVE TYPE

Occurring in a pattern representing a change from previous personality pattern

MAJOR or MILD NEUROCOGNITIVEY DISORDER DUE TO ANOTHER MEDICAL CONDITION (3.16.2), WITH BEHAVIORAL DISTURBANCE

SUBSTANCE INTOXICATIONDue to the physiological Y N DELIRIUM; SUBSTANCEeffects of a substance WITHDRAWAL DELIRIUM;(including medications) MEDICATION-INDUCED DELIRIUM (3.16.1)

Associated with a disturbance in attention and awareness characterized by a fluctuating course

Associated with evidence of decline in one of more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

Associated with a disturbance in attention Y and awareness characterized by a fluctuating course

2.23 Decision Tree for Aggressive Behavior 119

Psychotic Disorder (e.g., Y SCHIZOPHRENIA [3.2.1]).

See Delusions Tree (2.5) or Hallucinations Tree (2.6) for differential diagnosis

CONDUCT DISORDER (3.14.3)

Agitation associated with at least two characteristic Catatonia (see Catatonic symptoms of catatonia (e.g., Y Symptoms Tree [2.7] for catalepsy, waxy flexibility, differential diagnosis) negativism, posturing, stereotypy, echolalia)

Y ANTISOCIAL PERSONALITY DISORDER (3.17.4)

OTHER SPECIFIED MENTAL DISORDER DUE TO ANOTHER MEDICAL CONDITION

Occurring in the context of a delusion or hallucination

Over age 18

MANIC EPISODE in Occurring in the context of Y BIPOLAR I DISORDER (3.3.1) elevated mood or SCHIZOAFFECTIVE

DISORDER (3.2.2)

Occurring as part of a pattern of violation of the basic rights of others and age-appropriate social norms

Occurring as part of a persistent personality

Ydisturbance characterized by BORDERLINE PERSONALITY angry outbursts, mood DISORDER (3.17.5) dysregulation, and identity disturbance

120 DSM-5 Handbook of Differential Diagnosis

Y DISRUPTIVE MOOD DYSREGULATION DISORDER (3.4.4)

Occurring in reaction to SEPARATION ANXIETY attempts to separate the Y DISORDER (3.5.1) individual from major attachment figures

Occurring in the context of severe temper outbursts that are grossly out of proportion to the situation accompanied by persistent anger and irritability between outbursts

Occurring in association with persistent deficits in social communication and social Y AUTISM SPECTRUM interaction, accompanied by DISORDER (3.1.3) restricted repetitive patterns of behaviors, interests, or activities

Occurring in association with Y OPPOSITIONAL DEFIANTa pattern of argumentativeness DISORDER (3.14.1)defiance, and vindictiveness

Y ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (3.1.4)

Occurring in at least two Occurring in association with different situations and persistent symptoms of causing clinically hyperactivity, impulsivity, and significant impairment, inattention with several symptoms

present before age 12

Occurring in association with deficits in intellectual function,

Ywith accompanying deficits in INTELLECTUAL DISABILITY adaptive functioning and (3.1.1) onset during the developmental period

2.23 Decision Tree for Aggressive Behavior 121

Y INTERMITTENT EXPLOSIVE DISORDER (3.14.2)

Clinically significant aggressive behavior not UNSPECIFIED DISRUPTIVE,Y covered above that is IMPULSE-CONTROL, AND indicative of a psychological CONDUCT DISORDER dysfunction in the individual

Occurring in the context of episodes of aggressive behavior that are grossly out of proportion to the situation

ADJUSTMENT DISORDER (3.7.2)

Nonpsychiatric aggressive behavior (e.g., antisocial behavior)

Y POSTTRAUMATIC STRESS DISORDER or ACUTE STRESS DISORDER (3.7.1)

Stressor is of an extremely Occurring in the context of a traumatic nature (e.g., life- symptomatic response to a threatening situation) and psychosocial stressor there is recurrent

reexperiencing of the trauma

122 DSM-5 Handbook of Differential Diagnosis

2.24 Decision Tree for Impulsivity or Impulse-Control Problems Decision tree 2.24 covers two related symptoms: the trait of impulsivity and the problem

of diminished impulse control. Impulsivity involves the tendency to act on a whim, dis-

playing behavior characterized by little or no forethought, reflection, or consideration of

consequences. A number of DSM-5 disorders are characterized by excessive impulsivity.

Other disorders are characterized by problems in controlling certain impulses (e.g., the

impulse to pull out one’s hair in Trichotillomania, the impulse to binge in Binge-Eating

Disorder). Both excessive impulsivity and impairment in controlling specific impulses

can lead to impulsive behavior that can be both self-destructive and harmful to others.

Substance use is a common and devastating cause of impulsivity and must be consid-

ered as a possible sole or contributory factor in every presentation of impulsive behavior.

General medical conditions can also result in the disinhibition of impulse control, which

is often accompanied by poor judgment and other cognitive symptoms warranting a di-

agnosis of Delirium or Major or Mild Neurocognitive Disorder. When a general medical

condition results in persistent impulsivity that occurs in the absence of clinically signifi-

cant cognitive impairment, the diagnosis is Personality Change Due to Another Medical

Condition (usually of the Disinhibited or Aggressive Type).

Certain disorders are characterized by impulsivity that is confined exclusively to the

episode of the disturbance. Once substance use and a general medical condition are

ruled out, the next step is to determine whether the presentation includes symptoms

that would lead to a diagnosis of a Bipolar Disorder, Depressive Disorder, Schizophrenia

or one of the other psychotic disorders, or Posttraumatic Stress Disorder or Acute Stress

Disorder. Generalized impulsivity that has an early onset and persistent course is most

likely to be associated with Attention-Deficit/Hyperactivity Disorder, Conduct Disor-

der, Antisocial Personality Disorder, or Borderline Personality Disorder.

A wide range of DSM-5 disorders are characterized by specific behaviors that can be

conceptualized as manifestations of impaired impulse control. These include Gambling

Disorder, in which the person’s ability to control gambling behavior is impaired; Buli-

mia Nervosa and Binge-Eating Disorder, which are characterized by out-of-control

binge eating; Pyromania and Kleptomania, which are characterized by an inability to re-

sist impulses to, respectively, set fires and steal objects of little value; Trichotillomania

and Excoriation Disorder, characterized by an inability to control impulses to, respec-

tively, pull out one’s hair or pick one’s skin; and Intermittent Explosive Disorder, char-

acterized by an intermittent inability to resist aggressive impulses.

2.24 Decision Tree for Impulsivity or Impulse-Control Problems 123

Impulsivity or impulse- control problems

Due to the physiological DELIRIUM DUE TO ANOTHER effects of a general medical MEDICAL CONDITION condition (3.16.1)

MAJOR or MILD NEUROCOGNITIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION (3.16.2), WITH BEHAVIORAL DISTURBANCE

Occurring in a pattern representing a change from previous personality pattern

Y Y

Associated with a disturbance in attention and awareness characterized by a fluctuating course

OTHER SPECIFIED MENTAL DISORDER DUE TO ANOTHER MEDICAL CONDITION; UNSPECIFIED MENTAL DISORDER DUE TO ANOTHER MEDICAL CONDITION

Associated with evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition

MANIC EPISODE in BIPOLAR I DISORDER (3.3.1) or SCHIZOAFFECTIVE DISORDER (3.3.2)

PERSONALITY CHANGE DUE TO ANOTHER MEDICAL CONDITION (3.17.11)

Due to the physiological effects of a substance (including medications)

Occurring in the context of an episode of elevated, expansive, or irritable mood accompanied by increased activity or energy

Associated with a disturbance in attention and awareness characterized by a fluctuating course

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

SUBSTANCE INTOXICATION DELIRIUM; SUBSTANCE WITHDRAWAL DELIRIUM; MEDICATION-INDUCED DELIRIUM (3.16.1)

124 DSM-5 Handbook of Differential Diagnosis

Part of a pattern of violation of the basic rights of others ANTISOCIAL PERSONALITY and age-appropriate social DISORDER (3.17.4) norms

Y Y Age over 18 years

Associated with symptoms of inattention and hyperactivity with onset before age 12 and clear evidence of interference with functioning

N N

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER (3.1.4)

CONDUCT DISORDER (3.14.3)

Part of a pattern of impulsivity with onset in early adulthood

Y BORDERLINE PERSONALITY DISORDER (3.17.5)

Impaired ability to control use of substances

Y SUBSTANCE USE DISORDER (3.15.1)

Impaired ability to control gambling

GAMBLING DISORDER (3.15.2)

Failure to resist impulses to binge eat

BULIMIA NERVOSA (3.10.3); BINGE-EATING DISORDER (3.10.4)

Episodes of failure to resist an impulse to start fires

PYROMANIA

Episodes of failure to resist an impulse to steal objects not needed for personal use

KLEPTOMANIA

Episodes of failure to resist the impulse to pull out one’s hair

TRICHOTILLOMANIA (HAIR- PULLING DISORDER) (3.6.4)

MAJOR DEPRESSIVE EPISODE in MAJOR DEPRESSIVE DISORDER (3.4.1), BIPOLAR I (3.3.1) or BIPOLAR II (3.3.2) DISORDER, or SCHIZOAFFECTIVE DISORDER (3.2.2)

Occurring in the context of an episode of depressed mood or diminished interest or pleasure, accompanied by characteristic depressive symptoms (e.g., suicidal behavior)

2.24 Decision Tree for Impulsivity or Impulse-Control Problems 125

Impulsivity arising as a response to exposure to a traumatic stressor

POSTTRAUMATIC STRESSaccompanied by intrusion DISORDER (3.7.1)symptoms, avoidance

symptoms, and negative alterations in cognitions and mood

Y YDuration of more than 1 month

ACUTE STRESS DISORDER (3.7.1)

Clinically significant impulsivity not covered above ADJUSTMENT DISORDERthat represents a (3.7.2)psychological or biological dysfunction in the individual

Y YMaladaptive response to a psychosocial stressor

N OTHER SPECIFIED DISRUPTIVE, IMPULSE- CONTROL, AND CONDUCT

“Normal” impulsivity DISORDER; UNSPECIFIED DISRUPTIVE, IMPULSE- CONTROL, AND CONDUCT DISORDER

Episodes of failure to resist impulses to pick one’s skin

EXCORIATION (SKIN- PICKING) DISORDER (3.6.5)

Episodes of failure to resist aggressive impulses

INTERMITTENT EXPLOSIVE DISORDER (3.14.2)

126 DSM-5 Handbook of Differential Diagnosis

2.25 Decision Tree for Self-Injury or Self-Mutilation Self-injurious and self-mutilating behaviors include cutting, burning, head banging,

hair pulling, skin picking, self-biting, and hitting of various parts of one’s own body. No-

tably, the frequency of self-mutilation appears to be greatest in situations in which the

individual is confined (e.g., in a hospital, prison, children’s home). Therefore, an inter-

esting dilemma is presented when a patient who is about to be discharged from the hos-

pital increases self-mutilating behaviors, which may in fact be reinforced by remaining

in that setting.

Motivations for self-mutilation vary in the diagnoses for which it is a complication.

The most frequent diagnosis associated with self-mutilation is Borderline Personality

Disorder. For some patients with this disorder, the self-mutilating behavior often occurs

as a means of “treating” dissociative states wherein the patient returns to feeling alive

only when experiencing pain or seeing blood. In other patients with Borderline Person-

ality Disorder, self-mutilation is a means of “treating” intense dysphoria or counteracting

intense anger. The likelihood of self-mutilative episodes is greatly increased by Substance

Intoxication or Substance Withdrawal. The motivation for self-mutilation in psychotic

patients is usually a delusional belief (e.g., the need to punish evil spirits) or a response

to a command hallucination. In Delirium and Major Neurocognitive Disorder, the self-

mutilation sometimes occurs as a by-product of the confusion (e.g., struggling against re-

straints). The self-mutilation that infrequently occurs as a complication of Obsessive-

Compulsive Disorder results from the inability to resist the constant need to perform a

compulsive act (e.g., cleaning hands raw as a result of a hand-washing compulsion). In

Trichotillomania, there is an inability to resist the impulse to pull out one’s hair, which

may result in patches of hair loss. Similar failure to resist impulses to pick one’s skin in

Excoriation Disorder leads to noticeable skin lesions. In Sexual Masochism Disorder, the

motivation for the self-mutilation is sexual pleasure.

Stereotypies, which can result in self-injury, are the central component of Stereotypic

Movement Disorder. When Stereotypic Movement Disorder results in clinically signifi-

cant self-injury, this can be indicated by specifying “with self-injurious behavior.” Stereo-

typies are not infrequent in Intellectual Disability (Intellectual Developmental Disorder)

and should be diagnosed separately as Stereotypic Movement Disorder only if they are

not better explained by the underlying cause of the Intellectual Disability.

Self-mutilating behavior is sometimes a manifestation of Factitious Disorder or Ma-

lingering. The patient learns that cutting or burning will result in a desired hospitaliza-

tion or prevent an undesired discharge. Factitious Disorder and Malingering are

differentiated based on whether the feigned behavior occurs in the absence of obvious

external rewards; if so, the diagnosis is Factitious Disorder. If the feigned self-injurious

behavior only occurs in the presence of obvious external rewards, Malingering is diag-

nosed instead.

2.25 Decision Tree for Self-Injury or Self-Mutilation 127

Self-injury or self-mutilation

SUBSTANCE/MEDICATION- INDUCED MAJOR NEUROCOGNITIVE DISORDER (3.16.2); SUBSTANCE INTOXICATIONDue to the physiological Y Y DELIRIUM (3.16.1);effects of a substance SUBSTANCE WITHDRAWAL(including medication) DELIRIUM (3.16.1); MEDICATION-INDUCED DELIRIUM (3.16.1); SUBSTANCE/MEDICATION- INDUCED PSYCHOTIC DISORDER

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

A direct consequence of cognitive impairment or psychotic symptoms

Part of a failed suicide attempt

Y See Suicidal Ideation or Behavior Tree (2.11) for differential diagnosis

Culturally sanctioned behavior (e.g., piercings)

Y “Normal” self-mutilation

MAJOR NEUROCOGNITIVE DISORDER DUE TO ANOTHER MEDICAL

Due to the physiological CONDITION (3.16.2);Y Y effects of a general medical DELIRIUM DUE TO ANOTHER condition MEDICAL CONDITION

(3.16.1); PSYCHOTIC DISORDER DUE TO ANOTHER MEDICAL CONDITION

PERSONALITY CHANGE DUE TO ANOTHER MEDICAL CONDITION (3.17.11)

A direct consequence of cognitive impairment (e.g., confusion) or psychotic symptoms

N N

Motivation of self-injury is to reduce dysphoria, vent angry feelings, or reduce feelings of Y BORDERLINE PERSONALITY numbness or of “being dead,” DISORDER (3.17.5) in association with a pattern of impulsivity and identity disturbance

128 DSM-5 Handbook of Differential Diagnosis

A consequence of stereotyped Y STEREOTYPIC MOVEMENTmovements (e.g., head DISORDERbanging)

Psychotic Disorder (e.g., SCHIZOPHRENIA [3.2.1]).In response to a delusion or Y See Delusions Tree (2.5) orcommand hallucination Hallucinations Tree (2.6) for differential diagnosisN

A consequence of a Y OBSESSIVE-COMPULSIVEcompulsion (e.g., frequent DISORDER (3.6.1)vigorous hand washing)

YAssociated with recurrent hair TRICHOTILLOMANIA (HAIR- pulling with resulting hair loss PULLING DISORDER) (3.6.4)

Associated with recurrent skin Y EXCORIATION (SKIN-picking with resulting skin PICKING) DISORDER (3.6.5)lesions

Motivation is for sexual Y SEXUAL MASOCHISM pleasure DISORDER (3.18.1)

Y Y FACTITIOUS DISORDER Falsification of self-injury (3.9.5)

MALINGERING

Deceptive behavior is evident even in the absence of obvious external rewardsN

Clinically significant self- injurious behavior not covered Y Y ADJUSTMENT DISORDERabove that represents a (3.7.2)psychological or biological dysfunction in the individual

Section III: Nonsuicidal Self-Injury

Occurring as a maladaptive response to a stressor

N N

“Normal” self-injurious behavior

2.26 Decision Tree for Excessive Substance Use 129

2.26 Decision Tree for Excessive Substance Use Many individuals can take substances without having any clinically significant problems

that would warrant a DSM-5 diagnosis. However, substance-related disorders are among

the most common and impairing of the mental disorders. Because substance-related pre-

sentations are so frequently encountered in mental health, substance treatment, and pri-

mary care settings, a substance-related disorder must be considered in every differential

diagnosis.

In DSM-5, the term substance-related refers to disorders associated with drugs of

abuse, the side effects of medication, and toxin-induced states. There are two types of

substance-related diagnoses in DSM-5: the Substance Use Disorders, which describe a

pattern of problematic substance use, and the Substance-Induced Disorders (comprising

Substance Intoxication, Substance Withdrawal, and Substance/Medication-Induced

Mental Disorders), which describe behavioral syndromes that are caused by the direct

effect of a substance on the central nervous system (CNS). More often than not, Sub-

stance-Induced Disorders occur in the context of an accompanying Substance Use Dis-

order, and when this occurs, both should be diagnosed. The method for recording these

diagnoses depends on the requirements of the ICD-9-CM or ICD-10-CM coding system.

If a diagnosis is made while ICD-9-CM is in effect (i.e., up to October 1, 2014), two diag-

noses are given (e.g., Severe Alcohol Use Disorder and Alcohol Withdrawal). If a diag-

nosis is made while ICD-10-CM is in effect (i.e., beginning October 1, 2014, or after), then

a single combined diagnosis is given (e.g., Severe Alcohol Use Disorder With Alcohol

Withdrawal). See the recording procedures for Substance-Induced Disorders in DSM-5

for more information. For this reason, the decision tree starts off with a decision point

that highlights the fact that Substance Use Disorders and Substance-Induced Disorders

are often comorbid, and clearly indicates that if a Substance Use Disorder is present and

there is evidence that the substance has caused psychiatric symptoms because of its di-

rect effect on the CNS, the remainder of the tree must be reviewed to determine the dif-

ferential diagnosis of the relevant Substance-Induced Disorder.

Substance Intoxication and Substance Withdrawal can be characterized by psychopa-

thology that mimics other disorders contained in DSM-5 and must always be considered

in the differential diagnosis of every condition (see Step 2 in Chapter 1). The Substance/

Medication-Induced Mental Disorders (e.g., Substance/Medication-Induced Psychotic

Disorder, Substance/Medication-Induced Bipolar and Related Disorder, and so forth)

have been included in DSM-5 for presentations in which a particular symptom, such as

delusions, hallucinations, or mania, predominate in the clinical picture and warrant clin-

ical attention. For example, virtually every individual withdrawing from cocaine will

experience some dysphoric mood, and in most situations a diagnosis of Cocaine With-

drawal will suffice. However, were the individual to become suicidally depressed, the

diagnosis of Cocaine-Induced Depressive Disorder may be more appropriate. Often,

more than one symptom (e.g., depressed mood and anxiety) may be prominent enough

to be a focus of clinical attention. In such situations, it is generally preferable to give just

one substance/medication-induced diagnosis indicating the predominating symptom.

The psychiatric sequelae to substance/medication use can occur in any of four con-

texts: 1) as an acute effect of Substance Intoxication, 2) as an acute effect of Substance

Withdrawal, 3) as a medication side effect not necessarily related to Substance Intoxica-

tion or Substance Withdrawal, and 4) as an effect that endures even after Substance In-

130 DSM-5 Handbook of Differential Diagnosis

toxication or Substance Withdrawal has abated (in the case of Substance/Medication-

Induced Major or Mild Neurocognitive Disorder and Hallucinogen Persisting Percep-

tion Disorder).

Delirium Due to Multiple Etiologies and Major or Mild Neurocognitive Disorder

Due to Multiple Etiologies have been included in DSM-5 (and in this decision tree) to

emphasize that very often these conditions have multiple interacting etiologies, includ-

ing substances. A common (and sometimes devastating) error is to assume your job is

finished once you have identified a substance as a contributing etiology to the Delirium

or the Major or Mild Neurocognitive Disorder and therefore to miss the associated con-

tribution of head trauma or another medical condition.

2.26 Decision Tree for Excessive Substance Use 131

Excessive substance use

Problematic pattern of substance use leading to clinically significant impairment or distress (e.g., substance often taken in larger amounts than Y N SUBSTANCE USE intended; social, DISORDER (3.15.1) occupational, or recreational activities given up because of substance use; repeated use in situations in which it is physically hazardous)

Presence of psychiatric symptoms due to direct physiological effects of the substance on the central nervous system (CNS)

SUBSTANCE USE DISORDER; continue to determine whether Substance-Induced Disorder is also present

Presence of clinically significant psychiatric symptoms due to direct physiological effects of the substance on CNS

N No Substance- Induced Disorder

Disturbance in attention and Y awareness characterized by a fluctuating course

Y SUBSTANCE WITHDRAWAL DELIRIUM (3.16.1)

Evidence that the disturbance has more than one etiology (e.g., substance and a general medical condition)

N Onset of Delirium during Substance Withdrawal

SUBSTANCE INTOXICATION DELIRIUM (3.16.1)

DELIRIUM DUE TO MULTIPLE ETIOLOGIES (3.16.1)

Y MEDICATION- INDUCED DELIRIUM (3.16.1)

Delirium caused by medication use

132 DSM-5 Handbook of Differential Diagnosis

MAJOR or MILD NEUROCOGNITIVE DISORDER DUE TO MULTIPLE ETIOLOGIES (3.16.2)

Evidence that the disturbance has more than one etiology (e.g., substance and a general medical condition)

Evidence of decline in one or more of the SUBSTANCE/ following cognitive MEDICATION- domains: complex INDUCED MAJOR attention, executive or MILD function, learning and NEUROCOGNITIVE memory, language, DISORDER (3.16.2) perceptual-motor, or social cognition

Reexperiencing of HALLUCINOGEN perceptual symptoms PERSISTING experienced while PERCEPTION intoxicated with a DISORDER hallucinogen (flashbacks)

SUBSTANCE/Delusions or MEDICATION-hallucinations INDUCEDpredominate in the PSYCHOTICclinical picture and DISORDER (specify ifare sufficiently severe With Onset Duringto warrant clinical Intoxication orattention Withdrawal)

SUBSTANCE/Elevated, expansive, MEDICATION-and/or irritable mood INDUCED BIPOLARpredominates in the AND RELATEDclinical picture and is DISORDER (specify ifsufficiently severe to With Onset Duringwarrant clinical Intoxication orattention Withdrawal)

Depressed mood SUBSTANCE/ and/or markedly MEDICATION- diminished interest or Y INDUCED pleasure predominate DEPRESSIVE in the clinical picture DISORDER (specify if and are sufficiently With Onset During severe to warrant Intoxication or clinical attention Withdrawal)

2.26 Decision Tree for Excessive Substance Use 133

SUBSTANCE/ Clinically significant MEDICATION- sexual dysfunction INDUCED SEXUAL predominates in the DYSFUNCTION clinical picture and is (specify if sufficiently severe to With Onset During warrant clinical Intoxication, attention Withdrawal, or After

Medication Use)

SUBSTANCE/ A prominent and MEDICATION- severe disturbance in INDUCED SLEEP sleep predominates in DISORDER (specify if the clinical picture With Onset During and is sufficiently Intoxication or severe to warrant Discontinuation/ clinical attention Withdrawal)

SUBSTANCE/ Anxiety and/or Panic MEDICATION- Attacks predominate INDUCED ANXIETY

Yin the clinical picture DISORDER (specify if and are sufficiently With Onset During severe to warrant Intoxication, clinical attention Withdrawal, or After

Medication Use) N

Obsessions, compulsions, skin SUBSTANCE/ picking, hair pulling, MEDICATION- other body-focused INDUCED repetitive behaviors, OBSESSIVE- or other symptoms Y COMPULSIVE AND characteristic of the RELATED DISORDER Obsessive-Compulsive (specify if and Related Disorders With Onset During predominate in the Intoxication, clinical picture and Withdrawal, or After are sufficiently severe Medication Use) to warrant clinical attention

Clinically significant problematic behavioral or Y SUBSTANCEpsychological INTOXICATIONchanges that developed during substance use

134 DSM-5 Handbook of Differential Diagnosis

No Substance-Induced Disorder (substance- induced symptoms that are not clinically significant)

Development of a Ysyndrome due to SUBSTANCE

reduction or cessation WITHDRAWAL of use of a substance

Substance-induced Y UNSPECIFIEDclinically significant SUBSTANCE–symptoms not covered RELATED DISORDERabove

2.27 Decision Tree for Memory Loss 135

2.27 Decision Tree for Memory Loss Memory loss can be characterized by difficulty in laying down new memories and/or in

the recall of previous memories. The various aspects of memory functioning may be tested

separately. These include 1) registration (the ability of the patient to repeat numbers or

words immediately after hearing them), 2) short-term recall (the ability of the patient to

repeat the names of three unrelated objects after a period of several minutes), 3) recogni-

tion (the ability of the patient to retrieve previously forgotten names if provided with

clues), and 4) remote memory (the ability of the patient to recall important personal or his-

torical events). The differential decisions in this tree concern whether the etiology of the

memory loss is the direct physiological effect on the central nervous system of substance/

medication use or a general medical condition, whether it is an associated feature of an-

other mental disorder, or whether the memory loss is a dissociative phenomenon (e.g., as

in Posttraumatic Stress Disorder or a Dissociative Disorder).

Memory impairment is one of the types of cognitive impairment that characterize

Delirium and Major or Mild Neurocognitive Disorder. The hallmark of Delirium is a

fluctuating course of clouding of consciousness characterized by a disturbance in atten-

tion (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e.,

reduced orientation to the environment). The definition of Delirium also requires an ac-

companying disturbance in cognition (which can take the form of memory impairment,

language, visuospatial ability, or perception). Neurocognitive Disorder is defined as a

decline in one or more neurocognitive domains, which DSM-5 specifies as including

complex attention, executive functioning, learning and memory, language, perceptual-

motor, and social cognition. Although such cognitive impairment occurs on a contin-

uum, DSM-5 has split the dimension into two categorical disorders: Major Neurocogni-

tive Disorder and Mild Neurocognitive Disorder. Major Neurocognitive Disorder is

characterized by a significant decline in cognition that is so severe as to interfere with

independence. In Mild Neurocognitive Disorder, the cognitive decline is limited to be-

ing only at a “modest” level of severity. The diagnosis is made when the individual, a

knowledgeable informant, or the clinician notices a mild decline in the patient’s cogni-

tive function; this decline must be accompanied by evidence of a modest impairment in

cognitive performance preferably documented by standardized neuropsychological

testing or another quantified clinical assessment.

Memory impairment associated with substance use can be either temporary (as in

Substance Intoxication, Substance Withdrawal, Substance Intoxication Delirium or Sub-

stance Withdrawal Delirium, and Other Adverse Effect of Medication) or persistent (as

in Substance/Medication-Induced Major or Mild Neurocognitive Disorder, which re-

quires the cognitive impairments to persist beyond the usual duration of acute intoxica-

tion or withdrawal).

Memory impairment is also a common associated feature of a number of mental dis-

orders. For example, memory impairment occurring in the context of a Major Depressive

Episode can be so severe as to resemble an irreversible dementing process. Frequently, it

is only when the memory impairment resolves after antidepressant treatment that it be-

comes clear that there was no comorbid Major Neurocognitive Disorder. This differential

is further complicated by the fact that the medication (e.g., lithium) being taken by the

patient may also contribute to memory problems.

136 DSM-5 Handbook of Differential Diagnosis

Dissociation is a disruption in the usually integrated functions of consciousness,

memory, identity, or perception of the environment. Memory loss, especially for trau-

matic events, is a feature of Dissociative Amnesia and Dissociative Identity Disorder, as

well as of Posttraumatic Stress Disorder and Acute Stress Disorder. Particularly when

someone has been exposed to an event that is both physically and psychologically trau-

matic (e.g., car accident), it can be difficult to tease apart whether the memory loss is a

psychological reaction to the events or is due to direct damage to the brain. Moreover,

especially in forensic situations, feigned claims of memory loss may be used in an at-

tempt to deny responsibility. In such cases, the diagnosis is either Factitious Disorder or

Malingering, with Factitious Disorder diagnosed when the feigned memory loss is evi-

dent even in the absence of obvious external rewards. Otherwise, Malingering (which is

not considered to be a mental disorder) is diagnosed.

It should also be noted that virtually everyone wishes that his or her memory were

better than it is and that this longing usually becomes more poignant as people get older

and begin having more difficulty commanding their memories. Before considering the

disorders on this decision tree, it must be determined that the memory loss is sufficiently

severe to be clinically significant and that it is more severe than might be expected given

the person’s previous memory functioning and the norms for his or her age.

2.27 Decision Tree for Memory Loss 137

Memory loss

SUBSTANCE INTOXICATION Due to the physiological Y Y DELIRIUM; SUBSTANCE effects of a substance WITHDRAWAL DELIRIUM; (including medication) MEDICATION-INDUCED

DELIRIUM (3.16.1)

SUBSTANCE/MEDICATION- INDUCED MAJOR or MILD NEUROCOGNITIVE DISORDER (3.16.2)

Associated with a disturbance in attention and awareness characterized by a fluctuating course

Due to the physiological Y Y DELIRIUM DUE TO ANOTHER effects of a general medical MEDICAL CONDITION condition (3.16.1)

MAJOR or MILD NEUROCOGNITIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION (3.16.2) (see Cognitive Impairment Tree [2.28] for differentiation between Major and Mild Neurocognitive Disorder and for determination of etiological type)

Associated with a disturbance in attention and awareness characterized by a fluctuating course

N N

Memory loss predominates in the clinical picture and is sufficiently severe to warrant clinical attention

SUBSTANCE INTOXICATION; SUBSTANCE WITHDRAWAL; OTHER ADVERSE EFFECT OF MEDICATION

Occurring in the context of a Ydisruption of identity DISSOCIATIVE

characterized by two or more IDENTITY DISORDER distinct personality states

138 DSM-5 Handbook of Differential Diagnosis

Memory loss for Y Y POSTTRAUMATICaspects of an

STRESS DISORDERextremely traumatic (3.7.1)event

Occurring with intrusion symptoms, avoidance of stimuli associated with the event, negative alterations in cognitions and mood, and alterations in arousal and activity

Duration of more than 1 month

ACUTE STRESS DISORDER (3.7.1)

DISSOCIATIVE AMNESIA (3.8.1)

Feigned memory loss FACTITIOUS or impairment DISORDER (3.9.5)

MAJOR DEPRESSIVE EPISODE in MAJOR

Occurring as an DEPRESSIVE associated feature of DISORDER (3.4.1), Major Depressive BIPOLAR I (3.3.1) or Episode BIPOLAR II (3.3.2) (“pseudodementia”) DISORDER, or

SCHIZOAFFECTIVE DISORDER (3.2.2)

Consequent to aging process but within Aging-associated normal limits given cognitive decline person’s age

Memory loss for other autobiographical information that is inconsistent with ordinary forgetting

The deceptive behavior is evident in the absence of obvious external rewards

MALINGERING

“Normal” forgetfulness

2.28 Decision Tree for Cognitive Impairment 139

2.28 Decision Tree for Cognitive Impairment Although cognitive impairment is a broad term that can include impairment in virtually

any cognitive function, in the context of this decision tree, the term is referring to impair-

ment in one of the cognitive domains listed in the criteria for Major or Mild Neurocog-

nitive Disorder: complex attention, executive function, learning and memory, language,

perceptual-motor, or social cognition. If cognitive impairment is restricted to memory

loss, you should refer to the decision tree for memory loss (2.27) for the differential di-

agnosis.

The pattern of cognitive impairments that defines the Delirium syndrome is rather

specific. The hallmark of Delirium is a clouding of consciousness characterized by a dis-

turbance in attention (i.e., a reduced ability to direct, focus, sustain, and shift attention)

and awareness (i.e., by reduced orientation to the environment) that develops over a

short period of time and fluctuates in severity during the course of a day. The definition

of Delirium also requires an accompanying disturbance in cognition (which can take the

form of memory impairment, language, visuospatial ability, or perception). Once the syn-

drome of Delirium is established, the actual DSM-5 diagnosis depends on the etiology;

Delirium can be due to multiple etiologies (Delirium Due to Multiple Etiologies), to the

physiological effects of a substance or medication (Substance Intoxication Delirium, Sub-

stance Withdrawal Delirium, Medication-Induced Delirium), or to the physiological ef-

fects of a general medical condition (Delirium Due to Another Medical Condition).

Significant cognitive impairment also occurs in the context of various mental disor-

ders. Although cognitive impairment is not one of the defining symptoms of Schizophre-

nia, cognitive symptoms, especially decrements in declarative and working memory,

language function, and other executive functions, are extremely common and are a ma-

jor contributor to the poor long-term functioning that often characterizes Schizophrenia.

Similarly, although many individuals in the midst of a Manic Episode feel more confi-

dent in their cognitive abilities, in between mood episodes there may be significant cog-

nitive impairment that has a negative impact on long-term functioning. Depressive

Disorders, such as Major Depressive Disorder and Persistent Depressive Disorder (Dys-

thymia), are characterized by diminished ability to think or concentrate that in some

cases can be so severe as to resemble a dementing illness (“pseudodementia”). Difficulty

with concentration is common during the dysphoric periods in Premenstrual Dysphoric

Disorder, and is also part of the symptomatic pictures of Posttraumatic Stress Disorder,

Acute Stress Disorder, and Generalized Anxiety Disorder. Inattention and distractibility

are defining features of Attention-Deficit/Hyperactivity Disorder. Because Major or

Mild Neurocognitive Disorder may still occur comorbidly with these conditions, the de-

cision tree instructs you to keep moving down toward Neurocognitive Disorder if not

all of the cognitive symptoms that are part of the presenting picture are accounted for by

the mental disorder.

Neurocognitive Disorders are divided into Major and Mild Neurocognitive Disorder

and typed by etiology. They differ based on whether the individual has a substantial im-

pairment in cognitive functions that interferes with independence (Major Neurocogni-

tive Disorder) or has modest declines in functions that are insufficiently severe to

interfere with the capacity for independence in everyday activities (Mild Neurocogni-

140 DSM-5 Handbook of Differential Diagnosis

tive Disorder). Because of the relatively greater clinical importance of Major Neurocog-

nitive Disorder, this decision tree provides the decision points for determining the

etiological type only for this condition. The same decision points would apply to the de-

termination of the etiological type for Mild Neurocognitive Disorder as well.

As was the case for Delirium, if the Major Neurocognitive Disorder has more than one

contributing etiological factor, Major Neurocognitive Disorder Due to Multiple Etiologies

is diagnosed. Otherwise, decision points are given for the various specific medical etiol-

ogies, starting with Parkinson’s disease, then followed by traumatic brain injury, HIV

infection, Huntington’s disease, prion disease (e.g., Creutzfeldt-Jakob disease), fronto-

temporal lobar degeneration (e.g., Pick’s disease), Lewy body disease, vascular disease,

and Alzheimer’s disease. Several etiologies (i.e., Parkinson’s disease, frontotemporal lo-

bar degeneration, Lewy body disease, vascular disease, and Alzheimer’s disease) must

be further specified as being “probable” or “possible” based on specific diagnostic crite-

ria. If another medical etiology is responsible for the Major Neurocognitive Disorder

(e.g., multiple sclerosis), Major Neurocognitive Disorder Due to Another Medical Con-

dition is diagnosed. Finally, if the Major Neurocognitive Disorder is caused by the phys-

iological effects of a substance that persist beyond acute intoxication or withdrawal,

Substance/Medication-Induced Major Neurocognitive Disorder is diagnosed. If the eti-

ology for Major or Mild Neurocognitive Disorder cannot be determined, then Unspeci-

fied Neurocognitive Disorder is diagnosed.

2.28 Decision Tree for Cognitive Impairment 141

Cognitive impairment

Restricted to memory Y loss

DELIRIUM DUE TO MULTIPLE ETIOLOGIES (3.16.1)

Characterized by a disturbance in attention and awareness that has a fluctuating course

DELIRIUM DUE TO ANOTHER MEDICAL CONDITION (3.16.1)

Evidence that the Delirium has more than one etiology (e.g., more than one etiological general medical condition; a general medical condition and Substance Intoxication)

Y Y

Due to the physiological effects Y MEDICATION- of a substance INDUCED DELIRIUM (including (3.16.1) medications)

Delirium caused by medication use

See Memory Loss Tree (2.27) for differential diagnosis

SUBSTANCE WITHDRAWAL DELIRIUM (3.16.1)

Onset during Substance Withdrawal

Due to the physiological effects of a general medical condition

OTHER SPECIFIED DELIRIUM; UNSPECIFIED DELIRIUM

SUBSTANCE INTOXICATION DELIRIUM (3.16.1)

142 DSM-5 Handbook of Differential Diagnosis

Cognitive symptoms (e.g., decrements in declarative and

Y working memory, Y SCHIZOPHRENIA language function, (3.2.1) and other executive functions) are entirely accounted for by psychotic disorder

Duration is 6 months or more

SCHIZOPHRENIFORM N DISORDER (3.2.1)

Occurring in the context of a psychotic disturbance lasting at least 1 month and characterized by periods of active- phase symptoms (i.e., delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms) and prodromal or residual phases

Cognitive symptoms are entirelyY Y BIPOLAR Iaccounted for as

DISORDER (3.3.1)associated features of Bipolar I Disorder

Occurring in the context of recurrent Manic Episodes and Major Depressive Episodes

N N

MAJOR DEPRESSIVE Cognitive symptoms EPISODE in MAJOR (i.e., diminished DEPRESSIVE ability to think orY Y DISORDER (3.4.1), concentrate) are BIPOLAR I (3.3.1) or entirely accounted for BIPOLAR II (3.3.2) by Major Depressive DISORDER, or Episode SCHIZOAFFECTIVE

DISORDER (3.2.2)

Occurring in the context of an episode of depressed mood or diminished interest or pleasure, accompanied by characteristic depressive symptoms

Cognitive symptoms (i.e., poor concentration or

Y Y PERSISTENTdifficulty making DEPRESSIVEdecisions) are entirely DISORDER (3.4.2)accounted for by Persistent Depressive Disorder

Occurring in the context of depressed mood that persists more days than not for 2 years or longer

N N

2.28 Decision Tree for Cognitive Impairment 143

Cognitive symptoms (i.e., difficulty in

Y concentration) are Y PREMENSTRUAL entirely accounted for DYSPHORIC by Premenstrual DISORDER (3.4.3) Dysphoric Disorder

N N

Occurring in the context of periods of dysphoric mood starting in the week before onset of menses and becoming absent in the week after menses

ATTENTION- Y Y DEFICIT/

HYPERACTIVITY DISORDER (3.1.4)

Accompanied by other symptoms of inattention and/or hyperactivity/ impulsivity that interfere with functioning, that are present in at least two settings, and that have their onset before age 12 N

Cognitive symptoms (i.e., problems with POSTTRAUMATIC

Y concentration) are Y STRESS DISORDER or entirely accounted for ACUTE STRESS by traumatic stress DISORDER (3.7.1) disorder

Occurring in the context of a response to a traumatic stressor accompanied by intrusion symptoms, avoidance of stimuli associated with the trauma, negative alterations in cognition and mood, and alterations in arousal and reactivity

Cognitive symptoms (e.g., difficulty concentrating or mindY Y GENERALIZED going blank) are ANXIETY DISORDER entirely accounted for (3.5.7) by Generalized Anxiety Disorder

Occurring in the context of excessive anxiety and worry about a number of events or situations, lasting at least 6 months

N N

Cognitive symptoms (i.e., attentional difficulties) are entirely accounted for by Attention-Deficit/ Hyperactivity Disorder

Unable to undergo Y Y GLOBALsystematic assessment

DEVELOPMENTALof intellectual DELAYfunctioning

Onset during developmental period and including both intellectual and adaptive functioning deficits in conceptual, social, and practical domains

144 DSM-5 Handbook of Differential Diagnosis

Deficits in intellectual functioning (confirmed by clinical INTELLECTUAL assessment and Y DISABILITY standardized testing) (INTELLECTUAL and consequent DEVELOPMENTAL deficits in adaptive DISORDER) (3.1.1) functioning with onset during the developmental period

Evidence that the disturbance has more MAJOR

Y than one etiology Y NEUROCOGNITIVE (e.g., cerebrovascular DISORDER DUE TO disease and MULTIPLE Alzheimer’s disease) ETIOLOGIES (3.16.2)

Substantial impairment documented by neuropsychological testing or other quantified assessment, and the deficits interfere with independence

N N

MAJOR NEUROCOGNITIVE

Insidious onset and DISORDER PROBABLY gradual impairment DUE TO occurring in the PARKINSON’S setting of established DISEASE (code first Parkinson’s disease the Parkinson’s

disease) (3.16.2) N

Loss of previously acquired cognitive skills, as in severe traumatic brain injury

INTELLECTUAL DISABILITY (3.1.1) (continue to determine whether a diagnosis of Major or Mild Neurocognitive Disorder is also warranted)

No evidence of mixed etiology, and Parkinson’s disease clearly precedes onset of the Neurocognitive Disorder

MAJOR NEUROCOGNITIVE DISORDER POSSIBLY DUE TO PARKINSON’S DISEASE (3.16.2)

2.28 Decision Tree for Cognitive Impairment 145

MAJORInsidious onset, NEUROCOGNITIVEgradual progression, DISORDER DUE TOand evidence that Y HUNTINGTON’Ssymptoms are the DISEASE (code firstdirect consequence of the Huntington’sHuntington’s disease disease) (3.16.2)

MAJOR Insidious onset, rapid NEUROCOGNITIVE progression, and Y DISORDER DUE TO biomarker evidence PRION DISEASE of prion disease (code first the prion

disease) (3.16.2) N

Insidious onset, gradual progression, and either behavioral symptoms (e.g.,

PROBABLE MAJORdisinhibition, apathy, FRONTOTEMPORALloss of empathy, Y NEUROCOGNITIVEcompulsive behavior, DISORDER (code firsthyperorality) or the frontotemporalprominent decline in disease) (3.16.2)language ability; with

sparing of learning, memory, and perceptual-motor function

Documented infection MAJORwith HIV and not NEUROCOGNITIVEexplained by Y DISORDER DUE TOsecondary brain HIV INFECTIONdiseases such as (code first the HIVherpes encephalitis or infection) (3.16.2)cryptococcosis

Causative frontotemporal neurocognitive disorder genetic mutation or disproportionate frontal or temporal lobe involvement as evidenced in neuroimaging

POSSIBLE MAJOR FRONTOTEMPORAL NEUROCOGNITIVE DISORDER (3.16.2)

Symptoms manifest MAJOR after traumatic brain Y NEUROCOGNITIVE injury and persist past DISORDER DUE TO the acute postinjury TRAUMATIC BRAIN period INJURY (3.16.2)

146 DSM-5 Handbook of Differential Diagnosi

Presence of cerebrovascular disease and features consistent with vascular etiology PROBABLE MAJOR (e.g., onset of VASCULAR cognitive deficits is NEUROCOGNITIVE related to vascular DISORDER (3.16.2) events or evidence of decline is prominent in complex attention and frontal-executive function)

Insidious onset and gradual progression, with any of the following: fluctuating cognition with pronounced variations in attention and

PROBABLE MAJORalertness; recurrent NEUROCOGNITIVEwell-formed and DISORDER WITHdetailed visual LEWY BODIES (codehallucinations; first the Lewy bodyspontaneous features disease) (3.16.2)of parkinsonism with

onset after cognitive decline; Rapid Eye Movement Sleep Behavior Disorder; or severe neuroleptic sensitivity

Two of the following core features: fluctuating cognition, visual hallucinations, spontaneous features of parkinsonism after cognitive decline; or one core feature and either Rapid Eye Movement Sleep Behavior Disorder or severe neuroleptic sensitivity

POSSIBLE MAJOR NEUROCOGNITIVE DISORDER WITH LEWY BODIES (3.16.2)

Neuroimaging supports parenchymal injury due to cerebrovascular disease, the neurocognitive syndrome is temporarily related to documented cerebrovascular events, or there is both clinical and genetic evidence of cerebrovascular disease

POSSIBLE MAJOR VASCULAR NEUROCOGNITIVE DISORDER (3.16.2)

2.28 Decision Tree for Cognitive Impairment 147

N N

PROBABLE MAJOR NEUROCOGNITIVE DISORDER DUE TO ALZHEIMER’S DISEASE (code first the Alzheimer’s disease) (3.16.2)

Evidence from the history, physical MAJOR exam, or laboratory NEUROCOGNITIVE findings that another Y DISORDER DUE TO medical condition ANOTHER MEDICAL (e.g., multiple CONDITION (code sclerosis) is the cause first the other medical of the symptoms condition) (3.16.2)

Caused by the physiological effects SUBSTANCE/ of a substance that MEDICATION-Y persist beyond the INDUCED MAJOR usual duration of NEUROCOGNITIVE Substance Intoxication DISORDER (3.16.2) or Substance Withdrawal

UNSPECIFIED NEUROCOGNITIVE DISORDER

Insidious onset, gradual progression of impairment in at least two cognitive domains

Causative Alzheimer’s disease genetic mutation or all three of the following: clear evidence of decline in memory and one other cognitive domain, steadily progressive cognitive decline without extended plateaus, and no evidence of mixed etiology

POSSIBLE MAJOR NEUROCOGNITIVE DISORDER DUE TO ALZHEIMER’S DISEASE (3.16.2)

148 DSM-5 Handbook of Differential Diagnosis

Modest cognitive MILDdecline from a proven NEUROCOGNITIVElevel of performance, DISORDER DUE TOaccompanied by ANOTHER MEDICALmodest impairment in CONDITION1

cognitive (based on etiologicalperformance that is decision pointsinsufficient to interfere above for Majorwith capacity for Neurocognitiveindependence in Disorder)everyday activities

Due to the direct effects of a general medical condition

Y Y

Caused by the physiological effects of a substance that SUBSTANCE/ persist beyond the Y MEDICATION- usual duration of INDUCED MILD Substance Intoxication NEUROCOGNITIVE or Substance DISORDER Withdrawal

UNSPECIFIED NEUROCOGNITIVE DISORDER

SUBSTANCEY INTOXICATION; SUBSTANCE WITHDRAWAL

Due to the direct physiological effects of a substance

Y UNSPECIFIED NEUROCOGNITIVE DISORDER

Clinically significant cognitive impairment that represents a psychological or biological dysfunction in the individual

“Normal” cognitive impairment (e.g., forgetfulness)

1 The specific decision points for determining the various etiological types of Mild Neurocognitive Disorder have been omitted from this decision tree for brevity. Review the decision points for the various etiological types of Major Neurocognitive Disorder and consult the DSM-5 criteria.

2.29 Decision Tree for Etiological Medical Conditions 149

2.29 Decision Tree for Etiological Medical Conditions A crucial step in the evaluation of every patient is to consider the possibility that the

symptoms are due to the direct physiological effect of a general medical condition (see

Step 3 in Chapter 1). In fact, psychiatric symptoms are sometimes the first harbinger of

a not-yet-diagnosed general medical condition. Determining that a general medical con-

dition is responsible for the psychopathology has obvious treatment implications, be-

cause treatment of the general medical condition is itself important and often results in

the remission of the psychiatric symptoms.

Not every behavioral symptom arising from a general medical condition warrants a

diagnosis of a Mental Disorder Due to Another Medical Condition. Certainly, most pa-

tients who are experiencing anxiety, sadness, fatigue, or sleepless nights because of a

general medical condition do not have a mental disorder that would be covered in this

decision tree. The disorders in this tree should be considered only when the symptoms

are sufficiently severe and prolonged to warrant clinical attention. Not uncommonly, the

psychiatric presentation due to a general medical condition is characterized by a mix-

ture of symptoms from more than one section of the classification (e.g., depression, anx-

iety, and sleep). In most cases, you should choose the diagnosis that reflects the most

prominent aspect of the symptom presentation.

Delirium Due to Multiple Etiologies is included in DSM-5 (and in this tree) to em-

phasize that very often these conditions have multiple interacting etiologies. Moreover,

the medications used to treat general medical conditions often have behavioral side ef-

fects that may be confused both with primary psychiatric symptoms and with the psy-

chiatric manifestations of the general medical condition itself. This is particularly

common in elderly individuals who may be taking a number of different medications

and have a reduced ability to metabolize (or eliminate) them.

Major and Mild Neurocognitive Disorders, especially when persistent, are most of-

ten caused by a general medical condition and are subtyped based on the specific med-

ical etiology. They differ based on whether the individual has a substantial impairment

in cognitive functions that interferes with independence (i.e., Major Neurocognitive Dis-

order) or has modest declines in functions that are insufficiently severe to interfere with

the capacity for independence in everyday activities (i.e., Mild Neurocognitive Disor-

der). Because of the relatively greater clinical importance of Major Neurocognitive Dis-

order, this decision tree provides the decision points for determining the etiological type

only for this condition. The same decision points would apply to the determination of

the etiological type for Mild Neurocognitive Disorder.

Finally, when communicating or recording the diagnoses in this tree, the actual name

of the etiological general medical condition should be recorded rather than the generic

term “due to another medical condition” (e.g., 293.83 [F06.32] Depressive Disorder Due

to Hypothyroidism, With Major Depressive-Like Episode). In addition, it is mandatory

to list (and code) the etiological general medical condition on diagnostic reporting forms

immediately before the mental disorder due to another medical condition (e.g. 244.9

[E03.9] Hypothyroidism; 293.83 [F06.32] Depressive Disorder Due to Hypothyroidism,

With Major Depressive-Like Episode).

150 DSM-5 Handbook of Differential Diagnosis

Etiological medical conditions

DELIRIUM DUE TO MULTIPLE ETIOLOGIES (3.16.1)

Characterized by a disturbance in attention and awareness that has a fluctuating course

DELIRIUM DUE TO ANOTHER MEDICAL CONDITION (3.16.1)

Evidence that the Delirium has more than one etiology (e.g., more than one etiological general medical condition; a general medical condition and Substance Intoxication)

Y Y

Evidence that the MAJORdisturbance has more Y NEUROCOGNITIVEthan one etiology DISORDER DUE TO(e.g., cerebrovascular MULTIPLEdisease and ETIOLOGIES (3.16.2)Alzheimer’s disease)

N MAJOR NEUROCOGNITIVE DISORDER PROBABLY DUE TO PARKINSON’S DISEASE (code first the Parkinson’s disease) (3.16.2)

No evidence of mixed etiology, and Parkinson’s disease clearly precedes onset of the Neurocognitive Disorder

Evidence of decline in one or more of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition, with substantial impairment preferably documented by neuropsychological testing or other quantified assessment, and the deficits interfere with independence

Insidious onset and gradual impairment occurring in the setting of established Parkinson’s disease

MAJOR NEUROCOGNITIVE DISORDER POSSIBLY DUE TO PARKINSON’S DISEASE (3.16.2)

2.29 Decision Tree for Etiological Medical Conditions 151

MAJOR NEUROCOGNITIVE DISORDER DUE TO HUNTINGTON’S DISEASE (code first the Huntington’s disease) (3.16.2)

MAJOR NEUROCOGNITIVE DISORDER DUE TO PRION DISEASE (code first the prion disease) (3.16.2)

POSSIBLE MAJOR FRONTOTEMPORAL NEUROCOGNITIVE DISORDER (3.16.2)

Causative frontotemporal neurocognitive disorder genetic mutation or disproportionate frontal or temporal lobe involvement as evidenced in neuroimaging

Insidious onset, gradual progression, and evidence that symptoms are the direct consequence of Huntington’s disease

Symptoms that MAJORmanifest after NEUROCOGNITIVEtraumatic brain injury DISORDER DUE TOand persist past the TRAUMATIC BRAINacute postinjury INJURY (3.16.2)period

Documented infection MAJORwith HIV and not NEUROCOGNITIVEexplained by DISORDER DUE TOsecondary brain HIV INFECTIONdiseases such as (code first the HIVherpes encephalitis infection) (3.16.2)or cryptococcosis

Insidious onset, rapid progression, and biomarker evidence of prion disease

Insidious onset, gradual progression, and either behavioral symptoms (e.g., disinhibition, apathy, PROBABLE MAJOR loss of empathy, FRONTOTEMPORAL compulsive behavior, NEUROCOGNITIVE hyperorality) or DISORDER (code first prominent decline in the frontotemporal language ability; with disease) (3.16.2) sparing of learning, memory, and perceptual-motor function

152 DSM-5 Handbook of Differential Diagnosis

PROBABLE MAJOR VASCULAR NEUROCOGNITIVE DISORDER (3.16.2)

POSSIBLE MAJOR NEUROCOGNITIVE DISORDER WITH LEWY BODIES (3.16.2)

Insidious onset and gradual progression, with any of the following: fluctuating cognition with pronounced variations in attention PROBABLE MAJOR and alertness; NEUROCOGNITIVE recurrent well-formed DISORDER WITH and detailed visual LEWY BODIES (code hallucinations; first the Lewy body spontaneous features disease) (3.16.2) of parkinsonism with onset after cognitive decline; Rapid Eye Movement Sleep Behavior Disorder; or severe neuroleptic sensitivity

POSSIBLE MAJOR VASCULAR NEUROCOGNITIVE DISORDER (3.16.2)

Presence of cerebrovascular disease and features consistent with vascular etiology (onset of cognitive deficits is related to vascular events or evidence of decline is prominent in complex attention and frontal- executive function)

2.29 Decision Tree for Etiological Medical Conditions 153

MILD NEUROCOGNITIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION1

(based on etiological decision points above for Major Neurocognitive Disorder)

Due to the direct effects of a general medical condition

UNSPECIFIED NEUROCOGNITIVE DISORDER

MAJOR NEUROCOGNITIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION (code first the other medical condition) (3.16.2)

UNSPECIFIED NEUROCOGNITIVE DISORDER

PROBABLE MAJOR NEUROCOGNITIVE DISORDER DUE TO ALZHEIMER’S DISEASE (code first the Alzheimer’s disease) (3.16.2)

POSSIBLE MAJOR NEUROCOGNITIVE DISORDER DUE TO ALZHEIMER’S DISEASE (3.16.2)

Insidious onset, gradual progression of impairment in at least two cognitive domains

Evidence from the history, physical exam, or laboratory findings that another medical condition is the cause of the symptoms

Modest cognitive decline from a proven level of performance, accompanied by modest impairment in cognitive performance that is insufficient to interfere with capacity for independence in everyday activities

154 DSM-5 Handbook of Differential Diagnosis

At least three catatonia symptoms: stupor, catalepsy, CATATONIC waxy flexibility, DISORDER DUE TO mutism, negativism, ANOTHER MEDICAL posturing, mannerism, CONDITION (3.2.5) stereotypy, agitation, grimacing, echolalia, or echopraxia

PSYCHOTICProminent delusions or DISORDER DUE TOhallucinations ANOTHER MEDICALpredominate CONDITION

Prominent and persistent abnormally BIPOLAR AND elevated, expansive, RELATED DISORDER and/or irritable mood DUE TO ANOTHER and abnormally MEDICAL increased activity or CONDITION energy predominates

Prominent and persistent period of DEPRESSIVE depressed mood or DISORDER DUE TO markedly diminished ANOTHER MEDICAL interest or pleasure CONDITION predominates

N ANXIETY DISORDER

Prominent Panic DUE TO ANOTHER Attacks or anxiety MEDICAL

CONDITION

Prominent obsessions; compulsions; preoccupations with appearance; OBSESSIVE- hoarding behavior; COMPULSIVE AND skin-picking, hair- RELATED DISORDER pulling, and other DUE TO ANOTHER body-focused MEDICAL repetitive behaviors; CONDITION or other symptoms characteristic of Obsessive-Compulsive and Related Disorders

2.29 Decision Tree for Etiological Medical Conditions 155

PERSONALITY Change in previous CHANGE DUE TO personality pattern ANOTHER MEDICAL

CONDITION (3.17.11)

Clinically significant symptoms etiologically related OTHER SPECIFIED to a general medical MENTAL DISORDER condition not covered DUE TO ANOTHER above that represent MEDICAL a psychological or CONDITION biological dysfunction in the individual

No mental disorder (symptoms are not clinically significant)

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Differential Diagnosis by the Tables

157

In contrast to the 29 decision trees included in Chapter 2, which use presenting symp-

toms as their starting points, the entry points to the 66 differential diagnosis tables in-

cluded in this chapter are the DSM-5 disorders themselves. Although the practice of

quickly arriving at a working diagnosis based on the gestalt of the patient has its pitfalls

in terms of prematurely closing the clinician’s mind to other equally valid possible diag-

nostic contenders, this is likely the method most often used by experienced clinicians.

To help ensure that your working diagnosis is in fact the best diagnostic fit for your pa-

tient’s clinical presentation, the disorder-oriented differential diagnosis tables can be in-

valuable in providing a comprehensive listing of those DSM-5 disorders that share

important features with your initial working diagnosis so that these disorders can be

considered and ruled out.

The first step is to locate the differential diagnosis table(s) corresponding to your

working diagnosis (or diagnoses, if multiple diagnoses initially seem likely). In the list

included at the end of this introduction, the differential diagnosis tables are grouped ac-

cording to DSM-5 diagnostic class so that the relevant differential diagnosis table is eas-

ier to find. (An alphabetical index of differential diagnosis tables is also available at the

end of this handbook.) Each disorder-oriented differential diagnosis table in this chapter

includes two columns. The first left-hand entry in each table summarizes the definition

of the index disorder to facilitate its differentiation from the other disorders in the table.

The left-hand column lists those disorders (or nonpathological conditions) that share di-

agnostic features with the index disorder and thus need to be considered and ruled out

as part of the differential diagnosis of the index disorder. For each such disorder or non-

pathological condition in the differential diagnosis, the entry in the right-hand column

158 DSM-5 Handbook of Differential Diagnosis

indicates the diagnostic feature that differentiates it from the index disorder. For exam-

ple, the differential diagnosis table for Separation Anxiety Disorder (Table 3.5.1) in-

cludes Agoraphobia in the differential diagnosis because both Separation Anxiety

Disorder and Agoraphobia have anxiety and avoidance as shared diagnostic features,

indicating that if a clinician is considering a diagnosis of Separation Anxiety Disorder

based on the clinical presentation, Agoraphobia should also be considered as a possible

explanatory disorder. The corresponding entry in the right-hand column explains how

Separation Anxiety Disorder and Agoraphobia can be differentiated “[Agoraphobia] is

characterized by anxiety about being trapped or incapacitated in places or situations

from which escape is perceived as difficult in the event of panic-like symptoms or other

incapacitating symptoms. In Separation Anxiety Disorder, the focus of the fear is on sep-

aration from major attachment figures.”

Sometimes it may not be immediately obvious which diagnostic features the other

disorders have in common with the index disorder that would justify their being in-

cluded in the differential diagnosis table. In such cases, the entry in the right-hand col-

umn begins by stating what the putatively shared diagnostic feature is. For example, the

differential diagnosis table for Avoidant/Restrictive Food Intake Disorder (ARFID; Table

3.10.1) includes Autism Spectrum Disorder, which may seem mysterious given that re-

strictive eating behavior is not part of the definition of Autism Spectrum Disorder. The

entry in the right-hand column therefore begins by noting that Autism Spectrum Disor-

der “may be characterized by rigid eating behaviors and heightened sensory sensitivi-

ties,” which is also a feature of ARFID, and then goes on to differentiate the two disorders

by noting that “this often does not result in the level of impairment that would be re-

quired for a diagnosis of ARFID.”

Multiple disorders are grouped in some tables to reduce the number of differential

diagnosis tables. In some tables, such as Table 3.2.1, Schizophrenia or Schizophreniform

Disorder, and Table 3.7.1, Posttraumatic Stress Disorder or Acute Stress Disorder, the

disorders have been grouped together because they share virtually all the same diagnos-

tic features except duration (which is noted in an accompanying footnote) and therefore

share the same differential diagnosis list. In other tables, such as Table 3.1.2, Communi-

cation Disorders, a single differential diagnosis table is provided that covers all the dis-

orders in that diagnostic grouping as if that were a single disorder. In these types of

tables, if a disorder is included in the differential diagnosis list that pertains to only one

of the disorders within that diagnostic grouping, it will be indicated in a parenthetical

phrase. For example, in Table 3.1.2, although most of the differential diagnostic entries

listed apply to all of the communication disorders, the entry for Autism Spectrum Dis-

order applies only to Social (Pragmatic) Communication Disorder. Therefore, the phrase

“(as distinguished from Social [Pragmatic] Communication Disorder)” is included in

that row of the table to indicate that this differentiation applies only to that disorder.

Some caveats should be kept in mind regarding the use of the tables. First, although

the entries in the tables focus on the features that differentiate between disorders, given

that only a minority of DSM-5 disorders (e.g., Bipolar I Disorder and Major Depressive

Disorder) are by definition mutually exclusive, diagnostic comorbidity is the default po-

sition. Thus, unless otherwise stated, if the criteria are fully met for both the index dis-

order and a disorder in the table, both should be diagnosed.

Differential Diagnosis by the Tables 159

Second, although the pertinent other specified and unspecified categories are not in-

cluded in the differential diagnosis tables, they are an important consideration in the dif-

ferential diagnosis for every disorder. Every experienced clinician knows that the

complexity of practice offers many presentations that fall between the neatly defined

DSM-5 disorders. Many patients do not present a clear picture that comfortably approx-

imates the prototype for any of the disorders described in the DSM-5 criteria sets. In-

stead, patients often have clinical features that appear to be at the boundary between

criteria sets or that satisfy the criteria for a number of possibly related disorders. It is im-

portant to recognize that a boundary patient is indeed a boundary patient and should

not be shoehorned into a diagnosis that does not fit well. Such patients may require se-

rial trials of treatment to help clarify the most appropriate diagnosis and plan of man-

agement.

Third, the differential diagnosis tables tend to focus on cross-sectional symptom pre-

sentations because these are the easiest to define and evaluate. Other factors that may be

useful in guiding differential diagnosis include the patient’s previous history, family his-

tory of psychopathology, course, biological test results, and responses to previous treat-

ment trials. Especially in doubtful cases, these factors may tip the differential diagnostic

balance one way or the other.

Differential diagnostic tables grouped by DSM-5 diagnostic class

Neurodevelopmental Disorders 3.1.1 Intellectual Disability (Intellectual Developmental Disorder) 3.1.2 Communication Disorders 3.1.3 Autism Spectrum Disorder 3.1.4 Attention-Deficit/Hyperactivity Disorder 3.1.5 Specific Learning Disorder 3.1.6 Tic Disorders

Schizophrenia Spectrum and Other Psychotic Disorders 3.2.1 Schizophrenia or Schizophreniform Disorder 3.2.2 Schizoaffective Disorder 3.2.3 Delusional Disorder 3.2.4 Brief Psychotic Disorder 3.2.5 Unspecified Catatonia

Bipolar and Related Disorders 3.3.1 Bipolar I Disorder 3.3.2 Bipolar II Disorder 3.3.3 Cyclothymic Disorder

Depressive Disorders 3.4.1 Major Depressive Disorder 3.4.2 Persistent Depressive Disorder (Dysthymia) 3.4.3 Premenstrual Dysphoric Disorder 3.4.4 Disruptive Mood Dysregulation Disorder

160 DSM-5 Handbook of Differential Diagnosis

Anxiety Disorders 3.5.1 Separation Anxiety Disorder 3.5.2 Selective Mutism 3.5.3 Specific Phobia 3.5.4 Social Anxiety Disorder (Social Phobia) 3.5.5 Panic Disorder 3.5.6 Agoraphobia 3.5.7 Generalized Anxiety Disorder

Obsessive-Compulsive and Related Disorders 3.6.1 Obsessive-Compulsive Disorder 3.6.2 Body Dysmorphic Disorder 3.6.3 Hoarding Disorder 3.6.4 Trichotillomania (Hair-Pulling Disorder) 3.6.5 Excoriation (Skin-Picking) Disorder

Trauma- and Stressor-Related Disorders 3.7.1 Posttraumatic Stress Disorder or Acute Stress Disorder 3.7.2 Adjustment Disorder

Dissociative Disorders 3.8.1 Dissociative Amnesia 3.8.2 Depersonalization/Derealization Disorder

Somatic Symptom and Related Disorders 3.9.1 Somatic Symptom Disorder 3.9.2 Illness Anxiety Disorder 3.9.3 Conversion Disorder (Functional Neurological Symptom Disorder) 3.9.4 Psychological Factors Affecting Other Medical Conditions 3.9.5 Factitious Disorder

Feeding and Eating Disorders 3.10.1 Avoidant/Restrictive Food Intake Disorder 3.10.2 Anorexia Nervosa 3.10.3 Bulimia Nervosa 3.10.4 Binge-Eating Disorder

Sleep-Wake Disorders 3.11.1 Insomnia Disorder 3.11.2 Hypersomnolence Disorder

Sexual Dysfunctions 3.12.1 Sexual Dysfunctions

Gender Dysphoria 3.13.1 Gender Dysphoria

Differential diagnostic tables grouped by DSM-5 diagnostic class (continued)

Differential Diagnosis by the Tables 161

Disruptive, Impulse-Control, and Conduct Disorders 3.14.1 Oppositional Defiant Disorder 3.14.2 Intermittent Explosive Disorder 3.14.3 Conduct Disorder

Substance-Related and Addictive Disorders 3.15.1 Substance Use Disorders 3.15.2 Gambling Disorder

Neurocognitive Disorders 3.16.1 Delirium 3.16.2 Major or Mild Neurocognitive Disorder

Personality Disorders 3.17.1 Paranoid Personality Disorder 3.17.2 Schizoid Personality Disorder 3.17.3 Schizotypal Personality Disorder 3.17.4 Antisocial Personality Disorder 3.17.5 Borderline Personality Disorder 3.17.6 Histrionic Personality Disorder 3.17.7 Narcissistic Personality Disorder 3.17.8 Avoidant Personality Disorder 3.17.9 Dependent Personality Disorder 3.17.10 Obsessive-Compulsive Personality Disorder 3.17.11 Personality Change Due to Another Medical Condition

Paraphilic Disorders 3.18.1 Paraphilic Disorders

Differential diagnostic tables grouped by DSM-5 diagnostic class (continued)

162 DSM-5 Handbook of Differential Diagnosis

Neurodevelopmental Disorders 3.1.1 Differential Diagnosis for Intellectual Disability

(Intellectual Developmental Disorder)

Intellectual Disability, which is character- In contrast to Intellectual Disability.. . ized by global deficits in intellectual functions (such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learn- ing from experience) and deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility, must be differ- entiated from...

Specific Learning Disorder Is characterized by an impairment con- fined to a specific area of academic achievement (e.g., reading, spelling, written expression, performing arithme- tic calculations, mathematical reason- ing). There are no deficits in intellectual and adaptive behavior.

Communication Disorders (i.e., Language Are characterized by impairments that are Disorder, Speech Sound Disorder, confined to speech or language prob- Childhood-Onset Fluency Disorder lems. There are no deficits in intellectual [Stuttering], Social [Pragmatic] and adaptive behavior. Communication Disorder)

Autism Spectrum Disorder Is defined by the presence of persistent deficits in social communication and so- cial interaction, along with restricted, re- petitive patterns of behaviors, interests, or activities. Although there may be some impairment in social-communica- tive skills in Intellectual Disability, it is on par with deficits in other intellectual skills. Intellectual Disability is frequently comorbid with Autism Spectrum Disor- der, and if criteria are met for both, both diagnoses should be given.

Neurodevelopmental Disorders 163

Major Neurocognitive Disorder Is characterized by a significant cognitive decline from a previous level of perfor- mance in one or more cognitive domains such as executive function, learning, memory, and language. Both Major Neu- rocognitive Disorder and Intellectual Disability can be diagnosed if the onset of intellectual and adaptive deficits is during the developmental period.

Borderline intellectual functioning Is characterized by a lesser degree of intel- lectual impairment (typically IQ around 70) or no problems in adaptive function- ing if there are significant intellectual im- pairments (e.g., IQ is below 70).

3.1.1 Differential Diagnosis for Intellectual Disability

(Intellectual Developmental Disorder) (continued)

164 DSM-5 Handbook of Differential Diagnosis

3.1.2 Differential Diagnosis for Communication Disorders

Communication Disorders (i.e., Language In contrast to Communication Disorders.. . Disorder, Speech Sound Disorder, Child- hood-Onset Fluency Disorder [Stutter- ing], Social [Pragmatic] Communication Disorder) must be differentiated from...

Intellectual Disability (Intellectual Involves an overall impairment in intellec- Developmental Disorder) tual functioning as opposed to only lan-

guage impairment. A Communication Disorder can also be diagnosed if the lan- guage problems are in excess of those usually associated with Intellectual Dis- ability.

Communication difficulties related to Are attributable to hearing impairment, a hearing impairment, a neurological neurological deficit, a motor disorder, or deficit (e.g., Landau-Kleffner syndrome), a structural defect and are not in excess of a motor disorder (e.g., dysarthria), or a that expected given the sensory or structural defect (e.g., cleft palate) speech-motor deficit. A Communication

Disorder can be diagnosed if the prob- lems in communication are in excess of those usually associated with the deficits or disorders.

Selective Mutism Is characterized by a lack of speech in some settings (e.g., in school, with strangers), whereas the child speaks nor- mally in “safe” settings (e.g., at home). In a Communication Disorder, the commu- nication problems are consistent across all settings. Some children with a Com- munication Disorder may develop Selec- tive Mutism because of embarrassment about their speech deficits.

Tourette’s Disorder (as distinguished from Is characterized by vocal tics and repetitive Childhood-Onset Fluency Disorder) vocalizations that differ in nature and tim-

ing from the repetitive sounds of Child- hood-Onset Fluency Disorder, which are characterized by broken words (i.e., pauses within a word), audible or silent blocking (i.e., filled or unfilled pauses in speech), circumlocutions (i.e., word sub- stitutions to avoid problematic words), words produced with an excess of physi- cal tension, and monosyllabic whole- word repetitions (e.g., “I-I-I-I see him”).

Neurodevelopmental Disorders 165

Autism Spectrum Disorder (as Is characterized by restricted, repetitive distinguished from Social [Pragmatic] patterns of behavior, interests, or activi- Communication Disorder) ties in addition to social communication

deficits, whereas in Social (Pragmatic) Communication Disorder, restricted, re- petitive patterns of behavior, interests, or activities are absent.

Social Anxiety Disorder (Social Phobia) Is characterized by the lack of use of ap- (as distinguished from Social [Pragmatic] propriately developed social communi- Communication Disorder) cation skills because of anxiety, fear, or

distress about social interactions. In So- cial (Pragmatic) Communication Disor- der, these skills have never been present.

Normal dysfluencies or articulation Are developmentally appropriate. difficulties in young children

3.1.2 Differential Diagnosis for Communication Disorders (continued)

166 DSM-5 Handbook of Differential Diagnosis

3.1.3 Differential Diagnosis for Autism Spectrum Disorder

Autism Spectrum Disorder, which is char- In contrast to Autism Spectrum acterized by persistent deficits in social Disorder.. . communication and social interaction across multiple contexts, accompanied by restricted, repetitive patterns of be- havior, interests, or activities, must be differentiated from...

Rett’s Disorder Includes disruptions in social interactions during the regressive phase of this neuro- logical condition (i.e., between ages 1 and 4), which is also characterized by deceler- ation in head growth, loss of hand move- ments, and poor coordination.

Schizophrenia Childhood-onset Schizophrenia usually develops after a period of normal, or near-normal, development. The Schizo- phrenia prodromal state may include social impairment and atypical interests and beliefs, which could be confused with the social deficits seen in Autism Spectrum Disorder. Hallucinations and delusions, which are defining features of Schizophrenia, are not seen in Autism Spectrum Disorder.

Selective Mutism Is characterized by normal early develop- ment and by appropriate social commu- nication functioning in certain “safe” contexts and settings (e.g., at home with parents).

Language Disorder Is characterized by a lack of qualitative im- pairment in social interaction, and the in- dividual’s range of interests and behaviors are not restricted.

Social (Pragmatic) Communication Is characterized by impairment in social Disorder communication and social interactions

without the restricted and repetitive behaviors or interests characteristic of Autism Spectrum Disorder.

Neurodevelopmental Disorders 167

Intellectual Disability (Intellectual Involves general impairment in intellec- Developmental Disorder) tual functioning; there is no discrepancy

between the level of the social communi- cative skills and other intellectual skills. A diagnosis of Autism Spectrum Disor- der in an individual with Intellectual Dis- ability is appropriate when social communication and interaction are sig- nificantly impaired relative to the devel- opmental level of the individual’s nonverbal skills.

Stereotypic Movement Disorder Occurs in the absence of impairment of social interaction and language develop- ment. Stereotypic Movement Disorder is generally not diagnosed if the stereotypy is part of Autism Spectrum Disorder; however, when stereotypies cause self- injury and become a focus of treatment, both diagnoses may be appropriate.

3.1.3 Differential Diagnosis for Autism Spectrum Disorder (continued)

168 DSM-5 Handbook of Differential Diagnosis

3.1.4 Differential Diagnosis for Attention-Deficit/Hyperactivity

Disorder

Attention-Deficit/Hyperactivity Disorder In contrast to Attention-Deficit/Hyperac- (ADHD), which is characterized by tivity Disorder... symptoms of inattention, hyperactivity, and impulsivity that are inconsistent with developmental level and that nega- tively impact social and academic/occu- pational activities, must be differentiated from...

Normative behaviors in active children Are consistent with developmental level.

Understimulating environments Lead to inattention that is related to bore- dom.

Oppositional Defiant Disorder May be characterized by resistance to work or school tasks because of a refusal to submit to others’ demands, which is accompanied by negativity, hostility, and defiance. In ADHD, however, the aver- sion to school or mentally demanding tasks is due to difficulty in sustaining mental effort, forgetting instructions, and impulsivity.

Intermittent Explosive Disorder Is also characterized by high levels of im- pulsive behavior, but unlike ADHD, there are episodes of serious aggression toward others. An additional diagnosis of Intermittent Explosive Disorder can be made if the recurrent impulsive aggres- sive outbursts are in excess of those usu- ally seen in ADHD and warrant independent clinical attention.

Conduct Disorder May be characterized by high levels of im- pulsivity, but there is also a pattern of an- tisocial behavior.

Stereotypic Movement Disorder Is characterized by repetitive motor be- havior that may resemble the increased motor behavior in ADHD. In contrast to ADHD, however, the motor behavior is generally fixed and repetitive (e.g., body rocking, self-biting), whereas the fidgeti- ness and restlessness in ADHD are typi- cally generalized.

Neurodevelopmental Disorders 169

Specific Learning Disorder May be characterized by inattentive be- havior because of frustration, lack of in- terest, or limited ability. However, inattention in individuals with Specific Learning Disorder who do not have ADHD is not impairing outside of schoolwork.

Intellectual Disability (Intellectual May be characterized by symptoms of in- Developmental Disorder) attention, hyperactivity, and impulsivity

among children placed in academic set- tings that are inappropriate to their intel- lectual ability. Individuals with Intellectual Disability without ADHD do not have symptoms during nonacademic tasks. A diagnosis of ADHD in individu- als with Intellectual Disability requires that the inattention or hyperactivity be excessive for the individual’s mental age.

Autism Spectrum Disorder May be characterized by social disengage- ment and social isolation due to deficits in social communication, as well as tem- per tantrums due to an inability to toler- ate a change from the expected course of events, whereas social dysfunction and peer rejection in ADHD are related to symptoms of inattention and hyperactiv- ity, and misbehavior and temper tan- trums are related to impulsivity or poor self-control.

Disinhibited Social Engagement Disorder Is characterized by social disinhibition, but not the full ADHD symptom cluster. Children with Disinhibited Social En- gagement Disorder also have a history of extremes of insufficient care.

Disruptive Mood Dysregulation Disorder Is characterized by pervasive irritability and intolerance of frustration. Given that most children and adolescents with Dis- ruptive Mood Dysregulation Disorder also have symptoms that meet criteria for ADHD, an additional diagnosis may be made.

3.1.4 Differential Diagnosis for Attention-Deficit/Hyperactivity

Disorder (continued)

170 DSM-5 Handbook of Differential Diagnosis

Anxiety Disorders May be characterized by symptoms of in- attention due to fear, worry, and rumina- tion. In ADHD, the inattention is because of attraction to external stimuli or new activities, or preoccupation with enjoy- able activities.

Major Depressive Disorder May be characterized by an inability to concentrate; however, the poor concen- tration is prominent only during Major Depressive Episodes.

Bipolar I and Bipolar II Disorder May be characterized by increased activity, poor concentration, increased impulsiv- ity, and distractibility, but these features are episodic, occurring several days to weeks at a time. Moreover, the symptoms are accompanied by elevated or irritable mood, grandiosity, and other specific bipolar features. Although individuals with ADHD may show significant changes in mood within the same day, such lability is distinct from a Manic or Hypomanic Episode, which must be sustained and last at least a week (or 4 days for a Hypomanic Episode) to be a clinical indicator of Bipolar I or Bipolar II Disorder.

Borderline, Antisocial, and Narcissistic Share the features of disorganization, so- Personality Disorders cial intrusiveness, emotional dysregula-

tion, and cognitive dysregulation. These disorders are distinguished from ADHD by the presence of additional maladap- tive features, such as self-injury, antiso- cial behavior, fear of abandonment, and lack of empathy. If criteria are met for both ADHD and a Personality Disorder, both may be diagnosed.

3.1.4 Differential Diagnosis for Attention-Deficit/Hyperactivity

Disorder (continued)

Neurodevelopmental Disorders 171

Medication-induced symptoms of ADHD Are characterized by symptoms of inatten- tion, hyperactivity, or impulsivity caused by medications (e.g., bronchodilators, iso- niazid, neuroleptics [resulting in akathi- sia], thyroid replacement medication) and remit when the medications are stopped. ADHD is not diagnosed if the symptoms occur only during medication use.

Neurocognitive Disorders May be characterized by cognitive impair- ments similar to those in ADHD; they are distinguished by their typically later age at onset.

3.1.4 Differential Diagnosis for Attention-Deficit/Hyperactivity

Disorder (continued)

172 DSM-5 Handbook of Differential Diagnosis

3.1.5 Differential Diagnosis for Specific Learning Disorder

Specific Learning Disorder, which is char- In contrast to Specific Learning Disorder.. . acterized by difficulties in learning and using academic skills (e.g., reading, spell- ing, written expression, performing arithmetic calculations, mathematical reasoning), must be differentiated from...

Normal variations in academic Do not result in clinically significant inter- attainment ference with academic achievement, oc-

cupational performance, or activities of daily living that require these academic skills; the affected academic skills are not substantially and quantifiably below those expected for the individual’s chronological age (based on appropriate standardized measures); or the difficul- ties abate with the provision of interven- tions that target the difficulties.

Poor academic performance due to lack Represents factors external to the individ- of opportunity, poor teaching, or learning ual and thus not indicative of an internal in a second language dysfunction. To justify a diagnosis of

Specific Learning Disorder, the learning difficulties must persist in the presence of adequate educational opportunity, expo- sure to the same instruction as the peer group, and competency in the language of instruction.

Poor academic performance due to Is at a level that would be expected given impaired vision or hearing or other the nature of the sensory or neurological neurological deficit deficit. Specific Learning Disorder can

still be diagnosed if the academic diffi- culties are not adequately accounted for by the sensory or neurological deficit.

Intellectual Disability (Intellectual Consists of an overall impairment in intel- Developmental Disorder) lectual functioning that is not confined to

a particular academic skill. Specific Learning Disorder can be diagnosed along with Intellectual Disability as long as the learning difficulties are in excess of those usually associated with the Intel- lectual Disability.

Neurodevelopmental Disorders 173

Autism Spectrum Disorder Includes persistent deficits in social com- munication and social interaction, along with restricted, repetitive patterns of be- haviors, interests, or activities; these def- icits and patterns are not confined to a particular academic skill.

Communication Disorders Involves impairment in speech or lan- guage skills that are not restricted to par- ticular academic skills, such as reading or writing.

Major Neurocognitive Disorder The difficulties are manifested as a marked decline from a former state, whereas in Specific Learning Disorder the difficul- ties occur during the developmental pe- riod and do not represent a loss of previously acquired skills.

Attention-Deficit/Hyperactivity Disorder Is characterized by problems that reflect difficulties in performing academic skills due to inattention, hyperactivity, and/or impulsivity rather than specific difficul- ties learning academic skills.

Schizophrenia Associated academic and cognitive pro- cessing difficulties may result in an often rapid decline in academic functioning that has its onset in adolescence or early adulthood, whereas the learning difficul- ties in Specific Learning Disorder become apparent during the elementary school years when children are required to learn to read, spell, write, and do mathematics.

3.1.5 Differential Diagnosis for Specific Learning Disorder (continued)

174 DSM-5 Handbook of Differential Diagnosis

3.1.6 Differential Diagnosis for Tic Disorders

Tic Disorders (i.e., Tourette’s Disorder, Per- In contrast to Tic Disorders... sistent [Chronic] Motor or Vocal Tic Dis- order, Provisional Tic Disorder), which are characterized by sudden, rapid, re- current, nonrhythmic motor movements or vocalizations, must be differentiated from...

Choreiform movements associated with Are characterized by rapid, random, con- neurological or other medical conditions tinual, abrupt, irregular, unpredictable,

nonstereotyped actions that are usually bilateral and affect all parts of the body (i.e., face, trunk, and limbs).

Dystonic movements associated with Are characterized by the simultaneous neurological or other medical conditions sustained contracture of both agonist and

antagonist muscles, resulting in distorted posture or movement of parts of the body.

Myoclonus Is characterized by sudden unidirectional movements that are often nonrhythmic and may be worsened by movement and occur during sleep. Myoclonus is differ- entiated from tics by its rapidity, lack of suppressibility, and absence of a premon- itory urge.

Tics caused by substances or medications Remit when the substance or medication (e.g., stimulant) is discontinued and are diagnosed as Unspecified Substance– Related Disorder or Other Medication- Induced Movement Disorder.

Stereotypic Movement Disorder, or Are characterized by nonfunctional, usu- stereotypies in Autism Spectrum ally rhythmic, seemingly driven behav- Disorder iors that are generally more complex than

tics.

Compulsions in Obsessive-Compulsive Occur in response to an obsession or ac- Disorder cording to rigidly applied rules.

Schizophrenia May be characterized by disorganized or bizarre vocalizations or behaviors that are accompanied by the other characteristic symptoms (e.g., delusions, negative symp- toms) and have a characteristic course (e.g., marked decline in functioning).

Schizophrenia Spectrum and Other Psychotic Disorders 175

Schizophrenia Spectrum and Other Psychotic Disorders 3.2.1 Differential Diagnosis for Schizophrenia or

Schizophreniform Disordera

Schizophrenia and Schizophreniform Dis- In contrast to Schizophrenia or Schizo- order, which are characterized by a dis- phreniform Disorder.. . turbance lasting for months (at least 6 months for Schizophrenia and between 1 and 6 months for Schizophreniform Disorder) that significantly impairs func- tioning and that includes at least 1 month of active-phase psychotic symptoms, must be differentiated from...

Psychotic Disorder Due to Another Requires the presence of an etiological Medical Condition, Delirium, or general medical condition. Schizophre- Major Neurocognitive Disorder nia or Schizophreniform Disorder is not Due to Another Medical Condition diagnosed if the psychotic symptoms are

all due to the direct physiological effects of another medical condition.

Substance/Medication-Induced Psychotic Requires that the psychotic symptoms be Disorder, Substance/Medication-Induced initiated and maintained by substance Neurocognitive Disorder, Substance use (including medication side effects). Intoxication Delirium, Substance Schizophrenia or Schizophreniform Dis- Withdrawal Delirium, Medication- order is not diagnosed if the psychotic Induced Delirium, Substance Intoxication, symptoms are all due to the direct physi- or Substance Withdrawal ological effects of a substance (including

medication).

Schizoaffective Disorder Is characterized by symptoms that meet criteria for a Major Depressive Episode or Manic Episode, and the mood episodes are present for the majority of the total duration of the active and residual por- tion of the illness. In Schizophrenia or Schizophreniform Disorder, the mood episodes have been present for a minor- ity of the total duration of the active and residual periods of the illness.

Major Depressive Disorder With Psychotic Is characterized by psychotic or catatonic Features, Bipolar I or Bipolar II Disorder symptoms that occur exclusively during With Psychotic Features, Catatonia Manic or Major Depressive Episodes. Associated With Major Depressive Disorder, or Catatonia Associated With Bipolar I or Bipolar II Disorder

176 DSM-5 Handbook of Differential Diagnosis

Brief Psychotic Disorder Is characterized by a total duration of psy- chotic symptoms of at least 1 day but less than 1 month.

Delusional Disorder Is characterized by delusions occurring in the absence of the other characteristic symptoms of Schizophrenia (i.e., promi- nent auditory or visual hallucinations, disorganized speech, grossly disorga- nized or catatonic behavior, negative symptoms).

Posttraumatic Stress Disorder May be characterized by flashbacks that have a hallucinatory quality and hyper- vigilance that may reach paranoid pro- portions, but it is distinguished by the requirement of exposure to a traumatic event with a characteristic cluster of in- trusion, avoidance, and other symptoms.

Autism Spectrum Disorder Is characterized by an early onset (e.g., be- fore age 3 years) and an absence of prom- inent delusions or hallucinations. A diagnosis of Schizophrenia or Schizo- phreniform Disorder is warranted in in- dividuals with a preexisting diagnosis of Autism Spectrum Disorder only if prom- inent hallucinations or delusions have been present for at least 1 month.

Schizotypal, Schizoid, and Paranoid Are characterized by personality features Personality Disorders that are subthreshold versions of many of

the symptoms of Schizophrenia (e.g., odd beliefs, perceptual distortions, odd think- ing and speech, social anxiety).

a Schizophrenia and Schizophreniform Disorder have essentially the same differential diagnosis and thus have been combined for the purposes of this differential diagnosis table. They are dif- ferentiated primarily based on the duration of the disturbance. In Schizophreniform Disorder, the duration is between 1 and 6 months. In Schizophrenia, the duration is 6 months or longer.

3.2.1 Differential Diagnosis for Schizophrenia or

Schizophreniform Disordera (continued)

Schizophrenia Spectrum and Other Psychotic Disorders 177

3.2.2 Differential Diagnosis for Schizoaffective Disorder

Schizoaffective Disorder, which is charac- In contrast to Schizoaffective Disorder... terized by times in which Major Depres- sive or Manic Episodes overlap with active-phase symptoms of Schizophrenia and times in which there are delusions or hallucinations without mood symptoms, must be differentiated from...

Psychotic Disorder Due to Another Requires the presence of an etiological Medical Condition, Delirium, or Major general medical condition. Schizoaffec- Neurocognitive Disorder Due to Another tive Disorder is not diagnosed if the psy- Medical Condition chotic or mood symptoms are all due to

the direct physiological effects of another medical condition.

Substance/Medication-Induced Psychotic Requires that the psychotic and mood Disorder, Substance/Medication-Induced symptoms be due to substance use (in- Neurocognitive Disorder, Substance cluding medication side effects). Intoxication Delirium, Substance Schizoaffective Disorder is not diagnosed Withdrawal Delirium, Medication- if the psychotic or mood symptoms are Induced Delirium, Substance Intoxication, all due to the direct physiological effects or Substance Withdrawal of a substance (including medication).

Schizophrenia Is characterized either by no mood epi- sodes or, if mood episodes have been present, by mood episodes that have been present for a minority of the total duration of the active and residual peri- ods of the illness.

Bipolar I, Bipolar II, or Major Depressive Is characterized by psychotic symptoms Disorder With Psychotic Features that occur exclusively during Manic or

Major Depressive Episodes.

Delusional Disorder Is characterized by delusions occurring in the absence of other symptoms that meet DSM-5 Criterion A for Schizophrenia (i.e., prominent auditory or visual hallu- cinations, disorganized speech, grossly disorganized or catatonic behavior, nega- tive symptoms).

178 DSM-5 Handbook of Differential Diagnosis

3.2.3 Differential Diagnosis for Delusional Disorder

Delusional Disorder, which is character- In contrast to Delusional Disorder... ized by persistent delusions without other psychotic symptoms, must be dif- ferentiated from...

Psychotic Disorder Due to Another Requires the presence of an etiological Medical Condition, Delirium, or general medical condition. Delusional Major Neurocognitive Disorder Due to Disorder is not diagnosed if the delusions Another Medical Condition are all due to the direct physiological ef-

fects of another medical condition.

Substance/Medication-Induced Psychotic Requires that the psychotic symptoms are Disorder, Substance/Medication- due to substance use (including medica- Induced Neurocognitive Disorder, tion side effects). Delusional Disorder is Substance Intoxication Delirium, not diagnosed if the delusions are all due Substance Withdrawal Delirium, to the direct physiological effects of a Medication-Induced Delirium, substance (including medication). Substance Intoxication, or Substance Withdrawal

Schizophrenia or Is characterized by the presence of other Schizophreniform Disorder symptoms (in addition to prominent de-

lusions) that meet DSM-5 Criterion A for Schizophrenia (i.e., prominent auditory or visual hallucinations, delusions, disor- ganized speech, grossly disorganized or catatonic behavior, negative symptoms).

Bipolar or Major Depressive Disorder, Is characterized by delusions that occur With Psychotic Features exclusively during Manic or Major

Depressive Episodes. When there is a history of Manic or Major Depressive Episodes, Delusional Disorder can be diagnosed only if the total duration of all mood episodes remains brief relative to the total duration of the delusional disturbance. If not, then the appropriate diagnosis is Other Specified Psychotic Disorder.

Brief Psychotic Disorder Is characterized by psychotic symptoms that last for less than 1 month. In Delu- sional Disorder, the minimum duration of the delusions is 1 month.

Schizophrenia Spectrum and Other Psychotic Disorders 179

Obsessive-Compulsive Disorder If an individual with Obsessive-Compul- sive Disorder is completely convinced that his or her Obsessive-Compulsive Disorder beliefs are true, then the diagno- sis should be Obsessive-Compulsive Dis- order With Absent Insight/Delusional Beliefs, rather than Delusional Disorder.

Body Dysmorphic Disorder In situations in which an individual with Body Dysmorphic Disorder is com- pletely convinced that his or her beliefs that his or her appearance is defective are true, then the diagnosis should be Body Dysmorphic Disorder With Absent Insight/Delusional Beliefs, rather than Delusional Disorder.

Paranoid Personality Disorder Is characterized by paranoid ideation without clear-cut or persisting delusional beliefs.

3.2.3 Differential Diagnosis for Delusional Disorder (continued)

180 DSM-5 Handbook of Differential Diagnosis

3.2.4 Differential Diagnosis for Brief Psychotic Disorder

Brief Psychotic Disorder, which is charac- In contrast to Brief Psychotic Disorder... terized by psychotic symptoms lasting less than 1 month, must be differentiated from...

Psychotic Disorder Due to Another Requires the presence of an etiological Medical Condition, Delirium, or general medical condition. Brief Psy- Major Neurocognitive Disorder Due to chotic Disorder is not diagnosed if the Another Medical Condition psychotic symptoms are all due to the di-

rect physiological effects of a general medical condition.

Substance/Medication-Induced Psychotic Requires that the psychotic symptoms be Disorder, Substance/Medication-Induced due to substance use (including medica- Neurocognitive Disorder, Substance tion side effects). Brief Psychotic Disor- Intoxication Delirium, Substance der is not diagnosed if the psychotic Withdrawal Delirium, Medication- symptoms are all due to the direct physi- Induced Delirium, Substance Intoxication, ological effects of a substance (including or Substance Withdrawal medication).

Bipolar or Major Depressive Disorder, Is characterized by psychotic symptoms With Psychotic Features occurring exclusively during mood epi-

sodes. Brief Psychotic Disorder is not di- agnosed if the psychotic symptoms are better accounted for by Bipolar or Major Depressive Disorder With Psychotic Fea- tures.

Schizophreniform Disorder, Is characterized by psychotic symptoms Schizophrenia, or Delusional Disorder that last 1 month or longer.

Psychotic symptoms occurring in the Are usually transient and last less than context of some Personality Disorders 1 day. If clinically significant, they may be (e.g., Borderline Personality Disorder) diagnosed as Other Specified Schizo-

phrenia Spectrum and Other Psychotic Disorder or as Unspecified Schizophre- nia Spectrum and Other Psychotic Disor- der. If psychotic symptoms persist for at least 1 day, the additional diagnosis of Brief Psychotic Disorder may be war- ranted.

Schizophrenia Spectrum and Other Psychotic Disorders 181

3.2.5 Differential Diagnosis for Unspecified Catatonia

Unspecified Catatonia, which is for pre- In contrast to Unspecified Catatonia.. . sentations in which there are clinically significant symptoms of Catatonia and either the nature of the underlying men- tal disorder or general medical condition is unclear or full criteria for the syndrome of Catatonia are not met, must be differ- entiated from...

Catatonic Disorder Due to Another Is characterized by the full syndrome of Medical Condition Catatonia that is due to the physiological

effects of a medical condition, especially neurological conditions (e.g., neoplasms, head trauma, cerebrovascular disease, en- cephalitis) and metabolic conditions (e.g., hypercalcemia, hepatic encephalopathy, homocystinuria, diabetic ketoacidosis).

Mutism or posturing in Delirium Due to Is characterized by catatonic symptoms Another Medical Condition occurring in the context of a disturbance

in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment). Catatonic Disorder Due to Another Medical Condition is not diagnosed if the symptoms occur exclu- sively during the course of Delirium.

Akinesia, rigidity, or posturing in Is due to the direct physiological effects of medication-induced movement a medication, including neuroleptics. disorders (including Neuroleptic Malignant Syndrome)

Catatonia Associated With Schizophrenia, Is characterized by the full syndrome of Catatonia Associated With Catatonia that is accompanied by other Schizoaffective Disorder, Catatonia characteristic symptoms of the relevant Associated With Schizophreniform psychotic disorder. Disorder, or Catatonia Associated With Brief Psychotic Disorder

Catatonia Associated With Bipolar or Is characterized by the full syndrome of Major Depressive Disorder Catatonia that occurs exclusively during

a Manic or Major Depressive Episode.

Catatonia Associated With Autism Is characterized by the full syndrome of Spectrum Disorder Catatonia that is accompanied by the

characteristic symptoms of Autism Spec- trum Disorder (e.g., social communica- tion difficulties, restricted repertoire of interests and behaviors).

182 DSM-5 Handbook of Differential Diagnosis

Bipolar and Related Disorders 3.3.1 Differential Diagnosis for Bipolar I Disorder

Bipolar I Disorder, which is charac- In contrast to Bipolar I Disorder.. . terized by at least one Manic Epi- sode that may have been preceded by or followed by Hypomanic or Major Depressive Episodes, must be differentiated from...

Bipolar and Related Disorder Due to Requires the presence of an etiological medical Another Medical Condition condition. Bipolar I Disorder is not diagnosed if

the mood episodes are all due to the direct physiological effects of another medical condi- tion.

Substance/Medication-Induced Is due to the direct physiological effects of a sub- Bipolar and Related Disorder stance. A full Manic Episode that emerges dur-

ing antidepressant treatment (e.g., with a selective serotonin reuptake inhibitor) but per- sists at a fully syndromal level beyond the physiological effect of that treatment meets cri- teria for a Manic Episode and, therefore, a Bipo- lar I Disorder diagnosis.

Major Depressive Disorder Is characterized by the absence of both Manic Ep- isodes and Hypomanic Episodes. Given that the presence of some manic or hypomanic symptoms (i.e., fewer symptoms or for a shorter duration than required for mania or hy- pomania) may still be compatible with a diag- nosis of Major Depressive Disorder (and would warrant the use of the With Mixed Features specifier), it is important to ascertain whether the symptoms meet criteria for a Manic or Hy- pomanic Episode to determine whether it is more appropriate to make the diagnosis of a Bi- polar Disorder.

Bipolar II Disorder Is characterized by the presence of Hypomanic and Major Depressive Episodes and the ab- sence of Manic Episodes. Bipolar II Disorder cannot be diagnosed if the criteria have ever been met for Bipolar I Disorder.

Bipolar and Related Disorders 183

Cyclothymic Disorder Is characterized by numerous periods of hypo- manic symptoms that do not meet criteria for a Manic or Hypomanic Episode and periods of depressive symptoms that do not meet criteria for a Major Depressive Episode. Moreover, the criteria can never have been met for any of these mood episodes in order for the diagnosis of Cyclothymic Disorder to apply.

Schizophrenia, Delusional Disorder, Is characterized by psychotic symptoms, which or Schizophreniform Disorder may be accompanied by Manic or Major De-

pressive Episodes. The diagnosis is Schizophre- nia, Delusional Disorder, or Schizophreniform Disorder if either no Manic or Major Depressive Episodes have occurred concurrently with the psychotic symptoms or, if they have occurred concurrently, the Manic and Major Depressive Episodes have been present for only a minority of the time. The diagnosis is Bipolar I Disorder With Psychotic Features if the psychotic symp- toms have occurred exclusively during Manic and Major Depressive Episodes.

Schizoaffective Disorder Is characterized by periods in which Manic and/ or Major Depressive Episodes are concurrent with the active-phase symptoms of Schizophre- nia, periods in which delusions or hallucina- tions occur for at least 2 weeks in the absence of a Manic or Major Depressive Episode, and Manic and Major Depressive Episodes are pres- ent for a majority of the total duration of the ill- ness. The diagnosis is Bipolar I Disorder With Psychotic Features if the psychotic symptoms have occurred exclusively during Manic and Major Depressive Episodes.

Attention-Deficit/Hyperactivity Is characterized by persistent symptoms of inat- Disorder tention, hyperactivity, and impulsivity, which

may resemble the symptoms of a Manic Epi- sode (e.g., distractibility, increased activity, im- pulsive behavior) and have their onset before age 12, whereas the symptoms of mania in Bi- polar I Disorder occur in distinct episodes and typically begin in late adolescence or early adulthood.

3.3.1 Differential Diagnosis for Bipolar I Disorder (continued)

184 DSM-5 Handbook of Differential Diagnosis

Disruptive Mood Dysregulation Is characterized by severe recurrent temper out- Disorder bursts manifested verbally and/or behavior-

ally, which are accompanied by persistently irritable or angry mood most of the day, nearly every day, in between the outbursts. In contrast, the irritability in Bipolar I Disorder occurs in distinct episodes that last at least 1 week, is clearly different from the individual’s baseline, and is accompanied by the characteristic associ- ated symptoms of mania (e.g., grandiosity, de- creased need for sleep).

Personality Disorders (especially May be characterized by symptoms such as Borderline Personality Disorder) mood lability and impulsivity that are persis-

tent and have their onset by early adulthood. In contrast, the mood symptoms in Bipolar I Dis- order occur in distinct episodes that represent a noticeable change from normal baseline func- tioning.

3.3.1 Differential Diagnosis for Bipolar I Disorder (continued)

Bipolar and Related Disorders 185

3.3.2 Differential Diagnosis for Bipolar II Disorder

Bipolar II Disorder, which is charac- In contrast to Bipolar II Disorder.. . terized by at least one Hypomanic Episode and one Major Depressive Episode, must be differentiated from...

Bipolar and Related Disorder Due Requires the presence of an etiological medical to Another Medical Condition condition. Bipolar II Disorder is not diagnosed

if the mood episodes are all due to the direct physiological effects of another medical condi- tion.

Substance/Medication-Induced Is characterized by Hypomanic and Major De- Bipolar and Related Disorder pressive Episodes that are due to the direct

physiological effects of a substance (including medication). A full Hypomanic Episode that emerges during antidepressant treatment (e.g., with a selective serotonin reuptake inhibitor) but persists at a fully syndromal level beyond the physiological effect of that treatment meets criteria for a Hypomanic Episode, and there- fore, potentially a Bipolar II Disorder diagnosis if there has also been a history of Major Depres- sive Episodes.

Major Depressive Disorder Is characterized by the absence of both Manic Ep- isodes and Hypomanic Episodes. Given that the presence of some manic or hypomanic symptoms (i.e., fewer symptoms or a shorter duration than required for mania or hypoma- nia) may still be compatible with a diagnosis of Major Depressive Disorder (and would warrant the use of the With Mixed Features specifier), it is important to ascertain whether the symptoms meet criteria for a Hypomanic Episode to deter- mine whether it is more appropriate to make the diagnosis of Bipolar II Disorder.

Bipolar I Disorder Is characterized by the presence of at least one Manic Episode. Bipolar II Disorder cannot be diagnosed if the criteria have ever been met for Bipolar I Disorder.

186 DSM-5 Handbook of Differential Diagnosis

Schizophrenia Is characterized by active-phase psychotic symp- toms, which may be accompanied by Major De- pressive Episodes. The diagnosis is Schizophrenia if either no Major Depressive Ep- isodes have occurred concurrently with the ac- tive-phase symptoms, or if they have occurred concurrently, the Major Depressive Episodes have been present for only a minority of the time. The diagnosis is Bipolar II Disorder With Psychotic Features if the psychotic symptoms have occurred exclusively during Major De- pressive Episodes.

Schizoaffective Disorder Is characterized by periods in which Major De- pressive Episodes are concurrent with the ac- tive-phase symptoms of Schizophrenia, periods in which delusions or hallucinations occur for at least 2 weeks in the absence of a Major De- pressive Episode, and Major Depressive Epi- sodes are present for a majority of the total duration of the illness. The diagnosis is Bipolar II Disorder With Psychotic Features if the psy- chotic symptoms have occurred exclusively during Major Depressive Episodes.

Attention-Deficit/Hyperactivity Is characterized by persistent symptoms of inat- Disorder tention, hyperactivity, and impulsivity, which

may resemble the symptoms of a Hypomanic Episode (e.g., distractibility, increased activity, impulsive behavior) and have their onset before age 12. In contrast, the symptoms of hypomania in Bipolar II Disorder occur in distinct episodes and typically begin in late adolescence or early adulthood.

3.3.2 Differential Diagnosis for Bipolar II Disorder (continued)

Bipolar and Related Disorders 187

Disruptive Mood Dysregulation Is characterized by severe recurrent temper out- Disorder bursts manifested verbally and/or behavior-

ally, which are accompanied by persistently irritable or angry mood most of the day, nearly every day, in between the outbursts. In contrast, the irritability in Bipolar II Disorder occurs in distinct episodes that last at least 4 days, is clearly different from the individual’s baseline, and is accompanied by the characteristic associ- ated symptoms of hypomania (e.g., grandiosity, decreased need for sleep).

Personality Disorders (especially May be characterized by symptoms such as Borderline Personality Disorder) mood lability and impulsivity that are persis-

tent and have their onset by early adulthood. In contrast, the mood symptoms in Bipolar II Dis- order occur in distinct episodes that represent a noticeable change from normal baseline func- tioning.

3.3.2 Differential Diagnosis for Bipolar II Disorder (continued)

188 DSM-5 Handbook of Differential Diagnosis

3.3.3 Differential Diagnosis for Cyclothymic Disorder

Cyclothymic Disorder, which is character- In contrast to Cyclothymic Disorder... ized by numerous periods with hypo- manic symptoms that do not meet criteria for a Hypomanic Episode and nu- merous periods with depressive symp- toms that do not meet criteria for a Major Depressive Episode, must be differenti- ated from...

Bipolar I or Bipolar II Disorder, Is characterized by four or more mood ep- With Rapid Cycling isodes (each of which meets full criteria

for a Manic, Hypomanic, or Major Depressive Episode) occurring in a 12-month period. Cyclothymic Disorder is characterized by numerous periods of hypomanic and depressive symptoms that do not meet criteria for a Hypomanic or Major Depressive Episode. If criteria have ever been met for a Manic, Hypo- manic, or Major Depressive Episode, Cyclothymic Disorder is not diagnosed.

Borderline Personality Disorder Is characterized by additional personality features (e.g., identity disturbance, self- mutilating behavior) besides affective la- bility. If criteria are met for Cyclothymic Disorder and Borderline Personality Dis- order, both can be diagnosed.

Bipolar and Related Disorder Due to Requires the presence of an etiological Another Medical Condition general medical condition. Cyclothymic

Disorder is not diagnosed if the mood symptoms are all due to the direct physi- ological effects of a general medical con- dition.

Substance/Medication-Induced Bipolar Is due to the direct physiological effects of and Related Disorder a substance. Cyclothymic Disorder is not

diagnosed if the mood symptoms are all due to the direct physiological effects of a substance (including medication).

Depressive Disorders 189

Depressive Disorders 3.4.1 Differential Diagnosis for Major Depressive Disorder

Major Depressive Disorder, which is char- In contrast to Major Depressive acterized by episodes of depressed mood Disorder.. . or diminished interest or pleasure that last at least 2 weeks and that are accom- panied by characteristic associated symptoms (e.g., changes in sleep, appe- tite, or activity level; fatigue; difficulty concentrating; feelings of worthlessness or excessive guilt; suicidal ideation or be- havior), must be differentiated from...

Bipolar I or Bipolar II Disorder Includes one or more Manic or Hypo- manic Episodes. Major Depressive Disor- der cannot be diagnosed if a Manic or Hypomanic Episode has ever been pres- ent. A diagnosis of Major Depressive Dis- order may be compatible with the presence of some manic or hypomanic symptoms (i.e., fewer symptoms or a shorter duration than required for mania or hypomania) and would warrant the use of the With Mixed Features specifier.

Depressive Disorder Due to Another Requires the presence of an etiological Medical Condition medical condition. Major Depressive Dis-

order is not diagnosed if the major de- pressive–like episodes are all due to the direct physiological effects of a medical condition.

Substance/Medication-Induced Is due to the direct physiological effects of Depressive Disorder a substance or medication. Major Depres-

sive Disorder is not diagnosed if the ma- jor depressive–like episodes are all due to the direct physiological effects of a sub- stance (including medication).

Persistent Depressive Disorder Is characterized by depressed mood, more (Dysthymia) days than not, for at least 2 years. If crite-

ria are met for both Major Depressive Disorder and Persistent Depressive Dis- order, both can be diagnosed.

190 DSM-5 Handbook of Differential Diagnosis

Premenstrual Dysphoric Disorder Is characterized by dysphoric mood that is present in the final week before the onset of menses and that starts to improve within a few days after the onset of men- ses, and becomes minimal or absent in the week postmenses. In contrast, the ep- isodes in Major Depressive Disorder are not temporally connected to the men- strual cycle.

Disruptive Mood Dysregulation Disorder Is characterized by severe, recurrent tem- per outbursts manifested verbally and/ or behaviorally, accompanied by persis- tently irritable or angry mood most of the day, nearly every day, in between the out- bursts. In contrast, in Major Depressive Disorder, irritability is confined to the Major Depressive Episodes.

Schizophrenia, Delusional Disorder, or Is characterized by psychotic symptoms, Schizophreniform Disorder which may be accompanied by Major De-

pressive Episodes. The diagnosis is Schizophrenia, Delusional Disorder, or Schizophreniform Disorder if either no Major Depressive Episodes have occurred concurrently with the psychotic disorder or, if they have occurred concurrently, the Major Depressive Episodes have been present for only a minority of the time. The diagnosis is Major Depressive Disorder With Psychotic Features if the psychotic symptoms have occurred exclusively dur- ing Major Depressive Episodes.

Schizoaffective Disorder Is characterized by periods in which Major Depressive Episodes are concurrent with the active-phase symptoms of Schizo- phrenia, periods in which delusions or hallucinations occur for at least 2 weeks in the absence of a Major Depressive Epi- sode, and the Major Depressive Episodes are present for a majority of the total du- ration of the illness. The diagnosis is Ma- jor Depressive Disorder With Psychotic Features if the psychotic symptoms have occurred exclusively during Major De- pressive Episodes.

3.4.1 Differential Diagnosis for Major Depressive Disorder (continued)

Depressive Disorders 191

Major or Mild Neurocognitive Disorder Is characterized by evidence of decline Due to Another Medical Condition or from a previous level of performance in Substance/Medication-Induced Major or one or more cognitive domains that is Mild Neurocognitive Disorder due to the physiological effects of a med-

ical condition or the persisting effects of substance use.

Adjustment Disorder With Is characterized by depressive symptoms Depressed Mood that occur in response to a stressor and

do not meet criteria for a Major Depres- sive Episode.

Bereavement Occurs in response to the loss of a loved one and is generally less severe than a Major Depressive Episode. The predomi- nant affects in grief are feelings of empti- ness and loss, whereas in Major Depressive Episode they are persistent depressed mood and a diminished ability to experience pleasure. Moreover, the dysphoric mood in grief is likely to de- crease in intensity over days to weeks and occurs in waves that tend to be asso- ciated with thoughts or reminders of the deceased, whereas the depressed mood in a Major Depressive Episode is more persistent and not tied to specific thoughts or preoccupations.

Nonpathological periods of sadness Is characterized by short duration, few as- sociated symptoms, and lack of signifi- cant functional impairment or distress.

3.4.1 Differential Diagnosis for Major Depressive Disorder (continued)

192 DSM-5 Handbook of Differential Diagnosis

3.4.2 Differential Diagnosis for Persistent Depressive Disorder

(Dysthymia)

Persistent Depressive Disorder, which is In contrast to Persistent Depressive characterized by depressed mood for Disorder.. . most of the day, for more days than not, for at least 2 years, must be differentiated from...

Major Depressive Disorder Includes one or more Major Depressive Episodes, which are characterized by a period of depressed mood or diminished interest or pleasure, most of the day nearly every day for at least 2 weeks, ac- companied by at least five characteristic symptoms (e.g., sleep changes, appetite changes, changes in level of activity, fa- tigue, feelings of worthlessness or exces- sive guilt, difficulty concentrating, suicidal ideation or behavior). Persistent Depressive Disorder has a lower symp- tom threshold (i.e., only two symptoms plus depressed mood) and lower persis- tence threshold (i.e., more days than not) but requires at least a 2-year duration. Thus, a Major Depressive Episode lasting at least 2 years will meet criteria for Per- sistent Depressive Disorder. If criteria are met for both Major Depressive Disorder and Persistent Depressive Disorder, both should be diagnosed.

Chronic psychotic disorders (i.e., May be characterized by associated Schizophrenia, Delusional Disorder, chronic depressed mood. A separate di- Schizoaffective Disorder) agnosis of Persistent Depressive Disor-

der is not made if the symptoms occur only during the course of the psychotic disorder (including residual phases).

Depressive Disorder Due to Another Requires the presence of an etiological Medical Condition medical condition. Persistent Depressive

Disorder is not diagnosed if the depres- sive symptoms are all due to the direct physiological effects of a general medical condition. Chronic mild depression is a common associated feature of many chronic medical conditions (e.g., diabe- tes), and Persistent Depressive Disorder may be diagnosed if the medical condi- tion is merely comorbid with and not the physiological cause of the depression.

Depressive Disorders 193

Substance/Medication-Induced Is due to the direct physiological effects of Depressive Disorder a substance. Persistent Depressive Disor-

der is not diagnosed if the depressive symptoms are all due to the direct physi- ological effects of a substance (including medication).

Bipolar I and Bipolar II Disorders Are characterized by Manic Episodes and Hypomanic Episodes, respectively. Per- sistent Depressive Disorder cannot be di- agnosed if a Manic or Hypomanic Episode has ever been present.

Cyclothymic Disorder Is characterized by hypomanic periods in addition to depressive periods. Persistent Depressive Disorder cannot be diag- nosed if the criteria for Cyclothymic Dis- order have ever been met.

Personality Disorder Is characterized by an enduring pattern of inner experience and behavior that devi- ates markedly from the expectations of the individual’s culture, with onset by adolescence or early adulthood. Person- ality disorders commonly co-occur with Persistent Depressive Disorder. If criteria are met for Persistent Depressive Disor- der and a Personality Disorder, both may be diagnosed.

3.4.2 Differential Diagnosis for Persistent Depressive Disorder

(Dysthymia) (continued)

194 DSM-5 Handbook of Differential Diagnosis

3.4.3 Differential Diagnosis for Premenstrual Dysphoric Disorder

Premenstrual Dysphoric Disorder— In contrast to Premenstrual Dysphoric characterized by marked affective labil- Disorder.. . ity, irritability, anger, or increased inter- personal conflicts; marked depressed mood, feelings of hopelessness, or self- deprecating thoughts; or marked anxiety, tension, and/or feelings of being “keyed up” or “on edge”—which develops in the final week before the onset of menses, starts to improve within a few days after the onset of menses, and becomes mini- mal or absent in the week postmenses, must be differentiated from...

Premenstrual syndrome Is characterized by symptoms that occur during the premenstrual period of the menstrual cycle that fall short of the re- quired threshold of five symptoms for Premenstrual Dysphoric Disorder. More- over, there is no requirement for affective symptoms during the premenstrual pe- riod.

Dysmenorrhea Is characterized by painful menses that be- gin with the onset of menses. In contrast, Premenstrual Dysphoric Disorder begins before the onset of menses and is charac- terized by affective changes.

Depressive Disorder Due to Another Is characterized by dysphoric symptoms Medical Condition that are due to the direct physiological ef-

fects of an identified medical condition (e.g., hyperthyroidism).

Substance/Medication-Induced Is characterized by dysphoric symptoms Depressive Disorder (including that are due to the direct physiological ef- hormonal treatments) fects of a substance or medication. Mod-

erate to severe premenstrual symptoms may develop after initiation of exogenous hormone use. If the woman stops taking hormones and the symptoms disappear, this is consistent with Substance/Medica- tion-Induced Depressive Disorder.

Depressive Disorders 195

Bipolar I Disorder Is characterized by Manic and Major De- pressive Episodes that are temporally un- related to the menstrual cycle. However, because the onset of menses constitutes a memorable event, some women may re- port that mood symptoms occur only during the premenstrual period or that symptoms worsen premenstrually. Pro- spective daily symptom ratings during at least two symptomatic cycles are there- fore important for documenting the time of onset and offset of mood symptoms.

Major Depressive Disorder or Is characterized by Major Depressive Epi- Persistent Depressive Disorder sodes or depressive symptoms that are (Dysthymia) temporally unrelated to the menstrual

cycle. However, because the onset of menses constitutes a memorable event, some women may report that mood symptoms occur only during the pre- menstrual period or that symptoms worsen premenstrually. Prospective daily symptom ratings during at least two symptomatic cycles are therefore im- portant for documenting the time of on- set and offset of mood symptoms.

3.4.3 Differential Diagnosis for Premenstrual Dysphoric Disorder (continued)

196 DSM-5 Handbook of Differential Diagnosis

3.4.4 Differential Diagnosis for Disruptive Mood Dysregulation

Disorder

Disruptive Mood Dysregulation Disorder, In contrast to Disruptive Mood Dysregula- which is characterized by severe recur- tion Disorder.. . rent temper outbursts manifested ver- bally and/or behaviorally that are grossly out of proportion in intensity to the provocation and that are accompa- nied by a persistently irritable or angry mood most of the day, nearly every day, in between the outbursts, must be differ- entiated from...

Depressive Disorder Due to Another Is characterized by dysphoric symptoms Medical Condition that are due to the direct physiological ef-

fects of an identified medical condition.

Substance/Medication-Induced Is characterized by dysphoric symptoms Depressive Disorder that are due to the direct physiological ef-

fects of a substance or medication.

Bipolar I and Bipolar II Disorders Are characterized by episodic illnesses with discrete episodes of mood perturba- tion that are distinguishable from the child’s baseline. In addition, the change in mood during Manic or Hypomanic Episodes is accompanied by increased energy and activity as well as associated cognitive, behavioral, and physical symptoms (e.g., distractibility, rapid speech, decreased need for sleep). In con- trast, the irritability of Disruptive Mood Dysregulation Disorder is persistent and present chronically over many months.

Oppositional Defiant Disorder Is characterized by a pattern of angry/ irritable mood, argumentative/defiant behavior, or vindictiveness. In contrast, Disruptive Mood Dysregulation Disor- der is also characterized by the presence of severe and frequently recurrent out- bursts and a persistent disruption in mood between outbursts. If criteria are met for both disorders, only Disruptive Mood Dysregulation Disorder is diag- nosed.

Depressive Disorders 197

Major Depressive Disorder May be characterized by irritable mood ac- companying the episodes of depressed mood or diminished interest or pleasure. Children whose irritability is present only in the context of a Major Depressive Episode should receive a diagnosis of Major Depressive Disorder rather than Disruptive Mood Dysregulation Disor- der. If the irritability extends outside the depressed episodes, both diagnoses may be appropriate.

Anxiety Disorders May be characterized by irritable mood oc- curring in anxiety-provoking situations. Children whose irritability is manifest only in anxiety-provoking contexts should receive the relevant Anxiety Dis- order diagnosis rather than a diagnosis of Disruptive Mood Dysregulation Disor- der. If the irritability extends outside the anxiety-provoking situations, diagnoses of both Disruptive Mood Dysregulation Disorder and the Anxiety Disorder may be appropriate.

Autism Spectrum Disorder May be characterized by temper outbursts, especially when routines are disturbed. If temper outbursts are better explained by Autism Spectrum Disorder, then Disrup- tive Mood Dysregulation Disorder is not diagnosed.

Intermittent Explosive Disorder Is characterized by aggressive outbursts that can resemble the severe temper tan- trums in Disruptive Mood Dysregulation Disorder; however, there is no persistent irritable or angry mood between out- bursts as in Disruptive Mood Dysregula- tion Disorder. In addition, Intermittent Explosive Disorder requires only 3 months of active symptoms, in contrast to the 12-month requirement for Disrup- tive Mood Dysregulation Disorder. Inter- mittent Explosive Disorder is not diagnosed if criteria are met for Disrup- tive Mood Dysregulation Disorder.

3.4.4 Differential Diagnosis for Disruptive Mood Dysregulation

Disorder (continued)

198 DSM-5 Handbook of Differential Diagnosis

Anxiety Disorders 3.5.1 Differential Diagnosis for Separation Anxiety Disorder

Separation Anxiety Disorder, which is In contrast to Separation Anxiety characterized by developmentally inap- Disorder.. . propriate and excessive anxiety concern- ing separation from major attachment figures, must be differentiated from...

Generalized Anxiety Disorder Is characterized by anxiety and worry in a multitude of different areas and is not lim- ited to issues of separation from family.

Panic Disorder Is characterized by recurrent unexpected Panic Attacks. In contrast, individuals with Separation Anxiety Disorder may experience Panic Attacks but only when threatened with separation from major attachment figures.

Agoraphobia Is characterized by anxiety about being trapped or incapacitated in places or sit- uations from which escape is perceived as difficult in the event of panic-like symptoms or other incapacitating symp- toms. In Separation Anxiety Disorder, the focus of the fear is on separation from major attachment figures.

Posttraumatic Stress Disorder May be characterized by fear of separation from loved ones after traumatic events such as disasters, particularly when peri- ods of separation from loved ones were experienced during the traumatic event. However, the main symptoms involve re- experiencing memories or avoiding situa- tions associated with the traumatic event itself, whereas in Separation Anxiety Dis- order, the worries and avoidance concern the well-being of attachment figures and fears of being separated from them.

Social Anxiety Disorder (Social Phobia) May be characterized by school refusal that is due to the fear of being judged negatively by peers or teachers. In con- trast, school refusal in Separation Anxi- ety Disorder is due to worries about being separated from major attachment figures.

Anxiety Disorders 199

Illness Anxiety Disorder May be characterized by the individual’s worry about specific illnesses he or she may have, but the main concern is the medical diagnosis itself. In Separation Anxiety Disorder, the focus of illness con- cern is on the possibility that the illness might result in the person’s being sepa- rated from major attachment figures.

Conduct Disorder May be characterized by school avoidance (truancy), but anxiety about separation is not responsible for the school absences, and the child or adolescent usually stays away from, rather than returns to, the home.

Oppositional Defiant Disorder Is characterized by persistent oppositional behavior unrelated to the anticipation or occurrence of separation. In contrast, some children and adolescents with Sep- aration Anxiety Disorder may be opposi- tional in the context of being forced to separate from attachment figures.

Depressive disorders May be associated with reluctance to leave home that is due to loss of interest, fa- tigue, or concern about crying in public rather than worry or fear of untoward events befalling attachment figures.

Dependent Personality Disorder Is characterized by an indiscriminate ten- dency to rely on others. In contrast, in Separation Anxiety Disorder, the concern is about the proximity and safety of main attachment figures.

Borderline Personality Disorder Is characterized by fear of abandonment by loved ones, but there are also prob- lems with identity, self-direction, inter- personal functioning, and impulsivity. If criteria are met for both Separation Anxi- ety Disorder and Borderline Personality Disorder, both may be diagnosed.

3.5.1 Differential Diagnosis for Separation Anxiety Disorder (continued)

200 DSM-5 Handbook of Differential Diagnosis

Developmentally appropriate separation Is part of normal early development and anxiety may indicate the development of secure

attachment relationships, such as when infants around age 1 year experience stranger anxiety.

3.5.1 Differential Diagnosis for Separation Anxiety Disorder (continued)

Anxiety Disorders 201

3.5.2 Differential Diagnosis for Selective Mutism

Selective Mutism, which is characterized In contrast to Selective Mutism... by consistent failure to speak in specific social situations in which there is an ex- pectation for speaking, must be differen- tiated from...

Communication Disorders Are characterized by speech disturbances (e.g., dysfluencies, speech sound prob- lems) that occur consistently regardless of the situation that the individual is in. In contrast, in Selective Mutism the speech difficulties occur only in certain situations (e.g., social situations with children and adults) but not others (e.g., with immediate family).

Autism Spectrum Disorder and May also be characterized by difficulty Schizophrenia Spectrum and Other speaking in social situations, but unlike Psychotic Disorders Selective Mutism, these difficulties are

evident even when the individual is speaking with immediate family mem- bers.

Social Anxiety Disorder (Social Phobia) Is characterized by fear and anxiety occur- ring in social situations in which the per- son is exposed to possible scrutiny by others, whereas a diagnosis of Selective Mutism specifically describes a pattern of inability to speak in certain situations, which are typically social. In situations where the failure to speak is associated with feelings of social anxiety, both diag- noses of Selective Mutism and Social Anxiety Disorder may be made.

202 DSM-5 Handbook of Differential Diagnosis

3.5.3 Differential Diagnosis for Specific Phobia

Specific Phobia, which is characterized by In contrast to Specific Phobia.. . marked fear or anxiety about a specific object or situation, must be differentiated from...

Agoraphobia Is characterized by fear and avoidance of situations from two or more agoraphobic clusters (i.e., public transportation, open spaces, enclosed places, standing in line or being in a crowd, being outside of the home alone). In Specific Phobia, Situa- tional Type, the fear and avoidance is confined to only one situation (e.g., heights) or several situations, all of which fall within the same cluster (e.g., eleva- tors and airplanes, both within the public transportation cluster).

Social Anxiety Disorder (Social Phobia) Is characterized by fear and avoidance re- stricted to social situations.

Posttraumatic Stress Disorder or Is characterized by fear and avoidance Acute Stress Disorder confined to stimuli that remind the indi-

vidual of a previously experienced life- threatening event.

Obsessive-Compulsive Disorder May be characterized by fear and avoid- ance associated with the content of the obsessions (e.g., avoidance of dirt by an individual with a contamination obses- sion).

Separation Anxiety Disorder Is characterized by fear or avoidance of sit- uations in which the individual would be separated from major attachment figures.

Psychotic Disorders May be characterized by avoidance that occurs as a consequence of a delusional belief (e.g., avoidance of flying by an in- dividual with a persecutory delusional system who is convinced that he or she is going to be the target of a terrorist attack).

Anorexia Nervosa, Avoidant/Restrictive May be characterized by avoidance behav- Food Intake Disorder, Bulimia Nervosa, ior, but it is exclusively related to avoid- and Binge-Eating Disorder ing food and food-related cues.

Anxiety Disorders 203

3.5.3 Differential Diagnosis for Specific Phobia (continued)

Nonpathological avoidance of Either represents a realistic level of avoid- circumscribed objects or situations ance given the actual danger (e.g., avoid-

ance of skydiving from an airplane) or is not severe enough to cause clinically sig- nificant impairment or distress, often be- cause of the ease of avoiding the phobic stimulus (e.g., a person who fears snakes but rarely would encounter one because he or she lives in Manhattan).

Transient fears in childhood Are common and short-lived, lasting for less than 6 months.

204 DSM-5 Handbook of Differential Diagnosis

3.5.4 Differential Diagnosis for Social Anxiety Disorder

(Social Phobia)

Social Anxiety Disorder, which is charac- In contrast to Social Anxiety Disorder.. . terized by marked fear or anxiety about social situations in which the individual is exposed to possible scrutiny by others, must be differentiated from...

Panic Disorder Is typically not limited to social situations and is characterized by the initial onset of unexpected Panic Attacks.

Agoraphobia May be characterized by fear and avoid- ance of social situations (e.g., going to a movie), but the individual’s fear is that escape might be difficult or help might not be available in the event of incapaci- tation or panic-like symptoms. In Social Anxiety Disorder, the focus of the fear is scrutiny by others.

Generalized Anxiety Disorder May be characterized by social worries, but the focus is more on the nature of on- going relationships than on fear of nega- tive evaluation. For example, individuals with Generalized Anxiety Disorder, par- ticularly children, may be excessively worried about the quality of their social performance, but they also worry about the quality of their performance in non- social situations where social evaluation by others is not the issue (e.g., getting a good grade on a test). In Social Anxiety Disorder, the worries are exclusively fo- cused on social performance and the scrutiny of others.

Specific Phobia May be characterized by fear of embar- rassment or humiliation related to the in- dividual’s intense reaction to exposure to phobic stimuli (e.g., embarrassment about fainting when having blood drawn), but there is not a general fear of negative evaluation in other social situa- tions.

Anxiety Disorders 205

3.5.4 Differential Diagnosis for Social Anxiety Disorder

(Social Phobia) (continued)

Separation Anxiety Disorder May be characterized by avoidance of so- cial settings (including school refusal), but the avoidance is due to concerns about being separated from attachment figures or concerns about being embar- rassed by needing to leave prematurely to return to attachment figures. Individu- als with Social Anxiety Disorder tend to be uncomfortable even in social situa- tions in which attachment figures are present.

Selective Mutism Is characterized by a failure to speak in some situations due to a fear of negative evaluation, but unlike Social Anxiety Disorder, there is no fear of negative eval- uation in social situations where no speaking is required (e.g., nonverbal play).

Oppositional Defiant Disorder May be characterized by a refusal to speak due to opposition to authority figures. In- dividuals with Social Anxiety Disorder may be afraid to speak due to fear of neg- ative evaluation.

Autism Spectrum Disorder Is characterized by social anxiety and so- cial communication deficits that typically result in a lack of age-appropriate social relationships. Although individuals with Social Anxiety Disorder may appear im- paired when first interacting with unfa- miliar peers or adults, they typically have adequate age-appropriate social relation- ships and social communication capacity.

Avoidant Personality Disorder Is conceptualized as a Personality Disor- der but describes many of the same indi- viduals who have Social Anxiety Disorder. If criteria are met for Social Anxiety Disorder and Avoidant Person- ality Disorder, both diagnoses may be given.

206 DSM-5 Handbook of Differential Diagnosis

3.5.4 Differential Diagnosis for Social Anxiety Disorder

(Social Phobia) (continued)

Major Depressive Disorder Is characterized by negative self-esteem that may be accompanied by concerns about being negatively evaluated by oth- ers, but these concerns extend beyond so- cial situations. Individuals with Social Anxiety Disorder are worried about be- ing negatively evaluated because of cer- tain social behaviors, physical symptoms, or appearance, and generally do not experience negative self-esteem outside of social situations.

Body Dysmorphic Disorder Is characterized by the relatively fixed be- lief that particular features render the in- dividual misshapen or ugly, which may result in social anxiety and avoidance of social situations. A separate diagnosis of Social Anxiety Disorder is generally not warranted if the social fears and avoid- ance are restricted to body dysmorphic concerns.

Delusional Disorder May be characterized by delusions and/or hallucinations that focus on being re- jected or offending others. In contrast, the concerns in Social Anxiety Disorder are not held with delusional intensity.

Medical conditions May produce symptoms that may be so- cially embarrassing (e.g., trembling in Parkinson’s disease, reddening in rosa- cea). An additional diagnosis of Social Anxiety Disorder is given only when the fear of negative evaluation by others be- cause of those symptoms is dispropor- tionate.

Anxiety Disorders 207

3.5.4 Differential Diagnosis for Social Anxiety Disorder

(Social Phobia) (continued)

Social anxiety and avoidance associated Are characterized by anxiety that occurs with other mental disorders, such as only during the course of the other Eating Disorders or Schizophrenia mental disorder. If the anxiety is judged

to be better accounted for by the other mental disorder, an additional diagnosis of Social Anxiety Disorder is not given. For example, social fears and discomfort can occur as part of Schizophrenia, but other evidence for psychotic symptoms will also be present. Social anxiety may co-occur with Eating Disorders, but if the fear of negative evaluation about symptoms (e.g., purging and vomiting) is the sole source of social anxiety, an additional diagnosis of Social Anxiety Disorder is not warranted.

Normal shyness Is a common personality trait that for most shy people does not lead to clinically sig- nificant adverse impact on functioning.

208 DSM-5 Handbook of Differential Diagnosis

3.5.5 Differential Diagnosis for Panic Disorder

Panic Disorder, which is characterized by In contrast to Panic Disorder.. . recurrent unexpected Panic Attacks fol- lowed by a month of worry or a change in behavior related to the attacks, must be differentiated from...

Anxiety Disorder Due to Another Medical Requires the presence of an etiological Condition medical condition (e.g., hyperthyroid-

ism). Panic Disorder is not diagnosed if the Panic Attacks are all due to the direct physiological effects of a general medical condition on the central nervous system.

Substance/Medication-Induced Anxiety Is due to the direct physiological effects of Disorder a substance or medication. Panic Disor-

der is not diagnosed if the Panic Attacks are all due to the direct physiological ef- fects of a substance (including medica- tion).

Panic Attacks occurring as part of another Many mental disorders (e.g., Social Anxi- mental disorder ety Disorder [Social Phobia], Specific

Phobia, Separation Anxiety Disorder, Obsessive-Compulsive Disorder, Hoard- ing Disorder, Posttraumatic Stress Disor- der, Major Depressive Disorder) may be characterized by Panic Attacks occurring in situations in which the individual is al- ready experiencing some level of anxiety related to that disorder. For example, a person with Social Anxiety Disorder may become so anxious in a social situation that it triggers a Panic Attack, or an indi- vidual with contamination concerns in Obsessive-Compulsive Disorder may de- velop extreme distress when exposed to germs or dirt, which culminates in a Panic Attack. In such cases, the specifier “With Panic Attacks” may be noted. In contrast, the Panic Attacks in individuals with Panic Disorder are unexpected (i.e., the Panic Attacks come on “out of the blue”), at least during the initial phase of the disorder.

Anxiety Disorders 209

Exposure to an extremely anxiety- May be characterized by the development provoking experience of a Panic Attack (e.g., an individual hav-

ing a Panic Attack while being held up at gunpoint). In contrast, the Panic Attacks in individuals with Panic Disorder are unexpected (i.e., come on out of the blue), at least during the initial phase of the dis- order.

Isolated Panic Attack Is characterized by a single Panic Attack, which may or may not have come on out of the blue and by itself is not indicative of psychopathology. A diagnosis of Panic Disorder requires at least two unex- pected Panic Attacks.

Limited-symptom attacks Are characterized by panic-like attacks that have fewer than the minimum of four symptoms required for a Panic Attack.

3.5.5 Differential Diagnosis for Panic Disorder (continued)

210 DSM-5 Handbook of Differential Diagnosis

3.5.6 Differential Diagnosis for Agoraphobia

Agoraphobia, which is characterized by In contrast to Agoraphobia... fear or avoidance of multiple situations due to thoughts that escape might be dif- ficult or help might not be available in the event of developing panic-like symp- toms, must be differentiated from...

Social Anxiety Disorder (Social Phobia) Is characterized by avoidance specifically of social situations in which the person will be exposed to the scrutiny of others.

Specific Phobia, Situational Type Is characterized by avoidance of a specific feared situation, such as closed spaces, as opposed to fear and avoidance of multi- ple situations across two or more of the agoraphobic clusters (i.e., public trans- portation, open spaces, enclosed places, standing in line or being in a crowd, be- ing outside of the home alone).

Posttraumatic Stress Disorder or May be characterized by avoidance of peo- Acute Stress Disorder ple, places, activities, or situations that

arouse upsetting memories, thoughts, or feelings about the traumatic event.

Major Depressive Disorder Some individuals with Major Depressive Disorder may be housebound due to feel- ings of apathy, fatigue, loss of capacity to experience pleasure, or concerns about crying in public. In contrast, the lack of willingness of some individuals with Agoraphobia to leave their homes is a result of extreme fears that help might not be available in the event of develop- ing panic-like symptoms.

Psychotic Disorder featuring delusions May be characterized by avoidance that re- (e.g., Delusional Disorder, sults from delusional concerns (e.g., Schizophrenia, Major Depressive avoidance of going outside one’s house Disorder With Psychotic Features) because of the conviction that one is be-

ing followed).

Anxiety Disorders 211

Obsessive-Compulsive Disorder May be characterized by avoidance behav- ior that is intended to prevent triggering an obsession or compulsion (e.g., avoid- ance of “dirty” objects related to fears of contamination or avoidance of kitchen knives by someone who is having obses- sive thoughts of stabbing his or her spouse).

Separation Anxiety Disorder Is characterized by avoidance of situations that involve being away from major attachment figures, including refusing to go out of one’s house because of a fear of separation.

Avoidance related to potentially disabling May be characterized by avoidance that medical conditions results from realistic concerns (e.g., about

fainting for an individual with an arrhythmia). However, in contrast to Agoraphobia, the avoidance is at a level that is appropriate and realistic given the nature of the medical condition.

3.5.6 Differential Diagnosis for Agoraphobia (continued)

212 DSM-5 Handbook of Differential Diagnosis

3.5.7 Differential Diagnosis for Generalized Anxiety Disorder

Generalized Anxiety Disorder, which is In contrast to Generalized Anxiety characterized by excessive anxiety and Disorder.. . worry lasting at least 6 months, must be differentiated from...

Anxiety Disorder Due to Another Medical Requires the presence of an etiological Condition medical condition (e.g., pheochromocy-

toma). Generalized Anxiety Disorder is not diagnosed if the generalized anxiety is due to the direct physiological effects of a general medical condition.

Substance/Medication-Induced Is due to the direct physiological effects of Anxiety Disorder a substance or medication and may have

its onset during intoxication with or withdrawal from an abused substance, or occur as a side effect of a medication. Generalized Anxiety Disorder is not di- agnosed if the generalized anxiety is due to the direct physiological effects of a substance on the central nervous system, such as during Cocaine Intoxication or Opioid Withdrawal.

Panic Disorder Is characterized by anxiety and worry about having additional Panic Attacks. An additional diagnosis of Generalized Anxiety Disorder should be made only if there is additional anxiety and worry un- related to the Panic Attacks.

Social Anxiety Disorder (Social Phobia) Is characterized by excessive anxiety and worry focused exclusively on social situ- ations. An additional diagnosis of Gener- alized Anxiety Disorder should be made only if there is anxiety and worry focused on nonsocial situations (e.g., work or school performance).

Somatic Symptom Disorder or May be characterized by excessive anxiety Illness Anxiety Disorder and worry focused exclusively on health,

becoming ill, or the seriousness of so- matic symptoms (e.g., worry that a head- ache is indicative of a brain tumor). An additional diagnosis of Generalized Anx- iety Disorder should be made only if there is anxiety and worry focused on non-health-related situations.

Anxiety Disorders 213

Separation Anxiety Disorder Is characterized by excessive anxiety and worry focused exclusively on concerns about separation from major attachment figures. An additional diagnosis of Gen- eralized Anxiety Disorder should be made only if there is anxiety and worry focused on situations that are unrelated to separation concerns.

Posttraumatic Stress Disorder or Is characterized by anxiety occurring in re- Acute Stress Disorder lation to exposure to internal or external

cues that symbolize or resemble an as- pect of the traumatic event or as part of the generalized hyperarousal and reac- tivity associated with having been ex- posed to the traumatic event. An additional diagnosis of Generalized Anx- iety Disorder should be made only if there is anxiety and worry focused on sit- uations that are unrelated to the trau- matic event.

Anorexia Nervosa or Bulimia Nervosa May be characterized by anxiety or worry associated with the fear of gaining weight. An additional diagnosis of Gen- eralized Anxiety Disorder should be made only if there is anxiety and worry unrelated to issues about weight.

Obsessive-Compulsive Disorder Is usually characterized by repetitive anxi- ety-provoking thoughts that are experi- enced as intrusive, unwanted, inappropriate, and ego-dystonic, and that are usually accompanied by compul- sions that serve to reduce the anxiety. In contrast, the worries in Generalized Anx- iety Disorder typically arise from every- day routine life, such as possible job responsibilities, the health of family members, finances, or minor matters such as household chores or being late for appointments.

3.5.7 Differential Diagnosis for Generalized Anxiety Disorder (continued)

214 DSM-5 Handbook of Differential Diagnosis

Adjustment Disorder With Anxiety Is characterized by clinically significant anxiety symptoms that do not meet the criteria for any specific anxiety disorder (including Generalized Anxiety Disor- der) and that occur in response to a stressor.

Bipolar Disorders, Depressive Disorders, Are commonly characterized by anxiety and Schizophrenia Spectrum and Other occurring as an associated feature, but Psychotic Disorders include other specific symptoms charac-

teristic of the particular mood or Psy- chotic Disorder. Generalized Anxiety Disorder should not be diagnosed sepa- rately if it has occurred only during the course of a Bipolar, Depressive, or Psy- chotic Disorder.

Nonpathological anxiety Is characterized by worries that are more controllable or are not severe enough to cause clinically significant distress or im- pairment in functioning.

3.5.7 Differential Diagnosis for Generalized Anxiety Disorder (continued)

Obsessive-Compulsive and Related Disorders 215

Obsessive-Compulsive and Related Disorders 3.6.1 Differential Diagnosis for Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder (OCD), In contrast to Obsessive-Compulsive which is characterized by obsessions (i.e., Disorder.. . recurrent thoughts, urges, or images that are experienced as intrusive and un- wanted that the person attempts to ig- nore or suppress) and/or compulsions (i.e., repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly), must be differentiated from...

Obsessive-Compulsive and Requires the presence of an etiological Related Disorder Due to Another medical condition. OCD is not diagnosed Medical Condition if the obsessions and compulsions are all

due to the direct physiological effects of a general medical condition.

Substance/Medication-Induced Is due to the direct physiological effects of Obsessive-Compulsive and a substance or medication. OCD is not Related Disorder diagnosed if the obsessions and compul-

sions are all due to the direct physiologi- cal effects of a substance (including medication).

Hoarding Disorder Is characterized by a persistent difficulty discarding or parting with possessions and an excessive accumulation of objects. However, for an individual with certain obsessions (e.g., concerns about incom- pleteness or harm) with associated hoarding compulsions (e.g., acquiring all objects in a set to attain a sense of com- pleteness), a diagnosis of OCD should be given instead.

Body Dysmorphic Disorder or Is characterized by recurrent thoughts ex- Eating Disorder clusively related to a preoccupation with

appearance or body weight.

216 DSM-5 Handbook of Differential Diagnosis

Specific Phobia Is characterized by fear and avoidance cued to specific circumscribed objects or situations. In OCD, the fear and avoid- ance of a specific object or situation is re- lated to avoiding the triggering of an obsession or compulsion (e.g., avoidance of dirt in an individual with a contamina- tion obsession).

Social Anxiety Disorder (Social Phobia) Is characterized by fear and avoidance cued to social situations, and repetitive reassurance behavior is focused on reducing the social fear.

Trichotillomania (Hair-Pulling Disorder) Is characterized by recurrent thoughts and or Excoriation (Skin-Picking) Disorder actions limited to hair pulling or skin

picking.

Illness Anxiety Disorder Is characterized by recurrent thoughts ex- clusively related to the idea that one has a serious disease.

Major Depressive Episode May be characterized by recurrent rumi- nations that are usually mood congruent and not necessarily experienced as intru- sive or distressing. Moreover, depressive ruminations are not linked to compul- sions, as is typical of OCD.

Generalized Anxiety Disorder Is characterized by recurrent thoughts (i.e., worries) about real-life concerns, and the thoughts are not accompanied by com- pulsions.

Delusional Disorder Is characterized by recurrent thoughts that are held with delusional conviction.

Schizophrenia Is characterized by ruminative delusional thoughts and stereotyped behaviors that are accompanied by other characteristic symptoms of Schizophrenia (e.g., halluci- nations, disorganized speech, negative symptoms).

3.6.1 Differential Diagnosis for Obsessive-Compulsive Disorder (continued)

Obsessive-Compulsive and Related Disorders 217

Tic Disorders Are characterized by sudden, rapid, recur- rent, nonrhythmic motor movements or vocalizations (e.g., eye blinking, throat clearing) that are less complex than com- pulsions and are not aimed at neutraliz- ing obsessions.

Stereotypic Movement Disorder Is characterized by repetitive, seemingly driven, nonfunctional motor behaviors (e.g., head banging, body rocking, self- biting) that are less complex than com- pulsions and are not aimed at neutraliz- ing obsessions.

Driven (“compulsive”) behaviors Are associated with disorders such as associated with other mental disorders Gambling Disorder, Paraphilic Disor-

ders, and Substance Use Disorders, and are characterized by the person’s deriv- ing pleasure from the activity and want- ing to resist it only because of its deleterious consequences. In contrast, the obsessions and compulsions in OCD are a source of intense anxiety and are not experienced as pleasurable.

Obsessive-Compulsive Personality Involves an enduring and pervasive mal- Disorder adaptive pattern of excessive perfection-

ism and rigid control and is not characterized by the presence of obses- sions or compulsions.

Nonpathological superstitions and Are not time-consuming and do not result repetitive behaviors in clinically significant impairment or

distress.

3.6.1 Differential Diagnosis for Obsessive-Compulsive Disorder (continued)

218 DSM-5 Handbook of Differential Diagnosis

3.6.2 Differential Diagnosis for Body Dysmorphic Disorder

Body Dysmorphic Disorder, which is char- In contrast to Body Dysmorphic acterized by a preoccupation with per- Disorder.. . ceived defects or flaws in physical appearance, must be differentiated from...

Normal appearance concerns and Do not involve excessive appearance- concerns about clearly noticeable related preoccupations and repetitive physical defects behaviors that are time-consuming, are

usually difficult to resist or control, and cause marked distress or impairment.

Anorexia Nervosa and Bulimia Nervosa Are characterized by concerns that are lim- ited to body shape and weight. A comor- bid diagnosis of Body Dysmorphic Disorder may be appropriate if appear- ance preoccupations go beyond overall body shape and weight (e.g., preoccupa- tion with a perceived facial defect).

Gender Dysphoria Is characterized by bodily concerns that are limited to wanting to get rid of pri- mary or secondary sexual characteristics. Body Dysmorphic Disorder should be di- agnosed only if appearance preoccupa- tions go beyond physical manifestations of gender.

Major Depressive Episode, Are often characterized by feelings of low Avoidant Personality Disorder, and self-esteem and defectiveness that may Social Anxiety Disorder (Social Phobia) include concerns about body appear-

ance. In contrast, in Body Dysmorphic Disorder, the individual is preoccupied by his or her perceived defects in appear- ance and performs repetitive behaviors (e.g., mirror checking, excessive groom- ing, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in re- sponse to the appearance concerns.

Obsessive-Compulsive Disorder Includes intrusive thoughts and repetitive behaviors that are not limited to concerns about appearance.

Obsessive-Compulsive and Related Disorders 219

Trichotillomania (Hair-Pulling Disorder) Is characterized by recurrent pulling out of one’s hair resulting in hair loss, accompa- nied by repeated attempts to stop that are not motivated by a desire to improve de- fects in appearance related to excessive body hair. However, if the hair-pulling behavior occurs in conjunction with a preoccupation with a defect in appear- ance involving excessive body hair, then a diagnosis of Body Dysmorphic Disor- der may be more appropriate.

Excoriation (Skin-Picking) Disorder Is characterized by recurrent skin picking resulting in skin lesions, accompanied by repeated attempts to stop that are not motivated by a desire to improve the ap- pearance of a perceived skin defect. If the skin-picking behavior occurs in conjunc- tion with a preoccupation with a per- ceived skin defect, then a diagnosis of Body Dysmorphic Disorder may be more appropriate.

Delusional Disorder, Somatic Type Is characterized by prominent delusions involving bodily functions or sensations. For some individuals with Body Dys- morphic Disorder, their beliefs about a defect in appearance are held with delu- sional conviction (i.e., they are com- pletely convinced that their view of their perceived defects is accurate). These indi- viduals are diagnosed as having Body Dysmorphic Disorder With Absent In- sight, as opposed to having Delusional Disorder.

Histrionic Personality Disorder or May be characterized by concerns with Narcissistic Personality Disorder appearance that do not involve specific

defects.

Body integrity identity disorder May be characterized by a preoccupation (preoccupation with the desire to become with the desire to have a limb amputated disabled, with onset in childhood) to correct a perceived mismatch between

the person’s sense of bodily identity and his or her anatomical configuration. However, unlike with Body Dysmorphic Disorder, the preoccupation does not fo- cus on the limb’s appearance.

3.6.2 Differential Diagnosis for Body Dysmorphic Disorder (continued)

220 DSM-5 Handbook of Differential Diagnosis

3.6.3 Differential Diagnosis for Hoarding Disorder

Hoarding Disorder, which is characterized In contrast to Hoarding Disorder... by persistent difficulty discarding or parting with possessions because of a perceived need to save the items, must be differentiated from...

Obsessive-Compulsive and Related Requires the presence of an etiological Disorder Due to Another Medical medical condition (e.g., traumatic brain Condition injury, surgical resection for seizure con-

trol, cerebrovascular disease). Hoarding Disorder is not diagnosed if the hoarding behavior is due to the direct physiologi- cal effects of a general medical condition.

Major Neurocognitive Disorder Due to a The onset of the accumulating behavior is neurodegenerative condition, such as gradual and follows the course of the frontotemporal lobar degeneration or neurocognitive disorder and may be ac- Alzheimer’s disease companied with self-neglect and severe

domestic squalor, alongside other neuro- psychiatric symptoms. Hoarding Disor- der is not diagnosed if the accumulation of objects is judged to be a direct conse- quence of a degenerative brain disorder.

Autism Spectrum Disorder May include the excessive accumulation of objects related to a fixated interest that is abnormal in intensity (e.g., collecting matchbox covers), in which case a diag- nosis of Hoarding Disorder is not made.

Obsessive-Compulsive and Related Disorders 221

Obsessive-Compulsive Disorder Is characterized by repetitive behaviors that the individual feels driven to per- form in response to an obsession or ac- cording to rules that must be applied rigidly, and that are generally experi- enced by the individual as ego-dystonic. This is in contrast to the ego-syntonic ac- cumulation of items in Hoarding Disor- der. When an accumulation of objects occurs as a direct consequence of Obses- sive-Compulsive Disorder (e.g., not dis- carding objects to avoid endless checking rituals), a diagnosis of Hoarding Disor- der is not made. However, when severe hoarding appears concurrently with other typical symptoms of Obsessive- Compulsive Disorder but are judged to be independent from these symptoms, both Hoarding Disorder and Obsessive- Compulsive Disorder may be diagnosed.

Psychotic Disorder (e.g., Schizophrenia) May be characterized by an accumulation of objects as a consequence of a delu- sional belief (e.g., collecting discarded pieces of aluminum foil to protect oneself from radiation) or a command hallucina- tion, in which case a diagnosis of Hoard- ing Disorder is not made.

Major Depressive Episode May be associated with a cluttered envi- ronment that occurs as a direct conse- quence of depressive symptoms such as fatigue, inertia, and psychomotor retar- dation, in which case a diagnosis of Hoarding Disorder is not made.

Normal collecting behavior Is organized and systematic, even if in some cases the actual amount of possessions may be similar to an individual with Hoarding Disorder. Moreover, it does not produce the clutter, distress, or impair- ment typical of Hoarding Disorder.

3.6.3 Differential Diagnosis for Hoarding Disorder (continued)

222 DSM-5 Handbook of Differential Diagnosis

3.6.4 Differential Diagnosis for Trichotillomania

(Hair-Pulling Disorder)

Trichotillomania, which is characterized In contrast to Trichotillomania... by recurrent pulling out of one’s hair ac- companied by repeated attempts to stop hair pulling, must be differentiated from...

Medical conditions that cause hair loss Certain conditions such as scarring alope- cia (e.g., alopecia areata) and nonscarring alopecia (e.g., chronic discoid lupus ery- thematosus) can fully account for the hair loss. Trichotillomania is not diagnosed if the hair pulling is attributable to one of these medical conditions.

Obsessive-Compulsive Disorder Is characterized by behavior that is per- formed in response to an obsession or ac- cording to rules that must be applied rigidly. Trichotillomania is not diagnosed if the hair pulling is a direct consequence of an obsession or compulsion (e.g., indi- viduals with symmetry concerns may pull out hairs as part of their symmetry rituals).

Body Dysmorphic Disorder Is characterized by a preoccupation with an imagined defect in physical appear- ance that in some cases may result in a preoccupation with removing body hair that the individual perceives as ugly or abnormal. Trichotillomania is not diag- nosed if the hair pulling is a direct conse- quence of the preoccupation with a perceived defect in appearance.

Psychotic Disorder (e.g., Schizophrenia) May be characterized by hair pulling in re- sponse to delusions or hallucinations. Trichotillomania is not diagnosed if the hair pulling is better accounted for by a Psychotic Disorder.

Obsessive-Compulsive and Related Disorders 223

Stereotypic Movement Disorder Involves repetitive behaviors other than (or in addition to) hair pulling (e.g., hand shaking or waving, body rocking, head banging).

Normative hair removal or manipulation Is characterized by hair removal that is performed solely for cosmetic reasons (i.e., to improve one’s physical appear- ance) or by behavior that is confined to twisting, playing with, or biting one’s hair. In such cases, distress or impair- ment in functioning is not significant and thus such presentations would not qual- ify for a diagnosis of Trichotillomania.

3.6.4 Differential Diagnosis for Trichotillomania

(Hair-Pulling Disorder) (continued)

224 DSM-5 Handbook of Differential Diagnosis

3.6.5 Differential Diagnosis for Excoriation (Skin-Picking) Disorder

Excoriation Disorder, which is character- In contrast to Excoriation Disorder.. . ized by recurrent skin picking resulting in skin lesions accompanied by repeated attempts to stop, must be differentiated from...

Obsessive-Compulsive and Related The skin picking is due to the direct phys- Disorder Due to Another Medical iological effects of a general medical con- Condition dition. Excoriation Disorder is not

diagnosed if the skin picking is attribut- able to the direct physiological effects of a dermatological condition (e.g., scabies).

Substance/Medication-Induced The skin picking is due to the direct Obsessive-Compulsive and Related physiological effects of a substance Disorder (e.g., cocaine). Excoriation Disorder is

not diagnosed if the skin picking is fully attributable to the substance.

Obsessive-Compulsive Disorder May include skin lesions occurring as a consequence of severe washing compul- sions. Excoriation Disorder is not diag- nosed if the skin lesions are better explained by Obsessive-Compulsive Disorder.

Body Dysmorphic Disorder May include skin-picking behavior to im- prove a perceived defect in appearance. Excoriation Disorder is not diagnosed if the skin picking is better explained by Body Dysmorphic Disorder.

Psychotic Disorder (e.g., Schizophrenia) May include skin picking in response to a delusion (i.e., parasitosis) or tactile hallu- cination (i.e., formication). In such cases, Excoriation Disorder should not be diag- nosed.

Stereotypic Movement Disorder Involves repetitive behaviors other than (or in addition to) skin picking (e.g., hand shaking or waving, body rocking, head banging).

Trauma- and Stressor-Related Disorders 225

Trauma- and Stressor-Related Disorders 3.7.1 Differential Diagnosis for Posttraumatic Stress Disorder or

Acute Stress Disordera

Posttraumatic Stress Disorder (PTSD) and In contrast to Posttraumatic Stress Disor- Acute Stress Disorder (ASD), which are der or Acute Stress Disorder... characterized by exposure to actual or threatened death, serious injury, or sex- ual violence, followed by the develop- ment of intrusion symptoms, persistent avoidance of stimuli associated with the trauma, negative alterations of cogni- tions and mood, and marked alterations in arousal and reactivity, must be differ- entiated from...

Adjustment Disorder Is characterized by a stressor of any level of severity and does not have a specific response pattern (e.g., intrusion symp- toms). The diagnosis of Adjustment Dis- order is used when the response to an extreme stressor does not meet the crite- ria for PTSD or ASD (or another specific mental disorder) when the symptom pat- tern of PTSD or ASD occurs in response to a nontraumatic stressor (e.g., spouse leaving, being fired).

Persistent complex bereavement disorder Is characterized by intrusive thoughts and (in DSM-5 Section III) memories of the deceased that persist for

at least 12 months after the loss. In con- trast to PTSD, where the intrusions re- volve around traumatic events related to the loss, in persistent complex bereave- ment disorder the intrusions focus on many aspects of the deceased including positive aspects of the relationship and distress over the separation.

Other mental disorders that may occur Are characterized by a response pattern after exposure to an extreme stressor that meets criteria for another mental dis-

order in DSM-5 (e.g., Brief Psychotic Dis- order, Major Depressive Disorder).

Obsessive-Compulsive Disorder Is usually characterized by recurrent intru- sive thoughts, but these are experienced as inappropriate and are not related to an experienced traumatic event.

226 DSM-5 Handbook of Differential Diagnosis

Panic Disorder May be characterized by arousal and dis- sociative symptoms, but these occur dur- ing Panic Attacks and are not associated with a traumatic stressor.

Generalized Anxiety Disorder May be characterized by persistent symp- toms of irritability and anxiety, but unlike PTSD or ASD, these symptoms are not associated with a traumatic stressor.

Dissociative Disorders Are characterized by dissociative symp- toms that are not necessarily related to exposure to a traumatic stressor (but of- ten are). Dissociative symptoms occur- ring in the context of the full syndrome of PTSD might justify the use of the With Dissociative Symptoms specifier.

Psychotic Disorders (e.g., Schizophrenia) May be characterized by perceptual symp- toms such as illusions or hallucinations. These should be differentiated from flash- backs in PSTD or ASD, which are charac- terized by sensory intrusions comprising part of the traumatic event that can occur with complete loss of awareness of pres- ent surroundings. These episodes are typ- ically brief but can be associated with prolonged distress and heightened arousal. They are generally not considered to be psychotic phenomena.

Traumatic brain injury Is characterized by neurocognitive symp- toms (e.g., persistent disorientation and confusion) that develop after a traumatic brain injury (e.g., traumatic accident, bomb blast, acceleration/deceleration trauma). Because this traumatic event can also lead to the development of ASD and PTSD, both diagnoses should be con- sidered.

Malingering Is characterized by feigning of symptoms and must always be ruled out when legal, financial, and other benefits play a role.

aPTSD and ASD are differentiated based on duration. The duration of the response pattern in ASD is from

3 days to 1 month after exposure to the traumatic stressor. The duration of the response pattern in PTSD is

more than 1 month.

3.7.1 Differential Diagnosis for Posttraumatic Stress Disorder or

Acute Stress Disordera (continued)

Trauma- and Stressor-Related Disorders 227

3.7.2 Differential Diagnosis for Adjustment Disorder

Adjustment Disorder, which is character- In contrast to Adjustment Disorder.. . ized by the development of clinically sig- nificant emotional or behavioral symptoms that do not meet the criteria for another mental disorder, must be dif- ferentiated from...

All other specified mental disorders Are characterized by a specific symptom pattern and do not require that the symp- toms occur in response to a stressor (ex- cept Posttraumatic Stress Disorder, Acute Stress Disorder, Reactive Attachment Disorder, and Disinhibited Social En- gagement Disorder). Adjustment Disor- der is not diagnosed if the symptoms meet criteria for a specific mental disor- der or represent an exacerbation of an ex- isting disorder. Adjustment Disorder can be diagnosed in addition to another men- tal disorder if the latter does not explain the particular symptoms that occur in reaction to the stressor. For example, an individual may develop an Adjustment Disorder With Depressed Mood after losing a job while at the same time having a diagnosis of Obsessive-Compulsive Disorder.

Posttraumatic Stress Disorder or Each requires that the stressor be extreme Acute Stress Disorder and requires characteristic intrusion

symptoms, persistent avoidance of stim- uli associated with the trauma, negative alterations of cognitions and mood, and marked alterations in arousal and reac- tivity.

Other Specified or Unspecified categories Are diagnosed only when the criteria are (e.g., Other Specified Depressive not met for any specified DSM-5 disorder Disorder) (including Adjustment Disorder).

228 DSM-5 Handbook of Differential Diagnosis

Psychological Factors Affecting Other Are characterized by specific psychologi- Medical Conditions cal entities (e.g., psychological symp-

toms, behaviors, other factors) that precipitate, exacerbate, or put an individ- ual at risk for medical illness, or worsen an existing condition. In contrast, when a medical condition acts as a psychosocial stressor leading to a psychological reac- tion, Adjustment Disorder is diagnosed.

Bereavement Is characterized by a reaction to the loss of a loved one that is in keeping with what would be expected. Adjustment Disorder can be diagnosed only if the symptoms are in excess of what is expected.

Persistent complex bereavement disorder Is characterized by a persistent maladap- (in DSM-5 Section III) tive and pathological reaction to the

death of a loved one. In contrast to Ad- justment Disorder, which has a maxi- mum duration of 6 months, persistent complex bereavement disorder requires a minimum of 12 months of symptoms.

Nonpathological reactions to stress Are characterized by symptoms that are within what would be expected given the nature of the stressor and that do not lead to clinically significant distress or impair- ment.

3.7.2 Differential Diagnosis for Adjustment Disorder (continued)

Dissociative Disorders 229

Dissociative Disorders 3.8.1 Differential Diagnosis for Dissociative Amnesia

Dissociative Amnesia, which is character- In contrast to Dissociative Amnesia.. . ized by an inability to recall important autobiographical information, usually of a traumatic or stressful nature, must be differentiated from...

Memory impairment in a Major or Mild Is characterized by memory loss for per- Neurocognitive Disorder Due to Another sonal information that is usually embed- Medical Condition ded in cognitive, linguistic, affective,

attentional, and behavioral disturbances. In Dissociative Amnesia, memory defi- cits are primarily for autobiographical in- formation, and intellectual and other cognitive abilities are preserved.

Alcohol or other substance-induced Is characterized by the ability to recall memory loss events immediately (i.e., intact working

memory), but not after a few minutes, given the failure of memory storage sec- ondary to the direct effects of the sub- stance on the central nervous system. Substance-induced “blackouts” usually cannot be reversed.

Posttraumatic amnesia due to brain injury Is characterized by a history of a clear-cut physical trauma, a period of uncon- sciousness or amnesia, objective evi- dence of brain injury, and a brief retrograde amnesia for the time before the head injury. If the retrograde post- traumatic amnesia is so extensive that it is out of proportion to the brain injury, a comorbid diagnosis of Dissociative Am- nesia may be appropriate.

Dissociative Identity Disorder Is characterized by pervasive discontinui- ties in sense of self and agency, accompa- nied by many other dissociative symptoms. In individuals with Dissocia- tive Amnesia, the amnesia tends to be localized, selective, and relatively stable. Dissociative Amnesia is not diagnosed if the memory gaps are better explained by Dissociative Identity Disorder.

230 DSM-5 Handbook of Differential Diagnosis

Posttraumatic Stress Disorder or May be characterized by an inability to re- Acute Stress Disorder call part or all of a specific traumatic

event. Amnesia confined to the traumatic event occurring in the context of Post- traumatic Stress Disorder would gener- ally not warrant an additional diagnosis of Dissociative Amnesia. However, if the amnesia extends beyond the immediate time of the trauma, a comorbid diagnosis of Dissociative Amnesia may be war- ranted (e.g., for a rape victim who cannot recall most events for the entire day of the rape).

Malingering or Factitious Disorder Is characterized by amnesia that is feigned. No test, battery of tests, or set of proce- dures, however, can invariably distin- guish Dissociative Amnesia from feigned amnesia, and the same contextual factors associated with feigned amnesia (e.g., fi- nancial, sexual, or legal problems; or a wish to escape stressful circumstances) are also associated with Dissociative Am- nesia.

Everyday memory loss, amnesia for Is characterized by difficulties in memory dreams, amnesia for childhood that are normative given the context. experiences, posthypnotic amnesia, or age-related memory loss

3.8.1 Differential Diagnosis for Dissociative Amnesia (continued)

Dissociative Disorders 231

3.8.2 Differential Diagnosis for Depersonalization/Derealization

Disorder

Depersonalization/Derealization Disor- In contrast to Depersonalization/Dereal- der, which is characterized by persistent ization Disorder.. . or recurrent experiences of depersonali- zation, must be differentiated from...

Dissociative symptoms due to a general Require the presence of an etiological medical condition medical condition, such as a seizure dis-

order, and would be diagnosed as Other Specified Mental Disorder Due to An- other Medical Condition, With Dissocia- tive Symptoms. Depersonalization/ Derealization Disorder is not diagnosed if the symptoms are all due to the direct physiological effects of a general medical condition on the central nervous system.

Substance Intoxication or May be characterized by dissociative Substance Withdrawal symptoms along with the other symp-

toms of Substance Intoxication or Sub- stance Withdrawal. The most common precipitating substances are cannabis, hallucinogens, ketamine, ecstasy, and sal- via. Depersonalization/derealization symptoms attributable to the physiologi- cal effects of substances during acute in- toxication or withdrawal are not diagnosed as Depersonalization/Dereal- ization Disorder. However, substances can intensify the symptoms of a preexist- ing Depersonalization/Derealization Disorder. The differential diagnosis thus depends on a careful assessment of the temporal relationship between substance use and depersonalization/derealization symptoms.

Dissociative Identity Disorder May be characterized by symptoms of de- personalization or derealization accom- panying the pervasive discontinuities in sense of self and agency. Depersonaliza- tion/Derealization Disorder is not diag- nosed if the symptoms are better explained by Dissociative Identity Disorder.

232 DSM-5 Handbook of Differential Diagnosis

Panic Attacks May be characterized by symptoms of de- personalization or derealization accom- panying the other symptoms of the Panic Attack. Panic Attack symptoms have an abrupt onset and reach a peak within minutes. In contrast, episodes of deper- sonalization or derealization in Deper- sonalization/Derealization Disorder typically last for hours, weeks, or months. Depersonalization/Derealization Disor- der is not diagnosed if the symptoms oc- cur only during a Panic Attack.

Posttraumatic Stress Disorder or May be characterized by dissociative Acute Stress Disorder symptoms that develop in response to ex-

posure to a traumatic stressor (and for Posttraumatic Stress Disorder, would be indicated by using the specifier With Dis- sociative Symptoms). Depersonaliza- tion/Derealization Disorder is not diagnosed if the symptoms are better ex- plained by Posttraumatic Stress Disorder or Acute Stress Disorder.

Psychotic Disorders (e.g., Schizophrenia) May be characterized by delusions in which the individual believes that he or she is dead or that the world is not real. In contrast, reality testing about the depersonalization/derealization is intact in Depersonalization/Derealization Disorder (i.e., the person knows that he or she is not really dead and that the world is real).

Major Depressive Disorder May be characterized by feelings of numb- ness, deadness, apathy, and being in a dream along with the other characteristic symptoms of depression during Major Depressive Episodes. In Depersonaliza- tion/Derealization Disorder, feelings of numbness are associated with other symptoms of the disorder (e.g., a sense of detachment from one’s self) and occur when the individual is not depressed.

3.8.2 Differential Diagnosis for Depersonalization/Derealization

Disorder (continued)

Dissociative Disorders 233

“Normal” symptoms of depersonalization Are transient and lack clinically significant or derealization impairment or distress. Approximately

one-half of all adults have experienced at least one lifetime episode of depersonali- zation/derealization. Depersonaliza- tion/derealization symptoms meeting full criteria for this disorder are much less common, with a lifetime prevalence of approximately 2%.

3.8.2 Differential Diagnosis for Depersonalization/Derealization

Disorder (continued)

234 DSM-5 Handbook of Differential Diagnosis

Somatic Symptom and Related Disorders 3.9.1 Differential Diagnosis for Somatic Symptom Disorder

Somatic Symptom Disorder, which is char- In contrast to Somatic Symptom acterized by somatic symptoms that are Disorder.. . distressing or result in significant disrup- tion of daily life and are accompanied by excessive thoughts, feelings, or behaviors related to the somatic symptoms or asso- ciated health concerns, must be differen- tiated from...

Distressing somatic symptoms Are characterized by a lack of dispropor- characteristic of a medical condition tionate and persistent thoughts about the

seriousness of one’s somatic symptoms, the absence of a persistently high level of anxiety about health or the somatic symptoms, and not devoting excessive time and energy to the somatic symp- toms or health concerns. Having somatic symptoms of unclear etiology is not by it- self sufficient for the diagnosis of Somatic Symptom Disorder, and having somatic symptoms of an established medical con- dition (e.g., diabetes or heart disease) does not exclude the diagnosis of So- matic Symptom Disorder if the criteria are otherwise met.

Illness Anxiety Disorder Is characterized by extensive worries about health, but no or minimal somatic symptoms. In Somatic Symptom Disor- der, the predominant focus is on the dis- tressing somatic complaints.

Body Dysmorphic Disorder Is characterized by a preoccupation with a perceived defect in physical appearance. In Somatic Symptom Disorder, the con- cern about somatic symptoms reflects concerns about underlying illness, not of a defect in appearance.

Somatic Symptom and Related Disorders 235

Conversion Disorder (Functional Requires the loss of function (e.g., of a limb) Neurological Symptom Disorder) as the presenting symptom, whereas in So-

matic Symptom Disorder the focus is on the distress that particular symptoms cause. Moreover, a diagnosis of Somatic Symptom Disorder requires the presence of accompanying excessive thoughts, feel- ings, or behaviors related to the somatic symptoms or associated health concerns.

Generalized Anxiety Disorder Is characterized by worry about multiple events, situations, or activities, which may include concerns about the individ- ual’s health. The main focus of worry in Somatic Symptom Disorder is on somatic symptoms and health concerns.

Panic Disorder Is characterized by somatic symptoms oc- curring in the context of Panic Attacks and consequent worries about the health sig- nificance of the Panic Attacks. In Somatic Symptom Disorder, the anxiety and so- matic symptoms are relatively persistent.

Obsessive-Compulsive Disorder Is characterized by recurrent thoughts that are experienced as intrusive and un- wanted and that the person attempts to ignore or suppress, and that are accom- panied by repetitive behaviors that the individual feels driven to perform. In So- matic Symptom Disorder, the recurrent concerns about somatic symptoms or ill- ness are less intrusive and there are no as- sociated repetitive behaviors that the person feels driven to perform.

Depressive Disorders Are commonly accompanied by somatic symptoms, but these are usually limited to episodes of depressed mood. More- over, the somatic symptoms in the De- pressive Disorders are accompanied by dysphoric mood and their characteristic associated symptoms.

Psychotic Disorders (e.g., Schizophrenia) May have somatic concerns that are of a delusional nature.

Factitious Disorder or Malingering Is characterized by physical symptoms that are intentionally produced or feigned.

3.9.1 Differential Diagnosis for Somatic Symptom Disorder (continued)

236 DSM-5 Handbook of Differential Diagnosis

3.9.2 Differential Diagnosis for Illness Anxiety Disorder

Illness Anxiety Disorder, which is charac- In contrast to Illness Anxiety Disorder... terized by a preoccupation with having or acquiring a serious illness without ac- companying somatic symptoms, must be differentiated from...

Expectable concerns regarding a medical Concerns and distress about the medical condition condition are proportionate to its severity.

A comorbid diagnosis of Illness Anxiety Disorder is appropriate only if the health- related anxiety and disease concerns are clearly disproportionate to the seriousness of the medical condition. Transient preoc- cupations related to a medical condition generally do not justify a diagnosis of Ill- ness Anxiety Disorder.

Somatic Symptom Disorder Is characterized by the presence of signifi- cant somatic symptoms. In contrast, indi- viduals with Illness Anxiety Disorder have no or minimal somatic symptoms and are primarily concerned with the idea that they have a serious illness.

Specific Phobia of contracting a disease Is characterized by a fear that one might contract a disease rather than a fear that one already has the disease as in Illness Anxiety Disorder.

Generalized Anxiety Disorder Is characterized by anxiety and worry about multiple events, situations, or ac- tivities, only one of which may involve health.

Panic Disorder May be characterized by anxiety or worry specifically regarding the idea that the Panic Attacks reflect the presence of a se- rious medical illness such as heart dis- ease. Although individuals with Panic Disorder may have health anxiety, their anxiety is typically very acute and epi- sodic. In contrast, the health anxiety and fears in Illness Anxiety Disorder are more chronic and enduring. Some individuals with Illness Anxiety Disorder experience Panic Attacks that are triggered by their illness concerns.

Somatic Symptom and Related Disorders 237

Obsessive-Compulsive Disorder May be characterized by intrusive thoughts that focus on fears of getting a disease in the future, and there usually are addi- tional obsessions or compulsions involv- ing other concerns. The intrusive thoughts of individuals with Illness Anxiety Disor- der are about having a disease and may be accompanied by associated compulsive behaviors (e.g., seeking reassurance).

Body Dysmorphic Disorder Is characterized by concerns that are limited to the individual’s physical appearance, which is viewed as defective or flawed.

Adjustment Disorder Is characterized by marked distress or im- pairment in functioning that develops in response to a psychosocial stressor (e.g., being diagnosed with a medical condi- tion) and is time-limited (i.e., persisting for no longer than 6 months after the ter- mination of the stressor). A diagnosis of Illness Anxiety Disorder requires the continuous persistence of disproportion- ate health-related anxiety for more than 6 months.

Major Depressive Disorder May be characterized by ruminations about health and excessive worry about illness, along with the characteristic symptoms of a Major Depressive Episode (e.g., depressed mood, diminished inter- est or pleasure). A separate diagnosis of Illness Anxiety Disorder is not made if these concerns occur only during the Ma- jor Depressive Episodes. However, if ex- cessive illness worry persists after remission of an episode of Major Depres- sive Disorder, the diagnosis of Illness Anxiety Disorder should be considered.

3.9.2 Differential Diagnosis for Illness Anxiety Disorder (continued)

238 DSM-5 Handbook of Differential Diagnosis

Psychotic Disorders (e.g., Delusional May be characterized by somatic delu- Disorder) sions (e.g., that an organ is rotting or

dead) or delusional beliefs of having an illness. Concerns about illness in individ- uals with Illness Anxiety Disorder do not attain the rigidity and intensity seen in the somatic delusions occurring in Psy- chotic Disorders, and the person can ac- knowledge the possibility that the feared disease is not present.

3.9.2 Differential Diagnosis for Illness Anxiety Disorder (continued)

Somatic Symptom and Related Disorders 239

3.9.3 Differential Diagnosis for Conversion Disorder (Functional Neurological

Symptom Disorder)

Conversion Disorder, which is character- In contrast to Conversion Disorder... ized by symptoms of altered voluntary motor or sensory function that are incom- patible with recognized neurological or medical conditions, must be differenti- ated from...

Occult neurological or other medical Fully account for the deficits involving conditions, or substance/medication- voluntary motor or sensory functioning. induced disorders Conversion Disorder can be diagnosed

only if, after appropriate investigation, the symptom or deficit cannot be fully ex- plained by a neurological or general medical condition or by the direct effects of a substance or medication.

Somatic Symptom Disorder Is characterized by distressing somatic symptoms accompanied by excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns without regard to whether the somatic symptoms are ade- quately explained by a medical condi- tion. In contrast, in Conversion Disorder, clinical and/or laboratory findings must provide evidence that the neurological symptoms are incompatible with recog- nized neurological or general medical conditions.

Illness Anxiety Disorder Is characterized by a focus on the “serious disease” underlying the pseudoneuro- logical symptoms.

Depressive Disorders May be characterized by feelings of gen- eral “heaviness” of the limbs accompa- nied by core depressive symptoms, whereas the weakness of Conversion Disorder is more focal and prominent.

240 DSM-5 Handbook of Differential Diagnosis

Dissociative Disorders Involve neurological functions (e.g., mem- ory, consciousness) other than voluntary motor or sensory functioning.

Factitious Disorder or Malingering Is characterized by symptoms that are in- tentionally produced or feigned. In Con- version Disorder, even though the presenting neurological symptoms are inconsistent with a bona fide neurologi- cal condition, they are not being inten- tionally feigned by the individual. Conversion Disorder is not diagnosed if the symptoms are intentionally produced or feigned.

3.9.3 Differential Diagnosis for Conversion Disorder (Functional Neurological

Symptom Disorder) (continued)

Somatic Symptom and Related Disorders 241

3.9.4 Differential Diagnosis for Psychological Factors Affecting Other

Medical Conditions

Psychological Factors Affecting Other In contrast to Psychological Factors Affect- Medical Conditions, which are character- ing Other Medical Conditions... ized by psychological factors that ad- versely affect the course or treatment of a medical condition, that constitute health risks for the individual, or that influence the underlying pathophysiology, must be differentiated from...

Mental disorder due to a general medical Is characterized by a temporal association condition between symptoms of a mental disorder

and a general medical condition, but the causal relationship is in the opposite di- rection. In a mental disorder due to a gen- eral medical condition, the medical condition is judged to be causing the mental disorder through a direct physio- logical mechanism, whereas in Psycho- logical Factors Affecting Other Medical Conditions, the psychological or behav- ioral factors are judged to affect the course of the medical condition.

Adjustment Disorder May be characterized by a clinically signif- icant psychological response to a general medical condition that is the identifiable stressor. For example, an individual with angina who develops maladaptive antic- ipatory anxiety would be diagnosed as having an Adjustment Disorder With Anxiety, whereas an individual with an- gina that is precipitated whenever he or she becomes enraged would be diag- nosed as having Psychological Factors Affecting Other Medical Conditions.

242 DSM-5 Handbook of Differential Diagnosis

Mental disorder causing or exacerbating Symptoms meeting full criteria for a men- another medical condition tal disorder frequently result in medical

complications, most notably Substance Use Disorders (e.g., Severe Alcohol Use Disorder, Severe Tobacco Use Disorder). If an individual has a mental disorder that adversely affects or causes a general medical condition, both the mental disor- der and the medical condition are diag- nosed; however, Psychological Factors Affecting Other Medical Conditions is di- agnosed when the psychological traits or behaviors do not meet criteria for a men- tal disorder.

Somatic Symptom Disorder Is characterized by a combination of dis- tressing somatic symptoms and exces- sive or maladaptive thoughts, feelings, and behaviors occurring in response to these symptoms, with the emphasis be- ing on the maladaptive thoughts, feel- ings, and behaviors (e.g., an individual with angina who worries constantly that he will have a heart attack takes his blood pressure multiple times per day and re- stricts his activities). In Psychological Factors Affecting Other Medical Condi- tions, the emphasis is on the exacerbation of the general medical condition (e.g., an individual with angina that is precipi- tated whenever he becomes anxious).

Illness Anxiety Disorder Is characterized by high illness anxiety that is distressing or disruptive to daily life with no or minimal somatic symp- toms. In Psychological Factors Affecting Other Medical Conditions, anxiety may be a relevant psychological factor affect- ing a medical condition, but the clinical concern is the adverse effects on the med- ical condition.

3.9.4 Differential Diagnosis for Psychological Factors Affecting Other

Medical Conditions (continued)

Somatic Symptom and Related Disorders 243

3.9.5 Differential Diagnosis for Factitious Disordera

Factitious Disorder, which is characterized In contrast to Factitious Disorder... by falsification of physical or psychologi- cal signs or symptoms or induction of in- jury or disease in oneself or another person, associated with identified decep- tion, must be differentiated from...

Somatic Symptom Disorder May be characterized by excessive atten- tion and treatment seeking for perceived medical concerns, but there is no evidence that the individual is providing false in- formation or behaving deceptively.

Malingering Is characterized by the intentional report- ing or feigning of symptoms for personal gain (e.g., money, time off work), whereas the diagnosis of Factitious Dis- order requires that the feigning behav- iors persists even in the absence of obvious external incentives.

Conversion Disorder (Functional Is characterized by neurological symptoms Neurological Symptom Disorder) that are inconsistent with neurological

pathophysiology. Factitious Disorder with neurological symptoms is distinguished from Conversion Disorder by evidence of deceptive falsification of symptoms.

Borderline Personality Disorder May be characterized by deliberate physi- cal self-harm in the absence of suicidal in- tent. Factitious Disorder requires that the induction of injury occurs in association with deception.

Child or elder abuse (as distinguished Is characterized by lying about abuse inju- from Factitious Disorder Imposed on ries in dependents solely to protect one- Another) self from liability. Such individuals are

not diagnosed with Factitious Disorder Imposed on Another because the decep- tive behavior is motivated by an obvious external incentive (i.e., protection from criminal liability). Caregivers who are found to lie more extensively than needed for immediate self-protection may be diagnosed with Factitious Disor- der Imposed on Another.

a Factitious Disorder comes in two forms: Factitious Disorder Imposed on Self, in which an individual feigns

medical or psychiatric symptoms, and Factitious Disorder Imposed on Another, in which an individual de-

ceptively induces a disease or injury in another, usually a dependent child or elder.

244 DSM-5 Handbook of Differential Diagnosis

Feeding and Eating Disorders 3.10.1 Differential Diagnosis for Avoidant/Restrictive Food Intake

Disorder

Avoidant/Restrictive Food Intake Disor- In contrast to Avoidant/Restrictive Food der (ARFID), which is characterized by a Intake Disorder... persistent failure to meet appropriate nu- tritional and/or energy needs related to an eating or feeding disturbance, must be differentiated from...

Other medical conditions Restriction of food intake may occur in other medical conditions (e.g., gastroin- testinal disease, food allergies and intol- erances, occult malignancies), especially with ongoing symptoms such as vomit- ing, loss of appetite, nausea, abdominal pain, or diarrhea. A diagnosis of ARFID may be appropriate if the disturbance of intake exceeds that routinely associated with the medical condition and warrants additional clinical attention or if it per- sists after resolution of the medical con- dition.

Specific neurological, structural, or Feeding difficulties are common in a num- congenital disorders and conditions ber of congenital and neurological condi- associated with feeding difficulties tions often related to problems with oral/

esophageal/pharyngeal structure and function. A diagnosis of ARFID may be appropriate if the disturbance of food in- take exceeds that routinely associated with the medical condition and warrants additional clinical attention.

Reactive Attachment Disorder The disturbance in the caregiver-child re- lationship typically affects feeding and the child’s intake. A diagnosis of ARFID may be appropriate if the feeding distur- bance is a primary focus for intervention.

Autism Spectrum Disorder May be characterized by rigid eating be- haviors and heightened sensory sensitivi- ties. However, this often does not result in the level of impairment (e.g., weight loss, nutritional deficiency) that would be re- quired for a diagnosis of ARFID. ARFID should be diagnosed only if the eating dis- turbance requires specific treatment.

Feeding and Eating Disorders 245

Specific Phobia, Other Type, with a fear Is characterized by avoidance of situations of vomiting that may lead to choking or vomiting and

may result in food avoidance and some restriction of food intake. When the eat- ing problem itself becomes the primary focus on clinical attention, a diagnosis of ARFID is warranted.

Anorexia Nervosa Although both ARFID and Anorexia Ner- vosa are characterized by food restric- tions and low weight, individuals with Anorexia Nervosa also have a fear of gaining weight or becoming fat, or per- sistent behavior that interferes with weight gain, as well as specific distur- bances in their perception and experience of body weight and shape.

Major Depressive Disorder May be characterized by appetite loss to such an extent that individuals present with significantly restricted food intake and weight loss, which usually abates with resolution of the depression. A diag- nosis of ARFID may be appropriate if the eating disturbance requires specific treat- ment.

Schizophrenia Spectrum and May be characterized by odd eating be- Other Psychotic Disorders haviors, avoidance of specific foods due

to delusional beliefs, or other manifesta- tions of avoidant or restrictive intake. A diagnosis of ARFID may be appropriate if the eating disturbance requires specific treatment.

3.10.1 Differential Diagnosis for Avoidant/Restrictive Food Intake

Disorder (continued)

246 DSM-5 Handbook of Differential Diagnosis

3.10.2 Differential Diagnosis for Anorexia Nervosa

Anorexia Nervosa, which is characterized In contrast to Anorexia Nervosa.. . by a restriction of energy intake relative to requirements, leading to a significantly low body weight; an intense fear of gain- ing weight; and a disturbance in the way in which one’s body weight or shape is ex- perienced, must be differentiated from...

Other medical conditions A number of other medical conditions (e.g., neoplasms, infections, metabolic or endocrine conditions) are characterized by weight loss. However, with such con- ditions, unlike Anorexia Nervosa, there is no disturbance in the way the person’s body weight or shape is experienced, no intense fear of weight gain, and no per- sisting in behaviors that interfere with appropriate weight gain. The weight loss is often accompanied by loss of appetite and includes signs, symptoms, or labora- tory findings characteristic of the under- lying medical condition.

Substance Use Disorders May be characterized by low weight due to poor nutritional intake, but individu- als abusing substances generally do not fear gaining weight and do not have dis- turbances in body image. Some individu- als abusing stimulants for the purpose of appetite suppression may be motivated by a desire to interfere with weight gain; if the other symptoms of Anorexia Ner- vosa are also present, the diagnosis would be warranted.

Bulimia Nervosa In both conditions, the person may engage in recurrent episodes of binge eating, en- gage in inappropriate behavior to avoid weight gain (e.g., self-induced vomiting), and be overly concerned with body shape and weight. The conditions are dif- ferentiated based on body weight. Indi- viduals with Bulimia Nervosa maintain body weight at or above a minimally nor- mal level, whereas those with Anorexia Nervosa maintain a significantly low body weight.

Feeding and Eating Disorders 247

Avoidant/Restrictive Food Is characterized by significant weight loss Intake Disorder and nutritional deficiency and restriction

of food intake, but unlike Anorexia Ner- vosa the weight loss and food restrictions are not motivated by a fear of gaining weight or becoming fat.

Weight loss in Depressive Disorders Is not accompanied by a desire for exces- sive weight loss or an intense fear of gain- ing weight or getting fat, and includes the presence of characteristic features of a Depressive Disorder (e.g., depressed mood, loss of interest).

Schizophrenia May be characterized by unusual eating behavior, but it is not accompanied by a desire for excessive weight loss or an intense fear of gaining weight or getting fat, and it is accompanied by the characteristic features of Schizophrenia (e.g., delusions, hallucinations, disorganized speech).

Obsessive-Compulsive Disorder In both conditions, there may be repetitive intrusive thoughts and compulsive be- haviors. In Anorexia Nervosa, however, these thoughts and behaviors are limited to weight, eating, or food. An additional diagnosis of Obsessive-Compulsive Dis- order should be considered only if there are additional obsessions or compulsions unrelated to weight, eating, or food (e.g., contamination).

Social Anxiety Disorder (Social Phobia) In Anorexia Nervosa and Social Anxiety Disorder, individuals may feel humili- ated or embarrassed to be seen eating in public. In Anorexia Nervosa, social fears are limited to eating behaviors. An addi- tional diagnosis of Social Anxiety Disor- der is warranted only if there are fears of other social situations (e.g., speaking in public).

3.10.2 Differential Diagnosis for Anorexia Nervosa (continued)

248 DSM-5 Handbook of Differential Diagnosis

Body Dysmorphic Disorder In Anorexia Nervosa and Body Dysmor- phic Disorder, individuals may be preoc- cupied with an imagined defect in bodily appearance. In Anorexia Nervosa, the preoccupation is limited to body shape and weight. An additional diagnosis of Body Dysmorphic Disorder is warranted only if there are distortions about the body that are unrelated to weight or be- ing fat (e.g., preoccupation with the shape of one’s nose).

3.10.2 Differential Diagnosis for Anorexia Nervosa (continued)

Feeding and Eating Disorders 249

3.10.3 Differential Diagnosis for Bulimia Nervosa

Bulimia Nervosa, which is characterized In contrast to Bulimia Nervosa.. . by recurrent episodes of binge eating ac- companied by inappropriate compensa- tory behaviors to prevent weight gain, must be differentiated from...

Vomiting or diarrhea in general medical Is due to the direct physiological effects of conditions or with excessive substance the general medical condition or sub- use stance use.

Anorexia Nervosa May be characterized by episodes of binge eating and purging. In contrast to Buli- mia Nervosa, the diagnosis of Anorexia Nervosa requires significantly low body weight (i.e., weight that is less than mini- mally normal). Individuals whose binge- eating behavior occurs only during epi- sodes of Anorexia Nervosa are given the diagnosis Anorexia Nervosa, Binge- Eating/Purging Type. If the full criteria for Anorexia Nervosa, Binge-Eating/ Purging Type, are no longer met because for example, weight becomes normal, a diagnosis of Bulimia Nervosa should be given only if criteria for Bulimia Nervosa are met for at least 3 months.

Binge-Eating Disorder Is characterized by binge eating in the ab- sence of the regular use of inappropriate compensatory mechanisms to counteract the effects of binge eating. In contrast, Bulimia Nervosa requires binge eating and inappropriate compensatory behav- iors at least once a week for 3 months.

Kleine-Levin syndrome Is characterized by overeating, but the characteristic psychological features of Bulimia Nervosa, such as overconcern with body shape and weight, are not present.

250 DSM-5 Handbook of Differential Diagnosis

Major Depressive Episode With Atypical May be characterized by overeating along Features in Major Depressive Disorder or with the other symptoms of depression, Bipolar I Disorder but the overeating does not necessarily

occur in the form of binge eating and in- dividuals do not engage in inappropriate compensatory behaviors and do not ex- hibit the characteristic excessive concern with body shape and weight. If criteria are met for Bulimia Nervosa and a Major Depressive Episode With Atypical Fea- tures, then both should be diagnosed.

Borderline Personality Disorder May be characterized by binge eating along with the characteristic features of Borderline Personality Disorder (e.g., self-mutilation, unstable relationships). In contrast, the diagnosis of Bulimia Ner- vosa requires inappropriate compensa- tory behaviors after the binge eating as well as overconcern with body shape and weight. If criteria are met for Bulimia Nervosa and Borderline Personality Dis- order, both can be diagnosed.

3.10.3 Differential Diagnosis for Bulimia Nervosa (continued)

Feeding and Eating Disorders 251

3.10.4 Differential Diagnosis for Binge-Eating Disorder

Binge-Eating Disorder, which is character- In contrast to Binge-Eating Disorder... ized by recurrent episodes of binge eat- ing accompanied by marked distress, must be differentiated from...

Bulimia Nervosa Both conditions are characterized by re- current binge eating, but in Bulimia Ner- vosa there are recurrent inappropriate compensatory behaviors (e.g., purging, driven exercise).

Obesity Although many individuals with Binge- Eating Disorder are obese, those with Binge-Eating Disorder are more likely to have higher levels of overvaluation of body weight and shape, have signifi- cantly higher rates of psychiatric comor- bidity, and have a higher likelihood of long-term successful outcome of evi- dence-based psychological treatment.

occur in the form of binge eating and the eating may or may not be associated with a loss of control. If criteria are met for Binge-Eating Disorder and a Major De- pressive Episode With Atypical Features, then both should be diagnosed.

Borderline Personality Disorder Includes binge eating in the impulsive be- havior criterion that is part of the defini- tion of Borderline Personality Disorder. If the full criteria for Binge-Eating Disorder and Borderline Personality Disorder are met, both diagnoses can be given.

252 DSM-5 Handbook of Differential Diagnosis

Sleep-Wake Disorders 3.11.1 Differential Diagnosis for Insomnia Disorder

Insomnia Disorder, which is characterized In contrast to Insomnia Disorder... by dissatisfaction with sleep quantity or quality associated with difficulty initiat- ing or maintaining sleep, or early-morn- ing awakening with inability to return to sleep, must be differentiated from...

Short sleepers (individuals who require Short sleepers do not have any difficulty little sleep) falling or staying asleep and lack symp-

toms of daytime sleepiness (e.g., fatigue, concentration problems, irritability). By attempting to sleep for a longer period of time by prolonging time in bed, some short sleepers may create an insomnia- like sleep pattern.

Sleep deprivation Is characterized by an inadequate oppor- tunity or circumstance for sleep and is typically temporary (e.g., professional or family obligations forcing a person to stay awake). Insomnia Disorder would not be diagnosed in such circumstances.

Delayed Sleep Phase and Shift Work In Circadian Rhythm Sleep-Wake Disor- Types of Circadian Rhythm Sleep-Wake der, Shift Work Type, there is a history of Disorder recent shift work with consequent distur-

bance in sleep. Individuals with Circa- dian Rhythm Sleep-Wake Disorder, Delayed Sleep Phase Type (i.e., “night owls”), report sleep-onset insomnia only when they try to sleep at socially normal times, but do not report difficulty falling asleep or staying asleep when their bed and rising times are delayed coinciding with their endogenous circadian rhythm. Insomnia Disorder is not diagnosed if the difficulties initiating and maintaining sleep are better explained by, and occur exclusively during the course of, a Circa- dian Rhythm Sleep-Wake Disorder.

Sleep-Wake Disorders 253

Restless Legs Syndrome Is characterized by urges to move the legs and accompanying unpleasant leg sensa- tions, and often produces difficulties ini- tiating and maintaining sleep. Insomnia Disorder is not diagnosed if the difficul- ties initiating and maintaining sleep are better explained by, and occur exclu- sively during the course of, Restless Legs Syndrome.

Breathing-Related Sleep Disorders Are characterized by loud snoring, breath- ing pauses during sleep, and excessive daytime sleepiness, with up to half of these individuals reporting insomnia symptoms. Insomnia Disorder is not diagnosed if the difficulties initiating and maintaining sleep are better explained by, and occur exclusively during the course of, Breathing-Related Sleep Disorders.

Narcolepsy Is characterized by excessive daytime sleepiness, cataplexy, sleep paralysis, and sleep-related hallucinations, along with complaints of insomnia. Insomnia Disor- der is not diagnosed if the difficulties ini- tiating and maintaining sleep are better explained by, and occur exclusively dur- ing the course of, Narcolepsy.

Parasomnias (i.e., Non–Rapid Eye Are characterized by unusual behaviors or Movement Sleep Arousal Disorders, events during sleep that may lead to in- Nightmare Disorder, Rapid Eye termittent awakenings and difficulty re- Movement Sleep Behavior Disorder) suming sleep; however, it is these

behavioral events, rather than the insom- nia per se, that dominate the clinical pic- ture. Insomnia Disorder is not diagnosed if the difficulties initiating and maintain- ing sleep are better explained by, and oc- cur exclusively during the course of, the Parasomnia.

3.11.1 Differential Diagnosis for Insomnia Disorder (continued)

254 DSM-5 Handbook of Differential Diagnosis

Insomnia associated with another mental The diagnosis of Insomnia Disorder is disorder or general medical condition given whether it occurs as an indepen-

dent condition or is comorbid with an- other mental disorder (e.g., Major Depressive Disorder) or general medical condition (e.g., pain). A specifier is used to indicate if it is with a non–sleep disor- der mental comorbidity or with other medical comorbidity.

Substance/Medication-Induced Sleep Is due to the direct physiological effects of Disorder, Insomnia Type a substance or medication. Insomnia Dis-

order is not diagnosed if the symptoms are attributable to the direct physiologi- cal effects of a substance (including med- ication).

3.11.1 Differential Diagnosis for Insomnia Disorder (continued)

Sleep-Wake Disorders 255

3.11.2 Differential Diagnosis for Hypersomnolence Disorder

Hypersomnolence Disorder, which is char- In contrast to Hypersomnolence acterized by excessive sleepiness associ- Disorder.. . ated with lapses into sleep, unrefreshing prolonged main sleep episodes, or diffi- culty being fully awake after abrupt awakening, must be differentiated from...

Normal long sleepers Require a greater than average amount of sleep. Long sleepers do not have exces- sive sleepiness, sleep inertia, or auto- matic behavior when they obtain their required amount of nocturnal sleep, and they report their sleep to be refreshing. If social or occupational demands lead to shorter nocturnal sleep, daytime symp- toms may appear. In individuals with Hypersomnolence Disorder, symptoms of excessive sleepiness occur regardless of nocturnal sleep duration.

Inadequate amount of nocturnal sleep Can produce symptoms of daytime sleepiness very similar to those of Hypersomnolence Disorder. An average sleep duration of fewer than 7 hours per night strongly suggests inadequate nocturnal sleep, and an average of more than 9–10 hours of unrefreshing sleep per 24-hour period suggests a diagnosis of Hypersomnolence Disorder. Unlike Hypersomnolence Disorder, insufficient nocturnal sleep is unlikely to persist unabated for decades.

Daytime fatigue resulting from Is characterized by excessive sleepiness re- Insomnia Disorder lated to insufficient sleep quantity or

quality. Hypersomnolence Disorder is not diagnosed if the excessive sleepiness is better explained by, and occurs exclu- sively during the course of, Insomnia Disorder.

256 DSM-5 Handbook of Differential Diagnosis

Narcolepsy Is characterized by recurrent periods of irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day, which are accompanied by other characteristic features such as cata- plexy, hypocretin deficiency, and specific polysomnographic findings (i.e., rapid eye movement [REM] sleep latency of 15 minutes or less, or a multiple sleep latency test showing a mean sleep latency of 8 minutes or less and two or more sleep-onset REM periods). Hyper- somnolence Disorder is not diagnosed if the excessive sleepiness is better ex- plained by, and occurs exclusively dur- ing the course of, Narcolepsy.

Breathing-Related Sleep Disorders Are characterized by daytime sleepiness accompanied by specific polysomno- graphic findings (e.g., a minimum num- ber of apneas or hypopneas per hour) and often nighttime symptoms (e.g., loud snoring, breathing pauses). Hypersom- nolence Disorder is not diagnosed if the excessive sleepiness is better explained by, and occurs exclusively during the course of, a Breathing-Related Sleep Disorder.

Circadian Rhythm Sleep-Wake Disorders Are often characterized by daytime sleepi- ness, accompanied by a history of an ab- normal sleep-wake schedule (with shifted or regular hours). Hypersomnolence Dis- order is not diagnosed if the excessive sleepiness is better explained by, and oc- curs exclusively during the course of, a Circadian Rhythm Sleep-Wake Disorder.

Parasomnias (i.e., Non–Rapid Eye May be characterized by daytime sleepi- Movement Sleep Arousal Disorders, ness related to nightmares, sleep terrors, Nightmare Disorder, Rapid Eye sleepwalking, or episodes of arousal dur- Movement Sleep Behavior Disorder) ing REM sleep associated with vocaliza-

tion and/or complex motor behaviors. Hypersomnolence Disorder is not diag- nosed if the excessive sleepiness is better explained by, and occurs exclusively dur- ing the course of, a Parasomnia.

3.11.2 Differential Diagnosis for Hypersomnolence Disorder (continued)

Sleep-Wake Disorders 257

Hypersomnolence associated with The diagnosis of Hypersomnolence Disor- another mental disorder or general der is given whether it occurs as an inde- medical condition pendent condition or is comorbid with

another mental disorder (e.g., hypersom- nia in Major Depressive Disorder) or a general medical condition (e.g., Parkin- son’s disease). A specifier is used to indi- cate if it is with a non–sleep disorder mental comorbidity or with other medi- cal comorbidity.

Substance/Medication-Induced Sleep Is due to the direct physiological effects of Disorder, Daytime Sleepiness Type a substance. Hypersomnolence Disorder

is not diagnosed if the symptoms are at- tributable to the direct physiological ef- fects of a substance (including medication).

3.11.2 Differential Diagnosis for Hypersomnolence Disorder (continued)

258 DSM-5 Handbook of Differential Diagnosis

Sexual Dysfunctions 3.12.1 Differential Diagnosis for Sexual Dysfunctions

A Sexual Dysfunction, which is character- In contrast to a Sexual Dysfunction.. . ized by the presence of sexual symptoms (i.e., hypoactive desire, arousal problems, early ejaculation, delayed orgasm, pain during intercourse) that are experienced in all, or almost all, occasions of sexual activity, must be differentiated from...

Medical condition that accounts for the If the dysfunction is entirely attributable to sexual dysfunction the direct physiological effects of a gen-

eral medical condition (e.g., autonomic neuropathy), a DSM-5 Sexual Dysfunc- tion diagnosis is not made.

Substance/Medication-Induced Involves a sexual dysfunction that is better Sexual Dysfunction explained by the use, misuse, or discon-

tinuation of a substance or medication. A Sexual Dysfunction diagnosis is not given if the dysfunction is entirely attrib- utable to the direct physiological effects of a substance or medication.

Sexual problems associated with a Are characterized by a sexual dysfunction nonsexual mental disorder (e.g., Major that occurs only in the context of the Depressive or Bipolar Disorder, symptoms of the other mental disorder Posttraumatic Stress Disorder, Psychotic (e.g., low sexual desire in the context of a Disorder) Major Depressive Episode). If the sexual

dysfunction was present before the onset of the nonsexual mental disorder or per- sists once the nonsexual mental disorder has resolved, a separate diagnosis of Sex- ual Dysfunction may be warranted.

Sexual problems associated with severe If severe relationship distress or partner vi- relationship distress or partner violence olence better explains the sexual difficul-

ties, then a Sexual Dysfunction diagnosis is not made and an appropriate V or Z code for the relationship problem should be used instead.

Sexual Dysfunctions 259

Sexual problems associated with a Are often limited to a specific partner (sit- relational problem uational) and are characterized by an ex-

acerbation when the relational problem gets worse. In some situations, both a Sexual Dysfunction and relational prob- lem may be diagnosed together.

Sexual problems not due to a May be the result of inadequate sexual Sexual Dysfunction stimulation, which can prevent the expe-

rience of arousal or orgasm. Although there may still be a need for care, a diag- nosis of a Sexual Dysfunction is not made.

3.12.1 Differential Diagnosis for Sexual Dysfunctions (continued)

260 DSM-5 Handbook of Differential Diagnosis

Gender Dysphoria 3.13.1 Differential Diagnosis for Gender Dysphoria

Gender Dysphoria, which is characterized In contrast to Gender Dysphoria.. . by a marked incongruence between one’s experienced or expressed gender and assigned gender, is accompanied by a strong desire to be the experienced gen- der, and causes clinically significant dis- tress or impairment, must be differentiated from...

Nonconformity of gender roles Is characterized by nonconformity to ste- reotypical gender role behavior (e.g., “tomboyish” behavior in girls, occasional cross-dressing in adult men) that occurs in the absence of clinically significant dis- tress or impairment in social, occupa- tional, or other areas of functioning. Gender Dysphoria is characterized by the strong desire to be of the expressed gender rather than the assigned one and by the extent and pervasiveness of gen- der-variant activities and interests.

Transvestic Disorder Is characterized by cross-dressing behav- ior that generates sexual excitement and causes distress and/or impairment with- out the individual’s primary gender be- ing called into question. An individual who is aroused by cross-dressing and who also has Gender Dysphoria can be given both diagnoses.

Body Dysmorphic Disorder May be characterized by the persistent de- sire to alter or remove a specific body part or feature because it is perceived as abnormally formed and ugly and not be- cause it represents a repudiated assigned gender. When an individual’s presenta- tion meets criteria for both Gender Dys- phoria and Body Dysmorphic Disorder, both diagnoses can be given.

Gender Dysphoria 261

Psychotic Disorder (e.g., Schizophrenia) May rarely be characterized by delusions of belonging to the other gender. In the absence of other symptoms characteristic of a Psychotic Disorder (e.g., hallucina- tions, other delusions), insistence by an individual with Gender Dysphoria that he or she is of the other gender is not con- sidered a delusion.

3.13.1 Differential Diagnosis for Gender Dysphoria (continued)

262 DSM-5 Handbook of Differential Diagnosis

Disruptive, Impulse-Control, and Conduct Disorders 3.14.1 Differential Diagnosis for Oppositional Defiant Disorder

Oppositional Defiant Disorder (ODD), In contrast to Oppositional Defiant which is characterized by a pattern of an- Disorder.. . gry/irritable mood, argumentative/defi- ant behavior, or vindictiveness, must be differentiated from...

Nonpathological oppositional behavior Is not clinically significant or is not a per- typical of certain developmental stages sistent pattern.

Adjustment Disorder With Disturbance Is a time-limited maladaptive response to of Conduct a stressor and does not meet criteria for

ODD.

Conduct Disorder Is characterized by conduct problems that are of a more severe nature than those of ODD and include aggression toward people or animals, destruction of prop- erty, or a pattern of theft or deceit. More- over, Conduct Disorder does not include problems of emotional dysregulation (i.e., angry and irritable mood). If criteria are met for ODD and Conduct Disorder, both may be diagnosed.

Attention-Deficit/Hyperactivity Disorder May be characterized by oppositional be- havior that occurs solely in situations re- lated to the individual’s failure to conform to requests that demand sus- tained effort and attention or requests to sit still. If oppositional behavior occurs in other situations, then an additional diag- nosis of ODD may be appropriate.

Disruptive Mood Dysregulation Disorder Is characterized by temper outbursts that are much more frequent (three or more times per week), chronic (12 months or more), persistent (no periods lasting more than 3 months without symptoms), and severe (verbal rages or physical ag- gression toward people or property) than those in ODD. ODD is not diagnosed if criteria are met for Disruptive Mood Dys- regulation Disorder.

Disruptive, Impulse-Control, and Conduct Disorders 263

Intermittent Explosive Disorder Is characterized by recurrent behavioral outbursts that involve serious physical or verbal aggression toward others, which is not part of the definition of ODD. An additional diagnosis of Intermittent Ex- plosive Disorder can be made if the re- current impulsive aggressive outbursts are in excess of those usually seen in ODD and warrant independent clinical attention.

Bipolar Disorders, Depressive Disorders, Are associated with oppositional behavior or Psychotic Disorders that occurs only in the context of a mood

disturbance or in relation to delusions or hallucinations.

Intellectual Disability (Intellectual May be characterized by oppositional be- Developmental Disorder) havior that accompanies the intellectual

deficits. A diagnosis of ODD is given only if the oppositional behavior is mark- edly greater than is commonly observed among individuals of comparable mental age and with comparable severity of In- tellectual Disability.

Language Disorder May be associated with oppositional be- havior related to a failure to follow direc- tions that is the result of impaired language comprehension.

Selective Mutism Is characterized by a failure to speak due to fear of negative evaluation rather than by a motivation to be oppositional.

3.14.1 Differential Diagnosis for Oppositional Defiant Disorder (continued)

264 DSM-5 Handbook of Differential Diagnosis

3.14.2 Differential Diagnosis for Intermittent Explosive Disorder

Intermittent Explosive Disorder, which is In contrast to Intermittent Explosive characterized by recurrent behavioral Disorder.. . outbursts that are grossly out of propor- tion to the provocation or any precipitat- ing psychosocial stressors, must be differentiated from...

Substance Intoxication or May be characterized by aggressive be- Substance Withdrawal havior that is due to the direct physiolog-

ical effects of intoxication with, or withdrawal from, a substance. Intermit- tent Explosive Disorder is not diagnosed if the aggressive outbursts occur only during episodes of Substance Intoxica- tion or Substance Withdrawal.

Delirium Due to Another Medical Includes characteristic symptoms (e.g., Condition, Major or Mild impaired attention and orientation and Neurocognitive Disorder Due to fluctuating course in Delirium) Another Medical Condition, accompanying the aggressive outbursts Substance Intoxication Delirium, and requires the presence of an Substance Withdrawal Delirium, etiological medical condition or Medication-Induced Delirium, or substance/medication use. Nonspecific Substance/Medication-Induced Major abnormalities on neurological or Mild Neurocognitive Disorder examination (e.g., “soft signs”) and

nonspecific electroencephalographic changes do not constitute an etiological medical condition and instead are compatible with a diagnosis of Intermittent Explosive Disorder.

Personality Change Due to Another The change from the person’s previous Medical Condition, Aggressive Type characteristic personality pattern in-

volves aggressive outbursts and requires the presence of an etiological medical condition. Nonspecific abnormalities on neurological examination (e.g., “soft signs”) and nonspecific electroencepha- lographic changes do not constitute an etiological medical condition and instead are compatible with a diagnosis of Inter- mittent Explosive Disorder.

Disruptive, Impulse-Control, and Conduct Disorders 265

Disruptive Mood Dysregulation Disorder Is characterized by aggressive outbursts accompanied by a persistently negative mood state (i.e., irritability, anger) most of the day, nearly every day, between the impulsive aggressive outbursts with on- set before age 10 years. Intermittent Ex- plosive Disorder is not diagnosed if the aggressive outbursts are better explained by a diagnosis of Disruptive Mood Dys- regulation Disorder.

Antisocial Personality Disorder or May be characterized by recurrent prob- Borderline Personality Disorder lematic impulsive aggressive outbursts

occurring in the context of a long-stand- ing Personality Disorder. Intermittent Ex- plosive Disorder is not diagnosed if the aggressive outbursts are better explained by one of these Personality Disorders.

Attention-Deficit/Hyperactivity Disorder May be associated with aggressive out- (ADHD), Conduct Disorder, or bursts. In ADHD, the characteristic im- Oppositional Defiant Disorder pulsivity may be manifested by

impulsive aggressive outbursts; in Con- duct Disorder, aggression is characteristi- cally proactive and predatory; in Oppositional Defiant Disorder, the ag- gression typically takes the form of tem- per tantrums and verbal arguments with authority figures. An additional diagno- sis of Intermittent Explosive Disorder can be made if the recurrent impulsive ag- gressive outbursts are in excess of those usually seen in these disorders and war- rant independent clinical attention.

Other mental disorders (e.g., May include impulsive aggression as an Schizophrenia, Manic Episode) associated feature along with their char-

acteristic features. Intermittent Explosive Disorder is not diagnosed if the aggres- sive behavior occurs only during epi- sodes of one of these disorders (e.g., during Manic Episodes, during delu- sional periods).

Aggressive behavior not attributable to a Is motivated by political or religious belief, mental disorder revenge, monetary gain, thrill seeking, or

another reason not related to a mental disorder.

3.14.2 Differential Diagnosis for Intermittent Explosive Disorder (continued)

266 DSM-5 Handbook of Differential Diagnosis

3.14.3 Differential Diagnosis for Conduct Disorder

Conduct Disorder, which is characterized In contrast to Conduct Disorder... by a repetitive and persistent pattern of behavior in which the basic rights of oth- ers or major age-appropriate societal norms or rules are violated, must be dif- ferentiated from...

Oppositional Defiant Disorder Is characterized by disruptive behaviors that are typically of a less severe nature than those in Conduct Disorder and do not include aggression toward individu- als or animals, destruction of property, or a pattern of theft or deceit. Moreover, Oppositional Defiant Disorder includes problems of emotional dysregulation (i.e., angry and irritable mood) that are not part of the definition of Conduct Disorder. If criteria are met for both conditions, both may be diagnosed.

Attention-Deficit/Hyperactivity Disorder Is characterized by hyperactive and im- pulsive behavior that may be disruptive but does not by itself violate societal norms or the rights of others. If criteria are met for both disorders, both may be diagnosed.

Bipolar I or Bipolar II Disorder, May be characterized by behavioral prob- Major Depressive Disorder, lems associated with irritability and ag- Persistent Depressive Disorder gression and can be distinguished from (Dysthymia), or Disruptive Mood Conduct Disorder by the absence of sub- Dysregulation Disorder stantial levels of aggressive or nonag-

gressive conduct problems during periods in which there is no mood distur- bance.

Intermittent Explosive Disorder Is characterized by aggression that is lim- ited to impulsive aggression, is not pre- meditated, and is not committed to achieve some tangible objective. If crite- ria for both disorders are met, the diagno- sis of Intermittent Explosive Disorder should be given only when the recurrent impulsive aggressive outbursts warrant independent clinical attention.

Antisocial behavior related to a Occurs only in response to delusions or Psychotic Disorder (e.g., Schizophrenia) hallucinations.

Disruptive, Impulse-Control, and Conduct Disorders 267

Adjustment Disorder With Disturbance of Is characterized by time-limited conduct Conduct problems that are below the severity

threshold for Conduct Disorder and that clearly occur in response to a psychoso- cial stressor as opposed to being part of a long-standing pattern.

Child or Adolescent Antisocial Behavior Is below the severity threshold for Con- duct Disorder or is not part of a long- standing pattern (i.e., isolated antisocial acts).

Antisocial Personality Disorder Can be diagnosed only in individuals age 18 years or older. Conduct Disorder is not diagnosed if the individual is age 18 or older and if criteria are met for Antisocial Personality Disorder.

3.14.3 Differential Diagnosis for Conduct Disorder (continued)

268 DSM-5 Handbook of Differential Diagnosis

Substance-Related and Addictive Disorders 3.15.1 Differential Diagnosis for Substance Use Disorders

Substance Use Disorder, which is charac- In contrast to Substance Use Disorder... terized by a problematic pattern of sub- stance use leading to clinically significant impairment or distress, must be differen- tiated from...

Nonpathological use of the substance Is characterized by repeated use at rela- tively low doses and may involve occa- sional periods of intoxication not associated with negative consequences (e.g., intoxication restricted to occasional weekends so that it does not impair work or school functioning). Substance Use Disorders are characterized by heavy use leading to significant distress or im- paired functioning. Differentiating be- tween nonpathological substance use and a Substance Use Disorder may be complicated by the fact that denial of heavy substance use and substance- related problems is common with indi- viduals who are referred to treatment by others (e.g., school, family, employer, criminal justice system).

Substance/Medication-Induced Mental Are characterized by central nervous sys- Disorders (including Substance tem syndromes that develop in the con- Intoxication and Substance Withdrawal) text of the effects of substances of abuse,

medications, or toxin exposure. They are distinguished from Substance Use Disor- ders, which are pathological patterns of behaviors related to pattern of use of a substance. Given that the heavy sub- stance use characteristic of a Substance Use Disorder often leads to the develop- ment of a Substance-Induced Disorder, they commonly co-occur and both should be diagnosed (e.g., Severe Cocaine Use Disorder with comorbid Cocaine-Induced Psychotic Disorder, With Onset During Intoxication).

Substance-Related and Addictive Disorders 269

Conduct Disorder in childhood and Substance Use (including Alcohol Use) Antisocial Personality Disorder in Disorders are seen in the majority of indi- adulthood viduals with Antisocial Personality Dis-

order and preexisting Conduct Disorder and are associated with the early onset of the Substance Use Disorder.

Substance use during Manic Episodes Involves episodes of characteristic symp- toms (e.g., elevated mood, irritability, distractibility, decreased need for sleep, flight of ideas) that persist at times when the individual is not using substances. If substance use during a Manic Episode meets criteria for a Substance Use Disor- der, both may be diagnosed.

3.15.1 Differential Diagnosis for Substance Use Disorders (continued)

270 DSM-5 Handbook of Differential Diagnosis

3.15.2 Differential Diagnosis for Gambling Disorder

Gambling Disorder, which is characterized In contrast to Gambling Disorder.. . by persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, must be differentiated from...

Professional gambling Is characterized by discipline and limited risk taking and is intended to be a source of income.

Social gambling Usually occurs among friends and is char- acterized by limited time spent on gam- bling and limited risk taking.

Manic Episode Is characterized by symptoms (e.g., eu- phoric mood, rapid speech, increased self-esteem, flight of ideas) that persist at times when the individual is not gam- bling. Gambling Disorder is not diag- nosed if the gambling behavior is better accounted for by a Manic Episode.

Internet Gaming Disorder (in DSM-5 Is characterized by a preoccupation with Section III) the use of the Internet to play games, of-

ten with other players, leading to clini- cally significant distress or impairment. In contrast to Gambling Disorder, the wa- ger of money is not involved.

Neurocognitive Disorders 271

Neurocognitive Disorders 3.16.1 Differential Diagnosis for Delirium

Delirium, which is characterized by a dis- In contrast to Delirium... turbance in attention (i.e., reduced ability to direct, focus, sustain, and shift atten- tion) and awareness (reduced orientation to the environment) that tends to fluctu- ate during the course of the day and that is due to the physiological effects of a substance or medical condition, must be differentiated from...

Major or Mild Neurocognitive Disorder Is characterized by a relatively stable or gradually progressive course, typically a much longer duration, and despite a number of cognitive deficits, a lack of im- pairment of the ability to maintain atten- tion and be aware of one’s environment. Episodes of Delirium, however, can oc- cur in a preexisting neurocognitive disor- der. Major or Mild Neurocognitive Disorder is not diagnosed if the deficits occur exclusively in the context of Delir- ium. When Delirium occurs in the con- text of a preexisting neurocognitive disorder, it should be separately diag- nosed.

Substance Intoxication or May be characterized by deficits in atten- Substance Withdrawal tion and awareness, but these distur-

bances do not predominate in the clinical picture and are not sufficiently severe to warrant clinical attention. Substance In- toxication Delirium or Substance With- drawal Delirium is diagnosed instead of Substance Intoxication or Substance Withdrawal only when the disturbance in consciousness predominates and war- rants clinical attention.

272 DSM-5 Handbook of Differential Diagnosis

Substance/Medication-Induced Psychotic Is characterized by delusions or hallucina- Disorder or Psychotic Disorder Due to tions due to the physiological effects of a Another Medical Condition substance, medication, or general medi-

cal condition, but these symptoms are not accompanied by a disturbance in atten- tion and awareness and the additional disturbances in cognition, language, or visuospatial ability characteristic of a De- lirium are not present. Substance/Medi- cation-Induced Psychotic Disorder and Psychotic Disorder Due to Another Med- ical Condition are not diagnosed if the psychotic symptoms occur exclusively during the course of the Delirium.

Schizophrenia Spectrum and Other May be characterized by delusions, hallu- Psychotic Disorders, Bipolar Disorders, cinations, or agitation, but they are not or Depressive Disorders due to the direct physiological effects of a

general medical condition or substance/ medication use; they are not accompa- nied by a disturbance in attention and awareness and the additional distur- bances in cognition, language, or visuo- spatial ability characteristic of a Delirium.

3.16.1 Differential Diagnosis for Delirium (continued)

Neurocognitive Disorders 273

3.16.2 Differential Diagnosis for Major or Mild Neurocognitive

Disordera

Major or Mild Neurocognitive Disorder, In contrast to Major or Mild Neurocogni- which is characterized by evidence of tive Disorder.. . cognitive decline from a previous level of performance in one or more cognitive do- mains (complex attention, executive function, learning and memory, lan- guage, perceptual-motor, or social cogni- tion) that is due to a medical condition or the persisting effects of a substance, must be differentiated from...

Delirium Is characterized by a disturbance in atten- tion (i.e., reduced ability to direct, focus, sustain, and shift attention) and aware- ness (reduced orientation to the environ- ment) that develops over a short period of time, usually hours to a few days, and tends to fluctuate during the course of the day. In contrast, most types of Major or Mild Neurocognitive Disorder (e.g., due to Alzheimer’s disease) have a grad- ual onset and a gradually deteriorating course. Major or Mild Neurocognitive Disorder is not diagnosed if the cognitive deficits occur exclusively in the context of Delirium. However, periods of Delirium can be superimposed on a neurocogni- tive disorder and should be diagnosed if present.

Substance Intoxication or May be characterized by cognitive impair- Substance Withdrawal ment that remits when the acute effects of

intoxication or withdrawal subside. In contrast, Substance/Medication-Induced Major or Mild Neurocognitive Disorder is diagnosed only if the cognitive impair- ments persist long beyond the period of acute intoxication or withdrawal.

274 DSM-5 Handbook of Differential Diagnosis

Intellectual Disability Is characterized by intellectual and adap- (Intellectual Developmental Disorder) tive functioning deficits in conceptual,

social, and practical domains that have their onset during the developmental pe- riod. In contrast, Major or Mild Neuro- cognitive Disorder represents a decline in cognitive functioning. Individuals with Intellectual Disability can also be diag- nosed with a neurocognitive disorder if they undergo a decline in cognitive func- tioning due to the direct effects of a co- morbid medical condition (e.g., an individual with Down syndrome who loses further cognitive capacity following a head injury).

Schizophrenia May be characterized by cognitive impair- ment and deterioration in functioning, In contrast to Major or Mild Neurocognitive Disorder, Schizophrenia has a generally earlier age at onset, less severe cognitive impairment, and a characteristic symp- tom pattern (e.g., delusions and halluci- nations), and is not due to the direct effects of a general medical condition or substance/medication use.

Dissociative Amnesia or amnesia Usually involves a circumscribed loss of occurring in other dissociative disorders memory related to traumatic events and

is not due to the direct effects of a general medical condition or substance/medica- tion use.

Major Depressive Disorder May be characterized by memory deficits, difficulty concentrating, and other cogni- tive impairments, but in contrast to Ma- jor or Mild Neurocognitive Disorder, these deficits improve when the depres- sion remits, are associated with other characteristic depressive symptoms, and are not due to the direct effects of a gen- eral medical condition or substance/ medication use.

3.16.2 Differential Diagnosis for Major or Mild Neurocognitive

Disordera (continued)

Neurocognitive Disorders 275

Bipolar I Disorder May be characterized by chronic cognitive impairment that impacts long-term func- tioning. In contrast to Major or Mild Neu- rocognitive Disorder, Bipolar I Disorder generally has an earlier age at onset, less severe cognitive impairment, and the presence of Manic and Major Depressive Episodes, and is not due to the direct ef- fects of a general medical condition or substance/medication use.

Age-related cognitive decline Is characterized by cognitive impairment that is in keeping with what would be ex- pected for the individual’s age and is not due to the direct effects of a general med- ical condition or substance/medication use.

aThe two types of neurocognitive disorder in DSM-5, Major and Mild, are differentiated based on the severity of the neurocognitive deficits. Major Neurocognitive Disorder is characterized by a significant cognitive decline that is severe enough to interfere with independence, whereas Mild Neurocognitive Disorder is characterized by a modest cognitive decline that is not severe enough to interfere with everyday activities, although greater effort, compensatory strategies, or accommodation may be required.

3.16.2 Differential Diagnosis for Major or Mild Neurocognitive

Disordera (continued)

276 DSM-5 Handbook of Differential Diagnosis

Personality Disorders 3.17.1 Differential Diagnosis for Paranoid Personality Disorder

Paranoid Personality Disorder, which is In contrast to Paranoid Personality characterized by pervasive distrust and Disorder.. . suspiciousness of others such that their motives are interpreted as malevolent, must be differentiated from...

Delusional Disorder, Persecutory Type; Are characterized by a period of persistent Schizophrenia; Bipolar I or Bipolar II psychotic symptoms. To give an addi- Disorder With Psychotic Features; and tional diagnosis of Paranoid Personality Depressive Disorder With Psychotic Disorder, the personality disorder must Features have been present before the onset of

psychotic symptoms and must persist when the psychotic symptoms are in remission.

Personality Change Due to Another Is characterized by a change in personality Medical Condition, Paranoid Type related to the direct effects of a general

medical condition.

Social discomfort and paranoid ideation in Also include symptoms such as magical Schizotypal Personality Disorder thinking, unusual perceptual distur-

bances, and odd speech or behavior.

Aloof behavior in Is not characterized by paranoid ideation. Schizoid Personality Disorder

Reacting to minor stimuli in Is not necessarily associated with perva- Borderline Personality Disorder or sive suspiciousness. Histrionic Personality Disorder

Reluctance to confide in others in Is due to a fear of being embarrassed or Avoidant Personality Disorder found inadequate.

Suspiciousness or alienation in Is characterized by fears of having imper- Narcissistic Personality Disorder fections or flaws revealed.

Personality Disorders 277

3.17.2 Differential Diagnosis for Schizoid Personality Disorder

Schizoid Personality Disorder, which is In contrast to Schizoid Personality characterized by a pervasive pattern of Disorder.. . detachment from social relationships and a restricted range of expression of emo- tions in interpersonal settings, must be differentiated from...

Schizophrenia May be characterized by a period of persis- tent psychotic symptoms, diminished emotional expression, and social with- drawal accompanied by other symptoms of Schizophrenia, such as hallucinations or disorganized speech. To give an addi- tional diagnosis of Schizoid Personality Disorder, the personality disorder must have been present before the onset of Schizophrenia symptoms and must per- sist when the symptoms are in remission.

Autism Spectrum Disorder Is characterized by more severely im- paired social interactions and stereo- typed behaviors and interests.

Personality Change Due to Another Is characterized by a change in personality Medical Condition, Apathetic Type related to the direct effects of a general

medical condition.

Schizotypal Personality Disorder Is characterized by cognitive and percep- tual disturbances in addition to the social isolation.

Paranoid Personality Disorder Is characterized by suspiciousness and paranoid ideation.

Avoidant Personality Disorder Is characterized by an active desire for re- lationships that is constrained by a fear of embarrassment or rejection.

Obsessive-Compulsive Personality May be characterized by social detach- Disorder ment related to devotion to work and dis-

comfort with emotions rather than lack of capacity to form intimate relationships.

278 DSM-5 Handbook of Differential Diagnosis

3.17.3 Differential Diagnosis for Schizotypal Personality Disorder

Schizotypal Personality Disorder, which is In contrast to Schizotypal Personality characterized by a pervasive pattern of Disorder.. . social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, must be differentiated from...

Delusional Disorder, Schizophrenia, Are characterized by a period of persistent Bipolar I or Bipolar II Disorder With psychotic symptoms. To give an addi- Psychotic Features, and Depressive tional diagnosis of Schizotypal Personal- Disorder With Psychotic Features ity Disorder, the personality disorder

must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in re- mission.

Autism Spectrum Disorder Is characterized by more severely im- paired social interactions and stereo- typed behaviors and interests.

Language Disorders Are characterized by greater severity of disturbance in language accompanied by compensatory efforts to communicate by other means (e.g., gestures).

Personality Change Due to Another Is characterized by a change in personality Medical Condition, Paranoid Type related to the direct effects of a general

medical condition.

Social detachment in Is characterized by the lack of cognitive or Paranoid Personality Disorder and perceptual distortions and lack of Schizoid Personality Disorder marked eccentricity or oddness.

Avoidant Personality Disorder Is characterized by an active desire for re- lationships that is constrained by a fear of embarrassment or rejection.

Suspiciousness or social withdrawal in Is related to fears of having imperfections Narcissistic Personality Disorder revealed.

Borderline Personality Disorder Is characterized by impulsive and manip- ulative behavior.

Transient schizotypal traits in adolescents Reflect transient emotional turmoil rather than an enduring personality disorder.

Personality Disorders 279

3.17.4 Differential Diagnosis for Antisocial Personality Disorder

Antisocial Personality Disorder, which is In contrast to Antisocial Personality characterized by a pervasive pattern of Disorder.. . disregard for and violation of the rights of others occurring since age 15 years, must be differentiated from...

Isolated antisocial behavior due to Is exclusively related to drug taking and is substance use not part of a pattern of antisocial behav-

ior that began in childhood.

Antisocial behavior occurring in Is associated with the characteristic symp- Schizophrenia or a Manic Episode toms of these disorders and is not associ-

ated with preexisting Conduct Disorder. Antisocial Personality Disorder should not be diagnosed if the antisocial behav- ior occurs exclusively during the course of Schizophrenia or a Manic Episode.

Conduct Disorder Is characterized by a repetitive and persis- tent pattern of behavior in which the ba- sic rights of others or major age- appropriate societal norms or rules are violated; Conduct Disorder can be diag- nosed at any age. The diagnosis of Anti- social Personality Disorder is not given to individuals under age 18 years and is given only if there is a history of some symptoms of Conduct Disorder before age 15 years. For individuals over age 18 years, a diagnosis of Conduct Disorder is given only if the criteria for Antisocial Personality Disorder are not met.

Glibness, exploitativeness, and lack of Are not characterized by impulsivity, empathy in Narcissistic Personality aggressiveness, and a previous pattern of Disorder Conduct Disorder.

Superficial emotionality in Is not characterized by impulsivity, Histrionic Personality Disorder aggressiveness, and a previous pattern of

Conduct Disorder.

Manipulative behavior in Is not characterized by impulsivity, Borderline Personality Disorder aggressiveness, and a previous pattern of

Conduct Disorder.

280 DSM-5 Handbook of Differential Diagnosis

Antisocial behavior in Is motivated by revenge rather than desire Paranoid Personality Disorder for gain.

Adult antisocial behavior Is not characterized by a long-standing pattern of antisocial behavior with onset in childhood or adolescence and other personality features of Antisocial Person- ality Disorder.

3.17.4 Differential Diagnosis for Antisocial Personality Disorder (continued)

Personality Disorders 281

3.17.5 Differential Diagnosis for Borderline Personality Disorder

Borderline Personality Disorder, which is In contrast to Borderline Personality characterized by a pervasive pattern of Disorder.. . instability of interpersonal relationships, self-image, and affects, and marked im- pulsivity, must be differentiated from...

Histrionic Personality Disorder Is not characterized by self-destructive- ness, angry disruptions in close relation- ships, and chronic feelings of deep emptiness and loneliness.

Paranoid ideation or illusions in Are characterized by paranoid ideation Schizotypal Personality Disorder that is less interpersonally reactive and

less amenable to the provision of external structure and support.

Paranoid ideation or angry reactions to Are characterized by relative stability of minor stimuli in Paranoid Personality self-image and relative lack of self- Disorder and Narcissistic Personality destructiveness, impulsivity, and Disorder abandonment concerns.

Manipulative behavior in Is motivated by a desire for power, profit, Antisocial Personality Disorder or material gain rather than a desire for

nurturance.

Abandonment concerns in Are characterized by a reaction to the Dependent Personality Disorder threat of abandonment with increasing

appeasement and submission and attempts to seek a replacement relationship to provide caregiving and support.

Personality Change Due to Another Is characterized by a change in personality Medical Condition, Labile Type related to the direct effects of a general

medical condition.

282 DSM-5 Handbook of Differential Diagnosis

3.17.6 Differential Diagnosis for Histrionic Personality Disorder

Histrionic Personality Disorder, which is In contrast to Histrionic Personality characterized by a pervasive pattern of Disorder.. . excessive emotionality and attention seeking, must be differentiated from...

Borderline Personality Disorder Is characterized by self-destructiveness, angry disruptions in close relationships, and identity disturbance.

Manipulative behavior in Is motivated by a desire for profit, power, Antisocial Personality Disorder or material gain rather than a desire for

attention and approval.

Attention seeking in Is characterized by a need for praise for be- Narcissistic Personality Disorder ing superior.

Dependent Personality Disorder Is characterized by excessive dependence on others for praise and guidance with- out the flamboyant emotions characteris- tic of Histrionic Personality Disorder.

Personality Change Due to Another Is characterized by a change in personality Medical Condition, Disinhibited Type related to the direct effects of a general

medical condition.

Personality Disorders 283

3.17.7 Differential Diagnosis for Narcissistic Personality Disorder

Narcissistic Personality Disorder, which is In contrast to Narcissistic Personality characterized by a pervasive pattern of Disorder.. . grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, must be differentiated from...

Need for attention in Is related to a need for approval as Histrionic Personality Disorder opposed to a need for admiration.

Lack of empathy in Is characterized by impulsivity, aggres- Antisocial Personality Disorder sion, and deceit, and is less characterized

by a need for admiration by others.

Need for attention in Is characterized by instability in self- Borderline Personality Disorder image, self-destructiveness, impulsivity,

and abandonment concerns.

Perfectionism in Is characterized by striving to attain per- Obsessive-Compulsive Personality fection and a belief that others cannot do Disorder things as well, as opposed to a belief that

perfection has already been achieved.

Suspiciousness and social withdrawal in Are related to paranoid ideation as op- Schizotypal Personality Disorder and posed to fears that imperfections or flaws Paranoid Personality Disorder will be revealed.

Grandiosity in Manic or Occurs only during episodes of elevated or Hypomanic Episodes irritable mood.

Personality Change Due to Another Is characterized by a change in personality Medical Condition, Labile Type related to the direct effects of a general

medical condition.

284 DSM-5 Handbook of Differential Diagnosis

3.17.8 Differential Diagnosis for Avoidant Personality Disorder

Avoidant Personality Disorder, which is In contrast to Avoidant Personality characterized by a pervasive pattern of Disorder.. . social inhibition, feelings of inadequacy, and hypersensitivity to negative evalua- tion, must be differentiated from...

Avoidance in Agoraphobia Typically starts after the onset of Panic At- tacks and may vary based on their fre- quency and intensity.

Feelings of inadequacy, hypersensitivity to Are characterized by concerns about being criticism, and need for reassurance in taken care of as opposed to avoidance of Dependent Personality Disorder humiliation or rejection.

Social isolation in Is characterized by contentment with (or Schizoid Personality Disorder and even a preference for) the social isolation. Schizotypal Personality Disorder

Reluctance to confide in others in Is motivated by fears that personal infor- Paranoid Personality Disorder mation will be used with malicious intent

as opposed to fears of being embar- rassed.

Personality Change Due to Another Is characterized by a change in personality Medical Condition related to the direct effects of a general

medical condition.

Personality Disorders 285

3.17.9 Differential Diagnosis for Dependent Personality Disorder

Dependent Personality Disorder, which is In contrast to Dependent Personality characterized by a pervasive and exces- Disorder.. . sive need to be taken care of that leads to submissive and clinging behavior and fears of separation, must be differenti- ated from...

Separation Anxiety Disorder Is characterized by a persistent and exces- sive fear or anxiety concerning being physically separated from major attach- ment figures. In Dependent Personality Disorder, the focus on concern is specifi- cally on the need to be taken care of, rather than separated per se. If criteria are met for both disorders, both can be di- agnosed.

Dependency consequent to a mental Occurs exclusively during the mental dis- disorder or a general medical condition order or general medical condition and

varies according to its severity.

Fear of abandonment in Is characterized by a reaction to antici- Borderline Personality Disorder pated abandonment with feelings of

emotional emptiness, rage, and de- mands.

Need for reassurance and approval in Is characterized by gregarious flamboy- Histrionic Personality Disorder ance with active demands for attention.

Avoidant Personality Disorder Is characterized by such a strong fear of humiliation and rejection that there is so- cial withdrawal until the person is certain of being accepted.

Personality Change Due to Another Is characterized by a change in personality Medical Condition related to the direct effects of a general

medical condition.

286 DSM-5 Handbook of Differential Diagnosis

3.17.10 Differential Diagnosis for Obsessive-Compulsive Personality Disorder

Obsessive-Compulsive Personality Disor- In contrast to Obsessive-Compulsive Per- der, which is characterized by a perva- sonality Disorder.. . sive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, must be differentiated from...

Obsessive-Compulsive Disorder Is characterized by the presence of true ob- sessions and/or compulsions.

Hoarding Disorder Is characterized by persistent difficulty discarding or parting with possessions regardless of their actual value, which is only one of the criteria for Obsessive- Compulsive Personality Disorder. In Hoarding Disorder, in contrast to Obses- sive-Compulsive Personality Disorder, this symptom predominates in the clini- cal picture and results in the accumula- tion of possessions that clutter active living areas and substantially compro- mise their intended use. If criteria are met for both conditions, both can be diag- nosed.

Perfectionism in Is characterized by a belief that perfection Narcissistic Personality Disorder has already been achieved.

Lack of generosity in Is characterized by an indulgence of self as Antisocial Personality Disorder opposed to a miserly spending style to-

ward both self and others.

Social detachment in Occurs in the context of a lack of capacity Schizoid Personality Disorder for intimacy as opposed to discomfort

with emotion and excessive devotion to work.

Personality Change Due to Another Is characterized by a change in personality Medical Condition related to the direct effects of a general

medical condition.

Personality Disorders 287

3.17.11 Differential Diagnosis for Personality Change Due to Another

Medical Condition

Personality Change Due to Another Medi- In contrast to Personality Change Due to cal Condition, which is characterized by Another Medical Condition.. . persistent personality disturbance due to the direct physiological effects of a gen- eral medical condition that represents a change from the individual’s characteris- tic personality pattern, must be differen- tiated from...

Personality change as an associated Includes fluctuating cognitive deficits in feature in Delirium addition to personality changes. Person-

ality Change Due to Another Medical Condition is not diagnosed if the person- ality disturbance occurs exclusively dur- ing the course of Delirium.

Personality change as an associated Includes memory impairment and other feature in Major or Mild Neurocognitive cognitive deficits in addition to personal- Disorder ity changes. Personality Change Due to

Another Medical Condition may be diag- nosed in addition to the Major or Mild Neurocognitive Disorder if the personal- ity disturbance is a prominent feature.

Personality change associated with Includes additional prominent psychiatric another Mental Disorder Due to Another symptoms due to the direct physiological Medical Condition (e.g., Depressive effects of a general medical condition Disorder Due to Another Medical (e.g., depressed mood). Personality Condition) Change Due to Another Medical Condi-

tion is not diagnosed if the disturbance is better accounted for by the other Mental Disorder Due to Another Medical Condi- tion.

Personality change as a result of a Is not due to the direct effects of a general Substance Use Disorder medical condition and abates when the

Substance Use Disorder is in remission.

Personality change associated with Is not due to the direct effects of a general another mental disorder (e.g., social medical condition. withdrawal in Schizophrenia)

Personality Disorders Have a different age at onset (i.e., by ado- lescence or early adulthood), course, and characteristic features and are not due to the direct effects of a general medical condition.

288 DSM-5 Handbook of Differential Diagnosis

Paraphilic Disorders 3.18.1 Differential Diagnosis for Paraphilic Disorders

Paraphilic disorders—characterized by an In contrast to a paraphilic disorder... intense and persistent sexual interest in spying on others in private activities (Voyeuristic Disorder); exposing one’s genitals (Exhibitionistic Disorder); touch- ing or rubbing against a nonconsenting individual (Frotteuristic Disorder); un- dergoing humiliation, bondage, or suf- fering (Sexual Masochism Disorder); inflicting humiliation, bondage, or suf- fering (Sexual Sadism Disorder); sexual focus on children (Pedophilic Disorder); focusing on nonliving objects or body parts (Fetishistic Disorder); or cross- dressing (Transvestic Disorder) that causes clinically significant distress or impairment—must be differentiated from...

Nonpathological use of sexual fantasies, Does not cause clinically significant dis- behaviors, or objects tress or impairment, is typically not

obligatory for sexual functioning, and involves only consenting partners.

Sexual behavior resulting from a decrease Is typically not an individual’s preferred in judgment, social skills, or impulse or obligatory pattern, occurs exclusively control related to another mental during the course of the mental disorder, disorder (e.g., Manic Episode, Major or often has a later age at onset, and is ac- Mild Neurocognitive Disorder, companied by the characteristic features Schizophrenia) of the mental disorder (e.g., cognitive im-

pairment, delusions).

Spying on others engaged in private Are characterized by additional norm- activities in Conduct Disorder and breaking and antisocial behaviors. They Antisocial Personality Disorder (as are differentiated from the antisocial be- distinguished from Voyeuristic Disorder) havior in Voyeuristic Disorder by the lack

of the specific sexual interest in secretly watching unsuspecting others who are naked or engaging in sexual activity.

Paraphilic Disorders 289

Child molestation in Conduct Disorder Are characterized by a pattern of lack of and Antisocial Personality Disorder (as empathy and disregard for the rights of distinguished from Pedophilic Disorder) others, which may include opportunistic

child molestation. This is differentiated from Pedophilic Disorder, in which there is an established pattern of sexual arousal to children.

Substance Intoxication Is characterized by disinhibited behaviors that might involve committing certain sexual offenses (e.g., peeking, exhibiting one’s genitals, rubbing against an unsus- pecting person). It is differentiated from a Paraphilic Disorder by the absence of a persistent pattern of sexual interest in spying on others, exposing one’s geni- tals, or rubbing against an unsuspecting person.

Medication side effect (e.g., dopamine Is characterized by paraphilia-like sexual agonist medication) behavior that is a side effect of a medica-

tion (particularly dopamine agonist med- ications used to treat Parkinson’s disease) that is uncharacteristic of the individual’s sexual behavior when not taking the medication.

Obsessive-Compulsive Disorder (as May be characterized by ego-dystonic distinguished from Pedophilic Disorder) thoughts and worries about possible at-

traction to children as well as other ego- dystonic, intrusive sexual ideas (e.g., con- cerns about homosexuality). In contrast to Pedophilic Disorder, there is an ab- sence of sexual thoughts about children during high states of sexual arousal (e.g., approaching orgasm during masturba- tion).

3.18.1 Differential Diagnosis for Paraphilic Disorders (continued)

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Appendix

DSM-5 Classification

291

Before each disorder name, ICD-9-CM codes are provided, followed by ICD-10-CM

codes in parentheses. Blank lines indicate that either the ICD-9-CM or the ICD-10-CM

code is not applicable. For some disorders, the code can be indicated only according to

the subtype or specifier.

ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014.

Note for all mental disorders due to another medical condition: Indicate the name

of the other medical condition in the name of the mental disorder due to [the medical

condition]. The code and name for the other medical condition should be listed first im-

mediately before the mental disorder due to the medical condition.

Neurodevelopmental Disorders

Intellectual Disabilities

___.__ (___.__) Intellectual Disability (Intellectual Developmental Disorder) Specify current severity:

317 (F70) Mild

318.0 (F71) Moderate

318.1 (F72) Severe

318.2 (F73) Profound

315.8 (F88) Global Developmental Delay

319 (F79) Unspecified Intellectual Disability (Intellectual Developmental

Disorder)

292 DSM-5 Handbook of Differential Diagnosis

Communication Disorders 315.32 (F80.2) Language Disorder

315.39 (F80.0) Speech Sound Disorder

315.35 (F80.81) Childhood-Onset Fluency Disorder (Stuttering) Note: Later-onset cases are diagnosed as 307.0 (F98.5) adult-onset fluency

disorder.

315.39 (F80.89) Social (Pragmatic) Communication Disorder

307.9 (F80.9) Unspecified Communication Disorder

Autism Spectrum Disorder

299.00 (F84.0) Autism Spectrum Disorder Specify if: Associated with a known medical or genetic condition or environ-

mental factor; Associated with another neurodevelopmental, mental, or behavioral disorder

Specify current severity for Criterion A and Criterion B: Requiring very sub- stantial support, Requiring substantial support, Requiring support

Specify if: With or without accompanying intellectual impairment, With or without accompanying language impairment, With catatonia (use addi- tional code 293.89 [F06.1])

Attention-Deficit/Hyperactivity Disorder

___.__ (___.__) Attention-Deficit/Hyperactivity Disorder Specify whether:

314.01 (F90.2) Combined presentation

314.00 (F90.0) Predominantly inattentive presentation

314.01 (F90.1) Predominantly hyperactive/impulsive presentation Specify if: In partial remission Specify current severity: Mild, Moderate, Severe

314.01 (F90.8) Other Specified Attention-Deficit/Hyperactivity Disorder

314.01 (F90.9) Unspecified Attention-Deficit/Hyperactivity Disorder

Specific Learning Disorder

___.__ (___.__) Specific Learning Disorder Specify if:

315.00 (F81.0) With impairment in reading (specify if with word reading

accuracy, reading rate or fluency, reading comprehension)

315.2 (F81.81) With impairment in written expression (specify if with spelling

accuracy, grammar and punctuation accuracy, clarity or

organization of written expression)

315.1 (F81.2) With impairment in mathematics (specify if with number sense,

memorization of arithmetic facts, accurate or fluent

calculation, accurate math reasoning) Specify current severity: Mild, Moderate, Severe

DSM-5 Classification 293

Motor Disorders 315.4 (F82) Developmental Coordination Disorder

307.3 (F98.4) Stereotypic Movement Disorder Specify if: With self-injurious behavior, Without self-injurious behavior Specify if: Associated with a known medical or genetic condition, neurode-

velopmental disorder, or environmental factor Specify current severity: Mild, Moderate, Severe

Tic Disorders

307.23 (F95.2) Tourette's Disorder

307.22 (F95.1) Persistent (Chronic) Motor or Vocal Tic Disorder Specify if: With motor tics only, With vocal tics only

307.21 (F95.0) Provisional Tic Disorder

307.20 (F95.8) Other Specified Tic Disorder

307.20 (F95.9) Unspecified Tic Disorder

Other Neurodevelopmental Disorders 315.8 (F88) Other Specified Neurodevelopmental Disorder

315.9 (F89) Unspecified Neurodevelopmental Disorder

Schizophrenia Spectrum and Other Psychotic Disorders

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 disor-

der: 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 ep-

isodes, currently in partial remission; Multiple episodes, currently in full remission; Continu-

ous; Unspecified bSpecify if: With catatonia (use additional code 293.89 [F06.1]) cSpecify current severity of delusions, hallucinations, disorganized speech, abnormal psychomotor

behavior, negative symptoms, impaired cognition, depression, and mania symptoms

301.22 (F21) Schizotypal (Personality) Disorder

297.1 (F22) Delusional Disordera, c

Specify whether: Erotomanic type, Grandiose type, Jealous type, Persecutory type, Somatic type, Mixed type, Unspecified type

Specify if: With bizarre content

298.8 (F23) Brief Psychotic Disorderb, c

Specify if: With marked stressor(s), Without marked stressor(s), With post- partum onset

295.40 (F20.81) Schizophreniform Disorderb, c

Specify if: With good prognostic features, Without good prognostic features

295.90 (F20.9) Schizophreniaa, b, c

294 DSM-5 Handbook of Differential Diagnosis

___.__ (___.__) Schizoaffective Disordera, b, c

Specify whether:

295.70 (F25.0) Bipolar type

295.70 (F25.1) Depressive type

___.__ (___.__) Substance/Medication-Induced Psychotic Disorderc

Note: See the criteria set and corresponding recording procedures for sub- stance-specific codes and ICD-9-CM and ICD-10-CM coding.

Specify if: With onset during intoxication, With onset during withdrawal

___.__ (___.__) Psychotic Disorder Due to Another Medical Conditionc

Specify whether:

293.81 (F06.2) With delusions

293.82 (F06.0) With hallucinations

293.89 (F06.1) Catatonia Associated With Another Mental Disorder (Catatonia

Specifier)

293.89 (F06.1) Catatonic Disorder Due to Another Medical Condition

293.89 (F06.1) Unspecified Catatonia Note: Code first 781.99 (R29.818) other symptoms involving nervous and

musculoskeletal systems.

298.8 (F28) Other Specified Schizophrenia Spectrum and Other Psychotic

Disorder

298.9 (F29) Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

Bipolar and Related Disorders 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 293.89 [F06.1]); With peripartum onset; With seasonal pattern

___.__ (___.__) Bipolar I Disordera

___.__ (___.__) Current or most recent episode manic 296.41 (F31.11) Mild 296.42 (F31.12) Moderate 296.43 (F31.13) Severe 296.44 (F31.2) With psychotic features 296.45 (F31.73) In partial remission 296.46 (F31.74) In full remission 296.40 (F31.9) Unspecified

296.40 (F31.0) Current or most recent episode hypomanic 296.45 (F31.71) In partial remission 296.46 (F31.72) In full remission 296.40 (F31.9) Unspecified

___.__ (___.__) Current or most recent episode depressed

DSM-5 Classification 295

296.51 (F31.31) Mild 296.52 (F31.32) Moderate 296.53 (F31.4) Severe 296.54 (F31.5) With psychotic features 296.55 (F31.75) In partial remission 296.56 (F31.76) In full remission 296.50 (F31.9) Unspecified

296.7 (F31.9) Current or most recent episode unspecified

296.89 (F31.81) Bipolar II Disordera

Specify current or most recent episode: Hypomanic, Depressed 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 mood episode are currently met:

Mild, Moderate, Severe

301.13 (F34.0) Cyclothymic Disorder Specify if: With anxious distress

___.__ (___.__) Substance/Medication-Induced Bipolar and Related Disorder Note: See the criteria set and corresponding recording procedures for sub-

stance-specific codes and ICD-9-CM and ICD-10-CM coding. Specify if: With onset during intoxication, With onset during withdrawal

293.83 (___.__) Bipolar and Related Disorder Due to Another Medical Condition Specify if:

(F06.33) With manic features

(F06.33) With manic- or hypomanic-like episode

(F06.34) With mixed features

296.89 (F31.89) Other Specified Bipolar and Related Disorder

296.80 (F31.9) Unspecified Bipolar and Related Disorder

Depressive Disorders The following specifiers apply to Depressive Disorders where indicated: aSpecify: 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 293.89 [F06.1]); With peripartum onset; With seasonal pattern

296.99 (F34.8) Disruptive Mood Dysregulation Disorder

___.__ (___.__) Major Depressive Disordera

___.__ (___.__) Single episode 296.21 (F32.0) Mild 296.22 (F32.1) Moderate 296.23 (F32.2) Severe 296.24 (F32.3) With psychotic features 296.25 (F32.4) In partial remission 296.26 (F32.5) In full remission 296.20 (F32.9) Unspecified

296 DSM-5 Handbook of Differential Diagnosis

___.__ (___.__) Recurrent episode 296.31 (F33.0) Mild 296.32 (F33.1) Moderate 296.33 (F33.2) Severe 296.34 (F33.3) With psychotic features 296.35 (F33.41) In partial remission 296.36 (F33.42) In full remission 296.30 (F33.9) Unspecified

300.4 (F34.1) Persistent Depressive Disorder (Dysthymia)a

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

625.4 (N94.3) Premenstrual Dysphoric Disorder

___.__ (___.__) Substance/Medication-Induced Depressive Disorder Note: See the criteria set and corresponding recording procedures for sub-

stance-specific codes and ICD-9-CM and ICD-10-CM coding. Specify if: With onset during intoxication, With onset during withdrawal

293.83 (___.__) Depressive Disorder Due to Another Medical Condition Specify if:

(F06.31) With depressive features

(F06.32) With major depressive-like episode

(F06.34) With mixed features

311 (F32.8) Other Specified Depressive Disorder

311 (F32.9) Unspecified Depressive Disorder

Anxiety Disorders

309.21 (F93.0) Separation Anxiety Disorder

313.23 (F94.0) Selective Mutism

300.29 (___.__) Specific Phobia Specify if:

(F40.218) Animal

(F40.228) Natural environment

(___.__) Blood-injection-injury (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

DSM-5 Classification 297

300.23 (F40.10) Social Anxiety Disorder (Social Phobia) Specify if: Performance only

300.01 (F41.0) Panic Disorder

___.__ (___.__) Panic Attack Specifier

300.22 (F40.00) Agoraphobia

300.02 (F41.1) Generalized Anxiety Disorder

___.__ (___.__) Substance/Medication-Induced Anxiety Disorder Note: See the criteria set and corresponding recording procedures for sub-

stance-specific codes and ICD-9-CM and ICD-10-CM coding. Specify if: With onset during intoxication, With onset during withdrawal,

With onset after medication use

293.84 (F06.4) Anxiety Disorder Due to Another Medical Condition

300.09 (F41.8) Other Specified Anxiety Disorder

300.00 (F41.9) Unspecified Anxiety Disorder

Obsessive-Compulsive and Related Disorders 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

300.3 (F42) Obsessive-Compulsive Disordera

Specify if: Tic-related

300.7 (F45.22) Body Dysmorphic Disordera

Specify if: With muscle dysmorphia

300.3 (F42) Hoarding Disordera

Specify if: With excessive acquisition

312.39 (F63.3) Trichotillomania (Hair-Pulling Disorder)

698.4 (L98.1) Excoriation (Skin-Picking) Disorder

___.__ (___.__) Substance/Medication-Induced Obsessive-Compulsive and Related

Disorder Note: See the criteria set and corresponding recording procedures for sub-

stance-specific codes and ICD-9-CM and ICD-10-CM coding. Specify if: With onset during intoxication, With onset during withdrawal,

With onset after medication use

294.8 (F06.8) Obsessive-Compulsive and Related Disorder Due to Another

Medical Condition Specify if: With obsessive-compulsive disorder–like symptoms, With

appearance preoccupations, With hoarding symptoms, With hair-pulling symptoms, With skin-picking symptoms

300.3 (F42) Other Specified Obsessive-Compulsive and Related Disorder

300.3 (F42) Unspecified Obsessive-Compulsive and Related Disorder

298 DSM-5 Handbook of Differential Diagnosis

Trauma- and Stressor-Related Disorders

313.89 (F94.1) Reactive Attachment Disorder Specify if: Persistent Specify current severity: Severe

313.89 (F94.2) Disinhibited Social Engagement Disorder Specify if: Persistent Specify current severity: Severe

309.81 (F43.10) Posttraumatic Stress Disorder (includes Posttraumatic Stress

Disorder for Children 6 Years and Younger) Specify whether: With dissociative symptoms Specify if: With delayed expression

308.3 (F43.0) Acute Stress Disorder

___.__ (___.__) Adjustment Disorders Specify whether:

309.0 (F43.21) With depressed mood

309.24 (F43.22) With anxiety

309.28 (F43.23) With mixed anxiety and depressed mood

309.3 (F43.24) With disturbance of conduct

309.4 (F43.25) With mixed disturbance of emotions and conduct

309.9 (F43.20) Unspecified

309.89 (F43.8) Other Specified Trauma- and Stressor-Related Disorder

309.9 (F43.9) Unspecified Trauma- and Stressor-Related Disorder

Dissociative Disorders

300.14 (F44.81) Dissociative Identity Disorder

300.12 (F44.0) Dissociative Amnesia Specify if:

300.13 (F44.1) With dissociative fugue

300.6 (F48.1) Depersonalization/Derealization Disorder

300.15 (F44.89) Other Specified Dissociative Disorder

300.15 (F44.9) Unspecified Dissociative Disorder

Somatic Symptom and Related Disorders

300.82 (F45.1) Somatic Symptom Disorder Specify if: With predominant pain Specify if: Persistent Specify current severity: Mild, Moderate, Severe

DSM-5 Classification 299

300.7 (F45.21) Illness Anxiety Disorder Specify whether: Care seeking type, Care avoidant type

300.11 (___.__) Conversion Disorder (Functional Neurological Symptom Disorder) 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 Specify if: Acute episode, Persistent Specify if: With psychological stressor (specify stressor),

Without psychological stressor

316 (F54) Psychological Factors Affecting Other Medical Conditions Specify current severity: Mild, Moderate, Severe, Extreme

300.19 (F68.10) Factitious Disorder (includes Factitious Disorder Imposed on Self,

Factitious Disorder Imposed on Another) Specify Single episode, Recurrent episodes

300.89 (F45.8) Other Specified Somatic Symptom and Related Disorder

300.82 (F45.9) Unspecified Somatic Symptom and Related Disorder

Feeding and Eating Disorders 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

307.52 (___.__) Picaa

(F98.3) In children

(F50.8) In adults

307.53 (F98.21) Rumination Disordera

307.59 (F50.8) Avoidant/Restrictive Food Intake Disordera

307.1 (___.__) Anorexia Nervosab, c

Specify whether:

(F50.01) Restricting type

(F50.02) Binge-eating/purging type

307.51 (F50.2) Bulimia Nervosab, c

307.51 (F50.8) Binge-Eating Disorderb, c

307.59 (F50.8) Other Specified Feeding or Eating Disorder

307.50 (F50.9) Unspecified Feeding or Eating Disorder

300 DSM-5 Handbook of Differential Diagnosis

Elimination Disorders

307.6 (F98.0) Enuresis Specify whether: Nocturnal only, Diurnal only, Nocturnal and diurnal

307.7 (F98.1) Encopresis Specify whether: With constipation and overflow incontinence,

Without constipation and overflow incontinence

___.__ (___.__) Other Specified Elimination Disorder

788.39 (N39.498) With urinary symptoms

787.60 (R15.9) With fecal symptoms

___.__ (___.__) Unspecified Elimination Disorder

788.30 (R32) With urinary symptoms

787.60 (R15.9) With fecal symptoms

Sleep-Wake Disorders 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

307.42 (F51.01) Insomnia Disordera

Specify if: With non–sleep disorder mental comorbidity, With other medical comorbidity, With other sleep disorder

307.44 (F51.11) Hypersomnolence Disorderb, c

Specify if: With mental disorder, With medical condition, With another sleep disorder

___.__ (___.__) Narcolepsyc

Specify whether:

347.00 (G47.419) Narcolepsy without cataplexy but with hypocretin deficiency

347.01 (G47.411) Narcolepsy with cataplexy but without hypocretin deficiency

347.00 (G47.419) Autosomal dominant cerebellar ataxia, deafness, and narcolepsy

347.00 (G47.419) Autosomal dominant narcolepsy, obesity, and type 2 diabetes

347.10 (G47.429) Narcolepsy secondary to another medical condition

Breathing-Related Sleep Disorders 327.23 (G47.33) Obstructive Sleep Apnea Hypopneac

___.__ (___.__) Central Sleep Apnea Specify whether:

327.21 (G47.31) Idiopathic central sleep apnea

786.04 (R06.3) Cheyne-Stokes breathing

780.57 (G47.37) Central sleep apnea comorbid with opioid use Note: First code opioid use disorder, if present. Specify current severity

DSM-5 Classification 301

___.__ (___.__) Sleep-Related Hypoventilation Specify whether:

327.24 (G47.34) Idiopathic hypoventilation

327.25 (G47.35) Congenital central alveolar hypoventilation

327.26 (G47.36) Comorbid sleep-related hypoventilation Specify current severity

___.__ (___.__) Circadian Rhythm Sleep-Wake Disordersa

Specify whether:

307.45 (G47.21) Delayed sleep phase type Specify if: Familial, Overlapping with non-24-hour sleep-wake type

307.45 (G47.22) Advanced sleep phase type Specify if: Familial

307.45 (G47.23) Irregular sleep-wake type

307.45 (G47.24) Non-24-hour sleep-wake type

307.45 (G47.26) Shift work type

307.45 (G47.20) Unspecified type

Parasomnias

___.__ (___.__) Non–Rapid Eye Movement Sleep Arousal Disorders Specify whether:

307.46 (F51.3) Sleepwalking type Specify if: With sleep-related eating, With sleep-related sexual

behavior (sexsomnia)

307.46 (F51.4) Sleep terror type

307.47 (F51.5) Nightmare Disorderb, c

Specify if: During sleep onset Specify if: With associated non–sleep disorder, With associated other medical

condition, With associated other sleep disorder

327.42 (G47.52) Rapid Eye Movement Sleep Behavior Disorder

333.94 (G25.81) Restless Legs Syndrome

___.__ (___.__) Substance/Medication-Induced Sleep Disorder Note: See the criteria set and corresponding recording procedures for sub-

stance-specific codes and ICD-9-CM and ICD-10-CM coding. Specify whether: Insomnia type, Daytime sleepiness type, Parasomnia type,

Mixed type Specify if: With onset during intoxication, With onset during discontinuation/

withdrawal

780.52 (G47.09) Other Specified Insomnia Disorder

780.52 (G47.00) Unspecified Insomnia Disorder

780.54 (G47.19) Other Specified Hypersomnolence Disorder

780.54 (G47.10) Unspecified Hypersomnolence Disorder

780.59 (G47.8) Other Specified Sleep-Wake Disorder

780.59 (G47.9) Unspecified Sleep-Wake Disorder

302 DSM-5 Handbook of Differential Diagnosis

Sexual Dysfunctions

The following specifiers apply to Sexual Dysfunctions where indicated: aSpecify whether: Lifelong, Acquired bSpecify whether: Generalized, Situational cSpecify current severity: Mild, Moderate, Severe

302.74 (F52.32) Delayed Ejaculationa, b, c

302.72 (F52.21) Erectile Disordera, b, c

302.73 (F52.31) Female Orgasmic Disordera, b, c

Specify if: Never experienced an orgasm under any situation

302.72 (F52.22) Female Sexual Interest/Arousal Disordera, b, c

302.76 (F52.6) Genito-Pelvic Pain/Penetration Disordera, c

302.71 (F52.0) Male Hypoactive Sexual Desire Disordera, b, c

302.75 (F52.4) Premature (Early) Ejaculationa, b, c

___.__ (___.__) Substance/Medication-Induced Sexual Dysfunctionc

Note: See the criteria set and corresponding recording procedures for sub- stance-specific codes and ICD-9-CM and ICD-10-CM coding.

Specify if: With onset during intoxication, With onset during withdrawal, With onset after medication use

302.79 (F52.8) Other Specified Sexual Dysfunction

302.70 (F52.9) Unspecified Sexual Dysfunction

Gender Dysphoria

___.__ (___.__) Gender Dysphoria

302.6 (F64.2) Gender Dysphoria in Children Specify if: With a disorder of sex development

302.85 (F64.1) Gender Dysphoria in Adolescents and Adults Specify if: With a disorder of sex development Specify if: Posttransition

Note: Code the disorder of sex development if present, in addition to gender dysphoria.

302.6 (F64.8) Other Specified Gender Dysphoria

302.6 (F64.9) Unspecified Gender Dysphoria

Disruptive, Impulse-Control, and Conduct Disorders

313.81 (F91.3) Oppositional Defiant Disorder Specify current severity: Mild, Moderate, Severe

312.34 (F63.81) Intermittent Explosive Disorder

DSM-5 Classification 303

___.__ (___.__) Conduct Disorder Specify whether:

312.81 (F91.1) Childhood-onset type

312.82 (F91.2) Adolescent-onset type

312.89 (F91.9) Unspecified onset Specify if: With limited prosocial emotions Specify current severity: Mild, Moderate, Severe

301.7 (F60.2) Antisocial Personality Disorder

312.33 (F63.1) Pyromania

312.32 (F63.2) Kleptomania

312.89 (F91.8) Other Specified Disruptive, Impulse-Control, and Conduct Disorder

312.9 (F91.9) Unspecified Disruptive, Impulse-Control, and Conduct Disorder

Substance-Related and Addictive Disorders The following specifiers and note apply to Substance-Related and Addictive Disorders where in- dicated: aSpecify if: In early remission, In sustained remission bSpecify if: In a controlled environment cSpecify if: With perceptual disturbances dThe ICD-10-CM code indicates the comorbid presence of a moderate or severe substance use dis-

order, which must be present in order to apply the code for substance withdrawal.

Substance-Related Disorders

Alcohol-Related Disorders

___.__ (___.__) Alcohol Use Disordera, b

Specify current severity:

305.00 (F10.10) Mild

303.90 (F10.20) Moderate

303.90 (F10.20) Severe

303.00 (___.__) Alcohol Intoxication

(F10.129) With use disorder, mild

(F10.229) With use disorder, moderate or severe

(F10.929) Without use disorder

291.81 (___.__) Alcohol Withdrawalc, d

(F10.239) Without perceptual disturbances

(F10.232) With perceptual disturbances

___.__ (___.__) Other Alcohol-Induced Disorders

291.9 (F10.99) Unspecified Alcohol-Related Disorder

Caffeine-Related Disorders

305.90 (F15.929) Caffeine Intoxication

304 DSM-5 Handbook of Differential Diagnosis

292.0 (F15.93) Caffeine Withdrawal

___.__ (___.__) Other Caffeine-Induced Disorders

292.9 (F15.99) Unspecified Caffeine-Related Disorder

Cannabis-Related Disorders

___.__ (___.__) Cannabis Use Disordera, b

Specify current severity:

305.20 (F12.10) Mild

304.30 (F12.20) Moderate

304.30 (F12.20) Severe

292.89 (___.__) Cannabis Intoxicationc

Without perceptual disturbances (F12.129) With use disorder, mild (F12.229) With use disorder, moderate or severe (F12.929) Without use disorder

With perceptual disturbances (F12.122) With use disorder, mild (F12.222) With use disorder, moderate or severe (F12.922) Without use disorder

292.0 (F12.288) Cannabis Withdrawald

___.__ (___.__) Other Cannabis-Induced Disorders

292.9 (F12.99) Unspecified Cannabis-Related Disorder

Hallucinogen-Related Disorders

___.__ (___.__) Phencyclidine Use Disordera, b

Specify current severity:

305.90 (F16.10) Mild

304.60 (F16.20) Moderate

304.60 (F16.20) Severe

___.__ (___.__) Other Hallucinogen Use Disordera, b

Specify the particular hallucinogen Specify current severity:

305.30 (F16.10) Mild

304.50 (F16.20) Moderate

304.50 (F16.20) Severe

292.89 (___.__) Phencyclidine Intoxication

(F16.129) With use disorder, mild

(F16.229) With use disorder, moderate or severe

(F16.929) Without use disorder

292.89 (___.__) Other Hallucinogen Intoxication

(F16.129) With use disorder, mild

DSM-5 Classification 305

(F16.229) With use disorder, moderate or severe

(F16.929) Without use disorder

292.89 (F16.983) Hallucinogen Persisting Perception Disorder

___.__ (___.__) Other Phencyclidine-Induced Disorders

___.__ (___.__) Other Hallucinogen-Induced Disorders

292.9 (F16.99) Unspecified Phencyclidine-Related Disorder

292.9 (F16.99) Unspecified Hallucinogen-Related Disorder

Inhalant-Related Disorders

___.__ (___.__) Inhalant Use Disordera, b

Specify the particular inhalant Specify current severity:

305.90 (F18.10) Mild

304.60 (F18.20) Moderate

304.60 (F18.20) Severe

292.89 (___.__) Inhalant Intoxication

(F18.129) With use disorder, mild

(F18.229) With use disorder, moderate or severe

(F18.929) Without use disorder

___.__ (___.__) Other Inhalant-Induced Disorders

292.9 (F18.99) Unspecified Inhalant-Related Disorder

Opioid-Related Disorders

___.__ (___.__) Opioid Use Disordera

Specify if: On maintenance therapy, In a controlled environment Specify current severity:

305.50 (F11.10) Mild

304.00 (F11.20) Moderate

304.00 (F11.20) Severe

292.89 (___.__) Opioid Intoxicationc

Without perceptual disturbances (F11.129) With use disorder, mild (F11.229) With use disorder, moderate or severe (F11.929) Without use disorder

With perceptual disturbances (F11.122) With use disorder, mild (F11.222) With use disorder, moderate or severe (F11.922) Without use disorder

292.0 (F11.23) Opioid Withdrawald

___.__ (___.__) Other Opioid-Induced Disorders

292.9 (F11.99) Unspecified Opioid-Related Disorder

306 DSM-5 Handbook of Differential Diagnosis

Sedative-, Hypnotic-, or Anxiolytic-Related Disorders

___.__ (___.__) Sedative, Hypnotic, or Anxiolytic Use Disordera, b

Specify current severity:

305.40 (F13.10) Mild

304.10 (F13.20) Moderate

304.10 (F13.20) Severe

292.89 (___.__) Sedative, Hypnotic, or Anxiolytic Intoxication

(F13.129) With use disorder, mild

(F13.229) With use disorder, moderate or severe

(F13.929) Without use disorder

292.0 (___.__) Sedative, Hypnotic, or Anxiolytic Withdrawalc, d

(F13.239) Without perceptual disturbances

(F13.232) With perceptual disturbances

___.__ (___.__) Other Sedative-, Hypnotic-, or Anxiolytic-Induced Disorders

292.9 (F13.99) Unspecified Sedative-, Hypnotic-, or Anxiolytic-Related Disorder

Stimulant-Related Disorders

___.__ (___.__) Stimulant Use Disordera, b

Specify current severity:

___.__ (___.__) Mild 305.70 (F15.10) Amphetamine-type substance 305.60 (F14.10) Cocaine

305.70 (F15.10) Other or unspecified stimulant ___.__ (___.__) Moderate 304.40 (F15.20) Amphetamine-type substance 304.20 (F14.20) Cocaine 304.40 (F15.20) Other or unspecified stimulant

___.__ (___.__) Severe 304.40 (F15.20) Amphetamine-type substance 304.20 (F14.20) Cocaine 304.40 (F15.20) Other or unspecified stimulant

292.89 (___.__) Stimulant Intoxicationc

Specify the specific intoxicant

292.89 (___.__) Amphetamine or other stimulant, Without perceptual

disturbances (F15.129) With use disorder, mild (F15.229) With use disorder, moderate or severe (F15.929) Without use disorder

292.89 (___.__) Cocaine, Without perceptual disturbances (F14.129) With use disorder, mild (F14.229) With use disorder, moderate or severe (F14.929) Without use disorder

DSM-5 Classification 307

292.89 (___.__) Amphetamine or other stimulant, With perceptual disturbances (F15.122) With use disorder, mild (F15.222) With use disorder, moderate or severe (F15.922) Without use disorder

292.89 (___.__) Cocaine, With perceptual disturbances (F14.122) With use disorder, mild (F14.222) With use disorder, moderate or severe (F14.922) Without use disorder

292.0 (___.__) Stimulant Withdrawald

Specify the specific substance causing the withdrawal syndrome

(F15.23) Amphetamine or other stimulant

(F14.23) Cocaine

___.__ (___.__) Other Stimulant-Induced Disorders

292.9 (___.__) Unspecified Stimulant-Related Disorder

(F15.99) Amphetamine or other stimulant

(F14.99) Cocaine

Tobacco-Related Disorders

___.__ (___.__) Tobacco Use Disordera

Specify if: On maintenance therapy, In a controlled environment Specify current severity:

305.1 (Z72.0) Mild

305.1 (F17.200) Moderate

305.1 (F17.200) Severe

292.0 (F17.203) Tobacco Withdrawald

___.__ (___.__) Other Tobacco-Induced Disorders

292.9 (F17.209) Unspecified Tobacco-Related Disorder

Other (or Unknown) Substance–Related Disorders

___._ (___.__) Other (or Unknown) Substance Use Disordera, b

Specify current severity:

305.90 (F19.10) Mild

304.90 (F19.20) Moderate

304.90 (F19.20) Severe

292.89 (___.__) Other (or Unknown) Substance Intoxication

(F19.129) With use disorder, mild

(F19.229) With use disorder, moderate or severe

(F19.929) Without use disorder

292.0 (F19.239) Other (or Unknown) Substance Withdrawald

___.__ (___.__) Other (or Unknown) Substance–Induced Disorders

292.9 (F19.99) Unspecified Other (or Unknown) Substance–Related Disorder

308 DSM-5 Handbook of Differential Diagnosis

Non-Substance-Related Disorders

312.31 (F63.0) Gambling Disordera

Specify if: Episodic, Persistent Specify current severity: Mild, Moderate, Severe

Neurocognitive Disorders

___.__ (___.__) Delirium aNote: See the criteria set and corresponding recording procedures for sub-

stance-specific codes and ICD-9-CM and ICD-10-CM coding. Specify whether:

___.__ (___.__) Substance intoxication deliriuma

___.__ (___.__) Substance withdrawal deliriuma

292.81 (___.__) Medication-induced deliriuma

293.0 (F05) Delirium due to another medical condition

293.0 (F05) Delirium due to multiple etiologies Specify if: Acute, Persistent Specify if: Hyperactive, Hypoactive, Mixed level of activity

780.09 (R41.0) Other Specified Delirium

780.09 (R41.0) Unspecified Delirium

Major and Mild Neurocognitive Disorders

Specify whether due to: Alzheimer’s disease, Frontotemporal lobar degeneration, Lewy body dis-

ease, Vascular disease, Traumatic brain injury, Substance/medication use, HIV infection, Prion

disease, Parkinson’s disease, Huntington’s disease, Another medical condition, Multiple etiolo-

gies, Unspecified aSpecify Without behavioral disturbance, With behavioral disturbance. For possible major neurocog-

nitive disorder and for mild neurocognitive disorder, behavioral disturbance cannot be coded but should still be indicated in writing.

bSpecify current severity: Mild, Moderate, Severe. This specifier applies only to major neurocognitive disorders (including probable and possible).

Note: As indicated for each subtype, an additional medical code is needed for probable major neu- rocognitive disorder or major neurocognitive disorder. An additional medical code should not be used for possible major neurocognitive disorder or mild neurocognitive disorder.

Major or Mild Neurocognitive Disorder Due to Alzheimer’s Disease

___.__ (___.__) Probable Major Neurocognitive Disorder Due to Alzheimer’s

Diseaseb

Note: Code first 331.0 (G30.9) Alzheimer’s disease.

294.11 (F02.81) With behavioral disturbance

294.10 (F02.80) Without behavioral disturbance

331.9 (G31.9) Possible Major Neurocognitive Disorder Due to Alzheimer’s

Diseasea, b

331.83 (G31.84) Mild Neurocognitive Disorder Due to Alzheimer’s Diseasea

DSM-5 Classification 309

Major or Mild Frontotemporal Neurocognitive Disorder

___.__ (___.__) Probable Major Neurocognitive Disorder Due to Frontotemporal

Lobar Degenerationb

Note: Code first 331.19 (G31.09) frontotemporal disease.

294.11 (F02.81) With behavioral disturbance

294.10 (F02.80) Without behavioral disturbance

331.9 (G31.9) Possible Major Neurocognitive Disorder Due to Frontotemporal

Lobar Degenerationa, b

331.83 (G31.84) Mild Neurocognitive Disorder Due to Frontotemporal Lobar

Degenerationa

Major or Mild Neurocognitive Disorder With Lewy Bodies

___.__ (___.__) Probable Major Neurocognitive Disorder With Lewy Bodiesb

Note: Code first 331.82 (G31.83) Lewy body disease.

294.11 (F02.81) With behavioral disturbance

294.10 (F02.80) Without behavioral disturbance

331.9 (G31.9) Possible Major Neurocognitive Disorder With Lewy Bodiesa, b

331.83 (G31.84) Mild Neurocognitive Disorder With Lewy Bodiesa

Major or Mild Vascular Neurocognitive Disorder

___.__ (___.__) Probable Major Vascular Neurocognitive Disorderb

Note: No additional medical code for vascular disease.

290.40 (F01.51) With behavioral disturbance

290.40 (F01.50) Without behavioral disturbance

331.9 (G31.9) Possible Major Vascular Neurocognitive Disordera, b

331.83 (G31.84) Mild Vascular Neurocognitive Disordera

Major or Mild Neurocognitive Disorder Due to Traumatic Brain Injury

___.__ (___.__) Major Neurocognitive Disorder Due to Traumatic Brain Injuryb

Note: For ICD-9-CM, code first 907.0 late effect of intracranial injury without skull fracture. For ICD-10-CM, code first S06.2X9S diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela.

294.11 (F02.81) With behavioral disturbance

294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to Traumatic Brain Injurya

Substance/Medication-Induced Major or Mild Neurocognitive Disordera

Note: No additional medical code. See the criteria set and corresponding recording procedures for substance-specific codes and ICD-9-CM and ICD-10-CM coding. Specify if: Persistent

Major or Mild Neurocognitive Disorder Due to HIV Infection

___.__ (___.__) Major Neurocognitive Disorder Due to HIV Infectionb

Note: Code first 042 (B20) HIV infection.

294.11 (F02.81) With behavioral disturbance

310 DSM-5 Handbook of Differential Diagnosis

294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to HIV Infectiona

Major or Mild Neurocognitive Disorder Due to Prion Disease

___.__ (___.__) Major Neurocognitive Disorder Due to Prion Diseaseb

Note: Code first 046.79 (A81.9) prion disease.

294.11 (F02.81) With behavioral disturbance

294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to Prion Diseasea

Major or Mild Neurocognitive Disorder Due to Parkinson’s Disease

___.__ (___.__) Major Neurocognitive Disorder Probably Due to Parkinson’s

Diseaseb

Note: Code first 332.0 (G20) Parkinson’s disease.

294.11 (F02.81) With behavioral disturbance

294.10 (F02.80) Without behavioral disturbance

331.9 (G31.9) Major Neurocognitive Disorder Possibly Due to Parkinson’s

Diseasea, b

331.83 (G31.84) Mild Neurocognitive Disorder Due to Parkinson’s Diseasea

Major or Mild Neurocognitive Disorder Due to Huntington’s Disease

___.__ (___.__) Major Neurocognitive Disorder Due to Huntington’s Diseaseb

Note: Code first 333.4 (G10) Huntington’s disease.

294.11 (F02.81) With behavioral disturbance

294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to Huntington’s Diseasea

Major or Mild Neurocognitive Disorder Due to Another Medical Condition

___.__ (___.__) Major Neurocognitive Disorder Due to Another Medical Conditionb

Note: Code first the other medical condition.

294.11 (F02.81) With behavioral disturbance

294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to Another Medical Conditiona

Major or Mild Neurocognitive Disorder Due to Multiple Etiologies

___.__ (___.__) Major Neurocognitive Disorder Due to Multiple Etiologiesb

Note: Code first all the etiological medical conditions (with the exception of vascular disease).

294.11 (F02.81) With behavioral disturbance

294.10 (F02.80) Without behavioral disturbance

331.83 (G31.84) Mild Neurocognitive Disorder Due to Multiple Etiologiesa

Unspecified Neurocognitive Disorder

799.59 (R41.9) Unspecified Neurocognitive Disordera

DSM-5 Classification 311

Personality Disorders

Cluster A Personality Disorders 301.0 (F60.0) Paranoid Personality Disorder

301.20 (F60.1) Schizoid Personality Disorder

301.22 (F21) Schizotypal Personality Disorder

Cluster B Personality Disorders 301.7 (F60.2) Antisocial Personality Disorder

301.83 (F60.3) Borderline Personality Disorder

301.50 (F60.4) Histrionic Personality Disorder

301.81 (F60.81) Narcissistic Personality Disorder

Cluster C Personality Disorders 301.82 (F60.6) Avoidant Personality Disorder

301.6 (F60.7) Dependent Personality Disorder

301.4 (F60.5) Obsessive-Compulsive Personality Disorder

Other Personality Disorders 310.1 (F07.0) Personality Change Due to Another Medical Condition

Specify whether: Labile type, Disinhibited type, Aggressive type, Apathetic type, Paranoid type, Other type, Combined type, Unspecified type

301.89 (F60.89) Other Specified Personality Disorder

301.9 (F60.9) Unspecified Personality Disorder

Paraphilic Disorders The following specifier applies to Paraphilic Disorders where indicated: aSpecify if: In a controlled environment, In full remission

302.82 (F65.3) Voyeuristic Disordera

302.4 (F65.2) Exhibitionistic Disordera

Specify whether: Sexually aroused by exposing genitals to prepubertal chil- dren, Sexually aroused by exposing genitals to physically mature individ- uals, Sexually aroused by exposing genitals to prepubertal children and to physically mature individuals

302.89 (F65.81) Frotteuristic Disordera

302.83 (F65.51) Sexual Masochism Disordera

Specify if: With asphyxiophilia

302.84 (F65.52) Sexual Sadism Disordera

302.2 (F65.4) Pedophilic Disorder Specify whether: Exclusive type, Nonexclusive type

312 DSM-5 Handbook of Differential Diagnosis

Specify if: Sexually attracted to males, Sexually attracted to females, Sexually attracted to both

Specify if: Limited to incest

302.81 (F65.0) Fetishistic Disordera

Specify: Body part(s), Nonliving object(s), Other

302.3 (F65.1) Transvestic Disordera

Specify if: With fetishism, With autogynephilia

302.89 (F65.89) Other Specified Paraphilic Disorder

302.9 (F65.9) Unspecified Paraphilic Disorder

Other Mental Disorders

294.8 (F06.8) Other Specified Mental Disorder Due to Another Medical Condition

294.9 (F09) Unspecified Mental Disorder Due to Another Medical Condition

300.9 (F99) Other Specified Mental Disorder

300.9 (F99) Unspecified Mental Disorder

Medication-Induced Movement Disorders and Other Adverse Effects of Medication

332.1 (G21.11) Neuroleptic-Induced Parkinsonism

332.1 (G21.19) Other Medication-Induced Parkinsonism

333.92 (G21.0) Neuroleptic Malignant Syndrome

333.72 (G24.02) Medication-Induced Acute Dystonia

333.99 (G25.71) Medication-Induced Acute Akathisia

333.85 (G24.01) Tardive Dyskinesia

333.72 (G24.09) Tardive Dystonia

333.99 (G25.71) Tardive Akathisia

333.1 (G25.1) Medication-Induced Postural Tremor

333.99 (G25.79) Other Medication-Induced Movement Disorder

___.__ (___.__) Antidepressant Discontinuation Syndrome

995.29 (T43.205A) Initial encounter

995.29 (T43.205D) Subsequent encounter

995.29 (T43.205S) Sequelae

___.__ (___.__) Other Adverse Effect of Medication

995.20 (T50.905A) Initial encounter

995.20 (T50.905D) Subsequent encounter

995.20 (T50.905S) Sequelae

DSM-5 Classification 313

Other Conditions That May Be a Focus of Clinical Attention

Relational Problems

Problems Related to Family Upbringing

V61.20 (Z62.820) Parent-Child Relational Problem

V61.8 (Z62.891) Sibling Relational Problem

V61.8 (Z62.29) Upbringing Away From Parents

V61.29 (Z62.898) Child Affected by Parental Relationship Distress

Other Problems Related to Primary Support Group

V61.10 (Z63.0) Relationship Distress With Spouse or Intimate Partner

V61.03 (Z63.5) Disruption of Family by Separation or Divorce

V61.8 (Z63.8) High Expressed Emotion Level Within Family

V62.82 (Z63.4) Uncomplicated Bereavement

Abuse and Neglect

Child Maltreatment and Neglect Problems

Child Physical Abuse

Child Physical Abuse, Confirmed

995.54 (T74.12XA) Initial encounter

995.54 (T74.12XD) Subsequent encounter

Child Physical Abuse, Suspected

995.54 (T76.12XA) Initial encounter

995.54 (T76.12XD) Subsequent encounter

Other Circumstances Related to Child Physical Abuse

V61.21 (Z69.010) Encounter for mental health services for victim of child abuse by

parent

V61.21 (Z69.020) Encounter for mental health services for victim of nonparental

child abuse

V15.41 (Z62.810) Personal history (past history) of physical abuse in childhood

V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental

child abuse

V62.83 (Z69.021) Encounter for mental health services for perpetrator of

nonparental child abuse

Child Sexual Abuse

Child Sexual Abuse, Confirmed

995.53 (T74.22XA) Initial encounter

995.53 (T74.22XD) Subsequent encounter

314 DSM-5 Handbook of Differential Diagnosis

Child Sexual Abuse, Suspected

995.53 (T76.22XA) Initial encounter

995.53 (T76.22XD) Subsequent encounter

Other Circumstances Related to Child Sexual Abuse

V61.21 (Z69.010) Encounter for mental health services for victim of child sexual

abuse by parent

V61.21 (Z69.020) Encounter for mental health services for victim of nonparental

child sexual abuse

V15.41 (Z62.810) Personal history (past history) of sexual abuse in childhood

V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental

child sexual abuse

V62.83 (Z69.021) Encounter for mental health services for perpetrator of

nonparental child sexual abuse

Child Neglect

Child Neglect, Confirmed

995.52 (T74.02XA) Initial encounter

995.52 (T74.02XD) Subsequent encounter

Child Neglect, Suspected

995.52 (T76.02XA) Initial encounter

995.52 (T76.02XD) Subsequent encounter

Other Circumstances Related to Child Neglect

V61.21 (Z69.010) Encounter for mental health services for victim of child neglect by

parent

V61.21 (Z69.020) Encounter for mental health services for victim of nonparental

child neglect

V15.42 (Z62.812) Personal history (past history) of neglect in childhood

V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental

child neglect

V62.83 (Z69.021) Encounter for mental health services for perpetrator of

nonparental child neglect

Child Psychological Abuse

Child Psychological Abuse, Confirmed

995.51 (T74.32XA) Initial encounter

995.51 (T74.32XD) Subsequent encounter

Child Psychological Abuse, Suspected

995.51 (T76.32XA) Initial encounter

995.51 (T76.32XD) Subsequent encounter

Other Circumstances Related to Child Psychological Abuse

V61.21 (Z69.010) Encounter for mental health services for victim of child

psychological abuse by parent

DSM-5 Classification 315

V61.21 (Z69.020) Encounter for mental health services for victim of nonparental

child psychological abuse

V15.42 (Z62.811) Personal history (past history) of psychological abuse in childhood

V61.22 (Z69.011) Encounter for mental health services for perpetrator of parental

child psychological abuse

V62.83 (Z69.021) Encounter for mental health services for perpetrator of

nonparental child psychological abuse

Adult Maltreatment and Neglect Problems

Spouse or Partner Violence, Physical

Spouse or Partner Violence, Physical, Confirmed

995.81 (T74.11XA) Initial encounter

995.81 (T74.11XD) Subsequent encounter

Spouse or Partner Violence, Physical, Suspected

995.81 (T76.11XA) Initial encounter

995.81 (T76.11XD) Subsequent encounter

Other Circumstances Related to Spouse or Partner Violence, Physical

V61.11 (Z69.11) Encounter for mental health services for victim of spouse or

partner violence, physical

V15.41 (Z91.410) Personal history (past history) of spouse or partner violence,

physical

V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or

partner violence, physical

Spouse or Partner Violence, Sexual

Spouse or Partner Violence, Sexual, Confirmed

995.83 (T74.21XA) Initial encounter

995.83 (T74.21XD) Subsequent encounter

Spouse or Partner Violence, Sexual, Suspected

995.83 (T76.21XA) Initial encounter

995.83 (T76.21XD) Subsequent encounter

Other Circumstances Related to Spouse or Partner Violence, Sexual

V61.11 (Z69.81) Encounter for mental health services for victim of spouse or

partner violence, sexual

V15.41 (Z91.410) Personal history (past history) of spouse or partner violence,

sexual

V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or

partner violence, sexual

Spouse or Partner, Neglect

Spouse or Partner Neglect, Confirmed

995.85 (T74.01XA) Initial encounter

995.85 (T74.01XD) Subsequent encounter

316 DSM-5 Handbook of Differential Diagnosis

Spouse or Partner Neglect, Suspected

995.85 (T76.01XA) Initial encounter

995.85 (T76.01XD) Subsequent encounter

Other Circumstances Related to Spouse or Partner Neglect

V61.11 (Z69.11) Encounter for mental health services for victim of spouse or

partner neglect

V15.42 (Z91.412) Personal history (past history) of spouse or partner neglect

V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or

partner neglect

Spouse or Partner Abuse, Psychological

Spouse or Partner Abuse, Psychological, Confirmed

995.82 (T74.31XA) Initial encounter

995.82 (T74.31XD) Subsequent encounter

Spouse or Partner Abuse, Psychological, Suspected

995.82 (T76.31XA) Initial encounter

995.82 (T76.31XD) Subsequent encounter

Other Circumstances Related to Spouse or Partner Abuse, Psychological

V61.11 (Z69.11) Encounter for mental health services for victim of spouse or

partner psychological abuse

V15.42 (Z91.411) Personal history (past history) of spouse or partner psychological

abuse

V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or

partner psychological abuse

Adult Abuse by Nonspouse or Nonpartner

Adult Physical Abuse by Nonspouse or Nonpartner, Confirmed

995.81 (T74.11XA) Initial encounter

995.81 (T74.11XD) Subsequent encounter

Adult Physical Abuse by Nonspouse or Nonpartner, Suspected

995.81 (T76.11XA) Initial encounter

995.81 (T76.11XD) Subsequent encounter

Adult Sexual Abuse by Nonspouse or Nonpartner, Confirmed

995.83 (T74.21XA) Initial encounter

995.83 (T74.21XD) Subsequent encounter

Adult Sexual Abuse by Nonspouse or Nonpartner, Suspected

995.83 (T76.21XA) Initial encounter

995.83 (T76.21XD) Subsequent encounter

Adult Psychological Abuse by Nonspouse or Nonpartner, Confirmed

995.82 (T74.31XA) Initial encounter

995.82 (T74.31XD) Subsequent encounter

DSM-5 Classification 317

Adult Psychological Abuse by Nonspouse or Nonpartner, Suspected

995.82 (T76.31XA) Initial encounter

995.82 (T76.31XD) Subsequent encounter

Other Circumstances Related to Adult Abuse by Nonspouse or Nonpartner

V65.49 (Z69.81) Encounter for mental health services for victim of nonspousal

adult abuse

V62.83 (Z69.82) Encounter for mental health services for perpetrator of

nonspousal adult abuse

Educational and Occupational Problems

Educational Problems

V62.3 (Z55.9) Academic or Educational Problem

Occupational Problems

V62.21 (Z56.82) Problem Related to Current Military Deployment Status

V62.29 (Z56.9) Other Problem Related to Employment

Housing and Economic Problems

Housing Problems

V60.0 (Z59.0) Homelessness

V60.1 (Z59.1) Inadequate Housing

V60.89 (Z59.2) Discord With Neighbor, Lodger, or Landlord

V60.6 (Z59.3) Problem Related to Living in a Residential Institution

Economic Problems

V60.2 (Z59.4) Lack of Adequate Food or Safe Drinking Water

V60.2 (Z59.5) Extreme Poverty

V60.2 (Z59.6) Low Income

V60.2 (Z59.7) Insufficient Social Insurance or Welfare Support

V60.9 (Z59.9) Unspecified Housing or Economic Problem

Other Problems Related to the Social Environment V62.89 (Z60.0) Phase of Life Problem

V60.3 (Z60.2) Problem Related to Living Alone

V62.4 (Z60.3) Acculturation Difficulty

V62.4 (Z60.4) Social Exclusion or Rejection

V62.4 (Z60.5) Target of (Perceived) Adverse Discrimination or Persecution

V62.9 (Z60.9) Unspecified Problem Related to Social Environment

Problems Related to Crime or Interaction With the Legal System V62.89 (Z65.4) Victim of Crime

V62.5 (Z65.0) Conviction in Civil or Criminal Proceedings Without Imprisonment

318 DSM-5 Handbook of Differential Diagnosis

V62.5 (Z65.1) Imprisonment or Other Incarceration

V62.5 (Z65.2) Problems Related to Release From Prison

V62.5 (Z65.3) Problems Related to Other Legal Circumstances

Other Health Service Encounters for Counseling and Medical Advice V65.49 (Z70.9) Sex Counseling

V65.40 (Z71.9) Other Counseling or Consultation

Problems Related to Other Psychosocial, Personal, and Environmental Circumstances V62.89 (Z65.8) Religious or Spiritual Problem

V61.7 (Z64.0) Problems Related to Unwanted Pregnancy

V61.5 (Z64.1) Problems Related to Multiparity

V62.89 (Z64.4) Discord With Social Service Provider, Including Probation Officer,

Case Manager, or Social Services Worker

V62.89 (Z65.4) Victim of Terrorism or Torture

V62.22 (Z65.5) Exposure to Disaster, War, or Other Hostilities

V62.89 (Z65.8) Other Problem Related to Psychosocial Circumstances

V62.9 (Z65.9) Unspecified Problem Related to Unspecified Psychosocial

Circumstances

Other Circumstances of Personal History V15.49 (Z91.49) Other Personal History of Psychological Trauma

V15.59 (Z91.5) Personal History of Self-Harm

V62.22 (Z91.82) Personal History of Military Deployment

V15.89 (Z91.89) Other Personal Risk Factors

V69.9 (Z72.9) Problem Related to Lifestyle

V71.01 (Z72.811) Adult Antisocial Behavior

V71.02 (Z72.810) Child or Adolescent Antisocial Behavior

Problems Related to Access to Medical and Other Health Care

V63.9 (Z75.3) Unavailability or Inaccessibility of Health Care Facilities

V63.8 (Z75.4) Unavailability or Inaccessibility of Other Helping Agencies

Nonadherence to Medical Treatment

V15.81 (Z91.19) Nonadherence to Medical Treatment

278.00 (E66.9) Overweight or Obesity

V65.2 (Z76.5) Malingering

V40.31 (Z91.83) Wandering Associated With a Mental Disorder

V62.89 (R41.83) Borderline Intellectual Functioning

Alphabetical Index of Decision Trees

Aggressive behavior (2.23) (p.116) Insomnia (2.19) (p. 99)

Anxiety (2.13) (p.75) Irritable mood (2.9) (p. 56)

Appetite changes or unusual eating Medical conditions, etiological (2.29)

behavior (2.18) (p. 94) (p. 149)

Avoidance behavior (2.15) (p. 83) Memory loss (2.27) (p. 135)

Behavioral problems in a child or Panic attacks (2.14) (p. 80)

adolescent (2.2) (p. 25) Poor school performance (2.1) (p. 22)

Catatonic symptoms (2.7) (p. 49) Psychomotor retardation (2.12) (p. 72)

Cognitive impairment (2.28) (p. 139) School performance, poor (2.1) (p. 22)

Delusions (2.5) (p. 38) Self-injury or self-mutilation (2.25)

Depressed mood (2.10) (p. 61) (p. 126)

Distractibility (2.4) (p. 35) Sexual dysfunction in a female (2.21)

Eating behavior, unusual, or appetite (p. 109)

changes (2.18) (p. 94) Sexual dysfunction in a male (2.22)

Elevated or expansive mood (2.8) (p. 52) (p. 113)

Etiological medical conditions (2.29) Somatic complaints or illness/

(p. 149) appearance anxiety (2.17) (p. 91)

Excessive substance use (2.26) (p. 129) Speech disturbance (2.3) (p. 30)

Hallucinations (2.6) (p. 44) Substance use, excessive (2.26) (p. 129)

Hypersomnolence (2.20) (p. 104) Suicidal ideation or behavior (2.11) (p. 67)

Impulsivity or impulse-control problems Trauma or psychosocial stressors

(2.24) (p. 122) involved in the etiology (2.16) (p. 87)

319

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Alphabetical Index of Differential Diagnosis Tables

Acute Stress Disorder (3.7.1) (p.225) Conversion Disorder (Functional

Adjustment Disorder (3.7.2) (p. 227) Neurological Symptom Disorder) (3.9.3)

(p. 239) Agoraphobia (3.5.6) (p. 210)

Cyclothymic Disorder (3.3.3) (p. 188) Anorexia Nervosa (3.10.2) (p. 246)

Delirium (3.16.1) (p. 271) Antisocial Personality Disorder (3.17.4)

(p. 279) Delusional Disorder (3.2.3) (p. 178)

Attention-Deficit/Hyperactivity Dependent Personality Disorder (3.17.9)

Disorder (3.1.4) (p. 168) (p. 285)

Autism Spectrum Disorder (3.1.3) (p. 166) Depersonalization/Derealization

Disorder (3.8.2) (p. 231) Avoidant Personality Disorder (3.17.8)

(p. 284) Disruptive Mood Dysregulation Disorder

(3.4.4) (p. 196) Avoidant/Restrictive Food Intake

Disorder (3.10.1) (p. 244) Dissociative Amnesia (3.8.1) (p. 229)

Binge-Eating Disorder (3.10.4) (p. 251) Dysthymia (Persistent Depressive

Disorder) (3.4.2) (p. 192) Bipolar I Disorder (3.3.1) (p. 182)

Excoriation (Skin-Picking) Disorder Bipolar II Disorder (3.3.2) (p. 185)

(3.6.5) (p. 224) Body Dysmorphic Disorder (3.6.2) (p. 218)

Factitious Disorder (3.9.5) (p. 243) Borderline Personality Disorder (3.17.5)

Functional Neurological Symptom (p. 281)

Disorder (Conversion Disorder) (3.9.3) Brief Psychotic Disorder (3.2.4) (p. 180) (p. 239)

Bulimia Nervosa (3.10.3) (p. 249) Gambling Disorder (3.15.2) (p. 270)

Communication Disorders (3.1.2) (p. 164) Gender Dysphoria (3.13.1)

Conduct Disorder (3.14.3) (p. 266) (p. 260)

321

322 DSM-5 Handbook of Differential Diagnosis

Generalized Anxiety Disorder (3.5.7) Personality Change Due to Another

(p. 212) Medical Condition (3.17.11) (p. 287)

Hair-Pulling Disorder (Trichotillomania) Posttraumatic Stress Disorder (3.7.1)

(3.6.4) (p. 222) (p. 225)

Histrionic Personality Disorder (3.17.6) Premenstrual Dysphoric Disorder (3.4.3)

(p. 282) (p. 194)

Hoarding Disorder (3.6.3) (p. 220) Psychological Factors Affecting Other

Medical Conditions (3.9.4) (p. 241)Hypersomnolence Disorder (3.11.2)

(p. 255) Schizoaffective Disorder (3.2.2) (p. 177)

Illness Anxiety Disorder (3.9.2) (p. 236) Schizoid Personality Disorder (3.17.2)

(p. 277)Insomnia Disorder (3.11.1) (p. 252) Schizophrenia or Schizophreniform Intellectual Disability (Intellectual

Disorder (3.2.1) (p. 175) Developmental Disorder) (3.1.1) (p. 162)

Schizotypal Personality Disorder (3.17.3) Intermittent Explosive Disorder (3.14.2) (p. 278)(p. 264)

Selective Mutism (3.5.2) (p. 201)Major Depressive Disorder (3.4.1) (p. 189) Separation Anxiety Disorder (3.5.1) Major or Mild Neurocognitive Disorder

(p. 198)(3.16.2) (p. 273) Sexual Dysfunctions (3.12.1) (p. 258)Narcissistic Personality Disorder (3.17.7)

(p. 283) Skin-Picking (Excoriation) Disorder

(3.6.5) (p. 224)Neurocognitive Disorder, Major or Mild

(3.16.2) (p. 273) Social Anxiety Disorder (Social Phobia)

(3.5.4) (p. 204)Obsessive-Compulsive Disorder (3.6.1)

(p. 215) Somatic Symptom Disorder (3.9.1)

(p. 234)Obsessive-Compulsive Personality Specific Learning Disorder (3.1.5)Disorder (3.17.10) (p. 286)

(p. 172) Oppositional Defiant Disorder (3.14.1)

Specific Phobia (3.5.3) (p. 202)(p. 262)

Substance Use Disorders (3.15.1) (p. 268)Panic Disorder (3.5.5) (p. 208)

Tic Disorders (3.1.6) (p. 174)Paranoid Personality Disorder (3.17.1)

(p. 276) Trichotillomania (Hair-Pulling Disorder)

(3.6.4) (p. 222)Paraphilic Disorders (3.18.1) (p. 288)

Unspecified Catatonia (3.2.5) (p. 181)Persistent Depressive Disorder

(Dysthymia) (3.4.2) (p. 192)

Cover
Contents
Preface
1 Differential Diagnosis Step by Step
2 Differential Diagnosis by the Trees

2.1 Decision Tree for Poor School Performance
2.2 Decision Tree for Behavioral Problems in a Child or Adolescent
2.3 Decision Tree for Speech Disturbance
2.4 Decision Tree for Distractibility
2.5 Decision Tree for Delusions
2.6 Decision Tree for Hallucinations
2.7 Decision Tree for Catatonic Symptoms
2.8 Decision Tree for Elevated or Expansive Mood
2.9 Decision Tree for Irritable Mood
2.10 Decision Tree for Depressed Mood
2.11 Decision Tree for Suicidal Ideation or Behavior
2.12 Decision Tree for Psychomotor Retardation
2.13 Decision Tree for Anxiety
2.14 Decision Tree for Panic Attacks
2.15 Decision Tree for Avoidance Behavior
2.16 Decision Tree for Trauma or Psychosocial Stressors Involved in the Etiology
2.17 Decision Tree for Somatic Complaints or Illness/Appearance Anxiety
2.18 Decision Tree for Appetite Changes or Unusual Eating Behavior
2.19 Decision Tree for Insomnia
2.20 Decision Tree for Hypersomnolence
2.21 Decision Tree for Sexual Dysfunction in a Female
2.22 Decision Tree for Sexual Dysfunction in a Male
2.23 Decision Tree for Aggressive Behavior
2.24 Decision Tree for Impulsivity or Impulse-Control Problems
2.25 Decision Tree for Self-Injury or Self-Mutilation
2.26 Decision Tree for Excessive Substance Use
2.27 Decision Tree for Memory Loss
2.28 Decision Tree for Cognitive Impairment
2.29 Decision Tree for Etiological Medical Conditions

3 Differential Diagnosis by the Tables

Neurodevelopmental Disorders

3.1.1 Differential Diagnosis for Intellectual Disability (Intellectual Developmental Disorder)
3.1.2 Differential Diagnosis for Communication Disorders
3.1.3 Differential Diagnosis for Autism Spectrum Disorder
3.1.4 Differential Diagnosis for Attention-Deficit/Hyperactivity Disorder
3.1.5 Differential Diagnosis for Specific Learning Disorder
3.1.6 Differential Diagnosis for Tic Disorders

Schizophrenia Spectrum and Other Psychotic Disorders

3.2.1 Differential Diagnosis for Schizophrenia or Schizophreniform Disorder
3.2.2 Differential Diagnosis for Schizoaffective Disorder
3.2.3 Differential Diagnosis for Delusional Disorder
3.2.4 Differential Diagnosis for Brief Psychotic Disorder
3.2.5 Differential Diagnosis for Unspecified Catatonia

Bipolar and Related Disorders

3.3.1 Differential Diagnosis for Bipolar I Disorder
3.3.2 Differential Diagnosis for Bipolar II Disorder
3.3.3 Differential Diagnosis for Cyclothymic Disorder

Depressive Disorders

3.4.1 Differential Diagnosis for Major Depressive Disorder
3.4.2 Differential Diagnosis for Persistent Depressive Disorder (Dysthymia)
3.4.3 Differential Diagnosis for Premenstrual Dysphoric Disorder
3.4.4 Differential Diagnosis for Disruptive Mood Dysregulation Disorder

Anxiety Disorders

3.5.1 Differential Diagnosis for Separation Anxiety Disorder
3.5.2 Differential Diagnosis for Selective Mutism
3.5.3 Differential Diagnosis for Specific Phobia
3.5.4 Differential Diagnosis for Social Anxiety Disorder (Social Phobia)
3.5.5 Differential Diagnosis for Panic Disorder
3.5.6 Differential Diagnosis for Agoraphobia
3.5.7 Differential Diagnosis for Generalized Anxiety Disorder

Obsessive-Compulsive and Related Disorders

3.6.1 Differential Diagnosis for Obsessive-Compulsive Disorder
3.6.2 Differential Diagnosis for Body Dysmorphic Disorder
3.6.3 Differential Diagnosis for Hoarding Disorder
3.6.4 Differential Diagnosis for Trichotillomania (Hair-Pulling Disorder)
3.6.5 Differential Diagnosis for Excoriation (Skin-Picking) Disorder

Trauma- and Stressor-Related Disorders

3.7.1 Differential Diagnosis for Posttraumatic Stress Disorder or Acute Stress Disorder
3.7.2 Differential Diagnosis for Adjustment Disorder

Dissociative Disorders

3.8.1 Differential Diagnosis for Dissociative Amnesia
3.8.2 Differential Diagnosis for Depersonalization/Derealization Disorder

Somatic Symptom and Related Disorders

3.9.1 Differential Diagnosis for Somatic Symptom Disorder
3.9.2 Differential Diagnosis for Illness Anxiety Disorder
3.9.3 Differential Diagnosis for Conversion Disorder (Functional Neurological Symptom Disorder)
3.9.4 Differential Diagnosis for Psychological Factors Affecting Other Medical Conditions
3.9.5 Differential Diagnosis for Factitious Disorder

Feeding and Eating Disorders

3.10.1 Differential Diagnosis for Avoidant/Restrictive Food Intake Disorder
3.10.2 Differential Diagnosis for Anorexia Nervosa
3.10.3 Differential Diagnosis for Bulimia Nervosa
3.10.4 Differential Diagnosis for Binge-Eating Disorder

Sleep-Wake Disorders

3.11.1 Differential Diagnosis for Insomnia Disorder
3.11.2 Differential Diagnosis for Hypersomnolence Disorder

Sexual Dysfunctions

3.12.1 Differential Diagnosis for Sexual Dysfunctions

Gender Dysphoria

3.13.1 Differential Diagnosis for Gender Dysphoria

Disruptive, Impulse-Control, and Conduct Disorders

3.14.1 Differential Diagnosis for Oppositional Defiant Disorder
3.14.2 Differential Diagnosis for Intermittent Explosive Disorder
3.14.3 Differential Diagnosis for Conduct Disorder

Substance-Related and Addictive Disorders

3.15.1 Differential Diagnosis for Substance Use Disorders
3.15.2 Differential Diagnosis for Gambling Disorder

Neurocognitive Disorders

3.16.1 Differential Diagnosis for Delirium
3.16.2 Differential Diagnosis for Major or Mild Neurocognitive Disorder

Personality Disorders

3.17.1 Differential Diagnosis for Paranoid Personality Disorder
3.17.2 Differential Diagnosis for Schizoid Personality Disorder
3.17.3 Differential Diagnosis for Schizotypal Personality Disorder
3.17.4 Differential Diagnosis for Antisocial Personality Disorder
3.17.5 Differential Diagnosis for Borderline Personality Disorder
3.17.6 Differential Diagnosis for Histrionic Personality Disorder
3.17.7 Differential Diagnosis for Narcissistic Personality Disorder
3.17.8 Differential Diagnosis for Avoidant Personality Disorder
3.17.9 Differential Diagnosis for Dependent Personality Disorder
3.17.10 Differential Diagnosis for Obsessive-Compulsive Personality Disorder
3.17.11 Differential Diagnosis for Personality Change Due to Another Medical Condition

Paraphilic Disorders

3.18.1 Differential Diagnosis for Paraphilic Disorders

Appendix: DSM-5 Classification
Alphabetical Index of Decision Trees

Alphabetical Index of Differential Diagnosis Tables